The Oxford Handbook of Counseling Psychology

OXFORD LIBRARY OF PSYCHOLOGY

edi tor -in-chief

Peter E. Nathan

area ed itor s:

Clinical Psychology
David H. Barlow
Cognitive Neuroscience
Kevin N. Ochsner and Stephen M. Kosslyn
Cognitive Psychology
Daniel Reisberg
Counseling Psychology
Elizabeth M. Altmaier and Jo-Ida C. Hansen
Developmental Psychology
Philip David Zelazo
Health Psychology
Howard S. Friedman
History of Psychology
David B. Baker
Industrial/Organizational Psychology
Steve W. J. Kozlowski
Methods and Measurement
Todd D. Little
Neuropsychology
Kenneth M. Adams
Personality and Social Psychology
Kay Deaux and Mark Snyder
 OXFORD LIBRARY OF PSYCHOLOGY

Editor-in-Chief peter e. nathan

The Oxford Handbook

of Counseling
Psychology

Edited by
Elizabeth M. Altmaier
Jo-Ida C. Hansen

1
1
Oxford University Press, Inc., publishes works that further Oxford University’s
objective of excellence in research, scholarship, and education.
Oxford New York
Auckland Cape Town Dar es Salaam Hong Kong Karachi
Kuala Lumpur Madrid Melbourne Mexico City Nairobi
New Delhi Shanghai Taipei Toronto
With offices in
Argentina Austria Brazil Chile Czech Republic France Greece
Guatemala Hungary Italy Japan Poland Portugal Singapore
South Korea Switzerland Thailand Turkey Ukraine Vietnam

Copyright © 2012 by Oxford University Press, Inc.

Published by Oxford University Press, Inc.
198 Madison Avenue, New York, New York 10016
www.oup.com

Oxford is a registered trademark of Oxford University Press

All rights reserved. No part of this publication may be reproduced, stored in a
retrieval system, or transmitted, in any form or by any means, electronic, mechanical,
photocopying, recording, or otherwise, without the prior permission of
Oxford University Press

_________________________________________

Library of Congress Cataloging-in-Publication Data

The Oxford handbook of counseling psychology / edited by Elizabeth M. Altmaier, Jo-Ida

C. Hansen.
p. cm. — (Oxford library of psychology)
Includes index.
ISBN-13: 978-0-19-534231-4
ISBN-10: 0-19-534231-3
1. Counseling psychology—Handbooks, manuals, etc. I. Altmaier, Elizabeth M.
II. Hansen, Jo-Ida C.
BF636.6.O94 2012
158.3—dc23 2011027854
_________________________________________

9 8 7 6 5 4 3 2 1

Printed in the United States of America on acid-free paper

SHORT CONTENTS

Oxford Library of Psychology vii

About the Editors ix

Contributors xi

Contents xv

Chapters 1–922

Index 923

v
This page intentionally left blank
O X F O R D L I B R A R Y O F P S YC H O L O G Y

The Oxford Library of Psychology, a landmark series of handbooks, is published

by Oxford University Press, one of the world’s oldest and most highly respected
publishers, with a tradition of publishing significant books in psychology. The
ambitious goal of the Oxford Library of Psychology is nothing less than to span
a vibrant, wide-ranging field and, in so doing, to fill a clear market need.
Encompassing a comprehensive set of handbooks, organized hierarchically,
the Library incorporates volumes at different levels, each designed to meet a dis-
tinct need. At one level are a set of handbooks designed broadly to survey the
major subfields of psychology; at another are numerous handbooks that cover
important current focal research and scholarly areas of psychology in depth and
detail. Planned as a reflection of the dynamism of psychology, the Library will
grow and expand as psychology itself develops, thereby highlighting significant
new research that will impact on the field. Adding to its accessibility and ease of
use, the Library will be published in print and, later on, electronically.
The Library surveys psychology’s principal subfields with a set of handbooks
that capture the current status and future prospects of those major subdisciplines.
This initial set includes handbooks of social and personality psychology, clinical
psychology, counseling psychology, school psychology, educational psychology,
industrial and organizational psychology, cognitive psychology, cognitive neu-
roscience, methods and measurements, history, neuropsychology, personality
assessment, developmental psychology, and more. Each handbook undertakes to
review one of psychology’s major subdisciplines with breadth, comprehensiveness,
and exemplary scholarship. In addition to these broadly conceived volumes, the
Library also includes a large number of handbooks designed to explore in depth
more specialized areas of scholarship and research, such as stress, health and
coping, anxiety and related disorders, cognitive development, or child and adoles-
cent assessment. In contrast to the broad coverage of the subfield handbooks, each
of these latter volumes focuses on an especially productive, more highly focused
line of scholarship and research. Whether at the broadest or most specific level,
however, all of the Library handbooks offer synthetic coverage that reviews and
evaluates the relevant past and present research and anticipates research in the
future. Each handbook in the Library includes introductory and concluding chap-
ters written by its editor to provide a roadmap to the handbook’s table of contents
and to offer informed anticipations of significant future developments in that
field.

vii
 An undertaking of this scope calls for handbook editors and chapter authors
who are established scholars in the areas about which they write. Many of the
nation’s and world’s most productive and best-respected psychologists have
agreed to edit Library handbooks or write authoritative chapters in their areas of
expertise.
For whom has the Oxford Library of Psychology been written? Because of its
breadth, depth, and accessibility, the Library serves a diverse audience, including
graduate students in psychology and their faculty mentors, scholars, researchers,
and practitioners in psychology and related fields. Each will find in the Library the
information they seek on the subfield or focal area of psychology in which they
work or are interested.
Befitting its commitment to accessibility, each handbook includes a compre-
hensive index, as well as extensive references to help guide research. And because
the Library was designed from its inception as an online as well as a print resource,
its structure and contents will be readily and rationally searchable online. Further,
once the Library is released online, the handbooks will be regularly and thor-
oughly updated.
In summary, the Oxford Library of Psychology will grow organically to provide
a thoroughly informed perspective on the field of psychology, one that reflects
both psychology’s dynamism and its increasing interdisciplinarity. Once published
electronically, the Library is also destined to become a uniquely valuable interac-
tive tool, with extended search and browsing capabilities. As you begin to consult
this handbook, we sincerely hope you will share our enthusiasm for the more than
500-year tradition of Oxford University Press for excellence, innovation, and
quality, as exemplified by the Oxford Library of Psychology.

Peter E. Nathan
Editor-in-Chief
Oxford Library of Psychology

viii oxford library o f ps ych o lo g y

A B O U T T H E E D I TO R S

Elizabeth M. Altmaier
Elizabeth Altmaier is Professor in the Counseling Psychology program in the
Department of Psychological and Quantitative Foundations, College of Education,
at the University of Iowa, with a joint appointment in the Department of Commu-
nity and Behavioral Health in the College of Public Health. Dr. Altmaier received
her M.A. and Ph.D. in Psychology from The Ohio State University and her B.A. in
Psychology from Wheaton College (Ill.). Her research interests are in health psy-
chology, particularly the psychosocial sequelae of treatments for cancer, and in the
roles of spirituality and religiosity in recovery from trauma
Jo-Ida C. Hansen
Jo-Ida C. Hansen is Professor in the Department of Psychology and Director of
the American Psychological Association–accredited Counseling Psychology Program
at the University of Minnesota. She holds an adjunct appointment with the
Department of Human Resources and Industrial Relations in the Carlson School of
Business, University of Minnesota. She directs the Center for Interest Measurement
Research and the Vocational Assessment Clinic, an advanced practicum training site
and research laboratory for testing the hypotheses of the Theory of Work Adjustment
(TWA). Her awards include the E. K. Strong, Jr. Gold Medal, ACA Extended
Research Award, Leona Tyler Award, and Society of Vocational Psychology Lifetime
Achievement Award.

ix
This page intentionally left blank
 CO N T R I B U TO R S

Saba Rasheed Ali Thomas R. Cunningham

Department of Psychological and Education and Information Division
Quantitative Foundations National Institute for
University of Iowa Occupational Safety and Health
Iowa City, Iowa Centers for Disease Control and
Elizabeth M. Altmaier Prevention
Department of Psychological and Cincinnati, Ohio
Quantitative Foundations Gary M. Diamond
University of Iowa Department of Behavioral Sciences
Iowa City, Iowa Ben-Gurion University of the Negev
Margit I. Berman Beer-Sheva, Israel
Department of Psychiatry Michael Duffy
Dartmouth Medical School Department of Educational Psychology
Hanover, New Hampshire Texas A&M University
Nancy E. Betz College Station, Texas
Department of Psychology Timothy R. Elliott
The Ohio State University Department of Educational Psychology
Columbus, Ohio Texas A&M University
Rosie Phillips Bingham College Station, Texas
Student Affairs Donald E. Eggerth
University of Memphis Education and Information Division
Memphis, Tennessee National Institute for
Robert C. Chope Occupational Safety and Health
Department of Counseling Centers for Disease Control and
San Francisco State University Prevention
San Francisco, California Cincinnati, Ohio
Kevin O. Cokley Carolyn Zerbe Enns
Department of Educational Psychology Department of Psychology
University of Texas at Austin Cornell College
Austin, Texas Mount Vernon, Iowa
Robert K. Conyne Dorothy L. Espelage
College of Education, Criminal Justice, Department of Educational Psychology
and Human Services University of Illinois, Urbana-Champaign
University of Cincinnati Champaign, Illinois
Cincinnati, Ohio Ruth E. Fassinger
Stewart E. Cooper College of Graduate and
Department of Psychology Professional Studies
Valparaiso University John F. Kennedy University
Valparaiso, Indiana Pleasant Hill, California

xi
Nadya A. Fouad Arpana G. Inman
Department of Educational Psychology Department of Counseling Psychology
University of Wisconsin-Milwaukee Lehigh University
Milwaukee, Wisconsin Bethlehem, Pennsylvania
Patricia A. Frazier Larry C. James
Department of Psychology School of Professional Psychology
University of Minnesota Wright State University
Minneapolis, Minnesota Dayton, Ohio
Myrna L. Friedlander Nicholas Ladany
Department of Counseling Psychology Department of Educational
University at Albany, SUNY Support Services
Albany, New York Loyola Marymount University
Jairo N. Fuertes Los Angeles, California
The Derner Institute of Advanced Lisa M. Larson
Psychological Studies Department of Psychology
Adelphi University Iowa State University
Garden City, New York Ames, Iowa
Lawrence H. Gerstein James W. Lichtenberg
Department of Counseling Psychology & Department of Psychology and Research
Guidance Services, and in Education
Center for Peace and Conflict Studies University of Kansas
Ball State University Lawrence, Kansas
Muncie, Indiana William Ming Liu
Judy E. Hall Department of Psychological and
National Register of Health Service Quantitative Foundations
Providers in Psychology University of Iowa
Washington, D.C. Iowa City, Iowa
Jo-Ida C. Hansen Sara Maltzman
Department of Psychology County of San Diego Child Welfare
University of Minnesota Services
Minneapolis, Minnesota San Diego, California
Robert J. Harmison Melissa L. Morgan
Department of Graduate Psychology Department of Counseling,
James Madison University Clinical, & School Psychology
Harrisonburg, Virginia University of California, Santa Barbara
Beth E. Haverkamp Santa Barbara, California
Department of Educational and Bonnie Moradi
Counselling Psychology Department of Psychology
University of British Columbia University of Florida
Vancouver, British Columbia, Canada Gainesville, Florida
Martin Heesacker Susan L. Morrow
Department of Psychology Department of Educational Psychology
University of Florida University of Utah
Gainesville, Florida Salt Lake City, Utah
Mary Ann Hoffman Rhoda Olkin
Department of Counseling and California School of Professional
Personnel Services Psychology
University of Maryland Alliant International University
College Park, Maryland San Francisco, California

xii contributors
James N. O’Neil Carl E. Thoresen
Department of Educational Psychology School of Education
University of Connecticut Stanford University
Storrs, Connecticut Stanford, California
Trent A. Petrie Tammi Vacha-Haase
Department of Psychology Department of Psychology
University of North Texas Colorado State University
Denton, Texas Fort Collins, Colorado
Thomas G. Plante Beverly J. Vandiver
Department of Psychology Department of Educational
Santa Clara University Psychology, School Psychology,
Santa Clara, California and Special Education
Paul V. Poteat Pennsylvania State University
Department of Counseling, University Park, Pennsylvania
Developmental, and Educational Melba J. T. Vasquez
Psychology Independent Practice
Boston College Austin, Texas
Boston, Massachusetts Elizabeth M. Vera
Jeffrey P. Prince School of Education
Department of Counseling & Loyola University Chicago
Psychological Services Chicago, Illinois
University of California, Berkeley Janice D. Yoder
Berkeley, California Department of Psychology
Joseph F. Rath University of Akron
Department of Rehabilitation Medicine Akron, Ohio
New York University School of Medicine Stefania Ægisdóttir
New York, New York Department of Counseling Psychology
Sandra L. Shullman and Guidance Services
Executive Development Group, LLC Ball State University
Columbus, Ohio Muncie, Indiana
Jane Swanson
Department of Psychology
Southern Illinois University Carbondale
Carbondale, Illinois

cont r ibutor s xiii

This page intentionally left blank
CONTENTS

Part One • Introduction and Overview

1. A View Across the Life Span of Counseling Psychology 3
Elizabeth M. Altmaier and Saba Rasheed Ali

Part Two • Foundations

2. Professional Issues 11
Judy E. Hall
3. The Counseling Relationship 32
Beth E. Haverkamp
4. Theory and Research for Counseling Interventions 71
Martin Heesacker and James W. Lichtenberg
5. Process and Outcomes in Counseling and Psychotherapy 95
Sara Maltzman
6. Worklife Across the Lifespan 128
Lisa M. Larson
7. Training and Supervision 179
Nicholas Ladany and Arpana G. Inman
8. Measurement and Assessment in Counseling Psychology 208
Jane L. Swanson
9. Methodologies in Counseling Psychology 237
Nancy E. Betz and Ruth E. Fassinger
10. Ethics in Counseling Psychology 270
Melba J. T. Vasquez and Rosie Phillips Bingham

Part Three • Contextual Perspectives

11. Ethnic and Racial Identity 291
Kevin O. Cokley and Beverly J. Vandiver
12. Developing a Social Class and Classism Consciousness 326
William Ming Liu
13. The Psychology of Women 346
Bonnie Moradi and Janice D. Yoder
14. The Psychology of Men 375
James M. O’Neil
15. Sexual Orientations and Identities 409
Susan L. Morrow
16. Feminist Approaches to Counseling 434
Carolyn Zerbe Enns

xv
17. Disability: A Primer for Therapists 460
Rhoda Olkin
18. Counseling Psychologists Working with Older Adults 480
Tammi Vacha-Haase and Michael Duffy

Part Four • Applications

19. Individual Counseling As an Intervention 503
Mary Ann Hoffman
20. Prevention and Psychoeducation in Counseling Psychology 529
Melissa L. Morgan and Elizabeth M. Vera
21. Career Counseling 545
Robert C. Chope
22. Multicultural Counseling and Psychotherapy 570
Jairo N. Fuertes
23. Spirituality, Religion, and Psychological Counseling 589
Thomas G. Plante and Carl E. Thoresen
24. Group Counseling 611
Robert K. Conyne
25. Couple and Family Therapy 647
Myrna L. Friedlander and Gary M. Diamond

Part Five • Intersections

26. Rehabilitation Psychology 679
Timothy R. Elliott and Joseph F. Rath
27. School-based Prevention of Peer Relationship Problems 703
Dorothy L. Espelage and V. Paul Poteat
28. Counseling Health Psychology 723
Margit I. Berman and Larry C. James
29. Counseling Psychology and Occupational Health Psychology 752
Donald E. Eggerth and Thomas R. Cunningham
30. Sport Psychology 780
Trent A. Petrie and Robert J. Harmison
31. Trauma Psychology 807
Patricia A. Frazier
32. Counseling Psychologists As Consultants 837
Stewart Cooper and Sandra L. Shullman
33. Social Justice in Counseling Psychology 856
Nadya A. Fouad and Jeffrey P. Prince
34. Internationalization of Counseling Psychology 873
Lawrence H. Gerstein and Stefanía Ægisdóttir

Part Six • Conclusions

35. Contemporary Counseling Psychology 917
Jo-Ida C. Hansen

Index 923

xvi conten ts
 PART
1
Introduction and
Overview
This page intentionally left blank
 CHAPTER

1 A View Across the Life Span

of Counseling Psychology
Elizabeth M. Altmaier and Saba Rasheed Ali

Abstract
It has been said of psychology, as a discipline, that it has a long past and a short history. This contrast
refers to the roots of psychology in philosophy, medicine, and education that date back over several
hundred years—and in the case of philosophy and medicine, several thousand. Counseling psychology
has deep roots, as well, although its technical birth was in 1952. At that time, the Division of Personnel
and Guidance of the American Psychological Association renamed itself the Division of Counseling
Psychology. In this chapter, we consider three domains in which our specialty has begun with deep
“roots” and has “leafed” out into new ways of thinking about our work with clients and our broader
roles in the communities in which we live. These three domains are a focus on building strengths;
a holistic, or systems, perspective; and a collaborative, patient-centered model. We trace the
development of these domains, noting where, in other parts of this volume, more complete discussion
can be found, and we highlight their current explications.
Keywords: values, history, development

Counseling psychology, as a specialty, officially Readers will find this Handbook divided into
dates to 1952, when the Division of Counsel- four parts. The first part pertains to foundational
ing and Guidance of the American Psychological knowledge and methods. These chapters concern
Association changed its name to the Division of themselves with the basic interactions of
Counseling Psychology, thus formalizing a specialty counseling—the counseling relationship, a coun-
in psychology that had increasingly differenti- selor’s assessment of a client, the counselor’s choice
ated itself from related psychological specialties to of interventions—and how theory, research, and
form a unique identity. As discussed in many chap- professional context influence these interactions
ters that follow, counseling psychology is one of over time. Thus, this part covers those critical
three original specialties in psychology (the others issues of methodology, ethics and professional issues,
being clinical psychology and school psychology). and training and supervision that are foundational
Although these specialties differed in their target to all chapters that follow.
client population and the activities engaged in by From its inception, counseling psychology has
practitioners identified with the specialty, they emphasized three themes. The first theme is that
shared a commitment to client welfare, to the appli- psychologists work toward a goal larger than that
cation of scientific knowledge to assessment and of removing pathology. Rather, counseling psy-
intervention, and to training and education. Their chologists promote positive health through the
differences, however, are significant and continue to identification and enhancement of constructive
this day. aspects of human functioning, both personal

3
strengths and available resources. The second theme and alleviate maladjustment, disability, and dis-
is that clients are best understood in a systems per- comfort as well as to promote human adaptation,
spective: When conceptualizing persons, counseling adjustment, and personal development. Clinical
psychologists focus on interacting variables, includ- psychology focuses on the intellectual, emotional,
ing developmental stage, the person–environment biological, psychological, social, and behavioral
fit, and external systems acting on the person, includ- aspects of human functioning across the lifespan, in
ing family and community. The third theme is that varying cultures, and at all socioeconomic levels.
counseling psychologists are collaborative: They are Counseling psychology as a psychological spe-
client-centered, using shared relationships, sensitive cialty facilitates personal and interpersonal func-
to the multicultural components of the interaction, tioning across the lifespan with a focus on emotional,
to enhance client welfare and outcomes. social, vocational, educational, health-related, devel-
In this chapter, each of these themes will be con- opmental, and organizational concerns. Through
sidered in more detail. The purpose is to define a the integration of theory, research, and practice, and
context for the chapters that follow. By considering with a sensitivity to multicultural issues, this spe-
both the earliest and the most recent iterations of cialty encompasses a broad range of practices that
these themes, we hope that the reader will gain a help people improve their well-being, alleviate dis-
wider view in which to locate the general and specific tress and maladjustment, resolve crises, and increase
information contained in the Handbook chapters. their ability to live more highly functioning lives.
Counseling psychology is unique in its attention
Promotion of Health both to normal developmental issues and to prob-
As a discipline, psychologists respond to clients— lems associated with physical, emotional, and
whether individuals, couples, groups, or mental disorders.
organizations—who face difficulties with their emo- A focus on the promotion of mental health was a
tional and physical well-being. Are clients best vital characteristic of early counseling psychologists,
assisted when the difficulty is accurately diagnosed most of whom were operating as guidance special-
and an intervention is made to reduce or remove ists during the time between World War I and
the difficulty? Or, are they best served when the World War II. These early guidance professionals
assessment and intervention process assists clients were concerned with the problems of children and
in identifying their own personal strengths and adolescents, particularly those from poor urban
resources, then reinforces these strengths and environments, who left school early and needed to
resources within the intervention, so that they can work to support families but were unable to navi-
serve to prevent future distress? The response to this gate the work world. Frank Parsons, in particular,
question is part of the historical differentiation focused his efforts on the Civic Service House of
between clinical and counseling psychology, in Boston, where he assisted students in planning their
which clinical psychology has emphasized diagnosis work future. This foundation for guidance was well
and treatment of disorders, and counseling psychol- received, and national interest in “vocational guid-
ogy has emphasized normal development. Louttit ance” increased dramatically. Counseling psycholo-
(1939) defined clinical psychology as concerned gists of that time were also busy developing
with diagnosing the nature and extent of psychopa- curriculum to educate and train the persons who
thology, with abnormalities present even in “normal” would be guidance specialists in the future.
persons. In contrast, Gustad (1953) noted counsel- A second vital focus on health was present in
ing psychology’s concern with hygiology, with nor- the work of Carl Rogers. Rogers (1940), in contrast
malities and strengths present even in “abnormal” to the prevailing therapeutic model of his time, pro-
persons, and with the identification and promotion posed that clients were capable of their own emo-
of adaptive personal tendencies. tional growth and adjustment in the presence of
However, the specialties are more recently in the deeply supportive relationship environment
convergence on the notion of health promotion as provided by a counselor who was warm, genuine,
well as remediation. Taken from the websites of and fully present to the client. This view contrasted
clinical and counseling psychology are the following with the notion of the counselor as a removed
definitions (Division of Clinical Psychology, 2010; “expert,” whose knowledge would result in a diag-
Division of Counseling Psychology, 2010): nosis of the client and/or the provision of the
The field of clinical psychology integrates sci- necessary information to the client for his or her
ence, theory, and practice to understand, predict, adjustment. Rogers’ work was seconded by an early

4 life span of co u n s e l in g p s ych o lo gy

pioneer of counseling psychology, Leona Tyler, lecturer at a Boston settlement home established to
who wrote a seminal text in 1953 entitled The Work assist neighborhood immigrant residents to develop
of the Counselor, in which she set forth the prop- English fluency and complete high school. His
osition that the person and presence of the coun- favorite topic was the importance of matching one’s
selor was more important than counseling content abilities to a vocation. Largely, Parson’s work was
or techniques. built upon the premise of creating a more efficient
As is clearly detailed in many chapters that society by assisting youth in becoming and staying
follow, counseling psychology has maintained this employed in occupations that would provide them
emphasis on health promotion and has transformed with life’s necessities and ultimately assist them in
it into a promotion of positive psychology. Notably, transcending poverty.
this promotion of health by identifying and foster- From Parson’s work emerged the trait factor
ing strengths has expanded beyond the individual to approaches to career planning and development.
the point at which counseling psychologists main- For example, Holland’s (1959) theory of voca-
tain an advocacy role for clients and a commitment tional choice is centered on the premise that an
to fostering social justice in systems, organizations, individual’s personality and occupational environ-
and communities. Within this contemporary com- ments can be matched, and the greater the match,
mitment, counseling psychologists use research and the more successful the person will be in his or her
theory to identify persons at risk of difficulties and chosen career. Holland developed a series of per-
to intervene before serious adversity is present. They sonality instruments and theoretical positions that
also promote client welfare beyond the individuals outline this model in great detail. Another theory
whom they serve, acting as an advocate for commu- that was developed around the same time was the
nity betterment. And, finally, they are focused on theory of work adjustment (TWA; Dawis, Lofquist,
social justice as a necessary and appropriate goal for & Weiss, 1968), which is the only major theory
all clients. that took into account both the needs and interests
of the worker, as well as the needs and interests of
Systems Perspective the work environment. Very briefly, TWA outlines
As stated previously, counseling psychology emerged important relationships between the needs of the
as a specialty from the vocational guidance move- individuals and the requirements of the particular
ment. Yet, counseling psychology would eventually workplace and the constant adjustment between
branch into many different areas, one of which was the two.
the area of career development/vocational psychol- More recently, vocational psychologists have
ogy. This area of counseling psychology is mostly been interested in the application of developmental
concerned with helping individuals plan for a career. psychology perspectives to career development
More recently, vocational psychologists have been and to vocational psychology to explain the career
more concerned with how to help individuals find development process for disenfranchised groups.
and maintain gainful employment in the midst of For example, Bronfenbrenner’s ecological systems
economic crises and downsizing. theory (Bronfenbrenner, 1977) has been used to
Some of the earliest theories in career develop- explain the career development of women in pov-
ment were driven by historical and contextual influ- erty and women of color. Ecological systems theory
ences. During the Industrial Revolution, there was is a developmental theory that takes into account
a need to assist individuals to find the correct the multiple systemic influences and interactions
“match” in terms of their skills and a specific job. that occur for a given individual. Bronfenbrenner
This could be seen most prominently in factory asserts that each individual operates within a series
work, where efficiency was considered paramount. of nested systems in which development occurs
As mentioned previously, Frank Parsons, considered (e.g., family, culture, government), and that the
to be the founder of modern vocational psychology, individual is an active participant in many of these
was particularly interested in immigrant youth. systems and therefore, is not simply acted upon by
Parsons believed that the best way to help immi- the system but also influences and changes the envi-
grant youth find work was to help them find a job ronment. This perspective has been used within
that was “a function of the fit between a person’s vocational psychology/counseling psychology to
capacities and characteristics on one hand and the understand the complexity of career development
requirements of routines of the occupation on the from a multicultural standpoint, and it takes into
other” (Parsons, 1909). Parsons was a frequent account that human behavior and development

alt m aie r, ali 5

varies depending on the context in which it is occur- model (Altmaier & Claiborn, 1987) allows the
ring. Although Bronfenbrenner’s theory has been integration of both scientific activities and modes
developed for over 40 years, the application of the of thinking with the art of therapy. Thus, scholar-
model to vocational psychology, career develop- ship and practice share reciprocal and essential func-
ment, and counseling psychology is relatively new. tions in the advancement of science and clinical
work.
Collaborative, Client-centered Model This emphasis on collaboration between coun-
Perhaps the strongest characteristic of counseling selor and client resulted in significant thinking
psychology, particularly in comparison to the two about essential tasks of the counselor, who must be
closely related specialties of clinical and school psy- “present” for clients. In particular, how cultural
chology, is its emphasis on the collaborative nature differences between counselor and client influence
of the relationship between counselors and clients. successful or unsuccessful outcomes were consid-
A view of the client as working in a collaborative ered. Recently, counseling psychology has been
relationship with the counselor carries with it sev- characterized by and differentiated from clinical
eral important components. First, since the client and school psychology in its emphasis on critical
and counselor are working together, the client’s view aspects of the multicultural interaction between
of the nature of his or her distress and its origins counselor and client. The second part of this
carries as much weight as the counselor’s view. Thus, Handbook identifies essential elements of multi-
the counselor is not the source of information as cultural knowledge, attitudes, and skills. As noted
the expert on the client’s condition so much as the in the definition of counseling psychology pre-
counselor facilitates the client’s self-exploration, sented earlier, counseling psychologists carry a sen-
whereby both client and counselor gain valuable sitivity to multiculturalism into all their activities,
insights into the client. Second, the counselor res- ranging from counseling and therapy to testing to
pects the client in the counseling relationship as a research to supervision and training. Much of the
partner in both assessment and intervention pro- current work in the field of psychology in these areas
cesses. Clients are not “cured” by counselors; rather, has been accomplished by counseling psycholo-
clients work in relationships with counselors to gists. Although multiculturalism in its earliest mean-
achieve important outcomes, including, as noted ing was defined primarily as racial differences
above, the identification and promotion of personal between counselor and client, counseling psychol-
and contextual strengths. ogy now promotes the view of each encounter
Perhaps the earliest explication of these views between two people as a multicultural encounter.
was in Tyler’s 1953 book, referred to earlier. In her As chapters in this part consider, gender, social
writing, she emphasized the individuality of each class, and sexual minority concerns are examples of
client and each counselor, and the unique nature cultural encounters in which counseling psycholo-
of their interaction. Therefore, although technique gists have contributed to current knowledge.
and knowledge are critical, they are not enough.
As Tyler noted in a later edition of her book (1969), Conclusion
“at the heart of the counseling process is a meeting Counseling psychology is engaged in exhilarating
of counselor and client. Whether they meet for 15 new directions, as well as continuing time-honored
or 50 minutes, whether they talk about symptoms, domains of contributions. The fourth and fifth
explore feelings, or discuss facts and schedules . . . parts of the Handbook cover both of these applica-
whatever influence counseling has is related most tions. The fourth part considers how counseling
closely to the nature of the relationship that grows psychologists have traditionally assisted clients who
out of this encounter” (p. 33). are individuals, groups, couples, or families, and
A related view of the importance of a collab- who have a variety of identified difficulties. The fifth
orative model of counselor and client is the collab- part identifies “intersections,” new areas of practice
orative model of training and education adopted that have recently developed as counseling psy-
in counseling psychology programs, namely the chologists have embraced previously underserved
scientist–practitioner model. This model, estab- client populations—clients with medical concerns,
lished originally at the Boulder Conference, articu- school-aged children, persons who have experi-
lated the essential importance of the relationship of enced trauma—and used both the specialty’s roots
science and practice. During graduate education and and its leaves to explicate theories and applica-
after, a dual emphasis on the scientist–practitioner tions that build on the traditional strengths

6 life span of co u n s e l in g p s ych o lo gy

of counseling psychology in new ways. Increasingly, Division of Clinical Psychology, American Psychological Asso-
counseling psychologists operate outside of the bor- ciation. (2010). About clinical psychology. Retrieved from
http://www.div12.org/about-clinical-psychology.
ders of the United States, and our last chapter opens Division of Counseling Psychology, American Psychological Asso-
the boundaries of our specialty even wider, by iden- ciation. (2010). About counseling psychologists. Retrieved
tifying the increasing internationalism of counsel- from http://www.div17.org/students_defining.html.
ing psychology. Gustad, J. W. (1953). The definition of counseling.
All of the chapter authors share a deep commit- In R. F. Berdie (Ed.), Roles and relationships in counseling.
Minnesota Studies in Student Personnel Work, No. 3.
ment to our specialty, as well as recognized expertise Holland, J. L. (1959). A theory of vocational choice. Journal
in the areas they encompass in their chapters. We of Counseling Psychology, 6, 35–45.
acknowledge with gratitude their work in bring- Louttit, C. M. (1939). The nature of clinical psychology.
ing historical strengths, current directions, and the Psychological Bulletin, 36, 361–389.
exciting future agenda of our specialty. Parsons, F. (1909). Choosing a vocation. Boston: Houghton
Mifflin.
Rogers, C. R. (1940). The processes of therapy. Journal of
References Consulting Psychology, 4, 161–164.
Altmaier, E. M., & Claiborn, C. D. (1987). Some observations Tyler, L. E. (1953). The work of the counselor. New York:
on research and science. Journal of Counseling and Appleton-Century-Crofts.
Development, 66, 51. Tyler, L. E. (1969). The work of the counselor (3rd ed). Englewood
Bronfenbrenner, U. (1977). Toward an experimental ecology Cliffs, NJ: Prentice-Hall.
of human development. American Psychologist, 32,
513–531.
Dawis, R.V., Lofquist. L. H., & Weiss, D. L. (1968). A theory
of work adjustment: A revision. Minnesota Studies in
Vocational Rehabilitation, Vol. 23.

alt m aie r, ali 7

This page intentionally left blank
 PART
2
Foundations
This page intentionally left blank
 CHAPTER

2 Professional Issues

Judy E. Hall

Abstract
After addressing the attributes of a profession, this chapter discusses the requirements for
accountability due to the profession’s contract with society. The mechanisms of accountability for
the profession of psychology—education, training, licensure, and credentialing—are reviewed in the
context of counseling psychology. Information on the transition from an input model of education
and training to an outcome-driven model is presented. Current challenges in quality assurance are
outlined, including distance education, the movement toward competency assessment, and
international mobility.
Keywords: accreditation, designation, licensure, credentialing, competency, mobility, distance
education, internship, practicum, postdoctoral

In this chapter, the attributes of a profession, its Definition of a Profession

requirements for accountability, and its contract Psychology is a profession. There are many defini-
with society are addressed. We focus on the account- tions of a profession, but most share four compo-
ability mechanisms and their relationship to profes- nents (Pellegrino, 1991).
sional practice, and as applicable, to counseling
psychology. Of great consequence to prospective First, a profession is based on a systematic body of
psychologists are the decisions they make with knowledge, mastered through a broadly defined
regard to education, training, licensing, and creden- educational and training process. Second, a
tialing; and those are described. Organizations’ roles profession regulates its own practitioners through
in the development of the profession and today’s a code of ethics and a means of enforcing that code.
pressing issues related to distance education, com- Third, a profession is characterized by an expectation
petence, and international mobility are also of all of its members to serve the profession itself,
reviewed. through teaching and mentoring junior members
Professional attributes involve complex activities and through other activities that have as their goal
supported by the efforts of individuals, organiza- the advancement of the profession and the
tions, and legislative bodies, all of which are com- improvement of its contributions to human welfare.
mitted to ensuring quality assurance for the public. Fourth, a profession is held accountable by its
Space does not allow a comprehensive treatment of implicit contract with the public. The profession
all the forces, and the reader is encouraged to exam- agrees to use its special skills and knowledge to
ine these developments separately. promote human and societal welfare. In return for

11
 this promise, the public gives the profession some was inevitable. At this time, a large number of prac-
degree of control over the education and certification titioners were needed to serve the mental health
of its members. needs of returning World War II veterans. With
(Altmaier & Hall, 2008, p. 3) expansion of psychology’s scientific foundation,
Thus, as a profession, psychology has certain practitioners began to specialize and to define their
obligations predicated on its implicit social contract areas of specialization (e.g., vocational guidance)
with the public. These obligations often lead to pro- and their specialty (typically based on the title of
fessional issues, and thus are described in the follow- their doctoral program or training site, such as
ing section. counseling). Even today, after being prepared with
broad and general knowledge, skills, and abilities,
Professions have what has been called a “special students often begin to specialize while in their edu-
relationship” with society, the essence of which is cation and training sequence by focusing on popu-
that professions are given greater autonomy than lations, theoretical techniques, interventions or
other social groups. [They] set their own standards, locations of practice (e.g., clinics, counseling cen-
regulate entry into their own ranks, discipline their ters, schools). After licensure, professionals special-
members, and operate with fewer restraints than the ize further in the services they provide in order to
arts, trades, or business. In return, the professions are compete in the marketplace.
expected to serve the public good and enforce high Given the historical confusion and lack of agree-
standards of conduct and discipline. ment on what constitutes specialization, organized
(Skrtic, 1991, p. 87) psychology asked itself the question, “What is a spe-
Thus, a profession is accountable to society in cialty?” Even though earlier attempts had been made
maintaining its status. By carrying out the responsi- to wrestle with this problem, none was successful.
bilities noted, psychology provides assurance to the Thus, the American Psychological Association
public that it has purposely considered, developed, (APA) decided, in 1979, that a consistent set of
and disseminated the methods by which the quality policies and procedures needed to be developed to
of services is assured. Note that the words society, identify specialties. This was initiated by the Task
public, and consumer are used almost interchange- Force on Specialty Criteria (TFSC; APA, 1979),
ably, so as to be as inclusive as possible. In this chap- with the Subcommittee on Specialization (SOS;
ter, the word consumer includes the direct recipient Sales, Bricklin, & Hall, 1983, 1984a, b) completing
of services by psychologists as well as the prospective the extensive development of criteria and sample
student who is a consumer of the education, train- procedures. This effort involved articulating what
ing, and credentialing processes. psychology needed to do that was also develop-
Another example of the importance of terminol- mentally consistent with the history of specialty rec-
ogy is addressed by Ritchie (2008), when he consid- ognition in medicine, dentistry, and nursing. The
ers the evolution of the patient to client to consumer basic similarity of psychology and the other three
and the implications of these title changes. He professions is the assumption of a common core of
reminds us that the consumer of services has his or generalist skills and knowledge. Building upon this
her own responsibility to pursue quality by demand- perspective, the SOS principles and procedures
ing that standards be met through the provision of directly impacted on organized psychology’s subse-
feedback. quent efforts to define a specialty; this included
identifying the parameters of practice, delineating
Specialization the criteria for recognition/continuation of a spe-
Psychology as a profession was initiated with licen- cialty and proficiency, and separating the initial rec-
sure laws, program accreditation, and training con- ognition principles from the continued recognition
ferences. The Boulder Model, named for the principles.
location of the conference (Boulder, Colorado, The APA committees/task forces (APA Task
1949), shaped professional training by establishing Force on Scope and Criteria for Accreditation, Joint
the doctorate as the minimum educational require- Council on Professional Education in Psychology)
ment for entry into professional practice and the incorporated these criteria and concepts into their
scientist–practitioner model as the desired training policy documents. Outside of APA, the American
model (Raimy, 1950). With the knowledge that was Board of Professional Psychology (ABPP) developed
being generated, specialization (focusing on a smaller its own recognition procedures for new special-
subset than that encompassed by all of psychology) ties using the SOS principles and procedures

12 profession al is s u es
(Bent, Packard, & Goldberg, 1999). In Canada, a psychology that could be differentiated from clini-
task force appointed by the Canadian Psychological cal psychology (APA Committee on Definition,
Association (CPA) and the Council of Provincial 1956). In 1961, the Greystone Conference, the
Associations of Psychology (CPAP) built on the second training conference on the preparation of
work of SOS in its specialty deliberations (Service counseling psychologists, was held (Thompson
et al., 1989). In 1993, the APA established the & Super, 1964). Two possible directions for coun-
Joint Interim Committee on Recognition of seling psychology were proposed: one as a sub-
Specialties and Proficiencies in Psychology, which specialty of the clinical area, and the other as
drew representation from outside APA. Its succes- distinct from clinical and other areas of psychology.
sor, the Commission on Recognition of Special- The two recommendations were prescient in that
ties and Proficiencies in Professional Psychology counseling psychology, more so than any other area
(CRSPPP), proposed a set of specialty principles of psychology, is still consummately introspective,
and procedures that were approved by APA as policy comparing itself to its origins in counselor educa-
(American Psychological Association [APA], 1995). tion and vocational guidance (Thompson & Super,
That body continues to review and recommend for 1964) and its practice to clinical psychology
approval specialty and proficiency areas in profes- (Watkins, 1984).
sional psychology. (For current information, see Indeed, the debate about counseling psychology
http://www.apa.org/crsppp/rsp.html.) differing from clinical psychology remains an issue
The APA established the first accreditation pro- today for some individuals, especially as crossover
cess for clinical psychology programs in 1948 in practice occurs after graduation and distinc-
(Goodstein & Ross, 1966). To justify its position tion across programs is eroded. But, despite this
as a specialty, clinical psychology had both program continued dialogue about counseling psychology’s
accreditation standards and the recognition of definition within professional psychology, APA’s
clinical psychology practitioners by the American accreditation of counseling programs and board
Board of Examiners in Professional Psychology certification by American Board of Professional
(ABEPP). Counseling psychology was only shortly Psychology (ABPP, formerly ABEPP) justifies its
behind in its development as a specialty. The ABEPP position as a recognized specialty. Counseling psy-
awarded its first diploma in Counseling and chology, because of its having met many of the char-
Guidance in 1947. The first training conference, acteristics of a recognized specialty, was initially
held at Northwestern University, produced coun- recognized by the APA as a doctoral-level specialty,
selor education and training standards (APA Com- first through a de facto process and later through
mittee on Counselor Training, 1952). The APA a formal de jure process. (See http://www.apa.org/
accredited its first counseling program in 1950 crsppp/counseling.html for its current definition.)
(Goodstein & Ross, 1966). Much of this program- For more detail on the history of counseling psy-
matic development was stimulated by veterans chology, see Gelso and Fretz (2001).
returning from World War II who needed voca-
tional guidance. Since the numbers returning would Quality Assurance and Accountability
strain the usual resources of college counseling cen- of Programs and Individuals
ters, federal subsidies for training were made avail- Belonging to a profession includes assuming the
able to these counseling centers, thus providing responsibility to regulate that profession, both indi-
impetus for the development of counselor training vidually and as a group. The various groups in self-
programs. (The distinction between the labels coun- regulation of education, training, and credentialing
seling and counseling psychology was not an issue at include professional associations that accredit pro-
that time.) The Department of Medicine and grams (APA/CPA); licensing and credentialing
Surgery of the Veterans Administration (VA) insti- bodies that designate doctoral programs (Associa-
tuted a vocational counseling program in its hospi- tion of State and Provincial Psychology Boards
tals, so that, by 1958, the VA employed 130 [ASPPB] and the National Register of Health
doctoral-level counseling psychologists (Hall & Service Providers in Psychology [National Register]);
Sales, 2002). and organizations that designate or approve for list-
During this period of growth and definition, ing/membership internship and postdoctoral train-
a committee report from APA Division 17 encour- ing programs, such as the Association of Psychology
aged members to think of counseling psychology, Postdoctoral and Internship Centers (APPIC),
although still evolving, as a specialty within applied Canadian Council of Professional Psychology

hall 13
Table 2.1. Credentialing Organizations and Their Roles
Competence Program Evaluation Individual Evaluation
Level & Scope (Designation/Accreditation) (Credentialing)
Basic & Minimal Criteria-based designation of doctoral Certification of individual’s degree/
programs that produce professional training in professional psychology:
psychologists: ASPPB/National Register Universities/Professional Schools
Basic & Extensive Criteria-based accreditation of doctoral License to practice as a professional
programs and internships that produce psychologist:
professional psychologists: Commission on Regulatory bodies in States, Provinces &
Accreditation (CoA); Canadian Psychological Territories in United States & Canada
Association Committee on Accreditation Credentialing as a health service
Criteria-based review of internships: provider in psychology: National and
Association of Psychology Post-Doctoral & Canadian Register of Health Service
Internship Centers (APPIC); Canadian Providers in Psychology; State Recognition
Council of Professional Psychology of Health Service Provider
Programs; School Psychology APA Div 16,
Council of Directors of Programs in School
Psychology and National Association of
School Psychologists; National Register
of Health Service Providers in Psychology
Traditional Substantive Criteria-based accreditation of Board certification through
& Specialized postdoctoral programs in professional examination of advanced skill in
psychology in traditional substantive specialty areas:
& specialized areas: American Board of Professional
CoA; Criteria-based Membership of Psychology, American Board
Post Doctoral Training Programs: APPIC of Professional Neuropsychology, etc.
Certification bodies for proficiencies:
APA Practice Organization, College
of Professional Psychology

Training Programs (CCPPP), and a joint working of education and training standards for programs
group of organizations that review school psy- that voluntarily apply for professional recognition.
chology internships (APA Division 16, National Sometimes, there is a choice for the student. For
Association of School Psychologists and Council of instance, the developing professional psychologist
Directors of School Psychology Programs [CDSPP]) chooses whether to apply for admission to an accred-
(Go to http://www.ed.psu.edu/educ/espse/school- ited or a designated program and to an accredited
psychology/internship-directory for a current list.) or designated internship (and if so, approved by
These organizations and their roles are included in whom). At present, 900 doctoral programs, intern-
Table 2.1, which is updated from Drum and Hall ships, and postdoctoral programs are accredited by
(1993). Not mentioned are the state or provincial the APA Committee on Accreditation (CoA, now
mechanisms that approve doctoral programs for Commission on Accreditation) and 36 programs
their own jurisdictional purposes, such as in New are designated by the ASPPB/National Register as
York State (New York State Doctoral Evaluation doctoral programs in psychology, but are not APA
Project, 1990). accredited. The APPIC’s membership includes 700
The accreditation/designation of educational internship program and 126 postdoctoral training
programs, accreditation or approval of internships programs, including those that are accredited by
and postdoctoral residencies, and review of indi- CoA. The CCPPP has 38 Canadian internship pro-
vidual psychologists for licensing and credentia- grams as members. These decision points are illus-
ling involve multiple national bodies. The first trated in Figure 2.1 and discussed in greater detail
element of regulation relates to the establishment in the following sections.

14 profession al is s u es
 Typical Doctoral Sequence in US & Canada
From Entry into Graduate School to Graduation, Licensure,
HSPP Credentialing & Specialty Board Certification

APA/CPA National Canadian

Accredited Register Register
Internship
State, Provincial,
APA/CPA
Territorial
Accredited
Doctoral APPIC/
Program CCPPP Postdoctoral
(including Member Supervised
Practica) Internship Experience or Health
Licensure/ Specialty
Accredited Service
Applicant Certification/ Board
CDSPP Postdoctoral Provider
Registration Certification
ASPPB/NR Div. 16 Residency Credential
Designated NASP Program
Program Listed
(including Internship
Practica)
NR
Approved
Internship
Continuing
Education

Fig. 2.1 Typical doctoral sequence in the United States and Canada from entry into graduate school to graduation, licensure, Health
Service Provider in Psychology (HSPP) credentialing, and specialty board certification.

Education, Training, Licensure, Even though the USDOE does not accredit educa-
and Credentialing tional institutions and/or programs, it does publish
The first step in the education and training sequence a list of nationally recognized accrediting agencies
involves choosing a doctoral program. The potential that are considered reliable authorities as to the
student asks several questions: What are the app- quality of education or training provided by the
roved programs? How can I tell that the program is institutions of higher education and the higher edu-
approved? Will completing that program ensure cation programs they accredit. (The list can be found
that I meet the educational requirements for licen- online at http://www.ed.gov/admins/finaid/accred/
sure as a psychologist? To answer these questions, accreditation.html#Overview.)
the concepts of accreditation (institution and pro-
gram) and designation (program) are presented. approval of institutions and programs
Accreditation in the United States can be There are two types of accrediting agencies: special-
characterized as nongovernmental, voluntary, and ized and institutional. Institutional accreditation
self-regulatory. Doctoral education programs in refers to accreditation of the entire academic institu-
psychology are housed in academic institutions tion by one of the regional accrediting authorities
and professional schools. Accreditation assesses recognized by USDOE. These regional accrediting
these institutions and programs to determine their bodies are identified by licensing boards and cre-
quality and to provide for continuous improve- dentialing organizations as necessary but not suffi-
ment. Typically, the term applied to this process is cient assurers of quality. Laws and regulations for
accreditation. We also use the term designation to licensing typically refer to the program having to be
apply to the approval of programs. Thus, in the housed in an institution that is approved by one of
United States, there are accredited institutions, the regional accrediting bodies.
accredited programs, and designated programs. Thus, in choosing a program, the student should
Similarly, there are institutions and programs that first verify that the institution is regionally accred-
are not approved. ited by one of the following bodies. Such institu-
Resources for identifying accredited institu- tions are listed online under the regional association
tions and programs are provided online by the that is responsible for that geographic region of the
United States Department of Education (USDOE). United States.

hall 15
 • Middle States Association of Colleges Program in Psychology,” typically known as the
and Schools, http://www.msache.org designation criteria (http://www.nationalregister.
• New England Association of Schools org/designate.htm). Note that Criterion 1 specifies
and Colleges, http://www.neasc.org that programs that are APA/CPA accredited by defi-
• North Central Association of Colleges nition automatically meet the designation criteria.
and Schools, http://www. Programs that are not accredited must meet the
ncahigherlearningcommission.org remaining nine criteria. Graduates from ASPPB/
• Northwest Commission on Colleges and National Register designated programs typically
Universities, http://www.nwccu.org meet the educational requirements for licensing and
• Western Association of Schools and Colleges, credentialing in psychology.
http://www.wascweb.org
• Southern Association of Colleges and Unapproved Programs
Schools, http://www.sacscoc.org. The third category addresses regionally accredited
After verifying that the institution is regionally institutions with programs that are neither accred-
accredited, the potential applicant should then ited nor designated. Graduates of these programs
determine if the desired program (e.g., clinical, may not qualify for licensure. In a few states, the
counseling) is approved. Four categories describe applicants may be admitted to the licensing exami-
doctoral programs in psychology. nation on the basis of the institution’s regional
accreditation. However, these graduates will not
Accredited Programs qualify for credentialing by the National Register
The first category includes regionally accredited or ABPP. This category may include programs that
institutions with programs that are accredited by are so new that they have yet to apply for recogni-
the CoA. The CoA accredits doctoral training tion or ones that have applied and not met the
programs in the specialty areas of clinical, counsel- criteria.
ing, and school psychology; in other developed
practice areas; and a combination of two or three Unaccredited Schools
of those specialty areas. (A program may not apply The fourth category is institutions that are not
for accreditation in a developed practice area until regionally accredited, with a program that is neither
that area has been added to the scope of accredita- APA/CPA accredited nor ASPPB/National Register
tion. For more information about CoA accredita- designated. Graduates from these programs will not
tion and its purpose and process, see http://www. qualify for licensure or credentialing (except that
apa.org/ed/accreditation/accrfaq.html.) graduates of California programs established prior to
Although regional accreditation is not the term a change in California statute may be eligible for
used in Canada, all universities offering doctoral admission to the California licensure examination,
training must be similarly reviewed and approved. http://www.psychboard.ca.gov/exams/unaccredited.
The CPA accredits doctoral training programs in the shtml).
specialty areas of clinical, clinical neuropsychology, The desired outcome for graduates of doctoral
school, and counseling psychology. For more infor- education and training programs is preparation for
mation about CPA accreditation and its pur- and admission to professional practice. The current
poses and process, see http://www.cpa.ca/education/ APA Guidelines and Principles for Accreditation
accreditation. Graduates from APA and CPA accred- of Programs in Professional Psychology (G&PAPA,
ited programs typically meet the educational 2009) emphasize quality by measuring program
requirements for licensure and for credentialing in goals and outcomes, focusing on competencies
psychology in the United States and Canada. rather than curriculum, and stressing self-study
rather than external reviews. This shift in emphasis
Designated Programs
to outcomes was reflected first in the 1996 G&P
The second category includes regionally accred-
(APA, 1996).
ited institutions with programs that are designated
as psychology programs by the ASPPB/National That is, while it continued to be appropriate to
Register. The ASPPB/National Register Designa- assess the quality of an institution or program in
tion Committee reviews doctoral programs in terms of the appropriateness of its education
psychology from any specialty area to determine if resources (e.g., faculty, students, facilities, financial
they meet the “Guidelines for Defining a Doctoral support) and processes (e.g., curriculum, methods

16 profession al is s u es
 of pedagogy, faculty–student relationships) in the in psychology convened by the APA and the
context of its mission or goals, it is the final National Register brought together representatives
outcomes of an institution or program (e.g., attrition of organized psychology to establish guidelines
or graduation, demonstrated student learning, for the identification of doctoral programs in psy-
faculty productivity) that many argue are chology for credentialing purposes (Wellner, 1978).
ultimately the most accurate measures in This effort intended to present a unified front to
assessing quality. state legislatures and to courts as to the educational
(Nelson, Belar, Grus, & Zlotlow, 2008, p. 19) requirements of a psychologist.
However, lack of consistency among the many The Guidelines for Defining a Doctoral Program
programs’ outcomes and the methods by which they in Psychology were adopted as the educational stan-
are assessed raises concern for licensing and creden- dard for the National Register and the ASPPB in
tialing bodies and others within the profession 1978, were used by the National Register in its
of psychology. To counter this concern, advocates development of the Designation Project in 1980
of the revised standards point out that—in keeping (ASPPB became a partner in that project in 1986),
with the principle that such programs be broad and and as a result, had a major impact on licensing
general—there should be professional competence and credentialing standards for doctoral programs.
domains in which all students are prepared. These They were eventually included in the APA’s 1979
domains represent the knowledge, skill, and pro- accreditation standards (Nelson & Messenger,
fessional function bases of professional practice 2003). For instance, one criterion relates directly to
(e.g., scientific foundations, ethics, and assessment, counseling psychology programs: “The program,
intervention, and consultation). wherever it may be administratively housed, must
A requirement to report student achievement in be clearly identified as a psychology program. Such
terms of time to completion, tuition and fees, intern- a program must specify in pertinent institutional
ship acceptance, attrition, licensure outcomes, and catalogs and brochures its intent to educate and
job placement rates became effective January 1, 2007. train professional psychologists” (Wellner, 1978).
(See Implementing Regulation C-20 at http://www. Gelso and Fretz (2001) note that, “the more than
apa.org/ed/accreditation/implementregs200524. 100% increase in the number of APA-accredited
pdf.) Programs post outcomes on their websites and programs in counseling psychology from the early
include this information in other material made 1970s to the late 1980s was directly related to this
available to prospective students. For instance, of change. The majority of the newly approved pro-
great interest is the performance by graduates of grams were formerly counselor education or counsel-
doctoral programs on the Examination for ing and guidance programs in colleges of education”
Professional Practice in Psychology (known as the (p. 119).
EPPP) which is required for licensure in the Although program designation is different from
US and Canada. That information is now posted accreditation, both refer to a certification process
on the ASPPB web site (go to http://www.ASPPB. for programs and training facilities. Designation
org). Mayne, Norcross, and Sayette (2006) also is the process of reviewing programs, using publi-
provide program-reported measures to help pro- cally available documentation, to determine if they
spective students evaluate programs in advance of meet established and public criteria. There is no
application. site visit by peers, such as employed by the CoA.
Another distinction is that doctoral programs in
designation project any area of psychology may apply for designation
Licensure laws typically incorporate two paths to (e.g., industrial-organizational psychology), as the
meeting educational requirements: accreditation or focus is on whether the degree program meets
designation of programs. Designation was created the general criteria. Once approved, the program
in the late 1970s because of a concern about consis- is added to the online list of designated programs
tency in the educational curricula in accredited and re-reviewed by the ASPPB/National Register
programs and the fact that not all students applying Designation Committee at least every 3 years.
for licensure came from accredited programs. Rec- Although this imprimatur provides assurance to the
ognizing that psychology was behind other pro- program applicant, students who are considering
fessions in defining the core curriculum needed to enrollment in a doctoral program and intending to
meet the educational requirements for licensure, practice psychology should still contact the licens-
two national conferences on education and training ing board in the jurisdiction in which they intend

hall 17
to seek licensure to determine any unique education that the practicum can be “defined, delineated, and
and training requirements. However, typically, the formalized” (Rodolfa, Owen, & Clark, 2007).
licensing board rules require that the doctoral pro-
gram be APA/CPA accredited or ASPPB/National Internship
Register designated. (All these programs are listed at The first internship program in professional psy-
http://www.nationalregister.org/designate_stsearch. chology was accredited in 1956. Even then, the
html.) number of students seeking formal internships
was higher than the number of positions available.
Practicum As a result, students often developed their own
The Association of Psychology Training Clinics training experience “on the job,” leading to consid-
(APTC) is the APA-affiliated organization of direc- erable variability in training. To address this lack
tors of psychology training clinics. These 115 train- of standardization, in 1980, the National Register
ing clinics offer pre-internship training to clinical, Appeal Board developed specific internship criteria,
counseling, and school psychology doctoral stu- which were adapted by the APPIC, APA, and the
dents. Typically, these clinics are department- Council of Doctoral School Psychology Programs
or university-based facilities that provide behavioral/ (CDSPP) to meet their own needs. (See www.
mental health services to the community. Other nationalregister.org_internship.pdf for the current
types of training provided in doctoral programs National Register criteria.) The major difference
are the practicum that accompany specific courses between the criterion sets relates to the placement of
(e.g., assessment, intervention) Usually, 2 or 3 years the internship in the education and training
of practicum experiences are made available to stu- sequence.
dents by the program. Coming early in graduate Today’s internships are intended to provide broad
school, these are essential training experiences that and general education and training and are not clas-
provide a foundation for professional practice. sified with a specialty title, such as clinical or coun-
The doctoral student needs to have sufficient seling psychology. The APPIC, an organization
experiential training to be competitive when apply- composed of internship and postdoctoral training
ing for internship; this need has led to an increase sites that apply for membership, offers a searchable
in the number of practicum hours over the years, database containing internships in the United States
with current applicants for internship documen- and Canada. The database indicates if the internship
ting 1,800–2,000 hours (Association of Psychology is accredited by APA or CPA, and offers other infor-
Postdoctoral and Internship Centers [APPIC], mation, such as the specialization training areas
2008). The current APA G&P state the following: offered (populations, treatment modalities, and spe-
the applicant must “have completed adequate and cialty areas, such as neuropsychological assessment
appropriate supervised practicum training, which and intervention, primary care, substance abuse,
must include face-to-face delivery of professional and geropsychology). APPIC members can indicate
psychological services.” As this criterion no longer the preference given applicants by specialty area of
specifies a minimum number of hours needed for degree. For instance, of the 700 internships listed
admission to the internship, students often ask how online as of April 14, 2011, 634 would consider
much is enough. The numbers vary, depending counseling psychologists for internship placement.
upon the source: academic director versus training The current standard for the length of training (e.g.,
director. The percent of time spent in direct service APA, APPIC, National Register) is that the intern-
adds another variable when interpreting practicum ship must consist of 1 year of full-time training
hours and may place students in a quandary as to completed in no less than 12 months (for school
what makes them more competitive for internship psychology internships, 10 months) and in no more
placement. However, adding on hours is not the than 24 months.
solution. In fact, experience is only one of the three The APPIC developed the uniform application
factors that help a student secure an acceptable for internships (this application went online in
internship (letters of recommendation and the 2009) and then, in 1999, initiated the matching
internship application are the other two). None- process for internship placement, followed in 2011
theless, practicum remains a basic requirement that by a second match for those positions not filled in
can be fulfilled in a number of ways. With the poten- the initial match. Yearly match statistics are provided
tial changes at the state level in education and train- to the relevant constituencies, with the most recent
ing requirements leading to licensure, it is hoped results showing 79% of students matched in 2011

18 profession al is s u es
(without reference to degree, specialty area of degree, credentialing organizations have developed their
or location of doctoral program) out of a total of own approval criteria with little commonality other
3,899 students. There were 3166 available positions than length. Of concern is whether the experience is
in 2011. Even though new internship positions are supervised by qualified licensed psychologists (for
created each year, insufficient internship training instance, those not qualified would be psychologists
positions are available to meet the need. Thus, stu- in a dual relationship, master’s degree psychologists,
dents are experiencing difficulty in obtaining an and psychologists with degrees from unaccredited/
internship. For several years now, a portion of stu- unapproved program). With increasing difficulty in
dents have not matched to an internship on the first achieving an experience that is acceptable from one
attempt, now they either move to the second APPIC jurisdiction to another, standardization of the post-
match or to the Association of Counseling Center doctoral experience requirement was needed.
Training Agencies (ACCTA) clearinghouse for Concern about postdoctoral experience led to
placement (internship sites that have available posi- the second conference on postdoctoral training, in
tions after the match date). The ACCTA is an orga- 1992, the National Conference on Postdoctoral
nization composed of 150 internships located in Fellowship Training in Applied Psychology. This
college and university counseling centers, the largest APPIC-sponsored conference, supported by multi-
single category for internships. (See https://www. ple organizations, resulted in draft standards that
accta.net/default.asp for more information.) became the instigating force for organized psychol-
For counseling psychology students, a comparable ogy to work together in solving the quality assurance
decline in matching rates from 90% (1995–2005) to aspects of the postdoctoral year (Belar, Bieliauskas,
78% (2007) was reported on a survey of the mem- Klepac, Stigall, & Zimet, 1993). The first step was
bers of the Council of Counseling Psychology the formation of the Inter-Organizational Council
Programs (CCPTP). Using predictions from training for Accreditation of Postdoctoral Programs in Psy-
directors on which students would not have matched, chology (IOC), consisting of representatives from
Miville, Adams, and Juntunen (2007) believe that a United States and Canadian organizations con-
90% placement rate is achievable for APA-accredited cerned with accreditation, credentialing, and licens-
counseling psychology programs. Counseling psy- ing, along with the training council representative
chology programs typically admit seven or eight stu- from each specialty. The purpose was to develop
dents a year and account for only 10% of the consensual standards and procedures for a postdoc-
internship applications submitted yearly. toral accreditation process. Five years later, the APA
Although many argue that the best resolution to adopted as policy the postdoctoral accreditation
the supply-and-demand problem is admitting fewer standards (APA, 1996), and it accredited the first
students, a program failing to place a reasonable two postdoctoral residency training programs in
number of students in internships on a consistent 1997.
basis might constitute “an operational definition of Today, postdoctoral residencies may be accredited
taking too many students” (Stricker, 2008, p. 207). as programs preparing individuals for practice at an
With increasing attention paid to outcomes, doctoral advanced level in the traditional practice areas of
programs are taking more responsibility in helping clinical, counseling, or school psychology (there are
students locate an internship or are creating captive currently 30). Other types of postdoctoral residen-
internships designed for their students. Nonetheless, cies may be accredited in specialty practice areas (cur-
students must be careful about developing their own rently 30). Specialty areas that have met the guidelines
experiences, as internships developed outside the to be included within the scope of accreditation are
scrutiny of an objective, criterion-based organization clinical child psychology, clinical health psychology,
may not be acceptable for licensing or credentialing. clinical neuropsychology, family psychology, forensic
(For a more detailed consideration of the many ques- psychology, and rehabilitation psychology.
tions in applying for the internship, interested read- Finding postdoctoral sites for employment
ers should consult the handbook developed by or residency training is also a challenge for gradu-
Williams-Nickelson, Prinstein, and Keilin, 2008). ates. Although electronic mailing lists disseminate
information on available positions, there is no
Postdoctoral Year matching service such as is provided for internships
The second year of supervised experience typically (APPIC, 2008). The APPIC lists in their online
required for licensure and credentialing is a year directory 126 postdoctoral programs, 60 of those
of postdoctoral experience. Licensing boards and are APA-accredited residency programs. However,

hall 19
the number of psychologists potentially trained in Global universities represent a growth industry,
a year is even smaller than that in internship train- so major universities based in the United States are
ing, as the number of training positions at each site quickly establishing undergraduate and graduate
is usually two. A year (or more) of postdoctoral programs abroad. As a matter of policy, neither the
experience is required by the majority of state licens- APA nor the CPA accredits programs located
ing bodies, so graduates face a difficult time locat- outside their own country. However, the ASPPB/
ing an acceptable, adequately funded postdoctoral National Register Designation Project modified the
experience. designation criteria several years ago to permit for-
Licensure requirements for the postdoctoral year eign program review. These programs will be held to
of experience also vary, so the graduate is advised to the same criteria as programs in the United States
determine the specific geographic regulations in and Canada; however, the institution where the
advance of signing an employment contract. Then, program is located must be “accredited by a body
the specific responsibilities of the site can be included that is deemed by ASPPB/National Register Des-
in the negotiations so as to qualify the experience for ignation Committee to be performing a function
licensure purposes. Many settings will accommodate equivalent to U.S. regional accrediting bodies.” It is
a professional’s need to acquire experience for licen- likely that approved psychology programs in the
sure purposes, in the hopes of retaining the psychol- United States may decide to offer doctoral educa-
ogist after licensure, as this more likely will ensure tion in psychology in foreign countries and will
continuity in service provision to the client popula- want those programs approved in the United States.
tion. This is especially true of geographic, demo- If those programs apply for and meet the designa-
graphic, or institutional locations that are classified tion criteria, the key issue will be whether the state
as underserved (health professional shortage area and provincial regulatory bodies will find the gradu-
[HPSA]; see http://hpsafind.hrsa.gov). In general, ates acceptable on educational grounds.
however, both formal postdoctoral residency train-
ing programs and less organized experience, such as Licensing and Credentialing
supervised employment, meet licensure standards Licensing authorities determine that a psychologist
and credentialing requirements for a health service meets state, provincial, or territorial requirements
provider in psychology. for entry-level, generic practice. Professional licens-
Building upon the IOC’s success in bringing ing has very little to do with the assurance of qual-
together a postdoctoral accreditation system for pro- ity. Although most people assume it does, or wish it
fessional psychology, the training councils in profes- did, knowing that a provider is licensed assures one
sional psychology adopted a similar model when only that the state, province, or territory has deter-
they formed the Council of Chairs of Training mined him or her to possess a minimum level of
Councils (CCTC), consisting of training councils competence. This level of competence is defined
as members and liaisons from licensing and creden- as having completed a sequence of education, train-
tialing bodies. The credentialing organizations in ing, and experience, followed by successful perfor-
professional psychology did the same when they mance on an independent examination of knowledge
created the Council of Credentialing Organizations and skills.
in Professional Psychology (CCOPP). The CCOPP’s Credentialing and certification are terms that are
membership consists of the credentialing organi- often used interchangeably and usually refer to indi-
zations (including licensure) in the United States, vidual achievement. For instance, the university or
Canada, and now Mexico, with liaisons from the professional school certifies to the public that the
education and training community and graduate graduate has met the requirements for the degree
students. These organizations were initiated in the by awarding the diploma. Certification typically
1990s. Like the CoA, which is also interorganiza- indicates quality, “especially in the absence of
tional, the member organizations select the repre- knowledge to the contrary” (Drum & Hall, 1993,
sentatives for these important and sometimes p. 151). Credentials for health care professionals are
policy-recommending bodies. With the many orga- important because “in no other field does a con-
nizations in professional psychology concerned with sumer care so much about the quality of services
quality assurance and accountability, and in an era and yet have so little ability to judge quality them-
of diminishing resources, interorganizational work- selves. . . . Credentials serve as necessary proxies for
ing groups make the most sense in terms of ensuring direct measurement of quality” (Stromberg,1991,
essential and relevant representation. p. 1). Even though credentials signal distinction for

20 profession al is s u es
a professional, both in terms of services offered functions. If a professional performs those
as well as in education, training, licensure, and functions (such as diagnosing or treating behavioral,
advanced competency, compared to physicians, only emotional, or mental disorders) regardless under
a small percentage of psychologists pursue creden- what name (such as therapist, psychologist, or
tials beyond licensure. Credentialing organizations counselor), he is required to be licensed. In contrast,
then assess varying levels of specialized education certification focuses not on the function performed
and training, as well as specific competencies or but on the use of a particular professional title
areas of expertise, to determine if the licensee has (such as psychologist), and it limits its use to
met national standards, which are often more strin- individuals who have met specified standards for
gent than licensure requirements. education, experience and examination performance.
Credentialing organizations have no requirement (pp. 1–2)
to protect the public, yet they play a significant role
Not all jurisdictions have licensure laws. Many
in this special relationship with consumers. Typically,
have certification laws, including those labeled as
credentialing organizations conduct primary source
permissive acts, requiring the person to be licensed
verification of credentials (education, training, and
if he or she practices psychology and uses the title.
licensure). Thus, they provide an independent check
In this volume, the term license refers to either type
on the accuracy and currency of these qualifications.
of regulation.
Licensing authorities investigate and adjudicate pro-
fessional misconduct complaints, and then report General Licensing Criteria
the information to professional organizations and At present, the various admission requirements for
credentialing bodies and the federal disciplinary licensure as a psychologist in the United States are
health care databanks. Credentialing bodies may similar: a doctoral degree in psychology from an
review and take action on disciplinary information approved program housed in a regionally accredita-
and disseminate their actions to the public. Creden- tion institution of higher learning, and 2 years of
tialing organizations require psychologists to report properly supervised experience, 1 of which may be
disciplinary actions as part of an annual attestation. an internship and the other a year of postdoctoral
This process holds the psychologists accountable for experience. These requirements are evaluated by
professional misconduct. Noting this symbiotic rela- each jurisdiction somewhat differently in terms of
tionship between licensure and credentialing in terms implementing criteria (e.g., supervisor’s qualifica-
of protecting consumers, Hall (2000) stated that tions, number of hours on internship), so it is advis-
“neither licensing nor certification alone is suffi- able to complete an APA/CPA-accredited or ASPPB/
cient . . . [Rather,] both are needed” (pp. 317–318). National Register-designated doctoral program; to
complete an APA/CPA-accredited internship, if pos-
Licensure Laws sible; and if not, to seek an internship with an orga-
Licensing laws, established to define the practice nization that is a member of the APPIC or is
of the profession, set educational, training, and developed so that it meets the APPIC, CDSPP, or
examination standards for the profession and assist National Register criteria for internship. In general,
the consumer in identifying who is qualified to it is advisable for any student to acquire the maxi-
practice the profession. Although this is different mum number of hours on internship and in the
from saying that the license assesses quality, the postdoctoral year (2,000 hours) and to ascertain in
jurisdiction does offer a recourse for complaints advance what is required by the state of intended
against practitioners regarding professional con- residency (Hall, Wexelbaum, & Boucher, 2007).
duct. Presently, 64 jurisdictions in the United States
Generic Licensing
and Canada regulate the practice of psychology or
Following the tradition of other health care profes-
the title of psychologist. Both types of laws attempt
sions, such as medicine, generic licensing has been
to protect the public by clearly identifying who is
the model adopted by legislative bodies in seeking
qualified to practice as a psychologist (practice
to regulate the practice of psychology (Stigall, 1983).
including title act) or identify him- or herself as a
This approach assumes that a common body of
psychologist (title only act).
knowledge, skills, and ability should be mastered
Stromberg et al. (1988) explained the difference:
prior to entry into the profession, regardless of any
Licensure is a process by which individuals are specialty area. Using the word generic in reference
granted permission to perform a defined set of to the license to practice also stems from the fact

hall 21
that any psychologist is eligible to apply for licen- A Health Service Provider in Psychology is defined as:
sure. It does not mean that a licensed psychologist
[A] psychologist currently and actively licensed/
is qualified to practice in any area, as ethics and pro-
certified/registered at the independent level in
fessional conduct rules restrict practice to within
a jurisdiction, who is trained and experienced in the
specific areas of expertise. Continuing professional
delivery of direct, preventive, assessment and
education (CPE) is required by most jurisdictions as
therapeutic intervention services to individuals whose
a way of ensuring that psychologists remain current
growth, adjustment, or functioning is impaired or to
with scientific knowledge and applied skills. Crit-
individuals who otherwise seek services.
icized by many professionals as unrelated to con-
(National Register of Health Service Providers in Psychology,
tinuing competence, CPE has face validity from the 2011)
public perspective and can be a valuable tool for the
expansion of practice areas after graduation. On September 1, 1974, a joint letter from APA
Most graduates of professional psychology pro- President Bandura and National Register Chairman
grams become licensed as psychologists. The current Zimet was sent to 40,000 psychologists soliciting
number of licensed psychologists at the doctoral applications for credentialing by the National
level is approximately 92,000 (Andrew Boucher, per- Register. More than 11,000 licensed psychologists
sonal communication, July 11, 2008); the exact applied and met the criteria during the grandparent
number is unknown because some psychologists hold period, which ended January 1, 1978.
more than one license, and some states do not list Note that this more inclusive definition of psy-
a degree or differentiate between a master’s-level and chological practice did not refer to a specialty title.
a doctoral-level psychologist. Licensing criteria are set However, credentialing by the National Register
by each jurisdiction, but have been influenced over provided more protection to the consumer seeking
time by a series of APA guidelines for state legislation psychological services than did a generic license.
(1955, 1967, 1987 and 2010) and by the ASPPB After the National Register’s success, several state
model for state legislation (1992, 2001 and 2010). licensure boards decided to adopt the criteria for
their own provider certification, first in 1978 in
Health Service Provider in Psychology Texas, and soon after in eight more states (Indiana,
The National Register was established in 1974 to Iowa, Kentucky, Oklahoma, Missouri, Massachu-
meet the need for a system by which various insur- setts, North Carolina, and Tennessee). The National
ers, governmental agencies, health services, and Register also formed the basis for the later develop-
other organizations, as well as individual consum- ment of the Canadian Register in 1985. Today,
ers, could identify licensed psychologists who have approximately 11,000 psychologists are creden-
specific education, training, and supervised experi- tialed by the National Register as health service
ence in health services. Given that licensure was providers in psychology, with 1800 credentialed by
generic, a mechanism was needed that went beyond the Canadian Register (see Wise, Hall, Ritchie &
licensure to identify qualified providers of psycho- Turner, 2006, for a discussion of both registers).
logical services, especially given the wide variation
in states’ requirements. Although licensing was nec-
Clinical Versus Professional Psychologist
The necessity to be inclusive within the area of
essary, it alone was not sufficient to identify a quali-
health care is highlighted by the original federal leg-
fied health care provider.
islation for Medicare reimbursement. Rather than
Both the ABPP and the APA played a role in the
choosing the term professional psychologist, which
establishment of a credential that did provide the
would have avoided many of the definitional prob-
sufficient information. The APA Board of Profes-
lems that ensued, clinical psychologist was selected
sional Affairs formally voted on October 1, 1973, to
and predictably defined as someone who graduated
recommend that the APA request the ABPP to
from a clinical psychology program. (The intended
establish a National Register of Health Service
reference was to psychologists providing health
Providers in Psychology; on March 1, 1974, the
care.) Although this narrower legal definition would
ABPP Board of Trustees voted to implement the
have applied to the majority of graduates of profes-
project. On June 1, 1974, the initial meeting of
sional psychology programs, it would have elimi-
the 12-member Council for the National Register
nated many qualified health service psychologists
of Health Service Providers in Psychology was held,
from providing needed services to Medicare patients,
the Health Service Provider in Psychology was defined,
such as counseling psychologists. The word clinical
and the criteria for credentialing were established.

22 profession al is s u es
in other fields is an adjective that distinguishes pro- improvement in functioning. Psychologists who
vision of services from other roles in education and complete approved counseling psychology doctoral
research, such as clinical medicine and clinical social programs, as well as an internships and postdoctoral
work. This “small c clinical” problem became a experience in health service, are eligible for creden-
major problem in terms of reimbursement for those tialing as health service providers immediately upon
other qualified psychologists. Many years later, and licensure.
in response to public comments, the Center for
Medicare and Medicaid Services defined clinical Credentialing
psychologists as persons who hold doctoral degrees In deciding whether to pursue credentialing, it is
in psychology and are state licensed at the indepen- important to separate credible credentials from those
dent practice level of psychology to furnish diagnos- that are not, determine eligibility for credentialing,
tic, assessment, preventive, and therapeutic services and evaluate the benefits offered by the credential-
(Health Care Financing Administration, 2000). ing organization. For a full discussion of these issues,
From the perspective of serving the public’s see Hall and Boucher (2008). The large number of
health care needs, psychologists are essential team credentials available to professional psychologists
members in integrated health care. Psychologists necessitates careful evaluation by the consumer. For
serve as behavioral experts, reducing overall medical example, this author includes a list of 52 different
costs, enabling consumers to adhere to medical regi- acronyms for specialty and proficiency credentialing
mens, helping physicians make medical decisions organizations in her presentations to doctoral psy-
on the appropriate medication, and choosing the chology students.
best behavioral practices for treatment of mental From the public perspective, as Stromberg
health and addictions. Excellent tools are available (1991) noted, “credentialing performs a valuable
to guide the psychologist’s choice of the best evi- role by reducing search costs for consumers or payers
dence-based practices (Norcross, Hogan, & Koocher, who seek information about the qualifications of
2008). In addition, psychologists are essential to the a large universe of providers.” Credentialing orga-
education, training, and practice of physicians and nizations provide a public service by “efficiently
other health care professionals. Although many disseminating information to the marketplace with
organized practice settings, such as the United States respect to the training and expertise of health care
Department of Veterans Affairs, incorporate an inte- providers” (MacHovec v. Council, 1985). According
grated health care model, it is not restricted to insti- to Stromberg (1990), “certification is a process by
tutional practice; it is however, central to the practice which government or a private association assesses
of primary care physicians and other group practices a person, facility, or program and states publicly
seeking to serve patients with a comprehensive that it meets specific standards” (p. 1). These stan-
approach to health care. dards are considered to be significant measures.
The concept of a health care/health service pro- Accreditation and designation are approval mecha-
vider exists throughout health care and is not spe- nisms that refer to the certification of programs,
cific to psychology. However, when the National whereas credentialing applies to certification of
Register was initiated in 1974, it was a new concept individuals.
for psychology, partly because of its prior focus on The CCOPP, the organization for credentialing
serving the mental health needs of the public. Since organizations, recently completed a comprehensive
then, this definition has been adopted by other pro- sequential analysis of the roles played by the various
fessional organizations and state licensing boards. credentialing organizations in specialization. The
The APA has included health in its mission state- conceptual document provides another frame of
ment. The broad definition of a health service pro- reference for understanding specialization. (See http://
vider in psychology was developed especially to www.nationalregister.org/CCOPP.pdf for more
address psychology’s uniqueness as both a profession information.)
and a science; this definition does not describe a Once licensed, a psychologist is typically eligible
specialty area, but offers a definition of desired ser- for credentialing as a health service provider in psy-
vices tied to a doctoral degree in psychology and chology in the United States and Canada, followed
training (internship and postdoctoral year) in health by specialty board certification in the United States
service. It helped define psychology as essential to the (few Canadian psychologists seek specialty board
health care system, and in understanding and evalu- certification). Although there are many such certifi-
ating the body–mind interrelationship as crucial to cation bodies, only one specifically for counseling

hall 23
psychologists is offered by the ABPP. As of Febru- education or online universities, the current status
ary 17, 2011, there were 166 psychologists with of the definition and assessment of competencies,
ABPP specialty certification in counseling psychol- and barriers to international mobility. These issues
ogy. Also, of the existent board certification bodies are central to issues of accountability and quality
in psychology, only the ABPP is included in a assurance today.
number of state regulations to offer some degree
of mobility to its 2948 psychologists (Nancy Distance Learning and Online Education
McDonald, personal communication, February 17, Distance education is a thriving industry, with many
2011). companies publicly traded. Investors have seen their
The ASPPB offers the certificate of professional stocks increase in value and pay dividends. Histor-
qualification (CPQ) to psychologists with five years ically, higher education was not for profit. That has
of licensure experience. As of 3/11/11 the CPQ is changed. Other changes relate to the significant and
held by 2608 licensed psychologists. It was created pervasive use of technology in education. According
in 1998 to enhance mobility for licensed psycholo- to a survey conducted in 2000–2001, college-level,
gists. During its grandparenting period (until 2001), credit-granting distance education courses are offered
licensed psychologists credentialed by the National at the graduate level by 22% of all institu-
Register or ABPP qualified for an expedited review. tions. Furthermore, college-level, credit-granting dis-
tance education courses are offered at the graduate/
Ethical and Professional Conduct first-professional level by 52% of institutions that
As a doctoral student moves through the sequence, have graduate/first-professional programs (USDOE
there are repeated opportunities in which issues of National Center for Education Statistics, 2003).
being responsible for adhering to scientific and pro- The defining characteristic of distance programs
fessional ethics arise (e.g., research, practica, intern- is that students and faculty are geographically dis-
ship). Then, as that individual becomes licensed persed. Because online courses are the most common
and subsequently credentialed, additional ethical form of distance education, there is a tendency
guidelines and professional conduct codes pertain to assume that distance programs are exclusively
(for instance, annual attestation of any ethical com- provided over the Internet. However, the modalities
plaints/adjudications). At the time of licensure, the inherent in distance education are many, including
applicant is typically required to be examined about methods involved in campus-based education.
the laws and regulations that apply to practice in Distance learning appeals to those with under-
that jurisdiction. Licensed professionals are expected graduate or master’s degrees without easy access to
to adhere to these ethical and professional conduct traditional residency-based professional schools or
codes by virtue of membership in those associations university programs and who are unable to move
and for renewal of state and national credentials. or wish to remain in their geographic location. The
The APA (2002) and the CPA (2000) each has typical consumer is the adult learner. However, this
its own code of ethics and an ethics committee group may include students who are either not
that educates members and adjudicates complaints. admitted to or cannot afford tuition in doctoral
If a professional is licensed in two professions (psy- residency-based programs. Murphy, Levant, Hall,
chology and counseling), the provisions of both and Glueckauf (2007) report the results of an APA
ethics code apply (and may conflict). Ethics and Task Force that examined these issues in 2001,
professional conduct is a cornerstone in account- described educators’ opinions on best practices, and
ability, and the active monitoring of these responsi- reviewed the implications of the 1996 CoA accredi-
bilities is itself a responsibility of the profession. tation standards for distance education programs.
Ritchie (2008) addresses this accountability in an For those seeking to become professional psy-
excellent chapter while referencing international chologists, these programs carry considerable risk,
developments in ethics codes. A comprehensive dis- as few are approved by licensing bodies for admis-
cussion on this topic is also available in this volume sion to the profession. Such a program faces chal-
(Vasquez & Bingham, 2011, Chapter 10, this lenges in ensuring that the scientific foundation in
volume). psychology is acquired in an organized sequence
that is developmentally complex, that the faculty
Challenges to Accountability and students interact effectively with each other,
Professional educators and practitioners frequently and that outcomes are measured adequately—all at
debate the merits of programs housed in distance a doctoral level. Integration of the training aspects

24 profession al is s u es
of education, such as practicum or the laboratory, Previously, the psychologist was considered ready
presents an even greater task within this type of for independent practice upon completion of a
model. sequence of education and training that included
These programs attempt to match (or some doctoral program, practicum, internship, and post-
would argue exceed) the quality assurance and doctoral year of experience. That sequence was
accountability dimensions inherent in more tradi- articulated through various model acts from the
tional doctoral programs. A cornerstone of campus- APA and ASPPB but questioned by various training
based programs is a mandated residency period. conferences and in other organized meetings. For
Historically, residency was the mechanism that pro- instance, could the internship take place after the
vided for immersion in the discipline, socialization doctoral degree? Or, was the psychologist ready for
into the profession, and oversight by a faculty of independent practice once the doctoral degree was
the developing competencies essential for entry to granted?
independent practice (Nelson et al., 2008). Imple- With the movement toward competency assess-
menting residency in a professional program that is ment and foundations on which competencies were
totally online constitutes an even greater challenge. essential, it was decided to examine carefully the
(Jones International University, a totally online uni- steps in the sequence to determine if one did lead to
versity, is now regionally accredited by the North the other in terms of the acquisition of essential
Central Association.) competencies. Multiple factors impacted on these
In 2011, two CoA-accredited programs employ various developments.
distance education techniques as a major facet of Since the original model licensure act (APA,
doctoral education. The Philadelphia College of 1955), many changes in doctoral education and
Osteopathic Medicine uses both traditional meth- training occurred, related to the location of doctoral
ods of education and training at a central site and education, the number of students admitted per
at an extension campus where students meet in tra- year, the extent of the practicum, the diversity of
ditional classroom formats and interact through internship experiences, and the increasing adoption
teleconferencing. The Fielding Graduate University of the postdoctoral year as a standard for licensing
exemplifies a distributed educational model orga- laws and the variability in licensure rules. The latter
nized into clusters of students at various sites that led to difficulty in mobility.
also uses electronically mediated instruction. No Following the creation of the American Psycho-
primarily distance education programs have met the logical Association Graduate Students (APAGS) in
requirements for the ASPPB/National Register des- 1988, students actively represented their perspective
ignation, although several programs have been eval- throughout organized psychology. Psychology’s
uated. status in the health care marketplace, length of
The role of distance education programs for psy- training in comparison to other health care profes-
chology is unique among health care professions in sions, problems finding effective and supported
which the doctorate is the entry level for profes- internship and postdoctoral training, and the tre-
sional practice. Medicine and dentistry use distance mendous debt load assumed by some students were
education programs primarily for upgrading degrees identified as critical issues for the profession and
and certifications beyond the entry level. This sepa- a burden for those entering the profession. Thus, in
rates out the important issue of qualification for 2000, the APA invited 30 commissioners selected
independent practice from continuing professional from a wide range of constituencies to a meeting
education. which recommended changes to the sequence of
education and training leading to licensure (APA,
Competency Assessment 2001).
At the same time that the USDOE underscored a This potential policy change meant that it was
need to improve the quality assurance process very important to define the competencies of
involved in higher education, the CoA began to licensed psychologists and to determine when in
require programs to specify expected, essential com- the sequence those were attained. It also shifted the
petencies and to report information on student proof of competence from the postdoctoral year to
learning outcomes. As outcomes vary as a function internship completion. Several organizations urged
of the model adopted by the program, what was caution in implementing this recommendation
needed was agreement on the core competencies without collecting more information. Thus, an agree-
for psychologists entering independent practice. ment was reached to obtain the needed information

hall 25
and to consider the policy change for official process for further revisions was so open, APPIC
approval 5 years later. did not see a need to establish a separate process
Multiple efforts followed. The APPIC sponsored devoted exclusively to internship or postdoctoral
the Competencies Conference in 2002 (Kaslow, benchmarks.
2004; Kaslow et al., 2004). At about the same time, (Stephen R. McCutcheon, personal communication, June
Hatcher and Lassiter’s practicum competencies doc- 30, 2008)
ument was drafted as a follow-up to the 2001 APA The document is still evolving based upon public
Education Leadership Conference and approved in comment and continued refinement by various task
2005 by the relevant constituencies (go to http:// forces. Interested parties can follow further develop-
www.APTC.org). The APPIC urged the APA to ments by visiting the CCTC website periodically to
carefully examine the impact of not requiring a year look for updates (http://www.psychtrainingcouncils.
of postdoctoral experience for licensure by conven- org/documents.html).
ing another conference to develop the benchmarks Thus, psychology appears to be in transi-
for competencies at all levels of education and train- tion, from an input to an output model of quality
ing. If the levels could be integrated and coordinated, assurance. Although unlikely to ever relinquish the
and changes to the practicum and the internship former completely (degrees remain necessary), con-
made, it was more likely that the proposed change of siderable time and expertise have been applied
not requiring the postdoctoral year for a license toward the latter, with more to come.
would succeed.
Thus, in 2006, the APA Council of Representa- practicum competence
tives approved a change in APA policy, namely that The Practicum Competency Outline approved in
licensure applicants be allowed to complete a sequen- 2005 describes the baseline competencies needed to
tial, organized, supervised professional experience enter practicum training and the 11 competency
equivalent to 2 years of full-time training prior or domains that are the focus of that training. Using
subsequent to the granting of the doctoral degree. that outline, psychology training clinics can develop
The policy clarified that, for applicants intending to their own competency-based student evaluations
practice in the health services domain of psychology, (rated as novice, intermediate, or advanced) of the
one of those 2 years of supervised professional expe- essential practicum competencies. In addition, this
rience was the doctoral internship (APA, 2006). This methodology can be used to collect objective data
decision implied that state regulatory bodies should about specific training sites, thereby providing
be encouraged to offer applicants a choice of com- a frame of reference for prospective students, and
pleting required supervised hours either before or a method for relating the practicum and doctoral
after the internship, or some combination of both. program’s goals. Updates to the outline will be
This policy did not dismiss the year of postdoctoral posted online (http://www.aptc.org).
experience and reminded us that “postdoctoral edu-
cation and training remains an important part of
internship competence
the continuing professional development and cre-
Currently, licensing bodies and credentialing orga-
dentialing process for professional psychologists.
nizations view the internship, and in most states,
Postdoctoral education and training is a foundation
the postdoctoral year of supervised experience, as
for practice improvement, advanced competence,
necessary supplements to the doctoral education in
and inter-jurisdictional mobility” (APA, 2006).
determining readiness for practice. The internship’s
Instead of holding a conference, as the APPIC
purpose is to provide developing psychologists
recommended in 2007, the APA Board of Educa-
with the opportunity to master more skills. Some
tional Affairs decided to fund a benchmarks work-
skills are introduced in practicum; others may be
group to build upon what had already been
reserved for the internship. The identification and
completed by the APTC for practicum. A group of
assessment of specific competencies is handled by
32 psychologists participated in the Assessment of
each internship site, using multiple methods, such
Competencies Benchmarks Work Group and devel-
as observation of clinical work, apprenticeship to
oped a model for defining and measuring compe-
individual mentors, presentations to clinical semi-
tence in professional psychology (APA, 2007).
nars, and various evaluation tools including self
Because the group was so inclusive, because the assessment. The internship provides a much more
rough draft was of high quality, and because the extensive period (1 year full-time or 2 years half-time)

26 profession al is s u es
for the refinement of competencies than does practi- no document parallel to the practicum compe-
cum. At the conclusion of the internship, the direc- tencies outline exists for internships or for tradi-
tor certifies to the licensing/credentialing body the tional substantive postdoctoral training, given
completion of a satisfactory internship experience. the continuing dialogue by organized psychology
Although programs (doctoral degree and intern- in determining how to assess competencies across
ship) engage in formative evaluations (process) and the development of the professional, it should
summative evaluations (outcomes) throughout the emerge.
education and training sequence, there is no inde- Prior to this change in policy, Alabama was
pendent performance examination as part of the the only state that allowed independent practice
psychologist licensing process that directly assesses at the doctoral level without requiring a year of
competence in practice. Also, if no postdoctoral year postdoctoral experience. Today 11 states offer licen-
is required for a license, the graduate is deemed qual- sure at the culmination of the doctoral degree, based
ified for licensure at the successful completion of the upon documentation of sufficient supervised expe-
internship. The policy change regarding the sequence rience, including an internship, while in doc-
of education and training leading to licensure has toral training. These include Alabama, Arizona,
heightened the awareness of internship directors that Connecticut, Indiana, Maryland, Ohio, Kentucky,
they are more directly responsible for ascertaining North Dakota, Utah, Washington and Wyoming.
readiness for independent practice. It remains unclear For instance, Washington was the first to imple-
whether this realization means that the training ment regulations allowing the 2 years to be com-
directors will become more vigilant about signing off pleted before graduation, with 1 of the years being
on the internship as satisfactory only when they have practicum (or postdoctoral year) and the other an
determined that the person is indeed competent. internship. The supervision topics required for the
practicum are extensive and may be more complex
and difficult to implement than typical for practi-
postdoctoral competence
cum. A careful reading of those criteria is essential if
The third component in the sequence is the year of
planning to use those practicum hours toward licen-
postdoctoral supervised experience or postdoctoral
sure. It is entirely possible that the applicant will
residency training. The CoA guidelines for accredi-
find the postdoctoral year of supervised experience
tation of postdoctoral education and training pro-
more easily satisfied. Completing the postdoctoral
grams are parallel to those adopted for programs
year has the added benefit of meeting the require-
and internships. A judgment is made on the degree
ments for mobility. Regardless of whether it remains
to which the program achieves the goals and objec-
linked to the licensure requirements, the postdoctoral
tives specified in its training model. It should be “of
experience (before or after licensure) is important for
sufficient breadth to ensure advanced competence
advanced specialization/competency, licensure mobil-
as a professional psychologist and of sufficient depth
ity, and continuing professional development. For
and focus to ensure technical expertise and profi-
instance, credentialing mechanisms such as the CPQ
ciency in the substantive traditional or specialty
and the National Register require a year of postdoc-
practice areas” (APA, 2009, p. 22). The length of the
toral experience (Hall & Boucher, 2003).
program may vary from 1 year up to 3 for some
specialty areas.
The traditional substantive areas include counsel- International Mobility
ing psychology. The specialty practice areas include We have focused on the United States, and to some
clinical neuropsychology, clinical child, and reha- degree, Canada, in discussing the professional issues
bilitation psychology. To accomplish the accredi- involved in education, training, licensing, and cre-
tation of specialty postdoctoral residencies, the dentialing. However, psychologists increasingly seek
organizations that represent the specialty each devel- employment or training opportunities abroad. For
oped their specialty-specific education and training that to happen, at least for licensed psychologists,
guidelines. These organizations serve on the Council it is important to understand other countries’ per-
on Specialties (CoS). The CoS was formed upon the spectives on the preparation of psychologists. There
recommendation of the IOC, when it ceased opera- are positive signs that indicate that psychology may
tion, as essential to ensuring quality and self-gover- be ready to meet the needs of a global population.
nance in postdoctoral training. (See http://www. First, the numbers of psychologists and psychology
cospp.org for more information.) Thus, although students are increasing worldwide, and the definition

hall 27
of a psychologist is becoming articulated interna- Psychologists in training today in the United
tionally. At the same time, psychologists are forming States increasingly seek the opportunity to obtain
organizations within and across borders to promote part of their education and training outside the
globalization of practice. Advances in technology United States and Canada. These individuals want
make it more likely that expertise can be widely dis- to be able to qualify for licensure in the United
seminated and services provided across borders. States when they return. Because of the variability
Countries and geographical regions have devel- in models of education, training, and recognition/
oped their own systems of accountability. As psy- licensure outside the United States and Canada, this
chology operates within a societal context, its can be risky to achieve. Currently, there is no guar-
manifestation varies considerably from country to antee that state licensure boards will accept super-
country. Some examples of different systems of vision by an individual who meets the recognition
accountability noted by Altmaier and Hall (2008) requirements or licensure in another country if not
follow. also licensed in the United States. For a thorough
review of some of the mechanisms and the chal-
Regulatory lenges to international mobility, see Bullock and
In the United States and Canada, systems of cre- Hall (2008).
dentialing are regulated by 64 licensing bodies.
Mobility mechanisms developed by credentialing North American Mobility
organizations (ABPP, ASPPB, Canadian Register Anticipating more global activity due to the North
and the National Register) assist mobility within American Free Trade Agreement (NAFTA) signed
and between these two countries, and the Mutual in 1993, psychologists from the three signatory
Recognition Agreement promotes mobility for psy- countries participated for 11 years in the Trilateral
chologists within Canada. (See http://www.cpa.ca/ Forum on Professional Psychology, primarily to
psychologyincanada/psychologyintheprovincesand- compare structure and process for education and
territories for more information.) training in the U.S., Canada, and Mexico. Whether
or not directly related to those efforts, substantial
Independent changes did occur over that time period in Mexico’s
European countries do not adhere to a specific accreditation and certification process. At the same
template for regulation of the practice of psychol- time, mobility was facilitated for psychologists at
ogy. Governmental licensing does not exist in all the doctoral level between the United States and
43 countries. However, compliance with the Canada and within Canada. Mobility has not been
Bologna Declaration may raise the standard of edu- achieved between Mexico and the United States and
cation offered in universities, which, in turn, may Canada primarily due to an inability to compare
lead to a more universal criterion for the education outcomes from education and training. Thus, deter-
required for a license (Lunt, 2008). mining comparability of education and training
could be solved with competency-based assessments
Collaborative (outcomes).
Australia’s system is managed by cooperation Beginning in the late 1990s, emphasis was placed
between the professional association and the regula- on enhancing the mobility of psychologists within
tory boards and has a mutual recognition agreement the United States. Multiple mechanisms now exist,
with New Zealand. More importantly, the five states each with different criteria and purposes, with the
and two territories now implement national licen- foundation being a license to practice psychology
sure (Waring, 2008). in at least one jurisdiction, and the goal to facili-
tate virtual or geographic mobility (Hall & Boucher,
Evolving 2003). Such mobility serves a public purpose as
Mexico ties federal licensing to a specific degree well, in that delays in obtaining a license are
and a social service requirement. Now under way is decreased and faster access to services is provided the
a newly established accreditation system and a post- public. Often, newly licensed psychologists are most
licensure examination with opportunities for spe- interested in and seeking mobility. (See http://www.
cialized certification. Its national licensing is similar nationalregister.org/mobility.htm for up-to-date
to other countries in Central and South America information.)
and Spain (Hernández Guzmán & Sanchez-Sosa, A majority of the jurisdictions in the United
2008). States and Canada have incorporated one or more

28 profession al is s u es
mechanisms in laws or regulations permitting American Psychological Association. (2002). Ethical principles
psychologists with specialty board certification of psychologists and code of conduct. American Psychologist,
57, 1060–1073.
(ABPP), mobility certificate (CPQ), or health ser- American Psychological Association. (2007). Competency
vice provider certification (National Register) to Benchmarks Work Group. Retrieved June 28, 2008, from
expedite their license acquisition in the United http://www.apa.org/ed/graduate/competency.html.
States and Canada without waiting or without being American Psychological Association. (2010). Model Act for
examined again, except for a jurisprudence exami- State Licensure of Psychologists. http://www.apa.org/about/
governance/council/policy/model-act-2010.pdf Accessed
nation. Thus, having mobility or expedited licen- March 12, 2011.
sure is a major benefit of credentialing, and is American Psychological Association, Committee on Accre-
reported by early career psychologists as the major ditation. (1996). Guidelines and principles for accreditation
reason for applying for credentialing (Hall & of programs in professional psychology. Washington, DC:
Boucher, 2008). Author.
American Psychological Association, Committee on Accred-
itation. (2009). Guidelines and principles for accreditation
Conclusion of programs in professional psychology. Washington, DC:
Psychology meets its accountability requirement Author.
as a profession in many ways. It reviews and approves American Psychological Association, Committee on Counselor
education and training programs based upon Training, Division of Counseling and Guidance. (1952).
Recommended standards for training counseling psycholo-
national criteria using both formative and summa-
gists at the doctoral level. American Psychologist, 7, 175–181.
tive evaluations. It requires professional psycholo- American Psychological Association, Committee on Definition,
gists to be individually evaluated for licensure and Division of Counseling Psychology. (1956). Counseling psy-
credentialing. These evaluations take place at the chology as a specialty. American Psychologist, 11, 282–285.
state and national level. The move to assess compe- American Psychological Association, Committee on Legislation.
(1955). Joint report of the APA and CSPA (Conference of
tencies in practicum and internship will assist stu-
State Psychological Associations). American Psychologist, 10,
dents in directing their focus on which experiences 727–756.
will make them a more effective psychologist, quali- American Psychological Association, Committee on Legislation.
fied for independent practice and competitive in the (1967). A model for state legislation affecting the practice
health care marketplace. A similar evolution will of psychology 1967: Report of the APA Committee on
Legislation. American Psychologist, 22, 1095–1103.
eventually occur for postdoctoral training, as it is
American Psychological Association, Council of Representatives.
necessary for advanced competence, mobility, and (2006, February). Minutes. Washington, DC: Author.
specialization. Accountability also includes moni- American Psychological Association, Council of Representatives.
toring psychologists’ practice to protect the public. (1995, February). Minutes. Washington, DC: Author.
Monitoring ethical conduct is supported by the Association of Psychology Postdoctoral and Internship Centers.
(2011). Match statistics. Retrieved April 13, 2011, from
efforts of licensing boards and national credential-
http://www.appic.org/match/5_2_2_1_10_match_about_
ing bodies. Ultimately, the profession is accountable statistics_general_2011Comb.html.
to the consumer; self-regulation is the key to meet- Association of Psychology Postdoctoral and Internship Centers.
ing this responsibility. (2008, May). APPIC e-newsletter. Retrieved June 24, 2008,
Consumers have opinions about who is best from http://appic.org/news/Newsletter/May2008.pdf.
Association of State and Provincial Psychology Boards. (1992).
suited to address their issues. Their participation is
Model act for licensure of psychologists. Montgomery, AL:
fostered by the direct representation on policy- Author.
establishing and implementing organizations and Association of State and Provincial Psychology Boards. (2001).
by direct feedback on the quality of services pro- Model act of licensure for psychologists. Montgomery, AL:
vided. As pointed out by Stricker, “the rise in con- Author.
Association of State and Provincial Psychology Boards. (2010).
sumer voice increases the pressure on psychological
Model act of licensure for psychologists. Montgomery, AL:
groups to self-regulate” (p. 212). Author.
Belar, C. D., Bieliauskas, L. A., Klepac, R. K., Larsen, K. G.,
References Stigall, T. T., & Zimet, C. N. (1993). National Conference
Altmaier, E. M., & Hall, J. E. (2008). Introduction to interna- on Postdoctoral Training in Professional Psychology.
tional quality assurance for psychology. In J. E. Hall, & American Psychologist, 48, 1284–1289.
E. M. Altmaier (Eds.), Global promise: Quality assurance and Bent, R. J., Packard, R. E., & Goldberg, R. W. (1999). The
accountability in professional psychology (pp. 3–15). New York: American Board of Professional Psychology, 1947 to 1997:
Oxford University Press. A historical perspective. Professional Psychology: Research and
American Psychological Association. (1987). Model act for Practice, 29, 65–73.
state licensure of psychologists. American Psychologist, 42, Bullock, M., & Hall, J. E. (2008). The promotion of interna-
696 –703. tional mobility. In J. E. Hall, & E. M. Altmaier (Eds.), Global

hall 29
 promise: Quality assurance and accountability in professional Mayne, T. J., Norcross, J. C., & Sayette, M. A. (2006). Insider’s
psychology (pp. 216–231). New York: Oxford University guide to graduate programs in clinical and counseling psychol-
Press. ogy. New York: Guilford Press.
Canadian Psychological Association. (2002). Accreditation stan- Miville, M. L., Adams, E. M., & Juntunen, C. L. (2007).
dards and procedures for doctoral programmes and internships Counseling psychology perspectives on the predoctoral
in professional psychology. Ottawa, CA: Author. Retrieved internship supply-demand imbalance: Strategies for problem
June 24, 2008, from http://www.cpa.ca/accreditation. definition and resolution. Training and Education in
Canadian Psychological Association. (2000). Canadian code of Professional Psychology, 1, 258–266.
ethics for psychologists (3rd ed.). Ottawa, CA: Author. Retrieved Murphy, M. J., Levant, R. F., Hall, J. E., & Glueckauf, R. L.
July 10, 2008, from http://www.cpa.ca/publications. (2007). Distance education in professional training in psychol-
Drum, D. J., & Hall, J. E. (1993). Psychology’s self-regulation ogy. Professional Psychology: Research and Practice, 38, 97–103.
and the setting of professional standards. Applied and National Register of Health Service Providers in Psychology.
Preventive Psychology, 2, 151–161. (2011). Health service provider in psychology. Retrieved
Gelso, C., & Fretz, B. (2001). Counseling psychology. Orlando, April 14, 2011from http://www.nationalregister.org/about_
FL: Harcourt Brace. NR.html.
Goodstein, L. D., & Ross, S. (1966). Accreditation of grad- Nelson, P. D., Belar, C. D., Grus, C. L., & Zlotlow, S. (2008).
uate programs in psychology. American Psychologist, 21, Quality assessment in higher education through accredita-
218–223. tion. In J. E. Hall, & E. M. Altmaier (Eds.), Global promise:
Hall, J. E. (2000). Licensing and credentialing as quality Quality assurance and accountability in professional psychology
management tools in behavioral health care. In G. Stricker, (pp. 16–37). New York: Oxford University Press.
W. G. Troy, & S. A. Shueman (Eds.), Handbook of quality Nelson, P. D., & Messenger, L. C. (2003). Accreditation in
management in behavioral health (pp. 317–332). New York: psychology and public accountability. In E. M. Altmaier
Kluwer Academic/Plenum. (Ed.), Setting standards in graduate education: Psychology’s
Hall, J. E., & Boucher, A. P. (2003). Professional mobility commitment to excellence in accreditation (pp. 7–38).
for psychologists: Multiple choices, multiple opportunities. Washington, DC: American Psychological Association.
Professional Psychologist: Research and Practice, 34, 463–467. New York State Doctoral Evaluation Project. (1990). Doctoral
Hall, J. E., & Boucher, A. P. (2008). Early career psycholo- education in psychology. Doctoral Evaluation Project,
gists’ knowledge of credentialing in professional psychol- New York State Education Department, Albany NY 12230.
ogy. Professional Psychology: Research and Practice, 39, Norcross, J. C., Hogan, T. P., & Koocher, G. P. (2008). Clinician’s
480–487. guide to evidence-based practices: Mental health and the
Hall, J. E., & Sales, B. D. (2002). Evolution of specialty credential- addictions. New York: Oxford University Press.
ing in professional psychology. Unpublished manuscript. Pellegrino, E. D. (1991). Trust and distrust in professional ethics.
Hall, J. E., Wexelbaum, S., & Boucher, A. P. (2007). Doctoral In E. D. Pellegrino, R. Veatch, & J. Langan (Eds.), Ethics,
student awareness of licensure, credentialing, and profes- trust and the professions (pp. 69–89). Washington, DC:
sional organizations in psychology: The 2005 National Georgetown University Press.
Register international survey. Training and Education in Raimy, V. C. (Ed.). (1950). Training in clinical psychology.
Professional Psychology, 1, 38–48. New York: Prentice Hall.
Health Care Financing Administration. (2000). Medicare claims Ritchie, P. L.-J. (2008). Codes of ethics, conduct, and standards
manual, Part 3: Claims processes. Section 2150 clinical psy- as vehicles of accountability. In J. E. Hall, & E. M. Altmaier
chologists services. Retrieved July 2, 2008, from www.cms. (Eds.), Global promise: Quality assurance and accountability in
hhs.gov/transmittals/downloads/R1660B3.pdf. professional psychology (pp. 73–97). New York: Oxford
Hernández Guzmán, L., & Sanchez-Sosa, J. J. (2008). Practice University Press.
and professional regulation of professional psychology in Rodolfo, E. R., Owen, J. J., & Clark, S. (2007). Practicum train-
Latin-America. In J. E. Hall, & E. M. Altmaier (Eds.), Global ing hours: Fact and fantasy. Training and Education in
promise: Quality assurance and accountability in professional Professional Psychology, 1, 64–73.
psychology (pp. 109–127). New York: Oxford University Sales, B. D., Bricklin, P., & Hall, J. E. (1983). Manual for
Press. the identification and continued recognition of proficiencies
Kaslow, N. J. (2004). Competencies in professional psychology. and new specialties in psychology [Draft report of the subcom-
American Psychologist, 59, 774–781. mittee on specialization]. Washington, DC: American
Kaslow, N. J., Borden, K. A., Collins, F. L., Forrest, L., Illfelder- Psychological Association.
Kaye, J., Nelson, P. D., et al. (2004). Competencies confer- Sales, B. D., Bricklin, P., & Hall, J. (1984a). Specialization in
ence: Future directions in education and credentialing in psychology: Principles [Draft report of the subcommittee on
professional psychology. Journal of Clinical Psychology, 80, specialization]. Washington, DC: American Psychological
699–712. Association.
Lunt, I. (2008). Professional mobility and quality assurance Sales, B. D., Bricklin, P., & Hall, J. E. (1984b). Specialization in
within the European Union. In J. E. Hall, & E. M. Altmaier psychology: Procedures [Draft report of the subcommittee on
(Eds.), Global promise: Quality assurance and accountability in specialization]. Washington, DC: American Psychological
professional psychology (pp. 128–139). New York: Oxford Association.
University Press. Service, J., Sabourin, M., Catano, V. M., Day, V., Hayes, C., &
MacHovec v. Council for the National Register of Health Service MacDonald, G. W. (1989). Report of the CPA/CPAP Specialty
Providers in Psychology, 616 F. Supp. 258, 271 (E.D. Va. Designation Task Force. Ottawa, CA: Canadian Psychological
1985). Association.

30 profession al is s u es
Skrtic, T. M. (1991). Behind special education: A critical analysis Vasquez, M. J. T., & Phillips Bingham, R. (2011). Ethics
of professional culture and school organization. Denver: Love. in counseling psychology. In E. M. Altmaier, & J. C. Hansen
Stigall, T. T. (1983). Licensing and certification. In B. D. Sales (Eds.), The Oxford handbook of counseling psychology.
(Ed.), The professional psychologist’s handbook (pp. 285–337). New York: Oxford University Press.
New York: Plenum. Waring, T. (2008). The regulation of psychology in Australia.
Stricker, G. (2008). Quality assurance in professional psychology In J. E. Hall, & E. M. Altmaier (Eds.), Global promise:
education. In J. E. Hall, & E. M. Altmaier (Eds.), Global Quality assurance and accountability in professional psychology
promise: Quality assurance and accountability in professional (pp. 164–185). New York: Oxford University Press.
psychology (pp. 199–215). New York: Oxford University Watkins, C. E. (1984). Counseling psychology versus clinical
Press. psychology: Further explorations on a theme or once more
Stromberg, C. D. (1990, May). Associations’ certification pro- around the “identity” maypole with gusto. The Counseling
grams: Legal and operational issues. Paper presented at the Psychologist, 11, 76–92.
meeting of the American Speech and Hearing Association, Wellner, A. M. (Ed.). (1978). Education and credentialing in
Rockville, MD. Unpublished manuscript. psychology: Proposal for a national commission in education
Stromberg, C. D. (1991, April). Healthcare credentialing: and credentialing in psychology. Washington, DC: National
Implications for academic health centers. Paper presented at the Register of Health Service Providers in Psychology.
meeting of the Academic Health Centers, Washington, DC. Williams-Nickelson, C., Prinstein, M. J., & Keilin, W. G.
Unpublished manuscript. (2008). Internships in psychology: The APAGS workbook
Stromberg, C. D., Haggarty, D. J., Liebenluft, R. F., for writing successful applications and finding the right fit.
McMillian, M. H., Mishkin, B., Rubin, B. L., et al. (1988). Washington, DC: American Psychological Association.
The psychologist’s legal handbook. Washington, DC: National Wise, E. H., Hall, J. E., Ritchie, P. L.-J., & Turner, L. C. (2006).
Register of Health Service Providers in Psychology. The National Register of Health Service Providers in
Thompson, A. S., & Super, D. E. (Eds.). (1964). The professional Psychology and the Canadian Register of Health Service
preparation of counseling psychologists: Report of the 1964 Providers in Psychology. In T. J. Vaughn (Ed.), Psychology
Greystone Conference. New York: Teachers College. licensure and certification: What students need to know.
U.S. Department of Education, National Center for Education Washington, DC: American Psychological Association.
Statistics. (2003). Distance education at degree-granting
postsecondary institutions: 2000-2001 (NCES 2003-017).
Washington, DC: Author.

hall 31
 CHAPTER

3 The Counseling Relationship

Beth E. Haverkamp

Abstract
Counseling psychology offers a distinctive perspective on the therapeutic relationship, one that is
grounded in the discipline’s history, values, and professional identity. In the current work, selections
from one of the field’s pioneers, Leona Tyler, introduce key areas of contemporary research and
theory on the counseling relationship. The chapter begins with an examination of early formulations
of the therapeutic relationship, the historical context in which they emerged, and early efforts to
investigate its role in psychotherapy. Next, enduring themes within relationship research, as well as
key contemporary concerns, are surveyed, with an emphasis on the distinctive contributions of
counseling psychologists. Closing sections of the chapter identify emerging areas of research,
particularly as they relate to traditional counseling psychology concerns, and propose potentially
useful avenues for further investigation of the dynamic and interdependent character of counseling
relationships.
Keywords: counseling psychology, counseling relationship, therapeutic relationship, therapeutic
alliance, history of psychology

[I]t is the relationship with the counselor that makes on the relationship is a core element differentiating
the difference. . . . It is because of this principle that the field from other areas of applied psychology.
recent writers on the counseling process are stressing Notably, concern with the relationship was visible
relationships rather than techniques, the general at the outset of the field’s emergence. Leona Tyler,
structure of the situation rather than specific rules one of the field’s pioneers, assigned a central role to
about what to do and say. the counseling relationship in the three editions
—Leona Tyler, The Work of the Counselor of her influential text, The Work of the Counselor
(1953, p. 17) (1953, 1961, 1969), and her assertion that “it is the
relationship with the counselor that makes the dif-
The field of counseling psychology encompasses ference. . . .” (1953, p. 17), was echoed in Packard’s
extraordinary diversity in research and practice, yet 2008 Leona Tyler Award Address, in which he iden-
the phenomenon known as “the counseling rela- tified nine core values for counseling psychology;
tionship” has been a source of perennial interest the second of which is, “Positive relationships are
and investigation. Repeated references to the coun- a necessary condition for stimulating change in
seling relationship in counseling psychology’s self- those we seek to help” (2009, p. 622).
descriptions (Howard, 1992; Packard, 2009) suggest Research on the counseling relationship has
that the relationship lies at the heart of our field’s begun to accelerate and assume new prominence
identity as a specialization within applied psychol- within applied psychology, along with convincing
ogy and that counseling psychology’s perspective documentation of its role in therapeutic outcomes

32
(see Norcross, 2002a). But, before examining con- Historical Emergence of a Counseling
temporary research on the counseling relationship, Psychology Perspective on
it is informative to consider the historical context of the Relationship
counseling psychology’s contribution. In this chap-
Down through the years men have always found
ter, rather than attempt to address the full spectrum
that when they have difficult and important decisions
of relationships research (see Norcross, 2002a, for a
to make they can clarify their thinking by talking
synthesis), my goal is to present an explicit counsel-
the problems over with friends whom they trust and
ing psychology perspective on the counseling or
respect. . . . that sympathy and understanding
therapeutic relationship. I propose to do so in three
make it easier to face these troubles courageously.
areas: First, for those new to this literature (or for
(Tyler, 1953, p.1)
those who may have forgotten), I will examine early
formulations of the therapeutic relationship, the Counseling psychology’s formulation of the rela-
historical context in which they emerged, and early tionship is often traced to the 1940s and 1950s,
efforts to investigate its role in psychotherapy. coinciding with Carl Rogers’ introduction of the
Second, in discussing key contemporary areas of influential idea that an accepting relationship with
research on the counseling relationship, there will a counselor, characterized by empathy, warmth, and
be an emphasis on the distinctive contributions genuineness, is necessary and sufficient for change.
of counseling psychologists, as well as attention to Few would disagree that Rogers’ (1942, 1957, 1963)
enduring themes within relationship research. contributions constitute the single most important
Closing sections of the chapter will identify emerg- influence on contemporary understandings of the
ing areas of research on the counseling relationship, counseling relationship, but it is important to note
particularly as they relate to traditional counseling two earlier influences, both of which emerged in the
psychology concerns, and will propose potentially early years of the 20th century and which continue
useful avenues for further investigation. to be reflected in contemporary perspectives and
The selections of research and commentary research on the counseling relationship.
presented in the following sections reflect my view Freudian psychoanalysis contributed the view
that a unique counseling psychology perspective on that change occurs in the context of interaction
the relationship is discernible and that this perspec- between analyst and analysand, as well as the obser-
tive has influenced the development of counseling vation that, in transference and countertrans-
psychology as a specialization and continues to be ference, the process is influenced by forces and
reflected in relationship research being conducted feelings outside the awareness of client and thera-
by counseling psychologists. Early writing that pist. Both the processes of therapeutic interaction
emphasized respect for client autonomy, agency, and the phenomemon of transference/countertrans-
and a focus on client strengths is still visible in newer ference continue to be a focus of counseling psy-
areas of research, such as social justice (Vera & chology research (e.g., Gelso & Carter, 1994; Gelso
Speight, 2003) and positive psychology (Lopez & Samstag, 2008).
et al., 2006; Smith, 2006). The vocational guidance movement of the early
Readers of the current chapter will have an oppor- 1900s, a core forerunner of contemporary counsel-
tunity to consider, for themselves, the roots of coun- ing psychology, was a second key influence through
seling psychology’s unique perspective on the its focus on the identification of client skills and
relationship: Selected quotations from the first edi- strengths, not pathology. Parson’s early attention to
tion of Tyler’s (1953) The Work of the Counselor, are identifying client strengths and capacities as a basis
used to introduce key sections. Although the idea of for selecting occupations (Parsons, 1908, cited in
selecting a few key Tyler quotations was appealing Gelso & Fretz, 2001; Lopez et al., 2006) was later
from the start, I think readers will share my surprise at reflected in Super’s characterization of counseling
the extent to which Leona Tyler’s 1953 work remains psychology as emphasizing “a value system aiming
relevant to contemporary concerns. This chapter sum- at optimum functioning of the individual” (Super,
marizes what we have learned, over the past 50 years, 1955, cited in Samler, 1980, p. 155). Super used the
about the importance of the counseling relationship term hygiology in arguing that counselors were con-
in many domains; Tyler’s comments remind us that cerned with client strengths and health, rather than
many contemporary conclusions echo assertions pathology.
advanced at the time when counseling psychology With this base—Rogers’ attention to an empathic
first emerged as a specialization within psychology. relationship, the Freudian insight that relationship

have rkam p 33
is a dynamic process, and the vocational guidance pursued in ways that do not diminish rapport. Tyler
focus on skills and strengths—counseling psychol- also calls attention to additional aspects of the rela-
ogy formally defined itself as a field (see Whitely, tionship that continue to be influential in contem-
1980), differentiating itself from clinical psychol- porary counseling psychology: Each counseling
ogy, industrial organizational psychology, and relationship must focus on the individual’s unique-
school guidance. These distinctions were drawn ini- ness, a mandate now reflected in the field’s emphasis
tially on the basis of work setting and client on issues of diversity. In describing how counselors
populations but, before long, could also be charac- establish relationships, she often reminded readers
terized by different values and distinctive views that “counseling is basically a perceptual
of the counselor–client relationship. Super (1955) skill . . . learning to listen and watch and under-
credited Rogers with making people aware that “one stand” (p. 35), which foreshadows the cognitive
counsels people rather than problems” (Whitely, aspects of relationship formation and the subse-
1980, p. 18, italics in original) and went on to quent influence of social psychology (e.g., Heppner
note that, “Some clinical psychologists are begin- & Frazier, 1992, Strong, 1978).
ning to say, now that counseling psychology has Tyler’s core themes continue to be visible in com-
made clear this surprisingly novel philosophy [atten- prehensive reviews of relationship research, particu-
tion to strengths/hygiology] and these nonetheless larly those contributed by counseling psychologists,
time-honored methods, that clinical psychology and they helped create a template for a counseling
made a serious error in defining itself as it did, that psychology perspective on the therapeutic relation-
it should have been more independent of psychiat- ship. Those readers who may question the unique-
ric traditions and interests and concerned itself ness of Tyler’s counseling psychology perspective—
with hygiology as well as pathology” (Whitely, that a warm, safe, respectful counseling relationship
1980, p. 19). is essential to the therapeutic endeavor—are invited
At this nascent moment in the field’s devel- to consider an alternate view, also published in
opment, Leona Tyler’s (1953) The Work of the 1953. John Dollard who, with Neil Miller, advanced
Counselor offered a comprehensive portrait of the a highly influential synthesis of psychodynamic and
new discipline and, by extension, its characteriza- behavioral approaches to therapy, produced a text
tion of the counseling relationship. As noted by comparable to Tyler’s, titled Steps in Psycho-
Zilber and Osipow (1990), “Tyler integrated many therapy (Dollard, Auld, & White, 1953). The sec-
theories in developing her own view . . . her work tion, “The role of the therapist,” opens as follows:
reflects her own unique blending of the concepts
of Carl Rogers, individual differences and psy- We were tempted to refer to the therapist as circling
chometrics, psychoanalytic theory, behaviorism, around the embattled patient as an army might circle
developmental stage theory and existentialism. . . .” a citadel awaiting the moment of attack. . . . It is
(p. 337). Tyler’s defining contribution was to effect true that there are resistant forces operating within
this integration through the lens of the emerging the patient which make it difficult for him to
values and concerns of the new discipline of coun- cooperate as he would like to do; but it is equally
seling psychology. true that there are strong cooperative forces within
Tyler’s core themes can be summarized briefly the patient which keep him trying and proceeding
and, upon first reading, are likely to strike readers with therapy. (p. 16)
as self-evident or not remarkable to any practicing
Although this language will sound harsh to con-
therapist, but they provided one of the first system-
temporary practitioners, I believe it is important
atic sets of instruction for how a counseling rela-
for counseling psychologists to know that our field
tionship should be conducted. Tyler regarded the
has been focused on “cooperative forces” all along.
relationship itself as central to the whole therapeutic
endeavor and was specific about its essential charac-
Empiricism: Early Counseling Psychology
teristics: The counselor and client must establish a
Research on the Relationship
relationship of safety and trust; the relational focus
includes the whole person of the client; the counselor It seems to me very important that we do shift
adopts a core focus on client strengths, rather than over as rapidly as we can to the use of dependable
pathology; and counseling activities such as psycho- evidence rather than custom and intuition as a basis
logical testing or occupational information are for judgments as to how counseling should be done.
employed within the counseling relationship and (Tyler, 1953, p. ix)

34 the coun se l in g rel atio n s h ip

 From the outset of counseling psychology’s emer- issue of the Journal of Counseling Psychology ( JCP)
gence as a discipline, there was widespread interest in 1954. As reported by Wrenn (1966), the first
in conducting research on the process of counseling issue of JCP included ten research articles, three of
and the client–counselor relationship. This stance which reflect the field’s interest in therapist contri-
reflects counseling psychology’s enduring tradition butions to the counseling relationship: Dipboye’s
of empiricism and, to complete our understanding “Analysis of Counselor Style by Discussion Units,”
of counseling psychology’s historical perspective on Cottle and Lewis’ “Personality Characteristics of
the relationship, this tradition of and some of its Counselors: II. Male Counselor Responses to the
early contributions are considered. MMPI and GZTS,” and Shaw’s “Counseling from
Tyler’s work reflects a consistent commitment to the Standpoint of an ‘Interactive Conceptualist.’”
what we now call evidence-based practice. The rec- Rogers’ (1957) description of the “necessary
ommendations offered in her 1953 text were based and sufficient” conditions for change had a signifi-
on the earliest available relationship research; each cant impact on psychology’s views of the therapeu-
chapter of The Work of the Counselor was followed by tic relationship and generated substantive early
a research summary containing examples of early research on the core conditions of empathy, uncon-
research on the counseling relationship. For exam- ditional positive regard, and genuineness, as well
ple, Seeman (1949, cited in Tyler, 1953), in investi- as development of new research tools. Counseling
gating client response to different counselors, found psychologists made noteworthy contributions to inves-
that, “There were significant differences in the favor- tigations of Rogers’ hypotheses: A counseling psychol-
ableness of the response to different counselors, but ogist’s dissertation research operationalized the core
they were not related to techniques used. Counselor conditions (Barrett-Leonard, 1959), resulting in the
responsiveness seemed to be the quality that produced Relationship Inventory, a measure still used in counsel-
the favorable reactions” (p. 55). His research illus- ing process research (e.g., Heppner, Rosenberg, &
trates a perennial question, one that previews a con- Hedgespeth, 1992; Watson & Geller, 2005). Truax
temporary conclusion regarding the distinctive and Carhkuff’s (1967) five-level observational rating
contributions of the counselor (Kim, Wampold, & system, the Accurate Empathy Scale, is still used to
Bolt, 2006; Wampold, 2007). measure empathic understanding in client–counselor
Evidence-based practice tends to be associated interactions (e.g., Barone et al., 2005).
with outcome research, pursuing questions of “Is the Research on the counseling process and the role
treatment effective?” But a good deal of relationship of the counseling relationship also reflects the spe-
research is concerned with the counseling process, cialization’s openness to theory and research from
and counseling psychologists took an early interest other areas of psychology, being one of the first
in this type of inquiry. A group of eminent counsel- areas of counseling psychology research to incorpo-
ing psychology researchers (Gelso, Betz, Friedlander, rate ideas drawn from social psychology research.
Helms, Hill, Patton, Super, & Wampold, 1988), Stanley Strong (1968) drew on Jerome Frank’s
while noting that process research was not unique to (1961) characterization of counseling as a social
counseling psychology, described process research as influence process and reformulated Frank’s ideas
“particularly notable” in counseling psychology and as explicit counselor factors within the counseling
as having a “deep and substantial history in our spe- relationship. Strong’s model identified counselor
cialty” (p. 388). This group’s work alerted me to the expertness, perceived attractiveness, and trustwor-
pioneering contributions of Francis P. Robinson, of thiness as sources of persuasion. Once a counseling
the Ohio State University, and a former president of relationship was established in which the client
the American Psychology Association (APA) Division viewed the counselor as influential, the counselor
17, who inaugurated a program of process research selected an “influence base” which, in his or her
in the 1940s. Asserting that “a counselee’s willing- judgment, best suited the client’s needs (Dixon &
ness to talk is usually symptomatic of a good work- Claiborn, 1987). Strong’s characterization of the
ing relationship between client and counselor” counseling relationship as a social influence process
(Carnes & Robinson, 1948, p. 635), Robinson’s lab led to a flood of analogue investigations in which
used “typescripts” of counseling sessions to investi- variables such as “trustworthiness” and “credibility”
gate the relationship between the proportion of were investigated for their relationship to both out-
client talk time and counseling effectiveness. come (e.g., client attitude change; Bergin, 1962)
Evidence of early research interest in the coun- and process factors (e.g., openness to influence; Dell
seling relationship is also found in the inaugural & Schmidt, 1976; Strong & Schmidt, 1970).

have rkam p 35
 Specific counselor factors that are influential in symptom improvement and r = .17 ( p < .05) for tar-
creating effective therapy relationships are surveyed geted symptoms. Reviewers have pointed out that
in subsequent sections; this brief historical sketch the larger effect sizes were obtained with clients who
illustrates the roots of an empirical tradition that sought help for more subjective distress (e.g., depres-
continues to infuse counseling psychology’s rela- sion, self-esteem, generalized anxiety), as opposed
tionship research. Contemporary manifestations of to diagnosable illness. The implication of this find-
this orientation are reflected in contributions from ing for counseling psychologists, whose training
counseling psychologists to current definitions of tends to be more focused on adjustment concerns,
“empirically supported relationships,” a research- may be that the relationship plays an even greater
based complement to research on “empirically sup- role in their work than would be true in more clini-
ported treatments” (see Norcross, 2002b). cal or psychiatric settings.
Given the well-established consensus on the
Key Formulations of the Counseling importance of the counseling relationship in facili-
Relationship tating client change, the next questions concern
the unexplained variance in outcome and can be
The three aspects, understanding, acceptance,
framed as, “what type of relationship?” and, as “what
and communication, are so inextricably bound up
elements of the relationship?” The first question
together in the counseling process that it is only
can be explored by reviewing the findings asso-
for purposes of talking about them that we can single
ciated with varying definitions or components of
out one at a time. They cannot be separately
the counseling relationship. The second question,
practiced or learned, and it is inconceivable that
concerning factors that influence relationship
a competent counselor could ever be rated high
development, is addressed in a subsequent section.
on one and low on the others.
However, before we can examine the evidence asso-
(Tyler, 1953, p. 23)
ciated with various models of the counseling rela-
A consensus has emerged that the quality of the tionship, it is important to examine some of the
counseling relationship, across a range of therapeu- definitional challenges associated with this area of
tic approaches and client populations, is a consis- research.
tent predictor of positive client outcomes (Beutler
et al., 2004; Gelso et al., 2005; Horvath, 2001; Definitional and Conceptual Challenges
Lambert & Barley, 2001). In the current edition
[T]he relationship between two people is something
of the classic resource, Handbook of Psychother-
different than the sum of the contributions they
apy and Behavior Change (Lambert, 2004), Beutler
make to it.
et al. (2004) note that the 1994 edition had already
(Tyler, 1953, p. 17)
identified the therapeutic relationship as “among
the stronger predictors of treatment outcome” Many researchers would argue that meaning-
(p. 282). Lambert and Barley (2001) have gone ful description rests on precise definition; if we
so far as to argue that we now have decades of hold to that truism with regard to the counseling
research demonstrating that the therapeutic rela- relationship, we are in trouble. Gelso and Hayes
tionship is a foundational “curative” component. (1998) have pointed out that, despite agreement
These conclusions are supported by a series of on the centrality of the relationship in psychother-
meta-analyses (Horvath & Symonds, 1991; Stevens, apy, there has been a lack of definitional work and
Hynan, & Allen, 2000) that have produced moder- few explicit definitions offered. This is not to sug-
ate effect sizes for the association between the thera- gest that there have not been efforts to define the
peutic relationship and outcome. One relatively phenomenon but, in each case, the definitions
new conclusion, however, is that the magnitude offered have been criticized for either being incom-
of the relationship between the quality of the coun- plete, or not being “it.” In the 1960s, Carl Rogers
seling relationship and outcome is less substantial expressed his frustration that, “we were all talking
than had been identified previously. Where prior about the same experiences, but attaching different
estimates had suggested that 30% of the variance words, labels, and descriptions to these experi-
in outcome was attributable to the relationship ences. . . . the field of psychotherapy is in a mess”
(Lambert, 1992), more recent reviews (Beutler (1963; cited in Patterson, 1966, p. 506). In this sec-
et al., 2004) have produced mean effect sizes rang- tion, several influential conceptualizations of the
ing from r = .22 ( p < .05) for a general outcome in relationship are described briefly to illustrate some

36 the coun se l in g rel atio n s h ip

of the key definitional issues in this area of theory difficulty in separating therapist characteristics and
and research. In a subsequent section, several key actions from what we would label as the relation-
formulations, as well as associated research, are con- ship. Similar to Gelso and Hayes’ (1998) critique
sidered in greater detail. of Rogers, Strong’s conditions for influence cannot
One of the most widely cited contemporary be equated with the relationship itself.
definitions of the relationship was developed by An influential cluster of definitions for the
Gelso and Carter (1985, 1994), and asserts that relationship is associated with the general term
“The relationship is the feelings and attitudes that therapeutic alliance. In contrast to models of the
therapist and client have toward one another, and relationship that emphasized therapist contribu-
the manner in which these are expressed” (1985, tions, the alliance construct captures an interactive
p. 159). This definition was adopted by the APA process and recognizes both therapist and client
Division of Psychotherapy Task Force on Empir- roles. At the same time, it presents some distinctive
ically Supported Therapy Relationships (see definitional challenges, particularly with regard to
Norcross, 2002) for its comprehensive empirical the theoretical roots of the varying formulations.
review of relationship research; as such, it is assum- As Horvath and Bedi (2002) point out, varia-
ing an influential place in psychology’s under- tions on the term (e.g., working alliance, helping
standing of the counseling relationship. alliance) represent related but distinct constructs
The Gelso and Carter definition (1985, 1994) is with varying historical antecedents, some with clear
only one of several formulations that have been roots in psychodynamic thought (e.g., Greenson,
influential at some point in the history of relation- 1965, 1967) and others that have become more
ship research and, in each case, the definitions pantheoretical (e.g., Bordin, 1976). Two influential
offered have been criticized. As an initial example, formulations are those developed by Luborsky and
we can consider the model most familiar to counsel- Bordin. Luborsky’s (1976) formulation of a type I
ors, that of Carl Rogers’ person-centered therapy. and type II alliance makes distinctions based on
Rogers’ approach is defined by his view of the rela- the stage of engagement, with type I referring to ini-
tionship, which is considered to be the central tial establishment of the relationship and type II
mechanism of change and as healing in itself (Gelso emerging as the work of therapy begins. Bordin,
& Hayes, 1998). However, Gelso and Hayes (1998) who is most closely associated with the term “work-
have argued that Rogers equated the relationship ing alliance,” defined the alliance as a collabo-
with the core conditions of empathy, unconditional ration consisting of three components: a bond
regard, and congruence. In their view, the facilita- between therapist and client, and an agreement on
tive conditions are more appropriately viewed as both the goals of therapy and on the tasks pursued.
factors that help create a relationship, rather than Horvath and Bedi (2002) argue that the common
constituting the relationship itself. They also offered elements in alliance definitions of the relationship
the critique that the therapist-offered conditions fail have been collaboration and agreement between
to acknowledge the client’s role or contribution to client and counselor, in contrast to earlier work
the relationship. that was focused on either therapist contributions
A similar argument could be made regarding (e.g., Rogers) or on unconscious distortion (Gelso
Stanley Strong’s (1968) social influence model, & Carter, 1985, 1994).
which presented a view of the counseling rela- Although definitions based on the therapeutic
tionship derived from social psychological theory. alliance have shifted attention from therapist factors
Strong characterized the counseling relationship as to an interactive characterization of the relationship,
a venue for persuasion on the part of the counselor; most writers consider the alliance as only one com-
counselor expertness, attractiveness, and trustwor- ponent of the relationship, rather than constituting
thiness were bases for influence, and the coun- the whole (Horvath & Bedi, 2002). For Gelso and
selor’s role was to select the stance best suited to Carter (1985, 1994), the working alliance is one
the client’s receptivity to influence and, by exten- of three components of the therapeutic relationship,
sion, to adaptive change. Strong’s ideas generated the other two being a transferential component
extensive research in the 1970s and his contribu- (including therapist countertransference) and a real
tions expanded the field’s understanding of how relationship (Greenson, 1967), with features of
different therapist characteristics (e.g., trustworthi- genuineness and realistic perception. This tripar-
ness) are related to client response. As a model of tite model (see Gelso & Hayes, 1998, Gelso &
the relationship, however, his work illustrates the Samstag, 2008, for extended discussion) offers

have rkam p 37
a more comprehensive characterization of the rela- interaction and changes in and through the interac-
tionship than the scope of either Rogers’ proposal or tion across time” (p. 79).
the alliance literature and has been employed in sev- My own view is that Carter has captured a
eral influential surveys of relationship research (e.g., critical limitation in our definitions of the relation-
Norcross, 2002; Sexton & Whiston, 1994). ship, and likely one that has been shaped by the
However, Gelso and Carter’s extension in scope has quantitative methods that are familiar to us.
also become the focus of criticism. Hill (1994) has Counseling psychology researchers, who have dem-
charged that, by going beyond feelings and attitudes onstrated openness to qualitative methods and
to inclusion of their manner of expression, the a social constructionist paradigm (see Haverkamp,
model becomes overinclusive and could be applied Morrow, & Ponterotto, 2005), may be uniquely
to almost everything that happens in psychotherapy. prepared to explore how the dimensions of time
A related challenge to the model concerns the diffi- and purpose can inform our definitions of the ther-
culty in differentiating between the three compo- apeutic relationship.
nents, particularly in defining and differentiating In the sections that follow, three influential
the real relationship (Greenberg, 1994; Patton, formulations of the relationship are considered,
1994). along with illustrative research that has explored
What each of these definitions—and attendant their association with client outcomes: Rogers’ core
criticisms—reflects is the extreme difficulty of conditions of empathy, unconditional positive
differentiating the counseling relationship from regard, and congruence; investigations of the rela-
relationship-relevant techniques that a therapist tionship as a common factor; and research on the
employs (e.g., unconditional regard) and in mak- working alliance. Two more recent formulations,
ing clear distinctions between therapist factors, those of the real relationship and consideration of
client factors, and the relationship itself. The APA the “empirically supported relationship,” are also
Division of Psychotherapy Task Force on Empiri- considered. The following discussion cannot offer
cally Supported Therapy Relationships (see Nor- an exhaustive review but reports current consensual
cross, 2002), in its investigation of relationship conclusions and draws attention to counseling psy-
factors related to therapy outcome, wrestled with chology contributions.
these dilemmas and made a choice to include thera-
pist contributions as distinguishable from the rela- Carl Rogers’ Core Therapeutic Conditions
tionship itself. But, with regard to the issue of what
The value of the basic nondirective technique,
a therapist may do, they acknowledged the impos-
reflection of feeling, in stimulating self-exploration
sibility of fully separating these, noting, “The rela-
has been demonstrated.
tionship does not exist apart from what the
(Tyler, 1953, p. 227)
therapist does in terms of technique, and we can-
not imagine any techniques that would not have Graduate students tend to forget that, when
some relational impact” (Norcross, 2002b, p. 8). Carl Rogers’ (1957) proposed that empathy, uncon-
And, of course, others would argue that therapist ditional positive regard, and congruence were “nec-
contributions go well beyond “technique” (e.g., essary and sufficient” conditions for therapeutic
Gelso, 2004). change, he wanted to advance a testable hypothesis,
For relationship research to advance, investiga- not a “truth claim” or description of fact. Gelso
tors will need to grapple with the fact that, not and Hayes (1998) observed that our familiarity
only are these factors intertwined and reciprocal, with this triad puts us at risk for assuming that there
they are teleological in character. In other words, is little more to learn or to say—and, given that
they exist within the dimension of time and are Tyler was drawing a similar conclusion in 1953, it is
enacted with purpose. Several authors have offered not surprising that many would consider this to be
suggestions for a renewed examination of relation- an area where the answers are established. However,
ship variables; for example, Carter (1994) draws a although several decades of research have produced
useful distinction between form and process ele- a strong consensus as to the positive contribution
ments of the relationship. She describes form as those made by the core conditions, debate and uncer-
components that exist at a point in time or across tainty continue regarding their relative importance
people, typically assessed with quantitative methods, and the mechanisms through which they support
and process as “more individualized experiences of change. For example, in 1985, Gelso and Carter

38 the coun se l in g rel atio n s h ip

evaluated the empirical evidence and concluded outcomes and that the factors of congruence/
that the core conditions cannot be considered either genuineness and positive regard were “promising
necessary or sufficient, yet a recent review (Bohart, and probably effective” in facilitating positive
Elliott, Greenberg, & Watson, 2002) advances the change.
idea, with empirical support, that empathy may
play a causal role in positive client outcomes, par- The Counseling Relationship as a
ticularly when viewed from the client’s perspective. Common Factor
Contemporary researchers continue to explore the
There is some evidence that Rogerian, Freudian,
role of the facilitative conditions within different
and Adlerian therapy situations are more similar,
therapeutic models (e.g., Watson & Geller, 2005)
at least in the important matter of the counseling
and client populations (e.g., Chang & Berk, 2009).
relationship established with the client, than
What cannot be disputed, however, is that Rogers
they had been assumed to be.
was a remarkably keen observer, as his core thera-
(Tyler, 1953, p. 227)
peutic conditions have continued to be identified
as central to an effective counseling relationship Dare we ask whether psychotherapy researchers
(Norcross, 2002a). are “slow learners?’ Tyler’s observations in 1953 were
Some of the earliest investigations of Rogers’ empirically based, and Truax and Carkhuff’s (1967)
core conditions were conducted by Truax and review indicated that aggregate measures of the rela-
Carkhuff (1967), who provided some of the first tionship were a stronger predictor than theoretically
summary evidence for Rogers’ formulation of the derived components. Smith and Glass’ (1977) clas-
relationship. These early investigations indicated sic meta-analysis, which demonstrated both the
that, although the association between the individ- effectiveness of psychotherapy and the lack of sig-
ual facilitative conditions and outcome were mixed, nificant differences among treatments, was pub-
more positive results were obtained when the three lished over 40 years ago. But, as a field, we have
conditions were treated as an aggregate (Farber & been slow to abandon our faith in the uniqueness
Lane, 2002). This finding, that an aggregate of the of theoretically driven interventions. As Lambert,
core conditions has the greatest predictive power, Garfield, and Bergin (2004) note, “Yet, there is tre-
has continued to gain support. Contemporary mendous resistance to accepting this finding as a
investigations have reaffirmed that the association legitimate one. Numerous interpretations of the
with outcome for the individual core conditions is data have been given in order to preserve the idea
more variable than for the relationship as a single that technical factors have substantial, unique and
entity (Farber & Lane, 2002). specific effects” (p. 809). Perhaps in this new cen-
Client perception appears to play an important tury, given the consistent evidence that specific
role in the operation of Rogers’ core relationship approaches and treatments do not differ in effecting
conditions. Work by Batchelor (1988) revealed that positive client outcomes for most presenting con-
clients differ in what they perceive as an empathic cerns (Lambert, Garfield, & Bergin, 2004), we are
response, a point that highlights the necessity of ready to “give it up” and learn more about what
attending to individual differences in clients’ experi- makes the counseling relationship a critical element
ence of the relationship. Lambert and Barley (2002), of therapeutic success.
in a discussion of the facilitative conditions, point The common factors approach can be described
to consistent evidence that the more positive asso- as the search for those “active ingredients” that cut
ciations with outcome are obtained for client- across psychotherapeutic approaches, are important
perceived relationship factors, rather than those in all forms of psychotherapy, and are not linked
reported by therapists or observers. to the change mechanisms specified by specific the-
The most compelling contemporary support for oretical orientations. First advanced by Rosenzweig
the association between Rogers’ core conditions and (1936), the idea of common factors has attracted
client outcome is presented in the work of the increased attention as contemporary research con-
Division 29 Task Force on Empirically Supported tinues to document the lack of specificity attached
Therapy Relationships (Norcross, 2002a). Following to particular theoretical approaches (Ahn &
their comprehensive review of extant research, the Wampold, 2001). Various authors have advanced
Task Force concluded that the factor of empathy lists of potential common factors (e.g., Greencavage
was “demonstrably effective” in promoting positive & Norcross, 1990; Stiles, Shapiro, & Elliott, 1986;

have rkam p 39
Weinberger, 1995). Lambert and Ogles (2004), for (Baldwin, Wampold, & Imel, 2007, Wampold,
example, categorize common factors as support, 2007). Readers interested in learning more about
learning, and action factors. Regardless of the form this counseling psychologist’s perspective are invited
of categorization for common active ingredients, to review Wampold (2007).
the counseling relationship is named consistently as The broad consensus on the importance of the
an influential factor that crosses theoretical bound- therapeutic relationship as a common factor has
aries; Lambert and Ogles (2004) assert that, based prompted further investigation of the mechanisms
on a series of extensive empirical reviews, “Reviewers through which it may influence positive change.
are virtually unanimous in their opinion that the Some of the factors that have been identified as
therapist–patient relationship is critical to positive moderators and mediators are discussed in subse-
outcome” (p. 174). quent sections of this chapter.
As a common factor, the counseling relationship
is frequently operationalized as a constellation of The Working Alliance
Rogers’ core conditions, in contrast to assessing
In this first hour, some kind of relationship must be
the individual contributions of empathy, uncondi-
established. Out of this meeting the client must get
tional regard, and genuineness. As noted above,
something that will make him willing to come back
there is empirical support for treating them as an
and to put forth the further effort that is required.
aggregate, and Lambert and Ogles (2004) assert
When this first hour begins, counselor and counselee
that, “Virtually all schools of therapy accept the
are strangers; when it ends they must have formed
notion that these [client-centered necessary and
some sort of partnership.
sufficient conditions] or related therapist relation-
(Tyler, 1953, p. 24)
ship variables are important for significant progress
in psychotherapy and, in fact, fundamental in the Tyler may have underestimated the length of
formation of a working cooperative effort between time required to establish a working alliance, as cur-
patient and therapist” (p. 173). rent research indicates that the alliance established
A number of counseling psychology research- by the third session can predict outcome (e.g.,
ers have made important contributions to our Horvath & Symonds, 1991), but it is clear that she
understanding of the therapeutic relationship as appreciated the essential focus on collaboration and
a common factor. Louis Castonguay, who has partnership that defines the therapeutic alliance.
emerged as an influential psychotherapy process Horvath and Bedi’s (2002) definition of the
researcher, conducted comparative research show- alliance “refers to the equality and strength of the
ing that the relationship is associated with out- collaborative relationship between client and thera-
come more strongly than are specific treatments pist in therapy” (p. 41) and includes positive affec-
(e.g., Castonguay, Goldfried, Wiser, & Raue, 1996). tive and cognitive elements, and an active, conscious,
Bruce Wampold (2007; Ahn & Wampold, 2001) purposeful engagement. They also note that some
has been at the forefront of the argument that writers use the terms “alliance” and “counseling/
common factors account for more variance in out- therapeutic relationship” interchangeably, but point
come than do specific techniques. Wampold’s work out that there are subtle, yet important differences
on common factors and the counseling relation- between these terms. Although the contemporary
ship represents several of the themes that have understanding of the alliance is more pantheoretical,
long been central to a counseling psychology per- the construct has roots in psychodynamic theory
spective; in his program of research, he has used and has produced a range of definitions, with vary-
the tools of empiricism to explore the “particularity” ing emphasis on individual components.
of individual counseling relationships, concluding Given the diverse perspectives on this construct,
that factors unique to a given relationship are cen- any discussion of findings needs to reference the
tral to the change process. Wampold is not con- measures developed to operationalize the alliance.
cerned with the relationship as a curative factor The three measures used most widely are the Penn
in its own right; instead, he has advanced the Helping Alliance (HA) scales (Luborsky, Crits-
argument that the relationship with the therapist Cristoph, Alexander, Margolis, & Cohen, 1983),
is critical to the client’s engagement in other aspects the Vanderbilt Therapeutic Alliance Scale (VTAS;
of the change process, with a particular emphasis Hartley & Strupp, 1983), and the Working Alliance
on client perceptions of the therapist as a trustwor- Inventory (WAI, Horvath, 1981, Horvath &
thy guide in exploration of his or her concerns Greenberg, 1986). Horvath and Bedi (2002) report

40 the coun se l in g rel atio n s h ip

high correlations among the scales cited but empha- To pursue this work, Friedlander et al. (2006) devel-
size that differences do exist in both the inclusion oped an observational rating tool, the System for
and weighting of different alliance dimensions. This Observing Family Therapy Alliances. In recent work
discussion considers research using the WAI, given (2008), they learned that, in contrast to individual
its associations with counseling psychology in both counseling, a strong alliance within the family is
its development and ongoing research (Horvath, more important to treatment success than is an alli-
1981; Mallinckrodt, 1993, 1996). ance with the counselor.
The relationship between strength of the work- Another research focus pursued by counseling
ing alliance and therapy outcome is now firmly psychologists has considered whether counselors
established, across both assessment perspectives working in online modalities can establish effective
(client, therapist, or observer) and across various therapeutic alliances. A review published in The
forms of therapy (Horvath, 2001). Horvath (2005) Counseling Psychologist by Mallen et al. (2005)
provides a succinct summary of research to date, reported that, at that time, only three studies had
noting that, “At the risk of ignoring complexity, investigated this question and had produced mixed
a reasonable summary is that the relationships results. The authors note that variables related to
reported across reviews have been quite consistent: age and familiarity with online technologies have
the alliance–outcome correlation is moderate but not been isolated in previous research, making any
significant (ranges from .22 to .29), clients’ assess- conclusions highly tentative, and that the absence
ments tend to be more predictive of outcome than of nonverbal cues in online environments can
are other sources, early alliance is as good or better increase counselor susceptibility to common stereo-
predictor of outcome than assessments taken later, types. In contrast, other research indicates that cli-
and the alliance as measured appears to be related ents can establish an effective alliance in online
to but not identical to parallel therapeutic gains” counseling (e.g., Cook & Doyle, 2002). Knaevelsrud
(p. 4). Lambert and Barley (2002), following and Maercker (2006) found that clients seeking
their review of empirical research on the alliance– online assistance for post-traumatic stress reactions
outcome relationship, noted that therapist contri- reported positive alliance scores, although there
butions to the alliance go beyond provision of the was a variable association between the therapeutic
facilitative conditions to include reaching agree- relationship and treatment outcome ( r = .13 – .33).
ment with clients on goals and tasks and to the What may be most noteworthy is the finding that,
ability to manage ruptures in the alliance (Hatcher in a population at risk for premature termination,
& Barends, 1996; Safran, Muran, & Samstag, the alliance was associated with retention in online
1994). therapy. The 48 participants in their study had a
Contemporary research continues to extend drop-out rate of 17%, which the authors note con-
the application of the alliance formulation of the trasts with reported rates of up to 28%.
therapeutic relationship to new areas of counseling Although much of the extant research has exam-
practice and research, and counseling psycholo- ined the therapeutic alliance as a predictor of ther-
gists are key contributors. As examples, Patton and apy outcome, there has been an increased call to
Kivlighan (1997) used hierarchical linear modeling move beyond a direct association. More recently,
to explore the relationship between a supervisory alliance research has examined the alliance as a
working alliance and the working alliance experi- mediating variable between provision of Rogers’ core
enced by a trainee’s clients and found parallels conditions and client outcome. As one example,
between a trainee’s perceptions of the supervisory Watson and Geller (2005) used the Relationship
alliance and his or her client’s perceptions of the Inventory (Barrett-Lennard, 1962), one of the field’s
working alliance. Bedi (2006) used multivariate earliest measures of Rogers’ conditions, and the
concept mapping to understand what factors clients WAI (Horvath & Greenberg, 1986) to explore
experienced as contributing to the development of mediation in both cognitive-behavioral and process-
the alliance and learned that clients attached impor- experiential therapy. Although the two forms of
tance to both the counselor’s personal characteristics therapy did not differ on measured therapist empa-
and to the physical setting. Friedlander and col- thy, acceptance and congruence, the core conditions
leagues (2006, 2008) have investigated alliance for- were related to outcome measures of depression,
mation and its relationship to outcome in family interpersonal distress, self-esteem and negative atti-
therapy, in which the client perspective on the alli- tudes. Importantly, the alliance mediated the rela-
ance is represented by multiple family members. tionship between the core conditions and three of

have rkam p 41
the four outcome measures. The authors argued that example, questioned whether the real relationship,
Rogers’ core conditions make their contribution to consisting of genuineness and realistic perception,
outcome by fostering a strong working alliance. This can be differentiated from Rogers’ core condition of
point echoes arguments made by other counseling genuineness. It remains to be seen whether the
psychology researchers, as noted in a subsequent recent development of measures for the real rela-
section on therapist factors in the relationship. tionship will generate research that answers the
critics.
The Real Relationship
The Empirically Supported Relationship:
To put on a mask of friendliness to cover hostility,
Report of the APA Division 29
contempt, or plain lack of interest, is to confuse
(Psychotherapy) Task Force
the client, not to help him. Signs of the real feelings
will inevitably appear during the interview. . . . I still hope that the research summaries . . . will
(Tyler, 1953, p. 27) be a help to practicing counselors trying to
distinguish between things we do simply because
A more recent arrival on the theoretical land-
they seem to work well and things we do because
scape has been Gelso and colleagues’ elaboration
of some definite research evidence.
of the real relationship component of his tripartite
(Tyler, 1953, p. x)
model (see Gelso & Samstag, 2008), in which the
other components consist of the working alliance One of the most significant advances in our
and the transferential dimensions of relationship. understanding of the therapeutic relationship has
Gelso (2004) has defined the real relationship as, emerged from the work of a task force established by
“the personal relationship existing between two or Division 29 Psychotherapy of the APA (see Norcross,
more people as reflected in the degree to which 2002). The task force was commissioned in response
each is genuine with the other and perceives the to widespread concerns over the emphasis on empir-
other in ways that befit the other” (p. 6), and argues ically validated treatments (EVTs, Norcross, 2002b),
that it both emerges in the first moments of client– as advanced by APA Division 12 (clinical psychol-
counselor interaction and is the base from which ogy; e.g., Chambless & Hollon, 1998) and counsel-
a working alliance develops (Gelso et al., 2005). ing psychology (Wampold, Lichtenberg, & Waehler,
The importance of the real relationship construct 2002). Now termed empirically supported treatments,
to research on the counseling relationship resides in these lists of therapeutic approaches, with effective-
Gelso et al’s. (2005) claim that it plays a unique ness demonstrated through randomized clinical
and significant role in both the counseling process trials and manualized treatment, were viewed as
and outcome, across types of therapy, beyond that emphasizing technique over process factors that
contributed by variables previously under investiga- have demonstrable impact (Norcross, 2002b).
tion. Research on the real relationship has been Specifically, the Division 29 Task Force identified
catalyzed by the development of measures to opera- three areas that had not received attention: the ther-
tionalize therapist and client perspectives on the apy relationship, the person of the therapist, and the
construct (Fuertes et al., 2007; Gelso et al., 2005). client’s characteristics.
To date, the authors report that the real relation- The Task Force’s goal was to identify therapeutic
ship is empirically distinct from the working alli- relationship elements that had sufficient empirical
ance (r = .47, p < .01) and demonstrates an support to qualify as components of an “empirically
independent relationship with session outcome, supported relationship,” comparable to the claims
measured as depth and smoothness of sessions of empirically supported treatments (Norcross,
(Gelso et al., 2005). 2002a). After 3 years of careful analysis, using clear
New ideas often generate controversy, and the operational definitions and rigorous selection crite-
claims advanced for the real relationship by Gelso ria, the group advanced conclusions and recom-
and colleagues are no exception (e.g., Greenberg, mendations regarding the empirical evidence for the
1994; Horvath, 2009). It appears that the primary contribution of various components of therapeutic
criticisms are definitional and concerned with the relationships to positive client outcome. Relation-
most informative and defensible means of partition- ship elements and therapist factors that had accu-
ing elements of the relationship, as well as whether mulated broad and consistent research support were
conceptual clarity can be achieved in describing categorized as either “demonstrably effective” or, in
the separate components. Greenberg (1994), for cases in which the substantive evidence was positive

42 the coun se l in g rel atio n s h ip

but still mixed, elements were described as “promis- The following section surveys some of the individu-
ing and probably effective.” ating characteristics that have been investigated as
The conclusions of the Task Force, with regard to influential in the formation or operation of the
“general elements of the therapeutic relationship” counseling relationship. Although researchers have
(Norcross, 2002a, p. 441), were as follows: Factors considered factors associated with the therapist,
with sufficient empirical evidence to be regarded as the client, and their reciprocal interaction, the
demonstrably effective included the therapeutic alli- current discussion (for purposes of managing the
ance, cohesion in group therapy, empathy, and goal scope) emphasizes therapist factors. Once again,
consensus and collaboration. Evidence to support a Leona Tyler’s words provide evidence that counsel-
conclusion of promising and probably effective was ing psychologists have been aware of these factors for
found for the factors of positive regard, congruence/ a long time, and that contemporary efforts to under-
genuineness, feedback, repair of alliance ruptures, stand their influence rest on a substantial base of
self-disclosure, management of countertransference, scholarship.
and quality of interpersonal interpretations.
The alert reader will note that many of the fac- Attachment Style
tors identified by the Task Force have been cited in
It is almost inevitable that attitudes carried over from
the current work as influential components of the
parent–child relationships should weave themselves
various models of the therapeutic relationship.
into the complex fabric of the counseling
Much of the work reviewed here was considered by
relationship.
the Task Force, and the relevance of its conclusions
(Tyler, p. 41)
to counseling psychology is supported by the fact
that approximately one-third of the Task Force A number of psychotherapy researchers have
members are counseling psychologists. The thera- explored the relevance of Bowlby’s (1969) and
peutic relationship, congruent with its now estab- Ainsworth’s (1964) work on the attachment of
lished status as a common factor in change, is an infants to their caregivers, and extensions of this
arena in which applied psychologists from diverse work to adult relationships (Bartholomew, 1994;
specializations are collaborating to understand this Bartholomew & Thompson,1995) to characteristics
most basic element of the psychotherapy process. of the counseling relationship (e.g., Mallinckrodt,
A summary list cannot begin to capture the depth of Gantt, & Coble, 1995). A steady stream of investi-
investigation that underlies the Task Force conclu- gation has explored whether client and therapist
sions, or to convey the subtle variations or individu- attachment styles (characterized as anxious, avoi-
ating factors that would inform application of these dant, or secure) influence either the type or the
findings. Interested readers are strongly encouraged strength of the counseling relationship, which can
to consult the full report of the Task Force, which also present conditions of emotional vulnerability
appears in book form (Norcross, 2002a). and stress. In general, investigators have demon-
strated that both client and therapist attachment
Variables That Influence the style are important factors in the development and
Counseling Relationship maintenance of the counseling relationship. At the
same time, the modest correlations between the
Counselors have much to say about “the counseling
range of methods used to operationalize attach-
relationship” and psychoanalysts have had still
ment style (e.g., narrative, interview, self-report)
more to say about “the transference.” What has not
mandates caution in assuming that one study’s defi-
been stressed enough in all these discussions of “the
nition of “secure” attachment is comparable to
counseling relationship” or “the transference” is the
another’s (Meyer & Pilkonis, 2002).
fact that each relationship has its own individual
There appears to be a consensus that client
characteristics; each is unique. It is on these unique
attachment style plays an important role in the ther-
characteristics of this particular relationship that the
apeutic relationship, both in ability to form an alli-
counselor should focus his attention at the beginning.
ance (Eames & Roth, 2000) and in eliciting
(Tyler, 1953, p. 35)
different response styles from a therapist (Hardy
To this point, much of our discussion has treated et al., 1999). Clarkin and Levy (2004), in their
the counseling relationship as an entity, itself, with summary of the research, suggest a paradox that,
little attention to the factors that make each relation- although attachment anxiety or avoidance could
ship unique, as Tyler so pointedly reminds us. interfere with establishing a counseling relationship,

have rkam p 43
a preoccupation with intimacy could lead to suc- a sensitive human being, he will react on an
cessful engagement over time, and that the interac- immediate unconscious level to subtle indications
tion between therapist and client attachment style of hostility in a person he is interviewing. These
is important. things will be true no matter how well-integrated
Mallinckrodt, a counseling psychologist whose a person he is and even if he has set his own
work has been influential in examining the associa- personality in order through some thorough-going
tion between attachment style and the alliance, psychotherapy before beginning his work.
worked with colleagues to develop the Client (Tyler, p. 42)
Attachment to Therapist Scale (CATS; Mallinckrodt
et al., 1995). The CATS assesses client attachment Countertransference occurs when a therapist’s
to therapists as secure, avoidant, or preoccupied by reactions to a client are based in the therapist’s ear-
assessing client perceptions of their therapist as lier conflicts or relationships, rather than in the pres-
emotionally responsive, disapproving, or rejecting, ent interaction, and are assumed to be a distortion
and the client’s wish to feel closer to the therapist. (Gelso & Carter, 1994). Although the construct of
Support for the construct validity of the CATS countertransference has roots in psychodynamic
comes from evidence that clients with difficult thought, other definitions have included all thera-
family histories experience avoidant-fearful attach- pist reactions or highlighted its interactive dimen-
ment to their therapists (Mallinckrodt, King, & sion (Gelso & Samstag, 2008). One contemporary,
Coble, 1998), whereas those with secure therapeu- integrative formulation describes it as a component
tic attachments experience a stronger working alli- of all therapy relationships (Gelso & Hayes, 1998).
ance (Mallinckrodt et al., 1995). Given that countertransference emerges in the con-
In considering the impact of a therapist’s attach- text of therapist–client interaction, it needs to be
ment style, evidence is emerging that attachment considered as another potentially influential factor
plays an independent role in the form the alliance in the formation and maintenance of the therapeu-
takes. Some intriguing research indicates that hav- tic relationship.
ing an attachment style that differs from that of the There is a longstanding consensus that unrecog-
client is beneficial, in that clients have an opportu- nized countertransference has negative effects on
nity to disconfirm their expectations of relationships psychotherapy outcome (Gelso & Hayes, 1998), in
with others (e.g., Tyrrell, Dozier, Teague, & Fallot, part by limiting the therapist’s accurate understand-
1999). Other research indicates that therapists with ing of the client (Lambert & Ogles, 2004; Singer &
less secure attachment styles may be prone to Luborsky, 1977). As Hayes et al. (1997) noted,
respond less empathically (Rubino, Barker, Roth, & “relationships predicated and sustained on illusory
Fearson, 2000). perceptions are not likely to succeed in helping cli-
Meyer and Pilkonis (2002) have recommended ents attain their goals” (p. 151).
that researchers investigate attachment as a media- Much of the early research on countertransfer-
tor in the counseling relationship. They offer a com- ence attempted to identify factors or client types
pelling rationale, based on Mischel and Shoda’s that evoked negative therapist reactions (see Gelso
(1995) social cognitive work, that attachment & Hayes, 1998), rather than investigate its role in
styles be viewed as stable individual factors that the therapeutic relationship, and the first links
are expressed in a context-dependent manner. between countertransference and the therapeutic
In other words, a client or therapist with less secure relationship were indirect. In a qualitative investiga-
attachment may not act in an “insecure” manner tion, Hill et al. (1996) reported an association
until they perceive a sense of threat or insecurity in between countertransference and client–counselor
the environment. This formulation supports an disagreement and premature termination. Coun-
interactional view of the role of attachment in the selors in the study identified their own difficult
therapeutic relationship, one that adds a situational family histories as contributing to their impasses
dimension to the current exploration of therapist with clients. As a second example, Hayes and Gelso
and client factors. (1993) and Gelso et al. (1995) found that therapists
assessed as high in homophobia exhibited avoidance
of important client material presented by analogue
Countertransference
gay and lesbian clients. Given that many definitions
The counselor’s own feelings are bound up in of the relationship cite therapist–client engagement
[the relationship]. . . . Inevitably, since he is as a central component, it seems probable that

44 the coun se l in g rel atio n s h ip

therapist avoidance would have a negative effect on Although the conceptual link between counter-
the relationship. transference and the strength of the relationship
Counseling psychologist Charles Gelso, and a strikes many as intuitively obvious, there is still
research team with links to the University of scant research to support this claim. Further com-
Maryland, have been vigorous contributors to plicating the picture, several authors have argued
research on countertransference, both in expli- that, under certain circumstances, countertransfer-
cating definitional issues and in exploring its role in ence can be employed to facilitate a counselor’s
the counseling relationship (see Gelso & Hayes, understanding of a client. Finally, it is important
2002, for a review). This group has contributed to to note that countertransference does not operate in
growing evidence that countertransference influ- isolation; Mohr, Gelso, and Hill (2005) found that,
ences psychotherapy outcome through its influ- for counselor trainees, countertransference behavior
ence on the therapy relationship. In a large-scale reflected an interaction of both client and counselor
field study of therapist trainees (Ligiero & Gelso, attachment style. These initial findings strongly
2002), both therapist and supervisor ratings docu- suggest that countertransference, by producing
mented a relationship between therapists’ negative therapist behaviors that interfere with effective
countertransference behaviors and a less effective engagement, plays a role in the formation and main-
working alliance with clients. Interestingly, ratings tenance of therapeutic relationships. However, given
of therapists’ positive countertransference (e.g., the paucity of research, conclusions must remain
being overly friendly or supportive) were associated tentative.
with lower ratings of the bond component of the
alliance. Expectancies and Preferences
Another aspect of countertransference research
[T]he first question he asks himself is, “What are this
related to the counseling relationship suggests that
person’s expectations from counseling? What does he
the therapist’s ability to manage countertransference
think is going to happen? What does he hope to get
reactions may mediate the countertransference–
out of it?”
alliance link. For example, there are demonstra-
(Tyler, 1953, p. 36)
tions of a relationship between countertransference
and empathic ability (Hayes, Riker, & Ingram, Both client and therapist bring their indivi-
1997; Peabody & Gelso, 1982), in which greater dual expectations to the therapeutic encounter.
empathic ability has been associated with both the But, it is within the relationship that expectations
therapist’s recognition and management of counter- have their effect on process and outcome, as that is
transference reactions. In a case study of a 13 ses- the arena in which they are either met or not met.
sions of psychotherapy, Rosenberger and Hayes Each of us can recall the impact of unmet expecta-
(2002) found that the therapist’s effectiveness in tions. For example, the experience of receiving criti-
managing countertransference had positive associa- cal supervisory feedback on a counseling session
tions with the client’s assessment of their working that one considered a success can leave the recipient
alliance. feeling vulnerable and exposed, perhaps angry, and
One of the most explicit discussions of the role can raise questions about either oneself or the rela-
of countertransference in the relationship comes tionship. Psychologists were quick to note the rele-
from Gelso and Hayes’ (1998) reflections on their vance of expectations to the counseling process
survey of countertransference research. They argued and relationship—one of Carl Rogers’ students
that the negative impact of countertransference may investigated the association between client outcome
result from its effect in dividing the therapist’s atten- expectations and observed change (Lipkin, 1954;
tion between his or her internal concerns and the cited by Arnkoff, Glass, & Shapiro, 2002)—and
client’s concerns. Furthermore, they asserted that there has been a lengthy history of research on the
countertransference may have an impact on psycho- role of client expectancies in psychotherapy process
therapy by first influencing the therapist and then, and outcome (Clarkin & Levy, 2004).
by extension, the relationship. Gelso and Hayes Early research appeared to support the relevance
refer to this as “limiting the therapist’s instrumen- of client expectations to the development of a strong
tality of self ” (p. 100) and argued that its effects will therapeutic relationship. Clarkin and Levy (2004)
be most noticeable in therapeutic approaches that report that, in the 1960s, a series of investigations
employ the relationship as a key mechanism of characterized client role expectations as having
change. features such as reciprocity and interdependence,

have rkam p 45
nurturance, and collaboration, as well as character- considered a common factor in treatment, and
istics associated with authority and guidance. In Lambert and Barley (2002) include such expectan-
1980, counseling psychologist E. A. Tinsley and cies in their category of “placebo effects,” assigning
colleagues (1980) developed the Expectations About as much as 15% of outcome variance to these fac-
Counseling measure (EAC), based on four empiri- tors. Alternately, derived expectations, those that
cally derived factors that assessed client anticipation emerge in a specific counseling experience, were
of client personal commitment, counselor provision illustrated in the earlier discussion of how attach-
of Rogers’ facilitative conditions, counselor exper- ment influences relationship formation, in which
tise, and counselor nurturance. clients benefited from having a counselor discon-
Many researchers have pointed out that the con- firm their expectations for relational patterns (e.g.,
gruence, or match, between client and counselor Tyrrell et al., 1999).
expectations is likely to be most influential. In an The area of expectations that has generated
early study that surveyed both clients and counsel- the most research is associated with expectations
ors, Netzky et al. (1982) found that, although both that clients bring to the therapeutic encounter.
clients and counselors viewed a strong relationship Highlen and Hill (1984) have pointed out that
as a central expectation, clients differed from coun- these initial expectations are probably most influen-
selors in raising questions that centered on whether tial in the early stages of counseling, before client
the counselor would be trustworthy and respectful. and therapist have an opportunity to correct or
Specifically, clients expected to evaluate counseling disconfirm erroneous assumptions about what the
based on whether counselors treated them as equals, process may involve. Consistent with this point,
confronted them when appropriate, and would end client expectations have been consistent predictors
counseling if the client was not benefiting. for the complementary variables of premature ter-
Several decades of research support a conclusion mination and continuation in therapy (Clarkin &
that client expectancies do have a relationship to ther- Levy, 2004). Specifically, when client expectations
apeutic outcome, although the association appears for what will happen in psychotherapy are not
to be modest and is most likely to be indirect or met, there is a significant increase in premature
mediated by third variables (Clarkin & Levy, 2004). termination (Hardin, Subich, & Holvey. 1988;
Although the therapeutic relationship has been iden- Reis & Brown, 1999). Swift and Callahan (2008)
tified as a potential mediator of the correlation note that a large body of literature supports these
between expectations and outcome, very little conclusions; they also describe the magnitude of
research has explored the role of client expectations this issue. According to their review, between 40%
as a direct predictor of the strength of the therapeu- and 60% of clients drop out of therapy before
tic relationship. Several initial studies of actual psy- any beneficial change is achieved. Furthermore, sev-
chotherapy suggest that expectations may play a eral authors have pointed directly to unmet client
significant role. Joyce and Piper (1998) reported expectations as a key factor in premature termina-
a strong association between client expectations tion (e.g., see Wierzbicki & Pekarik, 1993, for
and the alliance, whereas two investigations by a meta-analysis).
counseling psychologists Al-Darmaki and Kivlighan One area within the body of research on client
(1993) and Tokar et al. (1996) produced mixed expectations that has been catalyzed by work on
findings. More recently, Rizvi et al. (2000, cited in premature termination is that of expectations held
Clarkin & Levy, 2004) found that client expecta- by clients outside the dominant culture. Comas-
tions, in comparison to therapist variables and Diaz (2006) reports earlier research, conducted
problem severity, were the strongest predictor of with colleagues, in which she studied both pre-
the therapeutic alliance for clients diagnosed with therapy expectations and expectations for therapists
borderline personality disorder. that were held by clients of color. Although she
Before further discussion, it is useful to consider found that “people of color have a complex set of
important distinctions between the various types of expectations related to the cultural variation in the
expectancies that may operate in a counseling rela- clinician’s role” (p. 93), she links this finding to
tionship. Garfield (1978) differentiated between recommendations for managing a multicultural
the expectations that clients bring into counseling relationship from a position of cultural empathy.
and those that develop out of experience with a In my view, one of the major contributions of
specific counselor; both can be influential. A client’s Comas-Diaz’s work, as well as that of the larger
initial, positive expectancies for change can be body of work on unmet expectations and premature

46 the coun se l in g rel atio n s h ip

termination, is that it invites us to reconsider what underlying beliefs and attitudes—not only on the
we are measuring when we investigate client expec- part of clients, but also on the part of counselors.
tations. A brief discussion follows. To illustrate this point, it is informative to con-
As noted above, little research explores a direct sider research on client and counselor expectations
link between unmet client expectations and the associated with class and socioeconomic status
therapeutic relationship. However, it appears likely (SES), as the association between client expectations
that these effects may be partially mediated by rela- and premature termination is particularly descrip-
tionship factors. Two areas of expectancy research tive of clients in disadvantaged economic circum-
that are directly relevant to the counseling relation- stances. A body of research on expectations emerged
ship are those focused on role expectations (in con- in the 1960s and, although cited sporadically, is
trast to client expectations for therapy effectiveness largely ignored. Smith (2005), responding to a 2000
or outcome) and those focused on client preferences, APA Resolution on Poverty and Socioeconomic
which refer to therapist characteristics one would Status, notes that, “Researchers of the 1960s had
choose if given the option. Role expectations refer to already established that poor clients terminate treat-
the behaviors one expects or considers appropriate ment prematurely—why, four decades later, does
in a given encounter and, for clients, can apply to that still constitute the sum of psychology’s knowl-
their own behavior or that of the therapist. Therapists edge about them?” (p. 690). Research conducted in
undoubtedly hold role expectations, as well; how- the 1960s and the 1970s is relevant to a discussion
ever, the overwhelming emphasis in expectancy of expectations but, to the surprise of some, chal-
research has been on client expectations. lenges our assumptions about therapist expectations,
An issue that has not been addressed in the rela- an area that may be amenable to therapist modifica-
tionship literature, but which may be critical to our tion and one likely to have indirect influences on
understanding, is an examination of the cognitive the therapeutic relationship.
structure and dynamic influence of expectations. In 1971, Graff, Kenig, and Radoff reported that
Expectations consist of what we think will, or therapists believed that poor people were unlikely to
should, happen and, as an independent construct, benefit from therapy (expectation) and, in any
appear to have limited predictive power. However, event, would drop out prematurely (expectation).
they may represent the tip of a cognitive iceberg, Lorion’s (1973, 1974) significant work on psycho-
particularly as highly cultural “signs” of the belief therapy with the poor refuted the notion that the
structures that give rise to expectations. Similar to lack of psychotherapeutic effectiveness was attribut-
other cognitive frames that we use to interpret able to clients’ unrealistic expectations about psy-
the world, expectations can arise from preexisting chotherapy; instead, he made a convincing argument
beliefs or prior experience. This formulation has that therapist attitudes and biases (a source of expec-
received recent attention from cognitive-behavioral tations) contributed to treatment failures. In sup-
therapists; Leahy (2008), for example, describes the port of this argument, consider research conducted
therapeutic relationship as reflecting therapist and by Jacobs et al. (1972), in which a brief, pre-therapy
client interpersonal schemas. When we measure orientation was provided for poor clients and, for
expectations, we are probably obtaining a window their therapists, a session to enhance awareness of
on existing cognitive schemas for how the world class and cultural factors. Findings indicated that
“should” work, according to either therapist or the orientation was associated with significant
client. A similar argument may apply to another increases in client continuation in therapy, when
construct employed in relationship research, that of both clients and therapists received the orientation,
“matching” client and therapist on various demo- and if only the therapist received the orientation. This
graphic characteristics; those issues are addressed in research did not assess the status of the therapeutic
a subsequent section that explores research on diver- relationship directly, so any connection must be
sity and the relationship. speculative; on the other hand, the fact that a brief
For individual clients, an expectation may reflect intervention for therapists produced positive effects
a belief about themselves (“I don’t believe anyone suggests that it had an impact on the connection
would care about me”) or a group to which they that therapists established with clients.
belong (“In my experience, people of my sexual ori- Our dominant models of the therapy relation-
entation may not be accepted”). The real relevance ship—the empathy, positive regard, and congruence
of expectancies to the strength of the counseling of Rogers’ facilitative conditions and the task, bond,
relationship may consist in what they tell us about and goal components of the working alliance

have rkam p 47
(Horvath, 1981)—will surely be undermined if experienced therapists. Mallinckrodt and Nelson
therapist attitudes and biases produce expecta- (1991) identified a series of complex interrelation-
tions that clients are not engaging in the way they ships between training level and working alliance,
“should” or are expected to. Future research on the and no differences on the bond component of the
role of attitudes and stereotypes, and more research alliance.
on therapist expectations, may offer promise in Recognition of the complexity of therapist eff-
advancing this dimension of relationship research. ects may contribute to what Beutler et al. (2004)
As further context for that effort, we can consider have described as a “precipitous decline” (p. 289)
what has been learned about other therapist factors in research on therapist variables. Although they
in the formation and maintenance of the therapeu- express dismay over this shift, the authors also point
tic relationship. out that researchers have reconceptualized many of
the variables previously employed in investigating
Therapist Factors therapist characteristics, going beyond observable
characteristics such as gender or age to an investiga-
Different personalities inevitably produce differences
tion of associated attitudes or values. For example,
in the way in which any specified counseling
contemporary research is investigating “ageism”
procedure will be used. Two counselors who are
rather than age, or sex role attitudes rather than bio-
attempting to use the same technique may not be
logical sex. Similarly, researchers are giving more
producing at all the same psychological effect.
attention to therapist factors or skill that emerge
(Tyler, 1953, p. 291)
situationally, rather than generally, such as the ear-
An interesting paradox exists in the history of lier point that client attachment style may elicit dif-
psychotherapy research: From some of the earliest ferential responses from therapists (Hardy et al.,
research on counseling outcomes, investigators 1999). The field does appear to be shifting to greater
have hypothesized that outcome would be related recognition of interactive and internal therapist fac-
to differences in the strength of the counseling rela- tors; some of these domains of research are described
tionship and to differences in various therapist char- below.
acteristics (e.g., level of experience, training,
ethnicity), but the two domains were not consid- therapist interpersonal style:
ered together. Until very recently, little research has reciprocity/complementarity and
examined therapist differences in forming or main- circumplex research
taining the counseling relationship (Baldwin et al.,
Counseling succeeds best when it steers clear of
2007).
the autocratic attitude on the one hand and the
The majority of research on therapist characteris-
laissez-faire on the other. . . .[and] views it always
tics has treated these factors either as independent
as a cooperative venture in which the two
predictors or as “matching” variables, paired with
participants are making contributions of different
client demographic characteristics. The most note-
sorts.
worthy conclusion that can be drawn from many
(Tyler, 1953, p. 102)
decades of research is that therapist characteristics
such as age, sex, race/ethnicity, training, skill, expe- One aspect of therapist behavior that has been a
rience, and style are poor predictors of outcome focus of relationship research in the past 30 years
(Beutler et al., 2004). When similar variables have concerns whether the therapist’s interpersonal style
been examined as predictors of relationship quality, provides an effective complement to the client’s style;
they have also produced equivocal results but also in this domain, complementarity is defined as sup-
demonstrate the limitations of treating therapist porting or confirming a client’s preferred style (Sexton
characteristics as isolated variables. For example, & Whiston, 1994). Although there is not a great deal
whereas Dunkle and Friedlander (1996) found that of research in this area, results have generally sup-
therapist experience did not predict strength of the ported the contention that complementary interper-
working alliance, Kivlighan et al. (1998) uncov- sonal styles between therapist and client are associated
ered a more complex association: Overall, therapist with positive relationship development, particularly
experience had no association with relationship in the early stages of counseling (Beutler et al., 2004;
strength but, for difficult clients, experienced thera- Caspar, Grossman, Unmussig, & Schramm, 2005;
pists achieved stronger relationships than did less Sexton & Whiston, 1994, Tracey, 1986).

48 the coun se l in g rel atio n s h ip

 Beutler et al. (2004) reviewed recent research Beutler et al. (2004) ended their discussion
and identified three subcategories of research in this of complementarity with an expression of concern
area: investigations of complementarity in inter- that this area of research is disappearing; however,
personal style; assessments of reciprocal verbal pat- their conclusion may have been premature. Recent
terns of interaction, focused on how a topic of frustration with static models of the counseling
conversation is negotiated through speaking turns; relationship (Angus, March 25, 2009, personal
and investigations of nonverbal or multichannel communication) has reactivated interest in more
communication, with an emphasis on the level of interactive models. A special issue of the journal
correspondence between verbal and nonverbal Psychotherapy Research (2005; Vol. 15, 1–2) explored
expression. a range of topics identified as germane to comple-
The first domain, that of complementarity in mentarity and interaction within the relationship.
interpersonal style, emerged from Leary’s (1957) Among others, these include perspective divergence
interpersonal circle, which posits that persons on dif- in the working alliance (Fitzpatrick, Iwakabe, &
ferent points of the circle are continually negotiating Stalikas, 2005), nonverbal relationship regulation
the two relationship dimensions of control (to assert (Benecke, Peham, & Banniger-Huber, 2005), ther-
or submit) and affiliation (to be friendly or hostile). apist–client connection in building the alliance
Benjamin (1982), Kiesler (1982), and Wiggins (Sexton, Littauer, Sexton, & Tommeras, 2005), and
(1982) extended the circumplex model to client– a new model of complementarity in the therapeutic
therapist interactions in psychotherapy. Research in relationship (Caspar et al., 2005). This renewed
this area, including contributions by counseling psy- interest is also reflected in the use of methods not
chologists (Kivlighan, McGovern, & Corazzini, often employed in relationship research; for exam-
1984; Reandeau & Wampold, 1991), generally sug- ple, Lepper and Mergenthaler (2007) employed
gests that complementary styles (e.g., similarity on conversation analysis, a qualitative method that
the friendly–unfriendly dimension and dissimilarity applies a contextualized turn-by-turn analysis of
on the dominant–submissive dimensions) are associ- talk, to examine the emergence of the therapeutic
ated with positive relationship development (Tracey, bond in a single dyad case study.
1986). In anticipating the next 40 years of psychother-
In a 1994 review of research, Sexton and Whiston apy research, process researcher Lynne Angus
(1994) identified 14 counseling psychology investi- predicts that influential therapist effects will reflect
gations of complementarity, indicating that this has the qualities of “responsiveness” and “attunement”
been an area of interest for the field. An illustrative (Angus, 2009). Indirect—and somewhat amusing—
example can be found in research conducted by support for Angus’ prediction comes from research
Terence Tracey, who explored client–counselor reci- that has examined the use of manualized treatment
procity in negotiating the topic focus of counseling protocols in controlled studies. In these research
sessions. In a series of investigations between 1985 trials, it appears that the most effective therapists
and 1989, Tracey and colleagues identified several did not conform to the manualized instructions
associations between complementarity and the coun- (Strupp & Anderson, 1997) and further, there was
seling relationship. To cite two examples, they found a negative correlation between measures of therapist
that high levels of client–counselor agreement on interpersonal skill and ability to learn the manual-
topic determination were associated with continua- ized approach (Henry, Schacht, Strupp, Butler, &
tion in counseling, a finding that was subsequently Binder, 1993a; Henry, Strupp, Butler, Schacht, &
cross-validated in a new sample (Tracey, 1986), and Binder, 1993b).
that more experienced counselors (in comparison The first years of the 21st century produced
to trainees) were more likely to use noncomplemen- a rapid escalation of interest in therapist effects, and
tary responses to challenge client’s problematic inter- a growing number of researchers contend that ther-
action patterns (Tracey & Hayes, 1989). Beutler et al. apist contributions have their effect via their role in
(2004), summarizing research in this area, noted that, forming strong, effective therapeutic relationships
“such findings suggest that a subtle pattern of col- (Wampold, 2007). As an example, Lutz and col-
laboration and tacit agreement exists between patient leagues (2007) studied a naturalistic dataset of 1,
and therapist in successful treatment, which may be 198 clients and 60 therapists and found that,
particularly important in the development of the whereas 8% of total outcome variance was attri-
therapeutic relationship” (p. 244). butable to therapist effects, 17% of the variance in

have rkam p 49
clients’ rate of improvement was attributable to (Lichtenberg et al., 1988), and being perceived as
therapist factors. Although not discussed by the “cold” (Hersoug, Monsen, Havik & Hoglend,
authors, one can speculate that the more we attend 2002) and as irritable (Sexton, 1996).
to moment-by-moment interaction between client Although there is little empirical evidence in this
and therapist, the larger the proportion of variance area, it is fair to say that our profession holds an
may be. Lutz et al.’s results produced proportions assumption that therapist distress or maladjust-
that are very similar to results obtained by other ment can have a negative impact on the counseling
investigators who have begun dismantling therapist relationship. Implicit evidence for this claim comes
contributions to the alliance and to outcome. from our professional ethics codes, which require
Bruce Wampold is a counseling psychologist psychologists to “refrain from initiating an acti-
whose research has brought greater attention to ther- vity when they know or should know that there is
apist effects. In an APA award address in 2007, he a substantial likelihood that their personal prob-
argued that “there is increasing evidence that it is the lems will prevent them from performing their
therapist and not the treatment per se that is respon- work-related activities in a competent manner”
sible for therapeutic change . . . and, it appears that (American Psychological Association [APA], 2002,
much of the variability among therapists is due to Standard 2.06a) and, “When psychologists become
therapists’ ability to form a working alliance with a aware of personal problems that may interfere with
variety of patients” (p. 868). As we move ahead with their performing work-related duties adequately,
our efforts to understand the counseling relation- they take appropriate measures, such as obtaining
ship, it is becoming increasingly clear that we must professional consultation or assistance, and deter-
also increase our efforts to understand what is con- mine whether they should limit, suspend, or termi-
tributed by the individual therapist. As we do so, nate their work-related duties” (APA, 2002,
there is a perennial area of research that receives little Standard 2.06b).
attention and is cited rarely in surveys of the thera- A substantial and possibly overlooked body of
peutic relationship: that of the therapist’s personal research may be relevant to the question of how
adjustment and well-being. therapist well-being effects the counseling relation-
ship. Given the ubiquity of computerized literature
Therapist Well-being, Mental Health, searches driven by author-selected key words,
Adjustment it appears likely that relevant research on this topic
has been categorized in other domains and not
One can say, for instance, that a counselor should
integrated with relationship research. For example,
be a very stable, well-adjusted individual himself so
Nutt-Williams, Hayes, and Fauth (2008) report
that the help he attempts to give others with their
that, for therapists, there is a consistent posi-
problems will not constitute a case of the blind
tive association between anxiety, negative self-talk,
leading the blind. It can just as well be said, however,
and lower self-assessments of effectiveness. Nutt-
that a counselor should have experienced anxiety,
Williams and Hill (1996) found that, as trainees
conflict, and indecision in his own life so that he
increased their level of negative self-talk, clients
can understand it in others.
rated them as less helpful. In a review of counselor
(Tyler, 1953, p. 267)
supervision literature, Ladany et al. (1999) found
Although many practitioners would accept the that a weaker supervisory working alliance was
idea that a therapist’s level of adjustment or distress related to supervisors’ lack of adherence to ethical
could have an impact on the therapeutic encounter, guidelines. Ethical violations can reflect interper-
there has been surprisingly little research on this sonal difficulties, a hypothesis that gains some sup-
topic, and even less on the relationship between port from Nigro’s (2004) work: Her qualitative
therapist adjustment and the counseling relation- survey of problematic dual relationships ( N = 206)
ship. Beutler et al. (2004) report a very modest documented negative consequences in therapists’
positive relationship between therapist well-being relationships with clients.
and therapeutic outcome, with an average effect Another area that suggests a connection between
size across nine studies of r = .12 ( p < .05). Horvath therapist factors and relationship quality is the lim-
and Bedi (2002), in their review of research on ited research on trainee impairment. In their major
the working alliance, cite several negative thera- contribution and review, Forrest et al. (1999) noted
pist characteristics that have been associated with that much of the research has focused on trainees
poor alliance formation: a “take charge” approach whose impairment is in the area of clinical and

50 the coun se l in g rel atio n s h ip

interpersonal skills. They further report that “we can tentative and preliminary. Lambert and Ogles
assume that most training programs in any 3-year (2004), in their review of research investigating the
period are probably dealing with four to five role of training, reported that therapist training had
impaired or possibly impaired trainees (and) will no relationship to outcome or to strength of the
dismiss one of those trainees” (p. 652). therapeutic alliance. However, a therapist or trainee’s
A student or researcher conducting a search on level of interpersonal skill had a significant and posi-
the key words “therapeutic relationship” would be tive relationship with both outcome and the alliance.
unlikely to uncover any of the research cited above. Despite consistency in results, there are too few
This may reflect a tendency to define relationship- studies to draw firm conclusions; one has to wonder
relevant research too narrowly. As we learn more why this area has received so little attention.
about the specificity of therapist contributions to Several investigators have evaluated the effects
relationship formation and maintenance, factors of specific training programs, and the results have
such as interpersonal skill and ethical adherence are not been encouraging. Henry et al. (1993a) pro-
likely to assume a greater role, and merit future vided systematic training on development of the
research. alliance but failed to produce gains in therapists’
ability to create stronger alliances. Horvath (2005)
Capacity for Relationship: Training reported on his own survey of projects designed to
and Selection of Counselors and train therapists in alliance skills, in which he found
Psychotherapists that the majority of such efforts failed to demon-
strate an association between training and a result-
The difficulty is that people with the necessary
ing positive alliance, whether assessed by clients or
mental ability and a strong desire to do counseling
independent raters. Intriguingly, he also noted that,
do not all show the personal characteristics that
although few identifiable skills were associated with
make for success and satisfaction. It is just these
alliance strength, researchers were successful in
personal characteristics which at present we are not
identifying personal attributes associated with alli-
able to analyze or predict.
ance strength (e.g., flexibility and warmth).
(L. Tyler, 1953, p. 267)
Crits-Cristoph and colleagues (2006) inves-
The field of relationship research is entering tigated whether training in “alliance-fostering
a new era: Psychotherapy researchers have identified psychotherapy” (p. 268) would enable practicing
the therapeutic relationship as our most consistent therapists to enhance their alliance with clients
predictor of outcome (Horvath & Bedi, 2002; Imel diagnosed with major depressive disorder. Note-
& Wampold, 2008), and further evidence is accu- worthy as a field study with actual therapists and
mulating that it is the therapist who carries the clients, the increases in alliance ratings for therapists
greatest weight in determining whether an effective failed to reach significance; further, decreases in alli-
relationship will be established. This presents the ance scores were observed for two of the five thera-
whole edifice of psychotherapy training with a pro- pists . The authors also noted that therapists varied
found challenge: If the most influential factor is in their general tendency to form positive alliances
the therapist, what is it about the therapist that mat- and that differences were unrelated to training.
ters? And, once those characteristics or skills are On a more positive note, a series of qualitative
identified, are they something that can be taught? investigations conducted with therapist trainees in
These may be uncomfortable questions for counsel- Norway (e.g., Nerdrum & Ronnestad, 2002, 2004)
ing psychologists. Although Tyler’s comments indi- documented positive outcomes in empathic under-
cate that such questions are not new, we have just standing following an empathy training program. At
begun to address them in a systematic fashion. Our the same time, qualitative results exploring the train-
historical values have emphasized the potential for ees’ perceptions indicated that many found it stress-
growth in each individual—each trainee—and we ful and difficult to change their preferred style.
may resist the idea that there are trait-like qualities One significant project that has the potential to
that determine who will, or will not, be effective in inform future research on the potential for training
developing therapeutic relationships. in therapist relationship skills is the Collaborative
At the same time, our legacy of empiricism pro- Research Network established by the Society for
pels us into an examination of these questions. What Psychotherapy Research. A summary report for this
little research has been conducted to date presents large-scale, international project (Orlinsky &
findings that are challenging, although admittedly Ronnestad; 2005) notes that, among the more than

have rkam p 51
5,000 therapists who participated, there were four Corbishley and Yost (1989) noted that several
identifiable patterns of engagement with clients: aspects of career counseling (e.g., the relationship
effective, challenging, disengaged, and distressing. and client resistance) require a psychological app-
Of concern, 17% of respondents reported disen- roach. Swanson (1995) argued that the process
gaged relationships and 10% reported distressing of career and personal counseling should be
engagement. The evidence that 27% of this sample regarded as similar, in that both require many of
described a stance toward therapeutic engagement the same skills, including a negotiation of client
that runs counter to descriptions of effective coun- and counselor roles and a relationship that supports
seling relationships calls to mind some of the research the client’s sharing of personal information.
cited earlier: Wampold’s findings on the variability A useful resolution to the debate was offered by
in therapist effectiveness and Forrest et al.’s report of C. H. Patterson who, in a postretirement inter-
the percentage of trainees identified as impaired view, remarked that, “Basically, the counselor as
while still pursuing their education. As Beutler et al. an understanding person is the commonality
(2004) note, “high levels of therapist well-being between therapy and career counseling” (Freeman,
cannot be assumed to be present among therapists 1990, p. 297) and, “You still need to think in terms
in research studies. It may be a hidden moderator of of the core conditions of counseling, whether it is
many contradictory or inconsistent therapy find- career counseling or not. The core conditions are
ings” (p. 276–277). The Orlinsky and Ronnestad the principles of any good relationship” (p. 292).
(2005) report concludes with some pointed recom- Patterson’s reference to the familiar core condi-
mendations. In particular, they argue that the avail- tions suggests that the counseling relationship
able evidence points to the importance of relational should be considered as central to client change in
skills that students bring to their training experi- career counseling. However, few empirical conclu-
ence, as opposed to those that may be developed sions can be drawn, given that there continues to be
through supervision, and they recommend that pos- a paucity of research in this area. This is a curious
session of good interpersonal skills become a crite- state of affairs—not only is career counseling one
rion in selection for psychotherapy training. of the defining domains of counseling psychology, it
also reflects some of the strongest applications of
Career Psychology and the our empiricist tradition, in which theory, assess-
Counseling Relationship ment, and intervention have been subjected to rig-
orous scrutiny (Fouad, 2007).
How would such a job suit Barney?. . . . It is to
The absence of research cannot be attributed to
be noted that [the counselor] has not picked out
the discipline’s failure to call attention to this gap.
a job for the client and is not preparing to sell
Swanson, in 1995, issued an urgent call for research
him a new idea. That would be out of keeping with
on process aspects of career counseling, including
the counseling relationship he has worked hard to
the role of the counseling relationship. Her encour-
create. He is simply insuring that the task the two
agement for additional research continues to be
of them are working on together, the consideration
cited (e.g., Whiston & Rahardja, 2008), typically in
of occupational alternatives and the choice of one,
either the introductory or summary paragraph of an
will be carried out as thoroughly and efficiently as
article on career counseling research, by authors
possible.
who lament the fact that there continues to be little
(Tyler, 1953, p. 175)
new to report in the process arena. This may be
A longstanding debate has existed within coun- overstating the case to some degree; it is clear that
seling psychology as to whether career and per- Swanson’s call did catalyze new research on the role
sonal counseling constitute independent domains of the counseling relationship in career counseling,
of practice or share much in common. The question which is reviewed below. However, there continues
is relevant to any discussion of the role of the coun- to be much more to learn.
seling relationship in career counseling, as one Overall, the conclusions that can be drawn
needs to consider whether the compelling findings from the limited research available are that effective
obtained for its role in psychotherapy and personal career counseling includes operation of a strong
counseling can be extended to the career arena. counseling relationship or working alliance, and
In general, those who have addressed the issue have that clients, counselors, and independent observers
pointed to commonalities: Crites (1981) described comment on its importance. However, the associa-
career counseling as an interpersonal process, and tion between the relationship and client outcomes

52 the coun se l in g rel atio n s h ip

is less understood or investigated than is the case in career client outcome have been mixed; the 1998
psychotherapy and personal counseling. study failed to find an association, but the 2001
Several early investigations used a case study study found that the alliance accounted for 17% of
method to investigate relational issues. Kirschner, the variance in outcome. Some reviewers (e.g.,
Hoffman, and Hill (1994) examined seven sessions Whiston & Raharja, 2008) have characterized this
of successful career counseling with a midlife as a weak association. However, recent summative
woman; their critical incident analysis identified an reviews of psychotherapy alliance research report an
important role for the counseling relationship. average association between alliance and outcome of
Specifically, client and counselor discussions of the .21, with a median effect size of .25 (Horvath &
counseling relationship were rated as positive criti- Bedi, 2002), suggesting that the results obtained by
cal incidents, whereas avoidance of discussion of Multon et al. are not widely discrepant.
the relationship was rated as a negative critical inci- An important program of research conducted by
dent. Heppner and Hendricks (1995) conducted Kim and colleagues has included the counseling rela-
a case study of two career clients, one classified as tionship among the variables explored in career
undecided and a second as indecisive and, in the counseling with Asian American clients. Kim and
context of assessing the utility of career interven- Atkinson (2002) identified an unexpected associa-
tions, determined that the counselor–client rela- tion, in that clients who endorsed high levels of Asian
tionship was important for both clients. This finding values rated an Asian American counselor as more
echoes the results of an investigation of career cli- empathic, but rated a European American counselor
ents who were either moderate or high in distress as more effective. In a further investigation (Li &
(Rochlen, Milburn, & Hill, 2004); although the Kim, 2004), in which a Euro-American counselor
more distressed client desired more active skill train- offered either directive or nondirective career assis-
ing, the two types did not differ in their perceptions tance, the Asian American clients, regardless of their
of the therapeutic relationship. endorsement of Asian values, associated the directive
In a large-scale, longitudinal field study in counselor’s approach with greater empathy, a stron-
Britain, Bimrose et al. (2004, 2005) conducted ger alliance, and cultural competence.
in-depth case studies of 50 career clients to identify In a qualitative study designed to identify influ-
effective career practice and its impact on clients’ ential aspects of the counseling process, Whiston
lives. In the analysis of counselor interventions, both and colleagues (2005) interviewed 12 vocational
clients and independent raters identified the devel- counseling experts and learned that each considered
opment of a working alliance as one of four core cat- the counseling relationship to be central to his or her
egories that characterized the career sessions. The work. Specifically, these counseling experts viewed
project’s detailed analysis offers one of the most com- the relationship as essential for supporting clients in
prehensive descriptions of career practice available, the exploration stage, as well as in forming a trusting
and its attention to the importance of the counseling base from which they could implement more chal-
relationship in career guidance is noteworthy. lenging interventions (e.g., challenging beliefs that
The most direct investigations of the role of the interfered with exploration or decision).
counseling relationship in career counseling have As noted previously, there is a very limited body
been conducted by Multon and colleagues (Heppner, of research that has explored the counseling rela-
Multon, Gysbers, Ellis, & Zook, 1998; Multon, tionship as a specific factor in career counseling.
Heppner, Gysbers, Zook, & Ellis-Kalton, 2001; However, there have been a series of investigations
Multon, Ellis-Kalton, Heppner, & Gysbers, 2003). that provide indirect evidence for its role in the
In each investigation, the researchers documented career counseling process. Perhaps the most impor-
the operation of a strong working alliance between tant of these is the global conclusion that emerged
career clients and their counselors and found that from a meta-analysis conducted by Whiston et al.
the strength of the alliance increased across sessions (2003). Based on a comprehensive review, they con-
(Heppner et al., 1998; Multon et al., 2001). The cluded that counselor-free career interventions are
strength of the measured alliance is noteworthy; for significantly less effective that those that include
example, Multon et al. (2003) obtained a mean active engagement by a counseling professional. To
alliance rating of 71.54, out of a maximum score further elaborate on the indirect evidence that has
of 84, with a mean item response of 5.96 on a seven- emerged, several investigations are noted briefly.
point Likert scale. Multon and colleagues’ findings Gold et al. (1993) determined that affective
regarding the relationship between the alliance and components of the career counseling process

have rkam p 53
(e.g., the experience of counselor support and A domain of counseling practice that has relevance
encouragement) were associated with the greatest for our discussion of the counseling relationship,
change in clients’ vocational identity. Anderson despite a marked absence of research investigation, is
and Niles (2000), in a study that identified help- the use of standardized testing. The current discus-
ful events in career counseling, reported that both sion attempts to catalogue what little research has
counselors and clients cited provision of emotional emerged in this area because, in contrast to many
support as important to client gains. McIlveen areas of psychotherapy, the counseling psychology
(2007) conducted phenomenological research on approach to the use of standardized assessment rep-
implementation of a constructivist career assess- resents a clear, historically embedded example of a
ment and guidance intervention and found that distinctive counseling psychology approach to prac-
counselors emphasized the importance of embed- tice, one that is wholly grounded in the field’s con-
ding the intervention within an established counsel- ceptualization of the core relationship between
ing relationship. counselor and client. And yet, this is an area virtu-
Healy (2001) investigated factors that hindered ally ignored by researchers.
counselor effectiveness in career counseling; the Students of the history of applied psychology
findings indicated that clients reacted negatively to may recall that expertise in standardized assessment
counselors who were perceived as inadequate, as was one of the first and most significant areas of
inattentive, and as delivering the results of standard- practice that differentiated psychology from the
ized testing in a mechanistic fashion. Although the medical domain of psychiatry. Furthermore, coun-
counseling relationship was not assessed directly in seling psychology was rapidly differentiated from
this study, few would argue that these identified clinical psychology in its endorsement of testing
characteristics are compatible with Rogers’ core practice that was focused on the needs of the client,
conditions; and, Healy’s attention to the importance and in advocating selection of tests that met client
of attending to relational factors when using stan- goals, rather than those of persons interested in cat-
dardized assessment provides an introduction to the egorization or diagnosis. As early as 1959, Barbara
next topic of interest. Kirk and one of her students (Rudikoff & Kirk,
In a final example, Dorn (1988) employed 1959) provided guidance to counselors for commu-
Strong’s social influence model in exploring the role nicating test information in a manner that clients
of the relationship in career counseling and used could comprehend and accept, anticipating a unique
the Counselor Rating Form (Barak & LaCrosse, counseling psychology perspective on the use of
1975) in process research with a single career client. standardized test information.
He found that client ratings of the counselor’s Exp- In 1986, Tinsely and Bradley asserted that the
ertness and Trustworthiness were uniformly high use of testing, and its interpretation, is best viewed
across sessions, whereas ratings of the counselor’s as an integral component of the counseling process,
Attractiveness were high in session 1, dropped in rather than as something separate and distinct from
session 3, then increased for session 5. This provides other aspects of the work that counselors and clients
another speculative glimpse of relationship develop- do together. In 1990, Jane Duckworth advanced
ment as a dynamic process, in career as well as per- a classic formulation of a counseling psychology
sonal counseling. approach to testing, one that placed the client’s con-
cerns in a central role and described how the process
The Counseling Relationship in of test use was integral to an overarching counseling
Standardized Assessment relationship. If some readers are unfamiliar with this
classic reference, I encourage each of you to read
It is not so many years ago that Bordin and Bixler,
Duckworth in its entirety; your practice will be
thoroughly imbued with the nondirective attitude,
enhanced. As one example, consider Duckworth’s
first proposed that tests should be chosen by the
advice to counselors on what elements of a test
client rather than by the counselor. At first it seemed
interpretation to address:
to many workers to be a fantastic idea, but as it was
tried out it began to seem quite a natural sort of Focusing on personal strengths as well as weaknesses
procedure. Its great advantage is that it keeps an leads to a more balanced picture of the individual
essential feature of the situation clear for the who is coming in for testing. It also lets clients know
counselee—namely, that he is to make the decisions that they can assist in their own treatment because
by which the course of his life is to be governed. they do have strengths . . . [this] approach to testing
(Tyler, 1953, p. 143) enlists the power of the client as well as the expertise

54 the coun se l in g rel atio n s h ip

 of the therapist to effect the therapeutic change. The (p. 203). Although readers familiar with the client-
assumption is made that clients can be powerful and centered perspective advocated by Tyler (1959),
solve problems when they have accurate information Kirk (Rudikoff & Kirk, 1959), Tinsley and Bradley
about themselves. (p. 201) (1986) and Duckworth (1990) will not be surprised
Other authors have addressed this issue; Prediger by the meta-analytic findings, these pioneering
and Garfield (1988), in offering a checklist of test- authors are virtually invisible in contemporary dis-
ing competencies and responsibilities, included the cussions of how to conduct a collaborative test
item, “Apply good counseling to test interpretation interpretation to achieve measurable impact on
by attending to the counselee first and the test therapy process and outcome. Further, a review
results second” (p. 53). Although indirect, these conducted for the current discussion identified no
established and noteworthy counseling psychology research with an explicit focus on the role of the
authors and researchers have pointed to the impor- counseling relationship in clients’ ability to make
tance of the counseling relationship in effective use constructive use of test data.
of standardized testing. One could argue that this is a missed opportu-
The activity of communicating test results can be nity to elucidate a distinctly counseling psychology
conceptualized as a form of client feedback and perspective on a core therapeutic activity. The use of
Claiborn et al. (2002), in a review of this aspect of standardized measures continues to be an important
the counseling relationship, report that feedback is aspect of applied psychology practice and I believe
most likely to be considered within a collaborative that counseling psychologists, with their distinctive
therapeutic relationship, and that positive feedback perspective on both the counseling relationship and
appears to be associated with establishment of the use of assessment, could make a significant con-
strong therapeutic relationships. Furthermore, tribution in elucidating how relationship factors
they note that the therapist’s position, conceptual- and assessment interact. Whiston et al. (2005)
ized according to Stan Strong’s social influence noted that a strong counseling relationship can pro-
model of expertness and attractiveness/similarity, vide a secure base for client exploration of poten-
plays an important role in client acceptance of test tially challenging material and, when used in the
feedback. service of client goals, tests often provide this sort of
In 1997, Finn and Tonsager published a report information. I encourage researchers to explore the
that described the positive impact of Minnesota role of the counseling relationship in the domain of
Multiphasic Personality Inventory (MMPI) inter- standardized assessment and, in particular, as a facil-
pretations on clients’ sense of self and encouraged itating factor in counselee acceptance and use of
the use of tests as an active means of engaging clients data derived from standardized assessment.
in both the therapeutic relationship and the work of
psychotherapy. Their work on the potential benefits Diversity and the Counseling Relationship
of test data as an intervention—akin to feedback– The accepting attitude is the opposite of
continues to be widely cited but, to date, does not contempt . . . and, it is a feeling about an individual,
appear to have had a significant impact on practice. not about mankind in the abstract. Lofty
Curry and Hanson (2010) conducted a national generalizations about the dignity of personality are
survey of counseling, clinical and school psychology irrelevant to it. . . . It is because acceptance is so
practitioners with respect to both their graduate closely tied to understanding the person as an
training and current practice in providing test feed- individual that the two qualities we have stressed
back; one third indicated that their training experi- cannot be separated, in counseling or anywhere else.
ence had not prepared them to deliver feedback. (Tyler, 1953, p. 26)
Of equal concern from an ethical perspective, only
one third reported providing verbal feedback each Counseling psychology’s distinctive perspective
time tests were administered to clients. on the therapeutic relationship, as argued previ-
A meta-analysis (Poston and Hanson, 2010) of ously, is an enactment of values that have long been
the impact of psychological assessment as a therapeu- central to the field’s identity. One area where this is
tic intervention provided robust evidence (Cohen’s particularly germane is the formation of effective
d = 0.423) that standardized testing can have a sig- therapeutic relationships with clients from diverse
nificant positive impact on the therapeutic process backgrounds. This is particularly salient with clients
and outcome, “when combined with personalized, from marginalized or disadvantaged backgrounds,
collaborative, and highly involving test feedback” whose cultural or ethnic heritage differs from that
have rkam p 55
of their counselor, or whose religion, sexual orienta- APA Division 17 (Counseling Psychology) and
tion, or gender differs from their counselor’s life Division 45 (The Society for the Study of Ethnic
experience. Given that a significant majority of Minority Issues). Vasquez (2007), among others,
North American psychologists continue to be per- has called attention to the relevance of the Guidelines
sons of European, Caucasian heritage, we are basi- for development of therapeutic relationships with
cally concerned with the question of whether culturally different clients, particularly in calling for
majority culture practitioners succeed in forming therapists to increase their awareness of unconscious
strong relationships with people different from beliefs and stereotypic attitudes.
themselves, and whether those relationships pro- A literature search on “therapeutic relationship”
mote positive outcomes for clients. will not produce citations for these important
Many have argued that the task of forming strong guidelines; at the same time, they are essential for
alliances with clients unlike oneself is an area in understanding how counseling psychologists regard
which our practice has fallen short of our ideals (e.g., establishment of an effective relationship with cli-
Comas-Dias, 2006; Smith, 2005) but, before exam- ents whose life history and experience differ from
ining some of the research conducted in this area, it that of the dominant culture. The research review
is worthwhile to note some of the early expressions that follows illustrates some of the ways in which
of our field’s commitment to issues of diversity and these questions have been explored.
social justice. Counseling psychology’s values and
commitment to diversity, if genuine, will be reflected Client–Counselor Matching on
in the types of relationships we construct with cli- Demographic Variables
ents from diverse backgrounds. The stance that our
Most high schools and many colleges arrange for
profession has taken on these issues can provide
men to take care of the boys and women the girls.
some insight on the values we aspire to enact.
There is no evidence, however, that this is the best
Despite the moments when we fall far short of
practice or the one making for best rapport in all
our ideals, counseling psychology has played a lead-
cases. . . . Furthermore, these questions are too
ership role in bringing these issues to the attention
complex to be thought through on the basis of
of the field at large. Roger Myers (2004) traces the
rapport alone . . . we simply do not know enough
field’s concern with social justice back to Frank
about these things to decide wisely. Probably the
Parsons in the early 1900s, as well as to E.G.
best procedure . . . is to let the client decide, if
Williamson’s effort to call attention to “the restric-
counselors of both sexes are available.
tions on freedom imposed by traditions and custom
(Tyler, 1953, p. 39)
on racial, religious, or ethnic minority groups”
(1965; cited by Myers, 2004, p. 129). In the second Some of the earliest investigations of counseling
half of the 20th century, counseling psychologists with clients whose ethnicity or culture differed from
understood that acceptance and understanding were that of the counselor (who was typically a member
not well served by what Tyler called “lofty general- of the majority culture) explored the hypothesis that
izations” (based largely on the dominant male cul- matched dyads—on variables such as gender, race
ture) and began to elucidate principles for practice or culture—would produce better outcomes. Several
that addressed the distinctive needs of specific decades of research have not supported this position
groups. In 1978, the American Psychological and, at best, the results for some groups are described
Association’s Division 17 (Counseling Psychology) as “mixed” (e.g., Comas-Diaz, 2006; Norcross,
approved the Principles Concerning the Counseling 2002). In hindsight, the prediction that a match on
and Psychotherapy of Women as official policy group membership would be predictive is simplis-
(Fitzgerald & Nutt, 1986). This contribution was tic. There has been a longstanding awareness
widely influential within the APA and was endorsed (although not always applied) that groups who share
by several other divisions. In the 1980s, counseling the same societal label also have significant within-
psychologists began to call attention to cultural group differences. More recently, several authors
diversity and to advocate for guidelines on cultur- have drawn attention to the necessity of recognizing
ally competent practice (e.g., Sue et al., 1982). “multiple identities” and the intersectionality of
These efforts led to APA’s Guidelines on Multi- varied group identifications within a single client
cultural Education, Training, Research, Practice, and (e.g., Cole, 2009; Vasquez et al., 2006).
Organizational Change for Psychologists (APA, 2003), The issue of multiple identities is particularly
originating with the work of a joint task force of important to the question of whether “matching

56 the coun se l in g rel atio n s h ip

research” can be a productive area for investigating published between 1990 and 2000, found a modest
the counseling relationship in diverse populations, positive effect (mean weighted effect size of r = .02),
as it is difficult to imagine how one could “match” particularly for Asian Americans and Mexican
a client on all dimensions that might be relevant to Americans, a finding that is consistent with conclu-
forming a strong counseling relationship. Some sions reported by Sue and Lam (2002). For our
cases of multiple identity can present a mix of mar- present discussion, it is important to note that the
ginalization and privilege, as in the case of an archi- authors found a great deal of heterogeneity in the
tect whose progressive disability requires use of data which, as they note, suggests that outcomes
a wheelchair and help from a health attendant; this may be moderated by unidentified third variables.
client might “match” a counselor on SES or disabil- This idea is considered in more detail below.
ity status, but rarely both. Other clients may present There is a growing consensus that, although
multiple forms of marginalization, as in the case of matching does not automatically produce a work-
a white lesbian refugee from Eastern Europe. Even ing alliance that predicts client outcome, it is likely
beyond the simplistic question of whether a “white” to produce an indirect effect on outcome, particu-
counselor would be the best “match,” we cannot larly for less acculturated clients (e.g., Buetler et al.,
assume that a lesbian counselor would be the best 2004; Karlsson, 2005; Sue & Lam, 2002). One
person to understand this client’s refugee experi- salient example is the research on matching and
ence. And, neither of these pairings may match the therapy drop-out, or the number of sessions com-
aspect of identity most salient to the client or to the pleted. A limited number of studies have found that,
issues she brings to counseling. One of the potential for African American, Asian American, American
contributions of the multiple identities literature is Indian, and Latino/Latina and Mexican American
its capacity to remind us, not only of the more visi- clients, matching on racial/ethnic similarity is asso-
ble forms of diversity that clients may embody, but ciated with less likelihood of therapy drop-out.
of the hidden diversities that may play an important Comas-Diaz (2006) cites research indicating that,
role in the formation of the counseling relationship. in racially similar physician–patient relationships,
The literature review conducted for this chapter did people of color participate more in their treatment
not identify any diversity research on the counseling than in racially dissimilar pairings.
relationship that has incorporated a multiple identi- As discussed in our examination of the role
ties perspective; until we accept this challenge, it is of expectations in therapy drop-out for low SES cli-
likely that our understanding of the factors influ- ents, the research on racial/ethnic matching and
encing relationship development with diverse cli- drop-out highlights the need to identify variables
ents will remain inconclusive. Nevertheless, every that may moderate or mediate these relationships.
summative review on the counseling relationship The following section presents examples of research
appears to consider it necessary to discuss the litera- on therapist, client, or relational characteristics that
ture on racial/ethnic/gender matching. Typically, have been investigated for their role in matching.
this subject becomes the focus of a section or head- The studies cited also provide an illustration of
ing, and the reports of mixed and inconclusive Hill’s (2005) point that client, therapist, and rela-
results are highly consistent. One can choose to be tionship variables are “inextricably intertwined”
either intrigued or discouraged by our continued (p. 431) and that we lose meaning if we consider
absorption with the topic. them in isolation. Several points are worth noting
Beutler et al. (2004) note that, although the by way of introduction. First, many of the variables
concept of matching is widely accepted and advo- to be considered fall within the first stage of therapy,
cated, there is little empirical evidence to support which Hill labels as one of initial impression
the recommendation to match clients and coun- formation, the stage at which critical elements
selors on demographic characteristics, particu- of relationship development occur. As noted by
larly with regard to outcome, where results are Horvath and Bedi (2002), measurement of the ther-
either equivocal or weakly supportive. Simply stated, apist alliance is predictive at three sessions.
client–counselor match does not automatically Second, the following discussion is organized
produce a working alliance that predicts client out- around variables, rather than summarizing findings
come; Karlsson (2005) attributes the failure to iden- for groups or populations. This is deliberate; the
tify consistent associations to both conceptual and paucity of research in this area precludes reliable
methodological problems with matching research. group generalizations or distinctions, and the value
Beutler et al.’s 2004 meta-analysis of 11 studies, of this overview is to suggest variables that are

have rkam p 57
potentially valuable targets for further investigation counseling clients rated their European American
in many groups. counselors more positively than they rated Asian
Third, the categorization of variables as client American counselors. The authors found that client
and therapist factors is necessarily somewhat arbi- ratings of empathy and counselor credibility were
trary; it is much more likely that these variables associated with the counselors’ attention to Asian
exert their effects through an interaction between values; in this sample, the attitudinal variable was
client and counselor perspectives on each factor more important than a demographic match on race
described. Those listed as client factors are variables or ethnicity. It appears likely that within-group dif-
that counselors should take as “given” in a particular ferences on variables such as racial identity, attitudes
counseling relationship. Just as a client’s attachment and values–for both clients and counselors–are an
history may challenge or facilitate the counselor’s influential component of client preference and
efforts to form a relationship, various diversity fac- likely moderate the link between group member-
tors are inextricable parts of the person with whom ship, strength of the alliance and outcome.
a counselor works to form a relationship. Those Research on gender matching has been inconclu-
variables listed as therapist factors represent vari- sive (Sue & Lam, 2002) and the findings of a small
ables that are most likely to be amenable to some but significant outcome effect for female therapists
level of therapist control. applies to both male and female clients (Bowman,
Scogin, Floyd, & McKendree-Smith, 2001). This
Matching Research: Client Factors result calls into question the conclusion that, for
female clients, it is the gender match that is associ-
[T]here is another whole set of factors affective the ated with greater satisfaction. Zlotnick and col-
structure of the initial relationship—the client’s leagues (1998), using National Institute of Mental
general attitudes toward broad categories of people. Health (NIMH) data from the Depression Colla-
These are extremely varied, as human beings classify borative Research Program, found that gender
their fellow-men in all sorts of ways. match was not related to outcome, or to client per-
(Tyler, 1953, p. 38) ception of therapist empathy. Furthermore, when
they examined clients’ expectations about whether
preference and satisfaction a male or female therapist would be more helpful,
The strongest evidence for the value of client– outcomes did not differ based on whether clients
counselor match is found in measures of client were matched or mismatched with the gender they
satisfaction, as well as the previously noted indi- expected to be most helpful.
rect outcomes, such as continuation in treatment It should be noted that this area of research has
(Sue & Lam, 2002). This is not insignificant, as sat- not fully explored whether client satisfaction is
isfaction may reflect a client’s sense that she has been mediated by the presenting problem that the client
understood, or that her needs or goals have been brings to counseling (see the discussion of counselor
met. Regrettably, there is little research to help us credibility, below). In matching, the notion of client
understand what constitutes client satisfaction, preference may tap some of the same characteristics
although a client’s preference for the type of coun- that, in Strong’s social influence model were classi-
selor she will see appears to be an important factor. fied as “attractiveness,” or the sense that a counselor
For example, research has been consistent in docu- was sufficiently similar to serve as a base of influence
menting that black clients prefer to work with black or help. Again, the challenge to researchers is to
therapists (Thompson, Bazile, & Akbar, 2004; identify what variables, beyond broad demographic
Townes, Chavez-Korell, & Cunningham, 2009). categories, may produce this effect.
However, even this finding is not without complex-
ity; a client’s degree of group identification, or racial culture and language
identity, predicts black American client preferences As noted previously, recent research has documented
for a black counselor (Ferguson, Leach, Levy, some modest benefits for matching with Asian
Nicholson, & Johnson, 2008) and earlier research American and Mexican American clients (e.g.,
(Parham & Helms, 1981) found that black clients Beutler et al., 2004; Kim & Atkinson, 2002; Sue
with pre-encounter racial identity attitudes expressed & Lam, 2002), and this research has also called
preferences for white counselors. attention to the potential roles of language and
In the area of career research. Kim and Atkinson cultural assumptions and beliefs. Concerning lan-
(2002) found that Asian American vocational guage, Stanley Sue and colleagues (1991) divided

58 the coun se l in g rel atio n s h ip

Latino clients based on primary language and found or questions about the diversity they represent, are
that, for those whose primary language was Spanish, under-represented or wholly absent in psychother-
ethnic match was related to drop-out and treatment apy research on how ethnicity and culture may influ-
outcome. Given the wealth of information that ence development of counseling relationships.
must be communicated verbally in “talk therapy,” One exception to this charge can be found in
one can easily understand how an ability to differ- a study that investigated the working alliance
entiate between affect-laden words such as ashamed and counselor problem solving style in Taiwanese
versus humiliated or disappointed versus devastated client–counselor dyads (Wei & Heppner, 2005).
might have importance in a client’s feeling under- In addition to documenting similarities in alli-
stood. Sue et al.’s results are salient to the question ance formation, this work provides a useful exam-
of developing therapeutic relationships with recent ple of how culture-specific factors are important
immigrant and refugee clients; these groups are in developing a strong counselor–client relation-
likely to have higher proportions of clients who ship. For example, both the quantitative and quali-
speak English as a second language. Refugees and tative component of this mixed-method study
immigrants are also populations who are extraordi- revealed that counselors’ active problem-solving
narily under-represented in psychotherapy research behaviors contributed to client perceptions of coun-
on how ethnicity and culture may influence devel- selor helpfulness.
opment of counseling relationships. The Wei and Heppner (2005) investigation
In exploring other cultural factors, Nolan also provides a conceptual link to earlier counseling
Zane, Stanley Sue, and colleagues (2005) have gone psychology research on the therapeutic relationship.
beyond purely demographic matching and have As they note, the construct of counselor “credibil-
explored the “cognitive match” between Asian cli- ity” can be conceptualized as client perceptions of
ents and their therapists. Their work measures coun- counselor expertness, attractiveness, and trustwor-
selor and client expectations and perceptions of thiness, variables central to Strong’s social influence
psychotherapy (e.g., presenting problem, treatment model (see Hoyt, 1996, for a review). The social
goals) and appears to provide a cultural formula- influence model has not been used widely to inves-
tion of the task and goal components of the work- tigate factors that may account for the role of match-
ing alliance. The authors found that cognitive ing in reducing therapy drop-out or increasing
matches between clients and therapists were predic- client satisfaction; however, it offers a convenient
tive of outcome and suggest that the cognitive and well-established umbrella for some of the vari-
match may account for the finding that ethnically ables associated with therapist factors, as discussed
matched therapy dyads complete more sessions. below.
One of their key contributions has been to expand
our conceptualization of what may be operating in Beyond Matching: Therapist Attitudes
a purely demographic match to include consider- and Values
ation of other cultural, cognitive, or attitudinal fac-
The capacity for accepting others is a trait far
tors that are important in determining the strength
broader than specific training in counseling skills.
of a therapeutic relationship.
The counselor’s basic attitudes toward human beings
In considering this area of research, it is impor-
are involved, and such basic attitudes are not the
tant to note that most counseling psychology
product of a year’s cultivation or of specific
research relevant to “diversity” has been concerned
educational experiences. They grow from the
with groups that are well established in the United
responses a person makes to all the experiences of his
States. In addition to domestic racial-ethnic groups,
life. . . .
diversity research has focused on gender, gay/lesbian,
(Tyler, 1953, p. 25)
and religious groups, but has given little attention to
immigrants, refugees, or to clients whose disability Historically, researchers have given little attention
status or age may present distinct “cultures” relevant to therapist factors that may influence the process or
to developing therapeutic relationships. There has outcome of psychotherapy with diverse clients
also been little attention to an international under- (Karlsson, 2005; Leong & Gupta, 2008). This is
standing of diversity, or consideration of how North particularly true for research on therapeutic rela-
American conceptualizations of cultural factors tionships with cultural or ethnic minority clients.
may translate to psychotherapy relationships in In contrast, literature on therapist attitudes, bias,
cultures outside the United States. These groups, and stereotypes has demonstrated that therapists

have rkam p 59
hold negative and stereotypic views of clients based satisfaction with counseling and perceptions of thera-
on gender, sexual orientation, age, culture, or eth- pist multicultural competence. One potential inter-
nicity (Beutler et al., 2004). These biases are pre- pretation would be that, as therapists increased their
sumed to have an impact on the process of therapy multicultural knowledge and skill, their perspective
but little empirical research has investigated their taking and empathic abilities also increased. This
influence on outcome or on the therapeutic rela- could address what Comas-Diaz (2006) refers to as
tionship. This is another area where evidence related “missed empathic opportunities” (p. 84), or
to the counseling relationship appears to be indi- instances when a therapist with limited knowledge
rect, although two broad areas of therapist attributes of the client’s culture fails to recognize or address
that have received attention are therapist beliefs, a client’s indirect but culturally appropriate intro-
attitudes, and values, and multicultural knowledge duction of important issues.
and skills. A social psychological perspective on the rela-
Therapist attitudes and values related to a range tionship between negative attitudes and the coun-
of diverse populations, reflecting many of the “isms” seling relationship is found in Vasquez’ (2007)
that embody negative stereotypes of particular discussion of how negative behaviors can emerge
groups, have been cited as potential barriers to effec- outside the therapist’s awareness. She cites a series
tive counseling. Similar to Smith’s (2005) docu- of studies by Dovidio et al. (2002), which demon-
mentation of negative therapist attitudes toward the strated that, when whites interact with persons of
poor and low-SES clients, Danziger and Welfel different racial background, they exhibit negative
(2000) found that therapists exhibited ageism in nonverbal behaviors. Although the whites report
holding negative, stereotypic views of older clients. no awareness of their behavior, the ethnic minority
Barrett and McWhirter’s (2002) analogue investiga- participants experienced the interaction as reflect-
tion of homophobia in counseling trainees found ing a negative attitude toward them.
that those holding more homophobic attitudes This research is relevant to what have been termed
viewed gay and lesbian clients more negatively than racial “microaggressions,” subtle actions that signal
they did heterosexual clients; male trainees, in par- power differences in ways that are demeaning and
ticular, were more likely to assign negative adjectives domineering (Fouad & Arrendondo, 2007). This
to gay and lesbian clients. area has begun to receive research attention and
There is evidence that negative attitudes toward appears to offer promise for understanding the pro-
client group membership are associated with less cess of relationship formation and maintenance. For
empathic responding, a core component of effective example, Constantine’s (2007) research with black
relationships. Nelson and Baumgarte (2004) propose American clients found their perceptions of in-ses-
that this may be associated with difficulties in per- sion microaggressions were associated with lower
spective taking on the part of the therapist, and report ratings of the working alliance, less satisfaction with
that individuals show less empathy when responding counseling, and lower therapist competence.
to another’s distress when the distress arises from Therapist attitudes appear to be important con-
unfamiliar cultural contexts. Given the evidence that tributors to the strength of therapeutic relation-
therapists are not immune to the negative attitudes ships, and the field has begun to explore their
that exist in the general population, therapists may operation through the construct of multicultural
experience less empathy for clients whose difficulties competence, which includes an awareness of both
arise from unfamiliar life experiences. one’s own attitudes and beliefs as well as those of
The argument that a lack of cultural knowledge diverse clients (Sue et al., 1982). The area of multi-
may be associated with negative therapist responses cultural competence has generated a significant
receives some support from research conducted amount of research but has been criticized for a
by Hayes and Erkis (2000), who found that reliance on survey and analogue research (e.g.,
homophobic attitudes were associated with less Leong & Gupta, 2008). However, in a wide-ranging
empathy and reluctance to work with a gay client, review, Beutler et al. (2004) concluded that the few
as well as with a tendency to attribute blame and studies that use actual clients for investigating cul-
responsibility to HIV-positive clients. For support turally sensitive therapist attitudes show promising
from the converse position, Constantine, Miville, results, with positive effect sizes (ES) ranging from
and Kindaichi (2008), report a series of studies ES = .12 to .71.
with ethnic minority clients in which thera- One aspect of multicultural knowledge and
pist empathy was positively associated with client skill is the ability to perceive and respond to client

60 the coun se l in g rel atio n s h ip

expectations for the counseling relationship. As that permit modeling of complex interactions over
noted previously, there is consistent evidence that time. Building on those ideas, I want to issue an
clients from many cultural and ethnic groups com- invitation to researchers to explore interdisciplinary
plete fewer sessions than do majority culture clients, research tapping the long tradition of social psycho-
providing indirect evidence that strong relationships logical research on close relationships.
had not been established. Many authors have noted One of the first calls for reconceptualizing the
that different groups can hold differing expectations counseling relationship from a social-constructionist
and needs for what constitutes a preferred counsel- perspective was advanced by Sexton and Whiston in
ing relationship. Although client preferences were 1994. To implement this perspective, they note
discussed in an earlier section, several types of expec- that, “the primary focus of attention shifts from the
tations that therapists could act to address are worth identification of components of the counseling rela-
noting. Comas-Diaz (2006) asserts that many Latino tionship to the jointly determined meaning systems
clients look to their therapists for familismo, a sense developed by the relationship participants” (p. 62).
of being part of a close family or social network, and The authors cite a range of studies, available at that
platica, taking time to open a session with small talk time, that were consistent with an interactional per-
in order to establish trust. spective. However, in the intervening decades, few
researchers have pursued explorations of the more
Future Directions: New Paradigms, qualitative notions of “meaning” or “purpose.” Exce-
New Methods ptions can be found in process research conducted
from a narrative paradigm and method (e.g., Angus
Perhaps we will be closer to the truth if we assume
& McLeod, 2004) and in explorations of career
that any personality pattern that permits rich and
counseling as goal-directed action, investigated
deep relationships with other human beings to
from an action theory perspective (e.g., Young &
develop is satisfactory. Just as there is no one kind of
Valach, 2009; Young, Valach, & Domene, 2005).
personality essential to one’s functioning as husband
A focus on purpose invites us to consider the
or wife, mother or father, lover, neighbor, or friend,
function of various elements of the counseling
so there is no one kind essential to the counselor.
relationship, beyond their identification or level of
(Tyler, 1953, pp. 267–268)
strength. In describing the operation of com-
In considering the body of relationship research, mon factors in psychotherapy, Lambert and Ogles
it is difficult to avoid the impression that our sci- (2004) note that, “they provide for a coopera-
ence has focused on a search for “the effective coun- tive working endeavor in which the patient’s
seling relationship” and has often conceptualized increased sense of trust, security, and safety, along
the alliance between client and counselor in rather with decreases in tension, threat, and anxiety, lead
static terms. However, a good deal of current to changes in conceptualizing his or her problems
research has begun to conceptualize the relationship and ultimately in acting differently by reframing
in a more complex form. In the previous discus- fears, taking risks, and working through problems
sion, this new attention to complexity was evident in interpersonal relationships” (p. 173). Or, as Young
in recent work examining the alliance in multicul- and Valach (2009) argue in their description of the
tural counseling through the lens of intersectional- career counseling process, we must consider the
ity rather than matching on demographic factors intent of actions that client and counselor under-
(e.g., Vasquez, 2007), in explorations of how a par- take, noting that, “this intent is not realized solely
ticular attachment style may only be activated under by the counselor or the client, but jointly and reflects
conditions of vulnerability (Meyer & Pilkonis, the goal-directed processes in which they are
2002), or in the discussion of how therapist factors engaged” (p. 300).
not often examined in alliance research, such as Some methodological advances, pursued from
impairment or ethical behavior (e.g., Nigro 2004), within a post-positivist quantitative framework,
may offer useful information. reflect an appreciation of the joint, relational
Two trends have begun to influence relation- character of the counseling relationship. Two exam-
ship research, which I believe offer the potential ples are offered as illustration. First, the title of
to expand both our conceptualization and knowl- a 2007 investigation by counseling psychologist
edge of this key area of the psychotherapeutic Dennis Kivlighan asks, “Where is the relationship
process: qualitative contributions from a social- in research on the alliance?” In response, the author
constructionism paradigm and emerging methods presents two statistical approaches for analyzing

have rkam p 61
interdependence in therapeutic dyads. The models dynamics in psychotherapy. Furthermore, interde-
are illustrated with alliance and session impact data pendence models differentiate between relationship
from 53 client–counselor pairs, and the results iden- formation and relationship maintenance; research
tified a shared dyad-level component in the alliance, on the latter (e.g., Reis, 2007) has identified a key
characterized by mutual influence. The findings, role for perceived security of the relationship, per-
although quantitative, are consistent with the social- haps comparable to establishment of trust in the
constructionist view that the counseling relation- counseling dyad.
ship emerges through client–counselor interaction. A second area of investigation with potential
A second example of an innovative and relational application to the dyadic nature of the counseling
approach appears in work conducted by Lakey, relationship is that of relational-independent self con-
Cohen, and Neely (2008), who drew upon recent strual (Cross, Bacon, & Morris, 2000), which builds
social support research in exploring the unique rela- on attention to cultural differences between an
tional characteristics that emerge in specific therapy interdependent self-in-relationship construal and
dyads. Their analysis was based on prior research the group-oriented interdependence more common
indicating that constructs like supportiveness are in collectivist cultures. The authors explored the
highly relational; in other words, they are not char- role of self-construal in relationship development
acteristics of an individual, but of a specific rela- and, specifically, investigated whether a partici-
tionship between a provider and recipient. Lakey, pant’s evaluation of a dyadic partner’s openness
Cohen, and Neely’s work found strong, statistically and responsiveness were related to that person’s self-
significant relational effects for both the working construal. Results were positive and confirmed pre-
alliance and appraisals of therapist competence, dictions for the role of self-construal in self-disclosure
indicating that the most influential factor was the and responsiveness, both qualities that characterize
specific relationship, not a uniquely effective thera- effective counseling relationships.
pist or receptive client. Finally, social psychologists have been investigat-
Both Kivlighan (2007) and Lakey, Cohen, and ing issues of “risk regulation” and emotional self-
Neely (2008) were investigating relationship con- protection in relationships (e.g., Murray, Holmes,
cepts that have long been of interest to social psy- & Collins, 2006). This approach draws on elements
chologists. And, to advance our understanding of both attachment theory and interdependence
of counseling relationships further, I believe that theory in exploring the importance of the expecta-
our field would benefit from greater familiarity tions people hold about a partner’s relationship
with that body of research. In doing so, we would goals. The relevance of this work for psycho-
be repeating a pattern that has characterized past therapy relationships is perhaps best illustrated
advances in therapy process research, dating back to by Baumeister et al.’s (1993) observation (offered
Strong’s (1968) use of social psychological theory with regard to intimate relationships) that the rela-
in conceptualizing the relationship as an interper- tionships with the greatest potential to satisfy adult
sonal influence process. There are several current needs for connection are precisely those that will
models that I believe warrant particular attention; evoke the greatest sense of vulnerability and anxiety
although space does not permit detailed descrip- about rejection. For many clients, progress toward
tion, I encourage interested readers to investigate their counseling goals requires a choice to become
the work of these authors. highly vulnerable, expose troublesome parts of the
One of the dominant models in current social self, and risk rejection by a therapist.
psychological research is interdependence theory, One can predict that the next advances in relation-
associated with the work of Caryl Rusbult and ship research will reflect an increased appreciation for
colleagues (see Rusbult & Van Lange, 2003). This both the complexity and the uniqueness of each
comprehensive model of relationship interaction dyadic encounter, a stance highly congruent with
accords an explicit role for long-term goals and con- the earliest expressions of counseling psychology’s
cern for a partner’s welfare, as well for social cogni- values as a discipline. Attention to social psychologi-
tive processes such as attribution, affect, and cal research on interdependence, methodological
disposition. Issues such as mutuality and perceived advances that help us untangle both shared and inde-
progress toward relationship goals have been exam- pendent influences, and a social-constructionist per-
ined as predictors of relationship quality (Avivi, spective on the meaning clients attach to therapeutic
Laurenceau, & Carver, 2009) and would appear to relationships, all hold potential for illuminating what
have relevance for understanding relationship contributes to an effective counseling relationship.

62 the coun se l in g rel atio n s h ip

We know that strong relationships are important in goals and perceived goal progress. Journal of Social and
counseling; it is time to shift our focus from describ- Clinical Psychology, 28, 137–164.
Baldwin, S. A., Wampold, B. E., & Imel, Z. E. (2007).
ing “the relationship” to understanding what facili- Untangling the alliance-outcome correlation: Exploring
tates or impedes the therapeutic connection between the relative importance of therapist and patient variability
counselor and client. In doing so, we can be guided in the alliance. Journal of Consulting and Clinical Psychology,
by Leona Tyler’s observation that effective relation- 75, 842–852.
ships, like counselor personalities, can take many Barak, A., & LaCrosse, M. B. (1975). Multidimensional percep-
tion of counselor behavior. Journal of Counseling Psychology,
forms. 22, 471–476.
Barone, D. F., Hutchings, P. S., Kimmel, H. J., Traub, H. L.,
Note Cooper, J. T., & Marshall, C. M. (2005). Increasing empathic
1. Leona E. Tyler (1906–1993), the 81st presi- accuracy through practice and feedback in a clinical inter-
dent of the American Psychological Association and viewing course. Journal of Social and Clinical Psychology, 24,
156–171.
long-time faculty member at the University of Barrett, K. A., & McWhirter, B. T. (2002). Counselor trainees’
Oregon, is widely acknowledged as one of counsel- perceptions of clients based on client sexual orientation.
ing psychology’s most influential pioneers. The three Counselor Education and Supervision, 41, 219–232.
editions of The Work of the Counselor have been Barrett-Lennard, G. T. (1962). Dimensions of therapeutic
described as a leading influence on the development response as causal factors in therapeutic change. Psychological
Monographs: General and Applied, 76(43, Whole No. 562).
of the counseling profession (Sundberg & Littman, Bartholomew, K. (1994). The assessment of individual differ-
1994), and the APA Society of Counseling ences in adult attachment. Psychological Inquiry, 5, 23–27.
Psychology’s most prestigious award is named in her Bartholomew, K., & Thompson, J. (1995). The application of
honor. Interested readers are encouraged to consult attachment theory to counseling psychology. The Counseling
Zilber and Osipow (1990) or Fassinger (2003) for a Psychologist, 23, 484–490.
Batchelor, A. (1988). How clients perceive therapist empathy:
biography. A content analysis of “received” empathy. Psychotherapy, 25,
227–240.
References Baumeister, R. F., Wotman, S. R., & Stilwell, A. M. (1993).
Ahn, H., & Wampold, B. E. (2001). Where oh where are the Unrequited love: On heartbreak, anger, guilt, scriptlessness
specific ingredients? A meta-analysis of component studies in and humiliation. Journal of Personality and Social Psychology,
counseling and psychotherapy. Journal of Counseling Psy- 64, 377–394.
chology, 48, 251–257. Bedi, R. P. (2006). Concept mapping the client’s perspective on
Ainsworth, M. (1964). Patterns of attachment behavior shown counseling alliance formation. Journal of Counseling Psy-
by the infant in interaction with his mother. Merrill-Palmer chology, 53, 26–35.
Quarterly, 10, 51–58. Benecke, C., Peham, D., & Banninger-Huber, E. (2005).
Al-Darmaki, F., & Kivlighan, D. M., Jr. (1993). Congruence in Nonverbal relationship regulation in psychotherapy. Psycho-
client-counselor expectations for relationship and work- therapy Research, 15, 81–90.
ing alliance. Journal of Counseling Psychology, 40, 379–384. Benjamin, L. S. (1982). Use of Structural Analysis of Social
American Psychological Association (APA). (2002). Ethical Behavior (SASB) to guide intervention in psychotherapy.
principles of psychologists and code of conduct. American In J. C. Anchin, & D. J. Kiesler (Eds.), Handbook of interper-
Psychologist, 57, 1060–1073. sonal psychotherapy (pp. 190–212). New York: Pergamon.
American Psychological Association (APA). (2003). Guidelines Bergin, A. E. (1962). The effect of dissonant persuasive commu-
on multicultural education, training, research, practice and nications upon changes in a self-referring attitude. Journal
organizational change for psychologists. American Psycholo- of Personality, 30, 423–438.
gist, 58, 377–402. Bergin, A. E., & Garfield, S. L. (1978). Handbook of psycho-
Anderson, W. P., Jr., & Niles, S. G. (2000). Important events in therapy and behavior change: An empirical analysis (2nd ed.).
career counseling: Client and counselor perceptions. Career New York: Wiley.
Development Quarterly, 48, 251–264. Beutler, L. E., Malik, M., Alimohamed, S., Talebi, H., Noble, S.,
Angus, L. (2009, March). Psychotherapy research. Colloquia pre- & Wong, E. (2004). Therapist variables. In M. J. Lambert
sented to the Faculty of Education, University of British (Ed.), Bergin and Garfield’s handbook of psychotherapy and
Columbia, Vancouver, BC, Canada. behavior change (5th ed., pp. 227–306). New York: Wiley.
Angus, L., & McLeod, J. (2004). Handbook of narrative and Bimrose, J., Barnes, S.-A., & Hughes, D. (2005). Effective guid-
psychotherapy: Practice, theory and research. Thousand Oaks, ance one year on: Evidence from longitudinal case studies in
CA: Sage. England. Coventry: Warwick Institute for Employment
Arnkoff, D. B., Glass, C. R., & Shapiro, S. J. (2002). Expectations Research. Retrieved June 29, 2009, from http://ww2.
and preferences. In J. C. Norcross (Ed.), Psychotherapy rela- warwick.ac.uk/fac/soc/ier/publications/bydate/2005/egre-
tionships that work: Therapist contributions and responsiveness portoct05.pdf
to patients (pp. 335–356). New York: Oxford University Bimrose, J., Barnes, S.-A., Hughes, D., & Orton, M.
Press. (2004). What is effective guidance? Evidence from longitu-
Avivi, Y. E., Laurenceau, J.-P., & Carver, C. S. (2009). Linking dinal case studies in England. Coventry: Warwick Institute
relationship quality to perceived mutuality of relationship for Employment Research. Retrieved June 29, 2009, from

have rkam p 63
 http://ww2.warwick.ac.uk/fac/soc/ier/publications/ Crites, J. O. (1981). Career counseling: Models, methods and mate-
bydate/2005/egr2004.pdf rials. New York: McGraw-Hill.
Bohart, A. C., Elliott, R., Greenberg, L. S., & Watson, J. C. Crits-Cristoph, P., Gibbons, M. B. C., Crits-Cristoph, K.,
(2002). Empathy. In J. C. Norcross (Ed.), Psychotherapy rela- Narducci, J., Schamberger, M., & Gallop, R. (2006).
tionships that work: Therapist contributions and responsiveness to Can therapists be trained to improve their alliances? A pre-
patients (pp. 89–108). New York: Oxford University Press. liminary study of alliance-forming psychotherapy. Psycho-
Bordin, E. S. (1976). The generalizability of the psychoanalytic therapy Research, 16, 268–281.
concept of the working alliance. Psychotherapy: Theory, Cross, S. E., Bacon, P. L., & Morris, M. L. (2000). The relational-
Research and Practice, 16, 252–260. interdependent self-construal and relationships. Journal
Bowlby, J. (1969). Attachment and loss. New York: Basic. of Personality and Social Psychology, 78, 791–808.
Bowman, D. G., Scogin, F., Floyd, M., & McKendree-Smith, N. Curry, K. T., & Hanson, W. E. (2010). National survey of
(2001). Effect of therapist sex on outcome of psychotherapy: psychologists’ test feedback training, supervision and prac-
A meta-analysis. Psychotherapy, 38, 142–148. tice: A mixed methods study. Journal of Personality Assess-
Carnes, E. F., & Robinson, F. P. (1948). The role of client talk in ment, 92, 327–336.
the counseling interview. Educational and Psychological Danzinger, P. R., & Welfel, E. R. (2000). Age, gender and health
Measurement, 8, 635–644. bias in counselors: An empirical analysis. Journal of Mental
Carter, J. A. (1994). Refining notions through converging para- Health Counseling, 22, 135–149.
digms. The Counseling Psychologist, 22, 79–81. Dell, D. M., & Schmidt, L. D. (1976). Behavioral cues to
Caspar, F., Grossmann, C., Unmussig, C., & Schramm, E. counselor expertness. Journal of Counseling Psychology, 23,
(2005). Complementary therapeutic relationship: Therapist 197–201.
behavior, interpersonal patterns, and therapeutic effects. Dixon, D. N., & Claiborn, C. D. (1987). A social influence
Psychotherapy Research, 15, 91–102. approach to counselor supervision. In J. E. Maddux,
Castonguay, L. G., Goldfried, M. R., Wiser, S., & Raue, P. J. C. D. Stoltenberg, & R. Rosenwein (Eds.), Social processes in
(1996). Predicting the effect of cognitive therapy for depres- clinical and counseling psychology (pp. 83–93). New York:
sion: A study of unique and common factors. Journal of Springer.
Consulting and Clinical Psychology, 64, 497–504. Dollard, J., Auld, F., & White, A. M. (1953). Steps in psycho-
Chambless, D. L., & Hollon, S. D. (1998). Defining empirically therapy. New York: Macmillan.
supported therapies. Journal of Consulting and Clinical Dorn, F. J. (1988). Utilizing social influence in career coun-
Psychology, 64, 497–504. seling: A case study. Career Development Quarterly, 36,
Chang, D. F., & Berk, A. (2009). Making cross-racial therapy 269–280.
work: A phenomenological study of clients’ experiences of Dovidio, J. F., Gaertner, S. L., Kawakami, K., & Hoson, G.
cross-racial therapy. Journal of Counseling Psychology, 56, (2002). Why can’t we just get along? Interpersonal biases and
521–536. interracial distrust. Cultural Diversity & Ethnic Minority
Claiborn, C. D., Goodyear, R. K., & Horner, P. A. (2002). Psychology, 8, 88–102.
Feedback. In J. C. Norcross (Ed.), Psychotherapy relationships Duckworth, J. (1990). The counseling approach to the use of
that work: Therapist contributions and responsiveness to patients testing. The Counseling Psychologist, 18, 198–204.
(pp. 217–233). New York: Oxford University Press. Dunkle, J. H., & Friedlander, M. L. (1996). Contribution of
Clarkin, J. F., & Levy, K. N. (2004). The influence of client vari- therapist experience and personal characteristics to the work-
ables on psychotherapy. In M. J. Lambert (Ed.), Bergin and ing alliance. Journal of Counseling Psychology, 43, 456–460.
Garfield’s handbook of psychotherapy and behavior change Eames, V., & Roth, A. (2000). Patient attachment orientation
(5th ed., pp. 194–226). New York: Wiley. and early working alliance—A study of patient and therapist
Cole, E. R. (2009). Intersectionality and research in psychology. reports of alliance quality and ruptures. Psychotherapy
American Psychologist, 64, 170–180. Research, 10, 421–434.
Comas-Diaz, L. (2006). Cultural variation in the therapeutic Farber, B. A., & Lane, J. S. (2002). Positive regard.
relationship. In C. D. Goodheart, A. E. Kazdin, & In J. C. Norcross (Ed.), Psychotherapy relationships that
R. J. Sternberg (Eds.), Evidence-based psychotherapy: Where work: Therapist contributions and responsiveness to patients
practice and research meet (pp. 81–105). Washington, DC: (pp. 175–194). New York: Oxford University Press.
American Psychological Association. Fassinger, R. E. (2003). Leona Tyler: Pioneer of possibilities.
Constantine, M. G. (2007). Racial microaggressions against In G. A. Kimble, & M. Wertheimer (Eds.), Portraits of
African American clients in cross-racial counseling relation- pioneers in psychology, vol. 5 (pp. 231–247). Washington,
ships. Journal of Counseling Psychology, 54, 1–16. DC: American Psychological Association.
Constantine, M. G., Miville, M. L., & Kindaichi, M. M. (2008). Ferguson, T. M., Leach, M. M., Levy, J. J., Nicholson, B. C., &
Multicultural competence in counseling psychology practice Johnson, J. D. (2008). Influences on counselor race prefer-
and training. In S. D. Brown, & R. W. Lent (Eds.), Handbook ences: Distinguishing Black racial attitudes from Black racial
of counseling psychology (4th ed., pp. 141–158). Hoboken, identity. Journal of Multicultural Counseling and Develop-
NJ: Wiley. ment, 36, 66–76.
Cook, J. E., & Doyle, C. (2002). Working alliance in Finn, S. E., & Tonsager, M. E. (1997). Information-gathering
online therapy as compared to face-to-face: Preliminary and therapeutic models of assessment: Complementary para-
results. CyberPsychology & Behavior, 5(2), 95–105. digms. Psychological Assessment, 9, 374–375.
doi:10.1089/109493102753770480. Fitzgerald, L. F., & Nutt, R. (1986). The Division 17 principles
Corbishley, M. A., & Yost, E. B. (1989). Psychological aspects concerning the counseling/psychotherapy of women: Ratio-
of career counseling. Journal of Career Development, 16, nale and implementation. The Counseling Psychologist, 14,
43–51. 180–216.

64 the coun se l in g rel atio n s h ip

Fitzpatrick, M. R., Iwakabe, S., & Stalikas, A. (2005). Perspective Gelso, C. J., Kelly, F. A., Fuertes, J. N., Marmarosh, C.,
divergence in the working alliance. Psychotherapy Research, Holmes, S. E., Costa, C., & Hancock, G. R. (2005).
15, 69–80. Measuring the real relationship in psychotherapy: Initial
Forrest, L., Elman, N., Gizara, S., & Vacha-Haase, T. (1999). validation of the therapist form. Journal of Counseling
Trainee impairment: A review of identification, remediation, Psychology, 52, 640–649.
dismissal, and legal issues. The Counseling Psychologist, 27, Gelso, C. J., & Samstag, L. W. (2008). A tripartite model of
627–686. the therapeutic relationship. In S. D. Brown, & R. W. Lent
Fouad, N. A. (2007). Work and vocational psychology: Theory, (Eds.), Handbook of counseling psychology (4th ed.,
research and applications. Annual Review of Psychology, 58, pp. 267–283). New York: Wiley.
543–564. Gold, P. B., Kivlighan, D. M., Jr., Kerr, A. E., & Kramer, L. A.
Fouad, N. A., & Arrendondo, P. (2007). Becoming culturally (1993). The structure of students’ perceptions of impactful,
oriented: Practical advice of psychologists and educators. helpful events in career exploration classes. Journal of Career
Washington, DC: American Psychological Association. Assessment, 1, 145–161.
Frank, J. D. (1961). Persuasion and healing. Baltimore: Johns Graff, H., Kenig, L., & Radoff, G. (1971). Prejudice of upper
Hopkins University Press. class therapists against lower class patients. Psychiatric
Freeman, S. C. (1990). C. H. Patterson on client-centered career Quarterly, 45, 475–489.
counseling: An interview. The Career Development Quarterly, Greenberg, L. S. (1994). What is “real” in the relationship?
38, 291–301. A comment on Gelso and Carter (1994). Journal of Couns-
Friedlander, M. L., Escudero, V., Horvath, S., Heatherington, L., eling Psychology, 41, 307–309.
Cabero, A., & Martens, M. P. (2006). System for observing Greencavage, L. M., & Norcross, J. C. (1990). Where are
family therapy alliances: A tool for research and practice. the commonalities among the therapeutic common
Journal of Counseling Psychology, 53, 214–225. factors? Professional Psychology: Research and Practice, 21,
Friedlander, M. L., Lambert, J. E., & de la Pena, C. M. (2008). 372–378.
A step toward disentangling the alliance/improvement Greenson, R. R. (1965). The working alliance and the transfer-
cycle in family therapy. Journal of Counseling Psychology, 55, ence neuroses. Psychoanalysis Quarterly, 34, 155–181.
118–124. Greenson, R. R. (1967). Technique and practice of psychoanalysis.
Fuertes, J., Mislowack, C., Brown, S., Shovel, G.-A., New York: International University Press.
Wilkinson, S., & Gelso, C. (2007). Correlates of the real Hardin, S. I., Subich, L. M., & Holvey, J. M. (1988). Expectancies
relationship in psychotherapy: A study of dyads. Psycho- for counseling in relation to premature termination. Journal
therapy Research, 17, 423–430. of Counseling Psychology, 35, 37–40.
Garfield, S. L. (1978). Research on client variables in psycho- Hardy, G. E., Aldridge, J., Davidson, C., Rowe, C., Reilly, S., &
therapy. In S. L. Garfield, & A. E. Bergin (Eds.), Handbook Shapiro, D. A. (1999). Therapist responsiveness to patient
of psychotherapy and behavior change (2nd ed., pp. 191–232). attachment styles and issues observed in patient-identified
New York: Wiley. significant events in psychodynamic-interpersonal psycho-
Gelso, C. J. (2004, June). A theory of the real relationship in psy- therapy. Psychotherapy Research, 9, 36–53.
chotherapy. Paper presented at the International Conference Hartley, D. E., & Strupp, H. H. (1983). The therapeutic
of the Society for Psychotherapy Research, Rome. alliance: Its relationship to outcome in brief psychotherapy.
Gelso, C. J., Betz, N. E., Friedlander, M. L., Helms, J. E., In J. Masling (Ed.), Empirical studies in analytic theories
Hill, C. E., Patton, M. J., Super, D. E., & Wampold, B. E. (Vol. 1, pp. 1–37). Hillsdale, NJ: Erlbaum.
(1988). Research in counseling psychology: Prospects Hatcher, R. L., & Barends, A. W. (1996). Patients’ view of
and recommendations. The Counseling Psychologist, 16, the alliance in psychotherapy: Exploratory factor analysis of
385–406. three alliance measures. Journal of Consulting and Clinical
Gelso, C. J., & Carter, J. A. (1985). The relationship in counseling Psychology, 64, 1326–1336.
and psychotherapy: Components, consequences, and theoreti- Haverkamp, B. E., Morrow, S. L., & Ponterotto, J. G. (Guest
cal antecedents. The Counseling Psychologist, 13, 155–243. Eds.). (2005). Special Issue: Knowledge in context:
Gelso, C. J., & Carter, J. A. (1994). Components of the psy- Qualitative methods in counseling psychology research.
chotherapy relationship: Their interaction and unfolding Journal of Counseling Psychology, 52, 121–260.
during treatment. Journal of Counseling Psychology, 41, Hayes, J. A., & Erkis, A. J. (2000). Therapist homophobia, client
296–306. sexual orientation, and source of client HIV infection as
Gelso, C. J., Fassinger, R. E., Gomez, M. J., & Latts, M. C. predictors of therapist reactions to clients with HIV. Journal
(1995). Countertransference reactions to lesbian clients: of Counseling Psychology, 47, 71–78.
The role of homophobia, counselor gender, and counter- Hayes, J. A., & Gelso, C. J. (1993). Counselors’ discomfort
transference management. Journal of Counseling Psychology, with gay and HIV-infected clients. Journal of Counseling
42, 356–364. Psychology, 40, 86–93.
Gelso, C. J., & Fretz, B. (2001). Counseling psychology (2nd ed.). Hayes, J. A., Riker, J. R., & Ingram, K. M. (1997). Coun-
Fort Worth, TX: Harcourt. tertransference behavior and management in brief counseling:
Gelso, C. J., & Hayes, J. A. (1998). The psychotherapy relation- A field study. Psychotherapy Research, 7, 145–153.
ship: Theory, research and practice. New York: Wiley. Healy, C. C. (2001). A follow-up of adult career counseling cli-
Gelso, C. J., & Hayes, J. A. (2002). The management of coun- ents of a university extension center. Career Development
tertransference. In J. C. Norcross (Ed.), Psychotherapy rela- Quarterly, 49, 363–373.
tionships that work: Therapist contributions and responsiveness Henry, W. P., Schacht, T. E., Strupp, H. H., Butler, S. F., &
to patients (pp. 267–283). New York: Oxford University Binder, J. L. (1993a). Effects of training in time-limited
Press. dynamic psychotherapy: Mediators of therapists’ responses

have rkam p 65
 to training. Journal of Consulting and Clinical Psychology, 61, Horvath, A. O., & Symonds, B. D. (1991). Relation between
441–447. working alliance and outcome in psychotherapy: A meta-
Henry, W. P., Strupp, H. H., Butler, S. F., Schacht, T. E., analysis. Journal of Counseling Psychology, 38, 139–149.
& Binder, J. L. (1993b). Effects of training in time- Howard, G. S. (1992). Behold our creation! What counseling
limited dynamic psychotherapy: Changes in therapist psychology has become and might yet become. Journal of
behavior. Journal of Consulting and Clinical Psychology, 61, Counseling Psychology, 39, 419–442.
434–430. Hoyt, W. T. (1996). Antecedents and effects of perceived thera-
Heppner, M. J., & Hendricks, F. (1995). A process and outcome pist credibility: A meta-analysis. Journal of Counseling
study examining career indecision and indecisiveness. Journal Psychology, 43, 430–447.
of Counseling and Development, 73, 426–437. Imel, Z. E., & Wampold, B. E. (2008). The importance of
Heppner, M. J., Multon, K. D., Gysbers, N. C., Ellis, C. A., & treatment and the science of common factors in psychother-
Zook, C. E. (1998). The relationship of trainee self-efficacy apy. In S. D. Brown, & R. W. Lent (Eds.), Handbook of
to the process and outcome of career counseling. Journal counseling psychology (4th ed., pp. 249–266). New York:
of Counseling Psychology, 45, 393–402. Wiley.
Heppner, P. P., & Frazier, P. A. (1992). Social psychological Jacobs, D., Charles, E., Jacobs, T., Weinstein, H., & Mann, D.
processes in psychotherapy: Extrapolating basic research to (1972). Preparation for treatment of the disadvantaged
counseling psychology. In S. D. Brown, & R. W. Lent (Eds.), patient: Effects on disposition and outcome. American
Handbook of counseling psychology (2nd ed., pp. 141–176). Journal of Orthopsychiatry, 42, 666–674.
New York: Wiley. Joyce, A. S., & Piper, W. E. (1998). Expectancy, the therapeutic
Heppner, P. P., Rosenberg, J. I., & Hedgespeth, J. (1992). Three alliance, and treatment outcome in short-term individual
methods in measuring the therapeutic process: Clients’ and psychotherapy. Journal of Psychotherapy Practice and Research,
counselors’ constructions of the therapeutic process versus 7, 236–248.
actual therapeutic events. Journal of Counseling Psychology, Karlsson, R. (2005). Ethnic matching between therapist
39, 20–31. and patient in psychotherapy: An overview of findings,
Hersoug, A. G., Monsen, J. T., Havik, O. E., & Hoglend, P. together with methodological and conceptual issues.
(2002). Quality of early working alliance in psychotherapy: Cultural Diversity and Ethnic Minority Psychology, 11,
Diagnoses, relationship, and intrapsychic variables as predic- 113–129.
tors. Psychotherapy and Psychosomatics, 71, 18–27. Kiesler, D. J. (1982). Interpersonal theory for personality
Highlen, P. S., & Hill, C. E. (1984). Factors affecting client and psychotherapy. In J. C. Anchin, & D. J. Kiesler
change in individual counseling: Current status and theoreti- (Eds.), Handbook of interpersonal psychotherapy (pp. 3–24).
cal speculations. In S. D. Brown, & R. W. Lent (Eds.), New York: Pergamon.
Handbook of counseling psychology (pp. 334–396). New York: Kim, B. S. K., & Atkinson, D. R. (2002). Asian American client
Wiley. adherence to Asian cultural values, counselor expression of
Hill, C. E. (1994). What is the therapeutic relationship? A reac- cultural values, counselor ethnicity and career counseling
tion to Sexton and Whiston. The Counseling Psychologist, 22, process. Journal of Counseling Psychology, 49, 3–13.
90–97. Kim, D. M., Wampold, B. E., & Bolt, D. M. (2006). Thera-
Hill, C. E. (2005). Therapist techniques, client involvement, and pist effects in psychotherapy: A random effects modeling
the therapeutic relationship: Inextricably intertwined in the of the NIMH TDCRP data. Psychotherapy Research, 16,
therapy process. Psychotherapy: Theory, Research, Practice, 161–172.
Training, 42, 431–442. Kirschner, T., Hoffman, M. A., & Hill, C. E. (1994). Case study
Hill, C. E., Nutt-Williams, E., Heaton, K. J., Thompson, B. J., of the process and outcome of career counseling. Journal of
& Rhodes, R. H. (1996). Therapist recall of impasses in Counseling Psychology, 41, 216–226.
long-term psychotherapy: A qualitative analysis. Journal of Kivlighan, D. M., Jr. (2007). Where is the relationship in
Counseling Psychology, 43, 207–217. research on the alliance? Two methods for analyzing dyadic
Horvath, A. O. (1981). An exploratory study of the working alli- data. Journal of Counseling Psychology, 54, 423–433.
ance: Its measurement and relationship to outcome. Unpublished Kivlighan, D. M., Jr., McGovern, T. V., & Corazzini, J. G.
doctoral dissertation, University of British Columbia, (1984). Effects of content and timing of structuring inter-
Vancouver, Canada. ventions on group therapy process and outcome. Journal
Horvath, A. O. (2001). The alliance. Psychotherapy: Theory, of Counseling Psychology, 31, 363–370.
Research, Practice, Training, 38, 365–372. Kivlighan, D. M., Jr., Patton, M. J., & Foote, D. (1998).
Horvath, A. O. (2005). The therapeutic relationship: Research Moderating effects of client attachment on the counselor
and theory. Psychotherapy Research, 15, 3–7. experience-working alliance relationship. Journal of Coun-
Horvath, A. O. (2009). How real is the “real relationship?” seling Psychology, 45, 274–278.
Psychotherapy Research, 19, 273–277. Knaevelsrud, C., & Maercker, A. (2006). Does the quality of
Horvath, A. O., & Bedi, R. P. (2002). The alliance. the working alliance predict treatment outcome in online
In J. C. Norcross (Ed.), Psychotherapy relationships that psychotherapy for traumatized patients? Journal of Medical
work: Therapist contributions and responsiveness to patients Internet Research, 8(4), e31. Published online December 19,
(pp. 37–69). New York: Oxford University Press. 2006. doi: 10.2196/jmir.8.4.e31.
Horvath, A. O., & Greenberg, L. S. (1986). Development of Ladany, N., Lehrman-Waterman, D., Molinaro, M., & Wolgast, B.
the working alliance inventory. In L. S. Greenberg, & (1999). Psychotherapy supervisor ethical practices: Adherence
W. M. Pinsof (Eds.), The psychotherapeutic process: A research to guidelines, the supervisory working alliance, and supervi-
handbook (pp. 529–556). New York: Guilford. see satisfaction. The Counseling Psychologist, 27, 443–475.

66 the coun se l in g rel atio n s h ip

Lakey, B., Cohen, J. L., & Neely, L. C. (2008). Perceived support Luborsky, L. (1976). Helping alliances in psychotherapy.
and relational effects in psychotherapy process constructs. In J. L. Cleghorn (Ed.), Successful psychotherapy (pp. 92–116).
Journal of Counseling Psychology, 55, 209–220. New York: Bruner/Mazel.
Lambert, M. J. (1992). Psychotherapy outcome research: Luborsky, L., Crits-Cristoph, P., Alexander, L., Margolis, M., &
Implications for integrative and eclectic therapists. Cohen, M. (1983). Two helping alliance methods for
In J. C. Norcross, & M. R. Goldfried (Eds.), Handbook of predicting outcomes of psychotherapy: A counting signs vs.
psychotherapy integration (pp. 94–129). New York: Basic a global rating method. Journal of Nervous and Mental
Books. Disease, 171, 480–491.
Lambert, M. J. (Ed.). (2004). Bergin and Garfield’s handbook of Lutz, W., Leon, S. C., Martinovich, Z., Lyons, J. S., & Stiles, W. B.
psychotherapy and behavior change (5th ed.). New York: (2007). Therapist effects in outpatient psychotherapy:
Wiley. A three-level growth curve approach. Journal of Counseling
Lambert, M. J., & Barley, D. E. (2001). Research summary Psychology, 54, 32–39.
on the therapeutic relationship and psychotherapy out- Mallen, M. J., Vogel, D. L., Rochlen, A. B., & Day, S. X. (2005).
come. Psychotherapy: Theory, Research, Practice, Training, 38, On-line counseling: Reviewing the literature from a coun-
357–361. seling psychology framework. The Counseling Psychologist, 33,
Lambert, M. J., & Barley, D. E. (2002). Research summary. 819–871.
In J. C. Norcross (Ed.), Psychotherapy relationships that Mallinckrodt, B. (1993). Session impact, working alliance, and
work: Therapist contributions and responsiveness to patients treatment outcome in brief counseling. Journal of Coun-
(pp. 17–32). New York: Oxford University Press. seling Psychology, 40, 25–32.
Lambert, M. J., Garfield, S. L., & Bergin, A. E. (2004). Overview, Mallinckrodt, B. (1996). Change in working alliance, social sup-
trends and future issues. In M. J. Lambert (Ed.), Bergin port, and psychological symptoms in brief therapy. Journal
and Garfield’s handbook of psychotherapy and behavior change of Counseling Psychology, 43, 448–455.
(5th ed., pp. 805–821). New York: Wiley. Mallinckrodt, B., Gantt, D. L., & Coble, H. M. (1995).
Lambert, M. J., & Ogles, B. M. (2004). The efficacy and effec- Attachment patterns in the psychotherapy relationship:
tiveness of psychotherapy. In M. J. Lambert (Ed.), Bergin Development of the Patient Attachment to Therapist Scale.
and Garfield’s handbook of psychotherapy and behavior change Journal of Counseling Psychology, 42, 307–317.
(5th ed., pp. 139–193). New York: Wiley. Mallinckrodt, B., King, J. L., & Coble, H. M. (1998). Family
Leahy, R. L. (2008). The therapeutic relationship in cognitive- dysfunction, alexithymia, and client attachment to therapist.
behavioral therapy. Behavioral and cognitive psychotherapy, Journal of Counseling Psychology, 45, 497–504.
36, 769–777. Malllinckrodt, B., & Nelson, M. L. (1991). Counselor training
Leary, T. (1957). Interpersonal diagnosis of personality. New York: level and the formation of the psychotherapeutic working
Roland. alliance. Journal of Counseling Psychology, 38, 133–138.
Leong, F. T. L., & Gupta, A. (2008). Culture and race in coun- McIlveen, P. (2007). Counsellors’ personal experience and
seling and psychotherapy: A critical review of the literature. appraisal of My Career Chapter. In 16th National Conference
In S. D. Brown, & R. W. Lent (Eds.), Handbook of counseling of the Australian Association of Career Counsellors. April,
psychology (4th ed., pp. 320–337). Hoboken, NJ: Wiley. 2007, Perth, Australia. Retrieved June 21, 2009, from http://
Lepper, G., & Mergenthaler, E. (2007). Therapeutic colla- eprints.usq.edu.au/2549.
boration: How does it work? Psychotherapy Research, 17, Meyer, B., & Pilkonis, P. A. (2002). Attachment style.
576–587. In J. C. Norcross (Ed.), Psychotherapy relationships that
Li, L. C., & Kim B. S. K. (2004). Effects of counseling style work: Therapist contributions and responsiveness to patients
and client adherence to Asian cultural values on counseling (pp. 367–382). New York: Oxford University Press.
process with Asian American college students. Journal of Mischel, W., & Shoda, Y. (1995). A cognitive-affective system
Counseling Psychology, 51, 158–167. theory of personality: Reconceptualizing situations, disposi-
Lichtenberg, J. W., Wettersten, K. B., Mull, H., Moberly, R. L., tions, dynamics, and invariance in personality structure.
Merkey, K. B., & Corey, A. T. (1988). Relationship and Psychological Review, 102, 248–268.
control as correlates of psychotherapy quality and out- Mohr, J. J., Gelso, C. J., & Hill, C. E. (2005). Client and coun-
come. Journal of Consulting and Clinical Psychology, 45, selor-trainee attachment as predictors of session evaluation
322–337. and countertransference behavior in first counseling sessions.
Ligiero, D. P., & Gelso, C. J. (2002). Countertransference, Journal of Counseling Psychology, 52, 298–309.
attachment, and the working alliance: The therapist’s contri- Multon, K. D., Ellis-Kalton, C. A., Heppner, M. J., &
bution. Psychotherapy: Theory, Research, Practice, Training, 39, Gysbers, N. C. (2003). The relationship between counselor
3–11. verbal response modes and the working alliance in career
Lopez, S. J., Magyar-Moe, J. L., Petersen, S. E., Ryder, J. A., counseling. Career Development Quarterly, 51, 259–273.
Krieshok, T. S., O’Byrne, K. K., et al. (2006). Counseling Multon, K. D., Heppner, M. J., Gysbers, N. C., Zook, C., &
psychology’s focus on positive aspects of human functioning. Ellis-Kalton, C. A. (2001). Client psychological distress:
The Counseling Psychologist, 34, 205–227. An important factor in career counseling. Career Development
Lorion, R. P. (1973). Socioeconomic status and traditional treat- Quarterly, 49, 324–335.
ment approaches reconsidered. Psychological Bulletin, 79, Murray, S. L., Holmes, J. G., & Collins, N. L. (2006). Optimizing
263–270. assurance: The risk-regulation system in relationships. Psy-
Lorion, R. P. (1974). Patient and therapist variables in the treat- chological Bulletin, 132, 641–666.
ment of low-income patients. Psychological Bulletin, 81, Myers, R. A. (2004). Conferring as a way of knowing. The
344–354. Counseling Psychologist, 32, 128–133.

have rkam p 67
Nelson, D. W., & Baumgarte, R. (2004). Cross cultural misun- Reandeau, S. G., & Wampold, B. E. (1991). Relationship of
derstandings reduce empathic responding. Journal of Applied power and involvement of working alliance: A multiple-case
Social Psychology, 34, 391–401. sequential analysis of brief therapy. Journal of Counseling
Nerdrum, P., & Ronnestad, M. H. (2002). The trainees’ pers- Psychology, 38, 107–114.
pective: A qualitative study of learning empathic com- Reis, H. T. (2007, August). What social psychologists would like
munication in Norway. The Counseling Psychologist, 30, to tell clinicians about close relationships. Division 8
609–629. Presidential Address, presented at the annual meetings of the
Nerdrum, P., & Ronnestad, M. H. (2004). Changes in thera- American Psychological Association, San Francisco.
pists’ conceptualization and practice of therapy following Reis, B. F., & Brown, L. G. (1999). Reducing psychotherapy
empathy training. The Clinical Supervisor, 22, 37–61. dropouts: Maximizing perspective convergence in the thera-
Netzky, W., Davidson, J., & Crunkleton, A. (1982). Pertinent peutic dyad. Psychotherapy: Theory, Research, Practice, Training,
consumer issues in choosing a counseling professional. 36, 123–136.
Journal of Counseling Psychology, 29, 406–413. Rochlen, A. B., Milburn, L., & Hill, C. E. (2004). Examining
Nigro, T. (2004). Counselors’ experiences with problematic the process and outcome of career counseling for different
dual relationships. Ethics and Behavior, 14, 51–64. types of career counseling clients. Journal of Career Develo-
Norcross, J. C. (Ed.). (2002). Psychotherapy relationships that pment, 30, 263–275.
work: Therapist contributions and responsiveness to patients. Rogers, C. R. (1942). Counseling and psychotherapy. Boston:
New York: Oxford University Press. Houghton-Mifflin.
Norcross, J. C. (2002b). Empirically supported therapy relation- Rogers, C. R. (1957). The necessary and sufficient conditions
ships. In J. C. Norcross (Ed.), Psychotherapy relationships of therapeutic personality change. Journal of Consulting
that work: Therapist contributions and responsiveness to patients Psychology, 21, 95–103.
(pp. 3–16). New York: Oxford University Press. Rogers, C. R. (1963). Psychotherapy today or where do we
Nutt-Willliams, E., Hayes, J. A., & Fauth, J. (2008). Therapist go from here? American Psychologist, 17, 5–16.
self-awareness: Interdisciplinary connections and future Rosenberger, E. W., & Hayes, J. A. (2002). Origins, conse-
directions. In S. D. Brown, & R. W. Lent (Eds.), Handbook quences, and management of countertransference: A case
of counseling psychology (4th ed., pp. 303–319). Hoboken, study. Journal of Counseling Psychology, 49, 221–232.
NJ: Wiley. Rosenzweig, S. (1936). Some implicit common factors in diverse
Nutt-Williams, E., & Hill, C. E. (1996). The relationship methods of psychotherapy. American Journal of Ortho-
between self-talk and therapy process variables for novice psychiatry, 6, 412–415.
therapists. Journal of Counseling Psychology, 43, 170–177. Rubino, G., Barker, C., Roth, T., & Fearon, P. (2000). Therapist
Orlinsky, D. E., & Ronnestad, M. H. (2005). How psycho- empathy and depth of interpretation in response to potential
therapists develop: A study of therapeutic work and professi- alliance ruptures: The role of therapist and patient attach-
onal growth. Washington, DC: American Psychological ment styles. Psychotherapy Research, 10, 408–420.
Association. Rudikoff, L. C., & Kirk, B. A. (1959). Test interpretation in
Packard, T. (2009). The 2008 Leona Tyler Award address: Core counseling. Journal of Counseling Psychology, 6, 224–229.
values that distinguish counseling psychology: Personal and Rusbult, C. E., & VanLange, P. A. M. (2003). Interdepen-
professional perspectives. The Counseling Psychologist, 37, dence and relationships. Annual Review of Psychology, 54,
610–624. 351–375.
Parham, T. A., & Helms, J. E. (1981). The influence of Black Safran, J. D., Muran, J. C., & Samstag, L. W. (1994). Resolving
students’ racial identity attitudes on preferences for counsel- therapeutic alliance ruptures: A task analytic investigation.
or’s race. Journal of Counseling Psychology, 28, 250–257. In A. O. Horvath, & L. S. Greenberg (Eds.), The working
Patterson, C. H. (1966). Theories of counseling and psychotherapy. alliance: Theory, research and practice (pp. 225–255).
New York: Harper & Row. New York: Wiley.
Patton, M. J. (1994). Components of the counseling relation- Samler, J. (1980). Where do counseling psychologists work?
ship–An evolving model: Comment on Gelso and Carter What do they do? What should they do? In J. M. Whitely
(1994). Journal of Counseling Psychology, 41, 313–314. (Ed.), The history of counseling psychology. Monterey, CA:
Patton, M. J., & Kivlighan, D. M., Jr. (1997). Relevance of the Brooks-Cole. (Original work published 1964).
supervisory alliance to the counseling alliance and to treat- Sexton, H. (1996). Process, life events, and symptomatic change
ment adherence in counselor training. Journal of Counseling in brief eclectic psychotherapy. Journal of Consulting and
Psychology, 44, 108–115. Clinical Psychology, 64, 1358–1365.
Peabody, S. A., & Gelso, C. J. (1982). Countertransference and Sexton, H., Littauer, H., Sexton, A., & Tommeras, E. (2005).
empathy: The complex relationship between two divergent Building an alliance: Early therapy process and the client-
concepts in counseling. Journal of Counseling Psychology, 29, therapist connection. Psychotherapy Process, 15, 103–116.
240–245. Sexton, T. L., & Whiston, S. C. (1994). The status of the coun-
Poston, J. M., & Hanson, W. E. (2010). Meta-analysis of psy- seling relationship: An empirical review, theoretical implica-
chological assessment as a therapeutic intervention. Psycho- tions, and research directions. The Counseling Psychologist, 22,
logical Assessment, 22, 203–212. 6–78.
Prediger, D. J., & Garfield, N. (1988). Testing competencies Singer, B. A., & Luborsky, L. (1977). Countertransference:
and responsibilities: A checklist for counselors. In J. T. Kapes, The status of clinical versus quantitative research.
& M. M. Mastie (Eds.), A counselors’ guide to career assessment In A. S. Gurman, & A. M. Razdin (Eds.), Effective psycho-
instruments (2nd ed.). Alexandria, VA: National Career therapy: Handbook of research (pp. 433–451). New York:
Development Association. Pergamon Press.

68 the coun se l in g rel atio n s h ip

Smith, E. J. (2006). The strength-based counseling model. Tokar, D. M., Hardin, S. I., Adams, E. M., & Brandel, I. W.
The Counseling Psychologist, 34, 13–79. (1996). Clients’ expectations about counseling and percep-
Smith, L. (2005). Psychotherapy, classism, and the poor: tions of the working alliance. Journal of College Student
Conspicuous by their absence. American Psychologist, 60, Psychotherapy, 11, 9–26.
687–696. Townes, D. L., Chavez-Korell, S., & Cunningham, N. J. (2009).
Smith, M. L., & Glass, G. V. (1977). Meta-analysis of psy- Re-examining the relationships between racial identity,
chotherapy outcome studies. American Psychologist, 39, cultural mistrust, help-seeking attitudes, and preference for
752–760. a Black counselor. Journal of Counseling Psychology, 56,
Stevens, S. E., Hynan, M. T., & Allen, M. (2000). A meta- 330–336.
analysis of common factors and specific treatment effects Tracey, T. J. (1986). Interactional correlates of premature termi-
across the outcome domains of the phase model of nation. Journal of Consulting and Clinical Psychology, 54,
psychotherapy. Clinical Psychology: Science and Practice, 7, 784–788.
273–290. Tracey, T. J., & Hays, K. (1989). Therapist complementarity
Stiles, W. B., Shapiro, D. A., & Elliott, R. (1986). Are all psycho- as a function of experience and client stimuli. Psychotherapy,
therapies equivalent? American Psychologist, 41, 165–180. 26, 462–468.
Strong, S. R. (1968). Counseling: An interpersonal influence Truax, C. B., & Carkhuff, R. R. (1967). Toward effective counsel-
process. Journal of Counseling Psychology, 15, 215–224. ing and psychotherapy. Chicago: Aldine.
Strong, S. R. (1978). Social psychological approach to psycho- Tyler, L. E. (1953). The work of the counselor. New York:
therapy research. In S. Garfield, & A. E. Bergin (Eds.), Appleton-Century-Crofts.
Handbook of psychotherapy and behavior change (2nd ed., Tyrrell, C. L., Dozier, M., Teague, G. B., & Fallot, R. D. (1999).
pp. 101–136). New York: Wiley. Effective treatment relationships for persons with serious
Strong, S. R., & Schmidt, L. D. (1970). Trustworthiness and psychiatric disorders: The importance of attachment states
influence in counseling. Journal of Counseling Psychology, 17, of mind. Journal of Consulting and Clinical Psychology, 67,
197–204. 723–733.
Strupp, H. H., & Anderson, T. (1997). On the limitations Vasquez, M. J. T. (2007). Cultural difference and the therapeutic
of therapy manuals. Clinical Psychology: Science and Practice, alliance: An evidence-based analysis. American Psychologist,
4, 76–82. 62, 878–885.
Sue, D. W., Bernier, J. B., Duran, M., Feinberg, L., Pederson, P., Vasquez, M. J. T., Lott, B., Garcia-Vasquez, E., Grant, S. K.,
Smith, E., et al. (1982). Position paper: Cross-cultural Iwamasa, G. Y., Molina, L. E., et al. (2006). Personal reflec-
counseling competencies. The Counseling Psychologist, 10, tions: Barriers and strategies in increasing diversity in psy-
45–52. chology. American Psychologist, 61, 157–172.
Sue, D. W., & Lam, A. G. (2002). Cultural and demographic Vera, E. M., & Speight, S. L. (2003). Multicultural competence,
diversity. In J. C. Norcross (Ed.), Psychotherapy relationships social justice, and counseling psychology: Expanding our
that work: Therapist contributions and responsiveness to patients roles. The Counseling Psychologist, 31, 253–272.
(pp. 401–421). New York: Oxford University Press. Wampold, B. E. (2007). Psychotherapy: “The” humanistic (and
Sue, S., Fujino, D. C., Hu, L. T., Takeuchi, D. T., & effective) treatment. American Psychologist, 62, 857–874.
Zane, N. W. S. (1991). Community mental health services Wampold, B. E., Lichtenberg, J. W., & Waehler, C. A. (2002).
for ethnic minority groups: A test of the cultural responsive- Principles of empirically supported interventions in counsel-
ness hypothesis. Journal of Consulting and Clinical Psychology, ing psychology. The Counseling Psychologist, 30, 197–217.
59, 533–540. Watson, J. C., & Geller, S. (2005). An examination of the rela-
Sundberg, N. D., & Littman, R. A. (1994). Leona Elizabeth tions among empathy, unconditional positive regard and
Tyler (1906-1993). American Psychologist, 49, 211–212. congruence in cognitive-behavioral and process-experiential
Super, D. E. (1955). Transition: From vocational guidance to psychotherapy. Psychotherapy Research, 15, 25–33.
counseling psychology. Journal of Counseling Psychology, 2, Wei, M., & Heppner, P. P. (2005). Counselor and client predic-
3–9. tors of the initial working alliance: A replication and exten-
Swanson, J. L. (1995). The process and outcome of career coun- sion to Taiwanese client-counselor dyads. The Counseling
seling. In W. B. Walsh, & S. H. Osipow (Eds.), The hand- Psychologist, 33, 51–71.
book of vocational psychology (pp. 217–259). Mahwah, NJ: Weinberger, J. (1995). Common factors aren’t so common: The
Erlbaum. common factors dilemma. Clinical Psychology: Science and
Swift, J. K., & Callahan, J. L. (2008). A delay discounting Practice, 2, 45–69.
measure of great expectations and the effectiveness of psy- Whiston, S. C., Brecheisen, B. K., & Stephens, J. (2003). Does
chotherapy. Professional Psychology: Research and Practice, treatment modality affect career counseling effectiveness?
39, 581–588. Journal of Vocational Behavior, 62, 390–410.
Thompson, V. L. S., Bazile, A., & Akbar, M. (2004). African Whiston, S. C., Lindeman, D. L., Rahardja, D., & Reed, J. H.
Americans’ perceptions of psychotherapy and psycho- (2005). Career counseling process: A qualitative analysis of
therapists. Professional Psychology: Research and Practice, 35, experts’ cases. Journal of Career Assessment, 13, 169–187.
19–26. Whiston, S. C., & Rahardja, D. (2008). Vocational counseling
Tinsley, H. E. A., & Bradley, R. W. (1986). Test interpretation. process and outcome. In S. D. Brown, & R. W. Lent (Eds.),
Journal of Counseling Psychology, 64, 462–466. Handbook of counseling psychology (4th ed., pp. 444–461).
Tinsley, H. E. A., Workman, K. R., & Kass, R. A. (1980). Factor Hoboken, NJ: Wiley.
analysis of the domain of client expectations about counsel- Whitely, J. M. (Ed.). (1980). The history of counseling psychology.
ing. Journal of Counseling Psychology, 27, 561–570. Monterey, CA: Brooks-Cole.

have rkam p 69
Wierzbicki, M., & Pekarik, G. (1993). A meta-analysis of psy- Zane, N., Sue, S., Chang, J., Huang, L., Huang, J., Lowe, S.,
chotherapy dropout. Professional Psychology: Research and et al. (2005). Beyond ethnic match: Effects of client-therapist
Practice, 24, 190–195. cognitive match in problem perception, coping orientation,
Wiggins, J. S. (1982). Circumplex models of interpersonal and therapy goals on treatment outcomes. Journal of Com-
behavior in clinical psychology. In P. C. Kendall, & J. N. munity Psychology, 33, 569–585.
Butcher (Eds.), Handbook of research methods in clinical psy- Zilber, S. M., & Osipow, S. H. (1990). Leona E. Tyler.
chology (pp. 183–221). New York: Wiley. In A. N. O’Connell, & N. F. Russo (Eds.), Women in psy-
Wrenn, C. J. (1966). Birth and early childhood of a journal. chology: A bio-bibliographic sourcebook (pp. 335–341).
Journal of Counseling Psychology, 13, 485–488. Washington, DC: American Psychological Association.
Young, R. A., & Valach, L. (2009). Evaluating the process Zlotnick, C., Elkin, I., & Shea, M. T. (1998). Does the gender
and outcomes of vocational counseling: An action theory of a patient or the gender of a therapist affect the treatment
perspective. L’Orientation Scolaire et Professionnelle, 38, of patients with major depression? Journal of Consulting
281–306. and Clinical Psychology, 66, 655–659.
Young, R. A., Valach, L., & Domene, J. F. (2005). The action-
project method in counseling psychology. Journal of
Counseling Psychology, 52, 215–223.

70 the coun se l in g rel atio n s h ip

 CHAPTER

Theory and Research for Counseling

4 Interventions

Martin Heesacker and James W. Lichtenberg

Abstract
This chapter describes the role of psychological theory and its relation to counseling practice, with
a special emphasis on counseling psychology’s unique opportunity to enhance the integration of
science and practice in psychology. Improving science–practice integration is presented as critical to
fulfilling counseling psychology’s claim that its interventions are science-based. The chapter discusses
psychological theory generally, and the pathways (both scientific and clinical) through which theory
influences counseling interventions. It reviews both the theoretical and research bases of treatment,
with a particular focus on how treatments are evaluated. This includes a focus on efficacy, effectiveness,
and meta-analytic studies, and how new treatments develop and are accepted by the field; and a focus
on differences between practitioners and researchers in their acceptance of treatments as established
practice. Matching specific, theoretically distinct, evidence-based treatments to specific client problems
is contrasted with the theory-integrating, common factors approach. The chapter closes with a series
of future directions for reducing the science–practice gap in counseling psychology.
Keywords: science–practice integration, theory and meta-theory, treatment efficacy and
effectiveness, empirically supported interventions, common factors

The disconnect between much of clinical practice by the best available research and economic evidence”
and the advances in psychological science is an (Abbot, 2009, p. 847). Echoing the alarms sounded
unconscionable embarrassment for many reasons, by Mischel and Abbot, a recent science column
and a case of professional cognitive dissonance with by Sharon Begley in Newsweek magazine entitled
heavy costs. “Ignoring the Evidence: Why Do Psychologists Reject
—Mischel, 2009, p. i Science?” (http://www.newsweek.com/id/216506)
sent the message to the American public that psy-
The author of the chapter’s opening quote, Walter chological psychotherapy is not science-based. This
Mischel, is one of psychology’s most respected theo- message, distributed to ever-widening groups of psy-
rists and researchers, and so it should come as no chology’s stakeholders, challenges a fundamental tenet
surprise that his influence extends beyond psychol- of the discipline: Namely, that psychological interven-
ogy. His 2009 editorial in a major psychological tions are applications of psychological science.
journal triggered an editorial in Nature entitled Notwithstanding the above criticisms of psycho-
“Psychology: A Reality Check,” which sent a similar logical psychotherapy, counseling psychology has
message throughout the scientific community: a unique and important opportunity to move for-
“There is a moral imperative to turn the craft of psy- ward as an applied specialty by fostering the integra-
chology—in danger of falling, Freud-like, out of tion of the science and practice that may be less
fashion—into a robust and valued science informed available to other applied specialties in psychology.

71
It is the purpose of this chapter to review current What we will not do is ascribe antiscience motives
issues in counseling theory and intervention prac- to practitioners of counseling psychology or anti-
tices to facilitate a positive, creative, comprehensive, practice motives to researchers in counseling psy-
and productive dialog that will result in a more chology. Unfortunately, for practical reasons, we
complete integration of science and practice in will not have the space to review specific theories
counseling psychology. This, in turn, will serve as per se. That is done in other chapters in this volume
a model for other specialties, highlighting effective and in other publications. Instead, our focus will
ways to address the important disciplinary challenge remain on the broader landscape of science–practice
of the integration of the science and practice of integration.
psychology and the furthering of a science-based
profession. What Is a Theory?
Counseling interventions are mostly based on schol-
Theory As the Key to Science–Practice arly theories (Brooks-Harris, 2008, p. 4), but what
Integration is a theory? A theory (also known as a symbolic
model, according to Ford and Urban, 1998, p. 6) is
There is nothing more practical than a good theory.
a description of some aspect of the natural world.
(Kurt Lewin, 1952, p. 169).
This description can be verbal, mathematical, or
The key premise of this chapter is that psycho- both. A scientific theory is presented in a manner
logical theory holds perhaps the greatest promise for that allows its utility to be assessed by comparing
the successful integration of counseling psychology the description to empirical observation. The assess-
science and practice. Theory is what researchers and ment of theory by comparing its description to
practitioners have in common: Researchers often empirical observation is called the scientific method,
are drawn to theory development and validation, and it is through this method that theory is vali-
whereas practitioners often are drawn to the appli- dated. Theory and method often operate recursively
cation of theory. Ideally, researchers and practi- in science.
tioners work in tandem to produce knowledge that Scientific theories can be basic or applied. Basic
helps the common good (see Cialdini’s [1980] full theories describe elements of the natural world that
cycle social psychology for a description of the may or may not have any direct application to the
reciprocal relationship between researchers and betterment of the natural world, but instead have
practitioners in theory development, refinement, as their primary objective a better understanding
validation, and application). Because a valuing of of nature—whether practically useful or not. Basic
theory is what counseling psychology’s researchers theories have often been developed and tested with-
and practitioners share, allocating effort toward out regard to application, and yet basic theories
understanding the state of the theoretical art and often later trigger important applications. In con-
addressing the challenges researchers and practitio- trast to basic theory, applied theory seeks to describe
ners face with regard to theory is likely to pay the aspects of the natural world that can be applied to
richest dividends by maximizing the link between create a benefit or reduce a cost. For example,
counseling psychology’s science and its practice. Schachter and Singer’s (1962) two-factor theory of
In this chapter, we discuss the nature and devel- emotion is a basic theory that posits that emotion
opment of theories within psychology generally and results from one’s cognitive processing and assessing
the translation of theories into counseling interven- of one’s physiological responses. On the other hand,
tions. In the process, we will be addressing both Albert Ellis’ rational emotive behavior therapy
the theoretical and scientific bases of treatment, theory (Ellis & Dryden, 2007) is an applied theory
how new treatments develop, and how they come to that describes how unwanted emotion may be
be accepted by the specialty. We will also address reduced or eliminated by disciplining oneself to
documented differences between practitioners and cognitively process experience rationally.
researchers with regard to acceptance of treatments
as established practice. All of this will be done Why Does Theory Matter?
with respect for differing perspectives and contexts, Other than the fact that most counseling interven-
and in the service of facilitating the complete inte- tions are theory-based, why do counseling psychol-
gration of counseling psychology science and prac- ogists care about theory? As mentioned earlier,
tice, knowing that the process will be imperfect and theory provides an excellent pathway through which
ongoing. the work of scientists and practitioners can be

72 coun seling in te rven tio n s

complementary. This is true for four reasons. First, change from dysfunctional behavior and to more
personality theories and other behavior-relevant functional behavior. Virtually every major theory of
basic science theories often tie very closely to theo- psychotherapy describes client development and the
ries of psychotherapy. For example, Carl Rogers’ processes and conditions for change.
(1957) self theory, a basic science theory, ties closely
to his theory of psychotherapy, which endeavors How Theory Influences Practice
to provide the conditions under which a client’s According to Ford and Urban (1998, p. 6), “A set of
ideal self may be realized fully. Another example transformation rules is required to map the mean-
is John Holland’s theory of vocational behavior ing of the symbol onto the phenomenon represented
(Holland, 1997). Holland’s work emphasizes [in a theory] because their relationship is completely
person-by-environment fit, that in turn ties closely arbitrary.” In practice, this means that theories must
with his theory of career counseling, which endeav- be transformed into specific interventions. Constructs
ors to provide clients with insights regarding their that are part of a theory have to be transformed into
work and career interests and aspirations, and to action. Descriptions of processes posited by a theory
match those with jobs and careers. likewise must be transformed into specific actions
A second reason that theory can reduce the or measures. These operationalizations of theory are
scientist–practitioner divide is that a theory is, in required for theory to translate into practice. Like-
essence, a story. Likewise, clients very frequently tell wise, operationalization is required for scientific
stories as part of therapy, and psychotherapists fre- assessment of the utility and validity of a theory.
quently work with, challenge, and help alter the So, psychotherapy practice can be understood as
narratives or stories that may contribute to or sus- the advancement of theory by transforming theory
tain client dysfunction. into practice. In turn, observations resulting from
There is a third reason theory may reduce this the transformation of theory into practice inform
divide between researchers and practitioners of theory and often provide necessary correction to
counseling psychology. Theory represents a common theory (see Cialdini, 1980).
factor among scholars of psychology. Likewise, The importance of this process of theory to oper-
theory represents a coherent narrative about the ation (or intervention) and back to theory cannot
nature of change and the nature of problems and be overstated. A theory is no better than the quality
problem resolution, and thus constitutes a common of the operations used to implement and evaluate it.
factor across nearly all recognized psychotherapeutic A psychotherapeutic approach that is judged to be
approaches. ineffective may be judged that way for three distin-
A final reason why a focus on theory may reduce guishable reasons: the theory is wrong, the opera-
the science–practice divide is that theory, as dis- tionalization of the theory is wrong, and/or the
cussed earlier, appeals to both scientists and prac- measures of the theory’s effectiveness are invalid.
titioners. The process of direct service delivery Likewise, theories of psychotherapy can wrongly be
(e.g., intense, personal interactions; ambiguity of judged to be valid if the operationalization was
outcome) is generally less appealing to researchers unfaithful to the theory and yet the operation pro-
than to practitioners. Likewise, the process of psy- duced a beneficial outcome, or if the measures of
chological research (e.g., research design, advances the theory’s effectiveness are invalid and yet inaccu-
in statistical analyses) often is less interesting to rately yielded results that indicate client improve-
practitioners than to researchers. In contrast, a focus ment. Again, collaboration between scientists and
on theory, especially on narrative theory, holds practitioners, this time on how to operationalize
interest and appeal for both groups. theory so that it improves practice, is essential in
Appealing to both scientists and practitioners are reducing the science–practice divide.
a host of important intellectual reasons for a theory
focus. Perhaps the most important of these is that Addressing Theory-related Challenges
theory provides causal explanations that are critical Having opined that focusing on theory is arguably
for effective counseling and psychotherapy. These the best approach to maximizing the link between
causal explanations include explanations for how counseling psychology’s science and its practice, we
clients developed into the people they are, and how must also readily admit that counseling psychology
they developed the functions and dysfunctions they has to address and overcome two theory-related
present in counseling. They also include explana- challenges to achieve that goal: the proliferation
tions of how and under what conditions clients of theories, which is a challenge because it creates

he e sacke r, licht e nbe rg 73

a psychotherapeutic Tower of Babble, in which concerning the consistency/specificity of behavior,
counseling psychologists do not enjoy a common developmental/contemporaneous parameters of the
conceptual language; and what has come to be theory, and strategies of research. In the history of
known as the common factors perspective, which is a science, meta-theories have been referred to as para-
challenge to the notion that specific theories and digms (Kuhn, 1970).
their posited change mechanisms even matter in These structural properties, viewed in combina-
psychotherapeutic intervention and change. tion, form the bases of a variety of different theories
of and approaches to counseling and psychotherapy
overcoming challenges associated with that populate the field—theories and approaches
theory proliferation that are often discontinuous and incompatible with
An interesting and perplexing theory-related chal- one another in significant ways. When considering
lenge involves the proliferation of theories that the diversity of theories, it is not possible to know
exist in the field, with their concomitant interven- which one best represents a true picture of human
tions and techniques. In the mid-1960s, Garfield functioning, but what is possible to acknowledge
(writing in 1989) collected a list of over 60 different is that different groups of theories reflect often radi-
approaches to therapy—each grounded in some cally different ways of construing human events. In
more or less explicitly stated theory explaining the short, these construal differences determine what
nature and bases for clients’ psychological problems can be observed and what practicing counseling psy-
and the mechanisms by which change in those chologists decide to do about those observations.
problems could be effected. A few years later, a Three meta-theoretical positions provide archi-
report of the Research Task Force of the National tecture for understanding more simply the welter
Institute of Mental Health (NIMH, 1975) noted of theories within counseling and psychotherapy.
over 130 different types of psychotherapy. Five years These three meta-theoretical positions are typically
after that, Herink (1980) published an account labeled personologism, situationism, and interaction-
of over 200 different forms of therapy, and within ism (Endler & Magnusson, 1976). Bowers (1973)
6 years of Herink’s publication, Kazdin (1986) has noted that there is a chronological order to their
referred to over 400 different therapeutic tech- appearance, with each representing the zeitgeist of
niques! Although it is not clear whether the list its historical period, and with each intended to serve
of theories in counseling and psychotherapy has a corrective function with regard to challenges
gotten bigger or smaller, it is clear that counseling unmet by the previously held view. As mechanisms
theories exist in a welter of forms and with a variety of change, theories of counseling and psychotherapy
of different conceptual and empirical justifications. derive from, or at least are reflective of, these three
The diversity-valuing ethic at the heart of counsel- meta-theoretical positions. Although it is tempting
ing psychology allows the counseling psychologist to view each of these positions as representing a dis-
to embrace this nearly incomprehensible diversity, crete and homogeneous cluster, there are notable
even while recognizing that some theories are better differences among the theories and models sub-
scientifically supported than others and that some sumed within each perspective, despite certain fun-
are more readily useful in application than others. damental paradigmatic structural similarities among
Diversity celebration notwithstanding, the pro- them.
liferation of theories constitutes a real challenge to Personologism or the personological paradigm
science–practice integration and must be addressed. (B = f P) represents the earliest meta-theoretical posi-
One approach to proliferation begins by asking tion. Characteristic of this paradigm is the assumption
which core assumptions and intellectual roots may that behavior (B) is a function (f ) of the person (P).
unite subgroups of theories of counseling and psy- This is the position that Cronbach (1957) identified
chotherapy. It is our perspective that theories of as correlational psychology, but which could
counseling and psychotherapy, like other scientific be construed in other terms, such as differential
theories, emerge from and are embedded in broader psychology, trait psychology, and psychodynamic
meta-theories, which often reflect the zeitgeist prev- theory. The common element in this paradigm is the
alent in the era of their development. By meta-theory, attribution of internal, dispositional, “psychody-
we are referring to certain structural properties of namic” factors as the primary causal determinants
the theories they subsume—properties including the of behavior.
basic assumptions and types of laws proposed, the Although there are a variety of different dispo-
determinants of behavior, units of analysis, issues sitional domains (e.g., aptitudes and traits) and

74 coun seling in te rven tio n s

constructs (e.g., psychoanalytic constructs), as well than individual differences. In effect, Cronbach
as methodological differences within each of the (1957) has noted that both personologism and situ-
theories subsumed under this meta-theory, certain ationism have an affinity for the variables that the
consistent consequences have followed from this par- other view ignores. However, they are similar in
ticular paradigm: First, the concept of causality is the sense of being linear, unidirectional models of
essentially a linear, unidirectional one emanating attributing causality, the only difference being the
from some internal source. Behavior is primarily source of cause. In the situational view, the source is
“pushed” from within. Second, the types of laws external and behavior is “pulled” from the organ-
derived are of a response–response (R–R) variety, ism; hence laws of the S–R type result.
with the intent being to discover consistent individ- In a more applied and strategic sense, this view
ual response patterns across different situations— typically frames questions that address “what treat-
with inconsistent response patterns usually attributed ment conditions are more effective in producing X?”
to the presence of a higher-order or more genotypic Treatments, of course, can be construed in a variety of
trait (Allport, 1966). And third, although the units ways, ranging from complex educational/therapeutic
of analysis may vary in conceptual size and clarity conditions and manipulations of single independent
across theories within this paradigm, they invariably variables in highly controlled experimental designs, to
involve some internal, dispositional system of inter- traits of others as external sources of influence.
vening or mediating constructs such as traits, needs, Perhaps the most specific applications of this
cognitive abilities, dynamic constructs (instincts). paradigm to the domain of counseling have been
As Endler and Magnusson (1976) suggest, the the behavior therapies—the application of general
B = f P paradigm has had a tremendous impact in learning theory principles (operant, respondent,
personality research, particularly in the myriad of and social modeling) to the amelioration of behav-
person measurement strategies. Consequently, the ioral problems and disorders. In each case—be it
measurement of alleged R–R consistencies has had the application of respondent conditioning princi-
enormous effects in the applied areas of counsel- ples to the extinction of a school phobia, operant
ing, selection, classification, and psychodiagnosis conditioning principles to the shaping of career
(e.g., the assessment of vocational interests, person- exploration behaviors, or modeling for increasing
ality traits and dispositions, needs, aptitudes, and social skill behaviors—counseling constitutes the
abilities). “experiment,” and the counselor’s intervention con-
Situationism or the situational paradigm (B = f E) stitutes the “experimental treatment.” The counselor
is the second meta-theoretical paradigm, appearing in essence controls, manipulates, determines, and
partly in reaction to the inadequacies of the persono- causes (in accord with the professed learning prin-
logical paradigm. Situationism stipulates that behavior ciples invoked) the change in the client’s behavior.
(B) is a function (f ) of factors in the environment (E) It is the counselor, serving as a benevolent and ther-
or situations in which people find themselves. This is apeutic (albeit deterministic) environment, who
the position that Cronbach (1957) identified as causes the client to change.
experimental psychology, with its primary intent being A situationist has a perspective on events that
to explain behavioral variability as a function of dif- is radically different from that of the personologist.
ferences in environmental conditions. In contrast to The view of the personologist is that the counselor,
the B = f P paradigm, which searches for although providing certain “core” therapeutic con-
consistency in response patterns across situations, ditions, is not the cause of client change per se;
the situational paradigm assumes that human behav- rather that change is generated by (or pushed from)
ior is considerably malleable, with the behaviors or the client as a consequence of the client’s own
forms of behavior that people take being primarily intrapersonal dynamics, traits, dispositions, and
a function of external stimulus factors. It is a struc- self-actualizing tendencies. Viewing the same change
ture that has been somewhat slower in deve1oping, phenomena, the situationist holds that the core
but as Moos (1973, 1974) described, a number of conditions, as well as other counselor behaviors,
different systems utilize quite different units of anal- elicit, modify, determine, and cause the behavior
ysis developed to describe environmental factors change of the client. That is, to a situationist, the
(e.g., contingencies of reinforcement, environmen- situation, not the client, determines client change
tal “presses,” and organizational patterns). (Truax, 1966).
As a general research approach, situationism Although many counseling psychologists reject
concerns itself with treatment differences, rather the mechanistic formalisms of situationism as

he e sacke r, licht e nbe rg 75

expressed in the behavior therapies, the B = f E par- a core commonality in their concept of causality.
adigm may find its way into their reasoning in more These views all posit a mutual and reciprocal (interac-
subtle ways. As Powers (1973a) notes; “A humanis- tive) system of causality or influence between the
tic (counselor) . . . may reject the idea that painful person and environment, such that causality is not
stimuli act on a passive nervous system to cause an a function of one or the other but a process of mutual
organ to secrete adrenalin, but he may be perfectly constraint or influence. A logical consequence of this
willing to say that stress acts on a person view is that the behavior of any individual may vary
to make him anxious” (p. 1). in its consistency, depending upon the nature of the
Running throughout this particular psychologi- individual and the situation in which the individual
cal paradigm (frequently referred to as scientific is performing. Thus, the focus is not on simple R–R
psychology) is a particular concept of cause and effect. or S–R consistencies, but on patterns or systems of
The cause, the immediate physical cause of what behavioral chains that may be relatively stable within
a person does, lies outside the person. Whether any given person–environment combination but
what is outside the client is the family, school, or which also may show different patterns between other
some other environment to which the cause and person–environment combinations (i.e., there may
maintenance of a client’s disturbance or dysfunction be instability across combinations) (see Claiborn &
is attributed, or whether what is outside the client Lichtenberg, 1989). The paradigm of interactionism
is a benevolent other attempting to change the client reflects a cybernetic, closed-loop feedback model in
in some “therapeutic” direction, the assumption is as much as “responses are dependent on present and
that the best the client can do is to modulate the past stimuli in a way determined by the current orga-
connections from the stimulus (environment/situa- nization of the nervous system . . . But it is equally
tion) that is the cause, to the behavior or behavior true that stimuli depend on responses according to
change that is the effect. In the best tradition of the current organization of the environment and the
experimental psychology, the strategy for research body in which the nervous system resides” (Powers,
and practice in counseling with this paradigm is to 1973b, p. 351).
determine the “main effects” of treatments—with In short, behavioral variation represents an adap-
little or no regard to individual differences among tive process that is governed by feedback emanating
clients. from the interaction of both internal and external
The interactional paradigm (B = f Person × sources. Consequently, the model of the person is not
Situation) can, in certain respects, be regarded as one of being strictly internally driven or externally
a synthesis of the personological and situational controlled but one of simultaneously being influ-
paradigms (i.e., it considers the interaction of per- enced as well as being influential. From this view, the
son and situational factors as the main source of usual dichotomies of internal–external, proactive–
behavioral variation). Although the most recent of reactive, and the like are rendered nonsensical.
the three meta-theoretical paradigms, the interac-
tional paradigm is not a new general meta-theory, as overcoming challenges associated
Ekehammar’s (1974) historical review points out. with a common factors perspective
Its application to and integration into counseling The previous section of the chapter described, com-
psychology has come about through the work of pared, and contrasted three meta-theoretical para-
personality psychologists (Bowers, 1973; Endler & digms. The goal of the section was to show how these
Magnusson, 1976; Harvey, Hunt, & Schroder, meta-theoretical paradigms can be used to categorize
1961; Mischel, 1976), counseling process research- the welter of existing theories into a much smaller
ers (Hertel, 1972; Lichtenberg & Hummel, 1976; number of more manageable groups, thus facilitat-
Raush, 1965; Tracey, 1993), therapy practitio- ing the link between science and practice. In this sec-
ners (Cashdan, 1973; Claiborn & Lichtenberg, tion we discuss what is arguably the most important
1989; Haley, 1963; Strong & Claiborn, 1982; theoretical challenge facing counseling psychologists
Watzlawick, Weakland, & Fisch, 1974), and family in recent times—the call to turn away from concen-
and marital researchers and practitioners (Madanes, trating on specific psychotherapy theories, and focus
1981; Raush, Barry, Hertel, & Swain, 1974; instead on an integrating and superordinate meta-
Watzlawick & Weakland, 1977). theoretical perspective known as the common factors
Although variations on the interactional paradigm perspective. This challenge comes from several sources.
may employ different units of analysis and do so in Meta-analyses of psychotherapy outcome studies
differing theoretical domains, they nonetheless have (e.g., Smith & Glass, 1977), common factors

76 coun seling in te rven tio n s

approaches (e.g., Frank & Frank, 1991), and cri- Science–Practice Integration Challenges
tiques of the randomized clinical trials approach Associated with Therapeutic Outcomes
to empirically supported treatments (ESTs; e.g., eysenck’s initial outcome study
Wampold, 2001) raise important questions regard- A notable first attempt to examine the evidence on
ing the validity of theoretical claims concerning how the effects of therapy was conducted in 1952, by
client psychotherapeutic change occurs in therapy Hans J. Eysenck. The evaluation of the efficacy of
and the sources of that therapeutic change. therapy requires that the effects of treatment be
Meta-analyses have revealed that, generally speak- compared with a no-treatment control group. To
ing, psychotherapies based on very different and conduct his evaluation, Eysenck compared the
often incompatible claims regarding client develop- outcomes found in 24 studies of psychodynamic
ment and the nature of client change nonetheless and eclectic psychotherapy with spontaneous remis-
perform similarly to one another on key client out- sion rates (i.e., rate of improvement in client
come variables. Moreover, meta-analytic evidence functioning—the remission of symptoms—without
fails to support the notion that tailoring the theory benefit of therapeutic intervention) using two con-
to the specific type of client and type of presenting trol groups. The control or comparison groups used
problem improves psychotherapy outcomes. The consisted of severely neurotic clients receiving mainly
common factors perspective emphasizes that non- custodial care in a state mental hospital and dis-
specific and contextual factors, rather than factors ability claimants who had been treated by general
unique to a particular theory, are largely responsible practitioners. The results of Eysenck’s study were dis-
for client change. The common factors perspective concerting, finding that clients who received psy-
raises the possibility that the specifics that distin- chodynamic or eclectic therapy improved less than
guish one theory (or meta-theory) from another are did those in his control/comparison no-treatment
largely irrelevant to whether theory-based psycho- condition. Not only did it appear that therapy was
therapy is effective (see Baker, McFall, & Shoham, ineffective—it might actually be harmful. The alarm
2009 for an alternate perspective on common one might experience in response to today’s widely
factors). Wampold’s (2001) critique of randomized publicized concern about the scientific basis of psy-
clinical trials of theory-based psychotherapies is chotherapy is but an echo of the alarm psychologists
based on the finding that the favorability of psycho- undoubtedly experienced with the publication of
therapy outcomes was uncorrelated with the level of Eysenck’s findings.
the ostensible “active ingredient” of change posited
by the theory. In other words, whether clients got efficacy versus effectiveness
better or worse was unaffected by whether the ther- The determination of therapy outcomes involves
apy had been successful in engaging the client in a variety of issues and considerations. Efficacy and
those processes that the theory holds to be required effectiveness are two ways in which the outcome of
for change. These findings present important issues counseling and psychotherapy are discussed. Efficacy
on which counseling psychology scientists and refers to the therapeutic benefits found in compar-
practitioners must collaborate as they grapple with ing the treatment and a no-treatment control group
the role and nature of theory in psychotherapy. within the context of a controlled clinical study. In
Furthermore, these findings suggest that research contrast, effectiveness refers to the benefits of therapy
efforts should switch from trying to determine that occur in the context of actual counseling prac-
which therapeutic approach is “the best approach” tice. In the former instance, the question is whether
to trying to understand why the current wide array a treatment or intervention is found to achieve a
of theory-based therapies fail to produce differential greater benefit for clients than no treatment. If so,
outcomes, why matching treatments to client con- the treatment is said to be “efficacious.” In the latter
cerns has failed to enhance outcomes, and why instance, the question is how effective is counseling
putative mechanisms of client change have not been for those clients who seek and receive treatment
reliably associated with differential psychotherapeu- within the community.
tic outcomes. These questions are of critical impor- It has been argued that clinical studies create
tance in the science and practice of counseling an artificial context in which the therapy that takes
psychology. Cooperation among, not Balkanization place is not characteristic of how treatments are
of, scientists and practitioners of counseling psychol- provided in actual practice with actual clients.
ogy is required to understand and respond effec- Consequently, finding that a treatment is efficacious
tively to these provocative and challenging findings. cannot be assumed to mean that it is effective

he e sacke r, licht e nbe rg 77

(i.e., will be beneficial to clients in practice settings). significantly worse, relative to the treatment group.
Although there is merit in this criticism, effective- To evaluate the statistical significance of change
ness findings are generally compromised by the within the treatment group (i.e., the statistical sig-
absence of a control group within a practice setting nificance of its outcome), a different approach is
against which to compare client therapeutic gains. needed. In this approach, a group’s pretreatment
As a result, it may not be possible to determine performance on some relevant outcome variable is
whether the benefits derived by clients receiving evaluated against its post-treatment performance on
counseling in community settings are the result of the same variable. If the difference between the pre-
the treatment or of some extraneous factors. and post-treatment assessments is in the expected
In the consideration of counseling and psycho- direction and not attributable to chance differences
therapy outcomes, it is important to ask, “When is in the measurement of the outcome variable (mea-
an outcome significant?” The significance of ther- surement error), then the change (or outcome) is
apy outcomes can be evaluated in several ways. said to be statistically significant.
Outcomes can be evaluated for their statistical sig-
nificance, and they can be evaluated for their clini- clinical significance
cal significance or clinical relevance. The statistical significance of outcome research
findings can provide empirical support for different
statistical significance treatment approaches, but Ogles, Lambert, and
Two types of statistical significance may be consid- Masters (1996) noted that “statistically significant
ered when evaluating therapy outcomes. The first differences between groups do not necessarily indi-
has to do with differences between or among cate meaningful or clinically significant differences
treatment groups. The second has to do with the between groups or for individuals within the groups”
changes experienced by individuals within those (p. 77). That is to say, although the treatment out-
groups. come for one group may differ from that of another
Between-group differences are examined by com- and be in the desired direction, such a finding may
paring the outcomes of two different approaches not be clinically meaningful. For example, although
to therapy (e.g., a new approach to therapy vs. an a treatment for depression might produce in a group
established approach), or by comparing the out- of clients therapeutic change that is significantly
come of a specific therapeutic approach with a pla- different statistically from that of a placebo treat-
cebo treatment or a nontreatment (wait-list) group ment, this does not necessarily mean that those who
(i.e., a control group). Whatever the comparison, if received the treatment are no longer depressed or
the research is designed to rule out extraneous fac- are experiencing a better quality of life. Furthermore,
tors as competing explanations for the change, sta- a statistically significant within-group pre–post
tistical procedures may be used to determine whether difference does not necessarily mean that the indi-
the observed differences that appear between groups viduals who received the treatment are meaningfully
(i.e., their respective outcomes) can reasonably be improved. It simply means that their post-treatment
attributed to differences in the administered treat- scores are reliably different from their pretreatment
ments, or whether it is more reasonable to conclude scores.
that the differences are due to chance (e.g., sampling Several approaches to the evaluation of clinically
differences). If the difference between the outcomes relevant change have been proposed. Researchers
of the treatment group and the comparison group is have suggested that evidence that treated clients are
in the expected direction and unlikely to be due to indistinguishable from a nondisturbed reference
chance sampling differences, then we may conclude group is probably the most convincing evidence
that the difference is statistically significant. In other of clinically meaningful change. This notion has
words, the treatment group was more efficacious been extended to a proposed standardized statistical
and yielded a statistically better outcome than did method involving two criteria for assessing clinical
the comparison group. significance (Jacobson & Truax, 1991). First, the
Although the treatment outcome of one group treated client should be more likely identifiable as
may differ significantly from that of another group, a member within a distribution of healthy persons
this does not necessarily mean that the change that than of a distribution of disturbed or troubled
occurred was itself significant. Indeed, it is conceiv- individuals. Second, the client change must be
able that the treatment group did not change at all, reliable; that is, it must be large enough that the
but rather that the comparison group became pre-to post-treatment change cannot be attributable

78 coun seling in te rven tio n s

to measurement error—a criterion for which they an answer to the larger question of whether therapy
have developed a reliable change index that can be is effective. Unlike the research methods used in
statistically computed. Notwithstanding the above individual studies, for which the client/participants
discussion, statistical significance, rather than clini- serve as data points for analysis, meta-analysis uses
cal significance, is the manner in which outcome the summary statistics from individual studies as the
efficacy is generally reported. data points for analysis. Although not without
detractors, meta-analytic procedures provide a meth-
meta-analysis odology to assemble an overall picture of therapy’s
Eysenck’s (1952) study was not without critiques, as effectiveness (relative to no therapy or a placebo
the study suffered from serious design problems. treatment) and allow investigators to compare stud-
Responding to the challenge to therapy implied by ies using different approaches to therapy to investi-
Eysenck’s study, numerous reviews of aggregated gate the relative efficacy of different treatments.
efficacy studies of counseling and psychotherapy The first meta-analysis of the outcome of psy-
were conducted during the 1960s and 1970s. chotherapy was conducted by Smith and Glass
Although having their own methodological prob- (1977). They analyzed the results of 375 published
lems, these subsequent studies generally contra- and unpublished therapy outcome studies. The
dicted those of Eysenck and instead yielded findings results of their study produced an effect size of .68,
supportive of therapy’s efficacy. which suggests that an average client receiving ther-
Over the years, examinations of the efficacy of apy would be better off (i.e., improved) than 75%
counseling and psychotherapy have reached different of untreated (control group) clients. Although their
and even contradictory conclusions. It is noteworthy results suggest that a proportion (34%) of untreated
that these earlier reviews of the outcome literature clients also improved (i.e., spontaneous remission),
often lacked objectivity and replicability. They gen- the success rate for those receiving treatment was
erally involved narrative descriptions of each study 66%, leading them to conclude that the research
included in the review, an evaluation of the results in showed the beneficial effects of counseling.
terms of the type of evidence offered with respect to As with the challenges to Eysenck’s methodology
therapy outcome, and then an implicit summing up and findings, there have been critics of and chal-
of the findings to render an overall conclusion about lenges to Smith and Glass’ meta-analytic findings.
therapy’s effectiveness. However, with the hundreds Subsequent meta-analyses of the therapy outcome
of outcome studies now available for consideration literature have challenged the validity of those criti-
in concluding therapy’s effectiveness (outcome), how cisms, while at the same time providing rather
to turn the thousands of pieces of evidence that convincing support for the absolute efficacy of
derive from all of these studies into an integrated counseling and psychotherapy. Therapy is not effec-
summary of the benefits of counseling and psycho- tive for every one who seeks it, but the likelihood
therapy is problematic. of someone benefitting from therapy is high, and
Although a single outcome study will reveal outcomes are generally much better than for those
information about the benefits received by the par- left untreated.
ticipants of that study, the answer to the broad ques- The finding that a particular treatment is effec-
tion, such as “Is counseling/psychotherapy effective?” tive or efficacious is not compelling evidence that
requires the examination of the body of research the theory is correct; rather, it is only evidence that
that has addressed this question. More recent inqui- the treatment worked. Why the treatment works—
ries into therapy efficacy have used the statistical its mechanism of change—and whether that com-
method of meta-analysis to examine the aggre- ports with the theory presumed as the basis for the
gated results of hundreds of different studies that treatment is an entirely different matter (Horan,
have compared counseling/psychotherapy with a 1980; Kiesler, 1966).
control group. Briefly, meta-analysis consists of a set An unfortunate tendency of intervention devel-
of statistical procedures that allow researchers to opers is to cite literature that supports the efficacy
gain a comprehensive picture of the research on a of their interventions as also supporting the role
research question and an unbiased answer to the of the theorized causal mechanisms of their inter-
research question. Through meta-analysis, outcome ventions. Findings that support an intervention’s
data from many individual counseling and psycho- efficacy may simply reflect the influence of common
therapy outcome studies are systematically aggre- or nonspecific factors in producing the change.
gated, allowing the findings to be analyzed to achieve As Wampold, Lichtenberg, and Waehler (2005)

he e sacke r, licht e nbe rg 79

noted, “Attributions of causality to specific ingredi- superiority of various counseling and psychotherapy
ents of an intervention should be made only if the approaches, contemporary meta-analytic reviews of
evidence supports such attributions. Relative efficacy the comparative outcome research reach a conclu-
does not necessarily imply that the superiority of an sion remarkably similar to that reached by
intervention was due to the specific ingredients; sim- Rosenzweig (1936)—quoting the Dodo in Alice in
ilarly, superiority to a placebo control does not imply Wonderland, who proclaimed, after much thought,
effectiveness of specific ingredients. The efficacy of following the Caucus race “Everybody has won, and
unique ingredients must be demonstrated by posit- all must have prizes” (italics in the text, Carroll,
ing and verifying a psychological process. Verification 1865/2001, p. 18). In their proportions of clients
can be made by examining mediating variables, estab- who improve by the end of therapy, differences
lishing parametric relationships (e.g., increased ingre- between various forms of therapy are generally insig-
dients or better implemented ingredients relate to nificant, but consistent with the absolute efficacy
better outcomes), or using other appropriate meth- outcome finding already noted—that is, across dif-
ods” (p. 34). Identifying those particular aspects of an ferent established approaches to counseling and
intervention that are responsible for outcomes is par- psychotherapy, efficacy appears to be uniform.
ticularly difficult because interventions are complex
amalgams of ingredients delivered in an interpersonal matching clients with treatments:
context that varies from client to client and from the empirically supported
instance to instance (Wampold, 1997, 2001). treatment approach
Because the results of treatment comparison studies
absolute versus relative suggest little in the way of outcome differences
treatment efficacy between different approaches to counseling and
Whether considering efficacy or effectiveness, or psychotherapy, it is reasonable to speculate that out-
statistical or clinical significance, there are two come differences might exist for different therapies,
primary approaches to examining the question of depending on the problems/disorders toward which
whether an intervention “works.” The first of these they were applied. Such a supposition is reflected
is to examine the absolute efficacy or effectiveness of in the question of what treatment works best for
the treatment. The question is this: Is this treatment what specific problem. The implication in this ques-
better than no treatment or a placebo? If clients do tion is that the comparison of various treatment
not reliably improve as a result of the intervention, outcomes is too gross a comparison to capture mean-
then the treatment should be abandoned; it is either ingful differences among therapy approaches for spe-
worthless or harmful. cific types of presenting concerns. Instead, it may be
In light of the proliferation of approaches to that one approach is best for treating depression,
therapy, it is also reasonable to ask whether some while another is best for treating anxiety, while yet
approaches are better than others. Such a question another is best for treating eating disorders, and so
addresses the relative efficacy of different treatments. on. In this regard, detractors of the finding of uni-
Specifically: “Does Treatment X produce a better form treatment efficacy contend that the lack of
outcome than Treatment Y?” In contrast to the eval- findings of superiority for certain various treatments
uation of the absolute efficacy of a treatment (“Is is the result of researchers failing to take into consid-
Treatment X better than no treatment?”), one evalu- eration the effect of different treatments on different
ates the relative efficacy of different approaches to client problems or concerns.
counseling and psychology by contrasting one treat- The vast array of approaches to therapy has
ment with another. An examination of the relative already been noted. Similarly, there are many dif-
efficacy of a treatment presumes that the absolute ferent sorts of concerns, problems, and disorders
efficacy of the treatment has been established that clients present to counselors and therapists.
(because it makes no sense to contrast a worthless A cross-tabulation of treatments by disorders
treatment against an established, efficacious treat- would be enormous. Adding therapist, client, and
ment to see which is better). The results of such circumstantial variables to this mix would result in
a study can be that the treatment is found to be an impossibly large number of combinations for
better than, equivalent to, or worse than the estab- researchers to test and compare, and for counselors
lished treatment. and therapists to master.
Although a history of comparative outcome Notwithstanding the enormity of the challenge
reviews reveals mixed results regarding the outcome posed by considering disorder-specific therapy,

80 coun seling in te rven tio n s

an increasingly large body of research supports Such a paradigm has for decades driven clini-
the efficacy of particular treatments for particular cal research in psychology, and now drives an
problems. These studies provided the evidentiary important (albeit contentious) movement toward
basis for what are referred to as empirically supported the identification and promulgation of empirically
treatments. The results of meta-analyses comparing supported inventions (American Psychological
different treatment approaches for different prob- Association, 2005; Task Force on Promotion and
lems, however, generally do not support an inter- Dissemination of Psychological Procedures, 1995).
pretation that certain treatments are more effective The thrust of the movement is to identify those
than others for specific client problem areas. interventions whose efficacy for particular diagnos-
In light of the proliferation of counseling tic groups is supported by empirical research. The
approaches, irrespective of the diversity of theoreti- proliferation of interventions seems to match and
cal notions upon which the variety of counseling therefore be justified by the proliferation of
interventions purportedly are based, it is reasonable Diagnostic and Statistical Manual (DSM) disorders.
to ask whether some forms of therapy are “better”
(i.e., more effective) than others, or at least better common factors
(or at least more appropriate) for some problems As discussed already, therapy (generically) is robust
or clients. The question would seem to argue for in its efficacy, but different types of therapy do not
a sort of treatment matrix within which treat- appear to produce different types or degrees of ben-
ments would be associated with different client efit for clients. This is not to say that certain thera-
characteristics—e.g., the nature of the client’s prob- pies applied to certain problems or disorders do not
lem or disorder, the client’s age, gender, or cultural work; rather, the result of multiple meta-analyses
background. (beginning with Smith, Glass, & Miller [1980]
The matrix idea is an attractive one—indeed, through Wampold [2001]) demonstrate that differ-
a responsible one—for practice psychology, resem- ent approaches to therapy seems to produce compa-
bling the way in which medicine is understood to rable outcomes. From this finding has emerged the
be practiced; namely, by matching the medical treat- perspective that factors common across therapies
ment to the patient’s medical condition. Although and nonspecific to any particular approach hold the
Paul (1967) is generally credited with first posing key to treatment efficacy.
the matrix, in reality it may have been articulated This thesis, initially based upon an arm-chair
first by a counseling psychologist in the Journal of analysis of the irreducible minimum variables in any
Counseling Psychology. counseling or psychotherapy interaction between
two persons, was first proposed by Rosenzweig
The agenda for counseling then must be to provide
in 1936, as we wrote earlier. Understandably, the
answers to this question:
notion that there were common therapeutic features
For clients desiring help on each type of problem
across different approaches to therapy could not
of concern to the counselor
have been proffered much earlier than this. But, as
What techniques and procedures,
noted by Wampold (2001), by the 1930s, the vari-
When used by what kind of counselors,
ety of psychoanalytic therapies—each claiming
With which type of clients,
therapeutic success and interpreting this success as
For how long,
evidence supporting its respective theory and inter-
And in what sequence,
ventions—had proliferated to the point that process
Will produce which types of behavior change?
and outcome comparisons across therapies were not
The overriding task of our profession must
only possible but inevitable.
be to use our highly developed understanding
Rosenzweig went on to suggest that, although
of client problems and concerns to generate
factors specific to particular therapeutic approaches
new and more effective ways of being of service.
may contribute to their efficacy, a reasonable expla-
(Krumboltz, 1965, p. 226).
nation for the apparent equivalence of the some-
Such a question suggests a treatment selection times vastly different orientations and interventions
paradigm according to which an intervention would was the presence of “certain unrecognized fac-
be selected for a particular client from a cell or set of tors . . . that may be even more important than
cells within a multidimensional matrix (e.g., treat- those being purposely employed” (p. 412). His posi-
ment by therapist by client by problems by setting; tion, one that has been reflected by others over the
Stiles, Shapiro, & Elliott, 1986). past nearly 75 years, was that these basic factors,

he e sacke r, licht e nbe rg 81

common to every form of therapy, play essentially to yield similar outcomes? What do they have in
the same role in every therapy model and account common?
for whatever positive results are obtained by any of Schofield (1964) has suggested that, to identify
them. common factors across various forms of therapy, it
To be sure, the proponents of each of the various may be most reasonable to start with a clear idea
individual theories and approaches to counseling of their explicit differences. To the extent that indi-
and psychotherapy believed that their theories and vidual systems of therapy have an articulated theory,
interventions captured the essence (and common- it is easy to point out differences among them at the
alities) of therapeutic change. Indeed, it was not level of theory. But, as Schofield has noted, psycho-
uncommon for the proponents of particular theo- therapy theories only have an indirect impact on
ries and approaches to situate other theories and clients. What clients experience are the theories
approaches within their own framework and to filtered through and by therapists who differ in how
claim (implicitly) that the specific therapeutic fac- faithfully and effectively they understand and trans-
tors of other therapeutic approaches were not only late any particular theory into practice. Not surpris-
common to, but also explained by, their own frame- ingly, evidence suggests that the therapist may be at
work. Shoben (1949), for example, argued that psy- least as important in psychotherapeutic outcomes as
chotherapy was fundamentally a problem in learning his or her theoretical approach (e.g., Crits-Christoph
theory, and he proposed a conceptualization of ther- & Mintz, 1991; Whitehorn & Betz, 1960).
apy in terms of then-current behavior theory. Although differences between theories need not
Dollard and Miller (1950) and Alexander (1963) be paralleled by notable differences in therapeutic
did essentially the same, recasting psychoanalytic techniques, there is evidence to suggest that theory-
psychotherapy in terms of a common set of learning based treatments can be distinguished by the pro-
theory principles. And Krasner (1962) offered the cesses used and that these differences are quite
notion that, across diverse approaches to therapy, consistent with the various theories underlying these
the therapist functioned as a “social reinforcement approaches (e.g., DeRubeis, Hollon, Evans, &
machine” (p. 61). Bermis, 1982; Luborsky, Woody, McLellan,
But these theory-specific common factors O’Brien, & Rosenzweig, 1982; also see Wampold,
were not exclusively learning or behavioral factors. 2001). Various theories of counseling and psycho-
Fromm-Reichmann (1950) proposed a set of gen- therapy can be distinguished by what must be pres-
eral psychoanalytic principles of intensive psy- ent or occur and by what must not be present
chotherapy that were presumed to apply across or may not occur (e.g., reinforcement must occur
successful approaches to therapy. Rogers (1957) in behavior modification but cannot in client-
proposed a general set of relationship principles that centered therapy; dream interpretation must occur
he believed to be common across effective counsel- psychoanalysis but cannot occur in cognitive-
ing and psychotherapy (also see Truax & Carkhuff, behavior therapy). There is also evidence, however,
1967). Others (e.g., Cashdan, 1973; Haley, 1963; of considerable variability in the implementation
Strong & Claiborn, 1982) have proposed that it is of specific types of therapy, even when that therapy
through the resolution of interpersonal control con- has been manualized (Malik, Beutler, Alimohamed,
flicts that therapeutic change takes place. Gallagher-Thompson, & Thompson, 2001).
Defining commonalities among diverse Granting the theoretical and procedural distinc-
approaches to therapy by reframing them into the tiveness of different approaches to counseling, one
language of a specific therapy is one way to explain factor common to all formal systems of therapy
the finding of different approaches yielding similar is that there is some theory—some more or less
(positive) outcomes. But recasting the specific ingre- highly explicated theoretical formulation of client
dients of one approach into the language of another troubles (psychopathology) and the therapeutic
is not what Rosenzweig (1936) was proposing and process—and it has been suggested by Frank (1961),
it is not what is generally meant when discussing Hobbs (1962), Rosenzweig (1936), and Schofield
“common factors.” Common factors are not theory- (1964), among others, that some sort of systematic
or approach-specific, and to suggest that psycho- ideology may be an essential contextual element in
analysis is really nothing but behavior therapy misses successful therapy (see Wampold, 2001). “Whether
the point. The various approaches to counseling the therapist talks in terms of psychoanalysis or
and psychotherapy are different—in theory and in Christian Science is from this point of view rela-
their implementation. So, how is it that they seem tively unimportant as compared with the formal

82 coun seling in te rven tio n s

consistency with which the doctrine employed is [Gendlin, 1970, 1978]), self-disclosure (Jourard,
adhered to, for by virtue of this consistency the 1971), and expectancies (e.g., Frank, 1982;
patient receives a schema for achieving some sort Goldstein, 1962; Schofield, 1964) are critical to
and degree of personality organization” (Rosenzweig, successful therapy.
1936, p. 415, cited in Wampold, 2001, p. 26).
Examining the broad outlines of therapy, other Relationship Factors
structural properties emerge that are unavoidably This group of common factors includes the elements
common to all form of counseling. These common defining the therapeutic alliance (also called the
factors do not contribute to differences in the con- working or helping alliance). In general, such an alli-
duct of the therapy, and they cannot explain any ance is distinguished by three aspects: an emotional
difference in results that might be demonstrated by bond between the client and therapist, the quality
different approaches. But it is the contention of the of the client and counselor involvement in the tasks
proponents of a common factors perspective that of therapy, and the concordance between the client
these common factors may well account for most of and the therapist on the goals of counseling (Bordin,
the positive results that each of the various schools 1979). Also included in this group of factors would
of therapy claim. be the status differential of the counselor and client
The specific common factors proffered as (Frank, 1973; Haley, 1963; Schofield, 1964).
accounting for therapeutic results have been “numer-
ous and varied” (Patterson, 1989). And, as a result
Contextual Factors
of different authors focusing on different levels and
Historically, Rosenzweig’s contextual perspective on
aspects of the counseling enterprise, diverse concep-
counseling and psychotherapy was the first common
tualizations of the commonalities across different
factors model proposed. Others articulating this
therapies have emerged. Historically, these concep-
perspective have been Frank (1961, 1973, 1982;
tualizations are of several types: therapist factors,
Frank & Frank, 1991), Hobbs (1962), and Schofield
client factors, relationship factors, and contextual
(1964)—and more recently and empirically,
factors—this latter conceptualization being a sort
Wampold (2001). A contextual model of therapy
of meta-conceptualization subsuming and integrat-
(Wampold, 2001) subsumes and integrates many of
ing the other three.
the features or components presented as therapist,
client, and relationship common factors. Although
Therapist Factors
presented somewhat uniquely by each of its various
Therapist factors—broadly defined as attitudes,
proponents, four features have been proposed as
qualities, and conditions provided by therapists in
common to or shared by all forms of counseling and
their relationships with clients—are qualities
psychotherapy and that create the context for thera-
embodied by therapists that cut across different
peutic change. These include the following:
schools despite their differences in response modes,
techniques, and verbal content. Stiles et al. (1986) 1. A special relationship between the client
proposed two broad categories of these factors: and the therapist. This has been described as “an
warm involvement with the client, and the commu- emotionally charged, confiding relationship with
nication of a new perspective on the client’s person a helping person” (Frank, 1982), but has been
and situation (p. 172). Perhaps the best known considered also to include features such as a status
example of the warm involvement factor is the triad differential between the therapist and client, in
of necessary and sufficient conditions proposed by which the therapist is in an ascendant (and socially
Rogers (1957). The new perspective factor was sanctioned) helping position relative to the client;
described by Frank (1973) as the process by which the client’s confidence in the therapist’s
the therapist provides the client with a new assump- competence and desire to be of help; the client’s
tive word. expectation of help; and the controlled,
circumscribed, and limited nature of the
Client Factors relationship (see Hobbs, 1962; Schofield, 1964).
Within this group of common factors are the 2. A healing setting. Such a setting sets
notions that (a) clients enter therapy sharing a counseling and therapy apart from the client’s
common “ailment” and motivation (Frank [1973] other environments, sanctioning the locale as
describes this as a sense of demoralization), and “place of healing” (Frank, 1973, p. 326),
(b) the client involvement (focusing and experiencing heightening the therapist’s prestige and status

he e sacke r, licht e nbe rg 83

differential, and providing a safe and protected and one addressed routinely in contemporary
place for self-examination, emotional expression, reviews of psychotherapy (e.g., Lambert & Bergin,
and other tasks of therapy. 1994). Most recently, the common factors perspec-
3. A rationale or “myth” that provides a plausible tive (reflected as a contextual model of therapy)
explanation for the client’s symptoms and distress. has achieved considerable empirical prominence as
This rationale (also described as a systematic ideology a result of Wampold’s carefully documented decon-
[Schofield, 1964] or more routinely as a theory of struction of the specific factors view of therapy, the
psychotherapy) additionally prescribes a therapeutic view that is driving the current EST movement.
“ritual” or the series of tasks and procedures to be Notwithstanding the evidence for common
implemented by the client and therapist. factors, the fact remains that a proliferation of
4. A therapeutic ritual or set of procedures approaches to therapy all claim distinctive differ-
or tasks prescribed (or informed) by the theory. This ences. How are those differences to be characterized?
ritual and these procedures characterize the therapy Acknowledging a commonality among theories/
process. They may include such diverse activities as approaches, Wampold has proposed that a given
gradual exposure/extinction procedures, catharsis, approach to therapy is distinctive to the extent that
disputing irrational beliefs, primal screaming, there are actions carried out in the therapy that are
dream interpretation, free association, selective unique and essential to the approach. These he refers
reinforcement, and role playing. to these as the “specific ingredients” of the approach—
those aspects of the therapy that differentiate it
It is with particular regard to Features 3 and 4 from other approaches and represent the sine qua
that the various approaches to therapy are dis- non of that approach. These specific ingredients
tinguished, and it is at this level of analysis that stand in contrast to factors common across different
each of the several hundred approaches to therapy approaches to therapy. Within that approach may
are most clearly differentiated. Nevertheless, it is also be found actions that are essential but not unique
the contention of subscribers to a common factors to the approach, actions that are acceptable but not
perspective that it is not the specific theory, ratio- necessary to the approach, as well as actions that are
nale, or myth, or the specific therapeutic procedures proscribed by the approach. These elements—
or ritual that are important. Rather, it is held that unique/essential, shared/essential, acceptable but
a client’s symptomatic and emotional relief derives not necessary, and proscribed occur at different
from the fact that an explanation for the client’s levels of abstraction in theory and practice.
symptoms and distress is provided to the client by
a caring, trustworthy, experienced socially sanctioned how new treatments develop and
healer within a designated healing setting and fol- are accepted by the field
lowed by the implementation of a conceptually con- As we noted at the outset of this chapter, perhaps
sistent set of procedures applied as therapy to the the most important issue in applied psychology is
client’s problems. the very deep schism between psychologists who
Together, these factors—common across the var- believe strongly that science must always and abso-
ious approaches to counseling and psychotherapy— lutely buttress everything done clinically (e.g.,
are presumed to influence client attitudes and Cummings & Donohue, 2009, pp. 128–129;
behavior in certain common and consistent ways, McFall, 1991; Yalom, 1985, p. 537) and those
including providing new opportunities for cogni- scholars and practitioners who believe that reality
tive and behavioral learning; enhancing the client’s dictates a reliance on other sources of information,
hope/expectancy of relief; providing success experi- such as clinical experience, context, and intuition,
ences that enhance the client’s sense of efficacy, mas- in addition to—and sometimes instead of—science
tery, and competence; combating and helping (e.g., Davison & Lazarus, 1995; Levant, 2004).
overcome the client’s sense of demoralization and People often view the science-central position as
alienation; and arousing the client emotionally. espoused only by scientists, which is not true.
The common factors perspective is now consid- Likewise, people view the pluralist position as
ered one of three central thrusts of the psychotherapy espoused only by practitioners, which, likewise, is
integration movement (Grencavage & Norcross, not true. Still, it only makes sense that scientists
1990), a direction within therapy that is considered would mostly espouse the science-central position
by some to be one of most significant and poten- and that practitioners would advocate reliance on
tially important trends in psychotherapy research, their experience.

84 coun seling in te rven tio n s

 As Levant (2004) has insightfully noted, “Since story, these clinical stories are more human and
this [one’s position on the centrality of science] is messy. The truth about treatment development and
a matter of faith rather than reason, arguments acceptance is multifaceted, ranging from the inten-
would seem to be pointless” (p. 219). So, the matter tional to the fortuitous. Despite, or perhaps because
will not be resolved in this or probably in any other of, that messiness, Davison and Lazarus (1995)
treatise. Nonetheless, the science-centrality issue observed “that most new methods have come from
largely defines or at least powerfully frames nearly the work of creative practitioners [not from scien-
every major issue related to counseling theories. tists]” (p. 96).
Readers will have seen specific examples of this issue We found no research addressing Yalom’s obser-
in play throughout the chapter, as well as in the vation that “Unfortunately, the adaption [adoption]
sections that follow. of a new method is generally a function of the
vigor, the persuasiveness, or the charisma of its
the scientific pathway proponent. . . .” (Yalom, 1985, p. 537). That is
There appear to be, in essence, two stories of not to say Yalom was wrong, but only to say it
how new treatments develop: one scientific, one remains a hypothesis untested, yet worth testing.
clinical. The scientific story is reflected in a spate of The one consistent principle that seems to influence
articles about how to develop manualized treatments whether treatments are accepted and implemented
(e.g., Carroll, & Neuro, 2002; Rounsaville, Carroll, is easy accessibility, with “easy” defined in multiple
& Onken, 2001) and in this description by Alan ways. It could be defined as intellectually easy. So,
Kazdin: “Systematic desensitization for the treat- treatments based on the epistemology a therapist
ment of anxiety and cognitive therapy for the treat- already relies on appear to be more readily accepted
ment of depression began with conceptual models (e.g., Neimeyer & Morton, 1997). A survey of
that explained how the therapies worked, generated 2,607 practitioners suggested that the biggest factor
hypotheses that could be tested, and fostered scores reported in adopting a new treatment was its simi-
of studies on the models” (Kazdin, 2009, p. 276). larity to currently used treatments (Cook, Schnurr,
One interesting omission in these scientific accounts Biyanova, & Coyne, 2009). Similarity makes a new
is the description of how these systematic develop- treatment easier to understand and use. Treatments
ments come to be embraced and implemented by that do not require practitioners to extrapolate from
practitioners. Some evidence that we discuss sug- scientific studies appear to be more readily accepted
gests that often they are not. On the other hand, (e.g., Stewart & Chambless, 2007). Reading a case
psychotherapy researchers have synthesized three study that uses the treatment is easier than extrap-
preexisting models into a set of best practices for dis- olating from scientific studies testing the treat-
semination of treatments (Stirman, Crits-Christoph, ment. Treatments presented in case studies have
& DeRubeis, 2004). How effective these best prac- been reported to be accepted more readily (Cook
tices prove to be remains to be seen. et al., 2009). Nearly all therapists who underwent
organization-wide, mandated training in new treat-
the clinical pathway ments reported adopting the new treatments
The second story of how new treatments develop, (Squires, Gumbley, & Storti, 2008). It is easy to use
the clinical one, is reflected in the stories of theorists something you have just been required to learn.
like Francine Shapiro, who developed eye move- This ease-of-use factor has been identified as
ment desensitization and reprocessing (EMDR) by an important one in the adoption of technological
accident (Maiberger, 2009, p. 33) and Bill Miller, advances, generally. Christiansen (1997) demon-
whose motivational interviewing resulted from him strated that a very important factor in the adoption
slowly noticing something that he later came to of new technologies is how much easier they make
learn was clinically significant (Treasure, 2004): peoples’ lives. Technologies that are easier to use,
“Motivational interviewing was conceived when cheaper, and simpler get selected over those cur-
Miller, a psychologist from the USA, sat with col- rently in use. This holds true even if the new tech-
leagues from Norway and described what sort of nology fails to produce better results than the
therapeutic approach worked for people with alco- established technology.
hol problems. The process of discovery may have Results of a practitioner survey conducted by
been like the technique itself: a gradual process of Cook et al. (2009) suggest that the psychotherapies
listening, reflecting to check understanding, and taught in graduate school strongly influence the
clarification” (p. 331). In contrast to the scientific approaches therapists adopt subsequently, a finding

he e sacke r, licht e nbe rg 85

similar to the mandated-training effect reported approaches and interventions based on their beliefs
by Squires et al. (2008). The Commission on about the nature of knowledge, rather than based
Accreditation of the American Psychological Asso- on empirical support for any given treatment. Going
ciation now requires students from accredited further, these findings might help to explain the
doctoral programs and predoctoral internships to scientist–practitioner divide. Perhaps researchers
demonstrate knowledge of and competence in tend to be rationalists, whereas practitioners may
ESTs. When coupled with Cook et al.’s (2009) find- tend more toward constructivist and other nonra-
ing on the influence of graduate school training and tionalist epistemologies, so they tend not to adopt
another finding of theirs that many practitioners do the rationalist approaches championed by research-
not engage in evidence-based practice, this Com- ers. This epistemic divide may be one way to under-
mission requirement suggests that practice will stand the common complaint of practitioners that
become more evidence based as today’s students psychotherapy research lacks relevance to practice.
become tomorrow’s practitioners. Psychiatry has In 1995, Persons suggested six potential reasons that
gone a step further, requiring that psychiatry practitioners do not adopt validated treatments:
residents be competent in five specified, evidence- psychologists receive little training in ESTs; psy-
based psychotherapies (Mellman & Beresin, 2003). chologists receive extensive training in nonempiri-
An informal survey of Canadian psychiatry resi- cally supported treatments; some practitioners are
dency programs suggests that important advances in not invested in reading the outcome literature;
training have resulted from psychiatry’s emphasis on research findings are difficult for practitioners to
demonstrating competency in evidence-based prac- use, perhaps because the writing is inaccessible;
tice (Ravitz & Silver, 2004). many practitioners believe that all psychotherapies
Less is known regarding those factors associated are equally effective; and consumers are not
with the sustained use of a newly adopted therapy. informed. Practitioners’ difficulties in applying
In a recent survey of practitioners described earlier, research findings to their clients may be the greatest
practitioners reported that they were more likely to difficultly in traversing the hypothesized epistemic
continue using new approaches when they felt effec- divide.
tive using them, enjoyed conducting therapy using
them, when their clients appeared to like the new weaknesses in science
approaches, and when clients reported improve- Scholars, beginning with Lakatos (1968) and Meehl
ment as a result of the new approach (Cook et al., (1978, 1990), have suggested that theorists and
2009). theoretical researchers are unwilling to discard
unsupported theories. Lakatos, for example, decried
Challenges Related to Accepting Treatments the lack of falsifiability in Freudian theory as reflect-
As Established Practice ing “intellectual dishonesty” (p. 150). Meehl’s pri-
epistemic style differences mary concerns included that psychotherapeutic and
There is little empirical research regarding how other “soft” psychological theories are not aban-
researchers and practitioners view each other’s work doned by scientists when they have been disproved,
(Weisz & Addis, 2006); however, evidence does exist but only when they become boring (Meehl, 1978,
regarding factors that influence practitioners’ selec- p. 807). In a 1990 paper, Meehl decried the mis-
tions of treatments. Several studies suggest that guided use of null hypothesis statistical testing to
client and therapist epistemic style guides the demonstrate the validity of a psychological theory
selection of and responsiveness to psychotherapeu- when, he argued, given that “everything correlates
tic approaches. One example of this work is by with everything,” significant findings often simply
Neimeyer and Morton (1997), whose data suggest reflect sufficient statistical power to detect the ubiq-
that cross-cutting the issue of empirical support uitous correlational clutter that Meehl argued is
may be the therapist’s epistemic style. With no infor- characteristic of psychological research. In short, to
mation provided regarding a treatment’s level of Meehl, these significance tests are sham demonstra-
empirical support, therapists with a rationalist tions of validity. So, in addition to the issue of prac-
epistemology reported a preference for behavior tical relevance raised by practitioners, Meehl has
treatments over others, whereas therapists with questioned the scientific validity of much psycho-
a constructivist epistemology reported a preference logical—and, by extension—psychotherapeutic
for constructivist approaches over others. These research. More recently, evaluations of published
studies raise the possibility that therapists select randomized clinical trials of psychotherapy techniques

86 coun seling in te rven tio n s

(which are viewed by many as the evidentiary practitioners). So, when difficulty in understanding
gold standard) suggest that nearly all have fallen ESTs was removed or reduced, practitioners used
short of the criteria described in widely accepted them. When given a choice, practitioners reported
guidelines regarding the proper execution of such most frequently relying on what is most familiar—
trials (Cook, Hoffmann, Coyne, & Palmer, 2007; namely, one’s direct experience. Cook, Biyanova,
Spring, Pagoto, Knatterud, Kozak, & Hedeker, and Coyne (2009) made a related point that vari-
2007). Finally, the vast majority of research on ability in the extent of scientific training across
psychotherapy tests linear effects, whereas practi- mental health professions represents a barrier to
tioners may often observe curvilinear and even some practitioners in understanding and using
recursive behavioral processes at work (see Collins, empirical research reports. This point is mirrored in
2006; Hayes, Laurenceau, Feldman, Strauss, & research by Mullen and Bacon (2003), who reported
Cardaciotto, 2007; Laurenceau, Hayes, & Feldman, that social workers lack the scientific background
2007). of psychologists and therefore relied on professional
consensus rather than empirical support in selecting
difficulty in understanding treatments. These findings suggest that reducing
A far more prosaic but probably more influential the science–practice gap may require the transfor-
factor than epistemology or quality of the science is mation of clinical science into readily teachable
the degree of clarity with which ESTs are presented. formats.
Mirroring results regarding adoption of treatment
approaches more generally, results from several lack of a common conceptual focus
studies converge in supporting the notion that the Another challenge in accepting treatments as estab-
clearer the presentation of the treatment and its lished practice involves the notion that scientists
implementation, the more readily ESTs are adopted may have a problem and problem-resolution focus
by practitioners. The highest reported level of adop- whereas practitioners may have a person focus,
tion of ESTs came from a study in which entire focusing more heavily on the particular client receiv-
agencies signed on for direct training in ESTs for all ing treatment than on the nature of the problem
of their staff members, in which case 96% of practi- and the nature of change. A potential pathway for
tioners were reported to have adopted ESTs in their reducing the gap between scientists and practitio-
practices (Squires et al., 2008). Interestingly, this ners therefore is through personality psychology. In
96% reported compliance rate may have come at their article articulating five fundamental principles
a cost. Research by Henry, Strupp, Butler, Schacht, for an integrative science of personality, McAdams
and Binder (1993) found that therapists who com- and Pals (2006) suggested that “psychopathology
plied most fully with manualized treatment training and problems in living can be conceived as operat-
also showed the greatest reduction in empathic ing with respect to different levels of personality”
sensitivity. and “clinical and counseling psychologists may find
Raine, Sanderson, Hutchings, Carter, Larkin, in . . . [personality psychology] an organizational
and Black (2004) found that when practitioners scheme for sorting through what aspects of person-
were randomly assigned to receive a summary of ality should be targeted for change in psychother-
the research evidence, they recommended evidence- apy” (p. 214). The notion is that personality
based treatments 60% of the time, and when they scientists and psychotherapists may be able to work
received no summary, they only recommended together through a shared focus on personality, and
evidence-based treatments 42% of the time. Cor- may do so more effectively than in the past. Adopt-
relational evidence is consistent with evidence from ing this approach mirrors a suggestion made by
intervention studies. Morrow-Bradley and Elliott Trierweiler (2006), namely, that the scientist–
(1986) surveyed APA Psychotherapy Division mem- practitioner divide should be traversed by an adop-
bers and, with a 72.7% rate of return, found that tion of a set of common methods. Trierweiler has
48% reported that their direct experience with cli- argued that currently, practice methodologies focus
ents was the most important source of information, on the individual whereas research methodologies
whereas only 10% reported that information from focus on the group. Davison and Lazarus (1995)
research was most useful. Less than a fourth of those made a related point as they championed the use
sampled reported relying on research, even for of case studies in clinical science.
difficult cases (similar findings were reported by Another potential pathway for creating a com-
Stewart and Chambless [2007] for independent mon conceptual focus and thereby reducing the

he e sacke r, licht e nbe rg 87

scientist–practitioner divide comes from Jeff one generally reflected by a specific theory. For
Brooks-Harris’ book, Integrative Multitheoretical example, behavioral psychotherapy reflects situa-
Psychotherapy (2008). Brooks-Harris clearly articu- tionism, yet one of the specific behavioral skills
lated specific skills and strategies associated with noted by Brooks-Harris (2009, p. 487) is “Fostering
seven major psychotherapy theories, dividing them Acceptance,” which appears to reflect personolo-
both by theory and by whether they address gism. Nonetheless, connecting meta-theories with
thoughts, feelings, actions, or cultural context. theories, and connecting theories with specific skills,
Brooks-Harris’ scheme constitutes a potential psy- is useful in spite of, and perhaps because of, the
chotherapy Rosetta Stone, allowing and even invit- epistemic complexity these connections reveal.
ing dialogue between and among scientists and
practitioners, united in a common language that
Future Directions
links theories with specific skills and strategies, with
This chapter has presented material on the theory
systems (the thought system, the feeling system, and
and research that underlay counseling interventions,
so on; see also Beutler & Harwood, 2000, for a fore-
with a special emphasis on reducing the gap between
runner approach). Each of the three meta-theories
science and practice. What follows are 13 specific
we described earlier is represented in at least one of
future directions for reducing the science–practice
Brooks-Harris’ seven major psychotherapy theories.
gap in counseling psychology, based on material
So, linking Brooks-Harris’ work with that of Endler
covered in this chapter.
and Magnusson (1976) provides the opportunity
to link meta-theories to theories and theories to 1. Most importantly, in the future do not
specific skills. Brooks-Harris (2008) provided delay in allocating significant professional
between 12 and 15 specific strategies for each of the resources in addressing the science–practice gap
seven theories, with descriptions of each strategy. in counseling psychology. Both the public (http://
Table 4.1 provides three example skills for each www.newsweek.com/id/216506, retrieved October
theory, to give readers some sense of how Brooks- 23, 2009) and the community of scientists (Abbot,
Harris translated theories into specific skills and 2009) have been told recently that psychological
links each theory to its meta-theory. Readers are practice lacks a scientific basis, thus seriously
encouraged to consult Brooks-Harris (2008, Appen- undermining the specialty’s credibility with
dix B) for a comprehensive and detailed list of spe- critically important stakeholders and raising
cific skills. Some of Brooks-Harris’ specific skills troubling concerns about the discipline.
appear to reflect a different meta-theory from the Practitioners in private practice are strongly

Table 4.1. Meta-theories, Theories, and Example Skills

Meta-theory Theory Example Skills
Personologism Cognitive Identifying thoughts, Clarifying the impact of thoughts,
challenging irrational beliefs
Personologism Experiential- Identifying feelings, clarifying the impact of feelings, encouraging
Humanistic expression of feelings
Personologism/ Psychodynamic- Listening to narratives, identifying relationship themes, observing the
Interactionism Interpersonal therapeutic relationship
Situationism Behavioral Illuminating reinforcement and conditioning, determining baselines,
establishing schedules of reinforcement
Situationism Multicultural- Viewing clients culturally, highlighting oppression and privilege,
Feminist supporting social action
Interactionism Biopsychosocial Exploring the effect of biology on psychological functioning,
recognizing the influence of psychological functioning on health,
considering the interaction between health and relationships
Interactionism Systemic- Understanding problems within their social context,
Constructivist viewing families as systems, searching for multigenerational patterns

88 coun seling in te rven tio n s

encouraged to emphasize science-focused training 4. Focus future science–practice integration
in their continuing education, and those in clinics efforts on theory and meta-theory. Theoretical
are encouraged to make use of relevant scientific perspectives arguably hold the greatest promise
articles with regard to challenging clinical cases at for uniting researchers and practitioners in
case conferences. Practitioners in various settings a common interest and in complementary
are encourage to provide feedback to authors and professional activities. Graduate programs in
journal editors regarding scientific articles they counseling psychology should emphasize and
find particularly helpful and, in contrast, those highlight learning and applying theory and
they find particularly frustrating to apply. In turn, meta-theory as a part of both the academic
researchers are encouraged to refocus at least a part training and the practice training of students.
of their research programs to ensure that they are They should develop theory- and meta-theory–
addressing practice-relevant research questions. based proximal outcomes for assessing
They may also wish to have practitioner colleagues graduate training. Furthermore, counseling
review research plans and manuscripts for their psychology’s leadership is encouraged to assure
relevance and utility to practice. Internships and that continuing education offerings and
doctoral training programs may want to focus convention programming emphasize theoretical
a portion of their research–practice integration integration of research and practice and to consider
on identifying and reducing gaps between research asking the American Board of Professional
and practice in their training. Psychology (ABPP) to emphasize a demonstration
2. Avoid future Balkanization of science and of science–practice integration at the theoretical
practice positions, favoring instead approaches level for all board certification in counseling
that appreciate and utilize the differing gifts psychology.
of scientists and practitioners, as well as the 5. Broaden one’s perspectives beyond
differing and valuable perspectives afforded a specific theory and instead operate within
by scientific and practice contexts. Doctoral a meta-theoretical/paradigmatic model, such as
training programs, in particular, should actively personologism, situationism, or interactionism,
foster dialogue among faculty members and in order to overcome the challenges posed to
practicum supervisors, and include participation reducing the science–practice divide by the welter
from program students whenever possible. of differing theories. This broadening will allow
Counseling psychology conferences should more meaningful future interactions between and
feature programming that highlights the among a wider array of scientists and practitioners.
complementarity of scientific and practice For example, graduate training programs could
knowledge, skills, and abilities. Researchers require demonstration of competence in
should partner with practitioners in the conduct understanding theories from at least two of the
of research, and practitioners should partner with three meta-theoretical approaches, as could state
researchers in analyzing cases and developing licensing boards. Special issues of primary
treatment plans. counseling psychology journals could be devoted
3. Remain realistically optimistic about the to helping readers transition from theory-
chances for success of substantially reducing orientation to a meta-theoretical orientation.
counseling psychology’s science–practice gap, 6. As an alternative to an undisciplined
recognizing that future science–practice eclecticism in either science or practice, and as
integration will necessarily remain an incomplete a way to reduce the science–practice gap, adopt
and ongoing process. In the same way that one or more specific theories—or, preferably,
attaining multicultural competence, softening adopt a meta-theory or a common factors
rigid gender role prescriptions, and recognizing approach to guide one’s counseling psychology
the injustices triggered by marginalization remain science, practice, and professional interactions.
“works in progress,” counseling psychologists Undisciplined eclecticism could be identified
(both practitioners and researchers) need to adopt in training program documents, in specialty
a similar perspective regarding the science–practice accreditation guidelines, in counseling psychology
gap. Graduate training, continuing education, and best practices documents, and in accreditation
convention programming can all be directed to guidelines as something to be avoided in practice,
helping people stay aware of the unresolved issue, in research, in training graduate students, and
while remaining optimistic about the future. in postdoctoral continuing education.

he e sacke r, licht e nbe rg 89

Accreditation of doctoral training programs no therapy and that different approaches
and internships could require demonstration of to therapy are surprisingly similar in their
competence in understanding and applying specific outcomes, we recommend that, in the training
theories, meta-theories, and/or common factors of practitioners, graduate programs assure that
approaches in practice and research. students understand that the information deriving
7. Accept and appreciate the differing from outcome research does not support the
information produced by controlled studies of notion that anything they do will necessarily be
psychotherapy (which assess efficacy and provide beneficial to clients nor that their clinical practices
insight regarding cause and effect) and studies are necessarily as good as those of anyone else.
of the benefits resulting from psychological 11. Understand treatment-matching
interventions in naturalistic settings (which assess approaches and the EST outcome methods, along
effectiveness and provide insight regarding external with the major findings produced using these
generalizability of approaches). Counseling approaches, as well as the limitations of these
psychology training program documents should approaches. In particular, graduate programs in
reflect the importance of doctoral training counseling psychology, regardless of bias toward
regarding both efficacy and effectiveness. a common/contextual factors orientation to
8. In addition to statistical significance, practice, need to assure that students understand
appreciate the importance of clinical significance, and appreciate that clients may be differentially
to reduce counseling psychology’s science–practice responsive to different types of empirically
gap. For example, in the reviews and critiques supported interventions and therapy styles, and
of each other’s work, researchers must respect that the most effective approach to therapy may
practitioners’ concerns that a statistically reliable require therapists to match their approaches to
change in a client’s functioning may translate to their clients.
remarkably little in terms of clinically meaningful 12. Understand and appreciate the
change in a client’s level functioning. At the same strengths and limitations of both the scientific
time, practitioners need to understand that and the clinical pathways through which new
empirically demonstrated, statistically significant treatments are developed and accepted. Both
change is reliable, meaningful, and not trivial. researchers and practitioners have a role in the
9. Understand meta-analysis as a psychotherapy development of new treatments. New treatments
outcome assessment method, along with the major emerge from thoughtfully building on and
findings produced by this technique and the extrapolating from theory, and researchers
limitations of this approach and of the findings it contribute to the development and acceptance
produces. In this regard, graduate programs should of new treatments through such scientific
attend to recent developments in expectations pathways. But new treatments also emerge as
for graduate training in evidence-based practice a result of the thoughtful reflective practice of
that require students to be conversant with the clinicians. Treatments emerging via scientific
most common methods used to examine the pathways require clinical validation and
outcomes of therapeutic factors and interventions effectiveness studies. Treatments emerging from
(e.g., efficacy studies, effectiveness studies, meta- clinical experience require scientific validation
analytic studies) and the conclusions drawn from and efficacy studies. In this regard, graduate
this research. Practitioners, as the consumers and training programs need to orient their students,
users of psychotherapy research, are urged to both as practitioners and as researchers, to
understand and appreciate that appropriately understand and embrace the reciprocal and
aggregated research findings provide a stronger complementary nature of science and practice in
and more reliable picture of the state of the the development, refinement, and adoption of
research support underlying their practices and new therapeutic interventions.
provide the best basis for evidence-based practice. 13. Accept, understand, and in the future
10. Appreciate the differing outcome work to resolve the epistemic style differences,
information produced by assessment of the science weaknesses, challenges in understanding
absolute versus relative efficacy of an intervention science, and the lack of shared conceptual foci
and where each type of information is most useful. that constitute continuing barriers to accepting
Notwithstanding evidence for the notion that science-based treatments as established practice.
therapy provides greater benefits for clients than Therapy researchers and practitioners may differ

90 coun seling in te rven tio n s

in the manner in which they view evidence for Carroll, K. M., & Nuro, K. F. (2002). One size cannot fit all:
the effectiveness of interventions, but neither has A stage model for psychotherapy manual development.
Clinical Psychology: Science and Practice, 9(4), 396–406.
“immaculate perception.” Each perspective has its Cashdan, S. (1973). Interactional psychotherapy. New York:
limits and is prone to bias, but they share a Grune & Stratton.
common concern for the improvement of the Christensen, C. M. (1997). The innovator’s dilemma: When new
human condition. And, whether it comes about technologies cause great firms to fall. Boston: Harvard Business
through their graduate education or as a function School Press.
Cialdini, R. B. (1980). Full-cycle social psychology.
of an open-minded approach to the profession, In L. Bickman (Ed.), Applied social psychology annual
practitioners and researchers, rather than focusing Vol. 1 (pp. 21–47). Beverly Hills, CA: Sage Publications.
on the liabilities of their different perspectives, Claiborn, C. D., & Lichtenberg, J. W. (1989). Interactional
both are urged to look for the synergy and counseling. The Counseling Psychologist, 17, 355–453.
complementarity of their views and how their Collins, L. M. (2006). Analysis of longitudinal data: The inte-
gration of theoretical model, temporal design, and statistical
different perspectives collectively may enhance model. Annual Review of Psychology, 57, 505–528.
their respective efforts. Cook, J. M., Biyanova, T., & Coyne, J. C. (2009). Influential
psychotherapy figures, authors, and books: An internet
survey. Psychotherapy Theory, Research, Practice, Training, 46,
Acknowledgments 42–51.
The authors wish to acknowledge with gratitude Cook, J. M., Hoffmann, K., Coyne, J. C., & Palmer, S. C.
the insights of Jeff E. Brooks-Harris regarding ways (2007). Reporting of randomized clinical trials in the Journal
that psychotherapy treatments develop and gain of Consulting and Clinical Psychology 1992 and 2002:
Before CONSORT and beyond. Scientific Review of Mental
acceptance, the insights of Timothy R. Elliot regard- Health Practice, 5(1), 69–80.
ing nonlinearity in psychotherapeutic change, the Cook, J. M., Schnurr, P. P., Biyanova, T., & Coyne, J. C. (2009).
library research conducted by Sean Loughridge, and Apples don’t fall far from the tree: Influences on psychothera-
especially the library research and analysis con- pists’ adoption and sustained use of new therapies. American
ducted by Zaday Sanchez, which were most helpful Psychiatric Services, 60(5), 671–676.
Crits-Christoph, P., & Mintz, J. (1991). Implications of
in completing this chapter. The contributions of therapist effects for the design and analysis of comparative
the two authors were approximately equal. studies of psychotherapies. Journal of Consulting and Clinical
Psychology, 59, 20–26.
References Cronbach, L. J. (1957). The two disciplines of scientific
Abbott, A. (2009). Psychology: A reality check. Nature, psychology. American Psychologist, 12, 671–683.
461(7266), 847. Cummings, N. A., & O’Donohue, W. T. (2009). Eleven blunders
Alexander, F. (1963). The dynamics of psychotherapy in the that cripple psychotherapy in America: A remedial unblunder-
light of learning theory. American Journal of Psychiatry, 201, ing. New York: Routledge.
440–448. Davison, G. C., & Lazarus, A. A. (1995). The dialectics of
Allport, G. (1966). Traits revisited. American Psychologist, science and practice. In S. C. Hayes, V. M. Follette,
21, 1810. R. M. Dawes, & K. E. Grady (Eds.), Scientific standards
American Psychological Association. (2005). Policy statement of psychological practice: Issues and recommendations
on evidence-based practice in psychology. Retrieved (pp. 95–120). Reno, NV: Context Press.
October 26th, 2009, from http://www2.apa.org/practice/ DeRubeis, R., Hollon, S., Evans, M., & Bermis, K. (1982).
ebpstatement.pdf. Can psychotherapies for depression be discriminated? A sys-
Baker, T. B., McFall, R. M., & Shoham, V. (2009). Current tematic investigation of cognitive therapy and interpersonal
status and future prospects of clinical psychology: Toward therapy. Journal of Consulting and Clinical Psychology,
a scientifically principled approach to mental and behavioral 50, 744–756.
health care. Psychological Science in the Public Interest, 9(2), Dollard, J., & Miller, N. (1950). Personality and psychotherapy.
67–103. New York: McGraw-Hill.
Beutler, L., & Harwood, T. M. (2000). Prescriptive Ekehammar, B. (1974). Interactionism in personality from a his-
psychotherapy: A practical guide to treatment selection. New torical perspective. Psychological Review, 81, 1026–1048.
York: Oxford. Ellis, A., & Dryden, W. (2007). The practice of rational emotive
Bordin, E. (1979). The generalizability of the psychoanalytic behavior therapy. New York: Springer.
concept of working alliance. Psychotherapy: Theory, Research Endler, N., & Magnusson, D. (1976). Toward an interactional
and Practice, 16, 252–260. psychology of personality. Psychological Bulletin, 83, 956–974.
Bowers, K. (1973). Situationism in psychology: An analysis and Eysenck, H. J. (1952). The effects of psychotherapy. Quarterly
critique. Psychological Review, 80, 307–336. Bulletin of the British Psychological Society, 3, 41.
Brooks-Harris, J. E. (2008). Integrative multitheoretical psycho- Ford, D. H., Urban, H. B., & Ford, D. H. (1998). Contemporary
therapy. Boston: Houghton Mifflin. models of psychotherapy: A comparative analysis (2nd ed.).
Carroll, L. (2001). Alice’s adventures in wonderland. London: Hoboken, NJ: John Wiley & Sons.
Macmillan. Mineola, NY: Dover. (Original work published Frank, J. (1961). Persuasion and healing. Baltimore: Johns-
1865). Hopkins.

he e sacke r, licht e nbe rg 91

Frank, J. (1973). Persuasion and healing (2nd ed.). Baltimore: psychotherapy Vol. II (pp. 61–94). Washington, DC: American
Johns-Hopkins. Psychological Association.
Frank, J. (1982). Therapeutic components shared by all psy- Krumboltz, J. D. (1965). The agenda for counseling. Journal of
chotherapies. In J. Harvey, & M. Parks (Eds.), Psychotherapy Counseling Psychology, 12(3), 226.
research and behavior change Vol. 1 (pp. 9–37). Washington, Kuhn, T. (1970). The structure of scientific revolutions. Chicago:
DC: American Psychological Association. University of Chicago Press.
Frank, J., & Frank, J. (1991). Persuasion and healing (3rd ed.). Lakatos, I. (1968). Criticism and the methodology of scientific
Baltimore: Johns-Hopkins. research programmes, Proceedings of the Aristotelian Society,
Fromm-Reichman, F. (1950). The principles of intensive psycho- New Series (69), 149–186. New York: Blackwell Publishing
therapy. Chicago: University of Chicago Press. on behalf of The Aristotelian Society.
Garfield, S. (1989). The practice of brief psychotherapy. Elmsford, Lambert, M., & Bergin, A. (1994). The effectiveness of
NY: Pergamon. psychotherapy. In A. Bergin, & S. Garfield (Eds.), Handbook
Gendlin, E. T. (1970). A theory of personality change. In J. Hart, of psychotherapy and behavior change (4th ed.). New York:
& T. Tomlinson (Eds.), New directions in client-centered Wiley.
therapy (pp. 129–173). Boston: Houghton-Mifflin. Laurenceau, J., Hayes, A. M., & Feldman, G. C. (2007). Some
Gendlin, E. T. (1978). Focusing. New York: Bantam. methodological and statistical issues in the study of change
Goldstein, A. (1962). Therapist-patient expectancies in psychology. processes in psychotherapy. Clinical Psychology Review, 27,
New York: Pergamon. 682–695.
Grencavage, L., & Norcross, J. (1990). Where are the common- Levant, R. F. (2004). The empirically validated treatments
alities among the therapeutic common factors? Professional movement: A practitioner/educator perspective. Clinical
Psychology: Research and Practice, 21, 372–378. Psychology: Science and Practice, 11(2), 219–224.
Haley, J. (1963). Strategies of psychotherapy. New York: Grune & Lewin, K. (1952). Field theory in social science: Selected theoretical
Stratton. papers by Kurt Lewin. London: Tavistock.
Harvey, O., Hunt, D., & Schroder, H. (1961). Conceptual sys- Lichtenberg, J. W., & Hummel, T. (1976). Counseling as sto-
tems and personality organization. New York: Wiley. chastic process: Fitting a Markov chain model to initial
Hayes, A. M., Laurenceau, J., Feldman, G., Strauss, J. L., counseling interviews. Journal of Counseling Psychology, 23,
& Cardaciotto, L. A. (2007). Change is not always linear: 310–315.
The study of nonlinear and discontinuous patterns of change Luborsky, L., Woody, G. E., McLellan, A. T., O’Brien, C. P., &
in psychotherapy. Clinical Psychology Review, 27, 715–723. Rosenzweig, J. (1982). Can independent judges recognize
Henry, W. P., Strupp, H. H., Butler, S. F., Schacht, T. E., & different psychotherapies? An experience with manual-
Binder, J. L. (1993). Effects of training in time-limited guided therapies. Journal of Consulting and Clinical Psy-
dynamic psychotherapy: Changes in therapists’ behavior. chology, 30, 49–62.
Journal of Consulting and Clinical Psychology, 61, 434–440. Madanes, C. (1981). Strategic family therapy. San Francisco:
Herink, R. (Ed.). (1980). The psychotherapy handbook: The A to Z Jossey-Bass.
guide to more than 250 different therapies in use today. Maiberger, B. (2009). EMDR essentials: A guide for clients and
New York: New American Library. therapists. New York: W. W. Norton.
Hertel, R. (1972). Application of stochastic process analysis to Malik, M., Beutler, L., Alimohamed, S., Gallagher-
the study of psychotherapeutic process. Psychological Bulletin, Thompson, D., & Thompson, L. (2001). Are all cognitive
77, 421–430. therapies alike? A comparison of cognitive and non-cognitive
Hobbs, N. (1962). Sources of gain in psychotherapy. American therapy process and implications for the application of empiri-
Psychologist, 17, 18–34. cally supported treatments. Unpublished manuscript.
Holland, J. L. (1997). Making vocational choices: A theory of University of California-Santa Barbara.
vocational personalities and work environments (3rd ed.). McAdams, D. P., & Pals, J. L. (2006). A new Big Five:
Odessa, FL: Psychological Assessment Resources. Fundamental principles for an integrative science of person-
Horan, J. J. (1980). Experimentation in counseling and psycho- ality. American Psychologist, 61(3), 204–217.
therapy. Part I: New myths about old realities. Educational McFall, R. M. (1991). Manifesto for a science of clinical psychol-
Researcher, 9, 5–10. ogy. Clinical Psychologist, 44(6), 75–88.
Jacobson, N. S., & Truax, P. (1991). Clinical significance: A sta- Meehl, P. E. (1978). Theoretical risks and tabular asterisks:
tistical approach to defining meaningful change in psycho- Sir Karl, Sir Ronald, and the slow progress of soft psych-
therapy research. Journal of Consulting and Clinical Psychology, ology. Journal of Consulting & Clinical Psychology, 46,
59, 12–19. 806–834.
Jourard, J. (1971). Self-disclosure. New York: Wiley. Meehl, P. E. (1990). Appraising and amending theories: The
Kazdin, A. E. (1986). Comparative outcome studies in psycho- strategy of Lakatosian defense and two principles that war-
therapy: Methodological issues and strategies. Journal of rant it, Psychological Inquiry, 1(2), 108–141.
Consulting and Clinical Psychology, 54, 95–105. Mellman, L. A., & Beresin, E. (2003). Psychotherapy competen-
Kazdin, A. E. (2009). Bridging science and practice to improve cies: Development and implementation. Academic Psychiatry,
patient care. American Psychologist, 64, 276–278. 27, 149–153.
Kiesler, R. (1966). Some myths of psychotherapy research Mischel, W. (1976). Introduction to personality. New York: Holt,
and the search for a paradigm. Psychological Bulletin, 65, Rinehart & Winston.
110–136. Mischel, W. (2009). Editorial: Connecting clinical practice to
Krasner, L. (1962). The therapist as a social reinforcement scientific progress. Psychological Science in the Public Interest,
machine. In H. Strupp, & L. Luborsky (Eds.), Research in 9(2), i–ii.

92 coun seling in te rven tio n s

Moos, R. (1973). Conceptualizations of human environments. Shoben, E. J. (1949). Psychotherapy as a problem in learning
American Psychologist, 28, 652–665. theory. Psychological Bulletin, 46, 366–392.
Moos, R. (1974). Psychological environments. American Smith, M. L., & Glass, G. V. (1977). Meta-analysis of psycho-
Psychologist, 29, 179–188. therapy outcome studies. American Psychologist, 32, 752–760.
Morrow-Bradley, C., & Elliott, R. (1986). Utilization of psycho- Smith, M. L., Glass, G. V., & Miller, T. L. (1980). Benefits of
therapy research by practicing psychotherapists. American psychotherapy. Baltimore: Johns Hopkins University Press.
Psychologist, 41(2), 188–197. Spring, B., Pagoto, S., Knatterud, G., Kozak, A., & Hedeker, D.
Mullen, E. J., & Bacon, W. F. (2003). Practitioner adoption and (2007). Examination of the analytic quality of behavioral
implementation of evidence-based effective treatments and health randomized clinical trials. Journal of Clinical
issues of quality control. In A. Rosen, & E. K. Proctor (Eds.), Psychology, 63(1), 53–71.
Developing practice guidelines for social work interventions: Squires, D. D., Gumbley, S. J., & Storti, S. A. (2008). Training
Issues, methods, and a research agenda (pp. 223–235). substance abuse treatment organizations to adopt evidence-
New York: Columbia University Press. based practices: The Addiction Technology Transfer Center
National Institute of Mental Health (NIMH). (1975). Report of New England Science to Service Laboratory. Journal of
of the Research Task Force of the National Institute of Substance Abuse Treatment, 34, 293–301.
Mental Health: Research in the service of mental health Stewart, R. E., & Chambless, D. L. (2007). Does psychotherapy
(No. ADM 75–236). Rockville, MD: DHEW Publications. research inform treatment decisions in private practice?
Neimeyer, G. J., & Morton, R. J. (1997). Personal epistemologies Journal of Clinical Psychology, 63(3), 267–281.
and preferences for rationalist versus constructivist psycho- Stiles, W., Shapiro, D., & Elliott, R. (1986). “Are all psycho-
therapies. Journal of Constructivist Psychology, 10(2), 109–123. therapies equivalent?” American Psychologist, 41, 165–180.
Ogles, B. M., Lambert, M. J., & Masters, K. S. (1996). Stirman, S. W., Crits-Christoph, P., & DeRubeis, R. J. (2004).
Assessing outcome in clinical practice. Needham Heights, MA: Achieving successful dissemination of empirically supported
Allyn & Bacon. psychotherapies: A synthesis of dissemination theory. Clinical
Patterson, C. (1989). Foundations for a systematic eclecticism in Psychology: Science and Practice, 11(4), 343–351.
psychotherapy. Psychotherapy, 25, 171–180. Strong, S., & Claiborn, C. (1982). Change through interaction:
Paul, G. (1967). Strategy of outcome research in psychotherapy. Social psychological processes of counseling and psychotherapy.
Journal of Consulting and Clinical Psychology, 64, 973–982. New York: Wiley.
Persons, J. B. (1995). Why practicing psychologists are slow to Task Force on Promotion and Dissemination of Psychological
adopt empirically-validated treatments. In S. C. Hayes, Procedures. (1995). Training in and dissemination of empir-
V. M. Follette, R. M. Dawes, & K. E. Grady (Eds.), Scientific ically validated treatments: Report and recommendations.
standards of psychological practice: Issues and recommendations The Clinical Psychologist, 48(1), 3–23.
(pp. 141–161). Reno, NV: Context Press. Tracey, T. J. (1993). An interpersonal stage model of the thera-
Powers, W. (1973a). Behavior: The control of perception. Chicago: peutic process. Journal of Counseling Psychology, 40, 1–14.
Aldine. Treasure, J. (2004). Motivational interviewing. Advances
Powers, W. (1973b). Feedback: Beyond behaviorism. Science, in Psychiatric Treatment, 10, 331–337.
179, 351–356. Trierweiler, S. J. (2006). Training the next generation of
Raine, R., Sanderson, C., Hutchings, A., Carter, S., Larkin, K., psychologist clinicians: Good judgment and methodological
& Black, N. (2004). An experimental study of determinants realism at the interface between science and practice.
of group judgments in clinical guideline development. In C. D. Goodheart, A. E. Kazdin, & R. J. Sternberg (Eds.),
Lancet, 354, 429–437. Evidence-based psychotherapy: Where practice and research meet
Raush, H. (1965). Interaction sequences. Journal of Personality (pp. 211–238). Washington, DC: American Psychological
and Social Psychology, 2, 487–499. Association.
Raush, H., Barry, W., Hertel, R., & Swain, M. (1974). Truax, C. B. (1966). Reinforcement and nonreinforcement in
Communication, conflict, and marriage. San Francisco: Rogerian psychotherapy. Journal of Abnormal Psychology,
Jossey-Bass. 71, 1–9.
Ravitz, P., & Silver, I. (2004). Advances in psychotherapy educa- Truax, C. B., & Carkhuff, R. (1967). Toward effective counseling
tion. Canadian Journal of Psychiatry, 49, 230–237. and psychotherapy. Chicago: Aldine.
Rogers, C. (1957). The necessary and sufficient conditions Wampold, B. E. (1997). Methodological problems in identifying
of therapeutic personality change. Journal of Consulting efficacious psychotherapies. Psychotherapy Research, 7,
Psychology, 21, 95–103. 21–43.
Rosenzweig, S. (1936). Some implicit common factors in Wampold, B. E. (2001). The great psychotherapy debate: Models,
diverse methods of psychotherapy. American Journal of methods and findings. Mahwah, NJ: Erlbaum.
Orthopsychiatry, 6, 412–415. Wampold, B. E., Lichtenberg, J. W., & Waehler, C. A. (2005).
Rounsaville, B. J., Carroll, K. M., & Onken, L. S. (2001). A broader perspective: Counseling psychology’s emphasis
A stage model of behavioral therapies research: Getting on evidence. Journal of Contemporary Psychotherapy, 35(1),
started and moving on from stage I. Clinical Psychology: 27–38.
Science and Practice, 8(2), 133–142. Watzlawick, P., & Weakland, J. (1977). The interactional view.
Schachter, S., & Singer, J. E. (1962). Cognitive, social and New York: Norton.
physiological determinants of emotional state. Psychological Watzlawick, P., Weakland, J., & Fisch, R. (1974). Change.
Review, 69, 379–399. New York: Norton.
Schofield, W. (1964). Psychotherapy: The purchase of friendship. Weisz, J. R., & Addis, M. E. (2006). The research-practice tango
Englewood Cliffs, NJ: Prentice-Hall. and other choreographic challenges: Using and testing

he e sacke r, licht e nbe rg 93

 evidence-based psychotherapies in clinical care settings. with schizophrenic patients. American Journal of Psy-
In C. D. Goodheart, A. E. Kazdin, & R. J. Sternberg (Eds.), chiatry, 117, 215–223.
Evidence-based psychotherapy: Where practice and research meet Yalom, I. D. (1985). The theory and practice of group psychotherapy
(pp. 179–206). Washington, DC: American Psychological (3rd ed.). New York: Basic Books.
Association.
Whitehorn, J., & Betz, B. (1960). Further studies of the
doctor as a crucial variable in the outcome of treatment

94 coun seling in te rven tio n s

 CHAPTER

Process and Outcomes in Counseling

5 and Psychotherapy

Sara Maltzman

Abstract
This chapter reviews process and outcome research in counseling and psychotherapy. An overview
of the research is described in its historical context. The imperative for evaluating mediator and
moderator variables is described. The interactional influence between methodology and outcome
research is discussed in the context of conclusions and causal inferences drawn from various
methodologies and analyses. In particular, the contribution of meta-analytic techniques is discussed.
Last, the medical and common factors contextual models are discussed. The biopsychosocial model
is suggested as an alternative model. Specific applications of the biospsychosocial model to process
and outcome research are described. A biopsychosocial understanding of attachment and resilience
is offered as a framework for facilitating process and outcome research and an understanding of
psychosocial flourishing.
Keywords: process, outcome, common factors, contextual model, biopsychosocial, attachment,
resilience, flourishing

This chapter reviews issues in process and outcome the contribution of meta-analytic techniques is
research in counseling and psychotherapy. The discussed.
extant literature in these areas is enormous, and spe- Last, this chapter reviews and discusses the med-
cific areas related to process and outcome (e.g., the ical and common factors contextual models that
counseling relationship, theories and interven- have been described in the literature. The biop-
tions, and methodologies) are covered in detail sychosocial model is suggested as an alternative
in other chapters of this Handbook. For these rea- model that offers a superior conceptual framework
sons, this chapter takes a broader perspective. It pro- for explicating treatment effectiveness and the con-
vides an overview of the research in its historical tributions of process and input variables. Specific
context by describing sociopolitical influences that examples are provided regarding possible applica-
have shaped research in counseling and psycho- tions of the biospsychosocial model. A biopsychoso-
therapy process and outcome over the past 30 years. cial conceptualization of attachment and resilience
It then traces the evolution of the research from is offered as a framework for future directions in
treatment efficacy studies to effectiveness studies process and outcome research.
and the imperative for evaluating mediator (process)
and moderator (input) variables. The interactional Definitions of Terms
influence between methodology and outcome Therapist, Client, and Treatment
research is discussed in the context of what con- To simplify nomenclature and for consistency, this
clusions and causal inferences can be drawn from chapter will use therapist to designate psychologists
various methodologies and analyses. In particular, and other licensed mental health professionals

95
engaged in the provision of counseling and psycho- depending upon the particular hypothesis and topic
therapy. Client will be used rather than “patient,” of study (Hill & Corbett, 1993).
consistent with the principles of client empower- Process variables include client and thera-
ment and a collaborative approach that minimizes pist behaviors within the therapeutic setting, and
the inherent power differential. Treatment refers to the therapist–client interaction (Hill & Corbett,
counseling and psychotherapy interventions that 1993; Hill & Williams, 2000). These behaviors
meet Kendal and Beidas’ (2007) criteria for empiri- include overt and covert thoughts and feelings
cally based or empirically supported interventions (i.e., they may or may not be directly observable).
designed to target specified aspects of the present- Examples include therapist attitudes and exper-
ing concern or disorder. Intervention is a broader tise, the “dose” of treatment, and the interac-
term that includes other professional activities, such tion among these variables (Hill & Corbett,
as assessment and case conceptualization, which 1993; Hill &Williams, 2000). There is consensus
are used within counseling and psychotherapy that evaluation of moderator and mediator vari-
paradigms. ables within the counseling and psychotherapeutic
process is critical to understanding mechanisms
Moderator (Input) and Mediator of change (Westen, Novotny, & Thompson-Brenner,
(Process) Variables 2004). Such studies also are necessary for devel-
Laurenceau, Hayes, and Feldman (2007) describe oping appropriate paradigms for flexibly imple-
input (moderator) and process (mediator) vari- menting empirically supported treatments (ESTs)
ables as follows: moderators of change are variables in naturalistic settings (Kazdin, 2008). Kazdin
that define and predict who will benefit from (2007, 2008) and others have called for the increased
treatment and under what conditions. Mediator use of qualitative methods to explicate these
(process) variables explain the why and how relationships.
change occurs (Laurenceau, Hayes, & Feldman,
2007). Variables originating outside of the thera- Outcome Variables
peutic setting can be external events (extra-therapy Outcomes are defined as changes that may
variables) or intraindividual characteristics (input be directly, or indirectly, the result of the treat-
variables). These external (extra-therapy) variables ment (Hill & Corbett, 1993). What constitutes
may directly or indirectly impact the client and “change” has been defined in a variety of ways:
the client’s presentation in therapy (e.g., natural client satisfaction with treatment, mutual termi-
disasters or personal life events). Moderator vari- nation (presumably after treatment goals have
ables are input variables such as client expectan- been achieved) versus premature termination (uni-
cies, personality, and severity of illness (Hill & lateral termination by the client), reduction in
Corbett, 1993; Hill &Williams, 2000). However, symptomatology as assessed by client and/or
intraindividual characteristics may or may not be therapist report, and/or improvement in psycho-
relatively stable over time. Gender, age, socio- social functioning as determined by client, thera-
economic status, ethnic, cultural, and religious pist, or collateral report. These outcomes can be
identity tend to be conceptualized as stable charac- evaluated at varying points in time relative to
teristics, although that can change based on the par- treatment termination. Initial response refers to
ticular research question. Age, for example, has its outcome at termination; sustained response refers
own associated developmental limitations, tasks, to assessment of positive treatment effects at
and opportunities. Gender is not immutable, and follow-up intervals (Westen & Morrison, 2001).
gender-related issues may become a focus in ther- Outcome also can be measured session-by-session
apy. Socioeconomic status may contribute to both to assess for dose–response effects and associated
the therapist and client’s worldview and can change client input variables that may be influencing treat-
dramatically as a consequence of mental illness or ment process (Stulz, Lutz, Leach, Lucock, &
external economic forces. Additionally, client and Barkham, 2007).
therapist expectations, attitudes, and subjective The potential blurring of process and out-
levels of distress are additional input variables that come variables is evident by these descriptions. The
originate outside of the therapeutic dyad. However, same variable can be considered a process or out-
these particular variables often are the subject of come variable depending on the research question
research, either as process or outcome variables, and methodology.

96 process an d o u tco mes

Efficacy and Effectiveness Thus, artificially constraining treatment to a speci-
Efficacy has been used to describe treatment fied duration in efficacy studies can potentially atten-
outcomes determined in controlled trials, ideally uate treatment effectiveness and result in a type II
randomized controlled trials (RCTs). Treatments error due to an inadequate trial of treatment.
are compared to no-treatment controls (e.g., wait-
list conditions) or other treatments. The goal is to History and Sociopolitical Context
control, to the greatest degree possible, for vari- of Process and Outcome Research
ability in settings, treatment delivery, therapist The need to demonstrate psychological treatment
variables, and client input variables. The ideal efficacy and effectiveness took on a greater sense
RCT for determining efficacy includes standard- of urgency in the 1970s in the context of the
ized (e.g., manualized) treatments to control debate regarding the economic feasibility of national
for intragroup variability in delivery. The purpose health insurance. There was no consensus among
of efficacy studies is to identify treatments psychologists that reimbursement for psycholog-
that causally contribute to positive outcomes ical treatments under such insurance was fiscally
(Seligman, 1995; Westen & Morrison, 2001). feasible or even appropriate.
Wampold (2000) further distinguished absolute effi- Arguments by psychologists against reim-
cacy studies, in which treatments are compared with bursement centered on three issues: treatment
a control group, from relative efficacy studies, in could not be cost-effectively financed, treatment
which two or more treatments are directly com- could not be adequately monitored to prevent
pared; these studies typically include a control fiduciary abuse, and treatment in outpatient
group, as well. The most common criticism of effi- private practice was dominated by psychiatrists
cacy studies is that the “real world” is not so neat. serving primarily the middle and upper socioeco-
Clients tend to present with multiple psychological nomic (SES) classes who were seeking self-
and/or physical complaints that impact treatment fulfillment (McSweeny, 1977; Strupp & Hadley,
delivery or outcome; private practice and mental 1977). This last issue was central to the expressed
health clinics are not run with the same degree of concerns because the Community Mental Health
structure and control as is the clinical laboratory in Centers Act of 1963, which mandated the develop-
terms of exposure to other clients and extra-therapy ment of public mental health services to meet the
events. needs of the poor, had not successfully bridged the
Effectiveness studies evaluate treatments in the quality gap between services accessible by upper
“real world”: the generalizability of efficacy to and lower SES clients. One reason was that public
naturalistic settings that include heterogeneous mental health centers tended to be staffed by less
client populations with comorbid presentations educated and trained therapists. Not only was there
(Seligman, 1995; Westen & Morrison, 2001). Thus, a quality gap in service delivery, but the values
effectiveness studies increase the external validity promoted by private therapists tended to reflect
of results because they reflect “real-world” condi- those of the middle-class, focusing on the explora-
tions. For example, treatment delivery in natural- tion of feelings, thoughts, intentions, and motiva-
istic settings may vary in length, whereas treatment tion of clients who did not experience the severity
delivery within an RTC tends to be of predeter- of symptoms and distress exhibited by lower SES
mined length. Because conditions are not well con- clients. Thus, carte blanche reimbursement for
trolled, it is more difficult to infer causal mechanisms psychological treatments would not benefit the
in naturalistic settings. On the other hand, the general American public nor their overall health;
artificial constraints of RTCs can attenuate treat- rather, it would amount to the subsidy of treatment
ment effectiveness. For example, Westen and for the rich by the poor (Cummings, 1977).
Morrison (2001) noted that duration of treatment Arguments supporting reimbursement cited the
for depression in naturalistic settings is approxi- overutilization of medical services by clients suffering
mately 6 months when cognitive-behavioral ther- psychological and emotional distress. Cummings
apy (CBT) is utilized, and longer for other (1977) reported that “60% of physician visits . . . are
modalities, assuming there are no imposed external from sufferers of emotional distress rather than
limitations (e.g., managed care constraints). Treat- organic illness” (p. 711). Therefore, the cost of cover-
ment duration approximately doubles when there ing psychological treatment should be offset by
is co-morbidity (Westen & Morrison, 2001). greater savings through decreased medical utilization.

m alt zm an 97
This tied psychological treatment for mental health and should be of equal quality and effectiveness
concerns to the amelioration of medical health for all clients served.
concerns and reductions in medical care costs • Effective treatment should mitigate the
(Olbrisch, 1977; Strupp & Hadley, 1977). misutilization or overutilization of medical care.
Rapprochement between these divergent per- • Psychological treatments should be integrated
spectives was achieved through agreement and rec- with physical health, both in its approach toward
ognition that clear standards were needed against improving physical health and in preventing
which treatments could be evaluated. disease.
Within this context, the American Psychological
Association (APA) Task Force on Standards for
Meta-Analysis and Treatment Efficacy
Service Facilities published the first revision of the
Within the above historical context, the Smith and
1974 Standards for Providers of Psychological Services
Glass meta-analysis (1977) reflected the contem-
(1977). The goal of this revision was to develop uni-
poraneous sociopolitical zeitgeist. It provided the
form standards for practicing psychologists regard-
first evidence of treatment efficacy that addressed
less of specialty, setting, or reimbursement. These
some of the core themes outlined above in the
standards specifically noted the goal of ensuring
debate regarding inclusion of psychological treat-
uniform quality across both the public and private
ments in a national insurance plan. The interven-
sectors. Although the standards were developed in
tions included in the study addressed psychosocial
the context of justifying reimbursement, there was a
functioning and core issues relevant to the broader
clear message that the ultimate goal was to ensure
population. Treatment goals targeted maladaptive
that the public’s best interests were met.
behaviors, feelings, values, and attitudes (Smith &
The 1977 standards specified that citizens
Glass, 1977). What Smith and Glass did not include
accessing private and public mental health ser-
was as important as what they did include. They
vices should be afforded the same quality of
eschewed interventions associated with higher-
care under similar regulatory safeguards in both
SES clients by excluding interventions that tended
domains, and that these services should address cli-
to last longer and thus were associated with finan-
ents’ needs without undue financial hardship (i.e.,
cial drain, and excluded outcomes that pertained
treatment must be cost-effective). These standards
to self-fulfillment and self-actualization. They also
(1977) reflected the consensus that reimbursement
excluded interventions that were not grounded in
guidelines should disallow payment for treatments
psychological principles (e.g., drug therapies, occu-
that were not clearly specified, supported by evi-
pational therapy), as well as interventions provided
dence, or that were focused on “obvious class biases,
by individuals who were unqualified to under-
such as existential crises and ennui. . . .” rather
stand and apply these psychological principles in
than on “real” (quotes in original) psychological
practice (e.g., peer counselors). Thus, the data met
problems that disrupt basic psychosocial function-
fundamental criteria around which professional
ing (McSweeny, 1977, p. 725). They also acknowl-
consensus had been built. The study justified reim-
edged the many stakeholders in this debate–
bursement. It not only represented a methodologi-
psychologists, client, society, government–all of
cal first, it was a sociopolitical boost for establishing
whom would have a unique perspective on what
psychological interventions as legitimate treatment
“effectiveness” meant.
for improving psychosocial functioning.
In summary, the 1977 standards and consen-
The Smith and Glass study (1977) may be one
sus in the professional community supported the
of the most widely cited works in psychology
following requirements:
(668 citations as of May 1, 2011, as noted in APA
• Treatment should focus on rehabilitative, PsychNET), underscoring its significance in the
ameliorative strategies rather than self-fulfillment field. Methodologically, it was the first published
and self-actualization. meta-analysis of individual outcome studies, and it
• Treatment should have demonstrated is cited for this significance. It included all studies
effectiveness as a prerequisite for reimbursement. that evaluated treatment outcomes, published and
• Therapists should be held accountable unpublished, that had utilized at least one treatment
for the effectiveness of their services. condition compared with a no-treatment control
• Treatment should be equally available group or second treatment condition. It also was the
to clients across the socioeconomic spectrum first study to determine effect sizes for treatment

98 process an d o u tco mes

outcome in each study, which leveled the playing recognition that access to adequate health care is
field across varying types of treatments and thus an essential human right” (p. 761). However, to
allowed for direct comparisons; and it attempted date, the United States still does not have univer-
to draw causal inferences among study characteris- sal health coverage, and parity for mental health
tics (such as therapist training) and treatment coverage did not occur until 2008, with the passing
outcome. Thus, it attempted to determine treat- of the Paul Wellstone and Pete Domenici Mental
ment efficacy as well as assess the contributions of Health Parity and Addiction Equity Act. The Act
process and input variables on outcome. For these requires health insurance plans that offer mental
reasons, the Smith and Glass (1977) meta-analysis health coverage to provide that coverage on par with
represented a promising methodology of choice financial and treatment coverage offered for other
for many investigators. Its legacy continues to influ- physical illnesses. This underscores the continuing
ence process and outcome research today. sociopolitical imperative to demonstrate psycho-
The results of the Smith and Glass (1977) meta- logical treatment effectiveness.
analysis were not universally applauded. Issues
were raised by several investigators. Wilson and The Development of Treatment Standards
Rachman (1983) pointed out two primary short- The debate regarding national health insurance,
comings: Smith and Glass (1977) omitted many and whether mental health interventions should
“well-controlled” studies, particularly in the area of be included, continued into the 1990’s and pro-
behavior therapy, without apparent reason or docu- vided the context for the development of the
mented rationale; and methodological rigor was APA Division 12 Task Force on the Promotion
not a criterion for inclusion in the meta-analysis. and Dissemination of Psychological Procedures.
For example, Smith and Glass (1977) included The goal of the Task Force was to develop empir-
theses and unpublished documents. Their meta- ical standards for the evaluation of interven-
analysis also categorized study variables in arbitrary tion effectiveness, specifically treatment efficacy
ways: internal validity was categorized as high, (Beutler, 1998). Psychologists agreed that if we
medium, or low depending on whether the study offer treatments that ameliorate, improve, or
included “randomization, low mortality [high]; enhance psychosocial functioning, it is logical that
more than one [unspecified] threat to internal valid- this effectiveness should be demonstrable and
ity [medium]; no matching of pretest information reportable. A shift toward managed health care
to equate groups [low]” (p. 755). Client diagno- during the previous 20 years appeared to include a
sis was categorized for the sake of analysis as shift toward cost containment as the primary crite-
either “neurotic” or “psychotic.” Smith and Glass rion of effectiveness, to the neglect of demonstrated
created four categories for assigning levels of client– efficacy. This increased the incentive for psycho-
therapist similarity: College students: very similar; logy to establish empirically derived criteria for
Neurotic adults: moderately similar; Juveniles, defining treatment efficacy as the critical compo-
minorities: moderately dissimilar; Hospitalized, nent of effectiveness. If psychology failed to develop
chronic adults, disturbed children, prisoners: very these criteria, there was concern that the promo-
dissimilar. tion of short-sighted and short-term cost-savings
For the above reasons, the Smith and Glass (i.e., medication only) over more effective treat-
(1977) meta-analysis evaluated outcomes on only ments (e.g., behavioral treatments, medication plus
the broadest level, using a study sample that disre- psychotherapy) might prevail.
garded methodological rigor and which did not, The Division 12 Task Force (DIV12TF) pub-
claims to the contrary, have the ability to compare lished efficacy criteria and a list of treatments–“finite
the relative efficacy of specific interventions for spe- and incomplete”–that met these criteria (Beutler,
cific presenting concerns. It also serves as an illustra- 1998). Prior to these efforts, it was generally
tion for the potential for bias in meta-analyses vis accepted that therapists were held to the principle
à vis decision making regarding study inclusion and of the community standard and/or the principle of
exclusion criteria and coding schemes. the respectable minority. Both reflected subjectivity
At the time of the Smith and Glass (1977) study, that allowed for the practice of treatments that
the establishment of a national health insur- could be ineffective or even harmful, as long as the
ance plan appeared to be imminent. For example, treatment was practiced with frequency within
Olbrisch (1977) noted that such a plan “will come a given community ( principle of the community
into being, a nearly certain result of growing standard) or was consistent with the theoretical

m alt zm an 99
orientation or model that met the criteria of hav- following the lead of Division 12 and listing treat-
ing “definite principles” and at least six followers ments that met a set of well-defined criteria. This
( principle of the respectable minority). Both princi- decision was based on the reluctance to uninten-
ples were established by case law pertaining to mal- tionally promote the misuse of the list by managed
practice allegations or contested managed care care systems for reimbursement decision making,
policies, rather than by the evaluation of empir- and to implicitly ascribe to a deficit-based model,
ical data (Beutler, 1998). Beutler noted that the such as reflected by the DIV12TF report, which
criteria published in 1995 by the Task Force were focused on Diagnostic and Statistical Manual (DSM)
adapted from the criteria used by the Federal diagnoses and the amelioration of psychopathology.
Drug Administration (FDA), again paralleling the In contrast, the DIV17STG report noted counsel-
increased pressure on both medicine and psychol- ing psychology’s strengths-based philosophy focus-
ogy to demonstrate effectiveness. ing on personal growth and enhancement across
In addition to the sociopolitical pressures regard- the continuum of “normal” psychosocial function-
ing reimbursement, there was a clear call to ensure ing. Another contribution of the DIV17STG report
that psychological treatments served the public was the inclusion of Principle 2, which recognized
welfare and represented the best of psychology as the importance of client input variables: cultural/
a science, rather than therapist bias or comfort ethnic diversity, attitudes, values, and other charac-
level (Kendall, 1998). Therefore, treatments pro- teristics representing individual differences that
moted as effective had to be gauged against stan- have an impact on the choice of treatment.
dardized criteria to minimize the potential for The DIV17STG report diverged from the
investigator bias, allegiance, or (financial) interest DIV12TF report (1995) in a few other significant
to influence research results (Kendall, 1998). At the ways. The former required that causal attribution
same time, there was recognition that one size does for specific treatment ingredients could only be
not fit all, and that various treatment evaluation made if the evidence was “persuasive,” a criterion
methodologies would be required to address the described as more “stringent” than the criteria set
effects and interactions known to influence out- by DIV12TF without an apparent trade-off in
come, such as therapist and client characteristics. increased clinical significance (Chambless, 2002).
Chambless and Hollon (1998) clarified and Additionally, the DIV17STG Principle 7 allowed
more clearly operationalized the criteria published therapists greater latitude in treatment utilization.
in the DIV12TF report. They defined three levels Principle 7: Outcomes Should Be Assessed Locally
of efficacy: possibly efficacious treatments have and Freedom of Choice Should Be Recognized
demonstrated superiority in one study (for single- states: “Although local decisions should be guided
case experiments the sample size must be three or by the critical application of empirical results, as
greater); efficacious treatments have demonstrated discussed above, outcomes should be monitored at
superiority in at least two independent research set- the local level” (p. 210). When considering Principles
tings (for single-case experiments, the sample size 2 and 7 together, the DIV17STG report suggested
must be three or greater at each site); and efficacious an increased latitude and therapist discretion in
and specific treatments have demonstrated superior- treatment application unless this higher standard of
ity beyond comparison with a no-treatment control efficacy could be met. Thus, both divisional reports
group in at least two independent settings; its supe- made substantial contributions to defining the
riority must be demonstrated in comparison with criteria for ESTs. However, there also were signifi-
an alternative treatment or a placebo treatment cant differences in the concerns described as the foci
(either medication or psychological). of treatment, standards for evaluating treatments,
In response to the publication of the DIV12TF and the allowable discretion at the therapist level.
Report (1995; as cited in Beutler, 1998), the Society Subsequent to the publication of these divisional
for Counseling Psychology (Division 17 of the standards, the APA 2005 Presidential Task Force on
APA) convened a Special Task Group (STG) to Evidence-Based Practice was convened and devel-
develop criteria and standards regarding evidence- oped a consensus paper (2006) that clearly articu-
based practice that reflected the historical perspec- lated the parallel development of evidence-based
tive and values of counseling psychology (Wampold, practice in psychology and medicine. Evidence-
Lichtenberg, & Waehler, 2002). The DIV17STG based practice in psychology was defined by the
report (2002) described seven principles regarding 2005 Presidential Task Force as “the integration of
“empirically supported interventions,” rather than the best available research with clinical expertise in

100 process an d o u tco mes

the context of patient characteristics, culture, and naturalistic settings, and studies evaluating the rela-
preferences” (p. 273), adapting the definition of tionship between process and treatment outcome.
evidence-based practice published by the Insti- The APA Task Force report (2006) specifically
tute of Medicine in 2001 (Task Force, 2006). Both noted two types of studies for evaluating specific
definitions allow flexibility in treatment applica- interventions: efficacy and clinical utility. Efficacy
tion, specifically noting the need to consider client has been discussed above. Clinical utility refers to
context and input variables. The Task Force also the generalization (external validation) of an effica-
noted the varying levels of established treatment cious intervention, in which its applicability and
efficacy or effectiveness across specific concerns and feasibility for use in that particular setting is evalu-
disorders. ated. Its applicability and feasibility include the
Effectiveness does not only mean that a causal assessment of the treatment’s cost effectiveness and
relationship between treatment and outcome has the cost–benefits associated with implementation
been empirically demonstrated. It also requires across diverse therapists, clients, and settings and
demonstration of cost effectiveness and account- the interactions among these variables (moderating
ability on the part of the therapist. These forces effects). Feedback loops for clients and therapists
have served as incentives for the development of across the course of treatment, development of
several lines of process and outcome research, as practice research networks, the need for developing
will be discussed below. These forces are not purely professional consensus regarding the research evi-
negative when seen from the perspective of the dence necessary to discredit treatments, and research
client as consumer. For example, the advent of hos- on the prevention of risk behaviors and psychologi-
pital and medical group “report cards” has been cal disorders also were listed by the Task Force as
lauded by consumer groups as a positive step in priorities for future research.
monitoring health care providers and identifying The APA Presidential Task Force (2006) distin-
those services and facilities that rank high on qual- guished ESTs from the more general concept of
ity standards, effectiveness, and service. Reporting evidence-based practice in psychology (EBPP).
morbidity and mortality rates, medication errors, Empirically supported treatments have demonstrated
and iatrogenic illnesses allows for objective evalua- efficacy with a particular client population experi-
tion of health services and empowers the public encing a particular presenting concern. Evidence-
to make informed choices. The same issues regard- based practice in psychology (EBPP) refers to a broader
ing the need to assess effectiveness across diverse range of psychological services and interventions
populations, with which psychology has struggled (e.g., assessment, case conceptualization) that
for over 30 years, have already been raised in this include, but are not limited to, specific treatments.
context. These interventions are derived through the integra-
For these reasons, the APA Task Force report tion of converging and varying types of evidence
(2006) recommendations included the call for vari- with the therapist’s expertise, resulting in the for-
ous types of research designs to balance the issues mulation that is acceptable to, and consistent with,
of external and internal validity. It also repeated the client’s values and psychosocial context. The
the need to evaluate evidence that is not restricted APA Task Force noted that efficacy data are sparse
to efficacy, but rather contributes to overall assess- or nonexistent for many psychological disorders and
ment of effectiveness, namely cost effectiveness, concerns. Under these conditions, the therapist
treatment utilization, cost–benefit, and epidemio- would integrate psychological principles, the best
logical data. They noted that different types of known research data, and best clinical judgment to
studies are required for the evaluation of these dif- develop an appropriate treatment.
ferent types of evidence. Randomized controlled
trials (and their logical equivalents) were cited as Evidence-based Practice, Empirically
the standard for drawing causal inference regard- Based Treatments, and Empirically
ing intervention effects, and meta-analyses are cited Supported Treatments
as a means for synthesizing results across studies. The above discussion exemplifies how different
The list of acceptable designs reflected differences terms have been used to describe different levels of
in methodology as well as differences in research research support for treatments and interventions:
goals. It included qualitative research designs, such evidence-based practice in psychology, empirically
as single-case and systematic case studies, experi- supported interventions (EVIs), evidence-based
mental single-case designs, effectiveness studies in treatments (EBTs), etc. Because of this confusing

m alt zm an 101
variability in nomenclature and what each term treatments acknowledge and accommodate the
signifies regarding relative research strength, Kendall necessary therapist skills required to ensure appro-
and Beidas (2007) provided definitions of terms priate matching with the client’s presentation and
used to denote varying levels of empirical support. characteristics. Thus, there is room for flexibility
Specifically, evidence-based practice (EBP), empiri- within fidelity (Kendall & Beidas, 2007).
cally based treatments (EBTs), and ESTs are used to
describe treatments that have received research sup- Efficacy Versus Effectiveness
port, but the distinctions among these terms have A consensus has been reached that a variety of
been blurred at times. These authors defined them research designs are required to evaluate treatment
as reflecting increasing levels of scientific control. ingredients, process–outcome relationships for
Evidence-based practice refers to the integration identifying mechanisms of change, and therapist or
of scientific principles (e.g., principles of operant client variables and the interactions among these
conditioning) with clinical judgment. As such, factors. Process variables, input variables, and the
it reflects the interaction of the application of interactions among them contribute to treatment
these principles with the specific characteristics of outcomes. In fact, these factors are significant and
the client. This represents the most flexibility in necessitate continued research to explicate these
research design and applied practice. Empirically relationships. It is in the evaluation of clinical utility
based treatments (EBTs) include specific components for treatments of established efficacy that process
that are based in, and derived from, empirical data and input variables become critical.
about the presenting concern or disorder. As such, Qualitative research, single-case experimental
the treatment is based in scientific principles and designs, effectiveness research in naturalistic set-
is designed to target aspects or symptoms of the tings, and meta-analysis for synthesizing results,
presenting concern that have been identified testing hypotheses, and estimating effect sizes were
through experimental research to be an inherent endorsed by the APA Task Force (2006). The design
aspect of the presentation. The specifics of this depends on the research question and the relative
intervention are devised by the therapist and may degree of internal or external validity required (APA
be idiographic–determined on a case by case basis. Task Force, 2006; Westen & Morrison, 2001). The
An EST consists of clearly specified components. Task Force identified directions for future research,
Through RCT, controlled single-case experiment, emphasizing studies evaluating the generalizability
or equivalent time-series design, it has been found of efficacious treatments, client × treatment interac-
to be superior to alternative treatment, placebo con- tions, and both efficacy and effectiveness studies
trol, or a no-treatment control group. The treatment with diverse populations (age, gender, culture, eth-
must be manualized (or its equivalent vis à vis the nicity, disability status, sexual orientation, children
logical sequencing of components and application), and youths at different developmental stages, and
the client sample must be homogeneous regarding older adults). Thus, the report recognized the
the presenting concern that is the target of treat- importance of evaluating both therapist and client
ment, and valid and reliable measures must be used process and input variables.
for the assessment of the presenting concern for The APA Task Force (2006) did not state that
inclusion in the study, as well as for the assessment meta-analysis was appropriate for identifying
of treatment outcome (Kendall & Beidas, 2007). whether specific ingredients across treatments were
Treatment fidelity refers to the implementation causally related to outcomes. What the APA Task
and application of a treatment with a client as it Force did state was that APA policy recognized two
was designed and described in the treatment man- accepted methods for evaluating the research on
ual (or equivalent). Fidelity checks guard against specific treatments. These methods were efficacy
the potential for selective implementation of some studies utilizing RCTs, and clinical utility studies
components but not others. Additionally, they evaluating the generalizability of an efficacious treat-
assist in preventing or minimizing the natural but ment to the setting in which it will be used, includ-
unintentional “drift” in the treatment applica- ing its applicability, feasibility, and usefulness in
tion over time if adherence to the manual guide- that particular setting.
lines is not routinely checked. However, it is a When the issue is demonstrating relative efficacy
misrepresentation to infer that manuals are rigid among treatments for a specific concern in a well-
and prescriptive in intrasession requirements and defined population, RCTs are the standard for sci-
client–therapist interactions. The best manualized entific rigor. Under these conditions, RCTs have

102 process an d o u tco mes

identified treatments with superior efficacy. For was continuing supervision of therapists to ensure
example, Chambless & Ollendick (2001) noted treatment fidelity.
that two independent RCTs reported that exposure This study by Neuner, Schauer, Klaschik,
plus response prevention was statistically superior Karunakara, and Elbert (2004) compared a cultur-
to progressive muscle relaxation for the treatment of ally adapted effective treatment for decreasing
adult anxiety disorder. In another RCT conducted PTSD-related symptomatology with supportive
by Borkovec and Costello (1993), both CBT and counseling (to control for nonspecific treatment
applied relaxation were statistically and clinically effects) and a one-session psychoeducational inter-
superior to nondirective therapy post-treatment in vention (control group). It is particularly signifi-
a sample of adults treated for generalized anxiety cant that an RCT was successfully implemented
disorder. At 1-year follow-up, only CBT demon- in a war-torn, traumatized Sudanese refugee com-
strated maintenance of statistically and clinically munity, the people of whom were uprooted from
significant change. Randomized controlled trials their homes and living in Imvepi, a Northern
also have identified the superiority of CBT in com- Ugandan refugee settlement. Symptoms and health
parison with nondirective, supportive therapy for status were assessed at pretreatment, post-treatment,
the treatment of depression among children and and at 4-month and 1-year follow-up. Treatment
adolescents (Chambless & Ollendick, 2001). duration with NET or supportive counseling was
Exposure-based therapy also has been identified as a four sessions. Results were mixed. Clients in all
superior treatment for phobias and posttraumatic groups improved somewhat during the 1-year post-
stress disorder (PTSD), even in very complicated treatment. The NET group showed more improve-
cases with severe PTSD and comorbidity, in com- ment in comparison with the supportive counseling
parison with relaxation training and eye movement and control conditions, but 50% of these individu-
desensitization and reprocessing (EMDR; Taylor als still evidenced severe psychological disturbance,
et al., 2003). and effect sizes did not indicate superior effective-
However, Lam and Sue (2001) and Bernal and ness of NET. This is not surprising because the study
Scharron-Del-Rió (2001) noted the dearth of participants were still living in the same desperate
research evaluating treatment outcomes for diverse circumstances.
populations. Bernal and Scharron-Del-Rió sug- However, one notable difference among study
gested a combination of qualitative and quantita- groups was that the majority of the NET partici-
tive research designs that address discovery and pants managed to leave the refugee camp within
hypothesis testing, in an iterative process that 1 year of treatment, whereas participants in the
emphasizes external and internal validity, in turn. other conditions did not. Data collected at 1-year
One example of a cultural adaptation of an EST follow-up indicated that 93% of study partici-
was an evaluation of narrative exposure therapy pants reported experiencing or witnessing one or
(NET) for refugees exposed to war-related trauma more additional traumatic events during that year.
who still lived in unsafe environments (i.e., refugee However, the participants who left the camp
camps; Neuner, Schauer, Klaschik, Karunakara, & reported a significantly lower mean number of trau-
Elbert, 2004). This study evaluated NET as a brief, matic events in comparison with refugees who did
culturally acceptable intervention that could be not leave (Neuner et al., 2004). This appeared to be
delivered by local staff who typically would not have due to the fact that the NET participants moved
backgrounds in therapy or research. Although the to places that were safer and/or more amenable to
treatments were administered by Caucasian psy- finding work or sustenance. In the context of the
chologists or graduate students from Konstanz biopsychosocial model described below, one might
University in Germany, rather than by therapists hypothesize that NET sufficiently increased emo-
from the community, there were many method- tion regulation through the reduction of chronic
ological strengths: Only one prospective client hyperarousal. This reduction facilitated increased
declined to participate (indicating acceptability of executive functioning that mediated the planning
intervention description and rationale), utilization required to successfully leave the refugee camp.
of local community members as research assistants
or translators was successful (i.e., the study was Evaluating Treatment Effectiveness
embedded within the community to the extent Evaluating ESTs under naturalistic conditions to
feasible), therapists were trained in three interven- ascertain effectiveness and clinical utility has proven
tions with equally plausible rationales, and there to be more challenging than evaluating efficacy

m alt zm an 103
under controlled conditions. This is particularly and to what extent a therapist should administer
true with clients who present with multiple con- manualized treatments. Running throughout this
cerns and complicated presentations (see Ruscio & discussion regarding generalizability and clinical
Holohan, 2006, for an excellent discussion of these utility is a philosophical question regarding models.
issues). Efficacy studies, by definition, control extra- Some investigators question the utility of RCTs
neous variables (setting, process, and input vari- for defining efficacy. The primary concern is that
ables) to the greatest extent feasible. Inclusion and RCTs reflect rigidity in the extent to which condi-
exclusion criteria are strict, typically eliminating tions (and client presentations) are controlled and
clients with comorbid psychological concerns, that therefore they do not and cannot develop treat-
although comorbidity is the rule, not the exception, ments applicable to real-world practice; in other
in the community (Westen, Novotny, & Thompson- words, the paradigm is too artificial and restrictive,
Brenner, 2004). Benchmarking is one analytical as evidenced in part by limiting inclusion to clients
strategy developed for bridging this gap. who meet DSM criteria. This was a primary objec-
The goal of benchmarking is to utilize treatment tion and concern noted in the DIV17STG report
outcome data from RCT efficacy studies as a stan- (2002). The RCT paradigm is seen as being consis-
dard of reference for evaluating the effectiveness of tent with a medical model that reflects a categorical,
these treatments when administered in naturalistic reductionistic taxonomy rather than a paradigm that
(clinic) settings. Benchmarking is the direct com- acknowledges dimensional continua of functioning
parison of pre- and post-treatment data of treat- (Goldfried & Eubanks-Carter, 2004). Therefore,
ments with established efficacy with the pre- and adherence to manualized treatment is viewed as
post-treatment data of the same treatment adminis- adherence to this medical model.
tered in a naturalistic (clinic) setting. Benchmarking These differences in perspective are highlighted
studies have identified equivalency between a treat- when considering theoretical models for organizing
ment’s efficacy and its effectiveness, thus indicating the data and directing future research, as discussed
generalizability (e.g., Hunsley & Lee, 2007; Minami, below in this chapter. From a balanced perspective,
Wampold, Serlin, Hamilton, & Kircher, 2008). the issue is how to extract what is learned through
However, issues concerning this strategy include RCTs regarding efficacy and apply that adaptively
inherent potential for bias regarding which studies to meet the client’s needs (Kazdin, 2008; Kendall &
to include in calculating benchmarks and heteroge- Beidas, 2007; cf. Westen, Novotny, & Thompson-
neity across diagnoses, client input characteristics, Brenner, 2004). More generally, how will therapists
and outcome measures, and the inability to identify reconcile the best research evidence (nomothetic
specific components causally related to outcomes. data) with their particular client at that particular
point in time? This represents, at a basic level, the
Treatment Implementation at the Case Level conflict between clinical and actuarial (statistical)
A significant issue in the literature is the dissemina- prediction (Lutz et al., 2006; Meehl, 1954). A treat-
tion of an efficacious treatment at the “real-world” ment of known efficacy, flexibly applied (and the
level. In the clinic and private practice, therapists operable word is “flexibly”) should have a higher
are faced with decisions regarding whether and how probability of positive treatment outcome in com-
to implement and administer treatments of known parison with clinical “expertise” integrated to an
efficacy with a particular client. The waters are par- unknown extent with knowledge of psychological
ticularly muddy when the treatment has not been principles. However, as Kazdin noted, there are no
evaluated with the client’s population in terms of models or algorithms for determining how to adapt
age, culture, ethnicity, or other characteristics as an efficacious treatment flexibly but with fidelity
described by the APA Presidential Task Force report (Kazdin, 2008). Without paradigms or decision
(2006). Client expectations and personality are rules, there remains the potential for reverting to
additional input variables that might not be readily the principle of community standard or the prin-
apparent to the therapist, but which could influence ciple of the respectable minority on one hand and,
treatment outcome. on the other hand, there is the potential for rigid
To what extent a therapist should adhere to a adherence to a treatment that disregards individ-
treatment of known efficacy when these client char- ual differences and threatens the therapeutic pro-
acteristics are diverse, complex, or unknown, has cess and alliance. Closer collaboration between
been an issue of debate (Goldfried & Eubanks-Carter, researchers and therapists is required to address
2004; Ruscio & Holohan, 2006). Issues include how these issues. In particular, practice must inform

104 process an d o u tco mes

research, as suggested by the community therapist treatment, discharge, and follow-up. These mea-
networks described and advocated by the APA sures can include client, therapist, and/or collateral
Presidential Task Force report (2006). report.
One way of utilizing survival analysis is to deter-
Process–Outcome Research: The Shape mine how many sessions (i.e., dose) are required to
of Change and Dose–Response achieve clinically significant change (response).
Pre- and post-test assessments of symptom reduc- Survival analysis can detect moderator variables
tion and functionality are inadequate for assessing (e.g., severity of illness) that contribute to outcome
change because they do not explicate the contribu- and what “dose” of treatment is required for positive
tions of moderator and mediator variables. Yet, outcome for each group (Anderson & Lambert,
understanding these effects is critical for establish- 2001). Survival analysis also has been used to iden-
ing effectiveness across diverse groups and, for tify factors contributing to poor outcome, defined
the therapist, within the single case over time. as premature termination (Corning & Malofeeva,
A comprehensive review of advances in quantita- 2004).
tive and qualitative methods for assessing change Corning and Malofeeva (2004) noted that
associated with moderator and mediator variables attempts to predict poor outcome, defined as pre-
is beyond the scope of this chapter. However, a few mature termination, have been particularly prob-
promising trends are noted below. lematic. Psychotherapy is a longitudinal process;
Several analytic approaches assess change longi- therefore, termination after one session should
tudinally over the course of treatment. This is not be treated statistically the same as termination
accomplished by sampling client status frequently after ten sessions because the causal factors are not
and then plotting progress over time. These analytic likely to be the same. For example, symptom
techniques include individual growth curve model- severity and the quality of the therapeutic relation-
ing, growth mixture modeling, dynamical systems ship can change over time, and not necessarily in
modeling (Laurenceau, Hayes, & Feldman, 2007; a linear fashion. Additionally, some cases may ter-
Stulz, Lutz, Leach, Lucock, & Barkham, 2007), minate for external reasons (college graduation) that
survival analysis (Anderson & Lambert, 2001; are irrelevant to progress in counseling and achieve-
Corning & Malofeeva, 2004), and case-based time- ment of mutually agreed upon goals. The advan-
series analysis (Borckardt et al., 2008). These tech- tages of survival analysis is that it can include static
niques identify changes in rate of progress in moderator variables that vary across clients but not
treatment over time, thus facilitating the ability over time, moderator variables that vary over time
to identify which process and input variables but not across clients, and predictor variables that
contribute causally to change during treatment. vary across time and across clients (e.g., number
These client-focused approaches utilize either a ratio- of sessions completed at any point in time). Survival
nally derived model to detect clinically signifi- analysis also can statistically address censored cases
cant change or an empirically driven decision that have unknown termination points; that is,
model (e.g., nearest-neighbors method; Lutz et al., those that continue beyond the conclusion of data
2006) to statistically estimate growth curves across collection or, conversely, those that terminate for
treatment phases to predict client outcome. At the arbitrarily imposed reasons unrelated to the thera-
single-case level, therapists can assess change over peutic process. Multiple types of termination also
time as treatment progresses. This assists the thera- can be evaluated simultaneously using survival
pist in objectively evaluating the dose (intensity) of analysis via a competing risks analysis. Competing
treatment, and in detecting problems related to risks assesses the relationship of the predictor vari-
moderator or mediator variables that must be ables to different types of events simultaneously,
addressed in treatment. such as different types of termination: premature,
The use of case-based time-series analysis was mutual, and arbitrary.
described by Borckardt et al. (2008), who noted an Assessing change and dose–response during
advantage of this design is the ease of imple- counseling and psychotherapy requires a case-level
mentation in clinic or private practice settings. approach with immediate feedback. Such an
Case-based time-series analysis allows the assess- approach can be utilized at the case level and then
ment of change by treatment phase. Client status on aggregated across clients to assess for treatment
multiple measures of symptomatology and func- effectiveness. It also can be used by therapists facing
tioning are sampled frequently during baseline, the dilemma of incorporating treatments whose

m alt zm an 105
efficacy has been evaluated via group differences The specific value of the OQ-45 is that it can
to case-specific treatment with a particular client be used in effectiveness studies of various designs
(i.e., implementing treatment with flexibility (survival analysis, case-based time-series). It pro-
within fidelity; Kendall & Beidas, 2007). Client- vides immediate feedback to the therapist, who can
focused systems for monitoring progress can facili- then identify “signal” cases (clients failing to
tate the therapist’s awareness of a negative response respond) for further attention to process variables
to treatment in an objective manner, so that modifi- and “dosing” (Lambert, Hansen, & Finch, 2001).
cations in treatment or process can be made For this reason, it is an example of an objective
(Whipple et al., 2003). method for assessing response to treatment for the
Whipple et al. (2003) reported that, in previous purpose of facilitating positive outcome that is ame-
studies, feedback about client nonresponders facili- nable for use by the private practice therapist. It also
tated the therapist’s ability to keep the client in serves as an option for assessing clinical utility and
therapy and prevent premature termination. For accountability at the therapist level. Such instru-
these nonresponders, staying in therapy longer was ments could potentially facilitate science–practice
associated with a better outcome in comparison dialogue and enrichment of the knowledge base
with nonresponders whose therapists did not receive through the objective collection of data by thera-
feedback. However, this improvement was not clin- pists (APA Presidential Task Force, 2006; Persons,
ically significant. Feedback regarding clients who 2007).
were responding to treatment allowed the thera-
pist to decrease the number of sessions without Length of Treatment
negatively impacting outcome. These results sug- The length of treatment required to reach mutually
gested that additional feedback information was agreed upon goals has been an issue of continuing
necessary to prevent premature termination and debate. Particularly in the age of managed care and
promote positive outcome in nonresponders and imposed time limits, there are ethical as well as
poor responders. clinical reasons for carefully evaluating how much
In a subsequent study at a university counsel- treatment is necessary and sufficient to attain initial
ing center (Whipple et al., 2003), a sample of positive outcome and to maintain gains. This ques-
981 clients (mean age = 23 years; 66% female, tion is directly tied to dose–response evaluation.
86% Caucasian) participated in a study evaluating Unfortunately, no clear guidelines have emerged
the effectiveness of clinical support tools (CSTs) in to date. Baldwin, Berkeljon, Atkins, Olsen, and
improving clinical outcome in treatment nonre- Nielsen (2009) attempted to identify the length of
sponders. The CSTs were organized in a decision necessary and sufficient treatment by evaluating two
tree format. They were hypothesized to assist the competing hypotheses: the dose–effect model, in
therapist in identifying specific moderator varia- which the client’s improvement is causally and posi-
bles (readiness to change, level of social support), tively related to the number of treatment sessions
mediator variables (quality of the therapeutic alli- but the rate of change slows across time (i.e., nega-
ance), and the evaluation of alternative, appropri- tively accelerates) versus the good-enough level (GEL)
ate psychological and/or psychotropic treatment model, which predicts that clients stay in therapy
options for clients who were not progressing as until they have reached a “good enough” level
expected in therapy (Whipple et al., 2003). of improvement, as determined in collaboration
Essentially, the CSTs formalized therapist decision- with their therapist. Therefore, the number of ses-
making as part of the therapeutic process. One sions (dose) will vary as a function of the amenabil-
component of the CSTs assessed psychological ity (“malleability”) of the presenting concern to
concerns (Subjective Discomfort, Interpersonal treatment.
Relationships, and Social Role Performance) as The GEL model predicts that sufficient change
measured by the Outcome Questionnaire-45 has occurred for each client at time of mutual ter-
(OQ-45; Lambert et al., 1996, as cited in Anderson mination, although the number of sessions will vary
& Lambert, 2001). This study indicated that more across clients. Furthermore, change is independent
nonresponders and poor responders whose thera- of the number of sessions attended, and rate of
pists received feedback on client progress and uti- change is faster for clients who terminate after
lized the CSTs achieved “reliable” or clinically fewer sessions in comparison with clients who
significant improvement and were less likely to be remain in psychotherapy longer before achieving
rated as deteriorated at therapy termination. good enough improvement. Participants in the

106 process an d o u tco mes

Baldwin, Berkeljon, Atkins, Olsen, and Nielsen described above, meta-analytic techniques are not
(2009) study were 4,676 clients seen at a university immune to bias because of the inherent subjectivity
counseling center. Demographics were as follows: involved in deriving the decision rules for study
client mean age: 22.3; gender: 62% female, marital inclusion/exclusion, nor are they immune to alle-
status: 65% single; ethnicity: Caucasian 88%, giance issues (Westen & Morrison, 2001).
Hispanic 5%, Asian 2%, Pacific Islander 1%. The Several investigators (e.g., Ahn & Wampold,
proportion of clients with a particular initial 2001; Lambert, 2005; Wampold, 2001) cite meta-
diagnosis varied: adjustment disorder 38%, mood analytic results as demonstrating equivalent efficacy
disorders 25%; anxiety disorders 12%, eating disor- for treatments utilized for a variety of client pop-
ders 5%. Twenty percent received other diagnoses. ulations and presenting concerns, thus providing
Archival OQ-45s completed at the initial session support for a common factors model of treatment
were reviewed to determine baseline level of distress. outcome. This equivalence has been labeled the
Data were included for analyses if the baseline total Dodo bird effect (Rosenzweig, 1936, as cited in
OQ-45 score was over 63 and the client improved Wampold et al., 1997). The Dodo bird effect refer-
by 14 or more points by termination, representing ences the dodo bird in Alice in Wonderland who
a reliable and clinically significant improvement declared that everyone had won and therefore “all
(RCSI). must have prizes” (as cited in Wampold et al., 1997,
Data for 2,985 clients met the OQ-45 baseline p. 203), and reflects their conclusion that all
criterion for inclusion in the analyses. Of these, psychological treatments are essentially equivalent
1,242 (41.6%) met the outcome criterion for RCSI. in efficacy. Wampold and colleagues (Ahn &
Results indicated that change over time was acceler- Wampold, 2001; Wampold, 2000) have described
ated for clients who participated in fewer sessions, this reported equivalence as a failing so significant
compared with clients who stayed longer in psy- that it “weakens support for psychotherapy as
chotherapy (Baldwin et al., 2009). In other words, a mental health treatment rather than strengthens
the results appeared to support the GEL model: it” (Wampold et al., 1997, p. 211). They further
Under naturalistic conditions in which there was state that psychologists should accept that treat-
no apparent imposition of termination that created ments are not analogous to medications: There is
artificial, censored cases, clients stayed in treatment no one-to-one relationship between psychological
until they achieve therapeutic gain. Those who concern/distress and intervention in the same way
improve more rapidly will participate in counseling that there is a one-to-one relationship between dis-
or psychotherapy for a shorter length of time. ease and medication. They further posit that inves-
However, it is important to note that less than 50% tigators who report differential efficacy across
of the clinically distressed clients had met the RCSI treatments (i.e., “specific ingredients” proponents)
criterion by therapy termination. The identification adhere to a medical model (described below).
of moderator and mediator variables that impacted It is clear that meta-analytic techniques have
the counseling and psychotherapy process could not improved over the past 30 years and that researchers
be addressed in this study. Clearly, elucidation of utilizing meta-analysis have attempted to respond
these variables would be critical for understanding to the concerns expressed by critiques of these
the suboptimal therapeutic outcome for the major- techniques, as described above in this chapter
ity of these clients. (e.g., Wilson & Rachman, 1983). Meta-analyses have
clearly established the absolute efficacy of counseling
Return to Meta-Analysis: What It Is and psychotherapy treatments (Wampold, 2000).
and What It Isn’t On the other hand, meta-analysis, by virtue of its
The use of meta-analytic techniques will be discussed logic and methodology, requires the collapsing of
in more detail because they are at the core of the client, treatment, and therapist variables, thus pre-
discussion regarding relative treatment efficacy. The venting the ability to identify relative efficacy among
promotion of meta-analysis as an objective technique treatments; that is, specific differences and interac-
and methodology has hinged on its putative ability tions among them (Beutler, 2002; Craighead, Sheets,
to statistically control for moderator and mediator & Bjornsson, 2005). Wampold (2000) stated:
variables that contribute to inconsistent findings
across individual studies. These include differences Because the evidence is presented at the meta-
in outcome measures, control conditions, treatment analytic level, evidence for a particular
plausibility, and researcher allegiance. However, as ingredient is precluded. The purpose of this

m alt zm an 107
 review [Wampold, 2000] is to establish whether the fundamental clinical question: “What treatment,
outcome data generally support common factors or by whom, is most effective with this individual
specific ingredients (or both) as determinants of the with that specific problem under which set of cir-
well-documented general efficacy of counseling and cumstances” (Paul, 1967, p. 111, as cited by Wilson
psychotherapy. (p. 719) & Rachman, 1983) cannot be answered through
meta-analytic inquiry.
The methodology of meta-analysis, which has
As can be seen from this discussion, the debate
advantages for synthesizing data, also is its lim-
regarding the appropriate use of meta-analytic tech-
itation: the inability to assess for differential effec-
niques and the interpretation of meta-analytic
tiveness across treatments. This inability is not the
results has been the running undercurrent of the
same as equivalence, and it is faulty logic to thus
argument regarding treatment efficacy, comparative
assume that the results must be attributable to
superiority and, ultimately, differential effectiveness
“common factors” (e.g., Kazdin, 2005). As Wampold
(e.g., Crits-Christoph, 1997; Howard, Krause,
et al. (1997) noted regarding the results of that
Saunders, & Kopta, 1997; Maltzman, S., 2001).
meta-analysis:
As is the case with the primary studies, the results Meta-analysis and the Common
reference average effects; but it is not appropriate Factors Model
to conclude that every treatment is equally effective The common factors model was derived from meta-
with every patient. The results of this meta-analysis analytic results that were interpreted as indicating
suggest that the efficacy of the treatments is treatment equivalence. The model is predicated on
comparable, not that the treatments are the assumption that insignificant (statistical and
interchangeable. (p. 211) clinical) variance in outcome is attributable to spe-
cific treatment components per se. It proposes that
These comments underscore the point that when most variance in treatment outcome is accounted
meta-analyses collapse data across various client for by common (mediator and/or moderator) vari-
populations and treatments, they are unable to ables, rather than components specific to a particu-
assess for potential differential efficacy. In contrast lar treatment (e.g., Lambert, 2005; Wampold,
with the tendency to collapse across populations 2001). Wampold (2001) described a common fac-
and treatments, Siev and Chambless (2007) directly tors model as inconsistent with a medical model, in
compared the efficacy of cognitive therapy and which specific treatment components causally con-
relaxation training for panic disorder (PD) and tribute to outcome. Several investigators agree that
generalized anxiety disorder (GAD) in two meta- nonspecific factors, in addition to specific treatment
analyses of five studies each. Each meta-analysis components, are causally related to outcome.
directly evaluated specific components for a clearly However, there is debate regarding whether
defined disorder. These authors found no difference specific treatment components contribute at all
in efficacy in treating GAD, but did find cognitive to outcome and how nonspecific common factors
therapy superior to relaxation training in the treat- are conceptualized. For example, Craighead, Sheets,
ment of PD. The included studies had crossed ther- and Bjornsson (2005) reviewed the superiority
apists with treatments, controlling therapist effects of specific treatment components for specific pre-
(allegiance, bias, experience) that have been hypoth- senting problems, such as PD. They acknowl-
esized to represent common factors responsible for edged the contribution of nonspecific effects but
treatment efficacy (rather than specific treatment pointed out that these effects are “nonspecific” only
components; e.g., Wampold, 2001). The authors because they have not yet been elucidated. They
also noted, consistent with comments above, that identify the therapeutic alliance and therapist vari-
their meta-analysis could not address causal mecha- ables as clear contributors to outcome that require
nisms (Siev & Chambless, 2007). The utility was in further investigation.
demonstrating superior efficacy in a “head-to-head”
comparison. This meta-analysis demonstrated that, The Medical Model
if only studies with fairly homogeneous and equiva- As noted above, some investigators who support
lent client samples and interventions are included, a common factors model have described psycholo-
meta-analysis appears able to determine differential gists who reject the notion of equivalence across
efficacy. However, even under these conditions, it treatments as adherents of the medical model.
cannot identify causal mechanisms. Therefore, the Wampold and colleagues (Wampold, Ahn, &

108 process an d o u tco mes

Coleman, 2001; Imel & Wampold, 2008) have Peterson & Elliott, 2008; Ruphuy, 1977; Sameroff
described the model as including five components: & Rosenblum, 2006; Thoresen & Eagleston,
1985).
(a) The client presents with a disorder, problem,
Other aspects of the medical model, not included
or complaint; (b) there exists a psychological
in the five components described above, also have
explanation for the disorder, problem, or complaint;
been criticized by psychologists. The traditional
(c) the theoretical conceptualization and knowledge
patient–physician relationship inherent to this
are sufficient to posit a psychological mechanism
model reflects an unequal power hierarchy and
of change; (d) the therapist administers a set of
promotes the role of patient as the passive, unques-
therapeutic ingredients that are logically derived
tioning recipient of treatment: “The good patient
from the psychological explanation and the
is passive, cooperative, dependent, uncomplain-
mechanism of change; and (e) the benefits of
ing, and willing to suffer in silence” (Chrisler &
psychotherapy are due, for the most part, to the
O’Hea, 2000, p. 325). Physician racism, sexism,
specific ingredients. The last component, which
and homophobia have historically impeded clients’
is often referred to as specificity, is critical to the
access to prompt and/or optimal physical health
medical model of psychotherapy and gives primacy
care (Chrisler & O’Hea, 2000; Meyerowitz, Bull, &
to the specific ingredients rather than common or
Perez, 2000; O’Hanlan, 2000). These characteristics
contextual factors.
(Wampold, Ahn, & Coleman, 2001, p. 268)
of the medical model have been rejected in psychol-
ogy, and by counseling psychology in particular.
This model reflects traditional medical practice, For these reasons, the medical model still
which historically has ignored psychosocial influ- may have relevance in describing pertinent issues
ences in health presentation. Traditional medical within medicine, but it would be difficult to find
practice also has been noted for deficiencies in inter- current adherents within psychology. In spite of
personal communication skills and subjective biases this, there appears to be a tendency to describe
that have created barriers to treatment. The issue is investigators who acknowledge biological compo-
whether this medical model can be extrapolated nents in mental illness or substance abuse, or who
directly to psychology: Does it reflect current question a common factors model, as adherents
research and practice? The first component of the to this medical model. For example, Imel and
medical model as described above implies agreement Wampold (2008) cited a few specific, older studies
with the notion of single-problem presentation– of treatment for alcohol dependence to make this
a lack of comorbidity, such as dual diagnosis point (Project Match Research Group, 1997;
(e.g., mental illness and substance abuse), or multi- Sobell & Sobell, 1973). Imel and Wampold (2008)
ple problems (e.g., chronic health concerns and wrote:
marital issues). However, that runs counter to much
More than 20 years ago, Mark and Linda Sobell
of the literature in psychology as documented above
(Sobell & Sobell, 1973) demonstrated that a regimen
in this chapter. Single-problem presentations are not
of controlled drinking was at least as effective as
reflective of typical real-world client populations
an abstinence based program, which was counter
(e.g., Westen & Morrison, 2001). It is generally rec-
to the dominant abstinence-based models of
ognized that most clients present with more than
treatment. . . . The Sobells’ conclusion that training
one problem or diagnosable mental health concern,
in moderation was as effective as abstinence was
and that certain problems also tend to co-occur in
subjected to an unprecedented level of criticism
certain populations (e.g., Cutuli, Chaplin, Gillham,
(e.g., congressional hearings) by advocates of the
Reivich, & Seligman, 2006). Second, the description
disease model of alcoholism (see Pendery, Maltzman,
of this medical model appears to ignore the roles of
& West, 1982). Although the Sobells were eventually
moderator (input) and mediator (process) variables
vindicated from [sic] any wrong-doing, controlled
as contributors to treatment process and outcome.
drinking has never gained wide acceptance in the
Historically, psychology also has described and
United States. (p. 251)
acknowledged the interactions and influences
among physiological, social, environmental, and Imel and Wampold used the above example to
psychological influences across subdisciplines (e.g., argue that adherence to a “disease” model of alco-
Alcorn, 1991; Altmaier, 1991; APA Presidential holism (requiring abstinence) was the same as
Task Force, 2006; Bronfenbrenner,1977; Nomura, adherence to their definition of the medical model.
Chemtob, Fifer, Newcorn, & Brooks-Gunn, 2006; They suggested that psychologists ignored and

m alt zm an 109
rejected the Sobell and Sobell (1973a) data because records) to verify client status. What these authors
the results of their study were not consistent with reported was that Patton State Hospital records
the disease model of alcoholism. This is a confusing documented rehospitalization of 13 of the 20 con-
argument because alcohol dependence is a disorder trolled drinking clients within 1 year of discharge
with known biological and genetic components from the study. Ten were readmitted to Patton; three
(e.g., Cloninger, 1987; Enoch, 2006; Nie et al., were admitted to other hospitals.
2004). The follow-up data reported by Pendery,
The Sobell and Sobell (1973a) study generated Maltzman, and West (1982) differed substantially
significant controversy. Because Imel and Wampold from the results reported by the Sobells (e.g., 1973b).
(2008) raised the issues again, it warrants discus- Clients assigned to controlled drinking fared very
sion. This study was conducted at Patton State poorly. By the 1981 conclusion of this follow-up
Hospital. Participants were 40 clients characterized study, six controlled drinking clients were abstain-
as “gamma” (physically dependent) alcoholics, all ing completely from alcohol; four of these stopped
of whom were judged to be appropriate for learn- drinking after multiple rehospitalizations related
ing controlled drinking strategies via an experi- to alcohol abuse. Four clients in the controlled
mental operant conditioning paradigm. The Sobells drinking condition died alcohol-related deaths. The
reported that they had conducted a RCT in which interested reader is referred to this 1982 report for
20 of these clients were assigned to the abstinence a detailed description of each client’s trajectory
arm and 20 were assigned to the experimental (con- post-discharge from the controlled drinking study.
trolled drinking) condition. In the experimental Pendery, Maltzman, and West (1982) refrained from
condition, clients were taught controlled drinking discussing methodological discrepancies between
strategies via 17 individualized behavior therapy their and the Sobells’ reports, stating their prefer-
sessions at a simulated bar in the hospital. Over the ence to address treatment outcome issues instead.
course of treatment, clients had access to alcoholic However, it is these methodological questions that
drinks of variable alcohol content (3%–43%) of resulted in consequent hearings. Therefore, it is
varying amounts and strength (“straight” vs. “mixed” inaccurate to attribute the contradictions in these
drinks). Clients received aversion conditioning via studies’ conclusions to theoretical bias.
electric shock during some sessions for “inappropri- Imel and Wampold (2008) described results
ate drinking behaviors” (1973a, p. 56). After com- reported by the Project Match Research Group
pletion of treatment and discharge from hospital, (1997) as indicating “no evidence of differences
clients and collaterals were contacted every 3–4 among treatments” (p. 251) for alcohol abuse and
weeks for a 2-year follow-up period. The primary dependence. What is notable is that abstinence
outcome measure was “days functioning well”: the during a 1-year post-treatment follow-up period
sum of abstinent + controlled drinking days vs. days was one of two dependent variables in this study.
not functioning well: sum of drunken days + days The second dependent variable, drinks per drinking
incarcerated in prison or hospital secondary to day, was used as a measure of drinking severity.
drinking. However, abstinence appeared to be the desired
Sobell and Sobell (1973b) reported that, at the outcome of treatment. Imel and Wampold did not
end of the Year 1 follow-up period, clients assigned criticize the use of abstinence as an outcome mea-
to the controlled drinking arm experienced signif- sure as adherence to a medical model. Rather, they
icantly more “functioning well” days in comparison cited the Project Match Research Group data as
with the clients assigned to the abstinence arm. indicating equivalence among alcohol treatments
Similar results were reported at the end of the Year (i.e., as support for a common factors model), with-
2 follow-up period (Pendery, Maltzman, & West, out noting that abstinence was an outcome mea-
1982). Pendery, Maltzman, and West (1982) con- sure. Thus, Imel and Wampold criticized proponents
ducted an independent follow-up study with the of abstinence and a “disease” model of alcoholism
cooperation of Patton State Hospital. These inves- as reflecting theoretical bias and a medical model in
tigators located and interviewed all clients assigned their first example, yet refrained from criticizing
to the controlled drinking condition and their abstinence as a goal in their second example.
collaterals during the period 1976–1979, with The suggestion that the Project Match Research
intermittent contact continuing until 1981. They Group study (1997) provided support for a common
also located collateral, objective documentation factors model is questionable. The Project Match
(e.g., hospital records, drunk driving arrests, jail study evaluated the matching hypothesis: It matched

110 process an d o u tco mes

clients to treatment based on specified a priori psychopathology (Project Match Research Group,
client attributes (moderator variables). The study 1997).
consisted of two parallel arms: One arm consisted The above review of the Sobell and Sobell (1973)
of clients who entered aftercare post-discharge and Project Match Research Group (1997) studies
from hospital or day treatment for alcohol abuse helps clarify why they were not viewed as providing
or dependence. The second arm consisted of outpa- definitive data for rejecting abstinence as the treat-
tient clients who had not been hospitalized or ment goal nor for accepting treatment equivalence
treated in intensive day rehabilitation. Although in the substance abuse field.
these clients also met DSM-III-R criteria for
alcohol abuse or dependence, the fact that they The Biopsychosocial Model
did not require hospitalization or intensive day Although psychology was debating whether psy-
treatment suggests that these clients evidenced chological treatments should be covered by national
less disease severity. Both parallel studies included health insurance, Engel (1977) published perhaps
three conditions consisting of individual therapy the earliest call for an integrated biopsychosocial
provided over a 12-week period. These conditions model to address “medicine’s crisis [due to] adher-
were cognitive-behavioral coping skills training ence to a model of disease no longer adequate for
(CBT), motivational enhancement therapy (MET), the scientific tasks and social responsibilities of
or a 12-step facilitation (TSF) therapy that encour- either medicine or psychiatry” (p. 129) and which
aged participation in a 12-step program. Engel described as reductionistic. He described
The CBT and TSF treatments were delivered the need for a biopsychosocial model “that would
weekly; the MET was delivered in four sessions account for the reality of diabetes and schizo-
at the first, second, sixth, and twelfth week. The phrenia as human experiences as well as disease
study described all three conditions as “treatments.” abstractions” (p. 131). Although Engel used schizo-
However, the MET and TSF conditions were not phrenia and diabetes as exemplars for application
treatments, per se, as noted by the Project Match of a biopsychosocial perspective, there were clear
Research Group authors (1997). Both conditions implications for research and practice across the
were designed to promote the client’s participa- continuum of psychological functioning. In fact,
tion in alcohol treatment. Effectiveness of a 12-step Engel’s position was not inconsistent with the 1977
intervention, such as Alcoholics Anonymous (AA), revision of the 1974 American Psychological
was not assessed. Client engagement in activities Association Standards for Providers of Psychological
intrinsic to 12-step programs, such as AA meeting Services, which acknowledged an interaction
attendance and obtaining a sponsor, also was not between psychology and medicine.
assessed. The authors noted that clients in all three Although Engel’s challenge has been hailed as
conditions in both study arms were exposed to a “landmark” publication (Biderman, Yeheskel, &
AA “and a 12-step approach” (p. 24). They also Herman, 2005), the transition within medicine to
commented that: “Direct comparisons between a biopsychosocial perspective has been slow and
treatments are difficult because the MET interven- inconsistent. Progress has been made in teaching
tion consisted of fewer sessions over the 12-week medical students communication skills and psy-
period and TSF clients were encouraged to attend chosocial history taking. However, the concept of
AA meetings in addition to the 12 individual treat- relationship (alliance) building with patients as a
ment sessions” (p. 13). core component of treatment has not been as
The primary focus of the Project Match Research accepted (Suchman, 2005). There are some exam-
Group 1997 study was the evaluation of client ples of a biopsychosocial approach. These include
matching as a moderator of treatment effective- an increased acknowledgment of individual differ-
ness. The authors reported that there was no clear ences within medicine, particularly in response to
advantage to matching clients to treatment. In gen- medications. There have been attempts to incorpo-
eral, client matching did not appear to improve rate a biopsychosocial model in treating major
number of abstinent days across conditions. mental illness, such as schizophrenia and chronic,
However, they reported that clients low in psychi- debilitating major depression (e.g., the Texas
atric severity in the outpatient study had more absti- Medication Algorithm Project; Rush et al., 1999,
nent days after TSF than did clients assigned to 2003). A comprehensive, biopsychosocial approach
CBT at 1 year post-treatment. There was no advan- has been incorporated in the research and treatment
tage for TSF in clients exhibiting moderate to high of persistent pain (e.g., Axford, Heron, Ross, &

m alt zm an 111
Victor, 2008; Daniel et al., 2008). Some health can be linked to “hard” science by developing
maintenance organizations advertise a commit- theories and constructs based on neurophysiolog-
ment to facilitating and promoting psychosocial ical data and validated with physiological measures,
interventions (e.g., lifestyle changes) to facilitate as described below. Additionally, psychology has
achievement or maintenance of medical treatment a long history of developing treatments for promot-
goals. However, these initiatives do not appear ing health and wellness, in addition to ameliorat-
to reflect medicine as generally practiced in the ing or eliminating psychological distress and mental
United States. illness. In particular, counseling psychology has
Various reasons have been offered for the limited developed strong research interests in positive psy-
incorporation of a biopsychosocial approach in chology, resilience, and mental health promotion
medicine. These include a lack of medical student (Lopez & Edwards, 2008; Robbins & Kliewer,
training, financial imperatives on new physicians 2000). These have been described as primary
to limit time with patients to maximize billings, requirements for a comprehensive approach to
and difficulties with implementation due to an mental health and mental health services (Keyes,
inadequate clinical model for assessing psychosocial 2007). Because these foci are preventive and proac-
factors (Weston, 2005). A more disturbing and tive, they have a clear advantage over a deficit-based,
sobering perspective was offered by Stein (2005), narrowly focused medical model. These interests
who placed Engel’s paper in a historical context of and foci are promoted and furthered by a biopsy-
particular interest to psychology: chosocial approach, examples of which are offered
below.
Historically, it is essential (and ironic) to remember
One obstacle to incorporating a biopsychosocial
that by 1977, when George Engel published his
perspective more broadly within psychology and
celebrated paper in Science advancing the BPS
across the sciences may be the explosion of research
[biospsychosocial] model, mainstream American
and data facilitated by technological advances over
psychiatry was already retreating from, if not
the last 30 years. This subsequently resulted in the
repudiating, its brief liaison with behavioral science
need for increased specialization within fields.
and becoming increasingly biomedical (largely
A consequence of this is an observed intellec-
pharmacological). This cultural lure of what many
tual “silo effect,” with suboptimal cross-threading
in American biomedicine call “real science” or
of research and multidisciplinary collaboration.
“hard science” promised higher status than anything
In spite of this, there are particular areas within
associated with the “softer” behavioral and social
psychology in which the biopsychosocial model
sciences. Even practitioners of family medicine–
has been evident, such as psychoneuroimmunol-
many of whose early leaders embraced an integrative
ogy, and developmental, rehabilitation, and health
model that encompassed the patient’s personality,
psychology (including counseling health psychol-
family, culture, community, and relationship with
ogy; e.g., Chwalisz & Obasi, 2008; Hoffman &
the physician–have not escaped this intense
Driscoll, 2000; Maltzman, S., 2005).
gravitational pull. (pp. 440–441)

Stein’s description of psychiatry’s “retreat” into A Biopsychosocial Approach to Process

the “hard science” of biomedicine, particularly and Outcome Research
psychopharmacology, in the 1970s underscores A biopsychosocial model is promising for process
the concerns expressed by psychologists at that time, and outcome research because it promotes the
in particular the imperative to empirically eval- incorporation of research across disciplines such as
uate and validate the efficacy of psychological treat- epidemiology, neurophysiology, and genetics to
ments. Since then, psychopharmacology has become generate integrated models of mental and physical
increasingly utilized and popularized as a “quick health. This integration provides a more detailed
fix,” with the goal of symptom amelioration, often and comprehensive explication of causal mecha-
to the exclusion of addressing the root causes of nisms as well as the opportunity to evaluate the
many psychological concerns. effects of moderator and mediator variables. This
In contrast to medicine, over the past 30–40 approach also increases scientific rigor through the
years, psychology has increasingly utilized a biop- integration of biological correlates of observed
sychosocial perspective in many subdisciplines of behavior (Melchert, 2007). This moves psychology
research and practice. This has advantageously from its position as an inherently “soft” science that
positioned psychologists to develop treatments that historically has relied on the imprecise measurement

112 process an d o u tco mes

of latent constructs. Such an approach required The Contextual Model from a
controlling the effects of moderator and mediator Biopsychosocial Perspective
variables that could have explanatory power (Meehl, Wampold and colleagues (e.g., Imel & Wampold,
1978). This arguably has impaired psychology’s 2008; Wampold, 2001) have proposed a common
ability to adequately evaluate treatment efficacy factors model called the contextual model. The
and effectiveness. Thus, working from a biopsycho- Cartesian conceptualization of mind–body dualism
social paradigm has the potential for facilitating is utilized to explain the distinctions between the
the adaptation of efficacious treatments to the needs specific effects of medical treatments on the body
of diverse clients seen in diverse practice settings. (soma) versus the nonspecific, common effects
The biopsychosocial model is consistent with the of psychotherapy in general on the mind (psyche).
goals of counseling psychology because it facilitates The contextual model describes treatment outcome
research and practice in life enhancement strategies, in counseling and psychotherapy as consistent
resilience, and flourishing rather than focusing only with a placebo effect. This means that the psycho-
on ameliorating mental illness. It also is consistent therapeutic intervention causally contributes to
with the historical foundations and values of coun- outcome because the client is provided with a
seling psychology because it recognizes client values, culturally and contextually acceptable explanation
worldviews, and individual differences as necessary for the distress and an acceptable rationale and
components in conceptualizing research hypotheses intervention for treatment. The contextual model
and in treatment administration. Thus, a biopsycho- acknowledges the therapeutic alliance as the means
social approach is congruent with counseling psy- by which psychological interventions exert their
chology in acknowledging the interactive influences effects as placebos. The model hypothesizes that
among biological, psychological, and social influ- the effectiveness of the alliance is due to the follow-
ences on psychosocial functioning and well-being. ing components: (a) a “healing,” therapeutic
relationship that (b) is “emotionally charged” and
biological indicators of which the client expects will continue to develop
treatment effectiveness over time through the disclosure of personal and
Neuroimaging studies provide one potential, albeit sensitive material; (c) the client believes that the
expensive, method for assessing treatment effi- therapist is working in the client’s best interests
cacy; some examples of neuroimaging studies are and will help the client, at least partly because
described below. Another promising method for (d) the therapist offers an explanation for the inter-
obtaining convergent biological data is the assess- vention that is plausible and consistent with the
ment of immune system functioning, which is an client’s worldview and because the intervention
indicator of emotional well-being as well as physical (e) includes a “ritual” or procedure that has face
health. For example, assessment of proinflammatory validity for the client because it is consistent with
cytokines could be one methodological strategy for the plausible explanation and rationale offered for
assessing treatment outcome (Kiecolt-Glaser, Page, the intervention and because it requires the active
Marucha, MacCallum, & Glaser, 1998). The release participation of both the client and therapist.
of stress hormones in response to acute or chronic Wampold (2001) minimizes the contribution of
stressors is associated with anxiety and depression. “neurobiological” processes, describing them as
Therefore, endocrinological measures (e.g., epineph- relevant only to understanding the etiology of
rine levels and cortisol diurnal patterns and levels), major mental illness (e.g., schizophrenia); a “neuro-
described elsewhere in this chapter, are additional biological model” of psychotherapy is described as
examples of biological indicators that could be used “reductionistic.”
to assess treatment outcome (e.g., Kiecolt-Glaser, However, the contextual model is limited in its
Bane, Glaser, & Malarkey, 2003; Fisher, Gunnar, heuristic value for hypothesis testing and ability to
Dozier, Bruce, & Pears, 2006). Biological measures suggest methodological strategies. It assumes inde-
offer an opportunity to explicate treatment outcome pendent relationships between physical–medical and
by serving as direct, objective measures of response emotional–psychological functioning (i.e., mind–
to treatment over time; measures for validating less body dualism). An integration of research from
intrusive or less expensive indicators for assessing other disciplines, such as neuroscience, provides
outcome, such as self-report instruments; and com- a more complete understanding of the phenomena
ponents of a multitrait–multimethod matrix for of interest and suggests methodologies for testing
the validation of latent constructs. the contextual model itself.

m alt zm an 113
 An example of this is a review of the meta- processes are believed to respond favorably to
analysis by Wampold, Minami, Tierney, Baskin, placebo, whereas hyperacute illnesses (i.e., heart
and Bhati (2005) from a cross-disciplinary perspec- attack), chronic degenerative diseases, or hereditary
tive. This meta-analysis reanalyzed data from an diseases are expected to resist” (Papakostas & Daras,
earlier meta-analysis by Hróbjartsson and Gøtzschse 2001, pp. 1620–1621). They also noted that “the
(2001). Hróbjartsson and Gøtzschse evaluated the establishment of predictable placebo response pat-
size of the placebo effect comparing active treat- terns to particular disorders has been proven diffi-
ment versus placebo treatment versus no-treatment cult. . . .” (p. 1620).
conditions; both psychological and physical disor- Consistent with Wampold et al.’s (2005) posi-
ders were included in their analysis. The goal was to tion, Papakostas and Daras (2001) described the
evaluate the clinical utility of the placebo response placebo (nonspecific) response as the patient’s
rather than evaluating its use as a control condition response to a healing environment. Where Papkostas
in randomized clinical trials per se. Studies utilizing and Daras differed from the conclusions later drawn
dichotomous or continuous outcome variables for by Wampold et al. is that the former authors stated
either subjective and/or objective measures of that a multidisciplinary research approach for eluci-
improvement were included in the analysis. Forty dating this nonspecific response is “mandatory.”
conditions were represented in the studies, includ- They called for the evaluation of moderator and
ing hypertension, asthma, smoking, alcohol abuse, mediator variables in medical practice, similar to
herpes simplex infection, depression, schizophre- the evaluation by psychologists of moderator and
nia, anxiety, phobia, “fecal soiling,” enuresis, epi- mediator variables in process and outcome research.
lepsy, carpal tunnel syndrome, Parkinson’s disease, In contrast, Wampold et al. attributed a nonspe-
Alzheimer’s disease, “marital discord,” bacterial cific (placebo) response to context and culture
infection, pain, nausea, and “undiagnosed ailments” and described these effects as the only causal factor
(Hróbjartsson & Gøtzschse, 2001). Acute (veni- contributing to outcome.
puncture), subacute (postoperative) and chronic Wampold et al. (2005) noted that the implica-
(rheumatoid arthritis, fibromyalgia) pain conditions tion of Hróbjartsson and Gøtzschse’s (2001) meta-
of both nociceptive and neuropathic origin were analysis was that the placebo effect was expected
included. to have the same potential impact on the outcome
Hróbjartsson and Gøtzschse (2001) reported measures of interest across trials, irrespective of
no significant effect for placebo in comparison the presenting concern. They reanalyzed the
with no treatment, although there was significant Hróbjartsson and Gøtzschse data, hypothesizing
heterogeneity across trials. They noted that these that the presenting conditions were not equally
results were found for three presenting concerns amenable to a placebo response (i.e., “psychological
evaluated in at least three independent studies with factors”). As defined by the contextual model, the
dichotomous outcomes (depression, relapse after potential for identifying a “true” placebo response
smoking cessation, and nausea), as well as in studies was attenuated in the Hróbjartsson and Gøtzschse
of five presenting concerns (anxiety, insomnia, meta-analysis because the studies were not differen-
asthma, hypertension, and pain) evaluated in at tially weighted based on the relative potential for
least three independent studies with continuous influence by placebo. For this reason, Wampold
outcome variables (Hróbjartsson & Gøtzschse, et al. classified the studies as “definitely amenable,”
2001). A statistically significant effect for placebo “possibly amenable,” or “not amenable” to psycho-
(vs. no treatment) was found only for pain intensity logical factors based on the disorder being treated.
as measured by visual analogue scale, although the The raters were five doctoral students in counseling
authors did not indicate whether there were differ- psychology. The categorization of all the conditions
ential effects based on pain type (nociceptive or included in the meta-analysis were not included in
neuropathic; acute vs. persistent/chronic). the paper but the authors listed examples of each
Papakostas and Daras (2001), commenting category as follows: “definitely amenable”: insom-
on the Hróbjartsson and Gøtzschse meta-analysis, nia, depression, and chronic pain; “possibly amena-
noted the beliefs held in the medical community ble”: acute pain, chemotherapy-induced nausea,
regarding which types of concerns are most amena- and asthma; and “not amenable”: bacterial infection
ble to a placebo response: “Generally, the presence and anemia. The authors did not describe the crite-
of anxiety and pain, the involvement of the auto- ria used to determine why, for example, acute pain
nomic nervous system, and the immunobiochemical was “less amenable” to “psychological factors” than

114 process an d o u tco mes

was chronic pain or why bacterial infection was major depressive episode, as assessed by the
deemed “not amenable.” Structured Clinical Interview. Treatment was con-
The results of their reanalysis indicated a large ducted by therapists expert in manual-based CBT.
placebo effect (Wampold et al., 2005). However, if Fourteen of the 17 participants completed treat-
research from neuroscience and psychoneuroimmu- ment. Of these, nine participants evidenced a
nology is considered, the conceptualization of these decrease of 50% or more on the HAM-D; the
presenting concerns and their “amenability” to psy- remaining five evidenced a decrease of at least 35%
chological factors likely would be very different, as on the HAM-D. The PETs at treatment comple-
would the generation of the decision rules for the tion indicated, among other changes, decreases in
meta-analysis. For example, both psychological and dorsolateral prefrontal cortex metabolism; the
physiological processes influence the perception of authors did not indicate whether this change was
both acute and chronic pain (Basbaum & Jessell, bilateral.
2000; Finniss, Kaptchuk, Miller, & Benedetti, Goldapple et al. (2004) also compared these
2010), and emotional distress influences suscepti- baseline and endpoint PETs with scans completed
bility to infection and wound healing time (Kiecolt- in a prior study evaluating the effects of paroxetine
Glaser & Glaser, 2002). Therefore, differential (a serotonin-specific reuptake inhibitor; SSRI) in
amenability to psychological factors becomes a less depression, as assessed by the HAM-D. They noted
tenable assumption and rationale for differentially no differences in glucose metabolism between the
weighting studies. Thus, the original meta-analysis CBT and paroxetine conditions at baseline. They
and subsequent reanalysis together serve as an also noted some similarities in the neuroanatomical
example of the extent to which methodology and sites impacted by CBT and paroxetine, as evidenced
results can be influenced by the knowledge base by PET at endpoint, although these effects were in
used for theory building and hypothesis testing. opposite directions. Goldapple et al. also reported
changes specific to CBT. These included decreased
the contextual model and metabolism in the medial frontal, orbital frontal,
the placebo effect anterior and dorsal midcingulate areas of the frontal
As noted above, the placebo effect is a primary tenet lobe in comparison with medication. They also
of the contextual model of psychotherapy. It was noted that past evaluations of medication placebo
described by Wampold et al. (2005) as the inciden- and fluoxetine (another SSRI) suggested that pla-
tal aspects of the psychological treatment that are cebo most closely mimicked the response to active
common to most, if not all, of these treatments. medication, in contrast to the effects of CBT
These incidental components are what contribute reported in their current study (2004).
causally to a positive outcome, whereas the pre- Benedetti, Mayberg, Wager, Stohler, and
defined, specific components of treatment are more Zubieta (2005) summarized research evaluating the
or less irrelevant to treatment outcome. However, effects of fluoxetine in a placebo-controlled study
a cross-disciplinary approach integrating research across drug responders/nonresponders and placebo
from neuroscience questions this assumption. There responders/nonresponders over a 6-week period as
are data from studies utilizing magnetic resonance assessed by PET. The PET scans were acquired at
imaging (MRI), positron emission tomography baseline (before treatment) and after 1 and 6 weeks
(PET), and functional MRI (fMRI) that suggest of treatment. Increased glucose metabolism was
that the placebo effect is similar to the neurophysi- noted in prefrontal cortex and posterior cingulate
ological effects of psychotropic medications, and gyrus in both the fluoxetine and placebo groups,
that these effects are distinguishable from the neu- indicating a similar clinical response in both groups
rophysiological effects of psychotherapy. Some after 6 weeks of treatment. However, the magnitude
research in this area is described and summarized of change for the fluoxetine-treated group was gen-
below. erally larger in comparison with the placebo group.
Goldapple et al. (2004) evaluated glucose metab- There also were additional, unique areas impacted
olism, as assessed by PET at baseline and at the end by fluoxetine in comparison with placebo. There
of 15–20 individualized sessions of CBT. Participants were no regional changes in activation unique to
included 11 women and six men with mean scores placebo.
of 20 (standard deviation = 3) on the 17-item Benedetti et al. (2005) further hypothesized that
Hamilton Depression Rating Scale (HAM-D). if the activation of brain areas common to both flu-
Participants met DSM-III or DSM-IV criteria for oxetine and placebo were due to a placebo effect,

m alt zm an 115
described as “nonspecific psychological effects” rather higher proportion of participants with positive
than a specific active ingredient in fluoxetine, simi- family histories. Thus, group assignment was
lar but hypothetically more robust changes in the skewed in favor of medication treatment. Thase
same brain areas would be expected secondary also commented that differential efficacy may
to completion of formal psychological treatment. exist between medication and psychotherapy
To test this hypothesis, they compared the PET depending on the nature of the specific symptoma-
results from the fluoxetine–placebo study with tology and the presumed neurophysiology mediat-
PET scans from the Goldapple et al. (2004) study ing the symptoms.
evaluating CBT and two studies evaluating inter- Kennedy et al. (2007) evaluated glucose metab-
personal therapy (IPT; Brody et al., 2001; olism via PET in a randomized trial comparing
Martin et al., 2001). Benedetti et al. noted distinct 16 weeks of venlafaxine, a serotonin-noradrenergic
differences in the activation patterns between the reuptake inhibitor (SNRI) with 16 weeks of CBT.
medication and placebo PET scans in comparison There were 12 participants in each condition. These
with the scans from the psychotherapy studies. investigators reported similar response rates in each
Cognitive behavioral therapy and IPT were associ- group: 9/12 in the venlafaxine condition; 7/12 in
ated with decreases in prefrontal cortical activa- the CBT condition. Thirteen men and 18 women
tion, whereas there were additional regional effects who met DSM-IV-TR criteria for a major depres-
specific to each intervention. They also noted that sive disorder and who were experiencing a current
response to CBT was observed in brain regions not major depressive episode, as assessed by the Struc-
affected by medication, including the dorsal ante- tured Clinical Interview and a minimum score of
rior cingulate gyrus, and the orbital frontal and 20 on the 17-item HAM-D, were included. The
medial frontal cortex. These authors concluded: CBT-assigned participants received weekly individ-
“These findings suggest that the placebo changes are ualized outpatient treatment from therapists with
unlikely attributable to passive psychotherapy effects extensive experience providing manual-based CBT.
but rather specific effects attributable to the effects Participants in the venlafaxine condition received
of expectation and conditioning facilitated by the 75 mg of medication daily for the first 2 weeks; this
psychosocial context of the trial” (p. 10397). They was titrated up to a target dose of 150–225 mg.
further noted: Data from five participants in the CBT condition
and two participants from the venlafaxine condition
The change patterns seen with these specific
were excluded because they failed to complete a
psychotherapies provide preliminary evidence
second PET scan and at least 8 weeks of treatment.
refuting the hypothesis that placebo response is
This resulted in a final N = 12 in each condition.
mediated by changes in a common antidepressant
There were no statistically significant differences
response pathway. These findings additionally
on the HAM-D between groups at baseline or end-
suggest that placebo response is also not the result
point. Responders in both groups exhibited similar
of uncontrolled, nonspecific psychological
decreases in symptomatology, as assessed by HAM-D
treatment effects.
scores. There also were no statistically significant
(Benedetti, Mayberg, Wager, Stohler, & Zubieta, 2005,
p. 10398)
differences in glucose metabolism between groups
at baseline. However, the second PETs in treatment
The studies by Martin et al. (2001) and Brody responders evidenced similar changes in glucose
et al. (2001) were cited as key data by Benedetti, metabolism across both groups in comparison with
Mayberg, Wager, Stohler, and Zubieta (2005). baseline. These included decreased metabolic activ-
However, when they were published, an accom- ity in the orbitofrontal cortex bilaterally, the right
panying commentary by Thase (2001) noted poten- dorsomedial prefrontal cortex, and left dorsomedial
tial confounds and methodological issues. These prefrontal cortex. An increase in glucose metabo-
included nonrandomized group assignment–Brody lism in the right lateral inferior occipital cortex
et al. assigned participants based on their preference also was observed in responders in both conditions.
and Martin et al. randomized 23 of 28 participants There also were changes in glucose metabolism that
(82%)–and nonequivalence between groups at base- were unique to each condition. Similarly, nonre-
line. The ITP-assigned participants in Brody et al. sponders in both conditions evidenced some sim-
appeared to have a longer history of depression ilar patterns in glucose metabolism at endpoint,
(onset at an earlier age), more prior treatment, yet there also were unique changes specific to each
higher baseline symptom severity scores, and a condition. Some overlap also occurred between

116 process an d o u tco mes

metabolic changes seen in nonresponders in both these nonspecific placebo effects are distinct from
groups and the responders in both groups; specifi- the effects of psychotherapy. The neuroimaging data
cally, decreased glucose metabolism was seen in the also suggest that the effects of psychotherapy may
left lateral orbital prefrontal cortex (Kennedy et al., be specific and distinguishable in comparison with
2007). pharmacotherapy. Thus, the data support the goals
Synthesizing and interpreting the above data is of process and outcome research in elucidating the
both complicated and confusing. As noted above, contributions of moderator variables and variables
neuroimaging studies are subject to the same meth- associated with the therapeutic process and alliance
odological concerns that arise in psychological (e.g., Craighead, Sheets, & Bjornsson, 2005).
research. These include random assignment and Additionally, these data question the validity of the
equivalence in baseline measures across conditions. major tenet of the contextual model (and of a
There also is the potential for interpreting averaged common factors interpretation in general), which is
results across clients as clinically significant findings that treatment efficacy is mediated only by a pla-
when, in fact, they may represent “noise” attribut- cebo effect.
able to measurement error. Additionally, differences
in the neurophysiological effects of various psy- placebo and process research
chotropic medications may be attributable to the In the context of process research, the neuroimaging
differences in the neurotransmitters and systems data described by Benedetti, Mayberg, Wager,
they were designed to target. Similarly, some of the Stohler, and Zubieta (2005) above suggest that indi-
differences observed between CBT and IPT may vidual differences exist in susceptibility to the influ-
reflect differential effectiveness mediated by differ- ences of the treatment context. These influences
ences in treatment specificity. Alternatively, the very appeared to be independent of the specific, active
specific, often unilateral neurophysiological effects ingredients, suggesting a moderator influence. The
observed across psychotherapies and medications data also have implications for evaluating the thera-
may be due to methodological differences and may peutic relationship and psychotherapy process in
ultimately be minimized with increasing method- promoting client engagement and preventing pre-
ological rigor. mature termination. Historically, the placebo has
Although acknowledging these concerns, there been conceptualized in negative terms. For example,
appear to be four emerging trends when summariz- Papakostas and Daras (2001) noted that placebo has
ing the accumulating data: medication and psycho- been described as a “deceptive” therapy (p. 1614).
therapy appear to share some neurophysiological However, reconceptualizing placebo as representing
effects associated with effectiveness in treating the treatment impact of moderator and mediator
depression; medication and psychotherapy appear variables reframes the construct more positively.
to each have some unique neurophysiological effects Placebo may represent the neurophysiological
associated with treating depression; the neurophysi- mechanisms by which moderator and mediator
ological effects of placebo appear to be measurable variables contribute adjunctively to psychotherapy
and to mimic, to a lesser degree, the effects of active treatment effectiveness. One goal of process and
ingredients in an SSRI; and the neurophysiological outcome research might be to delineate how this
effects of placebo appear to be distinct from the effect can be maximized.
neurophysiological effects of psychotherapy.
Consistent with the position of Wampold et al. Assessment of Moderator Variables
(2005), Papakostas and Daras (2001), and Client and Therapist Temperament
Craighead, Sheets, and Bjornsson (2005), the and Personality
neuroimaging studies just described suggest that Temperament and personality are two moderator
nonspecific effects are associated with treatment variables that may impact treatment process and
effectiveness for depression. They also support outcome. Temperament is defined for this discussion
Wampold et al.’s (2005) hypothesis that these non- as stable, physiologically based individual differ-
specific effects are consistent with a placebo effect. ences in emotion, attention, and arousal that essen-
This placebo effect is the client’s response to a heal- tially are present from birth (Strelau, 1994). Some
ing environment and reflects, at least in part, the researchers include individual differences in motiva-
expectation that treatment will be effective. tion as another aspect of temperament (e.g., Bates,
However, in contrast to the conclusions of Wampold 1989, as cited in Rothbart, Derryberry, & Posner,
et al. (2005), the neuroimaging data suggest that 1994), whereas others (e.g., Strelau, 1994) include

m alt zm an 117
motivation among the broader range of differences Capacity for insight is a potential moderator
associated with personality. Both temperament and variable, but also potentially a mediator variable in
personality are viewed as enduring characteristics psychotherapy. The capacity for insight and self-
across the lifespan. Eastern European and Russian understanding has been associated with positive
investigators have historically focused on theories treatment outcome (Hill & Knox, 2008). If this
of temperament. This research can be traced back capacity moderates the ability to benefit from treat-
to Pavlov’s proposed typology based on his observa- ment, psychotherapeutic interventions targeted to
tions of stable, enduring individual differences in increase these abilities could potentiate positive
conditional learning and response inhibition among treatment outcome. Because the ability to utilize
dogs in his laboratory (Teplov, 1964). However, insight and self-reflection is inversely related to
some researchers appear to have used the terms emotional reactivity, as described above, treatments
“temperament” and “personality” interchangeably or process strategies that target emotional reactivity
(e.g., Gray, 1964). Western psychologists have as the initial treatment goal would be an important
focused primarily on the construct of personality, initial step toward addressing and achieving longer-
typically when studying individual differences in term, designated treatment goals.
adult humans. “Temperament” is referenced when Identifying clients with impaired capacity for
studying biologically based differences in infants insight secondary to increased emotional reactivity
and young children, particularly individual differ- could theoretically be an important part of the
ences in reactivity to social stimuli and levels of assessment process. This hypothesis is consistent
arousal (e.g., Gunnar, 1994). with the conclusions of Beutler, Rocco, Moleiro,
There exists fairly substantive and robust research and Talebi (2001), which suggested nondirective
support for the construction of personality as con- treatment is more effective with resistant, reactive
sisting of five factors: neuroticism, extraversion, clients in comparison with directive treatments.
openness to experience, agreeableness, and consci- Addressing the client’s needs in such a hierarchical
entiousness (e.g., McCrae & Costa, 1997). These manner would hypothetically require longer-term
five factors have been confirmed cross-culturally. psychotherapy. Thus, increased emotional reactivity
Consistent gender differences also have been identi- and a requisite hierarchical therapy model might be
fied cross-culturally, with the magnitude of the dif- two predictors of psychotherapy length.
ference increasing with increases in measured gender
equality and national health and wealth (Costa, Attachment and Self-regulation:
Terracciano, & McCrae, 2001; McCrae et al., 2004; Implications for Process and
Schmitt, Realo, Vocacek, & Allik, 2008). Outcome Research
Individual differences in temperament and A recent and significant trend in counseling psy-
personality can moderate the therapeutic process. chology is the interest in attachment constructs,
For example, Beutler, Rocco, Moleiro, and Talebi their implications regarding the client’s and/or ther-
(2001) reviewed the literature on the moderating apist’s attachment style, and these effects on the
and mediating effects of trait-like resistance on therapeutic alliance.
treatment. From a biopsychosocial perspective of
emotion regulation (described below), one hypoth- Childhood Attachment Styles
esis is that observed resistance is a reflection of The quality of the primary attachment relationship
increased emotional reactivity mediated by chronic developed in childhood has been associated with
hypervigilance and hyperarousal to current or past the quality of later interpersonal peer relationships.
stressors. This interpretation is supported by data Bernier and Dozier (2002) cited research indicating
indicating that levels of stress hormones have been that preschoolers with secure attachment histories
associated with a decreased threshold for aggres- are more empathic, more effective at conflict resolu-
sive behavior, as well as a decreased ability to attend, tion, better at accurately interpreting social cues,
concentrate, learn, self-monitor, and self-reflect and initiate more play than do peers with other
(Dishion & Connell, 2006; Lewis, Granic, & types of attachment histories. Additionally, children
Lamm, 2006). This impairs the client’s ability to with avoidant attachment histories exhibited more
address treatment goals due to a compromised abil- hostility, bullying, and scapegoating behaviors in
ity to attend, concentrate, and engage in functions comparison with other children, children with resis-
mediated by the prefrontal cortex. Thus, the client is tant attachment histories were more likely to be vic-
less able to process the material or develop insight. timized by peers, and children with disorganized

118 process an d o u tco mes

attachment as assessed in infancy were more likely which emotional significance is attached to stimuli,
to aggress against peers in preschool and into later particularly social stimuli; the ability to avoid or
childhood (Bernier & Dozier, 2002). Therefore, the inhibit responses in anticipation of negative conse-
data suggest that the attachment developed in quences; the ability to select appropriately among
infancy and early childhood may be reflective of competing choices; the ability to self-monitor per-
enduring relationship patterns across childhood and formance; and the ability to learn new material
potentially into adult peer relationships. (Lewis, Granic, & Lamm, 2006). Emotion and
cognitive regulation are inextricably intertwined.
Childhood Development of When a child with emotion dysregulation perceives
Self-regulatory Systems a threat, executive functions mediated by the pre-
Development of the primary attachment relation- frontal cortex are decreased. Arousal and vigilance,
ship appears to be causally related to the develop- mediated by the limbic and autonomic nervous
ment of self-regulatory systems and resilience. systems, predominate. Individuals who have expe-
Regulation of emotional reactivity and impulsivity rienced chronic stressors and adversity develop
is gradual and is not fully developed until late a lower threshold for this chronic hyperarousal.
adolescence or young adulthood. Development They are more likely to misperceive social stimuli
of self-regulation is moderated, in part, by the and react in maladaptive ways. Thus, a lowered
child’s resilience. Resilience refers to protective fac- threshold for arousal and the experience of chronic
tors that reduce poor outcomes under conditions hyperarousal are associated with difficulties in atten-
of adversity and risk (Greenberg, 2006) and has tion, memory, and learning (Mayes, 2006).
been described as positive adaptation in the face of What is significant from an attachment per-
severe adversity (Sameroff & Rosenblum, 2006). spective is that abuse and neglect, as well as removal
An individual’s resilience reflects three interactive from the home if that is necessary to protect the
influences: intraindividual (temperament, cognitive child, represent disruptions in relationships with
abilities), quality of social relationships (e.g., the a primary caregiver (Fisher et al., 2006).
relationship with the primary caregiver, and the
quality of the broader environment, such as school Childhood Interventions for Promoting
and neighborhood (Greenberg, 2006). Intrain- Self-regulation and Coping
dividual resilience refers to the ability to self- Coping has been defined as the conscious, mindful
regulate in two broad areas. Emotion self-regulation effort to regulate the emotional, cognitive, behav-
is the ability to cope adaptively and inhibit inap- ioral, physiological, and environmental impact of
propriate emotional/behavioral responses to stres- stressors or adversity (Compas, 2006). Coping is an
sors. Cognitive self-regulation is the ability to focus executive function mediated by the prefrontal
attention and concentration to facilitate learning cortex. Factors that promote emotion regulation
(Dishion & Connell, 2006). also promote coping. Two interventions evaluated
Children exposed to proximal adversity, such as for infants, toddlers, and preschoolers in foster care
physical abuse, sexual abuse, emotional abuse, and/ were designed to target the neurodevelopment of
or neglect are at higher risk for neurodevelopmental emotion regulation and promote coping. These
delays in emotion regulation and associated cogni- interventions focused on caregiver interactive style
tive regulation. The experience of such severe adver- with infants and toddlers in one study, and pre-
sities by young children has been reliably related to schoolers in another. These interventions empha-
disrupted and atypical diurnal cortisol levels. These sized the role of the foster caregiver as a buffer for
atypical cortisol patterns reflect dysregulation of the the child’s experience of adversity. The primary
hypothalamic-pituitary-adrenal cortex (HPA) axis hypotheses were that positive interactive experi-
that mediates the response to stressors and the ences can impact and modify the neural bases of
release of stress-related hormones (Fisher, Gunnar, self-regulation, and that these modifications can
Dozier, Bruce, & Pears, 2006). Dysregulation of the reverse negative effects of adversity (Fisher, Gunnar,
HPA axis impacts the neurophysiological function- Dozier, Bruce, & Pears, 2006). In other words, the
ing of areas with bidirectional communication with caregiver provided the treatment through the pri-
the HPA axis including the amygdala, orbitofrontal mary social relationship with the child. The interac-
cortex, and medial prefrontal cortex. tive style was designed to facilitate the child’s ability
Functions mediated by these structures and to attach adaptively. The goal was to promote the
affected by chronic stressors include: the degree to caregiver’s ability to respond to the distress signals of

m alt zm an 119
infants and toddlers, even when the signals were goal for some clients. For example, endocrinological
unclear or ambiguous; respond in a sensitive and data (stress hormone levels) predicted marital satis-
respectful style; and follow the child’s lead. Caregivers faction and marriage dissolution 10 years later in
of preschoolers were supported to respond in a con- a sample of newlyweds married 1 year or less at the
sistent manner and to respond contingently to the time of baseline assessment (Kiecolt-Glaser, Bane,
child’s behavior by positively reinforcing positive Glaser, & Malarkey, 2003). Marital interactive
behavior and setting limits for negative behavior style, personality, and marital satisfaction at baseline
(Fisher et al., 2006). Evaluation of these interven- were not related to marital status 10 years later.
tions indicated normalized HPA function, as assessed Exaggerated daytime and nighttime fluctuations in
by salivary cortisol levels (Fisher et al., 2006). epinephrine levels at baseline predicted marital
status; individuals with statistically significant
Implications of Self-regulation Research for higher daytime levels and lower nighttime levels
Adult Counseling and Psychotherapy were more likely to be divorced 10 years later in
The ability to self-regulate has been researched pri- comparison with individuals whose levels did not
marily in infants, toddlers, and preschoolers who vary as widely. These data suggest that emotional
have experienced abuse and neglect and are therefore reactivity may be an important moderator vari-
at higher risk for life-long mental health concerns. able. When considered with the data reported by
However, there are data suggesting that even experi- Dishion and Connell (2006) and Lewis, Granic,
mentally induced stressors can have profound effects and Lamm (2006) regarding the relationship
in adults. These effects are similar to the cognitive between stress hormones and a decreased threshold
dysregulation and difficulties with executive func- for aggressive behavior, these data suggest that
tioning described in dysregulated children. Whitson modification of emotion regulation may be an
and Galinsky (2008) summarized six studies, each of appropriate treatment goal in and of itself.
which evaluated the effects of perceived lack of con-
trol on illusory pattern perception. In each study, The Therapeutic Alliance from
adult participants who were in the lack-of-control an Attachment Perspective
condition were statistically more likely to perceive Henry, Schacht, and Strupp (1990) conceptualized
patterns in stimuli or behavior when, in fact, none the therapeutic alliance from the theoretical per-
existed. An opportunity to participate in a standard- spective of interpersonal introjection. The introject
ized self-affirmation procedure after the lack-of- is the internalization of the manner in which one
control manipulation but prior to stimulus exposure was treated by others in early interpersonal rela-
negated the effects of the lack-of-control manipula- tionships. Although stable, the introject is modifi-
tion. Whitson and Galinsky interpreted these data able over the life span. The therapeutic alliance,
as indicating a strong, innate motivation in humans as an interpersonal process between client and ther-
to make sense of their perceptual world, and that apist, is hypothesized by these investigators as
the need to create organization increases when indi- reflecting the therapist’s past treatment by impor-
viduals perceive a loss of control. Thus, perceived tant others. Expanding on this conceptualization,
lack of control can result in an increased probability Hilliard, Henry, and Strupp (2000) attempted to
to misperceive sensory and social stimuli. The authors evaluate a model in which the therapist’s and cli-
noted that these results have implications for psycho- ent’s early parental relationships were hypothe-
therapeutic processes and treatments. sized to impact treatment outcome, directly and/
The simple addition of a self-affirmation proce- or indirectly, through the therapeutic process. These
dure could be viewed as consistent with the care- authors reported that data provided tentative
giver interventions reported by Fisher, Gunnar, support for these hypotheses. Based on self-report,
Dozier, Bruce, and Pears (2006). Taken together, clients’ early parental relations appeared to directly
these data have implications for process and out- and indirectly influence outcome, whereas the ther-
come research, particularly regarding the role of the apists’ self-reported early parental relationships
therapeutic relationship. appeared to directly influence the therapy process.
Meyer and Pilkonis (2001) reviewed research assess-
emotion regulation as a treatment goal ing the relationships among attachment styles of
As discussed above, decreasing emotional reactivity adult clients and therapists and their moderat-
to social stimuli and increasing emotion regulation ing effects on the therapeutic process. Attach-
hypothetically may be an appropriate treatment ment styles were assessed with either semistructured

120 process an d o u tco mes

interviews, such as the Adult Attachment Interview achieve this relationship could be predictive of pre-
(AAI), or self-report instruments. The AAI is based mature termination, alliance rupture, and/or resis-
on Bowlby’s research on infant attachment and tance to the therapeutic process. The AAI, or a
Ainsworth’s research on adult attachment style as self-report instrument validated against the AAI
assessed via direct observation of infant–parent and/or biological indicators of stress reactivity,
interaction (Main, Hesse, & Goldwyn, 2008). It is might be a useful approach for assessing a client’s
a qualitative measure consisting of 20 questions attachment style and, potentially, ability to emo-
that include, but are not limited to, the assessment tionally regulate. This information could inform the
of the respondent’s perceptions (thoughts and therapeutic relationship as well as identify whether
feelings) of their own experience with primary care- short-term goals should include decreasing emo-
givers, how these experiences affected adult person- tional reactivity and the promotion of emotion
ality, and the experience of major losses (Main, regulation.
Hesse, & Goldwyn, 2008; Steele & Steele, 2008).
Meyer and Pilkonis (2001) concluded that both Resilience, Positive Psychology,
client and therapist attachment styles, based on and Psychosocial Flourishing
childhood attachment relationships, likely are Counseling psychologists have been interested in
important moderators of the therapeutic process. the constructs of attachment and resilience to fur-
This conclusion was echoed by Eagle (2006), who ther an understanding of the emotionally healthy,
also reviewed attachment research and noted that self-actualized adult (Lopez, F. & Brennan, 2000).
client and therapist attachment styles may moderate Understanding the client’s presentation from an
both the therapeutic process and outcome. emotion and cognitive regulation perspective
supports a strengths-based approach, consistent
the therapeutic alliance and with the tenets of positive psychology (Lopez, S. &
the real relationship Kerr, 2006) and the values of counseling psychol-
Theoretically, increasing emotion and cognitive ogy. Secure attachment promotes resilience within
regulation could be achieved by addressing the the context of significant adversity and the ability
client’s preestablished attachment style. Attaining to mindfully cope with acute and chronic stressors.
this goal could be a prerequisite for addressing other Yet, attachment style alone is insufficient to explain
presenting concerns that create emotional distress why some individuals flourish in spite of signifi-
or psychosocial dissatisfaction for the client. This cant adversity, why some individuals appear to suc-
implies that the therapeutic relationship becomes cumb to the effects of adversity, or why some later
a corrective experience, similarly to the caregiver overcome these effects and function well.
interventions described by the Fisher, Gunnar, Assessment of moderator variables such as tem-
Dozier, Bruce, and Pears (2006) study. perament, personality, and emotion and cognitive
Gelso and colleagues have described the concept regulation, in addition to attachment style, could
of the real relationship as the underlying connec- elucidate what core variables contribute to psycho-
tion between therapist and client. It consists of two logical resilience and psychosocial flourishing. Com-
basic elements, genuineness and realism, each of plex interaction effects appear to exist among these
which can vary along the dimensions of magnitude variables and the social and environmental factors
and valance (Gelso & Samstag, 2008). Genuineness impacting a particular individual (Greenberg,
is defined as the ability to be present and authentic 2006; Werner, 2005). The emerging field of behav-
with others, whereas realism pertains to “the experi- ioral epigenetics, which explores the effects of social
encing or perceiving the other in ways that befit experience on neurobiological processes across the
him or her, rather than as projections of wished for lifespan, may elucidate these interactions (e.g., Bagot
or feared others (i.e., transference)” (Gelso & & Meaney, 2010; Champagne & Curley, 2009;
Samstag, 2008, p. 276). These investigators hypoth- Curley, Jensen, Mashoodh, & Champagne, 2011).
esized that it is the real relationship, rather than the Whether, and to what extent, emotion regulation
therapeutic alliance, that mediates treatment out- can be moderated via the therapeutic relationship
come. This perspective may be viewed from an remains an empirical question. The degree to which
attachment perspective as the therapist’s ability to emotion regulation reflects a stable congenital indi-
respond to the client’s attachment needs (Eagle, vidual difference in temperament may be the extent
2006). This ability could hypothetically be a core to which self-regulation is modifiable via the thera-
requirement of the therapeutic process. Failure to peutic relationship or specific treatment components.

m alt zm an 121
 Data discussed in this chapter suggest that the on design and methodology, applying the expertise
ability to utilize executive functions, such as the of each member. That is not often feasible in many
capacity for insight, empathy, the conscious alloca- environments, particularly those not associated with
tion of attentional resources for planning, and the a university. However, what is feasible is the integra-
ability to self-evaluate performance, are potential tion of cross-disciplinary research when conceptual-
core components necessary for utilizing adaptive izing and developing research hypotheses, thus
coping strategies. Additionally, the data suggest that informing the counseling psychologist’s decision
strategies for maximizing self-regulation, resilience, making regarding design and methodology. Future
perceived control, and mindful coping may pro- directions in research suggested in this chapter
mote self-actualization and flourishing. These include:
hypotheses are supported by data from longitudinal
• Evaluating temperament and personality
studies described by Werner and colleagues (as sum-
as moderator variables in outcome research
marized in Werner, 2005).
• Evaluating client resistance in psycho-
therapy as a manifestation of emotional
Conclusion
reactivity mediated by chronic hypervigilance
This chapter traced the development of process
and hyperarousal
and outcome research over the past 30 years. This
• Exploring the relationship between capacity
research is grounded in the premise that all clients
for insight and emotional reactivity
are entitled to the highest quality of psychological
• Testing a hierarchical therapy model based
treatment available for addressing their particular
on the client’s pretreatment level of emotional
concerns. Counseling psychology historically has
reactivity
been in the forefront of process and outcome
• Validating self-report instruments for
research. A cross-disciplinary, biospsychosocial per-
the assessment of treatment outcome against
spective has significant heuristic value for explicat-
biological markers
ing treatment effectiveness, as well as moderator
• Exploring components of executive
and mediator variables of the counseling and psy-
functioning as moderators of psychosocial
chotherapy process. The potential applications of
flourishing.
the biopsychosocial perspective described in this
chapter suggest a more positive prognosis for facil-
itating positive change and personal growth in References
individuals who have experienced severe adversity Ahn, H., & Wampold, B. E. (2001). Where oh where are
than that voiced by Arbona and Coleman (2008). the specific ingredients? A meta-analysis of component stud-
In their review of the literature on risk and resil- ies in counseling and psychotherapy. Journal of Counseling
ience, Arbona and Coleman commented that per- Psychology, 48, 251–257.
haps only policy and community-level changes that Alcorn, J. D. (1991). Counseling psychology and health applica-
tions. The Counseling Psychologist, 19, 325–341.
reduce or eliminate the root causes of social adver- Altmaier, E. M. (1991). Research and practice roles for counsel-
sity would be sufficient to facilitate resilience and ing psychologists in health care settings. The Counseling
adaptive coping in severely impacted individuals. Psychologist, 19, 342–364.
As a qualitative extension and complement to Anderson, E. M., & Lambert, M. J. (2001). A survival analysis
the amelioration of emotional distress and dysreg- of clinically significant change in outpatient psychotherapy.
Journal of Clinical Psychology, 57, 875–888.
ulation, counseling psychology promotes mental APA Presidential Task Force on Evidence-Based Practice. (2006).
health flourishing from a strengths-based perspec- Evidence-based practice in psychology. American Psychologist,
tive. A strengths-based perspective is supported by 61, 271–285.
a cross-disciplinary biopsychosocial model that Arbona, C., & Coleman, N. (2008). Risk and resilience.
emphasizes human potential. The constructs of In S. D. Brown, & R. W. Lent (Eds.), Handbook of counsel-
ing psychology (4th ed., pp. 483–499). New York: John Wiley
resilience and attachment offer a paradigm for inte- & Sons.
grating cross-disciplinary research to explicate psy- Axford, J., Heron, C., Ross, F., & Victor, C. R. (2008).
chological flourishing from a resilience perspective. Management of knee osteoarthritis in primary care: Pain and
depression are the major obstacles. Journal of Psychosomatic
Future Directions Research, 64, 461–467.
Bagot, R. C., & Meaney, M. J. (2010). Epigenetics and the
The biopsychosocial model emphasizes a cross- biological basis of gene × environment interactions.
disciplinary approach to research. Ideally, a multi- Journal of the American Academy of Child & Adolescent
disciplinary team of researchers would collaborate Psychiatry, 49, 752–771. doi:10.1016/j.jaac.2010.06.001.

122 process an d o u tco mes

Baldwin, S. A., Berkeljon, A., Atkins, D. C., Olsen, J. A., & Chwalisz, K., & Obasi, E. (2008). Promoting health and
Nielsen, S. L. (2009). Rates of change in naturalistic psy- preventing and reducing disease. In S. D. Brown, &
chotherapy: Contrasting Dose-Effect and Good-Enough R. W. Lent (Eds.), Handbook of counseling psychology (4th ed.,
level models of change. Journal of Consulting and Clinical pp. 517–534). New York: John Wiley & Sons.
Psychology, 77, 203–211. Cloninger, C. R. (1987). Neurogenetic adaptive mechanisms
Basbaum, A. I., & Jessell, T. M. (2000). The perception of pain. in alcoholism. Science, 236, 410–416.
In E. R. Kandel, J. H. Schwartz, & T. M. Jessell (Eds.), Committee on Standards for Providers of Psychological Services
Principles of neural science (pp. 472–491). New York: (1977). Standards for providers of psychological services.
McGraw- Hill. American Psychologist, 32, 495–505. doi:10.1037/0003-
Benedetti, F., Mayberg, H. S., Wager, T. D., Stohler, C. S., 066X.32.6.495.
Zubieta, J.-K. (2005). Neurobiological mechanisms of the Compas, B. E. (2006). Psychobiological processes of stress
placebo effect. The Journal of Neuroscience, 25, 10390–10402. and coping: Implications for resilience in children and
doi:10.1523/JNEUROSCI.3458-05.2005. adolescents–Comments on the papers of Romeo & McEwen
Bernal, G., & Scharron-Del-Rió, M. R. (2001). Are empirically and Fisher et al. In B. M. Lester, A. Masten, & B. McEwen
supported treatments valid for ethnic minorities? Toward an (Eds.), Annals of the New York Academy of Sciences: Vol. 1094.
alternative approach for treatment research. Cultural Diversity Resilience in Children (pp. 226–234). New York: New York
and Ethnic Minority Psychology, 7, 328–342. Academy of Sciences.
Bernier, A., & Dozier, M. (2002). The client-counselor match Corning, A. F., & Malofeeva, E. V. (2004). The application of
and the corrective emotional experience: Evidence from survival analysis to the study of psychotherapy termination.
interpersonal and attachment research. Psychotherapy: Theory/ Journal of Counseling Psychology, 51, 354–367.
Research/Practice/Training, 39, 32–43. Costa, P. T., Jr., Terracciano, A., & McCrae, R. R. (2001).
Beutler, L. E. (1998). Identifying empirically supported treat- Gender differences in personality traits across cultures:
ments: What if we didn’t? Journal of Consulting and Clinical Robust and surprising findings. Journal of Personality and
Psychology, 66, 113–120. Social Psychology, 81, 322–331.
Beutler, L. E. (2002). The dodo bird is extinct. Clinical Psychology: Craighead, W. E., Sheets, E. S., & Bjornsson, A. S. (2005).
Science and Practice, 9, 30–34. Specificity and nonspecificity in psychotherapy. Clinical
Beutler, L. E., Rocco, F., Moleiro, C. M., & Talebi, H. (2001). Psychology: Science and Practice, 12, 189–193.
Resistance. Psychotherapy, 38, 431–436. Crits-Christoph, P. (1997). Limitations of the Dodo bird verdict
Biderman, A., Yeheskel, A., & Herman, J. (2005). The biopsy- and the role of clinical trials in psychotherapy research:
chosocial model–have we made any progress since 1977?. Comment on Wampold et al. (1997). Psychological Bulletin,
Families, Systems, & Health, 23, 379–386. 122, 216–220.
Borckardt, J. J., Nash, M. R., Murphy, M. D., Moore, M., Cummings, N. A. (1977). The anatomy of psychotherapy
Shaw, D., & O’Neil, P. (2008). Clinical practice as natural under national health insurance. American Psychologist, 32,
laboratory for psychotherapy research: A guide to case-based 711–718.
time-series analysis. American Psychologist, 63, 77–95. Curley, J. P., Jensen, C. L., Mashoodh, R., & Champagne, F. A.
Borkovec, T. D., & Costello, E. (1993). Efficacy of applied (2011). Social influences on neurobiology and behavior:
relaxation and cognitive-behavioral therapy in the treat- Epigenetic effects during development. Psychoneuroen-
ment of generalized anxiety disorder. Journal of Consulting docrinology, 36, 352–371. doi: 10.1016/j.psyneuen.
and Clinical Psychology, 61, 611–619. doi:10.1037/ 2010.06.005
0022-006X.61.4.611. Cutuli, J. J., Chaplin, T. M., Gillham, J. E., Reivich, K. J.,
Brody, A. L., Saxena, S., Stoessel, P., Gillies, L. A., Fairbanks, L. A., & Seligman, M. E. P. (2006). Preventing co-occurring
Alborzian, S., et al. (2001). Regional brain metabolic changes depression symptoms in adolescents with conduct prob-
in patients with major depression treated with either parox- lems: The Penn resiliency program. In B. M. Lester,
etine or interpersonal therapy. Archives of General Psychiatry, A. Masten, & B. McEwen (Eds.), Annals of the New York
58, 631–640. Academy of Sciences: Vol. 1094. Resilience in children
Bronfenbrenner, U. (1977). Toward an experimental ecology (pp. 282–286). New York: New York Academy of Sciences.
of human development. American Psychologist, 32, 513–531. Daniel, H. C., Narewska, J., Serpell, M., Hoggart, B., Johnson, R.,
Chambless, D. L. (2002). Identification of empirically supported & Rice, A. S C. (2008). Comparison of psychological and
counseling psychology interventions: Commentary. The physical function in neuropathic pain and nociceptive pain:
Counseling Psychologist, 30, 302–308. Implications for cognitive behavioral pain management pro-
Chambless, D. L., & Hollon, S. D. (1998). Defining empirically grams. European Journal of Pain, 12, 731–741.
supported therapies. Journal of Consulting and Clinical Dishion, T. J., & Connell, A. (2006). Adolescents’ resilience as
Psychology, 66, 7–18. a self-regulatory process: Promising themes for linking
Chambless, D. L., & Ollendick, T. H. (2001). Empirically intervention with developmental science. In B. M. Lester,
supported psychological interventions: Controversies and A. Masten, & B. McEwen (Eds.), Annals of the New York
evidence. Annual Review of Psychology, 52, 685–716. Academy of Sciences: Vol. 1094. Resilience in children
Champagne, F. A., & Curley, J. P. (2009). Epigenetic mecha- (pp. 125–138). New York: New York Academy of Sciences.
nisms mediating the long-term effects of maternal care on Eagle, M. N. (2006). Attachment, psychotherapy, and assess-
development. Neuroscience and Biobehavioral Reviews, 33, ment: A commentary. Journal of Consulting and Clinical
593–600. doi:10.1016/j.neubiorev.2007.10.009. Psychology, 74, 1086–1097.
Chrisler, J. C., & O’Hea, E. L. (2000). Gender, culture, and Engel, G. L. (1977). The need for a new medical model: A chal-
autoimmune disorders. In R. M. Eisler, & M. Hersen (Eds.), lenge for biomedicine. Science, 196, 129–136.
Handbook of gender, culture, and health (pp. 321–342). New Enoch, M.-A. (2006). Genetic and environmental influences
York: Lawrence Erlbaum. on the development of alcoholism: Resilience vs. risk.

m alt zm an 123
 In B. M. Lester, A. Masten, & B. McEwen (Eds.), Annals Hoffman, M. A., & Driscoll, J. M. (2000). Health promo-
of the New York Academy of Sciences: Vol. 1094. Resilience in tion and disease prevention: A concentric biopsychosocial
children (pp. 193–201). New York: New York Academy of model of health status. In S. D. Brown, & R. W. Lent
Sciences. (Eds.), Handbook of counseling psychology (3rd ed., 532–567).
Finniss, D. G., Kaptchuk, T. J., Miller, F., & Benedetti, F. New York: Wiley.
(2010). Biological, clinical, and ethical advances of placebo Howard, K. I., Krause, M. S., Saunders, S. M., & Kopta, S.M.
effects. The Lancet, 375, 686–695. doi:10.1016/S0140- (1997). Trials and tribulations in the meta-analysis of treat-
6736(09)61706-2. ment differences: Comment on Wampold et al. (1997).
Fisher, P. A., Gunnar, M. R., Dozier, M., Bruce, J., & Pears, Psychological Bulletin, 122, 221–225.
K. C. (2006). Effects of therapeutic interventions for foster Hróbjartsson, A., & Gøtzsche, P. (2001). Is the placebo
children on behavioral problems, caregiver attachment, and powerless? An analysis of clinical trials comparing placebo
stress regulatory neural systems. In B. M. Lester, A. Masten, with no treatment. New England Journal of Medicine, 344,
& B. McEwen (Eds.), Annals of the New York Academy 1594–1602.
of Sciences: Vol. 1094. Resilience in children (pp. 215–225). Hunsley, J., & Lee, C. M. (2007). Research-informed bench-
New York: New York Academy of Sciences. marks for psychological treatments: Efficacy studies, effec-
Gelso, C. J., & Samstag, L. W. (2008). A tripartite model of tiveness studies, and beyond. Professional Psychology: Research
the therapeutic relationship. In S. D. Brown, & and Practice, 38, 21–33.
R. W. Lent (Eds.), Handbook of counseling psychology (4th ed., Imel, Z. E., & Wampold, B. E. (2008). The importance of
pp. 267–283). New York: Wiley and Sons. treatment and the science of common factors in psychother-
Goldapple, K., Segal, Z., Garson, C., Lau, M., Bieling, P., apy. In S. D. Brown, & R. W. Lent (Eds.), Handbook of
Kennedy, S., & Mayberg, H. (2004). Modulation of cortical- Counseling Psychology (4th ed., pp. 249–266). New York:
limbic pathways in major depression. Archives of General John Wiley & Sons.
Psychiatry, 61, 34–41. Kazdin, A. E. (2005). Treatment outcomes, common factors,
Goldfried, M. R., & Eubanks-Carter, C. (2004). On the need and continued neglect of mechanisms of change. Clinical
for a new psychotherapy research paradigm: Comment Psychology: Science and Practice, 12, 184–188.
on Westen, Novotny, and Thompson-Brenner (2004). Kazdin, A. E. (2007). Mediators and mechanisms of change in
Psychological Bulletin, 130, 669–673. psychotherapy research. Annual Review of Clinical Psychology,
Gray, J. A. (1964). Strength of the nervous system as a dimen- 3, 1–27.
sion of personality in man. In J. A. Gray (Ed.), Pavlov’s Kazdin, A. E. (2008). Evidence-based treatment and practice:
Typology (pp. 157–287). Oxford, England: Pergamon New opportunities to bridge clinical research and practice,
Press Ltd. enhance the knowledge base, and improve patient care.
Greenberg, M. T. (2006). Promoting resilience in children American Psychologist, 63, 146–159.
and youth: Preventive interventions and their interface with Kendall, P. C. (1998). Empirically supported psychological ther-
neuroscience. In B. M. Lester, A. Masten, & B. McEwen apies. Journal of Consulting and Clinical Psychology, 66, 3–6.
(Eds.), Annals of the New York Academy of Sciences: Vol. 1094. Kendall, P. C., & Beidas, R. S. (2007). Smoothing the trail for
Resilience in children (pp. 139–150). New York: New York dissemination of evidence-based practices for youth: Flex-
Academy of Sciences. ibility within fidelity. Professional Psychology: Research and
Gunnar, M. R. (1994). Psychoendocrine studies of tempera- Practice, 38, 13–20.
ment and stress in early childhood: Expanding current Kennedy, S. H., Konarski, J. Z., Segal, A. V., Lau, M. A., Bieling,
models. In J. E. Bates, & T. D. Wachs (Eds.), Temperament: P. J., McIntyre, R. S., & Mayberg, H. S. (2007). Differences
Individual differences at the interface of biology and behavior in brain glucose metabolism between responders to CBT and
(pp. 175–198). Washington, DC: American Psychological venlafaxine in a 16-week randomized controlled trial.
Association. American Journal of Psychiatry, 164, 778–788.
Henry, W. P., Schacht, T. E., & Strupp, H. H. (1990). Patient Keyes, C. L. M. (2007). Promoting and protecting mental health
and therapist introject, interpersonal process, and differen- as flourishing: A complementary strategy for improving
tial treatment outcome. Journal of Consulting and Clinical national mental health. American Psychologist, 62, 95–108.
Psychology, 58, 768–774. doi: 10.1037/0022-006X.58.6.768. Kiecolt-Glaser, J. K., & Glaser, R. (2002). Depression and
Hill, C. E., & Corbett, M. M. (1993). A perspective on the immune function: Central pathways to morbidity and mor-
history of process and outcome research in counseling psy- tality. Journal of Psychosomatic Research, 53, 873–876.
chology. Journal of Counseling Psychology, 40, 3–24. Kiecolt-Glaser, J. K., Bane, C., Glaser, R., & Malarkey, W. B.
Hill, C. E., & Knox, S. (2008). Facilitating insight in counseling (2003). Love, marriage, and divorce: Newlyweds’ stress hor-
and psychotherapy. In S. D. Brown, & R. W. Lent (Eds.), mones foreshadow relationship changes. Journal of Consulting
Handbook of counseling psychology (4th ed., pp. 284–302). and Clinical Psychology, 71, 176–188.
New York: Wiley and Sons. Kiecolt-Glaser, J. K., Page, G. G., Marucha, P. T., MacCallum,
Hill, C. E., & Williams, E. N. (2000). The process of individual R. C., & Glaser, R. (1998). Psychological influences on sur-
therapy. In S. D. Brown, & R. W. Lent (Eds.), Handbook of gical recovery: Perspectives from psychoneuroimmunology.
counseling psychology (3rd ed., pp. 670–710). New York: American Psychologist, 53, 1209–1218.
Wiley and Sons. Lam, A. G., & Sue, S. (2001). Client diversity. Psychotherapy, 38,
Hilliard, R. B., Henry, W. P., & Strupp, H. H. (2000). An inter- 479–486.
personal model of psychotherapy: Linking patient and Lambert, M. J. (2005). Early response in psychotherapy: Further
therapist developmental history, therapeutic process, and evidence for the importance of common factors rather
types of outcome. Journal of Consulting and Clinical than “placebo effects.” Journal of Clinical Psychology, 61,
Psychology, 68, 125–133. 855–869.

124 process an d o u tco mes

Lambert, M. J., Hansen, N. B., & Finch, A. E. (2001). Patient- Meehl, P. E. (1954). Clinical vs. statistical prediction: A theoretical
focused research: Using patient outcome data to enhance analysis and a review of the evidence. Minneapolis: University
treatment effects. Journal of Consulting and Clinical Psychology, of Minnesota Press.
69, 159–172. Meehl, P. E. (1978). Theoretical risks and tabular asterisks:
Laurenceau, J.-P., Hayes, A. M., & Feldman, G. C. (2007). Some Sir Karl, Sir Ronald, and the slow progress of soft psychol-
methodological and statistical issues in the study of change ogy. Journal of Consulting and Clinical Psychology, 46,
processes in psychotherapy. Clinical Psychology Review, 27, 806–834.
682–695. Melchert, T. P. (2007). Strengthening the scientific foundations
Lewis, M. D., Granic, I., & Lamm, C. (2006). Behavioral differ- of professional psychology: Time for the next steps.
ences in aggressive children linked with neural mecha- Professional Psychology: Research and Practice, 38, 34–43.
nisms of emotion regulation. In B. M. Lester, A. Masten, & Meyer, B., & Pilkonis, P. A. (2001). Attachment style.
B. McEwen (Eds.), Annals of the New York Academy of Psychotherapy, 38, 466–472.
Sciences: Vol. 1094. Resilience in children (pp. 164–177). Meyerwitz, B. E., Bull, A. A., & Perez, M. A. (2000). Cancers
New York: New York Academy of Sciences. common in women. In R. M. Eisler, & M. Hersen
Lopez, F. G., & Brennan, K. A. (2000). Dynamic processes (Eds.), Handbook of gender, culture, and health (pp. 197–225).
underlying adult attachment organization: Toward an attach- New York: Lawrence Erlbaum.
ment theoretical perspective on the healthy and effective self. Minami, T., Wampold, B. E., Serlin, R. C., Hamilton, E. G., &
Journal of Counseling Psychology, 47, 283–300. Kircher, J. C. (2008). Benchmarking the effectiveness of
Lopez, S. J., & Edwards, L. M. (2008). The interface of coun- psychotherapy treatment for adult depression in a managed
seling psychology and positive psychology: Assessing and care environment: A preliminary study. Journal of Consulting
promoting strengths. In S. D. Brown, & R. W. Lent (Eds.), and Clinical Psychology, 76, 116–124.
Handbook of counseling psychology (4th ed., pp. 86–99). Neuner, F., Schauer, M., Klaschik, C., Karunakara, U., & Elbert, T.
New York: John Wiley & Sons. (2004). A comparison of narrative exposure therapy,
Lopez, S. J., & Kerr, B. A. (2006). An open source approach to supportive counseling, and psychoeducation for treating
creating positive psychological practice: A comment on posttraumatic stress disorder in an African refugee settle-
Wong’s strengths-centered therapy. Psychotherapy: Theory, ment. Journal of Consulting and Clinical Psychology, 72(4),
Research, Practice, Training, 43, 147–150. 579–587.
Lutz, W., Lambert, M. J., Harmon, S. C., Tschitsaz, A., Schürch, Nie, Z., Schweitzer, P., Roberts, A. J., Madamba, S. G.,
E., & Stulz, N. (2006). The probability of treatment success, Moore, S. D., Siggins, G. R. (2004). Ethanol augments
failure and duration–What can be learned from empirical GABAergic transmission in the central amygdala via CRF1
data to support decision making in clinical practice? Clinical receptors. Science, 303, 1512–1514.
Psychology and Psychotherapy, 13, 223–232. Nomura, Y., Chemtob, C. M., Fifer, W. P., Newcorn, J. H., &
Main, M., Hesse, E., & Goldwin, R. (2008). Studying differ- Brooks-Gunn, J. (2006). Additive interaction of child
ences in language usage in recounting attachment history: abuse and perinatal risk as signs of resiliency in adulthood.
An introduction to the AAI. In H. Steele, & M. Steele (Eds.), In B. M. Lester, A. Masten, & B. McEwen (Eds.), Annals
Clinical applications of the Adult Attachment Interview of the New York Academy of Sciences: Vol. 1094. Resilience in
(pp. 31–68). New York: Guilford Press. children (pp. 330–334). New York: New York Academy of
Maltzman, S. (2001). The specific ingredients are in the match: Sciences.
Comments on Ahn and Wampold (2001). Journal of O’Hanlan, K. (2000). Health concerns of lesbians. In R. M.
Counseling Psychology, 48, 258–261. Eisler, & M. Hersen (Eds.), Handbook of gender, culture, and
Maltzman, S. (Spring 2005). Addressing the impact of environ- health (pp. 377–404). New York: Lawrence Erlbaum.
mental toxins. Counseling For Health. Retrieved from http:// Olbrisch, M. E. (1977). Psychotherapeutic interventions in
www.apa.org/divisions/div17/sections/health/News.html. physical health: Effectiveness and economic efficiency.
Martin, S. D., Martin, E., Rai, S. S., Richardson, M. A., & American Psychologist, 32, 761–777.
Royall, R. (2001). Brain blood flow changes in depressed Papakostas, Y. G., & Daras, M. D. (2001). Placebos, placebo
patients treated with interpersonal psychotherapy or effect, and the response to the healing situation: The evolu-
venlafaxine hydrochloride. Archives of General Psychiatry, 58, tion of a concept. Epilepsia, 42, 1614–1625.
641–648. Pendery, M. L., Maltzman, I. M., & West, L. J. (1982).
Mayes, L. C. (2006). Arousal regulation, emotional flexibility, Controlled drinking by alcoholics? New findings and
medial amygdale function, and the impact of early a reevaluation of a major affirmative study. Science, 217,
experience: Comments on the paper of Lewis et al. In B. M. 169–175.
Lester, A. Masten, & B. McEwen (Eds.), Annals of the Persons, J. B. (2007). Psychotherapists collect data during
New York Academy of Sciences: Vol. 1094. Resilience in children routine clinical work that can contribute to knowledge
(pp. 178–192). New York: New York Academy of Sciences. about mechanisms of change in psychotherapy. Clinical
McCrae, R. R., & Costa, P. T., Jr. (1997). Personality trait Psychology: Science and Practice, 14, 244–246.
structure as a human universal. American Psychologist, 52, Peterson, D. B., & Elliott, T. R. (2008). Advances in concep-
509–516. tualizing and studying disability. In S. D. Brown, &
McCrae, R. R., Costa, P. T., Jr., Martin, T. A., Oryol, V. E., R. W. Lent (Eds.), Handbook of counseling psychology (4th ed.,
Rukavishnikov, A. A., Senin, I. G., et al. (2004). Consensual pp. 212–230). New York: John Wiley & Sons.
validation of personality traits across cultures. Journal of Project Match Research Group. (1997). Matching alcohol-
Research in Personality, 38, 179–201. ism treatments to client heterogeneity: Project MATCH
McSweeny, A. J. (1977). Including psychotherapy in national postreatment drinking outcomes. Journal of Studies on
health insurance. American Psychologist, 32(9), 722–730. Alcohol, 58, 7–29.

m alt zm an 125
Robbins, S. B., & Kliewer, W. L. (2000). Advances in theory Strupp, H. H., & Hadley, S. W. (1977). A tripartite model
and research on subjective well- being. In S. D. Brown, & of mental health and therapeutic outcomes: With special
R. W. Lent (Eds.), Handbook of counseling psychology (3rd ed., reference to negative effects in psychotherapy. American
pp. 310–345). New York: Wiley and Sons. Psychologist, 32, 187–196.
Rothbart, M. K., Derryberry, D., & Posner, M. I. (1994). A psy- Stulz, N., Lutz, W., Leach, C., Lucock, M., & Barkham, M.
chobiological approach to the development of tempera- (2007). Shapes of early change in psychotherapy under
ment. In J. E. Bates, & T. D. Wachs (Eds.), Temperament: routine outpatient conditions. Journal of Consulting and
Individual differences at the interface of biology and behavior Clinical Psychology, 75, 864–874.
(pp. 83–116). Washington, DC: American Psychological Suchman, A. L. (2005). The current state of the biopsychosocial
Association. approach. Families, Systems, & Health, 23, 450–452.
Ruphuy, R. S. (1977). Psychology and medicine. A new approach Task Force on Standards for Service Facilities, American
for community health development. American Psychologist, Psychological Association Council of Representatives.
32, 910–913. (1977). Standards for providers of psychological services.
Ruscio, A. M., & Holohan, D. R. (2006). Applying empirically American Psychologist, 32, 495–505.
supported treatments to complex cases: Ethical, empirical, Taylor, S., Thordarson, D. S., Maxfield, L., Fedoroff, I. C.,
and practical considerations. Clinical Psychology: Science and Lovell, K., & Ogrodniczuk, J. (2003). Comparative efficacy,
Practice, 13, 146–162. speed, and adverse effects of three PTSD treatments:
Rush, A. J., Rago, W. V., Crismon, M. L., Toprac, M. G., Exposure therapy, EMDR, and relaxation training. Journal
Shon, S. P., Suppes, T., et al. (1999). Medication treatment of Consulting and Clinical Psychology, 71(2), 330–338.
of the severely and persistently mentally ill: The Texas Teplov, B. M. (1964). Problems in the study of general types of
Medication Algorithm Project. Journal of Clinical Psychiatry, higher nervous activity in man and animals. In J. A. Gray
60, 284–291. (Ed.), Pavlov’s Typology (pp. 3–153). Oxford, England:
Rush, A. J., Crismon, M. L., Kashner, T. M., Toprac, M. G., Pergamon Press Ltd.
Carmody, T. J., Trivedi, M. H., et al. (2003). Texas Thase, M. E. (2001). Commentary: Neuroimaging profiles and
Medication Algorithm Project, Phase 3 (TMAP-3): Ratio- the differential therapies of depression. Archives of General
nale and study design. Journal of Clinical Psychiatry, 64, Psychiatry, 58, 651–653.
357–369. Thoresen, C. E., & Eagleston, J. R. (1985). Counseling for
Sameroff, A. J., & Rosenblum, K. L. (2006). Psychosocial health. The Counseling Psychologist, 13, 15–87.
constraints on the development of resilience. In B. M. Lester, Wampold, B. E. (2000). Outcomes of individual counseling and
A. Masten, & B. McEwen (Eds.), Annals of the New York psychotherapy: Empirical evidence addressing two funda-
Academy of Sciences: Vol. 1094. Resilience in children mental questions. In S. D. Brown, & R. W. Lent (Eds.),
(pp. 116–124). New York: New York Academy of Sciences. Handbook of counseling psychology (3rd ed., pp. 711–739).
Schmitt, D. P., Realo, A., Voracek, M., & Allik, J. (2008). Why New York: Wiley and Sons.
can’t a man be more like a woman? Sex differences in Big 5 Wampold, B. E. (2001). Contextualizing psychotherapy as a
personality traits across 55 cultures. Journal of Personality and healing practice: Culture, history, and methods. Applied &
Social Psychology, 94, 168–182. Preventive Psychology, 10, 69–86.
Seligman, M. E. P. (1995). The effectiveness of psychotherapy: Wampold, B. E., Ahn, H., & Coleman, H. L. K. (2001). Medical
The Consumer Reports study. American Psychologist, 50, model as metaphor: Old habits die hard. Journal of Counseling
965–974. Psychology, 48, 268–273.
Siev, J., & Chambless, D. L. (2007). Specificity of treatment Wampold, B. E., Lichtenberg, J. W., & Waehler, C. A. (2002).
effects: Cognitive therapy and relaxation for generalized Principles of empirically supported interventions in counsel-
anxiety and panic disorders. Journal of Consulting and Clinical ing psychology. The Counseling Psychologist, 30, 197–217.
Psychology, 75, 513–522. Wampold, B. E., Minami, T., Tierney, S. C., Baskin, T. W., &
Smith, M. L., & Glass, G. V. (1977). Meta-analysis of psy- Bhati, K. S. (2005). The placebo is powerful: Estimating
chotherapy outcome studies. American Psychologist, 32, placebo effects in medicine and psychotherapy from ran-
752–760. domized clinical trials. Journal of Clinical Psychology, 61,
Sobell, M. B., & Sobell, L. C. (1973a). Individualized behavior 835–854.
therapy for alcoholics. Behavior Therapy, 4, 49–72. Wampold, B. E., Mondin, G. W., Moody, M., & Ahn, H.
Sobell, M. B., & Sobell, L. C. (1973b). Alcoholics treated by (1997). The flat earth as a metaphor for the evidence for
individualized behavior therapy: One year treatment out- uniform efficacy of bona fide psychotherapies: Reply to
come. Behaviour Research and Therapy, 11, 599–618. Crits-Christoph (1997) and Howard et al. (1997).
Steele, H., & Steele, M. (2008). Ten clinical uses of the Adult Psychological Bulletin, 122, 226–230.
Attachment Interview. In H. Steele, & M. Steele (Eds.), Wampold, B. E., Mondin, G. W., Moody, M., Stich, F.,
Clinical applications of the Adult Attachment Interview Benson, K., Ahn, H. (1997). A meta- analysis of outcome
(pp. 3–30). New York: Guilford Press. studies comparing bona fide psychotherapies: Empirically,
Stein, H. F. (2005). It ain’t necessarily so: The many faces of “all must have prizes.” Psychological Bulletin, 122, 203–215.
the biopsychosocial model. Families, Systems, & Health, 23, Werner, E. E. (2005). Resilience research: Past, present, and
440–443. future. In R. DeV. Peters, B. Leadbeater, & R. J. McMahon
Strelau, J. (1994). The concepts of arousal and arousability as (Eds.), Resilience in children, families, and communities:
used in temperament studies. In J. E. Bates, & T. D. Wachs Linking context to practice and policy (pp. 3–11). New York:
(Eds.), Temperament: Individual differences at the interface of Kluwer Academic/Plenum Publishers.
biology and behavior (pp. 117–141). Washington, DC: Westen, D., & Morrison, K. (2001). A multidimensional meta-
American Psychological Association. analysis of treatments for depression, panic, and generalized

126 process an d o u tco mes

 anxiety disorder: An empirical examination of the status of Further Reading
empirically supported therapies. Journal of Consulting and Bates, J. E., & Wachs, T. D. (Eds.). (1994). Temperament:
Clinical Psychology, 69, 875–899. Individual differences at the interface of biology and behavior.
Westen, D., Novotny, C. M., & Thompson-Brenner, H. (2004). Washington, DC: American Psychological Association.
The empirical status of empirically supported psychothera- Lester, B. M., Masten, A., & McEwen, B. (Eds.). (2006). Annals
pies: Assumptions, findings, and reporting in controlled of the New York Academy of Sciences: Vol. 1094. Resilience in
clinical trials. Psychological Bulletin, 130, 631–663. children. New York: New York Academy of Sciences.
Weston, W. W. (2005). Patient-centered medicine: A guide Peters, R. DeV., Leadbeater, B., & McMahon, R. J. (Eds.).
to the biopsychosocial model. Families, Systems, & Health, (2005). Resilience in children, families, and communities:
23, 387–405. Linking context to practice and policy. New York: Kluwer
Whipple, J. L., Lambert, M. J., Vermeersch, D. A., Smart, D. W., Academic/Plenum Publishers.
Nielsen, S. L., & Hawkins, E. J. (2003). Improving the Steele, H., & Steele, M. (Eds.). (2008). Clinical applications of
effects of psychotherapy: The use of early identification of the Adult Attachment Interview. New York: Guilford Press.
treatment failure and problem-solving strategies in routine
practice. Journal of Counseling Psychology, 50, 59–68.
Whitson, J. A., & Galinsky, A. D. (2008). Lacking control
increases illusory pattern perception. Science, 322, 115–117.
Wilson, G. T., & Rachman, S. J. (1983). Meta-analysis and the
evaluation of psychotherapy outcome: Limitations and lia-
bilities. Journal of Consulting and Clinical Psychology, 51,
54–64.

m alt zm an 127
 CHAPTER

6 Worklife Across the Lifespan

Lisa M. Larson

Abstract
An extensive literature search across the spectrum of vocational psychology was conducted using
the time frame of 1991–2008 and resulted in 47 quantitative reviews (i.e., meta-analyses). First,
theories of vocational psychology are presented including John Holland’s (1997) and René Dawis
and Loyd Lofquist’s (1984; Dawis, 2005) theory of work adjustment person–environment fit (P–E fit)
models; Lent, Brown, and Hackett (1994) social cognitive career theory; the social learning theory
of John Krumboltz (1990); Donald Super’s career construction theory (Super, 1992); and
L. S. Gottfredson’s (1999) circumscription theory. Next, vocational outcomes of young people
(the development of interests, educational and occupational aspirations, educational achievement, and
career choice) and wage-earning adults (job search, job entry, job performance, job satisfaction, career
success, and mental health outcomes) are reviewed. The last two major sections concern diverse
groups (women and racially and ethnically diverse groups) and individual differences (cognitive ability,
personality, and interests) as predictors of vocational outcomes.
Keywords: educational and occupational aspirations, career choice, job search, job satisfaction,
job performance, cognitive ability, personality, interests, women, diverse groups

Vocational psychology. . . . is the behavioral study of encompass both educational and work environments.
the worklife, the study of people’s behavior in The person predictors of vocational outcomes range
choosing, preparing for, entering, progressing in, and from status variables, such as sex and ethnicity, to indi-
finally retiring from one’s life work. Each of these vidual differences, such as interests, to more domain-
verbs represents a variable that ranges from negative specific person variables such as self-efficacy (SE). The
to positive; for example “choosing” can extend from a environmental predictors range from distal variables,
default or accidental to a well informed, fully rational such as socioeconomic status (SES) or tracking in
choice, and “progressing” includes regressing. And school, to proximal variables. Within industrial/
“life work” can be more than one kind of activity. organizational (I/O) psychology, proximal variables
—Dawis, 1996, p. 229 include taxonomies of the work environment (i.e.,
work design characteristics [e.g., job complexity],
Dawis’ definition of vocational psychology addresses social characteristics [e.g., supervisor support], and
the broad outcomes across the lifespan that includes work context characteristics [e.g., work conditions]).
both positive and negative outcomes, and paid and Within counseling psychology, the proximal vari-
unpaid work, although paid work is emphasized. ables are support (e.g., social support or parent sup-
This definition emphasizes vocational psychology’s port) or barriers (e.g., discrimination or harassment).
concern with processes as well as with outcomes. Mediators that explain part or all of the relation
As the title of the chapter implies, these outcomes between the predictor and the vocational outcome

128
(e.g., SE, job stress) have been examined. Moderators department and to hire a well-known applied psy-
that alter the relation of the predictor and the voca- chologist, Walter Dill Scott, who developed the first
tional outcomes were also examined (e.g., job com- occupational aptitude test.
plexity moderated the influence of SE on A second root, the vocational guidance move-
performance type of study [Judge, Jackson, Shaw, ment, was fueled by the transformation of an agri-
Scott, & Rich, 2007]). cultural society into a manufacturing society. As
Vocational psychology theories attempt to people moved to the cities, there was a societal need
explain a wide range of vocational outcomes across to help educate and train young men and place
children, adolescents, and adults. Donald Super’s them into employment (e.g., Young Men’s Christian
career construction theory (Super, 1992) concerns Association employment bureaus and classes). Frank
career development across the lifespan, whereas Parsons (1909) emerged from the vocational guid-
L. S. Gottfredson’s (1999) circumscription theory ance movement and was the first to articulate the
emphasizes the impact of sex roles and occupa- P–E fit model that continues to dominate the field
tional prestige on the ways in which children (Walsh & Savickas, 2005).
and adolescents ultimately narrow their career A third root in vocational psychology con-
choices. Lent, Brown, and Hackett (1994) adapted cerns the engagement of the pioneers of vocational
Bandura’s (1986) social cognitive theory to explain psychology in both world war efforts. During
academic performance, development of interests, World War I, offshoots of the field flourished,
and career choice. The social learning theory of namely aptitude testing (Army Alpha and Army
John Krumboltz (1990) focuses on how the person’s Beta group intelligence tests), the development of
learning experiences, shaped by the environment, performance ratings of officers, and the develop-
impact her or his career choices and guide future ment of qualification criteria for hundreds of mili-
career counseling. John Holland’s (1997) person– tary jobs (Savickas & Baker, 2005). After World
environment fit (P–E fit) model presents a hex- War I, vocational testing exploded, leading to the
agonal structure of interests and a corresponding development of the Strong’s Vocational Interest
hexagonal structure of work environments that Blank (Strong, 1927) and the predominance of
predict choice, satisfaction, and tenure. René Dawis the P–E fit orientation in the field. During World
and Loyd Lofquist’s (1984; Dawis, 2005) theory War II, vocational psychologists helped classify
of work adjustment (TWA) is the predominant 9 million men through the Army General
P–E fit theory that examines the satisfaction of Classification Test (Savickas & Baker, 2005). More-
the employee and the satisfaction of the employer over, vocational psychologists across 30 universities
(i.e., satisfactoriness), as well as work outcomes like generated research to study military problems. Air
tenure and adjustment. force psychologists were involved in selecting, clas-
sifying, and training Air Force personnel. (Donald
History Super was one of those psychologists.)
Vocational psychology has deep and enduring roots. A fourth root in vocational psychology concerned
One root is the individual difference tradition the schism in the 1930s between applied psychol-
(Thorndike, 1911), in which people vary systemati- ogists focused on selection and adjustment, and the
cally on a range of traits; by knowing that infor- applied psychologists focused on vocational guid-
mation, educators could help teach each individual ance. The former group persuaded employers that
(Walsh & Savickas, 2005). The individual differ- well-adjusted workers were more productive, thus
ence tradition also spawned the measurement of shifting the lens to industry rather than to the indi-
intelligence, followed by the measurement of inter- vidual (Savickas & Baker, 2005). Vocational guid-
ests and aptitudes at premier academic institutions ance psychologists continued to focus on the
like Teachers College, Columbia University. Here, individual. Besides a schism as to who the client was
James Mckeen Cattell, E. L. Thorndike, and Robert (industry vs. the individual), there was also a schism
S. Woodsworth mentored Harry Hollingsworth, between applied psychologists who remained in
who published the first vocational psychology text- academia and researched vocational choices of high
book in 1916. Hollingsworth was also important school students and college students versus applied
as a mentor as well, having mentored E. K. Strong. psychologists who worked in industry and clinics
Another critical academic institution in our history and concerned themselves with the application
was the Carnegie Institute of Technology; it became of psychology to business and industry. The selec-
the first institution to offer an applied psychology tion and adjustment psychologists, as a group, were

l ar son 129
ultimately excluded from joining the American I/O psychology). Only correlations equal to or
Psychological Association (APA) due to being larger than .20 will be reported.
viewed as unscientific; this led them to form their
own professional organization (the American Asso- Theories
ciation of Applied Psychology) (Savickas & Baker, Overview
2005). The vocational guidance psychologists, as Theories continue to be prominent in vocational
part of the APA, remained at universities. This psychology and to evolve. The P–E fit theories those
schism persists, with work adjustment and job selec- in which attributes of the person and attributes of
tion literature quite distinct from the vocational the environment are complementary. The key char-
choice literature. The final root for vocational psy- acteristics of the person and the environment vary
chology concerns the explosion of career theory in across these theories, and the definition of the envi-
the 1950s, during which most of the predominant ronment varies. In these theories, the influence of
theories were developed and first presented. the person is bidirectional. These theories assume
that positive vocational outcomes occur as a result
Organization of the Chapter of the match between the person and the environ-
The first section of the chapter is organized by the ment. René Dawis and Lloyd Lofquist’s (1984)
major theories in the field. Those that have received theory and John Holland’s (1997) theory are the
attention in the form of reviews or meta-analyses dominant P–E fit theories. The other dominant
will receive the most attention. The next section is theory is Lent, Brown, and Hackett’s social cogni-
devoted to vocational outcomes (e.g., vocational tive career theory (SCCT; Lent et al., 1994). This
choice) and vocational processes (vocational explo- theory is rooted in social learning theory (Bandura,
ration, career decision making) that precede entry 1977) and social cognitive theory (Bandura, 1982,
into the workforce and involve young people in 1986). The SCCT also involves interaction between
educational settings (i.e., children, adolescents, and the person and environment; in addition, the per-
college students). The third section concerns son’s actions are viewed as more than the outcome
employed adults and is organized by vocational out- of the P–E interaction. Thus, Bandura’s social cog-
comes (e.g., job satisfaction). The fourth section nitive theory is embedded in triadic causality
of the chapter will identify integrative vocational (person, environment, and actions) rather than
psychology reviews focused exclusively on the mul- bidirectional causality in which one’s actions are
ticultural variables of sex, race and ethnicity, and viewed as a function of P-E fit. Self-efficacy is the
culture. The fifth section of the chapter will be determining mechanism in career-related activities.
directed toward individual differences, since this John Krumboltz’s theory, reflecting more emphasis
area has been one of the most prolific arenas of on social learning theory will also be discussed. Two
investigation. In the final section, I will identify developmental theories, Super’s career construction
fruitful research directions for the next generation theory and L. S. Gottfredson’s circumscription and
of vocational psychologists. compromise theory, will also be described, with
major terms identified. Finally, sociological theories
Search Criteria will be briefly reviewed.
An extensive literature search was conducted The largest number of reviews was located for
using the time frame of 1991 to 2008. Three social cognitive career theory and reviews of SE in
approaches were used. First, all relevant handbooks particular. Holland’s hexagonal structure and the
were located. Second, the search involved pairings congruence construct also yielded large-scale stud-
of vocational terms with one of two terms “meta- ies. Dawis’ and Lofquist’s TWA was indirectly
analysis” or “review.” Third, relevant journals were related to much of the research that will be pre-
searched to identify any vocational reviews or meta- sented later in the chapter concerning adult out-
analyses that might have been missed in the litera- comes, including job satisfaction, job performance,
ture search. The literature search yielded more and career success. Some of Gottfredson’s con-
meta-analyses than conceptual reviews. Meta- structs, particularly occupational prestige and sex-
analysis is a statistical technique that empirically role socialization, will be discussed under the section
condenses the effect sizes of the relation of two pertaining to children. Career construction theory
variables into a correlation ranging from 0 to 1. does not lend itself as well to empirical reviews and,
The meta-analyses that were reviewed were across not surprisingly, none was found. However, several
multiple disciplines (e.g., counseling psychology, chapters were located elucidating Super’s theory.

130 worklife ac ro s s th e l if es pan

Theory of Work Adjustment the employee will be satisfied. Likewise, the employer
The TWA (Dawis & Lofquist, 1984), which origi- is satisfied with the worker (satisfactoriness) to the
nated in the 1950s, is a P–E fit theory that focuses extent that the employee performs the necessary job
on adults in the work environment. The theory requirements. The TWA predicts outcomes derived
explains job satisfaction, job performance, and job from both satisfaction and satisfactoriness. The
tenure. The theory is derived so that the employee is degree to which an employee is satisfied will deter-
at the center of the theory, with the focus placed mine whether the employee stays (job tenure) or
on her or his satisfaction and adjustment on the job. quits the job. The degree to which an employer
The employer is also at the center of the theory, with is satisfied with the employee (satisfactoriness) will
the employer’s satisfaction with the employee’s determine whether the employee is promoted, trans-
performance labeled as satisfactoriness. The theory ferred, retained, or fired. Other outcomes that may
is anchored in the assumption that the employee’s concern TWA scholars include productivity, profit,
satisfaction and satisfactoriness intertwine to pro- morale, mental health, turnover or retention rates,
duce beneficial work outcomes for both (Dawis, and accident or safety records (Dawis, 2002, 2005).
2005). The broader theory derived from TWA Occupational choice is also an outcome, although
extends beyond work to encompass other environ- rarely discussed (Dawis, 2002, 2005). The person
ments and is labeled the person–environment– examines the costs and benefits for a range of occu-
correspondence theory (PEC; Dawis, 2005). The PEC pations by examining his or her values attached to
theory is based on a harmonious relationship (cor- certain occupations and the skills required for those
respondence) between the person and the environ- occupations; the person chooses the best fit among
ment, and has been used as a unifying theory multiple options.
in the field (Savickas & Lent, 1994). The focus of The TWA identifies temporal process dimensions
this chapter will be on TWA, although the overlap (personality style and adjustment style) that are dis-
with PEC is extensive. tinct from the more structural person and environ-
The important attributes of the person are his or ment attributes. The first four personality style
her needs and abilities. Needs are defined as work dimensions describe how people interact with the
values and include achievement, comfort, status, work environment over time. These personality styles
altruism, safety, and autonomy (Dawis, 2002, are celerity or speed with which an individual initi-
2005). The person’s abilities are general dimensions ates interaction with the environment (quickness),
that underlie groups of acquired skills (i.e., behavior pace or activity level of one’s interaction with the
sequences emitted in response to a task) (Dawis, environment (intensity), the pace of interaction with
2005). The TWA theorist measures skills as to the the environment (e.g., steady, cyclical, or erratic; pat-
repeatability of the behavior sequence, energy tern), and the sustainability of the interaction with
expenditure, speed of performance, and difficulty the environment (endurance).
of the task. The attributes of the environment The remaining temporal process dimensions
correspond with the person’s needs and skills. The concern four adjustment styles that describe diff-
environment’s capacity to meet a person’s needs is erent ways people adjust to various degrees of dis-
called a reinforcer (Dawis, 2002). Reinforcers are the satisfaction in a job (discorrespondence). Initially,
aspects of the task that fulfill the person’s needs people vary as to their flexibility, defined as the abil-
or meets her or his important work values (e.g., a ity to tolerate a mismatch between needs and
person values achievement, and the task offers rewards. After time, the person becomes dissatisfied
achievement). The environment’s skill requirements and tries to change either self (reactive adjustment)
are those skills necessary for the satisfactory execu- or job (active adjustment). Finally, perseverance is
tion of the job duties. used to describe the duration of the adjustment
The correspondence between the person and behavior; that is, how long the person is in a state
environment predicts job satisfaction and job tenure. of discorrespondence.
The theory can be used to predict the person’s satis- In general, support is strong for TWA’s first three
faction with the job (satisfaction) or can be used to propositions concerning the role of satisfaction and
predict the employer’s satisfaction with the employee satisfactoriness (i.e., subjective job performance),
(satisfactoriness). A person is satisfied to the extent in work adjustment (e.g., intentions to quit [nega-
that her or his needs and work values are met on the tive]), and the prediction of satisfaction and satis-
job. For example, if the employee values autonomy, factoriness (Dawis, 2002). First, work adjustment
and the job can provide sufficient autonomy, then at any time is indicated by concurrent levels of the

l ar son 131
person’s satisfaction and the person’s satisfactoriness. data/numbers) forming a well-known acronym,
Second, the person’s satisfaction is predicted from RIASEC (Holland, 1997). The types are measured
how well reinforcers in the work environment meet with a myriad of well-known assessment tools, such
the person’s needs (provided that person’s abilities as the 2005 Strong Interest Inventory (SII; Donnay,
match the job’s requirements). Third, satisfactori- Morris, Schaubhut, & Thompson, 2005) (see
ness is predicted from how well the person’s abilities Swanson, 2011, Chapter 8, this volume). The theory
match what the job requires (provided that the rein- asserts that people can be described according to the
forcers in the job match the person’s needs). extent to which they identify with each of those six
There is also support for the tenure propositions, types. This results in a Holland three-letter code, in
particularly the relation of satisfaction to tenure which the first letter of each type is used (e.g., RIC
(Dawis, 2005). These concern propositions six would represent a person whose highest score was
through eight. One proposition states that the prob- the Realistic type followed by the next highest score,
ability that the person will quit is inversely related the Investigative type, followed by the third highest
to the person’s satisfaction. Second, the probability score, the Conventional type).
that the employer will fire the person is inversely The environment can also be described by these
related to the person’s satisfactoriness. Third, tenure same six types, arranged in the same hexagonal con-
is predicted from both the person’s satisfaction and figuration. The environment’s six types are derived
satisfactoriness. in two ways, based either on the preponderance
The rest of the theory’s propositions have either of people in that work setting from a particular
received mixed reviews or have been minimally type (e.g., most accountants’ first letter in their
examined. For example, the little-known personal- Holland code is Conventional) or based on the most
ity style and adjustment style variables have been common activities performed in that work envi-
under-researched (Dawis, 2005; Hesketh, 2001; ronment (e.g., predominant activities in an acco-
Hesketh & Griffin, 2005). unting firm are data management and processing).
The environment is usually considered the work
Person–Environment Fit environment but could be the intended environ-
John Holland’s (1997) theory continues to domi- ment or the academic environment (e.g., academic
nate the landscape of vocational psychology. This department). Holland code types for the environ-
P–E fit theory originated by Holland in the 1950s ment have been linked to the Occupational Infor-
(Holland, 1959) has shaped how many psycholo- mation Network (O∗NET). The O∗NET system
gists think about vocational psychology. The theory serves as the nation’s primary source of occupational
elaborates on Frank Parsons’ original idea of match- information, providing comprehensive information
ing people’s skills to the job. Holland’s (1997) theory on key attributes and characteristics of workers and
states that people search for environments that let occupations; this database can be easily accessed
them exercise their skills and abilities, express their online.
attitudes and values, and take on agreeable problems Four theoretical assumptions in Holland’s theory
and roles. Finally, behavior is determined by an are based on four diagnostic indicators: congruence,
interaction between the person and the environment consistency, differentiation, and vocational identity.
(Holland, 1997). The assumption is that, when there The first fundamental indicator in Holland’s (1997)
is a good match between the person and the envi- theory, labeled congruence, describes the degree to
ronment, people are more likely to make better which the person’s Holland code and environment’s
vocational choices and be better adjusted. code are similar. A highly congruent person would
Holland integrated theory and practice and be someone whose three-letter Holland code
identified six vocational personality/interests types matches the Holland code for the environment. The
that can adequately capture most people. Arranged congruence index is used to determine the degree
around a hexagon, these six types capture each type’s of P–E fit (see Swanson, 2011, Chapter 8, this
characteristics, self-descriptions, and occupations, volume).
and are labeled, in order, realistic (mechanical, prac- The second fundamental indicator in Holland’s
tical, working with ones hands, being outdoors), (1997) theory, labeled consistency, describes the
investigative (scientific, analytic, problem-solving), relation of the six personality/interest types to each
artistic (creative, musical, originator), social (serving/ other. The arrangement of the six types around
helping others), enterprising (persuading/managing a hexagon, the RIASEC, is important to the theory
others), and conventional (organizing/working with in terms of determining consistency. A highly

132 worklife ac ro s s th e l if es pan

consistent three-letter Holland code would be one types and between artistic and social types, and
in which three types are close to one another on less space between social and enterprising types.
the hexagon. The first letters of each of the six types Cross-culturally, support for the circumplex model
are described as the RIASEC; thus, a person whose is mixed. According to Long and Tracey’s (2006)
code type is ASE would be a very consistent code analysis on 29 independent RIASEC correlation
type because the top three scores are representing matrices across Chinese participants, Holland’s
three types that are right next to each other on the circumplex model did not fit the data well, although
hexagon. the RIASEC ordering was present. The ordering was
The third fundamental indicator in Holland’s consistent across instrument, age (middle school,
(1997) theory, labeled differentiation, describes the college, adult), sex, and region (mainland China,
distinctness of the personality/interest type (Spokane Taiwan, Hong Kong). More space than antici-
& Cruza-Guet, 2005). Differentiation is operation- pated by the theory existed between realistic and
alized as the person’s highest minus the lowest score conventional and between artistic and investiga-
among the six types, or among the three scores com- tive. Gati’s (1991) model, Rounds and Tracey’s
prising the three-letter code (Spokane & Cruza- (1996), and Liu and Rounds’ (2003) modified
Guet, 2005). The most differentiated profile would octant rating (circumplex with eight points with
be one in which the person could be described pre- an unidentified type between realistic and conven-
dominantly as one type on the hexagon and the tional and between investigative and artistic) fit the
least differentiated profile would be a flat profile Chinese data better than did the six evenly spaced
(i.e., the person’s scores across the RIASEC would points on the hexagon. Rounds and Tracey (1996)
be within a range of one or two points). examined 96 RIASEC samples from U.S. racial
The final fundamental indicator, labeled voca- and ethnic minorities (n = 16), U.S. white European
tional identity, refers to the degree to which a person samples (n = 4), and samples from 19 countries
has a clear “picture of one’s goals, interests, and tal- including Australia, Brazil, Canada, Columbia,
ents” (Holland, 1997, p. 5). A person with a high France, Guyana, Iceland, Indonesia, Israel, Japan,
degree of identity would have a profile that is con- Malaysia, Mexico, New Zealand, Pakistan, Papua
sistent, differentiated, and congruent. This person New Guinea, Paraguay, Portugal, and Taiwan. They
will likely do competent work, be satisfied and per- compared the structural equivalence of RIASEC
sonally effective, and engage in appropriate social models to U.S. matrices generated from 77 RIASEC
and educational behavior (Holland, 1997, p. 40). matrices reported by Tracey and Rounds (1993).
The theory (Holland, 1997) also allows for the work Rounds and Tracey (1996) found that Holland’s
environment to be described in terms of the same circular order model was not supported, but Gati’s
parallel constructs (work environment consistency, three-group partition (realistic/investigative, artistic/
differentiation, and identity) (Spokane & Cruza- social, and enterprising/conventional) and the
Guet, 2005). authors’ alternative three-class partition (realistic/
Many of Holland’s (1997) propositions have investigative, artistic, and social/enterprising/con-
been supported. First, six types can describe a per- ventional) were supported. The U.S. racial and
son’s work personalities or interests. Second, they ethnic minority samples did not yield a good fit
are arranged in a circumplex (Day & Rounds, across all three models.
1998), and this circumplex structure holds for U.S. Support for Holland’s assumption that con-
racial and ethnic minorities (Day & Rounds, 1998). gruence leads to better adjustment, satisfaction, and
Day and Rounds (1998) found structural equiva- performance seems mixed. Congruence, when
lence across samples of African American, Mexican assessed using an index, did not significantly relate
American, Asian American, Native American, and to job satisfaction in the most recent meta-analysis
Caucasian American groups ( N = 49,450) students on the topic (Tsabari, Tziner, & Meier, 2005;
using the UNIACT. An analysis by Darcy and Tracey N = 6557, k = 53, ρ = .17, which includes 0 in the
(2007) from the American College Testing database 95% confidence interval [CI]). There does seem to
across time (grades 8, 10, and 12, N = 69,987) shows be evidence that people who change jobs move in
that the RIASEC order is consistent with the data, a congruent direction (Spokane & Cruza-Guet,
and that it is consistent for both boys and girls and 2005). The ability to make congruent choices may
across the three age periods. However, they did not be mediated by adjustment variables like anxiety or
find equal spacing across the RIASEC types; there depression, or by the importance a person places on
was more space between realistic and conventional identification with a group (Spokane & Cruza-Guet,

l ar son 133
2005). Finally, people seem to have difficulty iden- beliefs about probable response outcomes (Lent
tifying congruent occupational options, seeking et al., 1994) and were classified by Bandura as phy-
congruent accurate information, evaluating options sical (e.g., monetary), social (e.g., approval), and
that are congruent, and engaging in effective entry self-evaluative (e.g., self-satisfaction). Goals were
behaviors (Spokane & Cruza-Guet, 2005). defined as the determination to engage in a particu-
Some researchers use a different way to measure lar activity or to affect a particular future outcome
congruence through continuous scores on the SII (Bandura, 1986). For SCCT, expressed choices,
across Holland’s hexagon for the P measure and career plans, decisions, occupational aspirations are
educational major or occupation as the E measure. all forms of goals. In SCCT, distinction is made
Researchers have shown interests across the RIASEC between a choice goal (an intention to act) and
to be predictive of choice of major that is parallel or a choice action (having made a selection or choice).
consistent with the interest profile (Gasser, Larson, In this model, SE is the mediator between thought
& Borgen, 2007; Harmon, Hansen, Borgen, & and action, between knowing what to do and
Hammer, 1994) and choice of occupation (e.g., executing the action or choice (Bandura, 1986).
Ackerman & Beier, 2003; Donnay & Borgen, 1996; The social cognitive model in general and SCCT
Donnay et al., 2005; Harmon et al., 1994). in particular has three key actors; namely, the
Holland’s assumption concerning consistency person, the proximal environment, and the person’s
(having a Holland three-letter code with the stron- actions. The person variables, referred to as human
gest types being closer to each other on Holland’s agency, are his or her motivational, emotional, and
hexagon) and differentiation (spikes on Holland cognitive processes. The person’s actions include
profile rather than a flat profile across all six types) not only his academic and vocational performance
leading to positive vocational outcomes has not been but also his choices (e.g., choice of occupation)
clearly demonstrated. However, one intriguing study (Bandura, 1986; Lent et al., 1994). The interplay
showed in a hierarchical regression analyses, sepa- among the person’s agency, his or her actions,
rated by sex, that the interaction of differentiation and the environment are dynamic and reciprocal.
with agreeableness and conscientiousness explained In this context, three vocational outcomes are
statistically significant variance in work performance prescribed, all of which are intricately linked with
for men, and that the interaction of congruence the other.
with agreeableness, artistic, and social subscales was The first set of outcomes predicted in SCCT is
significantly related to work performance in women the development of vocational interests. As exoge-
(Kieffer, Schinka, & Curtiss, 2004). nous variables, the four sources of SE are postulated
to directly impact SE and outcome expectations,
Social Cognitive Career Theory which in turn directly affect vocational interests.
Built upon Betz and Hackett’s earlier work on career Self-efficacy and outcome expectancies are postu-
SE of women in nontraditional domains, Lent, lated to directly and indirectly affect intentions/
Brown, and Hackett (1994) adapted Bandura’s goals, activity selection and practice, and perfor-
(1977, 1986) social cognitive theory to the voca- mance attainments. Interests are posited to directly
tional psychology domain. Their theory sees SE as influence intentions/goals and indirectly influence
the driving force to explain the development of inter- activity selection and practice, and performance
ests, academic and career choice, and performance attainments. Intentions/goals are thought to directly
and persistence in educational and occupational pur- influence activity selection and practice and indi-
suits (Lent et al., 1994). rectly influence performance attainments. Activity
The theory is anchored in the construct, SE. Self- selection and practice is thought to directly influ-
efficacy is defined as “people’s judgments of their ence performance attainments. Performance attain-
capabilities to organize and execute courses of action ments cycle back to influence the sources of SE
required to attain designated types of performances” (Lent et al., 1994).
(Bandura, 1986, p. 391). Lent and colleagues incor- The second set of outcomes predicted is career-
porated Bandura’s four sources of SE into SCCT. related choice behaviors. In this model, person
They were mastery, modeling, social persuasion, and inputs (e.g., gender, ethnicity) and background are
physiological arousal (anxiety). They identified two exogenous variables that predict learning experiences
other key sociocognitive mechanisms in their model, and contextual influences proximal to the choice
namely outcome expectations and goals. Outcome behavior. Learning experiences are posited to impact
expectations (OE) were defined as people’s personal SE and outcome expectations, which in turn directly

134 worklife ac ro s s th e l if es pan

influence interests, choice goals, and choice actions Self-efficacy also appears to contribute to mathe-
and indirectly influence performance domains and matics and/or science course interests after outcome
attainments. Interests directly affect choice goals and expectancies have been partialed out (Young et al.,
indirectly affect choice actions and performance 2004). Their meta-analyses concerned the relations
domains and attainments. Contextual influences of mathematics and science outcome expectancies
that are proximal to choice behaviors are thought to with other sociocognitive constructs, including SE
moderate the relation of interests and choice goals ( k = 10; N = 3331). Young and colleagues reported
and moderate the relation of choice goals and choice in their review that studies using structural equation
actions (Lent, 2005). Choice goals directly affect modeling consistently showed both direct and indi-
choice actions and indirectly affect performance rect effects of SE on mathematics course interests.
domains and attainments. Choice actions directly Finally, SE has also been shown to moderately relate
affect performance domains and attainments. Per- to course intentions, with Lent and colleagues
formance domains and attainments cycle back to (1994) reporting an effect size of r = .40.
directly influence learning experiences. Finally, there is some evidence that SE relates to
The third set of outcomes predicted is perfor- the four sources of SE. Lent and colleagues (1994)
mance and persistence in educational and occupa- in their meta-analysis of three studies presented the
tional pursuits (Lent et al., 1994). In this model, the following effect sizes: r = .51 for mastery, r = .20 for
exogenous variable is ability/past performance, modeling, r = .28 for social persuasion, and r = –.40
which directly affects SE and outcome expectations for emotional arousal.
and performance attainment level. Self-efficacy and In the model of the development of interests,
outcome expectations directly affect performance outcome expectancies are also an important con-
goals/subgoals and indirectly affect performance struct. Consistent with the model, outcome expec-
attainment level. Performance goals/subgoals are tations have also been shown to relate strongly to
thought to directly affect performance attainment SE (Lent et al., 1994; Young, et al., 2004 Lent and
level. Performance attainment level then cycles back colleagues (1994) reported an effect size of r = .49,
to directly influence future performance (Lent et al., whereas Young and colleagues (2004) reported a
1994). very similar effect size for the mathematics domain
Four meta-analyses were located that specifi- of r = .45 ( k = 7, N = 1208) and r = .41 ( k = 4;
cally examined SCCT. The findings will be pre- N = 2456) for the mathematics/science domains
sented in order of the presentation of the three combined. Also supporting the SCCT model, out-
models; namely, the development of interests, then come expectancies have also been shown to be
career-related choice, and then academic achieve- strongly related to interests based on these same two
ment. In all the studies, SE was domain-specific not meta-analyses (Lent et al., 1994; Young et al., 2004).
generalized SE. The relation of outcome expectancy and interests
was reported by Lent and colleagues to be a moder-
development of interests ate effect size (r = .52); Young and colleagues
Regarding interest development, SE seems to reported a similar effect size of .54 for the mathe-
strongly relate to interests when parallel content matics/science domain across ten samples with an
domains exist (Rottinghaus, Larson, & Borgen, N of 3,331 (Note: Lent et al. did not report num-
2003). In their meta-analyses ( k = 60, N = 39,154), ber of samples or sample size.) Finally, both meta-
academic SE (e.g., math, art) correlated strongly analyses reported a linkage of outcome expectancies
with academic interests; vocational SE across the with intentions. Lent and colleagues referred to
RIASEC correlated strongly with interests across them as choice goals (i.e., expressed choice, inten-
the RIASEC ( rs ranged from .51 to .69). Age, sex, tions, and range of occupational considerations)
and measure moderated the effect somewhat. Men related to outcome expectancies r = .42. Young
yielded slightly higher SE–interests (SE–I) relations and colleagues reported a correlation of r = .50 for
than did females; older versus younger samples mathematics outcome expectancies and course
yielded slightly higher SE–I relations, and the intentions ( k = 4, N = 774). Young and colleagues
Campbell Interest and Skill Survey (Campbell, reported in their review that studies using struc-
Hyne, & Nilsen, 1992) versus the SII yielded tural equation modeling consistently showed both
higher SE–I relations especially for the social, enter- direct and indirect effects of outcome expectations
prising, and conventional domains. These studies on mathematics course interests. Moreover, Young
were not experimental, so cause cannot be established. and colleagues also reported across eight studies that

l ar son 135
mathematics/science outcome expectancies and may elicit interests and what psychological processes
interests uniquely predicted mathematics course (e.g., attributional processes) may be involved.
intentions.
Although sources of SE (i.e., mastery, modeling, career-related choice
social persuasion, and lowering anxiety) are postu- The second model concerns the prediction of career-
lated to increase SE (Bandura, 1986), Lent et al. related choices. Lent and colleagues (1994) in their
(1994) identified the first three of these sources meta-analyses reported that choice goals were mod-
(mastery, modeling, and social persuasion) as erately related to SE ( r = .40), outcome expectations
impacting outcome expectancies, in that they pro- ( r = .42), and interests ( r = .60). Young, and col-
vide the reinforcing consequences that lead a per- leagues (2004) showed mathematics/science out-
son to expect more positive outcomes in the future. come expectations to be moderately related to
Young and colleagues reported evidence ( k = 3, intentions ( r = .50). Across several studies, Young
N = 391) that mathematics outcome expectancies and colleagues (2004) also reported that outcome
did relate moderately to perceived mastery in math- expectancies are unique predictors of course inten-
ematics ( r = .48), modeling ( r = .41), social persua- tions above and beyond SE, and that outcome
sion ( r = .50), and anxiety ( r = –.47). Although the expectancies may mediate the relation of SE and
model presumes that mastery would be the stron- course intentions. Young and colleagues also showed
gest source among the four sources, Young and col- evidence that course interests directly affected course
leagues did not find differential effect sizes across intentions after other sociocognitive variables were
the four sources in relating to mathematics outcome controlled.
expectancies. Besides the meta-analyses, multiple studies have
Although the theory presents SE as partly deter- shown SE to be predictive of choice of major (e.g.,
mining the development of interests, some empiri- Larson, Wei, Wu, Borgen, & Bailey, 2007), occupa-
cal evidence has emerged that suggests the pathway tion (e.g., Betz et al., 2003; Rottinghaus, Betz, &
is bidirectional. That is, SE may be partly deter- Borgen, 2003), and educational aspirations (e.g.,
mined by interests. First, the reciprocal relation of Rottinghaus, Betz, et al., 2003; Rottinghaus, Lindley,
SE and interests has been demonstrated (Nauta, Green, & Borgen, 2002). Likewise, researchers have
Kahn, Angell, & Cantarelli, 2002; Tracey, 2002). shown interests to be predictive of choice of major
Second, interests are in part inherited traits, with (Gasser et al., 2007; Harmon et al., 1994) and choice
at least 40%–50% of the variance being genetic of occupation (e.g., Ackerman & Beier, 2003;
(e.g., Betsworth et al., 1994; Gottfredson, 1999; Donnay & Borgen, 1996; Donnay et al., 2005;
Moloney, Bouchard, & Segal, 1991; Waller, Lykken, Harmon et al., 1994). Self-efficacy combined with
& Tellegen, 1995). Third, interests appear stable interests has also been shown to be predictive of
over many years (Hansen & Swanson, 1983; Low & choice of major (e.g., Betz, Harmon, & Borgen,
Rounds, 2007; Rottinghaus, Coon, Gaffey, & 1996; Larson, Wu, Bailey, Borgen, & Gasser, 2010)
Zytowski, 2007; Strong, 1955; Swanson & Hansen, and occupation (e.g., Betz, et al., 1996, 2003;
1988). Furthermore, in a meta-analysis ( k = 66, Donnay & Borgen, 1999). The SCCT theory postu-
N = 23,665), Low, Yoon, Roberts, and Rounds lates that SE is domain specific. Consistent with
(2005) provided convincing evidence that interests the theory, a number of studies have consistently
remain relatively unchanged in adolescence and shown evidence that specific versus general RIASEC
increased dramatically during the college years, and domains of SE and interest domains of SE and confi-
then remained stable for the next two decades. dence are significantly more predictive of career-
Stability was measured using both rank order and related goals and choice actions such as educational
profile correlations. Interests, in part, motivate peo- major, choice of occupation, and educational aspi-
ple to seek out activities in their environment and ration (e.g., Betz et al., 2003; Donnay & Borgen,
avoid other activities in their environment and deter- 1996, 1999; Gasser et al., 2007; Larson, Wu, et al.,
mine if, whether, and to what extent efficacy in some 2010; Rottinghaus et al., 2002; Rottinghaus, Betz
domains develop. Silvia (2006) sees initial interest et al., 2003).
(distinct from interests) as an emotion that, through
attributional processes and key variables of task diffi- academic performance attainment
culty, interacts over time to create enduring interests. The third model concerns academic performance.
He argues for more experimental research (e.g., Silvia, Self-efficacy appears to significantly predict aca-
2003) testing under what conditions confidence demic performance ( r = .34) based on Multon,

136 worklife ac ro s s th e l if es pan

Brown, and Lent’s (1991; k = 18, N = 1,194) find- expectations about performance, work habits, emo-
ings. Moderators revealed that the relation was tional responses).
stronger for younger versus older students, for low- These four factors (innate abilities, environmental
versus high-complexity tasks, and for subject versus conditions, learning experiences, and task approach
standardized tests. Finally, the relation was strong skills) interact over time to result in generalizations
for post-test rather than pretest measurement of SE. about self (self-observation generalizations) and the
Young and colleagues’ meta-analytic findings con- world (worldview generalizations). Six hypotheses
cerning subsequent mathematics grades are consis- predict a person’s preference for (or avoidance of ) an
tent with Multon and colleagues findings. Young occupation to the extent that she or he has: suc-
and colleagues reported an effect size of .24 for out- ceeded (or failed) at tasks typical of the occupation;
come expectancies and subsequent mathematics role models have been reinforced (or not reinforced)
grades. Studies examining the unique contribution for those activities; and someone has spoken posi-
of outcome expectancies after SE has been con- tively (or negatively) to him or her about that career
trolled for have found that only SE uniquely con- (Mitchell & Krumboltz, 1996).
tributes to subsequent academic achievement (Lent,
Lopez, & Bieschke, 1993; Tilley, 2002). career construction theory
The career construction theory (Super, 1992; Super,
Other Theories Savickas, & Super, 1996) covers career development
social learning theory of career across the lifespan. In this theory, the people’s own
choice and counseling subjective meaning of their experiences moves to the
John Krumboltz’s social learning theory of career forefront in the form of the narrative. People are
decision making and counseling (Krumboltz, believed to construct their careers by imposing
Mitchell, & Jones, 1976; Mitchell & Krumboltz, meaning on their vocational behaviors and occupa-
1990, 1996) focuses on how individuals learn from tional experiences. These constructions are elicited
interactions with the environment in making career from the career counselor in the form of stories or
choices. It also tries to address the origin of career narratives (Savickas, 2005).
choice. The emphasis is on instrumental learning Three key constructs to be gleaned from the
(reinforcement and punishment) and associative person’s narrative are his or her vocational personal-
learning (a neutral stimulus is paired with an emo- ity, life themes, and career adaptability. One’s voca-
tionally laden one). Mitchell and Krumboltz (1996) tional personality is the objective and subjective
outline four factors that influence a person’s career P–E fit. The objective P–E fit concerns the infor-
path. The first factor that influences career decision mation gleaned from the range of career assess-
making by interacting with the environment is the ments regarding the person and the environment
person’s innate genetic endowment and any special (e.g., Holland code, classification of occupation
abilities the person may possess. The second factor according to Holland’s RIASEC). The objective
that influences career decision making is environ- P–E fit includes the individual’s career-related needs,
mental conditions and events, broken up into 12 cat- abilities, values, and interests (Savickas, 2005). The
egories: job opportunities, social policies, rewards for subjective P–E fit encompasses the ideographic
some occupations, labor laws, physical events, natu- personal ideas about the self, work, and life. One’s
ral resources, technological developments, changes in vocational personality concerns the “what” regard-
social organization, family training and resources, ing vocational development.
educational system, neighborhood influences, and People’s life themes, referred to as the “why,” are
community influences. The third and most impor- their ideas of the kind of people they are, the way in
tant factor influencing career decision making has which their preferred or current occupations reflects
to do with learning experiences (i.e., instrumental their self-concepts, and the way in which work is
and associative learning). Instrumental learning reflective of the self. Vocational development is the
includes antecedents (e.g., innate ability and environ- process of trying to improve the P–E fit, express the
mental conditions), covert and overt behaviors, and self, and give back to the community (Savickas,
immediate or delayed consequences. Associative 2005).
learning occurs when two stimuli are paired (e.g., Career adaptability is defined as how people con-
smiles become associated with approval). The fourth struct their careers. It consists of the attitudes,
factor in career decision making is called task app- behaviors, and competencies a person uses in fitting
roach skills (i.e., skills one brings to a task, such as the self to work that suits the person. In this theory,

l ar son 137
the interaction of P–E fit is emphasized; that is, the work role an adequate outlet for his or her predom-
coping process. Savickas sees career adaptability as inant vocational characteristics.
a “psychosocial construct that denotes an indivi- The next propositions concern the development
dual’s readiness and resources for coping with cur- of vocational self-concepts defined as “symbolic
rent and imminent vocational development tasks, representations that are personally constructed,
occupational transitions, and personal traumas” interpersonally conditioned, and linguistically
(Savickas, 2005, p. 51). communicated” (Savickas, 2002, p. 161). The prop-
To be career adaptive, Savickas (2002, 2005) ositions concerning vocational self-concepts are
identifies four dimensions that must be addressed: as follows. Job satisfaction depends on the degree
becoming concerned about one’s future as a worker, the person has implemented his or her vocational
increasing personal control over one’s vocational self-concepts. The process of career construction
future, displaying curiosity by exploring possible is developing and implementing vocational self-
selves and future scenarios, and strengthening con- concepts in work roles. Self-concepts develop
fidence to pursue his or her aspirations. Career con- through interaction. These vocational self-concepts
cern, the first dimension, incorporates planfulness become increasingly stable, although they can
and foresight into career planning by having the change with time and experience.
individual connect the past to the future, by being The last set of propositions concerns the progres-
optimistic and future oriented. Career control, the sion of developmental tasks across time. People
second dimension, means the person and others experience a maxicycle of career stages across time,
believe he or she is responsible for constructing his labeled as periods of growth, exploration, establi-
or her career. Career curiosity, the third dimension, shment, management, and disengagement. Each
means the person is inquisitive about options and stage is subdivided into periods marked by voca-
explores the fit between self and the world of work. tional development tasks that are social expecta-
Career confidence, the final dimension, reflects tions. Minicyles of the stages occur when
anticipation of success in encountering challenges moving from one stage to the next. Vocational
and overcoming obstacles. Savickas (2005) provides maturity is a psychosocial construct that denotes the
an excellent case study example in which the reader degree of development along the stages. Crites
can see an illustration of how a career counselor (1978) defined vocational maturity as five attitudes
examines one’s vocational personality, life themes, about career decision making; namely, decisiveness,
and career adaptability by engaging in a person’s involvement, independence, orientation, and com-
narrative. The counselor becomes an active player in promise. One proposition defines career adapt-
helping to shape the narrative. ability (i.e., how one constructs a career). Career
Savickas (2002) elucidates propositions of construction is prompted by vocational develop-
Super’s theory, which emphasizes individual devel- ment tasks and produced by responses to these tasks
opment rather than an individual difference view. (Savickas, 2002).
The first three propositions anchor the theory in The theory’s scholars have generated some
developmental contextualism; that is, that people research and attracted a number of practitioners.
construct their careers within a particular context. No meta-analyses or recent conceptual reviews of
Life space is defined as a set of social roles. One’s the theory were located. The propositions of the
occupation is seen as a core role for most people. theory have received some support using data post
Career pattern is defined as a sequence and duration hoc. Scholars agree that the theory does a good job
of work positions determined by parents, person’s of describing vocational development and does cap-
education, abilities, traits, self-concepts, and adapt- ture, after the fact, the integration of empirical data
ability in transaction with opportunities presented (Savickas, 2002).
by society (Savickas, 2002).
The next propositions integrate the individual occupational circumscription and
difference tradition into the model. The theory compromise theory
states that the variation across people’s attributes, Occupational circumscription and compromise
such as ability, interests, and values, and the diver- theory (L. S. Gottfredson, 1996, 1999) “focuses on
sity across occupations and occupational require- how young people gradually come to recognize and
ments ensure considerable variation as to which deal with or fail to deal with the array of vocational
occupations people seek out. Occupational success choices their society provides” (L. S. Gottfredson,
depends on the extent to which the person finds the 2005, p. 71). Key concepts in the theory include

138 worklife ac ro s s th e l if es pan

self-concept (i.e., one’s public and private view of Discrimination of women and racial and ethnic
self [L. S. Gottfredson, 2002]), images of occu- minorities has been incorporated into understand-
pations (i.e., occupational stereotypes), cognitive ing the attainment process.
maps of occupations (sex type by prestige level, The strength of sociological approaches to career
organization of occupations [L. S. Gottfredson, choice and development has been the central role
2002]), compatibility (P–E fit), accessibility of of the social context outside the person as impacting
occupations (realistic and available occupations), the process. Some of the most important social con-
occupational aspirations (joint product of com- texts include cross-national differences in the struc-
patibility and accessibility), and social space (range ture of education and work (e.g., U.S. youth receive
of alternative within the cognitive map that person general high school diplomas vs. German youth,
considers acceptable [L. S. Gottfredson, 2002]). who are tracked to either the university or appren-
Circumscription is the process by which youth ticeships), structural features of schools (e.g., ineq-
narrow their range or zone of acceptable alterna- uities in access to college preparation courses,
tives (L. S. Gottfredson, 2002). Compromise is the differential learning due to tracking, quality differ-
process by which youth give up their most pre- ences in schools), and structural features of organi-
ferred choices for less compatible choices that they zations (e.g., formal hiring procedures vs. informal
perceive as more accessible (L. S. Gottfredson, procedures result in more or less hiring of racial
2002). Gottfredson also identified four stages cor- and ethnic minority workers). Sociological factors
responding to preschool (orientation to size and thought to influence occupational attainment
power), elementary school (orientation to sex roles), include the family (SES, occupation, work values,
middle school (orientation to social valuation), and conditions of employment, and access to opportu-
high school and beyond (orientation to internal, nities), adolescent employment, and community
unique self ). labor market conditions.
Gottfredson’s model has generated research In the next section, the literature has been orga-
particularly concerning occupational prestige and nized by vocational outcomes (e.g., vocational
sex role socialization in children and adolescents choice) and vocational processes (e.g., career deci-
(L. S. Gottfredson, 1999, 2002, 2005). Some sion making) that precede entry into the workforce.
researchers have found evidence supporting cir- The population of interest includes children, adoles-
cumscription, while other researchers have found cents, and college students.
evidence that does not support compromise
(L. S. Gottfredson, 2005). More research is needed Vocational Outcomes and Processes
that yields contrasting hypotheses for this theory in of Young People
contrast with other theories such as social cognitive The description of the history of vocational psychol-
theory (L. S. Gottfredson, 2005). The literature ogy already mentioned the split between vocational
search did not yield reviews or meta-analyses. guidance of adolescents and college students and
the work adjustment of employed adults. The litera-
sociological theories ture concerning adolescents and college students
Sociological theories of vocational choice develop- focused on the processes and outcomes preceding
ment emphasize societal factors that directly and entry into the workforce. The setting is the educa-
indirectly impact socioeconomic inequality and tional environment, with the majority of the sam-
mobility. Examples include occupational prestige, ples being high school students and college students.
parents’ SES, parents’ education, and structural fea- The outcomes evolve as the child matures. The
tures of secondary course preparation, like college development of vocational interests, educational
tracks versus vocational tracks. These societal fac- aspirations, and occupational aspirations are salient
tors are moved to the foreground while person beginning in childhood. Educational attainment for
variables are in the background (Johnson & all levels of schooling sets the stage for subsequent
Mortimer, 2002). Occupational choice became of education and career advancement and hence is
interest to sociologists as a context for studying a salient vocational outcome. In college, choice of
intergenerational mobility. Over time, sociolog- educational major and tentative career choice are
ical theories that tried to explain how the prestige important outcomes. The processes include the pre-
level of different occupations differs across people cursors to those aspirations, achievement, and
have incorporated sex, ethnicity, community size, choices, including exploration and the decision-
number of siblings, and family of origin features. making process. In the past 10 years, enough studies

l ar son 139
have been directed toward children so that several Educational aspirations appear to influence career
conceptual reviews have organized this literature choice because the higher the educational aspira-
(Hartung, Porfeli, & Vondracek, 2005; Watson & tion, the more opportunities are available to obtain
McMahan, 2005). Vocational outcomes will be pre- a higher educational degree, which in turn increases
sented first, including the development of interests, occupational opportunities. These educational aspi-
educational aspirations, occupational aspirations, rations do not simply concern postsecondary aspi-
educational achievement, and vocational choice. rations but concern aspirations in middle school
Vocational processes will be presented last, includ- and high school to pursue college-bound math and
ing career exploration and awareness, career deci- science courses. Educational achievement likewise
sion making/career maturity, and decision making opens (or closes) doors of opportunity, which, in
styles. turn, leads to higher (or lower) educational and
occupational aspirations. Rojewski and Yang (1997),
Vocational Outcomes for example, showed that achievement in grade 8
development of interests had a modest positive influence on occupational
Given the enormous attention interests have aspirations. In a sample of adolescents sampled first
received in vocational psychology, little work has in eighth grade and then 2 years after high school
focused on the interests of children, with notable graduation, two results were clear from their struc-
exceptions (e.g., Tracey, 2002). Some evidence tural equation modeling. The students’ occupational
shows that there are few differences across U.S. aspirations 2 years after high school were influenced
racial and ethnic groups in terms of structure, sta- more by academic achievement and educational
bility, and content of interests for middle school aspirations in grade 8 than by anticipated occupa-
students (Davison-Avilés & Spokane, 1999) and tional attainment in grade 8 (Rojewski & Kim,
high school students (Day & Rounds, 1998; Day, 2003).
Rounds, & Swaney, 1998). The hexagonal structure
of interests posited by Holland’s (1997) theory occupational aspirations
emerges more clearly for college students than for Occupational aspirations can be defined as an indi-
elementary and middle school students (Tracey & vidual’s expressed career-related goals or choices
Ward, 1998). Socialization and occupational gender (Johnson, 1995). Current aspirations predict future
stereotyping appear to influence the occupations occupational aspirations and occupational choices.
children prefer (e.g., Oppenheimer, 1991) and the E. K. Strong, Jr., as early as 1955 showed that
extent to which those interests are traditionally fem- occupational aspirations of first-year college stu-
inine or masculine (e.g., Barak, Feldman, & Noy, dents predicted occupational attainment 19 years
1991). Tracey (2002) showed that self-perceived later ( r = .69). Aspirations have been differentiated
competence in an activity predicted level of interests from occupational expectations, which reflect what
in that activity. The reverse was also true; level of occupations people realistically expect to enter.
interests predicted perceived competence in the Gottfredson’s theory (L. S. Gottfredson, 1999,
activity. Denissen, Zarrett, and Eceles (2007), in 2002, 2005) identifies two processes, circumscrip-
a longitudinal study of 1,000 children between tion and compromise, which account for the dis-
grades 1 and 12, showed a similar linkage between crepancy between aspirations and expectations.
interests in English, math, science, sports, and ins- Aspirations may be compromised when people do
trumental music and self-perceived competence in not feel they have the ability to be successful, think
those subjects. They provided evidence that the cor- the educational requirements are out of reach,
relation increased over time, which they referred to believe their aspirations are not supported by family
as longitudinal coupling. or friends, or perceive barriers regarding entry into
or success in their occupational aspirations
educational aspirations (Rojewski, 2005).
Educational aspirations are defined as the impres- Several theories account for the development
sions formed about academic abilities and the high- of occupational aspirations. Super’s stage of career
est level of education an individual would like exploration is characterized by a gradual narrow-
to attain (Rojewski, 2005). They are strongly related to ing of career options from fantasizing to identify-
occupational aspirations, seem stable from eighth grade ing tentative options (Super, 1992). Social cognitive
on (Rojewski & Kim, 2003), and are thought to be the career theory does not explicitly address occu-
bedrock of occupational choice (Rojewski, 2005). pational aspirations; rather, it identifies career

140 worklife ac ro s s th e l if es pan

goals and educational goals, which are dynami- more traditional across both Hispanic (Arbona &
cally impacted by SE, outcome expectancies, and Novy, 1991) and Caucasian girls (Arbona & Novy,
interests as well as past performance attain- 1991; Davey & Stoppard, 1993).
ments. Circumscription and compromise theory The literature regarding ethnicity has shown
(L. S. Gottfredson, 2002) purports that children mixed results when other variables are not con-
compromise their “ideal” aspirations by incor- trolled (see Rojewski, 2005). It may be that SES or
porating the salient barriers and reality of their sex is a more powerful predictor than ethnicity
situations to achieve an accessible realistic expecta- regarding occupational aspirations (Arbona & Novy,
tion. The circumscription process occurs when 1991; Rojewski, 2005). For example, Arbona and
expectations are narrowed by eliminating options Novy (1991) showed no differences across Hispanics
that do not fit with people’s occupational self- and Caucasians, but did find sex differences, with
concepts. These processes begin in the early stages, girls having more social and conventional occupa-
incorporating prestige and sex role stereotyp- tional aspirations whereas boys had more realistic
ing. Sociological theories posit that the link and investigative occupational aspirations. Socio-
between occupational aspirations and occupational economic status was reported to moderate the effe-
attainment are determined more by social forces cts of race/ethnicity on occupational aspirations
(e.g., SES) than by personal forces (e.g., ambition) (Rojewski & Yang, 1997).
(Rojewski, 2005). A longitudinal study by Cook, Church, Ajanaku,
Occupational aspirations appear to develop in and Shadish (1996) looked at career expectations
early childhood and become more realistic and and career aspirations over time of African American
stable over time (Rojewski & Kim, 2003; Rojewski inner-city boys and Caucasian boys, sampling the
& Yang, 1997). Studies have shown that half of children at second, fourth, sixth, and eighth grades.
children aged 8 and 11 years old reported stable As the inner-city African American boys group
aspirations 8 months later (Trice, 1991; Rojewski, (n = 110) aged, the gap widened between their own
1997). Change is also common, and most often expectations and aspirations. Cook and colleagues
occurs within the same prestige level (e.g., doctor (1996) reported that the relation between SES
to lawyer or plumber to electrician) rather than and age with occupational expectations was medi-
higher or lower prestige (e.g., McNulty & Borgen, ated by residing with both parents, having role
1988). If aspirations across prestige levels occur, the models, and anticipating obstacles.
change seems more likely to be from lower to higher Across multiple studies, higher SES is directly
prestige (Rojewski, 2005). or indirectly related to higher educational and
Sex, race and ethnicity, SES, and miscellaneous occupational aspirations (e.g., Rojewski & Yang,
variables have been investigated as influencing occu- 1997; Wahl & Blackhurst, 2000). A host of other
pational aspirations. Across multiple studies, sex variables have also been examined as to their influ-
continues to emerge as impacting occupational ence on occupational aspirations. One variable that
aspirations (Rojowski, 2005). It seems that children has consistently emerged is the role of the parents
as young as age 4 report sex-based occupational and families. Barber and Ecles (1992) showed that
preferences (Trice & Rush, 1995). Fantasy aspira- maternal employment, family processes, and paren-
tions for girls compared to boys increased more pro- tal expectations directly affected adolescents’ values,
portionally from second grade (10% more) to 12th self-concept, and achievement, which in turn, influ-
grade (20% more) (Helwig, 1998a,b, 2001, 2004). enced educational and occupational aspirations.
Females were more likely to have high- and low-
prestige aspirations, whereas males were more likely educational achievement
to aspire to moderate-prestige jobs (see Rojewski, The successful progression of children, adolescents,
2005). Despite higher aspirations, females’ actual and college students through school and college is
career expectations may not be consistent with those an important vocational outcome. Several clear
high aspirations. For example, females may restrict predictors within the child (i.e., person predictors)
their range of potential occupations at an early age have emerged in this literature. Cognitive ability
and may narrow their expectations downward over appears to be a potent predictor of educational
time (e.g., Hansen, 1994; Wahl & Blackhurst, achievement (Benbow & Stanley, 1996; Snow,
2000). Likewise, it appears that girls’ aspirations 1996). A recent meta-analysis examined graduate
and expectations may diverge, such that their aspi- business students’ academic success. The predictors
rations are high while their actual expectations are were undergraduate grade point average (GPA) and

l ar son 141
the aptitude test required for graduate degrees in and grade expectations ( r = .29, 50 findings); parent
business schools, the Graduate Management Admis- engagement (i.e., interested and knowledgeable
sion Test (GMAT) (Kuncel, Credé, & Thomas, about child’s life, spending time with child, active
2007). They showed that both predictors combined involvement, monitoring progress, positive atten-
contribute unique and substantial variance in pre- tion to child-rearing) ( r = .19, 25 findings); author-
dicting first-year graduate GPA and overall GPA itative parenting (i.e., being demanding and yet
of graduate students. In a meta-analysis of 58 stud- responsive to children’s needs and requests, showing
ies with German-speaking samples, the Big Five warmth, clear standards, encouraging verbal
personality factor conscientiousness was positively exchanges, social responsibility, psychological auto-
related to academic grades (Trapmann, Hell, Hirn, nomy) ( r = .20, 22 findings), autonomy support
& Schuler, 2007). This finding is similar to the (i.e., degree to which parents value and use tech-
meta-analysis conducted by Barrick and Mount niques that encourage independent problem solv-
(1991) that showed conscientiousness to be the ing, choice, and participation in decisions) ( r = .23,
only Big Five factor related to job performance. 12 findings), emotional support (i.e., showing per-
None of the other Big Five factors related to edu- sonal love and compassion, initiating and receiv-
cational achievement. The meta-analyses concern- ing positive physical contact with child, accepting
ing the social cognitive career theory by Lent and child for who she or he is) ( r = .28, 6 findings),
colleagues (1994) presented earlier in the chapter providing resources and learning experiences (i.e.,
showed that SE (Multon et al., 1991) and outcome establishing and supporting a positive learning envi-
expectancies (Young et al., 2004) were predictors of ronment at home, cultural enrichment) (r = .25,
educational achievement. However, it appears that 10 findings), and specific parent participation
outcome expectancies do not predict academic activities in school (i.e., participating in decision
grades in analyses in which SE is entered first in the making councils or frequency of participation in vol-
regression equation (Lent et al., 1993; Tilley, 2002). unteer activities at the school) ( r = .32, 6 findings).
In sum, cognitive ability, prior educational success Significant moderators included SES, grade level,
(i.e., GPA), conscientiousness, and SE seem sub- and ethnicity. Socioeconomic status (low, middle,
stantive contributors of educational attainment. high, mixed) was influential for high and low levels
Besides person predictors, the role of parental but less so for the middle level (Rosenzweig, 2001).
involvement in educational achievement has been suf- The relations of school success with the following
ficiently researched to warrant several meta-analyses. parent involvement variables were significantly
Fan and Chen (2001), across 25 studies, found paren- stronger for the low-SES children compared to
tal involvement overall (i.e., collapsing aspiration for other levels: parent participation in school, emo-
child’s education, communication, supervision, par- tional support, aspirations for educational attain-
ticipation, and other) related ( ρ = .25) to academic ment, engagement, and providing resources and
achievement (i.e., collapsing specific subject grades, learning experiences. The relation of educational
GPA, combined grades). The specific parental involve- attainment and authoritative parenting was signifi-
ment dimension of parental aspirations/expectations cantly stronger for high-SES children. The relation
for child’s education, in particular related to academic of educational attainment and parental engagement
achievement ( ρ = .40), whereas parental home super- was significantly higher for middle-class children.
vision (e.g., rules concerning television watching and Grade level (elementary, middle, and high school)
homework) did not relate ( ρ = .09). Also, parental was also a significant moderator. The relation of
involvement overall was moderately related to general educational attainment and the seven positive par-
achievement like GPA ( ρ = .33) and only somewhat enting practices was strongest for the elementary
related to achievement in specific domains ( ρ ranges level, weaker for the middle school level, and lowest
from .15 to .18) (Fan & Chen, 2001). for the high school level. Finally, ethnicity (white,
Rosenzweig (2001), examining 34 studies and African American, Asian American, Latino American,
438 independent findings, found that seven positive and other) emerged as a significant moderator. Only
parenting practices, when combined, accounted five of the seven positive parenting practices emerged
for 16.3% of the variance in educational attainment as significant in a regression equation for Asian
defined as standardized achievement tests, grades, American and Latino American students: parental
GPAs, teacher tests and ratings, and orientation engagement, authoritative parenting, parent par-
toward school. These seven practices were each signifi- ticipation in school, aspirations for educational
cantly related to educational attainment: aspirations attainment and grade expectations, and providing

142 worklife ac ro s s th e l if es pan

resources and learning experiences. Autonomy sup- evidence: “what we know is that people choose,
port and emotional support were not as supportive achieve, remain in, and are satisfied with their occu-
for these two groups compared to whites and the pations for reasons other than congruence” (Phillips
“other” category. For African American children, & Jome, 2005, p. 131). The point is that congru-
autonomy support was not related to educational ence accounts for very little explanatory power in
attainment; the other six positive parenting prac- why people choose and remain in their jobs.
tices were significantly related to educational attain- Gottfredson’s theory (L. S. Gottfredson, 1999,
ment (Rosenzweig, 2001). 2002, 2005) assumes that occupational choice
Finally, Jeynes (2007) conducted a meta-analysis comes about through a process, whereby occupa-
locating 52 studies that examined Hedges’ g as the tional prestige and sex role stereotyping over time
effect size unit of educational achievement in com- result in a narrowing of occupations under consid-
paring samples of urban secondary school students eration. This theory has received mixed support
who had parental involvement (i.e., expectations, (Phillips & Jome, 2005). People do share similar
parental style [extent to which parent demonstrated cognitive structures of the occupational world.
a supportive and helpful parenting approach], par- Constructs of sex-role stereotyping, occupational
ent–child communication, monitoring homework) prestige, and interests have been shown to be impor-
versus those who did not have parental involvement. tant in career choice (e.g., Leung & Plake, 1990).
Educational achievement was defined as grades, However, sex-based stereotypes appear to be learned
standardized tests, and other measures like teacher earlier than posited in the theory (e.g., Henderson,
rating scales and indices of academic attitudes and Hesketh, & Tuffin, 1988). Also inconsistent with
behaviors. The effect size overall was g = .53; those the theory is that girls perceive more flexibility than
parents who were more involved as opposed to less boys in the gender tradition of occupations they
involved had children who were more academically consider (e.g., Henderson et al., 1988). Moreover,
successful by one-half of a standard deviation unit. occupational alternatives seem to expand rather
Race did not moderate the effect size. than narrow over time, which is also inconsistent
with the theory. One difficulty that may account
vocational choice for some of the mixed findings concerns the inabil-
Vocational choice can be defined as a decision to ity to untangle some levels of prestige, sex roles, and
choose a particular educational major, a particular interests (Phillips & Jome, 2005). For example, it is
job, or a particular career or occupation. In the lit- hard to identify high-prestige, traditionally femi-
erature, occupational and career choice are used nine occupations across the six Holland types.
synonymously, although the former term has been Social cognitive career theory has received con-
seen as more inclusive of a broader array of occupa- siderable support in the prediction of vocational
tions across prestige level. Moreover, occupational choice. High scores on SE measures for the six
choice is more anchored to a particular point in Holland types have been shown to discriminate
time, whereas career choice could be interpreted as among educational major choices (Betz, et al., 1996;
a process that occurs across time. Choice of job is Larson et al., 2007; Lent, 2005) and among occupa-
quite specific to one point in time and may or may tional choices (e.g., Donnay & Borgen, 1999; Lent,
not imply stability over time. Young adults’ early 2005). Basic dimensions of confidence have also
entry into the workforce or entry into lower-prestige been shown to differentiate educational major
jobs may be best seen as actions of necessity rather choice (Rottinghaus, Betz, et al., 2003) and occupa-
than as something they aspire to or freely choose. tional choice (Betz et al., 2003). Interests have long
In this section, the term occupational choice refers to been shown to discriminate among educational
occupations unless otherwise noted. Factors con- major choices (e.g., Rottinghaus et al., 2002) and
tributing to occupational choice have been exten- occupational choice (e.g., Donnay & Borgen, 1996;
sively studied in vocational psychology for many Harmon et al., 1994). Self-efficacy and outcome
years. Different theories emphasize different deter- expectancies have also been shown to relate to career
minants of choice and have received variable choice partly through interests (Lent, 2005).
amounts of support.
Holland’s theory explains occupational choice as summary
congruence between the person’s primary interests It is clear that social cognitive constructs, predomi-
and the occupational environment. A clear picture nantly SE, are being widely researched as outcomes
emerges regarding congruence from over 40 years of and as predictors. Self-efficacy is predicted by the

l ar son 143
four sources of SE. Self-efficacy across the six evaporate with more accurate knowledge over time
Holland types seem to predict and be predictive (Watson & McMahon, 2005). In one study,
of vocational interests. Self-efficacy and outcome Hispanic ninth graders did reduced stereotyped
expectancies across academic domains are seem to attitudes toward careers after career interventions.
be Choice goals seem to be predicted by SE, out- However, children with stereotyped attitudes dis-
come expectancies, and interests within the respec- torted counter-stereotyped information (Haas &
tive domain. The prediction of choice goals across Sullivan, 1991).
academic domains has received some attention. In terms of gender, it seems girls are aware of
Interests continue to receive enormous amounts of work–family balance at a younger age than are boys,
attention as outcomes of SE, as predictors of career yet this may also impact girls’ choices about careers.
choice, and as an individual difference variable. The For example, girls as young as the sixth grade com-
literature concerning the structure of interests cross- pared to boys incorporated more diverse life roles in
culturally is impressive. Educational aspirations terms of how they viewed work and family, as well
have received some attention as an outcome with as other life roles (Curry, Trew, Turner, & Hunter,
sociocognitive variables like SE and interests as pre- 1994). At the same time, girls may consider fewer
dictors. Occupational aspirations are influenced by career options than boys and also are more decided
past achievement and past educational aspirations, about their careers than are boys; it may be that the
as well as by parents’ influences, gender, and SES. girls’ decisions are premature and lacking in speci-
Finally, academic performance is clearly predicted ficity and careful planning (McMahon & Patton,
by cognitive ability, SE, and parental involvement. 1997).
It also seems that SES, grade level, and ethnicity
alter the relation of parental involvement and aca- career decision making
demic success. and career maturity
Several theories identify decision making stages as
Vocational Processes well as related factors thought to be involved in the
career exploration and awareness decision making process. Tiedeman’s model (Super,
Few recent studies have sampled children and Tiedeman, & Borow, 1961; Tiedeman, 1979;
focused on career exploration and awareness. The Tiedeman & O’Hara, 1963) identifies the stages
findings are tentative and come from individual of exploring, crystallizing choice, and clarifying
studies (Hartung et al., 2005). It seems children choice by putting it into action. Harren (1979)
aged 10–12 engage in dynamic career exploration extended Tiedeman’s model to include person and
and increasingly work for pay outside the home as contextual factors. These stages were labeled aware-
they enter middle school (e.g., Entwisle, Alexander, ness, planning, commitment, and implementation.
Olson, & Ross, 1999). Parents may be more impor- Krumboltz and Hamel (1977) created the
tant than peers by age 12 in the career exploration DECIDES model standing for define, establish
process (Hartung et al., 2005). Career awareness plan, clarify values, identify alternatives, eliminate
has been examined by determining what children alternatives, and starting action. Katz (1966) and
know about various occupations. It seems clear that Pitz and Harren (1980) proposed expected utility
children by the age of 10 know about occupa- models that posit that the best decisions are those
tions. Moreover and not surprisingly, brighter chil- that include comprehensive information gathering
dren may know more about occupations than those and the weighing of probable outcomes and desired
peers who are less bright. It also seems that how utilities of options. Gati (1986) created the sequen-
much career information children and adolescents tial elimination model as an adaptation to the
learn is impacted by SES. For example, poverty expected utility models. Gati’s model has individu-
reduces the amount of career knowledge children als eliminate alternatives in arriving at an optimal
have acquired (Weinger, 1998). Two studies con- choice. There is weak support for these models in
ducted 25 years apart found that few job options, the literature, primarily because it appears that
lower SES, and ethnicity accounted for the most vari- people do not follow a systematic logical progres-
ance in predicting less occupational knowledge in sion in their career decision making, as the theories
180 children (Jordan, 1976; Jordan & Pope, 2001). propose (Phillips, 1997; Phillips & Jome, 2005).
Researchers have noted that children’s knowl- Difficulties in making vocational decisions have
edge does increase with age, but also have noted been investigated by categorizing subtypes of unde-
that children’s occupational stereotypes may not cided students. Researchers have identified subtypes

144 worklife ac ro s s th e l if es pan

of career indecision ranging from needing more styles; that is, a taxonomy of how young people
information to chronically indecisive regardless of make decisions in a relational context. Scholars are
information received (e.g., Chartrand, Martin, now speculating that the “best” decision making
Robbins, & McAuliffe, 1994). Measures have been style may depend on the context.
developed to assess indecision, such as the Careers
Factors Inventory (Chartrand et al., 1994); these Vocational Outcomes of
measures have been used to assist career counsel- Wage Earning Adults
ors in working with undecided students and used Overview
to assist researchers in identifying correlates of career Many theories have been used to explain the range
indecision, such as neuroticism and lack of confi- of vocational outcomes concerning adults in the
dence (Phillips & Jome, 2005). world of work. The theories have bridged counseling
Career maturity or vocational maturity, most psychology, industrial/organizational psychology,
commonly identified with Super’s (1992) model, and social/personality psychology. Holland’s (1997)
was defined by Super and Jordaan (1973) as “readi- P–E fit theory and Dawis and Lofquist’s TWA
ness to cope with developmental tasks of one’s life (Dawis, 2002, 2005; Dawis & Lofquist, 1984) have
stage, to make socially required career decisions, been the predominant theories from counseling psy-
and to cope appropriately with the tasks which chology. Work motivation theories have been domi-
society confronts the developing youth and adult” nant in I/O psychology. Work motivation is viewed
(p. 4). Vocational maturity is often linked to career as a “set of energetic forces that originate both within
decision making and assumes children will make as well as beyond an individual’s being to initiate
more mature decisions as they age (e.g., more deci- work-related behavior and to determine its form,
sive, involved, independent, oriented, and able to direction, intensity, and duration” (Pinder, 1998,
compromise). Walls (2000) did find that children’s p. 11). Social psychology’s contribution has come
accuracy of occupational knowledge increased as in the adaptation of mini-theories that explain why
they got older. It may be that children who have certain antecedents or mediator/moderators may
made a choice have a stronger vocational identity. have an impact on a particular vocational outcome.
Vondracek, Silbereisen, Reitzle, and Wiesner (1999) Two examples include attribution theory (i.e., job
showed, in a sample of German children aged 10–13, satisfaction or performance is based, in part, on how
that career maturity was higher in children who had the person attributes his or her situation [My job
made a vocational choice than for those who had not satisfaction is based on my hard work versus the
made a choice. It also seems that parents play a role whims of the organization]) and expectancy theory
in the timing of making a vocational choice. Evidence (i.e., satisfaction is produced by the reinforcers that
of occupational stereotyping that biases occupational follow performance).
preference was noted (Hartung et al., 2005). The The theories highlight different processes and
good news is that gender stereotyping of occupa- outcomes. Holland’s theory is most commonly seen
tions may have declined with successive generations as identifying congruence as an antecedent of job
of children, especially for girls (Watson & McMahon, satisfaction and subsequent work adjustment. Dawis’
2005). Other societal influences that appear to have TWA focuses on the complementary outcomes
some influence on vocational preferences were par- of job satisfaction and satisfactoriness (job satisfac-
ents, the school, media, and the home environment tion from employer’s perspective). Dawis identifies
(Hartung et al., 2005). For example, parental sup- processes that the person uses to stay within an orga-
port had an impact on the timing of vocational pref- nization when the P–E fit is in a state of discorre-
erences (Walls, 2000). spondence (Dawis, 2005). These include flexibility
(tolerating mismatch), reactive adjustment (change
decision making styles self ), active adjustment (change the job), and perse-
Most research in this area concerns Harren’s three verance (duration of discorrespondence). His theory
decision-making styles; namely, rational, intuitive, can be used to examine tenure and negative indica-
and dependent styles. The rational style is posited tors like intentions to quit and quitting. Work moti-
to be the most efficient for making deliberative vation theory identifies person characteristics that
choices, although the research is mixed. Results con- motivate the person to choose, persist, and be suc-
cerning career maturity were inconclusive. Phillips, cessful in the job (Latham & Pinder, 2005). Social
Christopher-Sisk, and Gravino (2001) have used a psychology theories focus on the explanation for a
relational continuum to describe decision making particular relation. For example, expectancy theories

l ar son 145
would explain how job performance leads to job sat- Personality is thought to have an impact on the
isfaction because satisfaction follows from the job search through the engagement of different
rewards produced by performance. search strategies and the extent to which people
use proactive job search behaviors (Kanfer et al.,
Outcomes 2001). Job search behaviors (measures of frequency
Since 1990, researchers have extensively examined of job search activities or time spent searching
the contribution of antecedents or predictors on were used) were related to extraversion ( ρ = .46),
a wide range of vocational outcomes. The vocational openness ( ρ = .27), and conscientiousness ( ρ = .38)
outcomes in this section are frequently multifaceted (Kanfer et al., 2001).
and often measured by more than one method. The Generalized expectancies are thought to have
organization of this section will be by outcomes an impact on job search behaviors through their
organized logically by how they occur sequen- influence on both problem-and emotion-focused
tially in people’s lives. The outcomes are job search coping. The two antecedents in this category—locus
behaviors and job search outcomes, job satisfaction, of control and optimism—were not predictive
job attitudes, organizational citizenship behavior of job search behaviors. However, self-evaluations
(defined as behaviors that facilitate the core aspects were predictive of job search behaviors, namely SE
of the job), job performance, counterproductive (ρ = .27) and self-esteem (ρ = .27). Self-evaluations
work behaviors, turnover intentions/intentions to were thought to have an impact on job search
quit, quitting/turnover, absenteeism, withdrawal, behaviors through their influence on persistence
career success, negative mental health outcomes, when difficulty increases (Kanfer et al., 2001).
and life satisfaction and well-being. When a con- Situational antecedents were also modestly
struct is both a predictor and an outcome (e.g., job related to job search behaviors, including motives
satisfaction is an outcome and a predictor of job of financial need (ρ = .21) and employment com-
performance), the construct will be discussed sepa- mitment, defined as the belief that having a job
rately as an outcome and also as an antecedent of is very important (ρ = .29) and social support
another outcome. (ρ = .24). Motives are thought to influence job
search behaviors by influencing job search effort
job search behaviors and and intensity, and social support is thought to influ-
job search outcomes ence job search behaviors as a way of coping
Job search behaviors can be defined as a purposive, with negative aspects of the job search by receiving
volitional pattern of action that begins with the iden- advice in the short term and encouragement in
tification and commitment to pursuing an employ- the long run (Kanfer et al., 2001). None of the
ment goal (Kanfer, Wanberg, & Kantrowitz, 2001). demographic variables influenced job search behav-
Most authors had measured only frequency (how iors, including age, gender, education, race, and job
many times the person engaged in job search behav- tenure.
iors) or effort (how many hours the person engaged The antecedents, in general were less predictive of
in job search activities over a specific time period). job search outcomes (i.e., job status, number of
In the meta-analyses, Kanfer and colleagues (2001) offers, and duration of search) than of job search
defined job search behaviors as both frequency behaviors (i.e., three dimensions labeled intensity of
and effort. Kanfer and colleagues defined job search effort, content duration, and temporal-persistence).
outcome in three ways: job status (I have/do not There were also less data on job search outcomes
have a job), job search duration, and number of job than on job search behaviors as criterion variables.
offers. In their meta-analyses ( k = 82, N = 21,898), Job search behaviors modestly related to job status
Kanfer and colleagues investigated the contribution (i.e., having a job) (ρ = .21) and number of offers
of sets of antecedents that influence both job search (ρ = .28). Neuroticism was modestly related to
behaviors and the job search outcome. The anteced- number of offers (ρ = –.22). Extraversion, openness,
ents were personality traits, generalized expectancies, and agreeableness modestly related to number of job
self-evaluations, situational antecedents (motives offers in the only study that measured both job offers
[financial need and employment commitment] and and those traits ( rs = .41, .28, .29) (Kanfer et al.,
social support), and demographic variables. They 2001). Interestingly, conscientiousness, which was
will be reviewed in that order, starting with the pre- measured more frequently, showed no relation with
diction of job search behaviors followed by job search job search outcomes. Generalized expectancies were
outcomes. not predictive of job search outcomes. Self-evaluation

146 worklife ac ro s s th e l if es pan

was related; self-esteem was modestly related to the N = 6557, k = 53). The congruence–job satisfaction
duration of the search ( ρ = –.24), and SE was mod- relation was .17, which included 0 in the 95% CI.
estly related to the number of offers ( ρ = .28). The In other words, there was no relation. Owings and
situational antecedent of motive was not related to Fritzsche (2000) suspect that one reason for the
job search outcomes, whereas the social antecedent weak relation of congruence and job satisfaction
of social support was moderately related to job status may be that job satisfaction often includes domains
( ρ = .30). Demographic variables were not related to that are not directly related to environmental con-
the job search outcomes. gruence, such as pay or coworkers. Another reason
may be that job satisfaction measures aspects of sat-
job satisfaction isfaction other than the tasks associated with one
Job satisfaction is defined as a “pleasurable or posi- of the six domains of Holland’s RIASEC (Spokane
tive emotional state resulting from the appraisal of & Cruza-Guet, 2005). Tsabari and colleagues
one’s job or job experiences” (Locke, 1978, p. 1300). (2005) did find that the correlation was influenced
Job satisfaction has been most frequently measured by several moderators. First, the correlation varied
by the Job Descriptive Index (Smith, Kendall, & by vocational type. Only social types on Holland’s
Hulin, 1969) and the Minnesota Job Questionnaire RIASEC hexagon did not include 0 in the 95% CI,
(Weiss, Dawis, & England, 1967). although the effect was small ( ρ = .11). The correla-
Surprisingly, one salient predictor of job satisfac- tion also varied by the congruence index used. The
tion may be a genetic influence. Arvey, Bouchard, strongest congruence index was the Lachan index,
Segal, and Abraham (1989) presented evidence with with ρ = .22 with a 95% CI ranging from .18 to
monozygotic twins reared together versus apart that .25. Finally, the correlation varied by interest ques-
job satisfaction was dispositional, and as much as tionnaire; the relation was .09 when the General
30% of the variance was inherited. This may par- Occupational Themes from the SII were used, com-
tially explain the strong relationship of job satisfac- pared to the relation being .20 when the Self-
tion with life satisfaction (Fritzsche & Parrish, Directed Search was used.
2005). Dik (2006) also found moderators of the
One class of job satisfaction predictors has been congruence–job satisfaction relation in a sample of
dispositional traits ranging from broad traits to a spe- employed young adults. Congruence was associated
cific trait, locus of control. Connolly and Viswesvaran more with job satisfaction for participants who
(2000), in their meta-analyses, were interested in the placed less importance on their jobs and who per-
interaction of negative and positive affectivity with ceived less opportunity for active involvement in
job satisfaction. They also examined a third trait their work. Congruence was associated more with
labeled affective disposition, defined as the “tendency intrinsic job satisfaction than with overall job satis-
to respond to classes of environmental stimuli in a faction. The modified C index (Eggerth & Andrew,
predetermined affect-based manner” (Judge & Hulin, 2006) resulted in a higher mean congruence score
1993). Their meta-analyses (N = 6233, k = .27) did and had larger congruence–satisfaction correlations
find moderate relations of job satisfaction with posi- compared to other congruence indices’ correlations
tive affectivity (ρ = .49), negative affectivity (ρ = –.33), with satisfaction (Dik, 2006).
and affective disposition (ρ = .36). The next study Within the I/O literature, the environment has
was the examination of the Big Five personality been defined as the organization, rather than by
factors as antecedents of job satisfaction. Judge, Holland’s six types. Person–organization fit has also
Heller, and Mount (2002), in their meta-analyses been shown to be an antecedent of job satisfaction.
(N = 24527, k = 163), reported small effect sizes Verquer, Beehr, and Wagner (2003), in their meta-
concerning the relation of job satisfaction with neu- analysis ( k = 21), reported an effect size of ρ = .28.
roticism (ρ = –.29), extraversion (ρ = .25), and con- Type of fit, method of calculating fit, dimension of
scientiousness (ρ = .26). Finally, locus of control has fit, and use of established measure moderated the
also been examined as a specific dispositional attri- relation. Saks and Ashforth (1997) also reported a
bute; it was shown to correlate with job satisfaction significant relation between person–organization fit
at about .20 (Fritzsche & Parrish, 2005). and job satisfaction.
Holland’s supposition concerning congruence Other antecedents of job satisfaction have been
as predictive of job satisfaction has received con- examined. Perceived organizational support posi-
siderable attention. The most recent meta-analyses tively relates to job satisfaction with a strong effect
was conducted Tsabari and colleagues (2005; size (ρ = .62) (Rhoades & Eisenberger, 2002; k = 73,

l ar son 147
N = 13,719). A second meta-analyses (Podsakoff, ( ρs = –.27, .47), and personal accomplishment
LePine, & LePine, 2007; k = 183; N = 20, 943) dif- ( ρs = .49, –.34), and somewhat with turnover inten-
ferentiated stressors into hindrance stressors, which tions ( ρs = –.17, .28). Positive and negative affectiv-
consist of role ambiguity, organization politics, and ity did seem to differentially relate to emotional
job security concerns, from challenge stressors, exhaustion ( ρs = –.32, .62).
which consist of levels of workload, time pressure, Second, Thoresen and colleagues (2003) were
job scope, and responsibilities. In Podsakoff and interested in differentiating the role of dispositional
colleagues’ model, hindrance and challenge stressors traits of affectivity from more state-like affect. They
were thought to have an impact on job satisfaction speculated that an argument could be made that
directly and indirectly through strain. Hindrance trait affectivity should be more influential than state
stressors (i.e., role ambiguity, organization politics, affect because work attitudes have accumulated over
and job security concerns) were significantly related time; thus, trait affectivity that is consistent across
to job satisfaction ( ρ = –.57); challenge stressors many situations would have had a cumulative effect
were not related to job satisfaction. on job attitudes. On the other hand, state affect
Meta-analyses have been conducted on specific could be argued to be more influential because it is
populations, namely, nurses and people employed more proximal to job attitudes. Their findings
part-time versus full-time. Zangaro and Soeken showed little difference between the relation of job
(2007; k = 31, N = 14,567) examined nurses’ job attitudes with trait measures versus state affect mea-
satisfaction and only reported uncorrected correla- sures. Another meta-analysis by Rhoades and
tions. They identified three antecedents of job satis- Eisenberger (2002) examined perceived organiza-
faction yielding medium effects. They were the tional support as contributing to job attitudes.
relation of job satisfaction with autonomy ( r = .30), Perceived organizational support was defined as
job stress ( r = –.43), and nurse-physician collab- employees’ belief that the organization values their
oration ( r = .37). Thorsteinson (2003), in his meta- contribution and cares about their well-being
analysis ( k = 38, N = 51, 231), examined whether (Rhoades & Eisenberger, 2002; k = 73, N = 13,719).
part-time workers versus full-time workers would Job attitudes included organizational commitment
differ in job satisfaction. Thorsteinson reported (affective commitment and continuance commit-
no significant differences between part-time versus ment [resulting from accumulated personal interests
full-time workers on either global job satisfaction or binding one to the organization; Meyer & Allen,
any of the facets of job satisfaction. 1997]), job-related affect (job satisfaction and posi-
tive mood at work [general emotional state without
job attitudes a specific object; George, 1989]) job involvement
Although job satisfaction was examined individu- (identification with and interest in the specific work
ally, job satisfaction has also been considered as part one performs; O’Driscoll & Randall, 1999), strains
of a larger constellation of job attitudes. From this (aversive psychological and psychosomatic reac-
perspective, job attitudes include positive attitudes tions), desire to remain on the job, and intentions
toward the job (job satisfaction and affective com- to quit. Rhoades and Eisenberger (2002), in their
mitment [employee’s emotional attachment to, iden- meta-analysis, showed that perceived organizational
tification with, and involvement in the organization]) support was moderately related to all of the job atti-
and negative attitudes toward the job (burnout and tudes including job satisfaction ( ρ = .62), positive
turnover intentions). Thoresen, Kaplan, Barsky, mood at work ( ρ = .49), job involvement ( ρ = .39),
Warren, and Chermont (2003), in their meta-analyses strain ( ρ = –.32), desire to remain with organization
( k = 205, N = 62,527), hoped to elucidate the role ( ρ = .66), and turnover intentions ( ρ = –.51).
of emotions in predicting job attitudes. First, they The final meta-analysis that examined job atti-
differentiated affect into two dimensions: namely, tudes as outcomes was that by Humphrey, Nahrgang,
positive and negative affect. They expected that job and Morgeson (2007). They were interested in how
attitudes and performances that are positive and much job characteristics, social characteristics, and
negative should differentially relate accordingly to work context characteristics influenced job atti-
indices of positive and negative affect. However, tudes. The job attitudes included satisfaction with
their meta-analyses did not support this. Positive the job, growth, supervisor, coworkers, compensa-
affectivity and negative affectivity related moder- tion, and promotion. Job attitudes also included
ately with job satisfaction ( ρs = .34, –.34), affective organizational commitment, job involvement, and
commitment ( ρs = .35, –.27), depersonalization internal work motivation.

148 worklife ac ro s s th e l if es pan

 The job characteristics included autonomy (free- Job involvement correlated with all work character-
dom an individual has in carrying out work), skill istics except task identity and none of the social
variety (the extent to which an individual must use characteristics. Internal work motivation correlated
different skills to execute his or her job), task variety with all work characteristics except task identity and
(extent to which an individual performs different all social characteristics except social support
tasks), task significance (extent to which a job impacts (Humphrey et al., 2007).
others’ lives), task identity (extent to which an indi-
vidual can complete a whole piece of work), feedback organizational commitment
from the job (extent to which a job imparts informa- Organizational commitment has been defined as
tion about an individual’s performance), information consisting of three components; namely, affective
processing (extent to which a job necessitates an commitment (identification with and attachment to
incumbent to focus on and manage information), the organization), continuance commitment (result-
job complexity (extent to which a job is multifaceted ing from accumulated personal interests binding
and difficult to perform), specialization (extent to one to the organization), and normative commit-
which a job involves the performance of tasks requir- ment (sense of obligation to remain with the organi-
ing specific knowledge and skill), and problem solv- zation; Meyer & Allen, 1997). Several meta-analyses
ing (extent to which a job requires the production of identify some antecedents of organizational com-
unique solutions or ideas). Social characteristics mitment. The first antecedent identified was job sat-
included interdependence (extent to which a job is isfaction. One meta-analyses ( N = 39,187 k = 112)
contingent on others’ work and other jobs are depen- by Harrison, Newman, and Roth (2006) showed
dent on the work of the focal job), feedback from organizational commitment to be strongly related to
others (extent to which other organizational mem- job satisfaction ( ρ = .60). A second antecedent, per-
bers provide performance information), social sup- ceived organizational support (support in the orga-
port (extent to which a job provides opportunities nizational environment), also was strongly related
for getting assistance and advice from either super- to organizational commitment ( ρ = .67), as shown
visors or coworkers), and interaction outside the by Rhoades and Eisenberger (2002) in their meta-
organization (extent to which a job requires person analysis (k = 73, N = 13,719). Person–organization
to communicate with people outside the organiza- fit has also been shown in a meta-analysis to be an
tion). Work context characteristics include physical antecedent of organizational commitment (Verquer
demands (amount of physical activity or effort neces- et al., 2003; ρ = .31). An additional antecedent, hin-
sary for a job) and work conditions (aspects of the drance stressors (i.e., role ambiguity, organization
work environment such as health hazards, tempera- politics, and job security concerns), was identified
ture, and noise). The studies that measured work in Podsakoff, LePine, and LePine’s (2007) meta-
demands included only job satisfaction. analyses. They showed hindrance stressors (and not
Satisfaction with the job and satisfaction with challenge stressors) significantly related to organiza-
growth opportunities were moderately correlated tional commitment ( ρ = –.52). Finally, part-time
above |.20| with all the work characteristics and versus full-time job status did not differ by organiza-
social characteristics except satisfaction with growth tional commitment (Thorsteinson, 2003).
was not related to feedback from others. Job satis-
faction was also modestly correlated above |.20| global job performance
with work demands. Satisfaction with the supervi- Job performance has been defined in either a broad,
sor and coworkers was correlated above |.20| with global way or based on separating job performance
work characteristics except task identity and with into two facets. The global job performance assess-
social characteristics. Satisfaction with compensa- ment has dominated and has often been measured
tion was only correlated above |.20| with the work as a subjective global rating (e.g., supervisor ratings)
characteristics of autonomy and feedback from the and an objective global rating (e.g., salary or pro-
job and the social characteristics of feedback from ductivity). Job performance will be specified as
others. Satisfaction with promotion was correlated either a global rating (subjective and/or objective) or
above |.20| only with the work characteristics of task instrumental performance. The predictors or ante-
variety and feedback from the job and the social cedents thought to influence global job performance
characteristic of feedback from others. Organizational will be presented in the following order: cognitive
commitment was moderately correlated with all abilities and job knowledge, personality, SE, job sat-
work characteristics and all social characteristics. isfaction, and additional antecedents.

l ar son 149
 Cognitive abilities and job knowledge, although skilled workers, and semiskilled workers. Consci-
seldom researched in counseling psychology, have entiousness was related to job performance across
long been examined as an antecedent of work per- three criteria (job proficiency, training proficiency,
formance in I/O psychology (Borman et al., 2003; personnel data) with ρs ranging from .20 to .23.
Hough & Oswald, 2000). The general factor in When the subjective supervisory data was separated
intelligence, referred to as the g factor, is predictive from the objective data (i.e., turnover/tenure, pro-
of job knowledge, job performance, and training ductivity data, status change, and salary), the sup-
performance (e.g., Hunter & Hunter, 1984; Judge ervisor ratings yielded a higher relation ( ρ = .26)
et al., 2007; Levine, Spector, Menon, Narayanan, & than the mean of the objective ratings ( ρ = .10).
Cannon-Bowers, 1996; Schmidt & Hunter, 1998) Extraversion and openness to experience yielded
with the influence strongest for high-complexity relations with training proficiency of ρs =.26 and
roles (see Bormon et al., 2003). Research findings .25, respectively.
accumulated over 85 years, primarily in the United Researchers continue to examine the role of con-
States, suggest that a general cognitive ability test scientiousness in job performance. Dudley, Orvis,
plus a structured interview is highly predictive of Lebiecki, and Cortina’s (2006) meta-analysis (k = 42,
future job performance (Schmidt & Hunter, 1998). N = 7,342) examined if facets of conscientiousness
The potency of cognitive ability as a predictor of job (achievement, dependability, order, and cautious-
performance is cross-culturally robust. This relation ness) related to indices of job performance beyond
of cognitive ability to job performance and job the general trait of conscientiousness. In this study,
training was supported in a meta-analysis using only prior meta-analytic estimates were included. Given
German samples ( ks = 9, 90, Ns = 7,46,11,969) the lower internal consistency estimates in subscales,
with ρ values of .534 and .467 (Hülsheger, Maier, the uncorrected rs rather than the population esti-
& Stumpp, 2007). A meta-analysis using only mates are reported. None of the facets was related to
British samples (Bertua, Anderson, & Salgado, overall job performance (rs ranged from-01 to .13).
2005; k = 283, 223, Ns = 1,32,62,75,311) found Likewise, the facets did not relate to task perfor-
similar strong relations of cognitive abilities and spe- mance (rs ranged from .06 to .13).
cific abilities relating to job performance and train- Three meta-analyses have examined the relation
ing success ( ρs = .50, .48). Salgado and colleagues of SE (not generalized SE) to predict job perfor-
(2003) widened the cross-cultural meta-analytic mance (Judge et al., 2007; Sadri & Robertson,
examination to 11 European countries ( ks = 19, 15, 1993; Stajkovic & Luthans, 1998). Sadri and
Ns = 1,93,62,897) to examine the relation of cogni- Robertson ( k = 16, N = 1,658) showed that SE was
tive ability with job performance and job training related to performance overall ( ρ = .40) and behav-
across occupational groups. They also found similar ioral intentions ( ρ = .34). Stajkovic and Luthans
moderate to large relations between cognitive ability (1998) added more studies to those located in 1993
and job performance ( ρs range from .24 [police] by Sadri and Robertson ( k = 157, N = 21,616) and
to .67 [manager]; and training success ( ρs range found a relation of SE and performance overall of
from .25 [police] to .74 [engineer]). As with ρ = .36. They identified several moderators of that
American studies, job complexity moderated the relation. The magnitude of the relation was stron-
relation to both outcomes, in that more cognitively gest for simple tasks, decreasing for moderate and
complex positions yielded a stronger relation high task complexity. The relation of SE and perfor-
(Salgado et al., 2003). Job knowledge is also predic- mance was also lower in magnitude for field settings
tive of job performance and training performance, ( r = .37) compared to lab settings ( r = .60). Judge
especially in conditions of high job-test similarity and colleagues (2007), in the final meta-analysis,
( ρs = .62, .76) (Borman et al., 2003). used prior meta-analytic estimates and computed
Personality traits have gained prominence as ante- some that were not reported in the literature. They
cedents of job performance. One well-known meta- examined whether the relation of SE and perfor-
analysis is Barrick and Mount’s (1991) meta-analysis mance would be attenuated after the relation of per-
(k= 162, N = 23,994) of the Big Five and objective formance and distal influences—namely, the Big
and subjective indices of job performance. Objective Five, ability, and experience—had been taken into
indices were productivity, salary, turnover, tenure, account. These authors showed that the contribu-
and status change. Subjective ratings were supervisor tion of SE to work-related performance is much
ratings. Five occupational groups were examined; smaller once the distal variables were controlled.
namely, professionals, police, managers, sales people, Self-efficacy’s standardized regression coefficient

150 worklife ac ro s s th e l if es pan

was .13 in the prediction of work performance and behavior forming the core of the job. An example
nonsignificant. Significant unique predictors of work of instrumental performance would be productivity
performance were cognitive ability (β = .52), consci- (number of articles published). Contextual per-
entiousness (β = .26), and experience (β = .26). Col- formance, most commonly called organizational
lectively, the Big Five, experience, and cognitive citizenship behavior (OCB), has been defined as
ability and SE accounted for 46% of the variance in supporting the core of the job. An example of OCB
work performance. Significant predictors of SE were would be the willingness to serve on committees
cognitive ability, conscientiousness, extraversion, or assist other workers. The examination of OCB
emotional stability, and experience. will be reviewed immediately after instrumental
One of the most discussed predictors of global job performance. Several meta-analyses have exam-
job performance is job satisfaction. Harrison and ined instrumental job performance or task perfor-
colleagues (2006) found a robust relation between mance as distinct from global job performance. Task
job satisfaction and job performance ( ρ = .30). performance was positively related to perceived
Judge, Thoresen, Bono, and Patton (2001), in their organizational support ( ρ = .18) (Rhoades &
meta-analysis ( k =312, N = 54,417), showed job Eisenberger, 2002; k = 73, N = 13,719). Trust was
satisfaction and global job performance to be related also related to task performance ( ρ = .33) (Colquitt,
ρ = .30. (The uncorrected relation was .18.) Judge Scott, & LePine, 2007; k = 132, N = 7,284).
and colleagues (2001) presented seven alternative
models of the possible explanatory relation of job organizational citizenship behavior
satisfaction and job performance with each pre- Organizational citizenship behavior has also been
dicting the other, no relation, no relation due to called contextual performance or interpersonal facili-
a third variable, and a model showing reciprocal tation. Some studies have reported the antecedents
influence. of OCBs as distinct from task performance.
Situational antecedents of job performance Regarding personality traits, Dudley and col-
were looked at extensively by Humphrey and col- leagues (2006) in their meta-analysis examined if
leagues (2007). In their meta-analysis ( k = 259, the facets of conscientiousness (i.e., achievement,
N = 2,19,625), they divided situational antecedents dependability, order, and cautiousness) related to
into motivational work characteristics (e.g., task interpersonal facilitation. The relation of the facet
variety), social characteristics (e.g., social support), scores with interpersonal facilitation yielded nomi-
and work context characteristics (working condi- nal uncorrected correlations.
tions). Job performance was defined subjectively Harrison and colleagues (2006) showed OCB to
(e.g., supervisor ratings) and objectively (e.g., salary). be related to job satisfaction ( ρ = .28), organizatio-
No motivational, social, or work context character- nal commitment ( ρ = .25), and focal performance
istics in the work environment predicted objective or task performance ( ρ = .23). The relation of OCB
performance. Motivational (autonomy, task variety, with job satisfaction is very similar to the findings
task significance, feedback from the job, and job reported by Organ and Ryan (1995) in their earlier
complexity) and social (feedback from other) char- meta-analysis.
acteristics in the work environment related to sub- Several other predictors have been examined.
jective performance ( ρs range from .20 to .37). Person–organizational fit models have been shown
Person–organizational fit models have been shown to be predictive of OCB ( ρ = .21) (Hoffman &
to be predictive of job performance. Hoffman and Woehr, 2006). Perceived organizational support
Woehr (2006), in their meta-analyses ( k = 24), rep- was positively related to extra role job performance
orted significant effect sizes of person–organization (i.e., OCB) ( ρ =.22) in Rhoades and Eisenberger’s
fit indices that related positively to both objective (2002) meta-analyses. Trust was related to OCB
measures of job performance ( ρ = .25) and subjec- ( ρ = .27) in Colquitt and colleagues’ meta-analysis.
tive measures of job performance ( ρ = .26). Some authors have conceptualized OCB as mul-
tifaceted, and have identified five facets; namely,
instrumental job performance altruism toward individuals, compliance (labeled
The two facets of job performance (instrumental conscientiousness), sportsmanship (not complaining),
performance and contextual performance) have courtesy (consulting with others before acting), and
received increasing attention. Instrumental per- civic virtue (keeping up with matters that affect the
formance, also called focal performance, in role organization). LePine, Erez, and Johnson (2002), in
behaviors or task performance has been defined as their meta-analyses, showed that OCB facets did not

l ar son 151
differentially relate to predictors. Moreover, the above .20 to CWBs. These included job satisfaction
OCB facets correlated highly with each other. ( ρ = –.37), organizational commitment ( ρ = –.36),
All five facets related to predictors around .20 (job organizational justice ( ρ = –.25), conscientiousness
satisfaction, organizational commitment, fairness, ( ρ = –.38) (the uncorrected correlation was much
leader support, and the Big Five conscientiousness). smaller, r = .2), positive affect ( ρ = –.34), and nega-
LePine and colleagues then tried dividing the five tive affect ( ρ = .41). Dudley and colleagues (2006)
facets into two facets, namely OCB-Interpersonal reported a similar correlation for CWBs and consci-
(courtesy and altruism) and OCB-Organizational entiousness with an uncorrected correlation of –.16
(sportsmanship, civic virtue, and compliance), and and a ρ = –.26. The facet scale, dependability, was
still the results yielded no differentiation. The global also modestly related to CWBs ( r = –.21; ρ = –.34).
measure of OCB correlated highest with outcomes: Colquitt and colleagues (2007) recently showed
job satisfaction ( ρ = .31), organizational commit- trust to negatively relate to CWBs ( ρ = –. 33).
ment ( ρ = .32), fairness ( ρ = .31), leader support
( ρ = .41), and conscientiousness ( ρ = .13) (LePine turnover intentions/intention to quit
et al., 2002). Intentions to quit are defined as one’s desire or will-
Dalal (2005) examined the relation of OCB ingness to leave an organization. The theory of rea-
and counterproductive work behaviors in his meta- soned action (Ajzen, 2002) explains intentions as
analysis (k = 49; N = 16,721). He theorized the the mechanism that leads to the action of quitting.
explanatory mechanism of the relation between This vocational outcome has received considerable
OCB and counterproductive work behaviors attention in meta-analyses. In terms of affective ant-
(CWB) on the one hand and organizational justice, ecedents, Thoreson and colleagues (2003) in their
job satisfaction, and organizational commitment on meta-analysis showed intentions to quit to be related
the other. Employees respond to working condi- to negative affectivity ( ρ = .28) but not to positive
tions that are satisfying and workplace processes affectivity. One situational antecedent among many
that are fair by behaving in ways that benefit the examined was shown to relate to turnover inten-
organization and/or others (OCB). However, if tions, namely a social antecedent (feedback from
employees are dissatisfied and feel workplace pro- others) ( ρ = .34). Person–organization fit has also
cesses are not fair, then they behave in ways that been shown to be an antecedent of intentions to
are not helpful (CWB). The relation of OCB and quit (Verquer et al., 2003) ( ρ = –.21). Perceived
CWB was ρ = –.32 (Dalal, 2005). The two con- organizational support relates strongly to turnover
structs were split into two separate constructs, an intentions, with a ρ = –.51 (Rhoades & Eisenberger,
interpersonal OCB and an organizational OCB, 2002). Hindrance stressors also strongly related to
and an interpersonal CWB and an organizational turnover intentions ( ρ = .49), as reported by Pod-
CWB. Only the OCB-O and the CWB-O were sakoff and colleagues (2007) in their meta-analysis.
related ( ρ = –.33) (Dalal, 2005). It appears that part-time versus full-time workers
Dalal (2005) also examined antecedents of OCB are no more or less likely to have intentions of leav-
and CWB. Significant OCB antecedents were orga- ing their job (Thorsteinson, 2003).
nizational commitment ( ρ = .28), organizational
justice ( ρ = .20), conscientiousness ( ρ = .23), and withdrawal behaviors
positive affect ( ρ = .34). Job satisfaction and nega- Withdrawal behaviors are identified as those that pull
tive affect were not significant antecedents. He the- employees away from the organization and are often
orized that positive affect and negative affect should seen as precursors to quitting. Two meta-analyses
have an impact on OCB and CWB because affect is were located concerning withdrawal behaviors. Per-
arousal that entices action, with positive affect lead- ceived organizational support did relate to with-
ing to constructive action and negative affect lead- drawal behavior ( ρ = –.26) (Rhoades & Eisenberger,
ing to destructive action. The results suggest that 2002). Hindrance stressors were also related to
positive and negative affect may operate differently withdrawal behaviors ( ρ = .22) in Podsakoff and
on the two constructs. colleagues’ meta-analysis (2007).

counterproductive work behaviors quitting/turnover

These negative work outcomes have received some This outcome has been used as one behavioral nega-
attention. In the meta-analysis reported earlier, Dalal tive job outcome. Several meta-analyses examined
(2005) reported several antecedents that related turnover or quitting. It seems turnover is negatively

152 worklife ac ro s s th e l if es pan

related to job satisfaction ( ρ = –19), organizational objective (i.e., salary attainment, number of promo-
commitment (ρ = –.22), contextual performance tions) and subjective (job satisfaction, career satis-
( ρ = –.22) and absenteeism ( ρ = –.26). Person– faction). They examined four sets of predictors:
organizational fit models have been shown to be human capital (e.g., amount of work experience or
predictive of turnover ( ρ = .26) (Hoffman & Woehr, knowledge); organizational sponsorship, defined as
2006). Perceived organizational support did not the extent to which the organization provides spe-
relate to turnover (Rhoades & Eisenberger, 2002), cial assistance to employees to facilitate their career
but hindrance stressors did relate to turnover success (Dreher & Ash, 1990); sociodemographic
( ρ = .23), as shown by Podsakoff and colleagues’ variables; and stable individual differences. Each of
(2007) meta-analysis. One creative suggestion in these predictors will be discussed in order by exam-
the literature concerning the examination of turn- ining the outcomes of objective career success first,
over as a construct was made by Griffeth, Steel, followed by subjective career success.
Allen, and Bryan (2005). They suggested that schol- Objective career success was measured in the
ars needed to measure perceived job alternatives if meta-analyses by Ng and colleagues (2005) as salary
a person quits the job. Their intent was to capture attainment and number of promotions. The number
positive reasons for leaving a job rather than only of promotions was predicted by one organizational
negative reasons (e.g., lack of organizational sup- sponsorship variable—namely, training and skill
port). They proceeded to develop such a measure, development opportunities ( ρ = .23) (Ng et al.,
titled the Employment Opportunity Index (Griffeth 2005). Salary attainment had several significant
et al., 2005). predictors across all four sets of predictors. Salary
attainment was modestly related to human capital,
lateness including hours worked ( ρ = .24), organizational
Lateness has rarely been investigated in meta- tenure ( ρ = .20), work experience ( ρ = .27), and
analyses. Harrison and colleagues (2006) found educational level ( ρ = .29). Salary attainment
no relation with job satisfaction, organizational was also modestly related to organizational sponsor-
commitment, or contextual performance. Lateness ship, including career sponsorship ( ρ = .22) and
was negatively related to focal performance training and skill development opportunities
(i.e., task performance) (ρ = –.26) and absenteeism ( ρ = .24). Salary attainment was related to one
(ρ = –.29). sociodemographic variable, age ( ρ = .26), and one
individual difference variable, cognitive ability
absenteeism ( ρ = .27). Salary attainment was below the cutoff
Absenteeism appears to be unrelated to many of |.20| but in women modestly had lower salaries
vocational antecedents. No relation was identified than men ( ρ = .18).
between absenteeism and job satisfaction (Harrison Subjective career success in the Ng and colleagues
et al., 2006), organizational commitment (Harrison (2005) study was predicted by some human capital
et al., 2006), motivational work characteristics, variables, almost all the organizational sponsorship
social characteristics (social support), or work con- variables, and several individual difference variables.
text characteristics in the work environment Career satisfaction was predicted by two human cap-
(Humphrey et al., 2007). These results suggest that ital variables, hours worked ( ρ = .22) and political
absenteeism perhaps should be viewed not as knowledge and skills ( ρ = .28). Satisfaction was pre-
absence per se, but rather as a process in which dicted by three organizational sponsorship variables;
workers are drawn away from the workplace by namely, career sponsorship ( ρ = .44), supervisor sup-
valued features of their nonwork environment port ( ρ = .46), and training and skill development
(Fritzsche & Parrish, 2005). opportunities (ρ = .38). Career satisfaction was nega-
tively related to neuroticism ( ρ = –.36), and was
career success positively related to extraversion ( ρ = .27), proactiv-
One outcome that cuts across any given job is career ity ( ρ = .38), and locus of control ( ρ = .47).
success. Career success can be defined as the accu-
mulated positive work outcomes and psychological negative mental health outcomes
outcomes resulting from one’s work experiences Negative mental health outcomes identified from
(Seibert & Kraimer, 2001). In their meta-analysis this literature search included anxiety, stress, over-
( k = 52, N = 45,293), Ng, Eby, Sorensen, and load, burnout, and strain. Humphrey and col-
Feldman (2005) operationalized career success as leagues’ (2007) meta-analysis identified specific

l ar son 153
work characteristics categorized as motivational, people assess their lives both at the moment and
social, or work context features of the job environ- over longer periods. Life satisfaction is included
ment as being potential antecedents of anxiety, as one indicator of well-being, as is work satisfaction
stress, overload, and emotional exhaustion. Anxiety and family satisfaction (Walsh & Eggerth, 2005).
was related to motivational antecedents (i.e., feed- Research studies have accumulated showing that
back from the job) and social antecedents (i.e., feed- two of the Big Five are clear predictors of well-
back from others) in the work environment being; namely, emotional stability (negative loading
( ρs = –.32, –.23). Stress was related to motivational on neuroticism) and extraversion. DeNeve and
antecedents (autonomy), social antecedents (social Cooper (1998), in their meta-analysis, showed, in
support, feedback from other), and work context fact, that all of the Big Five factors (emotional
antecedents (work conditions) in the work environ- stability for neuroticism) were positively related to
ment ( ρs range from –.26 to –.42). Overload was subjective well-being ( k = 197; N = 42,171) . Walsh
related to motivational antecedents (task variety, and and Eggerth (2005) presented evidence showing
job complexity) in the work environment that adults who are in more congruent careers expe-
( ρs =.38, .59). Emotional exhaustion from burn- rience more subjective well-being. Lent (2004)
out was related to motivational antecedents (auton- reviewed well-being as a construct and differenti-
omy, task significance, task identify) and social ated well-being into subjective well-being as defined
antecedents (social support) in the work environ- by Diener (2000) and psychological well-being
ment ( ρ = –.28 to –.34). defined as “the striving for perfection that represents
Burnout’s three facets, emotional exhaustion, the realization of one’s true potential” (Ryff, 1995,
depersonalization, and personal accomplishment p. 100).
were examined in two meta-analyses. Thoreson and
colleagues (2003) related positive affect and negative Vocational Psychology and Diverse Groups
affect to emotional exhaustion ( ρs = –.32, .54), dep- Overview
ersonalization ( ρs = –.27, .39), and personal accom- Vocational psychology has a rich tradition of exam-
plishment ( ρs = .49, –.27). Halbesleben (2006) ining the vocational issues affecting women (e.g., see
found that social support did not yield different rela- reviews by Borgen, 1991; Buboltz, Ebberwein,
tions across the three burnout dimensions. Watkins, & Savickas, 1995; London & Greller,
Finally, strain was examined as an outcome of 1991; Loscocco & Roschelle, 1991). Race and eth-
hindrance stressors and challenge stressors in nicity have been salient in vocational psychology for
Podsakoff and colleagues’ (2007) meta-analysis. many years, with the emphasis on multicultural
Hindrance stressors predicted strain ( ρ = .56), as training and attention to local norms for career
did challenge stressors ( ρ = .40) (Podsakoff et al., assessment. However, issues related to race and eth-
2007). nicity have become more prominent in the field.
The positive development in the field is that research-
life satisfaction and well-being ers are collecting data specific to different racial and
Life satisfaction positively relates to job satis- ethnic groups, and career counselors are generating
faction. This positive relation provides support for tailored interventions specific to different groups,
the spillover model, which says that happiness in rather than collapsing across racial and ethnic
one area of life spills over into other areas of life groups. In the literature search, some reviews and
(Fritzsche & Parrish, 2005). Likewise, life satis- meta-analyses were identified concerning gender
faction relates to the Big Five factors in a similar and race and ethnicity.
way that job satisfaction relates to the Big Five, with
the exception of openness (DeNeve & Cooper, Gender
1998; Judge et al., 2002). In Judge and colleagues’ Changing demographics of women will be dis-
(2002) meta-analysis, life satisfaction and job satis- cussed first, followed by barriers and supports for
faction correlated negatively with neuroticism women. Issues pertaining to sex and schooling,
( ρs = –.30, –.29), and positively correlated with work–family conflict, and sexual harassment will
extraversion ( ρs = .22, .25), openness ( ρs = .18, 02), also be examined.
agreeableness ρs = .17, 21), and conscientiousness
( ρs = .26, .28). demographics
Wellbeing, also known as subjective well-being, Some statistics paint a picture of women in the
is defined by Diener (2000) as the way in which United States that words cannot. First, 75% of

154 worklife ac ro s s th e l if es pan

women aged 25 to 44 work outside the home, and may lead girls to be less interested in the physical
71% of mothers of children under 18 work outside sciences, engineering, and technology. Girls take
the home (2006 Current Population Survey Annual fewer technology/engineering courses in high school
Social and Economic Supplement). Second, the (Science and Engineering Indicators, 2008), and
probability is 90% that a woman will work outside then proceed to college where they earned only 22%
the home during her lifetime (Betz, 2006). Women of computer science bachelor’s degrees, 20% of
work because they have to; in fact, they earn a third engineering bachelor’s degrees, and 21% of physics
of their family’s total income (Bureau of Labor bachelor’s degrees in 2005 (Science and Engineering
Statistics, 2007). Third, the average marriage lasts Indicators, 2008). Not surprisingly, given those sta-
7 years (Betz, 2006). Moreover, there are 12 million tistics, college women compared to college men
single parents in the United States, and most of report lower SE in computer science, using technol-
them are women. One in four children live in a ogy, mechanical, and science SE compared to men
single-parent household (2007 Current Population (Betz, 2006; Fassinger, 2005). Moreover, college
Survey). Three out of four of the elderly poor are women compared to college men report less voca-
women (Betz, 2006). In short, even if a woman tional interests in the mechanical domain and com-
does spend some of her adult years out of the work- puter hardware and software domains (Donnay
force, it is probable that most of her time will be in et al., 2005).
the workforce. The reality is, women, like men, need Girls and women are reaching parity in some tra-
to work (Betz, 2006). ditionally male domains within the high school
Although American society often gives women classroom, and this carries on into higher education.
the message that work will be a stressor for them in High school girls, compared to boys, have completed
their multiple roles (e.g., mothers, workers), research more advanced biology courses and more chemistry
has shown that paid work outside the home is a pro- courses, and have completed equal amounts of
tective factor against women’s depression (Betz, coursework in advanced math courses included
2006). The most satisfied women were employed, trigonometry, pre-calculus, statistics, calculus, and
and the least satisfied women were homemakers. In advanced placement calculus (Science and Engi-
fact, women who were married and not working neering Indicators, 2008). Moreover, in college,
were the most distressed among married women women earned 51% of the bachelor’s degrees in
(Betz, 2006). agricultural sciences, 62% of the degrees in biological
sciences, and 52% of the degrees in chemistry
barriers (Science and Engineering Indicators, 2008). How-
Girls and women face barriers in the workforce. ever, these gains are not reflected in the percentage of
Employed women are paid 80% of what employed women faculty in those disciplines.
men are paid (Bureau of Labor Statistics, 2007). Russell (2006) suggested that the field needed
The pay gap is greatest for older versus younger career development theories in business settings that
women, and greater for white women compared to addressed the career preparation, career entry, and
white men. Women continue to dominate lower- career progression of women, while also taking into
paying jobs. The inadequacy of the parental leave consideration the reality of marriage or committed
policy is one workforce barrier that may contribute relationships, pregnancy, and childrearing. She iden-
to women’s dominance in lower-paying jobs. The tified a number of barriers, including insufficient
Center for Economic and Policy Research issued mentoring, being frequently not placed in positions
a report in September 2008 that provided evidence sequenced for advancement, inadequate attention
that the United States had the least generous family to long-range goals, lack of a supportive spouse, and
leave policies of the 21 countries examined (Ray, the glass ceiling preventing most women from
Gornick, & Schmitt, 2008). These structural prac- achieving top positions.
tices regarding childrearing contribute to mothers’ Women of color experience the barriers listed
(and fathers’) experience of role overload. above, but they also suffer the double jeopardy of
Educational barriers are also present. Girls may discrimination and racism (Worthington, Flores, &
experience the “null environment” in educational Navarro, 2005). Oppression in the workplace and
classrooms, meaning that teachers may not encour- in society at large contributes to their stress levels
age and support them (Betz, 2006). Sexual harass- (Fassinger, 2005). There are some notable differ-
ment continues to be a barrier for girls and women ences in the barriers across different ethnic groups.
(Betz, 2006). Occupational and gender stereotypes For example, African American women have long

l ar son 155
been in the workforce, but find themselves shut out Meece and Scantelbury (2006) identify multiple
of higher-paying or more prestigious jobs due to the issues salient for girls’ success in education and sub-
glass ceiling and due to discrimination and lack of sequently, in their careers. Within the school set-
societal supports, such as day care and affordable ting, most girls attending school observe that the
health care. Mexican American women may be majority of women are teachers, secretaries, or
more likely than women from other ethnic groups nurses, whereas the majority of men are administra-
to be dealing with sex role stereotypes and the tors, coaches, or custodians. The proportion of male
extended family’s expectations, and perhaps their characters continues to outnumber female charac-
own expectations, of needing to be exclusively ters in basal readers (Fleming, 2000). Boys seem to
focused on the family (Betz, 2006). continue to initiate more interaction with teachers,
and teachers call on boys more frequently (e.g.,
supports Altermatt, Jovanovic, & Perry, 1998). Girls drop
Girls and women’s career development and work out of high school at a lower percentage than do
adjustment can be facilitated by a variety of support boys (28% vs. 36%) but are less likely to return if
structures within the educational system, family, they do drop out. In spite of girls’ and boys’ aca-
and job. Parental support and parent availability demic achievement being identical, by elementary
are crucial to girls’ educational success. Support for school, girls rate themselves higher in verbal, social,
career adjustment includes having a supportive and reading abilities and lower in math, physical
spouse, supportive coworkers, and employers. Orga- science, and sports abilities; boys rate themselves in
nizational and structural changes to allow women the opposite direction. Some girls’ self-esteem may
to meet the demands of work and family are essen- drop from elementary to middle school. Girls from
tial. These changes could include job flexibility, job different racial and ethnic groups receive different
sharing, parental leave with pay, affordable day care, messages from mothers as they mature. For exam-
time off for family responsibilities, and telecom- ple, African American mothers expect daughters to
muting. Some of these structural changes are being be self-reliant, resourceful, and attain autonomy
implemented systematically at institutions of hig- (Collins, 1998). These girls are more likely than
her learning across the country. For example, the their male peers to earn a higher GPA, finish high
National Science Foundation has awarded over school, attend college, and enter white-collar careers
40 institutions institutional 5-year grants geared (Weiler, 2000). In contrast, Latina girls, especially
toward transforming the culture of those institu- those who are economically disadvantaged, are less
tions to make them more conducive to the hiring likely to extend education past high school and are
and retention of women faculty in the sciences, more likely to move into low-paying positions
technologies, engineering, and mathematics depart- (Kahle et al., 2000).
ments. Internal supports, such as a sense of agency
combined with communion or expressiveness, are work–family conflict
also crucial. Other internal supports include persis- Work–family conflict research cannot be adequately
tence, passion for one’s work, coping efficacy, and reviewed here. Readers are directed to Chapter 29
a sense of connection with others (Betz, 2006). of this volume (Eggerth & Cunningham, 2011)
for more detailed information, as well as for meta-
schooling analyses of the topic (e.g., Allen, Herst, Bruck, &
Education is the foundation upon which career suc- Sutton, 2000; Kossek & Ozeki, 1998; Mesmer-
cess is built. Women earn more college degrees than Magnus & Viswesvaran, 2005). Two of the most
do men, and a record number of women are earning recent reviews on the topic are discussed here.
law, medical, and business degrees (Meece & Work–family conflict has been examined as two
Scantlebury, 2006). Girls also outperform boys in constructs referred to as work interference with the
almost all school subjects, with the exception of family (WIF) and family interference with work
high school physics. Yet, in spite of these achieve- (FIW). The antecedents for these two consequences
ments, disparities continue to exist for girls in pri- have been separated into work variables (job involve-
mary and secondary schools due to some schools ment, hours spent at work, work support, schedule
supporting climates conducive for verbal abuse of flexibility, and job stress) and nonwork variables
girls, sexual harassment, and discrimination against (family/nonwork involvement, hours of nonwork,
girls who are lesbian, bisexual, or transsexual (Kahle, family support, family stress, family conflict, number
Meece, & Scantlebury, 2000). of children, age of youngest child, marital status,

156 worklife ac ro s s th e l if es pan

spousal employment), and demographic variables workplace harassment
(sex, income, and coping style). The meta-analysis Workplace harassment is a major concern for men
( k = 61, N = 7,034) by Byron (2005) showed that and especially women with regard to their quality of
WIF was related above |.20| to all the work variables life at work. Bowling and Beehr (2006), in their
except job involvement ( ρs range from +/– .26 meta-analysis ( k = 90, N = 17,663), present an attri-
to .48) and family stress and family conflict butional model identifying the antecedents and
( ρs = .30, .35). The FIW construct was related consequences of workplace harassment. The model
above |.20| with the work variables schedule flexibility explains why negative consequences occur both to
and job stress ( ρs = .29, .29), and nonwork variables the self (blaming self leading to negative mental
(family/nonwork involvement, hours of nonwork, health outcomes), the perpetrator (blaming per-
family stress, family conflict, and age of youngest petrator impacting organizational justice), and the
child) with ρs ranging from +/– .21 to .32. Gender organization (blaming organization impacting indi-
yielded a non-zero relation with both WIF and FIW, vidual performance outcomes). The model presents
but its effect was marginal ( ρs = –.03, .12). However, the norm of reciprocity and attributional processes
gender and being a parent did moderate the relation of either blaming the organization and/or blaming
between job stress and WIF and FIW. Specifically, the self as a means of explaining the processes
when there were more parents in the sample, women involved in the consequences of workplace harass-
experienced more WIF and FIW than did men; ment. In their meta-analysis, Bowling and Beehr
when there were fewer parents in the sample, men reported workplace harassment related to some
experienced more WIF and FIW than did women. antecedents of harassment (i.e., role conflict, role
Also single parents had more WIF and FIW than ambiguity, role overload, work constraints, and
did parents who were married; married and single victim negative affectivity) with ρs ranging from
employees without children had similar levels of |.25 to .53|. (Sex was not related to workplace
WIF and FIW. harassment.)
Ford, Heinen, and Langkamer (2007) examined The consequences of workplace harassment
many of the same variables in their meta-analysis included negative impact on the victim’s well-being
( k = 120, N = 42,804). Like Byron (2005), they and on his or her job performance. Specifically,
found job stress, work support, and work hours to be workplace harassment was negatively correlated
related above |.20| to WIF ( ρs range from +/– .25 with the victim’s well-being (i.e., positive emotions
to .56.) They also did not find job involvement at work, self-esteem, life satisfaction, job satisfac-
to be related above |.20| to WIF. The prediction tion, organizational commitment), with ρs rang-
of FIW with family variables was similar to Byron ing from –.21 to .–39. Workplace harassment was
regarding the predictors family stress and family positively related to negative indices of well-being
conflict ( ρs = .27, .26), but not family hours (i.e., generic strain, anxiety, depression, burnout,
and family support. They also showed that WIF frustration, negative emotions at work, and physical
contributed additional variance (2%) to family symptoms), with ρs ranging from .31 to .46.
dissatisfaction after family variables were controlled Workplace harassment was positively related to the
for; FIW did not contribute additional variance to victim’s negative performance outcomes (CWBs,
job dissatisfaction after work variables were con- turnover intentions) ( ρs = .29, .30), and negatively
trolled for. Like the Byron meta-analysis, gender related to organizational justice ( ρ = –.35). Finally,
exerted few direct effects on WIF or FIW; however, Bowling and Beehr showed that workplace harass-
sex had an impact on the job stress–family satis- ment added incremental validity to the prediction
faction relation such that, for women, job stress had of the consequences of harassment after other stres-
a smaller negative correlation with family satisfac- sors had been controlled.
tion than for men. Also, the percentage of the
sample that had children was a moderator bet- Race and Ethnicity
ween work hours and family satisfaction, such that Two reviews and four meta-analyses, all of which
work stressors had a strong negative effect on family were published in the past 5 years, suggest vitality
satisfaction for individuals with children. Both stud- and integrative efforts occurring in the field exclu-
ies imply that parenthood, marital status, and sively focused on racial and ethnic groups and voca-
gender need to be considered as moderators in the tional psychology. In addition, one large-scale study
relation of work and family antecedents on WIF is included that has examined the structure of inter-
and satisfaction. ests across racial and ethnic groups in the United

l ar son 157
States (Day & Rounds, 1998). Career choice will be job knowledge tests, absenteeism, salary, promo-
discussed first, followed by the structure of interests, tion, accidents, and commendations–reprimands.
then job satisfaction and job performance. Finally, Of those 12 criteria, only one outcome—namely,
workplace learning and development will be briefly job knowledge tests—was notably different for
discussed. African Americans and Caucasians (d = .53, with a
90% CI of .33 to .74). Caucasians scored higher on
career choice variables job knowledge tests than did African Americans.
Culture and choice variables were examined by Caucasians and African Americans’ means did not
Fouad and Byars-Winston (2005). In their meta- differ more than d = .5 on the dimensions of task
analysis, they located 16 studies that examined performance, contextual performance, personality-
either career aspirations, perceptions of opportuni- applied social skills, on the job training, overall job
ties and barriers, and tasks related to decision performance, work samples, absenteeism, salary, pro-
making and exploration with a sample size of 19,611 motion, accidents, and commendations–reprimands.
high school or college students. Career aspirations/ Turnover was also not significantly different.
career choice did not differ between racial and
ethnic groups ( g = .01). (Hedge’s g is very similar to workplace career development,
Cohen’s d ). Career exploration/career decision promotion, and performance appraisals
making also did not differ between groups ( g = .23, Brooks and Clunis (2007) reviewed research over
ρ > .05). Career expectations and perceptions of the past 25 years in the U.S. workforce. Career
opportunities and barriers did differ across racial development, promotion, and performance apprais-
and ethnic groups ( g = .38, ρ < .02). The CI was als were three of the seven topics. Research concern-
large, ranging from .06 to .69. Racial/ethnic minor- ing Asian Americans and Latinos was much more
ities perceived fewer career opportunities and more limited than African American studies.
career barriers than did white individuals. Career development articles mostly focused
on supports, barriers, and strategies. Supports iden-
structure of interests tified included opportunity for feedback, access to
The structure of interests does not appear to differ information, interactive learning processes, and
across African Americans, Mexican Americans, conducive environments. Barriers for African
Asian Americans, Native Americans, and Caucasians; Americans included structural factors in the work-
( N = 49,450). This finding comes from a definitive place (e.g., lack of diversity), existence of a “good
article by Day and Rounds (1998), who examined old boy” network, lack of mentoring, and lack of
the circular structure of Holland’s six vocational adequate succession planning, prejudice, stereo-
types using the Revised Unisex Edition of the ACT types, and discrimination (Palmer & Johnson-
Interest Inventory (UNIACT; Swaney, 1995). These Bailey, 2005). Also, African Americans were more
findings concerned students going to college, likely to be denied training requests, be steered away
although similar results were found for tenth-grade from management track titles, be discouraged from
students regardless of whether they were going to seeking professional promotion opportunities, and
college (Day et al., 1998). have the requirements increased regarding promo-
tion (Brooks & Clunis, 2007). Models focused on
job performance women are insufficient for African American
McKay and McDaniel (2006) is the most recent women. Coping strategies that have been used suc-
meta-analysis ( k = 97, N = 1,09,974) comparing cessfully by women include networking, education
African Americans and Caucasians in terms of job and training, career self-management, mentoring,
performance. Their dataset includes many of the and supervisor support. Hispanic men and women’s
same studies that Roth, Huffcutt, and Bobko (2003) chance of promotion centered on English fluency,
reviewed, so the focus will be on McKay and whereas the non-Hispanic whites’ chance of promo-
McDaniel’s review. The effect size used in this study tion centered on years of education (Mundra,
was Cohen’s d. Medium effects or larger ( d ≥ .5) will Moellmer, & Lopez-Aqueres, 2003).
be discussed to allow the reader to focus on salient Performance attainments have been examined in
effects. McKay and McDaniel examined the follow- terms of bias in the ratings of employees based on
ing outcomes: task performance, contextual perfor- rater race. Most of the studies were atheoretical.
mance, personality-applied social skills, on the job Most studies show African Americans to be at a dis-
training, overall job performance, work samples, advantage regarding promotion, regardless of rank,

158 worklife ac ro s s th e l if es pan

and theories suggest that some workplaces may have extrinsic rewards and security compared to their
embedded practices and policies that may inadver- white counterparts (Leong, 1991). One study found
tently be discriminatory (e.g., extraversion of worker Asian Americans lower in career maturity compared
positively influencing ratings having nothing to do to white counterparts (Hardin, Leong, & Osipow,
with extraversion). 2001). The authors noted that career maturity
implies independent decision making (Crites,
asian american career development 1978); the interdependent decision making valued
Asian Americans, compared to other ethnic groups, in an Asian context implies more career immaturity
may be more encouraged by family members to (Hardin et al., 2001).
pursue occupations in the sciences and to pursue Work adjustment and vocational problems have
advanced degrees (Leong & Gupta, 2007). It seems been noted both for Asian immigrants and Asian
that Asian Americans may express more investiga- Americans in general. Immigration may result in
tive interests than creative or enterprising interests lower occupational prestige (Cheng, 1996). Lan-
(Leung, Ivey, & Suzuki, 1994). A report from the guage issues and acculturative stress are common
Division of Science Resources Statistics within for first-generation Asian Americans (Matsuoka &
the National Science Foundation in 2008 showed Ryujin, 1989). As employed Asian Americans
that Asian Americans, compared to other racial and become acculturated, their job satisfaction seems
ethnic groups (i.e., white, non-Hispanic and black, to increase (Leong, 2001). However, even with
non-Hispanic) were enrolled in more pre-calculus, Asian Americans who are not immigrants or first-
calculus, advanced placement calculus, chemistry, generation Americans, it appears that Asian
and physics courses during high school. Compared Americans as a group, compared to a group of
to other groups, they were twice as likely to European Americans, were less satisfied with their
choose an engineering discipline. Within the sci- jobs (Weaver, 2000). One reason for lower job satis-
ences, Asian Americans chose biology and compu- faction may be that Asian Americans in the work-
ter science more than did their white counterparts. force may report being more underemployed than
For those Asian Americans who earn a college white counterparts (Madamba & De Jong, 1997).
degree, 50% of them earn science and engineer- They also may be experiencing more social anxiety
ing degrees. For non-Asian Americans earning a than white counterparts (e.g., Hardin & Leong,
college degree, about 33% of them earn science and 2005), which may also contribute to job dissatisfac-
engineering degrees (Science and Engineering tion. Finally, Asian Americans may be experiencing
Indicators, 2008). A higher proportion of them additional financial strain if caring for an extended
compared to white counterparts aspire to either a family (Leong & Gupta, 2007).
doctorate or medical degree. Interestingly, Asian Within the work setting, Asian Americans have
Americans, especially women, aspire to more male- been shown to suffer discrimination. For example,
dominated occupations than do their European Asian Americans, compared to Caucasians, were
American counterparts (Leong & Gupta, 2007). not selected by classmates to be team managers in
The imbalance of college degrees across Holland’s mini-assessment centers set up in organizational
typology shows up in studies concerning the career behavior classes (Cheng, 1996). Occupational ste-
choices of Asian Americans and the occupations they reotyping was demonstrated by Leong and Hayes
select. Asian Americans were over-represented in (1990), who showed respondents thought Asian
career choices that were in the realistic and investiga- Americans were more likely to be successful as com-
tive domains according to Holland’s typology (Tang, puter scientists, engineers, and mathematicians and
Fouad, & Smith, 1999). This is consistent with the less likely to be successful as insurance sales people.
findings that Asian Americans in the workforce seem Occupational discrimination has also been docu-
to be over-represented in medicine and under-repre- mented against Asian American scientists and engi-
sented as managers (Leong & Gupta, 2007). neers within U.S. universities (National Science
Asian American’s values have been examined Foundation, 2004) and against women physicians
across individual studies with no consensus. Chinese (Corbie-Smith, Frank, Nickens, & Elon, 1999).
American children’s most important values in one More research is needed in all these areas, and the
study were money and task satisfaction (Leong & research needs to move beyond descriptive research
Tata, 1990). Occupational prestige was important to identify underlying processes that may explain
in a second study (Leung et al., 1994). A third study racism and discrimination. The focus on cultural
found Asian American college students valued more moderators such as cultural identity, acculturation,

l ar son 159
and SES will be much more illuminating than been discussed in this chapter. The quote also ampli-
simply describing differences between various groups fies how the educational and vocational choices
(Leong & Gupta, 2007). people make beginning in childhood and continu-
ing throughout adulthood are impacted by indi-
asian american educational experience. vidual differences. That is perhaps why vocational
Asian Americans’ educational experience can be psychology is rooted in the individual difference tra-
split into positive and negative outcomes. Often dition in psychology. Moreover, the quote reflects
viewed as the model minority, evidence has accu- counseling psychology’s emphasis on the individu-
mulated to verify that their academic successes are ality of each student and client. The foundation of
mostly comparable to European Americans and individual difference research lies in the understand-
greater than other American racial and ethnic ing that people differ in magnitude of any charac-
minority groups like Native Americans, Hispanics, teristic they possess (Dawis, 2005) and that the
and African Americans (Tseng, Chao, & Padmawjaja, range is five to six standard deviations or more
2007). Based on large, nationally represented sam- (Dawis, 2005; Lubinski, 2000) compared to the
ples collected over years (Tseung et al., 2007), much smaller (most often less than Cohen’s d of .5)
academic achievement in third grade (Rathbun, effect size of group differences (e.g., sex differences
West, & Germino-Hausken, 2004), middle school and racial and ethnic differences).
(Kao, 1995; Kao, Tienda, & Schneider, 1996), and Not surprisingly, individual differences, espe-
high school (National Center for Educational cially interests and personality traits, repeatedly
Statistics, 2001, 2002, 2003a,b) was demonstrated emerged as salient predictors of vocational outcomes
to be comparable to European Americans and supe- like educational aspirations, career choice, affective
rior to other racial and ethnic minority groups commitment in the job, job satisfaction, job perfor-
after controlling for contextual variables (e.g., SES, mance, intentions to quit, CWBs, career success,
sex). Asian Americans and European Americans, in career satisfaction, and mental health outcomes
comparison to other ethnic groups, reported lower (e.g., Lubinski, 2000). A discussion of individual
percentages of high school dropout rates, higher differences needs to start with a foundation in heri-
undergraduate graduation rates, and higher stan- tability. Following heritability, cognitive ability, per-
dardized test scores in mathematics (Tseng et al., sonality traits, interests, and values will be reviewed
2007). as they pertain to vocational outcomes. Finally, inte-
The negative outcomes that Asian Americans grative work in which more than one individual dif-
experience occur outside the classroom and often ference variable is examined will be presented.
are due to racism that results in peers resorting to
verbal abuse, physical harassment, and intimidation Heritability
(e.g., Juvonen, Nishina, & Graham, 2000; Kao, Heritability can be defined as the proportion of vari-
1995). This behavior is interwoven with SES, immi- ance in an observed trait that can be traced to genetic
gration status, language elitism (“In America, every- variation in the population (L. S. Gottfredson,
one should speak English”), and peers resenting 2002). It can range from 0% of the variance in
positive teacher reactions toward Asian Americans a trait due to genetics—meaning the variation is
(Gibson, 1988; Tseng et al., 2007). all due to nurture or the environment—to 100% of
the variance in a trait due to genetics—meaning that
Vocational Psychology and the variation is all due to nature. Scholars in voca-
Individual Differences tional psychology have begun to acknowledge the
accumulated evidence across multiple studies that
We inherit dispositions, not destinies. Life
children are born predisposed toward certain traits,
‘vocational’ outcomes are consequences of lifetimes
attitudes, and behaviors (Gottfredson, 2002).
of behavior choices. The choices are guided by our
For the domain of vocational psychology, the
dispositional tendencies and the tendencies find
facts accumulating about heritability are startling.
expression within environmental opportunities that
The variation in interests due to nature appears to
we actively create.
be about 40% (Betsworth et al., 1994; Lykken,
(Rose, 1995, p. 648)
Bouchard, McGue, & Tellegen, 1993). The herita-
This quote clearly explains how dispositional bility of personality traits appears to be around 50%
tendencies—namely, individual differences—are (Tellegen et al., 1988), whereas the heritability
interwoven into the vocational outcomes that have of cognitive abilities appear to be around 70%

160 worklife ac ro s s th e l if es pan

(Bouchard, 1998). Work values appear to be also (1994) predict performance and persistence in edu-
partly due to nature, although the variance due to cational and occupational pursuits (Lent et al.,
genetic variation is lower than interests, personality, 1994). One of the exogenous variables is ability,
and cognitive abilities, around 35% (Arvey, McCall, which directly affects SE and outcome expectations
Bouchard, Taubman, & Cavanaugh (1994). Self- and performance attainment level. Krumboltz’
rated competence across academic and social social learning theory (e.g., Mitchell & Krumboltz,
domains appears to be influenced by nature as well, 1996) also sees cognitive ability as an antecedent to
with a 50%–60% heritability estimate reported instrumental learning.
(McGuire, Neiderhiser, Reiss, Hetherington, & Cognitive ability, measured most commonly by
Plomin, 1994). Interestingly, some vocational out- the g factor, is a major attribute in educational
comes appear to also be substantially influenced by achievement (Benbow & Stanley, 1996; Snow,
nature, including level of education (60%–70%), 1996). Cognitive ability is also a potent attribute in
occupation (50%), and income (40%–50%) job performance and job training (e.g., Hunter &
(L. S. Gottfredson, 2002). Finally, overall job satis- Hunter, 1984; Judge et al., 2007; Levine et al., 1996;
faction appears to be partially attributed to nature, Schmidt & Hunter, 1998). Moreover, the more
with a heritability estimate of 30% (Arvey et al., complex the job or training demands, the more
1994). important cognitive ability becomes. These results
The influence of nature extends beyond the have also been supported cross-culturally with
person to interaction with the environment. Behav- German samples (Hülsheger et al., 2007), British
ioral geneticists have come to understand that the samples (Bertua et al., 2005), and samples from 11
environmental social context of the person is also in European countries (Salgado et al., 2003).
part due to nature, based on the people in the envi- Cognitive ability has also been shown to over-
ronment. “Behavioral genetic research consis- shadow the contribution of SE in the prediction of
tently shows that family environment, peer groups, work performance. Judge and colleagues (2007), in
social support, and life events often show as much their meta-analysis, examined whether the relation
genetic influence as do measures of personality” of SE and performance would be attenuated after
(Plomin, DeFries, McClearn, & Rutter, 1997, the relation of performance and distal influences,
pp. 203–204). People have differential suscepti- namely the Big Five, ability, and experience, were
bility to the same environment based on their taken into account. Self-efficacy’s standardized
internal predispositions. Nonshared (environmental regression coefficient was nonsignificant ( β = 13) in
influences not shared by siblings such as peer the prediction of work performance, whereas cogni-
groups), rather than shared, environmental influ- tive ability ( β = .52), conscientiousness ( β = .26),
ences have an impact on the development of general and experience ( β = .26) were significant. In that
traits. In sum, vocational psychologists need to same meta-analyses, Judge and colleagues also
better understand the processes involved in how showed cognitive ability (r = .20) to be predictive
and why and in what contexts individual difference of SE itself.
variables have the most impact on vocational psy- Finally, cognitive ability was shown to be an
chology (L. S. Gottfredson, 2002). antecedent in objective career success (i.e., salary) in
a meta-analysis (Ng et al., 2005). In fact, salary
Ability was related above .20 to only one individual dif-
Cognitive ability has been identified in many of the ference variable; namely, cognitive ability (ρ = .27;
theories of vocational psychology. Dawis postulates Ng et al., 2005). Ng and colleagues (2005) did
in his TWA that cognitive ability is the general not find cognitive ability related to the other objec-
dimension that underlies groups of acquired skills. tive indicator of career success; namely, number of
The work environment requires particular skills of promotions.
the individual for the job to be satisfied with the The general g factor appears quite salient in
person, or for the person to achieve satisfactoriness important vocational outcomes. As Lubinski (2000)
(Dawis, 2005). Holland’s theory (1997) includes clarifies, the measures of cognitive ability seem to
ability as part of the broad definition of the person capture one’s ability to learn as long as cognitive
including their interests, skills, abilities, and values. ability refers to ability to learn complex processes
Likewise, Super, in the career construction theory, and skills and that a different mix of those constitu-
hypothesizes that one’s vocational personality ents may be required in different learning tasks and
includes abilities. In SCCT, Lent and colleagues settings.

l ar son 161
Interests influences include parents’ actions in what activities
Interests seem to be stable dispositional tendencies they offer and reinforce to children (manual labor
that guide, direct, and maintain one’s actions toward not reinforced as career choice in homes with pro-
certain activities and away from other activities (Low fessional parents). Other influences include teachers
& Rounds, 2006). In many vocational psychology who encourage learning or engage the student
theories, interests have played a central role. The (Meece & Scantlebury, 2006). Mastery, modeling,
most obvious example is Holland’s P–E fit theory, in feedback, and responsiveness to the context (women
which interests form the core of the person side of being encouraged to be primary caretaker for small
the equation, and the match occurs when a person children) may encourage or discourage certain inter-
seeks out an environment that allows her or him to ests (Betz, 2006). Social and cultural influences are
express interests in a compatible educational or work potent, as illustrated by the scarcity of women in the
environment. In SCCT, interests become the crite- U.S. Senate and House of Representatives.
rion variable, with SE and outcome expectations Interests have been studied as outcomes of
hypothesized as the primary determinants of the personality traits, SE, and outcome expectancies.
development of interests over time (Lent et al., Scholars have ascertained that some personality
1994). In Super’s career construction model, inter- traits overlap with some of Holland’s six interests
ests are part of the objective P–E fit aspect of the (Barrick, Mount, & Gupta, 2003; Larson,
vocational personality (Savickas, 2005). Rottinghaus, & Borgen, 2002) and that specific
Interests have been one of the most researched facets of personality predict specific interests
constructs in vocational psychology. This may be (Staggs, Larson, & Borgen, 2003; Sullivan &
due to the early construction of E. K. Strong’s Hansen, 2004). Self-efficacy across Holland’s hexa-
Vocational Interest Blank (1927) and the popularity gon and across specific academic domains has been
of Holland’s hexagonal structure of interests. It moderately predictive of parallel interests
seems clear that interests are, in large part, due to (Rottinghaus, Larson, et al., 2003). Interests have
nature (e.g., Betsworth et al., 1994) and that they also been shown to influence SE bidirectionally
are relatively stable across time (e.g., Hansen & (Nauta et al., 2002; Tracey, 2002). Domain-specific
Swanson, 1983; Low & Rounds, 2007; Low et al., outcome expectations, particularly in math/science
2005; Rottinghaus et al., 2007; Strong, 1955). domains, have been predictive of parallel domains
Interests also appear to be robust for single individ- of interests (Lent et al., 1994: Young et al., 2004).
uals over time (Low & Rounds, 2006) and stable in Interests have been shown to be potent predic-
the relative placement of individuals within a group tors of other vocational outcomes. The most well-
(Low & Rounds, 2006). In fact, there is some evi- known outcome is educational major and career
dence that interests may be more stable than per- choice. Vocational interests across Holland’s hexa-
sonality, despite the assumption of many scholars gon have shown to be robust in discriminating
that personality traits are the developmental ante- among diverse educational majors (Gasser et al.,
cedents of interests. Low and Rounds (2006) 2007; Harmon et al., 1994) and among diverse
reported stability coefficients for interests that were occupational choices (e.g., Ackerman & Beier,
consistently more stable than the personality traits’ 2003; Donnay & Borgen, 1996; Donnay et al.,
stability coefficients reported in Roberts and 2005; Harmon et al., 1994). Basic domains of inter-
DelVecchio (2000) across ages 12 to 40. Moreover, ests (e.g., Basic Interest Scales of the Strong) com-
the structure of interests seems to be circular (the six pared to the six Holland domains have been shown
dimensions are not equidistant and may not be all to be superior predictors of both educational major
inclusive), with the six dimensions of Holland rep- and occupational choice (e.g., Betz et al., 2003;
resenting an excellent typology across multiple racial Donnay & Borgen, 1996, 1999; Gasser et al., 2007;
and ethnic groups in the United States (Armstrong, Larson, Wu, et al., 2010; Rottinghaus, Betz et al.,
Hubert, & Rounds, 2003; Day & Rounds, 1998), 2003). Interests across Holland’s dimensions have
across men and women in the United States (e.g., also been shown to be predictive of educational
G. D. Gottfredson, 1999; Low & Rounds, 2006), aspirations (Rottinghaus et al., 2002).
and cross-culturally (Low & Rounds, 2006; Rounds Finally, a specific type of vocational interest—
& Tracey, 1996). namely, interest in math/science content—has been
Interests, despite their stability, do interact with shown to predict course intentions (Young et al.,
the near environment to yield changes in interest 2004). Course interests remained significant pre-
patterns (G. D. Gottfredson, 1999). Environmental dictors of intentions even after parallel outcome

162 worklife ac ro s s th e l if es pan

expectations were controlled (Young et al., 2004). somewhat to differentiating among Taiwanese
Researchers have paid less attention to the role college students who had chosen one of four majors,
of interests as antecedents to job outcomes. One namely, accounting, engineering, counseling, or
meta-analysis (Hunter & Hunter, 1984) did report finance. For example, female counseling majors
a nominal mean correlation of interests with job were more agreeable and less conventional than
performance ( r = .10). were female finance majors. Male counseling
majors were more agreeable and less neurotic than
Personality Traits were the male finance majors. Ackerman and Beier
As opposed to interests that move people toward or (2003) also found that personality traits were part
away from activities, personality traits appear to of a set of trait complexes (composite traits of abil-
affect how a person copes with or adapts to an envi- ity, interests, and personality traits) that differenti-
ronment (Low & Rounds, 2006). Interestingly, ated among adults’ retrospective undergraduate
personality traits are not central in any of the well- college majors.
known vocational psychology theories and are, at Regarding the influence of personality traits on
best, distal exogenous predictors in some models, specific interests, Staggs and colleagues (2003),
like SCCT (Lent et al., 1994). showed in a hierarchical multiple regression that
Personality traits have received enormous atten- primary personality traits more specific than the Big
tion in their motivational role as antecedents of Five or the Big Three (Tellegen, 2000) were signifi-
a host of vocational outcomes. This is surely due cantly predictive of some basic interests even after
to the popularity of research involving the Big the variance due to the salient general trait had been
Five and negative and positive affectivity. Positive removed. For example, after removing variation due
and negative affectivity (labeled most recently by to constraint, harm-avoidance scores (person who
Tellegen [2000] as positive emotional temperament scores low tends to prefer excitement and danger;
and negative emotional temperament) are viewed as avoids safe activities because they are tedious
alternative higher-order affective dimensions to the [Tellegen, 2000]) contributed an additional 17%
Big Five. These two superordinate factors, along of the variance in the prediction of scores on the
with a third factor, constraint, were conceptualized Strong Basic Interest Scale, mechanical activities.
by Auke Tellegen (1982, 2000) and measured by Sullivan and Hansen (2004) showed that facet scales
the Multidimensional Personality Questionnaire of the Big Five captured most of the variance in
(MPQ; Tellegen, 1982, 2000; Tellegen & Waller, some Basic Interest Scales, leaving no significant
2008). The constraint factor captures behavioral variation due to the Big Five traits. For example,
regulation. Under these three factors are 11 primary they showed that the openness scores did not add
traits (Tellegen, 2000) labeled well-being (happi- unique variance to the prediction of the five artistic
ness), achievement (works hard), social potency Basic Interest scales (music/performing arts, art/
(forceful and decisive), social closeness (sociability), design, writing, international activities, fashion, and
absorption (entranced by evocative sights and culinary arts) after the variation due to one of open-
sounds), stress reaction (worry, vulnerable), aggres- ness’ facet scales, the aesthetics facet scale, had been
sion (victimizer), alienation (victim), control (cau- removed.
tious, careful), traditionalism (social conservative), Finally, Larson and Borgen (2006) wanted to
and harm-avoidance (chooses safe and boring over ascertain the relation of dimensions of vocational
danger). There is very little overlap among these SE (or confidence) across Holland’s hexagon and
traits, and strong psychometric properties exist Tellegen’s Big Three and his 11 primary traits
behind each one. (Tellegen, 2000). Across four samples of college
There has been a resurgence of scholars examin- students, they found positive emotional tempera-
ing personality traits in interest development and ment related substantially to all of Holland’s
career choice of college students (e.g., Ackerman & SE dimensions except conventional confidence
Beier, 2003; Larson & Borgen, 2006; Larson et al., ( rs range from .19 to .66). Moreover, social potency
2007; Staggs et al., 2003; Sullivan & Hansen, was associated with artistic, social, and enterprising
2004). Several studies examined choice of major, confidence ( rs range from .24 to .66). Achievement
contribution of personality traits in specific inter- correlated with investigative and enterprising con-
ests, and relation of personality traits and SE. fidence ( rs range from .19 to .34); well-being cor-
Regarding choice of major, Larson and collea- related with social and enterprising confidence
gues (2007) showed that the Big Five contributed ( rs range from .20 to .33); and social closeness

l ar son 163
correlated with social confidence ( rs range from .19 behaviors (frequency of activities or time spent
to .28) (Larson & Borgen, 2006). Larson and searching) ( ρ = .46, Kanfer et al., 2001); number
Borgen’s results suggest clearly that vocational con- of job offers ( ρ = .41, Kanfer et al., 2001); job satis-
fidence across Holland’s interest types is related to faction ( ρ = .25; Judge et al., 2002); training pro-
broad and specific personality traits. A study by ficiency ( ρ = .26; Judge et al., 2002); career
Judge and colleagues (2007) found similar results satisfaction ( ρ = .27; Ng et al., 2005); and life satis-
that suggest that SE needs to be untangled from faction ( ρ = .22; Judge et al., 2002).
personality traits. Judge and colleagues examined Openness was shown to be an antecedent to job
work outcomes and showed that the specific contri- search behaviors ( ρ = .27, Kanfer et al., 2001);
bution of task-specific SE to work-related perfor- number of job offers ( ρ = .28, Kanfer et al., 2001);
mance was much smaller once the distal variables, job satisfaction ( ρ = .29; Judge et al., 2002); and
including the Big Five, were controlled. Consci- training proficiency ( ρ = .25; Judge et al., 2002).
entiousness, extraversion, and emotional stability Agreeableness was predictive of number of job off-
were significant unique predictors of SE. ers ( ρ = .29, Kanfer et al., 2001). Conscientious-
In the adult literature, personality traits were ness was shown to be predictive of job search
significant predictors of job search behaviors, job behaviors ( ρ = .38; Kanfer et al., 2001); job satis-
satisfaction, global job performance, and training faction ( ρ = .26, Judge et al., 2002); subjective job
proficiency. The personality traits include positive performance (supervisor ratings) ( ρ = .26; Judge
and negative affectivity, neuroticism, extraversion, et al., 2002); CWBs ( ρs = –.39, –.26, Dalal, 2005;
openness to new experiences, agreeableness, and Dudley et al., 2006; and life satisfaction ( ρ = .26;
conscientiousness. Judge et al., 2002). Conscientiousness remained a
Positive affectivity was shown to be a posi- significant predictor of job performance even after
tive antecedent, whereas negative affectivity was accounting for experience, cognitive ability, and SE
shown to be a negative antecedent to job satisfaction (conscientiousness, β = .26; Judge et al., 2007).
( ρs = .49, –.33, Connolly & Viswesvaran, 2000;
ρs = .34, –34, Thoresen et al., 2003); affective com- Needs, Work Values, and Goals
mitment ( ρ = .36; Connolly & Viswesvaran, 2000; Needs and values have not received the attention
ρs = .35, –.27, Thoresen et al., 2003); and personal in counseling psychology that they deserve.
accomplishment ( ρs = .49, –.34; Thoresen et al., However, Rounds and Armstrong (2005) provided
2003). Conversely, positive affectivity was shown an excellent overview of this area. They identify
to be negatively related, whereas negative affecti- work values as shared interpretations of what people
vity was shown to be positively related to turnover want and expect from work. Needs, compared to
intentions ( ρs = –.17, 28, Thoresen et al., 2003); values, are defined as more biological, and Rounds
emotional exhaustion ( ρs = –.32, .62, Thoresen and Armstrong use Murray’s concept of needs as
et al., 2003); and depersonalization ( ρs = –.27, .47, being how individuals feel, behave, or react. In con-
Thoresen et al., 2003). Future scholars need to trast, values are conceptualized as more cognitive in
examine the relation of more specific traits beyond comparison to needs. In TWA, work values are cat-
the overarching dimensions of positive and negative egorized in the domains of achievement, comfort,
affectivity. Tellegen’s 11 primary traits would be status, altruism, safety, and autonomy (Dawis,
excellent specific traits to examine in the future 2002, 2005). Work motivation theories (Latham &
work adjustment literature. Pinder, 2005) attempt to explain the context and
The Big Five personality traits have been exam- processes that account for an individual’s energy,
ined extensively in the adult literature. One or more direction of effort, and maintenance of that effort in
of the Big Five have been significant predictors a work setting. Latham and Pinder (2005) list sev-
of job search behaviors, number of job offers, job eral individual studies that have shown that work
satisfaction, global subjective ratings of job perfor- values relate to job satisfaction, job choice, tenure,
mance, training proficiency, CWBs, career satisfac- commitment and cohesion, intention to quit, turn-
tion, and life satisfaction. Neuroticism, for example, over, and self-report ratings of teamwork (e.g.,
was shown to be a negative antecedent to job satis- Dawis, 1991; Kristof, 1996; Ronen, 1994).
faction ( ρ = –.29, Judge et al., 2002), life satisfac- Other constructs mentioned in work motivation
tion ( ρ = –.30; Judge et al., 2002), and career research that affect job performance include self-
satisfaction ( ρ = –.36; Ng et al., 2005). Extraver- monitoring strategies, self-regulating strategies (goal
sion was shown to be an antecedent to job search setting), core self-evaluations, and goal orientation.

164 worklife ac ro s s th e l if es pan

I found one meta-analysis by Judge and Ilies (2002) enterprising interests–extraversion ( r = .41),
that examined three indicators of performance eval- social interests–extraversion ( r = .31), investigative
uation (goal-setting, expectancy, and SE motiva- interests–openness ( r = .28), and social interests–
tion) and their relation to the Big Five. They showed agreeableness ( r = .19). Type of measure and sex
goal setting motivation to be related to neuroticism interaction moderated one additional relation. Con-
( ρ = –.29), agreeableness ( ρ = –.29), and consci- ventional interests–conscientiousness was related
entiousness ( ρ = .28). Expectancy motivation was .25 to .33 for men and for women who took the
related to neuroticism ( ρ = –.29) and conscientious- Self-Directed Search. For women who took the SII,
ness ( ρ = .23). Self-efficacy motivation was related to the relation was not present ( r = .07).
neuroticism ( ρ = –.35), extraversion ( ρ = .33), open- Barrick and colleagues (2003), using a broader,
ness ( ρ = –.20), and conscientiousness ( ρ = .22). more diverse sample, reached essentially the same
conclusions regarding the relation of the Big Six
Integration Across Ability, Personality, and the Big Five. Their significant I–P relations
and Interests: Cross-fertilization were artistic interests–openness ( ρ = .39), enter-
The scholarship concerning the overlap among prising interests–extraversion ( ρ = .41), social
attributes has been burgeoning in the past 10 years. interests–extraversion ( ρ = .29), investigative
On the counseling psychology side, the role of interests–openness ( ρ = .25), social interests–
personality traits has led to ongoing dialogue agreeableness ( ρ = .15), and conventional interests–
about the role of personality in training students conscientiousness ( ρ = .19).
(Walsh, 2001; Walsh & Eggerth, 2005) and the role Finally, Staggs and colleagues (2007) corro-
of personality and interests in optimal human func- borated the Big Six–Big Five relations using meta-
tioning (e.g., Borgen & Harmon, 1996; Borgen analyses ( k = 5, N = 2,023). Instead of the Big
& Lindley, 2003). Empirical studies have emerged Five model, they used Tellegen’s Big Three and his
investigating personality and interests (e.g., 11 primary traits. Five of those primary traits had
Ackerman & Beier, 2003; Lindley & Borgen, 2000; previously been identified as marker scales for the
Staggs et al., 2003; Sullivan & Hansen, 2004) and Big Five: stress reaction for neuroticism, social
personality and confidence (e.g., Betz, Borgen, & potency or social closeness for extraversion, absorp-
Harmon, 2006; Larson & Borgen, 2006). Mount, tion for openness, aggression (inversely) for agree-
Barrick, Scullen, and Rounds (2005) identified ableness, and control for conscientiousness (Blake
underlying higher-order dimensions that captured & Sackett, 1999; Church, 1994; Tellegen & Waller,
the overlap of interests and personality. Ackerman 2008). The substantive I–P relations were artistic
(1996) articulated a theory of adult intellectual interests–absorption (openness) ( r = .44), enterpris-
development that explains how people accumulate ing interests–social potency (extraversion) ( r = .36),
knowledge over time based on personality, interest, social interests–social closeness (extraversion) ( r = .29),
and cognitive abilities interrelations. He anchored and social interests–aggression (inverse of agreea-
the theory in a seminal work produced in partner- bleness) ( r = –.22). The investigative interests–
ship with Heggestad (Ackerman & Heggestad, absorption (openness) relation was null ( r = .15).
1997), in which they articulated an integrated Tellegen’s measures differentiated extraversion into
framework that reconsiders the uniqueness of abili- social potency (power), social closeness (love/
ties, interests, and personality. Finally, several quan- affiliation), and control (vs. impulsivity) (Tellegen
titative reviews have moved the field ahead (Barrick, & Waller, 2008). Staggs and colleagues’ (2003)
Mount & Gupta, 2003; Larson, Rottinghaus, & meta-analysis illustrated clearly how separating the
Borgen, 2002; Staggs, Larson, & Borgen, 2007). love/affiliation/warmth from social influence/power
was useful in clarifying the overlap of extraversion
Interests and Personality Overlap and vocational interests. Social closeness relates to
Three meta-analyses have converged to provide social interests but not enterprising interests,
an excellent grasp of the extent of overlap between whereas social potency relates to enterprising inter-
the Big Six (interests) and the Big Five. Larson and ests but not social interests.
colleagues (2002) conducted a meta-analysis ( k = 12, Mount and colleagues (2005) used meta-analyses
N = 2,571). Of the 30 interests–personality (I–P) to identify a higher-order structure of the interests–
relations, five appeared to be substantial for personality overlap. Cluster analysis and non-
both men and women across the six Holland types. metric multidimensional scaling were used to
They were artistic interests–openness ( r = .48), identify three dimensions that explained relations

l ar son 165
among the 11 attributes: interests versus personality investigative interests and openness, social interests
traits, striving for accomplishment versus striving and extraversion, enterprising interests and extraver-
for personal growth, and interacting with people sion, and conventional interests with conscientious-
versus interacting with things. ness (excluding women who completed the SII)
(Barrick et al., 2003; Larson et al., 2002). Like
Trait Complexes Ackerman and Heggestad, these two groups of
Ackerman and Heggestad (1997) reconceptualized scholars also did not find realistic interests to be
how many scholars now think of cognitive ability, linked to the Big Five. Finally, Staggs and colleagues
interests, and personality. That is, they encouraged (2007) provided meta-analytic interests–personality
scholars to think of them in a rearranged way, linkages using Tellegen’s 11 primary traits. They were
according to four trait complexes rather than gen- the first to show in a meta-analysis that the science/
eral and specific abilities, six domains of interests, math trait complex may include personality traits not
and five domains of personality (Big Five) or the included in the Big Five; namely, harm-avoidance
11 traits identified by Tellegen (1982, 2000). and achievement. Both of these traits related to real-
In their seminal work, they presented meta-analytic istic interests. Moreover, they provided support for
evidence showing that cognitive abilities and per- the proposed I–P linkages made by Ackerman and
sonality traits (the Big Five and the 11 primary traits Heggestad using the 11 primary traits including
identified by Tellegen [1982, 2000]) could be inte- artistic interests and absorption, social potency and
grated across these four trait complexes. In addition, enterprising interests (not social interests), social
they speculated without data as to where Holland’s interests (not enterprising interests) and well-being.
Big Six interests would be located. The four trait They did not find I–P linkages in the clerical/con-
complexes are labeled science/math, intellectual/ ventional trait complex; that is, conventional inter-
cultural, social, and clerical/conventional. They pro- ests were not related to control and traditionalism as
vided evidence that the cognitive ability of fluid Ackerman and Heggestad had proposed.
intelligence, visual perception, and math reasoning Staggs and colleagues (2007) went one step
would be located within the science/math complex; beyond the prior meta-analyses and provided, for the
no personality traits were identified as being in this first time, meta-analytic I–P linkages that were quite
complex. They speculated that realistic and investi- specific. They examined the linkages between the Big
gative interests would be located here. Next, the Six and the 25 basic dimensions of interests from the
intellectual/cultural complex included the cognitive Basic Interest Scales of the SII (Harmon et al., 1994)
abilities of ideational fluency, crystallized intelli- with Tellegen’s 11 primary traits. For example, artis-
gence, and knowledge and achievement and the tic interests are separated into writing, art, music/
personality traits of openness (Big Five) and absorp- drama, applied arts, and culinary arts, and realistic
tion (11 primary traits). They speculated that artis- interests are separated into mechanical, agricultural,
tic and some investigative interests would be located military, and athletic interests. Using these meta-
in this complex. Next, the social complex was shown analytic estimates, they revised Ackerman and
to include no cognitive abilities and was anchored Heggestad’s (1997) tentative I–P linkages located in
by the personality traits of extraversion (Big Five) each of their four trait complexes. Figure 6.1 shows
and social potency and well-being (primary traits). the hypothesized meta-analytic I–P relations made
They speculated that social and enterprising inter- by Staggs and colleagues (2007). The personality
ests would fall within the social complex. Finally, traits are in capital letters, and Holland’s typology
within the clerical/conventional complex, the cog- is abbreviated to form the RIASEC. Conventional
nitive ability, perceptual speed, was located along [C] is left off since there were no conventional I–P
with the personality traits of conscientiousness relations above |.20|. Their r values are shown on
(Big Five), and control and traditionalism (11 pri- Figure 6.1. The dotted lines represent those I–P link-
mary traits) were located. They placed Holland’s ages that were negative. Within the science/math
conventional interests in this complex. complex, they found realistic interests and mechani-
The meta-analyses that came after Ackerman cal and agricultural interests, in particular, to be
and Heggestad’s seminal (1997) article supported negatively linked with harm-avoidance (choosing
many of their hypothesized interests–personality boredom over danger) (rs range from –.21 to –.31)
linkages using Holland’s Big Six and the Big Five and investigative interests and science interests, in
personality traits. These I–P linkages from the meta- particular, to be positively linked to achievement
analyses included artistic interests and openness, ( rs = .27, .21). Within the intellectual/cultural

166 worklife ac ro s s th e l if es pan

 Science/Math
Mech -.28
Sci.21
Ag -.21
ACHIEVEMENT
HARMAVOIDANCE
-.31 -.19 .27
R I

ABSORPTION
.44

A Wri .35
Art .39
PubSpk .49 Mu/Dr .4
Law/Pol .41
Merch .29
Sales .29
Intellectual/Cultural
OrgMgmt .35
.26
E (.22)
.36 (.2)
S
WELLBEING
TRADITIONALISM
SOCIAL POTENCY
-.22 AGGRESSION
.29
SOCIAL CLOSENESS

Social

Fig. 6.1 Hypothesized MPQ and Strong Meta-analytic Findings.

Reprinted with permission from Journal of Career Assessment.

complex, absorption was positively related to general related to achievement. In the intellectual/cultural
and specific artistic interests ( rs range from .35 to complex, interests in applied arts, nature, and social
.44). Within the social complex, social and enterpris- service were positively related to absorption. Within
ing interests were differentiated based on the former the social complex, a large number of specific I–P
being related positively to well-being (dispositional linkages of |.2| or greater were reported. The partic-
happiness) and negatively related to aggression, and ular linkages provide more evidence that enterpris-
the latter being related to social potency (force- ing interests and social interests are uniquely linked
ful, dominant, charming). Social potency was also with different constellations of personality traits.
positively related to specific enterprising interests For example, the Basic Interest Scales that are listed
(public speaking, law/politics, merchandising, sales, as social interests related negatively to aggression;
and organizational management) with rs ranging none of the Basic Interest Scales that were listed as
from .29 to .49. enterprising interests related negatively to aggres-
Figure 6.2 shows additional specific I–P linkages sion. It also appears that the personality trait of
that were not hypothesized in which the I–P corre- well-being is related to primarily specific social
lations were .2 or greater. Similar to Figure 6.1, interests but also was linked to athletics, a realistic
dotted lines represent negative relations. In the interest, and culinary arts, an artistic interest.
science/math complex, additional I–P linkages not Finally, Staggs and colleagues also provide evidence
posited by Ackerman and Heggestad (1997) in both figures that traditionalism may need to be
emerged; interests in military activities were nega- moved from the clerical/conventional complex to
tively related to harm-avoidance and positively the social complex. Sex was not found to be a sub-
related to aggression. Math interests were positively stantial moderator of I–P correlations.

l ar son 167
 SCIENCE/MATH

ACHIEVEMENT
HARMAVOIDANCE

Math
Military
INT/CULT
AGGRESSION ABSORPTION
R I Nature
Applied Art
C A

E S
Religious Activities
Teaching Culinary Arts
Public Social Service
Speaking
Athletics

SOCIAL CLOSENESS
SOCIAL POTENCY
AGGRESSION WELLBEING

TRADITIONALISM

SOCIAL
Fig. 6.2 Additional MPQ Primary Scales - Strong BISs Meta-analytic Findings.
Reprinted with permission from Journal of Career Assessment.

Looking Back and Looking Ahead (e.g., G. D. Gottfredson, 2001; Hesketh, 2001;
Since Frank Parsons’ (1909) publication, Choosing Vondracek, 2001). Some argue that vocational psy-
a Vocation, which many consider to be the birth chology needs to be more grounded in the multi-
of vocational psychology, the field has evolved and cultural zeitgeist of the day and focus more on those
been transformed by the societal forces that shaped who have not had a voice in the literature (e.g.,
psychology in general and vocational psychology Blustein, 2001; Fouad, 2001; Subich, 2001).
in particular. Scholars have summarized the most The separation of the literature dealing with
recent past by celebrating the contributions of the youth and college students versus wage-earning
grand masters of vocational psychology, like Donald adults has been clearly established, based partly on
Super, John Holland, and René Dawis, and more tradition and partly on different outcomes and pro-
recently Sam Osipow (Borgen, 1991; Barak & cesses. Cross-fertilization is occurring, however,
Leong, 2001), and by reviewing trends in the jour- with the school-to-work efforts in counseling psy-
nals (e.g., Borgen, 1991; London & Greller, 1991; chology and the work of scholars in integrating per-
Watkins & Savickas, 1990), and trends in the field sonality, interests, values, and abilities. Multicultural
(Dawis, 1996; Lee, Mitchell, & Sablynski, 1999; scholars and feminist scholars writing about voca-
Loscocco & Roschelle, 1991). tional issues dealing with discrimination, sexual
Vocational psychology’s vision is a mosaic with harassment, worklife–family balance are also cross-
diverse viewpoints. Scholars do not speak with one ing the divide.
voice. Some argue that vocational psychology needs The field is vibrant and thriving. Multiple scholars
to break away from counseling psychology and form in counseling psychology, I/O psychology, organiza-
its own specialty (e.g., Tinsley, 2001), or that voca- tional psychology, and applied and individual differ-
tional psychology needs to be more scientific and ences psychology are generating research, educating
grounded in measurement and basic psychology the next generation, and disseminating findings.

168 worklife ac ro s s th e l if es pan

Also, more longitudinal studies are being conducted. structuring and choice (Locke & Latham, 2004).
Books and book chapters proliferate that serve to Also, some traits have a direct impact on perfor-
inform and energize new and old scholars alike. mance (like ability), and vocational psychologists
A number of scholarly journals are devoted exclu- need to understand when and why this occurs
sively to vocational psychology. Vocational counsel- (Latham & Pinder, 2005).
ors continue to provide assistance to university Our second task, as vocational scholars, is to inte-
clients, high school clients, and elementary students grate existing knowledge. Scholars need to continue
as they explore the world of work, learn about them- to generate more quantitative reviews in the form of
selves, and develop aspirations, goals, and initial meta-analyses. In searching the literature base, it
choices about what to study and what activities to became apparent that the number of meta-analyses
pursue. Psychologists in work settings provide assis- concerning children’s and adolescents’ vocational
tance to employees, employers, and the public at development was sparse in comparison to meta-anal-
large regarding how wage earners can be both pro- yses concerning adults in the workforce and/or indi-
ductive and well adjusted. vidual differences, especially personality. The 47
As scholars, our first task is to generate new meta-analyses that were located in researching this
knowledge concerning vocational psychology. That chapter could be organized according to the sections:
new knowledge needs to build on prior findings wage-earning adults (17), individual differences (16),
and also provide new lines of inquiry. Ideally, voca- diverse groups (6), achievement (5), children/adoles-
tional theories should fall out of favor due to lack cents/college students other than achievement (3).
of support for the propositions rather than simply The scarcity of quantitative reviews may be one reason
neglect. Likewise, vocational theories that are widely the vocational psychology of career choice and voca-
used and accepted should continue to be rigorously tional development is not more integrated into the
examined and anchored in science. For example, larger psychological domain.
scholars need to examine the proposition that con- Vocational scholars need to generate more con-
gruence defined by a congruence index leads to job ceptual reviews as well. The positive news is that
satisfaction and tenure; the empirical support is many conceptual reviews are being published in
absent. It may be that unexamined moderators are various handbooks and texts. Integrating knowl-
present or that measures of job satisfaction are theo- edge within particular domains of the field allows
retically inappropriate. Nonetheless, scholars need scholars to coalesce what is known and what new
to either give up on the proposition that congruence directions of inquiry to pursue. It also gives scholars
as defined by a congruence index leads to job satis- opportunities to discard aspects of theories that are
faction or discover under what conditions that not supported by evidence. For example, congru-
proposition holds true. To generate new knowledge, ence and job satisfaction’s relation is either insignifi-
all research methods need to be utilized. The litera- cant or too small to be practical. Scholars need to
ture search yielded insufficient findings anchored in consider moderators or be more precise about what
experimental or quasi-experimental design. Experi- might be going on through the use of moderators
mental design has many strengths, particularly in (Dik, 2006).
maintaining strong internal validity. It is hard to The third task is to disseminate information
eliminate alternative hypotheses without a propor- learned in vocational psychology to a range of audi-
tion of findings being anchored in experimental or ences. Career counselors need research findings
quasi-experimental design. Experimental studies to continue to update and upgrade their knowl-
may be particularly well-suited to examine potential edge base and skills. Vocational clients need the
mechanisms that may explain well-established link- most parsimonious and empirically grounded theo-
ages. For example, if SE and interests are moderately ries, measures, and tools to assist them in their
to strongly related, and interests are 40% genetic, learning, choosing, and working. Psychology under-
then what mechanisms initially lead children to graduates need to be informed of vocational psy-
pursue certain activities that they lack confidence chology in introductory psychology courses, as well
in because they have never attempted the activity? as in other advanced-level courses, such as indi-
Is it curiosity? More research is needed that exam- vidual difference courses, personality courses, and
ines how general variables (e.g., personality traits) specialized courses in vocational psychology or
are applied to and mediated by task- and situation- counseling psychology.
specific variables in affecting performance, and how The fourth task is to inform other areas and be
these variables are moderated and affect situational informed by those areas. Because the field is vast

l ar son 169
and scholars can only be well-informed in their par- Arbona, C., & Novy, D. M. (1991). Career aspirations and
ticular niches, it is crucial that we inform other the expectations of Black, Mexican American, and White
students. Career Development Quarterly, 39, 231–239.
scholars within and outside vocational psychology. Armstrong, P. I., Hubert, L., & Rounds, J. (2003). Circular uni-
Vocational psychology will benefit from increasing dimensional scaling: A new look at group differences in inter-
its visible contribution to psychology, so that the est structure. Journal of Counseling Psychology, 50, 297–308.
body of work cross-pollinates with related fields Arvey, R. D., Bouchard, T. J., Jr., Segal, N. L., & Abraham, L. M.
like industrial/organizational, clinical psychology, (1989). Job satisfaction: Environmental and genetic compo-
nents. Journal of Applied Psychology, 74, 187–192.
social psychology, and developmental psychology Arvey, R. D., McCall, B. P., Bouchard, T. J., Jr., Taubman, P., &
(Vondracek, 2001). Vocational researchers need to Cavanaugh, M. A. (1994). Genetic influences on job satis-
continue to learn broadly from areas within and faction and work values. Personality and Individual Differences,
outside our own niches, so that we can continue to 17, 21–33.
see with fresh eyes and new perspectives. The stron- Bandura, A. (1977). Self-efficacy: Toward a unifying theory of
behavioral change. Psychological Review, 84, 191–215.
gest benefit of counseling psychology’s commit- Bandura, A. (1982). Self-efficacy mechanism in human agency.
ment to multiculturalism is the understanding American Psychologist, 37, 122–147.
that seeing research from many dimensions adds Bandura, A. (1986). Social foundations of thought and action:
breadth and depth and allows us to be more helpful A social cognitive theory. Englewood Cliffs, NJ: Prentice-Hall.
to clients. Barak, A., Feldman, S., & Noy, A. (1991). Traditionality of chil-
dren’s interests as related to their parents’ gender stereotypes
and traditionality of occupations. Sex Roles, 24, 511–524.
Acknowledgments Barak, A., & Leong, F. (2001). Contemporary models in vocatio-
I would like to thank the following undergraduate nal psychology: A volume in honor of Samuel H. Osipow.
research assistants who have assisted in literature New York: Routledge.
searches, organization, and building references: Sara Barber, B. L., & Eccles, J. S. (1992). Long-term influence of
divorce and single parenting on adolescent family-related
Tiedman, Lisa Bildeaux, Steven Mahan, Arnold and work-related values, behaviors, and aspirations. Psyc-
Kong, Katrina Field, and Chris Demaria. A special hological Bulletin, 111, 108–126.
thanks goes to my graduate advisee, Tsui-Feng Wu, Barrick, M. R., & Mount, M. K. (1991). The Big Five personal-
who serves as my lab director. Appreciation goes to ity dimensions and job performance: A meta-analysis.
her for her supervision of the undergraduate research Personnel Psychology, 44, 1–26.
Barrick, M. R., Mount, M. K., & Gupta, R. (2003). Meta-
assistants, and her coordination and assistance with analysis of the relationship between the Five-Factor Model of
multiple tasks involved in bringing this chapter to personality and Holland’s occupational types. Personnel
fruition. A final thanks goes to my husband, Art Psychology, 56, 45–74.
Konar, who lovingly supported me throughout this Benbow, C. P., & Stanley, J. C. (1996). Inequity in equity:
endeavor. How “equity” can lead to inequity for high-potential stu-
dents. Psychological Public Policy and Law, 2, 249–292.
Bertua, C., Anderson, N., & Salgado, J. F. (2005). The predictive
References validity of cognitive ability tests: A UK meta-analysis. Journal
Ackerman, P. L. (1996). Intelligence as process and knowledge: of Occupational and Organizational Psychology, 78, 387–409.
An integration for adult development and application. Betsworth, D. G., Bouchard, T. J., Cooper, C. R., Grotevant, H. D.,
In W. A. Rogers, A. D. Fisk, & N. Walker (Eds.), Aging and Hansen, J. C., Scarr, S., & Weinberg, R. A. (1994). Genetic
skilled performance: Advances in theory and applications and environmental influences on vocational interests assessed
(pp. 139–156). Hillsdale, NJ: Lawrence Erlbaum Associates. using adoptive and biological families and twins reared apart
Ackerman, P. L., & Beier, M. E. (2003). Intelligence, personality, and together. Journal of Vocational Behavior, 44, 263–278.
and interests in the career choice process. Journal of Career Betz, N. (2006). Basic issues and concepts in the career devel-
Assessment, 11, 205–218. opment and counseling of women. In W. B. Walsh, &
Ackerman, P. L., & Heggestad, E. D. (1997). Intelligence, per- M. J. Heppner (Eds.), Handbook of career counseling for
sonality, and interests: Evidence for overlapping traits. women (2nd ed., pp. 45–74). Mahwah, NJ: Lawrence
Psychological Bulletin, 121, 219–245. Erlbaum Associates.
Ajzen, I. (2002). Perceived behavioral control, self-efficacy, locus Betz, N. E., Borgen, F. H., & Harmon, L. W. (2006). Vocational
of control, and the theory of planned behavior. Journal of confidence and personality in the prediction of occupational
Applied Social Psychology, 32, 665–683. group membership. Journal of Career Assessment, 14, 36–55.
Allen, T. D., Herst, D. E. L., Bruck, C. S., & Sutton, M. (2000). Betz, N. E., Borgen, F. H., Rottinghaus, P., Paulsen, A.,
Consequences associated with work-to-family conflict: Halper, C. R., & Harmon, L. W. (2003). The Expanded
A review and agenda for future research. Journal of Occupa- Skills Confidence Inventory: Measuring basic dimensions of
tional Health Psychology, 5, 278–308. vocational activity. Journal of Vocational Behavior, 62, 76–100.
Altermatt, E. R., Jovanovic, J., & Perry, M. (1998). Bias or Betz, N. E., Harmon, L. W., & Borgen, F. H. (1996). The rela-
responsivity? Sex and achievement-level effects on teachers’ tionships of self-efficacy for the Holland themes to gender,
classroom questioning practices. Journal of Educational occupational group membership, and vocational interests.
Psychology, 90, 516–527. Journal of Counseling Psychology, 43, 90–98.

170 worklife ac ro s s th e l if es pan

Blake, R. J., & Sackett, S. A. (1999). Holland’s typology and Collins, P. H. (1998). The social construction of Black feminist
the Five-Factor Model: A rational-empirical analysis. Journal thought. In K. A. Myers, C. D. Anderson, & B. J. Risman
of Career Assessment, 7, 249–279. (Eds.), Feminist foundations: Toward transforming sociology.
Blustein, D. L. (2001). Extending the reach of vocational psy- (pp. 371–396). Thousand Oaks, CA: Sage Publications.
chology: Toward an inclusive and integrated psychology Colquitt, J. A., Scott, B. A., & LePine, J. A. (2007). Trust, trust-
of working. Journal of Vocational Behavior, 59, 171–182. worthiness, and trust propensity: A meta-analytic test of
Borgen, F. H. (1991). Megatrends and milestones in vocational their unique relationships with risk taking and job perfor-
behavior: A 20-year counseling psychology retrospective. mance. Journal of Applied Psychology, 92, 909–927.
Journal of Vocational Behavior, 39, 263–290. Connolly, J. J., & Viswesvaran, C. (2000). The role of affectivity
Borgen, F. H., & Harmon, L. W. (1996). Linking interest assess- in job satisfaction: A meta-analysis. Personality and Individual
ment and personality theory: An example of conver- Differences, 29, 265–281.
gence between practice and theory. In M. L. Savickas, & Cook, T. D., Church, M. B., Ajanaku, S., & Shadish, W. R., Jr.
W. B. Walsh (Eds.), Handbook of career counseling theory and (1996). The development of occupational aspirations and
practice (pp. 251–266). Palo Alto, CA: Davies-Black. expectations among inner-city boys. Child Development, 67,
Borgen, F. H., & Lindley, L. D. (2003). Individuality and opti- 3368–3385.
mal health functioning: Interests, self-efficacy, and personal- Corbie-Smith, G., Frank, E., Nickens, H. W., & Elon, L. (1999).
ity. In W. B. Walsh (Ed.), Counseling psychology and optimal Prevalences and correlates of ethnic harassment in the U. S.
human functioning (pp. 55–91). Mahwah, NJ: Lawrence Women Physicians’ Health Study. Academic Medicine, 74,
Erlbaum Associates. 695–701.
Borman, W. C., Hedge, J. W., Ferstl, K. L., Kaufman, J. D., Crites, J. O. (1978). Career maturity inventory: Administration
Farmer, W. L., & Bearden, R. M. (2003). Current direc- and use manual. Monterey, CA: McGraw-Hill.
tions and issues in personnel selection and classification. Curry, C., Trew, K., Turner, I., & Hunter, J. (1994). The effect
In J. J. Martocchio, & G. R. Ferris (Eds.), Research in person- of life domains on girls’ possible selves. Adolescence, 29,
nel and human resources management (pp. 287–355). Oxford, 133–150.
UK: Elsevier Science Ltd. Dalal, R. S. (2005). A meta-analysis of the relationship between
Bouchard, T. J., Jr. (1998). Genetic and environmental influ- organizational citizenship behavior and counterpro-
ences on adult intelligence and special mental abilities. ductive work behavior. Journal of Applied Psychology, 90,
Human biology, 70, 257–279. 1241–1255.
Bowling, N. A., & Beehr, T. A. (2006). Workplace harassment Darcy, M. U. A., & Tracey, T. J. G. (2007). Circumplex structure
from the victim’s perspective: A theoretical model and meta- of Holland’s RIASEC interests across gender and time.
analysis. Journal of Applied Psychology, 91, 998–1012. Journal of Counseling Psychology, 54, 17–31.
Brooks, A. K., & Clunis, T. (2007). Where to now? Race and Davey, F. H., & Stoppard, J. M. (1993). Some factors affecting
ethnicity in workplace learning and development research: the occupational expectations of female adolescents. Journal
1980–2005. Human Resource Development Quarterly, 18, of Vocational Behavior, 43, 235–250.
229–252. Davison Avilés, R., & Spokane, A. R. (1999). The vocational
Buboltz, W. C., Ebberwein, C., Watkins, C. E., & Savickas, M. L. interests of Hispanic, African American, and White middle
(1995). A comparison of the content, authors, and institu- school students. Measurement and Evaluation in Counseling
tions represented in the Career Development Quarterly and and Development, 32, 138–148.
the Journal of Vocational Behavior. Journal of Vocational Dawis, R. V. (1991). Vocational interests, values, and prefer-
Behavior, 46, 216–226. ences. In M. D. Dunnette, & L. M. Hough (Eds.), Hand-
Bureau of Labor Statistics (BLS). (2007). Women in the labor book of industrial and organizational psychology (2nd ed.,
force: A datebook. Retrieved from http://www.bls.gov/cps/ pp. 833–871). Palo Alto, CA: Consulting Psychologists
wlf-datebook2007.htm. Press.
Bureau of Labor Statistics (BLS). (2006). Current population Dawis, R. V. (1996). Vocational psychology, vocational adjust-
survey annual social and economic supplement. Retrieved from ment, and the workforce: Some familiar and unantici-
http://www.bls.gov/cps/. pated consequences. Psychology, Public Policy, and Law, 2,
Bureau of Labor Statistics (BLS). (2007). Current population 229–248.
survey. Retrieved from http://www.bls.gov/cps/. Dawis, R. V. (2002). Person-environment-correspondence
Byron, K. (2005). A meta-analytic review of work-family conflict theory. In D. Brown (Ed.), Career choice and development
and its antecedents. Journal of Social Psychology, 135, 483–497. (4th ed., pp. 427–464). San Francisco: Jossey-Bass.
Campbell, D. P., Hyne, S. A., & Nilsen, D. L. (1992). Manual Dawis, R. V. (2005). The Minnesota theory of work adjustment.
for the Campbell Interest and Skills Survey: CISS. Minneapolis: In S. D. Brown, & R. W. Lent (Eds.), Career development
National Computer Systems. and counseling: Putting theory and research to work (pp. 3–23).
Chartrand, J. M., Martin, W. F., Robbins, S. B., & McAuliffe, G. J. Hoboken, NJ: John Wiley & Sons.
(1994). Testing a level versus an interactional view of career Dawis, R. V., & Lofquist, L. (1984). A psychological theory of
indecision. Journal of Career Assessment, 2, 55–69. work adjustment. Minneapolis: University of Minnesota
Cheng, C. (1996). We choose not to compete: The “merit” dis- Press.
course in the selection process, and Asian and Asian American Day, S. X., & Rounds, J. (1998). Universality of vocational inter-
men and their masculinity. In C. Cheng (Ed.), Masculinities est structure among racial and ethnic minorities. American
in organizations (pp. 177–200). Thousand Oaks, CA: Sage. Psychologist, 53, 728–736.
Church, A. T. (1994). Relating the Tellegen and Five-Factor Day, S. X., Rounds, J., & Swaney, K. (1998). The structure
models of personality structure. Journal of Personality and of vocational interests for diverse racial-ethnic groups.
Social Psychology, 67(5), 898–909. Psychological Science, 9, 40–44.

l ar son 171
DeNeve, K. M., & Cooper, H. (1998). The happy personality: Fritzsche, B. A., & Parrish, T. J. (2005). Theories and Research
A meta-analysis of 137 personality traits and subjective well- on Job Satisfaction. In S. D. Brown, & R. W. Lent (Eds.),
being. Psychological Bulletin, 124, 197–229. Career Development and Counseling: Putting Theory and
Denissen, J. J. A., Zarrett, N. R., & Eccles, J. S. (2007). I like Research to Work (pp. 180–202). Hoboken, NJ: John Wiley
to do it, I’m able, and I know I am: Longitudinal couplings & Sons.
between domain-specific achievement, self-concept, and Gasser, C. E., Larson, L. M., & Borgen, F. H. (2007). Concurrent
interest. Child Development, 78, 430–437. validity of the 2005 strong interest inventory: An examina-
Diener, E. (2000). The science of happiness and a proposal for tion of gender and major field of study. Journal of Career
a national index. American Psychologist, 55, 34–43. Assessment, 15, 23–43.
Dik, B. J. (2006). Moderators of the Holland-type congruence- Gati, I. (1986). Making career decisions: A sequential elimi-
satisfaction and congruence- performance relations. Doctoral nation approach. Journal of Counseling Psychology, 33,
dissertation, University of Minnesota-Minneapolis. 408–417.
Donnay, D. A. C., & Borgen, F. H. (1996). Validity, structure, Gati, I. (1991). Career counselors’ perception of the structure
and content of the 1994 Strong Interest Inventory. Journal of vocational interests. Journal of Counseling Psychology, 38,
of Counseling Psychology, 43, 275–291. 175–181.
Donnay, D. A., & Borgen, F. H. (1999). The incremental valid- George, J. M. (1989). Mood and absence. Journal of Applied
ity of vocational self-efficacy: An examination of interest, Psychology, 74, 317–324.
self-efficacy, and occupation. Journal of Counseling Psychology, Gibson, M. A. (1988). Accommodation without assimilation.
46, 432–447. Ithaca, NY: Cornell University Press.
Donnay, D. A., Morris, M. L., Schaubhut, N. A., & Gottfredson, G. D. (1999). John L. Holland’s contributions
Thompson, R. C. (2005). Strong Interest Inventory manual: to vocational psychology: A review and evaluation. Journal
Research, development and strategies for interpretation. Palo of Vocational Behavior, 55, 15–40.
Alto, CA: Counseling Psychology Press. Gottfredson, G. D. (2001). Fostering the scientific practice
Dreher, G. F., & Ash, R. A. (1990). A comparative study of of vocational psychology. Journal of Vocational Behavior, 59,
mentoring among men and women in managerial, profes- 192–202.
sional, and technical positions. Journal of Applied Psychology, Gottfredson, L. S. (1996). Gottfredson’s theory of circumscrip-
75, 539–546. tion and compromise. In D. Brown, & L. Brooks (Eds.),
Dudley, N. M., Orvis, K. A., Lebiecki, J. E., & Cortina, J. M. Career choice and development (3rd ed., pp. 179–232).
(2006). A meta-analytic investigation of conscientiousness in San Francisco: Jossey-Bass.
the prediction of job performance: Examining the intercor- Gottfredson, L. S. (1999). The nature and nurture of vocational
relations and the incremental validity of narrow traits. Journal interests. In M. L. Savickas, & A. R. Spokane (Eds.),
of Applied Psychology, 91, 40–57. Vocational interests: Meaning, measurement, and counseling use
Eggerth, D. E., & Andrew, M. E. (2006). Modifying the C index (pp. 57–85). Palo Alto, CA: Davies-Black.
for use with Holland codes of unequal length. Journal of Gottfredson, L. S. (2002). Gottfredson’s theory of circumscrip-
Career Assessment, 14, 267–275. tion, compromise and self-creation. In D. Brown (Ed.),
Eggerth, D. E., & Cunningham, T. R. (2011). Counseling Career choice and development (4th ed., pp. 85–148).
psychology and occupational health psychology. San Francisco: Jossey-Bass.
In E. M. Altmaier, & J. C. Hansen (Eds.), The Oxford Gottfredson, L. S. (2005). Applying Gottfredson’s theory of
handbook of counseling psychology. New York: Oxford circumscription and compromise in career guidance and
University Press. counseling. In S. D. Brown, & R. W. Lent (Eds.), Career
Entwisle, D. R., Alexander, K. L., Olson, L. S., & Ross, K. development and counseling: Putting theory and research to
(1999). Paid work in early adolescence: Developmental and work (pp. 71–100). Hoboken, NJ: John Wiley & Sons.
ethnic patterns. Journal of Early Adolescence, 19, 363–388. Griffeth, R. W., Steel, R. P., Allen, D. G., & Bryan, N. (2005).
Fan, X., & Chen, M. (2001). Parental involvement and students’ The development of a multidimensional measure of job
academic achievement: A meta-analysis. Educational Psy- market cognitions: The employment opportunity index
chology Review, 13, 1–22. (EOI). Journal of Applied Psychology, 90, 335–349.
Fassinger, R. E. (2005). Theoretical issues in the study of wom- Haas, N. S., & Sullivan, H. (1991). Use of ethnically matched
en’s career development: Building bridges in a brave new role models in career materials for Hispanic students.
world. In W. B. Walsh, & M. L. Savickas (Eds.), Handbook Contemporary Educational Psychology, 16, 272–278.
of vocational psychology (3rd ed., pp. 85–124). Mahwah, NJ: Halbesleben, J. R. B. (2006). Sources of social support and burn-
Lawrence Erlbaum Associates. out: A meta-analytic test of the conservation of resources
Fleming, P. (2000). Three decades of educational progress model. Journal of Applied Psychology, 91, 1134–1145.
and continuing barriers for women and girls. Equity and Hansen, J. C., & Swanson, J. L. (1983). Stability of interests
excellence in education, 33, 74–79. and the predictive and concurrent validity of the 1981
Ford, M. T., Heinen, B. A., & Langkamer, K. L. (2007). Strong-Campbell Interest Inventory for college majors.
Work and family satisfaction and conflict: A meta-analysis of Journal of Counseling Psychology, 30, 194–201.
cross-domain relations. Journal of Applied Psychology, 92, Hanson, S. L. (1994). Lost talent: Unrealized educational aspi-
57–80. rations and expectations among U.S. youth. Sociology of
Fouad, N. A. (2001). The future of vocational psychology: Education, 67, 159–183.
Aiming high. Journal of Vocational Behavior, 59, 183–191. Hardin, E. E., & Leong, F. T. L. (2005). Optimism and pessi-
Fouad, N. A., & Byars-Winston, A. M. (2005). Cultural context mism as mediators of the relations between self-discrepancies
of career choice: Meta-analysis of race/ethnicity differences. and distress among Asian and European Americans. Journal
The Career Development Quarterly, 53, 223–233. of Counseling Psychology, 52, 25–35.

172 worklife ac ro s s th e l if es pan

Hardin, E. E., Leong, F. T. L., & Osipow, S. H. (2001). Cultural Jeynes, W. H. (2007). The relationship between parental involve-
relativity in the conceptualization of career maturity. Journal ment and urban secondary school student academic achieve-
of Vocational Behavior, 58, 36–52. ment: A meta-analysis. Urban Education, 42, 82–110.
Harmon, L. W., Hansen, J. C., Borgen, F. H., & Hammer, A. L. Johnson, L. (1995). A multidimensional analysis of the voca-
(1994). Applications and technical guide for the Strong Interest tional aspirations of college students. Measurement and
Inventory. Palo Alto, CA: Consulting Psychologists Press. Evaluation in Counseling and Development, 28, 25–44.
Harren, V. A. (1979). Research with the assessment of career Johnson, M. K., & Mortimer, J. T. (2002). Career choice and
decision making. Character Potential: A Record of Research, 9, development from a sociological perspective. In D. Brown
63–69. (Ed.), Career choice and development (4th ed., pp. 37–84).
Harrison, D. A., Newman, D. A., & Roth, P. L. (2006). How San Francisco: Jossey-Bass.
important are job attitudes? Meta-analytic comparisons of Jordan, T. E. (1976). Preschool influences on occupational
integrative behavioral outcomes and time sequences. Academy knowledge of seven-year-olds: A prospective study. Journal
of Management Journal, 49, 305–325. of Experimental Education, 44, 27–37.
Hartung, P. J., Porfeli, E. J., & Vondracek, F. W. (2005). Child Jordan, T. E., & Pope, M. L. (2001). Developmental antecedents
vocational development: A review and reconsideration. to adolescents’ occupational knowledge: A 17-year prospec-
Journal of Vocational Behavior, 66, 385–419. tive study. Journal of Vocational Behavior, 58, 279–292.
Helwig, A. A. (1998a). Developmental and sex differences in Judge, T. A., Heller, D., & Mount, M. K. (2002). Five-Factor
workers’ functions of occupational aspirations of a longitudi- Model of personality and job satisfaction: A meta-analysis.
nal sample of elementary school children. Psychological Journal of Applied Psychology, 87, 530–541.
Reports, 82, 915–921. Judge, T. A., & Hulin, C. L. (1993). Job satisfaction as a reflec-
Helwig, A. A. (1998b). Occupational aspirations of a longitudi- tion of disposition: A multiple source causal analysis.
nal sample from second to sixth grade. Journal of Career Organizational Behavior and Human Decision Processes, 56,
Development, 24, 247–265. 388–421.
Helwig, A. A. (2001). A test of Gottfredson’s theory using a ten- Judge, T. A., & Ilies, R. (2002). Relationship of personality to
year longitudinal study. Journal of Career Development, 28, performance motivation: A meta-analytic review. Journal of
77–95. Applied Psychology, 87, 797–807.
Helwig, A. A. (2004). A ten-year longitudinal study of the career Judge, T. A., Jackson, C. L., Shaw, J. C., Scott, B. A., & Rich, B. L.
development of students: Summary findings. Journal of (2007). Self-efficacy and work-related performance: The
Counseling and Development, 82, 1–4. integral role of individual differences. Journal of Applied
Henderson, S., Hesketh, B., & Tuffin, K. (1988). A test of Psychology, 92, 107–127.
Gottfredson’s theory of circumscription. Journal of Voca- Judge, T. A., Thoresen, C. J., Bono, J. E., & Patton, G. K. (2001).
tional Behavior, 32, 37–48. The job satisfaction-job performance relationship: A qualitative
Hesketh, B. (2001). Adapting vocational psychology to cope and quantitative review. Psychological Bulletin, 127, 376–407.
with change. Journal of Vocational Behavior, 59, 203–212. Juvonen, J., Nishina, A., & Graham, S. (2000). Peer harassment,
Hesketh, B., & Griffin, B. (2005). Work adjustment. psychological adjustment, and school functioning in early
In W. B. Walsh, & M. L. Savickas (Eds.), Handbook of voca- adolescence. Journal of Educational Psychology, 92, 349–359.
tional psychology (pp. 245–266). Mahwah, NJ: Lawrence Kahle, J., Meece, J., & Scantlebury, K. (2000). Urban African-
Erlbaum Associates. American middle school science students: Does standards-
Hoffman, B. J., & Woehr, D. J. (2006). A quantitative review based teaching make a difference? Journal of Research in
of the relationship between person-organization fit and Science Teaching, 37, 1019–1041.
behavioral outcomes. Journal of Vocational Behavior, 68, Kanfer, R., Wanberg, C. R., & Kantrowitz, T. M. (2001). Job
389–399. search and employment: A personality-motivational analysis
Holland, J. L. (1959). A theory of vocational choice. Journal and meta-analytic review. Journal of Applied Psychology, 86,
of Counseling Psychology, 6, 35–44. 837–855.
Holland, J. L. (1997). Making vocational choices: A theory of Kao, G. (1995). Asian Americans as model minorities? A look at
vocational personalities and work environments (3rd ed.). their academic performance. American Journal of Education,
Odessa, FL: Psychological Assessment Resources. 103, 121–159.
Hough, L. M., & Oswald, F. L. (2000). Personnel selection: Kao, G., Tienda, M., & Schneider, B. (1996). Racial and ethnic
Looking toward the future—Remembering the past. Annual variation in academic performance. In A. M. Pallas (Ed.),
Review of Psychology, 51, 631–664. Research in sociology of education and socialization, 11, 263–297.
Hülsheger, U. R., Maier, G. W., & Stumpp, T. (2007). Valid- Katz, M. R. (1966). A model of guidance for career decision-
ity of general mental ability for the prediction of job per- making. Vocational Guidance Quarterly, 15, 2–10.
formance and training success in Germany: A meta- Kieffer, K. M., Schinka, J. A., & Curtiss, G. (2004). Person-
analysis. International Journal of Selection and Assessment, 15, environment congruence and personality domains in the
3–18. prediction of job performance and work quality. Journal of
Humphrey, S. E., Nahrgang, J. D., & Morgeson, F. P. (2007). Counseling Psychology, 51, 168–177.
Integrating motivational, social, and contextual work design Kossek, E. E., & Ozeki, C. (1998). Work-family conflict, poli-
features: A meta-analytic summary and theoretical extension cies, and the job-life satisfaction relationship: A review and
of the work design literature. Journal of Applied Psychology, directions for future organizational behavior-human resources
92, 1332–1356. research. Journal of Applied Psychology, 83, 139–149.
Hunter, J. E., & Hunter, R. F. (1984). Validity and utility of Kristof, A. L. (1996). Person-organization fit: An integrative
alternate predictors of performance. Psychological Bulletin, review of its conceptualizations, measurement, and implica-
96, 72–98. tions. Personnel Psychology, 49, 1–49.

l ar son 173
Krumboltz, J. D., & Hamel, D. A. (1977). Guide to career deci- Leong, F. T. L., & Hayes, T. J. (1990). Occupational stereotyp-
sion making skills. New York: College Entrance Examination ing of Asian Americans. Career Development Quarterly, 39,
Board. 143–154.
Krumboltz, J. D., Mitchell, A. M., & Jones, G. B. (1976). Leong, F. T. L., & Tata, S. P. (1990). Sex and acculturation dif-
A social learning theory of career selection. The Counseling ferences in occupational values among Chinese-American
Psychologist, 6, 71–81. children. Journal of Counseling Psychology, 37, 208–212.
Krumboltz, J. D., & Nichols, C. W. (1990). Integrating LePine, J. A., Erez, A., & Johnson, D. E. (2002). The nature
the social learning theory of career decision making. and dimensionality of organizational citizenship behavior:
In W. B. Walsh, & S. H. Osipow (Eds.), Career counseling: A critical review and meta-analysis. Journal of Applied
Contemporary topics in vocational psychology (pp. 159–192). Psychology, 87, 52–65.
Hillsdale, NJ: Erlbaum. Leung, S. A., Ivy, D., & Suzuki, L. (1994). Factors affecting the
Kuncel, N. R., Credé, M., & Thomas, L. L. (2007). A meta- career aspirations of Asian Americans. Journal of Counseling
analysis of the predictive validity of the graduate manage- and Development, 72, 404–410.
ment admission test (GMT) and undergraduate grade point Leung, S. A., & Plake, B. S. (1990). A choice dilemma approach
average (UGPA) for graduate student academic performance. for examining the relative importance of sex type and pres-
Academy of Management, Learning, and Education, 6, 51–68. tige preferences in the process of career choice compromise.
Larson, L. M., & Borgen, F. H. (2006). Do personality traits Journal of Counseling Psychology, 37, 399–406.
contribute to vocational self-efficacy. Journal of Career Levine, E. L., Spector, P. E., Menon, S., Narayanan, L., &
Assessment, 14, 295–311. Cannon-Bowers, J. (1996). Validity generalization for cogni-
Larson, L. M., Rottinghaus, P. J., & Borgen, F. H. (2002). Meta- tive, psychomotor, and perceptual tests for craft jobs in the
analyses of Big Six interests and Big Five personality vari- utility industry. Human Performance, 9, 1–22.
ables. Journal of Vocational Behavior, 61, 217–239. Lindley, L., & Borgen, F. H. (2000). Personal style scales of the
Larson, L. M., Wei, M., Wu, T.-F., Borgen, F. H., & Strong Interest Inventory: Linking personality and interests.
Bailey, D. C. (2007). Discriminating among educational Journal of Vocational Behavior, 57, 22–41.
majors and career aspirations in Taiwanese undergraduates: Liu, C., & Rounds, J. (2003). Evaluating the structure of
The contribution of personality and self-efficacy. Journal of vocational interests in China, Acta Psychologica Sinica, 35,
Counseling Psychology, 54, 395–408. 411–418.
Larson, L. M., Wu, T. F., Bailey, D. C., Borgen, F. H., & Locke, E. A. (1978). Job satisfaction reconsidered: Reconsidered.
Gasser, C. E. (2010). Male and female college students’ edu- American Psychologist, 33, 854–855.
cational majors: The contribution of basic vocational cofi- Locke, E. A., & Latham, G. P. (2004). What should we do about
dence and interests. Journal of Career Assessment, 18, 16–33. motivation theory? Six recommendations for the twenty-first
Latham, G. P., & Pinder, C. C. (2005). Work motivation theory century. Academy of Management Review, 29, 388–403.
and research at the dawn of the twenty-first century. Annual London, M., & Greller, M. M. (1991). Demographic trends
Review of Psychology, 56, 485–516. and vocational behavior: A twenty year retrospective and
Lee, T. W., Mitchell, T. R., & Sablynski, C. J. (1999). Quali- agenda for the 1990s. Journal of Vocational Behavior, 38,
tative research in organizational and vocational psychology, 125–164.
1979–1999. Journal of Vocational Behavior, 55, 161–187. Long, L., & Tracey, T. J. G. (2006). Structure of RIASEC scores
Lent, R. W. (2004). Toward a unifying theoretical and practical in China: A structural meta-analysis. Journal of Vocational
perspective on well-being and psychosocial adjustment. Behavior, 68, 39–51.
Journal of Counseling Psychology, 51, 482–509. Loscocco, K. A., & Roschelle, A. R. (1991). Influences on the
Lent, R. W. (2005). A social cognitive view of career develop- quality of work and nonwork life: Two decades in review.
ment and counseling. In S. D. Brown, & R.W. Lent (Eds.), Journal of Vocational Behavior, 39, 182–225.
Career development and counseling: Putting theory and research Low, K. S. D., & Rounds, J. (2006). Vocational interests:
to work (pp. 101–127). Hoboken, NJ: John Wiley & Sons. Bridging person and environment. In D. Segal, & J. Thomas
Lent, R. W., Brown, S. D., & Hackett, G. (1994). Toward (Eds.), Comprehensive handbook of personality and psycho-
a unifying social cognitive theory of career and academic pathology, Volume I: Personality and every day functioning
interest, choice, and performance. Journal of Vocational (pp. 251–267). New York: Wiley.
Behavior, 45, 79–122. Low, K. S. D., & Rounds, J. (2007). Interest change and conti-
Lent, R. W., Lopez, F. G., & Bieschke, K. J. (1993). Predicting nuity from early adolescence to middle adulthood. Inter-
mathematics-related choice and success behaviors: Test of an national Journal for Educational and Vocational Guidance, 7,
expanded social cognitive model. Journal of Vocational 23–36.
Behavior, 42, 223–236. Low, K. S. D., Yoon, M., Roberts, B. W., & Rounds, J. (2005).
Leong, F. T. L. (1991). Career development attributes and occu- The stability of vocational interests from early adolescence to
pational values of Asian American and White American col- middle adulthood: A quantitative review of longitudinal
lege students. Career Development Quarterly, 39, 221–230. studies. Psychological Bulletin, 131, 713–737.
Leong, F. T. L. (2001). The role of acculturation in the career Lubinski, D. (2000). Scientific and social significance of assess-
adjustment of Asian American workers: A test of Leong and ing individual differences: Sinking shafts at a few critical
Chou’s (1994) formulations. Cultural Diversity & Ethnic points. Annual Review of Psychology, 51, 405–444.
Minority Psychology, 7, 262–273. Lykken, D. T., Bouchard, T. J., McGue, M., & Tellegen, A.
Leong, F. T. L., & Gupta, A. (2007). Career development and (1993). Heritability of interests: A twin study. Journal of
vocational behaviors of Asian Americans. In F. T. L. Leong, Applied Psychology, 78, 649–661.
A. G. Inman, A. Ebreo, L. H. Yang, L. Kinoshita, & M. Fu Madamba, A. B., & De Jong, G. F. (1997). Job mismatch among
(Eds.), Handbook of Asian American psychology (2nd ed., Asians in the United States: Ethnic group comparisons.
pp. 159–178). Thousand Oaks, CA: Sage. Social Science Quarterly, 78, 524–542.

174 worklife ac ro s s th e l if es pan

Matsuoka, J. K., & Ryujin, D. H. (1989). Vietnamese refugees: grade. U.S. Department of Education, Institute of Education
An analysis of contemporary adjustment issues. Journal of Sciences. Washington, DC: Author.
Applied Social Sciences, 14, 23–45. National Center for Education Statistics. (2003b). The National
McGuire, S., Neiderhiser, J. M., Reeiss, D., Hetherington, E. M., Assessment of Educational Progress (NAEP). The nation’s report
& Plomin, R. (1994). Genetic and environmental influences card: Writing highlights 2002. Fourth and eight grade students
on perceptions of self-worth and competence in adolescence: make gains in writing since 1998. U.S. Department of
A study of twins, full siblings, and step-siblings. Child Education, Institute of Education Sciences. Washington,
Development, 65, 785–799. DC: Author.
McKay, P. F., & McDaniel, M. A. (2006). A reexamination of National Science Foundation (NSF). (2004). Women, minorities,
Black-White mean differences in work performance: More and persons with disabilities in science and engineering (Report
data, more moderators. Journal of Applied Psychology, 91, No. NSF04–317). Washington, DC: Author.
538–554. National Science Foundation (NSF). (2008). Science and engi-
McMahon, M., & Patton, W. (1997). Gender differences in chil- neering indicators (Report No. NSB 06–01). Washington,
dren and adolescents’ perceptions of influences on their DC: Author.
career development. School Counselor, 44, 368–376. Nauta, M. M., Kahn, J. H., Angell, J. W., & Cantarelli, E. A.
McNulty, W. B., & Borgen, W. A. (1988). Career expectations (2002). Identifying the antecedent in the relation between
and aspirations of adolescents. Journal of Vocational Behavior, career interests and self-efficacy: Is it one, the other, or both?
33, 217–224. Journal of Counseling Psychology, 49, 290–301.
Meece, J. L., & Scantlebury, K. (2006). Gender and schooling: Ng, T. W. H., Eby, L. T., Sorensen, K. L., & Feldman, D. C.
Progress and persistent barriers. In J. Worell, & (2005). Predictors of objective and subjective career success.
C. D. Goodheart (Eds.), Handbook of girls’ and women’s A meta-analysis. Personnel Psychology, 58, 367–408.
psychological health: Gender and well-being across the lifespan O’Driscoll, M. P., & Randall, D. M. (1999). Perceived organiza-
(pp. 283–291). New York: Oxford University Press. tional support, satisfaction with rewards, and employee job
Mesmer-Magnus, J. R., & Viswesvaran, C. (2005). Convergence involvement and organizational commitment. Applied
between measures of work-to-family and family-to-work Psychology: An International Review, 48, 197–209.
conflict: A meta-analytic examination. Journal of Vocational Oppenheimer, L. (1991). Determinants of action: An organis-
Behavior, 67, 215–232. mic and holistic approach. In L. Oppenheimer, & J. Valsiner
Meyer, J. P., & Allen, N. J. (1997). Commitment in the workplace: (Eds.), The origins of action: Interdisciplinary and international
Theory, research, and application. Thousand Oaks, CA: Sage. perspectives (pp. 37–63). New York: Springer–Verlag.
Mitchell, L. K., & Krumboltz, J. D. (1990). Social learning Organ, D. W., & Ryan, K. (1995). A meta-analytic review of
approach to career decision making: Krumboltz’s theory. attitudinal and dispositional predictors of organizational citi-
In D. Brown, & L. Brooks (Eds.), Career choice and develop- zenship behavior. Personnel Psychology, 48, 775–802.
ment (2nd ed., pp. 145–196). San Francisco: Jossey-Bass. Owings, S. R., & Fritzsche, B. A. (2000). The relationship between
Mitchell, L. K., & Krumboltz, J. D. (1996). Krumboltz’s learn- person-environment congruence and job satisfaction. Poster ses-
ing theory of career choice and counseling. In D. Brown, sion presented at the annual meeting of the Society for
& L. Brooks (Eds.), Career choice and development (3rd ed., Industrial and Organizational Psychology, New Orleans, LA.
pp. 233–280). San Francisco: Jossey-Bass. Palmer, G., & Johnson-Bailey, J. (2005). The career develop-
Moloney, D. P., Bouchard, T. J., & Segal, N. L. (1991). A genetic ment of African Americans in the areas of training and orga-
and environmental analysis of the vocational interests of nizational development. Human Resource Planning, 28,
monozygotic and dizygotic twins reared apart. Journal of 1–12.
Vocational Behavior, 39, 76–109. Park, S. E., & Harrison, A. A. (1995). Career-related interests
Mount, M. K., Barrick, M. R., Scullen, S. M., & Rounds, J. and values, perceived control, and acculturation of Asian
(2005). Higher-order dimensions of the Big Five personality American and Caucasian-American college students. Journal
traits and the big six vocational interest types. Personnel of Applied Social Psychology, 25, 1184–1203.
Psychology, 58, 447–478. Parsons, F. (1909). Choosing a vocation. Boston: Houghton
Multon, K. D., Brown, S. D., & Lent, R. W. (1991). Relation Mifflin.
of self-efficacy beliefs to academic outcomes: A meta-analytic Phillips, S. D. (1997). Toward an expanded definition of adap-
investigation. Journal of Counseling Psychology, 38, 30–38. tive decision making. The Career Development Quarterly, 45,
Mundra, K., Moellmer, A., & Lopez-Aqueres, W. (2003). 275–287.
Investigating Hispanic underrepresentation in managerial Phillips, S. D., Christopher-Sisk, E. K., & Gravino, K. L. (2001).
and professional occupations. Hispanic Journal of Behavioral Making career decisions in a relational context. The Counseling
Sciences, 25, 513–529. Psychologist, 29, 193–213.
National Center for Education Statistics. (2001). The National Phillips, S. D., & Jome, L. M. (2005). Vocational choices: What
Assessment of Educational Progress (NAEP). The nation’s report do we know? What do we need to know? In W. B. Walsh,
card: Mathematics 2000. U.S. Department of Education, & M. L. Savickas (Eds.), Handbook of vocational psychology
Office of Educational Research and Improvement. (3rd ed., pp. 127–154). Mahwah, NJ: Lawrence Erlbaum
Washington, DC. Author. Associates.
National Center for Education Statistics. (2002). The National Phillips, S. D., Savickas, M. L., & Lent, R. W. (1994). Choice
Assessment of Educational Progress (NAEP). The nation’s report and change: Convergence from the decision-making per-
card: Science highlights 2000. U.S. Department of Education, spective. In S. D. Phillips (Ed.), Convergence in career devel-
Institute of Educational Sciences. Washington, DC: Author. opment theories: Implications for science and practice
National Center for Education Statistics. (2003a). The National (pp. 155–163). Palo Alto, CA: CPP.
Assessment of Educational Progress (NAEP). The nation’s report Pinder, C. C. (1998). Work motivation in organizational behavior.
card: Reading highlights 2002. 2002 reading trends differ by Upper Saddle River, NJ: Prentice Hall.

l ar son 175
Pitz, G. F., & Harren, V. A. (1980). An analysis of career deci- Rottinghaus, P. J., Larson, L. M., & Borgen, F. H. (2003).
sion making from the point of view of information process- Theoretical and empirical linkages of self-efficacy and inter-
ing and decision theory. Journal of Vocational Behavior, 16, ests. Journal of Vocational Behavior, 62, 221–236.
320–346. Rottinghaus, P. J., Lindley, L. D., Green, M. A., & Borgen, F. H.
Plomin, R., DeFries, J. C., McClearn, G. E., & Rutter, M. (2002). Educational aspirations: The contribution of person-
(1997). Behavior genetics (3rd ed., pp. 203–204). New York: ality, self-efficacy, and interests. Journal of Vocational Behavior,
Freeman. 61, 1–19.
Podsakoff, N. P., LePine, J. A., & LePine, M. A. (2007). Rounds, J., & Armstrong, P. I. (2005). Assessment of needs
Differential challenge stressor-hindrance stressor relation- and values. In S. D. Brown, & R. W. Lent (Eds.), Career
ships with job attitudes, turnover intentions, turnover, and development and counseling: Putting theory and research to
withdrawal behavior: A meta-analysis. Journal of Applied work (pp. 305–329). Hoboken, NJ: Wiley.
Psychology, 92, 438–454. Rounds, J., & Tracey, T. J. (1996). Cross-cultural structural
Rathbun, A., West, J., & Germino-Hausken, E. (2004). equivalence of RIASEC models and measures. Journal of
From kindergarten through third grade (NCES Report No. Counseling Psychology, 43, 310–329.
2004–2007). Washington, DC: National Center for Russell, J. E. A. (2006). Career counseling for women in man-
Education Statistics. agement. In W. B. Walsh, & M. J. Heppner (Eds.), Handbook
Ray, R., Gornick, J. C., & Schmitt, J. (2008, September). of career counseling for women (2nd ed., pp. 453–512).
Parental leave policies in 21 countries: Assessing generosity and Mahwah, NJ: Lawrence Erlbaum Associates.
gender equality. Center for Economic and Policy Research Ryff, C. D. (1995). Psychological well-being in adult life. Current
Report. Retrieved from www.cepr.net/documents/publicatons/ Directions in Psychological Science, 4, 99–104.
parental_2008_09.pdf. Sadri, G., & Robertson, I. T. (1993). Self-efficacy and work-
Rhoades, L., & Eisenberger, R. (2002). Perceived organizational related behaviour: A review and meta-analysis. Applied
support: A review of the literature. Journal of Applied Psychology: An International Review, 42, 139–152.
Psychology, 87, 698–714. Saks, A. M., & Ashforth, B. E. (1997). A longitudinal investiga-
Roberts, B. W., & DelVecchio, W. F. (2000). The rank-order tion of the relationships between job information sources,
consistency of personality from childhood to old age: applicant perceptions of fit, and work outcomes. Personnel
A quantitative review of longitudinal studies. Psychological Psychology, 50, 395–426.
Bulletin, 126, 3–25. Salgado, J. F., Anderson, N., Moscoso, S., Bertua, C., de Fruyt, F.,
Rojewski, J. W. (1997). Characteristics of students who express & Rolland, J. P. (2003). A meta-analytic study of general
stable or undecided occupational expectations during early mental ability validity for different occupations in the European
adolescents. Journal of Career Assessment, 5, 1–20. community. Journal of Applied Psychology, 88, 1068–1081.
Rojewski, J. W. (2005). Occupational aspirations: Constructs, Savickas, M. L. (2002). Career construction: A developmental
meanings, and application. In S. D. Brown, & R. W. Lent theory of vocational behavior. In D. Brown (Ed.), Career
(Eds.), Career development and counseling: Putting theory and choice and development (4th ed., pp. 149–205). San Francisco:
research to work (pp. 131–154). Hoboken, NJ: John Wiley & Jossey-Bass.
Sons. Savickas, M. L. (2005). The theory and practice of career
Rojewski, J. W., & Kim, H. (2003). Career choice patterns and construction. In S. D. Brown, & R. W. Lent (Eds.), Career
behavior of work-bound youth during early adolescence. development and counseling: Putting theory and research to
Journal of Career Development, 30, 89–108. work (pp. 42–70). Hoboken, NJ: John Wiley & Sons.
Rojewski, J. W., & Yang, B. (1997). Longitudinal analysis Savickas, M. L., & Baker, D. B. (2005). The history of vocational
of select influences on adolescents’ occupational aspirations. psychology: Antecedents, origin and early development.
Journal of Vocational Behavior, 51, 375–410. In B. Walsh, & M. Savickas (Eds.), Handbook of vocational
Ronen, S. T. (1994). An underlying structure of motivational psychology (3rd ed.). Mahwah, NJ.: Lawrence Erlbaum
need taxonomies: A cross-cultural confirmation. Associates.
In H. C. Triandis, M. D. Dunnette, & L. M. Hough (Eds.), Savickas, M. L., & Lent, R. W. (1994). Convergence in career
Handbook of industrial and organizational psychology (2nd development theories: Implications for science and practice. Palo
ed., pp. 241–269). Palo Alto, CA: Consulting Psychologists Alto, CA: CPP.
Press. Schmidt, F. L., & Hunter, J. E. (1998). The validity and utility
Rose, R. J. (1995). Genes and human behavior. Annual Review of selection methods in personnel psychology: Practice
of Psychology, 46, 625–654. and theoretical implications of 85 years of research findings.
Rosenzweig, C. (2001). A meta-analysis of parenting and school Psychological Bulletin, 124, 262–274.
success: The role of parents in promoting students’ academic per- Seibert, S. E., & Kraimer, M. L. (2001). The Five-Factor Model
formance. Paper presented at the American Educational of personality and career success. Journal of Vocational
Research Association National Convention, Seattle, Behavior, 58, 1–21.
Washington. Silvia, P. J. (2003). Self-efficacy and interest: Experimental stud-
Roth, P. L., Huffcutt, A. I., & Bobko, P. (2003). Ethnic group ies of optimal incompetence. Journal of Vocational Behavior,
differences in measures of job performance: A new meta- 62, 237–249.
analysis. Journal of Applied Psychology, 88, 694–706. Silvia, P. J. (2006). Exploring the psychology of interest.
Rottinghaus, P. J., Betz, N. E., & Borgen, F. H. (2003). Validity New York: Oxford University Press.
of parallel measures of vocational interests and confidence. Smith, P. C., Kendall, L. M., & Hulin, C. L. (1969). The mea-
Journal of Career Assessment, 11, 355–378. surement of satisfaction in work and retirement: A strategy for
Rottinghaus, P. J., Coon, K. L., Gaffey, A. R., & Zytowski, D. G. the study of attitudes. Oxford, England: Rand McNally.
(2007). Thirty-year stability and predictive validity of voca- Snow, R. E. (1996). Aptitude development and education.
tional interests. Journal of Career Assessment, 15, 5–22. Psychological Public Policy and Law, 3, 536–560.

176 worklife ac ro s s th e l if es pan

Spokane, A. R., & Cruza-Guet, M. C. (2005). Holland’s theory Tellegen, A., & Waller, N. G. (2008). Exploring personality
of vocational personalities in work environments. through test construction: Development of the multidimen-
In D. Brown, & R. W. Lent (Eds.), Career development and sional personality questionnaire. In G. J. Boyle, G. Mathews,
counseling: Putting theory and research to work (pp. 24–41). & D. H. Saklofske (Eds.), The SAGE handbook of personality
Hoboken, NJ: John Wiley & Sons. theory and assessment. Personality measurement and testing Vol. 2
Staggs, G. D., Larson, L. M., & Borgen, F. H. (2003). (pp. 261–292). Thousand Oaks, CA: Safe.
Convergence of specific factors in vocational interests and Thoresen, C. J., Kaplan, S. A., Barsky, A. P., Warren, C. R., &
personality. Journal of Career Assessment, 11, 243–261. Chermont, K. (2003). The affective underpinnings of job
Staggs, G. D., Larson, L. M., & Borgen, F. H. (2007). perceptions and attitudes: A meta-analytic review and inte-
Convergence of personality and interests: Meta-analysis of gration. Psychological Bulletin, 129, 914–945.
the multidimensional personality questionnaire and the Thorndike, E. L. (1911). Individuality. Boston: Houghton-Mifflin.
strong interest inventory. Journal of Career Assessment, 15, Thorsteinson, T. J. (2003). Job attitudes of part-time vs. full-time
423–445. workers: A meta-analytic review. Journal of Occupational
Stajkovic, A. D., & Luthans, F. (1998). Self-efficacy and work- and Organizational Psychology, 76, 151–177.
related performance: A meta-analysis. Psychological Bulletin, Tiedeman, D. V. (1979). Career development: Designing our
124, 240–261. career machines. New York: Character Research Press.
Strong, E. K., Jr. (1927). Vocational interest blank. Palo Alto, CA: Tiedeman, D. V., & O’Hara, R. P. (1963). Career development:
Stanford University Press. Choice and adjustment. New York: College Entrance Exam-
Strong, E. K., Jr. (1955). Vocational interests 18 years after college. ination Board.
Minneapolis, MN: University of Minnesota Press. Tilley, B. ( June, 2002). The validation of the educational outcome
Subich, L. M. (2001). Dynamic forces in the growth and change expectancy scale. Unpublished master’s thesis, Iowa State
of vocational psychology. Journal of Vocational Behavior, 59, University, Ames, Iowa.
235–242. Tinsley, H. E. A. (2001). Marginalization of vocational psychol-
Sullivan, B. A., & Hansen, J. C. (2004). Mapping associations ogy. Journal of Vocational Behavior, 59, 243–251.
between interests and personality: Toward a conceptual Tracey, T. J. G. (2002). Development of interests and compe-
understanding of individual differences in vocational behav- tency beliefs: A 1-year longitudinal study of fifth- to eighth-
ior. Journal Counseling Psychology, 51, 287–298. grade students using the ICA-R and structural equation
Super, D. E. (1992). Toward a comprehensive theory of career modeling. Journal of Counseling Psychology, 49, 148–163.
development. In D. H. Montross, & C. J. Shinkman Tracey, T. J. G., & Rounds, J. (1993). Evaluating Holland’s and
(Eds.), Career development: Theory and practice (pp. 35–64). Gati’s vocational-interest models: A structural meta-analysis.
Springfield, IL: Charles C Thomas. Psychological Bulletin, 113, 229–246.
Super, D. E., & Jordaan, J. P. (1973). Career development theory. Tracey, T. J. G., & Ward, C. C. (1998). The structure of
British Journal of Guidance and Counselling, 1, 3–16. children’s interests and competence perceptions. Journal of
Super, D. E., Savickas, M. L., & Super, C. M. (1996). The Counseling Psychology, 45, 290–303.
life-span, life-space approach to careers. In D. Brown, & L. Trapmann, S., Hell, B., Hirn, J. O. W., & Schuler, H. (2007).
Brooks (Eds.), Career choice and development (pp. 121–178). Meta-analysis of the relationship between the Big Five and
San Francisco: Jossey-Bass. academic success at university. Zeitschrift für Psychologie/
Super, D. E., Tiedeman, D. V., & Borow, H. (1961). Vocational Journal of Psychology, 215, 132–151.
development: A symposium. Personnel & Guidance Journal, Trice, A. D. (1991). Stability of children’s career aspirations.
40, 11–25. Journal of Genetic Psychology, 152, 137–139.
Swaney, K. B. (1995). Technical manual: Revised Unisex Edition Trice, A. D., & Rush, K. (1995). Sex-stereotyping in four-year-
of the ACT Interest Inventory (UNIACT). Iowa City, IA: olds’ occupational aspirations. Perceptual and Motor Skills,
ACT. 81, 701–702.
Swanson, J. L. (2011). Measurement and assessment in counsel- Tsabari, O., Tziner, A., & Meir, E. I. (2005). Updated meta-
ing psychology. In E. M. Altmaier, & J. C. Hansen (Eds.), analysis on the relationship between congruence and satisfac-
The Oxford handbook of counseling psychology. New York: tion. Journal of Career Assessment, 13, 216–232.
Oxford University Press. Tseng, V., Chao, R. K., Padmawidijaja, I. A. (2007). Asian
Swanson, J. L., & Hansen, J. C. (1988). Stability of vocational Americans’ educational experiences. In F. T. L. Leong,
interests over 4-year, 8-year, and 12-year intervals. Journal A. G. Inman, A. Ebreo, L. H. Yang, L. Kinoshita, & M. Fu
of Vocational Behavior, 33, 185–202. (Eds.), Handbook of Asian American psychology (2nd ed.,
Tang, M., Fouad, N. A., & Smith, P. L. (1999). Asian Americans’ pp. 105–123). Thousand Oaks, CA: Sage.
career choices: A path model to examine factors influencing Verquer, M. L., Beehr, T. A., & Wagner, S. H. (2003). A meta-
their career choices. Journal of Vocational Behavior, 54, analysis of relations between person-organization fit and
142–157. work attitudes. Journal of Vocational Behavior, 63, 473–489.
Tellegen, A. (1982). Brief manual for the multidimensional per- Vondracek, F. W. (2001). The developmental perspective in
sonality questionnaire. Unpublished manuscript, University vocational psychology. Journal of Vocational Behavior, 59,
of Minnesota, Minneapolis, Minnesota. 252–261.
Tellegen, A. (2000). Manual for the Multidimensional Persona- Vondracek, F. W., Silbereisen, R. K., Reitzle, M., & Wiesner, M.
lity Questionnaire. Minneapolis: University of Minnesota (1999). Vocational preferences of early adolescents: Their
Press. development in social context. Journal of Adolescent Research,
Tellegen, A., Lykken, D. T., Bouchard, T. J., Wilcox, K. J., Segal, 14, 267–288.
N. L., & Rich, S. (1988). Personality similarity in twins Wahl, R. T., & Blackhurst, A. (2000). Factors affecting the occu-
reared apart and together. Journal of Personality and Social pational and educational aspirations of children and adoles-
Psychology, 54, 1031–1039. cents. Professional Counseling, 3, 367–374.

l ar son 177
Waller, N. G., Lykken, D. T., & Tellegen, A. (1995). Occupational Weaver, C. N. (2000). Work attitudes of Asian Americans. North
interests, leisure time interests, and personality: Three American Journal of Psychology, 2, 209–218.
domains or one? Findings from the Minnesota twin registry. Weiler, J. D. (2000). Codes and contradictions: Race, gender iden-
In D. Lubinski, & R. V. Dawis (Eds.), Assessing individual tity and schooling (pp. 46). Albany, NY: State University of
differences in human behavior: New concepts, methods, and New York Press.
findings (pp. 233–259). Palo Alto, CA: Davies Black. Weinger, S. (1998). Children living in poverty: Their perception
Walls, R. T. (2000). Vocational cognition: Accuracy of 3rd-, of career opportunities. Families in Society: The Journal of
6th-, 9th-, and 12th-grade students. Journal of Vocational Contemporary Human Services, 79, 320–330.
Behavior, 56, 137–144. Weiss, D. J., Dawis, R. V., & England, G. W. (1967). Manual for
Walsh, W. B. (2001). The changing nature of the science of the Minnesota Satisfaction Questionnaire. Minnesota Studies
vocational psychology. Journal of Vocational Behavior, 59, in Vocational Rehabilitation, 22, 120.
262–274. Worthington, R. L., Flores, L. Y., & Navarro, R. L. (2005).
Walsh, W. B., & Eggerth, D. E. (2005). Vocational psychology Career development in context: Research with people
and personality: The relationship of the Five-Factor Model of color. In S. D. Brown, & R. W. Lent (Eds.), Career devel-
to job performance and job satisfaction. In W. B. Walsh, & opment and counseling: Putting theory and research to work
M. L. Savickas (Eds.), Handbook of vocational psychology: (pp. 225–252). Hoboken, NJ: John Wiley & Sons.
Theory, research, and practice (3rd ed., pp. 267–295). Mahwah, Young, K., Bailey, D., Boysen, G., Quinn, A., Robinson, R.
NJ: Lawrence Erlbaum Associates. Ruxton, B., Seeman, J., Spencer, K., & Larson, L. M. (2004,
Walsh, W. B., & Savickas, M. L. (Eds.). (2005). Handbook August). Outcome Expectancy in the Career and Academic
of vocational psychology: Theory, research, and practice (3rd Domain: A Review. Poster presented at the American
ed.). Mahwah, NJ: Lawrence Erlbaum Associates. Psychological Association National Convention, Honolulu,
Watkins, C. E., Jr., & Savickas, M. L. (1990). Psychodynamic Hawaii.
career counseling. In W. B. Walsh, & S. H. Osipow (Eds.), Zangaro, G. A., & Soeken, K. L. (2007). A meta-analysis of stud-
Career counseling: Contemporary topics in vocational psychology ies of nurses’ job satisfaction. Research in Nursing & Health,
(pp. 79–116). Hillsdale, NJ: Lawrence Erlbaum Associates. 30, 445–458.
Watson, M., & McMahon, M. (2005). Children’s career devel-
opment: A research review from a learning perspective.
Journal of Vocational Behavior, 67, 119–132.

178 worklife ac ro s s th e l if es pan

 CHAPTER

7 Training and Supervision

Nicholas Ladany and Arpana G. Inman

Abstract
Training and supervision theory and research is reviewed, specifically in relation to counselor
education and training linked to the development of therapist competence, and supervision.
Counselor competence is defined and reviewed along three areas: knowledge, self-awareness, and
skills. Multiple areas of supervision are examined: history of supervision; predominant, theoretical
models of supervision; supervisor techniques; the supervisory relationship; multicultural diversity;
supervisor self-disclosure; supervisor countertransference; supervisee development; supervisee and
supervisor nondisclosures; sexual attraction; supervision ethics; parallel process; client outcome;
evaluation; supervisee competence; supervisee and supervisor professional competence problems;
harmful supervision; supervisor training and competence; and specialized methods and topic areas of
supervision. Throughout the chapter, we provide future research directions and practice implications
for each training and supervision area reviewed. We conclude with some ideas about why training and
supervision fails, fails to succeed, succeeds to fail, and succeeds.
Keywords: supervision, training, education

The single most important function of graduate practice implications based on this review. We divide
education in counseling psychology is training stu- the chapter into two broad sections: counselor
dents in the art and science of counseling/psycho- education and training linked to the development
therapy. It is the reason why graduate programs of therapist competence; and supervision, the pri-
exist. Even so, the empirical and theoretical litera- mary endeavor used in graduate education to impart
ture on training has lagged far behind counseling therapeutic competence.
process and outcome variables, as well as other areas
of counseling and psychotherapy traditionally Counselor Education and Training
linked with counseling psychology (e.g., career, Keeping with its scientist–practitioner roots
multiculturalism, etc.). But, like these traditional (Wampold, Lichtenberg, & Waehler, 2002), a major
areas, counseling psychologists have been the prime focus in the training of counseling psychology stu-
movers and shakers when it comes to training dents has been on didactic-experiential education,
and supervision theory and research. As such, train- in which students receive coursework and experien-
ing and supervision is arguably a core foundational tial training to facilitate the development of coun-
subfield of counseling psychology and is the focus of seling competence. Counseling competence, broadly
this chapter. speaking, has been “understood to mean that a pro-
The purpose of this chapter is to synthesize fessional is qualified, capable, and able to under-
our theoretical and empirical knowledge of training stand and do certain things in an appropriate and
and supervision, and reciprocally offer research and effective manner” (Rodolfa et al., 2005; p. 348).

179
The ability to engage in several professional activities be categorized as consisting of six scientifically based
or domains (e.g., diagnosis and assessment, applica- knowledge domains: foundations of psychology,
tion of ethical standards, translating research to prac- research methods, counseling approaches, supervi-
tice, and practicing cultural diversity) has been noted sion and consultation, cultural diversity, and ethics.
to encompass this general sense of competence. Courses specific to these domains have typically
Some of the earliest work related to highlighting been offered to meet the knowledge requirements.
domains of competence has been attributed to the Gaining knowledge in foundations of psychol-
National Council for Schools and Programs of ogy involves an understanding of how cognitive,
Professional Psychology (NCSPP), Joint Council biological, and affective bases of behaviors influ-
on Professional Education in Psychology (Stigall ence an individual’s functioning. Research methods
et al., 1990), and the Committee on Accreditation and evaluation have been addressed through a diver-
(Commission on Accreditation, 2007). In recent sity of courses (e.g., statistics, research methods,
years, the emphasis on counselor competence has univariate and multivariate statistics, and qualitative
received greater attention due to the increasing analyses) that tap into different methodologies and
emphasis on service accountability (Rodolfa et al., approaches. Counseling approaches have encom-
2005); this is reflected in the American Psycholog- passed aspects related to assessment and interven-
ical Association (APA) Ethical Principles and tions with coursework related to psychological,
Code of Conduct (APA, 2002) and the Guidelines vocational, personality, and intellectual assessment.
and Principles for the Accreditation of Programs In addition, counseling interventions, geared toward
in Professional Psychology initiated in 1996 with helping to alleviate suffering and to promote well-
targeted changes made in 2002 (Committee on being of individuals, have utilized courses that
Accreditation, 2007). Within this context, many emphasize traditional counseling theories, psycho-
have highlighted foundational competency domains pathology, lifespan development, group and family
(e.g., knowledge in areas of research methodolo- counseling approaches and modalities, and empiri-
gies, cultural diversity) needed to acquire func- cally supported therapies. Empirically validated
tional competences (e.g., knowledge, values, and therapies are specialized interventions that have
skills needed to perform the tasks) (Rodolfa et al., been deemed as efficacious for treating specific psy-
2005). Although counselors have to develop several chological disorders (Waehler, Kalodner, Wampold,
functional domains of competence (e.g., diagnosis & Lichtenberg, 2000). In a related fashion, the APA
and assessment, intervention, research), there is a (2000) has developed specific guidelines for incor-
general agreement that counselor competence is porating these treatments into the training of gradu-
defined as a counselor’s ability to effectively inte- ate students. However, the lack of attention to
grate a knowledge base, one’s personal and profes- diversity issues (i.e., the idea that one size does not
sional beliefs and attitudes, and appropriate skills fit all) has raised some concerns over such treatment
that influence the effective practice of various approaches (Waehler et al., 2000).
domains (Epstein & Hundert, 2002; Meier, 1993; Supervision and consultation is a fourth knowl-
McIlvried & Bent, 2003, Rodolfa et al., 2005). In edge domain that has been deemed important.
sum, we define counseling competence to include Specifically, supervision has been identified as one
three subconstructs—knowledge, self-awareness, of the top five crucial areas of training and profes-
and skills—and use this definition to frame our dis- sional activities for psychologists (Robiner &
cussion of counselor education and training. Schofield, 1990) and is discussed further later in
the chapter. In a related fashion, consultation, which
Knowledge is the ability to provide expert guidance in the ser-
According to the Guidelines and Principles for the vice of client needs, as well as relate effectively
Accreditation of Programs in Professional Psycho- within different systems, has been identified as a
logy (Committee on Accreditation, 1996, 2002), related competency area. Specific courses on super-
doctoral graduate training programs are required to vision and professional development have been used
provide didactic training to afford students the to impart knowledge particular to each of these
opportunity to gain knowledge about the basic areas. In recent years, greater attention has been
competencies necessary to provide psychological paid to the knowledge domain of cultural diversity,
services. Based in part on Rodolfa et al.’s (2005) whereby counselors in training are expected to gain
cube model for competency development, we believe knowledge of different cultural communities, appre-
that the knowledge dimension of competence can ciate the uniqueness of clients and their cultures,

180 tr ain in g and s u pervis io n

understand the intersection of power and privilege (Arredondo et al., 1996), triad training model
inherent in multiple identities (Anderson & Collins, (Pedersen, 1994), and racial-cultural labs (Carter,
2007; Carter & Qureshi, 1995; Pederson 1991), 2003). Other approaches have included reading
and understand culture-specific forms of healing about identity development (Arredondo et al.,
(Ancis & Rasheed Ali, 2005; Pederson, 1991, 1999). 1996) and culture- and class-bound values of tradi-
A recent focus in the field has been on developing tional psychotherapies (Ancis & Rasheed Ali, 2005),
a social justice agenda that broadens the multicul- reacting to critical incidents in cross-cultural inter-
tural emphasis. Finally, the knowledge domain of actions (i.e., Intercultural Sensitizer; Leong & Kim,
ethics pertains to professionalism and is rooted in 1991), and teaching students to perceive situations
ethics courses and professional development courses. from the perspectives of the “other community
The basic assumption is that students who have members” (intercultural assimilator model; Fiedler,
achieved proficiency in these knowledge domains Mitchell, & Triandis, 1971). However, the extent to
will, in part, have the foundation upon which to which these approaches have been generalized and
learn counseling skills. integrated with other knowledge areas seems mar-
ginal at best. Given the importance of self-awareness
• Research to practice: Educators have a
to a counselor’s professional development, it would
tradition of keeping with tradition, which is the
seem prudent to begin importing more of these
reason why these domains have changed little over
approaches to other knowledge domains. For exam-
time. They are encouraged to consider the means
ple, in a counseling theories course, having stu-
by which they test student knowledge (e.g.,
dents apply a particular construct to their personal
comprehensive exams, portfolios, etc.) and
lives (e.g., journaling on an issue that is an unfin-
empirically determine the efficacy of these
ished business) can not only help create greater per-
assessment methods.
sonal awareness, but also help the student translate
• Future research: Multiple courses have been
theory to practice. Similarly, in a career assessment
identified that tap into foundational competencies.
course, having trainees develop a career genogram
It is important to examine the extent to which this
in which they can symbolically represent career
knowledge indeed serves as a foundation to
decisions and choices made in their own families
therapist skill acquisition.
can help generate multiple perspectives on their
own career development.
Self-awareness
• Research to practice: Developing self-awareness
Engaging in self-assessment or self-reflective prac-
involves a critical self-assessment of one’s beliefs,
tice has been identified as a core foundational com-
values, and behaviors that may influence one’s
ponent of competent practice (Committee on
work. Developing such self-criticality can help
Accreditation, 1996, 2002). Researchers (Bennet-
trainees integrate multiple perspectives, maintain
Levy, 2001; Boswell & Castonguay, 2007) strongly
flexibility in their thinking, tolerate ambiguity, and
recommend that trainees engage in systematic self-
suspend judgment (Elder & Paul, 1994; Granello
reflections as a way to gain a deeper understanding
et al., 2008, Watkins, 1995).
of the therapeutic role, the change process, and the
• Future research: Although the role of self-
specific theoretical models being used. Although
awareness within the context of multicultural
self-reflection has been identified as an impor-
issues has been explored, additional work is
tant factor (Eells, 1997) and is consistent with cer-
needed to examine the impact and outcomes of
tain theoretical approaches (e.g., psychodynamic),
developing self-awareness through other knowledge
a major emphasis on self-awareness has been limited
domains.
in training programs. The one caveat is the knowl-
edge domain of multiculturalism (Richardson &
Molinaro, 1996), in which specific attention to how Counseling and Psychotherapy Skills
one’s identities (e.g., race, gender) may influence Skills cover a broad array of day-to-day activities
one’s worldview is attended to. Instructional tech- (e.g., assessment, diagnosis, conceptualization and
niques used to develop these competencies have intervention, consultation, evaluation, advocacy)
included personal genograms (Ivey, Ivey, & Simek- provided by counselors to their clients. These have
Morgan, 1993), autobiographical essays (Arredondo been identified as functional competencies needed
& Arciniega, 2001), self-reflective journals (Burnett, to perform the role of a psychologist (Rodolfo et al.,
& Meacham, 2002), cultural immersion exercises 2005). In the past, functional competencies or skills

l adany, inm an 181

were typically based in conceptualizations that Nonverbal behaviors such as gestures, facial expres-
evolved from theoretical frameworks (e.g., psycho- sions, head nods, glances, changes in tone of voice,
dynamic theory), suggesting that what happens keeping an open body posture are critical ways that
in the therapy session is directly related to the alter or emphasize what we say and do. These non-
therapist’s theoretical orientation. However, the verbal forms of communication provide a depth
uniform efficacy of all psychotherapies noted origi- to the emotions underlying one’s experience and
nally by Rosenzweig (1936) and the endorsement are often more important than what is being said
of common factors across therapeutic approaches orally. These nonverbals become all the more impor-
(Wampold, Mondin, Moody, Stich, Benson, & tant in cultural contexts, when communication
Ahn, 1997) has resulted in focusing on the pattern patterns may vary across communities. The nonver-
of contextualized variables or factors that influ- bal behaviors highlighted as an important skill in
ence therapeutic process. As such, in recent years, several of the training models (e.g., HTR, MC,
greater emphasis has been placed on examining the Hill’s helping skills model) and developed to teach
overt and covert client–therapist behaviors and, in trainees helping skills (e.g., nonverbal attending
particular, facilitating students’ development of used by Carkhuff, 1971, and based on Rogers,’
these overt–covert helping skills (e.g., reflection, 1957 work) emphasize the importance of nonverbal
open-ended questions, etc.) (Hill, 2004). In fact, behaviors. For example, microcounseling skills train-
the late 1960s and early 1970s saw the initial devel- ing (Ivey, 1971) proposes a meta-theory of counsel-
opment of systematic and structured training ing and uses four training components (instruction,
models that focused on teaching counseling trainees modeling, practice, and feedback) to teach a hierar-
these helping skills. Varying in learning philoso- chy of interviewing skills that include nonverbal
phies (Nerdrum & Ronnestad, 2002), methods for attending behaviors. The emphasis on nonverbal
training (e.g., rating scales, video and audio taped behaviors also comes through in Hill’s three-stage
feedback), and empirical support, four approaches (e.g., exploration, insight, and action) theoretically
received the greatest attention: human resource integrated approach. Specifically, the exploration
training (HTR; Carkhuff, 1971), microcounseling stage, informed by client-centered therapeutic
(MC; Ivey, 1971), interpersonal process recall (IPR; tenets, focuses on empathy, warmth, and positive
Kagan, 1984), and Hill’s helping skills model (Hill, regard, aspects often projected thorough nonverbal
2004; see Ladany & Inman, 2008, for a review of behaviors.
these models). What these four models share in
common is a focus on the moment-to-moment level 2: response modes
interactions that highlight the discrete helping skills According to Ladany et al., (2008), there are two
needed to engage in the therapeutic process. types of response modes. The first relates to the type
Based on Hill’s (1982, 1986) and Stiles (1979, of verbal exchange or how one communicates. For
1986) frameworks, Ladany, Walker, Pate-Carolan, example, a therapist may use an open-ended ques-
and Gray Evans (2008) offered a framework that tion with a client: “What brings you here today?”
conceptualizes therapy skills along four levels: The second type of response mode refers to the
(1) nonverbal behaviors (e.g., eye contact, arms content of the verbal exchange or what one commu-
crossed), (2) response modes (i.e., how something is nicates. Thus, the open-ended question (“What
said and what is said), (3) covert processes (internal brings you here today?”) may be labeled as the
thought and feelings experienced by the dyad), and therapist’s attempts at exploring the client’s reasons
(4) therapeutic strategies and techniques (i.e., theo- for treatment. Whereas therapist verbal response
retically driven techniques, such as dream interpre- modes (e.g., open or closed questions, direct guid-
tation, empty chair technique). These four levels ance, confrontation, pointing out incongruence,
not only highlight aspects relevant to the four train- approval, paraphrase, interpretation, and therapist
ing models (e.g., Hill’s helping skills model) but go self-disclosure) are pantheoretical, theoretical orien-
beyond the models to provide a clinically driven, tation has been noted to influence therapists’ choice of
conceptual framework. response mode (e.g., psychodynamic therapists use
interpretation more often than do behavioral thera-
level 1: nonverbal behaviors pists). Like therapists, clients also engage in a parallel
It has been suggested that at least 60% of what we system of response modes (e.g., resistance, agreement,
communicate when talking directly with others is affective exploration, cognitive-behavioral exploration,
through paralanguage or nonverbals (Sue & Sue, 2003). insight, and therapeutic changes). Continuing with

182 tr ain in g and s u pervis io n

the example, the client uses the invitation of the underlying this premise has been that therapeutic
open question to open up and share her or his rea- process is theory driven (e.g., psychodynamic theory
sons for coming to treatment. Both forms of verbal emphasizes insight and catharsis). Due to this prem-
exchanges are important in highlighting different ise, therapeutic strategies and techniques tended to
perspectives on the same issue. These response modes be largely examined within the context of theoretical
not only highlight the interpersonal and dialectic integration and technical eclecticism. However, with
nature of counseling but also help us understand the researchers endorsing some common factors across
relationship between the process (what is being said) therapeutic approaches as central to the therapy pro-
and outcome (why something happened) of a ses- cess (Luborsky, Singer & Luborsky, 1975; Smith,
sion. The focus on response modes is not only par- Glass, & Miller, 1980; Wampold et al., 1997), ther-
ticular to Hill’s helping skills model but is highlighted apeutic strategies and techniques are also currently
in the HTR model’s focus on advanced empathy seen to be embedded in common therapist–client
(e.g., interpretation, self-disclosure, immediacy) and factors. For instance, Hill’s three-stage model of
direct guidance skills (e.g., problem solving, decision helping skills integrated three of the most common
making), the use of a hierarchy of skills (reflection of theoretical orientations (humanistic, psychody-
feelings) in MC, and reflecting on the different pro- namic, and cognitive-behavioral) each of which not
cesses that hamper or facilitate the therapeutic pro- only draws on typical therapist–client covert and
cess in the IPR model. overt response modes but also conceptually contex-
tualizes the counseling process. Specifically, based
level 3: covert processes on client-centered theory, exploration involves
A lot that goes on in the therapeutic process often is counselors exploring client’s thoughts and feelings
not readily observable but significantly affects the about a particular problem. In the psychodynamic
therapeutic work. These covert processes can operate and interpersonally based insight stage, counselors
for both the therapist and the client. For instance, help clients construct new and deeper meanings for
Hill (2001) identified helper intentions (e.g., limit their problems. Finally, in the action stage, based in
setting, support, focus, instilling hope, educating, cognitive and behavioral theories, counselors work
intensifying feelings) that may underlie a particular with clients to change their feelings, thoughts, and
response mode (e.g., challenge, information gather- behaviors related to the problem. Throughout this
ing) and that are clinically meaningful and engaged process, the focus is on therapists building and
in by the therapist. Similarly, client covert processes maintaining a good working relationship/alliance
may include feeling understood, supported, unstuck, with their clients.
or being scared and confused, to name a few. In addi- Learning helping skills has been considered
tion, another form of covert process that both thera- important and necessary in most training pro-
pists and clients engage in relates to nondisclosures or grams. Yet, it is interesting to note that much of this
secrets that can dramatically influence the therapeu- training tends to occur in one or at the most two
tic process (Hill, 2001). These issues have also been classes that emphasize helping skills, the adequacy
highlighted in the various models that have been of which may leave many students short of profi-
developed for counselor development. For instance, cient levels of skill acquisition. Moreover, these
focusing on interpersonal dynamics in the counseling skills are not generally integrated throughout the dif-
process, IPR uses a unique recall process whereby an ferent knowledge domains. For instance, a course on
“inquirer” has trainees review and reflect on those counseling theories or family counseling may include
in-session thoughts, feelings, and bodily sensations a lab component. A course in group counseling may
that may have interfered with the therapeutic pro- include a simulated group or observation of group
cess (Kagan, 1984). Similarly in Hill’s three-stage processes using an existing group, or a program may
model, the insight stage, founded in psychodynamic- have a specific course on helping skills that focuses
interpersonal theories, focuses on the covert processes on discrete skills. Frequently, by engaging in role
that are salient to the therapeutic process. plays with other peer counselors, the simulated expe-
riences are the precursor to student practica and
level 4: therapeutic strategies internships, but these fall short of providing a realis-
and techniques tic experience for these trainees. Furthermore, these
Often based in theoretical frameworks, therapeutic courses and training may be too close to the practi-
strategies and techniques have evolved out of a trans- cum experience to allow for a thorough evaluation of
lation of theory to practice. A major assumption the student’s readiness for a practicum.

l adany, inm an 183

 • Research to practice: Educators may want models of psychotherapy (Ekstein & Wallerstein,
to begin with helping skills and determine whether 1958). In the 1980s, supervision shifted from psy-
students are proficient enough to move to a chotherapy-based models of supervision to models
beginning practicum. As it stands, the vast created for supervision proper (Bernard, 2005).
majority of students make it past pre-practicum During this same period, empirical work in supervi-
courses, which points to problems with evaluation sion began to flourish, or at least began to be seen in
criteria, rather than the field uniquely attracting the literature, typically with less than a dozen empir-
a disproportionate number of proficient students. ical studies published per year. The three fields most
In addition, counselor educators may want to connected with supervision research were, and con-
reconsider the disproportionate balance of tinue to be, counseling psychology, counselor edu-
knowledge, self-awareness, and skills, specifically cation, and social work (Ellis, Ladany, Krengel, &
increasing the attention to self-awareness Schult, 1996).
and skills. Over the past three decades, the result of super-
• Future research: What is enough in terms of vision theory and research can perhaps best be
helping skills acquisition? Researchers would do described as what happens when a bag of flour is
well to develop serious and rigorous methods for thrown into a swimming pool from a high diving
assessing skill acquisition at an early stage of board. There are some areas of concentration, but
professional development, prior to working with there are also many areas of single drops, and large
actual clients. swaths where no flour has landed. To be sure, a few
attempts have been made to address supervision in a
Supervision comprehensive fashion via theoretical formulations
Supervision is arguably the most important activity and programmatic research, but it is clear that there
related to the development of therapeutic compe- is much work to be done.
tence, particularly if importance is determined The rest of this section is devoted to two primary
based on the amount of energy and resources areas: theoretical formulations of supervision and
devoted to an aspect of learning. After all, most con- supervisor techniques, and variables in supervision
tent area courses in a doctoral counseling psychol- that are believed to be most salient to supervision
ogy curriculum consist of one or two semesters of process and to outcome based on the attention they
coursework, whereas supervised experiences typi- have received in the empirical, theoretical, and prac-
cally last 2–3 years, followed by a year-long intern- tice literature. Following these reviews, we offer
ship. Yet, compared to these other areas, which we theory and/or research to practice recommenda-
spend considerably less attention to in graduate tions and suggestions for future research. The bulk
school, supervision theory and research is limited. of the review is based on individual supervision of
The reasons for this are unclear, although they individual therapy. This focused review is not to
include, in part, the difficulty of conducting quality imply that other forms of supervision are less impor-
and rigorous research (Ellis & Ladany, 1997), lim- tant or relevant to counseling psychologists. The
ited theoretical formulations, the tradition of non- reality is that this additional literature base is at its
inclusion in curricula, and limited accreditation earliest stages (i.e., some practice writings and very
attention and requirements (e.g., the APA does not few, if any, empirical studies) and has a great deal
require didactic-practica in supervision). of catching up to do before it can be reviewed in a
Historically, the earliest roots of supervision substantive manner. For this review, we broadly
can be traced to the field of social work in the late define individual supervision as a dyadic activity
1800s as part of the Charity Organization Societies whereby the supervisor facilitates the provision of
(Kadushin & Harkness, 2002; Munson, 2002). feedback to the supervisee, which is based on the
In these societies, agents/social workers were trained interpersonal communication between both mem-
in the context of apprenticeships, in which supervi- bers of the dyad and can pertain to the work in
sors provided periodic individual meetings to mul- supervision, the supervisee, the supervisee’s clients,
tiple supervisees. In 1902, Freud provided an initial or the supervisor.
context for the provision of analyzing the analyst
(Goodyear & Guzzardo, 2000), and by 1925, super- Theoretical Models of Supervision
vision was required for the first time as a training There are arguably three leading models of super-
requirement (Kugler, 1995). Initial attempts at vision (Westefeld, 2009), all of which were devel-
developing supervision theory were largely based on oped by counseling psychologists: the integrated

184 tr ain in g and s u pervis io n

developmental model (IDM; Stoltenberg, McNeill, techniques, or processes such as interpersonal pro-
& Delworth, 1998), the systems approach to supervi- cess recall (Kagan, 1984), supervisor competencies
sion (SAS; Holloway, 1995), and the critical events (Falender & Shafranske, 2004; Ancis & Ladany,
model of supervision (CES; Ladany, Friedlander, & 2010 in press), reflective learning (Ward & House,
Nelson, 2005). Expanding upon Westefeld’s (2009) 1998), Socratic supervision (Overholser, 2004),
and Ladany and Inman’s (2008) rationale for iden- supervisor self-disclosure (Ladany & Walker, 2003),
tifying these supervision models, they share common and cognitive development (Blocher, 1983).
features that make them stand out among other Many of these circumscribed models have
models: they are comprehensive, are empirically influenced and were integrated within the com-
based, are derived and developed for supervision, prehensive models. For example, Hogan’s (1964),
can be used pantheoretically with diverse theoretical as well as Littrel, Lee-Bordin, and Lorenz’s (1979)
approaches to counseling and psychotherapy, offer developmental models were precursors of Stol-
testable hypotheses, are descriptive and prescriptive, tenberg et al.’s (1998) IDM, Bernard’s (1979) dis-
and are practitioner-friendly and applicable. crimination model is linked to Holloway’s (1995)
Before attending further to these three afore- SAS, and Bordin’s (1983) model of the super-
mentioned models, it is important to further con- visory working alliance served as the foundation
sider what makes these models unique and important for Ladany et al.’s (2005) CES. In subsequent
for discussion. As indicated previously, up until the sections, we provide for each model an overview
1980s, most models of supervision were geared of the theoretical propositions, identify and define
toward and linked to specific theoretical approaches the primary constructs, review strengths and
to counseling and psychotherapy. This habit contin- weaknesses, summarize past research and offer
ues to the present (e.g., Hyman, 2008), however, future research suggestions, and provide practice
we believe there are four fundamental problems recommendations.
with psychotherapy-based and theoretically linked
models of supervision. First, the models often integrated developmental model
do not fully recognize aspects of supervision that The foundational assumption of the IDM
are uniquely different from that of psychotherapy (Stoltenberg, McNeill, & Delworth, 1998) is that
(e.g., supervision, unlike psychotherapy is gener- supervisees typically grow in a developmental fash-
ally involuntary, evaluative, and didactic). Second, ion that can be tracked and observed by super visors.
psychotherapy-based models of supervision vary The model offers a complex interplay between
widely in their adherence or link to constructs asso- supervisee structures of professional growth and
ciated with the psychotherapy model to which they domains of clinical practice, from which super-
are tied (e.g., how does one “teach” psychoanalysis visee developmental level is assessed and deter-
via psychoanalysis?). Third, these psychotherapy- mined. The overriding structures that change
based models often ignore or lose sight of the inte- developmentally include: self and other aware-
grative nature of the counseling and supervision ness (e.g., high anxiety to low anxiety), motivation
enterprise (Wampold, 2001). In the worst cases. it is (e.g., high, fluctuating, and then stable), and auton-
like fitting a square peg into a round hole, and omy (e.g., dependence to independence). The pri-
everything gets jammed into a triangle (aka, The mary domains of clinical activity include
Client). Fourth, psychotherapy-based models have intervention skills competence (e.g., confidence in
little empirical foundation and have rarely been modality of therapy), assessment techniques (e.g.,
studied. In all, although we agree that psychother- using vocational or personality instruments),
apy models offer constructs that can be useful in interpersonal assessment (e.g., assessing the client’s
supervision (as do pedagogies of teaching), basing a interpersonal dynamics), client conceptualization
model of supervision on a particular psychotherapy (e.g., diagnosis), individual differences (e.g., cul-
offers too many shortcomings to warrant a high tural differences), theoretical orientation (e.g., psy-
quality rating and endorsement. chotherapy approach), treatment plans and goals
We should also recognize that a number of models (e.g., organization of treatment), and professional
developed for supervision—perhaps best described ethics (e.g., integration of personal and professional
as “mini-models”—attend to supervisory phenom- ethics). Depending on the assessed supervisee devel-
ena in a much more circumscribed manner than opmental level and the training environment, educa-
the aforementioned comprehensive models. These tors or supervisors choose to provide a variety
mini-models have attended to supervision variables, of interventions and mechanisms. Interventions can

l adany, inm an 185

be facilitative, prescriptive, conceptual, or catalytic. • Theory to practice: The IDM offers
Mechanisms include supervisory processes such as practitioners a theoretical lens through which
observations, skills training, role-playing, and group to assess supervisees developmental needs and
supervision. match these needs with techniques to help
A primary task for the supervisor is to assess supervisees develop into more competent
supervisees on their structures within particular clinicians.
domains. Supervisees can function at high or low • Future research: The development of
levels, depending on the domain of clinical activity. reliable and valid instrumentation will be necessary
Supervisees can then be classified as Level 1, Level 2, to test many of the model’s assumptions.
Level 3, or Level 3i. For example, Level 1 supervi- Specifically, instruments need to be developed
sees tend to be highly motivated, highly anxious, that attend to the multilevel nature of supervisees,
require a focus on skill acquisition, are dependent which accounts for supervisee structures and
on the supervisor, need structure, should be mini- domains of clinical activity.
mally confronted, have limited self-awareness, and
have difficulty seeing strengths and weaknesses. systems approach to supervision
As supervisees progress through the levels, and as The SAS (Holloway, 1995) has been categorized as
they develop skills across multiple domains, they a type of “social role model” of supervision (Bernard
eventually reach Level 3i, where integration occurs. & Goodyear, 2009). Social role models generally
At this point, they are considered master therapists, highlight the roles that supervisors play in the con-
something the authors do not believe occurs often. text of supervision. Bernard’s (1979, 1997) discrim-
In the IDM model, the supervisory relationship is ination model is one of the earliest developed social
seen as an important component. For example, IDM role models, and it can be credited with highlight-
postulates how the supervisor should approach the ing and popularizing the commonly referred to
relationship with the supervisee (e.g., supervisors supervisor roles of teacher, counselor, and consul-
need to be preparted with supervisee’s in Level 2, tant. Holloway’s SAS expanded upon Bernard’s
who will likely create more conflictual relationships model and conceptualized supervision as a seven-
than those in other levels). Although identified as factor enterprise. The supervisory relationship is
important by the IDM model, how the relationship considered the core factor; it consists of supervisory
is defined is unclear. power, as well as interpersonal intimacy and attach-
A clear strength of the IDM is that it added ment between the supervisor and supervisee. More-
much complexity and detail to earlier develop- over, the supervisory relationship is seen as passing
mental models, which were short of content. In through phases (e.g., beginning, mature) and involves
addition, the IDM has evolved over time, and its a negotiated goals contract between the supervisor
assumptions have been modified. Moreover, the and supervisee.
developmental framework seems to appeal to super- Two factors are used to determine supervision
visor practitioners. Nonetheless, the IDM has been process: supervisor functions (i.e., monitoring/
critiqued on a couple of grounds (Chang & O’Hara, evaluating, advising/instructing, modeling, consult-
2010 in press). First, empirical support for specific ing, and supporting/sharing), and supervision tasks
aspects of the model are limited (e.g., Ramos- (i.e., counseling skill, case conceptualization, profes-
Sanchez et al., 2002). Second, the integration sional role, emotional awareness, and self-evalua-
of multicultural issues is limited, specifically, the tion). Together, these functions and tasks offer the
manner in which multicultural issues influence the supervisor a way to identify what is happening in
interaction between the supervisor and supervisee. supervision at any point in time. Specifically, the
Finally, it is unclear if supervisors are able to use supervisor should be able to assess her or his func-
the IDM as more than a general heuristic devise tion in relation to the task at hand, thereby identify-
(e.g., supervisees change over time), rather than as a ing the type of supervisory process that is occurring.
prescriptive or theoretical template for working Additional factors, all of which are contextual
with supervisees (e.g., change their approach based in nature, include the client (i.e., client characteris-
on a moment-to-moment, multilayer assessment of tics, identified problems and diagnosis, counseling
the supervisee). Moreover, within the model, super- relationship), the trainee (i.e., experience in coun-
visors are assumed to be generally competent and seling, theoretical orientation to counseling, learn-
equipped to supervise, an assertion that may be sus- ing needs and style, cultural characteristics, and
pect (Ladany, 2002). self-presentation), the supervisor (professional

186 tr ain in g and s u pervis io n

experience, role in supervision, theoretical orienta- working alliance, a marker, the task environment,
tion to counseling, cultural characteristics, and self- and a resolution. The supervisory working alliance
presentation), and the institution (agency clientele, is deemed the foundation of the model and is
organizational structure and climate, professional based on Bordin’s (1983) model of the supervisory
ethics and standards). working alliance. The supervisory working alliance
The SAS is a very far-reaching model that relies consists of three components: mutual agreement
on a comprehensive understanding of multiple fac- between the supervisee and supervisor about the
tors and the interplay among factors. Unique to the goals of supervision (e.g., increase skill set), mutual
model is its recognition of institutional factors that agreement between the supervisee and supervisor
influence the supervisory work and could, at times, about the tasks of supervision (e.g., review audio
trump all other factors in relation to the training recordings), and an emotional bond between the
a supervisee receives. The SAS does well to include supervisee and supervisor consisting of mutual trust,
the relationship as a core factor; however, how it respect, liking, and caring. The supervisory working
is created and maintained is not clearly discussed. alliance is developed via listening, reflections, and
An important critique of the model’s adequacy is empathy, as well as through negotiations between
that it has spawned virtually no empirical work the supervisee and supervisor about the tasks and
since inception. Like any strong theory, its utility goals of supervision that best meet the supervisee’s
and credibility will be based on the extent to which needs.
it can be empirically tested, verified, and modified. The second component of the CES, the marker,
consists of a supervisee statement or behavior (e.g.,
• Theory to practice: The SAS provides
supervisee asks for guidance on a technique, super-
supervisor practitioners with the additional lens
visee chronically arrives late for supervision, super-
of institutional factors to take into consideration
visee expresses frustration at supervisor or client)
when understanding supervisory work.
that signals to the supervisor that a critical event
• Future research: An important contribution
may be initiating. Once the marker is identified, the
of the SAS is its predictions about functions and
supervisory dyad enter what is called the task envi-
tasks in supervision. Similar to other interpersonal
ronment, whereby the supervisor can engage in
coding schemes (e.g., structural analysis of social
a selection of interaction sequences, which in essence
behavior, Benjamin, 1996), researchers could
are techniques intended to assist the supervisee.
develop a coding system for functions and tasks
Interaction sequences include focus on the supervi-
in supervision, then test the extent to which these
sory alliance, focus on the therapeutic process,
functions and tasks adequately describe supervisory
exploration of feelings, focus on countertransfer-
process and indeed predict supervision outcomes.
ence, attention to parallel processes, focus on self-
efficacy, normalization of experience, focus on skill,
critical events in supervision assessment of knowledge, focus on multicultural
The fundamental assumption of the CES (Ladany awareness, and focus on evaluation. The selection of
et al., 2005) is that supervision can be broken down the number and frequency of interaction sequences
into meaningful critical events of learning that can depends on the critical event.
take place within a session or across multiple At the conclusion of the task environment
sessions. Over time, authors of the CES approach (i.e., the series of interaction sequences), the critical
have identified what are believed to be the most event (e.g., managing sexual attraction) ends with
common critical events in supervision. These a resolution or mini-outcome (e.g., increased aware-
include remediating skill difficulties and deficits, ness of sexual attraction). These outcomes consist
heightening multicultural awareness, negotiating of a change (from enhancing to declining) in self-
role conflicts, working through countertransference, awareness, knowledge, skills, or the supervisory
managing sexual attraction, repairing gender-related working alliance.
misunderstandings, addressing problematic super- A strength of the CES is that the theory offers
visee emotions and behaviors, facilitating supervisee practitioners a meaningful set of supervision-based
insight, and facilitating a supervisee correction outcomes that can be empirically tested in a rela-
relational experience. tively straightforward manner. In addition, it attends
The CES is intended to be pantheoretical in to managing and working with specific multicul-
nature and proposes that all critical events have tural issues, such as gender, race, and sexual orienta-
in common four components: the supervisory tion. Of all the aspects of the model, the supervisory

l adany, inm an 187

working alliance has been investigated the most the supervision genogram (Aten, Madson, & Kruse,
extensively (over a dozen empirical articles), and its 2008), processing multicultural issues (e.g., Gatmon
utility and importance in supervision seems quite et al., 2001), managing countertransference (Ladany
evident. That said, the model’s newness means that et al., 2008), supervisor self-disclosure (Ladany &
the empirical work that has tested its efficacy is lim- Walker, 2003), structured peer group supervision
ited, particularly the interaction sequences hypoth- (Borders, 1991), contracting (Munson, 2002), read-
esized for particular events. Furthermore, the model ing assignments (Munson, 2002), journaling
does not address events deemed “noncritical,” such (Griffith & Frieden, 2000; Guiffrida, 2005; Knowles
as when the supervisor asks the supervisee to spend et al., 2007), self-reflection (Neufeldt, 1999), and
extensive time on case overview. In addition, critical live observation (Bernard & Goodyear, 2009).
events currently absent from the model may need to Among the supervision techniques developed,
be considered in future work. interpersonal process recall (IPR; Kagan & Kagan,
1997) is arguably the only technique that clearly
• Theory to practice: The CES model offers
provided an educational method and that was
a prescriptive approach to handling a variety of
empirically tested in a programmatic manner
issues in supervision, such as how to handle
(e.g., Kagan, 1980; Kagan & Krathwohl, 1967;
supervisees with professional competence
Kingdon, 1975). The basic elements of IPR include:
problems. In addition, it offers supervisors an
the supervisee and supervisor review audio record-
enhanced awareness of the types and range of
ing of counseling sessions, impromptu stopping of
supervisor techniques available in the supervision
the recording can be made by either member of the
context.
dyad, and the supervisor facilitates supervisee self-
• Future research: The CES approach was
reflection and analysis of the counseling work. Once
designed intentionally to allow and promote
the reflection phase is complete, the recording is
empirical testing. The basic empirical approach
listened to again, and the process repeats itself.
would be to identify a critical event (e.g., upon
Although IPR has been well-defined and used in
supervisee or supervisor reflection, via video
many counseling training programs, current research
recording) and assess the supervisory alliance,
on its efficacy has been minimal.
the marker, interaction sequences, and resolution
(e.g., from perspectives of the supervisor, • Research to practice: A number of techniques
supervisor, and/or observer rating) to determine have been published for supervisor use. Supervisor
the extent to which the components hypothesized practitioners are encouraged to become aware of
occur as predicted. these techniques to broaden their repertoire of
skills.
• Future research: Supervisor techniques have
Supervisor Techniques
been prescribed, but there is limited research
Similar to therapist skills, supervisor skills can
testing their efficacy. To that end, it will be
be viewed as falling along four levels: nonverbal
important to determine the efficacy of supervisor
behaviors (e.g., head nods, nonverbal tracking, etc.),
techniques and specifically address the proximal
response modes (e.g., reflection of feelings, dem-
and distal supervision outcomes that are
onstrate understanding, etc.), covert processes
anticipated.
(e.g., intentions and reactions), and theoretical strat-
egies and techniques (e.g., IDM, SAS, CES) (Ladany
et al., 2008). We have already discussed three theo- Supervision Variables
retical models that offer broad and overarching As supervision theory began to develop in the early
strategies, as well as specific theoretically consistent 1980s, so did empirical work. Since that time, the
techniques associated with each of the models. In publication output of supervision research typically
addition, other stand-alone techniques have been consists of less than a dozen articles published per
developed specifically for supervision that are either year. This relatively low publication rate (as com-
couched in a mini-model or could be deemed pan- pared to counseling and psychotherapy research) has
theoretical in nature. Bernard and Goodyear (2009) been attributed to limited samples available, the dif-
and Walker (2010) present a series of supervision ficulty in obtaining perspectives from a multiperson
techniques that expand upon the aforementioned unit (i.e., supervisee, supervisor, clients), and the
theoretically based techniques; these include inter- limited number of supervision researchers interested
personal process recall (Kagan & Kagan, 1997), in programmatic work (Ladany & Inman, 2008).

188 tr ain in g and s u pervis io n

That said, we identified clusters of literature on par- alliance (Bordin, 1979). Similar to his therapeutic
ticular variables, on which at least a modicum of alliance, Bordin (1983) believed that it was not the
loosely tied-together programmatic work has been specific goals or tasks that were agreed upon that
conducted. Our review expanded recent reviews were important; rather, it was the agreement itself
(Inman & Ladany, 2008; Ladany & Inman, 2008) that was most critical. Hence, the scale developed to
and consists of studies from multiple psychotherapy measure the supervisory working alliance (Bahrick,
disciplines, including counseling psychology and 1989), which was based on the scale for the thera-
counselor education (the two disciplines with the peutic working alliance (Horvath & Greenberg,
largest concentration of research literature in super- 1986), assessed the extent to which goals and tasks
vision), as well as social work and clinical psychol- were agreed upon (e.g., “My supervisor and I agree
ogy. Although our review extends back to the 1970s, upon the goals of supervision”), rather than examin-
our focus tends to be on research publications over ing specific goals and tasks.
the past two decades, as that seems to be when the Bordin regarded the “mutual” nature of the com-
most rigorous research was conducted. ponents to be most critical. He thought the goals
of the supervisee and supervisor needed to be con-
The Supervisory Relationship gruent; otherwise, the work in supervision could
According to the literature, the term “relationship” not be done. Bordin also indicated some additional
in the supervisory context can mean many things processes that were important to establish a strong
(Chen & Bernstein, 2000; Efstation, Patton, & alliance, which included empathizing with the
Kardash, 1990; Ellis & Ladany, 1997; Heppner & supervisee, diffusing the hierarchical status between
Handley, 1981; Holloway & Wampold, 1983; the supervisee and supervisor, and balancing critical
Schact, Howe, & Berman, 1989). Often it is left to feedback with recognizing supervisee strengths.
the reader’s conception and is largely undefined. The supervisory working alliance has been
At other times, it has been defined in an all-inclusive empirically examined across a variety of studies.
fashion, essentially referring to all that occurs in Results from these investigations have found that
supervision. Given the relationship’s central role in a stronger supervisory working alliance was related
supervision, it is surprising how little attention has to more advanced racial identity interactions
been given to actually defining it, and how it has (Ladany, Brittan-Powell, & Pannu, 1997), increased
been studied in such a haphazard and obfuscatory supervisor self-disclosure (Ladany & Lehrman-
fashion. Presumably, a good definition of the super- Waterman, 1999), supervisee satisfaction (Inman,
visory relationship would define what it is, indicate 2006; Ladany, Ellis, Friedlander, & Stern, 1999),
how it is strengthened and weakened, and provide clearer goal-setting and feedback (Lehrman-
a link between the relationship and outcomes in a Waterman & Ladany, 2001), greater supervisor
relatively orthogonal fashion. Arguably, the defini- attractiveness and interpersonal sensitivity (Ladany,
tion that does this best is Bordin’s (1983) model of Walker, & Melincoff, 2001), and supportive gen-
the supervisory working alliance. In addition, his der-related events (Walker, Ladany, & Pate-Carolan,
model has been the definition most extensively 2007). Moreover, a weaker supervisory working alli-
tested in the literature (in over a dozen studies), and ance has been found to predict greater supervisee
his model is well-suited for clinical applicability role conflict and ambiguity (Ladany & Friedlander,
(Wood, 2005). 1995); less supervisor multicultural competence
As noted previously, Bordin (1983) conceptual- (Inman, 2006); insecure supervisor attachment
ized the supervisory working alliance as consist- styles (Riggs & Bretz, 2006); negative supervisory
ing of three components: agreement on the goals of experiences (Ramso-Sanchez et al., 2002); greater
supervision (e.g., mastery of skills, increasing anxiety, nondisclosure, and less willingness to dis-
conceptualization ability, increasing awareness of close (Mehr, Ladany, & Caskie, in preparation);
one’s self in the counseling process, maintaining and less supervisor adherence to ethical behaviors
ethics, etc.), agreement on the tasks of supervision (Ladany, Lehrman-Waterman, Molinaro, &
(e.g., feedback on reports, provide alternative con- Wolgast, 1999). Furthermore, the supervisory work-
ceptualizations, have supervisee select the topics of ing alliance can change over time, for better and for
discussion for supervision, etc.), and an emotional worse (Ladany et al., 2008). Recently, there has
bond (e.g., mutual caring, respecting, trusting). been a debate about the psychometric strengths of
Bordin’s model was a reconceptualized and extended the Supervisory Work Alliance (SWAI) scale, such
version of his model of the therapeutic working as whether the scale should be used as a single-score

l adany, inm an 189

measure, a three-subscale measure, or a shortened issues in the conceptualization (Ladany et al.,
measure (Ellis, Russin, & Deihl, 2003; Inman, 1997).
2006). Burkard et al. (2006), via a qualitative design,
cleverly teased out the differences between cultur-
• Research to practice: The supervisory alliance
ally responsive supervision and culturally unrespon-
has been considered the foundation upon which
sive supervision. Supervisors who were culturally
effective supervision is based (Ladany, 2005).
responsive tended to create a safe space for discuss-
To that end, supervisors are encouraged to
ing cultural issues and to share their own profes-
consider the alliance as a figure–ground-type
sional struggles with supervisees. Alternatively,
construct, such that it is highlighted early in
supervisors who were culturally unresponsive ten-
the relationship, and when conflicts arise in
ded to demonstrate a lack of cultural self-awareness,
the relationship, and/or when it is strong enough
use stereotypical explanations, minimize cultural
to engage in other supervisory work, it recedes
issues, and engage in gender, racial, and sexual ori-
into the background.
entation bias. In addition, supervisees of color expe-
• Future research: Although Bordin’s (1983)
rienced culturally unresponsive supervision more
model seems to be a solid construct to define the
frequently than did white supervisees. In an inter-
supervisory relationship, reformulation and
esting blend of qualitative and analog methodology,
modification of the model based on theoretical and
Utsey, Gernat, and Hammar (2005) sampled white
empirical grounds should occur (Ladany & Inman,
supervisees and found they were uncomfortable dis-
2008). Moreover, additional models of the
cussing racial issues. In addition, Constantine and
supervisory relationship may shed light on aspects
Sue (2007) in their qualitative study, found that
not attended to by Bordin, and in fact, may offer
black supervisees experienced multiple types of
a stronger construct for future study (Ellis, Russin,
microaggressions (e.g., invalidating racial concerns)
& Deihl, 2003).
from their white supervisors.
In terms of gender and supervision, early studies
Multicultural Diversity of gender matching in relation to supervision pro-
The literature related to multicultural supervision cess and outcome demonstrated equivocal results
has given us an understanding of two overarching (Behling, Curtis, & Foster, 1988; Gloria, Hird, &
areas of multicultural work: handling general multi- Tao, 2008; Goodyear, 1990; Jordan, 2007; Sells,
cultural issues and handling specific multicultural Goodyear, Lichtenberg, & Polkinghorne, 1997;
issues. In relation to managing general multicultural Petty & Odewahn, 1983; Putney, Worthington, &
issues, a number of researchers have found that McCullough, 1992; Schiavone & Jessell, 1988;
supervisees learn from and appreciate the discussion Stenack & Dye, 1983; Worthington & Stern,
of diversity in supervision (Dressel, Consoli, Kim, 1985). However, more refined investigations found
& Atkinson, 2007; Duan, & Roehlke, 2001 the extent to which a supervisor was task-or rela-
Fukuyama, 1994; Hird, Cavaleri, Dulko, Felice, & tionship-oriented, as well as displayed power mes-
Ho, 2001; Killian, 2001 Kleintjes and Swartz, 1996; sages, varied depending on the gender of the
Lawless, Gale, & Bacigalupe, 2001). supervisor and supervisee (Nelson & Holloway,
Authors have also identified and studied specific 1990; Robyak, Goodyear, & Prange, 1987; Sells,
multicultural issues in supervision, most of which Goodyear, Lichtenberg, & Polkinghorne, 1997).
has dealt with gender, race, sexual orientation, and In addition, Szymanski (2005) found that feminist
nationality. In the realm of race, the results of racial identity was related to feminist supervision prac-
matching in relation to supervision process and out- tices, and Fong and Borders (1985) offered evidence
come have been equivocal (Cook & Helms, 1988; that sex role orientation was a better predictor of
Hilton, Russell, & Salmi 1995; McRoy, Freeman, counseling skills than was gender in counseling
Logan, & Blackman, 1986; Vander Kolk, 1974), skills training. Finally, Walker, Ladany, and Pate-
however, racial identity seems to be a more promis- Carolan (2007) found that supervisors facilitated
ing variable in predicting process and outcome roughly equal numbers of supportive and unsup-
(Ladany, Brittan-Powell, & Pannu, 1997). In addi- portive gender-related events. In all, these studies
tion, evidence suggests that supervisees value the point to the fact that gender issues continue to be
discussion of racial issues in supervision (Kleintjes relevant in supervision.
& Swartz, 1996) and focusing supervisees on race in There continues to be a notable gap in the empir-
a case conceptualization leads them to include racial ical literature addressing sexual orientation and

190 tr ain in g and s u pervis io n

supervision. Only two studies have been conducted multicultural competence development, but addi-
that consider sexual orientation in supervision. tional work is needed.
Newman, Bogo, and Daly (2008) found that super- Most recently, the area of nationality and inter-
visees who are lesbian, gay, bisexual, or transgender national issues has been brought to the fore in rela-
(LGBT) found self-disclosing their sexual orienta- tion to diversity and supervision (Nilsson &
tion to their supervisors a useful enterprise when Anderson, 2004). There are two ways to consider
they felt safe enough to do so. Sherry, Whilde, and international issues: (1) non-U.S. nationality of at
Patton (2005) surveyed directors of training and least one of the members of the client–counselor–
found most thought that sexual orientation issues supervisor triad (Mori, Inman, & Caskie, 2009;
were discussed at some point during practicum and Nilsson & Anderson, 2004; Nilsson & Wang, 2009)
supervision experiences. However, it was unclear and (2) supervision in international contexts (e.g.,
what the extent and quality of these discussions Orlinsky & Ronnestad, 2005). In terms of national-
were. Without a doubt, further scholarship is war- ity issues, supervisors are encouraged to consider
ranted in this understudied area of knowledge. the effects of language, acculturation, and role
One emerging feature of the multicultural work ambiguity on counseling self-efficacy (Mori et al.,
has been the recognition that psychological vari- 2009; Nilsson & Anderson, 2004; Nilsson & Wang,
ables, such as racial identity or gender identity, 2009). In relation to supervision in international
are more predictive of cultural competence than contexts, an examination of practices can be quite
are simple nominal variables such as race or sex. enlightening and sometimes shed light on issues in
In addition, identity has been associated with the which U.S.-based training is lacking. For example,
self-awareness component of competence for both supervision in Great Britain is considered a lifelong
supervisees and supervisors. Ladany and Ancis (2010, professional development activity, whereas in the
in press) offered a revised theoretical model (the heu- United States, supervision is primary advocated
ristic model of nonoppressive interpersonal development; for in the context of graduate training and, at most,
HMNID) for conceptualizing multicultural identi- a couple of years beyond. Broadening the U.S.-
ties in both counseling and supervision. Based on based view of supervision is strongly suggested.
a variety of identity models (e.g., Cass, 1979;
• Research to practice: Supervisors are
Helms, 1990; Sodowsky, Kwan, & Pannu, 1995),
encouraged to look beyond simple nominal
the HMNID sets out to give supervisees and sup-
variables such as gender and race, and consider
ervisors a way of conceptualizing multiple identities
the role of identity in their supervisees and in
(i.e., gender, race, sexual orientation, ethnicity,
themselves.
disability, and socioeconomic status) in the client–
• Future research: The research has indicated
counselor–supervisor triad. For each demographic
that supervisors are too often providing biased and
variable, people pass through phases of identity
multiculturally incompetent supervision
development (i.e., adaptation, incongruence, explo-
(e.g., sexism, racism, etc.). Additional work is
ration, and integration) that vary depending on
sorely needed to examine the impact that these
whether the identity in question is related to a
biased supervisory approaches have on the
socially oppressed group (e.g., Asian American) or a
development of supervisees.
socially privileged group (e.g., white). Each supervisee–
supervisor or client–counselor dyad can be defined
based on the interpersonal relationship type that Supervisor Self-disclosure
is present: progressive, in which the supervisor is Supervisor self-disclosure has received attention in
at a more advanced identity phase than the supervi- recent years because of its purported influence on
see; parallel-advanced, in which the supervisor the supervisory relationship, evaluation on the
and supervisee are at comparable and advan- supervisee, and supervision outcome (Farber, 2006;
ced identity phases; parallel-delayed, in which the Yourman, 2003). The literature has supported these
supervisor and supervisee are at comparable and contentions and shown that supervisors self-disclose
delayed identity phases; and regressive, in which more when they perceived the need to normalize
the supervisee is at a more advanced identity the supervisee’s experience or when they witness
phase than the supervisor. Preliminary research the supervisee struggling. Furthermore, supervisor
(e.g., Constantine, Warren, & Miville, 2005; self-disclosure also tends to occur within a positive
Ladany, Brittan-Powell, & Pannu, 1997) has shown supervisory relationship and leads to positive eff-
that identity interactions can predict perceived ects on supervisees (Knox, Burkard, Edwards,

l adany, inm an 191

Smith, & Schlosser, 2008). Moreover, the types of by external events, less engagement, more or less
supervisor self-disclosures have ranged from helpful authoritativeness) and positive supervisor coun-
to unhelpful and included personal issues, struggles, tertransference thoughts, feelings, and behaviors
successes, and reactions to the supervisee’s clients (e.g., identification with the supervisee, engaged in
(Ladany & Lehrman-Waterman, 1999). Based on rapport building, provided support). These limited
the empirical work, Ladany and Walker (2003) investigations offer a pantheoretical look at the ways
hypothesized the conditions under which supervi- in which supervisor countertransference may be
sor self-disclosure would be most to least powerful. operating and influencing supervision process and
Specifically, they posited that the content of super- outcome.
visor self-disclosures could be considered along
• Research to practice: Supervisors would
three personalization dimensions: (1) discordant to
do well to consider the role that their personal
congruent, (2) nonintimate to intimate, and (3) in
biases may influence the supervision and
the service of the supervisor or in the service of the
counseling work.
supervisee, the latter of each dimension represent-
• Future research: Given the limited study
ing more powerful self-disclosures that would lead
that supervisor countertransference has received,
to strengthening the supervisory alliance, increased
replication and extension along the qualitative and
supervisee self-disclosure, and greater supervisee
quantitative lines is in order. Furthermore, the
edification.
development of measures of the construct would
• Research to practice: More does not always benefit future investigations.
indicate better when it comes to supervisor
self-disclosure. We suggest that supervisors Supervisee Development
examine the intentionality of their self-disclosures The research on supervisee development was pri-
and assess the kinds of impacts these marily conducted in the 1980s and early 1990s
self-disclosures have on their supervisees. (e.g., Borders, 1990; Ellis, 1991; Friedlander &
• Future research: Researchers are encouraged Snyder, 1983; McNeill, Stoltenberg, & Pierce,
to identify and assess the proximal outcomes of 1985; Wiley & Ray, 1986; Winter & Holloway,
supervisor self-disclosures. 1991), and over the last decade has been largely
left unattended (Ladany & Inman, 2008). Supervisee
development has been predominately defined
Supervisor Countertransference
based on some type of supervisee experience vari-
Supervisor countertransference, also dubbed “super-
able (e.g., type of practicum setting, years of experi-
transference” (Teitelbaum, 1990), has been recog-
ence). These investigations have been critiqued on a
nized in the theoretical literature for some time
variety of grounds (e.g., relied on self-report and
(Ackerman, 1953; Altschuler & Katz, 2002;
cross-sectional data) and have offered equivocal
Anastasopoulous & Tsiantis, 1999; Issacharoff,
results (Ellis & Ladany, 1997). The results have
1984; Lower, 1972; Strean, 2000). However, it has
varied; perhaps the two conclusions that can be
been studied only in a limited fashion. Via a quali-
drawn is that sometimes supervisees see themselves
tative investigation, Ladany, Constantine, Miller,
change with experience and sometimes supervisors
Erickson, and Muse-Burke (2000) defined super-
have different perceptions when they supervise
visor countertransference as “an exaggerated, unre-
supervisees with different amounts of experience
alistic, irrational, or distorted reaction related to
(e.g., the beginning practicum supervisee needs lots
a supervisor’s work with a trainee. This reaction
of guidance). That said, these general conclusions
may include feelings, thoughts, and behaviors
should be considered in light of reviews that have
that are likely to be in response to both the train-
demonstrated that experience is a better predictor of
ee’s interpersonal style and the supervisor’s unre-
confidence than competence (Garb, 1989).
solved personal issues and may also be in response to
trainee–supervision environmental interactions, • Research to practice: Although it may be
problematic client–trainee interactions, trainee– heuristically appealing for supervisors to view
supervisor interactions, or supervisor–supervision supervisees through a developmental lens, they
environment interactions” (p. 111; Ladany et al., are encouraged not to engage in simplistic
2000). In a separate investigation, Ladany et al. (2008) developmental devices, such as basing their
identified negative supervisor countertransference evaluation on amount of supervisee experience,
thoughts, feelings, and behaviors (e.g., distraction and instead consider more complex developmental

192 tr ain in g and s u pervis io n

processes such as those identified by Stoltenberg • Research to practice: Given the frequency and
et al., (1998). Relying on simplistic approaches to types of nondisclosure, it seems that supervisors
assessing developmental level can lead to, among would be prudent to complete every supervision
other things, the inappropriate infantalization of session without ending early.
supervisees. • Future research: Nondisclosure has been
• Future research: Curiously, almost all of the studied via multiple methods, including reflectively
developmental research has taken a quantitative over the course of a semester, after single sessions,
approach. As such, researchers are encouraged to cross-sectionally, and longitudinally, and from
engage in qualitative methodologies (e.g., Hill, the supervisees and supervisors perspectives.
Thompson, & Williams, 1997; Hill et al., 2005) The primary reciprocal predictors and outcomes
that may shed a better light on developmental related to nondislcosure have been the alliance
intricacies. and discussion of countertransference; however,
additional predictors and outcomes would be
Supervisee and Supervisor Nondisclosures fruitful to investigate (e.g., supervisor style,
For supervision to work effectively, supervisees must anxiety, openness) as well as the links
disclose pertinent information about themselves, between nondisclosure and
their work with clients, and their work in supervi- self-disclosure.
sion (Farber, 2006; Wallace & Alonso, 1994).
A number of studies have been conducted that
Sexual Attraction
addressed what supervisees withhold, or do not
In the context of therapy, Freud (1915) deemed
disclose to their supervisors (Hess et al., 2008;
sexual attraction an issue of countertransference;
Ladany, Hill, Corbett, & Nutt, 1996; Ladany et. al.,
yet, over time, authors have reexamined sexual
2008; Mehr, Ladany, & Caskie, 2010; Pisani, 2005;
attraction and found that it has both realistic and
Webb & Wheeler, 1998; Yourman & Farber, 1996;
unrealistic components. Moreover sexual attraction
Yourman, 2000). Findings from across these inves-
toward clients appears to be something that occurs
tigations have indicated that salient nondisclosures
for most therapists in their professional life (Bernsen,
occur for 90% of supervisees. The types of nondis-
Tabachnick, & Pope, 1994; Gabbard, 1994, 1995;
closures most frequently reported pertain to nega-
Pope, Keith-Spiegel, & Tabachnick, 1986; Pope,
tive reactions to the supervisor, evaluation concerns,
Sonne, & Holroyd, 1993; Rodolfa et al., 1994).
personal issues, clinical mistakes, and sexual attrac-
Given the salience of sexual attraction and its poten-
tion to clients or supervisors. Common reasons for
tial for influencing counseling work, it is surprising
nondisclosure included deference to the supervisor,
that so little work has examined how sexual attrac-
impression management, shame, and anticipated
tion issues play out in supervision. Housman and
negative consequences from the disclosure. Consis-
Stake (1999) found that students who discussed
tent across studies was also the indication that the
sexual attraction toward clients with their supervi-
supervisory relationship played an important role in
sors were those with the clearest understanding of
the extent to which important nondisclosure
sexual ethics. In a qualitative investigation of super-
occurred (i.e., the worse the relationship, the greater
visee attraction toward clients and their use of
the nondisclosure). In addition, discussion of coun-
supervision, Ladany et al. (1997) found that the
tertransference seemed related to nondisclosure
attraction affected counseling process and outcome;
(Yourman & Farber, 1996).
their supervisors were disinclined to broach the
Supervisor nondisclosure has been similarly stud-
topic, but when discussed in supervision, normal-
ied, although to a lesser extent. Ladany and Melincoff
ization and the opportunity to process their reac-
(1999) found that supervisors nondisclosure could
tions were found to be helpful; and training
be categorized in two ways: nondisclosures that
programs and internship sites did not address sexual
likely should be disclosed (e.g., reactions to the
attraction issues adequately. Clearly, more work
supervisee’s work in counseling or supervision) and
needs to be conducted in this underdiscussed and
nondisclosures better kept nondisclosed and dealt
understudied area.
with via another venue (e.g., personal issues, sexual
attraction to the supervisee). From both the supervi- • Research to practice: Because sexual attraction
see and supervisor nondisclosure research, the mean- is a common occurrence for supervisees and
ingful message seems to be that nondisclosure, at supervisors, in both counseling and supervision,
times, may be more important than disclosure. increased attention seems important.

l adany, inm an 193

 • Future research: A three-pronged approach In their study of supervisees’ perceptions of their
using qualitative and quantitative methodologies to supervisors’ adherence to the first 15 of these guide-
the study of sexual attraction issues seems lines, Ladany et al. (1999) found that supervisors
warranted: supervisee sexual attraction toward lacked adherence to at least one of the guidelines
clients and their use of supervision, supervisee 51% of the time, and the most frequent violation
sexual attraction toward their supervisors, and was nonadherence to performance evaluation,
supervisor sexual attraction toward their which occurred 33% of the time. A smattering of
supervisees. additional investigations into supervisor ethical
behaviors has found that dual relationships are rela-
Supervision Ethics tively common (Townend, Iannetta, & Freeston,
Unlike ethical guidelines for counseling and psy- 2002), psychologists who had engaged in sexual
chotherapy, supervision guidelines have undergone relationships with students or supervisees were
minimal advances over the years. In fact, the APA either ambivalent about their behavior or did not
continues to embed supervisory guidelines within view their involvement as harmful to the other indi-
the teaching guidelines, which is an indication that vidual (Lamb, Catanzaro, & Moorman, 2003), and
the enterprise of supervision continues to be under- practicum site supervisors differed from university
acknowledged. Moreover, this relegation to a sub- supervisors in terms of interpretations of ethical
section provides evidence that the guidelines do not issues in supervision (Lee & Cashwell, 2001).
fully recognize the unique and important features Beyond these investigations, the literature is bereft
that are part of the supervisory experience, and of empirical work examining the actual ethical
hence offer mixed guidance to supervisors regarding behaviors of supervisors. That said, a number of
the potential range of supervisory ethic issues that authors have explored and examined ways in which
can occur. supervisors can become more aware of ethical issues,
This state of affairs notwithstanding, other pro- prevent ethical lapses, and respond to ethical con-
fessional organizations, such as the Association of cerns (e.g., Barnett, Cornish, Goodyear, &
Counselor Education and Supervision, have created Lichtenberg, 2007; Cobia & Boes, 2000; Greer,
guidelines for supervision (Association of Counselor 2002; O’Connor, 2000; Peake, Nussbaum, &
Education and Supervision, 1993). Even so, their Tindell, 2002). Clearly, more work is needed to
guidelines do not attend to the full range of ethical understand supervisor ethical behavior.
concerns (e.g., diversity issues). A combined, inte- Just as supervisors should behave ethically, so
grated, and expanded look at supervisor ethical should supervisees. That was the premise of an
guidelines was created by Ladany et. al. (1999), important perspective offered by Worthington,
using guidelines from multiple mental health disci- Tan, and Poulin (2002), who asked supervisees
plines (American Association for Marriage and about 31 mild to serious unethical behaviors. They
Family Therapy, 2001; American Counseling found that 85% of supervisees engaged in at least a
Association, 2005; American Psychological few moderately unethical behaviors (e.g., gossiping
Association, 2002; National Board of Certified about a supervisory conflict, timely completion of
Counselors, 2005). These guidelines for the supervi- client documentation), and in 7% of all the cases,
sor included: performance evaluation and monitor- they acknowledged a serious unethical behavior
ing of activities, confidentiality issues in supervision, (e.g., fabricating client information). Worthington
ability to work with alternative theoretical perspec- et al. (2002) have opened the door to a novel and
tives, session boundaries and respectful treatment, important area of future investigation.
orientation to professional roles and monitoring of
site standards, expertise and competency issues, dis- • Research to practice: Supervisor practitioners
closure to clients, modeling ethical behavior and should become aware of the wide ranging types of
responding to ethical concerns, crisis coverage and ethical behaviors they are bound by, and it would
intervention, multicultural sensitivity towards cli- behoove them to become familiar with these
ents, multicultural sensitivity towards supervisees, guidelines in a fashion similar to their
dual roles, termination and follow-up issues, differ- understanding of ethics in counseling and
entiating supervision from psychotherapy/counsel- psychotherapy.
ing, sexual issues in supervision, financial issues in • Future research: Based on a limited number
supervision, financial issues in counseling/psycho- of studies, the frequency of unethical behaviors by
therapy, and supervisor training and consultation. supervisors and supervisees appears sobering.

194 tr ain in g and s u pervis io n

A two-pronged approach to the study of She provided a framework for contextualizing
supervisory ethics is warranted: replication of the client outcome in the scheme of supervision out-
frequency of unethical behaviors, and assessing the come (i.e., a component but not necessarily the pri-
reasons for these unethical breaches. mary component). She argues that, as opposed to
client outcomes, supervisee outcomes are more
Parallel Process readily accessible, influenced, and assessable. Since
One of the more fascinating constructs in supervi- her challenge, 18 investigations have specifically
sion is the theory of parallel process, which essen- attempted to assess the link between supervision
tially refers to the ways in which interactions, beliefs, and client outcome (e.g., Alpher, 1991; Harkness &
and feelings between the client and counselor are Hensley, 1991). Summaries of these studies have
replicated in supervision between the supervisee and noted significant methodological flaws (Ellis &
supervisor (Ekstein & Wallerstein, 1972; McNeill Ladany, 1997; Freitas, 2002); however, they seem to
& Worthen, 1989; Searles, 1955). These parallel point the field in directions that are worth consider-
processes can occur “up” from the counseling dyad ing. For example, client outcome seems to be posi-
to the supervisory dyad or “down” from the supervi- tively linked to supervisory feedback about poor
sory dyad to the counseling dyad. Upward parallel client progress (Lambert, Hansen, & Finch, 2001);
processes can be used by supervisors to assess the supervision nearer to client sessions (Couchon &
counseling work, and downward parallel processes Bernard, 1984); live supervision (Kivlighan,
can be used by supervisors to repair or modify the Angelone, & Swafford, 1991); and professional ther-
counseling work. With the exception of one survey apists who received supervision versus no supervi-
(Raichelson, Herron, Primavera, & Ramirez, 1997), sion (Bambling, King, Raue, Schweitzer, & Lambert,
the primary approach to study parallel process has 2006). In the end, the extent to which we under-
been case study (Alpher, 1991; Doehrman, 1976; stand what works and does not work in psychother-
Friedlander, Siegel, & Brenock, 1989; Ladany et al., apy will limit our ability to truly assess the impact of
2008). The results of these studies indicate that both supervision on client outcome (Lambert & Arnold,
upward and downward parallel processes exist, and 1987).
they can be very powerful experiences for supervi-
sees and supervisors. • Research to practice: Supervision may have
an effect on client outcome; however, supervisors
• Research to practice: Supervisors are should recognize that the effect in many instances
encouraged not to ignore the potential utility of may be minimal. Thus, it is important to consider
attending to the possibility of parallel processes, as supervisee-based outcomes as a goal of supervision.
they can prove to offer important supervisee • Future research: Large, multiple-method,
change events. That said, supervisors are cautioned multiparticipant studies involving clients,
about overinterpreting or over-relying on parallel counselors, and supervisors are needed to
processes (e.g., a dependent client just may happen understand the potential direct and indirect
to be working with a dependent supervisee). influences of supervision on client outcome
Finally, supervisors should be aware of their own (Ladany et al., 2008).
role in creating difficulties via parallel process
(e.g., acts toward the supervisee in a problematic
way that, in turn, the supervisee enacts in Evaluation
counseling). Evaluation of supervisees is one of the most critical
• Future research: Along with case studies, functions of supervision (Falender & Shafranske,
parallel processes could be studied via a true 2004; Robiner, Fuhrman, & Ristvedt, 1993), yet it
experimental design by using confederate clients is one of the least validated processes. Bernard and
(e.g., hostile, dependent) who see participant Goodyear (2009) aptly note that there are probably
supervisees, who in turn see confederate as many evaluation instruments as there are training
supervisors, and then determining differences sites. As a result, there is a dearth of psychometri-
in supervisee reactions based on client type. cally sound instruments (Ellis, D’Iuso, & Ladany,
2008; Ellis & Ladany, 1997; Lambert & Ogles,
Client Outcome 1997). All that said, the literature has provided
Holloway (1984) challenged the view that the pri- better information about the how rather than the
mary role of supervision is to positively affect client what of evaluation (we address the what in the next
outcome (short of preventing immediate harm). section on supervisee competence). A theoretical

l adany, inm an 195

model and corresponding instrument were devel- there are serious problems with the evaluative tools
oped by Lehrman-Waterman and Ladany (2001) to currently available (Ellis et al., 2008). Recently, the
assess the process of supervisor evaluation. Evaluation APA Task Force on Assessment of Competence in
was defined as consisting of two functions: goal- Professional Psychology released a set of 15 guiding
setting and feedback. Goal-setting determined the principles for the assessment of competence. These
extent to which a supervisor was able to facilitate include:
goals that were specific, clear, reachable, linked to
tasks, modifiable, measurable, prioritized, mutually • The career-long assessment of
agreed upon, and required supervisees to reach a bit competence requires a major culture shift.
beyond their current capacity. Feedback was defined • It is essential that competencies be
as consisting of two subconstructs: formative feed- conceptualized as generic, wholistic, and
back, which is ongoing throughout the supervisory developmental abilities.
work, and summative feedback, which is conducted • A developmental perspective must
after distinct periods of times, such as at the middle undergird the assessment of competence.
and end of semesters. From their study, evaluation • Assessment approaches must integrate
was found to be related to the supervisory working formative and summative evaluations.
alliance, supervisee self-efficacy, and satisfaction • There must be collaboration across
with supervision (Lehrman-Waterman & Ladany, constituency groups in creating coherence and
2001). continuity in strategies for evaluating
The process of evaluation also has been examined competencies.
in three other investigations. Supervisees and super- • The assessment of competence must reflect
visors found that formative feedback was related fidelity to practice and must incorporate reliable,
to good supervision (Chur-Hansen & McLean, valid, and practical methodologies.
2006), and supervisees found self-critiqued audio • Generic and specialty foundational and
recordings a positive way to accept critical feed- functional competencies must be evaluated in
back (Carter, Sobell, Manor, Sobell, & Dunn, a comprehensive assessment of competence.
2008). In a clever qualitative investigation, Hoffman, • Assessment of competence should be a
Hill, Holmes, and Freitas (2005) were able to tease multitrait, multimethod, and multi-informant
out the reasons that supervisors gave easy, difficult, process.
or no feedback. Easy feedback pertained to client • Self-reflection and self-assessment are key
concerns, was offered directly, and was well-received components of the assessment of competence and
by supervisees who were also open to feedback. have to be taught and encouraged.
Difficult feedback was related to counseling, per- • The comprehensive assessment of
sonal, and professional issues, and was offered indi- competence must include a focus on
rectly to supervisees who were not open to feedback. interpersonal functioning and professional
No feedback typically related to supervisee personal development.
concerns. • The assessment of competence must be
sensitive to and highlight the importance of
• Research to practice: A key responsibility for
individual and cultural diversity.
supervisors is to evaluate their supervisees. The
• Multimodal methods of assessment are
manner in which evaluation takes place should be
needed to ensure the development and
considered an essential supervisor skill that
maintenance of ethical practice skills, which
deserves attention and development.
underlie all professional activities and
• Future research: Attention is needed on how
performance.
well supervisors are able to perform evaluation
• It is important to assess capability in addition
competently, and the link between the process of
to competence.
evaluation and trainee learning needs to be
• When competence problems are identified
documented.
through assessment, it is important to have
strategies in place for their remediation and
Supervisee Competence management.
With the knowledge of how to evaluate, supervisees • Evaluators must be trained in effective
and supervisors can turn to what to evaluate in rela- methodologies for the ongoing assessment of
tion to supervisee competence. As already noted, competence.

196 tr ain in g and s u pervis io n

 These principles, to be sure, are a good place to and the guidelines offered by Ladany and Malouf
begin to develop competencies; however, they do 2010 (in press), educators and trainers could assess
not offer specific competencies to consider. Hatcher how well or how poorly they are assessing
and Lassiter (2007) attempted to develop practicum supervisees and determine what may be missing in
competencies based on these principles, but were their assessments for future modifications.
unable to overcome the challenges inherent in most • Future research: The aforementioned
competency measures created to date—that is, the principles for assessment and competence (Kaslow
competencies are not clearly defined, nor are they et al., 2007) are a good start; however, it would be
likely to be assessed reliably or validly. interesting to determine the extent to which these
As with other competency measures, specificity principles are perceived to be met, in whole or
seems to be the key to constructing items that are part, by supervisees and supervisors. Results from
reliable and valid. To that end, Ladany and Malouf this investigation would point to implications of
2010 (in press) present an approach to assessing competence measures.
evaluation measures to determine the measure’s util-
ity. They offer 12 components on which any evalua- Supervisee and Supervisor Impairment
tion instrument can be assessed: mode of counseling and Professional Competence Problems
(e.g., individual, family, group, etc.), domain of One of the most challenging situations in the field
supervisee behavior (e.g., counseling, supervision), is when supervisees are not performing adequately
competence area (e.g., helping skills, conceptualiza- to such a significant extent that they may put their
tion skills, multicultural competence, supervision clients at risk for minor to significant harm.
behaviors), method (e.g., supervisee self-report, case Historically, the term impairment was used for
notes, audio or video recordings), proportion of case supervisees in this situation; however, Elman and
load (e.g., multiple clients, one client), segment of Forrest (2007) eloquently, rationally, and legiti-
experience (e.g., one session, segment of session, mately argue for a term that includes the words
time period (e.g., late in client treatment, early in problems, professional, and competence in some order.
training experience), evaluator (e.g., supervisor, sup- Empirical work in this area has been limited but has
ervisee, client), level of proficiency (e.g., demon- shed light on the scope of the problem (e.g., Boxley,
strated skill, cohort group), reliability, validity, and Drew, & Rangel, 1986; Gallessich & Olmstead,
format (e.g., quantitative, qualitative). The extent to 1987; Tedesco, 1982), as well as ways in which these
which each component is addressed in an evaluation issues have been handled (Gizara & Forrest, 2004).
instrument should determine its utility. Forrest, Elman, Gizara, and Vacha-Haase (1999)
Arguably, the most active area of competency offer an excellent review, synthesis, and analysis of
research has been in relation to multicultural issues. the theoretical and empirical literature on supervi-
Specifically, measures have been developed to assess see professional competence problems, and this
general multicultural competence (e.g., Multicultural work should be used by educators and trainers as a
Awareness-Knowledge-and-Skills Survey [MAKSS], primer for developing policies and procedures for
D’Andrea, Daniels, & Heck, 1991; Multicultural identifying and working with these supervisees.
Counseling and Awareness Scale [MCAS], Ponterotto They also list a series of recommendations that
et al., 1996; Multicultural Counseling Knowledge remain apropos to the present status of the field:
and Awareness Scale [MCKAS], Ponterotto et al., clarify definitions, review program policies, develop
2002; Multicultural Counseling Inventory [MCI], model program policy, match evaluation criteria
Sodowsky, Taffe, Gutkin, & Wise, 1994), as well as and types of impairment, increase focus on assess-
specific cultural competence (e.g., Counseling ment, increase professional writing on the use of
Women Competencies Scale; Ancis, Szymanski, & personal therapy as remediation, expand options for
Ladany, 2008; POC or White Racial Identity remediation, increase attention to diversity, articu-
Measures, Helms & Carter, 1990; Sexual Orientation late the intersection between impairment and the
Counselor Competency Scale [SOCCS], Bidell, ADA, develop continuing education workshops,
2005). However, evidence of reliability and validity expand content on impaired psychologists in cur-
in relation to the use of these measures in actual riculum, and create a consultation network (Forrest
supervision has yet to be determined. et al., 1999). Most recently, Forrest, Miller, and
Elman (2008) offered an expanded model of recom-
• Research to practice: Using the principles for mendations that contextualizes the supervisee eco-
assessment and competence (Kaslow et al., 2007) logically and allows systemic factors to be considered.

l adany, inm an 197

In all, Forrest and colleagues provide a comprehen- to be disrespectful, unstable, unsupportive, and
sive look at supervisees with professional compe- blaming. In addition, supervisees experienced role
tence problems. ambiguity and weakened self-efficacy, and they usu-
Just as supervisees can demonstrate significant ally sought support from peers and other supervisors.
professional competence problems and impairment, Finally, from these experiences, typically, supervisees
so too can supervisors. Supervisors, often by virtue learned “what not to do” as a supervisor.
of their status in the institution in which they work,
• Research to practice: Training directors would
are left uninterrupted in relation to a poor evalua-
do well to consider patterns of harmful supervision
tion, even when they do psychological harm to
among supervisors and attend to concerns brought
trainees. Moreover, little attention has been given in
forth by supervisees. In addition, due process for
the literature to supervisor professional competence
supervisees should be clear, if it is to assist in the
problems (Ladany, 2002). It is possible that supervi-
remedy of harmful experiences (Bernard &
sor professional competence problems beget super-
Goodyear, 2009).
visee professional competence problems, as suggested
• Future research: Although it seems clear that
by studies that have shown that supervisees who are
supervisees can be harmed by supervision, the
sexually active with their supervisors are more likely
extent to which this occurs is unknown. Assuming
to be sexually active with their supervisees or clients
that most supervisees experience multiple
(Pope, Levenson, & Schover, 1979; Pope, Sonne, &
supervisors in their professional life, it is likely,
Holroyd, 1993). However, it is also likely the case
even if the percentage is relatively low cross-
that some impaired supervisors make it through
sectionally, that they can experience these
graduate school because they have not been identi-
negative events at some point
fied and offered alternative courses. In any case, it is
longitudinally.
clear that increased attention to supervisor impair-
ment, both practically and empirically is needed.
Supervisor Training and Competence
• Research to practice : Training directors would
Despite the supervisors’ key role in supervisees’ pro-
do well to consider Forrest et al.’s (1999)
fessional development, theoretical and empirical
recommendations to assess the adequacy with
work has been slow to focus on supervisor train-
which their training programs are equipped to
ing and competence (Inman & Soheilian, 2010
identify, assess, and manage supervisees with
in press). This limited attention to supervisor
professional competence problems.
training has come from myths about the similari-
• Future research: It seems relevant and salient
ties between supervision and counseling (Baker,
to examine and conduct and analysis of legal cases
Exum, & Tyler, 2000). Over the past decade, it
in counseling and analogous fields to determine
has been acknowledged that the development of
the legal implications of passing supervisees who
supervisor skills requires formal training (Vidlak,
have been identified with professional competence
2002). For instance, supervisor development has
problems, as well as those who have been
been perceived as requiring a developmental shift
unjustifiably accused of professional competence
(e.g., skill development, self-awareness, motivation,
problems.
autonomy) to professional identity as a supervisor
(Watkins, 1993); a perceptual shift from thinking
Harmful Supervision like a counselor to thinking like a supervisor (Baker,
Supervisor benevolence is arguably a fundamental et al., 2002; Steven, Goodyear, & Robertson, 1997);
assumption. However, as just discussed, impaired and the development of specific roles (i.e., teacher,
supervisors have a great deal of power at their dis- counselor, and consultant), functions (e.g., advis-
posal, given their position in the training environ- ing, modeling, evaluating) and tasks (e.g., case
ment. Recent literature has highlighted that, conceptualization; Bernard, 1979; Holloway, 1995)
benevolent intentions or not, supervisees can be inherent in the supervisory role. These perspec-
psychologically harmed (Gray, Ladany, Walker, & tives suggest the need for supervisors to gain com-
Ancis, 2001; Magnuson, Wilcoxon, & Norem, petence in dealing not only with the therapy system
2000; Nelson & Friedlander, 2001; Ramos-Sanchez (e.g., facilitating counselor skill development, client
et al., 2002). Across these investigations, a pattern problem focus) but also in managing the supervi-
of commonalities seems evident (Inman & Ladany, sion system (e.g., socialization into one’s profes-
2008). In these negative events, supervisors tended sional role, developing organizational competency),

198 tr ain in g and s u pervis io n

both of which are subsumed in the relational com- (e.g., Bernard & Goodyear, 2009), group supervi-
ponents of the supervisory relationship (Inman & sion of group counseling (e.g., Hayes et al., 2010, in
Soheilian, 2010 in press). Yet, little attention has press), supervision of family counseling (e.g.,
been given to training that focuses on this triadic Hernández-Wolfe, 2010), supervision of couples
system and the relational processes that influence it. counseling (e.g., Stratton & Smith, 2006), supervi-
To this end, Inman and Soheilian 2010(in press) sion of play therapy (Metcalf, 2003), Internet-based
offer a training model that encompasses moving supervision (Kanz, 2001), and supervision of assess-
beyond a problem-focused supervision format to ment (Markin, in press). Along with these addi-
a process-focused supervision. Supervision that is tional methods, some supervision work can be tied
process-focused puts the relationship at the center, to particular client presenting concerns, specialized
and supervisors learn about supervision by actively populations, or approaches to counseling that war-
attending to specific overt (e.g., setting the environ- rant recognition. These include supervision of career
ment, attending to counseling skills, evaluation; counseling (Bronson, 2010 in press), children and
Ladany, et al., 2008) and covert (e.g., parallel pro- adolescents (Neill, 2006), school counseling
cess, nondisclosure, countertransference) relational (Magnuson, Black, & Norem, 2004), post-degree
processes that impact the supervisory relationship. supervisees (King & Wheeler, 1999), and theoreti-
One interpersonal interaction that has received cal approach to counseling (e.g., Mahrer, 2008); as
much attention in recent years is the effect of well as supervisees working with older adults
a supervisor’s cultural competence on supervisee (McDonald & Haney, 1988), HIV patients (Bor,
development and the supervisory process (e.g., Scher, & Salt, 1992), military personnel (Ball &
Burkard et al., 2006). In a related fashion, Ancis and Gingras, 1991), rehabilitation patients (Strutts,
Ladany 2010 (in press) have provided some specific 1991), and drug and alcohol abusers (Powell &
guidelines for supervisor multicultural competen- Brodsky, 2004). In all, these methods and topic
cies. Although there is some empirical support for areas of supervision have garnered limited theoreti-
this model (Inman, 2006), additional research is cal and empirical work, but are worthy of much
required, such as identifying other supervisor com- further consideration in the literature.
petencies (e.g., internalization of supervisor identity,
• Research to practice: Supervisees, in all
ability to develop the supervisory relationship and
likelihood, benefit from multiple methods of
conduct evaluations).
supervision by addressing aspects of their learning
• Research to practice: Supervisor training is in different manners (e.g., normalization of
distinct, multifaceted, and complex. Supervisors experience from group supervision). At times,
need to give up the familiar clinical role and focus supervisors would do well to understand that the
on the intersection of the various systems supervisory work may change in predictable ways
(e.g., client, supervisee, supervisor, and the depending on unique features of those clients that
institution) in which supervision occurs (Holloway the supervisees see.
1995). Beyond a cognitive shift, supervisors need • Future research: As additional methods are
to internalize the functions and tasks specific to the considered, additional types of supervision
supervisory role. outcomes may need to be created (e.g., skills
• Future research: Multiple theoretical models of related to assessment). In addition, it will be
supervisor training need to be developed, along important to consider the variables identified in
with the empirical testing of these models. this review chapter in the context of methods and
topic areas of supervision and consider their emic
or etic applicability.
Specialized Methods and Topic Areas
of Supervision
Our review has focused on theory, research, and Conclusion
practice related to individual one-to-one supervi- why training and supervision fails,
sion of individual one-to-one counseling. However, fails to succeed, succeeds to fail,
there exists a variety of supplemental, adjunctive, and succeeds
and occasionally primary or sole methods for con- The bulk of the work in the supervision literature
ducting supervision that are worth noting. These has occurred over the past 30 years. A fair question
methods include group supervision of individual is: What are we to conclude, based on all of this
counseling (Carroll, 1996), peer group supervision theoretical and empirical work? Our answer to that

l adany, inm an 199

Table 7.1. Percentages of Supervisee Learning Based why multicultural competence can be so difficult
on Educator and Supervisor Competence of Educator to teach, and so on. To be sure, these teacher–
or Supervisor learner percentages are likely true of any profession
Type of Incompetent Average Highly (e.g., accountant, plumber, etc.); however, the con-
Learner (33.3%) Competence Competent sequences of incompetent supervisors and educators
(33.3%) (33.3%) in combination with poor learners within the coun-
seling psychology profession seems potentially and
Active 11.1% 11.1% 11.1%
uniquely harmful to people who are seeking help.
(33.3%)
It is our contention that the area of training and
Passive 11.1% 11.1% 11.1% supervision will not adequately demonstrate utility
(33.3%) until more work is done to demonstrate the efficacy
Indifferent 11.1% 11.1% 11.1% of training and supervision.
(33.3%)
From Ladany, N. (2007). Does psychotherapy training matter? Acknowledgments
Maybe not. Psychotherapy: Theory, Research, Practice, Training, 44,
392–396. Copyright American Psychological Association.
The authors would like to thank Kristin Bertsch,
Reprinted with permission. Amanda Busby, Grace Hung, and Karyn Shoval
for their superb literature review assistance.
question is that we have learned some things, but not
nearly enough to warrant a conclusion that we are References
doing what we should be doing in relation to training Ackerman, N. W. (1953). Selected problems in supervised analy-
and supervision. We conclude with a provocative idea sis. Psychiatry, 16(3), 283–290.
about training and supervision, and why we think it Alpher, V. S. (1991). Interdependence and parallel processes:
fails, fails to succeed, succeeds to fail, and succeeds. A case study of structural analysis of social behavior in super-
Extending and modifying Ladany’s (2007) model vision and short-term dynamic psychotherapy. Psychotherapy,
28, 218–231.
of supervision failures, we posit that training and Altschuler, J., & Katz, A. D. (2002). Clinical supervisors’
supervision varies from failure to success based countertransference reactions toward clients: Addressing
on the type of learner the student or supervisee is, in the unconscious guide. Journal of Gerontological Social Work,
conjunction with the competence of the educator 39, 4.
or supervisor (see Table 7.1). The model assumes American Association for Marriage and Family Therapy. (2001).
User’s guide to the AAMFT code of ethics. Alexandria, VA:
that both members of the dyad vary in terms of Author.
the ability to learn or teach/supervise, and from American Counseling Association. (2005). ACA Code of Ethics.
these hypothesized variabilities comes an under- Alexandria, VA: Author.
standing of the productivity of training and supervi- American Psychiatric Association. (2000). Diagnostic and statisti-
sion. The basic assumption is that the supervisor or cal manual of mental disorders: DSM-IV-TR. Washington,
DC: Author.
educator is highly competent one-third of the time, American Psychological Association. (2002). Ethical principles
demonstrates average competence about one-third of psychologists and code of conduct. Washington, DC:
of the time, and is incompetent one-third of the Author.
time. In a similar fashion, supervisees are active Anastasopoulos, D., & Tsiantis, J. (1999). Supervision of
learners one-third of the time, passive learners one- individual psychoanalytic psychotherapy in institutions:
The setting, the dynamics and the learning process.
third of the time, and indifferent learners one-third Psychoanalytic Psychotherapy, 13(2), 167–183.
of the time. Based on these assumptions, as can be Ancis, J. R., & Ali, S. R. (2005). Multicultural counseling
seen in Table 7.1, it is hypothesized that best teach- training approaches: Implications for pedagogy. In C. Z.
ing and learning takes place approximately 11.1% Enns, & A. L. Sinacore (Eds.), Teaching and social justice:
of the time, reasonable teaching and learning takes Integrating multicultural and feminist theories in the classroom
(pp. 85–97). Washington, DC: American Psychological
place about 33.3% of the time, and poor teach- Association.
ing and learning takes place about 55.5% of the Ancis, J., & Ladany, N. (2010). A multicultural framework for
time. These hypothesized percentages may offer an counselor supervision: Knowledge and skills. In N. Ladany
explanation of some of the supervision research and L. Bradley (Eds.). Counselor Supervision (4th ed.,
findings, such as why supervisors can harm super- pp. 53–95). New York: Routledge.
Ancis, J. R., Szymanski, D. M., & Ladany, N. (2008, in press).
visees, why supervisees do not disclose important Development and psychometric evaluation of the Counseling
material to their supervisors, how developmental Women Competencies Scale (CWCS). The Counseling
models may apply most to the best supervisees, Psychologist.

200 tr ain in g and s u pervis io n

Anderson, M. L., & Collins, P. H. (2007). Race, Class, and Bidell, M. P. (2005). The Sexual Orientation Counselor
Gender: An anthology. (6th ed.). Belmont, CA: Wadsworth Competency Scale: Assessing attitudes, skills, and knowledge
Publishing Co. of counselors working with lesbian/gay/bisexual clients.
Arredondo, P., & Arciniega, G. M. (2001). Strategies and Counselor Education and Supervision, 44, 267–279.
techniques for counselor training based on the multicultural Blocher, D. H. (1983). Towards a cognitive-developmental
counseling competencies. Journal of Multicultural Counseling approach to counseling supervision. The Counseling Psycho-
and Development, 29, 263–273. logist, 11, 27–34.
Arredondo, P., Toporek, R., Brown, S. P., Sanchez, J., Bor, R., Scher, I., & Salt, H. (1992). Supervising professionals
Locke, D. C., Sanches, J., & Stadler, H. (1996). involved in the psychological care of people infected with
Operationalization of the multicultural counseling compe- HIV/AIDS. Counseling Psychology Quarterly, 5(1), 95–109.
tencies. Journal of Multicultural Counseling & Development, Borders, L. D. (1990). Developmental changes during supervi-
24(1), 42–78. sees’ first practicum. Clinical Supervisor, 8(2), 157–167.
Association for Counselor Education and Supervision. (1993). Borders, L. D. (1991). A systemic approach to peer group
Ethical guidelines for counseling supervisors. Spectrum, supervision. Journal of Counseling and Development, 69(3),
53(4), 3–8. 248–252.
Aten, J. D., Madson, M. B., & Kruse, S. J. (2008). The supervi- Bordin, E. S. (1979). The generalizability of the psychoanalytic
sion genogram: A tool for preparing supervisors-in-training. concept of the working alliance. Psychotherapy: Theory,
Psychotherapy: Theory, Research, Practice, Training, 45(1), Research & Practice, 16, 252–260.
111–116. Bordin, E. S. (1983). Supervision in counseling: II. Contemporary
Bahrick, A. S. (1989). Role induction for counselor trainees: Effects models of supervision: A working alliance based model of
on the supervisory working alliance. Unpublished doctoral supervision. Counseling Psychologist, 11, 35–42.
dissertation, The Ohio State University, Columbus, Ohio. Boxley, R., Drew, C. R., & Rangel, D. M. (1986). Clinical
Bahrick, H. P. (1989). The laboratory and ecology: Supplementary trainee impairment in APA approved internship programs.
sources of data for memory research. In L. W. Poon, Clinical Psychologist, 39, 49–52.
D. C. Rubin, & B. A. Wilson (Eds.), Everyday cognition in Bronson, M. K. (2010). Supervision of career counseling.
adulthood and late life (pp. 73–83). New York: Cambridge In N. Ladany, & L. J. Bradley (Eds.), Counselor supervision:
University Press. Principles, process, and practice (4th ed., pp. 261–286).
Baker, S. B., Exum, H. A., Tyler, R. E. (2002). Supervision: New York: Brunner-Routledge.
The developmental process of clinical supervisors in training: Burkard, A. W., Johnson, A. J., Madson, M. B., Pruitt, N. T.,
An investigation of the Supervisor Complexity Model. Contreras-Tadych, D. A., Kozlowski, J. M., et al. (2006).
Counselor Education and Supervision, 42, 15–29. Supervisor cultural responsiveness and unresponsiveness in
Ball, J. D., & Gingras, T. (1991). A Psychotherapy and its super- cross-cultural supervision. Journal of Counseling Psychology,
vision in the U.S. military. In T. H. Peake, & J. D. Ball 53, 288–301.
(Eds.), Psychotherapy training (pp. 115–134). London: Burnett, P. C., & Meacham, D. (2002). Learning journals as
Haworth Press. a counseling strategy. Journal of Counseling and Development,
Bambling, M., King, R., Raue, P., Schweitzer, R., & Lambert, W. 80, 410–415.
(2006). Clinical supervision: Its influence on client-rated Carhkuff, R. R. (1971). The development of human resources.
working alliance and client symptom reduction in the brief New York: Holt, Rinehart & Winston.
treatment of major depression. Psychotherapy Research, 16, Carroll, M. (1996). Counseling supervision: Theory, skills, and
317–331. practice. London: Cassell.
Barnett, J. E., Cornish, J. A., Goodyear, R. K., & Carter, R. T. (2003). Becoming racially and culturally compe-
Lichtenberg, J. W. (2007). Commentaries on the ethical and tent: The racial-cultural counseling laboratory. Journal
effective practice of clinical supervision. Professional of Multicultural Counseling & Development, 31(1), 20–30.
Psychology: Research and Practice, 38(3), 268–275. Carter, R. T., & Qureshi, A. (1995). A typology of philoso-
Behling, J. C., Curtis, C., & Foster, S. A. (1988). Impact of phical assumptions in multicultural counseling and training.
sex-role combinations on student performance in field In J. G. Ponterotto (Ed.), Handbook of multicultural coun-
instruction. Clinical Supervisor Special Issue: Empirical studies seling (pp. 239–262). Thousand Oaks, CA: SAGE
in field instruction, 6, 161–168. Publications, Inc.
Benjamin, L. S. (1996). A clinician-friendly version of the inter- Cass, V. C. (1979). Homosexual identity formation: A theoreti-
personal circumplex: Structural analysis of social behavior cal model. Journal of Homosexuality, 4, 219–235.
(SASB). Journal of Personality Assessment, 66, 248–266. Chang, C. Y., & O’Hara, C. (2010). Supervision-based integra-
Bernard, J. M. (1979). Supervisor training: A discrimination tive models of counselor supervision: Developmental models.
model. Counselor Education and Supervision, 19, 60–68. In N. Ladany, & L. Bradley (Eds.), Counselor supervision
Bernard, J. M. (1997). The discrimination model. (4th ed., pp. 145–166). New York: Routledge.
In C. E. Watkins (Ed.), Handbook of psychotherapy supervision Chen, E. C., & Bernstein, B. L. (2000). Relations of com-
(pp. 310–327). New York: Wiley. plementarity and supervisory issues to supervisory working
Bernard, J. M. (2005). Tracing the development of clinical super- alliance: A comparative analysis of two cases. Journal of
vision. Clinical Supervisor, 24(1/2), 3–21. Counseling Psychology, 47, 485–497.
Bernard, J. M., & Goodyear, R. K. (2009). Fundamentals of Chur-Hansen, A., & McLean, S. (2006). On being a supervisor:
clinical supervision (4th ed.). Boston: Allyn & Bacon. The importance of feedback and how to give it. Australian
Bernsen, A., Tabachnick, B. G., & Pope, K. S. (1994). National Psychiatry, 14, 67–71.
survey of social workers’ sexual attraction to their clients: Cobia, D. C., & Boes, S. R. (2000). Professional disclosure state-
Results, implications, and comparison to psychologists. ments and formal plans for supervision: Two strategies for
Ethics and Behavior, 4, 369–388. minimizing the risk of ethical conflicts in post-master’s

l adany, inm an 201

 supervision. Journal of Counseling & Development, 78(3), a decade of empirical work. Journal of Counseling Psychology,
293–296. 43, 35–50.
Committee on Accreditation. (2007). Guidelines and principles Ellis, M. V., Russin, A., & Deihl, L. M. (2003, August).
for accreditation of programs in professional psychology. Dimensionality of the supervision working alliance: Supervisees’
Washington DC: APA. Retrieved from www.apa.org/ed/ perceptions. Paper presented at the 111th Annual Convention
accreditation/about/policies/guiding-principles.pdf. of the American Psychological Association, Toronto, Canada.
Constantine, M. G., & Sue, D. W. (2007). Perceptions of racial Elman, N. S., & Forrest, L. (2007). From trainee impairment
microaggressions among Black supervisees in cross-racial to professional competence problems: Seeking new termi-
dyads. Journal of Counseling Psychology, 54, 142–153. nology that facilitates effective action. Professional Psychology:
Constantine, M. G., Warren, A. K., & Miville, M. L. (2005). Research and Practice, 38(5), 501–509. doi:10.1037/0735-
White racial identity dyadic interactions in supervision: 7028.38.5.501.
Implications for supervisees’ multicultural counseling com- Epstein, R. M., & Hundert, E. M. (2002). Defining and assess-
petence. Journal of Counseling Psychology, 52(4), 490–496. ing professional competence. The Journal of the American
Cook, D. A., & Helms, J. E. (1988). Visible racial/ethnic group Medical Association, 287(2), 226–235.
supervisees’ satisfaction with cross-cultural supervision Falender, C. A., & Shafranske, E. P. (2004). Clinical supervision:
as predicted by relationship characteristics. Journal of Coun- A competency-based approach. Washington, DC: American
seling Psychology, 35, 268–274. Psychological Association.
Couchon, W. D., & Bernard, J. M. (1984). Effects of timing Farber, B. A., Berano, K. C., & Capobianco, J. A. (2006).
of supervision on supervisor and counselor performance. A temporal model of patient disclosure in psychotherapy.
The Clinical Supervisor, 2(3), 3–20. Psychotherapy Research, 16, 463–469.
D’Andrea, M., Daniels, J., & Heck, R. (1991). Evaluating Fiedler, F., Mitchell, T., & Triandis, H. (1971). The culture
the impact of multicultural counseling training. Journal assimilator: An approach to cross-cultural training. Journal
of Counseling and Development, 70(1), 143–150. of Applied Psychology, 55(2), 95–102.
Doehrman, M. J. (1976). Parallel processes in supervision Fong, M. L., & Borders, L. D. (1985). Effect of sex role orienta-
and psychotherapy. Bulletin of the Menninger Clinic, 40, tion and gender on counseling skills training. Journal
3–104. of Counseling Psychology, 32(1), 104–110.
Dressel, J. L., Consoli, A. J., Kim, B. S. K., & Atkinson, D. R. Forrest, L., Elman, N., Gizara, S., Vacha-Haase, T. (1999).
(2007). Successful and unsuccessful multicultural supervi- Trainee impairment. The Counseling Psychologist, 27(5),
sory behaviors: A Delphi poll. Journal of Multicultural 627–686.
Counseling and Development, 35(1), 51. Forrest, L., Elman, N., & Miller, D. (2008). Psychology trainees
Duan, C., & Roehlke, H. (2001). A descriptive “snapshot” of with competence problems: From individual to ecological
cross-racial supervision in university counseling center conceptualizations. Training and Education in Professional
internships. Journal of Multicultural Counseling and Develop- Psychology, 2(4), 183–192.
ment, 29(2), 131–146. Freitas, G. (2002). The impact of psychotherapy supervision on
Efstation, J. F., Patton, M. J., & Kardish, C. M. (1990). client outcome: A critical examination of two decades of
Measuring the working alliance in counseling supervision. research. Psychotherapy: Theory, Research, Practice, Training,
Journal of Counseling Psychology, 37, 322–329. 39(4), 354–367.
Ekstein, R., & Wallerstein, R. (1958). The teaching and learning Freud, S. (1915). Observations on transference-love. (Further
of supervision. New York: Basic Books. recommendations on the technique of psycho-analysis, III),
Ekstein, R., & Wallerstein, R. S. (1972). The teaching and learn- S.E., 12, 159–171.
ing of psychotherapy. (Rev. ed.). Oxford, UK: International Friedlander, M. L., Siegel, S. M., & Brenock, K. (1989). Parallel
Universities Press. process in counseling and supervision: A case study. Journal
Eells, T. D. (1997). Handbook of psychotherapy case formulation. of Counseling Psychology, 36, 149–157.
New York: Guilford. Friedlander, M. L., & Snyder, J. (1983). Trainees’ expectations
Elder, L., & Paul, R. (1994, Fall). Critical thinking: Why we for the supervisory process: Testing a developmental model.
must transform our teaching. Journal of Developmental Counselor Education and Supervision, 22, 342–348.
Education, 18(1), 34–35. Fukuyama, M. A. (1994). Critical incidents in multicultural
Ellis, M. V. (1991). Critical incidents in clinical supervision and counseling supervision: A phenomenological approach to
in supervisor supervision: Assessing supervisory issues. supervision research. Counselor Education and Supervision,
Journal of Counseling and Development, 72, 520–525. 34, 142–151.
Ellis, M. V., D’Iuso, N., & Ladany, N. (2008). State of the art Gabbard, G. O. (1994). Sexual excitement and countertransfer-
in the assessment, measurement, and evaluation of clinical ence love in the analyst. Journal of the American Psychoanalytic
supervision. In A. K. Hess, T. D. Hess, & T. H. Hess (Eds.), Association, 42, 1083–1106.
Psychotherapy supervision: Theory, research, and practice (2nd Gabbard, G. O. (1995). The early history of boundary violations
ed., pp. 473–499). New York: John Wiley & Sons. in psychoanalysis. Journal of the American Psychoanalytic
Ellis, M. V., & Ladany, N. (1997). Inferences concerning Association, 43, 1115–1136.
supervisees and clients in clinical supervision: An integrative Gallessich, J., & Olmstead, K. M. (1987). Training in counseling
review. In C. E. Watkins (Ed.), Handbook of psychotherapy psychology: Issues and trends in 1986. Counseling Psychologist,
supervision (pp. 447–507). Hoboken, NJ: John Wiley & 15, 596–600.
Sons, Inc. Garb, H. N. (1989). Clinical judgment, clinical training,
Ellis, M. V., Ladany, N., Krengel, M., & Schult, D. (1996). An and professional experience. Psychological Bulletin, 105(3),
investigation of supervision research methodology: 1983–1993, 387–396.

202 tr ain in g and s u pervis io n

Gatmon, D., Jackson, D., Koshkarian, L., Matos-Perry, N., Hill, C. E. (1982). Counseling process research: Philosophical
Molina, A., Patel, N., & Rodolfa, E. (2001). Exploring and methodological dilemmas. The Counseling Psychologist,
ethnic, gender, and sexual orientation variables in supervi- 10, 7–19.
sion: Do they really matter? Journal of Multicultural Hill, C. E. (1986). An overview of the Hill counselor and client
Counseling and Development, 29, 102–113. verbal response modes category systems. In L. S. Greenberg,
Gizara, S. S., & Forrest, L. (2004). Supervisors’ experiences & W. M. Pinsof (Eds.), The psychotherapeutic process:
of trainee impairment and incompetence at APA-accredited A research handbook (pp. 131–159). New York: Guilford Press.
internship sites. Professional Psychology, research and practice, Hill, C. E. (2001). Helping skills: The empirical foundation.
35(2), 131–140. Washington, DC: American Psychological Association.
Gloria, A. M., Hird, J. S., & Tao, K. W. (2008). Assessing Hill, C. E. (2004). Helping skills: Facilitating explorations, insight,
multicultural supervision: A nationwide survey of supervi- and action (2nd ed.). Washington, DC: American Psy-
sors. Training and Education in Professional Psychology, 2, chological Association.
129–136. Hill, C. E., Knox, S., Thompson, B. J., Williams, E. N.,
Goodyear, R. K. (1990). Gender configurations in supervisory Hess, S. A., Ladany, N. (2005). Consensual qualitative
dyads: Their relation to supervisee influence strategies and research: An update. Journal of Counseling Psychology, 52(2),
to skill evaluations of the supervisee. Clinical Supervisor, 8, 196–205.
67–79. Hill, C. E., Thompson, B. J., & Williams, E. N. (1997). A guide
Goodyear, R. K., & Guzzardo, C. R. (2000). Psychotherapy to conducting consensual qualitative research. The Counseling
supervision and training. In S. Brown, & R. W. Lent (Eds.), Psychologist, 25(4), 517–572.
Handbook of counseling psychology (3rd ed., pp. 83–108). Hilton, D. B., Russell, R. K., & Salmi, S. W. (1995). The effects
New York: Wiley. of supervisor’s race and level of support on perceptions
Granello, D. H., Kindsvatter, A., Granello, P. F., Underfer- of supervision. Journal of Counseling & Development, 73,
Babalis, J., & Hartwig-Moorhead, H. (2008). Multiple per- 559–563.
spectives in supervision: Using a peer consultation model to Hird, J. S., Cavaleri, C. E., Dulko, J. P., Felice, A. A. D., &
enhance supervisor development. Counselor Education and Ho, T. A. (2001). Visions and realities: Supervisee perspec-
Supervision, 48, 32–47. tives of multicultural supervision. Journal of Multicultural
Gray, L. A., Ladany, N., Walker, J. A., & Ancis, J. R. (2001). Counseling and Development, 29, 114–130.
Psychotherapy trainees’ experience of counterproductive Hoffman, M. A., Hill, C. E., Holmes, S. E., & Freitas, G. F.
events in supervision. Journal of Counseling Psychology, 48, (2005). Supervisor perspective on the process and outcome
371–383. of giving easy, difficult, or no feedback to supervisees. Journal
Greer, R. D. (2002). Designing teaching strategies. New York: of Counseling Psychology, 52, 3–13.
Academic Press. Hogan, R. A. (1964). Issues and approaches in supervision.
Griffith, B. A., & Frieden, G. (2000). Facilitating reflective Psychotherapy: Theory, Research & Practice, 1, 139–141.
thinking in counselor education. Counselor Education and Holloway, E. L. (1984). Outcome evaluation in supervision
Supervision, 40(2), 82–93. research. The Counseling Psychologist, 12(1), 167–174.
Guiffrida, D. A. (2005). The Emergence Model: An alternative Holloway, E. L. (1995). Clinical supervision: A systems approach.
pedagogy for facilitating self-reflection and theoretical fit in Thousand Oaks, CA: Sage Publications, Inc.
counseling students. Counselor Education and Supervision, Holloway, E. L., & Wampold, B. E. (1983). Patterns of verbal
44(3), 201–213. behavior and judgments of satisfaction in the supervision
Harkness, D., & Hensley, H. (1991). Changing the focus interview. Journal of Counseling Psychology, 30, 227–234.
of social work supervision: Effects on client satisfaction Horvath, A. O., & Greenberg, L. S. (1986). The development
and generalized contentment. Social Work, 36(6), 506–512. of the Working Alliance Inventory. In L. S. Greenberg, &
Hatcher, R. L., & Lassiter, K. D. (2007). Initial training in W. M. Pinsof (Eds.), The psychotherapeutic process: A research
professional psychology: The practicum competencies out- handbook (p. 529–556). New York: Guildford.
line. Training and Education in Professional Psychology, 1(1), Housman, L. M., & Stake, J. E. (1999). The current state
49–63. of sexual ethics training in clinical psychology: Issues of
Hayes, R. L., & Stefurak, T. (2010). Group work supervision. quantity, quality, and effectiveness. Professional Psychology,
In N. Ladany, & L. Bradley (Eds.), Counselor supervision Research & Practice, 30(3), 302–211.
(4th ed., pp. 215–232). New York: Routledge. Inman, A. G. (2006). Supervisor multicultural competence
Helms, J. E. (1990). Black and White racial identity: Theories, and its relation to supervisory process and outcome. Journal
research, and practice. Westport, CT: Greenwood Press. of Marital and Family Therapy, 32, 73–85.
Helms, J. E., & Carter, R. T. (1990). Development of the Inman, A. G., & Ladany, N. (2008). Research: The state of
White Racial Identity Inventory. In J. E. Helms (Ed.), Black the field. In A. K. Hess, K. D. Hess, & T. H. Hess (Eds.),
and White racial identity: Theory, research, and practice Psychotherapy supervision: Theory, research, and practice
(pp. 67–80). Westport, CT: Greenwood Press. (2nd ed., pp. 500–517). New York: John Wiley & Sons.
Heppner, P. P., & Handley, P. G. (1981). A study of the interper- Inman A. G., & Soheilian, S. S. (2010). Training supervisors:
sonal influence process in supervision. Journal of Counseling A core competency. In N. Ladany, & L. Bradley (Eds.),
Psychology, 28, 437–444. Counselor supervision (4th ed., pp. 413–436). New York:
Hernández-Wolfe, P. (2010). Family counseling supervision. Routledge.
In N. Ladany, & L. Bradley (Eds.), Counselor supervision Issacharoff, A. (1984). Countertransference in supervision:
(4th ed., pp. 287–308). New York: Routledge. Therapeutic consequences for the supervisee. In L. Caligor,
Hess, S., Knox, S., Schultz, J., Hill, C., Sloan, L., Brandt, S., P. Bromberg, & J. Meltzer (Eds.), Clinical perspectives in the
et al. (2008). Predoctoral interns’ nondisclosure in supervi- supervision of psychoanalysis and psychotherapy (pp. 89–105).
sion. Psychotherapy Research, 18(4), 400–411. New York: Plenum.

l adany, inm an 203

Ivey, A. E. (1971). Microcounseling: Innovations in interviewing Ladany, N. (2007). Does psychotherapy training matter? Maybe
training. Oxford, UK: Charles C Thomas. not. Psychotherapy: Theory, Research, Practice, Training, 44,
Ivey, A. E., Ivey, M. B., & Simek-Morgan, L. (1993). Counseling 392–396.
and psychotherapy: A multicultural perspective (3rd ed.). Ladany, N., Brittan-Powell, C. S., & Pannu, R. K. (1997). The
Boston: Allyn and Bacon. influence of supervisory racial identity interaction and racial
Kadushin, A., & Harkness, D. (2002). Supervision in social work. matching on the supervisory working alliance and supervisee
New York: Columbia University Press. multicultural competence. Counselor Education and Super-
Kagan, H., & Kagan, N. I. (1997). Interpersonal process recall: vision, 36, 284–304.
Influencing human interaction. In C. E. Watkins, Jr. (Ed.), Ladany, N., Constantine, M. G., Miller, K., Erickson, C. D., &
Handbook of psychotherapy supervision (pp. 296–309). Muse-Burke, J. L. (2000). Supervisor countertransference:
New York: John Wiley & Sons, Inc. A qualitative investigation into its identification and descrip-
Kagan, N. (1980). Influencing human interaction - Eighteen tion. Journal of Counseling Psychology, 47, 102–115.
years with IPR. In A. K. Hess (Ed.), Psychotherapy supervi- Ladany, N., Ellis, M. V., & Friedlander, M. L. (1999). The super-
sion: Theory, research, and practice (pp. 262–283). New York: visory working alliance, trainee self-efficacy, and satisfaction
Wiley. with supervision. Journal of Counseling & Development, 77,
Kagan, N. (1984). Interpersonal process recall: Basic methods 447–455.
and recent research. In D. Larson (Ed.), Teaching psychologi- Ladany, N., & Friedlander, M. L. (1995). The relationship
cal skills: Models for giving psychology away (pp. 229–244). between the supervisory working alliance and trainees’ expe-
Monterey, CA: Brooks/Cole. rience of role conflict and role ambiguity. Counselor Education
Kagan, N., & Krathwohl, D. R. (1967). Studies in human inter- and supervision, 34, 356–368.
action: Interpersonal process recall stimulated by videotape. East Ladany, N., Friedlander, M. L., & Nelson, M. L. (2005). Critical
Lansing, MI: Michigan State University. events in psychotherapy supervision: An interpersonal approach.
Kanz, J. E. (2001). Clinical-supervision.com: Issues in the provi- Washington, DC: American Psychological Association.
sion of online supervision. Professional Psychology: Research Ladany, N., Hill, C. E., Corbett, M., & Nutt, L. (1996). Nature,
and Practice, 32, 415–420. extent, and importance of what therapy trainees do not dis-
Kaslow, N. J., Rubin, N. J., Bebeau, M. J., Leigh, I. W., close to their supervisors. Journal of Counseling Psychology,
Lichtenberg, J. W., Nelson, P. D., Portnoy, S. M., 43, 10–24.
Smith, I. L. (2007). Guiding principles and recommenda- Ladany, N., & Inman, A. G. (2008). Developments in coun-
tions for the assessment of competence. Professional Psy- seling skills training and supervision. In S. Brown, &
chology: Research and Practice, 38(5), 441–451. R. Lent (Eds.), Handbook of counseling psychology. (4th ed.,
Killian, K. D. (2001). Differences making a difference: Cross- pp. 338–354). New York: Wiley.
cultural interactions in supervisory relationships. Journal Ladany, N., Inman, A. G., Constantine, M. G., & Hofheinz, E.
of Feminist Family Therapy, 12, 61–103. (1997). Supervisee multicultural case conceptualization abil-
King, D., & Wheeler, S. (1999). The responsibilities of coun- ity and self-reported multicultural competence as functions
sellor supervisors: A qualitative study. British Journal of of supervisee racial identity and supervisor focus. Journal of
Guidance & Counselling, 27, 215–229. Counseling Psychology, 44, 284–293.
Kingdon, M. A. (1975). A cost/benefit analysis of the Ladany, N., & Lehrman-Waterman, D. E. (1999). The content
Interpersonal Process Recall technique. Journal of Counseling and frequency of supervisor self-disclosures and their rela-
Psychology, 22, 353–357. tionship to supervisor style and the supervisory working
Kivlighan, D. M., Angelone, E. O., & Swafford, K. G. (1991). alliance. Counselor Education and Supervision, 38, 143–160.
Live supervision in individual psychotherapy: Effects on Ladany, N., Lehrman-Waterman, D. E., Molinaro, M., &
therapist’s intention use and client’s evaluation of session Wolgast, B. (1999). Psychotherapy supervisor ethical prac-
effect and working alliance. Professional Psychology, Research tices: Adherence to guidelines, the supervisory working
and Practice, 22(6), 489–495. alliance, and supervisee satisfaction. The Counseling
Kleintjes, S., & Swartz, L. (1996). Black clinical psychology Psychologist, 27, 443–475.
trainees at a “White” South African university: Issues for Ladany, N., & Malouf, M. A. (2010). Understanding and
clinical supervision. Clinical Supervisor, 14, 87–109. conducting supervision research. In N. Ladany and
Knowles, Z., Gilbourne, D., Tomlinson, V., & Anderson, A. L. Bradley (Eds.). Counselor Supervision (4th ed., pp. 353–388).
(2007). Reflections on the application of reflective practice New York: Routledge.
for supervision in applied sport psychology. Sport Psychology, Ladany, N., & Melincoff, D. S. (1999). The nature of counselor
21(1), 109–122. supervisor nondisclosure. Counselor Education and
Knox, S., Burkard, A., Edwards, L., Smith, J., & Scholsser, L. Supervision, 38, 161–176.
(2008). Supervisors’ reports of the effects of supervisor self- Ladany, N., Melincoff, D. S., Constantine, M. G., & Love, R.
disclosure on supervisees. Psychotherapy Research, 18(5), (1997). At-risk urban high school students’ commitment to
543–559. career choices. Journal of Counseling and Development, 76,
Kugler, P. (1995). Jungian perspectives on clinical supervision. 45–52.
Einsiedeln, Switzerland: Daimon. Ladany, N., & Muse-Burke, J. L. (2001). Understanding and
Ladany, N. (2002). Psychotherapy supervision: How dressed is conducting supervision research. In L. Bradley, & N. Ladany
the emperor? Psychotherapy Bulletin, 37, 14–18. (Eds.), Counselor supervision: Principles, process, & practice
Ladany, N. (2005). Conducting effective clinical supervision. (3rd ed., pp. 304–329). Philadelphia: Brunner-Routledge.
In G. P. Koocher, J. C. Norcross, & S. S. Hill (Eds.), Ladany, N., O’Brien, K. M., Hill, C. E., Melincoff, D., Knox, S.,
Psychologists’ desk reference (2nd ed., pp. 682–685). New York: & Petersen, D. A. (1997). Sexual attraction towards clients,
Oxford University Press. use of supervision, and prior training: A qualitative study of

204 tr ain in g and s u pervis io n

 predoctoral psychology interns. Journal of Counseling McIlvried, J., & Bent, R. (2003). Core competencies: Current
Psychology, 44, 413–424. and future perspectives. Paper presented at the annual
Ladany, N., & Walker, J. A. (2003). Supervisor self-disclosure: midwinter conference of the National Council of Schools
Balancing the uncontrollable narcissist with the indomi- and Programs of Professional Psychology, Scottsdale, AZ.
table altruist. In Session: Journal of Clinical Psychology, 59, McNeill, B. W., Stoltenberg, C. D., & Pierce, R. A. (1985).
611–621. Supervisees’ perceptions of their development: A test of
Ladany, N., Walker, J. A., Pate-Carolan, L., & Gray Evans, L. the counselor complexity model. Journal of counseling psy-
(2008). Practicing Counseling and Psychotherapy: Insights from chology, 32(4), 630–633.
Trainees, Clients, and Supervisors. New York: Routledge. McNeill, B. W., & Worthen, V. (1989). The parallel process in
Lamb, D. H., Catanzaro, S. J., & Moorman, A. S. (2003). psychotherapy supervision. Professional Psychology: Research
Psychologists reflect on their sexual relationships with clients, and Practice, 20, 329–333.
supervisees and students: Occurrence, impact, rationales, McRoy, R. G., Freeman, E. M., & Logan, S. (1986). Strategies
and collegial intervention. Professional Psychology: Research for teaching students about termination. Clinical Supervisor,
and Practice, 34(1), 102–107. 4, 45–56.
Lambert, M. J., & Arnold, R. C. (1987). Research and the super- Mehr, K. E., Ladany, N., & Caskie, G. I. L. (2010). Trainee non-
visory process. Professional Psychology, Research and Practice, disclosure in supervision. Counselling and Psychotherapy
18(3), 217–224. Research, 10, 103–113.
Lambert, M. J., Hansen, N. B., & Finch, A. E. (2001). Patient- Meier, S. T. (1993). Revitalizing the measurement curriculum:
focused research: Using patient outcome data to enhance Four approaches for emphasis in graduate education.
treatment effects. Journal of Consulting and Clinical Psychology, American Psychologist, 48, 886–891.
69, 159–172. Metcalf, L. M. (2003). Countertransference among play
Lambert, M. J., & Ogles, B. M. (1997). The effectiveness of therapists: Implications for the therapist development and
psychotherapy supervision. In C. E. Watkins (Ed.), Handbook supervision. The Association for Play Therapy, 12(2), 31–48.
of psychotherapy supervision. (pp. 421–446). Hoboken, NJ: Mori, Y., Inman, A. G., & Caskie, G. (2009). Supervising inter-
John Wiley & Sons, Inc. national students: Relationship between acculturation,
Lawless, J. J., Gale, J. E., & Bacigalupe, G. (2001). The discourse supervisor multicultural competence, cultural discussions,
of race and culture in family therapy supervision: A conversa- and supervision satisfaction. Training and Education in Pro-
tion analysis. Contemporary Family Therapy, 23, 181–197. fessional Psychology, 3, 10–18.
Lee, R. W., & Cashwell, C. S. (2001). Ethical issues in coun- Munson, C. E. (2002). Handbook of clinical social work supervi-
seling supervision: A comparison of university and site super- sion. New York: Haworth Press.
visors. Clinical Supervisor, 20(2), 91–100. National Board For Certified Counselors. (2005). Code of ethics.
Lehrman-Waterman, D., & Ladany, N. (2001). Development Greensboro, NC: Author.
and validation of the evaluation process within supervision Neill, T. K. (2006). Helping others help children: Clinical supervi-
inventory. Journal of Counseling Psychology, 48, 168–177. sion of child psychotherapy. Washington, DC: American
Leong, F. T. L., & Kim, H. H. W. (1991). Going beyond cultural Psychological Association.
sensitivity on the road to multiculturalism: Using the inter- Nelson, M. L., & Friedlander, M. L. (2001). A close look at
cultural sensitizer as a counselor training tool. Journal of conflictual supervisory relationships: The trainee’s perspec-
Counseling & Development, 70(1), 112–118. tive. Journal of Counseling Psychology, 48, 384–395.
Littrell, J. M., Lee-Borden, N., & Lorenz, J. A. (1979). A devel- Nelson, M. L., & Holloway, E. L. (1990). Relation of gender to
opmental framework for counseling supervision. Counselor power and involvement in supervision. Journal of Counseling
Education and Supervision, 19, 119–136. Psychology, 37, 473–481.
Lower, R. B. (1972). Countertransference resistances in the Nerdrum, P., & Rønnestad, M. H. (2002). The trainees’ pers-
supervisory situation. American Journal of Psychiatry, 129, pective: A qualitative study of learning empathic comm-
156–160. unication in Norway. The Counseling Psychologist, 30,
Luborsky, L., Singer, B., & Luborsky, L. (1975). Comparative 609–629.
studies of psychotherapies: Is it true that “Everyone has won Neufeldt, S. A. (1999). Supervision strategies for the first practicum
and all must have prizes”? Archives of General Psychiatry, 32, (2nd ed.). Alexandria, VA: American Counseling
995–1008. Association.
Magnuson, S., Black, L. L., Norem, K. (2004). Supervising Newman, P. A., Bogo, M., & Daley, A. (2008). Self-disclosure
school counselors and interns: Resources for site supervisors. of sexual orientation in social work field education:
Journal of Professional Counseling, Practice, Theory, & Research, Field instructor and lesbian and gay student perspectives.
32(2), 4–15. The Clinical Supervisor, 27(2), 215–237. doi:10.1080/
Magnuson, S., Wilcoxon, S. A., & Norem, K. (2000). A profile 07325220802487881.
of lousy supervision: Experienced counselors’ perspectives. Nilsson, J. E., & Anderson, M. Z. (2004). Supervising interna-
Counselor Education and Supervision, 39(3), 189–202. tional students: The role of acculturation, role ambiguity,
Mahrer, A. R. (2008). Supervision and training of experiential and multicultural discussions. Professional Psychology: Research
psychotherapists. In A. K. Hess, K. D. Hess, T. H. Hess, and Practice, 35, 306–312.
A. K. Hess, K. D. Hess, T. H. Hess (Eds.), Psychotherapy O’Connor, B. P. (2000). Reasons for less than ideal psychother-
supervision: Theory, research, and practice (2nd ed., 137–156). apy supervision. The Clinical Supervisor, 19(2), 173–183.
Hoboken, NJ: John Wiley & Sons Inc. Retrieved from doi:10.1300/J001v19n02_10.
EBSCOhost. Orlinsky, D. E., & Ronnestad, M. H. (2005). How psycho-
McDonald, P. A., & Haney, H. (1988). Counseling the older therapists develop: A study of therapeutic work and profes-
adult: A training manual in clinical gerontology (2nd ed.). sional growth. Washington, DC: American Psychological
Lexington, MA: Lexington Books. Association.

l adany, inm an 205

Overholser, J. C. (2004). The four pillars of psychotherapy Riggs, S., & Bretz, K. (2006). Attachment processes in the super-
supervision. Clinical Supervisor, 23, 1–13. visory relationship: An exploratory investigation. Professional
Peake, T. H., Nussbaum, B. D., & Tindell, S. D. (2002). Psychology: Research and Practice, 37, 558–566.
Clinical and counseling supervision references: Trends and Robiner, W., Fuhrman, M., & Ristvedt, S. (1993). Evaluation
needs. Psychotherapy: Theory, Research, Practice, Training, 39, difficulties in supervising psychology interns. The Clinical
114–125. Psychologist, 46, 3–13.
Pedersen, P. (1994). Simulating the client’s internal dialogue as Robiner, W. N., & Schofield, W. (1990). References on supervi-
a counselor training technique. Simulation & Gaming, 25(1), sion in clinical and counseling psychology. Professional
40–50. Psychology: Research and Practice, 21(4), 297–312.
Pederson, P. B. (1991). Multiculturalism as a fourth force in Robyak, J. E., Goodyear, R. K., & Prange, M. (1987). Effects
counseling. Journal of Counseling & Development, Special of supervisors’ sex, focus, and experience on preferences for
Issue. interpersonal power bases. Counselor Education and Super-
Pederson, P. B. (1999). Multiculturalism as a fourth force in coun- vision, 26, 299–309.
seling. Philadelphia: Brunner/Mazel. Rodolfa, E., Bent, R., Eisman, E., Nelson, P., Rehm, L., &
Petty, M. M., & Odewahn, C. A. (1983). Supervisory behavior Ritchi, P. (2005). A cube model for competency devel-
and sex role stereotypes in human service organizations. opment: Implications for psychology educators and regula-
The Clinical Supervisor, 1, 13–20. tors. Professional Psychology: Research and Practice, 36,
Pisani, A. (2005). Talk to Me: Supervisee disclosure in supervi- 347–354.
sion. Smith College Studies in Social Work, 75(1), 29–47. Rodolfa, E., Hall, T., Holms, V., Davena, A., Komatz, D.,
Ponterotto, J. G., Gretchen, D., Utsey, S. O., Rieger, B. P., & Antunez, M., & Hall, A. (1994). The management of sexual
Austin, R. (2002). A revision of the Multicultural Counseling feelings in therapy. Professional Psychology: Research and
Awareness Scale. Journal of Multicultural Counseling & Practice, 25, 168–172.
Development, 30(3), 153–181. Rogers, C. R. (1957). The necessary and sufficient conditions
Ponterotto, J. G., Rieger, B. P., Barrett, A., Harris, G., Sparks, R., of therapeutic personality change. Journal of Consulting
Sanchez, C. M., & Magids, D. (1996). Development Psychology, 21, 95–103.
and initial validation of the Multicultural Counseling Rosenzweig, S. (1936). Some implicit common factors in diverse
Awareness Scale. In G. R. Sodowsky, & J. C. Impara (Eds.), methods of psychotherapy. American Journal of Ortho-
Multicultural assessment in counseling and clinical psychology psychiatry, 6, 412–415.
(pp. 247–282). Lincoln, NE: Buros Institute of Mental Schacht, A. J., Howe, H. E., & Berman, J. J. (1989). Supervisor
Measurements. facilitative conditions and effectiveness as perceived by
Pope, K. S., Levenson, H., Schover, L. R. (1979). Sexual thinking- and feeling-type supervisees. Psychotherapy: Theory,
intimacy in psychology training: Results and implications Research, Practice, Trainin, 26, 475–483.
of a national survey. The American Psychologist, 34(8), Schiavone, C. D., & Jessell, J. C. (1988). Influence of attributed
682–289. expertness and gender in counselor supervision. Counselor
Pope, K. S., Sonne, J. L., & Holroyd, J. (1993). Sexual feelings Education and Supervision, 28, 29–42.
in psychotherapy: Explorations for therapists and therapists- Searles, H. F. (1955). The informational value of the supervisor’s
in-training. Washington, DC: American Psychological emotional experiences. Psychiatry, 18(2), 135–146.
Association. Sells, J. N., Goodyear, R. K., Lichtenberg, J. W., &
Pope, S., Keith-Spiegel, P., & Tabachnick, B. (1986). Sexual Polkinghorne, D. E. (1997). Relationship of supervisor
attraction to clients: The human therapist and the (some- and trainee gender to in-session verbal behavior and rat-
times) inhuman training system. American Psychologist, 41, ings of trainee skills. Journal of Counseling Psychology, 44,
147–158. 406–412.
Powell, D. J., & Brodsky, A. (2004). Clinical supervision in Sherry, A., Whilde, M. R., & Patton, J. (2005). Gay, lesbian,
alcohol and drug abuse counseling: Principles, models, methods and bisexual training competencies in American Psycholo-
(Rev. ed.). San Francisco: Jossey-Bass. gical Association accredited graduate programs. Psychotherapy:
Putne, M. W., Worthington, E. L., & McCullough, M. E. Theory, Research, Practice, Training, 42, 116–120.
(1992). Effects of supervisor and supervisee theoretical Smith, M., Glass, G., & Miller, T. (1980). The benefits of psy-
orientation and supervisor-supervisee matching on interns’ chotherapy. Baltimore: Johns Hopkins.
perceptions supervision. Journal of Counseling Psychology, 39, Sobell, L., Manor, H. L., Sobell, M. B., & Dum, M. (2008).
258–265. Self-critiques of audiotaped therapy sessions: A motivational
Raichelson, S. H., Herron, W. G., Primavera, L. H., & procedure for facilitating feedback during supervision.
Ramirez, S. M. (1997). Incidence and effects of parallel Training and Education in Professional Psychology, 2(3),
process in psychotherapy supervision. Clinical Supervisor, 15, 151–155. doi:10.1037/1931-3918.2.3.151.
37–48. Sodowsky, G. R., Kwan, K. L. K., & Pannu, R. (1995). Ethnic
Ramos-Sanchez, L., Esnil, E., Goodwin, A., Riggs, S., identity of Asians in the United States. In J. G. Ponterotto,
Touster, L. O., Wright, L. K., et al. (2002). Negative super- J. M. Casas, L. A. Suzuki, & C. M. Alexander (Eds.),
visory events: Effects on supervision satisfaction and supervi- Handbook of multicultural counseling (pp. 123 154).
sory alliance. Professional Psychology: Research and Practice, Thousand Oaks, CA: Sage.
33(2), 197–202. Sodowsky, G. R., Taffe, R. C., Gutkin, T., & Wise, S. L.
Richardson, T. Q., & Molinaro, K. L. (1996). White counselor (1994). Development of the Multicultural Counseling
self-awareness: A prerequisite for multicultural competence. Inventory: A self-report measure of multicultural competen-
Journal of Counseling & Development, 74, 238–242. cies. Journal of Counseling Psychology, 41, 137–148.

206 tr ain in g and s u pervis io n

Stenack, R. J., & Dye, H. A. (1983). Practicum supervision and supervision dyads. The Counseling Psychologist, 33,
roles: Effects on supervisee statements. Counselor Education 565–573.
and Supervision, 23, 157–168. Vander Kolk, C. J. (1974). The relationship of personality, values,
Stevens, D. T., Goodyear, R. K., & Robertson, P. (1997). and race to anticipation of the supervisory relationship.
Supervisor development: An exploratory study in changes in Rehabilitation, 18, 41–46.
stance and emphasis. Clinical Supervisor, 16, 73–88. Vidlak, N. W. ( January 1, 2002). Identifying important factors in
Stigall, T., Bourg, E., Bricklin, P., Kovacs, A., Larsen, K., supervisor development: An examination of supervisor experi-
Lorion, R., et al. (1990). Report of the Joint Council on ence, training, and attributes. ETD collection for University of
Professional Education in Psychology. Baton Rouge, LA: Land Nebraska - Lincoln. Paper AAI3055295. Retrieved from
and Land Printers. http://digitalcommons.unl.edu/dissertations/AAI3055295.
Stiles, W. B. (1979). Verbal response modes and psychotherapeu- Waehler, C. A., Kalodner, C. R., Wampold, B. E., &
tic technique. Psychiatry, 42, 49–62. Lichtenberg, J. W. (2000). Empirically supported treatments
Stiles, W. B. (1986). Development of a taxonomy of verbal (ESTs) in perspective. The Counseling Psychologist, 28(5),
response modes. In W. M. Pinsof (Ed.), The psychotherapeutic 657–671.
process: A research handbook (pp. 161–199). New York: The Walker, J., Ladany, N., & Pate-Carolan, L. (2007). Gender-
Guilford Press. related events in psychotherapy supervision: Female trainee
Stoltenberg, C. D., McNeill, B., & Delworth, U. (1998). IDM perspectives. Counselling and Psychotherapy Research, 7,
supervision: An integrated developmental model for supervising 12–18.
counselors and therapists. San Francisco: Jossey-Bass. Wallace, E., & Alonso, A. (1994). Clinical Perspectives on psycho-
Stratton, J. S., & Smith, R. D. (2006). Supervision of couples therapy supervision. Arlington, VA: American Psychiatric
cases. Psychotherapy: Theory, Research, Practice, Training, 43, Publishing.
337–348. Wampold, B. E. (2001). The great psychotherapy debate: Models,
Strean, H. S. (2000). Resolving therapeutic impasses by using methods, and findings. Mahwah, NJ: Lawrence Erlbaum
the supervisor’s countertransference. Clinical Social Work Associates.
Journal, 28(3), 263–279. Wampold, B. E., Lichtenberg, J. W., & Waehler, C. A.
Stutts, M. L. (1991). Supervision in comprehensive rehabilita- (2002). Principles of empirically supported interventions
tion settings: The terrain and the traveler. In T. H. Peake, in counseling psychology. Counseling Psychologist, 30(2),
& J. D. Ball (Eds.), Psychotherapy training (pp. 115–134). 197–217.
London: Haworth Press. Wampold, B. E., Mondin, G. W., Moody, M., Stich, F.,
Sue, D. W., & Sue, D. (2003). Counseling the culturally diverse: Benson, K., & Ahn, H. (1997). A meta-analysis of out-
Theory and practice (4th ed.). New York: Wiley. come studies comparing bona fide psychotherapies:
Szymanski, D. M. (2005). Feminist identity and theories as cor- Empirically, “all must have prizes.” Psychological Bulletin,
relates of feminist supervision practices. The Counseling 122, 203–225.
Psychologist, 33, 739–747. Ward, C. C., & House, R. M. (1998). Counseling supervision:
Tedesco, J. F. (1982). Premature termination of psychology A reflective model. Counselor Education and Supervision, 38,
interns. Professional Psychology: Research and Practice, 13, 23–33.
695–698. Watkins, C. E., Jr. (1993). Development of the psychotherapy
Teitelbaum, S. H. (1990). The impact of psychoanalytic supervi- supervisor: Concepts, assumptions, and hypotheses of the
sion on the development of professional identity: Intro- supervisor complexity model. American Journal of Psy-
duction. Psychoanalysis & Psychotherapy Special Issue: The chotherapy, 47(1), 58–74.
supervision of the psychoanalytic process, 8, 3–4. Watkins, C. E., Jr. (1995). Researching psychotherapy supervisor
Townend, M., Iannetta, L., & Freeston, M. H. (2002). Clinical development: Four key considerations. The Clinical
supervision in practice: A survey of UK cognitive behavioural Supervisor, 13(2), 111–118.
psychotherapists accredited by the BABCP. Behavioural and Westefeld, J. S. (2009). Supervision of psychotherapy: Models,
Cognitive Psychotherapy, 30(4), 485–500. issues, and recommendations. The Counseling Psychologist,
Utsey, S. O., Hammar, L., & Gernat, C. A. (2005). Examining 37(2), 296–316. doi:10.1177/0011000008316657
the reactions of White, Black, and Latino/a counseling
psychologists to a study of racial issues in counseling

l adany, inm an 207

 CHAPTER

Measurement and Assessment

8 in Counseling Psychology

Jane L. Swanson

Abstract
In this chapter, I present two broad topics: psychological measurement, or the process of assigning
numbers to observations to quantify important characteristics of individuals, and the use of testing
and assessment within counseling psychology. The first half of the chapter describes principles of
measurement, including methods of scale and test development and evaluating the psychometric
characteristics of tests (reliability and validity). The second half focuses on the use of testing and
assessment, including models of assessment within counseling psychology, various types of commonly
used assessment tools, computer-assisted and Internet-based assessment, gender and diversity issues,
considerations in the selection and use of assessment in counseling, and professional and ethical issues.
Keywords: assessment, testing, validity, reliability, individual differences

The psychological test was the invention that The purpose of this chapter is to present a broad
revolutionized psychological science, comparable in its overview of the interconnected topics of measure-
impact to the telescope in physics and the microscope ment, testing and assessment, beginning with the
in biology. It opened up a new world for psychology to philosophical foundation of the study of individual
explore. . . . [It] is the technological innovation from differences. The subsequent section of the chapter
psychology that has had the greatest effect on society. consists of a discussion of key principles of psycho-
—Dawis, 1992, p. 10 logical measurement, followed by a consideration of
the practice of testing and assessment in counseling
The principles of measurement and assessment pro-
psychology.
vide the bedrock on which scientific and applied
psychology has been built. From the standpoint of
theory and research, measuring constructs is funda- The Individual Differences
mental to understanding the laws governing human Tradition in Psychology
behavior, whether one is interested in social rela- The study of individual differences emerged in psy-
tionships, career development, or cognitive growth chology at the end of the 19th century through the
and decline. From the standpoint of applied psy- influences of Charles Darwin, who focused on dif-
chology, measuring the important characteristics of ferences among individuals within a species as the
an individual aids in diagnosis and treatment. basis for natural selection and evolution, and Francis
Measurement and assessment allow us to compare Galton, who developed ways to quantify differences
individuals to one another, to communicate impor- among individuals. In response to a practical prob-
tant information to and about others, and to make lem that needed a solution, Alfred Binet applied the
decisions about individuals on the basis of objective study of individual differences to the development
rather than subjective information. of the first successful psychological test that would

208
become the prototype for all later psychological assessment” (Dawis, 1992, p. 11), which was inter-
tests (Dawis, 1992). twined with the early development of vocational
The psychology of individual differences contin- guidance and counseling through the mechanism
ued to develop early in the 20th century, partic- of assessing interests, abilities, and personality, as
ularly as the field of applied psychology gained well as the characteristics of occupations (Dawis,
ground. The two growing specialties within American 1992; Hansen, 2005; Parsons, 1909). Dawis (1992)
applied psychology—educational psychology and described the influence of the “individual differ-
industrial psychology—were focused on the study ences point of view in assessment,” which included
of individual differences at school and at work an emphasis on quantitative assessment of individ-
(Dawis, 1992), and many of the proponents of indi- uals, along multiple dimensions, stated in relative
vidual differences methods and analyses were aligned (vs. absolute) and actuarial (likelihood) terms.
with these fields.
A primary purpose of the study of individual Psychological Measurement, Psychological
differences is to describe, in quantitative ways, how Testing, and Psychological Assessment
individuals and groups vary on important psy- What are the connections between testing, assess-
chological attributes. This quantitative description ment, and measurement? Because these terms are
is addressed by the field of psychometrics or psy- overlapping, and sometimes used interchangeably,
chological measurement. A second purpose of the it is useful to begin with a definition of each. As just
study of individual differences is to examine factors described, all three of these terms and activities
that are related to these differences, their anteced- are related to the study of individual differences.
ents or causes, and their outcomes or consequences; Measurement is at the root of it all, as the field
this purpose is reflected in much of the research of psychometrics provides the principles that guide
conducted within counseling psychology. the development of specific tests and assessment
The study of individual differences in the 20th procedures, as well as provides the framework for
century led to focused attention on psychological evaluating the quality of information obtained
measurement, or psychometric theory and princi- about individuals and the purposes to which the
ples. The concept of co-relation, as proposed by information will be put.
Galton and refined by Pearson into the contempo- Briefly, assessment is “a broad array of evaluative
rary correlation coefficient, provided the method of procedures that yield information about a person,”
quantifying the association between two separate with testing as a subset or as one component of
variables and thus offered a significant advance in assessment activities, using a standardized measure-
the study of individual differences. The correlation ment instrument that yields scores based on the
coefficient became central to the development structured gathering of data (Neukrug & Fawcett,
of psychological tests (Dawis, 1992). These meth- 2006, p. 3). Testing, in and of itself, entails “little
ods and their philosophical underpinnings led to or no continuing relationship or legally defined
what Cronbach (1957) called the “two disciplines” responsibility between examinee and examiner”
of scientific psychology—the correlational and (Matarazzo, 1990, p. 1000). Assessment, on the
experimental approaches to the study of human other hand, involves a one-to-one clinician–client
behavior—which treat variation among individuals relationship, “an activity by which the clinician
in fundamentally different ways: Experimental integrates test findings with information from the
psychology focused on minimizing individual dif- personal, educational, and occupational histories as
ferences, treating them as error in an otherwise care- well as from the findings of other clinicians”
fully controlled experimental treatment, whereas (Matarazzo, 1990, p. 1011).
correlational psychology focused on describing and For the purpose of the present chapter, the term
predicting such individual differences. Measurement test is used when referring to a specific instrument
theory and assessment practice both developed to or class of instruments, and assessment is used
describe individual differences and to use them to when referring to the broader endeavor. Tests (and,
predict other behavior and to make decisions about more broadly, assessments) are used in many dif-
individuals. ferent settings and for many different purposes.
The individual differences tradition has been Tests are used in educational settings, to make
particularly influential in the history of counsel- decisions about instruction and grading, admis-
ing psychology as a professional specialty. First and sions and placement, counseling and guidance,
foremost is that it offered a “technology for client curriculum, and educational policy. They are used

swanson 209
in organizational settings, for pre-employment numbers to individuals by devising ways of infer-
screening, selection and placement decisions, and ring the unobservable construct through a series
performance appraisal, and in legal and forensic of careful and systematic observations of an indi-
settings, to provide information for decisions such vidual’s behavior.
as mental competency or child custody. Tests also Why is it important to assign numbers to obser-
are used in clinical and counseling settings, to gather vations about an individual? Measurement proce-
information related to diagnosis, to plan thera- dures are used for many purposes, including the
peutic interventions, and to measure therapeutic research and theory building activities that lead to
change. All of these purposes represent the use of scientific advances (Nunnally & Bernstein, 1994).
testing to solve a wide range of practical problems, For the purpose of this chapter, though, the focus
a reflection of the history and evolution of testing is on those aspects of measurement that lead to
in general (Anastasi & Urbina, 1997; McIntire & standardized testing and assessment, which in turn
Miller, 2007). To be useful in solving problems, lead to therapeutic interventions and client change.
however, any test must meet psychometric stan- In this context, quantifying characteristics of indi-
dards, and test users must understand the principles viduals allows a comparison of individuals to one
of psychological measurement. another and to a standard or benchmark, but this
serves an intermediate goal. The ultimate goal is
Fundamental Principles of typically to choose a treatment, to measure change,
Psychological Measurement to assist clients in some way. But none of these
Definition and Purpose of Measurement intermediate or ultimate goals is achievable without
Measurement is a set of “rules for assigning symbols accurate measurement—without assigning numbers
to objects” (Nunnally & Bernstein, 1994, p. 3), or in a way that is precise and standardized.
“the process of assigning numbers according to All efforts to measure something must begin by
certain agreed-upon rules” (Walsh & Betz, 2001, carefully defining the construct of interest. For
p. 15). These “rules” imply that there is an explicit example, what, specifically, do we mean by self-
procedure for assigning numbers that can be con- esteem? How does this definition overlap with other
sistently applied to different individuals, and by dif- constructs, such as self-efficacy or self-confidence?
ferent individuals. In some cases, these rules are In defining a construct, it is important to be precise,
quite evident, such as the process of using a tape narrow, and parsimonious in definition. Note that
measure to quantify a person’s height, whereas in this definition is at the hypothetical or theoretical
other cases, the rules are not at all obvious, such as (that is, unobservable) level. In a classic paper,
how to quantify a person’s self-esteem or level of Cronbach and Meehl (1955) defined a construct
multicultural competence. Most of what is mea- as “some postulated attribute of people, assumed to
sured in counseling psychology falls into the latter be reflected in test performance” (p. 283). This con-
category, and so it is particularly crucial to under- struct occurs within a nomological network, “the
stand principles of psychological measurement. interlocking system of laws which constitute a
Measurement has been called “the major prob- theory” (p. 290). Laws within a nomological net-
lem in psychology” because it is not possible to test work “may relate (a) observable properties or quan-
a theory unless its components can be adequately tities to each other; or (b) theoretical constructs to
measured. Furthermore, psychology as a science observables; or (c) different theoretical constructs
“can progress no faster than the measurement of its to one another” (p. 290). For a construct to be “sci-
key variables” (Nunnally & Bernstein, 1994, p. 6). entifically admissible,” it must be located within
What are we attempting to measure? In counsel- a nomological network with at least some compo-
ing psychology (as in most areas of psychology), we nents that have defined “observables,” some evi-
are typically interested in attributes or characteris- dence of the hypothetical construct.
tics of individuals that are not directly observable, The next step in measurement is to determine
such as self-esteem, depression, psychopathology, how to operationalize the construct—how to trans-
multicultural competence, or work values. We act as late from the hypothetical to the observable. For
if these are tangible features of an individual, similar example, given a well-articulated definition of
to their height, weight, eye color—but these attri- self-esteem, how would we infer an individual’s
butes are hypothetical constructs, something that we level of self-esteem? In psychology, these “observ-
believe to exist but which we cannot directly see. ables” are some samples of behavior. Items on a test
Measurement thus becomes a process of assigning serve as samples of behavior, and thus are a way to

210 m easurement an d as s es s men t

operationalize the construct in question. These medal awarded to the winner of a swim meet does
observations, an individual’s response to items, then not provide any information about the differences
need to be converted into numbers and combined among participants, simply that this particular
into scales. individual had a faster time than the second-place
The purpose of assigning numbers to observa- finisher. Other examples include a student’s rank
tions is to infer some quantity of an attribute, or to within her graduating class, or a client’s three-
determine whether individuals fall into the same or letter code on the Self-Directed Search. Some
different categories in terms of some attribute statistical tools have been developed to use with
(Nunnally & Bernstein, 1994). The characteristics rank-order scores, but one cannot perform any other
and rules of these numbers (or scales) themselves mathematical operation on them, such as adding or
vary, and are classified as four levels of measurement subtracting. The numbers in ordinal scales thus rep-
(Stevens, 1951, cited in Nunnally & Bernstein, resent meaning (as compared to nominal scales);
1994): nominal, ordinal, interval, or ratio. Each however, the number assigned to an individual may
successive type allows greater flexibility in what not reflect much about the measured attribute itself,
may be done with the numbers and the conclusions but rather only the relative standing of the individ-
that may be reached. ual compared to other individuals—or the relative
Nominal scales are the most basic, in which standing of a specific characteristic of that individ-
numbers are used to classify, name, or identify indi- ual compared to other characteristics of that same
viduals by groups to which they belong (Walsh & individual. As such, the numbers need to be inter-
Betz, 2001); a nominal scale contains rules for preted carefully. For example, knowing that a stu-
deciding whether two individuals are equivalent or dent is ranked fourth in her class does not say how
not equivalent (Nunnally & Bernstein, 1994) in well she performed in absolute terms, just how well
terms of sharing a critical property, for example, she performed relative to her classmates. Likewise,
they are both female. The numbers serve as labels, knowing that a client’s score on the work value of
do not have meaning in and of themselves, do not “security” is higher than his score on the value of
imply an order, and no mathematical operations “income” does not reveal information about the
(that is, addition, subtraction, multiplication, or absolute value of either of these constructs.
division) may be applied. Other examples are num- Interval scales define a specific unit of measure-
bers assigned to runners in a marathon, telephone ment, and presume that the distances between
numbers, or social security numbers: A runner numerical points are equal; for example, the differ-
with #23 does not possess less of a characteristic ence between 20° and 30° Fahrenheit is the same
than a runner with #40, and adding phone num- as the difference between 50° and 60° Fahrenheit.
bers together would not yield any useful informa- In addition to knowing the rank order of individu-
tion. Categorizing individuals via nominal scales als (evident with ordinal scales), interval scales
may lead to useful conclusions, but the numbers permit addition and subtraction, and therefore it is
used to represent group members are essentially possible to perform linear transformations. The
irrelevant to such a conclusion. For example, mathematical operation of division is not allowed
researchers may assign a numerical value to racial/ because it requires an exact known zero point, which
ethnic group membership during the coding phase cannot be assumed about interval-level scales. We
of data entry, but those numbers may be used only cannot say that 60°F is “twice as warm” as 30°F
for description via frequency distributions; using because there is no exact zero point (even though
them to compute an average is not meaningful (and there is an assigned zero point on the Fahrenheit
could be misleading). temperature scale). Because it is possible to add
With ordinal scales, numbers are assigned to or subtract interval scale numbers, it is also permis-
indicate rank or order from highest to lowest; an sible to compute means, standard deviations, and
ordinal scale contains rules for deciding whether correlation coefficients, thus allowing a description
one individual is greater than or less than another of distributions of numbers such as test scores. It
individual on some characteristic. Ordinal scales is also possible to translate raw scores into different
thus reflect the property of magnitude or “more- kinds of derived scores through linear transforma-
ness” (Kaplan & Saccuzzo, 2009), but not how tions. Numbers in interval scales thus allow far
much of that characteristic the individual possesses greater interpretation than nominal or ordinal
nor how much the two individuals differ in terms scales. For example, interval scale numbers may be
of the characteristic. For example, the first-place transformed into T scores (i.e., scores that have been

swanson 211
converted, so that the distribution has a mean of 50 of interest. Then, a large pool of potential items
and standard deviation of 10), so that they are more is developed that encompasses the full range of
readily interpreted by test users. Likewise, means and the defined construct, and this initial pool of items
standard deviations may be obtained from interval- is administered to a large sample, the “development
level data, providing useful summary information sample.” Next, the original item pool is refined
about scale or sample distributions. Furthermore, a through factor analysis, expert judgment, item
wide range of statistical analysis techniques may be analysis, and other considerations, and the revised
applied to interval-level scales. measure is administered to a new sample; this step
Finally, ratio scales also assume equal intervals may be repeated to further refine the focus of the
between numbers, but with the additional property test. The final step is to look for evidence of reli-
of having an exact zero point, a “rational” or true ability and validity, and develop norms. These steps,
zero rather than an arbitrary one, which reflects simplified here, can be very time consuming, and
a true absence of the characteristic (Nunnally & frequently measures that are developed for a partic-
Bernstein, 1994). Numbers derived on a ratio scale ular research purpose (vs. as a published test) entail
permit use of all mathematical operations, includ- abbreviated development and testing of the initial
ing multiplication and division, and so it is possible item pool, and do not carry out the final step related
to express relative numbers as ratios. Examples are to reliability, validity, and normative information.
height, weight, and volume: An individual who A commercially available published test, however,
weighs 200 pounds is twice as heavy as one who will include the information outlined in these steps.
weighs 100 pounds. Few psychological measure-
ments qualify as ratio-level scales; those that do are methods of constructing
expressed in physical units, such as galvanic skin psychological tests
response, electroencephalogram tracings, or response There are three primary methods of developing
time (Walsh & Betz, 2001). However, Nunnally psychological tests: rational/theoretical, empirical,
and Bernstein (1994) advised that ratio scales are and factor-analytic. The rational or theoretical
“rarely needed to address the most common needs approach assumes that item content directly reflects
of scaling . . . defining an interval is very important, the construct being measured, and so each item
but ordering is the most crucial concept” (Nunnally shows a logical relationship to the construct. The
& Bernstein, 1994, p. 18). process of test development thus evolves in a “ratio-
To summarize, consider the way in which num- nal” or logical manner: The construct is clearly and
bers are used in a horse race. Multiple numbers thoroughly defined, the test developer writes items
might be used with any specific horse: A number is that directly reflect the construct, item analysis is
assigned to the horse to distinguish it from other used to hone the measure, and, as a result, the scores
horses (nominal), the horse finishes the race in are directly interpretable—the name of the scale has
a specific place relative to other horses (ordinal), and led to the content of the items and thus guides
the track posts the elapsed time in the race (ratio): interpretation of an individual’s score (Walsh &
Horse #7 may be in second place with a time of Betz, 2001).
3 minutes and 25 seconds, representing three dif- The empirical approach to test construction uses
ferent uses of numbers. Level of measurement is a different starting point, a defined criterion group
crucial to understand because the level determines (this approach is also called the external criterion
which mathematical operations are permissible to method; Dawis, 1987). Items are chosen for a mea-
apply to the resultant numbers, and therefore, ulti- sure based on their ability to differentiate among
mately what can be done to the numbers to make groups of people that are hypothesized or shown
them useful to the consumer of assessment results to differ on the characteristic of interest; in other
(clients, counselors, researchers). words, the item’s ability to predict membership in
the criterion group. The actual content of the item
Test Construction plays a lesser (or no) role. Two examples are the
Development of a psychological test involves Minnesota Multiphasic Personality Inventory
applying the principles of measurement to a specific (MMPI-2) and the Occupational Scales of the
task. Test construction, when done well and thor- Strong Interest Inventory, both of which rely on
oughly, is a complex process with a number of itera- contrast groups to select items for scales. For exam-
tive steps (Dawis, 1987; Walsh & Betz, 2001). ple, the Architect scale on the Strong was developed
Briefly, the starting point is to define the construct by identifying a sample of architects, administering

212 m easurement an d as s es s men t

a set of items to them, comparing their responses best items from the initial pool of items or in sub-
to a general reference group, and then selecting sequent revisions, in term of each item’s reliability
the items that show substantial differences between and validity. Two item-analysis indices were devel-
the architects and the general group. These items oped in the context of achievement tests or other
are then assembled into a scale. Interpretation of tests with right–wrong answers: item difficulty and
empirically derived scales is not as straightforward item discrimination. An item’s difficulty refers to the
as rationally derived scales, since the content of the proportion of people who respond correctly (or in
items may have no obvious or logical connection a defined direction) to an item, and thus reflects
to the construct and are likely to be more heteroge- how easy or difficult an item is relative to other
neous. Interpretation of an individual’s score is best available items. Item difficulty is expressed as a pro-
conceptualized as degree of similarity to the crite- portion, or p value. An item that is answered cor-
rion group’s responses, rather than as level or amount rectly by only 20% of people ( p = .20) is considered
of the scale’s content. Although more difficult to much more difficult than an item that is answered
interpret, empirically derived scales can have great correctly by 90% of people ( p = .90). Once item
practical utility due to their ability to predict impor- difficulty values are determined, then the test devel-
tant criteria, which is one goal of psychological oper may choose items based on varying difficulty,
assessment (Hansen, 1999; Walsh & Betz, 2001). depending on the purpose of the test. Generally, test
Factor-analytic scale construction begins with items are chosen to represent an appropriate level of
a large pool of items and uses the statistical tech- difficulty for the group to whom it will be given,
nique of factor analysis to determine the “best” and to yield a wide distribution of scores, suggest-
items to include in the measure. This method is ing that items should be chosen across the range of
useful in developing a set of scales, each of which difficulty levels (Walsh & Betz, 2001). If all of the
is internally consistent and relatively independent items chosen have high p levels (the items are too
from the other scales. Factor analysis is used to easy), then a “ceiling” effect is likely to occur, in
identify dimensions underlying a set of data, in this which scores will be clustered at the high end of the
case, items. Items that show the highest loadings on distribution. Similarly, if all of the items chosen
each factor are chosen for a specific scale. have low p levels (the items are too hard), then a
These three primary methods of test construc- “floor” effect is likely to occur, in which scores
tion are not necessarily mutually exclusive, and a will be clustered at the low end of the distribution.
combination of methods may be used in the process In either case, the test will not distinguish among
of developing a psychological test. For example, individuals, thus providing little useful information
Jackson (1977, as cited in Hansen, 1999) described about individual differences.
the use of a sequential method, beginning with An item’s “difficulty” is most obvious in class-
a rational/theoretical approach to develop items room or achievement tests; however, the concept
for his interest inventory, followed by statistical is also useful to consider in attitude (or other trait)
methods to select items and refine scales. measures that do not have right–wrong answers.
In the case of an item with a 5-point Likert-type
item formats scale, ranging from “strongly disagree” to “strongly
Items on psychological tests take several different agree,” the item’s “difficulty” would be the mean
forms. Tests that measure cognitive ability or achieve- score across the sample (e.g., 3.75 on a 5-point
ment are most likely to be multiple-choice or true– scale). Recall that one of the fundamental pur-
false items. Most other psychological tests are poses of measurement is to quantify individual dif-
designed to measure constructs that are attitudes, ferences to use in decision making and prediction.
such as interests, values, or personality. Items could So, a measure that produces a restricted distribu-
be formatted so that the test taker indicates his or her tion of scores is less useful than one that produces
level of endorsement on a 5-point scale, or chooses a wide distribution of scores. For example, if all of
his or her most preferred statement from a pair or the items in a measure of self-esteem are strongly
trio of options, or rank orders a group of statements endorsed in one direction by most people, then the
or words (Dawis, 1987; Walsh & Betz, 2001). resultant measure will not provide any useful infor-
mation about individuals, and, thus, will not add
item analyses any new information to what is already known.
Item analysis is a crucial part of the process of devel- The second index computed during item analy-
oping a test, and is used to identify and select the sis is an item’s discrimination, defined as the extent

swanson 213
to which responses to any individual item are related in attitude surveys). Raw scores may be useful in
to the scores on the measure as a whole. If an item some situations, but typically they are converted to
is not related to the total score (or, worse, negatively a score that provides more information about an
related), then its relationship to the construct being individual’s standing. Norms thus provide a frame
measured is suspect. Item discrimination is related of reference in which to interpret an individual’s
to a test’s internal consistency reliability (to be dis- score, most frequently by comparing an individual’s
cussed later). An item’s discrimination index is typi- raw score to a reference group of people (Walsh &
cally calculated as the correlation between the item Betz, 2001).
and the total score (the item–total correlation), and Norms may be based on characteristics of indi-
the test developer will want to select those items viduals that change over time in predictable ways
with the highest levels of discrimination. (such as age- or grade-related norms) or character-
Test developers also examine interitem correla- istics that classify individuals (such as sex or occu-
tions, which are related to a test’s internal consis- pation). Several features of norms are crucial for
tency reliability. Each item should be correlated the test user to understand. First and foremost is
with every other item that is purported to measure whether the norms on which scores are based are
the same construct, and so the test developer is par- appropriate for the specific individual taking the
ticularly alert to negative correlations or low posi- test; some assessments cannot be scored without
tive correlations. If a measure contains two or more demographic information (such as age and sex)
subscales, measuring different constructs, then each about the test taker, so that the appropriate norm
item should be correlated with other items on the group may be applied. Age- or grade-related norms
same subscale, and not correlated with items on could provide substantially different results if the
other subscales. incorrect norm group is used.
The development of item response theory (IRT) Norms are developed by identifying an appro-
has brought new concepts to item analysis, specifi- priate, representative sample of individuals, the
cally, the use of item characteristic curves (ICC) to normative or standardization sample. Test developers
evaluate the suitability of different items for a test. should include a thorough description of the nor-
An ICC is a graph of the probability of answering mative sample in the manual for a published test.
an item correctly (or in a defined way) given differ- The normative sample must be clearly defined, and
ent levels of the underlying trait, thus providing determined on the basis of appropriateness for the
a picture of the item’s difficulty and how well it ultimate use of the test. For example, if a test will
discriminates among people at different trait levels, be used with college students, then the normative
independent of the specific sample or test used. sample must be representative of the population of
ICCs are important in adaptive testing, in which college students for whom the test will be used, in
test takers are given different sets of items depend- terms of factors such as age, sex, race/ethnicity, class
ing on their trait level, thus providing a more effi- standing, and the context of assessment. Several dif-
cient and precise way to measure a particular trait. ferent normative samples may be necessary to ade-
ICCs also can be used to evaluate item (or test) per- quately provide the appropriate frame of reference
formance for different groups through differential for test takers.
item functioning (DIF), and therefore can identify There are several possible ways to convert raw
potential bias in test items (Bolt & Rounds, 2000; scores to normed scores. Two of the most typical
McIntire & Miller, 2007). are percentiles and standard scores, both of which
rely on the distributions of scores within the norma-
test norms tive sample to provide an interpretive framework
Most psychological tests incorporate some type for individuals’ scores. Percentile scores refer to how
of norms, which provide information on which many people in a distribution fall below a specific
an individual’s performance may be compared, or score. For example, if 65% of people in the norma-
a way of “making meaning out of raw scores” tive sample obtained scores below 40, then a score
(Neukrug & Fawcett, 2006, p. 65). Raw scores of 40 is considered to be at the 65th percentile. This
are typically a straightforward summing of an indi- example demonstrates the utility of norms—
vidual’s responses, whether correct answers (such although there is no inherent meaning in a score of
as in classroom tests or ability measures), “keyed” 40 (what was the range of scores, and how does this
responses (such as in interest or personality mea- score fall within that range?), a percentile score of
sures), or level of agreement or endorsement (such as 65 provides more meaning (the individual’s score is

214 m easurement an d as s es s men t

in the top 35% of scores). Raw scores are trans- so that the mean of the distribution equals 0, and
formed to percentile scores by constructing a fre- scores range from -3.0 to +3.0. Thus, negative z
quency distribution of the raw scores in the original scores are below the mean, and positive z scores are
normative sample and determining, for each possible above the mean of the normative sample; a score of
raw score, the percentage of individuals who score at +1.0 is exactly 1 standard deviation above the mean,
or below that point, or the percentile equivalent. and so z-scores may be directly interpreted in terms
Percentiles are not the same as percentages. of the distance of a score from the mean in standard
A percentage is not a normed score, but rather is deviation units.
another way of communicating a raw score; for A disadvantage of z scores is the use of nega-
example, receiving 25 correct on a 50-item achieve- tive numbers, and of non–whole numbers, and so
ment test could be expressed as a 50% score. other forms of standard scores are frequently used.
However, that 50% correct could be equivalent to For example, T scores are commonly used in mea-
the 75th percentile (on a very difficult test) or a sures such as the Strong Interest Inventory and the
25th percentile (on a very easy test), or any other MMPI. T scores are an extension of z scores, where
percentile score, depending on how other people the mean has been set to 50 and the standard devi-
scored on the same test. ation to 10, by multiplying the z score by 10 and
One disadvantage of percentile scores is that they adding 50 (T = 10z + 50). The resultant scores are
are not interval-level data; in other words, the dif- more user-friendly to interpret. A general form of
ference between the 20th and 30th percentile may this formula can be used to derive any type of stan-
not be the same as the difference between the 70th dard score: The desired standard deviation is multi-
and 80th percentile, in terms of the raw scores plied by the z score and added to the desired mean.
underlying the percentile distribution. Percentile For example, consider SAT scores used in college
score differences in the center of the distribution admissions and GRE scores used in graduate school
usually reflect small differences in raw scores, admissions. Both use the formula 100z + 500 to
whereas percentile score differences at the extreme derive scores, so that the resultant mean is 500 and
ends of the distribution usually reflect large differ- the standard deviation is 100.
ences in raw scores. Although this is usually not a Considering these ways of calculating normed
major factor in using percentile scores, it is impor- scores highlights the critical nature of the normative
tant to keep in mind. sample itself. Yet, too often, test users neglect to
A second method of raw-score-to-normed-score thoroughly consider the normative sample underly-
conversion is via the use of standard scores. Standard ing clients’ test scores. Consider, for example, the
scores are the most common way of expressing different types of conclusions that might result if
normed scores, and there are actually a few differ- a high school freshman’s achievement test raw score
ent variations of standard scores. Like percentiles, was compared to ninth-grade norms versus twelfth-
standard scores also use the raw score distribution grade norms. In the former case, her raw score might
within the normative sample to provide an inter- convert to a 90th percentile score, whereas in the
pretive frame of reference for an individual’s score, latter case, the same raw score might convert to
in this case by expressing an individual’s score in a 65th percentile equivalent. Similarly, comparing
terms of its distance from the mean or average of a client’s score on an interest inventory to a same-
the distribution, using standard deviation units. sex rather than a combined-sex norm group may
Converting raw scores to standard scores uses a influence the type of career options suggested.
linear transformation of the form Y = AX + B, where As noted earlier, test developers may present multi-
A and B are constants based on the distribution of ple scores based on different normative samples
scores in the normative sample. Standard scores (such as same-sex and combined-sex groups), or
reflect the characteristics of the distribution of the national, state, or local norms (such as achievement
normative sample, allow a variety of transformations test results).
to suit the user, and can be directly interpreted as The discussion of normed scores thus far has
distance from the mean of the normative sample. focused on the information they convey about an
Calculating a z score is one form of standard individual’s score relative to other people in the norm
score. A raw score is converted to a z score by sub- group. Another advantage of normed scores is that
tracting it from the mean of the sample distribu- they allow other types of comparisons, within and
tion, and then dividing by the standard deviation across individuals. Results can be compared across
of the sample. In other words, z scores are calculated test-takers who take the same test but receive scores

swanson 215
based on different norm groups; for example, two a psychological characteristic, such as depression,
high school students in different grades could be then random fluctuation in the results, or, worse
compared using the percentile scores they received yet, no connection between the results and “true”
on the basis of the grade-appropriate norms. Similarly, depression, render the instrument unusable.
an individual could be compared at two different Unfortunately, however, determining the utility of
times on the basis of those grade-appropriate norms, an assessment instrument is more difficult than
such as a student who receives an 80th percentile determining the utility of a bathroom scale: Psycho-
score in a fifth-grade reading test (using fifth-grade logical constructs, unlike physical ones, are not
norms), and a 30th percentile score in sixth grade visible nor tangible. How do we determine the pres-
(using sixth-grade norms). Another useful compari- ence of depression?
son would be two scores for one person at a single
point in time, such as comparing the percentile scores measurement theory
for two subscales of the ACT score to determine rela- Many of the principles of measurement rely on
tive strengths across content areas. classical test theory, but more recent developments
In addition to norm-referenced test scores, which in measurement, particularly IRT, have influenced
compare an individual’s performance or standing the way that tests are developed and evaluated (Bolt
to a defined group of individuals, some tests are con- & Rounds, 2000; Embretson, 1996). Two other
sidered criterion-referenced tests. In contrast to norm- theories, domain sampling theory and generaliz-
referenced scores, criterion-referenced test scores ability theory, also contribute to an understanding
compare an individual’s performance to a predefined of a test’s reliability and validity.
level or standard. Examples are the test used for
licensure as a psychologist (the Examination for Classical Test Theory
Professional Practice in Psychology, EPPP), and Estimating reliability relies on classical test score
school-based testing under the No Child Left Behind theory, which describes what occurs when we
legislation. In each case, an individual receives a attempt to measure something unobservable. Essen-
score, but the ultimate outcome is that he or she tially, we assume that each person has a “true score”
either passes or fails, either meets or does not meet on the attribute in question, which is inferred from
the standard. the score obtained on a relevant measure—
or an individual’s “observed score.” Any imper-
Psychometric Characteristics fection in the measuring procedures leads to a
of Psychological Tests discrepancy between a person’s observed and true
An assessment instrument is only as good as its scores, referred to as measurement error. Classical
psychometric characteristics, most notably, its reli- test theory denotes this relationship as X = T + E,
ability and validity, and development of a test should where an individual’s observed score (X) is the
include plans to provide reliability and validity evi- sum of his or her true score (T) plus measurement
dence. Reliability refers to the dependability of mea- error (E). Thus, every observed score consists of two
surement: Will a test-taker get the same results components, true score and error. Error is assumed
across different forms and different times? Validity to be random, an assumption that is important to
refers to the utility of assessment, whether the test is methods of estimating reliability. If error is indeed
truly measuring what it claims to measure. A bath- random, then the accumulation of repeated mea-
room scale is reliable if it yields the same weight sures should converge on the true score. An indi-
when an individual steps on it five times in a row; vidual’s true score will not change with repeated
it is valid if the number displayed corresponds to measurements, whereas the random errors of mea-
one’s actual weight. The point of using a bathroom surement will vary.
scale is to determine one’s weight at any given time,
to compare weights of two family members, or to Item Response Theory
monitor changes in one’s weight over time. If the In contrast to classical test theory, IRT focuses on
number displayed fluctuates (within a short time the interaction between the individuals and test
interval), or if it does not correspond to “true” items, modeling people and items on the same
weight, then the scale loses its utility: It cannot be underlying or latent trait. The original applications
trusted to produce a meaningful number to use for of IRT were related to the latent trait of ability, but
the defined purpose of the scale. Similarly, if an now IRT models have been extended to include
instrument is designed to produce an assessment of personality and attitudes.

216 m easurement an d as s es s men t

 A major advantage of IRT models is computer- attribute of an assessment instrument, test developers
adaptive testing, in which a provisional score can should conduct studies related to reliability as they
be calculated after each item, and the next item to devise new inventories, and test publishers should
be administered is chosen from all remaining items clearly report reliability for test consumers to evalu-
so that it provides the most information about the ate.
test taker. The degree of precision also can be deter- Error is inevitable from a number of different
mined after each item. This method of administer- sources, and the objective in developing a reliable
ing test items is considerably more efficient in most test is to minimize the impact of error on test scores
cases, since test takers are not taking items that pro- (Walsh & Betz, 2001). Error includes effects due to
vide little information (i.e., are too easy or too dif- (1) time, such as fluctuations in test performance
ficult). Many achievement and aptitude tests are over time due to carryover or practice effects (which
now based on IRT models, including the Graduate are separate from change over time due to “real”
Record Exam (GRE), Law School Admissions Test change in the true score); (2) test content, in which
(LSAT), and the SAT (Bolt & Rounds, 2000; items selected do not adequately represent the
Tinsley, 2000). domain; (3) examiner or scorer error, through incor-
rect administration or scoring of the test, such
Domain Sampling Theory as giving too much time on the GRE or reading
In developing a test of a particular construct, it is the instructions incorrectly; (4) the situation in
useful to think of a hypothetical universe or domain which the testing occurs, including fluctuation in
of possible test items for that construct, from which environmental conditions such as noise, light, or
a random sample will be chosen for the test. This is temperature; and (5) examinee factors, such as sick-
the premise of domain sampling theory, and true ness, fatigue, or lack of motivation. Through the
score is conceptualized as the result if the entire test construction process, there are ways to reduce
domain of items could be administered (Nunnally error in testing and therefore make measures more
& Bernstein, 1994). A contribution of domain sam- reliable, including writing items clearly, making
pling theory is the idea that the larger the sample of instructions easy to understand, closely following
items selected for the test, the more likely that test instructions for administering tests, making rules
will represent the underlying true characteristic, so for subjective scoring as explicit as possible, and
that reliability increases as length of test increases. training raters (Nunnally & Bernstein, 1994; Walsh
& Betz, 2001).
Generalizability Theory
An extension of classical test theory, generalizabil- Estimating Reliability
ity theory analyzes multiple sources of error and Because there are different sources of error, many
allows an evaluation of random sampling error and factors contribute to an observed score differing
systematic error. Generalizability theory is useful from the true score. Consequently, there are several
in situations in which multiple judges evaluate different ways of estimating reliability, which reflect
a number of individuals on multiple dimensions these different sources of variation: test–retest, par-
(Bolt & Rounds, 2000; Hoyt & Melby, 1999; allel forms, split-half, and internal consistency.
Nunnally & Bernstein, 1994). Moreover, any given test could be described by more
than one type of reliability coefficient, which may
test reliability differ from one another and across different samples
Reliability is defined as “the degree to which test and conditions (Walsh & Betz, 2001).
scores are free from errors of measurement” (American Test–retest reliability reflects the consistency of
Educational Research Association, American results for the same measure given at two different
Psychological Association, National Council on times, and is most appropriate for characteristics
Measurement in Education [AERA, APA, NCME], that are not expected to change over time; it is fre-
1999, p. 180), or the “consistency or dependability quently referred to as the “coefficient of stability.”
of the measurement tool” (Bolt & Rounds, 2000, To calculate test–retest reliability, the same individ-
p. 156). Since all psychological measurement includes uals are administered the same measure at two dif-
error—the discrepancy between the measurement ferent times, separated by a time interval of typically
and the “true” score—then determining the accu- not less than 1 week. Scores on the first administra-
racy of a measure involves estimating how much tion are correlated with scores on the second admin-
error exists. Because reliability is such an important istration, and the resultant correlation coefficient

swanson 217
reflects the degree to which individuals in the group Split-half reliability is related to the alternate
receive similar scores relative to other individuals in forms version. Instead of developing two separate
the group. forms of a measure, split-half reliability is computed
An important consideration in evaluating test– by administering a measure in its entirety, then
retest reliability is the possibility of practice or splitting the items into two sets and correlating
carryover effects, which occur when the second the two scores that result. Like alternate forms
administration of a measure is influenced by the reliability, split-half reliability focuses on the error
first administration. These effects may overesti- associated with the content within an instrument,
mate the true reliability of a measure, particularly if and eliminates the error associated with the time
individuals are differentially affected by the amount interval in test–retest reliability. A primary consid-
of carryover effects. A related consideration is the eration with split-half reliability is determining
amount of time that elapses between the first and how best to divide the items into two halves: The
second administrations of a measure: Too short, goal is to end up with two equivalent halves, similar
and carryover effects will be more likely to occur; to the process of developing alternate forms of
too long, and other factors are likely to decrease a measure. Several approaches are used to divide
reliability, such as real change in the characteristic items, such as assigning the odd-numbered items
over time. to one set and the even-numbered items to another
Another important consideration in evaluating set, or using a random numbers table. Items should
test–retest reliability coefficients is whether they not be divided into first and second halves, because
are an appropriate indicator of reliability for the this would introduce error due to carryover effects
particular construct being measured. If the trait such as practice, fatigue, and motivation. The coef-
or characteristic itself is not expected to be stable ficient that results from correlating two halves of
over time—that is, if it is expected to change, a test, however, is essentially an estimate of the reli-
whether in a normal development progression ability of each half. Generally speaking, longer tests
or due to some type of intervention—then test– (with more items) are more reliable than shorter
retest reliability may not be appropriate. Test users tests (with fewer items), and so the initial split-half
should pay attention to the time interval associ- coefficient is likely to be an underestimate of the
ated with a reported test–retest reliability coeffi- reliability of the whole test. To adjust for this under-
cient, and evaluate the coefficient in light of the estimate, a calculation known as the Spearman-
elapsed time and the nature of the characteristic Brown formula is used to estimate the reliability for
being measured. the entire test.
Parallel forms or alternate forms reliability uses Internal consistency reliability may be considered
two different yet equivalent forms of a specific test a logical extension of alternate forms and split-half
to estimate reliability, assuming that items compris- reliability in that these two previous estimates of
ing the two forms have been carefully drawn from reliability are based on similarity between specifi-
the same larger domain defined by the construct. cally defined sets of items (Walsh & Betz, 2001).
The two forms may be given at the same time, which Internal consistency reliability reflects the degree to
eliminates some forms of error and therefore is con- which each item on a test is measuring the same
sidered a more rigorous form of reliability estima- thing as every other item on the same test, or a test’s
tion (Kaplan & Saccuzzo, 2009). This type of homogeneity. To determine a test’s internal consis-
reliability obviously requires development of two tency, the test is given once to a group of individu-
different forms of the same measure. The reliability als, and then the interitem consistency is calculated,
index is the correlation coefficient between the two most commonly via Cronbach’s coefficient α, or the
different forms given to the same group of individ- Kuder-Richardson-20 (KR-20) for dichotomous
uals. The forms must be as equivalent as possible, items.
including the same number and type of items, and Internal consistency reliability is the most fre-
the same level of difficulty (in the case of achieve- quently cited type of reliability, perhaps due to the
ment/ability tests). The two forms should be admin- relative ease of determining an index such as coeffi-
istered in counterbalanced order (i.e., half of the cient α: The test is given once in its entirety to one
sample receives Form A first, whereas the other half group of individuals, and the coefficient is easily
of the sample receives Form B first) to minimize the obtained via computer statistical packages such as
impact of carryover effects due to fatigue, decreased IBM’s SPSS statistical package. However, coefficient
attention or motivation, or practice. α is not always an appropriate estimate of reliability,

218 m easurement an d as s es s men t

particularly for broadly defined constructs, and the Reliability coefficients provided by test publishers
coefficient as a reflection of a measure’s unidimen- also must be evaluated in the context of the use of
sionality may be overstated (Cortina, 1993; Schmitt, the test: If the samples used to estimate reliability do
1996). not generalize to the individuals for whom the test
will be used, then it is advisable to carry out local
Evaluating Reliability Evidence reliability calculations (Hansen, 1999; Kaplan &
Evaluation of reliability evidence for any specific Saccuzzo, 2009).
test begins with a review of the purpose of the test What should a test developer or test user do if
and the nature of the construct that the test is a test evinces low reliability? At the test develop-
designed to measure. Each type of reliability esti- ment stage, reliability can be improved by adding
mate (test–retest, parallel forms, split-half, and more items and increasing the length of the test, or
internal consistency) rests on different assumptions by examining item analyses and eliminating items
about which sources of error are most important that are deflating reliability due to low interitem
to control, and so test users need to be aware of correlations, or dividing the items into multiple
the information conveyed by different reliability subscales. Test–retest reliability coefficients should
coefficients. be high, particularly over short time intervals; coef-
Reliability coefficients may be interpreted in ficients lower than expected raise questions about
several different ways (Hansen, 1999; Walsh & the construct, the measure, or both.
Betz, 2001). A coefficient can be interpreted as the
proportion of observed score variance that is “true” test validity
rather than “error” variance; for example, a reliabil- Validity refers to the “scientific utility of a measur-
ity coefficient of .85 could be interpreted as 85% ing instrument . . . in terms of how well it measures
of the variance due to true score and 15% due to what it purports to measure” (Nunnally & Bernstein,
error. This perspective is used in determining stan- 1994, p. 83). Three broad categories of validity
dard error of measurement (SEM), an index that are content validity, criterion-related validity, and
reflects the relative size of the error component for construct validity, although some authors have
an individual taking a given measure. The SEM pro- argued that all types of validity really boil down to
vides an estimate of how close an individual’s construct validity (Messick, 1995; Nunnally &
observed score is to his or her true score. The for- Bernstein, 1994).
mula incorporates a test’s reliability coefficient, plus Establishing validity for a measure is based
the standard deviation (or spread) of scores on the on empirical evidence, which is accumulated and
test, and reliability is inversely related to the stan- replicated over a variety of investigations and cir-
dard error of measurement: The higher the reliabil- cumstances. Furthermore, a measure itself is not
ity coefficient, the smaller the SEM, and thus, the “validated”; rather, the use of a measure is validated.
more confidence that can be placed in an individu- Validity is “not an inherent property of the test itself,
al’s observed score as being close to his or her true but rather with respect to a particular interpretation
score. Calculating the SEM also provides a way to or use of the test” (Bolt & Rounds, 2000, p. 161).
construct a confidence interval around an individu-
al’s test score, thus indicating the probability that Content Validity
the true score is within a certain range around the Content validity refers to how well the specific
observed score. The smaller the SEM (and, the sample of items represents the entire domain
higher the reliability), the tighter the confidence of interest and is often viewed as an essential first
interval around the observed score. step in establishing the validity of a measure (Walsh
How reliable is reliable? It depends on the & Betz, 2001). In developing a test, one can think of
construct being measured, the characteristics of the a universe of possible items from which to sample
test itself, and the planned use of the test. Very high to assess a particular attribute. Again, it is crucial
reliability would be expected for a test that is very to carefully define the construct of interest before
narrow in focus; measures of complex constructs the universe of content can be defined. This is most
may not appear as reliable. If a test is being used obvious when discussing an achievement test over
to make major decisions about people’s lives, the a particular topic (e.g., calculus), but is important
test ought to be very reliable. The SEM can be in the construction of any measure. Evidence to
extremely useful when looking at one person’s score, support content validity may be achieved directly
particularly in relation to an important decision. by including expert judges’ ratings of content during

swanson 219
test development, as well as indirectly through a construct thought to be unrelated to depression,
evidence of internal consistency reliability, which such as attachment style (discriminant). Convergent
indicates that each item measures the same domain and discriminant validity are important to keep in
as other items (although it does not directly demon- mind because of our tendency to focus on conver-
strate validity). gent validity in determining content, criterion-
related, and construct validity, but it is important
Criterion-related Validity to also provide evidence of discriminant validity.
Criterion-related validity refers to the extent to If a new measure is too strongly related to some-
which a measure of a specific attribute is associated thing that it should not be, then doubt is cast on the
with some external or independent indicator (the measure.
“criterion”) of the same attribute; for example, Campbell and Fiske (1959) developed a method
whether a measure of depression correlates with an of examining the convergent and discriminant
independent diagnosis of depression. Criterion- evidence, using a matrix that combines multiple
related validity takes two forms that vary in terms measures of the same construct and of different con-
of the temporal relationship of the measure and structs. They also discussed the concept of method
the criterion. If the predictive measure and the cri- variance, a form of error that introduces a spurious
terion occur at the same time, then we speak of con- relationship between two measures existing solely
current validity, such as in the example related to because of the way in which the information is
depression. If the criterion occurs some time after obtained. Method variance artificially inflates the
the predictive measure, then we speak of predictive observed correlation between two measures, thus
validity, such as if a measure of depression is corre- overestimating convergent validity and underesti-
lated with a diagnosis obtained 3 months later. mating discriminant validity. Two different ways of
Evidence to support criterion-related validity measuring the same construct should yield higher
typically is either correlational evidence between correlations than the same way of measuring two
the predictor measure and a criterion variable, or different constructs. For example, a student’s career
observed differences among criterion groups. In the certainty assessed via a self-report paper-and-pencil
example of depression, correlational support might measure should be more highly correlated with an
come from clients’ ratings of their behavior, and advisor’s rating of the student’s certainty than it is
group-difference support could come from average with a self-report measure of anxiety.
test scores obtained from two groups on the basis of To disentangle the effects of method variance,
their diagnoses. Campbell and Fiske (1959) devised a multitrait-
multimethod matrix, which compares correlations
Construct Validity between measures of at least two different attri-
Construct validation is the “process of gathering butes measured in at least two different ways. The
data to support our contention that this test . . . is matrix is constructed with three different types of
actually a reflection of the construct or attribute it is coefficients—reliability coefficients (same construct
designed to reflect” (Walsh & Betz, p. 64). A sys- using same type of measurement), convergent
tematic investigation of the construct validity of validity coefficients (same construct using different
a measure must occur within the broader nomologi- types of measurement), and discriminant validity
cal network (Cronbach & Meehl, 1955) and involve coefficients (different constructs using the same type
a clear specification of the range of expected “observ- of measurement, and different constructs using dif-
ables” related to the construct, how these observ- ferent types of measurement). Test validity is sup-
ables measure the same or different things, and ported when the convergent validity coefficients are
examine how a measure correlates with similar or higher than discriminant validity coefficients.
different measures (Nunnally & Bernstein, 1994). Although Campbell and Fiske’s (1959) method of
Evidence in support of construct validity takes comparison relied on visual inspection of the coeffi-
many forms and is ideally focused on both conver- cients, more recent methods involve the use of con-
gent and discriminant evidence, or the relation of a firmatory factor analysis to evaluate the coefficients.
measure to other measures that should, and should
not, be related. For example, a new measure of Other Aspects of Validity
depression would be expected to be strongly corre- Before investing a substantial amount of time and
lated with an existing measure of depression (con- money in developing an assessment instrument, it
vergent) but weakly correlated with a measure of is important to determine whether the test adds

220 m easurement an d as s es s men t

enough information to justify the expense. Sechrest Exploration validity is a recent concept related
(1963) referred to this as incremental validity: Does to test construction and validation, and, like face
the test improve the accuracy of a prediction or validity, is not a standard form of validity. Explo-
decision that would be made without the test? ration validity has been discussed most extensively
Incremental validity does not necessarily correspond within vocational assessment, and refers to the
to the test’s validity per se, but must be considered “power” of an inventory to stimulate an individual
in the context of other methods of prediction. to pursue additional career exploration activities
Incremental validity is related to the base rate of after receiving test results (Randahl, Hansen, &
an event (Meehl & Rosen, 1955, cited in Walsh & Haverkamp, 1993). Similarly, Messick (1995) pro-
Betz, 2001), which refers to the proportion of posed the idea of consequential validity, or the
people who are expected to be in a certain cate- intended and unintended consequences of test use.
gory. If 80% of any and all students who begin Messick argued that validity is a feature of a test
college successfully finish their freshman year, then interpretation rather than of the test itself, and so
selection of any specific student to admit to college emphasized the importance of examining the actions
will be correct 80% of the time (if the defined that are based on test use. Finally, Walsh and Betz
outcome is measured as completion of freshman (2001) discuss interpretive validity, or the premise
year). If the base rate of an event is already high, that the test results and interpretation are presented
then adding the use of a test for selection will in a useful and valid manner.
not improve the accuracy of prediction by very
much. If, on the other hand, the base rate of Evaluating Validity Evidence
an event is low—say only 20% of the general popu- The process of validating a measure is ongoing; it
lation would complete freshman year—then a selec- is not possible to say that a test has a specific amount
tion tool could substantially improve the accuracy of validity, or that it has been “validated.” As Fouad
of predicting which students to admit. Thus, incre- (1999) noted, “counselors cannot merely look up
mental validity is the “extent to which a test can the validity coefficients of an inventory in a test
improve the accuracy of prediction beyond that manual . . . counselors need to know what evidence
possible by simply using base-rate data” (Walsh & is available about the validity of an instrument for
Betz, p. 69). particular populations, for particular settings, and
Another term used in the context of validity is at a particular time” (p. 193).
“face validity,” or whether the test appears to mea- Validity evidence may be found in varied
sure what it is designed to measure. Face validity is places. Unlike reliability, which is typically clearly
not considered a type of validity, and demonstrat- labeled in journal articles, validity evidence may
ing face validity is not a requirement for a test to be be less obvious. Because validity evidence is con-
judged as valid. However, face validity is useful to tinually accruing, it may be found in any subse-
consider as it relates to the perceptions of the test quent study that uses a measure. For example, a new
taker or to the general public. If a test does not measure developed to assess career adaptability may
appear to be measuring what the test taker believes be accompanied by adequate details regarding its
it does, then this may become an additional source development, reliability information, and some ini-
of error variance in the test-taking process. For tial concurrent or construct validity. However, any
example, if a student arrives to take a specialized subsequent study that uses the scale has potential
graduate school admissions test to be admitted to implications for the validity of the measure, such as
a doctoral program in psychology (such as the GRE) results among groups that would be expected given
and finds items related to American history, he or the definition of career adaptability, or correlations
she may question the relevance of the test—and with other measures of related and unrelated con-
may be upset or annoyed enough to not do as well structs, or changes in test scores due to relevant
as he or she could otherwise. The test may have interventions. Any of these results may contribute
a high degree of predictive validity (that is, students to validity evidence for a measure.
with high scores on the American history test A final comment about the psychometric char-
do well in psychology doctoral study), but the test acteristics of a test pertains to the relationship
itself does not have face validity. Lack of face valid- between reliability and validity. A perfectly reliable
ity thus affects test takers, but also may influence test may not be valid; conversely, a test cannot
administrators who decide whether or not to use be valid if it is not reliable. If a new test designed
tests for a specific purpose. to measure extroversion has excellent test–retest

swanson 221
reliability over a 2-week period and high internal directions within the two specialties. Clinical psy-
consistency reliability, it might be judged to be chologists are more likely to do formal compre-
a reliable measure. However, if scores on the test hensive assessment apart from treatment, usually
do not relate to other measures of extroversion, or before treatment commences, and assessment may
are not useful predictors of relevant behavior, then constitute a substantial part of a practitioner’s pro-
the measure has little utility: It may be reliable but fessional activity. Counseling psychologists, on the
not valid. On the other hand, if the same test does other hand, are more likely to conduct briefer
predict useful behavior, but it does not measure forms of assessment, integrate assessment into ther-
the construct consistently at different times, then it apy, and approach assessment from a compensatory
also has little utility: It cannot be valid if it is not and strengths-based perspective (Campbell, 2000;
reliable. Said another way, reliability sets an upper Dawis, 1992; Duckworth, 1990). Training in clini-
limit on validity. Thus, test developers and test users cal psychology is more likely to include assessment
need to pay attention to both reliability and validity, of children and neuropsychological assessment, and
and how they relate to one another. training in counseling psychology is more likely to
include vocational assessment (Agresti, 1992; Cobb
Testing and Assessment in et al., 2004; Larson & Agresti, 1992; May & Scott,
Counseling Psychology 1991; Ryan, Lopez, & Lichtenberg, 1999).
Assessment has long held a central role in profes- In spite of the aforementioned divergences, the
sional psychology (Camara, Nathan, & Puente, specialties of counseling psychology and clinical psy-
2000), although its implementation differs among chology actually do share many common features,
specialty areas, due in part to the disparate histor- and their gradual convergence has created new oppor-
ical roots of the specialties early in the 20th cen- tunities and practice settings for both counseling and
tury. Clinical psychology as a discipline emerged clinical psychologists, and differences in the use of
from the mental health movement and psychoana- tests and assessment may be lessening. Discussions of
lytic psychology, and has placed a continuing merging the training of the two specialties have been
emphasis on psychopathology and the assessment ongoing, with recent calls for combined or integrated
of intellectual and personality functioning (Cobb doctoral training (Cobb et al., 2004).
et al., 2004; Morgan & Cohen, 2008). Counsel-
ing psychology, on the other hand, emerged from Models of Assessment in
the vocational guidance movement, developed in Counseling Psychology
the environment of educational institutions, and The current practice of assessment in counseling
has placed a continuing emphasis on assessment psychology varies widely, from the traditional use
of career and developmental concerns in well- of testing as an integrated part of career counsel-
functioning individuals. ing, in which clients frequently expect to partici-
These traditional differences between the two pate in testing, to full-scale evaluation in medical
specialties remain in terms of training, students’ or forensic settings, with specific referral questions
career aspirations, internship placements, and even- that are addressed in written reports to relevant
tual work settings: Counseling psychology trainees parties.
and professionals are more likely to be found in uni- The unique aspects of counseling psycholo-
versity counseling centers, whereas those in clinical gy’s approach to the use of testing were outlined
psychology are more likely to be found in medical 20 years ago by Duckworth (1990); in contrast to
settings (Cassin, Singer, Dobson, & Altmaier, 2007; other applied specialties, counseling psychologists
Morgan & Cohen, 2008; Neimeyer, Bowman, & tend to use testing to enhance short-term therapy,
Stewart, 2001; Neimeyer, Rice, & Keilin, 2009). focus on developmental issues, facilitate problem
Furthermore, differences between the two specialties solving, assist with decision making, and, provide
are exhibited in choice of theoretical orientations: psychoeducational opportunities for clients. She
Counseling psychology trainees are more likely to further described the “counseling psychological
indicate interpersonal and humanistic/existential approach” to testing, in which testing is done for the
orientations and less likely to indicate cognitive- benefit of the client and the therapist, testing is
behavioral, behavioral, and biological orientations, than done to generate information for both the client
are clinical psychology trainees (Cassin et al., 2007). and counselor, the client needs to be an active par-
Because of the differing historical roots, the roles ticipant, the client is assumed to be able to profit
and practices of assessment have evolved in different from the testing process, testing should focus on

222 m easurement an d as s es s men t

both strengths and weaknesses, the test taker is more psychology of individual differences, and a major
likely to be “normal,” clients are capable of change, contribution of this approach was the technology
vocational tests are important part of assessment, for client assessment and the individual differences
and the goal of testing is empowerment of the test point of view in assessment (Dawis, 1992). This is
taker (Duckworth, 1990). particularly evident in the earliest uses of assess-
Duckworth’s observations still hold today, per- ment in counseling psychology, namely, in the
haps most noticeably in testing and assessment vocational/career realm. As counseling psychology
conducted as part of career counseling. It could expanded its scope, the range of tests and assess-
be argued that there are now two different models ment used also expanded.
of assessment within the specialty of counseling The traditional model encompasses an image
psychology, one that focuses on the use of tests in of a psychologist working in a collaborative rela-
counseling with career and/or “normal” develop- tionship with an “intact” client who can engage in
mental adjustment as its primary focus (a “tradi- and benefit from assessment. This model, in its
tional” model), and one that focuses on what might current form, allows more flexibility in the range
be considered a clinical psychology application of of acceptable assessment methods. For example,
assessment (a “diagnostic” model). In fact, for the Hartung (2005) discussed a merging of quantita-
purpose of the present chapter, it is useful to con- tive and qualitative methods of obtaining informa-
sider assessment used within the context of career tion, proposing such an approach as an “optimum
or developmentally-oriented counseling as funda- approach to career assessment and counseling”
mentally different from assessment outside of such (p. 378), and Walsh (2001) echoed the need to
a context. It seems misleading to classify career go beyond traditional assessment to consider “idio-
assessment together with other types of assessment, graphic, qualitative, and other creative approaches
because the goals, procedures, and outcomes differ to assessing multiple aspects of both people and the
substantially. For example, Duckworth’s (1990) contexts” (p. 271).
depiction of the client as an active part of testing Moreover, discussion of how to integrate assess-
decisions, and the client and counselor as being ment into counseling occurs primarily within the
equal beneficiaries of testing outcomes is very appar- realm of career counseling, because nowhere else
ent in the use of career assessment, more so than in is it as central to the role and purpose of counsel-
other areas. If a client comes to therapy to deal with ing. This is not to succumb to the “career-counseling-
depression, assessment may be used but will not be as-testing” mindset warned by Hartung (2005), in
a primary focus as it is in career counseling. which testing is viewed as the equivalent of coun-
Dividing the use of assessment in counseling seling; rather, it highlights the level of skill neces-
psychology into two models is not intended to fur- sary to effectively integrate test and nontest sources
ther any schism between “career” and “personal” (or of information in a way that is maximally effective
noncareer) counseling (Swanson, 2002). Rather, for clients’ goals (Tinsley & Bradley, 1986).
discussion of two models allows a more precise
consideration of how assessment is implemented a “contemporary”
within different professional settings in which coun- psychodiagnostic model
seling psychologists find themselves. The further As counseling psychologists share professional
that counseling psychology has expanded the scope activities and work environments with clinical psy-
of its professional activities, the more that the model chologists, their methods and uses of assessment
of assessment has diverged into two forms, one of will continue to converge, as reflected in this con-
which resembles the way in which clinical psycholo- temporary psychodiagnostic model. In this view,
gists do assessment. Previous writing about assess- appropriate uses of assessment are to describe cur-
ment within counseling psychology has focused on rent functioning, confirm or disconfirm impressions
career assessment, or assessment in general, but formed through other sources of information, iden-
rarely both, perhaps because of the differing models tify therapeutic goals, highlight issues likely to
that underlie assessment. emerge in treatment, recommend forms of inter-
vention, offer prognoses, assist in differential diag-
the “traditional” career/ nosis, evaluate success of interventions, identify
developmental model emerging therapeutic issues, and provide feedback
As described at the beginning of this chapter, coun- as a therapeutic intervention in itself (Meyer et al.,
seling psychology was heavily influenced by the 2001, p. 129).

swanson 223
 An advantage of considering this model of assess- cover a range of assessment formats, including
ment is that it clearly acknowledges the degree of structured or “formal” assessment, qualitative or
overlap in training, professional activities, and work informal assessment, interviews, and structured
settings for professional psychologists, regardless of interviews, as well as the role of examiner and exam-
the choice of specialty. In other words, the coun- inee. Because many tests are available, and because
seling and clinical psychology distinction is less in-depth assessment information and training is
evident in the noncareer side of counseling. beyond the scope of the present chapter, the presen-
Conceptualizing two models of assessment tation here will be cursory.
within counseling psychology may assist with fur-
ther discussion of the types of assessment and their Career/Vocational Testing
uses. It should be acknowledged, however, that this Vocational testing has long been the bailiwick of
obscures a wide segment of assessment that occurs counseling psychologists, although other applied
somewhere in between the two models, particularly specialties such as industrial/organizational psy-
because of the demonstrated specialty differences in chologists, school psychologists, and clinical psy-
theoretical orientations and work settings noted ear- chologists also may use such testing. The most
lier, which undoubtedly affect assessment practice. typical venue for using career assessment is in
the context of career counseling, as well as in edu-
Types of Assessment cational or other group interventions. By far, the
It may be helpful to revisit the distinction between most common type of vocational testing is assess-
testing and assessment. Psychological testing has ment of interests, such as with the Strong Interest
been defined as a “relatively straightforward process Inventory, the Self-Directed Search, or the Kuder
wherein a particular scale is administered to obtain (Hansen, 2005). The construct of values also is fre-
a specific score, [to which] a descriptive meaning quently assessed with instruments such as the
can be applied . . . on the basis of normative, nomo- Minnesota Importance Questionnaire (MIQ) or
thetic findings” (Meyer et al., 2001, p. 143). Super’s Work Values Inventory (Rounds &
Psychological assessment, in contrast, “is concerned Armstrong, 2005). Ability assessment may occur via
with the clinician who takes a variety of test scores, objective measures such as the Armed Services
generally obtained from multiple test methods, and Vocational Aptitude Battery (ASVAB) or the
considers the data in the context of history, referral O∗NET Ability Profiler (Ryan Krane & Tirre,
information, and observed behavior to understand 2005), although self-estimates of abilities are more
the person being evaluated, to answer the referral commonly used, such as the Kuder Skills Assess-
questions, and then to communicate findings to ment and ACT’s Inventory of Work-Relevant
the patient, his or her significant others, and refer- Abilities. Other constructs, such as self-efficacy,
ral sources” (Meyer et al., 2001, p. 143). To illus- career adaptability, and career indecision, have
trate, Meyer et al. (2001) distinguished between gained attention in the past few decades (Swanson
the nomothetic meaning in testing and the idio- & D’Achiardi, 2005). Career assessment is most
graphic nature of assessment, in which the same amenable to the recommendations of Duckworth
score on an intelligence test subscale may have very (1990), regarding the involvement of the client in
different meanings: The nomothetic interpretation all aspects of assessment. Moreover, assessment is
is that the client possesses “average” skills, whereas perhaps best considered as an intervention in and
the idiographic interpretation is of change, such as of itself within career counseling, and qualitative
decline after a head injury or improvement during methods of assessment have grown in popularity of
rehabilitation. use. For example, card sorts are frequently used
A further reminder from the discussion of test- during career counseling sessions as a tool to discuss
ing versus assessment is that tests are used in the a client’s interests, values, or skills (Swanson &
assessment process, but not all assessment proce- Fouad, 2010).
dures are tests. “Assessment” covers a variety of tech-
niques and procedures; thus far, the focus has been assessment of cognitive ability:
on “tests,” but there are other methods of assess- intelligence/aptitude/achievement
ment as well. Aptitude is defined as the capacity to learn, and
This section includes an overview of several dif- aptitude measures include a wide range of expe-
ferent categories of assessment, according to the riences and content, and typically are devel-
construct that is being assessed. These categories oped with criterion-related validity as a key goal

224 m easurement an d as s es s men t

(Kaplan & Saccuzzo, 2009). These tests are used damage within the brain, to determine the causes
to predict one’s ability to profit from or be success- or correlates of change, to assess changes over time
ful in some future situation. Tests of scholastic apti- and develop a prognosis, to determine the cause
tude include the ACT, SAT, the general tests of the and progression of a disease, and to determine
GRE, and Miller Analogies Test (MAT), as well as whether rehabilitation is occurring. Results of neu-
test batteries that measure multiple aptitudes, such ropsychological assessment can offer guidelines
as the General Aptitude Test Battery (GATB), for rehabilitation and education, for medical pro-
Differential Aptitude Test (DAT), and the ASVAB. fessionals and family members. Full neuropsycho-
Achievement refers to what has already been logical batteries, such as the Halstead-Reitan
learned, usually in a known or controlled set of Neuropsychological Battery (HRB) and the Luria-
experiences, and measures of achievement are Nebraska Neuropsychological Battery, require sub-
developed via strong content validation procedures stantial training to administer and interpret.
with clearly defined domains of content (Kaplan In many situations, a suitable alternative to a full
& Saccuzzo, 2009). Achievement tests are designed battery is to use a brief neuropsychological screen-
to assess what an individual has mastered (in con- ing, such as the Bender Visual-Motor Gestalt Test.
trast to intelligence tests, which measure ability
or capability). Commonly used tests include the personality assessment
Wide Range Achievement Test (WRAT-4) and the Psychologists have been interested in personality
Wechsler Individual Achievement Test (WIAT-II), assessment since early in the history of psychologi-
the advanced subject area tests of the GRE, and the cal assessment. Personality is typically considered
Medical College Admissions Test (MCAT). as the “relatively stable and distinctive patterns
Intelligence is typically thought of as general of behavior that characterize an individual and his
intellectual ability, although different theoretical or her reactions to the environment” (Kaplan &
perspectives have been proposed, and the concept of Saccuzzo, 2009, p. 334), although there are many
“intelligence” has been debated since Binet’s first different ways of measuring personality. Personality
test. Intelligence is typically measured via individ- assessment has developed according to several dif-
ual tests administered one-on-one by a trained ferent paradigms, depending on the theoretical view
assessor, such as the Wechsler tests: the Wechsler of the components and structure of personality
Adult Intelligence Scale (WAIS-III), the Wechsler (Wiggins, 2003), with psychodynamic, interper-
Intelligence Scale for Children (WISC-IV), and the sonal, multivariate, and empirical paradigms pro-
Wechsler Preschool and Primary Scale of Intelli- ducing the most commonly used measures.
gence (WPPSI-III). Similarly, the Stanford-Binet is Personality tests are classified as objective or
individually administered; the test consists of one projective. Objective tests are similar to other types
form that extends over the entire lifespan. Other of psychological tests, with a set of items to which
tests of intelligence include the Kaufman Assessment clients respond, from which quantitative, normed
Battery for Children (KABC-II) and the Kaufman scores are derived. The most common objective tests
Brief Intelligence Test (KBIT-II), and the Woodcock- of personality are the MMPI-2, the Personality
Johnson (Anastasi & Urbina, 1997; Goldfinger & Assessment Inventory (PAI), the Millon Clinical
Pomerantz, 2010). Multiaxial Inventory (MCMI-III), the California
Psychological Inventory (CPI-III), the 16PF, and
neuropsychological assessment the NEO Personality Inventory (NEO-PI). These
Neuropsychological assessment has historically inventories yield scores on a set of scales, the con-
been performed primarily by clinical psychologists, tent of which varies across the inventories according
but counseling psychologists are increasingly to the paradigm underlying the measure.
involved in this type of assessment (Larson & In projective tests, an individual responds to
Agresti, 1992; Ryan, Lopez, & Lichtenberg, 1999). some type of ambiguous or unstructured stimuli,
Neuropsychological assessment is used to identify and the responses are assumed to reveal something
cognitive dysfunction or brain damage, and serves about his or her personality. Scoring and interpreta-
a number of different purposes (Hebben & Milberg, tion of projective personality tests are less standard-
2002). A primary function is to describe and iden- ized than for objective tests, although scoring
tify changes in psychological functioning, in terms protocols have been developed to increase the reli-
of cognition, affect, and/or behavior. Relatedly, it ability and validity of these measures. The most
is used to determine the extent and location of common projective tests are the Rorschach Inkblot

swanson 225
Method, the Thematic Apperception Test (TAT), (EDI-3) are self-report measures that target specific
the Rotter Incomplete Sentences Blank, and the symptoms or problems (Goldfinger & Pomerantz,
Kinetic Family Drawing (Goldfinger & Pomerantz, 2010).
2010). Despite controversy surrounding the use of
projective tests, they are among the most extensively behavioral assessment
used tests (Camara, Nathan, & Puente, 2000; Behavioral or cognitive-behavioral assessment is
Groth-Marnat, 1999). particularly useful in identifying problematic behav-
ior, the context in which it occurs, and a treatment
diagnostic assessment and plan for modifying the behavior. The goal of the
intervention planning assessment, then, is not so much to understand
As noted earlier, intervention/treatment planning causes of the behavior, but to identify specific con-
is one of the primary purposes of assessment (Meyer ditions in which the behavior occurs. According
et al., 2001), particularly in the psychodiagnostic to Kaplan and Saccuzzo (2009), several important
model of assessment. The increasing role of man- differences exist between “traditional” and behav-
aged care has put pressure on psychologists to pro- ioral assessment: the target and goal of the assess-
vide more efficacious services, and to justify the ment (underlying cause vs. disordered behavior),
services that they do provide (Antony & Barlow, the importance of specifying symptoms (superficial
2002). The link between assessment and inter- vs. focus of treatment), assessment (indirectly vs.
ventions is particularly evident in empirically sup- directly related to treatment), and theory (medical
ported treatments, in which specific diagnoses lead model vs. behavioral model). An important compo-
to specific interventions. Spengler, Strohmer, Dixon, nent of behavioral assessment is to determine
and Shivy (1995), with elaboration by Meier (1999), whether the problem behavior is an excess or a defi-
presented a model linking conceptualization, assess- cit; in other words, whether the goal is to decrease
ment, intervention, and analysis of intervention or increase a specific behavior. Some measures have
effects in a reciprocal feedback loop. been developed for specific problem behaviors,
Brief screening assessments are frequently used including the Fear Survey Schedule, the Irrational
as part of intake procedures in university counsel- Beliefs Test, and the Assertive Behavior Survey
ing center, community mental health agencies, and Schedule.
primary care settings (Bufka, Crawford, & Levitt,
2002) and include measures such as the PAI. assessment/diagnostic interviews
In addition to broad screening measures, diagnos- Interviews can serve as valuable assessment tools
tic measures are designed to identify problems in and are used for the purposes of diagnosis and treat-
specific areas, such as eating disorders, attention ment planning. Interviews take many different
deficit disorders, depression, anxiety, or suicidality. forms, such as intake interviews, diagnostic inter-
Frequently, cutoff scores are used to determine views, mental status exams, crisis interviews, and
diagnosis, such as on the Beck Depression Inven- assessment interviews. Interviews also may be con-
tory (BDI), in which specific score ranges are ducted not only with the client, but also with par-
associated with diagnoses of “minimal,” “mild,” or ents, guardians, and other collateral informants
“moderate” depression. (Goldfinger & Pomerantz, 2010; Groth-Marnat,
1999). Similar to tests, interviews are a method for
symptom and behavior checklists gathering data, are used to make predictions, are
Checklists differ in format from other types of evaluated in terms of reliability and validity, can be
assessment in that they consist of a list of prob- group or individual, can be structured or unstruc-
lems, behaviors, or symptoms, and test-takers indi- tured, and have a defined purpose (Kaplan &
cate those that apply to them. Checklists may Saccuzzo, 2009).
be comprehensive or targeted to a few areas of In some sense, all therapeutic sessions could be
behavior, they may be used as screening devices, and considered assessment or diagnostic interviews, in
they may be completed by people other than the that the therapist is continually gathering infor-
client, such as by parents or teachers. The Symptom mation for use in making predictions about
Checklist-90 (SCL-90-R) and the Child Behav- in-session or later behavior. The use of standardized
ior Checklist (CBCL) are two examples of broad- or structured clinical interviews as a form of assess-
based checklists. The BDI-II, Beck Anxiety ment has grown substantially in the past several
Inventory (BAI), and Eating Disorder Inventory decades (Kaplan & Saccuzzo, 2009; Summerfeldt

226 m easurement an d as s es s men t

& Antony, 2002). Structured interviews include of issues arise regarding Internet-based assessment,
a specific set of questions presented in a particular some of which could not (and cannot) be antici-
order, with administrative procedures to ensure pated, as technology and popular culture change
standardization. Many structured interviews also and evolve in unpredictable ways. Assessment on
have scoring procedures with norms. One com- the Internet ranges from traditional tests converted
monly used structured interview protocol is the to web-based platforms to the equivalent of a maga-
Structured Clinical Interview (SCID), originally zine quiz, and vary in terms of their content, qual-
developed for the Diagnostic and Statistical Manual, ity, and function (Buchanan, 2002).
Third Edition, Revised (DSM-III-R) and subse- The APA Task Force on Psychological Testing
quently revised for the DSM-IV. on the Internet (Naglieri et al., 2004) provided
Like standardized tests, structured interviews a useful overview of pertinent issues. They noted
have important psychometric features to be consid- advantages of Internet testing, such as accessibility
ered. In the case of diagnostic interviews, reliability for clients in rural settings, those without transpor-
refers to consistency or replicability of measurement tation or with physical limitations; greater accuracy
and stability of diagnostic outcomes (Summerfeldt in scoring and suitability for using IRT models;
& Antony, 2002): Essentially, do the same diagno- and assessing abilities or skills not easily assessed
ses result from multiple psychologists using the via paper-and-pencil tests (e.g., musical aptitude).
interview protocol? The reliability of a diagnostic Several key problems include (a) ensuring test–
interview is most frequently evaluated via inter- client integrity (is the client the person actually
rater reliability, in which two or more independent taking the test?), which increases in importance
evaluators rate identical interview material. A statis- when the goals of test taker differ from the goals of
tic called Cohen’s κ is used to quantify the degree test user, such as with employment testing; (b) test
of agreement between two raters; κ can range security, in terms of access to client information,
from -1.00 (perfect disagreement) to +1.00 (perfect test scores, and test materials, such as preventing
agreement), with 0 indicating agreement equivalent unauthorized copying of test material that is pre-
to chance. The reliability of diagnostic interviews sented online; (c) issues for special populations, in
is an excellent reminder that reliability is not a fea- which lack of equal access to technology may result
ture of the instrument per se, but rather is depen- in poorer test performance for some groups, or con-
dent on the context in which the assessment occurs. textual factors may interact with Internet test per-
Structured diagnostic interview protocols have formance; and (d) ethical issues unique to Internet
been developed for specific psychological disorders, testing (to be discussed in a later section).
such as the Anxiety Disorders Interview Schedule Returning once again to the distinction between
(ADIS-IV; Brown, Di Nardo, & Barlow, 1994), or testing and assessment, Naglieri et al. (2004) con-
for a broad range of disorders, such as the Structured cluded that most of what is available on the Inter-
Clinical Interview (SCID), which has separate net is testing, not assessment: “Testing refers to the
forms for Axis I and Axis II disorders, as well as for administration, scoring, and perhaps the interpre-
research purposes. tation of individual test scores by applying a descrip-
tive meaning based on normative, nomothetic
Computer-assisted and data . . . with the focus on the test itself ”; whereas,
Internet-based Assessment “in psychological assessment, the emphasis is typically
Computer-assisted assessment has been around for on the person being assessed and the referral ques-
several decades, and many inventories previously tions, rather than on specific test results” (Naglieri,
administered via paper-and-pencil formats are now 2004, p. 153). Some of the negative consequences
available via desktop computer or the Internet. of Internet testing are due to the fact that they do
A new set of issues arises with assessment that is not occur within a broader assessment context, or
made available online. Such assessment is burgeon- with the assistance of a psychologist or other trained
ing, due to the explosive growth of individuals’ professional.
access to the Internet (nearly 75% of people in the
United States had access to the Internet in 2008, up gender and diversity
from 44% in 2000, www.internetworldstats.com); issues in assessment
and, because of the promise of “better, faster, and Discussions of assessment with diverse clientele
cheaper services and products” common to the have changed substantially in the past few decades—
Internet (Naglieri et al., 2004, p. 151). A whole host these issues have become more mainstream, perhaps

swanson 227
due to the pressing nature of psychologists’ prepa- norming, adjusting scores, and separate cutoff
ration to work with diverse clients given changes in scores.
demographics. On the other hand, the issues them- The second factor is the context of assessment—
selves have not changed. As Fouad and Chan (1999) the cultural competence of the counselor, the rela-
noted a decade earlier, psychologists often take tests tionship between counselor and client, and the
developed and normed for one group and apply client’s attitudes toward testing (Fouad & Chan,
them to another group. And, although test develop- 1999). Recent research regarding the impact of ste-
ers are more savvy to the need to include culture, reotype threat (Steele & Aronson, 1995) suggests
language, and gender in the development and that heightened awareness of one’s group member-
norming of tests, ultimately it is up to the individ- ship, whether gender, race, or age, can have nega-
ual psychologist to be aware of the multitude of tive effects on test performance (Hess, Hinson, &
issues surrounding use of an established assessment Hodges, 2009; Nguyen & Ryan, 2008). Psycholo-
instrument with any client, but particularly with gists must be aware of the impact of the context of
clients who historically have been outside of the assessment throughout all aspects, including selec-
mainstream. tion, administration, and interpretation of psycho-
It is useful to consider these issues from the logical tests.
perspective of multiculturalism or cultural pluralism Fortunately, many resources are available to
(Fouad & Chan, 1999; Leong, 2000)—the belief guide psychologists in the selection and interpreta-
that the dominant or mainstream culture in the tion of tests and assessments with a diverse range
United States is but one of many that coexist. This of clients. The American Psychological Associa-
perspective changes the lenses through which we tion (APA), for example, has created several com-
view assessment with diverse clients because the pendia of references for practitioners, including the
dominant culture no longer serves as the standard use of testing and neuropsychological assessment
of “normal” against which other cultures are judged with racial/ethnic minorities, cross-culturally, lin-
as deviations from that standard (Fouad & Chan, guistic minorities, women, and people with dis-
1999). Moreover, it is important to consider inter- abilities (Committee on Ethnic Minority Affairs,
actions among cultural dimensions, as individuals 2000; Committee on Psychological Tests and
have multiple group identities, such as gender and Assessment, 2002a, b). Furthermore, authors such
race/ethnicity. as Fernandez, Boccaccini, and Noland (2007) pro-
Two factors are of particular importance. The vide guidance to practitioners selecting tests that
first is test bias—its sources, implications, and rec- have been translated into Spanish, which is likely to
ommended solutions—which has been a topic of be useful, given the escalating increase in Spanish-
heated discussion. The Standards for Educational speaking clients.
and Psychological Testing recommends that item or Psychologists’ use of tests/assessment with cul-
performance differences among groups be researched turally diverse individuals also is related to ethical
as soon as possible, and that test developers design standards and practice guidelines. The APA Ethical
inventories to eliminate or minimize such bias Principles of Psychologists (APA, 2002) cautions psy-
(AERA, 1991). Betz (2000) identified three types chologists to use assessment instruments with estab-
of test bias: content bias, observable at the item lished reliability and validity for the population
level, in which a difference exists between groups in being tested, and appropriate for a client’s language
the probability of individuals with the same level preference. Similarly, the Standards for Educational
of ability answering an item correctly; internal and Psychological Testing (AERA, APA, NCME,
structure or factorial bias, in which the structure 1999) provides guidelines regarding assessment with
of test items or scales differs across groups, raising individuals of diverse linguistic backgrounds. At the
questions of whether the test can be interpreted as very least, test users must be aware of the material
the same for each group; and predictive or selection provided by test developers regarding the gender,
bias, in which a difference in prediction is observed race/ethnicity, and other cultural factors of the cli-
across groups, typically evaluated via regression lines ents with whom they work. Psychologists also need
that are used to predict successful performance in to be familiar with the Guidelines on Multicultural
a target behavior. Potential test bias has been iden- Education, Training, Research, Practice, and Orga-
tified in every form of psychological assessment, and nizational Changes for Psychologists (APA, 2003).
test developers have taken a number of different In addition to knowledge about reliability and
strategies to address it, including within-group validity, psychologists need to use assessment

228 m easurement an d as s es s men t

instruments with demonstrated measurement about a particular measure, including the primary
equivalence—including not only linguistic equiva- criticisms; how the test was developed, with impli-
lence (appropriate translations into target lan- cations for interpretation for a particular client;
guages), but also conceptual and functional the available reliability and validity data for the
equivalence—whether the assessed constructs have test; applicability of the test norms for a given cli-
the same meaning and serve the same function ent; and, groups for whom the test might produce
across cultures (APA, 2003). biased results, and the nature of these biases.
Information about assessment is available from a
Use of Assessment number of sources, including graduate-level course-
Responsible use of assessment includes several types work, assessment-focused journals, the Mental
of decisions: deciding whether to use assessment, Measurement Yearbook, information on the APA
what specific tests to use, how to use assessment website, and test manuals.
given the specific context, and interpreting and Psychologists who work in agencies or other
reporting test results. organizations may have little input about selec-
tion of assessment instruments, at least at the global
deciding whether to use assessment level. That is, the agency may have purchased cer-
Psychologists should be able to “furnish a sound tain inventories for practitioners’ use, and so
rationale for their work and explain the expected the individual practitioner will use what is available.
benefits of an assessment, as well as the anticipated On the other hand, the practitioner may have
cost” (Meyer et al., 2001, p. 129). Psychologists’ control over whether the assessment is used, or
own views of assessment vary, from those who may have several options from which to choose.
eschew testing to those who use it routinely with all For example, a career counselor may have access to
clients. Testing may be viewed as an invasion of both the Strong Interest Inventory and the Self-
a client’s privacy, not to mention a substantial Directed Search, and may choose to use either or
investment in terms of time and money. Yates and neither.
Taub (2003) describe procedures for determining Another scenario exists in which all clients in
the cost-effectiveness and cost–benefit of assess- an agency are administered a screening inventory
ment; expected cost–benefit ratios may vary from as part of intake, such as the PAI. In this case, the
person to person, and so must be evaluated in the individual practitioner does not control the
context of the individual. assessment selection process, but still must be well-
In recent years, the practice of assessment has informed about characteristics of the inventory and
come under scrutiny from third-party payers, and its interpretation.
reimbursement policies have influenced the fre-
quency and type of assessment that psychologists using assessment results in counseling
use (Camara, Nathan, & Puente, 2000; Cashel, Test interpretation can be viewed as a process that
2002; Meyer et al., 2001; Turchik, Karpenko, extends throughout the entire interaction between
Hammers, & McNamara, 2007). Thus, psycholo- therapist and client, beginning with an informed
gists will need to give thought to their decisions selection of appropriate assessment instruments and
about whether to use assessment, and be prepared ending with termination of therapy. In other words,
to provide a rationale to clients and other parties. “interpretation” is not limited to the specific points
in time that a psychologist is explaining test results
selection of assessment to a client, but rather, is an integrative process.
The scientist–practitioner approach in counseling Goodyear and Lichtenberg (1999) outlined three
psychology is evident in the selection and use of overlapping definitions and sequential steps of test
assessment results. Selecting a test for use with a interpretation. First, the psychologist makes sense
specific client entails determining the client’s goals of the test data. This is reminiscent of the distinc-
and choosing instruments to reach these goals, on tion between testing and assessment, in which the
the basis of available research and knowledge about latter is the synthesizing of the data obtained from
assessment instruments. Allison, Lichtenberg, and multiple tests that may include inconsistencies or
Goodyear (1999) offered a brief checklist of impor- contradictions, or may result in the whole picture
tant psychometric information that a practitioner being more than the sum of its parts. Second, data
should know before selecting an instrument: what obtained from the test(s), and implications of these
information is available in the existing literature data, are presented to the consumer, most frequently

swanson 229
the client him- or herself. This is the most com- have a gatekeeping or administrative intent. In these
monly used definition of test interpretation cases, the assessment and subsequent interpreta-
(Goodyear & Lichtenberg, 1999). Finally, the third tion is made on behalf of “an entity that wants
aspect of test interpretation is the client (or other guidance in making a judgment about a person
consumer) making meaning of the test data and being evaluated” (Goodyear & Lichtenberg, 1999,
deriving implications from the data. p. 2); as a consequence, the results may or may not
Although the technical aspects of testing may be helpful to the person who is being evaluated.
be systematically covered in graduate coursework, Moreover, the person requesting the assessment
how to actually interpret tests with clients may and the person being assessed may have different
receive less attention. Tinsley and Bradley (1986) goals and desired outcomes, highlighting the need
offered two guiding principles: first, that test inter- to carefully define the audience that will receive
pretation not be viewed as a discrete activity but the interpretation.
conceptualized as part of the ongoing counseling It is important to remember that the consumer
process and integrated into the flow of counseling; most frequently is a client who has taken tests as
and second, that tests are best thought of as struc- part of a counseling relationship, and has been
tured interviews that provide an efficient source of involved in the decision making about testing
information about clients. Furthermore, they rec- (Duckworth, 1990). A prime example within coun-
ommended practical pointers for interpreting tests seling psychology is a client who is engaged in career
with clients, including remembering clients’ goals, counseling, in which formal assessment is a typical
keeping the test precision in mind, minimizing intervention. However, as implied earlier, the con-
defensive reactions, avoiding jargon, encouraging sumer may be another individual or agency who
feedback, and being sensitive to the impact of infor- wants information about a client, such as a judge,
mation contained in test profiles. Other authors attorney, or human resources manager. Regardless
have reminded therapists not to lose sight of rap- of who the consumer is, eventually he or she will
port-building and basic counseling skills while con- attempt to make sense of the test data and decide
ducting test interpretation (Campbell, 2000). what the implications are for him- or herself
A useful interpretive strategy is to consider (Goodyear & Lichtenberg, 1999).
assessment as a rich source of information for gener- With these issues in mind, what is the goal of
ating ideas and hypotheses about clients. As Tyler test interpretation? First, psychologists interpret
(1984) noted, “what test scores give us are clues tests to make diagnoses and plan interventions. The
to be followed . . . the scores mean something, but psychologist him- or herself may be considered
in order to know what we must consider each indi- the primary consumer in this case, particularly if
vidual case in an empathic way, combining test they are providing psychotherapy, because the tests
evidence with everything else we know about the are used to guide their work with the client.
person” (Tyler, 1984, p. 50). This approach builds All mental health professionals “assess” their cli-
on the idea that therapists develop hypotheses and ents’ level of functioning as they formulate the
“working models” of clients throughout the therapy best course of action; formal testing provides more
process (Maloney & Ward, 1976, in Goodyear & structured data for doing so. A second purpose of
Lichtenberg, 1999; Swanson & Fouad, 2010; test interpretation is, as noted earlier, for psychol-
Walborn, 1996). Psychologists use all available ogists to interpret the results of tests directly to
sources of information to generate hypotheses, and clients. Goodyear and Lichtenberg (1999) argued
may select certain assessment instruments because that psychologists have an ethical imperative, given
they provide information relevant to their hypoth- that tests are intrusive and have consequences;
eses. Consistencies and inconsistencies can be iden- therefore, clients have the right to know the results
tified across several sources of information (Swanson of their tests. Tests may be interpreted to clients to
& Fouad, 2010). help them monitor their progress, such as repeated
As Goodyear and Lichtenberg (1999) noted, testing to document change throughout therapy,
“test interpretation can have real consequences” or to facilitate choice, such as in the practice of
(p. 2), including decisions about diagnosis, treat- career counseling. Assessment plays such a central
ment planning, hiring, career choice, occupational role in the delivery of career counseling that test
classification, custody, and so on. These decisions interpretation is an intervention.
often have a clinical intent, with the goal of help- Despite the importance of interpreting tests
ing the client. However, at times, the decisions directly to clients, there is little evidence regarding

230 m easurement an d as s es s men t

the impact or effectiveness of test interpreta- assessment, including the Code of Fair Testing
tion itself (Goodyear, 1990; Tinsley & Chu, 1999). Practices in Education (Joint Committee on Testing
In fact, Tinsley and Chu (1999), reviewing literature Practices, 2004), Standards for Educational and
related to the interpretation of vocational interest Psychological Testing (AERA, APA, NCME, 1999),
inventories, described the empirical foundation for APA’s Ethical Principles of Psychologists and Code
this activity as “shockingly inadequate” (p. 259). of Conduct (APA, 2002), and APA’s Guidelines for
A third purpose of test interpretation is psy- Test User Qualifications (Turner, DeMers, Fox, &
chologists interpreting test data to a third party, Reed, 2001).
most frequently in the form of a written report. The APA has focused on the qualifications of
Although traditionally the domain of clinical psy- those who use psychological tests, in reaction to
chology, the distinctions have eroded, so that coun- concerns that doctoral programs were providing
seling psychologists are also engaged in third- insufficient training related to statistics and mea-
party test interpretation. The psychologist’s role is surement (Aiken et al., 1990). As defined by the
as a consultant, typically responding to a specific APA, the term test user qualifications refers to “the
referral question raised by the third party about combination of knowledge, skills, abilities, training,
the client. This purpose of test interpretation raises experience, and where appropriate, practice creden-
ethical issues about who is the client and what the tials” considered desirable for responsible use of
psychologist’s responsibilities are toward the person psychological tests (Turner et al., 2001, p. 1099).
being tested. Furthermore, the APA focused on the qualifica-
The manner in which assessment results are used tions of test users because growing concerns about
may relate to the two models discussed earlier, the problems associated with test use seemed to be
traditional or contemporary models of assessment related to the competence of individuals using tests,
within counseling psychology. Relevant to the latter rather than with the quality of test materials or
model, Goldfinger and Pomerantz (2010) offer a practices of test developers. In other words, regard-
six-step model for assessment, beginning with the less of the quality of the test itself, tests can easily
referral and an analysis of the context of the referral: be misused by practitioners, through inappropri-
who requested the assessment, what are the goals, ate selection, administration, interpretation, and
who will receive the information, what are the conclusions (Betz, 2000; Turner et al., 2001). Early
implicit and explicit questions to be addressed? efforts to monitor the qualifications of test users
Next, the psychologist determines the information were developed by the APA in 1954, and classified
necessary to address the referral question, and then tests according to their level of complexity: Level A
gathers, scores, and interprets data. Based on these tests (such as achievement tests) could be adminis-
data, the psychologist draws conclusions in relation tered, scored, and interpreted by nonpsychologists;
to the referral question, and communicates the find- Level B tests (such as the Strong Interest Inventory)
ings to the primary (and secondary) audiences. require knowledge of technical aspects of test con-
struction and so users needed to have advanced
Training, Professional, and Ethical Issues coursework; Level C tests (such as the WAIS and
The first portion of this chapter focused on psy- MMPI) require an advanced degree in psychology
chometric theory and procedures, as a precursor to and/or licensure (Betz, 2000).
understanding the selection and use of assessment Consistent with discussion earlier in this chapter,
instruments. Training in psychometric concepts has the APA Guidelines for Test Users clearly acknowl-
been identified as crucial for counseling psychologists edged that psychological tests must be viewed within
due to their joint roles as test administrators and test the broader context of assessment, which necessarily
interpreters (Bolt & Rounds, 2000), as well as for entails a “complex activity requiring the interplay of
general training in research methodology, statistics, knowledge of psychometric concepts with expertise
and measurement (Aiken, West, Sechrest, & Reno, in an area of professional practice or application”
1990). In addition, counseling psychology training (Turner et al., 2001, p. 1100). The Guidelines
needs to include attention to the professional stan- include two types of qualifications for test users:
dards and guidelines related to the use of assessment. general psychometric knowledge and skills, and
specific qualifications for particular settings or pur-
standards and guidelines poses. General knowledge and skills include (a) psy-
It is imperative that psychologists be aware of chometric and measurement knowledge (descriptive
the range of standards and guidelines related to statistics, reliability and measurement error, validity

swanson 231
and meaning of test scores, normative interpreta- are addressed by Standard 3.10 of the Ethical
tion of test scores, selection of appropriate tests, Principles.
and test administration procedures); (b) ethnic, (d) Release of test data (Standard
racial, cultural, gender, age, and linguistic vari- 9.04): Psychologists provide test data (defined as
ables; (c) testing individuals with disabilities; and item responses, scale scores, and notes/recordings)
(d) supervised experience. Within each of these to clients or others as specified in a client release
categories, the authors provided detailed lists of document. Psychologists may choose not to
crucial knowledge and skills. The second type of release test data to protect clients or others from
qualifications pertains to specific contexts, includ- harm or misuse of data. In the absence of a client
ing six different purposes of tests (classification, release, psychologists release test data only as
description, prediction, intervention planning, required by law or court order.
tracking, and training and supervision) within five (e) Test construction (Standard
diverse contexts (employment, education, career 9.05): Psychologists who develop tests or
and vocational counseling, health care, and foren- assessment procedures use appropriate
sic). Clearly, all of these purposes and contexts are psychometric procedures and knowledge.
relevant to the practice of assessment within coun- (f ) Interpretation of results (Standard
seling psychology. 9.06): When interpreting test results, psychologists
take into account the purpose of the assessment, as
well as contextual factors related to test-taking
ethical issues
and the test-taker, that might influence the
The APA Ethical Principles of Psychologists and
accuracy or direction of the interpretation.
Code of Conduct devotes one of its ten ethical stan-
They also indicate any significant limitations
dards specifically to matters related to assessment.
of their interpretations.
This standard includes guidelines specifying the
(g) Assessment by unqualified individuals
following:
(Standard 9.07): Psychologists do not promote
(a) Bases for assessment (Standard the use of assessment tools by people who are
9.01): Psychologists base their recommendations not qualified, except as used in training with
or diagnoses on sufficient information, and only appropriate supervision.
after conducting an examination of the individual (h) Obsolete tests and outdated test results
that is adequate to support such recommendations. (Standard 9.08): Psychologists do not base
If recommendations are made based solely on recommendations or decisions on data or tests
a review of records, then the limits are explained. that are outdated for the current purpose.
(b) Appropriate use of assessment (Standard (i) Test scoring and interpretation services
9.02): Psychologists use assessment tools in (Standard 9.09): Psychologists who offer
a manner that is appropriate given the available assessment services to other professionals provide
research, use instruments with established an accurate description of the purpose,
reliability and validity for the given population psychometric properties, and applications of
(or, in the absence of psychometric evidence, the assessment; psychologists who select others’
note the limits of the instrument), and use services do so on the basis of evidence of validity;
assessment appropriate to an individual’s and, psychologists retain responsibility for the
language preference and competence. use of assessment even if they use others’ services.
(c) Informed consent (Standard (j) Explaining assessment results (Standard
9.03): Psychologists obtain clients’ informed 9.10): Psychologists ensure that the results are
consent for assessment; informed consent will explained to the test-taker, unless there are specific
include the nature of the assessment, fees, the role predetermined reasons not to do so (such as
of third parties, and limits of confidentiality. security screenings or forensic evaluations).
Several situations may obviate the need for (k) Maintaining test security (Standard
informed consent, such as when testing is 9.11): Psychologists maintain the integrity and
mandated by law, is implied because testing is security of test materials (instruments, manuals,
a routine activity (e.g., within an educational and protocols).
or employment context), or if a purpose of
the testing is to evaluate decisional capacity. In addition to these components of Standard 9,
Additional issues regarding informed consent other standards in the Ethical Principles are relevant

232 m easurement an d as s es s men t

to assessment, such as Standard 2 (Competence) measures in place, as well as the limits to security. For
and Standard 4 (Privacy and Confidentiality), as example, an APA Task Force on Psychological Testing
described next. on the Internet recommended the use of a three-tier
server model, in which the test system has three inde-
Competence pendent servers, one each for the Internet, the test,
Standards 2.01 and 2.03 pertain to boundaries of and the database, with appropriate firewalls and
competence, and maintaining competence. These other security measures (Naglieri et al., 2004).
standards state that psychologists provide services Internet-based assessment also raises additional
with populations and in areas only within the concerns related to many aspects of the ethical stan-
boundaries of their competence, based on educa- dard related to assessment. Access to the Internet
tion, training, experience, consultation, or study. has led to an explosive proliferation of informa-
Psychologists planning to provide services involving tion and access to materials that were previously
populations or techniques that are new to them unavailable. New concerns are emerging regarding
pursue relevant education, training, or experience. use of Internet tests by unqualified individuals,
Furthermore, psychologists continue to develop and appropriate release of test data, interpretation of
maintain competence (APA, 2002). Issues of com- test results, test security, and outdated test materials
petence thus are particularly important when psy- (Bartram, 2006; Naglieri et al., 2004). A recent
chologists use a test or assessment procedure that is example was provided by LoBello and Zachar
new on the market, recently revised, or new to (2007), who documented sales of current and obso-
them. lete test materials (including the WAIS, WISC,
MMPI, and Rorschach) on Internet auction sites
Confidentiality and Privacy such as eBay. Although the existing Ethical Principles
Generally, privacy refers to the individual’s right to provide guidance, monitoring compliance to the
control access to information about him- or herself. principles is becoming more difficult given the
Privacy is the right to be left alone. On the other growth of Internet services.
hand, confidentiality refers to how private informa-
tion provided by an individual will be protected by Additional Ethical and Professional Issues
the recipient of that information, in this case, a psy- The APA Ethical Principles provide broad guidance
chologist. Confidentiality is also shaped by legal related to testing and assessment (as well as other
considerations, which may vary by state. professional activities). In addition, there are many
Standard 4 of the Ethical Principles addresses unique situations that psychologists encounter
confidentiality and privacy. Psychologists have a regarding ethical dilemmas in testing. For example,
“primary obligation and take reasonable precautions Turchik, Karpenko, Hammers, and McNamara
to protect confidentiality information obtained (2007) described several examples for practitioners
through or stored in any medium” (Standard 4.01, working in rural or economically depressed areas:
APA, 2002, p. 1066) and discuss the limits of con- “What should a practitioner do when a third-party
fidentiality with clients. Psychologists also minimize payer denies authorization for a needed neuropsy-
intrusions on privacy, by including in reports only chological assessment? How does a clinic director
that information that is directly relevant to the pur- decide which tests to purchase and still stay within
pose of the report (Standard 4.04). the clinic’s limited budget? What does a small rural
community do when there are no practitioners
Ethical Issues Related to Use of the trained to provide psychological assessment?”
Internet in Assessment (Turchik et al., 2007, p. 158).
With the increase in Internet-based assessment, issues The examples provided by Turchik et al. (2007)
of privacy and confidentiality become more compli- are a reminder that ethical dilemmas are just
cated and more crucial. For example, a client may that—dilemmas—and the guidelines are just that—
take an assessment online, upload his or her responses guidelines. Although “ethical principles dictate
to a scoring service, which then scores and sends the that psychologists provide services that are in the
results electronically to the psychologist, who stores best interests of their patients” (Meyer et al., 2001,
or downloads the scores and materials. Each of these p. 129), frequently competing interests or needs are
transfer or storage points opens the possibility of a difficult to resolve.
breach of confidentiality, and psychologists using An additional professional issue regards the
these mechanisms should be aware of the security importance of ongoing training that occurs after

swanson 233
completion of the doctoral degree. Many of the the importance of knowledge regarding testing and
tests and assessments used by counseling psycholo- assessment. Understanding the key underlying
gists are stalwarts, some used for many decades principles of measurement will prepare psycholo-
(such as the MMPI or Strong Interest Inventory). gists for using assessment in their work, today and
However, test developers frequently update the in the future.
test materials—test items, scales, norms, interpre-
tive materials—and psychologists must be aware of References
these changes and update their own training and Agresti, A. A. (1992). Integrating neuropsychological training
preparation. into a counseling psychology curriculum. The Counseling
Psychologist, 20, 605–619.
Aiken, L. S., West, S. G., Sechrest, L., & Reno, R. R. (1990).
Future Directions in Testing Graduate training in statistics, methodology, and measure-
and Assessment ment in psychology: A survey of PhD programs in North
What does the future hold for the development America. American Psychologist, 45, 721–734.
and use of psychological tests and assessment? Allison, R. D., Lichtenberg, J. W., & Goodyear, R. K.
Several trends are worth noting. The first is the (1999). Science and the practice of test interpretation.
In J. W. Lichtenberg, & R. K. Goodyear (Eds.), Scientist-
often-cited changing demographic characteristics practitioner perspectives on test interpretation (pp. 167–182).
and continued cultural and linguistic diversifica- Needham Heights, MA: Allyn and Bacon.
tion of the U.S. population. In addition, there is American Educational Research Association, American
increasing diversity on other important individual Psychological Association, National Council on Measure-
difference variables that will have implications for ment in Education (AERA, APA, NCME). (1999). Standards
for educational and psychological testing. Washington, DC:
testing and assessment, such as age and disability. AERA.
Considering such diversification from the per- American Psychological Association (APA). (2002). Ethical prin-
spective of multiculturalism and acknowledging ciples of psychologists and code of conduct. American
multiple group identities presents somewhat of Psychologist, 47, 1597–1611. Retrieved from http://www.
a conundrum: Although it is clearly important to apa.org/ethics/code2002.html.
American Psychological Association (APA). (2003). Guidelines
develop and validate the use of tests for diverse indi- on multicultural education, training, research, practice, and
viduals, at what point does this become an unrealis- organizational change for psychologists. American Psychologist,
tic goal, given the wide range of test users? 58, 377–402.
The second trend is globalization, which has Anastasi, A., & Urbina, S. (1997). Psychological testing (7th ed.).
major implications for the use of psychological tests Upper Saddle River, NJ: Prentice-Hall.
Antony, M. M., & Barlow, D. H. (Eds.). (2002). Handbook of
both in the United States and internationally assessment and treatment planning for psychological disorders.
(Bartram, 2006; DeBell, 2006). Globalization New York: Guilford.
presents similar issues to those discussed related Bartram, D. (2006). The internationalization of testing and
to changing demographics, such as linguistic and new models of test delivery on the Internet. International
cultural equivalence of existing and newly devel- Journal of Testing, 6, 121–131.
Betz, N. E. (2000). Contemporary issues in testing use.
oped tests. Furthermore, the “internationalization In C. E. Watkins, Jr., & V. L. Campbell (Eds.), Testing and
of testing” (Bartram, 2006) is a direct result of assessment in counseling practice (2nd ed., pp. 481–516).
the explosive growth of the Internet, erasing the Mahwah, NJ: Lawrence Erlbaum.
borders between countries as well as between Bolt, D. M., & Rounds, J. (2000). Advances in psychometric
national rules and regulations regarding the use of theory and methods. In S. D. Brown, & R. W. Lent (Eds.),
Handbook of counseling psychology (3rd ed., pp. 140–176).
testing. New York: Wiley.
The third trend is increasing technology, particu- Brown, T. A., Di Nardo, P. A., & Barlow, D. H. (1994).
larly Internet assessment and computerized assess- Anxiety Disorders Interview Schedule for DSM-IV (ADIS-IV).
ment (Bartram, 2006; Naglieri et al., 2004; Tippins San Antonio, TX: Psychological Corporation.
et al., 2006). Coupled with the previously discussed Buchanan, T. (2002). Online assessment: Desirable or
dangerous? Professional Psychology: Research and Practice, 33,
trend of globalization, expanded technology raises 148–154.
intriguing questions about the delivery infrastruc- Bufka, L. F., Crawford, J. I., Levitt, J. T. (2002). Brief
ture of assessment; relationships among test pub- screening assessments for managed care and primary care.
lishers, test users, and test takers; and unproctored In M. M. Antony, & D. H. Barlow (Eds.), Handbook of
testing and assessment (Bartram, 2006; Tippins assessment and treatment planning for psychological disorders.
New York: Guilford.
et al., 2006). Camara, W., Nathan, J., & Puente, A. (2000). Psychological test
These trends, as well as other issues, such as the usage: Implications in professional psychology. Professional
evolving impact of managed care, serve to highlight Psychology: Research and Practice, 31, 141–154.

234 m easurement an d as s es s men t

Campbell, D. T., & Fiske, D. W. (1959). Convergent and Fouad, N. A., & Chan, P. M. (1999). Gender and
discriminant validation by the multitrait-multimethod ethnicity: Influence on test interpretation and reception.
matrix. Psychological Bulletin, 56, 81–105. In J. W. Lichtenberg, & R. K. Goodyear (Eds.), Scientist-
Campbell, V. L. (2000). A framework for using tests in counsel- practitioner perspectives on test interpretation (pp. 31–58).
ing. In C. E. Watkins, Jr., & V. L. Campbell (Eds.), Testing Needham Heights, MA: Allyn and Bacon.
and assessment in counseling practice (2nd ed., pp. 3–13). Goldfinger, K., & Pomerantz, A. M. (2010). Psychological assess-
Mahwah, NJ: Lawrence Erlbaum. ment and report writing. Thousand Oaks, CA: Sage.
Cashel, M. L. (2002). Child and adolescent psychological assess- Goodyear, R. K. (1990). Research on the effects of test interpre-
ment: Current clinical practices and the impact of managed tation: A review. The Counseling Psychologist, 18, 240–257.
care. Professional Psychology: Research and Practice, 33, 446–453. Goodyear, R. K., & Lichtenberg, J. W. (1999). A scientist-
Cassin, S. E., Singer, A. R., Dobson, K. S., & Altmaier, E. M. practitioner perspective on test interpretation. In J. W.
(2007). Professional interests and career aspirations of grad- Lichtenberg, & R. K. Goodyear (Eds.), Scientist-practitioner
uate students in professional psychology: An exploratory perspectives on test interpretation (pp. 1–14). Needham
survey. Training and Education in Professional Psychology, Heights, MA: Allyn and Bacon.
1, 26–37. Groth-Marnat, G. (1999). Handbook of psychological assessment
Cobb, H. C., Reeve, R. E., Shealy, C. N., Norcross, J. C., (3rd ed.). New York: Wiley.
Schare, M. L., Rodolfa, E. R., et al. (2004). Overlap among Hansen, J. C. (1999). Test psychometrics. In J. W. Lichtenberg,
clinical, counseling, and school psychology: Implications & R. K. Goodyear (Eds.), Scientist-practitioner perspectives
for the profession and combined-integrated training. Journal on test interpretation (pp. 15–30). Needham Heights, MA:
of Clinical Psychology, 60, 939–955. Allyn and Bacon.
Committee on Ethnic Minority Affairs, Committee on Hansen, J. C. (2005). Assessment of interests. In S. D. Brown, &
Psychological Tests and Assessment. (2000). Relevant litera- R. W. Lent (Eds.), Career development and counseling: Putting
ture addressing testing and assessment of cultural, ethnic, and theory and research to work (pp. 281–304). New York: Wiley.
linguistically diverse populations. Washington, DC: Author. Hartung, P. J. (2005). Integrated career assessment and counsel-
Retrieved May 2, 2009, from http://www.apa.org/science/ ing: Mindsets, models, and methods. In W. B. Walsh, & M. L.
minority_testing_ref.pdf. Savickas (Eds.), Handbook of vocational psychology (3rd ed.,
Committee on Psychological Tests and Assessment. (2002a). pp. 371–395). Mahwah, NJ: Lawrence Erlbaum.
Books and chapters pertaining to neuropsychological assess- Hebben, N., & Milberg, W. (2002). Essentials of neuropsychologi-
ment cross-culturally, with minorities, and with non-English cal assessment. New York: Wiley.
speaking individuals. Washington, DC: Author. Retrieved Hess, T. M., Hinson, J. T., & Hodges, E. A. (2009). Moderators
May 2, 2009, from http://www.apa.org/science/neuropsych_ of and mechanisms underlying stereotype threat effects
minority_cit.pdf. on old adults’ memory performance. Experimental Aging
Committee on Psychological Tests and Assessment. (2002b). Research, 35, 153–177.
References on testing of people of color, women, language minor- Hoyt, W. T., & Melby J. N. (1999). Dependability of measure-
ities, and people with disabilities. Washington, DC: Author. ment in counseling psychology: An introduction to general-
Retrieved May 2, 2009, from http://www.apa.org/science/ izability theory. The Counseling Psychologist, 27, 325–352.
women_and_dis_ref.pdf. Joint Committee on Testing Practices. (2004). Code of fair testing
Cortina, J. M. (1993). What is coefficient alpha? An examination practices in education. Washington, DC: Author.
of theory and applications. Journal of Applied Psychology, 78, Kaplan, R. M., & Saccuzzo, D. P. (2009). Psychological testing:
98–104. Principles, applications, and issues (7th ed.). Belmont, CA:
Cronbach, L. J. (1957). The two disciplines of scientific psychol- Wadsworth/Thomson.
ogy. American Psychologist, 12, 671–684. Larson, P. C., & Agresti, A. A. (1992). Counseling psychology
Cronbach, L. J., & Meehl, P. E. (1955). Construct validity and neuropsychology: An overview. The Counseling
in psychological tests. Psychological Bulletin, 52, 281–302. Psychologist, 20, 549–555.
Dawis, R. V. (1987). Scale construction. Journal of Counseling Leong, F. T. L. (2000). Cultural pluralism. In A. E. Kazdin
Psychology, 34, 481–489. (Ed.), Encyclopedia of psychology Vol 2 (pp. 387–389).
Dawis, R. V. (1992). The individual differences tradition in coun- Washington, DC: American Psychological Association.
seling psychology. Journal of Counseling Psychology, 39, 7–19. LoBello, S. G., & Zachar, P. (2007). Psychological test sales and
DeBell, C. (2006). What all applied psychologists should know Internet auctions: Ethical considerations for dealing with
about work. Professional Psychology: Research and Practice, 37, obsolete or unwanted test materials. Professional Psychology:
325–333. Research and Practice, 38, 68–70.
Duckworth, J. (1990). The counseling approach to the use Matarazzo, J. D. (1990). Psychological assessment versus psy-
of testing. The Counseling Psychologist, 18, 198–204. chological testing: Validation from Binet to the school, clinic,
Embretson, S. E. (1996). The new rules of measurement. and courtroom. American Psychologist, 45, 999–1017.
Psychological Assessment, 8, 341–349. May, T. M., & Scott, K. J. (1991). Assessment in counseling
Fernandez, K., Boccaccini, M. T., & Noland, R. M. (2007). psychology: Do we practice what we teach? The Counseling
Professionally responsible test selection for Spanish-speaking Psychologist, 19, 396–413.
clients: A four-step approach for identifying and selecting McIntire, S. A., & Miller, L. A. (2007). Foundations of psycho-
translated tests. Professional Psychology: Research and Practice, logical testing: A practical approach (2nd ed.). Thousand Oaks,
38, 363–374. CA: Sage.
Fouad, N. A. (1999). Validity evidence for interest inventories. Meehl, P. E., & Rosen, A. (1955). Antecedent probability and
In M. L. Savickas, & A. R. Spokane (Eds.), Vocational inter- the efficiency of psychometric signs, patterns, or cutting
ests (pp. 193–209). Palo Alto, CA: Davies-Black. scores. Psychological Bulletin, 52, 194–216.

swanson 235
Meier, S. T. (1999). Training the practitioner-scientist: Bridging Steele, C. M., & Aronson, J. (1995). Stereotype threat and the
case conceptualization, assessment, and intervention. The intellectual test performance of African Americans. Journal of
Counseling Psychologist, 27, 846–869. Personality and Social Psychology, 69, 797–811.
Messick, S. (1995). Validity of psychological assessment: Summerfeldt, L. J., & Antony, M. M. (2002). Structured and
Validation of inferences from persons’ responses and perfor- semistructured diagnostic interviews. In M. M. Antony, &
mances on scientific inquiry into score meaning. American D. H. Barlow (Eds.), Handbook of assessment and treatment
Psychologist, 50, 741–749. planning for psychological disorders (pp. 3–37). New York:
Meyer, G. J., Finn, S. E., Eyde, L. D., Kay, G. G., Moreland, K. L., Guilford Press.
Dies, R. R., et al. (2001). Psychological testing and psycho- Swanson, J. L. (2002). Understanding the complexity of
logical assessment: A review of evidence and issues. American clients’ lives: Infusing a truly integrative career-personal
Psychologist, 56, 128–165. perspective into graduate training. The Counseling Psychol-
Morgan, R. D., & Cohen, L. M. (2008). Clinical and counseling ogist, 30, 815–832.
psychology: Can differences be gleaned from printed recruit- Swanson, J. L., & D’Achiardi, C. (2005). Beyond interests,
ing materials? Training and Education in Professional needs/values, and abilities: Assessing other important career
Psychology, 2, 156–164. constructs over the life span. In S. D. Brown, & R. W. Lent
Naglieri, J. A., Drasgow, F., Schmit, M., Handler, L., Prifitera, A., (Eds.), Career development and counseling: Putting theory and
Margolis, A., Veslasquez, R. (2004). Psychological testing on research to work (pp. 353–381). New York: Wiley.
the Internet: New problems, old issues. American Psychologist, Swanson, J. L., & Fouad, N. A. (2010). Career theory and
59, 150–162. practice: Learning through case studies (2nd ed.). Thousand
Neimeyer, G. J., Bowman, J., & Stewart, A. E. (2001). Internship Oaks, CA: Sage.
and initial job placements in counseling psychology: A 26-year Tinsley, H. E. A. (2000). Technological magic, social change,
retrospective. The Counseling Psychologist, 29, 763–780. and counseling rituals: The future of career assessment.
Neimeyer, G. J., Rice, K. G., & Keilin, W. G. (2009). Internship Journal of Career Assessment, 8, 339–350.
placements: Similarities and differences between clinical and Tinsley, H. E. A., & Bradley, R. W. (1986). Test interpretation.
counseling psychology programs. Training and Education in Journal of Counseling & Development, 64, 462–466.
Professional Psychology, 3, 47–52. Tinsley, H. E. A., & Chu, S. (1999). Research on test and inter-
Neukrug, E. S., & Fawcett, R. C. (2006). Essentials of testing and est inventory interpretation outcomes. In M. L. Savickas, &
assessment: A practical guide for counselors, social workers, and A. R. Spokane (Eds.), Vocational interests (pp. 257–276). Palo
psychologists. Belmont, CA: Brooks/Cole. Alto, CA: Davies-Black.
Nguyen, H.-H. D., & Ryan, A. M. (2008). Does stereotype Tippins, N. T., Beaty, J., Drasgow, F., Gibson, W. M., Pearlman,
threat affect test performance of minorities and women? K., Segall, D. O., & Shepherd, W. (2006). Unproctored
A meta-analysis of experimental evidence. Journal of Applied Internet testing in employment settings. Personnel Psychology,
Psychology, 93, 1314–1334. 59, 189–225.
Nunnally, J. C., & Bernstein, I. H. (1994). Psychometric theory Turchik, J. A., Karpenko, V., Hammers, D., & McNamara, J. R.
(3rd ed.). New York: McGraw-Hill. (2007). Practical and ethical assessment issues in rural,
Parsons, F. (1989). Choosing a vocation. Garrett Park, MD: impoverished, and managed care settings. Professional
Garrett Park Press. (Original work published 1909). Psychology: Research and Practice, 38, 158–168.
Randahl, G. J., Hansen, J. C., & Haverkamp, B. E. (1993). Turner, S. M., DeMers, S. T., Fox, H. R., & Reed, G. M. (2001).
Instrumental behaviors following test administration and APA’s guidelines for test user qualifications. American
interpretation: Exploration validity of the Strong Interest Psychologist, 56, 1099–1113.
Inventory. Journal of Counseling & Development, 71, 435–439. Tyler, L. E. (1984). What tests don’t measure. Journal of
Rounds, J. B., & Armstrong, P. I. (2005). Assessment of needs Counseling & Development, 63, 48–50.
and values. In S. D. Brown, & R. W. Lent (Eds.), Career United States of America Internet usage and broadband usage report.
development and counseling: Putting theory and research to Retrieved May 20, 2009, from http://www.internetworld-
work (pp. 305–329). New York: Wiley. stats.com/am/us.htm.
Ryan Krane, N. E., & Tirre, W. C. (2005). Ability assessment Walborn, F. S. (1996). Process variables: Four common elements
in career counseling. In S. D. Brown, & R. W. Lent of counseling and psychotherapy. Pacific Grove, CA: Brooks/
(Eds.), Career development and counseling: Putting theory and Cole.
research to work (pp. 330–352). New York: Wiley. Walsh, W. B. (2001). The changing nature of the science of
Ryan, J. J., Lopez, S. J., & Lichtenberg, J. W. (1999). vocational psychology. Journal of Vocational Behavior, 59,
Neuropsychological training in APA-accredited counseling psy- 262–274.
chology programs. The Counseling Psychologist, 27, 435–442. Walsh, W. B., & Betz, N. E. (2001). Tests and assessment
Schmitt, N. (1996). Uses and abuses of coefficient alpha. (4th ed.). Upper Saddle River, NJ: Prentice-Hall.
Psychological Assessment, 8, 350–353. Wiggins, J. S. (2003). Paradigms of personality assessment.
Sechrest, L. (1963). Incremental validity. Educational and New York: Guilford.
Psychological Measurement, 23, 153–158. Yates, B. T., & Taub, J. (2003). Assessing the costs, benefits, cost-
Spengler, P. M., Strohmer, D. C., Dixon, D. N., & Shivy, V. A. effectiveness, and cost-benefit of psychological assessment:
(1995). A scientist-practitioner model of psychological We should, we can, and here’s how. Psychological Assessment,
assessment: Implications for training, practice and research. 15, 478–495.
The Counseling Psychologist, 23, 506–534.

236 m easurement an d as s es s men t

 CHAPTER

9 Methodologies in Counseling Psychology

Nancy E. Betz and Ruth E. Fassinger

Abstract
This chapter reviews quantitative and qualitative methodologies most frequently used in counseling
psychology research. We begin with a review of the paradigmatic bases and epistemological stances
of quantitative and qualitative research, followed by overviews of both approaches to empirical
research in counseling psychology. In these overviews, our goal is to provide a broad conceptual
understanding of the “why” of these methods. Among the quantitative methods receiving attention
are analysis of variance (ANOVA) and multivariate analysis of variance (MANOVA), factor analysis,
structural equation modeling, and discriminant analysis. We include discussion of such qualitative
methods as grounded theory, narratology, phenomenology, ethnography, and participatory action
research. Important general issues in designing qualitative studies are also discussed. The chapter
concludes with a discussion of mixed methods in research and the importance of knowledge of both
major approaches in order to maximally utilize findings from our rich and diverse counseling
psychology literature.
Keywords: quantitative research methods, qualitative research methods, methods in counseling
psychology research

All research in counseling psychology is based on Broadly speaking, observations can be divided
the fundamental principle that we learn about into those yielding numeric representations and
people—their thoughts, feelings, and behaviors— those yielding linguistic representations, and each
by “observing” them in some systematic manner. offers a unique and heuristically valuable approach
Certainly, we learn much about people from the to explaining the phenomenon of interest. The
processes of informal observation, as might be the manner in which we examine the observations to
case when we watch someone interact at a party and make sense of them is determined by the nature of
make inferences about his or her social skills. But to those observations, and science provides us with
advance science, our observations must be done a wide variety of methods from which to choose.
under conditions that include some sort of control These methods are the subject of this chapter.
over the process of gathering those observations. In this chapter, we begin with a review of the
The observations can be gained in a variety of ways: paradigmatic bases and epistemological stances of
via formalized assessments or measures, from inter- quantitative and qualitative research, followed by
views or other kinds of narratives, through struc- overviews of both approaches to empirical research
tured viewing and tracking of behavior, or even in counseling psychology. In these reviews, our goal
from cultural artifacts that provide information is to provide a broad conceptual understanding of
about the phenomenon of interest. the “why” of these methods rather than a detailed

237
technical “how-to” description of any method. We and cause-and-effect models that seek to predict and
note that our somewhat differential coverage of control the phenomenon under investigation. Onto-
quantitative and qualitative approaches in the logically, positivism assumes an objective reality that
chapter reflects the disproportionate attention to can be apprehended and measured, and epistemo-
quantitative methods currently seen in our field, logically, it posits separation between the researcher
an empirical imbalance that we hope will be recti- and the participant, so that the researcher can main-
fied over the next decade. We also point out that, tain objectivity in knowing. Axiologically, it presumes
although we cover quantitative and qualitative the absence of values in research, and methodologi-
approaches separately in this chapter for ease in pre- cally, it focuses on discovering reality as accurately
sentation, combining these approaches can yield the and dispassionately as possible (hence the emphasis
most informative programs of research over time. on experimentation and quasi-experimentation, as
Thus, we conclude the chapter with a brief discus- well as psychometric rigor). Finally, its rhetorical
sion of mixed methods research and of future direc- structure of detachment, neutrality, and third-person
tions in research methodology. voice is aimed at capturing the objectivity that has
characterized the entire research endeavor.
Paradigmatic Bases and Epistemological Post-positivism shares much in common with
Stances of Qualitative Research positivism, the main distinction being that post-
Ponterotto (2002, 2005) has written cogently about positivism assumes human fallibility and, ontologi-
the paradigmatic bases and epistemological stances cally, accepts a true reality that can be apprehended
underlying quantitative and qualitative research in and measured only imperfectly. Epistemologically,
counseling psychology, using a four-category system axiologically, methodologically, and rhetorically, the
that distinguishes among positivist, post-positivist, ideal of objectivity, the assumption of researcher–
constructivist-interpretivist, and critical-ideological participant independence, the prevention of values
paradigms. Beginning with several concepts integral from entering research, the controlled use of the
to the philosophy of science, Ponterotto (2005) out- hypothetico-deductive method, and the detached
lines the major premises of the four paradigms based scientific voice, respectively, are acknowledged as
on their assumptions regarding ontology (nature goals that may be realized only imperfectly in actual
of reality), epistemology (acquisition of knowledge), practice. For this reason, the post-positivist para-
axiology (role of values), rhetorical structure (lan- digm embraces theory falsification rather than veri-
guage of research), and methodology (research proce- fication, while maintaining the remainder of the
dures). Generally, it can be said that positivist and positivist assumptive structure. Both the positivist
post-positivist paradigms most often undergird quan- and post-positivist paradigms stand in contrast to
titative research, whereas constructivist-interpretivist the two broad classes of qualitative research para-
and critical-ideological paradigms most often form digms described below
the foundation for qualitative research. However,
these distinctions are not completely orthogonal; the Constructivist-Interpretivist Paradigms
post-positivist position, for example, can typify the In contrast to the ontological assumption of a fixed,
work of some qualitative as well as quantitative external, measurable reality that can be apprehended,
researchers, and some of the specific “qualitative” the constructivist-interpretivist paradigm assumes
approaches (e.g., participatory action research, eth- a relativist notion of multiple, equally valid realities
nography) may incorporate different forms of quan- that are constructed in the minds of actors and
titative data if appropriate to the goals of the study. observers; that is, there is no objective reality that
exists apart from the person who is either experi-
Positivist and Post-positivist Paradigms encing or processing the reality, or both. Thus, any
Positivism is often called the “received view” in psy- account of a phenomenon is necessarily an experi-
chology (Guba & Lincoln, 1994, cited in Ponterotto, entially driven, co-constructed account influenced
2005). It is based on the theory-driven, hypothesis- by the narrator/actor/participant and the listener/
testing, deductive methods of the natural sciences, observer/researcher, both of whom bring their
and involves a controlled approach to generat- unique interpretive lenses (shaped by context, his-
ing hypotheses about a phenomenon of interest, tory, individual differences, and other forces) to the
collecting carefully measured observations, testing co-constructed account, which itself is created
hypotheses for verification using descriptive and within a particular experiential context. Epistemo-
inferential statistics, and producing general theories logically speaking, then, there cannot be separation

238 m ethodologie s
between the participant and the researcher, as the Epistemologically, the mutual, transactional rela-
process of coming to know and understand is tionship between participant and researcher embed-
a transactional process that relies on the relationship ded in the constructivist-interpretivist paradigm is
between them and their mutual construction and presumed but expanded to a more dialectical aim of
interpretation of a lived experience. Imperative to “inciting transformation in the participants that
building the kind of relationship that facilitates leads to group empowerment and emancipation
a full and detailed sharing of lived experience is from oppression” (Ponterotto, 2005, p. 131). Thus,
connection to and entry into the participant’s world axiologically speaking, values on the part of the
on the part of the researcher; thus, methodologi- researcher not only are acknowledged and described,
cally, the research process often involves intense and but become the driving force behind the ultimate
prolonged contact between researchers and partici- goal of social change.
pants, utilizing narrative, observational, contextual, As might be expected in an approach in which
historical, and other kinds of data that reveal deep research constitutes a social intervention, the con-
or hidden aspects of the lived experiences under structivist-interpretivist methodological practice
investigation. of deeply connecting to individuals to document
It should be obvious that the role of the researcher their lived experiences becomes liberationist in the
differs markedly in this paradigm from the positiv- critical-ideological paradigm. As such, the researcher
ist or post-positivist researcher position. Researcher joins with participants not only as a reflective,
subjectivity in a constructivist-interpretivist para- empathic chronicler of their lived experiences, but
digm is not only acknowledged but becomes an as a passionate advocate for the social change that
integral part of the research process. Axiologically, would empower and emancipate them. This kind
values are acknowledged as important, but “brack- of approach necessitates much more prolonged
eted” so that they do not unduly influence the engagement between researchers and participants
lived experience or the perception of that experi- than is typical in behavioral research and often
ence being shared and documented, and researcher results in deeply forged alliances that are maintained
reflexivity (in the form of deep reflection, self- long after the formal research project has ended.
monitoring, and immersion in the participant’s The advocacy stance on the part of the researcher
world) is vitally important to maintaining the integ- also is reflected in the rhetorical structures used in
rity of the researcher–participant relationship. Rhe- critical-ideological research, which include descrip-
torically, the intense involvement of both the tion of the societal (interpersonal and intergroup
researcher and the participant in the constructivist- relationships, institutional, community, and policy)
interpretivist research process is captured in first- changes that resulted or are expected to result from
person language, detailed descriptions of how the research.
interpretations were generated, direct quotations The constructivist-interpretivist and critical-
from the primary data sources (e.g., narratives), and ideological paradigms give rise to and subsume
personal reflections of the researcher, including most of the specific qualitative approaches being
statements regarding values and expectations that used in psychology currently. Although qualitative
likely influenced the work. approaches share some basic philosophical and epis-
temological premises, each of the extant approaches
Critical-Ideological Paradigms has features that distinguish it from other approaches.
The critical-ideological paradigm shares a great deal However, some approaches are more fully developed
of its assumptive structure with the constructivist- and articulated than others, leading qualitative
interpretivist paradigm, upon which it is built. researchers to borrow and combine aspects of other
However, it is more radical in its goals, which approaches (e.g., coding procedures, interviewing
include disruption of the power inequalities of the techniques) in the implementation of studies that
societal status quo and the liberation and transfor- may emanate from very different philosophical and
mation of individual lives. Ontologically, it assumes epistemological foundations and goals. In addition,
relativist, constructed realities, but it focuses on a host of contextual factors shape the practical appli-
historically and societally situated power relations cation of qualitative research aims, such as academic
that permeate those realities, and it seeks to disman- publish-or-perish institutional structures, lack of
tle the power structures that have been socially qualitative expertise and training in most graduate
constructed to oppress particular groups of people programs, and lack of resources or support for the
(e.g., women, people of color, sexual minorities). kind of sustained effort considered ideal in these

be t z, fassinge r 239
approaches. Thus, the variability among approaches statistical methods would require several textbooks,
(as well as the specific philosophical underpinnings obviously beyond the scope of this chapter. We
of a study) may be masked by compromises in con- cover the most commonly used methods in counsel-
ducting the actual study. ing psychology research and refer readers to well-
Because qualitative approaches differ substan- known introductory statistics books and to advanced
tially based on their particular paradigms and epis- volumes such as Tabachnick and Fidell’s (2007)
temological assumptions throughout all phases of excellent text Using Multivariate Statistics.
the research (and the closer the adherence to core
tenets of the approaches, the greater the differences), Describing Observations
every qualitative research project must begin with a Two basic areas of introductory statistics are scales
thoughtful consideration of these issues (Denzin & of measurement (Stevens, 1951) and descriptive sta-
Lincoln, 2000; Patton, 2002; Ponterotto, 2002, tistics, and they will be mentioned here only briefly.
2005). Quantitative approaches, on the other hand, Scales of measurement—nominal, ordinal, interval,
because they tend to share in common a positivist and ratio—are important because our use of quan-
or post-positivist paradigm involving hypothetico- titative methods often depends on the kind of data
deductive theory verification or theory falsification we have. Nominal, or categorical, scales do not
methods, find their variability in approach primar- actually represent measurement but rather category
ily in the kinds of measurement (e.g., interval or membership, for example gender or marital status.
categorical) and statistical analyses (e.g., correlation Next in level of measurement is the ordinal scale,
or analysis of variance) utilized. In the following or rank orders. League standings in baseball and
section, we provide an overview of quantitative class rank are ordinal scales. These numbers have
methods. a “greater than” or “less than” quality, but the inter-
vals between numbers are not necessarily (or even
Quantitative Methods usually) equal. Next in level is the interval scale, in
As noted above, quantitative methods are based which not only order but interval size are presumed
on positivist or post-positivist epistemologies in to be meaningful. Most test data are interval scale
which theories are used to guide hypothesis genera- data. Finally, ratio scales have a true zero point as
tion and hypothesis testing regarding phenomena well as ordinal meaning and the assumption of equal
of interest. Hypotheses are examined using care- intervals. Ratio scales are often found in the physi-
fully defined and obtained empirical observations, cal or psychophysical sciences.
which are assumed to represent important abstract Basic descriptive statistics are also important—
constructs. These hypotheses are tested using in their eagerness to move to inferential statistics,
descriptive and inferential statistics. The usefulness many researchers underemphasize the basic impor-
of quantitative methods depends on the quality of tance of descriptive statistics, or how the numbers
the observational data, which in this case refers to “look.” If we recall that numbers reflect the observa-
the quality of measurement. Measurement is the tions of people, basic summary descriptions of those
process by which we assign numbers to observa- numbers become interesting. Observations can be
tions, usually of human characteristics or behaviors. described using frequency distributions (numbers
Measures (scores) could be derived from a voca- of observations at each score point or score interval,
tional interest inventory, from a measure of depres- often called histograms [bar diagrams] or frequency
sive symptoms, from a measure of client’s liking for polygons). The most important frequency distribu-
the therapist, or from an index of problematic eating tion is the normal distribution, or bell curve, which
behaviors. What is essential is the quality of mea- has certain very useful properties, most especially
surement, usually grounded in the concepts of predicted percentages of cases that fall above and
reliability and validity. Without reliable and valid below each z score point on the normal curve. These
measures, further data analysis is futile, a waste points are used in determining such critical statistics
of time. Detailed discussion of the quality of mea- as standard error of measurement and standard error
sures is outside the scope of this chapter, but see of estimate.
the chapter by Swanson (2011, Chapter 8, this The best known descriptive statistics are mea-
volume). sures of central tendency and variability. Measures of
The next sections will summarize different central tendency include the arithmetic mean,
types of data analysis using quantitative methods. median, and mode, and indices of variability include
It is important to note that complete coverage of the range, the variance, and the standard deviation

240 m ethodologie s
(the square root of the variance). Descriptive statis- of individual scores around that mean. The wider
tics are important in and of themselves. For exam- the variability, the greater will be the variance, or its
ple, we may want to answer the question, “How positive square root, the standard deviation. The
depressed are college students at our university?” variance and standard deviation are based on the
Not only the mean score on our measure of depres- sum of squared deviations of individual values from
sion but the range and variance of scores are critical the sample mean, divided by the degrees of free-
information—for example, how many of our stu- dom, generally n-1 to reflect that the mean used is
dents are at risk of suicidal thoughts or behavior? the sample rather than the population mean. The
We usually compare score means across gender or concept of SS is very important in ANOVA and
race/ethnicity, for which we need group standard regression as well, as it is a basis of the general linear
deviations as well as means. We may want to com- model (GLM) fundamental to many of our statisti-
pare the scores of a new sample with the original cal methods.
normative sample. We may want to compare the
scores of those receiving an intervention to those in the t test
a control group. Thus, the mean, variance, and stan- Given the above, we begin with a null hypothesis,
dard deviation are fundamental to many types of which usually is that group means are not different
analysis. from each other. The test statistic, in this case t, is
the difference between our two means divided by
Inferential Statistics—Group Differences the standard error of the difference. This latter value
When we want to compare means—such as those is the combined standard deviations divided by the
of women and men, normative versus new samples, combined degrees of freedom. Most computer pro-
or those of treatment versus control groups— grams will give the value of t for both pooled and
we usually begin with the assumption that we are separate variances—pooled variance estimates are
examining a sample or samples from a population/ appropriate if it can be assumed the two population
populations. Only in very rare instances would we variances are equal. Normally, the statistical soft-
assume that we have assessed the entire population, ware will provide as an option a test of homogeneity
and we will not deal with that possibility here. of variance, often Levene’s test, Hartley’s F max
Because we are assessing samples from populations, test (Kanji, 1993), or Bartlett’s test (see Glass &
we are using inferential statistics, making educated Hopkins, 1984; Kanji, 1993). If the hypothesis of
guesses about population parameters from sample homogeneity of variance is rejected, then the sepa-
statistics. In doing this, we assume that a population rate variance estimates must be used.
parameter has a sampling distribution with a mean The obtained value of t is taken to the table
and standard deviation, and that sample values of percentile points of the t distribution, sometimes
taken from the population will array themselves called the critical values of the t distribution. Using
around the population mean—this array of values is the degrees of freedom, we determine the critical
known as the sampling distribution. Generally speak- value for rejection of the null Ho at the prescribed
ing, the larger the standard deviation of the sam- value of α—for example, if our two groups each
pling distribution, the more variation in means we had an N of 21, then our df would be 40 and
will have when sampling from that distribution. the critical values of t are 2.021 (p < .05), 2.704
The key question for our statistical methods— (p < .01), and 3.551 (p < .001). As sample sizes
t-tests, analysis of variance (ANOVA) and multi- increase, t approaches the value of z. At df = infinity,
variate analysis of variance (MANOVA)—is to the critical t at .05 is 1.96, which is also the .05
estimate the probability that the means have come critical value for the z statistic.
from the same versus different populations (we do
not refer to z tests here because they assume that we confidence intervals and effect sizes
have sampled the entire population). In addition to acceptance or rejection of the null
hypothesis, we should compute both confidence
sum of squares intervals and effect sizes. There has been much criti-
Before proceeding, it may be helpful to review the cism of null hypothesis significance testing (NHST)
concept of sum of squares (SS), which is critical to based on the fact that it allows us only to reject a
the variance calculations required by all these tests. null hypothesis (which usually is not what we actu-
Recall that a sample has a mean that is an estimate ally want to know), at an arbitrary and necessarily
of the population parameter. And it has variability dichotomous level, instead of giving us a probability

be t z, fassinge r 241
that our desired hypothesis is true. Cohen (1994) standard deviation were 30, d would be .17, less
argues that what we want to know is, “Given these than what Cohen would require for a small effect.
data, what is the probability that Ho is true?” but In the first case, the difference is one-half a standard
that what it actually indicates is, “Given that Ho is deviation, but in the second case it is only one-sixth
true that is the probability of these (or more extreme) a standard deviation.
data?” (p. 997). One major use of effect size data is in the tech-
Confidence intervals improve hypothesis testing nique of meta-analysis, first coined by Glass (1976).
by providing estimates of the range of values that Meta-analysis is used to quantitatively summarize
likely includes the true population value. When the findings of many studies of the same general
based on a t test, the confidence interval is the mean topic. In the case of mean differences, we often use
difference plus or minus a value computed as the it to summarize a number of studies of a treatment
critical value of t, multiplied by the standard error versus a control group. In the classic study of Smith
of the difference. Thus, we derive a confidence inter- and Glass (1977), 833 comparisons of psychother-
val that contains the true (population) difference apy treatment versus control groups were done,
with a probability of 1- p; if that interval includes yielding a definitive conclusion of the effectiveness
zero, then we have not rejected the null hypothesis of psychotherapy. Meta-analysis involves searching
of no difference between the means. the literature for all relevant studies, extracting the
Also, because the statistical significance of t tests statistic of interest (in this case the effect size of
is dependent on sample size, we could find that a comparison of means) and then averaging the
a trivial difference in means was statistically signifi- effect sizes across studies, often weighted by sample
cant but practically unimportant. Likewise, we size or, in some cases, by judgments of the quality of
might overlook a potentially important difference if the studies. Meta-analyses can also be done within
small sample sizes prevented it from reaching statis- subgroups, such as gender or race/ethnicity; in the
tical significance. Because of this, it is always advis- case of Smith and Glass (1977), analyses were done
able to also calculate effect size, an index of the for each theoretical approach to therapy. Readers
importance of the difference or, as noted by Kirk may consult Glass (2006) for a comprehensive
(1996) “practical significance.” There are several discussion of how to conduct a meta-analysis.
indices of effect size in terms of standardized mean ANOVA is used to simultaneously test the differ-
differences, most commonly Cohen’s (1969) d and ences between two or more means. When there are
Glass’ (1976) δ. Cohen’s d is the mean difference only two means, its results are identical to those
divided by the combined (pooled) standard devia- from a t test, but it is more versatile in that three or
tion. It essentially can be interpreted as the size more means can be tested for difference simultane-
of the difference in standard deviation units, and is ously. The null hypothesis is that the population
directly related to the amount of overlap between means (μ) are equal: μ1 = μ2 = μ3, etc. This is also
two score distributions. Greater effect size equals called an omnibus test of the equality of means.
less overlap between the distributions. With cau- The method of ANOVA utilizes the decomposi-
tion, in that all interpretations must be based on the tion of variance components. In a simple one-way
context and purposes of the research, Cohen (1988) analysis of variance, when there is only one inde-
recommended the following ranges of d : .20 to .50 pendent variable, the total variance is the sum of the
is a small to medium effect, .50 to .80 is a medium variance between treatment and the variance within
to large effect, and over .80 is a large effect. There is treatments. We estimate these using the concept of
not a one-to-one correspondence between statistical sums of squares mentioned previously. The total SS
significance and effect size—a difference can be sta- is the squared deviation of each score in the entire
tistically significant but not practically important set from the grand mean of all the scores. The
and vice versa. SS Between is the SS from the squared deviation of
Effect size is especially important since a differ- each group mean from the grand mean, and the
ence of a given magnitude can be more or less SS Within is the sum of squares of each individual’s
important based on the overall spread of the score score from the mean of his or her group.
distributions. Assume we have a mean difference of To convert these into variances we obtain the
5 score points between men and women; if the stan- mean squares (MS) by dividing the SS by the degrees
dard deviation of the combined distributions is 10, of freedom, usually shown as the Greek letter ν.
we have an effect size (d ) of .5, what Cohen would For the between-group SS, ν is J–1, where J is
describe as a moderately large effect. But if the the number of groups, and for the within-group SS,

242 m ethodologie s
ν is n–J–1, where n is the total sample size and J is medium, and large effect sizes, respectively. ω2 esti-
again the number of groups. The test statistic F, is mates the effect size in the population (Tabachnick
MSB/MSW, or the between-group variance divided & Fidell, 2007). The intraclass correlation also
by the within-group variance. We take this value to can be used as an index of effect size in ANOVA
the F table using the df of 1 and 17. The closer the models.
value of F is to 1.0, the less likely it is to be statisti- Vacha-Haase and Thompson (2004) provide an
cally significant—if the MSB/MSW is close to 1, excellent table summarizing strategies for obtaining
then we can assume that they are estimating the effect sizes for different analyses using IBM’s SPSS
same variance, the population variance, and that the software suite (p. 477).
groups do not differ from each other. If the value of
F is statistically significant, we can reject the null confidence intervals for effect sizes
hypothesis of group mean equality. Note that, if There are two final important trends to mention
there are three or more groups, a significant result in hypothesis testing. First, the American Psycho-
does not tell us specifically which groups are differ- logical Association (APA) Task Force on Statistical
ent from each other—that is examined using post Inference included as a recommendation that confi-
hoc tests of means, such as the Tukey, Tukey-B, and dence intervals be provided for effect sizes them-
Scheffe tests. selves (see Tabachnick & Fidell, 2007, and Vacha-
Next in complexity to one-way ANOVA is two- Haase & Thompson, 2004, for further details).
or more-way ANOVA, used with factorial designs. Moreover, some journal editors are now recom-
A factorial design involves two or more independent mending that the statistic called prep (probability
variables, for example type of treatment and gender. of replication) should be reported instead of the
The IVs can be manipulated or formed into “natural p itself. The prep is the probability of replicating an
groups” (such as gender or ethnicity, groups, which effect and is itself a function of the effect size and
existed a priori and are not manipulated). When the sample size (Killeen, 2005). The value of prep is
each level of one IV is paired with each level of the inversely related to p—for example, in a given study,
other, we call it a completely crossed design. This is p values of .05, .01, and .001 might correspond
probably the most commonly used factorial design, respectively to prep values of .88, .95, and .99
although there are many others—see research design (Killeen, 2005). Note that prep is a positive way of
texts (e.g., Heppner, Wampold, & Kivlighan, 2008) attaching a probability to the likelihood that we will
for possibilities. A two-way ANOVA can provide find the same effect again, instead of a statistical
one or more main effects and/or an interaction sign that we should reject a null hypothesis.
effect. MANOVA is appropriate when we have several
In a two-way ANOVA, we calculate the MS for dependent variables (DVs). Using the logic of
each independent variable and the MS for the inter- type 1 error, rejecting the null hypothesis at p < .05
action between the independent variables. Each means that there is a .05 chance of error, that is, of
MS is divided by MSW(within) to get the F for that falsely rejecting the null hypothesis. When we do
effect. These are taken to the appropriate cell in the several tests at the .05 level, we compound that
F table to determine whether we accept or reject the probability of error—we have what is called “exper-
null hypothesis for that effect. Again, with an inter- iment-wise error” or “family-wise error.” With two
action or any main effect involving more than two DVs, the error rate is approximately .10, and with
levels, we must do post hoc tests. five DVs it is .23 (see Haase & Ellis, 1987, for the
formula). Clearly, these levels of experiment-wise
effect sizes error will lead to excessive type 1 error.
In the same way that we use effect sizes to evaluate One method of correction for this error is
the practical importance of the differences when we known as the Bonferroni correction, which sets the
have done t tests, effect sizes also should be provided per comparison level of α at approximately α/p,
for ANOVA and MANOVA. The effect sizes we use where p equals the number of dependent variables
here are in terms of variance accounted for, which is (Tabachnick & Fidell, 2007). This correction is
also known as strength of association. η2 is the pro- adequate if the variables are not correlated, or if they
portion of sample total variance that is attributable are highly correlated, but it is not preferable if the
to an effect in an ANOVA design. It is the ratio of variables are mildly correlated, which will be true in
effect variance to total variance; Cohen (1988) sug- most cases. In these cases, MANOVA can be used.
gests that η2 = .01, .09, and .25 correspond to small, It controls the experiment-wise error at the original

be t z, fassinge r 243
α, .05, .01, or .001, whatever probability had been for a correlation is that the population parameter ρ
determined as the critical value. Like ANOVA, is equal to 0. All statistics texts contain a table that
MANOVA can involve only one factor or it can presents this as a function of sample size—the larger
involve a factorial design with two or more IVs. The the sample size, the smaller an r must be to be statis-
analysis yields a multivariate F based on an “omni- tically different from zero. For example with an N of
bus” or simultaneous tests of means, which describes 100, a correlation of .20 is significant at p < .05,
the probability of type 1 error over all the tests whereas if the N were 1,000, a correlation of .06
made. If the multivariate F is statistically significant, would be significant at that level. As with all hypoth-
we may proceed to examine the univariate F statis- esis testing, we specify the level of type 1 error we
tics, the same as those we would receive in a uni- are willing to tolerate, and test our hypothesis at
variate ANOVA, to determine which dependent the .05, .01, or .001 levels. If the N is large enough,
variables are contributing to the significant over- very small correlations can be statistically signifi-
all F. The F statistics in MANOVA are provided by cant. For example, the critical value of r (p < .01) in
one or more of four statistical tests—Wilkes’ λ, a sample of 10,000 is .02.
Pillai’s trace, Hotelling’s trace, and Roy’s criterion The latter is an example of a case in which a sta-
(see Haase & Ellis, 1987). tistically significant value may be practically insig-
nificant. The square of the r is the coefficient of
Describing Relationships determination, which is the percentage of variance
Methods for studying relationships between and shared by the two variables. Thus, a correlation
among variables have at least two important uses of .10, when squared, is .01, meaning that only 1%
within psychology. The most basic use is to further of the variance is shared between the two variables,
the understanding of human behavior by helping and 99% of their variance is not shared. Under most
to elucidate the interrelationships of behavior, per- circumstances, this would be a trivial association. In
sonality, and functioning. Another important use the example given above, the statically significant
is that of prediction; when we understand relation- correlation of .02 when N = 10,000, we are account-
ships, we can use them to predict future behavior. ing for only an infinitesimal .0004% (4/10 of 1%)
The study of relationships, including those used in of the shared variance between the two variables.
prediction, begins with the topics of correlation and In addition to the percent of shared variance,
regression. The ideas of association, or covariation, practical importance also is reflected by effect size,
are fundamental in science, including psychology. as it is with the description of mean differences in t
Many of our quantitative methods are based on the tests and ANOVA. The value of r is itself an estab-
study of relationships. lished index of effect size, and its interpretation
The index of correlation we use depends on the is based on its relationship to the most common
nature of our variables, but the best known and measures of effect size, such as Cohen’s d (1988).
most frequently used is the Pearson product moment Cohen (1992) attaches values of r of .10, .30, and
correlation r. This statistic describes the relationship .50 to small, medium, and large effect sizes, respec-
between two interval scale variables, and its calcula- tively, but it should be recalled that these describe,
tion is based on the cross-products of the deviation respectively, only 1%, 9%, and 25% of the shared
of each score from its own mean. These values can variance.
be positive in value, indicating that, as one variable Table 9.1 contains a matrix of correlations among
becomes large, the other one does as well; negative, eight personality variables measured by the Healthy
indicating that larger values of one are associated Personality Inventory (Borgen & Betz, 2008), an
with smaller values of the other; or zero, meaning inventory designed to reflect the emphasis on posi-
that there is no association between the two vari- tive psychology and the healthy personality. The
ables. Pearson correlations range from 1 to –1, and table provides the bivariate correlations among the
it is the absolute value of the correlation that indi- eight variables. As is standard practice, no values
cates its strength—a correlation of –.5 is as strong are shown for the diagonal, as they are 1.0 (the cor-
as one of .5. relation of a variable with itself, although in some
Correlations can be interpreted in terms of sta- cases the value of coefficient α is shown instead).
tistical significance, percentage of variance accounted The table is bilaterally symmetric, so it is necessary
for, and effect size. Statistical significance when to show only the upper or lower diagonal. In some
applied to a correlation means that the correlation is cases, values for one gender are shown above the
statistically different from zero. The null hypothesis diagonal, and those for the other gender are shown

244 m ethodologie s
Table 9.1. Intercorrelations among Eight Scales whether or not one causes the other or whether
of the Healthy Personality Inventory (Borgen & both are caused by a third (or more) variable. For
Betz, 2008) example, we might find that depression and loneli-
Variable 1. 2. 3. 4. 5. 6. 7. 8. ness are correlated. We could postulate that depres-
sion leads to loneliness, that loneliness makes people
1. Confident .51 .44 .71 .37 .50 .28 .58 depressed, or that some third variable like low self-
2. Organized .68 .72 .17 .34 .03 .26 esteem or perceived social inadequacy causes both
depression and loneliness. Other research designs
3. Detail-oriented .66 .20 .38 .12 .27 (e.g., experimental examinations of treatments for
4. Goal-directed .30 .51 .20 .47 low self-esteem, depression, or loneliness, or struc-
tural equation modeling) are required to address
5. Outgoing .66 .56 .65
questions of causality.
6. Energetic .47 .58
7. Adventurous .71
other correlation coefficients
Although r is the most commonly used index of
8. Assertive correlation, a number of others are suitable when
Values for 206 college students. For an N of 206, values of r of .14, one or both variables are not interval in nature. φ is
18, and .23 are significant at the .05, .01, and .001 levels, often used with two categorical variables, whereas
respectively, for a two-tailed test.
the contingency coefficient is used with two poly-
chotomous variables (categorical variables with
below the diagonal. Values of r that are statistically more than two categories, such as marital status or
significant for an N of 206 are provided in a note race/ethnicity). The relationship between a dichoto-
below the table. mous variable (such as right–wrong or true–false
It is important to note four cautions. The value answers) and a continuous variable, such as total
of r reflects only linear relationships. If there is cur- test score, is indexed by the point-biserial coefficient
vilinearity in the relationship, then the relationship if we assume a true dichotomy, or the biserial coef-
is better described by the statistic η. Second, the ficient, which assumes that the dichotomous answer
value of the correlation coefficient will be restricted actually reflects an underlying continuum and is
if there is restriction in range in either or both of the therefore dichotomized. The biserial is not a Pearson
two variables being studied. If there is little variabil- product moment r, so its absolute value can exceed
ity in the scores, there is less chance for changes on 1.0. Correlations between data, when both sets of
one to be reflected by changes in the other. There numbers are ordinal, can be computed using the
are formulas for corrections for restriction in range Spearman rank correlation (see Glass & Hopkins,
(see Hogan, 2007, p. 122), and these are often used 1996).
in predictive validity studies (see Sireci & Talento-
Miller, 2006). But unless there is some reasonable Regression
expectation that score ranges can be increased, then Although the most basic reason for studying cova-
this correction is unduly optimistic and not reflec- riation is to understand the myriad relationships in
tive of what actual relationships will be found in the human behavior, characteristics, and functioning,
data. in many settings these relationships also are used to
A third caution is that we must resist the tempta- predict behavior, and in these cases we use the
tion to conclude that a statistically significant cor- method of regression. One of the oldest uses of
relation is “significantly larger” than a nonsignificant regression is based on the relationship between high
correlation. For example, if we had an N of 50, school grades and performance in college. Using a
a correlation of .28 would be significant (at p < .05), scatter plot, we could place the predictor variable,
whereas one of .25 would not be statistically signifi- high school grades, on the horizontal axis and the
cant, yet they are not statistically different from each criterion, college grade point average (GPA), on the
other. This must be tested by the z test for the sig- vertical axis. The relationship between these two sets
nificance of the difference between two values of of scores would be described by Pearson’s r. A regres-
ρ (see Glass & Hopkins, 1996). sion equation is an equation for a line Y ′ = bX + a,
Finally, correlation does not imply causation. where X is the value of the predictor variable and Y ′
Correlation reflects the covariation among two vari- is the predicted value of the criterion. In this equa-
ables, but does not allow any assumptions about tion, the a is the Y intercept, the value of Y where

be t z, fassinge r 245
the regression line crosses the y axis or, in other realistic estimate of the predictive power of the set
words, the value of y corresponding to an X of 0. of variables. The method of double cross validation
The b is the slope of the line and is a direct function involves separately obtaining an original set of
of the correlation r between X and Y. The slope of weights on each half of the sample, and then apply-
the line is the rate of change in Y as a function ing the within sample weights to the other sample.
of changes in X. Given the formula Y ′ = bX + a, we The average of the two R 2 is probably a good esti-
can estimate a person’s score on the criterion vari- mate of the predictive efficacy of the variable set.
able, given his or her score on the predictor vari-
able. The regression line is known as the “line of Meta-analysis
best fit” and is determined mathematically as that Meta-analysis, described previously in the discus-
equation which minimizes the errors of prediction sion of group differences, is used frequently in the
of the criterion from the predictor. In new samples, study of predictive validity. We use meta-analysis
we then could use this equation to make predictions in this context to summarize across many predictive
of collegiate performance from high school GPA. validity studies—the summary if we do find evi-
dence for predictive validity across studies is often
Multiple Regression called “validity generalization.” For example, DeNeve
In many cases, we wish to use multiple predictor and Cooper (1998) published a meta-analysis of
variables to predict a criterion—the simplest exam- 1,538 correlation coefficients from 148 studies of
ple of this is the use of both scholastic aptitude test the relationships of 137 personality variables to mea-
scores and high school GPA to predict college GPA. sures of subjective well being. In brief, they found
In this case, the formula for a line is generalized to that Big Five Neuroticism was the strongest (nega-
multiple predictors and takes the form Y ′ = b1 X1 + tive) predictor of life satisfaction and happiness and
b2 X2 +. . . bn Xn + a. The quality of prediction is the strongest predictor of negative affect. The stron-
based on the strength of the multiple correlation gest predictors of positive affect were Big Five
coefficient R, describing the relationship between a Extraversion and Agreeableness.
linear composite or summary of the predictor vari-
ables and the criterion variable Y. And R 2, like r 2, is Moderators and Mediators
referred to as the coefficient of determination. Two other types of variables often are used in pre-
Variables can be entered into a regression analy- dictive and other correlational studies—moderator
sis in several different ways. In simultaneous entry, variables and mediator variables. Perhaps because
all variables are entered together, and each is evalu- the two terms are similar and/or perhaps because
ated according to what it adds after the other vari- they both involve a “third variable” that influences
ables have been accounted for. In sequential or the interpretation and meaning of a bivariate corre-
hierarchical regression, variables are entered in a lation, these terms are often confused or are assumed
specific order as determined by the researcher. In to be equivalent. This is not the case.
stepwise regression, variables are entered one at As mentioned, both moderators and mediators
a time according to statistical criteria—forward, are third variables that can be involved in examin-
backward, and stepwise entry can be used (see ing the relationship between two other variables.
Tabachnick & Fidell, 2007). A moderator (see Frazier, Tix, & Barron, 2004) is
Regardless of the method of variable entry a third variable that influences the strength of rela-
utilized, weights in the equation should be cross- tionship of two other variables to each other but is
validated. Because multiple regression is a maximi- not related itself to either one. That third variable
zation procedure, meaning that it selects the weights can be categorical, such as gender, or interval, such
that will maximize predictive efficacy in that par- as job satisfaction. For example, two variables may
ticular sample, it is subject to shrinkage in subse- be more strongly related in women than in men or
quent samples. Therefore it is recommended that more strongly related in more highly versus less
the equation be cross-validated. This is done by highly satisfied workers. A moderator in ANOVA
dividing the original sample in two, with the devel- terms is an interaction in which the effect of one
opment sample being larger (see Tabachnick & variable depends on the level of the other. It may be
Fidell, 2007). In the cross validation step, the suggested that a moderator leads to “differential pre-
predictive weights derived for the first sample dictability” of criterion from predictor variables.
are applied to the second sample, and the resulting The analytic methods used to identify moderators
R 2 determined. The second R2 is probably a more include the z test comparison of two correlations

246 m ethodologie s
after conversion to Fisher’s Z (see Glass & Hopkins, or outcome (b); and (4) that the strength of the
1996) and moderated multiple regression (see relationship between predictor and criterion is sig-
Tabachnick & Fidell, 2007). Shown in Figure 9.1A nificantly reduced (c') after the variance due to the
is a hypothetical example wherein social support mediator is removed. This can be tested using mul-
moderates the relationship between stress and dis- tiple regression, structural equation modeling, or
tress. It is postulated that, for people high in social the Sobel (1982) test, a handy and easy-to-use test
support, the correlation between stress and distress is available online (e.g., www.quantpsy.org), or as a
lower than for those low in social support. The mod- subroutine of SPSS and other software.
erator effect is shown by an arrow leading down to
the arrow showing the relationship between stress Discriminant Analysis
and distress. Suppose that, for high support individ- Discriminant analysis is a topic that could be cov-
uals, the correlation is only .10, whereas for low sup- ered either in the section on MANOVA or in this
port individuals it is higher, .50. If these are shown section on multiple regression in that it has pur-
to differ significantly using the z test following trans- poses and procedures similar to both (see Sherry,
formation to Fisher’s Z, then we can conclude a 2006, for an extended description of discriminant
moderator effect for social support in this study. analysis). Probably the most common use of dis-
Moderator effects should always be replicated and criminant analysis is the use of multiple predictor
the search for them should be based on theoretical variables to predict a categorical criterion—thus, it
considerations rather than “data snooping.” is like multiple regression except that the criterion
A mediator is a variable that represents the gen- variable is categorical rather than continuous. It is
erative mechanism by which one variable affects like MANOVA in that it tells us which of a set of
another (Baron & Kenny, 1986). In this case, we variables differs significantly as a function of group
have a relationship between two variables, but we membership. Probably its most frequent use would
postulate that the intervening mechanism is the rela- be to use a set of predictor variables to predict suc-
tionship of each with a third variable, the mediator. cess versus failure, for example, in a job training
Figure 9.1B shows a postulated mediator relation- program or in completion of a college degree. Like
ship for the same variables shown in Figure 9.1A. regression, it yields a set of weights that are applied
Say, for example, that we postulate that stress causes to the predictors to yield the maximally predictive
people to avoid social support, which causes them composite of scores to predict group membership.
distress. If the relationship between stress and As another possibility, discriminant analysis could
distress is significantly reduced when the path to be used as a follow-up to a significant MANOVA.
social support is considered, we may have a media- MANOVA tells us whether or not a set of variables
tor. Baron and Kenny postulate that finding a medi- significantly differentiates two or more groups, con-
ator requires four steps (shown in the figure): trolling for the experiment-wise error by giving us
(1) that the predictor is related to the criterion a multivariate F. Post hoc univariate tests tell us for
(c); (2) that the predictor is related to the mediator which variables significant group differences exist,
(a); (3) that the mediator is related to the criterion but they do not tell us which variables contribute

Social Support Social Support

.48 (a) .40 (b)

Psychological or
Stress Psychological
Physical Distress Stress
Distress
.50 (c)
.10 (c’)

Fig. 9.1 (A) Hypothetical example of social support as moderator variable. (B) Hypothetical example of social support
as mediator variable.

be t z, fassinge r 247
most strongly to the overall group separation. Dis- the probability of correct classification is based on
criminant analysis will give us discriminant weights, the cumulative number of correct classifications
analogous to regression weights, which will tell us across all cases.
the strongest contributors to the group differences. An excellent example of the use of discriminant
Effect sizes could be used with the MANOVA to analysis in counseling psychology research is the
determine the variables leading to the largest differ- study of Larson, Wei, Wu, Borgen, and Bailey
ences between the groups, but that method would (2007) of the degree to which personality and con-
not control for the intercorrelations among the fidence measures differentiated four college major
predictors. groups in 312 Taiwanese college students. Persona-
Like MANOVA, discriminant analysis requires lity and confidence measures each differentiated the
a set of two or more variables for two or more college major groups well, but the combination of
groups. The method of analysis involves a search for both significantly improved prediction beyond
the linear equation that best differentiates the either set used alone.
groups, so it is (like multiple regression) a maximi-
zation procedure and must be cross-validated. The Other Related Analyses
analysis yields at least one discriminant function, Less often used in counseling psychology research
analogous to a regression equation, which contains but worth knowing about are logistic regression and
a set of β weights that are applied to the variables. multiway frequency analysis (MFA; or its extension,
Like β weights in regression, the weights indicate log-linear analysis). Both are used with data in
the importance of the variables in separation, or dif- which some or all are categorical. Logistic regression
ferentiating, the groups. The maximum number of (see Tabachnick & Fidell, 2007, for a full descrip-
discriminant functions is the number of groups tion) is used to predict a categorical dependent
minus 1 or the number of predictors, whichever variable (criterion) from a set of interval and/or cat-
is smaller. Of the discriminant functions, none, one, egorical variables. It is used extensively in the medi-
or more can be statistically significant. If not signifi- cal field. For example, gender and whether or not
cant, then the function is not making a meaning- a smoker (both categorical), and body mass index
ful contribution to our understanding of group and amount of exercise per week (both interval
differences. scale), could be used to predict whether or not
For predictive purposes, the weights are applied someone has a heart attack before age 50. Logistic
to each individual’s scores and compared with what regression is similar to discriminant analysis except
are termed group centroids to estimate the probabili- that the latter uses only continuous predictor vari-
ties of group membership. If the discriminant ables (unless categorical variables are dummy coded,
weights are applied to the mean scores within each e.g., assigning 1 to female and 2 to male).
group, the results, two or more centroids, depend- Multiway frequency analysis, or an extension
ing on the number of groups differentiated, will be called log-linear analysis, is used to examine the rela-
maximally separate from each other. We assign each tionships among multiple categorical variables. If
individual’s score composite to the closest centroid. we have only two categorical variables, we use the
The number of correct versus incorrect assignments χ-square test of independence to investigate the
is known as the “hit rate” and is compared to the relationship (vs. independence) between the two
probability of correct assignment by chance. For variables. For example, we could examine the rela-
example if we have three groups of equal size, the tionship between gender and whether or not a stu-
probability of making correct assignments by chance dent dropped out of college before finishing. If we
is .333. To the extent that the discriminant weights have three or more categorical variables (for exam-
can improve on that, which we examine using the ple, race/ethnicity and whether or not the student is
z test for the difference between proportions (Glass a first-generation college student in addition to
& Hopkins, 1996), the discriminant function is gender and completion of college), we would use
enhancing prediction. Cross-validation can be done MFA. For more information on all of these methods
using a holdout sample, double cross validation, see Tabachnick and Fidell (2007).
and the “jackknife” method. In the latter method, Finally, one problem which is common to all
one case is held out at a time, and the discriminant quantitative data analyses is the problem of miss-
function is calculated based on the remaining cases. ing data. Several recent papers (Schafer & Graham,
The weights are applied to the case held out to make 2002; Sterner, 2011) have detailed the types of
a group assignment. This is done for each case, and missing data and methods for handling each type.

248 m ethodologie s
Usually less problematic are those instances where Given such a matrix, software from packages
missing data are assumed to occur at random, such as SPSS, SAS, CEFA, BMDP, Systat, or
while more serious problems may be caused in RAMONA are used to do the analyses. However,
instances where there is non-randomness, or syste- any EFA involves a sequential series of consider-
maticity, in the missing data – for example if miss- ations that will determine the results of the analysis.
ing data is significantly more likely among one These considerations are the nature of the variables
gender or ethnic group than the other gender and sample, the appropriate method of analysis,
or another ethnic group. These articles provide method of factor extraction, number of factors to
excellent suggestions for handling missing data in extract, and method of rotation. In addition, the
all of these cases and provide recommendations for interpretation or naming of the factors and the deci-
statistical software that can be useful in each of these sion as to whether or not to compute factor scores
cases. follow the analyses themselves.

Examining Structure and Dimensionality assumptions regarding the data

factor analysis In both EFA and CFA, certain assumptions about
Factor analysis has been one of the most widely used the data are necessary. First, quality solutions result
analytical procedures in psychological research. It only from quality data—measures (or items, if it
began with the work of Charles Spearman (1904) is to be a factor analysis of an item set) must be
on the structure of mental abilities. He developed carefully selected to represent a defined domain
a mathematical model specifying that ability tests of interest (Fabrigar et al., 1999). Just as in scale
were composed of two factors—a general ability construction itself, the quality of the scale depends
factor ( g ) and a specific factor (s). Factor analysis on the care put into defining the construct or
has grown into a family of methods that enable us domain of interest. There should be evidence for
to study the structure and dimensionality of mea- item or scale reliability. MacCallum, Widman,
sures and of sets of variables. For example, we could Zhang, and Hong (1999) suggest that, if one has an
use factor analysis to determine dimensions under- idea of the common factors to be represented, three
lying several indices of social behavior or to ask how to five measured variables (MVs) per factor will pro-
many underlying dimensions of personality there vide stable and interpretable results. If the researcher
are in a new measure we have constructed. In recent does not have hypotheses about the number of
years, factor analytic methods have been differenti- common factors, then the domain of variables
ated as exploratory factor analyses (EFA) and confir- should be delineated carefully and as many of those
matory factor analyses (CFA). variables as possible included in the study. The data
should be interval or quasi-interval in nature and be
Exploratory Factor Analysis normally distributed, although the latter criterion
As defined by Fabrigar, Wegener, MacCallum, and depends on the method of factor extraction used.
Strahan (1999): “The primary purpose of EFA is to Some researchers have found that both EFA and
arrive at a more parsimonious conceptual under- CFA are relatively robust in the face of non-normal-
standing of a set of measured variables by determin- ity. However, less biased fit indices and more inter-
ing the number and nature of common factors pretable and more replicable solutions may follow
needed to account for the pattern of correlations when data are normally distributed.
among the measured variables” (p. 275). Exploratory
factor analysis is used when the researcher has no sample size and variable independence
a priori theories about the structure of the measure Although there has been much discussion of nec-
or construct, or when a priori theories have not essary sample sizes for factor analysis, a generally
been supported by confirmatory factor analyses. accepted guideline is five to ten participants per
The method utilizes a matrix of either correlations variable or item, if the analysis is at the item
or covariances describing the relationships among level (Joreskog & Sorbom, 2008). If sample sizes
the variables to be analyzed. The variables can be are larger than that, they may be divided into sub-
measures or items, for each of which there is a matrix samples, so that the solution can be replicated.
of scores for a sample of people. The correlation or However, other authors have demonstrated that
covariance matrix is a symmetrical matrix showing when common factors are overdetermined (three
the relationships of each variable with every other or four variables per factor) and communalities are
variable (or item). high (averaging at least .70), smaller sample sizes

be t z, fassinge r 249
(e.g., N = 100) are often sufficient (MacCallum with other variables in the set. There are several
et al., 1999). When the reverse is true—that is, fac- commonality estimates typically used, including the
tors are less well determined or communalities are largest correlation of a variable with any other vari-
lower—even very large sample sizes (up to N = 800) able in the set, the squared multiple correlation
may not be sufficient. It is clear there are no simple (SMC) of the variable with the remaining variables,
answers to the question of sample size. and iterated estimates based on preliminary SMCs.

methods of factor extraction number of factors to extract

It is necessary at the outset to differentiate two The decision regarding the number of factors to
different types of analysis: principal components extract should be based on a balance of parsimony
analysis (PCA) and factor analysis (EFA or CFA). with theoretical meaningfulness. In theory, we want
The major difference between them is that PCA to arrive at a smaller number of fundamental LVs,
analyzes all the variance among the variables, both but we also want those LVs to be important and to
common and unique, where unique variance accurately define the domain of interest. Especially
includes that specific to the variable and also error if our goal is to explore a reduced number of factors
variance. It is designed to rescale the original vari- that reflect underlying LVs, it is pointless to extract
ables into a new set of components that can be equal minor or trivial factors. However, researchers gener-
in number to the original set but that are now ally agree that it is more problematic to underfactor
uncorrelated with each other. It is not designed to (to select too few factors) than to overfactor—in the
elucidate underlying structure or latent variables former case, we may overlook important aspects of
(LVs) but to rescale or reassign the variables in the the behavioral domain, whereas in the latter case,
analysis. Generally speaking, it is not considered a we may simply end up focusing on an unimportant
method of factor analysis (Fabrigar et al., 1999), but or trivial aspect of behavior.
if the researcher’s goal is to determine the linear There are several approaches to determining how
composite of variables that retains as much infor- many factors to extract, all of them in some way
mation as possible from the original set of variables, attempting to operationalize factor importance, as
then PCA is appropriate. An example of an appro- we only want to extract important factors. One basis
priate use would be analysis of a large set of voca- for decisions is how much variance a factor accounts
tional interest items, where the purpose was to for. A variable’s contribution to a factor is repre-
assign them to interest scales, retaining as much sented by the square of the factor loading (factor
variance as possible from the original set. loadings are analogous to correlations, which, when
If the purpose of the analysis is to more par- squared, represent the proportion of variance
simoniously describe the underlying dimensions accounted for). In an unrotated solution, the factor
common to a set of variables, also known as the contribution is known as the eigenvalue. The best
underlying LVs, then common variance analysis is known and most commonly used is the Kaiser-
much more appropriate. The common factor model Guttman criterion (Gorsuch, 1983), in which fac-
is implemented by model-fitting methods, also tors having eigenvalues greater than 1 are extracted.
known as factor extraction techniques. The major This method is appropriate only for PCA or for
ones are maximum likelihood (ML) and principal other methods where 1’s are in the diagonal (such as
axis factoring (PAF). All use only common variance α or image FA) and should not be used in common
in the estimation of communalities. The advantage factor analyses where communality estimates are in
of ML procedures is that they are accompanied by the diagonal. This is the default in some statistical
a large number of fit indices that can be used to packages, although it tends to lead to overfactoring
evaluate the goodness of fit of the factor model to (more than an optimal number of components or
the data (see Browne, Cudeck, Tateneni, & Mels, factors) (Zwick & Velicer, 1986).
2004). However, they also require the assumption A frequently used method is the scree plot (Zwick
of multivariate normality. Principal axis factoring & Velicer, 1986), in which the values of the eigen-
does not require such distributional assumptions values are plotted, in order of factor extraction,
but also provides fewer fit indices. on the vertical axis. The point at which the plot
Although PCA places 1’s in the diagonal of the levels out (or the slope of the line approaches zero)
correlation matrix, common FA uses a communal- is where factoring should stop. Common sense
ity estimate in the diagonal, where commonality should be used, however, as there may be cases in
refers to the shared common variance of that variable which the scree plot would lead to the inclusion of

250 m ethodologie s
factors with eigenvalues below 1.0. In some cases, intercorrelations are themselves factor analyzed to
there is no clear leveling off, or there is more than examine high-order structures. Oblique rotations
one leveling off point. A logical criterion for number include direct oblimin and promax. Most quantita-
of factors to extract is to include only factors having tive researchers view direct oblimin as preferable
at least two or three variables loading highly on because the mathematical functions minimized
them. If only one variable loads on a factor, then it (and maximized) in factor rotation are made explicit
is questionable whether that variable reflects an (Browne, 2001).
underlying latent dimension. Other methods Regardless of which method of rotation is used,
include parallel analysis (Hayton, Allen, & Scarpello, a matrix of factor structure coefficients will result
2004) and root mean square error of approximation that is different from the coefficients generated
(RMSEA; Steiger, 1990), in which maximum likeli- before rotation. The structure coefficients represent
hood estimation is used to extract factors (see also the correlations between the variables and the fac-
Browne & Cudeck, 1993). tors. For clarity of interpretation, it is best if the
coefficients are either large or very small (near zero).
rotation The rule of thumb is to retain on a factor any vari-
The results of a factor analysis yield solutions based able with a loading of .40 or greater, although there
on mathematical maximization procedures, rather may be instances where loadings as small as .30 or as
than solutions that are psychologically or intui- large as .50 are determined as the minimum (Floyd
tively satisfying. Factor rotation is designed to lead & Widaman, 1995). A loading of .40 indicates
to a more interpretable set of factors. Methods a reasonably strong contribution of the variable to
of rotation are generally classified as orthogonal or determining the “nature” of that factor.
oblique. An orthogonal rotation yields factors that Another feature of the results will be the per-
are uncorrelated, whereas an oblique rotation allows centage of variance accounted for by each factor
factors to be correlated. and the total percentage of variance accounted for
To understand rotation methods, it is necessary by the solution. A general rule is that, to meaning-
to understand Thurstone’s (1947) concept of simple fully explain the interrelationships in the data, a
structure. Simple structure defines a maximal inter- factor structure should account for from 50% to
pretability and simplicity of a factor structure, such 80% of the common variance. If factors 1 and 2
that each factor is described by less than the total account for 40% and 20% of the variance and factor
number of variables, and each variable should be 3 accounts for only 2% of the variance, we may
described by only one factor. Ideally, each factor decide that factor 3 is too trivial to divert attention
should be loaded on by at least two but fewer than from the two more significant factors.
a majority of variables. Table 9.2 shows the factor matrix resulting when
Orthogonal rotational methods include varimax principal axis factor analysis is applied to the corre-
and quartimax; varimax (Kaiser, 1958) is regarded lation matrix shown in Table 9.1, the eight variables
as the best orthogonal rotation (Fabrigar et al., from the Healthy Personality Inventory. Direct
1999) and is often the default in computer pack- oblimin (an oblique) rotation was used. Using the
ages. Comparing the two, varimax is more likely to decision criterion that factors with eigenvalues over
“spread out” the variance across factors, reducing 1.0 should be retained led to the retention of two
the predominance of the general factor or of specific factors with eigenvalues of 4.1 and 1.8, respectively;
factors and increasing the number of common fac- two factors were also indicated by the scree plot.
tors (factors on which a few variables load strongly). Table 9.2 shows the resulting factor structure matrix.
Quartimax has the opposite effect—emphasizing The most important factor in terms of variance
general and specific factors and de-emphasizing accounted for is shown first—this factor accounts
common factors. for 47% of the common variance. The second factor
Oblique rotations are generally considered pref- accounts for an additional 18% of the common
erable because they allow correlated factors, and variance. For the factor loadings shown for each
the reality is that most psychological variables are variable on the two factors, larger loadings mean
at least partially correlated naturally. If the factors that the variable is more important to the definition
are truly uncorrelated, oblique rotations will yield of the factor. As we used oblique rotation, we
an orthogonal set of factors. Oblique rotations pro- allowed the factors to be correlated (they correlate
vide the correlations among factors and, there- r = .37). It is most useful to name the factors based
fore, second-order factor analyses, where the factor on the variables that load highly on them. Thus, in

be t z, fassinge r 251
Table 9.2. Factor loadings of eight scales of the HPI factors, we could use CFA to verify (or not) that
structure.
HPI Scales Factors and Factor Loadings
The first step in CFA is to specify the model to
Factor 1 Factor 2 be tested; that is, we specify which measures should
Confident .68 .53
load on which factor. In many cases, the CFA was
preceded by an EFA to get an idea of the factor
Organized .84 .20 structure of the domain in question, and this struc-
Detail-oriented .74 .25 ture is then tested using CFA. Hypotheses about
relationships (of items or measures to factors or
Goal-oriented .91 .43 among factors) are operationalized in the model,
Outgoing .29 .78 usually with Thurstone’s simple structure in mind.
We typically desire high loadings of items on one
Energetic .50 .71
and only one factor, and specification of a factor by
Adventurous .14 .75 a few strongly loading items. In some cases, we pos-
tulate that one or more factors may be correlated.
Assertive .42 .88
Statistical software is used to compare the esti-
N = 206; Highest loading of each scale on a factor is shown. mated covariance matrix of the specified model to
Factor 1 accounts for 47% of the common variance, whereas
factor 2 accounts for an additional 18% of the common variance.
the actual matrix of covariances found in the data.
Factor 1 was named Productivity Styles, whereas Factor 2 was A number of possible software programs are avail-
named Interpersonal styles. From Borgen, F. H., & Betz, N. E. able; all of these software packages are updated
(2008). Career self-efficacy and personality: Linking career
confidence and the healthy personality. Journal of Career
periodically. They include the SPSS subroutine
Assessment, 16, 22–43. AMOS (which must be purchased separately from
the standard package), LISREL (Joreskog &
the example shown, Factor 1 was named Productivity Sorbom, 2008), EQS (Bentler, 1995), and Mplus
Styles, as it had strong loadings from the variables (Methuen & Methuen, 1998). According to Kahn
of Confident, Organized, Detail Oriented, and (2006), the latter three yield comparable results for
Goal Directed; and Factor 2 was named Interper- a CFA, although Mplus may have more user-friendly
sonal Styles, as it included Outgoing, Energetic, syntax and also provides other multivariate analyses
Adventurous, and Assertive. not available on other packages.
Scores on the factors themselves also can be com- A number of fit indices are available to evaluate
puted. Factor scores are useful if we wish to predict the fit of the model to the data. Fit indices indicate
some type of criterion behavior from a concise set of how well the actual covariances (relationships) in
factor scores. For example, assume that we have a the data correspond to those in the hypothesized
battery of 15 ability tests—verbal ability, math abil- model (see Kahn, 2006, for a full explanation). The
ity, and spatial ability—that we wish to use to pre- traditional χ-square test of goodness of fit is best
dict job performance. When calculated in the same known and indicates the differences between the
sample, the factor score can be computed as the sum model-hypothesized covariances and those found
of the score on each variable multiplied by its weight in the data; the larger the value of the χ-square
on the factor(s) on which it loads significantly. statistic, the greater the discrepancy between the
However, since factor analysis is a maximization hypothesized and actual models. Thus, a statistically
procedure, if used in subsequent samples, it has significant χ-square indicates a lack of fit of the
been shown that simple unit weighting of all the hypothesized model to the data. But the χ-square
variables loading on a factor provides more stable statistic is highly sensitive to large sample sizes and/
results (Gorsuch, 1983). or a large number of observed variables and often
leads to the rejection of models that are good, if not
Confirmatory Factor Analysis perfect. One solution to this problem is the χ-square
Confirmatory factor analysis is used when we test of close fit (not perfect) developed by Brown
have an a priori hypothesis about the structure or and Cudeck (1993). This index seems to perform
dimensionality of the data or domain of behavior. better across a range of sample sizes and models.
There are several different types of such uses. One Other fit indices are not adversely affected
use is to examine the factor structure and/or con- by sample size. These include the Bentler-Bonnett
struct validity of a scale or a set of measures: If a non-normed fit index (NNFI; also known as the
measure is postulated to have three underlying Tucker Lewis index) and the Comparative Fit Index

252 m ethodologie s
(CFI). Using criteria suggested by Browne and Multidimensional Scaling
Cudeck (1993) and Hu and Bentler (1999), models Although used less frequently that factor analysis,
with CFI and NNFI (TLI) of at or above .95 indi- the structure of a set of variables or items also can
cate an excellent fit, whereas those between .90 and be described by multidimensional scaling (MDS).
.94 indicate an adequate fit. The standardized root Multidimensional scaling provides the structure
mean-squared residual (SRMR) and the RMSEA of variables in multidimensional (usually two-
(Bentler, 1995) are other fit indices; for these indi- dimensional) space. Analysis of proximity or simi-
ces, values at or below .05 indicate an excellent fit larity data (which can be represented as correlations
while those between .06 and .10 indicate an ade- between variables) yields a series of points in two
quate fit. Confidence intervals also are provided for dimensional space, where each point represents
the RMSEA. Most authors (e.g., McCallum & a variable or item and the closeness of the points
Austin, 2000) recommend using multiple fit indi- represents the variables’ similarity to each other.
ces, paying particular attention to the RMSEA due A good example of the use of MDS in counseling
to its sensitivity and its provision of a confidence psychology research is the work of Hansen, Dik,
interval. and Zhou (2008). They analyzed 20 leisure inter-
Although it makes intuitive sense that CFA est scales using both EFA and nonmetric MDS and
would be used most often to confirm structures found two dimensions of leisure interests in col-
(tentatively) established using EFA, there are lege students and retirees—expressive-instrumental
instances in which the reverse sequence can be put (e.g., arts and crafts vs. individual sports) and affili-
to good use. One example of the latter can be found ative–nonaffiliative (e.g., shopping vs. gardening).
in Forester, Kahn, and Hesson-McInnis (2004), With MDS, each leisure interest can be described
who reported the results of confirmatory and explor- on these two dimensions. For example, shopping
atory factor analyses of three previously published would be a more affiliative expressive activity,
inventories of research self-efficacy. Using a sample whereas arts and crafts would be an expressive but
of 1,004 graduate students in applied psychology less affiliative activity; team sports would be instru-
programs, Forester et al. began with a CFA of each mental and affiliative, whereas building and repair-
of the inventories separately, finding poor fit of each ing would be instrumental but less affiliative. For
to its postulated factor structure. They then used more information about MDS, readers may consult
EFA to evaluate the structure of the combined total Fitzgerald and Hubert (1987).
of 107 items from the three inventories, arriving at
a four-factor structure in which 58 items loaded at Examining Causal Models
least .50 on one and only one factor. Of course, the Structural Equation Models
next logical step in this research effort would be to Structural equation modeling is actually a family
return to CFA to examine whether the four-factor of methods that subsumes many of the methods
structure holds in new samples. we have discussed so far. In the general case, it is
Confirmatory factor analysis also is well-suited a method of statistically testing a network of inter-
to comparing factor structures in new demographic relationships among variables. It subsumes multiple
groups or across groups (such as gender or race/ regression analysis and confirmatory factor anal-
ethnicity). Often, EFA will have been used to derive ysis but also includes path analysis and testing
a factor structure in original normative samples of full structural equation models. To understand
dominated by white males (particularly in older the distinctions among these methods, it is useful
instruments), so it is crucial to demonstrations of to define two possible components of a structural
construct validity that the factor structure be vali- model.
dated, or explored anew, in other groups with which
we wish to use the measure(s). Kashubeck-West, Elements and Path Diagrams
Coker, Awad, Stinson, Bledman, and Mintz (2008), The elements of a structural model are MVs, usu-
for example, found, using CFA, that factor struc- ally shown as squares or rectangles, and LVs,
tures in three inventories of body image and eating usually shown as ellipses or circles. Measured vari-
behavior that had been derived from white samples ables are (as they sound) those that are measured
demonstrated poor fit in samples of African directly, whereas LVs are unobservable constructs.
American women. They subsequently used EFA to In addition to measured and latent variables, the
explore the factor structure in the African American model must postulate relationships among vari-
samples. ables, including error terms. These relationships are

be t z, fassinge r 253
 Self-Esteem Self-Esteem -.44∗
.03∗
.46∗

-.23∗
Social Social
Instrumentality Loneliness Instrumentality Loneliness
Self-Efficacy Self-Efficacy
.58∗
-.19∗
.39∗

Expressiveness Expressiveness

Fig. 9.2 (A) Path model of predictors of loneliness in college students. (B) Path model predicted 45% of the variance in loneliness.
From Hermann, K. (2005). Path models of the relationships of instrumentality and expressiveness, social self-efficacy, and self-esteem
to depressive symptoms in college students. Unpublished Ph.D. Dissertation, Department of Psychology, Ohio State University.

represented as unidirectional (one-way) and bidirec- A sample path model is shown in Figure 9.2A, where
tional (two-way) arrows. The values assigned to or the researcher (Hermann, 2005) was examining
resulting from directional relationships are regres- variables related to loneliness in college students.
sion coefficients, whereas those for nondirectional Note that all variables are shown as rectangles, as the
relationships are covariances (or correlations if vari- model does not incorporate latent variables; that is,
ables are standardized). Variables in the model can each variable is assumed to be measured fully by one
be endogenous or exogenous. Endogenous (depen- scale. Note also that only instrumentality in this
dent) variables are those in which there is a direc- model is exogenous—all other variables are endog-
tional influence to the variable from one or more enous; that is, they are postulated to be predicted by
other variables in the system. Exogenous (indepen- variables earlier in the model.
dent) variables are those that do not have directional A full structural model consists of two parts:
influence from within the system; their influences a measurement model, which represents the rela-
may be unknown or may not be of interest in the tionships of LVs and their indicators; and a struc-
current model. tural model, which represents the interrelationships
The simplest model is a path model, for which between LVs, both independent and dependent. In
each LV is directly measured—thus, this actually a full structural equation model (SEM), the mea-
models relationships among a series of measures (and surement model is tested first to evaluate the fidelity
directional relationships are shown using arrows). by which the measures are valid indicators of the

Par1 Par2 Par1 Par2

Par3 Par1
.96 .97
.92
.89 .84
.77

Body Acceptance Body Intuitive

by Others .59 Appreciation .63 Eating

.28
.92 .88
.87
Unconditional Par2 Par3 Par3
Acceptance
.79 .82
.85 Par3
Par1
Par2

Fig. 9.3 Measurement and structural mode1s of intuitive eating.

254 m ethodologie s
construct; following that, the full structural model (or may be provided by the software), and the sizes
is tested (see Figure 9.3 for an example of a full of standardized weights may be compared directly
structural model). as indicators of relative importance.
The steps in SEM are (1) model specification, The worth of the model tested can be evaluated
(2) identification, (3) estimation, and (4) modifica- by the significance and size of the path coefficients
tion (Schumaker & Lomax, 2004). In the first step, (indicating the strength of relationships among the
the researcher hypothesizes the relationships (includ- variables), the amount of variance accounted for
ing lack of relationship) among all variables. As in in endogenous variables, and indices of model fit.
CFA, relationships between variables, also known as Like CFA, fit indices include the χ-square goodness
parameters or paths, must be either specified in of fit, in which a nonsignificant value is indicative
advance or determined from the analysis of the cor- of fit, and the χ-square test of close fit, postulated to
relation or covariance matrix. A free parameter is be a more realistic examination of fit. Other indi-
one whose value is unknown and must be estimated, ces are the NNFI (Tucker-Lewis Index), CFI,
whereas a fixed parameter is one we determine in RMSEA, and SRMR (see Weston & Gore, 2006,
advance; the latter also is known as a constrained p. 742, for full descriptions). Criteria for good and
parameter (Weston & Gore, 2006). Three types of adequate fit were described previously for CFA, but
parameters are necessary in a structural model. First, it is important to recognize that fit indices do not
direct effects parameters specify relationships between always agree with one another, so the use of multiple
a LV and its postulated MVs (known as factor load- indicators of fit is recommended (MacCallum &
ings) and between LVs (known as path coefficients). Austin, 2000).
To scale the MVs, it is common to set one of the Figure 9.2B shows the results of simple path
factor loadings for each LV at 1.0, which has the analysis of the model presented in Figure 9.2A using
effect of standardizing the set. Parameters other a sample of 696 college students (Herman, 2005).
than those set at 1.0 need to be estimated (shown as The path coefficients are regression coefficients
asterisks). Error terms for dependent measured and showing relationships ranging from .58 (between
latent variables also must be either fixed or esti- instrumentality and social self-efficacy) and –.44
mated, and covariances among exogenous variables (between self-efficacy and loneliness) to as small
are specified as parameters as well. as .03 (between instrumentality and self-esteem).
All paths except the latter were statistically signifi-
model identification cant in testing this model. Results concerning the
This refers to the relationship between the number fit of the model were mixed, with acceptable values
of parameters to be estimated and the number of of RMSEA, NNFI, and CFI, but a statistically sig-
data points in the correlation or covariance matrix. nificant χ-square (which, it should be recalled, is
The number of elements in a correlation matrix is sensitive to large sample sizes). Further testing
equal to the number of variables k by the following indicated that the model demonstrated a good fit
formula: [k(k + 1)]/2; if there are six variables, there in males (N = 346) but an inadequate fit in females
are [6(7)]/2 = 21 elements in the matrix. Subtracting (N = 350) (see Hermann & Betz, 2006, for the final
the number of parameters to be estimated from the published findings).
number of elements yields the degrees of freedom Figure 9.3 presents an example of a full struc-
for the analysis—if it is positive, the model is said to tural equation model of intuitive eating developed
be overidentified, which is the optimal situation. and tested by Avalos (2005). Three indicators (or
parcels of items) were constructed from the scales
estimation measuring each LV following the recommendations
Structural equation modeling software is needed to of Russell, Kahn, Spoth, and Altmaier (1998). Parcels
estimate the free parameters and provide fit indices were constructed by using EFA to derive the loadings
for the fit of the postulated model to the data. This of scale items on a single factor—items were succes-
software includes the same software programs used sively assigned to the three parcels from highest to
with CFA, including LISREL, AMOS (SPSS), lowest loadings, so that the quality of the parcels as
Mplus, and EQS. Most programs describe path measures of the LVs is roughly comparable.
coefficients as either standardized β weights or The measurement and structural components of
unstandardized β weights, including standard errors, the model were tested in 461 college women. Testing
analogous to the results of a regression analysis. The of the measurement model using CFA indicated fit
statistical significance of weights can be computed indices ranging from adequate fit (RMSEA = .060)

be t z, fassinge r 255
to excellent fit (CFI = .982, TLI = .975, and SRMR kinds of quantitative data. Careful consideration
= .041). All indicators/item parcels loaded signifi- of the purposes of the research and the type of data
cantly on their latent factors, suggesting that all at hand or accessible will facilitate meaningful and
latent factors were adequately measured. The paths useful analyses. In the following section, we turn to
from the LVs to the parcels indicate the parcel load- qualitative research methods.
ings—in essence the factor saturation of each parcel;
as can be seen, all parcels loaded highly on their Qualitative Methods
respective LVs. Fit indices for the structural model Qualitative approaches to research increasingly
also were adequate (RMSEA = .058) to excellent are being used in counseling psychology, resulting
(CFI = .982; TLI = .977, SRMR = .046). All paths in what Ponterotto (2005) described as “a gradual
between LVs were statistically significant and ranged paradigm shift from a primary reliance on quan-
from .28 to .63. Thus, this is a plausible model titative methods to a more balanced reliance on
(although not the only plausible model that could quantitative and qualitative methods” (p. 126).
be hypothesized), and it shows a possible causal In contrast to the nomothetic perspective of quanti-
pathway by which variables related to acceptance tative approaches, which seeks to identify large-scale
can facilitative intuitive eating. normative patterns and universal laws, qualitative
approaches take an idiographic perspective, focus-
modification indices ing instead on in-depth understanding of the lived
When the model is not fitting optimally (one or experiences of individuals or small groups. As out-
more of the fit indices indicates poor or inadequate lined in the first half of this chapter, quantitative
fit), some researchers use modification indices to methods rely on quantifying carefully measured
attempt to improve it. Done through what is known observations amassed from large samples (with some
as a specification search, two major modification indi- measure of control over the variables as the ideal)
ces are the Wald test, which uses a χ-square differ- and statistically analyzing data to produce models
ence test to indicate any (non-zero) paths that might of relationship and prediction thought to apply to
profitably be eliminated, and the Lagrange multi- the general population. Qualitative methods, on
plier (LM) test, which uses a χ-square difference test the other hand, rely on detailed or “thick” descrip-
to indicate any new paths that would significantly tion of context-specific phenomena, most typically
improve the model if added (Bentler, 1995). as narratives voiced by relatively small numbers
MacCallum, Roznowski, and Necowitz (1992) of persons, with transparent interpretation by the
suggested that, to avoid a data-driven model that researcher into descriptions, summaries, stories, or
capitalizes too much on sample specificity, only theories thought to capture the complexity of the
changes that are theoretically meaningful, based phenomena under investigation. In quantitative
on prior evidence, should be made. And because research, the researcher seeks to remain distant and
modification of structural equation models based objective to avoid contaminating the data gather-
on statistical indices has been challenged as data- ing process, such that the data stand as accurately
driven and often unstable across samples, it is as possible as a representation of an assumed reality
important to cross-validate the modified model apart from the researcher. In qualitative research,
(MacCallum & Austin, 2000). This is done using however, data collection occurs through the rela-
calibration and validation samples, of which the tionship between the researcher and the participant(s)
first should be about two-thirds of the entire sample in a co-creative process, and consideration of the
to provide stable initial parameter estimates. subjectivity of the researcher is woven deliberately
Structural equation modeling can be used to into every phase of the research process.
compare models, for example, by testing models Thus, the perspectives, purposes, processes, and
across populations (e.g., Fassinger, 1990; Lent et al., products of qualitative research are very different
2005). Standard error of the mean also can be used from those of quantitative research, and they require
to examine longitudinal designs (e.g., Tracey, 2008) different mind sets and different standards for assess-
and to explore experimental designs more generally ing quality and rigor. Readers should keep these
(see Russell, Kahn, Spoth, & Altmaier, 1998). complexities in mind in reviewing the following
section, in which we present brief overviews of the
Summary most commonly used qualitative approaches within
It should be clear to readers that many analytic psychology and/or those most likely to enter the
methods are appropriate for use with a variety of repertoire of counseling psychologists. We note that

256 m ethodologie s
these do not represent the full range of qualitative sharing of the lived experience, and there is an
approaches available; discourse analysis and case expectation that participants’ perspectives and feed-
study methods, for example, offer considerable pos- back will be included throughout the process of
sibilities in counseling psychology (the former in data analysis and theory articulation, thus ensuring
studying counseling interactions and the latter in that the theory remains grounded in the partici-
organizational consultation, for example), but they pant’s lived experiences (Charmaz, 2000; Fassinger,
do not appear to have been embraced within our field 2005; Henwood & Pigeon, 2003).
at this time. We also note that, due to space limita- Although there is some debate about the
tions, we simply present broad descriptions of some appropriate paradigmatic home for grounded the-
of the distinctive features of these approaches, and ory, it most often is presented as a constructivist-
readers should consult several excellent handbooks interpretivist approach (Charmaz, 2000; Fassinger,
and overviews of qualitative methods (e.g., Camic, 2005; Henwood & Pigeon, 2003). This makes
Rhodes, & Yardley, 2003; Creswell et al., 2007; sense, given its ontological and epistemological
Denzin & Lincoln, 2000; Patton, 2002; Ponterotto, assumptions that researchers and participants will,
Haverkamp, & Morrow, 2005) to learn about these through their relationships, co-construct accounts
and other methods in greater detail. of the deep meanings of subjectively experienced
realities, as well as its axiological and methodolog-
Common Qualitative Research Methods ical foci on revealing, recording, and monitoring
grounded theory the expectations and interpretive lenses of the
Rooted in sociology and symbolic interactionism, researcher. However, Fassinger (2005) has argued
grounded theory is a highly influential qualitative that the considerable flexibility of the grounded
approach that is widely used throughout the health, theory approach allows for its conceptualization
social, and behavioral sciences, including counsel- and use across a broad paradigmatic range, from, for
ing psychology (Charmaz, 2000; Fassinger, 2005; example, a post-positivist attempt to triangulate
Henwood & Pigeon, 2003; Rennie, 2000). quantitative data to the liberationist aims of giving
Developed by Glaser and Strauss (1967) and fur- voice to and empowering marginalized populations
ther articulated by these researchers and colleagues characterized by the critical-ideological paradigm.
(e.g., Glaser, 1992, 2000; Strauss, 1987; Strauss Fassinger (2005) further asserts that grounded
& Corbin, 1998), grounded theory is so named theory can serve as a paradigmatic bridge for
because its aim is to produce theories that are researchers. It allows those researchers holding fast
“grounded” in participants’ lived experiences within to positivist and post-positivist empirical values to
a social context. The central question of grounded begin to venture into more naturalistic territory
theory is: “What theory emerges from systematic using the highly specified, rigorous analysis proce-
comparative analysis and is grounded in fieldwork dures of grounded theory. On the other hand, those
so as to explain what has been and is observed?” who are oriented toward radical social reformation
(Patton, 2002, p. 133). can find in this approach a means to tackle some of
Theory-building takes place inductively and society’s most challenging problems. The adaptabil-
iteratively using a method of “constant compari- ity of grounded theory is particularly well-suited to
son,” in which data collection, coding, conceptual- counseling psychology, as exemplified by the wide
izing, and theorizing occur concurrently in a process range of studies in our field that have used this
of continually comparing new data to emerging approach successfully. Examples include the work of
concepts until theoretical saturation is reached Fassinger and her colleagues (Gomez et al., 2001;
(no new information is being generated); at this Noonan et al., 2004; Richie et al., 1997), as well as
point, data collection/analysis ends and relation- Morrow and Smith (1995), Rennie (1994) and
ships among the emergent constructs are articulated Kinnier, Tribbensee, Rose, and Vaughan (2001).
in the form of an innovative theoretical statement
about the behavior under investigation. Data usu- narratology
ally consist of detailed narratives obtained in exten- Although narratives and narrative analysis tech-
sive interviews with participants, although other niques are used widely in many different approaches
forms of data (e.g., observations, archival docu- to qualitative research, Hoshmand (2005) uses the
ments, case notes) can be used as well. The rela- term “narratology” to denote a distinct qualitative
tionship between the researcher and the participant perspective that is informed by narrative theory.
forms the foundation for the participant’s deep Shaped broadly by the work of narrative theorists

be t z, fassinge r 257
such as Foucault and Ricouer and articulated within theorizing stage of grounded theory” (p. 181), rein-
psychology by Polkinghorne (1998, 2005) and forcing the difference between narrative analysis
others, the narratological approach to research is and narratological inquiry. The focus of the narrato-
“concerned with the structure, content, and func- logical approach on the formation and expression
tion of the stories that we tell each other and our- of individual and cultural identity through story
selves in social interaction” (Murray, 2003, p. 95). also renders it particularly useful for multicultural
Its central question is: “What does this narrative research, an area of interest to many counseling psy-
or story reveal about the person and the world chologists. Examples include Winter and Daniluk
from which it came? How can this narrative be (2004) and Hardy, Barkham, Field, Elliott, and
interpreted to understand and illuminate the life Shapiro (1998).
and culture that created it?” (Patton, 2002, p. 133).
Narratology relies on a “narrative mode of under- ethnography
standing” human experience (Hoshmand, 2005, Spawned from cultural anthropology at the turn of
p. 180) in which the researcher interrogates narra- the 20th century, including such giants as Boas and
tives of individuals’ lived experiences for the story- Malinowski, ethnography has found its way slowly
like elements that underlie those narratives. In this into contemporary psychology, highlighted recently
approach, narratives are considered to be storied for counseling psychologists by Suzuki and her col-
accounts of experience that have an internal, devel- leagues (Suzuki, Ahluwalia, Mattis, & Quizon,
opmental coherence containing plot-like elements, 2005). Focused on groups of people within their
thematic meanings, self-presentational style aspects, cultures and communities, the central question of
and temporal and causal sequences, and are medi- ethnography is: “What is the culture of this group
ated by culture, historical time, and other contex- of people?” (Patton, 2002, p. 132).
tual elements. Narratological inquiry seeks both The ethnographic approach focuses on study-
to understand narratives as well as to construct ing the cultural and community life (behaviors,
storied accounts of particular lived phenomena. language, artifacts) of individuals, and relies on the
Data may consist of documents already rendered researcher functioning as a participant-observer in
in narrative form (e.g., interviews, oral histories, extensive fieldwork under conditions of prolonged
biographies, journals) or may be more loosely orga- engagement with the community (e.g., 6 months
nized pieces of information (e.g., chronological to 2 years or more). Interviewing and direct obser-
events, observations, cultural artifacts) that will be vation are the chief means of data collection,
translated into narrative form by the researcher in although archival records, surveys, and other docu-
the data analysis process. Analyzing data may take mentation may be used as well. The end product
several forms (e.g., linguistic/literary, grounded, of ethnographic research is the creation of narratives
contextual), but each approaches the narrative holis- that are thought to capture the lived experiences
tically within its social context, and arranges its of people in their complex cultural contexts, an aim
elements into a coherently and chronologically that is consistent with and amenable to the multi-
sequenced account of experience (Hoshmand, 2005; cultural emphasis within counseling psychology
Murray, 2003). (Miller, Hengst, & Wang, 2003; Suzuki et al.,
Hoshmand (2005) asserts that narratological 2005).
research approaches are still evolving, and that Ethnographic approaches can span the paradig-
what exist currently to guide researchers are sim- matic spectrum from post-positivist methods that
ply concepts and principles rather than a unified rely largely on observations and quantitatively orga-
method per se. Paradigmatically, narratological nized data (particularly in seeking out negative cases
approaches appear to be constructivist-interpretivist or contradictory information) to critical-ideological
in their reliance on the co-construction of the aims of giving voice to and thus empowering mar-
storied account and the importance of researcher ginalized populations, especially if used in multicul-
positionality. However, Hoshmand (2005) distin- tural research in counseling psychology, as advocated
guishes the narrative mode of understanding, which by Suzuki et al. (2005). However, in its ideal form,
is focused on “descriptive and discovery-oriented ethnography probably most closely fits the con-
research involving configural patterns of interpreta- structivist-interpretivist paradigm in its epistemo-
tion and a part-to-whole logic of argumentation” logical focus on the awareness of the “subjectivities”
(p. 181), from the “paradigmatic mode of interpre- and “guesthood” of the researcher, a position of
tation brought to bear on narrative data such as the genuine connection with participants balanced by

258 m ethodologie s
enough distance to avoid compromising data collec- In this approach, the researcher seeks to enter
tion or interpretation (Miller et al., 2003). empathically into the participant’s life-world to
Indeed, one of the most intense debates within understand and communicate the subjective mean-
the ethnography literature concerns how and to ing of an individual’s lived experience. This is
what extent the insider or outsider status of the accomplished through a reflective process of sus-
researcher influences the investigation, a debate that pending assumptions and biases and focusing on
focuses, at its heart, on the relative roles of research- a phenomenon itself, then imaginatively varying
ers and participants in co-constructing the final concrete instances of the phenomena to distill their
account of the lived experience under investigation essential features, culminating in a description that
(Miller et al., 2003; Suzuki et al., 2005). From a is thought to portray the essence of that lived expe-
methodological perspective, the expectation that rience (Giorgi & Giorgi, 2003; Wertz, 2005). This
cultural immersion and a reflexive research stance kind of “intentional analysis begins with a situation
will produce narratives and observational data that just as it has been experienced—with all its various
constitute an accurate or true reflection of lived cul- meanings—and reflectively explicates the experien-
tural experience implicitly recognizes the subjectiv- tial processes through which the situation is lived”
ity of the researcher in the co-construction of the (Wertz, 2005, p. 169).
account (as well as the need to monitor that subjec- Data are collected as descriptions, and although
tivity). Moreover, the assumption that ethnogra- typically they are direct verbal or written accounts
phers will decide upon “skill sets, material goods, or from participants and others who interact with
resources that they can and will gift to the commu- and/or know participants or can provide some kind
nity” (Suzuki et al., 2005, p. 211; italics ours) also of insight on the phenomenon under investigation,
acknowledges the distance of the researcher even data also may consist of other forms of expression
in the final procedural stages of a study that may such as drawings, fictional accounts, poetry, and
have involved months or years of connection with the like. Analysis consists of generating “situated
participants. descriptions” of the participant’s experience, orga-
The many types of ethnographic approaches nized sequentially or thematically, that then are
available to researchers (e.g., memoir, life history, mined for underlying psychological meanings and
narrative ethnography, auto-ethnography) suggest processes. The descriptions finally are synthesized
wide variability in types of data and methods of into a case study representation that can be consid-
interpreting those data (Miller et al., 2003; Suzuki ered together with other cases to locate general
et al., 2005). Moreover, aspects of the ethnographic themes and experiences, as well as variations in
approach can be found in similar research methods “knowledge of types” (Wertz, 2005, p. 173). The
that may be more familiar to counseling psychology final product is a context-bound descriptive presen-
researchers (e.g., community-based research). These tation of the psychological structure of participants’
approaches offer considerable heuristic value, par- experiences in a specific life domain (Giorgi &
ticularly in multicultural counseling psychology Giorgi, 2003; Wertz, 2005).
research. Examples, can be found in Miller, Wang, Wertz (2005) locates phenomenology as the
Sandel, and Cho (2002), Pipher (2002), and Suzuki, historical birthplace of contemporary qualitative
Prendes-Lintel, Wertlieb, and Stallings (1999). research, and yet he also distinguishes phenome-
nology from other qualitative approaches in its
phenomenology unwavering commitment to bracketing researcher
Rooted in the work of philosopher Edmund Husserl presuppositions and biases and its singular emphasis
and the later American phenomenological and on pure description. Giorgi and Giorgi (2003) argue
existential psychologists, the phenomenological that phenomenology as a method is distinct from
approach has as its central question: “What is the phenomenology as a philosophical endeavor, and it
meaning, structure, and essence of the lived experi- generally is acknowledged that phenomenology
ence of this phenomenon for this person or group shares many procedural elements with other quali-
of people?” (Patton, 2002, p. 132). Phenomenology tative approaches (e.g., Giorgi & Giorgi, 2003;
is a descriptive method of investigating the life- Wertz, 2005). As a very well-established research
worlds of individuals, wherein the researcher approach (including an entire curriculum devoted
“attempts to grasp the essence of the individual’s life to phenomenology at Duquesne University), and
experience through imaginative variation” (Wertz, one with high relevance to many areas of psychol-
2005, p. 172). ogy, phenomenology has much to offer counseling

be t z, fassinge r 259
psychologists. Examples can be found in Arminio a context in which knowledge development and
(2001), Friedman, Friedlander, and Blustein (2005), change might occur—much like building a factory
and Muller and Thompson (2003). in which tools may be made rather than necessarily
using tools already at hand” (p. 187). In this sense,
participatory action research PAR is much like organizational consultation in its
Emanating from the work of Kurt Lewin (Fine collaborative approach to assessing needs, gathering
et al., 2003) and embodied in the writings of liber- data about what is happening in the collective,
ationists such as Frantz Fanon and Paulo Friere ensuring that all are given voice in articulating prob-
(Kidd & Kral, 2005), participatory action research lems and determining future directions, and build-
is widely used in community psychology, as well as ing readiness for implementation of clearly specified
in other social science fields. Participatory action changes and goals.
research (PAR; Fine et al., 2003; Kidd & Kral, Almost all experts in PAR note its challenges
2005) has as its goal the creation of knowledge that in practical use, including lack of time and resources
directly benefits a group or community (typically for the prolonged engagement that PAR requires,
marginalized, disenfranchised, or disempowered in resistance within traditional psychology to the
some way) through political and social empower- overtly radical change agenda PAR espouses, and
ment. Its central question is: How are systems of deeply entrenched societal and professional disre-
power and privilege manifested in the lived experi- spect and disdain for the stigmatized, disenfran-
ences of this person or group of people, and how chised groups that PAR usually seeks to empower.
can knowledge be gained and used to raise con- Moreover, lack of knowledge and training in the
sciousness, emancipate, and empower this person PAR approach, and the emotional and psycholog-
and group? ical energy PAR requires from researchers (includ-
It is an approach in which researchers and par- ing the need for flexibility, good group management
ticipants work collaboratively over an extended skills, and the ability to share power) make it diffi-
period of time to assess a need or problem in a par- cult for some researchers, particularly novices.
ticular social group, gather and analyze data, and Finally, the volatile and changing nature of social
implement results aimed at the “conscientization” groups and social problems can render the research-
(raising consciousness) of and giving voice to indi- intervention goal of PAR a moving target, and there
vidual participants, such that their collective are often contextual barriers that make community
empowerment leads directly to social action and participation and change extraordinarily difficult.
change. Participatory action research takes an Nevertheless, PAR is well-suited to the diversity
unabashedly political stance, and, ideally, the values and social justice focus within counseling psychol-
of the researcher and the participants mesh to drive ogy, and it provides unprecedented ways to enact
the social change agenda. The involvement of the the scientist–practitioner–advocate model of pro-
researcher is prolonged and intensive, and the suc- fessionalism (Fassinger, 2001; Fassinger & O’Brien,
cess of a PAR project is judged by the manner and 2000) becoming ever more popular in our field.
extent of changes that have occurred in the lives of Examples include Leff, Costigan, and Power (2004),
participants (Fine et al., 2003; Kidd & Kral, O’Neill, Small, and Strachan (2003), and Fine et al.
2005). (2003).
Although PAR clearly fits within the critical-
ideological paradigm, based on its focus on power other
relations and structural inequality, in its goals of In this final section on the various qualitative meth-
individual and group empowerment and social ods, we include two approaches developed by coun-
change, and its positioning of the researcher as a seling psychologists that are (so far) used by small
collaborator, it actually is more of a hybrid approach groups of researchers confined to counseling psy-
in many of its features. Data in a PAR project can chology. These approaches are consensual qualitative
take virtually any form (including quantitative sur- research developed by Hill and her colleagues (CQR;
veys and statistical analyses of archival data), and its Hill, Knox, Thompson, Williams, Hess, & Ladany,
final products may include a wide range of artifacts, 2005) and the action-project method of Young and
such as position papers, policy statements, charts his colleagues (Young, Valach, & Domene, 2005).
and tables, records, and even speaking or lobbying Consensual qualitative research, the better
activities. Kidd and Kral (2005) assert that PAR is known of the two approaches, was developed in the
not actually a method but rather is “the creation of mid-1990s in an effort to create an easy-to-use

260 m ethodologie s
method of summarizing narrative data, and it has qualitative paradigms, but rather “represents a unique
been used primarily in counseling-related investiga- epistemology and research paradigm” (p. 218). Cer-
tions to date. Most qualitative methods assume, tainly, the data collection procedures in the action-
implicitly or explicitly, that more than one researcher project method are distinctive and worth noting.
will be participating in data gathering and/or data They can include several taped dialogues over an
coding, monitoring, and interpretation. Consen- extended period of time (e.g., 6 months) in which
sual qualitative research, however, clearly delin- each subsequently is replayed and commented upon
eates a team approach to collecting data through separately by each participant, the data coded and
structured interviews (or counseling sessions) that summarized for distribution back to the partici-
are consistent across participants, with systematic pants, supplemented by journal entries, phone con-
coding and summarizing of data utilizing interjudge versations, and electronic communications. All of
ratings, discussion, and consensus. these data are captured in an analysis that is fed back
Hill and colleagues have claimed that CQR fits to participants in what is essentially a behavioral
within a constructivist-interpretivist paradigm (Hill intervention, a process that may be repeated many
et al., 2005), but there is considerable disagreement times with the same participants in the course
on this point. Most experts acknowledge that it is of a study. Indeed, the action-project approach
strongly post-positivist in its use of theoretically or resembles a highly specified behavioral counseling
empirically generated structures for framing the process, and it is not surprising that it offers consid-
study and starting the coding process, its reliance on erable utility in understanding interpersonal inter-
consistency across participants in data gathering actions and their impact on the goals and behaviors
(including the search for negative cases or discon- of the individuals involved. Counseling psycholo-
firming evidence), its goal of achieving inter-rater gists with strong interests in the integration of sci-
agreement in coding, its quantitatively oriented ence and practice might find the action-project
analytic techniques and rhetorical structures, and its method especially compelling. An example is found
overall attempt to maintain researcher objectivity in Young et al. (1997).
as much as possible throughout the research pro-
cess. Indeed, it bears considerable similarity to Basic Issues to Consider in
simple content analysis in its aims and procedures. Qualitative Research
Nevertheless, it offers clearly specified procedures Regardless of the specific qualitative approach a
and a substantial number of model studies (espe- researcher decides to adopt, there are a number of
cially related to counseling processes) for those basic issues and challenges with which every
interested in undertaking their own investigations. researcher must grapple. In this section, we review
Moreover, it provides a viable starting point for sampling, data collection, researcher role, data anal-
researchers interested in qualitative techniques but ysis and communication, evaluation, and ethical
needing more gradual movement in that direction. considerations in conducting qualitative inquiry.
An example is Juntunen, Barraclough, Broneck, Although we present these issues separately, it is
Seibel, Winrow, and Morin (2001). important to remember that these decisions are
The action-project method (Young, Valach, & inextricably linked paradigmatically, ontologically,
Domene, 2005) is based in action theory and con- epistemologically, axiologically, methodologically,
cerns itself with intentional, goal-directed behavior. and rhetorically.
It utilizes a three-dimensional model of action that
incorporates perspectives on action and levels of sampling
action organization into four action systems: indi- Quantitative sampling strategies, because they are
vidual action, joint action, the action project, and focused on generalizing findings, always are aimed
the career (Young et al., 2005, p. 217). Individual at isolating a clearly bounded group of observations
and joint actions are short-term, everyday occur- (represented numerically) that is sizable enough to
rences that cumulatively compose the longer-term support statistical inferences regarding the overall
“project” in their common themes and goals, which, population of interest. In qualitative research, how-
in turn, results in a long-term organization of proj- ever, the goal is an in-depth understanding of the
ects into a “career” of action that has significant meaning of a particular life experience to those who
importance in one’s life. live it, and data most often consist of narratives,
Young et al. (2005) insist that the action- observations, field notes, researcher journals, and
project method does not fit into any of the existing other kinds of data that are represented (primarily)

be t z, fassinge r 261
linguistically. Sample size depends entirely upon unusual for months and even years to be devoted
saturating the data set—that is, collecting enough to data collection. Moreover, most qualitative meth-
data to satisfy the judgment of the researcher that ods assume some sort of additional contact with par-
no new information would be gained by additional ticipants to verify the researcher’s interpretations
cases. Thus, sample sizes in terms of actual partici- during the analysis process, creating an iterative cycle
pants typically are much smaller in qualitative than of data collection, researcher analysis, participant
in quantitative studies, but the data sets themselves feedback, additional data collection and/or analysis,
are much larger and more complex. and repeated feedback from participants until no
Given the aim of in-depth understanding, sam- new information is emerging from the process.
pling in qualitative inquiry is always “purposeful,” Much has been written about the primary data
that is, to select participants who will provide the tool in qualitative research: the individual interview.
most “information-rich” accounts of the phenom- Researchers must conceptualize and articulate their
ena of interest (Patton, 2002, p. 239). The purposes interview strategy in terms of length, depth, kinds
in “purposeful” sampling can be quite varied, of open-ended questions, degree of structure, degree
depending on the focus of the research. Patton and kind of probing for sensitive information, ways
(2002), for example, includes 15 different types of of ensuring that participants’ words and ideas are
sampling strategies that may be of interest to quali- being captured, and ways of monitoring their own
tative researchers, including maximum variation, reactivity. Patton (2002, as but one example)
homogeneous, extreme case, snowball, intensity, includes detailed discussion of theoretical and prac-
typical case, critical case, disconfirming case, and tical issues in planning and conducting interviews,
other kinds of sampling. including sections on focus groups and cross-
Qualitative sampling also is criterion-based, in cultural interviewing, as well as numerous tables
that specific criteria used in selecting participants and checklists. It is imperative that counseling psy-
are based on the research questions that guide the chologists undertaking qualitative research for the
inquiry as well as the particular qualitative approach first time consult such resources, as there may be
being used (Creswell, Hanson, Clark, & Morales, a tendency to assume that competent clinical inter-
2007; Morrow, 2007). In a phenomenological viewing skills fully prepare one for conducting
study, for example, the sample may consist of a interviews aimed at gathering data for research pur-
small group of individuals who share a very specific poses. However, the roles of scientist and helper are
common experience (e.g., priests accused of sexual very different, and, although good clinical skills may
abuse), whereas a participatory action research facilitate the kind of relationship-building that is
approach may call for a sample that includes an critical to the success of any interview, acquiring
entire community or organization (e.g., a shelter an in-depth understanding for research purposes
providing services for women victimized by partner requires a different mindset and approach than
violence). In addition, there are decisions to be coming to understand an individual therapeutically
made about the extent and kind of contact with (an ethical issue to which we return below).
participants, ranging from one single lengthy inter- Because data collection in qualitative research is
view with follow-up contact to immersion in and implemented in a deeply interpersonal manner, the
observation of a community over several years. researcher also must consider when and how entry
These decisions about who will participate in the into the research context will occur and how trust
study and what the length and nature of the contact and rapport will be established. Again, the form
will be also determine how the process of actually that this process takes is determined largely by
gathering data will occur. the qualitative approach being used. If interviews
with participants who have no connection to one
data collection another constitute the primary means of data col-
As the goal of data collection in qualitative inquiry lection, then the task becomes one of establishing
is to ensure that all information relevant to under- credibility and trust with people one individual at
standing a particular phenomenon is obtained a time. But if data collection includes multiple
(i.e., the data set is saturated), the process of gather- interviews, behavioral observations, and scrutiny
ing data often is both prolonged and iterative. of organizational documents within a group of
Because interviews, observations, extensive field highly interconnected individuals, then the task of
notes, cultural artifacts, and other similar kinds of entry into the organization, identification of key
documentation form the corpus of data, it is not informants, rapport-building, and role clarification

262 m ethodologie s
will be considerably more complex. Similarly, exit studied, the intended and unintended audiences
from the research context also is driven by approach; for the inquiry, and the cultural and historical con-
a study that utilized single isolated interviewees text in which the scientific endeavor occurs. Fine
requires a different kind of process of following up (1992) captured the complexity of the reflexive
and sharing findings than does a study of an entire stance in her description of qualitative researchers as
community in which multiple stakeholders desire a “self-conscious, critical, and participatory analysts,
product they can use to initiate political redress of engaged with but still distinct from [their] infor-
identified problems. Of course, these different mants” (p. 254).
approaches to relationship-based data collection In actual practice, researcher reflexivity is fac-
also have important implications for the role and ilitated through a variety of strategies that are
stance of the researcher. articulated somewhat differently depending on
the particular qualitative approach being used.
researcher role These strategies may include publicly articulating
Implementing interpersonally based inquiry requires one’s biases through researcher-as-instrument state-
a different researcher stance than that taken in most ments, bracketing and monitoring one’s biases,
quantitatively based studies, in which the goals are being rigorously subjective in one’s observations and
appropriate distance, control, and avoidance of interpretations, keeping and using field notes
researcher contamination of data. Because qualita- throughout the research process, continuously sepa-
tive research relies on co-constructed representa- rating description from interpretation and judg-
tions of lived experience, the researcher is rendered ment, using thick description to ensure remaining
both a participant and an observer in the investiga- close to participants’ experiences, maintaining an
tive process, with values, assumptions, and world appropriate balance between participation and
views that must be made conscious and articulated observation, returning again and again to the data
clearly. As both participants and observers, research- and/or participants to verify one’s interpretations,
ers must grapple with the tension inherent in those memoing or keeping a journal throughout the
roles, including the extent to which they want to course of the study, and using external auditors or
function emically (as insiders) or etically (as outsid- teams of multiple researchers to maintain systems of
ers), the degree to which they want their observa- peer checking and review (Morrow, 2005).
tions to be overt or more covert and less obvious, Researcher reflexivity is important throughout the
the amount of self-disclosure and collaboration they entire inquiry, but it is especially critical during the
will offer, the expectation of entry into a long-term process of analyzing, interpreting, and communi-
or more short-term relationship with participants, cating the data in the study.
and the extent to which they will function as cata-
lysts for change (Fine, 1992, 2007; Morrow, 2007; analysis, interpretation,
Patton, 2002). and communication of data
Clearly, a research approach that requires inter- As noted earlier, qualitative approaches differ in
personal connection as its foundation and squarely the extent to which systematic analytic principles
places the researcher within that connection calls have been detailed in specific how-to formats.
for a researcher stance that differs markedly from However, all offer conceptual delineations of data
the distanced position of quantitative approaches. analyses that parallel the core paradigmatic assump-
Researcher “reflexivity” is the term used most often tions of the approach. Thus, a grounded theory
to capture this stance (e.g., Marecek, 2003; Morrow, analysis moves the researcher through a system of
2005, 2007), and refers to the capacity to use own coding and constantly comparing data to an end
one’s experiences, thoughts, and feelings, to recog- point of generating an emergent theory grounded
nize and understand one’s own perspectives and in the lived experiences of the participants. A nar-
world views, and to actively and constantly reflect ratological researcher, on the other hand, will (re)
upon the ways in which those might influence one’s arrange narratives into a chronologically and psy-
experience of observing, collecting, understanding, chologically coherent, storied account of lived expe-
interpreting, and communicating data. Rennie rience. Participatory action researchers involve the
(2004, cited in Morrow, 2005) described reflex- constituent group(s) in making sense of the data
ivity as self-awareness and agency within that self- and consciously use the data to mobilize individuals
awareness. Moreover, reflexivity is not just about the and the community into actions aimed at social
self; it also includes deep reflection about those change.

be t z, fassinge r 263
 Regardless of specific approach, all qualitative accomplish the same things, and that qualitative
methods rely heavily on researcher reflexivity in the studies are more appropriately evaluated using
analysis process. This reflexive stance compels a con- standards that are congruent internally with what
tinual return to and immersion in the data—not qualitative research seeks to do. Morrow advises
only the narratives or other data gathered from the development and use of “intrinsic standards of
participants, but also the memos, journals, field trustworthiness that have emerged more directly
notes, research team notes, and other documenta- from the qualitative endeavor” (2005, p. 252).
tion of the extensive and intensive process of rigor- Key to discussions of evaluating the rigor of
ous thinking that has occurred throughout the qualitative research is the concept of trustworthi-
inquiry. Thus, six or eight interview transcripts ness or credibility (Morrow, 2005). A comprehen-
alone (totaling, at minimum, about 150 pages of sive evaluation framework offered by Morrow
text) will generate hundreds more pages of an analy- (2005) outlines four overarching or “transcendent”
sis record and audit trail. Moreover, it can be criteria (p. 250), so termed because they transcend
assumed that many hundreds of hours will be the particular requirements of any specific approach
devoted to reading, coding, (re)arranging, thematiz- and apply to the evaluation of all qualitative inquiry.
ing or propertizing, theorizing, (re)checking, obtain- The first criterion for judging the trustworthiness
ing feedback, and discussing the data. When other of a study is social validity, or the social value of
kinds of data are added (e.g., behavioral observa- the project. The second criterion addresses the way
tions, artifacts, historical records), the sheer size and in which the study handles subjectivity and reflexiv-
complexity of the data set becomes quite challeng- ity on the part of the researcher, so that the reader
ing, and it should be clear why continually interro- can determine whether the participants’ accounts
gating the data corpus is an absolute necessity in are being honored or whether the findings merely or
qualitative research. predominantly reflect the opinions of the researcher.
Capturing the enormity and complexity of the Morrow (2005) advises that, regardless of para-
data analysis process for purposes of communicat- digmatic and axiological approach (i.e., whether
ing findings also is extremely challenging, and not researcher subjectivity is bracketed and monitored
particularly well-suited to the length and format or incorporated as a driving force in the study),
constraints of most scholarly journals (Morrow, researchers must make their implicit assumptions
2005). Morrow (2005) has provided a cogent guide and biases fully and clearly explicit to themselves
to writing publishable versions of qualitative inqui- and to all others.
ries, and many excellent studies have been published The third criterion for judging the trustworthi-
in counseling psychology journals despite the diffi- ness of a study lies in the adequacy of the data.
culties. Unfortunately, the brevity of most published Because sample size has little to do with the rich-
accounts belies the extensive work that undergirds ness, breadth, and depth of qualitative research data,
those studies and provides limited information the study must demonstrate other forms of evidence
about why particular conceptual, sampling, data that the data are maximally informative. Such evi-
collection, or analytic decisions were made, thus dence might include information-rich cases, appro-
offering little basis for judging the quality of the priate sampling, saturated data sets, lengthy and
research. open-ended interviews, feedback from participants,
multiple data types and sources, field notes indicat-
evaluating qualitative research ing rapport with participants, and inclusion of dis-
Because qualitative and quantitative research ema- crepant or disconfirming cases. The fourth criterion
nate from different paradigmatic assumptions, the for evaluating the trustworthiness of the inquiry
criteria for judging the quality and rigor of quanti- is the adequacy of the interpretation. There must
tative research simply do not apply to qualitative be clear evidence of immersion in the data set dur-
studies. Attempts have been made to describe evalu- ing analysis, the use of a specified analytic frame-
ation criteria for qualitative studies that parallel work and analytic memos, and a balance in the
the quantitative criteria of validity, reliability, gener- writing between the interpretations of the researcher
alizability, and objectivity (probably developed, at and the direct words of the participants (Morrow,
least in part, to make qualitative work more accept- 2005).
able to the positivist researchers comprising most In addition to these four transcendent criteria,
editorial and review boards). However, Morrow Morrow (2005) also includes criteria that are more
(2005) argues that such criteria do not mean or specific to the paradigm that undergirds a particular

264 m ethodologie s
study. In a constructivist/interpretivist study, for literature (e.g., Fine, 1999, 2007; Haverkamp, 2005;
example, the additional criteria of fairness, authen- Marecek, 2003; Morrow, 2007). Haverkamp (2005)
ticity, and meaning would be important, whereas offers a particularly useful discussion for counseling
a critical/ideological study would be expected to psychologists, recommending a synthesis of virtue
include those criteria but also demonstrate conse- ethics, principle ethics, and an ethic of care, all
quential and transgressive evidence. Finally, regard- of which are central to graduate training in our field
less of approach, the trustworthiness of a study also and thus known to counseling psychologists.
must include evidence that the researcher attended Haverkamp (2005) calls for “professional reflexiv-
to the social and ethical issues inherent in that ity” (p. 152), the ethical counterpart to research
study. reflexivity, which refers to a conscious consideration
of the ways in which our social roles, skills, and
ethics, politics, and knowledge base may influence our research prac-
social responsibility tices, including relationships with participants.
Social, political, and ethical considerations are Professional reflexivity is the cornerstone of compe-
not pertinent uniquely to qualitative inquiry, as tence, and Haverkamp (2005) notes that profes-
all research is embedded in a sociopolitical and sci- sionally reflexive competence includes not only
entific context and therefore must attend to issues expertise in the populations and topics we wish to
of social power, researcher responsibility, protec- investigate, but also in the qualitative methods that
tion of people from harm, and potential (mis) we will use in the investigation.
use of findings. However, “[b]ecause qualitative Probably the most widely discussed ethical issue
methods are highly personal and interpersonal, in qualitative research involves researcher boundar-
because naturalistic inquiry takes the researcher into ies and the complexities inherent in multiple rela-
the real world where people live and work, and tionships with participants. The deep and prolonged
because in-depth interviewing opens up what is engagement between researcher and participants;
inside people—qualitative inquiry may be more the centrality of the researcher’s positionality and
intrusive and involve greater reactivity than sur- values; the public and individual perceptions and
veys, tests, and other quantitative approaches” expectations of psychologists as healers; the skills
(Patton, 2002, p. 407). That is, relationship-based of clinically trained psychologists in eliciting
methods create unique challenges in the imple- deeply private and even unconscious information;
mentation of the standard ethical requirements of the co-creation of the meaning, interpretation, and
the scientific enterprise, and they “increase both the form of the research product; and the focus of
likelihood of ‘ethically relevant moments’ and the much qualitative inquiry on marginalized and disem-
ambiguity of how, or whether, specific ethical stan- powered social or cultural groups elicit a host of com-
dards apply to the question at hand” (Haverkamp, plex ethical issues that have clear social and political
2005, p. 148). ramifications. Such issues include dual relation-
The relational focus of qualitative inquiry also is ships, conflicts of roles and interests, confidentiality,
buttressed by the use of linguistically based data, informed consent, coercion, fiduciary responsibility,
which offer researchers considerable interpretive and use of professional and social power.
latitude. However, those constructions typically Although detailed discussion of these issues
are supported by participant verification which, in is well beyond the scope of this chapter, we return
turn, is obtained through repeated and prolonged to the concept of trustworthiness, noted above as
contact. In addition, qualitative inquiry trans- the primary criterion for evaluating the quality of
forms the notion of research benefit where, particu- a study. Haverkamp (2005) argues that trustwor-
larly in the critical/ideological approach, outcomes thiness does not pertain only to the rigor of meth-
of a study must include direct benefit to partici- ods used in a study, but that it “is an inherently
pants in the form of knowledge and empower- relational construct with relevance for multiple
ment. Finally, the very process of qualitative dimensions of the research enterprise” (p. 146).
research has ethical implications, as its flexibility, Trustworthiness in the realm of ethics recognizes
fluidity, and changeability necessitate ethical deci- the potential vulnerability of participants involved
sion making repeatedly throughout the entire in qualitative inquiry, and it reminds researchers
inquiry process. that they must maintain constant vigilance in their
Many discussions of ethical, political, and social responsibility to protect participants from harm.
issues in qualitative research may be found in the Fine (2007) extends this notion into the arena

be t z, fassinge r 265
of political and social responsibility by urging guarantees appropriate handling of social justice
a deeper kind of responsibility upon counseling goals or redress of social ills. Patton (2002) offers an
psychologists. She asks that we consider the harm assortment of possibilities that mix research design,
implicit in oppressive social structures and protect measurement, and analysis in creative approaches to
our participants by refusing to perpetuate their nar- specific problems.
ratives of denial, blame, or victimization. Fine Ponterotto and Grieger (1999, 2007) suggest
asserts that we “bear responsibility to theorize that that, just as psychologists can learn to embrace
which may not be spoken by those most vulnerable, different cultures and languages and become bicul-
or, for different reasons, by those most privileged” tural, researchers can learn to be facile in both
(p. 472), a clarion call for the kind of qualitative quantitative and qualitative inquiry and become
inquiry that also becomes individual and social bicultural or “merged” in their research identity
intervention. (1999, p. 59), termed “bimethodological” (2007,
p. 408). These authors argue that the flexibility of
Mixed Methods and Future Prospects a merged identity produces scientific richness, but
It should be clear that both quantitative and quali- they caution that becoming truly bicultural meth-
tative methods have much to offer in understand- odologically requires immersion in the unfamiliar
ing the kinds of issues of interest to most counseling culture—that is, counseling psychologists must
psychologists—relationships, work, counseling, cul- actively undertake qualitative research to learn
ture, health, and the like. It is our position that qualitative research. Ponterotto and Grieger (1999)
mixing these methods in creative ways offers much describe in detail two mixed-methods studies that
potential in solving some of the thorniest problems they judge to be of high quality (Jick, 1983, and
in our field today, and we urge researchers to con- Blustein et al., 1997), demonstrating how the
sider mixed method approaches. researchers successfully navigated the complexi-
That being said, it is also true that quantitative ties of contrasting paradigmatic approaches, and
and qualitative methods may not necessarily mesh explaining how and why a mixed-methods approach
well or complement one another within one study. was effective in these particular investigations. The
Because they utilize different paradigms, different work of Fassinger and her colleagues in women’s
conceptions of researcher role, different approaches career development provides an example of the
to interacting with participants, different ways of use of both quantitative (e.g., Fassinger, 1990) and
unearthing information, and different articulations qualitative (e.g., Gomez et al., 2001) approaches
of the research enterprise, the outcomes of qualita- in different studies over time to explicate a voca-
tive and qualitative methods may be not only dispa- tional process. These examples may be of help to
rate but wholly incompatible. Dealing with this counseling psychologists wishing to stretch their
fundamental gap requires great caution and care, scientific competence and work toward becoming
and it may be easier to alternate quantitative and more bimethodological.
qualitative approaches across studies within an
ongoing program of research over many years, shift- Conclusion
ing the approach to illuminate different aspects of In concluding this chapter, we express hope that
the same research problem (Ponterotto & Grieger, more researchers will embrace the notion of using
2007). mixed methods in their research programs. In some
Several authors have offered perspectives on the cases, this “mixing” may be done by one researcher—
challenges and possibilities of mixed-methods within one study or over time in a programmatic
approaches. Marecek (2003) offers a less polarized series of studies designed to enhance understand-
view of quantitative and qualitative methods, sug- ing of some phenomenon of interest. In other cases,
gesting that the tension is not that one approach groups of researchers may combine their efforts,
produces greater truth than the other, but that they some engaged in qualitative and others in quantita-
offer different kinds of truths, and researchers must tive investigations of a particular problem. In all
determine which truth is of greatest interest to them cases, we assert that researchers must become com-
in understanding a particular phenomenon. In petent in any method they wish to use, and that, at
addition, she observes that any research approach, the same time, we all become conversant enough in
regardless of paradigmatic and methodological both quantitative and qualitative research approaches
underpinnings, can be used oppressively or dismis- to appreciate their significant and unique contribu-
sively by researchers, and that no particular method tions to scholarly progress.

266 m ethodologie s
References Fassinger, R. E. (2005). Paradigms, praxis, problems, and prom-
AMOS. Structural equation modeling software. [Software]. ise: Grounded theory in counseling psychology research.
Available from www.spss.com/Amos/. Journal of Counseling Psychology, 52, 156–166.
Arminio, J. (2001). Exploring the nature of race-related guilt. Fassinger, R. E., & O’Brien, K. M. (2000). Career counseling
Journal of Multicultural Counseling and Development, 29, with college women: A scientist-practitioner-advocate model
239–252. of intervention. In D. Luzzo (Ed.), Career development of
Avalos, L. (2005). An initial examination of a model of intuitive college students: Translating theory and research into practice
eating. Unpublished honors thesis, Department of Psychology, (pp. 253–265). Washington, DC: American Psychological
the Ohio State University. Association Books.
Baron, R. M., & Kenny, D. A. (1986). The moderator-mediator Fine, M. (2007). Expanding the methodological imagination.
variable distinction in social psychological research. Journal The Counseling Psychologist, 35, 459–473.
of Personality and Social Psychology, 51, 1173–1182. Fine, M., Torre, M. E., Boudin, K., Bowen, I., Clark, J.,
Bentler, P. (1995). EQS: Structural equation modeling software. Hylton, D., et al. (2003). Participatory action research: From
[Software]. Available from Multivariate Software: www. within and beyond prison bars. In P. M. Camic, J. E. Rhodes,
mvsoft.com/. & L. Yardley (Eds.), Qualitative research in psy-
Blustein, D. L., Phillips, S. D., Jobin-Davis, K., Finkelberg, S. L., chology: Expanding perspectives in methodology and design
& Rourke, A. E. (1997). A theory- building investigation of (pp. 173–198). Washington, DC: American Psychological
the school-to-work transition. The Counseling Psychologist, Association Books.
25, 364–402. Fitzgerald, L. F., & Hubert, L. J. (1987). Multidimensional
Borgen, F. H., & Betz, N. E. (2008). Career self-efficacy and scaling: Some possibilities for counseling psychology. Journal
personality: Linking career confidence and the healthy per- of Counseling Psychology, 34, 469–480.
sonality. Journal of Career Assessment, 16, 22–43. Forester, M., Kahn, J., & Hesson-McInnis, M. (2004). Factor
Browne, M. (2001). An overview of analytic rotation in explor- structure of three measures of research self-efficacy. Journal
atory factor analysis. Multivariate Behavioral Research, 36, of Career Assessment, 12, 3–16.
111–150. Frazier, P. A., Tix, A. P., & Barron, K. E. (2004). Testing modera-
Browne, M., & Cudeck, R. (1993). Alternative ways of assess- tor and mediator effects in counseling psychology research.
ing model fit. In K. A. Bollen, & J. Long (Eds.), Testing Journal of Counseling Psychology, 51, 115–134.
structural equation models (pp 136–162). Newbury Park, Friedman, M. L., Friedlander, M. L., & Blustein, D. L. (2005).
CA: Sage. Toward an understanding of Jewish identity: A phenomeno-
Browne, M., Cudeck, R., Tateneni, K., & Mels, G. (2004). logical study. Journal of Counseling Psychology, 52, 77–83.
Comprehensive exploratory factor analysis (CEFA). Computer Giorgi, A. P., & Giorgi, B. M. (2003). The descriptive phenom-
software and manual. Retrieved from http://faculty.psy.ohio- enological psychological model. In P. M. Camic, J. E.
sttae.edu/browne/software.php. Rhodes, & L. Yardley (Eds.), Qualitative research in psy-
Charmaz, K. (2000). Grounded theory: Objectivist and con- chology: Expanding perspectives in methodology and design
structivist methods. In N. K. Denzin, & Y. S. Lincoln (Eds.), (pp. 243–274). Washington, DC: American Psychological
Handbook of qualitative research (2nd ed., pp. 509–536). Association Books.
Thousand Oaks, CA: Sage Publications. Glaser, B. G. (1992). Basics of grounded theory analysis: Emergence
Cohen, J. (1969). Statistical power analyses for the behavioral vs. forcing. Mill Valley, CA: Sociology Press.
sciences. New York: Academic Press. Glaser, B. G. (2000). The future of grounded theory. Grounded
Cohen, J. (1988). Statistical power analyses for the behavioral Theory Review, 1, 1–8.
sciences (2nd ed.). Hillsdale, NJ: Erlbaum. Glaser, B. G., & Strauss, A. L. (1967). The discovery of grounded
Cohen, J. (1992). A power primer. Psychological Bulletin, 112, theory: Strategies for qualitative research. Chicago: Aldine.
155–159. Glass, G. V. (1976). Primary, secondary, and meta-analysis of
Cohen, J. (1994). The earth is round (p < .05). American research. Educational Researcher, 5, 3–8.
Psychologist, 49, 997–1003. Glass, G. V. (2006). Meta-analysis: Quantitative synthesis of
Creswell, J. W., Hanson, W. E., Plano Clark, V. L., & Morales, A. research findings. In J. Green, G. Camilli, & P. Elmore
(2007). Qualitative research designs: Selection and imple- (Eds.), Handbook of complementary methods in education
mentation. The Counseling Psychologist, 35(2), 236–264. research (pp. 427–438). Mahwah, NJ: Erlbaum.
DeNeve, K. M., & Cooper, H. (1998). The happy personality. Glass, G. V., & Hopkins, K. (1996). Statistical methods in psy-
Psychological Bulletin, 124, 197–229. chology and education (3rd ed.). Englewood Cliffs, NJ:
Denzin, N. K., & Lincoln, Y. S. (2000). Handbook of qualitative Prentice Hall.
research (2nd ed.). Thousand Oaks, CA: Sage Publications. Gomez, M. J., Fassinger, R. E., Prosser, J., Cooke, K., Mejia, B.,
Fabrigar, L. R., Wegener, D. T., MacCallum, R. C., & & Luna, J. (2001). Voces abriendo caminos (voices forging
Starhan, E. J. (1999). Evaluating the use of exploratory paths): A qualitative study of the career development of nota-
factor analysis in psychological research. Psychological ble Latinas. Journal of Counseling Psychology, 48, 286–300.
Methods, 4, 272–299. Gorsuch, R. L. (1983). Factor analysis (2nd ed.). Hillsdale, NJ:
Fassinger, R. E. (1990). Causal models of career choice in two Erlbaum.
samples of college women. Journal of Vocational Behavior, 36, Haase, R. F., & Ellis, M. V. (1987). Multivariate analysis of
225–248. variance. Journal of Counseling Psychology, 34, 404–413.
Fassinger, R. E. (2001). On remodeling the master’s house: Tools for Hansen, J. C., Dik, B., & Zhou, S. (2008). An examination
dismantling sticky floors and glass ceilings. Invited keynote of the structure of leisure interests in college students, work-
address, Fifth Biennial Conference of the Society for ing age adults, and retirees. Journal of Counseling Psychology,
Vocational Psychology, Houston, TX. 55, 133–145.

be t z, fassinge r 267
Hardy, G. E., Barkham, M., Field, S. D., Elliott, R., & Killeen, P. R. (2005). An alternative to null-hypothesis signifi-
Shapiro, D. A. (1998). Whineging versus working: cance tests. Psychological Science, 16, 345–353.
Comprehensive process analysis of a “vague awareness” event Kinnier, R. T., Tribbensee, N. E., Rose, C. A., & Vaughan, S. M.
in psychodynamic-interpersonal therapy. Psychotherapy (2001). In the final analysis: More wisdom from people who
Research, 8, 334–353. have faced death. Journal of Counseling & Development, 79,
Haverkamp, B. E. (2005). Ethical perspectives on qualitative 187–195.
research in applied psychology. Journal of Counseling Kirk, R. (1996). Practical significance: A concept whose time
Psychology, 52(2), 146–155. has come. Educational and Psychological Measurement, 56,
Hayton, J. C., Allen, D. G., Scarpello, V. (2004). Factor reten- 746–759.
tion decisions in exploratory factor analysis: A tutorial Larson, L., Wei, M., Wu, T., Borgen, F., & Bailey, D. (2007).
on parallel analysis. Organizational Research Methods, 7, Discriminating among educational majors and career aspira-
191–205. tions in Taiwanese undergraduates. Journal of Counseling
Henwood, K., & Pidgeon, N. (2003). Grounded theory in Psychology, 54, 395–408.
psychological research. In P. M. Camic, J. E. Rhodes, & Leff, S. S., Costigan, T., & Power, T. J. (2004). Using partici-
L. Yardley (Eds.), Qualitative research in psychology: Expanding patory research to develop a playground-based prevention
perspectives in methodology and design (pp. 131–156). program. Journal of School Psychology, 42, 3–21.
Washington, DC: American Psychological Association Lent, R. W., Brown, S. D., Sheu, H.-B., Schmidt, J., Brenner, B.,
Books. Gloster, C., et al. (2005). Social cognitive predictors of
Heppner, P., Wampold, B., & Kivlighan, D. (2008). Research academic interest and goals in engineering: Utility for women
design in counseling (4th ed.). Belmont, CA: Brooks-Cole. and students at historically Black universities. Journal of
Hermann, K. (2005). Path models of the relationships of instru- Counseling Psychology, 52, 84–92.
mentality and expressiveness, social self-efficacy, and self-esteem MacCallum, R. C., & Austin, J. (2000). Applications of struc-
to depressive symptoms in college students. Unpublished PhD tural equation modeling in psychological research. Annual
Dissertation, Department of Psychology, Ohio State Review of Psychology, 51, 201–226.
University. MacCallum, R., Roznowski, M., & Necowitz, L. (1992).
Hermann, K., & Betz, N. E. (2006). Path models of the rela- Model modifications in covariance structure analysis: The
tionships of instrumentality and expressiveness, social self- problem of capitalization on chance. Psychological Bulletin,
efficacy, and self-esteem to depressive symptoms in college 111, 490–504.
students. Journal of Social and Clinical Psychology, 25, MacCallum, R. C., Widaman, K. F., Zhang, S., & Hong, S.
1086–1106. (1999). Sample size in factor analysis. Psychological Methods,
Hill, C. E., Knox, S., Thompson, B. J., Williams, E. N., Hess, S. A., 4, 84–89.
Ladany, N. (2005). Consensual qualitative research: An Marecek, J. (2003). Dancing through minefields: Toward a qual-
update. Journal of Counseling Psychology, 52(2), 196–205. itative stance in psychology. In P. M. Camic, J. E. Rhodes, &
Hogan, T. P. (2007). Psychological testing: A practical introduction L. Yardley (Eds.), Qualitative research in psychology: Expanding
(2nd ed.). New York: Wiley. perspectives in methodology and design (pp. 49–70).
Hoshmand, L. T. (2005). Narratology, cultural psychology, and Washington, DC: American Psychological Association
counseling research. Journal of Counseling Psychology, 52(2), Books.
178–186. Miller, P. J., Hengst, J. A., & Wang, S. (2003). Ethnographic
Hu, L., & Bentler, P. (1999). Cutoff criteria for fit indexes in methods: Applications from developmental cultural psychol-
covariance structure analysis: Conventional criteria versus ogy. In P. M. Camic, J. E. Rhodes, & L. Yardley (Eds.),
new alternatives. Structural Equation Modeling, 6, 1–55. Qualitative research in psychology: Expanding perspectives in
Jick, T. D. (1983). Mixing qualitative and quantitative methods: methodology and design (pp. 49–70). Washington, DC:
Triangulation in action. In J. Van Maanen (Ed.), Qualitative American Psychological Association Books.
methodology (pp. 135–148). Beverly Hills, CA: Sage. Morrow, S. L. (2005). Quality and trustworthiness in qualitative
Joreskog, K. G., & Sorbom, D. (2008). LISREL 8.8. [Software]. research in counseling psychology. Journal of Counseling
Lincolnwood IL: Scientific Software. Retrieved from www. Psychology, 52(2), 250–260.
ssicentral.com/lisrel/new.html. Morrow, S. L. (2007). Qualitative research in counseling psy-
Juntunen, C. L., Barraclough, D. J., Broneck, C. L., Seibel, chology: Conceptual foundations. The Counseling Psychologist,
G. A., Winrow, S. A., & Morin, P. M. (2001). American 35(2), 209–235.
Indian perspectives on the career journey. Journal of Morrow, S. L., & Smith, M. L. (1995). Constructions of survival
Counseling Psychology, 48, 274–285. and coping by women who have survived childhood sexual
Kahn, J. H. (2006). Factor analysis in counseling psychology abuse. Journal of Counseling Psychology, 42, 24–33.
research, training, and practice. The Counseling Psychologist, Murray, M. (2003). Narrative psychology and narrative analysis.
34, 684–718, inside back cover. In P. M. Camic, J. E. Rhodes, & L. Yardley (Eds.), Qualitative
Kanji, G. K. (1993). 100 statistical tests. Newbury Park, CA: research in psychology: Expanding perspectives in methodology
Sage. and design. Washington, DC: American Psychological
Kashubeck-West, S., Coker, A. D., Awad, G. H., Hix, R. D., Association Books.
Bledman, R. A., & Mintz, L. (2008, August). Psychometric Muthen, L. K., & Muthen, B. O. (2006). Mplus users guide
evaluation of body image measures in African American women. (4th ed.). Los Angeles: Muthen and Muthen. Retrieved from
Poster presented at the meeting of the American Psychological www.statmodel.com/company.shtml.
Association, Boston, MA. Noonan, B. M., Gallor, S., Hensler-McGinnis, N., Fassinger, R. E.,
Kidd, S. A., & Kral, M. J. (2005). Practicing participatory action Wang, S., & Goodman, J. (2004). Challenge and success:
research. Journal of Counseling Psychology, 52, 187–195. A qualitative study of the career development of highly

268 m ethodologie s
 achieving women with physical and sensory disabilities. Sterner, W. R. (2011). What is missing in counseling research?
Journal of Counseling Psychology, 51, 68–80. Reporting missing data. Journal of Counseling and Develop-
Patton, M. Q. (2002). Qualitative research & evaluation methods ment, 89, 56–63.
(3rd ed.). Thousand Oaks, CA: Sage Publications. Stevens, S. S. (1951). Handbook of experimental psychology.
Polkinghorne, D. (2005). Language and meaning: Data collec- New York: Wiley.
tion in qualitative research. Journal of Counseling Psychology, Strauss, A. L. (1987). Qualitative analysis for social scientists.
52, 137–145. New York: Cambridge University Press.
Ponterotto, J. G. (2005). Qualitative research in counseling Strauss, A. L., & Corbin, J. (1998). Basics of qualitative research:
psychology: A primer on research paradigms and philosophy Techniques and procedures for developing grounded theory
of science. Journal of Counseling Psychology, 52(2), 126–136. (2nd ed.). Thousand Oaks, CA: Sage Publications.
Ponterotto, J. G., & Grieger, I. (1999). Merging qualitative and Suzuki, L. A., Ahluwalia, M. K., Mattis, J. S., & Quizon, C. A.
quantitative perspectives in a research identity. In M. Kopala, (2005). Ethnography in counseling psychology research:
& L. A. Suzuki (Eds.), Using qualitative methods in psychology Possibilities for application. Journal of Counseling Psychology,
(pp. 49–61.). Thousand Oaks, CA: Sage Publications. 52, 206–214.
Ponterotto, J. G., & Grieger, I. (2007). Effectively communicat- Suzuki, L. A., Prendes-Lintel, M., Wertlieb, L., & Stallings, A.
ing qualitative research. The Counseling Psychologist, 35(3), (1999). Exploring multicultural issues using qualitative
431–458. methods. In M. Kopala, & L. A. Suzuki (Eds.), Using quali-
Rennie, D. L. (1994). Clients’ deference in psychotherapy. tative methods in psychology (pp. 123–134). Thousand Oaks,
Journal of Counseling Psychology, 41, 427–437. CA: Sage Publications.
Rennie, D. L. (2000). Grounded theory methodology as Swanson, J. L. (2011). Measurement and assessment in counsel-
methodological hermeneutics. Theory & Psychology, 10(4), ing psychology. In E. M. Altmaier, & J. C. Hansen (Eds.),
481–502. The Oxford handbook of counseling psychology. New York:
Rennie, D. L. (2004). Anglo-North American qualitative coun- Oxford University Press.
seling and psychotherapy research. Psychotherapy Research, Tabachnick, B. G., & Fidell, L. S. (2007). Using multivariate
14, 37–55. statistics (5th ed.). New York: Harper Collins College
Richie, B. S., Fassinger, R. E., Linns, S., Johnson, J., Prosser, J., Publishers.
& Robinson, S. (1997). Persistence, connection, and pas- Thurstone, L. L. (1947). Multiple factor analysis. Chicago:
sion: A qualitative study of the career development of highly University of Chicago Press.
achieving African American/Black and White women. Tracey, T. J. G. (2008). Adherence to RIASEC structure as a key
Journal of Counseling Psychology, 44, 133–148. career decision construct. Journal of Counseling Psychology,
Russell, D., Kahn, J., Spoth, R., & Altmaier, E. (1998). Analyzing 55, 146–157.
data from experimental studies. Journal of Counseling Vacha-Haase, T., & Thompson, B. (2004). How to estimate and
Psychology, 45, 18–29. interpret various effect sizes. Journal of Counseling Psychology,
Schafer, J. L., & Graham, J. W. (2002). Missing data: Our view 51, 473–481.
of the state of the art. Psychological Methods, 7, 147–177. Wertz, F. J. (2005). Phenomenological research methods for
Schumaker, R. E., & Lomax, R. G. (2004). A beginner’s guide to counseling psychology. Journal of Counseling Psychology, 52,
structural equation modeling. Mahwah, NJ: Lawrence 167–177.
Erlbaum. Weston, R., & Gore, P. (2006). A brief guide to structural equa-
Sherry, A. (2006). Discriminant analysis in counseling psychol- tion modeling. The Counseling Psychologist, 34, 719–751.
ogy research. The Counseling Psychologist, 34, 661–683. Wilkinson, L., & Task Force on Statistical Inference. (1999).
Sireci, S. G., & Talento-Miller, E. (2006). Evaluating the Statistical methods in psychology journals: Guidelines and
predictive validity of Graduate Management Admissions explanations. American Psychologist, 54, 594–604.
Test scores. Educational and Psychological Measurement, 66, Young, R. A., Valach, L., & Domene, J. E. (2005). The action-
305–317. project method in counseling psychology. Journal of
Smith, M. L., & Glass, G. V. (1977). Meta-analysis of psy- Counseling Psychology, 52(2), 215–223.
chotherapy outcome studies. American Psychologist, 32, Young, R. A., Valach, L., Paseluihko, M. A., Dover, C., Matthes,
752–760. G. E., Paproski, D., et al. (1997). The joint action of parents
Sobel, M. E. (1982). Asymptotic intervals for indirect effects in and adolescents in conversation about career. Career
structural equation models. In S. Leinhart (Ed.), Sociological Development Quarterly, 46, 72–86.
methodology (pp. 290–312). San Francisco: Jossey-Bass. Zwick, W. R., & Velicer, W. F. (1986). A comparison of five rules
Spearman, C. (1904). General intelligence: Objectively defined for determining the number of components to retain.
and measured. American Journal of Psychology, 15, 201–293. Psychological Bulletin, 99, 432–442.
Steiger, J. H. (1990). Structural model evaluation and modifica-
tion: An interval estimation approach. Multivariate Behavioral
Research, 25, 173–180.

be t z, fassinge r 269
 CHAPTER

10 Ethics in Counseling Psychology

Melba J. T. Vasquez and Rosie Phillips Bingham

Abstract
This chapter focuses on the contributions that counseling psychology has made to the evolution
of professional ethics. Kitchener’s moral principles and Meara, Schmidt, and Day’s (1996) virtue ethics
are examples of contributors whose work has influenced the ethics discourse. Changes to the 2002
American Psychological Association’s Ethical Principles of Psychologists and Code of Conduct are
discussed, as are mechanisms for accountability and key areas of concern for psychologists. Counseling
psychology’s unique contribution to social justice as an ethical imperative is addressed, and an ethical
decision-making model is suggested. Finally, future directions in ethics, especially in regard to the social
milieu, are described, including the direction of ethics training.
Keywords: ethics, virtue ethics, moral principles, counseling psychology, social justice,
practice guidelines, accountability, ethics education, ethical decision making

In this chapter, we discuss the evolution of the Counseling Psychologists and the
American Psychological Association (APA) ethics Ethics Codes
codes, including an overview of counseling psy- The influence of counseling psychologists on the
chologists’ contribution to the ethics discourse, such development of the last couple of revisions of the
as Kitchener’s (1984, 2000) moral principles and APA Ethical Principles of Psychologists and Code
Meara, Schmidt, and Day’s (1996) virtue ethics. of Conduct (1992, 2002) has been significant,
Throughout the chapter, we discuss changes to the although counseling psychologists were not involved
APA 2002 Ethical Principles of Psychologists and in the early development of the ethical discourse for
Code of Conduct. We describe the mechanisms for various reasons. The Division of Counseling Psy-
accountability, and identify key areas of concern chology was founded in 1943, as Division 17 of the
based on the areas of most common violation by American Psychological Association with the name
psychologists. We suggest a decision-making model of Division of Counseling and Guidance. The first
for use with ethical dilemmas. We also discuss coun- tentative draft of an APA ethics code occurred in
seling psychology’s unique contribution to social 1951. The early drafters of the code were operating
justice as an ethical imperative, and describe several in a climate that questioned the need for an ethics
of the aspirational guidelines that have been devel- code (Hall, 1952). The APA Ethics Committee
oped in large part through the contributions of was founded in 1938, 46 years after the APA was
various counseling psychologists. The final section founded. Given the increasing ethical questions
identifies our concluding thoughts on key dilemmas and dilemmas in the profession, the APA Council
yet to be fully addressed in the ethical realm of pro- of Representatives adopted the first official Ethical
fessional responsibilities and ethics education. Standards for Psychologists in 1953. The current

270
Ethical Principles of Psychologists and Code of Although the counseling psychology conferences
Conduct (APA, 2002) is the tenth revision, and was did not address ethics per se, several counseling
amended in 2010. psychologists have promoted key concepts in the
During the development of the first APA Ethics field of ethics. Schmidt and Meara (1984) provided
Code, counseling psychology was very inwardly a framework for understanding ethical, legal, and
focused on establishing itself as a discipline, to the professional issues for counseling psychology. Their
extent that it even concerned itself with finding an framework for discussing these issues through the
appropriate name. The professionals of the time lens of human services, research, teaching/training,
worked to distinguish counseling psychology from and public policy provided a useful method for
clinical psychology and to establish it as a viable effectively writing about and discussing ethics across
discipline. Several national counseling psychology the rather broad counseling psychology specialty.
conferences, including the 1951 Northwestern Con- The Schmidt and Meara (1984) contribution served
ference, the 1964 Greystone Conference, and the as an ethics educational tool for counseling
1987 Atlanta Conference, firmly solidified counseling psychologists and as a reminder that counseling
psychology as a legitimate field of study in psychol- psychology was a young field, struggling for credibil-
ogy. During the conferences, there appears to have ity and legitimacy. The authors clarified certain
been minimal attention paid to discussions of ethics. areas, such as the difference between privileged
Although there are no reported major publica- communication and confidential communication.
tions on ethics from these early counseling psy- In their roles as educators for counseling psycholo-
chology conferences, there were discussions of gists, they also highlighted portions of the Ethics
issues that would have bearing on the content of Code that dealt with matters such as informed con-
later ethics codes and guidelines. As early as the sent, confidentiality with clients and research sub-
Northwestern Conference in 1951, the discourse jects, sexual exploitation and sexual harassment,
referred to the need for counseling psychologists research subjects and the role of deceit and debrief-
to be concerned with culture (APA, 1952). The ing, and so on.
Greystone Conference was specifically charged to It is interesting to note that the Schmidt and
examine emerging diversity in the field (Thompson Meara (1984) contribution reflects some of coun-
& Super, 1964). Participants of the 1987 Atlanta seling psychology’s struggle for identity and legiti-
Conference identified five major areas of concern, macy in the early years. In several sections in which
including the call for more multicultural research the authors highlighted the ethical concerns for
and the integration of diversity, gender, and multi- clients and students, they also offered cautions
culturalism throughout the curricula and training. that the consequences of certain behaviors could
In 2001, the Houston Conference on counseling adversely affect counseling psychology as a whole.
psychology firmly and definitively staked a claim For example, Schmidt and Meara (1984) cau-
in the discipline’s commitment to social justice and tioned, “If the belief developed that counseling
acknowledged the implications of that commit- psychologists misled subjects in their research,
ment. In addition to the general focus of helping doubts might also arise over their treatment of cli-
individuals with emotional and psychological prob- ents in counseling relationships. This clearly is to be
lems, Bingham (2002) surmised that counseling avoided, both for the sake of the individual and the
psychology had these four foci: multiculturalism, profession at large” (p. 69). Schmidt and Meara
because culture is important and there is more than (1984) also talked about the “reputation and credi-
one culture; social justice, because of the emphasis bility of counseling psychologists” when they dis-
on development and growth and environmen- cussed the role and ethics of placebo treatments in
tal/ situation influences; vocational issues, because research.
counseling psychology has long held vocational Evidence that counseling psychology was a young
issues as one of the core components of the field; field was reflected in the Schmidt and Meara (1984)
and fostering human strengths, because counseling statements that very few counseling psychologists
psychology unequivocally proclaims a focus on were called as expert witnesses. Fretz and Mills
“healthy aspects and strengths of clients.” These (1980) indicated that, throughout the 1970s, coun-
were some major themes that have been addressed seling psychology was fairly closed and insular.
in more recent versions of the ethics code, which These statements may explain why the Schmidt and
includes diversity issues such as sexual harassment Meara (1984) contribution was written in such
and unfair discrimination. a way that it served almost as a primer on ethics.

va s qu e z , ph i l l i p s b i n g h a m 271
 During the time that Schmidt and Meara (1984) a number of counseling psychologists had begun to
were concerned with writing about ethics for coun- make notable forays into the ethics literature.
seling psychologists, it is important to note that Kitchener and Anderson (2000) suggested that “The
at least two other substantive developments were intensified involvement of state legislatures to regu-
taking root in the field. One focused on women. late psychology, the increased number of civil suits
The Division 17 Ad Hoc Committee was formed in filed against psychologists, and the public’s increased
1970. The committee developed a set of principles awareness and expectations that psychologists act
for counseling and therapy with women (Farmer, ethically calls for the profession to see good coun-
2002), Also at the close of the 1970s, the Division seling, research, and training as impossible without
adopted a position paper on cross-cultural compe- good or virtuous ethical behavior” (Kitchener &
tencies (Sue et al., 1982). These two documents Anderson, 2000, p. 75).
represented the cementing of part of counseling Several counseling psychologists have indeed
psychology’s identity and its focus on multicultural- made significant contributions to the literature on
ism and social justice. These two documents were psychological ethics. Karen Kitchener (1984, 2000)
significant contributions, and serve as forerunners adapted the Beauchamp and Childress (1979)
to the APA’s development and adoption of guide- conceptualization of principle ethics for decision
lines in these two areas: The APA Guidelines making in medicine to the field of psychology.
on Multicultural Education, Training, Research, Beauchamp and Childress conceptualized the prin-
Practice, and Organizational Change for Psychol- ciples of autonomy, nonmalefience, beneficence,
ogists (APA, 2003), and the APA Guidelines for and justice as well-established standards for bioethi-
Psychological Practice with Girls and Women (APA, cal medicine in the United States. Kitchener (1984)
2007). Counseling psychologists were key authors added the principle of fidelity and applied those to
in the development of these and other important psychology ethics. Since then, those principles have
guidelines, which provide guidance in the provision shaped the general principles of the APA’s Ethical
of the highest quality of care. Such guidelines are Principles of Psychology and Code of Conduct
important because they have implications for ethi- (1992, 2002). These principles are particularly help-
cal standards to speak to competence and admoni- ful in resolving ethical dilemmas. Ethical dilemmas
tions against discrimination. evolve when ethical principles sometimes compete
In 1992, Fretz and Simon (1992) summarized against each other, or an ethical principle may con-
views that indicated a maturing of counseling flict with law. Kitchener (1984, 2000) suggested
psychologists on matters of ethics. The discussion that a critical-evaluative level or moral reasoning
moved toward what it means to be an ethical person, could be developed by applying the five ethical
rather than focusing more narrowly on the codes principles as a foundation for ethical decision mak-
that provided the essential rules about ethical con- ing in psychology. These principles are often used in
duct. By 1992, the APA Ethics Code had been society to establish policy, such as in the court
through several revisions, including those that ended system. The APA 2002 Ethics Code was reorganized
APA’s restrictive practices on advertising. However, so that the introductory General Principles are more
other challenges to the 1981 code resulted in the consistent with these bioethical principles. Thus, we
courts’ ruling that the code was so ambiguous that it see that counseling psychology has had an enduring
was difficult to apply. So, although the mindset of impact on the APA Ethics Code.
counseling psychologists had undergone an ethical Meara, Schmidt, and Day (1996) have also had
maturing process, the code was about to experience an impact on the conceptualization of ethics in
a major revision. psychology. They described how virtue ethics
Perhaps Fretz and Simon (1992) could depart focuses on character traits and nonobligatory ideals
from the more explanatory focus on the content of that facilitate the development of ethical indi-
the Ethics Code because Hall (1987) had reported viduals. They suggested that these were comple-
that 85% of all APA accredited programs had some mentary ethical perspectives that helped provide
form of ethics education. Welfel and Lipsitz (1984) a coherent structure for enhancing the ethical com-
maintained that knowledge was not enough to pro- petence of psychologists and counselors and the
duce an ethical psychologist. Furthermore, Fretz level of public trust in the character and actions of
and Simon (1992) reported that there had been sig- these professions and their members. Virtue ethics,
nificant increases in the number of ethics articles rooted in the narratives, aspirations, and ideals of
and books being published. More significantly, specific communities, can be particularly helpful

272 ethics
to professionals in discerning appropriate ethical in psychotherapy, research, educational, and other
conduct in multicultural settings and interactions. business settings. There was growing diversity in the
Meara and her colleagues (Meara, Schmidt, & U.S. demographics and in the clientele seeking
Day, 1996, Jordan & Meara, 1990) moved the psychological services. These changes occurred at
ethics discussion beyond codification, rules, and a time when society was becoming more litigious.
regulations to a focus on the person, rather than on The number of cases brought before the APA ethics
cognitive analyses such as those embodied in the committees and state psychology boards increased,
principled ethics described by Kitchener. Jordan and the number of suits filed against psychologists
and Meara (1990) championed a message about the rose dramatically. Additionally, more psychologists
kind of ethical persons counseling psychologists were objecting to sanctions being imposed by ethics
should be. Such discussions led Fretz and Simon bodies. Change was needed. The 1992 revision of
(1992) to assert that training programs would need the ethics code was designed to be a utilitarian
to move beyond the mere teaching of ethics content document that would provide simple, straightfor-
to more foundational discussion of ethics philoso- ward, and direct guidance to psychologists (Canter,
phy and ethical decision-making models. Another Bennett, Jones, & Nagy, 1994). Principled ethics,
implication has been validation of the attention to like those espoused by Kitchener, were deemed
the selection of students into the field of counseling ambiguous and therefore were separated out as
psychology. That is, that character is a critical ele- aspirational and not enforceable. The code then
ment in ethical behavior and that the selection of delineated a series of topically divided declarative
future psychologists should assess for those aspects statements that would act as enforceable standards.
of character that support ethical behavior. Kitchener and Anderson (2000) raised the ques-
Like Schmidt and Meara (1984), Fretz and tion of whether such a collection of standards could
Simon (1992) highlighted ethical issues that were help an individual become a truly ethical counseling
receiving considerable attention at the close of psychologist. They argued for the inclusion of virtue
1980s. These issues included informed consent in ethics in the training of counseling psychologists.
supervision, research, and professional writing. Virtue ethics had been proposed by Meara (1996)
Furthermore, as the human immunodeficiency to examine the characteristics, emotions, motiva-
virus/acquired immune deficiency syndrome (HIV/ tion, prudence, and moral habits of individuals.
AIDS) epidemic burst onto the scene, new prob- Kitchener and Anderson maintained that “Moral
lems of confidentiality arose regarding the relation- behavior is complex; these philosophical and psy-
ship, obligations, and responsibility of the counseling chologically sophisticated models are necessary to
psychologist to an HIV-infected client who main- understand it” (p. 72.) Of course, such models were
tained a physical relationship with a person to considered far too complex to include in an ethics
whom the client had not disclosed his or her HIV code.
status. Fretz and Simon (1992) also raised issues of But Kitchener and Anderson (2000) advocated
a client’s right to end his or her own life. These for counseling psychologists to at least include such
authors were making it clear that ethical issues training in educational programs and then research
were becoming more nuanced and complex. In their effectiveness. The authors seemed to be con-
addition, the number of cases being referred to the cerned about the fact that no such research was
APA Ethics Committee experienced a steep rise. It being conducted in psychology. They did report
seemed that counseling psychologists and clients on Bebeau’s (1994) work with dental students,
were becoming more ethically sophisticated and whose data indicated that moral sensitivity and rea-
more aware of problems in the field. Fretz and soning can be improved with training. Kitchener
Simon (1992) also conveyed their understanding of and Anderson believed that such research is neces-
the increasing importance of cultural diversity and sary for counseling psychology students because
the implication of cultural competence as a key data suggests that, even after an ethics course, stu-
ethical requirement. dents will still make serious errors in deciding on
In 1992, the Ethics Code underwent a major ethical issues (Fly, vanBark, Weinman, Kitchener, &
revision. This revision occurred in part because Lang, 1997). Furthermore, they pointed to the
consumers and psychologists were beginning to increasing complexity of multiple relationships; the
understand the complexities of psychological rela- complication of competence, bias, and justice at
tionships, raising more questions about the impact the intersection of race, ethnicity, and gender; and
of psychologists’ behaviors and their consequences even the problems of confidentiality in various

va s qu e z , ph i l l i p s b i n g h a m 273
settings as examples of why a simple compendium minimal standards as their members carry out their
of utilitarian standards was insufficient in today’s work, and that those who are served by profession-
psychological environment. Kitchener and Anderson als are protected from harm in the case of incompe-
(2000) made such a compelling argument for virtue tent, negligent, and/or unscrupulous practitioners
ethics that it was clear that the ethics code would (Pope & Vasquez, 2007). Counseling psychologists
shortly require another revision. may have an even higher duty of care because of our
Werth, Cummings, and Thompson (2008) pro- emphasis on social justice. A commitment to social
vided an overview of select ethical and legal issues justice implies that the discipline is intentional and
affecting counseling psychologists, including risk purposeful in its attention to issues of relationships,
management and competence. They focused on justice, and fairness for all individuals. So, although
the APA Ethics Code, professional regulations, the accountability mechanism ensures that the pro-
state statutes, and federal laws. They emphasized fession meets minimal standards, the social justice
the importance of consultation and exposure to emphasis suggests that counseling psychologists
the literature in order to monitor competence and must challenge themselves to go beyond these mini-
biases in every professional situation. Werth et al. mum requirements.
and other counseling psychologists cited here chal-
lenged the profession to view ethics as more than The APA Ethics Code and Areas of Concern
a codification of rules and regulations. They demon- Pope and Vasquez (2007) reported a compilation
strated that ethics must be pervasive in all that psy- of data from the major areas of most frequently
chologists do, if they are to be competent and reported disciplinary action as described by the
accountable. APA Ethics Committee, the Association of State
Thus, counseling psychologists have contributed and Provincial Psychology Boards (ASPPB), and the
to the discourse and direction of professional ethics APA Insurance Trust. Based on those data, we will
in psychology. Considerations of key professional describe issues involved in the following categories:
obligations are integrated into the fabric of counsel- multiple relationships, including sexual intimacy/
ing psychology teaching, training and supervision, sexual misconduct and nonsexual boundary viola-
our publications, and in the research and practice of tions; confidentiality; insurance and fees; record
psychology. keeping; child custody; and terminations.

Mechanisms of Accountability Multiple Relationships: Sexual Misconduct

Four major mechanisms hold psychologists and and Nonsexual Boundary Violations
other mental health professionals accountable to Sexual intimacies with current clients/patients have
an explicit set of professional standards and legal been explicitly prohibited since the 1977 APA
requirements, including professional ethics com- Ethics Code; however, the standard of practice prior
mittees, state licensing boards, civil malpractice to that inclusion precluded a sexual relationship
courts, and criminal courts. Although considerable between therapist and client. The prohibition had
overlap exists, each of these mechanisms may use been indirectly implied by other standards before
different formulations of standards. Our profession that time (Pope &Vasquez, 2007). Several of the
has a social contract with society, based on attitudes general principles and standards in the 2002 Ethics
of mutual respect and trust, that the discipline will Code prohibit sexual relationships and involve-
do everything it can to assure that its members ments with clients and students.
will act ethically in conducting the affairs of the General Principle A, Beneficence and Nonma-
profession within society. The “contract” implies lefience, states that, “psychologists strive to benefit
a commitment to place the welfare of society and those with whom they work and take care to do no
individual members of the society above the welfare harm” (APA, p. 1062). Psychologists are cautioned
of the discipline and its professionals. So, psycholo- to avoid inflicting intentional harm and not to
gists have a higher duty of care to members of soci- engage in actions that risk harming others. Ethics
ety than the general duty of care that all members Code Standard 10.05 most directly addresses sexual
of society have to each other, including taking care intimacies with current therapy clients/patients,
that psychologists not abuse power, and in fact use and 10.08 prohibits sexual intimacies with former
it to help others. This is the basis on which mecha- therapy clients and patients for at least 2 years after
nisms of accountability are established; that is, to termination of professional services. Even then, the
be committed to ensuring that professions meet burden is on the psychologist to demonstrate that

274 ethics
no exploitation exists, based on several factors. risk management strategies encourage psycholo-
Standard 10.06, a new standard in the 2002 Ethics gists to be cautious about how easily touch can be
Code, prohibits sexual intimacies with relatives or misunderstood as a sexual overture by some clients/
significant others of current therapy clients/patients, patients, perhaps particularly those with a history
and 10.07 prohibits therapy with former sexual of incest or other similar violations. Cultural and
partners. Other standards relevant to the prohibi- theoretical orientations also inform this behavior;
tion include 3.04, Avoiding Harm, and 3.08 for example, some clients and therapists have cul-
Exploitative Relationships. In addition, Ethics Code tural or other orientations that allow for nonsexual
Standard 7.07 prohibits sexual relationships with hugs, handshakes, or other forms of affectionate
students and supervisees over whom psychologists communication. Because of cultural variations in
have or are likely to have evaluative authority. behavior around matters such as touching, it is rec-
The evidence is clear that sexual contact with ommended that psychologists must be knowledge-
clients/patients and students has a high potential able about relevant guidelines (for example, the
for harm, partly because the power differential and Guidelines for Psychological Practice with Girls and
influence that psychologists possess result in exploi- Women, APA, 2007, and the Multicultural Guide-
tation of the vulnerabilities of those with whom lines, APA, 2003) that provide further direction on
they work (Pope & Vasquez, 2007). It also harms appropriate therapist behavior.
the public image of psychologists, and the preva- It is important to note that “sex therapy”
lence of sexual involvement of mental health does not include romantic or erotic interaction
providers with clients/patients has resulted in an between the therapist and client/patient, although it
increasing criminalization of this behavior in over may involve communication about explicitly sexual
half of the states in the United States (Haspel, information, instructions, or readings. Psychologists
Jorgenson, Wincze, & Parsons, 1997). Sex with must still be cautious because clients/patients may
clients is the highest risk behavior in which a psy- perceive comments as erotic, without regard to the
chologist can engage. The behavior is risky in terms psychologist’s intent. The use of sexual surrogates
of the reported harm to clients/patients, as well as is controversial, but if the psychologist endorses the
in the risk to the psychologist. At one point, sexual use of surrogates, the surrogate may never be the
impropriety constituted over half (53.2%) of all psychologist.
costs of violations for professional liability insurance Judgments about nonsexual dual or multiple
for psychologists, although a recent APA Insurance relationships are more complex for all psychologists.
Trust evaluation reported that the percentage of The new Ethics Code acknowledges that not all
claims for sexual misconduct had decreased, based multiple or dual relationships are problematic, or
on a “snapshot” review of the data (Bruce Bennett, avoidable. These behaviors are not specifically pro-
personal correspondence, December 19, 2005). hibited. Instead, in Standard 3.05, Multiple
Hopefully, this means that psychologists have taken Relationships, psychologists are warned to avoid
to heart the risks such relationships pose to clients relationships that, “could reasonably be expected to
and to themselves. impair the psychologist’s objectivity, competence,
Self-awareness is a key to avoidance. We all have or effectiveness in performing his or her functions
to accept the fact that psychologists can become as a psychologist, or otherwise risk exploitation or
emotionally and sexually attracted to a client. harm to the person with whom the professional
In one survey, 87% of all therapists (95% of men, relationship exists”(APA, 2002, p. 1065). Authors
75% of women) reported that they have been of the code tried to indicate the risk factors and
attracted to their clients, at least on occasion situations that can lead to risk of harm. However,
(Bernsen, Tabachnick, & Pope, 1994; Pope, Keith- “Multiple relationships that would not reasonably
Spiegel, & Tabachnick, 1986)). Social psychological be expected to cause impairment or risk exploita-
literature informs us that “proximity” is the most tion or harm are not unethical” (APA, 2002,
salient variable predicting who gets together with p. 1065). It is important to note that most risk
whom. The skill of managing romantic/sexual feel- management guidelines would strongly discourage
ings toward clients throughout the course of therapy even the appearance of a conflict.
can help identify inappropriate feelings of attraction Kitchener (2000) relied on social role therapy
toward clients. to explain the problems with multiple role relation-
A complicating issue is that, although the ships. Responsibilities, needs, and expectations are
Ethics Code does not prohibit nonsexual touching, very different with a business partner than with

va s qu e z , ph i l l i p s b i n g h a m 275
a client, for example. Trying to maintain two dif- decision, including the duty to warn and/or protect
ferent roles with someone, especially a client, a third party from a threatening client) and the legal
increases the potential for misunderstanding and responsibility to report child, elderly, or disability
harm because the incompatibility of all these expec- abuse. Limits of confidentiality generally exist if the
tations is higher. As the obligations of different roles client files suit against the therapist for breach of
diverge, the potential for divided loyalties and loss duty, or if a court order requires disclosure.
of objectivity increases. As the power and prestige Bongar (1992) suggested that suicidal clients are
difference increases, so does the potential for exploi- the most stressful of all clinical endeavors. A national
tation and lowered objectivity and autonomy of the survey found that psychologists responded to the
consumer. loss of a patient to suicide in a manner akin to the
death of a family member. Psychologists have a
Confidentiality greater than 20% chance of losing a patient to sui-
Confidentiality, privacy, and privilege are three cide at some time during their professional careers.
overlapping concepts. In almost all states, privilege Psychiatrists have a 50% chance of losing a patient
belongs to the client. Confidentiality, considered to suicide. Rudd, Joiner, and Rajab (2001) identi-
a primary ethical obligation, is a commitment to fied a trend of increasing attention to the assessment
clients, research participants, and others that private and treatment of suicidal behavior. This reflects a
information will not be divulged without their con- heightened level of awareness of the complexity
sent. This obligation is embedded in the moral of the issues—clinical, ethical, and legal—facing
principles of autonomy, fidelity, beneficence, and clinicians when working with suicidal patients.
nonmaleficence. Individuals have the right to make Most would argue that the main goal of suicidal
decisions about those with whom they wish to share therapy (therapy for suicide prevention) is to defuse
private information and those from whom they the potentially lethal situation, and that to hold to
wish to withhold it (Kitchener, 2000). the principle of confidentiality is contradictory to
With some exceptions, only the client can permit a basic tenets of an ethical psychotherapeutic rela-
the therapist to release records to others. Psychologists tionship and the principle of helping clients.
sometimes have the obligation to ascertain whether Bongar (1992) suggested that therapists have a
the client is clear about the potential consequences professional duty to take appropriate affirma-
of the release of such records, but the client holds tive measures to prevent patients from harming
the legal privilege. Psychologists have the ethical themselves, including communicating with families
and legal obligation to maintain the confidentiality about the specifics of a patient’s case, attempting to
of records, including after the death of a client. ameliorate toxic family interactions with the patient,
Privacy speaks to the responsibility to share only or mobilizing support from the family and signifi-
that information that is vital to the purpose of the cant others. However, the scope of the disclosure
release of the information, such as to managed care should be limited to what is necessary to provide
utilization reviewers, when one has the client’s appropriate care; thus, for example, disclosures
signed release to do so. Key topics related to confi- made in good faith while seeking a civil commit-
dentiality are the exceptions to confidentiality, cop- ment for the patient would largely be protected.
ing with subpoenas and compelled testimony, and Psychologists also have ethical and legal obliga-
the obligation of informed consent. tions to address the situation if a client is a danger
to others. The nature of the legal obligations varies
Exceptions to Confidentiality from state to state, and it is critical for practitioners
One of the common conflicts or dilemmas that to be familiar with the requirements of their state
arises from the two moral principles of nonma- practice laws. In 1974, the California Supreme
lefience and autonomy occurs in the situation in Court issued an opinion stating that California
which the right to privacy and confidentiality con- therapists have a duty to warn potential victims of
flicts with the restriction that autonomous rights their patients’ threats of violence (Tarasoff I), rather
do not extend to infringing on the autonomous than simply doing something with the client, such
rights of others. Several limits to confidentiality as hospitalization or arrest. Two years later, the
exist, and it is the psychologist’s responsibility to Court revised its opinion to state that California
inform clients of those limits. Exceptions to confi- therapists have a duty to protect potential victims
dentiality encompass situations in which the client if their clients are dangerous (Tarasoff II). This
is a danger to self or others (e.g., the Tarasoff legal responsibility conflicts with the obligation

276 ethics
to maintain confidentiality. An additional issue is the court, preferably through the client’s attorney,
that the prediction of dangerousness is still a prob- or with the psychologist’s attorney.
lematic one for most therapists. Various states are In addition to requests for compelled testimony
increasingly adopting the duty to protect, but with and subpoenas for client records, test data may also
variations in some of the specifics. Some states indi- be requested. The Committee on Psychological
cate that mental health providers may warn or pro- Tests and Assessment of the APA published a “State-
tect potential victims, or take other actions such as ment on the Disclosure of Test Data” that was then
notifying officials. It is vital that each therapist incorporated as an addendum into the same article
become familiar with the requirements and obliga- that addressed strategies for dealing with subpoenas
tions of his or her jurisdiction. (APA COLI, 1996). The statement was developed
as a result of confusion regarding what is ethical
Coping with Subpoenas or Compelled and/or legal in the release of test data. A release from
Testimony for Client Records or Test Data a client did not at the time resolve the potential
The concerns involved with coping with subpoenas confidentiality claims of third parties, such as test
or compelled testimony for client records or test publishers, and psychologists continued to hold
data was addressed by APA’s Committee on Legal obligations to withhold test data or protocols. Such
Issues (American Psychological Association Com- dilemmas have been very controversial in a number
mittee on Legal Issues [APA COLI], 1996). Mem- of cases, especially when courts want to see items
bers of COLI prepared an article in response to a related to IQ testing of particular populations.
large number of inquires. As a general principle of Attorneys sometimes misuse test data, for example,
law, all citizens are required to provide information by selecting specific responses to the Minnesota
necessary for deciding issues before a court; the trier Multiphasic Personality Index (MMPI) and ask-
of fact is a judge or jury. The basic assumption is ing questions about the client’s/patients specific
that the more relevant information available, the responses to specific items (e.g., “I have engaged in
fairer the decision. Subpoenas (legal commands to strange sexual behaviors,” asked of a sexual harass-
provide testimony) or subpoenas duces tecum (legal ment complainant). The Task Force for revisions of
commands to appear and bring along specific docu- the 2002 Ethics Code struggled with this issue more
ments) are issued to obtain relevant material. A psy- than any other. Forensic psychologists tended to
chologist must respond to a subpoena in a timely want protection/support for withholding test data;
matter, but the request may be modified or made other practitioners wanted to avoid the expense of
void or invalid if the client chooses not to provide hiring attorneys to protect test publishers and the
a release. Federal law and most state jurisdictions validity of the tests, since the information is readily
allow the client to prevent confidential material available through libraries and other sources. The
from being communicated. However, a court order new Standard 9.04, Release of Test Data, defined
to provide testimony or produce documents must test data as “raw and scaled scores, client/patient
be honored regardless of client’s preference, or the responses to test questions or stimuli, and psycholo-
psychologist may be held in contempt of court. So, gists’ notes and recordings concerning client/patient
if a client provides a release, or if a court order is statements and behavior during an examination.
issued, psychologists are required to release therapy Those portions of test materials that include client/
notes, process notes, client information forms, bill- patient responses are included in the definition of
ing records, and other information, unless the psy- test data.” The APA Ethics Code (2002) Standard
chologist engages in attempts to quash the order. 9.04 Release of Test Data essentially states that psy-
Strategies for dealing with subpoenas include chologists may provide test data upon client/patient
verifying whether it is enforceable. A recommenda- release, or may refrain from doing so if they judge
tion is to have an attorney review it and to contact that substantial harm, misuse, or misrepresentation
the client in question to ensure that he fully under- of the data may occur.
stands that he is putting his entire file into the public
record. Often, the client wishes the records to be Informed Consent
released. In either case, the psychologist must obtain Related to the issue of confidentiality is the issue
a written consent and make sure that the client of informed consent. Emerging issues in informed
understands the purposes and scope of disclosure. consent include duty to assess and protect against
A psychologist may wish to negotiate with the client dangerousness (to self and others), obliga-
requester and/or may also wish to seek a ruling from tions to third parties (third-party payers, managed

va s qu e z , ph i l l i p s b i n g h a m 277
care, etc.), and issues of deception. The primary Consent may be written or oral, but in any case, must
moral principle underlying the obligation to obtain be documented by the psychologist. Psychologists
informed consent involves the promotion of auton- who are “covered entities” under the Health Insurance
omy. Any procedure performed on or on behalf of Portability and Accountability Act (HIPAA) must
a patient without his or her consent diminishes the also provide clients/patients with written information
patient’s autonomy or capacity to act in a free and (Notice of Privacy Practices) about their rights regard-
self-determining manner. Therefore, giving the per- ing the use and disclosure of their health information,
son an opportunity to make a choice emphasizes his including information about their rights to access
or her autonomy. to their protected health information (PHI), exclud-
Pope and Vasquez (2007) suggested that infor- ing psychotherapy notes. Other information should
mation provided during the consent process will include explanations of the uses and disclosures of
differ according to the professional service, whether the PHI, their individual rights, and the psycholo-
it is an assessment, psychotherapy, forensic evalua- gist’s legal duties in regard to the PHI. The APA
tion, or the like. They suggested the following ques- Practice Directorate and APA Insurance Trust have
tions to address in a form, as well as on an ongoing developed authorization model Notice of Privacy
basis (informed consent is an ongoing process): Practice forms to be compatible with the laws govern-
ing practice in each state; these are available at http://
• Does the client understand who is
apa.org/practice and http://apait.org/hipaa.
providing the service, the clinician’s qualifications,
and whether supervision is involved?
Custody Evaluations
• Does the client understand the reason for
Professionals get into trouble with child custody
the initial session (self-initiated, court-or
evaluations in a number of ways. The paramount
physician-referred)?
obligation in custody evaluations is to assess and
• Does the client understand the nature,
report factors that affect the best psychological
extent, and possible consequences of the services
interests of the child. Moral principles involved
the clinician is offering?
include Principle A, Beneficence and Nonmalefience,
• Does the client understand the degree
which involves helping others and doing no harm,
to which there may be alternatives to the services
and Principle B, Fidelity, which involves honest
provided by the clinician?
communication and obligation to fulfill certain
• Does the client understand actual or potential
functions. Principle E, Respect for People’s Rights
limitations to the services (a managed care plan’s
and Dignity is involved because the therapist must
limitation of four to six sessions unless a major
respect parental rights to share in the raising of their
mental illness diagnosis is given); does the client
children. Generally, a forensic child custody expert
understand how services may be terminated?
is employed to evaluate all persons involved. The
• Does the client understand fee policies and
biggest error psychotherapists make is to testify
procedures, including information about missed
on behalf of their client, and to make negative com-
or canceled appointments, use of fee collection
ments about the other parent without ever having
services, etc.?
seen, diagnosed, or assessed that other parent. It is
• Does the client understand policies and
not recommended that psychotherapists (as opposed
procedures concerning access to the clinician,
to objective child custody evaluators) serve as the
to those providing coverage for the clinician, and
evaluator, since objectivity will always be a challenge
to emergency services? For example, under what
in such cases.
conditions, if any, will a therapist be available
According to Ackerman and Ackerman (1997),
by phone between sessions?
90% of divorce custody situations agree to a restruc-
• Does the client understand limits to
turing arrangement. However, when a dispute
confidentiality in situations involving partner,
occurs, the court must help to determine the rela-
family, or group psychotherapy? Does the client
tive allocation of decision-making authority and
understand the conditions under which the
the physical contact each parent will have with the
clinician might be required to disclose information
child. The courts typically apply a “best interest
to an insurance company, utilization reviewers, the
of the child” standard in determining this restruc-
police, child protective services, the courts?
turing of rights and responsibilities. Psychologists
The information should be presented in a lan- are thus called upon to provide a competent, objec-
guage reasonably understandable to the client/patient. tive, impartial assessment. Often, in these disputes,

278 ethics
one of the two parties will be unhappy with the billing purposes that would not otherwise be
results and blame the psychologist. Therefore, those included in the record and which the psychologist
who are called upon to testify and/or who provide may think is detrimental to the welfare of the client.
assessment services for child custody evaluations Therefore it becomes necessary for the psychologist
must be clear about duties and responsibilities. to accurately provide details for billing purposes
Although specific instructions about custody evalu- while at the same time not including statements
ations are not provided in the ethics code, several that would potentially harm the client.
principles apply. The APA Guidelines for Child
Custody Evaluations in Divorce Proceedings (APA, Record Keeping
2004) provide helpful guidance. Several obligations are involved in the new clear
requirement to maintain records. The APA (2002)
Insurance and Fee Problems Ethics Code Standard 6.01 requires for the first time
Insurance fraud is a major area of violation, includ- that records be kept in written form. The Committee
ing billing insurance for services delivered by others; on Professional Practice & Standards (COPPS) of
billing insurance for missed sessions; waiving copay- the APA published guidelines regarding the mainte-
ments (this may be an option on an individual basis nance of records in 1993 and updated them in
in most states, but not as a rule, and the option may 2007. The Guidelines were revised by the COPPS,
have a requirement to inform the third party); bill- partly to incorporate the HIPAA guidelines; these
ing couple, family, or group sessions as individual new guidelines were approved by the APA Council
sessions; falsifying diagnostic categories to fit reim- of Representatives in 2007.
bursement criteria; and changing the date of the The content of psychotherapy notes should min-
onset of the client’s episode or the beginning of imally include identifying data, dates of services,
therapy to fit third-party reimbursement criteria, to types of services, fees, any assessment, plan for inter-
try to prevent denial of services based on preexisting vention, consultation, summary reports, and/or
condition. Often, well-meaning therapists try to testing reports, supporting data, and any release of
provide financial relief by, in effect, colluding with information obtained. It is also recommended that
a client to violate the client’s contract with his insur- a record be made of any unusual struggles and
ance company. Although continuously frustrated by dilemmas that surface during the therapeutic pro-
insurance companies, psychologists must fight those cess as part of an overall risk management strategy.
battles in the legislature through organizational The HIPAA legislation allows for two sets of notes:
advocacy efforts—or potentially end up in trouble one with basic information, and another set with
with insurance companies and the law. Such dilem- the therapist’s process notes. Notes for psychother-
mas are also a therapeutic issue in that, if this ethic apy group, family, and relationship therapy should
is violated, psychologists model and communicate also be kept. Complications regarding confidential-
lack of respect for the role of honesty and fidelity in ity can surface. Most recommend that group ther-
relationships. apy notes be kept per individual, in order to
It is critical to ensure the accuracy of billings maintain confidentiality of other group members
and payments. Record keeping and documenta- should the records be requested.
tion from a billing and payment frame of reference The Freedom of Information Act (1966) is a law
may include the reflection of transactions with pri- requiring that U.S. government agencies release
vate insurance companies, managed care companies, their records to the public on request, unless the
government entities including Medicare and Med- information sought falls into a category specifically
icaid, individual client billing, organizational bill- exempted, such as national security, an individual’s
ing, and forms of presenting services rendered, date right to privacy, or internal agency management.
of service, treatment, diagnosis, and other informa- This typically means that clients legally have access
tion requested. Accurate and understandable records to their records. Various options are provided by
that can explain the essential elements of services therapists—reviewing notes in a session(s) for thera-
rendered are an excellent protection against misin- peutic benefit is one option, as is the provision of
terpretations of services and resulting difficulties in a summary. Ultimately, if clients choose to obtain
billing questions and payment. The amount and their notes, they can do so. However, most jurisdic-
type of information included in records for billing tional administrative practice laws have a clause that
and payment can be challenging to determine. allows psychologists to withhold notes if they may
Psychologists may be asked for information for be deemed harmful to the client.

va s qu e z , ph i l l i p s b i n g h a m 279
 States, provinces, and territories vary in the period Vasquez, Bingham, and Barnett (2008) provided
of time that psychologists are required to maintain practice recommendations for helping to ensure the
records. The revised APA Record Keeping Guidelines clinically appropriate and effective termination of
(2007) suggest retaining full records for no less than each client.
7 years after the last date of service delivery for adults At the beginning of psychotherapy, and through-
or until 3 years after a minor reaches the age of out the treatment, psychologists have responsibilities
majority, whichever is longest, or the number of to provide informed consent about psychotherapy.
years required by one’s licensing board, whichever is That is, clients/patients should be educated about
longest. Jurisdictional licensing boards, other state the process of psychotherapy, including the factors
and federal laws, and institutional requirements may involved in deciding when to stop. Ending therapy
determine the length of time that psychologists must usually depends on the nature of the case, the
keep records. Psychologists should always retain the condition of the client/patient, the evolution and
complete record to comply with the more stringent attainment of goals as set forth by the client/patient
of the applicable requirements. Psychologists may and psychotherapist, and the client’s/patient’s
legally destroy their records after that time, but psy- financial situation (either personal or managed care
chologists may at times wish to keep some records limitations).
longer than the length required, for example, in situ- Ethical responsibilities include the responsibil-
ation in which records may be sought to illuminate ity to terminate when the client/patient no longer
some future legal issue, or when a minor may have needs the service, isn’t benefiting, or is being harmed
long-term developmental difficulties. by the service (APA 2002 Ethical Principles of Psy-
It is wise to make arrangements for the storage of chologists and Code of Conduct Standard 10.10a).
records when leaving one’s practice, and/or in case of Psychologists are also required to make reasonable
disability or death. Arrangements should be made so efforts to provide pretermination counseling and
that, in the case of death, someone, preferably a suggest alternative service providers as appropriate
mental health professional, knows how to access (APA Standards 10.10c, 10.09 and 3.12). A new
information about current clients and notify them. APA Ethics Code standard indicates that therapists
With clients’ permission, some psychologists make have the right to terminate psychotherapy when
reciprocal arrangements with colleagues to exchange threatened (10.10b). It is probably not appropriate
lists of patients’ names, phone numbers, and infor- to terminate when a client is in crisis. Some clients
mation about their treatment. In case of death or are able to easily announce that they are ready to
incapacitation, the covering therapist would notify stop coming, or that their employer has switched
patients/clients, and serve as a referral person or insurance providers, and that they’d like the current
“bridge therapist” for continuation of care, and to psychologist’s help to choose their next therapist
deal with the death or incapacitation of the therapist. from their new provider list. Others may be pan-
Some therapists arrange for a notice to be placed in icked at the notion of stopping without appropriate
the newspaper, informing former clients of the death preparation.
and letting them know who holds their records. The issue becomes complex if the psychothera-
pist perceives that the treatment is progressing well,
Terminations and the client/patient either is not clear about how
Terminations are an important part of the therapeu- long to continue, or no longer wishes to continue,
tic process, and there are ethical responsibilities to but has difficulty raising the issue. Often, these cli-
termination appropriately. Research indicates that ents just stop coming. They either indicate that they
30% to 57% of all psychotherapy patients drop out will call to schedule the next appointment, or cancel
prematurely (Garfield, 1994). Premature termina- and do not reschedule. In addition, many people
tion is a vexing problem and a subject of research currently utilize psychotherapy in short install-
investigation (Vasquez, Bingham, & Barnett, 2008). ments, “stop out” for a while, and later return to
Some clients/patients simply stop coming, despite either the same practitioner, or to another. A key
the recommendation of a “pretermination counsel- psychotherapeutic strategy is to review the present-
ing process,” and do not get the benefit of that pro- ing concerns, goals, and progress from time to
cess. Multiple factors influence how long a client/ time. This helps clarify how much has been accom-
patient remains in psychotherapy. What are those plished, as well as what still needs to be addressed,
factors, and what can be done to facilitate successful and whether the client/patient and psychotherapist
separations and psychotherapeutic terminations? collaboratively wish to continue or not. When

280 ethics
clients who seem successfully engaged in psycho- competence must be grounded in a commitment
therapy stop coming, a note or call to provide them to social justice that includes an expansion of pro-
with options can yield helpful and interesting fessional activities beyond counseling and psycho-
information. therapy. Vera and Speight (2003) suggested that
engaging in advocacy, prevention, and outreach are
Counseling Psychology’s Unique activities critical to social justice efforts. They sug-
Contribution of Social Justice gested that grounding teaching and research in col-
As an Ethical Imperative laborative and social action processes are ways to
Counseling psychology has a long history of interest expand roles.
and commitment to social justice and multicultural Toporek and Williams (2006) believe that even
issues (Ivey & Collins, 2003), and it has moved to the most recent 2002 APA Ethics Code needs to be
the forefront to join community and liberation psy- revised because it does not provide enough guidance
chologists in engaging more systematically in social for the social justice philosophy of counseling
justice work (Goodman et al., 2004; Vera & Speight, psychologists. The 2001 National Conference on
2003). Goodman et al. (2004) conceptualized the Counseling Psychology advocated for social justice
social justice work of counseling psychologists as as a primary foundation of the field. The Social
scholarship and professional action designed to Justice Ethics Work Group from the conference
change societal values, structures, policies, and defined social justice as:
practices, such that disadvantaged or marginalized
A concept that advocates engaging individuals
groups gain increased access to these tools of self-
as co-participants in decisions which directly affect
determination. Goodman et al. (2004) drew upon
their lives; it involves taking some action, and
an ecological model of social analysis to propose
educating individuals in order to open possibilities,
that social justice work occurs on three different
and to act with value and respect for individuals and
levels, including the micro level (individuals and
their group identities, considering power differentials
families); the meso level (including communities
in all areas of counseling practice and research.
and organization); and the macro level (including
(Blustein, Elman, & Gerstein, 2001, p. 9)
social structures, ideologies, and policies). The
authors also proposed several tenets, derived from Toporek and Williams (2006) argued that,
feminist and multicultural counseling theories and implied in this definition, are the themes of respect,
including ongoing self-examination, sharing power, responsibility, and action. They then looked at
giving voice, facilitating consciousness raising, the ethical issues of competence, multiple relation-
building on strengths, and giving clients with the ships, informed consent, and the do-no-harm tenet
tools to work toward social change. The authors through the social justice principles of respect,
provided an illustration of a thoughtful process for responsibility and action. The authors concluded
developing, managing, and evaluating a faculty-led that, although attention to these issues was implicit
collaboration with community-based projects as a in some of the 2002 APA Ethics Code principles,
training experience in social justice. the language was not explicit enough and therefore
An application of the micro level is the emphasis did not provide enough guidance to counseling
on cultural competence in the psychotherapeutic psychologists. For example, because a social justice
process. Cultural competence is no longer a mar- approach would dictate that a counseling psycholo-
ginal topic of interest, and cultural competence in gist should intervene on behalf of a client to end
today’s mental health care environment requires far discrimination or oppression, the client and thera-
more knowledge and sophistication on the part of pist could work together outside the counseling
the professional. It is becoming part of the main- office and the traditional counseling hour. The client
stream fundamental knowledge and skill set required and counselor could inadvertently end up in a dual
for effective practice. Therefore, multicultural com- relationship, and the client may not be fully informed
petency is a core social justice value, as well as an of the possible consequences of such action or alli-
ethical responsibility. Diversity training in general ance. Toporek and Williams argued that the APA
should be more incorporated into the fabric of Ethics Code did not provide enough guidance to
training programs, continuing education, and life- the therapist about how to make a virtuous social
long learning for psychologists (Vasquez, 2009). justice–oriented ethical decision.
Vera and Speight (2003) argued that counseling Toporek and Williams (2006) did advise that
psychology’s operationalization of multicultural more guidance could be found in other codes, such

va s qu e z , ph i l l i p s b i n g h a m 281
as those of the Association of Black Psychologists and other areas of practice that will benefit women
and the National Association of Social Workers. and girls” (see http://www.apa.org/about/division/
These codes go far beyond those of the APA code in girlsandwomen.pdf ). So, while Toporek and Williams
directing psychologists about advocacy matters. The maintain that the APA Ethics Code does not pro-
NASW Ethics Code 6.04 even states, for example, vide sufficient guidance for ethical decision making,
that “Social workers should engage in social and guidelines such as those listed above can be used to
political action. . . .” (NASW, 1996). At best, the enhance a psychologist’s ethical decision-making
APA code relegates such strong statements to the process and competence in providing the highest
nonenforceable aspirational principles section of standard of care to members of certain groups.
the ethics document. Structural limitations, such as
the APA’s tax status as a c(3) is limiting in that Decision-making Models
regard; NASW maintains a c(6) tax status, which Using the APA Ethics Code and all of the guidelines
allows for more political advocacy. listed above, can one arrive at an ethical decision?
Counseling psychologists may find more help Clearly Jordan and Meara (1990) and Kitchener
by reviewing the various practice guidelines that are and Anderson (2000) would argue that one must
designed to help practitioners across specializations combine knowledge gleaned from all of the stan-
to provide ethically competent service. The guide- dards, principles, and guidelines with one’s virtuous
lines include the Guidelines for Psychological Prac- character. Kitchener (2000) suggested that informa-
tice with Girls and Women (APA, 2007); Guidelines tion about the situation and one’s ordinary moral
for Psychotherapy with Lesbian, Gay, and Bisexual sense leads to an immediate level of impressions,
Clients (APA, 2000); Guidelines on Multicultural but that a critical-evaluative level of decision mak-
Education, Training, Research, Practice and Orga- ing, including ethical rules (codes, guidelines, laws)
nizational Change for Psychologists (APA, 2003); combined with foundational ethical principles and
and Guidelines for Psychological Practice with ethical theory is important. Kitchener proposed the
Older Adults (APA, 2004). All of these guidelines following five foundational moral principles as
tend to have social justice themes, and counseling essential to making virtuous ethical decisions:
psychologists were intimately involved in drafting
• Autonomy : Psychologists must make free
most of these documents. The guidelines for prac-
decisions, understand the consequences, and treat
tice with girls and women, for example, were
others in the same way. This means a fundamental
spearheaded by a joint group from the Society of
respect for the rights of others to make choices,
Counseling Psychology (Division 17) and the
unless those choices infringe on the rights of others.
Society for the Psychology of Women (Division 35),
• Nonmalefience : Above all psychologists
and the guidelines for practice with racial/ethnic
must not do harm. This generally means neither
minorities by a joint task group from Division 17
inflicting intentional harm nor engaging in
and the Society for the Psychological Study of
actions that risk harming others.
Ethnic Minority Issues (Division 45). These guide-
• Beneficence : Psychologists must strive to
lines tend to have a social justice emphasis that
do good or benefit others. At its core, psychology
addresses issues of marginalization, discrimination,
is committed to contributing to the health and
and oppression for certain groups, and the responsi-
welfare of others.
bilities that psychologists have to monitor those
• Justice : Psychologists must treat all fairly
concerns in their work with clients. In the introduc-
and equally and be concerned with issues of
tion to the guidelines for girls and women, for
social justice.
example, is the statement that “the changing and
• Fidelity : Psychologist must strive for
increasingly complex life experiences of girls and
truth, honor, faithfulness, and loyalty. Fidelity
women and the intersection of their gender roles
is at the core of the fiduciary relationship between
with ethnicity, sexual orientation, ability, SES etc.
psychologists and the people with whom they work.
demonstrate compelling evidence and need for
professional guidance for helping psychologists Models for ethical decision making tend to list
(a) avoid harm in psychological practice with girls steps that an individual might follow when a
and women, (b) improve research, teaching, con- dilemma arises. The Ethics Resource Center (http://
sultation, and psychotherapeutic and counseling www.ethics.org/decision-making-model.asp) uses
training and practice; and (c) develop and enhance a six-step model entitled The PLUS Decision-
treatment efforts, research, prevention, teaching Making Model. PLUS is a mnemonic for Policies,

282 ethics
Legal, Universal, and Self. PLUS is applied at steps What principles, rules, laws, or obligations are at
1, 3, and 6. At step 1, the problem is identified and issue? One’s theoretical orientation may sometimes
the therapist asks whether there are policy issues, enter into the conceptualization of the problem,
legal issues, universal principles, and values to con- and sometimes it is important to try to distinguish
sider, especially of his or her professional organiza- between a therapeutic issue/dilemma and whether
tion. In addition, the therapist considers self issues the dilemma potentially reaches the threshold of
of rightness, goodness, or fairness. At step 2, the a potential ethical and/or legal violation.
therapist lists alternative solutions to the dilemma. 3. Understand the key moral principles
Step 3 requires that the therapist evaluates the alter- in psychology, as described above, and apply
natives using PLUS questions. Step 4 asks for a deci- those principles.
sion. Step 5 is implementation, and step 6 is an 4. Determine alternative solutions.
evaluation of the decision, again using PLUS ques- If the options increase the potential for harm,
tions. This model further advises the use of empa- the psychologist should increase vigilance and
thy, patience, integrity, and courage. attention. Whose interests are involved in the
Other decision-making models essentially follow problem? What would be the positive and
the same step-wise pattern (Bersoff, 1995; Canter negative consequences of each choice?
et al., 1994; Clabon & Morris, 2004; Koocher & 5. Consult with others to help clarify the
Keith-Spiegel, 1998). Psychologists often argue issues. Ethics experts and/or ethics bodies can be
that knowing the Ethics Code, their jurisdictional helpful. Consider whether there is a need for legal
administrative and practice laws, and guidelines pro- advice from lawyers who specialize in mental
vide a good starting point for making an ethical health law.
decisions. They sometimes add a step that suggests 6. Decide on a solution based on the code,
consulting with a trusted colleague, ethics expert, or the culture, your moral principles, and your
mental health attorney on the matter. These two understanding of probable consequences.
suggestions would fit in well with any of the deci- Document the process and the results. Keeping
sion-making models that were reviewed for this track of the process through documentation can
chapter. Welfel (2002) proposed a ten-step model help one remain clear about the elements of the
that begins with becoming ethically sensitive as the problem, the options and potential consequences,
first step and includes, at step 7, consultation with a the guidance provided by others, and the rationale
supervisor or respected colleague. Houser, for the decision.
Wilczenski, and Ham (2006) declared that few if
Clabon and Morris (2004) claim that making
any of these decision-making models have been
good ethical decisions helps to build character.
empirically investigated or grounded in theory.
Hopefully good character helps to make virtuous
They argued that one thing missing from the models
ethical decisions.
is context. Houser et al. (2006) asserted that ethic
codes and ethical models are generally lists of rules
and principles that are stated as if they exist in a cul- Concluding Thoughts on Ethical
tural vacuum. They believe that, to make ethical deci- Dilemmas and Ethics Education
sions, ethical decision-making models must be Counseling psychologists have had significant input
situated in a cultural context and there must be a gen- into the evolution of professional ethics in psychol-
eral understanding of various worldviews. Also, the ogy, and we provided a brief summary of those
ethics must have some theoretical underpinnings. contributions. In addition, we described the various
Basically, it is important for counseling psychol- methods of accountability in our profession, and
ogists to develop a plan for ethical decision making identified key areas of vulnerability for psycholo-
before an ethical dilemma occurs. We recommend gists in ethical practice, including multiple relation-
these steps: ships, confidentiality, custody evaluations, insurance
and fee problems, record keeping, and terminations.
1. Regularly review the APA Ethics Code and
Finally, we described the role of counseling psychol-
be knowledgeable and/or review your jurisdictional
ogy in promoting social justice as an ethical impera-
rules. It is helpful to refer to relevant guidelines as
tive. The following section identifies our concluding
endorsed by the APA.
thoughts on key dilemmas yet to be fully addressed
2. Define and understand the ethical
in the ethical realm of professional responsibilities
dilemma. Why is the situation problematic?
and ethics education.

va s qu e z , ph i l l i p s b i n g h a m 283
 The social milieu affects the ethics code. Over (September 17, 2008 from http://www.apa.org/
time, society has dealt with cultural and legal issues releases/petition0908.html):
such as discrimination, sexual harassment, divorce.
The petition resolution stating that psychologists
These topics influence changes in the ethics code,
may not work in settings where “persons are held
and the code changes as society changes. With the
outside of, or in violation of, either International
advent of the World Wide Web, the Internet, e-mail,
Law (e.g., the UN Convention Against Torture and
listservs, blogs, and chat rooms, social issues and
the Geneva Conventions) or the U.S. Constitution
conditions are communicated far more rapidly and
(where appropriate), unless they are working directly
therefore pressure may emerge for the ethics code to
for the persons being detained or for an independent
change more frequently.
third party working to protect human rights” was
For example, during the United States’ war with
approved by a vote of the APA membership.
Iraq, serious questions were raised about the role
The final vote tally was 8,792 voting in favor of
psychologists should play in the interrogation of
the resolution; 6,157 voting against the resolution.
detainees from the war, especially if individuals
To become policy, a petition resolution needs to be
were being held in places considered illegal. The
approved by a majority of those members voting.
United States entered into war against the Taliban
Per the Association’s Rules and Bylaws, the
in Afghanistan in 2002, and into war with Iraq in
resolution became official APA policy as of the
2003. As a result of these wars, many individuals
Association’s August 2009 annual convention.
were imprisoned or “detained” at Guantanamo Bay,
The approval of the petition resolution represented
Cuba, and in Abu Ghraib, in Iraq. Subsequent to
a significant change in APA’s policy regarding the
their detainment, numerous allegations were made
involvement of psychologists in interrogations. The
of detainee abuse and illegal detention. Questions
petition resolution limits the roles of psychologists
arose regarding the role of psychologists in assisting
in certain defined settings where persons are
the government in questioning detainees, providing
detained to working directly for detainees or
psychological services to these individuals, and con-
for an independent third party to protect human
sulting with the government about these matters; it
rights, or to providing treatment to other military
was even questioned if it was legal for psychologists
personnel.
to work in some of these facilities. Psychologists and
This resolution expanded on the 2007 APA
members of the public turned to the APA Ethics
resolution, which called on the U.S. government
Code and the Ethics Committee for guidance. Some
to ban at least 19 specific abusive interrogation
thought they found answers in the code; others
techniques, including waterboarding, that are
thought the code was left wanting. Counseling
regarded as torture by international standards.
psychologists were actively involved on the APA
The 2007 resolution also recognized that “torture
governing bodies, the Council of Representatives,
and other cruel, inhuman or degrading treatment
and the Board of Directors as the organization grap-
or punishment can result not only from the behavior
pled with ethical, legal, and professional questions
of individuals, but also from the conditions of
about the detainee issue. Some were involved in the
confinement,” and expressed “grave concern over
actual intervention to ensure that interrogations
settings in which detainees are deprived of adequate
were conducted in safe, moral, and effective ways
protection of their human rights.”
(James, 2008).
APA will continue to call upon the Department of
The answer to whether or not the code provided
Defense and Congress to safeguard the welfare and
sufficient guidance is beyond the scope of this chap-
human rights of detainees held outside of the United
ter. However, the situation did shine light on the
States and to investigate their treatment to ensure
need for guiding ethical principles and standards,
the highest ethical standards are being upheld.
and the need for effective ethical decision-making
models and processes. Psychologists and members The question remains as to whether and how the
of the public demanded that the ethics code provide ethics code reflects the dictates of the referendum
much more direction about the role of psycholo- and how quickly the code can change if necessary.
gists. Their demands led to a referendum on the These situations are likely to become even more
matter. The APA Public Affairs Office released this prevalent as members of the profession look to the
announcement about the APA members’ approval Ethics Code and relevant policy development for
of the petition resolution on detainee settings guidance.

284 ethics
 Several other key dilemmas and issues are yet mutually agreed upon set of competencies underly-
to be fully addressed in the profession, and thus ing professional psychology practice (Kaslow et al.,
comprise “future directions.” Those include the use 2004). One of the issues is whether a competency-
of the Internet or other electronic communication based approach to the assessment of progress
methods, practicing across jurisdictional boundar- through training and readiness for practice, as well
ies, distance learning, testing for continued compe- as for expansion of practice into emerging areas,
tencies for initial licensure, and for expansion of might be applied. Continuing education and life-
practice into emerging areas. long learning for the ethical requirement to maintain
The use of telecommunications and informa- and develop competence is a goal embraced by pro-
tion technology to provide assessment, diagnosis, fessionals. The potential requirement of some kind
and intervention (psychotherapy, forensic and con- of demonstration of competence in the knowledge,
sultation services) information has increased in the judgment, and technical and interpersonal skills rel-
past few years. Yet, clear guidelines have not been evant to a therapist’s job throughout his or her career
developed. Pope and Vasquez (2005) suggested the is more controversial (DeMers et al., 2008).
importance of confidentiality in considering the What is the future role of education in ensuring
location of computers, as well as the use of “strong” that counseling psychologists receive quality ethical
passwords, encryption (software that adds an extra training and that programs produce ethical psy-
layer of protection and safeguards), firewalls (soft- chologists? The future of the teaching of psycho-
ware or hardware to help prevent break-ins), and logical ethics will continue to evolve, as psychology
other technological safeguards. Other challenges evolves as a growing field. Ethics education requires
include the importance of being aware of standard the ability to help learners “think well about doing
ethical, regulatory, and legal obligations if work good” (Kitchener, 2000). For example, vignettes
crosses jurisdictional boundaries. Questions asked and case presentations help us all think through
by DeMers, Van Horne, and Rodolfa (2008) dilemmas. The reality is that a particular dilemma
include: How will an emergency be handled? What may have a different outcome depending on various
are the limits of confidentiality? How are the HIPAA factors (e.g., therapist factors, client factors, theo-
regulations (1996) applicable? How are charges and retical orientation, etc.). Teaching the distinctions
payments handled? Will professional liability insur- and overlaps, for example, between ethics and the
ance cover practice across jurisdictional lines? How law, ethics and values, ethics and professional behav-
will a complaint be handled? ior, ethics and conscience are important to promote
Distance education has rapidly expanded, and critical thinking and understanding (Kitchener,
this has implications for the definition of quality 2000). Promoting knowledge of ethical theory,
assurance and regulation of student performance. foundational ethical principles and values, ethical
The APA (2006) Accreditation Guidelines and Prin- rules, and related laws in order to develop a critical
ciples require that each student serves a minimum evaluative judgment that involves evaluation, analy-
of 3 full-time academic years of graduate study, at sis, and reasoned judgment are important tasks of
least 2 of which must be at the institution from ethics education.
which the doctoral degree is granted, and at least Meara and her colleagues, who emphasize virtue
1 year of which must be in “full-time residence or ethics, seem to suggest that educational programs
the equivalent thereof ” (p. 10). This requirement must seek to select ethical students to be a part of
is assumed to allow for faculty and supervisors each incoming class. The challenge is that there is
to assess student competence. The dilemma of no evidence that psychologists know how to select
providing greater flexibility in meeting residency ethical individuals. There is some evidence to sug-
requirements versus the obligation to assess student gest that one can improve ethical decision making.
competency is an ethical challenge and responsibil- It could be that programs must be more intentional
ity to be faced by psychology education in the in training those skills. Forrest, Elman, Gizara, and
future. Vacha-Haase (1999) suggest various issues involved
Assessment of competency has been an issue and in evaluating and ensuring the competence and pro-
theme in the profession for the past few years. The fessional behavior of trainees in professional psy-
Association of Psychology Postdoctoral and Intern- chology training programs and internships. This is
ship Centers (APPIC) sponsored a Competencies a start in the academy’s responsibility in ensuring
Conference that focused on the identification of the the production of ethical, competent professionals.

va s qu e z , ph i l l i p s b i n g h a m 285
 Most state licensure laws now require that psy- Bebeau, M. J. (1995). Can ethics be taught? A look aat the evi-
chologist obtain some hours of ethics training dence: Revisited. The New York State Dental Journal, 50,
51–57.
during each licensure reissue period. Such practice Bernsen, A., Tabachnick, B. G., & Pope, K. S. (1994). National
suggests that educational programs might want to survey of social workers’ sexual attraction to their clients:
consider offering more ethics training. It may be Results, implications, and comparison to psychologists.
that we should seek to have ethics education inte- Ethics and Behavior, 4, 369–388.
grated into most of the courses that are taught, Bersoff, D. (1995). Ethical conflicts in psychology. Washington,
DC: American Psychological Association.
rather than the addition of one course on legal and Bingham, R. P. (2002). The issue may be the integration of
ethical issues. Ethics could be included in counsel- personal and career issues, A reaction to “The reintegrating
ing theories courses, marriage and family courses, of vocational psychology and counseling psychology.”
multicultural courses, and more. We encourage more The Counseling Psychologist, 30, 933–936.
intentional training experiences at all levels of train- Blustein, D., Elman, N., & Gerstein, L. (2001, August). Executive
report: Social action groups National Counseling Psychology
ing and for life-long learning. Conference. Houston, TX: Authors.
Bongar, B. (1992). Suicide: Guidelines for assessment, manage-
References ment, & treatment. New York: Oxford University Press.
Ackerman, M. J., & Ackerman, M. C. (1997). Custody evalua- Canter, M. B., Bennett, B. E., Jones, S. E., Nagy, T. F. (1994).
tion practices: A survey of experienced professionals (revis- Ethics for psychologists: A commentary on the APA
ited). Professional Psychology: Research and Practice, 28, ethics code. Washington, DC: American Psychological
137–145. Association.
American Psychological Association. (2002). Ethical principles Clabon, S., & Morris, J. F. (2004). A consensus model for
of psychologists and code of conduct. American Psychologist, making ethical decisions in a less-than-ideal world. The
57, 1060–1073. Retrieved from www.apa.org/ethics. ASHA Leader.
American Psychological Association. (2010). Ethical principles of DeMers, S. T., Van Horne, B. A., & Rodolfa, E. R. (2008).
psychologists and code of conduct with the 2010 amendments. Changes in training and practice of psychologists: Current
Retrieved from http://www.apa.org/ethics/code/index.aspx. challenges for licensing boards. Professional Psychology:
American Psychological Association. (1994). Guidelines for child Research and Practice, 29, 473–479.
custody evaluations in divorce proceedings. American Ethics Resource Center. The PLUS decision making model.
Psychologist, 49, 677–680. Retrieved October 23, 2008 from http://www.ethics.org/
American Psychological Association. (2007). Guidelines for psy- decision-making-model.asp.
chological practice with girls and women: A joint task force of Farmer, H. (2002). Focus on division 17’s Committee on
APA Divisions 17 and 35. Retrieved November 2, 2008, from Women/Section for the Advancement of Women (SAW)
http://www.apa.org/about/division/girlsandwomen.pdf. 1970–2030: Achievement challenges. The Counseling
American Psychologial Association (2004). Guidelines for psy- Psychologist, 30, 417–440.
chological practice with older adults. American Psychologist, Fly, B. J., van Bark, W. P., Weinman, L., Kitchener, K. S., &
59(4), 236–260. Lanf, P. R. (1997). Ethical transgressions of psychology
American Psychological Association. (2003). Guidelines on mul- graduate students: Critical incidents with implications for
ticultural education, training, research, practice, and organi- training. Professional Psychology: Research and Practice,
zational change for psychologists. American Psychologist, 28, 492–495.
58, 377–402. Forrest, L., Elman, N., Gizara, S., Vacha-Haase, T.
American Psychological Association. (2003). Guidelines for psy- (1999). Trainee impairment: A review of identification,
chological practice with older adults. Retrieved from http:// dismissal, and legal issues. The Counseling Psychologist, 27,
www.apa.org/practice/Guidelines_for_Psychological_ 627–686.
Practice_with_Older_Adults.pdf. Fretz, B. R. & Mills, D. H. (1980). Licensing and certification
American Psychological Association. (2000). Guidelines for psy- of psychologists and counselors: A guide to current policies,
chotherapy with lesbian, gay and bisexual clients. American procesures and legislation. San Francisco: Jossey-Bass.
Psychologist, 55, 1440–1451. Fretz, B. R., & Simon, N. P. (1992). Professional issues in
American Psychological Association. (2007). Record keeping counseling psychology: Continuity, change, and challenge.
guidelines. Retrieved November 2, 2008, from http:// In S. D. Brown, & R. W. Lent (Eds.), Handbook of counseling
apapractice.org/apo/insider/professional/apaapproved/ psychology (2nd ed., pp. 3–36). New York: Wiley.
revised_apa_record.html. Garfield, S. L. (1994). Research on client variables in psycho-
American Psychological Association. (2006, August 9). Resolution therapy. In A. E. Bergen, & S. L. Garfield (Eds.), Handbook
against torture and other cruel, inhuman, and degrading treat- of psychotherapy and behavior change (4th ed., pp. 190–228).
ment or punishment. Retrieved from http://www.apa.org/ New York: Wiley.
about/governance/council/policy/chapter-3.aspx. Goodman, L. A., Liang, B., Helms, J. E., Latta, R. E.,
American Psychological Association Committee on Legal Issues. Sparks, E., & Weintraub, S. R. (2004). Training counseling
(1996). Strategies for private practitioners coping with sub- psychologists as social justice agents: Feminist and multicul-
poenas or compelled testimony for client records or test data. tural principles in action. The Counseling Psychologist,
Professional Psychology: Research and Practice, 27, 245–251. 32, 793–837.
Beauchamp, T. L., & Childress, J. F. (1979). Principles of bio- Hall, C. S. (1952). Crooks, codes, and cant. American Psychologist,
medical ethics. Oxford, UK: Oxford University Press. 7, 430–431.

286 ethics
Hall, J. E. (1987). Gender-related ethical dilemmas and ethics Schmidt, L. D., & Meara, N. M. (1984). Ethical, professional
education. Professional Psychology: Research and Practice, and legal issues in counseling psychology. In S. D. Brown, &
18, 573–579. R. W. Lent (Eds.), Handbook of counseling psychology.
Haspel, K. C., Jorgenson, L. M., Wincze, J. P., & Parsons, J. P. New York: Wiley.
(1997). Legislative intervention regarding sexual miscon- Sue, D. W., Bernier, J. E., Durran, A., Feinberg, L., Pedersen, P.,
duct: An overview. Professional Psychology: Research and Smith, E., & Vasquez-Nutall, E. (1982). Position paper:
Practice, 28, 58–62. Cross-cultural counseling competencies. The Counseling
Houser, R., Wilczenski, F. L., & Ham, M. (2006). Culturally Psychologist, 10, 45–52.
relevant ethical decision-making in counseling. Thousand Thompson, A. S., & Super, D. E. (Eds.). (1964). The professional
Oaks, CA: Sage. preparation of counseling psychologists (Greystone Conference).
Ivey, A. E., & Collins, N. M. (2003). Social justice: A long-term New York: Columbia University. Teachers College, Bureau of
challenge for counseling psychology. The Counseling Publications.
Psychologist, 31, 290–298. Toporek, R. L., & Williams, R. A. (2006). Ethics and profes-
James, L. C. (2008). Fixing hell: An army psychologist confronts sional issues related to the practice of social justice in coun-
Abu Ghraib. New York: Grand Central Publishing. seling psychology. In R. L. Toporek, L. H. Gerstein,
Jordan, A. E., & Meara, N. M. (1990). Ethics and the profes- N. A. Fouad, G. Roysircar, & T. Israel (Eds.), Handbook for
sional practice of psychologists. Professional Psychology: social justice in counseling psychology: Leadership, vision, and
Research and Practice, 21, 107–114. action. Thousand Oaks, CA: Sage.
Kaslow, N. J., Borden, K. A., Collins, F. L., Forrest, L., Illfelder- Vasquez, J. J. T. (2009). Ethics in multicultural counseling
Kaye, J., Nelson, P. D., et al. (2004). Competencies confer- practice. In J. G. Ponterotto, J. M. Casas, L. A. Suzuki, &
ence: Future directions in education and credentialing in C. M. Alexander (Eds.). Handbook of Multicultural
professional psychology. Journal of Clinical Psychology, Counseling (3rd ed., pp. 127–136). Thousand Oaks, CA:
60, 699–712. Sage.
Kitchener, K. S. (1984). Intuition, critical evaluation and ethical Vasquez, M. J. T., Bingham, R. P., Barnett, J. E. (2008).
principles: The foundation for ethical decisions in counseling Psychotherapy termination: Clinical and ethical responsibili-
psychology. The Counseling Psychologist, 12, 43–55. ties. Journal of Clinical Psychology: In Session, 64, 653–665.
Kitchener, K. S. (2000). Foundations of ethical practice, research, Vera, E. M., & Speight, S. L. (2003). Multicultural competence,
and teaching in psychology. Mahwah, NJ: Lawrence Erlbaum social justice and counseling psychology: Expanding our
Associates. roles. The Counseling Psychologist, 31, 253–272.
Kitchener, K. S., & Anderson, S. K. (2000). Ethical issues Werth, J. L., Cummings, D. L., & Thompson, M. N. (2008).
in counseling psychology: Old themes—New problems. Legal and ethical issues affecting counseling psychologists.
In S. D. Brown, & R. W. Lent (Eds.), Handbook of counseling In S. D. Brown, & R. W. Lent (Eds.), Handbook of counseling
psychology (3rd ed., pp. 50–82). New York: Wiley. psychology (4th ed., pp. 3–20).
Koocher, G. P., & Keith-Spiegel, P. (1998). Ethics in psychology: Welfel, E. (2002). Ethics in counseling and psychotherapy:
Professionals standards and cases (2nd ed.). New York: Oxford Standards, research and emerging issues. Pacific Grove, CA:
University Press. Brooks/Cole.
Meara, N., Schmidt, L., & Day, J. (1996). Principles and virtues: Welfel, E. R., & Lipsitz, M. E. (1984). The ethical behavior of
A foundation for ethical decisions, policies, and character. professional psychologists: A critical analysis of the research.
The Counseling Psychologist, 24, 4–77. The Counseling Psychologist, 12(3), 31–42.
National Association of Social Workers. (1996). Code of ethics of
the National Association of Social Workers. Retrieved on Further Reading
November 2, 2008, from http://www.socialworkers.org/
Campbell, L., Vasquez, M. J. T., Behnke, S., & Kinscherff, R.
pubs/code/code.asp.
(in press). APA ethics code commentary and case illustrations.
Pope, K. S., Keith-Spiegel, P., & Tabachnick, B. G. (1986).
Washington, DC: American Psychological Association.
Sexual attraction to patients: The human therapist and the
Fisher, C. B. (2003). Decoding the ethics code: A practical guide for
(sometimes) inhuman training system. American Psychologist,
psychologists. Thousand Oaks, CA: Sage.
41, 147–158.
Knapp, S., & VandeCreek, L. (2003). A guide to the 2002 revision
Pope, K. S., & Vasquez, M. J. T. (2007). Ethics in psychotherapy
of the American Psychological Association’s ethics code. Sarasota,
and counseling: A practical guide (3rd ed.). San Francisco:
FL: Professional Resource Press.
Jossey-Bass/John Wiley.
Nagy, T. F. (2005). Ethics in plain English: An illustrative casebook
Pope, K., & Vasquez, M. J. T. (2005). How to survive and thrive
for psychologists (2nd ed.). Washington, DC: American
as a therapist: Information, ideas and resources for psychologists
Psychological Association.
in practice. Washington, DC: American Psychological
Association.
Rudd, M. D., Joiner, T., & Rajab, M. H. (2001). Treating sui-
cidal behavior: An effective, time-limited approach. New York:
Guilford Press.

va s qu e z , ph i l l i p s b i n g h a m 287
This page intentionally left blank
 PART
3
Contextual Perspectives
This page intentionally left blank
 CHAPTER

11 Ethnic and Racial Identity

Kevin O. Cokley and Beverly J. Vandiver

Abstract
This chapter discusses the significance of racial and ethnic identity to the work of counseling
psychologists and surveys historical and contemporary models of ethnic and racial identity. Many
racial identity models, including white identity, minority identity, and people of color racial identity,
were greatly influenced by the developmental thrust of early black identity models, in particular the
Nigrescence model. Ethnic identity models were influenced by social identity theory as well as by
developmental theories. The reliable and valid measurement of ethnic and racial identity remains an
area of great interest and concern. Ethnic and racial identity are complex, multidimensional constructs
whose influences are just starting to be understood. Nevertheless, there remains much to learn about
the mechanisms through which ethnic and racial identity influence behavior and well-being.
Keywords: racial identity, ethnic identity, black identity, white identity, minority identity,
people of color, nigrescence

More than any other event in our nation’s history, more acceptable. Whatever people think of his iden-
the campaign for the 2008 Democratic presiden- tity, the election of the first black president of the
tial nomination sparked a national dialogue and United States will likely have a psychological impact
debate about ethnic and racial identity. At the center on the racial and ethnic identity development of
of this debate was the Democratic nominee and ethnic minorities for years to come.
now President, Barack Obama, whose ethnic and Over the past 20 years, the discipline of counsel-
racial identity was a point of intrigue among ing psychology has increasingly become defined
Americans across racial, ethnic, and political lines. by its scholarly focus on multicultural issues in
Questions such as “Is he too black?” or “Is he black psychology, especially race. It is therefore not sur-
enough?” were asked as racial identity litmus tests. prising that a counseling psychologist, Joseph
Although Obama’s biracial heritage challenges Ponterotto, published the first content analyses
conventional notions of racial and ethnic identity, with a multicultural focus (Ponterotto, 1986, 1988;
he has consistently self-identified as being African Ponterotto & Sabnani, 1989). The purpose of the
American, because he says that he is viewed and 1989 study was to “identify the most influential
treated as a black man. Obama’s self-identification (i.e., frequently cited) books, book chapters, concep-
underscores the complexity of ethnic and racial tual/theoretical articles, empirical studies, and schol-
identity, because he can rightfully claim to be as ars in the multicultural counseling field” (Ponterotto
“white” as he can “black”; however, the combination & Sabnani, 1989, p. 24). Among the results reported
of his phenotype and the lingering influence of the was the finding that the classic article by Thomas
United States’ history of the “one-drop rule” make Parham and Janet Helms (1981) on the topic of
his self-identification as “black” or “African American” racial identity was the most cited empirical article.

291
Ponterotto concluded that the conceptual focus on articles involved African American or European
racial identity development, particularly as it per- American participants. The first article that focused
tained to blacks, was among the three most influen- on ethnic identity in TCP was published in 2001
tial themes in multicultural research and practice. (Pizarro & Vera, 2001). Since 2001, only two arti-
In an invited response to a series of articles on cles have been published in TCP that substantively
multicultural education and training, Ponterotto address ethnic identity. By comparison, the first
(1998) also identified racial identity development article published in TCP that focused on racial
as an important area that needs further research. identity was published in 1989 (Parham, 1989).
The fact that Ponterotto spent more than double Since 1989, 22 articles have been published in TCP
the amount of written space addressing research focusing on some aspect of racial identity. This brief
needs related to racial identity development com- survey of the literature indicates that racial identity
pared to other areas in multicultural counseling has been a much more popular construct for coun-
training underscored the importance of counseling seling psychologists than has ethnic identity.
psychologists gaining a better understanding of The reasons for this predisposition toward racial
racial identity. versus ethnic identity are not altogether clear. Some
Cokley et al. (1999) conducted a content analy- scholars have made arguments against the construct
sis to provide insight about where racial identity of ethnicity that include it being ill-defined and
articles were being published most frequently, as simply a euphemism for the more emotionally laden
well as to identify the individuals who had been the term, race (Helms, 1990; Helms & Talleyrand,
most prolific researchers of this topic over a 20-year 1997). This logic would presumably be extended to
period. Results revealed that approximately two out the correlate of ethnic identity.
of every three racial identity articles (64%) pub- The disproportionate focus of racial versus eth-
lished over the past 20 years had been published in nic identity articles has largely not been commented
the three counseling psychology–oriented journals. on by scholars in the discipline, perhaps because the
The greatest number of empirical articles was pub- constructs are seen to be more similar than differ-
lished in the Journal of Counseling Psychology ( JCP), ent. We draw attention to this phenomenon because
whereas the greatest number of conceptual or theo- reviewing the extant literature reveals two obvious
retical articles was published in The Counseling themes that will necessarily shape the approach in
Psychologist (TCP). Ninety percent of the top 16 this chapter. First, racial identity research is over-
contributors to the racial identity literature were whelmingly conducted with African American and
identified as counseling psychologists. European American samples, whereas the majority
At this point, it should be apparent that there of ethnic identity studies are conducted with Asian
has been far more discussion of racial identity com- American and Latino samples. Racial identity theo-
pared to ethnic identity. An examination of the ries appear to rely on a binary black–white racial
counseling psychology literature reveals several relations model as the paradigmatic experience
noteworthy observations on comparisons of ethnic for all ethnic groups. Although the history of slav-
versus racial identity. The first article that included ery, segregation, and the Civil Rights Movement
ethnic identity as a variable was published in JCP logically inform racial identity models for African
(Chang, Yeh, & Krumboltz, 2001).The first article Americans and European Americans, it is not
that focused on ethnic identity was published in clear whether they are adequate for understanding
JCP (Lee, 2003). Excluding a 2007 special issue on the experiences, cultural psychology, and “racial
ethnic and racial identity measurement, a total of identity” of ethnic groups who are not “black” or
13 articles that focus on or involve ethnic identity “white.” In spite of attempts to apply a racial iden-
have been published in JCP since 2001. Ten of these tity model to all racial and ethnic minority groups
published articles have involved Asian American (e.g., Atkinson, Morten, & Sue’s minority identity
participants, two involved African American par- development; Helms’ people of color (POC) racial
ticipants, and one involved Mexican American par- identity model; Sue & Sue’s racial/cultural identity
ticipants. By comparison, the first article that model), racial identity studies are still overwhelm-
focused on racial identity was published in JCP ingly conducted with African Americans, and to
in 1981 (Parham & Helms, 1981). Excluding the a lesser degree European American samples, and to
2007 special issue, since 1981, there have been an even lesser degree with Asian American sam-
29 articles that have focused on or involved racial ples. Consistent with this reality, the discussion of
identity. All but one of the published racial identity racial identity models focuses disproportionately

292 ethnic and racial id e n tit y

on black and white identity, whereas the discussion development model, which is an extension of
of ethnic identity is broader in scope. Nigrescence to other racial minorities. Then Helms’
Given the centrality of racial identity research (1990, 1995) modification and expansion of
among counseling psychologists, it is no surprise Cross’ 1971 Nigrescence model is summarized, fol-
that the Oxford Handbook of Counseling Psychology lowed by a review of her POC model (Helms,
would dedicate an entire chapter to this topic. 1995), a synthesis of Cross’ (1971) and Atkinson
Although previous handbooks of counseling psy- et al.’s (1989) work. Helms’ impact on the racial
chology incorporate racial identity in chapters that identity work in the social sciences, especially coun-
focus on racial and ethnic variables in counseling seling psychology, has been tremendous. Next,
(Brown & Lent, 1992), race and social class (Brown Sellers et al.’s (1998) multidimensional model of
& Lent, 2000), and multicultural psychology and racial identity is reviewed. Sellers’ impact on racial
research (Brown & Lent, 2008), none dedicates an identity is also significant, in large part because of
entire chapter to racial identity. This chapter surveys the productivity of his racial identity lab. We con-
historical and contemporary models of racial and clude this section on racial identity by providing
ethnic identity. The chapter will begin with an over- a review of the most influential white identity
view of theories and models of racial identity, then models, starting with the developmental models
move on to discuss black racial identity (BRI), first proposed by Hardiman (1979) and Helms
minority identity/POC racial identity, white racial (1990), and ending with the attitudinal model of
identity (WRI), roots of ethnic identity and social white racial consciousness (LaFleur, Rowe, & Leach,
identity theory, ethnic identity, implications for 2002; Rowe, Bennett, & Atkinson, 1994), which
counseling, measurement issues for racial identity, emerged as an alternative to Helms’ development
and measurement issues for ethnic identity. The model and led to several notable debates about con-
chapter concludes with a look at future research ceptualizing and measuring racial identity.
directions.
From Negromachy to “Boys No More”
Overview of Theories and Models No discussion of historical models of racial iden-
of Racial Identity tity would be complete without referencing the
A summary and review are provided of the most contributions of Charles Thomas. At the 1968
influential and prevalent theories and models of American Psychological Association’s annual con-
racial identity in that they significantly advanced vention, Thomas along with several other black
one or more areas of the social sciences: theory, psychologists formed the Association of Black
application, measurement, and research. Numerous Psychologists (ABPsi), and Thomas served as the
stage models, such as those by Cross (1971), Thomas first co-president. Before the articulation of his
(1971), Jackson (1976), and Millones (1980), Negromachy model (Thomas, 1971) and the now
described the impact of a social movement via the classic Nigresence model (Cross, 1970, 1971; Hall
process of transformation from Negro into black & Cross, 1970), Thomas published a relatively
(for more historical details, see Cross, 1991; Helms, unknown article that laid the groundwork for his
1990). To underscore the commonality of these and arguably other racial identity models to follow
models, Cross (1978) labeled them Nigrescence (Thomas, 1969). In that article, which reflected
(a term derived from the French) models—the “pro- the gendered/sexist language of the times, Thomas
cess of becoming black” (p. 108). Starting with discussed how the vestiges of slavery and oppres-
the most influential black identity development sive social policies contributed to the breakdown
models, we summarize and review the Nigres- and disintegration of black families. Thomas argued
cence models of Thomas (1971) and Cross (1971). that the cultural climate for black people sup-
The Thomas model provides a historical perspec- ported the belief that “white is right” (p. 39), and
tive of racial identity theorizing. Cross’ impact has he asked the reader to reflect on the long period
spanned over 30 years. One of the most forward of time that black people “accommodated and
thinkers of racial identity theories, Cross has revised internalized their astoundingly oppressive society”
and expanded his Nigrescence model to parallel (p. 39). Without explicitly identifying the causal
the evolving cultural climate over time. His think- mechanisms or developmental antecedents, Thomas
ing anchors the past with the present. The evolution described a new sense of blackness, which he com-
of Cross’ model is provided, followed by a review pared to “one’s first physical encounter” or a “deep
of Atkinson et al.’s (1979) minority identity religious conversion” (p. 40). He indicated that this

cokley, vandive r 293

new sense of blackness could occur when an indi- to black acceptance and activism (internalization-
vidual was “able to refer to himself as black in commitment). Due to limitation in space, the
public,” or when a lady could wear a natural hair original and revised models are not presented here.
style, or when an individual could comfortably wear Readers are referred to the seminal article “The
“Afro-American clothes.” Finally, Thomas charac- Negro-to-Black Conversion Experience” (Cross,
terized black people as “boys no more” (p. 40) 1971) and the book Shades of Black (Cross, 1991)
because they were discovering a collective group that delineate clearly both models. For an in-
awareness, which could be understood as occurring depth understanding of the expanded model, see
in a developmental fashion. Cross and Vandiver (2001), and for earlier cri-
Building on this article, Thomas (1971) wrote tiques of Nigrescence models, see the 1989 special
the more cited and better known book Boys No issue of TCP on Nigrescence and Reginald Jones’
More. In this book, Thomas gave form to his 1969 (1998) edited book African American Identity
musings by introducing the term Negromachy, Development. The expanded Nigrescence theory
which he described as a psychological illness of contains six elements, which have emerged in Cross’
preconscious blacks characterized by confusion of writings in the past decade: (a) the structure of the
self-worth and being dependent on white society self-concept; (b) the exemplars of black identities;
for self-definition. According to Thomas, the anti- (c) identity socialization from infancy to early adult-
dote to Negromachy was a succession of five stages, hood; (d) adult identity conversion; (e) recycling;
which would lead to a new sense of blackness. and (f ) daily strategies to manage racial encounters.
The first stage, withdrawal, required blacks to vol- A brief review of the expanded Nigrescence
untarily withdraw themselves from traditional rela- model (points a, b, d, and e) and the key assump-
tionships with whites in order to resolve power tions that demarcate it from the original model are
imbalances. The second stage, testifying, was char- presented here.
acterized by blacks testifying about all the pain The revised model was based on five changes
they had endured in denying their humanity. In the made to the original Nigrescence model, which
third stage, information processing, individuals are now fundamental to the expanded Nigres-
started to process the new information they were cence model. One, Nigrescence shifted from a stage
receiving about their black cultural heritage. The model (developmental) to an experiential process,
third stage led to the fourth stage, activity, in which although developmental elements were more pres-
blacks became active in a group or organization as ent in the revised model than in the current model.
a way to become connected to the larger black Two, personality was separated from social identity.
experience. Finally, in the transcendental stage, Three, a shift was made from the stage process to
blacks transcend the various social identities that the specification of exemplars of black racial identi-
divide people (e.g., race, sex, social class) and see ties in each stage and the respecification of other
themselves as part of humanity. exemplars. Four, a linear relationship was no longer
made between the stages and psychological func-
Nigrescence Models tioning. And five, racial identity was not due solely
As a clinical psychology doctoral student in the to the oppressive or discriminatory aspects of soci-
1960s, William Cross was very interested in how ety (Parham, 1989), but could occur for a variety of
the social turbulence of the Civil Rights Movement reasons.
and the Black Power Movement impacted black Cross shifted the focus on racial identity from
people. He noted and later documented what he “becoming black” to “being black” by creating
believed to be a progression or stages of black con- exemplars of black attitudes and incorporating
sciousness, which he labeled Nigrescence. There have the recycling mechanism, proposed by Parham
been three iterations of the Cross Nigrescence (1989). The stage model now reflects experiences
models: the 1971 version, now called the original of blackness, which may or may not be sequential.
model (NT-O; Cross); the 1991 version, called the Individuals may go through a series of experiences in
revised model (NT-R; Cross); and the current ver- developing a black identity, but not every black
sions, called the expanded model (NT-E; Cross & person will automatically start with a pre-encounter
Vandiver, 2001; Worrell, Cross, & Vandiver, 2001). racial identity. Thus, recycling to encounter can occur
The original five-stage model is well known, chroni- at any stage, leading to a deeper processing of an indi-
cling the movement from an initial adherence to vidual’s racial identity. Although Cross and colleagues
dominant cultural values by blacks (pre-encounter) (Cross & Vandiver, 2001; Worrell et al., 2001)

294 ethnic and racial id e n tit y

continue to use terminology (stage model) that adopt about other blacks. Self-hatred (high nega-
implies a developmental process, it isn’t clear tive race salience) characterizes the individual who
whether the terms are used to maintain a continuity personally rejects being black.
across the models or whether both represent experi- Immersion-emersion consists of the same two
ential and developmental processes. attitudes described in the revised model. Intense
Cross (1991) contended in the revised model black involvement refers to the idealized immer-
that self-concept is made up of two components: sion into black culture, whereas the anti-white atti-
personal identity (PI) and reference group orienta- tude reflects an individual’s intense dislike of white
tion (RGO). Reference group orientation refers to culture. Four racial attitudes make up internaliza-
an individual’s preference for social affiliation, tion: black nationalist, biculturalist, multiculturalist
whereas PI reflects the unique aspects of an indi- inclusive—all in the revised model—plus the addi-
vidual, including personality traits and psychologi- tion of multiculturalist racial. All attitudes have
cal functioning such as self-esteem, happiness, a high positive race salience for being black. The
depression, and anxiety. The focus of the Nigres- only difference is the number of cultural identities
cence model is not on PI, but RGO—the social that is salient, which in turn influences the focus
identity of the individual, which includes the of the individuals. Black nationalists focus solely
importance of race (race salience; Cross, 1991). on being black and the empowerment of other
Each stage contains multiple racial attitudes, blacks. Biculturalists focus on being black, plus
bound together by a core essence but reflecting have another salient cultural identity (e.g., gender
unique RGO characteristics. No assumptions are or American). And multiculturalists focus on mul-
made about a specific process from one attitude to tiple salient cultural identities (i.e., black, female,
another within or across stages. Thus, the focus lesbian) and on building coalitions with other
of the expanded model is on the attitudinal aspects cultural groups. The difference between the multi-
of RGO. The five-stage process remains the same culturalists is the extent of cultural inclusion.
if the focus is on the Nigrescence process that a A multiculturalist racial connotation refers to blacks
black adult might undergo in developing a black whose identity revolves around being black in rela-
identity, but a developmental process is not assumed. tion to other racial minority groups. Their RGO
The original stage names are still used for continuity does not extend to non–racial minority groups such
and underscore a theme that identities share within as gays/lesbians or well-informed whites. In con-
each stage. When the focus is on the exemplars of trast, those with a multiculturalist inclusive identity
attitudes, only the stages/themes of preencounter, build coalitions with anyone who is interested in
immersion-emersion, and internationalization are working toward social equity.
used. A racial attitude is not associated with encoun- Blacks with internalization attitudes are not
ter, as it is transitory in nature (Cross & Vandiver, expected to have a higher self-concept or psy-
2001). The expanded theory underscores that an chological functioning than those with immersion-
indefinite universe of black identities are representa- emersion or pre-encounter assimilation attitudes.
tive of the themes of each stage/theme (Cross & Only individuals with a pre-encounter self-hatred
Vandiver, 2001). attitude (the negative merger of PI and RGO) are
The racial identity exemplars, first noted in the expected to suffer from low self-esteem, as they hate
NT-R, have been further fleshed out, resulting in themselves for being black. Thus, no difference
the delineation of nine racial identities, two more in psychological functioning is expected between
than in NT-R (Vandiver, Fhagen-Smith, Cokley, individuals if they express a preference for one
Cross, & Worrell, 2001; Worrell et al., 2001). Three reference group over another, except if they have
identities, instead of two (assimilation and anti- a deep disdain for being black. Someone with
black) in the revised model, now make up the pre- a black nationalist identity could be just as
encounter stage: assimilation, miseducation, and depressed as someone with a pre-encounter assimi-
self-hatred. All reflect the endorsement of a main- lation identity.
stream social identity, but for different reasons. Pre-
encounter assimilation refers to a pro-American Evaluation
RGO (low race salience, but high salience to other It is to Cross’ (1971, 1991; Cross & Vandiver, 2001)
cultural aspects—e.g., social class, religion, etc.). credit that he continues to innovate the Nigres-
Miseducation (moderate negative race salience) cence model, modifying it based on an accumu-
refers to the stereotypical views that individuals lation of evidence and critique. There is a growing

cokley, vandive r 295

body of research on the NT-E using the Cross Racial and history: black, white, and people of color. These
Identity Scale (CRIS; Vandiver et al., 2000), with three models share several common features. One,
a host of sociocultural (RGO and PI) variables, such the racial identity process is described in terms of
as acculturation, psychological health, academic status, replacing the term stage, to reflect the dynamic
adjustment, and ethnic identity. The accumulated and complex cognitive, affective, and behavioral
research will in time determine the efficacy of the processes that guide the person in interpreting
expanded theory, in whole or in part. Despite racial information. Using stage seemed to imply
the burgeoning research using the CRIS, some of a static condition that was mutually exclusive of
the findings must be viewed with caution, as the other stages. Two, individuals still undergo a
common flaws have occurred across the research developmental sequence of ego differentiation and
process such as drawing the wrong conclusions due have available within their identity a repertoire of
to using the 1971 model (NT-O) and misusing the all ego statuses. The most dominant status is the
CRIS (separate subscale use). one usually expressed, but other statuses may be
Two issues may explain this state in the litera- strong enough for individuals to access when neces-
ture. One, conceptual confusion appears to exist sary. Three, content of the statuses will vary based
about the expanded model. Although Cross’ model on the sociocultural experiences, including power
is still called Nigrescence and the stages are still differences, of one’s racial group. Four, ego statuses
included, the model is no longer the original model will vary in maturation, from simplistic unexam-
and is not developmental. Scholars still write as if ined ones to more complex and dynamic ones, and
the original Nigrescence model is in force and will emerge based on the need to cope and digest
invoke developmental terminology (e.g., internal- meaningful experiences. Reliance on external
ization is a higher level than pre-encounter). Two, sources for identity reflects less mature ego statuses,
the original Nigrescence model has intuitive appeal whereas more mature ego statuses represent a
(R. Bingham, personal communication, February personal discovery and integration process of an
16, 2008; Stevenson, 1998). The stage process internalized identity. Five, schemata are the behav-
makes intuitive sense to people because psychologi- ioral manifestations of statuses and are what is
cal health and self-worth should be linearly linked tapped on paper-and-pencil measures. A reciprocal
to internalizing a black identity. However, the process is assumed to exist between the relevant
empirical evidence doesn’t support these common- schemata and statuses, strengthening or weakening
sense premises (Cross, 1991; Cross & Vandiver, each other depending on use. Finally, each status
2001). Perhaps it is time for a sea change in the ter- is defined by an “underlying cognitive-emotional
minology (i.e., cease using Nigrescence and stages) information-processing strategy” (Helms, 1995,
used to describe the current Cross model. This shift p. 187), which is assumed to be the same regardless
might result in facilitating best practice of the of the era in which the person was socialized (Helms,
theory/model. Currently, the most noteworthy 1995). Readers should review Helms (1990, 1995),
support for the expanded model has been the iden- and Thompson and Carter (1997) for an in-depth
tification of four cluster patterns, which parallel the understanding of Helms’ models.
exemplars in the model (Vandiver, Korell, & Miller,
2007; Worrell, Vandiver, Schaefer, Cross, & Fhagen- Black Racial Identity
Smith, 2006): assimilated, immersion, Afrocentric, Helms (1990) modified and extended Cross’ origi-
and multiculturalist. More work is needed in theo- nal Nigrescence model to create another model
rizing about BRI, as the cultural world continues to of BRI. The number of statuses was reduced from
change racially and sociopolitically. Cross’ BRI five to four: pre-encounter, encounter, immersion/
model is only one perspective in addressing the emersion, and internalizations. Each status repre-
complexity of identity. sents a separate racial perspective and differs in PI,
RGO, and ascribed identity. Within each status,
Janet Helms’ Models: Helms elaborated that two bimodal forms of
Nigrescence and Beyond expression existed. The original pre-encounter status
Helms (1995) has developed an overarching theory is an active expression of blacks intentionally ideal-
of racial identity development, with the under- izing whites and denigrating blacks. In the passive
standing that the process is applicable to all racial mode, considered the healthier of the two, the indi-
beings. Three separate models were developed to vidual actively assimilates the dominant worldview
capture the differences in their racial experiences to earn acceptance and status, while unconsciously

296 ethnic and racial id e n tit y

accepting the established racial stereotypes. Con- process: conformity (pre-encounter), dissonance
scious awareness of the need to discard being pro- (encounter), immersion/emersion, internalization,
white and to find another is the first mode of and integrative awareness. Ego statuses parallel the
expression in encounter, whereas the struggle to find process of the original Nigrescence model from
a new identity, comprised of a mixture of feelings, accepting white standards and devaluating own-
reflects the other mode of expression. Helms main- group values to accepting own racial identity and
tained Cross’ depiction of immersion-emersion (the willingness to collaborate with others. The differ-
active immersion into black culture vs. the with- ence is that the process is now written in the context
drawal into a supportive black environment to for other racial/ethnic minorities.
resolve identity). The first mode of expression in
internalization is the blend of one’s PI with a newly evaluation
found positive black identity. Internalization- Combining the Nigrescence and the minority
commitment is now the second mode of expres- identity development models reflect the forward
sion in internalization, in which commitment to thinking that Helms (1994) had about racial
a black identity is evidenced through social activ- identity development. The inclusion of other
ism. More nuanced details of Helms’ black identity racial/ethnic minorities recognized that discrimina-
model are presented in Helms (1990) and Carter tion wasn’t reserved just for blacks. Limitations
(1995). common to all models are discussed below, but
a unique concern is whether the same racial iden-
evaluation tity process is common to all racial/ethnic minor-
This model is intriguing in that Helms, early on, ities. Furthermore, whites are the comparison
advanced nuances (modes of expression) at each group for internalized racism. What about the
of the stages that most scholars are unaware of. racism that occurs between racial/ethnic minorities
The specifics of her model are typically overlooked, (e.g., Cubans and blacks; blacks and Koreans)? Does
as most scholars use the Black Racial Identity racism between racial/ethnic minorities have an
Attitude Scale (BRIAS; Helms & Parham, 1996), impact on racial identity development, or does
which is based on Cross’ (1971) model. No research only the white hegemony count at this point?
exists in support of Helms’ model, although it is Some research has been conducted on the POC
likely that the first modes of expression in pre- model using the People of Color Racial Identity
encounter and internalization are measured in the Attitudes Scale (PRIAS; Helms, 1995). Despite
BRIAS. It is not clear what modes of expression are the lengthy existence of the model (at least a decade),
tapped in the BRIAS for encounter and immersion- research is just emerging on it. Its value will
emersion. Like all Nigrescence models, Helms’ depend on the psychometric adequacy of the
model has been criticized on specific aspects, which PRIAS, which is just beginning to be tested.
will be summarized once at the end of the section.
The issue at this point is whether Helms still views White Racial Identity
this model as viable, given the lack of measurement Helms (1990, 1995) contends that whites are con-
of it and the development of the POC model, which sciously or unconsciously socialized to assume that
includes blacks. they are racially superior, thus giving whites the
privilege to ignore or deny their race. Thus, devel-
People of Color oping a positive WRI requires overcoming the influ-
The POC model is a synthesis of Cross’ original ence of racism, accepting the sociopolitical nature
Nigrescence model and Atkinson’s et al. (1989) of whiteness, and personally acknowledging the
minority identity development. Helms (1995) uses racial equality of others, as well as identifying as
the term people of color to refer “to those persons a racial being (Helms, 1990, 1995). Six ego statuses,
whose ostensible ancestry is at least in part African, differing in the degree of acceptance of racism
Asian, Indigenous, and/or combinations of these and whiteness, delineate the maturation process of
groups and/or white or European ancestry” (p. 189). WRI: contact, disintegration, reintegration, pseudo-
The underlying assumption of the model is that independence, immersion-emersion, and auton-
people of color have internalized societal racial omy. The contact status is characterized by whites’
stereotypes and that the central goal of racial iden- “obliviousness to racism,” in which they are satisfied
tity development is to overcome the internalized with the status quo. Sustained exposure to racial/
racism. Five ego statuses describe this maturation ethnic minorities may lead to the development of

cokley, vandive r 297

the disintegration status, which includes increased of being white (Hardiman, 2001). Three, it has
awareness of racial differences and concomitant been questioned whether the process of white iden-
feelings of anxiety in making sense of racial issues. tity development parallels the development of
The reintegration status emerges when individuals racial/ethnic minorities. Four, as a result, the theory
resolve these racial ambiguities by acknowledging is considered to be a “gross oversimplification” of
their whiteness and adopting the two-belief system the process of becoming white. Hardiman (1991,
of white superiority-racial/minority inferiority. pp. 116–117) contends that, “white identity devel-
Unless fixated in this status, poignant events may opment might entail different processes for indi-
precipitate whites to requestion their racist beliefs. viduals raised in all- or mostly white environments,
If successful, whites adopt the pseudo-independence and whites who were raised in close proximity to
status, an intellectual definition of positive white people of color.” At the same time, white racial
identity and the acceptance of other racial/ethnic consciousness scholars (Leach et al., 2002; Rowe
groups. Movement into the immersion-emersion et al., 1994, 1995) have criticized the white racial
status involves developing a personal definition model for being too complex and exhaustive, con-
of whiteness, which includes questioning racist taining an answer for any aspect of racial identity
beliefs and racial stereotypes. The final status is development. Thus, none of the models can ever
autonomy and involves the internalization of a pos- truly be confirmed (fully measured) nor discon-
itive WRI in which one actively does not oppress firmed, as there will always be missing elements
another, but seeks to build cross-racial relation- or conditional premises in explaining mixed empiri-
ships. These statuses reflect two phases of white cal findings. Despite these criticisms and issues
identity development: the abandonment of racism, about the psychometric adequacy of the White
which includes the first three statuses (contact, dis- Racial Identity Attitudes Scale (Helms & Carter,
integration, and reintegration), and the acceptance/ 1990), empirical findings have provided support for
internalization of a nonracist white identity, which an overarching aspect of white identity (Behrens,
covers the last three statuses (pseudo-independence, 1997; Swanson, Tokar, & Davis, 1994). In conclu-
immersion-emersion, and autonomy). sion, Helms’ models are at a crossroads. Should the
models be revised, or should the process of whites
evaluation accepting other racial/minorities or racial minorities
Comments in this section are pertinent to all of accepting their racial identity remain the same?
the racial identity models, with many of the com- Does the social era or the racial composition of the
ments pointed to WRI. Helms’ contribution to the United States matter?
field of psychology on racial identity has been enor-
mous. She has stimulated work on racial identity in Multidimensional Model of Racial Identity
several ways: the development of her own and other Thus far, the review of the literature has focused
racial identity models (e.g., Rowe et al., 1994; primarily on the contributions of counseling psy-
Sabnani, Ponterotto, & Borodovsky, 1991), the chologists and clinical psychologists (e.g., Charles
development of her own and other racial and Thomas, William Cross). Counseling psychologists
ethnic identity scales, and the development of a have especially been instrumental in conducting
racial identity interaction model (Helms, 1984, empirical research to advance our understanding
1990). However, major criticisms have been made of racial identity. However, interest in the racial
about all of the models. One, they don’t fit the cri- identity of African Americans has a much longer
teria for a developmental model (Leach, Behrens, & history in psychology than the contributions of
LaFleur, 2002; Rowe et al., 1994; Stokes, Murray, counseling psychology, dating back to the early
Chavez, & Peacock, 1998). Despite shifting from “Negro” self-concept and racial identification stud-
not using the term stage to using statuses, the devel- ies (Clark & Clark, 1939; Horowitz, 1939; Kardiner
opmental process is still believed to be embedded in & Ovesey, 1951). These studies were conducted by
the model. Two, the focus is not on white identity, social psychologists who were interested in under-
but on how whites view other racial/ethnic minori- standing the psychological impact of having a stig-
ties (Fischer & Moradi, 2001; Hardiman, 2001; matized racial identity.
Leach et al., 2002; Rowe et al., 1994). Thus, the As racial identity research increased through the
theory is considered prescriptive (chronicling what 1990s, concerns were expressed about inconsisten-
whites need to do to overcome being racist) instead cies in the literature. These inconsistencies were
of descriptive—describing the attitudes and process attributed to “mainstream” versus “underground”

298 ethnic and racial id e n tit y

approaches to the study of African American or BRI identity status is inherently good or bad. Instead,
(Sellers, Smith, Shelton, Rowley, & Chavous, 1998). the framework of the MMRI allows for the possi-
Mainstream approaches assume that the oppression bility that certain identities may be more likely to be
of white racism has resulted in blacks internalizing associated with more positive outcomes. However,
a negative black self-concept and having a stigma- even if this is the case, it is still important for empir-
tized racial identity (Sellers et al, 1998). Underground ical research that the identity be kept separate from
approaches emphasize the role of history and cul- the outcome.
ture in understanding what it means to be black. In addition to these four testable assumptions,
According to Sellers et al., mainstream approaches the MMRI consists of four dimensions that concen-
place more emphasis on the stigma of being black trate on both the qualitative meaning and signifi-
than on the experiential aspects associated with his- cance of race in the self-concepts of African
tory and culture related to what it means to be Americans (Sellers et al., 1998). The four dimen-
black. On the other hand, underground approaches sions consist of racial salience, racial centrality, racial
offer different perspectives about what it means to regard, and racial ideology. Racial salience “refers to
be black, but have not generated a lot of empirical the extent to which one’s race is a relevant part of
support for the internal processes hypothesized to one’s self-concept at a particular moment or in a
undergird the development of a black identity. particular situation” (Sellers et al., 1998, p. 24).
Finally, mainstream approaches focus more on the This dimension assumes that race is more salient
process and structure of racial identity, whereas for African Americans in certain situations than in
underground approaches focus more on the qualita- others. For example, regardless of how important
tive aspects of racial identity. race is to an individual’s self-concept, being the only
In an attempt to integrate the best of both black person in a meeting where a racist joke is told
approaches, Sellers et al. proposed a new theoretical using a racial epithet would most likely make race
framework for understanding black identity, the a salient part of the individual’s self-concept at that
Multidimensional Model of Racial Identity moment. Racial centrality “refers to the extent to
(MMRI). The MMRI is informed by social identity which a person normatively defines himself or her-
theories that state that social identities are influ- self with regard to race” (Sellers et al., 1998, p. 25).
enced by situations as well as by relatively stable This dimension addresses how central race is to an
properties of the individual (Stryker & Serpe, 1982, individual’s identity. For example, the individual
1994). According to Sellers et al., the theoretical who sees being black as an important part of her or
framework of the MMRI allows for the reconcilia- his self-concept is higher on racial centrality than is
tion of inconsistencies in the literature. The MMRI the individual who does not. Racial regard “refers to
starts with the supposition that race is one of a a person’s affective and evaluative judgment of her
number of salient social identities for African or his race in terms of positive–negative valence”
Americans, and not necessarily the most important. (Sellers et al., 1998, p. 26). This dimension exam-
Instead of assuming that race is an important social ines how positively or negatively an individual
identity for African Americans, the MMRI asks two feels about being black, and is included because this
questions: How important is race in the individual’s is a theme of much of the psychological literature
perception of self? What does it mean to be a on African Americans. The racial regard dimension
member of this racial group (Sellers et al., 1998)? consists of both private regard and public regard.
Four empirically testable assumptions form the Private regard refers to how individuals feel about
foundation of the MMRI. The assumptions are that being black, as well as how they feel about other
identities are situationally influenced and also stable blacks. Public regard refers to how much individ-
properties of the individual, individuals have a uals feel that others hold positive or negative views
number of hierarchically ordered identities, peoples’ toward or about blacks. Racial ideology “is com-
perceptions of their racial identity is the most valid posed of the individual’s beliefs, opinions, and
indicator of their identity, and the status of an indi- attitudes with respect to the way she or he feels that
vidual’s racial identity is of primary concern, as the members of the race should act” (Sellers et al.,
opposed to the development of the racial identity. 1998, p. 27).
A particularly noteworthy difference between the Historically, at least four dominant racial ideolo-
MMRI and underground approaches (such as the gies have been embraced by African Americans.
various permutations of the Nigrescence model) is These four ideologies have been incorporated into
that the MMRI does not assume that any racial the MMRI and include the nationalist philosophy,

cokley, vandive r 299

the oppressed minority philosophy, the assimila- development of these models. Namely, at its core,
tion philosophy, and the humanist philosophy. the MMRI is a social psychological theory of
A nationalist ideology is characterized by a strong identity developed by social psychologists whose
belief in the uniqueness of the black experience, orientations are as contemporary social scientists
self-determination with no interference from other living in a post Civil Rights and Black Power era.
racial groups, and an increased likelihood of partici- They did not live through segregation and the Black
pating in black organizations. An oppressed minor- Is Beautiful era. By contrast, the Nigrescence model
ity ideology is characterized by a belief in the was developed by a clinical psychology doctoral
similarities between blacks and other marginalized student living and experiencing the turbulence of
and disenfranchised minorities. An assimilationist the 1960s Civil Rights and Black Power era. The
ideology is characterized by the belief that African concern for many black social scientists during that
Americans are similar to other groups in American era was for black liberation, which by definition
society, and as such should work within the system assumed that black people were oppressed and
to effect change. Finally, a humanist ideology is needed to be liberated. The zeitgeist of those times
characterized by the belief in the similarities between clearly impacted the ideological thrust of the
humans, and that individuals should not be simply Nigrescence model. This, combined with a clinical
reduced to their race, gender, class, or other social psychology student’s orientation toward mental
identity. health, made it quite natural to link self-esteem to
As mentioned previously, the MMRI does not an individual’s racial identity attitudes. It might be
view any dimension of racial identity as being inher- argued that the MMRI places no explicit value on
ently positive or negative. It attempts to remove dimensions of racial identity because its authors
evaluation or judgment from the beliefs and atti- were fortunate enough to not live through the
tudes individuals have about being black. This is racially turbulent times of the 1960s. There is not
perhaps the most striking difference between the a sense of urgency in the MMRI or resoluteness of
MMRI and both mainstream and underground purpose, because the MMRI is essentially descrip-
approaches. Conducting research using the MMRI tive in scope rather than prescriptive. In other
does not mean that negative outcomes, such as words, there is no desired endpoint because the
low self-esteem, depression, or poor academic per- MMRI seeks only to capture and describe the
formance, are not legitimate areas of research dimensions of black identity. In spite of its theo-
inquiry. It simply means, as Sellers et al. (1998) retical sophistication, it is perhaps because of this
state, that the negative outcomes should be not orientation that the MMRI has not resonated very
defined as part of the dimensions of racial identity strongly with counseling psychologists. A review
themselves, because this becomes a tautological of the counseling psychology literature reveals that
problem. Although not explicitly mentioned, these the MMRI has largely not been utilized by coun-
concerns seem to be more applicable to Cross’s seling psychologists. In fact, outside of one study
(1971) original Nigrescence model, in which pre- published by the first author (Cokley, 1999), the
encounter attitudes were initially seen as anti-black authors are not aware of any counseling psychologists
and pro-white, with the implication being that who have published studies utilizing the MMRI as
blacks who exhibited these attitudes were self-hating their theoretical framework for racial identity.
and suffering from low self-esteem. However, in a
comprehensive review of the literature, Cross (1991) Minority Identity (Racial/Cultural
had already concluded that psychological function- Identity) Development
ing, such as self-esteem, should not be automatically In 1979, Atkinson, Morten, and Sue developed the
linked to racial identity attitudes, and with the assis- minority identity development model (MID) for
tance of his colleagues (Vandiver et al., 2001), he the purpose of assisting mental health profession-
sought to empirically support his evolved thinking. als in working better with racial minorities. Based
Thus, Sellers et al.’s concerns, while well-founded, on the BRI models of Cross (1971) and Jackson
do not seem to accurately reflect the evolution of (1976), and the authors’ clinical experience in work-
Cross’s thinking and his revised and expanded ing with minority clients, the MID was applied to
Nigrescence models. all racial/ethnic minority groups, such as blacks,
One final observation that should be pointed Latinos, and Asian Americans, because of their
out and that has relevance to this issue concerns common experience of oppression, even though
disciplinary and historical influences on the sociopolitical experiences varied. Several premises

300 ethnic and racial id e n tit y

undergird the model: it is not a theory of personal- Finally, continued use of the MID (R/CID) model
ity development; it is a developmental stage model; is primarily based on intuitive appeal and anecdotal
the stages are not discrete, but continuous; and clinical data, with little empirical support—a status
everyone may not go through all the stages in a life- acknowledged by Atkinson et al. (1993). A perusal
time, possibly remaining in only one stage. There is of PsychINFO for use of the model in the psycho-
no prerequisite that individuals must go through logical literature resulted in 14 articles, spanning
the lower stages first, that there is an irreversible 1983 to 2005: six dissertations—half quantitative
sequence to reach the higher stages, and that the (Fernandez, 1989; Lim, 2002; Lott-Harrison, 1999)
higher stages represent more valued attitudes and half conceptual or qualitative (DeJesus-Rueff,
(Atkinson et al., 1979). 1986; Pak, 2005; Ponpipom, 1997). In some arti-
The five MID stages are conformity, dissonance, cles, the MID was applied to various counseling
resistance and immersion, introspection, and syner- modalities (Barrett, 1990; D’Andrea & Daniels,
getic articulation and awareness. The essence of 1996; Sue, 1989; Thomas, 1985). Two published
each stage is similar to the original Nigrescence quantitative studies reported relationships between
model: individuals in conformity start with a pref- MID level and preference for counselors (Morten &
erence for dominant culture and denigration of Atkinson, 1983), and between MID level and psy-
their own culture only to undergo transformation chological help-seeking in Polish immigrants in the
in appreciating their own culture and have a more United Kingdom (Bassaly & Macallan, 2006). Both
discerning view about other cultures (synergetic). studies created a measure of MID, but no standard
The stages’ content has remained the same for measure has been developed that could be used
almost 30 years (Atkinson, 2003; Atkinson et al., across racial/ethnic groups.
1979) with only minor changes. Sue and Sue (1990) Helms and Carter (1986, 1990) developed the
renamed the MID the racial/cultural identity Visible/Racial Identity Attitudes Scale ([VIAS] and
development (R/CID) model and changed the noted by other acronyms as well) to measure four
name of the fifth stage to integrative awareness, to five attitudes on the MID, depending on the
which has been extended in subsequent editions version used. Some version of the VIAS has been
of the text (1999, 2003, 2008). Sue and Sue (1990) used up to 2000, and the findings have been in
also applied the model to white identity develop- keeping with theory. For example, increased racial
ment, crafting the description to reflect change from awareness (fifth stage) has been linked to increased
a dominant (ethnocentric) identity to developing career maturity in Asian Americans (Carter &
a nonracist identity. Atkinson et al. (1998) and Constantine, 2000), and positive racial identity has
Atkinson (2003), however, have continued to pres- been associated with achieved ego identity in
ent the original model, absent the modifications Hispanic Americans (e.g., Miville & Helms, 1996).
made by Sue and Sue. For a detailed review of the However, it is unclear whether this scale is viable, as
MID or R/CID models, the reader is referred to the limited psychometric research has been conducted
citations listed above. or reported (Kohatsu & Richardson, 1996), or that
it will continue to be used, since another scale has
Evaluation evolved from the VIAS to measure the people of
The primary strength of the model is its universal- color model (Helms, 1995), which is a fusion of the
ity, as it is appropriate to describe the cultural original Nigrescence and MID models. If not, what
identity development of all individuals, including is the implication of continuing to use a theory
whites. Also, the model was designed for counselors without sustained or clear empirical support?
in understanding the racial/minority identity
development of their clients. However, through six White Identity Development
editions of the text Counseling American Minorities: Hardiman (1982) developed what is considered
A Cross-Cultural Perspective from 1979 (Atkinson the earliest model of white identity develop-
et al.) to 2003 (Atkinson), the basic tenets of ment (WID) in order to shift the focus from the
the model have remained the same, except for victims of racial oppression to the oppressors
changes noted above (Sue & Sue, 2008). Substantive of racism and to describe the process of whites
changes in U.S. sociocultural landscape have not developing a nonracist identity. An underlying
been taken into account. The model continues to be assumption of the model is that no one can “escape
described as developmental, even though it doesn’t the racist socialization,” as it is a “by-product of
meet stage criteria (Stokes et al., 1998). living within . . . institutional and cultural racism”

cokley, vandive r 301

(Hardiman, 2001, p. 111). Using autobiograph- “toward racial/minority group members . . . identifi-
ical data of white writers and influenced by the able and recognized as non-white” (Rowe, Behrens,
early BRI models, Hardiman offered a five-stage & Leach, 1995, p. 225). These attitudes are acquired
model of WRI development, which has been in the same manner as other attitudes and are not
updated (Hardiman, 1994; Hardiman & Jackson, viewed as personality traits, but represent clusters
1992): no social consciousness of race or naivete, of attitudes held by whites. Each cluster represents
acceptance, resistance, redefinition, and internal- a describable set of related attitudes, which are
ization. The first stage, no social consciousness of called types. Individuals can possibly have attitudes
race or naïveté, begins and ends in early childhood representative of more than one type, but it
and is characterized by a lack of awareness or under- is assumed that most people can be classified as
standing of the meaning or value of race. In stage 2, holding one type of white racial consciousness.
acceptance, whites have unconsciously internalized White racial consciousness emerged as an alterna-
racism and a status of privilege. Movement to stage tive model in response to concerns about the con-
3, resistance, is marked by an individual’s question- ceptual underpinnings of the WRI development
ing of mainstream racial views and the onset of (WRID) models, most notably Helms’ (1990,
rejecting racist ideology and becoming an activist. 1995) model. Major criticisms cited by the WRC
Feelings of guilt and shame are prevalent. Individuals developers (Rowe & Atkinson, 1995; Rowe et al.,
begin to take responsibility for being white (a new 1994) about the WRID models include the inap-
white identity) in stage four, redefinition. And, in propriate use of developmental concepts to describe
the final stage, internalization, this new white iden- the movement between stages/statuses, a minority
tity is integrated into all aspects of an individual’s identity model to create a white identity model, and
life. Transition from one stage to the next is articu- the label of white identity when focus of the model
lated in the model. is not on awareness of a white identity but reflects
varying levels of awareness about other racial/
Evaluation minorities (Rowe et al., 1995, p. 224).
In an analysis of the model, Hardiman (2001, Rowe et al. (1994) originally proposed seven
p. 122) contends that the major contribution of types of WRC attitudes. These types were clustered
the WID model has been “the decentering of on two dimensions, exploration and commitment,
whiteness and the marking of whites as a race that terms adapted from Phinney’s (1989) work on
should be the subject of study.” She also indicates ethnic identity and used for ease of delineating the
that, in the fields of counseling psychology and types of attitudes. Exploration refers to the extent to
education, the model has had a major impact which individuals examine racial/ethnic minority
toward reducing racism and bias in practice and issues or not, and commitment refers to the extent to
in influencing the development of other cultural which an individual adopts a specific attitude about
models. Hardiman (2001) offered several problems racial/ethnic minority issues. Three types of atti-
with the WID model: white identity is seen tudes reflect either no exploration or commitment
through the lens of racial minorities instead of to racial/ethnic minority issues: avoidant, depen-
how whites identify with being white, the model dent, and dissonant. Individuals with avoidant-
represents the racial identity development of those type attitudes do not explore or commit to racial/
who become antiracist activists, and the model is ethnic minority concerns or consider their own race.
not based on empirical research. Hardiman (2001, People with dependent-type attitudes commit to
p. 112) stated, “It is a gross oversimplification to others’ (i.e., family or friends) views about racial/
say that WID defined the racial identity experience ethnic concerns, superficially endorsing one without
for all whites in the United States.” To date, no personally exploring their own attitudes. Dissonant-
empirical research has been published or found to type attitudes accrue to individuals who have
support the model. Rather, Hardiman (2001) explored various attitudes about these concerns, but
viewed the model as a “prescription of what whites who do not commit to a point of view. Individuals
needed to do” (p. 113) to develop a nonoppressor may take a dissonant attitude when they are in tran-
white identity. sition from one racial attitude to another. These
three attitude types are labeled as unachieved white
White Racial Consciousness racial consciousness status “because the attitudes are
White racial consciousness (WRC) represents a col- not securely integrated into the belief structure of
lection of racial attitudes white Americans have the individual” (Rowe et al., 1995, p. 227).

302 ethnic and racial id e n tit y

 In contrast, achieved white racial consciousness On one end of the dimension, white individuals
status refers to individuals who have explored with a dominative-type attitude have a highly nega-
and committed to a specific attitude about racial/ tive view of other racial/ethnic groups and are not
ethnic minority issues and are exemplified in four accepting of other races/ethnicities. The other end
types: conflictive, dominative, integrative, and reac- of the dimension best describes whites with a posi-
tive. Individuals with a conflictive-type attitude do tive/accepting accepting attitude toward racial/
not support overt discrimination toward racial/ ethnic minorities (integrative-type attitude). Also
ethnic minorities, but also do not think it is fair to sharing a common theme is the conflictive and
have systematic programs (i.e., affirmative action) reactive type attitudes. Individuals with either type
that would give advantages to minorities. The atti- of attitudes do not condone racial discrimination,
tudes of dominative-type individuals are that whites but their stance for racial justice—the common
are inherently superior to racial/ethnic minorities theme shared between the types—is different. Those
and, as a result, are entitled to be in charge and with a conflictive-type attitude do not want whites
dominate nonmajority people. Integrative-type atti- to be at an unfair advantage and therefore do not
tudes describe those whites who are secure in their think it is racially just to support any programs that
whiteness, are comfortable interacting with racial/ support racial/ethnic minorities. Whereas individu-
ethnic minorities, and value a fair and culturally als with a reactive-type attitude believe that whites
diverse society. Reactive types are sensitive to the have been privileged and believe is it racially just to
inequities in society and feel guilty and responsi- support programs for racial/ethnic minorities that
ble for discrimination, potentially romanticizing would realign the status quo. Although these two
minority plights and operating in a paternalistic type attitudes reflect a common theme, unlike dom-
manner (Rowe et al., 1994, 1995). inative and integrative, they are treated as separate
Although the achieved-type attitudes are con- constructs psychometrically. Thus, racial acceptance
sidered fairly stable, dissonance experiences are and racial justice provide an orientation to three
considered the likely process that results in an indi- types of attitudes: dominative/integrative, conflic-
vidual’s movement from one achieved-status atti- tive, and reactive (LaFleur et al., 2002).
tude type to another. As tension and conflict are Two, labeling the types of attitudes as achieved
necessary to produce a change, the dissonant-type and unachieved statuses is no longer necessary. The
attitude is considered the likely conduit when indi- original purpose for having unachieved types of
viduals with an unachieved-status attitude move to racial attitudes was to identify those who had not
an achieved-status attitude. Dissonance is not nec- explored and committed to a racial attitude. LaFleur,
essary between the unachieved-status type attitudes Rowe, and Leach (2002, p. 151) stated, “In truth,
because the views have not been internalized (Rowe the scores on the unachieved scales do not reflect
et al., 1994, 1995). racial attitude content.” Three, the previously
A measure was developed to tap the WRC atti- labeled unachieved attitudes are now considered
tude types, the preliminary form of the Oklahoma attitudes of commitment and are labeled as such.
Racial Attitude Scale (ORAS-P; Choney & Behrens, These attitudes reflect the extent of commit-
1996). Validation work (Behrens, Leach, Franz, & ment toward a racial attitude by individuals either
LaFleur, 1999; Pope-Davis, Dings, Stone, & expressing no concern (avoidant), relying on others
Vandiver, 1995; Pope-Davis, Vandiver, & Stone, (dependent), or being uncertain (dissonant). Thus,
1999; Summerson, 1997 on the ORAS-P to mea- scales representative of these attitudes on the ORAS
sure the WRC type attitudes resulted in the recon- are to be used as “indices of one’s expressed commit-
ceptualization of the model (LaFleur, Rowe, & ment to the four types of racial attitudes” (LaFleur
Leach, 2002) and the emergence of the standard et al., p. 151). For an in-depth reading of the WRC
form of the Oklahoma Racial Attitude Scale (ORAS; model and reconceptualization, see LaFleur et al.
LaFleur, Leach, & Rowe, 2003). In the recon- (2002), Leach, Behrens, and LaFleur (2002), and
ceptualized model, three major changes were made. Rowe et al. (1994, 1995).
One, dominative, integrative, conflictive, and reac-
tive type attitudes were reoriented based on one Evaluation
of two racial themes that had been identified In regards to the WRC model (LaFleur et al., 2002;
through factor analysis. Dominative and integrative Rowe et al., 1994, 1995) Ponterotto (2006, p. 101)
type attitudes are now viewed as a bipolar dimen- says it best: “One great strength of the Rowe et al.
sion best reflecting the theme of racial acceptance. (1994, 1995) white racial consciousness model is

cokley, vandive r 303

that it has been closely linked to empirical research that integrative and reactive attitudes were associ-
at the outset.” Empirical studies (Pope-Davis et al., ated with cultural awareness, whereas conflictive
1995, 1999; Summerson, 1997) conducted inde- attitudes were negatively associated with cultural
pendently of the WRC researchers were taken seri- awareness.
ously, resulting in the stimulation of further These findings are promising, especially for the
empirical studies on the ORAP-P and the recon- potential impact on multicultural education and
ceptualization of WRC. Another strength of the training, but continued systematic research is
WRC is the use of a typology model and its general needed. For example, is changing attitudes enough?
clarity. Although these models can be viewed as Does attitudinal change actually lead to behavioral
stereotypical and simplistic, the WRC extends changes in the interactions and cultural lifestyle
the early development of type models (e.g., Gaertner, of people? One of the criticisms of WRI models
1976; Kovel, 1970) on white racial attitudes through is their use of minority identity development
theory and empirical work. By using the term models to create a model about whites’ racial atti-
attitude type, the developers have been cautious to tudes (Rowe et al., 1994, 1995). Is there a relation-
avoid stereotyping individuals based on a score on ship between racial attitudes and RGO—social
a scale. It is clear that the model reflects a unidi- affiliation patterns? No assumptions are made in
mensional view of attitudes and describes types of the WRC model about racial attitudes and psycho-
attitudes that are commonly held by whites, which logical adjustment. Rowe and his colleagues (1994,
have as their basis empirical verification (Leach 1995, LaFleur et al., 2002; Leach et al., 2002) have
et al., 2002). More clarity, however, is needed in the contended that the WRC model is fundamentally
model about the relationship between the racial ori- different from the WRI models, especially Helms’
entation attitudes (dominative/integrative, conflic- (1990, 1995). However, Block and Carter (1996)
tive, and reactive) and the commitment attitudes. have refuted that contention, deeming the WRC
Labeling the avoidant, dissonant, and dependent a variant of WRI. Both views have been supported
attitudes with the term commitment may be mis- in that Pope-Davis et al. (1999) found that the WRI
leading as it is unclear in the reconceptualized model measure, the WRAIS, and the WRC measure, the
how they operate in relation to the racial orienta- ORAS-P, tapped similar and dissimilar constructs.
tions. Embedded in the model is the notion of atti- As the current WRC measure, the ORAS, is differ-
tude change, in which the process may be viewed ent from the preliminary form, further research is
as similar to what is found in the social psychology needed to demonstrate the differences between the
literature. This process may need to be made more WRI and WRC models, not only through scale
explicit, so that it isn’t viewed as a developmental work but in examining the WRC constructs in rela-
process (Block & Carter, 1996). tion to various sociocorrelates. It is important to
The revised WRC model has received some illuminate more clearly how whites view racial/
empirical support. Four dissertations were found ethnic minorities, as societal views about race/
that used the ORAS. One study (Schmidt, 2007) ethnicity continue to change. Another significant
found that the reactive attitude type was associated step in WRC research would be to examine how
with higher levels of ego development, whereas whites view other whites holding different racial
lower ego development was linked to the avoidant attitudes from their own. Such perspective taking
attitude type. The remaining studies focused on research might have implications in better under-
white racial attitudes to multicultural education/ standing whites’ racial attitudes about themselves
training and various professional groups. Loya and others.
(2007) reported that approximately a third of pro-
fessional social workers’ responses to the ORAS had Roots of Ethnic Identity:
categorized them as holding a negative racial atti- Social Identity Theory
tude type (e.g., dominative). College students taking As previously mentioned, ethnic identity has a
a multicultural education course had increased much briefer history in counseling psychology
reactive attitudes over time than did those stu- compared to racial identity. However, scholarly
dents taking a general education course (Weath- interest in ethnic identity has a much longer his-
ersby, 2005). Furthermore, women were found to tory outside of counseling psychology, with social
have higher reactive attitudes than were men, and psychological roots that can be traced back to
men had higher dominative and conflictive atti- the social identity theory of Henri Tajfel (1978).
tudes than did women. Fierstien (2004) also found Tajfel defines social identity as “that part of the

304 ethnic and racial id e n tit y

individuals’ self-concept which derives from their an elusive and difficult construct to define (Cokley,
knowledge of their membership of a social group 2007; Helms & Talleyrand, 1997). The difficulty
(or groups) together with the value and emotional in defining ethnicity is due in part to its history
significance of that membership (Tajfel, 1981, of instability and malleability. Cokley, citing the
p. 255). Tajfel along with his student John Turner Office of Management and Budget (1995), gave
(Tajfel & Turner, 1979) sought to explain how and Asian Indians as one example of this malleability
why social groups formed, and how social identity because they have been classified as Hindus, white,
contributed to intergroup relations, especially con- and Asian or Pacific Islander in various census
flicts. Tajfel and Turner proposed that individuals counts during the 20th century. The malleability
identify with groups for several reasons, and these of ethnicity, and by extension its corollary ethnic
reasons make up the four elements of social iden- identity, have contributed to the lack of a cohesive,
tity theory: categorization, identification, compari- general theoretical framework for understanding
son, and psychological distinctiveness. According ethnic identity (Galkina, n.d.). However, an argu-
to social identity theory, individuals have a natural ment can be made that a general theory of ethnic
tendency to categorize themselves into in-groups identity may be theoretically and methodologically
and out-groups, and identifying with in-groups impractical because the development of ethnic
boosts self-esteem. Social identity theory posits that identity across ethnic groups differs with respect to
individuals also tend to compare their in-groups social context, cultural experiences, historical con-
with out-groups, with the outcome often being text, and values (Cokley; 2007; Galkina, n.d.).
a more positive evaluation or a favorable bias toward Nevertheless, there is an interest in developing
their in-groups. Individuals want the groups to a general theoretical framework for understanding
which they belong to be distinct from, and posi- ethnic identity. The most influential work in this
tively compared to, groups to which they do not area has been the program of research conducted by
belong. Thus, social identity theory was created to Jean Phinney.
understand the psychology of intergroup discrimi-
nation and prejudice. Ethnicity and Ethnic Identity
The social identities of ethnic minorities have One of Phinney’s most important conceptual con-
been characterized as one of two American proto- tributions was unpacking the construct of ethnicity
types: assimilation and the remnants of legalized (Phinney, 1996). In her seminal article, Phinney
discrimination (Sears, Fu, Henry, & Bui, 2003). acknowledged the growing importance of ethnicity
The assimilation prototype is based largely on in American life and wanted to more clearly under-
European immigrants, and involves a reduction of stand what ethnicity meant, so that there could be
ethnically or culturally based traits (e.g., fluency in a clearer understanding of how ethnic group mem-
language, intraethnic friendships) while exhibiting bership impacted psychological outcomes. Phinney
an increase in behaviors (e.g., interethnic marriage believed that ethnicity was psychologically impor-
and interethnic friendships) that fall in line with the tant, and she identified three aspects that contrib-
American ideology of the melting pot. The rem- uted to its psychological importance. These three
nants of legalized discrimination prototype is based aspects included ethnicity as culture, ethnicity as
primarily on the African American experience, with identity, and ethnicity as minority status. Ethnicity
people who have a unique American experience that as culture refers to the norms, values, attitudes, and
includes slavery and Jim Crow segregation before behaviors that characterize and are embraced by an
experiencing equal rights (Sears et al.). The unique- ethnic group. Ethnicity as identity refers to the
ness of the African American experience is also evi- strength of identification an individual has with her
denced by blacks being the targets of the most or his ethnic group. Ethnicity as minority status
negative racial attitudes and of having the lowest refers to the experiences of ethnic groups of color
rates of intermarriage among all ethnic groups (Sears living in a country in which they have been histori-
et al., 2000). cally marginalized, under-represented, and discrim-
inated against. She concludes by suggesting that
Ethnic Identity researchers should discontinue the practice of treat-
Ethnic identity is one of the most researched social ing ethnicity as a simple categorical variable rather
identities in the social science literature (Galkina, than as a complex, multidimensional construct.
n.d.). Although ethnic identity is a popular social Individuals who are truly interested in the psycho-
identity among social scientists, ethnicity remains logical implications of ethnicity are best served by

cokley, vandive r 305

examining one of the three dimensions that she conceptualized at the individual level, whereas
identified. In her own line of research, Phinney has acculturation is conceptualized at the group level
chosen to focus on ethnicity as identity, otherwise (Phinney, 1990). Phinney makes the case that accul-
known as ethnic identity. turation should be used as a framework for under-
The first major review of ethnic identity research standing and studying ethnic identity. Using Berry
was conducted by Phinney (1990). In that review, et al.’s (1986) acculturation framework, Phinney
Phinney characterized the ethnic identity literature (1990) stated that an individual could have a strong
as “fragmentary” and “inconclusive,” in large part or weak identification with his or her ethnic group,
because researchers from different disciplines were while also having a strong or weak identifica-
largely unaware of each other’s work, so there was tion with the majority group. Individuals who
often duplication of effort; follow-up studies were strongly identity with both the majority group and
rarely undertaken to improve instruments or elabo- their ethnic group are acculturated or bicultural.
rate on concepts; and (3) there was no generally Individuals who strongly identify with the majority
agreed upon definition of ethnic identity. One obvi- group and weakly identify with their ethnic group
ous tendency in the review was the interchangeable are assimilated. Individuals who weakly identify
usage of the terms ethnic identity and racial iden- with the majority group but strongly identify with
tity. Phinney has made the argument that ethnicity their ethnic group are separated and dissociated.
and race should be combined into a superordinate Individuals who weakly identify with both the
construct because ethnicity subsumes race (Phinney, majority group and their ethnic group are marginal-
1990, 1996). Her assumption is that ethnic identity ized. Culture conflict becomes an issue as ethnic
and racial identity are essentially the same construct. groups come into contact with each other, and this
This assumption has sparked debate and disagree- conflict influences ethnic identity formation
ment in the field by several scholars (Cokley, 2005; (Phinney, 1990).
Helms & Talleyrand, 1997; Parham, 2002).
Although not providing a general definition of Ethnic Identity and Developmental Theory
ethnic identity, Phinney (1990) identified impor- Although Phinney’s conceptualization of ethnic
tant aspects of ethnic identity that included self- identity can be considered a framework and perhaps
identification, belonging and commitment, sense a model, there remain questions about whether her
of shared attitudes and values, attitudes toward one’s formulation can truly be considered a theory.
group, and cultural aspects such as language, behav- Additionally, there remains a question of whether
ior, values, and knowledge of group history. Phinney’s conceptualization of ethnic identity
Phinney next sought to identify the major remains true to its Eriksonian influences (Umana-
conceptual frameworks used to study ethnic iden- Taylor, Yazedijian, & Bamaca-Gomez, 2004). In the
tity. She identified social identity theory, accultura- first article that includes a thorough critique of
tion and culture conflict, and identity formation Phinney’s theoretical work, Umana-Taylor et al.
as the major conceptual frameworks; however, it review Phinney’s operationalization of ethnic iden-
should also be noted that she identified approxi- tity to determine to what degree it is consistent with
mately 25% of the studies as having no theoret- Erikson’s theory of identity formation vis à vis
ical framework. Social identity theory and identity Marcia’s (1980, 1994) operationalization (i.e., four
formation (e.g., Cross’s Nigrescence model) have identity statuses of diffused, foreclosed, morato-
already been briefly reviewed, so we will turn our rium, and achieved). Umana-Taylor points out that
attention to acculturation. Phinney indicated that Erikson’s (1968) theory of identity formation
ethnic identity is only meaningful “in situations emphasizes exploration and commitment as central
in which two or more ethnic groups are in contact elements of identity formation. They further argued
over a period of time” (p. 501). This is noteworthy that Erikson’s theory does not assume that commit-
because in countries that are relatively ethnically ment to an identity was always or necessarily posi-
homogeneous, such as Greece, South Korea, and tive. Commitment simply means that identity
Japan, ethnic identity is not a particularly salient exploration has been resolved. Next, they cited
concept. Phinney further indicated that very little Marcia’s four identity statuses, which operational-
distinction has been made between ethnic iden- ized the work of Erikson. Characterizing Phinney’s
tity and acculturation. For purposes of conceptual work on ethnic identity as a three-stage model, they
clarity, ethnic identity can be thought of as one briefly reviewed Phinney’s (1989) article, which
aspect of acculturation, and is most appropriately used a qualitative methodology to code interviews

306 ethnic and racial id e n tit y

of adolescents. The results were three identifiable relatively little work being published in the JCP or
“stages”: diffusion/foreclosure, moratorium, and the TCP. The third trend is that relatively little work
achieved. The first stage, diffusion/foreclosure, char- has been done on ethnic identity and counseling
acterizes individuals who have not really critically implications (e.g., Bowen, Christensen, Powers,
thought about or explored their ethnic identity. Graves, & Anderson, 1998; McNeill et al., 2001;
Instead, they have simply internalized the dominant Yeh & Hwang, 2000).
society’s view of them, or they have never been Regarding the first trend, a logical area of
exposed to other ethnic groups. The second stage, inquiry is how the racial identity attitudes of both
moratorium, characterizes individuals who have the client and the counselor interact to impact
begun to explore their ethnic identity. The third therapy. A question that arises is whether clients
stage, achievement, characterizes individuals who whose racial identity attitudes reflect a predomi-
have resolved their feelings about their ethnic iden- nant outlook or worldview would be better
tity and what it means to them. matches for counselors who share conceptually sim-
The crux of Umana-Taylor’s critique of Phinney’s ilar racial identity attitudes. For example, would
work lies in what she sees as a discrepancy between a black client who holds predominantly pre-
Phinney’s theoretical model of ethnic identity and encounter attitudes be best matched with a white
the way she measures ethnic identity. These mea- counselor who holds predominantly contact racial
surement issues form the basis of Umana-Taylor’s identity attitudes? The question is a difficult one to
conceptualization of ethnic identity and will be answer, and does not easily lend itself to empirical
addressed later in the chapter. investigation. Along these lines, do racial identity
attitudes, especially WRI attitudes, impact the ther-
Implications for Counseling apeutic working alliance, as asserted by prominent
Ethnic and racial identity research should not multicultural scholars (e.g., Helms, 1984; Sue &
simply be conducted for the sake of conducting Sue, 1990)?
research. Theoretical debates and disagreements The first (and perhaps only) attempt to incor-
about measurement issues should be waged to ulti- porate racial identity attitudes into a typology of
mately improve counseling outcomes for all ethnic counseling relationships was offered by Helms’
and racial groups. As Cokley (2007) noted, racial black–white interactional model (1984). In that
and ethnic identity research should be evaluated, in typology, Helms describes four relationship types
part, on the development of efficacious clinical involving black and WRI development: parallel,
interventions. A review of the literature regarding progressive, regressive, and crossed. A parallel rela-
racial and ethnic identity and counseling implica- tionship is characterized by the counselor and client
tions reveals three interesting trends. First, a dispro- having similar racial identity attitudes. A progressive
portionate amount of this research has focused relationship is characterized by the counselor being
either on the racial identity attitudes of white coun- at least one stage more advanced than the client.
selors in training (e.g., Burkard, Ponterotto, A regressive relationship is characterized by the client
Reynolds, & Alfonso, 1999; Burkard, Juarez- being at least one stage more advanced than the
Huffaker, & Ajmere, 2003; Carter & Helms, 1992; counselor. A crossed relationship is characterized by
Constantine, 2002; Constantine, Warren, & the counselor and client having opposite racial iden-
Miville, 2005; Middleton et al., 2005; Ottavi, Pope- tity attitudes toward blacks and whites (i.e., whites
Davis, & Dings, 1994; Utsey & Gernat, 2002) or have more positive attitudes toward blacks and
the racial identity attitudes of black students and blacks have more positive attitudes toward whites).
clients (e.g., Carter & Helms, 1992; Ford, Harris The premise of Helms’ interactional model is that
III, & Schuerger, 1993; Franklin, 1999; Hargrow, the four different relationship types are “associated
2001; Ponterotto, Anderson, & Grieger, 1986; with different counselor cognitive and behavioral
Richardson & Helms, 1994) with very little interest strategies, client reactions, and both participants’
in other groups (e.g., Alvarez & Kimura, 2001). The experience of the sessions and affective responses”
second trend is that the majority of this research has (Carter & Helms, p. 196).
been published in counselor education journals Using participants who were workshop attend-
such as the Journal of Counseling and Development, ees, Carter and Helms (1992) tested Helms’ typol-
the Journal of Multicultural Counseling and ogy using several measures, including the Racial
Development, Counselor Education and Supervision, Identity Attitude Scale and the White Racial Iden-
and the Journal of Mental Health Counseling, with tity Attitudes Inventory. Based on the highest

cokley, vandive r 307

percentile scores, counselor–client pair types were (Constantine, 2002; Ottavi, Pope-Davis, & Dings,
assigned to one of the four relationship types, which 1994; Middleton et al., 2005). Emphasis is placed
included various racial combinations (i.e., black on self-reported because it is entirely possible, and
therapist and black client; white therapist and white in fact probable, that individuals overestimated their
client; white therapist and white client; and black degree of multicultural counseling competence.
therapist and white client). Carter and Helms Research has shown that four self-reported multi-
(1992) emphasize that racial identity attitudes, cultural competency instruments are significantly
rather than race, were used to classify relationship correlated with a measure of social desirability, and
types. The end result was 17 parallel relationships, once social desirability is controlled for none of
seven progressive relationships, nine regressive these measures was significantly related to multicul-
relationships, and no crossed relationships. Con- tural counseling case conceptualization (Constantine
ducting multiple correlation analyses between client & Ladany, 2000). Therefore, it is still not clear
reactions, therapist intentions, session evaluation, whether more “sophisticated” WRI attitudes are
and affective measures, they found evidence for truly related to higher multicultural counseling
differential significant correlations among the rela- competencies.
tionship types. In spite of the methodological limi- In perhaps the most detailed discussion of the
tations of conducting multiple, sample-dependent counseling implications of racial identity to date,
correlation analyses that increase the possibility of Franklin (1999) examined the role of racial identity
type I errors (which they acknowledged), Carter development using a single case example of an
and Helms concluded that the study provided evi- African American man. Avoiding the temptation to
dence that black and WRI attitudes can be used to simply and formulaically apply Cross’s Nigrescence
understand counseling interactions. stages to the case example, Franklin writes an intri-
In one of the few empirical tests of Helms’ inter- cate narrative about how general race awareness
actional model, Constantine, Warren, and Miville and race consciousness can be viewed as a healthy
(2005) examined 50 supervisory dyads that con- and adaptive response to racism and racialized envi-
sisted of white supervisors and white supervisees. ronments. Franklin makes the observation that
They hypothesized that supervisees in parallel- what is missing from racial identity development
high and progressive racial supervision dyads theory, relevant to clinical work, is understanding
would report greater multicultural counseling com- about the individual’s intrapsychic process when
petency and demonstrate better multicultural case race is made salient. Nevertheless, he argues that
conceptualization than would supervisees in regres- racial identity development is a protective factor
sive and parallel-low racial supervision dyads. They against racism. Encounters of racism and discrimi-
found support for three of their hypotheses (with nation, while harmful, often result in African
the exception being the regressive racial supervi- Americans engaging in a “sanity check” (Franklin,
sion dyad), and concluded that there was support 1999, p. 781) that involves discussing racist or
for Helms’ interactional model. In their discus- racialized experiences with each other to receive
sion, they point out the negative consequences of support and validation. These sanity checks, fol-
white counselors who are low in racial conscious- lowed by validation, foster personal resilience.
ness (i.e., have less sophisticated racial identity In the case example, Franklin describes his client
attitudes). These negative consequences include dis- as having attitudes that were consistent with the
missing or devaluing racial and cultural issues pre- immersion-emersion ego profile (e.g., being reactive
sented in supervision or counseling relationships, and outspoken about racial slights and discrimina-
the higher likelihood of clinical misdiagnosis tion). His client was angry because of a racialized
because of lack of awareness and understanding of incident he experienced with a white woman on
cultural issues, and developing inadequate treat- an elevator. His anger came from his awareness
ment plans that do not address important cultural and knowledge of the history of racial oppression
issues (Constantine et al., 2005). that has impacted African Americans, and knowing
Another popular area of inquiry has been to that no matter how he presented himself he will
examine the relationship of WRI with multicul- always be feared because he is a black man. His
tural counseling competencies. Several studies sanity check was discussing the incident with
have shown that more “mature” or “sophisticated” another African American man who, because of
WRI attitudes are positively associated with self- his difference in temperament and style, offered a
reported multicultural counseling competencies more forgiving perspective. Franklin deduces that

308 ethnic and racial id e n tit y

his client’s colleague exhibited a racial identity ego belong to multiple subscales or different subscales,
profile consistent with either the latter phase of the depending on the version used. Individual subscale
immersion-emersion ego profile or the internaliza- scores are computed, but no total score is given.
tion ego profile. This article was a sophisticated Higher scores on any of the subscale indicate an
application of how racial identity development endorsement of the specific racial identity attitude.
theory can be used with other culturally relevant
themes to enhance the counseling process and clini- psychometric base
cal interventions with African Americans. Limited methodological information is available
It is clear that much more work needs to be con- on the scale development of the BRAIS. Form A
ducted to better understand the clinical implica- was developed with a sample of 58 black college
tions of racial and ethnic identity. It might be students in the Midwest (Helms, 1990), and across
generally stated that clients with strong ethnic and three samples, reliability estimates ranged from
racial identities may feel dissatisfaction and frustra- .50 (encounter) to .80 (internalization; Helms &
tion with counselors who either ignore or are not Parham, 1996). A four-factor solution of Form A
comfortable with addressing racial identity issues. resulted in the creation of Form B (Helms &
Similarly, counselors who have strong ethnic and Parham, 1996), which was based on two samples of
racial identities may also feel frustration with clients black college students (Helms & Parham, 1996).
who are at low levels of racial or ethnic identity, and Exploratory factor analyses (EFA) criteria were not
deny or minimize the impact of racial/ethnic dis- reported. Additional construct validity was based
crimination in their lives. In either case, it is still not on the correlational pattern between parallel scales
well known exactly how the racial and/or ethnic of the BRIAS and Developmental Inventory of
identity of the client and counselor impacts a coun- Black Consciousness (DIBC; Milliones, 1980;
seling session. Grace, 1984). Internal consistency scores of the
BRIAS subscales, compiled from previous reviews,
Measurement Issues for Racial Identity reveal the following: .37 to .72 for Form A (Sabnani
The popularity of racial identity models has resulted & Ponterotto, 1992); .41 to .79 for Form B (Fischer
in a proliferation of racial identity measures. Pre- & Moradi, 2001; Sabnani & Ponterotto, 1992);
dictably, the increased attention to racial identity and .27 to .86 for the Long Form (Fischer &
models has resulted in closer scrutiny of racial iden- Moradi, 2001; Sabnani & Ponterotto, 1992). Score
tity instruments, in which psychometric concerns reliability of the encounter subscale on any of the
have contributed to some of the most intense schol- forms has been the most variable: .27 to .72. Factor
arly debates in this area of research. analysis of the BRIAS forms has provided support
for three of the four subscales, but not encounter
Black Racial Identity Attitudes Scales (Form A; Ponterotto & Wise, 1987; Form B; Yanico,
theoretical base and scale Swanson, & Tokar, 1994; Long Form; Stevenson,
The BRIAS (formerly RIAS-B; Parham & Helms, 1995; Tokar & Fischer, 1998). The amount of total
1981; Helms & Parham, 1996) is designed to mea- variance accounted for has been small, ranging from
sure four of the five BRI attitudes as delineated 20% (Yanico et al., 1994) to 30.5% (Ponterotto &
in the original Nigrescence model (Cross, 1971): Wise, 1987). The four-factor structure tested
pre-encounter, encounter, immersion-emersion, and through confirmatory factor analysis has not been
internalization. The first BRIAS, Form A, contains supported (e.g., goodness of fit index [GFI] = .65;
30 items and is based on the Q-sort items created by comparative fit index [CFI] = .48, standardized root
Hall, Cross, and Freedle (1972). Two subsequent mean square residual [SRMR] = .012; Tokar &
BRIAS versions were developed, another 30-item Fischer, 1998). Two studies (Tokar & Fischer, 1998;
one, Form B (factor analytically derived) and a Yanico et al., 1994) also reported a restriction
50-item Long Form to increase the internal consis- in range of scores on pre-encounter and internal-
tency estimates of the BRIAS scores (Helms & ization, with more respondents disagreeing with
Parham, 1996). the pre-encounter items and more agreeing with
Instructions for taking the measures as well as the internationalization items. Also, a social desir-
the rating range of 5 points (1 = Strongly Disagree to ability methods effect was found to structurally con-
5 = Strongly Agree) are the same for all versions. The taminate the pre-encounter construct in the Long
forms, as also observed by Fischer and Moradi form (Fischer, Tokar, & Serna, 1998). Numerous
(2001), are not equivalent, and some of the items studies have been noted in providing support or

cokley, vandive r 309

mixed support for convergent and discriminant prove fruitful in understanding better the complex-
validity of the BRIAS (Fischer & Moradi, 2001; ity and measurement of BRI in relation to critical
Fischer et al., 1998; Ponterotto, Fuertes, & Chen, counseling psychology issues.
2000; Sabnani & Ponterotto, 1992) to an array of
sociocultural variables (i.e., psychological health, Cross Racial Identity Scale
racism, self-esteem, counselor preference, and voca- theoretical base
tional variables). Findings, however, have been met The CRIS (Vandiver et al., 2000) was developed
with caution due to the psychometric concerns of over a 5-year period across six phases of scale work
the measure. and is designed to measure racial identity attitudes
For the past 20 years, ongoing psychometric only articulated in the expanded Nigrescence model
evaluations of the BRIAS have raised concerns (Cross & Vandiver, 2001). Three attitudes are not
about its viability as a measure (Cokley, 2007; included in the scale. Validity work continues on
Fischer & Moradi, 2001; Fischer et al., 1998; the immersion-emersion intense black involvement
Lemon & Waehler, 1996; Ponterotto, Fuertes, & and internalization multiculturalist racial measures.
Chen, 2000; Ponterotto & Wise, 1987; Sabnani The biculturalist attitude is not measured due to its
& Ponterotto, 1992; Stokes et al., 1998; Tokar & linkage to the multiculturalist inclusive attitude
Fischer, 1998; Yanico et al., 1994). However, Helms and the limitations in empirically delineating the
(1996, 1997, 1999, 2005, 2007; Helms, Henze, two constructs well (Cross & Vandiver, 2001;
Sass, & Mifsud, 2006) has questioned the adequacy Vandiver et al., 2001, 2002). Finally, a developmen-
of classical test theory methods in capturing the tal process is not assumed or measured in the
validity of complex and dynamic racial identity CRIS.
constructs. Cokley (2007), in response, notes that
the primary problems with the measurement of scale
racial identity lie in the rigid allegiance to an estab- The 40-item CRIS consists of six subscales, which
lished ideology about racial identity and its outcome are composed of five items each (30 scorable items):
when it is measured. pre-encounter assimilation, miseducation, and self-
hatred; immersion-emersion anti-white; and inter-
evaluation nationalization Afrocentric and multiculturalist
The BRIAS has been the most used racial identity inclusive. Ten filler items, which are not scorable,
measure over the past 25 years. At the time of its are dispersed throughout the scale “to minimize
development, the BRIAS offered an avenue for response bias and to diminish the obviousness of
social scientists to test models of racial identity and the CRIS items” (Cross & Vandiver, 2001, p. 387).
to move cultural research beyond using racial clas- Respondents are asked to rate each statement on
sification as the primary predictor of cultural and a 7-point Likert scale from 1 (strongly disagree) to 7
psychological issues. The accumulated evidence (strongly agree). Scoring and interpretations are
indicates that the BRIAS is no longer a viable instru- summarized by Cross and Vandiver (2001) and are
ment for two major reasons. One, the scales have delineated in the second edition of the CRIS manual
not substantially changed since their development, (Worrell, Vandiver, & Cross, 2004). Strict guide-
despite the evaluation of their psychometric limita- lines are provided in using the CRIS. Modifications
tions. Two, the theory to which the scale is grounded in wording, which is crucial in the design of the
is outdated. Is the original Nigrescence model viable scale, are not permitted as these invalidate scores
37 years later? In fact, the RIAS scales do not tap obtained. Also, no total CRIS score can be created,
the advances that Helms made to the Nigrescence and the six subscale scores are used together unless
model (see the review on Helms’ BRI model). construct validity work is being conducted. Thus,
As sociopolitical issues of the world have evolved, multivariate analyses are the expected statistical
blacks in America have changed as well. The viabil- procedures to use. The CRIS is designed as a multi-
ity of any incarnations of the RIAS must be based dimensional scale, which is believed to reflect the
on new iterations of the theory, as well as the scales. view that racial identity attitudes are complex and
Using the additional statistical methods that Helms cannot be reflected by one score.
(2007) has highlighted, as well as the increased use
of sound qualitative research methods as recom- psychometric base
mended by Ponterotto et al. (2001)—in essence Establishing psychometric support for the CRIS is
a multimethod approach to racial identity—might ongoing, but the initial validity findings provide

310 ethnic and racial id e n tit y

strong support for its use. For a detailed account of constructs of black attitudes, as well as different
the scale development process, readers are directed constructs (Helm, 2002). Cokley (2002) found that
to the July 2001 special issue of the Journal of negative and positive black stereotypes were corre-
Multicultural Counseling and Development (Cross & lated to CRIS attitudes. Simmons et al. (in press)
Vandiver, 2001; Vandiver & Worrell, 2001; Vandiver found support for Afrocentric, multiculturalist
et al., 2002). Cronbach’s α for the final version of inclusive and self-hatred based on the correlational
the CRIS ranged from .78 (miseducation) to .89 pattern between the African Self-Consciousness
(anti-white), subscale intercorrelations ranged from Scale (Baldwin & Bell, 1982), MIBI (Sellers,
|.01| to |.55| (anti-white and Afrocentric). Struc- Rowley, Chavous, Shelton, & Smith, 1997), and
tural validity was established through a series the CRIS. Two studies examined the construct
of exploratory factor analyses (EFA) and sup- validity between the CRIS and Multigroup Ethnic
ported through confirmatory factor analyses (CFA; Identity Measure (MEIM; Phinney, 1992) scores.
CFI = .94; root mean square error of approxima- Worrell and Gardner-Kit (2006) found two pat-
tion [RMSEA] 90% confidence interval [CI] = terns between the measures: black/racial ethnic
.043, .055). Initial convergent validity was based on identification and grounded multiculturalism, as
correlations between the CRIS subscales and the did Cokley (2005) between racial identity (CRIS),
subscales of the Multidimensional Inventory of ethnic identity, Afrocentric values, and stereotyp-
black Identity (MIBI; Sellers et al., 1998), another ing of blacks: a nonracialized ethnic identity and a
measure of BRI. Discriminant validity was based on racialized ethnic identity. Most recent work on the
no statistically significant correlation between social CRIS focuses on its application. Worrell’s (2008)
desirability, self-esteem, and the Big Five and most cross-sectional analysis of CRIS scores across three
of the CRIS subscales. However, the expected pat- age groups (adolescents, emerging adults, and
tern between the CRIS subscales and global self-es- adults) supported factorial congruence among the
teem (Rosenberg Self-Esteem; Rosenberg, 1965) six factors and reported similarities and differences
was supported: Only a meaningful relationship was in CRIS across age groups. As noted earlier, cluster
found between high self-hatred scores and low analyses of the CRIS scores (Vandiver et al., 2007;
global self-esteem scores. Worrell et al., 2006) have resulted in finding four
clusters replicated across four samples and may have
recent validity work implications in how the CRIS is scored, interpreted,
Since the initial validity work, 11 other validity and used.
studies have been conducted on the CRIS and
approximately 25 dissertations, via PsychInfo, were evaluation
found that have used the CRIS. Adequacy of Alexander and Suzuki (2001) complimented the
score reliabilities for the CRIS across nine studies CRIS for its orthogonal subscales, and the strong
have been supported, with values ranging from reliability and validity of the subscale scores, but
.70 (assimilation) to .89 (self-hatred and anti-white; were concerned that the encounter and internaliza-
Worrell &Watson; 2008), and test–retest reliabil- tion-commitment stages were not measured, thus
ities over a 6-week period have been found to range limiting the full measurement of NT-E. Recently,
from .73 (multiculturalist) to .86 (assimilation; several reviews of racial and ethnic identity
Vandiver, 2007). Four structural validity studies, measurements have evaluated the psychometric
using EFAs with different populations, have repli- strengths of the CRIS (Burkard & Ponterotto, 2008;
cated the expected six-factor solution: a middle Cokley, 2007; Ponterotto & Park-Taylor, 2007),
and high school sample (Gardner-Kit & Worrell, highlighting it as an example of best practice in scale
2007), a sample of college students (Simmons, development. Despite the kudos, continued work
Worrell, & Berry, in press), a sample of college is needed on the CRIS. Several studies have raised
students and adults (Helm, 2002), and an adult questions about the definitional clarity and validity
sample (Worrell, Vandiver, Cross, & Fhagen-Smith, of the Afrocentric (Cokley, 2002, 2005, Helm,
2004). Using CFA, Worrell and Watson (in press) 2002) and multiculturalist (Helm, 2002) subscales.
also supported the six-factor structure (CFI = .94; Does the Afrocentric subscale actually measure the
RMSEA = .037). Afrocentric construct or something else, such as
Several convergent validity studies have provided racialized stereotyping? More construct work is
mixed support for the CRIS and the expanded needed in understanding the relationship between
model. The CRIS and MIBI seem to tap similar ethnic and racial identity, given that the CRIS taps

cokley, vandive r 311

a specific racial identity and the MEIM taps a broad included 51 items that made up four ideology sub-
perspective of ethnicity. Longitudinal studies are scales, the centrality subscale, and the private regard
needed to understand the process of racial identity subscale. The public regard subscale was dropped
development (Worrell, 2008) and its connection to due to only having two items. Reliability estimates
parent–child racial socialization (Stevenson, 1998; ranged from .60 to .79. Predictive validity was
Worrell, 2008). As the makeup of blacks (the influx determined by finding that several race-related
of people from the Caribbean and Africa and behaviors (e.g., having an African American best
increased numbers of biracial and multiracial chil- friend, enrolling in Black Studies classes, interracial
dren) in America change, examining self-labeling contact) were related to the MIBI dimensions in
and racial identity is another needed area of study. theoretically predictable ways. In an attempt to
The racial makeup of blacks, as well as the racial/ conduct a more rigorous psychometric study,
ethnic makeup of the U.S. population as a whole, Cokley and Helm (2001) conducted a CFA on
may have implications in the wording of items in a 56-item version of the MIBI. Unlike Sellers et al.
the CRIS and its subsequent revalidation. (1997), Cokley and Helm conducted the CFA
on all of the items, rather than on the three dimen-
Multidimensional Inventory sions (i.e., centrality, ideology, and regard) sepa-
of Black Identity rately. Thus, the data were fit to the seven-dimensional
theoretical base and scale MMRI. The initial fit index values were poor
The MIBI (Sellers et., 1997) is a 56-item instru- (i.e., normed factor index [NFI] = .53, CFI = .68,
ment designed to measure BRI as articulated in the SRMR = .097). Modification of the model based on
MMRI (Sellers et al., 1998). The model consists several misfitting parameters only slightly improved
of seven dimensions made up of four ideologies the fit index values (i.e., NFI = .56, CFI = .71,
(i.e., nationalist, assimilationist, humanist, and SRMR = .09). Concurrent validity was demon-
oppressed minority), private regard, public regard, strated through theoretically consistent relation-
and racial centrality. Although researchers can use ships with the African Self-Consciousness Scale.
all 56 items, much of the research conducted by Reliability estimates ranged from .72 to .83.
Sellers and his colleagues has used only specific sub-
scales in accord with the research questions being evaluation
asked. This usage is consistent with social psycho- The MIBI represents a viable alternative with which
logical approaches, but stands in contrast to the use to study racial identity with African Americans.
of racial identity instruments in counseling psychol- As pointed out by Cokley (2007), it is important
ogy, in which the authors discourage the sole use to approach the study of racial identity using
of any single subscale. different models and instruments. The centrality
Instructions for completing MIBI include com- and private regard subscales are particularly useful
pleting a set of items based on a 7-point Likert scale, for researchers interested in a brief assessment of
with response options ranging from 1 (strongly dis- racial identity. However, concerns still remain
agree) to 7 (strongly agree). Higher scores on any about the construct validity of the assimilationist
of the subscales indicate an endorsement of the and nationalist subscales. As an item analysis by
specific racial identity attitude. Cokley and Helm (2001) revealed, attempts to place
items into specific racial identity dimensions by
psychometric base individuals familiar with the model produced mixed
The original psychometric study conducted by results, which at least partially explained why the
Sellers et al. (1997) reported an exploratory factor CFA results were mediocre. Issues of defini-
analysis of a 71-item instrument. Sellers et al. tional and theoretical clarity surrounding the four
attempted to find a three-factor solution to corre- ideologies remain, and a review of the literature
spond with the three stable dimensions (i.e., cen- reveals that Sellers et al. have yet to respond, either
trality, ideology, and regard) proposed by the theoretically or empirically, to the concerns raised.
MMRI, but the initial exploratory factor analysis As mentioned earlier, counseling psychologists
resulted in Kaiser-Meyer-Olkin (KMO) values have not often used the MIBI in research (except as
of less than .60. Therefore, the factor analysis support for validity in scale development), most
reported in the 1997 article was only conducted on likely because its theoretical foundation does not
the ideology subscales. Based on the results of the easily lend itself to mental health applications.
factor analysis, the “final” version of the MIBI Nevertheless, the MIBI could easily be applied to

312 ethnic and racial id e n tit y

other areas germane to counseling psychology, such numerous items (12–20) with complex loadings.
as career counseling, vocational psychology, and One cluster analysis, using Asian American adults,
academic achievement. has been conducted and supports a four-cluster
solution, reflective of the named subscales (Chen
People of Color Identity Attitude Scale et al., 2006). Several published studies and over a
theoretical base and scale dozen dissertations have used the PRIAS, providing
The PRIAS (Helms, 1995) is a 50-item scale support or partial support for the PRIAS constructs
designed to measure the racial identity attitudes and expected relationships: self-esteem (Bianchi
of Asian, black, Hispanic, and American Indians, et al., 2002; Yacoubian, 2004), ethnicity-related
as delineated in the POC racial identity model stress (Lo, 2005), racism-related stress and color-
(Helms, 1995). Four subscales make up the PRIAS: blind attitudes (Chen et al., 2006), racial socializa-
conformity (minimization of race; 11 items); disso- tion and racism (Alvarez et al., 2006), and gender
nance (confusion and beginning awareness of race; role conflict and male role norms (Liu, 2002). No
14 items); immersion-emersion (idealization of meaningful correlations were found between the
one’s racial group; 15 items); and internalization PRIAS and a social desirability measure.
(intellectualized view about race; 10 items). The
internalization subscale also contains items reflec- evaluation
tive of the fifth status, integrative awareness in the The strength of the PRIAS is that it is grounded
POC model (Lo, 2005). Items are rated on a 5-point in theory, but one of its limitations is that it is mea-
Likert scale (Strongly Disagree = 1 to Strongly Agree = 5), suring only four of the five statuses delineated in the
and four subscale scores are computed instead POC model. Integrative awareness items have been
of a total score. Higher subscale score indicates folded into the internalization subscale. More clar-
higher preference for the specific racial attitude. ity is needed in understanding what the internal-
ization subscale is measuring. Score reliability and
psychometric base validity seem to reflect reasonable estimates, but
The PRIAS evolved from an earlier racial identity some concerns exist about the structural validity.
measure called the Visible Racial/Ethnic Identity One, outdated factor retention criteria were used;
Attitude Scale (VIAS; Helms & Carter, 1985), two, the factor structures accounted for a small per-
which was formerly called the Cultural Identity cent of the total variance; and three, approximately
Attitudes Scale (CIAS; Helms & Carter, 1990). 25%–40% of the items had complex loadings on
At this time, no published summary of the scale other factors, thus blurring the dimensionality of the
development of the PRIAS and its psychometric constructs. As a result, other factor analytic studies
properties exists. Several studies have used the mea- are warranted, using diverse samples as well as same
sure and provide some information about its valid- race/ethnic samples. Although this scale has been in
ity (Alvarez, Juang, & Liang, 2006; Bianchi, Zea, existence in some iteration for almost 20 years, more
Belgrave, & Echeverry, 2002; Bryant & Baker, empirical work, and possibly revisions, on the PRIAS
2003; Chen, LePhuoc, Guzman, Rude, & Dodd, is needed to ensure that the findings obtained are
2006; Juni, Bresnan, & Vescio, 2006; Liu, 2002; reliable and valid.
Lo, 2005). Cronbach’s α have ranged from .61
(conformity) to .86 (internalization/integrative) White Racial Identity Attitudes Scale
and are based on samples of various racial/ethnic theoretical base and scale
groups, such as Asian Americans, black Brazilians, The White Racial Identity Attitudes Scale (WRIAS;
Lumbee Native Americans, and Hispanic Americans. Helms & Carter, 1990) was originally designed
Most subscale intercorrelations have ranged between to measure the five stages, now statuses, of WRI
.20 and .30, with the largest correlations usually development proposed by Helms (1984): contact,
between conformity and dissonance (e.g., .49 disintegration, reintegration, pseudo-independence,
or .53). Three exploratory factor analyses have and autonomy. Another stage (immersion-emer-
been reported on the PRIAS. Two studies (Lumbee sion) was added, resulting in a six-stage model
Indians; Bryant & Baker, 2003; mixture of racial (Helms & Carter, 1990). The WRIAS is composed
groups; Lo, 2005) reported a four-factor solution of 50 items, 10 items per subscale, and all items
that accounted for 19% and 37% of the total are rated on a 5-point Likert scale (1 = Strongly
variance, respectively; used an outdated factor Disagree to 5 = Strongly Agree). Subscale scores are
selection method (eigenvalue rule of 1); and had computed, but no total score. Higher scores on any

cokley, vandive r 313

of the subscales indicate an endorsement of the five-factor structure. What has been found is a bipo-
specific racial identity attitude. The content of the lar factor pattern reflective of the two phases of WRI
items focuses on whites’ perceptions of and inter- development: abandoning racism and becoming
actions with blacks. nonracist (Pope-Davis et al., 1999; Swanson et al.).
Confirmatory factor analyses have been problem-
psychometric base atic to conduct on the WRIAS items, resulting in
No information is available on the development inadmissible solutions for the five-factor model
and selection of items for the WRIAS, other than (Alexander, 1992; Behrens, 1997) or poor fit models
that the scale was rationally derived and that items (e.g., one-factor model CFI = .67 and .72; root
had to have “a minimum item-total subscale corre- mean square residual [RMSR] = .08 and .07;
lation with its own scale of .30” (Helms & Carter, Behrens, 1997). Expected relationships have been
1990, p. 68). The initial psychometric findings found between the WRIAS and numerous sociocul-
were based on a pilot study and two other studies tural variables (e.g., interracial comfort, multicul-
with white college students. In the pilot study, inter- tural competencies skills, and psychological health;
nal consistency reliability estimates for the WRIAS Fischer & Moradi, 2001; Ponterotto et al., 2000).
subscale scores were reported to be above .90 (Helms No serious confound has been found between social
& Carter, 1990). Score reliability estimates, how- desirability and the WRIAS (Jome, 2000; Kurtzweil,
ever, in the subsequent studies were all below 1996). A viable explanation offered for this para-
.90, with the lowest for contact (.55–.67), pseudo- doxical pattern—poor structural validity, but still
independence (.65–.71), and autonomy (.65–.67). evidence for validity—is that the WRIAS does mea-
Subscale intercorrelations ranged from |.20| to |.72|, sure an overarching construct of positive and nega-
with the highest correlation between the disintegra- tive racial attitudes (Behrens, 1997; Fischer &
tion and reintegration subscales. A principal com- Moradi, 2001; Rowe et al., 1995).
ponents analysis conducted on the WRIAS, using
a varimax rotation and the eigenvalue rule of one, evaluation
identified 11 factors. No rationale was provided The value of the WRIAS is its theoretical base and
for interpreting an 11-factor solution and its rela- the implication of its content, bringing tangible
tionship to the scale’s five subscales. Additional evi- attention to the construct of WRI beyond what any
dence for construct validity was based on the theory could do. The items do not tap white iden-
WRIAS subscales correlated with other measures tity, but rather whites’ views of being white in rela-
of personality constructs (i. e., anxiety, interper- tion to blacks (Fischer & Moradi, 2001; Hardiman,
sonal behaviors, reaction to counselor interven- 2001). Reviewers have been clear about the inade-
tions), all in the direction expected theoretically. quacy of the WRIAS and its continued use as-is
Several studies (Alexander, 1992; Behrens, 1997; (Behrens, 1997; Behrens & Rowe, 1997; Fischer &
Helms, 1999; Lemon & Waehler, 1996; Mercer & Moradi, 2001). As indicated earlier, Helms (1997,
Cunningham, 2003; Pope-Davis et al., 1999; 1999, 2007; Helms et al., 2006) and Carter (1997)
Swanson et al., 1994; Tokar & Swanson, 1991) have contend that the negative evaluations of the scale
reported score reliabilities ranging from .33 to .67 are due to existing methodological and environ-
for contact, .75 to .81 for disintegrative, .74 to .88 mental issues when studying a construct as complex
for reintegrative, .60 to .72 for pseudo-indepen- as racial identity. Other scholars (Behrens, 1997;
dence, and .53 to .71 for autonomy. In a meta-anal- Behrens & Rowe, 1997; Cokley, 2007) have noted
ysis of 22 studies, Behrens (1997) found that the that these issues do not explain totally the psycho-
average score reliabilities for the WRIAS subscales metric problems of the WRIAS. The potential of
fell within the ranges listed above. High intercorre- the theory (Behrens & Rowe, 1997, Ponterotto
lations have been found between the disintegrative et al., 2000; Swanson et al., 1994) and its measure-
and reintegrative subscales, and between the pseudo- ment have been noted, resulting in the call for fur-
independence and autonomy subscales (Behrens, ther testing and revisions (Ponterotto et al., 2000;
1997, Jome, 2000; Mercer & Cunningham, 2003; Swanson et al., 1994). The accumulated evidence
Tokar & Swanson, 1991). Exploratory factor analy- indicates the potential presence of the superordinate
ses have found either a four-factor (Mercer & phases (abandonment of racism and acceptance
Cunningham, 2003) or five-factor (Alexander, of nonracist attitude; Helms, 1995). The scale
1992; Neuger, 2002; Swanson et al., 1994) solu- with revisions could still tap a multidimensional
tion, but none was in keeping with the expected construct, evidenced in the recent iteration of the

314 ethnic and racial id e n tit y

White Racial Consciousness Development Scale- attitudes of commitment toward a racial attitude
Revised (WRCD-R; Lee et al., 2007), which is by individuals either expressing no concern
designed to measure four white racial attitudes of (avoidant), relying on others (dependent), or being
Helms’ (1984) model. Reviews of the psychometric uncertain (dissonant). Thus, scales representative
properties of the WRCDS-R are promising (Burkard of these attitudes on the ORAS are to be used as
& Ponterotto, 2008; Ponterotto & Park-Taylor, “indices of one’s expressed commitment to the
2007). four types of racial attitudes” (LaFleur et al, 2002,
p. 151). For an in-depth reading of the WRC
White Racial Consciousness model and reconceptualization, see LaFleur et al.
White racial consciousness represents a collection 2002, Leach, Behrens, and LaFleur (2002), and
of racial attitudes that white Americans have “toward Rowe et al. (1994, 1995).
racial/minority group members” (Rowe, Behrens, &
Leach, 1995, p. 225). These attitudes, acquired in evaluation
the same manner as other attitudes, are not person- “One great strength of the Rowe et al. (1994, 1995)
ality traits, but clusters of attitudes held by whites. white racial consciousness model is that it has been
Each cluster represents a describable set of related closely linked to empirical research at the outset”
attitudes called types. Individuals can have attitudes (Ponterotto, 2006, p. 101). Empirical studies were
representative of more than one type, but most used to revise the model and the scale. Another
people can be classified as holding one type of white strength of the WRC is the use of a typology model
racial consciousness. White racial consciousness and its general clarity, extending the early develop-
emerged as an alternative model in response to con- ment of type models (e.g., Gaertner, 1976; Kovel,
cerns about the conceptual underpinnings of the 1970) on white racial attitudes through theory and
WRID models, most notably Helms’ (1990, 1995) empirical work. More clarity, however, is needed in
model. the model about the relationship between the racial
A preliminary form of the Oklahoma Racial orientation attitudes (dominative/integrative, con-
Attitude Scale (ORAS-P; Choney & Behrens, 1996) flictive, and reactive) and the commitment attitudes.
was developed to tap the WRC attitude types, but Labeling the avoidant, dissonant, and dependent
validation work (Behrens et al., 1999; Pope-Davis attitudes with the term commitment seems mislead-
et al., 1995; Pope-Davis, Vandiver, & Stone, 1999; ing, as it is unclear how they operate in relation to
Summerson, 1997) on the scale resulted in the the racial orientations. The revised WRC model has
reconceptualization of the model (LaFleur et al., received some empirical support in the publication
2002) and the emergence of the standard form of of four dissertations. The reactive attitude type was
the Oklahoma Racial Attitude Scale (ORAS; found associated with higher levels of ego develop-
LaFleur et al., 2003). In the reconceptualized ment, and lower ego development was linked to the
model, three major changes were made. First, dom- avoidant attitude type (Schmidt, 2007). College
inative, integrative, conflictive, and reactive type students reported increased reactive attitudes when
attitudes were reoriented based on one of two racial taking a multicultural education class (Weathersby,
themes that had been identified through factor 2005). And integrative and reactive attitudes were
analysis. Dominative (negative view of nonwhites) associated with cultural awareness, whereas conflic-
and integrative (positive view of nonwhites) type tive attitudes were negatively associated with cul-
attitudes are now viewed as a bipolar dimension tural awareness (Fierstien, 2004). These findings are
best reflecting the theme of racial acceptance. Also promising, especially concerning their potential
sharing a common theme of racial justice are the impact on multicultural education and training, but
conflictive- and reactive-type attitudes, with those continued systematic research is needed.
having a conflictive-type attitude not wanting
whites to be at an unfair advantage versus those with Oklahoma Racial Attitude Scale
a reactive-type attitude taking a pro-racial/ethnic theoretical base and scale
minority stance. Although these two type attitudes The ORAS (LaFleur et al., 2003) is a 35-item
reflect a common theme, they are treated as separate scale designed to measure the white racial con-
constructs psychometrically. Second, labeling the sciousness construct as delineated in the revised
types of attitudes as achieved and unachieved sta- conceptualization of WRC (LaFleur et al., 2002).
tuses is no longer necessary. Third, the previously Six subscales make up the ORAS—dominative/
labeled unachieved attitudes are now considered integrative (10 items), a bipolar measure of racial

cokley, vandive r 315

acceptance, ranging from negative view of racial between dominative and integrative). In the six-
minorities to acceptance; conflictive (seven items), factor model, the largest correlation was –.68
preferential treatment for whites; reactive (seven between conflictive and dominative/integrative
items), preferential treatment for racial minorities— (LaFleur et al., 2003). Marcell (2005) examined the
and three commitment indices tap being uncon- structural validity of the ORAS and found results
cerned (avoidant [three items]), being uncertain similar to those above—the six-factor model was
(dissonant [four items]), or relying on the views of the best fitting model tested, even though the fit did
others (dependent [three items]). not meet the expected standards (CFI < .90).
Items are rated on a 5-point scale (Strongly
Disagree =1 to Strongly Agree = 5), in which the evaluation
first item is not scored, but the remaining 34 are. Fischer and Moradi’s (2001) evaluation of the
LaFleur et al. (2003) specify in the ORAS manual ORAS is fitting. The strengths of the ORAS are in
the computation and scoring of the scales. For the its grounding in theory and the reciprocal itera-
bipolar dominative/integrative scale, dominative tion of theory and scale based on empirical find-
items are reverse-scored, with lower scores repre- ings. It is still unclear what role the commitment
senting the dominative view and the higher scores scales play in the interpretation of the racial atti-
representing the integrative attitude. For the other tudes. If these scales do not play a major role in
five scales, higher scores indicate the higher prefer- understanding or interpreting the racial attitudes, it
ence for that specific attitude. might be best to drop them. Further psychometric
evidence is needed on the ORAS, as the fit indices
psychometric base are below the expected guidelines (CFI > .90). There
The 50-item ORAS-P (Choney & Behrens, 1996) are no published studies using the ORAS, but sev-
was originally designed to measure seven types of eral dissertations have used the ORAS in examining
attitudes, delineated earlier in the WRC model racial attitudes in relation to various sociocultural
(Rowe et al., 1994, 1995). High correlations existed aspects.
between the achieved scales (conflictive and reac-
tive, and dominative and integrative), but the CFA Measurement Issues for Ethnic Identity
findings supported a seven- instead of a five-factor Unlike racial identity, which has multiple compet-
model (Choney & Behrens, 1996). However, a sub- ing models and instruments, ethnic identity research
sequent study (Pope-Davis, Vandiver, & Stone, has been dominated by the use of one measure.
1999) examining both the WRIAS (Helms & However, growing theoretical and psychometric
Carter, 1990) and ORAS-P items in the same EFA concerns over the adequacy of the most used mea-
and CFA failed to support separate factors for the sure of ethnic identity has resulted in the develop-
achieved scales. Further work on the ORAS-P led to ment of another promising measure.
the reformulation of the WRC model and the cre-
ation of a standard measure called the ORAS Multigroup Ethnic Identity Measure
(LaFleur et al., 2002). The most utilized and researched measure of ethnic
Psychometric evidence for the ORAS, as delin- identity is Phinney’s MEIM (1992). The MEIM
eated in the ORAS manual (LaFleur et al., 2003), is was created as a measure of ethnic identity that
based on the findings of two studies. Cronbach’s α could be used across ethnic groups because Phinney
for the ORAS scales were all above .70, except for believed that ethnic identity was relevant to all
the avoidant scale (.60). Correlations between the groups. In reviewing the literature to identify com-
ORAS scales ranged from .00 to –.57 (dominative/ ponents of ethnic identity, Phinney identified self-
integrative and conflictive). Convergent and dis- identification, ethnic behaviors and practices,
criminant validity of the ORAS was based on affirmation and belonging, and ethnic identity
correlations among three scales on the Interper- achievement. Regarding ethnic behaviors and prac-
sonal Reactivity Index (Davis, 1980). Correlations tices, she noted that the majority of measures of
between the ORAS and a social desirability measure ethnic identity focused on ethnic behaviors and
were below .30. Structural validity of the ORAS practices, which was good for studying individual
across both studies indicated that the fit indices for ethnic groups but not ideal for studying different
the six-factor model were similar (AGFI = 86 vs. ethnic groups. Phinney also believe that attitudes
CFI = .86; RMSR = .08 vs. RMSEA = .04, .05) and toward other ethnic groups, although not formally
more viable than a seven-factor model ( r = .87 a part of ethnic identity, were important inasmuch

316 ethnic and racial id e n tit y

as they may interact with ethnic identity and thereby ethnic identity (e.g., Lee & Yoo, 2004; Umana-
influence it. In constructing the MEIM, Phinney Taylor et al., 2004).
was especially interested in whether the compo- Earlier, it was stated that Umana-Taylor’s cri-
nents of ethnic identity were part of a global factor tique of Phinney’s work lies primarily in what she
or were instead independent aspects of ethnic sees as a discrepancy between Phinney’s theoretical
identity (Phinney, 1992). Through an iterative pro- model of ethnic identity (informed by Erikson
cess of scale construction, Phinney administered and Marcia) and the way ethnic identity is opera-
a 14-item version that measured what she believed tionalized by the MEIM. In Erikson’s theory of
to be three components of ethnic identity: affirma- identity development (1968), the eight develop-
tion and sense of belonging (measured with five mental stages are each characterized by a crisis or
items), ethnic identity achievement (measured with conflict. Each crisis or conflict must be successfully
seven items), and ethnic behaviors and practices resolved before progression to the next stage of
(measured with two items). Phinney also adminis- identity can take place. Resolution of each stage
tered a six-item scale to measure attitudes toward can either be positive and satisfactory, or negative
other groups. The results of a principal axis factor and unsatisfactory. An unsatisfactory resolution of
analysis with a high school sample initially resulted the stage has negative implications for the develop-
in three factors, but because of interpretability ment of self-concept. Marcia (1980) built upon
issues, two of the factors were collapsed into one. Erikson’s work by theorizing that identity achieve-
The result was two factors, with all the items mea- ment occurs once an individual has experienced and
suring ethnic identity loading on one factor while resolved a crisis by committing to a certain role,
the remaining six items all loaded on the second value, or perspective. It is important to note that
factor. This approach is tautological because the identity achievement from the perspectives of
factor of ethnic identity is used as a part of the defi- Erikson and Marcia does not necessarily mean
nition of ethnic identity (Cokley, 2007). The prin- affirming that aspect of identity. It simply means
cipal axis factor analysis with the college sample that one has thoroughly reflected on what that iden-
initially resulted in five factors, but high intercorre- tity means. The individual may affirm it, or may
lations among the factors resulted in Phinney again choose not to affirm it. With this understanding
identifying two factors that were similar to the high of Erikson and Marcia, Umana-Taylor argues that
school sample. The results of the factor analyses the scoring and use of Phinney’s MEIM are incon-
from both samples led Phinney to conclude that sistent with identity achievement as theorized by
ethnic identity consists of a single factor, whereas Erikson and Marcia. Specifically, items from the
other-group orientation constitutes a separate fac- affirmation component (e.g., “I have a lot of pride
tor. Even though the factor analyses did not provide in my ethnic group and its accomplishments”) are
strong evidence for the three hypothesized compo- summed with items from the achievement compo-
nents of ethnic identity, Phinney nevertheless calcu- nent (e.g., “I have spent time trying to find out
lated correlations among the three components and, about my own ethnic group, such as its history, tra-
unsurprisingly, found high intercorrelations. She ditions, and customs”) and behaviors component
concluded that the intercorrelations “provide fur- (e.g., “I participate in cultural practices of my own
ther support for the results of the factor analysis in group, such as special food, music, or customs”) to
suggesting a unified construct of ethnic identity create a total score. However, use of a total score
(consisting of three interrelated components) that obscures the unique contributions of each compo-
is distinct from other-group orientation” (Phinney, nent and essentially indicates that an individual
1992, p. 167). This statement is methodologically has an achieved ethnic identity by affirming it.
ambiguous because, although it seems to indicate In short, a better and more refined understanding
that ethnic identity consists of one factor, it also of ethnic identity and its correlates and associated
gives the impression that ethnic identity can be outcomes will occur by examining the distinct com-
examined using the three hypothesized compo- ponents as opposed to combining them into one
nents. Phinney’s conclusions and subsequent use of total score (Umana-Taylor et al., 2004).
the scale have influenced the entire field of ethnic
identity, with most researchers choosing to compute Ethnic Identity Scale
a single score of ethnic identity. This usage has led to In response to these aforementioned concerns about
concern among some researchers regarding the the MEIM, Umana-Taylor et al. created the Ethnic
importance of examining the specific aspects of Identity Scale (EIS). Two studies were conducted

cokley, vandive r 317

using samples of college and high school students. understanding of ethnic and racial identity is an
The first study submitted the original 46-item integral part of the foundation of knowledge that
measure to an exploratory and confirmatory factor counseling psychologists are expected to have.
analysis, and the second study examined the psy- Changes in the U.S. population and lifestyles
chometric properties of the resultant measure. indicate that racial identity is changing, with coun-
Results from the first study yielded eight initial seling psychology being required to follow social
factors, of which a three-factor solution was ulti- trends to accurately understand Americans in the
mately retained. The result was a 22-item measure 21st century. Four trends briefly summarized here
consisting of subscales for exploration, affirmation, seem to be influencing the meaning of racial iden-
and resolution. Construct validity of the EIS was tity in the U.S. and its measurement: U.S. racial
established through the differential intercorrelations classifications, multiracial people, the hip-hop gen-
of the subscales, which was consistent with theoreti- eration, and immigration.
cal expectations. A stronger correlation existed In 2000, U.S. Census allowed respondents to
between exploration and resolution than between select one or more races to self-identify or to note
affirmation and exploration or affirmation and reso- their belonging to the category of “Some Other
lution, leading the authors to conclude that it can Race.” Race is not treated as a static category and
not be assumed that “individuals will feel positively ethnicity is no longer considered exclusive of race
about their ethnicity just because they have explored (U.S. Census, 2000). This fluid treatment of racial
their ethnicity and/or feel that they have resolved and ethnic classifications means that those who are
how they feel about their ethnicity” (Umana-Taylor from interracial unions no longer have to choose
et al., 2004, p. 23). The follow-up confirmatory one race, and that race and ethnicity may not
factor analysis indicated a poor fit of the model to be reflective of separate constructs or realities (Cross
the data. Five items were removed because of sig- & Cross, 2008). Roughly 18.5 million people
nificant residuals, resulting in a 17-item measure. identified, as part of or as their only race response,
The second study used the 17-item measure of the as “Some Other Race,” with the majority writing in
EIS that consisted of three subscales: exploration a specific Hispanic origin for the 2000 census.
(measured with seven items), resolution (measured The birth of children from interracial unions
with four items), and affirmation (measured with has increased and has been made more public.
six items). All three subscales yielded scores that A number of biracial/multiracial identity models
were adequately reliable and differentially correlated were developed in the 1990s to capture the overt
with familial ethnic socialization and self-esteem. acknowledgment of the existence of these individu-
These findings lend support to their contention that als (e.g., Kerwin & Ponterotto, 1995; Poston, 1990;
the dimensions of ethnic identity are differentially Root, 1999). Societal pressure still exists for these
associated with various outcomes. children with any minority heritage to identify
as being minority (Root, 1999). Waters (2000,
Future Research Directions p. 1736) reported that “intermarried parents filling
Racial identity research, although not the sole prov- out the census form simplify their children’s ances-
ince of counseling psychology, has experienced the tries,” where approximately 40% do not report the
most heated debates and arguably reached its most logical combination of racial backgrounds, but
sophisticated understanding through the efforts report the race of only one parent. What impact
of counseling psychologists. Ethnic identity research do these variables and related ones have on racial
has a shorter history in counseling psychology socialization and subsequent racial identity?
research, but recent trends indicate a rise in interest Hip-hop culture emerged out of the post-Civil
over the last few years. Counseling psychology, more Rights era (mid-1960s and 1970), with racial ten-
than any other area of applied psychology, has sions as the backdrop due to the continued margin-
engaged in intense scholarly studies and debates alization (e.g., segregation and the right to vote) of
over racial and ethnic identity. This is evidenced blacks despite overt signs of equality. The messages
by special issues of TCP (1989, 1994) and the behind the movement were “come as you are” and
JCP (2007) being devoted to racial and ethnic iden- “we are family” (Herc, 2005, p. xi), indicative of
tity, as well as the numerous articles published in one’s individual and collective identities. Each new
both journals that have focused on various aspects generation of youth has added to the hip-hop iden-
of racial and ethnic identity theory and measure- tity. Its positive aspects (e.g., commerce, expression
ment. It can be confidently stated that an informed of individuality, and messages about sociopolitical

318 ethnic and racial id e n tit y

realities) have been overshadowed by its negative strife in their countries (e.g., Darfur and Haiti) was
impact, with adults of previous generations sharply and is clearly evident. In contrast, Cubans have had
critical of its music form, content, fashion state- political refugee status. What implications do immi-
ment, and general lifestyle (George, 1998). Despite gration policies have on the changing nature of race
its critics, hip-hop culture has been in existence for and racial identity?
at least 30 years, and its influence is pervasive, ever- As ethnic identity research continues to increase
changing, and expanding. The focus of the early in counseling psychology, researchers must be mind-
hip-hop generation (born between 1965–1984) is ful that ethnic identity is a multidimensional rather
on social responsibility, while younger generations than a unidimensional construct. Although both
continue to reinvent hip-hop (George, 1998). Phinney and Umana-Taylor agree with this in
So, what do counseling psychologists know theory, only Umana-Taylor consistently incorpo-
of the hip-hop generation? Psychological research rates this perspective in her program of research.
on the hip-hop generation and racial identity is This is because Phinney views the multiple dimen-
needed. A brief search in PsychInfo revealed 112 sions as interrelated, whereas Umana-Taylor views
publications (84 in journals, four books, three con- them as independent dimensions. Regardless of
ference proceedings, and 17 dissertations) from the perspective taken, relatively little is still known
1990 to 2008 when the term “hip-hop” was used about how the different dimensions of ethnic iden-
as the key words. No articles on hip-hop were found tity relate to specific outcomes. Umana-Taylor et al.
in any of the mainstream psychology journals such (2004) point out that previous studies that found
as the JCP, Journal of Personality and Social Psychology, modest positive relations between ethnic identity
or Journal of Black Psychology. Most publications and self-esteem are limited because they used
on hip-hop have come from arts and humanities, as MEIM total scores rather than examine individ-
the four main aspects (rapping, Djing, graffiti art, ual MEIM subscales. They argue that this method
and dancing) said to define hip-hop culture reflect introduces error, and ultimately may weaken the
both (George, 1998). But hip-hop is more than art; relationship. It may very well be the case that
it is a dominant influence on all spheres of life in observed relationships with specific outcomes will
countries around the world (e.g., England, Japan, depend on which aspect of ethnic identity is
Germany, Chile, etc.; George, 1998). Is racial iden- assessed. Future ethnic identity research must
tity, regardless of the era, the same for all, as defined explore the specific linkages of ethnic identity with
by Cross, Helms, or Sellers? Some aspects of hip- various outcomes.
hop seem to reflect black nationalism; other aspects Furthermore, debates around the conceptual-
seem to reflect a multicultural one. With its main- ization, measurement, and operationalization of
stream popularity, what role does it play in white or ethnic identity will no doubt continue. At least one
Asian identity? prominent scholar has controversially asserted that
More research on the impact of legal and illegal there is no evidence that ethnic identity has actually
immigration on racial identity is needed. According been measured (Helms, 2007, personal communi-
to Passel (2005) of the Pew Hispanic Center, as of cation). Future research should continue to refine
March 2004, approximately 81% of undocumented the theoretical underpinnings of ethnic identity,
migrants have come from Latin American countries paying particular attention to delineating where
(57% from Mexico), with the remaining percent it both converges with and diverges from racial
of undocumented individuals in the United States identity. Special attention should be paid to a more
coming from the rest of the world (i.e., 9% from robust operationalization of the content (e.g., cul-
Asia, 6% from Europe and Canada, and 4% from tural practices and experiences) of ethnic identity.
other countries). Approximately one in six are esti- Although both the MEIM and EIS include items
mated to be minors, with most falling between the that measure cultural experiences, multiple experi-
ages of 18 and 39, and about 60% are men. These ences are combined into a single item, which
statistics are presented to highlight several reasons is never ideal by test construction standards (e.g.,
why research is needed in this area. One, less than “I participate in cultural practices of my own group,
4% of the undocumented migrants are from coun- such as special food, music, or customs” and “I have
tries in which the predominant population repre- experienced things that reflect my ethnicity, such
sents the African diaspora. For centuries, legal as eating food, listening to music, and watch-
immigration of Africans and Caribbeans to the ing movies”). Current ethnic identity measures
United States has been difficult, even when political should be revised, or new ethnic identity measures

cokley, vandive r 319

should be created, to include more individual items References
that reflect cultural practices and experiences related Alba, R. D. (1990). Ethnic identity: The transformation of
to ethnic identity (Alba, 1990). A more robust mea- White America. New Haven, CT: Yale University Press.
surement of ethnic identity will certainly advance Alvarez, A. N., Juang, L., & Liang, C. T. H. (2006). Asian
Americans and racism: When bad things happen to “model
our understanding of this construct. minorities.” Cultural Diversity and Ethnic Minority Psychology,
One of the most important areas of future 12, 477–492.
research is to advance a better understanding of Alvarez, A. N., & Kimura, E. F. (2001). Asian Americans
how ethnic identity changes over time. Being and racial identity: Dealing with racism and snowballs.
informed by the developmental models of Erikson Journal of Mental Health Counseling, 23, 192–206.
Alexander, C. M. (1992). Construct validity and reliability of
and Marcia, more longitudinal research needs to be the White Racial Identity Attitude Scale (WRIAS).
conducted that charts the fluctuations of ethnic Dissertation Abstracts International, 53(11A), 3799.
identity. Numerous questions remain about the Alexander, C. M., & Suzuki, L. A. (2001). Measurement of
development of ethnic identity. Are there psycho- multicultural constructs: Integration and research directions.
logical antecedents to an increase or decrease in In J. G. Ponterotto, J. M. Casas, L. A. Suzuki, &
C. M. Alexander (Eds.), Handbook of multicultural counseling
ethnic identity? Does a change in the political cli- (2nd ed., pp. 499–506). Thousand Oaks, CA: Sage.
mate impact ethnic identity, and if so, in what Atkinson, D. R. (Ed.). (2003). Counseling American minorities: A
ways? Does an individual’s ethnic identity change cross-cultural perspective (6th ed.). Dubuque, IA: McGraw Hill.
from childhood to adolescence to adulthood? Do Atkinson, D. R., Morten, G., & Sue, D. W. (Eds.). (1979).
major life events (e.g., birth, weddings, death) Counseling American minorities: A cross-cultural perspective.
Dubuque, IA: Wm. C. Brown.
impact ethnic identity? Are individuals who have Atkinson, D. R., Morten, G., & Sue, D. W. (Eds.). (1989).
certain experiences (e.g., higher education, interna- Counseling American minorities: A cross-cultural perspective
tional travel) more likely to explore and reflect on (3rd ed.). Dubuque, IA: Wm. C. Brown.
their ethnic identity compared to individuals who Atkinson, D. R., Morten, G., & Sue, D. W. (Eds.). (1993).
do not have these experiences? Do certain experi- Counseling American minorities: A cross-cultural perspective
(4th ed.). Dubuque, IA: Wm. C. Brown.
ences shorten or lengthen ethnic identity forma- Atkinson, D. R., Morten, G., & Sue, D. W. (Eds.). (1998).
tion? Counseling psychologists know a lot about the Counseling American minorities: A cross-cultural perspective
correlates of ethnic identity, but virtually nothing (5th ed.). Dubuque, IA: McGraw Hill.
about developmental issues of ethnic identity over Baldwin, J. A., & Bell, Y. R. (1982). The African Self-Consciousness
the course of a lifetime. Scale manual. Unpublished manuscript, Florida A &
AM University, Tallahassee, FL.
Barrett, S. E. (1990). Paths toward diversity: An intrapsychic
Conclusion perspective. Women & Therapy, 8(1–2), 41–52.
As evidenced in the brief reviews about racial clas- Bassaly, A., & Macallan, H. (2006). Willingness to use psycho-
sification, multiracial individuals, hip-hop culture, logical help among Polish immigrants in the UK. Counselling
and immigration, race and ethnicity, and by exten- Psychology Review, 21(4), 19–27.
Behrens, J. (1997). Does the White Racial Identity Attitude
sion racial and ethnic identity, will continue to have Scale measure racial identity? Journal of Counseling Psychology,
an impact on the lives of Americans. With increas- 44, 3–12.
ing advances in technology, as well as the decreasing Behrens, J. T., Leach, M. M., Franz, S., & LaFleur, N. K. (1999,
proximity between people of diverse backgrounds, August). Revising the Oklahoma Racial Attitudes Scale: Work
the heterogeneity within a racial and ethnic group is in progress. Poster session presented at the meeting of the
American Psychological Association, Boston, MA.
becoming more pronounced. Each new generation Behrens, J. T., & Rowe, W. (1997). Measuring White racial
of Americans is experiencing different aspects of identity: A reply to Helms (1997). Journal of Counseling
American and global cultures. The generational Psychology, 44, 17–19.
aspects of social identity may become more demar- Berry, J., Trimble, J., & Olmedo, E. (1986). Assessment of accul-
cated as the ability to “be global” changes what it turation. In W. Lonner, & J. Berry (Eds.), Field methods in
cross-cultural research (pp. 291–324). Newbury Park, CA:
means to have a local identity. Sage.
Ethnic and racial identity are both complex, Bianchi, F. T., Zea, M. C., Belgrave, F. Z., & Echeverry, J. J.
multidimensional constructs whose influences in (2002). Racial identity and self- esteem among Black
various areas (e.g., mental health, career develop- Brazilian men: Race matters in Brazil too! Cultural Diversity
ment, academic achievement) are just starting to be and Ethnic Minority Psychology, 8, 157–169.
Bowen, D. J., Christensen, C. L., Powers, D., Graves, D. R., &
understood. Nevertheless, there remains much to Anderson, C. A. M. (1998). Effects of counseling and ethnic
learn about the specific mechanisms through which identity on perceived risk and cancer worry in African
ethnic and racial identity influence behavior and American women. Journal of Clinical Psychology in Medical
well-being. Settings, 5, 365–379.

320 ethnic and racial id e n tit y

Brown, S. D., & Lent, R. W. (1992). Handbook of counseling Cokley, K. O. (2007). Critical issues in the measurement of
psychology (2nd ed.). Hoboken, NJ: John Wiley & Sons. ethnic and racial identity: A referendum on the state of the
Brown, S. D., & Lent, R. W. (2000). Handbook of counseling field. Journal of Counseling Psychology, 54, 224–239.
psychology (3rd ed.). Hoboken, NJ: John Wiley & Sons. Cokley, K. O., & Helm, K. (2001). Testing the construct valid-
Brown, S. D., & Lent, R. W. (2008). Handbook of counseling ity of scores on the Multidimensional Inventory of Black
psychology (4th ed.). Hoboken, NJ: John Wiley & Sons. Identity. Measurement and Evaluation in Counseling and
Bryant, A., Jr., & Baker, S. B. (2003). The feasibility of con- Development, 34, 80–95.
structing profiles of Native Americans from the People of Cokley, K. O., Komarraju, M., Patel, N., Muhammad, G.,
Color Identity Attitude Scale: A brief report. Measurement Daniels, K., & Banet, M. (1999). Where are racial identity
and Evaluation in Counseling and Development, 36, 2–8. articles most published? A content analysis of journals and
Burkard, A. W., Juarez-Huffaker, M., & Ajmere, K. (2003). authors from 1980–1999. Unpublished manuscript.
White racial identity attitudes as a predictor of client percep- Constantine, M. G. (2002). Racism attitudes, White racial
tions of cross-cultural working alliances. Journal of Multi- identity attitudes, and multicultural counseling competence
cultural Counseling and Development, 31, 226–244. in school counselor trainees. Counselor Education &
Burkard, A. W., & Ponterotto, J. G. (2008). Cultural identity, Supervision, 41, 162–174.
racial identity, and multicultural personality. In L. Suzuki, & Constantine, M. G., & Ladany, N. (2000). Self-report multicul-
J. G. Ponterotto (Eds.), Handbook of multicultural assessment: tural counseling competence scales: Their relation to social
Clinical, psychological, and educational applications (3rd ed., desirability attitudes and multicultural case conceptualiza-
pp. 52–72). San Francisco: John Wiley & Sons, Inc. tion ability. Journal of Counseling Psychology, 47, 155–164.
Burkard, A. W., Ponterotto, J. G., Reynolds, A. L., & Alfonso, V. C. Constantine, M. G., Warren, A. K., & Miville, M. (2005). White
(1999). White counselor trainees’ racial identity and working racial identity dyadic interactions in supervision: Implications
alliance perceptions. Journal of Counseling & Development, for supervisees’ multicultural counseling competence. Journal
77, 324–329. of Counseling Psychology, 52, 490–496.
Carter, R. T. (1995). The influence of race and racial identity in Cross, W. E., Jr. (1970, April). The Black experience viewed as
psychotherapy: Toward a racially inclusive model. New York: a process: A crude model for Black self-actualization. Paper
John Wiley & Sons. presented at the 34th Annual Meeting of the Association of
Carter, R. T., & Constantine, M. G. (2000). Career maturity, life Social and Behavioral Scientists, Tallahassee, Florida.
role salience, and racial/ethnic identity in Black and Asian Cross, W. E., Jr. (1971). The Negro-to-Black conversion experi-
American college students. Journal of Career Assessment, 8, ence: Toward a psychology of Black liberation. Black World,
173–187. 20, 13–27.
Carter, R. T., & Helms, J. E. (1992). The counseling process as Cross, W. E., Jr. (1978). The Cross and Thomas models of
defined by relationship types: A test of Helms’ interactional psychological nigrescence. Journal of Black Psychology, 5,
model. Journal of Multicultural Counseling and Development, 13–19.
20, 181–201. Cross, W. E., Jr. (1991). Shades of black. Philadelphia: Temple
Chang, T., Yeh, C. J., Krumboltz, J. D. (2001). Process and University Press.
outcome evaluation of an on-line support for Asian American Cross, W. E., Jr., & Cross, T. B. (2008). The big picture: Theorizing
male college students. Journal of Counseling Psychology, 48, self-concept structure and construal. In P. B. Pedersen,
319–329. J. G. Draguns, W. J. Lonner, & J. E. Trimble (Eds.),
Chen, G. A., Lephuoc, P., Guzman, M. R., Rude, S., & Counseling across cultures (6th ed., pp. 73–88). Thousand
Dodd, B. G. (2006). Exploring Asian American racial iden- Oaks, CA: Sage.
tity. Cultural Diversity and Ethnic Minority Psychology, 12, Cross, W. E., Jr., & Vandiver, B. J. (2001). Nigrescence
461–476. theory and measurement: Introducing the Cross Racial
Choney, S. K., & Behrens, J. T. (1996). Development of the Identity Scale (CRIS). In J. G. Ponterotto, J. M. Casas,
Oklahoma Racial Attitudes Scale: Preliminary form L. A. Suzuki, & C. M. Alexander (Eds.), Handbook of multi-
(ORAS-P). In G. R. Sodowsky, & J. Impara (Eds.), cultural counseling (2nd ed., pp. 371–393). Thousand Oaks,
Multicultural assessment in counseling and clinical psychology CA: Sage.
(pp. 225–240). Lincoln, NE: Buros Institute of Mental D’Andrea, M., & Daniels, J. (1996). Promoting peace in our
Measurements. schools: Developmental, preventive, and multicultural con-
Clark, K. B., & Clark, M. P. (1939). The development of siderations. School Counselor, 44(1), 55–64.
consciousness of self and the emergence of racial identifica- Davis, M. H. (1980). A multidimensional approach to individ-
tion in Negro pre-school children. Journal of Social Psychology, ual differences in empathy. JASA Catalog of Selected Documents
10, 591–599. in Psychology, 10, 85.
Cokley, K. (1999). Reconceptualizing the impact of college racial DeJesus-Rueff, R. (1986). An exploratory study of ego identity
composition on African American students’ racial identity. status and ethnic identity among mainland Puerto Rican
Journal of College Student Development, 40, 235–246. female adolescents. Dissertation Abstracts International,
Cokley, K. O. (2002). Testing Cross’s revised racial identity 47(1-A), 124–125.
model: An examination of the relationship between racial Erikson, E. H. (1968). Identity: Youth and crisis. New York:
identity and internalized racialism. Journal of Counseling Norton.
Psychology, 49, 476–483. Fernandez, R. M. (1989). An empirical test of the minority
Cokley, K. O. (2005). Racial(ized) identity, ethnic identity, and identity development model with Cuban-Americans.
Afrocentric values: Conceptual and methodological chal- Dissertation Abstracts International, 49(9-B), 4035.
lenges in understanding African American identity. Journal of Fierstien, J. R. (2004). An exploration of relationships between
Counseling Psychology, 52, 517–526. cultural awareness, White racial consciousness, and referrals

cokley, vandive r 321

 to child study teams. Dissertation Abstracts International: Helms, J. E. (1984). Toward a theoretical explanation of the
Section B: The Sciences and Engineering, 64(9-B), 4676. effects of race on counseling: A Black and White model. The
Fischer, A. R., & Moradi, B. (2001). Racial and ethnic Counseling Psychologist, 12, 153–165.
identity: Recent developments and needed directions. Helms, J. E. (1990). Black and White racial identity: Theory,
In J. G. Ponterotto, J. M. Casas, L. A. Suzuki, & research, and practice. New York: Greenwood Press.
C. M. Alexander (Eds.), Handbook of multicultural counseling Helms, J. E. (1990). The measurement of Black racial identity
(2nd ed., pp. 341–370). Thousand Oaks, CA: Sage. attitudes. In J. E. Helms (Ed.), Black and White racial iden-
Fischer, A. R., Tokar, D. M., & Serna, G. S. (1998). Validity tity: Theory, research and practice (pp. 34–47). New York:
and construct contamination of the Racial Identity Greenwood.
Attitude Scale—Long form. Journal of Counseling Psychology, Helms, J. E. (1994). Racial identity and assessment. Journal of
45, 212–224. Career Assessment, 2, 199–209.
Ford, D. Y., Harris, D., III, & Schuerger, J. M. (1993). Racial Helms, J. E. (1995a). An update of Helms’ White and People
identity development among gifted Black students: of Color Racial Identity models. In J. G. Ponterotto,
Counseling issues and concerns. Journal of Counseling & J. M. Casas, L. A. Suzuki, & C. M. Alexander (Eds.),
Development, 71, 409–417. Handbook of multicultural counseling (pp. 181–198).
Franklin, A. J. (1999). Invisibility syndrome and racial identity Thousand Oaks, CA: Sage.
development in psychotherapy and counseling African Helms, J. E. (1995b). The People of Color (POC) Racial Identity
American men. The Counseling Psychologist, 27, 761–793. Attitude Scale. Unpublished manuscript. University of
Gaertner, S. L. (1976). Nonreactive measures in racial attitude Maryland, College Park, MD.
research: A focus on liberals. In P. A. Katz (Ed.), Towards the Helms, J. E. (1996). Toward a methodology for measuring
elimination of racism. New York: Pergamon. and assessing “racial” as distinguished from “ethnic” identity.
Galkina, H. (n.d.). Theoretical approaches to ethnic identity. In G. R. Sodowsky, & J. Impara (Eds.), Multicultural assess-
Retrieved June 30, 2008, from http://sincronia.cucsh.udg. ment in counseling and clinical psychology (pp. 143–192).
mx/galkina.html. Lincoln, NE: Buros Institute of Mental Measurements.
Gardner-Kitt, D. L., & Worrell, F. C. (2007). Measuring nigres- Helms, J. E. (1997). Implications of Behrens (1997) for the
cence attitudes in school-aged adolescents. Journal of validity of the White Racial Identity Attitude Scale. Journal
Adolescence, 30, 187–202. of Counseling Psychology, 44, 13–16.
George, N. (1998). Hip hop America. New York: Viking. Helms, J. E. (1999). Another meta-analysis of the White Racial
Grace, C. A. (1984). The relationship between racial identity Identity Attitude Scale’s Cronbach alphas: Implications for
attitudes and choice of typical and atypical occupations validity. Measurement & Evaluation in Counseling &
among Black college students. Dissertation Abstracts Development, 32, 122–137.
International, 45(2-B), 722. Helms, J. E. (2005). Challenging some misuses of reliability
Hall, W. S., & Cross, W. E., Jr. (1970). The formation of an as reflected in evaluations of the White Racial Identity
ego identity in black Americans: Toward a conceptualization Scale (WRIAS). In R. T. Carter (Ed.), Handbook of racial-
of stages in coming to terms with self. Paper presented at the cultural psychology and counseling: Theory and research Vol. 1
Annual Meeting of the National Association of Black (pp. 360–390). New York: John Wiley & Sons.
Psychologists, Miami Beach, Florida. Helms, J. E. (2007). Some better practices for measuring racial
Hall, W. S., Cross, W. E., & Freedle, R. (1972). Stages in and ethnic identity constructs. Journal of Counseling
the development of Black awareness: An empirical investiga- Psychology, 54, 235–246.
tion. In R. L. Jones (Ed.), Black psychology (pp. 156–165). Helms, J. E., & Carter, R. T. (1986). Manual for the Visible
New York: Harper & Row. Racial/Ethnic Identity Attitude Scale. University of Maryland,
Hardiman, R. (1982). White identity development: A process College Park, MD: Authors.
oriented model for describing the racial consciousness of Helms, J. E., & Carter, R. T. (1990). A preliminary overview
White Americans. Dissertation Abstracts International, of the Cultural Identity Attitude Scale. Unpublished
43(1-A), 104. manuscript.
Hardiman, R. (1994). White racial identity development in Helms, J. E., & Carter, R. T. (1990). Development of the
the United States. In E. P. Salett, & D. R. Koslow (Eds.), White Racial Identity Inventory. In J. E. Helms (Ed.), Black
Race, ethnicity, and self: Identity in multicultural perspective and White racial identity: Theory, research, and practice
(pp. 117–140). Washington, DC: National Multicultural (pp. 67–80). Westport, CT: Greenwood.
Institute. Helms, J. E., Henze, K. T., Sass, T. L., & Mifsud, V. A. (2006).
Hardiman, R. (2001). Reflections on White identity develop- Treating Cronbach’s alpha reliability coefficients as data
ment theory. In C. L. Wijeyesinghe, & B. W. Jackson (Eds.), in counseling research. The Counseling Psychologist, 34,
New perspectives on racial identity development: A theoretical 630–660.
and practical anthology (pp. 108–128). New York: New York Helms, J. E., & Parham, T. A. (1996). The development of
University Press. the Racial Identity Attitude Scale. In R. L. Jones (Ed.),
Hardiman, R., & Jackson, B. W. (1992). Racial identity develop- Handbook of tests and measurements for Black populations
ment: Understanding racial dynamics in college classrooms Vol. 2 (pp. 167–174). Hampton, VA: Cobb & Henry.
and on campus. In M. Adams (Ed.), Promoting diversity in Helms, J. E., & Talleyrand, R. M. (1997). Race is not ethnicity.
college classrooms: Innovative responses for the curriculum, fac- American Psychologist, 52, 1246–1247.
ulty, and institutions (pp. 21–37). San Francisco: Jossey-Bass. Helm, K. M. (2002). A theoretical and psychometric analysis
Hargrow, A. M. (2001). Racial identity development: The case of of the revised Black racial identity development model and
Mr. X., an African American. Journal of Mental Health the multidimensional model of racial identity: Outcomes on
Counseling, 23, 222–237. the Revised African American Acculturation Scale-33.

322 ethnic and racial id e n tit y

 Dissertation Abstracts International: Section B: The Sciences Liu, W. M. (2002). Exploring the lives of Asian American
and Engineering, 62(10-B), 4833. men: Racial identity, male role norms, gender conflict, and
Herc, D. J. K. (2005). Introduction. In J. Chang (Ed.), Can’t stop prejudicial attitudes. Psychology of Men & Masculinity, 3,
won’t stop: A history of the hip hop generation (pp. xi–xiii). 107–118.
New York: St. Martin’s Press. Lo, H. W. (2005). Construct validity of the People of Color
Horowitz, R. (1939). Racial aspects of self-identification in Racial Identity Attitude Scale. Dissertation Abstracts
nursery school children. Journal of Psychology, 7, 91–99. International Section A: Humanities and Social Sciences, 65(9-
Jackson, B. W. (1976). Black identity development. A), 3289.
In L. H. Golubchick, & B. Persky (Eds.), Urban, social, and Lott-Harrison, S. L. (1999). Racial and cultural identity
educational issues (pp. 158–164). Dubuque, IA: Kendall/ development of African-American and Puerto Rican indi-
Hunt. viduals: Same process, different content? Dissertation Abstracts
Jones, R. L. (Ed.). (1998). African American identity development. International, 59(10-B), 5600.
Hampton, VA: Cobb & Henry Publishers. Loya, M. (2007). Racial attitudes and cultural awareness in
Jome, L. M. (2000). Construct validity of the White Racial white social workers: A cross-sectional, correlational study.
Identity Attitude Dissertation Abstracts International: Section Dissertation Abstracts International Section A, 68, Retrieved
B: The Sciences and Engineering, 61(2-B), 1133. from EBSCOhost.
Juni, S., Bresnan, M. W., & Vescio, C. F. (2006). Reliability Marcia, J. E. (1980). Identity in adolescence. In J. Adelson (Ed.),
of a modified People of Color Identity Attitude Scale and Handbook of adolescent psychology (pp. 159–187). New York:
a White Racial Identity Attitude Scale for a sample of mas- Wiley.
ter’s counseling students. Psychological Reports, 98, 809–818. Marcia, J. E. (1994). The empirical study of ego identity.
Kardiner, A., & Ovesey, L. (1951). The mark of oppression. In H. A. Bosma, T. G. Graafsma, H. D. Grotevant, & D. J.
New York: Norton. de Levita (Eds.), Identity and development: An interdisciplin-
Kerwin, C., & Ponterotto, J. G. (1995). Biracial identity ary approach (4th ed., pp. 281–321). Belmont, CA:
development: Theory and research. In J. G. Ponterotto, Wadsworth.
J. M. Casas, L. A. Suzuki, & C. M. Alexander (Eds.), McNeill, B. W., Prieto, L. R., Niemann, Y. F., Pizarro, M.,
Handbook of multicultural counseling (pp. 199–217). Vera, E. M., & Gomez, S. P. (2001). Current directions in
Thousand Oaks, CA: Sage. Chicana/o psychology. The Counseling Psychologist, 29, 5–17.
Kohatsu, E. L., & Richardson, T. Q. (1996). Racial and ethnic Mercer, S. H., & Cunningham, M. (2003). Racial identity
identity. In L. A. Suzuki, P. J. Meller, & J. G. Ponterotto in White American college students: Issues of conceptu-
(Eds.), Handbook of multicultural assessment: Clinical, psycho- alization and measurement. Journal of College Student
logical, and educational applications (pp. 611–650). Development, 44, 217–230.
San Francisco: Jossey-Bass. Middleton, R. A., Stadler, H. A., Simpson, C., Guo, Y.,
Kovel, J. (1970). White racism: A psychohistory. New York: Brown, M. J., Crow, G., et al. (2005). Mental health
Pantheon Books. practitioners: The relationship between White racial iden-
Kurtzweil, P. L. (1996). The influence of life experience and tity attitudes and self-reported multicultural counseling
social desirability on the development and measurement of competencies. Journal of Counseling & Development, 83,
White racial identity attitudes. Dissertation Abstracts 444–456.
International: Section B: The Sciences and Engineering, Milliones, J. (1980). Construction of a black consciousness
56(10-B), 5836. measure: Psychotherapeutic implications. Psychotherapy:
LaFleur, N. K., Leach, M. M., & Rowe, W. (2003). Manual: Theory, Research, and Practice, 17, 175–182.
Oklahoma Racial Attitudes Scale. Unpublished manuscript. Miville, M. L., & Helms, J. E. (1996). Exploring relationships
LaFleur, N. K., Rowe, W., & Leach, M. M. (2002). of cultural, gender, and ego identity among Latinos/as. Poster
Reconceptualizing White racial consciousness. Journal of presentation at the annual meeting of the American
Multicultural Counseling and Development, 30, 148–152. Psychological Association, Toronto, Canada.
Leach, M. M., Behrens, J. T., & LaFleur, N. K. (2002). White Morten, G., & Atkinson, D. R. (1983). Minority identity
racial identity and white racial consciousness: Similarities, development and preference for counselor race. Journal of
differences, and recommendations. Journal of Multicultural Negro Education, 52(2), 156–161.
Counseling and Development, 30, 66–80. Neuger, D. A. (2002). Underlying dimensions of White racial
Lee, R. M. (2003). Do ethnic identity and other-group orienta- attitudes. Dissertation Abstracts International: Section B: The
tion protect against discrimination for Asian Americans? Sciences and Engineering, 63(3-B), 1610.
Journal of Counseling Psychology, 50, 133–141. Office of Management and Budget. (1995). Standards for the
Lee, S. M., Puig, A., Pasquarella-Daley, L., Denny, G., Rai, A. A., classification of federal data on race and ethnicity. Retrieved
Dallape, A., & Parker, W. M. (2007). Revising the White March 29, 2006, from http://www.whitehouse.gov/omb/
Racial Consciousness Development Scale. Measurement and fedreg/race-ethnicity/html.
Evaluation in Counseling and Development, 39, 194–208. Ottavi, T. M., Pope-Davis, D. B., & Dings, J. G. (1994).
Lemon, R. L., & Waehler, C. A. (1996). A test of stability and Relationship between White racial identity attitudes and
construct validity of the Black Racial Identity Scale, Form B self-reported multicultural counseling competencies. Journal
(RIAS_B) and the White Racial Identity Attitude Scale of Counseling Psychology, 41, 149–154.
(WRIAS). Measurement and Evaluation in Counseling and Pak, J. H. (2005). Narrative analysis of Korean American
Development, 29, 77–85. women’s acculturation and changing self. Dissertation
Lim, B. A. (2002). The role of experience and integrative com- Abstracts International, 66(6-B), 3421.
plexity in ethnic identity Development. Dissertation Abstracts Parham, T. A. (1989). Cycles of psychological nigrescence.
International, 62(11-B), 5430. The Counseling Psychologist, 17, 187–226.

cokley, vandive r 323

Parham, T. A. (Ed.). (2002). Counseling persons of African descent: at the meeting of the American Psychological Association,
Raising the bar of practitioner competence. Thousand Oaks, New York.
CA: Sage. Pope-Davis, D. B., Vandiver, B. J., & Stone, G. L. (1999). White
Parham, T. A., & Helms, J. E. (1981). The influence of Black racial identity attitude development: A psychometric exami-
students’ racial identity attitudes on preference for counsel- nation of two instruments. Journal of Counseling Psychology,
or’s race. Journal of Counseling Psychology, 28, 250–258. 46(1), 70–79.
Passel, J. S. (2005). Estimates of the size and characteristics of Poston, W. S. C. (1990). The biracial identity development
the undocumented population. Washington, DC: Pew Hispanic model: A needed addition. Journal of Counseling and
Center. Retrieved April 20, 2008, from http://pewhispanic. Development, 69, 152–155.
org/reports/archive/Report. Richardson, T. Q., & Helms, J. E. (1994). The relationship
Phinney, J. S. (1989). Stages of ethnic identity development in of the racial identity attitudes of Black men to perceptions
minority group adolescents. Journal of Early Adolescence, 9, of “parallel” counseling dyads. Journal of Counseling &
34–49. Development, 73, 172–177.
Phinney, J. S. (1990). Ethnic identity in adolescents and adults: Root, M. P. P. (1999). The biracial baby boom: Understand-
Review of research. Psychological Bulletin, 108, 499–514. ing ecological constructions of racial identity in the
Phinney, J. S. (1992). The Multigroup Ethnic Identity 21st century. In R. H. Sheets, & E. R. Hollins (Eds.), Racial
Measure: A new scale for use with diverse groups. Journal and ethnic identity in school practices: Aspects of human devel-
of Adolescent Research, 7, 156–176. opment (pp. 67–89). Mahwah, NJ: Lawrence Erlbaum.
Pizarro, M., & Vera, E. M. (2001). Chicana/o ethnic identity Rosenberg, M. (1965). Society and the adolescent self-image.
research: Lessons for researchers and counselors. Counseling Princeton, NJ: Princeton University Press.
Psychologist, 29, 91–117. Rowe, W., Behrens, J. T., & Leach, M. M. (1995). Racial/ethnic
Ponpipom, A. (1997). Asian-American ethnic identity develop- identity and racial consciousness: Looking back and looking
ment: Contributing factors, assessment, and implications forward. In J. G. Ponterotto, J. M. Casas, L. A. Suzuki, &
for psychotherapy. Dissertations Abstracts International, C. M. Alexander (Eds.), Handbook of multicultural counseling
58(1-B), 0425. (pp. 218–235). Thousand Oaks, CA: Sage.
Ponterotto, J. G. (1986). A content analysis of the Journal Rowe, W., Bennett, S. K., & Atkinson, D. R. (1994). White
of Multicultural Counseling and Development. Journal of racial identity models: A critique and alternative proposal.
Multicultural Counseling and Development, 14, 98–107. The Counseling Psychologist, 22, 129–146.
Ponterotto, J. G. (1988). Cross-cultural research in the Journal Sabnani, H. B., & Ponterotto, J. G. (1992). Racial/ethnic
of Counseling Psychology: A content analysis and methodological minority-specific instrumentation in counseling research:
critique. Unpublished manuscript. A review, critique, and recommendations. Measurement and
Ponterotto, J. G. (1989). Expanding directions for racial identity Evaluation in Counseling and Development, 24, 161–187.
research. The Counseling Psychologist, 17, 264–272. Sabnani, H. B., Ponterotto, J. G., & Borodovsky, L G. (1991).
Ponterotto, J. G. (1998). Charting a course for research in White racial identity development and cross-cultural coun-
multicultural counseling training. The Counseling Psychologist, selor training: A stage model. The Counseling Psychologist,
26, 43–68. 19, 76–102.
Ponterotto, J. G., Anderson, W. H., & Grieger, I. Z. (1986). Schmidt, C. (2007). Racial/ethnic identity formation and ego
Black students’ attitudes toward counseling as a function development. Dissertation Abstracts International Section A:
of racial identity. Journal of Non-White Concerns in Personnel Humanities and Social Sciences, 68(1-A), 96.
& Guidance, 14, 50–59. Sears, D. O., Fu, M., Henry, P. J., & Bui, K. (2003). The
Ponterotto, J. G., Casas, J. M., Suzuki, L., & Alexander, C. M. origins and persistence of ethnic identity among the
(2001). Handbook of Multicultural Counseling. Thousand Oaks, “New Immigrant” groups. Social Psychology Quarterly, 66,
CA: Sage. 419–437.
Ponterotto, J. G., Fuertes, J. N., & Chen, E. C. (2000). Sellers, R. M., Rowley, S. A. J., Chavous, T. M., Shelton, J. N.,
Models of multicultural counseling. In S. D. Brown, & R. & Smith, M. A. (1997). Multidimensional Inventory
W. Lent (Eds.), Handbook of counseling psychology (3rd ed., of Black Identity: A preliminary investigation of reliability
pp. 639–669). New York: John Wiley & Sons. and construct validity. Journal of Personality and Social
Ponterotto, J. G., & Park-Taylor, J. (2007). Racial and ethnic Psychology, 73, 805–815.
identity theory, measurement, and research in counseling Sellers, R. M., Smith, M. A., Shelton, J. N., Rowley, S. A., &
psychology: Present status and future directions. Journal of Chavous, T. M. (1998). Multidimensional model of racial
Counseling Psychology, 54, 282–294. identity: A reconceptualization of African-American racial
Ponterotto, J. G., & Sabnani, H. B. (1989). “Classics” in multicul- identity. Personality and Social Psychology Review, 2, 18–39.
tural counseling: A systematic five-year content analysis. Journal Simmons, C., Worrell, F. C., & Berry, J. M. (in press).
of Multicultural Counseling and Development, 17, 23–37. Psychometric properties of scores on three Black racial
Ponterotto, J. G., Utsey, S. O., & Pedersen, P. B. (2006). identity scales. Assessment.
Preventing prejudice: A guide for counselors, educators, and Stevenson, H. C., Jr. (1995). Relationship of adolescent
parents (2nd ed.). Thousand Oaks, CA: Sage. perceptions of racial socialization to racial identity. Journal of
Ponterotto, J. G., & Wise, S. L. (1987). Construct validity Black Psychology, 21, 49–70.
study of the Racial Identity Attitude Scale. Journal of Stevenson, H. C., Jr. (1998). The confluence of “both-and”
Counseling Psychology, 34, 218–223. in Black racial identity theory: Response to Stokes, Murray,
Pope-Davis, D. B., Dings, J. G., Stone, G. L., & Vandiver, B. Chavez and Peacock. In R. L. Jones (Ed.), African American
(1995, August). White racial identity attitude development: identity development (pp. 151–157). Hampton, VA: Cobb &
A comparison of two instruments. Poster session presented Henry Publishers.

324 ethnic and racial id e n tit y

Stokes, J. E., Murray, C. B., Chavez, D., & Peacock, M. J. (1998). Vandiver, B. J. (2007, August). Examining the reliability of the CRIS
Cross’ stage model revisited: An analysis of theoretical scores. Poster session presented at the annual conference of the
formulations and empirical evidence. In R. L. Jones (Ed.), American Psychological Association, San Francisco, CA.
African American identity development (pp. 121–140). Vandiver, B. J., Cross, W. E., Jr., Fhagen-Smith, P. E., Worrell, F. C.,
Hampton, VA: Cobb & Henry Publishers. Swim, J. K., &. Caldwell, L. D. (2000). The Cross Racial
Stryker, S., & Serpe, R. T. (1982). Commitment, identity Identity Scale. State College, PA: Author.
salience and role behavior. In W. Ickes, & E. Knowles Vandiver, B. J., Cross, W. E., Jr., Worrell, F. C., &
(Eds.), Personality, roles, and social behavior (pp. 199–218). Fhagen-Smith, P. E. (2002). Validating the Cross Racial Iden-
New York: Springer-Verlag. tity Scale (CRIS). Journal of Counseling Psychology, 49, 71–85.
Stryker, S., & Serpe, R. T. (1994). Identity salience and Vandiver, B. J., Fhagen-Smith, P. E., Cokley, K. O.,
psychological centrality: Equivalent, overlapping, or comple- Cross, W. E., Jr., & Worrell, F. C. (2001). Cross’ nigrescence
mentary concepts? Social Psychology Quarterly, 57, 16–35. model: From theory to scale to theory. Journal of Multicul-
Sue, D. W. (1989). Racial/cultural identity development among tural Counseling and Development, 29, 174–200.
Asian-Americans: Counseling/therapy implications. AAPA Vandiver, B. J., Korell, S. C., & Miller, A. R. (2007). CRIS cluster
Journal, 13(1), 80–86. project. State College, PA: Author.
Sue, D. W., & Sue, D. (1990). Counseling the culturally different: Vandiver, B. J., & Worrell, F. C. (Eds.). (2001). Psychological
Theory and practice (2nd ed.). New York: Wiley & Sons. nigrescence revisited: Theory and research [special issue].
Sue, D. W., & Sue, D. (2008). Counseling the culturally diverse: Journal of Multicultural Counseling and Development, 29,
Theory and practice (5th ed.). New York: Wiley & Sons. 165–213.
Summerson, M. T. (1997). White racial consciousness and Waters, M. C. (2000). Immigration, intermarriage, and the
preference for counselor ethnicity in White undergraduate challenges of measuring racial/ethnic identities. American
students. Dissertation Abstracts International: Section B: Journal of Public Health, 90, 1735–1737.
The Sciences and Engineering, 57(11-B), 7238. Weathersby, A. (2005). The effects of multicultural education
Swanson, J. L., Tokar, D. M., & Davis, L. E. (1994). Content on white racial consciousness. Dissertation Abstracts Interna-
and construct validity of the White Racial Identity Attitude tional: Section B: The Sciences and Engineering, 65(9 B), 4901.
Scale. Journal of Vocational Behavior, 44, 198–217. Worrell, F. C. (2008). Nigrescence attitudes in adolescence,
Tajfel, H. (Ed.). (1978). Differentiation between social groups: emerging adulthood, and adulthood. Journal of Black
Studies in the social psychology of intergroup relations. London: Psychology, 34, 156–178.
Academic Press. Worrell, F. C., Cross, W. E., Jr., & Vandiver, B. J. (2001).
Tajfel, H., & Turner, J. C. (1979). An integrative theory of Nigrescence theory: Current status and challenges for the
intergroup conflict. In W. G. Austin, & S. Worchel (Eds.), future. Journal of Multicultural Counseling and Development,
The social psychology of intergroup relations (pp. 94–109). 29, 201–209.
Monterey, CA: Brooks-Cole. Worrell, F. C., & Gardner-Kitt, D. L. (2006). The relationship
Thomas, C. W. (1969). Boys no more: Some social psychological between racial and ethnic identity in Black adolescents: The
aspects of the new Black ethic. The American Behavioral Cross Racial Identity Scale (CRIS) and the Multigroup
Scientist, 12, 38–42. Ethnic Identity Measure (MEIM). Identity: An International
Thomas, C. W. (1971). Boys no more. Beverly Hills, CA: Glencoe Journal of Theory and Research, 6, 293–315.
Press. Worrell, F. C., Vandiver, B. J., & Cross, W. E. (2004). The Cross
Thomas, R. E. (1985). Counseling diverse adults through transi- Racial Identity Scale: Technical manual (2nd. ed.). Berkeley,
tions. Journal of Employment Counseling, 22(3), 124–127. CA: Author.
Thompson, C. E., & Carter, R. T. (1997). An overview Worrell, F. C., Vandiver, B. J., Cross, W. E., Jr., & Fhagen-Smith, P.
and elaboration of Helms’ racial identity development theory. (2004). Reliability and structural validity of the Cross Racial
In C. E. Thompson, & R. T. Carter (Eds.), Racial identity Identity Scale scores in a sample of African American adults.
theory: Applications to individual, group, and organizational Journal of Black Psychology, 30, 489–505.
interventions (pp. 15–32). Mahwah, NJ: Lawrence Erlbaum Worrell, F. C., Vandiver, B. J., Schaefer, B. A., Cross, W. E., &
Associates, Inc. Fhagen-Smith, P. E. (2006). Generalizing nigrescence pro-
Tokar, D. M., & Fischer, A. R. (1998). Psychometric analysis of files: Cluster analyses of Cross Racial Identity Scale (CRIS)
the Racial Identity Attitude Scale—Long form. Measurement scores in three independent samples. The Counseling
and Evaluation in Counseling and Development, 31, 138–149. Psychologist, 34, 519–547.
Tokar, D. M., & Swanson, J. L. (1991). An investigation of the Worrell, F. C., & Watson, S. (2008). A confirmatory factor
validity of Helms’ (1984) model of White racial identity. analysis of Cross Racial Identity Scale (CRIS) scores: Testing
Journal of Counseling Psychology, 38, 296–301. the expanded nigrescence model. Educational and Psycho-
U. S. Census Bureau. (2001). The census 2000 brief overview logical Measurement, 68, 1041–1058.
of race and Hispanic origin. Retrieved June 15, 2008, from Yacoubian, V. V. (2004). Assessment of racial identity and self-
http://www.census.gov/prod/2001pubs/c2kbr01–1.pdf. esteem in an Armenian American population. Dissertation
Umana-Taylor, A. J., Yazedijian, A., & Bamaca-Gomez, M. Abstracts International: Section B: The Sciences and Engineering,
(2004). Developing the Ethnic Identity Scale using social 64(12-B), 6382.
identity perspectives. Identity: An International Journal of Yanico, B. J., Swanson, J. L., & Tokar, D. M. (1994). A psycho-
Theory and Research, 4, 9–38. metric investigation of the Black Racial Identity Attitude
Utsey, S. O., & Gernat, C. A. (2002). White racial identity atti- Scale—Form B. Journal of Vocational Behavior, 44, 218–234.
tudes and the ego defense mechanisms used by White coun- Yeh, C. J., & Hwang, M. Y. (2000). Interdependence in ethnic
selor trainees in racially provocative counseling situations. identity and self: Implications for theory and practice. Journal
Journal of Counseling & Development, 80, 475–483. of Counseling & Development, 78, 420–429.

cokley, vandive r 325

 CHAPTER

Developing a Social Class and Classism

12 Consciousness

William Ming Liu

Abstract
Current methods in psychology to study and understand social class are problematic because using
objective indicators of income, education, and occupation may not capture the meaningfulness of social
class in a person’s life. I argue for psychologists to shift to a subjective approach to social class and
classism. I revise the social class worldview model-revised (SCWM-R) (Liu, 2001, 2002; Liu & Ali, 2008)
and elaborate on a complementary framework embedded within the SCWM-R titled the social class
and classism consciousness model (SCCC). The SCCC explores the ways in which individuals come
to see themselves as socially classed persons. The SCCC has ten levels of social class consciousness
ranging from being unconscious about social class to being self-conscious to being social class
conscious. I present clinical and research implications and suggests future directions for research
concerning social class and classism in psychology.
Keywords: social class, classism, consciousness, worldview

The social class worldview model (SCWM) (Liu, experiences with social class and SES (Brown,
2001, 2006; Liu & Ali, 2008; Liu, Ali, et al., 2004; Fukunaga, Umemoto, & Wicker, 1996; Fouad &
Liu, Soleck, Hopps, Dunston, & Pickett, 2004) was Brown, 2001; Frable, 1997). The SCWM was a
created as a subjective and phenomenological framework in which psychologists could integrate an
approach to understanding an individual’s experi- individual’s contexts, experiences, and worldview, to
ences of and perspectives about social class and clas- help psychologists explore and understand social class
sism. Significant research suggested the utility of and classism (American Psychological Association
a subjective understanding of social class and socio- [APA], 2007; Liu, 2001; Liu & Ali, 2008).
economic status (SES) (Adler, Boyce, Chesney, The SCWM is a wholly subjectively based
Folman, & Syme, 1993; Cohen et al., 2008; approach to understanding and exploring social
Ostrove, Adler, Kuppermann, & Washington, 2000; class and classism, but one implicit assumption of
Sapolsky, 2005) that moved beyond using only the SCWM is that individuals understood and
sociodemographic indicators of income, education, could discuss social class in their lives. That is, the
and occupation as descriptors of social class and SCWM assumed that individuals already were con-
SES. It was important for psychologists to move scious and aware of themselves as a socially classed
beyond these sociological indices of social class and person and were able to discuss the meaning and
SES because, although these indicators provided importance of social class in their lives. Invariably,
some help in categorizing individuals into discreet however, social class awareness varies since exposure
groupings (e.g., middle-class), these sociodemo- to and familiarity with social class issues are not
graphic indices tended to be unhelpful in providing consistent across individuals. Thus, it was necessary
clarity or a deeper understanding of an individual’s to develop a framework to explore the ways in which

326
social class awareness and consciousness develop. to the client? How are clinicians to make sense of
The purpose of this chapter is to develop a central these sociodemographic descriptions? The likely prob-
construct in the SCWM that focuses on how indi- lem of using social class in clinical practice becomes
viduals think of themselves as socially classed per- more difficult as clinicians conceptualize a client’s
sons. That is, I will explore how people develop a sociodemographic characteristics or attempt to dis-
social class and classism consciousness. To do so, cuss “social class” with the client. This sociodemo-
this chapter will first present problems in our cur- graphic approach would likely limit the discussion to
rent understanding and use of the terms social class issues of income, education, or occupation, but may
and socioeconomic status. Second, I operationalize not provide clinicians with a “roadmap” to explore
two key constructs: class and status, and differenti- other issues such as classism, inequality, affluence,
ates between social class and SES. Third, I present a power, or privilege (Liu, Pickett, & Ivey, 2007).
model for developing a social class and classism con- Moreover, by unlinking measurement from
sciousness (SCCC). Finally, I discuss clinical and theory, categories such as middle- or upper-class lose
training implications and presents suggestions for their qualitative saliency. That is, by making the
future research directions for social class issues and focus on creating different social class or SES stria-
this model. tions within an economic hierarchy, the meaning-
ful concerns of power, privilege, access to resources,
The Problem with Current Uses of Social and inequality are lost in favor of a focus on accurate
Class and Socioeconomic Status in objective indices. Wright (2002) argues that tra-
Psychologists’ problems with understanding social ditional social class critiques from Max Weber and
class, classism, and SES stem from poor operation- Karl Marx were focused on qualitative groups such
alization of terms and variables and generally an as “capitalists and workers, debtors and creditors”
atheoretical use of social class and SES in research (p. 839) rather than on names such as “upper, upper-
(Brown et al., 1996; Duncan & Magnuson, 2003; middle, middle, lower-middle” classes (p. 839).
Ensminger & Fothergill, 2003; Liberatos, Link, & Although somewhat antiquated in terms and con-
Kelsey, 1988; Liu & Ali, 2008; Oakes & Rossi, structs, Wright’s critique is valid in that, rather than
2003). Liu (2001, 2006; Liu & Ali, 2008; Liu, Ali, explicating the power and privilege for those in the
et al. 2004) suggests that the importing of socio- upper classes, the current discussion in psychology
logical devices and frameworks to understand social may mostly be nominal and revolve around demo-
class and SES at the individual level has been prob- graphic characteristics, such as income or educa-
lematic for research and practice. Although income, tional level. Consequently, upper class becomes just
education, and occupation are frequently used as another group with inferred privileges versus a group
individual indicators and as a means to aggregate with explicit privileges and experiences. In effect,
people into social class groups (e.g., lower-class), no current uses of social class or SES have been dimin-
evidence suggests that these indicators affect any ished with regard to their political meaning. A cor-
particular social class group (Brown et al., 1996). ollary would be to study race and discuss racism, but
Attempts to make meaning of these different then limiting the discussion to describing racism as
groupings only created greater confusion. One typi- events without the emotional valence associated
cal strategy was to use income, education, and occu- with each event, thereby potentially neutralizing its
pation and create a series of pseudo social class interpersonal meaning.
groupings (Liu & Ali, 2008). This approach only Contributing to these problems is terms such as
produced an unlimited number and type of social social class and SES can simultaneously be meaning-
class striations (e.g., lower-working class, middle- less levels of measurement, and be meaningful levels
working class, working-class). But because these of measurement for different groups. Moreover,
groupings were unlinked to any particular theory or different indices may have different meanings for
rationale, these social class striations were idiosyn- individuals depending on their context, time
cratic to each researcher and practically meaningless of life, and demands and expectations. For instance,
between researchers. a social class and SES economic hierarchy implies
A similar problem arose when clinicians dis- a continuum of low (usually the impoverished) and
cussed the social class of individuals. What does it high (usually those possessing the most wealth). The
mean for a clinician to describe a client as “middle- assumption is that an economic hierarchy exists as
class?” What is the clinician drawing upon to a ratio level of measurement (with an absolute zero).
make this description, and what is being attributed Many of the current economic hierarchies have

liu 327
some baseline with zero or “poor” at the bottom, next higher or lower income group. Thus, in mea-
usually dictated by the amount of one’s income. suring a person’s income, it may be necessary to have
The belief by some researchers may be that, with individuals indicate their income, but to also demar-
appropriate measures and methods, one may be able cate the boundaries of their income group. This may
to perfectly assess objective indices and create give researchers a sense of the income level of a par-
a baseline with equal steps throughout the hierarchy ticular group of participants, and it may give clini-
(Pollack et al., 2007). But, in a modern economy, cians an indication of what individuals consider
there are several problems with these assumptions. their normative group. But meaningfulness of one’s
First, for some individuals, there certainly is an income may also be different. The meaningfulness
absolute zero (no income, no equity, no opportuni- of increasing income may also represent a type of
ties, or limited access to additional resources). For dose-response curve (in which a dose equals amount
these individuals, the felt loss of a single dollar is of income and the curve is related to specific out-
perceived much more severely than for those in come measures). That is, income may be differen-
a higher social class group (Tyszka & Przybyszewski, tially meaningful depending on the individual and
2006). And, there are real and meaningful educa- for what the income is used (i.e., leisure, material
tional, health, occupational, and life consequences objects, savings, debt).
attributed to being poor (Hopps & Liu, 2006). But Furthermore, because income, education, and
for others, “zero” is a relative term depending on the occupation are independently meaningful and lin-
indicator or measure. For example, one could have ked to different social class outcome variables (e.g.,
no income but live on an inheritance or on interest health, happiness, satisfaction) (Duncan, 1988),
from investments; one could have negative equity and because of the notorious problem of inaccu-
but still have wealth elsewhere; and opportunities rate reporting of data such as personal income
and access to additional resources are likely related or the emotional reactivity associated with reporting
to the quality and extensiveness of social networks income (Croizet & Claire, 1998), researchers have
(Lin, 1999), which may vary by individual. Thus, generally been more focused on how to accurately
a single measure with the assumed “zero baseline” measure social class rather than on determin-
may not accurately assess persons across the social ing what each variable means to the individual.
class and SES continuum. Additionally, for indi- Attempts have been made to shift from discrete
viduals for whom income is only one factor in their single variables to aggregate constructs, such as
overall self-assessment of wealth, the amount of wealth or affluence. Yet, even in these larger con-
their actual cash-on-hand is minor compared to structs, aggregating these variables still rests primar-
other indices and assets that reflect their position ily on the accurate reports of income, assets, and
and status. other wealth estimates by individuals (Pollack et al.,
Second, “distance” is relative. Clearly objective 2007), or the number and type of possessions (e.g.,
indicators may show discrete distances between “Does your family own a car, van, or truck?” [Family
income level and education, for instance. Increments Affluence Scale]) (Currie, Elton, Todd, & Platt,
of $10,000 in a demographic form suggest that 1997).
income distance is absolute and not relative. But But if individuals were to accurately report all
research suggests that these differences vary in mean- of their demographic data, what would that mean
ing (Pingle & Mitchell, 2002; Solnick & Hemenway, to our understanding of a person’s social class or
1998). People typically compare themselves on SES (Offer, 2006)? Liu and his colleagues made
income within their peer group and not necessarily a necessary critique of existing paradigms around
across income groups. Thus, individuals making the measurement and use of social class and SES in
$45,000–$55,000 may recognize how discrete dif- psychology, but the extent of these critiques was
ferences in levels of income translate to minor inc- insufficient. Psychologists do have problems in mea-
reases in their monthly paycheck. These individuals suring income, educational level, and occupation,
may recognize someone making several million dol- but these variables—much like any other demo-
lars, but the perceived “steps” to that level are less graphic variable, such as race or gender—have no
likely to be seen in $10,000 increments than as inherent value or meaning besides what the indi-
someone making “several million dollars.” That is, vidual or researcher ascribes to them. Thus, it is nec-
people may compare themselves with peers around essary to capture the individual meaning related to
them within a given context, but there may be each indicator rather than to seek accuracy or verisi-
income “cutoffs” between the individual and the militude. If we examine income for instance, it is

328 social cl ass an d cl as s is m co n s cio u sne ss

most meaningful to the individual as “relative Since no research has examined how different social
income” in comparison to others in his or her peer class groups value the hierarchy of occupations, it is
group (Pingle & Mitchell, 2002; Solnick & uncertain why one occupational prestige index
Hemenway, 1998). Therefore, understanding a would be used in all situations and populations.
$100,000 income may depend on the individual’s
taxes, neighborhood, the material objects his or socio- or idio-class?
her peers possess, and the size of the home, for The use of income or educational level has been con-
instance (Fletcher, 2001; The Wall Street Journal, founded and has led several researchers to explore
2001). A similar problem may exist for educa- the potential for a subjective approach to under-
tional level. Although degrees and ranks are stable standing an individual’s perspective on social class
among institutions, the meaning of degrees and and SES. One popular method used in various stud-
educational level will vary. For example, an indi- ies of SES and health revolves around using a
vidual’s doctorate from an accredited online col- “ladder.” Research participants are presented with
lege is likely to be very different from a doctorate a ten-rung ladder and given instructions to:
from Harvard University. The individuals in these
Think of this ladder as presenting where people
two examples are likely to recognize and imbue their
stand in the United States. At the top of the ladder
degrees with different levels of prestige and will
are the people who are the best off. . . . At the
employ this educational prestige differently dep-
bottom are the people who are the worst off. . . . The
ending on the context. For instance, the individual
higher up you are on the ladder, the closer you are to
with the online degree may, with people who may
the people at the very top and the lower you are, the
not be familiar with doctoral education, promote
closer you are to the people at the very bottom. . . .
the degree, but among those with Ivy League educa-
(Ostrove et al., 2000, p. 614)
tions, the online degree may not be promoted. Fur-
ther potentially moderating these attributions to Findings generally show that people, even in
academic level may be the age at which the indi- dire economic circumstances such as homelessness,
vidual receives the degree (i.e., younger age with are likely to have better self-rated health and poten-
advanced degrees may indicate higher intelligence), tially more favorable outcomes if they consider
if the individual is a first-generation student, and themselves higher on the ladder than do those
possibly the person’s race and gender—none of who rate themselves lower on the ladder (Adler,
which is considered in a question about educa- Epel, Castellazzo, & Ickovics, 2000). These findings
tional level. do not refute the social class and health gradient,
Finally, for occupations, prestige is usually the wherein better objective health is related to one’s
implied value when categorizing certain jobs as higher position (Adler et al., 1993; Singh &
lower-, middle-, or upper-class. A prestige index Siahpush, 2006) or contradict research findings on
assumes that every individual possesses the same or the causal relationship between poverty and poorer
similar perspective on all jobs and their relative mental and physical health (Costello, Compton,
value. However, occupational prestige may also Keeler, & Angold, 2003; Gallo, Bogart, Vranceanu,
vary between contexts and geographic region (Ali & Matthews, 2005; Gallo & Matthews, 1999,
& McWhirter, 2006; Blustein, 2006) such that, 2003; Gallo, Smith, & Cox, 2006; Geronimus,
in some situations, a traditional intergenerational Bound, Waidmann, Hillemeier, & Burns, 1996).
occupation (i.e., coal mining) may possibly be just Instead, the “ladder” research suggests that individ-
as prestigious as a college professorship. Similarly, to uals will vary in making meaning of objective cir-
ascribe prestige on a given occupation is to assume cumstances, and that within-group variation exists
that an individual would have full knowledge of even among those in abject situations.
any specific occupation along the prestige hierarchy. Since people vary in their interpretation of eco-
Yet, it may be fair to speculate that there may be nomic situations and their social class standing, this
some high-status and high-prestige occupations is not to suggest that “socio” should become idio-
that are not esteemed by persons unfamiliar with class or idioeconomic status. The study and explora-
those jobs. This unfamiliarity problem may also tion of social class and classism cannot be divorced
become worse as middle- and upper-class occupa- from the individual’s context and the interrelation-
tions proliferate in specizations within disciplines, ships that support and challenge a particular social
while lower- and working-class occupations remain class worldview. Yet, since the original nominal term
relatively stable in titles and job responsibilities. socioeconomic was used by Lester Ward in 1883 to

liu 329
link the social and economic spheres of people’s lives operationalize these as psychological constructs,
(Jones & McMillan, 2001), psychologists have such as identity, acculturation, dissonance, world-
concocted various synonyms to understand the view, and roles, to name a few.
individual-level social class experience and perspec- Regardless of the theory and psychological
tive. In one study, Liu, Ali et al. (2004) reviewed dimension, focusing on the individual-level experi-
three counseling journals for use of social class in ence does not negate or diminish the larger socio-
research. Liu, Ali et al. found approximately political (e.g., the unequal distribution of power),
448 words linked to the constructs of social class, sociohistorical (e.g., biased and inaccurate histories
classism, and SES. These terms varied from single of peoples), and sociostructural (e.g., legal, educa-
variables, such as educational level, to aggregates, tion, and economic systems) forces that marginalize
such as “school-lunch” or “welfare” participants. and oppress peoples (Liu & Ali, 2005). Liu and
The common theme in most studies was to use these Pope-Davis (2003a, 2003b) believe that a subjective
variables as demographic or categorical variables approach also allows psychologists to explore the
(socio) rather than asking the participants about complex networks of power that potentially rein-
their perception of being in “school-lunch” or “wel- force and perpetuate economic inequality. Rather
fare” programs (idio). than addressing only binary approaches to economic
As psychologists, the general focus is on the indi- disadvantage (Smith, 2005, 2006; Smith, Foley, &
vidual experiences and understanding, rather than Chaney, 2008), which creates procrustean groups
on the macro level. With social class or SES, the dif- of powerful and powerless, Liu and Pope-Davis
ferent levels of society (e.g., mesosystem, macrosys- (2003a) suggest that it would be advantageous for
tem) (Bronfenbrenner, 1986) may be used to inform psychologists to understand the ways in which
the individual’s current experiences (Liu & Ali, people negotiate power and privilege, and the ways
2008). Liu and Ali show that understanding how in which power and inequality are produced and
issues such as unemployment, materialism, policies recreated (Liu et al., 2007).
on poverty, and community violence, for instance,
are directly related to issues such as the individual’s class and status
self-esteem, stress level, coping styles, and intimate Heretofore, I have discussed social class and SES
relationships, to name a few. Moreover, the “socio” as similar constructs. In part, this reflects the gen-
issues related to an individual’s social class perspec- eral atheoretical problems related to operation-
tives and experiences implicate the ways in which alizing both social class and SES (Liberatos et al.,
society constructs meaning, imbues value, and mar- 1988; Oakes & Rossi, 2003). But social class and
ginalizes people and materials. Thus, it is still mean- SES could represent different but related aspects
ingful to focus on “social” class and “socio” economic of understanding a person’s experiences with his
status rather than on an idiographic approach. or her economic spheres of life. In a similar way,
Weberian and Marxian notions differ, in that
A Subjective Approach to Social Weberian analysis focuses on life chances and
Class and Classism Marxian analysis focuses on exploitation (Wright,
A subjective approach to social class and SES repre- 2002). Liu, Ali et al. (2004) already provided a
sents a shift from current paradigms of understand- nonexhaustive discussion of the potential differ-
ing these two constructs. Liu and his colleagues (Liu ences between social class and SES. In their descrip-
& Ali, 2008; Liu, Ali et al., 2004) felt that psychol- tion, individuals discussed within the framework
ogists needed to transform social class and SES into of social class are part of an economic hierarchy
meaningful psychological variables, constructs, and with in- and out-groups; with the out-groups
theories. For instance, psychologists interested in (e.g., people in lower social positions) being the tar-
racial or cultural issues within a specific population gets of derision and marginalization. Liu, Ali et al.
focus their research on theory-based constructs, suggest that a critical function within the social
such as racial identity and acculturation. Psychlo- class framework is “group awareness” (p. 8) and class
gists do not study specifically race or immigra- consciousness. Being aware of one’s belonging
tion. Instead, psychologists address racial identity within a particular social class group (Wright, 2002)
or acculturation, and in effect, the individual’s and the need to protect and reinforce the group, is
experiences with racism, migration, and cultural the root of classism. Therefore, a “class” is an eco-
adaptation are measured and explored. Similarly nomic group within which an individual belongs,
with social class and SES, psychologists should and the individual perceives material (i.e., types of

330 social cl ass an d cl as s is m co n s cio u sne ss

belongings, neighborhood) and nonmaterial (i.e., effects related to classism (Croizet & Claire, 1998;
educational level) boundaries. The individual may Croizet, Desert, Dutrevis, & Leyens, 2001; De
observe other “classes” that are perceived to be, in a Vogli, Ferrie, Chandola, Kivimaki, & Marmot,
subjective hierarchy, higher, lower, and at the same 2007; Miller, 2001; Vohs, Mead, & Goode, 2006).
place (i.e., lateral) as the individual’s own class. The SCWM is an individual’s “worldview” about
Social class mobility is possible, but only through social class, or the beliefs, attitudes, and values an
the comprehension of the other class’s norms, values, individual uses to interpret her economic situations
and culture; that is, each class is perceived to have its and conditions. These beliefs, attitudes, and values
own culture, and the further away the social class stem from the person’s socialization experiences
group is from the current position, the more dis- with family, friends, and peers, as well as the larger
sonant or unfamiliar the culture is to the individ- economic culture, and the worldview helps the indi-
ual. Consequently, classism is an employed behavior vidual make sense of the expectations and demands
and attitude, and an expected consequence as the of these groups (Liu, Ali et al., 2004). This world-
individual attempts to navigate within and between view also interprets experiences of classism and
classes. shapes the ways in which individuals use classism to
With SES, Liu, Ali et al. (2004) suggest that the maintain their perceived social class position.
individual’s place within an economic hierarchy is
temporary and mobile. The difference between The Social Class Worldview Model – Revised
social class and SES may be that individuals in an The original SCWM (Liu, 2001, 2002) was devel-
SES framework are not expected to share any group oped as a theoretical framework that shifts the
consciousness. Rather, the individual is an indepen- psychological discourse around social class away
dent actor in a dynamically fluid economic environ- from the stratification and sociological paradigms
ment. Status, as the name implies, focuses on the that have permeated much of the theoretical and
current perceived economic place of the individual. empirical literature. The SCWM provides a theo-
Perceived inequality in access to resources, for ins- retical model, a heuristic that integrates both social
tance, may be congruent within this approach. class and classism and allows psychologists a means
Inequality may be a consequence of classism, but by which to explore the subjective social class expe-
one cannot employ “unequalness.” In both frame- riences of individuals. Worldview is used as the psy-
works, social class and SES, income, educational chological construct from which social class is
level, occupational prestige, power, and access to understood by the individual. The SCWM is meant
resources may be perceived to have different func- as a way to model, frame, and understand social
tions. Within the social class framework, these vari- class behaviors, attitudes, and cognitions and is
ables may be aspects that the individual possesses comprised of multiple components; consequently,
and uses to maintain her social class position and there is no one measure that adequately assesses the
the boundaries of the group. Within a SES frame- entire model. The SCWM (Liu, 2001, 2002; Liu &
work, these same variables may be perceived as facets Arguello, 2006; Liu & Ali, 2008) is comprised
for social mobility. But these are not exhaustive cat- of three components that are theoretically linked in
egorizations of social class and SES. Instead, this is a feedback system to help the individual maintain
an attempt to operationalize variables that are often homeostasis or a positive sense of self within his
conflated with each other or used synonymously. or her social class. The first assumption of the
I use the term social class and classism hereafter SCWM is that people are motivated to maintain a
since the constructs are inherently linked, and the sense of normality within their perceived social class
hypothesis that individuals perceive different “clas- group. Individuals’ motivations are to perceive and
ses” is an important assumption for the SCWM. act on the world in ways similar to those of their
Additionally, the nominal term classism is widely peers and cohort, and if successful, they achieve a
accepted to represent marginalizing behaviors and sense of homeostasis. Disequilibrium occurs when
attitudes based on perceived economic variations new demands and expectations are exacted on the
(Lott, 2002; Smith et al., 2008). Social class and individual, and the person must configure behav-
classism are conceptualized as interdependent con- iors, resources, and attitudes to reestablish his or her
structs similar to race and racism. Research on and homeostasis. For instance, disequilibrium may occur
around issues of classism, economic marginalization, when new materialistic demands are placed on a
and economically motivated negative interpersonal person, such as a new car or a larger home. If the indi-
behavior and attitudes generally suggests negative vidual believes these new materialistic expectations

liu 331
are a part of being normal in his social class an individual may live in an EC in which social net-
group, then he will act in ways to obtain these work capital is highly valued, and one way that the
new objects. A second assumption of the SCWM is individual believes (and is reinforced) these interper-
that people live within different economic cultures sonal relationships are developed is through material
(ECs), neighborhoods, or communities within possessions. Thus, for this person, others are valued
which the individual seeks social class position and for “what they have,” the self is valued for what is
status. For instance, ECs vary, such that no one uni- possessed, and a motivational factor is the accumula-
tary “middle-class” group exists, but rather many tion of belongings as a way to maintain one’s social
“middle-class” groups or ECs. There are not neces- class position.
sarily any real geographic or material boundaries The final component is classism. In the SCWM,
demarcating these ECs, but certainly for some indi- classism is both interpreted and used by the indi-
viduals, an EC may be a certain neighborhood or vidual to maintain one’s social class. Classism, there-
community with familial roots, economic markers fore, is both employed by the individual to gain
(e.g., gated communities), or particular setting (e.g., resources and is similarly experienced by the indi-
school or work). vidual when interacting with people from perceived
These different ECs vary with regard to expecta- different social class groups. For example, if it were
tions and demands on a person. In one EC, physical important in an EC to maintain social capital
attributes may be highly valued, and individuals in and social networks through the exclusion of indi-
that EC may feel pressure to develop and maintain viduals believed to be from “upper-class” groups,
physical attributes and features. Athletes, for ins- then the labeling of those perceived to be “elitist”
tance, may find themselves in ECs in which physi- would be a form of upward classism. These forms
cality is valued above other resources, and physical of classism are in some ways independent of the
prowess is a type of capital (resource) employed to objective social class position of the individual, such
maintain one’s social class position. Another exam- that one could be from an upper social class group
ple may be professors, for whom intellectual abili- (defined by extreme wealth, high education, and
ties are favored and social capital (one’s social prestigious occupation), but still characterize some-
network) is equally important to nurture. Thus, an one similarly as “elitist” or a “snob.” Upward clas-
EC is important because it shapes the expectations sism is one of four types of classism in the SCWM.
and demands an individual experiences with regard The four types of classism are: downward (against
to accumulating and using certain kinds of capital those perceived to be in a lower social class), upward
or resources. Within the SCWM, there are three (against those perceived to be in a higher group, such
types of capital to accumulate: cultural capital (aes- that others in that group are labeled snobs or elit-
thetics important in the EC), social capital (impor- ists), lateral (against those perceived to be in a similar
tant relationships), and human capital (important group and may be experienced as pressure to keep
physical or intellectual skills). up with the Joneses because the Joneses keep remind-
The second component is the worldview, or the ing you), and internalized (against the self for not
lens through which the individual attempts to being able to maintain one’s social class position).
understand these different capital demands and Although downward classism has been largely
how these resources are to be used. The individual’s recognized as a dominant form of oppression and a
worldview is comprised of socialization messages principal factor related to inequality (Smith, 2005,
from parents and peers. Another group that pro- 2006, 2008; Smith et al., 2008), Liu and Ali (2008)
vides socialization messages is the group to which and Liu and Pope-Davis (2003a) have argued that
the individual aspires (e.g., upper-class groups). classism, much like other forms of oppression and
Other components of the worldview are an indi- marginalization, has to be conceptualized as a net-
vidual’s materialistic attitudes, perceived social class– work of power relationships and that this oppressive
congruent behaviors (e.g., etiquette, accent), and web is nurtured by any and all forms of classism.
lifestyle considerations, such as the way a person And, although the effects of downward classism and
spends his or her time (e.g., leisure, work, vacations). inequality are pernicious, upward and lateral clas-
These aspects of the worldview are not all equally sisms help to reinforce and feed the interpersonal
salient but vary depending on the EC. Depending prejudices and biases that solidify discrimination
on the individual’s EC, one of these dimensions will against those who are poor.
be prominent and be the likely way through which Internalized classism is but one form of pro-
the world is experienced and perceived. For instance, posed classism. Internalized classism is not just the

332 social cl ass an d cl as s is m co n s cio u sne ss

introjections of negative stereotypes about being inadequacy, anxiety) as the individual recognizes
poor. Instead, internalized classism, as part of the that he or she is deficient. At issue, and most impor-
SCWM, is conceptualized as the feelings of anxiety, tantly, is whether the individual possesses the capac-
depression, or inadequacy resulting from one’s ity to meet these new demands. If the opportunity
inability to maintain one’s social status. Internalized and capacity exists, then the individual may obtain
classism is not classism to be used against others, as the possession and maintain homeostasis. If the
is lateral or downward classism. This redefinition individual is unable, then the person is in a state of
of internalized classism represents a slight revision disequilibrium and must find some means to rein-
to the SCWM and posits that internalized classism state equilibrium (e.g., purchasing the material
is always activated as a result of experiences with object on credit) or potentially shift the EC within
upward, downward, or lateral classism, and not which these demands originate.
simply activated when the individual is unable to Internalized classism helps psychologists poten-
meet the expectations of his or her EC. More spe- tially understand the relationships between the indi-
cifically, internalized classism is an intrapsychic clas- vidual experiencing internalized classism and his or
sism experience that is triggered when new social her relationships and mental health. For instance, as
class demands and expectations are placed on the Liu (2002) speculated in his discussion of social
individual or when resources are inadequate to meet class and men, internalized classism may be a factor
one’s current social class standing (see Figure 12.1). related to the despair, depression, and anxiety men
For instance, Liu posits that internalized classism is experience when they lose their job. It is not only
regularly triggered when new products (e.g., cars, the loss of the “breadwinner” status (Kimmel,
computers) are introduced and meant to appeal to 1996); the job loss also means the man is unable to
the individual’s EC. As people within the EC pur- maintain his social class position. Liu also speculates
chase the product, lateral classism may be exerted that internalized classism is possibly one aspect
and experienced by the individual (i.e., keeping up related to adjustment disorders for first-generation
with others in one’s cohort). The effect of lateral college students. As these men and women enter
classism is to remind individuals what is necessary college and universities and begin interacting with
to maintain one’s social class position. Internalized students across the social class spectrum, they may
classism is always enacted internally (i.e., feelings of begin to experience internalized classism related to

HOMEOSTASIS

C MAT UP
SM
YES
EC S BEH LAT INTCLS
NO
SCCC
LSTYL DOWN
H

DISEQUILIBRIUM

Note. EC = Economic Culture; C = Cultural Capital; S = Social Capital; H = Human Capital; SM = Socialization
Messages; SCCC = Social Class and Classism Consciousness; MAT = Material Possessions; BEH = Social
Class Behaviors; LSTYL = Social Class Lifestyle; UP = Upward Classism; LAT = Lateral Classism;
DOWN = Downward Classism; and INTCLS = Internalized Classism.

Fig. 12.1 The Social Class Worldview Model – Revised EC, economic culture; C, cultural capital; S, social capital; H, human
capital; SM, socialization messages; SCCC, social class and classism consciousness; MAT, material possessions; BEH, social class
behaviors; LSTYL, social class lifestyle; UP, upward classism; LAT, lateral classism; DOWN, downward classism; and INTCLS,
internalized classism.

liu 333
Table 12.1. Social Class Interventions Using the Social Class Worldview Model
The social class interventions are targeted toward the client’s experiences of classism. Upward, downward, lateral,
and internalized classisms are the focus of the therapist. Through collaboration, the client is helped to gain
insight about his or her experiences of classism, worldview, and the pressures he or she experience as a part
of an economic culture.
The client is helped to identify situations in which certain feelings are tied to classism experiences.
Empathy by the therapist toward the client’s classism experiences is important.
The therapist challenges the client’s irrational cognitions about his or her social status and what he or she needs
to do to maintain or achieve a social status.
The therapist helps the client integrate his or her history with his or her current situation.
The client is encouraged to develop self-efficacy in coping and managing his or her situation.
Step 1—Help the Client identify and Understand his or her Economic Culture
Sample query: Tell me what kind of pressure you feel/experience as you try to keep up with your friends.
Identify answers that touch on cultural, social, and human capital pressures/expectations.
Step 2—Help the client identify the social class messages he or she receive(d)
Sample query: What would your parent(s)/peers say about your current situation?
How would your parent(s)/peers help you resolve your current situation?
List the ways in which you are acting to live out messages given to you by your parent(s)/peers.
Tell me about your peer group. Your support network.
Identify answers that focus on strong/salient cultural socialization messages still running in the client’s
mind, which drive the client’s behavior and attitudes.
Step 2a—Help the client identify social class behaviors, lifestyles, and material possessions that are salient to
the client in his or her current situation
Sample query: Tell me how you imagine your life.
How would you ideally be spending your time?
What do others have that you want?
What do you notice about how other people act/behave that you like?
Identify answers that pinpoint the client’s materialism values; how he has changed his lifestyle to fit into
a new group, and how he has changed his behavior to belong in a new group.
Step 3—Identify the client’s experiences with classism and move toward developing an adaptive, realistic, and
healthy expectation about him- or herself
Sample query: Do people look down on you?
Do you look down on others who are not like you?
What do your peers expect from you to maintain your status with them?
What does it feel like for you when you can’t keep up with your peers? What do you do?
Identify answers that express high social class expectations and the negative consequences related to not meeting
specific demands. Additionally, in what ways is the client participating in classism to maintain her social
class standing?
Step 4—Help the client integrate his or her experiences of classism
Sample query: Now that we’ve started talking about all these aspects of your social class experience, tell me what it
means to you?
What are you aware of about yourself that you didn’t know before we started?
Identify an ability to understand and integrate the social class discussions into other aspects of the client’s life.
Step 4a—Help the client take action and make changes in his or her life
Sample query: What is the one thing you could do to change your awareness, situation, or perception?
Identify an ability to make personal changes in the client’s life.
new social norms and values. Especially pertinent development provides some guidance. The research
for first-generation college students from working- in other areas of racial identity development, for
or lower-class backgrounds are distinct pressures instance, suggests that people may experience them-
toward obtaining new material goods and products. selves and others differently depending on their
Certainly, some material purchases are practical levels of cognitive maturity and sophistication
(i.e., computer), but others may be disguises that about race and racism, how well they integrate and
allow this particular student to “pass” for a social internalize their burgeoning sense of themselves as
class group (i.e., clothes, iPod). It may be no sur- a racial person, and how well they conceptualize
prise then that credit card use may often start in experiences around racism. Therefore, as clinicians
college (Roberts & Jone’s, 2005). Unfortunately, explore social class and classism with a client, they
focusing on material objects to cope with interper- should be prepared for the various ways in which
sonal issues and conflicts is ineffective and may only an individual may respond to seeing him- or herself
further exacerbate the interpersonal problems by as a social class being, new information about social
adding on financial burdens. class and classism, and a new perspective on classism
This framework has been used to guide the experiences. To account for these changes that a
exploration of an individual’s social class experiences person experiences, the social class and classism
and worldview (American Psychological Association consciousness model is presented.
[APA], 2007; Liu & Ali, 2008; Liu & Arguello,
2006). Clinicians are encouraged to explore the Developing Social Class and
three interrelated components as a means to help Classism Consciousness
the person develop insight about his or her experi- “I am bourgeois. I am deliberately so” (Marai,
ences and to develop healthy coping and skills to 1972/2000, p. 7). The character in The Right Man
navigate his or her economic culture and environ- speaks about his willingness to remain faithful to
ment. For example, Table 12.1 outlines the general others in his social class; an awareness of himself
structure clinical work uses when integrating the and others who share a similar socioeconomic place
framework from the original SCWM. in society. This self-awareness or consciousness of
One aspect identified but not previously explored self and others is the central construct of the Social
in the SCWM is the assumption that individuals, Class and Classism Consciousness (SCCC) frame-
upon exploring their social class worldview and exp- work. The individual develops a sense of him- or
eriences, would have little trouble understanding herself, an awareness, or consciousness of him- or
and conceptualizing social class as a system and herself as a socially classed person. Becoming aware
themselves within that system. In the original ver- of being a socially classed individual is dependent
sion of the SCWM, Liu (2001, 2002) put at the on becoming aware of social class and classism
center of the model the notion that individuals vary experiences, and allows the individual to be intro-
in their social class consciousness. It is true that, spective about his or her experiences, to recognize
within the SCWM, socialization messages from him- or herself in these experiences, and to poten-
family and friends are related to one’s social class tially deliberate about how social class is used in that
consciousness; however, the SCWM did not specify person’s life (Nelson, 1996). One impetus for the
how social class consciousness was related to the SCCC arose from my clinical experiences using the
worldview. It became clear that, depending on the SCWM with clients. When I walked through
depth and interest in social class among friends and various questions within each component of the
family, one might imagine that a person in an envi- SCWM, it became evident that clients presented
ronment rich with discussions about merit, social with varying levels of understanding related to how
class, inequality, and wealth would be much more they perceived themselves as socially classed indi-
aware of being a socially classed person than would viduals and with social class and classism issues.
an individual living in an environment in which Thus, before exploring the worldview of clients,
these topics were taboo. Therefore, in the current I found it necessary to understand the individual’s
iteration of the SCWM – R, social class conscious- level of social class consciousness. Additionally,
ness is considered a variable related to socialization I used the SCCC framework to conceptualize
messages. clients’ ever-developing awareness as they con-
In considering how social class consciousness stantly came into contact with new information
develops and evolves for a person, research and or experiences and made social class self-discoveries.
theoretical literature from other areas of identity The SCCC model is a descriptive framework

liu 335
outlining the various levels of social class and clas- classed person, but the rudimentary social class
sism consciousness. schema is ineffective in exploring, explaining, or
In the SCCC, there are three levels, starting with comprehending these new social class experiences.
no social class consciousness to the second level of Consequently, the individual may generate ques-
social class self-consciousness, to the last level of tions about these new experiences but not have the
social class consciousness. Among the three levels capacity to answer these questions.
are ten statuses: unawareness, status position At the second level of social class self-
saliency, questioning, exploration and justification, consciousness, the individual begins to develop a
despair, the world is just, intellectualized anger and self-consciousness and sensitivity to social class and
frustration, reinvestment, engagement, and equili- classism. Self-consciousness is meant here to charac-
bration (see Table 12.2). These changes also occur terize a person who is acutely sensitive to his or her
regardless of one’s objective situation (e.g., income context and environment and how he or she may be
level) since these are intrapsychic and are supposed perceived, but does not possess the requisite cogni-
to be personally meaningful. tive complexity to decipher how power, privilege,
At the beginning level of no social class con- and inequality operate in one’s life. In essence, the
sciousness, the individual who is largely unaware of individual knows that something is happening but
social class in his or her life is considered to have no does not know what is happening or how it is hap-
social class consciousness. This is not to say that the pening. This current social class self-consciousness
individual is devoid of all awareness, but rather that is an inward-focused approach to understanding
the individual does not possess a complex or sophis- social class and classism, and he or she is primarily
ticated understanding and awareness of how social interested in exploring and comprehending what
class operates in his or her life. At this first level, the he or she already knows. For instance, if the person
frameworks typically used are those introjected from was socialized to believe in the notion of meritoc-
one’s environment (e.g., media), friends, or family. racy, then one is likely to start with exploring and
Parroting these introjects is a characteristic of this justifying this belief system. Certainly, some evi-
first level. For instance, the individual may not dence may be found to support the belief, and
question the myth of meritocracy but believe in it disqualifying information is recognized but often
wholesale. As the individual gains more experience, minimized. The individual may come to despair
he or she may start to recognize economic differ- that alternative ways of explaining how social class
ences and begin to see him- or herself as a socially operates in one’s life are simply insufficient and
conclude that the economic world is largely just.
This approach categorizes the world dichotomously
Table 12.2. Social Class and Classism as either economically good or bad, and it is just
Consciousness Model Levels and Statuses (SCCC) for those who work to achieve. Some individuals
No social class consciousness may rest at this level of consciousness since it makes
relative sense of the world and does not require an
Unawareness individual to change attitudes or behaviors. Others,
Status position saliency however, may attempt to understand themselves
as socially classed beings by taking an alternative
Questioning
approach. Rather than seeing themselves as benefi-
Social class self-consciousness ciaries of a just economic world, they may focus on
the inequalities and disadvantages resulting from
Exploration and justification
the current economic system. This last status of
Despair social class self-consciousness may resemble a shift
The world is just from an inward focus to larger sociostructural and
economic injustice or inequality (outward). This
Intellectualized anger and frustration last status represents an intellectualized approach to
Social class consciousness these issues and may marshal feelings of anger and
frustration. Intellectualized is purposefully used
Reinvestment here to identify a defensive and personally protec-
Engagement tive approach to social class and classism and not
necessarily an intellectual approach to these same
Equilibration
issues. At this status, the person still focuses on large

336 social cl ass an d cl as s is m co n s cio u sne ss

(macro) concerns and envisions broad social move- the individual comes to understand social class and
ments but does not necessarily comprehend the classism and him- or herself as a socially classed
steps toward these larger social actions. Consequently, individual. The four relational components are
individuals at this status are easily frustrated and ways in which the individual sees him- or herself
may turn away from further social action because, as (self ), the perception and relationship with peers
they begin to see the enormity of the issues and (peers), the perception of how other people outside
problems, they become overwhelmed and believe the immediate social class group operate within the
these problems are intractable. At this status, social social class system and how the individual relates to
class and classism is focused on “other” exploration these “others,” and how society operates around
rather than “self ” exploration. social class and the individual’s connection to them.
At the final level of social class consciousness, Table 12.3 describes and outlines each level.
social class consciousness is developed and explored, The SCCC resembles a developmental model
and the individual shifts the focus of social class and in that there are less sophisticated or unaware sta-
classism toward the self. Rather than focusing on tuses (i.e., unaware) and more complex and aware
answering questions about social class and classism, statuses (i.e., equilibration). I posit that any person
however, he or she is interested in understanding would first need to experience or process through
how he or she impacts others as a socially classed all the statuses in some hierarchical order since it
person. This final level represents a focus of the would make sense that these social class–based sche-
socially classed self in relation to socially classed mas would need to be created before an individual
others and vice versa. As the person understands these has an ability to use them. Access to these schemas
interpersonal interactions around social class and could come from experience or from socialization
classism, he or she may find personally meaningful messages. For instance, someone coming from a
ways to positively impact the lives of others. The family who discusses social class may have some
individual may start to engage in individual (micro) sophistication in understanding the pressures of
activities and explore macro-level involvements social class in his or her life. After having access
that are connected to these activities. For instance, to these statuses, there may be dominant or pre-
an individual active at the micro level may be con- ferential ways of understanding the social class
cerned with donating food items to a local food world, and it is also possible that all these statuses
bank and may find macro-level involvements that are always active, but in different levels or in auxil-
address issues of diet, food access, and nutrition. iary positions. That is, people possibly may and do
The assumption here is that there are many ways shift between the statuses as a consequence of new
that economic inequality may be addressed, but social class and classism experiences and discourse
people find personally meaningful ways to contrib- within significant relationships. For illustration, the
ute and engage in these issues. Eventually, the last first-generation college student experiencing pres-
status assumes that the individual has some sophis- sures to purchase new material objects to maintain
tication and complexity in understanding him- or a social class position may start as being unaware of
herself as a socially classed person and how social being a socially classed person but, as a result of
class and classism operates. The individual is able these new expectations, begin to understand that
to approach issues of inequality, for instance, with there are those around him or her with more and
some reason and equilibrium and is capable of less. The student may realize that his or her social
considering multiple sides to an issue or concern. class position is important and meaningful, and
Because he or she is able to comprehend these issues begin to make changes in his or her life to accom-
with more complexity, the individual is also poten- modate these new demands. It is also possible that
tially better able to make better decisions with his this same student, at some later point, may be using
or her life in relation to shifting EC demands and equilibration as a dominant status and may not suc-
experiences with classism, especially feelings of cumb to new material demands as quickly or easily.
internalized classism. The purpose of the SCCC was to provide the clini-
Within each level, there are four relational cian and client with a framework to understand the
components of the self, peers, others, and society. possible changes in self- and other-awareness stem-
These relational components are meant to identify ming from an exploration of social class and clas-
how an individual in these different statuses may sism experiences. The SCCC is presented as a linear
perceive and possibly interact with others. Each model with discrete levels, and it assumes that indi-
of the ten levels represents different ways in which viduals become increasingly more complex in the

liu 337
Table 12.3. Social Class and Classism Consciousness Model
Status Definition Self-perception Perception of Peers Perception of Others Perception of Society
Unawareness Social class is not a salient part The self is an Peers are perceived to Some recognition that there The larger sociostructural
of one’s worldview. There is independent actor in reflect and endorse the are higher and lower “others” system works neutrally.
recognition of inequality, of the social class system. individual’s worldview but no acknowledgement that People get what they deserve.
rich and poor, but no real and are believed to the individual is also part of The individual believes that
conceptualization of how social share a similar a larger economic system. there are some unfair
systems may work to create unaware worldview. advantages but not so
inequality. Overall, there may much to unbalance
be a belief in the myth of the system.
meritocracy and an
acceptance of personal and
other peoples’ unqualified
privileges and entitlements.
Status Position The individual recognizes people The individual generally Peers are part of the The individual perceives of The larger society is
Saliency in higher and lower groups, and sees him- or herself as individual’s social class multiple social class groups recognized to be comprised
the individual is aware that he or belonging to a social group and the individual within which others belong of higher and lower social
she may belong to a social class class group and begins recognizes peers who and these groups are stratified class groups, some of which
group. to recognize the may belong to other but the individual is unclear deserve esteem and others
boundaries of his or her social class groups. what creates the hierarchy, deserve derision.
social class group. stratification, or inequality.
Questioning The individual questions the Some dissonance about Beginning sense that the Steady recognition that there Still greatly unsure how the
role of social class in his or her the individual’s role in individual and his or her are social class in-groups and larger sociostructural system
life. The questions may create social class and cohort have certain social out-groups. of social class operates but
anxieties and tensions related inequality; generally class boundaries which still some sense that status
to how social class operates in unsure what social seem diffuse and unclear considerations are important
the individual’s life and class and classism and some recognition that parts of one’s experience.
the larger society. means, but some the peer group has
burgeoning recognition boundaries.
that social class exists
and operates. The
individual may also question
how he or she came to his
or her particular social
class position.
Exploration and The individual seeks out The self is unsure and is Peers and the cohort Other people are unreliable A growing sense that society
Justification knowledge and experiences to vulnerable, but the group are sought out for because they do not “must” be just and inequality
answer these questions. The individual is willing to answers but a growing “understand” the individual’s “must” be a “natural”
individual is primarily explore answers that recognition that the peer experiences and perspectives product of people’s efforts.
interested in finding support may support his or her group may be an and are likely to challenge the
for his or her previously held already existing, albeit unreliable source of individual too much.
beliefs about how social class tenuous worldview. information.
functions and the role it plays
in his or her life.
Despair The individual resigns him- or The self is perceived as Peers are regarded in a People are not interested in There are rich and poor and
herself to believing there is no impotent against the similar situation and helping you cope with the society is made to make the
escape from the current current situation; the peers may be the target situation better. rich richer and the poor
circumstances. For instance, individual does not of anger if they try to poorer.
an individual in poverty may believe he or she deviate (improve) their
believe he or she cannot move possesses the skills to current situation.
beyond his or her situation. overcome his or her
situation.
The World Is Just The individual is resigned to Because the world is Peers are sought out who Other people have not Society is just and inequality
accepting inequality and the unchangeable, it is reinforce this same worked hard enough or is a natural product and
rationalization that people important to look out worldview. Usually made the right process.
get what they deserve. The for oneself. people reinforce the “life choices” to succeed.
individual is interested in individual’s current
his or her own privilege, social class position or who
entitlements, and are interested in upward
status attainment. mobility.
(Continued)
Table 12.3. (Continued)
Status Definition Self-perception Perception of Peers Perception of Others Perception of Society
Intellectualized As the individual explores The self is blameless, Interested in seeking Others are categorized into Society is unjust and
Anger and his or her questions around and it is others and out other groups and oppressed and oppressors– must be corrected–usually
Frustration social class, classism, and society who created expanding their peer with the oppressed being through some revolutionary
inequality, the individual inequality, and it is group to find additional those in poverty and low action. Large social action is
becomes angry and frustrated the individual who support for their income situations. sought.
at the state of inequality. must “correct” the experiences and growing Others are also encouraged
The individual becomes injustices. perspective. Peers are to fight against inequality.
increasingly interested expected to reflect the
in addressing economic individual’s worldview
inequality. The individual likely about inequality.
attempts to involve
him- or herself in broad and
far-reaching activities that
are outside his or her ability to
intervene and understand.
There is no introspection and
deep consideration about
poverty and inequality except
reactive anger and frustration.
Reinvestment The individual investigates The individual recognizes The individual observes Rather than focusing on Society is recognized to be
social class, classism, and that he or she is engaged how peers also enact society at large, the comprised of smaller contexts.
inequality again in his or her in unequal, unjust, and social class and classism. individual focuses on his or These smaller contexts are the
own personal life and explores sometimes classicist Peers are being evaluated her surrounding environment. ways in which society may be
how his or her actions impact actions. The individual on their social class The individual’s interest is changed to be more equitable.
others. The individual is recognizes these actions consciousness. the immediate context
interested in finding ways to having negative impacts within which social
understand social class in on others. He or she class and classism are enacted
his or her own world. begins to connect and how their individual
individual behavior to behaviors may make an impact.
possibly larger social
problems.
Engagement The individual is actively The individual recognizes New peer groups may It is important to find way to Society is largely unjust and
involved in social class, the importance of being be sought that reinforce help people in one’s classici and marginalizing of
inequality, and poverty issues vigilant against inequality this growing new community/neighborhood. people from poverty and the
in his or her community. and that social class consciousness. It is also important to support poor. The whole of society
The individual is testing his operates all around. Dissonance and conflict other causes against cannot be changed immediately,
or her developing awareness The individual is may still exist as the classism. but it is important to be a part
of being a socially classed intentional and deliberate individual shifts away of or start a process of change.
person. about how he or she from old friends to new
acts in certain contexts, networks. Anxiety may
and is sensitive to social increase from these new
class differences. experiences.
Equilibration The individual is able to The individual recognizes The individual has The individual recognizes Society is not an independent
complexly explore and that he or she is multiple groups of friends people in different strata and entity or organism outside the
understand the role of social constantly negotiating and peers which reflect sees the privileges, power, and individual, and the individual
class in his or her world. privilege and power, and their complex limits of each group. He or she can only make changes through
The individual struggles for there are some times and understanding of recognizes the fluidity of these constant vigilance in combating
equilibrium when trying to contexts in which he social class. The individual groups and how context classism.
figure out issues of or she has and uses the has some ability to move changes the quality of each
poverty/injustice. privilege, and others in between and within each group.
which he or she does not of these groups.
or cannot exercise
privilege.
ways in which they process social class information and classism is the potential incorporation of other
and the ways in which they regard themselves and aspects of the client’s identity. For instance, through-
others. The SCCC is presented as a hierarchy for out this chapter, race and gender were not specifi-
this presentation, but it is possible that these levels cally discussed. In part, a review of the social class
may also be present in every individual but with literature on race and gender is far too extensive for
varying degrees of salience and importance. this chapter and has been conducted elsewhere (Liu,
Additionally, individuals certainly may move 2002; Liu, Hernandez, Mahmood, & Stinson,
between each level in any order. Finally, becoming 2006). But using a subjective approach to social
conscious about social class and being aware of one- class, clinicians and researchers are likely more able
self as a socially classed person is not a singular to discuss the interrelationships of social class and
event. Rather, individuals are constantly confronted race or classism and racism. Although the SCWM
with and must struggle through always becoming (Liu, 2001; Liu & Ali, 2008) provides a heuristic
social class conscious. Thus, individuals may con- from which to explore the individual’s perceptions
stantly cycle through these levels. For psychologists, and experiences about social class and classism, the
working with clients on social class issues necessarily ways in which individuals come to see themselves as
means making the client aware of being a socially a socially classed persons were unexplored. This
classed person. To adequately approach and discuss chapter presents the SCCC as a complementary
these issues with clients, it is important to be at a framework to the SCWM. The SCCC was devel-
similar or higher level of understanding than the oped from my own clinical experiences, and the
client. That is, to help clients develop their own experiences and perspectives that clients discussed
awareness and consciousness, it is important that when their worldview was queried. The SCCC is
the clinician be at a higher level of social class con- comprised of ten levels of social class consciousness
sciousness than the client. Being incongruent in that range from unawareness to a balanced perspec-
levels of social class consciousness could potentially tive on social class. Within each level are four rela-
be related to therapeutic problems such as impasses tional components that are hypothetical ways in
or ruptures in the therapeutic relationship (Liu & which the individual views him- or herself, peers,
Pope-Davis, 2005). others, and society with regard to the developing
social class awareness. I hope this will be a useful
Conclusion tool in social class–based clinical practice and
The psychology of social class and classism needs to research, and a helpful alternative to the sociodemo-
focus on the personal and lived experiences of indi- graphic approach to social class and classism.
viduals and their perspectives on themselves and
others. As I have argued, the current use of sociode- Training Implications
mographic variables is insufficient in accessing and The SCWM is laid out as a framework to help clini-
exploring these socially classed experiences and per- cians and clinicians in training work with clients to
spectives. Instead of providing illumination in social explore, understand, and integrate social class and
class, the use of income, education, and occupation classism experiences. The sample queries provided
to stratify individuals into social class groups or to in Table 12.1 are meant to be exemplar questions
place them on an economic hierarchy may only that clinicians may use with clients, and these ques-
create confusion as researchers and clinicians disen- tions may also help supervisors work more effec-
tangle methodology from phenomenology. Gen- tively with trainees in developing their competencies
erally, the research seems to indicate that subjective around social class and classism (Liu & Pope-Davis,
approaches, even a simple question of placing an 2005b). But, along with assisting trainees in their
“X” on a ten-rung ladder, may be more helpful in work with clients, the SCWM and the SCCC are
explicating a person’s social class self-awareness and important ways in which trainees may be guided in
appraisal than an extensive questionnaire. It seems understanding their own social class experiences
that, as research by Adler et al. (2000) and Ostrove and the ways in which trainees understand them-
et al. (2000) suggests, it is how the individual con- selves as socially classed persons.
ceptualizes him- or herself as a socially classed indi- I posit that, within the SCWM, classism experi-
vidual within an economic system that is important ences are critical in shaping one’s social class con-
in understanding certain relationships, such as self- sciousness and how the individual may interact and
rated health. One additional benefit from taking a relate to others. Classism, especially early traumatic
subjective approach to understanding social class experiences of classism, may have enduring affects

342 social cl ass an d cl as s is m co n s cio u sne ss

on the individual and shape self and other percep- also have experiences of classism that could distort
tions and interactions. For instance, the multicul- and color the supervisory relationship with a trainee
tural competency literature generally encourages or affect the ways and type of supervisory direction
trainees to explore and understand how privilege and instruction. For instance, a supervisor who
shapes one’s worldview. Trainees unaware of the comes from an upper-class background may have
impact of privilege may assume clients to have had experiences of upward classism (i.e., being
had experiences, access to resources (i.e., long-term called a snob or elitist) directed at him or her during
health care), or a similar upward-mobility prefer- graduate school. Consequently, the supervisor may
ence that may minimize or distort a presenting develop a sensitivity toward any markers, behav-
issue. In a similar way, classism has to be explored iors, or attitudes that may indicate his or her upper-
and understood by the trainee. A trainee with an class upbringing. When the supervisor works with
early or traumatic experience with inequality or trainees who come from working-class backgrounds
classism, such as losing one’s home or being teased and experiences, the supervisor may try to overiden-
or bullied for not dressing correctly (i.e., fashion- tify with the supervisee; rather than challenge and
ably), for instance, may harbor a prejudice against confront the supervisee, the supervisor colludes
those perceived to be from higher social class back- with or minimizes the trainee’s mistakes.
grounds (i.e., upward classism), or they may be For training, the SCWM and SCCC allow clini-
especially sensitive to lateral classism (i.e., keeping cians to first develop self-awareness around social
up with the Joneses). These experiences with clas- class and classism. Before working with a client, this
sism are important since these therapists may work self-awareness has to focus on not only understand-
with clients perceived to be from higher social class ing these concerns but also on developing a capacity
backgrounds and potentially treat them less well and ability to articulate how social class and classism
than they do other clients. affected the clinician. Similar to becoming multi-
In working with trainees to understand their culturally competent with race or gender, clinicians
worldview or consciousness around social class and need to develop a familiarity and comfort with dis-
classism, it is important to consider the varying cussing topics that are generally considered taboo
ways in which trainees may understand themselves for public conversation. Because social class and
to be socially classed persons. For instance, the classism are relatively unfamiliar topics of discus-
trainee who had an early bullying experience in sion, it is critical to nurture conversations with cli-
grade school for wearing hand-me-down clothes nicians. In these discussions, instructors and
may harbor deep feelings of hurt, and may regard supervisors should be mindful of how the SCWM
these as “just bullying experiences” rather than and SCCC statuses are operating for clinicians, and
related to social class. Thus, this trainee may be how they are conceptualizing and discussing social
unaware of social class in his or her life, even though class and classism. As clinicians become more com-
the bullying was a form of classism and in part fortable with these topics, it may be inevitable that
related to the social class background of the trainee. clinicians will feel comfortable introducing these
It may be obvious to the supervisor that these con- topics into psychotherapy.
nections exist, but the supervisor should not be sur-
prised that this trainee does not see the apparent Future Directions
links. The trainee may not be fully aware of his poor Throughout this chapter, I addressed the impor-
treatment of clients from perceived higher social tance of exploring the ways in which people concep-
class backgrounds. tualize social class and classism and begin to see
Working with trainees from a social class and themselves as socially classed individuals. These are
classism informed approach also necessitates that theoretical notions on how people see their social
the supervisor receive training and education. There class world. But important work remains in research
are a number of references, articles, books, and and theory development. Future directions for social
chapters from which to choose, and these resources class and classism work in counseling and psychol-
should provide the supervisor with adequate knowl- ogy may include the following questions:
edge about social class and classism. The more How does counseling psychology research move
important and critical work for the supervisor is to beyond objective indices and social class demo-
also develop an understanding and awareness to the graphic proxy variables?
impact of social class and classism in his or her own In what ways may subjective and phenomeno-
life. Similar to the trainee, clinical supervisors could logical approaches to social class and classism be

liu 343
used to develop, improve, and implement public Duncan, G. J. (1988). The volatility of family income over the
policy focused on inequality? life course. In P. Baltes, & R. M. Lerner (Eds.), Life span
development and behavior Vol. 9 (pp. 317–358). Hillsdale,
How may we shift the discussion about social NJ: Erlbaum.
class and classism to encompass the entire range Duncan, G. J., & Magnuson, K. A. (2003). Off with
of economic experiences (e.g., from affluent to Hollingshead: Socioeconomic resources, parenting, and
poor)? child development. In M. H. Bornstein, & R. H. Bradley
How might issues around social class, classism, (Eds.), Socioeconomic status, parenting, and child development
(pp. 83–106). Hillsdale, NJ: Erlbaum.
and inequality be better infused in current training? Ensminger, M. E., & Fothergill, K. E. (2003). A decade of
measuring SES: What it tells us and where to go from here.
References In M. H. Bornstein, & R. H. Bradley (Eds.), Socioeconomic
Adler, N. E., Boyce, W. T., Chesney, M., Folkman, S., & Syme, status, parenting, and child development (pp. 13–27). Hillsdale,
L. (1993). Socioeconomic inequalities in health: No easy NJ: Erlbaum.
solution. Journal of the American Medical Association, 269, Fouad, N. A., & Brown, M. T. (2001). Role of race and social
3140–3145. class in development: Implications for counseling psychol-
Adler, N. E., Epel, E. S., Castellazzo, G., & Ickovics, J. R. (2000). ogy. In S. D. Brown, & R. W. Lent (Eds.), Handbook of coun-
Relationship of subjective and objective social status with seling psychology (pp. 379–408). New York: Wiley.
psychological and physiological functioning: Preliminary Fletcher, J. (2001, March 16). When a million isn’t enough. The
data in healthy white women. Health Psychology, 19, Wall Street Journal, p. W1, W14.
586–592. Frable, D. E. S. (1997). Gender, racial, ethnic, sexual, and class
Ali, S. R., & McWhirter, E. H. (2006). Rural Appalachian identities. Annual Review Psychology, 48, 139–162.
Youth’s Vocational/Educational Post-secondary Aspirations: Gallo, L. C., Bogart, L. M., Vranceanu, A. M., & Matthews, K. A.
Applying Social Cognitive Career Theory. Journal of Career (2005). Socioeconomic status, resources, psychological expe-
Development, 33, 87–111. riences, and emotional responses: A test of the reserve capac-
American Psychological Association. (2007). Taskforce report ity model. Journal of Personality and Social Psychology, 88,
on socioeconomic status. Retrieved January 31, 2007, from 386–399.
www2.apa.org/pi/SES_task_force_report.pdf. Gallo, L. C., & Matthews, K. A. (1999). Do negative emotions
Blustein, D. L. (2006). The psychology of working: A new pers- mediate the association between socioeconomic status and
pective for career development, counseling, and public policy. health? Annals of the New York Academy of Sciences, 896,
Mahwah, NJ: Lawrence Erlbaum. 226–245.
Bronfenbrenner, U. (1986). Ecology of the family as a context Gallo, L. C., & Matthews, K. A. (2003). Understanding the asso-
for human development: Research perspectives. Developmental ciation between socioeconomic status and physical health:
Psychology, 22, 723–742. Do negative emotions play a role? Psychological Bulletin, 129,
Brown, M. T., Fukunaga, C., Umemoto, D., & Wicker, L. 10–51.
(1996). Annual review, 1990–1996: Social class, work, Gallo, L. C., Smith, T. W., & Cox, C. M. (2006). Socioeconomic
and retirement behavior. Journal of Vocational Behavior, 49, status, psychosocial processes, and perceived health: An
159–189. interpersonal perspective. Annals of Behavioral Medicine, 31,
Cohen, S., Alper, C. M., Doyle, W. J., Adler, N., Treanor, J. J., & 109–119.
Turner, R. B. (2008). Objective and subjective socioeco- Geronimus, A. T., Bound, J., Waidmann, T. A., Hillemeier, M. M.,
nomic status and susceptibility to the common cold. Health & Burns, P. B. (1996). Excess mortality among blacks and
Psychology, 27, 269–274. whites in the United States. New England Journal of Medicine,
Costello, E. J., Compton, S. N., Keeler, G., & Angold, A. (2003). 355, 1552–1558.
Relationships between poverty and psychopathology: A nat- Hopps, J., & Liu, W. M. (2006). Working for social justice
ural experiment. Journal of the American Medical Association, from within the health care system: The role of social class in
290, 2023–2029. psychology. In R. L. Toporek, L. H. Gerstein, N. A. Fouad,
Croizet, J. C., & Claire, T. (1998). Extending the concept of G. Roysircar, & T. Israel (Eds.), Handbook for social justice
stereotype threat to social class: The intellectual underperfor- in counseling psychology: Leadership, vision, and action
mance of students from low socioeconomic backgrounds. (pp. 318–337). Thousand Oaks, CA: Sage.
Personality and Social Psychology Bulletin, 24, 588–594. Jones, F. L., & McMillan, J. (2001). Scoring occupational
Croizet, J. C., Desert, M., Dutrevis, M., & Leyens, J. P. (2001). categories for social research: A review of current practice,
Stereotype threat, social class, gender, and academic under- with Australian examples. Work, Employment and Society, 15,
achievement: When our reputation catches up with us and 539–563.
takes over. Social Psychology and Education, 4, 295–310. Kimmel, M. (1996). Manhood in America: A cultural history.
Currie, C. E., Elton, R. A., Todd, J., & Platt, S. (1997). Indicators New York: Free Press.
of socioeconomic status for adolescents: The WHO Health Lachman, M. E., & Weaver, S. L. (1998). The sense of control
Behaviour in School-aged Children Survey. Health Education as a moderator of social class differences in health and well-
Research, 12(3), 385–397. being. Journal of Personality and Social Psychology, 74,
De Vogli, R., Ferrie, J. E., Chandola, T., Kivimaki, M., & 763–773.
Marmot, M. G. (2007). Unfairness and health: Evidence Liberatos, P., Link, B. G., & Kelsey, J. L. (1988). The measure-
from the Whitehall II study. Journal of Epidemiological ment of social class in epidemiology. Epidemiologic Reviews,
Community Health, 61, 513–518. 10, 87–121.

344 social cl ass an d cl as s is m co n s cio u sne ss

Lin, N. (1999). Social networks and status attainment. Annual Lott, B. (2002). Cognitive and behavioral distancing from the
Review of Sociology, 25, 467–487. poor. American Psychologist, 57, 100–110.
Liu, W. M. (2001). Expanding our understanding of multi- Marai, S. (2000). Memoir of Hungary, 1944–1948 (A. Tezla,
culturalism: Developing a social class worldview model. Trans.). Corvina, Budapest: Central European University
In D. B. Pope-Davis, & H. L. K. Coleman (Eds.), The inter- Press. (Original work published 1972).
section of race, class, and gender in counseling psychology Miller, D. T. (2001). Disrespect and the experience of injustice.
(pp. 127–170). Thousand Oaks, CA: Sage. Annual Review of Psychology, 52, 527–553.
Liu, W. M. (2002). The social class-related experiences of men: Nelson, T. O. (1996). Consciousness and metacognition.
Integrating theory and practice. Professional Psychology: American Psychologist, 51, 102–116.
Research and Practice, 33, 355–360. Oakes, J. M., & Rossi, P. H. (2003). The measurement of SES
Liu, W. M. (2006). Classism is much more complex. American in health research: Current practice and steps toward a
Psychologist, 61, 337–338. new approach. Social Science and Medicine, 56, 769–784.
Liu, W. M., & Ali, S. R. (2005). Addressing social class and Offer, A. (2006). The challenge of affluence: Self-control and
classism in vocational theory and practice: Extending the well-being in the United States and Britain since 1950.
emancipatory communitarian approach. The Counseling New York: Oxford.
Psychologist, 33, 189–196. Ostrove, J. M., Adler, N. E., Kuppermann, M., &
Liu, W. M., & Ali, S. R. (2008). Social class and classism: Washington, A. E. (2000). Objective and subjective assess-
Understanding the impact of poverty and inequality. ments of socioeconomic status and their relationship to self-
In S. D. Brown, & R. W. Lent (Eds.), Handbook of coun- rated health in an ethnically diverse sample of pregnant
seling psychology 4th edition. New York: Wiley. women. Health Psychology, 19, 613–618.
Liu, W. M., Ali, S. R., Soleck, G., Hopps, J., Dunston, K., Pollack, C. E., Chideya, S., Cubbin, C., Williams, B.,
& Pickett, T., Jr. (2004). Using social class in counseling Dekker, M., & Braveman, P. (2007). Should health studies
psychology research. Journal of Counseling Psychology, 51, measure wealth? A systematic review. American Journal of
3–18. Preventive Medicine, 33, 250–264.
Liu, W. M., & Arguello, J. (2006). Social class and classism in Pingle, M., & Mitchell, M. (2002). What motivates positional
counseling. Counseling and Human Development, 39(3), concerns for income? Journal of Economic Psychology, 23,
1–12. 127–148.
Liu, W. M., Fridman, A., & Hall, T. (in press). Social class Roberts, J. A., & Jones, E. (2005). Money attitudes, credit
and school counseling. In H. L. K. Coleman, & C. Yeh card use, and compulsive buying among American college
(Eds.), Handbook of school counseling. New York: Erlbaum. students. Journal of Consumer Affairs, 35, 213–240.
Liu, W. M., Hernandez, J., Mahmood, A., & Stinson, R. (2006). Sapolsky, R. (2005, December). Sick of poverty. Scientific
The link between poverty, classism, and racism in mental American, 293(6), 92–99.
health. In D. W. Sue, & M. G. Constantine (Eds.), Racism Singh, G. K., & Siahpush, M. (2006). Widening socioeconomic
as a barrier to cultural competence in mental health and educa- inequalities in US life expectancy, 1980–2000. International
tional settings (pp. 65–86). Hoboken, NJ: Wiley. Journal of Epidemiology, 35, 969–979.
Liu, W. M., Pickett, T., Jr., & Ivey, A. E. (2007). White middle- Smith, L. (2005). Psychotherapy, classism, and the poor:
class privilege: Social class bias and implications for training Conspicuous by their absence. American Psychologist, 60,
and practice. Journal of Multicultural Counseling and Develo- 687–696.
pment, 35, 194–207. Smith, L. (2006). Addressing classism, extending multicultural
Liu, W. M., & Pope-Davis, D. B. (2003a). Moving from diver- competence, and serving the poor. American Psychologist, 61,
sity to multiculturalism: Exploring power and the implica- 338–339.
tions for psychology. In D. B. Pope-Davis, H. L. K. Coleman, Smith, L. (2008). Positioning classism with counseling psychol-
W. M. Liu, & R. L. Toporek (Eds.), Handbook of multicul- ogy’s social justice agenda. The Counseling Psychologist, 36,
tural competencies in counseling and psychology (pp. 90–102). 895–924.
Thousand Oaks, CA: Sage. Smith, L., Foley, P. F., & Chaney, M. P. (2008). Addressing
Liu, W. M., & Pope-Davis, D. B. (2003b). Understanding classism, ableism, and heterosexism in counselor education.
classism to effect personal change. In T. B. Smith (Ed.), Journal of Counseling and Development, 86, 303–309.
Practicing multiculturalism: Internalizing and affirming diver- Solnick, S. J., & Hemenway, D. (1998). Is more always better?:
sity in counseling and psychology (pp. 294–310). New York: A survey on positional concerns. Journal of Economic Behavior
Allyn & Bacon. & Organization, 37, 373–383.
Liu, W. M., & Pope-Davis, D. B. (2005). The Working alliance, The Wall Street Journal. (2001, March 16). The Dow Jones rich
therapy ruptures and impasses, and counseling competen- index. p. W14.
cies: Implications for counselor training and education. Tyszka, T., & Przybyszewski, K. (2006). Cognitive and affective
In R. T. Carter (Ed.) Handbook of racial-cultural psychology factors affecting currency perception. Journal of Economic
and counseling Vol. 2. (pp. 148–167). New York: John Wiley Psychology, 27, 518–530.
and Sons. Vohs, K. D., Mead, N. L., & Goode, M. R. (2006). The psycho-
Liu, W. M., Soleck, G., Hopps, J., Dunston, K., & Pickett, T. logical consequences of money. Science, 314, 1154–1156.
(2004). A new framework to understand social class in coun- Wright, E.O. (2002). The shadow of exploitation in Weber’s class
seling: The social class worldview and modern classism analysis. American Sociological Review, 67, 832–853.
theory. Journal of Multicultural Counseling and Development,
32, 95–122.

liu 345
 CHAPTER

13 The Psychology of Women

Bonnie Moradi and Janice D. Yoder

Abstract
In this chapter, we describe theory and research that highlights connections between the social
contexts of women’s lives and women’s intrapersonal and interpersonal functioning. Specifically, in
the first section of the chapter, we discuss how women’s social contexts are shaped by gender and
its intersections with other social categories and by sexism expressed as prejudice, stereotyping,
and discrimination. Next, we discuss women’s mental health, with attention to the interplay of
gender with psychological disorders and the role of sexist discrimination in women’s mental health.
In the third section, we focus on women’s relationships, starting with the socializing relationships
of childhood, turning to intimate relationships in adulthood, and then discussing the role of power
in women’s relationships. Finally, we review research on women’s identities, focusing on feminist,
lesbian, and womanist identity models. We conclude this chapter with a call to counseling
psychologists to adopt the feminist understanding that women’s well-being depends on both
their personal and their sociopolitical empowerment.
Keywords: women, gender, sexism, feminist psychology, psychology of women, sexist discrimination,
women’s mental health, women’s identity, women’s relationships

To better understand women as women, counsel- by gender and its intersections with other social
ing psychologists need to look outside individual categories and by sexism expressed as prejudice, ste-
women themselves to the gendered social context in reotyping, and discrimination. Next, we discuss
which all women live their lives. Certainly, how women’s mental health, with attention paid to the
these contexts affect individuals is highly personal- interplay of gender with psychological disorders and
ized, but there is common ground that brings all the role of sexist discrimination in women’s mental
women together, both as a single group and as sub- health. In the third section, we examine women’s
groups designated by other intersecting social mark- relationships, starting with the socializing relation-
ers, such as race/ethnicity, sexual orientation, age, ships of childhood, turning to intimate relation-
and physical ability. Feminists have captured this ships in adulthood, and then discussing the role of
understanding in the activist insight that “the per- power in women’s relationships. Finally, we review
sonal is political.” Guided by this perspective, in this research on women’s identities, focusing on femi-
chapter, we aim to highlight connections between nist, lesbian, and womanist identity models. We
the social contexts of women’s lives and women’s conclude this chapter with a call to counseling psy-
intrapersonal and interpersonal functioning. chologists to adopt the feminist understanding that
Specifically, in the first section of the chapter, women’s well-being depends on both their personal
we discuss how women’s social contexts are shaped and their sociopolitical empowerment.

346
Women in Social Context that necessarily affect their social interactions
Social psychologists define social context as the (Deaux & Major, 1987).
social environment in which individual behaviors
occur and can work to produce or constrain other intersectionality
behavior (Ross & Nisbett, 1991). In this chapter, Although humans’ propensity to categorize lays the
we contend that this social context is ubiquitously groundwork for us to think (Woll, 2002), the pro-
gendered, although more or less obviously so. This cess of grouping people together brings with it the
global truism begins with the simple process of pitfall of ignoring or underestimating within-group
social categorization. diversity—the individual differences that distin-
guish among individuals within the general cate-
Social Categorization gory of women. Additionally, although gender is
Social categorization refers to the essential human a very potent social representation through which
propensity to cognitively sort people into groups others label each of us, it is not the only social
based on perceived common properties (Hampson, marker others use (Loden & Rosener, 1991). Rather,
1988). Sex, along with age and race/ethnicity, is each of us is shaped by an interlocking set of
a primary category (Schneider, 2004) that we use social representations, including our race/ethnicity,
so seamlessly in our everyday lives that we often sort age, sexual orientation, religion, education, income,
people into groups without awareness or effort (Ito physical attributes, and so on. Each of these markers
& Urland, 2003). Indeed, sex is so important as brings with it either social privilege or oppression,
a social marker that we find it disconcerting when and each contributes to the complex social contexts
we cannot readily identify an individual’s sex (Butler, through which we pass every day, sometimes bene-
1990). Typically without definitive proof of anoth- fiting us and at other times disadvantaging us. None
er’s biological sex, we rely on social indicators of of these markers stands alone; they are interlocking
femaleness and maleness, that is, gender. Thus, or intersecting (West & Fenstermaker, 1995).
social constructionists like Judith Butler (1990)
argue that gender is something we actively do in our systems of inequality
everyday lives (expressed in our choice of clothes, Social categorization describes the role that indi-
hair styles, mannerisms, etc.) to ensure that we do viduals play in creating and maintaining the con-
not confuse others. One side effect of this con- textual status quo, a status quo that is ubiquitously
structed exaggeration of femaleness or maleness is gendered. A second building block focuses on
heightened gender polarization, that is, perceptions understanding the systems of inequality that struc-
that women and men are “opposites” (Bem, 1993). ture our interpersonal, organizational, and societal
In addition to undermining the fundamental contexts. The fundamental human propensity to
shared humanness that connects women with men, sort people into social hierarchies, in which some
using femaleness as a social representation glosses groups are privileged at the expense of others, is
over an individual’s unique qualities, such as her captured in social dominance theory (Pratto,
hopes, dreams, and feelings, and instead establishes Sidanius, & Levin, 2006). Within this framework,
expectations about what is appropriate or good and gender and age are the key markers for two universal
inappropriate or bad; that is, gendered injunctive hierarchical systems in which women, children, and
norms (Eagly & Karau, 2002). Given that these the elderly are relegated to less powerful statuses.
gender-linked expectations are formed within a The third category of systems, arbitrary sets, devel-
generally patriarchal culture, being female comes ops social hierarchies based on other socially con-
with less power and privilege than does being male structed characteristics such as race, ethnicity, and
(Johnson, 2006). With men’s conferred dominance sexual orientation. Interestingly, these arbitrary sets
over women comes greater access to resources and also may involve a gendered component; for exam-
rewards (Ridgeway, 1991), greater power in inter- ple, these systems are frequently used by men to
personal relationships (Felmlee, 1994), and more dominate other men (in addition to women and
privileges in the workplace and in politics (Lips, children). A central point for our discussion that
1991). In sum, being female is commonly regarded emerges from social dominance theory is that these
as essentially different from being male (subjective systems of inequality are produced and maintained
essentialism; Prentice & Miller, 2007) and of lower by prejudices and discrimination at multiple levels
social status, thus immersing women and men in of intergroup analysis, expanding in scope from the
fundamentally different gendered social contexts individual to the interpersonal, organizational, and

m or adi, yode r 347

societal levels. These interlocking systems are the communal expressiveness of feminine traits, the
strengthened to the degree that individuals endorse traditional roles of homemaker and sexy woman,
legitimizing myths that appear consensual, serve to and the female-dominated occupations) and com-
justify the existing social structure, and are expressed petence (which includes the agentic instrumentality
in values, attitudes, beliefs, stereotyping, and cul- of masculine traits, the roles of athlete/lesbian, busi-
tural ideologies. nesswoman, and feminist, and the male-dominated
Four basic points about systems of inequality will occupations). Seeing a group as “warm” originates
help inform our discussion (Johnson, 2006). First, from regarding its members as noncompetitive and
one must be a member of an oppressed social cate- nonthreatening. Regarding a group as “competent”
gory to be affected by that oppression. For example, reflects perceptions of its members’ higher status.
regarding sexism, although masculinity, especially The reason these seemingly benign gender stereo-
hypermasculinity, has documented costs for men, types become sexist is that none of the traits, real
such as negative health consequences (Good & roles, and occupations associated with actual women
Sherrod, 2001), on balance, the costs of being male engender perceptions of both warmth and compe-
are far overshadowed by the benefits. Peter Blood tence. Thus women, unlike men, are left to choose
and his colleagues (1995, p. 159) captured this point between being liked or respected. That is, women
succinctly: “However much men are hurt by sex roles become targets of sexist stereotyping, which by defi-
in this country [USA], the fact remains that they are nition, is directed toward women and restricts them
not systematically denied power simply because of to less powerful and/or disliked roles.
being born a certain sex, as women are.” Second, few A common example of this trade-off for women
people are universally oppressed. Given the wide is the stereotypically incompatible roles of mother
diversity of social markers used to categorize people, (warmth) with employment (competence). In the
very few of us escape being unjustly privileged by eyes of college student raters, when professional
some marker in some contexts. Third, having privi- women took on the role of mother, these women
lege is not the equivalent of being oppressive; and traded perceived competence for perceived warmth
fourth, being oppressed does not eliminate the pos- (Cuddy, Fiske, & Glick, 2004). In contrast, profes-
sibility of being oppressive. Although social catego- sional men who became fathers gained in warmth
ries likely affect how people treat each other, what without any reduction in their perceived compe-
individuals actually do within their social category is tence. This difference in perceptions of professional
their individual responsibility. mothers and fathers was not inconsequential
for women. Rather, raters predicted less interest
Sexism in Social Contexts in hiring, promoting, and educating professional
This basic understanding of how social categoriza- mothers, establishing a connection between sexist
tion, intersectionality, and systems of inequality stereotyping and sexist discrimination.
construct each individual’s social context helps us
better explore the concept of, and women’s experi- sexist prejudice
ences with, sexism. Sexism directed at women is the Sexist stereotyping describes the process of ascrib-
oppression or limiting of women “through a vast ing traits, roles, and occupations to women and
network of everyday practices, attitudes, assump- often goes hand-in-hand with sexist prejudice; that
tions, behaviors, and institutional rules” (Young, is, attitudes that serve to oppress women and girls.
1992, p. 180). There are three related, but concep- The attitudes that most typically affect women relate
tually distinct aspects to sexism: sexist stereotyp- to the stereotypic choice of being either warm or
ing, sexist prejudice, and sexist discrimination competent. Women who are stereotyped as warm,
(Lott, 1995). but not competent (e.g., housewives, the elderly)
face paternalistic prejudice, which is characterized
sexist stereotyping by pity and sympathy (Cuddy, Norton, & Fiske,
Although the specific contents of gender stereotypes 2005). Alternatively, women who are regarded as
may change over time (Diekman & Eagly, 2000), competent, but not warm (e.g., feminists, profes-
Fiske and her colleagues (2002) have identified the sionals) are challenged by envious prejudice, which
underlying mechanisms that drive the process of blends grudging admiration with envy and jealousy.
gender stereotyping. They reason that the contents Each combination is neither completely positive
of gender stereotypes can be filtered down to two nor completely negative, but rather reflects ambiva-
underlying dimensions: warmth (which includes lence (Glick & Fiske, 1996).

348 the psycholo gy o f wo men

 Generally, prejudice reflects antipathy toward its often maliciously motivated; and subtle sexist dis-
targets, and one component of sexist prejudice (hos- crimination, the most common type, that may pass
tile sexism) indeed expresses overtly disparaging unnoticed, may be unintentional, and is always dif-
attitudes (e.g., “Women seek to gain power by get- ficult to document and remedy (Benokraitis (1997).
ting control over men”; item from the Ambivalent Illustrative examples of each are sexist language and
Sexism Inventory) (Glick & Fiske, 2001). More jokes (blatant), discrete and intentional sabotage of
intuitively challenging to understand is benevolent women’s work (covert), and protective paternalism
sexism, which on its face appears positive. Benevolent and back-handed compliments (subtle).
sexism takes three forms: heterosexual intimacy At least two measures have been developed to
(e.g., “No matter how accomplished he is, a man is assess women’s experiences with sexist discrimina-
not truly complete as a person unless he has the love tion in general: The Schedule of Sexist Events
of a woman”), gender differentiation (e.g., “Many (Klonoff & Landrine, 1995) and a 25-item measure
women have a quality of purity that few men pos- of exposure to daily sexist events (Swim, Cohen, &
sess”), and protective paternalism (e.g., “A good Hyers, 1998). A general conclusion across studies
woman should be set on a pedestal by her man”). that use these measures is that women’s experiences
The distinguishing marker for benevolent sexism with sexist discrimination are virtually universal
is that it ultimately works to restrict women to lim- (Moradi & DeBlaere, 2010). Additionally, internal
ited roles. For example, although a “good” woman consistency reliabilities tend to be stronger within
deserves adoration, who decides which women are context-specific clusters of discriminatory experi-
good, and what do women need to do to remain in ences, and more specific subordinate constructs
good standing? Like hostile prejudice, benevolent have been well defined and researched. These spe-
sexism reflects a view of women as likeable or com- cific contexts include sexist discrimination based on
petent, but not both. appearance (e.g., body objectification, discussed
The “carrot” and “stick” implications of benevo- later), in relationships, in the workplace, and toward
lent sexism become clear in both group and indi- women as a group.
vidual research. At the broadest level, Glick, Fiske,
and colleagues’ (2000) comparison of 19 countries Interpersonal Discrimination
revealed that as men’s hostile sexism increased so In day-to-day relationships, Lott (1995) describes
did women’s endorsement of benevolent sexism. interpersonal sexist discrimination as attempts to
Similarly, individual women who were led to believe separate from women through exclusion, avoidance,
that research documented men’s negative attitudes and physical distancing. Research on interpersonal
toward women expressed stronger benevolently sexist discrimination documented that judges paid
sexist attitudes than did women who were assigned more attention to arguments made by male, as com-
randomly to either positive or no information con- pared to female, lawyers (MacCorquodale & Jensen,
ditions (Fischer, 2006). Both studies suggest that 1993); that participants taking memory tests
hostile and benevolent sexism are linked, function remembered the names of more famous men than
differently, and work together to perpetuate a power women (Banaji & Greenwald, 1994); and that male
hierarchy in which men dominate (Goodwin & students with female instructors signing up for class
Fiske, 2001). extra credit disrespectfully procrastinated more than
the other student–teacher combinations (Louie &
sexist discrimination Tom, 2005).
Sexist discrimination describes overtly negative acts
directed toward women and girls because they are Workplace Discrimination
female, as well as patronizing acts that assert male In the workplace, findings with general measures
superiority. These acts can include extreme forms of of sexist discrimination converge with the more fully
violence against specific women as well as less pro- developed literature on sexual harassment. In the
nounced, yet insidious everyday forms that are vir- workplace, harassment can involve obvious abuses
tually universal. Our focus first is on the latter, and of power (quid pro quo harassment) or take on
then we will return to the former. more covert and subtle forms to create a chill-
Generally, sexist discrimination encompasses ing educational or work climate (hostile work envi-
three forms: blatant sexist discrimination that is ronment harassment), such that the latter fits with
intentional, visible, and easily documented; covert our focus here on everyday discrimination. Similar
sexist discrimination that is hidden, purposeful, and to other forms of male violence against women, the

m or adi, yode r 349

prevalence of sexual harassment is high (likely 50%; These common beliefs and activities can lay the
Fitzgerald, 1993). Importantly, prevalence rates groundwork to take the next step toward dehuman-
likely reflect underestimates of sexual harassment izing or objectifying women: calling women degrad-
because targets commonly fail to label behaviors that ing names, judging and ogling women’s bodies,
meet criteria for defining harassment as harassment ridiculing and harassing women, trying to control
(Koss, Goodman, Browne, Fitzgerald, Keita, & women, and so on. Both steps build to set the con-
Russo, 1994), and ambiguities surround what con- text for the possibility of escalated violence.
stitutes “unwanted” and “nonconsensual” (key ele- There is growing piecemeal evidence to support
ments in the definition of sexual harassment) these proposed linkages, although theoretically
behaviors (Muehlenhard, Powch, Phelps, & Giusti, based, programmatic research is sorely needed. For
1992). In terms of responses to harassment, some example, college men who enjoyed sexist humor
women blame themselves and minimize the sever- also were found to harbor destructive rape attitudes
ity of their experiences (Kelly & Radford, 1996), as well as report a higher likelihood of using sexual
discrepancies exist between how hypothetical tar- coercion (Ryan & Kanjorski, 1998). This relation-
gets think they would respond (e.g., confrontation) ship is mutually reinforcing: college men exposed
compared to how most targets actually respond to a confederate who engaged in sexual harass-
(e.g., endurance, denial, detachment, and illusory ment or who was generally sexist subsequently told
control) (Fitzgerald, Swan, & Fischer, 1995), and more sexist jokes to a female student (Angelone,
some women’s resilience challenges definitions that Hirschman, Suniga, Armey, & Armelie, 2005).
demand devastation as necessary for legal restitution. Furthermore, male sexual aggressiveness has been
connected to exaggerations of the masculine gender
Discrimination and Violence role or hypermasculinity (Driscoll, Kelly, &
There is a subtle stepwise progression from the Henderson, 1998; Franchina, Eisler, & Moore,
seemingly minor daily hassles of being female cap- 2001; Murnen, Wright, & Kaluzny, 2002; Weisbuch,
tured in examples of interpersonal sexist discrimi- Beal, & O’Neal, 1999), reasserting masculinity
nation to more obviously troublesome instances of (Eisler, Franchina, Moore, Honeycutt, & Rhatigan,
sexual harassment in the workplace to even more 2000; Messerschmidt, 2000), and the masculine
destructive forms of male violence against women. ideal of control and dominance (Anderson &
Although it certainly would be sensationalistic to Umberson, 2001; Reitz, 1999). Similarly, men’s
propose that people can readily move from daily openly sexist attitudes have been associated with
slights directed toward women to despicable forms tolerance of sexual harassment (Russell & Trigg,
of violent misogyny toward women as a group, as 2004) as well as with men’s rape proclivity and mis-
well as toward individual women in the forms of perceptions that rape victims really “wanted it”
battering and rape, the social psychological litera- (Abrams, Viki, Masser, & Bohner, 2003). In fact,
ture on aggression clearly documents how major a meta-analysis of 72 studies of beliefs in rape myths
atrocities like genocide (Staub, 1989) build on a found greater rape myth acceptance among people
series of increasingly violent actions. This contin- endorsing traditional, polarized gender roles and
uum of increasing acceptance of, and engagement harboring adversarial sexual beliefs (Anderson,
in, aggression serves to gradually disempower its tar- Cooper, & Okamura, 1997). Furthermore, these
gets and draws on two important processes: polar- linkages are not confined to men: some women help
ization (i.e., regarding the target of violence as perpetuate rape myths through their own distrust
different from me) and objectification (i.e., regard- of, and hostility toward, women (Cowan, 2000).
ing the target as not human). All forms of male violence against women
Gender polarization is commonly assumed and (including sexual harassment, sexual abuse, and
reinforced when differences between women and male partner abuse) share several recurrent themes
men are regarded as inherent and natural (i.e., sub- (Yoder, 2007). First, understanding them is com-
jectively essentialized; Prentice & Miller, 2007), promised by definitional ambiguities about what
when masculinity and femininity are exagger- constitutes “unwanted” and “nonconsensual” behav-
ated, when we fall back on gender stereotyping iors (Muehlenhard et al., 1992) and language that
to think about and react to individuals, when can mask their severity (McHugh, Frieze, & Browne,
subtly sexist jokes highlight and perpetuate gender 1993). For example, “family violence” implies equal
differences, when gender roles become rigid and intent to harm, equal perceived vulnerability, and
strictly enforced, and so on (Yoder, 2007, p. 340). equal harm—equality rarely achieved in male

350 the psycholo gy o f wo men

violence against women (Gordon, 2000)—and cannot explain another’s; and systems of inequal-
passive-voice language (e.g., “she was beaten”), ity highlight how power differentials and status
which fails to acknowledge the responsibility of implications attached to gender cannot be ignored.
the perpetrator (Lamb & Koen, 1995). Second, In sum, these understandings provide a cogent
these ambiguities often serve to invalidate and rationale for considering women’s mental health
make invisible women’s experiences (Parrot & within the gendered social contexts described thus
Bechhofer, 1991), even at times for women them- far, and engaging in feminist psychotherapy (see
selves (e.g., unacknowledged date rape victims who Enns chapter).
confine their definition of rape to stranger rape)
(Kahn, Mathie, & Torgler, 1994). Still, carefully Gender and Psychological Disorders
collected data establish some realistic estimates The lifetime prevalence of having a psychological
of abuse prevalence across American women’s life- disorder appears to be similar for women and men
times: 15% for rape and sexual assault among adult (Kessler et al., 2005), but gender differences are
women (Rozee & Koss, 2001) and 21%–34% for found in the rates of some specific psychological
physical assault by an intimate adult partner disorders. For example, women appear to be at
(Browne, 1993; Randall & Haskell, 1995). Finally, greater risk for anxiety and mood disorders; men,
although even women may minimize the violence for impulse control and substance use disorders
in their experiences as a way to cope with their (Kessler et al., 2005). Such gender differences may
trauma (Kelly & Radford, 1996; Koss, Figueredo, be shaped by essential gender differences in disor-
Bell, Tharan, & Tromp, 1996), all of these forms of der prevalence, but additional factors may contrib-
trauma have serious physical and psychological ute to these observed gender differences as well.
consequences that heighten women’s distress and For example, an important limitation of available
jeopardize their well-being. Common psychologi- gender ratio data is that they are typically drawn
cal outcomes resulting from male violence against from nonprobability samples and can therefore
women include reduced self-esteem, heightened reflect sampling bias rather than actual gender dif-
feelings of helplessness and entrapment, self-blame, ferences in the population (Hartung & Widiger,
depression, anxiety, psychological numbing, and 1998).
fear (for example, see Goodman, Koss, & Russo, An additional consideration is that diagnostic
1993; Koss, 1990). Indeed, these consequences criteria for many psychological disorders may be
can spill over onto all women, even those not the gendered. For instance, the Diagnostic and Statistical
immediate targets of violence, because women, not Manual (DSM) diagnostic criteria for depression
men, live their everyday lives under the constant and personality disorders have been shown to evoke
threat of these forms of psychological, physical, and gender (and other demographic) categorization in
sexual abuse (Hollander, 2001; Thompson & undergraduate students (Landrine, 1988, 1989).
Norris, 1992). Such gender stereotyped disorders may contribute
to under-reporting symptoms that transgress ste-
Women’s Mental Health in Context reotypic gender roles (e.g., Bekker, 1996; Sigmon
As the previous section illustrates, examining gender et al., 2005). Relatedly, therapists may make gen-
and sexism in social context lays a foundation for der-stereotypical diagnoses more readily than gen-
understanding women’s mental health. Under- der-nonstereotypic diagnoses. For instance, Potts
standing the processes of social categorization and and colleagues (1991) found that medical and
intersectionality and the structure of systems of mental health practitioners diagnosed depression
inequality makes it clear that there is no genderless more frequently among women than among men in
person (Wise & Rafferty, 1982) and no generic patient groups who both did, and did not, meet cri-
woman (Landrine, 1985). Thus, every client comes teria for depression. Thus, depression was overdiag-
to therapy, and every therapeutic interaction takes nosed among women who were not depressed and
place, within a gendered context that includes auto- underdiagnosed among men who were depressed.
matically activated expectations (Devine, 1989) Similarly, in an analogue study, Robertson and
that, if left unexamined, can become detrimentally Fitzgerald (1990) found that therapists were more
self-fulfilling (Skrypnek & Snyder, 1982). Social likely to diagnose a videotaped male actor with a
categorization reminds counseling psychologists severe mood disorder if he described his professed
that gender matters; the intersections of social rep- “happy” marriage as nontraditional compared to
resentations make it clear that one’s own experiences traditional. Thus, any real gender differences in the

m or adi, yode r 351

prevalence of specific psychological disorders must contexts of women’s lives, including the continuum
be interpreted in the context of potential gender ste- of sexism from subtle gender role expectations to
reotyping of the disorders themselves, as well as of violence, can lead to pathologizing women for the
resultant biases in reporting symptoms and diagnos- consequences of those contexts.
ing disorders.
An additional consideration is that some disor- Sexist Discrimination and Women’s
ders may actually reflect extremes of feminine Mental Health
gender role socialization. For instance, Gelfond A growing body of research reveals the connection
(1991) conducted an exploratory comparison of between various manifestations of sexist discrimina-
independent, average, and agoraphobic women. tion and women’s mental health. Paralleling our ear-
The independent and average women were catego- lier discussion, we discuss potential mental health
rized as such based on their high or average scores implications of everyday interpersonal sexism,
on a measure of independent travel and activity. The sexism in the workplace, and discrimination and
agoraphobic group scored low on this measure, self- violence, adding a fourth section to explore sexual
identified as phobic, and scored as phobic on the objectification.
Brief Symptom Inventory (BSI). Gelfond noted
substantial similarities between the “average” and interpersonal discrimination
“agoraphobic” women. Specifically, she found that Kobrynowicz and Branscombe (1997) found that
over half of the women designated as average scored women’s perceptions of sexist discrimination
near the clinical range for agoraphobia (on the BSI), directed toward women in general were associated
and these average women were similar to agorapho- with depressive symptoms. Numerous studies also
bic women in their negative attitudes about travel- have linked women’s reports of personal experiences
ing alone, limited directional skills, and low use of of sexist events, across the past year or over their
recreational resources. In contrast, independent lifetime, with a range of psychological symptoms
women did not share these characteristics. Thus, and overall psychological distress; this link has been
“average” and “agoraphobic” women were similar in supported with predominantly white and African
their symptoms as well as in terms of the attitudes, American samples, college and community samples,
skills, and behaviors assessed by Gelfond. Gelfond predominantly heterosexual and lesbian and bisex-
suggested that these similarities were rooted in the ual samples, and with women seeking counseling
contexts of women’s lives (e.g., learning experiences, services (e.g., Berg, 2006; Fischer & Holz, 2007;
fear of crime) rather than in intrapsychic factors, Landrine, Klonoff, Gibbs, Manning, & Lund,
and that agoraphobia might reflect the extremes of 1995; Moradi & Funderburk, 2006; Moradi &
women’s learning histories. Subich, 2002a, 2003; Szymanski, 2005a). Although
A related issue is that the DSM may pathologize most studies examined retrospective reports of
feminine gender socialization more so than mascu- women’s experiences of sexism, Swim and associates’
line gender socialization. To illustrate this point, (2001) conducted a 2-week diary study and found
Caplan (1995) submitted “Delusional Dominat- that the number of daily sexist hassles reported by
ing Personality Disorder” for DSM consideration. college women predicted their end-of-day anger
Designed to reflect extremes of stereotypic mascu- and anxiety. Collectively, these studies suggest that
linity, this “disorder” included characteristics such sexist discrimination, from the global to the long-
as the inability to establish and maintain interper- term to the daily, is associated with psychological
sonal relationships, inability to identify and express distress.
feelings, and difficulty expressing empathy. This fic-
titious disorder was never seriously considered for workplace discrimination
inclusion in the DSM. By contrast, “Self-defeating These patterns of association between discrimi-
Personality Disorder,” which placed responsibility nation and distress are also documented for
for interpersonal mistreatment with the target and workplace harassment. Women’s experiences of
included feminine stereotypic criteria such as unso- sexual harassment have been related to anxiety
licited self-sacrifice, was slated for inclusion in the attacks, headaches, sleep disturbances, gastrointesti-
DSM-III. It was withdrawn only after a public nal disorders, nausea, weight loss or gain, and crying
outcry charging that it blamed survivors of abuse, spells (Crull, 1982; Gutek, 1985) and can lead to
mostly women, for being abused (Caplan & Gans, body dissatisfaction and disordered eating (Harned,
1991). As this example illustrates, ignoring the 2000). Women targets of sexual harassment

352 the psycholo gy o f wo men

described fear, anger, anxiety, depression, self- disorders (Darves-Bornoz, Lemperiere, Degiovanni,
questioning, and self-blame (Koss, 1990); their con- & Gaillard, 1995), and bodily self-harm (Shaw,
fidence can be shaken (Satterfield & Muehlenhard, 2002). In sum, sexism as a form of trauma has
1997); their job satisfaction may be undermined strong implications for women’s distress and well-
(Chan, Tang, & Chan, 1999); and their perceptions being.
of academic climate can deteriorate (Cortina, Swan,
Fitzgerald, & Waldo, 1998). Furthermore, the sexual objectification
effects of workplace mistreatment, including non– Sexual objectification is a specific manifestation of
gender-specific derogation, sexist treatment, and sexism that has received increasing attention in
sexual harassment, can be additive, leading to more research on women’s mental health. Messages that
negative work and psychophysical health outcomes equate girls’ and women’s value with white hetero-
when combined (Lim & Cortina, 2005). sexual standards of beauty, thinness, and sexual
availability to men are an omnipresent part of girls’
discrimination and violence and women’s socialization in Western cultures (APA
As we saw earlier, workplace sexual harassment falls Task Force on the Sexualization of Girls, 2007) and
along a broader continuum of sexist discrimination with increasing globalization, are being exported to
that ranges from everyday interpersonal hassles and non-Western cultures (Becker, 2004). These mes-
exclusion to severe forms of male violence against sages communicate standards that most girls and
women (e.g., sexual assault to femicide). The rela- women cannot achieve; indeed, the term normative
tionship of various forms of sexism with mental discontent has been used to capture women’s near
health outcomes can be understood through Root’s ubiquitous dissatisfaction with their bodies (Rodin,
(1992) dimensions of stressful trauma. Insidious Silberstein, & Striegel-Moore; 1984). Fredrickson
trauma results from being devalued because of an and Roberts (1997) offered objectification theory as
individual characteristic, such as gender, and it has a framework for explaining how women’s socializa-
obvious connections with interpersonal sexist dis- tion and body dissatisfaction can contribute to
crimination. At the other extreme, direct trauma mental health problems that have higher prevalence
results from being forced to commit an atrocity or among women than among men.
from maliciously perpetrated violence directly tar- Objectification theory posits that women’s life
geting an individual, with the latter relating here to experiences and socialization include routine expo-
victims of sexual harassment, sexual assault, and sure to sexual objectification from external sources
battering. Although the DSM diagnosis of Post- (Fredrickson & Roberts, 1997), and diary studies
Traumatic Stress Disorder captures the situational support sexual objectification as a dimension of
context for trauma, the remaining intrapsychic daily experiences of sexism in women’s lives (Swim,
DSM diagnoses do not, and observed connections Hyers, Cohen, & Ferguson, 2001). Within the
between these diagnoses and trauma are growing. objectification theory framework, sexual objecti-
For example, violence and trauma have been fication experiences are thought to socialize girls
linked to women’s depression (Cutler & Nolen- and women to treat themselves, to varying degrees,
Hoeksema, 1991; Hamilton & Jensvold, 1992) as as objects to be looked upon and evaluated based
well as to personality disorders (Lerman, 1996). upon bodily appearance (Fredrickson & Roberts,
Histories of sexual abuse and other violence were 1997). This individualized internalization of an
over-represented among women in substance abuse observer’s perspective upon one’s own body is called
programs (Teets, 1995), and incest rates were found self-objectification. Self-objectification is manifested
to be higher among alcoholic than nonalco- at its extreme by persistent body surveillance, or
holic women (Beckman, 1994). In studies of the act of “habitual monitoring of the body’s out-
women with eating disorders, sexual abuse or rape ward appearance” (Fredrickson & Roberts, 1997,
was reported in half or more cases, with sexual p. 180). Appearance-focused self-objectification
assault experiences emerging at even higher levels and manifest body surveillance parallel McKinley
(over 75%) in inpatient samples (Root, 1991; Tripp and Hyde’s (1996) earlier conceptualization of
& Petrie, 2001) and with recovery rates diminished body surveillance as a component of objectified
among women with a history of chronic physical body consciousness.
and sexual abuse (Hesse-Biber, Marino, & Watts- High levels of self-objectification and manifest
Roy, 1999). Sexual abuse has been connected with body surveillance are posited to promote body
somatization disorders (Morrison, 1989), psychotic shame resultant from perceived failure to meet an

m or adi, yode r 353

internalized or cultural appearance standard; Girls and Women in Relationships
increase anxiety about physical safety and about Our argument that to understand an individual one
when and how one’s body will be evaluated; reduce must take into strong consideration that individual’s
awareness of internal bodily states, such as satiety social context challenges us to closely examine girls’
and physiological sexual arousal; and interrupt and women’s relationships as the most immediate
cognitive processing and flow experiences or what forms of everyday social interaction. Furthermore,
Csikszentmihalyi (1982, 1990) described as “rare given our interest in power, privilege, and oppres-
moments during which we feel we are truly liv- sion as driving forces in a general system of social
ing, uncontrolled by others, creative and joyful” inequality, it becomes important to examine how
(Fredrickson & Roberts, 1997, p. 183). Objectification girls and boys, women and men operate within
theory proposes that this chain of relations—from a system of differential power and status. Here, we
external sexual objectification to internalized self- will look at girls and women in the context of their
objectification and body surveillance, to increased interpersonal relationships, starting with the social-
body shame and anxiety, reduced internal bodily izing relationships of childhood, then turning to
awareness, and disrupted flow—can exacerbate intimate relationships in adulthood.
women’s risks for depression, sexual dysfunction, and
eating disorders (Fredrickson & Roberts, 1997). Girls and Socialization Practices
Since its publication, research on objectification A comprehensive model of gender development
theory has proliferated and supported the direct that explores the differentiation of girls and boys is
and indirect relations of sexual objectification expe- offered by Bussey and Bandura (1999; 2004).
riences, self-objectification/body surveillance, and In general, these sociocognitive theorists regard
body shame with eating disorder and depressive gender socialization as the combination of a child’s
symptomatology (for review, see Moradi & Huang, learning through socializing agents (e.g., parents,
2008). Importantly, some of these aspects of the schools, media, and peers) with the child’s own cog-
theory also have been tested and supported with nitive processing and within a general cultural con-
women who identified as African American text. It is the embeddedness of socialization within a
(Buchanan, Fischer, Tokar, & Yoder, 2008), Deaf child’s culture, in this case a culture that emphasizes
or hearing impaired (Moradi & Rottenstein, 2007), gender polarization (Bem, 1993), that shapes each
and lesbian (Kozee, Tylka, Augustus-Horvath, & child’s ways of thinking (e.g., gender schema), that
Denchik, 2007). These latter studies also point leads to the self-regulation of behavior (e.g., repro-
to the importance of considering group-specific ducing what is normative for one’s gender), and that
variables, such as skin tone surveillance (Buchanan influences self-efficacy. Indeed, children’s actions are
et al., 2008), and Deaf cultural identity atti- so context-dependent that they have been shown to
tudes (Moradi & Rottenstein, 2007). In addition, vary according to the salience of gender in specific
contexts-heightening self-objectification (e.g., wear- contexts (Messner, 2000).
ing a swimsuit in front of a full-length mirror, even Lips (2002) synthesized the massive body of
in private) have been shown to inhibit women’s per- research on gender differentiated socialization prac-
formance in math and other concentration-related tices and outcomes to identify the pervasive meta-
tasks (e.g., Fredrickson, Roberts, Noll, Quinn, & message conveyed by girls’ socialization experiences.
Twenge, 1998; Quinn, Kallen, Twenge, & Fredrickson, She argues that girls are raised in a culture that pre-
2006). By contrast, research is limited on other objec- pares them for powerlessness. Although both girls
tification theory variables (e.g., sexual dysfunction). and boys begin with the potential to develop wings
Still, objectification theory provides an integrative and take flight, typically girls’ socialization experi-
framework for understanding how women’s social- ences clip their wings by teaching them habits of
ization can be translated into psychological risk silence, self-doubt, and acquiescence. In contrast,
factors and symptomatology. Consistent with femi- boys learn to achieve mastery over tasks and are
nist conceptualizations, research on objectification empowered to influence others. In sum, socializa-
theory points to changes needed at the societal level tion practices work to maintain the status quo of
(e.g., reducing the sexual objectification of women) gendered systems of inequality.
and also highlights potentially useful strategies at Although the literature exploring specific social-
the individual level (e.g., resisting internalized self- ization practices is vast, some recent examples
objectification) to reduce women’s psychological provide background for Lips’ conclusion and
distress. its continued relevance. For example, parents

354 the psycholo gy o f wo men

allowed boys greater risk-taking (Morrongiello & moderate difference in adult women’s and men’s
Hogg, 2004); fathers commonly told sons family self-esteem (Kling, Hyde, Showers, & Buswell,
stories with autonomy themes (Fiese & Skillman, 1999). Even more germane to our argument here
2000), whereas mothers often included emotional is the persistent superiority of men’s self-reported
references in their conversations with daughters agency or instrumentality; that is, how much an
(Flannagan & Perese, 1998); and computer games individual believes she or he can take charge of and
that target male audiences emphasized efficacy accomplish goals independently (Helgeson, 1994).
(Whitley, 1997). In their comprehensive review
of the gendered lessons taught in schools, the Women in Intimate Relationships
Sadkers (1994) concluded that girls learned to speak Worell (1988) describes the defining features of
quietly, to defer to boys, to value neatness over inno- close relationships: They are expected to endure over
vation, and to stress appearance over intelligence. In time and to provide each individual with respect,
the media, “bad” cartoon characters deviated from intimacy, caring, concern, support, and affection.
gender stereotypes (Ogletree, Martinez, Turner, & Specific romantic attachments go beyond general
Mason, 2004), birth announcements heralded hap- close relationships to include sexual passion, exclu-
piness for girls and pride for sons (Gonsalez & siveness, and commitment. The degree to which
Koestner, 2005), and even books touted as “nonsex- romantic attachments live up to an individual’s
ist” described girls’ personalities, domestic chores, expectations, preferences, and conceptualization
and leisure activities using feminine stereotyping of what constitutes a good relationship is reflected
(Diekman & Murnen, 2004). Among peers, the in relationship satisfaction, which in turn is posi-
more girls played only with other girls, the more tively associated with psychological and physical
they engaged in gender-stereotypic behavior (Martin well-being. Supportive relationships enhance an
& Fabes, 2001). individual’s responses to stress, self-esteem, feelings
Indeed, one of the strongest, overarching pat- of self-efficacy, reported happiness, and resistance
terns researchers have identified in the socialization to loneliness, depression, and serious illness (Worell,
of girls and boys is the typicality of sex-segregated 1988).
play and preferences (Ruble & Martin, 1998).
Paralleling the sex segregated world of employment multiple roles
(Padavic & Reskin, 2002), girls are drawn to play- Romantic attachments are one piece of the myriad
ing with other girls (rather than actively avoiding of interpersonal relationships that compose a healthy
boys) (Maccoby, 1990). The reasons why girls often- individual’s life. Two views of women’s multiple
times find girls more appealing than boys are roles envision them as engendering either scarcity
intriguing. Girls tend to share the belief that feel- or enhancement (Barnett & Hyde, 2001). The scar-
ings are important (in contrast to boys’ valuing of city hypothesis posits that more roles bring conflict
shared activities and interests), and girls’ interac- based in both competing time demands and spill-
tional style typically is marked by cooperation, over from one role to another. In contrast, the
politeness, and interaction with others (as opposed enhancement hypothesis contends that multiple
to being focused on dominance and restrictive inter- roles invigorate individuals and can even serve as
action) (Neppl & Murray, 1997; Voss, 1997). buffers against undesirable consequences when
In-group evaluation bias is strong among both sexes, troubles emerge in any one role or subset of roles
and girls’ valuation of gender equality tends to (Crosby, 1991). The common application of these
strengthen across elementary through middle school ideas to women’s lives concentrates on women’s
(whereas boys’ weakens) (Ruble & Martin, 1998). employment, partner, and parental roles.
Finally, children simply like peers better when they For most women, role conflict and enhancement
play stereotypically with same-sex friends (Colwell coexist. For example, Rankin (1993) studied 118
& Lindsey, 2005). The results of these peer prefer- employed mothers of preschoolers aged 23–43
ences then is that girls and boys grow up in strik- months. Most described their lives as stressful, citing
ingly different social contexts. lack of time, child-related problems, and maternal
Finally, a major component of sociocognitive guilt. Simultaneously, these women reported per-
theory is self-efficacy, the belief that one has the sonal benefits, financial rewards, and improved
capabilities to produce positive outcomes for one- family lives as the result of their multiple roles.
self. The generalized, long-term effect of cultural Febbraro (2003) offers an insightful resolution
preparedness for powerlessness may be a small to to these trade-offs that acknowledges both conflict

m or adi, yode r 355

and enhancement by calling on structural accom- A large-scale study of 445 women and 457 men lent
modations in the workplace rather than personal some credibility to this speculation by finding that,
role redefinition or unrealistic reactive role behavior indeed, women attached less importance to pure
(i.e., being a do-it-all superwoman) (also see Tiedje, pleasure, conquest, and relief of tension through
2004). These structural changes can include less sexual activities (Leigh, 1989). However, a closer
stressful flexible work schedules (Matsui, Ohsawa, look at the data revealed that, although women did
& Onglatco, 1995), autonomy to be absent from rank emotional closeness first and men gave plea-
work (Moen & Forest, 1990), supportive supervi- sure their top priority for engaging in sexual behav-
sors and workplace cultures, opportunities for iors, regardless of sexual orientation, men ranked
advancement (Galinsky, Bond, & Friedman, 1996), attachment as a close second. Furthermore, men
and maternity leave (Hyde, Klein, Essex, & Clark, rated pleasing their partner as more important than
1995). Unfortunately, though, women’s real-life women did. Additional research concluded that
choices often force them to make more family-role how women and men think about their own sexual-
accommodations than work-role redefinitions ity (i.e., their sexual schema) (Andersen, Cyranowski,
(Matsui et al., 1995). J.M., & Espindle, 1999), as well as about sexually
However, even within the often unyielding con- related terms (Noland, Daley, Drolet, Fetro,
straints of workplace demands, the negative conse- McCormack Brown, Hassell, & McDermott, 2004),
quences of multiple roles can be mitigated by having was remarkably similar.
strong social supports, both instrumental and emo- As for sexual attitudes and behaviors, Oliver and
tional. For example, Ozer (1995) found that a Hyde’s (1993) meta-analysis found widespread sim-
woman’s belief in her ability to enlist the help of her ilarities between women and men, with the largest
spouse for childcare predicted well-being and singular differences being men’s considerably more
reduced distress. Family emotional support reduced permissive attitudes about casual sexual behaviors
women’s family-related stress, which in turn low- and higher rates of masturbation. Moreover, look-
ered family-to-work interference (Bernas & Major, ing across the 1960s through the 1980s, gender dif-
2000) and contributed to women’s sense of mastery, ferences in sexual attitudes and behaviors narrowed
which then enhanced well-being (Martire, Stephens, considerably.
& Townsend, 1998). Gentry (1998) asked undergraduates to evaluate
a hypothetical woman or man who was portrayed
making relationships work for women as either monogamous or engaged in multiple het-
The next obvious question then becomes how to erosexual relationships, as well as enacted low, mod-
make relationships work for women. Popular self- erate, or high levels of sexual activity. On overt
help books focused on women’s intimate relation- measures, women targets were treated similarly
ships promulgate three general myths: women do to men, such that both female and male promiscu-
not know what will make them happy in a relation- ous and highly active targets were disparaged.
ship (ignorance); women lack the skills to initiate Women preferred the woman target described as
and maintain satisfying relationships (incompe- below average in sexual activity in contrast to men’s
tence); and the gender polarity between women and preference for the more active stimulus woman,
men in heterosexual relationships makes them basi- who was regarded as liberal and assertive. Taken
cally incompatible (Worell, 1988). Not surprisingly, together, these studies describe a newly evolving,
the more adults were exposed to these popular complex image of sexuality that combines permis-
myths through the media, the more dysfunctional sive expressed attitudes and some overt acceptance
and unrealistic were their beliefs about romantic of sexually assertive women.
attachments (Shapiro & Kroeger, 1991). Despite Additional studies, however, raise the specter
the popular wisdom that women do not know what that the traditional double standard of women’s
they want in relationships, researchers find that they and men’s sexuality has not fully disappeared. For
actually do: Quite simply put, women want inti- example, undergraduate students concocted a stron-
macy and equality. ger justification of love for an extramarital partner
when the transgression was committed by a woman
Intimacy and Sexuality than by a man (Sprecher, Regan, & McKinney,
Popular wisdom often portrays women as seeking 1998). Women pornography actors were rated more
genuine intimacy through their sexuality, as opposed harshly than were men (Evans-DeCicco & Cowan,
to men’s simplistic and hedonistic pleasure-seeking. 2001), and unobtrusive observations of Wisconsin’s

356 the psycholo gy o f wo men

procedures for establishing paternity and child has remained stable from 1965 through 1998
support uncovered that women were questioned (Bianchi, 2000). Becoming a first-time parent com-
far more extensively about their sexual practices monly reshapes women’s home (increases) and
and partners than were men (Monson, 1997). employment (reduces) lives, whereas men’s lives
Paralleling the pattern we have seen overall for sexist remain virtually unaltered (Sanchez & Thomas,
discrimination, the double standard for women’s 1997).
and men’s sexuality may simply have shifted from Recurrent themes of intimacy and equality are
more overt to more covert and subtle expressions. also central in lesbians’ descriptions of their roman-
Our discussion thus far has examined sexual atti- tic attachments. For example, Eldridge and Gilbert’s
tudes and behaviors of and about women relative (1990) extensive nationwide survey of 275 dual-
to men. But, women’s sexuality must also be consid- employed couples concluded that, despite folk
ered on its own terms, beyond phallocentirc defini- wisdom to the contrary, lesbian relationships were
tions of sex that render women’s experiences of stable, enduring, and committed, although often
sexual behavior, pleasure, and orgasm implicit largely invisible to outsiders. Relationship satis-
or even inconsequential in the sexual script (see faction was related not only to sexual intimacy, but
Fassinger & Arseneau, 2008). To this end, atten- also to recreational (common interests) and to intel-
tion to women’s same-sex sexuality can inform lectual intimacy, although not with social intimacy
understanding of women’s sexuality in general. For (possibly a causality of secrecy). Unlike both gay
example, available data suggest that the most preva- male and heterosexual partners, lesbian partners
lent dating script among lesbians is a friend- tend to perform an equal number of household
ship script, in which a friendship grows and is tasks (Kurdek, 1993). Beyond simple household
gradually expressed sexually (Rose & Zand, 2000). contributions, lesbian couples mention equality
Also, sexuality between women may not be focused of influence as a core goal (Eldridge & Gilbert,
on a single act of “sex” but rather on a sexual episode 1990) and actually use bilateral influence strategies
comprised of a range of behaviors that might or (Rosenbluth & Steil, 1995) and psychologi-
might not result in orgasm(s) (Fassinger & Arseneau, cally intimate communication (Mackey, Diemer,
2008; Rose, 2000). Such conceptualizations chal- & O’Brien, 2000) to achieve relationship equality
lenge us to think about a broad range of sexual and hence relational satisfaction.
behaviors that constitute sexual episodes in a range
of relationship contexts for women. Power in Women’s Relationships
As we saw previously in our discussion of social
Egalitarian Relationships dominance theory and systems of inequality, a core
Turning to the second quality women seek in their point for understanding women in context concerns
romantic attachments, equality, egalitarianism is their relatively disempowered intergroup status in
now rated as more desirable in marriage than it was relation with men. Although generally regarded as
40 years ago, reaching almost universal levels among influencing broad sociopolitical issues, social domi-
college students (Gilbert & Rader, 2001). In addi- nance theory contextualizes how these macroscopic
tion, women who see themselves as an equal partner forces penetrate into the most intimate and proxi-
in their marriage reported higher relationship satis- mal of women’s relationships.
faction and were less likely to resort to using power Starting with women’s sexuality, interpersonal
strategies to get their way (Donaghue & Fallon, power and sexual communication affect the safe
2003). However, true behavioral equality appears to sexual practices of African American (Bowleg,
be achieved in only a minority of marriages (Steil, Lucas, & Tschann, 2004) and European American
1997). Rather, women perform a disproportionate heterosexually active adolescents (Gutierrez, Oh, &
share of household labor (Bond, Thompson, Gillmore, 2000) and Mexican-born married women
Galinsky, & Prottas, 2003; Thomas, 2002) regard- (de Snyder, Acevedo, Diaz-Perez, & Saldivar-
less of socioeconomic class (Wright, 1992) and race/ Guaduno, 2000). In one study of sexual decision
ethnicity (John & Shelton, 1997). Imbalances also making, only 12% of couples in which the man
appear in women’s general caregiving (Gerstel & made the decision used condoms more than half the
Gallagher, 2001) and in the caretaking of children. time. This figure jumped to 49% when women
Mothers average over 11 more hours each week of made the decision and to 32% when both partners
child care than do fathers (Bond et al., 2003), about decided (Osmond et al., 1993). Through all these
5.8 waking hours of every day, a contribution that factors runs a strand of power: the more powerful

m or adi, yode r 357

person, both personally and interpersonally, con- Coltrane’s (1996), associated enhanced earnings
trols how sexuality is practiced (Amaro, Raj, & with more household sharing. Not surprisingly, the
Reed, 2001; Quina, Harlow, Morokoff, Burkholder, less emotionally involved partner in a relationship
& Deiter, 2000). Thus, violence and risk-taking has more power, and that partner is more commonly
prevention programs aimed at women must foster the man (Sprecher & Felmlee, 1997). Lennon and
women’s empowerment in negotiating sexual Rosenfield (1994) found that women who had
encounters and in ending those that put them at fewer alternatives to marriage because of limited
risk (Croteau, Nero, & Prosser, 1993). economic resources, in contrast to more indepen-
Power in an intimate relationship involves two dent women, were more likely to view unequal divi-
key dimensions that may be important in commu- sions of labor as fair. Although caregiving certainly
nication about safe sexual practices: relationship enriches people’s lives, it rarely benefits the caregiver
control and decision-making dominance (Pulerwitz, with anything exchangeable and thus does not
Gortmaker, & DeJong, 2000). Relationship control confer power to women (Pratto & Walker, 2004).
is exercised when women project that their male One of the most puzzling paradoxes of this litera-
partner’s response to them will include violence ture is women’s depressed entitlement, the finding
and/or anger, both within and outside the sexual that women often perceive objectively imbalanced
arena. For example, nonsexual signs of relationship domestic contributions as fair (Thompson, 1991).
control include doing what one’s partner wants to Major (1993) concluded that this apparent incon-
do most of the time and having a partner dictate sistency could be explained by considering women’s
what one wears. Decision-making dominance comparison group of other women, not men them-
includes deciding with whose friends the couple selves. In addition, women who compared them-
interacts, whether they engage in sexual relations, selves to normative standards of what women should
and what they do together. Further research is do felt inadequate despite their disproportionate
needed to directly tie these dimensions to sexual overcontributions. Alternatively, women who com-
risk-taking, although at this time the empirical and pared their husband’s level of participation to their
theoretical foundation for expecting such linkages is own inputs, rather than to those of other men, had
strong. husbands who contributed more (Hawkins,
Although there is much overlap between lesbi- Marshall, & Meiners, 1995).
ans’ and heterosexual women’s dating scripts and However, if we consider depressed entitlement
relational desires for intimacy and equality, one within the global context of social dominance
of the most glaring differences is in the more com- theory, then we might expect depressed entitlement
monly achieved egalitarianism among lesbians to be related to gendered power differentials. Indeed,
(Eldridge & Gilbert, 1990; Klinkenberg & Rose, this linkage was established by Hogue and Yoder
1994). Certainly there are multiple bases for power (2003) in their experimental examination of wom-
differentials in all relationships (e.g., being more en’s depressed entitlement in self-pay. The gap
emotionally invested); however, compared to het- between women’s underpayment relative to men’s
erosexual relationships, the internal workings of allocation in a control condition disappeared when
lesbians’ relationships are freed from the gendered women’s status was raised through either gender- or
system of inequality. This comparison also high- education-related status manipulations. Further-
lights the largely subtle and invisible ways in which more, in a vignette study examining domestic con-
heterosexual relationships support and reflect the tributions, Swearingen-Hilker and Yoder (2002)
general gender system of social dominance. Thus, showed that raters’ endorsement of hostile sexism
to understand heterosexual women in the context was associated with viewing men’s household under-
of their intimate relationships, it becomes impor- contributions as fair, thus serving as a legitimating
tant to understand the balance of power between attitude supportive of the gendered system of
partners. inequality.
Whether or not women’s greater earnings can Although women generally may feel less unfairly
offset men’s social power is unclear. For example, treated than might objectively be predicted, those
Steil and Weltman’s (1991) study with women earn- women who do perceive inequities suffer in terms of
ing at least one-third more than their spouses found heightened distress, marital dissatisfaction (Golding,
that women still performed more than their equal 1990; Robinson & Spitze, 1992), and depression
share of domestic labor, but had more influence in (Bird, 1999). This may be one reason why women
decision-making. Other studies, such as Pyke and try to deny, rationalize away (Blain, 1994), or work

358 the psycholo gy o f wo men

out ways to juggle excessive demands (Hessing, others’); importance of group membership to self-
1994) rather than admit that unfairness threatens definition; attachment and connection with the
their marriage. Shifting to a more positive interpre- group; embeddedness of the collective identity in
tation, women exhibited a stronger sense of fair- one’s everyday relationships; behavioral involve-
ness if men participated, if the couple actively ments with the collective identity; and view of the
decided together how to allocate chores, and if they characteristics, ideology, and narrative of the group
felt their labor was appreciated (Hawkins et al., as self-relevant. Several identity models have been
1995). Indeed, women who get what they desire proposed to capture these elements of group iden-
(e.g., interpersonal gratification) were unlikely to tity for women. We review three prominent models
sense injustice (Thompson, 1991). here, with emphasis on empirical findings that elu-
In sum, egalitarian marital relationships are cidate their relevance for women’s experiences and
embedded in a more global context of social domi- mental health: Downing and Roush’s (1985) model
nance that works against their realization, despite of feminist identity development, McCarn and
women’s clear valuation of and benefits from them. Fassinger’s (1996) model of lesbian identity forma-
Weitzman’s (1994) review of research on multiple- tion, and Helms’ (1990, as cited in Carter & Parks,
role realism concluded that although many college 1996; Ossana, Helms, & Leonard, 1992) model of
women wanted to combine work and family in their womanist identity development.
own future projections and were aware of the
existence of multiple-role conflict, they did not Feminist Identity Development
expect it to be problematic in their own lives. There are many philosophies of feminism, and fem-
Instead, personal, relationship, and even financial inism itself is an evolving construct (Frieze &
satisfaction was enhanced to the extent that women McHugh, 1998; Henley, Spalding, & Kosta, 2000).
and men directly confronted these issues. Egalitar- Nevertheless, most feminisms and feminists are
ian sharing does not just happen in relationships; “united by a belief that unequal and inferior social
rather, it is actively constructed by committed and status of women is unjust and needs to be changed”
vigilant partners (Blaisure & Allen, 1995). Tangri (Jaggar, 1983, p. 322). Consistent with this posi-
and Jenkins (1997) found that women who expected tion, Russo (1998) found that about 90% of women
work–family conflict and prepared accordingly— who identified as feminists desired equal distribu-
by asserting their career intentions with their tion of power between women and men in govern-
spouse, by postponing child-bearing, and by having ment, business, industry, and family. Importantly,
fewer children—experienced less marital conflict many individuals hold feminist values and attitudes
than did those who failed to acknowledge potential without self-identifying as feminist (e.g., Williams
problems. & Wittig, 1997; Zucker, 2004). Thus, researchers
have investigated the correlates of “feminism” using
Women’s Identities various operationalizations, including feminist self-
Shifting our focus from women in relationships to identification, but also pro-feminism or feminist
a focus on women themselves brings us to models attitudes, and egalitarian attitudes about the rights
of group identity that outline women’s sense of self and roles of women relative to men. Downing
as a member of the group “women.” Models of and Roush’s (1985) model of feminist identity
group identity have been proposed for various development connects feminist attitudes and values
stigmatized, marginalized, and oppressed popula- (independent of feminist self-identification) with
tions. Group identity is important to counseling attitudes about oneself as a woman.
psychologists’ research and practice because it is Informed by Cross’s (1971) model of racial iden-
linked with important outcomes including psycho- tity development, Downing and Roush (1985) ini-
logical distress and well-being, academic achieve- tially proposed a developmental process. But, as
ment, interpersonal relationships, and civic and with other identity development models, feminist
social engagement (for review, see Ashmore, Deaux, identity development has been operationalized as a
& McLaughlin-Volpe, 2004). In their review of the set of nonlinear attitudes that reflect profiles, rather
literature, Ashmore and coauthors (2004) articu- than stages of feminist identity (see Moradi &
lated the various elements of group identity that Subich, 2002b; Moradi, Subich, & Phillips, 2002b).
have been the focus of prior scholarship. These ele- The set of five feminist identity attitudes ranges
ments are self-categorization as a member of the from a denial of cultural discrimination against
group; evaluation of the group (one’s own and women to an understanding of such discrimination

m or adi, yode r 359

and commitment to social justice. Specifically, pas- Feminist identity attitudes have been linked
sive acceptance is characterized by unexamined with women’s mental health as well. For example,
acceptance of traditional gender roles and denial synthesis and active commitment scores are associ-
of individual, institutional, and cultural discrimi- ated with higher levels of empowerment and
nation against oneself and women in general. One psychological well-being, whereas revelation and
or more events (e.g., consciousness raising group, passive acceptance scores are related to lower levels
a college class, workplace discrimination) can cata- of these mental health indicators (Peterson, Grippo,
lyze revelation or a realization about sexism, which & Tantleff-Dunn, 2008; Saunders & Kashubeck-
is usually accompanied by feelings of anger toward West, 2006). Furthermore, passive acceptance and
a sexist society and feelings of guilt about one’s own revelation scores have been linked with greater
participation in the systematic oppression of women. psychological distress (Moradi & Subich, 2002a).
Embeddedness and emanation encompasses seeking Importantly, Fischer and Good (2004) found
immersion in women’s cultures and communities that the relation of revelation with distress was
(e.g., taking women’s studies courses, becoming mediated in part by state anger. Thus, consistent
involved in women’s support groups), often idealiz- with feminist identity development theory, the
ing such cultures and communities, as well as anger experienced as part of revelation can be asso-
approaching men cautiously. Synthesis involves inte- ciated with distress.
grating feminist consciousness with other aspects of Although findings related to general distress
a positive self-concept and replacing dichotomous and well-being indicators are consistent with femi-
thinking about women and men with an individual nist identity development theory, studies that have
differences approach. Finally, active commitment focused specifically on body image and eating
reflects a commitment to working toward societal problems have found mixed support for relations
change and eliminating oppression. between feminist identity attitudes and body image
Downing and Roush’s (1985) model was initially and eating problems (Cash, Ancis, & Strachan,
operationalized with the Feminist Identity Devel- 1997; Snyder & Hasbourck, 1996). However, a
opment Scale (Bargad & Hyde, 1991), which recent intervention study found expected connec-
assessed all five feminist identity attitudes, and tions between body image improvement and femi-
the Feminist Identity Scale (Rickard, 1989), which nist identity attitudes. Specifically, for participants
measured all but active commitment attitudes. exposed to a body image intervention grounded in
Responding to psychometric concerns about each feminist theory, improvements in body image were
of these measures, Fischer and colleagues (2000) associated with increased synthesis and decreased
developed the Feminist Identity Composite (FIC), passive acceptance (Peterson, Tantleff-Dunn, &
which integrated the FIDS and the FIS to capital- Bedwell, 2006).
ize on their psychometric strengths. Although some In addition to their direct links with mental
psychometric limitations remain with each of health indicators, some feminist identity attitudes
these instruments (see Moradi & Subich, 2002b), have been found to moderate links of perceived
they have been used to explore linkages of feminist sexism with psychological symptomatology. For
identity attitudes with a range of variables relevant instance, level of passive acceptance moderated the
to counseling psychologists. For example, prior link between perceived experiences of sexism and
research indicates that passive acceptance scores psychological distress such that the sexism–distress
are related negatively, whereas revelation, embed- link was stronger for women with high passive
dedness-emanation, synthesis, and active com- acceptance scores than for women with low passive
mitment scores are generally related positively acceptance scores (Moradi & Subich, 2002a).
with perceptions of sexism (e.g., Fischer & Good, Similarly, levels of synthesis and active commitment
1994; Fischer et al., 2000; Moradi & Subich, moderated the relation between perceived experi-
2002a, 2002b), activism in women’s organizations ences of sexism and disordered eating, such that the
(e.g., Fischer et al., 2000; White, Strube, & Fisher, sexism-disordered eating relation was positive for
1998), and egalitarian attitudes (Fischer & Good, women with low levels of synthesis and active com-
1994; Yoder, Perry, & Saal, 2007). Passive accep- mitment, but nonsignificant for women with high
tance may also underlie the link between egalitar- levels of these feminist identity attitudes. Thus, low
ian marital role expectations and assertiveness passive acceptance and high synthesis and active
regarding sexual initiation and safer sex practices commitment attitudes may buffer the link of per-
(Yoder et al., 2007). ceived sexism with some psychological symptoms.

360 the psycholo gy o f wo men

 An important caveat to the literature reviewed colleagues (1999) assessed the feminist identity
here is that most research on the feminist iden- attitudes of graduate students in a large mid-
tity development model has been conducted with southern university. They found some baseline dif-
predominantly young white women of unknown ferences between graduate programs, such that
sexual orientation. But, a few notable exceptions master’s and doctoral degree students in what they
exist. For instance, with a sample of African called a “gender aware” counseling psychology pro-
American women, White and coauthors (1998) gram reported lower passive acceptance and higher
found that feminist identity attitudes were associ- embeddeness-emanation and active commitment
ated in expected directions with parallel racial iden- scores than did similar students in school or educa-
tity development attitudes. In another study, Flores, tional psychology programs. They also found
Carrubba, and Good (2006) found that levels and evidence suggesting that level of training is associ-
factor structure of feminist identity attitudes for ated with shifts in feminist identity attitudes.
Mexican American adolescent girls differed from Specifically, revelation scores were higher for doc-
those found in other studies with primarily white toral students than for master’s students in the
and mostly college student samples, with the pat- counseling psychology program. By contrast, revela-
tern of findings suggesting higher revelation and tion scores were lower for doctoral students than for
active commitment scores for Mexican American master’s students in the noncounseling psychology
girls. Within the context of this limited sample programs (Worell, Stilwell, Oakley, & Robinson,
diversity, scholars have called for greater attention 1999). Thus, greater training in a gender-aware pro-
to how feminist identity attitudes may intersect gram may increase revelation, and interestingly,
with racial/ethnic, sexual orientation, and other training in not specifically gender-aware programs
identities (e.g., Moradi, Subich, & Phillips, 2002a, b; may reduce revelation.
Vandiver, 2002). This interpretation should be balanced, however,
Also of importance to counseling psycholo- with the possibility that students who are drawn to
gists are studies of feminist identity attitudes among and remain in a gender-aware program are more
therapists and clinical supervisors. Among thera- inclined to increase revelation attitudes than those
pists, passive acceptance scores were related nega- who do not choose to train in such programs. The
tively, and revelation and synthesis scores were possible selection bias across groups is eliminated
related positively, with reported use of femi- by short-term longitudinal studies that observe the
nist therapy behaviors, and revelation emerged as same individuals before and after an intervention.
the best predictor of self-identification as a feminist For example, Yoder and associates (2007) found
therapist (Juntunen, Atkinson, Reyes, & Gutierrez, that, across five different psychology of women
1994). Similarly, among clinical supervisors, pas- classes, passive acceptance scores decreased and the
sive acceptance scores were associated negatively, other four feminist identity attitude scores increased
whereas revelation, embeddedness-emanation, and from the beginning to the end of the course. These
active commitment scores were associated positively, studies suggest that feminist identity attitudes are
with self-reported feminist supervision practices responsive to training and education.
(Szymanski, 2005b). Thus, practitioners’ feminist
identity attitudes appear to be related to self- Lesbian Identity Formation
reported counseling and supervision practices. McCarn and Fassinger (1996) proposed a model
The demonstrated relations of feminist iden- of lesbian identity formation that teases apart indi-
tity attitudes with women’s mental health suggest vidual sexual identity formation processes from
that reducing passive acceptance, increasing synthe- group membership and sociopolitical identity for-
sis and active commitment, and helping women mation processes. McCarn and Fassinger (1996)
work through revelation might realize educational deemed this distinction important for acknowledg-
and intervention goals. Similarly, reducing passive ing that, for lesbian (and gay and bisexual) persons,
acceptance and increasing other feminist identity limited public identification or political activism
attitudes might be fruitful in education and training does not signify “unhealthy” or “low” identity devel-
aiming to promote feminist therapy and supervi- opment. Rather, choices regarding sexual minority
sion behaviors. The good news is that change in identity disclosure and political activism are shaped
feminist identity attitudes is possible, as demon- by contextual realities, including prejudice and dis-
strated by evidence of the effectiveness of vari- crimination in family, workplace, and other con-
ous training approaches. For instance, Worell and texts. McCarn and Fassinger (1996) proposed four

m or adi, yode r 361

phases of individual and group membership self-esteem was correlated positively with synthesis/
identity formation: awareness, exploration, deepen- internalization levels for both individual sexual
ing/commitment, and internalization/synthesis. They identity and group membership identity formation
emphasized that these phases may not necessarily (Swann & Spivey, 2004). This pattern of findings
occur in a linear or stage-wise progression; instead, is consistent with the notion that individual and
they could be continuous and circular. Furthermore, sociopolitical identity have distinct implications
phases of individual and group membership for self-esteem. Specifically, high awareness, explo-
branches of identity formation are not necessarily ration, and commitment to a marginalized socio-
simultaneous. political identity may be associated with self-esteem
Individual sexual identity formation begins costs. By contrast, individual and group mem-
with an awareness of feeling different from the het- bership synthesis and internalization, which are
erosexual norm. Exploration consists of active markers of self-acceptance and fulfillment, may be
examination of erotic feeling for women (or a par- associated with self-esteem benefits.
ticular woman). Deepening/commitment involves McCarn and Fassinger’s (1996) proposed lesbian
clarity about one’s sexuality and crystallization of identity formation phases also have been linked
one’s sexual identity (e.g., lesbian, bisexual). Finally, with self-perceptions of positive functioning in
internalization/synthesis reflects feeling comfort- terms of vocational development and within the
able and fulfilled with one’s sexual identity. For campus climate. Specifically, in a sample of pre-
group membership identity, identity formation dominantly white, college-age lesbian, bisexual, and
begins with awareness that different sexual orienta- questioning women, self-perceptions of more
tions exist and heterosexuality is not universal. advanced vocational development (i.e., greater sense
Exploration involves examining one’s position of vocational clarity, interest, and efficacy) were cor-
among sexual minority people and communities by related positively with scores on the internalization/
acquiring more knowledge about and exploring synthesis phase of both individual sexual identity
one’s attitudes toward these groups. Deepening/ and group membership identity (Tomlinson &
commitment includes engaging with and valuing Fassinger, 2003). Furthermore, perceptions of
sexual minority communities, and recognizing a supportive campus climate (i.e., quality of faculty–
shared experiences of prejudice and stigmatization student relations, feelings of acceptance, fair treat-
with those communities. Finally, internalization/ ment, safety and security, and academic competence)
synthesis reflects a sense of acceptance and fulfill- were correlated positively with scores on the
ment with one’s group membership identity across internalization/synthesis phase of individual sexual
contexts. McCarn and Fassinger’s (1996) model has identity, and correlated negatively with scores on
been operationalized with the Lesbian Identity the exploration/commitment phase of both indi-
Questionnaire (LIQ; see Swann & Spivey, 2004; vidual sexual identity and group membership iden-
Tomlinson & Fassinger, 2003), which was devel- tity (Tomlinson & Fassinger, 2003). Thus, greater
oped to assess the aforementioned four phases of exploration/commitment in both branches of iden-
individual sexual identity and group membership tity formation was associated with perceptions of a
identity formation. Later efforts to conceptualize less supportive campus climate, suggesting that per-
and operationalize sexual identity have yielded sup- ceived contextual challenges may heighten or
port for the model as well (e.g., Worthington, be heightened by individual and group identity
Navarro, Savoy, & Hampton, 2008), and the model exploration/commitment. By contrast, as with the
and instrument have been modified and validated previously described positive associations with self-
with gay men (Fassinger & Miller 1996). esteem, scores on the synthesis/internalization phase
Using the LIQ, researchers have found support of both branches of identity formation were associ-
for the distinctive relations of individual sexual ated with positive perceptions of vocational develop-
identity and group membership identity phases ment and campus climate. As such, greater synthesis/
with mental health indicators. For example, with internationalization of individual and group mem-
predominantly white lesbian women, self-esteem bership identity appears to be associated with positive
was correlated negatively with levels of group mem- functioning across various domains. To broaden
bership identity formation awareness, exploration, understanding of the mental health correlates of
and deepening/commitment, but it was uncorre- lesbian identity formation phases, research is needed
lated with these phases of individual sexual identity to build on the findings described here, and investi-
formation (Swann & Spivey, 2004). By contrast, gate the links of McCarn and Fassinger’s (1996)

362 the psycholo gy o f wo men

proposed identity formation phases with psy- oppression and exploration, synthesis, and inter-
chological symptomatology and other aspects of nalization of alternatives to oppressive roles; and
functioning. neither model presumes adoption of feminist self-
identification. Indeed, in data with African American
Womanist Identity Development and white women, moderate to high correlations
Consistent with the distinction that McCarn and have emerged between parallel womanist and femi-
Fassinger (1996) made between individual and nist identity development attitudes (Boisnier, 2003;
sociopolitical identity formation, Helms’ (1990, Hoffman, 2006).
as cited in Carter & Parks, 1996; Ossana et al., The womanist identity development model has
1992) proposed the womanist identity development been operationalized with the Womanist Identity
model to focus on the process of self-definition as Attitudes Scale (WIAS), which has four subscales
a woman, without entangling it with feminist corresponding to the four womanist identity atti-
sociopolitical identification or activism. Specifically, tudes (see Moradi et al., 2004; Ossana, 1986). As
according to Ossana et al. (1992), womanist iden- with measures of feminist identity development and
tity development involves moving from an exter- other identity development models, psychometric
nally based sociocultural or sociopolitical definition concerns about the WIAS have been noted (see
of oneself as a woman to an internally based self- Moradi et al., 2004). Nevertheless, research with
definition; this process is posited to be similar across the WIAS has yielded some theoretically consistent
diverse groups of women (e.g., in terms of race/ findings that are important for counseling psy-
ethnicity, social class). chology research and practice. For example, consis-
Descriptions of Helms’ four womanist identity tent with the proposition that womanist identity
development model stages—pre-encounter, encoun- development is similar across diverse groups of
ter, immersion-emersion, and internalization—were women, black and white women did not differ in
initially published by Ossana et al. (1992) and mean levels or intercorrelations of womanist iden-
Carter and Parks (1996). As with other develop- tity subscales (Moradi et al., 2004). Also, with both
mental models, conceptualizations of womanist black and white women, pre-encounter scores were
identity development have shifted from a stage-wise correlated negatively with egalitarian attitudes
progression to a set of attitudes that can occur simul- toward women and correlated positively with sexist
taneously, cyclically, or in other nonlinear fashions attitudes, and internalization scores were correlated
(Moradi, 2005; Moradi, Yoder, & Berendsen, 2004). positively with egalitarian attitudes toward women
Pre-encounter involves denial of societal oppression (Moradi et al., 2004). But, contrary to expectation,
of women and conformity to rigid social norms that encounter and immersion-emersion scores were
privilege men over women. Encounter occurs when generally uncorrelated with egalitarian and sexist
new information or experiences challenge a preen- attitudes.
counter lens, awareness of sexism and identification Like feminist identity attitudes and lesbian
with womanhood is heightened, and alternative identity phases, womanist identity attitudes have
conceptualizations of the roles of women and men been associated with mental health indicators (for
are explored. Immersion-emersion involves an ini- review, see Moradi, 2005). Specifically, with samples
tial phase during which women are idealized and of African American/black women, black South
patriarchal definitions of woman’s roles are rejected, African women, and predominantly white women,
and a second phase during which there is a search indicators of well-being, such as self-esteem and
for positive definitions of womanhood and affilia- self-efficacy, generally have been linked negatively
tion with other women. Finally, internalization with pre-encounter, encounter, and immersion-
reflects the integration of an internally defined posi- emersion scores and positively with internalization
tive view of womanhood into one’s identity “with- scores (e.g., Boisnier, 2003; Letlaka-Rennert,
out undue dependence on either sexist societal Luswazi, Helms, & Zea, 1997; Ossana et al., 1992;
norms or the antithetical positions of the women’s Poindexter-Cameron & Robinson, 1997). Also,
movement” (Carter & Parks, 1996, p. 74). pre-encounter and immersion-emersion scores were
It is important to note that, despite the aim related to external locus of control in a sample
to distinguish womanist identity development of black South African women (Letlaka-Rennert
from feminist identity development, both models et al., 1997), and immersion-emersion scores were
involve a shift in consciousness from denial of wom- correlated negatively, whereas internalization scores
en’s oppression to an acknowledgment of such were correlated positively, with life satisfaction in

m or adi, yode r 363

a sample of African American/black women (Con- of findings highlights the importance of attend-
stantine & Watt, 2002). In terms of psychologi- ing to intersections of identities when consider-
cal distress, Carter and Parks (1996) found that, ing women’s gender-related identity formation
for white women, pre-encounter, encounter, and (e.g., Moradi et al., 2002a, b; Vandiver, 2002).
immersion-emersion scores were related positively Indeed, the concept of womanist consciousness was
with psychological symptomatology, but relations coined (e.g., Brown, 1989; Walker, 1983) to reflects
between womanist identity attitudes and symp- the view that racial, gender, and other oppres-
tomatology did not emerge for black women in sions and identities as inextricably linked. Measures
their sample. This differential pattern may have have been developed to assess womanist conscious-
been due to the substantially smaller sample size ness (e.g., Henley, Meng, O’Brien, McCarthy, &
for black women than for white women. Sockloskie, 1998; King, 2003), but, research on
Womanist identity attitudes also have been womanist consciousness, including its implications
examined in relation to racial identity attitudes for women’s mental health, remains needed.
for African American/black and white women.
Poindexter-Cameron and Robinson (1997) found Distinguishing Group Identity
that African American women’s womanist and racial and Group Consciousness
identity pre-encounter, immersion-emersion, and Gurin and Townsend (1986) distinguished women’s
internalization scores (but not encounter) were cor- awareness of and feelings about being a woman
related positively. Parks et al. (1996) examined (group identity) from ideology about the group’s
covariation between womanist and racial identity sociopolitical position (group consciousness). Spe-
attitudes for African American/black and white cifically, group identity includes perceived similarity
women using canonical correlation. They found between the self and the group, sense of common
significant covariation for African American/black fate with the group, and the centrality of group
women but not for white women. Specifically, for membership to self-concept. For sociopolitically
African American/black women, womanist and subordinate groups, group consciousness includes
racial identity encounter and internalization scores sense of collective discontent about the group’s posi-
loaded positively, whereas womanist and racial iden- tion, perceived legitimacy or illegitimacy of that
tity pre-encounter and immersion-emersion scores position, and belief about the necessity of collective
loaded negatively, on the canonical root. This pat- action to improve the group’s condition. Data gath-
tern of findings suggests some parallels in racial and ered in the 1970s an 1980s from nationally repre-
womanist identity attitudes for African American/ sentative samples of women yielded low to moderate
black women, but not necessarily for white women. correlations among these group identity and group
Parks et al. (1996) reasoned that such a parallel consciousness dimensions, suggesting that they are
would be expected for African American/black related but distinct dimensions (Gurin & Townsend,
women because, for them, womanist and racial 1986).
identity development involve socioculturally mar- Gurin (1985) found that women’s group identity
ginalized identities, whereas for white women, racial and consciousness levels were generally lower than
identity development involves a socioculturally those of African American, older adult, and blue-
privileged identity. collar samples. Gurin (1985) suggested that contex-
Finally, in a study that examined the relations tual factors may serve as barriers to women’s group
of both womanist and feminist identity attitudes identity and consciousness. For example, familial
with ethnic identity in a racially/ethnically diverse connections and social segregation foster high levels
sample, Hoffman (2006) found that revelation, of in-group interaction and intimacy among racial/
embeddedness-emanation, and active commitment ethnic, social class, and some other groups. But, as
feminist identity scores and immersion-emersion children, siblings, parents, and romantic partners,
womanist identity scores each were correlated posi- most women’s lives are inextricably linked with
tively with an indicator of ethnic identity explora- men’s. These connections foster a sense of shared
tion and commitment (Hoffman, 2006). Thus, in values, common fate, and intimacy between women
a sample of women of various racial/ethnic back- and men. In addition, the ubiquity of sexism and
grounds, feminist and womanist identity atti- the fact that it is often perpetrated by intimate rela-
tudes that reflect heightened awareness of gender tions (e.g., parents, partners) can make sexism seem
oppression were associated with greater exploration normative and forgivable rather than unjust. Thus,
of and commitment to ethnic identity. This pattern the contexts of women’s lives may impede group

364 the psycholo gy o f wo men

identity and consciousness. This perspective also depends, at least in part, on personal empower-
suggests, however, that women’s connections with ment (Gibbs & Fuery, 1994; Worell & Remer,
other women and women’s communities might 1992). There is an extensive body of research
foster group identity and consciousness. Interestingly, reviewed by Helgeson (1994) clearly linking per-
the role of women’s connections with other women sonal agency or instrumentality with overall well-
has not received much attention in research on the being, including reduced depression, lower anxiety,
three identity models reviewed in this section. elevated self-esteem, fewer health complaints, and
Of the identity models reviewed here, McCarn mitigated distress. Similar associations between
and Fassinger’s (1996) model clearly distinguishes well-being and empowerment are evident in the
group identity from group consciousness, with indi- interpersonal spheres of women’s family and work
vidual sexual identity reflecting the former and relationships. For example, heterosexual women
group membership identity reflecting the latter con- who expect to have to grapple with work–family
struct. The feminist and womanist identity devel- conflict in their intimate relationships and prepare
opment models, however, seem to capture mostly for this inevitable conflict by asserting their career
group consciousness; although embeddedness- intentions with their partner, by postponing child-
emanation and immersion-emersion include the bearing, and by having fewer children tend to expe-
similarity and centrality aspects of group identity. rience less marital conflict than do women who fail
As such, Gurin and colleagues’ framework suggests to acknowledge potential problems (Tangri &
some interesting questions about feminist and Jenkins, 1997). Indeed successful egalitarian couples
womanist identity models. For example, should understand that they need to be vigilant and work
these models be refined to more clearly separate hard to realize equality in their relationship (Blaisure
group identity and group consciousness? Would & Allen, 1995; Knudson-Martin & Mahoney,
group identity and group consciousness aspects of 2005). Women are more likely to report achieving
feminist and womanist identity have different sexual satisfaction if they feel empowered by their
implications for women’s mental health? How do own personal agency to initiate sexual contact more
women’s connections with other women relate often, and to express their sexual needs clearly in
to feminist, womanist, and lesbian identity? These their primary relationships (Mosher & Danoff-
questions arise from attending to how the context Burg, 2005). In the workplace, women need to first
of women’s lives may shape and be shaped by establish their legitimacy in order to effectively
their sense of being a woman and its sociopolitical influence their coworkers (Ridgeway, 2001; Yoder,
meaning. Schleicher, & McDonald, 1998). Having the sup-
ports provided by a higher-status mentor helps
A Call for Feminist Thinking build women’s own power and resources (Dreher &
Because the goals of counseling psychology include Ash, 1990), which in turn promotes their global
minimizing psychological distress and maximizing job satisfaction (Mobley, Jaret, Marsh, & Lim,
well-being in people’s everyday lives, we took care 1994). Masculinizing information about job candi-
in each section of this chapter to draw linkages to dates for male-type occupations can help level the
these outcomes for women as often as the existing playing field for women applicants (Glick, Zion, &
literature would allow. We made the sweeping case Nelson, 1988). In general, adopting status-
that women and women’s experiences take place enhancing strategies in masculinized, hierarchal
within a surrounding social context that is not only work contexts can enhance women’s leadership
often different for women and men, but also value- effectiveness (Yoder, 2001).
laden, such that gender itself is confounded with A complete understanding of women’s empow-
power and status. We found evidence of these gen- erment, both personal and relational, must regard
dered power differences in sexist treatment directed empowerment as more of a process than as a static
toward women, in evaluations of women’s mental thing to be achieved, then taken for granted
health, in women’s relationships, and in women’s (Browne, 1995). The view of empowerment that
own attitudes and identities. The recurring theme works for women focuses on power as energy, poten-
across all of these areas of research is that women’s tial, and competence, not on traditional definitions
well-being is continually challenged simply by being of power as domination, coercion, and competition.
women in a patriarchal culture. Furthermore, the empowerment of women cannot
This analysis readily leads to an understanding be confined to these individual and relational arenas
that women’s psychological health and well-being alone, but rather must extend to changing broader

m or adi, yode r 365

social and political contexts through collective social self-fulfilling in that they elicit stereotype-consistent
activism (Kitzinger, 1991; Riger, 2000). Too often, behaviors (e.g., Skrypnek & Snyder, 1982). These
psychologists have focused on personal and rela- examples highlight the power of social situations
tional empowerment without making this necessary and point to the promise of identifying modifiable
connection to social activism (Kravetz & Marecek, aspects of social context that can improve women’s
1996; Marecek & Hare-Mustin, 1991; Parvin & experiences and functioning.
Biaggio, 1991). Nowhere is this point clearer than Longitudinal and experimental research is
in definitions and practice of feminist therapy, needed to reveal causal directions in the relations
a topic discussed in Carol Enns’ chapter in this of sexist stereotypes, prejudice, and discrimination
volume (Enns, 2011, Chapter 16, this volume). with outcome variables. Research is also needed to
By reviewing the ways in which the contexts of elucidate how stereotypes, prejudice, and discrimi-
women’s lives can shape their functioning and nation against women manifest when they intersect
mental health, the present chapter underscores the with other social category dimensions. For instance,
importance of feminist therapy in meeting the across subgroups of women, what are shared and
mental health needs of women, along with social unique manifestations of sexist discrimination?
justice efforts to transform the damaging aspects of How does sexist discrimination function with other
the contexts of women’s lives. forms of discrimination in shaping women’s experi-
ences across domains (e.g., mental health, physical
Future Directions health, work and career development)?
Throughout this chapter, we have offered an inte- Theoretically grounded and empirically informed
grative summary of available research and high- interventions programs aiming to prevent and
lighted specific needs for further research when reduce stereotypes, prejudice, and discrimination
appropriate. In this final section, we outline broad against women need to be developed and evaluated.
directions for advancing psychological scholarship Data on the long-term effectiveness of such inter-
with and about women. In each of the following ventions is particularly important.
areas, we see a need for articulating theoretical Connections along the continuum of subtle
frameworks that integrate available data and outline and everyday to violent and acute manifestations of
directions for future investigation. sexism need to be better understood. For instance,
Central to each of the proceeding directions what factors prevent or promote expressions of
for scholarship are questions about how multiple subtle sexism and their translation to more blatant
social categories (e.g., age, ethnicity, race, sexual ori- sexism, or even violence? Within this continuum,
entation, socioeconomic status) intersect with are there developmental processes that can be inter-
gender. Thus, our first recommendation is that the rupted to prevent the escalation of sexism?
diversity of women’s experiences should be the point What we know about potential biases in DSM
of initiating inquiry, rather than a dimension that diagnostic criteria and their use in clinical practice
is considered as an “add on” after white, presumably suggests the need for counseling psychologists
heterosexual, often young and middle class women (along with other stakeholders) to evaluate if and
are considered. To this end, theory and research how DSM criteria should be used to maximize their
with women of diverse backgrounds is integral utility and minimize their harm to women and
to advancing a complete psychology of women men. In addition, training approaches that reduce
(Yoder & Kahn, 1993), and such scholarship should clinician bias need to be developed, evaluated, and
always articulate which group(s) of women are the disseminated.
focus of study. Available data on the socialization of girls and
Understanding women’s experiences and boys underscore the omnipresence of disempower-
improving their functioning can be advanced by ing messages to girls. Within this context, research
moving from a focus on internal, enduring charac- is needed to understand girls’ positive function-
teristics to external, modifiable aspects of social ing despite sexist socialization. For example, what
contexts that shape behaviors by and toward conditions help girls and boys to resist sexist social-
women. For example, social psychological litera- ization? What factors promote girls’ self-efficacy,
ture has established that the power, status, and positive body image, career aspirations, and resil-
resources associated with gender, rather than gender ience in other domains?
itself, shape behaviors (Ridgeway & Smith-Lovin, Available research about women’s relation-
1999). Similarly, gender stereotypic expectations are ships points to factors that can hinder or promote

366 the psycholo gy o f wo men

relationship satisfaction and quality across domains Anderson, K. L., & Umberson, D. (2001). Gendering violence:
(e.g., romantic, workplace). Many of these fac- Masculinity and power in men’s accounts of domestic vio-
lence. Gender & Society, 15, 358–380.
tors revolve around managing and sharing power. Angelone, D. J., Hirschman, R., Suniga, S., Armey, M., &
An important future direction is to explicitly articu- Armelie, A. (2005). The influence of peer interactions on
late and study the role of power in women’s rela- sexually oriented joke telling. Sex Roles, 52, 187–199.
tionships. How do women and their relationship Ashmore, R. D., Deaux, K., & McLaughlin-Volpe, T. (2004).
partners view, assert, and manage power in their An organizing framework for collective identity: Articulation
and significance of multidimensionality. Psychological
relationships, and how do these approaches relate to Bulletin, 130, 80–114.
relationship quality and satisfaction? Banaji, M. R., & Greenwald, A. G. (1994). Implicit stereotyp-
Efforts are needed to integrate existing group ing and prejudice. In M. P. Zanna, & J. M. Olson (Eds.),
identity development models. What are the areas The psychology of prejudice: The Ontario symposium Vol. 7
of overlap and redundancy across models? What (pp. 55–76). Hillsdale, NJ: Erlbaum.
Bargad, A., & Hyde, J. S. (1991). Women’s studies: A study
are the unique dimensions of various models? And, of feminist identity development in women. Psychology of
what elements of group identity and collective Women Quarterly, 15, 181–201.
consciousness are captured and not captured by Barnett, R. C., & Hyde, J. S. (2001). Women, men, work, and
available models? Such efforts are important for family: An expansionist theory. American Psychologist, 56,
consolidating available theory and data and also for 781–796.
Becker, A. E. (2004). Television disordered eating, and young
identifying directions for developing a fuller under- women in Fiji: Negotiating body image and identity during
standing of women’s group identity and collective rapid social change. Culture, Medicine and Psychiatry, 28,
consciousness. 533–559.
The recommendations offered thus far focus Beckman, L. J. (1994). Treatment needs of women with
on advancing scholarship. But, at the heart of a alcohol problems. Alcohol Health and Research World, 18,
206–211.
feminist psychology of women is a commitment to Bekker, M. H. J. (1996). Agoraphobia and gender: A review.
reducing and ultimately eliminating sexism and Clinical Psychology Review, 16, 129–146.
other forms of oppression that hinder women’s (and Bem, S. L. (1993). The lenses of gender: Transforming the debate
men’s) potential. The scholarship reviewed in this on sexual inequality. New Haven, CT: Yale.
chapter illustrates the social justice implications of Benokraitis, N. V. (1997). Sex discrimination in the 21st cen-
tury. In N. V. Benokraitis (Ed.), Subtle sexism: Current prac-
psychological theory and research. But, psycholo- tice and prospects for change (pp. 5–33). Thousand Oaks, CA:
gists need to move beyond being producers and Sage.
consumers of research. Thus, our final recommen- Berg, S. H. (2006). Everyday sexism and posttraumatic stress dis-
dation is for efforts to translate research find- order in women: A correlational study. Violence Against
ings about women’s experiences into individual Women, 12, 970–988.
Bernas, K. H., & Major, D. A. (2000). Contributors to stress
and group counseling interventions, training for resistance: Testing a model of women’s work-family conflict.
researchers and mental health practitioners, public Psychology of Women Quarterly, 24, 170–178.
education programs, and public policy. Articulations Bianchi, S. (2000). Maternal employment and time with chil-
of how to engage in such translation can help to dren: Dramatic change and surprising continuity. Demog-
move the field toward fulfilling its social justice raphy, 37, 401–414.
Bird, C. E. (1999). Gender, household labor, and psychological
promise. distress: The impact of the amount and division of house-
work. Journal of Health and Social Behavior, 40, 32–45.
References Blain, J. (1994). Discourses of agency and domestic labor: Family
Abrams, D., Viki, G. T., Masser, B., & Bohner, G. (2003). discourse and gendered practice in dual-earner families.
Perceptions of stranger and acquaintance rape: The role Journal of Family Issues, 15, 515–549.
of benevolent and hostile sexism in victim blame and rape Blaisure, K. R., & Allen, K. R. (1995). Feminists and the ideol-
proclivity. Journal of Personality and Social Psychology, 84, ogy and practice of marital equality. Journal of Marriage and
111–125. the Family, 57, 5–19.
Amaro, H., Raj, A., & Reed, E. (2001). Women’s sexual Blood, P., Tuttle, A., & Lakey, G. (1995). Understanding
health: The need for feminist analyses in public health in and fighting sexism: A call to men. In M. L. Andersen &
the Decade of Behavior. Psychology of Women Quarterly, 25, P. H. Collins (Eds.), Race, class, and gender: An anthology
324–334. (2nd ed., pp. 154–161). Belmont, CA: Wadsworth.
Andersen, B. L., Cyranowski, J. M., & Espindle, D. (1999). Boisnier, A. D. (2003). Race and women’s identity development:
Women’s sexual self-schema. Journal of Personality and Social Distinguishing between feminism and womanism among
Psychology, 76, 645–661. Black and White women. Sex Roles, 49, 211–218.
Anderson, K. B., Cooper, H., & Okamura, L. (1997). Individual Bond, J. T., Thompson, C., Galinsky, E., & Prottas, D. (2003).
differences and attitudes toward rape: A meta-analytic review. Highlights of the 2002 national study on the changing workforce
Personality and Social Psychology Bulletin, 23, 295–315. (No. 3). New York: Families and Work Institute.

m or adi, yode r 367

Bowleg, L., Lucas, K. J., & Tschann, J. M. (2004). “The ball Croteau, J. M., Nero, C. I., & Prosser, D. J. (1993). Social
was always in his court”: An exploratory analysis of rela- and cultural sensitivity in group-specific HIV and AIDS
tionship scripts, sexual scripts, and condom use among programming. Journal of Counseling and Development, 71,
African American women. Psychology of Women Quarterly, 290–296.
28, 70–82. Crull, P. (1982). Stress effects of sexual harassment on the
Brown, E. B. (1989). Womanist consciousness: Maggie Lena job: Implications for counseling. American Journal of
Walker and the Independent Order of St. Luke. Signs, 14, Orthopsychiatry, 52, 539–544.
610–633. Csikszentmihalyi, M. (1982). Toward a psychology of optimal
Browne, A. (1993). Violence against women by male partners: experience. In L. Wheeler (Ed.), Review of personality and
Prevalence, outcomes, and policy implications. American social psychology. Beverly Hills, CA: Sage.
Psychologist, 48, 1077–1087. Csikszentmihalyi, M. (1990). Flow: The psychology of optimal
Browne, C. V. (1995). Empowerment in social work practice experience. New York: Harper Perennial.
with older women. Social Work, 40, 358–364. Cuddy, A. J. C., Fiske, S. T., & Glick, P. (2004). When profes-
Buchanan, T. S., Fischer, A. R., Tokar, D. M., & Yoder, J. D. sionals become mothers, warmth doesn’t cut the ice. Journal
(2008). Testing a culture-specific extension of objectification of Social Issues, 60(4), 701–718.
theory regarding African American women’s body image. The Cuddy, A. J. C., Norton, M. I., & Fiske, S. T. (2005). This old
Counseling Psychologist, 36, 697–718. stereotype: The pervasiveness and persistence of the elderly
Bussey, K., & Bandura, A. (1999). Social cognitive theory of stereotype. Journal of Social Issues, 61(2), 267–285.
gender development and differentiation. Psychological Review, Cutler, S. E., & Nolen-Hoeksema, S. (1991). Accounting for
106, 676–713. sex differences in depression through female victimization:
Bussey, K., & Bandura, A. (2004). Social cognitive theory of Childhood sexual abuse. Sex Roles, 24, 425–438.
gender development and functioning. In A. Eagly, et al. Darves-Bornoz, J. M., Lemperiere, T., Degiovanni, A., &
(Eds.), The psychology of gender (2nd ed., pp. 92–119). New Gaillard, P. (1995). Sexual victimization in women with
York: Guilford. schizophrenia and bipolar disorder. Social Psychiatry and
Butler, J. (1990). Gender trouble: Feminism and the subversion of Psychiatric Epidemiology, 30, 78–84.
identity. New York: Routledge. de Snyder, V. N. S., Acevedo, A., Diaz-Perez, M. J., & Saldivar-
Caplan, P. J. (1995). They say you’re crazy: How the world’s most Guaduno, A. (2000). Understanding the sexuality of
powerful psychiatrists decide who’s normal. Reading, MA: Mexican-born women and their risk for HIV/AIDS.
Addison-Wesley. Psychology of Women Quarterly, 24, 100–109.
Caplan, P. J., & Gans, M. (1991). Is there empirical evidence Deaux, K., & Major, B. (1987). Putting gender into context:
for the category of “self-defeating personality disorder”? An interactive model of gender-related behavior. Psychological
Feminism & Psychology, 1, 263–278. Bulletin, 94, 369–389.
Carter, R. T., & Parks, E. E. (1996). Womanist identity and Devine, P. G. (1989). Stereotypes and prejudice: Their automatic
mental health. Journal of Counseling and Development, 74, and controlled components. Journal of Personality and Social
484–489. Psychology, 56, 5–18.
Cash, T. E., Ancis, J. R., & Strachan, M. D. (1997). Gender Diekman, A. B., & Eagly, A. H. (2000). Stereotypes as dynamic
attitudes, feminist identity, and body image among college constructs: Women and men of the past, present, and future.
women. Sex Roles, 36, 433–447. Personality and Social Psychology Bulletin, 26, 1171–1188.
Chan, D. K., Tang, C. S., & Chan, W. (1999). Sexual harass- Diekman, A. B., & Murnen, S. K. (2004). Learning to be little
ment: A preliminary analysis of its effects on Hong Kong women and little men: The inequitable gender equality of
Chinese women in the workplace and academia. Psychology of nonsexist children’s literature. Sex Roles, 50, 373–385.
Women Quarterly, 23, 661–672. Donaghue, N., & Fallon, B. J. (2003). Gender-role self-
Colwell, M. J., & Lindsey, E. W. (2005). Preschool children’s stereotyping and the relationship between equity and satis-
pretend and physical play and sex of play partner: Connections faction in close relationships. Sex Roles, 48, 217–230.
to peer competence. Sex Roles, 52, 497–509. Downing, N. E., & Roush, K. L. (1985). From passive accep-
Constantine, M. G., & Watt, S. K. (2002). Cultural congruity, tance to active commitment: A model of feminist identity
womanist identity attitudes, and life satisfaction among development for women. The Counseling Psychologist, 13,
African American college women attending historically Black 695–709.
and predominantly White institutions. Journal of College Dreher, G. F., & Ash, R. A. (1990). A comparative study of
Student Development, 43, 184–194. mentoring among men and women in managerial, profes-
Cortina, L. M., Swan, S., Fitzgerald, L. F., & Waldo, C. (1998). sional, and technical positions. Journal of Applied Psychology,
Sexual harassment and assault: Chilling the climate for 75, 539–546.
women in academia. Psychology of Women Quarterly, 22, Driscoll, D. M., Kelly, J. R., & Henderson, W. L. (1998).
419–441. Can perceivers identify likelihood to sexually harass? Sex
Cowan, G. (2000). Women’s hostility toward women and rape Roles, 38, 557–588.
and sexual harassment myths. Violence Against Women, 6, Eagly, A. H., & Karau, S. J. (2002). Role congruity theory of
238–246. prejudice toward female leaders. Psychological Review, 109,
Crosby, F. J. (1991). Juggling: The unexpected advantages of 573–598.
balancing career and home for women and their families. Eisler, R. M., Franchina, J. J., Moore, T. M., Honeycutt, H. G.,
New York: Free Press. & Rhatigan, D. L. (2000). Masculine gender role stress and
Cross, W. E. (1971). Negro-to-Black conversion experience: intimate abuse: Effects of gender relevance of conflict situa-
Toward a psychology of Black liberation. Black World, 20(9), tions on men’s attributions and affective responses. Psychology
13–27. of Men and Masculinity, 1, 30–36.

368 the psycholo gy o f wo men

Eldridge, N. S., & Gilbert, L. A. (1990). Correlates of relation- men’s attributions and affective responses. Psychology of Men
ship satisfaction in lesbian couples. Psychology of Women and Masculinity, 2, 34–41.
Quarterly, 14, 43–62. Fredrickson, B. L., & Roberts, T. (1997). Objectification
Enns, C. Z. (2011). Feminist approaches to counseling. theory: Toward understanding women’s lived experiences
In E. M. Altmaier, & J. C. Hansen (Eds.), The Oxford and mental health risks. Psychology of Women Quarterly, 21,
handbook of counseling psychology. New York: Oxford 173–206.
University Press. Fredrickson, B. L., Roberts, T., Noll, S. M., Quinn, D. M., &
Evans-DeCicco, J. A., & Cowan, G. (2001). Attitudes toward Twenge, J. M. (1998). That swimsuit becomes you: Sex
pornography and the characteristics attributed to pornogra- differences in self-objectification, restrained eating, and
phy actors. Sex Roles, 44, 351–361. math performance. Journal of Personality and Social Psychology,
Fassinger, R. E., & Arseneau, J. R. (2008). Diverse women’s 75, 269–284.
sexualities. In F. L. Denmark (Ed.), Psychology of Women: Frieze, I. H., & McHugh, M. C. (1998). Measuring feminism
A handbook of issues and theories (2nd ed., pp. 484–505). and gender role attitudes. Psychology of Women Quarterly, 22,
Westport, CT: Praeger Publishers/Greenwood Publishing. 349–352.
Fassinger, R. E., & Miller, B. A. (1996). Validation of an inclu- Galinsky, E., Bond, J. T., & Friedman, D. E. (1996). The role
sive model of sexual minority identity formation on a sample of employers in addressing the needs of employed parents.
of gay men. Journal of Homosexuality, 32, 53–78. Journal of Social Issues, 52(3), 111–136.
Febbraro, A. R. (2003). Alpha and beta bias in research on labour Gelfond, M. (1991). Reconceptualizing agoraphobia: A case
and love: The case of enhancement versus scarcity. Feminism study of epistemological bias in clinical research. Feminism &
& Psychology, 13, 210–223. Psychology, 1, 247–262.
Felmlee, D. H. (1994). Who’s on top? Power in romantic Gentry, M. (1998). The sexual double standard: The influence
relationships. Sex Roles, 31, 275–295. of number of relationships and level of sexual activity on
Fiese, B. H., & Skillman, G. (2000). Gender differences judgments of women. Psychology of Women Quarterly, 22,
in family stories: Moderating influence of parent gender role 505–511.
and child gender. Sex Roles, 43, 267–283. Gerstel, N., & Gallagher, S. K. (2001). Men’s caregiving: Gender
Fischer, A. R. (2006). Women’s benevolent sexism as reaction and the contingent character of care. Gender & Society, 15,
to hostility. Psychology of Women Quarterly, 30, 410–416. 197–217.
Fischer, A. R., & Good, G. E. (1994). Gender, self, and others: Gibbs, J. T., & Fuery, D. (1994). Mental health and well-being
Perceptions of the campus environment. Journal of Counseling of Black women toward strategies of empowerment. American
Psychology, 41, 343–355. Journal of Community Psychology, 22, 559–582.
Fischer, A. R., & Good, G. E. (2004). Women’s feminist Gilbert, L. A., & Rader, J. (2001). Current perspectives on
consciousness, anger, and psychological distress. Journal of women’s adult roles: Work, family, and life. In R. K. Unger
Counseling Psychology, 51, 437–446. (Ed.), Handbook of the psychology of women and gender
Fischer, A. R., & Holz, K. B. (2007). Perceived discrimination (pp. 156–169). New York: Wiley.
and women’s psychological distress: The roles of collective Glick, P., & Fiske, S. T. (1996). The Ambivalent Sexism
and personal self-esteem. Journal of Counseling Psychology, Inventory: Differentiating hostile and benevolent sexism.
54, 154–164. Journal of Personality and Social Psychology, 70, 491–512.
Fischer, A. R., Tokar, D. M., Mergl, M. M., Good, G. E., Glick, P., & Fiske, S. T. (2001). An ambivalent alliance: Hostile
Hill, M. S., & Blum, S. A. (2000). Assessing women’s and benevolent sexism as complementary justifications for
feminist identity development: Studies of convergent, dis- gender inequality. American Psychologist, 56, 109–118.
criminant, and structural validity. Psychology of Women Glick, P., Fiske, S., Mladinic, A., Saiz, J. L., Abrams, D., Masser, B.,
Quarterly, 24, 15–29. et al. (2000). Beyond prejudice as simple antipathy: Hostile
Fiske, S. T., Cuddy, A. J. C., Glick, P., & Xu, J. (2002). A model and benevolent sexism across cultures. Journal of Personality
of (often mixed) stereotype content: Competence and and Social Psychology, 79, 763–775.
warmth respectively follow from perceived status and Glick, P., Zion, C., & Nelson, C. (1988). What mediates sex
competition. Journal of Personality and Social Psychology, 82, discrimination in hiring decisions? Journal of Personality and
878–902. Social Psychology, 55, 178–186.
Fitzgerald, L. F. (1993). Sex harassment: Violence against women Golding, J. M. (1990). Division of household labor, strain,
in the workplace. American Psychologist, 48, 1070–1076. and depressive symptoms among Mexican Americans and
Fitzgerald, L. F., Swan, S., & Fischer, K. (1995). Why didn’t non-Hispanic Whites. Psychology of Women Quarterly, 14,
she just report him? The psychological and legal implications 103–117.
of women’s responses to sexual harassment. Journal of Social Gonzalez, A. Q., & Koestner, R. (2005). Parental preference for
Issues, 51(1), 117–138. sex of newborn as reflected in positive affect in birth
Flannagan, D., & Perese, S. (1998). Emotional references in announcements. Sex Roles, 52, 407–411.
mother-daughter and mother-son dyads’ conversations about Goodman, L. A., Koss, M. P., & Russo, N. F. (1993). Violence
school. Sex Roles, 39, 353–367. against women: Physical and mental health effects: Part 1.
Flores, L. Y., Carrubba, M. D., & Good, G. E. (2006). Feminism Research findings. Applied and Preventive Psychology, 2,
and Mexican American adolescent women: Examining the 79–89.
psychometric properties of two measures. Hispanic Journal of Gordon, M. (2000). Definitional issues in violence against
Behavioral Sciences, 28, 48–64. women: Surveillance and research from a violence research
Franchina, J. J., Eisler, R. M., & Moore, T. M. (2001). Masculine perspective. Violence Against Women, 6, 747–783.
gender role stress and intimate abuse: Effects of masculine Good, G. E., & Sherrod, N. B. (2001). The psychology of
gender relevance of dating situations and female threat on men and masculinity: Research status and future directions.

m or adi, yode r 369

 In R. K. Unger (Ed.), Handbook of the psychology of women Hyde, J. S., Klein, M. H., Essex, M. J., & Clark, R. (1995).
and gender (pp. 201–214). New York: Wiley. Maternity leave and women’s mental health. Psychology of
Goodwin, S. A., & Fiske, S. T. (2001). Power and gender: Women Quarterly, 19, 257–285.
The double-edged sword of ambivalence. In R. K. Unger Ito, T. A., & Urland, R. (2003). Race and gender on the brain:
(Ed.), Handbook of the psychology of women and gender Electrocortical measures of attention to the race and gender
(pp. 358–366). New York: Wiley. of multiply categorizable individuals. Journal of Personality
Gurin, P. (1985). Women’s gender consciousness. Public Opinion and Social Psychology, 85, 616–626.
Quarterly, 49, 143–163. Jaggar, A. (1983). Political philosophies of women’s liberation.
Gurin, P., & Townsend, A. (1986). Properties of gender identity In L. Richardson, & V. Taylor (Eds.), Feminist frontiers:
and their implications for gender consciousness. British Rethinking sex, gender, and society (pp. 322–329). New York:
Journal of Social Psychology, 25, 139–148. Random House.
Gutek, B. A. (1985). Sex and the workplace. San Francisco, CA: John, D., & Shelton, B. A. (1997). The production of gender
Jossey-Bass. among Black and White women and men: The case of house-
Gutierrez, L., Oh, H. J., & Gillmore, M. R. (2000). Toward hold labor. Sex Roles, 36, 171–193.
an understanding of (em)power(ment) for HIV/AIDS Johnson, A. G. (2006). Privilege, power, and difference (2nd ed.).
prevention with adolescent women. Sex Roles, 42, 581–611. New York: McGraw Hill.
Hamilton, J. A., & Jensvold, M. (1992). Personality, psychopa- Juntunen, C. L., Atkinson, D. R., Reyes, C., & Gutierrez, M.
thology, and depression in women. In L. S. Brown, & (1994). Feminist identity and feminist therapy behaviors of
M. Ballou (Eds.), Personality and psychopathology: Feminist women psychotherapists. Psychotherapy, 31, 327–333.
reappraisals (pp. 116–143). New York: Guilford. Kahn, A. S., Mathie, V. A., & Torgler, C. (1994). Rape scripts
Hampson, S. E. (1988). The dynamics of categorization and and rape acknowledgment. Psychology of Women Quarterly,
impression formation. In T. K. Srull, & R. S. Wyer, Jr. (Eds.), 18, 53–66.
Advances in social cognition: Vol 1: A dual process model of Kelly, L., & Radford, J. (1996). “Nothing really happened”:
impression formation (pp. 77–82). Hillsdale, NJ: Erlbaum. The invalidation of women’s experiences of sexual violence.
Harned, M. S. (2000). Harassed bodies: An examination of the In M. Hester, L. Kelly, & J. Radford (Eds.), Women, violence and
relationships among women’s experiences of sexual harass- male power (pp. 19–33). Bristol, PA: Open University Press.
ment, body image and eating disturbances. Psychology of Kessler, R. C., Berglund, P., Demler, O., Jin, R., Merikangas, K. R.,
Women Quarterly, 24, 336–348. & Walters, E. E. (2005). Lifetime prevalence and age-of-
Hartung, C. M., & Widiger, T. A. (1998). Gender differences onset- distributions of DSM-IV disorders in the National
in the diagnosis of mental disorders: Conclusions and Comorbidity Survey Replication. Archives of General
controversies of the DSM-IV. Psychological Bulletin, 123, Psychiatry, 62, 593–602.
260–278. King, K. R. (2003). Do you see what I see? Effects of group
Hawkins, A. J., Marshall, C. M., & Meiners, K. M. (1995). consciousness on African American women’s attributions to
Exploring wives’ sense of fairness about family work: An ini- prejudice. Psychology of Women Quarterly, 27, 17–30.
tial test of the distributive justice framework. Journal of Kitzinger, C. (1991). Feminism, psychology, and the paradox
Family Issues, 16, 693–721. of power. Feminism & Psychology, 1, 111–129.
Helgeson, V. S. (1994). Relation of agency and communion to Kling, K. C., Hyde, J. S., Showers, C. J., & Buswell, B. N.
well-being: Evidence and potential explanations. Psychological (1999). Gender differences in self-esteem: A meta-analysis.
Bulletin, 116, 412–428. Psychological Bulletin, 125, 470–500.
Henley, N. M., Meng, K., O’Brien, D., McCarthy, W. J., & Klinkenberg, D., & Rose, S. (1994). Dating scripts of gay
Sockloskie, R. J. (1998). Developing a scale to measure the men and lesbians. Journal of Homosexuality, 26, 23–35.
diversity of feminist attitudes. Psychology of Women Quarterly, Klonoff, E. A., & Landrine, H. (1995). The Schedule of Sexist
22, 317–348. Events: A measure of lifetime and recent sexist discrimina-
Henley, N. M., Spalding, L. R., & Kosta, A. (2000). Development tion in women’s lives. Psychology of Women Quarterly, 19,
of the short form of the Feminist Perspectives Scale. Psychology 439–472.
of Women Quarterly, 24, 254–256. Knudson-Martin, C., & Mahoney, A. R. (2005). Moving beyond
Hesse-Biber, S., Marino, M., & Watts-Roy, D. (1999). A longi- gender: Processes that create relationship equality. Journal
tudinal study of eating disorders among college women: of Marital & Family Therapy, 31, 235–246.
Factors that influence recovery. Gender & Society, 13, Kobrynowicz, D., & Branscombe, N. R. (1997). Who considers
385–408. themselves victims of discrimination? Individual difference
Hessing, M. (1994). More than clockwork: Women’s time man- predictors of perceived gender discrimination in women
agement in their combined workload. Sociological Perspectives, and men. Psychology of Women Quarterly, 21, 347–363.
37, 611–633. Koss, M. P. (1990). The women’s mental health research agenda:
Hoffman, R. M. (2006). Gender self-definition and gender Violence against women. American Psychologist, 45,
self-acceptance in women: Intersections with feminist, wom- 374–380.
anist, and ethnic identities. Journal of Counseling & Koss, M. P., Figueredo, A. J., Bell, I., Tharan, M., & Tromp, M.
Development, 84, 358–372. (1996). Traumatic memory characteristics: A cross-validated
Hogue, M., & Yoder, J. D. (2003). The role of status in produc- mediational model of response to rape among employed
ing depressed entitlement in women’s and men’s pay alloca- women. Journal of Abnormal Psychology, 105, 1–12.
tions. Psychology of Women Quarterly, 27(4), 330–337. Koss, M. P., Goodman, L. A., Browne, A., Fitzgerald, L. F., Keita,
Hollander, J. A. (2001). Vulnerability and dangerousness: The G. P., & Russo, N. F. (1994). No safe haven: Male violence
construction of gender through conversation about violence. against women at home, at work, and in the community.
Gender & Society, 15, 83–109. Washington, DC: American Psychological Association.

370 the psycholo gy o f wo men

Kozee, H. B., Tylka, T. L., Augustus-Horvath, C. L., & Denchik, Mackey, R. A., Diemer, M. A., & O’Brien, B. A. (2000).
A. (2007). Development and psychometric evaluation of the Psychological intimacy in the lasting relationships of hetero-
Interpersonal Sexual Objectification Scale. Psychology of sexual and same-gender couples. Sex Roles, 43, 201–227.
Women Quarterly, 31, 176–189. Major, B. (1993). Gender, entitlement, and the distribution
Kravetz, D., & Marecek, J. (1996). The personal is political: of family labor. Journal of Social Issues, 49(3), 141–159.
A feminist agenda for group psychotherapy research. Marecek, J., & Hare-Mustin, R. T. (1991). A short history of the
In B. DeChant (Ed.), Women and group psychotherapy: Theory future: Feminism and clinical psychology. Psychology of
and practice (pp. 351–369). New York: Guilford. Women Quarterly, 15, 521–536.
Kurdek, L. A. (1993). The allocation of household labor in Martin, C. L., & Fabes, R. A. (2001). The stability and conse-
gay, lesbian, and heterosexual married couples. Journal of quences of young children’s same-sex peer interactions.
Social Issues, 49(3), 127–139. Developmental Psychology, 37, 431–446.
Lamb, S., & Keon, S. (1995). Blaming the perpetrator: Language Martire, L. M., Stephens, M. A., & Townsend, A. L. (1998).
that distorts reality in newspaper articles on men battering Emotional support and well-being of midlife women: Role-
women. Psychology of Women Quarterly, 19, 209–220. specific mastery as a mediational mechanism. Psychology &
Landrine, H. (1985). Race x class stereotypes of women. Aging, 13, 396–404.
Sex Roles, 13, 65–75. Matsui, T., Ohsawa, T., & Onglatco, M. (1995). Work-family
Landrine, H. (1988). Depression and stereotypes of women: conflict and the stress-buffering effects of husband support
Preliminary empirical analyses of the gender-role hypothesis. and coping behavior among Japanese married working
Sex Roles, 19, 527–541. women. Journal of Vocational Behavior, 47, 178–192.
Landrine, H. (1989). The politics of personality disorder. McCarn, S. R., & Fassinger, R. E. (1996). Revisioning sexual
Psychology of Women Quarterly, 13, 325–339. minority identity formation: A new model of lesbian identity
Landrine, H., Klonoff, E. A., Gibbs, J., Manning, V., & and its implications for counseling and research. The
Lund, M. (1995). Physical and psychiatric correlates of Counseling Psychologist, 24, 508–534.
gender discrimination: An application of the Schedule McHugh, M. C., Frieze, I. H., & Browne, A. (1993). Research
of Sexist Events. Psychology of Women Quarterly, 19, on battered women and their assailants. In M. Paludi, &
473–492. F. Denmark (Eds.), Handbook on the psychology of women
Leigh, B. C. (1989). Reasons for having and avoiding sex: (pp. 513–552). New York: Greenwood Press.
Gender, sexual orientation, and relationship to sexual behav- McKinley, N. M., & Hyde, J. S. (1996). The Objectified Body
ior. Journal of Sex Research, 26, 199–209. Consciousness Scale: Development and validation. Psychology
Lennon, M. C., & Rosenfield, S. (1994). Relative fairness and of Women Quarterly, 20, 181–215.
the division of housework: The importance of options. Messerschmidt, J. W. (2000). Becoming “real men”: Adolescent
American Journal of Sociology, 100, 506–531. masculinity challenges and sexual violence. Men and
Lerman, H. (1996). Pigeonholing women’s misery: A history and Masculinities, 2, 286–307.
critical analysis of the psychodiagnosis of women in the twentieth Messner, M. A. (2000). Barbie girls versus sea monsters: Children
century. New York: Basic. constructing gender. Gender & Society, 14, 765–784.
Letlaka-Rennert, K., Luswazi, P., Helms, J. E., & Zea, M. C. Mobley, G. M., Jaret, C., Marsh, K., & Lim, Y. (1994).
(1997). Does the womanist identity model predict aspects of Mentoring, job satisfaction, gender, and the legal profession.
psychological functioning in Black South African women? Sex Roles, 31, 79–98.
South African Journal of Psychology, 27, 236–243. Moen, P., & Forest, K. B. (1990). Working parents, workplace
Lim, S., & Cortina, L. M. (2005). Interpersonal mistreatment in supports, and well-being: The Swedish experience. Social
the workplace: The interface and impact of general incivility Psychology Quarterly, 53, 117–131.
and sexual harassment. Journal of Applied Psychology, 90, Monson, R. A. (1997). State-ing sex and gender: Collecting
483–496. information from mothers and fathers in paternity cases.
Lips, H. M. (1991). Women, men, and power. Mountain View, Gender & Society, 11, 279–295.
CA: Mayfield. Moradi, B. (2005). Advancing womanist identity development:
Lips, H. M. (2002). Female powerlessness: Still a case of “cultural Where we are and where we need to go. The Counseling
preparedness”? In A. E. Hunter & C. Forden (Eds.), Readings Psychologist, 33, 225–253.
in the psychology of gender (pp. 19–37). Boston, MA: Allyn & Moradi, B., & DeBlaere, C. (2010). Women’s experiences of
Bacon. sexist discrimination: Review of research and directions for
Loden, M., & Rosener, J. B. (1991). Workforce America: centralizing race, ethnicity, and culture. In H. Landrine &
Managing employee diversity as a vital resource. Homewood, N. F. Russo (Eds.), Handbook of Diversity in Feminist
IL: Business One Irwin. Psychology (pp. 173–210). New York: Springer.
Lott, B. (1995). Distancing from women: Interpersonal sexist Moradi, B., & Funderburk, J. R. (2006). Roles of perceived
discrimination. In B. Lott, & D. Maluso (Eds.), The social sexist events and perceived social support in the mental
psychology of interpersonal discrimination (pp. 12–49). health of women seeking counseling. Journal of Counseling
New York: Guilford. Psychology, 53, 464–473.
Louie, T. A., & Tom, G. (2005). Timely completion of class Moradi, B., & Huang, Y. P. (2008). Objectification theory and
requirements: Effects of student and faculty gender. Sex Roles, psychology of women: A decade of advances and future
52, 245–250. directions. Psychology of Women Quarterly, 32, 377–398.
Maccoby, E. E. (1990). Gender and relationships: A develop- Moradi, B., & Rottenstein, A. (2007). Objectification theory
mental account. American Psychologist, 45, 513–520. and deaf cultural identity attitudes: Roles in deaf women’s
MacCorquodale, P., & Jensen, G. (1993). Women in the law: eating disorder symptomatology. Journal of Counseling
Partners or tokens? Gender & Society, 7, 582–593. Psychology, 54, 178–188.

m or adi, yode r 371

Moradi, B., & Subich, L. M. (2002a). Perceived sexist events self-esteem and perceptions of environmental bias? Journal of
and feminist identity development attitudes: Links to wom- Counseling and Development, 70, 402–408.
en’s psychological distress. The Counseling Psychologist, 30, Ozer, E. M. (1995). The impact of childcare responsibility and
44–65. self-efficacy on the psychological health of professional work-
Moradi, B., & Subich, L. M. (2002b). Feminist identity develop- ing mothers. Psychology of Women Quarterly, 19, 315–335.
ment measures: Comparing the psychometrics of three Padavic, I., & Reskin, B. (2002). Women and men at work
instruments. The Counseling Psychologist, 30, 66–86. (2nd ed.). Thousand Oaks, CA: Pine Forge.
Moradi, B., & Subich, L. M. (2003). A concomitant examina- Parks, E. E., Carter, R. T., & Gushue, G. V. (1996). At the cross-
tion of the relations of perceived racist and sexist events to roads: Racial and womanist identity development in Black
psychological distress for African American women. The and White women. Journal of Counseling and Development,
Counseling Psychologist, 31, 451–469. 74, 624–631.
Moradi, B., & Subich, L. M. (2004). Examining the moderating Parrot, A., & Bechhofer, L. (Eds.) (1991). Acquaintance rape: The
role of self-esteem in the link between experiences of per- hidden crime. New York: Wiley.
ceived sexist events in psychological distress. Journal of Parvin, R., & Biaggio, M. K. (1991). Paradoxes in the practice of
Counseling Psychology, 51, 50–56. feminist therapy. Women & Therapy, 11(2), 3–12.
Moradi, B., Subich, L. M., & Phillips, J. (2002a). Beyond revis- Peterson, R. D, Grippo, K. P., & Tantleff-Dunn, S. (2008).
iting: Moving feminist identity development ahead. The Empowerment and powerlessness: A closer look at the rela-
Counseling Psychologist, 30, 103–109. tionship between feminism, body image and eating distur-
Moradi, B., Subich, L. M., & Phillips, J. (2002b). Revisiting bance. Sex Roles, 58, 639–648.
feminist identity development theory, research, and practice. Peterson, R. D., Tantleff-Dunn, S., & Bedwell, J. S. (2006). The
The Counseling Psychologist, 30, 6–44. effects of exposure to feminist ideology on women’s body
Moradi, B., Yoder, J. D., & Berendsen, L. L. (2004). An evalua- image. Body Image, 3, 237–246.
tion of the psychometric properties of the Womanist Identity Poindexter-Cameron, J. M., & Robinson, T. L. (1997).
Attitudes scale. Sex Roles, 50, 253–266. Relationships among racial identity attitudes, womanist
Morrison, J. (1989). Childhood sexual histories of women with identity attitudes, and self-esteem in African American col-
somatization disorder. American Journal of Psychiatry, 146, lege women. Journal of College Student Development, 38,
239–241. 288–296.
Morrongiello, B. A., & Hogg, K. (2004). Mothers’ reactions to Potts, M. K., Burnam, M. A., & Wells, K. B. (1991). Gender
children misbehaving in ways that can lead to injury: differences in depression detection: A comparison of clini-
Implications for gender differences in children’s risk taking cian diagnosis and standardized assessment. Psychological
and injuries. Sex Roles, 50, 103–118. Assessment, 3, 609–615.
Mosher, C. E., & Danoff-Burg, S. (2005). Agentic and commu- Pratto, F., & Walker, A. (2004). The bases of gendered power.
nal personality traits: Relations to attitudes toward sex and In A. H. Eagly, A. E. Beall, & R. J. Sternberg (Eds.), The psy-
sexual experiences. Sex Roles, 52, 121–129. chology of gender (2nd ed., pp. 242–268). New York: Guilford.
Muehlenhard, C. L., Powch, I. G., Phelps, J. L., & Giusti, L. M. Pratto, F., Sidanius, J., & Levin, S. (2006). Social dominance
(1992). Definitions of rape: Scientific and political implica- theory and the dynamics of intergroup relations: Taking
tions. Journal of Social Issues, 48(1), 23–44. stock and looking forward. European Review of Social
Murnen, S. K., Wright, C., & Kaluzny, G. (2002). If “boys will Psychology, 17, 271–320.
be boys,” then girls will be victims? A meta-analytic review of Prentice, A. D., & Miller, T. D. (2007). Psychological essential-
the research that relates masculine ideology to sexual aggres- ism of human categories. Association for Psychological Science,
sion. Sex Roles, 46, 359–375. 16, 202–206.
Neppl, T. K., & Murray, A. D. (1997). Social dominance and Pulerwitz, J., Gortmaker, S. L., & DeJong, W. (2000). Measuring
play patterns among preschoolers: Gender comparisons. Sex sexual relationship power in HIV/STD research. Sex Roles,
Roles, 36, 381–393. 42, 637–660.
Noland, V. J., Daley, E. M., Drolet, J. C., Fetro, J. V., McCormack Pyke, K., & Coltrane, S. (1996). Entitlement, obligation, and
Brown, K. R., Hassell, C. D., & McDermott, R. J. (2004). gratitude in family work. Journal of Family Issues, 17,
Connotative interpretations of sexuality-related terms. Sex 61–82.
Roles, 51, 523–534. Quina, K., Harlow, L. L., Morokoff, P. J., Burkholder, G., &
Ogletree, S. M., Martinez, C. N., Turner, T. R., & Mason, B. Deiter, P. J. (2000). Sexual communication in relation-
(2004). Pokemon: Exploring the role of gender. Sex Roles, 50, ships: When words speak louder than actions. Sex Roles, 42,
851–859. 523–549.
Oliver, M. B., & Hyde, J. S. (1993). Gender differences in sexu- Quinn, D. M., Kallen, R. W., Twenge, J. M., & Fredrickson, B. L.
ality: A meta-analysis. Psychological Bulletin, 114, 29–51. (2006). The disruptive effect of self-objectification on perfor-
Osmond, M. W., Wambach, K. G., Harrison, D. F., Byers, J., mance. Psychology of Women Quarterly, 30, 59–64.
Levine, P. Imershein, A., & Quadango, D. M. (1993). The Randall, M., & Haskell, L. (1995). Sexual violence in women’s
multiple jeopardy of race, class, and gender for AIDS risk lives: Findings from the Women’s Safety Project, a communi-
among women. Gender & Society, 7, 99–120. ty-based survey. Violence Against Women, 1, 6–31.
Ossana, S. M. (1986). The relationship between women’s percep- Rankin, E. D. (1993). Stresses and rewards experienced by
tions of the campus environment and self-esteem as moderated by employed mothers. Health Care for Women International, 14,
women’s identity attitudes. Unpublished master’s thesis, 527–537.
University of Maryland, College Park. Reitz, R. R. (1999). Batterers’ experiences of being violent:
Ossana, S. M., Helms, J. E., & Leonard, M. M. (1992). A phenomenological study. Psychology of Women Quarterly,
Do “womanist” identity attitudes influence college women’s 23, 143–165.

372 the psycholo gy o f wo men

Rickard, K. M. (1989). The relationship of self-monitored dating Satterfield, A. T., & Muehlenhard, C. L. (1997). Shaken confi-
behaviors to level of feminist identity on the feminist identity dence: The effects of an authority figure’s flirtatiousness on
scale. Sex Roles, 20, 213–226. women’s and men’s self-rated creativity. Psychology of Women
Ridgeway, C. L. (1991). The social construction of status value: Quarterly, 21, 395–416.
Gender and other nominal characteristics. Social Forces, 70, Saunders, K. J., & Kashubeck-West, S. (2006). The relations
367–386. among feminist identity development, gender-role orienta-
Ridgeway, C. L. (2001). Gender, status, and leadership. Journal tion, and psychological well-being in women. Psychology of
of Social Issues, 57(4), 637–655. Women Quarterly, 30, 199–211.
Ridgeway, C. L., & Smith-Lovin, L. (1999). The gender system Schneider, D. J. (2004). The psychology of stereotyping. New York:
and interaction. Annual Review of Sociology, 25, 191–216. Guilford.
Riger, S. (2000). From snapshots to videotape: New directions Shapiro, J., & Kroeger, L. (1991). Is life just a romantic novel?
in research on gender differences. In S. Riger (Ed.), The relationship between attitudes about intimate relation-
Transforming psychology: Gender in theory and practice ships and the popular media. American Journal of Family
(pp. 39–51). New York: Oxford. Therapy, 19, 226–236.
Robertson, J., & Fitzgerald, L. F. (1990). The (mis)treatment of Shaw, S. N. (2002). Shifting conversations on girls’ and women’s
men: Effects of client gender role and life-style on diagnosis self-injury: An analysis of the clinical literature in historical
and attribution of pathology. Journal of Counseling Psychology, context. Feminism & Psychology, 12, 191–219.
37, 3–9. Sigmon, S. T., Pells, J. J., Boulard, N. E., Whitcomb-Smith, S.,
Robinson, J., & Spitze, G. (1992). Whistle while you work? The Edenfield, T. M., Herman, B. A., et al. (2005). Gender dif-
effect of household task performance on women’s and men’s ferences in self-reports of depression: The response bias
well-being. Social Science Quarterly, 73, 844–861. hypothesis revisited. Sex Roles, 53, 401–411.
Rodin, J., Silberstein, L., & Striegel-Moore, R. (1984). Women Skrypnek, B. J., & Snyder, M. (1982). On the self-perpetuating
and weight: A normative discontent. Nebraska Symposium on nature of stereotypes about women and men. Journal of
Motivation, 32, 267–307. Experimental Social Psychology, 18, 277–291.
Root, M. P. P. (1991). Persistent, disordered eating as a gender- Snyder, R., & Hasbrouck, L. (1996). Feminist identity, gender
specific, post-traumatic stress response to sexual assault. traits, and symptoms of disturbed eating among college
Psychotherapy, 28, 96–102. women. Psychology of Women Quarterly, 20, 593–598.
Root, M. P. P. (1992). Reconstructing the impact of trauma on Sprecher, S., & Felmlee, D. (1997). The balance of power in
personality. In L. S. Brown, & M. Ballou (Eds.), Personality romantic heterosexual couples over time from “his” and
and psychopathology: Feminist reappraisals (pp. 229–265). “her” perspectives. Sex Roles, 37, 361–379.
New York: Guilford. Sprecher, S., Regan, P. C., & McKinney, K. (1998). Beliefs about
Rose, S. (2000). Heterosexism and the study of women’s roman- the outcomes of extramarital sexual relationships as a func-
tic and friend relationships. Journal of Social Issues, 56, tion of the gender of the “cheating spouse.” Sex Roles, 38,
315–328. 301–311.
Rose, S., & Zand, D. (2000). Lesbian dating and courtship from Staub, E. (1989). The roots of evil: The origins of genocide and other
young adulthood to midlife. Journal of Gay & Lesbian Social group violence. Cambridge, UK: Cambridge University Press.
Services: Issues in Practice, Policy & Research, 11, 77–104. Steil, J. M. (1997). Marital equality: Its relationship to the well-
Rosenbluth, S. C., & Steil, J. M. (1995). Predictors of intimacy being of husbands and wives. Thousand Oaks, CA: Sage.
for women in heterosexual and homosexual couples. Journal Steil, J. M., & Weltman, K. (1991). Marital inequality: The
of Social and Personal Relationships, 12, 163–175. importance of resources, personal attributes, and social
Ross, L., & Nisbett, R. E. (1991). The person and the situation: norms on career valuing and the allocation of domestic
Perspectives of social psychology. New York: McGraw-Hill. responsibilities. Sex Roles, 24, 161–179.
Rozee, P. D., & Koss, M. P. (2001). Rape: A century of resis- Swann, S. K., & Spivey, C. A. (2004). The relationship between
tance. Psychology of Women Quarterly, 25, 295–311. self-esteem and lesbian identity during adolescence. Child &
Ruble, D. N., & Martin, C. L. (1998). Gender development. Adolescent Social Work Journal, 21, 629–646.
In W. Damon (Series Ed.), & N. Eisenberg (Ed.), Handbook Swearingen-Hilker, N., & Yoder, J. D. (2002). Understanding
of child psychology: Vol. 3. Social, emotional, and personality the context of unbalanced domestic contributions: The influ-
development (5th ed., pp. 933–1016). New York: Wiley. ence of perceiver’s attitudes, target’s gender, and presenta-
Russell, B. L., & Trigg, K. Y. (2004). Tolerance of sexual harass- tional format. Sex Roles, 46, 91–98.
ment: An examination of gender differences, ambivalent Swim, J. K., Cohen, L. L., & Hyers, L. L. (1998). Experiencing
sexism, social dominance, and gender roles. Sex Roles, 50, everyday prejudice and discrimination. In J. K. Swim, &
565–573. C. Stangor (Eds.), Prejudice: The target’s perspective (pp. 37–60).
Russo, N. F. (1998). Measuring feminist attitudes: Just what does San Diego: Academic Press.
it mean to be a feminist? Psychology of Women Quarterly, 22, Swim, J. K., Hyers, L. L., Cohen, L. L., & Ferguson, M. J.
313–315. (2001). Everyday sexism: Evidence for its incidence, nature,
Ryan, K. M., & Kanjorski, J. (1998). The enjoyment of sexist and psychological impact from three daily diary studies.
humor, rape attitudes, and relationship aggression in college Journal of Social Issues, 57, 31–53.
students. Sex Roles, 38, 743–756. Szymanski, D. M. (2005a). Heterosexism and sexism as corre-
Sadker, M., & Sadker, D. (1994). Failing at fairness: How lates of psychological distress in lesbians. Journal of Counseling
America’s schools cheat girls. New York: Macmillan. and Development, 83, 355–360.
Sanchez, L., & Thomson, E. (1997). Becoming mothers and Szymanski, D. M. (2005b). Feminist identity theories as corre-
fathers: Parenthood, gender, and the division of labor. Gender lates of feminist supervision practices. The Counseling
& Society, 11, 747–772. Psychologist, 33, 729–747.

m or adi, yode r 373

Tangri, S. S., & Jenkins, S. R. (1997). Why expecting conflict is pro-feminist orientation and feminist social identity. Sex
good. Sex Roles, 36, 725–746. Roles, 37, 885–904.
Teets, J. M. (1995). Childhood sexual trauma of chemically Wise, E., & Rafferty, J. (1982). Sex bias and language. Sex Roles,
dependent women. Journal of Psychoactive Drugs, 27, 8, 1189–1196.
231–238. Woll, S. (2002). Everyday thinking: Memory, reasoning, and judg-
Thomas, S. (2002). The personal is the political: Antecedents ment in the real world. Mahwah, NJ: Erlbaum.
of gendered choices of elected representatives. Sex Roles, Worell, J. (1988). Women’s satisfaction in close relationships.
47, 343–353. Clinical Psychology Review, 8, 477–498.
Thompson, L. (1991). Family work: Women’s sense of fairness. Worell, J., & Remer, P. (1992). Feminist perspectives in therapy:
Journal of Family Issues, 12, 181–196. An empowerment model for women. New York: Wiley.
Thompson, M. P., & Norris, F. H. (1992). Crime, social status, Worell, J., Stilwell, D., Oakley, D., & Robinson, D. (1999).
and alienation. American Journal of Community Psychology, Educating about women and gender: Cognitive, personal
1, 97–119. and professional outcomes. Psychology of Women Quarterly,
Tiedje, L. B. (2004). Processes of change in work/home incom- 23, 797–811.
patibilities: Employed mothers 1986–1999. Journal of Social Worthington, R. L., Navarro, R. L., Savoy, H. B., & Hampton, D.
Issues, 60(4), 787–800. (2008). Development, reliability and validity of the Measure
Tomlinson, M. J., & Fassinger, R. E. (2003). Career develop- of Sexual Identity Exploration and Commitment (MoSIEC).
ment, lesbian identity development, and campus climate Developmental Psychology, 44, 22–33.
among lesbian college students. Journal of College Student Wright, D. (1992). Impediments to safer heterosexual sex:
Development, 44, 845–860. A review of research with young people. AIDS Care, 4,
Tripp, M. M., & Petrie, T. A. (2001). Sexual abuse and eating 11–23.
disorders: A test of a conceptual model. Sex Roles, 44, Yoder, J. D. (2001). Making leadership work more effectively for
17–32. women. Journal of Social Issues, 57(4), 815–828.
Vandiver, B. J. (2002). What do we know and where do we go? Yoder, J. D. (2007). Women and gender: Making a difference.
The Counseling Psychologist, 30, 96–104. Cornwall-on-Hudson, NY: Sloan.
Voss, L. S. (1997). Teasing, disputing, and playing: Cross-gender Yoder, J. D., Fischer, A. R., Kahn, A. S., & Groden, J. (2007).
interactions and space utilization among first and third grad- Changes in students’ explanations for gender differences
ers. Gender & Society, 11, 238–256. after taking a Psychology of Women class: More construc-
Walker, A. (1983). In search of our mother’s garden. New York: tionist and less essentialist. Psychology of Women Quarterly,
Harcourt. 31, 415–425.
Weisbuch, M., Beal, D., & O’Neal, E. C. (1999). How mascu- Yoder, J. D., & Kahn, A. S. (1993). Working toward an inclusive
line ought I be? Men’s masculinity and aggression. Sex Roles, psychology of women. American Psychologist, 48, 846–850.
40, 583–592. Yoder, J. D., Perry, R. L., & Saal, E. I. (2007). What good is
Weitzman, L. M. (1994). Multiple-role realism: A theoretical a feminist identity? Women’s feminist identification and role
framework for the process of planning to combine career and expectations for intimate and sexual relationships. Sex Roles,
family roles. Applied & Preventive Psychology, 3, 15–25. 57, 365–372.
West, C., & Fenstermaker, S. (1995). Doing difference. Gender Yoder, J. D., Schleicher, T. L., & McDonald, T. W. (1998).
& Society, 9, 8–37. Empowering token women leaders: The importance of orga-
White, A. M., Strube, M. J., & Fisher, S. (1998). A black femi- nizationally legitimated credibility. Psychology of Women
nist model of rape myth acceptance. Psychology of Women Quarterly, 22, 209–222.
Quarterly, 22, 157–173. Young, I. M. (1992). Five faces of oppression. In T. E. Wartenberg
Whitley, B. E. (1997). Gender differences in computer-related (Ed.), Rethinking power (pp. 174–195). Albany, NY: State
attitudes and behavior: A meta-analysis. Computers in Human University of New York Press.
Behavior, 13, 1–22. Zucker, A. N. (2004). Disavowing social identities: What it
Williams, R., & Wittig, M. A. (1997). “I’m not a feminist, means when women say “I’m not a feminist but . . .”
but . . .”: Factors contributing to the discrepancy between Psychology of Women Quarterly, 28, 423–435.

374 the psycholo gy o f wo men

 CHAPTER

14 The Psychology of Men

James M. O’Neil

Abstract
The status of the psychology of men in 2010 is assessed in terms of empirical research and knowledge
about men in therapy. A brief historical context for the psychology of men over the past decades is
presented. Men’s problems are reviewed from the survey research and the most frequently referenced
paradigms in the psychology of men. Empirical research studies are examined that assess whether
masculinity ideology, gender role conflict/stress, and other masculinity constructs are correlated with
men’s psychological problems. The results strongly suggest that masculinity conflicts are significantly
related to men’s psychological and interpersonal problems. The clinical knowledge on men as clients is
reviewed in the context of published paradigms that treat men in therapy. The chapter concludes with
recommendations for more complex research designs, greater emphasis on diversity, more evidence-
based interventions with men, and more extensive training and teaching about the psychology of men
in counseling psychology. The overall status of the psychology of men is “alive and well” but more
elaborate theoretical paradigms and focused empirical research are needed for the psychology of men
to significantly affect counseling psychology and mainstream psychology.
Keywords: men, masculinity, counseling psychology, gender

Over the last 30 years, the psychology of men has (Harrison, 1978; Lewis & Pleck, 1979; Levinson,
emerged as a recognized discipline in the social Darrow, Klein, Levinson, & McKee, 1978; Skovholt,
sciences. The feminist’s movements of the 1970s Gormally, Schauble, & Davis, 1978).
were the primary stimuli for activating the psy- Counseling psychology was one of the first
chology of men. As women deconstructed their American Psychological Association (APA) divisions
gender roles, men began to do the same. How to recognize the importance of the psychology of
sexism negatively affected women raised significant men. A special issue of The Counseling Psychologist
questions about how sexist norms affect men. The (TCP), titled “Counseling Men” (Skovholt et al.,
Men’s Liberation Movement was the precursor to 1978) introduced men’s issues to counseling psy-
the psychology of men (Pleck & Pleck, 1980), and chology. The special issue was the field’s first state-
in the early 1970s social scientists began to discuss ment about men, and established the psychology of
men’s roles. Six seminal books were published from men as a legitimate area of scientific and clinical
1974 to 1977 that gave men’s liberation a national importance. During the 1980s, continued efforts
prominence (David & Brannon, 1976, Farrell, were made to explore the psychology of men. Brooks
1974; Fasteau, 1974; Goldberg, 1977; Nichols, and Levant (1998) document the activities of psy-
1975; Pleck & Sawyer, 1974). Additional publica- chologists during this formative period in the psy-
tions appeared in scholarly journals that estab- chology of men. Most notably was a special issue in
lished an early rationale for the psychology of men the Personnel and Guidance Journal on “Counseling

375
Men” (Scher, 1981) and the Handbook of Counseling conflict/stress with men’s psychological and inter-
and Psychotherapy with Men (Scher, Stevens, Good, personal problems, to review the research on men as
& Eichenfield, 1987). In 1991, the Special Interest clients, to summarize assessment approaches for
Group (SIG) on Men, Masculinity and Men’s therapists who counsel men, to summarize the rec-
Studies was formed in Division 17 to better coordi- ommendations on therapeutic processes with men,
nate activities related to the psychology of men. and to discuss future directions for the study of men
During the 1990 APA Boston convention, a and masculinity. The first three sections of the chap-
group of 50 psychologists met to discuss institu- ter give historical, theoretical, and contextual over-
tionalizing the psychology of men as an official divi- views on the psychology of men. The next two
sion of the APA (Brooks & Levant, 1998). There sections review the empirical research that assesses
was consensus that the psychology of men deserved how masculinity conflicts relate to men’s psycho-
official recognition within the APA. In 1995, after logical problems and what is known about men as
5 years of lobbying, the APA endorsed the Society clients. The following two sections focus on recom-
for the Psychological Study of Men and Masculinity mended assessment approaches and therapeutic
(SPSMM) as an official division in APA. As SPSMM processes with men. The final section of the chapter
was becoming an APA Division, different factions enumerates nine critical directions for the future
in the men’s movement (Mythopoetic and Men’s study of men and masculinity.
Right’s groups) became active in communicating Over a 2-year period, an exhaustive literature
their positions about men’s roles and rights (Kimmel, review was conducted to synthesize the psychology
1995). The American Men’s Studies Association of men’s theory and research. Defined strategies of
was formed in 1988, and new journals like the review were employed. First, a review of the major
Journal of Men’s Studies and Men and Masculinities journals in men’s studies and the psychology of men
were created. In 2000, SPSMM published the was conducted. Theory and empirical research stud-
Psychology of Men and Masculinity, the first empiri- ies were read and organized on grid sheets to deter-
cal journal devoted to the psychology of men, and mine major concepts and empirical areas that
in 2007, Thymos: Journal of Boyhood Studies was the currently define the psychology of men. The grid
first journal devoted to research on boys. sheets were then sorted into various groupings to
The psychology of men is a new discipline and in facilitate the analysis of the findings. Separate sorts
its early stages of defining its identity and purpose. were implemented for the eight goals of the chapter.
Like most new disciplines, the psychology of men is Additional sorts were made for specific topic areas.
experiencing growing pains as it defines its mission Written summaries of each sorting were completed
and desired impact. Over the past 10 years, the pub- to establish the current knowledge of the psychol-
lished literature in the psychology of men has been ogy of men in theory, research, and clinical practice.
substantial, but the discipline suffers from few theo- All the findings of the review are not summarized
ries and measures to conceptualize the diversity here. Priority is given to published manuscripts and
of men’s attitudes, problems, and potentialities. thematic topics consistently appearing in the litera-
Furthermore, much of the empirical research has ture. The review is also limited to publications in
not been applied to clinical interventions with men. the psychology of men that have research and clini-
Therefore, knowledge about doing therapy with cal relevance to advance service delivery for men.
men is in its early stages of development.
Historical Background and Contemporary
Goals of the Chapter, Limitations, Status of the Psychology of Men
and Literature Search Process The history of masculinity documents how social,
The overall goal of this chapter is to review the status economic, and political factors have shaped men’
of the psychology of men, with specific attention lives. Historical analyses of masculinity have been
paid to theory, research, and clinical practice with made by authors over various time periods (Blazina,
men. The eight goals of this chapter are to briefly 2003; Doyle, 1995; Dubbert, 1979; Kimmel, 2006;
review the historical and contemporary views of Pleck & Pleck, 1980; Rotundo, 1993; Smiler,
men and masculinity, to report men’s problems as 2004). Most historical analyses describe how social,
they are described in the literature, to summarize political, and economic developments shape the
the main theories and concepts in the psychology understanding of men’s lives. Kimmel’s (2006) cul-
of men, to review the empirical research that has tural history of manhood concludes that men’s
correlated masculinity ideology and gender role problems and defensiveness today “lie deep in our

376 the psycholo gy o f men

nation’s past” (p. 1). He traces the idea of men test- From my literature review, one issue crystalized.
ing and proving their masculinity from the early The scholarly study of men’s lives has a short history
part of the 19th century and concludes that this in psychology. Only in the last 15 years has psychol-
single premise continues to affect contemporary ogy specifically focused on men’s psychological pro-
men’s lives. Kimmel argues “that the quest for man- cesses. The study of ordinary men’s lives has been
hood—the effort to achieve, to demonstrate, to neglected in psychology. One wonders why. What
prove our masculinity—has been one of the forma- has contributed to the limited study of men’s emo-
tive and persistent experiences in men’s lives” (p. 3). tional and interpersonal lives? Have patriarchal
This historical analysis is important because prov- structures been so strong (or maybe so vulnerable)
ing one’s masculinity has powerful psycholog- that the study of men’s lives threatens the status
ical significance in explaining men’s contemporary quo? The gradual emergence of the psychology of
problems. men over the last three decades has brought men’s
Kimmel is correct in stating that American men issues into psychological focus. Theoretical and
have not had a history of themselves as men. empirical advances have explained how sexism neg-
In almost all of the published historical analyses, atively affects male development. How restricted
men’s personal experiences with their gender roles gender roles affect men’s lives now has a firm base in
have not been explained. Famous men’s lives have psychology. The damaging effects of patriarchal
been studied, but analyses of the average men’s expe- sexism on men and women are now social justice
riences with their gender roles have gone unex- issues for many psychologists doing research or
plored. Whether men from previous generations felt providing clinical services.
gender role conflict and strain in their interpersonal
and work roles is unclear from the historical analy- Men’s Problems: Is There
ses. Little historical documentation exists on how a Crises in America?
men coped with changing gender roles or whether Survey data on men’s psychological problems are
they even consciously thought about them in any quite limited. Only two large epidemiological stud-
significant ways. Most historians do acknowledge ies of men’s problems were found (Robin & Reiger,
that American middle-class men had to “contend 1991; Kessler & Walters, 2002). Cochran (2005)
with a paradigmatic revolution in self-perception reviews the base rates of mental disorders of men
during the nineteenth and twentieth centuries” in these two large-scale surveys. According to
(Dubbert, 1979, p. 9). These paradigm shifts con- Cochran’s analysis, men are at the highest risk for
tinue today in men’s lives. Scholars are now assess- alcohol and drug abuse and dependency over the
ing men’s psychological experience of their gender lifespan. Between 31% and 47% of all men will
roles with scholarly rigor not witnessed before in develop a substance abuse problem over the life-
human history. Therapists should consider this past time. Additionally, these surveys indicate that life-
history when examining men’s contemporary dilem- time prevalence rates for men’s psychological
mas in therapy. problems are: depressive disorder (3. 6%–12.7%),
Capturing the evolution of the psychology of antisocial personality disorder (4.5%–5.8%), gener-
men over decades is easier than summarizing the alized anxiety disorder (2.4%–3.6%), and bipolar
current state of men’s lives. Contemporary concep- disorder (1.1%–1.6%). Conspicuously absent in
tions of masculinity are complex because of differ- the literature are many large-scale studies that evalu-
ences based on race, class, age, ethnicity, religion, ate men’s problems with their gender roles.
nationality, and sexual orientation. Many contex- Beyond these epidemiological studies, numerous
tual and diversity factors influence how men define authors indicate that boys and men have serious
themselves. The current state of masculinity in the physical and emotional problems (Glicken, 2005;
United States is best described as diverse and in con- Courtenay, 1998; 2000a, b; Robin & Reiger, 1991).
stant transition or flux. Furthermore, like the wom- Courtenay (1998) reports that men in the United
en’s movement of the 1970s, men’s issues have States, on average, die 7 years younger than women
stimulated cultural and political clashes between and have higher death rates for all leading causes of
feminists and traditionalists, as well as divisions death (DHHS, 1996a). Men commit suicide 4 to
within the men’s movements. These ideological con- 15 times more often than do women (Cochran &
flicts have rarely advanced our knowledge, and have Rabinowitz, 2000; Murphy, 1998). Seven of 10 of
sometimes polarized groups in unproductive ways the most common infectious diseases in the United
(Kimmel, 1995). States are higher among men compared to women

o’ne il 377
(CDC, 1997). Seventy-five percent of people a crucial part in the development of men’s problems.
under the age of 65 who die from heart attacks are Arguments were made about the “hazards of being
men (American Heart Association [AHA], 1994). male” (Goldberg, 1977) and that gender roles could
Surveys indicate that lifetime prevalence estimates be dangerous to men’s mental health (Harrison,
for alcohol and drug dependency is approximately 1978). In the 1970s and 1980s, very little empirical
30% for men (Robins & Reiger, 1991). This means support existed for these propositions.
that 1 of 3 men will have a problem with drugs and One of the critical questions in this chapter is
alcohol during their lives. Courtenay (1998) reports whether gender roles, masculinity ideology, and
that for males 1 -to 24 years old, 75% of the deaths gender role conflict and stress are empirically related
each year are from fatal injuries. This accounts to boy’s and men’s problems. In the next section,
for over 80% of all deaths among this age group. theories and paradigms about men and masculinity
Sixty-seven percent of all men experience some kind are summarized. A review of the current paradigms
of problem with violence during their lives, mostly on men and masculinity is necessary to evaluate the
by other men (U.S. Census Department, 1998; current status of empirical research and the clinical
Glicken, 2005). Thirty-five percent of boys who are knowledge in the psychology of men.
aged 15–17 years are below grade level in school
(United States Census Bureau, 2005), and boys are Paradigms on Men, Masculinity,
three times more likely to be enrolled in a special and Gender Role Conflict
education class compared to girls. Twelve percent of Overall, a lack of unified concepts about men
males who are 18 to 24 years old are high school exist in the psychology of men. Currently, no well
dropouts (United States Census Bureau, 2003), developed theories address how men’s gender role
37% of 12th grade boys score below basic levels on socialization occurs and how it affects men’s lives.
standardized writing tests (Persky, Daane, & Jin, The psychology of men has been primarily atheo-
2003), and 16% of school-aged boys have been retical and suffers from having only a few paradigms
diagnosed with attention deficit disorder (Center that explain men’s problems and potentialities.
for Disease Control, 2005). Finally, 80% of boys Theoretical perspectives on men have been pub-
report being bullied at least once, and 12% of high lished but represent general extrapolations from the
school boys report being threatened or injured with psychoanalytic and social psychological theories.
a weapon on school property (Center for Disease For example, Wong (1982) reviewed nine psycho-
Control, 2007). analytic theorists that describe the developmental
The statistics on boy’s and men’s lives are sober- dynamics of male gender role identity. More
ing when taken to heart. The temptation is to deny recently, Kilmartin (2007) reviewed how biological,
or explain away these statistics as distorted or exag- sociobiological, psychoanalytic, and ego psychology
gerated numbers. The statistics are from reliable theories may contribute to the formation of men’s
sources and capture the truth about boy’s and men’s gender roles. Furthermore, he reviewed relevant
lives. Levant (1997) and Brooks (1998) argue that conceptualization from social learning, humanistic,
a masculinity crisis exists with men and the reported and existential theories that provide insights into
statistics document it. Based on my review, the sta- male development. A useful review of theoretical
tistics also verify a “boy crisis” that is serious and real perspectives that explain men’s gender roles and
(Hall, 1999; Hoff Sommer, 2000; O’Neil & Lujan, masculinity was completed by Addis and Cohane
2009; Pollack, 1998a; Kindlon & Thompson, 1999; (2005). They reviewed four gender/masculinity par-
Tyre, 2006; Von Drehle, 2007). Denial exists about adigms that convey the different ways to understand
boy’s and men’s problems in our society. Telling the men’s gender roles. The four paradigms included
truth about men’s gender role issues can threatens psychodynamic, social learning, social construction-
the status quo and people who endorse traditional ist, and feminist perspectives. This analysis is impor-
gender role values. Furthermore, if the data were tant because for each paradigm specific directions
taken seriously, calls to action (O’Neil & Lujan, are given for future research and intervention.
2009) would significantly alter educational practices These reviews have advanced the psychology
and family socialization processes. of men by providing insights on how boys and men
The critical question is whether men and boys may develop their gender roles. More critical
have these problems because of socialized gender thought is needed on how the different masculin-
roles. During the 1970s and 1980s, the men’s lib- ity paradigms relate to both research and clinical
eration writers argued that gender roles played practice. The current paradigms do not provide

378 the psycholo gy o f men

comprehensive, coherent, or heuristic frameworks Current Paradigms and Concepts
to understand male development over the lifespan. in the Psychology of Men
Second, they do not adequately explain how men For the purpose of this review, the most frequently
develop problems from restrictive gender roles, nor cited paradigms and concepts in the psychology
do they suggest how to help men overcome them. of men are reviewed. Six theoretical areas have dom-
Another way to evaluate the status of theory in the inated the psychology of men: hegemonic mascu-
psychology of men is to focus on the controversial linity; masculinity ideology, masculine norms, and
issues discussed and the most widely referenced para- masculine conformity; gender role strain paradigm;
digms used in past empirical research. There have gender role conflict paradigm; masculine gender
been scholarly critiques of theoretical issues related role stress paradigm; reference group identity para-
to essentialism, the gender role identity paradigm, digm, and fear of femininity or antifemininity.
and the social constructivist view of gender roles A brief summary of these concepts is summarized
(Addis & Cohane, 2005; Kilmartin, 2007; Pleck, below as a context to understanding the current
1981; 1995). Criticism of previous psychodynamic research and to formulate ways to help boys and
theorists (Freud, Jung, Alder, and Horney) indicate men in therapy.
that they were primarily concerned with the uncon-
scious aspect of masculinity conflicts and viewed hegemonic masculinity paradigm
male femininity as an intrapsychic problems (O’Neil, Hegemonic masculinity is a consistently cited con-
2008). There has been endorsement of the notion of cept to understand men and masculinity (Connell,
hegemonic masculinity that originated in sociology 1995; Connell & Messerschmidt, 2005). Hegemony
(Connell, 1995). Masculinity ideology has been the is a cultural dynamic in which one group claims and
most prominent conceptualization describing the sustains a leading position in social life. Hegemonic
attitudes, values, and norms that boys and men learn masculinity is a set of practices that permit men’s
(Levant et al., 1992; Mahalik et al., 2003b; Pleck, dominance over women. Hegemonic masculinity
1995). Masculinity ideology has been the stimulus includes gender practices that legitimatize patriar-
for considerable research in the psychology of men. chal values and guarantee the dominant position
Furthermore, the gender role strain paradigm (Pleck, of some men over others and the subordination of
1981, 1995), gender role conflict (O’Neil, 2008), women. Hegemonic masculinity is the normative
and gender role stress (Eisler, 1995) are currently the ideal of masculinity to which men are suppose to
most widely used theoretical models to explain the aspire. Connell indicates that hegemonic masculin-
negative consequences of men’s gender roles. ity is not the most prevalent masculinity but the
In all of these paradigms, developmental per- most socially endorsed, and it represents the most
spectives that explain both dysfunctional and honored way to be a man. Therefore, many men
healthy development in men have been lacking define themselves in relation to hegemonic mascu-
(Smiler, 2004). There has been criticism that men’s linity. Men can receive benefits from this kind of
problems have not been contextualized. This means masculinity without being dominant and therefore
that studies have not considered the situational, endorse complicit acceptance of hegemonic domi-
demographic, and diversity contingencies that have nance over women. Qualities that define hegemonic
negatively affected individual men’s lives (O’Neil, masculinity include aggressiveness, strength, drive,
2008a,b; Smiler, 2004). How biological factors ambition, and self-reliance. There are currently no
may affect male attitudes and behaviors over the measures of hegemonic masculinity.
lifespan has been given limited attention. Further-
more, there have been very few interdisciplinary masculinity ideology and conformity
dialogues about masculinity between psychologists and hypermasculinity paradigms
and other scholars in other disciplines like medi- Masculinity ideology describes how men are social-
cine, sociology, history, and religious studies. Finally, ized to masculine stereotypes. Masculinity ideology
the psychology of men has been preoccupied with has been operationalized by the concepts of mascu-
describing the male role and identifying men’s prob- line norms and roles (Levant et al., 1992; Thompson
lems, rather studying men’s potentials and the posi- & Pleck 1986), and masculine conformity and non-
tive aspects of being a man (O’Neil & Lujan, 2008). conformity (Mahalik et al., 2003). Masculinity ide-
Unfortunately, the emergence of positive psychol- ology represents the primary values and standards
ogy has yet to make any significant difference in the that define, restrict, and negatively affect boy’s and
psychology of men. men’s lives (Levant et al., 1992; Mahalik et al., 2003b;

o’ne il 379
Pleck, 1995; Pleck, Sonenstein, & Ku, 1993; Hypermasculinity has been defined as an exag-
Thompson & Pleck, 1995). Masculinity ideology geration of traditional male stereotypes that includes
refers “to beliefs about the importance of men callous attitudes toward women and sexual behav-
adhering to culturally defined standards for male ior, the perception that violence is manly, and that
behavior” (Pleck, 1995, p. 19). Masculinity ideol- danger is exciting (Mosher & Sirkin, 1984; Mosher
ogy involves “the individual’s endorsement and & Tomkins, 1988). Hypermasculinity is like mas-
internalization of cultural belief systems about mas- culinity ideology but takes a more extreme form
culinity and male gender, rooted in the struc- (Mosher & Tomkins, 1988). Burk, Burkhart, and
tural relationships between the sexes” (Pleck, 1995, Sikorski (2004) expand the definition of hypermas-
p. 19). Masculinity ideologies can be restrictive culinity by providing more emphasis on men’s per-
because gender roles can have negative consequences sonal power and how fear and anger are associated
for men and can be dysfunctional in their interper- with interpersonal violence. They define hypermas-
sonal relationships. The negative outcomes of adher- culinity as exhibiting exaggerated traditional male
ing to or deviating from culturally defined and gender roles that include super-valuation of com-
restrictive masculinity ideologies result in gender petitive and aggressive activities and the devaluation
role conflict and strain (O’Neil, 2008; Pleck, 1995). of cooperative, care-taking behaviors. They indicate
Internalizing rigid masculinity ideologies can pro- that status and self-reliance are highly valued, and
duce distorted gender role schemas (Mahalik, interpersonal violence, dominance of others, and
1999a, 2001a; O’Neil & Nadeau, 1999) and pat- sensation-seeking behavior are necessary to being
terns of gender role conflict that are potentially considered male. Women are seen as sex objects and
damaging to men and others. are to be pursued as conquests.
Gender role norms provide guidance for both Scales that measure masculinity ideologies,
sexes on how to act, think, and feel but also can norms, and hypermasculinity include Brannon
restrict men and women from certain behaviors Masculinity Scale (BMS; Brannon & Juni, 1984),
that are considered inappropriate (Mahalik et al., Masculine Role Norms Scale (MRNS; Thompson
2005). One of the most widely cited typologies & Pleck, 1986), Male Role Norm Inventory (MRNI;
of masculinity ideology represents traditional Levant et al., 1992), Conformity to Masculine
masculinity themes including: antifemininity–no Norm Inventory (CMNI; Mahalik et al., 2003b),
sissy stuff, status and achievement–the big wheel, Adolescent Masculinity Ideology in Relationship
inexpressiveness and independence–the sturdy oak, Scale (AMIRS, Chu, Porche, & Tolman, 2005),
and adventurousness and aggressiveness–give ‘em Hypermasculine Inventory (HMI, Mosher & Sirkin,
hell (David & Brannon, 1976). Thompson and 1984), and the Auburn Differential Masculinity
Pleck (1986) have operationally defined the mascu- Inventory (ADMI, Burk et al., 2004). One of the
line norms of status, toughness, and antifemininity, critical questions of this review is whether empirical
whereas Levant et al. (1992)conceptualize the research indicates that masculinity ideology, mascu-
following aspects of traditional masculinity: avoid- line norms, and hypermasculinity relate to negative
ance of femininity, fear and hatred of homosexu- outcomes for men, women, and children.
als, self-reliance, aggression, achievement/status,
nonrelational attitudes toward sex, and restrictive pleck’s gender role strain paradigm
emotionality. Joseph Pleck’s gender role strain paradigm describes
Conformity to masculine norms is defined as how restrictive gender roles can be detrimental to
meeting societal expectations of masculinity in one’s psychological health (Garnets & Pleck, 1979; Pleck,
public or private life, whereas nonconformity to 1981, 1995). Gender role strain has been a domi-
masculine norms is defined as not meeting these nant paradigm in the psychology of men and has
societal expectations (Mahalik et al., 2003b). been explained in two separate statements. First,
Mahalik’s conformity paradigm is based on both Pleck specified ten gender role strain proposi-
societal and individual men’s masculine expectan- tions (Pleck, 1981). The propositions implied that
cies that are either accepted (conformity) or rejected gender roles are defined by gender role stereotypes,
(nonconformity). The male norms of conformity are contradictory and inconsistent, and are violated
include winning, emotional control, risk taking, by many individuals. Pleck also states that violating
violence, dominance, playboy, self-reliance, primacy gender role stereotypes is common and can lead
of work, power over women, disdain for homosexu- to social condemnation and negative evaluations
ality, and the pursuit of status. from others. Furthermore, he hypothesized that

380 the psycholo gy o f men

overconformity to the stereotypes has more severe that the “fulfillment of gender role standards can
consequences for males than females but that have negative consequences because the behavior
prescribed gender roles are psychologically dys- and characteristics these standards prescribe can
functional for both sexes in their works and family be inherently dysfunctional in the sense of being
roles. associated with negative outcomes either for the
Pleck’s second theoretical statement specified male himself or for others” (pp. 16–17). This is what
three subtypes of male gender role strain: discrep- early men’s liberation writers meant when they
ancy strain, trauma strain, and dysfunction strain discussed the “hazards of being male” (Goldberg,
(Pleck, 1995). Discrepancy strain implied that ste- 1977) or that the “male gender role may be danger-
reotypic gender role standards exist and that indi- ous to your health” (Harrison, 1978). Pleck’s dys-
viduals attempt to conform to them in varying function strain has theoretical relevance to men’s
degrees. Pleck’s assumption was that “not conform- gender role conflict and stress because this subtype
ing to these standards has negative consequences implies negative outcomes from endorsing restric-
for self-esteem and other outcomes reflecting psy- tive gender role norms.
chological well-being because of negative social
feedback as well as internalized negative self judg- gender role conflict paradigm
ments” (Pleck, 1995, p. 13). This assumption sug- and research
gests that nonconformity to masculinity ideology Gender role conflict (GRC) has been defined in a
can produce negative feeling in self (gender role self- series of theoretical statements and empirical studies
devaluations) because of people’s negative judg- (O’Neil, 1981a, b, 1982, 1990, 2006, 2008a, b, c;
ments. Not conforming to these gender role norms O’Neil & Egan, 1993; O’Neil & Fishman, 1992;
can cause devaluation from others, self-devaluations, O’Neil, Fishman, Kinsella-Shaw, 1987; O’Neil,
and attempts to compensate for the discrepancies Good, & Holmes, 1995; O’Neil, Helm, Gable,
through exaggerated masculine behaviors, some- David, & Wrightsman, 1986; O’Neil & Nadeau,
times referred to as machismo. Researchers have 1999). Gender role conflict is defined as a psycho-
attempted to empirically assess discrepancy strain logical state in which socialized gender roles have
(Liu, Rochlen, & Mohr, 2005; Nabavi, 2004), and negative consequences for the person or others.
this form of gender role strain holds promise for Gender role conflict occurs when rigid, sexist, or
future research. restrictive gender roles result in restriction, devalua-
Gender role trauma strain results from traumatic tion, or violation of others or self (O’Neil et al.,
experiences during men’s gender role socialization 1995). The ultimate outcome of GRC is the restric-
that can have serious negative consequences (Pleck, tion of a person’s human potential or the restriction
1995). Gender role trauma has not been fully con- of another person’s potential. Gender role conflict is
ceptualized in the literature, but theorists have dis- operationally defined by four psychological domains,
cussed boys’ separation from mothers and having numerous situational contexts, and three personal
an absent fathers as traumatizing (Levant, 1995; experiences. The domains, contexts, and experience
Pollack, 1992). How gender role trauma strain and of GRC represent the complexity of GRC in peo-
men’s conflicts interact has not been fully estab- ple’s lives, and each is defined below.
lished. There has been discussions about men as The psychological domains of GRC imply cogni-
victims (Brooks & Good, 2001b, O’Neil, 2008) tive, affective, unconscious, or behavioral problems
and how gender role socialization can be traumatiz- caused by socialized gender roles learned in sexist
ing (Brooks, 1998; Lisak, 2001). Gender role con- and patriarchal societies. The four domains of GRC
flict has also been hypothesized to be traumatizing include: cognitive, how we think about gender roles;
to boys and men during gender role socialization affective, how we feel about gender roles; behavioral,
(O’Neil, 1981, 2008). How trauma and masculine how we act, respond, and interact with others and
socialization interact is now being discussed with- ourselves because of gender roles; and unconscious,
out some of the political sensitivities of the past. how gender role dynamics beyond our aware-
Therefore, Pleck’s trauma strain and how it relates to ness affect our behavior and produce conflicts
men’s problems are likely to be an important topic (O’Neil et al., 1986, 1995). Furthermore, GRC
in future decades. occurs in situational contexts when men experience a
Dysfunction strain is Pleck’s third subtype and gender role transition or face difficult developmental
implies that the fulfillment of gender roles norms can tasks over the lifespan (O’Neil & Egan, 1992a, b;
have negative consequences. Pleck (1995) indicates O’Neil & Fishman, 1992; O’Neil, et al., 1987, 1995);

o’ne il 381
deviate from or violate gender role norms of or positive regard. Gender role restrictions occur
masculinity ideology (Levant et al., 1992; Mahalik when confining others or oneself to stereotypic
et al., 2003b; Pleck, 1981, 1995); try to meet or norms of masculinity ideology. Restrictions result in
fail to meet gender role norms of masculinity ideol- controlling people’s behavior, limiting one’s per-
ogy; experience discrepancies between their real sonal potential, and decreasing human freedom.
self-concepts and their ideal self-concepts, based Gender role violations result from harming oneself,
on gender role stereotypes and masculinity ideology harming others, or being harmed by others when
(Garnets & Pleck, 1979; Liu et al., 2005); person- deviating from or conforming to gender role norms
ally devalue, restrict, or violate themselves for failing of masculinity ideology. To be violated is to be vic-
to meet masculinity ideology norms (O’Neil, 1990; timized and abused, causing psychological and
O’Neil et al., 1995); experience personal devalua- physical pain. Gender role violations is a similar
tions, restrictions, and violations from others for concept to Pleck’s gender role trauma strain because
conforming to or deviating from masculinity ideol- it implies that experiences with gender roles can
ogy (O’Neil, 1981b, 1990; O’Neil et al., 1995); and have severe, negative outcomes in terms of psycho-
personally devalue, restrict, or violate others because logical functioning. According to GRC theory,
of their deviation from or conformity to masculin- gender role restrictions, devaluations, and viola-
ity ideology norms (O’Neil, 1990; O’Neil & Egan tions have a direct negative impact on men’s inter-
1993). The complexity of these situational contexts personal, career, family, and health lives (O’Neil,
can be reduced to four categories: GRC caused by 1981a, b, 1982, 1990; O’Neil & Egan, 1993;
gender role transitions, GRC experienced intraper- O’Neil et al., 1995; O’Neil & Nadeau, 1999).
sonally (within the man), GRC expressed toward Furthermore, the cognitive, affective, behavioral,
others interpersonally, and GRC experienced from and unconscious domains of GRC relate to men’s
others (O’Neil, 1990). problems with depression, anxiety, self-esteem,
Understanding gender role transitions is critical homophobia, restricted emotionality, communica-
to understanding men’s gender role conflict. Gender tion problems, intimacy, marital conflict, violence
role transitions are events in a man’s gender role toward women, health problems, and substance
development that alter or challenge his gender role abuse. The empirical question is whether any
self-assumptions and consequently produce GRC research shows that GRC relates to these negative
or positive life changes (O’Neil & Fishman; 1992; consequences for men.
O’Neil et al., 1987; O’Neil & Egan, 1992b). Four patterns of GRC have been measured using
Examples of gender role transitions are entering the 37-item Gender Role Conflict Scale (GRCS,
school, puberty, getting married, becoming a father, O’Neil et al., 1986; O’Neil, 2008; O’Neil, et al.,
or losing one’s father. 1995). The four patterns are success/power/compe-
Gender role conflict in an intrapersonal context tition (SPC), restrictive emotionality (RE); restric-
is the private experience of negative emotions and tive affectionate behavior between men (RABBM),
thoughts when experiencing gender role devalua- and conflict between work and family relations
tions, restrictions, and violations. Gender role con- (CBWFR). RE is defined as having restrictions and
flict expressed toward others occurs when men’s fears about expressing one’s feelings, as well as
gender role problems result in devaluing, restrict- restrictions in finding words to express basic emo-
ing, or violating someone else. Gender role conflict tions. RABBM represents restrictions in expressing
from others occurs when someone devalues, restricts, one’s feelings and thoughts with other men and dif-
or violates another person who deviates from or ficulty touching other men. The third factor, SPC,
conforms to masculinity ideology and norms. describes personal attitudes about success pursued
The personal experience of GRC constitutes the through competition and power. CBWFR reflects
negative consequences of conforming to, deviating experiencing restrictions in balancing work, school,
from, or violating the gender role norms of mas- and family relations resulting in health problems,
culinity ideology. Three personal experiences of overwork, stress, and a lack of leisure and relaxation.
GRC (devaluations, restrictions, and violations) are
operationally defined. Gender role devaluations the fear of femininity and
are negative critiques of self or others when con- antifemininity (no sissy stuff)
forming to, deviating from, or violating stereotypic paradigms
gender role norms of masculinity ideology. Deval- Fears about femininity have been consistently men-
uations result in lessening of personal status, stature, tioned as central to understanding men’s experience

382 the psycholo gy o f men

with their gender roles. Men’s conscious and uncon- Subscales of the MRNS (Thompson & Pleck,
scious fears of femininity have existed in the theo- 1986) and the MRNI (Levant et al., 1992) measure
retical literature for many years (Blazina, 1997, 2003; aspects of antifemininity. Furthermore, all of
Boehm, 1930; David & Brannon, 1976; Freud, O’Neil’s patterns of gender role conflict have been
1937; Hays, 1964; Horney, 1967; Jung, 1953; theoretically linked to the fear of femininity (O’Neil,
Lederer, 1968; Levinson et al., 1978; Menninger, 1981a,b, 1982; O’Neil et al., 1986) and operation-
1970; Norton, 1997). The fear of femininity consists alized through the GRCS (O’Neil et al., 1986).
of strong, negative emotions associated with stereo-
typic feminine values, attitudes, and behaviors. These eilser’s masculine gender role stress
fears are learned in early childhood when gender role paradigm
identity is being shaped by parents, peers, and soci- Richard Eisler has developed a theory of masculine
etal values. The dynamics of fearing are not well gender role stress (Eilser, 1995). Overall, the para-
understood and many times are unconscious to the digm suggests that men are required to adhere to
man (Jung, 1959). When a man fears his feminine culturally approved masculinity ideology that may
side, he really fears that others will see him as stereo- have dysfunctional health outcomes. He discusses
typically feminine (e.g. weak, dependent, submis- three theoretical perspectives in defining the gender
sive) rather than positively masculine. This is not an role stress paradigm, including Bem’s (1981) gender
unreasonable fear since certain aspects of femininity schema theory, Pleck’s (1981) gender role strain
are devalued in society. Men are cognizant that paradigm, and Lazarus’ theory-based measurement
women’s femininity is sometimes devalued by other of stress (Lazarus & Folkman, 1984). The paradigm
men, and they attempt to avoid situations in which consists of five propositions including that sociocul-
they could also be devalued. The cost of showing ste- tural contingencies reinforce masculine behavior
reotypic feminine qualities could be disrespect, fail- and punish feminine behavior, resulting in gender
ure, and emasculation. These are risky costs for the role cognitive schemas for boys and men; masculine
man who wants to actualize masculinity ideologies gender role schema are used by men to assess threats
and prove his masculinity (Kimmel, 2005). and challenges and to choose ways to cope; men
A similar concept to the fear of femininity is the have different commitments to culturally accepted
antifemininity (“no sissy stuff”) conceptualization models of masculinity that vary from full endorse-
(David & Brannon, 1976). Antifemininity suggests ment of traditional masculine norms to a complete
a stigma associated with all stereotypical feminine abandoning of these norms; masculine gender role
characteristics and qualities. Specifically, this con- stress occurs when there is full endorsement of cul-
cept suggests that the fear of femininity is learned by turally approved masculine schemas that limit ways
early anxiety of being considered a girl, sissy, or to cope in particular situations; and masculine
feminine; a rule dictating that a “real man” must gender role stress occurs when a man believes that
never resemble a woman or possess feminine char- he is not living up to culturally endorsed masculine
acteristics; openness and vulnerability being consid- gender role behavior. Based on these propositions,
ered unmasculine; and fear of being seen as a the Masculine Gender Role Stress Scale (MGRSS)
homosexual. Many times, antifemininity is rein- was developed (Eilser, 1995; Eisler & Skidmore,
forced by parents. Parents are concerned about how 1987). The MGRSS measures the following areas of
well boys conform to masculine norms, and fathers gender role stress: physical inadequacy, emotional
are particularly concerned if their sons manifest inexpressiveness, subordination to women, intellec-
feminine qualities. Boys learn to avoid most stereo- tual inferiority, and performance failure.
typic feminine qualities when experiencing parent’s
displeasure at their deviation from masculine norms. male reference group identity paradigm
Consequently, the male socialization process can Jay Wade has developed a paradigm of male refer-
produce a life-long aversion to any quality thought ence group identity (Wade, 2008; Wade & Gelso,
to be feminine, constant striving for the ways to be 1998). This paradigm suggests that differences in
masculine, an inexpressive male image that prohib- men’s attitudes and behaviors may be due to male
its open expression of feelings and feminine charac- reference group identity dependence. He defines
teristics, and an emotional and physical distance this as “. . . . the “extent to which males are depen-
between men because of feared homosexuality. dent on a reference group for their gender role self-
Therefore, boys learn to reject and repress the femi- concepts (Wade & Gelso, 1998, p. 384).” The
nine part of their personalities at an early age. theory suggests that the male reference group is the

o’ne il 383
purveyor of masculine culture and affects differ- sexual orientation, class, race, and ethnicity differ-
ences in men’s definitions of masculinity. Three male entially structure the form and content of men’s
reference group identity–dependent statuses are lives and the standards of masculinity to which they
defined by a man’s feelings of psychological related- adhere” (p. 602).
ness to other men: no reference group defined as Additionally, the role of biology, the politically
a lack of psychological relatedness to other men; the incorrect factor in gender studies for so long, needs
reference group–dependent status, meaning that much more attention from theoreticians if we are to
there is psychological relatedness to some men and discern the complex dynamics of nature and nur-
not others; and the reference group–nondependent, ture in men’s lives. Finally, more theorizing is needed
in which there is psychological relatedness to all on men’s lives contextually. Both developmental
men. The Reference Group Identity Dependence and social psychologists indicate that the study of
Scale (RGIDS, Wade & Gelso, 1998) measures gender roles needs to be contextualized (Eckes &
male reference group identity. Research has shown Trautner, 2000; Smiler, 2004; Trautner & Eckes,
that the three reference group statuses are related to 2000). Contextualism is defined by how human
masculine ideology and GRC (Wade, 2008; Wade experience is shaped by many factors operating
& Brittan-Powell, 2001; Wade & Gelso, 1998). in concert with each other (Lerner, 1992). A con-
textual analysis implies studying people in real-life
Summary of the Paradigms situations and the dynamic interaction between
How the masculinity paradigms discussed above individuals and the multiple contexts in which they
overlap or deviate from each other has gone unex- live. Knowledge is obtained by assessing the inter-
plained. Analyses of how these theoretical concepts play between the person and the environment. Con-
overlap and diverge could bring greater coherence textualism is concerned with how ecological factors
to the psychology of men. One of the future dynamically operate to shape experience, and how
challenges is to create more expansive operational biological, cultural, psychological, interpersonal,
definitions for these concepts. For example, it is spiritual, political, and social context affect behav-
important to understand how the macrosocietal ior. Therefore, theorizing about the psychology of
concept of hegemonic masculinity relates to the men needs to become more contextual because
personal aspects of learning masculinity ideology gender roles are activated by many personal, soci-
and experiencing GRC and stress. Men’s GRCs need etal, racial, cultural, political, religious, and situa-
to be better conceptualized from a larger social tional contingencies (Deaux & Majors, 1987).
structural and feminist perspective by giving more Without contextual knowledge, the psychology of
attention to how power, societal patriarchy, and men cannot move past its limited theoretical base.
institutional sexism operate in men’s lives (Enns,
2008). Research In The Psychology of Men:
The paradigms are also limited in explaining how What do We Know Empirically?
diversity variables affect men’s lives. A coherent, Research programs in the psychology of men paral-
multicultural approach to men’s diversity does not lel the emerging paradigms and psychometric scales
exist in the psychology of men. Very little has been that assess masculinity ideologies and conflicts.
written on how race, class, ethnicity, nationality, Research programs are now identified with the fol-
age, religion, and sexual orientation affect male lowing perspectives: masculinity ideology, GRC and
socialization. In a previous paper (O’Neil, 2008), stress, hypermasculinity, and reference group depen-
I indicated that: “The assumption that a single mas- dence identity. Four research questions are discussed
culinity exists (i.e., white, middle-class, heterosex- in this section of the chapter: Does evidence exist
ual, American) is erroneous, short sighted, and that masculinity ideology relates to men’s psycho-
biased. Race, class, age, ethnicity, sexual orientation, logical and interpersonal problems? Does evidence
religious orientation, nationality, and other vari- exist that GRC and stress relate to men’s psycho-
ables are assumed to affect men’s experience of logical and interpersonal problems? Does evidence
GRC. Exactly how these diversity variables affects exist that hypermasculinity and reference group
men is one of the most crucial issues to be assessed identity dependence relate to masculinity conflicts?
in the psychology of men and counseling psychol- Does evidence exist that GRC and masculinity ide-
ogy” (pp. 381–382). Thompson, Pleck, and Ferrara ology relate to adolescent’s boys’ problems?
(1992) amplified this point by indicating that “we To answer these questions, a literature review
are largely unfamiliar with how age, generation, was completed of published studies that assessed

384 the psycholo gy o f men

whether masculinity constructs and GRCs have masculinity ideology are significantly correlated
negative psychological consequences for men and with 25 separate variables that represent even more
boys. Empirical studies that used the following ten dangerous and hostile interpersonal behaviors of
measures were reviewed: the MRNS (Thompson & men. Furthermore, three studies using the RGIDS
Pleck, 1986), MRNI (Levant et al., 1992), CMNI found relationships between reference group status
(Mahalik et al., 2003b), MGRSS (Eisler & and eight male problems. Finally, for adolescent
Skidmore, 1987), GRCS (O’Neil, 2008; O’Neil boys, the three studies using the GRCS-A and
et al., 1986), GRC Scale for Adolescents (GRCS-A; AMIRS found indications that masculinity prob-
Blazina, Pisecco, & O’Neil, 2005), AMIRS (Chu lems and GRC related to 17 negative outcomes.
et al., 2005), HMI (Mosher & Sirkin, 1984), ADMI
(Burk et al., 2004), and RGIDS (Wade & Gelso, Summary of Masculinity Ideology, Gender
1998). Role Conflict and Stress, and Other
The studies were analyzed to determine whether Masculinity Constructs
men’s psychological and interpersonal problems The results in Table 14.1 represent the first sum-
have been statistically correlated with each scale. mary of empirical research that correlates studies
The goal of this literature search was to develop an measuring masculinity ideology, masculine gender
overall summary of the significant empirical rela- role stress, and GRC with men’s psychological and
tionships between masculinity scales and men’s and interpersonal problems. The results of the 249 stud-
boy’s problems. Significant statistical relationships ies in Table 14.1 provide a rather convincing case
were defined as any correlational tests at less than that masculinity ideology, GRC and stress, and
the .05 level between any scale (or any of its sub- other masculinity measures have significant rela-
scales) and a psychological and interpersonal vari- tionships to men’s and boy’s psychological and inter-
able. Given the complexity of reporting measures’ personal problems. Overall, the results across many
subscales, only overall relationships between each studies point to masculinity ideology and GRCs
scale and dependent measures are reported. relating to negative psychological attitudes toward
Table 14.1 summarizes the studies reviewed for women and gays, dangerous risk-taking with sex
ten published masculinity scales. The author and and health issues, substance use and abuse, psy-
the name of the scale are given first, followed by chological stress and strain, negative attitudes
the names of the subscales and number of studies toward help-seeking, delinquent behavior, low self-
reviewed. For each scale, the dependent variables esteem, hostility and aggression, higher blood pres-
that significantly correlate with men’s psychological sure levels, depression, anxiety, marital and family
and interpersonal processes are enumerated. Two problems, and violent attitudes toward women. The
hundred forty-nine studies were reviewed. Ref- hazards of being male appear to empirically related
erences to the individual studies summarized in to men’s attitudes about their masculinity and
Table 14.1 are available from the author upon gender roles.
request. The results of this analysis shed light on male
The summary of the masculinity ideology scales problem areas documented by the epidemiological
(MRNS, CMNI, and MRNI) indicate that atti- surveys discussed earlier in the chapter. The surveys
tudes about masculinity have been statistically and other statistical data indicated that men’s and
correlated with a wide variety of psychological boy’s problems included substance abuse, depres-
and interpersonal problems in 26 studies. Over 58 sion, anxiety, learning problems, threats, bullying,
dependent variables related to men’s problems have and violence. In answering the earlier question on
been significantly correlated with masculinity ideol- whether men’s problems are related to socialized
ogy, norms, and conformity. gender roles, the answer based on the correlational
A similar pattern is evident with the GRCS and data, is an absolute yes.
MGRSS studies. The ten MGRSS studies correlated There are some limitations to these findings.
with 19 dependent variables, and the 200 GRCS All of the results reported were statistically signifi-
studies correlated with 87 separate indices of men’s cant ( p < .05), but it is unclear how much of the
personal and interpersonal problems. A more com- variance in men’s problems relates to masculinity
plete summary of the GRCS studies over the last 25 ideology and GRC and stress. Future meta-analyses
years can be found in O’Neil (2008b). could assess the exact effect sizes for these studies.
The four studies using hypermasculinity scales Furthermore, these studies are simple correla-
(HMI and ADMI) suggest that extremes in tional studies and do not account for the effects

o’ne il 385
Table 14.1. Men’s Psychological and Interpersonal Problem Areas That Significantly Correlate With Ten Major
Masculinity Measures
1. Thompson and Pleck’s Male Role Norm Scale (MRNS)
Subscales: Status Norm; Toughness Norm; Antifemininity Norm
Number of Studies: 9
Men’s Problems Significantly Correlated with the MRNS:
Negative Attitudes Lesbians; Hostile Sexism; Negative Attitude Toward Women; Opposition to the ERA;
Preference for Virgin Wife; Ethnic Belonging; Suspension from School; Drinking and Use of Drugs;
Being Picked Up by Police; Being Sexually Active; Coercive Sex; Increased Sexual Risk; Loneliness;
Separation-Individuation Problems; Restricted Affectionate Behavior Between Men; Fear of Appearing Feminine;
Antigay Attitudes; Overt Hostility and Aggression; Adversarial Sexual Beliefs; Rape Myths;
Psychological Violence.
2. Mahalik’s Conformity to Male Role Inventory (CMNI)
Subscales: Winning; Emotional Control; Risk Taking; Violence; Power over Women; Dominance; Playboy;
Self-Reliance; Primacy of Work; Disdain for Homosexuals; Pursuit of Status; Total Conformity.
Number of Studies: 13
Men’s Problems Significantly Correlated with the CMNI:
Positive Relations with Others; Unhealthy Alcohol Use; Neglecting Preventive Skin Care; Health Screenings;
Not Seeking Help with Emotional Difficulties; Not Going to Health Care Appointments; Getting Into Physical
Fights; Difficulty Managing Anger; Taking Risks; Risky Behavior with Automobiles and Sexual Practices;
Substance Use; Marijuana Use; Binge Drinking; Responses to Depression; Health Risks; Few Health Promotion
Behaviors; Sexism; Health-Promotion Behaviors; Internalized Homophobia; Masculine Body Ideal Distress; Poor
Sexual Functioning; Racial Identity: Pre-encounter Phase; Lower Self-esteem; Psychological Distress; Attitudes About
Help-seeking; Shocks Given During Competition.
3. Levant’s Male Role Norms Inventory (MRNI)
Subscales: Avoidance of Femininity; Fear and Hatred of Homosexuals; Self-Reliance;
Aggression; Achievement/Status; Non Relational Attitudes
Toward Sex; Restrictive Emotionality.
Number of Studies: 4
Men’s Problems Significantly Correlated with the MRNI:
Alexithymia; Negative Attitudes About Racial Identity and Women’s Equality; Attitudes Toward Condoning
Sexual Harassment of Women; Racial Group Marginalization; Ethnocentrism; Negative Attitudes
Toward Help-seeking.
4. Eisler’s Masculine Gender Role Stress Scale (MGRSS)
Subscales: Physical Inadequacy; Emotional Inexpressiveness; Subordination to Women; Intellectual Inferiority;
Performance Failure.
Number of Studies: 10
Men’s Problems Significantly Correlated with the MGRSS:
Increases in Systolic Blood Pressure; Impaired Cognitive Performance; Higher State Anger; Negative Intent
Attributions; Verbal Aggression; Greater Negative Intent; Greater Irritation, Anger, Jealousy, and Aggression;
Anger; Increases in Anxiety; Poorer Health Habits; Greater Systolic Blood Pressure; Lower Work
Satisfaction; Negative Attributions and Negative Affect; Verbal Aggression; Alexithymia; Social Support;
Overt Hostility and Aggression; Controlling Behaviors; Fearful Attachment.
5. O’Neil’s Gender Role Conflict Scale (GRCS)
Subscales: Success, Power and Competition; Restrictive Emotionality; Restrictive Affectionate Behavior Between Men;
Conflict Between Work and Family Relations.
Number of Studies: 203
(Continued)

386 the psycholo gy o f men

Table 14.1. Continued
Men’s Problems Significantly Correlated with the GRCS:
Self-esteem; Anxiety; Depression; Stress; Shame; Help Seeking Attitudes; Alexithymia;
Alcohol and Substance Use and Abuse; Hopelessness; Coping; Psychological Strain; Traditional Gender Role Attitudes;
Machismo; Psychological Well-Being; Homonegativity; Self-Silencing; Body Image; Family Problems; Family Stress;
Conduct Problems; Problems with Anger; Physical Strain; Health Risk Taking; Problem Solving Attitudes; Anger;
Suicide; Physical Health Problems; Drive for Muscularity; Interpersonal Problems and Competence; Self-Disclosure;
Shyness; Attachment; Intimacy; Friendship; Marital Satisfaction; Family Enmeshment/Disengagement; Family Conflict/
Avoidance; Family Cohesion; Fathering Self Efficacy; Parenting Satisfaction; Women’s Psychological Health; Women’s
Depression and Anxiety; Women’s Marital Happiness and Adjustment; Women’s Negative Affect; Couple’s Marital
Adjustment and Depressive Symptoms; Gender Role Stereotyping; Stereotypic Beliefs About Man’s Emotions; Attitudes
Toward Women; Sex Role Egalitarianism; Racial Bias; Attitudes Toward African Americans; Anti-Gay Attitudes and
Beliefs; Homophobia; Abusive Attitudes and Behaviors; Hostile Sexism; Hostility Toward Women; Attitudes Toward
Sexual Harassment; Rape Myth Attitudes; Dating Violence; Sexual Aggression and Coercion; Men’s Entitlement; Victim
Blaming; Violence Against Women and Other Men.
6. Mosher and Sirkin’s Hypermasculinity Inventory (HMI)
Subscales: Violence; Danger; and Calloused Sex
Number of Studies: 1
Men’s Problems Significantly Correlated with the HMI:
Self-Reported Drug Use; Aggressive Behavior; Dangerous Driving Following Alcohol Consumptions; Delinquent
Behaviors During High School Years.
7. Burk, Burkhart and Sikorksi’s Auburn Differential Masculinity Inventory (ADMI)
Subscales: Hypermasculinity; Sexual Identity; Dominance and Aggression; Conservative Masculinity; Devaluation
of Emotion.
Number of Studies: 3
Men’s Problems Significantly Correlated with the ADMI:
Hostility Toward Women; Antisocial Practices; Negative Self-esteem; Sensation Seeking; Anxiety; Anger; Contempt;
Acceptance of Interpersonal Violence; Beliefs that Women are Manipulators; Hedonism; Not Loving; Social
Acceptance; Dominance; Sexual Competence; Consensual Sexual Experiences; Ignoring Partner’s Protests to Obtain
Sex; Use of Low Physical Force to Obtain Sex; Desired Orgasms Per Week; Number of Sexual Partners; Likelihood to
Use Force to Obtain Sex; Likelihood to Commit Rape; Negative Sexual Satisfaction.
8. Wade and Gelso’s Reference Group Identity Dependence Scale (RGIDS)
Subscales: Reference Group Nondependent; No Reference Group; Reference Group Dependent
Number of Studies: 3
Men’s Problems Significantly Correlated with the RGIDS:
Identity Diffusion; Social Anxiety; Low Self-Esteem; Anxiety; Depression; Negative Attitudes About Racial Diversity
and Women’s Equality; Positive Attitudes Toward Sexual Harassment; Health Related Behaviors; and Personal Wellness.
9. Chu, Porche, and Tolman’s Adolescent Masculinity Ideology Relationships Scale (AMIRS)
Single Scale: Adolescent Masculinity Ideology in Relationships
Number of Studies: 1
Boy’s Problems Significantly Correlated with the AMIRS:
Restrictive Emotionality; Inhibited Affection; Exaggerated Self-Reliance; Negative Attitudes Toward Women; Low
Self-esteem; Acting Out; GRC; Need for Achievement and Success; Restrictive Affectionate Behavior Between Men;
Status and Anti-femininity Norms; Engaging in Sexual Relations.
10. Blazina, Pisecco, and O’Neil’s GRC Scale for Adolescents (GRCS-A)
Subscales: Restricted Affection Between Men; Restrictive Emotionality; Conflict Between Work, School, and Family;
Need for Success and Achievement.
Number of Studies: 2
Boy’s Problems Significantly Correlated with the GRCS-A:
Emotional, Family, and Anger Management Problems; Conduct Problems; Family Stress; Emotional and Psychological
Stress; Masculinity Ideology; Anti-femininity Norms; Sexual Relations.

o’ne il 387
of moderator or mediator variables (Heppner, 1995; Studies on nonclient, male students also have
O’Neil, 2008b). Future studies will need to employ clinical relevance in understanding men in therapy.
more sophisticated methodologies to assess how Students’ GRC have been associated with psycho-
third variables increase, decrease, or mediate rela- logical defenses, treatment fearfulness, perceptions
tionships between gender role issues and men’s psy- of counselors, and expectations about counsel-
chological and interpersonal problems. Finally, the ing (Englar-Carlson, 2001; Englar-Carlson, &
analyses of the studies in Table 14.1 do not address Vandiver, 2001; Schaub & Williams, 2007; Wisch,
whether there are differences between men of differ- Mahalik, Hayes, & Nutt, 1995). One study found
ent races, classes, ages, ethnicities, religions, nation- that men’s psychological defenses and GRC were
alities, or sexual orientations. Future analyses should related (Mahalik, Cournoyer, DeFranc, Cherry, &
assess these potential differences related to men’s Napolitano, 1998). Additionally, SPC, RE, and
diversity. RABBM were significantly related to immature and
neurotic defenses (projection, denial, and isolation),
Empirical Research on Men As Clients and and SPC and RE predicted defenses that are turned
the Psychotherapeutic Process against others. Gender role conflict has also signifi-
Little research has been completed on male clients cantly predicted treatment fearfulness (Englar-
and the psychotherapeutic process (Good & Carlson & Vandiver, 2001), and men with higher
Sherrod, 2001). Only recently have psychologists GRC have rated counselors as significantly less
begun to explore how to do therapy with men. The expert and trustworthy (Wisch et al., 1995).
lack of clinical research may be related to the disci- Furthermore, men who reported RE, RABBM, and
pline’s difficulty in formulating significant questions SPC had significantly higher expectations of the
about men’s therapy. New therapeutic concepts counselor as an expert and lower self-expectations
about men may need to be developed, and tradi- for taking responsibility in counseling (Schaub &
tional therapeutic approaches may need to be exam- Williams, 2007).
ined or reconsidered. Overall, the theoretical Little research has been completed on how gen-
concepts discussed earlier (masculinity ideology, der roles affect men’s career attitudes and behaviors.
gender role stress, GRC, etc.) have not been assessed This is puzzling, given that men’s work has been
in a therapeutic context. The clinical research that defined as primary to male identity and self-worth.
does exist is primarily on client’s GRC (O’Neil, Four studies have assessed how GRC relates to men’s
2008b). Seven studies have assessed whether client’s career attitudes and needs (Dodson & Borders,
GRC relates to men’s psychological problems and 2006; Jome & Tokar, 1997; Rochlen, Blazina, &
processes (Coonerty-Femiano, Katzman, Femiano, Rajhunathan, 2002; Rochlen & O’Brien, 2002).
Gemar, & Toner, 2001; Cusack, Deane, Wilson, & In two studies, men with higher GRC reported
Ciarrochi, 2006; Good, Robertson, Fitzgerald, greater career counseling stigma, decreased will-
Stevens, & Bartels, 1996; Hayes & Mahalik, 2000; ingness to engage in career counseling, and greater
Mertens, 2000; Noyes, 2004; Van Delft, 1998). needs for self-clarity, career information, and
Two studies found that male counseling center assistance with career indecisiveness (Rochlen &
clients’ GRC significantly relates to psychological O’Brien, 2002; Rochlen et al., 2002). Additionally,
distress, hostility, compulsiveness, social discom- GRC appears to be more evident with career tradi-
fort, paranoia, psychoticism, obsessive-compulsivity, tional men and also to predict career choice tradi-
and interpersonal sensitivity (Good et al., 1996; tionality (Jome & Tokar, 1997; Tokar & Jome,
Hayes & Mahalik, 2000). Comparisons of clients’ 1998).
and nonclients’ GRC has been made. Four studies Therapists’ biases against men have been docu-
have found that clients experience more RE and mented (Robertson & Fitzgerald, 1990) but not
RABBM than do nonclients (Burke, 2000; widely studied. Therapists’ GRC and their negative
Coonerty-Femiano et al., 2001; Mertens, 2000; judgments of male clients have been assessed in
Van Delft, 1998). Furthermore, clients’ RE has been two studies (Hayes, 1985; Wisch & Mahalik,
found to be inversely related to perception of treat- 1999). Therapists with high RABBM reported
ment helpfulness (Cusack et al., 2006), and clients significantly less liking of male clients, less empathy
who experienced sexual abuse reported significantly with nontraditional male clients, and more malad-
greater RE and CBWFR than did nonabused clients justment for nontraditional male clients (Hayes,
(Thomson, 1995). 1985). Therapists reporting SPC and RABBM had

388 the psycholo gy o f men

significantly less liking for, empathy with, and com- its training agenda to the psychology of men
fort with male clients and were less willing to see (O’Neil, 2008b; Wester & Vogel, 2002). Assessment
clients who were homosexuals, angry, but not sad of both clients’ and therapists’ GRC should be a fer-
(Wisch & Mahalik, 1999). Furthermore, therapists tile area for future clinical research. Furthermore,
with significantly less RABBM were more comfort- there are very few documented ways to treat men’s
able seeing a homosexual client and reported better problems such as depression, restrictive emotional-
prognosis for him in therapy. In both of these stud- ity, and obsession with power and control. Case
ies, RABBM related to therapists’ biases about cli- studies of men in therapy (Blazina, 2004; Englar-
ents who were nontraditional or homosexual. These Carlson & Stevens, 2006; Mahalik, 1999a; O’Neil,
studies suggest that counselors may need additional 2006) currently provide the best evidence of effec-
training on men’s issues (Wester & Vogel, 2002) to tive therapy approaches and processes. Psycho-
examine their biases about men who deviate from or educational interventions have documented that
conform to masculinity ideology. men’s GRC can be altered, but the mechanism that
Psychoeducational interventions have tested cause the change have not been studied.
whether men’s masculine attitudes and conflicts can
be changed. Empirically tested programs indicate Therapeutic Assessment in the Psychology
that men can change their GRC and dysfunctional of Men: The Current Status
attitudes about gender roles (Davis & Liddell, 2002; Over the last decade, more information has been
Kearney, King, & Rochlen, 2004; Schwartz & published on assessing men in therapy. In this sec-
Waldo, 2003; Schwartz, Waldo, & Higgins, 2004). tion, assessment, as it relates to traditional diagnos-
These psychoeducational interventions have changed tic categories is discussed and how multiculturalism
men’s GRC related to dating violence (Schwartz, relates to therapeutic appraisal is reviewed. The
Magee, Griffin, & Dupius, 2004), partner abuse published diagnostic schemas, typologies, and prob-
(Schwartz & Waldo, 2003), rape prevention (Davis lems areas are summarized.
& Liddell, 2002), and sexual harassment (Kearney
et al., 2004). Most of these programs assessed short- Dilemmas, Bias, and Evidence-based
term change and used attitudinal measures. Whether Assessment
these treatments have long-term impact on men’s For many years, the literature on men’s therapy was
behaviors is still unclear. exclusively focused on describing male problems or
what is wrong with men. Recently, how these prob-
Summary of Empirical Research on Men lems relate to therapeutic assessment has received
and Therapy more attention from various perspectives. Glicken
The review of the clinical literature supports (2005) indicates that “diagnosing male problems
Cochran’s (2005) conclusion: “The psychology of seem particularly fraught with ambiguity, worker
men as distinct practice and research area has yet bias, and politically correct notions of men as dys-
to generate controlled studies demonstrating dif- functional without question” (p. 67). A critical
ferential effectiveness of specific treatments with question is to determine how accurately men’s psy-
men” (p. 650). Research on men in therapy is in the chological problems are captured by conventional
early stages of development. Few researchers have diagnostic criteria (Rochlen, 2005). For example,
specified focused clinical questions that could be questions have been raised whether men’s depres-
pursued through research. How masculinity ideol- sion can be understood using the Diagnostic and
ogy and GRC relate to the therapeutic processes is Statistical Manual (DSM-IV) criteria (Addis, 2008).
just now emerging as a critical area of research. Authors have speculated that men may present
Some evidence exists that clients report GRC with “masked depression” because of how defenses may
greater frequency than nonclients. Only a few stud- operate to keep symptoms covert (Addis, 2008;
ies have assessed whether clients’ problems are spe- Cochran & Rabinowitz, 2000; Lynch & Kilmartin,
cifically related to masculinity or GRCs. There are 1999; Magovcevic & Addis, 2008; Pollack, 1998b;
no counseling studies on clients from varied racial, Real, 1997). Cochran and Rabinowitz (2003) pro-
ethnic, cultural backgrounds, or on those who have pose that masked depression be assessed as male
different sexual orientations. The finding that thera- anger, alcohol and substance abuse, somatic com-
pists who have GRC have clinical biases may sug- plaints, interpersonal conflicts, and a host of other
gest that counseling psychology may need to expand problems.

o’ne il 389
 Therapists’ bias toward men is another critical diversity of men who come to therapy (Liu, 2005;
assessment area for therapists. Stereotyping and Wester, 2008a,b). Knowledge of how men’s gender
having biases about men are probably as frequent as roles vary by race, ethnicity, nationality, religion,
they were with women in the 1970s (Brodsky & and sexual orientation is evolving slowly in the
Holroyd, 1975) and therefore need to be monitored psychology of men. The assumption that a single
by therapists (Gilbert & Scher, 1999; Glicken, masculinity exists is the ultimate stereotypic bias
2005). Gilbert and Scher (1999) indicate that ther- and an illusion of the status quo. Race, class, age,
apists’ biases against men can occur in the following ethnicity, sexual orientation, religious orientation,
six ways: encouraging clients’ independence and nationality, and other variables affect every man’s
discouraging emotions and feelings in relation- personal experience in life and are critically impor-
ships; failing to recognize the costs of equating tant during the therapy process. Exactly how these
personal power with sexual power over women; diversity variables affect men is one of the most cru-
alienating men from their children by associating cial issues in the psychology of men and counseling
caring with weakness; encouraging and modeling psychology.
autonomy, success, and competition; leaving unchal- Liu (2005) recommends a multicultural perspec-
lenged the exaggerated importance of male sexual tive, so that therapists could recognize their biases
power in terms of personal meaning; and reinforc- and negative expectancies of men from diverse back-
ing homophobia and heterosexism. No effective grounds. The guidelines on multicultural education
assessment can exist if therapists hold conscious or have been accepted by psychology (APA, 2003) but
unconscious biases about men. More research is they have not been integrated with our current
needed to document whether and specifically which knowledge about men. The development of the
biases exist against men in order to determine how multicultural competencies with men from diverse
these may affect the therapeutic process. backgrounds could become an important diversity
Masculine-sensitive, evidence-based assessment agenda for counseling psychology. Contributions to
has been recommended by Cochran (2005). Using diversity by counseling psychology have significantly
a prevailing practice paradigm (Sackett, Straus, expanded American psychology’s overall view of
Richardson, Rosenberg, & Hayne, 2000), Cochran multiculturalism. Therefore, counseling psychology
enumerates three kinds of information critical to could take the next step in integrating diversity and
assessing men including: research-based evidence multiculturalism with the psychology of gender
pertaining to diagnosis and treatment, recom- roles. This integration would give prominence to
mendations based on clinical expertise, and patient the complexity of how male and female gender roles
values or preferences. This approach combines interact with racial, ethnic, class, age, religious, and
processes of evidence-based practice with gender- sexual orientation variables. The psychology of
sensitive expertise emerging in the psychology of men cannot be a credible force in psychology until
men. Cochran (2005) calls for greater research on there is a greater commitment to understanding
evidence-based treatment of men, particularly using diversity, multiculturalism, and oppression in men’s
masculine GRC and stress constructs. lives.

Assessment and Multiculturalism Diagnostic Schemas, Typologies,

No adequate assessment can also be completed and Problem Areas
without a multicultural framework that assesses Four diagnostic schemas to assess men have been
diversity variables and the role of oppression in previously published (O’Neil, 1990, 2006, 2008b;
men’s lives (O’Neil, 2008b; Wester, 2008a). All men O’Neil & Lujan 2010; Rabinowitz & Cochran,
and women are systemically oppressed by patriar- 2002). These diagnostic schemas have been devel-
chal values that interact with all forms of oppres- oped to assess men and help therapists better con-
sion. Making this oppression visible by explaining ceptualize clinical interventions. My own diagnostic
how people suffer from discrimination is one of schema (O’Neil, 2008b) has seven assessment
the primary goals of feminists and other activists. domains including therapist’s self-assessment; diver-
As mentioned earlier, masculinity and gender roles sity and oppression; men’s defenses; men’s emotion-
are multidimensional constructs affected by many ality and restrictive emotionality; men’s distorted
political, racial, ethnic, age, class, religious, and schemas about masculinity ideology; men’s patterns
sexual orientation variables. The psychology of men of GRC and gender role devaluations, restrictions,
has recognized the importance of honoring the and violations; and men’s needs for information,

390 the psycholo gy o f men

psychoeducation, and preventive programs. This of empathic recognition, alexithymia, unconscious
diagnostic schema emanates from the GRC research self-criticism, perfectionism, workaholism, inability
program, but only limited data exist on its validity to grieve or mourn, and vulnerability to substance
or utility. In the future, this diagnostic schema needs abuse and depression. Full explanations for these
to be empirically validated using evidence-based diagnostic symptoms are found elsewhere (Pollack,
research. 1995, 1998b) and represent how new diagnostic
The second assessment paradigm focuses on categories are changing how men’s problems are
appraising fathers or father–son, father–daughter understood.
relationships in the context of GRC (O’Neil & Other clinical researchers have developed other
Lujan, 2010. Overt and covert contexts to assess typologies that relate to assessing men. Seven mas-
men’s fathering problems are discussed in the con- culine scripts have been defined and reflect poten-
texts of masculinity ideology, unfinished business tial assessment areas. These include men as strong
with one’s own father, and the father wound. The and silent, tough guy, give ‘em hell, playboy,
same diagnostic areas found in O’Neil (2008b) are homophobic, winner, and independent (Mahalik,
applied to assess men’s fathering or past father Good, & Englar Carlson, 2003a). Furthermore,
wounds. This new paradigm suggests that fathering critical male problem areas have been defined that
can be a critical assessment area for therapists help- include depression, anxiety, stress, sexual dysfunc-
ing men with their GRC. tion, substance abuse, toughness, violence, and rape
Rabinowitz and Cochran (2002) outline a heu- (Good & Sherrod (2001). In a similar way, Gilbert
ristic, theoretically derived model for assessing men’s and Scher (1999) describe critical male problems as
problems that integrates psychodynamic perspec- discrepancy strain, male emotional restrictiveness,
tives of men with masculine GRC research. Four male shame, dysfunction strain, male prerogative,
intersecting dimensions of male psychological con- and violence against women. Additionally, recom-
flict are outlined including: assessing how male cli- mendations have been made to assess men’s
ents’ relational experiences relate to the managing of distorted cognitive schemas about masculinity
their dependency strivings and needs in relation- (O’Neil & Nadeau, 1999; Mahalik, 1999a, 2001a).
ships; assessing ways that clients learn to manage Cognitive schemas about masculinity represent
their feelings of sadness, grief, and loss; assessing how men think about gender roles in the context of
the extent to which clients develop a healthy set masculinity ideology, norms, and conformity (Levant
of masculine behavior and values; and assessing et al., 1992; Mahalik et al., 2003b; Mooney, 1998;
the balance between doing and being. The model Pleck, 1995; Thompson et al., 1992). Distorted
has four interacting and overlapping dimensions cognitive schemas are exaggerated thoughts and feel-
of male psychological experience including the ings about masculinity ideology in a man’s life
assessment of men’s psychological history, forma- (O’Neil & Nadeau, 1999). Distorted cognitive
tive experiences, cultural upbringing, and current schemas occur when men experience pressure, fear,
functioning. The dimensions of this assessment or anxiety about meeting (or failing to meet) stereo-
model provide a very useful and comprehensive typic notions of masculinity. Mahalik (1999) rec-
framework to assess men in therapy. ommends that cognitive distortions be assessed in
Other typologies for assessing men in therapy the following areas: success, power, emotional con-
are emerging in the psychology of men. Pollack trol, fearlessness, self-reliance, primacy of work,
proposes the Major Depressive Disorder-Male Type playboy, and disdain of homosexuals.
and Disorder of the Self: Male Type as diagnostic The status of assessing men in therapy appears
categories (Pollack, 1998b, 2001). Depressive to be progressing, but much is still unknown. There
Disorder-Male Type has 12 symptoms that include are the unanswered questions about whether stereo-
interpersonal withdrawal, over involvement in types and bias against men actually exist in therapy.
work, denial of pain, autonomy, denial of emotions, Also, evidence-based, gender-sensitive assessment is
substance abuse, changes in sexual interests, mood endorsed by the experts, as is incorporating a multi-
problems, and weight or sleep disorders to just cultural framework into any therapy with men.
name a few. The Disorder of the Self: Male Type Numerous assessment paradigms exist, but none
includes the following symptoms: affective– has been tested for utility and effectiveness. The
intellectual splits, anger, rage, or repressive personal- assessment of men in therapy could be strengthened
ity, loss of vulnerability, sexualized self-object with further case studies and both qualitative and
yearnings, shame-sensitive or shame phobic, blunting quantitative research.

o’ne il 391
Therapy Processes and Therapeutic (Mahalik, Good, & Englar-Carlson, 2003a), men’s
Interventions for Men depression (Cochran & Rabinowitz, 2003), clinical
Major Textbooks and Conceptualization of practice with men (Rochlen, 2005), men’s emotional
Men’s Therapy behavior (Wong & Rochlen, 2005), men’s inter-
Seven publications have contributed significantly to personal psychotherapy (Mahalik, 1999b, 2001b),
our knowledge about therapy with men and boys evidence-based assessment of men (Cochran, 2005),
(Brooks, 1998; Brooks & Good, 2001a; Englar- and training for counselors of men (Wester & Vogel,
Carlson & Stevens, 2006; Horne & Kiselica, 1999; 2002). Taken collectively, these publications have
Glicken, 2005; Pollack & Levant, 1998, Rabinowitz made men’s therapy credible in psychology, but con-
& Cochran, 2002). A full review of these pub- vincing men to seek help remains a critical challenge.
lications is not possible, but each provides valu-
able information on the critical issues with men’s Why Don’t Men Use Therapy Services?
therapy. Most notably is The New Handbook of Negative Attitudes Toward Help-seeking
Psychotherapy and Counseling with Men (Brooks & One of the most critical mental health problems in
Good, 2001a). This two-volume resource includes the United States is men’s underutilization of ther-
39 chapters that represent a comprehensive guide to apy services. How to convince men to actually show
men’s problems and treatment approaches. Further- up for therapy may be as difficult as helping them.
more, Pollack and Levant’s (1998) edited book The The research indicates that men have problems but
New Psychotherapy with Men is also a valuable col- prefer to solve them on their own. Men’s underuti-
lection of chapters that distill the dilemmas and lization of mental health services is one of the most
new possibilities with men’s therapy. Every chapter consistent themes in the help-seeking literature
develops new ideas about men’s therapy that have (Addis & Mahalik, 2003; Blazina & Watkins, 1996;
clinical applications. There are chapters on psycho- Good, Dell, & Mintz, 1989; Mahalik, Good, &
analytic and cognitive behavior therapy, depression, Englar-Carlson, 2003). Estimates on who uses ther-
shame, and approaches to African American, gay, apy vary, but Vessey and Howard (1993) indicate
and bisexual men. A New Psychotherapy for that only about one-third of clients are men.
Traditional Men (Brooks, 1998) provides an excel- Robertson (2001) indicates that the ratio of male
lent orientation to why men need therapy, and how and female clients in North America is “about one
to effectively implement interventions that work. to two, with one male visit for every two or more
Brooks presents seven basic principles of psycho- female visits” (pp. 147–148). Clinical researchers
therapy with traditional men that have therapeutic indicate that this underutilization is caused by
depth and practical approaches. Englar-Carlson and the incongruence of therapy processes with the
Stevens (2006) have assembled the first therapy rigid norms of masculinity (Brooks, 1998; Robertson
casebook on men. The 14 case studies provide an & Fitzgerald, 1992). Campbell (1996) enumerates
excellent analyses of how actual therapy has been the masculinity issues that contribute to underuti-
conducted by experienced therapists. Horne and lization of therapy services, including men’s achieve-
Kiselica’s (1999) text on counseling adolescent boys ment and goal orientation, restricted emotions,
describes the developmental dilemmas of male independence, self-reliance, instrumentality, and
youth, and how adaptive and maladaptive male worries about getting close to others, particularly
development is shaped by complex interaction of other men. Rochlen (2005) indicates that more
biological, cultural, and economic forces. This book information is needed on how clinicians can address
has a wealth of information on counseling boys in a the critical problem of incongruence between restric-
variety of settings. The clinical knowledge in these tive norms and the psychotherapeutic process.
seven texts has significantly expanded our under- Negative attitudes toward help-seeking have
standing about doing therapy with men and boys, been found to be a central reason why men under-
but more elaboration may be needed for evidence- utilize therapy services (Addis & Mahalik, 2003).
based treatments to be designed and tested. Research indicates that men’s negative attitudes
Many other authors have published important toward help-seeking relates to GRC. O’Neil (2008)
manuscripts that have focused on specific topics reported 17 studies indicating that men’s GRC sig-
about men’s therapy. Therapeutic topics related nificantly relates to negative attitudes toward seek-
to men’s therapy have focused on the fragile mas- ing psychological help. Knowledge about the
culine self (Blazina, 2001), men’s cognitive distor- significant relationship between attitudes toward
tions (Mahalik, 1999a; 2001a), masculinity scripts help-seeking and GRC are critical for therapists

392 the psycholo gy o f men

since negative attitudes have been empirically docu- recommendations lack coherence and clarity. Two
mented across race, age, sexual orientation, and comprehensive approaches have been defined that
nationality groups. Gender role conflict’s significant provide concrete direction for men’s therapy
relationship with negative help-seeking attitudes (Brooks, 1998; Rabinowitz & Cochran, 2002).
makes conceptual sense based on the rigid standards Rabinowitz and Cochran’s (2002) Deepening Psycho-
of masculinity ideology that boys and men learn. therapy with Men is the most comprehensive treat-
For many men, expressing feelings and vulnerabili- ment paradigm currently in the psychology of
ties and giving up some power and control may be men. This book provides detailed therapeutic meth-
violations of their masculinity ideology that threaten ods based on theory and research that can guide
their male identity. Therapists can use the help-seek- effective therapy with men. They integrate psycho-
ing research to facilitate men’s adjustment in therapy analytic and gender role strain formulations that
and to be more vigilant to premature terminations. actually translate to into concrete interventions with
Based on the past help-seeking research, Rochlen men. They recommend “deepening psychotherapy,”
and Hoyer (2005) discussed how to effectively pub- defined as uncovering and elucidating masculine-
licize services for men using a social marketing per- specific conflicts experienced on an emotional level.
spective. They suggest that descriptions of mental They conceptualize four psychological dynamics
health services for men should use less psycholog- that are part of deepening men’s psychotherapy,
ically loaded words and descriptions. Research does including assessment of men’s psychodynamic,
support using promotional information that is less developmental, and GRC/stress issues; recognition
threatening or that sounds less clinical. Three stud- of male dependence, prohibition related to emo-
ies have assessed men’s GRC and men’s preferences tions, grief, sadness, and loss; focus on masculine-
for help using varied counseling brochures (Blazina specific self-structure and gender role identity; and
& Marks, 2001; Robertson & Fitzgerald, 1992; recognition that men’s action orientation (doing)
Rochlen, McKelley, & Pituch, 2006). The results can conflict with discomfort with being. Moreover,
of these studies indicate that men reporting high they provide 43 different interventions for treating
GRC were significantly more likely to prefer a non- men in therapy that emanate from five different
traditional counseling brochure (i.e., describing theoretical frameworks. This paradigm is the most
workshops or classes) over a direct service counsel- developed approach in the literature for doing ther-
ing brochure, and that power issues are related to apy with men.
seeking help. Future marketing brochures should Another therapeutic contribution is the New
be tested that define counseling as empowering and Psychotherapy with Traditional Men (Brooks, 1998).
a sign of masculine strength and courage. This text is practical, coherent, and detailed. The
In summary, there is considerable evidence that core of Brooks’ psychotherapeutic approach com-
GRC significantly relates to men’s negative attitudes prises seven core elements that guide therapy with
about seeking help. Whether these results explain men. These core elements include countering resis-
the critical reasons why men do not seek help is still tance, valuing traditional men, assessing men’s
unclear. What is also unknown from these studies problems in the context of gender awareness, accom-
are the specific fears and reservations men have when modating the “good ol’ boy” style, evoking men’s
talking about their problems. Do men fear loss of emotional pain, recognizing masculine heritage,
control and power by entering therapy? Does the and challenging men to change. Within these core
distorted notion that “real men solve problem on areas are nine other critical approaches for doing
their own” keep them away? Does resistance to seek- therapy with men : selling therapy; avoiding pitfalls;
ing help relate to homophobia and fears about being envisioning a sequence of change; digging, prod-
“feminized” through therapy? Men’s resistance to ding, and provoking; holding and focusing; show-
seeking help is now being researched with the ing and modeling; using experiential exercises;
Barriers to Help-Seeking Measure (Mansfield, Addis, inciting and escalating tensions; and using thera-
& Courtenay, 2005). Through this research and peutic silence. Brook’s therapeutic concepts provide
more positive marketing of men’s services, the stigma therapists with a very useful approach when doing
that men associate with seeking help can decrease. therapy with men.
In addition to these two major contributions,
Treatment Models in Men’s Therapy 25 other publications provide overall approaches
As with assessment, the methods and models of for doing therapy with men. Table 14.2 enumer-
therapy with men are few, and the various treatment ates over 80 therapeutic approaches and their

o’ne il 393
publication citations. This table allows researchers the poor). The training of multiculturally compe-
and practitioners to locate specific therapeutic tent therapists of men has emerging support in the
approaches that interest them. On the left side of literature and therefore should be a vital topic in the
Table 14.2 are the specific therapeutic approaches decades ahead.
categorized in the following six categories: gender- The experts indicate that the assumptions or
aware, gender-sensitive approaches; gender-aware, expectancies that therapists make about male clients
gender-sensitive, contextual problem assessment; are important considerations. What is still lacking is
multicultural consciousness and assessment; expec- the assessment of clients’ expectations of therapy.
tancies and assumptions of therapists; therapeutic This is particularly important in regards to men’s
processes with men; and techniques, skills, and negative attitudes toward help-seeking and the
approaches with men. A complete elaboration of incongruence between traditional forms of therapy
the approaches enumerated in Table 14.2 is beyond and men’s socialization to restrictive gender roles.
the scope of the chapter. Some overall analyses of A careful examination of how clients’ masculinity
the approaches in Table 14.2 are given below. ideology and GRC contribute to negative stigma
Strong consensus exists that gender-aware about therapy is a critical issue for therapists of men.
and -sensitive approaches are critical when doing All the therapeutic approaches in Table 14.2
therapy with men. If men’s sexist gender role social- have been discussed in the context of men’s prob-
ization is harmful and sometimes traumatic (O’Neil, lems with their sexist gender role socialization.
1981a, b, 2008b; Brooks & Good, 2001b; Lisak, Brooks (1998) and Rabinowitz and Cochran
2001; Pleck, 1995), then focusing on distorted 2002) provide the most vital information about
notions of masculinity and femininity and GRC doing therapy with men that transcends traditional
would be critical to therapeutic healing. The many approaches to therapy. With the exception of these
gender-related approaches enumerated in Table 14.2 two approaches, many of the processes listed in
document that the psychology of men recognizes Table 14.2 do not significantly differ from general
that boys and men are gendered beings. The call for recommendations for men or women in therapy.
gender-aware therapy 20 years ago by Good, Gilbert, Maybe this reflects the belief that no unique pro-
and Scher (1990) has been heard in the psychology cesses are needed for men. It is more likely, however,
of men. How well gender-aware therapy is under- that we do not have enough knowledge to generate
stood in other clinical disciplines is unclear. How unique therapeutic processes for men. We do not
many therapists utilize gender-aware approaches in know enough about how masculinity ideology and
their therapy and at what level of effectiveness is a GRC interact in the psychotherapeutic processes.
critical empirical question. For example, a strong case can be made that
Furthermore, over 24 assessment areas have been homophobia, power, and control are universal issues
specified on how to make appraisals of men in ther- with men in therapy and should be addressed
apy (see Table 14.2). Collectively, these assessment directly or indirectly by therapists. To make this
areas do represent a new and emerging way to evalu- assumption is one thing, but to fully understand it
ate men that deviates from standard DSM-IV crite- in the interactive, psychotherapeutic moment with
ria and other traditional paradigms. Furthermore, a client is quite different and much more complex
there is also support for including men or maleness and important.
as a multicultural variable in therapy. Interventions There are many unanswered questions about
with men have been excluded from multicultural men’s therapy. Are there therapeutic approaches that
competencies (Liu, 2005). Of course, gender has are unique to men’s therapy? Should there be sepa-
been included in the multicultural competencies rate clinical approaches for men compared to
but exactly what that means for men has gone women? How does diversity competency (Miville
unspecified. The recommendations in Table 14.2 et al., 2009) relate to working with men from differ-
support full understanding of masculinity, male- ent racial, ethnic, religious, age, and sexual orienta-
ness, and boys’ and men’s gender role socialization tions categories? Is a new and gender-informed kind
processes as important multicultural competencies. of therapy developing in the psychology of men?
Multicultural assessment of white men should be If so, what are its unique components and processes?
included in this assessment, but even more impor- What exactly is the current status of doing therapy
tant is the multicultural issues for men of color, with men? Understanding men’s psychotherapeutic
immigrant men, gay and transgendered people, and processes should be a growth area in the psychology
men from different classes (both the wealthy and of men in the coming decades.

394 the psycholo gy o f men

Table 14.2. Therapy Approaches for Men Recommended by Published Authors

Therapeutic Approaches References

Gender-Aware, Gender-Sensitive Approaches
Regard conceptions of gender as integral to counseling Good, Gilbert, & Scher, 1990
Consider problems within their societal context Good, Gilbert, & Scher, 1990
Actively change gender injustices experienced Good, Gilbert, & Scher, 1990
by men and women
Emphasize the development of collaborative Good, Gilbert, & Scher, 1990
therapeutic relationships
Respect clients’ freedom to choose Good, Gilbert, & Scher, 1990
Understand the worldviews of men Good, Thompson, & Braithwaite, 2005; Liu, 2005
Recognize how patriarchal structures harm men
Accommodate and respect men’s gender role Brooks, 1998
values and masculine styles
Value traditional men Brooks, 1998
Help men yield to system pressures Brooks, 2001
Gender-Aware, Gender-Sensitive Contextual Problem Assessment
Assess one’s own biases, values, about men Mahalik, Good, Englar- Carlson, 2003a;
O’Neil, 2008; Liu, 2005
Assess one’s own knowledge about the O’Neil, 2008; O’Neil & Lujan, 2010
psychology of men
Assess men’s expectancies of therapeutic process Mahalik, Good, & Englar-Carlson, 2003a
Assess formative family and cultural heritage Rabinowitz & Cochran, 2002; O’Neil, 2008
in context of gender roles
Assess maladaptive patterns from family of origin Rabinowitz & Cochran, 2002
and psychological history in context of gender roles
Assess family system and interpersonal interactions Lazur, 1998; Philpot, 2001
Assess using a gender role analysis Englar-Carlson, 2006
Assess a portal (central focus or focal conflict) Rabinowitz & Cochran, 2002
Assessing conformity and nonconformity to Mahalik, Talmadge, Locke, & Scott, 2005
male norms
Assessing men’s wounds Rabinowitz & Cochran, 2002;
Assess the father wound O’Neil & Lujan, 2010
Assess overt and covert fathering contexts O’Neil & Lujan, 2010
Assess how clients manage dependency needs, Rabinowitz & Cochran, 2002
sadness, grief, and loss
Assess cognitive distortion, explore illogical Mahalik, 1991, 2001;O’Neil, 2008, 1990, 2006;
thoughts, modify biased thought with rationality Mooney, 1998
Assess fathering roles and relationships with father O’Neil & Lujan, 2010
Assess masculine-specific scripts and self- structures Rabinowitz & Cochran, 2002; Mahalik, Good, &
Englar-Carlson, 2003
(Continued )
o’ne il 395
Table 14.2. Continued

Therapeutic Approaches References

Contextual Problem Assessment Continued
Assessing and working with shame Krugman, 1998
Assess body language Rabinowitz & Cochran, 2002
Assessing defenses and resistance O’Neil, 2008; Mahalik, 2008; Good & Mintz, 2001;
Johnson, 2001
Assess emotionality and alexithymia O’Neil, 2008
Assess need for psychological information O’Neil, 2008; Levant 1998
Assess men’s health needs Courtenay, 2001
Assess men’s patterns of GRC O’Neil, 1990, 2008
Assess diversity & oppression in men’s lives O’Neil, 2008,; Good, Thompson, Braithwaite, 2005
Multicultural Consciousness and Assessment
Recognize that therapy is cross-cultural for men Good, Thompson, & Braitwaite, 2005; Glicken, 2005
Recognize the culture of therapy is in conflict Good, Thompson, & Braitwaite, 2005; Glicken, 2005
with traditional masculine socialization
Consider the culture of traditional masculinity Good, Thompson, & Braitwaite, 2005; Glicken, 2005
in the context of therapy
Recognize that therapy with men is about Good, Thompson, & Braitwaite, 2005; Glicken, 2005
changing cultural values
Develop culturally appropriate intervention Good, Thompson, & Braitwaite, 2005; Glicken, 2005
strategies and techniques
Respect men’s gender role values and cultural context Good, Thompson, & Braitwaite, 2005; Glicken, 2005
Recognize that men are different than women Good, Thompson, & Braitwaite, 2005; Glicken, 2005
Assess one’s own bias and stereotypes about O’Neil, 2008
men who are different than you
Assess men’s experience with oppression and O’Neil, 2008
discrimination
Assess the invisibility syndrome for men who Franklin, 1998
are victims of racism or other forms of oppression
Assess men’s experience with microaggressions Franklin, 1998
Therapist self-interrogation and self-confrontation Caldwell & White, 2001
of their racist socialization
Expectancies and Assumptions of Therapists
Assume men’s pain and vulnerability Brooks, 1998; Brooks, 2001
Define therapy as problem solving with men Glicken, 2005
Normalize therapy as positive; selling therapy Brooks, 1998
Respect men’s readiness to change Brooks, 2001
Recognize men’s ambivalence about therapy Good, Thompson, & Braithwaite, 2005
(Continued )

396 the psycholo gy o f men

Table 14.2. Continued

Therapeutic Approaches References

Expectancies and Assumption of Therapists Continued
Define male socialization in positive ways Glicken, 2005
Therapeutic Processes with Men
Work collaboratively Glicken, 2005
Develop culturally appropriate interventions, Good, Thomson, & Brathwaite, 2005
strategies, and techniques
Balance assessment and connection in early Cochran & Rabinowitz, 2002
parts of therapy
Structure therapy Glicken, 2005
Focus on men’s strengths Glicken, 2005
Recognize that trust develops slowly with men Glicken, 2005
Focus on areas of change: emotions, cognitions, Good & Mintz, 2001
behaviors, interpersonal relationships
Counter and work through resistance Good & Mintz, 2001; Glicken, 2005; Brooks, 1998;
Rabinowitz & Cochran (2002)
Avoid power struggles and psychological labeling Glicken, 2005
Avoid pitfalls Brooks, 1998 Brooks, 1998
Stimulate and evoke men’s emotional pain Brooks, 1998
Inciting and escalating tensions Brooks, 1998
Envision a sequence of change Brooks, 1998
Digging, prodding, and provoking Brooks, 1998
Holding and focusing Brooks, 1998
Help clients balance “doing with being” Rabinowitz & Cochran, 2002
Work with transference and countertransference Good & Mintz, 2001,; Johnson, 2001,; Gilbert &
Scher, 2001, Good, Thomson, & Brathwaite, 2005;
Rabinowitz & Cochran, 2002
Develop effective terminations Good & Mintz, 2001; Rabinowitz & Cochran, 2002
Techniques, Skills, and Approaches With Men
Rabinowitz and Cohran’s 43 approaches across Rabinowitz & Cochran, 2002
psychoanalytic, jungian, existential, self-psychology,
person-centered, experiential, transpersonal, and
spiritual forms of deepening psychotherapy with men
Educate about how cognitive thoughts, Mahalik, 1999a, 2001
feelings, behaviors interrelate
Use language that men will understand Robertson, 2001
Help clients develop a healthy set of masculine Rabinowitz & Cochran, 2002; Cochran, 2002
values and behaviors
Use humor, humility, metaphors, and self-disclosure Kiselica, 2001; Glicken, 2005
(Continued )

o’ne il 397
Table 14.2. Continued

Therapeutic Approaches References

Techniques, Skills, and Approaches With Men Continued
Use bibliotherapy and experiential exercise: Glicken, 2005; Rabinowitz & Cochran, 2002;
novels, poetry, films, and music Good & Mintz, 2002; Brooks, 1998
Showing and modeling Brooks, 1998
Challenging men to change Brooks, 1998
Therapeutic silence Brooks, 1998
Enumerate change patterns Good & Mintz, 2001
Humanize vulnerability and pain Courtenay, 2001
Use motivational interviewing and enhancement Isenhart, 2001; Good, Thomson, & Brathwaite, 2008
Use gender inquiry Philpot, 2001
Defining healthy manhood Courtenay, 2001

All therapists of men should consider Brook’s authors indicate that men’s problems may be
(1998) guidelines and Rabinowitz and Cochran’s “masked” or do not fit traditional diagnostic cate-
(2002) 43 therapeutic skill/techniques across eight gories (Magovcevic & Addis, 2008; Pollack, 1998b,
theoretical areas. These approaches open up a 2001; Rabinowitz & Cochran, 2002). Other critical
multitude of ways to help therapists who are strug- issues include how to get men to use psychological
gling with men’s resistance, defensiveness, or dilem- services, and how to effectively market men’s services.
mas that have been reached in therapy. The rest How to redefine help-seeking and the therapeu-
of the skills in Table 14.2 have a cognitive, behav- tic process so that men use mental health ser-
ioral, and humanistic emphasis but very few of them vices remains a critical challenge in the psychology
have been tested for effectiveness. Therefore, teams of men. Furthermore, no therapeutic paradigm cur-
of clinicians and researchers should collaborate in rently exists that assesses men across different races,
designing research that promotes evidence-based classes, ages, ethnicities, nationalities, and sexual ori-
assessment and treatment (Cochran, 2005). entations. Biases and discrimination against men
during therapy because of their sex, race, religion,
Summary of Therapy Process and sexual orientation, or nationality have not been stud-
Treatment Interventions for Men ied. The initial diagnostic criteria to assess men are in
Over the last 10 years, knowledge about men’s ther- the earlier stages of development and primarily based
apy has expanded significantly. Some diagnostic on clinical experience. Evidence-based assessment
paradigms and guidelines exist, and at least two has been recommended (Cochran, 2005), but this
comprehensive approaches to men’s therapy have kind of appraisal requires operational definitions of
been discussed in the literature (Brook, 1998; men’s problems and potentials. Therefore, more
Rabinowitz & Cochran, 2002) What is unclear is clearly defined therapeutic concepts need to be
whether these guidelines are being used by practi- developed that can be tested empirically.
tioners. Beyond these approaches, the literature on Almost all of the theorists define therapy with
men’s therapy is underdeveloped and scattered men using gender-sensitive approaches (Good,
across various journal articles, books, and other Gilbert, & Scher, 1990). It is now recognized that
publications. Very few empirically based or theo- patriarchal sexism can harm men in significant
retically robust models of men’s therapy currently ways. Consequently, men’s therapy should include
exist (Good & Sherrod, 2001). There has been lim- how gender role values contribute to men’s prob-
ited amount of research on clients or how actual lems. Numerous theorists suggest psychodynamic
therapeutic process work with men. and cognitive behavioral approaches in the context
Experts on men’s therapy indicate that chal- of men’s gender role development (Mooney,
lenges exist in assessing men’s problems. Numerous 1998; Pollack, 1995, 1998b; Rabinowitz &

398 the psycholo gy o f men

Cochran, 2002). The misdiagnosis of men and the Furthermore, studies need to use more behav-
limitations of previous diagnostic schemas are cur- ioral measures and be conducted in laboratory and
rently being discussed. The literature also under- real-life situations. Eisler’s (1995) research program
scores men’s resistance, ambivalence, and and Breiding’s research studies (Breiding, 2004;
defensiveness about therapy, and the incongruence Breiding, Windle, & Smith, 2008) provide excel-
between the client’s gender role socialization and lent examples of real-life, situational research. More
traditional approaches to therapy. Clinical processes behavioral measures and laboratory-based studies
to uncover men’s problems are emphasized and, as are needed when studying masculinity ideology,
in all therapies, a trusting relationship is considered fears of femininity, and GRC. Studies that assess
critical. Special male symptoms are identified as actual violations of masculine norms (Bosson, Taylor,
central to men’s problems including dependency, & Prewitt-Freilino, 2006) are needed to understand
emotional restrictiveness, sadness, grief, loss, power, how “gender role threats” activate men’s psychologi-
control, vulnerability, and pain. There are recom- cal problems and hypermasculinity. More qualita-
mendations to focus on men’s strengths, and to tive research and case studies that capture the
avoid power conflicts and psychological labels. complexity of male behavior are needed. The quali-
Empowering men and using experiential exercises tative research is needed to better conceptualize
to promote men’s growth are considered important men’s lives and develop more comprehensive con-
to therapeutic effectiveness. cepts than those reviewed in the chapter.

Diversity, Racial and Ethnic

Future Directions in the Psychology
Identity, and International Men
of Men: Theory, Research, Clinical
Discovering how racial and ethnic identities inter-
Practice and Training
act with the internalization of masculinity ideol-
The psychology of men has witnessed much schol-
ogy and gender-related conflict and stress needs
arly activity since it was officially recognized by
to be a high priority in the future. Research and
American psychology in 1995. For the discipline to
theory on how racial identity, racism, and other
mature and impact the rest of psychology, new
forms of discrimination relate to men’s problems is
agendas need to be pursued. Below are eight agen-
essential to understanding how the larger social
das to advance the research and clinical practice in
system is implicated in patriarchal dynamics (Carter,
the psychology of men.
Williams, Juby, & Buckley, 2005; Enns, 2008;
Heppner & Heppner, 2008; O’Neil, 2008b).
New Research Directions Studies that assess men who have been victimized
Empirical evidence now exists documenting that by societal or personal oppression need to be con-
men’s and boy’s gender roles have negative psy- ducted. Furthermore, men who victimize others
chological consequences (Good, Wallace, & Borst, need to be vigorously studied if we are to slow and
1994; Levant & Richmond, 2007; O’Neil 2008b). eliminate the senseless amount of victimization
The relationship between masculinity ideology that men inflict on human beings in our world.
and GRC and stress to men’s psychological prob- Additionally, how acculturation stress interacts
lems has been documented in hundreds of studies with masculinity conflicts is particularly relevant for
(see Table 14.1). How, why, and when men experi- the millions of immigrant men and women enter-
ence these conflicts with their masculinity is the ing our country. Another important diversity issue
next critical contextual question. More complex is how the psychology of men can engage research-
studies that assess contextual variables are needed if ers, therapists, and colleagues around the world in
the psychology of men is to make a significant collaborative efforts (Connell, 2003; Blazina &
contribution to society. This implies moving past Shen-Miller, 2011; O’Neil, 2011). Counseling
simple correlational studies to moderator and medi- psychology has been a leader in international net-
ator analyses that assess how third variables interact working, and the psychology of men could be an
with men’s experience with their gender roles attractive discipline to many countries that iden-
(Heppner, 1995; O’Neil, 2008b,c). In previous tify with Division 17. My literature review of the
papers, a contextual research agenda for GRC GRC research found over 60 empirical studies
(O’Neil, 2008b,c) was delineated that could easily on men from 24 different countries. Therefore,
be adapted to masculinity ideology and any other research networks on men are developing around
constructs in the psychology of men. the world, but no official mechanism exists to

o’ne il 399
promote collaborations of international researchers and abusive behavior and violence, and aggression.
in the psychology of men. Furthermore, more study is needed on how men’s
oppressive and discriminatory experiences stimulate
Future Directions for Understanding Men’s violence toward others. How men’s emotional and
Therapy and Psychological Assessment psychological processes contribute to violence
Recommendations to improve men’s therapy and deserves increased research studies and preventive
psychological assessment are difficult to specify. The programming.
current literature on men’s therapy is promising, but
overall the paradigms are preliminary and general. Marketing Psychological Services for Men
Almost all of the paradigms and approaches lack and Developing Prevention Programs
the rigors of empirical tests and evidence-based This chapter documents that men have serious
examination. Furthermore, I found in my review problems from gender roles but do not use thera-
very few recommendations for future research on peutic services to remediate them. Discovering how
men’s therapy. In many ways, it appears that schol- to more effectively market services for men and
ars have not been able to specify the critical research change negative attitudes toward help-seeking needs
questions needed to study men’s therapy. One to be a primary agenda in the psychology of men.
approach to remedy this situation would be to take Demystifying help-seeking and making therapy
the emerging therapeutic models (Brooks, 1998; services attractive requires creative interventions
Brooks, 2001, Glicken, 2005; Good & Mintz, and “thinking outside the box.” Help-seeking by
2001; Good, Thompson, & Braithwaite, 2000; men has been distorted by patriarchal structures
Mahalik, 1999a, 2001a; Rabinowitz & Cochran, that deny men the right to have human vulnera-
2002) and make them more operational for possible bilities to life’s inevitable problems. This is one of
empirical tests. More case studies (Englar-Carlson the saddest outcomes of modern patriarchy. Men
& Stevens, 2006) and qualitative research may be are socialized to have problems because of sexist
needed to generate important therapeutic questions. and patriarchal values, and simultaneously denied
Scientists and practitioners need to work together help by the very same system that causes the prob-
to generate a comprehensive research program lems. Variables that mediate negative help-seeking
assessing therapeutic interventions that are effective attitudes need to be studied by researchers. For
with all men, but particularly with men from diverse example, it has been found that men’s GRC and
backgrounds. negative attitudes toward help-seeking are mediated
by difficulties disclosing distressing information
Masculinity and Preventing Men’s Violence and the self-stigma associated with seeking counsel-
One of the most critical issues in the psychology of ing (Pederson & Vogel, 2007). This research find-
men is documenting what causes men’s violence ing supports developing preventive interventions
against women, children, and other men (Harway that describe the positive power of self-disclosure
& O’Neil, 1999; O’Neil & Nadeau, 1999). Physical and the origins of stigma about men seeking help.
violence is everyone’s fear in our current society, and For example, it may be that the advantages of ther-
men are the primary victimizers. Many discussions apy and self-disclosure need to be more publicized
on men’s violence become consumed in legitimate with men.
anger, blame, defensiveness, and outright helpless- Another study found that encouragement to seek
ness, given the enormity and heaviness of the prob- help or knowing someone who had sought help
lem. Psychologists need to lead the way past these were related to more positive expectations about
understandable but unfortunate emotions with mental health services and help-seeking (Vogel,
research and preventive programs. One way to do Wade, Wester, Larson, & Hackler, 2007). These
this is to generate masculinity hypotheses about results suggest that social networks that endorse
men’s violence (O’Neil & Nadeau, 1999). For help-seeking or specific individuals who have sought
example, how, when, and why does masculinity ide- help can be influential in mediating resistance to
ology and GRC stimulate threat, intimidation, and seeking help. This kind of mediation research holds
violent retaliation by men? The research cited in promise because it assesses the potential factors that
Table 14.1 indicates that masculinity ideology and can change men’s attitudes toward help-seeking.
GRC and stress are significantly correlated with Based on this research, testimonials of therapy by
negative and angry attitudes toward others, coercive past clients may be very valuable in helping resistant

400 the psycholo gy o f men

men seek the help that they need. Active experimen- (O’Neil, 2008b). Courtenay’s (2000c) health agenda
tation with unique ways to help men break through for men includes over 30 male behaviors that
their fears of being helped are critical to any preven- increase men’s risk of disease, injury, and death.
tion agenda in the psychology of men. Teams of psychologists could work with teams of
medical experts in developing preventive interven-
Promoting the Psychology of Boys tions and research that literally have life-and-death
The psychology of boys has been slow to develop implications for men.
as a speciality in the psychology of men. The publi-
cation of specific books on boys (Horne & Kiselica, Promoting Positive and Healthy Masculinity
1999; Pollack, 1998a) and media debates about The psychology of men needs to emphasis more
“boys crises” (Hall, 1999; Hoff Sommer, 2000; healthy criteria for being male. The psychology of
Pollack, 1998a; Kindlon & Thompson, 1999; Tyre, men has primarily focused on men’s problems,
2006; Von Drehle, 2007) have now given the psy- rather than on men potentials and possibilities.
chology of boys a central place in the psychology of Paradigms of positive masculinity are needed to
men. There is a great need to accelerate our efforts describe men’s strengths and how to transcend sexist
to create and evaluate prevention programming stereotypes (O’Neil, 2008; O’Neil & Lujan, 2009).
for boys in public schools and in the community Patterns of positive masculinity can help men and
(O’Neil & Lujan, 2009). First, we need to create boys learn alternatives to sexist attitudes and behav-
a curriculum that boys can use to promote their iors that cause GRC. Programming could empha-
psychological development. Suggestions on how to size what constitutes “healthy masculinity.” Men’s
enter public schools and how to develop user- strengths and potentialities could focus on themes
friendly curriculum that focuses on both life skills such as responsibility, courage, altruism, resiliency,
and masculinity conflicts have been suggested service, protection of others, social justice, positive
(O’Neil & Lujan, 2009). An important aspect of the fathering, perseverance, generativity, and nonvio-
development of boy’s psychology is understanding lent problem solving. Positive masculinity moves
the multiplicity of factors in families, schools, and away from what is wrong with boys and men by
peer groups that shape male gender role identity. identifying the qualities that empower males to
Many parents and educators are unaware of how improve themselves and society. Programs and
sexism and restrictive gender roles negatively affect research on healthy masculinity could change the
boy’s lives. There is denial about boy’s problems that common misperception that the psychology of
emanate from sexist stereotypes. The axiom “boys men is about documenting what is wrong with boys
will be boys” is frequently used to ignore significant and men. Attention to healthy masculinity could
problems of male youth. The assumption that boys attract more psychologists to the psychology of men
will outgrow their problems is seriously flawed as a critical discipline committed to social justice
because it represents a superficial assessment of boy’s for both men and women.
lives, and does not capture the deeper and unidenti-
fied sources of boys’ GRCs. A call to action to pre- Training and Teaching the
vent boys’ problems has been issued (O’Neil & Psychology of Men
Lujan, 2009) but will require much effort and com- The APA training programs in counseling psychol-
mitment by progressive educators. ogy and other mental health specialties can be
instrumental in promoting the psychology of men.
Interventions and Research on Recently an entire issue of The Counseling Psychologist
Men’s Health Issues recommended that race, ethnic, and gender issues
Courtenay’s (2000a,b) call to action for men’s health be better integrated into our training programs
issues is one of the most important areas for (TCP, 2009; Miller, Forrest, Elman, 2009; Miville
researcher and practitioners to pursue in the future. et al., 2009). Gender and masculinity issues were
To pursue men’s health issues, the psychology mentioned as important training areas, but no rec-
of men must venture into how the biological bases ommendations were given on how to teach the
of behavior interact with psychological and gender- psychology of men.
related factors for men. How masculinity ideology In published papers spanning over 25 years,
and GRC moderate and mediate men’s physical I advocated that the psychology of men become
problems deserves more expansive conceptualization a priority in counseling training programs (O’Neil,

o’ne il 401
1981a, b, 1982, 1990, 2008b). In the early years, GRC and stress, and other masculinity constructs
limited empirical research existed for this training. significantly contribute to men’s and boys’ mental
As this review demonstrates, strong empirical evi- health problems. These data deserve more attention
dence now exists indicating that masculinity atti- in psychology and a call to action is strongly recom-
tudes and conflicts are related to men’s poor mental mended to better serve boys and men.
health and significant interpersonal problems. The
research reviewed here supports increased atten- References
tion on men’s problems in our training programs, Addis, M. (2008). Gender and depression in men. Clinical
in the context of masculinity ideology and GRC. Psychology: Science and Practice, 15, 153–168.
Furthermore, sufficient knowledge exists on men’s Addis, M. E., & Cohane, G. H. (2005). Social scientific para-
digms of masculinity and their implications for research and
therapy to justify coursework specifically focused on practice in men’s mental health. Journal of Clinical Psychology,
techniques and skills when counseling men. 61, 1–15.
Teaching the psychology of men can become a Addis, M. E., & Mahalik, J. R. (2003). Men, masculinity, and
priority training issues in counseling psychology. the context of help seeking. American Psychologist, 58, 5–14.
Survey research indicates that the psychology of Alberta, A. J., & Wood, A. H. (2009). A practical skills model for
effectively engaging clients in multicultural settings. The
men has not been included in counseling psychol- Counseling Psychologist, 37, 564–579.
ogy training, even though there is high interest and American Heart Association (1994). Heart and stroke facts:
positive belief in its value (Mellinger & Liu, 2006). 1995. Statistical Supplement. Dallas: author.
What is unclear is whether counseling psychology American Psychological Association (2003). Guidelines on mul-
will address men’s issues with the same vigor that ticultural education, training, research, practice, and organi-
zational change for psychologists. American Psychologist, 58,
women’s issues were addressed over the past three 377–402.
decades. Furthermore, analyses have indicated that Anderson, A. J. (1998). Treating anger in Africn American men.
gender has been conspicuously lacking in the train- In W. S. Pollack & R. F. Levant (Eds.) New psychotherapy for
ing literature for both sexes (Silverstein, 2006). men (pp. 239–258). New York: John Wiley & Sons Inc.
What curriculum and skills should be taught thera- Bem, S. (1981). Gender schema theory: A cognitive account of
sex typing Psychological Review, 88, 354–364.
pists and psychoeducators remains unclear, but Blazina, C. (1997). The fear of the feminine in the western
methods of teaching the psychology of men are psyche and the masculine task of disidentification: Their
being explored (O’Neil, 2004; O’Neil, Addis, effect on the development of masculine gender role conflict.
Kilmartin, & Mahalik, 2004). Ultimately, training Journal of Men’s Studies, 6, 55–68.
standards for boys and men will need to be inte- Blazina, C. (2001). Analytic psychology and gender role conflict:
The development of the fragile masculine self. Psychotherapy,
grated with multicultural competencies (Liu, 2005). 38, 50–59.
Teaching the psychology of men and training needs Blazina, C. (2003). The cultural myth of masculinity. Westport,
to become part of diversity competence (Alberta & CT: Praeger.
Wood, 2009 ; Miville et al., 2009) for counsel- Blazina, C. (2004). Gender role conflict and disidentification
ing psychology to move beyond the traditional process: Two cases studies on fragile masculine self. The
Journal of Men’s Studies, 12, 151–161.
approaches to training clinicians, professors, and Blazina, C., & Marks, I. (2001). College men’s affective reactions
researchers. The future of the psychology of men to individual therapy, psychoeducation workshops, and
rests with the next generations of researchers and men’s support group brochures: The influence of gender role
practitioners who teach and train psychologists conflict and power dynamics upon help seeking attitudes.
about men’s problems and potentials. Psychotherapy, 38, 297–305.
Blazina, C., Pisecco, S., & O’Neil, J. M. (2005). An adaptation
of the Gender Role Conflict Scale for adolescents:
Conclusion Psychometric issues and correlates with psychological dis-
Final Thoughts on the Status of the tress. Psychology of Men and Masculinity, 6, 39–45.
Psychology of Men in 2010 Blazina, C., & Shen-Miller, D. S. (Eds.) (2011). An international
The overall status of the psychology of men in 2010 psychology of men: Theoretical advances, case studies, and
clinical innovations. New York: Routledge.
is healthy and vibrant. The number of publications Blazina, C., & Watkins, C. E. (1996). Masculine gender role
cited in this review is evidence that the psychology conflict: Effects on college men’s psychological well-being,
of men is growing and expanding. Some critical chemical substance usage, and attitudes toward help-seeking,
issues need to be addressed if the psychology of men Journal of Counseling Psychology, 43, 461–465.
is to fully explain how patriarchal norms negatively Boehn, F. (1930). The femininity-complex in men. International
Journal of Psychoanalysis, 11, 444–469.
affect men, women, and children. For the first time, Bosson, J. K., Taylor, J. N., & Prewitt-Freilino, J. L. (2006).
empirical evidence reviewed in this chapter docu- Gender role violations and identity misclassification: The
ments that masculinity ideology and conformity, roles of audience and actor variables. Sex Roles, 55, 13–24.

402 the psycholo gy o f men

Brannon, R., & Juni, S. (1984). A scale for measuring attitudes Center for Disease Control (CDC). (2007). Facts at a glance:
toward masculinity. JSAS. Youth Violence Center for Disease Control Center for
Breiding, M. J. (2004). Observed hostility and observed domi- Disease Control and Prevention, Atlanta, GA.
nance as mediators of the relationship between husbands’ Chu, J. Y., Porche, M. V., Tolman, D. L. (2005). The Adolescent
gender role conflict and wives’ outcomes. Journal of Masculinity Ideology in Relationships Scale. Men and
Counseling Psychology, 51, 429–436. Masculinities, 8, 93–115.
Breiding, M. J., Wundle, C. R., & Smith, D. A. (2008). Cochran, S. V., & Rabinowitz, F. (2000). Men and depression:
Interspousal criticism: A behavioral mediator between hus- Clinical and empirical perspectives. San Diego, CA: Academic
band’s gender role conflict and wife’s adjustment. Sex Roles, Press.
59, 880–888. Cochran, S. V., & Rabinowitz, F. (2003). Gender-sensitive
Brodsky, A., & Holroyd, J. (1975). Report of the Task Force recommendations for assessment and treatment of depres-
on Sex Bias and Sex-role Stereotyping in Psychotherapeutic sion in men. Professional Psychology: Research and Practice, 34,
Practice. American Psychologist, 30, 1169–1175. 132–140.
Brooks, G. R. (1998). A new psychotherapy for traditional men. Cochran, S.V. (2005). Evidence based assessment with men.
San Francisco: Jossey-Bass. Journal Clinical Psychology. 61, 649–660. Professional
Brooks, G. R. (2001). Counseling and psychotherapy for male Psychology: Research, and Practice, 30, 5–13.
military veterans. In G. Brooks & G. E. Good (Eds.), The new Connell, R. W. (1995). Masculinities. Cambridge, U K: Polity
handbook of psychotherapy and Counseling with men: A compre- Press.
hensive guide to settings, problems, and treatment approaches Connell, R. W. (2003). Masculinities, change, and conflict in
(pp. 206–225). Vol. 1, San Francisco: Jossey-Bass. global society: Thinking about the future of men’s studies.
Brooks, G. R., & Good, G. E. (Eds.). (2001a). The new handbook Journal of Men’s Studies, 11, 249–266.
of psychotherapy and counseling with men: A comprehen- Connell, R. W., & Messerschmidt, J. W. (2005). Hegemonic
sive guide to settings, problems, and treatment approaches. masculinity: Rethinking the concept. Gender and Society, 19,
San Francisco: Jossey-Bass. 829–859.
Brooks, G. R., & Good, G. E. (2001b). Introduction. Coonerty-Femiano, A. M., Katzman, M. A., Femiano, S.,
In G. R. Brooks & G. E. Good (Eds.), The new handbook of Gemar, M., & Toner, B. (2001, August). Gender role conflict
psychotherapy and counseling with men: A comprehensive guide in male survivors of childhood abuse. Paper presented at the
to settings, problems, and treatment approaches (pp. 3–21). American Psychological Association, San Francisco, CA.
San Francisco, CA: Jossey-Bass. Courtenay, W. H. (1998). College men’s health: An overview
Brooks, G. R., & Levant, R. F. (1998). A history of division 51 and a call to action. Journal of American College Health, 46,
(the Society for the Psychological Study of Men and 279–290.
Masculinity). In D. A. Dewsbury (Ed.) Unification through Courtenay, W. H. (2000a). Engending health: A social construc-
division: Histories of the Divisions of the American Psychological tionist examination of men’s health beliefs and behaviors.
Association, volume III (pp. 197–222). Washington, DC: Psychology of Men and Masculinity, 1, 4–15.
APA Books. Courtenay, W. H. (2000b). Teaming up for the new men’s health
Burke, K. (2000). Gender role conflict and psychological well movement. Journal of Men’s Studies, 8, 387–392.
being: An exploratrion in men enrolled to attend an initatory Courtenay, W. H. (2000c). Behavioral factors associated with
weekend. Unpublished master thesis. University of Maryland, disease, injury, and death among men: Evidence and implica-
Baltimore County. tion for prevention. Journal of Men’s Studies, 9, 81–142.
Burk, L. R., Burkhart, B. R., & Sikorski, J. F. (2004). Courtenay, W. H. (2001). Counseling men in medical settings:
Construction and preliminary validation of the Auburn The six-point health plan. In G. R. Brooks & G. E. Good
Differential Masculinity Inventory. Psychology of Men and (Eds.) The new handbook of psychotherapy and counseling
Masculinity, 5, 4–17. with men: A comprehensive guide to settings, problems, and
Campbell, J. L. (1996). Traditional men in therapy: Obstacles treatment approaches., Vol 1 (pp. 59–91), San Francisco, CA:
and recommendations. Journal of Psychological Practice, 2, Jossey-Bass.
40–45. Cusack, J., Deane, F. P., Wilson, C. J., & Ciarrochi, J. (2006).
Carter, R. T., Williams, B., Juby, H. L., & Buckley, T. R. (2005). Emotional expression, perception of therapy, and help seek-
Racial identity as mediator of the relationship between ing intentions in men attending therapy services. Psychology
gender role conflict and severity of psychological symp- of Men and Masculinity, 7, 69–82.
toms in Black, Latino, and Asian men. Sex Roles 53, David, D., & Brannon, R. (Eds.). (1976). The forty-nine percent
473–486. majority. Reading, MA.: Addison-Wesley.
Center for Disease Control (CDC). (1997). Demographic Davis, T. L., & Liddell, D. L. (2002). Getting inside the house:
differences in notifiable infections disease morbidity–United The effectiveness of a rape prevention program for college
States, 1992–1994. Morbidity and Mortality Weekly Report, fraternity men. Journal of College Student Development, 43,
46(28), 637–641. 35–50.
Center for Disease Control (CDC). (2005). Mental health in Deaux, K., & Majors, B. (1987). Putting gender in context: An
the United States: Prevalence of Diagnosis and medication integrative model of gender-related behavior. Psychological
treatment for attention-deficit hyperactivity disorder–United Review, 94, 369–389.
States, 2003. Center for Disease Control and Prevention, Department of Health and Human Services (1996). Report of
Atlanta, GA. 54(34), 842–847. final mortality statistics, 1994. Monthly Vital Statistics, Report
Center for Disease Control (CDC). (2006). Quick stats– 45, Suppl. 3., Hyattsville, MD: Published Health Services.
Excessive alcohol use and risks to men’s health, Center for Dodson, T., & Borders, D. (2006). Men in traditional and
Disease Control and Prevention, Atlanta, GA. nontraditional careers: Gender role attitudes, gender role

o’ne il 403
 conflict, and job satisfaction. Career Development Quarterly, Good, G. E., & Sherrod, N. B. (2001). Men’s problems
54, 283–296. and effective treatments: Theory and empirical support.
Doyle, J. A. (1995). The male experience. Dubuque, IA: Brown & In G. Brooks & G. E. Good (Eds.), The new handbook
Benchmark. of psychotherapy and counseling with men: A comprehensive
Dubbert, J. L. (1979). A man’s place: Masculinity in transition. guide to settings, problems, and treatment approaches Vol. 1
Englewood Cliffs: N. J.: Prentice-Hall. (pp. 22–40). San Francisco: Jossey-Bass.
Eckes, T., & Trauter, H. M. (2000). The developmental social Good, G. E., Thomson, D. A., & Brathwaite, A. D. (2005).
psychology of gender. Mahwah, NJ: Lawrence Erlbaum Journal of Clinical Psychology, 61, 697–708.
Associates Publishers. Good, G. E., Wallace, D. L., & Borst, T. S. (1994). Masculinity
Eisler, R. M. (1995). The relationship between masculine gender research: A review and critique. Applied and Preventive
role stress and men’s health risk: The validation of a con- Psychology, 3, 1.
struct. In R. F. Levant & W. S. Pollack (Eds.), The new psy- Hall, S. S. (1999). The trouble life of boys. The New York Times
chology of men (pp. 207–225) New York: Basic Books. Magazine, August 22, 1999. pp. 31–65.
Eisler, R. M. & Skidman, J. R. (1987). Masculine gender role Harrison, J. (1978). Warning: The male sex role may be danger-
stress: Scale development and component factors in appraisal ous to your health. Journal of Social Issues, 34, 65–86.
of stressful situations. Behavior Modifications, 1, 123–136. Harway, M., & O’Neil J. M. (Eds.). (1999). What causes
Englar-Carlson, M., & Stevens, M. A. (Eds.). (2006). In the room men’s violence against women? Thousand Oaks, CA: Sage
with men: A casebook of therapeutic change. Washington, DC: Publications.
APA Books. Hayes, J. A., & Mahalik, J. R. (2000). Gender role conflict and
Englar-Carlson, M., & Vandiver, B. (2001, August). Gender psychological distress in male counseling center clients.
role conflict, help seeking, and treatment fearfulness. Psychology of Men and Masculinity, 2, 116–125.
In J. M. O’Neil & G. E. Good (Chairs). Gender role conflict Hayes, M. M. (1985). Counselor sex-role values and effects
research: Testing new constructs and dimensions empirically. on attitudes toward, and treatment of non-traditional male
Symposium conducted at the annual meeting of the American clients. (Doctoral dissertation, Ohio State University, 1985).
psychology Association, San Francisco. Dissertation Abstracts International, 45, 3072.
Englar-Carlson, M. (2001). Two causal models of white male Hays, H. R. (1964). The dangerous sex: The myth of feminine evil.
psychological help-seeking attitudes and preferences for New York: Pocket Books.
psychotherapy. (Doctoral dissertation, Penn State University, Heppner, P. P. (1995). On gender role conflict in men: Future
2001). Dissertation Abstracts International, 58, 1599. directions and implications for counseling. Journal of
Enns, C. Z. (2008). Toward a complexity paradigm for under- Counseling Psychology, 42, 20–23.
standing gender role conflict. The Counseling Psychologist, 36, Heppner, P. P., & Heppner, M. J. (2008). The gender role
446–454. conflict literature: Fruits of sustained commitment. The
Farrell, W. (1974). The liberated man. New York: Bantam Books. Counseling Psychologist, 36, 455–461.
Fasteau, M. F. (1974). The male machine. New York: McGraw Hoff Sommer, C. (2000). The war against boys: How feminism
Hill. is harming our young men. New York: Simon & Schuster.
Freud, S. (1937). Analysis terminable and interminable. Horne, A. M., & Kiselica, M. S. (1999). Handbook of counseling
In P. Rieff (Ed.), Freud: Therapy and techniques. (pp. 233–271). boys and adolescent males: A practitioner’s guide. Thousand
New York: Macmillan. Oaks, CA: Sage Publications.
Garnets, L., & Pleck, J. (1979). Sex role identity, androgyny, and Horney, K. (1967). Feminine psychology. New York: Norton.
sex role transcendence: A sex role strain analysis. Psychology of Jome, L. M., & Tokar, D. M. (1997). Dimensions of masculinity
Women Quarterly, 3, 270–283. and major choice traditionality. Journal of Vocational Behavior,
Gilbert, L. A., & Scher, M. (1999). Gender and sex in counseling 52, 120–134.
and psychotherapy. Boston, MA.: Allyn & Bacon. Johnson, N. G. (2001). Women helping men: Strengths of
Glicken, M. D. (2005). Working with troubled men: A contemporary and barriers to women therapists working with men clients.
practitioner’s guide. Mahwah, NJ: Lawrence Erlbaum Associates. In G. R. Brooks & G. E. Good (Eds.) The new handbook
Goldberg, H. (1977). The hazards of being male. New York: of psychotherapy and counseling with men: A comprehensive
New American Library. guide to settings, problems, and treatment approaches Vol. 2
Good, G. E., Dell, D. M., & Mintz, L. B. (1989). Male role and (pp. 696–718), San Francisco, CA: Jossey-Bass.
gender role conflict: Relations to help seeking in men. Journal Jung, K. (1953). Animus and anima. Collected Works, vol. 7,
of Counseling Psychology, 36, 295–300. New York: Pantheon.
Good, G. E., Gilbert, L. A., & Scher, M. (1990). Gender aware Jung, K. (1959). Concerning archetypes, with special reference to
therapy: A synthesis of feminist therapy and knowledge about the anima concept (1954). Collected Works, Vol. 9, Part I.
gender. Journal of Counseling and Development, 68, 376–380. New York: Pantheon.
Good, G. E., & Mintz, L. B. (2001). Integrative therapy Kearney, L., King, E. B., & Rochlen, A. B. (2004). Male gender
for men. In G. R. Brooks & G. E. Good (Eds.), The new role conflict, sexual harassment tolerance, and efficacy of a
handbook of psychotherapy and counseling with men: A compre- psychoeducative training program. Psychology of Men and
hensive guide to settings, problems, and treatment approaches, Masculinity, 5, 72–82.
Vol.2 (pp. 582–602). San Francisco, CA: Jossey-Bass. Kessler. R. C., & Walters, E. (2002). The national comorbidity
Good, G. E., Robertson, J. M., Fitzgerald, L. F., Stevens, M., & survey. In M. T. Tsuang & M. Tohen (Eds.) Psychiatric
Bartels, K. M. (1996). The relation between masculine Epidemiology, Second edition, (pp. 343–362). New York:
role conflict and psychological distress in male university Wiley.
counseling center clients. Journal of Counseling and Kilmartin, C. T. (2007). The masculine self. (Third Edition)
Development, 75, 44–49. Cornwall-on-Hudson, New York: Sloan Publishing.

404 the psycholo gy o f men

Kimmel, M. S. (Ed.). (1995). The politics of manhood: Profeminist Mahalik, J. R. (2001b). Interpersonal therapy for men.
men respond to the mythopoetic movement (and the mythopoetic In G. R. Brooks & G. E. Good (Eds.), The new handbook of
leaders answer. Philadelphia: Temple University Press. psychotherapy and counseling with men: A comprehensive
Kimmel, M. S. (2006). Manhood in America: A contextual history. guide to settings, problems, and treatment approaches, Vol. 2
New York: Oxford University Press. (pp. 565–581). San Francisco, CA: Jossey-Bass.
Kindlon, D. F., & Thompson, M. (1999). Raising Cain: Protecting Mahalik, J. R., Cournoyer, R., DeFranc, W., Cherry, M., &
the emotional life of boys. New York: Ballantine Books. Napolitano, J. M. (1998). Gender role conflict: Predictors of
Lazar, R. F. (1998). Men in family: A family system’s approach men’s utilization of psychological defenses. Journal of
to treating men. In W. S. Pollack & R. F. Levant (Eds.) Counseling Psychology, 45, 247–255.
New psychotherapy for men (pp. 127–144). New York: John Mahalik, J. R., Good, G. E., & Englar-Carlson, M. (2003a).
Wiley & Sons Inc. Masculinity scripts, presenting concerns, and help seeking:
Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal, and Implications for practice and training. Professional Psychology:
coping. New York: Springer. Research and Practice, 34, 123–131.
Lederer, W. (1968). The fear of women. New York: Harcourt, Mahalik, J. R., Locke, B. D., Ludlow, L. H., Diemer, M. A.,
Brace, Jovanovich. Scott, R. P., Gottfried, M., et al. (2003b). Development of
Lerner, R. M. (1992). Developmental systems theory: An integrative the Conformity to Masculine Norms Inventory. Psychology of
approach. Newbury Park, CA: Sage. Men and Masculinity, 4, 3–25.
Levant, R. F. (1995). Toward the reconstruction of masculinity. Mahalik, J. R., Morray, E. B., Coonerty-Femiano, A., Ludlow, L. H.,
In R. F., Levant & W. S. Pollack (Eds.), A new psychology of Slattery, S.M., & Smiler, A. (2005). Development of the
men. (229–251). New York: Basic Books. Conformity to Feminine Norms Inventory. Sex Roles, 52,
Levant, R. F. (1997). The masculinity crises. The Journal of Men’s 417–435.
Studies, 5, 221–231. Mansfield, A. K., Addis, M. E., & Courtenay, W. (2005).
Levant, R. F., Hirsch, L., Celentano, E., Cozza, T., Hill, S., Measurement of men’s help seeking: Development and eval-
MacRachorn, M., et al. (1992). The male role: An investiga- uation of the Barriers to Help Seeking Scale. Psychology of
tion of contemporary norms. Journal of Mental Health Men and Masculinity, 6, 95–108.
Counseling, 14, 325–337. Mellinger, T. N., & Liu, W.M. (2006). Men’s issues in doc-
Levant, R. F., & Richmond, K. (2007). A review of research toral training: A survey of Counseling Psychology Programs.
on masculinity ideologies using the Male Norm Inventory. Professional Psychology, Research, and Practice, 37, 196–204.
The Journal of Men’s Studies, 15, 130–146. Menninger, K. (1970). Love against hate. New York: Harcourt,
Levinson, D. J., Darrow, C. N., Klein, E. B., Levinson, M. H., Brace, Jovanovich.
& McKee, B. (1978). The season’s of a man’s life. New York: Mertens, C. E. (2000). Male gender role conflict in depressed versus
Ballantine Books. nondepressed medical populations (Doctoral dissertation,
Lewis, R. A., & Pleck, J. H. (Eds.). (1979). Special issue: Men’s University of Iowa, 2000). Dissertation Abstract International,
roles in the family. The Family Coordinator, 28, 429–646. 61, 3068.
Lisak, D. (2001). Male survivors of trauma. In G. R. Brooks & Miller, D. D, Forrest, L., & Elman, N. S. (2009). Training
G. E. Good (Eds.), The new handbook of psychotherapy directors’ conceptualizations of the intersection of diversity
and counseling with men: A comprehensive guide to set- and trainee competence problems: A preliminary analysis.
tings, problems, and treatment approaches (pp. 263–277). The Counseling Psychologist, 37, 482–518.
San Francisco, CA: Josses-Bass. Miville, M. L., Changming, D., Nutt, R. L., Waehler, C. A.,
Liu, W. M. (2005). The study of men and masculinity as an Suzuki, L., Pistole, M. C., Arredondo, P., Duffy, M.,
important multicultural competency consideration. Journal Mejia, B. X., Corpus, M, (2009). Integrating practice guide-
of Clinical Psychology, 61, (Wiley.Com) DOI: 10 1002/ lines into professional training: Implications for diversity
jclp.20/02. competence. The Counseling Psychologist, 37, 519–563.
Liu, W. M., Rochlen, A. B., & Mohr, J. (2005). Real and ideal Mooney, T. F. (1998). Cognitive behavior therapy for men.
gender role conflict: Exploring psychological distress among In W. S. Pollack & R. F. Levant (Eds.) New psychotherapy
men. Psychology of Men and Masculinity, 6, 137–148. for men (pp. 57–82). New York: John Wiley & Sons, Inc.
Lynch, J., & Kilmartin, C. T. (1999). The pain behind the mask: Mosher, D. L., & Sirkin, M. (1984). Measuring a macho person-
Overcoming masculine depression. Binghamton, New York: ality constellation. Journal of Research in Personality, 13,
Haworth. 150–163.
Magovcevic, M., & Addis, M. (2008). The Masculine Depression Mosher, D. L., & Tomkins, S. S. (1988). Scripting the macho
Scale: Development and psychometric evaluation. Psychology male: Hypermasculine socialization and enculturation. The
of Men and Masculinity, 9, 117–132. Journal of Sex Research, 25, 60–84.
Mahalik, J. R. (1999a). Incorporating a gender role strain per- Nabavi, R. (2004). The “Masculinity Attitudes, Stress, and
spective in assessing and treating men’s cognitive distortions. Conformity Questionnaire (MASC)”: A new measure for
Professional Psychology: Research and Practice, 30, 333–340. studying psychology of men (Doctoral dissertation, Alliant
Mahalik, J. R. (1999b). Interpersonal psychotherapy with men International University, 2004). Dissertation Abstracts
who experience gender role conflict. Professional Psychology: International, 65, 2641.
Research, and Practice, 30, 5–13. Nichols, J. (1975). Men liberation: A new definition of masculin-
Mahalik, J. R. (2001a). Cognitive therapy for men. In G. R. Brooks ity. New York: Penguin.
& G. E. Good (Eds.), The new handbook of psychotherapy Norton, J. (1997). Deconstructing the fear of femininity.
and counseling with men: A comprehensive guide to Feminism & Psychology, 7, 441–447.
settings, problems, and treatment approaches, Vol. 2 Noyes, B. B. (2004). Gender role conflict as a predictor of therapy
(pp. 544–564). San Francisco, CA: Jossey-Bass. outcome. Unpublished masters thesis, The University of Utah.

o’ne il 405
O’Neil, J. M. (1981a). Male sex-role conflict, sexism, and mas- O’Neil, J. M., Good, G. E., & Holmes, S. (1995). Fifteen years
culinity: Implications for men, women, and the counseling of theory and research on men’s gender role conflict: New
psychologist. The Counseling Psychologist, 9, 61–80. paradigms for empirical research. In R. Levant & W. Pollack
O’Neil, J. M. (1981b). Patterns of gender role conflict and strain: (Eds.), The new psychology of men (pp. 164–206). New York:
Sexism and fear of femininity in men’s lives. Personnel and Basic Books.
Guidance Journal, 60, 203–210. O’Neil, J. M., Helm, B., Gable, R., David, L., & Wrightsman, L.
O’Neil, J. M. (1982). Gender role conflict and strain in men’s (1986). Gender role conflict scale (GRCS): College men’s
lives: Implications for psychiatrists, psychologists, and other fears of femininity. Sex Roles, 14, 335–350.
human service providers. In K. Solomon & N. B. Levy O’Neil, J. M., & Lujan, M. L. (2009). Preventing boy’s problems
(Eds.), Men in transition: Changing male roles, theory, and in schools through psychoeducational programming: A call
therapy (pp. 5–44). New York: Plenum Publishing Co. to action. Psychology in the Schools, 46, 257–266.
O’Neil, J. M. (1990). Assessing men’s gender role conflict. O’Neil, J. M. & Lujan, M. L. (2010). An assessment paradigm
In D. Moore & F. Leafgren (Eds.), Men in conflict: Problem for fathers and men in therapy using gender role conflict
solving strategies and interventions (pp. 23–38). Alexandria, theory. In C. Z. Oren & D. C. Oren (Eds.) Counseling fathers
VA: American Association for Counseling and Development. (pp. 49–71). New York: Routledge.
O’Neil, J. M. (2004b). Special Focus: Teaching the Psychology of O’Neil, J. M., & Nadeau, R. A. (1999). Men’s gender-role
Men. SPSMM Bulletin, 10, 20–71. conflict, defense mechanism, and self-protective defensive
O’Neil, J. M. (2006). Helping Jack heal his emotional wounds: strategies: Explaining men’s violence against women from
The gender role conflict diagnostic schema. In M. Englar- a gender-role socialization perspective. In M. Harway &
Carlson & M. Stevens (Eds.), In the therapy room with men: J. M. O’Neil (Eds.), What causes men’s violence against women?
A casebook about psychotherapeutic process and change with (pp. 89–116). Thousand Oaks, CA: Sage Publications.
male clients (pp. 259–284). Washington, DC: American Pederson, E. L., & Vogel, D. L. (2007). Male gender role conflict
Psychological Association. and willingness to seek counseling: Testing a mediation
O’Neil, J. M. (2008a). Special issue. Men’s gender conflict: model on college-aged men. Journal of Counseling Psychology,
25 year research summary. The Counseling Psychologist, 36, 54, 373–384.
358–476. Persky, H. R., Daane, M. C., & Jin, Y. (2003). The nation’s
O’Neil, J. M. (2008b). Special Issue: Summarizing Twenty-five report card: Writing 2002. National Center for Educational
years of research on men’s gender role conflict using the Gender Statistics, Washington, DC.
Role Conflict Scale: New research paradigms and clinical Pleck, E. H., & Pleck, J. H. (1980). The American man.
implications. The Counseling Psychologist. 36, 358–445. Englewood Cliffs, NJ: Prentice-Hall Inc.
O’Neil, J. M. (2008c). Complexity, contextualism, and multi- Pleck, J. (1981). The myth of masculinity. Cambridge, MA: MIT
culturalism: Responses to the critiques and future directions Press.
for the gender role conflict research program. The Counseling Pleck, J. H. (1995). The gender role strain paradigm: An update.
Psychologist, 36, 469–476. In R. F. Levant & W. S. Pollack (Eds.), A new psychology of
O’Neil, J. M. (2011). Exploring the psychology of Russian men men (pp. 11–32). New York: Basic Books.
with Russian psychologists during my fulbright scholarship Pleck, J. H., & Sawyer, J. (1974). Men and masculinity.
in the former soviet union. In C. Blazina, C. & D. S. Shen- Englewood Cliffs, NJ: Prentice Hall.
Miller, (Eds.). An international psychology of men: Theoretical Pleck, J. H., Sonenstein, F. L., & Ku, L. C. (1993). Masculinity
advances, case studies, and clinical innovations. (pp. 361–383). ideology and its correlates. In S. Oskamp & M. Costanzo
New York: Routledge. (Eds.), Gender issues in social psychology (pp. 85–110).
O’Neil, J. M., Addis, M., Kilmartin, C., Mahalik, J. (2004). Newbury Park, CA: Sage Publications.
Teaching the Psychology of Men: A potential growth area for Pollack, W. (1995). No man is an island: Toward a new
psychology and Division 51: A report from the APA psychoanalytic psychology of men. In R. Levant &
Honolulu convention. SPSMM Bulletin, 10, 36–47. W. Pollack (Eds.), A new psychology of men (pp. 33–67).
O’Neil, J. M., & Egan, J. (1992a). Men’s and women’s gender New York: Basic Books.
role journeys: Metaphor for healing, transition, and transfor- Pollack, W. (1998a). Real boys: Rescuing our sons from the myths of
mation. In B. Wainrib (Ed.), Gender issues across the life cycle. boyhood. New York: Random House.
(pp. 107–123). New York: Springer Publishing Co. Pollack, W. S. (1998b). Mourning, melancholia, and masculinity:
O’Neil, J. M., & Egan, J. (1992b). Men’s gender role transitions Recognizing and treating depression in men. In W. S. Pollack
over the life span: Transformations and fears of femininity. & R. F. Levant (Eds.), New psychotherapy with men.
Journal of Mental Health Counseling 14, 305–324. (pp. 147–166), New York: Wiley.
O’Neil, J. M., & Egan, J. (1993). Abuses of power against Pollack, W. S. (1992). Should men treat women? Dilemmas for
women: Sexism, gender role conflict, and psychological vio- the male psychotherapist and psychoanalytic and develop-
lence. In E. Cook (Ed.), Women, relationships, and power: mental perspectives. Ethics and Behavior, 2, 39–49.
Implications for counseling (pp. 49–78). Alexandria, VA: ACA Pollack, W. S. (2000). Real boys’ voices. New York: Random
Press. House.
O’Neil, J. M., & Fishman, D. (1992). Adult men’s career transi- Pollack, W. S. (2001). “Masked men”: New psychoanalyti-
tions and gender role themes. In H. D. Lee & Z. B. Leibowitz cally oriented treatment models for adult and young men.
(Eds.), Adult career development: Concepts, issues, and Practices In G. Brooks & G. E. Good (Eds.), The new handbook of
(2nd ed., pp. 132–162). Alexandria, VA: ACA Press. psychotherapy and counseling with men: A comprehensive guide
O’Neil, J. M., Fishman, D. M., & Kinsella-Shaw, M. (1987). to settings, problems, and treatment approaches (pp. 525–543).
Dual-career couples’ career transitions and normative dilem- San Francisco: Jossey-Bass.
mas: A preliminary assessment model. The Counseling Pollack, W. S., & Levant, R. F. (1998). New psychotherapies
Psychologist, 15(1), 50–96. for men. New York: Wiley.

406 the psycholo gy o f men

Rabinowitz, F. E., & Cochran, S. V. (2002). Deepening psycho- Skovholt, T., Gormally, J., Schauble, P., & Davis, R. (Eds.).
therapy with men. Washington, DC: American Psychological (1978). Counseling men [Special Issue]. The Counseling
Association. Psychologist, 7.
Real, T. (1997). O don’t want to talk about it: Overcoming the Smiler, A. P. (2004). Thirty years after the discovery of gender:
legacy of male depression. New York: Fireside. Psychological concept and measures of masculinity. Sex Roles,
Robertson, J. M. (2001). Counseling men in college settings. 50, 15–26.
In G. Brooks & G. E. Good (Eds.), The new handbook Thompson, E. H., & Pleck, J. H. (1986). The structure of the
of psychotherapy and counseling with men: A comprehensive male norms. American Behavioral Scientist, 29, 531–543.
guide to settings, problems, and treatment approaches Vol. 1 Thompson, E. H., & Pleck, J. H. (1995). Masculinity ideologies:
(pp. 146–169). San Francisco: Jossey-Bass. A review of research instrumentation on men and masculini-
Robertson, J. M., & Fitzgerald, L. F. (1990). The (mis) treatment ties. In R. Levant & W. Pollack (Eds.), A new psychology of
of men: Effects of client gender role and life-style on diagno- men (pp. 129–163). New York: Basic Books.
sis and attribution of pathology. Journal of Counseling Thompson, E. H., Pleck, J. H., & Ferrera, D. L. (1992). Men
Psychology, 37, 3–9. and masculinity: Scales for masculinity ideology and mascu-
Robertson, J. M., & Fitzgerald, L. F. (1992). Overcoming the linity-related constructs. Sex Roles, 27 (11/12), 573–607.
masculine mystique: Preferences for alternative forms of Thomson, P. (1995). Men’s sexual abuse: Object relations, gender
assistance among men who avoid counseling. Journal of role conflict, and guilt. (Doctoral dissertation, Adelphi
Counseling Psychology, 39, 240–246. University, 1995). Dissertation Abstracts International, 56,
Robin, L., & Reiger, D. (1991). Psychiatric disorders in America, 3467.
New York: Free Press. Tokar, D. M., & Jome, L. M. (1998). Masculinity, vocational
Rochlen, A. B. (2005). Men in (and out) of therapy: Central interests, and career choice traditionality: Evidence for a fully
concepts, emerging directions, and remaining challenges. mediated model. Journal of Counseling Psychology, 45,
Journal of Clinical Psychology, published online. Wiley 424–435.
Interscience, 10, 1002, 1–5. Trautner, H. M., & Eckes, T. (2000). Putting gender develop-
Rochlen, A. B., Blazina, C., & Raghunathan, R. (2002). Gender ment into context: Problems and prospects. In T. Eckes &
role conflict, attitudes toward career counseling, career deci- H. Trautner (Eds.), The developmental social psychology of
sion making, and perceptions of career advertising brochures. gender (pp. 419–435). Mahwah, NJ: Lawrence Erlbaum.
Psychology of Men and Masculinity, 3, 127–137. Tyre, P. (2006). The trouble with boys. TIME Magazine,
Rochlen, A. B., & Hoyer, W. D. (2005). Marketing mental pp. 44–52.
health to men: Theoretical and practical consideration. United States Census Department. (1998). United States Census
Journal of Clinical Psychology, 61, 675–684 (Wiley.com) Department Report. Washington, DC: Author.
DOI: 10 1002/jclp.20102. United States Census Bureau. (2005). School enrollment–social
Rochlen, A. B., McKelley, R. A., & Pituch, K. A. (2006). A pre- and economic characteristics of students: October, 2003,
liminary examination of the “Real Men. Real Depression” May 2005. U.S. Census Bureau, U.S. Department of
campaign. Psychology of Men and Masculinity, 7, 1–13. Commerce, Economic and Statistical Administration,
Rochlen, A. B., & O’Brien, K. M. (2002). The relation of male Washington, DC: Author.
gender role conflict and attitudes toward career counseling Van Delft, C. W. (1998). Gender role conflict and psychological
to interest in and preference for career counseling styles. distress in army men. Unpublished Master’s thesis, University
Psychology of Men and Masculinity, 3, 9–21. of Maryland.
Rotundo, E. A. (1993). American manhood: Transformation in Vessey, J., & Howard, K. (1993). Who seeks psychotherapy?
masculinity from the revolution to the modern era. New York: Psychotherapy, 30, 546–553.
Basic Books. Vogel, D. L., Wade, N. G., Wester, S. R., Larson, L., &
Sackett, D. L., Straus, S. E., Richardson, W. S., Rosenberg, W., Hackler, A. H. (2007). Seeking help from a mental health
& Haynes, R. B. (2000). Evidence based medicine: How to professional: The influence of one’s social network. Journal
practice and teach (2nd ed.) London: Churchill, Livingston. of Clinical Psychology, 63, 233–245.
Schaub, M., & Williams, C. (2007). Examining the relations Von Drehle, D. (2007). The Boys are all right. TIME Magazine,
between masculine gender role conflict and men’s expecta- pp. 38–47.
tions about counseling. Psychology of Men and Masculinity, 8, Wade, J. C. (2008). Masculinity ideology, male reference group
40–52. identity dependence, and African American men’s health
Scher, M. (Ed.). (1981). Special Issue: Counseling men. Personnel related attitudes and behaviors. Psychology of Men and
and Guidance Journal, 60, 198–264. Masculinity, 9, 5–16.
Scher, M., Stevens, M., Good, G. E., & Eichenfield, G. (Eds.). Wade, J. C., & Brittan-Powell, C. (2001). Men’s attitude toward
(1987). Handbook of counseling and psychotherapy with men. race and gender equity: The importance of masculinity ideol-
Newbury Park, CA: Sage. ogy, gender-related traits, and reference group identity depen-
Schwartz, J. P., Magee, M. M., Griffin, L. D., Dupius, W. (2004). dence. Psychology of Men and Masculinity, 2, 42–50.
Effects of a group preventive intervention on risk and protec- Wade, J. C., & Gelso, C. J. (1998). Reference group identity
tive factors related to dating violence. Group Dynamics: dependence scale: A measure of male identity. The Counseling
Theory, Research, and Practice, 8, 221–231. Psychologist, 26, 384–412.
Schwartz, J. P., & Waldo, M. (2003). Reducing gender role con- Wester, S. R. (2008a). Male gender role conflict and multicultur-
flict among men attending partner abuse prevention. Journal alism: Implications for counseling psychology. The Counseling
for Specialist in Group Work, 20, 1–15. Psychologist. 35, 294–324.
Silverstein, L. B. (2006). Integrating feminism and multicultur- Wester, S. R. (2008b). Thinking complexly about men, gender
alism: Scientific fact or science fiction? Professional Psychology: role conflict, and Counseling Psychology. The Counseling
Research and Practice, 37, 21–28. Psychologist, 36, 462–468.

o’ne il 407
Wester, S. R., & Vogel, D. L. (2002). Working with masculine Brooks, G. R. (2010). Beyond the crisis of masculinity: A transtheo-
mystique: Male gender role conflict, counseling self-efficacy retical model for male-friendly therapy. Washington, DC:
and the training of male psychologists. Professional Psychology, American Psychological Association. (Not reviewed in this
Research, and Practice, 33, 370–376. chapter but recommended)
Wisch, A., & Mahalik, J. R. (1999). Male therapists’ Brooks, G. R., & Good, G. E. (Eds.). (2001a). The new hand-
clinical bias: Influence of client gender roles and therapist book of psychotherapy and counseling with men: A comprehen-
gender role conflict. Journal of Counseling Psychology, 46, sive guide to settings, problems, and treatment approaches.
51–60. San Francisco: Jossey-Bass.
Wisch, A. F., Mahalik, J. R., Hayes, J. A., & Nutt, E. A. (1995). Englar-Carlson, M., & Stevens, M. A. (Eds.). (2006). In the room
The impact of gender role conflict and counseling technique with men: A casebook of therapeutic change. Washington, DC:
on psychological help seeking men. Sex Roles, 33, 77–89. APA Books.
Wong, M. R. (1982). Psychoanalytic-developmental theory Kilmartin, C. T. (2007). The masculine self. (Third Edition)
and the development of male gender role identity. Cornwall-on-Hudson, New York: Sloan Publishing.
In K. Soloman & N. B. Levy (Eds.) Men in transition: Theory Levant, R. F., & Pollack, W. S. (1995). The new psychology of men.
and therapy (pp. 5–44). New York: Basic Books.
Wong, Y. J., & Rochlen, A. B. (2005). Demystifying men’s O’Neil, J. M. (2008). Special Issue: Summarizing Twenty-
emotional behavior: New directions and implications for five years of research on men’s gender role conflict using
counseling and research. Psychology of Men and Masculinity, the Gender Role Conflict Scale: New research paradigms
6, 62–72. and clinical implications. The Counseling Psychologist. 36,
358–445.
Rabinowitz, F. E. & Cochran, S. V. (2002). Deepening psycho-
Further Readings
therapy with men. Washington, DC: American Psychological
Blazina, C., & Shen-Miller, D. S. (2011). An international psy- Association.
chology of men: Theoretical advances, case studies, and clinical
innovations. New York: Routledge.

408 the psycholo gy o f men

 CHAPTER

15 Sexual Orientations and Identities

Susan L. Morrow

Abstract
This chapter addresses critical issues for counseling psychologists regarding sexual minority people.
The first section lays the groundwork for the chapter by defining relevant terms and framing sexual
orientations and identities in a social constructionist context. Then, assumptions and values of
counseling psychologists that are relevant to lesbian, gay, bisexual, and transgender (LGBT)
orientations and identities are clarified. The second section of the chapter focuses on research issues
with LGBT people. Next, the chapter explores sexual orientations and identities in the identity
development process and in coming out. Finally, it addresses LGBT-affirmative counseling and
psychotherapy, including multicultural competence in working with sexual minorities, relationship and
family issues, spiritual and religious issues, and multiple identities and intersections. It ends with
a call for activism on the part of counseling psychologists and identifies future directions for counseling
psychology research and practice.
Keywords: lesbian, gay, bisexual, transgender, LGBT, sexual minority, sexual orientation,
sexual identity

Since our entry into the field of lesbian, gay, and Psychological Association (APA) issued a statement
bisexual (LGB) psychologies in the early 1990s, deploring discrimination against lesbian women and
counseling psychologists have been major contri- gay men and urging the repeal of discriminatory legis-
butors to the evolution of lesbian, gay, bisexual, lation against them (Conger, 1975), and 35 years after
and transgender (LGBT) research and practice in the first article on LGB issues appeared in the Journal
psychology. Several themes have emerged, includ- of Counseling Psychology (Haselkorn, 1956). The spe-
ing a move from pathology to affirmation, LGBT- cial issue of TCP included an overview of the then-
affirmative practice, developmental issues, and current issues related to research and practice with
intersections of identities and contexts (Croteau, lesbian women and gay men (Fassinger, 1991b); affir-
Bieschke, Fassinger, & Manning, 2008). mative psychotherapy with lesbian women (Browning,
To understand LGBT issues relative to counseling Reynolds, & Dworkin, 1991) and gay men (Shannon
psychology, it is important to examine the context and & Woods, 1991); training issues for therapists work-
rationale for addressing sexual orientations and identi- ing with lesbian women and gay men (Buhrke &
ties in our field. Counseling psychologists actively Douce, 1991); and work and career issues of lesbian
entered the dialog about sexual orientations and iden- women (Morgan & Brown, 1991).
tities with the publication of a landmark special issue Additionally, although gender was addressed as
of The Counseling Psychologist (TCP) in 1991, edited a “special populations” issue in the first and second
by Fassinger (1991a), on lesbian/gay affirmative coun- editions of Brown and Lent’s (1984, 1992) Hand-
seling practice. This came 16 years after the American book of Counseling Psychology, it was not until the

409
third and fourth editions (Brown & Lent, 2000, and other gendered and sexual categories are
2008) that sexual orientations and identities were overwhelmingly determined by social as opposed to
included. Thus, counseling psychologists were slow biological factors. This perspective is in direct con-
on the uptake of addressing LGBT issues in psy- trast with an essentialist perspective, which views
chology; we have, however, since our serious entry gender and sexual orientation as immutable char-
into the dialogue, been major contributors to acteristics often attached to biology (Broido, 2000).
research and scholarship in this area. In addition As I will discuss later, individuals with biological
to the 1991 special issue of TCP, the field has seen characteristics of female or male sex who deviate
three additional major contribution issues of TCP, from their expected gender roles are often subject
as well as numerous empirical articles and recent to persecution, regardless of their sexual orienta-
special issues of the Journal of Counseling Psychology tion. As Fukuyama and Ferguson (2000) argued,
(JCP) on “Advances in Research with Sexual “Homophobia . . . has been used as a means to
Minority People” (2009) and of TCP on “Research enforce traditional gender role behavior” (p. 85).
with Lesbian, Gay, and Bisexual People of Color” Thus, gender and sexuality are magnificently con-
(Moradi, DeBlaere, & Huang, 2010a). In addition, founded, and contemporary research often magni-
counseling psychologists have been active contri- fies, rather than necessarily clarifying, the confusion
butors to LGB scholarship in psychology journals over the relationships between the two (Fassinger,
outside counseling psychology. 2000).
Nonetheless, Croteau et al. (2008) challenged In her in-depth discussion of the intersections
the role of counseling psychologists in adequately of sex, gender, and sexuality, Fassinger (2000) pro-
dealing with issues related to sexual minority peo- vided concise definitions and a critical analysis of
ple, noting that our entry into the study of sexual terminology addressing sex, gender, sexuality, and
orientation came late. And, although counseling identity. At biological, psychological, and sociopo-
psychology takes an affirmative and nonpatho- litical levels, these intersections and definitions are
logizing stance toward LGBT people, this stance relevant to understanding the psychology of sex-
tends to be “often shallow, affirming that ‘gay is ual orientations and identities. Biological sex is
okay’ but failing to promote advocacy that would often confounded with gender, creating confusion
change systemic inequalities and heterosexist and misunderstanding on the part of medical
norms” (Croteau et al., 2008, p. 196; see also and psychological professionals, as well as the lay
Bieschke, Croteau, Lark, & Vandiver, 2005). public. When a child is born, numerous factors
Croteau et al. called for a new paradigm to address come into play that determine how that child will
the complexities of intersecting identities and con- be responded to, interpersonally and culturally,
textual factors (such as race, class, and gender), to as well as how that child will come to a self-identity.
include the experiences of bisexual and transgender Often, the first thing new parents look at when
people, and to examine multiple pathways toward an infant slips from the womb is the genitalia. With
developing identity. unambiguous genitalia, medical professionals and
This chapter will attempt to address those con- parents make a decision that the child is a boy or
cerns. To begin, in this introductory section, I have a girl based on external appearance, and the social-
included a section on definitions and dilemmas ization process begins from that point (it may have
related to the language used to describe sexual ori- begun even earlier if the parents knew the sex of
entations and identities that honors the complexity the child prior to birth). With ambiguous genitalia,
and fluidity of diverse, evolving, and self-defining chromosomal configuration, gonads, internal repro-
sexual minority people. ductive structures, external genitalia, hormonal
secretions, sex assigned at birth, and psychological
Language: Definitions and Dilemmas sex or gender identity all come into play to define
Over time, language and definitions related to sexual what is commonly thought of as the child’s biologi-
orientations and identities have expanded and cal sex (Shively & DeSecco, 1993) and determine
evolved and continue to do so at a rapid rate. This how that child is responded to as a gendered being.
chapter takes a social constructionist view of gender Thus, the apparent or assigned biological sex of
and sexual orientation (Hare-Mustin & Marecek, a child at birth determines how future socializa-
1990), arguing that our working definitions of tion will proceed, regardless of whether the child’s
women and men, lesbian women and gay men, biological sex is congruent with that child’s emer-
bisexual women and men, transgender individuals, gent gender identity. As Fassinger (2000) argued,

410 sexual orie n tatio n s an d id en tities

“Societal preoccupation with categorizing people and affectional orientation (Shively & De Cecco,
as males or females suggests difficulty in making 1993). Although traditionally sexual orientation
sense of those who do not fit neatly into these two has been seen along a bipolar continuum with het-
categories (e.g., intersexed or transgendered indi- erosexuality at one end and homosexuality at the
viduals), and general resistance to viewing human other, and bisexuality in the middle of the contin-
sexuality on the continuum that is generally thought uum (Kinsey, Pomeroy, & Martin, 1948; Kinsey,
to characterize this trait (Bohan, 1996; Fausto- Pomeroy, Martin, & Gebhard, 1953), there are
Sterling, 1998)” (p. 347). multiple dimensions to a person’s sexual orientation,
A number of circumstances have converged to including sexual attraction, desire, fantasy, feelings
create confusion about terminology used to describe of romantic love, actual sexual behaviors and his-
the broad umbrella of human sexuality, particularly tory, relationship history, community of support,
related to sexual orientations and identities (Moradi, patterns of intimacy, and even political affiliations
Mohr, Worthington, & Fassinger, 2009). Imprecise (Fassinger, 2000). Furthermore, an individual may
use of language has led to the terms sex and gen- be only situationally engaged in a sexual or affec-
der being used interchangeably. Essentialist per- tional relationship with a person of the same sex
spectives on sex would have us believe that there are (e.g., while in a sex-segregated environment such as
two biological sexes, male and female. In fact, 1 in prison) or may have a more enduring orientation
2,000 babies are born intersexed, with both female (Keys, 2002).
and male characteristics (Green, 2000). They are Sexual orientation identity relates to the way in
part of a larger transgender or gender variant popula- which an individual defines her or his sexual orien-
tion comprised of individuals whose biological, tation. The term sexual identity has typically been
behavioral, or psychological make-up runs counter used to describe sexual orientation identity; how-
to traditional notions of gender roles (Moradi et al., ever, properly used, sexual identity refers to one’s
2009). These individuals may identify as “transsex- identity regarding the full range of the “broadest
ual, gender queer, genderblend, drag king, drag dimensions of human sexual behavior, such as sexual
queen, and androgyne” (Moradi et al., 2009, p. 7), values and mores, sexual needs and preferences for
as well as male-to-female (MTF) transsexuals or sexual activities, and preferred modes of sexual
transwomen, female-to-male (FTM) transsexuals expression” (Moradi et al., 2009, p. 6). Sexual orien-
or transmen; or they may reject labels and not tation identity may or may not be congruent with
identify at all. sexual orientation itself (Bailey, 2003). For example,
In addition to confusion about sex and gender, a young woman may have dated men through-
a historical confusion regarding gender expression out high school, then fallen in love with her college
and sexual orientation has led to myths and stereo- roommate. The two may engage in a romantic
types about people who “transgress” traditional and sexual relationship while still identifying them-
gender roles (Fassinger & Arseneau, 2007). Thus, selves as heterosexual, either relating romantically
parents worry when their little boys are not mas- only to each other or continuing to relate to men
culine enough, or when their little tomboys don’t as well. Cultural variables may also be at play in
reject their pigtails in favor of dresses at the proper identity (DeBlaere, Brewster, Sarkees, & Moradi,
age. The underlying fears expressed over these depar- 2010). For example, Latino and African American
tures from accepted gender roles center around men may have sex with both men and women but
the belief that the child will grow up to be gay or not identify as gay or bisexual (Wolitski, Jones,
lesbian. So common is this confusion that gender- Wasserman, & Smith, 2006). In addition, active
nontraditional youth and adults are subject to or receptive (top/bottom) sexual behaviors may be
anti-gay violence, even if they are heterosexual. As more defining than sex of partner in some Latin
Moradi et al. (2009) noted, “Both same-sex- American communities (Zea, Reisen, & Díaz, 2003).
oriented and other-sex-oriented people exhibit both Among some American Indian communities, indi-
same-sex and other-sex behavior” (p. 7). viduals who are either gender-nontraditional or
A complex set of biological and cultural factors who engage in same-gender sexual behavior may be
determine a person’s gender identity, as well as one’s referred to as “two spirit” (Adams & Phillips, 2006).
sexual orientation. Sexual orientation refers to an Consistent with numerous cross-cultural examples
individual’s sexual attraction to women, men, or of the blending of concepts of gender roles and
both (Bailey, 2003). The term sexual orientation may sexual orientation identities, women in Thailand
more accurately be viewed as shorthand for sexual whose sexual orientation is to other women are

m or row 411
referred to as thoms (similar to the concept of “tom- have been seen as primarily sexual; resistance to
boys”) and dees (“ladies”). Thoms, although having these labels comes from their insistence on being
masculine characteristics, also value feminine, nur- viewed as whole people. The term sexual and affec-
turing behaviors, and may see themselves as a third tional orientation has become a preferred way to
sex (Thaweesit, 2004). describe sexual orientation because it does not imply
Sexual orientation identities can be very confus- that same sex-attracted people are only sexual.
ing to the uninitiated (and even to those who are Despite the inadequacy of selecting terminology
members of those communities), and definitions to describe people according to their preferences,
and preferences for labels—or for no labels at all— I will, for the most part, use the terms lesbian and
are constantly in flux. The terms heterosexual, bisex- gay to describe predominantly same-sex attracted
ual, and homosexual have been used consistently women and men in this chapter, except when dis-
over time, but although they may provide a some- cussing individuals in religious conflict or others
what accurate description of sexual orientations who acknowledge same-sex attractions but actively
(especially when placed on continua), they often do reject the terms.
not adequately express sexual orientation identities. Bisexuality has been a much-neglected topic in
Heterosexuality describes the orientation of being the counseling psychology literature. Bisexual women
sexually or affectionally attracted to a person of the and men are individuals whose sexual and affectional
opposite sex, and a heterosexual person may also be orientations are toward both women and men. Their
described as straight. Some heterosexual people attractions may be equally strong toward both gen-
prefer not to be called “straight” because of the ders, or they may be more strongly attracted to one
implications that such an identity is rigid, giving rise gender or the other. It may be more accurate to say
to the slogan, “Straight but Not Narrow” espoused that bisexual individuals are attracted to people, not
by some progressive heterosexual people. Homo- genders (Diamond, 2008). Historically, with the
sexuality is the term that has been used over time to emergence of an affirmative approach toward lesbi-
describe people whose sexual and affectional orienta- ans and gay men, bisexuality was viewed as a “stage”
tions are toward individuals of the same sex. The along the path to successfully “coming out” as gay or
term homosexual, although commonly used, has lesbian; individuals who expressed a bisexual identity
fallen into disfavor among many lesbian, gay, and were seen as having foreclosed on a healthy resolu-
bisexual activists because of its medical and pejora- tion of their presumed lesbian or gay identity (Fox,
tive history and implications. Terms used to describe 1996). This view reflected the dichotomous perspec-
people who are attracted to members of their same tive on sexual orientation articulated by Kinsey and
sex include gay, gay men, gay women, lesbian, same-sex his colleagues (1948, 1953), as well as the psycho-
attracted (SSA), men who have sex with men (MSM), analytic view that human beings were predisposed to
and women who have sex with women (WSW), along bisexuality in childhood and evolved into healthy
with numerous “code” labels that enable people in heterosexuality as adults. Bisexuality in adults, then,
their respective communities to communicate with was seen as an arrested state of development (Fox,
one another. Just as it is difficult for the culturally 1996). Even after the American Psychiatric Asso-
sensitive counselor or researcher to know the most ciation (followed later by the American Psychological
accessible and appropriate terms to use to describe Association) removed homosexuality from its diag-
various cultural groups, this plethora of terms is nostic list of disorders, pathologizing views of bisex-
fraught with confusion and contradiction. Some uality persisted. However, just as research on
individuals who are attracted to members of their homosexuality has failed to find a link to pathology,
same sex do not identify as gay or lesbian, sometimes research on bisexuality has also failed to find such
because of fear and sometimes because they do not a link. In fact, bisexuals have been found to have
identify with what they think of as “the gay (or les- high self-esteem, positive self-concept, assertiveness,
bian) community.” This may be particularly the case and cognitive flexibility (Fox, 1996).
for individuals who experience religious conflict over Complicating any discussion of sexual orienta-
their sexual orientation. Conversely, “out and proud” tions and identities is the debate about so-called
lesbians and gay men may be offended at being sexual preference. People have asked for decades
called “same-sex attracted” because of its association whether sexual orientation is innate or acquired,
with religious conservatism. The terms MSM and as well as if it can be changed. Unfortunately, polit-
WSW may be unappealing to many gay men and ical agendas have led this debate, with gay activ-
lesbian women, as historically gay and lesbian people ists arguing that, because sexual orientation is

412 sexual orie n tatio n s an d id en tities

biological and stable, lesbians and gay men cannot Transgender issues add further complexity to
be “blamed” for their orientations. Led primarily by the discussion of sexual orientations and identities.
the religious right, the view that sexual orientation The term transgender may be seen as an umbrella
is chosen, or at least acquired, is used to illustrate term that encompasses a broad range of gender-
that it can also be changed. Each side calls upon the variant experiences, behaviors, and bodies in which
“science” that supports its position. As Bailey (2003) individuals’ gender expression, behaviors, or bodies
suggested, this argument is largely unproductive, differ from traditional notions of masculinity
because research into hormonal and neuroendo- or femininity (Lev, 2007; Sánchez & Vilain, 2009),
crine contributors to sexual orientation has not been including “cross-dressers, transsexuals and transgen-
conclusive. The more important question regards derists, male-to-female transsexuals (MTFs), female-
the motives of those who promote the different per- to-male transsexuals (FTMs), androgynes, feminine
spectives and the consequences that these debates gay men, butch lesbians, drag queens [and kings],
have for lesbian, gay, and bisexual people in their heterosexual as well as gender-bent queers, . . . two-
family, religious, occupational, and social lives. spirit and intersex people,” (Lev, p. 151) and
Confounding discussions of sexual orientations eunuchs (Vale et al., in press; Wassersug & Johnson,
and identities are recent theory and research regard- 2007). Transsexual individuals are those whose
ing the fluidity of sexual orientation (Diamond, physical bodies do not represent what they experi-
2000). In a study of lesbian, bisexual, and “unlabeled” ence as their true sex (Lev), and they may or may
same-sex-attracted women, Diamond found that not seek sexual reassignment. They are properly
half of women changed their sexual orientation iden- referred to by the gender designation (man, woman)
tities in a 2-year period, although their attractions and pronouns that fit the gender they experience
changed very little. Based on her longitudinal as true for them or toward which they are transi-
research, Diamond (2005) identified subtypes of tioning. Thus, a FTM transsexual would be referred
women who experienced attractions to women: to as a man (or sometimes transman). So strongly
Those who had maintained consistent lesbian identi- are gender and sexual orientation blurred in our
fications over an 8-year span, whom she described as culture that transgender status has historically
stable lesbians; those who had alternated between les- been conflated with sexual orientation, so that male
bian and nonlesbian labels, described as fluid lesbians; cross-dressers have been thought of as gay, as have
and stable nonlesbians, who had never adopted the gender-nonconforming heterosexuals been assumed
label of lesbian. The notion of fluidity does not neces- to be gay or lesbian. However, cross-dressers may be
sarily deny a biological component. Diamond (2008) heterosexual, and gender expression is not necessar-
views “sexual feelings and experiences as simultane- ily related to sexual orientation.
ously embedded in both physical–biological and Queer, like transgender, is an umbrella term
sociocultural contexts” (p. 22) and suggests that that is sometimes used to cover the universe
women’s sexual attractions are more influenced by of LGBTQIA (Lesbian-Gay-Bisexual-Transgender-
environmental processes than are those of men. It Queer-Intersex-Ally) or LGBTQQIA (to include
should also be noted that, according to Diamond “Questioning”) individuals and communities. What
(2008), many, but not all, women who experience is common across this universe is gender “transgres-
attractions to other women have fluid identities, leav- sion” (Fassinger & Arseneau, 2007), even though
ing a significant number who were stable lesbians. the specific demonstrations of gender nonconfor-
The stability or instability of sexual orientation iden- mity are highly variable and subject to different
tities is highly political. At a time when the religious consequences in society at large, as well as in the
right insists that sexual orientation is a choice and medical and psychological arenas. The term “queer”
therefore subject to change, many sexual minorities was historically used pejoratively to describe LGB
are forced to defend the stability of their gay or les- people; LGB activists reclaimed the term in order
bian orientations. Despite evidence of fluidity in to dismantle its power and use it to express pride. Its
women, many lesbians and the majority of gay men current usage, in addition to being the umbrella
experience their same-sex orientations as immutable. described above, has emerged within queer theory
Many who have made attempts to change their ori- and describes individuals and a movement that
entations through conversion therapies have spoken attempt to deconstruct and undermine gendered
of the harms they endured both during and long after categories (Carroll & Gilroy, 2001). Thus, an indi-
such therapies (Beckstead & Morrow, 2004; Shidlo vidual identifying as gender-queer may identify
& Schroeder, 2002). as other than a man or a woman, as both male

m or row 413
and female, or as neither; or the individual may Wrenn’s (1962) concern about the culturally
reject the gender binary altogether. encapsulated counselor is still relevant today, despite
In some sense, the contradictions and dilemmas counseling psychology’s commitments to multicul-
identified above reflect the challenges in dealing turalism and social justice. Our field’s commitment
adequately with constructs of sexual orientations to looking at the individual in her or his cultural
and identities, as we are faced with constantly context is a core value of counseling psychology, and
changing terminology couched in an essentialist it is important that we not lose sight of what this
context while trying to talk meaningfully about means in the lives of LGBT people. Social move-
individuals, groups, and communities that are over- ments have accomplished great things. But, just as
whelmingly diverse and constantly changing. Given we do not live in a “postracial” society with the
these dilemmas, it is important to point out that election of a black president of the United States,
individuals may or may not find the terminology LGBT people—despite significant gains—continue
that is used to describe their experience relevant or to face barriers to employment and parenthood;
even acceptable. Thus, counseling psychologists face rejection by families, churches, and communities;
particular challenges as they attempt to find a com- and violence.
mon language among themselves and with their The cultural and political contexts of the lives
research participants and clients. These challenges of LGBT people in the United States are filled with
will be further addressed in subsequent sections contradictions. On the one hand, media increas-
of this chapter. Next, in striving for greater clarity, ingly portray sexual minorities in a positive light
I articulate some underlying values and assumptions and as the complex human beings that they are.
in counseling psychology related to sexual orienta- In urban areas and on the Internet, increasing num-
tions and identities and sexual minority people that bers and diversity of support networks are available
ground this chapter. for LGBT people from their teens to old age. In a
few jurisdictions, same-sex marriages, civil unions,
Assumptions and Values Underlying and adoptions have passed into law. At the same
This Chapter time, conservative political backlash has frequently
A number of premises underlie the perspectives pulled the civil rights rug out from under the feet
of counseling psychology regarding sexual orienta- of LGBT people and families. California’s Proposi-
tions and identities and LGBT people. These prem- tion 8, restricting marriage to opposite-sex couples,
ises are not without contradictions. In this section, was a massive blow to same-sex couples and their
I address the individual in context, violence in the families everywhere. According to DOMA Watch
lives of LGBT people, and the mental health treat- (http://www.domawatch.org/index.php, retrieved
ment of LGBT people. June 6, 2010), an organization dedicated to keep-
ing the public aware of the legal issues related to
The Individual in Context the Defense of Marriage Acts (DOMA), 37 states
Despite our historical valuing of context, counseling have such acts on their books, whereas 30 have
psychologists have a tendency to “psychologize” and actual constitutional amendments to restrict mar-
decontextualize the behaviors, emotions, and experi- riage to one man and one woman. These U.S. trends
ences of the human beings we counsel and study. are interesting in light of increasing acceptance of
Even LGBT-affirmative therapists adhere to stage same-sex marriage in many other countries. Spain, a
models to describe the development of LGB indi- largely Catholic country, was the third country in
viduals, and therapists who advocate for transsex- the world to legalize same-sex marriage in 2005.
ual clients are forced to use the Diagnostic and Other contemporary sociopolitico-cultural cli-
Statistical Manual (DSM; American Psychiatric Asso- mate issues include ongoing controversy over the
ciation, 2000b) diagnosis of gender identity disorder “Don’t Ask—Don’t Tell” (DADT; “House passes,”
to support their clients’ process of sexual reassign- 2010) military policy in which, since the passage
ment. In psychologizing the experiences of LGBT of Department of Defense (DOD) Directive
individuals, we run the risk of ignoring the contexts 1304.26 introduced by President Bill Clinton in
of their lives, as well as of pathologizing them. Two 1993, military personnel are not to be pursued
core counseling psychology values thus are violated: regarding information about their sexual orienta-
viewing human beings from a positive perspective as tions. Originally seen as a step forward in the rights
individuals who are coping with life stressors, and of LGB women and men in the military, it left
viewing individuals in the context of their lives. in place the longstanding policy that homosexuality

414 sexual orie n tatio n s an d id en tities

is incompatible with military service (DOD Direc- history of psychiatric and psychological perspectives
tive 1332.14, 1982). At present, the U.S. House of on same-sex orientations, people who were attracted
Representatives and the Senate Armed Forces Com- to or had sex with people of the same sex were
mittee have both voted in favor of repealing DADT viewed as mentally disturbed. Freud held an ambiv-
(“House Passes,” 2010). alent attitude toward homosexuality, insisting that
Despite notable progress, the civil liberties of it was not an illness (although seeing it as resulting
LGBT people continue to be challenged. Conser- from arrested sexual development) and, for his time,
vative backlash is strong, and violence against sexual adopting an affirmative stance toward homosexuals
minorities is a serious problem worldwide. (Rothblum, 2000). On the one hand, he considered
humans as psychologically bisexual; on the other,
Violence in the Lives of LGBT People he believed that homosexual feelings should be sub-
The history of violence toward individuals whose limated and pursued treatments to help his patients
sexual orientation is toward individuals of their own do so (Rothblum, 2000). Current-day conversion
gender is shocking. Both Europe and the United therapists built upon psychoanalytic theory; how-
States have early histories of castrating, mutilating, ever, they do not agree with Freud that people are
or putting to death people who engaged in same-sex innately bisexual, instead viewing homosexuality
sexual behaviors. Between 5,000 and 15,000 homo- as pathological and a result of faulty parent– (espe-
sexuals were put to death in Nazi prison camps in cially mother–) child relationships. Conversion
World War II (Herek, Berrill, & Berrill, 1992). (also known as “reparative” or “reorientation”) ther-
By the early 1990s, increasing numbers of lesbian apies have been demonstrated to be ineffective and
women and gay men were out of the closet, accom- often harmful (Haldeman, 1994; 2004); however,
panied by rapidly increasing anti-gay and lesbian they continue to be used, particularly by conser-
violence (Herek et al., 1992). The National Gay and vative, religiously oriented practitioners (Beckstead
Lesbian Task Force (http://www.thetaskforce.org/ & Israel, 2007). In addition to psychoanalytically
issues/hate_crimes_main_page) reported that, after based approaches to same-sex attractions, efforts to
27 years of antiviolence work by the NGLTF, “cure” homosexuality have included surgeries, elec-
President Barack Obama signed into law the troconvulsive treatments, hormonal therapies, and
Matthew Shepard and James Byrd, Jr. Hate Crimes behavioral and cognitive behavioral treatments
Prevention Act, which extended hate crimes legisla- (Morrow & Beckstead, 2004). In 1973 and 1975,
tion in the United States to include sexual orienta- respectively, the American Psychiatric Association
tion and gender identity, on October 28, 2009. and the American Psychological Association declas-
In November 2009, the National Transgender sified homosexuality as a mental disorder; and, at
Discrimination Survey, conducted by the National present, most mental health professions have issued
Center for Transgender Equality and the NGLTF, statements confirming the view that lesbian, gay, and
found that transgender people had double the rate bisexual orientations and identities are no more or
of unemployment, near universal harassment on the less pathological than are heterosexual ones and con-
job, significant losses of jobs and careers, high rates demning conversion therapy theory and practice.
of poverty, and significant housing insecurity (http:// Affirmative mental health treatment of trans-
www.thetaskforce.org/downloads/reports/fact_ sexual individuals has lagged behind that of LGB
sheets/transsurvey_prelim_findings.pdf ). Despite people and at present is caught in a dilemma. Most
true gains in the quality of life for LGBT people in medical and mental health professionals are shame-
the United States and many parts of the world, in fully un- or undereducated about the needs of trans-
most areas of the country, sexual minorities can be sexuals, leading to maltreatment ranging from
fired from their jobs without recourse, as well as face microaggressions to overt discrimination (Korrell &
discrimination in housing, health care, and family- Lorah, 2007). Yet, these same mental health profes-
related processes such as marriage, custody, and sionals may be called upon to assist transsexual cli-
adoption. Furthermore, violence or fear of violence ents in meeting psychological criteria for proceeding
continues to be commonplace. These concerns have with medical treatments for sexual reassignment.
clear relevance to counseling psychologists. Counseling psychologists and their transsexual cli-
ents seeking medical interventions face a values-
Mental Health Treatment of LGBT People based challenge. As multiculturally competent
A look at the mental health maltreatment of les- counseling psychologists, we do not view LGBT
bian and gay people is eye-opening. For most of the people through a lens of pathology; however, for

m or row 415
those transsexual people who seek sexual reassign- psychology, change slowly; and, in 1977, Morin
ment treatment, the psychologist is called upon to found that most published research still viewed
diagnose the individual with gender identity disor- homosexuality from an illness model. In 1991, the
der. Korrell and Lorah predicted that many thera- American Psychologist published an article by Herek,
pists will work with at least one transgender client Kimmel, Amaro, and Melton on heterosexist bias
at some point, and that many more will see family in research. Heterosexist bias was defined as “concep-
members of transgender people. To date, the only tualizing human experience in strictly heterosex-
mental health organization that has developed ual terms and consequently ignoring, invalidating,
guidelines for working with transgender/transsexual or derogating homosexual behaviors and sexual ori-
people is the Association of Lesbian, Gay, Bisexual, entation, and lesbian, gay, and bisexual relation-
and Transgender Issues in Counseling (ALGBTIC; ships and lifestyles” (p. 958). This article—a report
2009); these guidelines were approved by the from the American Psychological Association Task
American Counseling Association (ACA) Governing Force on Nonheterosexist Research convened in
Council in November, 2009. 1985 by the Board for Social and Ethical Respon-
The context for LGBT people might seem grim, sibility in Psychology—addressed the scientific,
and at times it is. Despite the decline in violent social, and ethical consequences of heterosexist
crime in the United States in recent years and grow- bias, raised questions for researchers interested in
ing visibility and acceptance of LGBT people in evaluating heterosexist bias in their own research,
the culture at large, violence against LGBT people and made recommendations for reducing hetero-
continues to rise. The successful passage of the sexist bias in research, publishing, and academe. The
Matthew Shepard and James Byrd, Jr. Hate Crimes authors addressed issues of sampling bias, research
Prevention Act was a milestone in the effort to end design and procedures, protection of research par-
this violence. Resistance to equal rights for LGBT ticipants, and interpreting and reporting results.
people in the United States and elsewhere appears These guidelines have relevance 20 years later and
to have increased with the virulence of the religious could productively be implemented by counseling
right (Herek, 2004); yet, LGBT people and their psychology researchers and educators today.
allies are undaunted in their fight for fair treatment More recently, the JCP published a special issue
for all. For many young people, particularly in larger on “Advances in Research with Sexual Minority
urban areas, sexual orientation appears to be a “non- People” (2009). In their lead article, in addition to
issue,” as youth of all genders and sexual orienta- describing the difficulties with conceptualizing and
tions identify as queer in unity and solidarity defining sexual minorities addressed above, Moradi
(Jacobson & Donatone, 2009). et al. (2009) outlined current challenges in sexual
Understanding the context of the lives of LGBT minority research and offered suggestions for con-
people is a central part of cultural competence in sideration in future research. These challenges fall
research, teaching, and practice with these popula- into seven areas: construct-related issues, issues
tions. The issues that are relevant to counseling related to population(s) of interest, internal validity,
psychologists related to sexual orientations and external and ecological validity, measurement, pro-
identities are many, and an exhaustive coverage is cedural issues, and writing.
not possible. Thus, I have selected what I consider
to be critical issues for counseling psychologists, Construct-related Issues
either because they are areas that have been addressed Research on sexual minority people is complicated
by counseling psychologists or are part of the core by the many definitional problems described above,
foci of our discipline. They include research issues as well as because researchers have used a variety of
on LGBT people; developmental issues, including terms (e.g., homophobia, heterosexism, heteronor-
identities and coming out; and LGBT-affirmative mativity, homonegativity) to capture a particular
counseling and psychotherapy, including issues of phenomenon or population group, as well as using
multiculturalism and intersectionality. the same term (e.g., internalized heterosexism) to
mean somewhat different things. This lack of con-
Research Issues on LGBT People sistency can lead to difficulty in comparing the find-
Research on LGBT issues has evolved over time ings of different studies (Frost & Meyer, 2009).
since Evelyn Hooker’s (1957) seminal research dem- Moradi et al. (2009) also argued that the “concep-
onstrating that homosexuality was not correlated tual breadth of constructs of interest” (p. 11) needed
with psychopathology. However, attitudes, even in greater attention in LGBT research. Clarity about

416 sexual orie n tatio n s an d id en tities

whether to investigate variables (e.g., social support) individuals from learning about or being willing to
at a broader, more global level or a more specific, participate in studies geared toward LGBT people
LGBT-focused level will contribute to more mean- (Herek et al., 1991). Furthermore, cultural variables
ingful outcomes. Citing Reise, Waller, and Comrey related to sexual orientation identity, such as those
(2000), Moradi et al. pointed out that “narrower described above, may negatively impact participa-
constructs tend to be more effective in predicting tion of sexual minority people of color (Moradi
specific outcomes, whereas global constructs tend to et al., 2009). Meyer and Wilson (2009) identified
be better at predicting complex and multifaceted challenges and recommended principles to guide
outcomes” (p. 11). Moradi et al. also recommended sampling with LGB populations.
that researchers investigating sexual minority issues
consider conducting multilevel analyses, including Measurement
within-person, between-person, and larger social- A considerable number of measurement challenges
unit levels. For example, heterosexism may vary confront researchers on LGBT issues (Moradi et al.,
within individuals according to the contexts in 2009). These concerns include the applicability of
which they find themselves (Levitt et al., 2009); it existing measures to sexual minority people on
may be explored as a between-person variable whom psychometric evidence is absent; validity
(Szymanski, 2009), or it may be investigated at a problems with an instrument created for use with
larger, systemic level (Rostosky, Riggle, Horne, & one sexual minority population and then applied to
Miller, 2009). another; heterosexist language in measures devel-
oped for heterosexual people; problems with attem-
Issues Related to Population(s) of Interest pting to investigate constructs for which measures
Given the complexity and ambiguity that surrounds have yet to be constructed; and challenges with
describing sexual minority people, as well as the tre- using older instruments to measure constructs that
mendous variation in their experiences and identi- are rapidly changing. Of particular concern is the
ties, it is important to clearly identify the population tendency on the part of some scholars to “add ‘B’
of interest in relation to research question and sam- and stir,” assuming that measures that reflect the
pling procedures (Moradi et al., 2009). Many with- realities of lesbian women and gay men will be
in-group differences (e.g., related to race/ethnicity/ equally applicable to bisexual women and men.
culture) may impact the results of a study, even The confounding of sexual orientation (LGB) and
when the population appears to be carefully identi- sexual identity (including transgender issues)
fied. Moradi et al. recommended careful consider- addressed earlier has further complicated this prob-
ation of what dimensions of sexual minority status lem. Moradi et al. (2009) recommended accurately
are of interest in formulating a research question. assessing sexual orientation and gender identities
when recruiting and measuring sexual minority
Issues Related to Internal Validity constructs, as well as developing “standards regard-
Moradi et al. (2009) recommended greater diversity ing core constructs to assess in sexual minority
in research approaches on sexual minority people, research” and “measures to assess those constructs”
expressing concern about the use of cross-sectional (p. 15).
data to test directional hypotheses. They suggested
considering experimental and repeated measures Procedural Issues
designs to test causal hypotheses. Furthermore, they The stigmatization and marginalization of sexual
recommended longitudinal research designs to minority people is a theme that runs throughout
investigate developmental processes, such as iden- research considerations with LGBT populations.
tity and vocational development. The sociopolitical context of such research compli-
cates the process, from the formulation of the
External and Ecological Validity research question to the dissemination of the results.
A number of problems regarding external and eco- Because of past and sometimes current research
logical validity confront investigators conducting abuses of marginalized groups, including sexual
research on sexual minorities. Over time, one of the minorities, LGBT people may experience what Sue
most common critiques of sampling bias in such and Sue (1999) termed “cultural paranoia” directed
research has been the difficulty of obtaining a repre- toward traditional researchers, in which past inju-
sentative sample, as sexual minority status and the ries within and outside the research setting may
accompanying stigma may prevent more closeted engender wariness on the part of potential research

m or row 417
participants. Alternatively, sexual minority people, been greatly under-reported in the literature on
weary of the silence surrounding their lives, may sexual orientation, and sexual orientation has been
be eager to contribute to research that will cast under-reported in studies of people of color (Moradi
them, their lives, and their communities in a posi- et al., 2010b).
tive light. Moradi et al. recommended that research-
ers carefully consider and minimize the potential Sexual Orientations and Identities:
risks to participants of participating in research and Development and Coming Out
conduct pilot studies to increase sensitivity to par- According to Croteau et al. (2008), sexual identity
ticipant needs. In addition, recognizing the unique theory is counseling psychology’s “most-studied
circumstances that may affect honest responding, concept” in relation to LGBT people. Sexual iden-
researchers can work to build collaborative relation- tity development is the “process by which individ-
ships that will increase trust on the part of partici- uals develop a psychological sense of themselves that
pants. Finally, the authors suggested that researchers embraces their sexual orientation amidst pervasive
“give back” to participants and their communities. societal heterosexism and sexual prejudice” (p. 196).
Models have been developed to understand the
Writing identity formation process of lesbian women and
As described above, clear communication in the gay men, bisexual women and men, and transsexual
form of precisely defining terms and constructs; individuals.
clearly stating research questions; and carefully des-
cribing sampling, recruitment, and procedures can Lesbian and Gay Identity Development
provide the basis for the accurate and meaningful Cass (1979) theorized six stages of sexual identity
reporting of findings (Moradi et al., 2009). Keeping development for lesbian and gay people: identity
in mind the sociopolitical nature of research with confusion, characterized by growing awareness of
sexual minority people, it is essential to understand one’s homosexuality and a sense of incongruence
the ways in which research findings can be misinter- with one’s prior identity or sense of morality; iden-
preted and abused by those with conservative agen- tity comparison, in which the individual tentatively
das (Gonsiorek, 1991). Moradi et al. recommended adopts a homosexual identity and experiences a
that researchers “anticipate and clarify points that sense of being different from the heterosexual major-
could be misunderstood or distorted by readers and/ ity; identity tolerance, in which the individual still
or the media” (p. 17). experiences ambivalence but becomes more com-
As articulated by Worthington and Navarro mitted to a homosexual identity; identity acceptance,
(2003), Croteau et al. (2008), and Moradi et al. in which the individual has increasing contact with
(2009), a major concern at this juncture in counsel- other lesbian and gay people and experiences feel-
ing psychology is to address the intersectionality ing “normal”; identity pride, in which the individ-
of various statuses and identities, in particular ual holds other gay and lesbian people in high regard
LGB people of color, in order to take research on and devalues heterosexual people and associated
sexual minorities to a more inclusive and complex values; and, finally, identity synthesis, in which the
arena. The authors of a major contribution of TCP individual continues to feel pride but no longer
(Moradi, DeBlaere, & Huang, 2010b) have devalues heterosexuality per se and is able to inte-
responded to this call by further addressing the grate her or his sexual orientation identity with the
invisibility of LGB people of color and making rec- rest of life. At any time, the individual may foreclose
ommendations for centralizing the experiences of on her or his identity.
LGB people of color in counseling psychology. Coleman (1982) also proposed a stage theory
Although it is certainly the case that stigma sur- model, including pre-coming out, when individ-
rounding sexual minorities in communities of color uals feel “different” but do not understand why;
may contribute somewhat to the invisibility of LGB coming out, when they acknowledge their homo-
people of color, Moradi et al. (2010b) argued that sexual feelings (corresponding to Cass’s identity
“LGB people of color have been leaders in LGB confusion); exploration, consisting of experimenta-
organizations” (p. 323) over time and have been tion and greater openness (corresponding to Cass’s
visible contributors to LGB communities and to identity tolerance); first relationships; and integra-
social change efforts. However, their visibility in tion (corresponding to Cass’s identity synthesis).
these arenas has not been reflected in the literature Coleman warned that this linear, progressive model
on LGB people of color; overall, race/ethnicity has was simplistic and may not accurately capture

418 sexual orie n tatio n s an d id en tities

reality; however, it could be useful for clinicians in These are referred to as phases to imply “greater flex-
understanding underlying dynamics of identity ibility and circularity” (Fassinger & Miller, 1996, p.
development. 56) than rigid stage models. Although similar in
Cass’s (1979) and Coleman’s (1982) models have some ways to other models, the McCarn and
been criticized more recently for being overly sim- Fassinger model does not view disclosure as evi-
plistic and decontextualized (Fassinger & Arseneau, dence of developmental progression because of the
2007; McCarn & Fassinger, 1996); however, they profound impact that an oppressive context may
provided the field with important tools to under- have on disclosure. For example, a teacher in a con-
stand identity development and the process of servative area may feel proud to be lesbian or gay
“coming out of the closet” for lesbian and gay but make a decision not to risk her or his career by
people. Reading the original articles, along with being open in the workplace or community.
Coleman’s (1978) review of the treatment literature Developmental tasks within each identity process
and proposal for a nonpathologizing approach to (individual sexual identity, group membership
psychotherapy with lesbians and gay men, provides identity) include awareness (Individual: feeling “dif-
an excellent historical grounding for understanding ferent,” experiencing confusion; Group: of the real-
just how far we have come. ity of varied sexual orientations); exploration
Contemporary theories are more contextual as (Individual: of erotic feelings toward same-sex indi-
well as inclusive of women, bisexual women and viduals; Group: of oneself in relation to lesbian/gay
men, and transgender people (Lev, 2007; Potoczniak, people); deepening/commitment (Individual: deep-
2007; Sophie, 1986) and of intersections of race, ening of self-knowledge, commitment to choices
ethnicity, and culture with sexual orientations and about sexuality; Group: to involvement with les-
identities (Fukuyama & Ferguson, 2000; Greene, bian/gay people, understanding the realities of
2000). Sophie critiqued stage models of identity oppression); and internalization/synthesis (Individual:
development proposed by Cass (1979) and Coleman of love for same-sex individuals, identity; Group: of
(1982), as well as others from whose work Sophie one’s identity as a member of lesbian/gay commu-
synthesized a general stage model consisting of nity, across contexts). Although the two processes
first awareness, testing and exploration, identity accep- (individual and group-oriented) are related and may
tance, and identity integration. She assessed this enhance one another, individuals may proceed in
model in terms of its applicability to lesbians based different ways and at different paces through them.
on her longitudinal interview-based qualitative This model has received considerable research sup-
study with 14 college-aged lesbian women. She port for both lesbian women (McCarn & Fassinger,
found that, although her participants experienced 1996) and gay men (Fassinger & Miller, 1996), as
some of the stages proposed by theorists, there were well as for lesbian women and gay men of color
serious limitations to their applicability. In particu- (Risco, 2008; Risco & Fassinger, 2007).
lar, her participants appeared not to follow a linear
path through stages, demonstrating more fluidity Bisexual Identity Development
than accounted for by stage theories. Sophie also The early development of stage theories of lesbian
emphasized the importance of contextual factors, and gay identity development was characterized
as her participants had also benefitted from the either by ignoring bisexuality or considering bisexu-
results of the gay liberation movement, noting that ality a “transitional identity” in the evolution of
“the development of lesbian identity is extremely a mature, stable lesbian or gay identity (Rust, 2007).
sensitive to variations in the prevailing attitudes Finally, in the 1980s, researchers began to view
toward homosexuality and in the availability of bisexuality as a legitimate identity in and of itself.
others who support a positive view of relations Despite evidence to the contrary, many theorists
between women” (p. 50). continue to view sexual identity as a fixed point
Striving for greater complexity and contextual- toward which sexual minority individuals develop
ity, McCarn and Fassinger (1996) further critiqued (Rust, 2007). On the contrary, Weinberg, Williams,
existing stage models, particularly for conflating and Pryor (2001) proposed a developmental model
individual and social aspects of identity, and pro- culminating in continued uncertainty following the
posed an inclusive model of sexual identity forma- adoption of a bisexual identity, thereby normalizing
tion in lesbian women, hypothesizing two separate, a “mature state of identity flux” (Rust, 2007, p. 4).
but reciprocal, developmental processes, indivi- Research by Diamond (1998, 2008) suggests that,
dual sexual identity and group membership identity. for women in particular, sexual orientation is quite

m or row 419
fluid, thus reinforcing Rust’s concept of identity It represents a challenge to traditional dichotomous
flux. Furthermore, investigating whether bisexua- notions of sex (female, male), gender (woman, man),
lity was (a) a transitional stage as described above, and sexuality (homo-, heterosexual). It reconstructs
(b) a “third” sexual orientation (in addition to het- bisexuality, commonly conceptualized as a hybrid
erosexual and lesbian/gay, or (c) a clear example combination of homo- and heterosexuality, by
of sexual fluidity in human beings, Diamond (2008) calling into question the distinction between these
found support for (b) and (c), but not (a). In par- two forms of gendered sexuality. “Queer” is about
ticular, she proposed an integrated model describ- crossing, blurring, and erasing boundaries, both
ing bisexual women’s identity in which “bisexuality conceptual and political. (p. 16)
may best be interpreted as a stable pattern of attrac-
Thus, bisexual identity tends to challenge tradi-
tion to both sexes in which the specific balance
tional developmental stage theories of identity dev-
of same-sex to other-sex desires necessarily varies
elopment and, in doing so, provides a paradigm for
according to interpersonal and situational factors”
greater creativity and flexibility in conceptualizing
(p. 12). Based on her findings, Diamond argued
sexual minority identity.
that, contrary to common wisdom, “identity change
is more common that identity stability” (p. 13).
Transgender/Transsexual
Research by Stokes, McKirnan, and Burzette (1993);
Identity Development
Stokes, Damon, and McKirnan (1997); Dickson,
To understand the identity development of gender
Paul, and Herbison (2003); and Weinberg et al.
variant or transgender people, it is important to
(1994) have also found evidence of fluidity in men;
place it in a cultural context (Lev, 2007). Today’s
Weinberg et al. noted the impact of both relation-
emphasis on hormonal treatments and surgical
ships and situational factors in bisexual men’s attrac-
interventions places transsexuals squarely in a medi-
tions and behaviors.
cal model in many people’s minds. However, trans-
Rust (2007) found a number of ways in which
gender people have lived their lives throughout
bisexual women and men experienced changes in
history and across cultures, sometimes given legiti-
their sexual orientation identities. For some, identity
mate positions in their societies and, at other times,
change was a personal process in which people became
passing for members of the other sex (Lev, 2007).
more deeply self-aware and redefined their sexual ori-
In the current cultural climate, the intersections
entation based on this new awareness. Although this
of medical, psychological, and activist agendas com-
process appears similar to the traditional “coming-
plicate the identity development process of trans-
out” process experienced by lesbians and gay men, it
gender people.
differs in that bisexuals do not reject their prior attrac-
In the process of coming to terms with one’s
tions to opposite-sex people, and many may experi-
gender identity, a trans person may also be in a posi-
ence a second coming-out after having been lesbian- or
tion in which a redefinition of sexual orientation is
gay-identified. In addition, for some, taking on the
necessary (Gagné, Tewksbury, & McGaughey,
identity of bisexuality provided a more flexible iden-
1997). In their research with transgender individu-
tity in which to experience and express their sexuality
als (MTF transsexuals and male cross-dressers),
without having to continually reconstruct their iden-
Gagné et al. identified a number of processes
tities. Rust also found that, for some individuals, a
through which their participants transited—which
sociopolitical context in which bisexuality became a
resemble developmental stage theories that have
possibility for them provided the impetus for identi-
been developed for LGB people—beginning with
fying as bisexual. For some individuals, a bisexual
early experiences of “not fitting” or wanting to be
identity can be a political statement. Although a
a girl or woman. Some experienced these feelings
reflection of their honest feelings and attractions,
and desires as children, whereas others became
some choose to make a statement of solidarity with
aware of their dissatisfaction with their assigned
other bisexuals by “coming out” as bisexual.
gender in adolescence or adulthood. Some, rather
Alternative identities also arise as individuals
than wanting to be, felt they actually were women
define and construct themselves (Rust, 2007). One
or girls in the wrong bodies. These experiences
example is reclaiming the term queer, formerly
were accompanied by confusion, especially if they
a pejorative term. According to Rust:
were given less-than-supportive messages by others.
“[Q]queer” identity . . . is a well-developed, nuanced Many experimented with cross-gender behavior and
identity within the sexual minority community. dress, usually in secret. This period was followed by

420 sexual orie n tatio n s an d id en tities

a process of coming out to self as they found names and healthy self-concepts. Nonetheless, they set the
for their feelings and learned that there were others stage for multiculturally competent practice when
with the same experiences. At this time, a search for working with sexual minority people.
authenticity became important. This was also
accompanied for many by a period of questioning LGBTQ Affirmative Counseling
their sexual orientations. Because transgender role and Psychotherapy
models are scarce, many sought information and Affirmative counseling and psychotherapy with
confirmation from media or on the Internet. Finally, sexual minority people is based on the premise that
these transgender individuals made decisions about healthy human beings hold a wide variety of identi-
coming out to others and developed strategies for ties and attractions; relate in many different ways
managing their identities in the various facets of as lovers, spouses, or life partners; and express them-
their lives. This enabled them to try out and legiti- selves sexually with an array of possibilities. LGBT-
mize their emerging identities. These activities, affirmative counselors and therapists challenge the
along with finding support groups, facilitated iden- medicalization and pathologizing of sexual orienta-
tity resolution, including making decisions about tions and identities and work as allies to LGB people
whether to “pass” as an individual of the new gender within and without the mental health setting.
and a desire to contribute to the positive develop- In addition, these therapists are committed to devel-
ment of other transgender people (Gagné et al., oping competence in their work with LGB clients.
1997).
Lev (2007) suggested a stage-developmental Multicultural Competence in Counseling
model for transgender people considering sex reas- Sexual Minorities
signment. This model consists of six stages: aware- At the heart of ethical practice when counseling
ness, seeking information/reaching out, disclosure sexual minorities is the therapist’s deep commitment
to significant others, exploration (identity and self- to becoming culturally competent. The counse-
labeling), exploration (transition issues/possible ling psychology literature has applied multicultural
body modification), and integration (acceptance counseling competencies to LGBT counseling
and post-transition issues). Lev’s model is illustra- (Fassinger & Sperber-Richie, 1997) as well as devel-
tive of the move away from a medicalized, patholo- oping knowledge, attitude, and skills-based compe-
gizing lens to one that honors sexual diversity. tencies (Israel, Ketz, Detrie, Burke, & Shulman,
2003). Bidell (2005) developed the Sexual Ori-
Intersecting Identities entation Counselor Competency Scale (SOCCS),
A caution is in order regarding identity models, as also based on multicultural models. Dillon and
individuals develop with multiple identities, some Worthington (2003) developed the Lesbian, Gay,
privileged and some not. Thus, a white lesbian and Bisexual Affirmative Counseling Self-Efficacy
woman will be privileged because of her skin color Inventory (LGB-CSI), which measured application
but will be in a nondominant position as a lesbian of knowledge, advocacy skills, awareness, relation-
and a woman. In the case of changing identities, ship, and assessment. Professional organizations
a woman may conceive of herself as heterosexual have been active in developing competency-based
and then fall in love with another woman, thus guidelines for working with sexual minority people.
transiting from a majority to minority sexual orien-
tation identity. A female-to-male transsexual may competence in therapeutic
experience greater discrimination because of his work with LGB clients
transsexual status (especially if it is obvious), but At the core of competent practice with LGB clients
may find himself taken more seriously in the work- are the guidelines published by the American
place as a man. Multiple oppressed identities can Psychological Association Division 44/Commit-
be confusing, as often the individual does not know tee on Lesbian, Gay, and Bisexual Concerns Joint
whether she or he is being oppressed based on race/ Task Force on Guidelines for Psychotherapy with
ethnicity, gender, sexual orientation, or another Lesbian, Gay, and Bisexual Clients (Division 44,
intersecting status or identity such as socioeconomic 2000). These 16 guidelines are organized into four
class, disability, age, or physical appearance. Thus, main categories: attitudes toward homosexuality
many of the foregoing models are highly simpli- and bisexuality, relationships and families, issues of
fied ways to attempt to understand what sexual diversity, and education. A brief synopsis of these
minority people experience as they develop positive guidelines follows.

m or row 421
 Psychologists who are competent to work with and suicide. Older LGB adults may have come out
LGB individuals first examine their attitudes toward during a time prior to or during the feminist and
homosexuality and bisexuality (Division 44, 2000). LGB movements, with varying influences depend-
They know from the research literature that neither ing on the time frame of coming out and various
homosexuality nor bisexuality is suggestive of men- cohort effects; they also may face stigma and invisi-
tal illness. They are also aware of their own homon- bility as they attempt to access services for older
egative biases and limits of their knowledge, so that adults. LGB people with disabilities comprise ano-
they know when to consult or refer. Furthermore, ther population that is uniquely affected. Many sup-
they understand the effects of stigma, prejudice, dis- port systems for LGB people may be inaccessible
crimination, and violence on LGB people, and they to LGB people with disabilities, and LGB commu-
work to be aware of how a lack of or inaccurate nities may be less than welcoming of people with
information and prejudice affect client presenta- disabilities.
tion, their own attitudes and behaviors, and the Ongoing education is essential to address many
therapy relationship and process. of the gaps between policy and practice related to
LGB people experience unique challenges in the LGB people (Division 44, 2000). Training and
areas of relationships and families, not because of supervision must incorporate current knowledge
inherent differences between them and heterosexu- about LGB issues, and counseling psychologists
als, but because of society’s treatment of them. need to be committed to their own ongoing train-
Therapists working with LGB people—and even ing, supervision, consultation, and continuing
LGB people themselves—may, because of the lack education in this area. Competent counselors and
of legitimacy in society, fail to recognize the impor- therapists also make themselves aware of mental
tance of or fully respect LGB relationships and fam- health and community resources for their LGB
ilies. Competent therapists recognize both the clients.
similarities and differences between LGB and het-
erosexual relationships. Unique issues such as com-
competence in therapeutic work
ing out to families and friends, gender socialization,
with transgender clients
reproduction, and child custody make expertise in
Although many of the guidelines designed for com-
this area essential when conducting relationship and
petent counseling with LGB people are applicable
family counseling. In addition, the stress and dis-
to competence in working with transgender people,
tress experienced by LGB individuals and couples
they were not developed with transgender clients
and their families that arise from the politics of
in mind. Thus, ALGBTIC (2009) of the American
same-sex marriage require special attention (Arm,
Counseling Association developed a document
Horne, & Levitt, 2009; Levitt et al., 2009; Rostosky
outlining competencies for counseling with trans-
et al., 2009). Familiarity with the research on chil-
gender clients based on a “wellness, resilience, and
dren of LGB parents and LGB parenting is essential
strengths-based approach” (p. 2) that is consistent
to combat prejudices long held by the majority of
with the values of counseling psychology. The com-
society (Division 44, 2000). It is also important to
petencies were developed using the multicultural
understand the varied family structures of LGB
knowledge, skills, and awareness model (KSA)
people, particularly when many families of origin
developed by Sue, Arredondo, and McDavis (1992).
have rejected their LGB children.
Key competency areas and illustrative competencies
Issues of diversity, or intersections of identities,
include:
are essential to understand to provide competent
services to LGB clients (Division 44, 2000). In par- 1. Human growth and development: “Affirm
ticular, LGB people of color may experience dual that all persons have the potential to live full
isolation from and marginalization by LGB com- functioning and emotionally healthy lives
munities and their families and communities of throughout their lifespan while embracing the
color. In a similar fashion, bisexual people may be full spectrum of gender identity expression,
unable to fully fit into either heterosexual or lesbian/ gender presentation, and gender diversity
gay communities, given the lingering stereotypes beyond the male-female binary” (ALGBTIC,
about bisexuality. Both LGB youth and older adults 2009, p. 6).
also experience unique challenges. Adolescents who 2. Social and cultural foundations: “Understand
have been rejected by their families are at greater risk the importance of using appropriate language
for homelessness, HIV, substance abuse, violence, (e.g., correct name and pronouns) with

422 sexual orie n tatio n s an d id en tities

transgender clients; be aware that language in the psychological symptoms, but do not necessarily
transgender community is constantly evolving indicate pathology for transgender individuals.
and varies from person to person; seek to be aware Consider these effects when collaboratively
of new terms and definitions within the deciding client’s readiness for body modifications”
transgender community; honor clients’ definitions (p. 15).
of their own gender; seek to use language that 8. Research: “Recognize research is never free
is the least restrictive in terms of gender of positive or negative bias by identifying the
(e.g., using client’s name as opposed to assuming potential influence personal values, gender bias,
what pronouns the clients assert are gender and heterosexism may have on the research
affirming); recognize that language has historically process (e.g., participant selection, data gathering,
been used to oppress and discriminate against interpretation of data, reporting of results,
transgender people; understand that the counselor DSM diagnosis of Gender Identity Disorder), and
is in a position of power and should model seek to address these biases in the best manner
respect for the client’s declared vocabulary” possible” (p. 17).
(p. 8).
3. Helping relationships: “Understand that These eight competencies are merely a sample of
attempts by the counselor to alter or change the 103 competencies contained in the ALGBTIC
gender identities and/or the sexual orientation document; thus, a careful reading of the document
of transgender clients across the lifespan may be as a whole will help a clinician assess her or his own
detrimental, life-threatening, and are not knowledge, awareness, and skills in this area. In
empirically supported; whereas counseling addition, therapists should have some basic under-
approaches that are affirmative of these standing of the processes in which transsexual
identities are supported by research, best clients who wish to transition to their gender of fit
practices, and professional organizations” must engage. Not all transgender individuals are
(p. 9). interested in gender reassignment; and “transsexual
4. Group work: “Recognize the impact of people make a wide range of choices as they attempt
power, privilege, and oppression within the to find alignment between sex and gender” (Korell
group especially among the counselor and & Lorah, 2007, p. 272), including doing nothing,
members and between members of advantaged dressing in the clothing of the preferred gender,
and marginalized groups” (p. 11). and choosing hormonal and/or sex reassignment
5. Professional orientation: “Understand and surgical (SRS) procedures. Those who choose (and
be aware that there has been a history of are able to afford) SRS follow recommendations of
heterosexism and gender bias in the Diagnostic the World Professional Association for Transgender
and Statistical Manual (DSM). For instance, Health (WPATH) Standards of Care, previously
counselors should have knowledge that known as the Harry Benjamin International Gender
homosexuality was previously categorized Dysphoria (HBIGD) Standards of Care (Meyer
as a mental disorder and that currently et al., 2001). These Standards clarify psychiatric,
‘Gender Identity Disorder’ remains in psychological, medical, and surgical management
the DSM” (p. 12). of gender identity disorders and are essential knowl-
6. Career and lifestyle development edge for mental health professionals working with
competencies: “Recognize that existing career transgender clients.
development theories, career assessment tools, Affirmative therapies for sexual minority people
employment applications, and career counseling are grounded in the competencies described above.
interventions contain language, theory, and In addition, I recommend that counseling psychol-
constructs that may be oppressive to transgender ogy practitioners and educators seek Safe Zone
and gender-conforming individuals. . . . training to provide a basic understanding of some
Acknowledge the potential problems associated of the history and constructs that affect the lives
with career assessment instruments that have of LGBT people. Safe Zone training is offered
not been normed for the transgender community” through many university and community LGBT/
(p. 13). Pride centers across the country. Although space
7. Appraisal: “Consider in the differential does not permit extensive coverage of all that coun-
diagnosis process how the effects of stigma, seling psychologists need to know to be effective
oppression, and discrimination contribute to counselors and therapists for sexual minority people,

m or row 423
the following section addresses a few issues that have “isolation, discrimination, and aggression and to
been addressed by counseling psychologists. fight for social justice” (p. 67). Counselors and ther-
apists should also be aware that, even though same-
Issues in Counseling LGBT Clients sex couples experience stress and distress as a result
Lesbian and gay people utilize mental health ser- of anti-marriage initiatives, not all desire to marry
vices at a somewhat higher rate than do heterosexual (Warner, 1999). Thus, counseling psychologists
people (Bieschke, McClanahan, Tozer, Grzegorek, should not make assumptions about a couple’s
& Park, 2000; Biescke, Paul, & Blasko, 2007). degree of commitment based on the parties’ deci-
These findings undoubtedly reflect distress on the sions about marriage.
part of individuals seeking to work out their identi- Because of the paucity of legal and social support
ties in an oppressive culture (Cochran, Sullivan, & for same-sex marriage, LGB people are at risk as
Mays, 2003); however, they likely also indicate that prospective or current parents (Patterson, 2007).
LGB people hold positive perceptions of the help- Many LGB parents have children from heterosexual
fulness of therapy, particularly if it is conducted in marriages, and it is still not uncommon in divorce
an affirmative way (Bieschke et al., 2000, 2007). situations for the heterosexual parent to use the
courts to take custody from the nonheterosexual
Relationships and Families parent. Although legal guidelines exist to facilitate
Croteau et al. (2008) urged counseling psycholo- fairness in these decisions, LGB parents are still at
gists to focus greater attention on LGB couples, risk of losing their children because of prejudice in
relationships, marriage, family, and parenting. the judicial system (Patterson, 2007). These deci-
Although LGB couples and families are challenged sions fly in the face of extensive research indicating
by many of the same issues that confront hetero- that children of lesbian women and gay men fare as
sexual people, the legal and social policy contexts in well as those of heterosexual parents developmen-
which LGB people find themselves have extraordi- tally and in terms of their adjustment (Patterson,
nary consequences in their everyday lives (Patterson, 2006).
2007). Despite greater acceptance of LGB people by Same-sex couples who wish to have children are
mainstream Americans (Herek, 2003) and increas- faced with decisions about how to have biological
ing legal victories for same-sex couples (Patterson), children (through heterosexual intercourse or alter-
few jurisdictions have passed civil unions or domes- native insemination) or to adopt. These options are
tic partner protections or benefits for unmarried fraught with complexity and may not be supported
couples, and the religious right has mounted a in some jurisdictions. Same-sex adoptions have been
largely successful campaign nationally to reverse the pursued legally in many states (Human Rights
very few marriage rights victories that have passed Campaign, 2010); however, the lack of favorable
(Patterson, 2007; Rostosky et al., 2009). The suc- rulings in a number of states leave many children
cess of these campaigns to refuse marriage rights to without legal ties to both of their parents (Patterson,
same-sex partners has resulted in high levels of 2007).
minority stress and psychological distress, not only Therapists are challenged to keep in mind the
for same-sex partners who wish to marry, but for social context of the parents and prospective parents
sexual minorities as a whole, due to the accelera- with whom they work. Decision-making on the
tion of epithets and judgments directed against part of same-sex couples may take place in the con-
them (Rostosky et al.). Thus, counseling psychol- text of certain legal restrictions, with which the
ogy practitioners are called on to be aware of the therapist should become familiar. Good parenting
impact of these experiences on the self-esteem of becomes complicated as parents make decisions
their sexual minority clients. Rostosky et al. empha- about how to relate to medical and school person-
sized the importance of counselors and therapists nel. Grief over loss of children through custody
being aware of the social context and assisting their battles is exacerbated by groundless attacks on the
clients in managing stigma during these inflamma- nonheterosexual parent’s morality and fitness to
tory political times. In addition, therapists must parent. Conversely, the creativity that is often req-
help their LGB clients balance the “dual dangers uired of same-sex parents to manage barriers may
of engagement with GLBT advocacy and self- lend itself to greater flexibility and creativity in par-
protection through withdrawal” (Levitt et al., 2009, enting. Thus, a supportive, strengths-based approach
p. 67), encouraging self-acceptance and advocat- to helping LGB parents negotiate the parenting
ing for clients to find social supports to combat process is essential.

424 sexual orie n tatio n s an d id en tities

 Recent research has also focused on biological orientations of the lack of evidence for efficacy and
and extended families of LGB people. Patterson the potential harms of these treatments. Based
(2007) acknowledged the complexities involved in on descriptive data (Beckstead & Morrow, 2004;
LGB people’s relationships with their families of Shidlo & Schroeder, 2002) and clinical experience
origin. If the LGB individual elects not to disclose and advice (Haldeman, 2001; 2004), Beckstead
her or his sexual orientation to the family of origin, and Israel (2007) stated, “Given that the positive
or if her or his family refuses to acknowledge or aspects found in conversion therapy (such as reli-
support the LGB child’s sexual orientation, partner, gious validation, reframing, behavioral strategies,
or family, the LGB person may distance emotion- and group work) can be found in most effective
ally from the extended family (Savin-Williams, therapies, and given that the potential exists for
2003). Alternatively, LGBT families of origin who significant harms from conversion ideology and
were supportive of their LGBT children were nega- interventions, it is unnecessary and unethical to
tively impacted by anti-LGBT legislation in terms provide such therapy” (p. 229).
of their own personal relationships, physical and Effective therapy with same sex-attracted clients
mental health, feelings about their country, and in religious conflict must begin with the therapist,
their hopes for the future (Arm et al., 2009). These whether religious or an LGB person or ally, holding
experiences continue to reinforce the importance of client autonomy as a central ethical tenet and closely
practice being informed by an awareness of the examining her or his biases and assumptions. Such
sociopolitical climate. a therapist will be aware both of religious/spiritual
resources as well as resources to provide clients with
Spiritual and Religious Issues positive perspectives of living openly lesbian, gay, or
Spiritual and religious concerns have gained increas- bisexual lives. Clients need information about the
ing attention in multicultural counseling, and distinction between sexual orientation, identity, and
LGBT people face challenges in this regard. Hetero- behavior, so that they can form realistic goals for
sexuality and the nuclear family—and consequently therapy and for their lives. They also need to know
adherence to rigid gender roles—form the basis for that they may make life choices that later need to be
many conservative and orthodox religious teach- revisited. Thus, the therapist must be able to pro-
ings. Thus, sexual minorities may find themselves vide a holding space for the ambivalence and ambi-
under attack from religious organizations, and they guity that surrounds what is often a long and rocky
may have internalized the heteronegative teachings road toward a tenuous peace of mind for the client.
of their families and religious communities. For Above all, the therapist has a moral and ethical
many people of color, their religious communities responsibility to value and respect the many selves
may be inseparable from their cultures. Thus, coun- that the client brings to counseling—the spiritual
selors and psychotherapists will encounter same-sex self, the sexual self, and the other possible selves that
attracted people in religious or spiritual conflict intersect the religious/spiritual/sexual self.
with their religious traditions. For some, their
religious/spiritual selves are as much an identity as Multicultural Issues and Intersections
other cultural identities, and clients are no more Although, for purposes of simplicity, I have used
able to separate themselves from their religious/ fairly restricted terminology (LGBT) to discuss sex-
spiritual identities than clients of color can from ual orientation and identity issues, those terms do
their ethnic identities. not necessarily describe the experiences of diverse
The American Psychological Association (1998) groups of sexual minority people. Across cultures,
has taken the relatively moderate stance that ther- same-sex attractions and gender variance are viewed
apists must advise clients that scientific evidence through different lenses. DeBlaere et al. (2010) gave
supporting conversion therapy does not exist. several examples of terms used in various cultures
Other professional associations, such as the ACA and contexts to describe alternative sexual and
(Whitman, Glosoff, Kocet, & Tarvydas, 2006), the gender orientations: down low (Latino and African
ALGBIC (2010), and the American Psychiatric American men who have sex with both women and
Association (2000a), maintain a stronger stance, men and do not identify as gay); girlfriend or sister
advising against attempts to change clients’ sexual (terms used by African American women that
orientations, particularly until more evidence exists describe an important woman-to-woman relation-
to support such treatments, and urging counselors ship but that may or may not designate a romantic
to inform clients wishing to change their sexual or sexual relationship); homo thugs (tough young

m or row 425
men in African American communities who have women or couples—their income is reflective of
sex with men); mati-ism (African term for women women in general and they are likely to be raising
who have sex with women); same-gender loving children. Transgender individuals are universally
(Latino or African American term to describe same- concerned about employment issues (Korrell &
gender sexual relating without identifying as gay); Lorah, 2007) as well. Thus, the very fact of being
top/bottom (term used by Latino gay and bisexual LGBT puts an individual at risk for lower socioeco-
men that distinguishes between the more insertive, nomic status. For people of color, who are often
and thus more masculine, and the more receptive, also systemically and systematically economically
or more “gay,” partner); two spirit (people in some oppressed, being LGBT may further increase their
American Indian cultures who live the gender role risk of economic disadvantage. These intersections
of the opposite sex and may engage in same- of sexual/gender orientation, race/ethnicity, socio-
sex sexual behaviors); and terms such as Warias economic class, and sometimes gender illustrate
(Indonesian), Kathoey (Thai), Bayot (Filipino), and how intersections complicate the lives of LGBT
Fa’fafine (Polynesian) (Asian-Pacific terms for people people exponentially, given other oppressed statuses.
who “cross traditional gender and sexual lines” Youth or older age, also associated with lower
p. 334). Therapists working with clients from diverse income levels, may also come into play to create
cultures do well to follow the client’s lead and lan- stress and distress for LGBT clients.
guage when exploring the meanings of gendered Multiple identities, and thus multiple layers of
and sexual orientations and identities. oppression, require multiple coping strategies on
It should be noted that the whole notion of the part of the individuals who hold them (Fukuyama
sexual identity is a culture-bound construct that & Ferguson, 2000). They also demand diligence on
may have limited or no value when working with the part of the counselor or therapist working with
clients from cultures in which sexuality is not per- LGBT people with multiple identities. As noted
ceived as a source of identity (Rust, 1996). Depen- above, the meanings of sexual and gender orienta-
ding on the client’s culture of origin, along with her tions across cultures can differ widely. In addition,
or his level of acculturation, achieving an identity an individual’s visibility or invisibility as a member
based on sexuality may or may not be salient. of each identity group, as well as the salience of each
This is relevant not only to counseling clients identity in a particular context, are important vari-
of color or from non-European American cultures, ables as the individual negotiates her or his identi-
but across age cohorts as well. Older same-sex- ties in various communities (Fukayama & Ferguson,
attracted clients may identify as homosexual; those 2000). Therapists must assist their clients in exam-
who came out or became activists via feminism ining the multiple layers of oppression that impact
or the LGB movement may be most comfortable them, as well as, when possible, to distinguish the
with the terms lesbian, gay, or bisexual; and young sources (racism, sexism, homonegativity, etc.) of
people of various sexual orientations—including oppression. An LGBT person dealing with a single
some heterosexual—may prefer the term queer. layer of oppression (e.g., a European American,
The paucity of scholarship on intersections of able-bodied, gay man of means) may need support
sexual and gender orientations with other diverse from a counselor to deal with internalized oppres-
identities—race/ethnicity, age, disability, socio- sion directed toward him as a gay person; a lesbian
economic status, and others—require counseling woman of color has at least three identity statuses to
psychologists to synthesize and integrate multi- negotiate, and not being clear why she is being tar-
ple literatures to provide competent services to a geted creates additional challenges. The therapist
diverse clientele. Despite calls for greater attention must also be on guard not to assume that a client
to intersecting identities (Croteau et al., 2008), has only one identity status, as many statuses (sexual
counseling psychology is still at the brink of or gender orientation, religion, class, and certain
grasping the full implications of this challenge. disabilities) are invisible until the client shares them.
LGB people are disproportionately below the pov- Fukayama and Ferguson recommended qualitative
erty line and/or homeless (Albelda, Lee Badgett, research methods to further elaborate the experi-
Schneebaum, & Gates, 2009), stemming from a ences and understand the needs of individuals with
complex interaction of factors, including being multiple cultural identities.
rejected by families while young, experiencing dis- I have barely scratched the surface of LGBT
crimination in educational and employment sys- counseling issues for counseling psychologists.
tems, and, for women, the likelihood that—as single Numerous other topics and issues have, because

426 sexual orie n tatio n s an d id en tities

of space constraints, been omitted in this chapter. Future directions for counseling psychology in the
They are nonetheless important issues for counsel- arena of sexual orientations and identities encom-
ing psychologists and deserve passing attention pass research and scholarship, practice, and social
before concluding. advocacy. I conclude by addressing each of these
Vocational issues are a key concern of counseling issues below.
psychologists. Croteau, Anderson, Distefano, and
Kampa-Kokesch (2000) identified five primary
Research and Scholarship on Sexual
areas of study in vocational psychology of LGBT
Orientations and Identities
people as LGB identity development; discrimina-
Counseling psychologists have led the field in many
tion and workplace climate (e.g., Chung, 2001);
areas of research and scholarship concerning LGBT
managing sexual identity at work; influences of
people and have called for more rigorous attention
societal messages on occupational interests, choices,
to areas that have been neglected in the past. Future
and perceptions; and career interventions (Chung,
directions for research and scholarship include:
2003a, 2003b). Croteau et al. (2008) further iden-
tified three recent trends in the research litera- • Expanded research on LGBT people of multiply
ture: nondiscrimination policies; LGBT-affirmative marginalized statuses, including race/class/culture,
workplace environments; and heterosexism, socioeconomic factors, differing physical and
homophobia/homonegativity, and discrimination mental abilities, age, and religious and spiritual
in workplace. They warned that vocational psychol- orientations. It is also important to study LGBTQ
ogy of LGBT people has not attended to people issues over time in the context of different
of color. This is in keeping with their observations geographies and cohorts. Identity development
about research overall on LGBT people. pathways of sexual minorities from different
Counseling psychologists have also been leaders groups need to be identified and understood.
in studying supervision and training, including In addition, research is needed to better
counselor supervision, mentoring, trainee attitudes, understand the intersections of sexual orientations
counseling skills, and LGBT issues in the training and identities with other marginalized or
process (Croteau et al., 2008). Croteau et al. noted oppressed statuses. This includes research on the
that efforts are being made to provide LGBT- effects of dual minority stress. Qualitative,
affirmative training, but these training interventions multilevel, and contextual analyses are needed to
need to be investigated systematically. Halpert, understand the complexity of these intersections.
Reinhardt, and Toohey (2007) proposed a theoreti- More effective recruitment approaches are needed
cal model of LGB-affirmative supervision; however, to access sexual minority people of under-
there have been no published empirical studies to represented cultures. Counseling psychologists
date. In this area, as in others discussed in this chap- conducting LGBT research need to become more
ter, further research is needed on transgender issues committed to giving voice to invisible sexual
in training as well as training issues that are cultur- minorities across doubly and multiply marginalized
ally sensitive. groups.
• Spiritual and religious concerns. Counseling
Conclusion psychologists need to continue to conduct rigorous
Future Directions qualitative and quantitative research to better
The overwhelming breadth of critical issues sur- understand the intersection of spiritual/religious
rounding sexual orientations and identities for and sexual orientation identities and provide
counseling psychologists made it necessary to competent services to individuals who are dealing
neglect a number of important issues when writing with conflicts in this area. Continued research
this chapter. Future scholarship should expand on on the effects of conversion treatments are
the issues I have identified above; in addition, I join necessary; in particular, ongoing research is needed
Croteau et al. (2008) in calling for more scholarship to demonstrate the harms of such treatments and
in counseling psychology on couples/relationships/ lead to more stringent guidelines regarding
families/parenting, adolescents and school safety, reorientation approaches.
and aging and gerontology. In addition, we need • Research on neglected areas such as couples,
greater attention to bisexual and transgender issues relationships, marriage, family, adoption,
and to the intersections of gender, race/ethnicity/ childbirth, and parenting. Sexual minority
culture, class, disability, and other identity statuses. people experience unique challenges in all

m or row 427
of these areas, and continued research is needed to • As this chapter was going to press, the news
pave the way to counseling interventions and social media reported a number of suicides of gay youth
advocacy. who had been bullied by peers or “outed” over
• Vocational research, particularly related to social networks. Intervention programs that
LGB identity and career development; address bullying, in particular that targeted at
discrimination and workplace climate; sexual minority and gender nontraditional youth,
nondiscrimination policies; LGBT-affirmative as well as research and intervention related to the
workplace environments; managing sexual identity impact of the Internet—positive, neutral, and
at work; influences of societal messages on negative—is necessary to bring a contemporary
occupational interests, choices, and perceptions; and relevant perspective to these issues.
and career interventions.
Social Advocacy
Counseling, Supervision, and Training Social advocacy cannot really be separated from
Future directions for counseling psychologists in research, scholarship, counseling, supervision, and
counseling, supervision, and training range from training. Using a scientist-practitioner-social justice
general issues of competence to more specific con- advocate model, our research and training must also
cerns. Counseling psychologists have been effective serve our social justice agenda.
in moving the field forward in this area; however,
• Counseling psychologists, in concert with
more work is needed.
members of other social justice-oriented divisions
• Efforts are being made to provide LGBT- of the American Psychological Association, have
affirmative training, but these training made great strides in creating an environment
interventions need to be investigated systematically of fairness and equality for people of traditionally
and applied more broadly. Training programs and marginalized and oppressed groups, including
continuing education opportunities need to be LGBT people—but our work is not yet complete.
developed to provide counseling psychologists with Counseling psychologists can assist in developing
the awareness, knowledge, and skills to intervene or implementing guidelines for working with
beyond the individual level to promote social transgender people. We can also continue to
justice for LGBT people. Although progress has address accreditation guidelines to prevent
been made in this area regarding training in LGB discrimination against sexual minorities and
issues, transgender concerns have been sorely to affect training on LGBT issues. Counseling
neglected. Competencies need to be defined, and psychologists have served and continue to serve
procedures for assessing competency developed in positions of leadership not only in the Society
and implemented. of Counseling Psychology, but in other divisions as
• The current state of treatment for transsexual well as in the highest reaches of American
people who wish to pursue gender reassignment Psychological Association governance. Ongoing
requires that therapists and clients operate within a mentorship for leadership in American
medical model that pathologizes the client’s desires Psychological Association and elsewhere should
to change gender. As this model contradicts basic be a top priority for counseling psychology.
counseling psychology values, new models that • Counseling psychologists need to be active in
support change but do not pathologize the client social issues that affect sexual minority people.
are needed. Recently, the news media reported that the
• Effective counseling and psychotherapy Church of Jesus Christ of Latter-day Saints (LDS,
approaches are needed to assist clients in religious or Mormon, church) had removed language from
or spiritual conflict about their sexual orientations. its Church Handbook of Instructions for leaders in
Because many sexual minority people have been the church that disparaged same-sex attractions;
rejected by or left their religious homes, competent instead, celibate gay Mormons are to be allowed
spiritual counseling is important to help them to be active members and participate fully in the
negotiate this aspect of their lives. In addition, church (Stack, 2010), although the church will
effective training and supervision models are still not support monogamous same-sex unions.
needed to assure competence in students Because religious groups such as the LDS church
whose religious beliefs may be at odds with hold tremendous political power (e.g., the LDS
LGB-affirmative therapy approaches. church gave tremendous sums of money to support

428 sexual orie n tatio n s an d id en tities

Proposition 8 in California), counseling perspectives on lesbian, gay, and bisexual experiences (2nd ed.,
psychologists must take an active stance against pp. 50–85). New York: Columbia University Press.
Beckstead, A. L., & Israel, T. (2007). Affirmative counseling
bad science and religious bigotry that negatively and psychotherapy focused on issues related to sexual orien-
affect LGBT people. Pivotal issues at this time tation conflicts. In K. J. Bieschke, R. M. Perez, & Kurt A.
include marriage, domestic partner, and parental DeBord (Eds.), Handbook of counseling and psychotherapy
rights as well as “Don’t Ask, Don’t Tell” policies in with lesbian, gay, bisexual, and transgender clients (2nd ed.,
the military. pp. 221–244). Washington, DC: American Psychological
Association.
I echo Rostosky et al. (2009) in identifying Beckstead, A. L., & Morrow, S. L. (2004). Mormon clients’
engagement in social activism as a healing factor for experiences of conversion therapy: The need for a new treat-
ment approach. The Counseling Psychologist, 32, 651–691.
many clients. I would also add that activism can Bidell, M. P. (2005). The Sexual Orientation Counselor
serve as a healing factor for counseling psychology Competency Scale: Assessing attitudes, skills, and knowledge
researchers who study and therapists who work with of counselors working with lesbian, gay, and bisexual clients.
LGBT people, as we counseling psychologists are Counselor Education and Supervision, 44, 267–279.
subject to vicarious traumatization or secondary Bieschke, K. J., Croteau, J. M., Lark, J. S., & Vandiver, B. J.
(2005). Toward a discourse of sexual orientation equity in
traumatic stress (Brown, 2008) as we work with the counseling professions. In J. M. Croteau, J. S. Lark,
people who are targets of prejudice, oppression, and M. A. Lidderdale, & Y. B. Chung (Eds.), Deconstructing
violence. I concur with Rostosky et al. in that, in heterosexism in the counseling professions: A narrative approach
addition to providing effective training in LGBT (pp. 189–210). Thousand Oaks, CA: Sage.
issues, training programs can teach skills for address- Bieschke, K. J., McClanahan, M., Tozer, E., Grzegorek, J. L., &
Park, J. (2000). Programmatic research on the treatment
ing social injustice. As counseling psychologists, we of lesbian, gay, and bisexual clients: The past, the present,
have the opportunity to use our leadership to influ- and the course for the future. In R. M. Perez, K. A. DeBord,
ence change in our profession, our communities, & K. J. Bieschke (Eds.), Handbook of counseling and
and the world. psychotherapy with lesbian, gay, and bisexual clients
(pp. 309–336). Washington, DC: American Psychological
Association.
References Bieschke, K. J., Paul, P. L., & Blasko, K. A. (2007). Review of
Adams, H., & Phillips, L. (2006). Experiences of two-spirit empirical research focused on the experience of lesbian, gay,
lesbian and gay Native Americans: An argument for stand- and bisexual clients in counseling and psychotherapy.
point theory in identity research. Identity, 6, 273–291. In K. J. Bieschke, R. M. Perez, & K. A. DeBord (Eds.),
Albelda, R., Lee Badgett, M. V., Schneebaum, A., & Gates, G. J. Handbook of counseling and psychotherapy with lesbian,
(2009). Poverty in the lesbian, gay, and bisexual community. gay, bisexual, and transgender clients (2nd ed., pp. 293–316).
Los Angeles: UCLA School of Law, Williams Institute. Washington, DC: American Psychological Association.
American Psychiatric Association (2000a). Commission on Bieschke, K. J., Perez, R. M., & DeBord, K. A. (Eds.). (2007).
Psychotherapy by Psychiatrists (COPP). Position statement Handbook of counseling and psychotherapy with lesbian, gay,
on therapies focused on attempts to change sexual orienta- bisexual, and transgender clients (2nd ed.). Washington, DC:
tion (reparative or conversion therapies). American Journal of American Psychological Association.
Psychiatry, 157, 1719–1721. Bohan, J. S. (1996). Psychology and sexual orientation: Coming
American Psychiatric Association. (2000b). Diagnostic and to terms. New York: Routledge & Kegan Paul.
statistical manual of mental disorders DSM-IV-TR (4th ed., Broido, E. M. (2000). Constructing identity: The nature and
Text Revision). Arlington, VA: American Psychiatric meaning of lesbian, gay, and bisexual identities. In R. M. Perez,
Publishing. K. A. DeBord, & K. J. Bieschke (Eds.), Handbook of coun-
American Psychological Association. (1998). Appropriate thera- seling and psychotherapy with lesbian, gay, and bisexual clients
peutic responses to sexual orientation in the proceedings of (pp. 13–33). Washington, DC: American Psychological
the American Psychological Association, Incorporated, for Association.
the legislative year 1997. American Psychologist, 53, 882–939. Brown, L. S. (2008). Cultural competence in trauma therapy:
Arm, J. R., Horne, S. G., & Levitt, H. M. (2009). Negotiating Beyond the flashback. Washington, DC: American Psycho-
connection to GLBT experience: Family members’ experi- logical Association.
ence of anti-GLBT movements and policies. Journal of Brown, S. D., & Lent, R. W. (Eds.). (1984). Handbook of
Counseling Psychology, 56, 82–96. counseling psychology. New York: Wiley.
Association of Lesbian, Gay, Bisexual, and Transgender Issues in Brown, S. D., & Lent, R. W. (Eds.). (1992). Handbook of
Counseling. (2009). Competencies for counseling with trans- counseling psychology (2nd ed.). New York: Wiley.
gender clients. Alexandria, VA: Author. Brown, S. D., & Lent, R. W. (Eds.). (2000). Handbook of
Association of Lesbian, Gay, Bisexual, and Transgender Issues in counseling psychology (3rd ed.). New York: Wiley.
Counseling. (2010). Statement from ALGBTIC Division on Brown, S. D., & Lent, R. W. (Eds.). (2008). Handbook of
Conversion Therapy. Retrieved July 18, 2010, from http:// counseling psychology (4th ed.). New York: Wiley.
www.algbtic.org/resources/tfct.htm. Browning, C., Reynolds, A. L., & Dworkin, S. H. (1991).
Bailey, J. M. (2003). Biological perspectives on sexual orienta- Affirmative psychotherapy for lesbian women. The Counseling
tion. In L. D. Garnets & D. C. Kimmel (Eds.), Psychological Psychologist, 19, 177–196.

m or row 429
Buhrke, R. A., & Douce, L. A. (1991). Training issues for coun- Dillon, F. R., & Worthington, R. L. (2003). The Lesbian, Gay,
seling psychologists in working with lesbian women and gay and Bisexual Affirmative Counseling Self-Efficacy Inventory
men. The Counseling Psychologist, 19, 216–234. (LGB-CSI): Development, validation, and training implica-
Carroll, L., & Gilroy, P. J. (2001). Teaching “outside the tions. Journal of Counseling Psychology, 50, 235–251.
box”: Incorporating queer theory in counselor education. Division 44/Committee on Lesbian, Gay, Bisexual Concerns
Journal of Humanistic Counseling, Education & Development, Joint Task Force on Guidelines for Psychotherapy with
40, 49–58. Lesbian, Gay, and Bisexual Clients. (2000). Guidelines for
Cass, V. C. (1979). Homosexual identity formation: A theoreti- psychotherapy with lesbian, gay, and bisexual clients.
cal model. Journal of Homosexuality, 4, 219–236. American Psychologist, 55, 1440–1151.
Chung, Y. B. (2001). Work discrimination and coping strate- Fassinger, R. E. (Ed.). (1991a). Counseling lesbian women and
gies: Conceptual frameworks for counseling lesbian, gay, gay men [Special issue]. The Counseling Psychologist, 19(2).
and bisexual clients. Career Development Quarterly, 50, Fassinger, R. E. (1991b). The hidden minority: Issues and chal-
33–44. lenges in working with lesbian women and gay men. The
Chung, Y. B. (2003a). Career counseling with lesbian, gay, bisex- Counseling Psychologist, 19, 157–176.
ual, and transgendered persons: The next decade. Career Fassinger, R. E. (2000). Gender and sexuality in human develop-
Development Quarterly, 52, 78–86. ment: Implications for prevention and advocacy in counsel-
Chung, Y. B. (2003b). Ethical and professional issues in career ing psychology. In S. D. Brown & R. W. Lent (Eds.),
assessment with lesbian, gay, and bisexual persons. Journal Handbook of counseling psychology (3rd ed., pp. 346–378).
of Career Assessment, 11, 96–112. New York: Wiley.
Cochran, S. D., Sullivan, J. G., & Mays, V. M. (2003). Prevalence Fassinger, R. E., & Arseneau, J. R. (2007). “I’d rather get wet
of mental disorders, psychological distress, and mental health than be under that umbrella”: Differentiating the experiences
services use among lesbian, gay, and bisexual adults in the and identities of lesbian, gay, bisexual, and transgender
United States. Journal of Consulting and Clinical Psychology, people. In K. J. Bieschke, R. M. Perez, & K. A. DeBord
71, 53–61. (Eds.), Handbook of counseling and psychotherapy with lesbian,
Coleman, E. (1978). Toward a new model of homosexuality: gay, bisexual, and transgender clients (2nd ed., pp. 19–50).
A review. Journal of Homosexuality, 3, 345–359. Washington, DC: American Psychological Association.
Coleman, E. (1982). Developmental stages of the coming-out Fassinger, R. E., & Miller, B. A. (1996). Validation of an inclu-
process. Journal of Homosexuality, 7(2), 31–43. Beverly Hills: sive model of sexual minority identity formation on a sample
Sage. of gay men. Journal of Homosexuality, 32, 53–78.
Conger, J. J. (1975). Proceedings of the American Psychological Fassinger, R. E., & Sperber-Richie, B. (1997). Sex matters: Gender
Association, Incorporated, for the year 1974: Minutes of the and sexual orientation training for multicultural counseling
Annual meeting of the Council of Representatives. American competency. In D. B. Pope-Davis & H. L. K. Coleman (Eds.),
Psychologist, 30, 620–651. Multicultural counseling competencies: Assessment, education
Croteau, J. M, Anderson, M. Z., Distefano, T. M., & and training, and supervision (pp. 83–110). Thousand Oaks,
Kampa-Kokesch, S. (2000). Lesbian, gay, and bisexual CA: Sage.
vocational psychology: Reviewing and planning construc- Fausto-Sterling, A. (1998). The five sexes: Why male and female
tion. In R. M. Perez, K. A. DeBord, & K. J. Bieschke (Eds.), are not enough. In D. L. Anselmi & A. L. Law (Eds.),
Handbook of counseling and psychotherapy with lesbian, gay, Questions of gender: Perspectives and paradoxes (pp. 24–28).
and bisexual clients (pp. 383–408). Washington, DC: Boston: McGraw-Hill.
American Psychological Association. Fox, R. C. (1996). Bisexuality in perspective: A review of theory
Croteau, J. M., Bieschke, K. J., Fassinger, R. E., & Manning, J. L. and research. In Firestein (Ed.), Bisexuality: The psychology
(2008). Counseling psychology and sexual orientation: and politics of an invisible minority (pp. 3–50). Thousand
History, selective trends, and future directions. In S. D. Brown Oaks, CA: Sage.
and R. W. Lent (Eds.), Handbook of counseling psychology Frost, D. M., & Meyer, I. H. (2009). Internalized homophobia
(4th ed., pp. 194–211). Hoboken, NJ: Wiley. and relationship quality among lesbians, gay men, and bisex-
DeBlaere, C., Brewster, M. E., Sarkees, A., & Moradi, B. (2010). uals. Journal of Counseling Psychology, 56, 97–109.
Conducting research with LGB people of color: Meth- Fukuyama, M. A., & Ferguson, A. D. (2000). Lesbian, gay,
odological challenges and strategies. The Counseling Psycho- and bisexual people of color: Understanding cultural com-
logist, 38, 331–362. plexity and managing multiple oppressions. In R. M. Perez,
Diamond, L. M. (1998). Development of sexual orientation K. A. DeBord, & K. J. Bieschke (Eds.), Handbook of counsel-
among adolescent and young adult women. Developmental ing and psychotherapy with lesbian, gay, and bisexual transgen-
Psychology, 34, 1085–1095. der clients (pp. 81–106). Washington, DC: American
Diamond, L. M. (2000). Sexual identity, attractions, and behav- Psychological Association.
ior among young sexual-minority women over a 2-year Gagné, P., Tewksbury, R., & McGaughey, D. (1997). Coming
period. Developmental Psychology, 36, 241–250. out and crossing over: Identity formation and proclama-
Diamond, L. M. (2005). A new view of lesbian subtypes: Stable tion in a transgender community. Gender and Society, 11,
versus fluid identity trajectories over an 8-year period. 478–508.
Psychology of Women Quarterly, 29, 119–128. Gonsiorek, J. C. (1991). The empirical basis for the demise of
Diamond, L. M. (2008). Sexual fluidity: Understanding women’s the illness model of homosexuality. In J. Gonsiorek &
love and desire. Cambridge: Harvard University Press. J. Weinrich (Eds.), Homosexuality: Research implications for
Dickson, N., Paul, C., & Herbison, P. (2003). Same-sex attrac- public policy (pp. 115–136). Thousand Oaks, CA: Sage.
tion in a birth cohort: Prevalence and persistence in early Greene, B. (2000). Beyond heterosexism and across the cultural
adulthood. Social Science & Medicine, 56, 1607–1615. divide: Developing an inclusive lesbian, gay, and bisexual

430 sexual orie n tatio n s an d id en tities

 psychology: A look to the future. In B. Greene (Ed.), Kinsey, A. C., Pomeroy, W. B., & Martin, C. E. (1948). Sexual
Education, research, and practice in lesbian, gay, bisexual, and behavior in the human male. Philadelphia: W. B. Saunders.
transgendered psychology (pp. 1–45). Thousand Oaks, CA: Kinsey, A. C., Pomeroy, W. B., Martin, C. E., & Gebhard, P. H.
Sage. (1953). Sexual behavior in the human female. Philadelphia:
Green, J. (2000). Introduction to transgender issues. Washington, W. B. Saunders.
DC: National Gay and Lesbian Task Force. Korrell, S. C., & Lorah, P. (2007). An overview of affirmative
Haldeman, D. C. (1994). The practice and ethics of sexual orien- psychotherapy and counseling with transgender clients.
tation conversion therapy. Journal of Consulting and Clinical In K. J. Bieschke, R. M. Perez, & K. A. DeBord (Eds.),
Psychology, 62, 221–727. Handbook of counseling and psychotherapy with lesbian, gay,
Haldeman, D. C. (2001). Therapeutic antidotes: Helping gay bisexual, and transgender clients (2nd ed., pp. 271–288).
and bisexual men recover from conversion therapies. Journal Washington, DC: American Psychological Association.
of Gay & Lesbian Psychotherapy, 5(3–4), 117–130. Lev, A. I. (2007). Transgender communities: Developing iden-
Haldeman, D. C. (2004). When sexual and religious orientation tity through connection. In K. J. Bieschke, R. M. Perez, &
collide: Considerations in working with conflicted same- K. A. DeBord (Eds.), Handbook of counseling and psychother-
sex attracted male clients. The Counseling Psychologist, 32, apy with lesbian, gay, bisexual, and transgender clients (2nd ed.,
691–715. pp. 147–176). Washington, DC: American Psychological
Halpert, S. C., Reinhardt, B., & Toohey, M. J. (2007). Affirmative Association.
clinical supervision. In K. J. Bieschke, R. M. Perez, & Levitt, H. M., Ovrebo, E., Anderson-Cleveland, M. B., Leone, C.,
K. A. DeBord (Eds.), Handbook of counseling and psychother- Jae, Y. J., & Arm, J. R., et al. (2009). Balancing dangers:
apy with lesbian, gay, bisexual, and transgender clients (2nd ed., GLBT experience in the time of anti-GLBT legislation.
pp. 241–258). Washington, DC: American Psychological Journal of Counseling Psychology, 56, 67–81.
Association. McCarn, S. R., Fassinger, R. E. (1996). Revisioning sexual
Hare-Mustin, R. T.; Marecek, J. (1990). Gender and the minority identity formation: A new model of lesbian identity
meaning of difference: Postmodernism and psychology. and its implications for counseling and research. The
In R. T. Hare-Mustin & J. Marecek (Eds.), Making a differ- Counseling Psychologist, 24, 508–534.
ence: Psychology and the construction of gender (pp. 22–64). Meyer, I. H., & Wilson, P. A. (2009). Sampling lesbian, gay, and
New Haven, CT: Yale University Press. bisexual populations. Journal of Counseling Psychology, 56,
Haselkorn, H. (1956). The vocational interests of a group of 23–31.
male homosexuals. Journal of Counseling Psychology, 3, 8–11. Meyer, W. J. III, Bockting, W. O., Cohen-Kettenis, P. T.,
Herek, G. M. (2003). Sexual prejudice: Prevalence. Retrieved July Coleman, E., Di Ceglie, D., Devor, H., et al. (2001).
18, 2010, from http://psychology.ucdavis.edu/rainbow/ The standards of care for gender identity disorders (6th ed.).
html/prej_prev.html. Minneapolis: Harry Benjamin International Gender Dys-
Herek, G. M. (2004). Beyond “homophobia”: Thinking about phoria Association.
sexual prejudice and stigma in the twenty-first century. Moradi, B., DeBlaere, C., & Huang, Y. (Eds.). (2010a). Research
Sexuality Research and Social Policy, 1(2), 6–24. with Lesbian, Gay, and Bisexual people of color [Special
Herek, G. M., Berrill, K., & Berrill, K. T. (1992). Hate crimes: issue]. The Counseling Psychologist, 38.
Confronting violence against lesbians and gay men. Newbury Moradi, B., DeBlaere, C., & Huang, Y. (Eds.). (2010b).
Park, CA: Sage. Centralizing the experiences of LGB people of color in
Herek, G. M., Kimmel, D. C., Amaro, H., & Melton, G. B. counseling psychology. The Counseling Psychologist, 38,
(1991). Avoiding heterosexist bias in psychological research. 322–330.
American Psychologist, 46, 957–963. Moradi, B., Mohr, J. J., Worthington, R. L., & Fassinger, R. E.
Hooker, E. (1957). The adjustment of the male overt homosex- (2009). Counseling psychology research on sexual (orienta-
ual. Journal of Projective Techniques, 21, 18–31. tion) minority issues: Conceptual and methodological chal-
House passes “Don’t ask, don’t tell” repeal amendment, Senate bill lenges and opportunities. Journal of Counseling Psychology,
advances. (2010, June 23). The Huffington Post. Retrieved June 56, 5–22.
23, 2010, from http://www.huffingtonpost.com/2010/05/27/ Morgan, K. S., & Brown, L. S. (1991). Lesbian career develop-
senate-armed-services-com_n_592782.html. ment, work behavior, and vocational counseling. The Coun-
Human Rights Campaign. (2010). Documenting discrimination. seling Psychologist, 19, 273–291.
Retrieved July 18, 2010, from http://www.hrc.org/issues/ Morin, S. F. (1977). Heterosexual bias in psychological research
parenting.asp. on lesbianism and male homosexuality. American Psychologist,
Israel, T., Ketz, K., Detrie, P. M., Burke, M. C., & Shulman, J. L. 32, 629–637.
(2003). Identifying counselor competencies for working Morrow, S. L., & Beckstead, A. L. (2004). Conversion therapies
with lesbian, gay, and bisexual clients. Journal of Gay and for same-sex attracted clients in religious conflict: Context,
Lesbian Psychotherapy, 7, 3–21. predisposing factors, and implications for therapy. The
Jacobson, B., & Donatone, B. (2009). Homoflexibles, omnisex- Counseling Psychologist, 32, 641–650.
uals, and genderqueers: Group work with queer youth in Patterson, C. J. (2006). Children of lesbian and gay parents.
cyberspace and face-to-face. Group, 33, 223–234. Current Directions in Psychological Science, 15, 241–244.
Journal of Counseling Psychology. (2009). Advances in research Patterson, C. J. (2007). Lesbian and gay family issues in the
with sexual minority people. [Special issue]. Journal of context of changing legal and social policy environments.
Counseling Psychology, 56(1). In K. J. Bieschke, R. M. Perez, & K. A. DeBord (Eds.),
Keys, D. P. (2002). Instrumental sexual scripting: An examina- Handbook of counseling and psychotherapy with lesbian, gay,
tion of gender-role fluidity in the correctional institution. bisexual, and transgender clients (2nd ed., pp. 359–377).
Journal of Contemporary Criminal Justice, 18, 258–278. Washington, DC: American Psychological Association.

m or row 431
Potoczniak, D. J. (2007). Development of bisexual men’s identi- Stokes, J. P., McKirnan, D., & Burzette, R. (1993). Sexual
ties and relationships. In K. J. Bieschke, R. M. Perez, & behavior, condom use, disclosure of sexuality, and stability of
K. A. DeBord (Eds.), Handbook of counseling and psychother- sexual orientation in bisexual men. Journal of Sex Research,
apy with lesbian, gay, bisexual, and transgender clients (2nd ed., 30, 203–213.
pp. 119–146). Washington, DC: American Psychological Sue, D. W., Arredondo, P., & McDavis, R. J. (1992). Multicul-
Association. tural counseling competencies and standards: A call to the pro-
Reise, S. P., Waller, N. G., & Comrey, A. L. (2000). Factor fession. Journal of Counseling & Development, 70, 477–486.
analysis and scale revision. Psychological Assessment, 12, Sue, D. W., & Sue, D. (1999). Counseling the culturally different:
287–297. Theory and practice (3rd ed.). New York: Wiley.
Risco, C. M. (2008). Evaluation of a culturally inclusive model Szymanski, D. M. (2009). Examining potential moderators of
of sexual minority identity formation (Unpublished master’s the link between heterosexist events and gay and bisexual
thesis). University of Maryland, College Park, MD. men’s psychological distress. Journal of Counseling Psychology,
Risco, C., & Fassinger, R. E. (2007). Exploring identity processes 56, 142–151.
for LGB people of color: Validation of a dual-trajectory model Thaweesit, S. (2004). The fluidity of Thai women’s gendered
of sexual minority development. Unpublished manuscript, and sexual subjectivities. Culture, Health, & Sexuality, 6,
University of Maryland. 205–219.
Rostosky, S. S., Riggle, E. D. B., Horne, S. G., & Miller, A. D. Vale, K., Johnson, T. W., Jansen, M. S., Lawson, B. K.,
(2009). Marriage amendments and psychological distress in Lieberman, T., Willette, K. H., & Wassersug, R. J. (In press).
lesbian, gay, and bisexual (LGB) adults. Journal of Counseling The development of standards of care for individuals with
Psychology, 56, 56–66. a male-to-eunuch gender identity disorder. International
Rothblum, E. D. (2000). “Somewhere in Des Moines or San Journal of Transgenderism, 12.
Antonio”: Historical perspectives on lesbian, gay, and bisex- Warner, M. (1999). Beyond gay marriage. In M. Warner, The
ual mental health. In R. M. Perez, K. A., DeBord, & trouble with normal: Sex, politics, and the ethics of queer life.
K. J. Bieschke (Eds.), Handbook of counseling and psychother- New York: Free Press.
apy with lesbian, gay, and bisexual clients (pp. 57–79). Wassersug, R., & Johnson, T. (2007). Modern-day eunuchs:
Washington, DC: American Psychological Association. motivations for and consequences of contemporary castra-
Rust, P. C. (1996). Managing multiple identities: Diversity tion. Perspectives in Biology and Medicine, 50, 544–546.
among bisexual women and men. In B. A. Firestein (Ed.), Weinberg, M. S., Williams, C. J., & Pryor, D. W. (1994). Dual
Bisexuality: The psychology and politics of an invisible minority attraction: Understanding bisexuality. New York: Oxford
(pp. 53–83). Thousand Oaks, CA: Sage. University Press.
Rust, P. C. R. (2007). The construction and reconstruction of Weinberg, M. S., Williams, C. J., & Pryor, D. W. (2001).
bisexuality. In B. Firestein (Ed.), Becoming visible: Counseling Bisexuals at midlife: Commitment, salience, and identity.
bisexuals across the lifespan (pp. 3–27). New York: Columbia Journal of Contemporary Ethnography 30(2), 180–208.
University Press. Whitman, H. L., Glosoff, M., Kocet, M., & Tarvydas, V. (2006).
Sánchez, F. J., & Vilain, E. (2009). Collective self-esteem as Ethical issues related to conversion or reparative therapy.
a coping resource for male-to-female transsexuals. Journal Retrieved July 18, 2010 from http://www.counseling.org/
of Counseling Psychology, 56, 202–209. PressRoom/NewsReleases.aspx?AGuid=b68aba97–2f08–40-
Savin-Williams, R. C. (2003). Lesbian, gay and bisexual c2-a400–0630765f72f4.
youths’ relationships with their parents. In L. D. Garnets & Wolitski, R. J., Jones, K. T., Wassserman, J. L, & Smith, J. C.
D. C. Kimmel (Eds.), Psychological perspectives on lesbian, (2006). Self-identification as “down low” among men who
gay, and bisexual experiences (2nd ed., pp. 299–326). New have sex with men (MSM) from 12 US cities. AIDS and
York: Columbia University Press. Behavior, 10, 519–529.
Shannon, J. W., & Woods, W. J. (1991). Affirmative psychother- Worthington, R. L., & Navarro, R. L. (2003). Pathways to the
apy for gay men. The Counseling Psychologist, 19, 197–215. future: Analyzing the contents of a content analysis. The
Shidlo, A., & Schroeder, M. (2002). Changing sexual orienta- Counseling Psychologist, 31, 85–92.
tion: A consumers’ report. Professional Psychology: Research Wrenn, C. G. (1962). The culturally encapsulated counselor.
and Practice, 33, 249–259. Harvard Educational Review, 32, 444–449.
Shively, M. G., & De Cecco, J. P. (1993). Components of sexual Zea, M. C., Reisen, C. A., & Díaz, R. M. (2003). Methodological
identity. In L. Garnets & D. C. Kimmel (Eds.), Psychological issues in research on sexual behavior with Latino gay and
perspectives on lesbian and gay male experiences. New York: bisexual men. American Journal of Community Psychology, 31,
Columbia University Press. 281–291.
Sophie, J. (1986). A critical examination of stage theories of
lesbian identity development. Journal of Homosexuality, 12,
39–51. Further Reading
Stack, P. F. (2010, November 11). Updated LDS handbook soft- Advances in Research with Sexual Minority People. (2009).
ens language on gays. The Salt Lake Tribune. Retrieved from [Special issue]. Journal of Counseling Psychology, 56(1).
http://www.sltrib.com/sltrib/home/50658721–76/church- Association of Lesbian, Gay, Bisexual, and Transgender Issues in
behavior-homosexual-gay.html.csp. Counseling. (2009). Competencies for counseling with trans-
Stokes, J. P., Damon, W., & McKirnan, D. J. (1997). Predictors gender clients. Alexandria, VA: Author.
of movement toward homosexuality: A longitudinal study of Bieschke, K. J., Perez, R. M., & DeBord, K. A. (Eds., 2007).
bisexual men. Journal of Sex Research, 34, 304–312. Handbook of counseling and psychotherapy with lesbian, gay,

432 sexual orie n tatio n s an d id en tities

 bisexual, and transgender clients (2nd ed.). Washington, DC: Minneapolis: Harry Benjamin International Gender
American Psychological Association. Dysphoria Association.
Division 44/Committee on Lesbian, Gay, and Bisexual Concerns Moradi, B., DeBlaere, C., & Huang, Y. (Eds.). (2010). Research
Joint Task Force on Guidelines for Psychotherapy with with lesbian, gay, and bisexual people of color. [Special issue].
Lesbian, Gay, and Bisexual Clients. (2000). Guidelines for The Counseling Psychologist, 38(3).
psychotherapy with lesbian, gay, and bisexual clients. Perez, R. M., DeBord, K. A., & Bieschke, K. J. (2000). Hand-
American Psychologist, 55, 1440–1151. book of counseling and psychotherapy with lesbian, gay, and
Meyer, W. J. III, Bockting, W. O., Cohen-Kettenis, P. T., bisexual clients. Washington, DC: American Psychological
Coleman, E., Di Ceglie, D., Devor, H., et al. (2001). Association.
The standards of care for gender identity disorders (6th ed.).

m or row 433
 CHAPTER

16 Feminist Approaches to Counseling

Carolyn Zerbe Enns

Abstract
This chapter summarizes central values and features of feminist counseling. It discusses feminist
theories that support feminist counseling, characteristics of an egalitarian feminist therapy
relationship, and the ways in which feminist counselors enact the maxim “the personal is political.”
A biopsychosocial, ecological approach to assessment and conceptualization is proposed. The chapter
articulates ways in which feminist counseling operates from a social justice perspective informed by
locational, intersectional, and multicultural frameworks, as well as approaches that are attentive to
the diverse gender and social identities of clients. Examples of feminist counseling as an integrative
approach are provided. Future directions include building linkages across social justice approaches
and practicing feminist values in a changing society, in counseling men, and in global contexts.
Keywords: the personal is political, social justice, feminist counseling, feminist theory, gender
counseling, counseling relationship, egalitarian, multicultural, social identity, biopsychosocial, ecological,
social identity

Feminist therapy emerged in the midst of second- Clarkson, Rosenkrantz, & Vogel, 1970), psycho-
wave feminist activism during the 1960s and 1970s therapy relationships in which the therapist defined
(Contratto & Rossier, 2005; Kaschak, 1981). The reality for the client (Chesler, 1972), and diagnostic
first forms of feminist counseling and therapy were practices that contributed to the labeling of persons
modeled after consciousness-raising groups, which without regard to the contexts in which they experi-
were created as a vehicle for exploring women’s enced distress (Kaplan, 1983). Extended definitions
experiences of sexism and discrimination, and buil- and principles of feminist counseling and psycho-
ding commitment to social and political activism. therapy were constructed during the mid-1970s and
Participants soon discovered that these ad hoc 1980s (e.g., Brodsky, 1980; Greenspan, 1983;
groups also offered therapeutic and personal growth Rawlings & Carter, 1977; Sturdivant, 1980).
benefits, assisted women in making connections During its 40-year evolution, feminist counsel-
between the personal and political realities of their ing has grown from a critique of psychotherapy
lives, and fostered visions of mental health based on practice to a well-developed approach that is embed-
egalitarian roles (Brodsky, 1977; Kravetz, 1978). ded within the rich research and theoretical founda-
In parallel developments, feminist psychologists tion of the feminist psychology of women and
identified biases within personality theories and gender (e.g., Crawford, 2006; Matlin, 2008; Yoder,
research (Barrett, Berg, Eaton, & Pomeroy, 1974; 2007) and featured in a variety of introductory
Weisstein, 1970), double standards of mental heath counseling texts (e.g., Corey, 2009; Murdock, 2008;
that overvalued “masculine” attributes and deval- Sharf, 2008). Feminist therapists have also contrib-
ued “feminine” attributes (Broverman, Broverman, uted to a wider consensus about values, ethics, and

434
consumer rights in counseling. For example, femi- historical perspective on feminist theories that
nist psychologists were among the first to call for inform feminist counseling. Following a discussion
informed consent practices and increased attention of the counseling relationship, it uses “the personal
to the rights of clients (Hare-Mustin, Marecek, is political” as an organizer for summarizing major
Kaplan, & Liss-Levinson, 1979). Feminist coun- characteristics. Later sections of the chapter illus-
selors brought attention to the ethical problems of trate several ways in which feminist counseling
violence and abuse in relationships, boundary viola- operates as an integrative approach. It concludes
tions in psychotherapy, careless and harmful diag- with a brief discussion of new directions and issues
nostic practices, gender role strains that limited in feminist counseling. The themes discussed in this
development, and a monocultural model of mental chapter are informed by the APA (2007) Guidelines
health. They also proposed aspirational approaches for Psychological Practice with Girls and Women
to ethics (Brabeck, 2000; Brown & Brodsky, 1992; (referred to hereafter as the 2007 Guidelines); the
Feminist Therapy Institute [FTI] 2000; Vasquez, APA (2003) Guidelines on Multicultural Education
2003). Most recently, many of the values and con- and Training, Research, Practice, and Organization
tributions of feminist psychologists have informed Change for Psychologists; and the APA (2000)
the American Psychological Association’s (APA) Guidelines for Psychotherapy with Lesbian, Gay,
Guidelines for Psychological Practice with Girls and and Bisexual Clients.
Women (2007).
Since its earliest days, feminist counseling has Values and Foundations of Feminist
been described as a large umbrella or awning that Counseling
supports a flexible scaffold for organizing philo- In her landmark description, Gilbert (1980) identi-
sophical assumptions about human experience, per- fied two core features of feminist therapy: the per-
sonal and social change, and approaches to seeking sonal is political, and the psychotherapy relationship
knowledge (Brown, 2010; Rawlings & Carter, is egalitarian. During the past 30 years, feminist
1977). This overarching structure provides a foun- practitioners have elaborated substantially on these
dation for social justice–oriented practice; is embed- tenets, and most of the central values of feminist
ded in interdisciplinary scholarship and activism; therapy can still be organized around these two
and encompasses personal, interpersonal, collective, major themes (Ballou, Hill, & West, 2008; Worell
and sociocultural transformation. It is informed by & Remer, 2003). The phrases “the personal is polit-
scholarship about multiculturalism, the study of ical” and the “the political is personal” emphasize
oppression in its many forms (e.g., racism, sexism, the systemic, sociocultural, and ecological pers-
heterosexism, classism, ageism, ableism), and meth- pectives that are central to feminist concepts of
ods for challenging and transcending biases and distress and change. These phrases also highlight the
discrimination. Feminist counseling represents an importance of consciousness-raising and empower-
integrative and technically eclectic approach that ment at individual, interpersonal, and societal levels.
can be compatible with many approaches to psy- The egalitarian relationship represents the context
chotherapy, prevention, and social activism. Fem- in which feminist values are modeled and enacted,
inist counseling is informed by values that are most and new forms of behavior are practiced and
consistently reflected in how one thinks about dis- affirmed. Egalitarian relationships are also valued as
tress and change, rather than in specific counselor goals and outcomes of feminist counseling (Ballou
behaviors. It is “a sensibility, a political and aesthetic & West, 2000; Brown, 1994, 2010; Enns, 2004;
center that informs a work pervasively” (Luepnitz, Worell & Remer, 2003; Wyche & Rice, 1997).
1988, p. 231), and “not a prescription or technique” As feminist counseling has matured, a third
(Brown & Brodsky, 1992, p. 51). As a result, femi- theme of diversity has become central to practice.
nist counseling holds affinity with theories that are Feminist counseling is informed by multicultural,
attentive to the diversity and complexity of women’s intersectional, and locational perspectives that con-
and men’s lives, recognize the intricate connections ceptualize identities and experience as complex,
between the internal and external worlds of all changing, and socially constructed (American Psy-
people, and give voice to the worldviews and per- chological Association [APA], 2007; Porter, 2005;
spectives of those who experience discrimination Shields, 2008; Stewart & McDermott, 2004;
and oppression. Worell & Remer, 2003). Porter (2005) uses the rep-
This chapter provides a glimpse of central values etition of one word—“location, location, location”
and features of feminist counseling and includes a (p. 144)—to highlight three central positionalities

e nns 435
or perspectives that are brought to the counse- most significant, or unifying form of oppression
ling context by the theorist, the therapist, and the that links all women and girls (e.g., Espín &
client. Contemporary feminist therapists seek to be Gawelek, 1992; Comas-Díaz & Greene, 1994).
attentive to the multiple and diverse realities, roles,
and needs of women and men in a 21st-century Feminist Theory and Feminist Counseling
world. Feminist theories have developed along a parallel
The premises of multiracial feminism (Zinn & course that intersects with and complements femi-
Dill, 1996) and critical race feminism (Wing, 2000) nist counseling practice. Although feminist counsel-
are helpful for framing the wide range of interlock- ors share an endorsement of the three principles
ing identities, inequalities, privileges, and realities identified in the previous section, these commit-
that contribute to the construction of gender. ments are interpreted in multiple ways, depending
Gender, class, race, sexuality, ability, and a variety on the feminist theoretical orientation that a coun-
of additional social identities are experienced dif- selor chooses either implicitly or explicitly. Because
ferently, depending on one’s position in a “matrix these theoretical positions mark major areas of “non-
of domination” (Collins, 2000) and one’s access to consensus” within feminist counseling (Ballou &
social privilege and power. These interlocking fea- Gabalac, 1985), it is important to briefly discuss
tures are not separable but operate simultaneously their development and the ways in which they have
and uniquely to shape an individual’s experience. informed feminist counseling. More detailed discus-
Each element of identity, such as religion, sexual sions of feminist theory and psychology can be found
orientation, or nationality, shapes how other aspects in Enns (2004) and Enns and Sinacore (2005).
of self are experienced, and the salience of any one
dimension may vary across contexts (Wing, 2000). Second-wave Feminisms and
Furthermore, privilege and oppression are not Feminist Practice
“always or never” experiences. As the foreground During the early years of feminist counseling,
and background of various identities shift across various civil rights movements, including anti-
contexts, a person may experience privilege in one psychiatry and radical psychiatry traditions, chal-
situation (e.g., due to light skin color, heterosexual lenged the very structure of society and its mental
orientation, or middle-class status) and discrimina- health professions (Ballou et al., 2008). Most femi-
tion in another setting (e.g., gender-based bias in nist theories addressed four themes: the descrip-
a setting in which a person is the only woman). This tion of gendered oppression, why and how power
locational perspective is not only relevant to women, differences and oppression exist and are perpetu-
but also to men and boys of all classes, genders, and ated, the goals of feminism or what “should be,” and
races. In addition, all groups are characterized by strategies for eliminating injustice and changing
within-group diversity (Shields, 2008; Stewart & reality (Bunch, 1987). Many second-wave feminist
McDermott, 2004). theorists developed comprehensive explanations
Visual cues, such as skin color or body size, may or “grand theories” (Jaggar, 2008) about why
also modify experiences of gendered privilege and oppression occurs and how inequality can be elimi-
oppression. For example, discrimination on the nated. The theories that gained the widest recogni-
basis of skin color, including skin tone, often perme- tion and prominence included liberal feminism,
ates class, gender, and sexual identities and life expe- socialist feminism, radical feminism, and cultural
riences (Higginbotham, 1992; Root, 1995). Thus, feminism.
for many women of color, racism is a more everyday In general, liberal feminist theorists and activists
and virulent experience than is sexism, and may be have worked to reform existing institutions rather
magnified by a variety of microaggressions that can than question their underlying foundations. They
have powerful negative effects on well-being, but emphasize equal opportunity, personal initiative,
may be discounted or minimized by perpetrators and fair treatment of individuals. The impact of
(Sue et al., 2007). Alternatively, the invisibility asso- liberal feminist thought can be found in a variety
ciated with statuses, such as a lesbian identity, can of research and therapeutic approaches that empha-
also contribute to complex decisions about “coming size “nonsexist” therapy and a “questioning” per-
out,” which are likely to affect experiences of oppres- spective within psychology (Ballou & Gabalac,
sion and privilege (Stein, 1997). Although gender is 1985; Rawlings & Carter, 1977). Consistent with
a powerful social cue associated with privilege and liberal feminism, these approaches focus on eff-
power, gender cannot be assumed to be the primary, orts to eliminate biases in treatment and research,

436 fem in ist ap p roach e s to co u n s el in g

disentangle myths about individual gender differ- of race/ethnicity, class/economics, and gender
ences, treat clients and research participants equi- to explain social problems, and emphasized the
tably, and enhance the objectivity with which importance of understanding intersecting forms of
researchers and therapists approach their work inequality (Tong, 2008). Socialist feminist theories
(McHugh, Koeske, & Frieze, 1986). also became a foundation for some second-wave
Second-wave radical feminist theorists proposed women of color feminisms (e.g., Combahee River
that gender-based oppression is the original and Collective, 1982).
most pervasive form of oppression. According to Feminist practice rooted in radical and socialist
radical theorists, gender oppression appears in all principles has occurred most frequently in grass-
cultures. It is often manifested through the exploita- roots, community-based feminist organizations.
tion of women’s sexuality, such as through violence Early practices were based on group process, infor-
against women, the imposition of heterosexual mal connections, advocacy for women as a group,
norms, and the control of women’s reproductive volunteerism, and decision-making by consensus.
physiology (Jaggar & Rothenberg, 1993). Theorists Over time, these organizations increasingly empha-
have called for the dismantling of patriarchal power sized meeting the individual needs of clients and
at its roots and a reconstruction of society, to be implemented more formal, hierarchical organiza-
accomplished by abolishing gender and sex roles tional and decision-making structures that suppor-
and replacing them with new possibilities that are ted efforts to acquire government funding (Kravetz,
free of gender stereotypes and mandates (Kaschak, 2004; Metzendorf, 2005). With external funding
1981; Lorber, 2005; Tong, 2008). came requirements for grassroots agencies to pro-
Radical approaches that challenge institu- vide “professional” services and to be accountable to
tional structures have been closely connected to funding agencies. As a result of these changes and
consciousness-raising activities, but the deep appli- the growing power of formal diagnosis to dictate the
cation of radical principles has not been compatible terms of psychotherapy, organizations that rely on
with well-established disciplines, including profes- radical and socialist practices have decreased in
sional and academic psychology (Ballou & Gabalac, number and become less visible.
1985; Crowley-Long, 1998). Many second-wave A fourth second-wave feminism, cultural femi-
grassroots antiviolence programs, such as domestic nism, has focused on transforming individuals
violence shelters and antirape programs, were built and the larger culture by challenging the hege-
on radical feminist principles and offered therapeu- mony or dominance of individualistic “masculine”
tic services consistent with a radical egalitarian values such as autonomy, independence, and self-
approach that rejected the use of diagnosis, relied on sufficiency. A major goal of cultural feminism is to
forms of psychotherapy informed by consciousness- revalue and infuse “feminine” and relationally ori-
raising practices, incorporated peer support among ented values throughout the culture (Donovan,
survivors/victims, and emphasized organizational 2000). Women’s historic roles as nurturers and
decision-making based on consensus and social mothers are seen as important foundations for new
activism as a cornerstone of counseling (Enns, 1992; social structures based on nonviolence and coopera-
Kaschak, 1981). Burstow’s (1992) enduring radical tion. Some cultural feminists began their feminist
antipsychiatry approach highlights ways in which journey as radical feminists and adopted a radical-
woman is reduced to a body that is beautified, objec- cultural position as they moved toward supporting
tified, sexualized, exploited, and violated. She rejects women’s institutions and alternative autonomous
the use of psychotropic medications, and places pri- communities (e.g., bookstores, music festivals, les-
ority on practical assistance, advocacy, and social bian communities) that were designed to model
change. Others operating from a radical perspective options for living based on women’s strengths (Rudy,
have argued that all psychotherapy, including femi- 2001; Taylor, Whittier, & Pelak, 2001). Others
nist counseling, places the burden of change on indi- gravitated toward a cultural feminist perspective
viduals, and is inconsistent with an emphasis on after being exposed to the writings of feminist phi-
social change (e.g., Kitzinger & Perkins, 1993). losophers, psychologists, and scholars who chal-
Socialist feminist theorists have shared radical lenged traditional and patriarchal values embedded
feminist beliefs that social structures need to be dis- in academic disciplines (Robb, 2006).
mantled and transformed. In contrast to those who Psychological approaches with the greatest simi-
view gender as a fundamental focus of oppression, larity to cultural feminist values have sought to
socialist feminists generated an integrated analysis revalue “women’s way’s of knowing” (e.g., Belenky,

e nns 437
Clinchy, Goldberger, & Tarule, 1986) or women’s not self-identify as feminist often endorse liberal
relational self (e.g., Gilligan, 1982; Miller, 1976), feminist beliefs (e.g., Aronson, 2003; Quinn &
and have often emphasized a unique mother– Radtke, 2006; Zucker, 2004). These individuals are
daughter bond that fosters connection and growth sometimes referred to as egalitarians, lifestyle femi-
(e.g., Eichenbaum & Orbach, 1983). Within nists, or “I’m not a feminist, but . . .” women, and
feminist circles, Gilligan’s (1982) book on women’s may be responsive to feminist counseling practices
“different voice” received wide acclaim as well based on liberal feminist thought.
as criticism (Becker, 2005). Efforts to increase
awareness of options for gaining empowerment Diversification and Locational
through participation in the development of others Third-wave Feminisms
offered a corrective to psychological theories that By the mid 1980s and early 1990s, theories inspired
emphasized autonomy to the exclusion of relational by cultural feminism and other related second-wave
themes, and became a source of inspiration for approaches were often identified as “essentialist.”
many who identified themselves as feminist thera- They were often criticized for drawing generaliza-
pists. Others viewed these relational models as tions about the “universal woman,” and were charac-
encouraging romantic oversimplification of wom- terized as being inattentive to the standpoints, life
en’s experience (Kerber, 1986) or a reintroduction challenges, and survival needs of women of color
of the “cult of true womanhood” (Luria, 1986, (Jaggar, 2008; Thompson, 1998). An essentialist
p. 320). position was defined as treating gendered behaviors
Some of the most influential theoretical and as “fundamental attributes” (Bohan, 1993, p. 7) that
practice-oriented contributions in feminist therapy are persistent and “resident within the individual”
are referred to as relational-cultural theory (e.g., West, (p. 6). In contrast, constructionist alternatives were
2005), and were inspired in large part by woman- often posited as preferred alternatives, and these
centered psychological theories that bear resem- conceptualize gender as “doing,” as a byproduct of
blance to cultural feminist thought. Over time, these activity and interactions within a social context, and
approaches have expanded and increasingly central- as attentive to differences among people. Antiessen-
ized the lives of diverse groups of women (Goldberger, tialist critiques examined the ways in which the lives
1996; Jenkins, 2000; Turner, 1997; West, 2005). of white, middle-class women had become norma-
In general, relational-cultural feminist therapists tive within feminist theory and often led to the era-
frame connection and mutual empathy as the source sure of differences among women. Within psychology,
of mental health and identify disconnection as a theories about women’s relational self and “ways of
major cause of problems (Miller & Stiver, 1997). knowing” (e.g., Belenky et al., 1986; Gilligan, 1982)
Jaggar (2008) described second-wave rival theo- were sometimes seen as oversimplifying gender or
ries and their “bold conjectures” as “so ambitious even seeking to replace “woman as inferior” models
that they were massively underdetermined by the with “woman as superior” options (Tavris, 1992).
available data” (p. 193). Despite their limitations, Also criticized were empirical methods that
these theories spawned concepts and language that tended to reduce the complexity of gender to binary
raised consciousness about a wide range of gendered categories, as well as approaches that obscured the
social problems, such as date and acquaintance rape, complex dynamics of oppression and detracted from
sexual harassment, domestic violence, the second strength and coping perspectives by relying on a
shift, comparable worth, the feminization of poverty, “woman as victim” discourse (Lamb, 1999). Finally,
heterosexism, and sexual objectification. Second- approaches that drew arbitrary or artificial distinc-
wave theories remain influential, but feminist psy- tions between the “personal and the political,” or
chologists are less likely to be influenced by a single social and individual manifestations of distress, were
position. In an effort to address gaps within specific perceived as ignoring myriad ways in which the
theories, they are more likely to endorse hybrid political and personal interact in people’s lives
options that integrate multiple perspectives. (Cosgrove, 2002; Hurtado, 1989). Corrective efforts
Although some elements of all second-wave fem- tended to emerge in two forms: postmodern femi-
inisms can be seen within feminist psychology, the nist perspectives, and a variety of “diversity” app-
impact of liberal feminism has been more enduring, roaches that focused on the standpoints of women
perhaps because of its compatibility with institu- of color and lesbian women.
tionalized social science (Crowley-Long, 1998). Although theories and activism by and for
Various studies also reveal that many women who do women of color had been crucial to second-wave

438 fem in ist ap p roach e s to co u n s el in g

feminism (Smith, 1983; Thompson, 2002), the feminisms provided feminist psychologists with
voices of women of color feminists and lesbians tools for asking meta-theoretical questions about the
were sometimes marginalized or overlooked. Along role and function of theory and practice, and became
with growing awareness of the inadequacy of previ- a mechanism for supporting less all-encompassing
ous theories, the perspectives of women of color or “grand” theories and more modest approaches to
and lesbians have been increasingly centralized feminism (Enns, 2004). Postmodern reality (includ-
within feminist psychology. As noted by Butler ing feminist reality) is viewed as invented and nego-
(2000), when the lives of women with diverse life tiated in social relationships and historical contexts,
experiences, sexual orientations, and ethnicities are and reproduced through power relationships.
placed at the center of inquiry, the lives of privi- Of particular interest to postmodern feminists is
leged persons are more likely to be decentered the manner in which language reveals power rela-
and “we raise our awareness and understand of the tionships, which are often communicated as bipolar
experiences of all women either implicitly or and polarized concepts (e.g., strong vs. weak). The
directly” (p. 177). deconstruction of language reveals, for example,
A variety of standpoint feminisms, which were that when masculine is compared to feminine, or
authored by and highlighted the “herstories” and objective is placed beside subjective, the first word
lives of specific groups of women, featured Black in a pair typically assumes primacy or is more highly
feminist thought (e.g., Collins, 2000), Chicana valued than the second term. Multiple, nonopposi-
feminism (e.g., Bernal, 1998; Hurtado, 2003), Asian tional, or integrative ways of constructing social
feminisms (e.g., Asian Women United of California, reality become obscured (Scott, 1988). Deconstruc-
1997; Nam, 2001), and lesbian feminism (e.g., tion challenges existing power relationships and
Garber, 2001; Ross, 1995; Rudy, 2001). Other the- reveals that binary constructs such as heterosexual–
orists emphasized the complex interactions of sta- homosexual, white–black, and masculine–feminine
tuses and identities in their discussions of multiracial are creations that only have meaning when they are
feminism (Zinn & Dill, 1996), critical race femi- viewed as dichotomous entities.
nism (Wing, 2000), antiracist feminism (Calliste, Some authors have expressed concern that post-
Dei, & Aguilar, 2000), queer theory (Garber, 2001; modern thought can result in a slide into relativism,
Weed & Schor, 1997), Third World feminism in which all realities are placed into question (Alcoff,
(Mohanty, Russo, & Torres, 1991), and global/ 1988). Despite concerns about its inability to offer
transnational feminisms (Basu, 1995). Within femi- universal, enduring truths and a united rationale for
nist psychology, the voices of women of color theo- pursuing social change, postmodernism has become
rists and psychologists such as Jean Chin, Lillian increasingly accepted as a reminder of the complex-
Comas-Díaz, Oliva Espín, Beverly Greene, Maria ity of gender and related intersecting identities, as
Root, and Carolyn West have been influential in well as the ways in which power structures evolve
centralizing perspectives that emphasize the integra- over time. Gergen (2001) proposed that postmod-
tion of sexuality, race, colonialism, indigenous heal- ern theory provides us with tools for critiquing
ing practices, and immigration status (Barrett et al., narrow ways of conducting science and construct-
2005; Chin, 2000; Comas-Díaz, 2000; Comas-Díaz ing theory; encouraging psychologists to practice
& Greene, 1994; Espín, 1999; Root, 1992, 1995; reflexivity, which involves ongoing self-reflection
Jackson & Greene, 2000; West, 2002). Locational and self-questioning about the limitations of our
themes, an intersectional perspective, and a multi- perspectives; and recognizing the role of values and
cultural framework have become cornerstones of language in knowledge construction.
contemporary feminist counseling practice (Enns, Recent locational and postmodern feminisms
2010; Enns & Byars-Winston, 2010). speak to the importance of relying on flexible femi-
In other developments, many critiques of the nisms that recognize wide-ranging social identities
1980s and 1990s relied heavily on “deconstruction,” without exaggerating differences or seeing difference
which involves examining the implied meanings of as divisive (Friedman, 1998). These feminisms are
texts and concepts, such as the underlying assump- also marked by engagement with multiculturalism,
tions about truth, reality, language, and the self, and cultural studies, postcolonial studies, queer theory,
how these suppositions imbue concepts with power and transnational and poststructual views (Brown,
and authority (Flax, 1987). Postmodern feminists 1994; Enns, 2004). Many contemporary feminist
argued that it is impossible to create knowledge that therapists draw on these perspectives to create inte-
is ahistorical, universal, or context free. Postmodern grative, flexible frameworks that can be modified.

e nns 439
 A postmodern outlook has also been incor- Transparency on the part of the feminist thera-
porated within third-wave feminism, an approach pist is another foundational concept. Feminist ther-
that is often endorsed by the daughters and sons apists are encouraged to provide appropriate levels
of second-wave feminists who have benefited from of information about their values in order to convey
the higher levels of equality earned by previous respect for the client’s right to full disclosure about
generations (Peltola, Milkie, & Presser, 2004). Self- the therapist’s approach, ensure that therapists do
identified third-wave feminists tend to resist “politi- not inadvertently bring limited self-awareness or
cally correct” elements of second-wave feminism. hidden agendas to the working alliance, and provide
Instead, they tend to adopt strategic, hybrid, and a basis for clients to become full partners (Hare-
flexible approaches, and seek to apply the most Mustin et al., 1979). Despite these stated values,
appropriate feminist lens for the specific need or Marecek and Kravetz’s (1998) qualitative study
occasion. Their goals include expanding what it revealed that feminist therapists sometimes reported
means to be feminist, transcending seeming contra- concealing their feminist values from clients, fearing
dictions among feminist theories, and becoming that disclosure might limit their effectiveness or
more global in orientation (Heywood & Drake, credibility, or might lead to loss of business. Marecek
1997). Their activist efforts focus on a wide range and Kravetz argued that withholding such informa-
of causes (e.g., AIDS, racism, poverty, violence tion can be a form of dishonesty, may convey a
against women) and often rely on personal stories, patronizing attitude, or reveal limited respect for
cyberspace, Internet “zines,” and unique forms of clients’ abilities to think for themselves.
grassroots projects to communicate about feminist Although egalitarian values are central to femi-
issues (Baumgardner & Richards, 2000, 2005; nist concepts of growth, power differences are inevi-
Dicker & Piepmeier, 2003; Hernández & Rehman, table in relationships in which one person has
2002). Body image and body self-acceptance are studied psychological and social issues, gained pro-
also identified as revealing political implications of fessional credentials, and built knowledge based on
the personal (Rubin & Nemeroff, 2001). Feminist substantial experience. The adoption of “undifferen-
approaches to eating disorders and trauma are espe- tiated egalitarianism,” which involves the belief that
cially relevant to third-wave feminist counseling the erasure of all power differences is possible, can
applications. lead to the blurring of boundaries, inappropriate
role reversals, and carelessness about the therapist’s
The Feminist Therapist and the responsibilities to the client (Brown, 1991; FTI,
Counseling Relationship 2000). The feminist counselor is attentive to the
From its earliest days, feminist counselors have levels and forms of self-disclosure that are in the best
emphasized the importance of egalitarian relation- interests of the client. For example, she or he may
ships. In her influential critique, Chesler (1972) avoid communicating information that may over-
characterized the traditional therapeutic relation- whelm the client, or may be of limited use to the
ship as that of patriarch and patient and “just one client who is in crisis (Wyche & Rice, 1997).
more instance of an unequal relationship, just one Feminist counselors have also raised conscious-
more opportunity to be rewarded for expressing ness about abuses of power within psychotherapy,
distress and to be ‘helped’ by being (expertly) domi- such as sexual harassment and sexual victimization
nated” (p. 140). To redefine this relationship, the (FTI, 2000). Cognizant of the importance of rela-
feminist therapist became a “supporter and believer” tionship integrity, some feminist therapists have
(Brodsky, 1976, p. 376) of women’s competence found traditional rule-oriented approaches to mul-
and worked toward sharing power and responsi- tiple relationships to be overly rigid or even inhu-
bility with clients (Marecek & Kravetz, 1977). mane (Marecek & Kravetz, 1998). The FTI (2000)
Rawlings and Carter (1977) also recommended Code of Ethics uses the phrase “overlapping rela-
forming counseling contracts that specified goals, tionships” to convey the reality that multiple rela-
supported client autonomy, and limited the likeli- tionships are sometimes unavoidable. The feminist
hood that the therapist could manipulate the client. counselor takes care to monitor any overlapping
Feminist therapists’ attentiveness to client and ther- relationships, and works to support best interests of
apist responsibilities led to increased awareness the client. The counselor also ensures that therapeu-
throughout psychology of ethical issues regarding tic interactions are not sexualized.
informed consent, collaboration, and power dynam- The importance of relational facets of the coun-
ics (Ballou & Hill, 2008). seling relationship was documented by Rader and

440 fem in ist ap p roach e s to co u n s el in g

Gilbert’s (2005) study of 42 female therapists with men, feminist therapists were more likely to
and their clients. This study revealed that feminist report supporting men’s efforts to expand behaviors
therapists (19 persons) were more likely than coun- beyond traditional gender roles. No differences were
selors who did not identify themselves as feminists found in self-reports about unconditional positive
(15 individuals) to report using power-sharing regard or empathy.
behaviors and to show higher levels of agreement Another study, based on a survey of 108 family
with feminist attitudes. Clients who worked with therapists, revealed that, although general endorse-
these feminist therapists described their therapists as ment of feminist therapy behaviors was high, a
using power-sharing behaviors to a greater degree minority (35%) identified feminist therapy as a
than did clients who were paired with counselors guiding orientation (25% of 40 men and 40% of
who did not identify themselves as feminist. These 68 women). In addition, self-identification as a
two groups of therapists (feminist and those who did feminist therapist and exposure to gender-sensitive
not identify themselves as feminist) showed similar training experiences were associated with higher
levels of endorsement of feminist therapy behaviors levels of reported use of feminist therapy behav-
and techniques. Furthermore, clients who worked iors (Dankoski, Penn, Carlson, & Hecker, 1998).
with both groups of therapists did not differ with Similarly, a survey of male therapists found that
regard to their perceptions of their therapists’ use of 24% of 81 respondents identified themselves as
collaborative behaviors with clients. The absence feminist therapists. These therapists scored higher
of difference in the area of reported collaborative than did nonfeminist male therapists on scales that
behaviors may reflect the growing value placed on assessed attitudes toward gender roles and feminism
collaboration across contemporary psychotherapy as well as endorsement of feminist therapeutic
approaches. The lack of difference with regard to behaviors (Szymanski, Baird, & Kornman, 2002).
reported therapy behaviors is consistent with the Several studies have used qualitative approaches
definition of feminist therapy as a set of attitudes to explore counselors’ perceptions of core feminist
and beliefs rather than techniques. relationship behaviors. Hill and Ballou (1998) com-
A second study examined therapists’ endorse- pleted a content analysis of 35 feminist therapists’
ment of feminist therapy behaviors associated responses to open-ended questions that asked coun-
with three factors: the personal is political, empow- selors to describe how they had made the “substance
erment, and assertiveness/autonomy (Moradi, or ongoing dialogue of therapy feminist” (p. 7).
Fischer, Hill, Jome, & Blum, 2000). Whereas self- A majority of responses focused on how therapists
identification as a feminist therapist predicted showed sensitivity to issues of power in the counsel-
endorsement of the first two groups of behaviors ing relationship. The second most frequent theme
(the personal is political and empowerment), it did emphasized sociocultural and structural causes of
not predict a greater emphasis on assertiveness and distress. Other themes included a valuing of the
autonomy. Although assertive behaviors are often reality and priorities of clients, providing an inte-
identified as a component of feminist empower- grated analysis of the interlocking matrix of oppres-
ment (e.g., Worell, 2001), assertive behaviors are sion (e.g., sexism, sizism, racism), and valuing both
also valued goals of many nonsexist therapies, and overt and subtle social change goals. Another quali-
thus, may not reflect unique features of the feminist tative study of 13 self-identified feminist family
counseling relationship. therapists (Whipple, 1996) identified the following
More specific findings (Moradi et al., 2000) priorities of therapists: the formation of collabora-
revealed that, compared to therapists who did not tive, nonhierarchical relationships; exploration of
identify themselves as feminist (60 persons), self- gender and egalitarianism in relationships; and
identified feminist therapists (15 individuals) were empowerment and the affirmation of women.
more likely to report paying attention to clients’ Finally, Chester and Bretherton’s (2001) study of
experiences of oppression and discrimination, 140 feminist counselors made use of a checklist of
assuming a collaborative role with clients, and sup- feminist counseling characteristics. Over 90% of res-
porting self-esteem by focusing on positive and pondents identified the following as essential: knowl-
unique qualities of clients. When asked about their edge of sex-role stereotyping and lifespan issues
feminist behaviors with women clients, feminist of women, belief in the ability of women to reach
therapists were more likely to report reframing their potential, acknowledgment of the sociocultural
clients’ definitions of problems to include socializa- aspects of women’s problems, and encouraging
tion explanations. When asked about their work women to value themselves on their own terms.

e nns 441
 A common finding of these studies is that femi- women with high self-esteem. More recently, Fischer
nist counselors share perceptions that sociocultural and Holz’s (2007) study found initial support for
contributors to distress are central to assessment and a sequence in which public and private collective
counseling (the personal is political), and that valu- self-esteem, as well as personal self-esteem mediated
ing the personhood, perspectives, strengths, and relationships between perceived sexist discrimina-
growth alternatives of clients is crucial (empower- tion and both depression and anxiety symptoms.
ment). All studies reveal that the egalitarian, collab- Although the literature on sexism, racism, and
orative counseling relationship and respect for clients other “isms” reveals that blatant forms of prejudice
are perceived as central to the counseling relation- have decreased during recent decades (Campbell,
ship. The next section turns to a more specific dis- Schellengerg, & Senn, 1997), contemporary forms
cussion of central features of feminist counseling. of sexism, racism, and related biases have taken on
more clandestine forms that are often referred to
The Personal Is Political as modern racism and sexism, or unintentional or
The notion that the personal is political informs the symbolic racism and sexism (Dovidio, Gaertner,
feminist therapist’s overall worldview, as well as his Kawakami, & Hodson, 2002; Gaertner & Dovidio,
or her goals and interventions. Feminist therapy 2005; Swim, Aikin, Hall, & Hunter, 1995).
shares the values of critical psychology (Prilleltensky Stereotype threat, which involves the internalization
& Nelson, 2002), including an interest in decon- of stereotypes about a marginalized social identity
structing and challenging power structures both (e.g., gender or race), has also been shown to gener-
within and beyond psychology; an analysis of opp- ate anxiety, affect working memory, and result in
ression, which can be defined as “a state of symmet- significant negative decrements on performance
ric power relations characterized by domination, (Osborne, 2001; Schmader & Johns, 2003; Spencer,
subordination, and resistance” (p. 13); an emphasis Steele, & Quinn, 1999).
on liberation, which involves resisting oppressive Theory and research on ambivalent sexism (Glick
influences; and the goal of well-being that balances & Fiske, 2001) reveals that sexism consists of two
personal, relational, and collective needs. Each of forms: hostile sexism and benevolent sexism.
these themes is reflected in feminist therapy’s con- Although hostile sexism is blatant and is recognized
ceptualization of “the personal is political” and its easily, benevolent sexism is more subtle, can be asso-
corollary, the “political is personal.” ciated with warmth and praise for women who ful-
fill traditional communal roles, and may be linked
External Forces and Psychological Distress to patronizing behaviors. This set of attitudes and
Rawlings and Carter’s (1977) classic definition of behaviors is not easily recognized as sexist; and
feminist psychotherapy declared that “the primary instead, it is frequently unchallenged and may con-
source of women’s pathology is social, not personal: tribute to increased justification of restrictive gender
external, not internal” (p. 55). Since that time, there relations (Barreto & Ellemers, 2005; Jost & Kay,
has been growing awareness that both intrapsy- 2005). Benevolent sexism, but not hostile sexism,
chic issues and external forces contribute to dis- has also been shown to have a negative impact
tress; however, an emphasis on sociocultural forces on performance (Dardenne, Dumont, & Bollier,
remains central to feminist analysis. The following 2007). The person experiencing benevolent sexism
paragraphs illustrate some of the ways in which typically feels that she is viewed as having limited
biases and “isms” may contribute to distress and/or competence, but the behavioral cues are ambiguous,
lowered achievement. and it is difficult to conclude whether the behavior
Studies have found that psychological distress is in question is sexist or merely polite. Self-doubt,
related to perceived sexist, racist, and heterosexist mental intrusions, and preoccupation with one’s
experiences and the degree to which personal stress performance appear to be mechanisms through
is experienced in response to these events and psy- which benevolent sexism may operate in perfor-
chological distress (e.g., Klonoff, Landrine, & mance situations. Fischer (2006) also found that
Campbell, 2000; Moradi & Subich, 2003; Moradi benevolent sexism can also become a type of self-
& Funderburk, 2006; Szymanski, 2005). Self- protective or defensive strategy that may be used by
esteem may play a role in these links. Moradi and women who encounter another person’s negative
Subich (2004) found a significant association bet- attitudes about women. In other words, endorsing
ween psychological distress and perceived sexist benevolent sexist beliefs (e.g., that women should
events for women with low self-esteem, but not for be cherished by men or are morally superior to men)

442 fem in ist ap p roach e s to co u n s el in g

allows women to maintain at least some level of self- As noted by the APA Guidelines (2007), “Being
esteem in the face of restrictive attitudes. attentive to the strengths and personal resources
Taken together, contemporary theory and of girls and women may also help decrease the like-
research indicate that perceived and subtle discri- lihood of committing inadvertent biases, over-
mination are associated with psychological distress, emphasizing problematic aspects of behavior, or
lowered self-esteem, decreased performance or pathologizing adaptive behaviors” (p. 964). Some of
achievement, or the adoption of subtle biases toward the pathways for developing resources in younger
other women. The exploration of these issues in the women and girls include education and positive
feminist counseling context may help the client attitudes toward academic activities, positive peer
reframe her or his experience, identify how her or and adult relationships, supportive and flexible
his internalized problems have wider “political” family systems, opportunities for problem-solving
implications, restore the client’s self-esteem, and skill development, supportive and flexible family
help the client plan active, self-affirming responses systems, experiences with growth-promoting com-
to these challenges. A more extended discussion of munity groups, and other satisfying skill-building
these issues can be found in Moradi and Yoder activities (Worell, 2006).
(2011; Chapter 13, this volume). Effective coping in the midst of obstacles is an
In addition to the “ordinary” external challenges important theme in the works of many feminists
identified above, a variety of gendered traumatic of color. For example, Anzaldúa (1987) described
stressors related to interpersonal traumas, such as the ways in which women of color develop la facul-
rape, battering, and sexual abuse, are summarized in tad, a survival skill that is informed by experiences
the APA (2007) Guidelines. These traumatic stres- of marginalization, discrimination, and outsider
sors are associated with posttraumatic stress reac- status. La facultad facilitates efficient perception
tions, depression, and anxiety. The Guidelines also of power dynamics in everyday experiences and
document a variety of biases and discrimination allows one to “adjust quickly and gracefully to
related to health systems, education, the workplace, changing (and often threatening) circumstances”
religious institutions, the workplace, legal systems, (Moya, 2001, p. 469). Although the creative sur-
and the family. Each of these external factors is vival skills of women of color have facilitated their
related to women’s and girls’ distress. ability to withstand economic, social, and sexual
exploitation, these skills can also be associated with
A Strength and Coping Perspective substantial emotional costs. West (1995) notes, for
Long before positive psychologists Seligman and example, that the Mammy stereotype reinforces the
Csikszentihihalyi (2000) called for an end to the notion that black women are capable of contri-
“exclusive focus on pathology” (p. 5) as well as buting endlessly to the needs of others without
human weakness, suffering, and disorder, feminist encountering negative outcomes. Feelings of being
psychologists advocated a strength and coping overburdened experienced by this “strong black
perspective for women as “enactors, not victims” woman” may be rendered invisible. As noted by bell
(Reid & Kelly, 1994). Klein (1976) declared: “Not hooks (1981), endurance and strength should not
all symptoms are neurotic. Pain in response to a be confused with opportunities for growth and
bad situation is adaptive, not pathological” (p. 90). transformation. A strengths-based perspective must
Building on this positive reframing of “pathology,” lead to opportunities for thriving.
feminist counselors argue that many symptoms The concept of posttraumatic growth, which is
have functional, coping, or survival value as indi- defined as “the experience of positive change that
viduals negotiate difficult challenges (Greenspan, occurs as a result of the struggle with highly chal-
1983). A major goal of the feminist therapist is to lenging life crises” (p. 1) is also relevant to feminist
find the kernel of health embedded in behaviors counseling. Posttraumatic growth includes a deeper
that may be defined as pathological, and to help appreciation of life and a redirection of priorities.
clients undo a “patient identity” by redirecting per- It may include increased warmth and intimacy in
ceived weaknesses into strengths that that can relationships, an expanded view of personal strength,
enhance well-being and alter oppressive circum- the identification of new directions for the future,
stances. This version of positive psychology empha- and the development of a more spiritual perspective
sizes the development of strength, resilience, and (Tedeschi & Calhoun, 2004). Within feminist psy-
optimism that is also grounded in a realistic assess- chology, an emphasis on posttraumatic growth can
ment of challenges. be seen most consistently in discussions of recovery

e nns 443
and empowerment following interpersonal violence of counselors who practice narrative, humanistic,
and trauma. It includes meaning-making following and existential psychotherapies. These approaches
trauma and generating possibilities for participating share the critique that DSM diagnosis can reduce
in social change. A study of female survivors of the client to a label, pathologize difference, limit the
childhood sexual abuse (Lev-Wiesel, Amir, & Besser, counselor’s or client’s vision to the lens provided by
2005) found that posttraumatic stress disorder and DSM criteria, decrease attentiveness to strengths,
posttraumatic growth coexisted. Studies of battered and even elicit client behaviors consistent with diag-
women (e.g., Humphreys, 2003; Werner-Wilson, nostic checklists (Rigazio-DiGilio, 2000; Winslade,
Zimmerman, & Whalen, 2000) have also revealed Crockett, & Monk, 1997; Yalom, 2002).
that high levels of physical and psychological dis- Although diagnosis has been used cautiously
tress can be accompanied by resourcefulness and by feminist counselors, the 1980 addition of post-
resilience. By emphasizing strengths, feminist coun- traumatic stress disorder (PTSD) to the DSM was
selors help clients expand existing skills, as well as welcomed by many feminist counselors as a non-
acknowledge the reality and relevance of their pain. stigmatizing diagnosis consistent with feminist
models (e.g., Walker, 1979, battered woman syn-
Assessment and Conceptualization drome) that would normalize clients’ reactions to
in Feminist Counseling interpersonal abuse, violence, and other external
Since its earliest days, feminist therapists have been causes of distress (Brown, 2004). Compared to
skeptical about the value of traditional diagnosis, diagnoses that lend themselves to victim blaming
which is exemplified by Rawlings and Carter’s (e.g., borderline personality disorder), PTSD
(1977) declaration that “the therapist does not use seemed to offer feminist therapists “a rhetorical
diagnostic labels” (p. 62). Instead, feminist coun- resource for voicing their objection, as feminists, to
selors were encouraged to use behavior analysis, sex/ conventional diagnoses and the medical model”
gender role analysis, and other context-based assess- (Marecek, 1999, p. 162). When diagnostic criteria
ments, thus ensuring that assessment emphasized for PTSD were broadened (APA, 1994), some fem-
client strengths and resources as well as deficit inist therapists found the category even more attrac-
behaviors. At the time when these early statements tive, assuming that it would reflect more accurately
were made, the Diagnostic and Statistical Manual the regularity with which intimate violence occurs,
of Mental Disorders was a 134-page document and might allow more individuals to gain access to
(DSM-II, American Psychiatric Association [APA], needed services (Brown, 2004).
1968) and represented “a mildly annoying for- Becker (2004) argued, however, that using
mality required for insurance reimbursement” disease-based labels to normalize reactions to trauma
(Wylie, 1995, p. 23). In contrast, the current edi- is illogical when greater energy could be directed
tion of the DSM (DSM-IV-TR, APA, 2000) is a toward the prevention of circumstances that con-
massive tome that exceeds 900 pages. Avoiding the tribute to trauma. Furthermore, the expanded ver-
use of formal diagnosis in the current era of man- sion of PTSD has the potential to become a “catch
aged care has become extraordinarily difficult all” category that contributes to greater medicaliza-
(Ballou et al., 2008). tion. For example, biological factors, such as hor-
Over time, feminist counselors have criticized monal differences, have been hypothesized as
DSM-based diagnoses for many reasons, including accounting for a portion of the 2:1 ratio of women
its overemphasis on intrapsychic symptoms and to men who meet the criteria for this diagnosis
inattentiveness to contextual factors; tendency to (Wolfe & Kimerling, 1997). In addition, the DSM
reinforce gender, cultural, and race-based stereo- category does not allow for full consideration of the
types (especially the personality disorders); arbitrary ways in which insidious and prolonged interper-
criteria for conceptualizing disorders; adjustment sonal trauma may affect the person (Courtois,
versus change focus; scientific inadequacies; ten- 2004), nor does it lend adequate insight about how
dency to “pigeonhole” misery rather than offering racism, sexism, heterosexism, ageism, classism, and
creative ways of addressing pain; and tendency to cultural factors may affect posttraumatic reactions
reinforce or extend the values of powerful psychiat- (Sanchez-Hucles & Hudgins, 2001). The PTSD
ric, medical, and pharmaceutical establishments example points to the complexity of conceptualiz-
(e.g., Caplan & Cosgrove, 2004; Eriksen & Kress, ing problems adequately when diagnostic options
2005; Lerman, 1996). Feminist counselors’ distrust are embedded within powerful institutional frame-
of formal diagnosis is also consistent with the views works. Some feminists have proposed alternatives

444 fem in ist ap p roach e s to co u n s el in g

for understanding reactions to trauma and include likelihood of pathologizing adjustments that may
Brown’s (1992) oppression artifact disorder, Root’s seem problematic on the surface, but may represent
(1992) insidious trauma model, and Herman’s temporary life course corrections. For example,
(1992) complex posttraumatic stress syndrome. important biopsychosocial developmental realities
Despite concern about the potentially negative relevant to reproduction include menarche, sexual
impact of many diagnostic categories, contempo- development, sexual health practices, pregnancy,
rary feminist counselors are less likely than early birth control, abortion, fertility/infertility, child-
feminist therapists to reject DSM-based diagnosis, birth, postpartum reactions, and menopause. Each
but see such diagnosis as only a starting point for of these experiences mark changes in a woman’s or
conducting assessment. Brown (2006, 2010) rec- girl’s life and may be associated with enhanced pos-
ommended “subversion” as a strategy for undermin- sibilities as well as challenge and difficulty (APA,
ing traditional diagnosis. Although the feminist 2007). The negotiation of these reproductive expe-
therapist is likely to provide a diagnosis required riences is also related to the timing of developmen-
by an insurance company, often in consultation tal changes, individual differences in priorities, and
with the client, the feminist counselor also high- the degree to which these reproductive events are
lights multiple layers of experience and meaning associated with supportive or complicated relation-
that inform distress, such as developmental factors, ship, environmental, and cultural realities. Using a
coping strategies the client uses to deal with power developmental approach supports and complements
and powerlessness, the competencies and strengths the strengths-based perspective discussed earlier.
of the client, her or his social identities and loca- A hallmark of feminist counseling is social iden-
tions, and dysfunctional and supportive aspects of tity analysis, which was originally referred to as sex
the client’s context. A holistic biopsychosocial per- role analysis (Kaschak, 1981; Rawlings & Carter,
spective is valued. 1977). This personalized assessment is designed to
Of particular value to biopsychosocial assess- clarify how a person’s socialization, privileges, opp-
ment is a feminist ecological perspective, which ressions, life phase issues, multiple social identities,
facilitates the assessment of the complex systems and current environmental realties may influence
that surround the individual (Ballou, Matsumoto, the client and his or her interactions within an eco-
& Wagner, 2002; Bronfenbrenner & Morris, 2006). logical network. This context includes, but is not
These systems encompass the individual’s microsys- limited to, the client’s family, educational environ-
tem, which includes the various familial, spiritual, ment, religious experience, peer relationships and
educational, and other support systems; the mesosys- groups, work settings, immigration/acculturation
tem, or interactions among the structures of the experiences, and cultural contexts (Brown, 1990).
microsystem; the exosystem, which consists of social, Open-ended questions about social identities can be
governmental, legal, and political institutions and integrated with tools such as power analysis (Worell
policies with which a person may not have direct & Remer, 2003) or a cultural genogram (Vasquez,
contact but have an impact on a person’s privileges, & Magraw, 2005). Major goals include identifying
opportunities, oppression, and general flexibility of ways in which external forces are internalized as
movement; and the macrosystem, which reflects cul- strengths or limitations, considering how public
tural values, worldviews, ideologies, and global and private aspects of the self interact, and explor-
influences. The manner in which the client’s social ing ways in which the personal is political and the
identities (e.g., race, class, gender, disability) inter- personal is political within a person’s larger ecologi-
sect with these systems is also relevant to an eco- cal context. This knowledge contributes to a deeper
logically valid understanding of a client’s problems understanding of the self, decreased self-blame and
and strengths. discouragement, and greater knowledge for becom-
Feminist assessment is also embedded within a ing an active change agent on one’s own behalf.
developmental approach (APA, 2007). Research Assessment of feminist development can be
conducted by feminist psychologists and summa- included within social identity analysis. Persons
rized in a variety of psychology of women and who adopt a feminist identity tend to navigate a
gender texts (e.g., Crawford, 2006; Matlin, 2012; series of developmental stages that begin with pas-
Yoder, 2007) has enriched our understanding of sive acceptance of dominant cultural values and lack
diverse gender-related biological, social, and psy- of awareness of gender identity issues. However, a
chological development. A developmental approach crisis phase of “revelation,” can be triggered by direct
helps normalize life transitions and decreases the experiences of bias, developmental transitions, or

e nns 445
general awareness of oppression that may be facili- and “isms.” As clients gain more complex and mean-
tated by educational experience. The recognition of ingful understandings of their feminist and other
unfair treatment and bias (e.g., sexism and racism) intersecting social identities, they are likely to
is typically followed by the desire to test and rein- benefit from interventions that support concrete
force one’s emerging awareness through interactions decision making and action-oriented responses
with like-minded individuals. Feminist identity (McNamara & Rickard, 1989; Rederstorff &
evolves over time and culminates in a phase of active Levendosky, 2007). Being mindful of the complex-
commitment to a nonsexist world (Downing & ity and multidimensionality of social identity
Rousch, 1985). throughout assessment and intervention is crucial.
Feminist identification and activism are also pre- Finally, it is important to note that womanist and/
dicted by exposure to feminism through life experi- or feminist identity development may be experi-
ences, participating in women’s and gender studies enced in unique ways that may not conform to this
courses, and social changes and milieu of childhood pattern (Park et al., 1996; Zucker & Stewart,
and adulthood (e.g., Liss, Crawford, & Popp, 2004; 2007).
Reid & Purcell, 2004; Stake, 2007; Zucker &
Stewart, 2007). Research reveals that early phases of Empowerment and Social Activism
development (e.g., denial of sexism) are associated The concept of “empowerment” defies easy defini-
with higher levels of psychological distress (Moradi tion, in part because the term has become a “sani-
& Subich, 2002), and feminist identification is tized buzz-word” (Cheater, 1999, p. 1) or an almost
related to psychological well-being (Saunders & mandatory term for the mission statements of many
Kashubeck-West, 2006; Yakushko, 2007). See human service organizations (Pease, 2002). The
Moradi and Yoder (2011; Chapter 13, this volume) term empowerment is appropriated by persons with
for more information. dramatically different ideologies to support diverse
Feminist identity development often intersects philosophies about “helping people gain control
with other social identities, such as lesbian, racial/ over their own lives” (Pease, 2002, p. 136). Some
ethnic, womanist, and white identity (Hoffman, suggest that the rhetoric of “empowerment” is in
2006; Jones & McEwen, 2000; Ossana, Helms, & danger of losing its radical potential. Use of the
Leonard, 1992; Parks, Carter, & Gushue, 1996; term may project an “illusion of equality” (p. 138)
Reynolds & Pope, 1991). A person’s ability to work without posing any real challenge to oppressive
through the implications and challenges associated power structures. Thus, clarification of feminist
with multiple identities is likely to be influenced empowerment practice is important.
by the degree to which various identities are related Feminist theorists, as well as critical and lib-
or can be integrated, the person’s life events and eration theorists, speak of the importance of
transitions, the salience and visibility of identity consciousness-raising or conscientização as a foun-
domains, the relevance of these identities to current dation for personal empowerment and activism.
developmental experiences, the extent to which Consciousness-raising involves using knowledge
identities are associated with oppression or privi- about personal distress, inequality, and stigmatiza-
lege, and family or cultural background (Stewart & tion to inform self-awareness, healing, and activism.
McDermott, 2004; Suyemoto, 2002). Similarly, conscientização or conscientization, is
The feminist counselor is prepared to use inter- defined as “learning to perceive social, political,
ventions that address these developmental concerns and economic contradictions, and to take action
(McNamara & Rickard, 1989; Rederstorff & against the oppressive elements of reality” (Freire,
Levendosky, 2007). At the earliest phases of femi- 1970, p. 19). Through involvement in conscious-
nist identity development, clients may prefer a ness-raising or conscientization, participants learn
relatively traditional relationship. Counselors may to recognize systems of oppression, articulate their
support development by asking open-ended ques- roles and positions in these systems, and devise con-
tions that facilitate clients’ awareness of how their crete responses (Burbules & Berk, 1999). Feminist
multiple social identities are related to presenting empowerment entails helping individuals see them-
concerns. During middle phases of development, selves as active agents in personal, interpersonal,
more active interventions, such as social and gender and sociopolitical contexts and includes analy-
identity analysis, anger work, and self-disclosure, zing how social power structures contribute to feel-
may be especially beneficial for addressing issues ings of powerlessness and distorted, negative
marked by greater awareness of biases, privileges, self-perceptions in an unequal world; exploring how

446 fem in ist ap p roach e s to co u n s el in g

individuals can learn to experience power in per- empathy as leading to mutual empowerment and
sonal, interpersonal, and institutional domains; and resilience (Miller & Stiver, 1997). Mutual empower-
applying advocacy skills in the service of social jus- ment consists of five aspects: zest, or vitality and
tice (Morrow & Hawxhurst, 1998). The new inter- energy that comes from emotional connection;
pretive framework associated with empowerment action and the motivation to use “relational inter-
can be liberating in and of itself, but also becomes play” to behave in new ways, greater knowledge
the foundation for developing personal and social about oneself and others; an increased sense of
action plans. worth based on relational connection; and a desire
Consciousness raising and conscientization lead for additional growth-facilitating connections with
to greater understanding about how the “personal is others. Consistent with a postmodern perspective,
political.” In addition, “the public is personally polit- Becker (2005) cautioned that feminist therapists
ical” (Hurtado, 1989, p. 849). Hurdado’s refram- emphasizing a relational approach can fall prey to
ing of the familiar maxim is consistent with the dichotomous or binary thinking about complex
realities of many people of color and poor people concepts such as relatedness and autonomy, which
whose personal lives have been so restricted by should be seen as informing each other rather than
social policies and institutionalized racism/sexism standing in opposition to each other.
that it is difficult to create private lives on their own Although original descriptions identified the goal
terms. Whereas many middle-class white women of feminist therapy as “social and political change”
experience at least some choice (e.g., choosing (Rawlings & Carter, 1977, p. 56), there is lack of
whether to work for monetary remuneration), less consensus about the importance of social activism
privileged women may not have such options. (Ballou & Gabalac, 1985). Marecek and Kravetz’s
These variations in experience need to be under- (1998) in-depth interviews with 25 practitioners
stood when considering the personal meaning of revealed that these therapists typically emphasized
consciousness-raising. “inner power” (p. 22), “private and static” (p. 22)
A feminist definition of empowerment is typi- aspects of empowerment, and “personal fulfillment
cally seen as inconsistent with “power over,” which through a process of private discovery, without
relies on dominance, coercion, and oppression. regard to social or political change” (p. 21). The
“Power within” is associated with a sense of inner empowerment strategies identified by these thera-
strength that allows one to make sound decisions, pists included: creating a climate of respect and
“power to” suggests a capacity to act in a manner acceptance, encouraging clients to co-direct the psy-
that is respectful of oneself and others, and “power chotherapy process, using self-disclosure to increase
with” implies an ability to cooperate and make awareness and model possibilities, and encouraging
connections with others in enacting personal and clients to participate in assessment by assisting in
social change (Smith & Douglas, 1990). Miller and the selection of a diagnostic label. Although research
Cummins’ (1992) study of women’s definitions participants spoke of the political and social changes
revealed that these participants distinguished bet- needed for achieving equality, they “did not overtly
ween “control over,” which included power over challenge systems of power operating in society”
people and resources, and “personal authority” (p. 26). Becker (2005) suggested that when empow-
(p. 419). Respondents tended to define personal erment is personalized and not connected to macro-
authority as experiencing self-control or engaging level change, “therapeutic feminism” (p. 139) can
in self-enhancing activity, such as gaining knowl- contribute to the myth that women’s problems are
edge or feeling physically healthy. more personal and medical than political.
Worell (2001) proposed ten goals of empower- Recent social justice developments within coun-
ment: self-esteem and self-valuing, positive daily seling psychology reinforce social change perspec-
functioning, gender and culture awareness, perceived tives in feminist counseling. The APA (2007)
self-efficacy and control, self-nurturing capacities, Guidelines recommend knowledge and use of com-
problems-solving skills, behavioral flexibility, asser- munity, mental health, and education resources for
tiveness, the ability to access and use community girls and women (Guideline 10). In addition, psy-
resources, and participation in social activism. The chologists “are encouraged to understand and work
Personal Progress Scale (Worell & Remer, 2003) can to change institutional and systemic bias that may
be used to assess progress toward many of these impact girls and women” (Guideline 11, p. 969).
goals. Another approach, the relational-cultural An ongoing challenge for the 21st century involves
model, identifies relational connections and mutual identifying and implementing meaningful social

e nns 447
action activities. Activism is an important priority of in light of personal realities or “truths.” A major goal
many third-wave feminists (e.g., Baumgardner & of narrative therapists is to work collaboratively with
Richards 2000, 2005; Labaton & Martin, 2004), clients in a series of co-authoring activities designed
and this commitment may facilitate higher levels of to disrupt and defy the power of culture, and to help
involvement in political action among third-wave clients reclaim or reauthor their lives according to
feminist therapists. Consistent with third-wave per- empowering metaphors (Maisel, Epston, & Borden,
spectives, new forms of activism are likely to be more 2004). Clients are viewed as major characters of their
diverse and less obvious expressions of activism than lives who actively create meaning by weaving together
those associated with second-wave feminism. the past, present, and future in a coherent life story
or narrative.
Feminist Counseling As an Integrative Narrative therapists avoid “totalizing” language,
Approach which refers to any effort to assign a single, all-
Feminist psychotherapy is a theoretically integrative encompassing description to a client’s problems or
and technically eclectic approach. Feminist counsel- identity. Therapists also reject totalizing terms such
ors link their foundation in feminist values to vari- as diagnosis, resistance, and denial, “which grant
ous psychotherapy systems. No limits are placed on precedence to ‘regimes of truth over clients’ knowl-
what frameworks are appropriate, provided these edge of their lives” (Winslade et al., 1997, p. 56),
systems do not support biases or limit human or tend to place blame on individuals and discount
potential. Worell and Remer (2003) identified areas their personal expertise about themselves. Clients
feminist counselors should consider when examin- are encouraged to develop more complex views
ing the compatibility of theories, including poten- of themselves and their options. From a narrative
tial sources of bias in historical development, therapy perspective, “therapeutic practices are never
theoretical concepts, assumptions about clients’ ‘objective,’ or culturally neutral, because they help
problems, forms of assessment, psychotherapy tech- reconfigure persons’ lives and relationships in par-
niques, and the respective roles of counselor and ticular social contexts” (Gremillion, 2004, p. 183).
client. When potential conflicts are identified, coun- This feature is consistent with “the personal is polit-
selors explore how biased aspects of theories can be ical” and a feminist emphasis on an ecological
restructured and transformed within a feminist framework for understanding distress and change.
framework. Considering the fit between psycho- The narrative therapy technique of externaliza-
therapy approaches and the counselor’s specific fem- tion involves deconstructing a problem by helping
inist and multicultural theoretical worldview is also separate the client from “being” the problem.
important (Enns, 2004). Although it is not possible Externalizing a problem includes distancing oneself
to provide extensive illustrations of feminist coun- from a problem-saturated story and self-definition,
seling as an integrative approach, the next section which may include self-labeling, self-blame, the
provides several examples: feminist narrative therapy adoption of a “victim” identity, or internalized opp-
and feminist trauma treatment. ression. Energy is redirected toward devising a coun-
terplot associated with hope, possibility, and creative
Feminist Narrative Therapy As alternatives for change (Gremillion, 2004; Miller,
Theoretical Integration Cardona, & Hardin, 2006). Narrative therapy and
Narrative therapy is often identified as a postmodern externalization are closely related to the strength
therapy that lends itself to integration with feminist and coping-based focus of feminist counseling, an
counseling because of their theoretical similarities emphasis on reframing problems, and the concept
(e.g., Brown, 2007; Gremillion, 2004; Lee, 1997). of empowerment. Similar to feminist practice, the
Consistent with the priorities of feminist counselors, counselor and client conceptualize an issue as a
narrative therapists attempt to understand clients’ “problem story” that is reinforced by dominant cul-
“insider” positions by paying close attention to the tural understandings of gender roles, ideal bodies,
ways in which clients internalize dominant cultural or a “proper self.”
messages that limit their agency and confine them to Authors have proposed specific feminist narra-
less than optimal functioning. Therapists do not look tive approaches for working with eating disorders
for externally validated definitions of problems or for (Brown, 2007; Gremillion, 2004; Maisel et al.,
“correct” interpretations or solutions. Instead, they 2004) and sexual assault (Miller et al., 2006). For
emphasize the capacities of clients to generate their example, an eating disorder can be described as a
own solutions and to make sense of their challenges vindictive entity that is supported by cultural myths

448 fem in ist ap p roach e s to co u n s el in g

and attacks unsuspecting individuals. The goal of Herman’s (1992) phase-based model of working
counseling is to “empower the ‘insider’ and weaken with long-term prolonged abuse, and Worell and
(and ultimately destroy) the dangerous external foes Remer’s (2003) empowerment model.
of anorexia and bulimia” (Strife, 2006, p. 121). The various feminist trauma approaches share
However, some feminist theories of eating disorders some common themes, including an understanding
(see Gilbert & Thompson, 1996) note that eating that trauma must be understood from an individu-
preoccupations can represent efforts to gain control al’s subjective frame of reference, which is likely
rather than merely reveal powerlessness in the to be shaped by the person’s multiple identities and
face of a vindictive opponent. Thus, feminist thera- experiences with discrimination (Brown, 2004).
pists point out the value of integrating narrative In the case of rape trauma, for example, the feminist
approaches with feminist models that reflect a wider therapist facilitates a client’s examination of the cul-
range of meanings associated with women’s bodies tural, gender role, and racial myths that contribute
and eating (Brown, 2007). In the case of sexual to victim blaming, as well as unequal power dynam-
assault, a narrative therapy approach begins with ics and socialization experiences that contribute to
the telling of the client’s story, which is followed self-blame (West, 2002; Worell & Remer, 2003).
by deconstructing societal messages about victims. Feminist therapists give visibility to the ways in
Using externalization, clients identify oppressive which violence is gendered, bring a sociocultural
social messages, which contribute to the silencing of and contextual analysis to trauma, and emphasize
victims and the shame and self-denigration that the importance of empowerment (Brown, 2004).
often accompany assault. This process paves the way Empowerment includes recovering a sense of per-
for resisting negative messages and creating a new sonal power and efficacy as a survivor rather than as
story (Miller et al., 2006). a victim, and, when appropriate, engaging in social
To summarize, narrative therapies and feminist change on behalf of other victims of violence (Worell
therapy share an emphasis on collaboration and & Remer, 2003).
co-authoring strategies for change. Similar to femi- Most feminist models address the challenges
nist therapy, narrative therapists avoid formal diag- of working through traumatic memories and deal-
nostic language because it tends to give greater ing with posttraumatic reactions, and recommend
priority to an external, “professional” truth than to the use of empirically supported interventions for
the client’s reality. Both approaches encourage cli- helping clients cope with symptoms of distress
ents to act as their own best experts and to generate related to rape, child sexual abuse, and other trau-
creative solutions. Furthermore, both approaches mas. In this way, feminist counselors draw on tech-
seek to decrease clients’ self-blame by understanding nically eclectic strategies for linking a feminist
how external factors or definitions influence the perspective with approaches such as cognitive
person’s distress. In contrast to most feminist coun- behavioral therapies (CBT; Ford, Courtois, Steele,
seling approaches, narrative approaches place less van der Hart, & Nijenhuis, 2005). For example,
emphasis on implications for social change and cognitive processing therapy (CPT) for sexual
social activism. Thus, social identity analysis, power assault victims (Resick & Schnicke, 1993) combines
analysis, and social change perspectives can be used successive writing assignments that expose clients to
to enhance narrative therapy within a feminist trauma memories. In addition, cognitive restructur-
framework. ing components focus on themes of safety, trust,
power, esteem, and intimacy. Foa and Rothbaum’s
Feminist Approaches to Trauma (1998) CBT intervention for rape, interpersonal
Feminist approaches to trauma include theoretical trauma, and PTSD holds many similarities to CPT
models, such as those focusing on insidious trauma- and integrates both prolonged exposure (PE) and
tization (Root, 1992) and betrayal trauma (Freyd, stress inoculation training within a structured inter-
1996), as well as diagnostic models such as battered vention program. This CBT approach is designed to
women’s syndrome (Walker, 1979), complex post- facilitate the emotional processing and reorganiza-
traumatic stress disorder (Herman, 1992), and tion of trauma; challenge unhelpful cognitions; and
oppression artifact disorder (Brown, 1992). Feminist help clients establish schemas that enhance a sense
therapists have also developed multiple intervention of personal efficacy and competence, control, and
approaches such as Harvey’s (1996) ecological model, meaning.
Walker’s (1994) survivor therapy, Courtois’ (2000) The efficacy of both approaches has been well-
approach to working with sexual abuse memories, supported, and researchers exploring both CBT and

e nns 449
CPT approaches have often worked collaboratively the use of assertive skills will naturally lead to suc-
(e.g., Resick, Nishith, Weaver, Astin, & Feuer, 2002; cessful interpersonal outcomes, and that human
Schnurr et al., 2007). Findings related to both CBT rights can be defined independently from the com-
and CPT have shown that combined PE and cogni- plex gender and cultural injunctions that shape
tive restructuring treatments do not show superior perceptions of rights. With modification, however,
outcomes over options that rely on PE alone or CBT tools can be integrated with more contextu-
cognitive restructuring alone (Foa & Rauch, 2004; ally valid approaches that consider the interper-
Foa et al., 2005; Resick et al., 2002; Resick, Galovski, sonal and social realities of participants and the
Uhlmansiek, Scher, Clum, & Youn-Xu, 2008). costs and benefits of any specific course of action
Other CBT options for working with posttraumatic (Enns, 2003). It should be noted that CBT inter-
symptoms and interpersonal affect regulation ther- ventions have also been effectively integrated with
apy options are reviewed by Ford et al. (2005). feminist eating disorder interventions, depression,
Brown (2002) also recommends the integration and anxiety.
of eye movement desensitization and reprocessing Because feminist counseling represents a world-
within a feminist therapy approach. view or system for organizing one’s thinking
In addition to using technically integrative options about interventions rather than a specific technique-
with nonsexist approaches, such as those described oriented approach, feminist counseling does not
above, it is also important for the feminist counselor lend itself to traditional outcome research. How-
to explore the theoretical connections between femi- ever, feminist therapists seek to employ techniques
nist counseling and CBT. During the first decades of that have been supported by research, especially
feminist therapy, CBT approaches were often inte- outcome research relevant to gender-related con-
grated with assertiveness and other group skills train- cerns. It can be argued, therefore, that feminist
ing programs, and framed as resocialization tools that therapists are practicing empirically supported or
would allow women to become aware of their inter- empirically validated counseling when they operate
personal rights; challenge self-beliefs that limited their from a well-articulated theoretical and technically
options; and adopt direct forms of self-expression integrative approach that is informed by research.
to increase self-confidence, empowerment, and influ- The APA Guidelines (2007) also call on psycholo-
ence over their environments (e.g., Fodor, 1988; gists to implement approaches that have been dem-
Jakubowski, 1977). These CBT interventions are onstrated to facilitate women’s and girls’ efforts to
based on a gender-neutral perspective. They also negotiate developmental transitions, resolve life
acknowledge the role that environments and external challenges, and achieve positive outcomes. The
factors place on human development, and emphasize Guidelines identify a wide range of approaches (e.g.,
the importance of a collaborative client–therapist family therapies, humanistic therapies) that can be
relationship (Enns, 2003; Worell & Remer, 2003). integrated within a feminist framework.
After initial enthusiasm, observers noted that
CBT approaches needed to be modified to be inte- Conclusion
grated effectively with feminist values. First, tradi- Future Directions
tional CBT interventions emphasize individual Feminist counseling and psychotherapy approaches
change, and methods for addressing wider ecologi- emerged approximately 40 years ago to facilitate
cal issues that limit personal choices (e.g., sexual work with women who had been disenfranchised
harassment, patterns of interruption in conversa- by traditional psychotherapy. Over time, feminist
tion) may be ignored (Fodor, 1988; Kantrowitz & therapy has become a broadly based social justice
Ballou, 1992). Second, CBT approaches provide no approach that combines knowledge from multiple
critical examination of androcentric assumptions disciplines in an intersectional and locational per-
that tend to prioritize rationality over emotion. spective that is attentive to the multidimensional
Labeling a client’s cognitions as “irrational” or “dis- social identities of clients. Feminist counseling
torted” may deny the client’s reality, which may approaches have been enriched by a range of femi-
include traumatic events or more insidious social nist theories (e.g., body objectification, violence)
conditions that may contribute to cognitions that and integrative approaches for working with highly
limit one’s perspective or wear down one’s ability to challenging problems and social change issues
challenge others directly. Even “feminist” assertive- (Brown, 2010). This chapter concludes with a brief
ness programs may fall short of the goals of feminist identification of four challenges and recent direc-
therapy because of the underlying assumption that tions: implementing feminist counseling approaches

450 fem in ist ap p roach e s to co u n s el in g

within changing (and sometimes conservative) cul- Second, it is also important to acknowledge
tural contexts, building solid working alliances that painful conflicts within feminism that have contrib-
decenter positions of privilege and centralize knowl- uted to the disavowal of a feminist label. For exam-
edge based in diversity, applying feminist frame- ple, many women of color prefer to self-identify as
works to interventions with boys and men, and “womanist” and remain wary because of white fem-
exploring possibilities for global partnerships. inists’ historical inattentiveness to their own privi-
In general, research reveals that, although feminist leged status, tendency to generalize research and
values and change efforts are often viewed positively, theory based on white women’s lives to all women,
individuals are often disinclined to identify them- and limited awareness that leads to difficulty in
selves as feminist (Aronson, 2003; Quinn & Radtke, acting on the egalitarian values they claim (Bowman
2006; Zucker, 2004). Furthermore, some therapists et al., 2001). Important directions for the future
who endorse many feminist counseling behaviors are include developing truly inclusive forms of feminist
hesitant to claim the label “feminist” (e.g., Dankoski practice that centralize diversities among individu-
et al., 1998), and some self-identified feminist thera- als, building alliances that involve implementing
pists avoid using this label with clients because of stated values, and expanding on feminist multicul-
potential business consequences (Marecek & Kravetz, tural counseling models.
1998). Still others appear uncomfortable with a fem- An emphasis on intersectionality and the insepa-
inist counseling commitment to social activism and rability of multiple social identities will be especially
prefer the “neutrality” of providing individual coun- useful for transcending past limitations of feminist
seling services informed by feminism without making theory and practice. Shields (2008) noted that,
a more radical, social change commitment (Morrow although intersectionality has become an accepted
et al., 2006). Claims that we have entered a “post- concept for approaching the study of gender, meth-
feminist” era further complicate the challenges of ods that are useful for implementing intersectional
working as a feminist counselor in the 21st century. research and practice have lagged behind. Cole
Despite the concerns identified above and popu- (2008) recommends the use of coalitions that foster
lar media sources that claim the erosion of feminist connections across differences as a central feature
values, a variety of researchers note that feminism for future work related to intersectionality. The
remains a vibrant force, but that each generation National Multicultural Conference and Summit
may need to define feminism in ways that are most (NCMS) has become one setting in which “difficult
meaningful to contemporary contexts (Hall & dialogues” about interrelationships across race/eth-
Rodriguez, 2003; Peltola et al., 2004). Similarly, nicity, gender, sexual orientation gender, and other
feminist therapy needs to be seen as a living, evolv- social identities have been fostered, and is an impor-
ing, flexible approach. The theoretical and practice tant base for coalition building (Sue, Bingham,
contributions of second-and third-generation femi- Porché-Burke, & Vasquez, 1999). Building appro-
nist therapists will become especially important to aches that integrate feminist approaches with other
this evolution. social justice undertakings can be facilitated in other
A recent working group (Mansour, Gosset, Elder, environments that resemble the NCMS and that
Averill, & Morrow, 2008) discussed challenges feature face-to-face dialogue.
for practicing feminist multicultural therapy in con- A third development is the growth of approaches
servative contexts. The group identified a list of for working with men and masculinity. The accu-
strategies, which included seeking mentoring and mulation of 25 years of research and theory on male
networking opportunities, resisting discouragement gender role conflict (GRC) and its implications for
and isolation by seeking out support and consulta- counseling has resulted in a robust body of literature
tion groups, being well-grounded in research about (O’Neil, 2008). To date, however, much of the
the costs of discrimination and oppression, empha- research literature on male GRC has emphasized
sizing patience and persistence, building collabora- individual and interpersonal aspects and costs of
tive alliances with others who share social justice GRC for men. This literature has only addressed the
goals, and placing priority on advocacy and social implications of gender as a system of power rela-
activism and advocacy. These suggestions reaffirm tions to a limited degree. Theory and research rele-
goals that date back to the earliest days of feminist vant to male GRC and its consequences can be
therapy, and also point to the types of environments further enhanced through the use of intersectional,
that are likely to nurture the contributions of future social structural analyses that are becoming increas-
feminist therapy theorists. ingly central within feminist psychology (Stewart &

e nns 451
McDermott, 2004). Similarly, depression and other Rice & Ballou, 2002), and there will be many chal-
psychological issues of men and women have been lenges ahead as Western feminists work toward
linked to gender-related challenges. Integrating implementing mutually enriching partnerships that
research on relationships between depression and truly enact the egalitarian values they espouse, and
conformity to masculinity norms (e.g., Mahalik & act as learners who are respectful of indigenous
Rochlen, 2006) and feminine communal norms forms of expertise.
(e.g., Mazure, Keita, & Blehar, 2002) will allow for Western feminists have often been slow to recog-
a more complete understanding of how gender- nize forms of privilege and power that may cloud
related cultural expectations may affect both men their thinking, including the power to “orientalize,
and women. By placing both female and male exoticize, ethnicize, racialize, or sexualize members
gender issues within ecological frameworks that of other nations or groups” (Mackie, 2001, p. 182).
address individual, interpersonal, and social struc- To create an egalitarian transnational psychology
tural dimensions, it will become increasingly possi- of women, it will be necessary to “shift the axis” and
ble to build useful connections between the rich, emphasize “world traveling” (Lugones, 1987). World
parallel literatures supporting the psychologies of traveling consists of three interrelated awareness-
men and women (Enns, 2008). building activities that focus on seeking insight
Exploring parallels between feminist or gender- about cultural practices that have created “us” (e.g.,
aware therapy by and/or for men and women is recognizing how systems of oppression have influ-
likely to be another productive avenue. Previous enced the West, and how these oppressions may
research about the attitudes and practices of male parallel or be different from experiences of people
feminist therapists (Baird, Szymanski, & Ruebelt, around the globe), looking at “what it is to be our-
2007; Szymanski, Baird, & Kornman, 2002) sug- selves in their eyes” (p. 18) (e.g., by understanding
gests that the attitudes and self-reported behaviors of our country’s role in colonization and how we may
male feminist therapists are similar to those of self- inadvertently perpetuate colonizing attitudes in our
identified female feminist therapists. A recent quali- relationships with others), and working toward
tative study (Baird et al., 2007) identified some of seeing people from various parts of the world as they
the important formative experiences for these men see themselves. World traveling calls for an attitude
as including personal experiences with social change of humility and a willingness to value the expertise
movements, personal relationships with women and of women as they speak in their own voices. Through
others who had influenced their individual and pro- egalitarian interaction, North American feminists
fessional development, professional training and may gain new lenses for evaluating Western feminist
experiences relevant to feminism and multicultural- models and therapies and learning from the insights
ism, and awareness of male privilege and political and practices of theorists and practitioners around
aspects of psychology (e.g., diagnostic practices, feel- the globe.
ings of isolation and difference from other men), In light of these issues, participants in a recent
among others. Brown’s (2010) recent book identifies working group on global aspects of feminist practice
feminist therapy as “not for women only.” Building (Enns & Machizawa, 2008) noted that feminist
on that theme, further explorations of the intersec- therapy concepts such as consciousness-raising,
tions between feminist psychotherapies for men and empowerment, identity development, personal goals,
women merit attention (Philpot, Brooks, Lusterman, personal power, assertiveness, and collaboration, are
& Nutt, 1997). typically embedded in Western indigenous, indi-
A fourth area for future development is the global vidualistic frameworks and need to be deconstructed
practice of feminist counseling. The problems for and transformed to be relevant beyond North
which individuals seek feminist counseling, such as American borders. Furthermore, the hegemony of
violence and gendered oppression, are global con- English and expectations that our partners will
cerns, and there are growing efforts to link feminist communicate in English limit opportunities for full
counselors and activists across national boundaries power-sharing collaborations. Third, although pro-
as co-learners, co-mentors, and co-constructors of blems such as violence and gendered oppression are
knowledge (Enns, 2004; Horne & Mathews, 2006; universal, these issues are manifested through spe-
Norsworthy & Khuankaew, 2004, 2006). Western cific cultural lenses that are shaped by many factors
psychologies are often exported to other parts of the such as colonial histories, imperialism, religious beli-
globe with minimal consideration of cultural factors efs, family structures, educational options, ethnic-
(APA, 2004; Norsworthy & Khuankaew, 2006; ity, economic realities, and legal and governmental

452 fem in ist ap p roach e s to co u n s el in g

systems. The “insider” perspectives and expertise of American Psychological Association. (2003). Guidelines on mul-
transnational feminists are essential for understand- ticultural education, training, research, practice, and organi-
zational change for psychologists. American Psychologist, 58,
ing the complexity of issues in specific contexts and 377–402.
intervening effectively at both individual and social American Psychological Association. (2004). Resolution on
change levels. The APA Resolution on Gender and culture and gender awareness in international psychology.
Culture Awareness in Psychology (2004) provides Washington, DC: Author.
initial direction and calls on psychologists to build American Psychological Association. (2007). Guidelines for
psychological practice with girls and women. American
respect for pluralism and cultural difference (with- Psychologist, 62, 949–979.
out implicitly condoning gendered oppressions), Anzaldúa, G. (1987). Borderlands, la frontera: The new mestiza.
incorporate an analysis of power and the reduction San Francisco: Aunt Lute Books.
of power asymmetries in partnerships, implement Aronson, P. (2003). Feminists or “postfeminists”? Young women’s
a critical analysis of Western perspectives, and attitudes toward feminism and gender relations. Gender and
Society, 17, 903–922.
emphasize the sociocultural realities that influence Asian Women United of California (Eds.). (1997). Making more
individual realities (Rice & Ballou, 2002). waves: New writings by Asian American women. Boston:
The principles of feminist counseling approaches Beacon.
are well-established. As we move further into the Baird, M. K., Szymanski, D. M., & Ruebelt, S. G. (2007).
Feminist identity development and practice among male
21st century, the applications of feminist counse- therapists. Psychology of Men and Masculinity, 8, 67–78.
ling will continue to diversify. As the purview of Ballou, M., & Gabalac, N. W. (1985). A feminist position on
feminist therapy has grown, new directions have mental health. Springfield, IL: C. C. Thomas.
emerged, and new possibilities for integrating femi- Ballou, M., & Hill, M. (2008). The context of therapy: Theory.
nist values with other frameworks in psychology are In M. Ballou, M. Hill, & C. West (Eds.), Feminist therapy:
Theory and practice (pp. 1–8). New York: Springer.
multiplying. During the past 40 years, great prog- Ballou, M., Hill, M., & West, C. (Eds.). (2008). Feminist ther-
ress toward achieving equality has occurred, and apy: Theory and practice. New York: Springer.
these gains have the potential to benefit the mental Ballou, M., Matsumoto, A., & Wagner, M. (2002). Toward
health of all. However, the resurgence of old oppres- a feminist ecological theory of human nature: Theory build-
sions and the emergence of more subtle forms of ing in response to real-world dynamics. In M. Ballou and
L. S. Brown (Eds.), Rethinking mental health and disorder:
discrimination call for even more creative feminist Feminist perspectives (pp. 99–141). New York: Guilford
counseling responses and social change efforts. New Press.
cultural issues continue to emerge in a world in Ballou, M., & West, C. (2000). Feminist therapy approaches.
which oppression also intersects with new technolo- In M. Biaggio & M. Hersen (Eds.), Issues in the psychology
gies, media forces, and global conflict (APA, 2007). of women (pp. 273–297). New York: Kluwer Academic/
Plenum.
A major challenge involves reinforcing core values Barreto, M., & Ellemers, N. (2005). The burden of bene-
of feminist thought while recognizing the diversity volent sexism: How it contributes to the maintenance
of human experience that calls for flexibility in the of gender inequalities. European Journal of Social Psychology,
application of these values, and the need to respond 35, 633–642.
to new gender-related opportunities and problems Barrett, C. J., Berg, P. I., Eaton, E. M., & Pomeroy, E. L. (1974).
Implications of women’s liberation and the future of psy-
that emerge in this rapidly changing society. chotherapy. Psychotherapy: Theory, Research and Practice, 11,
11–15.
References Barrett, S. E., Chin, J. L., Comas-Díaz, L., Espín, O, Greene, B.,
Alcoff, L. (1988). Cultural feminism versus post-structuralism: & McGoldrick, M. (2005). Multicultural feminist therapy:
The identity crisis in feminist theory. Signs: Journal of Theory in context. Women and Therapy, 28, 27–61.
Women in Culture and Society, 13, 405–436. Basu, A. (Ed.). (1995). The challenge of local feminisms: Women’s
American Psychiatric Association. (1968). Diagnostic and stati- movements in global perspective. Boulder: Westview Press.
stical manual of mental disorders (2nd ed.). Washington, DC: Baumgardner, J., & Richards, A. (2000). Manifesta: Young
Author. women, feminism, and the future. New York: Farrar, Straus, &
American Psychiatric Association. (1994). Diagnostic and statisti- Giroux.
cal manual of mental disorders (4th ed.). Washington, DC: Baumgardner, J., & Richards, A. (2005). Grassroots: A field guide
Author. for feminist activism. New York: Farrar, Straus and Giroux.
American Psychiatric Association. (2000). Diagnostic and statisti- Becker, D. (2004). Post-traumatic stress disorder. In P. M. Caplan
cal manual of mental disorders (DSM-IV-TR, 4th ed., text & L. Cosgrove (Eds.), Bias in psychiatric diagnosis
revision). Washington, DC: Author. (pp. 207–212). Lanham, MD: Rowman & Littlefield.
American Psychological Association. (2000). Guidelines for psy- Becker, D. (2005). The myth of empowerment: Women and the
chotherapy with lesbian, gay, and bisexual clients. American therapeutic culture in America. New York: New York University
Psychologist, 55, 1440–1451. Press.

e nns 453
Belenky, M. J., Clinchy, B. M., Goldberger, N. R., & Tarule, J. M. Burbules, N. C., & Berk, R. (1999). Critical thinking and
(1986). Women’s ways of knowing. New York: Basic Books. critical pedagogy: Relations, differences, and limits.
Bernal, D. D. (1998). Using a Chicana feminist epistemology In R. S. Popkewitz & L. Fendler (Eds.), Critical theories in
in educational research. Harvard Educational Review, 68, education: Changing terrains of knowledge and politics
555–579. (pp. 45–65). New York: Routledge.
Bohan, J. S. (1993). Regarding gender: Essentialism, construc- Burstow, B. (1992). Radical feminist therapy: Working in the
tionism, and feminist psychology. Psychology of Women context of violence. Newbury Park, CA: Sage.
Quarterly, 17, 5–21. Butler, J. E. (2000). Transforming the curriculum: Teaching
Bowman, S. L., Rasheed, S., Ferris, J., Thompson, D. A., McRae, M., about women of color. In J. A. Banks & C. A. M. Banks
& Weitzman, L. (2001). Interface of feminism and multicul- (Eds.), Multicultural education: Issues and perspectives
turalism: Where are the women of color? In J. G. Ponterotto, (4th ed., pp. 174–193). New York: Wiley.
J. M. Casas, L. A. Suzuki, & C. A. Alexander (Eds.), Calliste, A. M., Dei, G. J. S., & Agular, M. (Eds.). (2000). Anti-
Handbook of multicultural counseling (2nd ed., pp. 779–798). racism feminism: Critical race and gender studies. Halifax,
Thousand Oaks, CA: Sage. Nova Scotia, Canada: Fernwood Publishing.
Brabeck, M. (Ed.). (2000). Practicing feminist ethics in psychology. Campbell, B., Schellenberg, E. G., & Senn, C. Y. (1997).
Washington, DC: American Psychological Association. Evaluating measures of contemporary sexism. Psychology of
Brodsky, A. (1976). The consciousness-raising group as a model Women Quarterly, 21, 89–102.
for therapy with women. In S. Cox (Ed.s), Female psychology: Caplan, P., & Cosgrove, L. (Eds.). (2004). Bias in psychiatric
The emerging self (pp. 372–377). Chicago: Science Research diagnosis. Lanham, MD: Rowman & Littlefield.
Associates. Cheater, A. P. (1999). Anthropology of power: Empowerment and
Brodsky, A. (1977). Therapeutic aspects of consciousness-raising disempowerment in changing structures. New York: Routledge.
groups. In E. I. Rawlings & D. K. Carter (Eds.), Psychotherapy Chesler, P. (1972). Women and madness. New York: Doubleday.
for women (pp. 300–309). Springfield, IL: C. C. Thomas. Chester, A., & Bretherton, D. (2001). What makes feminist
Brodsky, A. (1980). A decade of feminist influence on psycho- counseling feminist? Feminism and Psychology, 11, 527–545.
therapy. Psychology of Women Quarterly, 4, 331–343. Chin, J. L. (Ed.). (2000). Relationships among Asian American
Bronfenbrenner, U., & Morris, P. A. (2006). The bioecological women. Washington, DC: American Psychological Association.
model of human development. In R. M. Lerner (Ed.), Hand- Cole, E. R. (2008). Coalitions as a model for intersectionality:
book of child psychology: Vol.1. Theoretical models of human From practice to theory. Sex Roles, 59, 443–453.
development (6th ed., pp. 793–828). Hoboken, NJ: Wiley. Collins, P. H. (2000). Black feminist thought: Knowledge, conscious-
Broverman, I. K., Broverman, D. M., Clarkson, F., ness, and the politics of empowerment (2nd ed.). New York:
Rosenkrantz, P., & Vogel, S. (1970). Sex-role stereotyp- Routledge.
ing and clinical judgments of mental health. Journal of Comas-Díaz, L. (2000). An ethnopolitical approach to working
Consulting and Clinical Psychology, 45, 250–256. with people of color. American Psychologist, 55, 1319–1325.
Brown, C. (2007). Talking body talk: Merging feminist and nar- Comas-Díaz, L., & Greene, B. (1994). Women of color: Integrating
rative approaches to practice. In C. Brown & T. Augusta- ethnic and gender identities in psychotherapy. New York:
Scott (Eds.), Narrative therapy: Making meaning, making lives Guilford Press.
(pp. 269–302). Thousand Oaks, CA: Sage. Combahee River Collective. (1982). A Black feminist statement.
Brown, L. S. (1990). Taking account of gender in the clinical In G. T. Hull, P. B. Scott, & B. Smith (Eds.), All the women
assessment interview. Professional Psychology: Research and are white, all the Blacks are men, but some of us are brave
Practice, 21, 12–17. (pp. 13–22). Old Westbury, NY: The Feminist Press.
Brown, L. S. (1991). Ethical issues in feminist therapy: Selected Contratto, S., & Rossier, J. (2005). Early trends in feminist ther-
topics. Psychology of Women Quarterly, 15, 323–336. apy theory and practice. Women and Therapy, 28(3/4),
Brown, L. S. (1992). A feminist critique of the personality disor- 7–26.
ders. In L. S. Brown & M. Ballou (Eds.), Personality and psy- Corey, G. (2009). Theory and practice of counseling and psycho-
chopathology: Feminist reappraisals (pp. 206–228). New York: therapy (8th ed.). Belmont, CA: Wadsworth.
Guilford. Cosgrove, L. (2002). Resisting essentialism in feminist therapy
Brown, L. S. (1994). Subversive dialogues: Theory in feminist ther- theory: Some epistemological considerations. Women and
apy. New York: Basic Books. Therapy, 25(1), 89–112.
Brown, L. S. (2002). Feminist therapy and EMDR: Theory Courtois, C. (2000). Recollections of sexual abuse. New York:
meets practice. In F. Shapiro (Eds.), EMDT as an integrative Norton.
psychotherapy approach (pp. 263–288). Washington, DC: Courtois, C. A. (2004). Complex trauma, complex reactions:
American Psychological Association. Assessment and treatment. Psychotherapy: Theory, Research,
Brown, L. S. (2004). Feminist paradigms of trauma treatment. Practice, Training, 41, 412–425.
Psychotherapy: Theory, Research, Practice, Training, 41, 464–471. Crawford, M. (2006). Transformations: Women, gender, and psy-
Brown, L. S. (2006). Still subversive after all these years: The chology. Boston: McGraw-Hill.
relevance of feminist therapy in the age of evidence-based Crowley-Long, K. (1998). Making room for many feminisms:
practice. Psychology of Women Quarterly, 30, 15–24. The dominance of the liberal political perspective in the psy-
Brown, L. S. (2010). Feminist therapy. Washington, DC: chology of women course. Psychology of Women Quarterly, 22,
American Psychological Association Press. 113–130.
Brown, L. S., & Brodsky, A. M. (1992). The future of feminist Dankoski, M. E., Penn, C. D., Carlson, T. D., & Hecker, L. L.
therapy. Psychotherapy: Theory, Research, & Practice, 29, 51–57. (1998). What’s in a name? A study of family therapists’ use
Bunch, C. (1987). Passionate politics: Feminist theory in action. and acceptance of the feminist perspective. American Journal
New York: St. Martin’s Press. of Family Therapy, 26, 95–104.

454 fem in ist ap p roach e s to co u n s el in g

Dardenne, B., Dumont, M., & Bollier, T. (2007). Insidious dangers Flax, J. (1987). Postmodernism and gender relations in feminist
of benevolent sexism: Consequences for women’s performance. theory. Signs: Journal of Women in Culture and Society, 12,
Journal of Personality and Social Psychology, 93, 764–779. 621–643.
Dicker, R., & Piepmeier, A. (2003). Catching a wave: Reclaiming Foa, E. B., Hembree, E. A., Cahill, S. P., Rauch, S. A. M.,
feminism for the 21st century. Boston: Northeastern University Riggs, D. S., Feeny, N. C., & Yadin, E. (2005). Randomized
Press. trial of prolonged exposure for posttraumatic stress disorder
Donovan, J. (2000). Feminist theory: The intellectual traditional of with and without cognitive restructuring: Outcome at aca-
American feminism (3rd ed.). New York: F. Ungar. demic and community clinics. Journal of Consulting and
Dovidio, J. F., Gaertner, S. L., Kawakami, K., & Hodson, G. Clinical Psychology, 73, 953–964.
(2002). Why can’t we just get along? Interpersonal biases and Foa, E. B., & Rauch, S. A. M. (2004). Cognitive changes during
interracial distrust. Cultural Diversity and Ethnic Minority prolonged exposure versus prolonged exposure plus cognitive
Psychology, 8, 88–102. restructuring in female assault survivors with posttraumatic
Downing, N. E., & Roush, K. L. (1985). From passive acceptance stress disorder. Journal of Consulting and Clinical Psychology,
to active commitment: A model of feminist identity develop- 72, 879–884.
ment for women. Counseling psychologist, 13, 695–709. Foa, E. B., & Rothbaum, B. O. (1998). Treating the trauma of
Eichenbaum, L., & Orbach, S. (1983). Understanding women: rape: Cognitive behavioral therapy for PTSD. New York:
A feminist psychoanalytic approach. New York: Basic Books. Guilford Press.
Enns, C. Z. (1992). Toward integrating feminist psychotherapy Fodor, I. G. (1988). Cognitive behavior therapy. Evaluation
and feminist philosophy. Professional Psychology: Research and of theory and practice for addressing women’s issues.
Practice, 23, 453–466. In M. A. Dutton-Douglas & L. E. Walker (Eds.), Feminist
Enns, C. Z. (2003). Contemporary adaptations of traditional psychotherapies: Integration of therapeutic and feminist systems
approaches to the counseling of women. In M. Kopala, & (pp. 91–117). Norwood, NJ: Ablex.
M. A. Keitel (Eds.), Handbook of counseling women Ford, J. D., Courtois, C. A., Steele, K., van der Hart, O.
(pp. 3–21). Thousand Oaks, CA: Sage. (2005). Treatment of complex posttraumatic self-dysregula-
Enns, C. Z. (2004). Feminist theories and feminist psychothera- tion. Journal of Traumatic Stress, 18, 437–447.
pies: Origins, themes, and diversity (2nd ed.). New York: Freire, P. (1970). Pedagogy of the oppressed. (M. B. Ramos, Trans.).
Haworth. New York: Seabury Press.
Enns, C. Z. (2008). Toward a complexity paradigm for under- Freyd, J. J. (1996). Betrayal trauma: The logic of forgetting abuse.
standing gender role conflict. The Counseling Psychologist, 36, Cambridge, MA: Harvard University Press.
446–454. Friedman, S. S. (1998). Mappings: Feminism and the cultural
Enns, C. Z. (2010). Locational feminisms and feminist social geographies of encounter. Princeton, NJ: Princeton University
identity analysis. Professional Psychology: Research and Practice, Press.
41, 333–339. Gaertner, S. L., & Dovidio, J. F. (2005). Understanding
Enns, C. Z., & Byars-Winston, A. (2010). Multicultural feminist and addressing contemporary racism: From aversive racism
therapy. In H. Landrine & N. F. Russo (Eds.), Handbook of to the common group identity model. Journal of Social Issues,
diversity in feminist psychology (pp. 367–388). New York: 61, 615–639.
Springer. Garber, L. (2001). Identity poetics: Race, class, and the lesbian-feminist
Enns, C. Z., & Machizawa, S. (2008, March). Psychological prac- roots of queer theory. New York: Columbia University Press.
tice with women and girls: Global perspectives. Working group Gergen, M. (2001). Feminist reconstructions in psychology.
conducted at the 2008 International Counseling Psychology Thousand Oaks, CA: Sage.
Conference, Chicago, Illinois. Gilbert, L. A. (1980). Feminist therapy. In A. Brodsky &
Enns, C. Z., & Sinacore, A. L. (Eds.). (2005). Teaching and R. T. Hare-Mustin (Eds.), Women and psychotherapy
social justice: Integrating multicultural and feminist theories (pp. 245–265). New York: Guilford Press.
in the classroom. Washington DC: American Psychological Gilbert, S., & Thompson, J. K. (1996). Feminist explanations
Association. of the development of eating disorders: Common themes,
Eriksen, K., & Kress, V. E. (2005). Beyond the DSM story: Ethical research findings, and methodological issues. Clinical Psyc-
quandaries, challenges, and best practices. Thousand Oaks, hology: Science and Practice, 3, 183–202.
CA: Sage. Gilligan, C. (1982). In a different voice. Cambridge, MA: Harvard
Espín, O. M. (1999). Women crossing boundaries: A psychology of immi- University Press.
gration and transformations of sexuality. New York: Routledge. Glick, P., & Fiske, S. T. (2001). An ambivalent alliance: Hostile
Espín, O. M., & Gawelek, M.A. (1992). Women’s diversity: and benevolent sexism as complementary justifications for
Ethnicity, race, class, and gender in theories of feminist gender inequality. American Psychologist, 56, 109–118.
psychology. In L. S. Brown & M. Ballou (Eds.), Personality Goldberger, N. R. (1996). Cultural imperatives and diversity in
and psychopathology: Feminist reappraisals (pp. 88–107). ways of knowing. In N. R. Goldberger & J. M. Tarule (Eds.),
New York: Norton. Knowledge, difference, and power: Essays inspired by “Women’s
Feminist Therapy Institute. (2000). Feminist therapy code of ethics Ways of Knowing” (pp. 335–371). New York: Basic Books.
(revised, 1999). San Francisco: Feminist Therapy Institute. Greenspan, M. (1983). A new approach to women and therapy.
Fischer, A. R. (2006). Women’s benevolent sexism as reaction to New York: McGraw-Hill.
hostility. Psychology of Women Quarterly, 30, 410–416. Gremillion, H. (2004). Unpacking essentialisms in therapy:
Fischer, A. R., & Holz, K. B. (2007). Perceived discrimination Lessons for feminist approaches from narrative work. Journal
and women’s psychological distress: The roles of collective of Constructivist Psychology, 17, 173–200.
and personal self-esteem. Journal of Counseling Psychology, Hall, E. J., & Rodriguez, M. S. (2003). The myth of postfemi-
54, 154–164. nism. Gender and Society, 17, 878–902.

e nns 455
Hare-Mustin, R. T., Marecek, J., Kaplan, A. G., & Liss- Kaplan, M. (1983). A woman’s view of DSM-III. American
Levinson, N. (1979). Rights of clients, responsibilities of Psychologist, 38, 786–792.
therapists. American Psychologist, 34, 3–16. Kaschak, E. (1981). Feminist psychotherapy: The first decade.
Harvey, M. R. (1996). An ecological view of psychological In S. Cox (Ed.), Female psychology: The emerging self
trauma and trauma recovery. Journal of Traumatic Stress, 9, (pp. 387–400). New York: St. Martin’s Press.
3–24. Kerber, L. K. (1986). Some cautionary words for historians.
Herman, J. L. (1992). Trauma and recovery: The aftermath of Signs: Journal of Women in Culture and Society, 11, 304–310.
violence. New York: Basic Books. Kitzinger, C., & Perkins, R. (1993). Changing our minds: Lesbian
Hernández, D., & Rehman, B. (2002). Colonize this! Young women feminism and psychology. New York: New York University
of color on today’s feminism. Emeryville, CA: Seal Press. Press.
Heywood, L., & Drake, J. (Eds.). (1997). Third wave agenda: Klein, M. H. (1976). Feminist concepts of therapy outcome.
Being feminist, doing feminism. Minneapolis: University of Psychotherapy: Theory, Research and Practice, 13, 89–95.
Minnesota Press. Klonoff, E. A., Landrine, H., & Campbell, R. (2000). Sexist dis-
Higgenbotham, E. B. (1992). African American women’s history crimination may account for well-known gender differences
and the metalanguage of race. Signs: Journal of Women in in psychiatric symptoms. Psychology of Women Quarterly, 24,
Culture and Society, 17, 251–274. 93–99.
Hill, M., & Ballou, M. (1998). Making therapy feminist: A prac- Kravetz, D. (1978). Consciousness-raising groups in the 1970s.
tice survey. Women and Therapy, 21(2), 1–16. Psychology of Women Quarterly, 3, 168–186.
Hoffman, R. M. (2006). Gender self-definition and gender self- Kravetz, D. (2004). Tales from the trenches: Politics and practice in
acceptance in women: Intersections with feminist, womanist, feminist service organizations. Dallas, TX: University Press of
and ethnic identities. Journal of Counseling and Development, America.
84, 358–372. Labaton, V., & Martin, D. L. (2004). The fire this time: Young
hooks, b. (1981). Ain’t I a woman. Boston: South End Press. activists and the new feminism. New York: Anchor Books.
Horne, S. G., & Mathews, S. S. (2006). A social justice approach Lamb, S. (Ed.). (1999). New versions of victims: Feminists struggle
to international collaborative consultation. In R. L. Toporek, with the concept. New York: New York University Press.
L. H. Gerstein, N. A. Fouad, G. Roysircar, & T. Israel Lee, J. (1997). Women re-authoring their lives through feminist
(Eds.), Handbook for social justice in counseling psychology narrative therapy. Women and Therapy, 20 (3), 1–22.
(pp. 388–405). Thousand Oaks, CA: Sage. Lerman, H. (1996). Pigeonholing women’s misery. New York:
Humphreys, J. (2003). Resilience in sheltered battered women. Basic Books.
Issues in Mental Health Nursing, 24, 137–152. Lev-Wiesel, R., Amir, M., & Besser, A. (2005). Posttraumatic
Hurtado, A. (1989). Relating to privilege: Seduction and rejection growth among female survivors of childhood sexual abuse in
in the subordination of white women and women of color. relation to perpetrator identity. Journal of Loss and Trauma,
Signs: Journal of Women in Culture an Society, 14, 833–855. 10, 7–17.
Hurtado, A. (2003). Voicing Chicana feminisms: Young women Liss, M., Crawford, M., & Popp, D. (2004). Predictors and cor-
speak out on sexuality and identity. New York: New York relates of collective action. Sex Roles, 50, 771–779.
University Press. Lorber, J. (2005). Gender inequality: Feminist theories and politics
Jackson, L. C., & Greene, B. (Eds.). (2000). Psychotherapy (3rd ed.). Los Angeles: Roxbury.
with African American Women: Innovations in psychodynamic Luepnitz, D.A. (1988). The family interpreted. New York: Basic
perspectives and practice. New York: Guilford Press. Books.
Jaggar, A. M. (Ed.). (2008). Just methods: An interdisciplinary Lugones, M. (1987). Playfulness, “world”-travelling and loving
feminist reader. Boulder, CO: Paradigm. perception. Hypatia, 2(2), 3–19.
Jaggar, A. M., & Rothenberg, P. S. (1993). Feminist frameworks: Luria, Z. (1986). A methodological critique. Signs: Journal of
Alternative theoretical accounts of the relations between women Women in Culture and Society, 11, 316–321.
and men (3rd ed.). New York: McGraw-Hill. Mackie, V. (2001). The language of globalization, transnational-
Jakubowski, P. A. (1977). Assertion training for women. ity and feminism. International Feminist Journal of Politics,
In E. I. Rawlings & D. K. Carter (Eds.), Psychotherapy 3(2), 180–206.
for women (pp. 147–190). Springfield, IL: Charles C. Mahalik, J. R., & Rochlen, A. B. (2006). Men’s likely responses
Thomas. to clinical depression: What are they and do masculinity
Jenkins, Y. M. (2000). The Stone Center theoretical approach norms predict them? Sex Roles, 55, 659–667.
revisited: Applications for African American women. Maisel, R., Epston, D., & Borden, A. (2004). Biting the
In L. C. Jackson & B. Greene (Eds.), Psychotherapy with hand that starves you: Inspiring resistance to anorexia/bulimia.
African American women (pp. 62–81). New York: Guilford. New York: Norton.
Jones, S. R., & McEwen, M. K. (2000). A conceptual model Mansour, E., Gosset, E., Elder, W., Averill, L., & Morrow, S.
of multiple dimensions of identity. Journal of College Student (2008, March). Practicing feminist multicultural therapy in
Development, 41, 405–414. conservative environments. Working group conducted at the
Jost, J. T., & Kay, A. C. (2005). Exposure to benevolent sexism 2008 International Counseling Psychology Conference,
and complementary gender stereotypes: Consequences for Chicago, Illinois.
specific and diffuse forms of system justification. Journal of Marecek, J. (1999). Trauma talk in feminist clinical practice.
Personality and Social Psychology, 88, 498–509. In S. Lamb (Ed.), New versions of victims: Feminist struggle
Kantrowitz, R. E., & Ballou, M. (1992). A feminist critique of with the concept (pp. 158–182). New York: New York
cognitive-behavioral therapy. In L. S. Brown & M. Ballou University Press.
(Eds.), Personality and psychopathology: Feminist reappraisals Marecek, J., & Kravetz, D. (1977). Women and mental health:
(pp. 70–87). New York: Guilford. A review of feminist change efforts. Psychiatry, 40, 323–329.

456 fem in ist ap p roach e s to co u n s el in g

Marecek, J., & Kravetz, D. (1998). Power and agency in feminist for social justice in counseling psychology (pp. 231–247).
therapy. In I. B. Seu & C. Heenan (Eds.), Feminism and Thousand Oaks, CA: Sage.
Psychotherapy (pp. 13–29). London: Sage. Moya, P. M. L. (2001). Chicana feminism and postmodernist
Matlin, M. W. (2012). The psychology of women (7th ed.). theory. Signs: Journal of Women in Culture and Society, 26,
Belmont, CA: Wadsworth. 441–483.
Mazure, C. M., Keita, G. P., & Glehar, M. C. (2002). Summit on Murdock, N. (2008). Theories of counseling and psychotherapy:
women and depression: Proceedings and recommendations. A case approach (2nd ed.). Old Tappan, NJ: Prentice-Hall.
Washington, DC: American Psychological Association. Nam, V. (2001). Yell-oh girls: Emerging voices explore culture,
McHugh, M. C., Koeske, R. D., & Frieze, I. H. (1986). Issues to identity, and growing up Asian American. New York:
consider in conducting nonsexist research: A guide for HarperCollins.
researchers. American Psychologist, 41, 879–890. Norsworthy, K. L., & Khuankaew, O. (2004). Women of Burma
Moradi, B., & Subich, L. M. (2002). Perceived sexist events and speak out: Workshops to deconstruct gender-based violence
feminist identity development attitudes: Links to women’s and build systems of peace and justice. The Journal for
psychological distress. The Counseling Psychologist, 30, 44–65. Specialists in Group Work, 29, 259–283.
McNamara, K., & Rickard, K. M. (1989). Feminist identity Norsworthy, K. L., & Khuankaew, O. (2006). Bringing social
development: Implications for feminist therapy with women. justice to international practices of counseling psychology.
Journal of Counseling and Development, 68, 184–189. In R. L. Toporek, L. H. Gerstein, N. A. Fouad, G. Roysircar,
Metzendorf, D. (2005). The evolution of feminist organizations: & T. Israel (Eds.), Handbook for social justice in counseling
An organizational study. Lanham, MD: University Press of psychology (pp. 421–441). Thousand Oaks, CA: Sage.
America. O’Neil, J. M. (2008). Summarizing 25 years of research on men’s
Miller, C. L., & Cummins, A. G. (1992). An examination of gender role conflict using the gender role conflict scale: New
women’s perspectives on power. Psychology of Women research paradigms and clinical implications. The Counseling
Quarterly, 16, 415–428. Psychologist, 36, 358–445.
Miller, J. B. (1976). Toward a new psychology of women. Boston: Osborne, J. W. (2001). Testing stereotype threat: Does anxiety
Beacon Press. explain race and sex differences in achievement? Contemporary
Miller, B. J., Cardona, J. R. P., & Hardin, M. (2006). The use of Educational Psychology, 26, 291–310.
narrative therapy and internal family systems with survivors Ossana, S. M., Helms, J. E., & Leonard, M. M. (1992).
of childhood sexual abuse: Examining issues related to loss Do “womanist” identity attitudes influence college women’s
and oppression. Journal of Feminist Family therapy, 18(4), self-esteem and perceptions of environmental bias? Journal
1–27. of Counseling and Development, 70, 402–408.
Miller, J. B., & Stiver, I. P. (1997). The healing connection: How Parks, E. E., Carter, R. T., & Gushue, G. V. (1996). At the cross-
women form relationship in therapy and in life. Boston: Beacon roads: Racial and womanist identity development in Black
Press. and White women. Journal of Counseling and Development,
Mohanty, C. T., Russo, A., & Torres, L. (1991). Third world 74, 624–631.
women and the politics of feminism. Bloomington, IN: Indiana Pease, B. (2002). Rethinking empowerment: A postmodern
University Press. reappraisal for emancipatory practice. British Journal of Social
Moradi, B., Fischer, A. R., Hill, M. S., Jome, L. M., & Blum, S. A. Work, 32, 135–147.
(2000). Does “feminist” plus “therapist” equal “feminist Peltola, P., Milkie, M. A., & Presser, S. (2004). The “feminist”
therapist”? Psychology of Women Quarterly, 24, 285–296. mystique: Feminist identity in three generations of women.
Moradi, B., & Funderburk, J. R. (2006). Roles of perceived Gender and Society, 18, 122–144.
sexist events and perceived social support in the mental Philpot, C. L., Brooks, G. R., Lusterman, D. D., & Nutt, R. L.
health of women seeking counseling. Journal of Counseling (1997). Bridging separate gender worlds: Why men and women
Psychology, 53, 4634–4473. clash and how therapists can bring them together. Washington,
Moradi, B., & Subich, L. M. (2003). A concomitant examina- DC: American Psychological Association.
tion of the relations of perceived racist and sexist events to Porter, N. (2005). Location, location, location: Contributions
psychological distress for African American women. The of contemporary feminist theorists to therapy theory and
Counseling Psychologist, 31, 451–469. practice. Women and Therapy, 28(3/4), 143–160.
Moradi, B., & Subich, L. M. (2004). Examining the moderating Prilleltensky, I., & Nelson, G. (2002). Doing psychology critically:
role of self-esteem in the link between experiences of per- Making a difference in diverse settings. New York: Palgrave
ceived sexist events and psychological distress. Journal of Macmillan.
Counseling Psychology, 51, 50–56. Quinn, J. E. A., & Radtke, H. L. (2006). Dilemmatic negotia-
Moradi, B., & Yoder, J. D. (2011). The psychology of girls and tions: the (un)tenability of feminist identity. Psychology of
women. In E. M. Altmaier, & J. C. Hansen (Eds.), The Women Quarterly, 30, 187–198.
Oxford handbook of counseling psychology. New York: Oxford Rader, J., & Gilbert, L. A. (2005). The egalitarian relationship in
University Press. feminist therapy. Psychology of Women Quarterly, 29, 427–435.
Morrow, S. L., & Hawxhurst, D. M. (1998). Feminist therapy: Rawlings, E., & Carter, D. (1977). Feminist and nonsexist psycho-
Integrating political analysis in counseling and psychother- therapy. In E. I. Rawlings & D. K. Carter (Eds.), Psychotherapy
apy. Women and Therapy, 21 (2), 37–50. for women (pp. 49–76). Springfield, IL: C. C. Thomas.
Morrow, S. L., Hawxhurst, D. M., Montes de Vegas, A. Y., Rederstorff, J. C., & Levendosky, A. A. (2007). Clinical applica-
Abousleman, T. M., & Castañeda, C. L. (2006). Toward a tions of feminist identity development: An illustrative case
radical feminist multicultural therapy: Renewing a com- study. Clinical Case Studies, 6(2), 119–130.
mitment to activism. In R. L. Toporek, L. H. Gerstein, Reid, A., & Purcell, N. (2004). Pathways to feminist identifica-
N. A. Fouad, G. Roysircar, & T. Israel (Eds.), Handbook tion. Sex Roles, 50, 759–769.

e nns 457
Reid, P. T., & Kelly, E. (1994). Research on women of color: Sharf, R. S. (2008). Theories of psychotherapy and counseling:
From ignorance to awareness. Psychology of Women Quarterly, Concepts and cases (4th ed.). Belmont, CA: Wadsworth.
18, 477–486. Shields, S. A. (2008). Gender: An intersectionality perspective.
Resick, P. A., & Schnicke, M. (1993). Cognitive processing therapy Sex Roles, 59, 301–311.
for rape victims: A treatment manual. Thousand Oaks, CA: Smith, A., & Douglas, M. A. (1990). Empowerment as an ethi-
Sage. cal imperative. In H. Lerman & N. Porter (Eds.), Feminist
Resick, P. A., Galovski, T. E., Uhlmansiek, M. O., Scher, C. D., ethics in psychotherapy (pp. 43–50). New York: Springer.
Clum, G. A., & Young-Xu, Y. (2008). A randomized clinical Smith, B. (Ed.). (1983). Home girls: A Black feminist anthology.
trial to dismantle components of cognitive processing ther- New York: Kitchen Table, Women of Color Press.
apy for posttraumatic stress disorder in female victims of Spencer, S. J., Steele, C. M., & Quinn, D. M. (1999). Stereotype
interpersonal violence. Journal of Consulting and Clinical threat and women’s math performance. Journal of Experi-
Psychology, 76, 243–258. mental Social Psychology, 35, 4–28.
Resick, P. A., Nishith, P., Weaver, T. L., Astin, M. C., & Feuer, C. A. Stake, J. E. (2007). Predictors of change in feminist activism
(2002). A comparison of cognitive-processing therapy with through women’s and gender studies. Sex Roles, 57, 43–54.
prolonged exposure and a waiting condition for the treat- Stein, A. (1997). Sex and sensibility: Stories of a lesbian generation.
ment of chronic posttraumatic stress disorder in female rape Berkeley, CA: University of California Press.
victims. Journal of Consulting and Clinical Psychology, 70, Stewart, A., & McDermott, C. (2004). Gender in psychology.
867–879. Annual Review of Psychology, 55, 519–544.
Reynolds, A. L., & Pope, R. L. (1991). The complexities of diver- Strife, S. (2006). Anti-anorexia/bulimia: Finding the voice of
sity: Exploring multiple oppressions. Journal of Counseling resistance. Psychology of Women Quarterly, 30, 121–122.
and Development, 70, 174–180. Sturdivant, S. (1980). Therapy with women. New York: Springer
Rice, J., & Ballou, M. (2002). Cultural and gender awareness in Publishing Co.
international psychology. Washington, DC: American Psy- Sue, D. W., Bingham, R., Porché-Burke, L., & Vasquez, M.
chological Association, Division 52, International Psychology, (1999). The diversification of psychology: A multicultural
International Committee for Women. revolution. American Psychologist, 54, 1061–1069.
Rigazio-DiGilio, S. A. (2000). Relational diagnosis: A cocon- Sue, D. W., Capodilupo, C. M., Torino, G. C., Bucceri, J. M.,
structive-developmental perspective on assessment and treat- Holder, A. M. B., Nadal, K. L., & Esquilin, M. (2007).
ment. Journal of Clinical Psychology: Psychotherapy in Practice, Racial microaggressions in everyday life: Implications for
56, 1017–1036. clinical practice.
Robb, C. (2006). This changes everything: The relational revolution Suyemoto, K. L. (2002). Constructing identities: A feminist,
in psychology. New York: Farrar, Straus & Giroux. culturally contextualized alternative to “personality.”
Root, M. P. P. (1992). Reconstructing the impact of trauma on In M. Ballou & L. S. Brown (Eds.), Rethinking mental health
personality. In L. S. Brown & M. Ballou (Eds.), Personality and disorder: Feminist perspectives (pp. 71–98). New York:
and psychopathology: Feminist reappraisals (pp. 229–265). Guilford.
New York: Guilford. Swim, J. K., Aikin, K. J., Hall, W. S., & Hunter, B. A. (1995).
Root, M. P. (Ed). (1995). The multiracial experience: Racial bor- Sexism and racism: Old fashioned and modern prejudices.
derlands as the new frontier. Thousand Oaks, CA: Sage. Journal of Personality and Social Psychology, 68, 199–214.
Ross, B. (1995). The house that Jill built: A lesbian nation in for- Szymanski, D. M. (2005). Heterosexism and sexism as correlates
mation. Toronto, ON: University of Toronto Press. of psychological distress in lesbians. Journal of Counseling and
Rubin, L., & Nemeroff, C. (2001). Feminism’s third wave: Development, 83, 355–360.
Surfing to oblivion? Women and Therapy, 23 (2), 91–104. Szymanski, D. M., Baird, M. K., & Kornman, C. L. (2002).
Rudy, K. (2001). Radical feminism, lesbian separatism, and The feminist male therapist: Attitudes and practices for the
queer theory. Feminist Studies, 27, 191–222. 21st century. Psychology of Men and Masculinity, 3, 22–27.
Sanchez-Hucles, J., & Hudgins, P. (2001). Trauma across diverse Tavris, C. (1992). The mismeasure of woman. New York: Simon
settings. In J. Worell (Ed.), Encyclopedia of women and gender & Schuster.
Vol. 2 (pp. 1151–1168). San Diego, CA: Academic Press. Taylor, V., Whittier, N., & Pelak, C. F. (2001). The
Saunders, K. J., & Kashubeck-West, S. (2006). The relations women’s movement: Persistence through transformation.
among feminist identity development, gender-role orienta- In L. Richardson, V. Taylow, & N. Whittier (Eds.), Feminist
tion, and psychological well-being in women. Psychology of frontiers (5th ed., pp. 559–574). New York: McGraw-Hill.
Women Quarterly, 30, 199–211. Tedeschi, R. G., & Calhoun, L. G. (2004). Posttraumatic
Schmader, T., & Johns, M. (2003). Converging evidence that growth: Conceptual foundations and empirical evidence.
stereotype threat reduces working memory capacity. Journal Psychological Inquiry, 15, 1–18.
of Personality and Social Psychology, 85, 3440–3452. Thompson, A. (1998). Not the color purple: Black feminist
Schnurr, P. P., Friedman, M. J., Engel, C. C., Foa, E. B., Shea, M. T., lessons for educational caring. Harvard Educational Review,
Chow, B. K., Resick, P. A., Thurston, V., Orsillo, S. M., 68, 522–554.
Haug, R., Turner, C., Turner, C., & Bernardy, N. (2007). Thompson, B. (2002). Multiracial feminism: Recasting the
Cognitive behavioral therapy for posttraumatic stress disor- chronology of second wave feminism. Feminist Studies, 28,
der in women: A randomized controlled trial. Journal of the 337–355.
American Medical Association, 297, 820–830. Tong, R. (2008). Feminist thought: A more comprehensive intro-
Scott, J. W. (1988). Deconstructing equality-versus-difference: duction (3rd ed.). Boulder, CO: Westview Press.
Or, the uses of poststructuralist theory for feminism. Feminist Turner, C. W. (1997). Clinical applications of the Stone Center
Studies, 14 (1), 35–50. theoretical approach to minority women. In J. V. Jordan
Seligman, M. E. P., & Csikszentmihalyi, M. (2000). Positive psy- (Ed.), Women’s growth in diversity: More writings from the
chology: An introduction. American Psychologist, 55, 5–14. Stone Center (pp. 74–90). New York: Guilford.

458 fem in ist ap p roach e s to co u n s el in g

Vasquez, H., & Magraw, S. (2005). Building relationships Wyche, K. F., & Rice, J. K. Feminist therapy: From dialogue to
across privilege: Becoming an ally in the therapeutic relation- tenets. In J. Worell & N. G. Johnson (Eds.), Shaping the
ship. In M. P. Mirkin, K. L. Suyemoto, & B. F. Okun (Eds.), future of feminist psychology (pp. 57–71). Washington, DC:
Psychotherapy with women: Exploring diverse contexts and iden- American Psychological Association.
tities (pp. 64–83). New York: Guilford. Wylie, M. S. (1995). Diagnosing for dollars? Psychotherapy
Vasquez, M. J. T. (2003). Ethical responsibilities in therapy: Networker, 19(3), 23–33, 65–66.
A feminist perspective. In M. Kopala & M. A. Keitel, Yakushko, O. (2007). Do feminist women feel better about their
Handbook of counseling women (pp. 557–573). Thousand lives? Examining patterns of feminist identity development
Oaks, CA: Sage. and women’s subjective well-being. Sex Roles, 57, 223–234.
Walker, L. E.A. (1979). The battered woman. New York: Harper Yalom, I. D. (2002). The gift of therapy. New York:
& Row. HarperCollins.
Walker, L.E. A. (1994). Abused women and survivor therapy. Yoder, J. D. (2007). Women and gender: Making a difference
Washington, DC: American Psychological Association. (3rd ed.). Cornwall-on-Hudson, NY: Sloan.
Weed, E., & Schor, N. (Eds.). (1997). Feminism meets queer Zinn, M. B., & Dill, B. T. (1996). Theorizing difference from
theory. Bloomington, IN: Indiana University Press. multiracial feminism. Feminist Studies, 22, 321–331.
Weisstein, N. (1970). Kinder, kuche, kirche as scientific law: Zucker, A. N. (2004). Disavowing social identities: What it
Psychology constructs the female. In R. Morgan (Ed.), means when women say, “I’m not a feminist, but . . .” Psy-
Sisterhood is powerful (pp. 205–219). New York: Vintage chology of Women Quarterly, 28, 423–435.
Books. Zucker, A. N., & Stewart, A. J. (2007). Growing up and growing
Werner-Wilson, R. J., Zimmerman, R. S., & Whalen, D. (2000). older: Feminism as a context for women’s lives. Psychology
Resilient response to battering. Contemporary Family Therapy: of Women Quarterly, 31, 137–145.
An International Journal, 22, 161–188.
West, C. M. (1995). Mammy, Sapphire, and Jezebel: Historical Further Reading
images of black women and their implications for psycho-
American Psychological Association. (2007). Guidelines for psy-
therapy. Psychotherapy: Theory, Research, and Practice, 32,
chological practice with girls and women. American Psy-
458–466.
chologist, 62, 949–979.
West, C. M. (2002). Violence in the lives of Black women: Battered,
Ballou, M., Hill, M., & West, C. (Eds.). (2008). Feminist therapy
black, and blue. New York: Haworth Press.
theory and practice: A contemporary perspective. New York:
West, C. K. (2005). The map of relational-cultural theory.
Springer.
Women and Therapy, 28(3/4), 93–110.
Brown, L. S. (1994). Subversive dialogues: Theory in feminist
Whipple, V. (1996). Developing an identity as a feminist family
therapy. New York: Basic Books.
therapist: Implications for training. Journal of Marital and
Brown, L. S. (2010). Feminist therapy. Washington, DC:
Family Therapy, 22, 381–396.
American Psychological Association Press.
Wing, A. K. (Ed.). (2000). Global critical race feminism: An inter-
Enns, C. Z. (2004). Feminist theories and feminist psychothera-
national reader. New York: New York University Press.
pies: Origins, themes, and diversity (2nd ed.). New York:
Winslade, J., Crocket, K., & Monk, G. (1997). The therapeutic
Haworth.
relationship. In G. Monk, J. Winslade, K. Crocket, &
Evans, K. M., Kincade, E. A., & Seem, S. R. (2011). Introduction
D. Epston (Eds.), Narrative therapy in practice: The archaeol-
to feminist therapy: Strategies for social and individual change.
ogy of hope (pp. 53–81). San Francisco: Jossey-Bass.
Thousand Oaks, CA: Sage.
Wolfe, J., & Kimerling, R. (1997). Gender issues in the assess-
Hill, M., & Ballou, M. (2005). The foundation and future of
ment of posttraumatic stress disorder. In J. P. Wilson &
feminist therapy. New York: Haworth.
T. M. Keane (Eds.), Assessing psychological trauma and PTSD
Kopala, M., & Keitel, M. A. (Eds.). (2003). Handbook of counsel-
(pp. 192–237). New York: Guilford.
ing women. Thousand Oaks, CA: Sage.
Worell, J. (2001). Feminist interventions: Accountability beyond
Landrine, H., & Russo, N. F. (Eds.). (2010). Handbook of diver-
symptom reduction. Psychology of Women Quarterly, 25,
sity in feminist psychology. New York: Springer.
335–343.
Worell, J., & Goodheart, C. D. (Eds.). (2006). Handbook of girls’
Worell, J. (2006). Pathways to healthy development: Sources
and women’s psychological health. New York: Oxford.
of strength and empowerment. In J. Worell &
Worell, J., & Remer, P. (2003). Feminist perspectives in therapy:
C. D. Goodheart (Eds.), Handbook of girls’ and women’s psy-
Empowering diverse women (2nd ed.). New York: Wiley.
chological health (pp. 25–35). New York: Oxford University
Press.
Worell, J., & Remer, P. (2003). Feminist perspectives in therapy:
Empowering diverse women (2nd ed.). New York: Wiley.

e nns 459
 CHAPTER

17 Disability: A Primer for Therapists

Rhoda Olkin

Abstract
This chapter is an overview of the concepts critical to an understanding of disability. A social justice
perspective underlies all four topics areas. Topics covered include, first, conceptualizing disability,
including models of disability, common disability experiences, legal issues relevant to persons with
disabilities, and sociocultural and familial factors for persons with disabilities. Next, issues related to
counseling individuals with disabilities are discussed. In particular, disability-affirmative therapy is
described, along with a template for key questions to explore with clients. Special issues in training and
supervision are discussed from two perspectives: when the client or when the therapist is the person
with a disability. Future issues to be illuminated and explored include abuse as a cause of disability,
bicultural partnerships between a person with and a person without a disability, and outcome studies
of therapy with persons with disabilities; finally, a research agenda is proposed.
Keywords: disability, handicap, impairment, disability-affirmative therapy, psychotherapy, counseling,
sociocultural experiences, social justice

This chapter is intended to introduce, in a relatively review basic disability concepts. These concepts
short space, all of the key concepts necessary for a include models of disability, common disability
basic understanding of disability. The purpose is to experiences, and legal and sociocultural influences
acquaint readers with sufficient conceptual founda- on persons with disabilities. Next, I turn to a model
tions to build competence in counseling individuals for counseling individuals with disabilities called
and families with disabilities. A skill set, under the disability-affirmative therapy (Olkin, 1999, 2008).
umbrella of disability-affirmative therapy (D-AT; Finally, special issues in training and supervision
Olkin, 1999, 2008), is introduced. Although it is not are presented, followed by future clinical issues
possible to convey the full richness of disability expe- needing further research and explication.
riences nor the range of knowledge and skills neces-
sary for cultural competence, it is hoped that readers Defining Disability
will feel enabled to undertake clinical work with cli- In this section and throughout this chapter, it is
ents with disabilities. Part of this empowerment will important to remember that disabilities are not
come from knowing that you can make mistakes in always visible to others, and persons with hidden
therapy with your clients with disabilities and yet disabilities can encounter special types of problems.
recover from them. Only when you are free to make Additionally, we need to keep in mind that the rate
mistakes are you free to engage in the work. of disability in the United States is rising, due to
In this chapter, I explore how disability affects aging of the population, the dramatic increase in
the counseling relationship, countertransference, rate of diabetes, and as a result of continuing wars in
and the therapeutic work itself. To do this, I first the Middle East (Smith, Foley, & Chaney, 2008).

460
 Many different words are used to describe disabil- From this, we see that there is no universal
ity, often as if these words are interchangeable. The definition of disability. Rather, disability is a fluid
most commonly used terms are disability, handicap, concept that can only be defined by the context in
and impairment. These words have different meanings, which it is occurs. In this way, disability is said to be
and understanding the differences in terminology illu- a social construct. In fact, the WHO states that
minates how disability is variously conceptualized. health and disability are not opposites but equally
An impairment refers to the cause of a functional part of the human experience:
difference (e.g., arthritis). A handicap is the way that
It acknowledges that every human being can
the impairment affects functioning (e.g., limited use
experience a decrement in health and thereby
of one arm and hand and reduced hand strength).
experience some degree of disability. Disability is
The disability is found in the mismatch between
not something that only happens to a minority
functioning and the environment (e.g., need to type
of humanity. The ICF thus “mainstreams” the
without access to voice dictation software). The
experience of disability and recognises it as a
impairment and handicap are about the person, but
universal human experience. By shifting the focus
the disability is about the environment; thus, as
from cause to impact it places all health conditions
environments change, disability can range from
on an equal footing, allowing them to be compared
pronounced to moot.
using a common metric—the ruler of health and
Definitions of disability are evolving, and can
disability. Furthermore ICF takes into account the
be found in a variety of sources (Brown, DeLeon,
social aspects of disability and does not see disability
Loftis, & Scherer, 2008). One place to start in defin-
only as “medical” or “biological” dysfunction.
ing disability is with the World Health Organization’s
By including Contextual Factors, in which
(WHO) International Classification of Functioning,
environmental factors are listed, ICF allows to
Disability, and Health (WHO, 2001). First, one can
record the impact of the environment on the
think of the functioning of various body functions.
person’s functioning. (Accessed June 3, 2008
These include mental, sensory, and speech functions.
from http://www.who.int/classifications/icf/en/)
Body systems include cardiovascular, hematologi-
cal, immunological, respiratory, digestive, metabolic, A legal definition of disability is different from
endocrine, genitourinary, and reproductive systems, any of those described above. In the United States,
as well as neuromusculoskeletal, movement, and skin the legal definition that was part of the Reha-
systems (WHO, 2001). Any of these systems and bilitation Act (1973) has remained the same in sub-
functions can work differently, be impaired or inhib- sequent legislation, notably in the Americans with
ited, or even work counterproductively. A second way Disabilities Act (1990). In these laws “disability
of thinking about what is altered in disability is to means, with respect to an individual–(a) A physical
consider the types of activities in which humans par- or mental impairment that substantially limits
ticipate, and how disability affects these activities. one or more of the major life activities of such indi-
These activities include learning, applying knowl- vidual; (B) A record of such an impairment, or
edge, communication, mobility, self-care, interper- (C) Being regarded as having such an impairment.”
sonal relationships, social interactions, domestic life, Note that the law incorporates the concepts of
and community involvement (WHO, 2001). A third body systems ( physical or mental impairment), func-
way to think about disability is to describe the assis- tioning (substantially limits), and perception (being
tance that enables participation by an individual. regarding as having such an impairment). However,
These might include use of a product (e.g., speech there have been ardent legal discussions over the
board) or technology (e.g., electric wheelchair), meanings of key phrases, particularly “substantially
changes to the environment (e.g., ramps and curb limits” and “major life activities.” (See section on
cuts), or support from other persons (e.g., financial Laws.)
management). Each of these methods of defining dis-
ability has value in particular contexts. In medical Models of Disability
venues, understanding of body systems and functions Various ways of conceptualizing disability have been
might be most helpful. In educational settings, the hypothesized, but a three-model system seems to
second method of focusing on activities may be most capture clinically useful ways of understanding how
useful. In working toward the goal of community inte- our clients view their disabilities. These three models
gration, understanding needed levels of assistance with are the moral, medical, and social models (Asch
activities of daily living would be most germane. & Rousso, 1985; Florian, 1982; Olkin, 1999, 2007;

olkin 461
Rose, 1997). The moral model posits that disability the moral implications that stem from the meaning,
is a manifestation of spiritual, moral, religious, or sample ideas associated with the model, origins of
personal weaknesses or strengths, either in this life the model, goals and providers of intervention, and
or past lives. In such a view, a client might say that both the benefits and deficits of each model. Each
a baby was born with a deformity because the model prevails in certain settings. The moral model
mother encountered evil during the pregnancy. is most prevalent in Eastern cultures, whereas the
Alternately, the client might say that this baby was medical model prevails in North America and
born with a deformity because the mother has a Western Europe, including in their medical service
special relationship with the deity who deemed her delivery systems and professional literature. The
capable of raising such a child. Thus, the event itself social model is prevalent within disability rights
(a baby with a deformity) is not in itself good or movements, embedded in many civil rights laws in
bad, but rather is interpreted positively or nega- the United States and England, and underlies the
tively, but all within the lens of morality. Healing WHO and some other global and governmental
comes from within spiritual, moral, or religious agencies.
beliefs. In the medical model, the disability is viewed A critical question is whether knowing about
as a defect in one or more bodily parts or func- these models helps with our understanding of
tions (as in the first method of defining disability clients and of the counseling process with clients
proposed by the WHO). Such a defect may stem with disabilities. First, we have to consider whether
from behaviors related to health (e.g., poor dental clients have been informed about the models and
hygiene) or unrelated to health (e.g., a car accident), their differences. Second, we need to know if we
from heredity (e.g., albinism), injury (e.g., a diving should teach clients about these models, and, if so,
accident), or environment (e.g., exposure to lead), we need ways of explaining these models to clients.
but are considered to be medical problems best Third, we have to evaluate the client’s beliefs related
attended to within the general medical service deliv- to these models. Fourth, we need to examine in
ery system. Some blame may be attached to the dis- what ways the client receives the benefits and/or the
ability (not getting vaccinated, taking risks, having deficits of the model. And fifth, we need to explore
a type A personality), but generally the stigma and whether a shift in models is desirable and, if so,
shame of disability often associated with the moral feasible. Let us take these questions one at a time.
model is alleviated in the medical model. However, Do clients know about these models? Generally
the role of the person with a disability is that of a speaking, I would say that most people, with or
patient or client who is expected to participate in without disabilities, have not been introduced to the
recovery and rehabilitation. idea of different ways of conceptualizing disability.
The social model is a paradigm shift from the Disability is not a topic in standard curricula or daily
moral and medical models. In the social model, discourse. It is safest to assume that some of the ideas
disability is a social construct, created by the inter- promulgated in the models are new to clients.
action or a mismatch of the person and the environ- Unfortunately, they are also new ideas to thera-
ment, rather than being located solely within the pists. Undergraduate students are mostly likely to
person. From this perspective, an impairment has learn about disability as part of abnormal psychol-
no valence, but rather is evaluated in terms of its ogy, if they learn about it at all. A content analysis
interaction with the physical, socioeconomic, and of undergraduate textbooks regarding content on
interpersonal environments. For example, using a diversity was unable to include disability because
wheelchair for mobility is not denigrated as inferior textbook coverage on disability was too sparse for
to walking, but rather as an alternate method of any meaningful analysis (Hogben & Waterman,
locomotion. The use of the wheelchair becomes 1997). The picture is hardly better in graduate psy-
problematic when the environment poses barriers chology training (Kemp & Mallinckrodt, 1996;
(stairs, absence of curb cuts, narrow passageways), Olkin & Pledger, 2003). Analysis of one graduate
many of which are readily remediable, and when program’s training curriculum revealed that physical
interpersonal interactions convey inferiority (pull- disability received the lowest amount of coverage of
ing young children out of the way, making disparag- seven areas of diversity (Bluestone, Stokes, & Kuba,
ing comments, failing to make eye contact). 1996). In a study of the required curriculum at
Table 17.1 shows a comparison of the moral, all graduate clinical and counseling psychology
medical, and social models. Each model is explored programs accredited by the American Psycholog-
in terms of how it makes meaning of disability, ical Association, the modal number of courses on

462 disabilit y
Table 17.1. Comparison of the Moral, Medical and Social Models of Disability
Moral Model Medical Model Social Model
Meaning of Disability is a manifestation of A defect in or failure Disability is a social
disability moral lapse, sins, failure of faith, of a bodily system that is construct. Problems reside in
or evil; alternatively, it is a test of inherently abnormal and the environment that fails to
faith or honor. pathological. accommodate people with
disabilities, and in the
mismatch between person
and environment.
Moral If viewed as a moral mark, the A medical abnormality Society has failed a segment
implications disability brings shame to the due to genetics, bad of its citizens, and oppresses
person with the disability and to health habits, person’s them.
his or her family. Alternatively, behavior.
it is a reminder of having been
chosen or saved.
Sample ideas “God gives us only what we can Clinical descriptions “Nothing about us without us.”
bear” or “There’s a reason I was of “patients” in medical “Civil rights, not charity.”
chosen to have this disability.” terminology; isolation
of body parts.
Origins Oldest model and still most Mid-19th century In 1975, with the demonstrations
prevalent worldwide. Most common model by people with disabilities in
in U.S. support of the yet-unsigned
Entrenched in most Rehabilitation Act.
rehabilitation clinics
and journals.
Goals of Spiritual or divine; acceptance. “Cure” or amelioration Political, economic, social, and
intervention of the disability to the policy systems; increased access
greatest extent possible. and inclusion.
Benefits of An acceptance of being selected, A lessened sense of Promotes integration of the
model a special relationship with God, shame and stigma disability into the self.
a sense of greater purpose to the Faith in medical A sense of community and
disability. intervention. pride. Depathologizing of
Spurs medical and disability.
technological advances.
Negative Shame, ostracism, need to conceal Paternalistic; promotes Powerlessness in the face of
effects the disability or person with the benevolence and charity. needed broad social and
disability. Services for but not by political changes.
people with disabilities. Challenges to prevailing ideas.

disability was zero (Olkin & Pledger, 2003). Data the social model of disability espoused in disability
from 1989, just prior to the passage of the Americans studies” (Olkin & Pledger, 2003, p. 297).
with Disabilities Act (ADA), and 1999, 9 years after Within psychology, disability is relegated to
passage of the ADA, showed that the situation had rehabilitation psychology (Smart & Smart, 2006),
gotten slightly worse. In 1999, “only 11% of pro- which has kept the focus more on acquired and
grams had at least one course on disability (less than acute conditions (e.g., traumatic brain injury, spinal
in 1989). Furthermore, this disability course was cord injury) and medical settings. However, most of
most likely to be on ‘exceptional’ children, learning the over 53 million persons in the United States
disabilities, or mental retardation—courses that gen- with a disability are not in such settings, and if they
erally reflect the medical model of disability. Only 7 seek psychological treatment, it is most likely to be
out of 210 programs had a course on psychosocial in an outpatient setting and delivered by a therapist
aspects of disability, i.e., courses more likely to reflect who was not trained in rehabilitation counseling.

olkin 463
Therefore, the lack of graduate training on disability resource room and/or assistant, use of reasonable
is a serious problem resulting in lack of availability accommodations in school or work, and visibility of
of therapists competent in disability culture and the disability. Any scale that elicited a client’s model
affirming therapy (Smart & Smart, 2006). If thera- of disability could potentially assess these factors,
pists are not familiar with the models of disability, but in and of themselves they would not lead to any
they are unable to discuss them with clients. Nor scores on the three models.
can they assess their clients’ views of disability. And, There is no reason to assume that clients would
potentially more damagingly, they are not attuned fit neatly into one and only one model. It is proba-
to the necessity of matching their language and ble that many clients would straddle more than one
treatment approach to the client’s model. model, would be en route from one model to
Should we teach clients with disabilities about these another, or hold contradictory ideas (see Table 17.3
models? This is an intricate clinical question that for a hypothetical array of models ascribed to by any
cannot receive a blanket answer. So, the answer is: one client). The combination of the moral and
It depends. For some clients, it can be helpful to medical, or the medical and social models seems
elucidate the ways in which they are thinking about psychologically consistent, whereas the simultane-
disability. This can be compared and contrasted ous holding of the moral and social models seems
with how the educational or medical systems might at odds, and theoretically would cause cognitive
be responding to disability. Bringing these issues to dissonance such that one would have to reconcile
light can help families find ways to communicate the opposing beliefs by shedding one set or the
better with professionals, understand how profes- other. This turns out not to be the case. In a study
sionals communicate with them, and create under- using interviews (in Cantonese) with 12 immigrant
standing of differences in perspectives and opinions. Chinese families of lower socioeconomic status
Furthermore, the person with a disability and his or about their beliefs related to their child with a dis-
her family may not agree about their models of dis- ability (usually autism), the modal perspective was
ability; teaching about models can be a useful way a hybrid of the moral and social models (Wong,
to elicit and elucidate similarities and differences in 2008). For example, a father might say that the son’s
how each family member views the disability. For autism was caused by evil spirits, and in the next
other clients, examining models of disability is too sentence state his conviction that his son has rights
abstract an idea that can detract from the symptoms under the law and that the father must assert those
and problems for which they seek treatment. Keep rights with the school.
in mind, however, the caveat that most therapists In what ways does the client receive benefits or
are not trained in models of disability; it is impera- negative effects of the model(s)? Whichever individual
tive that therapists first become familiar with the model or hybrid of models the client believes in
three models and have a chance to explore and leads to the potential for beneficial and/or negative
understand their own responses to disability in light consequences. The moral model may bring shame
of these models, so that they are better equipped to and dishonor, anger at the deity, a sense of purpose-
discuss them with clients. lessness. Conversely, it may strengthen beliefs, foster
How do we evaluate clients’ beliefs about disability? awareness of the preciousness of life, or create mean-
There is no scale extant to assess a client’s model ing in an otherwise random event. The medical
of disability. Such a scale would need to inquire about model may counter shame by medicalizing the dis-
beliefs related to the nature of the “problem” of dis- ability, foster support among persons with similar
ability, where the “problem” is located, and potential impairments, and provide technical and medical
remediators of the “problem.” Guber (2007) endeav- advances that improve the daily lives of people
ored to create such a scale, taking as his starting with disabilities. Alternatively, the medical model
point client questions posed by Olkin (1999; see can create passiveness, reinforce the role of receiver
Table 17.2). He was hampered in his efforts by lack rather than active participant or leader, and de-
of consensus on which models to use, what they emphasize the socioeconomic and political barriers
mean, and whether they are valid. There are myriad for persons with disabilities. The social model pro-
factors affecting one’s belief system related to dis- motes independence and interdependence, creates
ability, including current age and age of disability a disability community, empowers individuals and
onset, socioeconomic status, national origin, reli- groups, and promotes sociopolitical change. How-
gion, family history with disability, level of impair- ever, it can create schisms in beliefs within the
ment, placement in special education or use of family, enable hopelessness in the face of massive

464 disabilit y
Table 17.2. Assessing the Client’s Model of Disability
Model Questions to Ask Yourself
Moral Model: ∗ Do you feel shame or embarrassment about your disability?
∗ Do you feel you bring dishonor to the family?
∗ Do you try to hide and minimize the disability as much as possible?
∗ Do you try to make as few demands on others as possible, because it’s “your problem” and hence
your responsibility?
∗ Do you try to make your disability inconspicuous?
∗ Do you think your disability is a test of your faith, or as a way for you to prove your faith?
∗ Do you think your disability is a punishment for your or your family’s failings?
Medical Model: ∗ Compared to Franklin Delano Roosevelt (FDR)’s time, do you think that life for persons with
disabilities has improved considerably?
∗ Do you think FDR wouldn’t have to hide his disability today?
∗ Do you try to make as few demands on others as possible because you think you should be able
to find a way to do it yourself?
∗ Do you dress in ways that maximize your positive features and minimize the visibility of the
disability?
∗ Do you believe that the major goals of research should be to prevent disabilities and find cures for
those who already have disabilities?
∗ Do you think that persons with disabilities do best when they are fully integrated into the
nondisabled community?
Minority Model: ∗ Do you identify yourself as part of a minority group of persons with disabilities?
∗ Do you feel kinship and belonging with other persons with disabilities?
∗ Do you think that not enough is being done to assure rights of persons with disabilities?
∗ When policies and legislation are new, do you evaluate them in terms of their effects on persons
with disabilities?
∗ Do you think the major goals of research should be to improve the lives of persons with
disabilities by changing policies, procedures, funding, and laws?
∗ Do you think that persons with disabilities do best when they are free to associate in both the
disabled and nondisabled communities, as bicultural people?
Table reprinted with permission from Halstead, L. (1998).

societal changes that are needed, and detract from Is a shift in models clinically desirable, and if so, is
self-examination in the fostering of social examina- it feasible? As discussed later in this chapter, in D-AT,
tion. As we see from these descriptions of potential the therapist should ascribe to the social model.
benefits or drawbacks, models in and of themselves However, we should not insist on any particular
are not positive or negative, but can be either or model for our clients. Rather, we need to help them
both for any individual. realize the benefits and decrease the deficits that
come from the model they believe in. However,
Table 17.3. Theoretical Patterns in Ascribing to One some clients have been raised to believe in a particu-
or More of the Three Models of Disability lar model (most often the moral or medical model)
Moral Medical Social and wish to question those beliefs. Other clients
become exposed to ideas through the disability
Moral 1 4 6 community, which leads to reevaluation of beliefs.
Medical 4 2 5 Additionally, parents often want assistance in think-
ing about how to raise their children with disabili-
Social 6 5 3 ties. For these and other reasons, it can be useful to
1, 2, and 3 are pure models. (moral, medical, or social) explore models of disability with clients. Making
4 is a hybrid of moral and medical models. the models explicit can help in elucidating how doc-
5 is a hybrid of medical and social models.
6 is a hybrid of moral and social models. tors and other medical professionals, educational
7 (not shown) is a hybrid of all three models. systems, national organizations, and support groups

olkin 465
think and talk about disability, and how this fits for Vagueness comes from lack of other information
the family. about the person, the context, the nature or the
How does a therapist help a client who wishes to cause of the disability.
change models do so? This is an untested empirical A concept closely related to central characteristic
question. My own clinical experience suggests that is the concept of spread, which “refers to the power
repeated exposure to the ideas and groups that of single characteristics to evoke inferences about
espouse a particular model is the most effective. a person” (Wright, 1983, p. 32). When given a lim-
Changing models is not an intellectual exercise, ited amount of information about another person,
but one that goes to the heart of self-concept, self- the central characteristic, in this case disability, is
evaluation, and core beliefs, and can be an intensely allowed to color perceptions of unrelated areas. If
emotional journey for persons with disabilities. the central characteristic is viewed positively (e.g.,
warmth, masculinity, intelligence), then the spread
Common Disability Experiences is likewise positive. But in the case of disability, if
This section addresses some of the commonalities the disability is seen as a negative characteristic, the
in experiences for people with disabilities. Although spread is negative. Interestingly, participants in a
disabilities vary widely, there still is some universal- study on spread were able to give a logical progres-
ity in experiences of being a person with a disability sion of their ideas from the central characteristic to
in most cultures. The key issues addressed here the other characteristics to which it spread (Mussen
are how disability affects others’ perceptions of the & Barker, 1944; Ray, 1946).
person and attitudes toward disability, language Just as a disability is used by others to form
used to discuss disability, affective prescriptions and impressions, known characteristics about a person
prohibitions, personal boundaries, awareness of are said to be explained by a disability. For example,
vulnerability, and managing stigma. someone who is shy might be said to be so because
he has cerebral palsy; someone who excels at work
Perceptions and Attitudes might be thought of as overcompensating for a
“If there is a disability community, then its foun- disability. Both positive and negative traits can be
dation rests on this communal experience, whose pathologized when ascribed to a disability. One
essential components are not the disability per se, effect of spread is that the disability itself is seen as
but the interpersonal and psychosocial experiences more pervasive than it often is. Thus, a man who is
that result from being a persons with disabilities” blind gets talked to loudly by a waitress, as if his
(Olkin, 1999, p. 54). Research on attitudes toward hearing also was impaired, or a woman in a wheel-
disability and persons with disabilities is important chair gets asked if she can sign her name on a credit
because the attitudes of others are an important card receipt, as if the two things are related.
influence on the behavior and lives of people with People with disabilities are not immune to the
disabilities. Although attitudes toward disability are strait-jacket of attractiveness found in many societ-
“complex and multifaceted” (Yuker, 1988, p. xiii), ies. They are judged on attractiveness, as are others,
it must be acknowledged that, across many cul- but the disability itself may affect the assessment
tures, disability often is associated with negative of attractiveness. Furthermore, the disability may
characteristics (Chan, Lam, Wong, Leung, & Fang, cause body and facial movements that can be misin-
1988; Florian, 1982; Saetermoe, Scattone, & Kim, terpreted by others (e.g., a person with disability-
2001; Westbrook, Legg, & Pennay, 1993). In many related fatigue may give short answers to questions,
situations in which a person with a disability is first a person with muscle spasms may make random
encountered, the disability is viewed as a central movements). One problem is that the body can be
characteristic (Asch, 1946), such that the one char- seen as a window into the soul. This is a common
acteristic of disability comes to unduly influence the literary and fictional device, using a physical mani-
impression formation. There is potentially a funda- festation to denote a character trait, a way to short-
mental negative bias toward disability (Wright, hand the revealing of a person’s personality. This
1988). Wright posits that if three conditions exist works in literature; in life it does not.
(a salient characteristic, a negative valence associated
with that salient characteristic, and ambiguity or Language Used to Discuss and
vagueness of context), then the fundamental negative Describe Disability
bias is elicited. Disability is a salient characteristic, and In an important early study, the terms “blindness”
one that is associated with negative characteristics. and “physical handicap” elicited more negative

466 disabilit y
responses than the terms “blind people” and “physi- should be sad, then one clearly is exceptional. This
cally handicapped people” (Whiteman & Lukoff, might be called the “requirement of pluckiness.”
1965, as cited in Wright, 1988). It seems that insert- Both of these requirements (mourning and plucki-
ing the person into the image of the disability is ness) are prescriptions for what people with disabili-
important in changing perceptions. As such, people- ties should feel, and more importantly are dictates
first language has become the desired norm in the for how they should behave.
United States and Canada (it differs in other coun- Part of the mandate for pluckiness is the require-
tries). Such language utilizes phrases such as “person ment of gratitude. Accessibility and accommoda-
using a wheelchair,” “person with schizophrenia,” tions are seen as special needs; that is, needs for only
“persons with blindness,” as opposed to a “wheel- a few, not for everyone, not normal. Thus, if changes
chair-bound person,” “a schizophrenic,” or “the are made just for people with disabilities, and these
blind.” This may seem like mere semantics, but in changes are necessitated by needs that are special,
fact the use of language not only reflects but also then people with disabilities should be grateful for
influences our perceptions. the changes. People with disabilities are expected
A word commonly associated with disability in to be grateful—for having survived, for not having
the professional literature is burden. This is seen in worse conditions, for the people who hold open
phrases such as caregiver burden, the burden of doors for them, for the ramp that goes to an entrance
autism on families, the financial burden of disabil- in the back of the building, for the lifts on buses.
ity, the burden of schizophrenia on the mental Along with these prescriptions of mourning,
health system, etc. The idea is that people with dis- pluckiness, and gratitude is the prohibition against
abilities are costly to society in financial and per- anger about any issues related to the disability. The
sonal terms. The obvious next question is then: Are goal of rehabilitation, in addition to any physical or
people with disabilities too costly? Are the costs cognitive work, is to help the person adjust to being
worth it? Note that costs associated with preventing a person with a disability. Anger denotes maladjust-
disability are viewed differently (e.g., in prevention ment of the person, a failure to reach acceptance
of birth defects) than are costs associated with assis- of the disability. This prohibition has two problems.
tance for people with disabilities (e.g., personal One is that acceptance of the disability is an illusory
assistance, physical changes for accessibility, more goal. One lives with a disability, and some days are
mental health services). This difference is reflected diamonds, some days are stones. Changes in the dis-
in one of the slogans of the disability rights move- ability due to time and/or aging or reinjury neces-
ment, which would like to see a higher percentage sitate readjustment; new insights or experiences lead
of funds spent on improving the quality of life of to reevaluation; new relationships require renegotia-
persons with disabilities: Care, not cure. tions. In other words, adjustment implies that dis-
ability is static, when instead it is a lifelong affair
Affective Prescriptions and Prohibitions that is fluid and mercurial. The second problem
In her seminal books on physical disability, Wright with the prohibition against anger is that any mani-
discussed the requirement of mourning for people fested anger is decontextualized. Typically, people
with disabilities (Wright, 1960, 1983). There is with disabilities experience multiple events in any
myriad literature conceptualizing disability as a loss, given day that a person without a disability might
and from this stems the notion that the loss must not. These might include pain, fatigue, extra tasks
be mourned. Disability is viewed as a tragedy, and or time necessitated by the disability. Other events
persons experiencing tragedies must be in mourn- relate to interactions with the social and physical
ing. Two problems stem from this requirement of environment such as inaccessibility, stigma, discrim-
mourning. One is that depression is viewed as nor- ination, prejudice. These events can be considered
mative, when in fact it is not the modal response to microaggressions (Sue, Capodilupo, & Holder, 2008;
disability (Olkin, 2004). Depression in a person Sue, Nadal, Capodilupo, Lin, Torino, & Rivera,
with a disability, whether that disability is new or 2008) in the daily lives of people with disabilities.
ongoing, should be treated as aggressively as depres- One of these events may lead the person with a dis-
sion in a person without a disability. Second, when ability to feel angry on one day but sanguine on
the person with the disability is not depressed, sad, another day. But the anger, seen from the outside, is
or in mourning, others profess amazement and perceived only in relation to the one event that led
ascribe superhuman qualities to that person. If one to the anger, not in relation to the myriad events
is not sad in situations in which others think one that went by without much notice. This is an issue

olkin 467
common to minorities of various types, resulting in woman gets breast cancer while her sisters do not, a
an internal experience different from what is seen drunk driver hits the car to his right and leaves the
externally; behaviors are judged by others by the one to the left untouched. Thus, having a disability
externals only, and usually ascribed to traits of the can bring an awareness of vulnerability, or what can
person (what social psychology calls the fundamen- happen to the body and the mind due to seemingly
tal attribution error). It is probable that, just as for random events. Some people might easily shrug this
people of color (Sue, 2010), these daily microag- knowledge off, but others may find it brings an
gressions lead to psychological distress for people ever-present awareness that sits just behind them,
with disabilities. If a person with a disability tries to a bit off to the side. Examples might be the man
conform to nondisabled norms and standards, this who is blind in one eye who seems overly protective
too could lead to psychological stress. of his eye with vision, or the woman with a systemic
disability who leaves her job in the prison because
Personal Boundaries she is afraid of getting hurt, or the student who
The body has its boundaries, and disability seems to wants to rush through all her work for the quarter
distort other people’s sense of boundaries in a para- before she has a flare up of her Crohn’s disease, or
doxical way. On one hand, people with disabilities the mother with multiple sclerosis who is afraid her
may be touched less, due to stigma or fear of conta- baby will die of sudden infant death syndrome.
gion. People with certain conditions (cancer, AIDS, What is a rational fear, and how do we decide?
intellectual disabilities), especially, say that others Just as the person with a disability has to come to
are loathe to touch them. On the other hand, they terms with vulnerability, persons without disabili-
may be touched in situations in which a nondis- ties want to find reasons for the disability that could
abled person would not be—the elbow of a blind not apply to themselves. Furthermore, the more
woman grabbed to help her across the street, the severe the disability, the greater the tendency to find
cup of coffee taken away for refill without asking unique causative factors (Walster, 1966). Whether
from a man sitting in a wheelchair, the pat on the it is that someone failed to get a vaccine, or they
head of a person using a scooter, picking up a little weren’t careful enough drivers, or they led an
person. unhealthy lifestyle, others would like to attach a
Using assistive devices presents another set of cause to the disability. The alternative—namely,
issues about touch. Generally, people don’t come up that disability is sometimes random (a genetic muta-
to another person and feel the glasses on his face, or tion), or bad luck (struck by a drunk driver), or lies
rub her belly, or pat adults on the head. But there is completely outside personal control (living in neigh-
something about assistive devices that seems to erase borhoods with higher levels of toxins)—is scary.
these body boundaries. Someone might lean on the These alternatives imply that disability can happen
arm of a wheelchair, or allow her child to climb on in an instant, and to anyone. This is precisely the
the scooter, or grab an interesting device to look at case, and people with disabilities often have had this
it, or play with a machine. Since these devices are knowledge foisted upon them, whereas people with-
part of the body boundary of the person who uses out disabilities find cognitive maneuvers to distance
them, touching the device is akin to touching the themselves from this certainty.
person’s body. This is all right if that is the nature
of the relationship, but otherwise it can feel like an Managing Stigma
intrusion. Disability is a characteristic that is salient, stigma-
tized, and which creates a negative spread effect
Awareness of Vulnerability (Dembo, Leviton, & Wright, 1956/1975). As dis-
Disability often implies that something went wrong. cussed earlier, spread is the tendency to view the
It might be loss of oxygen during birth, or ear infec- disability as more pervasive than it is, as if the dis-
tions in infancy, a car accident, a heart valve prob- ability affected all aspects of the person. Similarly,
lem, an illness with lasting effects, a stroke. Some unrelated characteristics of the person with a dis-
of these causes are hereditary, some are related to ability are ascribed to the disability. Furthermore,
lifestyle, some are contagious, some happen in stigma can be associated with the ideas others have
an instant. What they share is the stamp of a certain about causes of the disability. As discussed above,
randomness to life, a roll of the dice that made persons find reasons for another’s disability that pre-
one household have two children with polio while cludes the possibility of that disability occurring to
the household next door went unscathed, a young themselves. Some of those reasons may be negative

468 disabilit y
personal traits ascribed to the person with a disabil- that people with disabilities were a class of persons
ity, such as negligence, carelessness, irresponsibility, in need of laws regarding nondiscrimination.
or deleterious beliefs (e.g., against vaccines). These Around the same time, the Education of All
negative traits then create a further desire for dis- Handicapped Children Act (1975) was passed by
tancing from the person with the disability. All of congress, and subsequently reauthorized and
these issues—stigma, spread effects, assumptions of renamed the Individuals with Disabilities Education
causality—create the need for the person with the Act (IDEA, 2004). The IDEA sets forth certain prin-
disability to be skilled in managing the interper- ciples that are critical to equity for people with dis-
sonal and social aspects of disability. This is an abilities. One is the principle of least restrictive
incredible social burden on people with disabilities. environment. In most cases, the least restrictive envi-
ronment is considered to be in the classroom with
Legal and Sociocultural Influences peers without disabilities. So, this principle encom-
on Disability passes the notion of inclusion; that the least restric-
Legions of laws have been written in the United tive environment is one that is not separate. Another
States related to disability, covering housing, air principle is inclusion of persons with disabilities or
travel, ground travel, taxes, and more. In this sec- their representatives (in this case, parents) in decision
tion, I discuss the three most important in terms of making about the person with the disability. A third
their range of applicability and implications, and principle is that plans are individualized to the person
consider what they do and do not provide. These with a disability. The Individualized Education Plan
three laws are the Rehabilitation Act (1973), the (IEP) is the bedrock of IDEA, and suggests that there
Individuals with Disabilities Education Act (1975) is no single modification or accommodation that
and its reauthorizations (currently, Individuals with works for all (or even most). A fourth principle is the
Disabilities Education Improvement Act of 2004), interdisciplinary team approach to modifications
and the Americans with Disabilities Act (ADA, and accommodations, thereby not locating disability
1990). within one field of specialization.
Laws can take the lead in changing attitudes and The ADA (1990) was passed after considerable
behaviors. Desegregation is a prime example of how committee review and revisions. One impetus for
federal legislation (Brown v. Board of Education of the ADA was a Harris Poll (1985) that indicated a
Topeka, KS, 1954) can lead to far-reaching socio- 66% unemployment rate among people with dis-
logical changes. And, as we see with desegregation, abilities, and that 70% of respondents had not gone
laws can create opportunities, provide equitable to a restaurant or movie in the past year because
resources, and address equal access (i.e., outlaw dis- of a disability and problems with accessibility. The
crimination), but they cannot eradicate prejudice Rehabilitation Act (1973) did not address public
and stigma, or, in the case of the Brown decision, places, and the variety of places that were poten-
racism. We need to keep this example in mind as we tially inaccessible to some people with disabili-
examine the three disability laws. ties included housing, employment, transportation,
The Rehabilitation Act, sections 503 (affirmative communication systems, recreational facilities,
action) and 504 (accessibility of places and services), voting places, libraries, and public services. Thus, a
passed in 1973 and set the stage for much of the more far-reaching law was necessary to remove
legislation that followed. It included a definition major barriers in the daily lives of people with dis-
of disability (see previous section on definitions of abilities. The beginning section of the ADA noted
disability), and this definition was used again for the that historically “society has tended to isolate and
ADA. The Rehabilitation Act prescribed affirmative segregate individuals with disabilities, and . . . such
action and nondiscrimination in all institutions forms of discrimination . . . continue to be a serious
receiving federal funding. This includes virtually and pervasive social problem” (www.apta.org/ada/
every college, university, and hospital, thus ensuring adalaw.html).
greater access to many public institutions. But it did The ADA has five Titles, addressing Employment
not affect private institutions that did not receive (Title I), Public Services (Title II), Public Accom-
federal funding, such as restaurants, theaters, or modations and Services Operated by Private Entities
department stores—the places and things that com- (Title III), Telecommunications (Title IV), and
prise the daily lives of people. Nonetheless, it set the Miscellaneous (V). In Title I a “qualified individual
stage for more encompassing legislation to follow, with a disability” is defined as “an individual with
and delineated an important principle—namely, a disability who, with or without reasonable

olkin 469
accommodations, can perform the essential func- shelters, half-way houses, banks, recreational areas,
tions of the employment positions . . . consider- voting places, gas stations, department stores, repair
ation shall be given to the employer’s judgment as to shops, bakeries. (Note that religious organizations
what functions of a job are essential.” There is no are exempt from the ADA, except for those religious
requirement to hire a person with a disability who is organizations that accept federal funding, such as
not qualified for the particular job, or who cannot church-affiliated colleges, or are open to the public,
perform an essential task of the job. The ability to such as a room that is used by Girl Scouts.) It would
define the essential functions are presumed to rest seem that the ADA provides a means of legal recourse
with the employer. Some examples may be clear- to redress discrimination. However, as vital and as
cut. For example, a professor’s ability to evaluate far-reaching as the ADA is, we need to examine
students’ work is an essential function of being an what it is not. Additionally, numerous U.S. Supreme
instructor; writing the evaluation by hand or enter- Court decisions have substantively weakened the
ing it into a computer could be performed by an ADA. The most potentially damaging of these
assistant without compromising the task. A differ- (Toyota v. Williams, 2002) sent the decision back
ent example is a graduate student who procures an to a lower court because it was not clear that the
internship at a Veteran’s Administration Medical woman involved was a person with a disability—
Center (VAMC). All interns are required to rotate she had only demonstrated limitations at the work-
through three settings during the year, one of which place, and work was not believed by the courts to be
must be neuropsychological assessment. A blind a major life function!
student who requests an accommodation to stay One major factor in the ADA is the notion of
longer at the other two settings and bypass the neu- whether separate is equal. Although other civil rights
ropsychological assessment placement may be met laws clearly embrace the philosophy that forced
with resistance. Several factors are important to separation is tantamount to segregation, the ADA
consider in this latter case. First, the ADA is not (and the IDEA) allows for separate services, access,
triggered unless the person with the disability does and systems. For example, a transit service only for
two things: identifies him- or herself as a person people with disabilities (often called paratransit or
with a disability, and requests a reasonable accom- some such equivalent) is prevalent in the United
modation. This is an important difference from States. Entrances to a restaurant or other public site
IDEA, which is an entitlement law; the ADA is a may be separate, with a sign near the building
civil rights law. Second, the ADA specifically states noting the entrance that persons with disabilities
that the person with the disability must be included who require accessibly should use. It is hard, in the
in the process of deriving reasonable accommoda- 21st century, to imagine a sign that would single out
tions. However, the final decision for an accommo- any other groups for a requirement of a separate
dation is left to the employer, who is not required line, entrance, or system, and be tolerated. But
to choose the optimal accommodation, but only because the access needs of people with disabilities
one that works. So, the VAMC might decide that can be different from those of persons without a dis-
the student should take a different third placement ability, such separateness is not only tolerated but
to substitute for the neuropsychological assessment sanctioned by law. A more equitable solution would
placement, even though the student feels that, be to make accessibility inherent in all design, such
because a visual impairment can slow acclimation to that there would be no need for separation of a class
a setting, it would be preferable to stay at one set- of persons.
ting longer. Note that the accommodation in this Each of the laws just discussed views people with
case accrues no costs (and 70% of reasonable accom- disabilities as a class in need of special protection and
modations in the workplace cost under $500), but civil rights laws. This shifts the view of disability from
rather a change in procedure. This is an important that of disability as defect or abnormality, as it has
factor as it involves attitudes, beliefs about the role traditionally been viewed (Olkin & Pledger, 2003;
of interns and psychologists, and determination of Reid & Knight, 2006), to that of a dimension of dif-
the essential functions of an intern, all of which are ference which is part of the multicultural spectrum
areas in which reasonable people can disagree. (Smith et al., 2008). As I turn to discussing counsel-
The list of places to which the ADA applies is ing with people with disabilities, this multicultural
long. It includes employment settings, buses, para- and social justice perspective dominates, as it does for
transit systems, trains, lodging, museums, libraries, counseling with other members of diverse but mar-
zoos, day care centers, private schools, homeless ginalized groups (D’Andrea & Heckman, 2008).

470 disabilit y
Counseling Individuals with Disabilities affirmative. For each of these areas, a list of ques-
In this section I outline the key aspects of D-AT tions that a clinician might ask or consider is given
and briefly present a template for understanding in Table 17.4.
and conceptualizing clients with disabilities (Olkin
2008). special knowledge areas
The essential tenets of D-AT are these: Clinicians virtually always take a history of their
clients, and doing so is one part of D-AT. The
• The therapist should ascribe to the social
difference is in examining the developmental and
model of disability; this presumes a social justice
personal/family history in light of the disability.
orientation to counseling and psychotherapy.
In addition to the usual history-taking questions,
• The client may ascribe to any one model or
one would include a medical history, such as the
combination of models.
onset of the disability, any surgeries, hospitalizations
• Therapy between an able-bodied therapist and
or other periods of separation from parents, and
a client with a disability is cross-cultural therapy.
changes in the disability or the treatment (e.g., leg
• No one therapeutic approach or theory of
braces, casts, new glass eyes, hearing implants).
therapy predominates. D-AT is meant to be
Along with the medical history, the therapist should
incorporated into the therapist’s own theory.
note the psychosocial concomitants of that history.
• A template for questions to consider
For example, if a child had surgery in the middle
about clients can help therapists systematically
of second grade and was absent from school for
understand the relevant disability history
3 months, what were the reactions of peers when
and issues.
the client returned to school, how did siblings
• The case formulation should neither
respond to the absence and reunification, how did
overinflate nor underestimate the role of disability
parents and teachers handle it, and what was the
in the client’s life and problems.
take-home message (some might say schemas) of
• There is no such thing as adjustment to
the experience for the client? Also embedded in the
disability; rather there is response to disability,
medical history is how the family conceptualizes
which is fluid, evanescent, and malleable.
disability and pain, the medical delivery service
• Therapists will need to have skills in working
system, and treatment.
with professionals in other disciplines, such as
In addition to a medical history, the educational
education, nursing, occupational and physical
history should be assessed. Important factors include
therapy, and medicine.
whether the child was mainstreamed in a regular
classroom, used an aide, went to a resource room, or
The D-AT Template was bused elsewhere, and how much time was spent
As in all cross-cultural counseling, necessary aspects with other children with disabilities. Within these
for the therapist are awareness of the importance of details are important clues to the model of disabil-
culture, an appreciation of one’s limits of knowl- ity, but also indications of what the client believes is
edge, receptivity to a culture different from one’s abnormal, atypical, unusual, or pathological about
own, knowledge about social oppression as it relates the self, and about disability per se.
to specific groups, and an orientation towards social
justice (D’Andrea & Heckman, 2008). Systemic using the models of
and institutional factors that promote D-AT are disability clinically
organizational support, a mission statement consis- There are no studies on what models clients believe
tent with D-AT, appropriate in-service evaluation in, how belief in one or more models is related to
and training, and valuing of diversity as exemplified mental health and functioning, and whether using
in a diverse staff (Whealin & Ruzek, 2008). the models of disability in therapy can help the
Additionally, specific skills are important in D-AT. therapeutic process. In the absence of such data,
This section walks the reader through five areas that I can surmise that an appropriate match between
are embedded in D-AT. These include special the client’s beliefs and the therapist’s intervention
knowledge areas (developmental history as affected would be a critical factor in the therapeutic alliance
by a disability, models of disability, disability com- and possibly in treatment outcome. Although I have
munity and culture, and psychosocial issues); using stated categorically that the therapist should hold
the models of disability clinically; making treatment the social model of disability, this is about the
accessible; case formulation; and being culturally awareness of the therapist of disability as a social

olkin 471
Table 17.4. Potential Questions for Clinicians and Clients
Topic Area Questions for Clients Questions for Clinicians
Special Knowledge Areas: What is my personal, family, Am I asking the client about
Developmental history medical, educational, social, everything I usually do, or am
Models of disability religious/spiritual, and economic I omitting some areas I believe are
Disability community/culture history? What is the role of my less relevant (e.g., sports, sexuality,
Psychosocial issues disability in each of these areas? occupational history)? Can I bring
In my friendships and relationships, up disability before the client does?
what role does my disability play? Are there questions I’m afraid to ask?
Why?
Using the Models of Disability See Table 17.2 See Table 17.2. Also:
Do I view people with disabilities as
constituting a minority group? Is
disability an abnormality or part of
human difference? Do I espouse
social justice as an integral part of
therapy?
Making Treatment Accessible Does this therapist get flustered Is there handicapped parking, a
when she or he learns that I have a ramp or curb cut, a wheel-chair
disability? Has the therapist thought accessible bathroom with grab bars?
in advance about what might be the Do addresses/rooms have Braille
needs of someone with my type of signage?
disability? Does the therapist seem Am I near a bus stop? Do I have
free to talk about disability openly? materials in alternate formats
Does she or he take some (online, large print)?
responsibility for learning about Can I schedule appointments at
disability on her or his own? times of day to accommodate
fatigue?
Case Formulation How central a role does disability Can I view disability as fostering
play in my life? resilience?
Can I list both positive and negative Have I made disability the most
outcomes of having a disability? Am important factor in the history?
I still striving for some ephemeral If I write the three to five most
level of adjustment to disability? important factors in this person’s
life, where would disability fall? Am
I using disability to explain features
of the client? Am I downplaying the
role of stigma, discrimination,
prejudice?
Being Culturally Affirmative Who are other people like me? Are there disability magazines,
Do I understand disability pride? websites or listservs I read or know
Do I shun or embrace other people about and can introduce the client
with disabilities? Do I keep up with to? Do I believe it is psychologically
major events affecting people with healthy for the person to know other
disabilities? Are there disability people with disabilities? Are there
magazines or websites or listservs positive disability images in the arts
I read? (movies, exhibits, dance, theater)
I can introduce a client to?

472 disabilit y
construct; familiarity with disability history, con- test can skew scores due to disability (e.g., a ques-
cepts, culture, and community; and an affirming tion about energy, when the person has multiple
approach to clients. The language the therapist uses sclerosis). And the fourth question is whether the
to discuss disability and the intervention methods accommodations have changed the fundamental
must match the client’s belief system. For example, nature of what is being tested. These are not readily
if a mother describes her son as having right hemi- answerable questions, but should be considered
plegia and a learning disability, she is describing the carefully, and possible consultation should be sought
son’s functional impairments. Think about the effect when assessing a person with a disability.
on the mother that the following questions might Accessible treatment also can be thought of as
have: Does your son play with other children with integrated treatment. Often, the person with a dis-
disabilities? What is your belief about the cause of your ability, especially the child with a disability, is treated
son’s disability? Have you consulted anyone (a priest, a in multiple settings by professionals from different
doctor, a shaman, a herbalist, a resource teacher) about disciplines. The therapist may need to be the one
how to treat your son’s disability? What kind of future who collects all relevant data and makes meaning of
do you imagine for you son? These are all good ques- the whole. Facility in communicating with profes-
tions, and the answers will teach the therapist much sionals in a variety of disciplines is a valuable and
about the mother’s belief system and model of dis- necessary skill (Lollar, 2008).
ability. But note that the questions are worded such
that they do not presume any of the models of dis- case formulation
ability, but leave answers free to come from any of The fundamental skill in being culturally receptive is
the models. the facility to incorporate the disability into the case
formulation without overinflating or underestimat-
making treatment accessible ing the role of the disability. It is important to set
Imagine a client who uses a wheelchair calling for a aside any question of who the person might be with-
first appointment. The client asks if your office is out the disability—this is tantamount to asking who
accessible. What is your answer? The most helpful the person would be if that person were another
answer might not be a simple yes or no, but rather a person. The disability, even if new, is an integral part
description (e.g., there is handicapped parking close of the client. For a new or sudden onset of disability,
by, a bus stops a block away and there are curb cuts, the impairment may be experienced as alien. Often
the bathroom has a handicapped stall with grab bars this is encouraged in the medical delivery service
and room for front or side transfer, there are no system. (Note Kaiser Permanente’s radio ad: I have
steps into the building, the office is wheelchair cancer, it doesn’t have me. The idea is that the cancer is
accessible). Go through this same exercise for a a separate entity, apart from the person.) This may be
client with a visual impairment, or a Deaf client. As a good model for illnesses such as cancer (Rolland,
you will note, the meaning of accessible changes 1994), especially one which could disappear with
quite a bit for different types of disabilities. So we treatment. The idea is that the impairment is a thing
see that accessible is not a fixed state. Some of the separate from the essence of the person. But this does
accessibility issues are about the facility. Others are not work for disability—a permanent condition that
about written materials, and others are about pro- will affect the person’s functioning, incur stigma, and
cess. For example, some clients may need shorter alter relationships. Such a disability needs to be incor-
sessions (e.g., a person with an intellectual disability porated into the sense of self, as one facet, but not
who fatigues), others may need particular times necessarily the defining one. This idea of incorporat-
of day (e.g., later in the day to accommodate a ing the disability but not making it overly central is,
morning routine), or accommodations in sessions in deriving a case formulation, the very task for the
(written homework, reminder cards). The types of therapist as well. A core question in formulation is:
changes noted above don’t alter the fundamental Why does this client have this problem, and why is he
aspects of therapy. Testing, however, can be more or she seeking treatment now? Does the history
profoundly altered in making accommodations. explain how the current functioning developed?
The first question has to be whether the test is What is maintaining the current functioning? What
appropriate, and second whether it is in an accessi- issues are seen in the relationship with others and
ble format for the person with a particular disability. with the therapist? Can the case formulation make
The third question is whether there are norms for some predictions about problem areas and future
persons with similar disabilities, and if items on the functioning? What are the person’s strengths?

olkin 473
 If the therapist makes a list of symptoms, or to even assess where the client stands with regard
behaviors, mood, cognitions, beliefs, functioning, to it.
and prognosis, and another list of positive traits and Not all clients with disabilities want to or need to
behaviors (initiative, creativity, humor, values, be part of the disability culture and community. To
morality, insight, independence, intimacy, and posi- force this would be as wrong as to ignore it. But it is
tive relationships), the disability should be exam- important that clients with disabilities be aware of
ined in relation to each of these areas. In addressing resources, supports, information, and places where
each of these areas, how relevant and salient are dis- responses to the disability will not be negative. It is
ability issues? In the summary of the client, the helpful if therapists can recommend books, maga-
therapist can state that this is a client who has this zines, listservs, movies, organizations, and commu-
set of problems, which were learned by this set of nity resources relevant to the type of disability the
circumstances, and which are maintained by this client has. Families of children with disability and
current set of circumstances. Is disability a factor in those with newly diagnosed disabilities especially
the current set of problems? Is it part of the learning can use assistance in finding resources.
history? Is disability an element of maintaining
problematic behaviors, thoughts, or mood? All of us Special Issues in Training and Supervision
are shaped by our heredity, environment, parenting, Two sets of issues will be examined in this section.
learning history, personality, traumas and experi- One set focuses on how to best train all students in
ences. Disability can be a major or a minor part of how to work with clients with disabilities, and what
each of these, and either a synergistically crucial issues are likely to emerge in supervision when the
element or merely part of the background. student without a disability is working with a client
The idea of using a template to assess clients from with a disability. The second set of issues is about
a marginalized group has been suggested by others. training and supervising the student with a disability.
For example, the RESPECTFUL1 model (D’Andrea
& Daniels, 2001) and the developmental counsel- students without disabilities
ing and therapy model (Ivey & Ivey, 1999) both As discussed above in the section on models of
have counselors use a holistic framework for devel- disability, few graduate students in counseling or
oping a case formulation of clients. What these clinical psychology receive training in disability
models share is an awareness of how marginalized history or culture, working with clients with dis-
status can impact every aspect of a person’s back- abilities, or disability-affirmative clinical processes.
ground and current life, and suggestions of a sys- To compound the problem, the student is likely to
tematic way of organizing the inquiry about a client be supervised by a therapist equally untrained in
and the resulting data from the client. These models working with clients with disabilities. Issues that
go beyond diagnosis to case formulation. However, are likely to arise are aversion to disability, self-
in putting more stock in social justice (and injus- consciousness about the therapist’s own body, and
tice) and the reality factors of marginalization, these use of language, hesitancy, ignorance, and becom-
models shift from a medical model, in which the ing “deskilled” (i.e., forgetting what skills one pos-
locus of the problem resides in the client, to a case sesses in the fluster over the presence of disability;
formulation model, in which multiple factors are Heller & Harris, 1987, p. 60). These issues cover
involved in psychosocial distress (Zalaquett, Fuerth, attitudes, knowledge, and skills; thus, supervision
Stein, Ivey, & Ivey, 2008). has to address all three of these areas. Although there
is a tendency to want to address attitudes first,
being culturally affirmative I believe that arming students with knowledge and
Disability community and culture is a relatively equipping them with skills should be the first line of
new idea (Hahn, 1993, 1999; Olkin, 2005; Peters, training. When students feel more competent, they
2000). More recently, the ideas of disability pride, can achieve greater self-efficacy and have more
affiliation with a disability community, and a cul- psychoemotional freedom to address their own atti-
ture unique to the disability community have tudes and prejudices. Additionally, getting to know
become more accepted. This is not to say that most their client with a disability better, as a fuller person,
children or even adults with disabilities are aware of will help put disability into perspective. And, thera-
the disability community and culture, nor a part of pists are more likely to be helpful to their clients
it. But therapists need this awareness, because with- with disabilities when they feel knowledgeable,
out it they are unable to introduce it to the client, capable, appropriate, and affirming in understanding

474 disabilit y
and working with clients’ disability identities (Israel, When the supervisor asks the student about clients’
Gorcheva, Walther, Sulzner, & Cohen, 2008). reactions, it may well be that the clients have
Although there is scant literature on positive not expressed any particular reactions. This can lead
aspects of disability, borrowing from literature on the unbelieving supervisor to accuse the student
gay or lesbian persons (Riggle, Whitman, Olson, of being in denial, or unable to handle open discus-
Rostosky, & Strong, 2008), areas to be explored are sion of disability with clients. This is a no-win situ-
belonging to a community (of people with similar ation for the student, because any further objections
or other types of disabilities), creating families of seemingly are proof of denial. In such cases, direct
choice (of people who are affirmative about the dis- observation of sessions (through one-way mirrors or
ability), forging strong connections with others in on video tape) can help supervisor and supervisee
the disability community, serving as a positive role look together at a session for signs of unaddressed
model to other people with disabilities, developing disability issues. It is important that the supervisor
empathy and compassion for others, greater flexibil- is available and supportive, disability-affirmative
ity in gender roles, and involvement in social justice with the student, and genuine in mentorship (Israel
and disability rights activism. In supervision of et al., 2008), so that exploration of the impact of the
students without disabilities, the student should student’s disability on therapy can be openly and
be encouraged to keep these positives in mind and nondefensively explored in a cooperative manner.
see how they might be assessed, developed, and
strengthened in therapy. Future Issues in Disability
If the supervisor feels ill-prepared to teach the In a dissertation on how to evaluate clients’ models
trainee about disability, this is an opportunity to of disability (Guber, 2007), the following two ques-
model how to address gaps in one’s skills. Two books tions were posed: What are the most salient clinical
are especially geared to helping therapists both in manifestations of each model of disability? What are
training and in the field increase their knowledge the more common clinical manifestations of the
and skills with regard to clients with disabilities three models of disability? Guber (2007) took ques-
(Mackelprang & Salsgiver, 1999; Olkin, 1999). tions from Olkin (1999) and expanded on them,
then got several rounds of feedback from profes-
students with disabilities sionals in rehabilitation and other persons with dis-
Trainees with disabilities are more likely than those ability expertise as he refined the set of questions.
without disabilities to possess knowledge about He found that there was no consensus on the valid-
disability that will be helpful in their provision of ity of the three models of disability as useful con-
treatment to clients with disabilities. It could be structs, nor on the clinical utility of these, or any
instructive to observe their interactions with clients other, models of disability. One concern is whether
to cull skills that could be transferable through the models of disability overly simplify the general
training to students without disabilities (Dillon, complexity of responses to disability. As Guber
Worthington, Soth-McNett, & Schwartz, 2008). (2007) points out, understanding a client’s model
But students with disabilities are not immune to the of disability is not diagnostic, nor does it dictate
pervasive negative social messages about disability, intervention.
and they may feel negatively or conflicted about Outside of rehabilitation settings, we know
their own disability. We should not assume disabil- remarkably little about therapy with clients with dis-
ity knowledge or skills just because the trainee has abilities. We need basic information on the types of
a disability. problems for which clients with disabilities seek
Trainees with disabilities being supervised by therapy, and whether they are any more or less likely
a professional without a disability may find that to seek treatment than are clients without disabili-
the supervisor’s attitudes toward and beliefs about ties. Numerous potential presenting problems are
disability are manifest in supervision. Supervision, more germane to clients with disabilities that could
like therapy, has to put disability in perspective use further exploration. One is the area of pain,
without overemphasizing it or ignoring it. One which can greatly impact quality of life (Lee,
problem that can happen is that the supervisor proj- Chronister, & Bishop, 2008). Chronic pain patients
ects onto clients his or her own difficulties with dis- for whom there is no known medical cause may
ability, and insists that clients will be put off by the differ from persons with disabilities for whom pain is
therapist with a disability, or protective of the thera- a part of their condition, but the similarities and
pist, or unable to genuinely discuss the disability. differences have not been systematically studied.

olkin 475
Fatigue is a major component of many disabilities, to set the research agenda for the coming decade.
and we need data to guide how to help clients manage This is not the same as a rehabilitation psychology
a lifestyle when fatigue forces a never-ending series of agenda, but rather an agenda for training in all grad-
choices about how to best spend one’s limited ener- uate counseling and clinical psychology programs,
gies. Employment, and the disheartening unemploy- dissertations related to therapy with people with dis-
ment rate among persons with disabilities, has not abilities, and research to address basic questions
improved since passage of the ADA (Lehmann & regarding such therapy. These basic questions
Crimando, 2008) and begs guidance on how to ame- include rates of use of psychotherapy by people with
liorate the situation. Employment tends to lead to disabilities, with what types of disabilities, and for
positive outcomes such as reduced poverty, more what types of problems; satisfaction and factors in
socialization, and the greater probability of partner- satisfaction with the therapeutic process; correla-
ing, and thus is a critical area of intervention for tions of premature drop-out; and impact of therapy
people with disabilities. How can we help achieve on presenting problems. The criticisms of other out-
those outcomes in the absence of employment? come studies conducted with diverse populations
Adjustment to earlier-than-desired retirement or must be addressed, such as threats to internal valid-
part-time employment is another area in need of ity and problems in sample selection (Sue, 1999).
exploration, as is aging with a disability (as opposed Studies are needed on D-AT, including how to
to aging and then acquiring a disability). The devel- teach D-AT, how best to incorporate D-AT into
opment of intimate relationships between a person different theories of therapy, and D-AT outcome
with and a person without a disability has received studies. Evidence-based practices need to be verified
remarkably little attention. with this population, which has generally been
Elsewhere, Olkin and Pledger (2003) identified excluded from outcome studies (Olkin & Taliaferro,
eight disability areas in need of further research. 2005). Barriers to treatment need to be explicated
A slightly modified list would include care versus and eradicated to the greatest extent possible.
cure (universal design, visitability laws, personal “Quality of life” is one catch phrase of our times.
assistant services, assistive technology, supported The effects of stigma, prejudice, and discrimination
living environments, job access, and economic are expected to take their toll on quality of life.
policy); disability in the context of other demo- What lessons can we learn from people with dis-
graphic variables, especially other marginalized abilities about stigma management, coping with
statuses2; abuse of people with disabilities and prejudice, and survival in the face of daily discrimi-
disability as a result of abuse; romance, dating, and nation? How can we take those lessons and use them
mating patterns for persons with disabilities; fertil- with our clients who are less adept at these skills?
ity, pregnancy, and childbirth; parenting with a The fields of counseling and psychology have much
disability; how to best foster and promote a positive to offer in the area of disability, as long as it is seen
disability identity; appropriate assessment and diag- as a worthy and fruitful area of inquiry. Of course,
nosis of clients with disabilities; and using the none of this can happen without a substantial boost
models of disability in clinical practice. in the priority level of disability as an area for psy-
Some of these are topics best suited for research chology to address, and concomitant funding for
within disability studies and interdisciplinary fields. research in this area.
But disability studies is not the venue for clinical
research, which should remain within counseling Conclusion
and psychology. The needs for clinical research on Disability has been a neglected area within main-
disability are legion, as there are many unaddressed stream clinical and counseling psychology. This
questions. The move toward evidence-based prac- chapter has addressed conceptualizations of disabil-
tice, the dictates of insurance reimbursement, and ity; counseling people with disabilities, in particu-
the necessity of training culturally competent thera- lar, using the D-AT model; training and supervision
pists all prescribe that more research with direct of students with and without disabilities; and
application to counseling and therapy be under- research necessary to guide future clinical work with
taken. There needs to be a conference or collabora- clients with disabilities. A thread that ties all these
tive effort within psychology to embrace disability areas together is a social justice approach to under-
studies and, within a social justice framework and standing and working with a highly marginalized
including the voices of people with disabilities, and disadvantaged group of potential clients.

476 disabilit y
Notes Bluestone, H. H., Stokes, A., & Kuba, S. A. (1996). Toward an
integrated program design: Evaluating the status of diversity
1. RESPECTFUL: R = religious/spiritual issues;
training in a graduate school curriculum. Professional
E = economic class issues; S = sexual identity issues; Psychology: Research & Practice, 27, 394–400.
P = psychological development issues; C = chrono- Brown, K. S., DeLeon, P. H., Loftis, C. W., & Scherer, M. J.
logical issues, T = trauma and threats to well-being; (2008). Rehabilitation psychology: Realizing the true
F = family issues; U = unique physical issues; potential. Rehabilitation Psychology, 53, 111–121.
Chan, F., Lam, C. S., Wong, D., Leung, P., & Fang, X. (1988).
L = language and location of residence issues.
Counseling Chinese-Americans with disabilities. Journal of
2. For some relatively recent work on disability Applied Rehabilitation Counseling, 19(4), 21–25.
and specific ethnicities or sexual orientation, see: Choi, K., & Wynne, M. E. (2000). Providing services to Asian
Asbury, C., Walker, S., Belgrave, F., Maholmes, V., Americans with developmental disabilities and their families:
& Green, L., 1994; Asbury, C. A., Walker, S., Mainstream service providers’ perspectives. Community
Mental Health Journal, 36, 589–595.
Maholmes, V., Rackley, R., & White, S., 1992; Bae
D’Andrea, M., & Heckman, E. F. (2008). Contributing to
& Kung, 2000; Balcazar, Keys, & Suarez-Balcazar, the ongoing evolution of the multicultural counseling
2001; Becker, Stuifbergen, & Tinkle, 1997; movement: An introduction to the special issue. Journal of
Belgrave, 1998; Choi & Wynne, 2000; Guter & Counseling and Development, 86, 259–260.
Killacky, 2004; Ino & Glicken, 1999; Hajat, Lucas, Dembo, T., Leviton, G. L., & Wright, B. A. (1956/1975).
Adjustment to misfortune: A problem of social-psychological
& Kington, 2000; Hanna & Rogovsky, 1991;
rehabilitation. Artificial Limbs, 3, 4–62. (Reprinted in
Hwang, 1997; Fine & Asch, 1988; Jarama, Reyst, Rehabilitation Psychology, 1975, 2, 1–100.)
Rodriguez, Belgrave, & Zea, 1997; Jones, Atkin, & Dillon, F. R., Worthington, R. L., Soth-McNett, A. M., &
Ahmad, 2001; Krause, Coker, Charlifue, & Schwartz, S. J. (2008). Gender and sexual identity-based
Whiteneck, 1999; Marshall, 2001; Olkin, 2006; predictors of lesbian, gay, and bisexual affirmative counseling
self-efficacy. Professional Psychology: Research & Practice, 39,
O’Toole & Bregante, 1993; Parkin & Nosek, 2001;
353–360.
Serafica, 1999; Shah, 1997; Smart & Smart, 1992, Fine, M., & Asch, A. (Eds.). (1988). Women with disabilities:
1993, 1997; Tews & Merali, 2008; Tezzoni, Essays in psychology, culture, and politics. Philadelphia: Temple
McCarthy, Davis, Harris-David, O’Day, 2001; University Press.
Whitfield & Lloyd, 2008. Florian, V. (1982). Cross-cultural differences in attitudes towards
disabled persons. International Journal of Intercultural
Relations, 6, 291–299.
References Guter, B., & Killacky, J. R. (Eds.). (2004). Queer crips: Disabled
Americans with Disabilities Act. (1990). Public Law 101-336, gay men and their stories. New York: Harrington Park
42 U.S.C. 1211, 12112. Press.
Asbury, C., Walker, S., Belgrave, F., Maholmes, V., & Green, L. Hahn, H. (1993). Can disability be beautiful? In M. Nagler
(1994). Psychosocial, cultural, and accessibility factors (Ed.), Perspectives in disability (pp. 217–226). Palo Alto, CA:
associated with participation of African-Americans in reha- Health Markets Research.
bilitation. Rehabilitation Psychology, 39(2), 113–121. Hajat, A., Lucas, J. B., & Kington, R. (2000). Health outcomes
Asbury, C. A., Walker, S., Maholmes, V., Rackley, R., & White, S. among Hispanic subgroups: Data from the NHIS, 1992–95.
(1992). Disability prevalence & demographic association among Advance Data, 310, 1–14.
race/ethnic minority populations in the United States: Implications Hanna, W. J., & Rogovsky, B. (1991). Women with disabilities:
for the 21st century. Washington, DC: Howard Univ. RTC for Two handicaps plus. Disability, Handicap & Society, 6(1),
Access to Rehab. & Economic Opportunity. 49–63.
Asch, S. E. (1946). Forming impressions of personality. Journal Heller, B. W., & Harris, R. I. (1987). Special considerations
of Abnormal and Social Psychology, 41, 258–290. in the psychological assessment of hearing impaired persons.
Asch, A., & Rousso, H. (1985). Clinicians with disabilities: In B. W. Heller, L. M. Flohr, & L. S. Zegans (Eds.),
Theoretical and clinical issues. Psychiatry, 48, 1–12. Psychosocial interventions with sensorially disabled persons
Bae, S., & Kung, W. W. (2000). Family intervention for Asian (pp. 53–77). Orlando, FL: Grune & Stratton.
Americans with a schizophrenic patient in the family. Hogben, M., & Waterman, C. K. (1997). Are all of your
American Journal of Orthopsychiatry, 70(4), 532–541. students represented in their textbooks? A content analysis
Balcazar, F. E., Keys, C. B., & Suarez-Balcazar, Y. (2001). of coverage of diversity issues in introductory psychology
Empowering Latinos with disabilities to address issues of textbooks. Teaching of Psychology, 24, 95–100.
independent living and disability rights: A capacity-building Hwang, K. (1997). Living with a disability: A woman’s perspec-
approach. Journal of Prevention and Intervention in the tive. In M. L. Sipski & C. J. Alexander (Eds.), Sexual function
Community, 21(2), 53–70. in people with disability and chronic illness: A health practitio-
Becker, H., Stuifbergen, A., Tinkle, M. (1997). Reproductive ner’s guide (pp. 119–130). Gaithersburg, MD: Aspen.
health care experiences of women with physical disabilities: Individuals with Disabilities Education Improvement Act of
A qualitative study. Archives of Physical Medicine and 2004, 20 U.S.C. § 1400 et seq. (2004).
Rehabilitation, 78(12), S26–S33. Ino, S. M., & Glicken, M. D. (1999). Treating Asian American
Belgrave, F. Z. (1998). Psychosocial aspects of chronic illness and dis- clients in crisis: A collectivist approach. Smith College Studies
ability among African Americans. Westport, CT: Auburn House. in Social Work, 69(3), 525–533.

olkin 477
Israel, T., Gorcheva, R., Walther, W., Sulzner, J. M, & Cohen, J. Olkin, R., & Taliaferro, G. (2005). Evidence-based practices have
(2008). Therapists’ helpful and unhelpful situations with ignored people with disabilities; Dialogue. In J. Norcross,
LGBT clients: An exploratory study. Professional Psychology: L. Beutler, & R. Levant (Eds.), Evidence-based practices
Research & Practice, 39, 361–368. in mental health (pp. 353–359; 365–367). Washington, DC:
Ivey, A. E., & Ivey, M. B. (1999). Toward a developmental APA.
diagnostic and statistical manual: The vitality of a contex- O’Toole, C., & Bregante, J. (1993). Disabled lesbians:
tual framework. Journal of Counseling & Development, 77, Multicultural realities. In M. Nagler (Ed.), Perspectives on
484–490. disability. Palo Alto, CA: Health Markets Research.
Jarama, S. L., Reyst, H., Rodriguez, M., Belgrave, F. Z., & Parkin, E. K., & Nosek, M. A. (2001). Collectivism versus
Zea, M. C. (1998). Psychosocial adjustment among Central independence: Perceptions of independent living and inde-
American immigrants with disabilities: An exploratory study. pendent living services by Hispanic Americans and Asian
Cultural Diversity and Mental Health, 4(2), 115–125. Americans with disabilities. Rehabilitation Education, 15(4),
Jones, L., Atkin, K., & Ahmad, W. I. U. (2001). Supporting 375–394.
Asian deaf young people and their families: The role of pro- Peters, S. (2000). Is there a disability culture? A syncretisation
fessionals and services. Disability and Society, 16(1), 51–70. of three possible world views. Disability & Society, 15(4),
Kemp, N. T., & Mallinckrodt, B. (1996). Impact of professional 583–601.
training on case conceptualization of clients with a disability. Ray, M. H. (1946). The effect of crippled appearance on personality
Professional Psychology: Research and Practice, 27, 378–385. judgment. Unpublished master’s thesis, Stanford University.
Krause, J. S., Coker, J. L., Charlifue, S., & Whiteneck, G. G. Rehabilitation Act of 1973, Public law 93-112.
(1999). Depression and subjective well-being among Reid, D. K., & Knight, M. G. (2006). Disability justifies
97 American Indians with spinal cord injury: A descriptive exclusion of minority students: A critical history grounded
study. Rehabilitation Psychology, 44(4), 354–372. in disability studies. Educational Researcher, 35, 18–23.
Lee, G. K., Chronister, J., & Bishop, M. (2008). The effects of Riggle, E. D. B., Whitman, J. S., Olson, A., Rostosky, S. S., &
psychosocial factors on quality of life among individuals with Strong, S. (2008). The positive aspects of being a lesbian or
chronic pain. Rehabilitation Counseling, 51, 177–189. gay man. Professional Psychology: Research & Practice, 39,
Lehmann, I., & Crimando, W. (2008). Unintended conse- 210–217.
quences of state and federal antidiscrimination and Family Rolland, J. (1994). Families, illness and disability. New York:
Medical Leave legislation on the employment rates of Basic Books.
persons with disabilities. Rehabilitation Counseling, 51, Rose, A. (1997). “Who causes the blind to see”: disability
159–169. and quality of religious life. Disability and Society, 12(3),
Lollar, D. (2008). Rehabilitation psychology and public 395–405.
health: Commonalities, barriers, and bridges. Rehabilitation Saetermoe, C., Scattone, D., & Kim, K. (2001). Ethnicity
Psychology, 53, 122–127. and the stigma of disabilities. Psychology and Health, 16,
Mackelprang, R. W., & Salsgiver, R. O. (1999). Disability: 699–713.
A diversity model approach in human service practice. Belmont, Serafica, F. C. (1999). Clinical interventions and prevention
CA: Wadsworth Publishing Company. for Asian American children and families: Current status
Marshall, C. A. (Ed.). (2001). Rehabilitation and American and needed research. Applied and Preventive Psychology, 8,
Indians with disabilities: A handbook for administrators, 143–152.
practitioners, and researchers. Rehabilitation Education, Smart, J. F., & Smart, D. W. (1992). Cultural issues in the
16(1), 103–104. rehabilitation of Hispanics. Journal of Rehabilitation, 58(2),
Mussen, P. H., & Barker, R. (1944). Attitudes toward cripples. 29–37.
Journal of Abnormal and Social Psychology, 39, 351–355. Smart, J. F. & Smart, D. W. (1993). The rehabilitation
Olkin, R. (1999). What psychotherapists should know about of Hispanics with disabilities: Sociocultural constraints.
disability. New York: Guilford. Rehabilitation Education, 7, 167–184.
Olkin, R. (2004). Disability and depression. In S. L. Welner & Smart, J. F., & Smart, D. W. (1997). The racial-ethnic demogra-
F. Haseltine (Eds.), Welner’s guide to the care of women with phy of disability. Journal of Rehabilitation, 63(4), 9–15.
disabilities (pp. 279–300). Philadelphia: Lippincott Williams Smart, J. F., & Smart, D. W. (2006). Models of disability:
& Wilkins. Implications for the counseling profession. Journal of
Olkin, R. (2005). Disability culture: A baker’s dozen. Newsletter Counseling & Development, 84, 29–40.
of the Contra Costa County Psychological Association. Smith, L., Foley, P. F., & Chaney, M. P. (2008). Addressing
Olkin, R. (2006). Persons of color with disabilities. classism, ableism, and heterosexism in counselor education.
In M. Constantine (Ed.), Clinical practice with people of Journal of Counseling and Development, 86, 303–309.
color: A guide to becoming culturally competent. New York: Sue, D. W. (2010). Microaggressions in everyday life: Race, gender,
Teacher’s College Press. and sexual orientation. Hoboken, NJ: John Wiley and Sons.
Olkin, R. (2008). Disability-Affirmative Therapy and case Sue, D. W., Capodilupo, C. M., & Holden, A. M. B. (2008). Racial
formulation: A template for understanding disability in a microaggressions in the life experience of black Americans.
clinical context. Counseling & Human Development, 39(8), Professional Psychology: Research & Practice, 39, 329–336.
1–20. Sue, D. W., Nadal, K. L., Capodilupo, C. M., Lin, A. I.,
Olkin, R. (2009). Disability-Affirmative Therapy. In I. Marini & Torino, G. C., & Rivera, D. P. (2008). Racial microaggres-
M. Stebnicki (Eds.), Professional Counselors’ Desk Reference sions against black Americans: Implications for counseling.
(pp. 355–370). NY: Springer. Journal of Counseling and Development, 86, 330–338.
Olkin, R., & Pledger, C. (2003). Can disability studies and psy- Sue, S. (1999). Science, ethnicity, and bias: Where have we gone
chology join hands? American Psychologist, 58(4), 296–304. wrong? American Psychologist, 54, 1070–1077.

478 disabilit y
Tews, L., & Merali, N. (2008). Helping Chinese parents Wong, D. (2008). Beliefs of immigrant Chinese families with
understand and support children with learning disabilities. children with disabilities: An investigation of three theoretical
Professional Psychology: Research & Practice, 39, 137–144. models of disability. Unpublished doctoral dissertation,
Tezzoni, L. I., McCarthy, E. P., Davis, R. B., Harris-David, L., California School of Professional Psychology at Alliant
O’Day, B. (2001). Use of screening and preventive services International University, San Francisco.
among women with disabilities. American Journal of Medical World Health Organization (2001). International classification
Quality, 16(4), 135–144.Toyota Motor MFG., KY., Inc. v. of functioning, disability, and health. Geneva, Switzerland:
Williams, 534 U.S. 184 (2002). Author.
Walster, E. (1966). Assignment of responsibility for an accident. Wright, B. A. (1960). Physical disability: A psychological approach.
Journal of Personality and Social Psychology, 3, 73–79. New York: Harper & Row.
Westbrook, M. T., Legge, V., & Pennay, M. (1993). Attitudes Wright, B. A. (1983). Physical disability: A psychosocial approach
towards disabilities in multi-cultural society. Social Science (2nd ed.). New York: Harper & Row.
and Medicine, 36, 615–623. Wright, B. A. (1988). Attitudes and the fundamental negative
Whealin, J. M., & Ruzek, J. (2008). Program evaluation bias: Conditions and corrections. (pp. 3–21). In H. E. Yuker
for organizational cultural competence in mental health (Ed.), Attitudes toward person with disabilities. New York:
practices. Professional Psychology: Research & Practice, 39, Springer.
320–328. Yuker, H. E. (Ed.) (1988). Attitudes toward persons with
Whitfield, H. W., & Lloyd, R. (2008). American Indians/ disabilities. New York: Springer.
Native Alaskans with traumatic brain injury: Examining Zalaquett, C. P., Fuerth, K. M., Stein, C., Ivey, A. E., &
the impairments of traumatic brain injury, disparities in Ivey, M. B. (2008). Reframing the DSM-IV-TR from a
service provision, and employment outcomes. Rehabilitation multicultural/social justice perspective. Journal of Counseling
Counseling, 51, 190–192. and Development, 86, 364–371.

olkin 479
 CHAPTER

Counseling Psychologists Working with

18 Older Adults

Tammi Vacha-Haase and Michael Duffy

Abstract
This chapter explores the relationship between counseling psychology and working with older adults.
A brief overview of the increasing expansion and core areas within the aging population is provided,
with focus on aging in society, intergenerational family, and issues of diversity. Clinical work with older
adults is addressed, highlighting later-life issues, as well as engaging in psychotherapy and assessment
with older adults. In the final section, opportunities for counseling psychologists are outlined, with
recommendations for the expansion of traditional areas for counseling psychology, as well as relatively
newer areas such as quality of life, pain management, and end-of-life treatment.
Keywords: geropsychology, older adult, counseling psychology, training counseling psychologists,
career opportunities

An exciting and increasing area of opportunity However, current trends are returning to a more posi-
for counseling psychology comes with the growing tive outlook of older adulthood, with increased focus
numbers of older adults. Not only is “America gray- on the optimizing of healthy aging. Rowe and Kahn
ing,” but the mental health needs of the older popula- (1998) popularized the term successful aging, and Hill
tion are expanding and becoming more apparent than (2005) expanded on Seligman and Csikszentmihalyi’s
ever before in history. The population growth of those (2000) work in positive psychology, bringing to center
over 65 years of age can be attributed to the aging of stage the movement of positive aging. Recognizing
baby boomer generation, as well as an increase in the aging as involving a “state of mind,” Hill (2005) iden-
average lifespan (Centers for Disease Control and tified four characteristics to living a longer and higher-
Prevention, 2007). People are living longer, with a quality life. These included the importance of coping
current average life expectancy of over 78 years (Kung, with age-related decline; choosing a lifestyle to pre-
Hoyert, Xu, & Murphy, 2008). Although old age has serve well-being; maintaining cognitive, emotional,
typically been defined as over 65 years, additional ter- and behavioral flexibility; and, focusing on the posi-
minology has emerged with the increasing lifespan, tives, rather than the negatives, of the aging process.
categorizing adults over 65 but under the age of 75 as Although not inevitable with aging, there is often
the “young-old,” those aged 75 to 85 as the “old-old,” a decline of physical health, with an increase of
and those over age 85 as the “oldest old.” With chronic medical problems such as arthritis, high
advances in medicine and public health, people are blood pressure, and late-onset diabetes. As a group,
not only living longer, but continuing to be in reason- older adults tend to visit physicians more frequently
ably good health for the majority of their years. than do younger adults, and approximately 87% of
Much has been written about the later years of older adult patients regularly see a primary care
the lifespan, with attention often given to the physi- physician (Ross, 2005). Unfortunately, declining
cal decline and challenges that come with age. health status is magnified for diverse elders, as the

480
health of older adults of racial and ethnic minorities (Schmidt et al., 1977). Unfortunately, LTC facilities
lags far behind that of nonminority populations. have not been traditionally well equipped (Lombardo,
Data from the 2004 National Health Interview 1994) or adequately financed or staffed to provide
Survey (NHIS) indicated that 39% of non-Hispanic psychological or psychiatric services to older adults,
white adults aged 65 years or older reported very leaving unmet the mental health needs for the major-
good or excellent health, compared with 24% of ity of LTC residents (Moak & Borson, 2000).
non-Hispanic blacks and 29% of Hispanics. Perhaps the greatest untold story today is the
A longstanding debate has focused on the mental effect of an aging population on families. It has been
health of older adults, with an ongoing assertion well established that caring for a sick relative pro-
that old age, in comparison to youth, brings about motes increased stress and burden for the caregiver
higher rates of depression and anxiety. However, it (Gatz, Bengtson, & Blum, 1990; Zarit, Johansson,
is now generally accepted that older adults actually & Jarrott, 1998). When caregivers are elderly and
have a lower incidence of anxiety (Brenes, Knudson, caring for their spouses with dementia, the stress of
McCall, Williamson, Mille, & Stanley, 2008) and this undertaking may be compounded, and marital
depression (Fiske, Wetherell, & Gatz, 2009) than satisfaction lessened as the degree of perceived care-
do younger adult groups, perhaps a testimony to the giver burden increases (Fitzpatrick & Vacha-Haase,
increasing resilience that comes from a lifetime of in press). However, it is often middle-generation
coping with and resolving problems. adults, particularly middle-generation women, who
However, a recent comprehensive study of older struggle with caregiving for older parents who have
adults found that 6% reported 14 or more days an increasing incidence of chronic medical and
each month of poor mental health due to stress, mental health concerns.
depression, or problems with emotions, with the
prevalence of frequent mental distress lower among Who Will Provide Needed Mental
non-Hispanic whites (5.9%) and Asians and Pacific Health Services?
Islanders (6.1%) compared with Native Americans There has been little change over the past several
and Alaska Natives (8.4%), non-Hispanic blacks decades regarding the number of psychologists
(9.8%), and Hispanics (11.2%) (CDC, 2007). interested in working with older adults (Qualls,
A review of the literature over the past decade Segal, Norman, Niederehe, & Gallagher-Thompson,
estimates that mental health disorders among the 2002). Research has consistently found that only a
elderly range from 18% to 28%, and if current few, between 1% and 4% of psychologists surveyed,
prevalence rates for mental disorders are applied, were either interested in or specializing in working
more than 7.5 million older Americans are suffering with the elderly (Gatz, Karel, & Wolkenstein, 1991;
from afflictions that require the professional services Koder & Helmes, 2008). Clearly, not all psycholo-
of psychologists. If these older individuals are resi- gists will specialize in older adults, nor will they all
dents of long-term care (LTC) facilities or nursing require specific training (Knight, Karel, Hinrichsen,
homes, the estimates are even higher, with the prev- Qualls, & Duffy, 2009). However, given changing
alence of psychiatric disorders in nursing homes for demographics, the majority of psychologists will
older adults ranging from 50% to 90% (Chandler eventually treat an older client. With the increase in
& Chandler, 1988; Rovner et al., 1990; Rovner the number of grandparents raising grandchildren,
et al., 1986; Tariot, Podgorski, Blazina, & Leibovici, even those specializing in children and adolescents
1993). will encounter older adults in need of mental health
Relatively few options are available for older services. Unfortunately, according to a 2002 survey
adults to obtain psychological treatment (Yang & of American Psychological Association (APA) prac-
Jackson, 1998), especially for the increasingly large ticing psychologists, less than 30% have been
number who have diminishing resources. Mental exposed to course work in geropsychology, and less
health utilization studies show a low access of older than 20% have completed practicum or supervised
adults to community mental health centers across clinical experience (Qualls et al., 2002).
the United States, with estimated utilization by older Unfortunately, the attention paid to an older
adults comprising only 4% of total outpatient mental population by counseling psychologists is limited if
health visits (Karlin & Duffy, 2006). With the down- publication within professional journals is represen-
sizing and closing of public state psychiatric facili- tative of the degree that a field includes older adults
ties, nursing homes have increasingly become the in its training, research, and clinical interest. Werth
new inpatient psychiatric hospitals for older adults and his colleagues (Werth, Kopera-Frye, Blevins,

vacha-haase , duffy 481

& Bossick, 2003) reviewed all published articles personality characteristics biologically based and
from 1991 to 2000 in counseling psychology’s lead- inherited in the range of 30%. His notable sum-
ing journals, The Counseling Psychologist (TCP) and mary statement was based on his extensive research,
The Journal of Counseling Psychology ( JCP), to explore as well as that of other personality psychologists
the extent of older adult representation in these pro- (Hettema & Deary, 1993). But this leaves a sig-
fessional publications. The final results identified a nificant 70% of human behavior that is highly
lack of published material focusing on older adults, influenced by social, physical, and environmental
an outcome similar to previous reviews of JCP variables. It might be said that, although one cannot
(Munley, 1974; Scherman & Doan, 1985). However, change a kangaroo into an elephant, it is possible to
the authors added the following caveat: “although improve the kangaroo! The simple divide of biologi-
JCP and TCP have not shown significant attention cal and environmental factors in development has
to geropsychological research and practice, this is moved from a simple dualism to an interactive and
not to insinuate that such work is not being con- process model of the relationship of the organism
ducted by counseling psychologists. There are a and environment in human development. Not only
number of researchers and practitioners who inte- do genetics and the environment interact in com-
grate gerontology with counseling psychology in plex ways, but the individual actively participates in
research and practice. The bottom line, however, is his or her own development. In turn, part of that
that their contributions to the literature are not participation is influenced by the enduring person-
being published in counseling psychology’s premiere ality make-up of the person, including such features
journals” (Werth et al., 2003; p. 805). as resilience (Eisold, 2005), which has a distinct
Counseling psychology provides a “natural” fit influence on the unfolding development of the
for being involved with older adults through older person. So, personality characteristics not only
research, treatment, training, outreach, and advo- influence but are in turn influenced; biology is not
cacy. The profession’s strengths-based approach to static but dynamic and plastic. This plasticity in
human behavior provides a positive psychological human capacity is also recognized in the world of
emphasis in both gaining knowledge and working neurobiology, in which neuropsychological studies
with elders. The valuing of diversity and social jus- reveal that the brain is not a static instrument but
tice embedded within counseling psychology creates is in dynamic interaction with the total environ-
a meaningful and significant framework from which ment including innate characteristics, interpersonal
to contribute to the rapidly growing older adult interactions, and the ongoing influences of life
population. And counseling psychology’s emphasis (Whitbourne, 2005). Such dynamic and process-
on a developmental model for both human behavior oriented views of human development strongly sup-
and emerging problems appears highly congruent port a role for intervention and counseling in the
with geropsychology. lives of older adults. It is clear that human persons
are not victims of biology but rather are positively
Core Areas in Geropsychology shaped by temperamental factors that allow them to
Geropsychology encompasses a multitude of areas, adapt, change, and move in positive and health-
each intersecting with the other. While areas inter- giving directions (Hill, 2005).
sect, they are also sufficiently distinct in focus and Finally, a major contribution to lifespan develop-
research contributions that this chapter defines mental understanding is Erik Erickson’s (Erikson,
them separately: the life span approach to develop- 1959, 1963) lifespan psychological theory. He
ment, an approach to development that optimizes focused on internal development, such as trust, inti-
compensation as a focus, aging viewed as gains or macy, and identity issues, whereas much previous
declines, and the challenges posed by physical ill- developmental psychology is probably best described
nesses and limitations. as describing developmental behavior. Erickson
Geropsychologists have been very prominent in focused on the development of the person’s internal
lifespan development research, extending the range psychological world. His addition of the late life stage
of developmental phases to include later life and of ego integrity versus despair brought his under-
contributing to the understanding of the classic standing of the lifespan full circle. His recognition
nature versus nurture debate. This includes recogni- that development of ego integrity is threatened by
tion that the biological and organic blueprint plays chronic illness and increasing body preoccupation in
a central role in development. In the mid-1980s, some persons is critical to understanding late-onset
Raymond Cattell indicated that the variance of somatic complaints. These various developmental

482 working with o l d er ad u lts

stages or themes are in fact not linear but recursive; likely to experience this disease. Osteoporosis, often
older adults continue to revisit issues of intimacy, considered a “silent” disease, as symptoms may not
trust, and identity development throughout the life be initially noticed, weakens the bones, increasing
cycle (Christianson & Palvovitz, 1998). In general risks for a fracture or break. High blood pressure,
there is a strengthening of the sense of self as an or hypertension, is often referred to as the “silent
individual moves through life. Erickson’s work is killer” of the elderly due to the lack of identifiable
compatible with the internal development processes symptoms; left unidentified or treated, high blood
enshrined in the tradition of counseling psychology. pressure can lead to stroke, heart disease, and kidney
It provides a model for counseling psychologists to failure.
understand and intervene effectively in the develop- Another critical dimension of deteriorating
mental processes of older adults. health in older adults is through cognitive changes
A major theoretical contribution within the and decline. Understanding the normal and patho-
tradition of lifespan development is the selection opti- logical changes in brain function in late life is a
mization compensation (SOC) developmental model vast, complex, and still little understood area. It is
(Baltes & Baltes, 1990), which clearly fits with a certainly true that not all memory problems, for
dynamic and realistic view of late-life development. example, are a sign of approaching dementia; by the
In developing the SOC model, the authors suggested same token, however, memory loss can be an initial
that development involves not only acquisition and stage of the dementing process. Estimates of the
maturation, but also decomposition and decline of presence of dementia in older adults suggest that
life processes and competencies. Thus, there is a need approximately 50% of adults over the age of 85
to proactively offset age-related losses. In this model, will develop some dementing process, either of the
S (Selection) involves choosing realistic and attain- Alzheimer’s type, vascular dementia, or subcortical
able goals and skills in later life that are compatible dementias such as Parkinson’s or Huntington’s
with functional level. O (Optimization) focuses on dementia (Corrada, Brookmeyer, Berlau, Paganini-
enhancing competencies that are active and available Hill, & Kawas, 2008). It is also critical to be aware
to the older person, and C (Compensation) develops of reversible dementias, such as those associated
new skills and strategies to cope with actual or with delirium or with medical disorders such as per-
predictable losses. nicious anemia, thyroid imbalance, or even severe
The compensatory emphasis given in the SOC constipation (Clarfield, 2005).
model and also the actual documented medical con- The skills of psychologists are pertinent in both
ditions that are prevalent in late life emphasize that understanding and interacting with older persons
everyone will age and die, and not before likely with dementing disorders, as well as simply work-
experiencing a selection of chronic illnesses. This ing with the age-related minimal memory dysfunc-
reality-based view is sometimes at odds with a tion that normatively accompanies aging. A risk of
“Pollyanna” view, in which aging is seen as unequiv- comorbid anxiety and depression is associated with
ocally positive. For many years in the early stages of dementia, often with the unintended “emotional
professional gerontology, researchers and policy ana- abandonment” by family and even professional staff.
lysts were rightfully bent on counteracting common There is a critical need for counseling psychologists
negative stereotypic views of aging. These negative to understand that the loss of logical language pro-
stereotypes accepted static inherent physical and cesses in dementing disorder does not mean the loss
psychological limitations and therefore did not of emotional life of the older adult. It is unfortu-
invite active intervention. nately common that, when younger adults identify
Although many older adults live full and healthy cognitive impairment in older adults, they begin to
lives up to the time of their deaths, there are also give up trying to communicate and distance them-
many who suffer from advancing mental and physi- selves emotionally (Duffy, 1999b). A simple exam-
cal problems with older age. For example, arthritis, ple is the frequent short-term loss of speech in a
a painful, chronic stiffing of joints is common, with stroke victim; all too often, emotional abandonment
over one-half of adults over the age of 65 suffering occurs when family members, even spouses, who are
from this disease. Diabetes, caused by blood levels no longer able to have usual conversation with their
of glucose being too high, can lead to dangerous older relative begin to ignore and often lessen the
health problems in older adults including kidney frequency of visits. It is as if the stroke victim is
failure, vision loss, and neuropathy. Although cancer encased in a “glass coffin,” from which they cannot
can develop at any age, older adults are also more communicate but can see and appreciate that they

vacha-haase , duffy 483

are not abandoned by love ones. At a time like this, The social and psychological implications of this
the most critical intervention is to “keep talking” complex structure and attendant social problems are
(Duffy, 1999b) even though the conversation is not obvious. The focal point of this stress is sometimes
appreciated logically by the impaired older adult. referred to as the sandwich generation. This refers to
Changes and decline in later life also affect middle-generational women who may be responsi-
couple relationships. The aging of the body often ble for up to two younger generations (e.g., a 25-year-
involves changes in sexuality and sexual responsive- old adult child and a 2-year-old grandchild) and
ness. Although sexual beings throughout life, there potentially two older generations (e.g., a 70-year-old
is a gradual decline in sexual performance and mother and a 90-year-old grandmother). This
sometimes also in sexual interest for both genders. middle generation, often a woman, is a heroine in
Such changes as decreases in testosterone (men) and coping with both caregiving situations, but can also
estrogen and progesterone (women), increased size be identified as a victim of the economic, domestic,
of the prostate (men), and decrease in vaginal lubri- health, and psychological pressures involved in care-
cation (women) frequently result in slowed or giving. Bear in mind also, that an increasing number
weaker response at excitement and orgasmic phases, of these middle-generation women are now working
respectively (Zeiss & Zeiss, 1999). Although these outside the home, so that their lives involve a double
changes are factual and should be realistically appre- role of worker and caregiver.
ciated, it is also important to develop strategies that However, this situation should not be taken to
are compatible, for example, with the SOC model, imply a negative view of the extended family. It also
which focuses on optimization and compensation does not necessarily imply a lack of connection or
for losses. Couples may benefit from counseling decline in the extended family. This popularized view
that helps adapt to changing sexual patterns and of decline in sociological views during the 1960s
develop adaptive sexual behaviors in tune with suggested that modern, highly mobile culture pre-
changed physiological conditions. Sexuality needs saged the decline of the extended family. In contrast,
also be handled sensitively in long-term care studies by social gerontologists in the last 20 years
settings, with ongoing staff education to promote have clearly indicated a continuing and meaningful
understanding and acceptance of older adult sexual contact between members of the extended family,
intimacy (Martin & Vacha-Haase, in press). This is even as it becomes more complex. For example,
true even in residents with dementia, as advanced Shanas (1979) found that about 85% of older adults
cognitive impairment does not preclude emotional have weekly contact with an immediate family
and sexual responsiveness (Duffy, 1999b). Disturbed member, and indeed a full 65% have a daily contact
sexual behavior, however, in long-term care settings with a family member.
can become intrusive on other residents as well as Furthermore, it is important to note that inci-
professional staff, and sensitive but firm manage- dence of contact, either physically or electronically,
ment is required. does not fully capture the quality and interior
importance of relationships. Even with distant older
The Intergenerational Family parents, the importance and quality of the relation-
With the aging demographics, especially the increa- ship is not simply correlated with the degree of con-
ses in the “old-old,” family structures are becoming tact. It is now known that the psychological
increasing complex. As mentioned earlier, the stress significance of parental relationships continues late
on intergenerational families is perhaps the greatest into adult life and continues throughout the later
untold story in contemporary society, especially phases of the extended family (Pillemer &
with stress on family caregivers increasing incremen- McCartney, 1991). Psychological connections with
tally. Increasing survival of older adults has meant parents are simply too strong (even when negative)
increases in the frequency of extended multigenera- to be discounted.
tional family systems. Whereas the two- or three- In a similar vein, a mythology has developed
generation family would have been normative in about families abandoning older adults to LTC
earlier years, it is now common to find four or facilities or nursing homes. In fact, this behavior is
even five generations coexisting in the multigenera- quite rare and is present in perhaps 5%–10% of
tional family (Matthews & Sun, 2006). Add in largely dysfunctional families. Note that this figure
a 50% divorce and remarriage rate and the com- is consistent with the presence of family and severe
plexity escalates, for example, with a child having personality pathology that exists in the population
up to eight (sometimes competing!) grandparents. as a whole (Kessler et al., 1994). In other words,

484 working with o l d er ad u lts

families largely do not abandon older parents, and well-being—financially, medically, and socially—of
indeed, the issue of caring for older parents is typi- older adults. A very common misconception about
cally an issue of great emotional sensitivity, not to late life is that older adults are homogeneous in
mention pain and stress. their political and social views. In fact, there is
Clearly, there is a role for active intervention by increasing heterogeneity among persons as they age.
counseling psychologists in these extended family Traditionally, politicians understood this and often
systems. Although society is indebted to the family felt there was no “power block” that must demand
therapy movement of the 1960s and beyond, tradi- their attention. However, with the ascendance of
tional family therapy was largely concerned with the AARP, Gray Panthers (a national group of older
nuclear family (mom, dad, and kids) and had little adults committed to aging social and advocacy
awareness of the critical emotional connections that issues), and like organizations, politicians now take
exist with older parents in the extended family. serious notice of organized political advocacy in
Family therapy methods with multigenerational Washington, D.C. on behalf of older adults. In
families need to be flexible and multimodal and terms of sheer numbers, older adults form a strong
deal with the pragmatic constraints of distance. lobby when they stand behind any given issue.
Often, family members might be reached only Work, retirement, and leisure issues also have
through telephone and conference-call connections a large personal and economic effect on society.
and background information gained from family Although the age limit requirements of mandatory
members at a distance. In a specific example, it is retirement have frequently been raised, older adults
likely that, in some cases, the most effective treat- still frequently choose to seek retirement and greater
ment of depression in an older adult will involve a opportunity for family time and leisure. In rural
strategic “therapeutic” phone call to an absent family and agrarian societies, it has been noted that there is
member with whom the older adult feels emotion- only a limited concept of retirement for example, as
ally disconnected. Late life is a time for resolution of the farmer continues to work until finally physically
unfinished family business, and the “ticking clock of unable to manage the physical demands of work
death” is often a signal for families to reach out to (Cavanaugh, 1997). In urban societies, however,
one another in caring and in forgiveness. retirement has become a norm and has been increas-
The increasing presence of older adults within ingly studied as a topic within social gerontology.
contemporary society has a large-scale societal effect, Clearly, counseling psychologists place a special
as well as consequences in the more intimate clinical emphasis on the psychological importance and pat-
areas discussed above. Not only is the older indi- terns of vocational choice and work. The emphasis
vidual threatened economically in terms of the on workplace psychology and the various patterns
adequacy of Social Security payments, Medicare, of retirement is much needed since older adults
Medicaid, and the depletion of private retirement are inclined to “escape” the world of work into a
homes, but there is also a societal impact. With the retirement in a manner that is often ill-considered
increasing older adult population, policy makers economically, socially, and psychologically. Naïve
and social strategists recognize that the extension of assumptions that happiness will be gained by either
the human lifespan has significant social, economic, staying in the workforce or “sitting on the balcony
and political impact. For example, Medicare, the and looking out to sea” are often the victims of later
universal healthcare system for older adults, pro- harsh reality. Not only are individual personality
vides as much as 65% of the income of those in differences relevant, but cultural and ethnic influ-
average acute and long-term care hospitalizations ences also need to be taken into account as a voca-
(MedPac, 2008). It is also noteworthy that, in the tional psychology of retirement is developed. In
current national fiscal woes, Medicare is under fairly addition, gender differences in retirees are critical.
routine pressure to reduce reimbursements, with It has been often noted that women tend to do
subsequent loss of physician providers for older better in retirement (Mandal & Roe, 2008) because
adults: As of now, only 38% of family physicians they retain connections with friends and family
remain Medicare providers (Xakellis, 2004). members, and often become the “family kin keeper”
However, older adults are a considerable force, who updates the address book and sends the holiday
socially and politically, and in more recent years cards. Men, on the other hand, frequently become
have become increasingly organized for political increasingly isolated and vulnerable to subsequent
action. The American Association of Retired Persons depression. It is conjectured that this pattern of
(AARP) is an influential political advocate for the isolation contributes to older white males having

vacha-haase , duffy 485

the second highest suicide rate across the lifespan and economic backgrounds similar to European
(Conwell & Thompson, 2008). Ethnic and cultural Americans, whereas Filipino older adults have
differences may explain the fact that older men in largely worked in poor and unskilled jobs
other ethnic groups are less isolated and affected by (Cavanaugh, 1997).
such processes. The smallest ethnic minority group older adults
are the earliest U.S. citizens, Native Americans.
Diversity in Aging Although the tribes have some degree of official
With the baby boom cohort aging, the elderly pop- independence, living on a reservation involves
ulation will not only increase, but racial and ethnic a paternalistic system that often cuts a person off
diversity will continue to enlarge with this popula- from the resources available to other older adults.
tion expansion (United States Census, 2003). For Although Native Americans often escape typical
example, in 2000, Latinos represented 12.5% of European ailments such as heart disease, they are
the nation’s population, but only 5% of those were vulnerable to alcoholism, diabetes, accidents, and
over 65. For African Americans, the average growth poor life expectancy; less than 42% reach age 65
for those over age 65 is about 31%. (Thorson, 1995). Not unrelated is the very limited
Although fundamental similarities exist in devel- quality of the health and mental health services
opmental trajectories, individual and group devel- provided on reservations.
opment is significantly influenced by gender, sexual Within these ethnic groups, there are differ-
orientation, and cultural and ethnic experiences. ences between rural and urban settings. Rural fami-
There are notable differences between African lies have tended to assume care for older parents,
American, Anglo, and Mexican American aging pro- whereas urban families, often involved in a corpo-
cesses in terms of cultural patterns, family priorities, rate workday, have relied on nursing homes as a part
and caregiving (Morales, 1999). The intersection of of the caregiving system. There are ethnic and cul-
age with ethnicity also signals a significant change in tural differences in the role and place of the older
socioeconomic status, specifically in access to mate- adult within the extended family and within society.
rial resources. Older adult members of most ethnic In some cultures, the Anglo culture being the most
groups are poorer than Anglo elderly, although typical, the significance of the role of older adults,
decreased resources characterize older adults in gen- socially and politically, diminishes over time. This is
eral. Older African Americans often experience a in contrast to other ethnic groups, such as Native
significant poverty that is the product of past and Americans, in which age is considered to give a
present racial discrimination that kept them from special role in society and the family as advisor,
well-paying jobs (Atchely, 1994). They tend to have wisdom bearer, and consultant.
significantly poorer health status than do Anglo In addition to racial or ethnic diversity, older
elderly, with several chronic conditions, such as heart adults must be understood within the context of
disease and cancer (Thorson, 1995). gender issues (Smith & Baltes, 1998). Older women
Hispanic Americans represent several different experience unique social challenges (Crose, 1999;
heritage groups, including Mexican, Cuban, and Davenport, 1999), as they are more likely to live
Puerto Rican, as well as several Latin American cul- below the poverty line, have significantly less income
tures, all of which have considerable intercultural than their male counterparts, live alone, and experi-
variations. A key issue with older Hispanic Americans ence some form of disability while outliving their
is the length of time living in the United States. partners. Older men also face unique challenges
Language differences are often the cause of discrimi- (Huyck & Gutmann, 1999; Vacha-Haase, Wester,
nation, and many older Mexican American adults, & Christianson, in press), including loss of inde-
for example, are monolingual and rely on younger pendence and power, social isolation, and increased
bilingual family members to deal with daily affairs. emotional distress with higher likelihood of suicide
There are approximately 5,00,000 older adults completion.
of Asian or Pacific Islander descent in the United An area of diversity that has received little atten-
States, a category composed of widely disparate gro- tion within society is the presence of gay and lesbian
ups differing in racial, cultural, religious, and lan- older adults (OLGBTs). Estimates suggest that there
guage characteristics: Japanese, Indian, Chinese, are approximately 3 million gay elders currently
Korean, Filipino, Hawaiian, and Southeast Asian peo- living in the Unites States; by 2030, there will be up
ples. The differences are also economic, with Chinese to 6 million lesbian and gay seniors (National Gay
and Japanese older adults having occupational and Lesbian Task Force, 2009). In earlier cohorts of

486 working with o l d er ad u lts

older adults, sexual orientation was largely invisible, knowledge of normal aging, and differentiation
although it was likely present in the same degree of when symptoms go outside the overall norms.
as in contemporary society. As the years pass, later The older adult population, more than any other,
cohorts will most likely deal with sexual orientation has the highest coexistence of physical and emo-
diversity with greater comfort and openness. In fact, tional ailments. An accurate diagnosis and follow-up
a recent study found that the more interaction older treatment calls for an investigative approach, look-
adults had with gay men or lesbian women, the ing at the entire picture in order to answer, “To
higher their comfort level in interacting with gay what extent is this disturbance due to psychological,
and lesbian peers. It is highly likely that the trans- environmental, or physical factors?” Older adults
formations in the social meaning of marriage and experience a number of mental disorders, many
legal unions happening today will influence the which are highlighted below. An expanded review
acceptance of sexual orientation diversity among of mental health issues affecting older adults is
future older adults. offered through an extensive literature review com-
Another related area interfacing with all of pleted by the Surgeon General (U.S. Department of
these diversities is religious belief and adherence. Health and Human Services, 1999).
The importance of spirituality and indeed religious All too often older individuals, their family
adherence increases with age, probably in relation- members, and even professionals mistakenly accept
ship to a parallel increase in introspection or interi- depression as a normal part of the aging process.
ority that has been identified with later phases of the This belief is especially unfortunate for those who
life cycle. Religious belief is a critical area of differ- first develop depression late in life, when such resig-
entiation and importance among older adults and is nation can prevent the individual from receiving
also an embedded factor within ethnic identity and effective care. Research suggests an increasing risk of
sexual orientation. depression with age, as statistics indicatethe preva-
Finally, an area of diversity that is critical in the lence of depression is 8% to 16% in community-
lives of older adults is the presence of disability, which dwelling older persons (Weyerer et al., 2008).
intersects across aging, gender, and minority status. However, it is not age, per se, that causes depres-
Disability of mobility, sensory processes (vision, sion, but rather impairment in physical health and
hearing), language (post stroke), and cognition the perceptions of health status. It is important to
(dementia or other mental limitations) are reported distinguish that increased risk of depression is due
by 4.8 million older adults (National Institutes of to decreased health, and not directly to age; physi-
Health, 2006). This does not take into account the cally healthy, normal functioning older adults are at
many disabling effects of the chronic health prob- no greater risk of depression than are younger adults.
lems endemic in late life. Again, these data are also However, complicating the diagnosis of depression
influenced by the intersection of ethnic minority is often the overlap of symptoms of a chronic illness,
status, in which African Americans and Hispanics are progressive dementia, or the propensity for somatic
disproportionately represented among disabled older symptoms. Older adults experiencing a mental dis-
persons (Song, Chang, Tirodkar, Chang, Manheim, order tend to approach their medical providers with
& Dunlop, 2007). Also, it is known that abusive persistent physical symptoms including headaches,
behavior, often by family members, shows an increase gastrointestinal problems, and chronic pain, which
toward disabled and therefore more vulnerable dis- often leads to depressed states among the elderly
abled older adults (Drayton-Hargrove, 2000). being neglected, underdiagnosed, and undertreated
All of these areas of diversity among older adults (Lebowitz et al., 1997; NIH Consensus Develop-
require a knowledgeable and calibrated approach in ment Panel on Depression in Late Life, 1992).
providing counseling and psychological services. Older Americans are disproportionately likely to
This requires a familiarity with the issues discussed die by suicide: Representing only 12% of the U.S.
above and also the application of sensitive listening population, nonetheless individuals aged 65 and
and attending skills that can grasp the specific con- older accounted for 16% of all suicide deaths in
cerns of the individual older person. 2004 (Centers for Disease Control and Prevention,
NationalCenter for Injury Prevention and Control,
Clinical Work with an Older 2005).Recent research has indicated that suicide is
Adult Population most related to physical illness, with older white
Working with older adults who are experiencing men over the age of 85 being most at risk for com-
emotional distress starts with an underlying pletion (Centers for Disease Control and Prevention,

vacha-haase , duffy 487

National Center for Injury Prevention and Control, Because of their high rates of comorbid illnesses,
2005). changes in drug metabolism with age, and the
It is critical to distinguish between later-life potential for drug interactions, prescription and
patients expressing suicidal ideation due to depres- over-the-counter drug abuse and misuse can have
sion and those indicating they are “ready to die.” more adverse health outcomes. In addition, older
Many older adults who are not suffering from adults have the poorest rates of compliance with
depression will openly state, “I wish it was my time,” directions for taking medication (Glantz & Leshner,
or more directly indicate that they would like to die. 2000).
Upon further exploration, the majority of these The misuse of alcohol or prescription medica-
older adults are identifying that they have enjoyed a tions by older adults has been viewed as the “invisi-
full and productive life, and view their death in ble epidemic” both in the literature and in practice.
somewhat objective and realistic terms. As one Addiction to alcohol or prescription medications
83-year-old woman summarized, “I know I have can also be missed due to the client’s reduced social
more years behind me than I do ahead of me. I am and occupational functioning. Signs may more
ready to go when it’s my time.” often present as poor self-care, unexplained falls,
Anxiety disorders, or the “silent geriatric giant,” malnutrition, and medical illnesses. Older adults
remain one of the most common psychiatric disor- may attempt to cope with challenges by drinking
ders of later life (Cassidy & Rector, 2008). More alcohol or misusing prescription medications, rather
than 10% of adults aged 55 years and older meet than seeking psychological treatment; they may
criteria for an anxiety disorder in 1 year (Flint, routinely use pharmacological interventions to deal
1994). However, actual occurrence may be even with feelings of depression or physical pain, which
higher given its coexistence with depression, medi- then leads to an addiction or abuse problem.
cal disorders, and dementia, although issues in rela- Unfortunately, problems resulting from sub-
tion to comorbidity and the nature of anxiety in old stance abuse may be missed due to the attitudes
age remain unresolved (Bryant, Jackson, & Ames, held by psychologists as well as other health practi-
2008). In fact, numerous medical conditions such tioners. Clinicians may be likely to avoid the topic
as chronic obstructive pulmonary disease, hyperten- of alcohol or drug use because it can be a difficult
sion, overactive thyroid, and Parkinson’s disease can topic to discuss with older patients. There may be a
mimic or even cause symptoms of anxiety. The same misguided belief that it is not necessary to screen for
can be seen as side effects of various medications, substance-related problems in older adults because
both prescription and over-the-counter. these patients cannot be treated “successfully,” or that
Alcohol use among older adults is thought to be the time and energy required to treat substance abuse
one of the fastest growing health problems in the is too great for patients who are so close to the end of
country, and is the third leading health problem their lifespans (Sharp & Vacha-Haase, in press).
among Americans 55 years of age and older (King, Given the numerous life changes experienced
Van Hasselt, & Segal, 1994). Although alcohol by older adults, many elderly clients may present
abuse among seniors has only recently begun to with situational difficulties or adjustment issues.
receive adequate empirical attention (Substance These may include loss, death and dying, physical
Abuse and Mental Health Services Administration, and mental health changes, chronic illness and dis-
2005), it is clear that older adults are at a higher ability, and debilitating pain. End-of-life issues are
risk for developing alcohol-related problems as age often at the forefront of the older client’s presenting
modifies the body’s responses to alcohol, including problems. Although choices for preferences at the
the manner and rate of absorption, distribution, end of life have received increasing recognition, they
and excretion. are often neglected and perhaps even ignored by
Although prescription medication abuse affects family members. Having these conversations is the
many Americans, a concerning trend can be seen best way to protect one’s autonomy in many unpre-
among older adults that suggests that prescription dictable situations.
abuse is on the rise. Persons 65 years of age and older Similar to younger adults, an older adult popula-
account for approximately 33% of all medications tion also includes those with a personality disorder.
prescribed in the United States, and older patients Current estimates suggest that approximately 10%
are more likely to be prescribed long-term and mul- of community-dwelling older adults exhibit a per-
tiple prescriptions, which could lead to uninten- sonality disorder (Widiger & Seidlitz, 2002). When
tional misuse (Special Committee on Aging, 1987). a personality disorder is suspected, it is important to

488 working with o l d er ad u lts

establish that these characteristics and behaviors were characterized by difficulties remembering names,
present in earlier adulthood, and cannot be better following a conversation, or misplacing things;
accounted for at this time by physiological causes increased difficulty in complex planning may also
such as neurological disease (e.g., multiple sclerosis, occur above and beyond normal changes with age.
Parkinson’s disease), a stroke, or dementia. Personality The person is generally aware of the increasing
changes often precede or accompany several neuro- “senior moments,” but is able to successfully com-
logical or medical conditions that have higher preva- pensate for the cognitive decline.
lence rates in older adulthood (Balsis, Carpenter, & The number of older adults experiencing MCI
Storandt, 2005). In addition, consistent problematic who go on to be diagnosed with dementia is not
behavioral symptoms being reported must be veri- well known. However, as noted previously, many
fied to ensure that these inflexible behaviors are long- older adults will be diagnosed with dementia, a
standing, and neither an outcome of the current chronic decrease in memory in addition to impair-
situation or due to a crisis, nor reactions to severe ment in at least one other area of thought process,
prolonged stress. Zweig (2008) provided an overview including impaired judgment, problemsolving,
for empirically informed assessment of personality emotional regulation, or language ability (American
disorder in older adults. Psychiatric Association, 1994). Dementia is an over-
Working with behavioral difficulties in older arching descriptive term, describing a number of
adults is an emerging area in which psychologists symptoms affecting the thought process. A number
can provide assessment and intervention. These of disorders cause dementia, with Alzheimer’s dis-
clients are often found living in communities, such ease being the most common type for people over
as assisted living or LTC facilities (Snyder, Chen, & the age of 65. Vascular dementia is another common
Vacha-Haase, 2007). Behaviors such as agitation, type of dementia, caused by cerebrovascular or car-
yelling or shouting, or inappropriate sexual activi- diovascular problems—usually strokes. A third type
ties are best managed through a behavioral modifi- of dementia frequently seen in the elderly is that of
cation or environmental approach. Pharmacological Lewy body dementia, often linked with neurological
treatments for behaviors are generally ill advised disorders such as Parkinson’s disease.
and often not effective. Clinicians are expanding Created by an APA presidential task force, the
their expertise in working with older adults who are Guidelines for the Evaluation of Dementia and
increasingly cognitively impaired (Logsdon, Age-Related Cognitive Decline (American Psycho-
McCurry, & Teri, 2007). logical Association [APA], 1998) was the first effort
Research consistently supports the decrease of to provide an overview of the knowledge, skill, and
memory and speed of thought processing with age, unique ethical issues related to assessing cognitive
but with little agreement on the specific domains changes. More recently, APA partnered with the
or timing of cognitive decline (Lindenberger & American Bar Association Commission on Law and
Ghisletta, 2009). Although few 80-year-olds would Aging to author the Assessment of Older Adults with
deny changes in their cognitive functioning com- Diminished Capacity: A Handbook for Psychologists
pared to when they were 40, cognitive change is (American Bar Association and APA, 2008). Not
predominated by individual differences. For some only does this handbook include helpful legal defi-
people, decline occurs rapidly and appears extreme. nitions and practical information regarding assess-
For others, decline may be a slow and gradual pro- ing varying capacities (e.g., sexual, driving, financial,
cess, or may not appear to occur at all until late life. medical), but it provides a listing and description of
It seems that cognitive decline in late life is not as cognitive functioning and corresponding neuropsy-
extensive or as devastating as once thought. chological assessments to use in evaluations.
The most natural or benign memory loss is
referred to age-associated memory impairment, and Psychological Interventions
predominantly occurs in many people over the age The core of effectively working with older adults in
of 50, who must work harder to remember things. both psychotherapy and assessment is a strong foun-
Mild cognitive impairment (MCI) is an advancing dation of basic clinical skills (Duffy, 1992), with
memory deficit, but one that does not meet criteria modifications made to meet the unique complexity
for diagnosis of dementia (Petersen et al., 2001). of needs in the later-life client (Knight et al., 2009).
It is the transitionary stage between age-related When working with later-life clients, counseling
memory changes and more serious problems associ- psychologists most likely will interact with profes-
ated with dementia. Mild cognitive impairment is sionals from other specialties, including physicians,

vacha-haase , duffy 489

nurses, social workers, dieticians, and physical and (e.g., “hooking up,” “awesome,” or “hanging out”).
occupational therapists. In addition to a myriad Use of general psychological terms such as “depres-
of health care providers, extended family members sion,” “anxiety,” “cognitive impairment,” and
and other caregivers may also be involved in the “dementia” may cause unnecessary concern to the
client’s care. older adult, and on occasion even initial denial of
It is well known that older adults are at risk for symptoms. Older clients may tend to say that they
physical and mental decline, with potential prob- are “feeling blue,” “not felt like myself lately,” or
lems of vision, hearing, mobility, or cognitive slow- “been down in the dumps.” More anxious clients
ing. If hearing is a challenge, the therapist may want may state they have “felt more on edge lately” or
to speak slightly lower, louder, and slower, remem- experienced a “hard time relaxing.” Client reaction
bering that maintaining eye contact is vital. Materials to terminology is determined not only by age, but
printed in a larger font are often useful, as is paying also by education level, cohort, religious preference,
particular attention to lighting, temperature con- culture, and geographical surroundings.
trol, appropriate seating (avoiding chairs that are Critical to working with older adults is avoiding
too low and difficult to get up out of ), and ease of “elder speak.” That is, speaking too loud or slow
accessibility (with a walker, cane, or wheelchair). to an older adult who does not having a hearing
The majority of counseling psychologists work- impairment, treating them like children, or using a
ing with older adults will provide psychological term of endearment such as “sweetie,” “honey,” or
services such as individual talk therapy, group ther- “dear.” Although perhaps meant in a positive way,
apy, psychological assessment, neuropsychological recent research indicates that elder speak is more
evaluation, and staff or family education. Regardless likely to be experienced as an insult, supporting
of the method of service delivery, clarifying the negative views of aging, and possibly even increas-
presenting problem and differential diagnosis are ing negative health consequences (Collins, 2008;
essential to effective intervention. For example, a Lelenad, 2008; Ryan, Giles, Bartolucci, & Henwood,
psychologist completing an intake with a client pre- 1986; Ryan, Hummert, & Boich, 1995). One
senting with symptoms of anxiety should rule out resource offering further guidance in communicat-
medical causes, in addition to recent cognitive and ing with older adults is Talking with Your Older
personality changes. Appropriate interventions will Patient: A Clinician’s Handbook (National Institute
not only be varied given the clinical problem, but of Aging, 2009).
also influenced by the context and characteristics of In addition, a significant part of working with
the person. For example, even if the diagnosis and older adults is self-awareness, in particular being
context are similar, the psychological intervention conscious of one’s own biases. Skilled clinicians are
may be different if the client is a retired African aware of personal preconceptions, while being sen-
American university professor versus a migrant farm sitive to the within-group differences of older adults
worker. Even if they have both just been diagnosed (Crowther & Zeiss, 2003). Even in today’s society,
with terminal cancer, a 95-year-old Hispanic women many myths and stigmas are attached to growing
living independently in the community will require older, leading to misinformation and “ageism.”
a different approach than will a 77-year-old man Older people are often thought of as being “all
who is bedridden in a LTC facility. alike,” and often mistakenly portrayed as being
At times, interactions with an older adult client weak, fragile, senile, asexual, and incompetent.
may be somewhat informal, taking on a “conversa- A number of individual psychotherapeutic inter-
tional” quality. In response to clinical questions, ventions have been offered in effective treatment
some older adults may offer additional information, with older adults, including interpersonal psycho-
sometimes with a “story-telling” quality. For exam- therapy (Hinrichsen, 2008), cognitive-behavioral
ple, a specific question about appetite may solicit treatments (e.g., Knight & Satre, 2006; Stanley,
a response that includes preferences for cooking, Beck, & Glassco, 1996), and reminiscence therapy
increased stomach problems, and associated bowel (Fielden, 1992). However, in an extensive review,
problems, with a summary, “I just don’t have an Scogin and McElreath (1994) suggested that no
appetite anymore.” single modality of psychological intervention is
When working with older adults, attention to most effective for older adults. Although the best
vocabulary and use of specific words calls for addi- intervention for mental disorders faced by older
tional consideration. Many current, commonly adults is not currently known, it is recognized
used words may have little meaning for older adults that older adults do benefit from both individual

490 working with o l d er ad u lts

psychotherapy (Scogin & McElreath, 1994) and screening instruments are available, ranging from
group treatment (Payne & Marcus, 2008). Research those that are broad, to those that are more spe-
also suggests that older adults find psychological cific or narrow in nature. Regardless of the specific
intervention to be an acceptable treatment (Lebowitz measurement chosen, it is important to be sensitive
et al., 1997), despite identifiable barriers such to normative information based on older samples,
as physical access, financial resources, cognitive lim- keeping in mind the limits of using assessment
itations, and attitudinal issues (Yang & Jackson, instruments created for younger persons with older
1998). adults, but without adequate standardization.
Although significant progress is being made In addition to cognitive screening, assessment of
regarding empirically supported treatments (ESTs) an older adult’s “capacity” or “diminished capacity”
or evidence-based practice (EBPP) for older clients, for decision making in a specific area may become
this research remains in its infancy. Future clinicians the focus. In these situations, the aim is to be spe-
will undoubtedly have access to more specific treat- cific in regards to the situational or contextual
ments as research continues to expand with older capacity, asking, “Does the patient have capacity for
adult populations. A significant contribution was ______?” (e.g., making a will, doing own finances,
provided recently in a special section on evidence- or making medical decision). Unfortunately, there
based psychological treatment for older adults, pub- is no “golden standard” or universal criteria for
lished in Psychology and Aging in 2007. Scogin (2007) judging capacity, as it is contextual (which does not
and his colleagues provided reviews of psychological easily allow for one standard) and can change over
treatment for anxiety (Ayers, Sorrell, Thorp, & time. The focus is on the client’s functional ability,
Wetherell, 2007), insomnia (McCurry, Logsdon, rather than the diagnosis, as a diagnosis by itself
Teri, & Vitiello, 2007), and behavior disturbances cannot determine capacity. In general, capacity is
among older adults suffering from dementia (Logsdon assessed in four main areas:medical (is the patient
et al., 2007). An additional article (Gallagher- able to understand the medical procedure, by com-
Thompson & Coon, 2007) reviewed treatment strat- prehending risk, benefit, and choice?); financial
egies for family caregivers of older adults. (what is the client’s financial performance in han-
Not only is psychological treatment effective dling change, paying bills, etc.? Is he or she able to
(Scogin & McElreath, 1994), but negative side act in his or her own best interest, with proper judg-
effects of this type of intervention are limited ment about financial matters?); contractual (does
(Sperry, 1995). Given that, on average, older adults the patient have the ability to comprehend the situ-
between 60 to 65 fill 13.6 prescriptions per year, ation?); and, testamentary (is this person able to
and those 80 to 84 years old average 18.2 pre- make a will; does he or she have a basic understand-
scriptions per year (American Society of Consultant ing of what a will is, who the heirs are, what consti-
Pharmacist, 2003), pharmacological intervention tutes his or her assets, and a plan for distribution?)
for mental disorders significantly increases the risk
for adverse interactions (Arnold, 2008). Research Training Counseling Psychologists to
has shown that, with mild clinical depression, psy- Work with Older Adults
chotherapy is as effective as chemical intervention Graduate training in professional psychology con-
and has no adverse side effects (Sperry, 1995). For tinues to be under pressure to respond to the grow-
more severe depression, treatment is most successful ing number of elderly and their mental health needs
if psychotherapy is utilized in addition to medica- (e.g., Fretz, 1993; Hinrichsen, Myers, & Stewart,
tion, as this can drastically reduce the noncompli- 2000; Jacobs & Formati, 1998; Qualls, 1998).
ance rate of medication use as well as contribute to A previous survey determined that only 16 to
longer-lasting change (Little et al., 1998; Reynolds 20 clinical and counseling psychology programs
et al., 1999). offered specialized training in aging (Blieszner,
1994). Hinrichsen, Myers, and Stewart (2000)
Cognitive Assessment and identified 65 doctoral internship sites training in
Neuropsychological Evaluation clinical geropsychology.
Although many of the important aspects of clinical In 2004, the geropsychology training offered in
assessment would be similar regardless of client age APA-accredited counseling psychology programs
(e.g., psychometric properties of the instrument), was explored (Vacha-Haase, 2004). Written mate-
a number of areas are also unique to working rial from all accredited doctoral programs in coun-
with older adults. A number of neuropsychological seling psychology (n = 73), as well as program

vacha-haase , duffy 491

websites for all accredited programs, were used to the document outlined areas of knowledge and clin-
compile information in the following areas for each ical skills considered imperative to those working
program: number of core faculty, number of faculty with an older population.
with “geriatrics” listed as an interest area, the avail- More recently, the Pike’s Peak model for training
ability of specializing in geropsychology, type of in professional geropsychology (Knight et al., 2009)
training offered in geropsychology, and whether outlined options at the doctoral, internship, postdoc-
coursework in geropsychology was offered on the toral, and postlicensure level of training. Specifically,
university campus. Results indicated that 12% of the Pike’s Peak document focused on competencies
the programs offered training in geropsychology that relate to attitudes toward older adults (e.g., com-
through options such as a minor, concentration, bating stereotypical, ageist attitudes), knowledge
track, or adaptation to the student’s area of interest. (e.g., biological and psychological dimensions), and
In addition, another 8% of the programs offered skills (e.g., assessment, psychotherapy, and consulta-
coursework, such as a seminar or workshop focus- tion) in working with older adults. Also included in
ing on geriatrics. According to written materials, these competencies were age-specific informed con-
counseling programs identified having from no sent and confidentiality guidelines, skills in capacity
faculty up to three faculty with an interest in geriat- and competence evaluation, end-of-life decision
rics, either through their research or clinical work. making, and elder abuse and neglect. Complementing
The average number of faculty per program with the training model, the Pike’s Peak Geropsychology
geriatric interest was less than 1%. Knowledge and Skill Assessment Tool (Council of
Anecdotally, many have speculated that working Professional Geropsychology Training Programs,
with older adults is not viewed as interesting or CoPGTP, 2008) is a competency evaluation measure,
exciting for faculty and students in counseling psy- providing ratings across levels (e.g., novice, interme-
chology programs. Others have focused on what is diate, advanced, proficient, expert). The assessment
believed to be a limited amount of available inter- scale assumes that the acquisition of competency in
ventions (e.g., only neuropsychological assessment geropsychology is developmental in nature, and thus
services) or the idea that an older client cannot be appropriate for both the graduate student in a spe-
“fixed” or “saved” or “really helped,” as can a younger cialized geropsychology program as well for the
client. And, finally, others have focused strictly on seasoned general practitioner attending continuing
economical issues, indicating low reimbursement education workshops. The tool can be accessed at:
rates for trained geropsychologists. http://www.uccs.edu/∼cpgtp/Pikes%2520Peak%25
Although these misrepresentations are unfortu- 20Evaluation%2520Tool%25201.1.pdf.
nate, perhaps the last is of greatest concern, given The Council of Professional Geropsychology
that, over the past few years, Medicare reimburse- Training Programs (http://www.usc.edu/programs/
ment has been financially competitive with man- cpgtp/) was established in 2006. Now with over
aged care companies’ reimbursement rates. In July 30 members, CoPGTP includes programs and
2008, Congress provided for Medicare coinsurance individuals that provide geropsychology training in
parity for Medicare patients when it enacted the psychology graduate, internship, and postdoctoral
Medicare Improvements for Patients and Providers programs as well training to postlicensure psycholo-
Act (MIPPA). Under MIPPA, mental health ser- gists. CoPGTP is committed to the promotion of
vices will enjoy an 80%–20% split in coinsurance excellence in and the development of high-quality
by 2014, with the phase-in to coinsurance parity for training programs in professional geropsychology.
outpatient mental health services scheduled to begin CoPGTP is especially interested in facilitating access
in January 2010. to resources in the acquisition of geropsychology
Over the past decade, a number of initiatives knowledge and skill competencies during formal
within the APA have produced guidance for prac- training at doctoral, internship, and postdoctoral
tice and training in geropsychology. As a valuable levels, as well as among licensed psychologists who
product of the APA Interdivisional Task Force on want to acquire this specialty later in their careers.
Professional Geropsychology, the APA Guidelines In response to impediments to increasing the
for Psychological Practice with Older Adults (APA, numbers of trained clinicians working with older
2004) were built on the profession’s ethical guide- adults, the importance of clinical “exposure” to
lines, providing a background repertoire of aca- older clients and age-related course content within
demic and clinical knowledge in the field of aging. training programs has been noted (Koder & Helmes,
Rather than specific methods that must be followed, 2008), with suggestions such as integration of

492 working with o l d er ad u lts

content focusing on older adults into existing cur- Counseling Psychology and Opportunity
riculum and offering a specialized geropsychology Within Geropsychology
course (Hinrichsen, 2000). The following section Perhaps no other area offers counseling psycholo-
describes a practicum model that is designed to give gists so many growing opportunities in today’s
intensive geropsychology experience to counseling healthcarefield as does the expanding need for those
psychology doctoral students (Duffy, 1992; Qualls, skilled in working with older adults. Many vibrant,
Duffy, & Crose, 1995). well-established areas within counseling psychology
Doctoral students are offered the opportunity have remained virtually untapped in application to
to take this practicum in geropsychology after the an older population, leaving ample opportunity for
conclusion of their basic counseling practicum counseling psychologists to expand their role with
training. After initial orientation, class meetings are older adults.
located in the various LTC facilities, retirement One of counseling psychology’s most senior and
communities, or rehabilitation hospitals in which principal components, vocational psychology and
the practicum students are placed. Each week, the career development (Brown & Lent, 2000; Gelso
class rotates around these various facilities, utilizing & Fretz, 2001), is an optimal example poised for
rounds-type supervision, in which the instructor expansion with an older population. As mentioned
and students visit the practicum students’ various earlier, “second-time-around” careers are on the
older clients in their rooms using a naturalistic increase, and the topic is in much need of theoreti-
“home visit” format. One hour of the 3-hour group cal understanding, as well as vigorous research and
class period is devoted to a didactic and experiential practical applications. Many current vocational the-
presentation of a specific clinical topic as it relates to ories could be utilized to shed light on older adults
working with older adults, such as depression and who wish to return to the workforce after retiring
aging, intergenerational family therapy, dementia from their initial occupation. Retirement is another
assessment, and the like. These topics frequently area ripe for significant contributions from coun-
involve a videotape of the instructor demonstrating seling psychology. In the general literature, the
the topic or relevant skill. Each week, students who majority of the focus in retirement planning has
do not receive supervision in the live, supervised traditionally been placed on financial preparation,
rounds receive individual supervision focused on with little attention given to other themes, such as
audio tape recordings, with special attention paid to identity changes or emotional experience. Coun-
dynamic and process aspects of their individual seling psychology’s interest and expertise in voca-
interactions with clients. Supervision, therefore, is tional psychology could easily be extended into a
experiential and involves two modalities: the first critical understanding of retirement’s dynamics and
is the live group supervision in the resident’s room, processes.
where the instructor/supervisor models and stimu- More specifically, the monumental contribu-
lates discussion with the resident, with increasing tions of Holland (1966, 1973, 1984) and Super
responsibility given to the supervisee. This is a (1957, 1963, 1980, 1994) have much to offer when
group activity in which other members of the class extended into increasing the understanding of
are present and learn from the events. The second retirement satisfaction and possibly other later-life
modality is individual, dynamic, process-oriented experiences. Holland’s theory proposed that indi-
supervision based on audio tapes as available, and viduals tend to thrive in environments consistent
focusing on individual dynamics between the thera- with their personality types, and noted that stability
pist and the client. and achievement depend on the congruence between
This type of intensive practicum training at the one’s personality and environment. Although he
predoctoral level is usually quite engaging to stu- was referring to vocational satisfaction, these asser-
dents, even those who were hesitant to take part tions would appear to be relevant to activities
initially. An important gain is losing the inhibition involving retirement choices, and even conceivably
that is understandably present when a 22-year-old be extended for use in guidance when choosing
student deals with an 85-year-old client. Also, a living arrangements and making end-of-life deci-
pragmatic effect of this kind of practicum experi- sions. Over a decade ago, Walsh and Chartrand
ence is to give students a decided advantage in (1994) called for the expansion of the person–
applying for internship positions that require either environment (PE) interaction paradigm. Counseling
specific training in geropsychology or in general psychologists could effectively increase efforts in
health psychology. extending this theory to retirement choices or to the

vacha-haase , duffy 493

choice of elder living environments, such assisted- to food and eating, in which a psychologist can
living or LTC facilities. help to refine the dietary regimen to make it more
Super’s developmental focus on social context palatable to the patient. H & B codes are also uti-
(life space) and self-concept also have a natural lized in some circumstances in which, due to cogni-
extension to older adults. In explaining his lifespan tive impairment, verbal psychotherapy is not an
approach, while focusing on the differential salience option, but in which significant psychological con-
of life roles during the life cycle, Super (1980) tributions will facilitate recovery or rehabilitation.
included the end of the lifespan, with one of the Assessment is another area in which counsel-
nine roles being “Pensioner” and a possible theater ing psychology can continue to expand upon its
as “retirement community or home.” His belief that strengths. Not only is neuropsychological evaluation
“the more a person’s abilities and interests find ready of great need, but so too is personality and behav-
and temporally compatible outlets in the full range ioral assessment, including functional analysis. The
of the activities engaged in, the more successful and individual approach to behavioral assessment allows
satisfied that person will be” (p. 287) seems to be as for the unique causes of an individual’s behaviors to
relevant to retirement and later years as it does to be monitored, through a number of multiple meth-
the vocational choice and career pattern to which he ods and sources congruent with the expertise of
was actually referring. counseling psychology. Through functional analysis,
Counseling psychology’s strengths-based approach the attention to explaining the relationship between
is a natural fit for the expanding need of a society that behavior and its causes facilitates the formulation of
is increasingly focused on prevention in healthcare, unique, context-specific and client-centered treat-
capitalizing on the three roles identified as central ment plans that will lead to the greatest improve-
throughout the history of the specialty—remedial ment. Because behavioral assessment is conceptually
(assisting people to remediate problems), prevention, based and methodologically diverse, it is well suited
and educative-developmental (Gelso & Fretz, 2001). for a wide range of clinical and research applications
With factors such as obesity and high-risk behaviors, for describing and explaining behaviors among the
such as smoking and substance abuse, implicated in diverse older adult population.
health decline, counseling psychologists have much Counseling psychologists will also find much
to contribute to the systematic provision of program- room for their expertise in the area of education and
matic treatments. training. For over a decade, there has been a warn-
Counseling psychologists can also be influential ing regarding the lack of professionals, including
in increased disease management. In January 2002 psychologists, trained to work with older patients.
(APA, 2002) codes for health and behavior assess- Thus, those who have a knowledge base for working
ment and intervention services (e.g., H & B codes) with older adults will be in great demand as other
could be applied to behavioral, social, and psy- mental health providers seek relevant education and
chophysiological procedures for the prevention, training experiences. As noted above, working with
treatment, or management of physical health prob- older adults requires an interdisciplinary approach.
lems. Thus, psychologists are able to bill for services This, too, provides challenges, as professionals must
provided to patients who have a physical health to learn how to collaborate effectively with one
diagnosis, rather than a mental health diagnosis, another. In addition, other healthcare fields will
thus allowing a blend of physical and psychological need skill sets for working with older adults, includ-
services delivery. Through engaging in a compre- ing basic knowledge of normal aging and develop-
hensive approach to patient care, the H & B codes ment, as well as appropriate and sensitive interview
pertain to psychological intervention that allows techniques and skills in interacting with older
clients to improve health and functioning in a mul- adults. For example, those providing direct care,
titude of ways. For example, psychologists may such as nurses and nursing assistants, can benefit
focus on helping clients to engage in behaviors that from increased education (Brescian & Vacha-Haase,
help promote their health through supporting com- in press). Fields outside of healthcare will undoubt-
pliance to treatment or by providing motivation for edly interact with a growing older adult population
various prescribed treatments. Psychologists may and also require specialized training. These groups
facilitate patient adjustment to physical illness, or include police officers, sales people, and even teach-
address behaviors that keeps patients from effec- ers who are working with grandparents raising
tively engaging in treatment. Some of the H & B grandchildren (Smith, Dannison, & Vacha-Haase,
services involve circumstances and behaviors related 1998).

494 working with o l d er ad u lts

 Counseling psychology’s foothold on inclusive- and prevention. Neuroscience is uncovering tech-
ness and sensitivity to multicultural issues provides niques to prevent cognitive decline, and creative
another example of areas of opportunity, given the services such as memory-enhancing programs, will
increasing diversity among the older adult popula- no doubt be sought after by older generations that
tion. Whether it is through culturally sensitive focus on brain fitness and increasingly know that
training or prevention, treatment programs for the “if you don’t use it, you lose it.” As noted above,
elderly, or advocacy for the needs for an older adult prevention programs, including those that promote
population, counseling psychology has much to weight loss or a decrease in high-risk behaviors, will
offer regarding not only valuing differences, but most likely be in high demand. Counseling psychol-
understanding them and incorporating them into ogists can provide a positive impact by encouraging
daily life. older adults to adopt healthier behaviors and obtain
At its most basic level, counseling psychology regular health screenings that can reduce the risk for
embraces social justice and advocacy by promoting many chronic diseases and help decrease the health
the inclusion of and increased competence in work- disparities that currently exist.
ing with older adults in both research and clinical At the other end of the health continuum, there is
settings. As counseling psychologists continue to need for counseling psychologists who are willing
enhance their involvement with social justice, social to work with the most frail and demented elderly.
action, and advocacy, older adults can receive sup- Psychologists have only begun to scratch the surface
port, and ageism can be opposed at all levels. of the psychological interventions that can be pro-
Recognition of social and economical issues, both vided to increase quality of life for those with demen-
individually and within society, emphasizes the aim tia, as well as to provide support for their caregivers
for equity and fair distribution of resources for older and family (Duffy, 1999a, 2005, 2006), including
adults. Older adults and their families can be diverse and culturally sensitive approaches (Borrayo,
empowered to seek the resources and support they Goldwaser, Vacha-Haase, & Hepburn, 2007). A crit-
require to maintain dignity and basic human ical role for counseling psychologists has emerged in
rights. the need to enhance care for institutionalized elders,
At the organizational level, just as racism is as LTC settings pose a particular challenge to the
addressed through changing institutional policies maintenance of mental health, given that physical
to promote advocacy against it (Arredondo et al., and social conditions have a pervasive and continuing
1996), counseling psychologists can help to address effect on residents.
institutional ageism. For example, counseling psy- The future also holds ample opportunity for
chologists might call for fair practices for older adults counseling psychologists to be influential in continu-
in the workplace; increased accessibility to health ing to provide progressive care through more effec-
care for the poorest of older adults; and support of tive pain management. Whether through behavioral
human rights, such as privacy while in a nursing changes in the early stages of an older adult’s life, or
home, or the right for older LGTB individuals to through pain management techniques to ease severe
name life-long partners as executors of their power or chronic pain, psychological intervention has much
of attorney or have the same visitation rights as het- to offer.
erosexual couples. They can promote these changes Counseling psychologists can also play a promi-
through organizing community agency partnership, nent role in providing holistic, culturally sensitive
influencing the legislative process, and increasing end-of-life care. Utilizing their strengths-based
their role in policy setting in regards to the welfare of approach and embracing the value of individual dif-
older adults. Counseling psychologists can call for ferences, counseling psychologists can ultimately
the profession to be more activist oriented (Toporek, help both older adults and their families during the
Gerstein, Fouad, Roysircar, & Israel, 2006), ques- dying process. Given that two states (Oregon and
tioning a system that disempowers an older adult’s Washington) now have legalized physician-assisted
choice in areas such as preference for housing, suicide, which allows physicians to prescribe a lethal
medical treatment, or end-of-life decisions. dose of drugs for mentally competent patients with
Counseling psychologists are well situated to less than 6 months to live, the focus on choices at
meet the needs of healthy older adults interested in the end of life is more prominent than ever.
prolonging a high quality of life. This generation is The employment opportunities for working with
the first of many to be more health minded, and older adults are likely to expand. For example,
more open to psychological intervention, outreach, Veteran Administration (VA) hospitals will not only

vacha-haase , duffy 495

continue to rely on doctoral-level psychologists, but Dementia. (1998). Guidelines for the evaluation ofdementia
most likely will continue to enlarge its programs and age-related cognitive decline. Washington, DC: American
Psychological Association.
for frailer, declining older adults, offering assistance American Society of Consultant Pharmacist. (2003). Seniors
through home and long-term care environments. at risk: Medication-related problems among older Americans.
Additional government opportunities will surface as Alexandria, VA: American Society of Consultant Pharmacists
increased focus is given to women (male patrons have Research and Education Foundation.
been the main recipients of VA care) and families. Arnold, M. (2008). Polypharmacy and older adults: A role for
psychology and psychologists. Professional Psychology: Research
Additional opportunities will continue to emerge and Practice, 39, 283–289.
from independent practice, both within the com- Arredondo, P., Toporek, R., Brown, S. P., Jones, J., et al. (1996).
munity on an outpatient basis, as well as through Operationalization of the multicultural counseling compe-
older adult living communities. Given that those tencies. Journal of Multicultural Counseling & Development,
living in independent and assisted-living facilities 24, 42–78.
Atchley, Robert. (1994). Social forces and aging. Belmont, CA:
are often among the least cared for adults, these Wadsworth Publishing.
communities are in need of psychological services, Ayers, C. R., Sorrell, J. T., Thorp, S. R., & Wetherell, J. L.
including prevention programs. In addition, the (2007). Evidenced-based psychological treatments for late-
need for psychologists in LTC settings will continue life anxiety. Psychology and Aging, 22, 8–17.
to exist and most likely expand. Balsis, S., Carpenter, B. D., & Storandt, M. (2005). Personality
change precedes clinical diagnosis of dementia of the
The aging of the U.S. population is one of Alzheimer type. Journal of Gerontology: Psychological Sciences,
the major societal occurrences in the 21st century. 60, 98–101.
More than ever before, focus is on the process of Baltes, P. B., & Baltes, M. M. (1990). Psychological perspectives
healthy aging, highlighting the optimal physical, on successful aging: A model of selective optimization with
mental, and social well-being and functioning of compensation. In P. B. Baltes and M. M. Baltes (Eds.),
Successful aging: Perspectives from the behavioral sciences.
older adults. Encapsulated within the increasing New York: Cambridge University Press.
older population comes both grave challenges and Blieszner, R. (1994). Doctoral programs in adult development and
momentous opportunity. There is much that coun- aging. Washington, DC: American Psychological Association,
seling psychologists can do to contribute to the Division 20.
number of older adults who will live longer, high- Borrayo, E. A., Goldwaser, G., Vacha-Haase, T., & Hepburn, K. W.
(2007). An inquiry into Latino caregivers’ experience caring
quality, productive, and independent lives. The pro- for older adults with Alzheimer’s disease and related dementias.
fession’s strengths-based, developmental approach, Journal of Applied Gerontology, 26, 486–505.
steeped within sensitivity to multiculturalism and Brenes, G. A., Knudson, M., McCall, W. V., Williamson, J. D.,
social advocacy, highlights the important contribu- Mille, M. E., & Stanley, M. A. (2008). Age and racial differ-
tions possible to this rapidly aging and diverse pop- ences in the presentation and treatment of Generalized
Anxiety Disorder in primary care. Journal of Anxiety Disorders,
ulation. Counseling psychologists are encouraged to 22, 1128–1136.
include older adults in their practice, theory devel- Brescian, N. E., & Vacha-Haase, T. (2007, August). Certified
opment, and research, and strive to combat ageism nursing assistants in long-term care: Exploring the relation-
at all levels, being active in the support of equity ship between locus of control and patient aggression. Poster
and empowerment for all older adults. session presented at the meeting of the American Psychological
Association, San Francisco, CA.
Brown, S. D., & Lent, R. W. (2000). Handbook of counseling
References psychology. New York: John Wiley & Sons.
American Bar Association and the American Psychological Bryant, C., Jackson, H., & Ames, D. (2008). The prevalence of
Association. (2008). Assessment of older adults with dimin- anxiety in older adults: Methodological issues and a review of
ished capacity: A handbook for psychologists. Retrieved the literature. Journal of Affective Disorders, 109, 233–250.
from http://www.apa.org/pi/aging/capacity_psychologist_ Cassidy, K., & Rector, N. A. (2008). The silent geriatric
handbook.pdf. giant: Anxiety disorders in late life. Geriatrics Aging, 11,
American Psychiatric Association. (1994). Diagnostic and statisti- 150–156.
cal manual of mental disorders (4th ed.). Washington, DC: Cavanaugh, J. C. (1997). Adult development and aging (3rd. ed.).
American Psychiatric Association. New York: Brooks/ColePublishing Company.
American Psychological Association (APA). (2002). APA Practice Centers for Disease Control and Prevention, National Center for
directorate announces new health and behavior CPT codes. Injury Prevention and Control. Web-based Injury Statistics
Retrieved from http://www.apa.org/practice/cpt_2002.html. Query and Reporting System (WISQARS) [online]. (2005).
American Psychological Association (APA). (2004). Guidelines Retrieved January 31, 2007 from www.cdc.gov/ncipc/
for psychological practice with older adults. American wisqars.
Psychologist, 59, 236–260. Center for Disease Control and Prevention. (2007). The state
American Psychological Association, Presidential Task Force of aging and health in America. Retrieved January 18, 2009
on the Assessment of Age-Consistent Memory Decline and from www.cdc.gov/aging/pdf/saha_2007.pdf.

496 working with o l d er ad u lts

Chandler, J. D., & Chandler, J. E. (1988). The prevalence of Fielden, M. A. (1992). Depression in older adults: Psychological
neuropsychiatric disorders in a nursing home population. and psychosocial approaches. British Journal of Social Work,
Journal of Geriatric Psychiatry Neurology, 1, 71–76. 22, 291–307.
Christianson, S. L., & Palvovitz, R. (1998). Exploring Erikson’s Fiske, A., Wetherell, J. L., & Gatz, M. (2009). Depression in older
psychosocial theory of development: Generativity and its adults. Annual Review of Clinical Psychology, 5, 363–389.
relationship to paternal identity, intimacy, and involvement Fitzpatrick, K., E., & Vacha-Haase, T. (in press). Marital satisfac-
in childcare. The Journal of Men’s Studies, 7(1), 133–156. tion and resilience in caregivers of spouses with dementia.
Clarfield, A. M. (2005). Reversible dementia the implications of Clinical Gerontologist, 33, 165–180
a fall in prevalence. Age and Ageing, 34, 544–545. Flint, A. J. (1994). Epidemiology and comorbidity of anxiety
Collins, A. T. (2008, July 28). “Baby talk” irritates Alzheimer’s disorders in the elderly. American Journal of Psychiatry, 151,
patients: Caregivers for the elderly should avoid certain pat- 640–649.
terns of speech. ABC Medical Unit. Retrieved from http:// Fretz, B. R. (1993). Counseling psychology: A transformation
abcnews.go.com/Health/ActiveAging/stor y?id= for the third age. The Counseling Psychologist, 21, 154–170.
5452861&page=1. Gallagher-Thompson, D., & Coon, D. W. (2007). Evidence-
Conwell, Y., & Thompson, C. (2008). Suicidal behavior in based psychological treatments for distress in family caregiv-
elders. Psychiatric Clinics of North America, 3, 333–356. ers of older adults. Psychology and Aging, 22, 37–51.
Corrada, M. M., Brookmeyer, R., Berlau, D., Paganini-Hill, A., Gatz, M., Bengtson, V. L., & Blum, M. J. (1990). Caregiving
& Kawas, C. H. (2008). Prevalence of dementia after age 90: families. In J. E. Birren & K. W. Schaie (Eds.), Handbook of
Results from the 90+ study. Neurology, July. Online. the psychology of aging (3rd ed., pp. 404–426). San Diego,
Council of Professional Geropsychology Training Programs. CA: Academic Press.
(2008). Pikes Peaks Geropsychology Knowledge and Skill Gatz, M., Karel, M. J., & Wolkenstein, B. (1991). Survey of
Assessment Tool. Retrieved from http://www.uccs.edu/∼cpgtp/ providers of psychological services to older adults. Professional
Pikes%2520Peak%2520Evaluation%2520Tool%25201.1.pd. Psychology: Research and Practice, 22, 413–415.
Crose, R. (1999). Addressing late life developmental issues for Gelso, C., & Fretz, B. (2001). Counseling psychology (2nd ed.).
women: Body image, sexuality and intimacy. In M. Duffy Orlando, FL: Harcourt College.
(Ed.), Handbook of counseling and psychotherapy with older Glantz, M. D. & Leshner, A. I. (2000). Drug abuse and develop-
adults. New York: Wiley. mental psychopathology. Development and Psychopathology,
Crowther, M. R., & Zeiss, A. M. (2003). Aging and mental 12, 795–814.
health. In J. S. Mio & G. Y. Iwamasa (Eds.), Culturally diverse Hettema, J., & Deary, I. J. (1993). Foundations of personality:
mental health: The challenge of research and resistance Proceedings of the NATO Advanced Research Workshop on Basic
(pp. 309–322). New York: Brunner-Routledge. Issues in Personality. New York: Springer.
Drayton-Hargrove, S. (2000). Assessing abuse of disabled older Hill, R. D. (2005). Positive aging: A guide for mental health profes-
adults: A family systems approach. Rehabilitation Nursing, sionals and consumers. New York: W. W. Norton.
25, 136–140. Hinrichsen, G. A. (2000). Knowledge of and interest in geropsy-
Davenport, D. (1999). Dynamics and treatment of middle chology among psychology trainees: Professional Psychology:
generation women: Heroines and victims of multigenera- Research and Practice, 31, 442–445.
tional families. In M. Duffy (Ed.), Handbook of counseling Hinrichsen, G. A. (2008). Interpersonal psychotherapy for
and psychotherapy with older adults. New York: Wiley. late life depression: Current status and new applications.
Duffy, M. (1992). A multimethod model for practicum and Journal of Rational-Emotive & Cognitive-Behavior Therapy,
clinical supervision in nursing homes. Counselor Education 26, 263–275.
and Supervision, 32, 61–69. Hinrichsen, G. A., Myers, D. S., & Stewart, D. (2000). Doctoral
Duffy, M. (1999a). Using process dimensions in psychotherapy: internship training opportunities in clinical psychology.
The case of the older adult. In M. Duffy (Ed.), Handbook of Professional Psychology: Research and Practice, 31, 88–92.
counseling and psychotherapy with older adults. New York: Holland, J. L. (1966). The psychology of vocational choice: A theory
Wiley. of personality types and model environments. Waltham, MA:
Duffy, M. (1999b). Reaching the person behind the dementia: Blaisdell.
Treating co-morbid affective disorders through subvocal and Holland, J. L. (1973). Making vocational choices: A theory of
non-verbal strategies. In M. Duffy (Ed.), Handbook of coun- careers. Englewood Cliffs, NJ: Prentice-Hall.
seling and psychotherapy with older adults. New York: Wiley. Holland, J. L. (1984). Making vocational choices: A theory of
Duffy, M. (2005). Strategies for working with women with careers (2nd ed.). Englewood Cliffs, NJ: Prentice-Hall.
dementia. In F. K. Trotman and C. Brody (Eds.), Women Huyck, M. H., & Gutmann, D. L. (1999). Developmental issues
therapists working with older women. New York: Springer. in psychotherapy with older men. In M. Duffy (Ed.),
Duffy, M. (2006). Psychotherapeutic interventions for older Handbook of counseling and psychotherapy with older adults.
persons with dementing disorders. In C. Brody, Strategies New York: Wiley.
for therapy with the elderly:Living with hope and meaning Jacobs, S. C., & Formati, M. J. (1998). Older adults and geriat-
(2nd ed.). New York: Springer. rics. In S. Roth-Roemer, S. E. R. Kurpius, & C. Carmin
Eisold, B. K. (2005). Notes on lifelong resilience: Perceptual and (Eds.), The emerging role of counseling psychology in health care
personality factors implicit in the creation of a particular (pp. 309–329). New York: W.W. Norton.
adaptive style, Psychoanalytic Psychology, 22, 411–425. Karlin, B. E., & Duffy, M. (2006). Geriatric mental health
Erickson, E. H. (1959). Identity and the life cycle: Selected policy: Impact on service delivery and directions for effecting
papers. Psychological Issues Monographs, 1, 1–177. change. Professional Psychology: Research and Practice.
Erikson, E. H. (1963). Childhood and society. New York: Kessler, R. C., McGonagle, K. A., Zhao, S., Nelson, C. B.,
Norton. Hughes, M., Eshleman, S., et al. (1994). Lifetime and

vacha-haase , duffy 497

 12-month prevalence of DSM-III-R psychiatric disorders in National Institute of Aging. (2009). Talking with your older
the United States. Archives of General Psychiatry. 51, 8–19. patient: A clinician’s handbook. Retrieved from http://www.
King, C., Van Hasselt, V., & Segal, D. (1994). Diagnosis nia.nih.gov/HealthInformation/Publications/ClinicianHB.
and assessment of substance abuse in older adults: Current National Institutes of Health Consensus Development Panel
strategies and issues. Addictive Behaviors, 19, 41–55. on Depression in Late Life. (1992). Diagnosis and treatment
Knight, B. G., & Satre, D. D. (2006). Cognitive behavioral of depression in late life. Journal of the American Medical
psychotherapy with older adults. Clinical Psychology: Science Association, 268, 1018–1024.
and Practice, 6, 188–203. National Institutes of Health. (2006). Disability in older adults:
Knight, B. G., Karel, M. J., Hinrichsen, G. A., Qualls, S. H., & Fact sheet. Washington, DC: National Institutes of Health.
Duffy, M. (2009). Pikes Peak model for training in profes- Payne, K. T., & Marcus, D. K. (2008). The efficacy of group
sional psychology. The American Psychologist, 64, 205–214. psychotherapy for older adult clients: A meta-analysis. Group
Koder, D. A., & Helmes, E. (2008). Predictors of working with Dynamics: Theory, Research, and Practice, 12, 268–278.
older adults in an Australian psychologist sample: Revisiting Petersen, R. C., Doody, R., Kurz, A., Mohs, R. C., Morris, J. C.,
the influence of contact. Professional Psychology: Research and Rabins, P. V., et al. (2001). Current concepts in mild cogni-
Practice, 39, 276–282. tive impairment. Archives of Neurology, 58, 1985–1992.
Lebowitz, B. D., Pearson, J. L., Schneider, L. S., Reynolds III, C. Pillemer, K, & McCartney, K. (Eds.). (1991). Parent-Child
F., Alexopoulos, G. S., Bruce, M. L., et al. (1997). Diagnosis Relations Throughout Life. Hillsdale, NJ: Lawrence Erlbaum.
and treatment of depression in late life: Consensus statement Qualls, S. H. (1998). Training in geropsychology: Preparing to
update. Journal of the American Medical Association, 278, meet the demand. Professional Psychology: Research and
1186–1190. Practice, 29, 23–28.
Leland, J. (2008, October 6). In “sweetie” and “dear,” a hurt for Qualls, S., Duffy, M., & Crose, R. (1995). Supervision in
the elderly. The New York Times. Retrieved from http://www. community practicum settings. In Handbook of Clinical
nytimes.com/2008/10/07/us/07aging.html?_r=3&ref=healt Geropsychology. Washington, DC: The American Psycho-
h&oref=slogin&oref=slogin. logical Association.
Lindenberger, U., & Ghisletta, P. (2009). Cognitive and sensory Qualls, S. H., Segal, D. L., Norman, S., Niederehe, G., &
declines in old age. Psychology and Aging, 24, 1–16. Gallagher-Thompson, D. (2002). Psychologists in practice
Little, J. T., Reynolds III, C. F., Dew, M. A., Frank, E., Begley, A. E., with older adults: Current patterns, sources of training, and
Miller, et al. (1998). How common is resistance to treatment in need for continuing education. Professional Psychology:
recurrent, nonpsychotic geriatric depression? American Journal Research and Practice, 33, 435–442.
of Psychiatry, 155, 1035–1038. Reynolds III, C. F., Frank, E., Perel, J. M., Imber, S. D.,
Logsdon, R. G., McCurry, S. M., & Teri, L. (2007). Evidenced- Cornes, C., Miller Mazumdar, S., et al. (1999). Nortriptyline
based psychological treatments for disruptive behaviors in and interpersonal psychotherapy as maintenance therapies
individuals with dementia. Psychology and Aging, 22, 28–36. for recurrent major depression: a randomized controlled trial
Lombardo, N. E. (1994). Barriers to mental health services for in patients older than 59 years. Journal of the American
nursing home residents. Washington, DC: American Asso- Medical Association, 28, 39–45.
ciation of Retired Persons. Ross, S. (2005). Alcohol use disorders in the elderly. Primary
Martin, K. L., & Vacha-Haase, T. (in press). Staff perceptions of Psychiatry, 12, 32–40.
resident sexual contact in long-term care facilities. Rovner, B. W., German, P. S., Broadhead, J., et al. (1990). The
Matthews, S. H., & Sun, R. (2006). Incidence of four-generation prevalence and management of dementia and other psychiat-
family lineages: Is timing of fertility or mortality a better ric disorders in nursing homes. International Psychogeriatrics,
explanation? The Journals of Gerontology Series B: Psychological 2, 13–24.
Sciences and Social Sciences, 61, S99–S106. Rovner, B. W., Kafonek, S., Filipp, L., et al. (1986). Prevalence
McCurry, S. M., Logsdon, R. G., Teri, L., & Vitiello, M. V. of mental illness in a community nursing home. American
(2007). Evidenced-based psychological treatments for insom- Journal of Psychiatry, 143, 1446–1449.
nia in older adults. Psychology and Aging, 22, 18–27. Rowe, J. W., & Kahn, R. L. (1998). Successful Aging. New York:
MedPac. (2008). Long-term care hospitals payment system. Pantheon.
Washington, DC: MedPac Retrieved at: www.medpac.gov/ Ryan, E. B., Giles, H., Bartolucci, R. Y., & Henwood, K. (1986).
documents/MedPAC_Payment_Basics_08_LTCH.pdf. Psycholinguistic and social psychological components of
Moak, G., & Borson, S. (2000). Mental health services in long- communication by and with the elderly. Language and
term care: Still an unmet need. American Journal of Geriatric Communication, 6, 1–24.
Psychiatry, 8, 96–100. Ryan, E. B., Hummert, M. L., & Boich, L. (1995).
Mandal, B., & Roe, B. (2008). Job loss, retirement and the Communication predicaments of aging: Patronizing behav-
mental health of older Americans. Journal of Mental Health ior toward older adults. Journal of Language Social Psychology,
Policy and Economics, 11, 167–176. 14, 144–166.
Morales, P. (1999). The impact of cultural differences in psycho- Scherman, A., & Doan, R. E., Jr. (1985). Subjects, designs, and
therapy with older clients: Sensitive issues and strategies. generalizations in Volumes 25–29 of the Journal of Counseling
In M. Duffy (Ed.), Handbook of counseling and psychotherapy Psychology. Journal of Counseling Psychology, 32, 272–276.
with older adults. New York: Wiley. Schmidt, L. J., Rheinhardt, A. M., Kane, R. L., et al. (1977).
Munley, P. H. (1974). A content analysis of the Journal of The mentally ill in nursing homes: New backwards in the
Counseling Psychology. Journal of Counseling Psychology, 21, community. Archives of General Psychiatry, 34, 687–691.
305–310. Scogin, F. (2007). Introduction to the special section on
National Gay and Lesbian Task Force. (2009). Aging. Retrieved evidenced-based psychological treatments for older adults.
from http://www.thetaskforce.org/issues/aging. Psychology and Aging, 22, 1–3.

498 working with o l d er ad u lts

Scogin, F., & McElreath, L. (1994). Efficacy of psychosocial US Department of Health and Human Services. (1999). Mental
treatments for geriatric depression: A quantitative review. health: A report of the surgeon general. Retried from http://
Journal of Consulting and Clinical Psychology, 62, 1, 69–74. www.surgeongeneral.gov/library/mentalhealth/home.html.
Seligman, M. E. P., & Csikszentmihalyi, M. (2000). Positive Vacha-Haase, T. (2004). Counseling psychology and geropsy-
psychology: An introduction. American Psychologist, 55, 5–14. chology training. Unpublished manuscript.
Shanas, E. (1979). The family as a social support system in Vacha-Haase, T., Wester, S. R., & Christianson, H. (in press).
old age. The Gerontologist, 19: 169–174. Psychotherapy with Older Men. New York: Routledge.
Smith, J., & Baltes, M. M. (1998). The role of gender in very Walsh, W. B., & Chartrand, J. M. (1994). Emerging direc-
old age: Profiles of functioning and everyday life patterns. tions of person-environment fit. In M. L. Savickas &
Psychology and Aging, 13, 676–695. R. W. Lent(Eds.), Convergence in career development
Smith, A. B., Dannison, L., & Vacha-Haase, T. (1998). When theories (pp. 187–195). Palo Alto, CA: CPP Books.
“Grandma” is “Mom”: What today’s teachers need to know. Werth, J. L., Kopera-Frye, K., Blevins, D., & Bossick, B. (2003).
Childhood Education, 75, 12–16. Older adult representation in the Counseling Psychology
Snyder, L. A., Chen, P. Y., & Vacha-Haase, T. (2007). literature. The Counseling Psychologist, 31, 789–814.
Underreporting aggressive incidents from geriatric patients by Weyerer, S., Eifflaender-Gorfer, S., Kšhler, L., Jessen, F., Maier,
certified nursing assistants. Violence and Victims, 22, 367–379. W., Fuchs, A. (2008). Prevalence and risk factors for depres-
Song, J., Chang, H. J., Tirodkar, M., Chang, R. W., sion in non-demented primary care attenders aged 75 years
Manheim, L. M., & Dunlop, D. D. (2007). Racial/ethnic and older. Journal of Affective Disorders, 111(2-3), 153–163.
differences in activities of daily living disability in older Whitbourne, S. R. (2005). Adult development and aging.
adults with arthritis. Arthritis Care and Research (doi: New York: John Wiley & Sons.
10.1002/art.22906). Widiger, T. A., & Seidlitz, L. (2002). Personality, psychopathology,
Special Committee on Aging. (1987). Medicare prescription drug and aging. Journal of Research in Personality, 36, 335–362.
issues. Report to the Chairman, Special Committee on Aging. Xakellis, G. C. (2004). Who provides care to medicare beneficia-
Washington, DC: General Accounting Office. ries and what settings do they use? The Journal of the American
Sperry, L. (1995). Psychopharmacology and psychotherapy. Board of Family Practice, 17, 384–387.
New York: Psychology Press. Yang, J. A., & Jackson, C. L. (1998). Overcoming obstacles
Stanley, M. A., Beck, J. G., & Glassco, J. D. (1996). Treatment in providing mental health treatment to older adults.
of generalized anxiety in older adults: A preliminary com- Psychotherapy, 35, 498–505.
parison of cognitive-behavioral and supportive approaches. Zarit, S. H., Johansson, L., & Jarrott, S. E. (1998). Family care-
Behavior Therapy, 27, 565–581. giving: Stresses, social programs, and clinical interventions.
Substance Abuse and Mental Health Services Administration. In I. H. Nordhus, G. R. VandenBos, S. Berg, & P. Fromholt
(2005). National survey on drug use and health. Rockville, (Eds.), Clinical geropsychology (pp. 345–360). Washington,
MD: U.S. Department of Health and Human Services. DC: American Psychological Association.
Super, D. E. (1957). The psychology of careers. New York: Harper, Zeiss. A. M., & Zeiss, R. A. (1999). Sexual dysfunction: Using
New York. an interdisciplinary team to combine cognitive-behavioral
Super, D. E. (1963). Self-concepts in vocational development. and medical approaches. In M. Duffy (Ed.), Handbook of
In D. E. Super, R. Starishevsky, N. Matlin, & J. P. Jordaan counseling and psychotherapy with older adults (pp. 294–313).
(Eds.), Career development: Self-concept theory (pp. 1–16). New York: Wiley.
College Entrance Examination Board. New York. Zweig, R. A. (2008). Personality disorder in older adults:
Super, D. E. (1980). A life-span, life-space approach to career Assessment challenges and strategies. Professional Psychology:
development, Journal of Vocational Behavior, 16, 282–298. Research and Practice, 39, 298–305.
Super, D. E. (1994). A life span, life space perspective on conver-
gence. In M. L. Savickas & R. W. Lent (Eds.), Convergence in Further Reading
career development theories: Implications for science and prac-
Duffy, M. (Ed.). (1999). Handbook of counseling and psychother-
tice. (pp. 63–74). Palo Alto: Consulting Psychologists Press.
apy with older adults. New York: Wiley.
Tariot, P. N., Podgorski, C. A., Blazina, L., & Leibovici, A.
Hill, R. D. (2005). Positive aging: A guide for mental health
(1993). Mental disorders in the nursing home: Another per-
professionals and consumers. New York: W. W. Norton.
spective. American Journal of Psychiatry, 150, 1063–1069.
Molinari, V. (Ed.). (2000). Professional psychology in long term
Thorson, J. A. (1995). Aging in a changing society. Belmont, CA:
care. New York: Hatherleigh.
Wadsworth.
Norris, M. P., Molinari, V., & Ogland-Hand (Eds.). (2002).
Toporek, R., Gerstein, L., Fouad, N., Roysircar, G., & Israel, T.
Emerging trends in psychological practice in long term care.
(Eds.). (2006). Handbook of social justice in counseling psy-
chology. New York: Sage. New York: The Haworth Press, Inc.
United States Census. (2003). Statistical abstract of the United Vacha-Haase, T., Wester, S. R., & Christianson, H. (2010).
States. Washington, DC: US Bureau of the Census. Psychotherapy with older men. New York: Routledge.
United States Census Bureau. (2001). The 65 years and over
population: 2000. Retrieved from http://www.census.gov/
prod/2001pubs/c2kbr01–10.pdf.

vacha-haase , duffy 499

This page intentionally left blank
 PART
4
Applications
This page intentionally left blank
 CHAPTER

19 Individual Counseling As an Intervention

Mary Ann Hoffman

Abstract
Individual counseling is the primary intervention of the practice component of the scientist–practitioner
model and a frequent focus of research related to the scientific component. A timeline of historical
events shaping individual counseling is presented, followed by an examination of commonalities across
schools of therapy that define this intervention. These include why clients seek counseling; the
therapeutic relationship; client expectancies; micro-skills; facilitating emotions, insight, and change in
counseling; phases of counseling; and extra-therapeutic factors. The role of theory, with its focus on
specific or unique effects, is examined and contrasted to the common factors approach. Conclusions
and recommendations for future research are presented, including those areas in which there is some
degree of consensus (e.g., need for research on the role of the relationship and insight) and areas in
which there is divergence (e.g., specific or unique factors vs. common factors; transferability of
evidence-based treatments to clinical settings; single theory vs. integrationist approaches).
Keywords: counseling, psychotherapy, therapeutic relationship, client expectancies, micro-skills,
emotion-focused therapy, insight, therapeutic efficacy, common factors, specific factors, termination

Individual counseling is arguably the cornerstone of More is known about these components of individ-
counseling psychology. Not only does it represent ual counseling than about how they interact to form
the primary intervention of the practitioner compo- the sum of this intervention. To wit, the most highly
nent of counseling psychology, but key aspects, such cited literature reviews in the past 20 years have
as process and outcome, comprise a large portion of focused on components such as counseling process
the scholarly work representing the scientific aspect and outcome (e.g., Hill & Williams, 2008), the rela-
of the scientist–practitioner model. Graduate train- tionship or therapeutic alliance (e.g., Gelso & Carter,
ing devotes considerable time to mastering this 1985), the process of therapy (e.g., Hill & Williams,
intervention, and approximately half of members of 2000; Orlinsky & Howard, 1986), and treatment
the Society of Counseling Psychology report that effects/outcome (e.g., Grissom, 1996; Wampold
they work in practice settings in which many likely et al., 1997).
utilize individual counseling as an intervention Paradoxically, at the same time that research
(American Psychological Association [APA], 2004). has focused on the common components of individ-
Yet, surprisingly, a review of the literature yields ual counseling that are present across orientations
relatively few studies when the terms individual (e.g., the therapeutic relationship), the number of
counseling or psychotherapy are entered into search purportedly distinct theories or systems of psycho-
engines, in contrast to those that appear for the therapy have proliferated. Beginning with psycho-
many components of individual counseling, such as analytic approaches in the early 1900s, relatively
process, outcome, and the therapeutic relationship. few systems of psychotherapy existed in the first

503
part of the century. But, by the late 1950s, Harper (led by development of clinical psychology
(1959) had identified 36 systems of psychotherapy, and Veterans Administration role in training).
most of which were individual approaches. Today, it • 1951: Carl Rogers publishes Client-centered
is estimated that over 400 therapies exist, with all Therapy (Rogers, 1951), leading to emergence of
claiming unique characteristics and successful out- humanist approaches including those of Abraham
comes (Prochaska & Norcross, 2007). The stagger- Maslow and Fritz Perls. Northwestern Conference
ing proliferation of systems of therapy might suggest on the Training of Counseling Psychologists
that theoretical constructs and strategies unique to (Division 17, Counseling and Guidance); terms
each system play the most important role in poten- “‘counseling psychology’” and “‘counseling
tiating the effectiveness of individual counseling. psychologist’” introduced; defined focus as on
Yet, research to date has provided more support for adaptive versus maladaptive behavior across
common factors in contrast to the specific or unique lifespan and on prevention (Super, 1955).
factors of these various therapies. One of the biggest • 1952: Hans Eysenck’s review of research
debates today is not whether individual psychother- concludes that therapy is no more effective
apy is effective but why and how. than spontaneous remission. Division 17’s name
is changed to the Division of Counseling
Psychology (see Munley, Duncan, McDonnell,
Historical and Contemporary Factors
& Sauer, 2004).
Influencing Individual Counseling, with
• 1953: B.F. Skinner outlined his theory
an Emphasis on Counseling Psychology
of behavioral therapy (although behavioral
A complete history of individual counseling as an
approaches began in the 1920s).
intervention is beyond the scope of this paper.
• 1954: Journal of Counseling Psychology (JCP)
In fact, some years ago, Jerome Frank (1982) noted
begun Milton E. Hahn, Harold G. Seashore,
that it would take over 250 pages to provide a his-
Donald E. Super, and C. Gilbert Wrenn
torical review of the development of individ-
(see Wrenn, 1966).
ual counseling, beginning with Freud, moving to
• 1957: Albert Ellis and rational emotive
the evolution of behavioral and humanistic app-
behavior therapy are at forefront of cognitive
roaches, and then moving to cognitive and affective
therapies that emerged through next two
approaches. With the more recent advent of feminist
decades (e.g., Aaron Beck).
and multicultural theories that focus on sociopolitical
• 1960s–1970s: Beginnings of contemporary
forces, constructivist theories, and integrationist
psychodynamic approaches based on attachment
approaches, a historical review is an even more daunt-
theory (John Bowlby) and self-psychology theory
ing undertaking. The zeitgeist of the time is one
(Hans Kohut).
thread that has defined this evolution in schools of
• 1964: Greyston Conference (Division
therapy. The timeline below presents significant
of Counseling Psychology) solidified identity
events and trends that have shaped individual coun-
and training of counseling psychologists
seling including events, with special relevance to the
(Thompson & Super, 1964).
development of counseling psychology:
• 1969: John Whiteley founded The Counseling
• 1900: Sigmund Freud published Psychologist (TCP).
Interpretation of Dreams, marking the beginning of • 1977: Albert Bandura leads emergence
psychoanalytic thought (Freud, 1953). Individual of social learning theory, with move away
therapy is focused on the intrapsychic world of from behaviorist and psychodynamic
client and viewed as a “one-person” approach perspectives. Meta-analysis supports the
• 1910–1930s: Key followers of Freud left efficacy of psychotherapy (Smith & Glass,
his psychoanalytic group to form variations on 1977; does therapy work?).
this school of therapy (neo-Freudians); • 1982: Carol Gilligan published In a Different
e.g., Alfred Adler, Carl Jung, Karen Horney. Voice (Gilligan, 1982), on feminist psychology, and
• 1942: Humanistic focus begins with leads the way for feminist therapies.
Carl Rogers’ publication of Counseling and • 1986: Albert Bandura continued to expand
Psychotherapy. Individual therapy moves toward his work to social cognitive theory.
constructivism and a “two-person” approach. • 1987: Atlanta Conference (counseling
• 1949: Boulder Conference outlined psychology’s third national conference)
scientist–practitioner model of psychology affirms value of the scientist–practitioner/

504 ind ivid ual co u n s e l in g as an in te rvent ion

scientist–professional model; strengths including opportunity for catharsis, self-awareness and insight,
prevention; lifespan development; importance and the acquisition and practice of new behaviors.
of culture, ethnicity, gender, and diversity Proponents of the common factors model take the
(Kagan et al., 1988, p. 351). view that active ingredients shared by most systems
• 1990s:- Narrative and other constructivist of psychotherapy account for the majority of the
approaches develop (e.g., Michael White). variance in effective outcomes (e.g., Frank & Frank,
Multicultural theories develop (e.g., Stanley 1991; Patterson, 1984; Wampold, 2001).
Sue and Derald Wing Sue). Integrative and On the other side of the debate are proponents
eclectic approaches begin to predominate over of the view that factors that are unique or specific
single-therapy models (e.g., John Norcross, to various theories or schools of therapy contribute
Paul Wachtel, Arnold Lazarus). Evidence- to outcome beyond that accounted for by common
based practice movement emerges (how and factors (e.g., Crits-Christoph, 1997; Garfield, 1991);
why does therapy work?). most of these researchers support the generic model
• 2001: Houston’s Fourth National Counseling that views outcomes as coming from a complex inter-
Psychology Conference (emphasis on social justice) action of common and specific factors (e.g., Beutler
is held. & Harwood, 2002).
• 2003: Division 17 changes name to
Currently, we know considerably less about out-
The Society of Counseling Psychology.
come variance attributable to the specific ingredients
• 2008: Chicago International Counseling
of various treatments and approaches (Wampold,
Conference (globalization of training, practice,
2001; Wampold & Brown, 2005). For example, the
and research) is held.
relative contribution of specific methods effects to
What we do know now is that individual coun- counseling outcomes is difficult to ascertain, as find-
seling is quite effective. Since the publication of ings have been inconsistent across studies. Cognitive
Eysenck’s (1952) review of 24 studies that con- therapy is one of the best established approaches for
cluded that psychotherapy is no more effective than successfully treating depression (Hollon & Beck,
remission following no treatment in samples of 2004). Yet, it is unclear whether changes in cogni-
neurotic clients, a number of meta-analyses and tions mediate changes in depression and anxiety or if
randomly controlled treatment studies across some other mechanism of change is responsible for
decades of research have clearly established the effi- outcomes (e.g., Burns & Spangler, 2001). In sum,
cacy of psychotherapy in the treatment of clients although we know that certain counseling processes
with various diagnoses and presenting concerns contribute to the efficacy of therapy, the mecha-
(Elkin, Shea, Watkins, Imber, Sotsky, S. M, Collins, nisms that explain the how and why of positive out-
J. F., et al., 1989; Lambert & Bergin, 1994; Lipsey comes are not yet well understood (Kazdin, 2006).
& Wilson, 1993; McNeilly & Howard, 1991; Because of the overwhelming number of theo-
Orlinsky, Rønnestad, & Willutzki, 2004; Roth & retical systems of therapy and the current support
Fonagy, 2005; Smith & Glass, 1977). for common factors across theories, the overarching
However, successful therapies of various orien- framework for this chapter will be to examine indi-
tations are described similarly by clients, suggest- vidual counseling as an intervention drawing from
ing that some common elements account for positive commonalities that have been found in the litera-
outcomes across therapeutic schools and systems ture. The chapter will begin by defining relevant
(Lambert & Ogles, 2004). Jerome Frank was among terms; then, the reasons why clients seek therapy
the first to identify the importance of common pro- will be examined. Next, sections on therapeutic
cesses across therapies based on his decades of research commonalities, including the therapeutic relation-
(1982). His classic paper continues to be persuasive ship, client expectancies, micro-counseling skills,
in light of more recent research that has consistently the role of catharsis and emotion, insight and self-
found that common factors contribute to positive awareness, and facilitating action and change, will
therapy outcomes. His findings remain timely in be examined. This will be followed by an examina-
light of the current debate between common and tion of the roles of theory and specific factors, the
specific factors and the efficacy of psychotherapy. phases of counseling, and a look at the effect of
These identified common factors typically extra-therapeutic factors. Because many topics in
include the development of a therapeutic alliance, this chapter overlap with other chapters in this
clients’ positive expectancies about therapy, the Handbook, the emphasis will be on individual

hoffm an 505
counseling as an intervention. Finally, conclusions Why Do Clients Seek Counseling?
and future directions will be discussed. Why do people seek counseling? This is an impor-
tant question but a difficult one to answer. For exam-
Definition of Terms ple, clients might present with multiple concerns,
Client will be used instead of patient, consistent such as anxiety, relationship issues, and social anxi-
with the positive, adaptive approach to psychologi- ety, making it difficult to capture specific reasons for
cal issues consistent with counseling psycho- seeking therapy; much of the research on this topic
logy. Counselor or therapist will be used to designate is based on college student populations that may
counseling psychologists as the target population differ from other populations, and many studies do
of mental health professionals providing services. not examine clinical populations but instead exam-
Counseling, psychotherapy, and therapy will be used ine the attitudes toward help-seeking of respondents
interchangeably to refer to individual counseling as who are not seeking psychotherapy, to determine
an intervention. their likelihood of seeking counseling.
Despite being a widely used type of intervention, We do know that interpersonal or relationship
a review of the literature provides surprisingly few issues are the most common reasons for seeking
definitions of individual counseling. The hundreds counseling, followed by mood concerns such as
of theories and systems of psychotherapy that exist depression and anxiety. In addition, several other
today make defining individual therapy challenging. factors have been found that contribute to seeking
The definition of individual counseling used in this counseling in actual clients, including prior success
chapter is modified from Norcross (1990, p. 218). with help-seeking (e.g., Deane & Todd, 1996), level of
Because his definition was not limited to individual psychological distress (e.g., Deane & Chamberlain,
psychotherapy, modifications are in parentheses. 1994), and being female (e.g., Cohen, Guttmann,
Psychotherapy is the informed and intentional & Lazar, 1998). Yet, such studies typically account
application (by a trained counselor or therapist) of for about 25% of the variance associated with help-
clinical methods and interpersonal stances derived seeking (Vogel & Wester, 2003).
from established psychological principles for the Attitudes toward help-seeking provide another
purpose of assisting (the client) to modify behav- way to understand why people may or may not be
iors, cognitions, emotions, and/or other personal open to seeking counseling. In a series of two stud-
characteristics in directions that (the counselor and ies, predictors of seeking psychological services were
client mutually) deem desirable. examined (Vogel, Wester, Wei, & Boysen, 2005).
This definition is pantheoretical, in that psycho- Study 1 examined the role of attitudes in mediating
logical principles can refer to specific theoretical the relationship between psychological factors pre-
strategies and/or to the relationship as the mecha- viously identified in the literature on help-seeking
nism of change. Unlike informal help from friends (e.g., distress, self-concealment, anticipated utility,
and family members, psychotherapy is a planned anticipated risk) and intent to seek help for specific
intervention between a trained counselor using psychological problems (interpersonal, academic,
established approaches to assist the client who is and drugs). Psychological factors and attitudes pre-
seeking help. An important part of this definition is dicted 62% of the variance in intent to seek help for
that the counselor and client collaborate and mutu- interpersonal problems but only 18% of the vari-
ally agree on the focus and the goals of the therapy. ance for drug problems. Attitudes toward counsel-
Although this is a contemporary definition of ing mediated relationships between most of the
counseling and psychotherapy, this definition is in psychological factors and intentions to seek help.
line as well with the original doctoral training Study 2 extended this research by examining the
report, which identified the roles and functions of relationship of having experienced a psychological
counseling psychologists as being to facilitate opti- stressor (e.g., abuse or severe loss) to attitudes toward
mal development of the individual across levels help-seeking. Results showed that significantly
of psychological adjustment but with an emphasis more of those who had experienced a psychological
on those individuals in the normal range of adjust- stressor sought counseling during the time period
ment and on the positive and preventative (APA, of data collection (about 20%) versus only about
1952a; Munley, Duncan, McDonnel, & Sauer, 8% who did not report having experienced a sig-
2004). Although individual counseling need not nificant stressor. This finding lends support to previ-
occur face-to-fact, the focus of this chapter will be ous findings that psychological distress is a common
on this type of individual psychotherapy. reason for seeking counseling, although these results

506 ind ivid ual co u n s e l in g as an in te rvent ion

and those of other studies have shown that distress a university counseling center, immediately after
does not consistently predict help-seeking. It is each intake interview, both clients and therapists
interesting that Study 2 also found that those who were asked to respond to 14 “wants” or things that
had experienced psychological distress were more they hoped would happen as a result of counseling
likely to seek psychological services but also were or believed that their client wanted to happen
more likely to anticipate the risks of disclosing emo- (Sacuzzo, 1975). Three items or wants were endorsed
tions. This finding is consistent with other studies by nearly all of the clients: “Get help in talking
(e.g., Kushner & Sher, 1989) that have found that about what is really troubling me,” “Understand
psychological distress was positively related to both the reasons behind my feelings and behavior,” and
the likelihood of seeking counseling and to greater “Have someone respond to me on a person-to-
fears and anxiety about seeking treatment. person basis.” Both clients and therapists were in
Researchers have also studied factors that con- high agreement about the underlying dimensions
tribute to the avoidance of therapy or that decrease of client wants, and three major themes emerged
the likelihood that an individual will seek counsel- for both samples: self-exploration, catharsis, and
ing or will lead to premature termination. Identified encouragement. These client wants are similar to
avoidance factors include a fear of treatment (Deane commonalities of individual therapy across theo-
& Chamberlain, 1994; Deane & Todd, 1996), retical orientations and systems identified by meta-
a wish to conceal distressing or shameful personal analytic studies.
information (Cepeda-Benito & Short, 1998; Kelly
& Achter, 1995), and a desire to avoid experiencing Developing a Facilitative Therapeutic
an increase in painful feelings (Komiya, Good, & Relationship
Sherrod, 2000). One of the primary reasons clients seek therapy is
Using structural equation modeling, Vogel, to “have someone respond to me on a person-to-
Wade, and Hackler (2008) found that the antic- person basis” (Sacuzzo, 1975). Decades of research
ipated risks and benefits of therapy fully medi- demonstrate that individual therapy is, at its core,
ated the relationship between feelings about an interpersonal process in which a main curative
emotional expression and attitudes toward help- component or element is the therapeutic relation-
seeking and willingness to seek help. This study sug- ship created by the counselor and the client. Both
gests that potential clients may first consider the the counselor and the client bring important aspects
risks and benefits of seeking therapy, which may of themselves to the relationship and together
in turn affect their feelings about emotional expres- co-create the therapeutic alliance. The view of the
sion (e.g., comfort/discomfort) and willingness to therapeutic relationship has moved from Freud’s
seek help. and other early psychoanalysts view of it as a “one-
Drawing from this literature, clients typically person” approach, with the therapist being an
seek counseling because of psychological distress observer of what unfolds from deep within the
due to the persistence of concerns exacerbated by client, to the more contemporary view of the rela-
ineffective or maladaptive emotions, thoughts, or tionship as a “two-person” dyadic, co-constructed
behaviors and the wish to find new, more effective alliance (Wachtel, 2008). The two-person view
ways to respond to difficult experiences. But impor- acknowledges that the counselor will have an impact
tant caveats must be added: The client must believe on the client and, in turn, the client will have an
or expect that counseling will be helpful, must impact on the counselor.
believe that the benefits outweigh the risks, must Based on a multidisciplinary review of the rela-
have the skills to manage disclosure, must be able tionship in therapy initiated by Division 29 of the
to experience painful emotions (cathart) in reaction American Psychological Association, 11 elements
to the clinical material; and must be motivated and eight processes that occur within the frame-
to translate what is learned in therapy into making work of the therapeutic relationship were identi-
changes outside of therapy. In other words, clients fied (see Norcross, 2002). These elements included
most often seek therapy when their beliefs in the the alliance, empathy, goal consensus and collabora-
benefits are sufficient to overcome the barriers (Hill, tion, cohesion, positive regard, congruence, feed-
2004). back, repair of alliance ruptures, self-disclosure,
This leads to another important question about management of countertransference, and relational
what clients want to occur as a result of seeking interpretation. Despite overlap on some of these ele-
therapy. In a study of clients seeking therapy at ments, agreement on conceptual aggregation has

hoffm an 507
not occurred, nor has a conceptual model evolved the therapeutic relationship—the working alliance.
that could unify these elements into an overarching Because another chapter in this Handbook is devoted
framework. to the therapeutic relationship, this chapter will
Several researchers have attempted to create limit its focus to the therapeutic alliance and its role
such cohesive models, but consensus on these frame- in individual counseling.
works has not occurred. For example, Gelso and col- The therapeutic or working alliance is often
leagues describe a tripartite model of the therapeutic viewed as being comprised of three components:
relationship that posits that every psychotherapy goals, tasks, and bonds (Bordin, 1979; Horvath &
relationship consists to some degree of a working Greenberg, 1986; Horvath & Symonds, 1991).
alliance, a transference–countertransference config- Although there is some question about the distinc-
uration, and a real relationship (Gelso & Carter, tiveness of these three components, there is much
1985; Gelso & Samstag, 2008). Although the tri- support for the relationship of the working alliance
partite model has a number of advocates, some to positive counseling outcomes. Randomized clini-
believe that transference and countertransference cal trials repeatedly find that a positive alliance is
cannot be kept distinct from alliance (e.g., Meisnner, one of the best predictors of outcome. For example,
1992); the distinctiveness between the three parts Krupnick, Sotsky, Simmons, Moyer, et al. (1996)
has not been established, and some believe that found that the therapeutic alliance was predictive
the transference–countertransference configuration, of treatment success across all treatments for depres-
with its attention to the unconscious, is not neces- sion, based on data from the large-scale National
sary to understanding the client–therapist relation- Institute of Mental Health Treatment of Depression
ship. For these and other reasons, the vast majority Collaborative Research Program. Nearly 300 empir-
of research published on the therapeutic relation- ical process and outcome studies published over a
ship has not yet adopted a consistent overarching recent 10-year period have demonstrated that the
model. relationship, most commonly conceptualized as the
Yet, as Gelso and Carter (1985) note in their working alliance, has shown the most consistent
seminal review of the literature in this area, the ther- and robust association between counseling process
apeutic relationship is widely viewed as playing and outcome (Orlinsky et al., 2004).
a key role in nearly all therapies, regardless of theo- A number of meta-analytic studies have dem-
retical orientation. Some therapies view the rela- onstrated this relationship as well. A meta-analytic
tionship as the sine qua non of effective therapy, in study of 20 datasets examining the relationship
that it is the mechanism that contributes most between the working alliance and therapeutic out-
directly to change, whereas others believe it plays comes found a moderate relationship between good
a key role in facilitating the application of strategies working alliance (especially from the client’s per-
and techniques that lead to change. For example, in spective) and positive outcomes (Horvath &
studies of the effects of cognitive therapy on depres- Symonds, 1991). More recently, Martin, Garske,
sion, although compliance with the requirements and Davis (2000) analyzed data from 79 studies
of the cognitive elements of the treatment predicted and concluded that the results “indicated that the
success, so did the quality of the therapeutic rela- overall relation of therapeutic alliance with outcome
tionship (Burns & Nolen-Hoeksema, 1991, 1992). is moderate, but consistent . . . [and that] . . . the
As defined by Gelso and Carter (1985, p. 159), the relation of alliance and outcome does not appear
relationship is “the feelings and attitudes that coun- to be influenced by other moderator variables. . . .”
seling participants have toward one another, and the (p. 438). Overall, meta-analyses have found small
manner in which these are expressed.” to medium effect sizes for the effect of the therapeu-
There is widespread agreement and evidence tic alliance on outcome (e.g., Horvath & Symonds,
that the counselor–client relationship is related to 1991; Norcross & Wampold, 2011).
positive outcomes in most, if not all, types of ther- Another consistent finding in the research in this
apy. In their review of the literature on psycho- area is the positive association between scores on
therapy process and outcome, Orlinsky, Grawe, measures of early treatment alliance and outcome
and Parks (1994) cite five process variables that have (Horvath & Symonds, 1991), despite the variety
consistently shown robust relationships with out- of alliance conceptualizations and instruments used
come. One of these is the overall quality of the to measure it (Horvath & Greenberg, 1994). For
therapeutic relationship. Yet, the vast majority of example, Bordin’s (1994) pantheoretical view of the
studies have actually examined only one aspect of therapeutic alliance emphasizes agreement between

508 ind ivid ual co u n s e l in g as an in te rvent ion

the client and counselor on tasks and goals, as well ruptures outside of therapy. These two studies also
as a sense of bonding. In contrast, Luborsky (1994) show the complexities inherent in studying the ther-
conceptualized the alliance from a psychodynamic apeutic alliance, as the manner in which it evolves
perspective having two parts: the client experienc- and develops likely differs among counselor–client
ing the therapist as helpful, and the client sensing dyads, thus making it difficult to capture using typi-
that therapy is a collaborative effort. Despite these cal research methodologies.
differences in conceptualization of the alliance, Although the importance of the therapeutic alli-
research on both Luborsky’s and Bordin’s views has ance to outcome has been well established, many
consistently found that alliance predicts outcome. things about this complex process are still unknown.
What is less clear is the relationship of the therapeu- In a paper examining the therapeutic alliance
tic alliance to outcome in later sessions. in a historical context, Horvath (2006) notes several
This issue is sometimes framed in the debate challenges that have persisted over the years and
about whether alliance is best viewed as the con- have received limited research in this area: the
sequence of effects that have already occurred absence of a clear definition of the alliance, the lack
(e.g., Crits-Christoph et al., 2006) or as having a of a broad consensus about the alliance’s relation
direct effect on outcome. However, research has to other aspects of the therapeutic relationship, and
shown that, when improvement up to the point the need to more clearly specify the role and func-
of alliance measurement is controlled, alliance pre- tion of the alliance throughout the phases of treat-
dicts outcome, thus suggesting that alliance has ment. Regarding the definitional issue, what is the
a direct effect on outcome (Barber, Connolly, Crits- nature of the therapeutic alliance? Is it intrapersonal
Christoph, Gladis, & Siqueland, 2000). “These (as would be suggested by psychodynamic scholars
findings suggest that alliance might have a direct who posit that transference–countertransference
effect on outcome as opposed to simply being a con- plays an essential role), or is it better described as
sequence of improvements that have already an interpersonal process, with an emphasis on col-
occurred because of a positive attitude toward treat- laboration (in line with more recent views of trans-
ment and the therapist” (Crits-Christoph et al., ference, such as those proposed by self-psychology
2006, p. 269). and interpersonal therapists). Evidence appears to
What is important about this research is that it support both these perspectives, which suggests that
supports the importance of the therapeutic alliance the therapeutic alliance can be described as both an
as a change factor in counseling. It is clear from intrapersonal and an interpersonal process.
other studies cited in this chapter that early alliance Moving to Horvath’s second issue, whether the
is predictive of outcome. Less is known about the role of the alliance in the therapeutic process is as
pattern of the alliance over time in the relationship. an active versus facilitative ingredient of change,
Research examining the stability of the alliance remains unclear. There is consistent support that
across therapy suggests that greater benefit may the alliance early in therapy predicts therapeutic
occur when the alliance is nonstable and nonlinear. outcomes, and it appears that the relationship con-
For example, Kivlighan and Shaughnessy (2000) tinues to play a role in outcome throughout therapy;
found that curvilinear U-shaped alliances were asso- however, the manner in which this occurs as therapy
ciated with better outcome than were linear. In a progresses is less clear (Horvath, 2006). Disruptions
replication and extension of this study, Stiles et al. and ruptures invariably occur in therapy, and the
(2004) found support for the U-shaped pattern in manner in which these are addressed likely affects
a subset of the clients, but found no main effect both the relationship and outcome. Finally, some
differences for alliance patterns. Some have specu- characteristics of the client and the counselor that
lated that the experience of alliance rupture followed contribute to the therapeutic relationship have
by alliance repair provides opportunities for clients been identified, but research on other factors has
to learn about how to manage painful interpersonal been mixed. As important as it seems to identify
situations in a more productive manner (e.g., Safran client and therapist variables that contribute to the
& Muran, 1996, 2000). These two studies on the therapeutic relationship and to the overall efficacy
patterning of the alliance suggest that the alliance of counseling across therapies, relatively few have been
may not follow a linear pattern of development identified. For example, Grencavage and Norcross’
and may serve as a means for managing therapeutic (1990) common factors study found that only 6%
ruptures and repairs, which are viewed as an impor- of the commonalities identified by researchers were
tant process in helping clients manage relationship client factors, and 21% were therapist factors.

hoffm an 509
The most consistent findings for client characteris- the role of the therapist or of the therapeutic rela-
tics that contribute to outcome are motivation for tionship in shaping expectancies. Yet, counselors
change (client actively seeking help), positive expec- play a key role in activating and shaping expecta-
tancies, and level of distress. Those commonalities tions. Positive expectancies are sometimes described
identified for therapists that are linked to positive as being similar to a placebo effect (Lambert &
outcomes are ability to enhance hope and increase Barley, 2001). Yet, the interpersonal nature of coun-
expectancies, empathy, warmth and positive regard, seling goes well beyond administering the classic
acceptance, and what was referred to as general pos- placebo pill to activate positive expectancies.
itive characteristics (e.g., Frank, 1982; Grencavage From the very first sessions, counselors strengthen
& Norcross, 1990). client expectations, activate hope, and shape expec-
tations to the treatment in a variety of ways (Frank
Facilitating Positive Expectancies & Frank, 1991). Presenting one’s credentials,
Client expectancies have been positively linked to describing one’s treatment approach, providing a
both seeking and persisting in counseling. For rationale for the approach, and suggesting that
example, people are more likely to seek counseling one has used it successfully before with clients with
if they are ready to change and believe that the similar issues are just a few of the ways that counsel-
intervention will help them make desired changes. ors communicate expectancies about the outcome
Clients who have had a prior positive counseling of the therapy. In the National Institute of Mental
experience have more positive expectancies about Health Treatment of Depression Collaborative
counseling and are more likely to seek therapy in Research study, expectancies of clients (who com-
the future (e.g., Deane & Todd, 1996). Based on pleted treatment) and therapists were examined
an analysis of over 100 studies of psychother- (Meyer et al., 2002). Clients who expected therapy
apy occurring over decades of research, Lambert to be effective engaged more constructively during
and Barley (2001) estimated that expectancies their sessions and had better therapy outcomes.
accounted for about 15% of the variance in coun- Therapists’ positive expectancies for client improve-
seling outcome. Moreover, client expectancies have ment predicted better outcomes as well.
been found to predict attrition from counseling. An intriguing aspect of expectancies that has
Pretreatment expectancies were examined during been documented in the medical field but ignored
intake in a sample of adults seeking counseling at a in the counseling literature is the nocebo effect on
training clinic utilizing the Psychotherapy Expec- expectancies of benefit from a treatment. Just as the
tancy Inventory–Revised (PEI–R) (Aubuchon- placebo effect refers to benefits produced by aspects
Endsley & Callahan, 2009). Results showed that of a treatment that should have no effect (e.g., the
clients who scored outside the reference range were classic sugar pill), the nocebo effect refers to the
seven times more likely to subsequently terminate opposite effect, in which clients (or counselors) pre-
treatment prematurely than were those who scored sume the worst and expect that a counseling inter-
within the reference range. This finding suggests vention will not be effective. This may occur when
that client expectancies prior to beginning therapy a client does not believe that a therapeutic approach
affect their persistence in counseling. will be effective, or when a therapist believes that
However, findings from research on the relation- a particular client cannot benefit from an approach.
ship between expectations and process variables, Nocebo effects have been described in the medical
specifically the alliance, have been mixed. In part, field when the patient (or physician) believes that
this has been attributed to inadequate measurement something will go wrong (Barsky, Saintfort, Rogers,
of expectations (see Arnkoff, Glass, Shapiro, & & Borus, 2002). For example, patients who believed
Norcross, 2002). One consistent finding is that cli- that they were prone to heart disease were four times
ents’ expectations regarding their commitment to more likely to die from a heart attack, and those
therapy contribute to developing an alliance early in who expected to die during surgery were more likely
treatment. For example, client expectancies that to do so. Barksy et al. (2002) concluded that a low
they will play an active, collaborative role in coun- expectancy for treatment success is the central char-
seling predict the task, bond, and goal dimensions acteristic of medical patients who are most likely to
of the working alliance (Patterson, Uhlin, & experience the nocebo effect. This parallels the find-
Anderson, 2008; Tokar, Hardin, Adams, & Brandel, ings in the psychotherapy literature that low expec-
1996). The vast majority of the research on counsel- tations for counseling success predict premature
ing expectancies focuses on the client and minimizes termination and poorer outcomes.

510 ind ivid ual co u n s e l in g as an in te rvent ion

Micro-skills: Facilitating Process repertoire of counselors and rarely explored in the
and Outcome recent literature.
Just as the therapeutic relationship is a component Helping skills that Hill associates with the
of all therapies, facilitates what happens during insight stage of her model include the advanced
counseling sessions, and contributes to outcome skills of challenge, interpretation, self-disclosure,
as well, so too do micro-skills. Counselors across and immediacy. Research on these skills has been
theoretical orientations use micro-skills to get infor- steady over several decades. Hoffman-Graff (1977)
mation, show support and understanding, clarify and Hoffman and Spencer (1978) found that cli-
emotions and thoughts, promote self-awareness and ents perceived therapist self-disclosure to be most
insight, and reinforce change (Hill & O’Grady, helpful when it normalized the presenting concern
1985). Perhaps the best known and most highly for clients and when it represented nonimmediate
researched model or taxonomy of micro-skills or (past) information about the therapist. Similar find-
helping skills in counseling is that of Clara Hill ings were found in a qualitative study of clients cur-
(e.g., Hill, 2001, 2004). In addition to the taxon- rently in long-term therapy (Knox, Hess, Petersen,
omy of helping skills, Hill has developed a three- & Hill, 1997). Clients reported that helpful
stage model of the helping process that integrates instances of therapist self-disclosure occurred when
these helping skills into each stage. The taxonomy they believed that their therapists’ intentions were
of helping skills is pantheoretical. Across theories to normalize or reassure them and when the disclo-
and systems, research has supported the presence sure was based on personal nonimmediate informa-
of these helping skills, albeit utilized to different tion about the therapists. Positive outcomes reported
extents in various theoretical perspectives, as being by these clients included insight or new perspective,
among the essential tools that therapists use to facil- normalization, and reassurance.
itate the counseling process and to express their Interpretation is another helping skill that
intentions (Hill, 2001). Given the extent of this has been discussed extensively in both the clinical
literature, a brief overview will be presented in this and empirical literature. In examining therapists’
chapter, and the reader is referred to several key interpretations on the outcome of dynamic ther-
writings by Hill and colleagues (Hill, 2001, 2004; apy, Crits-Cristoph, Cooper, and Luborsky (1988)
Hill & Knox, 2008). found the accuracy of these interpretations in terms
Hill’s three-stage model of helping includes of core conflictual themes was of interest. Results
exploration (establishing rapport, encouraging indicated that accuracy regarding core relationship
clients to tell their story, exploring clients’ thoughts themes was significantly related to outcome, even
and feelings, and facilitating arousal of emo- when controlling for the quality of the therapeu-
tions and affect), insight (constructing new aware- tic alliance. Other hypotheses were not supported,
ness and insight—including the client’s role in which leads to an important caveat about the diffi-
feelings, thoughts, and behaviors—and addressing culty of studying helping behaviors. As noted
issues in the therapeutic relationship), and action by Hill (2004, p. 59), “research on helping skills is
(deciding and implementing action based on explo- very difficult because the helping process is complex
ration and insight). The underlying philosophy of and research methods for studying this process are
this model is that certain helping skills are more crude.”
likely to be utilized in each stage, and these repre- Irrespective of theoretical framework, all coun-
sent counselor intentions to achieve the goals of that selors utilize micro-skills to facilitate the therapeutic
stage. For example, in the exploration stage, alliance, engage the client in the process of change,
common micro-skills are attending, open-ended explore client issues, promote awareness and insight,
questions, restatement, reflection, and probes. In a and facilitate change. A critical aspect of utilizing
study of these counselor behaviors on discussion of micro-skills, and one that has been related to both
feelings in undergraduate volunteer clients in a theoretical orientation and outcomes, is the inten-
single helping session, Hill and Gormally (1977) tion of the therapist in utilizing a particular helping
found that probes resulted in more discussion of skill or response mode (see Hill & Williams, 2000).
feelings than did either reflections or restatements, For example, a psychodynamic therapist might use
whereas no effects were found for nonverbal behav- a probe to encourage client insight, whereas a cogni-
iors. Although exploration-stage skills are essential tive therapist might use this same micro-skill to gain
in exploring client issues and establishing rapport, more detailed information to use in targeting mal-
mastery of these basic skills is assumed to be in the adaptive thoughts. Overall, counselors’ intentions

hoffm an 511
and response modes fit their theoretical orientation; this issue further by examining the relationship
helping skills have a small, but significant impact of varying amounts of emotional arousal to thera-
on immediate outcome during sessions; and some peutic outcomes (Carryer, J. & Greenberg, L.S.,
skills, such as interpretation and self-disclosure, 2011). After controlling for therapeutic alliance, the
have been found to be generally related to process authors concluded that too much or too little
and outcome but are used infrequently. heightened arousal was less effective than moderate
levels in predicting therapeutic outcome.
Experiencing and Regulating Affect Recent research on the role of emotion in ther-
in Individual Therapy apy has moved beyond the notion of the therapeutic
Facilitation of emotional arousal is another com- relationship as a holding environment for processing
monality of all or most psychotherapeutic app- distressing feelings to other processes of change that
roaches, and it appears to be a prerequisite to can occur when working with emotions. Research
cognitive and behavioral changes (see Grencavage suggests that not all emotions serve the same func-
& Norcross, 1990). Emotional distress is a conse- tion and that therapists may need to work with dif-
quence or cause of the problems that bring clients ferent emotional processes in different ways. For
to therapy, and amelioration or management of this example, work with a client who under-regulates
distress is one of the most wished-for outcomes. emotions would differ from therapy with a client
According to Leslie Greenberg, the preeminent who typically over-regulates emotions. Based on his
scholar on the role of emotion in psychotherapy, review of the empirical literature on the role of emo-
all therapeutic approaches converge on a “shared tion in therapy, Greenberg and colleagues have
view of emotion as a rapid-action, adaptive, control identified five principles or processes of change:
system that orients people to the relevance that emotion awareness, expression of emotion, emo-
events in their environment have to their well- tional regulation, reflection on emotion, and emo-
being” (Greenberg, 2008, p. 51). His view is that tional transformation or changing emotion by using
emotions are adaptive resources and that overregu- emotion. Each of these processes of change will be
lation is often problematic. Emotional reactions briefly reviewed (Greenberg, 2002; Greenberg &
create tendencies to act and to process in specific Watson, 2005).
ways in response to events. In other words, emo- The most basic goal of emotional change is help-
tions are intimately tied to meaning systems. ing clients gain emotional awareness. One of the
Frequently, emotional reactions to interpersonal basic skills taught to beginning therapists is to help
and environmental events are ineffective and trou- clients identify and label their emotions. Five levels
bling and an important signal that something needs of emotional awareness have been identified by Lane
to be addressed (Foa, Riggs, Massie, & Yarczower, and Schwartz (1992), with the most basic being
1995; Greenberg, 2002; Linehan et al., 2002). awareness of physical sensations followed by action
Catharsis or relief from troubling emotions typi- tendencies (e.g., responding quickly with anger to
cally begins in the first sessions of therapy, when a variety of situations), single emotions, recognizing
clients first tell their story and experience positive blends of emotion (e.g., loss and anxiety), and the
responses from the therapist, such as empathy and capacity to view the emotional experiences of self
normalization. and other in a complex manner.
The belief that exploring painful emotions in Emotional expression has an effect on affect, cog-
the holding environment of the therapeutic rela- nitions, physical well-being, and interpersonal
tionship can lead to positive changes is not a new interactions. Emotional expression in therapy has
idea (e.g., Kohut, 1977; Rogers, 1951). A good been shown to predict unique variance in solving
therapeutic relationship has long been viewed as the interpersonal problems (Greenberg & Malcolm,
vehicle for emotional processing, given the widely 2002).
recognized link between both the alliance and Emotion regulation refers to mechanisms that
empathy and outcome (Greenberg, Elliott, Watson, individuals use to help soothe and regulate dis-
& Bohart, 2001). In fact, the working alliance tress. A positive therapeutic relationship has been
appears to mediate emotional arousal and process- found to provide an empathic, validating, and safe
ing, in that high arousal predicted good session environment for emotional regulation (Bohart &
outcome, but only when there was a strong alli- Greenberg, 1997), especially for clients who have
ance (Beutler, Clarkin, & Bongar, 2000; Iwakabe, difficulty with self-regulation (Linehan et al., 2002).
Rogan, & Stalikas, 2000). A recent study explored Empathy from a therapist is one of the most basic

512 ind ivid ual co u n s e l in g as an in te rvent ion

tools used to help a client learn to self-soothe and Facilitating New Perspectives and Insight
gain emotional equilibrium (Greenberg, Auszra, & Understanding our feelings, thoughts, and behav-
Herrmann, 2007). Beyond empathy, therapeutic iors and the manner in which they connect to expe-
interventions such as meditation and helping riences in our lives provides a sense of meaning
clients gain self-compassion are helpful in reducing and mastery (Frank & Frank, 1991). From the cli-
overwhelming core emotions (Teasdale et al., ent’s perspective, to “understand the reasons behind
2000). my feelings and behavior” was one of the most
Reflection on emotion in therapy is an impor- important expectations hoped for in therapy
tant way for clients to gain information, create (Sacuzzo, 1975). This process has been referred to
new meaning, and develop new narratives to variously as insight (Hill, 2004; Hill, Castonguay,
explain their experiences and to shape future events et al., 2007), consciousness raising (Prochaska &
(Greenberg & Angus, 2004; Pennebaker, 1995). Norcross, 2007), and constructing new awareness
For example, putting traumatic emotional experi- (Hill, 2002), and is a component of most, if not all,
ences into words is one way of assimilating these therapies. When asked “What is insight?” a panel of
experiences into one’s view of oneself and lessening experts (Hill, Castonguay, et al., 2007) defined it
distress (Elliott, Llewelyn, Firth-Cozens, Margison, as “a conscious meaning shift involving new connec-
Shapiro, & Hardy, 1990; Van der Kolk, 1995). tions” (p. 441). More explicitly, insight is conscious;
According to research by Elliott et al. (1990), this involves something new, such as seeing something
process occurs as new schemata developed by the in a new light; involves making connections between
therapist and client are used to gradually assimilate things that had previously seemed to be disparate
painful feelings, leading to increased self-awareness (e.g., a past reaction to an event is connected to a
and less distress. Utilizing a technique based on cli- present reaction); and involves causality (e.g., under-
ents writing about their emotional experiences, standing the reasons for the intensity of a present
Pennebaker and colleagues have shown that this emotional reaction) (Hill & Knox, 2008).
type of writing can have positive effects on psycho- A number of studies have found that insight
logical and physical well-being (e.g., Pennebaker, occurs in therapy through methods ranging from
1995). examining expressions of insight during sessions
A novel and recent view of emotional change to post-session reports of helpful events that could
is the notion of emotion transformation. Greenberg be classified as insight. In-session findings on client
(2002) describes this as the process of changing expressions of judged insight show that it occurs
emotion with emotion. In other words, a maladap- across different types of therapies (but less frequently
tive or negative emotion can be managed by address- than other behaviors, such as exploration), that it
ing it with a more adaptive emotion. In research remains inconclusive as to whether it changes across
based on Frederickson’s broaden-and-build hypothe- sessions in a systematic fashion, and that it seems to
sis, the incompatibility of positive emotions with occur more frequently in insight-oriented therapies
negative emotions has been found to undo deleteri- such as psychodynamic approaches (Hill & Knox,
ous effects (Frederickson, 2001). For example, help- 2008). One limitation of these studies was that
ing clients experience positive emotions from an insight attainment was assessed by judges and based
experience that created negative emotions may pro- on single events that occurred in therapy.
mote better outcomes by helping them bounce In contrast, more compelling evidence for the
back. This does not entail simply telling clients importance of insight has been found in studies
to think positive thoughts, but rather helps them that have examined this construct as a client-rated
to evoke a meaningful alternate experience that helpful event in therapy or as a post-session measure
counteracts their negative feelings. For example, of insight attainment. A number of studies have
a counselor might assist a client who is faced with asked clients to rate the most helpful event in their
a life-threatening disease and is experiencing fear therapy. For example, Elliott and James (1989)
and anger to explore an alternate view of his situa- found that self-understanding/insight was rated
tion (e.g., the opportunity to reprioritize what is most often as the most helpful event in a review
most important in his life; to reconnect with people of 21 studies. In a study assessing results from a set
who have been sources of social support in the past; of eight studies of dream interpretation, Hill and
to use his experience to assist others facing a similar Goates (2004) found that the level of client-reported
experience), which leads to positive emotions that gains in insight was consistently more than a stan-
help counteract the negative emotions. dard deviation higher than insight levels reported

hoffm an 513
by clients in sessions in which they did not work Finally, how does insight affect therapeutic
on dreams. The finding that insight seemed to occur outcomes? Kivlighan, Multon, and Patton (2000)
at a higher rate in dream interpretation sessions is in found a significant negative relationship between
line with the research suggesting that clients partici- target complaints and judge-rated insight. Spe-
pating in psychodynamic sessions are rated as higher cifically, increases in client insight preceded symp-
in insight, in that both of these therapy modalities tom reduction (but symptom reduction did not in
have a strong focus on gaining insight. turn lead to insight). However, findings of other
The most compelling evidence for the role of studies have been mixed. In their review of studies
insight in individual therapy comes from studies examining the relationship between insight and
examining changes in insight as a therapeutic out- therapy outcome, Hill and Knox (2008) found that
come. Hill and Knox (2008) calculated effect sizes six studies found this relationship and four did not.
for changes in insight that occurred over time in They attributed these inconsistent findings to the
therapy in a series of studies ranging in methodolo- great variation in the manner that insight is assessed,
gies and utilizing both client- and judge-rated different measures of outcome, and the different
insight. In two different case studies of therapist types of therapy (e.g., dream work, psychodynamic)
immediacy, clients showed medium to large gains examined. Despite the mixed findings about the
in self-understanding (Kasper, Hill, & Kivlighan, role of awareness and insight in individual counsel-
2008; Hill et al., 2006). Judge-rated increases in ing, two factors are compelling. First, clients expect
insight in a series of dream work studies showed that they will learn new perspectives and insight
medium effects across eight samples of clients in when they seek counseling. And second, although
six different studies (Hill & Knox, 2008). Overall, the results of this body of literature are mixed, they
studies examining insight utilizing a range of meth- are in the direction of positive or nonsignificant
odologies have consistently found gains in insight effects, rather than deleterious effects. This suggests
ranging from small to large effects. Several issues that problems in measurement are impeding exami-
remain unclear from current research: the role that nation of this complex process of change and that
client insight plays across theoretical orientations, the role of insight in therapy is an important change
the best way to measure client insight (e.g., client vs. process for further examination.
judge-rated; in-session vs. post-therapy), and the
pattern of change for insight across therapy. Facilitating Action and Change
What leads to insight in therapy? Several specific The wish to alleviate psychological distress caused
therapist interventions have been linked to client by emotions, thoughts, or behaviors is a common
attainment of insight. Therapist probes for insight reason for seeking counseling (e.g., Vogel et al.,
have been found to lead to client insight across mul- 2005). Although insight alone can result in change,
tiple studies (e.g., Baumann & Hill, 2008; Hill, sometimes insight represents simply the first step
Knox, Hess, Crook-Lyon, et al., 2007). Findings for in the change process. A client may need to take
therapist interpretation have been mixed (see Hill & action to achieve goals or to solidify insight or self-
Knox, 2008). Several other counselor interventions awareness (Hill, 2004). According to Hill’s (2004)
have been linked to client insight in multiple studies, three-stage model of helping, during the action
including confrontation, paraphrasing, and open stage of counseling, therapists move to a more col-
questions (Hill & Knox, 2008). Based on their laborative role with clients as they explore options
research and clinical experience, a panel of experts and ways for change to occur. Commonly used
were asked to reflect on what leads to insight in ther- counseling skills include giving information, feed-
apy (Hill, Castanguay et al., 2007). Panelists agreed back, process advisement, direct guidance, and dis-
that clients are more likely to gain insight if they are closures about strategies.
psychologically minded, demonstrate a higher level of Seeking counseling may represent one of the
cognitive ability, lack defensiveness, exhibit low levels early stages in client change, according to Prochaska
of psychopathology, and show a readiness or motiva- and DiClemente’s (2005) transtheoretical model of
tion to achieve insight. Belief in the importance of readiness to change. The contemplation of making
insight was identified as an important therapist factor changes precedes actually making preparations for
that facilitates insight. Environmental factors were taking action and then initiating the action. Once
noted as well, including social support and having clients identify changes they would like to make,
others in one’s life to provide reliable feedback about they often practice new behaviors, thoughts, and
the client’s behavior or effect on others. reactions, both during the counseling session and

514 ind ivid ual co u n s e l in g as an in te rvent ion

outside the session. Getting feedback and support In fact, consumer satisfaction and perceived bene-
from the therapist is an important part of enhanc- fit should be viewed as important indices of coun-
ing the client’s sense of mastery and self-efficacy seling efficacy. In summary, in terms of a global view
(Frank, 1982). Moreover, maintaining changes by of the efficacy of therapy, numerous studies have
managing demoralization due to lack of success or found that those who receive therapy do better than
preventing and managing relapse is another func- those who do not on outcome measures, they per-
tion that occurs in therapy. ceive that they benefit, and they are satisfied with
How do people who receive counseling change therapy.
compared with those who do not receive counsel-
ing? What types of changes occur as a result of coun- Types of Changes That Occur in Counseling
seling? And, what are the processes or mechanisms The second question to be examined is “What types
of change? The first question will be addressed by of changes occur as a result of counseling?” Clients
a brief overview of literature on the overall efficacy typically seek counseling because of ongoing psy-
of counseling; in other words, do those who receive chological distress due to persistent concerns exacer-
counseling do better than those who do not? bated by ineffective or maladaptive emotions,
thoughts, or behaviors, and because they wish to be
Overall Efficacy of Counseling happier and to manage their lives more effectively.
In 1977, Smith and Glass were the first to use meta- Therefore, the issue of what types of changes occur
analysis to analyze the results of multiple studies is important. This brief overview will discuss some
on counseling process and outcome. They found a of the more robust findings on types of changes that
medium to large effect size, meaning that about occur.
75% of those receiving counseling did better than
those who had not received counseling. This result changes that ameliorate distressing
has been supported by numerous meta-analyses and painful emotions
since the Smith and Glass study, and results have Depression and anxiety are the most common
typically concluded that the effect size for the effi- distressing emotions that clients wish to change
cacy of psychotherapy is large and that common in counseling. The identification of efficacious treat-
factors account for more of the variance in outcomes ments for anxiety disorders has been more suc-
than do specific techniques or theoretical approaches cessful than for any other major diagnostic class
(e.g., Lambert & Bergin, 1994; Lipsey & Wilson, (e.g. Roth & Fonagy, 2005). In their review of
1993; Wampold, 2001). Depending on criteria for psychological treatments for this class of concerns,
inclusion, meta-analyses of the effectiveness of ther- Barlow and Lehman (1996) stated, “Evidence now
apy may include designs ranging from analogue exists on the effectiveness (i.e., efficacy) of psycho-
studies to clients in clinical settings, and may include social treatment approaches for every anxiety disor-
outcomes including personality traits, interpersonal der when compared with no treatment or credible
behaviors, and affective ratings. psychosocial placebos” (p. 727). Thus, clients seek-
A study conducted by Consumer Reports maga- ing counseling for specific anxiety disorders such
zine (CR; 1995; Seligman, 1995) asked readers who as social anxiety, generalized anxiety disorder
had received psychotherapy to answer several ques- (GAD), and posttraumatic stress disorder (PTSD)
tions about their experience. Results found that can expect some degree of relief from interventions
most (2,900 responded) reported that they received that have been found to be efficacious.
benefits from therapy and were satisfied with their Social anxiety is one of the most prevalent
treatment. Differences in effectiveness were not diagnosable disorders and is common in settings
found between type of therapy, more improvement in which counseling psychologists work, such as
was reported for long- versus short-term therapy, university counseling centers. Although both expo-
and respondents reported that psychotherapy alone sure and cognitive restructuring have both been
was just as effective as medication plus psychother- shown to be efficacious, there is a developing con-
apy. Despite limitations in the design of the survey sensus that a combination of the two is most benefi-
(e.g., no control group, no consideration of sponta- cial (see Barlow & Lehman, 1996). Anxiety and
neous remission, assessing outcome from only the GAD are prevalent client concerns as well, and are
client’s perspective), the findings are important often difficult to ameliorate. Applied relaxation
because they reflect the public’s view of the benefits (Borkovec & Costello, 1993) has been shown to be
and effectiveness of therapy (Seligman, 1995, 1996). effective with GAD, and recent research on other

hoffm an 515
applied relaxation techniques, such as meditation examined in psychotherapy clients to track improve-
and mindfulness, will likely prove efficacious as ment in subjective well-being and to see its relation-
well. Another approach that shows promise in treat- ship to symptom improvement. Howard et al.
ing anxiety and other mood disorders is well-being (1993) found that improvement in subjective well-
therapy (WBT), which is based on Ryff’s (1989) six being precedes and is likely a necessary condition
dimensions of psychological well-being: autonomy, for reduction in symptomatic distress. In turn,
personal growth, environmental mastery, purpose symptomatic improvement precedes and is likely
in life, positive relations, and self-acceptance. For a necessary condition for improvement in life
clients with anxiety disorders, studies have docu- functioning.
mented the efficacy of this psychotherapeutic Examining clients’ reports of positive changes
intervention in improving on all six dimensions (see in quality of life over the course of a variety of
Fava, Rafanelli, Cazzaro, Conti, & Grandi, 1998; types of therapies and client concerns, five studies
Rafanelli et al., 2000). using a common assessment battery were combined
Depression is another mood disorder that is (Crits-Christoph et al., 2008). The purpose of this
common in clients seeking counseling. Cognitive study was to evaluate change in positive quality
therapy, which focuses on altering the maladaptive of life (assessed at intake, termination, and 6 and
thoughts, beliefs, attitudes, and behaviors that cause 12 months post-treatment), to see if these changes
and maintain depression, has been found to be resulted in symptom change. Results showed that
effective in treating depression (e.g., DeRubeis positive quality of life improved moderately over
et al., 1990; Whisman, Miller, Norman, & Keitner, the course of psychotherapy and was maintained
1991). However, the exact mechanisms of change at follow-up. Changes in quality of life were moder-
in cognitive therapy are not known, and whether ately related to changes in symptoms and interper-
it is more effective than other interventions is sonal functioning. However, the amount of change
unknown. In sharp contrast to viewing maladap- in positive quality of life varied considerably by dis-
tive cognitions as the cause of depressive symp- order, in that those with major depressive disorder
toms, psychodynamic-interpersonal therapy (IPT) and generalized panic disorder changed the most
has been shown to be as effective as cognitive and those with panic disorder changed the least.
therapy in treating depression (e.g. Barkham et al., The types of changes that have been described
1996; Elkin et al., 1989). This approach views are simply representative examples and not inclusive
interpersonal problems as the cause of depression, of other types of changes that have often been
and counseling focuses on improving interpersonal found. Other common changes include improved
deficits. A final example of the efficacious treatment interpersonal relationships; benefit-finding follow-
of depressive symptoms in therapy is based on ing traumatic experiences; lifestyle changes, such
a positive psychology intervention that utilizes as changes in self-care; and self-modification of
activities aimed at facilitating positive feelings, problematic behaviors, such as smoking and not
behaviors, and cognitions, with the goals of increas- exercising.
ing well-being and ameliorating depression. A meta-
analysis of 51 studies utilizing this approach Mediators and Mechanisms
with 4,266 individuals (Sin & Lyubomirsky, 2009) of Change in Counseling
found that positive psychology interventions sig- “What are the mechanisms of change in therapy?”
nificantly enhance well-being and decrease depres- asks the question of why change occurs in successful
sive symptoms. therapies—or what mechanisms result in change.
This is important to address, given current economic
Changes That Improve Quality of Life and political forces that press for evidence that cer-
Improved quality of life is an important and mean- tain therapies are efficacious in addressing specific
ingful change in counseling. Studies have con- client concerns (see APA, 1995). Furthermore, from
sistently found that therapy increases scores on the perspective of advancing the field, Kazdin
quality of life indices, such as subjective well-being (2006) states that understanding therapeutic change
and happiness. One of the few studies to examine mechanisms will maximize therapeutic change and
subjective well-being and to show the why of enhance generalization of treatment study results to
change through identifying mediators was a phase clinical practice.
therapy model by Howard, Lueger, Maling, and Kopta, Lueger, Saunders, and Howard (1999)
Martinovich (l993). Three phases of therapy were suggest that this area of research will advance only

516 ind ivid ual co u n s e l in g as an in te rvent ion

if three critical questions are addressed: Which psy- before the client can move on to more global changes,
chotherapies work as specified (e.g., according to such as increases in happiness, improved interper-
theory) under controlled conditions? Which psy- sonal skills, and subjective well-being. These types
chotherapies work as practiced in actual clinical of changes might then generalize outside of therapy
settings? And, which psychotherapies work most in the form of increased social support, better inti-
efficiently? These questions are essential to address mate relationships, and greater life satisfaction.
for the future of individual therapy. Kopta et al. Individual counseling is often conceptualized
(1999) posit that creative, randomly controlled as encompassing three phases: beginning phase,
treatment studies that are able to distinguish working phase, and termination phase. During
unique active ingredients can address the first ques- the beginning phase, clients tell their story, the ther-
tion: Which psychotherapies work as specified apeutic alliance is established, expectancies are
(e.g. Jacobson et al., 1996)? To address the second discussed and facilitated, concerns to explore are
question, they conclude that dose–effect studies identified, and goals are mutually determined. The
can identify the change mechanisms of different working or middle phase of counseling includes
types of therapy that affect outcomes for clients in managing and exploring emotions, gaining new
real clinical settings. Efficiency of therapy can also awareness and insight, learning new perspectives
be examined using dose–effect strategies that show and skills, and persisting in the face of painful emo-
rate of improvement using statistical techniques tions and slow progress or setbacks. The termina-
such as growth curves (rather than the change scores tion phase includes internalizing and transferring
typically used). Recent research on the mediators of what has been learned to other environments out-
change and dose–effects of change utilize these side of counseling, managing extra-therapeutic
design and statistical approaches to identify unique factors that might impede change, and managing
active ingredients (e.g., Baldwin, Berkeljon, Atkins, relapse and setbacks. This section will examine
Olsen, & Nielsen, 2009; Harwood, Beutler, Castillo, factors that relate to premature termination and to
& Karno, 2006; Hofmann, 2000). continuance in counseling, indices of improvement
The most important question emerging from that occur as therapy progresses, dose–effects of
the research on mechanisms of change in therapy treatment duration, and the termination process.
is whether results from evidence-based treatment
findings translate into clinical practice (sometimes Beginning Phase of Counseling
defined as evidence-based practice). As noted by the One of the findings across numerous studies is that
American Psychological Association Presidential Task treatment duration relates positively to outcomes
Force on Evidence-Based Practice (2006), psycho- (Orlinksy et al., 1994), and the likelihood of accom-
therapeutic treatment effects found in highly plishing therapeutic goals is lessened in premature
controlled contexts like randomly controlled treat- termination. Planned termination typically occurs fol-
ment studies may not translate to similar findings in lowing the working phases of counseling. Yet, a meta-
clinical practice settings. Specifically, key conditions analysis of 125 studies found that a mean of 47% of
and characteristics of treatment studies (e.g., therapist clients drop out of therapy prematurely (Wierzbicki
and client characteristics, treatment, and contexts) & Pekarik, 1993). A large portion of these clients ter-
frequently differ from those in clinical practice (see minated against their therapists’ advice after just one
Hoagwood, Hibbs, Brent, & Jensen, 1995; Kazdin, session (Deane, 1991), and most dropped out of
2008). Generalizability of findings from evidence- counseling prior to completing their therapeutic goals
based treatments and other gaps between research (e.g., Garfield, 1986; Pekarik, 1992).
and practice must be bridged, so that both research In their meta-analysis, Wierzbicki and Pekarik
and practice contribute to understanding how and (1993) found significant effect sizes for three client
why clients change in therapy (see Kazdin, 2008). demographic variables (low education, low income,
and ethnic or racial minority status) in predicting
Moving Through the Phases higher dropout rates. Lower dropout rates were
of Individual Counseling found when therapist judgment was used to define
Change is often associated with the end of therapy, dropout rather than number of sessions. Client
but different types of changes occur across all phases (nondemographic), therapist, and problem charac-
of therapy. For example, amelioration of painful teristics were not predictive of dropout.
feelings and thoughts may occur in the early or Utilizing Bandura’s (1986) social cognitive
middle phases of counseling and may be necessary theory to predict client motivation and attrition in

hoffm an 517
counseling, measures of self-efficacy regarding outcome. Examining clients’ responses to counsel-
counseling-related tasks, outcome expectations, ing using both pretreatment and post-treatment
motivation, distress level, state anxiety, and self- measures is another way to examine client charac-
esteem were completed by university counseling teristics, number of sessions, dropout, and change
center clients at intake (Longo, Lent, & Brown, (Snell, Mallinckrodt, Hill, & Lambert, 2001).
1994). Self-efficacy and outcome expectations each A follow-up survey was sent to clients who had
explained unique variation in both motivation and received one or more counseling sessions at a uni-
client return status. Client characteristics, such as versity counseling center 10 months after termina-
state anxiety and self-esteem, were not related to the tion. Likelihood of clinically significant change
outcome variables. depended on the number of sessions received, but
These findings are important because duration the pattern of change was not linear. For example,
of treatment may be predictive of positive therapy some achieved significant change after eight ses-
outcomes (Orlinsky et al., 1994) Moreover, unlike sions, and 50% did after 16 sessions. However cer-
client demographics, variables related to premature tain client personality characteristics were associated
termination, such as self-efficacy and readiness to with needing fewer sessions to achieve reliable
change, are often modifiable. In addition, because change.
the type or intensity of symptomatology does not Symptomatic recovery is another way to deter-
consistently predict continuation or dropout, other mine that a client is ready to move from the work-
factors are important to consider. ing phase of counseling to termination. Using a
dosage model in which the effect of dose was the
Working Phase of Counseling probability of recovery, client-reported psychologi-
In a study examining the relationship of readiness cal symptoms were grouped into three categories
to change to predicting termination and continua- (Kopta et al., 1994). On average, chronic distress
tion status in therapy, nearly 92% of clients were symptoms responded to treatment most quickly,
correctly classified as premature terminators, appro- whereas character-based symptoms had the slowest
priate terminators, or therapy continuers (Brogan, response. Across doses, clients exhibiting acute dis-
Prochaska, & Prochaska, 1999). Specifically, the tress symptoms showed the highest average response.
best predictors of termination status and continua- Similar to other studies reported in this section, the
tion status were high endorsement of contempla- typical outpatient needed about a year of psycho-
tion and low endorsement of precontemplation in therapy (doses) to have a 75% chance of symptom-
terms of readiness to change, and high expectations atic recovery.
of utilitarian gains from therapy.
Dose–effect studies are another way to look Termination Stage of Counseling
at the gains that clients make in counseling dur- Studies of termination following the working phase
ing the working phase. Most of these studies have of counseling have examined affective reactions
examined grouped client data (rather than individ- and behaviors associated with this phase of counsel-
ual growth curves of clients with specific concerns) ing. Private-practice clients’ perspectives on reasons
and have found that duration or amount (dose) of for termination and their relationship to demo-
therapy leads to better outcomes. For example, an graphic and treatment variables and to satisfaction
overview of studies shows that, for most clinical with therapy were examined using quantitative and
issues, 16 sessions of therapy provide at least a 50% qualitative analyses (Roe, Dekel, Harel, & Fennig,
chance for recovery to normal functioning (Barkham 2006). Based on quantitative results, the most fre-
et al., 1996; Kadera, Lambert, & Andrews, 1996; quent reasons for termination were accomplishment
Kopta, Howard, Lowry, & Beutler, 1994), and 26 of goals, circumstantial constraints, and dissatisfac-
to 58 sessions (Kadera et al., 1996; Kopta et al., tion with therapy. Client satisfaction with therapy
1994) improve success to about 75%. It is impor- was positively related to positive reasons for termi-
tant to note that patterns of improvement across ses- nation. Qualitative results showed two additional
sions in these studies (e.g., Kadera et al., 1996) vary reasons for termination, which were viewed as posi-
substantially for specific clients and may not follow tive outcomes: the client’s involvement in new,
a linear trend, which may have implications at the meaningful relationships and the client’s need for
clinical level. increased independence.
Other studies have looked at both the number of Termination represents an ending to what is
sessions and symptomatology at intake to examine often a significant relationship. Using the metaphor

518 ind ivid ual co u n s e l in g as an in te rvent ion

of termination as loss, Marx and Gelso (1987) exam- sets of concerns. Because the common ingredients
ined client-reported affective reactions and behav- perspective has received support over decades of
iors in a sample of former university counseling research (see Ahn & Wampold, 2001; Wampold,
center clients. Most reported being satisfied with 2001), the question becomes: Is it important to
the termination experience, and the set of loss- demonstrate specific ingredients or effects? Because
related variables did not predict satisfaction. How- this issue is discussed extensively in the chapter in
ever, a smaller cluster of these loss-related variables this Handbook on counseling process and outcome,
was predictive of the importance that clients placed here, we briefly overview two key issues.
on discussing their feelings about ending the ther- One part of the answer to this question rests on
apy with counselors. the role that theory plays in the implementation of
Boyer and Hoffman (1993) examined the termi- individual counseling as an intervention. A common
nation process from the therapist’s perspective using reason that clients seek therapy is to gain awareness
the metaphor of termination as loss. Affective reac- of and insight into their concerns. It is difficult to
tions to termination as a function of counselor loss think of this occurring absent the therapist using
history and perceived client sensitivity to loss were theory as a roadmap to form a conceptual schema
examined in a sample of licensed psychologists. for making sense of the causes of a client’s distress,
Counselor loss history (age at time of most sig- to explain or express this rationale to the client, and
nificant loss, past grief reactions, and present grief to provide a method or strategy consistent with the
reactions) was a significant predictor of counselor rationale for relieving it (Frank, 1961; Frank &
anxiety and depression during termination. Per- Frank, 1991). Theoretical choice reflects the thera-
ceived client sensitivity to loss (sensitivity to loss pist’s beliefs about how and why problems occur
and experiencing of other losses at time of termina- and the conditions that allow change to occur, as
tion) was a significant predictor of counselor anxi- well as the therapist’s worldview and values. Clients
ety during termination when the effect of counselor often seek therapies that match their beliefs and
loss history was partialed out. Counselor task satis- worldview as well.
faction during termination was not predicted by Utilizing a theoretical rationale not only helps
counselor loss history or by perceived client sensitiv- the therapist structure what occurs in therapy,
ity to loss. This study is unique in that the results but supports therapist efficacy and influence and
support the view that the termination process is increases client confidence in the therapeutic work.
affected by both counselor and client variables As noted throughout this chapter, learning to iden-
related to loss. tify and name affective, cognitive, and behavioral
reactions allows clients to develop a framework
Utilizing Theory in Individual Counseling: of awareness and understanding that helps them
Specific and Unique Factors transfer what they learn in therapy.
It is difficult to imagine conducting counsel- The second issue to address is whether theories
ing without a theoretical framework to use in con- or schools of therapy must do more than provide
ceptualizing expected processes and outcomes. a roadmap for counseling. Proponents of the spe-
Although great progress has been made in empiri- cific ingredients model posit that it is necessary to
cally demonstrating the efficacy of individual ther- demonstrate that those components that are unique
apy, less is known about why and how it works. This to a system or theoretical approach are responsible
is especially the case when considering the specific for meaningful therapeutic gains. Most who sup-
factors associated with various theories and schools port this view acknowledge the important role that
of therapy (see Kazdin, 2006). Because training common factors (such as the relationship) play in
in counseling and the practice of psychotherapy is client improvement, but view this as occurring in
based in part on adherence to specific theoretical some combination with the unique ingredients of
orientations, debate centers on whether the differ- the therapeutic approach (e.g., Crits-Christoph,
ent theories and systems each contain unique active 1997).
ingredients that contribute to positive outcomes Accepting the common ingredients theory in its
beyond those that have been attributed to common entirety creates several critical dilemmas: It makes it
factors, such as the therapeutic relationship. The more difficult to distinguish how psychotherapy
unique ingredients theory posits that different differs from other helping interventions that include
schools of psychotherapy produce different specific common ingredients such as a helping relationship,
effects for different types of clients with different it calls into question the value of teaching and

hoffm an 519
implementing systems of therapy that require spe- diagnostic criteria for GAD) in anxiety and depres-
cific steps and processes if those cannot be sup- sion that was maintained at a 2-year follow-up, and
ported empirically, and it might discourage the no significant differences in outcome were found
development of new, more effective theoretically between treatments. Borkovec et al. (2002) concluded
based interventions (see Ahn & Wampold, 2001). that the absence of significant differences between
Most important, there is evidence that specific treatments may have been due to strong effects
effects contribute meaningfully to the outcome of produced by each component condition. Finally,
therapy, although less is known about the specific interpersonal difficulties remaining at post-therapy in
manner in which they do so. For example, Lambert a subset of clients were negatively associated with
and Barley (2001) derived estimates of the contri- improvement, suggesting the possible utility of adding
bution of various components of psychotherapy to interpersonal treatment to cognitive-behavioral ther-
psychotherapeutic outcomes and estimated that apy to increase therapeutic effectiveness.
15% of outcome is due to specific techniques. Another important issue in how therapists view
Although research suggests that specific effects theory in their work is the trend in psychotherapy
account for a meaningful amount of variance in to move away from a single theoretical orientation
outcome, the empirical support for common ingre- perspective and toward integration, in which empir-
dients continues to surpass the support for effective ically supported active ingredients from various the-
unique ingredients. Several of the reasons that ories are identified and brought together under a
have been suggested for the difficulties in establish- single, more generic overarching theoretical umbrella.
ing support for unique ingredients are that clients A related trend is a move toward eclecticism, which
rarely seek therapy for a single presenting concern can be expressed in several ways, including combin-
(e.g., depression); even clients with the same pre- ing two or more theoretical orientations or conceptu-
senting concern may vary in meaningful ways in alizing client dynamics from one orientation but
terms of how that concern is expressed; the interper- utilizing interventions from one or more other orien-
sonal nature of therapy leads to constant change, tations. Currently, more therapists describe their
based on the dyadic interchange; therapists may theoretical orientation as eclectic or integrative, rather
self-correct based on this dyadic interchange; inter- than following any single orientation (Norcross, Bike,
ventions have multiple components, and it may be & Evans, 2009), with 34% of counseling psycholo-
difficult to identify that component that is neces- gists identifying themselves in this manner.
sary for change; and current research methodologies Early proponents of an integrative approach
typically used may not be optimal for identifying concluded that behind the specific methods of vari-
the effects of unique ingredients. ous theories were commonalities that contributed to
It is important to note that recent research, espe- outcomes (e.g., Frank, 1982). More recent propo-
cially on cognitive-based therapies and on certain nents of this approach have argued that the unique
client concerns (such as anxiety and worry), have but only partially effective strengths of various
shown some success in identifying unique ingre- schools can be combined into more effective thera-
dients related to outcome (e.g., Borkovec, Newman, pies that fit into one of four categories: common
Pincus, & Lyttle, 2002; Foa, Rothbuam, & Furr, factors, technical eclecticism, theoretical integra-
2003). Foa et al. (2003) reviewed studies that com- tion, or assimilative integration (Stricker, 2008;
pared exposure therapy for PTSD to other treat- Wachtel, 2000). The movement toward eclecticism
ments. Results showed that exposure therapy is and integrationism represents both a disenchant-
highly effective and that attempting to augment ment with the utility of single-theory approaches
it with other treatments appears to diminish its and a recognition of the value of the planned inte-
effectiveness through dilution. This suggests that gration of two or more approaches. Despite the
exposure therapy contains sufficient and perhaps appeal of eclecticism and integrative approaches for
necessary ingredients for change. most clinicians, definitional issues remain challeng-
In a similar study, Borkovec et al. (2002) con- ing, and this perspective can run contrary to evi-
ducted a component analysis of cognitive-behavioral dence-based, manualized treatment approaches.
therapy for GAD by assigning clients to one of
three treatments: applied relaxation and self-control Extra-therapeutic Factors Effects
desensitization, cognitive therapy, or a combina- on Individual Counseling
tion of these methods. All treatments resulted in To this point, the focus has been on what occurs
significant improvement (e.g., no longer meeting within the context of the individual counseling.

520 ind ivid ual co u n s e l in g as an in te rvent ion

An area that has received limited attention is what A series of two studies examined five areas of
happens outside of therapy, both in terms of what clients’ environment (life adjustment, external sup-
the client brings to therapy and what happens to the port, alternative counsel, current stress events, and
client once he or she leaves the counseling session. logistical barriers) that were hypothesized to influ-
Psychotherapy is just one of many influences that ence continuation or premature termination from
affect clients’ lives, typically occupying only 1 hour therapy (Cross & Warren, 1984). Participants were
a week for a limited duration. As Jerome Frank continuers and terminators from an outpatient
so aptly stated, “What goes on between sessions clinic. The only variable that differentiated these
may be more important in determining outcome two groups of clients was that continuers reported
than what occurs in sessions” (Frank, 1982, p. 13). access to more individuals in the community (such
Environmental factors that may influence ongoing as spouses) with whom they received informal
therapy include social support, work, and fortu- support in conjunction with therapy. This study
itous (and not so fortuitous) events. For example, supports the importance of significant others out-
as the client begins to change, so must his or her side of therapy supporting the client while in ther-
environment, which changes the status quo. Other apy. Although research has identified the importance
environmental characteristics, such as social and of extra-therapeutic factors to therapy continuation
political factors, can exert a powerful influence on and outcome, far less is known about their myriad
clients as well. For example, feminist and multicul- effects and their relationships to process and out-
tural theories have long recognized the role of socio- come than is known about other therapeutic com-
political and cultural factors such as oppression, ponents.
privilege, stigma, and culture in affecting client out-
comes (e.g., Brown, Sue, & Sue, 2003). In other
Conclusion
words, environmental factors at times support client
Future Directions
changes and at other times undermine these changes
Individual counseling as an intervention has been
in ways that facilitate or hinder transferability of
shown by over 30 years of research to be effective,
therapeutic changes.
beneficial, and satisfying. Much has been learned
In addition, client background variables influence
about the efficacy of psychotherapy and the com-
the effectiveness of therapy. These include personality
monalities that contribute to change across thera-
variables, beliefs and values, cultural values, and read-
pies, and progress has been made in understanding
iness to change. Based on their review of psychother-
the how, what, and why of counseling outcomes.
apy research, Lambert and Barley (2001) concluded
Yet, many challenges remain, ranging from a need
that extra-therapeutic factors account for about 40%
for a greater understanding of commonalities in
of outcome variance. Despite the importance of extra-
counseling (e.g., the therapeutic relationship),
therapeutic factors to therapy outcomes, the literature
to the search for effective, unique ingredients
in this area is relatively sparse. In part, this may be
in counseling, to how much therapy is needed to
because an unlimited number of extra-therapeutic
lead to good outcomes. This chapter ends with rec-
factors may affect therapy. It is difficult to identify
ommendations for future directions in research that
and separate these factors to study their unique con-
are relevant to the effective practice of individual
tribution to therapy process and outcome.
counseling.
Examples of client characteristics and environ-
mental factors will illustrate the importance of • Although a large body of research has shown
extra-therapeutic factors. Reviews of the literature that certain common factors or commonalities
have identified several personality variables that cli- across therapies are effective, important areas of
ents bring to therapy and that are related to success- inquiry on these factors remain. For example,
ful counseling outcomes (e.g. Luborsky, Chandler, the relationship is widely viewed as a component
Auerbach, Cohen, & Bachrach, 1971). In Luborsky of counseling that has direct effects on outcomes,
and colleagues classic review of over 100 studies on or one that can, at other times, facilitate the
psychotherapy, personality variables most predictive application of therapeutic specific factors, which
of positive therapy outcome were level of initial per- in turn have outcome effects. Yet, work remains
sonality functioning, motivation/expectations for in defining the therapeutic relationship because
therapy, and history of previous psychotherapy. most research focuses on one only aspect—the
Somatic concerns and defensiveness were predictive therapeutic alliance. What are the components of
of more negative therapy outcomes. the therapeutic relationship? Given the contextual,

hoffm an 521
dyadic, and dynamic nature of the relationship, a range of client concerns, research has shown
is it best viewed in its entirety rather than in its limited success in identifying mediators of change.
component parts? For example, can the Some proponents of unique effects posit that this
transference–countertransference configuration may be resolved through the use of different design
and the real relationship be viewed separately and data analytic methodologies (e.g., growth
from the therapeutic relationship? curves) to identify mediators, which seems the
• Client expectancies about psychotherapy most promising direction for future research in
prior to seeking counseling or that are facilitated this area (e.g., Kazdin, 2007).
during therapy by the counselor are another • In contrast, integrative researchers advocate
commonality factor. Most research focuses on moving away from evidence-based treatments
client pretherapy expectancies, with far fewer based on narrowly defined diagnostic criteria
studies examining how counselors facilitate and step-by-step treatment manuals. They
expectancies. Clients typically seek counseling recommend alternative treatment paradigms that
expecting it will be helpful, yet nearly half use integrative approaches, including a focus on
terminate prematurely (often after just one the two-person relationship and on contextual
session), before their goals can be fully met. factors that more closely approximate clinical
What role do expectancies play in continuance practice (Wachtel, 2000, 2008).
in counseling? And, how do counselors influence • A pressing concern recognized by proponents
expectancies? of both common and specific factors approaches
• Experiencing and regulating emotions is the importance of finding treatment evidence
represents another commonality across therapies utilizing actual clinical contexts, or what is referred
that predicts successful outcomes. To date, to as evidence-based practice (Howard et al., 1993;
cognitive therapies have been studied most Kazdin, 2009; Seligman, 1996; Wachtel, 2000).
frequently and have shown the greatest efficacy Unlike the typical protocol for evidence-based
across the widest range of problem areas related treatment, in the clinical context, decisions are
to affect regulation. Recent research on emotion- made by individual therapists based on their
focused therapy shows promise to move the field expertise, their judgment of the evidence they
forward in a different direction, based on its see in their sessions, and their view of their client
success with concerns ranging from depression and their relationship with the client. In contrast,
to forgiveness (see Greenberg, 2008; Greenberg, commonly cited limitations of most randomized
Warwar, & Malcolm, 2008). Moreover, emotion- clinical trials are that they do not study clients in
focused therapy is in line with a growing interest real settings, adherence to manualized treatments
in positive emotions, such as compassion and may limit responsiveness to contextual concerns,
forgiveness. and narrow definitions for client inclusion limit
• Insight and self-awareness is another common generalizability to clinical samples, where clients
factor of counseling. One of the primary reasons typically present with multiple concerns.
clients give for seeking counseling is to understand • A related issue that warrants more research
the reasons behind their feelings, thoughts, and is therapist use of self-correcting processes to
behaviors. Yet, a panel of experts found it difficult enhance responsiveness to client reactions to
to reach consensus on a definition of insight and therapy and to achieve better outcomes. Lambert
to describe how it manifests in therapy and how and colleagues have conducted a series of studies
it relates to outcomes (Hill, Castonguay, et al., examining the effects of providing therapists
2007). A fruitful area for future research is a with client feedback during psychotherapy
greater understanding of how clients obtain insight (e.g., Lambert et al., 2001). Results show that
and understanding and how that facilitates the feedback reduces premature dropout, improves
process and outcome of counseling. outcome relative to nonfeedback conditions,
• Many believe that research should continue and facilitates clinically significant change.
to focus on identifying the mechanisms of change, In addition, feedback to therapists may reduce
by determining which specific or unique effects the number of therapy sessions without reducing
serve as mediators of therapeutic outcome. Yet, this positive client outcomes. This is an interesting
has proved challenging. Cognitive therapies have direction for future research as it may address
been studied most often, and although these two important needs in this area: efficacy and
approaches have been found to be efficacious across efficiency.

522 ind ivid ual co u n s e l in g as an in te rvent ion

 • The efficiency and effectiveness of combine theories and intervention strategies, and
psychotherapy are important areas for future their effectiveness.
research due to concerns with cost containment • Face-to-face individual counseling was the
and competition with biological psychiatry, which focus of this chapter. Yet, the use of online
asserts that medication is less expensive, faster, technologies such as the Internet, Skype, and
and more effective. Which psychotherapies are teleconferencing are being utilized with a variety
both effective and efficient, and for whom? of settings, modalities, and client populations
One of the best but underutilized research (see Casper & Berger, 2005; Mallen, Vogel,
designs to examine these questions uses dose– Rochlen, & Day, 2005). Research is at the nascent
effect strategies that utilize growth curves rather stage with these technologies, and many issues,
than change scores and that provide an index of such as the client types and problems for which
the rate of improvement for either groups or this is effective and the ethical guidelines related
subsets of clients. to “remote counseling” remain unresolved.
• Another area of surprisingly little research
is that on extra-therapeutic effects that affect who
seeks counseling, who remains in counseling, References
and therapy outcomes. This research has primarily Ahn, H., & Wampold, B. E. (2001). Where oh where are the
focused on identifying client characteristics that specific ingredients? A meta-analysis of component studies
predict better outcomes, such as motivation in counseling and psychotherapy. Journal of Counseling
to change, expectancies, and nondefensiveness. Psychology, 48(3), 251–257.
American Psychological Association, Division if Counseling,
In contrast, less attention has focused on Guidance, & Committee on American Psychological
environmental factors that affect therapy Association. (2004). 2002 APA Directory survey. (Table 3,
outcomes, such as social support, oppression, Current major field of APA members by membership status,
and logistical barriers. 2002). Compiled by APA Research Office. Washington, DC:
• Termination continues to be defined as the American Psychological Association.
American Psychological Association Presidential Task Force on
ending of therapy in the majority of research Evidence-Based Practice. (2006). Evidence-based practice in
and scholarly writings. Several researchers have psychology. American Psychologist, 61, 271–285.
questioned this view of the finality of termination, Arnkoff, D. B., Glass, C. R., Shapiro, S. J., & Norcross, J. C.
yet few studies have examined other models (2002). Expectations and preferences Psychotherapy relation-
(e.g., Cummings, 2001; Wachtel, 2002). For ships that work: Therapist contributions and responsiveness to
patients. (pp. 335–356). New York: Oxford University Press.
example, counseling could be viewed as an Aubuchon-Endsley, N. L., & Callahan, J. L. (2009). The hour
adaptive and preventative intervention that clients of departure: Predicting attrition in the training clinic from
pursue intermittently throughout their lifetimes, role expectancies. Training and Education in Professional
in contrast to the view that they continue in Psychology, 3(2), 120–126.
therapy until they are “cured” or “done.” Baldwin, S. A., Berkeljon, A., Atkins, D. C., Olsen, J. A., &
Nielsen, S. L. (2009). Rates of change in naturalistic psy-
• A focus on adaptive functioning and chotherapy: Contrasting dose-effect and good-enough
prevention across the lifetime is in line with the level models of change. Journal of Consulting and Clinical
current interest in positive psychology. Researchers Psychology, 77(2), 203–211.
are examining interventions that focus on client Bandura, A. (1986). Social foundations of thought and action:
strengths rather than deficits. Examples include A social cognitive theory. New York: Prentice-Hall.
Barber, J. P., Connolly, M. B., Crits-Christoph, P., Gladis, L., &
interventions that facilitate well-being, benefit- Siqueland, L. (2000). Alliance predicts patients’ outcome
finding following traumatic events, and positive beyond in-treatment change in symptoms. Journal of Con-
emotions such as forgiveness and gratitude sulting and Clinical Psychology, 68(6), 1027–1032.
(Malcolm, Warwar, & Greenberg, 2005). Barkham, M., Rees, A., Shapiro, D. A., Stiles, W. B., Agnew, R. M.,
• An important change affecting individual Halstead, J., et al. (1996). Outcomes of time-limited psycho-
therapy in applied settings: Replicating the Second Sheffield
counseling is the movement away from single- Psychotherapy Project. Journal of Consulting and Clinical
theory orientations to theoretical integrationism Psychology, 64(5), 1079–1085.
and eclecticism. Although both dissatisfaction Barlow, D. H., & Lehman, C. L. (1996). Advances in the psy-
with single theories and appreciation for points chosocial treatment of anxiety disorders: Implications for
of convergence between two or more theories national health care. Archives of General Psychiatry, 53(8),
727–735.
drive this change, there is little consensus about Barsky, A. J., Saintfort, R., Rogers, M. P., & Borus, J. F. (2002).
what integrationism looks like. Future research Nonspecific Medication Side Effects and the Nocebo
needs to examine the manner in which therapists Phenomenon. JAMA, 287(5), 622–627.

hoffm an 523
Baumann, E., & Hill, C. E. (2008). The attainment of insight in Crits-Christoph, P. (1997). Limitations of the dodo bird verdict
the insight stage of the Hill dream model: The influence of and the role of clinical trials in psychotherapy research:
client reactance and therapist interventions. Dreaming, Comment on Wampold et al. (1997). Psychological Bulletin,
18(2), 127–137. 122(3), 216–220.
Beutler, L. E., Clarkin, J. F., & Bongar, B. (2000). Guidelines for Crits-Christoph, P., Connolly Gibbons, M. B., Crits-Christoph, K.,
the systematic treatment of the depressed patient. New York: Narducci, J., Schamberger, M., & Gallop, R. (2006). Can
Oxford University Press. therapists be trained to improve their alliances? A prelimi-
Beutler, L. E., & Harwood, T. M. (2002). What is and can be nary study of alliance-fostering psychotherapy. Psychotherapy
attributed to the therapeutic relationship? Journal of Research, 16(3), 268–281.
Contemporary Psychotherapy, 32(1), 25–33. Crits-Christoph, P., Connolly Gibbons, M. B., Ring-Kurtz, S.,
Bohart, A. C., & Greenberg, L. S. (1997). Empathy reconsidered: Gallop, R., Stirman, S., Present, J., et al. (2008). Changes
new directions in psychotherapy (1st ed.). Washington, DC: in positive quality of life over the course of psychother-
American Psychological Association. apy. Psychotherapy: Theory, Research, Practice, Training, 45,
Bordin, E. S. (1979). The generalizability of the psychoana- 419–430.
lytic concept of the working alliance. Psychotherapy: Theory, Crits-Christoph, P., Cooper, A., & Luborsky, L. (1988). The
Research & Practice, 16(3), 252–260. accuracy of therapists’ interpretations and the outcome of
Bordin, E. S. (1994). Theory and research on the therapeu- dynamic psychotherapy. Journal of Consulting and Clinical
tic working alliance: New directions. In A. O. Horvath, & Psychology, 56(4), 490–495.
L. S. Greenberg (Eds.), The working alliance: Theory, research, Cross, D. G., & Warren, C. E. (1984). Environmental factors
and practice (pp. 13–37). New York: Wiley. associated with continuers and terminators in adult out-
Borkovec, T. D., & Costello, E. (1993). Efficacy of applied patient psychotherapy. British Journal of Medical Psychology,
relaxation and cognitive-behavioral therapy in the treatment 57(4), 363–369.
of generalized anxiety disorder. Journal of Consulting and Cummings, N. A. (2001). Interruption, not termination: The
Clinical Psychology, 61(4), 611–619. model from focused, intermittent psychotherapy throughout
Borkovec, T. D., Newman, M. G., Pincus, A. L., & Lytle, R. the life cycle. Journal of Psychotherapy in Independent Practice,
(2002). A component analysis of cognitive-behavioral ther- 3, 3–18.
apy for generalized anxiety disorder and the role of interper- Deane, F. P. (1991). Attendance and drop-out from outpatient
sonal problems. Journal of Consulting and Clinical Psychology, psychotherapy in New Zealand. Community Mental Health
70, 288–298. in New Zealand, 6, 34–51.
Boyer, S. P., & Hoffman, M. A. (1993). Counselor affective reac- Deane, F. P., & Chamberlain, K. (1994). Treatment fearfulness
tions to termination: Impact of counselor loss history and and distress as predictors of professional psychological help-
perceived client sensitivity to loss. Journal of Counseling seeking. British Journal of Guidance & Counselling, 22(2),
Psychology, 40, 271–277. 207–217.
Brogan, M. M., Prochaska, J. O., & Prochaska, J. M. (1999). Deane, F. P., & Todd, D. M. (1996). Attitudes and intentions to
Predicting termination and continuation status in psycho- seek professional psychological help for personal problems or
therapy using the transtheoretical model. Psychotherapy: suicidal thinking. Journal of College Student Psychotherapy,
Theory, Research, Practice, Training, 36(2), 105–113. 10(4), 45–59.
Brown, L. S. (1994). Subversive dialogues: Theory in feminist DeRubeis, R. J., Evans, M. D., Hollon, S. D., Garvey, M. J.,
therapy. New York: Basic Books. Grove, W. M., & Tuason, V. B. (1990). How does cogni-
Burns, D. D., & Nolen-Hoeksema, S. (1991). Coping styles, tive therapy work? Cognitive change and symptom change
homework compliance, and the effectiveness of cognitive- in cognitive therapy and pharmacotherapy for depression.
behavioral therapy. Journal of Consulting and Clinical Journal of Consulting and Clinical Psychology, 58(6),
Psychology, 59(2), 305–311. 862–869.
Burns, D. D., & Spangler, D. L. (2001). Do changes in dys- Elkin, I., Shea, M. T., Watkins, J. T., Imber, S. D., Sotsky, S. M,
functional attitudes mediate changes in depression and anxi- Collins, J. F., et al. (1989). National Institute of Mental
ety in cognitive behavioral therapy. Behavior Therapy, 32, Health Treatment of Depression Collaborative Research
337–369. Program: General effectiveness of treatments. Archives of
Carryer, J. R. & Greenberg, L. S. (2010). Optimal levels of General Psychiatry, 46(11), 971–982.
emotional arousal in experiential therapy of depression. Elliott, R., & James, E. (1989). Varieties of client experience in
Journal of Consulting and Clinical Psychology, 78(2), psychotherapy: An analysis of the literature. Clinical
190–199. Psychology Review, 9(4), 443–467.
Caspar, F., & Berger, T. (2005). The future is bright: How can Elliott, R., Llewelyn, S., Firth-Cozens, J., Margison, F., Shapiro, D.,
we optimize online counseling, and how can we know & Hardy, G. (1990). Assimilation of problematic expe-
whether we have done so? Counseling Psychologist, 33, riences by clients in psychotherapy. Psychotherapy, 27,
900–909. 411–420.
Cepeda-Benito, A., & Short, P. (1998). Self-concealment, avoid- Fava, G. A., Rafanelli, C., Cazzaro, M., Conti, S., & Grandi, S.
ance of psychological services, and perceived likelihood of (1998). Well-being therapy: A novel psychotherapeutic
seeking professional help. Journal of Counseling Psychology, approach for residual symptoms of affective disorders.
45(1), 58–64. Psychological Medicine, 28(2), 475–480.
Cohen, B.-Z., Guttmann, D., & Lazar, A. (1998). The willing- Foa, E. B., Riggs, D. S., Massie, E. D., & Yarczower, M. (1995).
ness to seek help: A cross-national comparison. Cross-Cultural The impact of fear activation and anger on the efficacy
Research: The Journal of Comparative Social Science, 32(4), of exposure treatment for PTSD. Behavior Therapy, 26,
342–357. 487–499.

524 ind ivid ual co u n s e l in g as an in te rvent ion

Foa, E. B., Rothbaum, B. O., & Furr, J. M. (2003). Augmenting Grissom, R. J. (1996). The magical number .7 ± .2: Meta-
exposure therapy with other CBT procedures. Psychiatric meta-analysis of the probability of superior outcome in
Annals, 33, 47–53. comparisons involving therapy, placebo, and control.
Frank, J. D. (1961). Persuasion and healing: A comparative study Journal of Consulting and Clinical Psychology, 64(5),
of psychotherapy. Baltimore: Johns Hopkins University Press. 973–982.
Frank, J. D. (1982/1989). Therapeutic components shared by all Harper, R. A. (1959). Psychoanalysis and psychotherapy: 36
psychotherapies. In J. H. Harvey, & M. M. Parks (Eds.), systems. Englewood Cliffs, NJ: Prentice Hall.
Psychotherapy research and behavior change. Master lecture Harwood, T. M., Beutler, L. E., Castillo, S., & Karno, M. (2006).
series Vol. 1 (pp. 9–37). Washington, DC: American Common and specific effects of couples treatment for alco-
Psychological Association. holism: A test of the generic model of psychotherapy.
Frank, J. D., & Frank, J. B. (1991). Persuasion and healing: Psychology and Psychotherapy: Theory, Research and Practice,
A comparative study of psychotherapy (3rd ed.). Baltimore: 79(3), 365–384.
Johns Hopkins University Press. Hill, C. E. (2001). Helping skills: The empirical foundation.
Frederickson, B. (2001). The role of positive emotions in positive Washington, DC: American Psychological Association.
psychology: The broaden-and-build theory of positive emo- Hill, C. E. (2004). Helping skills: Facilitating exploration, insight,
tions. American Psychologist, 56, 218–226. and action (2nd ed.). Washington, DC: American Psycholo-
Freud, S. (1953). The interpretation of dreams Vols. 4–5. London: gical Association.
Hogarth Press. (Original work published 1900). Hill, C. E., Castonguay, L. G., Angus, L., Arnkoff, D. B.,
Garfield, S. L. (1986). Research on client variables in psycho- Barber, J. P., Bohart, A. C., et al. (2007). Insight in psycho-
therapy. In S. L. Garfield, & G. Bergin (Eds.), Handbook of therapy: Definitions, processes, consequences, and research
psychotherapy and behavior change (3rd ed., pp. 213–256). directions. In L. G. Castonguay, & C. E. Hill (Eds.), Insight
New York: John Wiley. in psychotherapy (pp. 441–454). Washington, DC: American
Garfield, S. L. (1991). Psychotherapy models and outcome Psychological Association.
research. Am Psychol, 46(12), 1350–1351. Hill, C. E., Crook-Lyon, R. E., Hess, S. A., Goates-Jones, M.,
Gelso, C. J., & Carter, J. A. (1985). The relationship in coun- Roffman, M., Stahl, J., et al. (2006). Prediction of session
seling and psychotherapy: Components, consequences, and process and outcome in the Hill dream model: Contributions
theoretical antecedents. Counselling Psychologist, 2, 155–243. of client characteristics and the process of the three stages.
Gelso, C. J., & Samstag, L. W. (2008). A tripartite model of the Dreaming, 16(3), 159–185.
therapeutic relationship. In S. Brown, & R. Lent (Eds.), Hill, C. E., & Goates, M. K. (2004). Research on the Hill
Handbook of counseling psychology (4th ed., pp. 267–283). Cognitive-Experiential Dream Model. In C. E. Hill (Ed.).
New York: Wiley. Dream work in therapy: Facilitating exploration, insight, and
Gilligan, C. (1982). In a different voice: Psychological theory and action (pp. 245–288). Washington, DC: American Psycholo-
women’s development. Cambridge, MA: Harvard University gical Association.
Press. Hill, C. E., & Gormally, J. (1977). Effects of reflection, restate-
Greenberg, L. J., Warwar, S. H., & Malcolm, W. M. (2008). ment, probe, and nonverbal behaviors on client affect.
Differential effects of emotion-focused therapy and psy- Journal of Counseling Psychology, 24, 92–97.
choeducation in facilitating forgiveness and letting go of Hill, C. E., & Knox, S. (2008). Facilitating insight in counseling
emotional injuries. Journal of Counseling Psychology, 55, and psychotherapy. In S. Brown, & R. Lent (Eds.), Handbook
185–196. of counseling psychology (4th ed., pp. 284–302). New York:
Greenberg, L. S. (2002). Emotion-focused therapy: Coaching Wiley.
clients to work through their feelings. Washington, DC: Hill, C. E., Knox, S., Hess, S. A., Crook-Lyon, R. E., Goates-
APA Press. Jones, M. K., Sim, W., et al. (2007). The attainment of
Greenberg, L. S., & Angus, L. (2004). The contributions of emo- insight in the Hill Dream Model: A case study. Insight in
tion process to narrative change in psychotherapy: A dialectical– Psychotherapy, 18, 200–215.
constructivist perspective. In L. E. Angus, & J. McLeod Hill, C. E., & O’Grady, K. E. (1985). List of therapist inten-
(Eds.), Handbook of narrative psychotherapy: Practice, theory, tions illustrated in a case study and with therapists of vary-
and research (pp. 331–350). Thousand Oaks, CA: Sage. ing theoretical orientations. Journal of Counseling Psychology,
Greenberg, L. S., Auszra, L., & Herrmann, I. R. (2007). The 32(1), 193–22.
relationship among emotional productivity, emotional Hill, C. E., Williams, E. N. (2000). The process of individual
arousal and outcome in experiential therapy of depression. therapy. In S. Brown, & R. Lent (Eds.), Handbook of counsel-
Psychotherapy Research, 17(4), 482–493. ing psychology (3rd ed., pp. 670–710). Hoboken, NJ: John
Greenberg, L. S., Elliott, R., Watson, J. C., & Bohart, A. (2001). Wiley & Sons, Inc.
Empathy. Psychotherapy: Theory, Research, Practice, Training, Hoffman-Graff, M. A. (1977). Interviewer use of positive and
38, 380–384. negative self-disclosure and interviewer-subject sex pairing.
Greenberg, L. S., & Malcolm, W. (2002). Resolving unfinished Journal of Counseling Psychology, 24(3), 184–190.
business: Relating process to outcome. Journal of Consulting Hofmann, S. G. (2000). Treatment of social phobia: Potential
and Clinical Psychology, 70, 406–416. mediators and moderators. Clinical Psychology: Science and
Greenberg, L. S., & Watson, J. (2005). Emotion-focused therapy Practice, 7, 3–16.
of depression. Washington, DC: APA Press. Hollon, S. D., & Beck, A. T. (2004). Cognitive and cognitive
Grencavage, L. M., & Norcross, J. C. (1990). Where are the behavioral therapies. In M. J. Lambert (Ed.), Bergin and
commonalities among the therapeutic common factors? Garfield’s handbook of psychotherapy and behavior change
Professional Psychology: Research and Practice, 21, 372–378. (5th ed., pp. 447–492). New York: Wiley.

hoffm an 525
Horvath, A. O. (2006). The alliance in context: Accomplishments, Komiya, N., Good, G. E., & Sherrod, N. B. (2000). Emotional
challenges, and future directions. Psychotherapy: Theory, openness as a predictor of college students’ attitudes toward
Research, Practice, Training, 43(3), 258–263. seeking psychological help. Journal of Counseling Psychology,
Horvath, A. O., & Greenberg, L. S. (1986). The development 47(1), 138–143.
of the Working Alliance Inventory. In L. S. Greenberg, & Kopta, S. M., Howard, K. I., Lowry, J. L., & Beutler, L. E.
W. E. Pinsof (Eds.), The psychotherapeutic process: A research (1994). Patterns of symptomatic recovery in psychother-
handbook. New York: The Guilford Press. apy. Journal of Consulting and Clinical Psychology, 62(5),
Horvath, A. O., & Greenberg, L. S. (1994). The Working alli- 1009–1016.
ance: theory, research, and practice. New York: Wiley. Kopta, S. M., Lueger, R. J., Saunders, S. M., & Howard, K. I.
Horvath, A. O., & Symonds, B. D. (1991). Relation between (1999). Individual psychotherapy outcome and process
working alliance and outcome in psychotherapy: A meta- research: Challenges leading to greater turmoil or a positive
analysis. Journal of Counseling Psychology, 38(2), 139–149. transition? Annual Review of Psychology, 50, 441–469.
Howard, K. I., Lueger, R. J., Maling, M. S., & Martinovich, Z. Krupnick, J. L., Sotsky, S. M., Simmens, S., Moyer, J., Elkin, I.,
(1993). A phase model of psychotherapy outcome: Causal Watkins, J., et al. (1996). The role of the therapeutic alliance
mediation of change. Journal of Consulting and Clinical in psychotherapy and pharmacotherapy outcome: Findings
Psychology, 61(4), 678–685. in the National Institute of Mental Health Treatment of
Iwakabe, S., Rogan, K., & Stalikas, A. (2000). The relationship Depression Collaborative Research Program. Journal of
between client emotional expressions, therapist interven- Consulting and Clinical Psychology, 64(3), 532–539.
tions, and the working alliance: An exploration of eight emo- Kushner, M. G., & Sher, K. J. (1989). Fears of psychological
tional expression events. Journal of Psychotherapy Integration, treatment and its relation to mental health service avoidance.
10, 375–402. Professional Psychology: Research and Practice, 20, 251–257.
Kadera, S. W., Lambert, M. J., & Andrews, A. A. (1996). How Lambert, M. J., & Barley, D. E. (2001). Research summary on
much therapy is really enough? A session-by-session analysis the therapeutic relationship and psychotherapy outcome.
of the psychotherapy dose-effect relationship. Journal of Psychotherapy: Theory, Research, Practice, Training, 38(4),
Psychotherapy Practice & Research, 5(2), 132–151. 357–361.
Kagan, N., Armsworth, M. W., Altmaier, E. M., Dowd, E. T., Lambert, M. J., Bergin, A. E., & Garfield, S. L. (1994).
et al. (1988). Professional practice of counseling psy- The effectiveness of psychotherapy. In A. E. Bergin &
chology in various settings. Counseling Psychologist, 16(3), S. L. Garfield (Eds.), Handbook of psychotherapy and behavior
347–365. change (4th ed., pp. 143–189). New York: Wiley.
Kasper, L. B., Hill, C. E., & Kivlighan, D. M., Jr. (2008). Lambert, M. J., & Ogles, B. M. (2004). The efficacy and effec-
Therapist immediacy in brief psychotherapy: Case study I. tiveness of psychotherapy. In M. Lambert (Ed.), Bergin
Psychotherapy: Theory, Research, Practice, Training, 45(3), and Garfield’s handbook of psychotherapy and behavior change
281–297. (5th ed., pp. 139–193). New York: Wiley.
Kazdin, A. E. (2006). Mechanisms of change in psychotherapy: Lambert, M. J., Whipple, J. L., Smart, D. W., Vermeersch, D. A.,
Advances, breakthroughs, and cutting-edge research (do not Nielsen, S. L., & Hawkins, E. J. (2001). The effects of pro-
yet exist). In R. R. Bootzin, & P. E. McKnight (Eds.), viding therapists with feedback on patient progress during
Strengthening research methodology: Psychological measurement psychotherapy: Are outcomes enhanced? Psychotherapy
and evaluation (pp. 77–101). Washington, DC: American Research, 11(1), 49–68.
Psychological Association. Lane, R. D., & Schwartz, G. E. (1992). Levels of emotional
Kazdin, A. E. (2007). Mediators and mechanisms of change in awareness: Implications for psychotherapeutic integration.
psychotherapy research. Annual Review of Clinical Psychology, Journal of Psychotherapy Integration, 2, 1–18.
3, 1–27. Linehan, M., Dimeff, L. A., Reynolds, S. K., Comtois, K. A.,
Kazdin, A. E. (2008). Evidence-based treatment and practice: Welch, S. S., Heagerty, P., et al. (2002). Dialectal behavior
New opportunities to bridge clinical research and practice, therapy versus comprehensive validation therapy plus 12-step
enhance the knowledge base, and improve patient care. for the treatment of opioid dependent women meeting crite-
American Psychologist, 63, 146–159. ria for borderline personality disorder. Drug and Alcohol
Kelly, A. E., & Achter, J. A. (1995). Self-concealment and Dependence, 67(1), 13–26.
attitudes toward counseling in university students. Journal Lipsey, M. W., & Wilson, D. B. (1993). The efficacy of psycho-
of Counseling Psychology, 42(1), 40–46. logical, educational, and behavioral treatment: Confirmation
Kivlighan, D. M., Jr., Multon, K. D., & Patton, M. J. (2000). from meta-analysis. American Psychologist, 48, 1181–1209.
Insight and symptom reduction in time-limited psychoana- Luborsky, L., Chandler, M., Aurbach, A. H., Cohen, J., &
lytic counseling. Journal of Counseling Psychology, 47(1), Bachrach, H. M. (1971). Factors influencing the outcome of
50–58. psychotherapy: A review of quantitative research. Psychological
Kivlighan, D. M., Jr., & Shaughnessy, P. (2000). Patterns of Bulletin, 75(3), 145–185.
working alliance development: A typology of client’s work- Luborsky, L., Horvath, A. O., & Greenberg, L. S. (1994).
ing alliance ratings. Journal of Counseling Psychology, 47, Therapeutic alliances as predictors of psychotherapy outcomes:
362–371. Factors explaining the predictive success. In A. O. Horvath
Knox, S., Hess, S. A., Petersen, D. A., Hill, C. E., et al. (1997). and L.S. Greenberg (Eds.) The working alliance: Theory,
A qualitative analysis of client perceptions of the effects of research, and practice (pp. 38–50). Oxford, England:
helpful therapist self-disclosure in long-term therapy. Journal John Wiley & Sons.
of Counseling Psychology, 44(3), 274–283. Malcolm, W., Warwar, S., & Greenberg, L. (2005). Facilitating
Kohut, H. (1977). The restoration of the self. New York: forgiveness in individual therapy as an approach to resolv-
International Universities Press. ing interpersonal injuries. In E. L. Worthington, Jr. (Ed.),

526 ind ivid ual co u n s e l in g as an in te rvent ion

 The handbook of forgiveness (pp. 379–393). New York: Pennebaker, J. W. (1995). Emotion, disclosure, and health:
Routledge. An overview. In J. W. Pennebaker (Ed.) Emotion, disclosure,
Mallen, M. J., Vogel, D. L., Rochlen, A. B., & Day, S. X. (2005). & health (pp. 3–10). Washington, DC: American Psycholo-
Online counseling: Reviewing the literature from a coun- gical Association.
seling psychology framework. Counseling Psychologist, 33, Prochaska, J. O., DiClemente, C. C., Norcross, J. C., &
819–871. Goldfried, M. R. (2005). The transtheoretical approach.
Martin, D. J., Garske, J. P., & Davis, K. M. (2000). Relation of In J. C. Norcross & M. R. Goldfried (Eds.) Handbook of
the therapeutic alliance with outcome and other variables: psychotherapy integration (2nd ed., pp. 147–171). New York:
A meta-analytic review. Journal of Consulting and Clinical Oxford University Press.
Psychology, 68, 438–450. Prochaska, J. O., & Norcross, J. C. (2007). Systems of psycho-
Marx, J. A., & Gelso, C. J. (1987). Termination of individual therapy: a transtheoretical analysis (6th ed.). Belmont, CA:
counseling in a university counseling center. Journal of Thomson Brooks/Cole Pub.
Counseling Psychology, 34(1), 3–9. Rafanelli, C., Park, S. K., Ruini, C., Ottolini, F., Cazzaro, M., &
McNeilly, C. L., & Howard, K. I. (1991). The effects of psycho- Fava, G. A. (2000). Rating well-being and distress. Stress
therapy: A reevaluation based on dosage. Psychotherapy Medicine, 16(1), 55–61.
Research, 1(1), 74–78. Roe, D., Dekel, R., Harel, G., & Fennig, S. (2006). Clients’ rea-
Meisnner, W. W. (1992). The concept of the therapeutic alliance. sons for terminating psychotherapy: A quantitative and
Journal of the American Psychoanalytic Association, 40(4), qualitative inquiry. Psychology and Psychotherapy: Theory,
1059–1087. Research and Practice, 79(4), 529–538.
Meyer, B., Pilkonis, P. A., Krupnick, J. L., Egan, M. K., Rogers, C. R. (1951). Client-centered therapy. Boston: Houghton
Simmens, S. J., & Sotsky, S. M. (2002). Treatment expectan- Mifflin.
cies, patient alliance and outcome: Further analyses from the Roth, A., & Fonagy, P. (2005). What works for whom: A critical
National Institute of Mental Health Treatment of Depres- review of psychotherapy research. (2nd ed.). New York: Guilford
sion Collaborative Research Program. Journal of Consult- Press.
ing and Clinical Psychology, 70(4), 1051–1055. Ryff, C. D. (1989). Happiness is everything, or is it? Explorations
Munley, P. H., Duncan, L. E., McDonnell, K. A., & Sauer, E. M. on the meaning of psychological well-being. Journal of
(2004). Counseling psychology in the United States of Personality and Social Psychology, 57(6), 1069–1081.
America. Counselling Psychology Quarterly, 17(3), 247–271. Sacuzzo, D. P. (1975). What patients want from counseling and
Norcross, J. C. (1990). An eclectic definition of psychotherapy. psychotherapy. Journal of Clinical Psychology, 31(3), 471–475.
In J. K. Zeig, & W. M. Munion (Eds.), What is psychotherapy? Safran, J. D., & Muran, J. C. (1996). The resolution of ruptures
San Francisco: Jossey-Bass. in the therapeutic alliance. Journal of Consulting and Clinical
Norcross, J. C. (2002). Empirically supported therapy relation- Psychology, 64, 447–458.
ships. In J. C. Norcross (Ed.), Psychotherapy relationships that Safran, J. D., & Muran, J. C. (2000). Negotiating the therapeutic
work: Therapist contributions and responsiveness to patients alliance: A relational treatment guide. New York: Guilford
(pp. 3–16). New York: Oxford University Press. Press.
Norcross, J. C., Bike, D. H., & Evans, K. L. (2009). The thera- Seligman, M. E. P. (1995). The effectiveness of psychotherapy:
pist’s therapist: A replication and extension 20 years later. The Consumer Reports study. American Psychologist, 50(12),
Psychotherapy: Theory, Research, Practice, Training, 46(1), 965–974.
32–41. Seligman, M. E. P. (1996). Science as an ally of practice. American
Norcross, J. C. & Wampold, B. E. (2011). Evidence-based ther- Psychologist, 51(10), 1072–1079.
apy relationships: Research conclusions and clinical practices. Smith, M. L., & Glass, G. V. (1977). Meta-analysis of psy-
Psychotherapy, 48(1), 98–102. chotherapy outcome studies. American Psychologist, 32(9),
Orlinsky, D. E., Grawe, K., & Parks, B. K. (1994). Process and 752–760.
outcome in psychotherapy: Noch einmal. In A. E. Bergin, & Snell, M. N., Mallinckrodt, B., Hill, R. D., & Lambert, M. J.
S. L. Garfield (Eds), Handbook of psychotherapy and behavior (2001). Predicting counseling center clients’ response to
change (4th ed., pp. 270–376). New York: John Wiley & counseling: A 1-year follow-up. Journal of Counseling
Sons. Psychology, 48(4), 463–473.
Orlinsky, D. E., & Howard, K. I. (1986). The psychological inte- Stiles, W. B., Glick, M. J., Osatuke, K., Hardy, G. E., Shapiro, D. A.,
rior of psychotherapy: Explorations with the therapy session Agnew-Davies, R., et al. (2004). Patterns of alliance devel-
report questionnaires. In L. S. Greenberg, & W. M. Pinsof opment and the rupture-repair hypothesis: Are productive
(Eds.), The psychotherapeutic process: A research handbook. relationships U-shaped or V-shaped). Journal of Counseling
New York: Guilford. Psychology, 51, 81–92.
Orlinsky, D. E., Rønnestad, M. H., Willutzki, U. (2004). Fifty Stricker, G. (2008). Milestones in psychotherapy integration.
years of psychotherapy process outcomes and research: Psychotherapy Bulletin, 43, 25–28.
Continuity and change. In M. J. Lambert (Ed.), Bergin Sue, D. W., & Sue, D. (2003). Counseling the culturally diverse:
and Garfield’s handbook of psychotherapy and behavior change, Theory and practice (4th ed.). New York: Houghton Mifflin.
(5th ed., pp. 307–393). New York: Wiley. Sin, N., & Lyubomirsky, S. (2009). Enhancing well-being and
Patterson, C. H. (1984). Empathy, warmth, and genuineness alleviating depressive symptoms with positive psychology
in psychotherapy: A review of reviews. Psychotherapy: Theory, interventions: A practice- friendly meta-analysis. Journal of
Research, Practice, Training, 21(4), 431–438. clinical psychology: In session, 55, 467–487.
Pekarik, G. (1992). Posttreatment adjustment of clients who Super, D. E. (1955). Transition: From vocational guidance to
drop out early vs. late in treatment. Journal of Clinical counseling psychology. Journal of Counseling Psychology, 2,
Psychology, 48, 378–387. 3–9.

hoffm an 527
Teasdale, J. D., Segal, Z. V., Williams, J. M. G., Ridgeway, V. A., Wachtel, P. (2008). Relational theory and the practice of psycho-
Soulsby, J. M., & Lau, M. A. (2000). Prevention of relapse/ therapy. New York: Guilford Press.
recurrence in major depression by mindfulness-based cogni- Wachtel, P. L. (2002). Termination of therapy: An effort
tive therapy. Journal of Consulting and Clinical Psychology, 68, at integration. Journal of Psychotherapy Integration, 12,
615–623. 373–383.
Thompson, S. D., & Super, D. E. (Eds.). (1964). The professional Wampold, B. E. (1997). Methodological problems in identifying
preparation of counseling psychologists: Report of the 1964 efficacious psychotherapies. Psychotherapy Research, 7(1),
Greyston Conference. New York: Bureau of Publications, 21–43.
Teachers College, Columbia University. Wampold, B. E. (2001). The great psychotherapy debate: Models,
Tokar, D. M., Hardin, S. I., Adams, E. M., & Brandel, I. W. methods, and findings. Mahwah, NJ: Lawrence Erlbaum
(1996). Clients’ expectations about counseling and percep- Associates.
tions of the working alliance. Journal of College Student Wampold, B. E., & Brown, G. S. J. (2005). Estimating variabil-
Psychotherapy, 11(2), 9–26. ity in outcomes attributable to therapists: A naturalistic study
Van der Kolk, B. A. (1995). The body keeps the score: Memory of outcomes in managed care. Journal of Consulting and
and the evolving psychobiology of posttraumatic stress. Clinical Psychology, 73(5), 914–923.
Harvard Review of Psychiatry, 1, 253–265. Wampold, B. E., Mondin, G. W., Moody, M., Stich, F.,
Vogel, D. L., Wade, N. G., & Hackler, A. H. (2008). Emotional Benson, K., & Ahn, H. -N. (1997). A meta-analysis of out-
expression and the decision to seek therapy: The mediating come studies comparing bona fide psychotherapies:
roles of the anticipated benefits and risks. Journal of Social & Empirically, “all must have prizes.” Psychological Bulletin,
Clinical Psychology, 27(3), 254–278. 122(3), 203–215.
Vogel, D. L., & Wester, S. R. (2003). To seek help or not to seek Whisman, M. A., Miller, I. W., Norman, W. H., & Keitner, G. I.
help: The risks of self-disclosure. Journal of Counseling (1991). Cognitive therapy with depressed inpatients: Specific
Psychology, 50(3), 351–361. effects on dysfunctional cognitions. Journal of Consulting and
Vogel, D. L., Wester, S. R., Wei, M., & Boysen, G. A. (2005). The Clinical Psychology, 59(2), 282–288.
Role of Outcome Expectations and Attitudes on Decisions to Wierzbicki, M., & Pekarik, G. (1993). A meta-analysis of psy-
Seek Professional Help. Journal of Counseling Psychology, chotherapy dropout. Professional Psychology: Research and
52(4), 459–470. doi:10.1037/0022-0167.52.4.459. Practice, 24, 190–195.
Wachtel, P. (2000). Integrative psychotherapy. In A. E. Kazdin Wrenn, C. G. (1966). Birth and early childhood of a journal.
(Ed.), Encyclopedia of psychology Vol. 4 (pp. 315–318). Journal of Counseling Psychology, 13, 485–488.
Washington, DC: American Psychological Association.

528 ind ivid ual co u n s e l in g as an in te rvent ion

 CHAPTER
Prevention and Psychoeducation
20 in Counseling Psychology

Melissa L. Morgan and Elizabeth M. Vera

Abstract
The history of prevention and its long role in counseling psychology are discussed in this chapter.
Traditional definitions of primary, secondary, and tertiary prevention are provided, as well as newer
definitions that insist that true prevention must occur before the onset of a diagnosable disorder.
We further discuss what constitutes a successful prevention program, prevention’s role in training in
counseling psychology programs, and selected examples of recent prevention programs. Finally, the
closely related construct of psychoeducation is discussed, along with applications of best practice in
this area. Application to current societal problems is provided.
Keywords: prevention, psychoeducation, counseling psychology mission, remediation alternative,
counselor roles

Prevention is an intuitively appealing approach to What Is Prevention?

the maintenance of well-being for people around Several definitions for prevention currently exist in
the world. Numerous daily activities are intended to the literature, based on multiple conceptualizations
prevent a host of health problems. For example, we of the term. Prevention has historically been subdi-
wear seat belts, take vitamins, exercise regularly, and vided into three categories: primary, secondary, and
watch what we eat, all in an effort to maintain our tertiary. Primary prevention has been defined as that
health and well-being (Conyne, 2004). However, which reduces the incidence of new cases of a desig-
activities aimed at the prevention of mental health nated disorder (Albee, 1983). Secondary prevention
problems, such as actions taken to reduce sub- targets populations exhibiting early symptoms, with
stance abuse, depression, and suicide, are less widely the purpose of preventing further symptoms (Durlak,
accepted and understood in the general population. 1997), and tertiary prevention aims to reduce the
Even among mental health professionals, preven- effects of existing problems (Caplan, 1964).
tion activities may be less frequently adopted for use The three levels of prevention can be illustrated
with clients. Counseling psychology, however, is with a relevant problem, binge drinking on college
one of the mental health professions that has his- campuses. An example of primary prevention of
torically been a proponent of prevention. In this binge drinking is teaching students refusal skills that
chapter, we examine the role of counseling psychol- would help them to resist peer pressure to drink.
ogists in contemporary prevention research, prac- Providing students with such skills would ostensibly
tice, and training; describe qualities of effective prevent them from ever beginning patterns of drink-
prevention programs; and suggest future directions ing that would include binge drinking. Thus, any
for the field of prevention. We also review the use of emergence of the problem could be effectively cir-
psychoeducation in the field of counseling psychol- cumvented, and new cases of this problem would be
ogy, a topic that is closely related to prevention. decreased.

529
 Providing education to students who had exhib- people who have symptoms of nutrition problems
ited early warning signs of binge drinking (possibly but have not yet been identified as having nutri-
through public intoxication arrests or self-report) tional disorders is an indicated preventive interven-
about the nature of addiction is an example of sec- tion. Note that in all of the examples for this specific
ondary prevention. These students, who exhibit model of conceptualizing prevention, the problem
early symptoms of substance abuse already, or have (in this case, diagnosed nutritional disorder) has not
at least been noted to have an increased propensity yet actually occurred.
for binge drinking, would be targeted for interven- Romano and Hage (2000) classify prevention in
tion, and the goal would be to prevent further epi- a way that encompasses several major strands of pre-
sodes of binge drinking or other serious symptoms vious conceptualizations of the construct. They
of substance abuse from developing. posit prevention as consisting of interventions that
Finally, using a 12-step program as a form of have one or more of the following characteristics:
relapse prevention for binge drinking would be an stopping a problem from ever occurring; delaying
example of tertiary prevention. In this case, the sub- the onset of a problem behavior; reducing the
stance abuse has already become a problem for the impact of an existing problem behavior; strengthen-
individual, and the prevention effort is designed to ing knowledge, attitudes, and behaviors that pro-
remediate the effects of the problem on the person mote emotional and physical well-being; and/or
and to help him/her avoid any future incidents. supporting institutional, community, and govern-
To further exemplify these concepts in the public ment policies that promote physical and emotional
health realm, the recommendation that we all eat well-being. This definition is a broader, more inclu-
five servings of fruits and vegetables per day to sive way of thinking about prevention activities. To
reduce the occurrence of poor health and nutrition is return to the binge drinking example, a prevention
a primary prevention initiative. Educating individu- program meeting these criteria might either pre-
als who may have evidenced patterns of unhealthy vent, delay, or reduce the impact of binge drinking,
eating already about nutrition and dietary changes educate on the strengths-based behaviors surround-
is a secondary prevention initiative, and providing ing non–binge drinking, and/or be in line with
nutritional supplements and a set diet to remediate school policy promoting student wellness.
existing nutrition problems is an example of tertiary Finally, Robert Conyne, a pioneer in the field of
prevention. In each of these illustrations, what dif- prevention, has proposed the following definition:
ferentiates the three types of prevention is the extent
Prevention is a goal for both everyday life and
to which problems have already appeared for the
for service delivery, through which people become
target audience of the intervention.
empowered to interact effectively and appropriately
More recently, theorists within the field of medi-
within varying levels of systems (micro, meso, exo,
cine have proposed that true preventive interven-
and macro) and settings (individual, family, school,
tions are only those which occur before the onset of
community, work). Preventive application can
a diagnosable disorder. Specifically, they recommend
yield a reduction in the occurrence of new
use of the terms universal preventive interventions to
cases of a problem, in the duration and severity of
characterize activities targeting general public or
incipient problems, and it can promote strengths
nonindividual audiences, selective preventive inter-
and optimal human functioning.
ventions to describe those activities that focus on
(Conyne, 2004, p. 25)
specific populations that have been identified as
being at risk, and indicated preventive interventions For the purposes of this chapter, we will primar-
to classify those interventions targeting high-risk ily discuss primary and secondary prevention pro-
individuals with current symptoms or biological grams. These interventions may occur at any of the
markers that do not yet meet diagnostic criteria levels defined by Munoz, Mrazek, and Haggerty
(Munoz, Mrazek, & Haggerty, 1996). To connect (1996).
these terms to the aforementioned example, the rec-
ommendation to all to eat five servings of fruits and History of Prevention
vegetables per day could be classified as a universal The concept of prevention has been traced back to
preventive intervention, providing diet information ancient civilizations, drawing from such sources as
to those identified as at risk for nutritional disorders Greek philosophers and folk wisdom (Spaulding &
is a selective preventive intervention, and providing Balch, 1983). Prevention has been a longstanding
vitamins and specific diet recommendations to topic in the professional literature of many fields in

530 preven tion an d p s ych o ed u catio n

the United States. In the field of public health, for National Prevention Conference, the term preven-
example, attention has often been given to specific, tion science was coined. This term was put forth as
targeted outreach programs related to specific disor- a descriptor of previous prevention studies that
ders (i.e., obesity, HIV, sexually transmitted dis- exclusively focused on reduction of risk factors for
eases). Along with this focus has been an emphasis mental disorders. The Institute of Medicine differ-
on addressing inequalities in health care. In 1979, entiated between “prevention activities” and “pro-
for example, the public health field initiated an motion activities,” stating that promotion activities
ongoing public health agenda, “Healthy People are not included in the spectrum of prevention
2010,” for increasing quality of life and eliminat- activities because they “focus on the enhancement
ing health disparities (Romano & Hage, 2000). of well-being” rather than intervening “to prevent
In a recent Institute of Medicine brief by the psychological or social problems or mental disor-
Committee on Assuring the Health of the Public ders” (Mrazek & Haggerty, 1994, p. 27). Many in
in the 21st Century, a new call and new recommen- the field of psychology felt this designation was
dations were made to focus prevention efforts limiting (Masten & Coatsworth, 1998), including
on communities, to take into account socioeco- APA President Seligman’s task force. In 2003, an
nomic inequities, and to create political policies that issue of the American Psychologist was devoted to
address issues such as education, adequate housing, presenting empirically based prevention studies
a living wage, and clean air (National Academy of with children and youths, in which prevention is
Sciences, 2002). conceptualized as encompassing activities that focus
Primary prevention’s role within the field of psy- on enhancement of well-being, as well as prevention
chology and mental health as a whole has been spo- of psychological disorders.
radic, although several significant events have taken
place. In 1976, the National Institute of Mental Prevention and Counseling Psychology
Health declared that primary prevention was an Prevention has long been a central component in
idea whose time had come (Klein & Goldston, the identity of counseling psychology, and can
1977), and by the 1980s, many programs had been be traced back to the vocational guidance move-
developed that utilized primary prevention. Because ment and the mental health and hygiene efforts
some felt that these programs were not always of the early 1900s in the United States. The voca-
tied to evidence of their effectiveness, however, a tional guidance movement, spurred by Frank
general skepticism arose about primary prevention Parsons, looked at the match between worker and
as practiced by psychologists (Conyne, 1991). The societal needs to allow workers to be more produc-
American Psychological Association (APA) res- tive, satisfied, and able to contribute to societal
ponded to this skepticism by creating a task force solutions (Conyne, 1987; Gelso & Fretz, 1992). In
for Promotion, Prevention, and Intervention Alter- the mental health movement, Clifford Beers called
natives in Psychology to identify effective preven- for improved treatment and prevention of mental
tion programs. Several common characteristics of illness (Romano & Hage, 2000). Despite this long-
these programs were delineated (Conyne, 1991), standing historical and philosophical commitment
resulting in the manual 14 Ounces of Prevention to well-being and prevention in the field as a whole,
(Price, Cowen, Lorion, & Ramos-McKay, 1988). the actual practice of prevention has ebbed and
In 2003, APA President Martin Seligman created flowed. Calls have been made through the years to
a second APA task force on prevention, entitled more fully integrate prevention into the identity of
Prevention: Promoting Strength, Resilience, and counseling psychologists, a proposition that essen-
Health in Young People. This task force synthesized tially calls counseling psychology back to its roots.
prevention knowledge and offered prevention prac- Hurdles such as the debate over an evidence-based
tice guidelines in a special issue of the American practice approach within the field of psychology as a
Psychologist (2003). whole have caused counseling psychologists to peri-
Despite the occurrence of these significant odically contemplate their unique contribution to
events, one issue that has perhaps slowed the prog- the field, and whether such a perspective takes us fur-
ress of prevention activities from being more incor- ther from our roots of commitment to prevention,
porated into the field of psychology as a whole multiculturalism, and social justice (Hage, 2003).
is disagreement on the definition of what consti- A Special Interest Group for Prevention and
tutes a prevention activity. In 1991, at the National Public Interest was formed by Division 17 (Society
Institute of Mental Health (NIMH)-sponsored of Counseling Psychology) of the APA in the early

m organ, ve r a 531
1990s, and in 2000, Romano and Hage proposed include prevention. For example, it is unknown
a prevention-based agenda for the field, which out- what percentage of training programs either require
lined the goals of utilizing systemic and integrative or offer classes on the topic. It is also unknown to
models, targeting children and youth for early what extent practicum or internship programs
intervention, emphasizing sensitivity to diversity, include prevention activities as required elements.
and advocating for more thorough training in pre- So, at best, these special issues might indicate that a
vention interventions. In the same issue of The critical mass of scholars is now arguing for the inclu-
Counseling Psychologist (2000), Conyne proposed a sion of prevention training in doctoral curricula.
resolution to formally incorporate prevention into
counseling psychology. Prevention has also been Successful Prevention Programs
specifically called for in therapy practices, with What constitutes a successful prevention program?
Lewis and Lewis (1981) outlining skills needed by Cowen (1984) stressed that any good prevention
counselors engaging in primary prevention counsel- program must include thoughtful planning and be
ing (Conyne, 1997). founded on a “generative base,” derived from theory
and research. Such theoretical bases can come from
Prevention Training in Counseling a variety of sources, including positive psychology,
Psychology Programs behavioral theories, and ecological frameworks. All
Although it has been argued by some counseling of these frameworks should be culturally informed,
psychologists that specialized training in prevention as a frequently cited downfall of prevention activi-
is not needed in graduate programs (as students ties is a lack of cultural relevance. One way that
already learn skills such as effective communication cultural relevance can be successfully accomplished
and knowledge of theoretical models of change in is to engage in collaborative, community-based pro-
therapeutic training; Conyne, 2004), some grad- grams in which the participants are stakeholders
uate training programs within counseling psy- in the process and help to plan the program compo-
chology have begun to emphasize specific training nents (Vera et al., 2007). Key factors in this process
in prevention. This commitment is evidenced by include addressing existing community structures
practicum settings related to prevention activities, that perpetuate inequality and not focusing exclu-
opportunities for faculty and student prevention sively on the individual participants themselves,
practice and research, emphasis on theoretical as this may have the result of placing undeserved
change models, courses on prevention methodol- blame and responsibility on the individual and not
ogy, and an emphasis on strengths and resilience the system or environment (Prilletensky, 1997; Vera
perspectives in working with clients (Romano & & Reese, 2000).
Hage, 2000). Such efforts, however, are not the Operating from a theoretically and culturally
norm. Most training programs still emphasize indi- informed base helps program leaders to choose an
vidual remediation of psychological disorders, and appropriate direction for the project. This, in com-
funding sources still seem to prefer individualized bination with collaborative involvement from com-
rather than systemically based preventive interven- munity constituents, can be a good starting point
tions (Roche & Sadowski, 1996). for the development of culturally responsive pro-
There is recent evidence that the commitment grams, which must include both addressing “surface
to training in prevention may be increasing in structure modifications” and “deep structure modi-
the field, however. The Counseling Psychologist has fications,” according to Resnicow, Solar, Breathwaite,
published two special issues on prevention. “Best Ahluwalia, and Butler (2000). Examples of surface
Practice Guidelines on Prevention” (2007) and structure modifications would include the transla-
“Culturally Relevant Prevention” (2007) provide tion of interventions into the primary language
comprehensive summaries of how to design pre- of the participants, whereas deep structure modifi-
vention programs and how to integrate cultural cations would increase perceptions of “face validity”
relevance into such efforts, respectively. These con- or relevance of a program’s goals to the needs of the
tributions are significant since the journal had not participants. We return to a discussion of this issue
published an issue focused on prevention since in the section on psychoeducation.
2000. Notwithstanding the significance of these In their work, Hage et al. (2007) outlined several
special issues, no current database demonstrates the overarching goals that have been found to contrib-
level of commitment that training programs have ute to effective prevention programming. They
to preparing their students to engage in careers that point out that such programs must include risk

532 preven tion an d p s ych o ed u catio n

reduction, use methods to increase strengths in a comprehensive prevention program will be pre-
community or individuals, and have social justice sented later in this chapter.
as a goal. Risk factors to be reduced may include Similarly, varied teaching methods have been
those at the individual or systemic level. These found to increase the chances of successfully reach-
efforts are differentiated from treatment efforts in ing more participants and increasing positive out-
that treatment addresses symptoms, thereby possi- comes of prevention programs. The range of effective
bly alleviating some distress, but not reducing risk teaching methods typically include some type of
per se because it does not reduce the occurrence of focused skill set development (e.g., using role plays
new cases. When risk is not reduced, prevention or modeling), which varies across type of interven-
programs will fail to address prominent societal tion program. Promoting strong relationships, par-
health disparities among people of different races, ticularly with at least one adult, have been associated
ethnicities, and socioeconomic levels—a philosoph- with positive outcomes for prevention in children,
ical goal of prevention work that is representative of in contrast with prevention programs that rely solely
social justice. on peer evaluation and mentorship (Grossman &
Increasing strengths or well-being in communi- Tierney, 1998). Well-trained prevention personnel
ties of individuals consists of promoting awareness or staff help to ensure a successful and effective pre-
of existing assets and providing ways to capitalize vention program. Finally, issues such as timing, com-
on these strengths. Promotion of well-being via petent and culturally sensitive interventions, and
a focus on strengths promotion has been found to supervision of the program all contribute in crucial
be both cost effective and psychologically beneficial ways to the success of a prevention program (Lewis,
for individuals and societies (Albee & Ryan-Finn, Battistich, & Schaps, 1990).
1993). Finally, social justice–oriented prevention The research methodology by which prevention
programs often focus on social policy change (which programs are developed and evaluated should
is a component of social justice). Successful exam- be carefully considered, as it has been noted that
ples of this in the United States include the women’s processes that contribute to social change are not
movement, Social Security, and Medicare programs easily measured with only experimental or quasi-
(Hage et al., 2007). Such programs are essentially experimental designs (Prillentensky & Nelson,
examples of distributive justice interventions which, 1997). Another concern is that, with the use of ran-
by changing opportunities, strive to prevent the domized, control-group designs, although they are
development of mental health problems associated often preferred for federally funded projects (Biglan
with injustice (e.g., sexism, classism). Although there et al., 2003), it can be difficult to reconcile the
is still undoubtedly much more that needs to be design of the evaluation with the needs of the com-
done to combat oppression in this society, such poli- munity (Reese & Vera, 2007). Specifically, it can be
cies often indicate a willingness at the macro level to difficult to convince underserved communities of
begin this process. the value of no-treatment or delayed-treatment con-
Recommendations for the more structural aspects trol groups, when the goal of community leaders
of effective prevention programs call for initiatives to may be to obtain as many services for as many indi-
be comprehensive, utilize varied teaching methods, viduals as possible.
have sufficient dosage or program intensity, build Qualitative or mixed methodological studies may
positive relationships for participants, give good staff therefore be more easily utilized to address commu-
training, and have sufficient program evaluation nity needs. Such types of research have the advan-
components (Nation et al., 2003). Comprehensive tage of being able to more fully address cultural
programs are those that address multiple factors contexts and to more deeply understand the partici-
across multiple contexts. In other words, rather than pant’s perspective. First of all, qualitative methodol-
a narrow focus on one prevention strategy and one ogy, such as semistructured interviewing, allows the
problem behavior (e.g., teaching conflict resolution researcher to get the perspective of the participant
to reduce violence), comprehensive prevention pro- and therefore gain context for any interventions,
grams use several different types of interventions thereby helping to increase the chances that any
that may take place in a variety of settings and affect resulting program will be responsive to community,
a range of problem behaviors. It has been shown that rather than only researcher needs. Second, in quali-
such comprehensive approaches to prevention are tative studies, each participant is given a distinctly
the most effective for reducing or preventing prob- individual voice, which increases the feeling of
lem behaviors (Nation et al., 2003). An example of involvement of participants and possibly increases

m organ, ve r a 533
participant investment in the project, as well as attractive green space before the program was even
avoids the above-mentioned problems associated implemented, thus saving time and money and
with no-treatment or delayed-treatment quantita- making the goals of the program much more rele-
tive designs. Certain types of qualitative research, vant to the community.
such as participatory action research, stress both col-
laboration with participants and a social justice Recent Prevention Literature/Programs:
agenda (Creswell, 2007), and are thus particularly An Update
well suited to prevention activities. In general, increased attention has been paid to pre-
For example, in utilizing a participatory action vention in the psychology field in the last 5 to 10
research approach for a qualitative study involving years. In 2003, a special issue of The American
recent immigrants to the United States, interview Psychologist was devoted to “Prevention that Works
data and observations collected would give infor- for Children and Youth.” An outgrowth of APA
mation on the process of immigration for the par- President Martin Seligman’s emphasis on positive
ticipants at a very detailed level. Such specific psychology (i.e., a focus on more strengths-based
information could be invaluable in gaining the psychological approaches and research), this journal
“inside perspective” needed to inform effective poli- issue highlighted the state of prevention with chil-
tical and social change in this area. For example, if a dren and youths in the past several years. Major
participant discussed the specific difficulty of obtain- themes included advocacy for the integration of
ing community connections when he or she first science and prevention (Biglan, Mrazek, Carnine,
arrived in the United States, then the interviewer & Flay, 2003), more effective evaluation of preven-
might ask what would have been helpful to the tion programs and the need for more results-based
immigrant to address this problem of social support. accountability (Wandersman & Florin, 2003), a
The participant’s response could potentially provide highlight of prevention work being done in various
valuable information for informing prevention pro- contexts, such as health care settings, schools, and
grams for recent immigrants (Morgan, 2006). family environments (Kumpfer & Alvarado, 2003;
Ethics is a final, very important, consideration in Greenberg, Weissberg, O’Brien, Zins, Fredericks,
the development of an effective prevention pro- Resnik, & Elias, 2003; Johnson & Millstein, 2003),
gram. Because prevention programs often deal with and the state of federal prevention funding for chil-
a system, many ethical considerations and possible dren (Ripple & Zigler, 2003).
negative impacts may not be initially obvious. In The recent literature on prevention in the field
addition to considering the issues of informed of counseling psychology has frequently contained
consent and competency, some particular areas of an emphasis on cultural relevance, and, in fact, cul-
possible negative impact include publicly identify- turally relevant prevention is where the field of
ing a stigmatized group (Bloom, 1993), targeting counseling psychology seems to have made the
behaviors that serve a protective purpose for the greatest contribution within the prevention arena.
community (Pope, 1990), and long-term negative In the 2007 issue of The Counseling Psychologist that
impact on the community even though short-term focused on “Culturally Relevant Prevention,” a call
impact is positive (Brown & Liao, 1999). For exam- was made for counseling psychologists to continue
ple, if parents in a low-income neighborhood choose to devise and implement prevention programs that
to keep their children indoors most of the time are truly multicultural in nature, not in name only.
because of a lack of neighborhood safety, and a pre- Specifically, both cultural relevance (i.e., the extent
vention program focuses on building a green space to which outcomes are consistent with beliefs,
to bring children outside more, there may be short- values, and desired outcomes of a particular com-
term gain in the children having a place to play, but munity; see Kumpfer, Alvarado, Smith, & Bellamy,
long-term harm in that more children fall victim 2002; Nation et al., 2003) and cultural competence
to random gang violence. Again, designing collab- (i.e., a standard that calls for the program adminis-
orative, community-based programs, in which par- trators to have the required training and experience
ticipants actively engage with researchers in the to work with a specific population; see Lopez, 1997)
discussion of such topics, helps to address concern- were discussed as being necessary for a culturally
ing issues effectively from the beginning of the relevant prevention program (Reese & Vera, 2007).
research process. In this case, neighborhood partici- Another theme of the issue was the need to bring
pants would likely be able to alert researchers to the together social justice, prevention, and multicultur-
possible long-term consequences of providing an alism, which are each components of the identity

534 preven tion an d p s ych o ed u catio n

of a counseling psychologist. More frequent attempts to better understand the viewpoint of youths
to merge these efforts in research and literature was in Moscow and to incorporate this understanding
suggested as one way to begin to approach this goal into their cross-cultural adaptation. Materials for
of integration (Adams, 2007). Several prevention the program were all translated and back-translated,
programs based in the United States were high- and an iterative consultation process was utilized in
lighted throughout the issue. Each program focused which cultural linguistic advisors and cross-cultural
on health, educational, and/or familial outcomes consultants gave input on the cultural appropriate-
designed to reduce disparities. Another issue of The ness on the program. The adapted program was
Counseling Psychologist focused on “Best Practices in used to successfully decrease identified risk factors
Prevention” and was discussed extensively earlier in and increase protective factors in the Russian youths
this chapter. (Tsarouk, Thompson, Herting, Walsh, & Randell,
On the international front and within the broader 2006).
psychological and academic realms, several recent These examples demonstrate current and suc-
prevention studies have also highlighted cultural cessful prevention projects that encompass many
issues and contain examples of many of the elements of the traits of effective programs discussed in this
of successful prevention efforts discussed previously chapter. Since counseling psychology is a discipline
in this chapter. In an international program for pre- not specifically represented in all countries (Leong
venting human immunodeficiency virus/sexually & Leach, 2007), the international programs des-
transmitted disease (HIV/STD) for married men in cribed here exemplify work being done in other dis-
urban poor communities in India, for example, both ciplines within the area of prevention in general.
a community-based research and programming and
a multidisciplinary approach (psychologists, anthro- Psychoeducation
pologists, microbiologists, and educators) was uti- Psychoeducation is a topic closely related to preven-
lized. The mixed methodological study was grounded tion in the literature. Within the history of counsel-
in a philosophy of transdisciplinary research and ing psychology, psychoeducation has always been
was funded by a grant from the U.S. National considered a staple of the field and, in fact, is identi-
Institute of Mental Health (NIMH) grant, thus pro- fied as one of the defining themes of the profession
viding an example of community-based, collabora- (Gelso & Fretz, 1992). Within the history of the
tive prevention programming that received external mental health professions, psychoeducation has
funding (Schensul, Nastasi, & Verma, 2006). played an important role in the treatment of many
In another recent international and cross- psychological problems. Authier (1977) documents
culturally collaborative project, Brazilian profes- various influences on the field of psychology that
sionals designed a program to prevent child abuse have contributed to the emergence of psychoeduca-
in Rio de Janeiro. This endeavor included interview- tional approaches. Among these influences is the
ing child protective professionals to explore their community mental health movement of the 1960s,
beliefs about what would be needed in an effective during which time the feasibility of a remedial
program for preventing child abuse in Rio de approach as a hallmark of mental health services was
Janeiro, obtaining their input on necessary systemic questioned (Hobbs, 1964). It was thought that
change (i.e., utilizing qualitative methodology), and teaching people the skills they would need to avoid
providing training that evolved from a larger nine- psychological symptoms (e.g., coping techniques,
country initiative sponsored by the International parenting approaches) was a more productive role
Society for the Prevention of Child Abuse and for mental health professionals. However, some
Neglect (IPSCAN) and that incorporated the views scholars trace the history of psychoeducation as far
of these Brazilian child protective professionals back as Alfred Adler, who, in the 1920s, gave public
(Lidchi, 2007). demonstrations of counseling with families to edu-
The final example of recent international preven- cate the community about healthy family function-
tion efforts is a program developed in the United ing (Carlson, 2006).
States that was adapted for use in Russia. The Recon- More recent literature has defined psychoedu-
necting Youth (RY) drug use prevention program cation as “among the most effective of evidence-
developed at the University of Washington was uti- based practices that have emerged in both clinical
lized with youth in Moscow through funding by the trials and community settings” (p. 205) (Lukens
National Institute on Drug Abuse. In their adapta- & McFarlane, 2004). Many working definitions
tion, the program administrators used focus groups of psychoeducation exist in the literature. For the

m organ, ve r a 535
purposes of this chapter, psychoeducation will be reduces suicidality mainly by increasing adolescents’
defined as an intervention approach that integrates understanding of symptoms of suicidal ideation/
psychotherapeutic and educational components intent and by promoting help-seeking behavior
(Lukens & McFarlane, 2004) and that can be used (Aseltine & Martino, 2004). As such, the intended
in both remedial and preventative contexts. Dixon positive outcomes of such programs are an increased
(1999) argued that psychoeducation embodies a ability to detect suicidal symptoms in self and others
paradigm of empowerment and collaboration that and an increased willingness to reach out for help for
stresses competence-building and coping, and bui- oneself, or for friends and family who may be sui-
lds on the strengths of the client. Rather than solely cidal. However, few studies have shown a decrease in
focusing on the amelioration or prevention of symp- the incidence of suicide attempts in connection with
toms, psychoeducation focuses on health promo- such programs. Critics of these psychoeducational
tion, viewing clients as learners and therapists as prevention programs have argued that it is important
teachers. to design programs that alter knowledge and atti-
Psychoeducation has become a widespread tudes that will translate into behavioral changes.
approach to the treatment of a variety of psycho- One recent psychoeducational prevention pro-
logical problems. For example, recent reviews of gram that was able to demonstrate a reduction in
the literature and meta-analyses have been pub- suicidal behavior was Signs of Suicide (SOS)
lished on the use of psychoeducation in the treat- (Aseltine & DeMartino, 2004), the focus of which
ment and/or prevention of eating disorders (Fingeret is on peer education and intervention. Peer inter-
et al., 2006), bipolar disorders (Rouget & Aubry, vention as a focus of adolescent suicide preven-
2006), teenage suicide (Portzky & van Heering, 2006), tion programs is rooted in studies that have found
and bullying (Newman-Carlson & Horne, 2004). that adolescents communicate distress more often
As a result of accumulating evidence, psychoeduca- and more easily with their friends than with family
tion is now seen as an important component in members or other concerned adults (Kalafat &
treating a variety of medical problems, where it is Elias, 1995). The content of SOS includes provid-
used to enhance treatment compliance and prevent ing information about incidence rates of suicide
disease progression. Recent mandates at both the attempts and completions, presenting data on risk
federal and international levels have pushed to and protective factors, and describing what is called
include psychoeducation as a focal point in treat- the “suicide process.” The suicide process involves
ment for schizophrenia and other mental illnesses, the progression of suicidality from ideation to
and these efforts are backed by national policy attempts to completion (van Heeringen, 2001). The
makers (President’s New Freedom Commission on model is used in psychoeducation because it implies
Mental Health, 2003) as well as influential family the possibility of intervention and help being valu-
self-help groups such as the National Alliance for able at multiple points in the process.
the Mentally Ill (NAMI) (Lehman & Steinwachs, The peer intervention component of the pro-
1998; McEvoy, Scheifler, & Frances, 1999). gram teaches participants to recognize warning signs
In the remainder of this section, a sample of of suicidal ideation and behavior, and teaches appro-
psychoeducational best practices in the prevention priate strategies of intervention (i.e., active listen-
of three psychological problems will be presented, ing, encouragement of help-seeking). Finally, such
along with a discussion of several important con- programs also identify school- and community-
siderations in the development and evaluation of based resources, such as school counselors. The obj-
psychoeducational interventions. Finally, the role ective of this program is to help adolescents better
and preparation of the counselor as psychoeducator monitor their friends and peers for signs of suicidal
will be presented. ideation or intent and to increase the likelihood
that such signs will be reported to adults capable of
Psychoeducation Best Practices in providing help. Although psychoeducational suicide
Adolescent Suicide Prevention, prevention programs may not be optimal for use
Bullying, and Eating Disorders with actively suicidal teens, they appear to be an
adolescent suicide prevention appropriate intervention to change peers’ awareness
Psychoeducation programs have been the most of and ability to identify those who may be at risk
popular forms of adolescent suicide prevention from among their peer groups (Portzky & van
(Portzky & van Heeringen, 2006). Psychoeducation Heeringen, 2006).

536 preven tion an d p s ych o ed u catio n

bullying will never be completely eliminated from the expe-
In the research on bullying, psychoeducational rience of children, programs that attempt to change
programs that have adopted social learning theo- school and peer climates have been shown to be
retical underpinnings have been in use for over very promising.
30 years (Olweus, 1978). One of the most com-
monly used psychoeducational prevention pro- eating disorders
grams based on learning theory to date, Bully Although the aforementioned programs have aimed
Busters (Newman, Horne, & Bartolomucci, 2000) to influence important significant others as agents
was designed to instruct teachers in elementary of change, the majority of eating disorders psycho-
schools to acquire the skills and knowledge to better educational prevention programs have targeted
confront bullying and victimization in their class- individuals, namely girls, and have focused on
rooms. As role models, teachers play a powerful changing unhealthy thinking that can lead to eating
role in what their students learn about norms regard- disorder symptomatology. A large number of pro-
ing bullying, as documented by previous research grams have been designed with such objectives in
(Wilezenski et al., 1994). If teachers ignore or mind. However, recently, there has been some con-
tolerate bullying as normative behavior, it teaches troversy over these programs. One area of debate
children to do the same. revolves around potential iatrogenic effects of incor-
The Bully Busters program is taught to teachers porating descriptive information about eating disor-
in three sessions and has seven content areas includ- ders into an intervention. O’Dea and Abraham
ing increasing awareness of bullying, recognizing (2000) argued against the inclusion of such psycho-
bullies and victims, teaching potential interven- educational material by warning of the potential for
tions, assisting victims appropriately, preventing glamorizing and normalizing eating disorders and
bullying behavior, and promoting healthy coping introducing young people to dangerous methods of
skills. The program was offered to the teachers as weight control. Fortunately, a recent meta-analysis
part of a school-based in-service session. The results found no evidence of this effect on program partici-
of a controlled experiment found that teachers pants (Fingeret, Warren, Cepeda-Benito, & Gleaves,
who participated in the program were more self- 2006).
efficacious in regard to identifying bullies and vic- The content of psychoeducational approaches
tims, and had acquired a greater repertoire of to eating disorders prevention typically includes
intervention skills than were teachers who did not information about healthy nutrition and diet; body
participate in the program. In terms of long-term satisfaction; idealization of thinness; the dangers of
change, such programs have been found to reduce overexercising, binging, and purging; and other
incidents of bullying in the school by as much as symptoms of eating disorders. Evaluations of these
50% (Newman et al., 2000). programs have found that participants generally
As is the case with suicide psychoeducation pre- demonstrate an increase in knowledge from pre- to
vention programs, the emphasis in the majority post-test, changes in levels of body satisfaction are
of the bullying psychoeducational prevention typically minimal, and providing information about
programs is on raising awareness and empowering symptoms of eating disorders does not result in an
individuals who have special access to the perpetra- increase in unhealthy behaviors, such as excessive
tors and victims. Although some psychoeducational exercising or purging.
programs target individuals who may be at risk One of the most interesting recent findings from
for such problems (e.g., potential victims, suicidal a meta-analysis conducted by Fingeret et al. (2006)
youth), such programs have ignored the role of sig- is that specific program content differences are not
nificant others in the prevention of these problems. related to significant effect size differences. Rather,
By including a wider scope of participants, rather what does account for larger effect sizes in such pro-
than simply attempting to identify and work with grams is targeting participants who are at higher-risk
only depressed youth, bullies, or victims, these pro- for eating disorders, using interactive and multiple-
grams have a systemic philosophical underpinning session formats, and working with girls who are over
whereby the power of the environment in shaping 15 years of age. Additionally, the authors found that
individuals’ behavior is not only affirmed, but is the purely psychoeducational approaches were equally
target of the intervention. Although it is probably as effective in influencing knowledge, eating pat-
the case that bullying or adolescent suicidal attempts terns, and body dissatisfaction as were interventions

m organ, ve r a 537
that incorporated a cognitive-behavioral therapy and to encourage the use of positive parenting
component. techniques (i.e., positive reinforcement) (Carlson,
In general, it appears that good evidence sup- 2006). A long-term benefit of such a program may
ports the use of psychoeducation to prevent eating be to reduce incidents of child abuse; if the program
disorders and related symptoms. The research in this was offered to parents who might be at risk of such
area in particular suggests that targeting specific behavior, the program would be an example of sec-
audiences may be an important element in maxi- ondary prevention. However, a program might also
mizing the effects of such interventions. The research be able to demonstrate its effectiveness by tracking
that identifies moderators of effect sizes—or who changes in participants’ knowledge base and inten-
responds most dramatically to psychoeducational tions regarding parenting. In the case of psychoedu-
interventions—is a critical area for future studies in cation that is used to increase compliance to medical
a variety of content areas. This type of information treatment, evaluations may also be based on inci-
not only will be helpful in terms of maximizing the dence rates of relapse, disease complication, and
cost effectiveness of such interventions, but it is also other measures of compliance.
critical to tailoring programs to specific audiences One of the most critical characteristics of effec-
who may be in greatest need. tive psychoeducation, however, is its perceived rele-
vance to the participants. This perception is often
Developing and Evaluating a function of the extent to which the program has
Psychoeducational Interventions cultural relevance to the targeted audience. Cultural
What makes for a “good” psychoeducation preven- relevance refers to the extent to which interventions
tion program? The answer to this question in many are consistent with the values, beliefs, and desired
ways parallels the discussion contained earlier in outcomes of a particular community (Kumpfer,
this chapter on what constitutes effective preventa- Alvarado, Smith, & Bellamy, 2002; Nation et al.,
tive interventions. For example, good psychoeduca- 2003). Nation et al. (2003) argued that prevention
tion models are based on research and theory; are program relevance, to which psychoeducation pro-
delivered by trained, competent professionals; are gram relevance is related, is a function of the extent
developmentally appropriate; are well-timed; and to which a community’s norms, cultural beliefs, and
are culturally relevant to the participants. In many practices have been integrated into program con-
ways, good psychoeducation programs are similar to tent, its delivery, and evaluation. Kumpfer et al.
good psychotherapeutic interventions. The primary (2002) argued that including cultural relevance in
differences, however, often lie within the context of prevention programs improves recruitment, reten-
delivery and the outcomes measures. tion, and outcome effectiveness.
Psychoeducation can and does occur on an indi- One of the superficial ways that cultural adapta-
vidual level. However, to be most cost effective tions have been made in many past prevention
and to capitalize on the benefits of group coun- efforts has been what Resnicow, Solar, Braithwaite,
seling, most psychoeducation occurs with groups Ahluwalia, and Butler (2000) termed “surface struc-
of individuals. For example, parenting groups, stress ture modifications.” As previously discussed, such
management workshops, job search clubs, and bio- efforts could include translating intervention mate-
feedback training are typically taught to groups of rials into the primary language of the participants
individuals who share characteristics, have com- or hiring program staff who have ethnic back-
mon needs, and can provide important support to grounds similar to those of the participants. Such
one another. The objectives of many psychoeduca- modifications may be one important aspect of cul-
tional programs are often to promote healthy devel- tural adaptation. It may be highly advantageous to
opment or adjustment, rather than to solely stave have program participants communicate with pro-
off psychopathology (Carlson, 2006). Although the gram staff in their first languages or to interact with
prevention of pathology may be an added benefit of staff of the same ethnicity and/or gender. However,
the interventions, these programs are rarely evalu- when program content does not reflect the reality of
ated based on such criteria. the participants’ experience, interventions delivered
For example, a good parenting program might by racially or linguistically similar staff will not
be based on learning theory, offered to parents early make the program relevant or, more importantly,
in the process (i.e., while their children are very effective.
young), and have goals to increase parents’ knowl- Rather than surface modifications, “deep struc-
edge of the developmental needs of their children ture modifications” (Resnicow et al., 2003) often

538 preven tion an d p s ych o ed u catio n

determine the cultural relevance of prevention pro- familiar with literature on risk and protective factors
grams. Often, the adaptations required for a preven- associated with such disorders. Rutter (1987) defines
tion program to be culturally relevant result in a risk and protective factors as variables that are likely
program that may be substantively different from to increase and minimize the emergence of a par-
its prototype. Dryfoos (1990), Lerner (1995), and ticular problem, respectively. Many epidemiological
Reiss and Price (1996), among others, have sug- studies that identify risk and protective factors are
gested that the most effective, culturally relevant conducted by researchers who are not psychologists.
prevention and psychoeducation programs include Therefore, it is important that psychologists consult
the target program participants in the planning, multidisciplinary sources of information in their
implementation, and evaluation of the program. searches, particularly for topics that may be more
As discussed with prevention programming, if frequently researched by public health professionals
this approach is followed, the content of the psy- or psychiatrists.
choeducation program may not only become more The second skill set, program development and
relevant, but the very structure of the program may evaluation, is usually a matter of consulting the lit-
look significantly different from a program designed erature on existing programs rather than developing
for a culturally dissimilar population. Although a programs from scratch. A number of empirically
preponderance of the literature suggests that a rela- supported psychoeducational approaches to bully-
tionship with the target community is a key to acq- ing, for example, could be adapted to new commu-
uiring cultural knowledge, there is still a need for nity groups. However, the importance of cultural
large-scale epidemiological research that identifies relevance in the development of psychoeducation
risk factors and how they affect particular commu- cannot be overemphasized. Often, psychoeduca-
nities. Such studies must be designed carefully and tional programs that were developed on majority
their findings examined responsibly, to assist pre- populations are not generalizable to minority popu-
vention researchers and practitioners in more accu- lations. This has been discussed in detail previously
rately understanding the communities in which in this chapter.
they work. The third skill set involves the ability to effec-
tively communicate information to the program’s
Psychologists As Psychoeducators participants. This not only involves the ability to be
Watkins (1985) argued that psychologists must be an effective lecturer and group facilitator, but it also
given distinct training in psychoeducation and involves the ability to use developmentally appro-
should not assume that their more general training priate language and to find common ways of com-
in counseling and psychotherapy has prepared them municating often complex psychological constructs.
for this important type of service delivery. More For example, discussing self-esteem with first grad-
specifically, he argued that at least three types of ers is very different from doing so with adults. Since
training are necessary for psychologists who wish to most first graders would not use or be familiar with
be competent psychoeducators. One, psychologists the term “self-esteem,” it would be important for
must be trained with the skills to seek out the psy- psychoeducators to adjust their language appropri-
chological knowledge that is relevant to the identi- ately. Using the phrase “feeling good about who you
fied problem. Two, psychologists must be trained are” or “loving yourself ” might be more appropriate
in program development and evaluation skills. ways to communicate the construct of self-esteem
Three, psychologists must be capable of communi- to children. Being able to avoid jargon and consis-
cating program content effectively. Watkins argued tently defining terms in one’s presentation is a key
that, although many psychologists gain training and component of effective psychoeducation.
experience in the first skill—seeking out appropri- Also, assuming that a great deal of psychoeduca-
ate psychological knowledge—few are trained suffi- tion takes place in group, not individual settings, it
ciently in the latter two skills. Each of these skill is important for psychologists to be capable of pro-
development areas will be discussed in greater detail cessing group dynamics and facilitating productive
below. group discussion during psychoeducational pro-
Obtaining appropriate knowledge on the devel- grams. Since there is no guarantee of confidentiality
opment of specific psychological problems (e.g., during most psychoeducational sessions, it is also
eating disorders) requires that psychologists know critical that psychologists monitor and focus group
where to find literature on the etiology and develop- discussions such that participants do not become
ment of particular problems and that they become too vulnerable, which is a major divergence from

m organ, ve r a 539
the role of counselor or therapist. Often, despite project, participants were divided randomly into
one’s efforts, participants in psychoeducational pro- two groups, the Education Program (for whom par-
grams can border on disclosing things about them- ticipant interventions began in 1991) or the Delayed
selves that would be more appropriate for therapy Program (for whom participant interventions began
sessions. in 1994) condition. Student self-report surveys were
The issue of how counselors-in-training can given when participants began the study, and after
acquire such skill sets is the topic of considerable each year of subsequent involvement (i.e., sixth, sev-
debate in the literature. Most programs in counsel- enth, and eighth grades). Parent surveys (conducted
ing psychology and other related fields find it chal- via telephone), interviews of community leaders,
lenging to add courses or required experiences to observation of potential underage drinking (using
their already lengthy curricula. However, it has been confederates as underage buyers), and a survey of
argued that creating flexibility in course content and alcohol salespeople were also conducted (Perry et al.,
the type of practica experiences we offer our students 1993).
could be a great first step in broadening graduates’ To address prevention at an individual level, stu-
skill sets. Adams (2007), for example, argued that dents were given two self-report surveys, one consist-
there are many core content areas within most pro- ing of questions on students’ knowledge of alcohol,
grams where prevention and psychoeducational attitudes and expectations about drinking, family
experiences could be included as course assignments rules about drinking, the presence of alcohol in
or as service-learning opportunities. As was the case a students’ environment, and problematic alcohol
with providing training experiences for prevention use, and the other consisting of assessment of psy-
(discussed previously in this chapter), many adapta- chosocial risk factors related to early alcohol use,
tions to current curricula are feasible. including some items from the drug problems scale
of the Minnesota Multiphasic Personality Inventory
Example of a Comprehensive for Adolescents (MMPI-A) (Perry et al., 2002).
Psychoeducational Prevention Program To address systemic and environmental needs
In this final section, we provide an example of a for change, community task forces were organized
comprehensive psychoeducational prevention pro- through identifying community leaders interested
gram that includes both individual and environ- in prevention during the community leader inter-
mental approaches and incorporates many of the views. These leaders formed groups that identified
elements of effective psychoeducational prevention major community problems related to teen alcohol
discussed in this chapter. abuse, and developed and implemented a commu-
Project Northland addresses the prevention of nity policy action plan. Task forces focused on such
substance abuse in adolescents; it utilized psychoed- topics as educating merchants about legal conse-
ucation and operated at both the individual and sys- quences of underage sales and ways of avoiding
temic levels (Perry et al., 2002). This long-term them, and the development and enforcement of
project took place in northeastern Minnesota, an alcohol-related school policies.
area shown to be particularly at risk for alcohol use. The Interim Phase of the project (1994–1996)
The project was conducted in three phases and uti- consisted of a five-session classroom psychoeduca-
lized a variety of interventions in different contexts. tion component called “Shifting Gears.” Students
Interventions included the development of social- began this in the ninth grade and discussed topics
behavioral classroom curricula (i.e., an example of such as drinking and driving, tactics of alcohol
psychoeducation in prevention), parent involve- advertising, and effective coping in the face of these
ment programs, peer leadership opportunities, and pressures.
community task forces. The goal of the program was Phase 2 (1996–1998), begun when students
to empower community residents to sustain their were in the eleventh grade, entailed implementation
own substance abuse prevention program for ado- of classroom curriculum on social and legal conse-
lescents (Perry et al., 2002). quences of drinking, parent education programs,
Participants for Project Northland were recruited a media campaign focused on not providing alco-
through school district superintendents beginning hol to people under age 21, peer action teams
in 1991 and resulted in all adolescents in the gradu- that developed campaigns for their classmates not
ating class of 1998 (sixth graders in 1991) in 24 to drink, and community action teams focused
public school districts in the northeastern Minnesota on decreasing access to alcohol among high school
counties taking part in the study. For Phase 1 of the students (Perry et al., 2002).

540 preven tion an d p s ych o ed u catio n

 Results of the 7-year project included students • Training. Despite the efforts by some
in the participating schools being significantly less training programs mentioned above, the existence
likely to have increased tendency to use alcohol, to of consistent prevention training in graduate
be influenced by peers to use alcohol, and to have programs is probably not widespread. We strongly
decreased self-efficacy to use alcohol (i.e., maintain suggest that, much in the way that sensitivity
a higher self-efficacy about refusal). Parents in the to multicultural issues has been successfully
intervention programs were also less permissive than integrated into aspects of all courses in many
those not in the programs. Researchers gained valu- programs, the “meta-lens” of prevention be utilized
able information about ideal developmental levels as an element of the framework for thinking
(i.e., earlier is more effective than later) for sub- about any coursework. This would mean
stance abuse prevention in adolescents and the introducing the concepts of prevention to students
increased effectiveness of multilevel and context immediately during their training, exposing them
interventions (Perry et al., 2002). to various concrete models of effective and ethical
We present the Project Northland prevention prevention programs, then following-up with
project as one example of effective prevention pro- continued reinforcement of this way of thinking
gramming, not as the sole way of doing effective about issues (i.e., from a preventive perspective) in
prevention work. As discussed previously, effective every course. Such training would also include
prevention programs can look quite different from incorporating prevention activities into practicum
each other, depending on the populations involved settings and experiences, so that students may
and the prevention goals. This project incorporated apply the ideas they have learned. In this way,
both individual and community approaches, with prevention could be taught as a central
attention to policy change. It was quite comprehen- component of our identity, much in the way
sive, utilizing multiple contexts for interventions. that issues of social justice have come to be
The program obtained cultural relevance through emphasized by many programs
community collaboration and provided positive (Adams, 2007).
relationships for its participants to build upon in the • Collaboration. As exemplified in the
future. Methodologically, the program used both international prevention studies described
qualitative and quantitative approaches, providing above, there can be great benefit in cross-cultural
data at varying levels of depth that were beneficial in and cross-disciplinary collaboration. Such alliances
program planning. Altogether, it met many of the serve to enhance the ability of practitioners to
“ideal goals” of a well-executed and informative psy- take different perspectives and to enrich the final
choeducational prevention program. product of the program. It therefore seems a
worthy goal, as we continue to incorporate
Future Directions prevention more solidly into our identity as
The areas of prevention and psychoeducation, as counseling psychologists, to increase efforts for
well as the counseling psychologists who work such collaborations, whether domestic or
within these specialty areas, have made some prog- international. This process parallels the process
ress in recent years toward increasing awareness of collaborative participant participation, and has
of our need for such activities in our daily work many of the same benefits. It is important to think
lives. As outlined above, several important coun- of this process broadly and creatively, as all
seling psychology venues have begun to publish collaborations may not look the same. This
more literature in this area, and some specialized flexibility should affect both logistical and
training in prevention is beginning to take place in theoretical aspects of the project. For example,
our graduate programs. All of these advancements an international collaboration may be framed in
can be seen as evidence of the field’s interest in and public health theory (particularly given
commitment to effective prevention work. Never- this field’s longstanding contributions to
theless, we still have many important lessons to the area).
learn from our sister disciplines, and there is much • Evaluation. Counseling psychologists need
more to be done if prevention work is to become to continue to work on ways to effectively evaluate
a consistently sustained part of the overall identity prevention and psychoeducation programs.
of counseling psychologists. We make the following As discussed, this can be quite difficult, as we do
suggestions toward the accomplishment of this not want “empirical outcome evaluation” to take
important goal. precedence over community needs. In other words,

m organ, ve r a 541
we must continue to think about what constitutes developmental epidemiology program. American Journal of
a “successful program,” not just in terms of Community Psychology, 27, 673–710.
Caplan, G. (1964). Principles of preventive psychiatry. New York:
practical steps to take for the programming, but in Basic Books.
how we can balance this with social justice and Carlson, J., Watts, R. E., & Maniacci, M. (2006). Consultation
cultural responsiveness. This may mean utilizing and psychoeducation. Adlerian therapy: Theory and practice
more nontraditional forms of program evaluation (pp. 251–276). Washington, DC: American Psychological
or incorporating the evaluation component into Association.
Conyne, R. K. (1987). Primary preventive counseling: Empowering
the program itself, in a way that aids the people and systems. Muncie: IN: Accelerated Development
participants in self-reflection while also being of Inc.
benefit to the researcher (i.e., is a mutually Conyne, R. K. (1991). Gains in primary prevention: Implications
beneficial component of the program to all for the counseling profession. Journal of Counseling and
involved parties). Development, 69, 277–279.
Conyne, R. K. (1997). Educating students in preventive coun-
seling. Counselor Education and Supervision, 36(4), 259–270.
Conclusion Conyne, R. K. (2000). Prevention in counseling psychology:
We seem to still be at a crossroads for truly incor- At long last, has the time now come? The Counseling
porating prevention work into our identities as Psychologist, 28(6), 838–844.
counseling psychologists. With the newly minted Conyne, R. K. (2004). Preventive counseling: Helping people to
become empowered in systems and settings. New York: Brunner-
guidelines for best practices in prevention, counsel- Routledge.
ing psychologists now have detailed plans for how Cowen, E. (1984). A general structural model for program
good prevention can occur. With our values of development in mental health. Personnel and Guidance
social justice and multiculturalism, we have lenses Journal: Special Issue on Primary prevention in schools, 62,
through which we can teach and look for imple- 485–490.
Creswell, J. W. (2007). Qualitative inquiry and research design:
mentations of these programs that are consistent Choosing among five approaches. Thousand Oaks, CA: Sage
with our professional identities. What remains is for Publications.
more counseling psychologists to awaken to and Dixon, L. (1999). Providing services to families of persons with
embrace prevention as part of their identity and schizophrenia: Present and future. Journal of Mental Health
to go out and put it into practice, teach future coun- Policy and Economics, 2, 3–8.
Dryfoos, J. (1990). Adolescents at risk: Prevalence and prevention.
seling psychologists to do the same, and thereby New York: Oxford University Press.
change the course of problem behavior and mental Durlak, J. A. (1997). Successful prevention programs for children
health issues. We feel that the issues of training, col- and adolescents. New York: Plenum Press.
laboration, and evaluation must be addressed for Fingeret, M. C., Warren, C. S., Cepeda-Benito, A. & Gleaves, D. H.
this to successfully occur. (2006). Eating disorder prevention research: A meta-analysis.
Eating Disorders: The Journal of Prevention and Research, 14,
191–213.
References Gelso, C., & Fretz, B. (1992). Counseling psychology (2nd ed.).
Adams, E. (2007). Moving from contemplation to prepara- Tokyo: Harcourt College.
tion: Is counseling psychology ready to embrace culturally Greenberg, M. T., Weissberg, R. P., O’Brien, M. U., Zins, J. E.,
responsive prevention? The Counseling Psychologist, 35(6), Fredericks, L., Resnik, H., & Elias, M. J. (2003). Enhancing
840–849. school-based prevention and youth development through
Albee, G. (1983). Psychopathology, prevention, and the just coordinated social, emotional, and academic learning.
society. Journal of Primary Prevention, 4, 5–36. American Psychologist, 58, 466–481.
Albee, G. W., & Ryan-Finn, K. D. (1993). An overview of Grossman, J. B., & Tierney, J. P. (1998). Does mentoring work?
primary prevention. Journal of Counseling and Development, An impact study of the Big Brothers Big Sisters program.
72, 115–123. Evaluation Review, 22(3), 403–426.
Aseltine, R., & DeMartino, R. (2004). An outcome evaluation Hage, S. M. (2003). Reaffirming the unique identity of counsel-
of the SOS suicide prevention program. American Journal ing psychology: Opting for “The road less traveled by”. The
of Public Health, 94, 446–451. Counseling Psychologist, 31, 555–563.
Authier, J. (1977). The psychoeducation model: Definition, Hage, S. M., Romano, J. L., Conyne, R. K., Kenny, M.,
contemporary roots and content. Canadian Counsellor, 12, Matthews, C., Schwartz, J., & Waldo, M. (2007). Best prac-
15–22. tice guidelines on prevention, practice, research, training,
Biglan, A., Mrazek, P. J., Carnine, D., & Flay, B. R. (2003). The and social advocacy for psychologists. The Counseling
integration of research and practice in prevention of youth Psychologist, 35(4), 493–566.
problem behaviors. American Psychologist, 58, 433–440. Hobbs, N. (1964). Mental health’s third revolution. Journal
Bloom, M. (1993). Toward a code of ethics from primary of Orthopsychiatry, 34, 822–833.
prevention. Journal of Primary Prevention, 13, 173–182. Johnson, S. B., & Millstein, S. G. (2003). Prevention oppor-
Brown, C. H., & Liao, J. (1999). Principles for designing ran- tunities in healthcare settings. America Psychologist, 58.
domized preventive trials in mental health: An emerging 475–481.

542 preven tion an d p s ych o ed u catio n

Kalafat, J., & Elias, M. (1995). Suicide prevention in an educa- Newman, D., Horne, A., & Bartolomucci, L. (2000). Bully bust-
tional context: Broad and narrow foci. Suicide and Life ers: A teacher’s manual for helping bullies, victims, and bystand-
Threatening Behavior, 25, 123–133. ers. Champaign, IL: Research Press.
Klein, D. C., & Goldston, S. E. (1977). Primary prevention: Newman-Carlson, D., & Horne, A. (2004). Bully busters: A psy-
An idea whose time has come (DHEW Publication No. ADM choeducational intervention for reducing bullying behavior
77–747). Washington, DC: U.S. Government Printing in middle school students. Journal of Counseling and
Office. Development, 82, 259–267.
Kumpfer, K. L., & Alvarado, R. (2003). Family-strengthening O’Dea, J., & Abraham, S. (2000). Improving body image,
approaches for the prevention of youth problem behaviors. eating attitudes, and behaviors of young male and female
American Psychologist, 58, 457–465. adolescents: A new educational approach that focuses on
Kumpfer, K. L., Alvarado, R., Smith, P., & Bellamy, N. (2002). self-esteem. International Journal of Eating Disorders, 28,
Cultural sensitivity and adaptation in family based interven- 43–57.
tions. Prevention Science, 3, 241–246. Olweus, D. (1978). Aggression in the schools: Bullies and whipping
Lehman, A., & Steinwachs, D. (1998). Translating research into boys. Washington, DC: Hemisphere.
practice: The Schizophrenia Patients Outcomes Research Perry, C. L., Williams, C. L., Forster, J. L., Wolfson, M.,
Team treatment recommendations. Schizophrenia Bulletin, Wagenaar, A. C., Finnegan, J. R., et al. (1993). Background,
24, 1–10. conceptualization and design of a community-wide research
Leong, F., & Leach, M. M. (2007). Internationalising counseling program on adolescent alcohol use: Project Northland.
psychology in the United States: A SWOT analysis. Applied Health Education Research, 8(1), 125–136.
Psychology: An International Review, 56(1), 165–181. Perry, C., Williams, C. L. Komro, K. A., Veblen-Mortenson, S.,
Lerner, R. M. (1995). America’s youth in crisis: Challenges and Stigler, M. H., Munson, K. A., Farbakhsh, K., Jones, R. M.,
options for programs and policies. Thousand Oaks, CA: Sage. & Forster, J. L. (2002). Project Northland: Long-term out-
Lewis, C., Battistich, V., & Schaps, E. (1990). School-based comes of community action to reduce adolescent alcohol use.
primary prevention: What is an effective program? New Health Education Research, 17, 117–132.
Directions for Child Development, 50, 35–39. Pope, K. (1990). Identifying and implementing ethical standards
Lewis, J. A., & Lewis, M. D. (1981). Educating counselors for primary prevention. Prevention in Human Services, 8,
for primary prevention. Counselor Education and Supervision, 43–64.
20, 172–181. Portzky, G., & van Heeringen, K. (2006). Suicide prevention in
Lidchi, V. L. (2007). Reflections on training in child abuse adolescents: A controlled study of the effectiveness of a
and neglect prevention: Experiences in Brazil. Child Abuse school-based psychoeducational program. Journal of Child
Review, 16(6), 353–366. Psychology and Psychiatry, 47, 910–918.
Lopez, S. (1997). Cultural competence in psychotherapy: President’s New Freedom Commission on Mental Health.
A guide for clinicians and their supervisors. In C. E. Watkins (2003). Achieving the promise: Transforming mental health care
(Ed.), Handbook of psychotherapy supervision (pp. 570–587). in America. Rockville, MD: Author.
New York: John Wiley. Price, R. H., Cowen, E. L., Lorion, R. P., & Ramos-McKay, J.
Lukens, E., & McFarlane, W. (2004). Psychoeducation as (Eds.). (1988). 14 ounces of prevention: A casebook for practitio-
evidence-based practice: Considerations for practice, research, ners. Washington, DC: American Psychological Association.
and policy. Brief Treatment and Crisis Intervention, 4, Prilleltensky, I. (1997). Values, assumptions, and practices:
205–225. Assessing the moral implications of psychological discourse
Masten, A. S., & Coatsworth, J. D. (1998). The development and action. American Psychologist, 52, 517–535.
of competence in favorable and unfavorable environments: Prilleltensky, I., & Nelson, G. (1997). Community psychology:
Lessons form research on successful children. American Reclaiming social justice. In D. Fox, & Prilleltensky, I. (Eds.),
Psychologist, 53(2), 205–220. Critical psychology: An introduction (pp. 166–184). Thousand
McEvoy, J., Scheifler, P., & Frances, A. (1999). Expert consensus Oaks, CA: Sage.
guideline series: Treatment of schizophrenia. Journal of Reese, L., & Vera, E. (2007). Culturally relevant prevention: The
Clinical Psychiatry, 60, 3–80. scientific and practical considerations of community-based
Morgan, M. L. (2006). International comparisons of resilience programs. The Counseling Psychologist, 35, 763–778.
in Mexican national and Mexican immigrant populations. Reiss, D., & Price, R. H. (1996). National research agenda for
Doctoral dissertation, Loyola University Chicago. Dissertation prevention research: The National Institute of Mental Health
Abstracts International, 67 (9-B). Report. American Psychologist, 51, 1109–1115.
Mrazek, P. J., & Haggerty, R. J. (Eds.). (1994). Reducing risks Resnicow, K., Solar, R., Braithwaite, R., Ahluwalia, J., &
for mental disorders: Frontiers for preventive intervention Butler, J. (2000). Cultural sensitivity in substance abuse pre-
research. Washington, DC: National Academy Press. vention. Journal of Community Psychology, 28, 271–290.
Munoz, R. F., Mrazek, P. J., & Haggerty, R. J. (1996). Insti- Ripple, C. H., & Zigler, E. (2003). Research, policy, and the
tute of Medicine report on prevention of mental disor- federal role in prevention initiative for children. American
ders: Summary and commentary. American Psychologist, 51, Psychologist, 58, 482–490.
1116–1122. Roche, S. E., & Sadoski, P. J. (1996). Social action for battered
Nation, M., Crusto, C., Wandersman, A., Kumpfer, K., Seybolt, D., women. In A. R. Roberts (Ed.), Helping battered women:
Morrissey-Kane, E., et al. (2003). What works in prevention: New perspectives and remedies (pp. 13–30). New York: Oxford
Principles and effective prevention programs. American University Press.
Psychologist, 58, 449–456. Romano, J. L., & Hage, S. M. (2000). Prevention and counsel-
National Academy of Sciences. (2002). The future of the public’s health ing psychology: Revitalizing commitments for the 21st cen-
in the 21st century. Institute of Medicine. Washington, DC. tury. The Counseling Psychologist, 28, 733–763.

m organ, ve r a 543
Rouget, B., & Aubry, J. (2006). Efficacy of psychoeducational Vera, E. M., Caldwell, J., Clarke, M., Gonzales, R., Morgan, M.,
approaches on bipolar disorders: A review of the literature. & West, M. (2007). The Choices Program: Multisystemic
Journal of Affective Disorders, 98, 11–27. interventions for enhancing the personal and academic effec-
Rutter, M. (1987). Psychological resilience and protective tiveness of urban adolescents of color. The Counseling
mechanisms. American Journal of Orthopsychiatry, 57, Psychologist, 35(6), 779–796.
316–331. Vera, E. M., & Reese, L. E. (2000). Preventive interventions
Schensul, S., Nastasi, B., & Verma, R. (2006). Community- with school-age youth. In S. Brown, & R. Lent (Eds.),
based research in India: A case example of international and Handbook of counseling psychology (pp. 411–434). New York:
transdisciplinary collaboration. American Journal of Com- John Wiley.
munity Psychology, 38, 95–111. Wandersman, A., & Florin, P. (2003). Community interven-
Spalding, J., & Balch, P. (1983). A brief history of primary pre- tions and effective prevention. American Psychologist, 58,
vention in the twentieth century: 1908–1980. American 441–448.
Journal of Community Psychology, 11, 59–80. Watkins, C. E. (1985). Counseling psychology, psychoeduca-
Tsarouk, T., Thompson, E. A., Herting, J. R., Walsh, E., & tion, and health psychology: A comment on Klippel and
Randell, B. (2006). Culturally specific adaptation of a pre- DeJoy. Journal of Counseling Psychology, 32(1), 147–149.
vention intervention: An international collaborative research Wilezenski, R., Steegman, R., Braun, M., Feeley, F., Griffin, J., &
project. Addictive Behaviors, 32, 1565–1581. Horowitz, T. (1994). Promoting fair play. Paper presented at
Van Heeringen, C. (2001). Understanding suicidal behavior. The the annual meeting of the National Association of School
process approach to research and treatment. Chichester, UK: Psychologists, Seattle, WA. (ERIC Document Reproduction
John Wiley & Sons. Service, No. ED380744).

544 preven tion an d p s ych o ed u catio n

 CHAPTER

21 Career Counseling

Robert C. Chope

Abstract
The field of career counseling began with a well-defined, but narrow scope. Its goal was to match
a person’s skills, interests, and predilections to an appropriate job. Although it offered a means of
allowing people to consider new vocational options, the approach did not require the in-depth
knowledge of occupations; psychological and assessment skills; the understanding of the larger
contexts of ethnicity, gender, and economic and social status; and the intuitive understanding of the
counseling process that have become such important parts of the field today. This chapter describes
the evolution of the career counseling field, which now includes all of these aspects. Ironically, the
chapter also reveals how the founder of the field, Frank Parsons, formulated an approach to vocational
counseling with a social justice perspective; this perspective is currently fueling one of the fastest
growing bodies of career counseling research and practice.
Keywords: assessment, career counseling, counseling process, interests, vocational counseling,
social justice

This chapter is about career counseling, a disci- Pope suggests that the development of the career
pline closely aligned with vocational psychology, counseling discipline can be put into perspective by
a topic Larson covers earlier in this Handbook (2011, enumerating six sequential stages of its history: job
Chapter 6, this volume). The theories of career selec- placement services (1890–1919), educational guid-
tion, adjustment, and satisfaction, along with theo- ance in the schools (1920–1939), coursework in col-
ries of vocational behavior—all drawn from leges and universities and the training of counselors
vocational psychology—are used in the career coun- (1940–1959), the creation of meaningful work and
seling process. organizational career development (1960–1979), the
But career counseling is distinct in compelling independent practice of career counseling and out-
ways and has had a storied history of over 100 years. placement counseling (1980–1989), and school-to-
Pope (2000) has explored this history and contextu- job transition, the internalization of career counseling,
alized it by offering a social transition stage model, multicultural career counseling, and increasing sophis-
positing that the development of career counseling tication in the use of technology (1990–present).
was influenced by continuing societal changes. Clearly, economic expansion and contraction
Other approaches to the history of career counsel- along with societal changes have affected the devel-
ing may be explored with Aubry (1977), Borow opment of career counseling both within the
(1964), Brewer (1942), and Herr, Cramer, and United States and abroad. Pope contends that the
Niles (2004). enumeration of the stages of development that

545
career counseling has undergone in the United perhaps due to several factors. First, the origin of
States has the potential to assist all career profes- career counseling is typically credited to Frank
sionals, regardless of where they practice, to prepare Parsons (1909) and his relatively straightforward,
their responses to social and economic upheavals three-pronged approach to career counseling, which
while continuing professional growth. Herr (2003) included developing an awareness of the self, analyz-
agrees to some extent with Pope, pointing out that ing and understanding occupations, and using true
career counseling is largely a “creature of public reasoning to choose an occupation. His approach
policy” (p. 8). did not appear on its face to have the in-depth reflec-
Career counseling has been characterized as the tive and intuitive understanding that was to become
“cornerstone upon which the counseling profes- such a hallmark of personal counseling. Instead, it
sion was built” (Dorn, 1992, p. 176). Indeed, career involved more the matching of worker characteris-
counseling, known earlier by other titles such as tics with the demands of the work environment, an
vocational guidance or vocational counseling, has approach frequently referred to as trait-factor theory
been the subject of state and federal public policy or “lock and key.”
and legislation adopted to address a variety of eco- In spite of the simplicity of Parson’s approach, it
nomic, workforce, and political issues. Herr adds offered a means of allowing people to consider new
that legislators, along with policy developers, pro- vocational or career-related options, although “career”
moted the popular utilization of career counsel- was not then a term in popular usage. Parson’s career
ing services at significant turning points in people’s counseling was enormously important at the turn
lives: deciding upon higher education or vocational- of the 20th century because impoverished immi-
technical training, school-to-work transitions (STW), grants and farmers dwelling in urban settings were
career change in mid-life, reentry into work, and, of struggling to change their lots in life. Curiously,
course, in dealing with unemployment, job loss, and Parson’s model offered an early example of the social
retirement. justice influences of career counseling as a means
The career counseling process, to be sure, utilizes of creating options for people living on the edges of
many of the techniques of the generic, personal society.
counseling process, covered by Hoffman (2011,
Chapter 19, this volume), although the relationship Assessing Soldiers and Veterans
between career and personal counseling has been After World War I and World War II, many orga-
distinguished by some thorny complications and a nizational and differential psychologists were drawn
lack of appreciation on the part of some personal together to assist in developing instrumentation
counselors. Attempts at reconciliation have been for the selection and placement of military per-
made, however. According to Zunker (2006), for sonnel (e.g., Kelly, Thorndike, Strong, Wechsler,
the past 20 years, there has been a call for the inte- Woodworth, Yerkes). The results of these efforts fil-
gration of career and personal counseling. He points tered into the general public with the advent of new,
out that, in 1993, a portion of one issue of The popular, work-related tests. These included mea-
Career Development Quarterly (CDQ) (Volume 42, sures of vocational interests, work personalities,
pp. 129–173) focused upon and supported the inte- aptitudes, and skills, and were brought into the
gration of career and personal counseling by defin- career and vocational guidance process to assist with
ing counseling as being concerned with problems the development of self-awareness among those
that are a part of the many roles everyone adopts seeking career directions. Data extracted from mili-
over the course of a lifetime. Highly influential the- tary testing, of course, became especially useful to
orists in the field, such as Donald Super (1993) and veterans seeking employment or retraining after
John Krumboltz (1993), who contributed to that their service. For almost a century now, researchers
perspective, agreed that a dichotomous relationship have continued to develop new means of gathering
should not exist between career and personal coun- information on career-related worker characteristics
seling for the simple reason that career and personal such as aptitudes and skills, interests, values, and
problems cannot be compartmentalized. personality characteristics because of these early
large-scale test development projects.
Frank Parsons: The Origin This “goodness of fit” information gathering
Unfortunately, many counseling professionals fre- process with which career counseling began led to
quently view career counseling as a rather rudimen- the perception among mental health professionals
tary and mechanistic form of counseling. This is and the consumers of counseling services that career

546 career cou n s el in g

counseling was an unimaginative, mechanistic expe- technology (IT), certain work does not necessarily
rience. Furthermore, the publication of career coun- have to be done face-to-face or locally. There are
seling resources like the Dictionary of Occupational more opportunities to work off-site than ever, and
Titles, Occupational Outlook Handbook, and the these opportunities continue to grow as workers
Guide to Occupational Information by the Depart- plan their professional development around their
ment of Labor (now replaced by links to the United choices of lifestyle and job tasks.
States Department of Labor’s O ∗Net at www.onet. Career counseling motivates individuals to find
org) gave a greater body of information to individu- work and a life path, but also assists in understand-
als wanting to understand the nature of work, but ing how meaning can be put into one’s life through
detracted from the psychology of career develop- work (Savickas, 2005). Earlier writers on career per-
ment. Certainly, career counselors use a great mass spectives (Okun, 1984; Super, 1984) suggest that
of information to become more proficient in the work interfaces with all of our life roles, whether
true reasoning process, but it has become strikingly with family, in hobbies and leisure activities, or in
clear that the more recent psychology of the self and volunteer pursuits.
the context of self-experience and meaning making Career counseling is also a process that has
have taken career counseling practitioners far become increasingly dynamic and is not necessarily
beyond Parson’s original vision. concerned with initial job placement; instead, it
focuses on the integration of various life roles and
Integrating Counseling and Psychotherapy work. Accordingly, it has been recommended that
Crites (1981) takes the perspective that the incorpo- career counselors be used by individual clients over
ration of the very best from the theories of counseling the course of a lifetime, just as they use other help-
and psychotherapy into the best models of career ing professionals. Goodman (1994) has offered the
counseling results in five propositions that offer a dif- dental model for career counselors, suggesting that
ferent way of considering the integration of career consumers consult a career counselor for regular
and personal counseling. These propositions include: checkups, just as they regularly visit their dentists.
Career counselors are quite cognizant that the work
• The need for career counseling is greater than
world, along with available information about work,
the need for psychotherapy.
is changing at break-neck speeds, and most individ-
• Career counseling can be therapeutic.
uals do not have the time or resources to pinpoint
• Career counseling should follow
opportunities that they could avail themselves of.
psychotherapy.
Career counselors can assist with this as they aid in
• Career counseling is more effective than
the upward management of an individual’s career.
psychotherapy.
Most of the approaches to career counsel-
• Career counseling is more difficult than
ing today call attention to a field that covers the
psychotherapy. (pp. 14–15).
lifespan in a holistic and meaningful way. Amundson,
Career counseling has evolved; it incorporates Harris-Bowlsbey, and Niles (2009) define career
self-awareness with information on occupations. counseling as a “process in which a counselor works
The career counseling process in modern times is collaboratively to help clients/students clarify, spec-
less focused upon the initial entry of individuals ify, implement, and adjust to work-related deci-
into careers and more concerned with the manner sions. Career counseling addresses the interaction
in which individuals plan a career path that will of work with other life roles” (p. 7).
cover a variety of opportunities over the course of a Adding to their definition, Amundson, Harris-
lifetime. Career information is readily available in Bowlsbey, and Niles (2009) outline the many meth-
the United States and can be accessed through offi- ods and interventions that career counselors utilize
cial portals like O ∗Net (www.onet.gov). in their everyday work. Career counselors select,
administer, and interpret a variety of assessment
Life Path: The New Context tools, gathering information on interests, values,
Unlike Parson’s experience, in the 21st century, indi- abilities, and other personal characteristics as
viduals now change jobs regularly and are in and out deemed necessary for the counseling process to be
of new jobs and training programs as new opportu- effective.
nities develop and abound. Individuals can now Career counselors also suggest and encourage
work locally as well as globally, work face-to-face their clients to obtain job experience and knowledge
or be virtually present. In the age of information through the job shadowing process, internships,

chope 547
externships, or term-time employment during their were identified within four developmental levels
secondary and higher educational experiences. from childhood through adulthood. Throughout
Career counselors are knowledgeable about different life, structural family variables like parental places
marketing tools that job seekers need, so that they of work and process variables including warmth,
can assist with resume development, teach inter- support, and attachment were found to influence a
viewing skills, and coach clients regarding the devel- variety of career constructs.
opment of support networks. They also assist with Chope (2005) offered a review of the qualita-
pointing clients toward appropriate occupational tive methods for assessing influential factors in
information, developing career plans, and resolving the family relative to career decision making. These
work-related conflicts, including the effects of work- included retrospective questionnaires, career geno-
to-family or family-to-work spillover. grams, career-o-grams (Thorngren & Feit, 2001),
Particular approaches to career counseling have and critical incident techniques. However, it was
been provided by Luzzo (2000), who covers career noted that, although qualitative assessment meth-
counseling with college students. Swanson and ods can be applicable to the career counseling pro-
Fouad (1999) offer a means of demonstrating the cess, these tools are time-consuming and demand
intertwining of career theory with career counsel- a high level of clinical skill to utilize effectively.
ing. General theories of career development are Still, the career genogram (Okiishi, 1987), a type
made available by Sharf (2006). of occupational family tree, is undeniably the most
commonly recognized and frequently administered
Detecting Family Influence qualitative instrument for gathering information
In what can amount to highly personal activities in about the influence of the family in career decision
their work, career counselors also help clients to making. As a postmodern tool, it allows for the
explore and understand the influence of their fami- understanding of career decision making in the con-
lies in their career choices, as well as the potential text of the family (Dagley, 1984). More recently,
links between their career choices and their cultures. there has been the establishment of the multicul-
To this extent, counselors must be aware of the con- tural genogram (Sueyoshi, Rivera, & Ponterotto,
textual issues that influence career choice. There is a 2001), currently used to explore how ethnicity, race,
strong view that career development and career culture, and religion can affect a person’s attitudes
counseling must be understood from a “relational” and decision making. It has been recommended
point of view, making the developmental process that the multicultural genogram be combined with
dynamic since both the individual and the context a career genogram to intensify and give a multicul-
are changing (Blustein, 2001; Schultheiss, 2003). tural perspective to the career counseling process.
As part of these relational approaches to career
counseling, career counselors must also be aware of National Career Development Association
the influence of families on career decision making. Only 4 years after Parson’s seminal work, the
Two substantial literature reviews have been devoted National Career Development Association (NCDA)
to the topic of family influence on career decision was founded in 1913, as the National Vocational
making. The first, prepared by Schulenberg, Guidance Association (NVGA), the first national
Vondracek, and Crouter in 1984, summarized professional counseling association. The NVGA
research findings, examining the impact of structural name was changed to NCDA in 1984, reflecting the
variables like socioeconomic status, birth order, and greater use of the term career counseling in contrast
gender, along with process variables such as career to vocational guidance.
choice modeling, parental support, and parenting The NCDA website (www.ncda.org) lists the
styles. The review, however, lacked any material rep- competencies required by practitioners to engage in
resentative of the multiethnic and multicultural career counseling (National Career Development
society evolving in the last quarter century. Association [NCDA], 1997). These competencies
A more recent review by Whiston and Keller include career development theory; individual and
(2004) delineated the findings of 77 studies related group counseling skills; individual and group assess-
to the influence of the family of origin on career ment; career information and resources; career devel-
development. The work covered 29 different jour- opment program, promotion, management and
nals from various disciplines, including psychology, implementation; coaching, consultation, and per-
education, counseling and guidance, and career formance improvement; providing services to diverse
development. Influential family contextual factors populations; giving and receiving supervision;

548 career cou n s el in g

knowledge of the ethical and legal issues in career individuals in entering the job market. But, in a
counseling; knowledge for understanding research changing and more globalized world, it has become
and evaluation in career counseling; and knowing incumbent upon career counselors to focus upon
how to utilize essential technology to assist clients worker adaptations to a changing workplace, in
with career planning. which skill requirements as well as the needs of
workers change over the course of their lifespan. For
Career Choice, Work Adjustment, example, Carless and Bernath (2007) used a sample
and Job Transitions of career-changing Australian psychologists to study
Adjustment to Work the antecedents to their intent to change careers.
Career counselors clearly help individuals decide Monitoring the change of employment patterns in
upon career and educational choices. But their work both Western society and their native Australia, they
goes far beyond helping people find a job and earn observed that professionals are currently redefining
a paycheck. Career counselors today are enormously success, a process unheard of just a few years ago.
concerned with a worker’s current and future happi- There appears to be less interest among workers
ness, along with their satisfaction and adjustment in in climbing a professional, linear, corporate ladder,
the workplace. Individuals and professionals unfa- and more focus placed upon self fulfillment, profes-
miliar with the field are often unaware of this. sional engagement, and self-awareness. Whether this
People want to feel as if their work has meaning trend has emerged from workers engaged in life and
(Brief & Weiss, 2002). Blustein (2006) says that this career balancing, work-to-family spillover, or “time-
meaning is affected by the workplace experience, in sensitive” two-career families is not established.
which a career identity is developed, interactions Nevertheless, career change and reeducation to
take place with other workers, and satisfaction is develop new career paths are now becoming com-
experienced by investment of effort, activity, and mon threads in the emerging, globalized work
energy into work tasks. world. People who are dissatisfied with their jobs or
Lent (2008) has pointed out that happy workers life path tend to take more action toward change.
have a tendency to be more productive, and this can They are more willing to tell others of their job
lead to greater consistency in their attendance at search intentions, and to actively engage in an actual
work, being helpful and mentoring to their cowork- job search, culminating in a job or career change.
ers, and accruing longevity on the job. This greater Dissatisfied workers are more willing to engage
positive affect in the workplace can affect not only in career planning as they seek out greater job satis-
an employee’s adjustment to work, but can also lead faction, in which their needs are matched by work-
to overall improvements in both physical and mental place reinforcers. The job changers tend to trust
health, even though these are known to fluctuate their own resilience as they relinquish their career
over time and with varying conditions (Judge & identities with less than predictive discomfort and
Ilies, 2004). conscientiousness.
The adjustment to work has been studied care-
fully by researchers using the theory of work adjust- Dealing with Disappointment
ment (TWA; Dawis & Lofquist, 1984), and it is The complexity of career counseling and its inher-
impossible to leave this out of any material discuss- ent blending with psychotherapy can be illustrated
ing career counseling. The theory matches workers’ with a variety of cases, and dealing with disappoint-
needs and skills with the reinforcers of their needs in ment due to barriers to opportunities stands out as
the workplace, along with the skill requirements of one important example. There are, unfortunately,
the job they are currently in or hope to pursue. The many situations that demand a career change or a
correspondence between the needs of the worker rethinking of career choices when external threats to
with the reinforcer system of the workplace is used to an individual’s career goals arise.
predict job satisfaction. Similarly, the correspon- This phenomenon has been studied by Pizzolato
dence between the worker’s skills and the skills (2007) using the narratives of individuals who had to
required in the work environment are used to predict cope with looming disappointment or severe block-
job satisfactoriness. Workers who experience both ages to their career plans. Denial of admission to a
job satisfaction and job satisfactoriness are expected particular professional school or being prevented from
to accrue job tenure in their particular workplace. entering their chosen major illustrates their point.
The TWA is a model not unlike other “goodness- Earlier, Gottfredson (1981, 2004) had studied
of-fit” models used by career counselors to assist and theorized about the nagging compromises

chope 549
regarding career paths that were influenced by social remain resilient and what, in their minds, consti-
and economic contingencies, available resources, tutes adversity. In addition, they questioned the use-
and support from a client’s family or community. fulness of some job-seeking groups. It could be that,
Pizzalato (2007) cites an abundance of literature for some, remaining in groups with unsuccessful job
describing how perceptions of achievement, compe- seekers could foster feelings of helplessness, futility,
tence, and self-concept are deleteriously affected by and depression.
the experiences of failure. In turn, this forces com- Job loss is, however, always difficult, and career
promises to plans. She goes on to articulate that counselors who work with people experiencing
many people sharing this experience do not know job loss take on a therapeutic role. In light of this
of or are not given information about alternative truism, Blau (2007) has identified and success-
options. This is where career counselors play a sig- fully measured grieving stages during job loss in
nificant role. Her study added to the literature on a fashion similar to that of Kubler-Ross (1969).
how college students cope with external threats to These included negative stages—denial, anger, bar-
their career fantasies. The findings showed that gaining, and depression—as well as those that were
threat attributions and coping strategies resulted in more positive—exploration, acceptance. Greater
students either exiting or recycling through the anger was the most influential negative grieving
career development process. Most importantly, the stage, whereas acceptance was the most influential
simultaneous consideration of both career goals and positive stage.
noncareer or personal goals led to retention or revi-
sion, as opposed to the abandonment of the highly Evidence-based Approaches
anticipated career-possible self. to Career Counseling
Kazdin (2008) remarks that the essential focus of
Developing Resilience evidence-based approaches to counseling is upon
In difficult circumstances, career counselors assist the extent to which empirically supported findings
clients in developing resilience as a healthy response. from research can be applied to clinical practice. He
Moorhouse and Caltabiano (2007) examined adult goes on to add that there remains quite a debate
resilience in the context of unemployment using regarding the merits of evidence as it pertains to
a sample of 77 unemployed job seekers. They clinical interventions. He emphasizes that evidence-
pointed out that resilience is an important ingredi- based practice (EBP) refers to “clinical practice that
ent in the job search process in the face of unem- is informed by evidence about interventions, clini-
ployment. They also advised that research has shown cal expertise, and patient needs, values, and prefer-
the unfortunate effects of unemployment on emo- ences and their integration in decision making
tional well-being. Using scales for measuring resil- about individual care” (p. 147). Evidence-based
ience, depressed mood, and assertive job hunting, practice goes beyond the well-known clinical prac-
they found that resilience is indeed related to posi- tice maxim, “Different folks benefit from different
tive outcomes among the unemployed. Low levels strokes” (Beutler, 1991, 2002).
of depression were also significantly correlated with The interventions that encompass the practice of
high resilience, and resilience was positively and career counseling have been the subject of EBP in
significantly correlated with the self-reported like- counseling psychology for many years (Swanson,
lihood of job search assertiveness. Moorhouse 1995; Whiston, 2002; Whitely, 1984). The selec-
and Caltabiano further noted that unemployed tion of appropriate outcomes has been an issue for
people who are self-reliant, independent, deter- some time, although useful considerations of out-
mined, resourceful, persevering, and resilient were come variables have been offered years ago (Oliver,
more prone to be assertive in their job search. 1979). Three meta-analyses have been done regard-
This study demonstrated that resilience helps ing the general effectiveness of career counseling
individuals cope with the adversity of unemploy- and indicators of EBP (Oliver & Spokane, 1988;
ment, and lessens the likelihood of depression with Spokane & Oliver, 1983; Whiston, Sexton, &
repeated failures of job searching. The authors point Lasoff, 1998). Moreover, Whiston (2002) applied
out that the adversities of unemployment are quite the principles of empirically supported interventions
different from other adversities that people confront (PESI) (Wampold, Lichtenberg, & Waehler, 2002)
and bring to counseling. They suggested that quali- to research related to career counseling and inter-
tative research might be useful to bring greater ventions. Whiston highlighted the concerns over
insight to what makes unemployed job seekers career intervention outcome investigations and

550 career cou n s el in g

pointed out that more focus needs to be given to in the practice of career counseling and the ways
client attribute by treatment interactions to deter- that work can be handled in the 21st century. These
mine which career interventions are most effective can include discussions of topics like telecommuting
with which clients. to work, distance learning, virtual offices, web-based
Although a great deal is known about the career career development programming, online assess-
development needs of multiethnic, multicultural, ments, and the use of the Internet for information
and diversified clients, an equal level of research has gathering. All of these topics are examined from a
not explored the differing effects of career interven- research base. Other issues of concern include
tions with these groups, although the information gender, work and family, and multiculturalism. The
contained in this chapter suggests that circumstance annual review allows researchers and practitioners
may be changing. Whiston also reported that the alike to explore the variables set forth by Kazdin: the
use of multiple outcome measures appears to be the integration of client needs, the expertise of the clini-
norm and that the most salient evidence of EBP cian, and the needs and values of the client. From
comes from the use of standardized instruments. the review, counselors and researchers can choose to
read the complete articles in primary sources that
NCDA Annual Review have been summarized.
For the past 29 years the journal of the NCDA, The
Career Development Quarterly (CDQ), has pro- Calls for More Evidence-based Practice
duced an annual review on the subject matter of Career counseling researchers and practitioners
research and practice in career counseling. The remain interested in the science of their profession
annual review’s authors cull the most significant in an ever-changing world. Bernes, Bardick, and
articles from a calendar year’s worth of career devel- Orr (2007) recently made a call for new efficacy
opment literature and subsequently summarize the studies, including both experimental and longitudi-
contents. The review not only provides information nal research to evaluate the impact of career counsel-
on evidence-based career development interven- ing technique, in order to advance the field with
tions, but appears to go beyond what Kazdin spe- additional EBP. They also drew attention to the need
cifically defines as EBP. Moreover, Kazdin suggests for both new and continuing EBP research with a
that three shifts in research need to occur to fulfill multicultural and diversified clientele, and suggested
his advocacy of EBP. These include giving more pri- that new techniques also be evaluated within an
ority to “a) the study of the mechanisms of thera- international context. Without a body of literature
peutic change, b) the study of the moderators of that tests career development theories and the effec-
change in ways that can be translated to clinical tiveness of various techniques, Bernes et al. sug-
practice, and c) qualitative research” (p. 151). All of gest that we are only assuming that the work of the
these are a part of the past research literature cov- career counseling professional has had any lasting
ered in the CDQ annual review. impact. Like others cited in the CDQ annual reviews
The annual review covers the literature that over the years, they call for linking practice with
addresses professional issues and provides informa- theory, increasing methodological diversity, increas-
tion on those career assessment devices that were ing field studies in outcome research, creating new
produced or updated over the course of the year. experimental designs, increasing longitudinal research,
There is also an abundance of new literature that ties constructing new instruments to operationalize new
prominent and new career theories to innovations theories, internationalizing career counseling, and
in practice. But, for the most part, the annual review disseminating research findings in the literature.
tackles the major counseling issues of process and Borgen and Maglio (2007) exemplify the continu-
outcome research. Perhaps even more significantly, ing work in EBP that reflects Kazdin’s statement
the annual review sets the agenda for the next ave- and the issues brought forth by Bernes et al. It is
nues of career counseling research that need to be important for all career counselors to know which
undertaken. These new roads are often a reflection interventions work and which do not over the course
of changing societal times and can be broad-based, of practice with a client. But it is also important to
including new interventions from the elementary know what seems to stay with the client over time and
school ages through higher education, and well into what does not. Swanson, Gore, Leuwerke, Achiardi,
adulthood and retirement. Edwards, and Edwards (2006) made it abundantly
Areas that have been focused on recently include clear that clients often do not accurately recall career-
the arguments for and against emerging innovations related information from their counseling sessions.

chope 551
 With this in mind, Borgen and Maglio (2007) addressing needs for shelter, along with other basic
used the critical incident technique to understand human necessities.
what aided and hindered unemployed clients and There are, of course, continuing challenges for
career changers in implementing action plans that EBP, and some reflect new conceptual and political
they had developed during the career and employ- concerns as well as practice. Blustein, McWhirter,
ment counseling process. Although action planning and Perry (2005) have questioned many of the
and goal setting have been researched in the past, assumptions regarding the practice of career coun-
empirical research on the variables that help and seling, suggesting that practitioners and researchers
hinder the action planning process has been lacking. “look beyond the concerns of the well-educated seg-
To be sure, career counseling clients frequently take ment toward a more activist social agenda” (p. 143).
action regarding their careers after they have discon- They suggest that career counseling must conduct
tinued counseling. The 23 women and 16 men who research on members of all segments of society,
participated in the study responded to the questions, along with the supports and the hindrances that
“What helped you implement your action plan?” affect their lives. Blustein et al. have characterized
and “What hindered you in implementing your this as emancipatory communication. They encour-
action plan?” Data were collected in an interview age research that identifies unfair practices that have
format, and tapes of the interviews were transcribed. kept people from fulfilling their expectations.
In the helping category, the following incidents and
percentages of clients reporting them were recog- Career Counseling with Culturally Diverse
nized: positive attitude (92%); psychological sup- Populations: Attending to Race, Ethnicity,
port (85%); determination, seriousness, motivation Ability, Gender, Sexual Identity
(77%); self-knowledge (64%); information gather- Working allows people to establish an identity that
ing (59%); goal focus or clarity (51%); bigger- is laced with their interactions among coworkers.
picture perspective (44%); structured or flexible To that extent, work is framed within a cultural
approach (38%); financial resources (31%). Incidents context and focused by the effort that is given to the
that were characterized as hindering action planning work tasks at hand. Helms and Cook (1999) have
and the percentages of clients reporting them were: maintained that the development of racial identity
lack of goal or motivation (62%); dealing with dif- intersects with working life. For those who are priv-
ficult emotions (59%); difficulty with a system or ileged enough to take part in the work world, work
discrimination (51%); lack of experience, education, is a life constant, often absorbing a third of a per-
or skills (46%); financial difficulties (44%); poor son’s waking hours. On the other hand, in less priv-
health in mind and body (38%); difficulty with ileged circumstances, work has also been called the
counseling agency (36%); difficulty connecting with luxury of the poor and disenfranchised (Chope &
companies (36%); lack of support (31%). Toporek, 2007).
These data suggest several ideas regarding the In the past quarter century, the populace of the
use of EBP in career counseling, as well as in other United States has been witness to a dramatic transfor-
human services delivery systems. First, support mation in its mixture of multiracial, multiethnic, and
appears to be an important ingredient in the career multiple-language groups. Moreover, individual and
development process and is, unfortunately, often cultural identities have continued to diverge with
taken for granted. Counselors would be well served each generation, while cultural and ethnic homoge-
to build family or collegial support into the process. neity have decreased with the greater frequency of
Second, it’s clear that personal problems can impede intermarriage (Evans, 2008).
the action planning or strategic implementing pro- Career counselors have looked for models to
cess, whereas psychological well-being can facilitate assist with their understanding and application
it. These are certainly not novel ideas, but they may of career development with a multicultural per-
not be emphasized as much as they should be in the spective. For many years, Bronfenbrenner’s model
career counseling experience. The data also suggest (Bronfenbrenner, 1977) had a particularly strong
that there should be continuing follow-up with influence, especially with regard to the career coun-
clients to ensure that they are proceeding with their seling of women. It allowed counselors to consider
plans and goals, and to lend support whenever influences at the micro level, such as the home and
possible with additional services. These can include school; the exo level, which included external envi-
referrals to individuals who help with life circum- ronments such as the workplace; the macro level,
stances such as interfacing with the legal system or which included society at large; and the meso level,

552 career cou n s el in g

which focused upon the interactions among the different gender, sexual orientation, ethnic group,
different levels. race, and physical or mental capacity.
King and Madsen (2007) developed an ecologi- • Define career development programs to
cal approach for understanding the contextual influ- accommodate needs unique to various diverse
ences of career development among low-income populations.
African American youth. They described contextual • Find appropriate methods or resources to
factors “as environmental variables which interact communicate with limited-English-proficient
with each individual’s personal characteristics and individuals.
experiences to influence career interests and choices” • Identify alternative approaches to meet career
(p. 396). Their approach embraced the strengths of planning needs for individuals of various diverse
the youth rather than their deficits. Influenced by populations.
Bronfenbrenner’s (1977) ecological systems theory, • Identify community resources and establish
they used the phenomenological variant of ecological linkages to assist clients with specific needs.
systems theory (PVEST; Lee, Spencer, & Harpalani, • Assist other staff members, professionals, and
2003) to identify the strengths and skills of low- community members in understanding the unique
income African American youth, advocating that needs/characteristics of diverse populations with
this information would help counselors to facilitate regard to career exploration, employment
these clients in the engagement of successful career expectations, and economic/social issues.
development activities. The person–context model • Advocate for the career development and
embodied in PVEST has five components: vulner- employment of diverse populations.
ability, evaluated by considering risk and protective • Design and deliver career development
factors; stress engagement, including an individual’s programs and materials to hard-to-reach
view of experiences; reactive coping strategies; stable populations.
coping responses; and life-stage coping outcomes.
Fouad and Kantamneni (2008) have also In identifying specific multicultural competen-
expanded upon Bronfenbrenner’s model to create cies, shown in the first ability above, many counsel-
a new model that illustrates the many contex- ors use the multicultural counseling competencies
tual influences in career counseling. Their cubic articulated by Arredondo, Toporek, Brown, Jones,
model has three dimensions: individual influences Locke, Sanchez, and Stadler (1996), which are also
that reflected individual differences (e.g., interests, available on the American Counseling Associ-
needs, values, self-efficacy), group-level influences ation (ACA) website at www.counseling.org. These
(e.g., gender, race, ethnicity, family), and societal- include three sections that address a counselor’s
level influences (e.g., acculturation, cultural values, awareness of his or her own cultural values and
opportunities, discrimination). All of these dimen- biases, an awareness of the client’s worldview, and
sions can be considered by practitioners as they culturally appropriate intervention strategies. Each
increase their awareness of the many-faceted con- section is further divided into beliefs and attitudes,
textual forces that impact people’s lives. knowledge, and skills.
By creating competencies and performance In August 2002, the American Psychologi-
indicators, the NCDA has had a strong presence cal Association (APA) Council of representatives
in the development of multicultural awareness for approved the policy on Guidelines on Multicul-
practitioners and researchers. The NCDA Career tural Education, Training, Research, Practice, and
Counseling Competencies and Performance Indi- Organizational Change for Psychologists. The
cators (NCDA, 1997) include career counseling Guidelines are available on the APA website at www.
with diverse populations as one of its 11 compe- apa.org. The six guidelines cover attitudes and
tency categories. The knowledge and skills that are beliefs, as well as skills and knowledge similar to
considered to be essential in relating to diverse pop- those presented on the ACA web site. However, the
ulations, and that impact career counseling and guidelines go further in encouraging practitioners,
developmental processes, include the ability to: educators, and researchers to utilize constructs of
multiculturalism and diversity in psychological edu-
• Identify development models and multi- cation, training, research, and practice, as well as in
cultural counseling competencies. facilitating organizational change.
• Identify developmental needs unique to Whether it is the NCDA, ACA, or APA, the
various diverse populations, including those of professional counseling organizations have strived

chope 553
to ensure that career counseling specialists are drawn among unrepresented groups. Stead (2004) is one
into the continuing evolution of their field, in the writer who has been critical of career theories for
face of changes that are taking place both in the what he characterizes as ethnocentric views. And,
United States and around the world. Although nei- Fassinger (2008) suggests that four groups of people
ther the competencies nor guidelines are mandatory have been disadvantaged by educational institutions
standards, they do serve to aid in assisting profes- and the workplace. These groups include women,
sionals in the provision of high-quality, appropriate, people of color, sexual minorities, and people with
and relevant services. disabilities.
The effectiveness of career counseling with mul- To be fair, researchers and writers in the field have
ticultural, multiethnic, and diversified populations responded with new articles addressing these con-
is an intricate topic. The NCDA multicultural cerns. For example, Young, Marshall, and Valach
competencies were criticized by Vera and Speight (2007) took on Stead’s challenge. Drawing from their
(2003) as lacking in attention to social justice 2004 paper presented at the International Association
issues, although Arredondo and Perez (2003) have of Educational and Vocational Guidance-National
challenged that social justice and multicultural Career Development Association (IAEVG-NCDA)
competence are “intertwined and interdependent” Symposium on International Perspectives (Young
(p. 282). Still, Fassinger (2008) reminds us that it is et al., 2004), they orchestrated a structure for mak-
extremely demanding to unscramble the contextual ing career theories more culturally sensitive. Their
effects of oppression based on racial/ethnic status approach was articulated in a fashion that is useful
from those problems prevalent among people living to both practitioners and researchers. The compo-
in conditions of poverty, with limited educational nents of their structure include understanding cul-
and financial resources, and with few, if any, net- ture, establishing links between career and culture,
works of support. developing narrative and folk explanations for career
Quite clearly, career decision making and plan- choices, using observations in local communities,
ning are ultimately affected by relevant cultural recognizing ongoing processes, and finally, subjecting
factors. Thus, one primary challenge for career observations and reports of ongoing processes to sys-
counselors is to develop a shared worldview with the tematic analysis. Young et al. (2007) suggested that
client. The shared worldview can enhance the coun- culture should be treated as more than a statistic, and
seling relationship and assist in the success of the that theorists as well as practitioners must work with
counseling process (Consoli & Chope, 2006). the unambiguous links between culture and career,
The rising attention by authors toward offering as well as context and history.
new empirical data and EBP in the area of multicul- Recent research reflects a fresh focus on the link-
tural career counseling has begun to have a signifi- age between specific cultures and career decision
cant presence in the career development literature making. Okubo, Yeh, Lin, and Fujita (2007) showed
(Chope, 2008). Diversity clearly interacts with con- the relationship between Asian American accultura-
text and personal characteristics, hence influencing tion level and ethnic identity on the construction of
career choices, career development, and school-to- career interests and aspirations. King and Madsen
work transitions (Constantine, Kindaichi, & Miville, (2007) presented an ecological approach for under-
2007; Constantine, Wallace, & Kindaichi, 2005; standing the contextual influence of career develop-
King & Madsen, 2007). Stead (2004) has noted ment on low-income African American youth.
that everyday activities are culturally embedded and Diemer (2007) has given a perspective on the two
are proved to affect an individual’s career develop- worlds that African American men negotiate while
ment. Gold, Rotter, and Evans (2002), with their interacting with an educational and occupational
out-of-the-box (OTB) model, have added that career world that is predominately white. Quimby, Wolfson,
counseling cannot be very effective without the and Seyala (2007), citing the growing body of new
consideration of both family and culture. career development research, have questioned the
It has been of great concern to many career coun- applicability of traditional career theory to African
seling practitioners and researchers that the authors Americans. A more extensive review of the impact
and reviewers of career theories be sensitive to cul- of culture on career development, including Asian
tural inclusiveness. Career theories, developed over a American culture, African American culture, African
period of 100 years, have not embraced the great American Hispanic culture, Hispanic culture, and
diversity of cultural practices that can help counsel- Appalachian culture can be found in the 2007
ors better understand the career development process NCDA annual review (Chope, 2008). There are also

554 career cou n s el in g

comprehensive reviews of these and other cultures in Intervention Models for Career Counseling
Blustein (2006) and Leong (1995). Individual Interventions
New contributions have been made to the career The models of career intervention stem from the dif-
development literature with regard to those issues ferent theories of career choice and development.
career counselors must understand when working They can be goodness-of-fit models, like those of
with transgender clients (Kirk & Belovics, 2008). John Holland (1997); developmental models, like
Irwin (2002) was very clear that career counselors those of Donald Super (1963, 1980); constructivist
must understand the conditions that gay, lesbian, approaches, like those of Mark Savickas (2005); or
bisexual, and transgender (GLBT) people face in behavioral ones, like those of John Krumboltz (1996).
the workplace as they pursue their chosen careers. Some of the great career theorists can serve as founda-
Transgender employees face enormous workplace tions for new approaches, as Krumboltz did for
discrimination, and career counselors need to under- Kathleen Mitchell and Al Levin (Mitchell, Levin, &
stand the clinical and legal issues, as well as legal pro- Krumboltz, 1999) when they “came up with” the
tections, that are in place for transgender employees. planned happenstance theory of career counseling,
In working with clients who have been marginalized an approach whereby counselors help clients learn
in their workplace environments, career counselors how to create opportunities from unexpected events.
must consider being advocates as well as clinicians. The career development processes that are dis-
Still, practical research exemplified by Hogue, cussed in most career theories are written with a
Yoder, and Singleton (2007) suggest that men con- particular context in mind, according to Gysbers,
tinue to be more likely to feel entitled to higher pay Heppner, and Johnston (2003). They point to five
than women. Wage fairness will be a social, politi- key tenets of career development theories and inter-
cal, economic, and career development issue for ventions: individualism and autonomy, affluence,
some time. Even when men are told outright that structure of opportunity open to all, the centrality
women perform with greater competence than men of work in people’s lives, and the linearity, progres-
on the same isolated work tasks, their study of 120 siveness, and rationality of the career development
undergraduate men demonstrated that the men still process. People from different cultures may not
felt worthy of higher wages. Women have also been share a worldview that incorporates all of these
discriminated against in the content of letters of tenets. That truism suggests that the use of any
support for career and educational positions. They theory of career choice and the selection of inter-
are often described with fewer research related ventions must be done with knowledge and the
descriptors and they are said to be more communal integration of multicultural perspectives.
and less agentic (Schmader, Whitehead, & Wysocki, All individual approaches use the counseling
2007). Moreover, family planning and pregnancy relationship to explore both individual as well as
appear to lead to discrimination, which affects the contextual variables that appear to dictate the
career development process for women (Cunningham choices that people make about their career and life
& Macan, 2007). And, Masser, Grass, and Nesic plans. Career counseling clients can approach a
(2007) provided data predicting that pregnant career counselor with any number of problems. It is
women are often stereotyped as warm, but incom- then incumbent on the counselor to know how to
petent, and experience workplace discrimination, identify and hone in on the primary issue that
especially in masculine-oriented jobs. brought the client to counseling. Along the way, the
To incorporate the many contextual variables into career counselor can develop hypotheses about the
the career counseling process, career counselors have nature of the problem.
begun to frequently utilize the narrative approach to
the career counseling process. Conceivably, this type Using Assessments in Career Counseling
of approach to career counseling might be consid- The information-gathering process can be many
ered not just as a technique, but also as a method of faceted. There are counselors who choose to gather
understanding culture (Cochran, 1997). In addition information through the use of tests or other struc-
Young et al. (2007) believe that counselors should be tured measuring devices. Some of the commonly
especially attuned to socially embedded processes used tests are also linked to particular theories of
that influence the psychology of working and career career choice.
development, recognizing those processes that con- The Self-Directed Search (SDS; Holland, 1994) is
tain a longer series of activities involving cultural an instrument used to assess a person’s career person-
complexity. ality type and interests in six different occupational

chope 555
groupings (Realistic, Investigative, Artistic, Social, when a client may be resistant, or not have the experi-
Enterprising, Conventional) with the goal of match- ence or knowledge to explore particular life themes.
ing the individual to careers utilizing the same However, those counselors utilizing tests and other
groupings. It is reflective of Holland’s theory of assessment devices are best served when they use
career choice. One of the oldest and most popular instrumentation that is most consistent with their
measures of interests, the Strong Interest Inventory own theory of career choice and counseling. Osborn
(Campbell, Strong, & Hansen, 1991), frames the and Zunker (2006) have provided a conceptual
entire interest profile of general occupational model for career counselors using assessment results,
themes, basic interest scales, and occupational scales noting that assessment in career counseling can be
in alignment with Holland’s occupational catego- used for diagnosis, prediction, comparisons to others,
ries. With slightly different categorizations, the and developmental checks over the lifespan. Their
Campbell Interest and Skill Survey (Campbell, 1992) model includes an analysis of a client’s needs for
and Harrington-O’Shea Career Decision Making assessment or testing, establishing the purpose for
System (CDMS; Harrington & O’Shea, 2000) also engaging in the process, selecting the instruments,
use variations on Holland’s scheme. utilizing the results, and assisting the client with deci-
Similarly, Super’s lifespan, life space theory is sion making. Assessment allows counselors to create
operationalized in the Career Development Inventory their own data-based hypotheses about their clients
(CDI; Super, Thompson, Linderman, Jordan, & and discuss these during their sessions as clients’
Myers, 1984), an instrument devoted largely to the stories unfold.
assessment of readiness for career decision making. Of course, it is essential that the selection of
The Career Maturity Inventory (CMI; Crites & instruments be culturally relevant, fair, and appro-
Savickas, 1995), which uses some of Savickas’ think- priate for the client’s life context. Career assessment
ing in career development, also explores the readi- results serve as opportunities for the career coun-
ness of students in the sixth through twelfth grades selor to engage the client in developing new hypoth-
to make career decisions. eses about the possibilities that are available to the
Some instruments may be independent from client in a rapidly changing work world. They also
any particular counseling theory but are concerned help the counselor and client discuss complicated
with those clinical issues that may hinder career issues such as the client’s worldview, work and life
planning and decision making. The Career Thoughts balance, vocational as well as avocational decision
Inventory (CTI; Sampson, Peterson, Lenz, Reardon, making, achievement needs, and career identity.
& Saunders, 1996) makes an assessment of the irra- In cases in which testing is accomplished with com-
tional thoughts or dysfunctional thinking that indi- puter scoring, the test publishers frequently include
viduals experience when making career plans, and is additional reference material for the client to add to
drawn from the theory of cognitive information his or her information base. In summary, when used
processing (CIP; Peterson, Sampson, & Reardon, effectively, assessment instruments will enhance the
1991). Likewise, the Career Beliefs Inventory (CBI; client’s self-knowledge and awareness.
Krumboltz, 1991) inventories particular personal
beliefs that may interfere with the clarity of percep- Worldviews and Cognitive Predispositions
tions about one’s self and one’s worldview when In the past, much of the counseling process consid-
making career decisions; it stems from Krumboltz’s ered the goodness of fit that people shared with
learning theory of career counseling. occupations, generally using testing. Career counsel-
In the end, individual interventions come down ing often was symbolized by a “lock and key” model.
to understanding a person’s past behavior and the The career counseling work of the 21st century takes
themes that emerge from that behavior in order to a much broader view of career development, one in
make future predictions. A person’s genetic endow- which worldviews and cognitive predispositions are
ment, along with the contextual influences that included in the clinical information gathering pro-
have guided his or her life experience, need to be cess. This has been characterized in Krumboltz’
taken under consideration, as does the client’s sense work, but it is also suggested by the work of Lent,
of self-concept or self-esteem. The degree to which a Brown, and Hackett (1994) in their social cognitive
person has the wherewithal to develop a vocational career theory (SCCT). In this regard, they view the
identity also needs to be considered. importance of the client’s history of performance
Assessment devices can be useful when there is not accomplishments, along with vicarious learning,
enough time for lengthy individual consultation and appropriate emotional arousal, and perseverance to

556 career cou n s el in g

add to the creation of positive outcome expectations It allows the client to experience authenticity, by
and self-efficacy. Added to this is the contextual sup- listening to an inner voice that facilitates the fullest
port that comes from social persuasion or encour- expression of core values.
agement from significant others. So, the interviewing Amundson, Harris-Bowlsbey, and Niles (2009)
process attempts to address these variables. suggest that the narrative approach can help coun-
Several writers have suggested that information selors understand the context of a client’s career
be gathered and then integrated into a life planning development. Savickas (2005) has added to the nar-
process. Hansen (1997) has suggested that multiple rative approach with his career styles interview.
aspects of life are interrelated, and her lifespan Using this approach, the focus is on vocational per-
approach to career counseling explores the differen- sonality, life themes, and career adaptability. In
tial identities that clients have developed. She uses short, individual narrative career counseling helps
information that connects clients’ lives to both their to create meaning in the work that individuals try
local and larger communities. She also promulgates to pursue. Savickas’ career styles interview, formu-
the gathering of information about an individual’s lates questions that concentrate on lifestyle and per-
culture and those critical life tasks that are part of sonal issues. These can include questions about role
belonging to that culture. models, favorite books, magazines and newspapers,
In a vein similar to Hansen’s, the systems theory leisure activities, school subjects, mottos, and ambi-
framework (STF) of career development (McMahon, tions. They can also include questions, such as:
2002; McMahon & Patton, 1995) is a constructiv- What would you do if you won the super lottery?
ist approach to career counseling. It was originally Amundson et al. also suggest questions in a sim-
created to manufacture a meta-theoretical frame ilar vein. These include gathering information about
for recognizing the contribution of many theories memories, knowing information about early role
of career development. However, STF has been models, and having clients describe favorite books,
found to be useful in multicultural career counseling, movies, and television programs (p. 25).
qualitative career assessment, and career counselor Chope and Consoli (2006) developed a template
training. Most importantly, the STF is an integra- for career counselors to consider when engaging
tive framework that uses information from 16 in therapeutic storytelling related to career choice.
intraindividual influences, six social influences, and In the narrative process of construction, deconstruc-
six societal-environmental influences to assist clients. tion, and reauthoring, they suggest that counselors
consider a number of issues to explore using an inte-
Narratives grative, constructivist approach. The template uses
One of the most prominent means of gathering the following components: client’s cultural persona,
information in career counseling has been the use acculturation modes, demographic environment,
of the narrative approach. The therapeutic telling diversity within cultural groupings, legal status, lan-
of life narratives allows career counseling clients to guage, religion, attitudes about work, rules in the
incorporate their personal histories in giving mean- family system, and gender stereotypes. Discrimi-
ing to their evolving identities, so that they can nation history can also be included. Using this tem-
structure their cultural and perceptual experience as plate facilitates the establishment of a comprehensive,
they organize their thoughts about education and shared worldview between the client and counselor.
work. The narrative is particularly useful for career A client’s narrative can capture the importance
counselors to utilize in gathering information about and influence of cultural identity on his or her career
a multicultural client’s worldview (Howard, 1991). decision making. It also aids in considering the
Cochran (1997) suggests that narratives in career experiences a client may have when attempting to
counseling help clients share their history, current find work in those areas where few if any people
circumstances, and future goals. Some cultures actu- represent the client’s culture.
ally appreciate oral histories over the written word. All acculturation modes involve a mainstream
Not unlike Super’s idea that one’s view of work is cultural context that can be supportive of other cul-
a reflection of self-concept, storytelling allows clients tures or discriminating and marginalizing. Different
to become empowered as they construct new actions clients will be ashamed or proud of their culture;
based on their stories. Revising a client’s concept some will wish to remain separate from their own
of work and life planning appears to be a major ther- ethnic group, while others will reject mainstream
apeutic building block, one that launches a new culture. Contextual interactions between the client,
perceptual experience in the therapeutic process. the family, and the social environment must be

chope 557
taken into consideration when seeking an under- speak volumes. Questions regarding this informa-
standing of acculturation processes (Berry, 1997). tion can be asked by using a protocol developed by
Sensitivity to acculturation modes is an important Chope (2006). The protocol includes six major
feature in the process. questions that help to both guide and deepen the
It is also valuable to understand the demographic exploration of family influences on career choices.
environment, or the nature of the population in
• What kind of career information did the
which the client resides. In addition, the career
family provide?
counselor must be sensitive, in this narrative pro-
• What tangible assistance was provided, and
cess, to variations within a culture. For example, the
were any obligations attached?
broad categorization of “Latino/a” or “Hispanic”
• What type of emotional support was available?
needs to be articulated further into the cultural
• What was the impact of the client’s career
differences between and within South American,
choice on the family?
Central American, Iberian, Cuban, Caribbean,
• Were there any disruptive family events that
Mexican, and other cultures.
affected the client?
Legal status and documentation are likely to be a
• What were the actions of family members
sensitive topic for immigrants. Questions about
whom the client asked for help, and the actions of
status implications for career counseling can be used
those who were not asked to help?
to deconstruct a client’s story, as well as help to
create additional support systems for the client. Families may have different rules about the power
Career counselors who advocate for and empower and influence of the extended family. Grandparents,
undocumented workers through the legalization aunts, cousins, and uncles may or may not have a
process may serve to enable all workers to compete role regarding career selection, depending on the
on a level playing field. culture.
In addition, language is a source of identity for Other information can be gathered and the
people from all cultures. A sense of identity is devel- narrative process can be enhanced with the use of
oped with language use, and it can reflect the dual- a career genogram (Dagley, 1984; Okiishi, 1987).
ism of acculturation. According to Kamasaki (2008), This occupational family tree can be quite useful,
the desire to learn English is so pervasive in the but it can entail gathering pertinent information
immigrant community that, nationwide, English as from extended family members. The genogram,
a Second Language (ESL) programs for adults are accompanied by good follow-up questions, allows
overbooked. In 2006, 57.4% of ESL providers in an understanding of career expectations in the
the United States indicated that they had waiting family and in the culture. Career counselors can
lists for their prospective students. explore dominant values in the family going back
Religious values also play an important role in several generations. They can also accrue informa-
the career choices of many. In the United States, a tion on family myths, secrets, and “ghosts.”
Protestant work ethic is thought to drive much of Most cultures tend to affirm some gender stereo-
the economy. This ethic is often seen as anti-women types regarding the roles that men and women play
and anti-immigrant, with limited multicultural relative to work, educational experiences, and family
applicability. Any person who follows a non-main- responsibilities. Views on relationship status can
stream religion may feel uncomfortable on the job. also be influenced by the culture, the family, and the
Jewish workers in the United States, for example, client’s partner.
felt for years that they couldn’t ask for time off
during the High Holy Days and Yom Kippur. The Group Interventions
counselor needs to know how religion affects the In addition to working with individual clients,
client’s sense of self and personal worth. career counselors often engage in the process of
The worldview of the family and culture regard- career group counseling. Group interventions allow
ing work must be addressed. Some families want counselors to enhance their efficiency in the career
their children to earn money and be independent. counseling process by taking on more than one
Others want them to be high achievers, while others client per hour. Groups are particularly popular in
want them to refrain from drawing attention to high school and college settings, but they are also
themselves. Attitudes about work can also be related the fundamental means of intervention in adult
to earnings. Family attitudes about money, savings, job-seeking groups and job clubs. Groups can be
and the trustworthiness of financial institutions can used alone or in conjunction with individual career

558 career cou n s el in g

counseling. Smith, Dean, Floyd, Silva, Yamashita, United States and the specific challenges with
Durtschi, and Heaps (2007), in a survey of 133 which low-income Chinese immigrants must con-
American College Counseling Association (ACCA) tend, developed a culturally specific career explora-
members, found that there was a need for devel- tion group for low-income Chinese immigrant
oping more career group counseling interventions youth, Career Exploration Development and
among college students. Resources (CEDAR). CEDAR includes an assess-
Pyle (2000) has written extensively on the sub- ment of the participants’ interests, values, abilities,
ject of career groups and has suggested that less and aspirations, but also recognizes the role of the
structured groups can be useful for clients looking family, depicted by having the participants complete
for direction or a change in direction. He offers a career genograms. The psychological complexity of
four-stage model for working with career groups. the group was appreciated through discussions about
These stages include the opening, the investigation, the participants’ immigration experience. Guest
the working stage, and the decision/operational speakers were invited to assist the group with infor-
stage. He also provides scripts for a model group mation regarding cultural adjustment. Transition
career counseling program. issues and perceived barriers were addressed, along
Groups can clearly be used as sounding boards, with the roles of racism and sexism at work. Time
and they can serve to support individuals who may was also set aside for skill building, including resume
be struggling with career loss or unemployment. development, college application preparation, and
Career groups can also be useful in helping individu- information distribution regarding financial aid for
als to manage their career upward. They can be con- continuing their education. In summary, CEDAR is
structive for individuals who need to sort out their a career group process with culturally specific career
personal reasons for considering a job change as interventions that is clearly structured, content spe-
well. Having a group of listeners available in a short- cific, and relatively straightforward to replicate.
term process with a positive atmosphere can be a
healthy arena for career clients to discuss motiva- The Increased Use of Technology
tion, career satisfaction, and career disappointments. As an Intervention
Career groups can be used for people exploring Once a career counselor understands a client’s
retirement options. Sullivan and Mahalik (2000) problem and assists him or her in creating a plan,
have used groups to enhance career self-efficacy by clients generally have the expectation that the career
having group members focus and discuss the major counselor is an expert at providing information
components of their personal career self-efficacy: about the labor market. In the not too distant past,
performance accomplishments, emotional arousal, career counselors would refer clients to information
vicarious experience, and verbal persuasion. resources that were available in the career libraries
Rutter and Jones (2007) have described a time- of colleges and universities, or in general libraries
honored group process called the job club. This is a available to the public. As the clients gathered infor-
group technique that uses behavioral principles and mation, they would be encouraged to use their
positive reinforcement contingencies to assist indi- imagination to create a sense of direction for them-
viduals in beginning their job search. Job clubs can selves. Clients were also encouraged to “shadow” or
be very intense, meeting several times per week. closely follow workers who engaged in job activities
These groups have been used most frequently for that they might be interested in. Internships or
new job hunters, and for those who have recently apprenticeships might also be recommended for the
suffered a job loss or forced termination. They have purposes of gathering both information and experi-
also been available for career clients with severe dis- ence. Today, the Internet and the use of online web-
abilities who function best in groups with others sites to provide information has enabled clients
who are sensitive to the contextual variables that work on their own.
affect their lives. The job club keeps job seekers from Since the 1960s, computers have been used
being isolated and lonely, while it also introduces a to enhance career counseling services, and the
behavioral program that demands that participants early work has been summarized by Super (1970).
engage in and document their job-seeking activi- A variety of systems have been developed over the
ties. Job clubs also emphasize empowerment and years, exemplified by the System for Interactive
collaboration. Guidance Information (SIGI; Katz, 1963), SIGI Plus
Shea, Ma, and Yeh (2007), noting the rapid (Educational Testing Service, 1997), and Discover
rise in the number of Chinese immigrants in the (ACT, 2000) to name just a few. Originally, these

chope 559
systems were developed for high school and college found that younger employees, along with those
students, but they are now pertinent for career who participated in a defined contribution retire-
clients at all levels. These systems have provided ment plan and those who made joint personal
computer-based assessments of individual needs, financial decisions, were more likely to use online
interests, skills, and values, which then are matched procedures. With regard to age, 38.5 years appeared
to some extent with occupational and educational to be the cutoff for those who used online services
information found in the respective databases. regularly. Nonusers were typically born before 1970
In the mid-1970s, the U.S. government estab- and entered their adulthood before the beginning of
lished the National Occupational Information the explosion of Internet use. For those born after
Coordinating Committee (NOICC), which was 1970, the World Wide Web has been a part of edu-
developed to lend support to the states to assist in cation and work life, and they are used to having
the development of career information delivery sys- information at their fingertips.
tems. Partially in response to that effort, websites Clearly, career counselor educators have become
have been constructed to offer massive amounts of more comfortable with teaching others how to be
occupational information, including occupational career counselors through online programs. They
outlook, nationwide and local salary levels for par- have also become more experienced in teaching
ticular jobs, the knowledge skills and abilities that students how to use the internet to engage clients
are required to enter different occupations, job in online career counseling. However, Lewis and
availability, and the job tasks that make up different Coursol (2007) point out the enduring and afore-
fields of employment. mentioned questions about the depth of career
There are no-fee sites, like the Department of counseling. The enthusiasm that counselor educa-
Labor sites CareerInfoNet (www.acinet.org) and tors have for online counseling is moderated by a
O ∗Net (www.onetcenter.org), along with for-fee sites lingering perception that career issues are less com-
like the Kuder Career Planning System (www.kuder. plex than noncareer issues and, as such, are more
com). CareerInfoNet also has links to the Department amenable to counseling that utilizes online technol-
of Labor’s Occupational Outlook Handbook (www. ogy. For example, the first six of the client problems
bls.gov/oco). most endorsed by counselor educators tended to
The Internet and the larger Information Age be of an information-generating variety. So, coun-
have had a terrific influence on the provision of selors may be more willing to respond to these issues
counseling services. Online employment applica- because they are also less enduring, usually less com-
tions and applications to educational institutions plex, and most likely responsive to counseling.
are now commonplace. Professional career counsel- There are, of course, many career counseling
ors working in local career centers continuously issues that are not appropriate for online counsel-
gather information, as well as pertinent journal arti- ing. These include issues like how to manage one’s
cles, over the Internet. The Internet is also available career upward, how to get along with coworkers and
to make career and other counseling services more supervisors, how to assess the stress of balancing
accessible to people through distance education, one’s work and educational demands with family
training, and counseling. life, and how to address issues of self-esteem.
Counseling via the Internet has been defined as Career counselors must be sensitive to the fact
“web counseling” by the National Board for Cer- that many potential clients use career issues as an
tified Counselors (NBCC), although career coun- entry into the counseling process. Quite often, these
seling can also be done through the utilization of clients may be experiencing other clinical issues. And,
video conferencing and e-mail. Career information although online counseling is moving into its adoles-
can be readily tapped through virtual career centers, cence, it has not developed into its adulthood. There
and institutions can give information about in-per- also remains a lack of research into its effectiveness.
son services and also online services such as career Counselors need to be trained in online procedures,
assessments, employer databases, and alumni data- and new training guidelines and continuing ethical
bases (Amundson et al., 2009). The NBCC has pro- and legal updates for counselors will be needed. In
posed new ethical standards for those who utilize addition, the use of other technologies like personal
the web counseling experience (NBCC, 2007). digital assistants, iPods, and podcasts will affect the
There is, however, a significant divide among practice of career counseling in the near future.
people who are willing to gather online information Zalaquett and Osborn (2007) wrote that a number
from the Internet. Joo, Grable, and Choe (2007) of career counselor educators are developing websites

560 career cou n s el in g

to foster career information literacy among stu- work and education, understanding how to use
dents taking graduate career classes. They remind career information, understanding decision making,
their readers to use the Association for Counselor being aware of different occupations, and developing
Education and Supervision (ACES) and the NCDA an awareness of the interrelationship of life roles.
joint statement on the use of computers and the This is a tall order. The key to having elementary
Internet in guidance and counseling (ACES/NCDA, school children meet the competencies suggested by
2000). With computer and online career informa- NOICC lies both in the schools and in the family.
tion delivered on systems like O∗NET and the Career researchers have emphasized that the family
online Occupational Outlook Handbook (www.bls. must be involved at an early age to help children
gov/oco), the authors suggest that counselor educa- understand the ramifications of career development
tors must assist students in acquiring online technical over the lifespan. Niles and Harris-Bowlsbey (2005),
competencies. for example, point to the sway parents have in their
children’s career choices. Parents have a profound
Career Counseling in Elementary School, influence on the intellectual, social, and emotional
High School, and College components of their children’s lives (Steinberg,
Considering the idea that career development is 2004). Their guidance is a powerful component in
essentially a life-long process, Zunker (2006) has the decision-making process, and they expose their
suggested the possibility that it begin as early as pre- children to a particular variety of career choices.
kindergarten. Career-related programs can continue Brown (2003, p. 332) posits that “parents exercise
throughout the entire educational process as educa- more influence than any other adults on the educa-
tional institutions prepare people for the job-related tional and vocational choice of children.”
needs of their community, state, and nation. Super Others have suggested that the entire family
(1990) has been mindful of the various concepts of be given more focus in understanding career and
self that individuals have, whether they be educa- life planning in the early ages (Blustein, Walbridge,
tionally related, career related, or peer related. These Friedlander, & Palladino, 1991). More recently, the
various concepts remain fluid throughout life as impact of siblings (Kenny & Perez, 1996), as well as
self-concept and self-efficacy emerges with differen- extended family members, on the career decision-
tiating experiences. As self-esteem develops, for making process, has been suggested as a source
some, it may be related to educational endeavors, of potential research material (Schultheiss, Kress,
whereas for others it may be based in relationships, Manzi, & Glasscock, 2001).
and for others it may be reflected in lifestyle. So, parents, extended family members, and sig-
Gottfredson (1996) has pointed out that gender ste- nificant others play highly influential roles in the
reotypes with regard to the work world often force career decision making process, and it is incumbent
children to give up on particular fantasies about upon career counselors to bring in these notable
careers because they do not appear to be appropriate people to help in the career counseling process. They
for their gender or socioeconomic class. can be encouraging character models, serving as the
original “network,” confronting occupational stereo-
Elementary School types, and offering new opportunities for children to
With the current interest in lifespan approaches to be exposed to new and challenging opportunities.
career counseling and the research in the contextual
variables that influence the career counseling pro- Middle School
cess, there is concern about developing appropriate Middle school lends itself to a strong transition-
developmental interventions for children at remark- ing process. Accordingly, NOICC (1992) suggested
ably young ages. This interest has had support that middle school students understand the influ-
for close to 20 years. In 1992, the National ence of a positive self-concept as they develop the
Occupational Information Coordinating commit- skills to interact with others. It was also suggested
tee (NOICC) prepared guidelines for counselors at that they know the benefits of educational achieve-
all levels to develop goals and methods of reaching ment and career opportunities while understanding
those goals over the course of one’s life (NOICC, the relationship between work and learning. Career
1992). In summary, NOICC recommended that counselors need to be sensitive to the rapid develop-
elementary school children develop competencies mental changes taking place as they help students
in self-knowledge and awareness of growth and with the development of significant new relation-
change, understanding the relationship between ships and a personal identity. Toward the end of

chope 561
middle school, many counselors begin to use apti- Counselors work with students to prepare them
tude and interest testing to assist students in plan- to clarify their concepts of their life roles. They
ning the future of their educational lives. Career encourage continued exploration and refinement of
librarians can help with the organization of appro- what will emerge as a vocational identity.
priate career information, and schools can provide
opportunities for exposure to career opportunities Higher Education
previously unthought-of. Counselors can assist stu- Higher education has been witness to a dramatic
dents in experimenting with new life roles while change in recent years, with increases in interna-
they stimulate their imaginations, and can help tional students, students from a multicultural heri-
them to develop new interests through exposure to tage, and students with disabilities. The NOICC
new activities. has established competencies for students entering
higher education and adulthood. Much of the focus
High School of career counselors with students in higher educa-
In high school, career counselors assist students tion is the development of a strong concept of self,
with a process that involves the “crystallization” of a along with the skills to explore, enter, and partici-
career or vocational identity (Super, 1990). Students pate in the educational and work worlds. Tansley,
in high school begin to prepare themselves for the Jome, Haase, and Martens (2007) have pointed out
timely transition into work or vocational technical that verbal persuasions can affect an individual’s
education, community college, or baccalaureate- self-efficacy as well as outcome expectations, goals,
degree colleges. and intentions. But they also suggested that, accord-
The NOICC Guidelines suggest that high school ing to prospect theory, negatively framed messages
students develop the competencies to further develop can have a powerful, deleterious effect.
their self-concept and relationship-building skills. There will be stronger demands for the skills to
But, most importantly, they should begin to prepare not only enter new occupations, but also to make
for the work world. They will need to locate, evalu- transitions from education to work, along with
ate, and interpret career information, but they will making future career transitions. Duffy and Sedlacek
also need to become job ready as they seek, obtain, (2007) explored the presence of and search for a
maintain, and change jobs. Career planning and “calling” to the future among 3,091 first-year col-
educational planning become essential in these years lege students. The presence of a calling correlated
(Herr, Cramer, & Niles, 2004). positively with decidedness, comfort, self-clarity,
Savickas (1999) suggested that career counselors and choice–work salience, whereas the search for a
intervene to ensure that students are oriented toward calling correlated positively with indecisiveness and
career choice and become competent at planning a lack of educational information. To some extent,
and exploring on their own. He also suggested that this sets the agenda for career counselors working
group formats could be both efficient and support- with students in higher education and adults.
ive of students. Group formats could also be used Helping students to achieve cognitive clarity and
to discuss any tests of vocational choice, career refine their decision-making process will have last-
maturity, or concerns about work and careers. ing results.
High school also sees a greater preponderance of
interest in the utilization of tests and other assess- Career Interventions with Marginalized
ment devices. Not only are students given the Persons: A Primer on Social Justice in
opportunity to take college entrance examinations, Career Counseling
but they will also be directed to some of the more
No country, however rich, can afford the waste of its
popular instruments assessing career interests like
human resources. Demoralization caused by vast
the SDS (Holland, 1994) or the CAI (Johansson, unemployment is our greatest extravagance. Morally
1986) for those who may pursue community col- it is the greatest menace to our social order.
leges or vocational-technical education, or the SII
The test of our progress is not whether we add
(Campbell, Strong, & Hansen, 1991), the Campbell
more to the abundance of those who have much;
Interest and Skills Survey (CISS; Campbell, 1992),
it is whether we provide enough for those who
and the CDMS (Harrington & O’Shea, 2000).
have too little.
Popular assessments of personality like the Myers-
Briggs Type Indicator (MBTI; Myers & Briggs, 1993) Franklin Delano Roosevelt’s words, inscribed on
are also frequently taken at this time. his memorial in Washington, DC, characterize his

562 career cou n s el in g

thoughtfulness about social justice. Toporek and understand both the internal psychological and
Chope (2006) conceptualized social justice in career external sociological impacts that incarceration has
counseling as the practice of alleviating injus- had on these individuals.
tice and oppression for all people, but particularly Career counselors can also be involved in either
those who may be marginalized. Four areas of con- advising or assisting these clients in the develop-
cern must be addressed: social justice awareness and ment of new programs of an entrepreneurial nature,
advocacy in individual counseling, social justice referred to as “social entrepreneurship.” These for-
program development, assisting in social entrepre- profit programs are able to endure because they are
neurship, and training. divorced from the need to constantly generate
A number of potential roles are available for income through donations and grants.
career counselors interested in social justice and Unfortunately, one of the problems with any
working with people who are marginalized. In indi- not-for-profit program is that it is often unable to
vidual counseling, career counselors can play a role sustain itself, given its dependence upon grants and
in assisting others to learn about and pursue a career volunteer efforts. Helms (2003) noted that one his-
that involves social justice factors. And, career coun- torical and structural problem in integrating social
selors can play roles as advocates for some their justice in counseling is that it most often relies
clients. Advocacy may be considered with clients on pro bono and volunteer work, or going beyond
who have had experiences that include employment the scope of one’s duty. Alternatively, social justice
and educational discrimination, sexual harassment, efforts have also included developing innovative,
workplace violence or trauma, and observing wrong- entrepreneurial, and self-sustainable organizations.
doing and trying to decide whether to “blow the Blustein (2008) has pointed out that unemploy-
whistle.” ment continues to hamper well-developed countries
Career counselors can also be involved in new like the United States, with the loss of jobs to interna-
program development for those who have been tional markets. He has also identified three funda-
placed in marginalized situations. These can include mental needs that having a job has the capacity to
people who are homeless, impoverished, undocu- impact greatly: need for survival, need for relatedness,
mented, incarcerated, or physically and emotionally need for self-determination (Blustein, 2006). Still,
disabled, among others. the impact of characteristics of ethnicity on earning
Probationers, parolees, and ex-offenders make potential, mobility, and education are legion.
up a significant population of individuals who are Accompanying the decline of strong unions
often underserved by the career counseling commu- and union-protected work, employers have offered
nity. According to Shivy, Wu, Moon, Mann, Holland, workers more part-time jobs, fewer fringe benefits,
and Eacho (2007) incarceration rates in the United and little or no job security. Reflecting on reports
States are climbing at an unprecedented rate; close issued by the United States Department of Labor,
to 2.2 million people are currently incarcerated. Johnson (2008) notes that changes such as these
Approximately 650,000 inmates are released from are important factors contributing to rates of long-
prison each year, to face immense challenges with term joblessness among traditional blue-collar
regard to returning to their communities, keeping workers.
straight, finding work, or continuing their educa- Diemer (2007), referenced earlier in this chapter,
tion. Most are under some form of continuing has a perspective on the different worlds and margin-
supervision. Shivy et al. outlined several different alized experiences that African American men nego-
domains of difficulties for ex-offenders including tiate when interfacing with predominately white
the need for education, training and practical assis- educational and occupational worlds. Two worlds is
tance, differential challenges in obtaining and main- the moniker that Diemer cites when he describes
taining a job, and locating and obtaining available the negotiation of one’s culture of origin with the
support services. Substance abuse was also an issue predominately white opportunity structure. Using
that affected the reentry and employment process. seven African American men, Diemer’s well-mined
Shivy et al. suggested that career counselors begin to qualitative data were eventually described with one
participate in relevant community activities when category (two worlds: experience and motivation)
working with ex-offenders by visiting their social and four subcategories (barriers in the white world,
networks and the various workplaces where they barriers in the black world, bicultural balance, bicul-
are employed or seeking employment. Participation tural skill). Participants described how they had to
at this level can help career counselors to further “move within circles” when they wanted to achieve

chope 563
success in the white environment without losing career counseling has been far less influential as the
touch with their connection and identification with field has changed dramatically over the past 25 years.
African American culture. Barriers in the white From its very narrowly conceived beginning, career
world included the obvious forms of discrimina- counseling is now tied to a host of new approaches
tion, but also accounted for the tension that devel- that attempt to link individual characteristics with
oped in different settings when one participant contextual and relationship variables to assist indi-
was asked to essentially represent all African viduals in the pursuit of their life goals. Career coun-
Americans. Barriers in the black world included selors may need to be more eclectic than others
fears of jealousy and contempt for the success of due to the complex nature of career counseling. Part
the participants. Participants also discussed the of the counseling process with a client might call
experience of bicultural balance in their lives and for a trait and factor approach, whereas for another
the discomfort that it created. And, they pointed part of the process a relational, contextual, or social
out the bicultural skills that were necessary to allow learning approach might be used.
them to go back and forth between their two worlds. The interviewing process in career counseling
Diemer suggested that further research eagerly look has also changed, in that counselors ask questions
at the psychological distress that individuals from that have as much to do with lifestyle as job skills.
all cultures experience when negotiating two envi- There is continuing interest in the lifespan of a
ronments. He also called for continuing research on client, so that clinical information about childhood,
the skills that make up bicultural competence, adolescence and adulthood are given equal time.
information potentially useful for clients as well as This evolution in the interviewing process contin-
practitioners. ues to blur the line between personal and career
Diemer and Blustein (2007) offer a refresh- counseling. Career counselors may also be called
ing twist to career identity by suggesting that a upon to address particular personal issues with one’s
new construct, “vocational hope” be considered in career domain, including self-esteem and self-effi-
the mix. The authors, responsive to the few career cacy, burnout, work–family and family–work spill-
assessment tools appropriate for urban adoles- over, and employment discrimination.
cents, explored the component structure of three Providing career counseling services to the
indices of career development with a sample of marginalized and underserved will continue to
115 females and 105 males. These indices were be among the greatest challenges for the career
vocational identity, career commitment measured, counseling profession and for professional associa-
and work salience. Their analyses produced a four- tions such as the NCDA, the National Employ-
component solution (connection to work, voca- ment Counseling Association (NECA), the Society
tional identity, commitment to chosen career, of Counseling Psychology-Division 17 of APA,
salience of chosen career). They pointed out that and the Division 17 section, the Society for
remaining connected to a vocational future or incul- Vocational Psychology. In short, career counseling
cating vocational hope, especially with countless must return to its roots. It is indeed curious that
barriers and pressure to disconnect, is an important a profession that began with the perspective of social
consideration for career counselors and educators justice envisioned by its founder, Frank Parsons,
working with urban adolescents. Diemer and has failed to address many of the concerns that
Blustein suggested that counselors provide new psy- were used to create the career counseling field. The
chosocial and career development interventions that very poor, urban youth, the homeless, the impris-
facilitate vocational hope. They also suggested that a oned, the disabled, the marginalized, and those
new measure of the construct of vocational hope be on probation and parole will continue to need a
considered for development. Perhaps the inculcat- much greater degree of focus from the field and
ing of hope is in essence of what career counselors the professional associations. It would be wise for
should do best. the professional associations to represent these vari-
ous potential clients most in need of services.
Conclusion
Career counseling is a unique approach to counsel- Future Directions Questions
ing because it is so intimately tied to the utilization The career counseling field will confront a variety of
of tests to extract information about individual cli- new challenges in the future. Here, I review several
ents and families and match that with jobs and career of the issues that need to be taken on, along with
choices. But the “test ‘em and tell ‘em” approach to problems that need to be resolved.

564 career cou n s el in g

 There will need to be a greater degree of interna- along with federal, state, and local legislators,
tional focus in the field, especially with increasing and especially with those individuals who regulate
globalization and the migration of so many workers government policies. They should find a way to
from country to country in search of new opportu- participate as advocates in legislation like the
nities. In anticipation of this sea change in the field, Employment Non-Discrimination Act (ENDA)
Pope (2007), during his editorship of the Career and other legislation serving to eliminate discrim-
Development Quarterly (CDQ), created a new sec- ination against oppressed people. The founder of
tion in the journal titled “Global Vision.” Many the field, Frank Parsons, engaged in advocacy over
contributions to the CDQ and the Journal of 100 years ago.
Vocational Behavior ( JVB) are provided by authors Career counselors also need to be involved in
living outside of the United States. Career counsel- new program development and evaluation for those
ing and assessment have evolved within the capital- who have been placed in marginalized situations.
ist structure of the United States. But how do career These can include people who are homeless, impov-
choices evolve in socialist and communist countries? erished, undocumented, incarcerated or paroled,
And, how might the major political changes in a and physically and emotionally disabled, among
country influence the career development of the others. Many inner-city youth in the United States
citizens of that country? Some international con- are unemployed or underemployed and not neces-
texts may not be friendly toward the individualistic, sarily involved in job-seeking activities. Career
self-directed career development that many people counselors have valuable expertise in vocational
experience in the United States. To address some of program development for these and other “difficult
these emerging issues, the Society of Counseling to employ” populations. They can advise and assist
Psychology (Division 17 of the APA) sponsored in the development of new entrepreneurial pro-
an International Counseling Psychology Confer- grams or social entrepreneurship. These for-profit
ence (www.icpc2008.org) with keynote speakers programs can directly address social problems as
from South America, Portugal, South Africa, their central mission and endure because they are
Taiwan, and the United States, among others. Access divorced from income generated only through
to services around the world, honoring indigenous donations and grants.
career models, the interface of health ethics and Career counselors need to prepare for the baby
social science, and the future of counseling psy- boomers who will be reaching retirement age soon.
chology were among the topics given a global It is popularly known that 78 million baby boomers
perspective. will reach the age of 65 in 2011. Many of these
Should career counseling be seen as part of a retirees will wish to explore new opportunities, and
system of health care? Although almost all of the others will wish to keep working. Career counselors
states have licensed professional counseling laws, with training in gerontology will need to be able to
career counselors are not seen in the same light as provide necessary services to this group.
other counselors providing services. Will this atti- Finally, career counselors will need to advocate
tude change as people realize that clinical depression for themselves as counselors. Quite clearly, the field
is often a by-product of job loss? More people has changed substantially over the years, as has
migrate for work-related reasons than for any other the workplace. As this chapter has demonstrated,
phenomenon. Work-to-family and family-to-work contextual variables of the family, community, and
spillover continue to disrupt marriages and relation- culture are now included as essential ingredients in
ships. Career stress leads to general anxiety prob- the career counseling process. Evans (2008) has sug-
lems. Career counselors are the experts in these gested that there must be an integration of career
areas, yet they are often marginalized by federal and counseling, personal counseling, and multicultural
state health care systems, not to mention HMOs, counseling. This integration should take place
unwilling to recognize their services as fundamental within the framework of the APA guidelines, and
to an individual’s mental health. the NCDA and ACA competencies previously dis-
Career counseling has been largely influenced cussed. Career counselors can serve in a variety of
by legislation, but will professionals in the career roles: as individual practitioners, social service pro-
counseling field see the need to continue to develop gram developers, and advocates. They have the
advocacy models for the profession and for clients? capacity to change lives in the area most significant
Career professionals should continue to have a in the development of a person’s individual identity:
strong a relationship with the Department of Labor, the work that the person does.

chope 565
References Bronfebrenner, U. (1977). Toward an experimental ecology of
human development. American Psychologist, 32, 513–531.
ACT, Inc. (2000). Discover [Computer software]. Iowa City, IA:
Brown, D. (2003). Career information, career counseling, and
Author.
career development (8th ed.). Boston: Allyn & Bacon.
Amundson, N. E., Harris-Bowlsbey, J., & Niles, S. G. (2009).
Campbell, D. (1992). Campbell interest and skill survey.
Essential elements of career counseling: Processes and techniques.
Minnetonka, MN: National Computer Systems.
Upper Saddle River, NJ: Pearson Education, Inc.
Campbell, D., Strong, E. K., & Hansen, J. (1991). The Strong
Arredondo, P., & Perez, P. (2003). Expanding multicultural
Interest Inventory. Palo Alto, CA: Consulting Psychologists
competence through social justice leadership. The Counseling
Press.
Psychologist, 31, 282–289.
Carless, S. A., & Bernath, L. (2007). Antecedents of intent to
Arrendondo, P., Toporek, R., Brown, S. P., Jones, J., Locke, D. C.,
change careers among psychologists. Journal of Career
Sanchez, J., & Stadler, H. (1996). Operationalization of the
Development, 33, 183–200.
multicultural counseling competencies. Journal of Multicul-
Chope, R. C. (2005). Qualitatively assessing family influence
tural Counseling and Development, 24, 42–78.
in career decision making. Journal of Career Assessment, 13,
Association for Counselor Education and Supervision/National
395–414.
Career Development Association. (2000). Preparing counselors
Chope, R. C. (2006). Family matters: The influence of the family
for career development in the new millennium [ACES/NCDA
in career decision making. Austin, TX: Pro-Ed.
position paper]. Retrieved December 18, 2006, from http://
Chope, R. C. (2008). Practice and research in career counseling—
www.ncda.org/pdf/CommissionPaper.pdf.
2007. Career Development Quarterly, 57, 98–173.
Aubry, R. F. (1977). Historical development of guidance and
Chope, R. C., & Consoli, A. J. (2006). A storied approach to
counseling and implications for the future. Personnel and
multicultural career counseling. In K. Maree (Ed.), Shaping
Guidance Journal, 55, 288–295.
the story: A guide to facilitating career counseling (pp. 83–96).
Beutler, L. E. (1991). Have all won and must all have prizes?
Pretoria, South Africa: Van Schaik.
Revisiting Luborsky et al.’s verdict. Journal of Consulting and
Chope, R. C., & Toporek, R. L. (2007). Providing human
Clinical Psychology, 59, 226–232.
services with a social justice perspective. In J. Z. Calderon
Beutler, L. E. (2002). The dodo bird is extinct. Clinical Psychology:
(Ed.), Race poverty and social justice (pp. 148–166). Sterling,
Science & Practice, 9, 30–34.
VA: Stylus.
Bernes, K. B., Bardick, A. D., & Orr, D. T. (2007). Career
Cochran, L. (1997). Career counseling: A narrative approach.
guidance and counselling efficacy studies: An international
Thousand Oaks, CA: Sage.
research agenda. International Journal for Educational and
Consoli, A. J., & Chope, R. C. (2006). Contextual integrative
Vocational Guidance, 7, 81–96.
psychotherapy: A case study. In G. Stricker, & J. Gold
Berry, J. W. (1997). Acculturation and health. In S. Kazarian, &
(Eds.), A casebook in psychotherapy integration. Washington,
D. Evans (Eds.), Cultural clinical psychology (pp. 39–57).
DC: APA.
New York: Oxford.
Constantine, M. G., Kindaichi, M., & Miville, M. L. (2007).
Blau, G. (2007). Partially testing a process model for under-
Factors influencing the educational and vocational transi-
standing victim responses to an anticipated worksite closure.
tions of Black and Latino high school students. Professional
Journal of Vocational Behavior, 71, 401–428.
School Counseling, 10, 261–265.
Blustein, D. L. (2001). The interface of work and relationships:
Constantine, M. G., Wallace, B. C., & Kindaichi, M. M. (2005).
A critical knowledge base for 21st century psychology. The
Examining contextual factors in the career decision status of
Counseling Psychologist, 29, 179–192.
African American adolescents. Journal of Career Assessment,
Blustein, D. L. (2006). The psychology of working: A new
13, 307–319.
perspective for career development, counseling, and public policy.
Crites, J. O. (1981). Career counseling: Models, methods, and
Mahwah, NJ: Erlbaum.
materials. New York: McGraw-Hill.
Blustein, D. L. (2008). The role of work in psychological health
Crites, J. O., & Savickas, M. (1995). Career maturity inventory.
and well-being. American Psychologist, 63, 228–240.
Boulder, CO: Crites Career Consulting.
Blustein, D. L., McWhirter, E. H., & Perry, J. C. (2005).
Cunningham, J., & Macan, T. (2007). Effects of applicant
An emancipatory communication approach to vocational
pregnancy on hiring decisions and interview ratings.
development theory, research, and practice. The Counseling
Sex Roles, 57, 497–508.
Psychologist, 33, 141–179.
Dagley, J. (1984). A vocational genogram (mimeograph). Athens,
Blustein, D. L., Walbridge, M. M., Friedlander, M. L., &
GA: University of Georgia.
Palladino, D. E. (1991). Contributions of psychological
Dawis, R. V., & Lofquist, L. (1984). A psychological theory
separation and parental attachment to the career develop-
of work adjustment. Minneapolis: University of Minnesota
ment process. Journal of Counseling Psychology, 38, 39–50.
Press.
Borgen, W. A., & Maglio, A. T. (2007). Putting action back into
Diemer, M. A. (2007). Two worlds: African American men’s
action planning: Experiences of career clients. Journal of
negotiation of predominantly White educational and occu-
Employment Counseling, 44, 173–184.
pational worlds. Journal of Multicultural Counseling and
Borow, H. (1964). Notable events in the history of vocational
Development, 35, 2–14.
guidance. In H. Borow (Ed.), Man in a world of work
Diemer, M. A., & Blustein, D. L. (2007). Vocational hope and
(pp. 45–64). Washington, DC: Houghton Mifflin.
vocational identity: Urban adolescents’ career development.
Brewer, J. M. (1942). History of vocational guidance. New York:
Journal of Career Assessment, 15, 98–118.
Harper.
Dorn, F. J. (1992). Occupational wellness: The integration of
Brief, A. P., & Weiss, H. M. (2002). Organizational behavior:
career identity and personal identity. Journal of Counseling &
Affect in the workplace. Annual Review of Psychology, 53,
Development, 71, 176–178.
279–307.

566 career cou n s el in g

Duffy, R. D., & Sedlacek, W. E. (2007). The presence of and Holland, J. L. (1994). Self-directed search. Odessa, FL:
search for a calling: Connections to career development. Psychological Assessment Resources.
Journal of Vocational Behavior, 70, 590–601. Holland, J. L. (1997). Making vocational choices: A theory of
Educational Testing Service. (1997). SIGI Plus. Princeton, NJ: vocational personalities and work environments (3rd ed.).
Author. Odessa, FL: Psychological Assessment Resources.
Evans, K. (2008). Gaining cultural competence in career counsel- Howard, G. S. (1991). Cultural tales: A narrative approach
ing. Boston: Lahaska Press. to thinking, cross-cultural psychology, and psychotherapy.
Fassinger, R. E. (2008). Workplace diversity and public policy: American Psychologist, 46, 187–197.
Challenges and opportunities for psychology. American Irwin, J. (2002). Discrimination against gay men, lesbians, and
Psychologist, 63, 252–268. transgender people working in Education. Journal of Gay &
Fouad, N. A., & Kantamneni, N. (2008). Contextual factors in Lesbian Social Services, 14, 65–77.
vocational psychology: Intersections of individual, group, and Johansson, C. B. (1986). Career assessment inventory. Minneapolis:
societal dimensions. In S. D. Brown, & R. W. Lent (Eds.), NCS Assessments.
Handbook of counseling psychology (4th ed., pp. 408–425). Johnson, R. A. (2008). African-Americans and homelessness:
Hoboken, NJ: John Wiley. Moving through history. Journal of Black Studies, 40,
Gold, J. G., Rotter, J. C., & Evans, K. M. (2002). Out of 583–605.
the box: A model for counseling in the twenty-first century. Joo, S., Grable, J. E., & Choe, H. (2007). Who is and who is not
In K. Evans, J. C. Rotter, & J. C. Gold (Eds.), Synthesizing willing to use online employer- provided retirement invest-
family, career, and culture: A model for counseling in the ment advice. Journal of Employment Counseling, 44, 73–85.
twenty-first century (pp. 19–33). Alexandria, VA: American Judge, T. A., & Ilies, R. (2004). Affect and job satisfaction:
Counseling Association. A study of their relationship at work and home. Journal of
Goodman, J. (1994). The dental model for counseling. American Applied Psychology, 89, 661–673.
Counselor, 1, 27–29. Kamasaki, C. (2008, July). Five facts about undocumented work-
Gottfredson, L. S. (1981). Circumscription and compromise: ers in the United States. Keynote address presented at the
A developmental theory of occupational aspirations. Journal National Employment Counseling Association (NECA)
of Counseling Psychology, 28, 545–579. Workforce Development Institute II, Washington, DC.
Gottfredson, L. S. (1996). Gottfredson’s theory of circum- Katz, M. (1963). Decisions and values. New York: College
scription and compromise. In D. Brown, & L. Brooks Entrance Examination Board.
(Eds.), Career choice and development: Applying contemporary Kazdin, A. E. (2008). Evidence-based treatment and practice:
theories to practice (3rd ed., pp. 179–232). San Francisco: New opportunities to bridge clinical research and practice,
Jossey-Bass. enhance the knowledge base, and improve patient care.
Gottfredson, L. S. (2004). Applying Gottfredson’s theory of American Psychologist, 63, 146–159.
circumscription and compromise in career guidance and Kenny, M. E., & Perez, V. (1996). Attachment and psychological
counseling. In S. D. Brown, & R. W. Lent (Eds.), Career well being among racially and ethnically diverse first-year
development an counseling: Putting theory and research to work college students. Journal of College Student Development, 37,
(pp. 71–100). Hoboken, NJ: John Wiley. 527–535.
Gysbers, N. C., Heppner, M. J., & Johnston, J. A. Career counsel- King, N. J., & Madsen, E. (2007). Contextual influences on the
ing: Process, issues, and techniques (2nd ed.). Boston: Allyn career development of low-income African American youth.
and Bacon. Journal of Career Development, 33, 395–411.
Hansen, L. S. (1997). Integrative life planning—Critical tasks for Kirk, J., & Belovics, R. (2008). Understanding and counseling
career development and changing life patterns. San Francisco: transgender clients. Journal of Employment Counseling, 45,
Jossey-Bass. 29–39.
Harrington, T., & O’Shea, A. (2000). Harrington-O’Shea career Krumboltz, J. D. (1991). The career beliefs inventory. Palo Alto,
decision making system. Circle Pines, MN: American Guidance CA: Consulting Psychologists Press.
Service. Krumboltz, J. D. (1993). Integrating career and personal coun-
Helms, J. E. (2003). A pragmatic view of social justice. The seling. Career Development Quarterly, 42, 143–148.
Counseling Psychologist, 31(3), 305–313. Krumboltz, J. D. (1996). A learning theory of career counseling.
Helms, J. E., & Cook, D. A. (1999). Using race and culture In M. Savickas, & B. Walsh (Eds.), Integrating career theory
in counseling and psychotherapy: Theory and practice. Boston: and practice (pp. 233–280). Palo Alto, CA: Consulting
Allyn & Bacon. Psychologists Books.
Herr, E. L. (2003). The future of career counseling as an instru- Kubler-Ross, E. (1969). On death and dying. New York:
ment of public policy. Career Development Quarterly, 52, MacMillan.
8–17. Larson, L. M. (2011). What do we know about work life across
Herr, E. L., Cramer, S. H., & Niles, S. G. (2004). Career guid- the lifespan? In E. M. Altmaier, & J. C. Hansen (Eds.), The
ance and counseling through the lifespan: Systematic approaches Oxford handbook of counseling psychology. New York: Oxford
(6th ed.). Needham Heights, MA: Allyn & Bacon. University Press.
Hoffman, M. A. (2011). Individual counseling as an interven- Lee, C., Spencer, M. B., & Harpalani, V. (2003). Every shut eye
tion. In E. M. Altmaier, & J. C. Hansen (Eds.), The Oxford ain’t sleep: Studying how people live culturally. Educational
handbook of counseling psychology. New York: Oxford Leadership, 32, 6–13.
University Press. Lent, R. W. (2008). Understanding and promoting work satisfac-
Hogue, M., Yoder, J. D., & Singleton, S. B. (2007). The gender tion: An integrative view. In S. D. Brown, & R. W. Lent (Eds.),
wage gap: An explanation of men’s elevated wage entitle- Handbook of counseling psychology (4th ed., pp. 462–480).
ment. Sex Roles, 56, 573–579. Hoboken, NJ: John Wiley.

chope 567
Lent, R. W., Brown, S. D., & Hackett, G. (1994). Toward a Pope, M. (2000). A brief history of career counseling in
unifying social cognitive theory of career and academic inter- the United States. The Career Development Quarterly, 48,
ests, choice, and performance. Journal of Vocational Behavior, 194–211.
45, 79–122. Pope, M. (2007). Introduction to a new section: Global vision.
Leong, F. T. L. (1995). Career development and vocational behav- The Career Development Quarterly, 56, 2–3.
ior of racial and ethnic minorities. Hillsdale, NJ: Lawrence Pyle, K. R. (2000). A group approach to career decision-making.
Erlbaum Associates. In N. Peterson, & R. C. Gonzalez (Eds.), Career counseling
Lewis, J., & Coursol, D. (2007). Addressing career issues online: models for diverse populations: Hands on applications for
Perceptions of counselor education professionals. Journal of practitioners (pp. 121–136). Belmont, CA: Wadsworth/
Employment Counseling, 44, 146–153. Thompson Learning.
Luzzo, D. (2000). Career counseling of college students. Quimby, J. L., Wolfson, J. L., & Sayala, N. D. (2007). Social
Washington, DC: American Psychological Association. cognitive predictors of African American adolescents’ career
Masser, B., Grass, K., & Nesic, M. (2007). “We like you, but we interests. Journal of Career Development, 33, 376–394.
don’t want you” the impact of pregnancy in the workplace. Rutter, M. E., & Jones, J. V. (2007). The job club redux: A step
Sex Roles, 57, 703–712. forward in addressing the career development needs of coun-
McMahon, M. (2002). The systems theory framework of career selor education students. Career Development Quarterly, 55,
development: History and future directions. Australian 280–288.
Journal of Career Development, 11, 63–68. Sampson, J. P., Jr., Peterson, G. W., Lenz, J. G., Reardon, R. C.,
McMahon, M., & Patton, W. (1995). Development of a systems & Saunders, D. E. (1996). Career thoughts inventory. Odessa,
theory framework of career development. Australian Journal FL: Psychological Assessment Resources.
of Career Development, 4, 15–20. Savickas, M. L. (1999). The transition from school to work:
Mitchell, K. E., Levin, A. S., & Krumboltz, J. D. (1999). Planned A developmental perspective. Career Development Quarterly,
happenstance: Constructing unexpected career opportunities. 47, 326–336.
Journal of Counseling and development, 77, 115–124. Savickas, M. L. (2005). The theory and practice of career
Moorhouse, A., & Caltabiano, M. L. (2007). Resilience and construction. In S. D. Brown, & R. W. Lent (Eds.), Career
unemployment: Exploring risk and protective influences for development and counseling: Putting theory and research to
the outcome variables of depression and assertive job search- work (pp. 42–70). Hobeken, NJ: Wiley.
ing. Journal of Employment Counseling, 44, 115–125. Schmader, T., Whitehead, J., & Wysocki, V. H. (2007).
Myers, I., & Briggs, K. (1993). The Myers-Briggs type indicator. A linguistic comparison of letters of recommendation for
Palo Alto, CA: Consulting Psychologists Press. male and female chemistry and biochemistry job applicants.
National Board of Certified Counselors. (2007). The practice of Sex Roles, 57, 509–514.
internet counseling. Greensboro, NC: Author. Schulenberg, J. E., Vondracek, F., & Crouter, A. (1984).
National Career Development Association (NCDA). (1997). The influence of the family on vocational development.
Career counseling competencies. Retrieved June 4, 2008, from Journal of Marriage and the Family, 46, 129–143.
www.ncda.org/pdf/counselingcompetencies.pdf. Schultheiss, D. (2003). A relational approach to career counsel-
National Occupational Information Coordinating Committee ing: Theoretical integration and practical application. Journal
(NOICC). (1992). The national career development guidelines of Counseling and Development, 81, 301–311.
project. Washington, DC: U.S. Government Printing Office. Schultheiss, D., Kress, H., Manzi, A., & Glasscock, J. (2001).
Niles, S. G., & Harris-Bowlsby, J. (2005). Career development Relational influences in career development: A qualitative
interventions in the 21st century (2nd ed.). Upper Saddle inquiry. The Counseling Psychologist, 29, 214–239.
River, NJ: Pearson Education. Sharf, R. S. (2006). Applying career development theory to
Okubo, Y., Yeh, C. J., Lin, P.-Y., & Fujita, K. (2007). The career counseling. Belmont, CA: Thompson Higher Education.
decision making process of Chinese American youth. Journal Shea, M. M., Ma, P. W., & Yeh, C. J. (2007). Development of a
of Counseling and Development, 85, 440–449. culturally specific career exploration group for urban Chinese
Okun, B. (1984). Working with adults: Individual, family, and immigrant youth. Career Development Quarterly, 56, 62–73.
career development. Monterey, CA: Brooks/Cole. Shivy, V. A., Wu, J. J., Moon, A. E., Mann, S. C., Holland, J. G.,
Okiishi, R. W. (1987). The genogram as a tool in career counsel- & Eacho, C. (2007). Ex-offenders reentering the workforce.
ing. Journal of Counseling and Development, 66, 139–143. Journal of Counseling Psychology, 54, 466–473.
Oliver, L. W. (1979). Outcome measurement in career counsel- Smith, T. B., Dean, B., Floyd, S., Silva, C., Yamashita, M.,
ing research. Journal of Counseling Psychology, 26, 217–226. Durtschi, J., & Heaps, R. A. (2007). Pressing issues in college
Oliver, L. W., & Spokane, A. R. (1988). Career-intervention counseling: A survey of American College Counseling
outcome: What contributes to client gain? Journal of Coun- Association members. Journal of College Counseling, 10, 64–78.
seling Psychology, 35, 447–462. Spokane, A. R., & Oliver, L. W. (1983). The process and out-
Osborn, D. S., & Zunker, V. G. (2006). Using assessment results come of career counseling. In W. B. Walsh, & S. H. Osipow
for career development. Belmont, CA: Thompson Higher (Eds.), Handbook of vocational psychology (pp. 99–136).
Education. Hillsdale, NJ: Lawrence Erlbaum.
Parsons, F. (1909). Choosing a vocation. Boston: Houghton-Mifflin. Stead, G. (2004). Culture and career psychology: A social
Peterson, G. W., Sampson, J. P., Jr., & Reardon, R. C. (1991). constructionist perspective. Journal of Vocational Behavior,
Career development and services: A cognitive approach. Pacific 64, 389–406.
Grove, CA: Brooks/Cole. Steinberg, L. (2004). The ten basic principles of good parenting.
Pizzolato, J. E. (2007). Impossible selves: Investigating students’ New York: Simon and Schuster.
persistence decisions when their career-possible selves border Sueyoshi, L. A., Rivera, L., & Ponterro, J. G. (2001). The family
on impossible. Journal of Career Development, 33, 201–223. genogram as a tool in multicultural career counseling.

568 career cou n s el in g

 In J. G. Ponterro, J. M. Casas, L. A. Suzuki, & C. M. Alexander Wampold, B. E., Lichtenberg, J. W., & Waehler, C. A. (2002).
(Eds.), Handbook of multicultural counseling (2nd ed., Principles of empirically supported interventions in counsel-
pp. 655–671). Thousand Oaks, CA: Sage Publications. ing psychology. The Counseling Psychologist, 30, 197–217.
Sullivan, K. R., & Mahalik, J. R. (2000). Increasing career-self Whiston, S. C. (2002). Application of the principles: Career
efficacy for women: Evaluating a group intervention. Journal counseling and interventions. The Counseling Psychologist, 30,
of Counseling and Development, 78, 54–62. 218–237.
Super, D. E. (1970). Computer-assisted counseling. New York: Whiston, S. C., & Keller, B. (2004). The influences of the family
Teachers College, Columbia University. of origin on career development: A review and analysis.
Super, D. E. (1980). A life-span, life-space approach to career The Counseling Psychologist, 32, 493–568.
development. Journal of Vocational Behavior, 16, 282–298. Whiston, S. C., Sexton, T. L., & Lasoff, D. L. (1998). Career
Super, D. E. (1984). Career and life development. In D. Brown, intervention outcome: A replication and extension. Journal
L. Brooks, et al (Eds.), Career choice and development: of Counseling Psychology, 45, 150–165.
Applying contemporary theories to practice (pp. 192–234). Whitely, J. M. (1984). A historical perspective on the
San Francisco: Jossey-Bass. development of counseling psychology as a profession.
Super, D. E. (1990). A life span, life-space approach to career In S. D. Brown, & R. L. Lent (Eds.), Handbook of counseling
development. In D. Brown, L. Brooks, et al (Eds.), Career psychology (pp. 3–55). New York: John Wiley.
choice and development: Applying contemporary theories to Young, R. A., Marshall, S. K., & Valach, L. (2004, June). Cultural
practice (2nd ed., pp. 197–261). San Francisco: Jossey-Bass. sensitivity, career theory, and counseling. Paper presented at the
Super, D. E. (1993). The two faces of counseling: Or is it three? IAEVG-NCDA Symposium on International Perspectives in
Career Development Quarterly, 42, 132–136. Career Development, San Francisco, CA.
Super, D. E., Thompson, A. S., Lindeman, R. H., Jordan, J. P., Young, R. A., Marshall, S. K., & Valach, L. (2007). Making
& Myers, R. A. (1984). Career development inventory. Palo career theories more culturally sensitive: Implications for
Alto, CA: Consulting Psychologists Press. counseling. Career Development Quarterly, 56, 4–18.
Swanson, J. L. (1995). The process and outcome of career Zalaquett, C. P., & Osborn, D. S. (2007). Fostering counseling
counseling. In W. B. Walsh, & S. H. Osipow (Eds.), The students’ career information literacy through a comprehen-
handbook of vocational psychology (pp. 217–259). Mahwah, sive career web site. Counselor Education & Supervision, 46,
NJ: Lawrence Erlbaum. 162–171.
Swanson, J., & Fouad, N. (1999). Career theory and practice. Zunker, V. G. (2006). Career counseling: A holistic approach.
Thousand Oaks, CA: Sage. Belmont, CA: Thomson/Brooks Cole.
Swanson, J. L., Gore, P. A., Jr., Leuwerke, W., Achiardi, C. D.,
Edwards, J. H., & Edwards, J. (2006). Accuracy in recalling Further Reading
interest inventory information in three time intervals. Amundson, N. E. (2003). Active engagement: Enhancing the
Measurement and Evaluation in Counseling and Development, career counseling process (2nd ed.). Richmond, BC, Canada:
38, 236–246. Ergon Communications.
Tansley, D. P., Jome, L. M., Haase, R. F., & Martens, M. P. Chope, R. C. (2006). Family matters: The influence of the family
(2007). The effects of message framing on college students’ in career decision making. Austin, TX: Pro-Ed.
career decision making. Journal of Career Assessments, 15, Evans, K. (2008). Gaining cultural competence in career
301–316. counseling. Boston: Lahaska Press.
Thorngren, J. M., & Feit, S. S. (2001). The career-o-gram: Harris-Bowlsbey, J., Riley Dikel, M., & Sampson, J. P., Jr.
A post modern career intervention. The Career Development (2002). The internet: A tool for career planning (2nd ed.).
Quarterly, 49, 291–303. Tulsa, OK: National Career Development Association.
Toporek, R. L., & Chope, R. C. (2006). Individual, program- John, J. (2001). Treatment planning in career counseling.
matic, and entrepreneurial approaches to social justice: Belmont, CA: Wadsworth/Thomson Learning.
Counseling psychologists in vocational and career counseling. Maree, K. (Ed.). (2007). Shaping the story: A guide to facilitat-
In R. L. Toporek, L. Gerstein, N. A. Fouad, G. S. Roysircar, ing narrative counseling. Pretoria, South Africa: Van Schaik
& T. Israel (Eds.), Handbook for social justice in counseling Publishers.
psychology: Leadership, vision, & action (pp. 276–293). Patton, W., & McMahon, M. (1999). Career development
Thousand Oaks, CA: Sage. and systems theory: A new relationship. Pacific Grove, CA:
Vera, E. M., & Speight, S. L. (2003). Multicultural competence, Brooks Cole.
social justice, and counseling psychology: Expanding our Sharf, R. S. (2006). Applying career development theory to
roles. Counseling Psychologist, 31, 253–272. counseling. Belmont, CA: Thompson Higher Education.

chope 569
 CHAPTER

22 Multicultural Counseling and Psychotherapy

Jairo N. Fuertes

Abstract
This chapter addresses three limitations to the current state of thinking and research on the topic
of multicultural counseling. One, theories of multicultural counseling have not been integrated
within a broader theoretical framework of counseling research and practice. Two, research in
multicultural counseling has not been grounded in or directed to explain the process and outcome
of psychotherapy; and three, research in multicultural counseling has not been adequately targeted
at explaining or treating problems that affect racial and ethnic minority populations. The chapter also
points to some potentially fruitful areas in the field of multicultural counseling, including opportunities
for further theory development, research program development, and interventions that may help
ameliorate conditions of injustice and human suffering.
Keywords: multicultural counseling, psychotherapy, process, outcome, ethnic racial minorities,
research.

The field of multicultural counseling has now achieved Minority Psychology, as well as in traditional journals
a level of growth, maturation, and sophistication of psychology and counseling (see Worthington,
worth noting. Demographic changes in the United Soth-McNett, & Moreno, 2007). New ideas and
States in the last 40 years, the daily influx of immi- research are being presented in areas such as psy-
grants to this country every day—approximately chotherapy, consultation, supervision, guidance, and
3,000 legal immigrants a day (U.S. Department of trainee development, and new research is being pub-
Homeland Security, 2004), the increase and diversifi- lished based on constructs from multicultural coun-
cation of the clientele and professional corps in coun- seling in related domains like medical health care
seling, and the emerging interest in counseling in delivery and public policy. The training, ethical, and
international markets have all contributed to an accreditation guidelines of the American Psychological
increase in thinking, research, and advocacy for the Association and the American Counseling Association
needs and services provided to immigrants, minority, also include numerous and important principles with
and historically marginalized populations. In the last respect to multicultural awareness, competence, and
20 years alone, numerous theories and models have sensitivity, reflecting the need for practitioners to
been proposed on the topic of multicultural counsel- practice their craft in ways that are effective and
ing; a constant flow of research has appeared on racial accommodating to an increasingly diverse clientele.
identity, multicultural competence, multicultural In essence, multicultural counseling is a field that is
therapy, and social justice in specialized journals relevant and essential in the practice and growth of
such as the Journal of Multicultural Counseling and psychology and counseling. However, despite these
Development and Cultural Diversity and Ethnic developments, or perhaps as a consequence of them,

570
many challenges and opportunities exist in the field modalities, such as group therapy or consultation.
of multicultural counseling with respect to service The intent of the chapter is to address three limita-
delivery, research, and training for professionals in tions to the current state of thinking and research
our field. The needs in terms of service delivery on this topic. One, theories of multicultural coun-
center around further empirical support/evidence for seling are not integrated within a broader theoreti-
multicultural approaches and theoretical/technical cal framework of counseling research and practice;
integration between multiculturalism and “tradi- two, research in multicultural counseling has not
tional” theoretical and technical approaches to coun- been situated within the process and outcome of
seling. As such, these challenges parallel those that are psychotherapy; and three, research in multicultural
still being discussed and addressed in “traditional” counseling has not been targeted at explaining or
counseling, for example the search for evidence- treating problems that affect racial and ethnic
supported treatments and the continuing goal for minority populations.
theoretical integration. There are also needs for evi- The chapter is organized into three broad sec-
dence of efficacy for specific approaches with specific tions. First, there is an integrated discussion of the
populations, for research that integrates multicultural theoretical developments in the area of multicul-
constructs in the process of counseling, and perhaps tural counseling. This section builds primarily on
most importantly, for data that show that multicul- the author’s and his collaborators’ work in identify-
tural approaches, including counselor multicultural ing theories and models of multicultural counsel-
competence, can decrease outcome disparities in the ing, and includes observations gleaned from this
mental health treatment of minorities and immigrant theoretical literature. Following this discussion, the
populations in the United States. reader will find a review of recent research on the
The rationale for this chapter is the seriousness of topic of counselor multicultural competence and of
the issues with which it relates. Besides the evidence the challenges and opportunities with respect to
of outcome disparities for racial/ethnic minorities research on racial/ethnic identity. The second sec-
who receive mental health services in the United tion also builds on previous work and presents
States are the issues that affect these populations, research that appears to have implications for clini-
including racism, poverty, violence, alcohol/drug cal practice. It is important to emphasize that this
abuse, teen pregnancy, and high school dropout research does not provide evidence or support for
rates. Although the evidence suggests that racial/ any one approach or intervention, but tentative
ethnic minority groups do not experience psychiatric hypotheses are presented because of their relevance
disorders in greater proportion or intensity than the to clinical practice. The final section of the chapter
majority population, the quality and availability of presents an agenda for future research on the topic
services to them is clearly a problem (Department of of multicultural counseling.
Health and Human Services, 2001). The problem is
the lack of insurance, disproportionate poverty, and Definition
less access to and less quality of services. Furthermore, In a previous paper, Fuertes and Ponterotto (2003)
even in the event of an African American or Hispanic defined multicultural competence as
or immigrant patient having insurance, access, and
[A] counselor’s ability to integrate into his or her
quality of services, the Institute of Medicine and the
theoretical and technical approach to assessment
Surgeon General (Department of Health and Human
and intervention relevant human diversity factors
Services, 2001) concluded that racism still plays a
that are important to the process and successful
significant part in explaining outcome disparities
outcome of counseling. These factors may be relevant
for these populations.
to the counselor, the client, and/or the counseling
In this chapter, the focus is on individual
relationship. Human diversity refers to salient
counseling/psychotherapy (in this chapter, these
group-reference factors that are meaningful to the
terms are used interchangeably, as are the terms
individual; these may include gender, socioeconomic
counselor and therapist) and on racial and ethnic
background, religion, race, ethnicity, and/or regional/
minorities and immigrants in the United States, pri-
national origin, sexual orientation, all or any of which
marily those who arrive from preindustrialized
may inform or shape individual identity, behavior,
nations. Despite this focus, it is possible that the
worldviews, values, attitudes, and/or beliefs. (p. 52)
content and ideas presented here will be relevant
to other marginalized populations inside and out- This content also provides a good definition of
side the United States, and to other intervention multicultural counseling, if one changes the text

fue rt e s 571
from “as a counselor’s ability to integrate” to “when common factors perspective; Sue, Ivey, and Pedersen’s
a counselor integrates” and leaves the rest the same. (1996) theory of multicultural counseling; Gonzalez,
The definition is worth discussing because it Biever, and Gardner’s (1994) social constructionist
contains several assumptions about multicultural approach; Ho’s (1995) perspective on internalized cul-
counseling that can be highlighted here. One is the ture; Coleman’s (1995, 1997) coping with diversity
concept of integration, which implies that the coun- counseling model; Ramirez’s (1999) multicultural
selor identifies and appropriately brings into the model of psychotherapy; Hanna, Bemak, and Chung’s
work of assessment and intervention relevant human (1999) counselor wisdom paradigm; Locke’s (1998)
diversity information; the other is the link between model of multicultural understanding; Herring and
multicultural counseling and process and outcome Walker’s (1993) cross-cultural specific model (CSS);
in counseling, for example in facilitating additional and Steenbarger’s (1993) multicontextual model.
therapist interventions that go toward relationship The discussion that follows builds on these previ-
building and symptom relief. There is also the delin- ous four papers and does so by presenting observa-
eation of levels between counselor, client, and their tions and tentative conclusions from a review of the
relationship, meaning that multicultural material literature in multicultural counseling. Although it is
may be particularly salient at one, two, or three important to begin with theory, the entire the chap-
levels, separately or combined, such as when racial ter could be consumed with revisiting the theoreti-
identity statuses for both counselor and client are of cal papers noted above. Thus, the current discussion
consequence to the work. Finally, the definition fur- is limited to identifying patterns in the literature
ther highlights layered complexity and the variety of and opportunities that may provide direction for
sources that may inform or shape the perspective of further thinking, writing, and research in this area,
the client or counselor, and may need to be attended and the reader is referred to the original papers
to if counseling is to be successful. for in-depth reading or to the summative reviews
published in the four papers noted above.
Theory-based Research and Related Multicultural approaches are at various stages of
Observations theoretical and empirical development, with respect
Four papers provide the bases for a synthesis of to their comprehensiveness as counseling theories/
the latest thinking in the field of multicultural models, their operationalization for testing, and
counseling. The first paper was published in 2000 their operationalization for clinical utility. A current
(Ponterotto, Fuertes, & Chen), the second in 2001 review of the literature indicates that the amount
(Fuertes & Gretchen), the third in 2003 (Fuertes & of theoretical or empirical development on the
Ponterotto), and the fourth in 2008 (Constantine, 16 theories of multicultural counseling has been
Fuertes, Roysircar, & Kindaichi). Ponterotto et al. limited since 2001. The exception, however, has
and Fuertes and Gretchen reviewed the theoretical been continuing research on the theory of therapist
underpinnings and research for 16 different theo- multicultural competence, continued research (and
retical papers on the topic of multicultural counsel- considerable debate) on racial/ethnic identity devel-
ing (see Ponterotto et al., 2000; Fuertes & Gretchen, opment, and the development of a cultural accom-
2001 for a full review of these approaches). Fuertes modation model (Leong, 2007) based on Leong’s
and Gretchen (2001) also provided a critique and (1996) integrative multidimensional model of cross-
some preliminary observations with respect to cultural counseling. These developments are pre-
theory, research, and practice, based on nine of these sented below. Fuertes and Gretchen’s (2001) original
approaches. All 16 multicultural theories/approaches assessment of these approaches generated ratings
included the following: Sue et al.’s (1998) multicul- that were mostly “low” to “medium” on three
tural counseling competency model; Helms’ (1990, dimensions: comprehensiveness as counseling
1995, 1996; Helms & Cook, 1999) racial identity theory, operationalization for testing, and their
theory and interaction model; Atkinson, Thompson, operationalization for clinical utility; however, some
and Grant’s (1993) acculturation, locus of problem approaches were rated as more developed than
etiology, and goals of counseling model; Trevino’s others, and have generated far more research and
(1996) model of worldview and change; Ridley, scholarly attention. In fact, it is quite safe to con-
Mendoza, Kanitz, Andgermeier, and Zenk’s (1994) clude that the focus of the research on multicultural
perceptual schemata model of cultural sensitivity; counseling in the last 10 years or so has converged
Leong’s integrative model of cross-cultural counseling almost exclusively on two areas: counselor multi-
(Leong, 1996); Fischer, Jome, & Atkinson’s (1998) cultural competence and racial/ethnic identity.

572 m ulticultural co u n s e l in g
Why has this been true for the theories of multicul- is needed to elevate this literature to a level of pre-
tural competence and racial/ethnic identity? These scription for practice, from additional theoretical
are longstanding models in the literature, going developments to the development of measures that
back to the 1970s, and thus have been examined might allow for empirical examination. There are
and reformulated by teams of scholars for some also possibilities for further integration and strength-
time. Another practical reason for the research con- ening of perspectives, such as that occurring now
ducted on these models may be that measures to between multicultural competence and racial iden-
assess each have been developed and submitted to tity, with more studies jointly examining these per-
review and subsequent revisions. The result is well- spectives in research (e.g., Constantine, Warren, &
articulated statements with respect to their focus Miville, 2005).There is also a need for theoreticians
and structure, and fairly high psychometric proper- to tie their ideas and constructs to processes and
ties for their respective assessment instruments, targeted outcomes in counseling, particularly to the
which can be readily picked up and used in research. therapy relationship, which all empirical and clini-
Having said this, these theories and their measures cal evidence suggests is fundamental to effective
are still a subject of attention, reformulation, and therapy at all stages of the helping process. The rela-
debate in the literature (see Ponterotto & Park- tionship in multicultural counseling is the founda-
Taylor, 2007; Worthington et al., 2007). tion on which trust can develop, and through which
Despite some of the limits of the theoretical respect for the person and appreciation for the
perspectives published thus far on multicultural dignity of the human being is communicated. It
counseling, it is worth pointing out that they con- also becomes the mechanism for leverage, to help
tain many compelling and thoughtful statements encourage and challenge clients to engage in the
about the topic, and as a group, represent a diversity process of psychological growth and behavioral
of perspectives that can inform the practice and change. Many multicultural writers have directly
research in psychotherapy. Although the theories of or indirectly implicated the relationship in both
multicultural competence and racial identity have successful and unsuccessful treatment.
attracted considerable empirical testing, different Multicultural counseling approaches also delve
researchers and thinkers have chosen specific con- into issues that have the potential to inform all
cepts on which to develop their own thinking about counseling interactions. The issues raised by mul-
multicultural counseling, and these represent viable ticultural theories—for example, issues of identity,
areas that are ripe for development. For example, worldview, self-acceptance, tolerance of others,
some (e.g., Fischer et al., 1998) have highlighted and racism—seem relevant and important, albeit
common factors of therapy, such as the relation- to various degrees, in all counseling interactions. As
ship, to address problems in service delivery with the United States continues to diversify, and immi-
racial and ethnic minority populations; some have grant, majority, and minority populations clamor
highlighted differences, for example differences in for shared power and adjust to increasing social and
worldviews (e.g., Trevino, 1996) between counselor economic interdependence, the kind of issues being
and client and the dynamics associated with this addressed today in multicultural counseling will
difference in treatment; some have highlighted cog- become more pressing and more common. The
nitive processes (e.g., Ramirez, 1999) of clients, and psycho-social-cultural dimensions of living will
others internal dynamics evident for the counselor become more accentuated and provide more fodder
(e.g., Gonzalez et al., 1994) to identify mecha- for counseling interactions for a greater number of
nisms and possible venues for intervention. In sum, people. Thus, multicultural counseling is not a fad
just as there are various theoretical approaches in nor likely to become passé; rather, it may increas-
“traditional” counseling, there seems to be a grow- ingly represent the future of all counseling, provided
ing literature on ways to approach multicultural that further theoretical and technical counseling
counseling. This is an important point to empha- interventions are developed to meet the challenges
size. Many professionals and students in our and psychological needs of the burgeoning diver-
profession are genuinely interested in becoming sity in the United States. And yet, with increasing
“multiculturally sensitive” or “multiculturally com- diversity, some counseling interactions are likely to
petent,” with the implication being that there is remain more multicultural in nature than others, to
“one way” to do so. At this point, there are several the extent to which cultural and social issues are
compelling and elegant statements for conceptual- at the forefront of the interactions in some counsel-
izing multicultural counseling. Clearly, more work ing sessions (for example, race differences or racism,

fue rt e s 573
or when a U.S. born and trained psychologist treats is as an individual. The reader is directed to Locke’s
an immigrant family), or possibly in counseling (1998) multicultural theory, with its emphasis on
pairings that echo historical political and economic the role of the counselor being able to balance cul-
power differences, as when a European American tural presses with individual concerns of the client,
counselor works with an African American client. and to Leong’s (1996, 2007) papers, in which he
Another observation gleaned from the theories is delineates three dimensions of personality at the
that multicultural counseling pulls for complexity, individual, group, and universal levels. Leong pres-
with respect to case/person conceptualization, treat- ents an interesting discussion in which these dimen-
ment planning, and service delivery. The professional sions of personality are described, and presents a
must move beyond his or her theory of counseling to model for multicultural counseling that addresses
be able to adequately assess the individual not only their interplay and implications for counselors. The
in terms of pathology and strengths, and not only in reader is also encouraged to read Ho’s (1995) paper
traditional psychosocial dimensions, but in terms of on internalized culture for a good treatise on the
sociocultural dimensions and immediate living cir- individual psychology of culture.
cumstances that may be foreign to the life of the Current theories of multicultural counseling
therapist. Add to this the challenge of delivering supplement but do not supplant other counselor
services in a way that is palpable and ultimately help- techniques and skills and appear to be necessary
ful to the person, and the complexity and challenges but insufficient as standalone approaches to help-
associated with multicultural counseling become ing. Multicultural approaches appear to complete
appreciable. Although all clients tend to have social and enrich counseling by directing the counselor to
circumstances that are difficult, multicultural coun- important psychological material, interpersonal
seling demands very careful attention to ecology, processes, and client experiences that might other-
environments, sociopolitical histories and reali- wise be missed or minimized by traditional
ties, and the living circumstances of the individual approaches (e.g., by REBT, Gestalt, or psychoana-
person. It is a broader and deeper embrace of the lytic approaches). But multiculturalism does not
person than traditional training and textbook learn- replace effective skills in relationship building, such
ing would indicate. Furthermore, when multicul- as Rogerian skills; nor does it replace a counselor’s
tural issues are at the forefront of counseling ability to work with issues of existence such as those
interactions, the relationship becomes a social micro- addressed by Rollo May, or replace the use of help-
cosm of the history and circumstances for both citi- ful cognitive interventions, for example those advo-
zens in the dyad. Thus, the relationship might be cated by REBT approaches, which can help people
tested and strained, and therapist might have his diminish perspectives that promulgate personal dis-
or her work cut out to manage and diffuse misun- tress. Multiculturalism can add a dimension to
derstandings or tensions. effective counseling without taking away from the
Complexity is also evident in the work of the good skills and approaches that counselors already
counselor in attending to factors that pertain to use. Surveys of psychologists and counselors indi-
racial, ethnic, national, and/or continental alli- cate that many are eclectic and multifaceted in their
ances, while at the same time attending to the approaches to assessment and intervention; thus,
individuality of the person. A balanced perspective they are likely to further integrate into their palette
is optimal, based on an analysis of the current cir- of options compelling perspectives to increase their
cumstances, history of socialization, personality and comfort and skill in dealing with the human diver-
development of the person, and the cultural, shared sity evident in their client base. By noting that these
experiences that individuals believe they share with approaches play a supplemental role does not mean
others like them (e.g., women and sexism, or African that their value is diminished. In my opinion, mul-
Americans and whites and their experiences with ticultural approaches highlight key pieces missing
race differences and racism). Counselor assump- from traditional theories of counseling (e.g., the
tions or hypotheses cannot go unchecked, since central role of race in personal identity for counsel-
multicultural awareness and/or sensitivity can easily ors and clients, the unquestioned reality of racism
be misused to stereotype the client. Even in cases in and the significant distress associated with experi-
which there is appreciable group membership mate- encing it, and the suffering and psychological decay
rial relevant to counseling, the reality for the client that can come from internalized oppression). The
is one of unique circumstances and concerns that current argument is analogous to Leong’s (2007)
have to be addressed in the context of who the client recommendation in his cultural accommodation

574 m ulticultural co u n s e l in g
model that counselors identify gaps or blind spots get onto the “same page” with their clients, for
in existing theories of counseling, infuse in these example in terms of developing a working alliance
theories relevant cultural material to address the in which there is agreement on the goals and tasks
gaps, and test the newly integrated or enhanced of treatment; effectiveness in multicultural treat-
theory for incremental validity. ment also rests on counselors being able to commu-
Multicultural theories tend to emphasize the nicate genuine nonpossessive caring and respect for
external factors associated with behavior, more so their clients. This is not to say that clients’ prefer-
than do traditional theories of counseling, personal- ences are not important, and many times clients are
ity, and psychopathology. The direct influence of accommodated in counseling centers and agencies,
contexts on individual behavior has been demon- when possible, with the type of counselor that they
strated beyond possible doubt by social psychology ask for and prefer: For example, a client may very
research. The implication for practitioners is the well prefer a female counselor, or an African
possibility that the “problem” that the client brings American counselor, or one who speaks his native
is not entirely intrapsychic etiologically but may language (e.g., Spanish). But as an institutional
be more completely understood and resolved by policy, this would obviously be illegal and unethical,
an analysis of the context of the individual. The to the extent that it amounts to discrimination.
context may not change, but the individual’s inter-
action and experience in the environment can Recent Research on Multicultural
change to his or her benefit once he or she learns Competence
to identify and negotiate the surrounding chal- Perhaps the area of multicultural counseling that
lenges. Multicultural counseling demands on the has received the greatest amount of attention and
part of the counselor awareness of social and politi- research in the last 20 years has been multicultural
cal issues, historical and current events, and a pro- competence, including studies in areas such as theo-
gressive, affirmative posture with respect to issues of retical refinement, scale development, counselor
racism, race relationships, and psychological devel- training, and correlates of competence (Worthington
opment in the context of oppression and/or possi- et al., 2007). The studies presented here as part
bly poverty. Furthermore, multicultural counseling of an integrated discussion have examined the
demands counselor advocacy for the person. In this multicultural competencies directly, with respect
sense, multicultural and feminist approaches con- to counseling/therapy and counseling supervision.
verge, in that personal issues are political issues, and The reader is referred to Worthington et al. and to
the demands of the counselor may include help- Hays (2008) for two excellent, recent reviews of the
ing clients find or use services that may help instrumentation and broader literature on multicul-
with employment, housing, or legal concerns. tural competence.
Similarly, counselors’ personal/cultural self-aware- Constantine et al. (2008) recently reviewed
ness is important in helping them continually mon- the literature on multicultural competence and con-
itor their personal reactions or assumptions about sistently found among the empirical studies that
clients, including the insidious role that racism can multicultural training and education are strongly
play in the counseling hour. associated with increased levels of multicultural com-
Theories of multicultural counseling also provide petency. When novice or experienced therapists are
mixed support for the “matching hypothesis,” which exposed to multicultural training, they seem to per-
is the notion that clients should be matched by race/ form at a higher level with respect to multicultural
ethnicity or gender with their clients. There are competency (Arthur, 2000; Constantine, Ladany,
equivocal findings with respect to outcome when Inman, & Ponterotto, 1996; Pope-Davis, Reynolds,
clients are matched on the basis of race or gender. Dings, & Ottavi, 1994; Sodowsky, Kuo-Jackson,
A possible explanation for the equivocal findings Richardson, & Corey, 1998; Spanierman, Poteat,
may be that, when matching works, the results are Wang, & Oh, 2008; Vereen, Hill, & McNeal, 2008).
based not on the demographic variables of match- And, multicultural training works for a diverse group
ing, but rather on matching that occurs when the of counseling professionals. Even a single course in
talents, competence, and sensitivity of counselors multicultural counseling leads to counselors demon-
dovetail the needs of their clients. I do not believe strating higher levels of multicultural competence.
that matching on demographics is effective or even There is also a positive association between multicul-
ethical as an institutional policy but that counseling tural competence and racial identity development, as
is effective when counselors make serious efforts to well as a positive association between multicultural

fue rt e s 575
competence and confidence levels in practicing did not find a significant association between thera-
multicultural counseling (see Constantine, Juby, pist multicultural competence and general compe-
& Liang, 2001; Cumming-McCann & Accordino, tence. Taken as a whole, the findings from these
2005; Neville, Spanierman, & Doan, 2006; Ottavi, studies indicate that multicultural competence is
Pope-Davis, & Dings, 1994). Professionals with strongly associated with client satisfaction, and may
higher levels of multicultural competence report be more salient for clients than are factors such as
feeling better prepared to work with diverse clientele. empathy and the working alliance. The research also
Another strand of research has shown that profes- suggests that a level of overlap exists between thera-
sionals who are minority group members have a pist competence, broadly defined, and multicultural
higher interest and skill in multicultural competence competence. Fuertes, Bartolomeo, and Nichols
(see Bernal et al., 1999; King & Howard-Hamilton, (2001) speculated about this association and sug-
2003; Sodowsky et al., 1998) than do European gested that multicultural competence and general
American counselors, which suggests that multicul- competence are associated, since multicultural com-
tural competence is more of a challenge for European petence can only be properly integrated in therapy
American counselors. This is not surprising when by therapists who have a solid foundation in general
one considers that the majority of advocates for mul- competence skills, such as listening, empathy, prob-
ticultural counseling have been minority group ing, and other basic skills. In multicultural counsel-
members and women, and based on personal experi- ing, the basic and advanced skills of caring and
ence and professional interests, these advocates have competent counselors remain the same (e.g., empa-
gravitated to this area. thy, or probing); it is the intent of the therapist, the
Constantine et al. (2008) also examined research content of the conversations, and the focus of the
that has investigated the role of counselor multicul- interactions that expand and deepen substantially.
tural competence directly with counseling dyads. As a side note, a recent study examining predictors
The results of their review, which included studies of minority patients’ medical treatment adherence
by Constantine (2002) and Fuertes and Brobst indicated that the only predictor of their adher-
(2002), revealed a significant level of associa- ence was their ratings of their physicians’ multicul-
tion between minority clients’ ratings of counselor tural competence. In explaining this result, Fuertes,
general and multicultural competence and between Boylan, and Fontanella (in press), speculated that
their ratings of counselor multicultural compe- physician’s multicultural competence communi-
tence and satisfaction with treatment. Fuertes and cated respect to the patients, which in turn enhanced
Brobst (2002) further found that when comparisons the patients’ perceptions of their doctors as compe-
were made between European American and ethnic tent and trustworthy, and earned the doctors the
minority clients on satisfaction, counselor multicul- respect of their patients—thus patients complied
tural competency explained a large and significant with the treatments.
amount of variance for the ethnic minority sample Constantine et al. (2008) also reviewed two stud-
only, above and beyond counselor general compe- ies that examined therapist multicultural compe-
tency and empathy. More recently, Fuertes et al. tence using qualitative methods. Fuertes, Mueller,
(2006) investigated the role of counselor multicul- Chauhan, Walker, and Ladany (2002) conducted
tural competency among 51 therapy dyads in coun- interviews with nine European-American counsel-
seling. These authors examined the relationship ing and clinical psychologists. These psychologists
between counselor multicultural competence and revealed that they generally attended to differences
several indices of counseling, such as the working in race between themselves and clients directly and
alliance, counselor empathy, counselor social influ- openly, within the first two sessions of counseling.
ence, and client and counselor satisfaction. Fuertes They acknowledged this difference to convey to the
et al. (2006) found that, for counselors, their ratings client comfort and trust; psychologists also intended
of the working alliance but not self-ratings of multi- to engender client trust and participation in ther-
cultural competence were significantly associated apy. The psychologists saw race as a central compo-
with their satisfaction, along with clients’ ratings of nent to be discussed and continually attended to in
them on social influence. For clients, ratings of establishing and maintaining a trusting and solid
counselor multicultural competence were associated working relationship. They typically saw race-related
with their satisfaction with counseling, as well as issues as relevant to clients’ concerns. Fuertes et al.
with ratings of counselor empathy and of coun- (2002) found that, despite wide variability in
selor social influence. Fuertes et al. (2006) however, participant theoretical orientation and in clients’

576 m ulticultural co u n s e l in g
presenting problems, the psychologists typically found that progressive and parallel-high racial iden-
reported using Rogerian core skills to engage the tity interactions between supervisor and supervisee
client and to establish the relationship. Additionally, were associated with greater supervisee multicul-
they also typically reported using more specific and tural competence, in comparison with parallel-low
sensitive interventions to deepen and strengthen the and regressive interactions. Constantine et al. also
therapy relationship. These interventions included reported on a study by Ladany, Inman, Constantine,
relying on their level of racial identity development and Hofheinz (1997), who found that multicultural
to understand the client, being attuned to the competence was associated with white and minority
client’s racial identity development and worldview, supervisee racial identity development, but found
and very prominently, attending and effectively no significant association between supervisee multi-
intervening to client reports of racism and oppres- cultural competence and their multicultural case
sion. This last ability, of being able to work with conceptualization ability. Constantine et al. also
clients with reports of racism and oppression, was presented findings from Constantine and Ladany
described as the most sensitive part of the work with (2000), who found that self-report competency
their clients, and failing at that would have had dire measures did not correlate significantly with expert-
consequences for the relationship or any further rated evaluations of case conceptualization skills.
work in treatment. They noted that Constantine et al. (2005) had
Pope-Davis et al. (2002) used grounded theory found that white supervisees in supervision dyads
to account for clients’ perspectives of multicultural characterized by more advanced white racial iden-
counseling. Clients were ten racially/ethnically tity schemas reported higher multicultural com-
diverse undergraduate students who had experi- petence and multicultural case conceptualization
enced individual counseling with a counselor whom skills than did whites in dyads with lower white
they deemed culturally different from themselves. racial identity schemas. Finally, Constantine et al.
The results indicated that clients’ perceptions of also reported on Inman (2006), who found that
multicultural competence and counseling were con- supervisees’ ratings of their supervisors’ multicul-
tingent on clients’ needs/issues in counseling, and tural competence were positively associated with
that these needs were influenced by client character- their ratings of the supervisory working alliance and
istics (e.g., client expectations, role of family and satisfaction with supervision, but negatively associ-
support), the counseling relationship (e.g., equity ated with their multicultural case conceptualization
and power in the relationship), client processes (e.g., of etiology.
salience of culture in relationships, educating the
counselor), and client appraisals of the counseling Recent Research on Racial
experience. Pope-Davis et al. (2002) noted the and Ethnic Identity
importance of understanding client variables in Considerable and substantial theoretical and empir-
counseling, for example by noting that clients who ical work has been done in the areas of ethnic and
did not see culture as influencing their interpersonal racial identity. Phinney and Ong (2007) noted
relationships placed less importance on counselor general parallels in both racial and ethnic identity
multicultural competence. The authors underscored theories. For example, both involve participants’
the importance of context for clients in order to estimations of belonging to and learning about
truly understand the process and outcome of treat- a group, and both include values, attitudes, and
ment for them. Findings from these two studies behaviors associated with culture and as responses
highlight the importance of therapist skill in the to discrimination. However, whereas the focus of
nuances of relating with their clients in sensitive and racial identity has been on responses to racism and
informed ways, and the importance of the discus- on the assessment of internalized racism, primarily
sion in therapy as being based on therapists’ under- using African American and white samples, Phinney
standing of clients’ needs, particularly with respect and Ong (2007) point out that ethnic identity has
to the salience of race, culture, and racism in their focused on examining belonging to a culture or a
everyday life and as possible mediating factors in heritage and exploration and commitment to its
their problems. traditions, and has included a greater variety of
Constantine et al. (2008) also cited research on ethnic and racial groups. In fact, a review of the
multicultural competence in relation to supervision recent literature shows that studies of ethnic iden-
and training. For example, they uncovered a study tity tend to include a more diverse set of partici-
by Ladany, Brittan-Powell, and Pannu (1997) that pants among minority groups in the United States,

fue rt e s 577
including subgroups of Hispanics and Asian on the New Racism Scale (Jacobsen, 1985), which
Americans (e.g., Lee, Noh, Yoo, & Doh, 2007; captures a more subtle type of racism. Silvestri and
Umana-Taylor & Shin, 2007). An impressive find- Richardson (2001) examined white racial identity
ing from studies on ethnic identity is that the con- in relation to personality constructs, and among
struct is usually examined within complex models their findings, they reported a significant negative
with clearly delineated outcomes. For example, association between Reintegration and Agreeable-
ethnic identity has been examined as a moderating ness, and a significant positive association between
effect of psychological distress (Yip, Gee, & Reintegration and Neuroticism and Openness.
Takeuchi, 2008), well-being (Yoo & Lee, 2005), Gushue and Constantine (2007) examined the level
self-esteem (Lopez, 2008), race-related stress and of overlap between white racial identity and color-
quality of life (Utsey, Chae, Brown, & Kelly, 2002), blind racial attitudes among 177 counseling and
situational well-being (Yoo & Lee, 2008), alcohol clinical psychology trainees. They reported a pattern
and marijuana use (Pugh & Bry, 2007), and depres- in which attitudes that minimize racism were sig-
sion and suicidal ideation (Walker, Wingate, Obasi, nificantly and positively correlated with less inte-
& Joiner, 2008). Ethnic identity has also been grated forms of racial identity.
examined as a mediator with respect to delinquency Studies on black racial identity have focused on
and violence (Le & Stockdale, 2008), and to aca- correlates of psychological well-being or on the
demic grades, prosocial behaviors, and externalizing adverse psychological effects of racism on African
symptoms (Schwartz, Zamboanga, & Jarvis, 2007). Americans. For example, Mahalik, Pierre, and Wan
The results of this literature generally point to a sig- (2006) examined racial identity in relation to mas-
nificant effect for ethnic identity, in some instances culinity, self-esteem, and psychological distress, and
as a buffer from psychological illness and in other found a positive relationship between more sophis-
instances as a contributor to distress. ticated levels of racial identity and self-esteem and a
Studies of racial identity tend to focus on either negative relationship between racial identity and
African Americans and/or whites, although there psychological distress. Sellers and Shelton (2003)
are also studies in the literature examining multiple examined the role of racial identity in perceived
racial identities (Miville, Constantine, Baysden, & racial discrimination and found, among 267 African
So-Lloyd, 2005), Asian American racial identity American college students, a positive relationship
(Chen, LePhuoc, Guzman, Rudem, & Dodd, 2006; among these constructs and a moderating role for
Liu, 2002), and American Indian racial identity racial identity between perceived discrimination
(Bryant & LaFromboise, 2005). Studies of white and global psychological distress. Johnson and
racial identity have by and large focused on either Arbona (2006) examined racial and ethnic identity
multicultural competence of counselors or corre- (the only study that examines both jointly) and
lates of professionals or trainees in counseling. their impact on race-related stress, and found in 140
For example, Middleton et al. (2005) and Neville African American college students a positive associ-
et al. (2006) examined racial identity with respect ation between black racial identity and ethnic iden-
to multicultural counseling competence, and Con- tity, and that black racial identity, but not ethnic
stantine et al. (2005) examined racial identity identity, was associated with race-related stress.
with respect to supervisees’ multicultural compe- Anglin and Wade (2007) examined racial socializa-
tence. The results from these studies are unequivo- tion and racial identity in relation to college
cal: More sophisticated statuses of racial identity are students’ adjustment to college and found that,
correlated with higher therapy and supervision mul- among 141 African American students, an internal-
ticultural competence. Carter, Helms, and Juby ized multicultural identity was positively associated
(2004) implemented a new statistical technique to with adjustment to college, but that an Afrocentric
develop white racial identity profiles and to discour- racial identity was negatively associated with college
age the conceptualization of racial identity as a adjustment.
linear progression of stages. They examined racial Beyond these studies, there was a recent and
identity profiles with respect to racist attitudes for healthy debate with respect to racial identity, ethnic
217 white college students. Their results showed identity, and alternative conceptualizations and
that the flat profile was the most frequently measures of racial and ethnic identity (Ponterotto &
observed, and that this profile, in which no racial Park-Taylor, 2007). The essence of the arguments
identity status dominates, along with a profile called seem to revolve around the lack of conceptual
Autonomy, was associated with the highest scores clarity of the constructs (e.g., whether the theory

578 m ulticultural co u n s e l in g
is about race or racism), about the focus that each identification with one’s ethnic group and to
theory takes with respect to identity development being prepared for discrimination, and that there
(e.g., whether it examines a one-dimensional vs. is a developmental hierarchy to ethnic identity
multidimensional aspect of identity), and the ade- development, but no support for a hierarchy of
quacy of measurement for each (e.g., whether best development with respect to racial identity. These
practices in scale construction have been observed, observations provide a framework for future research
such as confirmatory factor analysis). As noted by and application in helping ethnic and racial minori-
Ponterotto and Park-Taylor (2007), there are at least ties with normative problems of development and
22 models of racial, ethnic, and group membership with normative problems that are exacerbated by
identity in the literature, and the recent issue of the racism and discrimination. In fact, Quintana (2007)
Journal of Counseling Psychology ( JCP; Volume 54, noted the importance of school-based programs at
No. 3) presented a wealth of ideas on racial and the middle school to early high school level, when
ethnic identity that might provide an alignment and many adolescents seem to grapple with issues of
redirection for future research in this area. identity, autonomy, and interpersonal competence
Ponterotto and Park-Taylor (2007) provided and belonging. He suggested that this would be an
some excellent recommendations at the end of this ideal stage in which school counselors and psychol-
special issue, in a comment article that integrated ogists could intervene to assess issues that are prob-
and commented on the most salient challenges and lematic with respect to identity and to facilitate a
opportunities facing theory development and mea- development of attitudes with respect to self that
surement. They suggested that researchers define promote exploration and self-acceptance, as well as
their constructs more clearly, in the context of the acceptance of others.
existing literature, and provide a rationale for their Although it seems extremely helpful to focus on
selection of constructs and instrumentation. They school-aged populations, issues of racial identity
also noted the importance of conducting reliability development, racism and discrimination, and the
generalizability studies, of reporting sample charac- ability of persons to effectively cope with race and
teristics and score properties, and of conducting racism pertain to populations beyond the school
analyses of sample selection and group data pat- years, as is evident in counseling centers on college
terns. They also suggested that researchers looking campuses and in work environments throughout the
to revise or develop new measures of racial and United States. A survey of the literature indicates
ethnic identity instruments use the published best that, although some research is being conducted with
practices guidelines available in the literature—all college students, gaps still need to be addressed by
with a view toward improving research on racial and researchers who study racism, race, and racial and
ethnic development. Ponterotto and Park-Taylor ethnic identity. There is a need for applied studies
(2007) also provided a review of the instrumenta- that examine race in the context of human problems
tion in this area and reviewed some of the more in natural environments. That is, we need field
novel measures in the literature assessing racial and research with targeted outcomes; for example, studies
ethnic identity. that examine efficacy of treatments that account for
In this same special issue of JCP, another article racial/ethnic identity of both clients and therapists.
provided helpful observations and suggestions for There is also a need for research that ties racial and
future research in the area of racial and ethnic iden- ethnic identity to process and outcome in psycho-
tity. Quintana (2007) examined the research on therapy. Janet Helms’s theory of regressive, parallel,
racial and ethnic identity development and arrived and progressive racial identity interactions has not
at seven theoretical formulations with respect to its received sufficient empirical or recent theoretical
meaning in the broader context of developmental attention, and could well be integrated into studies of
psychology. These formulations were derived from psychotherapy with multicultural populations. There
an analysis of empirical studies; however, it seems as also seem to be opportunities in this particular area
if these formulations could also serve to stimulate for multidisciplinary teams of researchers, from per-
further research on racial/ethnic identity, to either sonality, social, and developmental psychology, to
confirm or refine them. Quintana (2007) noted that work jointly with counseling psychologists to develop
racial and ethnic identity development involves a parsimonious nomological explanation of identity
exploration and crisis in early adolescence, that that accounts for personality, development, and social
experiences of racism trigger racial and ethnic iden- interactions and includes the psychology of race,
tity exploration, that there are benefits to positive racism, culture, and ethnicity.

fue rt e s 579
Applied Research with Implications need to work to integrate them systematically.
for Clinical Practice A competent practitioner with a high percentage of
A review by Fuertes and Ponterotto (2003) allowed racial/ethnic minority clients must know the litera-
them to distill several “knowledge” and “skill” areas ture in multicultural counseling, and have thought
that seem to come out of research studies looking at consciously about how multiculturalism fits with
multicultural counseling effects. These areas have him or her as a person, with his or her approach to
possible implications for practice, as well as for future assessment and intervention, and how it can inform
research, and so they are developed here for tentative his or her approach to maximize effectiveness.
consideration and evaluation. It seems useful to con- Counselors usually integrate new techniques or
nect the current research on multicultural counsel- concepts such as those promoted in multicultural
ing with practice, although it is emphasized that counseling into their wider framework for interven-
these connections are tenuous at best, and in no way ing, and that framework is itself often integrated with
represent empirical support for any of these perspec- traditional approaches such as humanistic, cognitive,
tives. Clearly more research, particularly doctoral and behavioral interventions. For a counselor to dis-
dissertations, is needed for firm conclusions to be cuss issues of racial identity or bias with a client, he or
derived with respect to research-supported multicul- she must still rely on core skills in establishing a safe
tural practice. and therapeutic clinical environment, on empathy
and appropriate probing skills, and on advanced skills
knowledge areas such as challenging and interpretation, in order to
With various perspectives in the literature on help the client. Thus, the framework of multicultural
multicultural counseling, it seems likely that some counseling seems to add another dimension to effec-
constructs or concepts will be more attractive to or tive practice, one that accounts for important and
easily integrated by counselors, based on their essential components. Mechanisms for service deliv-
approach to assessment and intervention. For exam- ery in multicultural counseling will involve basic
ple, a psychologist who works with school-aged counseling skills and a host of clinical interventions
populations may gravitate toward racial/ethnic that are central to the process of counseling. Since
identity theories because of the developmental many counselors are eclectic, the issue is not whether
nature of these theories and their focus on identity. they become multicultural and abandon every-
A REBT psychologist may find Ho’s (1995) per- thing else taught in graduate school, but how they
spective on internalized culture persuasive, or choose multicultural principles and ideas that fit
Gonzalez et al.’s (1994) social constructionist their approach to helping, and how they integrate
approach appealing since it places a great deal of those principles and ideas to enrich their overall
emphasis on personal experience and interpretation. framework. An example of this is the use of empathy.
Parenthetically, in teaching graduate students theo- Some of my colleagues in the broad field of psycho-
ries of counseling, personality, and multicultural therapy believe that empathy is “all you really need”
counseling, my advice to them when they ask about to be effective. Meaning that if one can practice
the best or “right” theoretical perspective in coun- empathy effectively, one can experience what the
seling is to engage in personal reflection. An impor- client experiences, and thus empathy alone is all that
tant criterion for selecting a theory of counseling is is needed to understand the client and intervene
whether it fits with the counselor’s personality, the accordingly. I agree that all counselors have to rely on
way a garment fits with a person’s taste or body/ the basic skill of empathy to understand the client,
shape. A theory is persuasive if it is consistent with how things feel like or look like for him or her.
who the counselor is as a person, with how she or he However, even with empathy, two things are likely to
sees the world, with what she or he values, or with happen: filtered listening and/or filtered talk. The
how she or he solves or approaches problems in counselor may not understand the experience of the
living. This is all the more reason for exposing client because it is simply too foreign or complex for
students in training during their formative years the counselor to understand it, and empathy does not
to the various approaches or constructs that com- guarantee that the client will express everything going
prise multicultural counseling, just as students are on with him or her to the counselor—the client may
exposed to various theoretical approaches to therapy not even be aware of what is going on with him or
early on in graduate training. There are choices in her, due to stress or denial.
multicultural approaches, therapists may gravitate Empathy alone is not enough, nor is any one
to one or more multicultural ideas, and thus will counseling skill for that matter, whether probing,

580 m ulticultural co u n s e l in g
immediacy, or self-disclosure, in multicultural coun- This becomes appreciable when demographic differ-
seling. It is the combination of these skills, along with ences exist between the counselor and the client, or
a strong relationship and the ability of the counselor when the client presents with issues that are imbued
to direct the client to relevant social, interpersonal, with loss and pain stemming from racism, inequal-
and psychological-cultural material based on self- ity, and indifference. Multicultural competence is
awareness and knowledge of the client, that allows for not so much about having knowledge about various
effective outcome. These observations are consistent cultures of the world, although this can help in ther-
with the emphasis in relational-cultural theory (RCT) apy and be personally valuable to counselors. The
on the supreme importance of the relationship in real, crucial knowledge is how racism, marginaliza-
effective helping, and the emphasis in RCT on the tion, or poverty can affect the individual, particu-
limits of traditional Rogerian empathy on counsel- larly the devastating effects that these can have on a
ing interactions (Comstock, et al. 2008). Ridley, child. This knowledge is more proximal to the needs
Ethington, and Heppner (2007) also discussed the and discomforts of the client, and is essential to the
important role of the relationship and of informed process of relationship development and the ability
counselor empathy in cultural confrontation, which for counselors to intervene for their clients. In the
they proposed as the appropriate confrontation of United States, African Americans and Hispanics
clients whose rigid adherence to traditional beliefs or experience poverty rates that are 2.5 times those of
to an unhealthy developmental context run counter whites (U.S. Bureau of the Census 2007). And
to their psychological well-being. while poverty-related stress affects families in similar
Another seemingly important bit of knowledge ways across racial/ethnic groups (Wadsworth &
gleaned from the multicultural literature is that race, Santiago, 2008), the disproportionate number of
ethnicity, and human diversity factors are dynamic Hispanic and African American families who live in
and thus are always present and relevant in the coun- poverty in the United States makes it a particularly
seling session; the importance of race and ethnicity salient topic for these populations.
to clients is never downplayed or seen as peripheral,
but rather central to the process of helping. For cli- skill areas
ents solving an array of problems, from significant There is a dearth of applied, in-session multicul-
relationship problems to behavioral difficulties, tural research in this area. However, Fuertes and
issues of race and identity will intermingle with other Ponterotto (2003) and Constantine et al. (2008)
psychological factors, such self-efficacy or develop- examined the limited available research, and from
mental history, and will be relevant and possibly cen- these reviews the following tentative observations
tral to the process of counseling and recovery. Issues are developed here as possible skill areas for effective
of race or race differences, as an example, may be counseling. These represent hypotheses that are
most pressing in the beginning and early stages of based on just a few studies, and must be examined
counseling, as the client assesses his or her counselor, empirically and modified/enhanced before they
and deals with possible (and understandable) issues become prescriptive of best practice.
of trust, ambivalence, and fear about receiving help Effective multicultural counselors are able to
and engaging in the process of change. Race or eth- establish core conditions in counseling, regardless
nicity will remain relevant as therapy progresses, as of their preferred theoretical and technical approach
the client gains insight and plans venues or options to counseling. A safe, respectful, and warm environ-
for action/behavior change. Race or ethnicity may be ment, characterized best as being Rogerian in nature,
factors and come into play for example, as the client is crucial to winning patients’ trust and respect. The
deals with self-acceptance, or with managing racism, core conditions also promote the establishment of
or with selecting a college major, or establishing inti- rapport and working relationships with clients. The
macy, or making a decision to leave home. reader may wonder how this is unique to multicul-
All of the research examined by Fuertes and tural counseling, since these factors are essential to
Ponterotto (2003) addressed an important com- all counseling interactions. The rationale is that
mon factor in multicultural counseling: Namely, normal issues of client trust and ambivalence can be
the importance of core conditions of safety, support, exacerbated by seeming power differences and race
rapport, and the relationship. Since the relationship or ethnic differences in the dyad. Even in dyads of
in counseling/therapy is consistently the best the same race or ethnicity, there may be client
predictor of outcome, it is just as important, if ambivalence about who the counselor really is and
not more important, in multicultural counseling. the power that he or she represents.

fue rt e s 581
 A related skill is counselors’ ability to discuss interpersonal stance for counselors who work with
“hot button” issues with their clients, including an array of human diversity.
topics associated with gender, race, ethnicity, cul-
ture, socioeconomic background, sexual orienta- Future Research
tion, and religious beliefs. A sign of ineffectiveness There is a need for outcome research in several areas.
would be counselors writing off these issues as First, there is a need for outcome research that
beyond the scope of counseling or as superfluous to examines the effectiveness of therapy with ethnic/
the treatment that they offer. It also seems impor- minority clients. The reader may believe that this
tant that counselors can name or identify a client’s fact has been established, given the hundreds of out-
experiences that may be of a racist or oppressive come studies conducted in our profession over the
nature, even though the client is unaware of or past four decades. However, Fuertes, Mueller, Costa,
unwilling to examine these issues. This is sensitive, and Hersch (2004) examined the outcome evidence
since counselors also need to know when not to dis- in the most widely referenced meta-analyses and
cuss race or salient cultural differences with their uncovered, through a random selection of articles,
clients. This skill resides on clinician expertise and that the effectiveness of psychotherapy could not be
wisdom, and would always be a judgment call based ascertained from the research. Most of the studies
on the best interests of the client and not on a need conducted and included in the meta-analyses either
of the counselor. Not enough can be said about the did not include racial/ethnic minority group mem-
importance of the relationship in multicultural bers as reported in their methods sections, or did
counseling and of the core conditions being funda- not disclose this information at all, and no analyses
mental to the development of that relationship. were conducted by race or ethnicity. Thus, although
It is crucial to establishing trust, to client involve- there is anecdotal and clinical evidence of efficacy—
ment and empowerment, which in turn facilitates and every reason to believe that racial/ethnic minor-
discussion of very painful and sensitive issues in ities benefit from therapy—research is still needed
multicultural counseling. to establish the effect size of psychological interven-
Effective multicultural counselors also need to tions, and whether the effect is the same in com-
demonstrate authentic and genuine behavior with parison with whites or other groups. In sum, as far
their clients, including unconditional positive regard as the available research is concerned, it has not
and an authentic acceptance and respect for the been established if the effect size of .80 is replicated
client. This goes to the importance of counselor self- with minority patients when using traditional
awareness, integrity, and sufficient moral strength approaches to helping.
to discuss difficult issues with the client. These dif- Another research question is whether value is
ficult issues include, for example, discussing racism, added by using enhanced or adapted methods with
institutionalized racism, and challenging clients racial and ethnic minority clients. Griner and Smith
to examine internalized racism and oppression. (2006) recently published a meta-analysis of out-
A related skill is the ability of counselors to be genu- come for culturally adapted approaches to counsel-
ine in their behavior and to rein in socially desirable ing, using a database of 76 studies and 25,225
(i.e., politically correct) behavior that may come participants. Griner and Smith (2006) included stud-
across as a “put on.” Interestingly, the broader field ies that involved a comparison between one cultur-
of counseling is beginning to examine more empiri- ally adapted treatment with a traditional treatment,
cally the importance of the “real relationship” in and noted that cultural adaptation indicated that the
counseling, which is comprised of realistic percep- treatment “involved explicitly including cultural
tions and genuine behaviors in treatment (Gelso, values/concepts into the intervention” (p. 535), as
2002). The real relationship is hypothesized to well as matching by ethnic group and language, or
be immediate, arising when the counselor and included consultation with others familiar with the
client first make contact; it is the person-to-person culture of the client, among others modifications and
relationship between the participants, and their additions to treatment. Their findings indicated a
perceptions and assessments of each other as like- substantial effect size of .43 for these treatments, sug-
able and agreeable people. The real relationship is gesting a benefit for culturally adapted treatments
hypothesized to precede the development of a work- versus more traditional treatments. Significant mod-
ing relationship based on trust, agreement, and erators included Hispanic ethnicity, particularly
client collaboration. The real relationship may have low-acculturation Hispanics, age (older patients did
implications for the development of an effective better), and treatment offered in the native language

582 m ulticultural co u n s e l in g
of the client. Nonsignificant moderators were gender competence. I believe that it is possible to advance
or being African American or Asian American, or the the knowledge and science base in a rigorous manner
status of the client as being either high risk, diag- while at the same time conducting research that
nosed with mental illness, or clients who represented demonstrates the relevance and external validity of
normal problems in living. This study represented a our concepts and measures.
significant step forward in beginning to ascertain Having just written about the need to establish
the “value-added” benefit of culturally adapted treat- outcome effect sizes and the need for outcome
ments to outcome. As Griner and Smith (2006) research, there is evidence that outcome disparities
noted, however, their study has limitations because exist in the treatment of mental health problems in
many of the cultural adaptations were not described racial/ethnic minority groups. However, these data,
in the original studies but inferred by the researchers, presented by the Surgeon General in 2001, repre-
and experimenter bias and allegiance effects were not sented sociological studies that examined factors
controlled for in the analyses. Also, the treatments such whether patients received free services, had
were not identified as including therapists who were insurance, the type of services they received, and
either trained or exhibited multicultural competence other social-economic factors that tilted the balance
or sensitivity. However, despite these limitations, the against minority patients who received treatment.
results from this study seem to support integrated The Surgeon General’s report concluded that, as in
treatment protocols that enhance services to meet the medical care, quality of care and outcome dispari-
needs of racial and ethnic minority clients. Future ties exist for racial/ethnic minority patients, even
research is warranted along this line. Griner and when controlling for availability of insurance and
Smith (2006) noted the need for future research to patient level of education. The Surgeon General’s
account for therapist multicultural competence, the report also concluded that “culture counts,” in that it
quality of the working relationship, and client trust influences the way people view, physically experi-
in the therapist and in treatment. ence, and seek help for mental illness. He outlined
There is also need for more applied research that several recommendations for service providers,
examines outcome using the various approaches professionals, and research scientists. Some of these
mentioned in this chapter. Although some research recommendations included empirically investigat-
has examined the role of competencies with respect ing the efficacy of evidence-based treatments for
to client satisfaction, no research has examined the minority members, exploring the ways in which dif-
effect of multicultural competence with respect to ferent cultures experience mental illness, improving
outcome. There is still a great deal of research on minority client access to care, eliminating barriers
multicultural competence and racial identity link- to and enhancing the quality of psychological ser-
ing these constructs to demographic factors such as vices, and specifically, promoting the advancement
race or to ancillary factors such as comfort level and in evidenced-based multicultural competency train-
social desirability. But the research agenda for the ing for counselors, psychologists, psychiatrists, social
future must include applied in-session research that workers, and other mental health professionals
examines the role of multicultural constructs to (Department of Health and Human Services, 2001).
important events in counseling, particularly out- These challenges and opportunities for research in
come. Data from applied outcome-oriented research multicultural counseling are still valid and represent
may ultimately show the value added to assessment, the future of a serious research agenda that is both
intervention, and education when professionals are rigorous and socially responsible.
proficient in multicultural counseling. There also Beyond outcome questions of efficacy or multi-
seems to be interest, but not much available research, cultural competence, research should be directed at
on the part of health care professionals and fund- improving the resolution of chronic problems in
ing agencies in knowing how multicultural coun- mental health treatment, such as the efficacy of
seling may improve health care practices and how multicultural approaches in improving longer-term
it may address the irrefutable evidence showing outpatient participation and in improving commu-
the presence of racism in health care (Department nity-based treatment for chronic and severe psycho-
of Health and Human Services, 2001). The empha- pathology. As a counseling psychologist, I would be
sis on applied research does not need to take away remiss to not mention research targeting outcome
from good research on scale development or further indices of positive psychology that are also needed,
theoretical developments and refinements, specifi- such as the effectiveness of interventions that pro-
cally racial identity and counselor multicultural mote vocational development for workers at all

fue rt e s 583
stages of the work life-cycle, and that promote therapist interventions, the timing, and selection
psychological growth and wellness, and the devel- of these interventions), how counselors address
opment of healthy loving families. clients’ race/cultural-based concerns, and how coun-
There are also many opportunities for process- selors use specific interventions in counseling to
oriented research vis à vis multicultural compe- defuse conflict or misunderstanding in counseling.
tence. There is a need for multicultural research that Qualitative designs may also answer some funda-
focuses on clients’ experiences in counseling, and mental questions central to multicultural counsel-
for research that describes how the relationship ing and competence, such as the type of latent and
is established, maintained, and used as leverage manifest components of race/culture evidenced by
to make counseling effective. A review of the litera- clients and counselors in counseling, how culture
ture in multicultural counseling indicates that the facilitates client coping and functioning, and the
relationship between counselor multicultural com- extent to which counseling is a social influence pro-
petence and process and outcome variables in psy- cess and an acculturation experience for clients.
chotherapy has not been studied, outside of the Data that address these questions would have impli-
those studies noted above by Constantine, Fuertes, cations for practice, training, scale development,
and their collaborators. Thus, we need to study the and future hypothesis-testing research in the area of
role of multicultural competence in counseling. multicultural competence.
Research may be directed at studying how counselor Above and beyond the emphasis on process and
multicultural competence promotes counselor and outcome, there are opportunities for research that
client involvement in therapy, enhances client trust is informed or anchored on constructs from the
in counseling as well as client affective experiencing broader field of psychology, but which can inform
and insight, and promotes client satisfaction with multicultural counseling assessment and interven-
psychological treatment. Studies that examine the tions. For example, I have been involved in develop-
relationship between multicultural competencies ing two models of intervention for racial/ethnic
and culture-dependent or culturally relevant process minority and immigrant clients. These two models
and outcome indices (e.g., acculturation stress, were published recently, have not been examined
amelioration of cultural conflict, internalized xeno- empirically, but were derived rationally from the
phobia) are also needed. available theoretical and empirical literature, which
There is also a need for research designs that is substantial in both areas. The first model targets
involve actual therapists and clients, such as field problem areas for minority and immigrant children
studies and quasi-experimental designs, and applied and adolescents and is anchored on the concept of
in-session research may highlight the value-added self-regulation. The second model targets the needs
dimension of multicultural competence. For exam- of minority and immigrant adults and is anchored
ple, research could examine the amount of variance on the concept of social support. The model of self-
in process and outcome variables that is explained regulation (Fuertes, Alfonso, & Schultz, 2007)
by counselor multicultural competence, above and includes risks and assets as two broad categories that
beyond variance explained by more “traditional” have a potentially adverse impact on behavioral,
counselor skills, such as empathy and expertness. interpersonal, and academic self-regulation. Risks
Case studies of multicultural counseling may prove are major stressors that minority and immigrant
particularly revealing. For example, a cross-cultural children and youth experience, such as having to
dyad may be observed over several sessions, and learn a new language or having to face poverty or
these observations may yield temporal and sequen- discrimination. Conversely, assets comprise a posi-
tial data about the role of counselor multicultural tive mechanism associated with resilience in chil-
competence in facilitating the development of the dren. Intrinsic assets are inherent qualities that, for
therapy relationship, client progress, and counselor the most part, stem from within the individual,
adaptation to the needs of the client. Consensual such as level of cognitive functioning, self-efficacy,
qualitative research and case study methodologies and motivation. Extrinsic assets include external
(Hill, Thompson, & Williams, 1997; Hill et al., influences on children that may include family
2008) also provide excellent ways of interviewing members, school personnel, and caretakers and/or
clients and counselors during or after therapy has peers. These external assets function as supportive
been completed. This research could provide “thick buffers that help children adapt and adjust to their
description” to reveal how multicultural competence new environment. These factors in isolation are not
is manifested in therapy (i.e., the actual content of sole contributors to a racial or ethnic minority or

584 m ulticultural co u n s e l in g
immigrant child’s adaptation and adjustment in important work conducted until now, and noted
school; rather, self-regulation is seen as moderating some of the limitations of the research to date as
behavior and performance. The outcome of pro- well as possible areas for further work in theory
ficient self-regulation is hypothesized to be healthy development, applied research, and training.
adaptation to the environment, the outcome of
which would be appreciable with respect to positive References
family relations, healthy peer relations, and success- Anglin, D. M., & Wade, J. C. (2007). Racial socialization, racial
ful school performance (Fuertes et al., 2007). identity, and Black students’ adjustment to college. Cultural
The model of social support (Fuertes, Alfonso, & Diversity and Ethnic Minority Psychology, 13, 207–215.
Schultz, 2005) is analogous to the self-regulation Arthur, N. (2000, April). Predictive characteristics of multicultural
counseling competence. Paper presented at the annual confer-
model in that it examines risks for the adult person, ence of the American Educational Research Association,
internal and external resources, and targeted out- New Orleans, LA.
comes of interpersonal and vocational adjustment. Atkinson, D. R., Thompson, C. E., & Grant, S. K. (1993).
The interest in social support stems primarily from A three-dimensional model for counseling racial/ethnic
its importance as a mediating variable between stress minorities. The Counseling Psychologist, 21, 257–277.
Bernal, M. E., Sirolli, A. A., Weisser, S. K., Ruiz, J. A.,
and mental and physical pathology. Social support Chamberlain, V. J., & Knight, G. P. (1999). Relevance of
also has been linked with reduction of mortality, pos- multicultural training to students’ applications to clinical
itive rehabilitation processes, compliance and man- psychology programs. Cultural Diversity and Ethnic Minority
agement of diabetes, protection against work strain, Psychology, 5, 43–55.
life satisfaction, general well-being or quality of life, Bryant, A., & LaFromboise, T. D. (2005). The racial identity and
cultural orientation of Lumbee American Indian high school
and ease of migration. A fundamental assumption students. Cultural Diversity and Ethnic Minority Psychology,
in developing this model of social support is the 11, 82–89.
belief that humans are deeply social beings and that, Carter, R. T., Helms, J. E., & Juby, H. L. (2004). The relation-
without human relationships and social support ship between racism and racial identity for White Americans:
people, cease to develop or even function. It is also A profile analysis. Journal of Multicultural Counseling and
Development, 32, 2–17.
assumed that, for racial and ethnic minorities, and Chen, G. A., LePhuoc, P., Guzman, M. R., Rude, S. S., &
for any other immigrant group, factors such as a Dodd, B. G. (2006). Exploring Asian American racial
sense of community, social support, and group identity. Cultural Diversity and Ethnic Minority Psychology,
belongingness become particular sources of concern 12, 461–476.
as they are uprooted from their native countries and Coleman, H. L. K. (1995). Strategies for coping with cultural
diversity. The Counseling Psychologist, 23, 722–741.
begin to adapt to a new life in the United States. Coleman, H. L. K. (1997). Conflict in multicultural counseling
Some research shows that social support helps relationships: Source and resolution. Journal of Multicultural
people cope with an array of difficulties, and other Counseling and Development, 25, 195–200.
research suggests that it helps people with major life Comstock, D. L., Hammer, T. R., Strentzsch, J., Cannon, K.,
transitions and migrations. In sum, there are possi- Parsons, J., & Salazar, G. (2008). Relational-cultural theory:
A framework for bridging relational, multicultural, and social
bilities for research to examine the viability of these justice competencies. Journal of Counseling and Development,
concepts—self-regulation with children and adoles- 86, 279–287.
cents, and the effective use of social support for Constantine, M. G. (2002). Predictors of satisfaction with
adults—in helping them adjust, develop, and thrive. counseling: Racial and ethnic minority clients’ attitudes
There are also opportunities, as highlighted here via toward counseling and ratings of their counselors’ general
and multicultural competence. Journal of Counseling Psy-
these models, for researchers to avoid “re-inventing chology, 49, 255–263.
of the wheel” and instead examine, evaluate, adapt, Constantine, M. G., Fuertes, J. N., Roysircar, G., &
and test ideas and interventions from the broader Kindaichi, M. M. (2008). Multicultural competence:
discipline of psychology, with a goal of developing Clinical practice, training and supervision, and research.
and strengthening multicultural interventions that In W. B. Walsh (Ed.), Biennial review of counseling psychology
Vol. 1 (pp. 97–128). New York: Routledge.
might work. Constantine, M. G., Juby, H. L., & Liang, J. J.-C. (2001).
Examining multicultural counseling competence and race-
Conclusion related attitudes among white marital and family therapists.
While a significant amount of work has been Journal of Marital and Family Therapy, 27, 353–362.
directed at developing the field of multicultural Constantine, M. G., & Ladany, N. (2000). Self-report
multicultural counseling competence scales: Their relation
counseling/psychotherapy, the current state of the to social desirability attitudes and multicultural case con-
research in this area can be considered as a “good ceptualization ability. Journal of Counseling Psychology, 47,
start”. This chapter has highlighted some of the 155–164.

fue rt e s 585
Constantine, M. G., Ladany, N., Inman, A. G., & Ponterotto, J. G. Gelso, C. J. (2002). Real relationship: The “something more” of
(1996). Students’ perceptions of multicultural training in psychotherapy. Journal of Contemporary Psychotherapy, 32,
counseling psychology programs. Journal of Multicultural 35–40.
Counseling and Development, 24, 241–253. Gonzalez, R., Biever, J. L., & Gardner, G. T. (1994). The multi-
Constantine, M. G., Warren, A. K., & Miville, M. L. (2005). cultural perspective in therapy: A social constructionist
White racial identity dyadic interactions in supervision: approach. Psychotherapy, 31, 515–524.
Implications for supervisees’ multicultural counseling com- Griner, D., & Smith, T. B. (2006). Culturally adapted mental
petence. Journal of Counseling Psychology, 52, 490–496. health interventions: A meta-analytic review. Psychotherapy:
Cumming-McCann, A., & Accordino, M. P. (2005). An investi- Theory, Research, Practice, Training, 43, 531–548.
gation of rehabilitation counselor characteristics, White racial Gushue, G. V., & Constantine, M. G. (2007). Color-blind racial
attitudes, and self-reported multicultural counseling compe- attitudes and White racial identity attitudes in psychology
tencies. Rehabilitation Counseling Bulletin, 48, 167–176. trainees. Professional Psychology: Research and Practice, 38,
Department of Health and Human Services. (2001). Mental health: 321–328.
Culture, race, and ethnicity: A supplement to mental health: Hanna, F. J., Bemak, F., & Chi-Ying Chung, R. (1999). Toward
A report of the Surgeon General. Retrieved September 26, a new paradigm for multicultural counseling. Journal of
2008, from http://mentalhealth.samhsa.gov/cre/ch2_racism_ Counseling and Development, 77, 125–134.
discrimination_and_mental_health.asp. Hays, D. G. (2008). Assessing multicultural competence in
Fischer, A. R., Jome, L. M., & Atkinson, D. R. (1998). counselor trainees: A review of instrumentation and future
Reconceptualizing multicultural counseling: Universal heal- directions. Journal of Counseling and Development, 86,
ing conditions in a culturally specific context. The Counseling 95–101.
Psychologist, 26, 525–588. Helms, J. E. (Ed.). (1990). Black and White racial identity: Theory,
Fuertes, J. N., Alfonso, V. C., & Schultz, J. J. (2005). Counseling research, and practice. Westport, CT: Greenwood.
South American immigrants. Journal of Immigrant and Helms, J. E. (1995). An update of Helms’s White and people of
Refugee Services, 3, 155–169. color racial identity models. In J. G. Ponterotto, J. M. Casas,
Fuertes, J. N., Alfonso, V. C., & Schultz, J. J. (2007). Counseling L. A. Suzuki, & C. M. Alexander (Eds.), Handbook of
culturally and linguistically diverse children and youth: multicultural counseling (pp. 181–198). Thousand Oaks,
A self-regulatory approach. In G. B. Esquivel, E. C. Lopez, CA: Sage.
& S. G. Nahari (Eds.), The handbook of multicultural school Helms, J. E. (1996). Toward a methodology for measuring
psychology (pp. 409–427). New York: Lawrence Erlbaum. and assessing racial as distinguished from ethnic identity.
Fuertes, J. N., Bartolomeo, M., & Nichols, C. M. (2001). Future In G. R. Sodowsky, & J. C. Impara (Eds.), Multicultural
research directions in the study of counselor multicultural assessment in counseling and clinical psychology (pp. 143–192).
competencies. Journal of Multicultural Counseling and Lincoln, NE: Buros Institute of Mental Measurements.
Development, 29, 3–12. Helms, J. E., & Cook, D. A. (1999). Using race and culture in
Fuertes, J. N., Boylan, L. S., & Fontanella, J. A. (In press). counseling and psychotherapy: Theory and process. Boston:
Behavioral indices in medical care outcome: The working Allyn & Bacon.
alliance, adherence, and related factors. Journal of General Herring, R. D., & Walker, S. S. (1993). Synergetic counseling:
Internal Medicine. Toward a more holistic model with a cross-cultural specific
Fuertes, J. N., & Brobst, K. (2002). Clients’ ratings of counselor approach. TCA Journal, 22, 38–53.
multicultural competency. Cultural Diversity and Ethnic Hill, C. E., Sim, W., Spangler, P., Stahl, J., Sullivan, C., &
Minority Psychology, 8, 214–223. Teyber, E. (2008). Therapist immediacy in brief psychother-
Fuertes, J. N., Costa, C., Mueller, L., & Hersh, M. (2004). apy: Case study II. Psychotherapy: Theory, Research, Practice,
Process and outcome psychotherapy research from a cultural- Training, 45, 298–315.
racial perspective. In R. Carter (Ed.), Handbook of racial- Hill, C. E., Thompson, B. J., & Williams, E. N. (1997). A guide
cultural psychology and counseling Vol. 1 (pp. 256–276). to conducting consensual qualitative research. The Counseling
New York: Wiley. Psychologist, 25, 517–572.
Fuertes, J. N., & Gretchen, D. (2001). Emerging theories of Ho, D. Y. F. (1995). Internalized culture, culturocentrism, and
multicultural counseling. In J. G. Ponterotto, J. M. Casas, transcendence. The Counseling Psychologist, 23, 4–24.
L. A. Suzuki, & C. M. Alexander (Eds.), Handbook of multi- Inman, A. G. (2006). Supervisor multicultural competence and
cultural counseling (pp. 509–541). Newbury Park, CA: Sage. its relation to supervisory process and outcome. Journal of
Fuertes, J. N., Mueller, L. N., Chauhan, R. V., Walker, J. A., Marital and Family Therapy, 32, 73–85.
Ladany, N. (2002). An investigation of Euro-American Jacobsen, C. K. (1985). Resistance to affirmative action:
therapists’ approach to counseling African-American clients. Self interest or racism? Journal of Conflict Resolution, 29,
The Counseling Psychologist, 30, 763–788. 306–329.
Fuertes, J. N., & Ponterotto, J. G. (2003). Culturally appropriate Johnson, S. C., & Arbona, C. (2006). The relation of ethnic
intervention strategies. In G. Roysircar, P. Arredondo, identity, racial identity, and race-related stress among African-
J. N. Fuertes, R. Toporek, & J. G. Ponterotto (Eds.), 2003 American students. Journal of College Student Development,
Multicultural counseling competencies: AMCD (pp. 51–58). 47, 495–507.
Alexandria, VA: American Counseling Association. King, P. A., & Howard-Hamilton, M. (2003). An assessment of
Fuertes, J. N., Stracuzzi, T. I., Bennett, J., Scheinholtz, J., multicultural competence. NASPA Journal, 40, 119–133.
Mislowack, A., Hersh, M., et al. (2006). Therapist multicul- Ladany, N., Brittan-Powell, C. S., & Pannu, R. K. (1997).
tural competency: A study of therapy dyads. Psychotherapy: The influence of supervisory racial identity interaction and
Theory, Research, Practice, Training, 43, 480–490. racial matching on the supervisory working alliance and

586 m ulticultural co u n s e l in g
 supervisee multicultural competence. Counselor Education Pope-Davis, D. B., Reynolds, A. L., Dings, J. G., & Ottavi, T. M.
and Supervision, 36, 284–304. (1994). Multicultural competencies of doctoral interns at
Ladany, N., Inman, A. G., Constantine, M. G., & Hofheinz, E. W. university counseling centers: An exploratory investigation.
(1997). Supervisee multicultural case conceptualization ability Professional Psychology: Research and Practice, 25, 466–470.
and self-reported multicultural competence as functions of Pope-Davis, D. B., Toporek, R. L., Ortega-Villalobos, L.,
supervisee racial identity and supervisor focus. Journal of Ligiero, D. P., Brittan-Powell, C. S., Liu, W. M., et al. (2002).
Counseling Psychology, 44, 284–293. Client perspectives of multicultural counseling competence:
Le, T. N., & Stockdale, G. (2008). Acculturative dissonance, A qualitative examination. The Counseling Psychologist, 30,
ethnic identity, and youth violence. Cultural Diversity and 355–393.
Ethnic Minority Psychology, 14, 1–9. Pugh, L. A., & Bry, B. H. (2007). The protective effects of ethnic
Lee, R. M., Noh, C.-Y., Yoo, H. C., & Doh, H. S. (2007). identity for alcohol and marijuana use among Black young
The psychology of diaspora experienced: Intergroup contact, adults. Cultural Diversity and Ethnic Minority Psychology, 13,
perceived discrimination, and ethnic identity of Koreans in 187–193.
China. Cultural Diversity and Ethnic Minority Psychology, 13, Quintana, S. M. (2007). Racial and ethnic identity: Develop-
115–124. mental perspectives and research. Journal of Counseling
Leong, F. T. L. (1996). Toward an integrative model for cross- Psychology, 54, 259–270.
cultural counseling and psychotherapy. Applied and Preventive Ramirez, M., III. (1999). Multicultural psychotherapy: An
Psychology, 5, 189–209. approach to individual and cultural differences (2nd ed.).
Leong, F. T. L. (2007). Cultural accommodation as method and Boston: Allyn & Bacon.
metaphor. American Psychologist, 62, 916–927. Ridley, C. R., Ethington, L. L., & Heppner, P. P. (2007).
Liu, W. M. (2002). Exploring the lives of Asian American men: Cultural confrontation: A skill of advanced cultural empathy.
Racial identity, male role norms, gender role conflict, and In P. B. Pedersen, W. J. Lonner, J. G. Draguns, &
prejudicial attitudes. Psychology of Men and Masculinity, 3, J. E. Trimble (Eds.), Counseling across cultures (pp. 377–393).
107–118. San Francisco: Sage.
Locke, D. C. (1998). Increasing multicultural understanding Ridley, C. R., Mendoza, D. W., Kanitz, B. E., Angermeier, L., &
(2nd ed.). Newbury Park, CA: Sage. Zenk, R. (1994). Cultural sensitivity in multicultural coun-
Lopez, I. (2008). “But you don’t look Puerto Rican”: The moder- seling: A perceptual schema model. Journal of Counseling
ating effect of ethnic identity on the relation between skin Psychology, 41, 125–136.
color and self-esteem among Puerto Rican women. Cultural Schwartz, S. J., Zamboanga, B. L., & Jarvis, L. H. (2007). Ethnic
Diversity and Ethnic Minority Psychology, 14, 102–108. identity and acculturation in Hispanic early adolescents:
Mahalik, J. R., Pierre, M. R., & Wan, S. S. C. (2006). Examining Mediated relationships to academic grades, prosocial behav-
racial identity and masculinity as correlates of self-esteem iors, and externalizing symptoms. Cultural Diversity and
and psychological distress in Black men. Journal of Ethnic Minority Psychology, 13, 364–373.
Multicultural Counseling and Development, 34, 94–104. Sellers, R. M., & Shelton, J. N. (2003). The role of racial identity
Middleton, R. A., Stadler, H. A., Simpson, C., Guo, Y. J., in perceived racial discrimination. Journal of Personality and
Brown, M. J., Crow, G., et al. (2005). Mental health practitio- Social Psychology, 84, 1079–1092.
ners: The relationship between White racial identity attitudes Silvestri, T. J., & Richardson, T. Q. (2001). White racial identity
and self-reported multicultural counseling competencies. statutes and NEO personality constructs: An exploratory
Journal of Counseling and Development, 83, 444–456. analysis. Journal of Counseling and Development, 79, 68–76.
Miville, M. L., Constantine, M. G., Baysden, M. F., & Sodowsky, G. R., Kuo-Jackson, P. Y., Richardson, M. F., &
So-Lloyd, G. (2005). Chameleon changes: An exploration of Corey, A. T. (1998). Correlates of self-reported multicultural
racial identity themes of multiracial people. Journal of competencies: Counselor multicultural social desirability, race,
Counseling Psychology, 52, 507–516. social inadequacy, locus of control racial ideology, and multicul-
Neville, H., Spanierman, L., & Doan, B.-T. (2006). Exploring tural training. Journal of Counseling Psychology, 45, 256–264.
the association between color-blind racial ideology and Spanierman, L. B., Poteat, V. P., Wang, Y. F., & Oh, E. (2008).
multicultural counseling competencies. Cultural Diversity Psychosocial costs of racism to White counselors: Predicting
and Ethnic Minority Psychology, 12, 275–290. various dimensions of multicultural counseling competence.
Ottavi, T. M., Pope-Davis, D. B., & Dings, J. G. (1994). Journal of Counseling Psychology, 55, 75–88.
Relationship between White racial identity attitudes and self- Steenbarger, B. N. (1993). A multicontextual model of
reported multicultural counseling competencies. Journal of counseling: Bridging brevity and diversity. Journal of
Counseling Psychology, 41, 149–154. Counseling and Development, 72, 8–15.
Phinney, J. S., & Ong, A. D. (2007). Conceptualization and Sue, D. W., Carter, R. T., Casas, J. M., Fouad, N. A., Ivey, A. E.,
measurement of ethnic identity: Current status and future Jensen, M., et al. (1998). Multicultural counseling competen-
directions. Journal of Counseling Psychology, 54, 271–281. cies: Individual and organizational development. Thousand
Ponterotto, J. G., Fuertes, J. N., & Chen, E. C. (2000). Models of Oaks, CA: Sage.
multicultural counseling. In S. D. Brown, & R. W. Lent (Eds.), Sue, D. W., Ivey, A. E., & Pedersen, P. B. (Eds.). (1996). A theory
Handbook of counseling psychology (3rd ed., pp. 639–669). of multicultural counseling and therapy. Pacific Grove, CA:
New York: Wiley. Brooks/Cole.
Ponterotto, J. G., & Park-Taylor, J. (2007). Racial and ethnic Trevino, J. G. (1996). Worldview and change in cross-cultural
identity theory, measurement, and research in counseling counseling. The Counseling Psychologist, 24, 198–215.
psychology: Present status and future directions. Journal of Umana-Taylor, A. J., & Shin, N. (2007). An examination of ethnic
Counseling Psychology, 54, 282–294. identity and self-esteem with diverse populations: Exploring

fue rt e s 587
 variation by ethnicity and geography. Cultural Diversity and Walker, R. L., Wingate, L. R., Obasi, E. M., & Joiner, T. E.
Ethnic Minority Psychology, 13, 178–186. (2008). An empirical investigation of acculturative stress and
U.S. Bureau of the Census. (2007). Selected characteristics of ethnic identity as moderators for depression and suicidal ide-
racial groups and Hispanic/Latino population: 2005. Retrieved ation in college students. Cultural Diversity and Ethnic
October 10, 2008, from http://www.census.gov/compendia/ Minority Psychology, 14, 75–82.
statab/tables. Worthington, R. L., Soth-McNett, A. M., & Moreno, M. V.
U.S. Department of Homeland Security. (2004). Yearbook (2007). Multicultural counseling competencies research:
of immigrant statistics, 2003. Washington, DC: Office of A 20-year content analysis. Journal of Counseling Psychology,
Immigration Statistics, National Serials Program, Library of 54, 351–361.
Congress. Yip, T., Gee, G. C., & Takeuchi, D. T. (2008). Racial discrimina-
Utsey, S. O., Chae, M. H., Brown, C. F., & Kelly, D. (2002). tion and psychological distress: The impact of ethnic identity
Effect of ethnic group membership on ethnic identity, race- and age among immigrant and United States-born Asian
related stress, and quality of life. Cultural Diversity and Ethnic adults. Developmental Psychology, 44, 787–800.
Minority Psychology, 8, 366–377. Yoo, H. C., & Lee, R. M. (2005). Ethnic identity and approach-
Vereen, L. G., Hill, N. R., McNeal, D. T. (2008). Perceptions type coping as moderators of the racial discrimination/
of multicultural counseling competency: Integration of the well-being relation in Asian Americans. Journal of Counseling
curricular and the practical. Journal of Mental Health Psychology, 52, 497–506.
Counseling, 30, 226–236. Yoo, H. C., & Lee, R. M. (2008). Does ethnic identity buffer
Wadsworth, M. E., & Santiago, C. D. (2008). Risk and resil- or exacerbate the effects of frequent racial discrimination
iency processes in ethnically diverse families in poverty. on situational well-being of Asian-Americans? Journal of
Journal of Family Psychology, 22, 399–410. Counseling Psychology, 55, 63–74.

588 m ulticultural co u n s e l in g
 CHAPTER
Spirituality, Religion, and
23 Psychological Counseling

Thomas G. Plante and Carl E. Thoresen

Abstract
A substantial majority of people believe in God in some form and consider themselves to be spiritual,
religious, or both. However, most psychologists and other mental health professionals perceive
themselves as not religious and have little if any training in spirituality and religious diversity.
Psychologists can use spiritual principles and practices to better serve clients, even if they do not share
the same or any religious or spiritual perspective. We review and illustrate the emerging relationship
between psychology, spirituality and religion, and its current status. Benefits of religious/spiritual
engagement for physical, social, and mental health are outlined. We also comment on religious hazards
to health. Spiritual tools commonly found in major religious traditions are discussed and suggested for
use by counseling psychologists and others under certain conditions. A brief spiritual inquiry method
is presented. Results of a spiritually focused intervention using spiritual practices serves as an example.
Ethical and research issues are also discussed, along with important questions to consider.
Keywords: spirituality, religion, faith, health, counseling, psychotherapy, professional issues

We are not human beings trying to be spiritual. conferences and workshops have been conducted
Rather we are spiritual beings trying to be human. for health care professionals interested in the inter-
—Jacquelyn Small play between spirituality and health. Since 2000,
the topic has been featured in almost all popu-
Where is the wisdom we have lost in knowledge? lar news magazines and television news programs
Where is the knowledge we have lost in information? (e.g., making its third appearance on the cover of
—T.S. Eliot Time, in February 2009). In part, this growing
What accounts for the growing interest of health- interest stems from a public fascinated with spiritu-
related disciplines and professions, such as psychol- ality and its connection with health (e.g., Oprah
ogy and medicine, in religion and spirituality, introduced “Spirituality 101” in 2008, as a regular
especially in its relationship to health, disease, and feature of her popular television program).
well-being? In the past decade, many professional The popular interest also comes from a society
books have been published dealing with this issue seeking a greater sense of meaning, purpose, and
(e.g., Koenig, McCullough, & Larson, 2001; significance in life, especially recently, in the wake
Paloutzian & Park, 2005; Plante & Thoresen, of the unanticipated abrupt economic recession
2007). Literally hundreds of mostly empirical arti- starting in 2008 and still lingering What really mat-
cles have appeared (e.g., Miller & Thoresen, 2003; ters in life? What is sacred? Help with these ques-
McCullough, Hoyt, Larson, Koenig, & Thoresen, tions is not readily found in today’s time-pressured
2000; Thoresen & Harris, 2002) and scores of society, where there is less involvement in social and

589
community groups and organizations, less involve- person, within local organizations, within regions,
ment in developing and maintaining close personal within nation states, and within the world at large).
and intimate relationships, and diminishing partic- For example, the term religion can be used on a
ipation in religious organizations that provide a societal level as a social institution with organi-
majority of society’s “social and moral capital” zational structures. It can also be defined on a
(Putnam, 2000). group level as a faith community, or on an individ-
Current intrigue with spirituality and religion is ual level as involved with the search for signifi-
found not only among the general population and cance in life in ways related to what is perceived as
some health care professionals but also among the sacred (Pargament, 2007). Emmons and Paloutzian
psychological and counseling community as well. (2003), in reviewing theory and research over past
Although indifferent and antagonistic toward reli- 25 years, observed that the past decade in partic-
gion and spirituality for decades, psychology, among ular has seen major changes in how religion and
other disciplines, seems to be rediscovering its reli- spirituality are conceptualized. Mention is made
gious and spiritual roots with renewed interest of changing religious landscapes in the broader
(Oman & Thoresen, 2002). This renaissance seems culture, especially with a “new breed of spirituality
most apparent in the professional services side of that is often distinct from traditional conceptions
psychology (Miller & Thoresen, 2003). of religion” (p. 381). Zinnbauer and Pargament
In this chapter, we discuss the reviving relation- (2005) offer the many pros and cons of viewing
ship between psychology and religion and spiritual- spirituality as a part of religion or viewing religion
ity, especially as it pertains to psychological practice, as a part of spirituality.
such as counseling. We discuss empirical research, One of the biggest changes has been the broad-
using some examples, of the mental and physical ening perspective of how spirituality is conceived.
health benefits of spiritual and religious involve- Essentially, the term is no longer exclusively tied
ment. We also note some of its hazards to health. directly or indirectly to religious institutions and
Spiritual and religious principles and tools are men- traditions. Now, it is also applied to situations and
tioned that counselors can use ethically and with experiences that are independent of any formal ties
sensitivity in their professional work, regardless of with religion. One of the most significant recent
their personal beliefs or religious affiliation. We also developments concerning spirituality has been the
mention ethical mandates and issues, as well as some emerging relationship of spirituality with positive
empirical problems deserving consideration. emotions viewed from an evolutionary perspective
In the spirit of full disclosure, we as authors per- (e.g., Vaillant, 2008). We discuss this development
ceive ourselves as spiritually and religiously active later in the chapter.
persons. We are committed to fostering a greater We view religion broadly as a social institution
overall understanding of the role of spirituality and with organizational and community structures that
religion in psychology as a scientific discipline and offer ways for people to understand and honor the
as a health-related helping profession. As empirical wisdom traditions, generally through scriptures or
scholars and health professionals, we use a variety religious writings and through rituals viewed as
of quantitative and qualitative research methods sacred. Religious institutions generally offer an
in addition to our teaching, supervising, and con- articulated doctrine or belief structure describing
sulting roles. the specific values and beliefs of a traditional faith
community. Stated somewhat differently, religion
Definitions, Ethics, and Diversity Issues commonly provides answers to what have been
Before continuing, we need to address three impor- termed perennial questions about life and death
tant issues. They concern defining key terms, ethical (e.g., What really matters? Why do people suffer?
precautions, and diversity issues. What happens after I die?). Religion especially high-
lights one or more revered religious leaders or spiri-
Defining Religion, Spirituality, tual models to emulate, such as Jesus, Buddha, or
and the Sacred Mohammed. For a comprehensive discussion of the
People are often confused about the definition seminal role of spiritual modeling and how spiritu-
of the words “religion” and “spirituality.” Such con- ality is primarily “caught not taught,” see Oman and
fusion is understandable since these terms are mul- Thoresen (2003, 2005) and Bandura (2003).
tidimensional (e.g., social, emotional, cognitive) The world’s major religious faith traditions
and multilevel concepts (e.g., processes within the include Christianity, Judaism, Buddhism, Hinduism,

590 spiritualit y, re l igio n , an d ps ych o logical counse ling

Islam, Taoism, and Confucianism. Each tradition a major basis of motivation and focus in that per-
includes various branches, some highly similar and son’s life.
some quite differing from others in specific beliefs, The phrase “spiritual but not religious” has
values, and practices. For example, Christianity recently become a popular way to describe some
includes Roman Catholics, many Protestant denom- people’s religious/spiritual identity. Estimates of
inations (such as Methodists and Baptists), and those identifying themselves in the United States
countless nondenominational churches not affili- as spiritual but not religious range from 20% to
ated with an organized religious tradition but based 35% (Fuller, 2001; Hood, 2005). For example, in
on their interpretation of the Bible and the teach- a recent study of 1,010 college students in four
ings of Jesus. Within the Jewish tradition, variations American universities (in west, east, and south), 30%
exists as well, such as Orthodox or Reform version described themselves as “spiritual but not religious,”
of Judaism. As noted earlier, a key role of a religion whereas 41% saw themselves as “spiritual and reli-
as an organized faith community is to help mem- gious” (Oman, Thoresen, Park, Shaver, Hood, et al.,
bers and others better understand and relate to what 2008). Interestingly, such data compare favorably to
is sacred through community and through rituals, other major studies of spirituality and religion in
traditions, beliefs, and practices. Although some young adults (Astin et al., 2005).
religions are quite centralized and highly structured Keep in mind that the “spiritual but not reli-
(e.g., the Roman Catholic Church), others are very gious” designation represents a fairly heterogeneous
decentralized with little organizational structure group. Some have rejected religious organizations
(e.g., Buddhism). for many reasons, such as their perceived rigid
We view spirituality primarily at the level of the dogma, decrees, demands to be submissive, and
individual’s experiences in seeking what is perceived requirements to accept unquestionably specific reli-
as sacred in life and associated in some way with the gious beliefs and traditions. For some, the connota-
transcendent belief that a higher power or spirit tion of being spiritual is currently perceived as quite
exists that is greater than oneself. This connection positive, whereas being religious is viewed as fairly
might be to God (however defined or understood), negative. Fewer see spirituality as a “New Age” phe-
to religious models, such as Jesus or Buddha, or to nomenon that is unnecessary if not antireligious
the natural world in general. The word spirituality and thus as very negative, with religion seen as quite
comes from the Latin word, spiritus, meaning that positive (in the 10%–15% range).
which is absolutely vital to life, such as the breath Pargament (2007) reports that psychologists and
or life force (Hage, 2006). William James (1936) other contemporary mental health professionals
defined spirituality in relational terms as “the feel- often view spirituality among their clients as a good
ings, acts, and experiences of individual men in thing, whereas religiousness is typically a bad thing.
their solitude, as far as they apprehend themselves The extremely negative press associated with various
to stand in relation to whatever they may consider religious scandals, as well as religiously inspired ter-
the divine” (p. 32). In many ways, spirituality can rorism and violence, has contributed to the notion
be perceived as a blend of positive emotions mixed that organized religion is destructive, hypocritical,
with prosocial behaviors, such as the joy of feeling and outdated (e.g., Hitchens, 2007). Perhaps it is
connected to something greater than oneself or with a typical American penchant to be very individual-
“heartfelt” gratitude associated with feeling loved istic, such that many Americans seek and select
or loving another person (see Fredrickson, 2009, some elements of spirituality and religion that work
for an excellent overview of positive emotions). for them and simply reject the rest (Fuller, 2001).
Sacred we view as what is perceived as holy, Yet, although some have rejected organized religion
divine, eternal, or meaningful. Pargament (2007) altogether, many more others have held fast to their
defines the sacred as “concepts of God, the divine, faith traditions and communities, even following
and transcendent reality, as well as other features of remarkable religious scandals and embarrassments
life that take on divine character and significance (Putnam & Campbell, 2010).
by virtue of their association with or representation It is interesting to note the results of the first
of divinity . . . at the heart of the sacred lies God, major national study of spirituality and religion
divine beings, or a transcendent reality” (pp. 32–33). of the so-called “millennium generation,” those
In effect, a person can perceive many different things born in the mid to late 1980s and now attending
and experiences as sacred. Clarifying what a person college (Astin et al., 2005). In this study of 112,232
deems as sacred can help one better understand college youth attending 236 American colleges and

p l ant e , t hore se n 591

universities, a clear majority viewed themselves as Professionals, as well as the general population,
both spiritual and religious. Of these students, four often may have certain positive or negative per-
out of five believed in God, have attended at least ceptions about particular religious or spiritual com-
one religious service in the past year, and frequently munities. We must be, as noted earlier, very attentive
have discussed religion with friends and family. to the rich diversity of beliefs and practices, even
Almost one in two believe that it is “essential” or within each particular religious or spiritual tradi-
“very important” to seek ways to grow spiritually, tion. We must steer clear of religious stereotyping
69% pray regularly, and over 75% reported that of others, a problem that is highly prevalent in many
they are searching for greater meaning and purpose cultures. This is especially true for those psycholo-
in life. These students expressed a great deal of inter- gists who have had little or no contact with mem-
est in spiritually related questions, such as “What bers of particular religious group in either their
am I going to do with my life?” “What kind of professional or personal lives.
person do I want to be?” “How do I know I am All religious and spiritual communities, along
doing the right thing?” Almost two out of three with their beliefs, rituals, and practices, exist as a
indicated that most people can grow spiritually part of a particular culture or subculture. Spiritual
without being religious. and religious customs are commonly steeped in
Importantly, a great deal of diversity emerged ethnic diversity. For example, Roman Catholics
among students in different faith traditions and from Eastern Europe may engage in different reli-
from attending colleges in different regions of the gious traditions and practices relative to Catholics
United States. For example, students in Southeast- from Latin America. Jews from Israel may experi-
ern colleges and universities were less likely to be ence their faith and cultural tradition quite differ-
interested in spirituality (cf. religion) than were stu- ently than do those from parts of Eastern Europe or
dents from other regions. Those who identified with North America. Subtle and not so subtle cultural,
more conservative denominations were less likely to ethnic, geographic, and political differences may be
be interested in social issues, such as gender and part of religious experience, customs, and traditions.
sexual orientation, as well as less interested in world- In fact, many religious and spiritual beliefs and
wide humanitarian issues (e.g., world hunger, pov- practices originated within a particular ethnic and
erty, discrimination; Astin et al., 2005). Clearly, the cultural community before being adopted more
topics of spirituality and religion hold substantial broadly by a particular religious tradition. Two very
interest among current young adults. simple examples: Christmas trees and Easter bun-
nies. The point here is that specific cultural influ-
Ethical and Diversity Issues ences are often intimately woven into religious and
Several ethical concerns deserve comment. First, spiritual experience and expression (American
when it comes to matters of spirituality and reli- Psychological Association [APA], 2003).
gion, counselors need to work within their area of
competence and must not overstep professional Benefits of Religious and
bounds. We, as psychologists, and other profession- Spiritual Engagement
als are obligated to perform our duties consistent Mills (2002) reported that almost 1,700 empirical
with our training and experience. That means fol- studies of religion and health had been published
lowing ethical guidelines of competence as well as in professional and research-oriented journals by
legal requirements that license to practices demands. 2000. During the same time, about 700 had been
Second, professionals must carefully avoid potential published on spiritually/spirituality and health.
dual relationships, especially when their clients are We suspect that since 2000, well over 4,000 articles
members of their own faith tradition and perhaps and reports have appeared, given the exponential
part of the same church community. Unforeseen rate of annual publications documented by Mills
dual relationships and conflicts can easily emerge. (2002).
One must be very sensitive to potential exploitive The term health itself has been expanding
dual relationships, as well as to the unforeseen con- to include not only “conditions of the body” but, more
sequences that can unfold when working with fellow importantly, “states of mind” (Ryff & Singer, 1998;
congregants. Finally, professionals must be careful Thoresen & Eagleston, 1985). Although most people
to avoid potential bias by not promoting one par- still associate health with medicine, biology, and dis-
ticular religious belief system over another, espe- ease, many are expanding its meaning to include a
cially their own. person’s overall life experiences. Examples include the

592 spiritualit y, re l igio n , an d ps ych o logical counse ling

hospice care movement, global environmental fac- as the only factor. Rather, spiritual and religious
tors, and positive emotions. Some have suggested factors appear to serve as one of many other indirect
that, although in the 20th century, psychology first but significant factors in promoting good health
lost its soul and then its mind; it is now beginning and well-being (see Thoresen & Harris, 2002).
to recall them both in the 21st century. In doing so,
psychology may be becoming more focused on Physical Health and Longevity
human nature and the whole person in context, To date, the physical health benefits associated
rather than only focused on a person’s behaviors, with spirituality and religious involvement have
cognitions, or personality (Miller & Delaney, been impressive (Powell, Shahabi, & Thoresen,
2005). 2003). Spiritual and religiously active people tend
The vast majority of high-quality research to live longer, be less likely to develop serious medi-
supports a positive relationship between religious cal illnesses, and recover faster from illnesses than
involvement and beneficial health outcomes (Koenig others. In fact, meta-analytic research based on
et al., 2001; Pargament, 1997; Plante & Sherman, long-term prospective studies involving tens of
2001; Plante & Thoresen, 2007; Richards & Bergin, thousands of adults show that religiously oriented
2005). People engaged in regular participation in people, in general, live on average 7 years lon-
a religious and spiritual tradition tend to be health- ger than do non–religiously minded people. This
ier, happier, maintain better habits, and experience is the case even when statistically controlling for
more social support compared to those less active age, gender, socioeconomic status, family history
or not at all involved. of disease, health behaviors (such as smoking,
drinking alcohol, and diet), and other known risk
Mental Health Benefits of Spirituality factors for mortality, such as social support
and Religion (McCullough, Hoyt, Larson, Koenig, & Thoresen,
An extensive review of research involving hundreds 2000; Oman & Thoresen, 2005; Powell et al.,
of studies of mental health benefits of spiritu- 2003). For example, Hummer, Rogers, Nam, and
ality and religious involvement suggests that it is Ellison (1999) investigated over 21,000 adults in
related to less anxiety, depression, chronic stress, a national sample examining disease and mortality.
and greater perceived well-being and self-esteem They controlled for 15 likely factors that influence
(Koenig et al., 2001; Plante & Sharma, 2001; health outcome, such as those mentioned above,
Thoresen, 2007). Persons with religious involve- plus others. Compared to the highest religious
ment often tend to cope better with major and attendance group (attending some kind of religious
minor life stress. They are, for example, less likely service more than once per week), the non–religious
to have alcohol and other substance abuse prob- attendance group suffered 50% more deaths, the
lems, eating disorders, be divorced, and are less occasional religious attendance group (defined as
likely to attempt suicide, homicide, or engage in once per month) had 24% more deaths, and the
criminal behavior. Generally, they live a healthier group attending religious services once per week
overall lifestyle, with better social support, usually group had 15% more deaths. Examining results in
avoiding health damaging behavior patterns. In years of life, the highest religious attendance group
general, they have better mental health function- lived 7.6 more years longer than nonattendees.
ing, including mood and general affect control, These results provide the kind of evidence that
than do those not regularly involved religiously or mandates the need to clarify which factors best
spiritually. explain these results. Not considered in most stud-
Despite hundreds of studies, the evidence does ies, however, were indicators of quality of life and
not demonstrate or prove that religion or spiritual- several other mental health indicators, particularly
ity by itself directly causes better mental or physical positive indicators that could shed even more light
health. Instead, the evidence clearly implicates spiri- on these extraordinary findings.
tual or religious practices over time in processes When 29 independent studies of religious
involved with better physical and mental health involvement were reviewed using meta-analysis
compared with non–religiously active people. totaling 125,826 adults and 15 potentially influ-
Specific causes of this beneficial relationship, how- encing factors were controlled, weekly or more reli-
ever, remain unclear (Thoresen, 2007). We strongly gious attendance yielded 29% fewer deaths than
suspect that religion and spirituality serve as a posi- did nonattendance. This figure dropped to 23%
tive factor in good health and well-being but not when social support was included in the analysis.

p l ant e , t hore se n 593

The longevity benefit for frequent church attendance It is expressed in an individual’s search for
was 7 additional years of life (McCullough et al., ultimate meaning through participation in religion
2000). Using a review process focused on the qual- and/or belief in God . . . (and) . . . can influence
ity of the research designs, statistical analyses used, how patients and health care professionals
and precision of other measures, Powell, Shahabi, perceive health and illness and how they interact
and Thoresen (2003) found that, in nine highly with one another.
rated studies, frequent religious attendance at ser- (Association of American Medical Colleges, 1999,
vices mortality rates were 25% lower than for non- pp. 25–26)
attendees in general population samples of
reasonably healthy adults. Community Benefits
In recent years, for the first time, the National Many community benefits exist for active spiritual
Institutes of Health convened an expert panel and religious involvement. Since those who tend to
(see Miller & Thoresen, 2003; Powell, Shahabi, & be religious and spiritual also tend to stay married
Thoresen, 2003) to conduct a critical evaluation of and are less likely to engage in behaviors that could
published clinical trials using rigorous scientific harm others, such as unsafe sexual practices, drunk
criteria. The panel concluded that “persuasive” evi- driving, and criminal activity, spirituality and reli-
dence exists that active religious and spiritual giousness appear to foster a more livable and healthy
involvement is significantly correlated over time in community. Spiritually and religiously oriented
controlled prospective studies with lower all-cause people tend to take better care of their local as well
mortality. The overall results indicated a 25% to as global community, supporting charitable causes,
30% reduction in mortality. On average, people and especially participating in volunteerism. In fact,
who are active in religious or spiritual activities can an added benefit of helping others in need through
expect to live about 7 years longer than nonreligious volunteerism is less disease and longer life (Oman &
or less religiously active people. In one major study, Thoresen, 2005).
African Americans males lived almost 14 years To illustrate, in one major study Oman,
longer than did nonactive African males (see Powell, Thoresen, and McMahon (1999) followed almost
Shahabi, & Thoresen, 2003). Clearly, active reli- 2,000 older persons in Northern California for over
gious and spiritual engagement for many consis- two decades in terms of how many regularly volun-
tently appears to enhance their health, when broadly teered to help others in the community (i.e., they
viewed over time. received no material compensation). Roughly one-
Tragically, many mental and physical health third of the sample volunteered regularly on a
problems are self-inflicted and thus could be pre- scheduled basis for 4 to 6 hours a month. Volunteers
vented. Roughly 50% of all deaths in Americans had 40% fewer deaths than did those who did not
and in the developed world are due to lifestyle regularly volunteer. That difference increased to
habits and behaviors, such as smoking cigarettes, over 60% fewer deaths if the person who volun-
excessive eating and drinking, and lack of regular teered also was religiously active. These dramatic
physical exercise (Centers for Disease Control, 2004). differences were found even after statistically con-
As already discussed those who are actively engaged trolling for over 12 known mortality risk factors.
in religious and spiritual practices live a healthier In a large nationally stratified sample, Harris and
lifestyle than do those less active or not at all active. Thoresen (2005) found about 15% volunteered
In doing so, they minimize many risks associated regularly. They experienced significantly fewer
with the major chronic diseases, such as various car- deaths, but when the other factors known to predict
diac diseases (e.g., Koenig et al., 2001; Oman & higher death rates were added to the analysis, only
Thoresen, 2005; Powell, Shahabi, & Thoresen, those who volunteered and who were regularly reli-
2003). giously active had significantly fewer deaths (30%
In response to these and other findings, the fewer deaths).
Association of American Medical Colleges has Those engaged in spiritual and religious activities
expressed the value of spirituality and religion in tend to be good citizens of the world who make the
quality health care, stating: community a better place for others. In doing so,
they also seem to benefit themselves by gaining a
Spirituality is recognized as a factor that contributes greater sense of meaning and significance in life, as
to health in many persons. The concept of well as enjoying better health and longevity along
spirituality is found in all cultures and societies. with heightened quality of life.

594 spiritualit y, re l igio n , an d ps ych o logical counse ling

How Could Religious Involvement in volunteerism (helping others in need without
Benefit Health? material compensation). Not surprisingly, positive
Several theories have been suggested. First, religious psychology endorses the need for more posi-
involvement is often conducted within a particular tive emotions in daily life that may result in
social structure termed a congregation. This social better mental health functioning. It is possible that
structure provides for many ready-made groups the relationship between spirituality and religious
(including smaller groups) with similar interests and involvement and positive mental health benefits
values to lend invaluable social and emotional sup- and outcomes could most likely be indirectly
port. Supportive congregational activities may help related through a variety of causal mechanisms or
prevent mental health problems from developing pathways.
or may help reduce these problems by offering bet- Recently, positive emotions and positive social
ter ways to cope with serious challenges and trou- behaviors, mentioned earlier, have been described
bles. Second, spiritual and religious practices often in evolutionary terms when it comes to spirituality.
involve activities similar to secular relaxation or For example, Keltner (2009) in Born to Be Good,
mind-calming strategies. Mental health profession- makes a compelling case that humans survived over
als often suggest various kinds of relaxation strate- thousands of years not only because of their indi-
gies to help clients cope with anxiety, depression, vidual fitness but because of their collaborative
substance abuse, and other mental health prob- kindness, and their spiritual and social capacities
lems. Many spiritual and religious practices, such as well. That is, survival of the human species over
as meditation, prayer, and attending various kinds 200 million years was not due solely to their physi-
of services, can be considered as forms of mental cal genetics but more to their social and spiritual
and physical relaxation strategies. However, such capacities, especially those selected for positive and
practices also offer, compared to secular relax- prosocial emotions toward others. These included,
ation practices, the added value of bolstering a for example, faith, hope, love, joy, compassion, and
diminished sense of meaning or significance in gratitude. One could argue that it was more of
life, along with strengthening perceptions of self- a survival of the kindest than just a survival of the
efficacy about coping better with life’s challenges fittest, especially if fitness is viewed only as physical
(Oman & Thoresen, 2005). This strengthened and intellectual abilities. This spiritual evolutionary
perceived self-efficacy to cope with mental health perspective finds support in several recent studies,
challenges may depend on the person’s perception primarily in psychology, neuroscience, ethology/
that a relationship exists for them with a higher animal studies, and cultural anthropology (see, for
power or source, such as God. example, Brooks, 2011; Balter, 2005; Dalai Lama &
McAdams (2006), for example, offers a fascinat- Ekman, 2008; Damasio, 1994; Panksepp, 1998).
ing perspective based on the study of personal nar- In an excellent overview, Vaillant (2008) makes
ratives (“life stories”) focused on Erikson’s stage a strong case that spirituality is essentially made of
of generativity (the person’s concern and commit- positive emotional experiences within social con-
ment to promoting the well-being of others, such as texts—such as hope and compassion—that have
future generations). Some who are actively involved evolved over the past 200 million years. Some of the
in religion and spirituality seem to benefit greatly major points he makes include:
in having been able to reframe their suffering
and pain as actually beneficial to them (sometimes • Three kinds of evolution exist—genetic,
called “benefit finding”). For such persons, pain cultural, and individual—and have continually
and suffering is often viewed as having redemptive influenced each other. For example, evolving
consequences. cultural changes have altered the size and functions
We also note that the field of positive psychol- within the brain, making it more likely to select
ogy, with its focus on human virtues (e.g., courage, for those living in more supportive, affiliative,
humanity, and transcendence) and specific char- and cooperative cultures characterized as fostering
acter strengths (e.g., hope, forgiveness, and grati- positive social emotions and strong social
tude), enhances mental health functioning attachments.
(Seligman, Steen, Park, & Peterson, 2005; Snyder • The human brain shares with all
& Lopez, 2007). Spiritual and religious people are mammals and primates the limbic system
much more likely, for instance, to forgive others, (or paleomammalian brain), the neurophysio-
express compassion, display gratitude, and engage logical home of positive emotions, empathy,

p l ant e , t hore se n 595

and communal bonding and cooperation. influence several physiological processes. Thus, the
This limbic system processes information from processes involved mutually enhance each other and
other organs of the body, coordinates emotions other related processes. For example, engaging in
with past memories, and sends and receives daily spiritual meditation can lead to more social
information from the neocortex (especially the support and less depression which, in turn, can
left prefrontal cortex), leading to more subtle foster more spiritual fellowship, as well as more
and nuanced thoughts and motivation. optimistic thoughts and expectations. All of these
• The supremacy of words, texts, logic, and may impact several major organ systems of the body
language in Western science (the primary domain (e.g., immune competence, cardiovascular function-
of the left prefrontal cortex) have construed human ing, and metabolism) and may also, for example,
experience and consciousness much too narrowly, impact left prefrontal cortical processes related to
leaving out the crucial role of emotional thinking more positive self-perceptions, wiser decisions and
and intuitive wisdom in understanding human judgments, and a richer consciousness.
experiences, perceptions, decisions, and judgments.
• Spirituality is clearly not the same as religion. Methodological Concerns
Spirituality is individual-oriented, more emotional, Conducting well-controlled studies, such as ran-
universal in humans, more experiential, and more domized experiments or prospective longitudinal
tolerant; religion is institutional and interpersonal- studies, to examine important research and clinical
oriented, more cognitive, more culture-bound, questions has always been challenging. This is espe-
more dogmatic, and less tolerant. Note, however, cially true in examining the influence of religion
that religion is the greatest depository of spiritual and spirituality on mental, social, and physical
resources, such as religious texts, rituals, music, health. Researchers, for example, obviously cannot
and prayers/meditations. randomly assign people to different religious and
nonreligious groups and then examine health out-
This evolutionary perspective in highlighting comes. Researchers are, of course, not permitted to
the primary role of positive emotions in spirituality coerce people to engage in randomly assigned reli-
can help dispel the oversimplified and false dichot- gious activities, prayer, or meditation, or to attend
omy about cognitions and emotions, science and religious services. Therefore, most research in this
spirituality, and causes and effects. area to date has been limited to correlational designs,
Oman and Thoresen (2002) proposed a combi- including nonexperimental or quasi-experimental
nation of four major causal pathways that could, in designs that do not randomize participants to differ-
combination, explain the mental and physical health ent groups.
benefits of spiritual and religious factors: strong However, many important problems related
social and emotional support; health-enhancing to human health and well-being have been suc-
behaviors (e.g., no or moderate drinking, not smok- cessfully studied without having to randomize
ing); positive psychological states (e.g., faith, hope, some participants to the hypothesized disease con-
inner peace, positive emotions); and subtle processes dition. For example, decades of successful research
not yet understood scientifically (e.g., nonlocal pro- in the health effects of tobacco on health did not
cesses, such that cognitions can be transmitted over require randomizing participants to become smok-
long distances). Although contemporary science ers for several years, nor has successful research on
cannot at present assess some of these unidentified the causes and processes of morbid obesity required
factors, it does not necessarily mean that they do randomizing normal weight participants to become
not exit. The history of science is a story of phenom- clinically obese over time. Science clarifies causal-
ena that at one time were thought to be inconceiv- ity by gathering and critically examining patterns
able, not to mention unmeasurable at the time, such of evidence from a variety of sources and settings
as the proposition that earth revolves around the over time. There is no one best scientific method
sun or that emotions are linked to certain areas of used in understanding complex human experi-
the brain or to the body’s immune system. ence, such as the health effects of spiritual
If religious and spiritually minded people tend to or religious practices, that can unequivocally estab-
live a healthier lifestyle, live more ethically, act more lish causality. Instead, there are a variety of research
compassionately and forgivingly toward others and designs using a variety of data and analytic tech-
toward themselves, then they are more likely to have niques, depending on the specific topic, that
better psychological functioning that, in turn, could can shed light on the role of spiritual and religious

596 spiritualit y, re l igio n , an d ps ych o logical counse ling

factors in health. Clearly, the almost exclusive use of The Down Side of Religion
self-report questionnaires or inventories is inade- and Health Outcomes
quate for many topics in spirituality and religion Are there mental and physical health hazards to
(Hill & Pargament, 2003; Oman & Thoresen, health and well-being associated with religion and
2002). Studies need to also include behavioral spirituality? The answer is yes (Pargament, 2007).
observation data, for example, along with assess- For some, the policies and practices of organized
ments of physiological markers indicative of the religion, including the actions of religious profes-
issue or question being studied. sionals (e.g., pastors, priests, nuns, rabbis), have at
To illustrate, Ironson, Solomon, Balbin, times been harmful, if not devastating, to a person’s
O’Creirigh, George et al. (2002) demonstrated or a group’s health and well-being. Historically, over
that a comprehensive spiritual and religious self- hundreds of years, grave abuses were authorized and
report measure failed to directly predict mortality sometimes implemented by religious authorities
in HIV/AIDS patients. Instead the relationship based upon a variety of reasons and doctrines. Some
was mediated by reduced cortisol, which in turn have noted that, even today, abuses associated with
predicted less mortality. In the same way, the behav- religion continue to happen (e.g., Hitchens, 2007;
ior of helping others significantly mediated the Plante, 2004).
relationship between overall spirituality and mortal- One area of hazards to health associated with
ity. Such studies highlight an important point cited religion encompasses those experiencing religious
earlier: The spirituality and religion connection struggles; that is, when a person perceives that he
with all-cause mortality exists because of several or she is being punished or abandoned by God in
health-related factors that mediate the relationship, the face of a major trauma or by a perceived threat
rather than having an independent, direct influence to one’s existence. Although some religious beliefs
(Oman & Thoresen, 2002; Thoresen, Oman, & and worldviews offer a greater sense of meaning,
Harris, 2005). purpose, and direction in life along with sources
Most studies to date have focused on questions of comfort and support, for others, certain beliefs
as to whether religious people or those actively and worldviews can create very serious problems
engaged in spiritual and religious practices tend and threats that endanger health. When a person
to benefit overall from better mental and physical struggles chronically with personal faith, doing so
health when compared to those not engaging can lead to serious health problems, sometimes with
in spiritual and religious behaviors. This kind of fatal consequences.
correlational research is clearly worthwhile, espe- For example, Edmondson, Park, Chaudoir, and
cially longitudinal studies that assess participants Wortmann (2008) studied the negative impact of
more than once over time (often called prospective religious struggles in terminally ill heart failure
designs). However, correlational evidence has impor- patients suffering from their fear of death. Those
tant limitations in trying to pin down possible struggling in terms of their religious beliefs were
causes of observed change, such as improved health. much more likely to suffer more serious depressive
Well-designed prospective studies, sometimes with symptoms that were linked to their elevated fears
relatively small prospective samples (n = 25–50), of death. Such concerns were found to fully mediate
can nevertheless shed valuable light on identifying the positive relationship of religious struggles and
possible causes. For example, the fascinating find- depression, which is serious mortality risk for those
ing of a small study of participants’ daily ratings for suffering from advanced cardiac diseases.
1 month of how effective their spiritual coping was Religious involvement can be destructive to self,
in reducing chronic pain that day turned out to be to others, and to the community. Tragically, reli-
the most powerful predictor of actual pain experi- gious beliefs have been used to wage war, oppress
enced the very next day (Keefe et al., 2001). Such women, murder others who do not share the same
evidence encourages consideration of why this hap- religious beliefs and practices, and to instill guilt,
pened and how spiritual coping could be linked to depression, and anxiety among many. Religious-
reduced pain. One possibility is that reduced pain ness can also be associated with harmful if not fatal
from a spiritual coping practice, such as using a health practices, such as the rejection on religious
short mantram (a short sacred word or phrase often grounds to seek needed medical and psychi-
repeated during the day), could alter the person’s atric care. Religious beliefs and practices can and
perception of his or her perceived competence (self- unfortunately continue to be used in certain areas
efficacy) to manage pain. of the world to justify, support, and enflame group

p l ant e , t hore se n 597

conflicts as well. Curiously, religious conflicts about faith communities, which helps people to cope with
moral transgressions can be significant predictors life’s challenges and troubles. Finally, the focus on
of panic disorder (Trenholm, Trent, & Compton, love, compassion, and serving others in need, along
1998). Patients with HIV/AIDS can suffer poorer with the emphasis on ethical conduct linked to
health if they hold a more rigid view of a punishing specific religious and spiritual beliefs and traditions,
and judgmental of God, compared to a compas- can have an effect of making the world a better place
sionate and forgiving view of God or an impersonal to live. This is especially true for the vast majority
view of God or a higher power (Kremer & Ironson, of people who live impoverished and marginal-
2007). ized lives. However, as discussed, there is evidence
Clearly, empirical evidence exists that religion that involvement in some religious communities
can be hazardous mentally and physically to health contributes to personal and social problems, such
under certain circumstances. These negative effects as anxiety, panic, obsessive compulsive symptoms,
unfortunately remain understudied and deserve terrorism, and various forms of abuse, oppression,
more study using well-controlled research designs. violence, and hatred. Typically, for most normal
Such designs need to be especially sensitive to assess- expressions of spiritual and religious beliefs and
ing ongoing cognitive, social, and emotional experi- practices, positive mental and physical health bene-
ences as well as specific contexts (e.g., time, place, fits can be expected. We believe it is therefore rea-
others present, cultural factors, internal narratives sonable for professionals to expect that spiritual and
in the setting). Methods are available to capture religious engagement could be useful, and to at least
much of these phenomena, but seldom have been consider the role of spiritual and religious factors in
used. Tennen, Affleck, Armeli, and Carney (2000) an overall counseling treatment plan.
offer, for example, useful research designs to study Above all, given the fact that a clear majority of
daily processes, such as very specific experiences. Americans are religious or spiritually active, we
These could include specific ways to cope with dis- believe that the counseling psychologist, as well as
tress, such as perceived spiritual support and daily other psychologists, should at least initially broach
spiritual self-efficacy perceptions. As mentioned, the topic of religious and spiritual involvement with
Keefe, Affleck, Lefebvre, Underwood, Caldwell a client. But how would one do that in a way that
et al. (2001) offer an excellent example of this kind would not be perceived as offensive or insensitive?
of much-needed research.
Keep in mind that almost all of the world’s major Barriers to Spirituality and Health
religions have urged people, for example, to avoid Benefits in Counseling
smoking, excessive drinking (or no use of alcohol), The Public Is Religious, Psychologists
unsafe sexual practices, and to engage regularly in Are Not
physical exercise and eat healthy foods. Although The vast majority of people in the United States
these health behaviors are vital to better health and and across the globe describe themselves as being
to preventing disease, religious traditions also have spiritual, religious, or both. Most belong to a tradi-
long been focused on helping people cope or manage tional faith community and are affiliated and identi-
a broad variety of major and minor life stressors and fied with a major religious tradition. Others view
distresses, which is associated with enhanced psy- themselves as spiritual but not being interested
chological functioning. These coping approaches in organized religion. Most participate in regular,
have included optimism, positive emotions, com- formalized religious services, celebrate religious
passion for self and others, forgiveness of others, holidays, and pray often or daily. In fact, over 95%
and less anxiety, depression, and perceived stress of Americans report that they believe in God and
(Plante & Thoresen, 2007). 40% attend religious services once a week or more
Overall, research clearly supports the many (Gallup & Lindsay, 1999). According to Gallup
mental, physical, and community health benefits polls, most Americans are Christian, with 85%
for those who engage in spiritual and religious activ- affiliated with either a Protestant (59%) or Cath-
ities. It is likely that many spiritual and religious olic (26%) denomination. About 2% are Jewish,
people generally lead lifestyles that are more health whereas Hindu, Muslim, and Buddhists together
promoting and less health damaging than do those account for 3% of the population. Only 6% of
who are not actively religious or spiritual. Religions Americans are not affiliated with any religious group
also have generally provided a variety of ways to (Gallup & Lindsay, 1999). More than 80% of
offer social support through involvement in their Americans report that they wish to grow spiritually

598 spiritualit y, re l igio n , an d ps ych o logical counse ling

(Myers, 2000). Thus, religion and spirituality is anything positive to say about religion or spiritu-
clearly an important component of life for most ality (e.g., Ellis, 1971; Freud, 1961; Watson,
people. 1924/1983). For example, in Future of an Illusion,
By contrast, most psychologists are not spiritual Freud referred to religion as an “obsessional neuro-
or religious. Only 33% are affiliated with a reli- sis” (Freud, 1961, p. 43). Watson referred to reli-
gious tradition, only 72% report belief in God or gion as a “bulwark of medievalism” (Watson,
higher power, and 51% report that religion is not 1924/1983, p. 1). These and other leaders clearly
important to them (Shafranske, 2000). Miller and implied that religious interest or concerns typically
Delaney (2005) poignantly observed that, in the served as signs of pathology and not good health.
20th-century United States, of all the scientific, Psychology has long prided itself in working
professional, or academic disciplines, psychology hard to be viewed as a rigorous, empirical, “hard
became by far one of least interested in religion and science” discipline. Many psychologists appear to
spirituality. Despite the work of some major psy- hold a dualistic if not stereotyped perception about
chologists of the 20th century (e.g., William James, religious and spiritual constructs; that is, if a con-
Gordon Allport, and Carl Jung) on spirituality and struct is perceived as religious or spiritual, then it
religion, Miller and Delaney (2005) observed that, is viewed by definition as nonscientific or antiscien-
at best, “The modal response of psychologists to tific. This dualistic attitude about anything religious
religion in research, practice, and training, however, or spiritual as antiscientific has been especially evi-
became one of silence and neglect” (p. 4). dent in the applied professional areas of psychol-
Recently, 68% of current training directors of ogy. For example, the recent efforts to focus on
clinical psychology internship programs state that empirically supported and manualized treatments
they “never foresee religious/spiritual training being (Task Force on Promotion and Dissemination of
offered in their program” (Russell & Yarhouse, 2006, Psychological Procedures, 1995), as well as more
p. 434). Perhaps people who pursue a career as a psy- rigorous scientific approaches to psychological ser-
chologist are more secular and less religious or spiri- vices are evidence for the continuing emphasis on
tual than the average person. Perhaps psychologists science, which may have little if any interest in spir-
develop a “trained incapacity” in college or graduate itual or religious issues.
school, such that they view religion as inherently A related issue concerns the secularization of tra-
antiscientific or spirituality as involving supernatural ditional religious or spiritual practices used in inter-
hocus-pocus. Shafranske (2000) suggested that most ventions (e.g., procedures to manage distress, calm
psychologists who bring this topic into their research the body, or quiet the mind). Doing so may have
or clinical practice do so because of a unique train- been done, in part, to make them more acceptable
ing experience, compared to anything systematic in to the professional community. For example, the
their training program, or to their own personal field of positive psychology has categorized some
faith commitment. Whatever the reason, the fact is topics as major virtues (e.g., humanity, wisdom,
that, although most people are religious, spiritual, or transcendence) and related subtopics as specific char-
both, most psychologists studying or serving people acter strengths (e.g., love, gratitude, forgiveness).
are neither religious nor spiritual. These topics have been secularized for the most part;
As noted, some of our famous and influen- that is, presented outside of any religious tradition
tial psychology forefathers, such as William James, or practice (see Seligman et al., 2005). The widely
Carl Jung, and Gordon Allport, wrote extensively used mindfulness-based stress reduction (Kabit-
about the relationship between psychology and reli- Zinn, 1990; Shapiro & Walsh, 2007) also offers an
gion (e.g., Allport, 1950; James, 1890, 1902/1936; example of secularizing of spiritual and religious
Jung, 1938). Nevertheless, the topic of religious and practices (e.g., Buddhist meditation). Perhaps a
spiritual beliefs, attitudes, and behavior has been secular approach was perceived as less controversial
largely ignored by psychological writers (Collins, or more subject to empirical study than using a
1977). Glancing through the subject index of spiritual or religious approach.
any basic psychology text, for example, one seldom A question worthy of attention, given that most
finds mention of religion or spirituality. Psychologists clients or patients are religiously active and seek-
in the 20th century undoubtedly have been influ- ing greater spirituality in their lives, is to ask if
enced by the perspectives of important leaders in spiritual practices, when secularized, have the same
the field, such as Sigmund Freud, B.F. Skinner, John effectiveness as do those used within a spiritual or
Watson, and Albert Ellis. These leaders seldom had religious tradition. We know of few such studies.

p l ant e , t hore se n 599

One, however, is worthy of some detailed comment Perhaps more problematic, if not destructive, is
because it is based on a well-controlled randomized the fact that secular and nonreligious psychologists
clinical trial design in an area lacking any such stud- working with religiously oriented or spiritually
ies (Wachholtz & Pargament, 2008). minded clients often unwittingly preconceive or
The study examined a spiritually focused medita- interpret their client’s interest in spirituality and
tion practice to reduce the frequency of long-term religion as a sign or symptom of pathology, delu-
chronic migraine headaches compared with two sion, or weakness. Or, a psychologist may be oblivi-
highly similar meditations and a relaxation control ous of how clients could draw upon their religious
procedure without any spiritual focus. Two questions or spiritual beliefs or practices in trying to overcome
were asked in the investigation: Is spiritual medita- problems. Are the interests of a client best served if
tion more effective in enhancing pain tolerance and a psychologist ignores completely anything in the
in reducing the frequency of migraine headaches over spiritual and religious realm? Or, would a client be
a 30-day period? Does spiritual meditation create better served if a psychologist at least inquires about
better mental, physical, and spiritual health outcomes the client’s interests and perceptions about spiritual-
compared to secular meditation and relaxation tech- ity and religion? We discuss this and other related
niques? Eighty-three headache sufferers were ran- questions later in this chapter.
domized to one of four conditions. One included the Despite the long history of “silence and neglect”
spiritual meditation group, in which each person of spirituality and religion in modern psychology,
selected among a list of spiritually focused medita- in recent years, change has come. A greater rec-
tions such as “God is love” or “God is peace.” ognition of the value of religious and spiritual con-
Participants in two other secular experimental groups cerns is under way, in psychology and in other social
(internal or external meditations) selected meditation and behavioral sciences. This recognition seems
statements, such as “I am joy” or “I am good” in the greatest in health and disease, in which professional
internal group or “Sand is soft” or “Grass is green” in and public support is expanding (Hartz, 2005;
the external group. Progressive muscle relaxation was Koenig et al., 2001). Many secular professional
used in the fourth comparison group. organizations, such as the Society of Behavioral
After 30 consecutive days of 20-minute daily Medicine, now offer special interest groups that
meditations, outcome results were impressive. Those focus on spirituality and health research and prac-
in the spiritually focused experimental condition tice. Major organization such as the Templeton,
experienced significant reductions in headaches Lilly, and Fetzer foundations, as well as government
compared to modest reductions in the other three granting agencies such as the National Institute
secular conditions. Reductions in pain tolerance of Health (NIH), have also funded large research
(using the cold pressor task, in which participants projects in this area.
place their hand in circulating freezing water until The American Psychological Association (APA)
pain is too great to tolerate) were significant and has embraced these changes as well. For example,
dramatic as well. The baseline pain tolerance for all the 1999 National Multicultural Conference and
four groups was 45 seconds. The spiritual medita- Summit sponsored by the APA stated: “spiritual-
tion group’s pain tolerance rose to almost 2 minutes, ity is a necessary condition for a psychology of
whereas the other three groups showed either no human existence” and that “people are cultural
change or modest gains up to only 20 seconds. and spiritual beings” (Sue, Bingham, Porche-Burke,
Gains in spiritual measures, such as existential well- &Vasquez, 1999, p. 1065). The ethics code for psy-
being and spiritual experiences, also favored the chologists states: “Psychologists are aware of and
spiritual meditation group, as did reductions in trait respect cultural, individual, and role differences,
anxiety and negative emotions. including those based on age, gender, gender iden-
The Wachholtz and Pargament (2008) interven- tity, race, ethnicity, culture, national origin, religion,
tion study suggests that the inclusion of a spiri- sexual orientation, disability, language, and socio-
tual focus might enhance—if used in a sensitive, economic status and consider these factors when
appropriate, and respectful manner—the effective- working with members of such groups” (APA, 2002,
ness of psychological practices and interventions. p. 1064). Thus, being “aware of and respect(ful)” of
Hopefully, other researchers will pursue this prom- religious issues is now demanded by the ethics code.
ising topic using appropriate research designs and Finally, the APA has itself published a dozen books
assessments exemplified by these researchers. on psychology, spirituality and religion during the

600 spiritualit y, re l igio n , an d ps ych o logical counse ling

past 10 years, when previously it offered almost capable of sustained commitment when dealing
none. with the complexities of spiritual and religious con-
cepts as they relate to health and well-being (Miller
Psychology Can Learn from & Delaney, 2005).
Religion and Spirituality Although relatively few psychologists, with the
Psychology as a scientific discipline has been around exception of those in Division 36 (Society for the
for a little more than 100 years, whereas religion Psychology of Religion and Spirituality), have stud-
and spirituality have been around for thousands ied religion or spirituality, noticeably more are now
of years. Perhaps psychology could learn some- starting to do so, thus helping to expand the scope
thing from its older cousin. After all, the goal of and depth of inquiry. Psychology as a discipline can
counseling and psychological services is, in part, and will benefit from the challenge of trying to better
about developing healthier strategies for living understand, especially empirically, the number of
and better ways of coping with many stressful life religious and spiritual constructs and practices
events. Counseling seeks to help people manage involved. Psychology as a behavioral and social sci-
their lives in a more thoughtful, significant, and ence discipline is known for its primary focus on the
healthy way. Since spiritual and religious traditions individual and the many differences within and
have long offered wise council on these issues for among individuals. Spirituality is eminently personal
thousands of years, perhaps the counseling commu- and individual as well as experiential. It works within
nity could learn a few things from the collective each person at various levels of conscious personal
wisdom of these faith traditions. We believe that experiences, seasoned by a range of beliefs, emotions,
one needs to at least consider carefully and respect- and behaviors across time (past, present moment,
fully ways to incorporate some spiritual concepts future). Religions were created by people in part to
and practices into the scientific and professional help individuals within a perceived community deal
work of psychology. with issues of making life more meaningful, gaining
What concepts or practices might be considered? a greater sense of purpose and direction, such as how
Some possibilities include the following: Focus- to live a “good life.” Building and sustaining com-
ing on forgiveness (self, situations, others), promoting munities of faith that provide support for living a
greater acceptance of others as well as self-acceptance, values-centered life is what religions seek to do. How
using significant rituals, providing group and com- successful they are in doing so is another issue.
munity support (i.e., physically, socially, emotionally, As psychologists, we need to be more attentive
and materially), emphasizing selfless love, encourag- to the broad range of diversity issues that individu-
ing kindness, and volunteering regularly to serve als represent, such as religious and spiritual beliefs
others in need. At a broader level, the concept of and practices. Since the APA ethics code (2002)
learning to perceive oneself as a part of something mandates that psychologists be respectful and mind-
much larger than just oneself (i.e., less egoistic) seems ful of cultural diversity that includes religious tradi-
significant, as does the concept of enhancing a greater tions and beliefs, psychologists should not ignore or
sense of meaning and purpose in life. Note that these automatically pathologize religious and spiritual
and others topics have been thoughtfully considered issues among their clients and students.
in many ways in all of the major religious and spiri-
tual wisdom traditions over thousands of years Implementing Spiritually
(Armstrong, 2006; Smith, 1991). Oriented Interventions:
The field of psychology has indeed matured as an What the Religious and Spiritual
independent and international discipline, offering Traditions Offer the Counselor
rigorous scientific inquiry with state-of-the-art Given the fact that religion and spirituality may
methodologies and statistics to study many human offer many mental and physical health benefits, how
issues, some quite challenging. The many complexi- might professional counselors use the research find-
ties of human perception and judgment, for exam- ings to enhance their clinical activities with clients?
ple, continue to be better understood by using more First, let us briefly introduce two important steps in
sophisticated concepts and methods. The study of ways to think about what the religious and spiritual
personality is another complex, multidimensional, traditions offer the professional counselor.
if not multilevel topic. The field of psychology deals In the now classic book, The World’s Religions
with complex and challenging concepts, and it is (Smith, 1991), Huston Smith well articulates an

p l ant e , t hore se n 601

ancient view that the world’s great religions are much Some Spiritual Principles and Tools
more similar than different. He refers to the Hindu for the Counselor
notion that the “various religions are but different What do religious traditions at their best offer
languages through which God speaks to the human the psychological community? At the top of the
heart” (p. 73). Quoting Rig-Veda (4,000 BCE), the metaphorical mountain where the traditions con-
often-quoted Hindu sage states, “Truth is one; sages verge, a number of highly desirable and useful prin-
call it by different names” (p. 73). ciples and values are beneficial. These include
Smith provides an illustration of how to under- a focus on the sacredness of life and of the world,
stand the world’s religions that we believe can be ethical behavior toward others, prayer and medita-
helpful to use. He states: “It is possible to climb life’s tion, community and service involvement, and love
mountain from any side, when the top is reached and respect for all. Many also conveyed the notion
the trails converge. At base, in the foothills of theol- that God, while existing in many forms and set-
ogy, ritual, and organizational structure, the reli- tings, could be found within every person, regard-
gions are distinct. Differences in culture, history, less of their status and gender, as well as in other life
geography, and collective temperament all make and inanimate forms. The task of the person, how-
for diverse starting points” (p. 73). He then describes ever, was to use spiritual practices to access this
that, as we move higher, toward the top of the divine presence within. The religious traditions
mountain, the world’s religious traditions become emerging from the Axial age all emphasized com-
one path seeking truth stating, “But beyond these passion toward oneself and all others. These values
differences, the same goal beckons” (p. 73). He and principles can be helpful to many, regardless of
quotes Sri Ramakrishna, a 19th-century Hindu their particular religious traditions or affiliations,
teacher, who said, “God has made different religions including those with no interest in any religious tra-
to suit different aspirations, times, and countries. ditions or beliefs.
All doctrines are only so many paths; but a path The variety of empirically supported treatment
is by no means God Himself. Indeed, one can programs and protocols now available can integrate
reach God if one follows any of the paths with spiritual and religious tools and perspectives in
whole-hearted devotion. One may eat a cake with services offered by psychologists and other mental
icing either straight or sideways. It all tastes sweet health professionals. Alcoholics Anonymous (AA)
either way” (p. 74). At their best and most thought- is perhaps the oldest and best known self-help
ful, the religious traditions converge together and and peer-led program to integrate spiritual and
ultimately are saying much the same thing, using religious perspectives in its program (Alcoholic
different languages, customs, and traditions. Anonymous World Services, 1977). Of course, AA
Concepts from all of the major contemporary is not an empirically supported treatment pro-
religious traditions, as well as from Greek philo- gram administered by mental health professionals.
sophical rationalism, can be traced to the ninth cen- However, the program well illustrates the popular
tury BCE, during the Axial age in four different integration of spirituality into self-help services for
regions of the then civilized world (Armstrong, alcohol and other addictions. In recent years, pro-
2006). They all struggled with similar questions and fessionally developed empirically supported treat-
came to similar conclusions about religious, ethical, ments have been developed and tested that integrate
and social views. This includes “the spirit of com- spiritual and religious principles in professionally
passion . . . lies at the core of all our traditions” administered treatment services. This includes inter-
(Armstrong, 2006, p. 476). However, all of the reli- ventions for substance abuse, eating disorders, and
gious traditions have “fallen prey to exclusivity, cru- marital discord to name a few, and these interven-
elty, superstition, and even atrocity. But at their tions have used bibliotherapy, meditation, forgive-
core, the Axial faiths share an ideal of sympathy, ness training, and other spiritually and religiously
respect, and universal concern” (Armstrong, 2006, based interventions with roots in all of the major
p. 466). The “Golden Rule,” or treating others as religious traditions. In addition to mental health
you would like to be treated, is the main point and and relationship problems, interventions have also
is well articulated in the sacred texts of all of the been developed to help those coping with a number
religious traditions (Armstrong, 2006; Pargament, of medical disorders as well, such as HIV/AIDS and
2007; Peterson, 1986). In fact, Armstrong states coronary heart disease. A list of empirically sup-
that the Axial sages concluded that “religion was the ported treatment interventions that integrate spiri-
Golden Rule” (Armstrong, 2006, p. 468). tual and religious principles and tools, along with

602 spiritualit y, re l igio n , an d ps ych o logical counse ling

Table 23.1. Examples of Empirically Supported
Spiritual/Religious Interventions for Counseling Box 23.1. Brief Description of Eight Point
Program (EPP) of Easwaran (1991/1978)
Name of Intervention Author Reference
1. Passage Meditation: Silent repetition in the
Program
mind of memorized inspirational passages from the
Opening Your Heart Ornish, 1990 world’s great religions, such as the 23rd psalm, the
(Coronary heart disease Prayer of Saint Francis, or the Discourse on Good
and prevention) Will of the Buddha’s Sutta Nipata. Practiced for
one-half hour each morning.
Christian Marriage Worthington, 1990 2. Repetition of a Holy Word or Mantram: Silent
Counseling repetition at times other than meditation of a single
Becoming a more Worthington, 2004 chosen Holy Name, hallowed phrase, or mantram
Forgiving Christian from a major religious tradition.
3. Slowing Down: Setting priorities and reducing
Coping with Divorce Rye and Pargament, 2003 the stress and friction caused by hurry.
Solace for the Soul Murray-Swank and 4. Focused/One-pointed Attention: Giving full
Pargament, 2005 concentration to the matter at hand.
5. Training the Senses: Overcoming conditioned
Lighting the Way Pargament, McCarthy, habits and learning to enjoy what is beneficial.
Shah, Anon, Tarakeshwar, 6. Putting Others First: Gaining freedom from
et al., 2004 selfishness and separateness; finding joy in helping
others.
(Group treatment for
7. Spiritual Association: Spending time regularly
women with HIV/AIDS)
with others following the Eight Point Program (EPP)
Spiritual Renewal Richards, Hardman, and for mutual inspiration and support.
(Eating disorders) Berrett, 2000 8. Inspirational Reading: Drawing inspiration
from writings by and about the world’s great spiritual
Re-Creating your Life Cole & Pargament, 1998 figures and from the scriptures of all religions.
(Group treatment for
serious mental illness)
From Vice to Virtue Ano, 2005 (Easwaran, 1991/1978; Flinders, Oman, & Flinders,
Eight Point Spiritual Easwaran, 1991 2007). Box 23.1 lists a brief description of each
Skills Program spiritual practice, drawn from the wisdom tradi-
tions spanning all major religions. See also an intro-
Mindfulness Meditation Kabat-Zinn, 2003 ductory primer that provides case material and
Mantram Training Bormann, Gifford, Shively, narratives focusing on using the mantram, slow-
Smith, Redwine, et al., 2006 ing down, and one-pointed attention to reduce
worries, foster inner peace, and encourage kindness
REACH Model Worthington, 2004
for Forgiveness (Easwaran, 2005).
Working with a psychologist and other health
professionals this physician, with others assisting,
an appropriate reference for further information, is conducted eight weekly 2-hour sessions on the EPP
provided in Table 23.1. for 29 professionals, with another 30 randomized to
a wait group condition. A variety of assessments
Caregiving of Health Professionals: were conducted just before the weekly group started,
A Spiritual Practices Example at the end and at 8-week and 19-week follow-ups,
How might a practicing psychologist or other health spanning almost 6 months. Over 90% remained
professional use spiritual practices in a work setting? active in the study, and attendance at weekly ses-
We use the example of a large Denver hospital that sions was above 85%.
was seeking help to reduce perceived stress of staff Briefly, participants were mostly female (86%),
and foster better care of patients and their families had at least 5 years of full-time work experience,
(Oman, Hedberg, & Thoresen, 2006). A physician identified themselves as “spiritual but not religious”
connected with the hospital suggested that a com- (50%) or “spiritual and religious” (45%), or neither
prehensive, spiritually based, nonsectarian program (5%). Of all, 77% stated that they were very or
called the Eight Point Program (EPP) could be used moderately spiritual. Very few stated they were “very

p l ant e , t hore se n 603

religious.” Each session focused on one or more of conducted a controlled study with 118 oncology
the eight points, with initial attention on what is patients to assess the effect of using this protocol
termed “passage meditation,” use of the mantram, with oncology patients. Patients were alternately
slowing down, and being more one-pointed in assigned to intake with a brief spiritual inquiry
attention. group included or the usual intake interview group.
Results were encouraging. First, the reductions Most patients were Caucasian, 55% were women
in perceived stress were impressive and were main- with mixed diagnoses, and 81% identified them-
tained through the last follow-up (roughly 6 selves as being Christian in background.
months). Effect sizes were significant at post-treat- Assessments of mental health factors plus patient
ment and at follow-ups: –0.63, –1.00, and –0.84, and physician ratings of the interview were con-
respectively. Translated into levels (%) for this mea- ducted just before the initial interview and 3 weeks
sure in national populations samples, baseline scores later. Physicians rated themselves comfortable with
for these health professionals were in the high-stress inquiry with 85% of patients, and 76% of patients
range (above 80%), whereas the immediate post- felt inquiry was somewhat or very useful. At 3-week
treatment score dropped to 50% or average stress follow-up, patients in the spiritual inquiry group
level. The two follow-up levels stayed below 50%. showed significant improvements compared to the
In addition, the Caregiving Self-Efficacy Scale comparison group (at least p < .05) in quality of life,
(32 items tapping the perceived confidence level to spiritual well-being, and perceived sense of interper-
do something successfully, such as “Control my sonal caring by their physician. The major steps in
temper with patients,” “Help families of patients to this protocol are as follows (with some of the sug-
deal with the death of patients,” and “Sense the gested words used by the health professional in
needs of other coworkers [so I can help them with- quotes):
out being asked]”) was used. Encouraging effect
1. Introduce the issue in neutral inquiring
sizes were found in the moderately strong range
manner.
(0.48, 0.59, 0.47). Improvements in other mental
health indicators were less significant, but all in the “When dealing with this problem, many people
desired direction. Importantly, no evidence emerged draw on religious or spiritual beliefs to help cope
that practicing the specific eight points from a spiri- with it. It would be helpful to me to know how you
tual perspective was associated with any kind of feel about this.”
negative effect on health and well-being (see Oman,
2. Inquire further, adjusting inquiry to client’s
Richards, Hedberg, & Thoresen, (2008) for detailed
initial response. If it is a:
information on a qualitative, structured interview
narrative study that offers some confirmation of the a. Positive-active faith response: “What have
results cited above). you found most helpful about your beliefs since
this problem came up?”
Conducting a Spiritual Inquiry b. Neutral-receptive response: “How might
in the Initial Interview you draw on your faith or spiritual beliefs to help
Recently, a team of psychologists, working with you?”
others, developed a simple, short, yet sensitive and c. Spiritually-distressed response: (e.g., anger
respectful way to conduct a spiritual inquiry. Jean or guilt): “Many people feel that way . . . what
Kristeller, working with a team that included physi- might help you come to terms with this?”
cians, learned from survey data that a majority d. Defensive-rejecting response: “It sounds
of physicians believed that a patient’s spirituality like you’re uncomfortable I brought this up. What
could be important in understanding the patient’s I’m really interested in is how you are
health status, but that in fact physicians seldom (less coping . . . can you tell me about that?”
than 10%) brought the topic up with patients.
3. Continue to explore further as indicated:
When asked why, physicians often mentioned that
they were unsure how to do so and did not want “I see. Can you tell me more (about . . . )?”
to be seen as imposing upon the patient’s privacy.
4. Inquire about ways of finding meaning and
Kristeller and others developed a standardized brief
a sense of peace:
protocol called the patient-centered spirituality
protocol that could be routinely used by physicians “Is there some way in which you are able to find
(Kristeller, Rhodes, Cripe, & Sheets, 2005). They a sense of meaning or peace in the midst of this?

604 spiritualit y, re l igio n , an d ps ych o logical counse ling

 5. Inquire about resources. foundation of knowing and understanding peren-
nial human virtues and character strengths
“Whom do you have to talk to about this/these
(Armstrong, 2006; Oman, Flinders & Thoresen,
concerns?”
2008). These traditions offer advice about learn-
6. Offer assistance as appropriate and available. ing how to discover the sacred in life and make
specific suggestions about building and maintain-
“Perhaps we can arrange for you to talk
ing intimate relationships with others, including a
to someone . . . there’s a support group.”
transcendent relationship with a power or spirit
7. Bring inquiry to a close. greater than oneself, sometimes called God. Ways to
manage major and minor stressful life events have
“I appreciate you discussing these issues with me.
also been recommended in dealing with common
May I ask about it again?”
problems in the contexts of marriage, family, work,
Obviously the wording would need to be modi- and community.
fied to fit the specific mental or physical health Although the wisdom accumulated in religious
problem (e.g., posttraumatic stress disorder, marital traditions may use different languages, customs,
conflict, leadership management issues), but the beliefs, and rituals about life’s perennial questions,
general format can provide a structure that could be they have reached very similar conclusions over thou-
taught in graduate training programs and also used sands of years. “When religions [traditions] are sifted
by practicing psychologists with some brief train- for their best qualities,” wrote Huston Smith (1991),
ing. Doing so could help the client, and could also the eminent scholar of the world’s major religions,
help psychologists fill the mandate of honoring the “they begin to look like data banks that house the
spiritual and religious diversity of their clients. winnowed wisdom of the human race” (p. 5).
Plante (2009) outlined 13 spiritual and religious Undoubtedly, as human institutions, organized reli-
tools useful for counselors to have in their therapeu- gions have also been a source of hatred, fear, violence,
tic toolbox, regardless of their interest or lack deprivation, and hypocrisy. At times, certain religious
of interest in specific religious faith traditions. These policies and practices have contradicted the essence
include meditation; prayer; seeking a sense of voca- of spirituality and the sacred, such as love, hope, and
tion, meaning, purpose, and calling in life; biblio- compassion. We need, however, to look beyond spe-
therapy, including sacred scripture reading; attending cific cultural differences and the dogma that goes
community services, ceremonies, and rituals; volun- along with very questionable practices to acknowl-
teering and charitable works and service; ethical edge and seek what religions offer at their best.
values and behavior with others; approaching others Every major religion, for example, offers life
with forgiveness, gratitude, love, kindness, and stories—in effect spiritual models—that convey
compassion; engaging in social justice issues; learn- admirable human qualities and character strengths
ing from spiritual models; accepting oneself and (e.g., Jesus, Buddha, Gandhi, Moses, Mother Teresa).
others (even with faults); being part of something These traditions and historical spiritual exemplars
larger than yourself; and understanding the sacred- also have been used to illustrate how persons faced
ness of life. Some of these tools are likely to be with great challenges were able to deal with them by
appropriate and helpful with particular clients and using spiritual practices and perspectives. We can
counselors, whereas others are not. We believe these learn from spiritual exemplars, regardless of the
tools can add value to the effectiveness of profes- status of our own spiritual and religious affiliation,
sional services and research offered by counseling beliefs, and practices (“Spirituality is caught more
and other psychologists involved in health care. than taught”).
Empirical evidence clearly supports the view that
Conclusion people actively engaged in spiritual or religious activ-
Future Directions ities on average are physically, socially, and mentally
Religious and spiritual wisdom traditions have far better off than those seldom or not engaged. This
evolved over thousands of years. A careful reading robust empirical relationship between active involve-
of the history and development of these traditions ment and health, as noted earlier, does not demon-
indicates that all have grappled with much the same strate that a direct and specific cause-and-effect
theological and philosophical issues. Wisdom tradi- relationship exists (e.g., that religion directly causes
tions also offer guidance in how to live a more satis- better health). Rather, what has been demonstrated
fying, happy, and meaningful life, one based on a is that a consistent relationship exists of the benefits

p l ant e , t hore se n 605

of active spiritual and religious involvement for most now require attention, training, and respect for reli-
people. Studies also suggest that clients prefer to have gious diversity. Since a majority of clients studied
their religious and spiritual issues and traditions at and served by psychologists and other health pro-
least acknowledged and possibly integrated into their fessionals are religiously engaged and spiritually
professional health care services. focused, we believe that it makes good professional
As noted, the great wisdom traditions provide and clinical sense for counseling psychologists and
a variety of useful tools and practices used over more other health professionals to at least understand the
than three millennia. These can be employed by role of spiritual and religious factors.
the competent and interested psychologist. Impor- The field of counseling psychology has long his-
tantly, many of these practices can be used in a tory within the discipline of psychology as a specialty
secular manner, depending on particular circum- devoted to understanding and serving those dealing
stances. For example, mindfulness-based stress with life’s inevitable “normal” problems, compared
reduction has been often used in secular settings, yet to those with severe mental, physical, or social health
has roots in a particular religious tradition (Tibetan problems. How can the field of counseling psychol-
Buddhism). Although clients are not required to be ogy capitalize on the collective wisdom of the world’s
religious or spiritually active to benefit from the major religions discussed earlier? Much of this wisdom
tools derived from religious traditions, it remains relates to fundamental issues of character, conduct,
unclear if use of a completely secularized practice is and consciousness. Recently, the terms virtues and
more or less effective than when used in a more character strengths have been essentially reintroduced
spiritually or religiously framed manner (Wachholtz to psychology by the positive psychology move-
& Pargament, 2007). ment (e.g., Seligman et al., 2005; Snyder & Lopez,
Religious and spiritual beliefs and practices 2007). As noted earlier, these virtues (e.g., humanity,
clearly can be harmful and hazardous to overall temperance, and transcendence) each involve several
health. Frankly, this topic has been seldom exam- character strengths (e.g., humanity includes love,
ined rigorously, and with the needed sensitivity. kindness, leadership; temperance includes forgive-
Candid and comprehensive examinations of possi- ness, humility, self-regulation; and transcendence
ble negative effects merit using rigorous empirical includes gratitude, hope, and humor). Most would
methods, and the collaboration of professional col- view these character strengths as important if not
leagues is needed in such areas such as specific reli- essential personal and social qualities.
gious beliefs and spiritual practices (Thoresen, How do people learn to be virtuous and to honor
Oman, & Harris, 2005). a character in their daily lives that displays such
Most people report that they are religious, spiri- strengths as forgiveness, humility, and gratitude in
tual, or both. Some, such as Vaillant (2008) dis- their thoughts and actions? We believe that an
cussed earlier believe that all humans are by nature important future direction for counseling psychol-
spiritual but not religious due to cultural factors. ogy lies in focusing more on virtues and character
Overall, a clear majority of people in the United strengths, given that many can benefit from acquir-
States are affiliated with a religious tradition, believe ing these virtues and strengths: the person, the
in God (however defined), and pray regularly. family, the community, and in effect, all on earth.
Roughly 40% of Americans attend spiritual or Recent work in spiritual modeling, drawing on social
religious ceremonies, services, or rituals weekly or cognitive theory and the distilled wisdom of all
more often. By contrast, in Northern European cul- major religious traditions, offers an empirically based
tures, only a clear minority are actively religious. strategy to help people learn spiritual skills and prac-
Interestingly, a clear majority of mental health pro- tices that can enhance health in its broadest sense
fessionals in the United States and in European cul- (Bandura, 2003; Oman & Thoresen, 2003, 2005).
tures are not active religiously or spiritually, nor do Four important future directions for work in this
they identify with a particular religious tradition. area of spirituality and religion strike us as timely, in
Furthermore, although there has been considerable the sense of clarifying some major issues:
focus on cultural diversity in recent years, the vast
majority of graduate training programs in the mental • Exploring the growing trend in American
health professions continue to ignore religious and as well as other cultures of those who perceive
spiritual issues, offering no instruction or training themselves as “spiritual but not religious”
on religious diversity. The APA ethics guidelines • Studying relationships among social, mental,
(and other codes) in the mental health disciplines and physical factors among those who are more

606 spiritualit y, re l igio n , an d ps ych o logical counse ling

spiritually or religiously active compared to those can provide confirming evidence that survey ques-
less or not active. tions could never reveal. See the Oman, Richards,
• Identifying and understanding possible Hedberg, and Thoresen (2008) study for an exam-
mediating factors that may help explain how ple of using repeated interviews to complement a
a spiritual or religious factor may play a causal variety of survey measures used on four occasions in
role in one’s overall health status. Possible a hospital-based spiritual intervention with health
mediators include various forms of meditation, professionals.
volunteering to serve others, attending religious How might a spiritual practice, such as frequent
or spiritual services weekly or more often, and attendance at religious or spiritual services, play a
experiencing positive social emotions. causal role in reducing stress or mortality? Recall
• Consider further the evolutionary evidence that this attendance and mortality relationship
that spirituality is inherently linked to positive offers to date the strongest empirical evidence in the
emotions, suggesting that humans are by nature United States that spirituality and religion may
spiritual, but may need certain cultural experiences enhance health in most people (Miller & Thoresen,
to express their spirituality in positive, prosocial 2003). This question reveals the impressive com-
ways. plexities of factors at play in seeking answers. For
example, what is there about attending services
We currently know little about that segment that “gets under the skin” in ways that alter, at
of the population who identify themselves as only some points in time, the physiological processes
spiritual. As indicated earlier, studies have found that lead eventually to death? Such a question
sizable numbers (from 15% to 30%) were identified speaks to the search for mediators, factors that help
as spiritual but not religious. In what ways is this explain what can be called indirect causes of an
group a mix of several subgroups, characterized by outcome, such as the connection between atten-
such factors as age, gender, socioeconomic status, dance and mortality. To date, several possible
educational level, ethnic identity, and geographical answers have been suggested involving lifestyle
region? Are there significant differences among spir- issues, such as health behaviors (e.g., less smoking,
itual but not religious compared to other subgroups less high-risk behaviors), beliefs, perceptions, and
(e.g., religious only or spiritual and religious) when emotions (e.g., believe in something greater than
it comes to health? What does it mean in terms of oneself, sense of meaning and significance), commu-
attitudes, beliefs, and actions for someone who nity/social and spiritual support (e.g., emotional sup-
describes herself as spiritual but not religious? What port from congregation), and possible processes not
difference exits, if any, in the kind of problems per- assessable by current scientific methods. Counseling
sons present for counseling services if identified as psychologists and other health professionals can help
spiritual only or religious only or both or neither? clients understand that a number of factors are at
Few, if any, studies have documented the rela- work that will help mediate the solutions to their
tionships among those who are very active spiritu- problems. Spiritual practices and perspectives can be
ally and those less or not active in terms of physical, good candidates to serve as mediators in helping cli-
mental, and social health problems. Typically, stud- ents work out solutions to their problems of living.
ies have seldom used a variety of assessments other As long as counseling psychologists and other
than survey questions; different modes of assess- health professionals are open-minded, well-trained,
ment (interviews, structured diaries, daily behavior have access to appropriate consultation, and closely
ratings, ambulatory electronically based devices) are monitor ethical issues with competence, respect,
rarely used. Assessment of an individual’s spiritual integrity, and responsibility in mind, they can learn
beliefs and practices has been usually based on one a great deal from spiritual and religious wisdom
short questionnaire, and seldom have an individual’s traditions. In doing so, their clients can benefit
experience of what is sacred in their lives been greatly as well.
assessed. Little has been done to gather a person’s
“narrative identity” with a focus on spiritual experi-
ences, as discussed by McAdams (2006). Interviews References
can provide data that speaks more deeply to a per- Allport, G. W. (1950). The individual and his religion: A psycho-
logical interpretation. New York: Macmillan.
son’s spiritually related experiences, especially if American Psychological Association (APA). (2002). Ethical prin-
gathered on more than one occasion. Rather than ciples of psychologists and code of conduct. American
using only interviews or only surveys, using both Psychologist, 57, 1060–1073.

p l ant e , t hore se n 607

American Psychological Association (APA). (2003). Guidelines Flinders, T., Oman, D., & Flinders, C. L. (2007). The eight-
on multicultural education, training, research, practice, and point program of passage meditation: Health effects of
organizational change for psychologists. American Psychologist, a comprehensive program. In T. G. Plante, & C. E. Thoresen
58, 377–402. (Eds.), Spirit, science, and health: How the spiritual mind fuels
Ano, G. A. (2005). Spiritual struggles between vice and virtue: physical wellness (pp. 72–93). Westport, CT: Praeger/
A brief psychospiritual intervention. Unpublished doctoral Greenwood.
dissertation, Bowling Green State University, Bowling Fredrickson, B. (2009). Positivity. New York: Random House.
Green, OH. Freud, S. (1961). The future of an illusion (J. Strachey, Ed. &
Armstrong, K. (1993). A history of God: The 4,000 year quest of Trans.). New York: Norton. (Original work published 1927
Judaism, Christianity, and Islam. New York: Gramercy. by Doubleday).
Armstrong, K. (2006). The great transformation: The beginning of Fuller, R. C. (2001). Spiritual but not religious. New York: Oxford
our religious traditions. New York: Anchor Books. University Press.
Association of American Medical Colleges. (1999). Report III: Gallup, G., Jr., & Lindsay, D. M. (1999). Surveying the religious
Contemporary issues in medicine: Communication in medicine, landscape: Trends in U.S. beliefs. Harrisburg, PA: Morehouse.
medical school objectives project. Washington, DC: Association Hage, S. M. (2006). A closer look at the role of spirituality in
of American Medical Colleges. Retrieved August, 2007, from psychology training. Professional Psychology: Research and
http://www.aamc.org/meded/msop/report3.htmtask. Practice, 37, 303–310.
Astin, A. W., Astin, H. S., Lindholm, J. A., Bryant, A. N., Harris, A. H. S., & Thoresen, C. E. (2005). Volunteering is
Calderone, S., & Szelenyi, K. (2005). The spiritual life of col- associated with delayed mortality in older people: Analysis of
lege students: A national study of college students’ search for the longitudinal study of aging. Journal of Health Psychology,
meaning and purpose. Los Angeles: Higher Education 10, 739–752.
Research Institute, University of California. Retrieved from Hartz, G. W. (2005). Spirituality and mental health: Clinical
http://spirituality.ucla.edu/reports/index.html. applications. Binghamton, NY: Haworth Pastoral Press.
Balter, M. (2005). Are human brains still evolving? Brain genes Hill, P., & Pargament, K. I. (2003). Advances in the conceptual-
show signs of selection. Science, 309, 1662–1663. ization and measurement of religion and spirituality.
Bandura, A. (2003). On the psychosocial impact and mecha- American Psychologist, 58, 64–74.
nisms of spiritual modeling. The International Journal for the Hitchens, C. (2007). God is not great: How religion poisons every-
Psychology of Religion, 13, 167–174. thing. New York: Twelve Books.
Bormann, J. E., Gifford, A. L., Shively, M., Smith, T. L., Hood, R. W., Jr. (2005). Mystical, spiritual, and religious
Redwine, L., Kelly, A., et al. (2006). Effects of spiritual man- experiences. In R. F. Paloutzian, & C. L. Park (Eds.),
tram repetition on HIV outcomes: A randomized controlled Handbook of the psychology of religion and spirituality
trial. Journal of Behavioral Medicine, 29, 359–376. (pp. 348–364). New York: Guilford.
Brooks, D. (2009, April 7). The end of philosophy. New York Hummer, R. A., Rogers, R. G., Nam, C. B., & Ellison, C. G.
Times, A23. (1999). Religious involvement and U.S. adult mortality.
Centers for Disease Control. (2004). National vital statistics Demography, 36, 272–285.
report. Washington, DC: Author. Ironson, G., Solomon, G. F., Balbin, E. G., O’Cleirigh, C.,
Cole, B. S., & Pargament, K. I. (1998). Re-creating your life: George, A., & Kumar, M., et al. (2002). The Ironson-Woods
A spiritual/psychotherapeutic intervention for people diag- Spirituality/Religiousness Index is associated with long
nosed with cancer. Psycho-Oncology, 8, 395–407. survival, health behaviors, less distress, and low cortisol in
Collins, G. R. (1977). The rebuilding of psychology: An integration people with HIV/AIDS. Annals of Behavioral Medicine,
of psychology and Christianity. Wheaton, IL: Tyndale House. 24, 34–48.
Dali Lama, Ekman, P. (2008). Emotional awareness: Overcoming James, W. (1890). Principles of psychology. New York: Holt.
the obstacles to psychological balance and compassion. New James, W. (1936). The varieties of religious experience: A study in
York: Times Books. human nature. New York: Modern Library. (Original work
Damasio, A. (1994). Descartes’ error. New York: Penguin. published 1902).
Easwaran, E. (1991/1978). Meditation: A simple eight-point Jung, C. G. (1938). Psychology and religion. New Haven, CT:
program for translating spiritual ideals into daily life. Yale University Press.
Tomales, CA: Nilgiri Press. Retrieved from http://www. Kabat-Zinn, J. (1990). Full catastrophe living. New York:
easwaran.org. Delacourte Press.
Easwaran, E. (2005). Strength in the storm: Creating calm in dif- Kabat-Zinn, J. (2003). Mindfulness-based interventions in con-
ficult times. Tomales, CA: Nilgiri Press. text: Past, present, and future. Clinical Psychology: Research
Edmondson, D., Park, C. L., Chaudoir, S. R., & Wortmann, J. H. and Practice, 10, 144–156.
(2008). Death without God: Religious struggle, death con- Keefe, F. J., Afflect, G., Lefebvre, J., Underwood, L.,
cerns, and depression in the terminally ill. Psychological Caldwell, D. S., Drew, J. (2001). Living with rheumatoid
Science, 19, 754–758. arthritis: The role of daily spirituality and daily religious and
Ellis, A. (1971). The case against religion: A psychotherapist’s view. spiritual coping. Journal of Pain, 2, 101–110.
New York: Institute for Rational Living. Keltner, D. (2009). Born to be good: The science of a meaningful
Emmons, R. A., & McCullough, M. E. (2003). Counting bless- life. New York: Norton.
ings versus burdens: Experimental studies of gratitude and Koenig, H. G., McCullough, M. E., & Larson, D. B. (2001).
subjective well-being. Journal of Personality and Social Handbook of religion and health. New York: Oxford University
Psychology, 84, 377–389. Press.
Emmons, R. A., & Paloutzian, R. F. (2003). The psychology Kremer, H., & Ironson, G. (2007). Spirituality and HIV/AIDS.
of religion. Annual Review of Psychology, 54, 377–402. In T. G. Plante, & C. E. Thoresen (Eds.), Spirit, science, and

608 spiritualit y, re l igio n , an d ps ych o logical counse ling

 health: How the spiritual mind fuels physical wellness Pargament, K. I. (2007). Spiritually integrated psychotherapy:
(pp. 176–190). Westport, CT: Praeger/Greenwood. Understanding and addressing the sacred. New York:
Kristeller, J. L., Rhodes, M., Cripe, L. D., & Sheets, V. (2005). Guilford.
Oncologist Assisted Spiritual Intervention Study (OASIS): Pargament, K. I., McCarthy, S., Shah, P., Anon, G.,
Patient acceptability and initial evidence of effects. Inter- Tarakeshwar, N., Wachholtz, A. B., et al. (2004). Religion
national Journal of Psychiatry in Medicine, 35, 329–347. and HIV: A review of the literature and clinical implications.
McAdams, D. P. (2006). The redemptive self: Stories Americans live Southern Medical Journal, 97, 1201–1209.
by. New York: Oxford University Press. Peterson, R. (1986). Everyone is right: A new look at comparative
McCullough, M. E., Hoyt, W. T., Larson, D. B., Koenig, H. G., religion and its relation to science. Marina del Ray, CA:
& Thoresen, C. E. (2000). Religious involvement and DeVorss.
mortality: A meta-analytic review. Health Psychology, 19, Plante, T. G. (Ed). (2004). Sin against the innocents: Sexual abuse
211–221. by priests and the role of the Catholic Church. Westport, CT:
Miller W. R., & Delaney, H. D. (Eds.). (2005). Judeo-Christian Praeger/Greenwood.
perspectives on psychology. Washington, DC: American Plante, T. G. (2009). Spiritual practices in psychotherapy: Thirteen
Psychological Association. tools for enhancing psychological health. Washington, DC:
Miller, W. R., & Thoresen, C. E. (2003). Spirituality, religion American Psychological Association.
and health: An emerging research field. American Psychologist, Plante, T. G., & Sharma, N. (2001). Religious faith and mental
58, 24–35. health outcomes. In T.G. Plante, & A. C. Sherman (Eds.),
Mills, P. J. (2002). Spirituality, religiousness, and health: From Faith and health: Psychological perspectives (pp. 240–261).
research to clinical practice. Annals of Behavioral Medicine, New York: Guilford.
24, 1–2. Plante, T. G., & Sherman, A. S. (Eds.). (2001). Faith and health:
Murray-Swank, N. A., & Argument, K. I. (2005). God, where Psychological perspectives. New York: Guilford.
are you? Evaluating a spiritually- integrated intervention Plante, T. G., & Thoresen, C. E. (Eds.). (2007). Spirit, science
for sexual abuse. Mental Health, Religion & Culture, 8, and health: How the spiritual mind fuels physical wellness.
191–203. Westport, CT: Praeger/Greenwood.
Myers, D. (2000). The American paradox: Spiritual hunger in a Powell, L., Shahabi, L., & Thoresen, C. E. (2003). Religion and
land of plenty. New Haven, CT: Yale University Press. spirituality: Linkages to physical health. American Psychologist,
Oman, D., Hedberg, J., & Thoresen, C. E. (2006). Passage med- 58, 36–52.
itation reduces stress in health professionals: A randomized Putman, R. D. (2000). Bowling Alone: The collapse and revival of
controlled trial. Journal of Consulting and Clinical Psychology, the American community. New York: Simon & Schuster.
74, 714–719. Putman, R. D., & Campbell, D. E. (2010) American Grace;
Oman, D., Richards, T. A., Hedberg, J., & Thoresen, C. E. How religion divides and unites us. New York: Simon &
(2008). Passage meditation improves caregiving self-efficacy Schuster.
among health professionals: A randomized clinical trial. Richards, P. S., & Bergin, A. E. (2005). A spiritual strategy
Journal of Health Psychology, 13, 922–1007. for counseling and psychotherapy (2nd ed.). Washington, DC:
Oman, D., & Thoresen, C. E. (2002). Does religion cause American Psychological Association.
health? Differing interpretations and diverse meanings. Richards, P. S., Hardman, R. K., & Berrett, M. E. (2000).
Journal of Health Psychology, 7, 365–380. Spiritual renewal: A journal of faith and healing. Orem, UT:
Oman, D., & Thoresen, C. E. (2003). Spiritual modeling: A key Center for Change.
to spiritual and religious growth? The International Journal Russell, S. R., & Yarhouse, M. A. (2006). Religion/
for the Psychology of Religion, 13, 149–165. Spirituality within APA-accredited psychology predoctoral
Oman, D., & Thoresen, C. E. (2005). Do religion and spiritu- internships. Professional Psychology: Research and Practice,
ality influence health? In R. F. Paloutzian, & C. L. Park 37, 430–436.
(Eds.), Handbook of the psychology of religion and spirituality Rye, M., & Pargament, K. I. (2003). Coping with divorce: A jour-
(pp. 435–459). New York: Guilford. ney toward forgiveness. Unpublished manual, University
Oman, D., Thoresen, C. E., & McMahon, K. (1999). of Dayton, OH.
Volunteerism and mortality among the community-dwelling Ryff, C. D., & Singer, B. (1998). The contours of positive human
elderly. Journal of Health Psychology, 4, 301–316. health. Psychological Inquiry, 9, 1–28.
Oman, D., Thoresen, C. E., Park, C. L., Shaver, P. R., Hood, R. W., Seligman, M. E. P., Steen, T. A., Park, N., & Peterson, C. (2005).
& Plante, T. G. (2009). How does one become spiritual? The Positive psychology progress: Empirical validation of inter-
spiritual modeling inventory of life environments (SMILES). ventions. American Psychologist, 60, 410–421.
Mental Health, Religion & Culture. 12, 427–456. Shafranske, E. P. (2000). Religious involvement and professional
Ornish, D. (1990). Dr. Dean Ornish’s program for reversing practices of psychiatrists and other mental health profession-
heart disease: The only system scientifically proven to reverse als. Psychiatric Annals, 30, 525–532.
heart disease without drugs or surgery. New York: Galantine Shapiro, S. L., & Walsh, R. (2007). Meditation: Exploring
Books. the farther reaches. In T. G. Plante, & C. E. Thoresen (Eds.),
Paloutzian, R. F., & Park, C. L. (Eds.). (2005). Handbook of the Spirit, science, and health: How the spiritual mind fuels physical
psychology of religion and spirituality. New York: Guilford. wellness (pp. 57–71). Westport, CT: Praeger/Greenwood.
Panksepp, J. (1998). Affective neuroscience: The foundation Smith, H. (1991). The world’s religions: Our great wisdom tradi-
of human and animal emotion. New York: Oxford University tions. San Francisco: Harper.
Press. Snyder, C. R., & Lopez, S. J. (2007). Positive psychology: The sci-
Pargament, K. I. (1997). The psychology of religious coping: Theory, entific and practical explorations of human strengths. Thousand
research, practice. New York: Guilford. Oaks, CA: Sage.

p l ant e , t hore se n 609

Sue, D. W., Bingham, R. P., Porche-Burke, L., & Vasquez, M. Zinnbauer, B. J., & Pargament, K. I. (2005). Religiousness and
(1999). The diversification of psychology: A multicultural spirituality. In R. F. Paloutzian, & C. L. Park (Eds.),
revolution. American Psychologist, 54, 1061–1069. Handbook of the psychology of religion and spirituality
Task Force on Promotion and Dissemination of Psychological (pp. 21–42). New York: Guilford.
Procedures. (1995). Training in and dissemination of empir-
ically validated psychological treatments: Report and recom- Further Reading
mendations. Clinical Psychologist, 48, 3–23.
Brooks, D. (2011). The Social Animal, New York: Random
Tennen, H., Affleck, G., Armeli, S., & Carney, M. A. (2000).
House.
A daily process approach to coping: Linking theory, research,
Fredrickson, B. (2009). Positivity. New York: Random House.
and practice. American Psychologist, 55, 626–636.
Miller, W. R. (Ed.). (1999). Integrating spirituality into treatment:
Thoresen, C. E. (2007). Spirituality, religion and health: What’s
Resources for practitioners. Washington, DC: American
the deal? In T. G. Plante, & C. E. Thoresen (Eds.), Spirit,
Psychological Association.
science, and health: How the spiritual mind fuels physical
Pargament, K. I. (2007). Spiritually integrated psychotherapy:
wellness (pp. 3–10). Westport, CT: Praeger/Greenwood.
Understanding and addressing the sacred. New York:
Thoresen, C. E., & Eagleston, J. R. (1985). Counseling
Guilford.
for health. The Counseling Psychologist, 13, 15–87.
Plante, T. G. (2009). Spiritual practices in psychotherapy: Thirteen
Thoresen, C. E., & Harris, A. H. S. (2002). Spirituality and
tools for enhancing psychological health. Washington, DC:
health: What’s the evidence and what’s needed? Annals of
American Psychological Association.
Behavioral Medicine, 24, 3–13.
Plante, T. G., & Thoresen, C. E. (Eds.). (2007). Spirit, science
Thoresen, C. E., Oman, D., & Harris, A. H. S. (2005).
and health: How the spiritual mind fuels physical wellness.
The effects of religious practices: A focus on health. In W. R.
Westport, CT: Praeger/Greenwood.
Miller, & H. D. Delaney (Eds.), Judeo-Christian perspectives
Richards, P. S., & Bergin, A. E. (Eds.). (2003). Casebook for a
on psychology (pp. 205–226). Washington, DC: American
spiritual strategy in counseling and psychotherapy. Washington,
Psychological Association.
DC: American Psychological Association.
Trenholm, P., Trent, J., Compton, W. C. (1998). Negative
Richards, P. S., & Bergin, A. E. (2005). A spiritual strategy for
religious conflict as a predictor of panic disorder. Journal of
counseling and psychotherapy (2nd ed.). Washington, DC:
Clinical Psychology, 54, 59–65.
American Psychological Association.
Vaillant, G. E. (2008). Spiritual evolution: A scientific defense of
Siegel, D. J. (2010). Mindsight: The new science of personal trans-
faith. New York: Broadway.
formation. New York: Bantam.
Wachholtz, A. B., & Pargament, K. I. (2008). Migraines and
Vaillant, G. E. (2008). Spiritual evolution: A scientific defense of
meditation: Does spirituality matter? Journal of Behavioral
faith. New York: Broadway.
Medicine, 31, 351–366.
Watson, J. B. (1983). Psychology from the standpoint of a behavior-
ist. Dover, NH: Frances Pinter (Original work published
1924).

610 spiritualit y, re l igio n , an d ps ych o logical counse ling

 CHAPTER

24 Group Counseling

Robert K. Conyne

Abstract
Three perspectives of group counseling are highlighted, leading to a suggested definition, in part, as an
important therapeutic and educational method to facilitate interpersonal problem-solving processes
among members as they learn how to resolve difficult but manageable problems of living and how to
apply gains in the future. Group counseling’s evolution across 100 years is presented. Research in key
group counseling processes is examined, including therapeutic factors, group climate, and group
development. Group counseling leadership research is summarized, focused on intentionality in leader
tasks, roles, functions, and intervention choices. Group work standards, guidelines, and multicultural
principles are addressed. Group work is expanding in contemporary society through face-to-face and
online forms, leading to what might be termed an “Age of Ubiquity.” The chapter concludes with
research and practice suggestions for the future and an extensive reference list.
Keywords: group counseling, group work, history, therapeutic factors, group climate, group
development, group leadership, standards, multicultural, online

Group counseling is a sub-set of the broad and 2008; Shechtman, 2007; Toseland & Siporin, 1986).
varied field of “groups.” Knowledge of that field is For instance, in one meta-analytic analysis of 23
an important contributor to becoming a competent studies investigating the comparative effectiveness of
group counselor (Forsyth, 2011). group and individual modes of helping (McRoberts
Indeed, group counseling is an essential inter- et al., 1998), the group approach was found equiva-
vention for counseling psychologists and other lent for producing client change in the areas of
practitioners (Leszcz & Kobos, 2008). It has been chemical dependency, vocational choice, and with a
found through experience and empirical research number of stress syndromes and V-code diagnoses.
to be at least as effective as individual therapy in After reviewing hundreds of studies, Barlow,
promoting client change while offering addi- Burlingame, and Fuhriman (2000) provided the
tional efficiencies and cost benefits (e.g., Barlow, following clear statement about the effectiveness of
Fuhriman, & Burlingame, 2004; Bednar & groups:
Kaul, 1994; Burlingame, Fuhriman, & Johnson,
With few exceptions (cf. Piper & McCallum, 1991),
2004; Burlingame, Kapetanovic, & Ross, 2005;
the general conclusion to be drawn from
Burlingame, MacKenzie, & Strauss, 2004; Dies,
approximately 730 studies that span almost three
1983; Fuhriman & Burlingame, 1994; Kosters,
decades is that the group format consistently
Burlingame, Nachtigall, & Strauss, 2006; Horne &
produced positive effects with a number of disorders
Rosenthal, 1997; Johnson, 2008; McRoberts,
using a variety of treatment models (p. 122).
Burlingame, & Hoag, 1998; Payne & Marcus,

611
 Despite the strong support for group counseling’s These settings include education, private practice,
effectiveness, MacKenzie (1995), McRoberts et al. religious organizations, social service agencies, plan-
(1998,and a number of other noted researchers (see ning boards, health care organizations, mental health
Conyne, 2011 for extensive treatment) observe that care agencies, and business and industry. At the
more research is needed to specify what group treat- same time, successful incorporation within man-
ment variables account for effectiveness, especially aged care occurs but awaits more progress.
when the group approach is being increasingly rec- Groups also are used frequently as an important
ommended for a wide range of client problems means for reaching a wide range of targeted popula-
and populations. Indeed, it is the recommendation tions. These populations include school children,
of Burlingame et al. (2004) that future group the aged, employees, members of religious congre-
research be directed “to measure, and hence under- gations, college students, “baby boomers,” children
stand, the interactive, connected, and holistic of divorce, those who abuse substances, people in ill
processes of group and then link these with long- health and in good health, mutual help group mem-
term outcome” (p. 657). A summative statement on bers, and many others.
this topic might read: There remains a critical need Groups are remedial, preventive, developmental,
for empirically-supported group processes and and all points between. They are professionally
conditions, for development of more measures to led and self-help in format. They are personally ori-
accurately detect them, and for actionable group ented and task-related. They are offered within
leadership that is tied to these group processes organizations, neighborhoods, and communities,
and conditions (e.g., Barlow, 2011; Brabender, within this country and around the world, face-
2011; Kivlighan, Miles & Paquin, 2011; McClendon to-face and online. In short, groups are omnipresent
& Burlingame, 2011; Schwartz, Waldo & Moravec, in contemporary life, including being made avail-
2011; Stockton & Morran, 2011). able in a multitude of settings (Kalodner & Hanus,
Group counseling is the subject of considerable 2011). With the above discussion as background,
and increasing research and scholarly activity. this chapter on group counseling is organized into
Several journals are devoted specifically to the inter- sections that discuss the definition of group coun-
vention (e.g., Group Dynamics: Theory, Research, seling; present a historical overview of group coun-
and Practice; Journal for Specialists in Group Work; seling; delineate key change processes; and examine
International Journal of Group Psychotherapy; Social group leadership; discuss the expansion of groups in
Work with Groups; Group & Organization Mana- contemporary society. The chapter concludes with
gement; Small Group Research; Group Processes and some ideas for future research directions.
Intergroup Relations; and Group Facilitation: A Res-
earch and Applications Journal), and an increasingly Definition of Group Counseling
steady stream of books and handbooks addressing Three Perspectives on Defining
various facets of group practice has appeared over Group Counseling
the last two decades. Groups abound. How does group counseling fit?
In addition, exposure to group counseling is In fact, defining group counseling has proved to be
included in several subdisciplines of psychology. an elusive and, some would claim, frustrating task.
However, sustained attention in psychology to group Perhaps this situation should be expected. After all,
training now is being moved to the postdoctoral group counseling has emerged over decades from a
level. By contrast, group training in graduate-level number of different academic disciplines, traditions,
disciplines related to psychology (e.g., counselor edu- professions, and organizations—as the following
cation) occurs earlier and more consistently. In fact, chapter section on historical evolution will illustrate.
master’s degree-level curricular standards in counsel- Therefore, to describe group counseling as being
ing include required training and supervised experi- “multidisciplinary” would be an understatement. By
ence in group work (CACREP, 2001). The interrelated contrast, to describe it as being “interdisciplinary,” in
areas of teaching, training and supervision in group which contributions from different sources are effec-
counseling leadership is of great import, with many tively inter-related and applied, would be inaccurate.
improvements needed (e. g., Brown, 2011; Riva, Continuing to advance the interdisciplinary nature
2011; Shapiro, 2011). of group counseling is important, in my view.
The use of group work approaches, in general, At present, group counseling can be under-
has grown exponentially over the last two decades, stood through the lenses of three related, but
finding application in the major settings of society. different, perspectives: Undifferentiated from

612 group couns el in g

group psychotherapy and including other group many different clinical settings that it is no longer
types, independent-type within group work, and correct to speak of group therapy. Instead, we must
overlapping therapeutic and educational goals and refer to group therapies” (p. 475) (italics retained).
processes. These perspectives are described next, Fuhriman and Burlingame (2000, p. 31) describe
followed by an attempt to produce an integrative group psychotherapy as “the treatment of emo-
definition. tional or psychological disorders or problems of
adjustment through the medium of a group setting,
perspective 1: group counseling the focal point being the interpersonal (social),
is undifferentiated from group intrapersonal (psychological), or behavioral change
psychotherapy and includes other of the participating clients or group members.”
group types Burlingame et al. (2005) expands on this definition
Here, group counseling is viewed as being undif- by classifying the “plethora of groups found in
ferentiated from group psychotherapy and— today’s practice” (p. 388) into three categories:
increasingly—from other group therapeutic forms, formal change theory used (e.g., behavioral), struc-
including support groups and those used for preven- tural features (e.g., size, composition), and patient
tion, guidance, and training. Identifying terms rep- population (e.g., anxiety disorders).
resenting this undifferentiated and comprehensive
perspective include group counseling, group psycho-
perspective 2: group counseling
therapy, and group counseling and psychotherapy.
is an independent group type
This perspective is reflected in the writings of
within group work
many experts (e.g., Barlow et al., 2004; Burlingame
Ward (2006) observes that interest in categorizing
et al., 2005; Dagley, Gazda, Eppinger, & Stewart,
groups into types has captured the attention of
1994; DeLucia, Gerrity, Kalodner, & Riva, 2004;
scholars for at least 25 years. Group counseling is
Forsyth, 2006; Fuhriman & Burlingame, 2000;
considered by some scholars to stand as its own
Gazda, 1982) and seems generally consistent with
function, connected to other forms of group work
the mission of the Association for Group Psychology
but still unique (e.g., Conyne, Wilson, & Ward,
and Group Psychotherapy of the American
1997; Corey & Corey, 2006; Gladding, 6; Wilbur,
Psychological Association (APA Division 49, 2007),
Roberts-Wilbur, & Betz, 1981). Here, group coun-
which is concerned with the study and practice
seling often is embedded within the broad definition
of the broad field of group psychology and group
of “group work,” a conception developed within
dynamics and with group psychotherapy, particu-
the Association for Specialists in Group Work
larly. John Borriello, Division President in 1996,
(ASGW, 2000), a division of the American Cou-
underlined this inclusive approach in noticing
nseling Association (ACA). Group counseling is
that the Division’s convention program titles for
identified as one of four major group work types,
that year included “self-help, support, therapeutic,
the others being psychoeducation groups, psycho-
team building, psychosocial, behavioral-cognitive,
therapy groups, and task groups. All types are
change agent, systems-centered, and prevention”
thought to share a core set of basic processes and
(Andronico, 2001, p. 16).
dynamics, with each also possessing additional dis-
In a classic expression of group counseling and
tinctive characteristics.
psychotherapy, group therapists or counselors use
When it is considered as an independent func-
interpersonal processes to promote change in mem-
tion, common understandings have evolved over
bers who are dealing with psychological, behavioral,
several decades to describe aspects of group coun-
and/or emotional problems. This description gener-
seling. For example, stretching back to 1960,
ally reflects the position of the American Group
Brammer and Shostrom characterized group coun-
Psychotherapy Association (AGPA) (2007).
seling as “educational, supportive, situational, prob-
However, with many new group forms and
lem-solving, conscious awareness, emphasis on
approaches appearing within the “group helping
‘normals,’ and short-term” (p. 6). Forty-six years
field” (Scheidlinger & Schmess, in MacKenzie,
later, Trotzer (2006) expanded these descriptors of
1992, p. 17), the AGPA has extended its breadth of
group counseling to include:
focus to match. Yalom and Leszcz (2005) referred to
the variety of groups today as being “mind-bog- [R]emedial, normal individuals, thoughts-feelings-
gling” in volume and form. They note, “Group behaviors, problem-oriented, focus de123-termined
therapy methods have proved to be so useful in so by individuals, situational, relationship important,

cony ne 613
 empathy and support is stressed, tendency toward (along with some other group forms, such as
homogeneity (common problems), verbal techniques, T-groups and encounter groups) are viewed as being
feelings and needs emphasized, conscious awareness, primarily preventive and growth engendering, with
leader facilitates, present-oriented, non-medical some aspects of remediation. Psychotherapy groups
setting, relatively short longevity. (p. 43) are viewed as being primarily remedial and to a
lesser degree preventive and growth engendering.
Group counseling is situated in the ASGW train-
Group guidance/psychoeducation is viewed as being
ing standards as a standalone method within the
preventive and growth engendering.
broader span of group work itself. The umbrella
Conyne (1985) suggested a “group work grid.” It
term of group work is defined as:
includes a wide array of group methods according
[A] broad professional practice involving the to their emphasis on correction or enhancement
application of knowledge and skills in group facilitation (purpose) and level of group work intervention
to assist an interdependent collection of people to reach (individual, interpersonal, organization, communi-
their mutual goals, which may be intrapersonal, ty-population). In this schema, group counseling fit
interpersonal, or work related. The goals of the group with a corrective purpose and an interpersonal
may include the accomplishment of tasks related to level.
work, education, personal development, personal and As mentioned, no single orientation is right or
interpersonal problem solving, or remediation of wrong, and all operate to nourish the growth of
mental and emotional disorders. (pp. 2–3) group work applications. Moreover, it may be of
interest to readers that a proactive “Group Summit”
As one of the four types of group work, the
was held in January 2008, attended by these and
ASGW Standards define group counseling as:
other group work organizations, to discuss possible
The application of principles of normal human interorganizational cooperation to promote “group.”
development and functioning through group based The Group Practice and Research Network (GPRN)
cognitive, affective, behavioral, or systemic was formed at this Summit, with members from par-
intervention strategies applied in the context of ticipating organizations beginning to focus on the
here-and-now interaction that address personal and following initiatives: altruistic programs, guild/pro-
interpersonal problems of living and promote fessional identity, exchange of member services and
personal and interpersonal growth and development resources, public education, education and research,
among people who may be experiencing transitory and funding.
maladustment, who are at risk for the development
of personal or interpersonal problems, or who seek
enhancement of personal qualities and abilities.
Toward a Suggested Integrative Description
(ASGW Training Standards, p. 4)
of Group Counseling
As is obvious from the above discussion, developing
a clear and generally acceptable definition of group
perspective 3: group counseling, and
counseling is challenging and complex. Ward’s
other group work types, are defined by
view (2011) of group counseling emphasizing an
overlapping therapeutic and
interpersonal, process-oriented, and strengths-based
educational goals and processes
approach would seem to capture essential elements.
This view, focusing on relationships among groups
Drawing elements from the three perspectives
according to goals and processes (Gazda, Ginter, &
discussed previously, the following definition of
Horne, 2001, Trotzer, 2006, Waldo & Bauman,
group counseling is offered as an attempt to inte-
1998) or to purposes and methods (Conyne, 1985),
grate the foregoing material:
tends to combine the first two perspectives discussed
above. Here, a spectrum of group approaches are Group counseling is an important therapeutic and
organized in terms of their primary emphasis on educational method that psychologists, counselors,
therapeutic goals and processes. For instance, Gazda and other helpers can use to facilitate interpersonal
et al. (2001) organized different types of groups as problem-solving processes among members as they
being either: exclusively preventive and growth learn how to resolve difficult but manageable
engendering; primarily preventive, growth engen- problems of living and how to apply gains in the
dering, and to a lesser extent, remedial; or primarily future through building on their strengths. Although
remedial and to a lesser extent preventive and growth being a unique service delivery method, group
engendering. In this conception, group counseling counseling also shares much in common with related

614 group couns el in g

 group work approaches, including psychoeducation Running alongside the need for empirical evi-
groups and psychotherapy groups. In general, group dence of group effectiveness (now beginning to be
counseling occupies a broad middle section of the termed research-supported group treatment, RSGT;
helping goals continuum where prevention, Johnson, 2008) was an awareness among many that
development, and remediation all play important the group circle holds particular healing value in
roles, depending on member needs and situational many cultures and that it may hold particular value
supports and constraints. for reaching minority populations:

Historical Overview of Group Counseling: The group is the circle, the microcosm of life, where
100+ Years of Development power moves. For this reason, it may be suggested
How did these understandings of group counseling that the group format is the most effective approach
and other groups evolve? Over 100 years of history to serving the needs of minority clients.
(Rivera, Garrett, & Crutchfield, 2004, p. 304)
is involved. In this section, some of the significant
events and persons responsible to shaping group The preceding quotations provide a perspective
counseling are chronicled. Let us begin by high- on the evolution of group counseling and compan-
lighting some salient quotations about group coun- ion group approaches over several decades. Met at
seling and group work from over several decades. first with a general level of disbelief, an increasing
C. Gilbert Wrenn provides a starting point; assertion developed that group approaches are essen-
interestingly, Wrenn was a counseling “seer” who tial for personal and societal change. A need for con-
accurately predicted many future trends for coun- tinued documentation of effectiveness emerged, as
seling long before others (e.g., see Wrenn, 1962)— well as the realization that the circle is a basic symbol
but he missed on this one: of life that informs group work, which may be, in
First of all, counseling is personal. It cannot be
general, the best suited of all services for multicul-
performed with a group. “Group counseling”
tural practice. Signs today point to group being an
is a tautology; counseling is always personal.
omnipresent force in our society, but more about
(Wrenn, 1938, p. 119, cited in Gazda, 1982) that at the end of this chapter.
Association in groups has characterized human
Rather than being inappropriate, the use of functioning since the beginning of time. In fact,
group methods in counseling and other applications many (e.g., Foulkes & Anthony, 1957) have sug-
increased dramatically, leading to the following pre- gested that groups are the fundamental unit of soci-
diction in 1985: ety. Healing practices in various cultures and
Groups will abound. . . . Group methods will be locations began centuries before modern advance-
used increasingly with families, with diverse ments in group counseling or any other form of
populations, within organizations, and even . . . professional help-giving, and many of these prac-
to achieve social change across all levels of systems: tices continue to this day across cultures, with the
in groups, organizations, communities, regions, group-circle playing an important role in several of
nations, and the world. them (e.g., Native American practices using the
(Conyne, Dye, Gill, Leddick, Morran, & sweat lodge, the talking circle, and the talking stick).
Ward, 1985, p. 114) Garrett (2004), for instance, in considering group
counseling with Native Americans, referred to group
This expansion of group applications has work as the “medicine of healing” (p. 173).
occurred, along with a concern about the ability
The following historical discussion of group
to demonstrate their empirical effectiveness across
counseling is based primarily, but not exclusively, on
settings:
earlier historical reviews by Andronico (1999);
The meta-analytic data from this study confirm the Barlow, Burlingame, and Fuhriman (2000, 2005);
general and selected diagnostic effectiveness of group Barlow et al. (2004); Bertcher (1985); Burlingame,
treatment, and in a day when group treatment is on Fuhriman, and Mosier (2003); Burlingame,
the rise, this indeed is encouraging. Nonetheless, this Fuhriman, and Johnson (2004); Gazda (1982, 1985);
is also a time when there is increased interest on the Gazda et al. (2001); Forester-Miller (1998);
part of service recipients and public and private Gladding (2002); Leddick (2008, 2011), and
agencies for assurance that treatment will be effective, Scheidlinger and Schmess (in MacKenzie, 1992).
regardless of where it takes place. Because of these reviews and the availability of
(Burlingame, Fuhriman, & Mosier, 2003, p. 11) several others (e.g., Blatner, 2007; Hadden, 1955;

cony ne 615
Z. Moreno, 1966; Rosenbaum, Lakin, & Roback, work to fit differing populations and settings,
1992), the current presentation will content itself and for experimentation of group methods
with listing some of the important milestones in the into online and other electronic vehicles;
history of groups across four overlapping time peri- see Table 24.4.
ods organized and labeled by this author.
The method of group counseling has been dis-
Please take note of two points. Sources, includ-
tilled from this series of historical events that
ing dates, contained in the chronology to follow are
occurred over the last 100 years, from “thought-
presented largely without descriptive narrative and
control classes” to the “Age of Ubiquity.” Its success-
are intended for documenting historical evolution;
ful conduct depends on effectively stimulating
therefore, they are not included in the chapter refer-
and using key processes for change, discussed in the
ences. Also, I acknowledge in advance the certain
next section.
degree of inevitable arbitrariness that can accom-
pany any such effort at historical description and
categorization. Key Change Processes: Therapeutic Factors,
A brief description of these four time periods Group Climate, and Group Development
follows. Each time period is then detailed in its own As Yalom (Yalom & Leszcz, 2005) observes, thera-
table: peutic change in group is an “enormously complex
process that occurs through an intricate interplay of
• Period 1, the “Years of Development”: human experiences” (p. 1). These human experi-
1900–1939, marked by early forays into working ences are termed “therapeutic factors.” Two other
with people collectively, group work aimed important partners in therapeutic change also will
at changing social conditions, and laying be addressed in this section, group climate and
a foundation for the progress to come; see group development.
Table 24.1.
• Period 2, the “Years of Early Therapeutic Factors
Explosion”: 1940–1969, a remarkable two Irvin D. Yalom’s seminal research and scholarly
decades beginning with accelerating the spread contributions in many areas of group psychother-
of group approaches following World War II and apy have been essential in the development of
noted for innovation and experimentation; seminal group therapeutic approaches. His concept
for production and organization of theory, of the “social microcosm,” in which members
techniques, and research; for the formation of enact their dominant interpersonal style and pathol-
group organizations; and for the spread of groups ogy within the free-flowing group itself, plays a
throughout society occurring during the human pivotal role in group therapy. An adaptation of this
potential movement of the 1960s; see process is presently occurring, connecting learn-
Table 24.2. ing from the in-group social microcosm with both
• Period 3, the “Years of Settling In”: personal application and, where it fits, applica-
1970–1989, two decades noted for sifting tion aimed at system change and social justice
through earlier advancements and documenting (e.g., Jacobson & Rugeley, 2007; Orr, Wolfe, &
what worked through substantial and influential Malley, 2008).
publications, the emergence of group training In addition, Yalom championed the importance
in universities and elsewhere, and the formation of therapeutic factors in promoting change and
of key group work organizations; see growth in the group. Reviewing the importance of
Table 24.3. therapeutic factors, one of the concepts chiefly
• Period 4, the “Years of Standardization associated with Yalom, researchers Kivlighan and
and Further Expansion to the Age of Holmes (2004) observe that, “Of Yalom’s many
Ubiquity”: 1990–Present, a time noted for contributions to group theory, research, and prac-
efforts to define group work and the place of group tice his delineation and description of the concept
counseling in relation to it, for products of 11 therapeutic factors as the essential elements
intended to clarify guidelines and standards for of group-promoted change is arguably the single
group training and practice, for the publication most influential aspect of his theoretical and research
of more sophisticated research into process and endeavors” (pp. 24–25). Readers may wish to
outcomes and for the emergence of group consult the very useful history surrounding these
handbooks, for the wide expansion of group therapeutic factors documented by Crouch, Bloch,

616 group couns el in g

Table 24.1. Period 1, the Years of Development—1900–1939
1905 Joseph H. Pratt conducts “thought-control classes” for tuberculosis patients, realizing that something therapeutic happens by bringing them together.
1907 Jesse B. Davis focuses English classes on “vocational and moral guidance.”
1910 Jane Addams, the originator of social work, uses group work processes to advance democratic principles and promote social change at Hull House in Chicago.
In World War I, U.S. Army Alpha and Beta intelligence tests are administered in groups.
About 1919 E. W. Lazell used lecture procedures within a group to inspire schizophrenics.
L.C. Marsh, around the same time, used multiple methods involving inspirational lecture, group discussions, and the arts with hospitalized mental patients.
This approach was a forerunner to milieu therapy. He is known for his famous words, “By the crowd they have been broken; by the crowd they shall be healed.”
1921 The Theater of Spontaneity (Stegreiftheatre) is formed by Alfred Adler; it is a precursor to psychodrama.
1922 Adler develops “collective counseling,” a new form of group guidance and, later, “family councils,” to help families resolve and improve their relations.
1923 The first course on group work is offered, graduate school of social work, Western Reserve University.
1925 C.R. Foster, in Extra Curricular Activities, urges counselors to hold “many group conferences with students on the subject of future
educational or vocational plans” (p. 182).
Late 1920s Trigant Burrow develops group analysis, emphasizing the importance of working with people in relation to the group in which they are a member.
1931 Richard D. Allen writes “A Group Guidance Curriculum in the Senior High School,” published in Education, using the term “group counseling.”
1932 Jacob Moreno coins the term “group psychotherapy.”
Mid-1930s Alcoholics Anonymous (AA), the first self-help group in the U.S. is founded by Bill Wilson and Dr. Bob Smith.
1934 A. Jones, in his Principles of Guidance (2nd ed.), refers to the “Boston Plan for Group Counseling in Intermediate Schools.” In his review, Gazda later)
observed that both Allen (above) and Jones really were referring to group guidance.
1934 Maxwell Jones provided early precedent for psychoeducation to members of his large groups through lectures-in-group on psychiatric symptoms,
nervous system, and other topics of relevance.
1936 Formation of the American Association for the Study of Group Work
Progressive education movement sets the stage for group guidance movement to follow.
1936 Kurt Lewin develops field theory based on person × environment interaction. Contributions of
Lewin, the “practical theorist”, to group dynamics are of high importance.
1939 Lewin, Lippitt, and White’s leadership field study is reported, identifying and comparing autocratic, democratic, and laissez-faire styles.
Table 24.2. Period 2, the Years of Early Explosion—1940–1969
1942 Carl Rogers introduces client-centered therapy, one foundation of group counseling.
1941–42 Jacob Moreno establishes the American Society of Group Psychotherapy and Psychodrama (ASGPP). Its journal, Sociatry, is created in 1947
(re-named Group Psychotherapy in 1949).
1943 Samuel Slavson forms the American Group Psychotherapy Association (AGPA). Its journal, the International Journal of Group Psychotherapy, is created in 1951.
1944 First Annual Conference of AGPA is held at Russell Sage Foundation, January 14–15, 1944.
Search for more economical treatments occurs following World War II.
1946 Kurt Lewin, Leland Bradford, Kenneth Benne establish the National Training Laboratories (NTL) at Bethel, Maine, in 1946. The “Basic Skills Training Group”
in 1947 changed to “T-group” (Training Group) in 1949.
1946 The Tavistock Institute of Human Relations is created.
1948 Wilfred Bion, of the Tavistock Institute, focuses on group cohesiveness, identifying group dependency, pairing, and fight–flight as basic tendencies.
1950 Study of group phenomena begins to intensify with Robert F. Bales’ study of task and maintenance roles.
1951 International Journal of Group Psychotherapy is founded.
1953 Cartwright and Zander edit Group Dynamics, organizing research addressing social problems.
Mid-1950s First International Social group workers are recognized as effective in treatment and clinical settings.
1954 Congress of Group Psychotherapy is established.
1955 Hare, Borgatta, and Bales edit Small Groups: Studies in Social Interaction, organizing influential social-psychological small group research.
1956 Herbert A. Thelen’s Dynamics of Groups at Work is published.
1956 Richard Blake and Jane Mouton are among those providing a set of new group concepts with their term “developmental groups.”
1958 First textbook in group work is published, Counseling and Learning through Small-Group Discussion (Helen J. Driver).
1961 Rudolph Dreikurs and others, such as John Bell, apply Adler’s concepts to family groups. Virginia Satir and others
(such as Nathan Ackerman and Gregory Bateson) continue adapting group procedures with families.
1961 Muzafer and Carolyn Sherif and colleagues conduct classic field study, “The Robbers Cave Experiment,” on intergroup conflict.
1961 Jack Gibb develops the TORI model for groups: Trust, Openness, Realization, Interdependence.
1964 Leland Bradford, Jack Gibb, and Kenneth Benne’s, T-Group Theory and Laboratory Method: Innovation in Re-education appears.
1964 George Bach and Fred Stoller develop marathon groups.
1965 Bruce Tuckman publishes influential group development stage model: Forming, Storming, Performing, Adjourning (later a fifth stage is added: Mourning).
1966 Eric Berne develops transactional analysis in groups.
Some graduate programs in counselor education and psychology begin to develop group courses.
1969 William Fawcett Hill introduces Hill Interaction Matrix and Learning thru Discussion.
1960s–early Human potential movement flourishes, with encounter groups at its center.
1970s
1967 Fritz Perls popularizes gestalt groups through his work at Esalen Institute in Big Sur, California.
1967 Wil Schutz, who developed the Fundamental Interpersonal Orientation-Behavior (FIRO-B) scale in 1958, publishes his popular book, Joy: Expanding Human
Awareness, praising aspects of the encounter movement.
1968 New York Times names 1968 as “Year of the Group.”
1969 Arthur Burton edits Encounter: The Theory and Practice of Encounter Groups.
1969 George Gazda holds the first of ten annual symposia on group counseling.
Table 24.3. Period 3, the Years of Settling In—1970–1989
Experiential groups expand and are focused, signified by the Esalen Institute on the West Coast and the National Training Laboratories (NTL) on the East Coast.
1970 Carl Rogers on Encounter Groups provides person-centered substance to the human potential movement.
1970 Robert Golembiewski and Arthur Blumberg publish their edited book, Sensitivity Training and the Laboratory Approach: Reading About Concepts and Applications.
1970 Irvin Yalom publishes the first edition of Theory and Practice of Group Psychotherapy, a seminal text that now has four additional editions.
1970 Yalom identifies 11 curative (later, therapeutic) factors in groups (e.g., group cohesion, interpersonal learning), central ingredients for producing change in groups.
1971 Jane Howard publishes the wildly popular book, Please Touch: A Guided Tour of the Human Potential Movement.
1972 Lawrence Solomon and Betty Berzon edit New Perspectives on Encounter Groups.
1973 Morton Lieberman, Irvin Yalom, and Matthew Miles publish Encounter Groups: First Facts, which enumerates group leadership functions and styles.
1973 Association for Specialists in Group Work (ASGW) established, becoming the 11th Division of the American Personnel and Guidance Association (now known as the
American Counseling Association).
Spring 1976 Together, the journal of ASGW is founded.
Gerald Corey and Marianne Corey begin their continuing string of publications on group counseling.
1978 Together title is changed to Journal for Specialists in Group Work.
1978 Journal, Social Work with Groups, is established.
1980 Ethical Guidelines for Group Leaders and Guidelines for Training Group Leaders are approved by ASGW.
1980s Structured groups and training for life skills begin to appear in professional literature.
1980s and Group counseling texts, articles, research increase dramatically in numbers.
beyond
Self-help groups flourish (with Frank Riessman championing them), containing some 20 million members.
1989 ASGW Ethical Guidelines for Group Leaders changed to Ethical Guidelines for Group Workers.
1989 The Division of Group Psychology and Group Psychotherapy, the 49th Division of the American Psychological Association, is established to further the study of
groups and to advance therapeutic change through groups.
Group Dynamics appears by Forsyth, organizing research on group dynamics to examine their psychological, sociological, and personal importance.
Books appear showcasing various ways the group method can be used, in addition to group counseling and psychotherapy.
Table 24.4. Period 4, the Years of Standardization and Further Expansion to the Age of Ubiquity—1990–present
1991 ASGW’s Professional Standards for the Training of Group Workers is revised significantly and then is refined to include a broad definition of group work, core
competencies for group work across group types, and four types of groups: task, psychoeducation, counseling, and psychotherapy.
1994 Handbook of Group Psychotherapy is published.
1997 APA’s Division 49 (Group Psychology and Group Psychotherapy) produces the first issue of its journal, Group Dynamics: Theory, Research, and Practice.
1998 ASGW’s Best Practice Guidelines for Group Workers is created and then later revised, providing ethically based guidance specific to group work.
1998 ASGW’s Principles for Diversity-Competent Group Workers is created, providing guidance and expectations for multicultural group leadership.
Group research becomes increasingly sophisticated into such concepts as therapeutic factors, process-outcome, group leadership, group development, group climate,
group cohesion, supervision, feedback, co-leadership, situational leadership, cognitive-behavioral approach, structure, and interaction.
Group research methodologies expand to include meta-analysis, qualitative design, focus groups, Tuckerized Growth Curve Analysis (TCGA), hierarchical linear
modeling, structural analysis of group arguments, and a range of measures to study group efficacy.
Development begins of empirical support of group approaches for many specific problems and disorders (e.g., anxiety disorders with cognitive-behavioral groups).
Psychoeducation groups brief therapy groups, and focal groups flourish, matched to targeted populations for people with disabilities, the elderly, children, offenders,
women, veterans, and many others.
2000s In the 2000s, groups enter an “Age of Ubiquity.”
Prevention and promotion groups are described), aimed at forestalling the development of disorders and problems such as substance abuse, bullying, bereavement,
trauma, and academic failure; for stimulating healthy functioning, such as problem solving, social skills, well-being; and for addressing a wide variety of health issues,
such as cancer, Parkinson’s disease, eating disorders, fibromyalgia, AIDS, chronic physical illness, obesity, healthy heart functioning, and many others.
Group work for social justice assumes a renewed emphasis, in which the social microcosm concept and procedures such as community-based participatory research and
action are employed.
Post-9/11, AGPA seeks to expand from a professional guild serving professional members to include a public health resource function providing services to
address trauma, grief, and community crises.
The number and scope of groups approached a crescendo, becoming common not only in educational and mental health settings but in task environments, also.
The latter settings included workplace, medical, business and industry, governmental organizations, religious settings, and in neighborhoods and the community.
Multicultural groups address people of various cultures, including Latino/a, African American, Native American, Asians, Gay-Lesbian-Bisexual-Transgender, and
others.
E-learning tools develop (e.g., Blackboard), allowing for virtual group activity.
(Continued )
Table 24.4. Continued
2002 AGPA publishes Guidelines for Ethics—Revised.
2004 Handbook of Group Counseling and Psychotherapy is published.
2007 AGPA publishes Practice Guidelines for Group Psychotherapists.
Online groups and social networking channels develop.
2008 A “Group Summit,” initiated by Division 49 of APA, is held (January 10–11, 2008) to explore connections among Division 49, the Society of Consulting Psychology
of APA, ASGW, AGPA, the Division of Addictions of APA, and the Division of Psychoanalysis (Group Section) of APA. At this meeting an umbrella “Group Practice
and Research Network” (GPRN) is established.
2008 Research Supported Group Treatments become a focal area.
and Wanlass (1994). Kivlighan, Miles, and Paqin represented, beginning in 1970, within the five edi-
(2011) add that: tions of The Theory and Practice of Group Psycho-
therapy, as well as by many other research studies
Therapeutic factor research continues to lack a focus
(e.g., reported in Crouch et al. 1994; Colijn,
on the group itself and, more critically, to account
Hoencamp, Snijders, van der Spek, &
for essential group interactional constructs.
Duivenvoorden, 1991; Shechtman & Gluk, 2005)
They urge that group theorists and researchers
and reviews (e.g., Kivlighan, Coleman & Anderson,
ground their work within the group
2000; Kivlighan & Holmes, 2004). In addition,
perspective.
one would be hard-put to find any text on the topic
Yalom purports that the 11 therapeutic factors, of group counseling and group psychotherapy that
although being arbitrary constructs, comprehen- did not assign a prominent place for a discussion
sively identify the operations and mechanisms of these therapeutic factors.
accounting for therapeutic change in groups. He A brief description of the 11 therapeutic factors
indicates that they do not function independently, follows. Interpersonal learning and cohesion, both
but are interdependent. Therapeutic factors have marked by an asterisk in the table, are described
spawned his own research and theory, most notably more extensively following Table 24.5.

Table 24.5. Therapeutic Factors

Factor Description
1) Instillation of hope Belief of members that group participation will be helpful; member optimism
in improving through group involvement
2) Universality Members perceive that they are not alone in the world, that other members
in their group share similar problems, thoughts, and feelings.
3) Imparting information Group leader and fellow members provide information, planned theoretical inputs,
didactic instruction, direct advice, and guidance.
4) Altruism Members benefit through being of help to other members. No other helping mode
provides this opportunity.
5) Corrective Members re-experience past family conflicts in a corrective way, helping
recapitulation of to repair past damage.
the primary
family group
6) Development of Social skills are gained through an adaptive and supportive group environment.
socializing
techniques
7) Imitative behavior Members learn by vicariously observing the leader(s) and other members.
8) ∗Interpersonal This factor is the therapeutic analogue in individual therapy of insight, working
learning (Input through transference, and the corrective emotional experience.
and Output) A dynamic interaction emerges through which members gain personal insight
(input) while permitting them to interact adaptively (output).
9) ∗Group This factor is the therapeutic analogue to the relationship in individual therapy.
cohesiveness The mechanism of cohesion is considered to be the most central therapeutic factor
because it is a therapeutic mechanism in its own right and it also stimulates others.
Cohesion appears to best define the group therapeutic relationship.
10) Catharsis Members release emotion about past experiences and events within the group,
leading them to feel better.
11) Existential factors Members confront the challenging “givens” of life—the ultimate concerns of the
human condition—learning life lessons and about their own personal responsibility
for life choices.

cony ne 623
 As mentioned above, more attention is given to Johnson, 2002; Yalom & Leszcz, 2005) which, in
interpersonal learning (input and output) and to turn, is the central process cutting across all thera-
group cohesion because of their central roles in pies (Martin, Garske, & Davis, 2000). Cohesion
group counseling. appears as important, if not more important, in
explaining client improvement than the specific the-
interpersonal learning oretical orientation practiced by the therapist
This key group therapeutic factor is the analogue (Norcross, 2002). In turn, it appears that group cohe-
in individual therapy of insight, working through sion can be affected by the attachment style of lead-
transference, and the corrective emotional experi- ers and by factors such as race, ethnicity, and sexual
ence. Interpersonal learning results when a group, orientation (Marmarosh & Van Horn, 2011).
acting as a social microcosm, allows for each mem- A majority of research demonstrates that a strong
ber’s personal style to be manifested within the group positive correlation exists between group cohesion
itself. A dynamic interaction emerges through which and therapeutic group outcomes (Riva, Wachtel, &
members gain personal insight (input) while permit- Lasky, 2004). For instance, Marmarosh, Holtz, and
ting them to interact adaptively (output). Schottenbauer (2005) studied 102 counseling
Interpersonal learning is central to group process center clients participating in process and theme
(AGPA, 2007); Leszcz & Kobos, 2008). It can be groups. The purpose was to examine Yalom’s hypoth-
understood as resulting from productive interper- esis that group therapy cohesiveness precipitates
sonal relationships, the corrective emotional experi- group-derived collective self-esteem (CSE), hope
ence, and the group operating as a social microcosm for the self (HS), and psychological well-being. Path
(Yalom, 2005). In fact, according to Yalom, the analyses reinforced the hypothesis that cohesiveness
critical member behavior of self-disclosure in a is the primary group factor and is directly related to
group is always an interpersonal act, as it occurs and CSE and HS.
is responded to within the interpersonal context.
Although individual therapy limits interpersonal general therapeutic factors research
sharing and feedback to the dyadic relationship As pointed out by Burlingame, Fuhriman, and
of therapist and client, group counseling expands Johnson (2004) most of the extensive research into
those opportunities to include not only the group therapeutic factors has used Yalom’s self-report instru-
leader(s) but, also all other members. Thus, the ment, which allows for members to assign value to
ongoing input for interpersonal learning is expo- the factors. For instance, in a study by Colijn et al.
nentially increased, leading to heightened possibili- (1991), group members generally valued catharsis,
ties for members to produce interpersonal learning self-understanding, interpersonal learning, and cohe-
that can be applied outside the group (Bernard, sion while ascribing least value to the corrective
Burlingame, Flores, Greene, Joyce, & Kobos, 2008; family reenactment factor. This finding was consis-
Holmes & Kivlighan, 2000). tent across gender, age, group type, or treatment and
is consistent with previously conducted studies on
group cohesiveness therapeutic factors.
This essential group therapeutic factor is the ana- Yalom (Yalom & Leszcz, 2000) summarized
logue to the relationship in individual therapy. research of homogeneous group members’ choice of
Cohesion stems from the Latin, cohaesus, meaning therapeutic factors. As a sampling, it has been found
“to cleave or stick together” (Dion, 2000). Dion that Alcoholics Anonymous and Recovery, Inc.
proposes that group cohesion is a multidimensional members emphasize instillation of hope, imparting
construct consisting of social, task, and vertical information, universality, altruism, and some aspects
(member to leader) cohesion, and also belonging- of group cohesion. Spousal abusers in a psychoedu-
ness and attraction of members for each other and cational group most valued imparting information,
the group. To be cohesive, group members also feel and members of occupational therapy groups prized
a common unity and are able to coordinate their cohesiveness, instillation of hope, and interpersonal
actions, much like a team (Forsyth, 2006). The learning. A pilot study (Waldo, Kerne, & Van Horn
mechanism of cohesion is considered to be the most Kerne, 2007) compared male members’ experienc-
central therapeutic factor because it is a therapeutic ing of therapeutic factors in domestic violence
mechanism in its own right and it also stimulates groups. Results were in predicted directions, indi-
others. Cohesion appears to best define the group cating that guidance group members experienced
therapeutic relationship (Burlingame, Fuhriman, & instillation of hope, imparting information, and

624 group couns el in g

existential factors most frequently. In comparison, Research results reported by Kivlighan and
counseling group members reported experiencing Mullison (1988) and Kivlighan and Goldfine (1991)
universality, cohesion, and interpersonal learning were used to examine the clusters of therapeutic
most often. factors (mentioned earlier) in relation to group
Kivlighan and Holmes (2004) conducted meta- development stages (Kivlighan & Holmes, 2004).
analytic studies to examine past reports ranking Connecting with Tuckman’s (1965) four stages of
therapeutic factors, using cluster analysis to create group development (forming, storming, norming,
a typology of groups based on their therapeutic and performing), four hypotheses were generated
mechanisms. They named these clusters of groups from this research: cognitive support experiences
by the therapeutic factors that were rated highest will characterize the forming stage of group devel-
and lowest in each cluster: opment, affective support experiences will pre-
dominate in the storming stage, cognitive insight
• Cluster 1: Affective Insight groups
experiences will dominate during the norming stage,
(e.g., containing the therapeutic factor
and affective insight experiences will command the
of catharsis)
performing stage of group development.
• Cluster 2: Affective Support groups
Shechtman and Gluk (2005) adopted therapeu-
(e.g., containing the therapeutic factor of
tic factor clusters similar to those used by Holmes
instillation of hope)
and Kivlighan (2000) in their study of adults to
• Cluster 3: Cognitive Support groups
examine therapeutic factors in children’s groups:
(e.g., containing the therapeutic factor of
emotional awareness-insight, relationship-climate,
universality)
other-versus-self focus, and problem identification-
• Cluster 4: Cognitive Insight groups
change. The group relationship-climate was the the-
(e.g., containing the therapeutic factor of
rapeutic factor most frequently mentioned by the
interpersonal learning).
children, whereas the problem-identification-change
Yet, the results related to therapeutic factors and factor was least appreciated, pointing to the value of
type of group remain somewhat cloudy. Following relationships for children in group therapy.
a review of therapeutic factors according to type of After considering the large body of literature
group, Kivlighan et al. (2000) conclude that there is addressing the importance of therapeutic factors,
little evidence of consistent findings across types Kivlighan and Holmes (2004) were led to conclude
of groups. They observe that a lack of theoretical that little progress has been made in answering
conceptualization exists to guide these comparisons, an initial basic question raised by Yalom: “How does
a point that has been made strongly before by other group therapy help patients?” Complexities of
researchers (Beck & Lewis, 2000; Durkin, 1981; client, therapist, and group variables—and their
Fuhriman & Burlingame, 1994). Perhaps use of the interaction—continue to vex efforts.
four group work types (task, psychoeducation, Future research into these and other areas raised
counseling, and psychotherapy), defined in the in this section will help further clarify how thera-
ASGW training standards (ASGW, 2000) might aid peutic factors operate and how group leaders can
in clarifying this kind of research. harness their power. Perhaps incorporating a wider
range of research methodologies into this search,
therapeutic factors and such as qualitative designs, might yield valuable
group development insights that could not be found by relying solely on
With regard to the relationship between therapeu- quantitative approaches (Rubel & Atieno Okech,
tic factors and group development, Yalom (Yalom 2011). Developing answers to these questions is
& Leszcz, 2005) painted the following impres- important to group counseling.
sionistic picture. Early in a successful group, the
therapeutic factors of instillation of hope, universal- Group Climate
ity, and imparting information tend to emerge. Group climate is the atmosphere, the culture, or
At the group’s middle stage, the therapeutic factors the general personality of a group. It is described
of altruism, imitative learning, catharsis, socializa- by MacKenzie (1983) as an environmental press
tion techniques, corrective recapitulation of the that serves to facilitate or to restrict the efforts
family experience, and cohesiveness tend to be man- of individuals to reach their goals. Thus, group cli-
ifested. Late in the group, the therapeutic stages of mate is thought to exert a strong effect on outcomes.
interpersonal learning and existential matters assert. Yalom (1995) holds that it is a group leader’s task

cony ne 625
to establish a group culture, or climate, that is max- best predictors of member perceptions of the thera-
imally conducive to effective group interaction peutic process are the fellow members, not the lead-
(pp. 109–110). Through this climate therapeutic ers (similar to individual therapy). Finally, Johnson
factors are stimulated, accounting for change in the points out that it matters if assessment is aimed at
group. the individual or the group level, and if it examines
This contention has been supported by research. both working and relational components. Results
For example, Ogrodniczuk and Piper (2003) exam- obtained, then, may need to be considered in rela-
ined the association between dimensions of the tion to these issues.
common factor of group climate and treatment out- Multilevel, structural equation models were used
come using MacKenzie’s Group Climate Ques- by Johnson, Burlingame, Olsen, Davies, and Gleave
tionnaire-Short From (GCQ-S; MacKenzie, 1983). (2005) to examine four relationship constructs cen-
In general, they found that group climate is related tral to group psychotherapy: group climate, cohe-
to positive outcome in group psychotherapy. More sion, alliance, and empathy. Data were collected
particularly, results showed that the dimension of from three relationship vantage points, member to
engagement, reflecting a cohesive group environ- member, member to group, and member to leader,
ment and a willingness of members to participate in involving 662 participants from 111 counseling
the group, was significantly related to positive out- center and personal growth groups. The research
come. Avoidance and conflict, conversely, were shows that nearly every measure of therapeutic rela-
found to be inimical to development of a positive tionship was significantly correlated, with the sug-
climate. Adding to the assertions of other research- gestion that three relationships operate in the group
ers before them (e.g., Budman, Soldz, Demby, context: positive relational bonds, referring to the
Feldstein, Springer, & Davis, 1989), the authors emotional connection or attachment to other mem-
observe that cohesion, which can be viewed as a net- bers, leader, and group as a whole; positive work-
work of engaged relationships, likely serves a similar ing relationships in the group, or the collaborative
purpose in group therapy as the therapeutic alliance engagement aimed toward goal attainment; and
does in individual therapy. negative relationship factors, including aspects of
Continuing this line of research Joyce, Piper, and process that may unfavorably impact attachments
Ogrodniczuk (2007) examined cohesion and thera- or slow therapeutic progress. In sum, group mem-
peutic alliance (the relationship between members bers in this study were found to distinguish their
and leader) in relation to outcome in a time-limited within-group relationships by relationship quality
psychotherapy group for complicated grief. They rather than by who was involved.
found alliance and cohesion to be positively corre- Following from the above study, the AGPA
lated, but not all measures of each construct pre- released the Core Battery-R (Burlingame, 2005;
dicted outcomes. Therapeutic alliance was found in MacNair-Semands, 2006; Ogrodniczuk, 2005).
this study to be a consistently stronger predictor of This set of instruments is designed to help track the
member outcomes. In a study of one long-term psy- individual improvement of members and to assess
choanalytically oriented group, Lorentzen (2008) the therapeutic relationship in groups focusing on
found that therapeutic alliance deepened over time positive relational bond, positive working relation-
and that the group therapist’s rating of early alliance ship, and negative factors that interfere with the
was a positive predictor of symptom improvement bond or with therapeutic work (Burlingame, Strauss,
in group members. Joyce, MacNair-Semands, MacKenzie, Ogrodniczuk,
Do the findings of the Joyce et al. study throw & Taylor, 2006). Each of these components can be
into question the role of cohesion in affecting group assessed from the perspective of a member’s rela-
outcomes? Johnson (2007), in discussing the Joyce tionship with the group leader and the member’s
et al. article, seeks to place the results in context. She relationship with the whole group.
points out that both cohesion and alliance have An earlier study tested Yalom’s hypothesis that
been defined, operationalized, and measured in dif- group climate mediates the relationship between
ferent ways as increased precision is pursued. group leadership and outcome (Kivlighan & Tarrant,
Moreover, she points out that timing in relation to 2001). More specifically, they explored whether
measuring these factors is an important consider- the use of structure and formation of positive
ation, as levels of cohesion and alliance often change relationships with group members would be related
in relation to a group’s developmental progress. to increased levels of active engagement and decreas-
Who makes what ratings deserves attention, as the ing levels of conflict-distance. If these results

626 group couns el in g

occurred, the study was geared to explore if they and to the “social field” (Lewin, 1951) provided
would be related to positive member outcome. a robust platform for considering group develop-
Findings supported the above hypotheses about ment. Bales (1950) made group development an
group leadership and group climate, suggesting area of study by developing a system for coding
directions for how group leaders can build a thera- small group interaction using his Interaction Process
peutic group climate. Based on this and previous Analysis. Hill’s (1965) instrumentation and con-
research (e.g., Braaten, 1989; Budman et al., 1989; ceptual map for analyzing group verbal interaction
Kivlighan & Lilly, 1997), Kivlighan and Tarrant developmentally advanced study in this area.
(2001) suggest: Agazarian (e.g., 1999) contributed a view of group
therapy as a living human system that shapes and is
Group members will increase their active
shaped by group development phase dynamics.
involvement with the group when group leaders
In fact, over 100 conceptual models of group
refrain from doing individual therapy in the
development have been formulated (Conyne,
group and actively set goals and norms while
1989). These models are arranged into recurring-
maintaining a warm and supportive
phase (e.g., Schutz’s FIRO phase model, 1958) and
environment . . . the group leader’s major task
sequential-stage approaches (e.g., Corey & Corey’s
is to create a therapeutic group climate . . .
initial-transition-working-final stages model, 2006).
unlike individual treatment, where the relationship
Regardless of approach or model, reiteration rather
between the client and therapist is tantamount,
than linearity applies as any one group lurches along
in group treatment leaders should probably
its way. Capturing this outlook, Yalom reports that
de-emphasize their relationships with individual
Hamburg (1978) suggested the term “cyclotherapy”
group members and focus on creating a therapeutic
to refer to the kind of ebb and flow that character-
group climate. (p. 231).
izes progress in a group.
Learning more about how group leaders can Patterns are observable when examining many
concretely promote and maintain a positive group groups from a distance, although chance and seren-
climate is needed. Recent efforts to conceptualize dipity associated with the unique composition of
“ecological group work” (Bemak & Conyne, 2004; a group and the often unpredictable interactions
Conyne & Bemak, 2004; Conyne, Crowell, & occurring among members contribute strongly to
Newmeyer, 2008) are focused in this direction. any one group’s development. Still, group develop-
Other work showing special promise results from mental models can be used by group leaders to assist
several large-scale international studies (McClendon in managing events under way in a group, to help in
& Burlingame, 2011) organizes a 3-factor model of predicting general future events, and to guide
group climate: (a) positive bonding relationship creation of a plan for a new group (Brabender,
among members, (b) positive working relationship 2011; Conyne et al., 1997, 2007; MacKenzie, 1997;
and group climate, and (c) negative relationship and Wheelan, 1997). A number of studies (e.g.,
affect connected to tension, withdrawal, avoidance, Kivlighan, McGovern, & Corazzini, 1984) have
and conflict. shown that successful group outcome is strongly
dependent on the group being able to move posi-
Group Development tively through developmental levels (Donigian &
Group conditions evolve and fluctuate over time. Malnati, 1997) and the capacity of a group coun-
The degree and direction of these shifts are depen- selor to mirror interventions with developmental
dent on many factors and their interaction, similar progress is important (Brabender, 2011).
to most aspects of group counseling. The type of But, of course, there is no guarantee of such pos-
group, number of sessions, whether it is open or itive movement. Too many groups falter early and
closed, the degree of cohesion developing early, disband. Others may make it to the end but with-
amount of structure used, and other factors are out successful outcomes for members. Being attuned
involved. One of the factors strongly influencing not only to nomothetic but also to idiographic per-
functioning and later outcomes is group develop- spectives is important (Kivlighan et al., 2000).
ment (Wheelan, 2005). Structuring, which plays a generally impor-
The term “group development” refers to patterns tant role in group development, seems especially
of growth and change that evolve during the lifespan useful to provide pre-group preparation and growth
of a group (Forsyth, 2006). Lewin’s contributions to in the early developmental stages of a group
group dynamics (e.g., Lewin, Lippitt, & White, 1939) (Burlingame et al., 2004). In addition to using

cony ne 627
structure appropriately, MacKenzie (1997) provides ethical group leadership; and a role for improvisa-
a number of suggestions for group leaders to follow tion in group leadership.
in managing positive group development, including Despite so much being written over the decades
selecting a particular group theory or format. in so many disciplines, as well as in popular media,
MacKenzie (1997) and Conyne et al. (2008) both the political scientist James McGregor Burns wryly
demonstrate how the purposeful selection of group claimed that leadership is “one of the most observed
techniques by leaders can be timed to group devel- and least understood phenomena on earth” (cited in
opmental stages, taking strategic advantage of their Forsyth, 2006, p. 373). Is leadership related to
unique dynamics. power, to fidelity and honor? Does it involve great
Wheelan (1997), although agreeing that group people doing heroic things? Is it all about motivat-
leader behavior is important for approaching suc- ing others? Are leaders born or made? Is it a func-
cess, makes the point that member behavior is of tion emerging from the structure and processes of a
equal importance. She suggests that both leader and particular organization or environment? Is it shared
members need to understand the foundational by everyone in the system? Does it emerge from the
dynamics and developmental patterns attending the wisdom of the leader?
complex system of groups for them to move to the According to Forsyth’s (2006) review and sum-
higher stages of group development associated with mary of it, leadership is the ability to lead others by
positive growth. Such a level of shared understand- guiding them in their pursuits—often by organiz-
ing and participation might also support Lewin’s ing, directing, coordinating, supporting, and moti-
“law” of change in groups: “It is usually easier to vating their efforts. Although this definition seems
change individuals formed into a group than to to be generally useful, many other perspectives on
change any one of them separately” (Lewin, 1951, leadership exist, as well. For example, some focus
cited in Forsyth, 2006, p. 525). on leadership being a shared function of those in the
system, illustrated by Raelin’s (2003) notion of
Group Leadership “leaderful” organizations. Other viewpoints focus
on leadership being defined more by organizational
A leader is best
structure than by individual behaviors (e.g., Fuqua
When people barely know he exists.
& Newman, 2004), by the ability to facilitate
Not so good when people obey and acclaim him.
effectiveness by improving process and structure
Worse when they despise him.
(Schwarz, 2002), or by the performance of the
Fail to honor people, they fail to honor you;
group or team for which a leader is responsible
But of a good leader, who talks little,
(Kaiser, Hogan, & Craig, 2008). The Aristotelian
When his work is done, his aim fulfilled,
notion of phronesis, in which the group leader dem-
They will say, “We did this ourselves.”
Lao-Tse (cited in Cohen & Smith, 1976, viii).
onstrates a “practical wisdom” (Holliday, Statler, &
Flanders, 2007) combining intelligence, creativity,
There are many perspectives about leaders and and knowledge aimed to better the common good
leadership. Lao-Tse’s prescient view of a leader, (Sternberg, 2004) suggests a different perspective on
adapted above (from the 6th century b.c., long leadership.
before the advent of sexist terminology), is no doubt
one of the earliest on record. Its components mesh Defining Group Leadership Remains Elusive
well with aspects of contemporary group leader- Leading counseling groups is a particular applica-
ship, perhaps most notably with showing caring, tion of leadership, as these groups are formed
empathy, and respect and with the importance of and conducted to benefit member growth and
collaboration. change. An impressive number of texts, handbooks,
In this section, I examine important aspects book chapters, journal articles, and videotapes
of group counseling leadership, attending to: defin- address group counseling and its leadership.
ing this elusive ability; identifying its functions, Considering texts alone, group leadership func-
tasks, and roles; pre-group preparation and plan- tions, tasks, competencies, interventions, strategies,
ning in creating groups; the positive valence of techniques, challenges, principles, and more have
the leader; stimulating and focusing here-and- been researched and described (e.g., Corey, 2007;
now interaction; using meaning attribution; leader Corey & Corey, 2006; Conyne et al., 2008; Conyne,
choice of interventions; drawing from standards, Wilson, & Ward, 1997; DeLucia, Gerrity, Kalodner,
guidelines, and principles to guide effective and & Riva, 2004; Gazda et al., 2001;Gladding, 2006;

628 group couns el in g

Jacobs, Harvill, & Masson, 2006; Trotzer, 2006; were 210 Stanford University students who were
Yalom & Leszcz, 2005). arranged into 18 encounter groups, each of which
However, summative concise definitions of met for 30 hours. Ten different theoretical models
group counseling leadership seem generally to be and approaches were expressed through the groups:
implied rather than explicated in the literature. National Training Laboratory t-group, gestalt, trans-
Maybe this condition is due to the complexity of actional analysis, Esalen eclectic, personal growth,
the activity. Type of population, leader experience, Synanon, psychodrama, marathon, psychoana-
measurement methods, and other factors all con- lytically oriented, and encounter tapes—leaderless.
tribute (Shechtman, 2007). For example, according A wide battery of tests were employed to investigate
to Higgenbotham, West, and Forsyth (1988), how issues related to person variables, leader character-
much group leaders should participate in the group istics, leader variables, group characteristics, par-
process remains the most significant single problem ticipants’ experience, and outcome. Although this
being faced by practitioners and researchers. Many study is dated because it was conducted decades ago
other challenges persist, such as determining how during a unique time of excitement about groups
leaders can effectively promote group cohesion. and social change and was comprised of college stu-
Therefore, it is appropriate to wonder how any one dents from one campus on the West Coast, it remains
definition could capture the variety and nuances as one of the most significant studies available on
involved in group leadership. group leadership.
Nonetheless, an integrative definition of group Among the results, it was found that theoretical
counseling leadership is suggested below, based disposition mattered little in producing member
on three central tasks of the group therapist change, but leadership style was significant. Six
that were identified by Yalom (Yalom & Leszcz, different leadership styles were identified, each one
2005): to create and maintain the group, to build a combination of four leadership functions. These
a group culture, and to activate and illuminate the leadership functions are: caring, or demonstrating
here-and-now. empathy and a genuine concern for members; mean-
Group leadership is the ability to draw from ing attribution, or helping members to convert
best practices and good professional judgment to: experiences occurring within the group to personal
meaning; emotional stimulation, or catalyzing the
Create a group and, in collaboration with members,
expression of emotion and sustaining energy in
build and maintain a positive group climate that
the group; and executive function, or managing the
serves to nurture here-and-now interaction and its
group as an ongoing social system. The most effec-
processing by leader and members, aimed at
tive group leadership style, called the “Provider,”
producing lasting growth and change.
resulted from a combination of high levels of caring
and meaning attribution, with moderate levels of
Functions, Tasks, and Roles emotional stimulation and executive functioning.
of Group Leaders Coche, Dies, and Goettelman (1991) also found
How do group leaders apply the components of the that a high amount of meaning attribution and a
above definition or, indeed, of any definition of moderate amount of executive functioning are
leadership? Results from Lewin, Lippitt, and White’s advantageous in therapeutic groups.
(1939) famous laboratory study provided early These and other findings from the Lieberman
guidance. In this social psychological experiment, et al. (1973) study have served many training pro-
10- and 11-year-old boys met in three after-school grams well in preparing future group leaders. Yet,
groups to work on differing hobbies. Each group not all subsequent studies have been able to produce
included a male leader who manifested one of three similar results. For instance, Tinsley, Roth, and
leadership styles: authoritarian, democratic, or lais- Lease (1989), in their survey of 204 experienced
sez-faire. Results, although not clear cut and marked group leaders, identified eight functions, not four:
by differences in such criteria as efficiency, satisfac- cognitive direction, affective direction, nonverbal
tion, and participation, favored the democratic exercise (leader style factor); nurturant attractive-
style, which tended to be friendlier and more group ness and charismatic expertness (leader personal
oriented. qualities factor); and group functioning and per-
Leaping ahead four decades, Lieberman, Yalom, sonal functioning (leader objectives factor).
and Miles (1973) reported their classic study of the Kivlighan (1997), in discussing situational leader-
processes and effects of encounter groups. Participants ship (Hershey, Blanchard, & Johnson, 1982), draws

cony ne 629
upon Dies’ (1983) and Higgenbotham et al.’s analy- and planning, including member selection, is
ses to suggest that a more general level of consen- detailed in the Planning section of the ASGW Best
sus is emerging that only two dimensions capture Practice Guidelines (ASGW, 1998a, 2008).
the wide variety of group leader behaviors and
styles: personal, relationship dimensions and tech- Positive Valence of the Group Leader
nical, task dimensions. Yet, one gets the sense that As mentioned earlier, research has accumulated
this question, as many others in group counseling, about the importance of a positive group climate
is not completely answered—due, in part, to the use in mediating growth and change in members.
of different research methodologies and research Likewise, research demonstrates that leaders con-
participants. tribute strongly to the creation and maintenance of
Hershey and Blanchard’s situational leadership group climate, for good or ill. Trotzer (2011) has
approach, mentioned above, suggests that effective described the group leader’s positive valence as her
leader use of task and relationship behaviors varies or his “personhood.” Those leaders who behave con-
in relation to the developmental trajectory of the sistently with members in a caring and empathic
group. Task behavior is relatively more salient early manner, who constructively confront, and who
in the group when rules, norms, and structure are maintain a supportive therapeutic relationship with
created, with relationship behavior more important members aid significantly in producing a posi-
later. tive group climate. As stated by Yalom: “The basic
Consistent with this view, Yalom (1995) main- posture of the (group) therapist to a client must be
tains that the group leader’s initial goals are to create one of concern, acceptance, genuineness, empathy.
a therapeutic culture drawing largely from task- Nothing, no technical consideration, takes precedence
oriented behaviors; this is known as the technical over this attitude” (italics retained; Yalom & Leszcz,
expert role. As the group proceeds, the leader may 2005, p. 117).
shift to providing increased relationship behaviors Likewise, a quote about the value of positive
and modeling of positive attitudes and behaviors, leader behavior from Dies (1994) is worth repeat-
consistent with a model-setting participant role as ing. After reviewing 135 studies, he concluded:
the group evolves. Both of these roles are important “Group members favor and seem to benefit more
in shaping the group climate and its norms. In fact, from a positive style of intervention, and that as
Bauman suggests that the place to begin with train- leaders become more actively negative, they increase
ing group counseling leaders is to identify what the possibility that participants will not only be dis-
roles they will be expected to perform. satisfied, but also potentially harmed by the group
experience” (cited in Riva et al., 2004, p. 40).
Pre-Group Preparation and Planning in This positive valence of the leader contributes
Creating the Group to the creation and maintenance of an affirming
Pre-group preparation has been shown to be essen- therapeutic relationship and to group cohesion. In
tial to promoting group cohesion, member satisfac- turn, these conditions promote progress toward
tion, and comfort with the group (e.g., Bednar & member goals.
Kaul, 1994; Bowman & DeLucia, 1993; Burlingame
et al., 2001, 2004; Riva et al., 2004). Pre-group Stimulating and Focusing Here-and-Now
preparation enjoys the strongest empirical support Interaction
of all structuring approaches. Group counseling interaction needs to be “presen-
Developing an overarching group plan, within tized” to be therapeutic (Bradford, Gibb, & Benne,
which pre-group preparation is included, provides 1964; Golembiewski & Blumberg, 1970; Zinker,
group leaders with a valuable resource. Such a plan 1980). As Yalom (Yalom & Leszcz, 2005) stressed,
may include the group’s underlying conceptual “[this is] perhaps the single most important point
framework, general goals, pre-group orientation, I make in this entire book: the here-and-now focus,
methods, session details, the target population, to be effective, consists of two symbiotic tiers, neither
recruitment and selection procedures, and evalua- of which has therapeutic power without the other”
tion, among other elements (Conyne et al., 1997, (p. 141) (italics retained).
2007). Following selection, the pre-group prepara- In Yalom’s first tier, the immediate, here-and-
tion of members helps to set expectations, establish now interaction of members in a group session take
rules, and it provides guidance about effective par- clear precedence over those occurring in the cur-
ticipation in the group. This kind of preparation rent, outside lives of members or in their distant

630 group couns el in g

past. Adapting from statistical terminology to illus- Making active use of ongoing, within-group pro-
trate this point, in group counseling “the main effect cess observations by group leaders is receiving increas-
is in the interaction” (e.g., Bronfenbrenner, 1977, ing attention for group leader practice and training
cited in Conyne & Cook, 2004, p. 341). Dye (e.g., Armstrong & Berg, 2005; Bieschke, Matthews,
(2008) referred to the introduction of the here- & Wade, 1996, 1998; Conyne, 1998). Group lead-
and-now focus in group work as the equivalent of ers learn how to observe and incorporate group pro-
a “tsunami” in its overall effect on how groups would cesses (such as participation, task-maintenance, and
henceforth function. decision-making; Hanson, 1972) within leader inter-
In the second tier, which is discussed in the next ventions. Doing so provides a way to tie leader inter-
chapter section, illumination of the process (again, ventions concretely to here-and-now activity, and
italics retained) is led to occur. This step is a kind can provide opportunities for group members to
of “doubling back” on itself, in which experience become more aware of how their group participation
is reviewed and processed, on the way toward attri- can influence progress and learning.
bution of meaning. Continuing with Dye’s analogy, As mentioned, practice and training are critical
if not quite the tsunami of the here-and-now, the elements in helping to produce qualified group
realization that experiencing needs meaning to be counselors. Attention to the “personhood” (Trotzer,
genuinely valuable amounted to at least a large tidal 2011) of the trainee also is a vital component.
wave. Finally, on-going supervision is critically important,
What are some important “tier 1” skills for group because it can provide a continuing source of feed-
leaders? They catalyze here-and-now interaction by back, support, constructive challenge, and guid-
promoting meaningful member self disclosure, feed- ance. However, as Riva (2011) observes, the quality
back, appropriate use of structure, catharsis, and of supervision cannot be taken for granted. Training
acquisition of social skills. These areas are associated programs need to track client outcomes as a conse-
with the group leadership function of emotional quence of group leader supervision and of group
stimulation identified by Lieberman et al. (1973). leader practice under supervision.
Discussions of these leader skills and interventions
are contained in numerous sources (e.g., Conyne Using Meaning Attribution
et al., 2008; Corey, Corey, Callanan, & Russell, The experience of group counseling can be bewilder-
2004; Gladding, 2006; Morran, Stockton, & ing due to its ongoing dynamic activity. It also can
Whittingham, 2004). One illustration (Trotzer, be emotionally overpowering at times or, conversely,
2006) indicates the importance of leaders appropri- it can sap the patience of everyone involved. In any
ately providing skills of reaction (e.g., active listening), and all cases, the experience of group participation
interaction (e.g., linking), and action (confronting) to can become more understandable and meaningful,
promote positive group and member functioning. as mentioned above, when group leaders assist mem-
Tier 1 skills of group leadership also involve the bers in converting experience to cognition.
proper use of positive and corrective feedback and This lesson was learned through the empirical
their sequencing in a group (DeLucia-Waack & research of Lieberman et al. (1973) who found,
Kalodner, 2005; Hulse-Killacky & Orr, 2006; among other important results, that “meaning attri-
Morran, Stockton, Cline, & Teed, 1998; Morran, bution” is an essential group leader function to be
Stockton & Harris, 1991; Robison, Stockton, performed. Yalom (Yalom & Leszcz, 2005) explained
Morran, & Uhl-Wagner, 1988). In general, these that “process illumination” promotes meaning attri-
studies chart the value of emphasizing positive feed- bution, while releasing what he terms the vital
back in beginning sessions of a group followed in “power cell of the group.” Potency surges when the
middle and later group sessions by positive and cor- “here-and-now” interaction among members is
rective feedback. In addition, research shows (e.g., examined through a kind of “self-reflective loop,” or
Davies & Jacobs, 1985) that the delivery of feed- process commentary. That is, an interpersonal expe-
back within a group session should follow a sequence rience in the group is examined by the members for
that is positive then corrective, or positive, then cor- its meaning. This kind of reflective process engage-
rective, then positive all the while focusing on ment sparks energy and stimulates the making of
member behaviors that are both observable and spe- meaning. Yalom has phrased the critical question to
cific (Jacobs, Jacobs, Cavior, & Burke, 1974) and ask in relation to an interpersonal event: “What
giving careful consideration to member readiness to does it tell about the interpersonal relationships of
receive feedback (especially corrective feedback). the participants?” (p. 143).

cony ne 631
 As mentioned in relation to increased attention integrate several additional elements thought to be
being given to intentionality in stimulating here- important in group leadership to create the purpose-
and-now interaction, a similar emphasis is emerging ful group technique model (PGTM). This model is
that centers on the purposeful planning and pro- used intentionally to guide the consideration and
cessing of experiences in the group (Conyne, 1997, selection of group techniques. It is based on viewing
1999; Conyne et al., 2008; Cox, Banez, Hawley, & a group as an ecological system. The model includes
Mostade, 2003; DeLucia-Waack, 1997; Glass five steps:
& Benshoff, 1999; Kees & Jacobs, 1990; Kees &
• Identify the group type, best practice area,
Leech, 2002; Pistole & Filer, 1991; Stockton,
and group developmental stage.
Morran, & Krieger, 2004; Stockton & Morran,
• Analyze the group’s ecology using the
2011; Stockton, Morran, & Nitza, 2000; Thomas,
concepts of context, interconnection,
2006; Ward & Litchy, 2004). Group leadership is
collaboration, social system maintenance, meaning
becoming a more empirically based, intentionally
making, and sustainability.
practiced endeavor.
• Review possible techniques considering their
focus (cognitive, affective, behavioral, and
Leader Choice of Interventions
structural) and level (individual, interpersonal, and
Intentionality extends to the leader choice of inter-
group).
ventions to more purposefully stimulate here-and-
• Select a best-fit technique by evaluating for
now experience and its meaning (e.g., Cohen &
adequacy, appropriateness, effectiveness, efficiency,
Smith, 1976; Conyne, et. al., 2008; Corey & Corey,
and side-effects.
2006; Ivey, Pedersen, & Ivey, 2001; Jacobs, Masson,
• Implement and evaluate, allowing for
& Harvill, 2006; Stockton, Morran, & Clark, 2004;
adaptation and future change.
Trotzer, 2004). Stockton et al. (2004) studied the
intentions of group leaders. They found four inten- Practice and supervision in applying these steps
tion clusters in relation to interventions made in can lead to an increased fluidity of use in real time.
group sessions: promoting insight/change, planning
and guiding, attending, and assessing growth. Drawing from Standards, Guidelines, and
Cohen and Smith (1976), in their critical inci- Principles to Guide Group Leadership
dent growth group model, long ago provided a The increased intentionality in group leadership has
useful map for how to intervene and when. Their been marked by the creation and adoption of vari-
use of critical incidents is currently popular, being ous standards, guidelines, principles, and codes that
applied in counselor training in different spheres, are particular to group work. It is important for
including in contemporary group leader train- group leaders to be aware of and guided by existing
ing (e.g., Tyson, Perusse, & Whitledge, 2004). The ethics, best practice guidelines, legal statutes, and
Cohen and Smith critical incident growth group other professional codes that are relevant to their
model provides for 27 group leader interven- practice (Wilson, Rapin, & Haley-Banez, 2004).
tion possibilities that emerge from the interaction In this section, we will briefly examine consider-
of three intervention factors: intervention type (cog- ations for ethical and for diversity and multicultural
nitive, experiential, structural), intervention level practice.
(group, individual, interpersonal), and intervention
intensity (high, medium, low). The authors hold ethical practice
that cognitive-group-low intensity interventions The Association for Specialists in Group Work’s Best
generally are suitable early in a group, then shifting Practice Guidelines (ASGW, 1998a, 2008), the
to more experiential and intensive personal and AGPA’s practical guidelines for group psychother-
interpersonal interventions as the group progresses, apy (AGPA, 2007) and its ethical guidelines (2002),
then shifting back to less intense interventions as ASGW’s professional training standards for group
the group moves toward its conclusion. Leader flex- work (2002), and the Association for the Advance-
ibility (Dies, 1983; Kivlighan, 1997) is a key behav- ment of Social Work’s standards for practice (2006)
ior, in that good leaders are able to adjust behavior represent professional associational efforts to pro-
and style to fit the developmental needs of members vide guidance and direction to effective group train-
and of the group itself. ing and practice. For consumers, AGPA’s friendly
Building on the Cohen and Smith critical inci- and informative brochure, Group Works! Information
dent model, Conyne et al. (2008; Newmeyer, 2011) About Group Psychotherapy (n.d.a.) provides an

632 group couns el in g

introduction to group therapy that is both readable an ever-expanding multicultural and diverse
and understandable. clientele and contexts—including internationally
The special sections on the “ethical group psy- (e.g., Conyne, Wilson, & Tang, 2000; Conyne,
chotherapist” in the International Journal of Group Wilson, Tang, & Shi, 1999; McWhirter, J. J.,
Psychotherapy (2007), and book chapters by DeLucia- McWhirter, P., McWhirter, B., & McWhirter, E. H.,
Waack and Kalodner (2005), Rapin (2004, 2011), 2011;Walker & Conyne, 2007; Yau, 2004).
and Rapin and Conyne (2006), addressing guide- Merchant (2008) is actively involved in specifying
lines for the ethical and legal practice of counseling multicultural group skills that are appropriate for
and psychotherapy groups and in group work, add culturally specific groups, for groups containing
further substantiation to the trend toward increased members from various cultures, as well as for all
intentionality, purposefulness, and accountability in groups.
group leadership. Group leaders need to become comfortable and
Sound ethical practice is accomplished through competent in providing multicultural group coun-
giving appropriate attention to planning, perform- seling. Specific recommendations have been pro-
ing, and processing groups. Thorough planning, for vided to assist in meeting this charge (DeLucia-Waack,
example, can help control for committing errors in 2011; DeLucia-Waack & Donigian, 2003): develop
confidentiality, informed consent, and recruitment awareness of the worldviews of different cultures
and selection of members, and to designing a group and how these might impact group work interven-
that more closely reflects the needs and culture of tions, develop self-awareness of racial identity and
participants. Careful attention to performing, that one’s own cultural and personal worldviews, and
is, attending to what leaders do within sessions, can develop a repertoire of group leader interventions
enhance the effectiveness and appropriateness of that are culturally appropriate. The ASGW princi-
leader interventions. Thoughtful processing can ples for diversity-competent group workers, refer-
protect against ignoring how ethical and legal prin- enced earlier, offer specific guidance. Three areas of
ciples apply to situations being confronted, and can multicultural competences for group leaders and
promote regular scrutiny and evaluation of the group members alike are emphasized in the princi-
group being led. ples: group leader attitudes and beliefs, knowledge,
In addition, Rapin (2011) suggests that ethical and skills.
behavior in group counseling can be viewed as being Conyne et al. (2001) underlined important
derived from an interaction of several factors occur- aspects of diversity in therapeutic groups, including
ring within a decision-making model. These factors worldview, acculturation, ethnic/racial identity, and
are: moral and ethical development, professional clients’ differing levels of development and life style.
ethics, core knowledge and skills, specialty best Ritter (2011) and Keim and Olguin (2011) have
practices, and legal parameters. elaborated on multicultural group work focused on
sexual orientation and for individuals across the life
diversity and multicultural practice span, respectively. For all these uniquely expressed
Following the leads of Rapin (2004) and D’Andrea groups—and for groups in general, Conyne, et al.
(2004), Macnair-Semands (2007) emphasizes that (2001) suggest that group leaders apply the follow-
intentional interventions in group therapy require ing general guideline when working with diverse
the group leader to be culturally competent. ASGW’s groups: “Create a social ecology in the group that
diversity-competent principles (ASGW, 1998b), the allows for differences to be acknowledged and
APA’s Multicultural Guidelines (2002), the Asso- respected and where commonalities can be recog-
ciation for Multicultural Counseling and Diver- nized and accepted” (p. 359).
sity’s multicultural competencies and standards
(Sue, Arredondo, & McDavis, 1992), and scholarly Improvisation
contributions such as book chapters (e.g., Conyne, When all is said and done, there is more to group
Tang, & Watson, 2001; Merchant, 2006; Rivera leadership than purposefulness and intentional
et al., 2004), books (e.g., DeLucia-Waack & behavior guided by research, theory, and standards—
Donigian, 2003; Ivey, Pedersen, & Ivey, 2008), and despite the thrust of this chapter. There is some
sections of handbooks (e.g., the extensive coverage of risk involved in group leadership because leaders
multicultural group applications in DeLucia-Waack often cannot predict the course of events or the
et al., 2004) attest to the vital importance of group consequences of their own actions. Dye (2008)
work being applied with cultural appropriateness to wryly used flying in an airplane as a metaphor.

cony ne 633
He suggested that if group work could be thought of There are, of course, professionally led groups,
as flying in an airplane, then group leadership would commonly referred to as counseling and therapy
be comparable to sky diving. groups. These have garnered the attention of this
Risk acknowledged, I suggest that group leader- review chapter. As well, many specifications and
ship can be viewed as an informed improvisational adaptations exist of ASGW’s four types of groups
art form, a creative and spontaneous act (Gladding, (task, psychoeducational, counseling, and psycho-
2011) with at least as many similarities to the jazz therapy), including a myriad of support groups and
musician as to the symphony orchestra conductor. self-help/mutual-help groups. Groups are multi-
Its music is an ongoing riff, not a charted score. splendored, therefore. They are tailored to a wide
Nearly always, there are apparent discordances range of specific populations, addressing a myriad
and conflicting melodies running through group of health and mental health care issues. Groups
interaction. At times, group interaction may “sound” are offered across the lifespan and provided in
cacophonous. Different members “play” idiosyn- brief therapy formats supported by managed care
cratic tunes on their own separate instruments, just (but, alas, much more needs to be done in this
as in a jazz ensemble, seemingly at times at odds arena). There are quality circle groups, community
with each other. Yet, underneath there often is a action groups, prevention groups, social justice
“matter of consistency” (Kaul, 1990)—a unison groups, trauma groups, and the list goes on . . . and
refrain, a groove, if you will—and it is the group on. As a sampling, let us briefly consider brief ther-
leader’s role to find it, if no one else can, to bring it apy groups, mutual-help groups, social justice
home to every member’s awareness. Then, leaders groups, trauma and disaster preparedness groups,
need to show members how their interactive partici- and online groups.
pation can become harmonious even as they con-
tinue to express their individuality. Theory, research,
and supervised practice contribute substantively to Brief Therapy Groups
inform and guide group leadership, indeed; but per- Brief group therapy (BGT) (e.g., Spitz, 1996),
sonal factors, along with spontaneity and intuition, sometimes referred to as focal group psychotherapy
may be just as important. (McKay & Paleg, 1992) is a specific form of group
therapy. Most of these kinds of groups are 2 to
3 months in duration, containing 8 to 12 sessions.
Expansion of Groups in Contemporary Thus, they are time limited.
Society: The “Age of Ubiquity”? Brief group therapy is of considerable interest for
Sometimes when in the midst of a torrent of ongoing a variety of reasons. Research attests to its efficacy
events and activities, the significance of the action and wide applicability (e.g., Piper & Joyce, 2002;
can be overlooked. The Renaissance, for instance, Spitz, 1996). In addition, BGT may be a treatment
was not experienced as a special time by Michelangelo, of choice for specific client problems, such as com-
it is said. plicated grief, adjustment problems, trauma reac-
I earlier noted Yalom’s observation that the tions, existential concerns, and more recently with
myriad of group therapies available today is “mind- medically ill patients. Combinations of BGT can be
boggling as is there application and use across the used for those with personality disorders (Piper &
wide variety of settings in our society (Kalodner & Ogrodniczuk, 2004).
Hanus, 2011). Although certainly not approaching Limitations of BGT also reflect those of groups
the status or significance of the Renaissance, when in general. (Although I have not addressed these
group historians look back at the early 21st century, concerns earlier, they represent nagging roadblocks
they may assign special notice to the variety and to be overcome in order to deliver group counsel-
expanse of groups occurring in our contemporary ing more satisfactorily.) An appreciable number of
society—whether these be called group “therapies,” people who could benefit from groups find them, at
“group work,” or some other terms. Certainly, from least on the surface, threatening and intimidating.
the beginnings of Pratt’s mini-lectures, to numbers Many people sometimes feel vulnerable disclosing
of tuberculin patients gathered together, to the pres- in the presence of others they do not know or trust
ent day, populated by hundreds of thousands of (at least initially) and sense that they would like
face-to-face and online groups, the always robust more privacy than a group affords. Thus, many
group method can be said to have entered an Age people are resistant to the thought of joining a ther-
of—what? Perhaps, I suggest, “Ubiquity.” apeutic group.

634 group couns el in g

 Administratively, it requires more time and effort Social Justice Groups
to organize a group than it does to work with people The origins of counseling and social work are traced
individually. Obtaining referrals to a new group, or to the early 1900s and are rooted in social change
recruiting and selecting members in other ways can efforts. For instance, Jane Addams (social work)
be challenging. Forming groups comprised of mem- and Jesse B. Davis (guidance) worked in the settle-
bers for whom the intended group will be useful ment house movement and in schools, respectively,
sometimes is difficult. During the course of a group, using groups to introduce democratic processes,
certain members may withdraw prematurely, which promote social support, advance learning and
may heighten the anxiety of other members about human development, and to seek social change. As
staying in the group. Developing an organized Leddick (2008, 2011) pointed out, Addams used
group system within agencies requires concerted groups with immigrants at Hull House in Chicago,
dedication, commitment, and skill. seeking to engage them in social skills, hygiene, and
Leading groups requires a unique perspective, nutrition but also to promote larger community
training, and competencies. The shorter-term focus change.
of BGT demands that group leaders trained in lon- After decades during which group work targeted
ger-term methods adapt successfully. Training and person-change areas while minimizing attention to
supervision for leading groups is an issue needing social change, the end of the last century was marked
general attention, with the demand for groups by renewed vigor in addressing change approaches
sometimes outpacing the supply of well-trained aimed at social justice and community development
group leaders (Brown, 2011; Conyne et al., (e.g., see Lee, 2007; Toporek, Gerstein, Fouad,
2008;Riva, 2011; Shapiro, 2011). Roysircar-Sodowsky, & Israel, 2005), including
Piper and Ogrodniczuk (2004) point to a unique attention to using prevention groups (e.g., Waldo,
limitation of BGT that is related to managed care. Schwartz, Horne, & Cote, 2011) for these purposes.
Although coverage is generally a positive factor, Examples of groups being used for social justice and
consumers and group leaders both sometimes ques- system change can be found in the area of commu-
tion the tendency of managed care companies to nity-based participatory research and action (Finn
prioritize efficiency and cost savings over the quality & Jacobson, 2003; Jacobson & Rugeley, 2007),
of care. Counselors also may be wary of involve- expanding learning from the group social micro-
ment due to reimbursement concerns. cosm to external system application (Orr et al.,
2008), and in using empowerment groups in schools
Mutual-help Groups (Bemak, 2005). Using groups and group processes
Klaw and Humphreys (2004) reviewed the role of for social justice is emerging as an important
peer-led mutual-help groups in enhancing well- approach, leading Hage, Mason and Kim Jung Eun
being and health. Drawing from a national survey (2011) to emphasize that it no longer is wise to treat
(Kessler, Mickelson, & Zhao, 1997) they reported or prevent human problems without incorporating
that approximately 7% (about 11 million) of adults attention to social problems.
in the United States participated in a mutual-/self-
help group in the year studied, and that 18% of
Americans had done so at some time during their Trauma and Disaster Preparedness Groups
lives. Not counting self-help groups for prevention Group-based interventions for trauma survivors
purposes (Conyne, 2004; Waldo, Schwartz, Horne, were receiving attention (Burlingame & Layne,
& Cote, 2011), some examples of these groups 2001) prior to the tragedy of the September 11,
include: Mended Hearts (ischemic heart disease), 2001 terrorist attacks (9/11). Following it, many
Overeaters Anonymous, Young at Heart (arthritis), professional associations in the helping fields
Narcotics Anonymous, and Make Today Count responded through publications (e.g., Webber, Bass,
(malignant neoplasms). Klaw and Humphries point & Yep, 2005; Buchele & Spitz, 2004) and provision
out that these kinds of groups are low-cost, partici- of training and services that addressed trauma, ter-
pation in them can produce positive health out- rorism, and recovery. For instance, in their post-
comes while often lowering health care expenditures, 9/11 initiative aimed at group interventions for
and that professionally led groups can be improved trauma treatment and disaster preparedness and
by integrating with self-help approaches, perhaps response, the AGPA now provides direct services
especially if professionals leaders can collaborate to victims, survivors, witnesses, and early respond-
with their group members (Silverman, 2011). ers; support systems to helpers; publications; and

cony ne 635
training for mental health practitioners (Klein & no professional help would be readily available
Phillips, 2008). This type of program by a profes- (Galinsky, Schopler, & Abell, 1997). This form of
sional association illustrates how groups are being online group also has been shown to provide sup-
used to address a critically important contemporary port generally and to individual members specifi-
issue. While some promising group approaches are cally (Winzelberg, 1997), perhaps because they are
being used with people from trauma and disaster able to include therapeutic factors such as universal-
situations, they are presently “evidence-informed” ity, instillation of hope, and cohesion (Gary &
and await the generation of evidence (Foy, Drescher, Remolino, 2000). Page’s review also pointed to pos-
& Watson, 2011). itive outcomes from asynchronous groups for mem-
bers in alcohol treatment programs and for reduction
Online Groups of pain in hospitalized children (Holden, Bearison,
Groups always have been conducted face-to-face, Rode, Kapoloff, & Rosenberg, 2000; King, 1994).
and nearly all of the existing research and practice At the same time, concerns are raised in these
knowledge is premised on that direct format. With groups. Information transmitted is unable to con-
the explosion in the creation and availability of tain nonverbal behavior, such as voice tones and
computers and online technologies, however, a body language. Issues related to safety and the com-
whole new arena has been opened. Although there munication of inaccurate information can be espe-
remains concern about losing the value of personal, cially problematical in these groups, too, which
face-to-face groups, online formats have flour- typically are led by peers or nonprofessionals (Finn,
ished in what was termed an “electronic frontier” 1996; Galainsky, et al., 1997).
(Bowman & Bowman, 1998)—an eon ago when The newest wave of online groups seems to be
counting in technological years. synchronous video groups, although the research lit-
An increasing range of possibilities exists for erature on them has yet to emerge, in part because
online group application. These include but are not the technology needed to conduct them is not
limited to: interactive e-journaling (Haberstroh, widely available (it uses polycoms connected through
Parr, Gee, & Trepal, 2006), Internet support groups Internet 2). Its potential is attractive, though,
(Lieberman, Wizlenberg, Golant, & Minno, 2005), because these high-quality, video-based groups allow
synchronous and asynchronous online discussions for interaction that is analogous to that occurring in
(Romano & Cikanek, 2003), and making use of face-to-face groups. Nonverbal information, as well
videos and computer simulations for training as verbal information, becomes available in real-time
(Smokowski, 2003). situations (Page et al., 2003; Smokowski, 2003).
In general, online groups take two forms: asyn- Ethical considerations need attention. Online
chronous and synchronous. In the first case, par- communication presents some unique ethical con-
ticipants join an Internet discussion at different siderations about which standards have been devel-
times to post their input. In synchronous groups, oped: Standards for the Ethical Practice of Internet
members logon at the same time, and they are Counseling (National Board for Certified Coun-
able to communicate with each other in real time. selors [NBCC], 2007) and Ethical Standards for
Regardless, most of these groups use an e-mail Internet On-line Counseling (American Counseling
format in which members post to a message board Association [ACA], 1999). The APA’s Statement on
or a common site. These sites are ubiquitous. Page Services by Telephone, Teleconferencing, and Internet
(2004) reports that an Internet review conducted in (APA, 2008) addresses general matters of interest in
September 2001 revealed approximately 403,000 this area but not online services. In general, these
sites for “online group counseling,” and another documents apply general ethical principles to online
1,720,000 sites for “support groups online.” No practice, but they do not address online group ser-
doubt these numbers have increased considerably vices specifically.
today.
Research on online groups is scarce. Page (2004) one example of a synchronous
also has summarized results from the few number of online group
studies extant of online groups. For asynchronous A brief description of one such online group
groups, where most of the online group research option, a synchronous online support groups, may
exists, convenience is an attractive factor because give some shape to the various options that exist
they are available 24/7, thus permitting members to (Page et al., 2000). The Palace (The Palace
read and react at any time, including at times when Incorporated, 1998), downloaded Internet software,

636 group couns el in g

enables members to connect online in a graphical It seems that comprehensive group work today
“room” to “talk” interactively by typing messages (Conyne et al., 1997) must include online, Internet,
synchronously to each other. For instance, group social networking, and other electronic possibilities.
members can be represented visually by their pho- At a time in history when solid research and practice
tographs, which are taken with a digital camera, continues to accumulate about group counseling, it
scanned into the computer, and transferred to the also is clear that the use and adaptations of both
prop window of The Palace. Messages are typed face-to-face groups and those groups provided
using one of four formatting icons (e.g., a speech online are proliferating. A key question is if group
bubble or a thinking bubble). These messages appear counselors will become involved in using these
immediately and simultaneously on all members’ modes and, if they do, will they promote ethical
screens, so that it is possible for group members to practice and effective care? (Page, 2011).
interact in real time. A spiked bubble allows for Although this expansion into the online world
emotions to be communicated. Other visual cues can be concerning with regard to many currently
and procedures accompany this software. Leaders unanswered issues of quality and measured effec-
skilled in the use of technology, in how to plan tiveness, the fact that groups literally are everywhere
groups, and in group process, and who are knowl- stands as good news for those who have always
edgeable about the ethical practice of Web counsel- believed, in the end, in “giving groups away.”
ing (e.g., National Board of Certified Counselors,
2007) may find this kind of option worthy of explo- Conclusion
ration and possible use. Face-to-face group counseling is effective and effi-
As Page (2004) points out, one of the discrepan- cient in promoting change and growth in members.
cies between online and face-to-face groups is that Its more than 100-year history is marked by expan-
traditional conceptual frameworks and labels (such sion, solidification, and continued innovation.
as task, psychoeducation, counseling, and psycho- Standards, principles, and guidelines have emerged
therapy) do not appear to provide a good fit for the as reference points.
legions of groups populating the Internet. Online Group counseling and other group forms are
groups vary from customary groups along several conducted across the spectrum of remediation,
dimensions. For instance, they tend to be self-help development, and prevention to address a range of
or support groups in nature, they can be synchro- target populations. Groups are located in an array of
nous or asynchronous, and many of these groups settings from private practice to schools, communi-
are not led by mental health professionals. ties, and organizations. They are professionally led
Social networking Internet formats, such as and are self-help, offered face-to-face and online,
Facebook.com, Twitter.com,Academia.com, others they are brief or longer-term, the address trauma
presently in place and those that undoubtedly and wellness. Mechanisms for positive change have
will mushroom in the future, appear to be rich in been identified generally, with further refinements
research opportunities. The quotation, below, addresses emerging in robust research programs, being dis-
Facebook.com: seminated through respected scholarly vehicles. We
have entered an “Age of Ubiquity,” with a future full
[I]t is Facebook’s role as a Petri dish for the social
sciences—sociology, psychology, and political
of opportunities and challenges.
science—that particularly excites some scholars,
because the site lets them examine how people, Future Directions
especially young people, are connected to one The future of group counseling is bright. To inten-
another—something few data sets offer, sify and expand its glow, the following ten points
the scholars say. are offered, which evolve from the preceding narra-
(Rosenbloom, 2007) tive. They are arranged generally into research and
practice categories:
For further review of online and other forms
of electronic groups, consult special journal issues
Research
dealing with the general topic of electronic group
work, published in Group Dynamics (2002) and • The group research agenda needs to deepen,
in the Journal for Specialists in Group Work (2003). widen, and integrate.The promising lines of
A special issue of The Counseling Psychologist (2005) research focused on the process engines that
also focused on online counseling. drive groups, including cohesion, culture, and

cony ne 637
therapeutic factors are revealing important psychology need to find their way more
practice applications that invite deepening and quickly and strategically into
focusing more closely on group phenomena group practice.
(e.g., Kivlighan et al., 2000;Kivlighan, et al., 2011; • Group research, practice, and training
Riva et al., 2004; Stockton & Morran, 2011). knowledge that is reported through the
A widening of group research will explore organs of different professional associations, and
multicultural, online, prevention, trauma, and sometimes in different disciplines, needs to be
other expansions of group application (Chen, interconnected by scholars, with emerging best
Kakkad, & Balzano, 2008; DeLucia-Waack et al., practices made available to trainers and
2004; Foy, Deschler & Watson, 2011; Gazda et al., practitioners (Berdahl & Henry, 2005;
2001), and wider adoption of various credible Rapin, 2011).
research methodologies, such as qualitiative • Group researchers need to study the various
research, needs to occur (Rubel & forms of online group systems (Williams, 2002)
Atieno Okech, 2011). for efficacy, to determine what modes work best
• Continued investigation of the evidence for what situations and which people. As well,
basis for group counseling needs to continue and tending toward practice, more group counselors
be extended (Burlingame & Beecher, 2008). need to explore the appropriate use of electronic
This focal area is beginning to coalesce around the and online vehicles in their work (McGlothlin,
designation of RSGT Barlow, 2011; 2003). Ethical guidelines that are specific to these
(Johnson, 2008; McClendon & Burlingame, online group systems also await development
2011). As well, RSGT efforts also need to include (Page, 2004, 2011). Online offerings would
cultural and setting differences (Chen et al., 2008) match the daily life practice of millions of teens
and the whole span of group dynamics and adults in contemporary society.
(Kivlighan, 2008).
• Adopting common conceptions of
Practice
group counseling and other group formats
(e.g., the ASGW delineation of group work types: • The “Age of Ubiquity” in group counseling
task, psychoeducation, counseling, and means, in part, that training in counseling
psychotherapy (Ward, 2011); the multifaceted psychology must rearrange itself to make
model of group psychotherapy described by obvious room for group work in the curriculum
Burlingame et al., 2005; the Group Work (Brown, 2011; Conyne et al., 1997; Conyne &
Grid of Conyne, 1985) would assist group Bemak, 2004; Shapiro, 2011). Group counseling
research, for example, of therapeutic factors across should not be a postdoctoral specialty only.
different types of groups and settings (Kivlighan, In addition, it should permeate and support other
2008; Kivlighan & Holmes, 2004). Such counseling and psychological interventions and
definitions could emerge through coordinated stand on its own as an important method,
attention by major professional associations in capable of delivery by a wide range of trained
the area of groups (Brown, 2011; Rapin, 2011) practitioners.
such as the GPRN which presently includes the • Groups are effective (e.g., Payne & Marcus,
AGPA, the ASGW, the Society of Group 2008) and, of course, efficient. Group counseling
Psychology and Group Psychotherapy of the APA, advocates must build on these realities to develop
and the Association fo the Advancement of Social concerted strategies to influence the future of
Work with Groups. health care, particularly managed care, to fully
• The connection among group research, incorporate group delivery formats as reimbursable
group training, group supervision, and group services (Spitz, 1996). Group services must
practice needs to be bridged more fully (e.g., become an integral part of any future renovation
Anderson & Wheelan, 2005; Brabender, 2011; of the nation’s health care system.
McClendon & Burlingame, 2011; Kivlighan, • Professionally led group methods—
Miles & Paquin, 2011; Marmarosh &Van Horn, developed largely from group psychotherapy
2011; Riva, 2011). This is a continuing challenge research with majority adults in closed groups—
in virtually all areas of counseling psychology, and need to be intentionally adapted, where needed, to
it certainly exists in the domain of groups. support work with open groups and with groups
For instance, relevant research findings in social for children, minorities, the aged, for prevention,

638 group couns el in g

for social justice, and in international contexts Association for Specialists in Group Work (ASGW). (1998b).
(Conyne, 2004; DeLucia-Waack, 2011; Hage, Principles for diversity-competent group workers. Retrieved
October 30, 2007, from http://www.asgw.org/PDF/
et al., 2011; Keim & Olguin, 2011; McWhirter, Principles_for_Diversity.pdf.
et al., 2011; Ritter, 2011; Waldo, Schwartz, Association for Specialists in Group Work (ASGW). (2000).
Horne, & Cote, 2011) and also to support Professional standards for the training of group workers.
mutual help groups (Silverman, 2011). Retrieved October 31, 2007, from http://www.asgw.org/
• Barriers against group counseling PDF/training_standards.pdf.
Association for Specialists in Group Work (ASGW). (2008). Best
(e.g., ineffective referral processes, cumbersome practice guidelines: 2007 revisions. Journal for Specialists in
processes for organizing groups within agencies, Group Work, 33, 111–117.
or inaccurate myths about group counseling) Association for the Advancement of Social Work with Groups,
need to be reduced to allow groups to become Inc. (2006). Standards for social work practice with groups
more attractive and available to more people (2nd ed.). Alexandria, VA: Author.
Bales, R. F. (1950). Interaction process analysis. Cambridge,
(DeLucia-Waack, 2011; Kleim & MA: Harvard University Press.
Olguin, 2011; Ritter, 2011;Trotzer, 2006). Barlow, S. (2011). Evidence bases for group practice.
In R. K. Conyne (Ed.), The Oxford handbook of group
counseling. New York: Oxford University Press.
References Barlow, S., Burlingame, G., & Fuhriman, A. (2000). Therapeutic
Agazarian, Y. (1999). Phases of development in the system- applications of groups: From Pratt’s “thought control classes”
centered group. Small Group Research, 30, 82–107. to modern group psychotherapy. Group Dynamics: Theory,
American Counseling Association (ACA). (1999). Ethical stan- Research, and Practice, 4, 115–134.
dards for Internet on-line counseling. Retrieved December 22, Barlow, S., Fuhriman, A., & Burlingame, G. (2004). The history
2008, from http://www.angelfire.com/co2/counseling/ of group counseling and psychotherapy. In J. DeLucia-
ethical.html. Waack, D. Gerrity, C. Kalodner, & M. Riva (Eds.), Handbook
American Group Psychotherapy Association (AGPA). (2002). of group counseling and psychotherapy (pp. 3–22). Thousand
Ethical guidelines for group therapists. Retrieved October 31, Oaks, CA: Sage.
2007, from http://agpa.org/group/ethicalguide.html. Barlow, S., Fuhriman, A., & Burlingame, G. (2005). The history
American Group Psychotherapy Association (AGPA). (n.d.). of group practice: A century of knowledge. In S. Wheelan
Group works! An introduction to group therapy. Retrieved (Ed.), Handbook of group research and practice (pp. 39–64).
October 30, 2007, from http://agpa.org/group/consumers Thousand Oaks, CA: Sage.
guide2000.html. Beck, A., & Lewis, C. (Eds.). (2000). The process of group psycho-
American Group Psychotherapy Association (AGPA). (2007). therapy: Systems for analyzing change. Washington, DC:
Practical guidelines for group psychotherapy. Retrieved American Psychological Association.
October 31, 2007, from http://www.agpa.org/guidelines/ Bednar, R., & Kaul, T. (1978). Experiential group research:
index.html. Current perspectives. In A. Bergin & S. Garfield (Eds.),
American Psychological Association (APA). (2002). Guidelines on Handbook of psychotherapy and behavior change. New York:
multicultural education, training, research, practice, and organi- Wiley.
zation change for psychologists. Retrieved October 31, 2007, Bednar, R., & Kaul, T. (1994). Experiential group research:
from http://www.apa.org/pi/multiculturalguidelines.pdf. Can the cannon fire? In A. Bergin, & S. Garfield (Eds.),
American Psychological Association (APA). (2008). APA Handbook of psychotherapy and behavior change (4th ed.,
statement on services provided by telephone, teleconferencing, pp. 631–663). New York: Wiley.
and Internet. Retrieved December 22, 2008, from http:// Bemak, F. (2005). Reflections on multiculturalism, social justice,
www.apa.org/ethics/stmnt01.html. and empowerment groups for academic success: A critical
American Psychological Association (APA). Division 49. discourse for contemporary schools. Professional School
Retrieved October 29, 2007, from http://www.apa49.org. Counseling, 8, 401–406.
Andronico, M. (1999). A history of Division 49. In D. Dewsbury Bemak, F., & Conyne, R. (2004). Ecological group work.
(Ed.), Unification through division: Histories of the divisions In R. Conyne & E. Cook (Eds.), Ecological counseling: An
of the American Psychological Association (pp. 175–196). innovative approach to conceptualizing person-environment
Washington, DC: American Psychological Association. interaction (pp. 195–217). Alexandria, VA: American Coun-
Andronico, M. (2001). A history of Division 49 (Group seling Association.
Psychology and Group Psychotherapy). The Group Psy- Berdahl, J., & Henry, K. B. (2005). Contemporary issues in
chologist, 10–18. group research. In S. Wheelan (Ed.), The handbook of group
Anderson, G., & Wheelan, S. (2005). Integrating group research research and practice (pp. 19–37). Thousand Oaks, CA:
and practice. In S. Wheelan (Ed.), The handbook of group research Sage.
and practice (pp. 545–552). Thousand Oaks, CA: Sage. Bernard, H., Burlingame, G., Flores, P., Greene, L., Joyce, A.,
Armstrong, S., & Berg, R. (2005). Demonstrating group process & Kobos, J. (2008). Clinical practice guidelines for group
using “12 Angry Men.” Journal for Specialists in Group Work, psychotherapy. International Journal of Group Psychotherapy,
30, 135–144. 58, 455–542.
Association for Specialists in Group Work (ASGW). (1998a). Bertcher, H. (1985). Social group work: Past, present, and future.
Best practice guidelines. Retrieved October 30, 2007, from Journal for Specialists in Group Work: Special Issue on Critical
http://www.asgw.org/PDF/Best_Practices.pdf. Issues in Group Work: Now and 2001, 10, 77–82.

cony ne 639
Bieschke, K., Matthews, C., & Wade, J. (1996). Training group Burlingame, G., Kapetanovic, S., & Ross, S. (2005). Group psy-
counselors: The process observer method. Journal for chotherapy. In S. Wheelan (Ed.), The handbook of group
Specialists in Group Work, 21, 181–186. research and practice (pp. 387–406). Thousand Oaks, CA:
Bieschke, K., Matthews, C., & Wade, J. (1998). Evaluation of Sage.
the process observer method. Journal for Specialists in Group Burlingame, G., & Layne, C. (2001). Group-based interventions
Work, 23, 50–65. for trauma survivors: Introduction to the special issue. Group
Blatner, A. (2007). A historical chronology of group psychother- Dynamics: Theory, Research and Practice, 5, 243–245.
apy and psychodrama. Retrieved December 6, 2007, from Burlingame, G., MacKenzie, K., & Strauss, B. (2004).
http://www.blatner.com/adam/pdntbk/hxgrprx.htm. Small group treatment: Evidence for effectiveness and mech-
Bowman, R., & Bowman, V. (1998). Life on the electronic fron- anisms for change. In M. Lambert (Ed.), Bergin and Garfield’s
tier: The application of technology to group work. Journal for handbook of psychotherapy and change (5th ed., pp. 647–696).
Specialists in Group Work, 23, 428–445. New York: Wiley.
Bowman, V., & DeLucia-Waack, J. (1993). Preparation for Burlingame, G., Strauss, B., Joyce, A., MacNair-Semands, R.,
group therapy: The effects of preparer and modality on group MacKenzie, K., Ogrodniczuk, J., & Taylor, S. (2006). Core
process and individual functioning. Journal for Specialists in Battery-Revised. New York: American Group Psychotherapy
Group Work, 18, 67–79. Association.
Braaten, L. (1989). Predicting positive goal attainment and Chen, E., Kakkad, D., & Balzano, J. (2008). Multicultural
symptom reduction from early group climate dimensions. competence and evidence- based practice in group psycho-
International Journal of Group Psychotherapy, 39, 377–387. therapy. Journal of Clinical Psychology, 64, 1261–1278.
Brabender, V. (2011). Group development. In R. K. Conyne Council for the Accreditation of Counseling and Related Programs
(Ed.), The Oxford handbook of group counseling. New York: (CACREP). (2001). 2001 standards. Retrieved November 1,
Oxford University Press. 2007, from http://www.cacrep.org/2001Standards.html.
Bradford, L., Gibb, J., & Benne, K. (Eds.). (1964). T-group Coche, E., Dies, R., & Goettelman, K. (1991). Process variables
theory and laboratory method: Innovation in re-education. mediating change in intensive group therapy training. Inter-
New York: Wiley. national Journal of Group Psychotherapy, 41, 379–397.
Bronfenbrenner, U. (1977). Toward an experimental ecology of Cohen, A., & Smith, R. D. (1976). The critical incident in growth
human development. American Psychologist, 32, 515–531. groups: Theory and technique. La Jolla, CA: University Associates.
Brown, N. (2011), Group leadership treaching and training: Colijn, S., Hoencamp, E., Snijders, H., van der Spek, M., &
Methods and issues. In R. K. Conyne (Ed.), The Oxford Duivenvoorden, H. (1991). A comparison of curative factors
handbook of group counseling. New York: Oxford University in different types of group psychotherapy. International
Press. Journal of Group Psychotherapy, 41, 365–378.
Buchele, B., & Spitz, H. (Eds.). (2004). Group interventions for Conyne, R. (Ed.). (1985). The group worker’s handbook: Varieties
treatment of psychological trauma. New York: American Group of group experience. Springfield, IL: Thomas.
Psychotherapy Association. Conyne, R. (1987). Developing framework for processing expe-
Budman, S., Soldz, S., Demby, A., Feldstein, M., Springer, T., & riences and events in group work. Journal for Specialists in
Davis, M. (1989). Cohesion, alliance, and outcome in group Group Work, 22, 167–174.
psychotherapy. Psychiatry, 52, 339–350. Conyne, R. (1989). How personal growth and task groups work.
Burlingame, G. (2005). Revisiting AGPA’s CORE battery: Newbury Park, CA: Sage.
Another approach for group therapists to use in adapting to Conyne, R. (1998). What to look for in groups: Helping trainees
the pressure for evidence-based group practice. Group Circle, become more sensitive to multicultural influences. Journal
Winter. for Specialists in Group Work, 23, 22–32.
Burlingame, G., & Beecher, M. (2008). Special issue: New Conyne, R. (1999). Failures in group work. Thousand Oaks, CA:
directions and resources in group psychotherapy: Introdu- Sage.
ction to the issue. Journal of Clinical Psychology, 64(11), Conyne, R. (2004). Prevention groups. In J. DeLucia-Waack,
1197–1291. D. Gerrity, C. Kalodner, & M. Riva (Eds.), Handbook of
Burlingame, G., & Fuhriman, A. (Eds.). (1994). Handbook group counseling and psychotherapy (pp. 621–629). Thousand
of group psychotherapy: An empirical and clinical synthesis Oaks, CA: Sage.
(pp. 559–562). New York: Wiley. Conyne, R., Wilson, F. R., & Ward, D. (1997). Comprehensive
Burlingame, G., Fuhriman, A., & Johnson, J. (2001). Cohesion group work: What it means and how to teach it. Alexandria,
in group psychotherapy. Psychotherapy, 38, 373–379. VA: American Counseling Association.
Burlingame, G., Fuhriman, A., & Johnson, J. (2002). Cohesion Conyne, R. K. (Ed.). (2011). The Oxford handbook of group coun-
in group psychotherapy. In J. Norcross (Ed.), Psychotherapy seling. New York: Oxford University Press.
relationships that work (pp. 71–87). New York: Oxford Conyne, R., & Bemak, F. (2004). Teaching group work from
University Press. an ecological perspective. Journal for Specialists in Group
Burlingame, G., Fuhriman, A., & Johnson, J. (2004). Process Work: Special Issue on Teaching Group Work, 29, 7–18.
and outcome in group counseling and psychotherapy: A per- Conyne, R., & Cook, E. (Eds.). (2004). Ecological counseling:
spective. In J. DeLucia-Waack, D. Gerrity, C. Kalodner, & An innovative approach to conceptualizing person-environment
M. Riva (Eds.), Handbook of group counseling and psychother- interaction. Alexandria, VA: American Counseling Association.
apy (pp. 49–61). Thousand Oaks, CA: Sage. Conyne, R., Crowell, J., & Newmeyer, M. (2008). Purposeful
Burlingame, G., Fuhriman, A., & Mosier, J. (2003). The differ- group techniques: How to use them more purposefully. Upper
ential effectiveness of group psychotherapy: A meta-analytic Saddle River, NJ: Prentice-Hall.
perspective. Group Dynamics: Theory, Research, and Practice, Conyne, R., Dye, A., Gill, S., Leddick, G., Morran, D. K.,
7, 3–12. & Ward, D. (1985). A retrospective of “critical issues.”

640 group couns el in g

 Journal for Specialists in Group Work: Special Issue on Critical Dion, K. (2000). Group cohesion: From “field of forces” to mul-
Issues in Group Work: Now and 2001, 10, 112–115. tidimensional construct. Group Dynamics: Theory, Research,
Conyne, R., Tang, M., & Watson, A. (2001). Exploring diversity and Practice: Special Issue on One hundred years of groups
in groups. In E. Welfel, & R. Ingersoll (Eds.), The mental research, 4, 7–26.
health desk reference (pp. 358–364). New York: Wiley. Donigian, J., & Malnati, R. (1997). Systemic group therapy:
Conyne, R., Wilson, F. R., & Tang, M. (2000). Evolving lessons A triadic model. Pacific Grove, CA: Brooks/Cole.
from group work involvement in China. Journal for Specialists Durkin, H. (1981). The group therapies and general sys-
in Group Work, 25, 252–268. tem theory as an integrative structure. In J. Durkin (Ed.),
Conyne, R., Wilson, F. R., Tang, M., & Shi, K. (1999). Cultural Living groups: Group psychotherapy and general system theory
similarities and differences in group work: Pilot study of (pp. 5–23). New York: Brunner/Mazel.
a U.S.-Chinese task group comparison. Group Dynamics: Dye, H. A. (2008, February 21). Color comments on the history
Theory, Research, and Practice, 3, 40–50. of group work. In B. Bertram, & H. A. Dye, ASGW living
Conyne, R., Wilson, F. R., & Ward, D. (1997). Comprehensive genogram. Presentation at the national conference of the
group work: What it means & how to teach it. Alexandria, VA: Association for Specialists in Group Work, St. Pete Beach,
American Counseling Association. Florida.
Corey, G. (2007). Theory and practice of group counseling Finn, F. (1996). Computer-based self-help groups: On-line recov-
(7th ed.). Pacific Grove, CA: Brooks/Cole. ery for addictions. Computers in Human Services, 13, 21–41.
Corey, M., & Corey, G. (2006). Groups: Process and practice Finn, J., & Jacobson, M. (2003). Just practice: A social justice
(7th ed.). Pacific Grove, CA: Brooks/Cole. approach to social work. Peosta, IA: Eddie Bowers Publishing,
Corey, G., Corey, M., Callanan, P., & Russell, J. (2004). Inc.
Group techniques (3rd ed.). Belmont, CA: Thomson Brooks/ Forester-Miller, H. (1998). History of the Association for
Cole. Specialists in Group Work: ASGW—Timeline of significant
Cox, J., Banez, L., Hawley, L., & Mostade, J. (2003). Use of events. Journal for Specialists in Group Work, 23, 335–337.
the reflecting team in the training of group workers. Journal Forsyth, D. (Ed.). (2000). One hundred years of groups research
for Specialists in Group Work, 28, 89–105. [Special Issue]. Group Dynamics: Theory, Research, and
Crouch, E., Bloch, S., & Wanlass, J. (1994). Therapeutic factors; Practice, 4.
Interpersonal and intrapersonal mechanisms. In A. Fuhriman, Forsyth, D. (2006). Group dynamics. Belmont, CA: Thomson
& G. Burlingame (Eds.), Handbook of group psychotherapy: Wadsworth.
An empirical and clinical synthesis (pp. 269–318). New York: Forsyth, D. (2011). The nature and significance of groups.
Wiley. In R. K. Conyne (Ed.), The Oxford handbook of group counsel-
Dagley, J., Gazda, G., Eppinger, S., & Stewart, E. (1994). Group ing. New York: Oxford University Press.
psychotherapy research with children, preadolescents, and Foulkes, S., & Anthony, E. (1957). Group psychotherapy: The
adolescents. In A. Fuhriman, & G. Burlingame (Eds.), psychoanalytic approach. London: Penguin Books.
Handbook of group psychotherapy (pp. 340–369). New York: Foy, D., Drescher, K., & Watson, P. (2011). Groups for trauma/
Wiley. disaster. In R. K. Conyne (Ed.), The Oxford handbook of
D’Andrea, M. (2004). The impact of racial-cultural identity group counseling. New York: Oxford University Press.
of group leaders and members: Theory and recommen- Fuhriman, A., & Burlingame, G. (1994). Measuring small group
dations. In J. DeLucia-Waack, D. Gerrity, C. Kalodner, & process: A methodological application of chaos theory. Small
M. Riva (Eds.), Handbook of group counseling and psychother- Group Research, 25, 502–519.
apy (pp. 265–282). Thousand Oaks, CA: Sage. Fuhriman, A., & Burlingame, G. (2000). Group psychotherapy.
Davies, D., & Jacobs, A. (1985). Sandwiching complex interper- In A. Kazdin (Ed.), Encyclopedia of psychology (pp. 31–35).
sonal feedback. Small Group Behavior, 16, 387–396. Oxford, UK: Oxford University Press.
DeLucia-Waack, J. (1997). The importance of processing activi- Fuqua, D., & Newman, J. Moving beyond the “great leader”
ties, exercises, and events to group work practitioners. Journal model. Consulting Psychology Journal: Practice and Research,
for Specialists in Group Work, 22, 82–84. 56, 146–153.
DeLucia-Waack, J. (2011). Diversity in groups. In R. K. Conyne Galinsky, M., Schopler, J., & Abell, M. (1997). Connecting
(Ed.), The Oxford handbook of group counseling. New York: group members through telephone and computer groups.
Oxford University Press. Health and social work, 22, 181–188.
DeLucia-Waack, J., & Donigian, J. (2003). The practice of multi- Garrett, M. T. (2004). Group counseling with Native Americans.
cultural group work: Visions and perspectives from the field. In J. DeLucia-Waack, D. Gerrity, D. Kalodner, & M. Riva
Monterey, CA: Wadsworth. (Eds.), Handbook of group counseling and psychotherapy
DeLucia-Waack, J., Gerrity, D., Kalodner, C., & Riva, M. (Eds.). (pp. 169–182). Thousand Oaks, CA: Sage.
(2004). Handbook of group counseling and psychotherapy. Gary, J., & Remolino, L. (2000). Coping with loss and grief
Thousand Oaks, CA: Sage. through on-line support groups. In J. Bloom, & G. Walz
DeLucia-Waack, J., & Kalodner, C. (2005). Contemporary (Eds.), Cybercounseling and cyberlearning: Strategies and
issues in group practice. In S. Wheelan (Ed.), The handbook resources for the millennium (pp. 95–114). Alexandria, VA:
of group research and practice (pp. 65–84). Thousand Oaks, American Counseling Association.
CA: Sage. Gazda, G. (1982). Basic approaches to group psychotherapy and
Dies, R. (1983). Clinical implications of research on leadership group counseling. (3rd ed.). Springfield, IL: Thomas.
in short-term group psychotherapy. In R. Dies, & Gazda, G. (1985). Group counseling and therapy: A perspective
K. MacKenzie (Eds.), Advances in group psychotherapy: on the future. Journal for Specialists in Group Work: Special
Integrating research and practice (pp. 27–75). Madison, CT: Issue on Critical Issues in Group Work: Now and 2001, 10,
International University Press. 74–76.

cony ne 641
Gazda, G., Ginter, E., & Horne, A. (2001). Group counseling emotional and behavioral feedback delivered in groups.
and group psychotherapy: Theory and application. Boston: Journal of Counseling Psychology, 21, 106–111.
Allyn and Bacon. Jacobs, E., Masson, R., & Harvill, R. (2006). Group counseling:
Gladding, S. (2006). Group work: A counseling specialty (5th ed.). Strategies and skills (5th ed.). Pacific Grove, CA: Brooks/
Upper Saddle River, NJ: Prentice-Hall. Cole.
Gladding, S. (2011). Creativity and spontaneity in groups. Jacobson, M., & Rugeley, C. (2007). Community-based partici-
In R. K. Conyne (Ed.), The Oxford handbook of group counsel- patory research: Group work for social justice and commu-
ing. New York: Oxford University Press. nity change. Social Work with Groups, 30, 21–39.
Glass, J., & Benshoff, J. (1999). PARS: A processing model for Johnson, J. (2007). Cohesion, alliance, and outcome in group
beginning group leaders. Journal for Specialists in Group psychotherapy: Comments on Joyce, Piper, & Ogrodniczuk.
Work, 24, 15–26. International Journal of Group Psychotherapy, 57, 533–540.
Golembiewski, R., & Blumberg, A. (Eds.). (1970). Sensitivity Johnson, J. (2008). Using research-supported group treatments.
training and the Laboratory approach: Readings about concepts Journal of Clinical Psychology, 64, 1206–1225.
and applications. Oakland, CA: New Harbinger. Johnson, J., Burlingame, G., Olsen, J., Davies, D. R., & Gleave, R.
Haberstroh, S., Parr, G., Gee, R., & Trepal, H. (2006). Interactive (2005). Group climate, cohesion, alliance, and empathy in
E-journaling in group work: Perspectives from counselor group psychotherapy: Multilevel structural equation models.
trainees. Journal for Specialists in Group Work, 31, 327–337. Journal of Counseling Psychology, 52, 310–321.
Hadden, S. (1955). Historic background of group psychother- Joyce, A., Piper, W., & Ogrodniczuk, J. (2007). Therapeutic
apy. International Journal of Group Psychotherapy, 5, 62. alliance and cohesion variables as predictors of outcome in
Hamburg, D. Personal communication. In I. Yalom, & short-term group psychotherapy. International Journal of
M. Leszcz (Eds.) (2005), The theory and practice of group psy- Group Psychotherapy, 57, 269–296.
chotherapy (5th ed., p. 320). Kaiser, R., Hogan, R., & Craig, S. B. (2008). Leadership and the
Hanson, P. (1972). What to look for in groups. In J. Pfeiffer, & fate of organizations. American Psychologist, 63, 96–110.
J. Jones (Eds.), 1972 annual handbook for group facilitators Kalodner, C., & Hanus, A. (2011). Groups across settings.
(pp. 21–24). La Jolla, CA: University Associates. In R. K. Conyne (Ed.), The Oxford handbook of group counsel-
Hershey, P., Blanchard, K., & Johnson, D. (1982). Manage- ing. New York: Oxford University Press.
ment of organizational behavior: Utilizing human resources Kaul, T. (1990). A matter of consistency: There are just two
(3rd ed.). Englewood Cliffs, NJ: Prentice-Hall. things. The Counseling Psychologist, 18, 121–125.
Higgenbotham, H., West, S., & Forsyth, D. (1988). Psychotherapy Kees, N., & Jacobs, E. (1990). Conducting more effective
and behavior change: Social, cultural and methodological per- groups: How to select and process group exercises. Journal for
spectives. New York: Pergamon. Specialists in Group Work, 15, 21–30.
Hill, W. F. (1965). HIM: Hill Interaction Matrix. Los Angeles, Kees, N., & Leech, N. (2002). Using group counseling tech-
CA: University of Southern California Youth Studies Center. niques to clarify and deepen the focus of supervision groups.
Holden, G., Bearison, D., Rode, D., Kapoloff, M., & Journal for Specialists in Group Work, 27, 7–15.
Rosenberg, G. (2000). The Effects of a computer network on Keim, J., & Olguin, D. (2011). Group counseling across the life
pediatric pain and anxiety. In J. Finn, & G. Holden (Eds.), span: A psychosocial perspective. In R. K. Conyne (Ed.),
Human services online: A new arena for service delivery The Oxford handbook of group counseling. New York: Oxford
(pp. 27–47). Binghamton, NY: Haworth. University Press.
Holliday, G., Statler, M., & Flanders, M. (2007). Developing Kessler, R., Michelson, K., & Humphreys, K. (1997). Patterns
practically wise leaders through serious play. Consulting and correlates of self-help group membership in the United
Psychology Journal, 59, 126–134. States. Social Policy, 27, 27–46.
Holmes, S., & Kivlighan, D. (2000). Comparison of therapeutic King, S. (1994). Analysis of electronic support for recovering
factors in group and individual treatment processes. Journal addicts. Interpersonal Computing and Technology: An Electronic
of Counseling Psychology, 47, 478–484. Journal for the 21st Century, 2, 47–56.
Horne, A., & Rosenthal, R. (1997). Research in group work: Kivlighan, D., Jr. (1997). Leader behavior and therapeutic
How did we get where we are? Journal for Specialists in Group gain: An application of situational leadership theory. Group
Work, 22, 228–240. Dynamics: Theory, Research, and Practice, 1, 32–38.
Hulse-Killacky, D., & Donigian, J. (2001). Making task groups Kivlighan, D., Jr. (2008). Overcoming our resistance to “doing”
work in your world. Upper Saddle River, NJ: Prentice-Hall. evidence-based group practice: A commentary. Journal of
Hulse-Killacky, D., & Orr, J. (2006). The Corrective Feedback Clinical Psychology, 64, 1284–1291.
Instrument-Revised. Journal for Specialists in Group Work, 31, Kivlighan, D., Jr., Coleman, M., & Anderson, D. (2000).
263–281. Process, outcome and methodology in group counseling
International Journal of Group Psychotherapy. (2007). Special research. In S. Brown, & R. Lent (Eds.), Handbook of
section: The ethical group psychotherapist. International counseling psychology (3rd ed., pp. 767–796). New York:
Journal of Group Psychotherapy, 57, 1–41. Wiley.
Ivey, A., Pedersen, P., & Ivey, M. (2001). Intentional group counsel- Kivlighan, D., Jr., & Goldfine, D. (1991). Endorsement of ther-
ing: A microskills approach. Pacific Grove, CA: Brooks/Cole. apeutic factors as a function of stage of group development
Ivey, A., Pedersen, P., & Ivey, M. (2008). Group microskills: and participant interpersonal attitudes. Journal of Counseling
Culture-centered group process and strategies. Alexandria, VA: Psychology, 38, 150–158.
Microtraining Associates and the American Counseling Kivlighan, D., Jr., & Holmes, S. (2004). The importance of
Association. therapeutic factors. In J. DeLucia-Waack, D. Gerrity,
Jacobs, A., Jacobs, M., Cavior, N., & Burke, J. (1974). Anon- C. Kalodner, & M. Riva (Eds.), Handbook of group counseling
ymous feedback: Credibility and desirability of structured and psychotherapy (pp. 23–36). Thousand Oaks, CA: Sage.

642 group couns el in g

Kivlighan, D., Jr., & Lilly, R. (1997). Developmental changes in group-derived hope, and the well-being of group therapy
group climate as they relate to therapeutic gain. Group members. Group Dynamics: Theory, Research, and Practice, 9,
Dynamics: Theory, Research, and Practice, 1, 208–221. 32–44.
Kivlighan, D., Jr., McGovern, T., & Corazzini, J. (1984). The MacKenzie, K. R. (1983). The clinical application of a group
effects of the content and timing of structuring interventions climate measure. In R. Dies, & K. MacKenzie (Eds.),
on group therapy process and outcome. Journal of Counseling Advances in group psychotherapy: Integrating research and practice
Psychology, 31, 363–370. (pp. 159–170). Madison, CT: International Universities Press.
Kivlighan, D., Jr., Miles, J., & Paquin, J. (2011). Therapeutic MacKenzie, K. R. (1995). Rationale for group psychotherapy in
factors in group counseling: Asking new questions. managed care. In K. MacKenzie (Ed.), Effective use of group
In R. K. Conyne (Ed.), The Oxford handbook of group counsel- therapy in managed care (pp. 1–26). Washington, DC:
ing. New York: Oxford University Press. American Psychiatric Press.
Kivlighan, D., Jr., & Mullinson, D. (1988). Participants’ percep- MacKenzie, K. R. (1997). Clinical application of group develop-
tion of therapeutic factors in group counseling: The role of ment ideas. Group Dynamics: Theory, Research, and Practice,
interpersonal style and stage of development. Small Group 1, 275–287.
Behavior, 19, 452–468. MacNair-Semands, R. (2006). CORE-R battery: Group selection
Kivlighan, D., Jr., & Tarrant, J. (2001). Does group climate and pre-group preparation. Group Circle (pp. 3–5), Winter.
mediate the group leadership-group outcome relationship? Martin, D., Garske, J., & Davis, M. (2000). Relation of the
A test of Yalom’s hypotheses about leadership priorities. therapeutic alliance with outcome and other variables:
Group Dynamics: Theory, Research, and Practice, 5, 220–234. A meta-analytic review. Journal of Consulting and Clinical
Klaw, E., & Humphreys, K. (2004). The role of peer-led mutual Psychology, 68, 438–450.
help groups in promoting health and well-being. McGlothlin, J. (2003). Response to the mini special issue on
In J. DeLucia-Waack, D. Gerrity, C. Kalodner, & M. Riva technology and group work. Journal for Specialists in Group
(Eds.), Handbook of group counseling and psychotherapy Work, 28, 42–47.
(pp. 630–640). Thousand Oaks, CA: Sage. McKay, M., & Paleg, K. (Eds.). (1992). Focal group psychother-
Klein, R., & Phillips, S. (Eds.). (2008). Group interventions for apy. Oakland, CA: New Harbinger.
disaster preparedness and response. New York: American Group McKenna, Y., & Green, A. (2002). Virtual group dynamics.
Psychotherapy Association. Group Dynamics: Theory, Research, and Practice: Special Issue
Kosters, M., Burlingame, G., Nachtigall, C., & Strauss, B. on Groups and the Internet, 6, 116–127.
(2006). A meta-analytic review of the effectiveness of inpa- McRoberts, C., Burlingame, G., & Hoag, M. (1998).
tient group psychotherapy. Group Dynamics: Theory, Research, Comparative efficacy of individual and group psychotherapy:
and Practice, 10, 146–163. A meta-analytic perspective. Group Dynamics: Theory,
Leddick, G. (2008, February 22). Illustrated history of group work. Research, and Practice, 2, 101–117.
Presentation at the national conference of the Association for McWhirter, J. J., McWhirter, P., McWhirter, B., &
Specialists in Group Work, St. Pete Beach, Florida. McWhirter, E. H. (2011). International group counseling.
Leddick, G. (2011). The history of group counseling. In R. K. Conyne (Ed.), The Oxford handbook of group counsel-
In R. K. Conyne (Ed.), The Oxford handbook of group counsel- ing. New York: Oxford University Press.
ing. New York: Oxford University Press. Merchant, N. (2006). Multicultural and diversity-competent
Lee, C. (2007). Counseling for social justice (2nd ed.). Alexandria, group work. In J. Trotzer (Ed.), The counselor and the group:
VA: American Counseling Association. Integrating theory, training, and practice (4th ed., pp. 319–349).
Leszcz, M., & Kobos, J. (2008). Evidence-based group psycho- New York: Brunner-Routledge.
therapy: Using AGPA’s practice guidelines to enhance clinical Merchant, N. (2008, February 22). Types of multicultural group
effectiveness. Journal of Clinical Psychology, 64, 1238–1260. work: A closer look. Key Note Address at national conference
Lewin, K. (1951). Field theory in social science. New York: of the Association for Specialists in Group Work, St. Pete
Harper. Beach, Florida.
Lewin, K., Lippitt, R., & White, R. (1939). Patterns of aggres- Morran, D. K., Stockton, R., Cline, R., & Teed, C. (1998).
sive behavior in experimentally created “social climates.” Facilitating feedback exchange in groups: Leader interven-
Journal of Social Psychology, 10, 271–299. tions. Journal for Specialists in Group Work, 23, 257–268.
Lieberman, M., Wizlenberg, A., Golant, M., & Minno, M. Morran, D. K., Stockton, R., & Harris, M. (1991). Analysis
(2005). The impact of group composition on Internet sup- of group leader and member feedback messages. Journal
port groups: Homogeneous versus heterogeneous Parkinson’s of Group Psychotherapy, Psychodrama, and Sociometry, 44,
groups. Group Dynamics: Theory, Research, and Practice, 9, 126–135.
239–250. Morran, D. K., Stockton, R., & Whittingham, M. (2004).
Lieberman, M., Yalom, I., & Miles, M. (1973). Encounter groups: Effective leader interventions for counseling and psychother-
First facts. New York: Basic Books. apy groups. In J. DeLucia-Waack, D. Gerrity, C. Kalodner,
Lorentzen, S. (2008). Cohesion, alliance, and outcome in group & M. Riva (Eds.), Handbook of group counseling and psycho-
psychotherapy: Comments on Joyce et al. (2007) and therapy (pp. 91–103). Thousand Oaks, CA: Sage.
Johnson (2007). International Journal of group psychotherapy, National Board of Certified Counselors. (2007). The practice of
58, 403–409. Internet counseling. Retrieved December 22, 2008, from
Macnair-Semands, R. (2007). Attending to the spirit of social http://www.nbcc.org/webethics2.
justice as an ethical approach in group therapy. International Norcross, J. (Ed.). (2002). Psychotherapy relationships that work.
Journal of Group Psychotherapy, 57, 61–66. New York: Oxford University Press.
Marmarosh, C., Holtz, A., & Schottenbauer, M. (2005). Ogrodniczuk, J. (2005). CORE-R battery: Assessment of group
Group cohesiveness, group-derived collective self-esteem, therapy outcomes. Group Circle (pp. 4–5), Spring.

cony ne 643
Ogrodniczuk, J., & Piper, W. (2003). The effect of group climate Handbook of group counseling and psychotherapy (pp. 37–48).
on outcome in two forms of short-term group therapy. Group Thousand Oaks, CA: Sage.
Dynamics: Theory, Research, and Practice, 7, 64–76. Rivera, E. T., Garrett, M. T., & Crutchfield, L. B. (2004).
Orr, J., Wolfe, A., & Malley, J. (2008, February 22). From ripple to Multicultural interventions in groups: The use of indigenous
wave: Using social microcosms in group to address systemic change. methods. In J. DeLucia-Waack, D. Gerrity, C. Kalodner, &
Presentation at the national conference of the Association for M. Riva (Eds.), Handbook of group counseling and psychother-
Specialists in Group Work, St. Pete Beach, Florida. apy (pp. 295–306). Thousand Oaks, CA: Sage.
Page, B. (2003). Introduction to using technology in group Robison, F., Stockton, R., Morran, D. K., & Uhl-Wagner, A.
work. Journal for Specialists in Group Work, 28, 7–8. (1988). Anticipated consequences of communicating correc-
Page, B. (Ed.). (2003). Technology and group work [Special tive feedback during early counseling group development.
issue]. Journal for Specialists in Group Work, 28. Small Group Behavior, 19, 469–484.
Page, B. (2004). Online group counseling. In J. DeLucia-Waack, Romano, J., & Cikanek, K. (2003). Group work and computer
D. Gerrity, C. Kalodner, & M. Riva (Eds.), Handbook of applications: Instructional components for graduate stu-
group counseling and psychotherapy (pp. 609–620). Thousand dents. Journal for Specialists in Group Work, 28, 23–34.
Oaks, CA: Sage. Rosenbaum, M., Lakin, M., & Roback, H. (1992).
Page, B. (2011). Online groups. In R. K. Conyne (Ed.), The In D. Freedharm (Ed.), History of psychotherapy: A century of
Oxford handbook of group counseling. New York: Oxford change. Washington, DC: American Psychological
University Press. Association.
Page, B., Delmonico, D., Walsh, J., L’Amoreauz, N., Rosenbloom, S. (2007, December 17). On Facebook, scholars
Danninhirsh, C., Thompson, R., et al. (2000). Setting up link up with data. New York Times. Retrieved December 17,
on-line support groups using The Palace software. Journal for 2007, from http://www.nytimes.com/2007/12/17/style/
Specialists in Group Work, 25, 133–145. 17facebook.html?_r=1&ref=todayspaper&oref=slogin.
Page, B., Jencius, M., Rehfuss, M., Foss, L., Dean, E., Petruzzi, M., Rubel, D., & Atieno Okech, J. E. (2011). Qualitative research
et al. (2003). PalTalk online groups: Process and reflections approaches and group counseling. In R. K. Conyne (Ed.),
on students’ experience. Journal for Specialists in Group Work, The Oxford handbook of group counseling. New York: Oxford
28, 35–41. University Press.
Payne, K., & Marcus, D. (2008). The efficacy of group psycho- Scheidlinger, S., & Schmess, G. Fifty Years of AGPA 1942–1992:
therapy for older adult clients: A meta-analysis. Group An overview. In K. R. MacKenzie (Ed.). (1992). Classics in
Dynamics: Theory, Research, and Practice, 12, 268–278. group psychotherapy (pp. 1–22). New York: Guilford.
Piper, W., & Joyce, A. S. (2002). Time-limited groups. In D. Brook Retrieved November 1, 2007, from http://agpa.org/
& H. Spitz (Eds.), The group therapy of substance abuse. pubs/50%20Years%20of%20AGPA.pdf.
Binghanton, NY: Haworth Press. Schutz, W. (1958). FIRO: A three-dimensional theory of interper-
Piper, W., & McCallum, M. (1991). Group interventions for those sonal behavior. New York: Rinehart.
who have experienced loss. Group Analysis, 24, 363–373. Schwarz, R. (2002). The skilled facilitator: A comprehensive
Piper, W., & Ogrodniczuk, J. (2004). Brief group therapy. resource for consultants, facilitators, managers, trainers, and
In J. DeLucia-Waack, D. Gerrity, C. Kalodner, & M. Riva coaches (2nd ed.). San Francisco, CA: Jossey-Bass.
(Eds.), Handbook of group counseling and psychotherapy Schwartz, J., Waldo, M., & Moravec, M. S. (2011). Assessing
(pp. 641–660). Thousand Oaks, CA: Sage. groups. In R. K. Conyne (Ed.), The Oxford handbook of group
Pistole, C., & Filer, R. (1991). Evaluating experiential elements counseling. New York: Oxford University Press.
and stimulating research in the teaching of group counseling. Shapiro, J. (2011). Brief group treatment. In R. K. Conyne
Journal for Specialists in Group Work, 16, 40–45. (Ed.), The Oxford handbook of group counseling. New York:
Raelin, J. (2003). Creating leaderful organizations: How to bring Oxford University Press.
out leadership in everyone. San Francisco: Jossey-Bass. Shechtman, Z. (2007). How does group process research inform
Rapin, L. (2004). Guidelines for ethical and legal practice in leaders of counseling and psychotherapy groups? Group
counseling and psychotherapy groups. In J. DeLucia-Waack, Dynamics: Theory, Research, and Practice: Special Issue on
D. Gerrity, C. Kalodner, & M. Riva (Eds.), Handbook of Groups in educational settings, 11, 293–304.
group counseling and psychotherapy (pp. 151–165). Thousand Shechtman, Z., & Gluk, O. (2005). An investigation of thera-
Oaks, CA: Sage. peutic factors in children’s groups. Group Dynamics: Theory,
Rapin, L. (2011). Ethics, best practices and law in group coun- Research, an Practice, 9, 127–134.
seling. In R. K. Conyne (Ed.), The Oxford handbook of group Silverman, P. (2011). Mutual help groups: What are they and
counseling. New York: Oxford University Press. what makes them work? In R. K. Conyne (Ed.), The Oxford
Rapin, L., & Conyne, R. (2006). Best practices in group work. handbook of group counseling. New York: Oxford University
In J. Trotzer (Ed.), The counselor and the group: Integrating Press.
theory, training, and practice (4th ed., pp. 291–318). Smokowski, P. (2003). Using technology to enhance modeling
Ritter, K. (2011). Group counseling with sexual minorities. and behavioral rehearsal in group work practice. Journal for
In R. K. Conyne (Ed.), The Oxford handbook of group counsel- Specialists in Group Work, 28, 9–22.
ing. New York: Oxford University Press. Spitz, H. (1996). Group psychotherapy and managed mental health
Riva, M. (2011). Supervision of group counseling. care: A clinical guide for providers. New York: Brunner/Mazel.
In R. K. Conyne (Ed.), The Oxford handbook of group counsel- Sternberg, R. (2004). Words to the wise about wisdom? Human
ing. New York: Oxford University Press. Development, 47, 286–289.
Riva, M., Wachtel, M., & Lasky, G. (2004). Effective leadership Stockton, R., & Morran, D. K. (2011). General research models.
in group counseling and psychotherapy. In J. DeLucia- In R. K. Conyne (Ed.), The Oxford handbook of group counsel-
Waack, D. Gerrity, C. Kalodner, & M. Riva (Eds.), ing. New York: Oxford University Press.

644 group couns el in g

Stockton, R., Morran, D. K., & Clark, M. (2004). An investiga- Ward, D., & Litchy, M. (2004). The effective use of processing
tion of group leaders’ intentions. Group Dynamics: Theory, in groups. In J. DeLucia-Waack, D. Gerrity, C. Kalodner, &
Research, and Practice, 8, 196–206. M. Riva (Eds.), Handbook of group counseling and psychother-
Stockton, R., Morran, D. K., & Krieger, K. (2004). An overview apy (pp. 104–119). Thousand Oaks, CA: Sage.
of current research and best practices for training beginning Webber, J., Bass, D., & Yep, R. (2005). Terrorism, trauma, and
group leaders. In J. DeLucia-Waack, D. Gerrity, C. Kalodner, tragedy (2nd ed.). Alexandria, VA: American Counseling
& M. Riva (Eds.), Handbook of group counseling and psycho- Association.
therapy (pp. 65–75). Thousand Oaks, CA: Sage. Wheelan, S. (1997). Group development and the practice of
Stockton, R., Morran, D. K., & Nitza, A. (2000). Processing group psychotherapy. Group Dynamics: Theory, Research, and
group events: A conceptual map for leaders. Journal for Practice, 1, 288–293.
Specialists in Group Work, 25, 343–355. Wheelan, S. (2005). The developmental perspective. In S. Wheelan
Sue, D. W., Arredondo, P., & McDavis, R. (1992). Multicultural (Ed.), The handbook of group research and practice. Thousand
counseling competencies and standards: A call to the profes- Oaks, CA: Sage.
sion. Journal of Counseling & Development, 70, 477–486. Wheelan, S. (Ed.). (2005). The handbook of group research and
The Counseling Psychologist. (2005). In M. Mallen & D. Vogel practice. Thousand Oaks, CA: Sage.
(Eds.), Online counseling: Challenges for the information Wilbur, M., Roberts-Wilbur, J., & Betz, R. (1981). Leader and
era [Special Issue]. The Counseling Psychologist, 33. member behaviors in three group modalities: A typology.
The Palace Incorporated. (1998). The Palace (Version 3.4.2). Journal for Specialists in Group Work, 6, 224–234.
[Computer Software]. Cupertino, CA: Electric Communities Williams, K. (Ed.). (2002). Groups and the Internet. [Special
Company. issue]. Group Dynamics: Theory, Research, and Practice, 6(1).
Thomas, G. (2006). Facilitator education: Learning from coun- Wilson, F. R., Rapin, L., & Haley-Banez, L. (2004). How teach-
selor education. Group Facilitation: A Research and ing group work can be guided by foundational documents:
Applications Journal, 7, 3–12. Best practice guidelines, diversity principles, training stan-
Tinsley, H., Roth, J., & Lease, S. (1989). Dimensions of leader- dards. Journal for Specialists in Group Work: Special Issue on
ship and leadership style among group leadership specialists. Teaching group work, 29, 19–29.
Journal of Counseling Psychology, 36, 48–53. Winzelberg, A. (1997). The analysis of an electronic support
Toporek, R., Gerstein, L., Fouad, N., Roysircar-Sodowsky, G., & group for individuals with eating disorders. Computers in
Israel, T. (Eds.). (2005). Handbook for social justice in counsel- human behavior, 13, 393–407.
ing psychology. Thousand Oaks, CA: Sage. Wrenn, C. G. (1938). Counseling with students. In G. Whipple
Toseland, R., & Siporin, M. (1986). When to recommend (Ed.), Guidance in educational institutions, Part I, National
group treatment: A review of the clinical and research litera- Society for the Study of Education. Bloomington, IL:
ture. International Journal of Group Psychotherapy, 36, Bloomington Public School Publishing Co.
171–201. Wrenn, C. G. (1962). The counselor in a changing world.
Trotzer, J. (2004). Conducting a group: Guidelines for choosing Washington, DC: American Personnel and Guidance
and using activities. In J. DeLucia-Waack, D. Gerrity, Association.
C. Kalodner, & M. Riva (Eds.), Handbook of group counseling Yao, T. (2004). Guidelines for facilitating groups with inter-
and psychotherapy (pp. 76–90). Thousand Oaks, CA: Sage. national college students. In J. DeLucia-Waack, D. Gerrity,
Trotzer, J. (2006). The counselor and the group: Integrating theory, C. Kalodner, & M. Riva (Eds.), Handbook of group counseling
training, and Practice (4th ed.). New York: Routledge. and psychotherapy (pp. 253–264). Thousand Oaks, CA:
Trotzer, J. (2011). Personhood of the leader. In R. K. Conyne Sage.
(Ed.), The Oxford handbook of group counseling. New York: Yalom, I. (1970). The theory and practice of group psychotherapy.
Oxford University Press. New York: Basic Books.
Tuckman, B., & Jensen, M. (1977). Stages of small group Yalom, I. (1995). The theory and practice of group psychotherapy
development revisited. Group & Organizational Studies, 2, (4th ed.). New York: Basic Books.
419–427. Yalom, I., & Leszcz, M. (2005). The theory and practice of group
Tyson, L., Perusse, R., & Whitledge, J. (Eds.). (2004). Critical psychotherapy (5th ed.). New York: Basic Books.
incidents in group counseling. Alexandria, VA: American Zinker, J. (1980). Beyond the hot seat. Gouldsboro, ME: Gestalt
Counseling Association. Journal Press.
Waldo, M., & Bauman, S. (1998). Regrouping the categoriza-
tion of group work: A goals and process (GAP) Matrix for
groups. Journal for Specialists in Group Work, 23, 164–176. Further Reading
Waldo, M., Kerne, P., IV, & Van Horn Kerne, V. (2007). Journal Group Journals
for Specialists in Group Work, 32, 346–361. Group counseling is a multi-disciplinary intervention that has
Walker, L., & Conyne, R. (2007). Group work with inter- emerged through and continues to be informed by numerous
national students. In H. Singaravelu, & M. Pope (Eds.), sources. Continuous streams of knowledge flow forth, which
A handbook for counseling international students in the United find their way into disciplinary-specific vehicles, such as journals
States (pp. 299–310). Alexandria, VA: American Counseling and conference presentations. Advancements in group work will
Association. come from those who become aware of these cross-disciplinary
Ward, D. (2006). Editorial: Classification of groups. Journal and cross-profession knowledge bases and are able to effectively
for Specialists in Group Work, 31, 93–97. span them. The journals listed earlier in this chapter can
Ward, D. (2011). Definition of group counseling. In R. K. provide exposure to important sources to obtain the contempo-
Conyne (Ed.), The Oxford handbook of group counseling. raneous, interdisciplinary information and perspective that will
New York: Oxford University Press. be invaluable.

cony ne 645
Key Chapter References Gazda, G. (1982). Basic approaches to group psychotherapy and
Bradford, L., Gibb, J., & Benne, K. (Eds.). (1964). T-group group counseling (3rd ed.). Springfield, IL: Thomas.
theory and laboratory method: Innovation in re-education. Gladding, S. (2002). Group work: A counseling specialty (4th ed.).
New York: Wiley. Upper Saddle River, NJ: Prentice-Hall.
Burlingame, G., & Fuhriman, A. (Eds.). (1994). Handbook Kivlighan, D., Jr., Coleman, M., & Anderson, D. C. (2000).
of group psychotherapy: An empirical and clinical synthesis. Process, outcome, and methodology in group counseling
New York: Wiley. research. In S. Brown, & R. Lent (Eds.), Handbook of coun-
Conyne, R. (Ed.). (1985). The group workers’ handbook: Varieties seling psychology (3rd ed., pp. 767–796). New York: Wiley.
of group experience. Springfield, IL: Thomas. Lieberman, M., Yalom, I., & Miles, M. (1973). Encounter groups:
Corey, M., & Corey, G. (2006). Groups: Process and practice First facts. New York: Basic Books.
(7th ed.). Pacific Grove, CA: Brooks/Cole. Wheelan, S. (Ed.). (2005). The handbook of group research
DeLucia-Waack, J., Gerrity, D., Kalodner, C., & Riva, M. (Eds.). and practice. Thousand Oaks, CA: Sage.
(2004). Handbook of group counseling and psychotherapy. Yalom, I., & Leszcz, M. (2005). The theory and practice of group
Thousand Oaks, CA: Sage. psychotherapy (5th ed.). New York: Basic Books.

646 group couns el in g

 CHAPTER

25 Couple and Family Therapy

Myrna L. Friedlander and Gary M. Diamond

Abstract
The conceptual underpinnings, fundamental assumptions, and interventions used in couple and family
therapy (CFT) are consistent with counseling psychology’s traditional emphasis on normative
development and person–environment fit, and its focus on clients’ problems in living, resilience, and
cultural context rather than psychiatric diagnoses. In this chapter, we begin by outlining the history of
the couple and family therapy movement, identifying the central systems constructs and assumptions,
and providing an overview of several classic and contemporary approaches to conjoint treatment.
Next, we describe eight exemplary programs of efficacy research that address the question, “For
whom does CFT work?” Finally, addressing the question, “How does CFT work?,” we summarize the
theory and research on three basic mechanisms of change in conjoint treatment: therapeutic alliance,
reframing, and enactment. The chapter concludes with recommended future directions for the
field—theoretical, empirical, and practical.
Keywords: couple and family therapy, systems theory, psychotherapy outcome, psychotherapy
process, therapeutic alliance, enactment, reframing

Although couple and family therapy did not origi- writing about positive psychology, counseling psy-
nate within the field of counseling psychology, it chologists were being trained to assess emotional
might well have. Unlike early clinical psychologists, problems from a strengths-based perspective (Gelso
who embraced the medical model, locating symp- & Fretz, 2001). That is, not only noting clients’ dif-
toms within individuals and paying little attention ficulties and deficiencies, counseling psychologists
to a client’s psychosocial context, counseling psy- also inquire about past successes, coping strategies,
chologists took a broader view (Gelso & Fretz, 2001). and environmental supports. Like a solution-focused
Traditionally, counseling psychologists worked in family therapist, a counseling psychologist would
schools and outpatient settings with clients who had consider close ties with adult children, a solid work
problems in living (e.g., test anxiety, divorce, career history, and multiple leisure avocations as integral to
indecision, bereavement) rather than psychiatric the assessment and treatment of a depressed, middle-
diagnoses. Even when contemporary counseling psy- aged man whose wife had died 5 years prior. The cli-
chologists see clients suffering from diagnosable ent’s depressive symptoms would not be overlooked,
emotional disorders, they are more likely to view of course, but treatment planning would also take
emotional distress as integrally related to person– into account the client’s aspirations and adjustment
environment fit and to psychosocial development, in to each of his life roles since his wife’s death.
much the same way that couple and family therapists Paying attention to person–environment fit is
conceptualize problems. but a short step to working directly with family
Moreover, long before clinical psychologists systems. In treating family problems, it is essential
(e.g., Seligman & Csikszentmihalyi, 2000) began to consider the broad social and cultural context, the
647
family’s developmental stage (e.g., recently married, In other words, the family therapist would assume
raising young children, transitioning to retirement), that by restoring this overburdened mother’s compe-
the current developmental tasks of each member of tence as head of household and guiding her to help
the family, and the family’s unique strengths and her children become closer siblings and better func-
resources (e.g., religious commitment, community tioning individuals, her depression could be reduced
involvement, ties with extended family). Thus, and her desire to attend to her personal life goals
although family therapy as a treatment model did could be increased.
not originate within counseling psychology, work- Take a different example. A “therapist who sees
ing clinically with couples and families is a natural families” agrees to work with a 10-year-old girl who is
fit for counseling psychologists. doing poorly in school, has no friends, and responds
What distinguishes a “family therapist” from a explosively to parental demands. The therapist asks the
“therapist who sees families”? Although in common mother, and sometimes the father, to attend sessions
parlance these terms are interchangeable, at a con- in which behavioral goals (doing chores, finishing
ceptual level the distinction is more than semantic. homework, increasing physical activity) are planned,
Family therapists consider familial relationships to using charts, therapy “homework,” and rewards for
be “the client”; they design interventions to shift good behavior. In other words, the parent serves as the
power dynamics between and among family mem- coach, helping the therapist carry out the treatment
bers, and they view changes within individuals as plan at home.
both catalysts and markers of fundamental system A “family therapist” approaches the situation
shifts. Therapists who “see families,” on the other differently. This therapist takes note of the parents’
hand, bring family members into the session to help distancing from one another, their focus on the
the troubled individual who is the identified focus 10-year-old to the exclusion of their marriage or
of concern, and these “extra” family members often their individual pursuits, and the father’s contempt
see themselves as consultants or witnesses to the of his wife, which is mirrored by the 13-year-old sis-
recovery process of their child or partner (Friedlander, ter’s contempt of the 10-year-old “identified patient.”
Escudero, & Heatherington, 2006a). The family therapist’s strategies include empowering
Moreover, what distinguishes couple and family the mother’s relationships with both daughters, sug-
therapy (CFT) from individual therapy is not read- gesting that she resume working or volunteering out-
ily identifiable. That is, CFT is not defined by who side the home, encouraging the older sister to go away
or how many family members attend a therapy to summer camp, recommending a smaller school, a
session, nor by the presenting problems or even the religious youth group, or a team sport for the 10-year-
treatment goals. To illustrate, a “family therapist” old, and (eventually) working with the parents to
may work solely with an isolated, depressed single improve their relationship and connect with their
mother, but that therapy is likely to look quite dif- families of origin. All of these strategies are designed
ferent from the one offered to the same client by an to simultaneously reduce the family’s isolation by
“individual” therapist. Although both clinicians may bringing in new systems (work, camp, school, youth
have as a goal to reduce the client’s isolation and group, team, extended family), rebalance the family’s
depression, their conceptualizations and treatment power dynamics, improve the spousal relationship,
strategies are likely to be strikingly different. A cog- give the two girls some space from each other, and
nitive-behavioral therapist might challenge this cli- eliminate the intense focus on the younger child. In
ent’s negative self-appraisals, encourage her to engage other words, systems change begets individual change,
in more pleasurable activities, and teach her parent- and individual changes beget systems change.
ing skills. A psychoanalytic therapist might explore In this chapter, we begin by summarizing the
the client’s sense of self, her internal representations history of CFT from a theoretical perspective,
of significant others, her fantasies and dreams, her including a review of several classic approaches to
memories and childhood attachment history. A CFT.1 We then present a brief overview of selected
“family therapist,” on the other hand, might encour- empirically supported couple and family therapies.
age the client to renew ties with her estranged family This overview serves as a backdrop for the next, more
of origin, negotiate a better relationship with her detailed discussion of the unique challenges of work-
children’s father and his family, establish clearer ing clinically from a family systems perspective and
emotional boundaries with her children, promote investigating the effectiveness of CFT. Specifically,
the children’s sibling relationships, and explore ways we describe three critically important process phe-
to bring other caring adults into her children’s lives. nomena—the therapeutic alliance, reframing, and

648 couple an d family th e rap y

enactment: their purported role in the change pro- Beginning with a few marriage counseling centers,
cess and how they have been subjected to empirical the family relations profession gave birth in 1945 to
inquiry. The chapter concludes with suggested future the American Association of Marriage Counselors.
directions to increase our understanding of CFT as a Second, workers in child guidance centers, which
unique treatment format. were created throughout the country to help pre-
vent childhood mental disorders, began treating
Brief History of Couple and families when they saw children’s emotional disor-
Family Therapy ders as expressions of family dysfunction.
Early Influences Perhaps the most influential contribution to
Working independently in the mid-20th century, CFT began with research on human and animal
pioneers such as Nathan Ackerman (1958), Don communication. The “Palo Alto group,” an interdis-
Jackson (1965), John Bell (1961), Virginia Satir ciplinary team with scientists Gregory Bateson, Jay
(1964), and Murray Bowen (1961) felt constrained Haley, and John Weakland, joined by psychiatrists
by the psychoanalytic injunction against meeting Don Jackson and William Fry, began extrapo-
with a patient’s family members. Psychoanalysis, lating from basic research on humor, the behav-
the prevailing treatment approach at that time, was ior of otters, and patterns of communication
a highly intimate and private experience. It was between indigenous South Pacific tribes to the
believed that a patient’s transference to the analyst, family interactions of young adults with schizophre-
crucial for treatment success, would be irrevocably nia (Nichols & Schwartz, 2007). In developing
contaminated by the presence of other family mem- their double-bind theory, Bateson and colleagues
bers (Nichols & Schwartz, 2007). (Bateson, Jackson, Haley, & Weakland, 1956) pro-
In the 1950s and 1960s, some of the most dis- moted the radical idea that mental illness was caused
turbed psychiatric patients in “mental hospitals” and maintained by repetitive and pernicious pat-
were the first to experience conjoint family therapy. terns of parent–child interaction, which paradoxi-
A few analysts cautiously began involving family cally stabilized family relationships. In other words,
members in treatment after noticing that the psychotic behavior was seen as functional within a
patients, who had seemingly recovered in the hospi- disturbed family system by preventing change,
tal, relapsed on returning home. These analysts also which the family perceived as threatening. According
noted the curious phenomenon that, when a patient’s to the theory, a child who continually receives pun-
mental health improved, another family member’s ishing, demanding, and contradictory messages
would often deteriorate (Nichols & Schwartz, (“Show me that you love me”/“Bad boy, I’ll punish
2007). you for touching me”) learns to make “insane”
Seeing the family as the context for emotional responses because either protesting the contradic-
problems was not unique to psychiatrists. Social tion or escaping is forbidden. Over time, the child
workers had long recognized family (and commu- begins responding to any aspect of a double-bind
nity) factors in causing and maintaining mental ill- message with rage or panic (Bateson et al., 1956).
ness (Nichols & Schwartz, 2007). In fact, since the Although later discredited as the cause of schizo-
early 1900s, social workers described their clients as phrenia, the double-bind theory opened the door
“cases,” a term that refers to an individual within for treatments focusing on modifying dysfunctional
patterns of family interaction.
a specific family and neighborhood context. Early family therapists were also heavily influ-
Caseworkers often visited patients in their homes, enced by general systems theories (Bertalanffy,
and early social workers wrote about concentric 1950) and cybernetics (Wiener, 1948) in the fields
levels of influence on the individual, a concept that of engineering, physics, and mathematics (Nichols
foreshadowed later theorizing about the interrela- & Schwartz, 2007). Systems theorists discovered
tions of systems (Nichols & Schwartz, 2007). that, from the smallest to the most complex, entities
Two other influences outside mainstream psy- (or systems) have interlocking parts that function as
chiatry also propelled the family therapy movement organized units. Understanding a system cannot be
forward (Nichols & Schwartz, 2007). First, in the accomplished by examining its parts individually,
early 20th century, religious leaders, teachers, and and when a unit’s properties are not maintained,
attorneys began offering “professional marriage it breaks down.
counseling” to couples in distress who were not From cybernetics, family theorists (e.g., Jackson,
likely to seek help from mental health providers. 1959) adopted the notion of feedback loops, which

fr ie dl ande r, diam ond 649

refer to processes by which a system self-regulates, parents no longer function as “executives;” rather,
either by compensating to maintain a steady state the children have too much power. In other fami-
(called homeostasis) or by evolving to an entirely new lies, one parent may form a “coalition” with a child
state (called second-order change). Extrapolating to to discredit or control the other parent.
families, early theorists applied these concepts to In the case of families with anorexia, the ten-
explain how emotional problems, located within an sions in the marital “subsystem” are said to be
individual, are expressions of systemic (i.e., family) “detoured” onto the starving child, who has come to
dysregulation. A young adolescent’s chronic refusal have too much power in the family system. Freeing
to eat, for example, is not a mental illness, but rather family members from symptoms, even severe symp-
a habitual pattern of behavior that stabilizes her par- toms like anorexia, requires modifying boundaries
ents’ dysfunctional marriage (Minuchin, Rosman, by changing how people interact with each other
& Baker, 1978). (Note that the term “stabilize” does (Minuchin et al., 1978). The daughter, with the
not refer to psychological stability but rather to help of professionals, is put in charge of maintaining
homeostasis.) That is, by worrying, commiserating a healthy weight, and the parents are relieved of this
together, and focusing exclusively on their daughter’s burden (Sargent, Liebman, & Silver, 1985). Instead,
anorexia, mother and father avoid facing the danger- they are encouraged to assert their parental author-
ous, unspoken tensions within their marriage. ity, work out their marital problems, and begin pur-
By conceptualizing families as functioning like suing individual interests. In a family session, the
machines, which have moving parts but no mental structural therapist might encourage an enactment,
consciousness, many early family theorists eschewed in which the parents are asked to discuss something
all notions of psyche. In other words, whether indi- of importance and the child is constrained from
viduals’ behaviors are conscious or unconscious is interrupting. Such therapeutic strategies are designed
irrelevant. From a purely behavioral perspective, the to disrupt parent–child enmeshment and break the
child’s self-starvation and the parents’ conflict avoid- circular causality (self-starvation → avoidance of
ance are mutually reinforcing, a behavioral feedback marital problems → self-starvation). Theoretically,
loop that keeps a homeostatic balance in the family when the family’s behavioral interactions reflect a
and prevents change. Because of this circular causal- healthier structure, and when family relationships
ity, freeing the daughter from her self-destructive become more functional and mutually rewarding,
behavior cannot be accomplished without a corre- individuals’ emotional disorders will disappear
sponding shift in the parents’ behavior toward her (Minuchin & Fishman, 1981).
and toward each other. If a therapeutic change Another early family therapy approach, which
can be accomplished, there will be a second-order later combined with structural therapy, applied
change, a new family system that behaves differently Gregory Bateson’s patterns of communication to the
and has family members who think and feel differ- understanding and treatment of families. Strategic
ently about themselves and each other. therapists Jay Haley (1963) and Cloe Madanes
(1981), members of the Mental Research Institute
Classic Models of Family Therapy group (Fisch, Weakland, & Segal, 1982; Watzlawick,
It is no surprise, then, that some of the earliest theo- Weakland, & Fisch, 1974), and the Milan (Italy)
retical approaches to CFT were uniquely focused on associates (Selvini Palazzoli, Boscolo, Cecchin, &
modifying interpersonal behavior. Structural family Prata, 1978), worked uniquely with family behavior,
therapist Salvador Minuchin (1974; Minuchin & with minimal focus on clients’ cognitions or emo-
Fishman, 1981; Minuchin et al., 1978) was argu- tions. Using constructs from cybernetics, these
ably the theorist whose approach most closely problem-focused theorists assess the covert “rules”
reflected the principles of general systems theory. that function as feedback loops to keep family
According to Minuchin (1974), families are systems systems in a homeostatic state. Like structural thera-
that go awry when their structure is dysfunctional, pists, strategic therapists view the attempted solu-
and repetitive patterns of interaction reveal these tion to the problem (cajoling a starving daughter to
dysfunctional structures. When boundaries between eat) as maintaining the problem (marital distancing)
individuals are too diffuse (or “enmeshed”), family in a circular fashion. The cybernetic solution for this
members cannot operate autonomously. At the kind of impasse is to create a “positive feed-
other extreme, when interpersonal boundaries are back loop,” which can interrupt the “negative feed-
too rigid (or “disengaged”), the family has no sense back loop” (i.e., vicious cycle) that maintains the
of “we-ness.” In some dysfunctional families, the problem.

650 couple an d family th e rap y

 Theoretically, it is not necessary for family mem- the triangles of Wife-Husband-Lover and Wife-
bers to understand the mutually reinforcing cycle Husband-Alcohol interlock, so that change is
that keeps them stuck. Rather, the strategic thera- extremely difficult. Two other triangles, Wife-
pist creates a ritual or ordeal that disrupts the system. Husband-Rebellious Son and Wife-Grandmother-
Often using consulting teams observing behind a Son, further freeze the system. That is, when Wife is
one-way mirror, strategic therapists use their author- upset with Husband or Son, she turns to Lover or
itative power to impose creative interventions that Grandmother. Similarly, when Husband is distressed
will disrupt homeostatic cycles. Because families by Wife or Son, he turns to Alcohol. When Son sees
resist change, strategic therapists cleverly devise his parents argue, he acts out. The system is stable
“therapeutic double-binds,” paradoxical interven- but highly dysfunctional.
tions that force behavioral shifts. The Milan group By forming emotional triangles, family mem-
(Selvini Palazzoli, 1986), for example, might pre- bers remain locked in dysfunctional patterns that,
scribe a parental vacation for the overbearing, wor- according to Bowen (1976; Kerr & Bowen, 1988),
ried parents of symptomatic young adults. The are passed down through generations in the behav-
parents, whose overprotection reinforces their child’s ior of individual family members. In a family’s life
extreme dependence, would be told to leave the cycle (Carter & McGoldrick, 1999), certain devel-
child alone in the home for an extended period of opmental tasks create emotional stress that activates
time, sometimes weeks. This “prescription” would triangles through increased fusion or distancing.
be designed to force the young adult to become self- Consider the family described above. When newly
reliant and to put the parents in a situation where married, the wife finds herself unable to separate
they could not avoid dealing directly with one enough from her own mother to fully commit
another. to her new relationship. Possibly, her mother was
Although in Murray Bowen’s family systems divorced and lonely, or maybe her mother’s mar-
theory (Bowen, 1966, 1976; Kerr & Bowen, 1988) riage was stable but stale. The husband, who had
the central construct, differentiation of self, refers to been attracted to his wife because of her emotional
individual experience, this theory is based on gen- availability, begins distancing from her in the same
eral systems concepts. Differentiation of self refers way that his parents distanced from him and from
to an individual’s ability to separate and balance each other. When the first child is born, the Wife-
thinking and feeling, on the intrapsychic level, and Husband-Baby triangle interlocks with the Wife-
autonomy and closeness, on the interpersonal level Grandmother-Baby triangle to further push the
(Bowen, 1976). According to Bowen, highly differ- young husband away. Eventually, the wife’s intense
entiated individuals are effective problem solvers. focus on her child, which compensates for the
In the face of an emotional crisis, they are able to increasing coldness she feels from her spouse, repeats
acknowledge their feelings but also think through the pattern in her own family. The husband, feeling
the alternatives and decide on the best course of pushed out of the marriage by his son, distances
action. Poorly differentiated individuals, on the through alcohol, mirroring what occurred in his
other hand, either become flooded with emotion or parents’ marriage. Eventually, when the boy becomes
are so cut off from their feelings that they cannot a pre-teen, he rebels fiercely. The wife takes a lover,
function well in anxiety-laden situations, and at and the husband becomes an alcoholic.
other times, they have difficulty behaving in a
mature manner. Whether they remain “fused” with
others or “reactively distance,” these individuals
behave in ways to reduce intolerable levels of stress.
grandmother
Poorly differentiated people characteristically
create emotional triangles with others, which stabi-
lize otherwise immature relationships (Bowen, wife alcohol
1976). Take the example of a wife who has an excit-
ing affair with a coworker. By distancing from her
husband in this way, the couple avoids discussing the
husband’s impotence due to alcohol abuse. Aware of son
his wife’s infidelity, the husband does not confront
lover husband
her because of his personal shame (impotence) and
guilt (alcoholism). As illustrated in Figure 25.1, Fig. 25.1 Example of interlocking emotional triangles.

fr ie dl ande r, diam ond 651

 In contrast to structural therapists, who encour- structural-strategic therapists. Urging therapists to
age in-session enactments, Bowenian family systems adopt a warmer, more collaborative stance with fam-
therapists (Kerr & Bowen, 1988) discourage clients ilies, feminists moved the field forward in a different
from interacting directly with each other in the direction.
therapy sessions. Rather, these therapists work to By the late 1990s, family therapists were demon-
promote an understanding of the family forces that strating a strong interest in the cognitive and emo-
constrain individual behavior and healthy relation- tional problems that sustain couple and family
ships. Insight, rather than action, is said to be the key problems. From strategic, problem-focused therapy
to treatment success. To facilitate insight, Bowenian came solution-focused therapy (de Shazer, 1985),
therapists stay as neutral as possible, striving to which rejected the focus on problem-maintaining
reduce the emotionality in the system and enhance behavioral cycles in favor of helping families imagine,
individuals’ self-reflection. In fact, Bowen main- hope for, and work toward a more fulfilling life.
tained that family systems therapy was best accom- Adopting the postmodern, social constructionist per-
plished by working solely with the most differentiated spective on human problems—that people are con-
individual in the family, the one who is most able to strained by life stories that derive from oppressive
reflect on and then begin “detriangulating” from the social forces (Foucault, 1965)—narrative therapists
nuclear family’s “emotional process.” Michael White (1995) and David Epston (White
Not all of the first-wave family therapists & Epston, 1990) taught clients to “re-author” their
embraced systems thinking, however. One of the lives by viewing their problems as external to them-
pioneers in the field, Nathan Ackerman (1958), selves and then finding ways to struggle against them.
stayed closer to his psychoanalytic roots than On the psychoanalytic front, the increasingly popular
other analysts, e.g., Jackson (1959) and Bowen object relations theory was integrated with couple
(1976). Experiential family therapists, notably Carl and family work (Scharff & Scharff, 1987; Slipp,
Whitaker (Whitaker & Keith, 1981) and Virginia 1984). Using this approach, therapists help family
Satir (1964), immersed themselves in their clients’ members develop insight into how their unrealistic
emotional world, believing that caring attunement internal representations of each other play out in
and personal involvement gave families the courage destructive ways. Traditional behavioral therapists, as
to change. Behavioral family therapists used learn- well, began to focus on cognitive processes. Recog-
ing theory to teach parents how to extinguish their nizing that behavioral marital therapy was limited for
children’s misbehavior (Boardman, 1962; Patterson, many couples, Jacobson and Christensen (1996;
1971; Williams, 1959) or facilitate new behavior Jacobson, Christensen, Prince, Cordova, & Eldridge,
(Risley & Wolf, 1967). Spouses were used as coaches 2000) devised integrative couple therapy. This approach
in anxiety management (Wolpe, 1958). Contingency moved beyond teaching behavior exchange and com-
management (Stuart, 1969) and social learning munication skills to help couples change their destruc-
principles (Liberman, 1970) were applied to cou- tive patterns and find mutual acceptance. Explicitly
ples’ problems in other early behavioral approaches focusing on emotion, Greenberg and Johnson (1988)
to CFT. created emotion-focused therapy for couples, which
evolved from experiential individual therapy and sys-
Later Developments temic family theory. By encouraging partners to access
From the late 1970s through the 1980s, the predom- and communicate their need for attachment and inti-
inant approach to couples treatment was behavioral macy, emotion-focused therapists help couples move
marital therapy (Jacobson, 1977; Jacobson & from blame and defensiveness to expressions of under-
Margolin, 1979), whereas the major therapies for lying, primary emotions, such as hurt and sadness.
families were structural-strategic (e.g., Haley, 1976;
Minuchin & Fishman, 1981), functional family Contemporary Family Therapy
therapy (Alexander & Parsons, 1982), and parent Over the past two decades, the parameters of family
management training (e.g., Kazdin, 1987; Patterson, therapy have expanded greatly. Notably, there has
1982). In the late 1980s into the 1990s, family ther- been a blurring of boundaries between theories, as
apists took a step away from the general systems well as the development of treatment models that
and behavioral interaction theories that predomi- integrate different approaches (Nichols & Schwartz,
nated a decade earlier. One impetus was the femi- 2007). We have also seen a proliferation of CFT
nist challenge (e.g., Luepnitz, 1988) to the highly therapies tailored for specific client problems, such
paternalistic conceptualizations and interventions of as infertility, children’s behavior disorders, substance

652 couple an d family th e rap y

abuse, depression, and juvenile offending, as well as Another development that has changed the
interventions designed to prevent psychosocial dif- landscape of family therapy practice is the use of
ficulties (e.g., Tolan, 2003). Contemporary family manuals for specific treatment approaches. Typically,
therapists are also being encouraged to pay close these evidence-based approaches are informed by
attention to ethnic and cultural norms that suggest theory and research from a wide range of domains,
important differences in how diverse families define including normative development, developmental
dysfunction and in how these families should be psychopathology, cognition and emotion, and have
assessed and treated (Nichols & Schwartz, 2007). a clearly articulated conceptualization of the forces
Whereas early theorists and practitioners focused maintaining the disorder of interest, the optimal
almost exclusively on family dynamics and on change strategies, and the corresponding interven-
understanding the problem as functional within the tions. As a result, contemporary family-based treat-
family system, it is now clear that problems are mul- ments have become more systematic, standardized,
tiply determined—influenced not only by family and targeted.
but also by individual, biological, and extrafamilial The next sections of this chapter focus on the
factors (i.e., peer group, school, etc.). Consequently, empirical evidence that informs CFT practice. First,
current family therapists often intervene in multi- we review a number of exemplary research pro-
ple life domains (Liddle, 2005; Schoenwald & grams that address the outcome question, “Which
Henggeler, 2005), no longer confining their efforts approaches to CFT work for specific kinds of
to the behavioral interactions of the nuclear family. clients?” Then, we turn our attention to process
Take the example of a therapist who is treating a research that addresses “how” CFT works, focusing
boy with attention deficit hyperactivity disorder. on three specific mechanisms of change in actual
The therapist might begin by providing both par- clinical settings.
ents and child with psychoeducation about the dis-
order. As the parents and siblings begin to understand Current Evidence-based Treatment
the origins of certain behaviors, family interactions Programs
and relationships are likely to change. That is, rather By the late 1990s, several comprehensive reviews
than interpreting the child’s unresponsiveness as of the outcome literature (e.g., Baucom, Shoham,
defiance, family members come to understand it as Mueser, Daiuto, & Stickle, 1998; Dunn &
related to neurological deficits in attentional and Schwebel, 1995; Pinsof, Wynne, & Hambright,
behavioral control, and their responses to the boy 1996) concluded that couple and family treatments
become more empathic and supportive. The thera- were as effective as no-treatment or wait-list con-
pist is then positioned to help family members trols. An influential meta-analysis of 71 studies
understand how their own behaviors contribute to (Shadish, Ragsdale, Glaser, & Montgomery, 1995)
escalating conflict (“When you yell directions from showed that clients in CFT treatments did, on aver-
the other room, he is not very likely to register them age, approximately half a standard deviation better
and respond. You then become frustrated and angry. than untreated controls, and the effect sizes for CFT
He feels frustrated because he has no memory of were comparable to those reported for individual
being asked to complete the task and so becomes therapies. Moreover, in studies that compared CFT
defiant. This gets you even angrier and leads to to individual treatment, the differences in outcome
extreme punitive behavior and his sense of injustice were negligible (Shadish et al., 1995).
and hopelessness”). At the same time, the therapist Although there is substantial evidence, generally,
coaches the parents to teach their son compensatory for the efficacy of CFT, some disorders and clinical
strategies, which the child can use in school and populations have been more extensively researched.
with peers. Finally, the therapist may encourage par- In the following section, we summarize the find-
ents to consult with a physician about medication ings from recent clinical trials of prominent CFT
and begin developing collaborative relationships approaches that target specific client problems or
with important extrafamilial systems or agents. For disorders.
instance, therapist and parent(s) might meet with
the school psychologist and teachers to engineer a Conjoint Couples Therapy
school environment that provides the best chance integrative behavioral couple therapy
for the child to succeed. This multifaceted approach Beginning with Stuart’s (1969) classic report on
to treatment exemplifies how the field has moved applying behavioral reinforcement to the treatment
beyond a singular focus on family dynamics. of couples’ problems, traditional behavioral couple

fr ie dl ande r, diam ond 653

therapy (TBCT) has been the most widely studied emotion-focused therapy
approach for treating marital distress, with over Another couple therapy that has been extensively
20 randomized clinical trials demonstrating its researched and applied is emotion focused therapy
relative efficacy and clinical significance (Baucom, (EFT; Greenberg & Johnson, 1988; Johnson &
Shoham, Mueser, Daiuto, & Stickle, 1998; Jacobson, Greenberg, 1985). Developed from humanistic and
Christensen, Prince, Cordova, & Eldridge, 2000). systemic theories, EFT focuses on couples’ negative
However, as Jacobson et al. (2000) pointed out, interaction cycles and poor communication pat-
despite positive results, at least one-third of couples terns that result from the disowning of primary
remain clinically distressed at the end of treatment needs for attachment. As mentioned earlier, by
and, even among those who improve, many do not identifying and working with negative cycles, EFT
maintain their gains beyond 2 years. therapists help partners to access underlying, pri-
In an effort to improve the effectiveness of the mary emotions (hurt, sadness) and communicate
model, Andrew Christensen and Neil Jacobson their attachment needs clearly before generating
(Christensen, Jacobson, & Babcock, 1995; Jacobson solutions for specific problems. In contrast to ICBT,
& Christensen, 1996) developed integrative behav- EFT specifically targets attachment as the key to
ioral couple therapy (IBCT), which added humanistic emotional intimacy.
elements to the traditional change-oriented strate- Based on a number of randomized clinical trials
gies of TBCT. ICBT’s acceptance-based interven- conducted throughout the 1990s (Johnson, 1998),
tions are designed to help partners accept aspects of EFT has been recognized as one of the foremost
each other that are intransigent and considered empirically supported treatments for couples. Over
intolerable. Emphasizing a contextual, functional the past few years, clinical researchers have continued
analysis of the couple’s problems, ICBT therapists to explore the use of EFT with a wide range of clinical
work with the naturally occurring contingencies in populations. For example, in one small, exploratory
couples’ lives rather than inventing new reinforc- study (MacIntosh & Johnson, 2008), ten couples
ers, as was done in TBCT contingency contracts with a partner reporting childhood sexual abuse
(Gollan & Jacobson, 2002). In addition to promoting received an average of 19 sessions of EFT. Results
an understanding of destructive patterns and part- indicated that half of the couples reported clinically
ners’ mutual acceptance, ICBT therapists “promote significant increases in relationship satisfaction and
empathic joining or unified detachment with the goal decreases in trauma symptoms at post-treatment. In
of turning problem areas into sources of renewed inti- another small, open trial in which 24 couples with a
macy” (Gollan & Jacobson, 2002, p. 111). partner who reported an attachment injury (e.g., per-
The efficacy of IBCT was demonstrated in two ceived betrayal, abandonment, etc.) received, on aver-
early studies (Christensen, Jacobson, & Babcock, age, 13 sessions of EFT, 15 of the 24 couples were
1995; Christensen & Heavey, 1999). In a subse- identified as being resolved by the end of treatment
quent, large clinical trial comparing IBCT to TBCT, (Makinen & Johnson, 2006).
Christensen and colleagues (Christensen et al., 2004)
randomly assigned 134 seriously and chronically dis- Conjoint Family Therapy
tressed couples to one of the two treatments. Results In the field of family therapy, no area has received as
indicated that, at post-treatment, the two treatments much attention or has been researched as thoroughly
produced similar levels of clinically meaningful as adolescent substance abuse and problem behaviors
improvement (71% for IBCT, 59% for TBCT). (i.e., delinquency and conduct disorder). A number
Interestingly, couples receiving TBCT improved of groups have established impressive, longstand-
more quickly, although their gains tended to plateau, ing, systematic research programs to develop, test,
whereas couples receiving IBCT improved steadily adapt, and transport these family-based treatments
over time. to community clinics. All of these models are based,
One question raised by the authors was whether to some degree, on structural and strategic princi-
these differential trajectories had implications ples and intervention strategies; they address not
for long-term outcome. In a later study examin- only the adolescent’s functioning but also the nature
ing couple functioning 2 years post-treatment, and quality of adolescent-parental relationships.
Christensen et al. (2006) found that both treat- Furthermore, all of these treatments address, to vary-
ments produced substantial and similar rates of ing degrees, ecological factors (e.g., school, peers)
clinically significant improvement (ICBT 69%; that are known to have an impact on the adolescent’s
TBCT 60%). functioning.

654 couple an d family th e rap y

brief strategic family therapy members and members of other influential social
One influential treatment approach is brief strategic groups.
family therapy (BSFT), developed by José Szapocznik In 2008 Multidimensional family therapy was
and colleagues (Szapocznik et al., 2002) at the recognized—along with functional family therapy
University of Miami. Brief strategic family therapy (Alexander & Parsons, 1982)—as one of only two
combines elements from structural and strategic family treatments considered “well established” for
theories, with the goal of changing dysfunctional treating adolescent substance abusers (Waldron &
family patterns that maintain teen drug use. Turner, 2008). In the first large-scale study of the
Interventions with school officials and other systems model (Liddle et al., 2001), 182 racially diverse,
are used to reduce risk and enhance protective marijuana and alcohol abusing adolescents were
factors. randomly assigned to MDFT, adolescent group
Throughout the 1980s and 1990s, a number of therapy, or a multifamily educational interven-
clinical trials demonstrated that BSFT was effica- tion. Although adolescents in all three treatments
cious in reducing Hispanic adolescents’ drug use improved from intake to termination, those receiv-
and problem behaviors (see Robbins, Szapocznik, ing MDFT showed the most improvement on
& Perez, 2007 for a review). A number of recent drug use and family functioning. Furthermore, par-
studies provide further evidence regarding the mod- ticipants receiving MDFT showed the highest rates
el’s efficacy. For example, in one study, 126 Hispanic of clinically significant change 12 months post-
families were randomly assigned to either BSFT or treatment (Liddle et al., 2001).
a problem-solving group treatment. Adolescents In a second study (Liddle, Dakof, Turner,
who received BSFT showed greater pre- to post- Henderson, & Greenbaum, 2008), 224 primarily
treatment improvements on parent-reported con- African American, substance using male adolescents
duct problems and delinquency, adolescents’ report were randomly assigned to 3 months of MDFT or
of marijuana use, and observers’ reports of family individual cognitive-behavioral therapy for drug use.
functioning (Santisteban et al., 2003). In another Both treatments were associated with significant and
study, Robbins et al. (2008) found that a family- similar reductions in frequency of marijuana use
based ecological approach, integrating BSFT with a over the course of treatment and at 6 months follow-
school assessment and intervention, with the teen’s up. However, MDFT was more effective in reducing
peer group and with juvenile justice, was more effec- drug use, with these effects continuing to remain
tive in reducing Hispanic adolescents’ drug use than significant at the 12-month follow-up.
traditional BSFT or a community treatment- In yet another study (Dennis et al., 2004),
as-usual comparison group. The same effect was not MDFT was one of five treatment conditions in
found for African American adolescents, however. a multisite Cannabis Youth Treatment Study.
An ambitious, ongoing, multisite trial with diverse Although all five treatments evidenced significant
samples is investigating changes in family function- post-treatment gains on the two primary outcome
ing as a mediator of BSFT’s treatment effectiveness measures (days of abstinence and percent of adoles-
(Shoham, Rohrbaugh, Robbins, Szapocznik, & cents in recovery), there were no between-treatment
Feaster, 2003). differences.
Other studies have shown that MDFT can be
multidimensional family therapy transported to community clinics and effectively
Another well developed and researched conjoint administered by front-line clinicians. In one study
approach is multidimensional family therapy (MDFT; (Liddle, Rowe, Dakof, Ungaro & Henderson, 2004)
Liddle, 2005), which combines elements from conducted at a nonprofit community drug abuse
strategic and structural family therapy, develop- clinic, 80 urban, low-income, ethnically diverse
mental psychology, and ecological principles. In this substance abusing and problem behavior adoles-
approach, adolescents’ symptoms are targeted and cents were randomly assigned to MDFT or group
their prosocial behaviors are increased when the therapy. Assessments at 6 weeks and at discharge
therapist focuses on normative, developmentally showed that MDFT was more effective at reducing
appropriate behavior, peer relations, identity, attach- drug use and various risk factors (e.g., delinquent
ment to school, and autonomy in relation to par- peer involvement) as well as promoting protective
ents. Interventions delivered to parents separately factors, such as family cohesion. At the 12-month
focus on improving parenting strategies, and meet- follow-up (Liddle, Rowe, Dakof, Henderson, &
ings commonly take place with extended family Greenbaum, in press), clients receiving MDFT

fr ie dl ande r, diam ond 655

evidenced less substance use, substance use prob- individual therapy), fewer arrests, and fewer days of
lems, delinquency, internalized distress, and family, confinement.
peer and school risk factors. More recently, MST has been examined by inde-
pendent investigators, both within and outside the
multisystemic therapy United States. In a randomized clinical trial con-
Today, multisystemic therapy (MST; Bourduin, ducted in Norway (Ogden & Halliday-Boykins,
Henggeler, Blaske, & Stein, 1990; Henggeler, 2004), 100 adolescents referred for severe behavior
Schoenwald, Bourduin, Rowland, & Cunningham, problems received either MST or regular child wel-
1998) is one of the most established and effec- fare services. Results indicated that MST was more
tive treatments for criminal, delinquent, and sub- effective in reducing out-of-home placements and
stance use behaviors among adolescents. Like MDFT, behavior problems at termination and at 2 years
MST addresses individual development, family struc- post-treatment (Ogden & Hagen, 2006). In the first
ture and functioning, and the key social systems randomized clinical trial conducted in the United
in adolescents’ lives. Because of its intensity, thera- States without the direct oversight of the model
pists using this model tend to see a small number developers, Timmons-Mitchell, Bender, Kishna, and
of families, working closely with all of the systems Mitchell (2006) randomly assigned 93 juvenile
involved in the teen’s life and managing crises as offenders to either MST or usual child welfare ser-
they occur. vices. Importantly, this effectiveness study took place
Results from the first set of randomized clinical in a community setting with master’s degree-level
trials conducted in the 1990s found that MST was therapists. It was found that adolescents who partici-
particularly effective in increasing abstinence from pated in MST evidenced lower recidivism rates and
marijuana and reducing re-arrests, criminal activity, higher functioning at home, school, and in the com-
out-of-home placements, and self-reported drug munity than did the teens who received treatment
and alcohol use (Borduin et al., 1995; Henggeler, as usual.
Melton, & Smith, 1992; Henggeler, Melton, Brondino, Multisystemic therapy has also been success-
Scherer, & Hanley, 1997; Henggeler, Pickerel, & fully used with psychiatric patients (Henggeler
Brondino, 1999). Furthermore, most of these gains et al., 1999; Huey et al., 2005; Rowland, 2005;
were maintained up to 4 years post-treatment (Borduin, Schoenwald, Ward, Henggler & Rowland, 2000),
Henggeler, Blaske, & Stein, 1990; Borduin, et al., children with health disorders, such as type I diabe-
1995; Henggeler, et al., 1991; Henggeler, Melton, & tes (Ellis et al., 2007; Naar-King et al., 2007), and
Smith, 1992; Henggeler, Melton, Smith, Schoenwald, children with perinatally acquired HIV (Ellis, Naar-
& Hanley, 1993). King, Cunningham, & Secord, 2006).
Over the past few years, a number of investiga-
tions examined the long-term results of some of the family-focused treatment
earlier studies. Henggeler, Clingempeel, Brondino, Over the past decade, Miklowitz and colleagues
and Pickrel (2002), for example, assessed the 4-year (Miklowitz & Goldstein, 1990) have developed and
outcomes of 80 substance abusing juvenile offenders tested family-focused treatment (FFT) for patients
who had participated in a randomized clinical trial suffering from bipolar disorder and their families.
comparing MST to usual community services. The Originally created for adults (Miklowitz & Goldstein,
adolescents who had received MST evidenced lower 1997), this approach has also been used effectively
rates of aggressive criminal activity, but not property with adolescents (Miklowitz et al., 2004) as well as
crimes. Analyses of urine and hair samples indicated younger children (Pavuluri et al., 2004). The treat-
that the teens in the MST treatment showed greater ment is designed to reduce family criticism and con-
marijuana abstinence, although there were no treat- flict and consists of three phases: psychoeducation,
ment differences in self-reported drug use. the learning of effective communication skills, and
In one of the most impressive follow-up studies training in problem solving. Family members learn
conducted to date, Schaeffer and Borduin (2005) about the disorder, share coping strategies, and
examined arrest and incarceration data from 176 attempt to reduce emotional reactivity. With younger
seriously offending youths who had received either children, the unique symptoms of pediatric bipolar
MST or individual therapy 12–15 years prior disorder are emphasized (Pavuluri et al., 2004).
(Borduin et al., 1995). Even after such a lengthy In the first large scale randomized clinical trial
time period, participants who had received MST (Miklowitz et al., 2000), 101 bipolar adult patients
showed lower rates of recidivism (50% vs. 81% for were randomly assigned to either 21 sessions of FFT

656 couple an d family th e rap y

or to two family education sessions with follow-up Moye, & Tice, 1994), investigators showed that this
crisis management. Both groups received ongoing family therapy approach was efficacious and poten-
mood stabilizing medication. Patients who received tially superior to individual therapy for adolescents
FFT had fewer relapses and longer periods of time suffering from anorexia nervosa. More recently, a
between relapses at the 1-year evaluation. These study was conducted in which 40 families received
patients also showed greater improvement in family either 1 year of conjoint or separated family therapy
communication and in depressive, but not manic, (SFT), a treatment in which the therapist meets
symptoms. Results at 2 years post-randomization with family members separately (Eisler, Dare,
showed that patients receiving FFT continued to Hodes, Russell, Dodge, & Le Grange, 2000). A ran-
be less likely to relapse, and benefited from longer domized, stratified design was used to account for
intervals prior to relapse, than the patients who level of maternal criticism. Overall, there were sig-
received crisis management (Miklowitz, George, nificant reductions in anorexic symptoms, as well as
Richards, Simoneau & Suddath, 2003). gains in psychological and family functioning,
In a second, more rigorously designed study, across the two treatments, with nearly two-thirds of
Rea at al. (2003) compared FFT to an individually the adolescents achieving a normal weight. As might
focused therapy, which included psychoeducation, be expected, SFT was more efficacious for families
case management and problem solving, for a sample high in maternal criticism, whereas there were no
of recently hospitalized adult manic patients. Again, treatment differences for families with low levels of
both groups received concurrent mood stabilizing emotional reactivity. A follow-up study found that
medication. Compared to those receiving individual the gains were maintained 5 years post-treatment,
treatment, patients receiving FFT were less likely to with more than 75% of patients demonstrating
be re-hospitalized or to experience mood disorder no eating disorder symptoms (Eisler, Simic, Russell,
relapses over the two year period including active & Dare, 2007). Notably, high maternal criticism
treatment (1 year) and follow-up (1 year). continued to be associated with poor outcome at
Finally, a large-scale (N = 293), multisite study the 5-year follow-up.
(Miklowitz et al., 2007) examined the benefit of Researchers at Stanford University (Lock, Agras,
medication plus one of four psychosocial interven- Bryson, & Kraemer, 2005) explored the role of dose
tions. Results indicated that patients receiving FFT, and length of Dare and colleagues’ Maudsley treat-
interpersonal and social rhythm therapy, or cogni- ment model. Lock et al. (2005) randomly assigned
tive therapy had better recovery rates, less time to 86 adolescents to either 10 therapy sessions over the
recovery, better total functioning, better relation- course of 6 months, or 20 sessions over the course of
ship functioning, and greater life satisfaction than 1 year. Results indicated that although 96% of the
patients receiving brief collaborative care (i.e., three patients showed improvement and 67% could con-
sessions of psychoeducation). servatively be described as remitters, there were no
significant treatment effects, suggesting that the
family-based treatment for anorexia shorter course of therapy was sufficient. In a subse-
Over the course of the 1990s, a group of clini- quent study that examined the effects of this treat-
cal researchers at Maudsley Hospital in London ment at, on average, 4 years post-therapy, 89% of
(Dare, Eisler, Russell, Treasure & Dodge, 2001; the sample weighed 90% of more of their ideal body
Dare & Eisler, 1995) developed and successfully weight and 74% did not evidence any eating disor-
tested a family therapy model for treating anorexia der symptoms (Lock, Couturier, & Agras, 2006).
nervosa in adolescents (Eisler, Lock, le Grange, Again, no significant differences were found between
2007). The treatment first involves defining the the short- and long-term therapy conditions.
anorexia as a severe psychiatric illness and subse- Although most studies of family therapy for
quently helps parents to take control of their adoles- anorexia have focused on adolescents, Dare, Eisler,
cent’s eating behavior. Once the lost weight has Russell, Treasure and Dodge (2001) examined the
been restored, the adolescent is helped to manage comparative efficacy of 1 year of family therapy,
his or her own eating habits and cope with the 1 year of focal psychoanalytic psychotherapy,
development tasks of adolescence (school, peer 7 months of cognitive-analytic therapy, and 1 year
relations, etc.). of low-contact, routine treatment for young adults
In a series of studies (Dare, Eisler, Russell, & suffering from anorexia nervosa. Results showed
Szmukler, 1990; Russell, Szmukler, Dare, & Eisler, that, across treatments, there was modest symp-
1987; Eisler et al., 1997; Robin, Siegel, Koepke, tomatic improvement over the course of the year.

fr ie dl ande r, diam ond 657

However, in contrast to studies on adolescents, with normal developmental tasks (i.e., school, peer
more than two-thirds of patients remained abnor- relationships).
mally underweight at the end of treatment. Family In the initial pilot randomized clinical study of
therapy and focal psychoanalytic therapy were ABFT (Diamond, Reiss, Diamond, Siqueland, &
found to be equally effective and more effective in Isaacs, 2002), 32 depressed adolescents, primarily
producing weight gain than the control treatment. female and African American, were assigned to
In contrast to its utility for treating anorexia ner- either 12 weeks of ABFT or 6 weeks of a minimal
vosa, family therapy may not be the treatment of wait-list control condition. At the end of treatment,
choice for adolescents suffering from bulimia ner- 81% of the adolescent clients no longer met criteria
vosa. In the only published study to date, Schmidt for major depressive disorder, as compared to 47%
et al. (2007) found that after 6 months of treatment, of those on the waiting list. Furthermore, adoles-
adolescents receiving individual cognitive-behavioral cents who received ABFT showed greater reductions
therapy reported less binging behavior than those in anxiety symptoms and family conflict. Of the 15
receiving Eisler et al’s (2005) family therapy model. ABFT cases assessed at follow-up, 13 (87%) contin-
These group differences, however, disappeared at ued not to meet the criteria for major depressive
12-month follow-up, at which time patients main- disorder 6 months post-treatment.
tained their treatment gains or improved. In a larger, recently completed study (Diamond,
Winterstein, Brown, Gallop, Shelef, Diamond, &
attachment-based family therapy Levy, under review), 66 adolescents with severe
Diamond and colleagues (Diamond, Siqueland & suicidal ideation and moderate to severe depres-
Diamond, 2003; Diamond, 2005) at the Children’s sive symptoms were randomly assigned to either
Hospital of Philadelphia have developed and gath- 14 weeks of ABFT or 14 weeks of enhanced usual
ered efficacy data for attachment-based family ther- care. Over the active phase of treatment, adolescents
apy (ABFT), the first manualized family therapy in ABFT showed significantly more rapid reduc-
approach specifically designed to treat seriously tions of suicidal ideation. These relative gains were
depressed and suicidal adolescents. The model is maintained over follow-up assessments. In addition,
based on structural family therapy, MDFT, attach- rates of clinical recovery were higher for patients in
ment theory, adolescent development research, and ABFT across all time points. Patients in ABFT also
emotion-focused principles and intervention strate- experienced greater initial reductions in depression.
gies. The model is structured as a series of specific, These findings were true even when looking at the
interrelated treatment tasks. The first task is to shift subsample of adolescents who met criteria for a
the focus of therapy from one of behavioral control diagnosis of depression and/or reported a history of
or management to a focus on the quality of the sexual abuse.
adolescent–parent attachment relationship. The ther- As indicated by these eight exemplary research
apist then typically meets with the adolescent and programs, there is now substantial evidence for the
then the parent alone. In the session with the adoles- efficacy and effectiveness of CFT for a number of
cent, the therapist aims to identify conflicts that, specific problems and diagnosable mental disorders.
from the adolescent’s perspective, have damaged the However, less is known about “how” CFT works.
family’s attachment bond. Sessions alone with the More research is needed to examine the CFT therapy
parents aim to deepen their commitment to repair- process in order to understand how, specifically,
ing attachment and facilitating meaningful com- change comes about in conjoint treatment.
munication with their child. Once this foundation
has been set, the family is brought back together What Makes Couple and Family
to discuss core conflicts that have damaged trust. Therapy Work?
Sometimes, these conflicts arise from the stress of To move psychotherapy research forward, Greenberg
normal family life; however, often these conflicts (1986) advocated studying specific change pro-
stem from a history of abuse or neglect. The work- cesses. Greenberg’s advocacy for “change process
ing through process occurs in the context of con- research” differentiated this kind of study from tra-
joint enactments, or reattachment episodes. Once ditional process research. That is, rather than simply
the attachment ruptures have been resolved, the describing what takes place in therapy sessions,
therapy focuses on helping parents support and change process research seeks to identify specific
guide the adolescent as she or he gets back on track mechanisms of change. In other words, the focus of

658 couple an d family th e rap y

this kind of research is what, specifically, produces a components or change mechanisms in CFT: the
meaningful shift in clients’ psychosocial problems. therapeutic alliance (at the relationship level),
Describing change process research, Greenberg reframing (at the speech act level), and enactment
(1986) described concentric levels of therapeutic (at the event level). In the following sections, a defi-
influence. If we envision the therapy process as nition of each construct is followed by an explana-
layers of an onion, at the most micro level, or the tion of its purported role in the change process, its
center, is content—what is discussed in treatment. complexity and uniqueness in CFT and relevant
Examples include dreams, irrational thoughts, or ethical considerations. We then review the empirical
coping strategies. Although informative, content research in each area, highlighting not only the
has less to do with facilitating change than the results of published studies but also the method-
next process level, speech acts (Greenberg, 1986). ological challenges for future research.
By studying speech acts, or therapeutic techniques
(e.g., interpretation, confrontation, reframing), we Therapeutic Alliance
can discover what “works” across content areas. It is widely accepted that, in individual treatment, a
When the topic under discussion is the client’s hos- strong therapeutic alliance between client and thera-
tility, for example, is the most effective technique pist plays an important role in outcome, especially
confrontation, reflection of feelings, or interpreta- when the alliance is assessed from the client’s per-
tion? At the next process level is the episode, or event. spective (Horvath & Bedi, 2002; Horvath &
That is, content and technique occur within a period Symonds, 1991). Far less has been written about the
of time in which a specific task is the focus. Like nature or importance of the working alliance in con-
a chapter in a book, a therapeutic episode has joint CFT. As described previously, early family the-
a beginning, middle, and end (Greenberg, 1986). orists (e.g., Minuchin & Fishman, 1981; Watzlawick
In individual therapy, for example, an episode might et al., 1967) focused on designing strategies to dis-
involve an entire session (or more) that is specifi- rupt rigid and dysfunctional family patterns, the
cally focused on the client’s “unfinished business” result being that the therapeutic relationship took
with a deceased parent (Greenberg & Malcolm, a back seat to technique.
2002). In couple therapy, an episode might be half What is the therapeutic alliance? This construct
a session devoted to working out an equitable bal- has its roots in early psychoanalytic writings (Freud,
ance of household chores during which the partners 1912/1940; Sterba, 1934) that emphasized the
are encouraged to negotiate with each other and importance of analyst–analysand (i.e., patient) col-
achieve a compromise. Finally, at the highest pro- laboration. In 1967, Greenson distinguished the
cess level (the outer layer of the onion) is the “working alliance” from transference and the “real
therapeutic relationship, most often studied as the relationship” between analyst and patient. It was
working alliance. That is, in the context of purpose- Bordin (1979, 1994), however, who popularized
ful collaboration between therapist and client(s), we the construct by defining it in a way that could be
might study how specific episodes and techniques operationalized for empirical research.
bring about therapeutic change. Or, when the ther- According to Bordin (1979, 1994), the working,
apeutic relationship is not firmly established, we or therapeutic, alliance has three related components.
could investigate what takes place in session to First, client and therapist mutually negotiate the
enhance it. goals of treatment—what the client wishes to achieve
In a 1994 article, Friedlander, Wildman, from psychotherapy. Examples include reducing
Heatherington, and Skowron used Greenberg’s depression, overcoming test anxiety, or managing
(1986) model of change process research to review anger. The second component is mutual agreement
the published studies to date in CFT. At that time, about the tasks of therapy—what will take place in
research at the intervention, or technique, level pre- session and between sessions. Will the therapist
dominated (Friedlander et al., 1994). In the two assign “homework?” Ask the client to free associate
decades since that publication, many CFT research- or analyze dreams? Use an empty chair to facilitate
ers have turned their attention to the therapeutic emotional catharsis? Third, the working alliance
relationship and to episodes of change, also called requires a strong emotional bond. The bond is more
change events. than simply rapport. To do the hard work necessary
In selecting CFT process areas to review for for therapeutic change, the client needs to care for,
this chapter, we decided to focus on three core trust, and respect the therapist, and the therapist

fr ie dl ande r, diam ond 659

needs to care about and communicate deep empathy occurrences in both couples and family treatment.
for the client. Splits can be predicted both by individual and mar-
Beginning with Pinsof and Catherall’s (1986) ital distress (Knobloch-Fedders et al., 2004;
seminal work on the alliance in CFT, theory and Mamodhoussen et al., 2005; Symonds & Horvath,
research on this construct has steadily increased over 2004), and their “repair” is said to be essential for
the past two decades. As a common factor in CFT, treatment to be successful (Friedlander et al., 2006a;
the alliance cuts across theoretical boundaries Muñiz de la Peña et al., 2009; Pinsof, 1995).
(Sprenkle & Blow, 2004). That is, just as in individ- What makes CFT alliances unique? It goes with-
ual therapy, the alliance in conjoint CFT treatment out saying that complexity is inherent when work-
is not theory specific. Its importance for treatment ing with multiple couples simultaneously. Aside
retention and outcome has been demonstrated in from that, in conjoint treatment, family members
solution-focused family therapy (Beck, Escudero, & observe each other responding to the therapist
Friedlander, 2006; Escudero, Friedlander, Varela, & (Heatherington & Friedlander, 1990; Pinsof &
Abascal, 2008), MFT (Shelef, Diamond, Diamond, Catherall, 1986; Rait, 2000), and these observa-
& Liddle, 2005; Robbins et al., 2006), functional tions can have reverberating effects. A husband, for
family therapy (Robbins et al., 2003), integrative example, finds that a male therapist takes his wife
problem solving (Knobloch-Fedders, Pinsof, & seriously (when he, himself, does not), so that the
Mann, 2004), EFT for couples (S. M. Johnson & wife’s alliance with the therapist is affected not only
Talitman, 1997), and BSFT (Robbins, Mayorga, by her own bond with him but also by her husband’s
Mitrani, Szapocznik, Turner, & Alexander, 2008), as new attitude toward her. As another example, a
well as nonmanualized couple and family “treatment- mother may not be impressed by the therapist but
as-usual” (Friedlander, Lambert, & Muñiz de la may nonetheless be pleased with the progress made
Peña, 2008; L. N. Johnson, Wright, & Ketring, by her son, who does apparently like and trust the
2002; Symonds & Horvath, 2004)(see Friedlander, therapist.
Escudero, Heatherington, & Diamond (2011) for a These examples illustrate why CFT alliances
meta-analysis of alliance-outcome research). differ from therapeutic alliances in individual treat-
However, in conjoint CFT, the alliance–outcome ment. As explained by Friedlander et al. (2006a),
relationship is not as straightforward as it is in indi- family members often have differing motivation
vidual therapy (Friedlander et al., 2008). Research levels and agendas. People usually seek conjoint
suggests that the degree to which each individual’s therapy when conflicts between them are insur-
alliance with the therapist affects retention and out- mountable, and they naturally expect the therapist
come depends on the quality of other family mem- to take sides. Adults and children are at different
bers’ alliances. Robbins et al. (2003), for example, developmental levels, and family members may have
found that the discrepancy between adolescents’ and different capacities for taking risks, tolerating anxi-
parents’ alliances with the therapist had greater pre- ety, or expressing emotions. Perhaps more impor-
dictive value than their alliances considered inde- tantly, clients in conjoint therapy generally have less
pendently. Symonds and Horvath (2004) reported control over what is said, or what is said about them,
that a couple’s agreement on the alliance, regardless than do clients in individual therapy. The private
of its strength, was more influential than either part- thoughts, feelings, or secrets that may be revealed in
ner’s individual alliance alone. In contrast, Knobloch- a conjoint therapy session cannot be as easily pushed
Fedders et al. (2004) found that outcomes were aside after the session. A woman comes to therapy
better when husbands’ alliances surpassed those of to improve her relationship with her partner but
their wives, but the opposite pattern was found in finds out that the partner is planning to leave her.
another study of couples (Quinn, Dotson, & Jordan, A mother brings her depressed daughter to a thera-
1997). pist, only to discover that her husband, the girl’s
Despite these contradictions, it seems clear that stepfather, has been molesting her regularly.
“split” family alliances; that is, considerable discrep- Ethical considerations play a role in developing
ancies in the self-reported alliances of different family and maintaining strong alliances with couples and
members (Beck et al., 2006; Friedlander et al., 2006a; families. Relationships are inevitably affected when
Heatherington & Friedlander, 1990; Mamodhoussen, the therapist is mandated to report suspected child
Wright, Tremblay, & Poitras-Wright, 2005; Muñiz abuse, for example. Consider a couple who came to
de la Peña, Friedlander, & Escudero, 2009; Pinsof & treatment to work out some marital difficulties, which
Catherall, 1986; Quinn et al., 1997), are common had escalated after the birth of their second child.

660 couple an d family th e rap y

Therapy was proceeding fairly well until the husband no harm” since people have the right to know and
brought in photographs of the toddler’s bruises, act on vital information about their own intimate
which he said were caused by his wife. Although the relationships. In these authors’ words, “[I]t is incon-
wife admitted to restraining the child “too force- sistent and contradictory for couple therapists to
fully,” she minimized the injuries. Although the ostensibly affirm ethics of justice, equality, and indi-
therapist did his best to retain the couple in treat- vidual rights in relationships while at the same time
ment after calling Child Protective Services (CPS), accommodating and/or facilitating clients in keep-
the alliance with the husband was strengthened but ing relationship-relevant information from a spouse”
the alliance with the wife deteriorated. She refused (p. 127). Citing data indicating that most couples
to return to treatment, despite the fact that the CPS who address infidelity in treatment do, in fact, stay
worker found no conclusive evidence of abuse. together, Butler et al. (2009) argued for “facilitated
Another ethical issue arises when secrets are disclosure,” by which the “aggrieved partner” is told
revealed, a not uncommon occurrence in CFT. Cli- (preferably by the “offending partner”) that there is
ents reveal secrets when they need the therapist to some relevant information of which he or she is
serve as a buffer or protector. That is, for many cli- unaware. Then the recipient has the choice to ask or
ents, telling a secret in the consulting room is far safer not ask for disclosure of the secret. This interven-
than revealing it at home, where other family mem- tion, which is designed to respect the individual’s
bers might react extremely. If the secret involves right to privacy, requires the therapist to explain the
harm, such as ongoing molestation, the therapist is need for disclosure and, once the infidelity is dis-
mandated to report it to authorities. Although the closed, to focus intensively on the healing process
consequences may be similar to those in the earlier (Butler, Seedall, & Harper, 2008).
example, sometimes taking such action can strengthen We see, then, that alliances in CFT are complex.
the family’s ties with the therapist (see Friedlander They can shift dramatically over time, based on
et al., 2006a, for some clinical examples). what happens in the family’s life outside therapy or
A secret may challenge the therapeutic alliance in by who chooses to come (or not come) to a therapy
other ways. To illustrate, consider another couples session. For these reasons, advancing our under-
case. A woman calls the therapist between sessions standing of the alliance through empirical study is
to explain that she is having an ongoing, secret love essential.
affair. Although she wants the therapist to have this To study the development, maintenance, and
information, she does not want it revealed to her effects of the alliance in CFT, researchers must
partner. This bid to align with the therapist creates a first consider the nature of their alliance measures
dysfunctional emotional triangle that puts the alli- and also decide what constitutes a “family alliance.”
ance at risk and is counterproductive for treatment Taking Bordin’s (1979) classic conceptualization of
and for the couple’s well-being. the alliance (an emotional bond with the therapist
Although confidentiality is an ethical principle, and mutually agreed upon goals and therapy tasks)
for the therapist to keep this secret would be harm- as a point of departure, Pinsof and Catherall (1986)
ful to the partner, to the couple’s relationship, and developed couple and family alliance measures, in
to the therapeutic alliance. On the other hand, which clients were asked to report on the alliance
revealing it without the client’s consent would not (goals, tasks, and bonds) from their own perspective,
only be unethical but also would destroy the client’s from the perspective of “other family members,” and
faith in the therapist. One strategy would be to from the perspective of the “group as a whole.”
give the client a choice—she can inform her part- Subsequently, Pinsof (1994, 1995; Pinsof, Zinbarg,
ner, either at home or in the next therapy session & Knobloch-Fedders, 2008) added the “within-
because, otherwise, the conjoint therapy has little system alliance,” which other authors (Friedlander
chance of success. However, if the client refuses et al., 2006a, 2008; Friedlander, Escudero, Horvath,
either alternative, discontinuing the treatment with- Heatherington, Cabero, & Martens, 2006b) term
out divulging the reason risks damaging both the family’s “shared sense of purpose,” or the degree
clients’ trust in the therapist—and perhaps in all to which family members concur on the need,
mental health providers. purpose, and value of conjoint treatment.
As Butler, Harper, and Seedall (2009) pointed When multiple family members report on their
out, infidelity damages attachment bonds and alliances with the therapist, the question becomes:
obstructs authentic intimacy. Therapists who collude How should these individual scores be analyzed?
to keep infidelity secrets violate the ethic of “doing Averaging family members’ scores “washes out”

fr ie dl ande r, diam ond 661

individual differences, making it impossible to iden- something that other family members didn’t know”)
tify split alliances. Subtracting alliance scores (e.g., and negative (“Client refuses or is reluctant to
the father’s score minus the son’s score) does allow respond when directly addressed by another family
splits to be identified but fails to take into account member”) (Friedlander et al., 2006a, p. 273).
the alliances’ relative strength (e.g., a discrepancy After observing a live or video-taped session and
score of 5 could reflect family scores of 30 and 35 considering the number, valence, intensity, and clin-
as well as scores of 12 and 17). ical context of the observed behaviors, trained raters
For these reasons, Friedlander and colleagues make global judgments of each dimension on a –3
(2006a, 2006b) developed an observational rating (extremely problematic) to +3 (extremely strong) scale,
system, the System for Observing Family Therapy where 0 = unremarkable or neutral. Based on specific
Alliances (SOFTA-o), to assess the strength of rating guidelines, family members are judged indi-
the alliance from in-session behavior, specifically vidually on engagement, emotional connection, and
family members’ individual interactions with the safety, whereas the entire family or couple is rated as
therapist and with each other. A corresponding self- a unit on shared sense of purpose. The assumption
report measure (SOFTA-s; Escudero et al., 2008; underlying the SOFTA-o is that external observers
Friedlander et al., 2006a; Muñiz de la Peña et al., can make judgments about the quality and strength
2009) asks individuals to report on their own alli- of the alliance from observing specific alliance-
ance with the therapist and their perceptions of the related client behaviors, just as clinicians make infer-
entire family’s shared sense of purpose; that is, the ences about their relationships with clients from the
alliance between and among family members irre- behavior that unfolds in front of them in a session
spective of the therapist. An example of a shared (Friedlander et al., 2006a, 2006b).
sense of purpose item is, “Each of us in the family Research with the SOFTA-o, and its self-report
helps the others get what they want out of therapy” version, the SOFTA-s, suggests that the two unique
(Friedlander et al., 2006a, p. 298). By assessing the aspects of the alliance, safety and shared sense of
within-system alliance in this way, the SOFTA-s purpose, are of particular importance. In intensive
avoids the problem some authors (Beck et al., 2006; analyses of individual families (Beck et al., 2006;
L. N. Johnson et al., 2002) reported with Pinsof Friedlander, Lambert, Escudero, & Cragun, 2008),
and Catherall’s (1986) measures—that clients often poor outcome cases were distinguished from good
do not know how their family members feel about outcome cases by low ratings on these two observed
the therapist. variables. In a study of 22 low-income families
Like the SOFTA-s, the SOFTA-o contains two (Friedlander, Lambert, & Muñiz de la Peña, 2008),
dimensions that reflect Bordin’s (1979, 1994) per- the parents’ degree of safety predicted the family’s
spective on the alliance, engagement in the therapeu- shared sense of purpose in session 1, which in turn
tic process (which includes client–therapist agreement predicted parent reports of improvement-so-far after
on goals and tasks) and emotional connection with session 3. In another study (Escudero et al., 2008),
the therapist (which is similar to Bordin’s emotional shared sense of purpose was the alliance dimension
bond). Two other dimensions reflect the uniqueness that most consistently predicted therapeutic prog-
of CFT. Shared sense of purpose within the family has ress, and it was the only dimension that improved
behavioral items that are both positive (“Family significantly over time in therapy.
members offer to compromise,” “Family members To date, there have been few empirical studies of
validate each other’s point of view”) and negative effective alliance repair in CFT. In the first explor-
(“Family members try to align with the therapist atory investigation, five improving and five deterio-
against each other”) (Friedlander et al., 2006a, rating alliances with adolescents were compared.
p. 274). The other unique SOFTA dimension is Results showed that the therapists in the improving
safety within the therapeutic system. Although safety cases were more likely to ally with the adolescent,
is important in all forms of therapy, in CFT it is focusing on his or her experience and suggesting
unique because clients need to take risks and discuss therapy goals that were of personal interest to the
intimate topics in front of other family members, teen (Diamond, Liddle, Hogue, & Dakof, 1999).
with whom they are likely to be in conflict. Like However, this study focused uniquely on improv-
shared sense of purpose, safety behaviors are both ing the adolescent’s initially poor alliance with the
positive (“Client directly asks other family members therapist. Repairing a “split” alliance requires simul-
for feedback about his/her behavior or about her- taneous attention to the discrepant alliances of two
self/himself as a person,” “Client reveals a secret or or more family members. How can a therapist best

662 couple an d family th e rap y

repair a split alliance—by encouraging the parents alliance is conceived of as a necessary, preliminary
to engage the teen in working for systemic change? step in the change process: the development of a
Research on this complex change process has yet to platform or safe base from which family members
be conducted. draw the courage and confidence to risk relating to
In terms of other future directions, it is time for one another in a different manner. It is a sufficiently
researchers to move beyond alliance-outcome inves- strong therapeutic alliance that allows the therapist
tigations. It is abundantly clear that poor within- to challenge clients to be more direct and assertive,
family alliances and differences in how individual more vulnerable and less defensive. The two spe-
family members view the therapist have negative cific change mechanisms described in the following
consequences for retention and treatment outcome. sections, reframing and enactment, require solid
At this point, it seems worthwhile to investigate the therapeutic alliances with all participating clients
factors, both individual and systemic, that contrib- in a couple or family in order to be effective.
ute to poor family alliances. Since split alliances
seem to be most likely when clients begin therapy Reframing
with high levels of individual, marital, and family- Reaching agreement on the goals and tasks of therapy
of-origin distress (Knobloch-Fedders et al., 2004; in CFT is arguably more complicated than in indi-
Mamodhoussen et al., 2005; Symonds & Horvath, vidual psychotherapy. Often family members present
2004), investigators might well study family mem- for treatment with different goals in mind. For exam-
bers’ attachment styles and relational patterns. ple, although the mother of an adolescent daughter
When both partners in a couple are highly avoidant, may come to therapy looking for ways to get her
for example, their ability to form a strong bond with 16-year-old daughter to be more obedient, her daugh-
the therapist is likely to be difficult. What interven- ter may hope that treatment helps to get her mother
tions can help make therapy a safe place for these “off her back.” In the context of couple therapy, it is
clients to take emotional risks? Partners with highly not unusual for one partner to think that the other
anxious attachment styles, on the other hand, may is not sufficiently committed to the relationship or
relate quite well to the therapist but poorly with emotionally available. When this person seeks greater
each other. How can a therapist use a strong thera- closeness, the other partner may feel that she or he is
peutic bond to disrupt a couple’s rigid and dysfunc- being smothered and, consequently, seeks more psy-
tional interactions? chological-emotional distance. Under such circum-
We should also begin studying the episodes and stances, it may appear that there is no way to formulate
speech acts that contribute to strong (and problem- a mutually agreed upon treatment goal toward which
atic) family alliances. For example, how do effective all members of the system can work in concert.
therapists build alliances with couples and families One method for creating a shared goal or sense
who see their presenting problems in terms of of purpose about attending therapy is through
winning or losing? Which techniques are most reframing (Friedlander et al., 2006a), an interven-
helpful when a family begins treatment with a poor tion that is common to many forms of CFT. In the
sense of shared purpose? Investigating questions like words of Watzlawick et al. (1974), “to reframe . . .
these would move family alliance research away means to change the conceptual and/or emotional
from global predictions of outcome to more practi- setting or viewpoint in relation to which a situation
tioner-friendly studies of effective interventions for is experienced and to place it in another frame
therapeutic change. which fits the “facts’ of the same concrete situation
Finally, although an abundance of research find- equally well or even better and thereby changes its
ings demonstrates the link between alliance and entire meaning” (p. 94). According to structural
outcome in CFT (Friedlander et al., 2011), one therapists Minuchin and Fishman (1981), “the
important but understudied question is how, exactly, therapist’s task is to . . . convince the family mem-
the alliance facilitates the change process in conjoint bers that reality as they have mapped it can be
therapy. Certainly, the therapist’s support, recogni- expanded or modified” (p. 76).
tion, and validation can increase each family mem- As a speech act, reframing can be accomplished
ber’s sense of self-esteem, agency, and hopefulness, using a wide variety of interventions, including posi-
which in itself may promote change (Satir, 1964; tive attributions (“It is wonderful how the two of
Shirk & Russell, 1996). However, many CFT theo- you protect each other from feeling pain. When your
rists do not view the client–therapist relationship as wife becomes emotional, you focus her attention
the primary change vehicle. Rather, the therapeutic on problem solving. When you become emotional,

fr ie dl ande r, diam ond 663

she focuses your attention on other problems”), par- the issue becomes the nature of the interaction
adox (“I would like you to devote 15 minutes each or relationship itself, not one partner or family
evening to worrying about your relationship”), met- member.
aphor (“In many ways, the two of you remind me of In a study examining the impact of reframe
a teeter-totter: one must be down so that the other interventions in functional family therapy for delin-
is up”) or externalization of symptoms (“The two of quent adolescents, Robbins and colleagues (Robbins,
you are in a fight against this thing called depression Alexander, Newell & Turner, 1996) found that ado-
which has invaded your lives. I’ll help you stand lescents responded to reframes more positively than
together against it”) (White & Epston, 1990), among to other types of interventions. This finding is par-
others. ticularly important in light of the fact that behavior
Each of these interventions places the problem in disordered, other-referred adolescents typically pres-
a different light, either in terms of the motivation ent for therapy reluctantly (Taylor, Adelman, &
behind or function of a person’s behavior, the degree Kaiser-Boyd, 1985) and have high levels of negativ-
to which the behavior is controllable, intentional, or ity (Robbins et al., 1996). Further analyses of this
harmful. By changing the scope and/or meaning same sample revealed that reframes actually served
of the problem or impasse, the goals and tasks of to disrupt defensive or negative family interactions.
therapy change as well. The emergence of new frames More specifically, when therapists used reframes in
offers people the opportunity to construct new response to family members’ defensive statements,
treatment goals—goals that supersede and bridge such as sarcasm or blame, family members were less
what initially appear to be family members’ conflict- likely to respond with defensive behavior than when
ing aims. For example, the mother and daughter therapists used reflection, structuring, or informa-
described above seemingly want different, incongru- tion gathering interventions (Robbins, Alexander &
ous outcomes: The mother wants the daughter to be Turner, 2000).
more obedient, the daughter wants more autonomy. Two studies examined the impact of relational
In systemic terms, these goals can be characterized reframes in ABFT for depressed adolescents. In the
as attempts at “first order” change or “more of the first study, Diamond and colleagues (Moran,
same.” However, by reframing the conflict in devel- Diamond, & Diamond, 2005) found that reframes
opmental, relational terms, a third option emerges, led parents to adopt an interpersonal, rather than an
which may resonate for both mother and daughter. intrapersonal construction of the problem. Inter-
The therapist might explain, for example, “Clearly personal constructions promote a sense of shared
your relationship is important, and it’s not hard to responsibility and possibilities for change, whereas
see the love you have for one another. However, it intrapersonal constructions refer to an individual’s
seems to me that you are trying to beat each other personality or other constitutional factors, which are
into concession rather than work together to help hard to change and connote blame. Not surprisingly,
Karie grow up, and this battle has undermined one results from the second study (Moran & Diamond,
of the most important things in your lives—your 2008) found that following a relational reframe,
relationship.” This intervention speaks to the under- parents were more likely to exhibit neutral or even
lying attachment themes, while reframing the prob- positive attitudes toward their depressed adolescent
lem as a difficulty in how the two go about managing rather than negativity. This finding is particularly
the developmentally normative process of negotiat- important in light of the pernicious role played by
ing autonomy in a collaborative fashion. In other parental criticism in the development and mainte-
words, the goal changes from two individuals want- nance of depression during adolescence (Sheeber,
ing to “get their way” to, instead, finding a mutu- Hyman, & Davis, 2001).
ally acceptable method to work together—one that Clinical experience and research findings suggest
strengthens rather than undermines their personal that reframing can influence not only clients’ cogni-
relationship. tive constructions and behaviors, but also their
Not only can reframing facilitate the formation emotional experience. For example, after listening
of the therapeutic alliance, but systemic reframes to a husband and wife battle for the first 10 minutes
can also reduce criticism, blame, and negativity of a session, the therapist might ask, “I wonder if
between and among family members (Friedlander, the two of you miss those times when you felt sup-
Heatherington, & Marrs, 2000). That is, when the ported, understood, and close to one another and
problem at hand is framed in relational terms wish it could be like that again? Maybe your fights
(e.g., “We don’t seem to understand one another”), allow you to find a way, even if it’s a negative way,

664 couple an d family th e rap y

to bring some strong emotion back into your rela- reframe, clients should be more willing to engage
tionship?” Such reframing interventions, which in certain behaviors/tasks that they may previously
shift clients’ attention away from blame and anger have been reluctant to try. Other questions have
and onto underlying or emergent vulnerable emo- to do with what constitutes an effective reframe
tions that fuel conflict, typically lead to a dramatic and how it should be formulated. Good reframing
shift in the emotional tone of the session: anger and requires substantial competence. It involves observ-
acrimony are suddenly replaced by sadness and ing and understanding the couple or family dynamic,
longing (Diamond & Liddle, 1996). as well as the personality and level of defensiveness
Indeed, reframing seems to be a powerful clinical of each family member. As with interpretations in
tool when partners or family members blame one individual therapy, a premature, overly threatening,
another in session. Friedlander et al. (2000) ana- or poorly delivered reframe will not resonate with
lyzed therapeutic interactions following blaming family members; in some instances, it may even
sequences in videotaped family therapy sessions generate resistance or undermine the therapeutic
with experts in narrative, solution-focused, and con- alliance. In contrast, effective reframes echo the
structivist family therapy. Results showed that underlying, core relational themes that are fueling
reframing was a frequent therapeutic intervention the family’s conflict or disengagement and are deliv-
following within-family blame. Reframes took the ered in a manner in which family members feel
form of focusing on competence, focusing on the heard and deeply understood.
positive, using metaphors, redefining or reinterpret-
ing, and expanding the theme to bring in a new per- Enactment
spective. For example, one therapist reframed a The therapeutic alliance in general, and the formu-
child’s silence, another therapist pointed to a child’s lation of interpersonal, systemic therapy goals in
competence in the face of her mother’s criticism, particular, are preludes to a second core feature
and yet another therapist interpreted a couple’s argu- of most CFT approaches: transforming family/
ment as due to their being “under a spell” that they couple interactions in a session through enact-
needed to fight against (Friedlander et al., 2000). ment. The importance of enactment as a therapeu-
In another study of constructivist family ther- tic event is reflected in one of the central tenets of
apy (Sluzki, 1992), Coulehan, Friedlander, and CFT: that problem behaviors are the function of, or
Heatherington (1998) found that, during intake at least influenced by, family interaction patterns.
sessions, the therapist’s exploration of positive Indeed, there is voluminous research on the associa-
attributes of individuals and the family unit was tion between couple and family functioning and a
associated, not only with shifts from intrapersonal wide range of psychopathologies and problems in
to interpersonal, relational constructions of the living, including anxiety (Rapee, 1997) and conduct
presenting problem, but also with a shift from nega- disorders (Snyder, Cramer, Afrank, & Patterson,
tive to positive emotions. In the “old story,” parents 2005), adolescent drug use (Fletcher, Darling, &
described the child as the “identified patient,” the Steinberg, 1995), adult alcoholism and marital
one who was being brought to therapy to be “fixed.” violence (Foran & O’Leary, 2008), depression
Using circular questioning (e.g., “How does his (Rehman, Gollan, & Mortimer, 2008; Sheeber,
misbehavior affect your marital relationship?”), Hymans, & Davis, 2001) and severe mental illness,
asking about exceptions to the problem (“Tell me including bipolar disorder and schizophrenia
about a time when Sean did what you asked with- (Miklowitz, 2008). Moreover, a number of studies
out a fuss”), and stimulating hope, the therapists in have found that when family relations improve over
this study helped bring about a “new story” for four the course of treatment, treatment outcomes are
families. In one of these cases, a father declared at better (Huey, Henggeler, Brondini & Pickrell, 2000;
the end of the interview, “I guess we need a little Schmidt, Liddle & Dakof, 1996). Unfortunately,
more respect all around” (Coulehan et al., 1998). however, there are, as yet, few studies that support
This comment suggested that, at least for him, the the proposition that changes in parent–child or
presenting problem was not his daughter but rather partner interactions mediate treatment outcomes.
a problem shared throughout the family. Enactment is a unique and powerful method for
A number of important yet unstudied questions transforming couple/family relationships through
remain. For example, do reframes increase clients’ in-session, face to face encounters between family
hope, motivation for change and productive partici- members. Essentially, therapeutic enactments are
pation in treatment? In theory, after a successful in-session experiential events during which the

fr ie dl ande r, diam ond 665

therapist encourages family members to generate become more vulnerable and direct with each other,
and experiment with new, more functional interac- the slightest sign of invalidation or criticism can
tions (Minuchin & Fishman, 1981). In some cases, lead family members to retreat to earlier behaviors.
enactment involves introducing structural changes, In other words, the process is one of two steps for-
such as helping a daughter to speak directly to her ward, one step backward, with the therapist mark-
father rather than communicate to him through her ing positive changes and using them to shape future
mother. In other cases, enactment involves intro- behavior.
ducing and sustaining focused, explicit conversation In theory, effective enactments produce change
about previously avoided topics or themes, such as a via multiple pathways simultaneously. When family
husband’s fear that he no longer interests his wife. members change their behavior (i.e., listen more,
In yet other cases, enactment involves changing the divulge previously undisclosed information about
process or rules of the conversations. For example, themselves that puts them in a vulnerable posi-
partners who regularly fight about how much time tion, express love or caring in a new and different
they do or do not spend with their in-laws may way), other family members’ attributions, emotional
be encouraged to, alternately, refrain from trying experience, and interactional patterns are influ-
to persuade or defend their position and, instead, enced. For example, when a newly divorced mother
listen carefully and with curiosity to their partner’s explains to her daughter that she never spoke about
experience. being abused by the girl’s father so as not to nega-
Many times, such changes create a therapeutic tively influence her daughter’s feelings for him, the
space in which new themes, underlying feelings, and daughter’s resentment about the divorce may sub-
previously unformulated and unarticulated thoughts side. Suddenly, the daughter sees her mother as
emerge. Without having to defend himself, the hus- caring and protective, rather than as selfish and
band may, for the first time, become aware of and insensitive, and feelings of appreciation and warmth
express his concern that if he does not visit his par- begin to surface. Furthermore, the daughter’s self-
ents every Saturday, he is a “bad, uncaring son.” This representation is likely to change. Whereas before
type of revelation expands his wife’s experience of she thought that her mother disregarded her needs,
and empathy for her husband, reducing conflict she now sees how important she is to her mother.
and increasing the couple’s motivation for problem Reinforced by such positive responses, both mother
solving and compromise. and daughter engage in further disclosure and
Enactments may also involve challenging part- approach behaviors. In this sense, changes in inter-
ners or family members to successfully finish a task actions are both a change target and a change mech-
that they have previously not been able to complete. anism (Davis & Butler, 2004).
In one example from Minuchin and Fishman’s Although enactment is a common and poten-
(1981) book on structural technique, Minuchin tially potent CFT intervention, it requires a great
tells the mother of a disruptive, oppositional girl to deal of skill to conduct effectively (Butler, Davis &
find a way to make the child play independently in Seedal, 2008). In some instances, habitual negative
a different area of the treatment room so that he can interactional patterns between partners or family
speak with the couple without being interrupted. members can escalate quickly when “hot topics” are
When the mother is not able to accomplish the task, introduced. In order for therapy not to become a
Minuchin simply tells her to “make it happen” retraumatizing experience, it is essential that the
(Minuchin & Fishman, 1981). In this way, thera- therapist work to modulate, draw meaning from,
pists can simultaneously push and support family and transform negative interactions into reparative
members to try out new ways of relating. experiences. In other instances, family members
Through enactments, therapists instruct and may resist speaking with one another about con-
guide family members to interact with one another, flictual topics, afraid to re-experience the frustration
rather than channeling the interaction through and or pain they felt in the past when trying to dis-
themselves (Davis & Butler, 2004). Indeed, the role cuss such topics at home (Nichols & Fellenberg,
of the therapist is to initiate conversations, behav- 2000). Frequently, family members try to enlist the
iors, and generally new ways of interacting and then therapist as an ally to support or validate their own
to get out of the way, intervening only when the side or conception of the problem by, for example,
interaction becomes stuck or unproductive. only addressing the therapist and avoiding speak-
Typically, the process is one of successive approxi- ing directly to other family members. Effective
mation. Initially, as family members take risks and enactment demands that the therapist be prepared

666 couple an d family th e rap y

for such occurrences with specific intervention thereby transforming contentious, negative interper-
strategies. sonal interactions into safe, satisfying, attachment-
Two papers offer general guidelines for pro- promoting interactions.
moting successful enactments. First, Nichols and Quite a few task analytic studies support the
Fellenberg (2000) conducted a discovery-oriented validity of a three-stage enactment sequence in EFT
study of successful versus unsuccessful enactments. (Greenberg, Ford, Alden & Johnson, 1993; Makinen
These authors found that in successful enactments & Johnson, 2006), as outlined by Johnson and
therapists instructed clients how to talk to one Greenberg (2006). In stage 1, a strong therapeutic
another (e.g., “Ask her how she feels” or “Instead of alliance is established with each member of the
explaining what was going on for you, just listen couple by exploring their emotional experience in
to what he has to say”) and specified a topic. Once the relationship and their attempts to meet attach-
the enactment was initiated, successful facilitation ment needs for safety, security and comfort. The
involved not interrupting family members and therapist works with each partner to access previ-
repeatedly directing them to continue speaking to ously unacknowledged, underlying emotions that
one another, either explicitly or nonverbally, for fuel interpersonal behaviors. In doing so, the thera-
example, by leaning backward or breaking eye con- pist reframes the problematic interactional cycle
tact. When such conversations stalled or became as the partners’ ineffective attempts to get their
less productive, therapists either challenged family attachment needs met. In stage 2, the therapist
members to be clearer or more explicit about their actively restructures the couple’s in-session inter-
feelings or probed for deeper, underlying affect. actions to help the partners become more accessi-
Finally, successful closure of enactments involved ble and responsive to each other’s attachment needs.
helping clients make sense of their experience by For example, the therapist may turn to a wife and
describing the interactional dynamic that was fuel- say, “When your husband criticizes you, you feel
ing the impasse and praising family members for ashamed and worthless, which makes you even more
their courage and ability to relate differently. anxious about how safe you are in the relationship.
In a later study, Davis and Butler (2004) pre- Can you turn to him and tell him how afraid you
sented a similar model. Importantly, they empha- are?” During such events, the disengaged, avoidant
sized how critical it is to evaluate the enactment partner typically becomes more engaged and, in
once it has ended. In the true spirit of enactment, response, the aggrieved, blaming partner tends to
these authors suggested that the post-enactment become softer and more forgiving, The result is
processing should occur between family members, the formation of a more secure emotional bond.
not between the therapist and individuals. However, Finally, in stage 3—consolidation and integration—
the therapist may remind family members of their the therapist facilitates the emergence of new solu-
goals for the enactment and how these goals relate tions to old relationship problems: solutions based
to aspirations for changing their relationship. The on acknowledging each member’s underlying attach-
therapist may also invite clients to reflect on what ment needs. The therapist also helps the couple rec-
went well or was helpful, commend them for their ognize the benefits of being open and persevering in
successes and express gratitude, note how the inter- expressing fears and attachment needs.
action may have gone even better, and commit to Enactment has also been shown to be effective
working further to improve their relationship. for resolving therapeutic impasses in the context of
In addition to these pantheoretical guidelines MDFT for adolescent substance abusers (Diamond
for conducting enactments, a number of clinical & Liddle, 1996). In-session impasses are defined as
researchers have outlined specific moment-by- conflictual, negative, escalating parent-adolescent
moment intervention models for facilitating pro- arguments about behavioral issues, such as cur-
ductive, clinically significant interpersonal processes few, chores, etc. (Diamond & Liddle, 1999). Such
within a given therapeutic approach and task. Per- impasses are said to result from ruptures in the ado-
haps the most well known and well researched lescent–parent attachment relationship. Theoreti-
of these models involves promoting connection cally, the opposition, acrimony, and anger that are
(i.e., attachment) in the context of EFT for couples characteristic of such conflicts derive, at least
(Greenberg & Johnson, 1988; Johnson, 1998). In in part, from failures in the attachment system—
most cases, the expression of vulnerable emotions lapses in trust and care associated with a history of
and needs elicits by one partner nurturance and betrayal, neglect, abandonment, and abuse. Such
understanding on the part of the other partner, ruptures are repaired by shifting family members’

fr ie dl ande r, diam ond 667

focus from the behavioral conflict to the underlying families were able to generate sustained engage-
attachment-related themes and emotions fueling ment, the first therapeutic step was to help family
the conflict. members get in touch with underlying emotions
The therapist plays a central role in generating and cognitions that were contributing to their
and maintaining this shift, typically by first eliciting relational impasse, such as a sense of hopelessness
or highlighting feelings of regret, loss or sadness or anger. In step 2, the therapists helped the
regarding the quality of the adolescent-parent rela- clients describe these heretofor unexpressed feelings
tionship. For example, the therapist might say to a or thoughts to each other. Such revelations often led
father, “I wonder if somewhere inside you also feel to the emergence of softer emotions and more
sad that your relationship with your son has become benevolent attributions. In step 3, the therapists
so distant and angry—if you had thought or hoped worked to keep family members focused on and to
it would be different?” Then, when the parent validate each other’s experience. In step 4, family
adopts a more reflective and softer posture, the members’ attributions regarding the impasse and
therapist turns to the adolescent to ask if she or understanding of each other’s motivations and feel-
he also feels regret. Once both family members are ings seemed to lead to good will, empathy, and flex-
on-board regarding their desire for things to be dif- ibility. Throughout the process, the therapists
ferent between them, the enactment starts. That is, highlighted the importance and potential benefits
therapist asks the parent to find out from the ado- of family members sustaining engagement with
lescent why he or she is so angry or detached. As each other (Friedlander, Heatherington et al.,
long as the parent is sincere and nondefensive, the 1994).
adolescent is likely to respond by expressing long- Enactment is a particularly potent intervention.
standing grievances, such as abandonment, abuse, When employed skillfully, it has the potential to
or neglect. At this point, the therapist works to help affect dramatic, therapeutic changes in the manner
the parent contain and acknowledge the child’s in how family members experience themselves and
experience without explaining, justifying, or cor- others. However, negative interactional processes
recting. This simple but profound act of validation between family members, such as attack and with-
and care is the first step in re-establishing trust and drawal behaviors, can escalate quickly among vola-
an emotional bond (Diamond & Liddle, 1996, tile, highly reactive couples and families. When left
1999; Liddle, 2005). unchecked, enactments can deteriorate and end up
Basing their work with MDFT (Liddle, 2005) replicating the highly negative, traumatic experi-
and Emotion-Focused Therapy (Greenberg & ences that brought the family to therapy in the first
Johnson, 1988), Diamond and colleagues articu- place. The last thing a therapist wants to have
lated a step-by-step approach to preparing and con- happen is for partners to demean or somehow act
ducting reattachment episodes or enactments to destructively toward one another and then leave the
repair relational ruptures between depressed and consulting room feeling worse and more demoral-
suicidal adolescents and their parents (Diamond, ized than when they arrived.
Diamond, & Liddle, 2000; Diamond & Siqueland, Therefore, the ethical, responsible use of enact-
1995, 1998; Diamond & Stern, 2003). Results ment involves careful assessment and continuous
from a task analytic study (Diamond & Stern, 2003) monitoring of the level of volatility/reactivity/
suggested that successful reattachment enactments receptivity of each family member, and a corre-
were characterized by parents’ affiliative focus on sponding level of therapist involvement or directive-
their adolescent’s experience and expressions and ness. Indeed, Davis and Butler (2004) presented a
the aggrieved adolescent’s focus on her- or himself. well-articulated, five-stage developmental model for
This pattern reflects the parental empathic holding conducting enactments in which the degree to
and validation promoted by the reattachment task which family members speak directly toward one
and purported to positively influence adolescent another (vs. through the therapist), the level of
attachment schema and behavior. emotional intensity and amount of verbal auton-
Yet another microanalytic enactment model omy (i.e., how freely they interact) corresponds to
was described in a task analytic study (Friedlander, the level of relationship distress, emotional reactiv-
Heatherington, Johnson, & Skowron, 1994) of the ity, and interactional volatility. In short, initiating
process by which therapists help families move from and managing enactments in a constructive, thera-
disengagement to sustained, productive engagement peutic manner requires a great deal of training,
in problem solving. The authors found that when practice, and supervision.

668 couple an d family th e rap y

 Whereas considerable progress has been made does now, 100 years later. As globalization is rapidly
in delineating the sequence of client and therapist affecting cultural norms around the world, academ-
behaviors associated with resolving interpersonal ics and professionals across disciplines are respond-
conflict, attachment injuries, and so on, a number ing to the problems of our increasingly heterogeneous
of important questions remain. For example, what is societies. Having traditionally examined psychoso-
the minimum level of emotional arousal required to cial well-being contextually, counseling psycholo-
facilitate change, and at what point is the emotional gists are in a position to make an important, unique
arousal too high to allow for productive discussion contribution to the understanding and treatment of
and information processing? Every family therapist couples and families from diverse cultures.
has wondered, at one time or another, whether the To do so, we need to move further away from the
emotion being expressed in the session—particularly medical model, with its “top-down” approach to
anger—has become too intense and therefore unpro- theory, research, and practice, in which standard
ductive or, alternatively, whether family members treatments are tested for their efficacy with various
are not sufficiently engaged or connected to their client groups. Rather, by applying our knowledge of
feelings. More research is needed to identify and contextual factors, we can develop couple and family
quantify the optimal range of emotional arousal for interventions “from the bottom up,” that is to say,
effecting cognitive and behavioral change in the by focusing on the specific needs of different
context of in-session enactments. Such research may clientele. In our view, it is more desirable to create
benefit from including continuous, objective mea- (and investigate) new treatments, or to substantially
sures of physiological arousal, along with observer modify existing ones, for specific populations rather
and client self-report measures. than to simply apply the tried-and-true methods to
Another understudied question relates to both various client groups.
the immediate and longer-term impact of successful One intervention that exemplifies the “bottom-
enactments on clients’ subsequent cognitive schema, up” approach is a filial therapy group that was
emotions, and behavior. For example, do successful designed specifically for first-generation Chinese
enactments in attachment-based, emotion-focused parents in Toronto who were experiencing accul-
treatments actually lead to changes in family mem- turative strains with their children (Chau &
bers’ attachment schema (i.e., how trusting they are Landreth, 1997). Culture-specific family interven-
of one another)? Do effective enactments actually tions like this are essential because many of the
promote more approaching, affiliative behaviors immigrants and refugees needing mental health ser-
on the part of family members, not only in the con- vices have within-family conflicts arising from cul-
sulting room but also in the family’s daily life? Are tural mistrust, bicultural identities, acculturative
family members better able to solve problems, stress, and social class mobility. Moreover, immi-
resolve conflicts, disclose vulnerable emotions, and grants and refugees from Asia, Latin America,
turn to each other for support and help after a Africa, and the Middle East come from collectivist
powerful enactment or series of enactments? societies, in which family well-being is crucial for
individual well-being.
The Future of Couple and Family Therapy In addition to developing or adapting cultur-
Conjoint psychotherapy began as an experiment. ally sensitive treatment models, our future agenda
Now, roughly 50 years later, the field is thriving. should include a better integration of what we
No longer an “also ran,” CFT has been shown to now know about psychopathology, development,
work as well as individual psychotherapy, and for personality, and empirically supported individual
some clinical problems it surpasses individual treat- interventions with couple and family treatments.
ment in effectiveness. Although the early pioneers of family therapy
The challenges faced by families in the second emphasized (perhaps overemphasized) the role and
millennium were inconceivable when Sigmund impact of systemic forces in order to differentiate
Freud began treating individual patients for psy- CFT from the individually based models that pre-
chological problems. Early psychoanalysts concep- ceded it, contemporary authors are rediscovering
tualized emotional disorders in light of patients’ and acknowledging the power and impact of intra-
childhood histories, paying notably less attention to psychic forces on the individual and on the family or
the sociocultural factors that affect individual func- couple system. This relatively new focus in the
tioning. At that time, culture arguably played a CFT field has led to the development of multisys-
smaller role in an individual’s mental health than it temic and multidimensional family-based treatments

fr ie dl ande r, diam ond 669

that target intrapersonal as well as interpersonal address the myriad challenges facing contemporary
concerns. couples and families.
However, more work is needed to integrate
specific individual and systems treatment models. Notes
For example, it would be wise to offer individual 1. Although we view couple and family therapy
therapy to an adolescent who was raped along with as a way of conceptualizing and treating emotional
conjoint family sessions to prevent her from being problems, which can be accomplished with a single
isolated by family members who are secondarily individual, the focus of this chapter is on conjoint
traumatized. Likewise, exposure therapy with a hus- CFT—i.e., therapy in which two or more partners
band who suffers from obsessive-compulsive disor- or family members are physically present in the
der could alternate with couples sessions in which session.
the origins and nature of the disorder are explained 2. We use the word “patient” (rather than
and the wife is helped to recognize and avoid safety “client”) because psychoanalysis evolved from and
behaviors that work against her husband’s recovery. embraced the medical model of diagnosis and treat-
Becoming a competent couple and family thera- ment, locating emotional disturbances within an
pist requires a substantial knowledge base and exten- individual’s psyche.
sive supervised training. Given our field’s traditional 3. In a therapist version for the SOFTA-o, the
focus on individual young adults, most counseling therapist’s behavioral contributions to the therapeu-
psychology programs do not sufficiently prepare tic alliance are rated along the same four dimensions
students to become CFT therapists. Programs that (Friedlander et al., 2006a).
offer one or perhaps two courses in couple and
family therapy do just enough for entry-level thera- References
pists to recognize and appreciate the complexity of Ackerman, N. W. (1958). The psychodynamics of family life.
systems work. In our experience, however, it takes New York: Basic Books.
Alexander, J., & Parsons, B. (1982). Functional family therapy.
at least 2 to 3 years of training (theoretical and Monterey, CA: Brooks Cole.
practical) to become a relatively competent CFT Bateson, G., Jackson, D. D., Haley, J., & Weakland, J. (1956).
practitioner. Toward a theory of schizophrenia. Behavioral Sciences, 1,
To expand our students’ skills in this area, we 251–264.
encourage counseling psychology programs to recruit Baucom, D. H., Shoham, V., Mueser, K. T., Daiuto, A. D., &
Stickle, T. R. (1998). Empirically supported couple and
faculty who are interested and skilled in CFT and family interventions for marital distress and adult mental
expand practicum options to allow students to gain health problems. Journal of Consulting and Clinical Psychology,
focused, supervised experience in systems-based treat- 66, 53–88.
ments. One possible training model is to offer a sub- Beck, M., Friedlander, M. L., & Escudero, V. (2006). Three per-
specialty or certificate that could be pursued by spectives on clients’ experiences of the therapeutic alliance:
A discovery-oriented investigation. Journal of Marital and
students who are interested in CFT. This focused Family Therapy, 32, 355–368.
experience should include four to six systems-oriented Bell, J. E. (1961). Family group therapy. Public Health Monograph
courses, including relational assessment, a review of No. 64. Washington, DC: U.S. Government Printing
empirically supported CFT approaches, and inten- Office.
sive supervised practica in CFT. We have found that Berg, I. K. (1994). Family-based services: A solution-focused
approach. New York: Norton.
counseling psychology students, who have a broad Bertalanffy, L. von. (1950). An outline of general systems theory.
knowledge base in psychology, can be competitive for British Journal of Philosophy of Science, 1, 139–164.
internships with a specialized family track. Moreover, Boardman, W. K. (1962). Rusty: A brief behavior disorder.
these students tend to be quite successful in these Journal of Consulting Psychology, 26, 293–297.
internships because of their background in normative Bordin, E. S. (1979). The generalizability of the psychoanalytic
concept of the working alliance. Psychotherapy, 16, 252–260.
development, person–environment fit, and strengths- Bordin, E. S. (1994). Theory and research on the therapeutic
based assessment and intervention. working alliance: New directions. In A. O. Horvath, &
As counseling psychologists, we have a unique L. S. Greenberg (Eds.), The working alliance: Theory, research,
perspective on human functioning that has yet to and practice. (pp. 13–37). New York: John Wiley & Sons, Inc.
be realized the broader CFT field. With continued Bourduin, C. M., Mann, B. J., Cone, L. T., Henggeler, S. W.,
Fucci, B. R., Blaske, D. M., & Williams, R. A. (1995).
theorizing and empirical attention to the unique- Multisystemic treatment of serious juvenile offenders: Long-
ness and promise of CFT as a treatment modality, term prevention of criminality and violence. Journal of
counseling psychologists will be better equipped to Clinical and Consulting Psychology, 63, 569–578.

670 couple an d family th e rap y

Bowen, M. (1966). The use of family theory in clinical practice. The cannabis youth treatment (CYT) study: Main findings
Comprehensive Psychiatry, 7, 345–374. from two randomized trials. Journal of Substance Abuse
Bowen, M. (1976). Theory in the practice of psychotherapy. Treatment, 27, 197–213.
In P. J. Guerin (Ed.), Family therapy: Theory and practice Diamond, G. M., Diamond, G. S., & Liddle, H. A. (2000). The
(pp. 42–90). New York: Gardner Press. therapist-parent alliance in family-based therapy for adoles-
Butler, M. H., Davis, S. D., & Seedall, R. B. (2008). Common cents. Journal of Clinical Psychology, 56, 1037–1050.
pitfalls of beginning therapists utilizing enactments. Journal Diamond, G. M., Hogue, A., Liddle, H. A., & Dakof, G. A.
of Marital and Family Therapy, 34, 329–352. (1999). Alliance-building interventions with adolescents in
Butler, M. H., Harper, J. M., & Seedall, R. B. (2009). Facilitated family therapy: A process study. Psychotherapy, 36, 355–368.
disclosure versus clinical accommodation of infidelity secrets: Diamond, G. S. (2005). Attachment-based family therapy for
An early pivot point in couple therapy. Part 1: Couple rela- depressed and anxious adolescents. In J. L. Lebow (Ed.),
tionship ethics, pragmatics, and attachment. Journal of Handbook of clinical family therapy (pp. 17–41). Hoboken, NJ:
Marital and Family Therapy, 35, 125–143. Wiley & Sons.
Butler, M. H., Seedall, R. B., & Harper, J. M. (2008). Facilitated Diamond, G. S., & Liddle, H. A. (1996). Resolving and thera-
disclosure vs. clinical accommodation of infidelity secrets: peutic impasse between parents and adolescents in multidi-
An early pivot point in couple therapy. Part 2: Therapy ethics, mensional family therapy. Journal of Consulting and Clinical
pragmatics, and protocol. American Journal of Family Therapy, Psychology, 64, 481–488.
36, 265–283. Diamond, G. S., & Liddle, H. A. (1999). Transforming negative
Carter, B., & McGoldrick, M. (1999). The expanded family life parent-adolescent interactions: From impasse to dialogue.
cycle (3rd ed.). Boston: Allyn & Bacon. Family Process, 38, 5–26.
Chau, I. Y., & Landreth, G. L. (1997). Filial therapy with Diamond, G. S., Reis, B. F., Diamond, G. M., Siqueland, L.,
Chinese parents: Effects on parental empathic interactions, & Isaacs, L. (2002). Attachment-based family therapy
parental acceptance of child and parental stress. International for depressed adolescents: A treatment development study.
Journal of Play Therapy, 6, 75–92. Journal of the American Academy of Child and Adolescent
Christensen, A., Atkins, D. C., Berns, S., Wheeler, J., Psychiatry, 41, 1190–1196.
Baucom, D. H., & Simpson, L. E. (2004). Traditional versus Diamond, G. S., & Siqueland, L. (1995). Family therapy for
integrative behavioral couple therapy for significantly and the treatment of depressed adolescents. Psychotherapy: Theory,
chronically distressed married couples. Journal of Consulting research, practice, training, 32, 77–90.
and Clinical Psychology, 72, 176–191. Diamond, G. S., & Siqueland, L. (1998). Emotions, attachment
Christensen, A., Atkins, D. C., Yi, J., Baucom, D. H., & and the relational reframe: The first session. Journal of
George, W. H. (2006). Couple and individual adjustment for Systemic Therapies, 17, 36–50.
2 years following a randomized clinical trial comparing tradi- Diamond, G. S., Siqueland, L., & Diamond, G. M. (2003).
tional versus integrative behavioral couple therapy. Journal of Attachment-based family therapy for depressed adolescents:
Consulting and Clinical Psychology, 74, 1180–1191. Programmatic treatment development. Clinical Child and
Christensen, A., & Heavey, C. L. (1999). Interventions for Family Psychology Review, 6, 107–127.
couples. Annual Review of Psychology, 50, 165–190. Diamond, G. S., & Stern, R. (2003). Attachment-based family
Christensen, A., Jacobson, N. S., & Babcock, J. C. (1995). therapy for depressed adolescents: Repairing attachment
Integrative behavioral couple therapy. In N. S. Jacobson, failures. In V. E. Whiffen, & S. M. Johnson (Eds.), Attachment
& A. S. Gurman (Eds.), Clinical handbook of couple therapy processes in couple and family therapy (pp. 191–212). New York:
(pp. 31–62). New York: Guilford Press. Guilford.
Coulehan, R., Friedlander, M. L., & Heatherington, L. (1998). Dennis, M., Godley, S. H., Diamond, G. S., Tims, F. M., Babor, T.,
Transforming narratives: A change event in constructivist Donaldson, J., et al. (2004). The cannabis youth treatment
family therapy. Family Process, 37, 465–481. (CYT) study: Main findings from two randomized trials.
de Shazer, S. (1985). Keys to solutions in brief therapy. New York: Journal of Substance Abuse Treatment, 27, 197–213.
Norton. Dunn, R. L., & Schwebel, A. I. (1995). Meta-analytic review
Dare, C., & Eisler, I. (1995). Family therapy. In G. I. Szmukler, of marital therapy outcome research. Journal of Family
C. Dare, & J. Treasure (Eds.), Handbook of eating disorders: Psychology, 9, 58–68.
Theory, treatment and research. London: Wiley. Eisler, I., Dare, C., Hodes, M., Russell, G., Dodge, E., &
Dare, C., Eisler, I., Russell, G. F., & Szmukler, G. I. (1990). The LeGrange, D. (2000). Family therapy for adolescent anorexia
clinical and theoretical impact of a controlled trial of family nervosa: The results of a controlled comparison of two family
therapy in anorexia nervosa. Journal of Marital and Family interventions. Journal of Child Psychology and Psychiatry, 42,
Therapy, 16, 39–57. 727–736.
Dare, C., & Eisler, I., Russell, G., Treasure, J., Dodge, L. (2001). Eisler, I., Dare, C., Russell, G. F., Szmukler, G. I., le Grange, D.,
Psychological therapies for adults with anorexia nervosa. & Dodge, E. (1997). Family and individual therapy in
British Journal of Psychiatry, 178, 216–221. anorexia. A 5-year follow-up. Archives of General Psychiatry,
Davis, S. D., & Butler, M. H. (2004). Enacting relationships in 54, 1025–1030.
marriage and family therapy: A conceptual and operational Eisler, I., Lock, J., & le Grange, D. (2007). Family-based treat-
definition of an enactment. Journal of Marital and Family ments for adolescents with anorexia nervosa: Single-family
Therapy, 30, 319–333. and multi-family approaches. In C. Grilo, & J. Mitchell
Dennis, M., Godley, S. H., Diamond, G. S., Tims, F. M., (Eds.), The treatment of eating disorders. New York: Guilford.
Babor, T., Donaldson, J., Liddle, H., Titus, J. C., Eisler, I., Simic, M., Russell, G. F. M., & Dare, C. (2007).
Kaminer, Y., Webb, C., Hamilton, N., & Funk, R. (2004). A randomized controlled treatment trial of two forms of

fr ie dl ande r, diam ond 671

 family therapy in adolescent anorexia nervosa: A five-year the process of family therapy. Journal of Family Psychology, 8,
follow-up. Journal of Child Psychology and Psychiatry, 48, 390–416.
552–560. Gelso, C., & Fretz, B. (2001). Counseling psychology (2nd ed.).
Ellis, D. A., Naar-King, S., Cunningham, P. B., & Secord, E. Belmont, CA: Wadsworth/Thompson Learning.
(2006). Use of multisystemic therapy to improve antiretrovi- Gollan, J. K., & Jacobson, N. S. (2002). Developments in
ral adherence and health outcomes in HIV-infected pediatric couple therapy research. In H. A. Liddle, D. A. Santisteban,
patients: Evaluation of a pilot program. AIDS Patient Care R. F. Levant, & J. H. Bray (Eds.), Family psychology: Science-
and STDs, 20, 112–121. based interventions (pp. 105–122). Washington, DC:
Ellis, D. A., Templin, T., Naar-King, S., Frey, M. A., American Psychological Association.
Cunningham, P. B., Podolski, C., & Cakan, N. (2007). Greenberg, L. S. (1986). Change process research. Journal of
Multisystemic therapy for adolescents with poorly controlled Consulting and Clinical Psychology, 54, 4–9.
Type I diabetes: Stability of treatment effects in a randomized Greenberg, L. S., Ford, C. L., Alden, L., & Johnson, S. M.
controlled trial. Journal of Consulting and Clinical Psychology, (1993). In-session change in emotionally focused therapy.
75, 168–174. Journal of Consulting and Clinical Psychology, 61, 78–84.
Escudero, V., Friedlander, M. L., Varela, N., & Abascal, A. Greenberg, L. S., & Johnson, S. M. (1988). Emotionally focused
(2008). Observing the therapeutic alliance in family therapy: therapy for couples. New York: Guilford Press.
Associations with participants’ perceptions and therapeutic Greenberg, L. S., & Malcolm, W. (2002). Resolving unfinished
outcomes. Journal of Family Therapy, 30, 194–204. business: Relating process to outcome. Journal of Consulting
Fisch, R., Weakland, J., & Segal, L. (1982). The tactics of change. and Clinical Psychology, 70, 406–416.
San Francisco: Jossey Bass. Greenson, R. (1967). The technique and practice of psychoanalysis.
Fletcher, A. C., Darling, N., & Steinberg, L. (1995). Parental New York: International Universities Press.
monitoring and peer influences on adolescent substance use. Haley, J. (1963). Strategies of psychotherapy. New York: Grune &
In J. McCord (Ed.), Coercion and punishment in long-term Stratton.
perspectives (pp. 259–271). New York: Cambridge. Haley, J. (1976). Problem-solving therapy. San Francisco:
Foran, H. M., & O’Leary, K. D. (2008). Alcohol and intimate Jossey-Bass.
partner violence: A meta-analytic review. Clinical Psychology Heatherington, L., & Friedlander, M. L. (1990). Couple and
Review, 28, 1222–1234. family therapy alliance scales: Empirical considerations.
Foucault, M. (1965). Madness and civilization: A history of Journal of Marital and Family Therapy, 16, 299–306.
insanity in the age of reason. New York: Random House. Henggeler, S. W., Borduin, C. M., Melton, G. B., Mann, B. J.,
Freud, S. (1912/1940). The dynamics of transference. In J. Strachey Smith, L. A., Hall, J. A., et al. (1991). Effects of multisys-
(Ed.), Standard edition of the complete psychological works of temic therapy on drug use and abuse in serious juvenile
Sigmund Freud Vol. 12 (pp. 122–144). London: Hogarth. offenders: A progress report from two outcome studies.
(Original work published 1912). Family Dynamics of Addiction Quarterly, 1, 40–51.
Friedlander, M. L., Escudero, V., and Heatherington, L. (2006a). Henggeler, S. W., Clingempeel, W. G., Brondino, M. J., &
Therapeutic alliances in couple and family therapy: An empiri- Pickrel, S. G. (2002). Four-year follow-up of multisystemic
cally informed guide to practice. Washington, DC: American therapy with substance-abusing and substance-dependent
Psychological Association. juvenile offenders. Journal of the American Academy of Child
Friedlander, M. L., Escudero, V., Horvath, S., Heatherington, L., and Adolescent Psychiatry, 41, 868–874.
Cabero, A., & Martens, M. P. (2006b). System for observing Henggeler, S. W., Melton, G. B., Brondino, M. J., Scherer, D. G.,
family therapy alliances: A tool for research and practice. & Hanley, J. H. (1997). Multisystemic therapy with violent
Journal of Counseling Psychology, 53, 214–224. and chronic juvenile offenders and their families: The role
Friedlander, M. L., Escudero, V., Heatherington, L., & of treatment fidelity in successful dissemination. Journal of
Diamond, G. M. (2011). Alliance in couple and family Consulting and Clinical Psychology, 60, 821–833.
therapy. Psychotherapy, 48, 25–33. Henggeler, S. W., Melton, G. B., & Smith, L. A. (1992). Family
Friedlander, M. L., Heatherington, L., Johnson, B., & Skowron, preservation using multisystemic therapy: An effective alter-
E. A. (1994). “Sustaining engagement”: A change event in native to incarcerating serious juvenile offenders. Journal of
family therapy. Journal of Counseling Psychology, 41, 438–448. Consulting and Clinical Psychology, 60, 953–961.
Friedlander, M. L., Heatherington, L., & Marrs, A. (2000). Henggeler, S. W., Melton, G. B., Smith, L. A., Schoenwald, S. K.,
Responding to blame in family therapy: A narrative/ & Hanley, J. (1993). Family preservation using multisystemic
constructionist perspective. American Journal of Family therapy: Long-term follow-up to a clinical trial with serious
Therapy, 28, 133–146. juvenile offenders. Journal of Child and Family Studies, 2,
Friedlander, M. L., Lambert, J. E., Escudero, V., & Cragun, C. 283–293.
(2008). How do therapists enhance family alliances? Henggeler, S. W., Pickrel, S. G., & Brondino, M. J. (1999).
Sequential analyses of therapist → client behavior in two Multisystemic treatment of substance abusing and depen-
contrasting cases. Psychotherapy: Theory, Research, Practice, dent delinquents: Outcomes, treatment fidelity, and trans-
Training, 45, 75–87. portability. Mental Health Services Review, 1, 171–184.
Friedlander, M. L., Lambert, J. E., & Muñiz de la Peña, C. Henggeler, S. W., Rowland, M. D., Randall, J., Ward, D.,
(2008). A step towards disentangling the alliance/improve- Pickrel, S. G., Cunningham, P. B., et al. (1999). Home-based
ment cycle in family therapy. Journal of Counseling Psychology, multisystemic therapy as an alternative to the hospitalization
55, 118–124. of youth in psychiatric crisis: Clinical outcomes. Journal of
Friedlander, M. L., Wildman, J., Heatherington, L., & the American Academy of Child and Adolescent Psychiatry, 38,
Skowron, E. A. (1994). What we do and do not know about 1331–1339.

672 couple an d family th e rap y

Henggeler, S. W., Schoenwald, S. K., Borduin, C. M., Liberman, R. P. (1970). Behavioral approaches to family and couple
Rowland, M. D., & Cunningham, P. B. (1998). Multisystemic therapy. American Journal of Orthopsychiatry, 40, 106–118.
treatment for antisocial behavior in youth. New York: Guilford Liddle, H. A. (2005). Multidimensional family therapy:
Press. A science-based treatment for adolescent drug abuse.
Horvath, A. O., & Bedi, R. P. (2002). The alliance. In J. L. Lebow (Ed.), Handbook of clinical family therapy
In J. C. Norcross (Ed.), Psychotherapy relationships that (pp. 128–163). Hoboken, NJ: Wiley & Sons.
work: Therapist contributions and responsiveness to patients Liddle, H. A., Dakof, G. A., Parker, K., Diamond, G. S.,
(pp. 37–69). New York: Oxford University Press. Barrett, K., & Tejeda, M. (2001). Multidimensional family
Huey, S. J., Henggeler, S. W., Brondino, M. J., & Pickrel, S. G. therapy for adolescent drug abuse: Results of a randomized
(2000). Mechanisms of change in multisystemic therapy: clinical trial. American Journal of Drug and Alcohol Abuse, 27,
Reducing delinquent behavior through therapist adherence 651–688.
and improved family and peer functioning. Journal of Liddle, H. A., Dakof, G. A., Turner, R. M., Henderson, C. E.,
Consulting and Clinical Psychology, 68, 451–467. & Greenbaum, P. E. (2008). Treating adolescent drug
Huey, S. J., Henggeler, S. W., Rowland, M. D., Halliday- abuse: A randomized trial comparing multidimensional
Boykins, C. A., Cunninghham, P. B., Pickrel, S. G., & family therapy and cognitive behavior therapy. Addiction,
James, E. (2005). Multisystemic therapy effects on attempted 103, 1660–1670.
suicide by youths presenting psychiatric emergencies. Journal Liddle, H. A., Rowe, C. R., Dakof, G. A., Henderson, C. E.,
of the American Academy of Child and Adolescent Psychiatry, & Greenbaum, P. E. (in press). Multidimensional family
43, 183–190. therapy for young adolescent substance abuse: Twelve month
Horvath, A. O., & Symonds, B. D. (1991). Relation between outcomes of a randomized controlled trial. Journal of
working alliance and outcome in psychotherapy: A meta- Consulting and Clinical Psychology. Forthcoming.
analysis. Journal of Counseling Psychology, 38, 139–149. Liddle, H. A., Rowe, C. R., Dakof, G. A., Ungaro, R. A., &
Kerr, M., & Bowen, M. (1988). Family evaluation. New York: Henderson, C. E. (2004). Early intervention for adolescent
Norton. substance abuse: Pretreatment to posttreatment outcomes of
Jackson, D. D. (1965). Family rules: The marital quid pro quo. a randomized clinical trial comparing multidimensional
Archives of General Psychiatry, 12, 589–594. family therapy and peer group treatment. Journal of
Jacobson, N. S. (1977). Problem solving and contingency Psychoactive Drugs, 36, 49–63.
contracting in the treatment of marital discord. Journal Lock, J., Agras, W. S., Bryson, S., & Kraemer, H. C. (2005).
of Consulting and Clinical Psychology, 45, 92–100. A comparison of short- and long-term therapy for adolescent
Jacobson, N. S., & Christensen, A. (1998). Acceptance and change anorexia nervosa. Journal of the American Academy of Child
in couple therapy: A therapist’s guide to transforming relation- and Adolescent Psychiatry, 44, 632–639.
ships. New York: Norton. Lock, J., Couturier, J., & Agras, W. S. (2006). Comparison of
Jacobson, N. S., Christensen, A., Prince, S. E., Cordova, J., & long-term outcomes in adolescents with anorexia nervosa
Eldridge, K. (2000). Integrative behavioral couple therapy: treated with family therapy. Journal of the American Academy
An acceptance-based, promising new treatment for couple of Child and Adolescent Psychiatry, 45, 666–672.
discord. Journal of Consulting and Clinical Psychology, 68, Luepnitz, D. (1988). The family interpreted: Feminist theory in
351–355. clinical practice. New York: Basic Books.
Jacobson, N. S., & Margolin, G. (1979). Marital therapy: MacIntosh, H. B., & Johnson, S. (2008). Emotionally focused
Strategies based on social learning and behavior exchange therapy for couples and childhood sexual abuse survivors.
principles. New York: Brunner/Mazel. Journal of Marital and Family Therapy, 34, 298–315.
Johnson, S. (1998). Emotion focused couple therapy. Madanes, C. (1981). Strategic family therapy. San Francisco:
In F. M. Dattilio (Ed.), Case studies in couple and family Jossey Bass.
therapy: Systemic and cognitive perspectives (pp. 450–472). Makinen, J. A., & Johnson, S. M. (2006). Resolving attachment
New York: Guilford. injuries in couples using emotionally focused therapy: Steps
Johnson, S. M., & Greenberg, L. S. (1985). Emotionally focused toward forgiveness and reconciliation. Journal of Consulting
couples therapy: An outcome study. Journal of Marital and and Clinical Psychology, 74, 1055–1064.
Family Therapy, 11, 313–317. Mamodhoussen, S., Wright, J., Tremblay, N., & Poitras-
Johnson, S. M., & Greenman, P. S. (2006). The path to a secure Wright, H. (2005). Impact of marital and psychological
bond: Emotionally focused couple therapy. Journal of Clinical distress on therapeutic alliance in couples undergoing
Psychology, 62, 597–609. couple therapy. Journal of Marital and Family Therapy, 31,
Johnson, L. N., Wright, D. W., & Ketring, S. A. (2002). 159–169.
The therapeutic alliance in home-based family therapy: Is it Miklowitz, D. J. (2008). Bipolar disorder: A family–focused
predictive of outcome? Journal of Marital and Family Therapy, treatment approach (2nd ed.). New York: Guilford.
28, 93–102. Miklowitz, D. J., George, E. L., Axelson, D. A., Kim, E. Y.,
Johnson, S. N., & Talitman, E. (1997). Predictors of success in Birmaher, B., Schneck, C., et al. (2004). Family-focused
emotion focused marital therapy. Journal of Marital and treatment for adolescents with bipolar disorder. Journal of
Family Therapy, 23, 135–152. Affective Disorders, 82, S113–S128.
Kazdin, A. E. (1987). Conduct disorders in childhood and Miklowitz, D. J., George, E. L., Richards, J. A., Simoneau, T. L.,
adolescence. Newbury Park, CA: Sage. & Suddath, R. L. (2003). A randomized study of family-
Knobloch-Fedders, L. M., Pinsof, W. M., & Mann, B. J. (2004). focused psychoeducation and pharmacotherapy in the out-
The formation of the therapeutic alliance in couple therapy. patient management of bipolar disorder. Archives of General
Family Process, 43, 425–442. Psychiatry, 60, 904–912.

fr ie dl ande r, diam ond 673

Miklowitz, D. J., & Goldstein, M. J. (1990). Behavioral family Pinsof, W. M. (1994). An integrative systems perspective on the
treatment for patients with bipolar affective disorder. Behavior therapeutic alliance: Theoretical, clinical, and research impli-
Modification, 14, 457–489. cations. In A. O. Horvath, & L. S. Greenberg (Eds.), The
Miklowitz, D. J., & Goldstein, M. J. (1997). Bipolar disorder: working alliance: Theory, research, and practice (pp. 173–195).
A family-focused treatment approach. New York: Guilford Press. New York: Wiley & Sons.
Miklowitz, D. J., Otto, M. W., Frank, E., Reilly-Harrington, N. A., Pinsof, W. M. (1995). Integrative problem-centered therapy.
Wisniewski, S. R., Kogan, J. N., et al. (2007). Psychosocial New York: Basic Books.
treatments for bipolar depression: A 1-year randomized trial Pinsof, W. M., & Catherall, D. R. (1986). The integrative psy-
from the Systematic Treatment Enhancement Program. chotherapy alliance: Family, couple and individual therapy
Archives of General Psychiatry, 64, 419–427. scales. Journal of Marital and Family Therapy, 12, 137–151.
Miklowitz, D. J., Simoneau, T. L., George, E. L., Richards, J. A., Pinsof, W. M., Wynne, L. C., & Hambright, A. B. (1996). The
Kalbag, A., Sachs-Ericsson, N., & Suddath, R. (2000). outcomes of couple and family therapy: Findings, conclu-
Family-focused treatment of bipolar disorder: 1-year effects sions, and recommendations. Psychotherapy: Theory, Research,
of a psychoeducational program in conjunction with phar- Practice, Training, 33, 321–331.
macotherapy. Biological Psychiatry, 48, 582–592. Pinsof, W. M., Zinbarg, R., & Knobloch-Fedders, L. M. (2008).
Minuchin, S. (1974). Families and family therapy. Cambridge, MA: Factorial and construct validity of the revised short form
Harvard University Press. Integrative Psychotherapy Alliance Scales for family, couple,
Minuchin, S., & Fishman, H. C. (1981). Family therapy and individual therapy. Family Process, 43, 281–301.
techniques. Cambridge, MA: Harvard University Press. Quinn, W., Dotson, D., & Jordan, K. (1997). Dimensions of
Minuchin, S., Rosman, B., & Baker, L. (1978). Psychoso- therapeutic alliance and their associations with outcome in
matic families: Anorexia nervosa in context. Cambridge, MA: family therapy. Psychotherapy Research, 7, 429–438.
Harvard University Press. Rait, D. S. (2000). The therapeutic alliance in couples and family
Moran, G., & Diamond, G. M. (2008). Generating nonnegative therapy. In Session: Psychotherapy in Practice, 56, 211–224.
attitudes among parents of depressed adolescents: The power Rapee, R. M. (1997). Perceived threat and perceived control
of empathy, concern, and positive regard. Psychotherapy a predictors of the degree of fear in physical and social situa-
Research, 18, 97–107. tions. Journal of Anxiety Disorders, 11, 455–461.
Moran, G., Diamond, G. M., & Diamond, G. S. (2005). Rea, M. M., Tompson, M. C., Miklowitz, D. J., Goldstein, M. J.,
The relational reframe and parents’ problem constructions Hwang, S., & Mintz, J. (2003). Family-focused treatment
in attachment-based family therapy. Psychotherapy Research, versus individual treatment for bipolar disorder: Results of a
15, 226–235. randomized clinical trial. Journal of Consulting and Clinical
Muñiz de la Peña, C., Friedlander, M. L., & Escudero, V. Psychology, 71, 482–492.
(in press). Frequency, severity, and evolution of split family Rehman, U. S., Gollan, J., & Mortimer, A. R. (2008). The
alliances: How observable are they? Psychotherapy Research. marital context of depression: Research, limitations, and new
Forthcoming. directions. Clinical Psychology Review, 28, 179–198.
Naar-King, S., Ellis, D. A., Idalski, A., Frey, M. A., & Robbins, M. S., Alexander, J. F., Newell, R. M., & Turner, C. W.
Cunningham, P. (2007). Multisystemic therapy decreases (1996). The immediate effect of reframing on client attitude
parental overestimation of adolescent responsibility for Type in family therapy. Journal of Family Psychology, 10, 28–34.
I diabetes management in urban youth. Families, Systems & Robbins, M. S., Alexander, J. F., & Turner, C. W. (2000). Disrup-
Health, 25, 178–189. ting defensive family interactions in family therapy with delin-
Nichols, M. P., & Fellenberg, S. (2000). The effective use of quent adolescents. Journal of Family Psychology, 14, 688–701.
enactments in family therapy: A discovery-oriented process Robbins, M. S., Liddle, H. A., Turner, C. W., Dakof, G. A.,
study. Journal of Marital and Family Therapy, 26, 143–152. Alexander, J. F., & Kogan, S. M. (2006). Adolescent and
Nichols, M. P., & Schwartz, R. C. (2007). Family therapy: parent therapeutic alliances as predictors of dropout in mul-
Concepts and methods (7th ed.). Boston, MA: Pearson tidimensional family therapy. Journal of Family Psychology,
Education, Inc. 20, 108–116.
Ogden, T., & Hagen, K. A. (2006). Multisystemic treatment of Robbins, M. S., Mayorga, C. C., Mitrani, V. B., Szapocznik, J.,
serious behavior problems in youth: Sustainability of effec- Turner, C. W., & Alexander, J. F. (2008). Adolescent and
tiveness two years after intake. Child and Adolescent Mental parent alliances with therapists in brief strategic family ther-
Health, 11, 142–149. apy with drug-using Hispanic adolescents. Journal of Marital
Ogden, T., & Halliday-Boykins, C. A. (2004). Multisystemic and Family Therapy, 34, 316–328.
treatment of antisocial adolescents in Norway: Replication of Robbins, M. S., Szapocnik, J., Dillooon, F. R., Turner, C. W.,
clinical outcomes outside of the US. Child and Adolescent Mitrani, B. B., & Feaster, D. J. (2008). The efficacy of struc-
Mental Health Volume, 9, 77–83. tural ecosystems therapy with drug-abusing/dependent
Patterson, G. R. (1971). Families: Application of social learning African American and Hispanic American adolescents. Journal
theory to family life. Champaign, IL: Research Press. of Family Psychology, 22, 51–61.
Patterson, G. R. (1982). Coercive family process. Eugene, OR: Robbins, M. S., Szapocznik, J., & Perez, G. A. (2007). Brief
Castalia. strategic family therapy. In L. L’Abate, & N. Kazantzis (Eds.),
Pavuluri, M. N., Grazyk, P. A., Henry, D. B., Carbray, J. A., Handbook of homework assignments in psychotherapy: Research,
Heidenreich, J., & Miklowitz, D. J. (2004). Child- and family- practice, prevention. New York: Springer.
focused cognitive behavioral therapy for pediatric bipolar Robbins, M. S., Turner, C. W., Alexander, J. F., & Perez, G. A.
disorder: Development and preliminary results. Journal of the (2003). Alliance and dropout in family therapy for adoles-
American Academy of Child and Adolescent Psychiatry, 43, cents with behavior problems: Individual and systemic
528–537. effects. Journal of Family Psychology, 17, 534–544.

674 couple an d family th e rap y

Robin, A. L., Siegal, P. T., Koepke, T., Moye, A. W., & Tice, S. Shoham, V., Rohrbaugh, M. J., Robbins, M. R., Szapocznik, J.,
(1994). Family therapy versus individual therapy for adoles- & Feaster, D. (2003). Mediators and moderators of Brief
cent females with anorexia nervosa. Developmental and Strategic Family Therapy (BSFT) for adolescent drug use. Award
Behavioral Pediatrics, 15, 111–116. R01 DA17539 from National Institute on Drug Abuse,
Rowland, M. D., Halliday-Boykins, C. A., Henggeler, S. W., Rockville MD.
Cunningham, P. B., Lee, T. G., Kruesi, M. J. P., & Slipp, S. (1984). Object relations: A dynamic bridge between
Shapiro, S. B. (2005). A randomized trial of multisystemic individual and family treatment. New York: Jason Aronson.
therapy with Hawaii’s Felix class youths. Journal of Emotional Sluzki, C. (1992). Transformations: A blueprint for narrative
and Behavioral Disorders, 13, 13–23. changes in therapy. Family Process, 31, 217–230.
Russell, G. F. M., Szmukler, G. I., Dare, C., & Eisler, I. (1987). Snyder, J., Cramer, A., Afrank, J., & Patterson, G. R. (2005).
An evaluation of family therapy in anorexia nervosa and buli- The contributions of ineffective discipline and parental hos-
mia nervosa. Archives of General Psychiatry, 44, 1047–1056. tile attributions of child misbehavior to the development
Santisteban, D. A., Coatsworth, J. D., Perez-Vidal, A., Kurtines, of conduct problems at home and school. Developmental
W. M., Schwartz, S. J., LaPerriere, A., & Szapocnik, J. Psychology, 41, 30–41.
(2003). Efficacy of brief strategic family therapy in modify- Sprenkle, D. H., & Blow, A. J. (2004). Common factors and our
ing Hispanic adolescent behavior problems and substance sacred models. Journal of Marital and Family Therapy, 30,
use. Journal of Family Psychology, 17, 121–133. 113–129.
Sargent, J., Liebman, R., & Silver, M. (1985). Family therapy for Sterba, R. (1934). The fate of the ego in analytic therapy.
anorexia. In J. Harkaway (Ed.), Family therapy for eating International Journal of Psychoanalysis, 15, 117–125.
disorders: Vol. 20. Family therapy collection. Rockville, MD: Stuart, R. B. (1969). An operant-interpersonal treatment for
Aspen Systems. marital discord. Journal of Consulting and Clinical Psychology,
Satir, V. (1964). Conjoint family therapy. Palo Alto, CA: Science 33, 675–682.
and Behavior Books. Symonds, D., & Horvath, A. O. (2004). Optimizing the alliance
Schaeffer, C. M., & Borduin, C. M. (2005). Long-term in couple therapy. Family Process, 43, 443–455.
follow-up to a randomized clinical trial of multisystemic Szapocznik, J., Robbins, M. S., Mitrani, B. B., Santisteban, D. A.,
therapy with serious and violent juvenile offenders. Journal of Hervis, O., & Williams, R. A. (2002). Brief strategic family
Consulting and Clinical Psychology, 73, 445–453. therapy. In F. W. Kaslow (Ed.), Comprehensive handbook
Scharff, D., & Scharff, J. (1987). Object relations family therapy. of psychotherapy: Integrative/eclectic Vol 4 (pp. 83–109).
New York: Jason Aronson. Hoboken, NJ: Wiley & Sons.
Schmidt, S. E., Liddle, H. A., & Dakof, G. A. (1996). Changes Taylor, T., Adelman, H. S., & Kaser-Boyd, N. (1985). Exploring
in parenting practices and adolescent drug abuse during mul- minors’ reluctance and dissatisfaction with psychotherapy.
tidimensional family therapy. Journal of Family Psychology, Professional Psychology: Research and Practice, 16, 418–425.
10, 12–27. Timmons-Mitchell, J., Bender, M. B., Kishna, M. A., &
Schmidt, U., Lee, S., Beecham, J., Perkins, S., Treasure, J., Yi, I., Mitchell, C. C. (2006). An independent effectiveness trial of
et al. (2007). A randomized controlled trial of family therapy multisystemic therapy with juvenile justice youth. Journal of
and cognitive behavior therapy guided self-care for adoles- Clinical Child and Adolescent Psychology, 35, 227–236.
cents with bulimia nervosa and related disorders. American Tolan, P. H. (2003). Family-focused prevention research:
Journal of Psychiatry, 164, 591–598. “Tough but tender.” In H. A. Liddle, D. A. Santisteban,
Schoenwald, S. K., & Hengeller, S. W. (2005). Multisystemic R. F. Levant, & J. H. Bray (Eds.), Family psychology:
therapy for adolescents with serious externalizing problems. Science-based interventions (pp. 197–213). Washington, DC:
In J. L. Lebow (Ed.), Handbook of clinical family therapy American Psychological Association.
(pp. 103–127). Hoboken, NJ: Wiley & Sons. von Bertalanffy, L. (1950). An outline of general systems theory.
Schoenwald, S. K., Ward, D. M., Henggeler, S. W., & British Journal of Philosophy of Science, 1, 139–164.
Rowland, M. D. (2000). Multisystemic therapy versus Waldron, H. B., & Turner, C. W. (2008). Evidence-based psy-
hospitalization for crisis stabilization of youth: Placement chosocial treatments for adolescent substance abuse. Journal
outcomes 4 months postreferral. Mental Health Services of Clinical child and Adolescent Psychology, 37, 238–261.
Research, 2, 3–12. Watzlawick, P., Beavin, J., & Jackson, D. (1967). Pragmatics of
Seligman, M. E. P., & Csikszentmihalyi, M. (2000). Positive human communication. New York: Norton.
psychology: An introduction. American Psychologist, 55, 5–14. Watzlawick, P., Weakland, J., & Fisch, R. (1974). Change: Principles
Selvini Palazzoli, M., Boscolo, L., Cecchin, G., & Prata, G. of problem formation and problem resolution. New York: Norton.
(1978). Paradox and counterparadox. New York: Jason Whitaker, C. A., & Keith, D. V. (1981). Symbolic-experiential
Aronson. family therapy. In A. S. Gurman, & D. P. Kniskern (Eds.),
Shadish, W. R., Ragsdale, K., Glaser, R. R., & Montgomery, L. M. Handbook of family therapy (pp. 187–225). New York:
(1995). The efficacy and effectiveness of marital and family Brunner/Mazel.
therapy: A perspective from meta-analysis. Journal of Marital White, M., & Epston, D. (1990). Narrative means to therapeutic
and Family Therapy, 21, 345–360. ends. New York: Norton.
Sheeber, L., Hyman, H., & Davis, B. (2001). Family processes in Wiener, N. (1948). Cybernetics or control and communication in
adolescent depression. Clinical Child and Family Psychology the animal and the machine. Cambridge, MA: MIT Press.
Review, 4, 19–35. Williams, C. D. (1959). The elimination of tantrum behavior
Shelef, K., Diamond, G. M., Diamond, G. S., & Liddle, H. A. by extinction procedures. Journal of Abnormal and Social
(2005). Adolescent and parent alliance and treatment Psychology, 59, 269.
outcome in multidimensional family therapy. Journal of Wolpe, J. (1958). Psychotherapy by reciprocal inhibition. New York:
Consulting and Clinical Psychology, 73, 689–698. Pergamon Press.

fr ie dl ande r, diam ond 675

This page intentionally left blank
 PART
5
Intersections
This page intentionally left blank
 CHAPTER

26 Rehabilitation Psychology

Timothy R. Elliott and Joseph F. Rath

Abstract
As one of the oldest psychology specialties active in interdisciplinary medical centers and health and
public policy, rehabilitation psychology focuses on the optimal adjustment of individuals with disabilities,
their families, and primary support systems. The wide array of circumstances confronting individuals
with disabilities demands a broad skill set and flexibility in the rehabilitation psychologist’s approach.
Throughout its 50-year history, the field has been shaped and informed by theory and research
drawn from other academic and practice areas of psychology including social, clinical, and counseling
psychology, rehabilitation counseling, behavioral neuroscience, and neuropsychology. This rich heritage
contributes to the specialty’s resilience and potential to address current challenges facing American
health care, including the aging of the baby boom generation and the unprecedented numbers of
wounded veterans returning to society with injuries that may require life-long services.
Keywords: Rehabilitation psychology, disability, chronic illness, health care, assessment
and intervention

In a current statement, the Division of Rehabilitation With over 50 years of organized professional
Psychology within the American Psychological involvement, rehabilitation psychology is one of the
Association (APA) offered this definition of reha- oldest psychological specialties active in interdisci-
bilitation psychology: plinary medical settings, health and public policy,
and the study of and service to persons with chronic
Rehabilitation Psychology is the study and
and disabling health conditions. Rehabilitation psy-
application of psychological principles on behalf
chologists are active in a wide range of institutions
of persons with physical, sensory, cognitive,
serving individuals living with disabling conditions,
developmental or emotional disabilities. People with
including hospitals, universities, medical schools,
disabilities, including those with loss of function due
schools, nonprofit organizations, and federal and
to chronic illness, may face personal, social, or
state agencies.
situational barriers to healthy and satisfying lifestyles.
In this chapter, we review the history of reha-
Some barriers are inherent in the disabling condition,
bilitation psychology and the various theoretical
while others arise from the environment, including
systems that have shaped and informed the spe-
social myths that contribute to devaluation of
cialty, both historically and in the present. We
persons who are different. Through clinical
will comment on major streams of research and
interventions, research, and advocacy, rehabilitation
identify the clinical practices that typify rehabilita-
psychologists seek to improve health and functioning
tion psychology practice. Finally, we will comment
and broaden opportunities available to persons with
on training and emerging issues that now shape
disabilities.
the field.
(Scherer et al., 2004, p. 801)

679
History and Background legislation to provide disabled workers with some
Unlike the primary areas of psychology that have form of compensation.
strong roots in academia, rehabilitation psychology Organized labor and increased urbanization of the
was born on the fields of public and health policy. workforce also created a need for relevant training
Unlike the primary practice disciplines of profes- and vocational education programs. Often, workers
sional psychology that originally focused on mental lacked skills or possessed skills rendered obsolete by
health issues, rehabilitation psychology was among new technology and industry. The Smith–Hughes
the first specialties to operate in health care settings Act of 1917 provided states with matching funds to
and focus on personal health and optimal adjustment develop vocational education programs, and the
in social, personal, and vocational roles among people Federal Board of Vocational Education was created to
with disabilities and chronic health problems. administer vocational rehabilitation (VR) programs
Public attention and federal policies to rehabili- under this same legislation.
tate and retrain injured workers in late 19th- and
early 20th-century American cities provided an World Wars and Rehabilitation
essential backdrop for the field. Most landmark The aftermath of World War I led to several impor-
activities germane to vocational rehabilitation and tant legislative policies designed to address the needs
psychology have been discussed (in varying levels of of returning soldiers. The Soldiers Rehabilitation
detail) in other places (e.g., Elliott & Leung, 2005; Act (1918) provided funds to rehabilitate disabled
Larson & Sachs, 2000; Oberman, 1965; Peterson & veterans, with the Federal Board for Vocational
Aguiar, 2004; Rubin & Roessler, 2001). In general Education administering these services. In 1921, the
terms, the Industrial Revolution is recognized as Veterans Bureau was created, and in time, evolved
the major precursor to federal and public policies into the Department of Veterans Affairs.
concerning rehabilitation. As workers incurred Following World War II, the need for psychol-
disabling injuries in rapidly expanding industrial ogy service providers increased exponentially as
enterprises, the need to provide support, assistance, armed services personnel returned to society. The
education, and training for those injured became demand for professionals in every area of psychol-
evident. Several charitable and nonprofit agencies ogy was greater than at any time in the nation’s
(e.g., Goodwill Industries, B’nai B’rith) tried to history (Buchanon, 2003; Pickren, 2005). This
address these needs, while others developed special- unprecedented need exceeded the available supply;
ized services for the vocational assessment and consequently, individuals from various specialties
guidance of injured workers. within psychology, as well as from the larger field of
At the end of the 19th century, ongoing indus- education, took clinical positions providing a vari-
trialization of the American workforce, combined ety of services. For example, one of the early leaders
with pressures ensuing from immigration, urbaniza- of the Division of Rehabilitation Psychology within
tion, and advocacy from the Populist and Progressive the APA—Beatrice Wright—completed her gradu-
political movements, led to a greater recognition ate training in social psychology with Kurt Lewin at
of the complexity of social issues germane to wel- the University of Iowa. She then worked as a coun-
fare and the economy. Social welfare concerns selor with the United States Employment Service
pressed into the federal agenda during Theodore helping veterans and learning about “jobs and facto-
Roosevelt’s administration. In 1908, a presidential ries and hard-to-place people [and the] . . . Dictionary
committee concluded that public health was a of Occupational Titles” (Hollingsworth, Johnson, &
responsibility of the federal government, being too Cook, 1989, p. 385).
much of a responsibility for private charities to The overwhelming need for specialized services
address alone (Oberman, 1965). For example, the for returning veterans prompted federal policy
number of workers left disabled by the high rate makers to promote specialization in various profes-
of industrial accidents was too great for private sions. Federal policies contributed to the medical
agencies to accommodate, leaving many injured specialization of physiatry. Medical management of
workers with no opportunity for rehabilitation or cases that involved disability, neurological trauma,
retraining for the workforce. With passage of the and long-term medical management necessitated
Federal Employees Compensation Act of 1908, the particular expertise in “physical medicine and reha-
first worker’s compensation legislation was enacted bilitation,” which was recognized in 1947 as a spe-
to assist federal workers employed in hazardous cialty board by the American Medical Association
occupations. By 1921, most states had enacted (Allan, 1958).

680 rehabilitatio n p s ych o lo gy

 Many physicians who served in the medical occupational therapy) attended the Princeton
corps during World War II returned to work in hos- conference. Several attendees are well known for
pital settings and advocated for the needs of their their contributions in other areas of psychology
patients. The Vocational Rehabilitation Act of 1954 (see Table 26.1 for a selective listing of participants).
provided funds to colleges and universities for train- Counseling psychology, for example, was well repre-
ing rehabilitation service providers and “qualified sented and representatives from the specialty played
rehabilitation personnel.” In essence, this act cre- influential roles in these formative days of rehabilita-
ated the field of rehabilitation counseling. The legis- tion psychology. One participant, John McGowan, a
lation also stipulated the model of VR services in counseling psychologist from the University of
which the rehabilitation counselor served as the Missouri, would later be the lead author of one of the
primary service coordinator. most influential books in VR (An Introduction to the
Vocational Rehabilitation Process: A Training Manual;
Bringing Rehabilitation Psychology McGowan & Porter, 1967. The book was published
into Being by the federal government.). Attendees Anne Roe,
Federal support to professional psychology was less John G. Darley, and Lloyd H. Lofquist were well
obvious, but present nonetheless. Many psycholo- known for their work in vocational psychology and
gists were hired as VR specialists to work in medical career development theory. In the ensuing years,
facilities operated by the Veterans Administration Lofquist’s work in developing the Minnesota Theory
(Larson & Sachs, 2000). Furthermore, federal agen- of Work Adjustment was supported by funding from
cies identified with VR—the Department of Health, the Rehabilitation Services Administration and other
Education, and Welfare (in 1958) and the Office federal and state vocational rehabilitation agencies
of Vocation Rehabilitation (in 1959)—financially (Dawis & Lofquist, 1984).
supported conferences for psychologists interested
in rehabilitation. These conferences were sponsored,
in part, because of the influence and support of Table 26.1. Select Participants at the 1958
James Garrett, who was then associate director of Princeton Conference and Their Historical Area
the Office of Vocational Rehabilitation (OVR) in of Contributions to Professional Psychology
the Department of Health, Education, and Welfare Name Historical Area of Contributions
(Larson & Sachs, 2000).
Two conferences in particular were vital to orga- John G. Darley Counseling Psychology
nizing rehabilitation psychology research, practice, Tamara Dembo Social Psychology
and training. The first, conducted in Princeton, New
Leonard Diller Neuropsychological
Jersey in 1958, typically is acknowledged as the
Rehabilitation
formal beginning of rehabilitation psychology
(Wright, 1959). A second conference, held in Miami Salvatore DiMichael Vocational Rehabilitation
the following year, was convened to determine the James Garrett Department of Health,
possible contributions of the broader domains of Education and
psychology to rehabilitation research and practice
(Lofquist, 1960). Prior to these founding confer- Welfare, World
ences, psychologists and counselors who identified Rehabilitation Fund
with the field of rehabilitation had organized as the Lloyd H. Lofquist Counseling Psychology
National Council on the Psychological Aspects of
John McGowan Counseling Psychology
Disability (NCPAD). NCPAD, which became a spe-
cial interest group of APA in 1949 (Wright, 1993), Lee Meyerson Rehabilitation Psychology
met at several APA conventions and published a
Victor Raimy Clinical Psychology
newsletter. The Princeton and Miami conferences,
along with NCPAD, provided an organizational Anne Roe Counseling and Vocational
springboard that contributed in part to the develop- Psychology
ment of the Division of Rehabilitation Psychology Harold Seashore Founder, The Psychological
within APA. Corporation
A mix of academicians, clinicians, federal agency
Beatrice A. Wright Rehabilitation and
administrators, and representatives from other pro-
Social Psychology
fessions (e.g., social work, nursing, physical therapy,

e lliot t, r at h 681
 In contrast to the Princeton conference, psychol- Patterson, George England, Donald Patterson, as
ogists “visible” in areas other than rehabilitation well as Darley and Lofquist, worked with other
were invited to the Miami conference to assist in figures renowned for their achievements in social
developing a research agenda of interest to psychol- psychology (Lazarus, Kelley, Hastorf, Jones, Thibaut),
ogy as a whole that would inform and advance reha- learning theory (Mowrer, Osgood), and psychomet-
bilitation. Counseling psychologists were again well rics (Cronbach). These workgroup themes remain
represented among conference planners and work- viable in contemporary rehabilitation psychology.
group members (see Table 26.2). Leona Tyler, Cecil These conferences concluded that a unique
specialty for rehabilitation was not needed for psy-
Table 26.2. Planning Committee Members and
chologists, primarily because the field was much
Work Group Members at the 1960 Miami Conference too broad, and all branches of psychology could
make meaningful contributions to the research base
Planning Committee Members and inform clinical practice and public policy.
Emory L. Cowen Lee Meyerson Participants agreed that doctoral-level training in
psychology was required for work in rehabilitation
John G. Darley Howard L. Roy settings. In addition, both conferences laid out a
Erasmus L. Hoch Morton Seidenfeld research agenda that relied on psychological exper-
tise and also recommended funding from federal
Harold H. Kelley Franklin Shontz
granting agencies to support the research enterprise,
Lloyd H. Lofquist as it represented important public and health policy
priorities.
Work Group I: Cognition: Sensory
and Perceptual Organization
Decisions from these conferences concerning
research, scholarship, policy, and training in reha-
Franklin Shontz Seymour Wapner bilitation psychology had tremendous influence on
Tamara Dembo Cecil H. Patterson the development and health of the field that persists
to this day. In the following section, we will sum-
Martin Scheerer marize the major strands of these influences.
Work Group II: Career
Development Defining the Literature Base
Rehabilitation psychology remains a field steeped in
George W. England Leona E. Tyler
interdisciplinary endeavors, and as such, its litera-
Lee J. Cronbach Abraham Jacobs ture base is heavily dependent upon various threads
of scholarship within psychology, as well as from
Donald G. Patterson
research conducted by other professions invested in
Work Group III: Learning the health and rehabilitation of persons living with
Lee Meyerson Charles E. Osgood disabilities. In the decades following the Princeton
and Miami conferences, we can trace the particular
John L. Michael Arthur W. Staats impact of research from boarder areas of psychology,
O. Hobart Mowrer including social, clinical, and counseling psychol-
ogy, rehabilitation counseling, behavioral neurosci-
Work Group IV: Personality ence, and neuropsychology.
Theory and Motivation
Emory L. Cowen Morton Wiener Social Psychology
The influence of academic social psychology was
Richard S. Lazarus O. Bruce Thomason
immediately apparent at the Princeton and Miami
Abraham S. Luchins conferences. Beatrice Wright, one of the enduring
Work Group V: Social Psychology pioneers of rehabilitation psychology, studied with
faculty noted for their outstanding contributions
Harold H. Kelley John W. Thibaut to social psychology (Kurt Lewin, Tamara Dembo,
Albert H. Hastorf William M. Usdane Solomon Asch) and with others recognized for
their contributions to clinical psychology (Kenneth
Edward E. Jones Spence, Carl Rogers, Abraham Maslow; Dunn &
From Lofquist, 1960, pp. 2–5. Elliott, 2005). She participated in a faculty-student

682 rehabilitatio n p s ych o lo gy

discussion group (the “Topological Group”) that research [Katz, Farber, Glass, Lucido, & Emswiller,
included Margaret Mead, Henry Murray, Erik 1978]), and it expanded with the development
Erikson, and Fritz Heider (Hollingsworth, Johnson, of the popular Attitudes Toward Disabilities Scale
& Cook, 1989). Her field research with Roger (Yuker, Block, & Younng, 1966), which was used in
Barker, funded by the Social Science Research scores of empirical—albeit mostly correlational—
Council in 1946, resulted in a landmark critique studies (Yuker, 1988; Yuker & Block, 1986).
of the extant literature on adjustment following Wright’s book (1960) appeared at a time when
illness and disability (Barker, Wright, Meyerson, & the newly minted rehabilitation counseling training
Gonick, 1953). After serving as chronicler of the programs needed contemporary texts for their
Princeton conference (Wright, 1959), Wright pub- curricula. The book, along with its later revision
lished the seminal Physical Disability: A Psychological (Wright, 1983) proved immensely influential: The
Approach (1960), the first theory-driven psycho- first edition was the second most frequently cited
logical statement from rehabilitation psychology, work published prior to 1973 in articles that
grounded in the best scholarly traditions, informed appeared in three volumes of two major rehabilita-
by the extant literature, and enriched with applica- tion counseling journals (Rehabilitation Counseling
tions and illustrations to inform both academicians Bulletin, Journal of Applied Rehabilitation Counseling;
and clinicians. Elliott, Byrd, & Nichols, 1987), and the second edi-
In her book, Wright (1960) persuasively argued tion (Wright, 1983) was the second most frequently
for appreciating disability within context, relying cited work published after 1973 in articles in these
heavily on Lewian field theory (in which B = f (P, E); same volumes. The first edition also was the most
Lewin, 1935) to depict disability as a social psycho- frequently cited publication in articles appearing
logical phenomenon in which any atypical appear- in three volumes of Rehabilitation Psychology
ance, physique, or behavior attracts the attention of, (Vols. 27–29; Elliott & Byrd, 1986).
and stimulates inferences from, observers. In doing The direct influence of Wright’s books may
so, she extended previous work with Tamara Dembo have dimmed in recent years: In a survey of board-
to draw explicit ramifications for understanding certified rehabilitation psychologists, neither edition
behaviors and issues presented by clients in clinical was listed among the influential readings identified
settings (see Dembo, Leviton, & Wright, 1956). by this relatively small and restricted sample (Ryan
Wright’s contributions ran parallel to other work & Tree, 2004). Nevertheless, Wright’s work has
informed by social psychological perspectives that remained influential in the emerging area of positive
appeared in the literature throughout the formative psychology, particularly as her work pertains to
years of rehabilitation psychology. For example, in assessment of deficits and assets, and the impact of
1948, Lee Meyerson—a contemporary and collabo- context on assessment, generally (Wright, 1991;
rator of Wright’s—edited a special issue of the Journal Wright & Lopez, 2002). Current interest in positive
of Social Issues entitled “The Social Psychology of psychology may serve to regenerate social psycho-
Disability” that, in part, surmised the Barker research logical applications in rehabilitation psychology for
program to that time and drew implications for a number of reasons. In particular, many theoretical
theory and policy. Decades later, in an update and positions concerning growth, happiness, gratitude,
review of the relevant research in this area, Fine and life satisfaction, and well-being often are tested and
Asch (1988) asserted that Meyerson’s 1948 publica- refined in rigorous, real-life applications; therefore,
tion had a lasting and fundamental influence on many empirical tests are conducted among persons
social policy concerning disability and rehabilitation. who have incurred or live with severe disabilities
In addition to addressing subtle and blatant matters (e.g., Emmons & McCullough, 2003, study 4;
of stigma and discrimination concerning persons Lucas, 2007; for integrative summaries, see Dunn,
with disability, Meyerson’s contribution also pro- Uswatte, & Elliott, 2009; Elliott, Kurylo, & Rivera,
vided considerable scholarly and intellectual heft to 2002). Current perspectives on subjective well-
the emerging area of disability rights, advocacy, and being following disability using sophisticated pro-
disability studies. spective methodologies now inform theoretical
Indeed, the study of social stigma associated with models of adjustment over time (e.g., Resch et al.,
disability was informed by scholarly essays (notably 2009).
Goffman, 1960) and experimental analogue research An enduring contribution of social psychology
(e.g., “kindness norm” work [Kleck,1968; Kleck, may be found in the disability studies literature
Ono, & Hastorf, 1966], and “attitude amplification” of the past few decades. Spurred on by Fine and

e lliot t, r at h 683
Asch’s (1988) update of Meyerson’s earlier work, use of appropriate comparison groups in studying
several scholars have advanced a scholarly under- self-report data in rehabilitation psychology, and it
standing of the “insider’s” perspective and experi- provided some of the first evidence that certain
ence of disability (Nosek, Howland, Rintala, Young, behavioral patterns—notably, “imprudent, impul-
& Chanpong, 2001; Vash, 1981). Consumers of sive, and excitement seeking” tendencies that can
rehabilitative services and their advocates tend to jeopardize health in risk-taking activities prior to
be much more sensitive to the demands and issues injury—may be important clinical factors in under-
centered in the environment in which behavior standing adjustment and well-being following
is framed than are service providers (Olkin, 1999). disability. This study also revealed relatively low
To a great extent, federal funding priorities have levels of psychopathology, generally, in the sample.
been influenced by these perspectives (e.g., at the Many of these same themes—the study of self-
National Institute on Disability Rehabilitation and report assessment devices; use of appropriate sam-
Research; Olkin & Pledger, 2003). To a lesser extent, ples, comparison groups, and normative data; and
psychology doctoral training programs also have investigations into psychopathology, behavioral pat-
been influenced, albeit only among those few train- terns, and well-being—are ongoing hallmarks of
ing programs that address disability as a minority contemporary rehabilitation psychology literature.
experience (Olkin, 2002). Despite this influence, Fordyce’s application of operant conditioning
contemporary disability studies programs seem to theory to understanding the dynamics and contin-
be more aligned in content and mission with aca- gencies that shape and reinforce “pain behavior”
demic public health than with conventional doc- (Fordyce, 1971) and suffering following disability
toral training programs in clinical and counseling (Fordyce, 1988) had a broad, sweeping impact on
psychology. research, practice, and policy. His 1976 book, enti-
tled Behavioral Methods for Chronic Pain and Illness,
Clinical Psychology is a classic in the rehabilitation and health psychology
Clinical psychology has steadily and powerfully literature (Elliott & Byrd, 1986; Patterson, 2005).
grown in significance to the core of rehabilitation In his conceptualization, pain behaviors are condi-
psychology practice and research. Although this tioned by a patient’s interpersonal and social envi-
influence may not have been readily apparent at the ronment, and these environmental reactions serve to
Princeton and Miami conferences, many clinical maintain or increase pain behaviors. Applying oper-
psychologists were working in medical settings that ant learning theory, Fordyce also argued persuasively
provided services to persons with acquired disabili- about the dangers of “as needed” medication sched-
ties. Some, like Wilbert E. Fordyce, were in depart- ules and advocated use of time-contingent schedules
ments specifically created to meet the medical needs to prevent acquisition of maladaptive behavioral pat-
of these patients. Others, like Jerome Siller, were in terns, with the additional benefit of maintaining
academic departments, and their roles were often steady medication levels in the patient (Patterson,
consultative, providing liaison services to medical 2005). This model also was central in illuminating
teams and agencies providing therapeutic services the value of exercise and activity at regular intervals
and assistive devices. Colleagues in these roles were by taking into account the initial “punishing” aspects
compelled to understand and improve services to of this activity in terms of increased pain, which may
the cases they routinely encountered. contribute to faulty learning patterns and decreased
Fordyce entered the clinical rehabilitation envi- activity levels that reward pain behavior over time.
ronment with expertise in personality assessment In direct contrast to Fordyce, who relied on
(evidenced in his early published work concerning behavioral-learning theory in his wide-ranging work
the MMPI) and an apparent high regard for on assessment and intervention strategies in reha-
behavioral learning theories. Although clinical anec- bilitation psychology, Jerome Siller extrapolated
dotes about personality and disability were preva- many of his ideas from psychoanalytic theory.
lent during these times (many emanating from Leaning on logic and clinical experience, Siller
psychiatry), Fordyce conducted one of the earliest refined existing “stage models” of adjustment that
empirical studies of personality and disability in could enlighten understanding of acceptance and
his examination of MMPI profiles and manner of adjustment following the acute onset of severe dis-
disability onset among patients with spinal cord ability (Siller, 1969, 1988). Certain features of stage
injuries (SCI; Fordyce, 1964). This work was among models would vary, but to a degree, many of these
the first to demonstrate the thoughtful, judicious Freudian-based extrapolations posited that the ego

684 rehabilitatio n p s ych o lo gy

would likely feel a sense of “castration” at the loss of counseling profession (indeed, to this day, many
a limb or motor function. Losses accompanying dis- psychologists in some specialty areas mistakenly
ability would deal a severe blow to the individual’s equate rehabilitation psychology with rehabilitation
inherent narcissism, and most individuals would counseling). As we have seen, many academic coun-
use denial to defend against the anxiety precipi- seling psychologists were key figures at the Princeton
tated by the loss. As the ego became able to permit and Miami conferences. Their presence supplied
experience of the loss, denial would be replaced expertise in areas of vocational psychology, career
by depression. Presumably, for individuals with a development, and training. During the “golden
strong enough ego, depression eventually would be years” of VR (Rusalem, 1976), these counseling
replaced by acceptance of the reality of their perma- psychologists maintained their identity in their
nent injury. academic “home” of counseling psychology and
Siller’s writings on this model were revisited and assumed leadership roles in rehabilitation psychol-
reworked over the years by others in rehabilitation ogy, primarily in their training and research activi-
(Cubbage & Thomas, 1989; Grzesiak & Hicock, ties. Often, these activities were centered in the
1994), and he expanded his thinking to incorporate graduate programs that they (e.g., John McGowan,
contemporary ideas from object relations theory Cecil Patterson, and others) developed to train reha-
(Thomas & Siller, 1999). Unfortunately, these theo- bilitation counselors, using financial support from
retical models generated very little empirical research state and federal agencies. Virtually all of these
(although recent evidence indicates that certain training programs were housed in colleges of edu-
constructs from self-psychology models can account cation. For many years, a significant number of
for significant variance in clinical outcomes follow- APA Division 22 (i.e., Division of Rehabilitation
ing acquired disability; Elliott, Uswatte, Lewis, & Psychology) members had earned their doctoral
Palmatier, 2000). Siller and his colleagues also degrees in rehabilitation counseling (Jansen &
developed measures of attitudes toward disability Fulcher, 1982; Neff, 1971).
and adaptation to disability based on classical psy- The chief mission of rehabilitation counseling
choanalytic theory (Siller, Chipman, Ferguson, & programs, however, was dictated by the 1954 reha-
Vann, 1967), but this work, too, failed to stimulate bilitation legislation that created the field. This leg-
rigorous, sustained empirical scrutiny from others. islation dictated a model of VR services in which the
Nevertheless, the intuitive, clinical appeal of stage rehabilitation counselor was at the core as the pri-
models influenced—and continue to influence— mary coordinator. Many rehabilitation counseling
many clinical conceptualizations of adjustment programs flourished when federal support was pro-
following disability. vided to colleges and universities to train rehabilita-
The attention to clinical assessment and theo- tion service providers and “qualified rehabilitation
retical models to improve practice and predict personnel” to administer and coordinate programs.
outcomes—evident in the diverse contributions of Rehabilitation counseling subsequently has been
Fordyce and Siller—characterize the bulk of modern considered “synonymous with . . . the State-Federal
rehabilitation psychology research and practice. Tra- rehabilitation program” (Jenkins, Patterson, &
ditionally, psychologists in rehabilitation settings Szymanski, 1997, p. 1). In a seminal text, George
spend the majority of their time conducting assess- N. Wright (1980, p. 22) acknowledged the academic
ments of intelligence, personality, adjustment, and roots of the rehabilitation counseling profession in
neuropsychological functioning (Eisenberg & Jansen, counseling psychology, but asserted that, although
1987; Grzesiak, 1979; Jansen & Fulcher, 1982). The counseling was an integral part of the VR process,
clinical psychology heritage undoubtedly has made rehabilitation counselors were uniquely skilled to
the most pronounced and long-lasting impression on meet the needs of persons with disabilities and
the field. address the psychosocial issues that they encounter.
Counseling psychologists in attendance at the
Counseling Psychology and Rehabilitation Princeton and Miami conferences clearly were
Counseling familiar with psychology training models and the
One of the more remarkable and intriguing stories use of theory-driven research and practice; they
in the evolution of rehabilitation psychology is conducted research programs and produced schol-
the rise and demise of contributions from counsel- arly materials that informed training and counsel-
ing psychology to the field, and its ambivalent rela- ing strategies. For example, the development of
tionship with the highly influential rehabilitation the Minnesota Theory of Work Adjustment

e lliot t, r at h 685
(Dawis & Lofquist, 1984) at the University of ongoing identification with state VR agencies,
Minnesota resulted in many instruments for use noting that clinical psychology was not considered
with a VR clientele. Other counseling psycholo- synonymous with the Veterans Administration
gists, some of whom were working in the Veterans despite clear support from that branch of the federal
Administration health care system, used established government over the years. Finally, doctoral gradu-
instruments in vocational psychology to develop ates of rehabilitation counseling programs found it
appropriate norms and study specific behaviors. As increasingly difficult to obtain psychology licenses
an example, patterns in vocational interest profiles in most states, as licensing boards created strict stan-
indicative of specific personality characteristics and dards for applicants to meet concerning accredited
behavioral patterns were associated with how a dis- training programs, internships, and postdoctoral
ability was acquired (“accident proneness;” Kunce experiences.
& Worley, 1966), a finding consistent with Fordyce’s
earlier work using the MMPI. Behavioral Neuroscience and
Academic counseling psychology’s interest in dis- Neuropsychology
ability and rehabilitation generally waned over time, According to the reports from the Miami conference
however. Peterson and Elliott (2008) reported that (Lofquist, 1960), considerable weight was placed on
disability-related topics (physical, intellectual, and the potential of learning theory to further under-
sensory disabilities and associated services) appeared standing about conditioned responses and improve-
in the titles of 18 articles published in the ten vol- ments in learning and rehabilitative therapies. Several
umes of the Journal of Counseling Psychology pub- members of the Learning workgroup (see Table 26.2)
lished from 1970 to 1979, but the next 18 articles had extensive experience with animal models of
on disability accumulated slowly over the ensuing behavior and were familiar with existing paradigms
27 volumes (volumes 27–53, published from 1980 in psychophysiology. It was recommended that
to 2006). Perusal of recent Division of Rehabil- advanced students steeped in these models and para-
itation Psychology membership rosters (maintained digms should be given financial support and ample
by APA) indicates that a very small percentage of opportunity to “rub their noses in . . . rehabilitation
division members have earned doctorates in coun- problems in facilities where they can come face to
seling psychology (7.8% in the 2008 report), and face with the behavioral problems involved” in reha-
fewer still had joint membership in APA’s Society of bilitation (Lofquist, 1960, p. 71).
Counseling Psychology (4%). Neal Miller experienced this very scenario when
Rehabilitation counseling itself faced unique his students (Bernard Brucker, Lawrence Ince) con-
problems and professional identity issues at the vinced him of the unique opportunities for apply-
end of the 20th century that still persist. Many ing classical and operant conditioning theory to the
practitioners were skeptical of the relevance of psy- study of visceral, reflex, and motor responses in the
chological coursework and theory in the VR enter- “clinical laboratory” of the rehabilitation hospital
prise (Olshansky & Hart, 1967). Increased workload (Brucker & Ince, 1977; Ince, Brucker, & Alba,
(requiring additional time commitments with job 1978; Miller & Brucker, 1979). In a series of cre-
placement activities, case management, and interac- ative, yet rigorous, single-case designs, this research
tions with employers) typically left little time or team obtained sufficient evidence to establish bio-
expectation for rehabilitation counselors to provide feedback as an empirically based technique for use
adjustment “counseling” (Thomas & Parker, 1981). with persons with disabling conditions, and to cul-
Consequently, rehabilitation counseling drifted tivate a great appreciation for using behavioral strat-
away from the broader field of counseling psychol- egies to augment rehabilitation therapies, enhance
ogy toward a more distinct and separate profession, adjustment, and condition responses previously
characterized by administrative and managerial thought to be autonomic (Ince, 1980).
duties (Thomas & Parker, 1984). Training models A contemporary extension of this work, grounded
for rehabilitation counseling subsequently shifted in state-of-the-art behavioral neuroscience, is evi-
away from their academic roots in response to, and dent in Edward Taub’s theory of learned nonuse of
with increased dependence upon, federal legislation motor behavior (Taub & Uswatte, 2000), which
and its accompanying financial support (Hershenson, stems directly from animal models of behavior.
1988; Thomas, 1991). Thomas (1991) was particu- The resulting strategy—constraint-induced move-
larly critical of rehabilitation counseling’s depen- ment therapy (CIMT)—derived from laboratory
dence upon federal money for training and its and clinical studies of learned nonuse, has immense

686 rehabilitatio n p s ych o lo gy

implications for researchers’ understanding of brain– learning, memory, planning, organization, emo-
behavior relationships and neuroplasticity that tional self-regulation, and other “executive-function”
extend far beyond the walls of the rehabilitation set- skills). These empirical studies led to the develop-
ting. Notably, the intervention strategy—like the ment and clinical application of strategies to amelio-
model developed by Fordyce for chronic pain reha- rate these deficits and improve function, techniques
bilitation programs—is implemented by the multi- now known collectively as cognitive rehabilitation
disciplinary treatment team, and not by the and cognitive remediation (Ben-Yishay & Diller,
psychologist, per se, in face-to-face interactions. 1983; Gordon & Hibbard, 1991). Eventually,
The contributions of neuropsychology to the Diller’s clinical and research programs at the Rusk
rehabilitation enterprise may sound less dramatic in Institute would provide training experiences in cog-
the telling, but the steady application of contempo- nitive rehabilitation to over 400 students, interns,
rary assessment procedures, careful observations, and postdoctoral fellows (Brownsberger, 2003).
and empirical studies has grown in proportion with Over the years, neuropsychology has grown
the number of neurological disabilities that occur in tremendously in influence and appearance in reha-
modern society. Leonard Diller, a participant at the bilitation psychology. Brain injuries and stroke are
Princeton conference and founder of scientifically among the most frequent disabilities in society, so it
based cognitive rehabilitation (Goldstein, 2009), is understandable that many rehabilitation psychol-
remarked that he “stumbled” into his position in ogists encounter some form of neurological deficit
the Rusk Institute of Rehabilitation Medicine at in clinical practice. Currently, data from the APA
the New York University School of Medicine. He indicate that 51% of the members of the Division
described having “almost nobody to talk to” about of Rehabilitation Psychology also have member-
the everyday clinical problems he encountered until ship in the Division of Clinical Neuropsychology
he read Tamara Dembo’s seminal work describ- (Division 40). This is one of the highest percentages
ing the problems experienced by individuals with of dual membership among APA divisions.
acquired disabilities (Brownsberger, 2003, p. 12).
He credited interactions and collaborations with Summarizing the Literature Base
Dembo and other colleagues at the Princeton con- Over 25 years ago, in an attempt to distinguish
ference with helping him develop his early notions rehabilitation psychology from the emerging areas
of neuropsychological rehabilitation. of health psychology and behavioral medicine,
In traditional approaches to clinical neuropsy- Jansen and Eisenberg (1982) observed that rehabili-
chology, the psychologist’s role stopped at assess- tation psychology often “seemed isolated from the
ment and interpretation, and patients were “handed mainstream of psychology” (p. 3), due in part to the
over to the speech, occupational, and physical ther- publication of important research and training arti-
apists for rehabilitation” (Goldstein, 2009, p. 141). cles in nonpsychological journals (Shontz & Wright,
Diller was instrumental in developing informed, 1980). Leaders in the field were certainly prolific,
tailored interventions to help patients with acquired and as we have seen, they made many lasting contri-
brain injuries and their families compensate for cog- butions that have benefited several core areas of psy-
nitive and psychosocial deficits. In 1970, Diller and chology, far beyond the rehabilitation environment.
colleagues at the Rusk Institute published two land- However, the literature base did not have a periodi-
mark research papers: Accidents in Hemiplegia (Diller cal that served as a “centerpiece” for the field.
& Weinberg, 1970) and Relationships Between Initial Scholars in rehabilitation counseling contrib-
Competence and Ability to Profit from Cues in Brain- uted to outlets published by their professional asso-
Injured Individuals (Ben-Yishay, Diller, Gerstman, ciations and, in the process, arguably established
& Gordon, 1970), which firmly established the their own literature base. These peer-review outlets
contribution of neuropsychology to the field of included the Rehabilitation Counseling Bulletin, the
rehabilitation (Goldstein, 2009). Journal of Rehabilitation, and the Journal of Applied
Funded by grants from the Department of Rehabilitation Counseling. Prior to the 1980s, many
Education, the National Institutes of Health (NIH), counseling psychologists published studies relevant
and other public and private agencies, Diller led a to rehabilitation practice and training in the Journal
series of seminal research programs that advanced of Counseling Psychology. Psychologists housed in
understanding of the nature of cognitive impair- medical schools tended to be “team players” in their
ments that typically follow brain injury and other choice of outlets, striving to advance the interdisci-
neurological insults (e.g., problems in attention, plinary enterprise of rehabilitation, inform colleagues

e lliot t, r at h 687
of their work, advance knowledge, and show their to modify patient behavior to promote skill acquisi-
home institutions in the best light. This required tion, health, and adjustment (Fordyce, 1976; Taub
publishing in medical outlets, including the leading & Uswatte, 2000). VR research and practice also
journal in the field, the Archives of Physical Medicine has championed multidisciplinary collaborations,
and Rehabilitation (APMR). Currently, several mem- and this is readily visible in the utility of supported
bers of the Division of Rehabilitation Psychology employment as a job placement strategy (Anthony
serve as associate editors for APMR. As specialties & Blanch, 1987; Wehman, 1988; Wehman, Sale, &
in rehabilitation grew, multidisciplinary journals Parent, 1992). This model, influenced considerably
devoted to specific diagnostic conditions emerged. by teaching strategies in special education (particu-
As of this writing, members of the Division of larly the individualized approaches pioneered by
Rehabilitation Psychology serve as editor-in-chief of Gold, 1974) has enjoyed substantial empirical sup-
the Journal of Head Trauma Rehabilitation, Brain port. At least 12 published randomized clinical trials
Injury, and Neuro Rehabilitation. (RCTs) have demonstrated the effectiveness of this
Such commitments to multidisciplinary outlets job placement strategy for persons with psychiatric
activity drained energy and contributions from the disorders (Bond, 2004; Cook, Leff, et al., 2005;
divisional journal, Rehabilitation Psychology (now Cook, Lehman, et al., 2005; Mueser et al., 2004).
published by the APA). Now in its 53rd volume, Supported employment is recognized as an evi-
Rehabilitation Psychology began as a division news- dence-based practice. Finally, the unique value that
letter and evolved into a peer-reviewed outlet. Given rehabilitation psychology places on multidisci-
its small circulation and lack of currency among the plinary collaborations is manifested in contempo-
health professions active in the rehabilitation enter- rary applications of virtual reality technologies to
prise, the journal has yet to receive the same level of train patients in activities of daily living, driving
enthusiastic and scholarly support enjoyed by the skills, and as an adjunct treatment for adjustment
more senior publications in the broader, multidisci- problems (Hoffman, Patterson, & Carrougher,
plinary rehabilitation literature. 2000; Schultheis & Rizzo, 2001).
The multidisciplinary nature of rehabilitation
also has influenced the scope and parameters in Issues in the Research and Evidentiary Base
which a unique “rehabilitation psychology” litera- In an interview published in the Division 22 newslet-
ture developed. Rehabilitation research often is ter, Leonard Diller—an early leader of the division—
dependent upon external funds for support, and reflected that rehabilitation started as a “compromise
interdisciplinary collaborations are paramount in between vocational/education forces and medicine”
the pursuit of federal funds. Consequently, rehabili- (Brownsberger, 2003, p. 12). The major funding for
tation psychologists often are well positioned to rehabilitation efforts following World War II came
address stated national priorities and health and from the Department of Education (with a subse-
public policy needs (e.g., rehabilitation of veterans quent emphasis on education, retraining, and labor
returning from international conflicts, facilitating needs), and other money was directed from the Office
vocational rehabilitation of persons with acquired of Special Education to support medical inpatient
disabilities; Elliott & Leung, 2005; Larson & Sachs, programs to ensure excellence in medical manage-
2000). Such opportunities place a premium on mul- ment for persons with understudied and underserved
tidisciplinary collaborations and applied, pragmatic conditions (Diller, 2008). A lasting consequence of
solutions. These activities reward practical products the compromise between education and medicine
or services, but esoteric, jargonized academic theo- is evident in the historic ties between the rehabilita-
ries that are difficult to communicate to colleagues tion professions and the Office of Special Education
from other disciplines are viewed as impractical (and the Rehabilitation Services Administration, the
or professionally self-serving (Dunn & Elliott, National Institute for Disability Rehabilitation and
2008). There are a few well-identified, theory-driven Research [NIDRR]) and the longstanding lack of
research programs readily identifiable in the con- presence at—and a lack of support from—NIH.
temporary rehabilitation psychology literature. Disability advocates and various agencies lobbied
Indeed, the most influential, long-lasting theo- the Department of Education for a systematic, col-
retical and clinical contributions from rehabilitation laborative, and coordinated database across sites to
psychology emphasize the ways that multidisci- inform and improve clinical care and service delivery
plinary team members (including nurses, physia- to persons with complicated, high-cost, low-incidence
trists, and physical therapists) work collaboratively disabilities. This resulted in the establishment of the

688 rehabilitatio n p s ych o lo gy

federally funded Model Systems of Care program in peer-reviewed literature (Elliott & Kennedy, 2004).
the mid-1970s. Each center in the Model Systems Unfortunately, an expert panel—composed of col-
was to provide comprehensive services within a leagues representing several professions active in
defined catchment area and feature five components medical rehabilitation—had previously reviewed
of care: emergency medical services, acute care, physi- this literature and granted the highest grade of evi-
cal rehabilitation, psychosocial and vocational ser- dence to psychopharmacological therapies and gave
vices, and ongoing follow-up and evaluation (Thomas, a much lower evidence grade to psychological inter-
1995). Participating sites also offered improved acces- ventions (Consortium for Spinal Cord Medicine,
sibility to care, coordination of clinical services from 1998).
emergency to acute to post-discharge settings, a criti- Obtaining and grading empirical evidence for
cal volume of patients and referrals for service, ongo- evidence-based practice (EBP) remains a conun-
ing research and evaluation of services and clientele, drum for all professions involved in rehabilitation.
education and training for staff and consumers, and Interdisciplinary treatments are often tailored to
community outreach and advocacy services for per- individuals in medical rehabilitation settings, and
sons with specific disabilities designated by the proj- there are considerable difficulties obtaining partici-
ect (Thomas, 1995). pants from low-incidence disability conditions in
The first Model Systems program addressed numbers sufficient to impress review panels (Dijkers
SCI, and others were developed to study and treat et al., 2009). It is difficult to construe meaningful
traumatic brain injuries (TBI) and burn injuries. control or “placebo” conditions for RCTs in reha-
Initially, these programs emphasized the collection bilitation, as there are often no “treatment as usual”
of demographic and medical information pertinent conditions to approximate, and the provision of any
to the clinical management of these disabilities and clinical attention may be above and beyond routine
associated complications. However, as consumer experience (Dijkers et al., 2009; Elliott, 2007).
involvement increased, and as outcome data impli- Many outcomes following disability are influ-
cated social and behavioral mechanisms in the occur- enced by a wide range of social, behavioral, and
rence of disability and secondary complications, demographic factors that are not amenable to any
more research has been directed to psychosocial fac- single intervention (Elliott & Warren, 2007) or
tors and adjustment. Additional grant programs by adequately controlled by randomization, particu-
NIDRR funded Research and Training Centers to larly when the number of participants may be rela-
support projects that increasingly attended to behav- tively low. The impact of factors that impinge upon
ioral and social factors (e.g., return-to-work, family measurable outcomes, independent of methodolog-
support, community integration). ical and statistical controls, assure that practically
These collaborative projects enriched the knowl- any psychological intervention in rehabilitation will
edge base concerning the rehabilitation enterprise, likely have effects sizes that range from small to
generally, but the study of effective, efficacious moderate at best. Large effect sizes may be realized
psychological interventions was not funded by in rigorous research designs that examine tailored
these agencies in any meaningful, systematic fash- interventions for specific problems of great personal
ion. To be fair, relatively few RCTs of rehabilitation importance to the individual. Although consonant
interventions exist, generally, and this poses consid- with the rehabilitation ideal, this does not translate
erable problems for identifying evidence-based well into the kind of multisite clinical trial of a man-
practices in medical rehabilitation as well (Johnstone, ualized protocol with numbers large enough to
2003). With the high premium currently placed on impress most policy makers and third-party payers.
evidence-based treatments, rehabilitation psychol- Finally, RCTs are especially problematic for psy-
ogists now assist in establishing evidence for multi- chological interventions in rehabilitation as these
disciplinary practices in medical rehabilitation designs are usually disinterested in theoretical models
(cf. Cicerone et al., 2005), while facing increasing of change; we already know from prior study of
expectations to provide evidence for psychological behavioral contingencies and family dynamics that
interventions in rehabilitation settings for people some behavioral problems may exacerbate before
with various disabling conditions. These are not improvement is observed. Behavior following dis-
necessarily complementary activities: One review of ability is best studied with theoretical models that
interventions for treatment of depression following anticipate the various mediators and moderators
SCI found no RCTs for either antidepressant of change over time, rather than a linear model of
medication or psychological interventions in the change often associated with drug therapies for

e lliot t, r at h 689
specific symptoms (for which RCTs are better suited; programs. Only a few programs state an explicit
Tucker & Reed, 2008). identification with rehabilitation psychology, and to
The present market value on EBP and the divided date, none of these have APA accreditation.
loyalties that rehabilitation psychology researchers In the late 20th century, the debate concerning
face in medical and multidisciplinary settings may professional training and identity renewed. Several
eventually result in greater scrutiny of many psycho- advocates—notable because of their pivotal roles in
logical interventions that have documented support. the formation of the division and the specialty—
Such interventions as hypnosis for burn pain tried to distinguish rehabilitation psychology from
(Patterson, Everett, Burns, & Marvin, 1992); bio- the emerging and popular areas of health psychol-
feedback to enhance self-regulation for persons with ogy and behavioral medicine (Shontz & Wright,
SCI (Brucker, 1980); and group interventions to 1980). However, empirical descriptions of actual
improve social skills (Glueckauf & Quittner, 1992), practice demonstrated considerable overlap between
problem-solving abilities (Rath, Simon, Langenbahn, rehabilitation psychology activities and clinical
Sherr, & Diller, 2003), coping skills (King & health psychology (Eisenberg & Jansen, 1987;
Kennedy, 1999), and general adjustment (Wegener, Jansen & Fulcher, 1982). Consequently, other col-
Mackenzie, Ephraim, Ehde, & Williams, 2009) fol- leagues advocated for core training common to
lowing disability may best be construed as empiri- APA-approved doctoral programs in clinical and
cally supported treatments. Understandably, many counseling psychology with subsequent specializa-
critics of the false premiums placed on RCTs have tion in practica, internship, and postdoctoral train-
urged an expansion of the evidentiary base to appre- ing (Elliott & Gramling, 1990; Glueckauf, 2000).
ciate contributions of alternative research designs, Despite these well-intentioned assertions, there is
sound theory, sophisticated meta-analytic techniques, some indication that most APA-approved doctoral
and cumulative evidence across studies and designs training programs provide no more exposure to
(Dijkers et al., 2009; Dunn & Elliott, 2008; Horn & rehabilitation- and disability-relevant issues now
Gassaway, 2007; Tucker & Reed, 2008). (Olkin, 1999, 2002) than they did in the past
(Leung, Sakata, & Ostby, 1990; Spear & Schoepke,
Professional Training 1981).
Throughout its existence, rehabilitation psychology An understandable shift to guidelines for training
has experienced difficulties in training and mentor- experiences at the internship and postdoctoral level
ing future colleagues. This is due, in part, to the lack initially appeared promising (Patterson & Hanson,
of doctoral training programs in rehabilitation psy- 1995). These training guidelines were particularly
chology, and to the longstanding lack of attention timely and congruent with the competencies identi-
in clinical and counseling psychology doctoral pro- fied by the American Board of Rehabilitation
grams to disability- and rehabilitation-related issues Psychology (ABRP; established under the auspices
in coursework and practica. Very few members of of the American Board of Professional Psychology;
the Division of Rehabilitation Psychology hold aca- Hibbard & Cox, 2010). These competencies are
demic positions in APA-approved doctoral training contained in Table 26.3.

Table 26.3. Required and Supplemental Competencies for the American Board of Rehabilitation
Psychology
ASSESSMENT
Required
Adjustment to Disability: Patient
Adjustment to Disability: Family
Assessment of extent and nature of disability and preserved abilities
Assessment as it relates to educational and/or vocational capacities
Personality and emotional assessment
(Continued )

690 rehabilitatio n p s ych o lo gy

Table 26.3. Continued
Cognitive testing
Competency evaluation
Sexual functioning assessment
Pain assessment
Substance use/abuse
Social and behavioral functioning assessment
INTERVENTION
Required
Individual therapeutic intervention as it relates to adjustment to disability
Family/couples therapeutic intervention as related to adjustment to disability
Behavioral Management
Sexual Counseling with disabled population(s)
Supplemental
Pain management
Cognitive retraining
Group therapeutic intervention as it relates to adjustment to disability
CONSULTATION
Required
Behavioral functioning improvement
Cognitive Functioning
Vocational and/or Education Considerations
Personality/Emotional Factors
Substance Abuse Identification and Management
Sexual Functioning and Disability
Supplemental
Improvements in physical functioning
Integration of assistive technology for enhancement of cognitive, sensory, and physical functioning
COMPETENCE IN CONSUMER PROTECTION
Required
State laws of practice
Laws related to and including ADA
APA Ethical Principles
(Continued )

e lliot t, r at h 691
Table 26.3. Continued
Awareness and sensitivity to multicultural and diversity factors
Issues related to patient confidentiality and privacy (e.g., HIPAA)
Supplemental
Advance directives/Wish to Die
Abuse/Exploitation (sexual, financial, physical, psychological)
Prevention e.g. Advocacy of legislative policy changes, Education
Establishment of Standards of Care/Practice in Rehabilitation
PROFESSIONAL DEVELOPMENT COMPETENCE
Required
Continuing education: must include documented CE credits in
rehabilitation psychology areas within the previous 2 years.
Supplemental
Professional presentation - local, state, national levels
Publications
Teaching
Involvement in advocacy groups
Gain expertise in related subspecialty areas (e.g., supervision, workshops)

The ABRP recognizes that qualified applicants Clinical Practice

may have an earned doctorate in clinical, coun- Populations Served
seling, or school psychology, neuropsychology, Rehabilitation psychologists provide services to
or health psychology (Hibbard & Cox, 2010). individuals with a wide range of disorders typi-
Therefore, the basic, fundamental skills underpin- cally encountered in medical rehabilitation settings,
ning these competencies ideally are acquired during including traumatic injuries (e.g., SCI), catastrophic
doctoral training in any of these programs. The spe- illness (e.g., cancer), and chronic disabling condi-
cific competencies unique to rehabilitation may be tions (impaired vision, deafness and hearing loss;
refined in internship and postdoctoral experiences. Scherer et al., in press; Warschausky, Kaufman, &
Recent survey research suggests that relatively Stiers, 2008). However, it is not uncommon for
few internship and postdoctoral training pro- rehabilitation psychologists to cover a particular area
grams are providing training experiences that meet or unit of an inpatient or outpatient setting repre-
the expectations for competency as delineated by senting a specific diagnostic group or to choose to
the ABRP (Stiers & Stucky, 2008). These data also specialize in work with one particular patient popu-
indicate that, among the responding programs that lation (e.g., individuals with amputations, chronic
had outcome data, trainees were as likely to pursue pain, or brain injuries) or age group (e.g., children,
board certification in clinical neuropsychology older adults).
(15%) as in rehabilitation psychology (12%). Conditions commonly addressed range from neu-
Although current programs seem to be providing rologic (e.g., traumatic brain injury [TBI], SCI,
more training experiences in rehabilitation psychol- Guillain-Barré syndrome) to orthopedic (e.g., frac-
ogy principles and competencies than previously tures, joint replacements) to general medical (e.g.,
documented, the overall quality and type of training HIV/AIDS, multiple sclerosis, vestibular disorders)
remains less than ideal, and perhaps too low to meet to psychiatric (e.g., schizophrenia, major depression)
current labor demands and opportunities (Stiers & to developmental (e.g., mental retardation, cerebral
Stucky, 2008). palsy) to any combination of these (e.g., polytrauma

692 rehabilitatio n p s ych o lo gy

secondary to motor vehicle accidents). Conditions assistance from state or private agencies that will
may be acute (e.g., stroke, TBI) or chronic (e.g., then participate in the rehabilitation process.
fibromyalgia, rheumatoid arthritis, diabetes), static,
or progressive. Substance use disorders are considered Scope of Practice
elsewhere in this volume; however, they are certainly Regardless of the specific disability or practice set-
prevalent in medical rehabilitation settings (e.g., alco- ting, the wide array of circumstances confronting
hol abuse, dependence on pain medication). Such individuals with disabilities demands a broad skill
disorders may contribute to the onset of disability, set and flexibility in the rehabilitation psychologist’s
development of preventable secondary complications approach. For example, in many general rehabilita-
following disability (e.g., ER visits, infections, skin tion settings, on any given day, a psychologist may
ulcers), and poor outcome (Heinemann, 1993). be engaged in consultation with nursing staff regard-
Regardless of type, severity, or duration of disability, ing behavioral management of a patient with TBI,
people with disabilities may receive services from offering supportive psychotherapy to a polytrauma
rehabilitation psychologists to help address limita- patient grieving the loss of a loved one, and provid-
tions in psychological, familial, social, and vocational ing sexual counseling to the spouse of a patient
aspects of their lives due to physical, cognitive, and/ with SCI with questions about sexual functioning.
or emotional aspects of their conditions. Consistent with the historical background of the
field, rehabilitation psychologists routinely provide
Practice Settings services informed by other academic and practice
Rehabilitation psychologists practice in a wide vari- areas of psychology including, but not limited to,
ety of inpatient and outpatient settings that serve social, clinical, and counseling psychology; rehabili-
individuals with disabilities and chronic illnesses. tation counseling; behavioral neuroscience; and
Common settings are public and private acute- and neuropsychology. In their case conceptualizations,
postacute care hospitals, other postacute inpatient they balance traditional field-theory perspectives on
settings (i.e., skilled nursing facilities and interme- disability (i.e., Wright, 1960, 1983) with an under-
diate care facilities), comprehensive outpatient reha- standing of the major impact that preinjury behav-
bilitation facilities, specialty clinics (e.g., cardiac iors (e.g., substance abuse) have on physical and
rehabilitation), and private practice, but also include psychological adjustment (cf. Elliott & Gramling,
schools, universities, nonprofit organizations, and 1990).
state and federal agencies (Scherer et al., in press). In planning clinical services, rehabilitation psy-
In hospitals and other institutional practice settings, chologists are sensitive to issues of social stigmatiza-
rehabilitation psychologists almost always work tion due to disability, confidentiality, and consumer
within interdisciplinary teams. Depending on the protection (e.g., laws related to the Americans with
particular setting and the individual’s needs, teams Disabilities Act), as well as multicultural and diver-
generally include some combination of the follow- sity issues (e.g., race/ethnicity, age, gender, sexual
ing disciplines: physiatrists (physicians specializing orientation; Hanjorgiris, Rath, & O’Neill, 2004).
in rehabilitation medicine), nurses, physical thera- In addition, they take into account limitations that
pists (PT), occupational therapists (OT), speech may be imposed by such factors as geographic loca-
and language pathologists (SLP), social workers, tion, socioeconomic status, and architectural barri-
audiologists, vocational counselors, and recreational ers; they are knowledgeable about, and recommend
therapists, as well as consulting physicians such as as necessary, relevant environmental modifications
neurologists, orthopedists, psychiatrists, internists, and assistive technologies, devices, products, and
and others (Strasser, Uomoto, & Smits, 2008). services.
Over the past 15 years, there has been a trend Services typically provided by rehabilitation psy-
for rehabilitation resources to be reallocated from chologists can be divided into three broad categories
traditional acute and post-acute inpatient settings (Elliott & Gramling, 1990): assessment (e.g., psy-
to outpatient and home-based programs (Elliott & chological, neuropsychological, and psychosocial),
Jackson, 2005). In addition, new initiatives such as intervention (e.g., counseling/psychotherapy, psy-
telehealth approaches are being developed to aug- choeducation, behavioral management, family inter-
ment ongoing treatment after discharge from acute ventions, sexual counseling, cognitive remediation),
and postacute treatment facilities and return to the and consultation (e.g., with interdisciplinary teams,
community (Glueckauf et al., 2003). Individuals primary caregivers, and/or outside parties and regu-
may qualify for educational and/or vocational latory systems).

e lliot t, r at h 693
Assessment behavioral disturbances, vocational potential, moti-
Rehabilitation psychologists are involved in the vational issues, and family concerns (Elliott &
formal psychometric assessment of intelligence, Gramling, 1990). Rehabilitation psychologists pro-
cognition, personality, mood, social functioning, vide guidance to the treatment team regarding the
and/or outcome. In addition, they use a variety of patient’s specific learning style, needed accommoda-
standardized and nonstandardized methods, includ- tions, motivational needs, cognitive abilities, and
ing structured and unstructured interviews, rating emotional reactions. Such collaboration can help
scales, and questionnaires to assess aspects of adjust- the interdisciplinary team establish realistic treat-
ment such as extent and nature of disability, sexual ment goals.
functioning, pain level, and substance use. Regardless Psychologists may consult individually with
of the setting or specific disability, assessment often certain staff members or develop larger-scale psycho-
involves adaptations of traditional tests for patients educational interventions (see below) for staff. In
with mobility and sensory limitations (e.g., Caplan many practice settings, rehabilitation psychologists
& Shechter, 2008). Rehabilitation psychologists formally communicate with team members during
are thus acutely aware of, and skilled in, issues such weekly meetings, but are available for informal con-
as test selection, administration and interpretation sultation between meetings. In addition to working
issues, and threats to test validity that may exist in a directly with interdisciplinary teams, rehabilitation
given case. They use a flexible approach to balance psychologists play a key role in providing consulta-
proper test administration with effective accommo- tions to authorized outside parties, such as family
dations for specific disabilities. A primary concern is members, attorneys, courts, governmental and social-
making evaluation data relevant to the individual’s service agencies, schools, employers, and insurance
functional life skills, including, but not limited to, companies.
educational and/or vocational capacities.
Inpatient rehabilitation settings typically require Intervention
rapid assessment of cognitive and emotional func- In rehabilitation psychology practice, interventions
tioning, preexisting and reactive psychopathology, focus on the provision of therapeutic strategies
and motivation for treatment. In situations in which designed to assist individuals, their families, and
the individual is experiencing extreme distress, the primary support systems cope with, and adapt to,
rehabilitation psychologist may be called upon to the effects of disability. Rehabilitation psychologists
differentiate between situational and characterologi- address the implications of disability in the context of
cal sources of psychological symptoms. Especially in the individual’s life circumstances, both currently and
acute inpatient settings, but in other settings as well, developmentally, as the person’s needs change over
rehabilitation psychologists also use both formal time. They are skilled in a variety of psychotherapeu-
and informal methods to assess family and caregiver tic strategies and treatment options appropriate to
adjustment. various stages of adaptation to physical injury or dis-
When developing treatment plans for individu- abling illness. Intervention techniques and modalities
als with cognitive deficits due to TBI, stroke, or include, but are not limited to, individual and group
other conditions that impact neurological function- counseling/psychotherapy, behavioral intervention/
ing, rehabilitation psychologists typically employ management, cognitive remediation/rehabilitation,
a process approach to assess patients’ strengths and couples’ counseling and family therapy, psychoeduca-
limitations. A comprehensive neuropsychological tion, sexual counseling, pain management, biofeed-
evaluation typically is completed to identify specific back, and clinical hypnosis.
cognitive deficits, preserved abilities, and measur- In inpatient counseling/psychotherapy, the reha-
able goals to guide treatment planning. Once again, bilitation psychologist’s interventions often are
a primary concern is making the assessment data focused on facilitating psychological adjustment to
relevant to the patient’s functional life skills (Wilson, new physical disability, traumatic injury, or cata-
1997). strophic illness. Depending on theoretical orienta-
tion, the psychologist may incorporate psychodynamic
Consultation formulations or learning theory, as well as specific
Rehabilitation psychologists routinely provide cognitive-behavioral interventions (Chan, Berven,
consultations regarding patient behavior, especially & Thomas, 2004). Regardless of orientation, reha-
in inpatient settings. Consultations address such bilitation psychologists stress the development of
diverse issues as adherence to treatment regimens, flexible coping and problem-solving approaches.

694 rehabilitatio n p s ych o lo gy

 Throughout the course of treatment, rehabilita- to minimize distractions, break complex tasks down
tion psychologists tailor psychotherapeutic strate- into steps, and to self-monitor and self-regulate
gies and treatment options to the individual’s stages behavior. The two approaches are not mutually
of adaptation to injury or illness. For example, exclusive; both techniques are usually employed
to further a patient’s overall rehabilitation goals, as necessary, depending upon the individual’s
the psychologist initially might focus on maintain- needs (NIH Consensus Development Panel on
ing day-to-day motivation, but then later address Rehabilitation of Persons with TBI, 1999).
issues of long-term adjustment to disability and Disability and chronic illness affect not only the
future educational/vocational goals. Sexual counsel- individual with the disability, but also the individu-
ing may include educational and counseling strate- al’s primary caregivers and support systems. Reha-
gies to encourage communication, increase sexual bilitation psychology practice therefore includes
pleasure, and lessen the impact of disability (Schover provision of psychoeducational and counseling/
& Jensen, 1988). When providing sexual counsel- psychotherapy services to family members and pri-
ing services, rehabilitation psychologists are mind- mary caregivers (Kosciulek, 2004; Padrone, 1999).
ful not to limit their interventions to married Rehabilitation psychologists are proficient in engag-
couples or presume heterosexuality. Similarly, they ing couples and families, and formulating and exe-
are sensitive to the sexual concerns of individuals cuting systemic interventions. Typical interventions
who are not in relationships and may be struggling might include stress management and/or problem-
with issues related to stigma and disability. solving training (with emerging evidence from ran-
To address maladaptive behaviors, rehabilitation domized clinical trials that these may be effectively
psychologists employee a variety of behavioral man- provided in the home using long-distance technolo-
agement techniques, such as positive reinforcement, gies; Grant, Elliott, Weaver, Bartolucci, & Giger,
shaping, time-outs, and modeling (Stoll, 2004). 2002; Elliott, Brossart, Berry, & Fine, 2008; Rivera,
Behavioral intervention techniques may be espe- Elliott, Berry, & Grant, 2008).
cially useful in reducing impulsivity and improving Rehabilitation psychologists offer psychoeduca-
self-control in patients with TBI, and addressing tional services to provide family caregivers with
aggressive or disruptive behavior in general. When specific information about the particular disability
implementing behavioral management plans, reha- or chronic illness, along with skills for coping with
bilitation psychologists typically work closely with their family member’s disabling condition. Simi-
interdisciplinary team members, including nursing, larly, psychoeducational training programs may be
PT, OT, and SLP. provided for interdisciplinary team members to
When working with individuals with TBI, stroke, improve coping and practical skills. Psychoeducational
and other conditions that affect brain function, groups also can be used to bring together individu-
rehabilitation psychologists typically employ cogni- als coping with the same type of disability or chronic
tive remediation, a systematic intervention designed illness. Learning that occurs through the group
to improve functional abilities and increase levels process of sharing similar concerns and strategies
of independence (Ben-Yishay & Prigitano, 1990). for overcoming them may be more effective than
There are two general approaches to cognitive reme- direct didactic transmission of information (Hale &
diation: restoration and compensation (cf. Wilson, Cowls, 2009).
1997). The restoration approach is based on the Finally, rehabilitation psychologists may incorpo-
premise that repetitive exercise can restore com- rate any number of specialized intervention methods
promised cognitive abilities. Techniques include tailored to individual patient needs. For example,
visual and auditory exercises, numerical tasks, when working with patients with chronic pain, reha-
computer-assisted exercises, and feedback on per- bilitation psychologists may utilize clinical hypnosis
formance, practice, and reinforcement. The com- or biofeedback, in addition to more routine pain and
pensation approach reinforces the individual’s anxiety management treatment strategies (e.g., visu-
preserved cognitive strengths, while teaching strate- alization, progressive muscle relaxation, diaphrag-
gies to circumvent (or compensate for) impaired matic breathing). In some settings, biofeedback
cognitive abilities, with the goal of increasing inde- therapy may be provided for individuals with such
pendent functioning. Compensatory strategies diverse conditions as migraine, diabetes, Guillain-
include the use of cues, written instructions, notes, Barré syndrome, and fibromyalgia (e.g., Huyser,
calendars, and date books, and electronic devices Buckelew, Hewett, & Johnson, 1997), as well as
such as beepers and pagers. The individual is taught orthopedic and neurological cnditions such as SCI,

e lliot t, r at h 695
TBI, stroke, and cerebral palsy (e.g., Ince, Leon, & genetic predispositions that can increase suscepti-
Christidis, 1987). Overall, across practice settings, bility, with risk increased by behavioral and social
rehabilitation psychologists use a broad skill set factors. Pharmacological interventions have had a
and a flexible approach while working with patients, radical effect on increased longevity of life, permit-
families, and interdisciplinary teams to facilitate ting individuals to manage their symptoms and cur-
maximal functioning and adjustment. tail disease progression. Similarly, advanced medical
technologies have increased the life expectancy
Conclusion of persons with acquired and congenital physical
Future Directions and Challenges disabilities.
Throughout its history, rehabilitation psychology People with chronic health conditions account
has been responsive to and shaped by contextual for two-thirds of prescribed medication use, and
and economic events in larger society. It has main- they have the highest rates of hospitalization and
tained involvement in the larger interdisciplinary office visits (Partnerships for Solutions, 2004).
enterprise of rehabilitation (as conducted in medi- In 2001, the care they received accounted for 83%
cal settings, primarily). Unlike other psychological of all health care expenditures. Individuals with
specialties, it is a long-time participant in policy- multiple chronic conditions account for 96% of
relevant activities with federal agencies (the National Medicare expenditures. It should be noted that the
Institute of Disability Research and Rehabilitation, majority of persons with chronic health conditions
the Centers for Disease Control, the National are of working age (younger than 65 years of age;
Center for Medical Rehabilitation Research within Partnerships for Solutions, 2004). Persons who
NIH) and consumer groups (e.g., the Paralyzed acquire physical disabilities (e.g., SCI, TBI) with
Veterans of America). This rich heritage contrib- considerable life expectancies often require life-long
utes to the resilience and far-reaching influence that commitments from a family member to perform
rehabilitation psychology has demonstrated for caregiving duties (Lollar & Crews, 2003). Therefore,
several decades. the health and well-being of family caregivers—and
Undoubtedly, rehabilitation psychology also will the subsequent ability to assist their care recipients—
be shaped by the current times and challenges. is a public health priority (Talley & Crews, 2007).
Current changes sweeping across the landscape of Healthy People 2010 (US Department of Health
American health care are dramatic and uncompro- and Human Services, 2000) recognized the need for
mising. The primary drivers of these changes will behavioral and social initiatives to promote the
have a tremendous impact on professional psychol- health and quality of life of persons with disabilities
ogy, generally, and rehabilitation psychology, spe- and their family caregivers.
cifically. The aging of the baby boomers in American Finally, the number of wounded veterans return-
society is one major factor, but this demographic ing to society from the international conflicts in Iraq
trend does not account for other forces that are in and Afghanistan present with conditions that may
play. require a lifetime of assistance and health care ser-
The number of people living with chronic vice. Many returning service personnel from the
health conditions in American society has increased Operation Iraqi Freedom/Operation Enduring Free-
steadily over the past 50 years. In fact, for the first dom theatres have documented problems with
time in the nation’s recorded history, almost half of depression and posttraumatic stress disorder (PTSD).
all Americans live with a chronic health condition The rates of depression and PTSD are complicated
(i.e., condition that lasts longer than a year, limits a further by the high incidence of acquired brain inju-
person’s activities, and may require ongoing medical ries incurred by personnel in these theatres:
care to manage symptoms), and almost half of this Depression is a common complication of acquired
number has more than one condition (Partnerships brain injury, and the high rate of concomitant PTSD
for Solutions, 2004). This increase is due, in part, with brain injury among returning personnel is
to drastic improvements in emergency care and without precedent in the extant literature. Increased
technologies that have increased the likelihood of anger, agitation, fatigue, and impulsivity commonly
survival following motor vehicle accidents, acts of accompany these injuries. The veteran’s decreased
violence, and other forms of trauma. Some diseases, functioning and increased emotional fragility can be
such as HIV/AIDS or Lyme disease, stem from a source of immense distress for families. The loss of
infectious processes, but other chronic diseases (e.g., this supportive safety net may increase the vulnera-
hypertension, heart disease, and diabetes) often have bility of the veteran and place a greater responsibility

696 rehabilitatio n p s ych o lo gy

for care on the health system (Eibner, 2008). The developing collaborative partnerships with people
long-lasting physical and emotional concomitants of who live with disabilities and other chronic health
these wounds will also tax social and legal services problems, as it recognizes and seeks to empower
for some time (Stern, 2004; Tanielian, 2009). their active role in their ongoing health and well-
In sum, the ensuing costs to American society are being (Israel, Schulz, Parker, & Becker, 1998).
enormous. American health care systems are over- Effective program and policy development for per-
whelmed by the sheer number of persons presenting sons with disabilities and their families may be real-
with chronic conditions, their accompanying behav- ized when these people are recognized as experts on
ioral and social needs (which may extend over the their service needs, and they can exercise an element
course of a lifetime), and the complexity of manag- of choice, control, and direction in the delivery of
ing multiple symptoms across primary and specialty services (Kosciulek, 2000; Turnbull & Stowe, 2001).
care. This dilemma has been called the “epidemic These programs will circumvent environmentally
of survival” (Oeffinger, Eshelman, Tomlinson, & imposed limitations and restrictions that contribute
Buchanan, 1998). These factors, combined with the to health disparities among persons with disabilities
aging of the baby boom generation and the two (Lollar, 2008). To be cost-effective, they will likely
wars, may “produce the largest population of per- involve the use of low-cost, non–doctoral level
sons with disabilities in this century” (Johnson, service providers in programs administered and/or
2008, p. 182). supervised by psychologists (Callahan, 2010).
As in post-World War II America, the demand The role of rehabilitation psychology in medical
for professionals with expertise regarding behavioral settings will likely entail more applications of neu-
and social issues in health care will exceed the avail- ropsychological skills, as illustrated in many of the
able supply. Furthermore, the subsequent demands ABRP competencies. These skills already are valued
on health care systems to support and provide in the medical setting for assessment and consulta-
appropriate services will not sustain doctoral-level tion, but decreasing support and reimbursement for
service provision at a rate required to meet the needs psychological interventions will limit therapeutic
of these individuals and their families throughout activities in the inpatient environment. As we have
urban, rural, and suburban American communities. seen, many rehabilitation psychologists already have
To meet these challenges, many rehabilitation some identity with neuropsychology, and prelimi-
psychologists may respond by embracing a more nary survey data indicate that postdoctoral trainees
public health perspective of disability and other may place greater value on board certification in
chronic health conditions (Elliott, 2002). Ideally, neuropsychology than rehabilitation psychology.
such a perspective is chiefly concerned with “large- At least one recent review of neuropsychological
scale behavior change to address social problems” and rehabilitation places heavy weight on neuropsy-
influence public policy in the process (McKnight, chological practice with little or no reference to
Sechrest, & McKnight, 2005, p. 559). Psychological rehabilitation psychology’s contributions to the
science can be used to inform and direct decisions area (Wilson, 2008), despite listing values that are
about meaningful policy, particularly when it dem- remarkably similar to those historically espoused by
onstrates the potential for large-scale changes rather rehabilitation psychology (e.g., Wright, 1972).
than relatively expensive, time-consuming, face-to- Rehabilitation psychologists who focus on com-
face interventions that involve doctoral-level service munity approaches and those who identify with cer-
providers. tain medical specialties may have different reactions
Consequently, programs will be developed to to the increasingly popular reconceptualization of
provide ongoing, community-based assistance that disability defined in the International Classification
fully embraces the reality that an individual’s life- of Functioning (ICF; World Health Organization,
style and day-to-day choices—and the immediate 2001). The ICF conceptualizes disability as an over-
social factors that influence these behaviors— arching term that refers to any impairments, activity
have more impact on the course of their health limitations, or participation restrictions, or “the
than do services offered by any single health profes- outcome or result of a complex relationship between
sion (Glass & McAtee, 2006). This will necessitate an individual’s health condition and personal fac-
a conscious move away from a patient-oriented tors, and of the external factors that represent the
“paternalistic” medical model of service delivery to circumstances in which the individual lives” (WHO,
one that promotes a “participatory ethic” (Mechanic, 2001, p. 17). This perspective places a greater recog-
1998, p. 283). This ethic is considered essential in nition on the disabling features of the environment

e lliot t, r at h 697
and the person–environment interaction in a fash- Bond, G. R. (2004). Supported employment: Evidence for an
ion consistent with the social psychological heritage evidence-based practice. Psychiatric Rehabilitation Journal,
27, 345–359.
of rehabilitation psychology, and it is quite compat- Brucker, B. S. (1980). Biofeedback and rehabilitation.
ible with the views of most disability advocates In L. P. Ince (Ed.), Behavioral psychology in rehabilitation
(Pledger, 2003). However, it poses conceptual and medicine: Clinical applications (pp. 188–217). Baltimore:
practical challenges for many medical specialties Williams & Wilkins.
that are dedicated in service and research to specific Brucker, B. S., & Ince, L. P. (1977). Biofeedback as an experi-
mental treatment for postural hypotension in a patient with
diagnostic conditions, and by extension, to those a spinal cord lesion. Archives of Physical Medicine and
health professions that do likewise. Rehabilitation, 58, 49–53.
Psychologists who are wedded to medical spe- Brownsberger, M. G. (2003, Fall). Interview with Leonard Diller,
cialties in research and in practice implicitly and Ph.D. Division 22 Newsletter, 31(1), 12–13.
explicitly embrace a medical model that champions Buchanon, R. (2003). Legislative warriors: American psychiatrists,
psychologists, and competing claims over psychotherapy in
assessment and diagnosis essential to the specialty the 1950s. Journal of the History of the Behavioral Sciences, 39,
practice, and promotes services deemed essential by 225–249.
the specialty. Community-residing consumers are Callahan, C. (2010). Rehabilitating the health care organization:
more likely to prefer services that are accessible and Administering psychology’s opportunity. In R. G. Frank,
meaningful to their everyday lives. With the steady M. Rosenthal, & B. Caplan (Eds.), Handbook of rehabilita-
tion psychology (2nd ed., pp. 459–466). Washington, DC:
influx of neuropsychologists into rehabilitation set- American Psychological Association.
tings, it is likely that these psychologists will likely Caplan, B., & Shechter, J. (2008). Test accommodations for the
assume most of the rehabilitation psychology posi- geriatric patient. NeuroRehabilitation, 23, 395–402.
tions in medical settings along with other doctoral- Chan, F., Berven, N. L., & Thomas, K. R. (Eds.). (2004).
level specialties that champion assessment, diagnosis, Counseling theories and techniques for rehabilitation health
professionals. New York: Springer.
and expert interventions from medical perspectives. Cicerone, K. D., Dahlberg, C., Malec, J. F., Langenbahn, D. M.,
Psychologists who are more generalists in outlook Felicetti, T., Kneipp, S., et al. (2005). Evidence-based cogni-
and competence will be more likely to participate tive rehabilitation: Updated review of the literature from
in public health programs to promote the health 1998 through 2002. Archives of Physical Medicine and
and well-being of community-residing individuals Rehabilitation, 86, 1681–1692.
Consortium for Spinal Cord Medicine. (1998). Depression
with disabling conditions, generally, regardless of following spinal cord injury: A clinical practice guideline for
the specific medical or psychological diagnosis, in a primary care physicians. Washington, DC: Paralyzed Veterans
manner congruent with the ICF. These dynamics of America.
will undoubtedly shape the next iteration of the Cook, J. A., Leff, H. S., Blyler, C. R., Gold, P. B., Goldberg, R. W.,
rehabilitation psychology specialty. et al. (2005). Results of a multisite randomized trial of sup-
ported employment interventions for individuals with severe
mental illness. Archives of General Psychiatry, 62, 505–512.
References Cook, J. A., Lehman, A. F., Drake, R., McFarlane, W. R.,
Allan, W. S. (1958). Rehabilitation: A community challenge. Gold, P. B., Leff, H. S., et al. (2005). Integration of psychiat-
New York: Wiley. ric and vocational services: A multisite randomized, con-
Anthony, W. A., & Blanch, A. (1987). Supported employment trolled trial of supported employment. American Journal of
for persons who are psychiatrically disabled: A historical and Psychiatry, 162, 1948–1956.
conceptual perspective. Psychosocial Rehabilitation Journal, Cubbage, M. E., & Thomas, K. R. (1989). Freud and disability.
11, 5–23. Rehabilitation Psychology, 34, 161–173.
Barker, R. G., Wright, B. A., Meyerson, L., & Gonick, M. R. Dawis, R. V., & Lofquist, L. H. (1984). A psychological theory
(1953). Adjustment to physical handicap and illness: A survey of of work adjustment. Minneapolis: University of Minnesota
the social psychology of physique and disability. New York: Press.
Social Science Research Council. Dembo, T., Leviton, G. L., & Wright, B. A. (1956). Adjustment
Ben-Yishay, Y., & Diller, L. (1983). Cognitive remediation. In to misfortune: A problem of social-psychological rehabilita-
M. Rosenthal, E. R. Griffith, M. R. Bond, & J. D. Miller tion. Artificial Limbs, 3(2), 4–62.
(Eds.), Rehabilitation of the head injured adult (pp. 167–183). Dijkers, M. P. J. M. for the NCDDR Task Force on Systematic
Philadelphia: F. A. Davis. Review and Guidelines. (2009). When the best is the enemy of
Ben-Yishay, Y., Diller, L., Gerstman, L. J., & Gordon, W. A. the good: The nature of research evidence used in systematic
(1970). Relationships between initial competence and ability reviews and guidelines. Austin, TX: SEDL. Retrieved from
to profit from cues in brain damaged individuals. Journal of http://www.ncddr.org/kt/products/tfpapers/.
Abnormal Psychology, 75, 248–259. Diller, L. (2008, February). Rehabilitation psychology: A subjective
Ben-Yishay, Y., & Prigatano, G. P. (1990). Cognitive remedia- view. Paper presented at the annual Rehabilitation Psychology
tion. In M. Rosenthal, E. R. Griffith, M. R. Bond, & conference, Jacksonville, FL.
J. D. Miller (Eds.), Rehabilitation of the adult and child with Diller, L., & Weinberg, J. (1970). Accidents in hemiplegia.
traumatic brain injury (2nd ed., pp. 393–409). Philadelphia: Archives of Physical Medicine and Rehabilitation, 51,
F. A. Davis. 358–363.

698 rehabilitatio n p s ych o lo gy

Dunn, D. S. (2009). The social psychology of disability. Emmons, R. A., & McCullough, M. E. (2003). Counting
In R. G. Frank, B. Caplan, & M. Rosenthal (Eds.), Handbook blessings versus burdens: An experimental investigation of
of rehabilitation psychology (2nd ed.). Washington, DC: gratitude and subjective well-being in daily life. Journal of
American Psychological Association. Personality and Social Psychology, 84, 377–389.
Dunn, D., & Elliott, T. R. (2005). Revisiting a constructive Fine, M., & Asch, A. (1988). Disability beyond stigma: Social
classic: Wright’s Physical disability: A psychosocial approach. interaction, discrimination, and activism. Journal of Social
Rehabilitation Psychology, 50, 183–189. Issues, 44, 3–21.
Dunn, D., & Elliott, T. R. (2008). The place and promise of Fordyce, W. E. (1964). Personality characteristics in men
theory in rehabilitation psychology research. Rehabilitation with spinal cord injury as related to manner of onset of
Psychology, 53, 254–267. disability. Archives of Physical Medicine and Rehabilitation,
Dunn, D. S., Uswatte, G., & Elliott, T. R. (2009). Happiness, 45, 321–325.
resilience and positive growth following disability: Issues Fordyce, W. E. (1971). Behavioral methods in rehabilitation.
for understanding, research, and therapeutic intervention. In W. S. Neff (Ed.), Rehabilitation psychology (pp. 74–108).
In S. J. Lopez (Ed.), The handbook of positive psychology Washington, DC: American Psychological Association.
(2nd ed., pp. 651–664). New York: Oxford University Press. Fordyce, W. E. (1976). Behavioral methods for chronic pain and
Eibner, C. (2008, June). Invisible wounds of war: Quantifying the illness. Saint Louis, MO: C. V. Mosby Company.
societal costs of psychological and cognitive injuries. Santa Fordyce, W. E. (1988). Pain and suffering. American Psychologist,
Monica, CA: Rand Corporation. Retrieved from http:// 43, 276–283.
www.rand.org/pubs/testimonies/CT309/. Glass, T. A., & McAtee, M. (2006). Behavioral science at the
Eisenberg, M., & Jansen, M. A. (1987). Rehabilitation psy- crossroads in public health: Extending horizons, envisioning
chologists in medical settings: A unique specialty or a redun- the future. Social Science and Medicine, 62, 1650–1671.
dant one? Professional Psychology: Research and Practice, 18, Glueckauf, R. L. (2000). Doctoral education in rehabilitation
475–478. and health care psychology: Principles and strategies for uni-
Elliott, T. R. (2007). Registering randomized clinical trials fying subspecialty training. In R. G. Frank, & T. R. Elliott
and the case for CONSORT. Experimental and Clinical (Eds.), Handbook of rehabilitation psychology (pp. 615–627).
Psychopharmacology, 15, 511–518. Washington, DC: American Psychological Association.
Elliott, T. R., Brossart, D., Berry, J. W., & Fine, P. R. (2008). Glueckauf, R. L., Pickett, T. C., Ketterson, T. U., Loomis, J. S.,
Problem-solving training via videoconferencing for family & Rozensky, R. H. (2003). Preparation for the delivery of
caregivers of persons with spinal cord injuries: A randomized telehealth services: A self-study framework for expansion of
controlled trial. Behaviour Research and Therapy, 46, practice. Professional Psychology: Research and Practice, 34,
1220–1229. 159–163.
Elliott, T. R., & Byrd, E. K. (1986). Frequently cited works, Glueckauf, R. L., & Quittner, A. L. (1992). Assertiveness train-
authors, and sources of research in Rehabilitation Psychology. ing for disabled adults in wheelchairs: Self-report, role-play,
Rehabilitation Psychology, 31, 112–115. and activity pattern outcomes. Journal of Consulting and
Elliott, T. R., Byrd, E. K., & Nichols, R. (1987). Influential Clinical Psychology, 60, 419–425.
publications and authors in contemporary rehabilitation Goffman, E. (1960). Stigma: Notes on management of a spoiled
counseling research. Journal of Applied Rehabilitation identity. Englewood Cliffs, NJ: Prentice Hall.
Counseling, 18(3), 45–48. Gold, M. (1974). Breaking the expectancy cycle. Education and
Elliott, T. R., & Gramling, S. (1990). Psychologists and rehabili- Training of the Mentally Retarded, 9, 37–40.
tation: New roles and old training models. American Goldstein, G. (2009). Neuropsychology in New York City (1930–
Psychologist, 45, 762–765. 1960). Archives of Clinical Neuropsychology, 24, 137–143.
Elliott, T. R., & Jackson, W. T. (2005). Cognitive-behavioral Gordon, W. A., & Hibbard, M. R. (1991). The theory and prac-
therapy in rehabilitation psychology. In A. Freeman (Ed.), tice of cognitive remediation. In J. Kreutzer, & P. Wehman
Encyclopedia of cognitive behavior therapy (pp. 324–327). (Eds.), Cognitive rehabilitation for persons with traumatic
New York: Springer Science + Business Media. brain injury: A functional approach (pp. 13–22). Baltimore:
Elliott, T. R., & Kennedy, P. (2004). Treatment of depression Paul H. Brookes.
following spinal cord injury: An evidence-based review. Grant, J., Elliott, T., Weaver, M., Bartolucci, A., & Giger, J.
Rehabilitation Psychology, 49, 134–139. (2002). A telephone intervention with family caregivers
Elliott, T. R., Kurylo, M., & Rivera, P. (2002). Positive growth of stroke survivors after hospital discharge. Stroke, 33,
following acquired physical disability. In C. R. Snyder, & 2060–2065.
S. J. Lopez (Eds.), Handbook of positive psychology Grzesiak, R. (1979). Psychological services in rehabilitation
(pp. 687–699). New York: Oxford University Press. medicine: Clinical aspects of rehabilitation psychology.
Elliott, T. R., & Leung, P. (2005). Vocational rehabilitation: Professional Psychology, 10, 511–520.
History and practice. In W. B. Walsh, & M. Savickas (Eds.), Grzesiak, R. C., & Hicock, D. A. (1994). A brief history of
Handbook of vocational psychology (3rd ed., pp. 319–343). psychotherapy in physical disability. American Journal of
New York: Lawrence Erlbaum Press. Psychotherapy, 48, 240–250.
Elliott, T. R., Uswatte, G., Lewis, L., & Palmatier, A. (2000). Hale, S., & Cowls, J. (2009). Psychoeducational groups.
Goal instability and adjustment to physical disability. Journal In I. Soderback (Ed.), International handbook of occupational
of Counseling Psychology, 47, 251–265. therapy interventions (pp. 255–260). New York: Springer
Elliott, T. R., & Warren, A. M. (2007). Why psychological issues Science.
are important. In P. Kennedy (Ed.), Psychological manage- Hanjorgiris, W. F., Rath, J. F., & O’Neill, J. H. (2004). Gay men
ment of physical disabilities: A practitioner’s guide (pp. 16–39). living with chronic illness or disability: A sociocultural, minor-
London: Brunner-Rutledge Press. ity group perspective on mental health. In B. Lipton (Ed.),

e lliot t, r at h 699
 Gay men living with chronic illnesses and disabilities: From Kleck, R. E., Ono, H., & Hastorf, A. (1966). The effects of
crisis to crossroads (pp. 25–42). Binghamton, NY: Haworth physical deviance upon face-to-face interaction. Human
Press. Relations, 19, 425–436.
Heinemann, A. W. (Ed.). (1993). Substance abuse and physical Kosciulek, J. F. (2000). Implications of consumer direction for
disability. Binghamton, NY: Haworth Press. disability policy development and rehabilitation service
Hershenson, D. (1988). Along for the ride: The evolution of delivery. Journal of Disability Policy Studies, 11(2), 82–89.
rehabilitation counselor education. Rehabilitation Counseling Kosciulek, J. F. (2004). Family counseling. In F. Chan,
Bulletin, 31, 204–217. N. L. Berven, & K. R. Thomas (Eds.), Counseling theories
Hibbard, M. R., & Cox, D. R. (2010). Competencies of a reha- and techniques for rehabilitation health professionals
bilitation psychologist. In R. G. Frank, M. Rosenthal, & (pp. 264–281). New York: Springer.
B. Caplan (Eds.), Handbook of rehabilitation psychology Kunce, J. T., & Worley, B. H. (1966). Interest patterns,
(2nd ed., pp. 467–475). Washington, DC: American accidents, and disability. Journal of Clinical Psychology, 22,
Psychological Association. 105–107.
Hoffman, H. G., Patterson, D. R., & Carrougher, G. J. (2000). Larson, P., & Sachs, P. (2000). A history of Division 22.
Use of virtual reality for adjunctive treatment of adult burn In D. A. Dewsbury (Ed.), Unification through division:
pain during physical therapy: A controlled study. The Clinical Histories of the divisions of the American Psychological
Journal of Pain, 16, 244–250. Association (pp. 33–58). Washington, DC: American
Hollingsworth, D. K., Johnson, W. C., Jr., & Cook, S. W. Psychological Association.
(1989). Beatrice A. Wright: Broad lens, sharp focus. Journal Laurenceau, J. P., Hayes, A. M., & Feldman, G. C. (2007). Some
of Counseling and Development, 67, 384–393. methodological and statistical issues in the study of change
Horn, S. D., & Gassaway, J. (2007). Practice-based evidence processes in psychotherapy. Clinical Psychological Review, 27,
study design for comparative effectiveness research. Medical 682–695.
Care, 45(10 Supplement 2), S50–S57. Leung, P., Sakata, R., & Ostby, S. (1990). Rehabilitation
Huyser, B., Buckelew, S. P., Hewett, J. E., & Johnson, J. C. psychology professional training: A survey of APA accredited
(1997). Factors affecting adherence to rehabilitation inter- programs. Rehabilitation Education, 4, 177–183.
ventions for individuals with fibromyalgia. Rehabilitation Lewin, K. (1935). A dynamic theory of personality. New York:
Psychology, 42, 75–91. McGraw-Hill.
Ince, L. P. (1980). Behavioral psychology in rehabilitation Lofquist, L. H. (1960). Psychological research and rehabilitation.
medicine. Baltimore: Williams & Wilkins. Washington, DC: American Psychological Association.
Ince, L. P., Brucker, B. S., & Alba, A. (1978). Reflex condition- Lollar, D. (2008). Rehabilitation psychology and public
ing in a spinal man. Journal of Comparative and Physiological health: Commonalities, barriers, and bridges. Rehabilitation
Psychology, 92, 796–802. Psychology, 53, 122–127.
Ince, L. P., Leon, M. S., & Christidis, D. (1987). EMG Lollar, D. E., & Crews, J. (2003). Redefining the role of
biofeedback with the upper extremity: A critical review of public health in disability. Annual Review of Public Health,
experimental foundations of clinical treatment with the 24, 195–208.
disabled. Rehabilitation Psychology, 32, 77–91. Lucas, R. E. (2007). Long-term disability is associated with
Israel, B. A., Schulz, A. J., Parker, E. A., & Becker, A. B. (1998). lasting changes in subjective well-being: Evidence from two
Review of community-based research: Assessing partnership nationally representative longitudinal studies. Journal of
approaches to improve public health. Annual Review of Personality and Social Psychology, 92, 717–730.
Public Health, 19, 173–202. McGowan, J., & Porter, T. (1967). An introduction to the voca-
Jansen, M. A., & Fulcher, R. (1982). Rehabilitation psycholo- tional rehabilitation process: A training manual. Washington,
gists: Characteristics and scope of practice [Comment]. DC: U. S. Department of Health, Education, and Welfare,
American Psychologist, 37, 1282–1283. Vocational Rehabilitation Administration.
Jenkins, W. H., Patterson, J. B., & Szymanski, E. M. (1997). Mechanic, D. (1998). Public trust and initiatives for new health
Philosophical, historical, and legislative aspects of the care partnerships. The Milbank Quarterly, 76, 281–302.
rehabilitation counseling profession. In R. M. Parker, & Meyerson, L. (Ed.). (1948). The social psychology of physical
E. M. Szymanski (Eds.), Rehabilitation counseling: Basics and disability [Special Issue]. Journal of Social Issues. 4(4).
beyond (pp. 1–31). Austin, TX: Pro-Ed. Miller, N. E., & Brucker, B. S. (1979). A learned visceral response
Johnson, W. G. (2008). There is a difference between differences apparently independent of skeletal ones in patients paralyzed
and disparities. Disability and Health Journal, 1, 181–183. by spinal lesions. In N. Birbaumer, & H. D. Kimmel (Eds.),
Johnston, M. V. (2003). Desiderata for clinical trials in medical Biofeedback and self-regulation (pp. 287–304). Hillside, NJ:
rehabilitation. American Journal of Physical Medicine & Erlbaum.
Rehabilitation, 82(10 Suppl.), S3–S7. Mueser, K. T., Clark, R. E., Haines, M., Drake, R. E.,
Katz, I., Farber, J., Glass, D. C., Lucido, D., & Emswiller, T. McHugo, G. J., Bond, G. R., et al. (2004). The Hartford
(1978). When courtesy offends: Effects of positive and nega- Study of supported employment for persons with severe
tive behavior by the physically disabled on altruism and mental illness. Journal of Consulting and Clinical Psychology,
anger in normals. Journal of Personality, 46, 506–518. 72, 479–490.
King, C., & Kennedy, P. (1999). Coping effectiveness training National Institutes of Health Consensus Development Panel
for people with spinal cord injury: Preliminary results of on Rehabilitation of Persons With Traumatic Brain Injury.
a controlled trial. British Journal of Clinical Psychology, 38, (1999). Rehabilitation of persons with traumatic brain
5–14. injury. JAMA, 282, 974–983.
Kleck, R. E. (1968). Physical stigma and nonverbal cues emitted Neff, W. (1971). Rehabilitation psychology. Washington, DC:
in face to face interactions. Human Relations, 21, 19–28. American Psychological Association.

700 rehabilitatio n p s ych o lo gy

Nosek, M. A., Howland, C. A., Rintala, D. H., Young, M. E., & Rivera, P., Elliott, T., Berry, I., & Grant, J. (2008). Problem-
Chanpong, G. F. (2001). National study of women with solving training for family caregivers of persons with trau-
physical disabilities: Final report. Sexuality and Disability, matic brain injuries: A randomized controlled trial. Archives
19(1), 5–39. of Physical Medicine and Rehabilitation, 89, 931–941.
Oberman, C. E. (1965). A history of vocational rehabilitation in Rubin, S. E., & Roessler, R. T. (2001). Foundations of the
America. Minneapolis: T. S. Denison. vocational rehabilitation process (5th ed.). Austin, TX:
Oeffinger, K. C., Eshelman, D., Tomlinson, G., & Buchanan, G. R. Pro-Ed.
(1998). Programs for adult survivors of childhood cancer. Rusalem, H. (1976). A personalized recent history of vocational
Journal of Clinical Oncology, 16, 2864–2867. rehabilitation in America. In H. Rusalem, & D. Malikin
Olkin, R. (1999). What psychotherapists should know about (Eds.), Contemporary vocational rehabilitation (pp. 29–45).
disability. New York: Guilford Press. New York: New York University Press.
Olkin, R. (2002). Could you hold the door for me? Including Ryan, J. J., & Tree, H. A. (2004). Essential readings in rehabilita-
disability in diversity. Cultural Diversity and Ethnic Minority tion psychology. Teaching of Psychology, 31, 138–140.
Psychology, 8, 130–137. Scherer, M. J., Blair, K. L., Banks, M. E., Brucker, B.,
Olkin, R., & Pledger, C. (2003). Can disability studies and Corrigan, J., & Wegener, S. H. (2004). Rehabilitation psy-
psychology join hands? American Psychologist, 58, 296–304. chology. In W. E. Craighead, & C. B. Nemeroff (Eds.), The
Olshanksy, S., & Hart, W. R. (1967). Psychologists in voca- concise Corsini encyclopedia of psychology and behavioral science
tional rehabilitation or vocational rehabilitation counselors? (3rd ed., pp. 801–802). Hoboken, NJ: Wiley.
Journal of Rehabilitation, 33(2), 28–29. Scherer, M. J., Blair, K. L., Bost, R., Hanson, S., Hough, S.,
Padrone, F. J. (1999). Treating family members. In K. G. Langer, Kurylo, M., et al. (in press). Rehabilitation psychology.
L. Laatsch, & L. Lewis (Eds.), Psychotherapeutic interventions In I. B. Weiner, & W. E. Craighead (Eds.), The concise Corsini
for adults with brain injury or stroke: A clinician’s treatment encyclopedia of psychology and behavioral science (4th ed.).
resource (pp. 191–209). Madison, CT: Psychosocial Press. Hoboken, NJ: Wiley. Forthcoming.
Partnerships for Solutions. (2004). Chronic conditions: Making Schultheis, M. R., & Rizzo, A. A. (2001). The application of
the case for ongoing care. Baltimore: Johns Hopkins University virtual reality technology in rehabilitation. Rehabilitation
Press. Psychology, 46, 296–311.
Patterson, D. R. (2005). Behavioral methods for chronic pain Schover, L. R., & Jensen, S. B. (1988). Sexuality and chronic
and illness: A reconsideration and appreciation. Rehabilitation illness: A comprehensive approach. New York: Guilford.
Psychology, 50, 312–315. Shontz, F., & Wright, B. A. (1980). The distinctiveness of reha-
Patterson, D. R., Everett, J. J., Burns, G. L., & Marvin, J. A. bilitation psychology. Professional Psychology, 11, 919–924.
(1992). Hypnosis for the treatment of burn pain. Journal of Siller, J. (1969). Psychological situation of the disabled with
Consulting and Clinical Psychology, 60, 713–717. spinal cord injuries. Rehabilitation Literature, 30, 290–296.
Patterson, D. R., & Hanson, S. (1995). Joint Division 22 and Siller, J. (1988). Intrapsychic aspects of attitudes toward persons
ACRM guidelines for post-doctoral training in rehabilitation with disabilities. In H. E. Yuker (Ed.), Attitudes toward
psychology. Rehabilitation Psychology, 40, 299–310. persons with disabilities (pp. 58–67). Springer: New York.
Peterson, D. B., & Aguiar, L. (2004). History & systems: United Siller, J., Chipman, A., Ferguson, L. T., & Vann, D. H. (1967).
States. In T. F. Riggar, & D. R. Maki (Eds.), The handbook of Attitudes of the nondisabled toward the physically disabled.
rehabilitation counseling (pp. 50–75). New York: Springer. New York: New York University School of Education.
Peterson, D. B., & Elliott, T. (2008). Advances in conceptualiz- Spear, J., & Schoepke, J. (1981). Psychologists and rehabilita-
ing and studying disability. In R. Lent, & S. Brown (Eds.), tion: Mandates and current training practices. Professional
Handbook of counseling psychology (4th ed., pp. 212–230). Psychology, 12, 606–612.
New York: Sage. Stern, J. M. (2004). Traumatic brain injury: An effect and cause
Pickren, W. E. (2005). Science, practice, and policy: An introduc- of domestic violence and child abuse. Current Neurology and
tion to the history of psychology and the National Institute of Neuroscience Reports, 4, 179–181.
Mental Health. In W. E. Pickren, & S. F. Schneider (Eds.), Stiers, W., & Stucky, K. (2008). A survey of training in rehabili-
Psychology and the National Institute of Mental Health: A his- tation psychology practice in the United States and Canada:
torical analysis of science, practice, and policy (pp. 3–15). 2007. Rehabilitation Psychology, 53, 536–543.
Washington, DC: APA Books. Stoll, J. L. (2004). Behavior therapy. In F. Chan, N. L. Berven, &
Pledger, C. (2003). Discourse on disability and rehabilitation K. R. Thomas (Eds.), Counseling theories and techniques for
issues: Opportunities for psychology. American Psychologist, rehabilitation health professionals (pp. 136–176). New York:
58, 279–284. Springer.
Rath, J. F., Simon, D., Langenbahn, D., Sherr, R., & Diller, L. Strasser, D. C., Uomoto, J. M., & Smits, S. J. (2008). The inter-
(2003). Group treatment of problem-solving deficits in out- disciplinary team and polytrauma rehabilitation: Prescription
patients with traumatic brain injury: A randomized outcome for partnership. Archives of Physical Medicine and Reha-
study. Neuropsychological Rehabilitation, 13, 461–488. bilitation, 89, 179–181.
Reed, G. M., Olkin, R., Spaulding, W. D., Elliott, T. R., Olivera Talley, R. C., & Crews, J. E. (2007). Framing the public
Roulet, G., Di Nanno, A. E., et al. (in press). Psychological health of caregiving. American Journal of Public Health, 97,
and counselling services. In World report on disability and 224–228.
rehabilitation. Geneva: World Health Organization. Tanielian, T. (2009). Assessing combat exposure and post-traumatic
Resch, J. A., Villareal, V., Johnson, C., Elliott, T., Kwok, O., stress disorder in troops and estimating the costs to society:
Berry, J., & Underhill, A. (2009). Trajectories of life satisfac- Implications from the RAND invisible wounds of war study.
tion in the first five years following traumatic brain injury. Santa Monica, CA: Rand Corporation. Retrieved from http://
Rehabilitation Psychology, 54, 51–59. www.rand.org/pubs/testimonies/2009/RAND_CT321.pdf.

e lliot t, r at h 701
Taub, E., & Uswatte, G. (2000). Constraint-induced movement Wilson, B. A. (1997). Cognitive rehabilitation: How it is and
therapy based on behavioral neuroscience. In R. G. Frank, & how it might be. Journal of the International Neuropsychological
T. R. Elliott (Eds.), Handbook of rehabilitation psychology Society, 3, 487–496.
(pp. 475–496). Washington, DC: American Psychological Wilson, B. A. (2008). Neuropsychological rehabilitation. Annual
Association. Review of Clinical Psychology, 4, 141–162.
Thomas, J. P. (1995). The model spinal cord injury concept: World Health Organization. (2001). ICF: International classifica-
Development and implementation. In S. L. Stover, J. DeLisa, tion of functioning, disability and health. Geneva, Switzerland:
& G. Whiteneck (Eds.), Spinal cord injury: Clinical outcomes Author.
from the model systems (pp. 1–9). Gaithersburg, MD: Aspen World Health Organization. (2002). Innovative care for chronic
Publishers. conditions: Building blocks for action. Geneva, Switzerland:
Thomas, K. R., & Associates. (1991). Rehabilitation counseling: Author.
A profession in transition. Athens, GA: Elliott & Fitzpatrick. Wright, B. A. (1959). Psychology and rehabilitation. Washington,
Thomas, K., & Parker, R. (1981). Promoting counseling in DC: American Psychological Association.
rehabilitation settings. Journal of Applied Rehabilitation Wright, B. A. (1960). Physical disability: A psychological approach.
Counseling, 12(2), 101–103. New York: Harper & Row.
Thomas, K., & Parker, R. (1984). Counseling interventions. Wright, B. A. (1972). Value-laden beliefs and principles for reha-
Journal of Applied Rehabilitation Counseling, 15(3), 15–19. bilitation psychology. Rehabilitation Psychology, 19, 38–45.
Thomas, K. R., & Siller, J. (1999). Object loss, mourning, Wright, B. A. (1980). Developing constructive views of life with
and adjustment to disability. Psychoanalytic Psychology, 16, a disability. Rehabilitation Literature, 41, 274–279.
179–197. Wright, B. A. (1983). Physical disability: A psychosocial approach
Tucker, J. A., & Reed, G. (2008). Evidentiary pluralism as a (2nd ed.). New York: Harper & Row.
strategy for research and evidence-based practice in rehabili- Wright, B. A. (1991). Labeling: The need for greater
tation psychology. Rehabilitation Psychology, 53, 279–293. person–environment individuation. In C. R. Snyder, &
Turnbull, H. R., & Stowe, M. J. (2001). A taxonomy for D. R. Forsyth (Eds.), Handbook of social and clinical
organizing the core concepts according to their underlying psychology (pp. 469–487). New York: Pergamon Press.
principles. Journal of Disability Policy Studies, 12, 177–197. Wright, B. A., & Lopez, S. J. (2002). Widening the diagnostic
U. S. Department of Health and Human Services. (2000). focus: A case for including human strengths and environ-
Healthy people 2010. Washington, DC: Author. mental resources. In C. R. Snyder, & S. J. Lopez (Eds.),
Vash, C. L. (1981). The psychology of disability. New York: Handbook of positive psychology (pp. 26–44). New York:
Springer. Oxford University Press.
Wegener, S. T., Mackenzie, E. J., Ephraim, P., Ehde, D., & Wright, G. N. (1980). Total rehabilitation. Boston: Little, Brown,
Williams, R. (2009). Self-management improves outcomes & Co.
in persons with limb loss. Archives of Physical Medicine and Yuker, H. E. (Ed.). (1988). Attitudes toward persons with
Rehabilitation, 90, 373–380. disabilities. New York: Springer.
Wehman, P. (1988). Supported employment: Toward zero exclu- Yuker, H. E., & Block, J. (1986). Research with the attitudes
sion of persons with severe disabilities. In P. Wehman, & toward disabled persons scales. Hempstead, NY: Hofstra
M. S. Moon (Eds.), Vocational rehabilitation and supported University.
employment (pp. 3–16). Baltimore: Brookes Publishing. Yuker, H. E., Block, J., & Younng, J. (1966). The measurement
Wehman, P., Sale, P., & Parent, W. (1992). Supported employ- of attitudes toward disabled persons. Albertson, NY: Human
ment: Strategies for integration of workers with disabilities. Resources Center.
Boston: Andover Medical Publishers.

702 rehabilitatio n p s ych o lo gy

 CHAPTER
School-based Prevention of Peer
27 Relationship Problems

Dorothy L. Espelage and V. Paul Poteat

Abstract
Research on bullying, social/relational aggression, and prejudice are reviewed with some guidance for
ways in which schools can begin to prevent these phenomena and how counseling psychology can
enter the very important conversation that will lead to making our schools safer. Bullying is verbal,
physical, or social in nature, and is seen as repeated acts of aggression that differs from normal peer
conflict. Relational aggression includes behaviors that damage relationships and feelings of acceptance,
friendship, or group inclusion, and that seeks to exclude a person from making or maintaining one or
more relationships. Prejudiced attitudes toward student’s racial/ethnic affiliation or sexual orientation
are often used as a basis to exclude, harass, and humiliate. Recommendations are provided for
school-based efforts to prevent these disruptive attitudes and behaviors.
Keywords: Bullying, social aggression, relational aggression, homophobia, racial prejudicial,
school-based prevention

Children and adolescents face many psychosocial during the earlier developmental periods of child-
challenges, but perhaps at the forefront are the basic hood and adolescence (Aboud, 2005; Fishbein,
needs to develop a positive identity and to estab- 1996). Emerging findings have begun to note the
lish rewarding social relations with peers (Rubin, interconnections between these two prominent
Bukowski, Parker, & Bowker, 2008). Interactions issues of bullying and prejudice, including their
among peers are focused on the goal of develop- combined impact on mental health, their similar
ing mutual friendships, which sometimes involves associations with dominance and establishments
establishing dominance through competitiveness of social hierarchies, and the influence that peers
and sometimes exclusion and teasing. As children have on the socialization of attitudes and behav-
enter adolescence, being accepted and “fitting in” iors related to bullying and prejudice (D’Augelli,
are central goals that contribute to the establish- Pilkington, & Hershberger, 2002; Espelage et al.,
ment of social hierarchies (Rodkin, 2004). As such, 2003; Pellegrini & Long, 2002; Poteat, 2007;
children with less social power may develop feelings Poteat, Espelage, & Green, 2007; Snyder et al.,
of anger and/or contempt toward peers, and these 2003).
emotions can exacerbate rejection, bullying, and Counseling psychologists are well-positioned
social aggression (Crick, Bigbee, & Howes, 1996; to be strong assets to schools looking to develop
Espelage, Holt, & Henkel, 2003). In addition, the prevention programs to address peer- and school-
development of stereotypes, prejudiced attitudes, related adjustment issues. Although much work
and engagement in discriminatory behavior also needs to be conducted to increase the presence of
represent critical social issues that must be addressed counseling psychology in school-based prevention


and intervention work, there has been a growing bullying, cyberviolence, digital bullying, and the
trend for faculty and graduate students within coun- like. A recent definition of cyber-bullying posited by
seling psychology programs across the United States Ybarra and Mitchell (2004) is “intentional and overt
to focus their research and practice on child/adoles- act of aggression toward another person online.”
cent developmental issues. These scholars, who have
expertise in theories of human development and prevalence
employ a lens toward prevention, play a critical role Bullying may be the most prevalent type of school
in educating teachers, administrators, and parents violence (Batsche & Porter, 2006). Worldwide inci-
about the importance of intervening early and dence rates for bullying among school-aged youth
often. Counseling psychologists also understand the range from 10% of secondary students to 27% of
importance of designing prevention programs that middle school students who report being bullied
consider multiple contexts and are sensitive to indi- often (Whitney & Smith, 1993). Studies in the
vidual differences (e.g., gender, race, socioeconomic United States have yielded slightly higher rates of
status). Counseling psychologists can also play a bullying, ranging from a low of 10% for “extreme
direct role in improving the social and emotional cli- victims” of bullying (Perry, Kusel, & Perry, 1988) to
mate in schools by influencing school policy and the a high of 75% who reported being bullied at least
implementation of outreach programs for students. one time during their school years (Hoover, Oliver,
Furthermore, Walsh, Galassi, Murphy, and Park- & Hazler, 1992). In a nationally representative study
Taylor (2002) note the extraordinary expertise char- of American students in grades 6 through 10, Nansel
acteristic of counseling psychology—the knowledge and colleagues (2001) reported that 17% had been
base of multicultural issues—an especially critical bullied with some regularity (several times or more
area given the demographic changes in contempo- within the semester) and 19% had bullied others.
rary American schools. In this chapter, the research Bullying is not a part of normative development for
on bullying, social/relational aggression, and preju- children and adolescents and should be considered
dice will be reviewed with some guidance for ways in a precursor to more serious aggressive behaviors
which schools can begin to prevent these phenom- (Nansel et al., 2001).
ena and how counseling psychology can enter the Since Olweus’ seminal work on bullying in
very important conversation that will lead to making Norway, significant changes have emerged in how
our schools safer. children and adolescents interact with technology and
how technology is used to bully others. For example,
Bullying Pew Internet and American Life (2005) reported that
Olweus spearheaded a nationwide Scandinavian 87% of U.S. teenagers (aged 12 through 17) currently
campaign against bullying in the 1970s, and set use the Internet, and a Forrester report (2007) found
forth the following definition of bullying, which that nearly 80% of youth between these same ages use
remains current today: “A student is being bullied or MySpace (networking site) at least weekly. A more
victimized when he or she is exposed, repeatedly and recent Pew Internet and American Life (2007) study
over time, to negative actions on the part of one or reports that the preferred modality of communication
more students” (Olweus, 1993). This definition is instant messaging (IM); 75% of teens between the
highlights the aggressive component of bullying, its ages of 12 and 17 years used IM and of these teens,
associated inherent power imbalance, and its repeti- 48% report using IM at least every day. These envi-
tive nature. However, in recent years, scholars have ronments are social in nature; however, they do not
recognized the wide range of behaviors consistent involve face-to-face interactions. Thus, these social
with bullying, including both physical and relational environments are not immune to the various nega-
manifestations, cyber-bullying, and bullying in tive interactions that are encountered in schools, fam-
dating relationships. Smith and Sharp noted “a stu- ilies, and neighborhoods. Studies have found that
dent is being bullied or picked on when another stu- 10% –33% of youth between the ages of 11 and 19
dent says nasty and unpleasant things to him or her. have experienced being the target of aggression/bully-
It is also bullying when a student is hit, kicked, ing online (Finn, 2004; Patchin & Hinduja, 2006),
threatened, locked inside a room, sent nasty notes, and more than 15% of youth reported being perpe-
and when no one ever talks to him” (Sharp & Smith, trators of such behaviors (Patchin & Hinduja, 2006).
1991, p.1). Cyber-bullying has emerged as a common The influx of technology in the lives of children and
occurrence among children and adolescents. Cyber- adolescents is a relatively new field, but it is likely that
bullying has also been called: e-bullying, electronic it will have a major impact on how teens interact with

704 school-bas ed preven tio n o f pee r p roble m s

each other and may impact the development of social delinquent (Haynie, Nansel, & Eitel, 2001; Nansel
skills (see Swearer, Espelage, & Napolitano, 2009, for et al., 2001). Furthermore, long-term outcomes for
discussion). bullies can be serious; compared to their peers,
bullies are more likely to be convicted of crimes in
associations with outcomes adulthood in Norway/Sweden (Olweus, 1993).
Bullying, in its many forms, is a serious problem Bully–victims demonstrate more externalizing behav-
that can harm students’ school performance in the iors, are more hyperactive, and have a greater proba-
form of school avoidance, lower levels of academic bility of being referred for psychiatric consultation
achievement, and more conflictual relations with than do their peers (Kumpulainen, Rasanen, &
teachers and students. A recent study by Glew and Henttonen, 1998; Nansel et al., 2001, 2003).
colleagues (2005) found an association between
certain bullying experiences and low academic school-based prevention efforts
achievement. Among third-, fourth-, and fifth-grade for bullying
students, victims (adjusted odds ratio [AOR] 0.8; Although some evaluation efforts of school-based
95% confidence interval [CI] 0.7–0.9) and bully– prevention programs for bullying have offered
victims (AOR 0.8; 95% CI 0.6–1.0) were less likely promising findings, results of a recent meta-analysis
to be high achievers in school (measured by a com- of 14 whole-school antibullying programs provide a
posite score including reading, math, and listening) more modest assessment (Smith, Schneider, Smith,
as compared to bystanders, although the finding for & Ananiadou, 2004). These programs were based
bully–victims was borderline significant (Glew, Fan, on the Olweus Bullying Prevention Program (OBPP,
Katon, Rivara, & Kernic, 2005). A bully–victim is a Olweus, 1993), which has yet to demonstrate con-
child who is both a bully and a recipient of bullying sistent efficacy within U.S. schools (as measured by
behavior. A more recent study by Glew and col- being published in peer-reviewed journals). Results
leagues (2008) of seventh-, ninth-, and eleventh- indicated that there were moderate effect sizes on
graders in an urban public school district found self-reported victimization that students experienced
that for each 1-point rise in grade point average from bullies (e.g., being teased, called names, shoved
(GPA), the odds of being a victim versus a bystander or hit) and small to negligible effects on self-reported
decreased by 10% (Glew, Fan, Katon, & Rivara, bullying perpetration (e.g., teasing, name-calling,
2008). A study of 930 sixth-graders in the first year hitting or pushing others). The authors concluded
of middle school found that students who were bul- that significant caution should be observed when
lies, victims, or bully–victims showed poorer school implementing school-wide programs. However,
adjustment (e.g., doing well on schoolwork, getting very few of the studies under investigation looked
along with classmates, following rules, doing home- beyond mean level differences and examined how
work) than their uninvolved peers over three assess- effects varied across individuals and schools. Thus,
ments into the end of the seventh grade (Nansel, Guerra, Boxer, and Cook (2006) called for the pre-
Haynie, & Simons-Morton, 2003). vention field to examine potential moderators of
Bullying can also result in negative psychological, effectiveness, including baseline levels of aggression
emotional, and behavioral outcomes. Victims, bul- among students, classroom practices that promote
lies, and bully–victims often report adverse psycho- aggression, peer social status, and implementation
logical effects and poor school adjustment as a result rates.
of their involvement in bullying, which might also Indeed, educators and researchers have been
lead to subsequent victimization or perpetration charged by the 2001 No Child Left Behind Act
(Juvoven, Nishina, & Graham, 2000). Nansel et al., (NCLB) to use data to guide the selection of pro-
2003). For example, targets of bullying evidence grams and implementation methods. Although
more loneliness and depression, greater school avoid- 200 violence prevention programs are available, less
ance, more suicidal ideation, and less self-esteem than one-fourth of these are empirically validated
than their nonbullied peers (Hawker & Boulton, (Howard, Flora, & Griffin, 1999). What has been
2000; Kaltiala-Heino, Rimpelae, & Rantanen, learned to date is that zero-tolerance policies (policies
2001; Kochenderfer & Ladd, 1996; Olweus, 1992; that provide for punishment regardless of the basis of
Rigby, 2001). Whereas victims tend to report more the problem behavior) are not effective in curbing
internalizing behaviors, bullies are more likely than aggressive behaviors (Casella, 2003), and expulsion
their peers to engage in externalizing behaviors like appears to be equally ineffective (Morrison, Redding,
anger, to experience conduct problems, and to be Fisher, & Peterson, 2006). Thus, interventions that

e spe l age , p ot e at 705

have been typically employed in school settings Programs should be research-based, promote ethi-
(group treatment, zero-tolerance, and expulsion) are cal behavioral principles, and advocate prosocial
ineffective in dealing with bullying. behavior and include skills training (Beard, Colvin,
Additionally, intervention programs designed to Hagan, Sprague, & Tobin, 1998). Prosocial behav-
combat bullying have tended to allocate more ior change includes promoting forgiveness and
resources to identifying individual bullies and address- empathy, examining perceptions of the school cli-
ing their behavior than to developing universal pro- mate and social hierarchy, and promoting problem-
grams that address the entire student body. Furlong, solving and social skills (Cupach & Willer, in press).
Morrison, and Grief (2003) noted that, despite the Problem-solving skills training effectively reduces
value of taking a relational approach to bullying, aggressive behaviors (Kazdin, 1996) and results in
most formalized legislation addressing bullying and decreased reports of externalizing behaviors in
peer aggression in schools continues to emphasize schools (Rothman & Teglasi, 1999). Anger man-
taking action with bullies to the exclusion of address- agement is also important. Students reported that
ing the needs of victims or addressing the larger they believe they react to provocative instances less
school climate. A relational approach dictates that aggressively following anger management training
responses to bullies need to rely less on the traditional (Dwivedi & Gupta, 2003). Programs should also be
punitive approach and more on targeting the pat- longitudinal and developmentally based, thus tar-
terns of behavior of both bullies and their victims, geting behaviors common to each group. Finally, as
with attention to the noninvolved bystanders of the schools are determining which programs to adopt,
schools, as well as the classroom/school climate peer mediation strategies are counterproductive to
(Furlong et al., 2003; Orpinas & Horne, 2006). their objective (Cavell & Hughes, 1999).
As we become increasingly knowledgeable about A third suggestion relates to how to address
how bullying overlaps with other problem behaviors, a specific bullying incident. When a specific bully-
intervention strategies should consequently shift to a ing incident arises, it is essential to be mindful of
more comprehensive approach. Research has dem- the appropriate intervention techniques to utilize.
onstrated that problem behaviors tend to be interre- Antibullying programs typically encourage inter-
lated and share common risk factors (Donovan, ventions in a group model, but this method is not
Jessor, & Costa, 1991; Jessor, 1991), suggesting the always successful (Dishion, McCord, & Poulin,
need for prevention programs that implement a 1999). Therefore, staff and counselors involved with
coordinated set of interventions to target and reduce the intervention must determine the need for a
overlapping risk factors, rather than programs that group- or individual-based intervention, depending
focus on specific problems or separate disorders on the specificity of the given situation. Typically, it
(Kenny, Waldo, Warter, & Barton, 2002). is most effective for the counselor to assess sepa-
Rather than a discussion of specific bullying rately each individual involved in a particular inci-
prevention or intervention programs, we provide dent and subsequently evaluate the severity of the
general suggestions for program planning. Consis- issue at hand; thereafter a decision may be better
tently, the effectiveness of a prevention/intervention made regarding the potential effectiveness, and
program within a school environment relies on safety, of a group intervention. Whatever the pre-
tailoring prevention to school needs. Therefore, the ferred form of intervention, constant communica-
first suggestion is for school personnel to systemati- tion among staff members and counselors is crucial
cally assess the nature and frequency of the bullying (Cupach & Willer, in press).
and other forms of aggression that exists within Regardless of the program adopted, some addi-
their school. These data can be used to tailor the tional suggestions will increase the efficacy of the
intervention efforts to address the unique aspects of prevention program (Cupach & Willer, in press):
the school. For example, one school might deter-
mine through an anonymous survey that students • Create an open-door policy for all students to
are engaging in bullying through text messaging. report instances of bullying and aggression
This school then might select a prevention program (emphasize confidentiality).
that addresses both within-school and online bully- • Develop a uniform code of conduct for
ing experiences. responding to incidents (this should address the
Many schools have to select from a number of need to intervene immediately).
marketed programs. Thus, a second suggestion is for • Create an open-door policy for teachers and
schools to be smart consumers of these products. staff to report instances.

706 school-bas ed preven tio n o f pee r p roble m s

 • Train teachers and school counselors to otherwise stated for the remainder of this chapter.
address both incidents of victimization and the Children’s and adolescents’ preference for nonphysi-
possible internalizing effects (i.e., depression, cal aggression may surface when the costs of more
anxiety). direct targeting are high (e.g., punishment; Archer
• Counselor interventions should include an & Coyne, 2005). Both relationally and socially
assessment for anxiety and depression in both aggressive behavior tends to be subtle and insidious,
perpetrator and target. Counseling should be often making the identification of the perpetrators
individualized for each group involved in the difficult for observers.
aggression, including perpetrator, target, bystander, In sum, social or relational forms of aggression
and supportive bystander. can include rejection (e.g., relational termination,
• Include bullying topics in educational social ostracism), humiliation (e.g., pranks, actively
curricula whenever applicable. undermining target), betrayal (e.g., revealing a peer’s
secret/revoking confidence, spreading false rumors),
Relational Aggression personal attack (e.g., insults, spiteful teasing, gossip),
Three subcategories of nonphysical aggressive behav- relational manipulation (e.g., flirting with target’s
ior have been noted in the literature: relational, boyfriend/girlfriend/romantic interest, disparaging
indirect, and social. The term “relational aggression” target to this individual), relational depreciation
was initially used to describe the bullying behaviors (e.g., declining closeness or commitment), and cyber-
of female adolescents that primarily focused on bullying (i.e., any of the aforementioned behaviors
damaging a peer’s social connections within a given exerted via communication technologies).
peer group (Crick & Grotpeter, 1995). Relational
aggression includes acts that “harm others through prevalence
damage (or the threat of damage) to relationships or In one of the earliest studies of relational aggression,
feelings of acceptance, friendship, or group inclu- Crick and Grotpeter (1995) found that 2% of boys
sion” and seeks to exclude a person from making or and 17% of girls in grades 3 through 6 (n = 491)
maintaining one or more relationships (Bjoerkqvist, reported rates of relational aggression perpetration
Kaukiainen, & Lagerspetz, 1992). Relationally over 1 standard deviation above the mean. Among
aggressive behavior is defined by the use of a rela- some 4,496 third-graders in Maine, 34% of the stu-
tionship as a weapon or collateral. The threat of the dents reported being left out on purpose at least once
destruction of the relationship by the perpetrator is a month (Silvernail, Thompson, Yang, & Kopp,
inherent to the action taken against the target. 2000). Along with knowledge of the possible adverse
Relational aggression includes behaviors such as effects on young people due to aggressive behaviors,
friendship manipulation, social exclusion, negative it is crucial for educators to remain aware of certain
gossip or backstabbing, using negative body lan- indicators, or “red flags,” that are apparent in the
guage, and ignoring someone for vengeful reasons classroom and that may be a sign of relational and
(Crick et al., 1996). social aggression. A partial list of such indicators
Socially aggressive behaviors intend to damage includes: negative body language or physical gestures
the social status of an individual within a peer group, toward an individual (e.g., pointing, whispering,
or possibly within a greater environmental context laughing, eye-rolling, increase in glancing); covert,
(e.g., school, summer camp, etc.). Social aggression exclusive communication (e.g., note passing, texting,
consists primarily of indirect forms of victimization, etc.); noticeable change in social groups (e.g., partner
such as rumor spreading and social exclusion (Crick, changing, group shifting, seating changes); notice-
1996). The act of excluding an individual from able change in potential target’s mood, demeanor,
normal peer activities and social relations is the key expression, physicality; and decrease in class partici-
component to social aggression. It is distinct from pation or GPA.
both relational and indirect aggressive behaviors in From the initial onset of research investigating
that the relationship harm can result from both nonphysical forms of aggression, those who spear-
direct and indirect actions (Archer & Coyne, 2005) headed the studies focused solely on females’ ten-
and may include nonverbal forms of exclusion dency toward the behavior. The results of these
(Galen & Underwood, 1997). However, as a result beginning studies showed that girls were more rela-
of the overlap of behavioral characteristics, relational tionally victimized, whereas boys were more overtly,
aggression and social aggression are in many aspects and often physically, victimized (Crick & Bigbee,
synonymous, and therefore will be combined unless 1998). When investigating the aggressive behavioral

e spe l age , p ot e at 707

patterns of middle school students in Canada, the behavior and joint exhibitions of this nonphysical
results indicated that males reported more acts of aggression may in fact strengthen the relationship
physical aggression than did other comparison between the two girls: “When two friends collabo-
groups (Craig, 1998). When asked what actions are rate in the use of relational aggression against another
instigated when there is intent to harm another, person . . . [it] might actually promote cohesiveness,
boys reported fewer accounts of typical relationally or otherwise strengthen the ties between the two
aggressive behaviors (Crick et al., 1996). friends” (Crick & Werner, 2004, p. 499). Indeed,
Other research results have shown that both boys girls’ friendship cohesion tends to be more strongly
and girls report equal frequencies of social aggression related to exclusive remarks and exclusive gestures
(Espelage, Mebane, Swearer, & Turner, 2004). In a than are boys’ friendship cohesions. Also, the exclu-
recent study of the aggression trajectories of adoles- sivity of a peer relationship may be positively related
cents living in rural areas, it was found that boys per- to the pairing’s involvement in relationally aggres-
petrated more physical aggression than did girls, but sive behaviors (Sebanc, 2003). This was especially
there was no difference in the perpetration of social true of girls’ friendships. As young females strive to
aggression between boys and girls (Ennett, Foshee, gain and maintain intimacy within their relation-
Karriker-Jaffe, & Suchindran, 2008). However, girls ships, they tend to favor the social exclusion of
tend to think about the instances of social aggression others to uphold this intimacy. To girls, the more
more frequently and were more distressed by them. exclusive the relationship, the more unattainable for
Also, the instances of social aggression were more others, and thus the more prized. In a study of 406
strongly related to girls’ self-concepts than to those 7-year-old twins, a genetic–environment interaction
of boys’ (Paquette & Underwood, 1999). Therefore, was found for predicting social aggression; genetics
it appears that the effect of social and relational vic- plus friends’ social aggressiveness had direct effects
timization is stronger for young females than for on children’s tendency toward social aggression
males, which might be related to the greater impor- (Brendgen et al., 2008). These findings highlight the
tance that girls place on their friendships in com- need to carefully observe children’s and adolescents’
parison to boys (Underwood, 2003). peer involvements, as the relationships may indi-
Adolescents of both genders utilize sexualized cate an affinity for certain negative social behaviors;
peer abuse as a form of nonphysical aggression, spe- therefore, teachers, administrators, and school per-
cifically social aggression. Gossip and rumors can sonnel may be better able to prevent relational and
often target an individual’s physical development, social aggression in their classrooms.
involvement in sexual relations, and general sexual
experience and maturity (Levy, 2005). Adolescents associations with outcomes
have shown tendencies to utilize rumors of sexual Knowledge and understanding of the possible effects
activity, both heterosexual and homosexual in and risks associated with relational and social aggres-
nature, as a way to ostracize and reject a classmate sion are critical for two reasons. First, calling atten-
from his or her previous social standing within the tion to relational and social aggression highlights the
school (Levy, 2005). urgency and severity of a behavior that has com-
When working with children and adolescents in monly been viewed as innocuous, or even “phase”-
a classroom setting, it is imperative to not only like. Second, possessing awareness of the possible
observe and recognize victimizing behaviors but to correlating symptoms of such victimization or per-
possess the tools necessary to predict the behaviors petration can better assist school personnel in iden-
before they come to fruition. With this in mind, tifying students involved in each. Children and
recent research has focused on the influence peer adolescents who engage in relational and/or social
and friendship groups have on a young person’s like- aggression either as perpetrators or victims are at risk
lihood to exhibit relational and social aggression. for developing social, behavioral, emotional, and
Although there are numerous studies document- academic problems, including peer rejection, depres-
ing the socialization of bullying among friendship sion, loneliness, and anxiety (Underwood, Galen, &
groups (Espelage et al., 2003 for an example), only a Paquette, 2001). These youth may also be at risk for
handful of studies examining this possible behav- eating disorders, borderline personality as adults,
ioral predictor exist for relational aggression. For substance abuse, school refusal, poor self-esteem,
girls, having a friend who exhibited high levels of gang involvement, social isolation (Crick, Casas, &
relationally aggressive behavior predicted substantial Nelson, 2002), and social withdrawal (Hodges &
increases in the target girls’ relationally aggressive Perry, 1999). Peer victimization in kindergarten is

708 school-bas ed preven tio n o f pee r p roble m s

connected to later loneliness and school avoidance Much of the research conducted on the sustain-
(Kochenderfer & Ladd, 1996), whereas experiences ability and effectiveness of general bullying preven-
of rejection and isolation predicted instances of tion programs has not specifically addressed relational
social anxiety and depression (Abwender, Beery, aggression (Espelage & Swearer, 2003). Therefore, a
Ewell, & Vernberg, 1992). Specifically in adolescent need exists to develop more effective programming
females, experiences of victimization can lead to within schools that targets more covertly aggressive
self-injury (Levenkron, 1998) and potential involve- behaviors among students (Barton, Taiariol, & Yoon,
ment in dating violence (Downey & Purdie, 2000). 2004). Existing programs may be modified to spe-
It has been surmised that the victimization that may cifically target socially and relationally aggressive
condition a young woman to remain passive in a behaviors. However, the research that has been done
relationally aggressive situation may influence her to on relational and social aggression programs conveys
become submissive in future, more physically and/ the need for schools to develop systematic approaches
or sexually threatening relationships. to better prevent these behaviors.
Relational aggression is related to both social The first systematic study of a theory-based social
skills deficits and increased child psychopathology aggression prevention program (SAPP) for preado-
(see Crick & Zahn-Waxler, 2003). Moreover, recent lescent girls in public schools found that the effort
research also demonstrates that relational aggres- had a positive impact on students’ social problem-
sion is associated with negative school outcomes. solving ability (Cappella & Weinstein, 2006).
Relational aggression is associated with lack of Teachers reported that the implementation of this
school engagement, poor academic achievement, small-group curriculum increased the participants’
teacher–student conflict, and health-risk behaviors prosocial behaviors. Researchers indicated that a
that are indirectly related to school performance concentrated focus on social conflict resolution
(i.e., substance use) (Murray-Close, Ostrov, & skills, from various perspectives (including target,
Crick, 2007; Sullivan, Farrell, & Kliewer, 2006; perpetrator, bystander), may significantly contrib-
Woods & Wolke, 2004). Additionally, exposure to ute to the success and productivity of such a pro-
relational aggression at school negatively impacts gram. It has also been noted that, when working
the social, emotional, and psychological climate of with female adolescents, specifically, a focus on
schools, resulting in students’ perceiving school as peer intervention and social assertiveness may help
unsafe (Boxer, Edwards-Leeper, Goldstein, Musher- reduce relationally aggressive behaviors (Underwood,
Eizenman, & Dubow, 2003; Glew et al., 2008; 2003). Data have also shown that in addition to
Goldstein, Young, & Boyd, 2008) and leading to addressing conflict resolution, programs should
declines in classroom participation and increases in address students’ aggressiveness within a social-
school avoidance over time (Buhs, Ladd, & Herald, cognitive information-processing framework (Boxer
2006). & Dubow, 2001).
M. Underwood, a leading scholar of social aggres-
school-based prevention efforts sion, offers a developmental approach to the preven-
for social aggression tion of social aggression (Underwood, 2003). When
The nature of relational and social aggression among working with preschool-aged children, Underwood
children and adolescents is usually covert; thus, stresses the importance of explicitly acknowledging
these behaviors can often remain all but invisible to the negative and unacceptable nature of social
teachers and school administrators (Underwood, aggression, as children in this age bracket frequently
2003). Therefore, it is essential not only to assess report that socially aggressive behavior is often
and identify potentially aggressive situations as they acceptable. This theory posits that the more children
arise, but to also implement appropriate preventa- recognize the apparent wrongfulness of a certain
tive techniques within the school. Although there is behavior, the more likely they are to report it. With
a widespread acknowledgment of the short- and school-aged children, it is important to assist indi-
long-term consequences of bullying, the tendency viduals to recognize their own paranoid and self-
of schools to address incidences as they arise allows negative thinking in social situations, as young
more indirect aggression to go gravely unnoticed. people often have the tendency to interpret benign
Children and adolescents have also reported that, in instances as direct attacks. The most critical aspect of
many cases, schools’ and adults’ attempts at inter- social aggression prevention is the promotion of
vention may increase cases of social aggression rather positive assertiveness within peer relations. Children
than reduce them (Underwood, 2003). and adolescents should learn to express their needs

e spe l age , p ot e at 709

and emotions in positive ways and to accept that on students, while concomitantly noting the absence
relational conflict is natural (Underwood, 2003). of established programs and policies within the
Encouraging bystander and peer intervention may schools that are specific to this social concern and the
also help diminish the frequency and effects of lack of resources that have been made available to
victimization. racial and sexual minority students (Kosciw, Diaz, &
Greytak, 2008; Muller, 2000).
Addressing Prejudice Through An interdisciplinary approach is especially needed
School Programming as counseling psychologists become more involved
Childhood and adolescence have been considered in providing school-based prevention and interven-
critical and formative periods for the develop- tion services to address prejudice. This can include
ment and expression of stereotypes, prejudiced collaborating with scholars in related subdisciplines
attitudes, and discriminatory behavior (Aboud, 2005; of psychology (e.g., developmental, school, social,
Fishbein, 1996). However, relative to the research or community psychology), as well as with scholars
conducted among adult populations, fewer studies in other fields (e.g., social work or education). The
and interventions have focused on prejudice among growing attention to multicultural counseling com-
younger age groups. Increasingly, scholars have petencies within the field of counseling psychology
discussed the need for prejudice prevention and and its attention to best practices and guidelines for
intervention programming during these earlier working with diverse clients (American Psychological
developmental periods (Bigler & Liben, 2006; Association, 2003) could significantly contribute to
Salzman & D’Andrea, 2001). Bigler and Liben and inform the research and programming that has
(2006) argued that, although changing the stereo- been conducted within related disciplines. Similarly,
types and prejudiced attitudes of children may be it is important for counseling psychologists to be
difficult, the level of difficulty in achieving this task aware of the current prevention and intervention
can be even greater among adults. This underscores programs that have been developed. In this section,
the need for a greater focus on both prevention and we focus on two forms of diversity, sexual orienta-
toward early development. Although programming tion and race, to highlight the current state of
can and should be provided across the multiple school-based intervention research and practice as it
social settings in which children and adolescents relates to prejudice.
interact, the school setting represents a particularly
important and central social context considering the Prejudiced Attitudes and Behavior
proportion of time most individuals spend in this in Schools
environment, the degree of interaction among indi- For counseling psychologists to provide effective
viduals, and the growing student diversity within school-based interventions to address prejudice, it is
school systems. important to have some knowledge of the extent to
Specific to the school system, the expression of which individuals hold prejudiced attitudes during
prejudice and the marginalization of racial and sexual earlier developmental periods, the general preva-
minorities (i.e., lesbian, gay, bisexual, and transgen- lence of prejudiced behavior among students, and
der youth; LGBT) remains a prominent concern the reasons why students engage in this behavior.
among administrators, students, practitioners, and In this section, we provide an overview of the extant
policy makers. For example, legal cases involving research on each of these issues.
homophobic victimization of sexual minority youth
while at school have ruled school administrators as prejudice during early development
partially responsible for such occurrences (see Few studies have been conducted to examine the
American Civil Liberties Union, 2005, for a review development of and changes in prejudice among
of recent lawsuits). A number of students have labeled children and adolescents. Those studies examining
homophobic bullying as a form of sexual harassment homophobic attitudes have presented inconsistent
(Fineran, 2002). Of the range of verbal content used findings with regard to age and grade differences.
as part of many bullying episodes, students have Among white adolescents, Hoover and Fishbein
indicated homophobic language to be among the (1999) noted a trend in which students in grades 7
most disturbing to them (American Association of and 11 reported lower levels of homophobic attitudes
University Women, 2001; Thurlow, 2001). Policy than did students in grade 9. This suggested that an
makers and practitioners also have commented on increase, followed by a decrease, in homophobic atti-
the prevalence of prejudiced behavior and its effects tudes occurred during adolescence. However, only the

710 school-bas ed preven tio n o f pee r p roble m s

difference between ninth- and eleventh-grade stu- including physical and verbal harassment, isolation
dents was identified to be significant. A continued and stigmatization, and physical assault (Kosciw
decreasing pattern also was noted between students in et al., 2008; Pilkington & D’Augilli, 1995; Rivers,
grade 11 and college students, although this differ- 2001). Despite attempts to address homophobia
ence also was not significant. In an earlier study test- within the school system, rates of discrimination
ing for gender differences, Baker and Fishbein (1998) while at school have changed little over the past
noted a nonsignificant trend among boys, in which decade (Kosciw et al., 2008; Pilkington & D’Augelli,
boys in grade 11 reported more homophobic atti- 1995). For example, in a recent national survey of
tudes than did boys in grade 9. In contrast, girls in LGBT youth, approximately 85% reported experi-
grade 11 reported lower homophobic attitudes than encing some form of bullying or harassment while
did girls in grade 9. More recently, Horn (2006) noted at school (Kosciw et al., 2008). The most frequent
similar cohort differences among adolescents and specific forms of victimization experienced by
young adults. Specifically, students in grade 10 reported LGBT youth have included name-calling, assault,
more homophobic attitudes than did students in grade rumor spreading, and teasing (82%, 60%, 59%,
12 or college students. This added support to the non- and 58%, respectively; Rivers, 2001). Most often,
significant decreasing trend in homophobic attitudes LGBT students report being bullied by groups of
noted by Hoover and Fishbein (1999). students, as opposed to single individuals (Rivers,
Specific to racial and ethnic prejudice, Black- 2001). Although research has focused primarily on
Gutman and Hickson (1996) found that Anglo- homophobic bullying and the use of homophobic
Australian children aged 7–9 reported less bias toward epithets among boys, studies have found that ado-
Aborigines than did children aged 5–6, and that chil- lescent girls also engage in this behavior (Poteat &
dren aged 10–12 reported greater perceived similarity Espelage, 2005; Rivers, 2001). In addition to dis-
between groups than did children in the youngest crimination perpetuated by other students, LGBT
(i.e., ages 5–6 years) and middle (i.e., ages 7–9 years) youth report that school administrators, staff, and
age groups. However, the oldest age group did not teachers can contribute to creating or perpetuat-
differ significantly from the middle age group on neg- ing a negative school climate (Chesir-Teran, 2003;
ative evaluations of Aborigines. Also documenting age Sears, 1991). Level of perceived support and accep-
cohort differences, Nesdale and Brown (2004) found tance from teachers was a significant predictor of
that, among Anglo-Australian 6-, 9-, and 12-year-old academic performance for sexual minority youth
children, 6-year-old children reported more likability (Russell, Seif, & Truong, 2001). Finally, a majority
for an in-group (Anglo-Australian) member than an of LGBT youth (64%) have reported feeling unsafe
out-group (Chinese) member described in a vignette, while at school (Kosciw, 2004).
whereas this difference was not evident among Of equal importance to documenting the preva-
12-year-old children. Furthermore, 12-year-old chil- lence of prejudiced behavior among students is an
dren remembered more positive traits of the out- understanding of its underlying function and intent.
group member compared to 6-year-old children. The use of homophobic and racist language and
Although findings from studies examining homopho- engagement in other forms of prejudiced behavior
bic and racist attitudes suggest the potential for against marginalized groups of students can perhaps
changes in prejudiced attitudes across childhood and most clearly be seen as an expression of homopho-
adolescence, the interpretation and validity of these bic and racist attitudes. However, researchers also
findings remain limited due to cross-sectional design have noted that homophobic and racist language
confounds. However, regardless of the specific pat- can serve multiple additional functions, which can
terns of change, the documentation of various levels include enforcing peer norms, gaining status and
of stereotyping, in-group preference, and prejudice attention within peer groups, and establishing dom-
among children and adolescents further indicates the inance hierarchies (Connolly, 2000; Guerin, 2003;
need for school-based prevention programs to be Korobov, 2004; Phoenix, Frosh, & Pattman, 2003;
developed and implemented during these early devel- Poteat & Espelage, 2005). Among children and ado-
opmental periods. lescents, homophobic behavior often is used to assert
their masculinity and heterosexuality, to challenge
prevalence and functions of the masculinity of other boys, or to enforce gender-
prejudiced behavior normative behavior among peers (Kimmel, 1997;
Many LGBT students continue to report experienc- Korobov, 2004; Phillips, 2007; Phoenix, Frosh, &
ing victimization and discrimination while at school, Pattman, 2003; Plummer, 2001; Stoudt, 2006).

e spe l age , p ot e at 711

Based on these additional functions, students can be services (Muller, 2000). This disconnect represents
targets of homophobic epithets regardless of their an important area of service that could be provided
actual or perceived sexual orientation. Male young by counseling psychologists.
adults have reported that their engagement in Experiences of homophobic victimization can
homophobic behavior during adolescence was not contribute to increased mental health and social
always a comment on the targeted individual’s actual concerns among sexual minority youth. A number
or perceived sexual orientation, but rather was of studies have documented concerns such as anxi-
intended to attack the targeted individual’s mascu- ety, depression, and suicidal ideation (D’Augelli
linity (Plummer, 2001). However, it should be noted et al., 2002; Herek, Gillis, & Cogan, 1999), stigma-
that students who identify as or who are perceived tization from peers (Nichols, 1999), and substance
to be LGBT remain more frequently targeted than use (Garofalo, Wolf, Kessel, Palfrey, & DuRant,
their heterosexual peers (Espelage, Aragon, Birkett, 1998; Jordan, 2000; Marshal et al., 2008). Yet,
& Koenig, 2008; Poteat & Espelage, 2005). when sexual minority youth perceive the school cli-
Similarly, the use of racist language has been docu- mate to be positive, this can act as a buffer against
mented within children’s peer groups (Connolly, the experience of negative psychological and social
2000), and adolescents use racist language as a way concerns (Espelage, Aragon, Birkett, & Koenig,
to gain the attention of their peers and in some 2008). Of interest, homophobic victimization also
situations to elevate their status within the peer has been found to predict higher levels of psychoso-
group (Guerin, 2003). Guerin has noted that indi- cial concerns among targeted heterosexual students
viduals can often minimize any potential repercus- (Poteat & Espelage, 2007).
sions of their use of racist language through humor However, scholars also have indicated the need
(e.g., “it was only a joke”). However, research has for caution in how the psychological and social
consistently documented the seriousness of such experiences of sexual minority youth are described
behavior and its negative psychological and social and how comparisons to heterosexual youth are
effects on targeted individuals (Burchinal, Roberts, made (Poteat et al., 2009; Savin-Williams, 2001).
Zeisel, & Rowley, 2008; D’Augelli, Pilkington, & Broad group comparisons between heterosexual and
Hershberger, 2002; Mattison & Aber, 2007; Poteat, sexual minority youth, when significant, often are
Aragon, Espelage, & Koenig, 2009). qualified by relatively small effect sizes (Poteat
et al., 2009; Rosario, Schrimshaw, & Hunter, 2004;
Psychosocial Consequences of Prejudice Williams et al., 2005). Similarly, a common limita-
in the Schools tion in many studies among sexual minority youth
The negative consequences of racism in the schools is the use of smaller convenience samples, and
continue to be documented with regard to the aca- limited generalizability to the broader population
demic performance and mental health of students of sexual minority youth (Savin-Williams, 2001,
of color (Burchinal et al., 2008; Mattison & Aber, 2008). Scholars also have highlighted the need to
2007). Following the transition from elementary consider the diversity within the sexual minority
school to middle school, the expectation of experi- youth community with regard to the intersection
encing racial discrimination was identified as a of sexual orientation, gender, and racial identity
factor that could negatively impact the academic (Balsam, Huang, Fieland, Simoni, & Walters, 2004;
achievement and social adjustment among African Poteat et al., 2009; Rosario et al., 2004). Program-
American children (Burchinal et al., 2008). Similar ming could be more effective if tailored to the
findings have been documented among high school unique needs of specific subgroups within the sexual
students, in whom the perception of a positive racial minority community, including sexual minority
climate within the school was associated with better youth of color, bisexual and transgender youth, and
academic performance (Mattison & Aber, 2007). youth who are questioning their sexual orientation
Higher reported internalizing and externalizing identity (Hollander, 2000; Mulick & Wright, 2002;
mental health and behavioral concerns also have Poteat et al., 2009; Rosario et al., 2004).
been documented for African American students Finally, additional research is needed with a
who experienced more frequent discrimination greater emphasis on resilience for both racial minor-
(Clark, Coleman, & Novak, 2004). Concurrently, ity and sexual minority youth. Counseling psycholo-
however, scholars have noted that racial minority gists in particular have advocated strongly for this
students frequently are under-represented and over- approach in both providing services for clients and
looked in the provision of school-based counseling in conducting research. Several factors promoting

712 school-bas ed preven tio n o f pee r p roble m s

resilience have received attention in the literature, into consideration relevant developmental factors
including various sources of social support (Anderson, during childhood and adolescence. Several authors
1998; Elias & Haynes, 2008; Hammack, Richards, have provided comprehensive reviews of the advances
Luo, Edlynn, & Roy, 2004; Li, Nussbaum, & in cognitive and social development in general
Richards, 2007; Nesmith, Burton, & Cosgrove, (e.g., Collins & Steinberg, 2006; Rubin, Bukowski,
1999; Shin, Daly, & Vera, 2007), adaptive coping & Parker, 2006) and in relation to stereotyping
styles (Clauss-Ehlers, 2008; Yeh, Kim, Pituc, & and prejudice (e.g., Bigler & Liben, 2006) during
Atkins, 2008), and positive self-esteem and identity these developmental periods. Counseling psycholo-
development (Grossman & Kerner, 1998; Shin et al., gists interested in developing prejudice prevention
2007). The integration of resilience-based models in and intervention programs for children and adoles-
the development and provision of programming to cents should consult these resources to ensure that
address prejudice and its psychosocial effects within their activities and materials are developmentally
the schools could be a significant and distinct contri- appropriate.
bution made by counseling psychologists. A number of school-based interventions have
been implemented and evaluated on their effective-
Types of School-based Interventions ness to decrease prejudiced attitudes and behavior
for Prejudice and to increase appreciation for diversity. Evaluation
School-based interventions and programs have research has demonstrated that programs and inter-
targeted prejudiced attitudes and behavior using ventions with either cognitive or social emphases
a variety of approaches grounded in the theoret- have positive effects on reducing prejudiced attitudes
ical and empirical literature. Many interventions (Aboud & Doyle, 1996; Aboud & Fenwick, 1999;
have been based on cognitive information-processing, Molina & Wittig, 2006; Pettigrew & Tropp, 2000;
social contact theories, and ecological models Turner et al., 2007; Walker & Crogan, 1998). From
(e.g., Allport, 1954; Bronfenbrenner, 1977; Evans an 11-week classroom program among fifth-grade
& Prilleltensky, 2007; Tajfel & Turner, 1979). The students that included group, dyadic, and individual
focus, strategies, and activities of intervention pro- activities, Aboud and Fenwick (1999) found that
grams can vary according to the models on which white students in the intervention group, who
they are based. For example, interventions grounded initially expressed high levels of racial prejudice,
in cognitive theories attempt to decrease prejudice reported lower levels of prejudice 2 months after
by changing cognitive schemas, the ways in which the intervention, whereas high-prejudiced white stu-
children categorize individuals into groups, how dents in the control group did not report a decrease
students encode and interpret social information in their prejudiced attitudes. Also, low-prejudiced
about minority groups, and by correcting stereo- white students in the intervention group did not
types (e.g., Aboud & Doyle, 1996; Bigler & Liben, increase their prejudiced attitudes. Similarly, Aboud
1992). Programs based on social contact encourage and Doyle (1996) found that white children, ages 8
extended interpersonal interaction among stu- through 11, who initially expressed high levels of
dents from different groups (e.g., sexual orientation, racial prejudice later reported lower levels of preju-
racial, or ethnic groups) and cooperative learning or dice after talking about racial issues with a friend
group projects as part of the educational process who initially expressed low levels of racial prejudice.
(e.g., Molina & Wittig, 2006; Turner, Hewstone, & In addition to providing more structured program-
Voci, 2007; Walker & Crogan, 1998). Broader eco- ming, research also suggests that promoting positive
logical approaches may include attention to factors cross-cultural friendships among students could
at both the individual level and within the broader contribute to lower prejudiced attitudes among chil-
social context (Evans & Prilleltensky, 2007), such as dren. Among elementary school students, Turner
attention to the overall school climate (Benner, et al. (2007) found that self-disclosure and empathy
Graham, & Mistry, 2008). Additional initiatives expressed within cross-racial friendships were media-
under this approach might extend beyond the tors of more positive racial attitudes among white
immediate school environment to include family children. Furthermore, because peers can contribute
systems (e.g., addressing parental prejudiced atti- to the socialization of prejudiced attitudes during
tudes) and the connections among schools and other adolescence (Poteat, 2007), school-based interven-
community-based contexts in which students inter- tions might focus specifically on developing pro-
act. Across these various approaches, it is important gramming that addresses intergroup relations within
that prevention and intervention programming take peer groups. Paluck (2006) found that providing

e spe l age , p ot e at 713

diversity training to a select group of students led frameworks within psychology. Researchers involved
to some measurable positive effects on other stu- in participatory action research work closely and in
dents with whom these individuals interacted. Also, collaboration with participants to develop projects to
Molina and Wittig (2006) found that providing address the issues relevant to the specific group of
opportunities for personal interactions and social participants (Kidd & Kral, 2005). Similarly, empow-
contact, and promoting interdependence among erment and liberation frameworks focus on address-
racially diverse groups of students can reduce preju- ing both the structural forms of oppression and the
diced attitudes and facilitate the development of empowerment of marginalized groups within society
a common in-group identity among high school (Prilleltensky & Prilleltensky, 2003). These programs
students. often focus on student empowerment, build critical
The impact of Gay-Straight Alliances (GSAs) on awareness of institutional and cultural oppression,
levels of homophobia, discrimination against LGBT focus on healthy psychosocial development, and
students, and academic achievement of LGBT stu- emphasize the strengths and resources available to
dents also has been examined (California Safe students to buffer against the psychosocial risks asso-
Schools Coalition, 2004; Lee, 2002; Russell, ciated with victimization and discrimination (Balcazar,
Kostroski, McGuire, Laub, & Manke, 2006). Tandon, & Kaplan, 2001; Diemer, Kauffman,
Students in schools with GSAs reported higher levels Koenig, Trahan, & Hsieh, 2006; Lee, 2002; McKown,
of perceived safety than did students in schools 2005). For example, among a sample of predomi-
without GSAs (California Safe Schools Coalition, nantly racial minority students in an urban school,
2004). As these data suggest, the involvement of students who perceived support among their peers
heterosexual student allies (e.g., heterosexual stu- and other adults to challenge racism and sexism also
dents who support their LGBT peers or counter the reported greater critical consciousness of these issues
homophobic attitudes and behaviors of other peers (Diemer et al., 2006). In addition, researchers have
in schools) can significantly contribute to creating commented on the positive effects of school-based
safer schools and promoting understanding and psychoeducational dialogue groups in which students
appreciation of sexual minority youth among other can discuss and process issues around race, such as
students. However, although the process of ally racial identity development and experiences of dis-
development has been explored (Anzaldua, 2000; crimination (Candelario & Huber, 2002). Similarly,
Broido, 2000), little research has been conducted psychoeducational groups also have been proposed
on the effectiveness of ally training models for to promote social justice awareness and engagement
adolescents and the influence of heterosexual youth for elementary school through high school students
allies on reducing prejudice among peers. This high- (Portman & Portman, 2002).
lights a current need in the school intervention In addition to working with students, school-
literature addressing prejudice. Relative to the docu- based intervention and training programs should
mentation of students’ engagement in prejudiced involve administrators and teachers for a more
behavior, less research has focused on students’ comprehensive approach to prejudice reduction and
engagement in antiprejudice and social justice prevention (McFarland & Dupuis, 2001; Pickett,
behavior. Furthermore, students who reported that 1995; Suyemoto & Tree, 2006; Walters & Hayes,
LGBT issues were included in school curriculum 1998). These programs often include educational
reported higher levels of perceived safety in school modules and activities intended to promote multi-
(Russell et al., 2006). Similarly, LGBT students who cultural knowledge and awareness, empathy, and
attended schools that had support groups reported perspective-taking; to highlight terminology, rele-
lower victimization and suicidality (Goodenow, vant laws, and school policies regarding diversity
Szalacha, & Westheimer, 2006). Generally, interac- and discrimination; and to identify effective ways to
tive and experiential activities have greater effects on intervene when incidences of prejudice and dis-
student attitudes and behaviors than do more didac- crimination occur (Cho & DeCastro-Ambrosetti,
tic and less participatory curriculum and instruction 2005; Paluck, 2006; Rivers, Duncan, & Besag,
(Slavin & Madden, 1979; Spencer, 1998; Turner & 2007). The provision of these training modules is also
Brown, 2008). needed among preservice teachers (Cho & DeCastro-
School-based interventions also can involve work- Ambrosetti, 2005). Cho and DeCastro-Ambrosetti
ing with minority group members. This approach has found that classes addressing multicultural issues
been grounded in several frameworks, such as partici- contributed to the development of multicultural
patory action and liberation and empowerment awareness and knowledge among preservice teachers

714 school-bas ed preven tio n o f pee r p roble m s

in a way that could inform their work with students teenagers that discuss how to address prejudice,
in the school system. Researchers also have empha- and these sections contain activities, stories, and
sized the importance for teachers and administrators news items related to diversity. For example, the
to model appreciation and respect for diversity and parenting section includes the handbook, Beyond
multiculturalism for students within the school the Golden Rule: A Parent’s Guide to Preventing
(Onyekwuluje, 2000). Furthermore, developmental and Responding to Prejudice. The Anti-Defamation
research suggests that educators might reconsider League (ADL; www.adl.org/education) offers online
how they use certain social categories among chil- educational material appropriate for use with chil-
dren. For example, the functional use of gender in dren through adolescents that address various forms
classrooms (e.g., dividing the class according to of prejudice and offer ways to build appreciation
gender or assigning individuals to groups based on for diversity (e.g., A Classroom of Difference™ cur-
gender) led to higher levels of occupational gender riculum), as well as professional development mate-
stereotyping among elementary school children rial for educators. Their Curriculum Connections
in this condition compared to children in control resources offer educators lesson plans and activities
group conditions (Bigler, 1995). that can be used to address prejudice, diversity, and
social justice. Examples of specific issues include
Intervention Programs and Resources bullying, racial diversity, religious diversity, Native
In this section, we provide information on several Americans and Indigenous People, people with
current programs and resources at the national level disabilities, and gender diversity.
that have been used or are currently being tested as One of the largest national organizations to pro-
part of school-based interventions to address preju- vide educational resources and research on LGBT
dice. Additional information about each program, issues in the schools is the Gay, Lesbian, and Straight
as well as accessible materials for practitioners, stu- Education Network (GLSEN; www.glsen.org). Its
dents, teachers, and parents may be accessed through research publications include the biennial National
the website of each organization. School Climate Survey (NSCS) and other research
Many professional and nonprofit national orga- briefs on current LGBT issues in schools. Using
nizations offer resources to address diversity issues a national sample of LGBT youth, the NSCS pro-
and prejudice in the schools. Many of these organi- vides data on the prevalence of homophobia and
zations provide material targeted toward teachers homophobic bullying within the school system,
and administrators, students, and parents. However, while also including additional information on
these materials also can be used by counseling academic and mental health issues among LGBT
psychologists and other mental health practitio- youth, as well as the availability of school policies
ners who are interested in providing programming and support programs. The organization also pro-
around prejudice prevention and reduction in vides resources such as lesson plans, training pro-
schools. Additionally, many of these organizations gram kits, and various materials for educators,
provide a range of resources tailored to be appropri- students, and parents that can be accessed through
ate for elementary school students through high their website. Some cities have local GLSEN chap-
school students. The National Education Association ters that can be contacted for additional materials or
(NEA; www.nea.org) provides resources and activi- training opportunities. Other prominent national
ties for a number of diversity topics and social issues organizations that include a focus on LGBT issues
around sexual orientation, race, gender, social class, in schools include Parents, Families, and Friends of
and English-language learners. For example, this Lesbians and Gays (PFLAG; www.pflag.org) and
includes their Diversity Toolkit, which provides rec- the Human Rights Campaign (HRC; www.hrc.org).
ommendations and activities that educators can Current intervention and educational programming
use to promote appreciation for diversity and social for LGBT issues include the Respect for All Project
justice within the school system. The Teaching (www.groundspark.org) and the Welcoming Schools
Tolerance program (www.tolerance.org), formed project (www.welcomingschools.org). Comprising
through the Southern Poverty Law Center, also pro- the Respect for All Project are several educational
vides a substantial number of resources, including films on LGBT issues in education (It’s Elementary),
handbooks, curricula, and activities for teachers to homophobic bullying (Let’s Get Real ), family diver-
use in classrooms to address prejudice and inter- sity (That’s a Family! ), and gender norms and
group relations. Also, this program includes addi- homophobia (Straightlaced ), as well as accompany-
tional sections specifically for parents, children, and ing curricula and activity guides and workshops.

e spe l age , p ot e at 715

The Welcoming Schools pilot program was initiated of programs that contribute to their effectiveness,
through the HRC to address LGBT issues in ele- identifying the conditions under which programs
mentary schools, and includes lesson plans, profes- are more effective, and for whom these programs are
sional development for teachers and administrators, more effective. Generally stated, research is needed
and additional educational resources for families. to identify the moderators of program efficacy.
Issues such as aggression and prejudice within
Conclusion the schools, far from being isolated and distinct
Interactions with peers during childhood and ado- problems, have complex associations with myriad
lescence are formative in the development of healthy other individual and social concerns (Clark et al.,
relationships, a secure identity, and a strong, resil- 2004; D’Augelli et al., 2002; Donovan et al., 1991;
ient personality. As noted in this chapter, children Jessor, 1991; Nansel et al., 2001). This necessitates
and adolescents are often exposed to bullying and the implementation of more comprehensive pro-
relational aggression. Furthermore, bullying and gramming that also addresses common underlying
other forms of aggression are often connected with risk and causal factors that contribute to the devel-
prejudice. All of these are preventable, but it will opment and perpetuation of these interrelated con-
take a concerted effort on the part of schools and cerns (Kenny et al., 2002). For example, programs
communities to tackle these growing problems. addressing homophobic behavior would likely need
Rather than seeing these phenomena in isolation, it to incorporate the discussion of a variety of issues
is time that these peer-related problems are seen as that are associated with this behavior, including
symptomatic of school climates in which disrespect sexual minority stereotypes and homophobic atti-
and exclusion are fostered by school-wide policies, tudes, the pressure to conform to rigid expectations
lack of teacher/staff training, and ineffective teacher for gender-normative behavior, addressing its con-
and staff responses to peer problems. Furthermore, nection to bullying and aggression, and discussing
future prevention and intervention efforts need to how this behavior negatively affects all students.
also consider how the school community is influ- Finally, as counseling psychologists become
enced by other social contexts, such as families, involved in school-based prevention and interven-
neighborhoods, and media. tion, it is critical that we form committed and col-
It is time for counseling psychology to contrib- laborative partnerships with school administrators,
ute to the research and practice of school-based pre- teachers, and students. Through both research and
vention efforts. Indeed, Walsh and colleagues (2002) practice, counseling psychologists must attend to
stated that, upon consideration of all the applied the unique needs of these schools, and translate our
subfields within psychology, only school psychol- research into practice and services that will directly
ogy emerges as one that has maintained an empha- benefit the individuals within these schools. Walsh
sis on K–12 education. This is unfortunate, given the et al. (2002) have highlighted the importance of
strength of counseling psychologists in developing counseling psychologists becoming more involved
and evaluating large-scale investigations. Counsel- in schools. Long-term partnerships are needed in
ing psychology programs should include graduate this area, as our understanding of these social con-
coursework in human development, prevention sci- cerns within schools and the impact and efficacy of
ence, and training in randomized clinical trials. our programs cannot be determined based on single
time point approaches. These long-term commit-
Future Directions ments can also contribute to addressing the impact
As highlighted throughout this chapter, there are of such programs on attitudes, behaviors, and mental
many future directions for school-based preven- health outcomes later in adulthood. Ultimately, the
tion and intervention programming in relation to involvement of counseling psychologists in school-
addressing aggression and prejudice. In this section, based intervention and prevention programming
we review several of these directions for counseling expands upon the growing commitment of our field
psychologists. to addressing social justice issues in our community
Continued research is needed to evaluate preven- and society.
tion and intervention programs for their effective-
References
ness. As part of this effort, clearer criteria and
Aboud, F. E. (2005). The development of prejudice in childhood
standards are needed for assessing and quantifying and adolescence. In J. F. Dovidio, P. Glick, & L. A. Rudman
the degree of program effectiveness. This should also (Eds.), On the nature of prejudice: Fifty years after Allport
include the identification of the specific components (pp. 310–326). Malden, MA: Blackwell Publishing.

716 school-bas ed preven tio n o f pee r p roble m s

Aboud, F. E., & Doyle, A. B. (1996). Does talk of race foster Bigler, R. S., & Liben, L. S. (2006). A developmental intergroup
prejudice or tolerance in children? Canadian Journal of theory of social stereotypes and prejudice. In R. Kail
Behavioural Science, 28, 161–170. (Ed.), Advances in child development and behavior Vol. 34
Aboud, F. E., & Fenwick, V. (1999). Exploring and evaluating (pp. 39–89). New York: Academic Press.
school-based interventions to reduce prejudice. Journal of Bjoerkqvist, K., Kaukiainen, A., & Lagerspetz, K. M. J. (1992).
Social Issues, 55, 767–786. Do girls manipulate and boys fight? Developmental trends in
Abwender, D. A., Beery, S. H., Ewell, K. K., & Vernberg, E. M. regard to direct and indirect aggression. Aggressive Behavior,
(1992). Social anxiety and peer relationships in early adoles- 18, 117–127.
cence: A prospective analysis. Journal of Clinical Child and Black-Gutman, D., & Hickson, F. (1996). The relationship
Adolescent Psychology, 21, 189–196. between racial attitudes and social-cognitive development in
Allport, G. (1954). The nature of prejudice. Cambridge, MA: children: An Australian study. Developmental Psychology, 32,
Addison-Wesley. 448–456.
American Association of University Women. (2001). Hostile Boxer, P., & Dubow, E. F. (2001). A social-cognitive
hallways: Bullying, teasing, and sexual harassment in school. information-processing model for school-based aggression
Washington, DC: American Association of University Women. reduction and prevention programs: Issues for research
American Civil Liberties Union. (2005, June 20). Summary of and practice. Applied and Preventative Psychology, 10(3),
school harassment lawsuits. Retrieved August 5, 2008, from 177–192.
http://www.aclu.org/lgbt/youth/11898res20050620.html. Boxer, P., Edwards-Leeper, L., Goldstein, S. E., Musher-
American Psychological Association. (2003). Guidelines on Eizenman, D., & Dubow, E. F. (2003). Exposure
multicultural education, training, research, practice and to “low-level” aggression in school: Associations with aggres-
organizational change for psychologists. American Psychologist, sive behavior, future expectations, and perceived safety.
58, 377–402. Violence and Victims, 18(6), 691–704.
Anderson, A. L. (1998). Strengths of gay male youth: An untold Benner, A. D., Graham, S., & Mistry, R. S. (2008). Discerning
story. Child and Adolescent Social Work Journal, 15, 55–71. direct and mediated effects of ecological structures and pro-
Anzaldua, G. (2000). Allies. In M. Adams, W. J. Blumenfeld, cesses on adolescents’ educational outcomes. Developmental
R. Castaneda, H. Hackman, M. Peters, & X. Zuniga Psychology, 44, 840–854.
(Eds.), Readings for diversity and social justice (pp. 475–477). Brendgen, M., Boivin, M., Vitaro, F., Bukowski, W. M.,
New York: Routledge. Dionne, G., Tremblay, R. E., & Perusse, D. (2008). Linkages
Archer, J., & Coyne, S. M. (2005). An integrated review of between children’s and their friends’ social and physical
indirect, relational, and social aggression. Personality and aggression: Evidence for a gene-environment interaction?
Social Psychology Review, 9(3), 212–230. Child Development, 79(1), 13–29.
Baker, J., & Fishbein, H. (1998). The development of prejudice Broido, E. M. (2000). The development of social justice allies
towards gays and lesbians by adolescents. Journal of during college: A phenomenological investigation. Journal of
Homosexuality, 36, 89–100. College Student Development, 41, 3–18.
Balcazar, F., Tandon, D., & Kaplan, D. (2001). A classroom- Bronfenbrenner, U. (1977). Toward an experimental ecology of
based approach for promoting critical consciousness among human development. American Psychologist, 32, 513–531.
African American youth. The Community Psychologist, 34, Buhs, E. S., Ladd, G. W., & Herald, S. L. (2006). Peer exclusion
30–32. and victimization: Processes that mediate the relation
Balsam, K. F., Huang, B., Fieland, K. C., Simoni, J. M., & between peer group rejection and children’s classroom
Walters, K. L. (2004). Culture, trauma, and wellness: engagement and achievement? Journal of Educational
A comparison of heterosexual and lesbian, gay, bisexual, and Psychology, 98(1), 1–13.
two-spirit Native Americans. Cultural Diversity and Ethnic Burchinal, M. R., Roberts, J. E., Zeisel, S. A., & Rowley, S. J.
Minority Psychology, 10, 287–301. (2008). Social risk and protective factors for African
Barton, E., Taiariol, J., & Yoon, J. S. (2004). Relational American children’s academic achievement and adjustment
aggression in middle school: Educational implications of during the transition to middle school. Developmental
developmental research. The Journal of Early Adolescence, Psychology, 44, 286–292.
24(3), 303–318. California Safe Schools Coalition, & 4-H Center for Youth
Batsche, G. M., & Porter, L. J. (2006). Bullying. In G. G. Bear, Development, University of California, Davis. (2004).
& K. M. Minke (Eds.), Children’s needs III: Development, pre- Consequences of harassment based on actual or perceived sexual
vention, and intervention (pp. 135–148). Washington, DC: orientation and gender non-conformity and steps for making
National Association of School Psychologists. schools safer.
Beard, K., Colvin, G., Hagan, S., Sprague, J., & Tobin, T. Candelario, N., & Huber, H. (2002). A school-based group
(1998). The school bully: Assessing the problem, developing experience on racial identity and race relations. Smith College
interventions, and future research directions. Journal of Studies in Social Work, 73, 51–72.
Behavioral Education, 8(3), 293–319. Cappella, E., & Weinstein, R. (2006). The prevention of
Bigler, R. S. (1995). The role of classification skill in moderating social aggression among girls. Social Development, 15(3),
environmental influences on children’s gender stereotyping: 434–462.
A study of the functional use of gender in the classroom. Casella, R. (2003). Zero tolerance policy in schools: Rationale,
Child Development, 66, 1072–1087. consequences, and alternatives. Teachers College Record, 105,
Bigler, R. S., & Liben, L. S. (1992). Cognitive mechanisms in 872–892.
children’s gender stereotyping: Theoretical and educational Cavell, T. A., & Hughes, J. N. (1999). Secondary prevention
implications of a cognitive-based intervention. Child as a context for assessing change processes in aggressive
Development, 63, 1351–1363. children. Journal of School Psychology, 38, 199–235.

e spe l age , p ot e at 717

Chesir-Teran, D. (2003). Conceptualizing and addressing consciousness development. Cultural Diversity and Ethnic
heterosexism in high schools: A setting-level approach. Minority Psychology, 12, 444–460.
American Journal of Community Psychology, 31, 269–279. Dishion, T. J., McCord, J., & Poulin, F. (1999). When interven-
Cho, G., & DeCastro-Ambrosetti, D. (2005). Is ignorance tions harm: Peer groups and problem behavior. American
bliss? Pre-service teachers’ attitudes toward multicultural Psychologist, 54, 755–764.
education. The High School Journal, 89, 24–28. Donovan, J. E., Jessor, R., & Costa, F. (1991). Adolescent health
Clark, R., Coleman, A. P., & Novak, J. D. (2004). Initial psycho- behavior and conventionality - unconventionality: An exten-
metric properties of the everyday discrimination scale in sion of problem-behavior theory. Health Psychology, 10,
black adolescents. Journal of Adolescence, 27, 363–368. 2–61.
Clauss-Ehlers, C. S. (2008). Sociocultural factors, resilience, Downey, G., & Purdie, V. (2000). Rejection sensitivity and
and coping: Support for a culturally sensitive measure of adolescent girls’ vulnerability to relationship-centered
resilience. Journal of Applied Developmental Psychology, 29, difficulties. Child Maltreatment, 5, 338–349.
197–212. Dwivedi, K., & Gupta, A. (2003). Keeping cool: Anger
Collins, W. A., & Steinberg, L. (2006). Adolescent development management through group work. Support for Learning, 15,
in interpersonal context. In N. Eisenberg, W. Damon, & 76–81.
R. M. Lerner (Eds.), Handbook of child psychology: Vol. 3. Elias, M. J., & Haynes, N. M. (2008). Social competence, social
Social emotional and personality development (6th ed., support, and academic achievement in minority, low-income,
pp. 1003–1067). Hoboken, NJ: John Wiley & Sons. urban elementary school children. School Psychology Quarterly,
Connolly, P. (2000). Racism and young girls’ peer-group rela- 23, 474–495.
tions: The experiences of South Asian girls. Sociology, 34, Ennett, S. T., Foshee, V. A., Karriker-Jaffe, K. J., & Suchindran, C.
499–519. (2008). The development of aggression during adolescence:
Craig, W. M. (1998). The relationship among bullying, victim- Sex differences in trajectories of physical and social aggression
ization, depression, anxiety, and aggression in elementary among youth in rural areas. Journal of Abnormal Child
school children. Personality and Individual Differences, 24, Psychology, 36(8), 1227–1236.
123–130. Espelage, D. L., Aragon, S. R., Birkett, M., & Koenig, B. W.
Crick, N. R. (1996). The role of overt aggression, relational (2008). Homophobic teasing, psychological outcomes, and
aggression, and prosocial behavior in the prediction of chil- sexual orientation among high school students: What influ-
dren’s future social adjustment. Child Development, 67, ence do parents and schools have? School Psychology Review,
2317–2327. 37, 202–216.
Crick, N. R., & Bigbee, M. A. (1998). Relational and overt Espelage, D. L., Holt, M. K., & Henkel, R. R. (2003).
forms of peer victimization: A multi-informant approach. Examination of peer-group contextual effects on aggression
Journal of Consulting and Clinical Psychology, 66, 337–347. during early adolescence. Child Development, 74, 205–220.
Crick, N. R., Bigbee, M. A., & Howes, C. (1996). Gender Espelage, D. L., & Swearer, S. M. (2003). Research on school
differences in children’s normative beliefs about aggression: bullying and victimization: What have we learned and where
How do I hurt thee? Let me count the ways. Child do we go from here? School Psychology Review, 32, 365–383.
Development, 67, 1003–1014. Espelage, D. L., Mebane, S. E., Swearer, S. M., & Turner, R.
Crick, N. R., Casas, J. F., & Nelson, D. A. (2002). Toward a (2004). Gender differences in bullying: Moving beyond
more comprehensive understanding of peer maltreatment: mean level differences. In D. L. Espelage, & S. M. Swearer
Studies of relational victimization. Current Directions in (Eds.), Bullying in American schools: A social-ecological
Psychological Science, 11(3), 98–101. perspective on prevention and intervention (pp. 15–35).
Crick, N. R., & Grotpeter, J. K. (1995). Relational aggression, Mahwah, NJ: Erlbaum.
gender, and social-psychological adjustment. Child Devel- Evans, S. D., & Prilleltensky, I. (2007). Youth and democracy:
opment, 66, 710–722. Participation for personal, relational, and collective well-
Crick, N. R., & Werner, N. E. (2004). Maladaptive peer being. Journal of Community Psychology, 35, 681–692.
relationships and the development of relational and physical Fineran, S. (2002). Sexual harassment between same-sex peers:
aggression during middle childhood. Social Development, 13, Intersection of mental health, homophobia, and sexual
495–514. violence in schools. Social Work, 47, 65–74.
Crick, N. R., & Zahn-Waxler, C. (2003). The development of Finn, J. (2004). A survey of online harassment at a university
psychopathology in females and males: Current progress and campus. Journal of Interpersonal Violence, 19(4), 468–483.
future challenges. Development and Psychopathology: Special Fishbein, H. D. (1996). Peer prejudice and discrimination:
Issue on Conceptual, Methodological, and Statistical Issues in Evolutionary, cultural, and developmental dynamics. Boulder,
Developmental Psychopathology, 15(3), 719–742. CO: Westview Press.
Cupach, W. R., & Willer, E. K. (in press). When sugar and Forrester Research. (2007, July 11). Retrieved October 23, 2007,
spice turn to fire and ice: Factors affecting the adverse from http://www.forrester.com/ER/Research/Survey/Excerpt/
consequences of relational aggression among adolescent girls. 1,5449,535,00.html.
Communication Studies. Forthcoming. Furlong, M. J., Morrison, G. M., & Grief, J. L. (2003). Reaching
D’Augelli, A. R., Pilkington, N. W., & Hershberger, S. L. (2002). an American consensus: Reactions to the special issue on
Incidence and mental health impact of sexual orientation school bullying. School Psychology Review, 32, 456–470.
victimization of lesbian, gay, and bisexual youths in high Galen, B., & Underwood, J. K. (1997). A developmental inves-
school. School Psychology Quarterly, 17, 148–167. tigation of social aggression among children. Developmental
Diemer, M. A., Kauffman, A., Koenig, N., Trahan, E., & Psychology, 33, 589–600.
Hsieh, C. A. (2006). Challenging racism, sexism, and Garofalo, R., Wolf, R. C., Kessel, S., Palfrey, J., & DuRant, R. H.
social injustice: Support for urban adolescents’ critical (1998). The association between health risk behaviors and

718 school-bas ed preven tio n o f pee r p roble m s

 sexual orientation among a school-based sample of adoles- implications for future research. Applied and Preventative
cents. Pediatrics, 101, 895–902. Psychology, 8, 197–215.
Glew, G. M., Fan, M., Katon, W., Rivara, F. P., & Kernic, M. A. Jessor, R. (1991). Risk behavior in adolescence: A psychosocial
(2005). Bullying, psychosocial adjustment, and academic framework for understanding and action. Journal of Adolescent
performance in elementary school. Archives of Pediatric Health, 12, 597–605.
Adolescent Medicine, 159, 1026–1031. Jordan, K. M. (2000). Substance abuse among gay, lesbian,
Glew, G. M., Fan, M., Katon, W., & Rivara, F. P. (2008). bisexual, transgender, and questioning adolescents. School
Bullying and school safety. The Journal of Pediatrics, 152, Psychology Review, 29, 201–206.
123–128. Juvoven, J., Nishina, A., & Graham, S. (2000). Self-views versus
Goldstein, S. E., Young, A., & Boyd, C. (2008). Relational peer perceptions of victim status among early adolescents.
aggression at school: Associations with school safety and In J. Juvonen, & S. Graham (Eds.), Peer harassment in schools:
social climate. Journal of Youth and Adolescence, 37(6), The plight of the vulnerable and victimized (pp. 105–124).
641–654. New York: The Guilford Press.
Goodenow, C., Szalacha, L., & Westheimer, K. (2006). School Kaltiala-Heino, R., Rimpelae, M., & Rantanen, P. (2001).
support groups, other school factors, and the safety of sexual Bullying at school: An indicator for adolescents at risk for
minority adolescents. Psychology in the Schools, 43, 573–589. mental disorders. Journal of Adolescence, 23, 661–674.
Grossman, A. H., & Kerner, M. S. (1998). Self-esteem and Kazdin. A. E. (1996). Parent management training: Evidence,
supportiveness as predictors of emotional distress in gay male outcomes, and issues. Journal of the American Academy of
and lesbian youth. Journal of Homosexuality, 35, 25–39. Child & Adolescent Psychiatry, 36, 1349–1356.
Guerin, B. (2003). Combating prejudice and racism: New inter- Kenny, M. E., Waldo, M., Warter, E. H., & Barton, C. (2002).
ventions from a functional analysis of racist language. Journal School-linked prevention: Theory, science and practice for
of Community and Applied Social Psychology, 13, 29–45. enhancing the lives of children and youth. Counseling
Guerra, N. G., Boxer, P., & Cook, C. R. (2006). What works Psychologist, 30, 726–748.
(and what does not) in youth violence prevention: Rethinking Kidd, S. A., & Kral, M. J. (2005). Practicing participatory action
the questions and finding new answers. In C. Hudley, & research. Journal of Counseling Psychology, 52, 187–195.
R. N. Parker (Eds.), Pitfalls and pratfalls: Null and negative Kimmel, M. S. (1997). Masculinity as homophobia: Fear,
findings (pp. 59–71). Monograph from New Directions for shame, and silence in the construction of gender identity.
Evaluation, 110. In M. M. Gergen, & S. N. Davis (Eds.), Toward a new
Hammack, P. L., Richards, M. H., Luo, Z., Edlynn, E. S., & psychology of gender (pp. 223–242). Florence, KY: Taylor &
Roy, K. (2004). Social support factors as moderators of com- Frances.
munity violence exposure among inner-city African American Kochenderfer, B. J., & Ladd, G. W. (1996). Peer victimization:
young adolescents. Journal of Clinical Child and Adolescent Cause or consequence of school maladjustment? Child
Psychology, 33, 450–462. Development, 67, 1305–1317.
Hawker, D. S. J., & Boulton, M. J. (2000). Twenty years’ research Korobov, N. (2004). Inoculating against prejudice: A discursive
on peer victimization and psychosocial maladjustment: approach to homophobia and sexism in adolescent male talk.
A meta-analytic review of cross-sectional studies. Journal of Psychology of Men and Masculinity, 5, 178–189.
Child Psychology and Psychiatry and Allied Disciplines, 41, Kosciw, J. G. (2004). The 2003 national school climate survey:
441–455. The school-related experiences of our nation’s lesbian, gay,
Haynie, D. L., Nansel, T., & Eitel, P. (2001). Bullies, victims, bisexual, and transgender youth. New York: GLSEN.
and bully/victims: Distinct groups of at-risk youth. Journal Kosciw, J. G., Diaz, E. M., & Greytak, E. A. (2008). The 2007
of Early Adolescence, 21, 29–49. national school climate survey: The experiences of lesbian, gay,
Herek, G. M., Gillis, J. R., & Cogan, J. C. (1999). Psychological bisexual, and transgender youth in our nation’s schools.
sequelae of hate-crime victimization among lesbian, gay, and New York: GLSEN.
bisexual adults. Journal of Consulting and Clinical Psychology, Kumpulainen, K., Rasanen, E., & Henttonen, I. (1998).
67, 945–951. Children involved in bullying: Psychological disturbance and
Hodges, E. V. E., & Perry, D. G. (1999). Personal and interper- the persistence of the involvement. Child Abuse & Neglect,
sonal antecedents and consequences of victimization by peers. 23, 1253–1262.
Journal of Personality and Social Psychology, 76, 677–685. Lee, C. (2002). The impact of belonging to a high school gay/
Hollander, G. (2000). Questioning youth: Challenges to work- straight alliance. The High School Journal, 85, 13–26.
ing with youths forming identities. School Psychology Review, Levenkron, S. (1998). Cutting: Understanding and overcoming
29, 173–179. self-mutilation (pp. 40–83). New York: W.W. Norton &
Hoover, J. H., Oliver, R., & Hazler, R. (1992). Causal attribu- Company, Ltd.
tions: From cognitive processes to collective beliefs. Oxford, UK: Levy, A. (2005). Female chauvinist pigs: Women and the rise of
Blackwell. raunch culture (pp. 139–170). New York: Free Press.
Hoover, R., & Fishbein, H. D. (1999). The development of Li, S. T., Nussbaum, K. M., & Richards, M. H. (2007). Risk and
prejudice and sex role stereotyping in White adolescents and protective factors for urban African-American youth.
White young adults. Journal of Applied Developmental American Journal of Community Psychology, 39, 21–35.
Psychology, 20, 431–448. Marshal, M. P., Friedman, M. S., Stall, R., King, K. M., Miles, J.,
Horn, S. S. (2006). Heterosexual adolescents’ attitudes and Gold, M. A., et al. (2008). Sexual orientation and adolescent
beliefs about homosexuality and gay and lesbian peers. substance use: A meta-analysis and methodological review.
Cognitive Development, 21, 420–440. Addiction, 103, 546–556.
Howard, K. A., Flora, J., & Griffin, M. (1999). Violence- Mattison, E., & Aber, M. S. (2007). Closing the achievement
prevention programs in schools: State of the science and gap: The association of racial climate with achievement and

e spe l age , p ot e at 719

 behavioral outcomes. American Journal of Community Paquette, J. A., & Underwood, M. K. (1999). Gender differ-
Psychology, 40, 1–12. ences in young adolescents’ experiences of peer victimization:
McFarland, W. P., & Dupuis, M. (2001). The legal duty to Social and physical aggression. Merrill-Palmer Quarterly, 48.
protect gay and lesbian students from violence in school. Patchin, J. W., & Hinduja, S. (2006). Bullies move beyond the
Professional School Counseling, 4, 171–179. schoolyard: A preliminary look at cyberbullying. Youth
McKown, C. (2005). Applying ecological theory to advance the Violence & Juvenile Justice, 4, 148–169.
science and practice of school-based prejudice reduction Pellegrini, A. D., & Long, J. D. (2002). A longitudinal study
interventions. Educational Psychologist, 40, 177–189. of bullying, dominance, and victimization during the transi-
Molina, L. E., & Wittig, M. A. (2006). Relative importance tion from primary school through secondary school. British
of contact conditions in explaining prejudice reduction in a Journal of Developmental Psychology, 20, 259–280.
classroom context: Separate and equal? Journal of Social Perry, D. G., Kusel, S. J., & Perry, C. L. (1988). Victims of peer
Issues, 62, 489–509. aggression. Developmental Psychology, 24, 807–814.
Morrison, G. M., Redding, M., Fisher, E., & Peterson, R. Pettigrew, T. F., & Tropp, L. R. (2000). Does intergroup contact
(2006). Assessing school discipline. In S. R. Jimerson, & reduce prejudice? Recent meta-analytic findings. In S. Oskamp
M. Furlong (Eds.), Handbook of school violence and school (Ed.), Reducing prejudice and discrimination (pp. 93–114).
safety: From research to practice (pp. 211–220). Mahwah, NJ: Mahwah, NJ: Lawrence Erlbaum Associates, Inc.
Erlbaum. Pew Internet. (2005, July 25). Teens forge forward with the Internet
Mulick, P. S., & Wright, L. W. (2002). Examining the existence and other new technologies. Retrieved October 23, 2007, from
of biphobia in the heterosexual and homosexual populations. http://www.pewinternet.org/press_release.asp?r=109.
Journal of Bisexuality, 2, 45–64. Pew Internet & American Life Project, February 15–March 7, 2007
Muller, L. E. (2000). A 12-session, European-American-led http://www.pewinternet.org/trends/User_Demo_6.15.07.
counseling group for African-American females. Professional htm.
School Counseling, 3, 264–269. Phillips, D. A. (2007). Punking and bullying: Strategies in
Murray-Close, D., Ostrov, J. M., & Crick, N. R. (2007). middle school, high school, and beyond. Journal of
A short-term longitudinal study of growth of relational Interpersonal Violence, 22, 158–178.
aggression during middle childhood: Associations with Phoenix, A., Frosh, S., & Pattman, R. (2003). Producing contra-
gender, friendship intimacy, and internalizing problems. dictory masculine subject positions: Narratives of threat,
Development and Psychopathology, 19(1), 187–203. homophobia, and bullying in 11–14 year old boys. Journal of
Nansel, T. R., Haynie, D. L., & Simons-Morton, B. G. (2003). Social Issues, 59, 179–195.
The association of bullying and victimization with middle Pickett, L. (1995). Multicultural training workshops for teach-
school adjustment. Journal of Applied School Psychology, 19, ers. Transactional Analysis Journal, 25, 250–258.
45–61. Pilkington, N. W., & D’Augelli, A. R. (1995). Victimization of
Nansel, T. R., Overpeck, M., Pilla, R. S., Ruan, W. J., Simons- lesbian, gay, and bisexual youth in community settings.
Morton, B. G., & Scheidt, P. (2001). Bullying behaviors Journal of Community Psychology, 23, 34–56.
among US youth: Prevalence and association with psychoso- Plummer, D. C. (2001). The quest for modern manhood:
cial adjustment. Journal of the American Medical Association, Masculine stereotypes, peer culture and the social signifi-
285, 2094–2100. cance of homophobia. Journal of Adolescence, 24, 15–23.
Nesdale, D., & Brown, K. (2004). Children’s attitudes towards Portman, T. A. A., & Portman, G. L. (2002). Empowering stu-
an atypical member of an ethnic in-group. International dents for social justice (ES2J): A structured group approach.
Journal of Behavioral Development, 28, 328–335. Journal for Specialists in Group Work, 27, 16–31.
Nesmith, A. A., Burton, D. L., & Cosgrove, T. J. (1999). Gay, Poteat, V. P. (2007). Peer group socialization of homophobic
lesbian, and bisexual youth and young adults: Social support attitudes and behavior during adolescence. Child Development,
in their own words. Journal of Homosexuality, 37, 95–108. 78, 1830–1842.
Nichols, S. L. (1999). Gay, lesbian, and bisexual youth: Poteat, V. P., Aragon, S. R., Espelage, D. L., & Koenig, B. W.
Understanding diversity and promoting tolerance in schools. (2009). Psychosocial concerns of sexual minority youth:
The Elementary School Journal, 99, 505–519. Complexity and caution in group differences. Journal of
Olweus, D. (1992). Bullying among schoolchildren: Intervention Consulting and Clinical Psychology, 77, 196–201.
and prevention. In R. D. Peters, R. J. McMahon, & Poteat, V. P., & Espelage, D. L. (2005). Exploring the relation
V. L. Quinse (Eds.), Aggression and violence throughout the life between bullying and homophobic verbal content: The
span (pp. 100–125). London: Sage. Homophobic Content Agent Target (HCAT) scale. Violence
Olweus, D. (1993). Bully/victim problems among schoolchil- and Victims, 20, 513–528.
dren: Long-term consequences and an effective intervention Poteat, V. P., & Espelage, D. L. (2007). Predicting psychosocial
program. In S. Hodgins (Ed.), Mental disorder and crime consequences of homophobic victimization in middle school
(pp. 317–349). Thousand Oaks, CA: Sage. students. Journal of Early Adolescence, 27, 175–191.
Onyekwuluje, A. B. (2000). Adult role models: Needed voices for Poteat, V. P., Espelage, D. L., & Green, H. D. (2007). The social-
adolescents, multiculturalism, diversity, and race relations. ization of dominance: Peer group contextual effects on
Urban Review, 32, 67–85. homophobic and dominance attitudes. Journal of Personality
Orpinas, P., & Horne, A. M. (2006). Bullying prevention: Creating and Social Psychology, 92, 1040–1050.
a positive school climate and developing social competence. Prilleltensky, I., & Prilleltensky, O. (2003). Synergies for well-
Washington, DC: American Psychological Association. ness and liberation in counseling psychology. The Counseling
Paluck, E. L. (2006). Diversity training and intergroup contact: Psychologist, 31, 273–281.
A call to action research. Journal of Social Issues, 62, Rigby, K. (2001). Health consequences of bullying and its
577–595. prevention in schools. In J. Juvonen, & S. Graham (Eds.),

720 school-bas ed preven tio n o f pee r p roble m s

 Peer harassment in school: The plight of the vulnerable and Slavin, R. E., & Madden, N. A. (1979). School practices that
victimized (pp. 310–331). New York: Guilford Press. improve race relations. American Educational Research
Rivers, I. (2001). The bullying of sexual minorities at school: Journal, 16, 169–180.
Its nature and long-term correlates. Educational and Child Smith, J. D., Schneider, B. H., Smith, P. K., & Ananiadou, K.
Psychology, 18, 32–46. (2004). The effectiveness of whole-school antibullying pro-
Rivers, I., Duncan, N., & Besag, V. E. (2007). Bullying: A hand- grams: A synthesis of evaluation research. School Psychology
book for educators and parents. Westport, CT: Praeger Review, 33(4), 547–560.
Publishers. Snyder, J., Brooker, M., Patrick, M. R., Snyder, A.,
Rodkin, P. (2004). Peer ecologies and bullying. In D. L. Espelage, Schrepferman, L., & Stoolmiller, M. (2003). Observed peer
& S. M. Swearer (Eds.), Bullying in American schools: A social- victimization during early elementary school: Continuity,
ecological perspective on prevention and intervention. Mahwah, growth, and relation to risk for child antisocial and depres-
NJ: Erlbaum. sive behavior. Child Development, 74, 1881–1898.
Rosario, M., Schrimshaw, E. W., & Hunter, J. (2004). Ethnic/ Spencer, M. S. (1998). Reducing racism in schools: Moving
racial differences in the coming-out process of lesbian, gay, beyond the rhetoric. Social Work in Education, 20, 25–36.
and bisexual youths: A comparison of sexual identity devel- Stoudt, B. G. (2006). “You’re either in or you’re out”: School
opment over time. Cultural Diversity and Ethnic Minority violence, peer discipline, and the (re)production of hege-
Psychology, 10, 215–228. monic masculinity. Men and Masculinities, 8, 273–287.
Rothman, L., & Teglasi, H. (1999). Stories: A classroom-based Sullivan, T. N., Farrell, A. D., & Kliewer, W. (2006). Peer
program to reduce aggressive behavior. Journal of School victimization in early adolescence: Association between
Psychology, 39, 71–94. physical and relational victimization and drug use, aggres-
Rubin, K. H., Bukowski, W. M., & Parker, J. G. (2006). sion, and delinquent behaviors among urban middle school
Peer interactions, relationships, and groups. In W. Damon, students. Development and Psychopathology, 18(1), 119–137.
R. M. Lerner, & N. Eisenberg (Eds.), Handbook of child psy- Suyemoto, K. L., & Tree, C. A. F. (2006). Building bridges across
chology, volume 3, social emotional and personality development differences to meet social action goals: Being and creating
(6th Ed., pp. 1003–1067). Hoboken, NJ: John Wiley & allies among people of color. American Journal of Community
Sons. Psychology, 37, 237–246.
Rubin, K. H., Bukowski, W. M., Parker, J. G., & Bowker, J. C. Swearer, S. M., Espelage, D. L., & Napolitano, S. A. (2009).
(2008). Peer interactions, relationships, and groups. Bullying prevention and intervention Realistic strategies for
In W. Damon, & R. Lerner (Eds.), Child and adolescent schools. New York: Guilford Publications.
development: An advanced course. Hoboken, NJ: Wiley. Tajfel, H., & Turner, J. C. (1979). An integrative theory of
Russell, S. T., Kostroski, O., McGuire, J. K., Laub, C., & intergroup conflict. In W. G. Austin, & S. Worchel (Eds.),
Manke, E. (2006). LGBT issues in the curriculum promotes The social psychology of intergroup relations (pp. 33–48).
school safety. California Safe Schools Coalition research brief Monterey, CA: Brooks Cole.
no. 4. San Francisco: California Safe Schools Coalition. Thurlow, C. (2001). Naming the “outsider within”: Homophobic
Russell, S. T., Seif, H., & Truong, N. L. (2001). School outcomes pejoratives and the verbal abuse of lesbian, gay and bisexual
of sexual minority youth in the United States: Evidence from high-school pupils. Journal of Adolescence, 24, 25−38.
a national study. Journal of Adolescence, 24, 111–127. Turner, R. N., & Brown, R. (2008). Improving children’s
Salzman, M., & D’Andrea, M. (2001). Assessing the impact of attitudes toward refugees: An evaluation of a school-based
a prejudice prevention project. Journal of Counseling and multicultural curriculum and an anti-racist intervention.
Development, 79, 341–346. Journal of Applied Social Psychology, 38, 1295–1328.
Sears, J. T. (1991). Educators, homosexuality, and homosexual Turner, R. N., Hewstone, M., & Voci, A. (2007). Reducing
students: Are personal feelings related to professional beliefs? explicit and implicit outgroup prejudice via direct and
Journal of Homosexuality, 22, 29–79. extended contact: The mediating role of self-disclosure and
Sebanc, A. M. (2003). The friendship features of preschool chil- intergroup anxiety. Journal of Personality and Social Psychology,
dren: Links with prosocial behavior and aggression. Social 93, 369–388.
Development, 12, 249–268. Underwood, M. K. (2003). Preventing and reducing social
Sharp, S., & Smith, P. K. (1991). Bullying in UK schools: The aggression among girls. The Brown University Child and
DES Sheffield bullying project. Early Child Development and Adolescent Behavior Letter, 19, 6–12.
Care, 77, 47–55. Underwood, M. K., Galen, B. R., & Paquette, J. A. (2001).
Shin, R., Daly, B., & Vera, E. (2007). The relationships of peer Top ten challenges for understanding gender aggression in
norms, ethnic identity, and peer support to school engage- children: Why can’t we all just get along? Social Development,
ment in urban youth. Professional School Counseling, 10, 10, 248–266.
379–388. Walker, I., & Crogan, M. (1998). Academic performance,
Silvernail, D. L., Thompson, A. M., Yang, Z., & Kopp, H. J. P. prejudice, and the jigsaw classroom: New pieces to the
(2000). A survey of bullying behavior among Maine third grad- puzzle. Journal of Community and Applied Social Psychology,
ers. Retrieved February 20, 2005, from http://lincoln.mid- 8, 381–393.
coast.com/~wps/against/bullying.html. Walsh, M. E., Galassi, J. P., Murphy, J. A., & Park-Taylor, J.
Savin-Williams, R. C. (2001). Suicide attempts among sexual (2002). A conceptual framework for counseling psycholo-
minority youths: Population and measurement issues. Journal gists in schools. The Counseling Psychologist, 30, 682–704.
of Consulting and Clinical Psychology, 69, 983–991. Walters, A. S., & Hayes, D. M. (1998). Homophobia within
Savin-Williams, R. C. (2008). Then and now: Recruiting, schools: Challenging the culturally sanctioned dismissal of
definition, diversity, and positive attributes of same-sex gay students and colleagues. Journal of Homosexuality, 35,
populations. Developmental Psychology, 44, 135–138. 1–23.

e spe l age , p ot e at 721

Whitney, I., & Smith, P. K. (1993). A survey of the nature and Ybarra, M. L., & Mitchell, K. J. (2004). Online aggressors/
extent of bullying in junior/middle and secondary schools. targets, aggressors, and targets: A comparison of associated
Educational Research, 35, 3–25. youth characteristics. Journal of Child Psychology and
Williams, T., Connolly, J., Pepler, D., & Craig, W. (2005). Peer Psychiatry, 45, 1308–1316.
victimization, social support, and psychosocial adjustment of Yeh, C. J., Kim, A. B., Pituc, S. T., & Atkins, M. (2008). Poverty,
sexual minority adolescents. Journal of Youth and Adolescence, loss, and resilience: The story of Chinese immigrant youth.
34, 471–482. Journal of Counseling Psychology, 55, 34–48.
Woods, S., & Wolke, D. (2004). Direct and relational bullying
among primary school children and academic achievement.
Journal of School Psychology, 42, 135–155.

722 school-bas ed preven tio n o f pee r p roble m s

 CHAPTER

28 Counseling Health Psychology

Margit I. Berman and Larry C. James

Abstract
Although the involvement of counseling psychologists in health care has raised questions about our
professional identity since the beginning of our field, counseling psychology has made important
contributions to health. Counseling health psychologists have provided theory, interventions, and
research initiatives to enhance primary care and the treatment of pain, chronic illness, and injury;
improve physical rehabilitation; and augment care in cancer, HIV/AIDS, other life-threatening illnesses,
and other health issues. Multicultural expertise, social justice values, and a focus on health promotion
and disease prevention have distinguished counseling health psychology (CHP) as a developing field.
A conceptual framework for CHP is presented, which draws upon core themes of positive health and
wellness, patient-centeredness, and a systems perspective to make recommendations for theory,
research, practice, and advocacy.
Keywords: counseling health psychology, health psychology, health promotion, disease prevention,
wellness, positive health

Health care in the United States and throughout the helping people adjust to the effects of illness and
world has changed dramatically since the birth of injury (vocational rehabilitation of disabled return-
counseling psychology. In 1946, when Division 17 ing soldiers was a major early activity for counseling
was formed, five of the top ten causes of death in the psychologists), it may have seemed, in 1946, that
United States were either accidents, infections, or there was little role for the new discipline in under-
diseases associated with infection, such as nephritis standing or treating physical illness itself.
(National Center for Health Statistics, n.d.). But Today, however, the world has changed. Although
medicine was rapidly changing: The fields of epide- acute infections remain a major killer both in the
miology and public health, and the biomedical United States and worldwide, particularly in low-
model of disease—themselves only about a century income countries, diseases with multiple causes
old—were gathering steam. By 1946, young public and a chronic course, such as heart disease, stroke,
health departments around the world were begin- chronic obstructive pulmonary disease, and lung
ning to analyze statistics and change laws to pre- cancer, now claim many more lives (World Health
vent deaths by accident or infection—helped by Organization, 2008). The role of behavioral vari-
vaccines for smallpox, anthrax, rabies, yellow fever, ables, such as smoking, sexual behavior, psycho-
tuberculosis, and mumps, which by then had all logical stress and strain, or failure to engage in
been developed. Bacterial infections had a new positive self-care, are more evident in the current
enemy in the form of sulfa antibiotics. Penicillin most common causes of death than they may have
was not yet widely available; polio was still a menace. been when bacterial infections claimed millions of
Although psychologists played important roles in lives.

723
 Several authors have observed that counseling concern about the relevance of such involvement
psychologists have much to offer when it comes to for counseling psychologists, have been present
improving health care in a complex world (Alcorn, since the very beginnings of the field. In the original
1991; Klippel & DeJoy, 1984), including holistic draft bylaws of Division 17, composed by John G.
attention to the ecologies or systems in which an Darley and distributed to the provisional member-
individual’s health is embedded; a focus on human ship of the division in 1946, several purposes were
strengths, well-being, and the concept of “positive delineated for the emerging division, including: “to
health” rather than the absence of disease; interest in collaborate with those clinical psychologists who are
diverse and underserved populations; and a develop- primarily attached to medical activities in arriving
mental lifespan perspective. We also have specific at definitions and working relationships between
skills that may be useful in enhancing health care, these related psychological specialties” (Scott, 1980).
such as interpersonal and relationship-building skills This aim captures both the presence of counseling
that may enhance patient compliance, or behavioral psychologists in medical settings, and their multi-
interventions that may target health-related behav- disciplinary, diffuse, and sometimes problematic
iors. Although the involvement of counseling psy- professional identity.1
chologists in health care has raised questions about Neither the presence of nor the tensions inherent
our identity as counseling psychologists and our to counseling psychologists in medical settings
interface with clinical psychology since the begin- at the beginnings of our field should be surprising.
ning of our field (cf. Scott, 1980), we believe that It was in a medical setting—the Veterans Admini-
counseling psychology can make and in fact has stration (VA) hospital system—that applied psy-
made and continues to make an important contri- chology, both counseling and clinical, developed
bution to human health. (Cranston, 1986). After World War II, thousands of
With this thesis, in this chapter, we first sum- veterans returned with physical and psychiatric
marize the history of counseling health psychology problems: 40,000 of them were hospitalized for psy-
(CHP) and some of the major theoretical perspec- chiatric conditions alone. Millions of veterans
tives counseling psychologists have offered to under- applied for training under the G.I. Bill; about 10%
stand human health and illness. We then present an of them had disabilities and would require addi-
overview of major health areas in which counseling tional rehabilitation and counseling. The need for
psychologists are making contributions, including psychological services was profound, and a VA-based
in primary care and in the understanding and treat- training program in clinical psychology—a disci-
ment of specific diseases. Next, we consider two tra- pline that prior to that time served mainly children,
ditional areas of strength for CHP, specifically our not adults—was established in 1946. At the same
attention to multicultural counseling and social jus- time, counseling psychologists were providing voca-
tice issues related to health disparities, and our focus tional and personal guidance to healthy veterans
on positive health promotion and disease preven- through the VA system, as well as vocational reha-
tion. The chapter concludes with recommendations bilitation services to disabled veterans, but their
for research, training, and practice. duties were largely limited to these more traditional
counseling psychology tasks (Cranston, 1986).
A Brief History of Counseling In 1952, however, the VA launched a training
Health Psychology program in counseling psychology similar to that
Counseling psychologists have frequently consid- offered 6 years earlier for clinical psychologists
ered professional involvement in health care, disease (Cranston, 1986). The launch of this formal train-
prevention and health promotion, or behavioral ing program, as well as a number of other concur-
medicine activities as nontraditional or innovative rent and related changes in counseling psychology
activities, distinct from more typical professional as a field, served to open up for counselors greater
roles. Some authors have even expressed concern involvement in a variety of roles, including in health
that counseling psychologists working in health care care and non-VA hospital settings. In 1953, Division
settings may be subject to a loss of professional 17 changed its name from the Division of Counseling
identity, given the distinct role they play and its dif- and Guidance to the Division of Counseling
ferences from “traditional” counseling psychology Psychology, emphasizing a shift in focus away from
(Mrdjenovich & Moore, 2004). educational and vocational guidance and toward
In fact, both professional involvement in health broader roles (Scott, 1980). With the launch of the
and medical care, and also professional tension and VA training program, the doctorate also became

724 coun seling h e alth ps ych o lo g y

required for counseling psychology at the VA, with psychologists, as behavioral medicine specialists, in
the rationale that only doctoral-level psychologists physical rehabilitation as well as vocational reha-
would be equipped to handle vocational rehabilita- bilitation, in neuropsychology, in gerontology, in
tion for profoundly disabled veterans (Cranston, patient education, and in pain management, among
1986), a move that emphasizes the link between other roles (Bernard, 1992). Counseling psycholo-
counseling psychology’s growth as a profession and gists, like other psychologists, had begun to be
our involvement with health and recovery. These interested in health care. The 1979 Annual Review
changes were controversial: By the early 1960s, some of Psychology article on counseling included for the
Division 17 past presidents were lamenting the lack first time a section on “Health Related Outcomes”
of distinction between clinical and counseling psy- including issues such as insomnia, smoking cessa-
chology and the loss of focus on more purely voca- tion, chronic pain, and weight loss (Krumboltz,
tional or guidance concerns (Scott, 1980). Mitchell Becker-Haven, & Burnett, 1979). A chapter on
Dreese, president of Division 17 in 1952–1953, health psychology was included, albeit in the
noted specifically that the fact that clinical psycholo- “Special Issues and Emerging Areas” section, in the
gists practiced mainly in medical settings was one of first edition of the Handbook of Counseling Psychology
the remaining thin lines of demarcation between the (Thoresen & Eagleston, 1984). The same authors
two fields (as cited in Scott, 1980). wrote a major contribution on “Counseling for
Obscured in these early concerns about the Health” for The Counseling Psychologist the following
demarcation of counseling and clinical psychology year (Thoresen & Eagleston, 1985).
in health care was the soon-to-be-growing interest In the midst of this scholarly activity within psy-
among psychologists of all kinds in applying psy- chology, counseling psychologists with experience
chological principles to health concerns. In 1969, in health issues were beginning to emerge out of
William Schofield wrote a seminal American Psycho- VA internships and postdoctoral fellowships into
logist article that launched the field of health psy- other hospital and health care settings. In longitu-
chology via the argument that psychology is a health dinal surveys of counseling psychology training
science, and that applied psychologists were health programs, a consistent trend across time has been
professionals (Altmeier, Johnson, & Paulson, 1998; increasing placement of both predoctoral interns
Matarozzo, 1980). In the 1970s, psychology as a and counseling psychology graduates seeking their
whole took up his charge and became more signifi- first jobs into hospital settings. This is not the result
cantly involved in health issues. The American of growth in the VA system: The percentage of
Psychological Association (APA) established a task counseling psychologists completing internships or
force on health research (chaired by Schofield). taking first jobs at VA settings has remained rela-
Division 18 began a section on health research that tively steady since the 1970s, with about 20% of
rapidly grew and was formally recognized as a divi- counseling psychology students having internship
sion of its own (38; Health Psychology) in 1978. placements and about 5%–6% taking their first
The first doctoral training program in health psy- jobs in a VA hospital. Internships and first job
chology was established in 1977, at the University placements in non-VA hospital settings, in contrast,
of California, San Francisco. By the 1980s, psychol- have increased since the 1970s, such that by 1998,
ogists were considering the definitions and limits of about 23% of counseling psychology interns were
health psychology (Matarrozzo, 1980; Millon, placed in non-VA hospital settings, and nearly 10%
1982; Singer & Krantz, 1982), and training pro- took their first jobs in such settings (Neimeyer,
grams continued to grow, such that by the late Bowman, & Stewart 2001). Counseling psychology
1990s, 50 institutions offered some formal train- has responded to this growth in health psychology
ing opportunity in health psychology (Altmeier, with both excitement about the contributions coun-
Johnson, & Paulson, 1998). seling psychologists can make to health care (e.g.,
Meanwhile, the controversial line between clini- Alcorn, 1991; Altmeier, 1991), as well as fear of a
cal and counseling psychologists in the VA system loss of professional identity or a merger of counsel-
grew even more diffuse. By the 1980s, VA counseling ing with clinical psychology (Fitzgerald & Osipow,
psychologists worked in all the same areas as clinical 1986; Lent, 1990). At the institutional level,
psychologists, with the possible exception of acute Division 17 has reflected the growth of CHP with
psychiatric care. Many of these new roles involved the development and steady growth of a health
health care: By the 1980s, counseling psychologists psychology section. Bylaws for the Division 17
in VA hospitals were working as generic health Health Psychology Section were developed in 1995;

be r m an, jam e s 725

by 2002, the section had 140 members (Mrdjenovich any conveniently modifiable subsystem, which then is
& Moore, 2004). Theoretical approaches to CHP posited to communicate and control related subsys-
have also developed along with this institutional tems at other layers of the hierarchy to improve
growth, emphasizing a perspective on health con- health.
cerns that provides a counterpoint to biomedical Similarly, Hoffman and Driscoll’s (2000) concen-
models of disease and pathology. tric biopsychosocial model of health status focuses on
the development of positive health and wellness, as
Theoretical Approaches to Counseling well as on the amelioration of disease, via a concen-
Health Psychology tric circles model that emphasizes the interactions
Since the pathogenic theory of disease revolution- among and between a variety of variables at three
ized medicine beginning in the mid-19th century, different levels of analysis to influence health status
a biomedical model of disease and health has held (both good health and presence or absence of dis-
sway among physicians and in hospitals, and for eases). Their model rejects an explicitly hierarchical
good reason. But as diseases caused by pathogens approach, with bidirectional interactions between
have succumbed, at least in part, to the incredible elements of the system, in favor of a more complex
advances in medication, vaccination, hygiene, and systems approach that emphasizes the role of psy-
public health made possible by the biomedical chosocial factors as mediators and moderators bet-
model, physicians and researchers have identified ween biomedical and biosocial variables that affect
the limits of this model for understanding illness health status. Psychosocial contributors included in
and wellness, and have articulated the need for a the model are both intrapersonal and interpersonal,
more holistic model of medicine that incorporates including cognitions, attitudes, moods, affect, cop-
psychosocial and biomedical aspects of health ing style, behaviors, interpersonal and functional
(Engel, 1977; Schwartz, 1982). Counseling psy- roles, and interpersonal and institutional supports.
chologists have responded to this demand for a They also identify biosocial contributors as dis-
biopsychosocial view of health and disease with a tinct from biomedical contributors, including
variety of theoretical models that bring traditional variables with both biomedical and socially con-
counseling values and strengths to our understand- structed aspects, such as culture, race, ethnicity,
ing of illness and health. gender, socioeconomic status (SES), environmental
Seeman (1989) applied cybernetics theory and a factors, and sexual orientation. Like the positive
focus on what he described as “positive health” to health model (Seeman, 1989), the concentric biop-
elaborate and extend systems theory in health psychol- sychosocial model includes a systemic, interactive
ogy (Schwartz, 1982). In this model, living systems approach and focuses on positive health promotion,
such as human beings are conceptualized as made up not only the absence or amelioration of disease. It
of hierarchically organized subsystems that interact also emphasizes the complexity of determinants of
with one another bidirectionally across time, using health outcomes, and the need for interventions at
cybernetic processes of communication and control to all levels of the system to create change.
coordinate the subsystems, often in “feedback loop” These two models do not represent the limits of
systems that promote regulation or dysregulation. For counseling psychologists’ contribution to a systems-
a human system to achieve health, all the subsystems based understanding of human health; additional
must function and communicate effectively; dysregu- similar models have been proposed that add to this
lation in any part of the system must be communi- basic approach a more nuanced awareness of feed-
cated and responded to effectively by the other forward as well as feedback mechanisms, additional
elements of the system, a state that Seeman described dysregulatory and developmental processes, and an
as organismic integration. The system hierarchy includes awareness of human beings’ tendency to actively
ecological, interpersonal, environmental, cognitive, self-organize and self-construct their own systems
perceptual, physiological, and biochemical subsystems toward health and illness (Ford, 1987, 1990;
interacting bidirectionally to communicate and con- Nicholas & Gobble, 1990).
trol the individual system; developmental processes In addition to these theoretical models, counsel-
are also included, as the system interacts and develops ing psychologists (Alcorn, 1991; Bor, Miller, Latz &
complexly over time. From this perspective, individual Salt, 1998; Thoresen & Eagleston, 1985) have also
health can be assessed at any stage of wellness or dis- suggested a variety of other theoretical perspectives
ease, and positive health can be promoted regardless of traditional to our field that should be brought to
an individual’s current health status by strengthening bear on an understanding of health psychology,

726 coun seling h e alth ps ych o lo g y

such as the adoption of a developmental, lifespan One important advantage to integrating psycho-
perspective on health; attention to relationship vari- logical services with primary care is that coordinat-
ables, such as attachment to caregivers or health care ing and delivering mental health services in primary
providers; attention to attitudes and beliefs as they care can reduce patient attrition while simultane-
impact health and health care; use of a cognitive ously increasing access, as patients are already famil-
social learning model for understanding and inter- iar with the clinic, and may prefer to have access to
vening with health concerns; and a focus on our psychological services in a familiar, nonspecialty set-
strengths as providers of educational, rather than ting. If patients are seeking psychological services in
medical or remedial interventions, to promote posi- primary care clinics, it may be reasonable for coun-
tive health. Counseling psychologists have also gen- seling health psychologists to provide services there.
erally raised cautions about deterministic models of And, once integrated within a primary care setting,
health and well-being in favor of dynamic models there may be unique opportunities for counseling
that express hope for human growth and change health psychologists to enhance not only mental
even under conditions of disease and adversity health treatment, but overall health care for patients
(Elliott & Shewchuk, 1996). seen in the integrated setting.
Using these and similar theoretical perspectives Counseling psychology training and experiences
to ground their work, counseling health psycholo- may be uniquely well suited to primary care service
gists have offered innovative benefits in a variety delivery, particularly because counseling psycholo-
of medical and hospital settings, to address a variety gists are traditionally trained to see health, strength,
of health problems. The work of these psychologists and resilience in our patients. Counseling psycholo-
is considered next, first in a section discussing the gists may also be well trained in prevention, in the
role of counseling psychologists in primary care, promotion of well-being, and in behavioral inter-
and next in a section considering the application of ventions. Because patients often come to primary
CHP to a variety of specific health concerns. care clinics for regular health maintenance, patients
seen there are often diagnosed with both physical
Counseling Psychologists in Primary Care and mental health problems relatively early in the
When Americans have problems in living, many of disease process, when strengths-based and preven-
them do not seek out the services of a psychologist. tive interventions may be more effective and prob-
In fact, most Americans receive mental health ser- lems may be more amenable to change. For example,
vices from their primary care provider (Narrow, many type 2 diabetics are seen and identified at the
Reiger, Rae, Manderscheid, & Locke, 1993), rather prediabetes stage by their primary care provider.
than from either a psychologist or a psychiatrist. At this juncture in the disease process, psychoeduca-
Primary care physicians prescribe 67% of all psy- tion and healthy lifestyle interventions delivered
chotropic medications, and as many as 70% of all by a well-trained counseling health psychologist can
primary care patient visits have a primary underly- be efficacious. Similarly, identifying and intervening
ing psychosocial basis rather than a medical cause with difficulties in mood in response to a major life
for the presenting symptoms (James, 2006). Several stressor soon after the event, rather than when the
authors (Cummings, Cummings, & Johnson, 1997; problem has escalated to a major depressive episode
James & Folen, 2005; O’Donohue, Byrd, Cum- and the patient presents in a mental health clinic,
mings, & Henderson, 2005; Strosahl, 2005) have may permit more rapid improvement in psycho-
therefore concluded that the primary care setting logical symptoms, as well as effective use of shorter,
is the largest de facto mental health care system focal interventions.
in the United States. Although primary care clinics What does a counseling health psychologist do
may not be the obvious or currently the ideal set- in a primary care clinic? James and Folen (2005,
ting for mental health services, traditional mental adapting the work of Frank, McDaniel, Bray, &
health care in the United States is also plagued with Heldring, 2004) have defined primary care psychol-
difficulties. Mental health services in the United ogy as “the provision of integrated care that includes
States are disorganized, and care is often fragmented; the prevention of disease and the promotion of
attrition rates are high, and the great majority of health behaviors in individuals, families and com-
psychologically distressed individuals receive no munities via the primary care setting. Primary Care
mental health care even when care is free (Regier Psychologists are experts in: (a) assessment & evalu-
et al., 1993; Ware, Manning, Duan, Wells, & ation of common psychosocial symptoms seen in
Newhouse, 1984). the primary care setting; (b) able to distinguish

be r m an, jam e s 727

between symptoms associated with a medical dis- the patient’s physician to share information about
ease and a mental health condition; (c) collaborate the patient’s diagnosis, treatment plan, goals, and
with primary care teams; (d) have the knowledge to recommendations.
triage appropriately; (e) have an understanding of One question that arises in considering the inte-
biomedical conditions commonly seen in primary gration of CHP with primary care is: Is this effec-
care and applicable pharmacological interventions.” tive? A series of pilot projects conducted in the
Primary care counseling health psychologists play Kaiser Health System in California and a Native
several roles. They serve as the primary care clinic’s Hawaiian Community Health Clinic in Hawaii
resident consultants on patient behavioral health, suggested that integrating psychological services
behavior management, interpersonal communica- into primary care could offer cost-effective and effi-
tion skills, and mental health resources and referral. cacious service to address primary care patients’
They may teach, supervise medical residents, or mental and physical health concerns from a behav-
conduct research. Primary care counseling health ioral medicine perspective (Cummings, et al., 1997).
psychologists also provide direct patient care, usu- Patient satisfaction increased, access to mental
ally from a brief, consultative model. health care improved, and primary care providers
Rowan and Runyan (2005) provided a model for (PCPs) were pleased with being able to consult with
the conceptual organization of a 30-minute primary the psychologists whose offices were now colocated
care CHP treatment session. This brief session is with them.
divided into three parts: introduction and assess- Since these initial studies, counseling health psy-
ment, intervention, and follow-up. In the introduc- chologists have continued to integrate an ever-
tion and assessment phase the psychologist sets the expanding array of services into the primary care
conceptual framework for the office visit. The intro- setting, including interventions for obesity and
duction and assessment phase has two goals; first, to weight loss (Bacho, Myhre, & James, 2008; James
help patients understand that the appointments are et al., 1997; James, Folen, Page, Noce, & Britton,
brief and goal-oriented, and second, to ascertain the 1999), diabetes (Earles, 2005), insomnia (Isler,
patient’s needs, whether for referral to longer-term Peterson, & Isler, 2005), depression (Jarrett, 2008),
therapy, psychoeducational interventions, or access heart disease (Kop, 2005), smoking cessation (Lavin,
to other resources, such as support groups. A critical 2008), HIV/AIDS (Law & Buermeyer, 2005),
part of the assessment phase is prescreening: Patients improved medication adherence (Levensky, 2005),
are given self-report questionnaires at every session pain management (Otis, Reid, & Kerns, 2005), and
to screen for suicidal ideation and major psychiatric women’s health (Poleshuck, 2005). Several authors
disorders and to quantify the patient’s progress. have also suggested that primary care counseling
Instruments such as the OQ-45 can be adminis- interventions need not be limited to adults. Clay
tered in 8–10 minutes on a computer, a PDA, or in and Stern (2005) and Etherage (2005) have concep-
paper and pencil form. The psychologist quickly tualized pediatric clinics as part of the primary care
reviews the results of these screening measures to psychology model. Etherage provided six case exam-
help guide and focus the discussion on the patient’s ples of providing primary behavioral health services
most pressing concerns. The second phase is the to children in pediatric clinics. Etherage described
intervention phase. In this phase, the psychologist the conceptual framework for the delivery of ser-
provides the patient with brief cognitive-behavioral vices in this setting, as well as criteria for an effective
coping strategies and bibliotherapy in the form of pediatric primary care consultant. McDaniel and
handouts, books, or websites to help patients man- Hepworth (2004) described the delivery of family
age their concerns independently. In the follow-up therapy in the primary care setting.
phase, the psychologist integrates the information Although counseling health psychologists in pri-
obtained from the referring physician and the mary care settings provide enormous opportunities
patient and devises a plan in the form of a “prescrip- for improved patient care and enhanced health and
tion.” This prescription may be written on the well-being, there are also pitfalls for counselors
familiar physician’s prescription pad, and may list working and researching in this setting. Training
goals for the patient, websites, and/or the critical resources and opportunities specific to the needs of
things to be done prior to the next visit. Feedback is counseling psychologists in primary care are scant
also provided to the physician in this phase; ideally, or nonexistent, and counseling psychologists must
at the conclusion of the initial appointment, the therefore adapt more general training materials in
psychologist and patient actually walk next door to health psychology. Many of the core competency

728 coun seling h e alth ps ych o lo g y

areas for a psychologist in primary care, such as counseling skills in positive psychology and preven-
competence in the interaction of biology and behav- tion to enhance human health and well-being.
ior, human anatomy, physiology, pharmacology, DeLeon, Rossmando, and Smedley (2004) envi-
and pathophysiology (McDaniel, Hargrove, Belar, sioned a future in which the services that psy-
Schroeder, & Freeman, 2004), may not be available chologists provide will take on a larger role in health
even as electives in counseling psychology training care, prevention, medicine, and daily living for all
programs or even in hospital- or clinic-based psy- Americans, leading to more affordable and quality
chology internships and postdoctoral fellowships. health care that is available to more people. Some
Issues of professional identity can also be prob- counseling health psychologists (James & Follen,
lematic for the counseling health psychologist prac- 1999) even envision that we may become the pri-
ticing in primary care. Altmaier (1998) highlighted mary health care managers and coordinators of the
many of the pitfalls with professional identity for future, as we employ our unique skills to enhance
psychologists working in medical settings. The lure health-related behaviors, provide behavioral consul-
of the “white lab coat” may create confusion in pro- tation to individual and organizations, and use
fessional identity or raise colleagues’ concerns. James research to inform practice to become invaluable
(2009), for example, described the initial impres- contributors to health care of the future.
sions of the senior psychologists in his department
when he returned from an inpatient surgery ward Counseling Psychology and Specific
wearing a lab coat. His colleagues were chagrined Health Concerns
and alarmed and could not apprehend why any In addition to expanding involvement in primary
psychologists would wear a lab coat. James was told care settings, counseling health psychologists have
“after all, you’re not a doctor,” by a senior member applied counseling psychology methods, values,
of his department. It is common for primary care research, and conceptual models to tackle serious
departments to have one lone psychologist, which and chronic health concerns that extend beyond the
can lead to professional and personal feelings of scope of primary care. A review of every disease or
isolation. Without a plan to stay connected to the specific health issue that counseling psychologists
psychology department, primary care psychologists’ have addressed in research or practice is beyond the
professional identity can begin to shift away from scope of this chapter. However, in this section, we
psychology. Attending psychology grand rounds, provide an overview of some major diseases and
supervising psychology interns, and retaining for- health issues with which counseling psychology has
mal and service links to a hospital psychology been concerned, highlighting changes over time as
department can help lessen this isolation and loss of well as specific contributions counseling psycholo-
identity. gists have made. We make no effort here to provide
Ethical concerns also arise for counseling health a comprehensive review of research in each area;
psychologists in primary care. In a medical clinic instead, we highlight illustrative studies to demon-
setting, psychologists need basic knowledge of psy- strate CHP’s unique contribution to knowledge
chopharmacology, pathophysiology, anatomy, and and social change in each area. We conclude this
how to interpret laboratory studies. However, there section by identifying themes, values, and areas of
may be pressure to use medical information or to strength in these contributions by counseling psy-
practice in ways that extend beyond our competen- chology, to set the stage for our consideration of
cies as psychologists. For example, some primary our professional strengths and values in more detail
care physicians lack confidence in prescribing psy- in the following sections.
chotropic medications, and may seek guidance from
resident counseling health psychologists; counseling pain
health psychologists have to be careful to respect the Counseling psychologists have been interested in
limits of their knowledge and facilitate consultation chronic pain for decades; the 1979 Annual Review
with appropriate professionals (e.g., a psychiatrist) of Psychology article on counseling psychology
when asked for advice that goes beyond our profes- (Krumboltz et al., 1979) included pain control
sional competencies. (along with insomnia, weight control, and smoking
Despite the potential pitfalls that face counseling cessation) in a section on health-related outcomes of
health psychologists in primary care, the opportu- importance to counselors, stating in its summary of
nity to provide innovative services in this setting the research to date that “Counselors can help cli-
may offer tremendous potential to use traditional ents to control the perception of physical pain by

be r m an, jam e s 729

teaching them how to relax and how to use relevant with disabilities because they may prepare us to
cognitive coping strategies” (p. 567). Since that ini- adopt a social/educational rather than medical
tial summary, counseling psychologists have focused model of disability, and to understand and incorpo-
on developing and testing treatments for chronic rate the “new paradigm” of disability, which repudi-
physical pain. One experimental trial, for example, ates a medical model of disability and emphasizes
compared standard inpatient rehabilitation and issues of oppression, power, civil rights, and the
physical therapy with standard therapy enriched social construction of ability and disability, while
with training in relaxation, coping skills, and con- focusing on enhancing independent living (National
tingency management for exercise behavior, finding Institute on Disability and Rehabilitation Research,
that both treatments were effective (Altmaier, 1999). Psychologists have been criticized for their
Lehmann, Russell, Weinstein, & Kao, 1992). Cou- failure to develop knowledge and skills reflective of
nseling psychologists have also conducted research the new paradigm, instead treating the presence of
to identify the components or mechanisms of effec- physical disabilities in their clients as a “medical
tive treatment for chronic pain, demonstrating, for condition” requiring the services of a rehabilitation
example, that imagery and relaxation training are specialist, instead of an aspect of human identity
particularly powerful elements of stress inoculation and development with which all psychologists
therapy for increasing pain tolerance (Hackett & should be concerned and familiar (Olkin & Pledger,
Horan, 1980; Worthington & Shumate, 1981) or 2003).
that increases in self-efficacy beliefs during treat- Although counseling psychology graduate train-
ment for chronic pain predicted long-term outcome ing programs continue to do a poor job of providing
(Altmaier, Russell, Kao, Lehmann, & Weinstein, training in disability, with few courses in disability
1993). Fewer studies of chronic pain have appeared available and fewer still that approach disability
in counseling psychology journals in recent years, from a new paradigm perspective (Olkin & Pledger,
as the field of behavioral pain management has 2003), there is some evidence that counseling psy-
matured and become more specialized; counselors chology could emerge as a leader in a new paradigm
continue to do this work, and to provide guidance approach to human disability. Counseling health
about how to address chronic pain with cognitive psychologists have been active in emphasizing the
behavioral interventions (Okey, 1998). degree to which disability and chronic illness are
normal developmental tasks eventually faced by
chronic illness, injury, and most adults, and in identifying the intersection
rehabilitation between work and chronic illness or disability as
Counseling psychology has a long history in the a typical midcareer challenge that counseling psy-
rehabilitation of disabled individuals. Vocational chologists must address (Chwalisz, 2008). Coun-
rehabilitation of disabled returning soldiers in World seling health psychologists have helped define the
War II was a foundational initial activity for the ways that disability is imposed on our clients
field, as previously noted. Even apart from voca- through environmental, personal, and social factors
tional rehabilitation, counseling psychologists have that limit their full participation in all aspects of
provided services in substantial numbers in rehabili- life, rather than as the result of a disease or injury
tation settings for decades (Parker & Chan, 1990). per se (Peterson & Elliott, 2008).
The advantages that have been described for coun- Research in vocational psychology in particular
seling psychologists in rehabilitation echo those for has begun to attend to disability from a new para-
counseling health psychologists in general. Coun- digm perspective, as counseling psychologists learn
seling psychologists’ background in vocational psy- more about disability as one of a number of inter-
chology, multicultural and social justice issues, and secting elements of identity that shape career devel-
developmental, lifespan concerns make them uni- opment. Mpofu and Harley (2006), for example,
quely well-suited to working with individuals adjust- reviewed the intersection of African American
ing to disability, who may face vocational challenges, and disability elements of identity as they affect
discrimination and oppression based on their dis- career development, whereas Noonan et al. (2004)
ability or other factors, and changes in their abilities conducted a qualitative study of highly achiev-
to navigate developmental tasks (Chwalisz, 1998). ing women with disabilities. In both cases, these
These traditional counseling psychology strengths researchers emphasized the complex interactive
may make counseling health psychologists well- nature of various aspects of identity (including dis-
poised to enhance rehabilitation for individuals ability) with the world of work, and also identified

730 coun seling h e alth ps ych o lo g y

specific ways that these multiple identities could be cope with the demands of the illness at various
used as assets or strengths, as well as the basis of stages in the disease process. Self-efficacy in turn
oppression and discrimination in the world of work. affects the individual’s adjustment, quality of life,
and longevity. Although this model is overly sim-
cancer and other life-threatening plistic in terms of explanatory power (e.g., we would
illnesses expect disease stage at diagnosis to have direct
Early CHP research on cancer tended to focus as well as mediated effects on longevity), it serves as
on the process of death and dying, as viewed from a valuable guide for counselors, who can assess the
both patient and counselor perspectives, finding, variety of factors that may impact an individual’s
for example, that religiosity and previous experience sense of self-efficacy in coping with life-threatening
with death and dying were related to less fear of illness, and then bolster self-efficacy indirectly
death among indigent cancer patients (Gibbs & through improving these factors or directly via
Achterberg-Lawliss, 1978), or that terminal cancer interventions designed to increase clients’ confi-
patients had less death anxiety overall and over time dence in their ability to cope with illness.
than those with other chronic but non–life-threat- In addition to self-efficacy, counseling health
ening illnesses (Dougherty, Templer, & Brown, psychologists have also investigated other psycho-
1986). Fear of cancer was also identified as an logical factors and means of coping that may assist
important variable to explain why counselors in individuals with their progress through life-threat-
experimental settings were less helpful with patients ening illness, making medical decisions, and healing
with cancer than with clients with other comparably from or adjusting to disease. Depth of processing
serious disabilities (Pinkerton & McAleer, 1976). information relevant to making a decision about
More recent research, however, has emphasized medical treatment, for example, has been shown to
adaptive means for cancer patients to adjust to and be associated with how well cancer patients cope
even grow from their experience with life-threatening with illness. When an important medical decision
disease. Merluzzi and Sanchez (1998) described arises, cancer patients who engaged in thoughtful,
a developmental model of coping with cancer and effortful processing of relevant information, seeking
life-threatening illnesses in order to inform coun- out information on their own, and actively choos-
selors about the processes required to cope adap- ing an approach for their treatment, used more
tively at each stage, from diagnosis through treatment effective, active coping strategies, had greater posi-
and post-treatment (although their model did not tive focus, and were better able to find meaning in
include a stage for terminal or end-of-life coping, their situations, than were those who simply fol-
which they acknowledge as a limitation). For exam- lowed their doctors’ advice. This was true regardless
ple, they describe the diagnosis phase in cancer of the stage of cancer diagnosis or the prognosis,
as one in which uncertainty and anxiety are often suggesting that patients who most readily accept
very high, and may be ameliorated somewhat by the advice from their physicians (and may be perceived
process of committing to a treatment plan, whereas as “good” patients) may be at increased risk of dif-
in the treatment phase, chemotherapy drugs them- ficulty adjusting to illness at any stage of treatment
selves may cause psychological symptoms that may (Petersen, Heesacker, & Marsh, 2001).
overwhelm previously psychologically healthy cli- Being able to find benefits and meaning in the
ents. At post-treatment, even when treatment is suc- experience of life-threatening illness has been
cessful, fear of recurrence and/or adjustment to found to be more generally important, predicting
changes in functioning may cause difficulties. These both better psychological and physical functioning
researchers point out that demands may overwhelm in bone marrow transplant patients, for example,
coping resources at any phase in this process, and 2 years later (Tallman, Altmaier, & Garcia, 2007).
they developed a model of successful adjustment to Using religious beliefs and resources (e.g., church
life-threatening illness to conceptualize how coun- ties) to cope is also beneficial: Religious coping
selors could foster such adjustment. strategies were associated with improved adjustment
In this model (Merluzzi & Sanchez, 1998), a both concurrently and over time among both kidney
variety of psychological, disease, treatment, social, transplant patients and their spouses (Tix & Frazier,
and environmental factors, such as premorbid psy- 1998). Social support is well-known as an impor-
chiatric problems, disease stage at diagnosis, treat- tant element of positive health, but counseling
ment aggressiveness, social support, optimism, and health psychologists have pointed out that the qual-
other life events, lead to changes in self-efficacy to ity of the relationship in which the support is

be r m an, jam e s 731

enacted may matter more for recovery from life- to social communities of other gay men, AIDS
threatening illness than the support behaviors or could serve as an impetus to homophobia and
perceptions of support themselves (Frazier, Tix, & targeted violence or other negative impacts from
Barnett, 2003). One problem with the literature on stigma; could serve to “out” individuals who were
effective coping with life-threatening illness is the previously closeted, causing distress or exposure to
lack of theoretical consensus regarding the relations violence; could trigger feelings of grief as valued
among various variables known to be adaptive for members of gay communities became ill (“AIDS-
cancer sufferers. Social support, for example, has related bereavement”); or could permit positive out-
been described as a predictor of an important medi- comes, such as improved access to medical care and
ator (e.g., self-efficacy, Merluzzi & Sanchez, 1998), social support via clinics and activist groups com-
a mediating variable (e.g., between religiosity and prised of and for gay men. For women, people of
adjustment, Tix & Frazier), and an outcome (e.g., color, heterosexuals, or IV drug users, on the other
of better depth of processing of medical decisions, hand, AIDS could serve to further isolate or inhibit
Petersen et al., 2001). access to health care and social support, while rais-
ing issues of misidentification, stigma, and shame.
hiv/aids Since this early seminal work, CHP research,
As with cancer and other life-threatening illness, theory, and practice relevant to PWHIV have con-
early CHP research and theory about HIV/AIDS tinued to evolve to reflect changes in the spread
focused on end-of-life issues and controversies, such and treatment of HIV. The development of highly
as “rational suicide” (Rogers & Britton, 1994; active antiretroviral therapy (HAART) as a treat-
Werth, 1992), and on counselors’ fear of HIV and ment for HIV in the mid-1990s dramatically shif-
their consequent anxiety and discomfort in work- ted the outcome of HIV from almost certain
ing with affected individuals (Hayes & Gelso, progression to AIDS and death, to a more manage-
1993). Important parallels between HIV/AIDS able chronic illness, such that patients taking
and cancer or other life-threatening illnesses were HAART drugs can remain essentially free of HIV
identified, with some authors suggesting that the virus indefinitely, as long as they remain on the
process of coping with the course of these illnesses, medications. However, HAART comes with seri-
as well as adaptive coping behaviors, should be ous challenges, including high financial cost, com-
similar (Merluzzi & Sanchez, 1998). However, early plicated drug regimens (sometimes requiring
researchers also identified important differences in combining three or more different drugs at multi-
the needs of persons with HIV (PWHIV) compared ple, specific times each day), and potentially serious
to persons with other life-threatening illnesses. side effects. The provision of HAART therapy thus
Hoffman’s early work on PWHIV in particular raises both behavioral (e.g., medication adherence)
(Hoffman, 1991, 1993) emphasized the psychoso- and social justice (e.g., considerations of how or
cial and multicultural elements unique to HIV/ whether to provide medication to those who can-
AIDS at the beginning of the epidemic. Her psy- not afford it) issues of interest to counseling health
chosocial model of HIV infection encouraged coun- psychologists.
selors to consider the special characteristics unique The spread of the epidemic has also changed
to HIV/AIDS infection, such as the disruption in ways of importance to counselors seeking to
created by the (then rapidly progressive and fatal) understand or help PWHIV. In the United States,
disease for young people’s developmental life course initial HIV infections were mainly among white
and timing, as well as the profound legal and social gay men, intravenous drug users, and people who
stigma experienced by seropositive individuals had received contaminated blood products through
early in the epidemic, when, for example, nearly medical care. Currently, however, new HIV infec-
half of Americans surveyed reported that they tions in the United States disproportionately
would refuse to work with an individual with affect African Americans. Nearly 50% of new HIV
AIDS (Blendon & Donelan, 1988). infections in 2005 were in African American men
Hoffman (1993) also considered multicultural and women, and 70% of infants born with HIV
issues and the intersection of identity in prescient were African American. HIV infections in women
detail, describing how AIDS diagnosis and pro- are also growing rapidly, such that women now
gression affected individuals from a variety of cul- account for 31% of new infections (Werth, Borges,
tural groups differently. As she described, for white McNally, Maguire, & Britton, 2008a). Worldwide,
gay men who lived in metropolitan areas with access women now account for 50% of the world’s new

732 coun seling h e alth ps ych o lo g y

HIV infections in adults; half of all new HIV infec- programs (Schmidt, Hoffman, & Taylor, 2006),
tions are in children and young people under age 25 and direct political advocacy (Werth, Borges,
(Joint United Nations Programme on HIV/AIDS, McNally, Maguire, & Britton, 2008b) have all been
2008). used to enhance our understanding of PWHIV, as
As it has spread, HIV has increasingly emerged well as to promote vocational, psychological, and
as a social justice issue, in that who acquires HIV physical health and wellness for PWHIV.
infection, and how the infection proceeds once it
has been acquired, is strongly and increasingly influ- Multicultural and Social Justice Values in
enced by socioeconomic class and access to com- Counseling Health Psychology
modities associated with class and other forms of As the foregoing review of CHP involvement in
privilege, such as health care, economic means to primary care and in the prevention, understanding,
pay for medication, and freedom from rape or oth- and treatment of various specific health concerns
erwise coercive or economically motivated sexual makes clear, CHP may be distinguished from
interactions. Members of traditionally disenfran- other health disciplines and from health psychology
chised groups are at increased risk of acquiring in general by its emphasis on bringing core coun-
HIV infection, and may become more disenfran- seling strengths and values to the health arena.
chised as a result of the infection itself, via economic In the following sections, we explore these values
deprivation, discrimination, disability, or other neg- and strengths in more depth. In this section, we
ative outcomes (Werth, Borges, McNally, Maguire, focus on multicultural and social justice values as
& Britton, 2008b) they inform CHP. In the next section, we focus on
As a result, counseling health psychologists have health promotion and prevention as guiding prin-
grown increasingly interested in HIV as a social jus- ciples that have shaped—and we hope will continue
tice issue and as an arena with potential to unite to shape—counseling’s contribution to human
a variety of traditional counseling psychology values health in the future.
and concerns. Recently, counseling psychologists Social justice is a core value for counseling
with interest in the interface of health and voca- psychologists and integral to both the history and
tional concerns have pointed out that even though current aims of the field. Frank Parsons, the father
our traditional interests and values as counsel- of vocational psychology, focused in the 1900s
ing psychologists, such as multiculturalism, voca- on vocational counseling as a tool for sociopolit-
tional development, strengths-based interventions, ical change and access to equity for young men
and social justice, lend themselves well to address- in impoverished areas of Boston (Fouad, Gerstein,
ing the holistic needs of individuals with chronic & Toporek, 2006). Similar concerns and interests
health concerns, in practice we have done a rela- informed counseling psychologists working with
tively poor job of integrating these traditional values veterans in the 1940s and 1950s, with home-
to help people and cause community- and social- lessness and community mental health in the
level change (Werth, Borges, McNally, Maguire, & 1960s, and with civil rights and feminism in the
Britton, et al. 2008b). 1960s and 1970s (Fouad, Gerstein, & Toporek,
These psychologists have offered HIV and 2006). This interest in social justice endures. At the
PWHIV as a case study example in which CHP, 2001 National Counseling Psychology Conference
PWHIV, and our broader communities would ben- in Houston, for example, more than 40% of con-
efit by increased integration of core counseling ference attendees signed up for one or more social
psychology interests and values (Werth, Borges, action groups, which worked throughout the con-
McNally, Maguire, & Britton 2008a, b). Further- ference and beyond developing action plans to
more, these psychologists describe how counseling address issues such as racism, domestic abuse, and
health psychologists can both increase our under- violence; 88% of conference attendees indicated
standing of HIV and promote the dissemination of strong support for social justice activities as impor-
the counseling psychology knowledge base for tant to the field of counseling psychology (Fouad
positive social change, via a variety of methods. et al., 2004).
Participatory, action research paradigms and Because social justice is inherently concerned
qualitative research methods (Maguire, McNally, with the equitable distribution of advantages and
Britton, Werth, & Borges, 2008), training-research- disadvantages among individuals and groups in
service partnerships between community agencies society, counseling psychologists’ interest in social
serving PWHIV and counseling psychology training justice has often been closely linked to our traditional

be r m an, jam e s 733

expertise in multicultural counseling (Fouad et al., assure that we have something necessary to offer our
2006). Counseling psychologists have a consider- health care colleagues (Tucker, Ferdinand, et al.,
able strength in multicultural counseling and ther- 2007). Specifically, these authors suggest that coun-
apy. The field has been at the forefront of developing, seling psychologists can ameliorate health dispari-
training, and researching cultural competence in ties by using their unique expertise in health care
counseling and psychotherapy; writing essential and settings to take on roles such as health care staff
widely adopted texts in the area (e.g., Sue & Sue, trainer and consultant (with a special focus on train-
1999); and demonstrating leadership in developing ing health care colleagues in culturally competent
guidelines for multicultural competence for psy- health care delivery), patient and community health
chologists as a whole (e.g., American Psychological empowerment coach (including facilitating contact
Association, 2003). and collaboration between indigenous health care
These strengths in social justice and multicul- providers and more traditional medical providers),
tural issues are of exceptional importance in health public policy advocate, health counselor and psy-
care. There is abundant evidence that simply belong- chotherapist, and health care researcher.
ing to various groups, as well as specific experiences Indeed, counseling health psychologists have
of group-based oppression, bias, and discrimina- already begun to develop important theory, research,
tion, negatively impact health and health care. For training, interventions, and assessments designed to
example, African American patients are more likely understand and eliminate health disparities. In the
than whites to experience amputations (Gornick process, they have also generated important cri-
et al., 1996), but less likely to receive analgesics tiques of existing research and health practice as it
when they are seen in emergency rooms for bone affects individuals from a variety of cultural groups.
fractures (Todd, Deaton, D’Adamo, & Goe, 2000). They have identified a variety of variables that con-
Whites and men are more likely to be referred for tribute to the existence and maintenance of health
cardiac catheterization to diagnose heart disease disparities for people from diverse groups and have
than African Americans and women (Schulman made efforts to explain how aspects of culture may
et al., 1999). Medicare recipients who are least afflu- influence health outcomes.
ent are much less likely to receive mammograms or Factors that influence health for group members
influenza immunizations compared to the most may be divided into biological variables, behav-
affluent (Gornick et al., 1996.). Women from a vari- ioral and psychological variables, and social or envi-
ety of ethnic groups have as much as a 200% greater ronmental variables (Anderson, 1998, as cited in
risk of mortality following a breast cancer diagnosis Tucker, Ferdinand et al., 2007). Biological, behav-
than do non-Hispanic white women (Li, Malone, ioral, and psychological variables, in turn, may be
& Daling, 2003). Differences by racial or ethnic classified as “micro” or individual factors affect-
group, gender, SES, and other group memberships ing health for group members, whereas social and
(e.g., sexual orientation, geographic location) have environmental variables are “macro” or systemic fac-
been demonstrated across the developmental spec- tors (Hopps & Liu, 2006). In the broader literature
trum of health care, from variables that may affect on health disparities, extensive and programmatic
need for health care, such as health knowledge; to attention has been paid to understanding and devel-
health behaviors such as smoking or exercise, or oping interventions to address micro factors. Coun-
attitudes toward medical care; to access to and cost seling health psychologists have also been involved
of care; to bias and poor treatment once in the med- in innovative ways in addressing micro-level vari-
ical system in terms of diagnosis, recommendations, ables, including biological and genetic variables,
referrals, and treatment received; to outcomes such and incorporating these into a lifespan developmen-
as life expectancy, morbidity, and mortality from tal, biopsychosocial approach; for example, in devel-
disease (Tucker, Ferdinand, et al., 2007). As a result, oping a CHP approach to genetic counseling (Kaut,
there has been both increased research and increased 2006).
federal funding for research to eliminate these However, counseling health psychologists also
group-based health disparities. have pointed out that intense attention on micro
Some authors have observed that the stark injus- factors, although obviously useful, is nevertheless
tice revealed by research into health disparities problematic for several reasons, including poten-
should compel counseling psychologists to become tially diverting attention from macro factors that
involved in this area, whereas our traditional skills may be the primary cause of health disparities,
in providing multiculturally competent health care “blaming the victim” through the implication that

734 coun seling h e alth ps ych o lo g y

minority groups affected by health disparities are control, with both variables affecting health directly
inferior biologically or psychologically, reifying and in interaction. For social justice–oriented coun-
racial or other group-based stereotypes, or attempt- seling health psychologists, the social and political
ing to change intractable individual-level behaviors, community in which people live must be seen as
which, even if improved, would not affect larger part of any given health problem, to be considered
sociopolitical imbalances (e.g., if micro-level differ- independently as a consumer or participant for
ences such as increased smoking among low-SES research or intervention (Roysircar, 2006).
individuals were eliminated through research or Because there is a risk that the health care com-
intervention, low SES would remain and continue munity may replicate aspects of the social environ-
to cause health disparities in other areas; Tucker, ment that create health disparities for diverse groups
Ferdinand et al., 2007; Hopps & Liu, 2006). (Herman et al., 2007), recent CHP attention has
Instead, counseling health psychologists have focused on identifying and reviewing macro-level
called for a focus on systemic, macro variables as social and environmental characteristics of the
mechanisms to explain health disparities, while also health care environment that contribute to health
giving appropriate attention to micro-level, and disparities. Tucker, Ferdinand et al. (2007) identi-
particularly psychological, variables that may affect fied several aspects of the health care environment
health. Social class has been one area of particular already demonstrated to contribute to health dis-
interest for researchers interested in health dis- parities. These included health care quality factors
parities, because SES consistently emerges as one (such as evidence that low-income ethnic and racial
of the strongest predictors of morbidity and mortal- minority groups receive poorer quality of health
ity (Angell, 1993), and because SES operates as care even when they have health insurance and
an influence on health in an intriguing, graded fash- similar health problems compared to others; Insti-
ion, such that even within social classes, those at the tute of Medicine, 2003) and access to care factors.
lower end of the class continuum are less healthy Access to care factors include impaired entry into
than those of higher status. In other words, not the health care system because of lack of insurance
only is it the case that those in poverty are less or lack of a usual source of health care; structural
healthy than those whose basic needs are met, but barriers to care within the health system, such as
even among the wealthy, the very wealthiest are lack of geographic availability of health care, lack of
healthier than the less wealthy (Adler & Conner transportation or work-convenient hours; difficul-
Snibbe, 2003). Counseling health psychologists ties with patient–provider communication because
have pointed out that several micro-level variables of language barriers, inappropriate language use by
have emerged as important mediators of this rela- providers, illiteracy or difficulties with health liter-
tionship between social class and health, including acy, differences in health-related beliefs between
patterns of health risk behaviors; feelings of control, patients and providers; and lack of provider cultural
security, and ability to cope; social support; negative competence and cultural sensitivity.
cognitions; and self-perceptions of social status Counseling health psychologists have demon-
(Herman et al., 2007; Hopps & Liu, 2006). strated leadership in attending to both macro- and
By comparison, macro-level variables have micro-level variables (and their interactions) in
received relatively little research or intervention understanding and intervening upon health prob-
attention as mechanisms to explain health dispari- lems, as well as in creating positive health and well-
ties. Interactions between micro- and macro-level being. However, they have also contended with a
variables have received even less attention. Never- variety of difficult conceptual and practical prob-
theless, certain systemic variables have emerged as lems in their efforts to eliminate health disparities.
important for various groups. Experiences of opp- Counseling health psychologists have joined with
ression, for example, may account for the relation- other health professionals in calling for the provi-
ship between perceived control or stress and health sion of multiculturally competent and sensitive
for minority groups. Racism and discrimination health care (Herman et al., 2007: Institute of
may also exert direct effects on health; racial dis- Medicine, 2003), but they have also described how
crimination is linked to hypertension in African the lack of a clear definition of “cultural competence”
Americans, for example (Williams & Neighbors, or “cultural sensitivity” create barriers to achieving
2001). These macro-level factors likely interact with this goal. In addition, counseling health psycholo-
micro-level variables complexly: For example, gists have highlighted the overfocus in the cultural
discrimination may lead to decreased perceived competence literature on the health care provider as

be r m an, jam e s 735

the center of cultural competence, rather than also make participating in socially just efforts to
paying attention to cultural competence as a improve health for diverse populations more diffi-
function of the interaction among the patient, pro- cult. These barriers include those common to coun-
vider, and health care environment. Both of these seling psychology in any health care setting, such as
problems—lack of clear definitions of cultural sensi- perceived lack of role fit between counseling and
tivity and an overfocus on health care providers as a medicine, either by medical providers or by coun-
source of such sensitivity—have impeded effective seling psychologists themselves; lack of adequate
research, training, and implementation of culturally power or status to effect change in medical settings;
competent health care to address health disparities and lack of funding for psychologists to take a
(Herman et al., 2007). research, consultative, or interventive role to imp-
Terms such as “cultural sensitivity,” “cultural lement interventions (Tucker, Ferdinand et al.,
competence,” and “culturally responsive” have all 2007). Lack of access to communities and individu-
been used in the counseling and health care litera- als who do not present for health care may also be
ture; although these terms have been distinguished a problem (Roysircar, 2006). Counseling health
from one another in various ways, their definitions psychologists may also be daunted in their efforts to
also overlap, and counseling psychologists have provide culturally competent or sensitive health care
also critiqued these terms. The term cultural sen- by the need to know detailed cultural information
sitivity, for example, has been criticized by coun- about all groups and intersections among groups
selors because it has various meanings and has been that occur in individual patients who may present
used interchangeably with the other terms men- for care.
tioned above, its elements are poorly described Counseling health psychologists have been cre-
and specified, it lacks theoretical grounding, and ative in addressing these barriers and in encouraging
we have poor means of measuring or assessing colleagues to take on the challenge of provisioning
it (Ridley, Mendoza, Kanitz, Angermeier, & Zent, social justice in health care settings. In particular,
1994). Definitions of cultural competence, which they have emphasized that, although the Society
focus on understanding and integrating informa- for Counseling Psychology has an important role to
tion specific to each patient population served, also play in fostering training opportunities and positive
risk inadvertently promoting or reifying culturally relationships between medicine and counseling psy-
based stereotypes, and have difficulty accounting for chology, individual psychologists can circumvent
the fact that all patients have identities that inter- difficulties with inadequate acceptance in medical
sect with multiple cultural memberships (e.g., an settings by calling attention to the empirical basis of
African American lesbian or a deaf, upper-class our work, offering relevant training experiences
Latino man). Also missing from all definitions of and continuing medical education credits to our
cultural competence, sensitivity, or responsiveness, colleagues in medicine, publishing research in
is any consideration of the multicultural patients’ medical journals, and including medical profes-
perspective (Herman et al., 2007). Culturally com- sional colleagues in our research and publication
petent, responsive, and sensitive health care has efforts. They point out that federal funding for
been defined by experts and located as a property research into health disparities remains relatively
of expert health-care providers, rather than emerg- abundant, and that counseling health psychologists
ing out of the provider behaviors, attitudes, knowl- have not taken full advantage of our skills in tap-
edge, and health-care environments that patients ping these funding sources (Tucker, Ferdinand et al.,
from diverse cultures or underserved groups con- 2007).
sider to be evidence of respect for their culture or Community–university partnerships, as well
evidence of good care. Thus, counseling health psy- as involving members of underserved commu-
chologists have recently moved to defining, research- nities in research and intervention efforts, have
ing, and implementing patient-centered, culturally been used to circumvent access barriers for psychol-
sensitive health care, which has also been described ogists (Roysircar, 2006; Schmidt et al., 2006).
as “cultural competence plus” (Herman et al., 2007). In considering how to address the potentially daunt-
Patient-centered culturally sensitive health care will ing task of providing culturally sensitive health
be described in more detail later, when considering care to all cultural groups, some researchers have
CHP efforts to address health disparities. suggested that a patient-centered approach might
Aside from conceptual barriers to understanding uncover that diverse patient groups have relatively
or ameliorating health disparities, practical barriers modest needs, including universally desirable health

736 coun seling h e alth ps ych o lo g y

care characteristics such as individualized attention an example of CHP research and intervention with
and basic respect, as well as functional mechanisms underserved community populations.
for patients to provide feedback about their health Buki and her colleagues (Buki, 1999; Buki,
care needs and wishes and the quality of the care Borrayo, Feigal, & Carrillo, 2004; Schiffner &
they receive (Tucker, Herman et al., 2007). Buki, 2006) have developed a program of research
Despite the practical and conceptual challenges designed to increase the rate of breast and cervical
involved in enhancing social justice by eliminating cancer screening among Latina women via qualita-
health disparities, counseling health psychologists tive and quantitative research into Latina beliefs
have been involved in a variety research and inter- about cancer and sexual health, as well as cultural
vention projects that address health disparities and and environmental barriers to cancer screening. Par-
social justice in health care. Schmidt, Hoffman, and ticularly striking about this program of research is
Taylor (2006) described a university and community the emphasis on the differences as well as similarities
agency partnership (U-CAP) model to create social among Latina women of various ancestries; for
justice and liberate and empower communities serv- example, one qualitative study found that embar-
ing people with HIV/AIDS by offering university rassment about touching their own breasts was a
counseling psychology department resources to barrier for older Mexican-American women engag-
community agencies that serve PWHIV in recipro- ing in breast self-exams, whereas older South
cal needs assessment, research, program implemen- American women who had migrated to the United
tation, and evaluation. States felt comfortable with this type of self-touching
Huynh and Roysircar (2006) provided a case (Buki, et al., 2004).
study of development of a community health pro- Tucker and her colleagues (Tucker, Herman
motion curriculum designed to enhance health edu- et al., 2007; Tucker et al., 2003) have developed an
cation, self- and preventative health care, and ambitious program including intervention and
linkages between indigenous health practice and assessment tools as well as a theoretical model of
Western medical care among Southeast Asian refu- CHP to address health disparities. This intervention
gees. The program built working alliances with includes training health care providers and office
community agencies and indigenous leaders serving staff to engage in behaviors and display attitudes
Southeast Asian refugees in a large U.S. city, and that help patients feel comfortable, trusting, and
provided a psychoeducational curriculum for par- culturally respected; changing the physical clinic
ticipants that focused on medical and psychiatric environment in ways that patients report enhance
conditions that are highly prevalent in Southeast their sense of belonging and comfort in the clinic;
Asian refugee communities. The 6-week course cov- and empowering patients directly, via training in
ered topics including good versus bad health from health-promoting lifestyles and in how to obtain
a Southeast Asian perspective; the importance of desired changes from their health care providers and
health education and prevention of disease; the health care environment.
importance of the doctor–patient relationship; heart The patient-centered culturally sensitive health
problems; other physical health problems common care model (Tucker, Herman et al., 2007; Tucker
in Southeast Asian refugee populations (e.g., hyper- et al., 2003) specifies theoretical links between this
tension, liver disease, stomach cancer); behaviors intervention program and patient-centered cultur-
such as relaxation, smoking, and nutrition; mental ally sensitive changes in the physical environment
health; medication; and participant questions. Ins- where health care is received, health care provider
truction was provided by a health professional with behaviors, and patient behaviors. These changes
specific expertise in refugee mental health and expe- interact with one another to produce increased
rience working with Southeast Asian refugees, and a patient-perceived cultural sensitivity and interper-
translator. Informed consent forms, psychoeduca- sonal control, which interact to improve patient
tional materials, and assessments were provided in health-promoting lifestyles and patient satisfaction.
Vietnamese and Kru/Khmer. In a pretest–posttest Patient satisfaction leads to improved treatment
design pilot study with 25 Vietnamese and Cam- adherence; improved adherence and enhanced
bodian refugee participants, significant improve- health-promoting lifestyles, in turn, are theorized to
ment in health confidence was found for participants improve patients’ health status and outcomes. To
at the end of the class. Although this research is date, this research program has included qualitative
obviously preliminary, with inadequate sample size research with African American, Hispanic, and non-
and limited study-designed assessments, it provides Hispanic white focus groups to identify behaviors,

be r m an, jam e s 737

attitudes, and aspects of health care considered help- remedial” (paragraph 8), the field of counseling psy-
ful and culturally affirming (Tucker et al., 2003); chology continues to emphasize remedial, individ-
development and initial psychometric evaluation of ual interventions to address problems rather than
the Tucker Culturally Sensitive Health Care preventive or systemic efforts at promotion of health
Inventories for these cultural groups for patients (Romano & Hage).
to evaluate their health care, as well as parallel The requirements for licensure as a psychologist,
forms for providers and staff to self-evaluate their accreditation requirements for training programs,
behaviors; and pilot-testing of the above-described and payment for the practice of psychology have all
intervention (Tucker, Herman, et al., 2007). This focused heavily on individual remediation, psycho-
program of research, although still in its early stages, pathology, and crisis intervention at the expense
shows tremendous promise in terms of determining of systemic or preventive interventions (Romano &
cultural competence from culturally diverse patients’ Hage, 2000a). This neglect has also extended to
perspectives, as well as for providing specific train- research; a 2002 review of four major counseling
ing and intervention for patients, providers, staff, journals found that fewer than 2% of articles
and health care environments to enhance cultur- published in the 1980s and 1990s focused on
ally competent service delivery and eliminate health primary prevention (O’Byrne, Brammer, Davidson,
disparities. & Poston, 2002). The impact of this neglect in
All of the research, training, and intervention research and training may be noted in the daily
efforts just described share a focus on serving under- practice of counseling psychologists. Only a quar-
served populations, empowering members of tradi- ter of one random sample of counseling psycholo-
tionally oppressed and marginalized groups to gists reported any regular involvement in prevention
achieve better health, and enhancing social justice or outreach activities; among those who did involve
in human health. All of these programs also share a themselves in this work, it occupied only about
focus on health promotion and prevention rather 10% of their time on average (Goodyear et al.,
than on amelioration of health problems after they 2008). More troublesome still is the evidence that
have arisen. This interest in health promotion and this may in fact represent a substantial decrease over
prevention represents another core CHP value, time in involvement in prevention by counseling
which we will consider next. psychologists (Hage et al., 2007).
Nevertheless, there is some evidence that coun-
Health Promotion and Disease Prevention seling psychologists, along with other psychologists,
in Counseling Psychology may be again increasing their attention to preven-
It may seem that the prevention of problems in tion. Romano and Hage (2000a) noted that pri-
normal, healthy individuals, and the promotion of mary prevention had significantly advanced in the
human health and well-being, ought to be founda- 1990s, with the launch by the APA of a peer-
tional to the discipline of counseling psychology. reviewed electronic journal, Prevention and Treatment,
Several authors, however, have observed that pre- devoted to the topic, and an APA convention, in
vention and health promotion activities have been 1998, which took prevention as its theme. Although
long neglected in counseling psychology (Adams, this new journal had ceased publication by 2003,
2007; Krumboltz et al., 1979; Romano & Hage, counseling psychologists have continued to show
2000a). Krumboltz et al. famously said that preven- new interest in prevention issues. Although The
tion activities occupied “last place in the hearts of Counseling Psychologist did not publish a major con-
counseling psychologists.” Although the current tribution on prevention until 2000 (Romano &
summary archival description of counseling psy- Hage, 2000a), it has made up for lost time, with two
chology provided by the American Psychological additional major contributions on the topic in 2007
Association (APA) as a means of recognizing and alone (Hage et al., 2007; Reese & Vera, 2007). All
identifying the specialty states that “Counseling editions of the Handbook of Counseling Psychology
psychology is a general practice and health service have included a section devoted to prevention;
provider specialty [which] . . . centers on typical or the last three editions included chapters on health
normal developmental issues as well as atypical or promotion and disease prevention specifically
disordered development [and] . . . help[s] people . . . (Altmaier & Johnson, 1992; Chwalisz & Obasi,
improve well-being” (APA, n.d, paragraph 1), and 2008; Hoffman & Driscoll, 2000). Division 17
specifically states that counseling psychology inter- has active sections on prevention and on the
ventions may be “preventive, skill-enhancing or related and emerging field of positive psychology.

738 coun seling h e alth ps ych o lo g y

Nevertheless, it is clear that prevention and health individuals at risk for or in the early stages of a dis-
promotion activities are not currently central activi- order, and tertiary efforts focused on decreasing the
ties for most counseling psychologists. negative impact of a disorder already acquired
Adams (2007) conceptualized the field of coun- (Caplan, 1964). However, conceptually distinguish-
seling psychology as resistant to change in terms of ing tertiary prevention from remediation is difficult,
adopting prevention science as a focus of the field, particularly when the onset or cause of the problem
and used the transtheoretical stages of change model is unclear. In addition, it can be difficult to distin-
(Prochaska & DiClemente, 2005) to conceptualize guish whether a given intervention is in fact pri-
the field’s resistance. She suggested that Romano mary, secondary, or tertiary prevention, especially
and Hage’s (2000a) major contribution moved when it is broadly applied to a large group, in which
counseling psychology from the precontemplation some individuals may not have the problem, and
to the contemplation stage of change with respect to others may have it severely (Romano & Hage,
involving itself in prevention more deeply, and that 2000a).
later research and theory has placed us at the prepa- Nevertheless, more recent efforts to define the
ration stage. However, she indicated that both bar- field have provided some navigational guidance to
riers to and benefits of changing our field to include counseling psychologists. Counseling psychologists
more prevention work must be identified to tip the have encouraged a broad but clearly elaborated
field into the action stage of change. definition of prevention that includes efforts to
Adams (2007) identified barriers to culturally stop a problem behavior from ever occurring; delay
responsive prevention work in counseling psychol- the onset of a problem behavior; reduce the impact
ogy, which included the greater interest of counsel- of a problem behavior; strengthen knowledge, atti-
ing psychologists in understanding and intervening tudes, and behaviors that promote emotional and
with individuals, rather than systems; the emotion- physical well-being; and promote institutional,
ally draining and difficult nature of preventive or community, and government policies that further
community interventions; lack of reimbursement by physical, social, and emotional well-being. Preven-
insurers for prevention; lack of funding for preven- tion in counseling psychology thus may include risk
tion research; the time-intensive nature of preven- reduction, wellness or strengths-based, or social jus-
tion research and the lack of respect for this activity tice efforts and approaches (Hage et al., 2007;
among tenure committees; the emphasis in training Romano & Hage, 2000a). Counseling psycholo-
programs on individual remediation; counselors’ gists have also recently produced detailed guidelines
discomfort with the unfamiliar community settings for psychology as a field to define best practice in
that may be most appropriate for prevention inter- prevention practice, research, training, and social
ventions; and the quantity of required coursework in advocacy (Hage et al., 2007). These 15 best-practice
counseling psychology training programs that leads guidelines are intended to provide both clear stan-
to resistance to creation of new courses. dards and a vision for prevention work by psycholo-
The conceptual and theoretical difficulties in gists, and to move psychologists toward improving
defining prevention, and the resulting controversies health and well-being for more individuals and
inside and outside the field of prevention science, communities. As such, they are likely to be useful to
although not mentioned as a barrier by Adams counseling health psychologists in developing a set
(2007), may also make it more difficult for counsel- of principles to guide health promotion and disease
ing health psychologists to enter the field. Classic prevention efforts.
descriptions of prevention research capture the dif- Some counseling psychologists have suggested
ficulties, describing the field as “a friendly and virtu- that, since initial efforts to define prevention mainly
ous territory of high abstraction and low practicality” took place in departments of epidemiology and
(Bower, 1977, p. 24) or a conceptual swamp that public health and focused on physical health con-
“lures the unwary into quagmires” (Kessler & Albee, cerns, these definitions might be better suited to
1975, p. 558). CHP interests, at least in comparison to mental
One major difficulty in defining prevention is disorders or other complex psychological or social
separating it from remediation. Early mental health ills (Romano & Hage, 2000a). However, many of
efforts to clarify prevention activities delineated pri- the same conceptual difficulties in defining pre-
mary, secondary, and tertiary forms of prevention, vention efforts extend to physical health concerns.
in which primary efforts reduced the number of new As previously noted, the etiologies of many of the
incidences of disorder, secondary efforts targeted most serious and prevalent physical health concerns,

be r m an, jam e s 739

such as heart disease or cancer, are complex, with Despite the barriers to participation in preven-
behavioral and psychological variables interacting tion efforts and the challenges of successful health
with other mechanisms to produce illness. For many promotion and disease prevention, counseling
of the most common physical illnesses, although health psychologists are beginning to be active and
numerous risk factors have been identified that innovative in developing prevention science, prac-
correlate with disease, it remains unclear how well tice, training, and advocacy. The importance of
these risk factors prospectively predict disease acqui- theory and model development to guide creation,
sition, morbidity, or mortality. For example, the dissemination, and research into disease prevention
well-known Framingham Risk Score, which uses and health promotion interventions by counsel-
a collection of risk factors to determine individuals’ ing psychologists has been noted (Hage et al.,
risk of coronary heart disease, has demonstrated 2007). Hoffman and Driscoll’s (2000) concentric
poor predictive power and specificity both in elderly biopsychosocial model of health status, previously
(Koller et al., 2007) and young (Berry, Lloyd-Jones, described, represents one example of a theoretical
Garside, & Greenland, 2007) populations. model developed to help guide disease prevention
In addition, even when risk factors do predict and health promotion intervention development.
disease, it is unclear that altering them actually The theory of reasoned action and planned behavior
reduces the negative impact of disease. For example, (TRA/PB) has also been applied to prevention sci-
heart health programs that target multiple risk fac- ence within counseling psychology (Romano &
tors for cardiovascular disease do demonstrate suc- Netland, 2008). Romano and Netland provide an
cessful (albeit small) changes in risk factors; however, example of how TRA/PB could be used to guide a
these programs have no impact on disease mortality program of research and intervention designed to
(Ebrahim, Beswick, Burke, Davey, & Smith, 2006). prevent violence among school-aged children.
One of the largest experimental studies of dietary Counseling health psychologists have developed
modification ever conducted, The Women’s Health and implemented a variety of preventive interven-
Initiative Dietary Modification Trial, provides a tions to prevent diverse health problems or promote
similar cautionary example. More than 48,000 general health and well-being. Adams (2007)
postmenopausal women were enrolled in this study; describes a U.S.–Mexico border health class offered
they were followed for a mean of more than 8 years. at New Mexico State University that leads to a com-
Women in the experimental arm of the study munity-based behavioral health practicum in which
underwent an intensive behavioral intervention students provide multidisciplinary health care with
that successfully reduced their dietary fat intake family medicine residents in a primary care clinic to
and increased their intake of vegetables, fruits, and support systemic change in health care service deliv-
grains, compared to a control group of women ery among this patient population. D’Andrea
who ate their usual diet. However, these dietary (2004) developed an intriguing community-and-
changes did not significantly reduce the partici- school-based violence prevention program that used
pants’ risk of heart disease, stroke, or most forms a theoretical model of comprehensive school-based
of cancer (Beresford et al., 2006; Howard, Van violence prevention programming (D’Andrea &
Horn, et al., 2006; Prentice et al., 2006). In addi- Daniels, 1999; Daniels, Arredondo, & D’Andrea,
tion, despite successfully maintaining significant 1999) to develop a graduate-level course in school-
caloric restriction compared to controls throughout based violence prevention that was offered to admin-
the study, the women enrolled in the experimen- istrators, counselors, and teachers at four targeted
tal arm of the study had lost an average of only elementary schools in Hawaii. Course participants
1 pound compared to controls at the study end- used the training they received to develop violence
point (Howard, Manson, et al., 2006). Promoting prevention efforts in their schools that targeted stu-
health and preventing disease is of obvious major dents and the school community itself both directly
importance, and it is likely and in many cases evident (e.g., through support groups or classroom-based
that alterable social, psychological, and behavioral interventions) and indirectly (e.g. via community
factors in which counseling health psychologists outreach or policy change). This intervention had
have expertise cause or contribute to ill health. effects beyond the four schools initially included;
However, altering these factors in a fashion that for example, course participants collaborated with
decreases the impact of disease is conceptually and local officials to organize a community Peace Day,
practically difficult. which was ultimately attended by more than 3,000

740 coun seling h e alth ps ych o lo g y

elementary school students in Hawaii. Kenny, legislative, and political advocacy activities that
Waldo, Warter, and Barton (2002) describe another enhance the health and well-being of the broader
elementary school-based intervention, the Gardner population served” (Hage et al., 2007, p. 550).
Extended Service School, where counseling psy- Several authors have observed that disease preven-
chologists have collaborated with other stakehold- tion, human wellness, and social justice must
ers in an urban community to enhance a variety include political advocacy, because many social and
of outcomes, including children’s physical health health ills may have sociopolitical injustice as a root
and well-being. The intervention uses developmen- cause (Albee, 2000a; Prilleltensky & Prilleletensky,
tal psychological principles to reduce student risk 2003). Albee (2000a) noted that some research sug-
and enhance resiliency by extending school services gests that countries with the smallest gap between
to address children’s biopsychosocial developmental the average incomes of the rich and poor had the
needs via changes in the context in which they best longevity, as well as the best mental health
live. (Wilkinson, 1996); therefore, he noted, psycholo-
Counseling health psychologists have also used gists interested in disease prevention and health
research and consultation expertise to help measure promotion should advocate for congressional inter-
physician performance in cognitive and noncogni- ventions, such as doubling the minimum wage. He
tive aspects of job performance using a job analysis observed that effective prevention interventions will
and critical incident interview methodology (Tarico, include efforts to address injustice and political
Smith, Altmaier, Franken, & VanVelzen, 1984). changes that may be controversial. Whether indi-
This line of research, which has been shown to vidual counseling health psychologists agree with
generalize across a number of specialties and train- Albee’s (2000) specific policy prescriptions or not, it
ing sites (Altmaier et al., 1990; Altmaier, From, is clear that for the field, our core values of social
Pearson, Garbatenko-Roth, & Ugolini, 1997; justice and multiculturalism support and enhance
Altmaier, Johnson, Tarico, & Laube, 1988), has our efforts to improve human health through pre-
been used to develop behaviorally based selection ventive and ameliorative means.
interviews that better predict medical resident suc-
cess than traditional interview procedures (Altmaier, Conclusion
Smith, O’Halloran, & Franken, 1992; Wood, Recommendations for Research, Training,
Smith, Altmaier, Tarico, & Franken, 1990), an Practice, and Advocacy
important outcome for medical care and education. The serious and ongoing human health problems
Education and training within counseling psy- and health disparities identified by Albee (2000a)
chology training programs can also advance health and others make it clear that work in CHP has only
promotion or disease prevention. Hage et al. (2007) just begun. Even though, as we have reviewed,
describe a graduate course that used problem-based efforts to date to eliminate unjust health disparities,
learning principles to teach prevention science and to enhance physical health and well-being, and
practice to trainees through their participation in to prevent and ameliorate disease are intriguing and
developing proposals for a grant-funded Summer in many cases of obvious utility, it is clear that
Prevention Academy whose focus was on promot- counseling psychology’s involvement in these issues
ing healthy schools and families in the community. has not reached its full potential. Whereas there is
Students, individually and in teams, developed a some evidence that CHP as a field is picking
poster conference to highlight community needs up speed and increasing its efforts in all these areas,
and best practices in prevention, and local experts in other cases, we also echo and extend Adams’
chose the best projects for implementation. (2007) formulation that counseling psychology has
Just as the value of multiculturalism and social sometimes demonstrated resistance to change and
justice has supported and encouraged a focus on growth. The various calls to action (e.g., Altmaier,
prevention and health promotion, so too have coun- 1991; Romano & Hage, 2000b) to counseling
seling psychologists interested in prevention urged psychologists to involve themselves more deeply in
involvement in social justice and political advocacy health promotion and disease prevention and ame-
as an essential aspect of counseling psychologists’ lioration have been unevenly, if sometimes enthusi-
work. Indeed, the Best Practice Guidelines on Pre- astically, heeded.
vention include the specific statement that “Psy- Others have already noted that counseling psy-
chologists are encouraged to engage in governmental, chology has unique expertise and values to promote

be r m an, jam e s 741

and improve human health (Altmaier, 1991). In professional activities and attitudes held by many
this conclusion, we hope to enhance the field’s read- counseling health psychologists. We do not intend
iness to extend our skills to address ongoing human these themes or the conceptual framework to be
health needs by highlighting these strengths and exhaustive or prescriptive of what counseling health
values as a means to enhance our motivation to psychologists do or ought to do. Instead, we believe
move forward. Toward that end, we will first pro- these themes reflect our unique strengths as coun-
vide a summary of three themes (and associated seling health psychologists, and serve as resources to
subthemes) elaborated in this chapter that we believe draw upon. We are hopeful that these themes,
represent core strengths and areas of value for CHP embedded in a conceptual framework such as that
and that we believe can and should be extended to presented here, can enhance both theory, research,
aid the broader enterprise of enhancing human practice, and advocacy in health psychology, as well
health. For each of these positive themes, and their as strengthen the professional identity of counseling
subthemes, all identified in italics below, we offer health psychologists.
relevant recommendations for research, training, One major theme in this chapter and for CHP as
practice, and advocacy. We also discuss two barrier a whole is our value of and expertise in positive
themes identified in the chapter (and also noted health and wellness, rather than only the ameliora-
below in italics) that prevent the ongoing improve- tion of disease. Because of this emphasis on positive
ment and development of CHP as a field. health, we are uniquely well suited to developing
We conclude by drawing upon these positive and testing interventions and identifying advocacy
themes to create a conceptual framework for CHP, efforts that are likely to be of greatest value in pre-
displayed in Figure 28.1, which we hope can be venting disease and promoting good health. Among
used to circumvent the identified barriers. This con- individuals with disabilities and chronic illnesses, an
ceptual framework seeks to provide a graphical rep- emphasis on positive health and wellness also sug-
resentation of the field in terms of prototypical gests that we reject an individualistic, deterministic,

Counseling Health
Psychologists....

Take a systems Work for positive

perspective. health and wellness.
• Focus on complex • Work to prevent disease.
systems. • Promote positive health.
• Identify multiple, • Alter systemic and socially
interacting variables. constructed sources of
• Take a developmental, disability and disease.
life-span perspective.

Are patient-centered.
• View patient as expert.
• Gather data using:
• Qualitative research skills.
• Quantitative research skills.
• Develop multicultural competence.

Fig. 28.1 A conceptual framework for counseling health psychology.

742 coun seling h e alth ps ych o lo g y

medical model of disability and disease, instead pro- multiple requirements for training posed by licen-
moting and advancing a “new paradigm” that sure and accreditation authorities are well-known
focuses on altering systemic and socially constructed barriers to enhanced training in preventive inter-
sources of disability and disease. ventions (Romano & Hage, 2000a), an integration
What does this theme of positive health and well- of a positive health and wellness orientation into
ness imply for research, training, practice, and advo- existing coursework is possible. Several authors have
cacy in CHP? One important implication is that provided examples or guidelines for how prevention
human health problems cannot be solved exclusively interventions, health promotion projects, and efforts
or even mainly by treatment (Albee, 2000a). to alter systemic or socially constructed sources of
Treatment resources are always limited in compari- disease and disability can be integrated into coun-
son to the incidence of problems, leading to the seling practica (e.g., Adams, 2007; Schmidt et al.,
public health aphorism that “no disorder or disease 2006). Problem-based or service-learning pedagogi-
has ever been treated out of existence” (Albee, cal approaches can be integrated into a variety of
2000b). Thus, in research, practice, and training of typical counseling courses (e.g., multicultural coun-
future counseling health psychologists, a focus on seling, history and systems) to permit enhanced
disease prevention and promotion of good health is training in preventive or systemic intervention
of major practical importance. If the aim is to (Hage et al., 2007).
enhance human health and wellness, we can no A second important theme and area of value
longer afford to train students or conduct research or and expertise for CHPs is our patient-centeredness.
practice solely with an eye toward curing disorders As counseling psychologists, we have traditionally
or diseases. Professional involvement in political looked to the people we serve as the primary source
advocacy by counseling health psychologists should of expertise informing how we may be helpful. We
also be encouraged and supported, given that politi- use our traditional strengths in both qualitative and
cal and systemic changes at the level of the commu- quantitative research to better access and understand
nity may have the strongest positive impact on the experiences of the people we serve. These meth-
human health and well-being (Hage et al., 2007). odological skills are a resource we can offer col-
Students in counseling psychology have been leagues in other health professions as we collaborate
identified as a possible barrier to effective preven- to identify and assist with the health needs of indi-
tion work, as they may “self-select” into counseling viduals and groups. Counseling psychology’s leader-
psychology because of an interest in individual ship in developing and defining multicultural
treatment or with hopes of making high incomes in competence is another extension of our traditional
the private practice of psychotherapy (Albee, 2000a). respect for and focus on the individual needs and
However, the first author was struck by the systems- wishes of the people we serve.
level ambitions identified by advanced counseling How can patient-centeredness be used to enhance
psychology graduate students in a consultation research, training, practice, and advocacy in CHP?
practicum she taught at the University of Maryland. The patient-centered approach to multicultural sen-
Asked to write a personal mission statement for sitivity and multicultural competence developed by
their future consultation work, students’ responses Tucker and her colleagues (Tucker, Herman, et al.,
reflected profound interest in advancing a preven- 2007) is an ambitious program that shows tremen-
tive, positive health agenda. Prototypical student dous promise for addressing and ameliorating health
mission statements included advocacy and wellness disparities among traditionally underserved groups.
as main themes, such as: “advocating for those More broadly, the insight that current definitions of
whose needs have been underserved”; “fighting for culturally competent health care are not grounded
girls’ and women’s rights”; and “changing the image in patients’ perspectives or experiences of health care
of mental health” (C. Risco, personal communica- is of major importance in delineating a CHP agenda
tion, April 16, 2008; H. Ganginis & K. McGann, for research and practice to address health disparities
personal communication, April 1, 2008). Training (Herman et al., 2007). Research on patient groups
in CHP would benefit if these ambitions were nur- affected by health disparities to identify their spe-
tured in practica and courses that permitted stu- cific health needs and barriers to good health is in its
dents to learn the challenges and rewards of health infancy and is an area in which counseling health
promotion and disease prevention. psychologists can contribute; qualitative research
Although the crowded nature of counseling methods are particularly underused in identifying
psychology graduate program curricula and the patient perspectives on health disparities.

be r m an, jam e s 743

 Several authors have noted that skills in research As we described above, nurturing the ambitions of
methodology, multicultural service delivery, and students to engender systems-level change is also
patient-centered interpersonal communication are a important and should be addressed through the
resource we can offer to allied health professionals integration of such opportunities into coursework
(Altmaier, 1991; Tucker, Ferdinand, et al., 2007). and practica.
Altmaier and colleagues’ program of research using Comparative research that tests the impact on
critical incident interviewing to improve selection health outcomes of altering macro- versus micro-
of the most competent medical residents, nearly all level variables would also be helpful for model and
of which has been published in medical journals, is theory development. The comprehensive school-
an excellent example of using counseling psychol- based violence programming theoretical model
ogy research methods to improve human health (D’Andrea & Daniels, 1999; Daniels et al., 1999),
(Altmaier et al., 1992; Wood et al., 1990). Similarly, for example, includes service and intervention com-
D’Andrea provides an example of using counseling ponents that target both micro-level (e.g., services
psychology theory and training programs to create offered directly to troubled students) and macro-
systemic change in exposure to violence among level (e.g., services intended to indirectly impact an
school children (2004). Counseling health psychol- entire school, such as political advocacy) variables.
ogists should follow these examples, using their cre- Experimental research that compares these elements
ativity to consider how their typical daily activities of the model for their impact on subsequent inci-
in academic, counseling, psychiatric, or medical set- dence of student violence in affected schools would
tings can be extended into the communities in shed light on how elements of the model interrelate,
which they live and work. as well as which level of analysis is most fruitfully
A final theme developed in this chapter and in targeted for intervention.
CHP is our systems perspective, and our interest Counseling health psychologists have demon-
in the operation of complex systems and multiple strated leadership in developing systemic models of
variables interacting to produce health or disease. human health and wellness. However, in some cases,
Counseling health psychologists have developed CHP models of health are overly simplistic, with
models of human health and health promotion that poorly specified relations among components of
eschew simple or deterministic relations among fac- the model, or a lack of research effort to opera-
tors in favor of highlighting the interactive and tionalize the components or test their proposed
holistic operation of complex biopsychosocial sys- relations. In contrast, the patient-centered cultur-
tems in determining wellness (e.g., Hoffman & ally sensitive health care model (Tucker, Herman,
Driscoll, 2000; Seeman, 1989). A related CHP et al., 2007) provides a high-quality example of
focus is our developmental, lifespan perspective, which how model development, measurement, interven-
offers value to the enterprise of health promotion tion, and practice could be conducted in CHP. The
and disease prevention in a variety of ways. For model describes a complex system with multiple
example, counseling health psychologists are likely components in a nuanced, empirically informed
to identify disability as a normal developmental task fashion, and sequential, well-organized, program-
faced by most adults, rather than evidence of abnor- matic efforts have already been made to test the
mality or atypicality, or to focus on how the experi- model through the development of potentially
ence of illness or disease alters developmental tasks useful interventions, qualitative research, and mea-
and timing. sure development. More research that is similarly
How should counseling health psychologists programmatic, theoretically and empirically driven,
do research, provide training, practice, or conduct and relevant is much needed.
advocacy informed by a systems perspective? We agree The three themes—positive health and wellness,
with other authors that systemic, macro-level vari- patient-centeredness, and a systems perspective—as
ables affecting health have been seriously neglected well as their subthemes detailed above, represent
in research and intervention efforts, and that CHP professional attitudes and behaviors that counseling
is well-poised to address this deficiency (Tucker, health psychologists can use as a resource. As such,
Ferdinand et al., 2007; Hopps & Liu, 2006). we have embedded them into a conceptual frame-
Research on how macro-level variables affect health work for CHP displayed in Figure 28.1. All three
should be prioritized so that a programmatic of the CHP themes developed thus far, as well as
research base comparable to that still developing for the conceptual framework, represent positive areas
micro- individual-level variables can be developed. of expertise and professional values that counseling

744 coun seling h e alth ps ych o lo g y

health psychologists can and should draw upon in values; and ethical concerns, such as the possibility
their efforts to enhance human health. These themes that counseling health psychologists will be asked to
are not entirely novel; others have noted similar practice outside their competencies by virtue of
areas of strength and potential for CHP (Altmaier, their isolation in medical settings.
1991; Mrdjenovich & Moore, 2004). However, in Even when these concerns are ameliorated,
addition to these positive themes, some themes one professional identity barrier may arise simply
can also be identified that describe barriers or prob- because counseling psychologists may not think of
lems that prevent CHP from making a complete health psychology as a natural and typical extension
contribution to human health. The two most impor- of their work. Unlike departments of psychiatry,
tant barrier themes we would like to highlight here which are housed in medical schools and therefore
include limited resources for CHP and counseling clearly linked with the enterprise of enhancing
health psychologists’ insecure professional identity. human health, counseling psychology programs are
Several authors have described the various prac- housed in departments of education or psychology,
tical and resource barriers that prevent counseling where colleagues’ interests and resources may be
health psychologists from becoming more fully geared toward other or more diverse concerns. Phy-
involved in improving human health, including sical health may also be a minor proportion of client
limited opportunities for new or enhanced courses presenting concerns in college counseling centers;
in CHP in crowded counseling psychology training clients with either acute or chronic (e.g., a disabil-
programs, limited funding for health psychology ity) physical health concerns who do present at
research, lack of reimbursement for preventive inter- counseling centers may be referred to other campus
ventions, or limited access to community settings agencies, such as disability services or a student
where CHP may occur most usefully (Adams, 2007; health service. Similarly, research conducted in
Tucker, Ferdinand, et al., 2007). counseling programs often uses healthy college stu-
Problems arising from counseling health psy- dents as participants, a pool that does not lend itself
chologists’ insecure professional identity may come well to most studies of disease prevention or health
from within counseling psychology and from psy- promotion, since physical health status is likely to
chologist colleagues, or it may come from within be less variable among this group. In addition, the
medicine and from medical professional colleagues. movement in both counseling psychology and psy-
Several authors have described the pressures and chology as a whole toward greater professional
barriers to effective CHP that may arise from col- diversity and specialization may have led counseling
leagues in medicine, such as a lack of professional psychologists interested in health away from coun-
respect or parity with physicians, lack of power to seling and toward other professional “homes.”
effect change in medical settings, or role confusion Between seven and nine divisions per decade were
and a lack of role fit between what counseling health formed within APA from the 1960s through the
psychologists have to offer and what medical profes- 1990s, and currently there are 54 divisions. Many
sionals see as their needs (Good, 1992; Tucker, divisions publish their own journals, and counseling
Ferdinand et al., 2007). In addition, as previously psychologists interested in health psychology may
reviewed, counseling psychologists have expressed have closer professional ties to Division 38 and
concerns about involvement in health care and hos- Health Psychology or medical journals than to
pital settings and about the diffusion of responsibil- Division 17 and the Journal of Counseling Psychology
ity demarcating counseling from clinical psychology or The Counseling Psychologist. Perhaps it is partly for
since virtually the beginning of the field (Scott, this reason that little health research is currently
1980). Although larger numbers of counseling psy- published in the flagship counseling journals.
chologists are training and working in health care We have not included these barrier themes in
settings (Neimeyer et al., 2001), psychologists con- our conceptual framework for CHP, but, in the tra-
tinue to express concerns about the potential loss of dition of strengths-based counseling (Smith, 2006),
professional identity that counseling health psy- which encourages clients to use their strengths to
chologists may experience when they enter medical circumvent weaknesses and solve problems, we
settings (Altmaier et al., 1998; Fitzgerald & Osipow, suggest that CHP would benefit from using the
1986; Mrdjenovich & Moore, 2004). These authors strengths identified in the conceptual framework to
identify a number of concerns, such as the possibil- address these barriers, strengthening our profes-
ity of professional isolation; lack of connection to sional identity and enlarging our influence in health
counseling psychology organizations, research, or promotion and disease prevention and recovery.

be r m an, jam e s 745

For example, the blurring of professional identity our core values in defining ourselves as counseling
between counseling and clinical psychology, or bet- health psychologists, we may liberate ourselves from
ween counseling psychology and allied professions those aspects of allied fields, such as a medical model
such as medicine or psychiatry, may have arisen in or a focus on individual-level change, that limit our
part because counseling psychologists practicing in professional influence. This growing wellness and
medical and psychiatric settings adopt a medical liberation as a field may operate synergistically, per-
model or other approaches borrowed from allied mitting us to improve the well-being of and advance
fields to address patient problems. Although this justice for the people we serve, allowing an expand-
may be often appropriate and helpful in the context ing cycle of health and social change for CHP and
of interdisciplinary collaboration, in many cases, for community and individual health.
this adoption of the medical model may occur when
counseling health psychologists lack a clear, unique, Note
and persuasive counseling perspective to offer allied 1. I am indebted to Mrdjenovich and Moore
colleagues. (2004) for the broad outlines of the historical back-
Instead, counseling health psychologists could ground of counseling health psychology sketched
use the conceptual framework presented here to here.
describe, promote, and offer their unique strengths
to professionals in other health service fields. As
others have noted, promoting our unique skills and References
strengths, such as in multiculturally competent ser- Adams, E. M. (2007). Moving from contemplation to prepara-
tion: Is counseling psychology ready to embrace culturally
vice delivery or qualitative and quantitative mea- responsive prevention? The Counseling Psychologist, 35,
surement, may enhance our influence and enlarge 840–849.
the resources available to us to promote human Adler, N. E., & Conner Snibbe, A. (2003). The role of psychoso-
health. In so doing, both individuals and organiza- cial processes in explaining the gradient between socioeco-
tions that represent CHP can strengthen our iden- nomic status and health. Current Directions in Psychological
Science, 12, 119–123.
tity and expand our reach. (Tucker, Ferdinand, Albee, G. W. (2000a). Commentary on prevention and counsel-
et al., 2007). Counseling health psychologists also ing psychology. The Counseling Psychologist, 28, 845–853.
need to use their systems perspective to advocate for Albee, G. W. (2000b). Critique of psychotherapy in American
public policy and other social change that would society. In C. R. Snyder, & R. E. Ingram (Eds.), Handbook of
facilitate the integration of health issues with coun- psychological change: Psychotherapy process and practices for the
21st century (pp. 689–706). New York: Wiley.
seling. For example, counselors should advocate for Alcorn, J. D. (1991). Counseling psychology and health applica-
funding and reimbursement mechanisms for out- tions. The Counseling Psychologist, 19, 325–341.
reach and prevention activities, and for changes Altmaier, E. M. (1991). Research and practice roles for counsel-
in accreditation requirements to permit more train- ing psychologists in health care settings. The Counseling
ing in systemic and preventive interventions. Coun- Psychologist, 19, 342–364.
Altmaier, E. M., From, R. P., Pearson, K. S., Gorbatenko-Roth,
seling health psychologists should also build tighter K. G.,& Ugolini, K. A. (1997). A prospective study to
professional ties and market our skills to medical select and evaluate anesthesiology residents: Phase I, the
schools, hospitals, and departments of public critical incident technique. Journal of Clinical Anesthesia, 9,
health. 629–636.
With this conceptual model for CHP as a core Altmaier, E. M., & Johnson, B. D. (1992). Health-related appli-
cations of counseling psychology: Toward health promotion
element of their professional identity, we are hope- and disease prevention across the life span. In S. D. Brown,
ful that counseling health psychologists may con- & R. W. Lent Eds., Handbook of counseling psychology
tinue to develop language, shared values, and (pp. 315–347). New York: Wiley.
motivation to retain their ties to counseling psy- Altmaier, E. M., Johnson, B. D., & Paulsen, J. S. (1998). Issues
chology and indeed provide leadership to the field. in professional identity. In S. Roth-Roemer, S. E. R. Kurpius,
& C. Carmin (Eds.), The emerging role of counseling psychol-
The wellness-liberation model (Prilleltensky & ogy in health care (pp. 7–29). New York: W.W. Norton &
Prilleltensky, 2003) provides a synergistic example Company.
of how adoption of these CHP themes could be Altmaier, E. M., Johnson, S. R., Tarico, V. S., & Laube, D.
used to enhance the field. By using our unique skills (1988). An empirical specification of residency performance
in defining ourselves as counseling health psycholo- dimensions. Obstetrics and Gynecology, 72, 126–130.
Altmaier, E. M, Lehmann, T. R., Russell, D. W., Weinstein, J.
gists, we may strengthen our professional identity N., & Kao, C. F. (1992). The effectiveness of psychological
and expand our influence and reach, leading to interventions for the rehabilitation of low back pain: A ran-
enhanced wellness for the field. By adhering to domized controlled trial evaluation. Pain, 49, 329–335.

746 coun seling h e alth ps ych o lo g y

Altmaier, E. M., McGuinness, G., Wood, P. S., Ross, R. R., Chwalisz, K. (2008). The future of counseling psychology:
Bartley, J., & Smith, W. L. (1990). Defining successful perfor- Improving quality of life for persons with chronic health
mance among pediatric residents. Pediatrics, 85, 139–143. issues. The Counseling Psychologist, 36, 98–107.
Altmaier, E. M., Russell, D. W., Kao, C. F., Lehmann, T. R., Chwalisz, K., & Obasi, E. (2008). Promoting health and
& Weinstein, J. N. (1993). Role of self-efficacy in rehabilita- preventing and reducing disease. In S. D. Brown, &
tion outcome among chronic low back pain patients. Journal R. W. Lent (Eds.), Handbook of counseling psychology (4th ed.,
of Counseling Psychology, 40, 335–339. pp. 517–534). New York: Wiley.
Altmaier, E. M., Smith, W. L., O’Halloran, C. M., & Clay, D. L., & Stern, M. (2005). Pediatric psychology in primary
Franken, E. A. (1992). The predictive utility of behavior- care. In L. C. James, & R. A. Folen (Eds.), The primary
based interviewing compared with traditional interviewing care consultant: The next frontier for psychologists in hospitals
in the selection of radiology residents. Investigative Radiology, and clinics (pp. 155–172). Washington, DC: American
27, 385–389. Psychological Association Press.
American Psychological Association. (n.d.). Archival description Cranston, A. (1986). Psychology in the Veteran’s Administration:
of counseling psychology. Retrieved July 19, 2009, from http:// A storied history, a vital failure. American Psychologist, 41,
www.apa.org/crsppp/counseling.html. 990–995.
American Psychological Association. (2003). Guidelines on mul- Cummings, N. A., Cummings, J. L., & Johnson, J. N. (1997).
ticultural education, training, research, practice, and organi- Behavioral health in primary care: A guide for clinical integra-
zational change for psychologists. American Psychologist, 58, tion. Madison, CT: Psychosocial Press.
377–402. D’Andrea, M. (2004). Comprehensive school-based violence
Angell, M. (1993). Privilege and health: What is the connection? prevention training: A developmental-ecological training
New England Journal of Medicine, 329, 126–127. model. Journal of Counseling and Development, 82, 277–286.
Bacho, E., Myhre, J., & James, L. C. (2008). An integrative D’Andrea, M., & Daniels, J. (1999). Exploring the psychology
approach to treating obesity and comorbid disorders. In of White racism through naturalistic inquiry. Journal of
R. Kessler, & D. Stafford (Eds.), Collaborative medicine case Counseling & Development, 77, 93–101.
studies: Evidence in practice (pp. 287–298). New York: Springer. Daniels, J., Arredondo, P., & D’Andrea, M. (1999). Expanding
Beresford, S. A. A., Johnson, K. C., Ritenbaugh, C., counselors’ thinking about the problem of violence. Coun-
Lasser, N. L., Snetselaar, L. G., Black, H. R., et al. (2006). seling Today, 41, 12–17.
Low-fat dietary pattern and risk of colorectal cancer: The DeLeon, P. H., Rossmando, N. P., & Smedley, B. D. (2004).
Women’s Health Initiative Randomized Controlled Dietary The future is primary care. In R. Frank, S. McDaniel, J. Bray,
Modification Trial. Journal of the American Medical & M. Heldring (Eds.), Primary care psychology (pp. 63–92).
Association, 295, 643–654. Washington, DC: American Psychological Association Press.
Bernard, C. B. (1992). Counseling psychologists in general Dougherty, K., Templer, D. I., & Brown, R. (1986). Psychological
hospital settings: The continued quest for balance and chal- states in terminal cancer patients as measured over time.
lenge. The Counseling Psychologist, 20, 74–81. Journal of Counseling Psychology, 33, 357–359.
Berry, J. D., Lloyd-Jones, D. M., Garside, D. B., & Greenland, P. Earles, J. E. (2005). Innovative strategies for treating diabetes
(2007). Framingham risk score and prediction of coronary mellitus. In L. C. James, & R. A. Folen (Eds.), The primary
heart disease death in young men. American Heart Journal, care consultant: The next frontier for psychologists in hospitals
154, 80–86. and clinics. (pp. 105–120). Washington, DC: American
Blendon, R. J., & Donelan, K. (1988). Discrimination against Psychological Association Press.
people with AIDS: The public’s perspective. New England Ebrahim, S., Beswick, A., Burke, M., & Davey Smith, G. (2006).
Journal of Medicine, 319, 1022–1026. Multiple risk factor interventions for primary prevention of
Bor, R., Miller, R., Latz, M., & Salt, H. (1998). Counselling in coronary heart disease. Cochrane Database of Systematic
health care settings: Some theoretical and practical consider- Reviews, 4, CD001561.
ations. Counselling Psychology Review, 13, 26, 34. Elliott, T. R., & Shewchuk, R. M. (1996). Defining health
Bower, E. (1977). Mythologies, realities, and possibilities. and well-being for the future of counseling psychology. The
In G. W. Albee, & J. M. Joffe (Eds.), Primary prevention Counseling Psychologist, 24, 743–750.
of psychopathology: Vol. 1. The issues (pp. 18–41). Hanover, Engel, G. L. (1977). The need for a new medical model: A chal-
NH: University Press of New England. lenge for biomedicine. Science, 196, 129–136.
Buki, L. P. (1999). Early detection of breast and cervical cancer Etherage, J. (2005). Pediatric behavioral health consultation:
among medically underserved Latinas. In M. Sotomayor, A new model for primary care. In L. C. James, & R. A. Folen
& A. Garcia (Eds.), La familia: Traditions and realities (Eds.), The primary care consultant: The next frontier for psy-
(pp. 67–85). Washington DC: National Hispanic Council chologists in hospitals and clinics (pp. 173–190). Washington,
on Aging. DC: American Psychological Association Press.
Buki, L. P., Borrayo, E. A., Feigal, B. M., & Carrillo, I. Y. (2004). Fitzgerald, L. F., & Osipow, S. H. (1986). An occupational anal-
Are all Latinas the same? Perceived breast cancer screening ysis of counseling psychology: How special is the specialty?
barriers and facilitative conditions. Psychology of Women American Psychologist, 41, 535–544.
Quarterly, 28, 400–411. Ford, D. H. (1987). Humans as self-constructing living systems:
Caplan, G. (1964). Principles of preventive psychiatry. New York: A developmental perspective on personality and behavior.
Basic Books. Hillsdale, NJ: Erlbaum.
Chwalisz, K. (1998). Rehabilitation medicine. In S. Roth- Ford, D. H. (1990). Positive health and living system frame-
Roemer, S. E. R. Kurpius, & C. Carmin (Eds.), The emerging works. American Psychologist, 45, 980–981.
role of counseling psychology in health care (pp. 210–231). New Fouad, N. A., Gerstein, L. H., & Toporek, R. L. (2006).
York: W.W. Norton & Company. Social justice and counseling psychology in context.

be r m an, jam e s 747

 In R. L. Toporek, L. H. Gerstein, N. A. Fouad, G. Roysircar, Howard, B. V., Manson, J. E., Stefanick, M. L., Beresford, S. A.,
& T. Israel (Eds.), Handbook for social justice in counseling Frank, G., Jones, B., et al. (2006). Low-fat dietary pattern
psychology (pp. 1–16). Thousand Oaks, CA: Sage. and weight change over 7 years: The Women’s Health
Fouad, N. A., McPherson, R. H., Gerstein, L., Blustein, D. L., Initiative Dietary Modification Trial. Journal of the American
Elman, N., Helledy, K. I., & Metz, A. J. (2004). Houston, Medical Association, 295, 39–49.
2001: Context and legacy. The Counseling Psychologist, 32, Howard, B. V., Van Horn, L., Hsia, J., Manson, J. E.,
15–77. Stefanick, M. L., Wassertheil-Smoller, S., et al. (2006). Low-
Frank, R. G., McDaniel, S. H., Bray, J. H., & Heldring, M. fat dietary pattern and risk of cardiovascular disease: The
(2004). Primary care psychology. Washington, DC: American Women’s Health Initiative Randomized Controlled Dietary
Psychological Association Press. Modification Trial. Journal of the American Medical
Frazier, P. A., Tix, A. P., & Barnett, C. L. (2003). The rela- Association, 295, 655–666.
tional context of social support: Relationship satisfaction Huynh, U. K., & Roysircar, G. (2006). Community health
moderates the relations between enacted support and promotion curriculum: A case study of Southeast Asian refu-
distress. Personality and Social Psychology Bulletin, 29, gees. In R. L. Toporek, L. H. Gerstein, N. A. Fouad,
1133–1146. G. Roysircar, & T. Israel (Eds.), Handbook for social justice in
Gibbs, H. W., & Achterberg-Lawlis, J. (1978). Spiritual values and counseling psychology (pp. 338–357). Thousand Oaks, CA:
death anxiety: Implications for counseling with terminal cancer Sage.
patients. Journal of Counseling Psychology, 25, 563–569. Institute of Medicine Committee on Understanding and
Good, G. E. (1992). Counseling psychologists in hospital/ Eliminating Racial and Ethnic Disparities in Health Care.
medical settings: Dilemmas facing new professionals. The (2003). Unequal treatment: Confronting racial and ethnic dis-
Counseling Psychologist, 20, 67–73. parities in health care. Washington, DC: National Academy
Goodyear, R. K., Murdock, N., Lichtenberg, J. W., of Science.
McPherson, R., Koetting, K., & Petren, S. (2008). Stability Isler III, W. C., Peterson, A. L., & Isler, D. E. (2005). Behavioral
and change in counseling psychologists’ identities, roles, treatment of insomnia in primary care. In L. C. James, &
functions, and career satisfaction across 15 years. The Coun- R. A. Folen (Eds.), The primary care consultant: The next
seling Psychologist, 36, 220–249. frontier for psychologists in hospitals and clinics (pp. 155–172).
Gornick, M. E., Eggers, P. W., Reilly, T. W., Mentnech, R. M., Washington, DC: American Psychological Association
Fitterman, L. K., Kucken, L. E., & Vladeck, B. C. (1996). Press.
Effects of race and income on mortality and use of services James, L. C. (2006). Integrating clinical psychology into
among Medicare beneficiaries. New England Journal of Medi- primary care settings. Journal of Clinical Psychology, 62,
cine, 335, 791–799. 1207–1212.
Hackett, G., & Horan, J. J. (1980). Stress inoculation for pain: James, L. C. (2009, January 9). Integrating mental health services
What’s really going on? Journal of Counseling Psychology, 27, into the primary care setting. Workshop presented at Walter
107–116. Reed Army Medical Center, Washington, DC.
Hage, S. M., Romano, J. L., Conyne, R. K., Kenny, M., James, L. C., & Folen, R. (1999). A paradigm shift in the
Matthews, C., Schwartz, J. P., & Waldo, M. (2007). Best scope of practice for health psychologists: Training health
practice guidelines on prevention practice, research, training, psychologists to be primary care case managers. Professional
and social advocacy for psychologists. The Counseling Psychol- Psychology: Research and Practice, 30, 352–356.
ogist, 35, 493–566. James, L. C., & Folen, R. A. (2005). The primary care consul-
Hayes, J. A., & Gelso, C. J. (1993). Male counselors’ discomfort tant: The next frontier for psychologists in hospitals and
with gay and HIV-infected clients. Journal of Counseling clinics. Washington, DC: American Psychological Association
Psychology, 40, 86–93. Press.
Herman, K. C., Tucker, C. M., Ferdinand, L. A., James, L. C., Folen, R. A., Garland, F., Noce, M., Edwards, C.,
Mirsu-Paun, A., Hasan, N. T., & Beato, C. (2007). Culturally Gohdes, D., et al. (1997). The Tripler LEAN Program:
sensitive health care and counseling psychology: An over- A healthy lifestyle model for the treatment of obesity. Military
view. The Counseling Psychologist, 35, 633–649. Medicine, 162, 328–332.
Hoffman, M. A. (1991). Counseling the HIV-infected client: James, L. C., Folen, R. A., Page, H., Noce, M., & Britton, C.
A psychosocial model for assessment and intervention. The (1999). The Tripler LEAN Program: A two-year follow-up
Counseling Psychologist, 19, 467–542. report. Military Medicine, 164, 389–395.
Hoffman, M. A. (1993). Multiculturalism as a force in counsel- Jarrett, E. M. (2008). Treating depression in the primary
ing clients with HIV-related concerns. The Counseling care setting. In L. C. James, & W. T. O’Donohue (Eds.), The
Psychologist, 21, 712–731. primary care toolkit (pp. 133–168). New York: Springer.
Hoffman, M. A., & Driscoll, J. M. (2000). Health promotion Joint United Nations Programme on HIV/AIDS. (2008).
and disease prevention: A concentric biopsychosocial model 2008 report on the global AIDS epidemic. Retrieved June 26,
of health status. In S. D. Brown, & R. W. Lent (Eds.), 2009, from http://www.unaids.org/en/KnowledgeCentre/
Handbook of counseling psychology (3rd ed., pp. 532–570). HIVData/GlobalReport/2008/2008_Global_report.asp.
New York: Wiley. Kaut, K. P. (2006). Counseling psychology in the era of genetic
Hopps, J. A., & Liu, W. M. (2006). Working for social justice testing: Considerations for practice, research, and training.
from within the health care system: The role of social class in The Counseling Psychologist, 34, 461–488.
psychology. In R. L. Toporek, L. H. Gerstein, N. A. Fouad, Kenny, M. E., Waldo, M., Warter, E. H., & Barton, C. (2002).
G. Roysircar, & T. Israel (Eds.), Handbook for social justice in School-linked prevention: Theory, science, and practice for
counseling psychology (pp. 318–337). Thousand Oaks, CA: enhancing the lives of children and youth. The Counseling
Sage. Psychologist, 30, 726–748.

748 coun seling h e alth ps ych o lo g y

Kessler, M., & Albee, G. W. (1975). Primary prevention. Annual Americans with disabilities. Rehabilitation Counseling Bulletin,
Review of Psychology, 26, 557–591. 50, 14–23.
Koller, M. T., Steyerberg, E. W., Wolbers, M., Stijnen, T., Mrdjenovich, A. J., & Moore, B. A. (2004). The professional
Bucher, H. C., Hunink, M. G. M., & Witteman, J. C. M. identity of counselling psychologists in health care: A review
(2007). Validity of the Framingham point scores in the and call for research. Counselling Psychology Quarterly, 17,
elderly: Results from the Rotterdam study. American Heart 69–79.
Journal, 154, 87–93. Narrow, W. E., Reiger, D. A., Rae, D. S., Manderscheid, R. W.,
Kop, W. J. (2005). Psychological interventions with coronary & Locke, B. Z. (1993). Use of services by persons with
heart disease. In L. C. James, & R. A. Folen (Eds.), The pri- mental and addictive disorders: Findings from the National
mary care consultant: The next frontier for psychologists in hos- Institute of Mental Health Epidemiological Catchment Area
pitals and clinics (pp. 61–82). Washington, DC: American Program. Archives of General Psychiatry, 50, 95–107.
Psychological Association Press. National Center for Health Statistics. (n.d.). Leading causes of
Krumboltz, J. D., Becker-Haven, J. F., & Burnett, K. F. (1979). death 1900–1998. Retrieved June 6, 2009, from http://www.
Counseling psychology. Annual Review of Psychology, 30, cdc.gov/nchs/data/dvs/lead1900_98.pdf.
355–402. National Institute on Disability & Rehabilitation Research.
Lavin, D. (2008). Smoking. In L. C. James, & W. T. O’Donohue (1999). NIDRR long-range plan. Washington, DC: Office of
(Eds.), The primary care toolkit (pp. 277–290). New York: Special Education and Rehabilitation Services.
Springer. Neimeyer, G. J., Bowman, J., & Stewart, A. E. (2001). Intern-
Law, W. A., & Buermeyer, C. (2005). Management and treat- ship and initial job placements in counseling psychology:
ment of HIV/AIDS in primary care. In L. C. James, & A 26-year retrospective. The Counseling Psychologist, 7,
R. A. Folen (Eds.), The primary care consultant: The next fron- 82–85.
tier for psychologists in hospitals and clinics (pp. 83–104). Nicholas, D. R., & Gobble, D. C. (1990). On the importance
Washington, DC: American Psychological Association Press. of disregulatory processes in models of health. American
Lent, R. W. (1990). Further reflections on the public image Psychologist, 45, 981–982.
of counseling psychology. The Counseling Psychologist, 18, Noonan, B. M., Gallor, S. M., Hensler-McGinnis, N. F.,
324–332. Fassinger, R. E., Wang, S., & Goodman, J. (2004). Challenge
Levensky, E. (2005). Increasing medication adherence in chronic and success: A qualitative study of the career development
illness: Guidelines for behavioral health-care clinicians of highly achieving women with physical and sensory dis-
working in the primary care setting. In W. T. O’Donohue, abilities. Journal of Counseling Psychology, 51, 68–80.
M. R. Byrd, N. A. Cummings, & D. A. Henderson (Eds.), O’Byrne, K. K., Brammer, S. K., Davidson, M. M., &
Behavioral integrative care: Treatments that work in primary Poston, W. S. C. (2002). Primary prevention in counseling
care (pp. 347–366). New York: Brunner-Routledge. psychology: Back to the future. The Counseling Psychologist,
Li, C. I., Malone, K. E., & Daling, J. R. (2003). Differences 30, 330–344.
in breast cancer stage, treatment, and survival by race and O’Donohue, W. T., Byrd, M. R., Cummings, N. A., & Henderson,
ethnicity. Archives of Internal Medicine, 163, 49–56. D. A. (2005). Behavioral integrative care: Treatments that work
Maguire, C. P., McNally, C. J., Britton, P. J., Werth, J. L., Jr., & in primary care. New York: Brunner-Routledge.
Borges, N. J. (2008). Challenges of work: Voices of persons Okey, J. L. (1998). Pain management. In S. Roth-Roemer,
with HIV disease. The Counseling Psychologist, 36, 42–89. S. E. R. Kurpius, & C. Carmin (Eds.), The emerging role of
Matarazzo, J. D. (1980). Behavioral health and behavioral medi- counseling psychology in health care (pp. 191–209). New York:
cine: Frontiers for a new health psychology. American W. W. Norton & Company.
Psychologist, 35, 807–817. Olkin, R., & Pledger, C. (2003). Can disability studies and
McDaniel, S. H., Hargrove, D. S., Belar, C. D., Schroeder, C. S., psychology join hands? American Psychologist, 58, 296–304.
& Freeman, E. L. (2004). Recommendations for education Otis, J. D., Reid, M. C., & Kerns, R. D. (2005). Multidisciplinary
and training in primary care. In R. Frank, S. H. McDaniel, approaches to pain management in primary care settings.
J. Bray, & M. Heldring (Eds.), Primary care psychology In L. C. James, & R. A. Folen (Eds.), The primary care consul-
(pp. 63–92). Washington, DC: American Psychological tant: The next frontier for psychologists in hospitals and clinics
Association Press. (pp. 41–60). Washington, DC: American Psychological
McDaniel, S. H., & Hepworth, J. (2004). Family psychology Association Press.
in primary care: Managing issues of power and dependence Parker, H. J., & Chan, F. (1990). Psychologists in rehabilitation.
through collaboration. In R. Frank, S. H. McDaniel, Preparation and experience. Rehabilitation Psychology, 35,
J. Bray, & M. Heldring (Eds.), Primary care psychology 239–248.
(pp. 113–132). Washington, DC: American Psychological Peterson, D. B., & Elliott, T. R. (2008). Advances in conceptual-
Association Press. izing and studying disability. In R. Lent, & S. Brown (Eds.),
Merluzzi, T. V., & Sanchez, M. A. M. (1998). Psychological Handbook of counseling psychology (4th ed., pp. 212–230).
perspectives on life-threatening illness: Cancer and AIDS. New York: John Wiley & Sons.
In S. Roth-Roemer, S. E. R. Kurpius, & C. Carmin Petersen, S., Heesacker, M., & Marsh, R. D. (2001). Medical
(Eds.), The emerging role of counseling psychology in health care decision making among cancer patients. Journal of Counseling
(pp. 157–190). New York: W.W. Norton & Company. Psychology, 48, 239–244.
Millon, T. (1982). On the nature of clinical health psychology. Pinkerton, S. S., & McAleer, C. A. (1976). Influence of client
In T. Millon, C. J. Green, R. B. Meagher (Eds.), Handbook diagnosis–cancer–on counselor decisions. Journal of Coun-
of clinical health psychology. New York: Plenum. seling Psychology, 23, 575–578.
Mpofu, E., & Harley, D. A. (2006). Racial and disability iden- Poleshuch, E. L. (2005). Women’s health and the role in primary
tity: Implications for the career counseling of African care psychology. In L. C. James, & R. A. Folen (Eds.),

be r m an, jam e s 749

 The primary care consultant: The next frontier for psychologists Schulman, K. A., Berlin, J. A., Harless, W., Kerner, J. F.,
in hospitals and clinics (pp. 217–242). Washington, DC: Sistrunk, S., Gersh, B. J., et al. (1999). The effect of race and
American Psychological Association Press. sex on physicians’ recommendations for cardiac catheteriza-
Prentice, R. L., Caan, B., Chlebowski, R. T., Patterson, R., tion. New England Journal of Medicine, 340, 618–626.
Kuller, L. H., Ockene, J. K., et al. (2006). Low-fat dietary Schwartz, G. E. (1982). Testing the biopsychosocial model: The
pattern and risk of invasive breast cancer: The Women’s ultimate challenge facing behavioral medicine? Journal of
Health Initiative Randomized Controlled Dietary Modi- Consulting and Clinical Psychology, 50, 1040–1053.
fication Trial. Journal of the American Medical Association, Scott, C. W. (1980). History of the division of counseling
295, 629–642. psychology: 1945–1963. In J. M. Whiteley (Ed.), The history
Prilleltensky, I., & Prilleltensky, O. (2003). Synergies for well- of counseling psychology (pp. 25–40). Monterey, CA: Brooks/
ness and liberation in counseling psychology. The Counseling Cole.
Psychologist, 31, 273–281. Seeman, J. (1989). Toward a model of positive health. American
Prochaska, J. O., & DiClemente, C. C. (2005). The transtheo- Psychologist, 44, 1099–1109.
retical approach. In J. C. Norcross, & M. R. Goldfried Singer, J. E., & Krantz, D. S. (1982). Perspectives on the inter-
(Eds.), Handbook of psychotherapy integration (pp. 147–171). face between psychology and public health. American
New York: Oxford University Press. Psychologist, 37, 955–960.
Reese, L. E., & Vera, E. M. (2007). Culturally relevant prevention: Smith, E. J. (2006). The strengths-based counseling model. The
The scientific and practical considerations of community- Counseling Psychologist, 34, 13–79.
based programs. The Counseling Psychologist, 35, 763–778. Strosahl, K. (2005). Training behavioral health and primary care
Regier, D. A., Narrow, W. E., Rae, D. S., Manderscheid, R. W., providers for integrated care: A core competence approach.
Locke, B. Z., & Goodwin F. K. (1993). The de facto US In W. T. O’Donohue, M. R. Byrd, N. A. Cummings, &
mental and addictive disorders service system: Epidemio- D. A. Henderson (Eds.), Behavioral integrative care: Treat-
logic catchment area prospective 1-year prevalence rates of ments that work in the primary care setting (pp. 15–52).
disorders and services. Archives of General Psychiatry, 50, New York: Brunner-Routledge.
85–94. Sue, D. W., & Sue, D. (1999). Counseling the culturally different:
Ridley, C. R., Mendoza, D. W., Kanitz, B. E., Angermeier, L., & Theory and practice (3rd ed.). Hoboken, NJ: John Wiley &
Zent, R. (1994). Cultural sensitivity in multicultural coun- Sons Inc.
seling: A perceptual schema model. Journal of Counseling Tallman, B. A., Altmaier, E., & Garcia, C. (2007). Finding
Psychology, 41, 125–136. benefit from cancer. Journal of Counseling Psychology, 54,
Rogers, J. R., & Britton, P. J. (1994). AIDS and rational suicide: 481–487.
A counseling psychology perspective or a slide on the slip- Tarico, V., Smith, W. L., Altmaier, E. M., Franken, E. A., &
pery slope. The Counseling Psychologist, 22, 171–178. VanVelzen, D. R. (1984). Critical incident interviewing in
Romano, J. L., & Hage, S. M. (2000a). Prevention and counsel- evaluation of residency performance. Radiology, 152, 327–329.
ing psychology: Revitalizing commitments for the 21st cen- Thoresen, C. E., & Eagleston, J. R. (1984). Counseling, health,
tury. The Counseling Psychologist, 28, 733–763. and psychology. In S. D. Brown, & R. W. Lent (Eds.),
Romano. J. L., & Hage, S. M. (2000b). Prevention: A call to Handbook of counseling psychology (pp. 930–955). New York:
action. The Counseling Psychologist, 28, 854–856. Wiley.
Romano, J. L., & Netland, J. D. (2008). The application of the Thoresen, C. E., & Eagleston, J. R. (1985). Counseling for
theory of reasoned action and planned behavior to preven- health. The Counseling Psychologist, 13, 15–87.
tion science in counseling psychology. The Counseling Tix, A. P., & Frazier, P. A. (1998). The use of religious coping
Psychologist, 36, 777–806. during stressful life events: Main effects, moderation, and
Rowan, A., & Runyan, C. N. (2005). A primer on the consul- mediation. Journal of Consulting and Clinical Psychology, 66,
tation model of primary care behavioral health integration. 411–422.
In L. C. James, & R. A. Folen (Eds.), The primary care consul- Todd, K. H., Deaton, C., D’Adamo, A. P., & Goe, L. (2000).
tant: The next frontier for psychologists in hospitals and clinics Ethnicity and analgesic practice. Annals of Emergency
(pp. 9–28). Washington, DC: American Psychological Asso- Medicine, 35, 11–16.
ciation Press. Tucker, C. M., Ferdinand, L. A., Mirsu-Paun, A., Herman, K.
Roysircar, G. (2006). Counseling health psychology’s collabora- C., Delgado-Romero, E., van den Berg, J. J., & Jones, J. D.
tive role in the community. In R. L. Toporek, L. H. Gerstein, (2007). The roles of counseling psychologists in reducing
N. A. Fouad, G. Roysircar, & T. Israel (Eds.), Handbook for health disparities. The Counseling Psychologist, 35, 650–678.
social justice in counseling psychology (pp. 313–317). Thousand Tucker, C. M., Herman, K. C., Pedersen, T. R., Higley, B.,
Oaks, CA: Sage. Montrichard, M., & Ivery, P. (2003). Cultural sensitivity in
Schiffner, T., & Buki, L. P. (2006). Latina college students’ sexual physician-patients relationships: Perspectives of an ethnically
health beliefs about HPV. Cultural Diversity and Ethnic diverse sample of low-income primary care patients. Medical
Minority Psychology, 12, 687–696. Care, 41, 859–870.
Schmidt, C. K., Hoffman, M. A., & Taylor, N. (2006). Social Tucker, C. M., Herman, K. C., Ferdinand, L. A., Bailey, T. R.,
justice related to working with HIV/AIDS from a counseling Lopez, M. T., Beato, C., et al. (2007). Providing patient-
health psychology perspective. In R. L. Toporek, centered culturally sensitive health care: A formative model.
L. H. Gerstein, N. A. Fouad, G. Roysircar, & T. Israel The Counseling Psychologist, 35, 679–705.
(Eds.), Handbook for social justice in counseling psychology Ware, J. E., Manning, W. G., Duan, N., Wells, K. B.,
(pp. 358–374). Thousand Oaks, CA: Sage. & Newhouse, J. P. (1984). Health status and the use of out-
Schofield, W. (1969). The role of psychology in the delivery of patient mental health services. American Psychologist, 39,
health services. American Psychologist, 24, 565–584. 1090–1100.

750 coun seling h e alth ps ych o lo g y

Werth, J. L., Jr. (1992). Rational suicide and AIDS: Williams, D. R., & Neighbors, H. W. (2001). Racism, discrimi-
Considerations for the psychotherapist. The Counseling nation, and hypertension: Evidence and needed research.
Psychologist, 20, 645–659. Ethnicity and Disease, 11, 800–816.
Werth, J. L., Jr., Borges, N. J., McNally, C. J., Maguire, C. P., Wood, P. S., Smith, W. L., Altmaier, E. M., Tarico, V. S., &
& Britton, P. J. (2008a). Integrating health and vocational Franken, E. A. (1990). A prospective study of cognitive and
psychology: HIV and employment. The Counseling noncognitive selection criteria as predictors of resident per-
Psychologist, 36, 8–15. formance. Investigative Radiology, 25, 855–859.
Werth, J. L., Jr., Borges, N. J., McNally, C. J., Maguire, C. P., World Health Organization. (2008). The top 10 causes of death.
& Britton, P. J. (2008b). The intersections of work, health, Retrieved June 6, 2009, from http://www.who.int/media-
diversity, and social justice: Helping people living with HIV centre/factsheets/fs310/en/index.html.
disease. The Counseling Psychologist, 36, 16–41. Worthington, E. L., Jr., & Shumate, M. (1981). Imagery and
Wilkinson, R. G. (1996). Unhealthy societies: The afflictions of verbal counseling methods in stress inoculation training for
inequity. London: Routledge. pain control. Journal of Counseling Psychology, 28, 1–6.

be r m an, jam e s 751

 CHAPTER
Counseling Psychology and Occupational
29 Health Psychology

Donald E. Eggerth and Thomas R. Cunningham

Abstract
Given its historical roots in vocational psychology and its current emphases on multiculturalism,
positive psychology and social justice, counseling psychology is uniquely poised to contribute to the
emerging, interdisciplinary field of occupational health psychology (OHP). Despite a halving of work-
related injury rates in recent decades, work remains the sixth leading cause of death in the United
States. The goal of OHP is to protect and promote the health of workers and of their families, and to
improve the quality of work life. Occupational health psychology has a threefold focus on the work
environment, the individual worker, and the interface between work and family. Specific topics that
OHP is attempting to address include work-related stress; occupational health disparities related to
gender, age, ethnicity or race, work–family interface; increasing intervention effectiveness; improving
safety climate; job design; and work organization.
Keywords: Occupational health psychology, work stress, occupational health disparities, burnout,
safety climate, work–family interface, person–environment fit

As a field, counseling psychology never seems afraid the field (allowing for differences in terminology),
to take on big challenges. This should not be surpris- vocational psychology, positive psychology, multi-
ing, given its roots in Frank Parsons’ visionary efforts cultural psychology, and social justice were all pres-
to improve the lives of the huge cohort of recent ent from the start and were not viewed as separate
immigrants to the United States at the turn of the themes, but as facets of a common goal—the better-
20th century. In subsequent decades, counseling psy- ment of the individual and society (Eggerth, 2008).
chology repeatedly proved itself robust and relevant For these founders, work was the powerful vehicle by
enough to successfully contribute to addressing emer- which self-, economic, political, and social empow-
gent social concerns including the Great Depression, erments were attained. Indeed, Frank Parsons, the
the Civil Rights Movement, Women’s Liberation and individual considered by most to be the father
Gay Pride—not to mention the world wars. of vocational psychology, and therefore a “grandfa-
The current breadth of counseling psychology ther” of counseling psychology, was very much con-
applications may be seen in Bingham’s (2001) cate- cerned with all of these topics (Blustein, McWhirter,
gorization of the field around four core themes: & Perry, 2005; O’Brien, 2001). Parsons hoped to
vocational psychology, positive psychology, multi- improve the overall quality of life of poor immigrant
cultural psychology, and social justice. Positive psy- workers and their families by more thoughtfully
chology, multicultural psychology, and social justice matching workers with jobs. Careful matching of
are frequently viewed as more recent structures job skills to employment led to job security and
built upon the foundation of vocational psychology. therefore financial security, the foundation upon
However, if one looks at the intent of the founders of which all else could be built.

752
 Subsequent generations of vocational psycholo- less relevant, “First World” manufacturing jobs were
gists developed more sophisticated tools and models shifting to less developed countries. Corporations
to meet the needs of adult workers. Many of the scrambled to maintain a competitive edge through
approaches used in the first college counseling cen- a flurry of mergers and/or downsizings (National
ters were adapted from those developed during the Institute for Occupational Safety and Health;
Great Depression to facilitate matching unemployed NIOSH, 2002). New management models, such as
adults with new jobs. In this first generation of just-in-time production, lean management, multi-
counseling centers, vocational psychologists sought tasking, outsourcing, and an ever-increasing use of
to further empower Parsons’ immigrant families by contractors or temporary employees, were embraced.
facilitating the success of their children at colleges Union membership steadily declined. The bonds of
and universities (Williamson, 1939). The need for loyalty between employer and worker broke down.
the military to classify and train millions of new Workers no longer expected, nor could realistically
recruits during World War II provided a huge boost expect, to work their entire careers for a single
to the development of vocational psychology. These employer. Making a virtue out of necessity, workers
newly developed models and methods were further were encouraged to view themselves as entrepre-
refined in campus settings as returning servicemen neurs who moved frequently from job to job on the
took advantage of G.I. Bill benefits and sought road to independence and self-sufficiency.
college degrees in unprecedented numbers. Although these many changes positively bene-
Clearly, during these very productive early fited corporate bottom lines, they exacted great
decades, meeting the needs of adult workers set the costs from workers. Many workers found themselves
agenda for vocational psychologists. These models needing to switch employment, if not careers, often
were then fruitfully adapted for use with students. at lower incomes, in their forties and fifties—ages
However, in subsequent decades, the primary empha- that previously were associated with stable employ-
sis of the field shifted toward meeting the needs of ment and peak earning potential. All of these changes
students, with only indirect consideration of adult were accompanied by stress, both for workers losing
workers. For many, vocational psychology is now vir- or changing jobs and for those retaining employ-
tually synonymous with career guidance performed ment, but needing to adapt to new contingencies.
in campus settings. Choosing a college major has Citing the results from several surveys, the National
become the proxy for an actual job or career. Institute for Occupational Safety and Health
A number of interconnected factors likely led (NIOSH; 1999) reported that between 26% and
to this shift in emphasis. Prominent among these 40% of American workers consider themselves to be
factors was the postwar economic boom. Unem- very stressed at work.
ployment was low and union membership was at Work-related stress has now become one of the
all-time highs—adult workers simply did not need leading occupational health problems in the United
the level of assistance they had in prior decades. States (NIOSH, 2004). In 2001, workers with anx-
At the same time, their children, the demographic iety, stress, or neurotic disorders lost a median of
bulge of the “baby boom,” were working their way 25 workdays, as compared to a median of 6 work-
through the educational system. Sheer numbers, days for all other sources of nonfatal occupational
coupled with an economic prosperity that allowed injury and illness. Over 42% of workers with anxi-
many to be the first in their families to attend col- ety, stress, or neurotic disorders were away from
lege, greatly increased enrollment at colleges and work more than 30 days, as compared to only 22%
universities. Civil rights advances opened the doors of workers suffering from all other sources of occu-
of higher education to yet more students and further pational injury and illnesses. Clearly, on a case-by-
swelled enrollment. It is no wonder that vocational case basis, stress-related disorders have the potential
psychology focused on successfully assimilating this to cost businesses far more than other sources of
mass of new students. occupational injury and illness. Of course, these sta-
tistics do not even touch upon the “ripple effect” of
Globalization stress-related disorders on family and friends.
In the 1980s, the economic phenomena now
referred to as globalization first began to adversely Emergence of Occupational
impact businesses and workers in industrialized Health Psychology
countries. As technology and international agree- Although its earliest roots can be traced back a
ments increasingly rendered distance and borders century, occupational health psychology (OHP)

e gge rt h, cunningham 753

largely emerged, as a discipline, in response to the psychology as a whole has been slow to perceive the
human costs associated with the changes to work relevance OHP. In 1992, NIOSH partnered with
organization and structure that were first imple- the American Psychological Association (APA) to
mented in the 1980s and continued through the develop postdoctoral training in OHP. NIOSH
1990s to the present (Barling & Griffiths, 2003). has funded (through APA) the development of
Professionals in medicine, public health, and behav- OHP training programs at 12 universities across the
ioral sciences could not help but to take notice of United States. To date, only one of these programs
the accumulative costs of work-related stress upon (University of Minnesota) is based within a counsel-
workers and their families. The term occupational ing psychology program. The other programs are
health psychology was introduced by Raymond, affiliated with industrial/organizational, clinical and/
Wood, and Patrick (1990) in their seminal paper or social psychology programs, schools of public
arguing for the creation of doctoral-level training health, and schools of medicine.
programs that integrated health psychology and Exceptional among counseling psychologists,
public health, and which incorporated elements of more than a decade ago in her presidential address
occupational medicine, nursing, preventative medi- to the Society of Counseling Psychology, Jo-Ida
cine, behavioral medicine, political science, sociol- Hansen (1995) called for counseling psychology to
ogy and business. recognize and address the ever-increasing levels of
The goal of OHP is to improve the quality of work stress and ever-decreasing levels of job satisfac-
work life, and to protect and promote the health tion experienced by American workers. Hansen
of workers and of their families (Quick, 1999). made a clear case for the expanding conceptualiza-
Occupational health psychology is interdisciplin- tion of career guidance beyond mere choice of career
ary, involving most areas of psychology and draw- and into the realm of ongoing work adjustment
ing upon fields such as public health, sociology, by addressing topics such as the impact of corpo-
medicine, and industrial engineering. Occupational rate restructuring on worker well-being, the work–
health psychology is typically characterized as having family interface, and the incursion of work upon
a threefold focus on the work environment, the leisure time through advances in communication
individual worker, and the interface between work technologies. Hansen called for the development
and family. Interventions and/or research range of counseling psychology training programs and
across all three levels (primary, secondary, and ter- research agendas to address these and other occupa-
tiary) of the public health model of prevention. tional health issues. She is a founding member of
Although work-related stress continues to be of the Society for Occupational Health Psychology,
central interest to OHP, the scope of the field has and it is due to her leadership that the University of
expanded to address a wide range of behavior inter- Minnesota became the only counseling psychology
actions and consequences related to reducing the program in the United States to take advantage
number of workers injured or killed and/or increas- of APA/NIOSH funding for the development of
ing worker well-being. Examples of these areas OHP training programs.
include worker decision processes concerning the Lawrence Jones (1996) was another early voice
use of personal protective equipment (PPE), such for OHP concerns in counseling psychology. Jones
as safety glasses and helmets; the managerial deci- argued forcefully that, in an increasingly insecure
sion processes related to providing PPE and other world of work, career counselors were doing their
occupational safety and health (OSH) resources; clients a disservice by only focusing on the “posi-
risk perception and risk acceptance; improving the tive” aspects of a given occupation. Jones argued
impact of OSH training and occupational health that the “negative” aspects should also be taken
disparities related to gender, age, ethnicity, or race; into account. For example, a student contemplating
the impact of work upon family life in an era during medical school should not just be allowed to view it
which the barriers between work and home are as an opportunity to express interests and skills in
dissolving; safety climate; and safety culture. science or to meet values related to altruism, social
esteem, or income. This same student should be
Connecting Counseling Psychology and made aware of the risks from exposures to diseases,
Occupational Health Psychology such as blood-borne pathogens, the very long work
Given its roots in addressing the needs of working hours, high levels of work-related stress, and the
adults, it would seem that OHP would be a natural attendant toll upon families, including a high
fit for counseling psychology. However, counseling divorce rate.

754 occupational h ealth p s ych o lo gy

 More recently, David Blustein (2006) called for cost for all forms of cancer was $171 billion,
broadening the focus of vocational psychology from $164 billion for heart disease, $67 billion for
matching college students with majors, which pre- Alzheimer’s disease, and $30 billion for HIV/AIDS.
sumably lead to related careers, to the entire spec- It is significant to note that Leigh et al. estimated
trum of how work impacts individuals and society. that 6%–10% of all cancers and 5%–10% of heart
He termed to this new perspective the psychology of disease are likely attributable to occupational causes.
work. Blustein used Maslow’s hierarchy of needs as a These illnesses can take many years to develop prior
framework within which to discuss all of the reasons to medical diagnosis; in some instances, the indi-
people work. He argues that vocational psychology vidual may have long since changed employment
has focused too much on meeting higher-level needs and consequently no connection is made between
related to self-actualization and self-expression and past workplace exposures and current medical con-
has largely ignored the plight of individuals who ditions. This time lag further complicates efforts to
work to meet basic survival needs—food, shelter, calculate the monetary costs of OSH failures and
security. suggests that the $26 billion estimate for illnesses
Before further exploring connections between may be low.
counseling psychology and OHP, let us first explore The economic burden of OSH failures is so large
the scope of OSH problems and delve deeper into for two reasons. One is the sheer number of people
the historical roots of OHP. involved. Most adults have jobs. The second reason
is the enormous impact of disabling injuries and
The Impact of Occupational Safety work-related diseases. Disabled workers may be off
and Health failures their jobs for days, weeks, months, or years. Some
Despite a nearly 50% decrease in the rate of work- never return to work. Their injury-related expenses
related injuries since the Occupational Safety and include initial and long-term medical costs, reha-
Health Act of 1970 was implemented (NIOSH, bilitation, lost productivity, and in some cases, med-
2004), working for a living remains the sixth lead- ical retirements.
ing cause of death in the United States (Pickle, Work-related diseases are often the result of toxic
Mongiole, Jones, & White, 1996). Although the exposures and can involve years of convalescence
number of work-related mortalities is not nearly as prior to death. Of course, these statistics do not even
high as the deaths attributable to heart disease, begin to quantify the nonmonetary costs of OSH
strokes, or lung cancer (first, second, and third lead- failures. For workers, these losses may include well-
ing causes of death, respectively), it is larger than being, work identity, and family role. For family
those of “higher-profile” causes of death, such as members, these costs may include adverse impact
diabetes (seventh), motor vehicle accidents (eighth), upon career goals due to the demands of caregiving,
breast cancer (ninth), suicide (tenth), and HIV/ increased stress levels, role reassignment within the
AIDS (eleventh), all of which have been the targets family, or even the emotional toll of watching a
of ongoing public health prevention campaigns. loved one die slowly, and perhaps painfully.
NIOSH (2003) estimates that each day (7 days a As discussed previously, the number of lost work
week/365 days a year) in American workplaces, days for workers with anxiety, stress, and neurotic
there are 9,000 disabling injuries and 16 deaths disorders was, on average, more than four times
from injuries. An additional 137 people die each greater than the number of workdays lost for all
day from work-related diseases. nonfatal injuries or illnesses together (NIOSH,
Due to underreporting and miscategorizations, 2004). So, although the prevalence of these disor-
it is extremely difficult to estimate the true costs ders was low in comparison to other types of ill-
of OSH failures to the United States economy nesses and injuries, on a case-by-case basis, anxiety,
(Schulte, 2005). The most comprehensive study of stress, and neurotic disorders have the potential
the burden of occupational injury and disease to be far more costly than other work-related inju-
(Leigh, Markowitz, Fahs, Shin, & Landigan, 1997) ries or illnesses. Goetzel et al. (1998) reported that
is now over a decade old. However, even when health care costs were nearly 50% greater for work-
unadjusted for inflation, the economic cost remains ers who report high levels of stress. Stress also costs
staggering. Leigh et al. estimated the annual cost (in businesses in other ways. Atkinson (2004) reported
1992 dollars) of OSH failures in the United States that stress was a contributing factor in 80% of
to be $171 billion, of which injuries cost $145 bil- all work-related injuries and in 40% of workplace
lion and illnesses $26 billion. In comparison, the turnovers. A recent survey of more than 7,600 U.S.

e gge rt h, cunningham 755

workers found that 78% say they feel burned-out, research participants. However, what is glossed over
46% feel their workload has increased over the past in such a presentation of study findings is that at
6 months, and 45% describe their current work- each stage of the study, workers were given feedback
load as “heavy” or “too heavy” (Harris Interactive, on performance and productivity. Parson’s (1991)
2008). interpreted the Hawthorne results from an operant
Traditionally, OSH has been viewed as the conditioning perspective and suggested that the
domain of industrial hygienists, toxicologists, and feedback served as a consequence that reinforced
engineers. Until recently, the only behavioral scien- (motivated) improved performance. Gottfredson
tists contributing to OSH were human factors spe- concludes that the evidence most strongly supports a
cialists. However, with recognition of the importance long-term learning effect, because in subsequent
of work-related stress and the subsequent emergence phases of the study, when manipulation of break
of the field of OHP, it is now recognized that all periods caused unhappiness among workers, pro-
psychologists can play an important role in reduc- ductivity did drop, but at all times remained well
ing the incidence and impact of OSH failures. above baseline levels.
As a result of many such findings, researchers
Historical Roots of Occupational began to look more closely at the role of worker
Health Psychology motivation and satisfaction in productivity and
Barling and Griffiths (2003) suggest that the roots found that many of the same factors associated with
of OHP may be found in efforts to understand physical and mental health (stimulation, variety,
and later to remedy the impact of application of task control, autonomy, etc.) are also associated
Frederick Taylor’s management principles on factory with higher levels of job performance (Barling &
workers. Early in the last century, Taylor argued that Griffiths, 2003). Job design theorists proposed that
industrial productivity can be improved by simplify- worker motivation and job satisfaction could be
ing, compartmentalizing, and standardizing worker increased through skill use, challenge, and/or recog-
tasks. Taylor’s approach came to be termed scientific nition. Karasek’s (1979) paper describing the rela-
management. Taylor advocated the separation of tionships between job demands, worker decision
“thinking” about work from the actual “doing” of making latitude, and job stress has been particularly
work. Thinking about work was considered the influential.
domain of industrial engineers, who designed pro- Paralleling these American efforts, and indeed,
cesses that were then implemented by managers. often leading the way, were important research
Doing the actual work, without thinking, was the programs in Europe, particularly Britain and the
role of workers. In its purest form, scientific man- Scandinavian countries (Barling & Griffiths, 2003).
agement aimed to make workers interchangeable, In important early work, Trist and Bamforth (1951)
and consideration of the emotional responses of found that British coal miners experienced high
workers was thought to interfere with productivity. levels of anxiety, anger, and depression when shifted
Although scientific management seemed to hold from autonomous workgroups doing a wide range
great economic promise, managers quickly realized of interrelated tasks to a mechanized system in
that its implementation did not guarantee increases which they only performed segmented job tasks,
in production (Barling & Griffiths, 2003). It did and in which their ability to complete these tasks
however, tend to lower employee morale and increase was contingent on the output of other workgroups.
the physical and mental health problems of workers. Bertil Gardell, Lennart Levi, and Töres Theorell
In addition, research guided by Taylor’s principles were among the most important Scandinavian
found that, contrary to expectations, workers feel- researchers (Barling & Griffiths, 2003). Gardell and
ings and perceptions did impact productivity. One his colleagues at the University of Stockholm inves-
early finding is famously known as the Hawthorne tigated the relationship between new technologies,
effect. The Hawthorne effect is typically presented as autonomy, participation, and worker mental health,
the principal finding from a series of studies in which finding that machine-paced work, monotonous
researchers varied illumination levels in an effort to work, lack of control, and fragmented and isolated
determine optimal lighting levels for an assembly work all had adverse effects upon workers. After
line (Gottfredson, 1996). Contrary to expectations, having studied with the pioneering stress researcher
productivity increased with each change in lighting. Hans Selye, Levi returned to Sweden to establish
The Hawthorne effect is frequently presented as a a stress research lab at the Karolinska Institute. Levi
classic illustration of the impact of observation upon and his colleagues conducted foundational work

756 occupational h ealth p s ych o lo gy

investigating the relationship between working The Current Status of Occupational
conditions and physical health, and the psycho- Health Psychology
physiological mechanisms associated with stressful As was discussed earlier, the roots of OHP can
conditions, and argued for the importance of con- be traced to investigations of the impact of Taylor
sideration of psychosocial factors from a more global management principles on the emotional and phys-
perspective in connection with worker health. Levi ical health of workers. However, in recent decades,
went on to found, and to serve as the first director the focus of OHP has broadened considerably.
of, the Institute for Psychosocial Factors and Health. As the result of globalization, there have been sig-
Theorell, a younger colleague of Levi, was a cardi- nificant changes in the structure of work in both the
ologist interested in the impact of stressful life events United States and Europe. Many manufacturing
on health. Theorell’s work laid the solid founda- jobs were lost, and economies shifted toward service
tion upon which Karasek and other OHP stress jobs. Corporate mergers and downsizing left many
researchers have since built. workers needing to switch employment, at ages
(forties and fifties) that previously were associated
American Developments with stable employment and peak earning poten-
In the United States, NIOSH has been a leader tial (NIOSH, 2002). Companies moved away
in researching work-related stress. Although OSH from making long-term commitments to employ-
often seems to only concern itself with traumatic ees, relying instead upon temporary workers and/or
injuries and toxic exposures, it is significant that the contractors. Correspondingly, there has been an
Occupational Safety and Health Act of 1970 which increase in the number of self-employed people. All
created NIOSH, specifically recognized the need to of these changes were accompanied by stress, both
investigate the role of “psychological factors” related for workers losing or changing jobs and for those
to OSH. As was mentioned earlier, the term occupa- retaining employment, but needing to adapt to new
tional health psychology was first introduced by contingencies.
Raymond, Wood, and Patrick (1990) in their semi- In addition to the structural changes discussed
nal paper arguing for the creation of doctoral-level above, to remain competitive, many employers sig-
training programs that integrated health psychol- nificantly changed management systems, supervi-
ogy and public health, and which incorporated ele- sory practices, and production processes (NIOSH,
ments of occupational medicine, nursing, preventa- 2002). Among these changes were compressed work
tive medicine, behavioral medicine, political science, schedules, flexible work schedules, home-based
sociology, and business. This proposed training was work, lean management, and an increased reliance
to follow a scientist–practitioner model and would on technology. These practices are intended to
prepare graduates to function in interdisciplinary increase the ability of companies to respond quickly
settings researching and/or remedying occupational and efficiently to changing production demands
health concerns. without compromising quality. However, following
Another watershed moment for the emerging implementation of these practices, employees work
field of OHP was the 1990 conference titled Work longer and harder, and often bear greater respon-
and Well-Being: An Agenda for the 1990s that was sibility for outcomes, although not always with
cosponsored by NIOSH and the APA (Schneider, increased decision-making latitude. Learning new
Camara, Tetrick, & Stenberg, 1999). The success of processes and new technologies places increased
the conference led to a second conference, Work, cognitive demands on workers, leading to stress that
Stress, and Well-being, and NIOSH/APA partnership has been tied to negative health effects.
to develop postdoctoral training in OHP, both in
1992. Building upon the success of these initial ven- Organization of Work
tures, NIOSH funded (through APA) the develop- Within OHP, the term organization of work is used
ment of OHP training programs at universities across to denote the interactive network of relationships
the United States. Twelve university programs have discussed above. NIOSH (2002) proposed a three-
participated in this project, with results ranging from tiered model for the study of the organization of
OHP curriculum development to formal graduate work. The highest level of this “top-down” model is
minors. The momentum surrounding these activities termed the external context. The external context
also led to the founding of the Journal of Occupational includes factors such as economic, legal, political,
Health Psychology (published by APA) and the Society technological, and demographic forces acting at the
for Occupational Health Psychology. national and international level. Examples include

e gge rt h, cunningham 757

the advent of globalization, the signing of the North levels, blood pressure, and heart rate. Researchers
American Free Trade Agreement (NAFTA), and the grounded in the social sciences tend to define it in
development of high-speed computer networks. terms of self-report measures focusing on affect, cog-
The second level of this model is termed the organi- nitions, and self-perceptions. These differences in
zational context. This level includes the management approach would be relatively unimportant if the
structures, supervisory practices, production meth- research findings dovetailed nicely, but unfortu-
ods, and human resources policies that are typically nately they do not. Physiological markers of stress
made in response to changes in the external context. do not always correlate significantly with self-report
The final level of the model is the work context. This measures of perceived stress.
includes job characteristics, job demands, and con- One reason for this lack of correspondence may
ditions in the workplace. be found in the distinction between eustress and
As a field, it is beyond the power of OHP to distress (Quick, Quick, Nelson, & Hurrell, 1997).
have a significant impact upon factors related to Eustress can be thought of as a healthy or positive
the external context. However, the organizational stress response. Eustress is experienced when one
and work contexts are within reach. Consequently, successfully marshals one’s resources to rise to a
much OHP research has focused upon organiza- challenge. Although objectively, from a physiologi-
tional practices (management and production meth- cal standpoint, one is experiencing stress, from an
ods and human resources policies), work processes affective standpoint one is likely experiencing the
(the way jobs are designed and performed), and the thrill of competition or a satisfying sense of accom-
impact of these two areas upon worker well-being plishment from rising to the occasion. From a
(work-related stress levels) and occupational injury cognitive standpoint, one might be experiencing a
rates. period of sharpened focus and enhanced concentra-
tion. Distress may be thought of as a negative or
Work Stress unhealthy stress response, with the sort of affective
After having written at some length about the and cognitive experiences more commonly associ-
importance and impact of work-related stress, it is ated with the term “stress.” Here, one is far more
somewhat awkward to now admit how difficult this likely to feel threatened or overwhelmed than chal-
concept is to fully define and operationalize. Hans lenged. Physiologically, eustress and distress may be
Selye (1950), the father of modern stress research manifested similarly, but their subjective psycho-
defined stress as “the nonspecific response of the logical experiences are very different.
body to any demand for change.” One might be Quick, Quick, Nelson, and Hurrell (1997) relate
tempted to view this definition as deceptively simple eustress and distress to the familiar performance
or so broad as to be meaningless. In a sense it is curve of the Yerkes-Dodson Law. Very low and very
both and neither. As pointed out by Quick, Quick, high levels of stress are associated with low levels of
Nelson, and Hurrell (1997), the term “stress” is a performance. Optimal levels of performance are
rubric for a complex series of physiological and psy- typically associated with moderate levels of stress.
chological reactions. On the physical level, stress Moderate levels of stress will likely be associated
involves a cascade of interrelated events including with eustress, whereas high levels of stress will be
increased heart rate, respiration, and perspiration; associated with distress.
elevated blood pressure; release of hormones; and
the tightening of large muscle groups. Psychological Person–Environment Fit
aspects of stress can include affective responses such As might be expected for so complex a construct, a
as anxiety, fear, anger, or depression, and cognitive number of different theoretical models have been
symptoms such as inability to concentrate, rumina- developed to describe work-related stress. One group
tion, or distractibility. of theories is person–environment (P–E) fit models of
Obviously, this familiar term covers a lot of stress. Many current P–E fit models, such as the
ground and means many things, often to many NIOSH stress model, are refinements of a model
different people. Consequently, stress has been oper- of job stress originally developed by researchers at
ationally defined in different ways by different the University of Michigan (Landsbergis, Schnall,
researchers depending both upon discipline and pro- Scwartz, Warren, & Pickering, 1995). Like the per-
fessional bias. Researchers grounded in the biologi- son–environment fit models used in career guidance,
cal sciences tend to define stress in terms of objectively these models attempt to characterize salient features
measured physiological markers such as hormone in both the work environment and the worker.

758 occupational h ealth p s ych o lo gy

Job stress is hypothesized to arise from a mismatch threat and experience distress (Quick et al., 1997).
between the skills and abilities of the worker and the Given its grounding in a mainstream cognitive-
pressures and demands of the work environment behavioral therapy approach, Lazarus’ model may
(Spielberger, Vagg, & Wasala, 2003). Lack of fit can well offer more guidance for interventions than
lead to both physical and psychological strain, which other models of job stress.
in turn can be expected to lead to behavioral conse- Speilberger’s state-trait process (STP) model
quences such as lowered production, absenteeism, of occupational stress attempts to integrate his
turnover, or health-related problems. Although P–E widely known state-trait conception of anxiety and
fit models are praised by some (Landsbergis et al., anger with Lazarus’ transactional process model
1995) for their descriptive richness, others have (Spielberger et al., 2003). The STP model focuses
faulted them for lacking specificity and for failing to on perceived severity and frequency of occurrence
distinguish between different types of fit (Spielberger of two major categories of work-related stressors—
et al., 2003). Vogel and Feldman (2009) state that job pressures and lack of support. Like Lazarus’
most P–E fit research has focused on either person– model, the STP model allows for individual differ-
organization fit or person–job fit and has tended to ences in appraisal of threats. If a threat is judged to
neglect related, but distinct variables such person– be severe and occurs frequently, it can be expected
vocation fit and person–group fit. to lead to a range of negative behavior and/or health
outcomes.
Demand–Control Model
One of the most influential job stress models Responsibility for Stress and Coping
is Karasek’s (1979) demand–control model. The Work-related stress can be viewed as either “personal
demand–control model focuses on the interaction trouble” related to personality characteristics or a
between the psychological demands of a job and the “public concern” related to work characteristics and
decision latitude (control) that a worker has to meet the epidemiology of occupational health (Kenny &
those demands (Radmacher & Sheridan, 1995). Cooper, 2003). How one approaches interventions
This interaction gives rise to four categories of job to manage occupational stress will vary depending
strain: low strain (low demand and high control), on which conceptualization is endorsed. NIOSH
active (high demand and high control), passive (low (1999) characterizes this dichotomy as worker char-
demand and low control), and high strain (high acteristics and work conditions. Traditionally, OSH
demand and low control). High-strain jobs are professionals have considered providing a safe work
expected to have the most negative health effects, environment to be an obligation employers owe
a finding that has been borne out by numerous to workers. For work hazards involving the risk of
studies. However, as Theorell (2003) acknowledges, injury or illness from toxic exposures, this seems
this finding seems to be stronger for cardiovascular a fairly straightforward approach. For example, if
problems than for other work-related health prob- an employee is working on a potentially dangerous
lems such as musculoskeletal disorders. Research piece of equipment, such as a table saw, the business
support has been consistent in finding a main effect owner clearly should have safety features such as
for both demand and control, but support for the blade guards in place. In addition, the business
hypothesized interaction effect is somewhat mixed owner should provide PPE, such as safety glasses
(Landsbergis et al., 1995; Radmacher & Sheridan, and respirators, as needed. Given this perspective,
1995). nearly all responsibility for OSH lies with the com-
pany. The worker need only show up for work, use
Cognitive-Behavioral Models provided PPE, and perform his or her work safely—
Lazarus’ extension of the transactional process model as they have been trained (by the employer) to do.
to occupational stress takes into account both the Placing any other obligation for OSH upon workers
worker’s emotional reaction to a given stressor and risked being labeled “blaming the victim.”
cognitive appraisal of the level of threat represented However, with an occupational hazard such as
by the stressor (Spielberger et al., 2003). By allowing work-related stress, in which the research indicates
for individual differences in responding to the same individual worker response plays a key role in out-
stressor, Lazarus’ model accounts for why some comes, the lines of responsibility become somewhat
workers will perceive a given stressor as a challenge blurry. NIOSH (1999) acknowledges the role that
and consequently experience eustress when coping individual differences make in responding to work-
with it and others will perceive the same stressor as a place stressors, but emphasizes that it is preferable

e gge rt h, cunningham 759

to address working conditions rather than worker Rothstein, 2008). Cognitive-behavioral interven-
characteristics for the simple reason that research tions are intended to alter individuals’ appraisal of
has identified a number of workplace practices that stressful situations and their responses to them by
increase the risk for adverse stress reactions for all providing education on the role played by one’s
workers. Examples of these include long work hours, thoughts and emotions in response to stressful events
backward rotating work shifts, and a breaking down and teaching skills to modify thoughts and improve
of barriers between work and home life (Caruso coping effectiveness. Another effective intervention
et al., 2006). Addressing these factors alleviates cur- is teaching relaxation and meditation techniques.
rent stress levels and prevents future work stress These approaches work by evoking a physiological
problems for all workers in that company. Moreover, state that is the opposite of stress. Multimodal inter-
there is a question regarding the ethics of training ventions that included a mix of cognitive-behavioral,
a worker to cope with what would otherwise be relaxation, and/or organizational interventions were
unreasonable workplace demands. Who benefits also found to be effective. However, organizational
most? The worker—for being able to continue on interventions alone were found to be the least
the job? Or, the employer—who can now make effective.
greater demands of the worker? Or, is it a “win-win” A meta-analysis conducted by van der Klink et al.
situation for both? Should workers be asked to (2001) found an effect size of 0.68 for cognitive-be-
change themselves to adapt to work demands that havioral interventions, 0.51 for multimodal interven-
could be remedied in other ways? In particular, tions, 0.35 for relaxation interventions, and 0.08 for
should workers be asked to undergo what in other organizational interventions. All effect sizes were
circumstances might be considered psychotherapy statistically significant except for organizational inter-
to successfully cope with demands at work? ventions. A follow-up meta-analysis conducted by
Richardson and Rothstein (2008) found a similar pat-
Work Stress Interventions tern, although somewhat larger effect sizes. The effect
As indicated in the discussion above, work stress size for cognitive-behavioral interventions was 1.164;
management interventions can be aimed at work for relaxation, 0.497; for multimodal, 0.239; and for
conditions or worker characteristics. Ivancevich et al. organizational, it was 0.1444. Once again, all effect
(1990) identified three potential targets for inter- sizes were statistically significant except for organiza-
vention: the intensity of stressors in the workplace, tional interventions. Richardson and Rothstein also
the employee’s appraisal of stressful situations, or the included a category they labeled “Alternative” that
employee’s ability to cope with the outcomes. included a “grab bag” of worker interventions (exer-
Following the public health model of preven- cise, journaling, and time management) that did not
tion, work stress interventions can be classified fit well into the other categories. This alternative
as primary, secondary, or tertiary (Quick, 1999; category fared well, with an effect size of 0.909.
Richardson & Rothstein, 2008). Primary interven- It would seem with findings like these that work
tions aim to alter the sources of stress and may stress interventions aimed at worker characteristics,
include redesigning job roles, increasing individuals’ particularly cognitive-behavioral and relaxation/
decision-making authority, or organizing coworker meditation interventions, would be the clear meth-
support groups. Secondary interventions attempt to ods of choice. However, the case is far from closed.
reduce severity of stress symptoms in the individual Semmer (2003), arguing strongly for organizational
before significant health problems arise and may interventions, points out that effective organiza-
include cognitive-behavioral skills training, medita- tional interventions are far more difficult to conduct
tion, relaxation, deep breathing, exercise, journal- because they involve changing a large and complex
ing, time management, and goal setting. Tertiary social system. Individual worker interventions are
interventions treat individuals’ existing stress-related far less disruptive to the functioning of the com-
mental health conditions via access to mental health pany because they do not involve significant organi-
professionals, often in the form of free and confi- zational changes. Semmer (2003) points out that no
dential employee assistance programs. matter how successful individual worker interven-
Reviews of the work stress intervention literature tions may be, they ultimately do nothing to address
indicate that secondary interventions are the most the primary sources of work stress. It is almost defi-
often used and among these interventions the most nitional that worker interventions can be secondary
effective is cognitive-behavioral (van der Klink, prevention at best as the ongoing environmental
Blonk, Schene, & van Dijk, 2001; Richardson & contributors toward work stress remain unchanged.

760 occupational h ealth p s ych o lo gy

Each new worker will need to be “inoculated” organizations without stress management programs
against stressful conditions that might otherwise be (Shirom, 2003). Others consider burnout so extreme
alleviated by organizational changes. Only by elimi- as to be qualitatively different from common stress
nating these organizational sources of work stress reactions. As of yet, researchers looking toward indi-
can one truly do primary prevention. Moreover, as vidual personality traits as a predisposing factor
discussed above, there exists the ethical question of for burnout have found no clear patterns. Some
who is more obligated to change—the worker or the question whether it is even meaningful to differenti-
employer. Semmer and many others would argue ate burnout from depression (Schonfeld, 1992),
that it is the employer. considering the high degree of overlap between
items found on scales assessing burnout and on
Burnout those assessing depression.
Burnout is a chronic pattern of negative affective In a review of the burnout literature, Shirom
responses associated with reduced job satisfaction, (2003) points out that, although burnout was ini-
lower job performance, absenteeism, and turnover tially conceptualized in terms of the helping profes-
(Quick et al., 1997). Most burnout research has sions, it is now recognized that individuals in other
focused on the “helping professions”—occupations occupations who suffer from chronic stressors, such
such as physician, nurse, social worker, teacher, and as high demand and low social support, can develop
therapist. Miller (1998) cautioned that not only can burnout. Conceptually, it is now recognized that
the compassion fatigue of doing challenging psycho- one could suffer burnout in nonwork life domains
therapy produce burnout among mental health such as family and marriage. The terminology used
providers, but that the stresses inherent to doing to describe two of the dimensions of burnout has
therapy, particularly with trauma victims, can some- also been modified. Depersonalization is now fre-
times produce posttraumatic stress disorder (PTSD) quently referred to as cynicism and reduced personal
in the therapist as well. accomplishment is referred to as inefficacy.
Maslach (1982) proposed that burnout consists
of three dimensions. Emotional exhaustion consists Individual Treatment Approaches
of feelings of being depleted of one’s emotional The treatment of burnout has tended to be focused
resources, emotionally overextended, and drained on the affected individual (Le Blanc, Hox, Schaufel,
by interactions with others. Depersonalization is a Taris, & Peeters, 2007; Shirom, 2003). In part, this
negative, cynical, and detached response to other is a reflection of the empirical literature, which has
people at work, in particular toward those seeking largely focused on burnout as an individual phenom-
one’s services. Reduced personal accomplishment refers enon rather than attempting to identify organiza-
to feelings of reduced professional competence, tional practices contributing to its development. No
productivity, and self-efficacy. doubt, this also reflects Semmer’s (2003) observation
Maslach developed a burnout inventory using regarding the difficulty of conducting organizational
these three dimensions that is the most widely interventions. In any event, individual treatment for
used instrument for assessing burnout in empirical burnout tends to very closely resemble the cognitive-
research (Shirom, 2003). The three dimensions of behavioral approaches used to address other work
Maslach’s model were identified by conducting stress problems and/or depression (Shirom, 2003).
factor analyses of burnout symptoms. There is no Review of the treatment literature suggests that
theoretical rationale for the co-occurrence of these burnout interventions are most effective in reducing
three clusters of symptoms. Consequently, other symptoms of emotional exhaustion, but typically
researchers have challenged this conceptualization have little or no impact on depersonalization or pro-
of burnout. Some argue that emotional exhaustion fessional efficacy. Van Dierondonck, Garssen, and
is the central characteristic of burnout. Others argue Visser (2005) suggested that these findings might
that these three dimensions are really a single factor, arise from nearly all interventions being cognitive-
not three separate factors. Yet others challenge the behaviorally oriented. Positing that a more holistic
notion that reduced professional competency is therapy model would address a broader range of
really a symptom of burnout, but rather a natural burnout symptoms, they developed an interven-
consequence of the condition (Schaufeli, Keijers, & tion based upon Assagioli’s (1965) psychosynthesis
Miranda, 1995). model. The intervention included activities such as
Some researchers conceptualize burnout as being meditation, group discussions, guided imagery, and
the logical endpoint for individuals working in education on relevant aspects of the psychosynthesis

e gge rt h, cunningham 761

model. In a sample consisting primarily of engi- Westman and Eden (1997) explored whether a
neers, the study found both a significant decrease in simple respite from the work environment had an
emotional exhaustion and an increase in profes- impact on work stress and burnout. They tracked a
sional efficacy. However, depersonalization remained sample of workers before, during, and after a vaca-
unchanged. tion. As might be expected, these workers reported
Salmela-Aro, Naatanen, and Nurmi (2004) also a reduction in stress and burnout symptoms during
tested non–cognitive-behavioral burnout interven- their vacations. However, this effect was fleeting
tions on a sample of workers suffering from severe as workers had returned to their baseline levels of
burnout. Over the course of a year, workers in the stress and burnout within 3 weeks after returning
treatment condition received 16 group therapy ses- to work.
sions. Half of the workers in the treatment condi-
tion participated in psychoanalytically oriented group Organizational Treatment Approaches
therapy based upon free association within the groups. Semmer (2003) argued that organizational interven-
Therapeutic interpretations were provided by group tions represent primary prevention, as opposed to
facilitators. The remaining workers participated in the secondary, if not tertiary prevention of individual
group therapy based primarily upon psycho-dramatic interventions. Consequently, despite the consider-
techniques such as role-playing. Compared to a able challenges inherent to attempting organizational
control group, both treatment groups experienced interventions, from a public health perspective, they
decreases in their level of burnout, particularly symp- clearly remain a more desirable approach. Recent
toms of emotional exhaustion. However, these differ- publications in the empirical literature eloquently
ences were not statistically significant. testify to both the promise and the frustrations of
Shapiro, Astin, Bishop, and Cordova (2005) organizational treatment approaches.
used a mindfulness-based stress reduction program Le Blanc et al. (2007) worked with the staffs from
with a sample of health care providers. Over the 29 oncology wards over a 6-month period. Nine
course of 8 weeks, participants were taught medita- wards were randomly selected to participate in an
tion, yoga, and other techniques intended to raise intervention program consisting of monthly 3-hour
their awareness of body sensations, thoughts, and training sessions facilitated by program counselors.
emotions. Compared to a control group, study par- Training topics included the emergence of unwanted
ticipants experienced significant increases in life collective behaviors, communication, social support,
satisfaction and self-compassion and decreases in and emotional investment in one’s job. The workers
perceived stress. Although the treatment group did in the treatment condition experienced significantly
experience a reduction in burnout symptoms, it was less emotional exhaustion and less depersonalization
not statistically significant. than did those in the control condition.
Along more cognitive-behaviorally oriented lines, In what might be viewed as a mixed individual/
Van Dierenconck, Schaufeli, and Buunk (1998) organizational approach, Hatinen, Kinnunen,
tested an intervention that conceptualized burnout in Pekkonen, and Kalimo (2007) compared traditional
terms of perceived inequity, on the part of the worker, intervention with a participatory intervention with
between their efforts and contributions on the job a group of female professionals. The traditional
and outcomes such as recognition, status, and/or pay. treatment intervention consisted primarily of indi-
The intervention encouraged workers to restore their vidual and group therapy, and education regarding
perceptions of equity in one of three ways: by identi- individual responses to stress, depression, and burn-
fying strategies to change either their own contribu- out. In addition, individuals in the traditional treat-
tions and/or to elicit more desired outcomes from ment intervention participated in a small number of
the workplace, by changing their perceptions of con- group and individual therapy sessions focusing on
tributions and/or outcomes to better match, and by work-related factors. The individuals in the partici-
leaving the job to pursue a more congruent work situ- patory intervention received the same treatment
ation elsewhere. In a study sample of direct-care pro- package as those in traditional treatment. However,
fessionals working with mentally disabled individuals, on two occasions, representatives from their work-
this study found a significant effect for the reduction places participated in their treatment to identify
of emotional exhaustion and a moderating effect for ways to improve conditions and climate at work. At
social support. However, similar to other studies, it a 1-year follow-up, individuals in the participatory
found neither a reduction in depersonalization nor intervention reported significant improvements in
an increase in professional efficacy. both emotional exhaustion and depersonalization.

762 occupational h ealth p s ych o lo gy

Individuals in the traditional treatment reported effect—the transfer of reactions to work to other life
some improvement, but it was not statistically domains (Kelloway & Barling, 1994). Implicit to
significant. most conceptualizations of work–family balance is
On a less hopeful note, Elo, Ervast, Kuosma, and the notion of a “zero sum” game. Individuals are
Mattila (2008) reported the findings of an ambi- considered to have finite levels of time and energy,
tious, 2-year organizational intervention in a public which if used in one life domain are no longer avail-
services organization in Finland. Interventions able for use in another (Greenhaus & Parasuraman,
included training on relevant topics for both work- 2002).
ers and managers and a series of “work conferences” Frone (2003) suggested that the term work–
in which participants discussed work organization family balance, although widely used in the literature,
factors and strategies for improving the climate in was not consistently defined nor understood.
their organization. Despite earlier work finding sig- Although spillover from one domain to the another
nificant effects for the individual treatment compo- has always been conceptualized as either positive or
nents of this study, no statistically significant results negative, the work in this area has focused almost
were found for the overall field study. exclusively on negative impact—work demands upon
family life or family demands upon work. Aiming at
Burnout and Counseling Psychology both balance and clarification, Frone proposed a
Maslach (2003) characterizes burnout as arising model of work–family balance (see Table 29.1). One
from the chronic stress due to incongruence, or dimension is work-to-family/family-to-work. The
misfit, between worker and job. Given this defini- other is conflict–facilitation. The interaction of these
tion, it is dismaying that most interventions in the dimensions yields four cells: work-to-family conflict,
literature are aimed not at correcting this incongru- family-to-work conflict, work-to-family facilitation,
ence but at helping the worker to better adapt to it. and family-to-work facilitation. Conflict represents
It is also a definition that suggests counseling psy- negative impact and facilitation positive impact.
chology might hold the key to the most powerful of Citing what little facilitation research there is in
primary prevention interventions for burnout—a the literature, Frone states that there is evidence for
well-informed, thoughtful career choice. Occupa- family-to-work facilitation, but little for work-to-
tional health psychology reminds counseling psy- family facilitation.
chology that a good initial choice of career has an
impact on far more than college major. It helps to Sources of Conflict
preserve quality of life many decades later. In the last half century, ever-increasing numbers of
women have sought employment and careers
Work–Family Balance (Marshall & Barnett, 1994). The rise in the number
The term work–family balance refers to the impact of dual-income families has been paralleled by a rise
that work and family have upon one another. in divorce rates and consequently single-parent
Although work–family balance has been identified families. Both situations leave parents with less time
as one of three areas of primary interest to OHP to accomplish necessary domestic tasks and to raise
(Quick, 1999), it has received far less research atten- children. Despite significant social, political, and
tion than the other two areas (the individual worker economic advances by women in the last several
and the work environment). Among the earliest, decades, within the home, tasks still tend to be
and still one of the most common, conceptualiza- divided along traditional gender lines. Although
tions of the work–family balance is the spillover research indicates that married men and women

Table 29.1. Dimensions of Work–Family Balance

Type of Effect
Conflict Facilitation
Direction of Influence Work-to-Family Conflict Work-to-Family Conflict ↓ Work-to-Family Facilitation ↑
Family-to-Work Conflict Family-to-Work Conflict ↓ Family-to-Work Facilitation ↑
From Frone, M.R. (2003). Work–family balance. In J.C. Quick & L.E. Tetrick (Eds.), Handbook of OHP, American Psychological Association.
Reprinted with permission.

e gge rt h, cunningham 763

tend to work about the same number of hours per stress for workers. One must actually be in immedi-
week on domestic activities, the tasks performed by ate need of these family-friendly policies to benefit
women tend to have significantly lower levels of from them. Consequently, a study by Tetrick et al.
control than those performed by men. For example, (1994) that looked only at parents found that those
feeding and bathing of children takes place daily at with childcare difficulties (both male and female)
more or less the same times. Mowing the lawn can suffered from more frequent and larger losses of pro-
be put off without significant consequences. ductivity than did parents with reliable childcare.
An often overlooked source of stress is eldercare In a study based upon Karasek’s (1979) demand–
(Jarvik & Small, 1988). Medical advances are keep- control model, Kelloway and Barling (1994) found
ing individuals with significant physical and/or cog- that simply increasing worker job control did little to
nitive impairments alive far longer than in decades ameliorate work–family stress. They concluded that
past. Their middle-aged children are increasingly to be effective, work–family interventions needed to
called upon to serve as their primary caregiver and/ be more comprehensive and tailored to individual
or legal decision maker. Given the famously tran- need.
sient American lifestyle, many children live hun-
dreds if not thousands of miles from their aging Occupational Health Disparities
parents, adding further complications to an already Any differences in disease incidence, mental illness,
stressful situation. or morbidity and mortality that exist among specific
It is important to realize that work–family con- populations due to work-related causes are termed
flict does not only adversely impact the individual an occupational health disparity. For reasons beyond
employee experiencing the conflict. Tetrick et al. actual OSH needs, the bulk of research efforts have
(1994) reported that in a sample of nearly 3,000 focused on three groups: women, aging workers,
respondents, 28% reported that the childcare obli- and Hispanic immigrant workers. Clearly, women,
gations of coworkers had adversely impacted their aging workers, and Hispanic immigrants are not the
own job performance. In addition, the impact of only groups worthy of study. Rather, they represent
stressful work conditions upon the family is not the response in the literature to fairly specific socio-
simply limited to reducing the emotional quality of political pressures: the success of the women’s move-
life of a family. A study by Dompierre and Lavoie ment, the aging of the baby boom, and the massive
(1994) found relationships between work stress and influx of undocumented Hispanic immigrants into
family violence. the United States in recent decades.
Other groups also suffer occupational health dis-
Promoting Work–Family Balance parities, but have not received nearly as much atten-
In recent decades, many workplaces have introduced tion. For example, despite being barred from the most
a range of “family-friendly” policies (Marshall & hazardous jobs by law, young workers (19 and
Barnett, 1994; Frone, 2003). These policies include younger), particularly male, are killed on the job at
facilitating dependent care (onsite daycare, subsi- rates twice those of adults (NIOSH, 2004). African
dies for child- or eldercare, referral services), flexible Americans comprise 9.8% of the American work-
work arrangements (flexible starting and ending force, but suffer 11.9% of work-related nonfatal inju-
times, work-at-home, reduced or compressed work ries and illnesses and have a fatality rate (1.4 per
schedules), flexible leave policies (maternity leave, 100,000) significantly higher than the population
leave to care for sick family members), and employee average (1.0). Asians are sometimes referred to as the
assistance programs offering an increasing number of “model minority” because so many achieve a higher
services related to family concerns. Although well- degree of success than the population average. How-
intended and costly, there has been little research to ever, this characterization ignores the 1.5 million
support the efficacy of such programs. In a broad undocumented Asian immigrants in the United States
survey of workers, Marshall and Barnett (1994) (Passel, 2006). Many of these immigrants work in
found a fair amount of variability across industries low-paying jobs and are socially marginalized because
and occupations in terms of family-friendly benefits, they speak Cantonese, not Mandarin, the dialect of
but found no relationship between the availability of the educated classes in Chinese societies (Fujishiro
these benefits and job satisfaction, work conflict, and et al., 2009). Although the OSH literature is begin-
the mental health of respondents. However, as ning to address the needs of young workers, it is sparse
pointed out by these and other researchers, just for African American workers and there is almost
having these benefits does not necessarily alleviate nothing concerning Asian immigrant workers.

764 occupational h ealth p s ych o lo gy

 It is important to recognize that occupational Violence Against Women Workers
health disparities are not just an American concern. Although it would cause dismay, it would likely not
Within the European Union, most legal barriers to greatly surprise most to learn that roughly 50% of
the flow of workers from one country to another have women can expect to be sexually harassed at some
been eliminated. Some European Union countries point in their work or academic lives (Bell, Cycyota,
have also experienced an influx of undocumented & Quick, 2002). However, most would be surprised
workers. The large influx non-native workers— that homicide was the leading cause of death on the
both documented and unauthorized—has left many job among women, accounting for roughly 40% of
European Union countries struggling to overcome all work-related fatalities (NIOSH, 1995). Hoskins
the barriers of language, culture, and legal status that (2005) reports that female homicide victims are far
can leave immigrant workers vulnerable to exploita- more likely to have been killed by a family member
tion. An example is Ireland, with a population of less than are male victims. Domestic violence spills over
than 5 million, but with the same proportion of non- into the workplace in less lethal ways as well. Three-
native workers as the United States (Beggs, Mangan, quarters of battered women report having been
Concagh, & Pollock, 2005). Whereas the United harassed at work by their batterer (Friedman, Tucker,
States has been challenged to simply meet the Neville, & Imperial, 1996). In addition, 20%
needs of Spanish-speaking immigrants, Ireland must reported having been late for work because of the
attempt to overcome barriers of language and culture interference of their partners, and more than half
for a dozen nationalities. reported missing an average of 3 workdays a month
because of injuries, emotional responses, or appoint-
Women Workers ments with physicians and/or lawyers. More than
In the decades following World War II, ever-increas- half reported having lost a job as a direct result of
ing numbers of women have sought employment domestic violence. Nicoletti and Spooner (1996)
and careers (Stellman & Mailman, 1999). The suc- report that domestic violence and stalking vio-
cesses of the women’s movement in the 1960s and lence now account for more workplace injuries and
1970s further increased the number of women deaths than violence committed by disgruntled or
working. Barriers were broken down, and women ex-employees.
entered occupations that previously had been closed
to them and began to regularly rise to heights Equipment and Exposures
in organizational leadership seldom previously As women continue to move into fields traditionally
attained. dominated by men, OSH professionals are faced
Unfortunately, these hard-fought advances did with re-evaluating longstanding recommendations
not come without ongoing costs. Quick et al. (1997) and practices. For example, exposure to some work-
reported research from a number of studies indicat- place toxins at levels thought to be safe for men
ing that work-related stress takes a significant toll are known to be hazardous for a developing fetus
among female managers. As a group, female manag- (Messing & de Grosbois, 2001). Safety profession-
ers smoked more, and took more tranquilizers, anti- als and business owners are faced with either trying
depressants, and sleeping pills than did their male to reduce exposure levels even further or banning
counterparts. The rise in dual-income families have women of child-bearing years from working in cer-
left parents struggling to balance the often conflict- tain work settings. In fields such as construction
ing demands of work and family. The great work- and manufacturing, women find that most of the
place gains of the past several decades have not been PPE is manufactured in sizes appropriate for men
matched by a significant shift in traditional family and is too large for them to use (NIOSH, 1999;
roles. Women still bear the responsibility of the Ontario Women’s Directorate and the Industrial
majority of childrearing, cooking, cleaning, and Accident Prevention Association, 2006). In addi-
laundry (Marshall & Barnett, 1994). Research indi- tion, tools and equipment are also sized for men,
cates that married men and women tend to work making it difficult or even hazardous for many
about the same number of hours per week on women to use them.
domestic activities. However, the tasks performed
by women tend to have significantly lower levels of Musculoskeletal Disorders
control than those performed by men. This can be Musculoskeletal disorders (MSDs), ranging from
expected to lead to higher levels of stress and more repetitive strain to back injuries, were the leading
work–family conflicts. source of nonfatal, work-related health problems for

e gge rt h, cunningham 765

women (Hoskins, 2005). Women are much more to encourage older workers to retire, thereby open-
likely to develop MSDs than men (Stellman & ing positions for younger workers and reducing
Mailman, 1999). In part, this may be due to the unemployment. This somewhat arbitrary line of
nature of the work of traditionally female-domi- demarcation is reflected in much of the literature
nated fields. For example, in nursing, back injuries regarding aging workers and because of its reification
occur at very high rates due to activities such as lift- through widespread practice, it goes unquestioned.
ing and positioning patients (Trinkoff, Lipscomb, Arbitrary definitions aside, there are some sig-
Geiger-Brown, & Brady, 2002). Clerical work is nificant differences between aging workers and their
notorious for high rates of repetitive strain injuries. younger colleagues. Kisner and Pratt (1997) found
However, as pointed out by Stellman and Mailman that the workplace fatality rate for workers 65
(1999), women working in nonclerical fields, such and older was 2.6 times that of workers aged 16–64
as assembly and retail trade, actually suffer from (14.1 per 100,000 vs. 5.4). Significant gender differ-
higher rates of repetitive strain injuries. They sug- ences were found for older workers. Men 65 and over
gest that a major factor in this counterintuitive find- had a fatality rate nearly ten times that of women 65
ing is, as discussed above, that women frequently and over (22.1 per 100,000 vs. 2.3). This compares
have to use tools and equipment sized for men. The to a rate of 9.0 per 100,000 for men aged 16–64 and
awkward and/or stressful positions women must 0.7 per 100,000 for women aged 16–64. For older
put themselves in to perform job tasks using inap- men, the most prevalent cause of death was accidents
propriately sized tools or equipment significantly involving machines, followed by motor vehicle acci-
elevates their risks of developing MSDs. dents, falls, and homicides. For older women, the
most prevalent causes of death were homicide and
Aging Workers motor vehicle accidents. By far, the most dangerous
The workforce in many industrialized countries industry area for older workers was agriculture/for-
is aging (Wegman, 1999). In part, this shift simply estry/fishing, with fatality rates six times higher than
reflects the demographics of the baby boom. Other the next highest industry category (transportation/
factors are in play as well. With advances in medical communications/public utilities).
science, people are healthy and fit later in life, and It is widely recognized that older workers are
some choose to continue working past the age affected by age-related declines in strength and
at which they are eligible for retirement benefits. endurance and consequently are less robust physi-
However, due to economic downturns, retirement cally than their younger colleagues (Wegam &
accounts have suffered and companies have defaulted McGee, 2004). However, as Wegman (1999) points
on employee pension plans. Consequently, many are out, these physical declines may not be as occupa-
working due to economic necessity. In the United tionally relevant as one might suppose. These are
States, the eligibility age for Social Security retire- declines in maximum performance, and even physi-
ment benefits has been incrementally raised, so that cally demanding jobs tend to only require submaxi-
many current workers need to work until they are mal effort.
nearly 70 to receive full benefits. Much of Western Wegman divided jobs in four broad categories:
Europe has experienced declining birthrates since age-enhanced, age-neutral, age-counteracted, and
World War II. There are simply not enough replace- age-impaired. Age-enhanced jobs involve knowl-
ment workers being born. Consequently, there is edge-based decision making without time pressures.
great interest in keeping older workers healthy and Given that older workers can bring the wisdom of
satisfied enough to remain working (Barling & decades to a job, Wegman argues that they can out-
Griffiths, 2003). In some European countries, such perform younger workers in such activities. Age-
as Finland, this has been a major factor in the devel- neutral jobs involve relatively undemanding tasks
opment of OHP. and are not expected to be impacted significantly by
It is interesting to note how quickly 65 became age. Age-counteracted jobs involve skilled manual
enshrined as the typical retirement age. Wegman work. Here, any decrements in physical capacity
(1999) points out that prior to World War II, most can be expected to be counteracted by the enhanced
people died while still in their fifties. People simply skills and expertise acquired from years performing
worked as long as they were able. However, follow- the job. Age-impaired jobs involve continuous high-
ing the war, with lifespans increasing dramatically, pace data processing and are the only category in
governments, in a sense, defined old age by setting which older workers can be expected to suffer age-
the age for most retirement benefits at 65 in an effort related deficits in job performance.

766 occupational h ealth p s ych o lo gy

Accommodating Older Workers the Southeast and the Midwest, that have not tradi-
Although the overall job performance for older tionally been destinations for Hispanic immigrant
workers is the same, if not better, in most categories workers have experienced explosive growth in the
of work as compared to younger workers (Wegman, size of their Hispanic communities since the early
1999), there are some age-related factors that can 1990s (Passel, 2005). In addition to political issues
have an impact on job performance, but which can and legal consequences related to their undocu-
be easily addressed in most workplaces (Wegman & mented status, Hispanic immigrants in these “new
McGee, 2004). Most of these factors are environ- settlement areas” are further socially marginalized
mental. Aging diminishes the sensitivity of the eyes, and subject to exploitation due to lack of a Spanish-
so older workers may benefit from higher levels of speaking public and/or social services infrastructure
lighting in work areas than needed by younger (Passel, Capps, & Fix, 2002).
workers. Older workers also tend to be far more The Hispanic population in the United States
sensitive to extremes of temperature than younger represents many unique challenges for OSH.
workers. If environmental modifications cannot be Trainers are challenged by barriers of both language
easily made, managers might consider assigning and culture (O’Connor, 2003). Regulatory officers
older employees to tasks that avoid extremes of tem- are challenged by distrust on the part of the many
perature. Older workers may also be less tolerant of undocumented Hispanic immigrant workers for
background noise than younger workers. This can any government official. These problems are com-
make it more difficult for them to hear important pounded because Hispanic immigrant workers tend
auditory signals. If minimizing background noise to be employed in the least desirable, poorest paid,
levels cannot be accomplished, managers might and most dangerous occupations, so that they are at
consider using different or redundant signal chan- increased risk to suffer from negative health conse-
nels. For example, instead of using an auditory tone, quences (Dong & Platner, 2004; Loh & Richardson,
substitute a warning light or better yet, use both. 2004; Richardson, Ruser, & Saurez, 2003).
Research indicates that older workers are less able to The popular perception of undocumented
adapt to shift work than younger workers. However, Hispanic immigrants is that most work in agricul-
they tend to wake earlier than younger workers and ture or as day laborers. This is far from reality.
perform better in morning hours (Wegman, 1999). Approximately 4% work in agriculture (Passel, 2006)
Consequently, managers should attempt to assign and less than 1% of Hispanic immigrants work as
older workers early morning hours and day shifts, day laborers (Valenzuela, Theodore, Melendez, &
avoiding evening and night shifts. In those instances Gonzalez, 2006). The remainder work for compa-
in which retired individuals return to work out of nies ranging in size from small businesses to interna-
economic need, they frequently find themselves tional corporations. Almost a third work in service
working in low-level service industry jobs, often industries (e.g., cleaning & food preparation), nearly
with colleagues and managers who are many years a fifth work in construction or mining, and 15%
younger. If older workers are subjected to stereo- work in manufacturing, installation and repair
types about the elderly or disrespect due the (Passel, 2006).
unskilled nature of their current employment, they
will likely begin to suffer from unacceptable levels Fatal Injury Rates
of work-related stress. Organizational interventions Between 1996 and 2000, the number of foreign-
addressing attitudes toward older workers could born workers in the United States grew 22%, but
help to alleviate such situations. the fatal injury rate for these workers increased by
43% (Loh & Richardson, 2004). During this same
Hispanic Immigrant Workers period, the overall injury rate for all U.S. workers
Currently, over 42 million persons of Hispanic declined by 5%. In 2001, the fatality rate for all
descent are living in the United States, approxi- U.S. workers decreased to a low of 4.3 per 100,000
mately half of whom are foreign-born (U.S. Census workers. However, the fatality rate for foreign-
Bureau 2005, 2006). Hispanics recently became the born workers increased to a high of 5.7 per 100,000
largest minority group in the United States. It is esti- workers. In 2000, 51.6% of all foreign-born work-
mated that by 2050, 15% of the American work- ers in the United States were from Latin American
force will be Hispanic. It is estimated that 12 million countries (Loh & Richardson, 2004). However,
of these Hispanics are in the country unauthorized they suffered 61.2% of fatal work-related injuries.
(Passel, 2006). Areas of the United States, such as This disparity does not appear to be directly related

e gge rt h, cunningham 767

to being Hispanic. Richardson, Ruser, and Suarez status of the safety officer, perceived effects of safe
(2003) reported that, between 1995 and 2000, conduct on social status, and perceived status of the
the fatal work injury rate for all workers in the safety committee.
United States was 4.6 per 100,000 workers. This Safety climate is essentially a workgroup’s con-
compares to a rate of 4.5 per 100,000 for native- sensus on how seriously management takes and how
born Hispanics and 6.1 per 100,000 for foreign- consistently management enforces safe work prac-
born Hispanics. Most of this disparity in fatal injury tices. A workplace that holds employees to a high
rates arises from injuries to Mexican-born workers standard of safety conduct during periods of normal
(Loh & Richardson, 2004). Mexicans account for production, but which orders workers to “cut cor-
27.3% of all foreign-born workers in the United ners” in terms of safety in order to meet production
States, but suffer 42.1% of all fatal work-related goals during periods of high demand is likely to have
injuries. a poor safety climate even though the “crunch peri-
ods” may only constitute a very small percentage of
Nonfatal Injuries and Illnesses total production time over the course of a year
Between 1998 and 2000, Hispanic men had (Zohar, 2003). Workers in this situation realize that
the highest overall relative risk (1.51 per 100,000) safety is considered optional depending upon the
of nonfatal occupational injuries and illnesses immediate needs of management. On the other
(Richardson et al., 2003). This compares to a relative hand, if a company refuses to compromise safety
risk of 1.07 per 100,000 for white, non-Hispanic standards during periods of high demand, it will
men and of 1.40 for black, non-Hispanic men. likely have a very good safety climate as workers here
Although Hispanic women were not at greater risk realize that here indeed, “Safety comes first.” Workers
(1.0 per 100,000) when compared to all working in a good safety climate are more likely to use proper
women (1.0 per 100,000), they were at greater risk safety equipment, even when not closely supervised.
when compared to white, non-Hispanic women They are more likely to monitor coworkers’ safety
(0.76 per 100,000). However, Hispanic women behaviors and to assist them in performing safely.
were at slightly lower risk than black, non-Hispanic These workers will bring previously unidentified
women (1.06 per 100,000). workplace hazards to the attention of management
and will sometimes propose even safer ways of doing
Safety Culture and Safety Climate a hazardous task. In short, these workers are
In the OHP literature, the concept of safety climate actively invested in thinking about, maintaining,
is frequently, but incorrectly, used interchangeably and improving workplace safety. Workers in organi-
with the related, but distinct, concept of safety cul- zations with poor safety climates can be expected to
ture (Zohar, 2003). Safety culture is defined as the perform few or none of these behaviors.
embodiment of the values, beliefs, and underlying
assumptions of an organization about safety (Flin, The “Structure” of Safety Climate
Mearns, O’Connor, & Bryden, 2000). Defined In the decades since Zohar first introduced the
thusly, safety culture is simply one facet of organiza- concept of safety climate, researchers have found
tional culture. Quick et al. (1997) consider organiza- varying degrees of support for his eight proposed
tional culture as a “top-down” emanation of the dimensions (Neal & Griffin, 2004). Some research-
values and practices promoted by the top leaders of ers have identified as few as two or three dimen-
an organization. sions, whereas others have found an intermediate
In contrast, safety climate is considered to be number of dimensions. The number of dimensions
“an emergent property, characterizing groups of indi- found by a given study seems to arise from an inter-
viduals” (Zohar, 2003, p. 124) and has been defined action between study instrumentation, sample char-
as the shared perceptions regarding safety policies, acteristics, and the statistical procedures used to
procedures, and practices among groups of workers. analyze the data. It is of fundamental importance to
Zohar (1980) was the first to introduce the concept recognize that the research does not call into ques-
of safety climate. He proposed there were eight tion the existence or importance of safety climate.
dimensions to safety climate: perceived importance It merely argues over how its constituent parts are
of safety training, perceived management attitudes clustered.
toward safety, perceived effects of safe conduct on Based upon a review of the literature and their
promotion, perceived level of risk in the workplace, own research, Neal and Griffin (2004) proposed a
perceived effects of work pace on safety, perceived comprehensive, hierarchical model that can be used

768 occupational h ealth p s ych o lo gy

to characterize safety climate. In many respects, this However, one of counseling psychology’s earliest
model reconciles previous contradictory findings efforts to characterize environments was at the level
regarding the number of dimensions. This model of person–organization fit. The environmental assess-
contains two broad dimensions, which can be ment technique (EAT; Astin & Holland, 1961; Astin
thought of as higher-order factors. These dimen- 1962, 1963a,b, 1965a,b, 1968) classified environ-
sions each have a number of component elements ments in terms of size, average intelligence of inhab-
or lower-order factors. One dimension is organiza- itants, and a census of Holland vocational personality
tional policies and procedures and has three compo- types in the environment. The EAT was successfully
nent elements: perceived management commitment used to categorize university settings and to differen-
to safety, human resource practices (which impact tially predict student performance in these settings.
safety), and perceived quality of existing safety sys- Counseling psychologists must move beyond view-
tems. The other dimension is local work conditions ing the work-related interests and activities charac-
and practices, which has five component elements: terized by Holland’s six vocational types (Holland,
perceived supervisor support (for safety), internal 1997) and/or the occupational reinforcers and work
group processes (communication and cohesion), values of the theory of work adjustment (Dawis &
perceived quality of communications between the Lofquist, 1984) as representing the whole of the
workgroup and others regarding safety, perceptions work environment, but rather as facets of a greater
of risk magnitude for work tasks, and work pressure whole.
(at the expense of safety).
Counselor Psychologists As Agents of Change
Microclimates Counseling psychologists, who have been trained to
It is important to recognize that safety climate may “save the world one person at a time,” usually do not
not be homogenous throughout an organization. receive any training in organizational interventions
Neal and Griffin (2004) suggest that, in some orga- and may feel somewhat at a loss regarding how to
nizations, there may be more than one safety climate develop and implement interventions on the orga-
depending upon the worker groups being consid- nizational level. Although counseling psychologists
ered. Some work groups may be isolated from others working in isolation would find it difficult to shift
in the organization due to location or the differing the culture of an organization, as part of an interdis-
nature of their work tasks (i.e., factory line workers ciplinary team, they can play a key role in facilitat-
as compared to factory office workers). The safety ing change. However, even when working on the
climates of these smaller groups are sometimes level of the individual worker, counseling psychol-
referred to as safety microclimates. For example, given ogy can help to initiate a “ripple effect” that has the
the barriers of language and culture experienced by potential to impact on the broader organization in a
most Hispanic immigrant workers working in the manner analogous to the positive impact of therapy
United States, these workers likely have their own upon the individual benefiting family and friends.
safety microclimate within the larger organizations For example, addressing the needs of an individual
that employ them. with substance abuse issues or an anxiety disorder
undoubtedly also serves the needs of the family and
Counseling Psychology and Safety Climate support system. Similarly, assisting an individual
At first glance, the concepts of organizational culture worker in developing better safety and health prac-
and safety climate seem relatively distant from coun- tices also indirectly affects the safety climate of that
seling psychology. However, if one views them as individual’s coworkers. Safety culture and climate
representing a cataloging of salient aspects of a given measures are group-level indicators that arise from
work environment, then connections can quickly be the actions of groups of individuals. Consequently,
made among organizational culture, safety climate, the safety culture of the organization can be affected
and the rich vocational psychology heritage of per- by the work of counseling psychologists with indi-
son–environment fit models. Vogel and Feldman vidual workers.
(2009) remind us that person–environment fit is a
generic term given meaning from specific compari- Occupational Safety and
sons: person–organization fit, person–vocation fit, Health Interventions
person–job fit, and person–group fit. Currently, It has long been accepted in the OSH community
in counseling psychology most applications of that it is better to eliminate a hazard than it is to
P–E fit are used to predict person–vocation fit. attempt to control it (Smith, Karsh, Carayon, &

e gge rt h, cunningham 769

Conway, 2003). If a hazard cannot be entirely elim- have a significant impact, but cautioned that train-
inated, then access to it should be blocked. If a ing does not occur in a vacuum, and it alone will not
hazard can be neither eliminated entirely nor access result in a safer workplace. Counseling psychology
to it blocked, then employees should be warned of can make significant contributions to improving
the hazard and trained to avoid it. In the case of workplace health and safety by helping both manag-
toxic substances or potentially dangerous machin- ers and workers better understand and overcome the
ery, the elimination or blocking of access has typi- challenges inherent to any attempt to change human
cally fallen within the realm of engineering controls. behavior—in the workplace or elsewhere.
As its name implies, this approach tends to be
guided by engineers, and it attempts to achieve goals Training Factors
through redesign of manufacturing processes and/ In broad terms, the factors impacting the effective-
or machinery. For example, a process may be rede- ness of training may be divided into three categories:
signed to no longer require the use of a hazardous the training model, the work context that the worker
substance or to use a nontoxic or less toxic substi- returns to, and the individual worker. Colligan
tute. A machine may be redesigned so that a for- and Cohen (2004) point out that two of the most
merly dangerous part (e.g., saw blade) can no longer obviously important variables impacting training
be reached by a worker. Common sense alone effectiveness—frequency and duration of training—
dictates that in those instances where engineering are also among the least studied. Many companies
controls can be practically implemented, they are base their training schedules on Occupational Safety
preferable to relying upon the impact of warnings and Health Administration regulations and/or
and training upon the workers. However, despite insurance carrier minimum requirements. In many
tremendous reductions in work-related injuries and instances, this consists of an initial training when
mortalities since the adoption of the Occupational starting a new job, followed by annual refresher
Safety and Health Act of 1970 (NIOSH, 2004), training. Colligan and Cohen report, as might be
work remains the sixth leading cause of death in the expected, the literature indicates more frequent and
United States (Pickle et al., 1996). lengthier training is more effective. However, there
Clearly, much more remains to be done. If these is little in the literature to guide optimal frequencies
safety efforts cannot be fully accomplished through or length of training. As might be expected, more
engineering controls, then one must rely upon complex functions that are seldom performed dete-
OSH interventions with workers—a realm in which riorate more quickly than those requiring simple
behavioral scientists should have far more to offer manual operations. This suggests that those complex
than engineers. However, even the implementation functions that are critical to emergency response,
of engineering controls is not without room for but only performed during an emergency, should be
behavioral sciences. After all, the managers who practiced far more frequently than those that are
make decisions about whether to devote resources to not. For example, respirator usage, which requires
implementing these controls are subject to the same not only a proper device fit, but correct selection
influences upon their decision-making processes as of appropriate filters, should be practiced more fre-
other humans. Examination of this decision-making quently than less complex behaviors, such as evacu-
process clearly falls within the realm of OHP. Among ating a building during a fire drill.
the most common worker OSH interventions are Colligan and Cohen (2004) suggested the more
training and behavior-based safety programs. interactive and “hands-on,” the more effective train-
ing will be. Support for this contention is found in
Occupational Safety and Health Training the recent meta-analysis of OSH training effective-
Colligan and Cohen (2004) argue that learning new ness conducted by Burke et al. (2006). Burke et al.
information is a process that occurs so frequently, found that training effectiveness was related to the
and often so effortlessly, we tend to take its efficacy level of engagement of the training. Low-engagement
for granted. However, if one looks at the massive training consists of activities such as lecture or film
public health information campaigns concerning presentations that are not followed by any discus-
smoking, safe sex, exercise, and driving while intox- sion. Medium-engagement might consist of a lec-
icated, one must conclude that information alone is ture followed by an interactive discussion of content.
not the answer. In their comprehensive review of High-engagement training typically has “hands-on”
the OSH training literature, Cohen and Colligan opportunities and allows for a high degree of inter-
(1998) concluded that OSH training can indeed action between participants and instructors.

770 occupational h ealth p s ych o lo gy

Work Environment following training. These programs usually consist
Unfortunately, no matter how much is learned in of an initial safety training that is then followed
training, the safety recommendations can only be by implementation of a monitoring system (Geller,
practiced to the extent that the work setting allows or 2001). A safe practices monitoring system typically
endorses a given practice (Colligan & Cohen, 2004). consists of systematic observation and recording of
In some settings, the proper PPE is not provided. the targeted behaviors (e.g., proper use of PPE), fol-
In others, the actual physical layout of the facility will lowed by feedback to workers regarding the frequency
not allow proper practices to be implemented. An or percentage of safe versus at-risk behaviors observed.
example of this would be a warehouse shipping facil- These programs may also include goal setting, com-
ity that was so arranged that ergonomically recom- mitment strategies, and/or incentives to encourage
mended lifting and carrying practices could not be participation.
used. Perhaps the most important factor influencing Critics of behavior-based safety programs claim
actual implementation of safety practices on the job is the widespread use of incentives has the potential
management support or safety climate. As discussed to turn OSH into a “numbers game,” in which the
earlier, the workers in a company that consistently number of observations completed and percentage
requires safe work practices, without compromise of safe behavior are manipulated so that individuals
during periods of high production demand, are more and/or work groups will achieve program goals—at
likely to use proper safety equipment, even when least on paper—and thereby qualify for an award
not closely supervised and will identify ways to (Geller, 2001). In response to these criticisms, Geller
improve safety of their own initiative (Zohar, 2003). (2005) developed an approach he dubbed people-
In contrast, a company that compromises safe work based safety. This approach melds aspects of behav-
practices during periods of high demand will tend to ior-based safety programs with a focus on individual
have workers who are less likely to follow safe work worker feelings and thoughts regarding safety and
practices even during periods of normal work load. a strong management commitment to a safe work-
place. In many respects, Geller’s people-based safety
The Worker approach is intended as a mechanism by which
Another important factor related to compliance with an organization can positively transform its safety
training recommendations is worker motivation climate.
(Colligan & Cohen, 2004). A worker who knows the Transforming the safety climate in a given work
correct practice may simply choose not to do it. environment requires not only increasing critical
Campbell, McCloy, Oppler, and Sager (1993) char- health and safety behaviors, but also influencing the
acterized the difference between knowledge and attitudes of workers to hold safety as a value, and
motivation as “can do” versus “will do.” Worker not just a temporary priority. Geller’s (2005) people-
motivation at the individual level has received little based safety approach directly targets workers’
attention in the OSH literature. In part, this reflects thoughts about safety, so that attitude change and
the traditional OSH bias against approaches that behavior change are impacted simultaneously, rather
have the potential to “blame the victim”—after all, than one following from the other. This is analogous
poor motivation could easily be characterized as a to cognitive-behavioral therapy for the organiza-
character flaw. However, it does seem clear from the tion. Counselors can support these kinds of group-
discussion above that improving a company’s safety level intervention processes by providing additional
climate would be an excellent way to improve worker targeted intervention for individuals who are less
motivation. Referring back to the core components responsive than their coworkers.
of counseling psychology, there is clearly a role for
positive psychology here. Focusing on identifying the Health Promotion Interventions
critical positive health and safety behaviors and pro- For decades, many European public health agencies
viding contingencies to increase and maintain those have been taking advantage of the “captive audience”
critical behaviors is the primary aim of behavior- provided by the workplace and using it as a forum
based safety processes and should be the lens through for broader public health initiatives, such as weight
which worker motivation challenges are viewed. loss and smoking cessation. However, it is only in
the last decade, in response to increasing health care
Behavior-based Safety costs, that this strategy has been implemented in
Behavior-based safety processes are one widely used American workplaces. NIOSH (2009) has launched
approach to maintain recommended safety behaviors the WorkLife Initiative (WLI). The WLI views the

e gge rt h, cunningham 771

division of health concerns into “at home” or Cardiovascular disease is of particular concern in
“at work” as being artificial and inefficient. The the realm of disease prevention as it remains the
WLI seeks to improve overall work health through number one cause of death in the United States
better work-based programs, policies, practices, and (National Center for Health Statistics, 2007). The
benefits. most effective work-based cardiovascular disease
prevention interventions address multiple factors
Weight Control and Physical Fitness (i.e., controlling hypertension, reducing cholesterol,
One of the most common health concerns addressed managing stress, quitting smoking) rather than
by work-based health promotion programs is weight focusing solely on reducing one targeted risk factor,
control. Similar to the success of occupational safety as these interventions allow different employees to
training initiatives, most research supports the posi- benefit from the program in different ways (Pelletier,
tive effect of worksite physical activity programs for 2005). A review of multifactorial cardiovascular
increasing physical activity and reducing musculo- intervention programs also found providing oppor-
skeletal disorders (Proper et al., 2003). A differenti- tunities for individualized cardiovascular risk reduc-
ation is made between physical activity and exercise. tion counseling for high-risk employees to be a
Physical activity refers broadly to bodily movement critical component of successful interventions, as
produced by contraction of skeletal muscles, which well as gradually increasing dose–response relative
substantially increases energy expenditure. Exercise to risk (Pelletier, 2005).
refers to a subset of physical activity that is planned,
structured, and includes repetitive bodily move- A Framework for Occupational
ment done to improve or maintain components of Health Psychology
physical fitness (Pratt, 1999). Physical activity refers Clearly, OHP is a field that is interested in many
to any sort of moderate level of continuous move- topics: the individual worker, the work organization,
ment (e.g., walking, bowling, playing Nintendo job design, work stress, person–environment fit,
Wii©), whereas exercise refers specifically to aero- gender, aging, racial/ethnic group differences, social
bic activity in which one engages in moderate- to climate, prevention, remediation, learning, motiva-
high-intensity activity with sustained increases in tion, compliance, and the work–family interface.
heart rate and respiration (e.g., running, swimming, In part, this list reflects the interests of the many
cardio-boxing). disciplines involved in OHP, but to a greater extent
Although most recommendations for worksite this list reflects just how cross-cutting work is.
interventions suggest increasing physical activity In an effort to better frame OHP, Quick
along with improving diet through education and (1999) proposed an organizational matrix for OHP.
nutrition counseling, research shows significant This framework crosses the public health levels of
reductions in overweight and obesity conditions prevention—primary, secondary, and tertiary—with
and increases in fitness are realized only when inter- the three primary emphasis areas of OHP—work
ventions include a high dose level of some type of environment, individual worker, and the work–
aerobic exercise (Church, Earnest, Skinner, & Blair, family interface. The crossing of levels of prevention
2007). This is not to say that physical activity is with areas of interest in this model yields nine cells,
ineffective in low and moderate doses, but rather each of which represents a different set of challenges
that there is a dose–response relationship that can and solutions (see Table 29.2).
be characterized as “Even a little is good; more may In public health, primary prevention refers to
be better!” (Lee, 2007, p. 2139). activities intended to prevent problems from ever
occurring (Quick, 1999). Secondary prevention refers
Disease Prevention to activities intended to remedy problems after they
Exercise and nutrition interventions may also be have already occurred, but are not yet at the level of
applied in work settings for disease prevention crisis. Tertiary prevention is somewhat of a misno-
outcomes. Worksite health interventions may be mer as it refers to activities intended to control the
targeted for specific types of disease, including damage of problems that have reached the point
cancer, diabetes, and cardiovascular disease. Many of crisis. In Quick’s model, the work environment
of these efforts can be characterized as “lifestyle refers to virtually everything on the job other than
change” interventions, as they tend to require par- the individual worker. For example, this broad cat-
ticipants to not only change their behavior at work, egory includes the job tasks, the equipment used,
but also at home and with family. the physical environment, supervision received,

772 occupational h ealth p s ych o lo gy

Table 29.2. An Intervention Framework for Occupational Health Psychology
Level of Workplace Individual Work–family Interface
Prevention
Primary job design or redesign, time management, learned flexi-time, flexi-place, daycare,
organizational culture optimism elder care
Secondary social supports, team building physical fitness, relaxation family leave policies, family
training support systems
Tertiary task revision, EAP psychotherapy, education, health insurance, family
career counseling counseling
From Quick, J.C. (1999). Occupational health psychology: The convergence of health and clinical psychology with public health and
preventative medicine in an organizational context. Professional Psychology: Research and Practice, 30, 123–128. American Psychological
Association. Reprinted with permission.

company policies, and corporate decision making. to achieve long-term success. Quick (1999) suggests
The individual refers to everything a given worker that one important way to build a bridge between
brings to a job—work history, education, skills, atti- management and workers is to use P–E fit models.
tudes, habits, expectations, and motivations. The By definition, P–E fit models describe the
work–family interface refers to the overlapping of work environment and individuals using shared
life domains, in this case work and family. This dimensions and attempt to identify optimal matches
dynamic construct recognizes that, not only does between the two—typically viewed as being of ben-
work impact family life in ways such as mandatory efit to both. However, in practice, most applications
overtime, shift work, business travel, the carrying have followed the division of interests discussed
home of work-related stress—but that family needs above. For example, industrial/organizational psy-
and events impact work. Examples include the avail- chologists might use Holland types for selection
ability of child or elder care, dual-career households, purposes, without consideration of the needs of the
and the chronic illness of a family member. individual. Similarly, counseling psychologists use
the same Holland types to guide students toward
Finding Common Ground college majors without consideration of the larger
Quick (1999) predicates this model on two princi- context in which they will spend their working years.
ples: individual health and organizational health Even in isolation, both approaches have proven
are interdependent, and organizational leaders have useful enough to become nearly ubiquitous in their
responsibility for individual and organizational respective settings. However, OHP challenges and
health. Given that, in many companies, there is a inspires us to consider how much more powerful
history of conflict between management and work- P–E fit models could be if used to simultaneously
ers, the first challenge for an occupational health meet the needs of both work environments and
psychologist may be to help management and work- workers.
ers find common ground upon which to ease into
the cooperation implied by these principles. The Theory of Work Adjustment
Indeed, it has long been conventional wisdom Perhaps the P–E fit model best positioned for use in
that an inherent tension exists between meeting OHP is the theory of work adjustment (TWA; Dawis,
the needs of the organization and meeting the 2004; Dawis & Lofquist, 1984). Hesketh and Griffin
needs of workers. This is reflected in the traditional (2005) observed that few theories are comprehensive
emphases of the two disciplines working in the area enough to be applied to career choice, selection,
of vocational psychology. Industrial/organizational training, and organizational interventions. The TWA
psychologists have typically approached problems accomplishes this by placing equal emphasis on sat-
from the perspective of the company. Counseling isfying the worker and the workplace and by using
psychologists have focused on the needs of the indi- symmetrical processes to describe both.
vidual. In OHP, this division is recognized, but is The TWA views work as an interactive and recip-
not viewed from an “either/or” perspective; rather, rocal process between the individual and the work
the needs of both parties are considered so inter- environment (Dawis, 2004; Dawis & Lofquist, 1984).
twined that both require attention for any solution In simplest terms, the individual may be viewed as

e gge rt h, cunningham 773

fulfilling the labor requirements of the work environ- stress. At the secondary prevention level for the
ment, in exchange for which the work environment workplace, counseling psychologists would surely
fulfills a wide range of financial, social, and psycho- have the background to contribute to the fostering
logical needs for the individual. The TWA provides of social support networks within a work setting.
a framework within which to predict the outcomes At the tertiary level of prevention, the general
of the match between individual and work environ- counseling background every counseling psycholo-
ment and to describe the ongoing process of interac- gist receives would certainly be congruent with
tion (work adjustment) between worker and work employee assistance programs, and any skills useful
environment. for initial job design would also be applicable to job
In his review of P–E fit models, Tinsley (2000) redesign.
opined that TWA had accumulated the most evi- Let us now look at the individual. At the primary
dence of validity of all P–E fit models and that its prevention level, counseling psychology, which
instrumentation was an exemplar of psychometric prides itself on having practiced positive psychology
rigor. The NIOSH job stress model that conceptual- before it was ever labeled as such, could surely teach
izes job stress as arising from a mismatch between learned optimism. Also, what could be a better pri-
job demands and/or rewards with worker skills and/ mary prevention measure at the individual level for
or needs was directly influenced by TWA (Lawrence job dissatisfaction and work stress than appropriate
R. Murphy, personal communication). In addition, initial choice of career? At the secondary level of pre-
the core variables of the TWA prediction model were vention, relaxation training and cognitive-behavior
adopted by the Occupational Information Network interventions for work stress are clearly within the
(O∗NET), the United States Department of Labor’s potential scope of practice of counseling psycholo-
online database that is the successor to the Dictionary gists. Finally, at the tertiary level of prevention, psy-
of Occupational Titles. The O∗NET database is being chotherapy, education, and counseling for career
increasingly used by OHP researchers to define change are already common practice among coun-
important work-related variables. Interested readers seling psychologists.
should refer to Larson (2011, Chapter 6, this volume) The primary prevention level of the work–family
for a more thorough discussion of P–E fit models interface may initially appear to be in the realm of
and TWA. managerial policy setting. However, counseling psy-
chology could provide input to the process. Similar
Counseling Psychology and Occupational input could also be provided at the secondary level
Health Psychology regarding the development of family-friendly poli-
Even with the benefit of Quick’s organizational cies for the workplace. Finally, at the tertiary level,
framework and powerful P–E fit models such as one finds family counseling, as another area in
TWA, the sprawling field of OHP still is far from which many counseling psychologists are already
unified and seamless. Of the disciplines most actively practicing.
involved in OHP, none can come close to addressing
all the cells of Quick’s matrix. Indeed, most can Recent Developments in Counseling
claim expertise in only one or two and relevance to Psychology
few more. However, counseling psychology, which One might get the impression that many counsel-
has been minimally involved in OHP to date, argu- ing psychologists have already been working in
ably has the potential to provide expertise and rele- the field of OHP—but did not realize they were
vant input to nearly all the cells in Quick’s matrix. doing so. Imagine the impact they could have if
At the primary intervention level, starting with their efforts were coordinated! A recent special sec-
the workplace, counseling psychology does not have tion in American Psychologist (see 2008, vol. 63,
the ergonomic expertise to assist in the physical no. 4) on work and career written by several of the
aspects of job design. However, counseling psychol- most prominent counseling psychologists currently
ogy could certainly contribute to the psychological active in the field seems to have initiated just such
aspects of job design. For example, simple applica- a call.
tion of Holland types would guide the sort of Citing findings from the positive, vocational,
primary activities that were assigned to a position. multicultural, and clinical psychology literatures,
By clustering activities that were of the same or Blustein (2008) argued strongly for the centrality of
adjacent Holland types, one has the potential to work to well-being and called for breaking down
eliminate sources of job dissatisfaction and work artificial barriers between vocational psychology

774 occupational h ealth p s ych o lo gy

and other areas of psychology. Blustein identified four core areas of vocational psychology, positive
OHP as being congruent with both the historical psychology, multicultural psychology, and social
and current goals of vocational psychology and the justice was discussed. If this is an apt characteriza-
psychology of work. He suggested that a conscious tion, then counseling psychology and OHP share
and purposeful linkage of these three “would yield a considerable overlap. Vocational psychology has rel-
powerfully compelling scholarly and public policy evance to better understanding the psychological
agenda” (Blustein, 2008, p. 236). aspects of job design and redesign, the work–family
Arguing along similar lines, Fouad and Bynner interface, work stress, and person–environment fit
(2008) suggest that vocational psychology has models. However, to be most useful, it will need to
focused primarily on the transition from school to be the vocational psychology of the working class,
work and has tended to turn a blind eye to the many not just the college educated. It will need to be the
transitions workers experience in the remainder of vocational psychology of adult workers, not just
their working lives. Some of these transitions are college undergraduates. It will need to be the voca-
voluntary and are largely associated with positive tional psychology that sees work not just as an
outcomes. Examples include advancement within opportunity for self-expression, but as an essential
one’s field through promotion or accepting a new tool for survival, advancement, and empowerment.
job that offers greater benefits and satisfactions. Positive psychology, the study of well-being, has
Other transitions are involuntary and associated clear implications for guiding the development of
with significant stress. Examples of stressful transi- organizational culture, work stress prevention pro-
tions include the loss of employment due to corpo- grams and interventions, and family-friendly poli-
rate downsizing, merger, or closure. Fouad and cies. It will be a positive psychology that identifies
Bynner state that it is not possible to separate the commonalities in high-functioning organizations
impact of work transitions from other life domains. and develops methods to implement these practices
For example, the financial security (or lack thereof ) in less functional settings. It will be a positive psy-
of one’s job impacts decisions such as marriage, chology that embraces that most powerful of pri-
having children, and purchasing a home. Work- mary prevention interventions for work stress—a
related stress clearly impacts one’s functioning as a well-informed, thoughtful career choice.
life partner and/or a parent. Even “positive” transi- Multiculturalism can assist organizations to
tions are likely to generate stress for both the indi- engender policies and an organizational culture that
vidual and their family. For example, an exciting truly embraces diversity and views it as an advantage
new job may require moving to another city, uproot- in a competitive, increasingly global world of busi-
ing children from school, and initiating a job search ness. Multiculturalism can also contribute much
for a working spouse. Although Fouad and Bynner to better understanding and then eliminating occu-
discuss these concerns without reference to OHP, pational health disparities. It will need to be a
clearly these are all topics that have long been of multiculturalism that places less emphasis on cata-
interest to OHP. loging discrimination and victimization, and more
In a third paper, Fassinger (2008) explored the on achieving and maintaining social, economic, and
interconnections between the core counseling psy- political power.
chology themes of vocational psychology, multicul- Social justice is, in many respects, a paradox.
turalism, and social justice within Blustein’s (2006) On one hand, it is the most ephemeral of these core
psychology of work framework. The implications values and at the same time the most concrete in its
of Fassinger’s paper are a powerful argument that final impact. It is far easier to recognize its absence
the barriers separating the study of work from than its presence. However, it provides counseling
the remainder of life are not only arbitrary, but psychology and OHP with a powerful moral com-
counterproductive. Ultimately, Fassinger concluded pass pointing us toward the question of why simply
her paper with a call for action that pushes counsel- working for a living, something we all have to do to
ing psychology toward issues (occupational health survive—barring being born to wealth or winning
disparities, organization of work, and work–family the lottery—should remain a leading cause of injury
interface) that are of central interest to OHP. and death. Social justice can be the force that does
not ask why employers are hiring undocumented
Future Directions immigrants, but why these immigrants are killed and
At the beginning of this chapter, Bingham’s (2001) injured at two to three times the rate of American-
categorization of counseling psychology into the born workers. Social justice can help us to explore

e gge rt h, cunningham 775

the ethical issues related to choosing between the References
immense resources required to change work organi- Assagioli, R. (1965). Psychosynthesis: A manual of principles and
zations to stress workers less versus the far more techniques. New York: The Viking Press.
modest resources needed to train workers to better Astin, A. W. (1962). An empirical characterization of higher
education institutions. Journal of Educational Psychology,
cope with higher levels of stress. 53(5), 224–235.
Conclusion Astin, A. W. (1963a). Differential college effects on the motiva-
tion of talented students to obtain the PhD. Journal of
A Return to Our Roots Educational Psychology, 54(1), 63–71.
In many respects, the counseling psychology Astin, A. W. (1963b). Further validation of the environmental
described above represents a return to the roots of assessment technique. Journal of Educational Psychology,
our field, a field that viewed vocational psychology, 54(4), 217–226.
positive psychology, multicultural psychology, and Astin, A. W. (1965a). Effects of different college environments
on the vocational choices of high aptitude students. Journal
social justice not as four separate themes, but insep- of Counseling Psychology, 12(1), 28–34.
arably interconnected and intertwined. This was a Astin, A. W. (1965b). Who goes where to college? Chicago: Science
counseling psychology that viewed the workplace, Research Associates.
for better or worse, as the venue in which social bet- Astin, A. W. (1968). The college environment. Washington, DC:
terment, economic advantage, and political empow- The American Council on Education.
Astin, A. W., & Holland, J. L. (1961). The environmental assess-
erment were obtained. ment technique: A way to measure college environments.
It is just this vision from our past that is OHP’s Journal of Educational Psychology, 53(6), 308–316.
future. As a field, OHP has matured enough that it Atkinson, W. (2004). Stress: Risk management’s most serious
is no longer merely cataloguing the adverse impact challenge? Risk Management, 51(6), 20–24.
of organizational practices upon worker health and Barling, J., & Griffiths, A. (2003). A history of occupational
health psychology. In J. C. Quick, & L. E. Tetrick (Eds.),
well-being. It is increasingly interested in developing Handbook of occupational health psychology (pp. 19–33),
both interventions to remedy current problems and Washington, DC: American Psychological Association.
best-practices guidelines that organizations can use Beggs, J., Mangan, O., Concagh, G., & Pollock, J. (2005).
to prevent problems from ever occurring. In both Non-national workers in the Irish economy. Dublin, Ireland:
the United States and the European Union, occupa- AIB Global Treasury Economic Research.
Bell, M. P., Cycyota, C. S., & Quick, J. C. (2002). An affirmative
tional health psychologists have recognized the defense: The preventive management of sexual harassment.
importance of the work–life interface and of alleviat- In D. L., Nelson, & R. J. Burke (Eds.), Gender, work stress,
ing occupational health disparities. With both glo- and health (pp. 191–210). Washington, DC: American
balization and advances in technologies rendering Psychological Association.
distances and borders less relevant, OHP will become Bingham, R. P. (2001). Counseling psychology: Looking to the
future. Paper presented at the American Psychological
of increasingly relevance to the remainder of the Association Annual Conference, Chicago, IL.
world as well, in part, to help developing countries Blustein, D. L. (2006). The psychology of working: A new perspec-
to learn to avoid repeating our mistakes and in part, tive for career development, counseling, and public policy.
to remedy mistakes already made in the course of Mahwah, NJ: Lawrence Erlbaum.
their rapid industrialization. Blustein, D. L. (2008). The role of work in psychological health
and well-being: A conceptual, historical and public policy
The fit between counseling psychology and perspective. American Psychologist, 63(4), 228–240.
OHP is so obvious that there is no doubt that some Blustein, D. L., McWhirter, E. H., & Perry, J. C. (2005).
counseling psychologists will play a leading role in An emancipatory communitarian approach to vocational
OHP. The question is whether as a field, counseling development theory, research, and practice. The Counseling
psychology recognizes and embraces OHP as being Psychologist, 33, 141–179.
Burke, M. J., Sarpy, S. A., Smith-Crowe, K., Chan-Serafin, S.,
of the same intellectual and moral lineage and Salvador, R. O., & Islam, G. (2006). Relative effectiveness of
“become(s) not just part of the mainstream, but the worker safety and health training methods. American Journal
mainstream of this movement toward the science of Public Health, 96(2), 315–324.
and application of occupational health” (Hansen, Campbell, J. P., McCloy, R. A., Oppler, S. H., & Sager, C. E.
1995, p. 137). (1993). A theory of performance. In N. Schmitt, &
W. C. Borman (Eds.), Personnel selection in organizations.
Acknowledgments San Francisco: Jossey-Bates.
The views and opinions expressed in this manuscript Caruso, C. C., Bushnell, T., Eggerth, D., Heitmann, A.,
Kojola, B., Newman, K., et al. (2006). Long working
are those of the authors and do not represent official hours, safety, and health: Toward a national research
policies or findings of the National Institute for agenda. American Journal of Industrial Medicine, 49,
Occupational Safety and Health. 930–942.

776 occupational h ealth p s ych o lo gy

Center to Protect Workers’ Rights. (2002). The construction chart Geller, E. S. (2001). The psychology of safety handbook. Boca
book: The U.S. construction industry and Its workers (3rd ed.). Raton, FL: CRC Press.
Silver Spring, MD: Author. Geller, E. S. (2005). People-based safety: The source. Virginia
Church, T. S., Earnest, C. P., Skinner, J. S., & Blair, S. N. Beach, VA: Coastal Training Technologies.
(2007). Effects of different doses of physical activity on Goetzel, R. Z., Anderson, D. R., Whitmer, R. W.,
cardiorespiratory fitness among sedentary, overweight or Ozminkowski, R. J., Dunn, R. L., & Wasserman, J. (1998).
obese postmenopausal women with elevated blood The relationship between modifiable health risks and health
pressure: A randomized controlled trial. JAMA, 297(19), care expenditures: An analysis of the multi-employer HERO
2081–2091. health risk and cost database. Journal of Occupational and
Cohen, A., & Colligan, M. (1998). Assessing occupational safety Environmental Medicine, 40(10), 843–854.
and health training (No. 98–145). Wasington, DC: National Gottfredson, G. D. (1996). The Hawthorne misunderstanding
Institute for Occupational Safety and Health. (and how to get the Hawthorne effect in action research).
Colligan, M. J., & Cohen, A. (2004). The role of training Journal of Research in Crime and Delinquency, 33(1), 28–48.
in promoting workplace safety and health. In J. Barling, & Greenhaus, J. H., & Parasuraman, S. (2002). The allocation
M. R. Frone (Eds.), The psychology of workplace safety of time to work and family roles. In D. L. Nelson, &
(pp. 223–248). Washington, DC: American Psychological R. J. Burke (Eds.), Gender, work stress and health
Association. (pp. 115–128). Washington, DC: American Psychological
Dawis, R. V. (2004). The Minnesota Theory of Work Adjustment. Association.
In S. D. Brown, & R. W. Lent (Eds.), Career develop- Hansen, J. C. (1995). No one ever died wishing they had spent
ment: putting theory and research into practice (pp. 3–23). more time in the office. The Counseling Psychologist, 23(1),
Hoboken, NJ: Wiley. 129–141.
Dawis, R. V., & Lofquist, L. H. (1984). A psychological theory Harris Interactive. (2008). Poll: 78% of U.S. workers burned out.
of work adjustment. Minneapolis: University of Minnesota Rochester, NY: Author.
Press. Hatinen, M., Kinnunen, U., Pekkonen, M., & Kalimo, R.
Dompierre, J., & Lavoie, F. (1994). Subjective work stress (2007). Comparing two burnout interventions: Perceived
and family violence. In G. P. Keita, & J. J. Hurrell (Eds.), job control mediates decreases in burnout. International
Job stress in a changing workforce: Investigating gender, Journal of Stress Management, 14(3), 227–248.
diversity, and family issues (pp. 213–228). Washington, DC: Hesketh, B., & Griffin, B. (2005). Work adjustment.
American Psychological Association. In W. B. Walsh, & M. L. Savickas (Eds.), Handbook of
Dong, X., & Platner, J. W. (2004). Occupational fatalities of vocational psychology (3rd ed., pp. 245–266). Mahwah, NJ:
Hispanic construction workers from 1992 to 2000. American Lawrence Earlbaum.
Journal of Industrial Medicine, 45, 45–54. Holland, J. L. (1997). Making vocational choices (3rd ed.).
Eggerth, D. E. (2008). From theory of work adjustment fit to Odessa, FL: Psychological Assessment Resources.
person-environment correspondence counseling: Vocational Hoskins, A. B. (2005). Occupational injuries, illnesses, and
psychology as positive psychology. Journal of Career fatalities among women. Monthly Labor Review, 128(10),
Assessment, 16(1), 60–74. 31–37.
Elo, A., Ervasti, J., Kuosma, E., & Mattila, P. (2008). Evaluation Ivancevitch, J. M., Matteson, M. T., Freedman, S. M., &
of an organizational stress management program in a munic- Phillips, J. S. (1990). Worksite stress management interven-
ipal public workers organization. Journal of Occupational tions. American Psychologist, 45, 252–261.
Health Psychology, 13(1), 10–23. Jarvik, L. F., & Small, G. W. (1988). Parentcare: A commonsense
Fassinger, R. E. Workplace diversity and public policy: Challenges guide for adult children. New York: Crown Publishing.
and opportunities for psychology. American Psychologist, Jones, L. K. (1996). A harsh and challenging world of work:
63(4), 252–268. Implications for counselors. Journal of Counseling and
Flin, R., Mearns, K., O’Connor, P., & Bryden, R. (2000). Development, 74, 453–459.
Measuring safety climate: Identifying the common features. Karasek, R. (1979). Job decision latitude, job demands and
Safety Science, 34, 177–192. mental strain: Implications for job redesign. Administrative
Fouad, N. A., & Bynner, J. (2008). Work transitions. American Science Quarterly, 24, 285–307.
Psychologist, 63(4), 241–251. Kelloway, E. K., & Barling, J. (1994). Stress, control, well-being,
Friedman, L. N., Tucker, S. B., Neville, P. R., & Imperial, M. and marital functioning: A causal correlational analysis.
(1996). The impact of domestic violence on the workplace. In G. P. Keita, & J. J. Hurrell (Eds.), Job stress in a changing
In G. R. VandenBos, & E. Q. Bulatao (Eds.), Violence on the workforce: Investigating gender, diversity, and family issues
job: Identifying risks and developing solutions (pp. 153–161). (pp. 241–252). Washington, DC: American Psychological
Washington, DC: American Psychological Association. Association.
Frone, M. R. (2003). Work-family balance. In J. C. Quick, & Kenny, D. T. & Cooper, C. L. (2003). Introduction: Occupational
L. E. Tetrick (Eds.), Handbook of occupational health stress and its management. International Journal of Stress
psychology (pp. 143–162). Washington, DC: American Management, 10(4), 275–279.
Psychological Association. Kisner, S. M., & Prat, S. G. (1997). Occupational fatalities
Fujishiro, K., Gong, F., Baron, S., Jacobson, J. C., DeLaney, S., among older workers in the United States: 1980–1991.
Flynn, M., & Eggerth, D. E. (2009). Translating question- Journal of Occupational and Environmental Medicine, 39(8),
naire items for a multi-lingual worker population: The itera- 715–721.
tive process of translations and cognitive interviews with Landsbergis, P. A., Schnall, P. L., Scwartz, J. E., Warren, K.,
English-, Spanish-, and Chinese-speaking workers. American & Pickering, T. G. (1995). Job-strain, hypertension, and
Journal of Industrial Medicine. cardiovascular disease: Empirical evidence, methodological

e gge rt h, cunningham 777

 issues, and recommendations for future research. National Institute for Occupational Safety and Health. (2009).
In S. L. Sauter, & L. R. Murphy (Eds.), Organizational risk The WorkLive Initiative (DHHS/NIOSH Publication
factors for job stress (pp. 97–112). Washington, DC: American No. 2009–146). Washington, DC: Author.
Psychological Association. Neal, A., & Griffin, M. A. (2004). Safety climate and safety
Larson, L. M. (2011). What do we know about worklife across at work. In J. Barling, & M. R. Frone (Eds.), The psychology
the lifespan. In E. M. Altmaier, & J. C. Hansen (Eds.), of workplace safety (pp. 15–34). Washington, DC: American
The Oxford handbook of counseling psychology. New York: Psychological Association.
Oxford University Press. Nicoletti, J., & Spooner, K. (1996). Violence in the workplace:
Le Blanc, P. M., Hox, J. J., Schaufeli, W. B., Taris, T. W., & Response and intervention strategies. In G. R. VandenBos,
Peeters, M. C. W. (2007). Take care! The evaluation of a & E. Q. Bulatao (Eds.), Violence on the job: Identifying risks
team-based burnout intervention program for oncology care and developing solutions (pp. 267–282). Washington, DC:
providers. Journal of Applied Psychology, 92, 213–227. American Psychological Association.
Lee, I. M. (2007). Dose-response relation between physical activ- O’Brien, K. M. (2001). The legacy of Parson: Career counselors
ity and fitness: Even a little is good; more is better. Journal of and vocational psychologists as agents of change. Career
the American Medical Association, 297(19), 2137–2139. Development Quarterly, 50, 66–76.
Leigh, P. J., Markowitz, S. B., Fahs, M., Shin, C., & Landigan, P. J. O’Connor, T. (2003). Reaching Spanish-speaking workers and
(1997). Occupational injury and illness in the United States. employers with occupational safety and health information.
Archives of Internal Medicine, 157, 1557–1568. In Safety is Seguridad (pp. 93–111). Washington, DC: The
Loh, K., & Richardson, S. (2004). Foreign-born workers: Trends National Academies Press.
in fatal occupational injuries, 1996–2001. Monthly Labor Ontario Women’s Directorate and the Industrial Accident
Review, 127(6), 42–53. Prevention Association. (2006). Personal protective equipment
Marshall, N. L., & Barnett, R. C. (1994). Family-friendly for women: Addressing the need. Toronto, Canada: Industrial
workplaces, work-family interface and worker health. Accident Prevention Association.
In G. P. Keita, & J. J. Hurrell (Eds.), Job stress in a changing Parsons, H. M. (1991). Hawthorne: An early OBM experiment.
workforce: Investigating gender, diversity, and family issues Journal of Organizational Behavior Management, 12(1), 27–43.
(pp. 253–264). Washington, DC: American Psychological Passel, J. S. (2005). Estimates of the size and characteristics of the
Association. undocumented population. Washington, DC: Pew Research
Maslach, C. (1982). Burnout: The cost of caring. Englewood Center.
Cliffs, NJ: Prentice-Hall. Passel, J. S. (2006). The size and characteristics of the unauthorized
Maslach, C. (2003). Job burnout: New directions in research and migrant population in the U.S. estimates based on the March
intervention. Current Directions in Psychological Science, 2005 current population survey. Washington, DC: Pew
12(5), 189–192. Research Center.
Messing, K., & de Grosbois, S. (2001). Women workers con- Passel, J. S., Capps, R., & Fix, M. E. (2002). The dispersal of
front one-eyed science: Building alliances to improve wom- Immigrants in the 1990s. Immigrant families and workers:
en’s occupational health. Women and Health, 33, 125–141. Facts and perspectives, Brief no. 2. Washington, DC: Urban
Miller, L. (1998). Our own medicine: Traumatized psychothera- Institute.
pists and the stresses of doing therapy. Psychotherapy, 35(2), Pelletier, K. (2005). A review and analysis of the clinical and cost-
137–146. effectiveness studies of comprehensive health promotion and
National Center for Health Statistics (2007). Health, United disease management programs at the worksite: Update VI
States, 2007 With Chartbook on Trends in the Health of 2000–2004. Journal of Occupational and Environmental
Americans. Hyattsville, MD: Author. Medicine, 47(10), 1051–1058.
National Institute for Occupational Safety and Health. (1995). Pickle, L. W., Mongiole, M., Jones, G. K., & White, A. A.
Preventing homicide in the workplace (DHHS/NIOSH (1996). Atlas of United States mortality (DHHS Publication
Publication No. 93–109). Washington, DC: Author. No. 97–1015). Hyattsville, MD: National Center for Health
National Institute for Occupational Safety and Health. (1999). Statistics.
Providing safety and health protection for a diverse construction Pratt, M. (1999). Benefits of lifestyle activity vs. structured exer-
workforce: Issues and ideas (DHHS/NIOSH Publication No. cise. Journal of the American Medical Association, 281(4),
99–140). Washington, DC: Author. 375–376.
National Institute for Occupational Safety and Health. (1999). Proper, K., Koning, M., Van der Beek, A., Hildebrandt, V.,
Stress . . . at work (DHHS/NIOSH Publication No. 99–101). Bosscher, R., & van Mechelen, W. (2003). The effectiveness
Washington, DC: Author. of worksite physical activity programs on physical activity,
National Institute for Occupational Safety and Health. (2002). physical fitness, and health. Clinical Journal of Sport Medicine,
The changing organization of work and safety and the health of 12, 106–117.
working people: Knowledge gaps and research directions Quick, J. C. (1999). Occupational health psychology:
(DHHS/NIOSH Publication No. 2002–116). Washington, The convergence of health and clinical psychology with
DC: Author. public health and preventative medicine in an organizational
National Institute for Occupational Safety and Health. (2003). context. Professional Psychology: Research and Practice, 30,
National occupational research agenda, Update 2003 (DHHS/ 123–128.
NIOSH Publication No. 2003–148). Washington, DC: Quick, J. C., Quick, J. D., Nelson, D. L., & Hurrell, J. J. (1997).
Author. Preventive stress management in organizations. Washington,
National Institute for Occupational Safety and Health. (2004). DC: American Psychological Association.
Worker health chartbook, 2004 (DHHS/NIOSH Publication Radmacher, S. A., & Sheridan, C. L. (1995). An investigation
No. 2004–146). Washington, DC: Author. of the demand-control model of job strain. In S. L. Sauter, &

778 occupational h ealth p s ych o lo gy

 L. R. Murphy (Eds.), Organizational risk factors for job stress Tetrick, L. E., Miles, R. L., Marcil, L., & Van Dosen, C. M.
(pp. 127–138). Washington, DC: American Psychological (1994). Child-care difficulties and the impact on concentra-
Association. tion, stress, and productivity among single and nonsingle
Raymond, J. S., Wood, D. W., & Patrick, W. K. (1990). mothers and fathers In G. P. Keita, & J. J. Hurrell (Eds.),
Psychology doctoral training in work and health. American Job stress in a changing workforce: Investigating gender, diver-
Psychologist, 45, 1159–1161. sity, and family issues (pp. 229–240). Washington, DC:
Richardson, K. M., & Rothstein, H. R. (2008). Effects of American Psychological Association.
occupational stress management intervention programs: Theorell, T. (2003). To be able to exert control over one’s own
A meta-analysis. Journal of Occupational Health Psychology, situation: A necessary condition for coping with stressors.
13, 69–93. In J. C. Quick, & L. E. Tetrick (Eds.), Handbook of occupa-
Richardson, S., Ruser, R., & Suarez, P. (2003). Hispanic workers tional health psychology (pp. 201–219). Washington, DC:
in the United States: An analysis of employment distribu- American Psychological Association.
tions, fatal occupational injuries, and non-fatal occupational Tinsely, H. E. A. (2000). The congruence myth: An analysis
injuries and illnesses. In Safety is Seguridad (pp. 43–82). of the efficacy of the person-environment fit model. Journal
Washington, DC: The National Academies. of Vocational Behavior, 56, 147–179.
Salmela-Aro, K., Naatanen, P., & Nurmi, J. (2004). The role of Trinkoff, A. M., Lipscomb, J. A., Geiger-Brown, J., & Brady, B.
work-related personal projects during two burnout interven- (2002). Musculoskeletal problems of the neck, shoulder, and
tions: A longitudinal study. Work & Stress, 18(3), 208–230. back and functional consequences in nurses. American
Schaufeli, W. B., Keijsers, G. B., & Miranda, D. R. Journal of Industrial Medicine, 41, 170–178.
(1995). Burnout, technology use and ICU performance. Trist, E. L., & Bamforth, K. W. (1951). Some social and psycho-
In S. L. Sauter, & L. R. Murphy (Eds.), Organizational risk logical consequences of the longwall methods of coal-getting.
factors for job stress (pp. 259–272). Washington, DC: Human Relations, 14, 3–38.
American Psychological Association. U.S. Census Bureau. (2005). Facts of features: Hispanic heritage
Schneider, D. L., Camara, W. J., Tetrick, L. E., & Stenberg, C. R. month 2005. Retrieved September 8, 2005, from http://
(1999). Training in occupational health psychology: Initial www.census.gov/.
efforts and alternative models. Professional Psychology: Research U.S. Census Bureau. (2006). Current population survey: Annual
and Practice, 30, 138–142. social and economic supplement. Retrieved January 8, 2008,
Schonfeld, I. S. (1992). Assessing stress in teachers: Depressive from http://www.census.gov/.
symptom scales and neutral self-reports of the work environ- Valenzuela, A., Theodore, N., Melendez, E., & Gonzalez, A. L.
ment. In J. C. Quick, L. R. Murphy, & J. J. Hurrell (Eds.), (2006). On the corner: Day labor in the United States.
Stress and well-being at work: Assessments and interventions for Los Angeles: UCLA Center for the Study of Urban
occupational mental health (pp. 270–285). Washington, DC: Poverty.
American Psychological Association. van der Klink, J. C. L., Blonk, R. W. B., Schene, A. H., &
Schulte, P. A. (2005). Characterizing the burden of occupational van Dijk, F. J. H. (2001). The benefits of interventions for
injury and disease. Journal of Occupational and Environmental work-related stress. American Journal of Public Health, 91(2),
Medicine, 47, 607–622. 270–276.
Selye, H. (1950). Diseases of adaptation. Wisconsin Medical van Dierendonck, D., Garssen, B., Visser, A. (2005). Burnout
Journal, 49(6), 515–516. prevention through personal growth. International Journal of
Semmer, N. K. (2003). Job stress interventions and organization Stress Management, 12(1), 62–77.
of work. In J. C. Quick, & L. E. Tetrick (Eds.), Handbook of van Dierendonck, D., Schaufeli, W. B., & Buunk, B. P. (1998).
occupational health psychology (pp. 325–353). Washington, The evaluation of an individual burnout intervention pro-
DC: American Psychological Association. gram: The role of inequity and social support. Journal of
Shapiro, S. L., Astin, J. A., & Cordova, M. (2005). Mindfulness- Applied Psychology, 83(1), 392–407.
based stress reduction for health care professionals: Results Vogel, R. M., & Feldman, D. C. (2009). Integrating levels of
from a randomized trial. International Journal of Stress person-environment fit: The roles of vocational fit and group
Management, 12(2), 164–176. fit. Journal of Vocational Behavior, 75(1), 68–81.
Shirom, A. (2003). Job-related burnout: A review. In J. C. Quick, Wegman, D. H. (1999). Older workers. Occupational Medicine:
& L. E. Tetrick (Eds.), Handbook of occupational health psy- State of the Art Reviews, 14(3), 537–557.
chology (pp. 245–264). Washington, DC: American Wegman, D. H., & McGee, J. P. (2004). Health and safety needs
Psychological Association. of older workers. Washington, DC: The National Academies
Smith, M. J., Karsh, B., Carayon, P., & Conway, F. T. (2003). Press.
Controlling occupational safety and health hazards. In J. C. Westman, M., & Eden, D. (1997). Effects of a respite from work
Quick, & L. E. Tetrick (Eds.), Handbook of occupational on burnout: Vacation relief and face-out. Journal of Applied
health psychology (pp. 35–68). Washington, DC: American Psychology, 82(4), 516–527.
Psychological Association. Williamson, E. G. (1939). How to counsel students. New York:
Spielberger, C. D., Vagg, P. R., & Wasala, C. F. (2003). McGraw-Hill.
Occupational stress: Job pressures and lack of support. Zohar, D. (1980). Safety climate in industrial organizations:
In J. C. Quick, & L. E. Tetrick (Eds.), Handbook of occupa- Theoretical and applied implications. Journal of Applied
tional health psychology (pp. 185–200). Washington, DC: Psychology, 65, 96–102.
American Psychological Association. Zohar, D. (2003). Safety climate: Conceptual and measurement
Stellman, J. M., & Mailman, J. L. (1999). Women workers: issues. In J. C. Quick, & L. E. Tetrick (Eds.), Handbook of
The social construction of a special population. Occupational occupational health psychology. Washington, DC: American
Medicine: State of the Art Reviews, 14, 559–580. Psychological Association.

e gge rt h, cunningham 779

 CHAPTER

30 Sport Psychology

Trent A. Petrie and Robert J. Harmison

Abstract
Although sport psychology is an interdisciplinary field, it has a natural and strong philosophical and
historical connection to counseling psychology. With this connection as the foundation, we discuss
sport psychology’s history and identify the current issues in the field, such as graduate training and
professional certification. We define mental toughness and identify the skills and strategies consultants
use to assist athletes, teams, and coaches in attaining it and improving their performances. Several
clinical issues are then discussed in the context of the uniqueness of the sport environment. Given the
centrality of training to the field, we present an ideal training model for students and professionals who
want to be applied sport psychologists. Finally, we identify the issues that we believe will define the
future of applied sport psychology and offer suggestions on how to address them.
Keywords: sport psychology, mental toughness, applied training, eating disorders, athletic injury,
professional issues, sport psychology values, performance enhancement interventions

In the last 40 years, sport psychology has become education, kinesiology, and exercise science (Lutz,
more applied as athletes, teams, coaches, and par- 1990; Petrie & Watkins, 1994). Even today, profes-
ents have sought professionals who can assist them sional organizations (e.g., Association for Applied
with gaining the mental edge to improve perfor- Sport Psychology [AASP]) recognize the interdisci-
mances and increase the likelihood of winning com- plinary nature of the field, offering certification to
petitions (Smith, 1989). With this shift to service those who have training in both psychology and
delivery, psychologists have become more involved exercise/sport science.
in the field, working with athletes of all levels (e.g., We begin this chapter by providing an overview of
elite, college, youth) and using their skills and the history and current perspectives in sport psychol-
knowledge of human behavior to help athletes reach ogy. In doing so, we identify the key events and fig-
their performance goals, work more effectively as a ures that represent modern-day applications of sport
unit, and enjoy the process of learning new and psychology and discuss the field’s current status in
improving existing skills (Petrie & Diehl, 1995; terms of graduate training, national organizations,
Petrie, Diehl, & Watkins, 1995). Although some and professional certification and status. In this dis-
professionals have argued that sport psychology is cussion, we affirm our respect for sport psychology
simply a subfield of psychology and that those work- as an interdisciplinary field, yet, like others (e.g.,
ing in the field should be trained as psychologists Howard, 1993; Petitpas, Giges, & Danish, 1999),
(e.g., Nideffer, 1984), the reality is that sport psy- argue that counseling psychology’s values, training,
chology is an interdisciplinary field whose historical and philosophy are ideally suited for working in the
roots are embedded within departments of physical sport environment and for counseling/consulting

780
with athletes of all levels. Second, we define mental laboratory in the United States (Joyce & Baker,
toughness and then discuss the psychological skills 2008), and his career is a prophetic illustration of
and strategies that have been identified by athletes what we now refer to as the scientist–practitioner—
and coaches as essential for their success, and how he conducted laboratory and field research, wrote
such strategies can be used to help athletes be men- two influential books (Psychology of Coaching; Griffith,
tally tougher performers. Third, we identify clinical 1926; Psychology and Athletics; Griffith, 1928), and
issues that occur with some regularity among ath- consulted with professional sport teams on psycho-
letes, and then discuss how these issues are affected logical methods to improve their performances
by unique factors of the sport environment. Fourth, (Singer). Joyce and Baker, in their review of the his-
we present what we believe is an ideal model for tory of sport psychology, affirmed the importance of
training applied sport psychologists. Consistent with Triplett and Griffith, but also noted the collaborative
our view that counseling psychology’s values and phi- work psychologists Graves and Miles did with
losophy are an excellent fit with athletes’ needs and Stanford football coach, Glenn “Pop” Warner during
the demands of the sport environment, the founda- the 1920s. They suggested that Graves and Miles’
tional training program is housed within counseling studies represented another example of how psycho-
psychology. Throughout this chapter, we rely not logical research methods and principles were applied
only on relevant empirical research and literature in within sport settings with the intent purpose of
the field, but also our combined 35 years of working improving performance.
with athletes, teams, coaches, and organizations at all Although these individuals are historical icons
competitive levels. and represent the origins of the field, their direct
legacies were limited because they lacked students to
A Brief History of (and Current Perspectives carry on their work. Thus, it was not until the 1960s
in) Sport Psychology that sport psychology really emerged, both in aca-
Sport psychology has been defined as “the educa- demia and the world of sport. In colleges and uni-
tional, scientific, and professional contributions of versities, sport psychology was becoming an accepted
psychology to the promotion, maintenance, and academic subdiscipline within then departments of
enhancement of sport-related behaviors . . .” (p. 239, physical education (Feltz, 1987), solidifying its con-
Rejeski & Brawley, 1988). Division 47 (Exercise and nection to the exercise/sport sciences. Furthermore,
Sport Psychology) of the American Psychological Singer (1989) suggested that the book, Problem
Association (APA) has suggested that sport psycholo- Athletes and How to Handle Them (Ogilvie & Tutko,
gists are interested in “helping athletes use psycho- 1966), put sport psychology back into the public’s
logical principles to achieve optimal mental health eye and renewed athletes’ and coaches’ interests in
and to improve performance (performance enhance- how psychological issues could influence physical
ment) . . .” (APA, n.d.). Although these definitions performances. The fact that the two authors were
highlight the centrality of “psychology” in the field, psychologists represented a continuation of sport
its roots do not lie solely within this discipline. The psychology’s early connection to psychology.
reality is that, historically, sport psychology has con-
nections to the early work of psychologists who did Professionalization of Sport Psychology
field work on sport performances and to exercise/ Over the last four decades, sport psychology has
sport scientists who defined it as a subdiscipline undergone tremendous change and experienced
within their then departments of physical education. many of the growing pains associated with the emer-
gence and definition of a new professional field,
Historical Roots including: development of professional organiza-
Singer (1989) identified two psychologists—Nor- tions and journals, credentialing and service pro-
man Triplett and Coleman Griffith—whose work vision, and graduate training. For example, during
represented the origins of what is now modern- this time, sport psychology organizations have been
day sport psychology. In 1898, Triplett studied how formed (e.g., North American Society for the Psy-
the presence of others affected physical perfor- chology of Sport and Physical Activity [NASPSPA]
mances, such as bicycle racing, and set the stage for in 1967) and have splintered, such as when members
future work on social facilitation and inhibition. of NASPSPA formed a new professional organiza-
Coleman Griffith’s work occurred during the 1920s tion in 1985 (i.e., AASP) whose focus was more
and early 1930s at the University of Illinois. He is applied than experimental. The APA’s Division 47
credited with establishing the first sport psychology also was formed in the 1980s and provided another

pe t r ie , har m ison 781

anchoring point to psychology. In addition to the services to athletes, but to consult with them (and
formation of organizations that would help to define with sport teams) on issues (e.g., teaching imagery)
and represent the field’s professional interests, jour- and in areas (e.g., team cohesion) that would best
nals were started to disseminate research findings be described as performance enhancement and that
and promote a discussion of professional issues. previously had been considered the sole province of
Currently, there are over 15 sport- and exercise- exercise/sport science–trained sport psychologists.
related journals, such as: Journal of Sport & Exercise Psychologists increasing involvement in the pro-
Psychology, The Sport Psychologist, Journal of Applied vision of sport psychology services has been a dou-
Sport Psychology, Journal of Clinical Sport Psychology, ble-edged sword for the field. On the one hand,
Medicine and Science in Sport and Exercise, Research there are many more licensed psychologists (and
Quarterly for Sport and Exercise, Journal of Sport other licensed mental health professionals) than tra-
Behavior, Sport, Exercise and Performance Psychology, ditional sport psychologists, and these licensed
and Psychology of Sport and Exercise, to name a few. professionals have an extensive understanding of
Many of these journals are indexed within traditional human behavior and are experts in promoting
psychology databases (e.g., PsychInfo) and are pub- change, growth, and improvement in performance.
lished by organizations that represent a membership So, having psychologists available to provide coun-
beyond just sport psychologists (e.g., American seling and consulting services increases the opportu-
College of Sports Medicine [ACSM]; American nities for athletes, coaches, and sport teams to
Alliance for Health, Physical Education, Recreation receive assistance, such as developing preperfor-
and Dance [AAHPERD]), suggesting that sport psy- mance routines, regulating emotions, communicat-
chology has become an increasingly recognized and ing effectively, or coping with stress and anxiety.
accepted discipline within psychology and exercise/ This more “etic” perspective suggests that general
sport sciences. training in counseling or clinical psychology is suf-
ficient to work competently with sport performers;
service provision interdisciplinary training would not be necessary.
As sport psychology has developed from a primarily On the other hand, sport performers, from the
lab- or experimentally based discipline to a profes- youth to the elite level, represent a subgroup whose
sional, applied field, it has had to contend with environment, experiences, and needs are unique
issues concerning who should provide services and and specialized. Thus, psychologists who lack inter-
how those professionals should be credentialed. disciplinary training may not have the knowledge,
Although the majority of leading sport psycholo- skills, or understanding to provide the highest level
gists from the 1960s through the early 1980s were of service to sport performers. This “emic” perspec-
trained in and graduated from departments of exer- tive suggests that training as a psychologist is an
cise/sport science and practiced as “educational” important, but not sufficient, condition for provid-
sport psychologists (Straub & Hinman, 1992), over ing competent and ethical services (Petrie et al.,
the last two decades, psychologists have become 1995). Psychologists who want to work in the field
increasingly involved in the provision of sport psy- need also to have had training in the exercise/sport
chology services to athletes and other performers sciences (e.g., motor learning, exercise physiology),
(Hays, 2002, 2006; Leffingwell, Wiechman, Smith, and have received supervision for their applied work
Smoll, & Christenson, 2001; Petrie & Diehl, 1995; (Danish, Petitpas, & Hale, 1993). Despite the pro-
Petrie et al., 1995). In their study of APA Division motion of interdisciplinary training by professional
17 counseling psychologists, Petrie et al. found that organizations (e.g., AASP), few counseling or clini-
38% and 68%, respectively, reported consulting cal psychologists have pursued this option (Petrie &
with athletes and sport teams and counseling ath- Diehl, 1995; Petrie et al., 1995), whether that
letes in individual therapy. Furthermore, these pro- involves formal training (i.e., coursework) or super-
fessional interactions were not limited to traditional vision of applied sport psychology work.
counseling/clinical areas (e.g., inter-/intrapersonal
concerns, depression), but also focused on sport spe- credentialing
cific issues, such as performance enhancement, anx- This state of the field—psychologists interested in
iety and stress related to performances, and team and actually working with sport performers but also
dynamics. Studies such as these (e.g., Petrie & Diehl, lacking what some view as necessary interdisciplin-
1995) have shown that psychologists are being ary training—has served as a catalyst for organiza-
sought to provide not only counseling/therapeutic tions to address the issue of professional credentials.

782 sport psych o lo gy

Although limited options are available for estab- credentialing processes represent advances in iden-
lished psychologists who want to demonstrate their tifying the scope, limits, and ethics of practicing as
competency in sport psychology, there is agreement a sport psychologist; establishing a designation that
among the major sport psychology organizations defines minimum levels of training, education, and
(e.g., AASP, APA Division 47) that interdisciplin- experience needed; and offering some protections for
ary training in psychology (e.g., counseling) and consumers by promoting these designations to the
exercise/sport sciences is necessary for competent public, AASP and APA Division 47 have recognized
practice. Currently, AASP offers the only process the limitations of these credentials, particularly for
in which professionals, through a review of their established and currently practicing psychologists.
coursework and practical experiences (a portfolio- Thus, the executive committees of these two profes-
based approach), can achieve a credential in the sional organizations continue to work on developing
field (designation of Certified Consultant, AASP). other mechanisms (e.g., examination-based processes)
Although AASP’s credentialing criteria are ideal for for defining competency and protecting the public
current students because they offer a model for how from professionals who are providing services, but
to structure graduate training so as to achieve certi- who also may lack the necessary training.
fication, its portfolio-based approach represents a
substantial barrier to established, practicing psy- graduate training
chologists who do not have the time, energy, nor The existing credentialing processes, and the fact
inclination to return to school to take courses in that all the major professional organizations have
the exercise/sport sciences. Thus, the total number formally recognized sport psychology’s interdisci-
of active AASP certified sport psychology profes- plinary basis, have influenced graduate training in
sionals remains small (only 275 as of 2011; personal the United States as well as in other countries. In the
communication, Sarah Castillo, April 17, 2011), 1980s, doctoral graduates in sport psychology came
limiting its benefit to the profession and public. almost solely from departments of exercise/
Furthermore, because the scope of practice defined sport science (e.g., kinesiology; Waite & Pettit,
in the AASP certification criteria is somewhat lim- 1993). In the 1990s, though, increasing numbers of
ited (e.g., teaching goal setting skills, enhancing doctoral students in sport psychology were graduat-
team cohesion, etc., and not counseling athletes ing from departments of psychology, in particular
regarding personal issues, psychometric assessment from counseling and clinical psychology programs
of athletes, etc.), it is not clear what benefit this cer- (Andersen, Williams, Aldridge, & Taylor, 1997;
tification provides to those who are licensed mental Williams & Scherzer, 2003), and the majority
health providers (e.g., psychologists). of these graduates were completing two or more
The United States Olympic Committee (USOC) semesters of practica devoted solely to working
offers another type of “credential” through member- with athletes and sport teams and taking the neces-
ship on its Sport Psychology Registry. Profession- sary exercise/sport science courses to meet the crite-
als seeking membership on the Registry (and thus ria for AASP certification (Williams & Scherzer).
a recommended referral source for Olympic level Furthermore, over 60% of the directors of APA-
athletes), though, must be a Certified Consultant, accredited counseling psychology programs could
AASP, be a member of APA, and have their applica- identify at least one student in their programs who
tion reviewed and approved by the USOC Sport had sport psychology interests (Petrie & Watkins,
Sciences committee. Thus, this credential has simi- 1994). This increase in the number of counseling
lar limitations in not being practical for a larger pool psychology doctoral graduates who have specialized
of psychologists. in sport psychology reflects counseling psychology
APA Division 47 also has been involved in the program’s openness to, support of, and interest in
issue of credentialing, developing a proficiency state- the field. Although almost no APA-accredited coun-
ment for sport psychology in the profession of psy- seling psychology programs reported offering actual
chology that was recognized in 2003 (APA, n.d.). sport psychology courses, over 40% stated that they
This designation provides psychologists with infor- had sport psychology practica available to their doc-
mation on the knowledge and experiences that are toral students (Petrie & Watkins, 1994). Furthermore,
deemed necessary to practice competently in this spe- these programs deemed it very acceptable for their
cialized area, but does not offer a formal or approved doctoral students to want to specialize in sport
process for signifying one has achieved proficiency psychology, propose a sport psychology research
(or specialization) in the field. Although these three topic for their dissertation, and take exercise/sport

pe t r ie , har m ison 783

sciences courses in addition to their general program if recognized, not be able to treat them (or if they
requirements. tried to, which sometimes occurs, would be practic-
ing outside of their bounds of competence, a clear
current job market ethical violation). For organizations that want a
These shifts in graduate training in applied sport sport psychologist to oversee the health, well-being,
psychology also have been influenced by financial and performance of their athletes, having a profes-
factors and by the demands and realities of the cur- sional who has the training to provide not only edu-
rent job market. Although the percentage of income cational performance enhancement services, but
from sport-related sources is greater for unlicensed, work with the wide range of psychological problems
exercise/sport science trained sport psychology pro- that may arise (e.g., depression, eating disorders,
fessionals in comparison to licensed sport psycholo- anxiety, interpersonal problems) makes practical
gists (i.e., licensed psychologists who have specialized and financial sense. Why would an organization not
in sport psychology), the licensed sport psycholo- hire someone who has the training to work effec-
gists’ overall income is up to three times greater than tively in both the performance enhancement and
their unlicensed counterparts (Meyers, Coleman, mental health domains? In making this observation,
Whelan, & Mehlenbeck, 2001). Thus, psychologists, we acknowledge that there are some very competent
who are not limited to only working with athletes and highly skilled exercise/sport science trained
and sport teams from an educational perspective, sport psychology practitioners. We are fortunate to
have earning potentials that are substantially greater have them as colleagues. However, in the current
than their unlicensed counterparts. Regarding the professional environment, in which interdisciplin-
broader job market, recent trends suggest that sport ary training is the acknowledged standard and avail-
organizations—professional teams, the USOC, uni- able to graduate students, we believe that students
versity athletic departments—are hiring sport psy- wanting to be applied sport psychologists would be
chologists who also are licensed mental health best served by selecting an applied psychology pro-
providers. For example, all the sport psychologists gram (i.e., counseling psychology) as their founda-
employed by the USOC are licensed psychologists tional academic discipline and then take courses in
(USOC, n.d.), and recent sport psychology jobs at exercise/sport science and practica in sport psychol-
universities across the United States (e.g., University ogy while pursuing their doctorates. In other words,
of Oklahoma, University of Kansas, University of the ideal academic training environment, which we
Arizona) have been filled by licensed psychologists discuss in more detail later in the chapter, would
who have specialized in sport psychology (e.g., be interdisciplinary with counseling psychology as
Kansas Jayhawks, n.d.; Winerman, 2005). its foundation.
Staffing an athletic department or sport organi-
zation with licensed sport psychologists makes sense
The Sport Psychology–Counseling
for two major reasons. First, athletes, like nonath-
Psychology Interface
letes, experience myriad mental health concerns
A primary reason that counseling psychology, as
(e.g., depression, relationship concerns, eating dis-
opposed to other applied psychology programs or
orders; Brewer & Petrie, 2002) that, on their own,
other exercise/sport science–based programs, repre-
can be highly distressing, but also can significantly
sents the ideal environment for applied sport psy-
undermine successful sport performances. In fact,
chology is because the values that long have been a
licensed sport psychologists who have worked at
part of counseling psychology’s history and define
major sport competitions suggest that athletes seek
its “worldview” are an excellent match with the real-
assistance primarily for psychological concerns and,
ities and demands of the sport environment and the
secondarily, for performance enhancement issues
work sport psychologists generally do with athletes,
(Meyers, 1997). Second, athletes initially may pres-
teams, and organizations. Howard (1992), in his
ent with performance enhancement concerns, but
conceptual and philosophical evaluation of counsel-
the underlying cause of these decrements may be
ing psychology’s history, identified 14 such values.
psychological distress or dysfunction and, even if
Eight of these values seem to be particularly relevant
not, the ability to differentially determine the etiol-
to sport psychology:
ogy is essential for planning and implementing
effective treatments. Sport psychologists who are • Solid, positive interpersonal relationships are
not trained as mental health providers may not important. Between teammates, a coach and an
recognize the psychological problems that exist or, athlete, and/or players and their parents, the quality

784 sport psych o lo gy

of the relationship often determines whether a • The multiple and diverse ways in which
performance is successful, new skills or strategies counseling psychologists can intervene. In working
are learned, or athletes even stay involved in sports. with athletes and sport teams, applied sport
Applied sport psychologists often work to improve psychologists have to understand situations from
communication between coach and athlete, increase multiple perspectives (e.g., athlete, coach, parent)
the social and task cohesion of a team, or educate and be able to intervene on multiple levels.
parents on how to create a positive, supportive Sometimes, the intervention may be at the group
sport environment for their children, so that they level (e.g., improving team communication) or at
can have fun and stay involved in athletics. Being the level of the group leader (e.g., helping the
able to form positive, solid, working relationships coach understand the personality of a star player).
is the hallmark of a successful applied sport At other times, the sport psychologist may work at
psychologist (Orlick & Partington, 1987). the individual level and, even there, the
• Viewing human problems through a intervention will vary depending on whether the
developmental/growth lens. Because athletes often focus is more on general counseling issues or solely
are involved in sports for many years, some over on performance enhancement. Being able to take
the course of their lifetimes, it is important to an eclectic, multifaceted approach is a key for
understand the general developmental changes successfully intervening.
that occur as children become adolescents and • Counseling psychologists work to increase
then move into adulthood. In addition, the longer individual’s ability to solve problems, make
athletes are involved in sports, the more likely they decisions, and cope more effectively with stress and
will be to experience sport-specific developmental life demands. Athletes generally view themselves
changes and challenges. For example, the focus of as healthy individuals who are in control and able
training and challenges will be very different for a to successfully handle the demands in their lives.
5-year-old youth soccer player than for a collegiate They recognize that training can be stressful and
basketball player. At age 5, the focus should be on demanding, but they do not shrink from it and,
having fun, learning new skills, and making new when they encounter obstacles, work in a direct
friends. But, years later, as athletes continues to manner to solve the problem that is interfering
play and their skills have solidified, they will with their progress. Applied sport psychologists
become more focused on and challenged by often take a very direct, solution-focused
learning how to train in practice. Still later approach when working with athletes. They
in their development, their attention is likely attempt to build on the athletes’ existing
to shift to learning how to compete and win. strengths, set goals for what they want to
Thus, sport psychologists, by understanding the achieve, teach new psychological skills/strategies,
general and sports-specific changes that occur as and/or develop new and effective ways to cope so
athletes participate in sports over time, are able the athletes can perform at their best. Sport
to develop and implement interventions that competition is the stressor that athletes learn
take into account the developmental needs, how to handle.
issues, and challenges that are specific to • Prevention is valued over remediation. In
different ages and experience levels. sports, a major focus of athletes, coaches, and
• Understanding the influences of the teams is predicting the problems that might arise
environment on human functioning and problems. in training and upcoming competitions, and then
Athletes are embedded in multiple environments preparing for those in advance to either minimize
that strongly influence their behaviors, such as their effect or eliminate their occurrence
those created by their sport organization (e.g., high completely. This approach is referred to as
school team), their coaches, their teammates, their developing a training regimen and preparing a
parents, and even their opponents during “game plan” for an upcoming competition.
competition. Applied sport psychologists try to Applied sport psychologists work from this
understand such contextual factors, and help perspective when they teach athletes to use imagery
athletes, coaches, and teams work effectively with to “practice” events that might occur in future
them, even modifying the environments (e.g., competitions (but are difficult to simulate in live
changing location of training, having parents not practices) or have athletes plan for and think
yell at their children during competitions) if such through the challenges that will exist when they
changes would lead to improved performances. go to their first national/international

pe t r ie , har m ison 785

competition (e.g., world championship). We are not the only counseling psychologists
Prepared, conditioned, trained athletes who have noted the interface between counseling
increase their chances of having successful and sport psychology and have argued that counsel-
performances. ing psychology’s philosophy was aligned with the
• A holistic approach that acknowledges the entire values of sport and the work sport psychologists
person and recognizes the connection between mind, traditionally do in athletics (Danish et al., 1993;
body, and environment. Athletes, because of what Howard, 1993; Petitpas, Giges, & Danish, 1999).
they do, can view themselves primarily from a For example, Petitpas et al. (1999) suggested that
physical perspective and believe that they are counseling psychology’s focus on psychoeducation
valued, such as by their coaches, only for what and development, goal attainment, and prevention
their bodies can do or for the results of their most were some of what distinguished it from clinical psy-
recent physical performance. Sport psychologists, chology and made it an ideal approach for work-
though, offer athletes a broader perspective on who ing with athletes and sport teams who were healthy
they are (multiple identities, such as student, and wanted to improve on their existing strengths.
worker, son/daughter) and often help them Furthermore, they argued that it was time for a para-
appreciate or plan for other successes in their lives digm shift in applied sport psychology training, one
(e.g., graduating from college), while still helping that embraced not only the teaching of cognitive-
them achieve their athletic goals. Through behaviorally based skills but one that focused on the
interventions, such as positive thinking, emotion development, growth, and self-awareness of the
regulation, and relaxation, sport psychologists sport psychology consultant. From this perspective,
help athletes understand the connections between sport psychology would become more like counsel-
their emotions and thoughts and how these ing psychology, a profession that views a positive
interact to affect their bodies and their physical working relationship as the primary agent of change
performances. and improvement (Andersen, 2000, 2005). In a sub-
• An appreciation of and respect for diversity. sequent section, we elaborate on this idea of counsel-
Sports represent a venue through which individuals ing psychology (and its values) being the ideal
from all different areas/spectrums of life (e.g., race/ foundational academic environment by offering an
ethnicity) come together to set, work toward, and, ideal model for training applied sport psychologists.
in many instances, achieve, a common goal. For
some athletes, sport is the one place where they Intervening with Performance Issues
interact with individuals who are different from The optimization of athletic performance is an area
themselves in some meaningful way (e.g., race/ of great interest to many applied sport psycholo-
ethnicity, socioeconomic status). In fact, in many gists, and issues related to intervention/performance
high-profile sports, such as basketball and football, enhancement have received considerable attention.
racial/ethnic minority players are represented at Thorough discussions of all relevant performance
rates higher than exist in the general population issues have been provided elsewhere (e.g., Hardy,
(Coakley, 2009). Each sport, in its own right, also Jones, & Gould, 1996; Weinberg & Gould, 2007),
has a history and culture that is unique and is and it is not our intention to do the same here.
passed down from coach to player and so on. In Rather, in this section, we present several topics of
addition, each team, within a sport, has its own current interest that sample the array of perfor-
separate culture that is determined by the demands mance issues addressed by most applied sport psy-
of that specific sport, the training that this set of chologists, are consistent with our view of the scope
coaches require, the traditions of this team, and the of sport psychology practice, and reflect the inter-
current set of athletes (and their experiences and face between counseling psychology and sport psy-
values) that comprise the team at this point in chology related to the core values described earlier.
time. Applied sport psychologists who work
successfully with athletes and sport teams have an Mental Toughness
understanding not only of broad issues of diversity, Although mental toughness has long been consid-
such as gender and race/ethnicity, that exist and ered one of the most important characteristics for
likely are to be encountered in sports, but also of athletes to possess, only recently have sport psychol-
the diversity that is represented at the level of the ogists defined it. Through a series of interviews and
sport (e.g., badminton vs. rugby) and of a focus group work with elite-level athletes, Jones,
particular team. Hanton, and Connaughton (2002) defined mental

786 sport psych o lo gy

toughness as a natural or learned psychological edge the importance she places on her grit and determi-
that allows athletes to cope better than their oppo- nation in such situations, as well as to the enjoy-
nents with the demands of their sport (e.g., train- ment that mastering such challenges brings to her
ing, competition, lifestyle); and more specifically, be (goals and values). Also, if this truly is her self-belief,
better and more consistent than their opponents in she will feel confident in her ability to be successful
remaining determined, focused, confident, and in even during a critical game when she is not playing
control under pressure. In addition, they identified well (affects), which may be the result of her ability
the attributes of the mentally tough performer: self- to remain optimistic and hopeful despite some fail-
belief, desire/motivation, handling competition- ure and set-backs (self-regulation skills).
related pressure (external) and anxiety (internal),
performance-related focus, lifestyle-related focus, Interventions with Individual Athletes
and dealing with physical and emotional pain/ A major thrust of applied sport psychologists’ work
hardship. with individual athletes is to teach them psychologi-
Although criticisms have surfaced regarding the cal skills (referred to as mental skills in the sport
clarity of Jones et al.’s (2002) definition (Crust, psychology literature) in an effort to improve their
2007; Middleton, Marsh, Martin, Richards, & Perry, mental toughness and enhance their sport perfor-
2004), other researchers have provided support for mances (Petrie et al., 1995). Successful, mentally
this conceptualization (e.g., Bull, Shambrook, James, tough athletes possess a certain set of cognitive and
& Brooks, 2005; Connaughton, Wadey, Hanton, & behavioral skills (e.g., thought control strategies,
Jones, 2008; Harmison & Roth, 2006). In addition, arousal management techniques, attentional control)
Mischel and Shoda’s (1995) social-cognitive model that, in the end, facilitate performance (Krane &
of personality functioning, also referred to as the Williams, 2006; Vealey, 2007). Since a complete
cognitive-affective processing system (CAPS), can be review of all of the mental training strategies and
applied to add precision to its definition. The CAPS techniques utilized by successful athletes is beyond
model views personality as a dynamic network of the scope of this chapter, we introduce the four pri-
five types of processing and behavior-generation mary mental skills from the applied sport psychology
units: encodings (e.g., personal constructs for the canon—goal setting, imagery, physical relaxation,
self, people, events, and situations), expectancies and and self-talk.
beliefs (e.g., beliefs about the self, the world, and
“how things are”), affects (e.g., cognitive and physi- basic mental skills
ological emotional responses), goals and values (e.g., Goal setting is a popular technique used by coaches
short- and long-term desired and undesired out- and athletes at all competitive levels to help them
comes), and self-regulation skills (e.g., cognitive, achieve performance success. Goal setting is thought
affective, and behavioral capabilities to respond and to work because goals provide motivation (e.g.,
influence). Not only do these CAPS units respond to mobilize effort and enhance persistence) and regu-
and activate or inhibit one another, the units also late behavior (i.e., planning and adapting thoughts,
collectively interact with situational factors to pro- emotions, and actions to achieve goals) (Weinberg,
duce the expression of one’s personality, in what is Harmison, Rosenkranz, & Hookom, 2005). Effective
referred to as behavioral signatures. goal setting strategies include setting specific goals,
From this model, mental toughness can be con- challenging yet realistic goals, and a combination
strued as a personality construct characterized by of short-term and long-term goals; developing goal
the distinctive organization of the athletes’ cogni- achievement strategies; utilizing outcome, perfor-
tions and affects, the interrelations among the ath- mance, and process types of goals; and providing
letes’ cognitions and affects, and the relationship support for and feedback on athletes’ goal achieve-
between athletes’ cognitions/affects and the psy- ment efforts. A number of systematic goal setting
chological features of the competitive situation approaches can be found in the literature to guide
(Harmison, Hehn, Sims, & Poupeney, 2007; Smith sport psychology professionals as well (e.g., Burton,
2006). For example, if a woman’s basketball player Naylor, & Holliday, 2001; Weinberg et al., 2005).
perceives herself as capable of being one of the very Imagery can be defined as a polysensory experi-
best at her position (encodings), then she likely has ence that occurs in the absence of external stimuli
strong beliefs in her ability to respond successfully that includes recreating external events or past expe-
to challenging, competitive situation (expectancies riences or creating new internal pictures in one’s
and beliefs). This self-belief may be connected to mind from memory (Vealey & Greenleaf, 2006).

pe t r ie , har m ison 787

Athletes use imagery for myriad motivational (e.g., athletes master both types of techniques to develop
achieving specific goals, mastering challenging situa- the ability to deal with multiple types of anxiety
tions, managing emotions) and cognitive (e.g., simultaneously (e.g., excessive muscle tension, over-
learning specific sport skills, rehearsing competition whelming self-doubt) (Burton, 1990).
strategies) purposes in hopes of improving perfor- Finally, self-talk consists of interpretive and
mance (Hall, Mack, Paivio, & Hausenblas, 1998). content-specific verbalizations or statements
Imagery appears to work because it enhances the addressed to the self, is multidimensional and
learning and performance of sport skills and helps dynamic in nature, and serves both instructional
athletes regulate competition-related thoughts and and motivational functions (similar to those of
emotions (e.g., confidence, motivation, anxiety) imagery) (Hardy, 2006; Hardy, Gammage, & Hall,
related to successful performance (Vealey & 2001). Despite the common use of self-talk by
Greenleaf, 2006). Traditional explanations for how athletes and the understanding that cognitive pro-
imagery improves the learning and performance of cesses are critical determinants of sport performance,
sport skills have focused on the psychoneuromuscu- very little theory-based research exists to adequately
lar theory (i.e., imagery enhances performance by account for the reasons why self-talk may improve
increasing muscle memory), symbolic learning performance. Some researchers have suggested that
theory (i.e., imagery enhances performance by self-talk facilitates performance by improving an
increasing familiarity and automaticity of move- athlete’s attentional focus, whereas others have indi-
ments), and bioinformational theory (i.e., imagery cated that perhaps self-talk serves to improve infor-
enhances performance by providing a template for mation processing to enhance performance (e.g.,
overt responding), and recent advances have included Landin, 1994; Ziegler, 1987). The available research
a cognitive neuroscience approach using functional does suggest that athletes would be wise to rely on
equivalence theory to better integrate the strengths positive, rational, and task-focused self-talk and
and limitations of these theoretical explanations learn how to modify maladaptive, irrational, and
(Murphy, Nordin, & Cumming, 2008). Useful task-irrelevant self-talk (Hardy et al., 1996).
guidelines can be found in the literature for imagery
work with athletes as well. For example, the efficacy of mental skills training
PETTLEP model (Holmes & Collins, 2001) interventions
emphasizes the use of various elements (e.g., physi- Qualitative literature reviews (e.g., Meyers, Whelan,
cal, timing, emotion) in imagery scripts to activate & Murphy, 1996; Vealey, 2007) have provided
selected brain structures, and a model of imagery use evidence for the efficacy of goal setting, imagery,
(Martin, Moritz, & Hall, 1999) suggests that differ- physical relaxation, and self-talk to enhance the
ent types of imagery (e.g., motivational specific, cog- psychological state of athletes and improve their
nitive general) should be used by athletes to obtain performance. In addition, three quantitative reviews
specific results (e.g., increased motivation to achieve (Greenspan & Feltz, 1989; Martin, Vause, &
a goal, rehearse competition strategies). Schwartzman, 2005; Meyers et al., 1996) also
Applied sport psychologists (e.g., Krane & support the effectiveness of applied sport psychol-
Williams, 2006) typically advocate the use of physi- ogy interventions. Specifically, a meta-analysis of
cal relaxation techniques by athletes to regulate 56 published intervention studies yielded an average
arousal levels, in particular, competitive state anxi- effect size of .62 (standard deviation [SD] = .85) for
ety, which is defined as the subjective, consciously cognitive-behavioral interventions compared to the
perceived feelings of worry and physical nervous- control group (Whelan, Meyers, & Berman, as cited
ness related to competition (Weinberg & Gould, in Meyers et al., 1996). In addition, Greenspan and
2007). Learning to relax helps athletes self-regulate Feltz (1989) reviewed intervention research that
their physiological (e.g., muscle tension, increased only utilized athlete-participants in noncontrived
heart rate), psychological (e.g., worry, doubt), and competitive situations and found positive results on
behavioral (e.g., fatigue, loss of coordination) performance for 20 out of 23 (87%) interventions.
anxiety-related responses to various competitive Eliminating studies that assessed performance in
stressors. Specific approaches to relaxation include mock competitions, relied on athlete self-reports
muscle-to-mind techniques, such as deep breathing of their performance as the dependent variable, or
and progressive muscle relaxation, and mind-to- failed to incorporate an acceptable between-groups
muscle techniques, such as meditation and imagery research or appropriate single-subject design, Martin
(Williams & Harris, 2006). It is recommended that et al. (2005) found a positive effect on performance

788 sport psych o lo gy

for 14 out of 15 (93%) interventions, with nine relationship between cohesion and team success is
showing a substantial impact (i.e., mean improve- found; both task and social cohesion is significantly
ment ranged from 3%–80% over baseline or con- correlated to team performance; team success and
trol). Criticisms (e.g., Gardner & Moore, 2006; cohesion are both predictive of one another; and
Morgan, 1997) of this research include a very lim- cohesion is related to better performance in both
ited number of experimental studies, lack of external team (e.g., basketball) and individual (e.g., bowling)
validity (e.g., non–sport research setting), inad- sports (Carron et al., 2002).
equate experimental designs (e.g., lack of a control
group), behavioral artifacts (e.g., halo effect), and a team building
large number of equivocal findings, leading some Many applied sport psychologists engage teams
sport psychology professionals to suggest that prac- in activities designed to enhance group cohesion.
titioners should proceed with caution in the absence These activities commonly are referred to as team
of confirming, supportive research. building, which is defined as a method of helping a
team increase its effectiveness, meet the needs of
Interventions with Teams team members, or improve training or competition
Applied sport psychologists also strive to enhance environmental conditions (Brawley & Paskevich,
mental toughness in teams by providing perfor- 1997). When delivering team building interven-
mance enhancement services to groups of athletes. tions, applied sport psychologists generally take
The nature of these services range from enhancing either a direct or indirect services approach. A direct
group mental skills (e.g., team goal setting) to services approach (e.g., Yukelson, 1997) involves a
addressing various group dynamics (e.g., cohesion, coach or sport psychology professional implement-
communication). Fortunately, a number of useful ing the team building intervention (e.g., team goal
texts are available for practitioners with interests in setting) directly with the team. By contrast a typical
working with teams to increase a more collective indirect services approach (e.g., Carron, Spink, &
mental toughness (e.g., Carron, Hausenblas, & Eys, Prapavessis, 1997) consists of the sport psychology
2005; Dosil, 2006). A particularly important group professional providing a coaching staff with insights
dynamic, group cohesion, often is placed at the and strategies to enhance team productivity and sat-
center of the conceptual framework in the under- isfy team members’ needs and then equipping them
standing of the psychology of sport teams (Carron with the skills, strategies, and/or knowledge to carry
et al., 2005). out the team building interventions themselves.
Despite the intuitive appeal and popular use of
group cohesion team building interventions, very little research
Group cohesion in sports is defined as the tendency exists to guide practitioners in their implementation.
for a team to stick together and remain unified in A review of the available research, though, sheds
the pursuit of the team’s task-related goals and/ some positive light on the efficacy of team building
or for the satisfaction of team members’ affective interventions. Specifically, athlete self-reports related
needs (Carron, Brawley, & Widmeyer, 1998). It is a to the effectiveness of multicomponent, season-long
dynamic process that is multidimensional in nature, team building programs suggest that these interven-
consisting of both task (i.e., teamwork) and social tions may lead to improved team performance, team
(i.e., team spirit) aspects, and based on individual unity and harmony, role definition, accountability,
team member’s attraction to the team as well as to team communication, focus on team goals, and
their perceptions of the team overall (Carron, motivation (Bloom & Stevens, 2002; Voight &
Widmeyer, & Brawley, 1985). Historically, qualita- Callaghan, 2001). Also, brief team building inter-
tive literature reviews of the relationship between ventions in which personal disclosure/mutual shar-
group cohesion and team performance have been ing among team members is emphasized can result
inconclusive and sometimes contradictory (e.g., Gill, in self-reported enhanced understanding of others
1986). More recent meta-analyses (Carron, Colman, and self, increased cohesion (e.g., closeness, playing
Wheeler, & Stevens, 2002; Mullen & Cooper, for each other), and more confidence (e.g., trust in
1994), however, have revealed the existence of a self and teammates and feelings of invincibility)
positive linear relationship between cohesion and (Dunn & Holt, 2004; Holt & Dunn, 2006).
performance. When the cohesion–performance rela- However, other findings suggest that less-than-clear
tionship is examined exclusively within a sport set- conclusions can be drawn regarding the efficacy of
ting, a significant, moderate to large, and positive team building interventions. Season-long team

pe t r ie , har m ison 789

building interventions have revealed initial improve- establishing clear expectations, rewarding wanted
ments in task and/or social cohesion that were not behaviors, and avoiding nagging or threatening
maintained over the entire course of the teams’ com- actions to keep control; and provide spontaneous
petitive season (Cogan & Petrie, 1995; Stevens & instruction and encouragement to get positive things
Bloom, 2003), maintenance but not improvement to happen with their players. In addition, coaches
in both task and social cohesion over the course of are encouraged to adopt a philosophy of winning
an entire competitive season (Senécal, Loughead, & that emphasizes “doing your best” and “having fun”
Bloom, 2008), and no effect on cohesion whatso- versus a “winning at all costs.”
ever (Bloom & Stevens, 2002; Prapavessis, Carron, Coach effectiveness training has been found
& Spink, 1996). to positively change youth sport coaching behaviors,
influence young athletes’ perceptions of their coaches,
Interventions with Coaches increase young athletes’ positive perceptions of them-
A final area in which applied sport psychologists selves, and enhance the motivational climate of
address the development of mental toughness is youth sport participants. More specifically, CET-
related to their consultation work with coaches at all trained coaches engage in more observable reward/
levels of sport, and intervention programs with reinforcement behaviors than do non–CET-trained
youth sport coaches have been subject to the most coaches (Smith et al., 1979), an effect that has been
extensive empirical investigation. Research suggests found to be moderate to large (Conroy &
that the attributes of mental toughness described Coatsworth, 2004). In addition, youth sport ath-
earlier begin forming with athletes’ initial involve- letes perceive CET-trained coaches as displaying
ment in sport at a very young age, and their coaches’ more desirable coaching behaviors (e.g., reinforce-
leadership and behaviors throughout their youth ment, encouragement, instruction) and less unde-
sport’s experience play a crucial role in its ultimate sirable coaching behaviors (e.g., nonreinforcement,
development (Connaughton et al., 2008). Thus, punishment; Smith et al., 1979; Smith, Smoll, &
intervention programs with young athletes, such as Barnett, 1995; Smoll, Smith, Barnett, & Everett,
coach effectiveness training (CET; Smith, Smoll, & 1993). Similarly, youth who played for CET-trained
Curtis, 1979), that have a growth/developmental coaches have demonstrated increased perceptions
focus and place a high value on the prevention of of self-esteem, more enjoyment, and greater posi-
undesirable coaching behaviors would appear to tive relationships with teammates (Coatsworth &
be effective approaches to be used by applied sport Conroy, 2006; Smith et al., 1979, 1995; Smoll
psychologists to promote the development of mental et al., 1993). Finally, with regard to motivational
toughness in athletes. climate, young athletes have reported experiencing
lower levels of performance anxiety (Smith et al.,
coach effectiveness training 1995) and a rate of attrition from sport that was five
Coach effectiveness training is based on a media- times lower (Barnett, Smoll, & Smith, 1992) as a
tional model of the psychosocial impact of coaching result of playing for CET-trained coaches.
behaviors on athletes (Smoll & Smith, 1984) that
suggests coaching behaviors influence athletes’ per- Characteristics of Successful Applied
ceptions and recall of their sport experiences, which Sport Psychologists
in turn impacts the athletes’ evaluation of and atti- The previous discussion of mental toughness and
tudes toward their sport experiences. The crux of mental skills focused on the nature of the interven-
the model rests on athletes’ perceptions of their tion, but ignored the potential influence of athlete
coaches’ behavior, and the key objectives of CET and applied sport psychologist characteristics. We
include helping coaches become more aware of their agree, though, with Smith’s (1989) assertion that the
behaviors, increase their desire to generate positive evaluation of a change program goes beyond a
consequences for their athletes, and enhance their simple determination of whether a specific interven-
ability to perform desirable coaching behaviors more tion is effective or not and further believe that the
effectively (Smith et al., 1979). Coach effective- nature of the relationship between the athlete and
ness training teaches coaches to reward their play- applied sport psychologist is a critical component
ers for good plays and not take their efforts for in the effectiveness of any intervention. Fortunately,
granted; encourage players immediately follow- anecdotal accounts (e.g., Dorfman, 1990; Halliwell,
ing their mistakes, provide corrective instruction, 1990), survey evidence (e.g., Gould, Murphy,
and avoid punishment; prevent misbehaving by Tammen, & May, 1991; Orlick & Partington, 1987),

790 sport psych o lo gy

and empirical studies exist to provide an idea of to and coping with athletic injury, and transitions
what personal and professional characteristics are from sport (i.e., ending a career)—that may be
important in the effective provision of sport psy- common among athletes, may be complicated by
chology services. aspects of the sport environment or the sport experi-
In sum, the literature suggests that successful ence, and/or have been the focus of specific interven-
applied sport psychologists not only possess excel- tions within the sport environment. Consistent with
lent technical knowledge and skills related to the counseling psychology’s core values, interventions
psychology of sport, but they also have highly devel- associated with these concerns have focused not only
oped interpersonal skills with the ability to estab- on the amelioration of existing symptoms but also
lish good working relationships with athletes and on preventing their occurrence.
coaches. They are perceived as likeable, trustworthy,
positive, caring, and warm by athletes and coaches, Eating Disorders
and are people-oriented helpers with a clear under- Although athletes generally are more body satisfied
standing of themselves, a genuine willingness to than nonathletes (Hausenblas & Symons Downs,
learn from athletes and coaches, and an ability to fit 2001), which is a protective factor when consider-
within a team environment. This evidence has led ing the development of eating disorders (Stice,
some sport psychology professionals (e.g., Tod & 2002), the reality is that athletes experience higher
Andersen, 2005) to conclude that the relationship levels of disordered eating in comparison to their
between the applied sport psychologist and the ath- nonathletic counterparts (Hausenblas & Carron,
lete/coach is the actual intervention and the sport 1999; Smolak, Murnen, & Ruble, 2000). For exam-
psychologist is the primary consulting tool whose ple, in samples of male and female collegiate ath-
main responsibility is to form a collaborative rela- letes, respectively, Petrie and his colleagues (Petrie,
tionship and strong working alliance. In other Greenleaf, Reel, & Carter, 2008; Greenleaf, Petrie,
words, it is through the relationship that change Carter, & Reel, 2009) found that 0.0% and 2.0%
occurs. could be categorized as having a clinical eating dis-
order, whereas another 19.2% and 25.5% engaged
Counseling/Clinical Issues in in behaviors that were symptomatic (subclinical).
Sport Performance Furthermore, in a study of elite athletes, Sundgot-
The optimization of sport performances does Borgen and Torstveit (2004) reported that the male
not occur solely by teaching athletes mental skills/ and female athletes were three times more likely to
strategies; it also happens through the prevention have a subclinical or clinical eating disorder than
and remediation of personal and clinical issues. The were a matched group of nonathletes. The female
reality is that athletes (and coaches for that matter) athletes, as is found in the general population, had
experience inter- and intrapersonal concerns, and higher prevalence rates than the male athletes,
these personal and clinical issues, which can range regardless of how severe the disordered eating symp-
from problems in romantic relationships to mood toms. Often occurring in tandem with disordered
disorders (Petrie et al., 1995), can significantly inter- eating for female athletes are high levels of amenor-
fere with sport performances. Likewise, how well rhea (Sanborn, Horea, Siemers, & Dieringer, 2000)
athletes or coaches perform in their sport can exac- and less frequently, osteoporosis (or osteopenia).
erbate underlying mental health problems and affect Together, this cluster of events is known as the
core issues of self-worth, self-identity, interpersonal female athlete triad. In addition to the general phys-
relationships, and family dynamics (Barber & Krane, ical and psychological symptoms associated with
2005). Thus, being able to assist athletes in resolving disordered eating, athletes who have the triad may
personal and clinical issues can be a primary and experience increased bone fractures, increased skel-
necessary focus for applied sport psychologists. etal fragility, and permanent bone loss (Sanborn
It is beyond the scope of this chapter to review all et al., 2000).
possible clinical issues/concerns that could affect ath- Like nonathletes, athletes are exposed to the gen-
letes’ performances, and there are recent reviews con- eral sociocultural pressures concerning attractiveness
cerning the presence of psychopathology among and media images about the ideal male or female
athletes and within sport and exercise settings that body, yet they also experience weight- and body-
interested professionals can peruse (see Brewer & related pressures unique to the sport environment
Petrie, 2002). Thus, in this section, we focus on three that may increase their risk of developing disordered
specific issues/concerns—eating disorders, reactions eating attitudes and behaviors (Petrie, Greenleaf,

pe t r ie , har m ison 791

Reel, & Carter, 2009). First, some athletes experi- health, though, then limitations need to be consid-
ence pressures from judges to have a certain “look” ered. Second, athletes are part of integrated systems
(e.g., thin) and thus may believe that to succeed in which multiple individuals—coaches, athletic
in their sport, they must diet or exercise more to trainers, general managers, etc.—may be privy to
achieve this “required” body type/style. Second, the personal and medical information and may be in
uniforms of certain sports, such as swimming/diving, the position to refer them for treatment. Thus, con-
triathlons, volleyball, wrestling, and gymnastics, are fidentiality, including its limits and who should be
form-fitting and revealing and may contribute to made aware of the athletes’ treatment, needs to be
athletes feeling self-conscious and uncomfortable discussed in advance. In such discussions, the issues
with their bodies. Thus, athletes may be motivated of informed consent and best interest of the client
to reduce excess body fat and, for males, gain lean (i.e., athlete) must be kept at the forefront. Third,
muscle mass, often through extreme measures (e.g., depending on the athletes’ competitive level, their
excessive exercise, vomiting, steroids), to look better participation may be very public. In fact, at the col-
in their uniforms. Third, characteristics of disordered lege, elite, and professional levels (and nowadays,
eating (in particular, anorexia nervosa), when dis- even at the high school level), athletes and their per-
played in the sport environment, may be viewed as formances come under daily scrutiny and coverage
normal and even reinforced by coaches. Are athletes by the media. Thus, if athletes are restricted from
who pursue excellence in sport no matter what practice/competition because participation would
the cost, comply with all coaches’ requests, train/ be health-compromising, then it may become nec-
compete despite pain or discomfort, and exercise/ essary to discuss how this public absence from the
train excessively to improve simply demonstrating team will be explained to the media (and possibly
their devotion to sport and desire to improve, or are to teammates). For more information on working
these the traits of a person with an eating disorder with these and other issues that may arise when
(Thompson & Sherman, 1999)? Fourth, health counseling athletes with eating disorders, see Petrie
status often is secondary to weight loss and per- and Sherman (2000) and Thompson and Sherman
formance because many coaches mistakenly believe (2010).
that being lighter is associated with improved In the last decade, research on eating disorder
performance (Griffin & Harris, 1996). Coaches prevention (e.g., Stice, Presnell, Gau, & Shaw, 2007)
may send direct or subtle messages to their athletes suggests that body-dissatisfied women’s risk can be
that they should diet, increase exercise loads, and/ reduced through a variety of interventions, including
or engage in other pathogenic weight control tech- cognitive dissonance-based approaches. Studies such
niques (e.g., vomit, take steroids) to become leaner, as that by Stice et al. have shown that women who
gain strength/muscle mass, and achieve a perfor- participate in 1-hour weekly meetings during which
mance body ideal. These messages communicate they critique the societal thin ideal, both verbally
that the highest value is placed on sport perfor- and behaviorally, report decreases in internalization
mance, no matter what the personal, physical, and/ of societal beauty ideals, body dissatisfaction, diet-
or psychological costs may be to the athlete. ing, and negative affect, to name a few, that can last
Although providing individual counseling to for years. Recently, such programs have been under-
athletes with eating disorders will follow many of taken with athletes, showing initial promise as effec-
the same treatment principles used with nonathletes tive and efficient ways to reduce eating disorder risk
(e.g., Stein et al., 2001), several issues are unique to among this group of women. For example, Smith
the sport environment that must be considered as and Petrie (2008) tested a modification of the Stice
well. First, depending on the severity of the eating et al. dissonance program with female collegiate ath-
disorder, the issue of continuing to practice and/or letes and found that the women showed decreases in
compete must be addressed. Often, athletes’ partici- sadness/depression and internalization of the physi-
pation in their sport is the primary thing of value in cally fit and in-shape body type and increases in their
their lives, so the decision to prohibit involvement levels of body satisfaction over the course of the
must be made thoughtfully and in consultation 3-week intervention. Prevention programs such as
with the treatment team (e.g., psychologist, physi- the one used by Smith and Petrie represent an impor-
cian, nutritionist). If athletes can continue to train/ tant avenue of continued study with athletes, given
compete and it not be detrimental to their physical their elevated risk for disordered eating. In addition,
health, then allowing them to do so may be an such programming should be tested with male ath-
advantage in treatment. If training compromises letes, although such interventions would need to be

792 sport psych o lo gy

modified to address the concerns most relevant to interventions can help athletes (1) adapt to and
men, including muscle dysmorphia, pressures to recover from the high intensity training regimens
gain weight and muscle, and ingestion of muscle that are a necessary part of sport, and (2) reduce neg-
building products (e.g., steroids). ative psychosocial factors that exist (e.g., life stress),
increase positive psychosocial factors (e.g., social
Athletic Injury support), modify psychological appraisals of situa-
Injury is an unfortunate, but very real, part of the tions, and learn to reduce anxiety, worry, and stress
sport environment. Every year, tens of millions of responses that occur. Recent research has shown that
athletes, from recreational to competitive levels, cognitive-behaviorally based interventions that
suffer sport injuries (American Sports Data, 2003). employ techniques such as relaxation, cognitive-
Injury rates among male and female athletes tend restructuring, and imagery can reduce injury rates,
to be relatively equal (Centers for Disease Control days missed due to injury, and number of illnesses
[CDC], 2006; Hootman, Dick, & Agel, 2007), and health center visits (Johnson, Ekengren, &
although injuries occur more frequently in competi- Andersen, 2005; Maddison & Prapavessis, 2005;
tions than practices, and in contact sports, such as Perna, Antoni, Baum, Gordon, & Schneiderman,
football, wrestling, and ice hockey (men’s and wom- 2003). Although these initial results suggest that
en’s), and noncontact sports, such as soccer, volley- athletes who are taught a variety of psychologically
ball, basketball, and gymnastics, than in other sports based skills can better manage their stress, alleviate
(Hootman et al., 2007). Thus, at some point in their negative mood, and reduce their risk of injury
time, applied sport psychologists are likely to have and illness than those who have not, more research is
an athlete under their care who has suffered injury needed in this area, specifically testing other inter-
and, depending on its severity, may require surgery ventions and examining their effectiveness over
and extensive rehabilitation. longer periods of time.
Injury often is viewed solely as a physical/ Second, some athletes will be injured during
physiological event, yet psychological factors, such their seasons and may experience psychological dis-
as life stress, social support, coping skills, and sport tress in relation to their being out of sport (includ-
anxiety, do in fact contribute to athletes’ risk of ing a loss of confidence) and may behave in ways
becoming injured and can influence how athletes’ that are counterproductive to their rehabilitation
respond once injured (Petrie & Utley-Hamson, in and recovery. For example, an athlete who has expe-
press). Furthermore, injury rehabilitation is not rienced a season- or career-ending injury may
solely a physical process. Athletes must recover from become depressed and withdrawn, and then may
not only the physical trauma they have experienced, not attend rehabilitation sessions, may not put forth
but also cope with the extreme negative emotions sufficient effort when in session, and/or may not do
(e.g., anger, confusion, anxiety, depression) that may assigned rehabilitation homework. The end result is
occur in association with their injury (Albinson that the athlete’s recovery will be slower and longer
& Petrie, 2003). Although initial injury response than needed. In such instances, working coopera-
models took a simple “stage” approach, subsequent tively with the athlete’s physical therapist and help-
formulations have conceptualized it as an individ- ing the athlete become reengaged in and motivated
ualized, interactional process in which personal, about the rehabilitation process will be an impor-
social, and environmental factors influence how ath- tant step. In addition, some athletes may experience
letes respond emotionally, cognitively, and behav- a loss of sport confidence due to not being able
iorally to their injuries and engage in the recovery to physically train and/or a fear of reinjury. Thus,
process. The etiology of and responses to injury is some medically cleared athletes may not immedi-
a complex, interactive, multifactorial process in ately return to play because of psychological factors.
which both physical and psychological factors play Many of the same cognitive-behavioral skills that
an important role (see Petrie & Utley-Hamson, in reduce injury rates, such as relaxation and imagery,
press, for a review of the psychological etiology and can be used to help athletes’ cope more effectively
responses to injury). when injured (for a review, see Petrie & Utley-
There are two primary routes through which Jordan, in press). Such skills can be taught during
applied sport psychologists can intervene in the area individual counseling sessions; however, group
of athletic injury (Petrie & Perna, 2004). First, counseling may be particularly effective because it
because physical training and psychological factors provides the added dimension of peer social sup-
do increase athletes’ risk of injury (e.g., Petrie, 1993), port, which may be missing among injured athletes

pe t r ie , har m ison 793

who are not as centrally involved with their teams might be present? How long has the athlete been
due to their injured status (see Petrie, 2007, for a involved in sport? How strongly is the athlete iden-
review on working with injured athletes). tified with the athlete role, and does the athlete have
any other areas in which he or she has a strong iden-
Transitions from Sport tity? Brewer, Van Raalte, and Petitpas (2000) have
Athletes transition out of sports at all ages and for suggested that athletic identity, particularly when
any number of reasons. The common factor, though, it has been foreclosed, can contribute to distress
is that at some point all athletes will leave their pri- during the transition from sport. Athletes who see
mary sport, being unable to compete at the level themselves primarily in that role and do not have
they once did. Even if athletes stay involved in any other well-defined and informed identities may
another capacity (e.g., coaching), they still must struggle with the idea of not being involved in sport.
adjust to life away from competition and their sport, For them, the question becomes, “Who am I if I am
and research suggests that upward of 20% of them not an athlete?” Applied sport psychologists can
experience psychological distress associated with assist athletes with this identity issue by helping
this transition (Grove, Lavallee, Gordon, & Harvey, them internalize the other important roles in their
1998). How athletes adjust to this “career” transi- lives, such as student, son/daughter, romantic part-
tion can be influenced by three factors: the reason ner, friend, and more. Athletes whose identities
the athlete is transitioning out of sport (i.e., what is are multiply determined are likely to transition most
the cause of the career termination?), the current successfully from sport to other careers and life
developmental or life factors (e.g., age, relationship pursuits.
status, level of athletic identity) that are present for Internal and external resources can influence how
the athlete, and the internal (e.g., coping skills) and athletes’ cognitively appraise the transition from
external (e.g., social support) resources that exist for sport and thus affect their emotional and behavioral
the athlete (Lavallee & Andersen, 2000). Like ath- reactions. For example, athletes who are optimistic,
letic injury, applied sport psychologists are likely to self-confident, and instrumental in their approach
work with athletes who are facing or are undergoing to life, who are able to cope effectively with life
a transition from sport while under their care, so stressors, and who have broad and deep social sup-
being aware of and able to work with these factors port systems may appraise the transition in a more
will be important when intervening. positive manner, viewing it as an opportunity to try
Athletes leave sports for voluntary (e.g., no longer a new role in their lives or as a time to reconnect
enjoy participating) and involuntary (e.g., cut from with friends and family. Thus, applied sport psy-
team) reasons. A voluntary or planned departure chologists who are working with athletes in transi-
may produce less psychological distress and be easier tion will need to assess a wide range of personal and
to handle. Many transitions from sport, though, are situational factors to accurately assess the resources
sudden or involuntary in nature, resulting from ath- that are available to the athlete. Lavallee and
letic injury, declining physical abilities, and/or being Andersen (2000) provided a list of questions applied
cut from the team for financial reasons. Because ter- sport psychologists might ask when working with
mination from sport will occur at some point in athletes in transition, such as how the athlete has
time, athletes may benefit from discussing and plan- coped with prior transitions and to what extent the
ning for this transition before it occurs. Applied athlete has achieved sport-competition goals.
sport psychologists can assist athletes (particularly Keeping these questions in mind can facilitate the
those who are at the college level and beyond) by counseling process. In addition to working individ-
helping them define their after-sport career goals ually with athletes who actually are undergoing a
and begin preparing themselves now for that change. career transition, applied sport psychologists could
Although athletes who are currently performing well intervene proactively by providing them with career
initially may resist discussions concerning the end workshops and training while they still are playing
of their career, planning in advance may be a par- in their sport, to get them thinking about and
ticularly important coping strategy for successfully preparing for what is an inevitable transition.
weathering the transition when it occurs (Lavallee &
Andersen, 2000). An Ideal Training Model for Applied
Developmental and life factors also will influ- Sport Psychology
ence athletes’ transition from sports. How old is the As discussed previously, applied sport psychology
athlete, and what other general developmental issues is an interdisciplinary profession that requires

794 sport psych o lo gy

training, knowledge, skills, and experience in the of applied sport psychology training. Ideally, sport
practice and science of both psychology and the psychology professionals-in-training would acquire
exercise/sport sciences (McCullagh & Noble, 2002; a broad knowledge base, develop a diverse set
Zizzi, Zaichkowsky, & Perna, 2002). Although of skills, and be eligible for whatever credentialing
there is agreement that sport psychology is an inter- is available to them to increase their career options
disciplinary field, there is no uniform consensus and job marketability. Doctoral graduates from
regarding the specific coursework, training experi- counseling psychology programs who have taken
ences, and necessary credentialing that should be sport psychology and exercise/sport science course-
required. In this section, we discuss current career work and been a part of extensive, supervised sport
possibilities and explore the issues of accreditation psychology practica would be ideally suited for
of training programs. We conclude by offering an entering and being successful in the applied sport
ideal training program in applied sport psychology. psychology job market.
In doing so, we acknowledge that other models and
pathways for training exist, yet we have based ours Current Perspectives on Accreditation
within counseling psychology because we believe its A major development toward the identification of
values and training are best suited, as a foundational a set of educational standards occurred in 1989,
academic environment, for training applied sport when the AASP approved an interdisciplinary certi-
psychologists. fication program that was based on obtaining a grad-
uate degree in exercise/sport science or psychology;
Current Career Possibilities completing coursework in sport psychology, psy-
Unlike other professions in psychology, detailed chology/counseling, sport science, ethics, and
data on applied sport psychology as an occupation research design/statistics or assessment; demonstrat-
are limited. However, three survey studies of sport ing competence in sport; and receiving supervision
psychology professionals and recent graduates in sport psychology practice (AASP, n.d.). The certi-
(Andersen et al., 1997; Meyers et al., 2001; Williams fication of applied sport psychology professionals
& Scherzer, 2003) indicate that their primary work generally is lauded as necessary and fundamental to
environment appears to be equally split between increase the accountability of training, recognition
academic (i.e., faculty positions in departments of of professionals, credibility of the field, preparation
psychology or exercise/sport science) and applied of professionals, and public awareness (Zaichkowsky
(e.g., private practice, hospital) settings. In addi- & Perna, 1992). As discussed previously, though,
tion, these surveys revealed that professionals with a AASP’s portfolio-based certification program pres-
full-time interest in sport psychology-related activi- ents considerable challenges to established psychol-
ties primarily are employed in exercise/sport science ogists who want to demonstrate their competence
academic positions, and that psychology-trained in sport psychology.
professionals do indeed work with athletes and in In psychology, a relatively direct link exists
sport settings. Direct applied work with athletes, between matriculating from an APA-accredited
though, does not constitute a major portion of training program and being approved to sit for
either the academic’s or the practitioner’s income or a state licensure exam (or ultimately having the
time spent in their jobs, regardless of the profes- opportunity to be “credentialed”). In sport psy-
sional’s academic background. chology, however, there is no such mechanism in
Despite these findings, there are full-time, applied place (i.e., professional organization) for accredit-
sport psychology professionals making a living (e.g., ing programs, and thus there is no established path-
Taylor, 2008; USOC, n.d.; Winerman, 2005; way or set of educational criteria for training in
Wysocki, 2005), and there has been, and likely will applied sport psychology. As a result, graduate pro-
be in the future, some growth in the availability of gram accreditation could be a useful mechanism for
full-time consulting positions at universities and improving applied sport psychology training. Silva,
among professional sport organizations. The cur- Conroy, and Zizzi (1999) presented a compelling
rent market, though, is not likely to be able to sup- argument in favor of program accreditation, citing a
port a large number of full-time applied sport number of potential benefits to the profession of
psychology practitioners, so professionals who desire sport psychology (e.g., raising of standards of train-
a career in this field would be wise to consider doing ing for future professionals, strengthening of certifi-
so, at least initially, on a supplemental, part-time cation/licensure criteria, and creation of graduate
basis. This reality also has implications for a model programs with stronger identities and greater clarity

pe t r ie , har m ison 795

of focus). Others have been more critical of the need include obtaining a master’s or doctoral-level degree
for sport psychology program accreditation, though, in sport psychology from an exercise/sport science
suggesting it is premature to pursue the issue before based training program. These programs historically
a greater need for sport psychology services has been have prepared students rather well for careers in aca-
established, with sport psychology having limited demia, with opportunities to do some part-time
status in most graduate training programs, and with performance enhancement consulting work with
high political, financial, and psychological costs athletes and teams, and in some rare cases, full-time
associated with obtaining accreditation (Hale & consulting work. In addition, exercise/sport science-
Danish, 1999). Consistent with this position, in a based training programs recently have begun to
curricular review of 79 sport psychology graduate surface that allow students to meet AASP certifica-
programs, Van Raalte et al. (2000) found that most tion criteria and also be eligible to obtain licensure/
training programs did not offer all the courses or certification as master’s level professional counsel-
experiences that would be necessary to meet existing ors. However, each of these training options restrict
credentialing criteria (i.e., AASP). Currently, there graduates in some form or another, such as limiting
are no plans among the primary sport psychology their competence (e.g., sport science trained not
organizations (i.e., AASP, APA Division 47) to able to ethically provide counseling services), reduc-
develop accreditation guidelines or criteria. Thus, ing their marketability (e.g., master’s degree-level
current graduate students are somewhat left on their counselors not eligible for jobs requiring licensure
own to determine what constitutes an ideal applied as a psychologist), and requiring additional charac-
sport psychology training program that would pre- teristics, knowledge, and skills for success (e.g.,
pare them to function competently and ethically as entrepreneurial spirit, service product development,
a professional in the field. marketing). Thus, we define doctoral-level training
in applied sport psychology as the sine qua non of
An “Ideal” Applied Sport Psychology the field, including the need for licensure, and make
Training Model the case for why we believe a doctoral program in
Because a universally accepted educational pathway counseling psychology is an ideal training environ-
leading to sport psychology professional qualifica- ment. We are fully aware of the potential implica-
tion currently does not exist, and there are no cur- tions this training model could have on other
rent plans for any professional sport psychology academic programs. That being said, we believe
organization to develop and institute an accredi- that the principles, values, and educational experi-
tation process, we offer a model of training in ences that form the foundation of our model can
applied sport psychology that is interdisciplinary, be integrated into existing training programs as
has an identified set of core values, and emphasizes well, resulting in the best possible training even for
practical training in both general mental health those students with primary (sole) interests in
issues and specific sport psychology interventions performance enhancement consulting work and/
(e.g., performance enhancement). This model can or a lesser desire or resources to pursue a doctoral
serve as a guide for the preparation of future applied degree.
sport psychology professionals, for the acquisition Our training model consists of a set of eight
of the necessary knowledge and skills, and ulti- core values, eight learning/knowledge areas, and
mately, to be eligible for existing professional cre- four primary training outcomes (see Figure 30.1).
dentials. In presenting this model, we acknowledge For us, any training model must have a defined set
the previous work completed by the sport psychol- of values that describe what is important, influence
ogy professionals who established the AASP certifi- decisions regarding students’ training experiences,
cation program, because these criteria are an integral and impact the course of action taken by program
part of the model’s curriculum. However, we also directors; in our model, those values come from
incorporate the additional knowledge base and skill counseling psychology. Enveloped by this set of
sets suggested by APA Division 47 and consider the core values are the specific learning/knowledge areas
realities of the current job market in applied sport that represent the coursework, scholarly activity,
psychology. and applied experiences that define the students’
In offering this training model, we also acknowl- training. Students’ mastery of these eight learning/
edge that several different options currently are knowledge area results in the outcomes presented
available to students who want careers in applied in the center of the model. We discuss each level
sport psychology. Most notably, these options below.

796 sport psych o lo gy

 CORE VALUES pos
rs ity itiv
er
d ive Sport ela
f or Psychology tio
Courses

ns
ct
pe

hi
Clinical/ Sport

ps
es
~r Counseling Science

~g
Practica Courses
m

row
Professional Identity,
ol is

Attitudes, Values,

th v
iation ~ mind-body h

& Behaviors
Outcome

s. pat
hology ~ enviro
Sport Clinical/
Sport Psychology Counseling Clinical/
Psychology Knowledge Knowledge Counseling
& Skills
Practica & Skills
Outcome
Courses
Outcome
med

Critical Thinking

nm
re

& Scholarly

ent
Communication
vs.

Research Outcome General

al
Courses & Psychology
ion

inf
Scholarship Courses
nt

lu
ve

en
Professional
re

ce
p Issues
s
~ ~
g Courses u lt
m
pi n ipl
co es
ce way
s of in han
tervening ~ en

Fig. 30.1 An ideal training model for applied sport psychology.

core values identities, and thus have the worldview that is con-
In the outer ring of the figure are the eight core sistent with the environmental demands of sport
values from counseling psychology (defined earlier and the experiences of athletes.
in the chapter) that provide the foundation for
students’ training experiences. These values also are learning/knowledge areas
very consistent with what applied sport psychology On the inner ring of the figure are the eight learn-
encompasses (Danish et al., 1993), including: opti- ing/knowledge areas that encompass training in the
mization of performance by eliminating obstacles essential knowledge, skills, attitudes, and behaviors
and building on existing strengths; counseling of for professional practice. These areas include an
athletes to work through the daily challenges of understanding and application of applied sport psy-
life; remediation of more severe clinical issues that chology principles and practices; physical, techni-
may emerge; development of life skills through psy- cal, and social aspects of sport behavior; abnormal
choeducation and generalization/transfer of sport aspects of human behavior and counseling inter-
experiences; prevention of and, when necessary, ventions; general human cognitions, affect, and
psychological rehabilitation from, athletic injury; behavior; professional issues and ethics; scientific
facilitating systemic change in sport organizations, methodology and scholarship activity; individual
sport teams, and coaching staffs; and promoting and group clinical/counseling skills; and individual
involvement in and enjoyment of sport throughout and group sport psychology skills. Although we
the lifespan. Because of this connection, students present each learning/knowledge area separately,
who choose counseling psychology as their founda- they are not independent areas. Rather, we view
tional educational degree (the area in which they them as reciprocally interacting knowledge areas
receive their doctorate) would be trained in and that increase individuals’ understanding of and
thus incorporate these values into their professional ability to work effectively with individuals.

pe t r ie , har m ison 797

 1. Sport psychology core. Applied sport insufficient to only be exposed to courses and
psychology is a discipline of study that is distinct experiences in counseling and clinical psychology.
but not separate from the psychological and sport Thus, a basic understanding of the complexity
sciences, and as such, a firm understanding of the of human beings and the myriad factors that
principles and practices related to sport psychology influence human cognitive processes, emotions,
is one of the core learning/knowledge areas. Thus, and actions is the fourth core learning/knowledge.
a combination of courses in applied sport Courses in the biological, cognitive-affective, and
psychology would provide students with a broad social bases of human behavior, as well as an
foundation of the science and practice of sport understanding of historical and philosophical
psychology. These courses should cover the content perspectives in psychology, would provide students
areas of intervention/performance enhancement, with a foundation in this area. Examples of specific
social psychology in sport, and health/exercise courses include physiological psychology, learning
psychology and serve as a theoretical and empirical and emotion, and social psychology.
base for practice. Examples of specific courses 5. Professional issues. Together, training in ethics,
include sport psychology theory and research, diversity, and other professional issues is
applied sport psychology interventions, team the fifth learning/knowledge area. Courses in
dynamics in sport, and psychological aspects of ethics, legal issues, and professional standards
athletic injury. of behavior, and courses that provide learning
2. Exercise/sport science core. Applied sport opportunities on understanding diversity in a
psychologists must have a basic understanding multicultural world and expanding one’s own
of how socio-environmental, physiological, self-awareness and worldview would provide
and biomechanical factors influence sport students with a foundation in the essential
performance if they are to differentiate the causes attitudes, values, and behaviors of professional
of performance decrements, such as whether a practice. Examples of specific courses include
baseball player’s poor hitting is due to poor ethical and legal issues, professional orientation,
swing mechanics or worry that is disrupting his and multicultural counseling.
attentional focus (or a combination of the two). 6. Research and scholarship. The sixth
Thus, courses in the physiological, biomechanical, knowledge/learning area concerns training in
motor, social, and/or philosophical bases of sport quantitative and qualitative research methods, the
behavior would provide a foundation of general use of statistics to analyze data, the ability to think
human performance principles. Examples of critically about complex issues/information, and
specific courses include exercise physiology, the skills to communicate findings in a coherent
biomechanics of human movement, motor and scholarly manner. Thus, courses in research
learning, and history of physical education. design and statistics in combination with
3. Counseling/clinical core. The third core supervised scholarly/research activities, such as the
learning/knowledge area concerns having a completion of a doctoral dissertation, is a central
firm understanding of personality and abnormal part of our model. Not only do these experiences
human behavior, problems in daily living, human teach students critical thinking skills, scientific
development and issues that exist across the methodology, and the ability to evaluate data, but
lifespan, and counseling theory and interventions. the process of doing their dissertation is the
A combination of courses in this area provides pathway to becoming an expert on a specific topic
students with a foundation in human psycho- and an opportunity to make a professional and
pathology, assessment of psychopathology, and scientific contribution within the field. Examples
counseling interventions that emphasize human of specific courses include applied research
development from a positive, growth-oriented methods, multivariate statistical methods, and
perspective. Examples of specific courses include qualitative research design and analysis. Examples
abnormal psychology, psychological assessment, of scholarly activities include conducting original
theories of counseling, cognitive-behavioral research, developing theoretical position papers,
therapy, human development, and counseling writing critical reviews of literature, creating
methods and skills. innovative intervention programs, and evaluating
4. General psychology core. Just as it would outcomes of existing intervention programs.
limiting to only have knowledge about the 7. Counseling/clinical practica. The seventh
psychology of sport behavior, it would be knowledge/learning area centers on the

798 sport psych o lo gy

development of individual and group counseling/ a system influence one another. Like general
therapy skills in the general mental health area. counseling practica, it is important for students to
This area represents the translation of theory and have experiences across modalities (e.g., individual,
research into actual intervention activities and is team, organization), level of sport (e.g., youth,
what most applied psychologists consider to be the collegiate), sport team (e.g., basketball, soccer),
central part of their training. These experiences and gender if at all possible. These experiences, of
with “live” clients should be supervised to guide course, should be supervised, and the supervisor
students in their work and provide them with should be experienced in applied sport psychology,
opportunities to gain self-understanding and preferably holding one of the existing credentials
awareness and acquire counseling skills in (e.g., Certified Consultant, AASP), within the
intervening with individuals, couples, families, field.
and groups who may be experiencing a wide
range of mental health issues. Specific training 0utcomes
competencies to be developed in this area At the center of the figure is a set of intersecting
include the ability to appropriately assess and circles that designate the four outcomes that ideally
conceptualize case material, evaluate one’s result from integrated training in the eight core
own reactions to client issues and therapeutic areas. The intersecting circles denote that the out-
interactions, plan and implement individual and comes are linked and interact with one another,
group interventions, and evaluate the effectiveness and it is the successful demonstration of the four
of said interventions. Students may benefit from training outcomes that represents the competently
having a broad range of experiences (e.g., type of trained applied sport psychology professional. Two
mental health service, age/gender or client, mental of the training outcomes—sport psychology and
health issue) and a diverse group of supervisors clinical/counseling knowledge and skills—result
(e.g., theoretical orientation), particularly in their from the requisite knowledge bases and skill sets
predoctoral practica. Predoctoral internship needed for effective sport psychology practice.
may offer students an opportunity to pursue Consistent with the interdisciplinary focus of our
more in-depth training in a specific domain model, applied sport psychologists need to demon-
(e.g., college counseling centers) or therapeutic strate that they are knowledgeable and skilled in the
approach (e.g., cognitive-behavioral, principles and practices of both sport psychology
interpersonal). and clinical/counseling psychology. Meeting these
8. Sport psychology practica. The eighth two training outcomes will not only ensure compe-
knowledge/learning area concerns sport tent, broadly defined sport psychology practice, but
psychology specific practica training. Although it will result in a more marketable practitioner
meeting the requirements of this core area may be eligible to be licensed as a psychologist and creden-
difficult, we believe it is important for students to tialed as a sport psychology consultant.
have supervised applied sport psychology training With the third outcome, the demonstration of a
experiences that are nearly equal to their general professional identity and essential attitudes, values,
counseling practica in terms of depth and breadth. and behaviors for professional practice, we suggest
These applied experiences provide students with that future applied sport psychologists need more
opportunities to gain experience and acquire than just knowledge and skills to be effective practi-
individual and group performance enhancement, tioners. Rather, a healthy professional identity, an
counseling/clinical, and/or consultation skills with attitude of openness and respect for others, an inter-
athletes and teams. In addition, these experiences nalization of the foundational values, and conscien-
will help students understand the connection tious and responsible ethical behavior are among
between general mental health issues and the other requirements for competent professional
performance decrements and learn to discern practice in sport psychology. Finally, effective sport
when the intervention’s focus should be on psychology practice should be based in sound theo-
general performance enhancement skills and retical and empirical science, and the fourth train-
when consultants need to help athletes address ing outcome of our model highlights the importance
their inter-/intrapersonal concerns. Furthermore, of applied sport psychology professional being good
these experiences, if with teams or organizations, scholars/scientists as well. Specifically, future applied
can provide important opportunities to learn sport psychologists need to demonstrate critical
how systems work and how components within thinking in the application of their knowledge with

pe t r ie , har m ison 799

clients, in addition to being able to communicate about what sport and exercise psychologists actually
their understanding, both orally and in writing, in a do and who they might want to seek for assistance
scholarly and informed way. with performance-based sport problems. Instead of
being linked as they are, sport psychology, which
model summary involves both science and practice, needs to be
Although we promote doctoral-level training pro- defined and pursued as its own field, one that recog-
gram in counseling psychology as the foundational nizes that its aims, goals, theories, and services are
educational environment because it prepares gradu- different from exercise psychology. A clear distinc-
ates for the necessary credentialing (i.e., licensure as tion between the two fields, as we are suggesting,
a psychologist) and puts them in the most market- would benefit both fields, in particular applied sport
able position for applied sport psychology jobs, psychology, as it moves to establish itself as a needed
we recognize and appreciate the value of different resource for athletes and coaches.
models of applied sport psychology training (e.g.,
exercise/sport science based, master’s level licensure/ Define the Scope and Practice of
certification). In addition, we know that not every Sport Psychology.
student interested in applied sport psychology Following the separation of the fields, profes-
will pursue a Ph.D. in counseling psychology, so sional organizations, particularly those closely affili-
we identified and included the core values and ated with the parent discipline of psychology (i.e.,
knowledge/learning areas in it, so that students in Division 47), need to more clearly define the scope
other training programs (e.g., exercise/sport science) and practice of the field. What do sport psycholo-
could have the opportunity to obtain the types of gists actually do? With what populations do they
training experiences that may lead to the develop- work? How do they bring about change and growth
ment of ethical, knowledgeable, competent, and in their clientele? What interventions are effective
self-aware practitioners. with which clients under what circumstances? What
defines competent practice? What makes working
Future Directions with athletes and within the sport environment
Based on our review of the literature and our many unique? What training is needed to become a com-
years in the field, we offer the following suggestions/ petent applied sport psychologist? What ethical
comments about the issues that are pressing in the issues and practices are unique to sport and must be
field and about what we think can be done to considered in ways perhaps different from traditional
advance sport psychology as a profession. psychology? Questions such as these will be impor-
tant to answer. In addition, like counseling psychol-
Separate “Exercise” from Applied ogy, sport psychology must recognize the importance
Sport Psychology of both science/research and applied practice, and
Over 20 years ago, Rejeski and Brawley (1988) encourage open communication between those who
made the argument that sport psychology was identify primarily as researchers and those who make
poorly defined, often overlapping with exercise, their livings as practitioners. Such collaborations are
health, and rehabilitation psychology. In their arti- crucial to advance knowledge, develop and test theo-
cle, they offered clear definitions of each field, com- ries, implement and evaluate treatments, and estab-
pelling arguments concerning the benefits that lish applied sport psychology as a needed resource
would come with definitional clarity, and mecha- for athletes, coaches, and sport organizations.
nisms for determining in which area research would
best fit. Unfortunately, little has changed in that Define, Evaluate, and Support
sport psychology still remains linked to exercise Ideal Models of Training
psychology despite their different foci. Such link- Although we have offered a training model in this
ages seem part of the fabric of the field, and profes- chapter, we recognize its limitations in scope and
sional organizations (e.g., Division 47, Exercise and ability to effect change. But we do hope it serves as
Sport Psychology, of the American Psychological a catalyst for academics in psychology and exercise/
Association) and journals (e.g., Journal of Sport & sport science departments (and in counseling psy-
Exercise Psychology) are illustrations of this question- chology programs) to work across departmental
able alliance. From our perspective, both fields boundaries to create dynamic, content-based train-
suffer from this marriage. For example, this linkage ing opportunities that reflect what sport psycho-
likely creates unneeded confusion for the public logists ultimately do. We also hope that models

800 sport psych o lo gy

such as ours can help us move beyond the artifi- lack of need for and public recognition of applied
cial dichotomy that exists between performance sport psychology services, in reality, these issues
enhancement and counseling/clinical issues. As a need to be addressed simultaneously. First, profes-
field, we have too long fought that battle, and the sional organizations, as we mentioned previously,
reality is that it likely is more of an issue to us than need to define the scope and practice of applied
to our consumers. There is diversity in the training sport psychology and, through that, provide a de
that professionals in sport psychology have, and facto training curriculum/model that university
everything applied sport psychologists do, whether programs can use in developing their programs.
dealing with a relational issue or helping an athlete Second, professional organizations need to establish
develop a preperformance routine, is geared toward a system through which training programs’ curri-
improving performance. The broader, and more cula can be evaluated. Third, professional organiza-
important, question is whether professionals are tions need to promote applied sport psychology
practicing within the boundaries of their training as a necessary component in the health, wellness,
and competence. and performance of athletes and sport teams.
Fourth, professional organizations need to help
Lack of Influence sport teams and organizations understand the value
In comparison to other fields, such as athletic train- of applied sport psychologists having certain train-
ing and strength and conditioning, applied sport ing (or coming from certain credentialed programs)
psychology’s role and influence in the world and holding specific credentials. If these steps are
of sport appears relatively limited. Although applied taken in concert with one another, they can pro-
sport psychology services are used at all levels of mote growth and influence in the field.
sport, there has yet to be substantial public under-
standing of (and support for) what sport psychology Evaluation of Treatments/Interventions
is, how it plays an essential role in any sport perfor- At present, very few applied sport psychology inter-
mance, and its value (in terms of time and money ventions have been evaluated to determine their
spent on it) to an athlete, team, or sport organiza- efficacy (Greenspan & Feltz, 1989; Martin et al.,
tion. This lack of influence in the public sphere may 2005). More evaluation research is needed, and the
be due to several factors, including the unneeded work of Ron Smith and his colleagues at the
connection between sport and exercise psychology, University of Washington provide a model for how
the lack of one voice (in terms of professional orga- that can be done (e.g., Smith et al., 1995). If the
nizations) that speaks for the field, and the fact that field is going to advance and raise the value of what
there is no accepted and influential credential defin- it has to offer, applied sport psychologists and
ing competence. From our perspective, a viable researchers must learn to collaborate, not only with
strategy would be for applied sport psychologist to each other, but with coaches and sport organiza-
consider rallying behind a single professional orga- tions. Applied sport psychologists must understand
nization that has the necessary power, infrastruc- the need to test and document what they do, and
ture, and influence to effect change and raise the academic researchers must be willing to get out into
status and visibility of the field. In our mind, there the field and learn from practitioners. Although
are two such influential organizations, the AASP experimental designs will remain the sine qua non
and APA Division 47. Perhaps it is time for these of scientific research, much can be learned through
organizations to merge or at least consider mecha- quasi-experimental and N-of-one methods that are
nisms for pooling resources in some meaningful conducted in the field. Applied sport psychologist
way for the broader benefits to the field. Although must work to convince coaches, parents, and other
we understand that this suggestion is anathema to gatekeepers of the value associated with participat-
some, we hope that a conversation can be started to ing in research while practicing or competing.
look at all viable options for how our professional
organizations can advance the standing and influ- Conclusion
ence of the field. Applied sport psychology is an interdisciplinary
field with roots in the exercise/sport sciences and
Credentialing (or Recognition) strong ties to psychology. Over the past 40 years, as
of Training Programs sport psychology has moved increasingly out of the
Although some (e.g., Hale & Danish, 1999) have laboratory and onto the playing field and, through
argued that credentialing is premature, given the that, recognized the importance of applied training

pe t r ie , har m ison 801

in psychology, the field has faced many challenges to References
its identity. These challenges—which have ranged Albinson, C., & Petrie, T. (2003). Cognitive appraisals, stress,
from the establishment of professional organiza- and coping: Preinjury and postinjury factors influencing
tions able to address the practice issues to creden- psychological adjustment to sport injury. Journal of Sport
Rehabilitation, 12, 306–322.
tialing and titling to graduate training—have served American Psychological Association (APA). (n.d.). Summary:
as a catalyst for growth as professionals within Sport psychology a proficiency in professional psychology.
the field have struggled to establish guidelines for Retrieved November 24, 2008, from http://www.apa.org/
ethical practice and define its future. There is a crsppp/ archsportpsych.html.
depth, breadth, and complexity within the field of American Sports Data. (2003, June). A comprehensive study of
sports injuries in the U.S. Retrieved June 6, 2008, from http://
applied sport psychology that belies its historical www.americansportsdata.com/sports_injury1.asp.
youth. Andersen, M. (Ed.) (2000). Doing sport psychology. Champaign,
Although we support the historical and present IL: Human Kinetics.
interdisciplinary structure of sport psychology, we Andersen, M. (Ed.) (2005). Sport psychology in practice.
believe that individuals wanting to engage in the Champaign, IL: Human Kinetics.
Andersen, M., Williams, J., Aldridge, T., & Taylor, J. (1997).
practice of sport psychology should be trained within Tracking the training and careers of graduates of advanced
a curriculum that is grounded in counseling psy- degree programs in sport psychology, 1989 to 1994. The
chology and its values, training, and philosophy. Sport Psychologist, 11, 326–344.
In particular, counseling psychology values are con- Association for Applied Sport Psychology. (n.d.). Become a
sistent with the breadth of issues that athletes pres- certified consultant. Retrieved October 31, 2008, from http://
appliedsportpsych.org/consultants/become-certified.
ent across the performance enhancement and Barber, H., & Krane, V. (2005). The elephant in the locker room:
clinical/interpersonal domains. That counseling psy- Opening the dialogue about sexual orientation on women’s
chology values strengths-based interventions and sports teams. In M. Andersen (Ed.), Sport psychology in prac-
prevention fits well with athletes and their focus on tice (pp. 265–285). Champaign, IL: Human Kinetics.
performance outcome. Counseling psychology Barnett, N., Smoll, F., & Smith, R. (1992). Effects of enhancing
coach-athlete relationships on youth sport attrition. The
values also address the developmental issues and Sport Psychologist, 6, 111–127.
ethical nuances inherent in effective applied sport Bloom, G., & Stevens, D. (2002). Case study: A team-building
psychology practice. As we illustrate in Figure 30.1, mental skills training program with an intercollegiate eques-
counseling psychology’s core values provide the trian team. Athletic Insight, 4. Retrieved from www.athle-
foundational structure that supports individuals’ ticinsight.com/Vol4Iss1/EquestrianTeamBuilding.htm.
Brawley, L., & Paskevich, D. (1997). Conducting team-building
pursuit of the interdisciplinary training that defines research in the context of sport and exercise. Journal of
the field. Such training and internalization of these Applied Sport Psychology, 9, 11–40.
values can lead to outcomes that we associate with Brewer, B., & Petrie, T. (2002). Psychopathology in sport and
competent and ethical practice. exercise. In J. Van Raalte, & B. Brewer (Eds.), Exploring sport
As sports become more important and popular and exercise psychology (pp. 307–323). Washington, DC:
American Psychological Association.
and as athletes and coaches continue to search for Brewer, B., Van Raalte, J., & Petitpas, A. (2000). Self-identify
the “edge” that will improve their performances, issues in sport career transitions. In D. Lavallee, &
applied sport psychology will continue to grow as a P. Wylleman (Eds.), Career transitions in sport: International
field. Counseling psychology can be at the vanguard perspectives (pp. 29–43). Morgantown, WV: Fitness
of this growth by collaborating with departments of Information Technologies.
Bull, S., Shambrook, C., James, W., & Brooks, J. (2005). Towards
exercise/sport science at their universities to create an understanding of mental toughness in elite English crick-
the interdisciplinary curriculum that is necessary to eters. Journal of Applied Sport Psychology, 17, 209–227.
train competent, ethical applied sport psychologists. Burton, D. (1990). Multimodal stress management in sport:
Current counseling psychologists, by seeking addi- Current status and future directions. In J. Jones, & L. Hardy
tional training in the exercise/sport sciences and (Eds.), Stress and performance in sport (pp. 171–201).
New York: John Wiley & Sons.
supervision from appropriately trained colleagues, Burton, D., Naylor, S., & Holliday, B. (2001). Goal-setting
also can become more involved in the field, bring- in sport: Investigating the goal effectiveness paradox.
ing their expertise and understanding of human In R. Singer, H. Hausenblas, & C. Janelle (Eds.), Handbook
growth and development, appreciation of diversity, of sport psychology (pp. 497–528), New York: Wiley.
and commitment to proactive intervention to this Carron, A., Brawley, L., & Widmeyer, W. (1998). The measure-
ment of cohesiveness in sport groups. In J. Duda
unique population. It is exciting to consider that (Ed.), Advancements in sport and exercise measurement
applied sport psychology’s ideal “home” may be (pp. 213–226). Morgantown, WV: Fitness Information
within counseling psychology. Technology.

802 sport psych o lo gy

Carron, A., Colman, M., Wheeler, J., & Stevens, D. (2002). disordered eating behaviors. Journal of American College
Cohesion and performance in sport: A meta analysis. Journal Health, 57, 489–495.
of Sport & Exercise Psychology, 24, 168–188. Greenspan, M., & Feltz, D. (1989). Psychological interventions
Carron, A., Hausenblas, H., & Eys, M. (2005). Group with athletes in competitive situations: A review. The Sport
dynamics in sport. Morgantown, WV: Fitness Information Psychologist, 3, 219–236.
Technology. Griffin, J., & Harris, M. (1996). Coaches’ attitudes, knowledge,
Carron, A., Spink, K., & Prapavessis, H. (1997). Team-building experiences, and recommendations regarding weight control.
and cohesiveness in the sport and exercise setting: Use of The Sport Psychologist, 10, 180–194.
indirect interventions. Journal of Applied Sport Psychology, 9, Griffith, C. (1926). Psychology of coaching. New York: Scribners.
61–72. Griffith, C. (1928). Psychology of athletics. New York: Scribners.
Carron, A., Widmeyer, W., & Brawley, L. (1985). The develop- Grove, J., Lavallee, D., Gordon, S., & Harvey, J. (1998).
ment of an instrument to assess cohesion in sport teams: The Account-making: A model for understanding and resolving
group environment questionnaire. Journal of Sport Psychology, distressful reactions to retirement from sport. The Sport
7, 244–266. Psychologist, 12, 52–67.
Centers for Disease Control. (2006). Sports-related injuries Hale, B., & Danish, S. (1999). Putting the accreditation cart
among high school athletes United States, 2005–06 school before the AAASP horse: A reply to Silva, Conroy, and Zizzi.
year. Morbidity and Mortality Weekly Report, 55, 1037–1040. Journal of Applied Sport Psychology, 11, 321–328.
Retrieved November 6, 2008, from http://www.cdc.gov/ Hall, C. R., Mack, D. E., Paivio, A., & Hausenblas, H. A.
mmwr/preview/mmwrhtml/mm5538a1.htm. (1998). Imagery use by athletes: Development of the
Coakley, J. (2009). Sports in society: Issues and Controversies sport imagery questionnaire. International Journal of Sport
(10th ed.). New York, NY: McGraw-Hill. Psychology, 29, 73–89.
Coatsworth, J., & Conroy, D. (2006). Enhancing the self-esteem Halliwell, W. (1990). Providing sport psychology consulting
of youth swimmers through coach training: Gender and age services in professional hockey. The Sport Psychologist, 4,
effects. Psychology of Sport & Exercise, 7, 173–192. 369–377.
Cogan, K., & Petrie, T. (1995). Sport consultation: An evalua- Hardy, J. (2006). Speaking clearly: A critical review of the self-
tion of a season-long intervention with female college talk literature. Psychology of Sport and Exercise, 7, 81–97.
gymnasts. The Sport Psychologist, 9, 282–296. Hardy, J., Gammage, K., & Hall, C. (2001). A descriptive study
Connaughton, D., Wadey, R., Hanton, S., & Jones, G. (2008). of athlete self-talk. The Sport Psychologist, 15, 306–318.
The development and maintenance of mental toughness: Hardy, L., Jones, G., & Gould, D. (1996). Understanding
Perceptions of elite performers. Journal of Sports Sciences, 26, psychological preparation for sport: Theory and practice of elite
83–95. performance. New York: John Wiley & Sons.
Conroy, D., & Coatsworth, J. (2004). The effects of coach train- Harmison, R., Hehn, M., Sims, N., & Poupeney, N. (2007,
ing on fear of failure in youth swimmers: A latent growth October). Understanding and developing mental toughness
curve analysis from a randomized, controlled trial. Journal of in sport: An application of the CAPS approach and prelimi-
Applied Developmental Psychology, 25, 193–214. nary investigation. In R. Stratton (Chair), Understanding and
Crust, L. (2007). Mental toughness in sport: A review. developing mental toughness in sport. Symposium presented at
International Journal of Sport & Exercise Psychology, 5, the 22nd annual meeting of the Association for Applied
270–290. Sport Psychology, Louisville, KY.
Danish, S., Petitpas, A., & Hale, B. (1993). Life development Harmison, R., & Roth, R. (2006, September). Mental toughness:
interventions for athletes: Life skills through sport. The Developing determined, focused, and confident athletes that per-
Counseling Psychologist, 21, 352–385. form under pressure. Colloquium presented at the 21st annual
Dorfman, H. (1990). Reflections on providing personal and per- meeting of the Association for the Advancement of Applied
formance enhancement consulting services in professional Sport Psychology, Miami, FL.
baseball. The Sport Psychologist, 4, 341–346. Hausenblas, H. A., & Carron, A. V. (1999). Eating disorder
Dosil, J. (2006). The sport psychologist’s handbook: A guide for indices and athletes: An integration. Journal of Sport &
sport-specific performance enhancement. Chichester, UK: John Exercise Psychology, 21, 230–258.
Wiley & Sons. Hausenblas, H., & Symons Downs, D. (2001). Comparison
Dunn, J., & Holt, N. (2004). A qualitative investigation of a of body image between athletes and nonathletes: A meta-
personal-disclosure mutual-sharing team building activity. analytic review. Journal of Applied Sport Psychology, 13,
The Sport Psychologist, 18, 363–380. 323–339.
Feltz, D. (1987). The future of graduate education in sport and Hays, K. (2002). Putting sport psychology into (your) practice.
exercise science: A sport psychology perspective. Quest, 39, Professional Psychology: Research and Practice, 26, 33–40.
217–223. Hays, K. (2006). Being fit: The ethics of practice diversification
Gardner, F., & Moore, Z. (2006). Clinical sport psychology. in performance psychology. Professional Psychology: Research
Champaign, IL: Human Kinetics. and Practice, 37, 223–232.
Gill, D. (1986). Psychological dynamics of sport. Champaign, IL: Holmes, P., & Collins, D. (2001). The PETTLEP approach
Human Kinetics. to motor imagery: A functional equivalence model for
Gould, D., Murphy, S., Tammen, V., & May, J. (1991). sport psychologists. Journal of Applied Sport Psychology, 13,
An evaluation of U.S. Olympic sport psychology consultant 60–83.
effectiveness. The Sport Psychologist, 5, 111–127. Holt, N., & Dunn, J. (2006). Guidelines for delivering personal-
Greenleaf, C., Petrie, T., Carter, J., & Reel, J. (2009). disclosure mutual-sharing team building interventions. The
Female collegiate athletes: Prevalence of eating disorders and Sport Psychologist, 20, 348–367.

pe t r ie , har m ison 803

Hootman, J., Dick, R., & Agel, J. (2007). Epidemiology of Middleton, S., Marsh, H., Martin, A., Richards, G., & Perry, C.
collegiate injuries for 15 sports: Summary and recommenda- (2004). Discovering mental toughness: A qualitative study of
tions for injury prevention initiatives. Journal of Athletic mental toughness in elite athletes. Self Research Centre
Training, 42, 311–319. Biannual Conference, Berlin. Retrieved from http://self.uws.
Howard, G. (1992). Behold our creation! What counseling edu.ou/Conferences/2004_Middleton_Marsh_Martin-
psychology has become and might yet become. Journal of Richards_Perryb.pdf.
Counseling Psychology, 39, 419–442. Mischel, W., & Shoda, Y. (1995). A cognitive-affective system
Howard, G. (1993). Sport psychology: An emerging domain for theory of personality: Reconceptualizing situations, disposi-
counseling psychologists. The Counseling Psychologist, 21, tions, dynamics, and invariance in personality structure.
349–351. Psychological Review, 102, 246–268.
Johnson, U., Ekengren, J., & Andersen, M. (2005). Injury Morgan, W. (1997). Mind games: The psychology of sport.
prevention in Sweden: Helping soccer players at risk. Journal In D. Lamb, & R. Murray (Eds.), Optimizing sport perfor-
of Sport & Exercise Psychology, 27, 32–38. mance (pp. 1–62). Carmel, IN: Cooper.
Jones, G., Hanton, S., & Connaughton, D. (2002). What is Mullen, B., & Cooper, C. (1994). The relation between group
this thing called mental toughness? An investigation of elite cohesiveness and performance: An integration. Psychological
sport performers. Journal of Applied Sport Psychology, 14, Bulletin, 115, 210–227.
205–218. Murphy, S., Nordin, S., & Cumming, J. (2008). Imagery in
Joyce, N., & Baker, D. (2008). The early days of sport sport, exercise, and dance. In T. S. Horn (Ed.), Advances in
psychology. Monitor on Psychology, 39(7), 28–29. sport psychology (pp. 297–324). Champaign, IL: Human
Kansas Jayhawks. (n.d.). Sports psychologist joins Kansas Athletics. Kinetics.
Retrieved November 27, 2008, from http://kuathletics.cstv. Nideffer, R. (1984). Current concerns in sport psychology.
com/genrel/042706aab.html. In J. Silva, & R. Weinberg (Eds.), Psychological foundations of
Krane, V., & Williams, J. (2006). Psychological characteristics sport (pp. 35–44). Champaign, IL: Human Kinetics.
of peak performance. In J. Williams (Ed.), Applied sport psy- Ogilvie, B., & Tutko, T. (1966). Problem athletes and how to
chology: Personal growth to peak performance (pp. 207–227). handle them. London: Pelham.
New York: McGraw-Hill. Orlick, T., & Partington, J. (1987). The sport psychology
Landin, D. (1994). The role of verbal cues in skill learning. consultant: Analysis of critical components as viewed
Quest, 46, 299–313. by Canadian Olympic athletes. The Sport Psychologist, 1,
Lavallee, D., & Andersen, M. (2000). Leaving sport: Easing 4–17.
career transitions. In M. Andersen (Ed.), Doing sport psychol- Perna, F. M., Antoni, M. H., Baum, A., Gordon, P., &
ogy (pp. 249–260). Champaign, IL: Human Kinetics. Schneiderman, N. (2003). Cognitive behavioral stress
Leffingwell, T., Wiechman, S., Smith, R., Smoll, F., & management effects on injury and illness among competitive
Christensen, D. (2001). Sport psychology training within a athletes: A randomized clinical trial. Annals of Behavioral
clinical psychology training program and a department of Medicine, 25, 66–73.
intercollegiate athletics. Professional Psychology: Research and Petitpas, A., Giges, B., & Danish, S. (1999). The sport
Practice, 32, 531–536. psychologist – athlete relationship: Implication for training.
Lutz, D. (1990). An overview of training models in sport The Sport Psychologist, 13, 344–357.
psychology. The Sport Psychologist, 4, 62–71. Petrie, T. (1993). Coping resources, competitive trait anxiety,
Maddison, R., & Prapavessis, H. (2005). A psychological and playing status: Moderating effects on the life stress-injury
approach to the prediction and prevention of athletic injury. relationship. Journal of Sport & Exercise Psychology, 15,
Journal of Sport & Exercise Psychology, 27, 289–310. 261–274.
Martin, K., Moritz, S., & Hall, C. (1999). Imagery use in sport: Petrie, T. (2007). Using counseling groups in the rehabilitation
A literature review and applied model. The Sport Psychologist, of athletic injury. In D. Pargman (Ed.), Psychological bases of
13, 245–268. sport injuries (pp. 191–216). Morgantown, WV: Fitness
Martin, G., Vause, T., & Schwartzman, L. (2005). Experimental Information Technology.
studies of psychological interventions with athletes in com- Petrie, T., & Diehl, N. (1995). Sport psychology in the
petitions: Why so few? Behavior Modification, 29, 615–641. profession of psychology. Professional Psychology: Research
McCullagh, P., & Noble, J. (2002). Education for becoming a and Practice, 26, 288–291.
sport psychologist. In J. Van Raalte, & B. Brewer (Eds.), Petrie, T., Diehl, N., & Watkins, C. (1995). Sport psychology:
Exploring sport and exercise psychology (pp. 439–457). An emerging domain in the counseling psychology profes-
Washington, DC: American Psychological Association. sion? The Counseling Psychologist, 23, 535–545.
Meyers, A. (1997). Sport psychology service to the United States Petrie, T., Greenleaf, C., Reel, J., & Carter, J. (2008). Prevalence
Olympic Festival: An experiential account. The Sport of eating disorders and disordered eating behaviors among
Psychologist, 11, 454–468. male collegiate athletes. Psychology of Men and Masculinity, 9,
Meyers, A., Coleman, J., Whelan, J., & Mehlenbeck, R. (2001). 267–277.
Examining careers in sport psychology: Who is working and Petrie, T., Greenleaf, C., Reel, J., & Carter, J. (in press).
who is making money? Professional Psychology: Research and An examination of psychosocial correlates of disordered
Practice, 32, 5–11. eating among female collegiate athletes. Research Quarterly
Meyers, A., Whelan, J., & Murphy, S. (1996). Cognitive for Exercise & Sport, 80, 621–632.
behavioral strategies in athletic performance enhancement. Petrie, T., & Perna, F. (2004). Psychology of injury: Theory,
In M. Hersen, R. Eisler, & P. Miller (Eds.), Progress in research, and practice. In T. Morris & J. Summers (Eds.),
behavior modification (pp. 137–164). Pacific Grove, CA: Sport psychology: Theory, applications and issues (pp. 547–571).
Brooks/Cole. Queensland, Australia: Wiley & Sons.

804 sport psych o lo gy

Petrie, T., & Sherman, R. (2000). Counseling athletes with Stice, E., Presnell, K., Gau, J., & Shaw, H. (2007). Testing
eating disorders: A case example. In M. Andersen (Ed.), mediators of intervention effects in randomized controlled
Doing sport psychology (pp. 121–138). Champaign, IL: trials: An evaluation of two eating disorder prevention
Human Kinetics. programs. Journal of Consulting and Clinical Psychology, 75,
Petrie, T., & Utley-Hamson, J. (in press). Psychosocial anteced- 20–32.
ents of and responses to athletic injury. In T. Morris, & Straub, W., & Hinman, D. (1992). Profiles and professional
P. Terry (Eds.), Sport psychology: Theory, applications and perspectives of 10 leading sport psychologists. The Sport
issues (3rd ed.). Morgantown, WV: Fitness Information Psychologist, 6, 297–312.
Technologies. Sundgot-Borgen, J., & Torstveit, M. K. (2004). Prevalence of
Petrie, T., & Watkins, C. (1994). Sport psychology training in eating disorders in elite athletes is higher than in the general
counseling psychology programs: Is there room at the inn? population. Clinical Journal of Sports Medicine, 14, 25–32.
The Counseling Psychologist, 22, 335–341. Taylor, J. (2008). Prepare to succeed. Private consulting in
Prapavessis, H., Carron, A., & Spink, K. (1996). Team-building applied sport psychology. Journal of Clinical Sport Psychology,
in sport. International Journal of Sport Psychology, 27, 2, 160–177.
269–285. Thompson, R., & Sherman, R. (1999). “Good athlete” traits and
Rejeski, W., & Brawley, L. (1988). Defining the boundaries of characteristics of anorexia nervosa: Are they similar? Eating
sport psychology. The Sport Psychologist, 2, 231–242. Disorders, 7, 181–190.
Sanborn, C., Horea, M., Siemers, B., & Dieringer, K. (2000). Thompson, R., & Sherman, R. (2010). Eating disorders in sport.
Disordered eating and the female athlete triad. Clinics in New York: Routledge.
Sport Medicine, 19, 199–213. Tod, D., & Andersen, M. (2005). Success in sport psych:
Senécal, J., Loughead, T., & Bloom, G. (2008). A season-long Effective sport psychologists. In S. Murphy (Ed.), The sport
team-building intervention: Examining the effect of team psychology handbook (pp. 305–314). Champaign, IL: Human
goal setting on cohesion. Journal of Sport & Exercise Psychology, Kinetics.
30, 186–199. Van Raalte, J., Brown, T., Brewer, B., Avondoglio, J.,
Silva, J., Conroy, D., & Zizzi, S. (1999). Critical issues confront- Hartmann, W., & Scherzer, C. (2000). An on-line survey
ing the advancement of applied sport psychology. Journal of of graduate course offerings satisfying AAASP certification
Applied Sport Psychology, 11, 298–320. criteria. The Sport Psychologist, 14, 98–104.
Singer, R. (1989). Applied sport psychology in the United States. Vealey, R. (2007). Mental skills training in sport.
Journal of Applied Sport Psychology, 1, 61–80. In G. Tenenbaum, & R. C. Eklund (Eds.), Handbook of sport
Smith, A., & Petrie, T. (2008). Reducing the risk of disordered psychology (pp. 287–309). Hoboken, NJ: John Wiley &
eating among female athletes: A test of alternative interven- Sons.
tions. Journal of Applied Sport Psychology, 20, 392–407. Vealey, R., & Greenleaf, C. (2006). Seeing is believing:
Smith, R. (1989). Applied sport psychology in the age of account- Understanding and using imagery in sport. In J. Williams
ability. Journal of Applied Sport Psychology, 1, 166–180. (Ed.), Applied sport psychology: Personal growth to peak perfor-
Smith, R. (2006). Understanding sport behavior: A cognitive- mance (pp. 306–348). New York: McGraw-Hill.
affective processing systems approach. Journal of Applied Voight, M., & Callaghan, J. (2001). A team building interven-
Sport Psychology, 18, 1–27. tion program: Application and evaluation with two univer-
Smith, R., Smoll, F., & Barnett, N. (1995). Reduction of chil- sity soccer teams. Journal of Sport Behavior, 24, 420–431.
dren’s sport performance anxiety through social support and Waite, B., & Pettit, M. (1993). Work experiences of graduates
stress-reduction training for coaches. Journal of Applied from doctoral programs in sport psychology. Journal of
Developmental Psychology, 16, 125–142. Applied Sport Psychology, 5, 234–250.
Smith, R., Smoll, F., & Curtis, B. (1979). Coach effectiveness Weinberg, R., & Gould, D. (2007). Foundations of sport and
training: A cognitive-behavioral approach to enhancing rela- exercise psychology. Champaign, IL: Human Kinetics.
tionship skills in youth sport coaches. Journal of Sport Weinberg, R., Harmison, R., Rosenkranz, R., & Hookom, S.
Psychology, 1, 59–75. (2005). Goal setting. In J. Taylor, & G. Wilson (Eds.),
Smolak, L., Murnen, S. K., & Ruble, A. E. (2000). Female Applying sport psychology: Four perspectives (pp. 101–116).
athletes and eating problems: A meta-analysis. International Champaign, IL: Human Kinetics.
Journal of Eating Disorders, 27, 371–380. Williams, J., & Harris, D. (2006). Relaxation and energizing
Smoll, F., & Smith, R. (1984). Leadership research in youth sports. techniques for regulation of arousal. In J. Williams (Ed.),
In J. Silva, & R. Weinberg (Eds.), Psychological foundations of Applied sport psychology: Personal growth to peak performance
sport (pp. 371–386). Champaign, IL: Human Kinetics. (pp. 285–305). New York: McGraw-Hill.
Smoll, F., Smith, R., Barnett, N., & Everett, J. (1993). Williams, J., & Scherzer, C. (2003). Tracking the training
Enhancement of children’s self-esteem through social sup- and careers of graduate of advanced degree programs in sport
port training for youth sport coaches. Journal of Applied psychology, 1994 to 1999. Journal of Applied Sport Psychology,
Psychology, 78, 602–610. 15, 335–353.
Stein, R., Saelens, B., Dounchis, J., Lewczyk, C., Swenson, A., & Winerman, L. (2005). Psychology in the stadium. Monitor on
Wifley, D. (2001). Treatment of eating disorders in women. Psychology, 36, 50.
The Counseling Psychologist, 29, 695–732. Wysocki, B. (2005, September, 25). It’s a living: For a sports
Stevens, D., & Bloom, G. (2003). The effect of team building on psychologist, life is a nonstop consultation. Wall Street
cohesion. Avante, 9, 43–54. Journal, p. B1.
Stice, E. (2002). Risk and maintenance factors for eating pathol- Yukelson, D. (1997). Principles of effective team building inter-
ogy: A meta-analytic review. Psychological Bulletin, 128, ventions in sport: A direct services approach at Penn State
825–848. University. Journal of Applied Sport Psychology, 9, 73–96.

pe t r ie , har m ison 805

Zaichkowsky, L., & Perna, F. (1992). Certification of consul- Zizzi, S., Zaichkowsky, L., & Perna, F. (2002). Certification
tants in sport psychology: A rebuttal to Anshel. The Sport in sport and exercise psychology. In J. L. Van Raalte, &
Psychologist, 6, 287–296. B. W. Brewer (Eds.), Exploring sport and exercise psychology
Ziegler, T. (1987). Effects of stimulus cueing on the acquisition (pp. 459–477). Washington, DC: American Psychological
of groundstrokes by beginning tennis players. Journal of Association.
Applied Behavior Analysis, 20, 405–411.

806 sport psych o lo gy

 CHAPTER

31 Trauma Psychology

Patricia A. Frazier

Abstract
The purpose of this chapter is to review research on the prevalence of traumatic life events, risk
factors for exposure to traumatic events, the psychological effects of traumatic life events, risk factors
for posttraumatic stress disorder (PTSD), the effectiveness of interventions for PTSD, and
posttraumatic growth. This research suggests that virtually everyone experiences a traumatic event in
their lifetime, although some individuals are more at risk for exposure than are others (e.g., members
of racial minority groups). Although the vast majority of people exposed to traumatic events do not
develop PTSD, several individual (e.g., gender), trauma-related (e.g., event type), and posttrauma
(e.g., social support) factors are reliably associated with greater risk. There are several effective
psychotherapeutic interventions for PTSD, including exposure therapies and cognitive-behavioral
therapies (CBT). Most individuals who have experienced traumatic events report that the event led to
positive changes in their lives, although recent evidence suggests that self-reported growth may not be
associated with actual positive changes from pre- to posttrauma. Future research directions related to
each of these topics are discussed.
Keywords: trauma, posttraumatic stress disorder, posttraumatic growth

Many people grow up believing that bad things These events often happen to “normal” people, and
do not happen to good people. Unfortunately, bad most people recover from them without developing
things happen to everyone. Friends and loved ones diagnosable psychological disorders. As a result, the
die. Life-threatening illnesses develop. Long-term study of the prevalence and effects of traumatic
marriages dissolve, sometimes unexpectedly. events fits squarely within counseling psychology’s
The purpose of this chapter is to review research emphasis on the normal range of human function-
on the prevalence of these kinds of traumatic life ing and positive adaptation. In addition, because of
events, who is most at risk of experiencing traumatic the ubiquity of trauma, counseling psychologists in
events, how these events affect people for better or practice are almost certain to work with trauma sur-
for worse, factors that are related to better or worse vivors, and several psychotherapeutic interventions
adjustment to traumatic events, and the effective- that can be delivered by counseling psychologists
ness of interventions that have been developed to are effective in ameliorating the effects of trauma.
help people overcome the effects of traumatic events. Thus, to be effective practitioners, it is imperative
The chapter will conclude with a discussion of future for counseling psychologists to be knowledgeable
directions in research on these topics. about the prevalence and effects of, and interven-
These topics are particularly relevant to counsel- tions for, trauma (Courtois & Gold, 2009).
ing psychology for several reasons. As this chapter The literature on trauma is vast. For example,
will illustrate, virtually everyone experiences at a PsychInfo search using the keyword “trauma” con-
least one traumatic event in his or her lifetime. ducted in February 2009 yielded 15,668 hits just
807
since 2002. Thus, the coverage of topics within the events that involved actual or threatened death or
broad areas mentioned above necessarily will be serious injury, or a threat to the physical integrity
selective. In choosing topics to cover within each sec- of self or others” (Criterion A1) and “the per-
tion, research and issues congruent with the tra- son’s response involved intense fear, helplessness, or
ditional foci of counseling psychology, such as diver- horror” (Criterion A2) (APA, 2000, p. 467). Several
sity, strengths, and individual differences, are examples of qualifying events are listed in the DSM-
highlighted. The focus also is on research on longer- IV-TR for the three categories of directly experienced
term effects of trauma rather than immediate reac- (e.g., combat, violent personal assault, life-threatening
tions. Within particular topics, the goal was to illness), witnessed (e.g., observing the serious injury
introduce the reader to the key studies in the area or unnatural death of another person due to violent
and the most recent meta-analyses, when available. assault or accident), and confronted events (e.g., seri-
ous accident, sudden unexpected death of a close
Brief History of Research on Trauma friend or family member).
Although the effects of traumatic events on people
have been noted in literature throughout history Trauma Prevalence
(Friedman, Resick, & Keane, 2007; van der Kolk, The following section contains a review of the results
2007), interest in the effects of trauma within psy- of large-scale epidemiological studies of trauma prev-
chology and psychiatry is more recent and has waxed alence among community samples (see Table 31.1).
and waned, even within this more recent history To narrow the scope, studies of children and adoles-
(Courtois & Gold, 2009; van der Kolk, 2007). The cents were excluded, as were studies that focused
first edition of the Diagnostic and Statistical Manual only on specific events, such as spousal abuse. Studies
of Mental Disorders (DSM-I; American Psychiatric of life events that generally are not considered trau-
Association [APA], 1952) contained the diagnosis matic (e.g., repeating a grade in school) also were
of gross stress reaction for people who were previ- excluded. Because many counseling psychologists
ously well-adjusted but who had symptoms follow- work in educational settings as faculty members or as
ing extreme stressors such as combat. Interestingly, counselors (Munley, Pate, & Duncan, 2008), studies
this diagnosis was dropped from the DSM-II (APA, of trauma prevalence among undergraduate students
1968), which was published at the height of the also are reviewed (see Table 31.2). Studies that assess
Vietnam War. During the 1970s, several factors exposure using traumatic event checklists rather than
converged to bring increased attention to the issues studies that ask a screening question (e.g., Have you
faced by trauma survivors. Most notable among ever experienced something traumatic?) will be high-
these was recognition of the problems faced by lighted because the former method yields higher
Vietnam veterans returning from the war and recog- and presumably more accurate trauma prevalence
nition, spurred by the women’s movement, of the rates than does the latter (Breslau, 2002; see Peirce,
prevalence of violence against women (e.g., sexual Burke, Stoller, Neufeld, & Brooner, 2009, for a com-
assault, sexual abuse, domestic violence). parison of the two methods). Using trauma check-
Because the symptoms and problems reported by list measures also is now standard practice in the field
female survivors of sexual violence were very similar (Breslau, 2002). This section concludes with a sum-
to those reported by Vietnam veterans, when the mary and critique of studies on trauma prevalence.
posttraumatic stress disorder (PTSD) diagnosis was
first introduced in the DSM-III (1980), reactions to Trauma Prevalence in Community Samples
all traumatic events were described under one cate- One of the largest and best-known studies of trauma
gory. Traumatic events were defined as events that prevalence in the United States is the National
were outside the range of usual human experience Comorbidity Survey (NCS; Kessler, Sonnega,
that would be very distressing to almost anyone, and Bromet, Hughes, & Nelson, 1995). In the NCS, a
symptom criteria were outlined and further refined nationally representative sample of adults in the
in the DSM-III-R (APA, 1987). The definition of a United States was surveyed regarding various mental
trauma was changed in the DSM-IV (APA, 1994) disorders, including PTSD. As part of the assess-
and DSM-IV-TR (APA, 2000) to focus on the sub- ment of PTSD, respondents were asked whether
jective experience of the event. Specifically, accord- they had experienced several traumatic events (e.g.,
ing to the DSM-IV-TR, an individual has been combat, rape), all of which qualified as traumas
exposed to a traumatic event if she or he “has experi- according to the DSM-III-R (APA, 1987). Sixty-one
enced, witnessed, or was confronted with an event or percent of the male respondents and 51% of the

808 tr aum a psych o lo g y

Table 31.1. Epidemiological Studies of Trauma and Posttraumatic Stress Disorder (PTSD) Prevalence
Authors Sample Trauma Measure Trauma PTSD Measure PTSD Prevalence PTSD Prevalence for
Prevalence for Exposed Sample Total Sample
Breslau et al. Random sample of 2,181 adults 19 events grouped into 90% DIS DSM-IV Lifetime, for random N/A
(1998) aged 18–45 in Detroit, MI (N = 2,181) 4 categories event (9%); for worst
event (14%)
Creamer et al. Representative sample of 10,641 adults in 9 events plus “other” event men 64%, CIDI DSM-IV N/A 12-month, for worst
(2001) Australia and any “confronted” women 49% PTSD module event (1%)
event
Elliott (1997) National, stratified, random sample 13 events grouped into 72% N/A N/A N/A
of 505 adults aged 18–90 in U.S. 3 categories
Frans et al. Random sample of 1,824 adults aged 7 events plus “other” 81% PTSD Checklist Lifetime, for worst Lifetime, for worst event
(2005) 18–70 in Sweden event (PCL) DSM-IV event (7%) (6%)
Kessler et al. Stratified random sample of 5,887 11 events plus 1 “other” men 61%, Revised DIS Lifetime for worst Lifetime for worst
(1995) adults aged 15–54 in U.S. event women 51% DSM-III-R event (8% for men, event (8%)
20% for women)
Kessler, Berglund, Stratified random sample of 5,692 9 events plus “other” event N/A CIDI DSM-IV N/A Lifetime for worst
et al. (2005) adults over age 18 in U.S. and any “confronted” event PTSD module event (7%)
Kessler, Chiu, Stratified random sample of 5,692 9 events plus “other” event N/A CIDI DSM-IV N/A 12-month, worst
et al. (2005) adults over age 18 in U.S. and any “confronted” event PTSD module event (4%)
Norris (1992) 1000 adults over age 18 in 4 cities in 9 events (besides Hurricane 69% Nonstandard Lifetime (7%) Lifetime (6%)
SE U.S. affected by Hurricane Hugo Hugo) measure;
DSM-III-R
Perkonigg et al. Random sample of 3,021 adolescents and 10 events plus “other” 21% CIDI DSM-IV Lifetime, for worst Worst event, lifetime (1%);
(2000) young adults aged 14–24 in Munich, Germany event PTSD module event (8%) past 12-months (1%)
Resnick et al. Representative sample of 4,008 women 4 types of crime and one 69% NWS PTSD Lifetime (18%); Lifetime (12%); past
(1993) age 18 or older in the U.S. category of noncrime module - DSM- past 6-month (7%) 6-months (5%)
events III-R
Stein et al. Random sample of 1,002 adults age 11 events plus “other” women 74%, Modified PTSD N/A Past month, worst
(1997) 18 or older in Winnipeg, Manitoba, event men 81% Symptom Scale, event (1% for men, 3% for
Canada DSM-IV women)
DIS, Diagnostic Interview Schedule; CIDI, Composite International Diagnostic Interview; NWS, National Women’s Study.
Table 31.2. Studies of Trauma and Posttraumatic Stress Disorder (PTSD) Prevalence in Undergraduate Samples
Authors Sample Trauma Measure Trauma PTSD Measure PTSD Prevalence PTSD Prevalence
Prevalence For Exposed Sample for Total Sample
Amir and Sol (1999) Ben Gurion University, 10 events (many 67% Self-report PTSD Past month (6%) Past month (4%)
Israel (N = 983) military-related), measure, DSM-IV
plus other event
Bernat et al. (1998) University of Georgia 17 events 67% Impact of Event Past week, worst Past week, worst
(N = 937) Scale-Revised, event (12%) event (4%)
DSM-IV
Daugherty (1998) Freshman male military 24 unspecified events 91% Modified PTSD N/A N/A
students (N = 515) symptom scale
Frazier, Anders, et al. Four Universities in US 22 events plus “other” 85% PTSD Checklist - Past 2 weeks, worst Past 2 weeks, worst
2009 (N = 1,528) event Specific Version, event (6%) event (5%)
DSM-IV
Goodman et al. (1998) Large Eastern University 11 events and 2 72% N/A N/A N/A
(N = 202) “other” events
Green et al. (2000) Sophomore women 11 events and 2 65% Trauma Symptom N/A N/A
at 6 colleges in “other” events Inventory
Washington DC
area (N = 2,507)
Kirk and Dollar (2002) Rural University in 11 events 68% N/A N/A N/A
Georgia (N = 234)
Owens and Chard Southern University 10 events 52% Modified PTSD N/A N/A
(2006) (N = 221) symptom scale,
DSM-IV
Scarpa (2001) Rural Western 16 witnessed and 96% (witnessed); N/A N/A N/A
college (N = 476) 9 experienced events 82% (experienced)
of community
violence
Scarpa et al. (2002) Unspecified University 16 witnessed and 93% (witnessed); N/A N/A N/A
(N = 518) 9 experienced events 76% (experienced)
of community
violence
Vrana and Lauterbach Unspecified University 11 events plus 2 84% Impact of Event N/A N/A
(1994) (N = 440) “other” events Scale, Mississippi
Scale, DSM-III-R
Watson and Haynes University of Hawaii, 22 events plus 94% Distressing Event Past month, worst N/A
(2007) female students “other” event Questionnaire, event (12%)
seeking medical DSM-IV
care (N = 339)
Unless stated otherwise, samples include male and female students in United States.
female respondents reported having experienced at trauma checklist measure that assessed a wide range
least one of these events in their lifetime, and most of events. The vast majority of the sample (85%)
had experienced more than one event. The most reported experiencing at least one event during their
common events were witnessing someone being lifetime. The unexpected death of a close friend or
badly injured or killed; experiencing a fire, flood or loved one, a life-threatening event that happened
disaster; or being involved in a life-threatening acci- to a loved one, and witnessing family violence were
dent. Other studies that have assessed nationally rep- the most common events. The average number of
resentative samples in the United States also reveal lifetime events reported was 2.79.
high rates (69%–72%) of trauma exposure (Elliott, Approximately ten other studies have assessed
1997; Resnick, Kilpatrick, Dansky, Saunders, & lifetime trauma prevalence among undergraduate
Best, 1993). students, primarily in the United States. All of these
Other studies have assessed trauma exposure in studies indicated that the majority of students
random samples of adults in cities in the United States (52%–96%) reported having experienced a trau-
and Canada (as opposed to national samples). For matic event in their life time. High rates (76%–96%)
example, Breslau et al. (1998) surveyed a large com- were reported in two studies that assessed witness-
munity sample of adults in the Detroit metropolitan ing or experiencing community violence (Scarpa,
area regarding exposure to 19 different events. Using 2001; Scarpa et al., 2002), and in two studies that
this list of events, 90% of the sample reported experi- assessed a broad range of traumatic events (Vrana &
encing at least one event, with an average of almost Lauterbach, 1994; Watson & Haynes, 2007). Some-
five lifetime events. The higher rate of trauma expo- what lower trauma prevalence rates (52%–72%)
sure in this study was likely due to the inclusion of were reported in six studies that assessed a narrower
sudden death of a close loved one, which was reported range of potentially traumatic events (Amir & Sol,
by 60% of the sample. Studies in the southeastern 1999; Bernat, Ronfeldt, Calhoun, & Arias, 1998;
United States (Norris, 1992) and in Winnipeg, Goodman, Corcoran, Turner, Yuan, & Green, 1998;
Canada (Stein, Walker, Hazen, & Forde, 1997) also Green et al., 2000; Kirk & Dollar, 2002; Owens
yielded high (69%–81%) trauma exposure rates. & Chard, 2006). For example, Owens and Chard
Three other studies have assessed trauma preva- did not include any events that happened to close
lence in representative samples outside of the United friends or family members (e.g., life-threatening
States and Canada. Studies in Australia (Creamer, illness, unexpected death).
Burgess, & McFarlane, 2001) and Sweden (Frans,
Rimmö, Åberg, & Fredrikson, 2005) yielded fairly Summary and Critique
high rates of trauma exposure (49%–81%). The It is clear from this review that most people report
trauma prevalence rate in a study of young adults having experienced a traumatic event in their life-
(aged 14–24) in Munich, Germany (Perkonigg, time and that many people report having experi-
Kessler, Storz, & Wittchen, 2000) was much lower enced more than one traumatic event. However, the
(21%). The authors attributed this to the fact that lifetime trauma prevalence rates do vary consider-
Germany has few natural disasters, very restrictive ably. For example, in large-scale epidemiological
weapons laws, and much lower crime rates than the studies in the United States, trauma prevalence rates
United States. ranged from 51% of women in the NCS (Kessler
et al., 1995) to 90% of the total sample in the
Trauma Prevalence in Undergraduate Detroit area study (Breslau et al., 1998). Similarly,
Samples in studies of college students, rates ranged from
There have been no studies of trauma exposure among approximately 50% (Owens & Chard, 2006) to
undergraduate students in the United States using over 90% (Daugherty, 1998; Scarpa, 2001, 2002;
nationally representative samples (see Table 31.2). Watson & Haynes, 2007). Because the specific
Most studies of the prevalence of traumatic events events that were assessed varied across studies, it is
among undergraduate students sample students in difficult to say which events were most common.
one geographic area, and typically at one campus. Part of this variability in trauma prevalence rates
One of the largest studies of trauma prevalence owes to the lack of consistency across studies in how
among undergraduate students was recently com- traumas are defined and assessed. Which specific
pleted by a multisite team of investigators (Frazier, events are assessed greatly influences overall trauma
Anders, et al., 2009). In this study, 1,528 students prevalence rates. For example, studies that do not
at four U.S. universities completed a validated include the sudden death of a loved one as a trauma

812 tr aum a psych o lo g y

report much lower trauma prevalence rates because In summary, although these studies consistently
sudden death is the most commonly reported event suggest that the majority of people experience at
in studies that do assess it (see e.g., Breslau et al., least one and probably multiple traumatic events in
1998; Frazier, Anders, et al., 2009). More consistent their lifetime, additional studies are needed that
use of validated trauma checklists would greatly assess trauma exposure in representative samples;
facilitate comparison of trauma prevalence across that assess a wide range of traumatic events, includ-
studies. Even unvalidated checklists are preferable ing the sudden unexpected death of close friends or
to open-ended screening questions that ask whether relatives; that use well-validated trauma exposure
the respondent has experienced anything traumatic measures; and that assess trauma exposure both
which, as noted, result in much lower trauma preva- retrospectively and prospectively.
lence rates (e.g., 39%; Breslau, Davis, Andreski, &
Peterson, 1991). Using a validated checklist resulted Individual Differences in Trauma Exposure
in a nine-times higher trauma prevalence rate than Even though overall trauma prevalence rates are
did using an open-ended screening question in one high, it is nevertheless the case that some people are
recent study (Peirce et al., 2009). at greater risk for trauma exposure than are others.
Another limitation of most studies of trauma Because of the strong interest among counseling
prevalence is that they assess lifetime event exposure psychologists in issues related to diversity, differences
retrospectively. This is problematic because individ- in trauma exposure related to gender, ethnicity,
uals may not accurately remember what they have socioeconomic status (SES), and age are highlighted.
experienced (see Rubin, Berntsen, & Bohni, 2008, Information about the demographic distribution
for a review of research related to memory and of stressful life events can help to identify groups
PTSD). For example, in a study in which soldiers at greatest risk of exposure, which can then guide
were asked to report on stressful experiences while further research and prevention efforts.
in the military both after their return and a few
years later, reports of stressful-event exposure Gender Differences in Trauma Exposure
increased over time, particularly among those who There is a great deal of interest in gender differences
had more PTSD symptoms (Roemer, Litz, Orsillo, in trauma exposure, because as discussed later,
Ehlich, & Friedman, 1998). This illustrates both the women are much more likely to be diagnosed with
inaccuracy of memory and the effect of current PTSD than are men. Gender differences in trauma
distress on retrospective recall. Not surprisingly, exposure were assessed in a recent meta-analysis
consistency in reporting over time varies by event (Tolin & Foa, 2006). Across 19 studies, men were
(Krinsley, Gallagher, Weathers, Kutter, & Kaloupek, significantly more likely to report having experi-
2003). For example, directly experienced events enced a traumatic event than were women. This was
were more likely to be remembered than were especially true in more rigorous studies (e.g., those
witnessed events. that used interviews vs. questionnaires, and epide-
Very few studies have assessed trauma exposure miological vs. convenience samples). Tolin and Foa
prospectively, asking people to describe the events also examined whether men and women differed
they have experienced over a specific period of time. with regard to exposure to specific events. Specifically,
Although these reports may still be influenced by they analyzed 64 studies with 482 independent
memory problems and the effects of current mood, gender comparisons of the frequency of exposure to
they may be more accurate than reports of exposure nine categories of traumatic events. Men were more
over a lifetime. They also provide useful data on likely to report six of the nine events: accidents;
who is most at risk for experiencing traumatic life nonsexual assault; combat, war, or terrorism; disas-
events because risk factors can be measured prior to ter or fire; witnessing death or injury; and illness
trauma exposure. Frazier, Anders et al. (2009) or unspecified injury. However, women were six
assessed trauma exposure prospectively in their times more likely to report having experienced adult
multisite study and found that 21% of their under- sexual assault and were almost three times more
graduate student sample reported experiencing a likely to report having experienced child sexual
traumatic event during a 2-month period. Other abuse. These differences were robust and unaffected
prospective studies that have assessed trauma expo- by methodological characteristics of the studies.
sure over 3- to 4-year periods have found similar There was no gender difference in reported exposure
rates of trauma exposure (Breslau, Davis, & to nonsexual child abuse or neglect. Thus, whether
Andreski, 1995; Stein et al., 2002). there is an overall gender difference in trauma

fr azie r 813
prevalence in a specific study will depend on what With regard to specific events, racial minorities were
kinds of traumatic events are assessed. Tolin and Foa more likely to report having witnessed family vio-
did not assess gender differences in reporting the lence, having witnessed a beating, having been sexu-
sudden or unexpected death of a loved one, but ally or physically abused as a child, and having lived
other studies have not found gender differences in in a war zone.
exposure to this event (e.g., Breslau et al., 1998; Thus, whether studies find racial/ethnic group
Frazier, Anders, et al., 2009; Vrana & Lauterbach, differences in trauma exposure depends on a number
1994). of factors, including the specific ethnic groups
included in the sample, whether or not all ethnic
Racial and Ethnic Group Differences groups were combined into one “minority” group,
in Trauma Exposure and the types of events studied. In their review of
Data on ethnic and racial group differences in research on ethnic and racial group differences in
trauma exposure are surprisingly sparse and some- exposure to stressful and traumatic life events,
what inconsistent. In their large-scale epidemio- Hatch and Dohrenwend (2007) concluded that
logical study, Breslau et al. (1998) examined when racial and ethnic group differences in experi-
differences between whites and nonwhites for four encing prejudice and discrimination are included,
classes of events (i.e., assaultive violence, nonas- African Americans (and perhaps members of other
saultive traumas, trauma to others, and unexpected minority groups) tend to experience more stressful
death). Nonwhites reported almost twice as much events than do whites.
exposure to assaultive violence as did whites, con-
trolling for several other demographic factors (e.g., Socioeconomic Status Differences in
education, income). Differences in exposure to Trauma Exposure
other events were small. Another study that com- The data on SES differences in trauma exposure
pared lifetime exposure to nine traumatic events are consistent in showing that individuals from
found that a higher percentage of whites (77%) lower SES groups tend to report more traumatic (and
than African Americans (61%) reported having stressful) life events than do individuals from higher
experienced the traumatic events assessed, even SES groups (Hatch & Dohrenwend, 2007). For
though whites were far more advantaged socioeco- example, the risk of experiencing assaultive violence
nomically (Norris, 1992). Differences were signifi- was approximately twice as high for those with less
cant for four of the nine events (e.g., robbery, than high school education (compared to college
physical assault). In a study that compared four spe- graduates) and for those with annual incomes of less
cific ethnic groups (i.e., Cubans, Caribbean Basin than $25,000 (compared to those with annual
Hispanics, African Americans, and non-Hispanic incomes of $75,000 or more; Breslau et al., 1998).
whites), non-Hispanic whites reported the highest Turner and Avison (2003) found that those in the
rates of sexual molestation and physical abuse by lowest third of the SES distribution reported more
someone other than a partner or parent, whereas lifetime traumas, more witnessed violence, more trau-
African Americans reported the highest rates of mas to people they knew, and more deaths of close
being threatened or injured with a deadly weapon associates than did those in the middle or upper third
(Turner & Lloyd, 2004). African Americans of the SES distribution. In every event category, lower
reported all six witnessed events (e.g., witnessed SES was associated with greater stress exposure.
someone being killed) more frequently than did the
other ethnic groups. African Americans also reported Age Differences in Trauma Exposure
more traumatic events among loved ones (e.g., loved The data regarding age differences in trauma expo-
one being attacked or killed with a deadly weapon), sure also are consistent across studies. Somewhat
whereas hearing of the suicide or rape of someone surprisingly, younger individuals tend to report
they knew was more prevalent among white non- more traumatic events than do older individuals
Hispanic participants. Overall, African Americans (Hatch & Dohrenwend, 2007). For example, in the
reported the highest number of adversities. Detroit area study, the highest risk age for exposure
The only study to examine racial/ethnic differ- was 16–20, particularly for trauma to others and
ences in trauma exposure among undergraduate assaultive violence (Breslau et al., 1998). The only
students found that racial minorities reported event type that was not most frequent in this age
significantly more lifetime traumatic events than group was the unexpected death of a close friend or
did white students (Frazier, Anders, et al., 2009). family member. Norris (1992) compared lifetime

814 tr aum a psych o lo g y

and past-year trauma exposure for younger (18–39), lead to other psychological problems, such as depres-
middle-aged (40–59), and older (60+) adults. The sion and other anxiety disorders (e.g., Krupnick
three groups did not differ in terms of the overall et al., 2004; Turner & Lloyd, 2004), most of the
percentage who reported lifetime trauma exposure large-scale studies of trauma focus on PTSD.
(67%–72% across groups), but there were differ-
ences in exposure to some specific events. In addi- Diagnostic Criteria for Posttraumatic
tion, younger (27%) and middle-aged (21%) adults Stress Disorder
reported more traumatic events in the past year The diagnostic criteria for PTSD in the DSM-IV-TR
than did older adults (14%). For example, younger (APA, 2000) consist of five additional criteria
and middle-aged adults were more likely than older (Criteria B–F) besides Criterion A (which defines
adults to report having been physically or sexually qualifying traumas). To meet the criteria for a diag-
assaulted in their lifetime and in the past year. nosis of PTSD, individuals who have been exposed
It was not clear whether these differences were due to a Criterion A event must report at least one
to cohort effects (i.e., young people now are more at re-experiencing symptom, such as recurrent dis-
risk of violence than were young people in previous tressing dreams (Criterion B); at least 3 symptoms
generations) or whether older individuals report reflecting avoidance of stimuli associated with the
fewer events because they have forgotten events that trauma (e.g., avoiding activities, places, or people)
happened a long time ago. or numbing (e.g., feelings of detachment from
others) (Criterion C); and at least two symptoms
Summary and Critique reflecting increased arousal, such as irritability or
More research has been conducted on gender differ- difficulty concentrating (Criterion D). The symp-
ences in trauma exposure than on other types of toms described in Criteria B, C, and D have to last
diversity. This research indicates that men are more for at least 1 month (Criterion E), and cause sig-
likely to experience several types of traumatic events nificant distress or impairment in functioning
(e.g., accidents) than are women, but that women (Criterion F).
are much more likely to experience sexual violence.
Studies also fairly consistently show that younger Posttraumatic Stress Disorder Prevalence
individuals and those from lower SES groups are in Epidemiological Studies
more likely to report traumatic events. To facilitate Table 31.1 includes the PTSD prevalence rates in
prevention efforts, the reasons behind the higher large-scale epidemiological studies. As indicated,
rates in these samples need to be explored. For exam- some studies report the overall lifetime PTSD prev-
ple, Hatch and Dohrenwend (2007) concluded alence rate for the entire sample and some report it
that, to understand why younger individuals report for the trauma-exposed sample. Some also report
more traumatic events than do older individuals, current or past 12-month prevalence rates (vs. life-
long-term longitudinal studies are needed in which time rates). The methods by which PTSD was
trauma exposure is assessed over time within individ- assessed are included in the table. Most of these
uals using methods that can improve recall of events studies used structured diagnostic interviews, which
(see Turner & Lloyd, 2004, for an example). Research is the preferred method of assessment (Weathers,
on racial and ethnic group differences in trauma Keane, & Foa, 2009). Lifetime PTSD prevalence
exposure is surprisingly sparse and inconsistent. rates for those exposed to traumatic events ranged
from 7% to 8% for studies conducted outside of the
Effects of Traumatic Life Events United States (Frans et al., 2005; Perkonigg et al.,
The research reviewed thus far suggests that, when 2000) to 14% for men and women in Detroit
exposure to traumatic events is measured using (Breslau et al., 1998), to 18% for a national sample
checklists that assess a broad range of traumatic of women in the United States (Resnick et al.,
events, the vast majority of people report having 1993). PTSD prevalence rates for representative
experienced a traumatic event in their lifetime. The samples of the U.S. population (regardless of trauma
obvious next question is: How are people affected by exposure) were very similar in the NCS (8%; Kessler
these events? To answer this question, the prevalence et al., 1995) and in the NCS replication study (7%;
of PTSD in the large-scale epidemiological studies Kessler, Berglund, et al., 2005). A similar rate was
of trauma exposure and the studies of trauma expo- reported in a national sample in Sweden (6%; Frans
sure in undergraduate students reviewed previously et al., 2005), whereas population rates were lower
will be highlighted. Although traumatic events can in Munich (1%; Perkonnig et al., 2000) and higher

fr azie r 815
among women in the United States (12%; Resnick (which most people have), to pick the worst event and
et al., 1993). report on PTSD symptoms related to that event. One
It is more difficult to compare current (vs. life- problem with this method is that it can overestimate
time) PTSD prevalence rates because researchers the probability of PTSD following traumatic events
have used different time frames to define “current” because these “worst” events might be more likely to
(e.g., past month vs. past year). Nonetheless, current result in PTSD than more “typical” events. To address
PTSD rates in the population (regardless of trauma this question, Breslau et al. (1998) compared PTSD
exposure) were low (Creamer et al., 2001; Kessler, prevalence rates for individuals’ self-nominated worst
Chiu, Demler, & Walters, 2005; Resnick et al., events and an event randomly selected from all trau-
1993; Stein et al., 1997), ranging from 1% of nation- matic events reported. The PTSD prevalence rate was
ally representative samples in Australia (Creamer lower for the randomly selected events (9%) than for
et al., 2001) and Germany (Perkonnig et al., 2000) the self-selected worst events (14%). Thus, the typical
to 5% of women in the United States (Resnick method of assessing the effects of self-nominated
et al., 1993). Current PTSD prevalence rates were “worst” events may overestimate the risk of PTSD.
slightly higher (7%) among trauma-exposed women Another issue is that not all studies use struc-
(Resnick et al., 1993). tured interviews to assess PTSD. This is particularly
true of studies of undergraduate students, but it
Posttraumatic Stress Disorder Prevalence applies to some epidemiological studies as well (e.g.,
in Undergraduate Samples Norris, 1992). Studies that use self-report measures
Unlike the large-scale epidemiological studies, only often do not assess all the criteria necessary to make
four studies of undergraduate students reported a diagnosis of PTSD (e.g., impairment). This makes
PTSD prevalence rates, and all four reported current it difficult to compare PTSD prevalence rates across
(vs. lifetime) rates (Amir & Sol, 1999; Bernat et al., studies because studies using these different meth-
1998; Frazier, Anders, et al., 2009; Watson & ods are not really assessing the same thing.
Haynes, 2007). None used structured diagnostic A final issue with regard to assessing the effects
interviews to assess all of the diagnostic criteria for of trauma in terms of PTSD is that, because some
PTSD. Rather, probable PTSD prevalence rates were PTSD symptoms are linked to a traumatic event
estimated based on responses to self-report mea- (e.g., recurrent thoughts about an event), it is very
sures that assess the PTSD symptoms listed in the difficult to compare PTSD symptoms in groups who
DSM-IV. Only two studies (Frazier, Anders, et al., have and have not experienced traumatic events.
2009; Watson & Haynes, 2007) used established Traumatic events can be compared to each other
cutpoints to determine PTSD rates. Current PTSD in terms of risk of PTSD, but it is very difficult to
prevalence rates for trauma-exposed samples ranged know whether individuals experience similar kinds
from 6% (Amir & Sol, 1999; Frazier, Anders, et al., of symptoms without having experienced traumatic
2009) to 12% (Bernat et al., 1998; Watson & Haynes, events. One study addressed this issue by asking
2007). Current PTSD prevalence for the total sam- participants (who were all seeking treatment for
ples (including trauma-exposed and nonexposed major depressive disorder) about PTSD symp-
groups) ranged from 4% to 5% (Amir & Sol, 1999; toms, even if they denied experiencing any traumatic
Bernat et al., 1998; Frazier, Anders, et al., 2009). events (Bodkin, Pope, Detke, & Hudson, 2007).
Specifically, participants who denied having any
Summary and Critique traumatic events were asked if they had any thoughts,
The evidence reviewed clearly suggests that most worries, or fears that had troubled them, and were
people do not develop PTSD following traumatic life then asked about PTSD symptoms with regard to
events. Lifetime prevalence rates for individuals who these thoughts, worries, or fears. Surprisingly, the
have experienced traumatic events ranged from 7% PTSD rates did not differ between those who had
to 18% in large-scale epidemiological studies. Current and those who had not experienced a traumatic event
PTSD prevalence rates were 6%–12% in trauma- (78% for both groups). This suggests that PTSD
exposed undergraduate samples. However, several symptoms may not be specific to traumatic events.
limitations of these studies are discussed below.
The typical method of assessing PTSD in both Risk Factors for Posttraumatic
community and student samples is to ask respondents Stress Disorder
if they have experienced each of several traumatic The previous review indicates that most people do
events and, if they have experienced more than one not develop diagnosable PTSD following traumatic

816 tr aum a psych o lo g y

events. However, these overall prevalence rates are psychiatric history.) To explore what might explain
averages that combine rates across a range of events the differences in effect sizes across studies, Brewin,
and people. One of the central questions in trauma Andrews, and Valentine (2000) examined the
research concerns identifying who is most (and impact of six sample and study characteristics on
least) at risk of developing PTSD (or more severe the relations between the risk factors and PTSD
PTSD symptoms). Categories of potential risk (e.g., type of trauma, retrospective vs. prospective
factors include personal characteristics and back- design). The main conclusion from these analyses
ground, the nature of the event experienced, subjec- was that the relations between many of the risk fac-
tive reactions to the event, and others’ reactions tors and PTSD differed as a function of these sample
after the event. and study characteristics. For example, the relation
between age at trauma and PTSD was significant in
Meta-analyses of Risk Factors for retrospective but not prospective studies. As a result
Posttraumatic Stress Disorder of these complex findings, Brewin et al. concluded
To date, two meta-analyses have summarized the that we cannot assume that risk factors are the same
results of studies assessing general risk factors for across different samples (e.g., men and women;
PTSD (Brewin, Andrews, & Valentine, 2000; Ozer, civilian vs. military) or that a single model of risk
Best, Lipsey, & Weiss, 2003). The goal of Brewin for PTSD can be developed. Race was one of the
et al.’s meta-analysis was to provide a quantitative few demographic variables that weakly predicted
estimate of the absolute and relative effect sizes asso- PTSD across all of the studies. However, because
ciated with various risk factors for PTSD. They race was coded as white majority versus minority
identified 77 studies containing 85 separate datasets group, and the minority category included a wide
that examined the relation between a risk factor and range of ethnic groups, Brewin et al. warned against
either a PTSD diagnosis or PTSD symptom sever- drawing any conclusions about the role of race in
ity. They included risk factors in their meta-analysis predicting PTSD.
that had been assessed in at least four studies, for The other recent meta-analysis (Ozer et al., 2003)
a total of 14 factors. These variables can generally focused more specifically on factors that were either
be divided into demographic characteristics (i.e., characteristics of the person related to psychological
gender, age at trauma, SES, education, intelligence, processing of the traumatic event (i.e., prior psy-
race), prior history (i.e., previous psychiatric his- chological adjustment, family history of psychopa-
tory, prior traumas, childhood abuse, other adverse thology, prior trauma) or trauma/posttrauma factors
childhood experiences, family history of psychiatric (i.e., perceived life-threat, peritraumatic emotions,
disorder), event characteristics (i.e., trauma sever- peritraumatic dissociation, social support). Thus,
ity), and posttrauma experiences (i.e., life stress, there was quite a bit of overlap in the risk factors
social support). assessed in these two meta-analyses, although Ozer
The relations between all 14 risk factors and et al. did not include demographic characteristics
PTSD were significant. The effect sizes for the demo- and Brewin et al. did not include peritraumatic
graphic variables were small to moderate (ranging emotions or dissociation. The Ozer et al. meta-anal-
from r = .05 for race to r = .18 for low intelligence). ysis included 68 studies, 21 of which were not
The effect sizes for the prior history characteristics included in the previous meta-analysis (Brewin,
also were small to moderate and ranged from r = .11 Andrews, & Valentine, 2000). All seven factors were
(prior psychiatric history) to r = .19 (other adverse assessed in a minimum of five studies and with at
childhood experiences). The effect size associated least 600 participants.
with trauma severity was r = .23. The largest effect As in the previous meta-analysis, all seven factors
sizes were for the posttrauma variables: posttrauma were significantly related to PTSD. The three person-
life stress (r = .23) and posttrauma social support related variables all had effect sizes (r’s) of .17,
(r = .40). Thus, the three trauma or posttrauma fac- slightly higher than the effect sizes in the previous
tors (i.e., greater trauma severity, less social support, meta-analysis for similar factors. The effect size for
more subsequent life stress) were most strongly asso- perceived threat was r = .26 (similar to the .23 for
ciated with greater risk of PTSD. trauma severity reported by Brewin, Andrews, &
Although all 14 effects were significant, 11 dif- Valentine, 2000). The effect size for social support
fered significantly across studies. (The three predic- (r = .28) was somewhat smaller than the effect size
tors that had similar effect sizes across studies were (r = .40) reported by Brewin et al. The effect size
psychiatric history, childhood abuse, and family for peritraumatic emotions (i.e., negative emotions

fr azie r 817
during or immediately following the trauma) was as non-interpersonal traumas, even though these
r = .26 and the strongest effect size was for peritrau- are very different kinds of events. Finally, events may
matic dissociation (r = .35). be more likely to lead to PTSD in some groups
Ozer et al. (2003) examined four factors that (e.g., women) than in others (e.g., men), making it
might affect the relations between a given risk difficult to identify an absolute level of risk associ-
factor and PTSD: sample, time since trauma, type ated with any given event.
of trauma, and method of PTSD assessment (self- Despite these issues, some consistent findings
report versus interview). Type of trauma was the emerge across studies. Probably the most consis-
most consistent moderator: It affected the size of the tent finding is that sexual assault is associated with
relation between the risk factors and PTSD for five among the highest—or the highest—PTSD rates in
of the seven risk factors. The basic pattern of find- epidemiological studies. For example, in the NCS
ings was that the effect sizes were stronger if the (Kessler et al., 1995), rape was associated with higher
trauma involved noncombat interpersonal violence. rates of PTSD for men (65%) than any other event.
In other words, five of the risk factors (e.g., life- In one study (Breslau et al., 1991), the PTSD rate
threat) were more strongly related to PTSD if the for rape was as high as 80% among women. Even
trauma involved interpersonal violence versus other when PTSD was assessed with regard to a randomly
kinds of traumas. selected event (vs. a self-nominated worst event), the
Ozer et al. (2003) concluded their meta-analysis PTSD rate was higher (49%) for rape than for all
by stating that if they had to “bet” on only one vari- other events except being held captive, tortured,
able in predicting PTSD they would bet on peritrau- or kidnapped (54%; Breslau et al., 1998). In the
matic responses (emotions and dissociation). The Swedish study, experiencing sexual assault was asso-
importance of dissociation was confirmed in a recent ciated with a five-times higher risk of developing
meta-analysis, in which the average relation between PTSD (Frans et al., 2005). The same holds true in
peritraumatic dissociation and PTSD across 59 stud- college student samples: In the Frazier, Anders, et al.
ies was .40 (Lensvelt-Mulders et al., 2008). However, (2009) study, sexual assault was associated with the
the authors of this latter meta-analysis stressed that highest current probable PTSD rate (13%). Physical
these significant relations do not necessarily mean assaults also are associated with high rates of PTSD,
that dissociation is causally related to the develop- especially for women (39% in Resnick et al., 1993;
ment of PTSD. 49% in Kessler et al., 1995). In contrast, some of the
events associated with the lowest rates of lifetime
Type of Trauma and Risk for Posttraumatic PTSD include natural disasters, with PTSD rates of
Stress Disorder 4%–5% (Breslau et al., 1998; Kessler et al., 1995),
One factor not examined in these meta-analyses is and witnessed events, with PTSD rates of 6%–7%
the effect on PTSD rates of the type of trauma expe- (Breslau et al., 1998; Kessler et al., 1995). Thus,
rienced (although this was examined as a moderator although overall PTSD prevalence rates are low, this
of the relation between other risk factors and PTSD). is somewhat misleading because the probability of
Even though overall rates of PTSD are low, some developing PTSD depends greatly on what spe-
events might be associated with higher PTSD rates cific traumatic event a person has experienced. The
than others. Events that are particularly likely to lead majority of people may develop PTSD following
to PTSD might be good targets for prevention or some events, such as rape.
outreach efforts. However, differences across events In addition to reporting the risk of PTSD follow-
in PTSD prevalence rates are difficult to summarize ing different events, Breslau et al. (1998) reported
for a few reasons. First, there is little consistency the percentage of PTSD cases that were attributable
in the measurement of traumatic events across stud- to different events. For example, an event may carry
ies. Second, because studies usually assess multiple a high risk of PTSD, but if that event is very rare it
(i.e., 10 to 20) events, researchers often do not report will not account for a very high proportion of PTSD
statistical comparisons across events. Third, when cases overall. This analysis indicated that the single
researchers do report statistical comparisons across event that was responsible for the most cases of PTSD
event types, they typically combine events into larger was the sudden unexpected death of a close friend or
categories that may mask the effects of specific relative. Almost one-third (31%) of all cases of PTSD
events. For example, directly (e.g., life-threatening were attributable to this event because it was the
illness) and indirectly (e.g., witnessing an assault) single most common event (reported by 60% of the
experienced events are sometimes grouped together sample) and because it carried a moderate risk of

818 tr aum a psych o lo g y

PTSD (14%) when randomly selected as the index indirectly experienced events). In the Detroit area
trauma for PTSD assessment. As a category, assault- study, PTSD rates were 21% for directly experi-
ive violence accounted for 39% of the PTSD cases. enced assaultive violence compared to 2% for learn-
In the NCS, rape and sexual molestation accounted ing about events that happened to others (Breslau
for almost half (49%) of the PTSD diagnoses among et al., 1998). However, PTSD rates for all directly
women (Kessler et al., 1995). experienced events and all indirectly experienced
As mentioned previously, it can be difficult to events were not directly compared. This is impor-
say which events are most likely to lead to PTSD tant because some directly experienced events (e.g.,
because PTSD rates may vary across individuals natural disasters) are associated with much lower
even following the same events. For example, in the PTSD rates than are assaultive violence. Two studies
NCS, the PTSD prevalence rates differed signifi- that have statistically compared directly and indi-
cantly between men and women for seven of the rectly experienced events have yielded mixed results.
12 events (Kessler et al., 1995). Tolin and Foa In a community sample of 894 women, directly
(2006) examined this issue by assessing the size experienced events were associated with an almost
of the gender difference in PTSD symptoms in four times greater risk of PTSD than were indirectly
216 studies that compared men and women who experienced events (Anders, Frazier, & Frankfurt,
had experienced the same events. This analysis also 2011). However, in an undergraduate sample,
addressed the question of whether gender differ- directly experienced events were not associated with
ences in PTSD remained when differences in the higher levels of PTSD symptoms (Frazier, Anders,
events experienced by men and women were con- et al., 2009).
trolled. Their analysis showed that, even when Thus, although the data are not entirely con-
men and women had experienced the same events, sistent, they generally suggest that directly experi-
women reported more PTSD symptoms (d = .29). enced events are associated with more PTSD
They also found that, in general, women were two symptoms than are indirectly experienced events.
times more likely to meet criteria for PTSD than Relatedly, perceived life-threat, which would be
were men (see Olff, Langeland, Draijer, & Gersons, more likely for directly experienced events, was
2007, for a qualitative review of research on possible associated with more PTSD symptoms in Ozer
factors underlying gender differences in PTSD). et al.’s (2003) meta-analysis.
Although it is important to compare PTSD prev- Another event characteristic that is not explicitly
alence rates across specific discrete events, due to the mentioned in the description of Criterion A in the
number of different traumatic events that can be DSM-IV-TR (APA, 2000) is whether the event was
experienced, this can quickly become unwieldy. intentionally or unintentionally perpetrated. Events
Thus, another approach is to identify the underlying involving intentional harm may be especially likely
dimensions that might discriminate among events to shatter one’s views about the world and lead to
and compare events along these dimensions. One PTSD. For example, one of the reasons why assault-
such dimension is whether the event was directly or ive violence is more associated with PTSD symp-
indirectly experienced. The description of Criterion toms than are natural disasters may be because the
A in the DSM-IV-TR (APA, 2000) explicitly men- former involves the intentional infliction of harm.
tions that traumatic events can be directly experi- Again, few studies have assessed the importance of
enced, witnessed, or can involve learning that a this event dimension in predicting PTSD. In one
loved one experienced a traumatic event. Surprisingly national study of injured trauma survivors seen in
few studies have directly compared events that vary hospitals around the United States, the risk of prob-
along this dimension. For example, one study found able PTSD (based on a self-report measure) was
higher rates of probable PTSD (based on a self- 1.69 times higher among those who experienced
report measure of PTSD symptoms) for events that intentional (e.g., physical assaults) versus unin-
involved injuries or life-threat to the respondent tentional (e.g., motor vehicle accidents) injuries
(19%–24%) than for events that involved injuries (Zatzick et al., 2007). In their study of undergradu-
or life-threat to someone else (10%–13%) in two ate students who had experienced a range of trau-
undergraduate samples (Bedard-Gilligan & Zoellner, matic events, Frazier, Anders, et al. (2009) also
2008). However, this difference was not apparent in found that intentionally perpetrated events were
a small community sample of women with trauma associated with more PTSD symptoms. Although
histories in the same study (probable PTSD rates of the effect size was small, whether the event was
74% for directly experienced events and 70% for intentionally versus unintentionally perpetrated was

fr azie r 819
as strongly related to PTSD symptoms as was medium effect sizes in terms of their relations to
whether or not the event met Criterion A2 (i.e., PTSD. However, many other aspects of the appraisal
caused fear, helplessness, or horror). process may be important in addition to perceived
threat and fear, some of which are reviewed below.
Other Important Risk Factors for Cognitive appraisals will be highlighted, consistent
Posttraumatic Stress Disorder with the efficacy of cognitive behavioral approaches
Although the two meta-analyses described above to the treatment of PTSD, discussed in a later
(Brewin, Andrews, & Valentine, 2000; Ozer et al., section.
2003) were very helpful in identifying the strength Ehlers and Clark (2000) developed a cognitive
of the relation between various risk factors and model of PTSD that described numerous types of
PTSD, they both also left out some important vari- appraisals that can maintain PTSD symptoms. The
ables. This is partly because there has been an enor- basic thesis of their model was that persistent PTSD
mous amount of research on PTSD since these develops if the way in which individuals appraise
meta-analyses were conducted. A thorough review the event or its sequelae produces a sense of a serious
of this research is beyond the scope of the chapter current threat. Their model includes cognitive pro-
(for reviews see McKeefer & Huff, 2003; Olff et al., cessing during the event (e.g., mental defeat), nega-
2007; Ozer & Weiss, 2004). However, factors that tive appraisals of reactions (e.g., negative appraisals
appear to hold particular promise for understanding of actions taken during the event), and negative
who develops PTSD (or more severe PTSD symp- appraisals of event sequelae (e.g., negative appraisals
toms) will be highlighted. Although biological fac- of initial PTSD symptoms).
tors clearly are important, the focus will be on Dunmore, Clark, and Ehlers (2001) tested this
psychosocial factors that are amenable to change model in a longitudinal study of recent survivors of
through psychotherapeutic interventions. Several physical or sexual assault. Cognitive variables were
other sources review biological risk factors for PTSD used to predict later PTSD symptoms, controlling
(see e.g., McKeever & Huff, 2003; Nemeroff et al., for earlier PTSD symptoms. The cognitive variable
2006; Olff et al., 2007; Ozer & Weiss, 2004; that was most consistently related to later PTSD
Yehuda, 2004). symptom severity was negative appraisal of initial
PTSD symptoms. Negative appraisals of symp-
Appraisals toms involve believing that having PTSD symp-
The two primary meta-analyses (Brewin, Andrews, toms, such as lack of concentration, mean that one
& Valentine, 2000; Ozer et al., 2003) of general risk is going crazy or is permanently damaged, as opposed
factors for PTSD suggested that how the event is to experiencing a normal reaction to a traumatic
appraised by the individual is a key aspect of how event (see also Ehlers, Mayou, & Bryant, 1998).
the individual will be affected by the event. In fact, The Posttraumatic Cognitions Inventory (PTCI;
subjective reactions to the event in terms of whether Foa, Ehlers, Clark, Tolin, & Orsillo, 1999) was devel-
it caused fear, helplessness, or horror are part of the oped to measure individual differences in appraisals
criteria for a diagnosis of PTSD (i.e., Criterion A2). of traumatic events and their sequelae. It includes
According to Olff et al.’s (2007) conceptual model three subscales: negative cognitions about self, nega-
of the development of PTSD, “the appraisal process, tive cognitions about the world, and self-blame.
reflecting a person’s subjective perception, interpre- Respondents answer the questions with regard to
tation, and evaluation of the traumatic event, is the thoughts they may have had after the traumatic
crucial first step in the cascade of psychobiological experience. All three subscales had very high correla-
responses that can eventually lead to pathological tions (greater than .56) with a measure of PTSD
symptoms” (p. 187). Similarly, in her review, Yehuda symptoms in a sample that had experienced a variety
(2004) noted that the development of PTSD is not of traumatic events. However, in a sample of motor
just associated with exposure to trauma, but with vehicle accident survivors, the negative cognitions
how the event is interpreted and how the person acts about self and world subscales were again highly cor-
in the immediate aftermath of the trauma. The pri- related with PTSD symptoms, but the relation
mary variables most closely related to appraisals between self-blame and PTSD symptoms was essen-
included in the previous meta-analyses were per- tially zero (Beck, Coffey, Palyo, Gudmundsdottir,
ceived life-threat and peritraumatic emotions. The Miller, & Colder, 2004), suggesting that the rela-
latter was primarily assessed in terms of Criterion tions between appraisals and PTSD symptoms may
A2 (fear, helplessness, or horror). Both had small to differ across events. One limitation of the PTCI is

820 tr aum a psych o lo g y

that the negative cognitions about the self scale, in Frazier et al.’s (2002) review of the literature
particular, includes a wide range of items, some of using a temporal framework suggested that past,
which are appraisals (e.g., “My reactions since the present, and future control had very different rela-
event mean that I am going crazy”) and some of tions with measures of posttrauma adjustment and
which seem to reflect symptoms or consequences of that, contrary to the truism “control is good,” per-
the event (e.g., “I have no future”). Thus, high cor- ceived control was not always adaptive. That is, past
relations between this subscale and PTSD may be control generally was either not associated with dis-
due to overlap in item content with PTSD measures tress or was associated with more distress, present
(which also include items about having a foreshort- control was nearly always associated with less dis-
ened future). tress and fewer PTSD symptoms, and future control
was generally (although not always) associated with
Perceived Control fewer PTSD symptoms. Studies that examined the
Another aspect of trauma appraisal that is men- relation between perceived control and PTSD were
tioned in many reviews and theoretical accounts is rare, however. Subsequent research has confirmed
the appraisal of the controllability of the trauma. that perceived present control (operationalized as
For example, Foa, Zinbarg, and Rothbaum (1992) control over the recovery process) was associated
developed a theoretical model of the etiology of with less PTSD symptom severity in survivors of
PTSD that focuses on control. Based on animal sexual assault and bereavement (Frazier, Steward, &
research showing that exposure to uncontrollable Mortensen, 2004). Moreover, present control was a
and unpredictable aversive events leads to PTSD- stronger predictor of PTSD than was either past or
like symptoms, Foa et al. hypothesized that events future control, and predicted PTSD symptoms con-
that are less controllable and predictable are more trolling for several other important factors such as
likely to lead to PTSD in humans as well. They neuroticism. A measure that assesses these three
stressed, however, that perceptions of control are aspects of perceived control, as well as the perceived
more important than actual contingencies. Foa et al. likelihood that the event will happen again, has been
argued that the perceived uncontrollability and developed (Frazier, Keenan, et al., 2011). Across sev-
unpredictability of an event are so important that eral studies conducted in the process of developing
they should be incorporated into the definition of a this measure, perceived present control had the
traumatic event in the DSM. In Olff et al.’s (2007) strongest relations with PTSD symptoms of any of
conceptual model, appraisals that include greater the aspects of control, with effect sizes generally in
loss of control also are thought to contribute to the medium to large range (Frazier, Keenan, et al.,
PTSD. 2011). Thus, individuals who perceive that they
Despite the importance of control in current have more control over their thoughts, feelings, and
theories of the etiology of PTSD and other trauma- reactions to the event report fewer PTSD symptoms.
related disorders, the ways in which control is con- Importantly, unlike the past or the future, the pres-
ceptualized in these theories do not reflect the ent is something over which one does actually have
complexity of the construct. That is, these theories some control.
tend to discuss event controllability as a unitary
construct, whereas, in fact, there are various aspects Coping
of events over which people can perceive that they Conceptual models of the development of PTSD
have control. In fact, Skinner (1996) identified often link appraisals, including control appraisals,
more than 100 control-related constructs that differ to the methods individuals use to cope with the
along several dimensions. According to Frazier, traumatic event. For example, in Olff et al.’s (2007)
Berman, and Steward (2002), the temporal dimen- model, “appraisals that include greater threat or loss
sion (i.e., past, present, and future) is particularly of control perceptions may contribute to PTSD . . .
important for understanding the role of control in because they direct coping toward excessive emo-
adjustment to traumatic life events. Specifically, past tional regulation and divert it from problem solv-
control refers to the perception that the occurrence ing” (p. 185). Negative appraisals are thought to be
of the event itself was controllable, present control associated with coping strategies such as disengage-
refers to perceived control over the current impact ment, social isolation, self-destructive behaviors,
of the event (i.e., current symptoms), and future denial, rumination, and blaming others that consis-
control refers to perceived control over the event tently have been associated with more posttrauma
happening again. distress (Olff et al., 2007). Ehlers and Clark (2000)

fr azie r 821
also outlined the coping strategies that follow from that individuals who score higher on measures of
specific kinds of negative appraisals. For example, neuroticism respond to laboratory and daily stres-
if individuals negatively appraise posttrauma symp- sors with more negative affect. In fact, Lahey noted
toms (e.g., “If I think about the trauma, I will fall that “the construct of neuroticism would have little
apart”) they may engage in dysfunctional coping meaning if persons high in neuroticism did not
strategies (e.g., trying hard not to think about respond with negative emotions more frequently and
the trauma, drinking) that may in turn prevent intensely when they experience stressful life events”
them from developing more positive appraisals. (p. 248). With regard to PTSD, in one study, neu-
In an empirical test of their model, Dunmore et al. roticism significantly predicted PTSD symptoms
(2001) assessed two forms of dysfunctional cogni- after controlling for several other important factors
tive/behavioral coping strategies: avoidance/safety (e.g., history of affective disorder, history of multiple
seeking (e.g., avoiding thoughts and activities asso- trauma exposure; Cox, MacPherson, Enns, &
ciated with the trauma) and undoing (i.e., attempts McWilliams, 2004). For women, neuroticism was
to mentally erase or alter memories of the event). the only significant predictor of PTSD when other
Only the avoidance/safety seeking behaviors pre- factors were controlled. Both neuroticism and self-
dicted later PTSD symptoms, controlling for earlier criticism were significant in the final model for men.
symptoms. However, as mentioned in relation to Although this study examined cross-sectional rela-
the PTCI, there is overlap between the items in the tions between neuroticism and PTSD, prospective
avoidance/safety seeking scale and PTSD symp- studies also have consistently found that neuroticism
toms, especially the avoidance symptoms. Thus, assessed prior to the trauma predicts higher levels of
although there are consistent relations between PTSD following a subsequent trauma (e.g., Bramsen,
avoidance coping and PTSD in the literature, the Dirkzwager, & van der Ploeg, 2000; Engelhard,
extent to which the relations are due to item overlap Huijding, van den Hout, & de Jong, 2007; Frazier,
is unclear. In addition, Dunmore et al. did not assess Gavian, et al., 2011; Hodgins, Creamer, & Bell,
the relations between appraisals and coping. Other 2001; Parslow, Jorm, & Christensen, 2006).
studies suggest, however, that control appraisals are Individuals higher in pretrauma neuroticism also
associated with coping strategies and that cop- have been found to appraise subsequent events as
ing mediates the relation between control apprais- more distressing and to perceive that they have less
als and distress. For example, in two samples of control over their reactions to the event (Frazier,
sexual assault survivors, self-blame was associated Gavian, et al., 2011).
with more distress primarily because it was associ- The relations between other personality-related
ated with greater social withdrawal (Frazier, variables and PTSD also have been established pro-
Mortensen, & Steward, 2005). Conversely, present spectively. For example, in four prospective studies,
control (perceived control over the recovery process) individuals with higher self-esteem or more positive
was associated with less distress because it was asso- self-views assessed prior to a trauma reported fewer
ciated with less social withdrawal. PTSD symptoms following a subsequent trauma
(Bryant & Guthrie, 2005; Card, 1987; Frazier,
Personality Gavian, et al., 2011; Lengua, Long, Smith, &
Given the crucial role of appraisals in understand- Meltzoff, 2005). Pretrauma optimism was identi-
ing who develops PTSD, it also is important to fied as a protective factor in two prospective studies
identify factors that may put individuals at risk of (Frazier, Gavian, et al., 2011; Oxlad & Wade,
making more negative appraisals of traumatic events 2008). Both self-esteem (e.g., Adams & Boscarino,
and their sequelae or of perceiving events as less 2006) and optimism (e.g., Zoellner, Rabe, Karl, &
controllable. Identifying pretrauma characteristics Maercker, 2008) also were related to lower PTSD
that predict appraisals could help us to intervene symptoms in cross-sectional studies. In their review
with at-risk individuals and perhaps teach them of cognitive vulnerabilities for PTSD, Elwood and
skills to appraise events less negatively. colleagues (2009) identified several personality-
The personality trait of neuroticism has received related factors that may put individuals at risk for
the most attention in the PTSD literature. Neu- PTSD, including negative attributional style, anxi-
roticism is defined as a relatively stable tendency to ety sensitivity, and looming cognitive style. However,
respond to threat, frustration, or loss with negative it was not clear whether any of the relations between
emotion (Lahey, 2009). In a recent review of research these factors and PTSD had been established pro-
on neuroticism, Lahey reviewed evidence suggesting spectively. Finally, general self-efficacy beliefs, which

822 tr aum a psych o lo g y

involve beliefs that one can control one’s environ- retrospectively report more pretrauma distress.
ment and cope effectively with challenge, also were Assessing pretrauma factors prior to the event pro-
related to lower PTSD symptoms (see Luszczynska, vides a much stronger test of which factors are asso-
Benight, & Cieslak, 2009, for a meta-analysis of ciated with more or less risk for PTSD. Even if
studies on self-efficacy and PTSD following collec- posttrauma factors truly are more important than
tive trauma). pretrauma factors, they likely reflect the effects of
pretrauma factors (e.g., someone who is more neu-
Summary and Critique rotic may be less likely to have adequate social sup-
In summary, numerous factors have been found to port, which in turn is associated with greater PTSD
be related to greater risk of PTSD including pre- symptom severity). Knowledge of these pretrauma
trauma background characteristics of the person, factors can help us identify individuals who are
characteristics of the trauma and reactions to it, and more at risk of appraising events negatively, perceiv-
posttrauma factors. Among pretrauma factors, neu- ing a lack of control, or having inadequate support
roticism is one of the most firmly established risk posttrauma. Thus, knowledge of pretrauma factors
factors, having been established in several prospec- can help us identify those most at risk.
tive studies. Female gender is also a consistent risk
factor, with women being twice as likely to develop Interventions for Posttraumatic
PTSD as men. The reasons behind this consistent Stress Disorder
gender difference are not yet fully understood (see Even though most people who have experienced
Olff et al., 2007; Tolin & Foa, 2006). Several char- traumatic events do not develop PTSD, it is still a
acteristics of the traumatic event itself also are associ- relatively common disorder, with an estimated life-
ated with greater risk of PTSD, including whether time population prevalence of approximately 7% in
it was directly (vs. indirectly) experienced and the United States (Kessler, Berglund, et al., 2005).
whether it was intentionally (vs. unintentionally) In addition, individuals with PTSD are at greater
perpetrated. Interpersonal violence, especially sexual risk for other disorders, including depression, other
assault, is consistently associated with the highest anxiety disorders, and substance abuse disorders
rates of PTSD. More research is needed to under- (Breslau, 2002). Fortunately, several forms of psy-
stand the factors that make sexual assault so much chotherapy and some medications have been found
more distressing than other events. In addition to to be effective for PTSD. Prior to describing research
these objective characteristics, subjective reactions on the efficacy of these interventions for PTSD,
are very important, including subjective appraisals research on early interventions for trauma survivors,
of the event and emotional reactions during the guidelines for the assessment of trauma and PTSD,
event (e.g., dissociation). Finally, several posttrauma and theories that inform the interventions for PTSD
factors are important, including social support fol- will be reviewed.
lowing the event (see Charuvastra & Cloitre, 2008,
for a recent review of research in this area) and the Early Interventions
related constructs of posttrauma appraisals of symp- In their review of research on early interventions
toms and perceived control over one’s reactions to for trauma, Litz and Maguen (2007) distinguished
the event. Posttrauma factors generally are thought among three phases of the posttrauma recovery
to be more strongly related to PTSD symptoms than process. The first phase is the immediate phase
are pretrauma factors, but this could be because they (0–48 hours posttrauma). Many people who have
are caused by PTSD symptoms as well as cause them. experienced a trauma are severely distressed during
The direction of the relations between posttrauma this phase. The next period is the acute phase, which
factors and PTSD symptoms cannot be established lasts from a few days to 1 month following the
using typical cross-sectional designs. trauma. Distress diminishes greatly between the
As this last statement suggests, one of the major immediate and acute period for most people. As dis-
limitations of research on risk factors for PTSD is cussed, even fewer people (less than 10%) develop
that the vast majority of studies assess risk factors chronic PTSD with significant symptoms lasting
retrospectively, after the trauma, at the same time as for more than 1 month and sometimes many years
PTSD symptoms are measured. This is problematic following the trauma (chronic phase).
because the effects of the trauma may influence Because many people experience significant dis-
the reporting of pretrauma factors. For example, tress in the immediate aftermath of trauma, inter-
individuals with more posttrauma distress may ventions have been developed to decrease distress

fr azie r 823
and prevent chronic PTSD from developing. These PTSD symptoms are the prominent issue (Foa,
immediate interventions are called psychological Keane, Friedman, & Cohen, 2009b). Even if an
debriefing (PD). The most commonly used form of individual comes to counseling to deal with a spe-
PD is critical incident stress debriefing (CISD). cific discrete event (e.g., a sudden death), it is useful
CISD is typically a single-session intervention last- to conduct a thorough trauma history because indi-
ing 3–4 hours that includes both psychoeducation viduals are likely to have experienced more than one
about stress reactions and emotional processing of traumatic event. The assessment of trauma exposure
the event. Despite its intuitive appeal, expert treat- and PTSD is also done in forensic contexts when,
ment guidelines have concluded that there is no for example, individuals sue for psychological dam-
evidence that single-session PD is effective for pre- ages following a traumatic event such as a motor
venting the development of PTSD symptoms (Foa, vehicle accident.
Keane, Friedman, & Cohen, 2009a). Rather, these In their treatment guidelines for the assessment of
guidelines recommend that, shortly after a trauma, PTSD, Weathers et al. (2009) reviewed interview
individuals should be provided with practical psy- and self-report measures of PTSD symptoms that
chological support and information about possible can be used in these various contexts. The National
stress reactions, how to help themselves, how to Center for PTSD web site (www.ncptsd.va.gov) also
access support, and where to get further help if has very useful lists of self-report and interview mea-
needed. Litz and Maguen (2007) describe this as sures of both trauma exposure and PTSD (see also
“psychological first aid.” The primary difference Keane, Brief, Pratt, & Miller, 2007; Wilson & Keane,
between PD and psychological first aid is that the 2004). With regard to the assessment of PTSD,
latter does not include emotional processing of the Weathers et al. recommended that structured inter-
event. For individuals who continue to experience views be used whenever possible. If a structured
significant distress beyond the immediate post- interview is not feasible, self-report measures that
trauma period, 5 to 12 weekly sessions of CBT is assess all of the PTSD diagnostic criteria (e.g., the
recommended in the acute period (Foa et al., 2009a; Posttraumatic Diagnostic Scale; Foa, Cashman,
Litz & Maguen, 2007). However, at present, the Jaycox, & Perry, 1997) are preferred. Weathers et al.
optimal time for intervening is not known. What also recommended using multiple assessments when-
does seem to be clear is that, because most people ever possible. They described a typical comprehen-
recover on their own, it is not appropriate to inter- sive protocol as including a trauma exposure measure,
vene with everyone. Individuals at high risk, based a structured diagnostic interview for PTSD, one
on the factors outlined previously, should be or more self-report PTSD measures, a multiscale
screened and monitored, and offered CBT if they inventory (such as the Minnesota Multiphasic Per-
remain distressed. sonality Inventory [MMPI]) that assesses response
bias, and possibly a psychophysiological assessment.
Assessment This type of comprehensive approach seems par-
The assessment of trauma exposure and PTSD ticularly important for assessing PTSD in a forensic
symptoms can serve different purposes in different context but would not be feasible in all settings or
contexts. The specific assessment tools used will vary contexts.
as a function of the assessment goals, the population
and the assessment context, and available resources Theories of the Development of
(Weathers et al., 2009). For example, as noted in the Posttraumatic Stress Disorder
previous discussion of early interventions, one pur- Prior to reviewing evidence regarding the effective-
pose of assessment is to identify traumatized indi- ness of various interventions for PTSD, it is useful
viduals who continue to experience significant to review prominent theories regarding the develop-
distress, and thus may be at greater risk of develop- ment of PTSD. These theories inform interventions
ing chronic PTSD and may benefit from CBT in and must be able to account for the efficacy of inter-
the acute posttrauma period. In the more typical ventions. In their review and critique of various
general counseling context, given the high preva- theories of PTSD, Cahill and Foa (2007) noted that
lence of trauma exposure, it is important to assess any adequate theory of PTSD must be able to
lifetime trauma on a routine basis (Weathers et al., account for the specific symptoms of PTSD such as
2009). If an individual reports a significant trauma, re-experiencing and avoidance; the natural course of
a comprehensive diagnostic evaluation is needed to posttraumatic reactions, including that most people
determine the presence of PTSD and whether the have symptoms immediately posttrauma but do not

824 tr aum a psych o lo g y

develop chronic PTSD; and the efficacy of CBT for disorders (e.g., Foa & Kozak, 1986) but was later
PTSD. expanded to include a comprehensive theory of
Cahill and Foa (2007) reviewed five categories PTSD (Foa & Jaycox, 1999). The two main prem-
of theories of PTSD: conditioning theories, schema ises of emotional processing theory are that anxiety
theories, emotional processing theory, cognitive the- disorders (including PTSD) reflect the presence of
ories, and theories positing multiple representation pathological fear structures in memory and that
structures. Some of these theories, such as Ehlers successful treatment involves modifying these fear
and Clark’s (2000) cognitive theory of PTSD, have structures so that stimuli that once evoked anxiety
been mentioned in the previous description of no longer do so. Natural recovery results from acti-
research on risk factors for PTSD. The key features vation of the trauma memory through engaging
of these models are described below (see Cahill & trauma-related thoughts and feelings, talking about
Foa, 2007, for more information). the trauma with others, and being confronted with
Conditioning theories (e.g., Keane, Zimerling, & reminders of the trauma. All of these processes will
Caddell, 1985) explain the development of PTSD result in the trauma survivor being confronted with
through the processes of classical and operant condi- information that is inconsistent with information in
tioning. Specifically, fear is acquired through the the fear structure, such as that the world is danger-
process of classical conditioning because previously ous. The development of PTSD is thought to result
neutral stimuli (e.g., time of day, smells) that were from a failure to process the trauma adequately.
present during the trauma become associated with Cognitive theories of PTSD, like cognitive theo-
intense anxiety. Avoidant symptoms are acquired ries of depression and anxiety, focus on individuals’
through the process of operant conditioning. In interpretation of a traumatic event. According to
other words, because the trauma memory and other Ehlers and Clark’s (2000) cognitive theory, PTSD
stimuli elicit fear and anxiety, they are avoided. This results when an individual’s interpretation of the
avoidance in turn reduces fear and anxiety. However, event or its consequences leads to a sense of current
this avoidance also prevents the extinction of the link threat. The nature of the traumatic memory can also
between the previously neutral stimuli and anxiety. lead to a sense of current threat in this model. For
Schema (also called social-cognitive) theories example, fragmented trauma memories, the percep-
(e.g., Horowitz, 1986; Janoff-Bulman, 1992) draw tion of the memory as happening in the present,
from theories in personality and social psychology and lack of incorporation of the trauma memory
rather than from learning theories. These theories with other memories are thought to explain why a
focus on the impact of traumatic events on people’s past event can cause a sense of current threat.
preexisting schemas (i.e., core assumptions and Theories positing multiple representation struc-
beliefs) about the world and the self. Often these tures derive from research in cognition and cogni-
theories assume that a traumatic event shatters pre- tive neuroscience. These theories describe different
existing positive beliefs, such as that the world is safe, memory systems that can in turn explain differ-
people are good, and the self is strong and compe- ent types of PTSD symptoms. One impetus for
tent. Information about self and the world ema- these theories is the belief that the concept of a sin-
nating from the trauma that is inconsistent with gle emotional memory is too narrow to explain
these preexisting positive beliefs must be assimilated the symptoms of PTSD. One example of this type
into existing beliefs, or existing beliefs must be of theory is dual-representation theory (Brewin,
accommodated to incorporate information about Dalgleish, & Joseph, 1996), which posits two mem-
the self and world learned from the trauma. The ory systems: verbally accessible memory and situa-
recovery process involves repetitive efforts to inte- tionally accessible memory. As the name implies,
grate these two sources of information, which is verbally accessible memories contain information
thought to explain the reexperiencing symptoms about the traumatic event and its meaning that
of PTSD. Competing with this is the tendency to can be deliberately retrieved and communicated.
avoid the distress caused by the reexperiencing symp- Situationally accessible memories cannot be deliber-
toms, which accounts for the avoidance symptoms ately recalled but are triggered by reminders of the
of PTSD. However, avoidance prevents the resolu- trauma and are responsible for the re-experiencing
tion of the discrepancy between existing beliefs and and arousal symptoms of PTSD. According to this
trauma-related information. theory, emotional processing of the event involves
Emotional processing theory was originally activating the situationally accessible memories, so
developed to explain the development of anxiety that they can be altered or replaced and changing the

fr azie r 825
verbally accessible memories to reconcile discrepan- an average effect size of d = .11. Although differences
cies between preexisting beliefs and trauma-related between treatments were small, there tended to be
information (similar to schema theories). more studies that have established the effectiveness
In sum, although the theories differ, they all pro- of exposure, CBT, or exposure plus CBT than stud-
pose that the reduction of PTSD symptoms involves ies that have established the effectiveness of EMDR.
exposure to the event (e.g., to change fear structures Another excellent resource for information on
or memories) and reinterpretation of the event and the efficacy of various interventions for PTSD is the
its meaning (e.g., reconciling the trauma with exist- set of treatment guidelines developed by a task force
ing beliefs). Thus, it is not surprising that effective of the International Society for Traumatic Stress
treatments for PTSD involve exposure and CBT, as Studies (ISTSS; Foa et al., 2009a). This book con-
described below. tains chapters summarizing evidence regarding the
efficacy of various forms of treatments for PTSD for
Psychosocial Interventions for Posttraumatic adults, children, and adolescents, followed by briefer
Stress Disorder treatment guidelines. The review was not limited to
Two meta-analyses describe the evidence for both empirically supported treatments and the evidence
the absolute and relative efficacy of psychotherapeu- for each form of intervention was graded in terms of
tic interventions for PTSD (Bisson et al., 2007; six levels, reflecting the strength of the evidence.
Bradley, Greene, Russ, Dutra, & Westen, 2005). Consistent with the results of the meta-analyses
Although the two reviews differed somewhat in the described previously, these treatment guidelines rec-
comparisons they reported and how they categorized ommended CBT (which includes exposure therapy)
treatments, some general conclusions can be drawn. as the first-line treatment for both acute and chronic
First, with regard to absolute efficacy, several treat- PTSD. According to Friedman et al. (2007), all
ments have been shown to be more effective than clinical practice guidelines identify CBT as the
wait-list or supportive counseling control condi- treatment of choice for PTSD.
tions. These include exposure therapy, CBT, expo- The ISTSS guidelines also provide information
sure plus CBT, and eye movement and desensitization for practitioners to use in treatment planning. In
and reprocessing (EMDR). The effect sizes for com- terms of treatment duration, they offered a general
parisons of these treatments to wait-list control guideline of 8 to 12 sessions lasting 60 to 120 min-
groups were large (d’s = 1.11 to 1.53) in both meta- utes each, administered once or twice weekly. They
analyses. In other words, on average individuals who also concluded that there was more evidence for the
received one of these treatments scored more than efficacy of individual than of group therapy. The
1 standard deviation lower on measures of PTSD guidelines also stressed the importance of establish-
symptoms than did individuals on a wait-list who ing a trusting relationship with the client, assessing
received no treatment. Effect sizes for comparisons the client’s safety, providing education and reassur-
to supportive counseling control conditions were ance regarding PTSD symptoms, monitoring the
somewhat lower (d’s = .75 to 1.01) but still large client’s symptoms and functioning over time, and
(Bradley et al., 2005). Effect sizes associated with identifying and addressing any comorbid problems
pre- to post-treatment reductions (vs. comparisons and issues. Assessing and addressing readiness for
to control groups) in symptoms also were large for treatment also is important. Because avoidance is
these treatments (d’s = 1.43 to 1.66; Bradley et al., one of the hallmark features of PTSD, many clients
2005). The pre- to post-treatment effect size was .59 are reluctant to seek help that may involve confront-
for the supportive counseling control conditions ing the trauma. They may need to be educated and
(and these conditions did not differ from wait-list reassured about the treatment process. Engaging cli-
control conditions, d = -.01). Across active treat- ents with PTSD in the therapy process is a crucial
ments, 67% of those who completed treatment no first stage in treatment (Friedman, Cohen, Foa, &
longer met criteria for PTSD at the end of treat- Keane, 2009).
ment, although many of those who no longer met The ISTSS guidelines also reviewed evidence
PTSD criteria remained symptomatic (Bradley et al., regarding whether the effectiveness of PTSD treat-
2005). Second, with regard to relative effectiveness, ment varies as a function of various factors (Foa et al.,
in both meta-analyses differences between treat- 2009b; Friedman et al., 2009). This review suggested
ments were small (see also Benish, Imel, & Wampold, there was no conclusive evidence that the effective-
2008). For example, studies that directly compared ness of PTSD treatment depends on the type of
exposure therapy to other kinds of treatment yielded trauma that caused the PTSD, whether the PTSD

826 tr aum a psych o lo g y

was due to single or multiple traumas, or the client’s just between 2002 and 2009. There are also frequent
gender or age at time of trauma exposure. However, anecdotal reports in the media regarding posi-
there generally is little research on these issues. tive life transformations following traumatic events.
Research also has not reached the point at which In the following, evidence regarding the prevalence
we can identify specific types of treatments that and correlates of self-reported PTG will be reviewed,
are more effective for certain types of clients. The followed by a discussion of some concerns that
guidelines do, however, provide some guidance on have been raised about the validity of self-reported
choosing among treatment approaches by, for exam- growth. Tedeschi and Calhoun (2004) and Joseph
ple, considering client preferences, cultural accept- and Linley (2005) provide theoretical accounts of
ability, cost, and availability of resources (Friedman the development of PTG.
et al., 2009, pp. 632–634). Data on the most effec- Substantial evidence suggests that most people
tive combinations of treatments also are lacking, who have experienced traumatic events report expe-
although, again, some guidelines are provided regard- riencing positive life changes as a result of those
ing how to most effectively combine treatments events. For example, more than 80% of women
(Friedman et al., 2009, pp. 635–637). The authors with cancer (Sears, Stanton, & Danoff-Burg, 2003)
also acknowledged that little is known about the and HIV/AIDS (Siegel & Schrimshaw, 2003)
treatment of PTSD for people in nonindustrialized reported at least one positive change in their life
countries. resulting from their illness. Similar findings have
been reported in individuals who have experienced
Pharmacological Interventions other events including bereavement (Davis, Nolen-
Evidence regarding the effectiveness of psychotropic Hoeksema, & Larson, 1998), disasters (McMillen,
medications for treating PTSD is less conclusive Smith, & Fisher, 1997), and sexual assault (Frazier,
than the evidence for the effectiveness of psycho- Conlon, & Glaser, 2001). The positive changes most
therapeutic interventions. In one recent review of frequently reported include greater life appreciation,
randomized controlled trials of pharmacotherapy closer relationships with family and friends, changed
for PTSD, symptom severity was significantly priorities (e.g., more concern for others, more com-
reduced in 17 of the 35 trials (Stein, Ipser, & Seedat, passion), greater spirituality and religiousness, and
2006). There was most evidence for the efficacy of positive self-changes (e.g., feeling stronger).
selective serotonin reuptake inhibitors (SSRIs). The A recent meta-analysis reviewed 87 studies
PTSD treatment guidelines developed by ISTSS reporting data on correlates of PTG and relations
(Foa et al., 2009a) concluded that both SSRIs between measures of PTG and distress or well-being
and serotonin-norepinephrine reuptake inhibitors (Helgeson, Reynolds, & Tomich, 2006). Research on
(SNRIs) can be recommended as first-line treat- correlates of PTG addresses the question of whether
ments for PTSD. However, they also concluded certain types of people are more likely to report
that these medications are not as effective as CBT growth following traumatic events or whether certain
and that relapse is more likely after discontinuing types of events are more likely to lead to growth.
medications than after completing psychotherapy. Specifically, their review focused on four categories of
Other evidence-based guidelines have concluded variables that have often been examined as correlates
that medications should not be used as a routine of PTG: demographic factors (n = 5), stressor charac-
first-line treatment for PTSD in adults (National teristics (n = 3), personality-related variables (n = 3),
Collaborating Centre for Mental Health, 2005). and coping strategies (n = 3). Of the 14 variables
assessed, ten had significant relations with PTG
Posttraumatic Growth although the relations generally were small. For
Thus far, the focus has been on PTSD as the pri- example, of the five demographic variables the stron-
mary outcome of trauma. However, a growing body gest relation (r = –.08) indicated that women reported
of research focuses on the positive transformations more PTG than did men. Of the three stressor char-
that can occur in individuals’ lives following trau- acteristics, perceived stressor severity had the stron-
matic events. This phenomenon is referred to as gest relation with PTG (r = .14) indicating that
posttraumatic growth, stress-related growth, benefit- individuals who perceived the events they experi-
finding, and positive life change in the literature. The enced as more stressful reported more growth. With
term posttraumatic growth (PTG) will be used here, regard to personality, neuroticism (r = –.05) was not
which tends to be most common. Using these search associated with PTG, but individuals who were more
terms in the PsychInfo database resulted in 434 hits optimistic (r = .27) and more religious (r = .17)

fr azie r 827
reported more growth. Positive reappraisal coping survivors actually report decreases over time in
had the strongest relation with PTG (r = .38), which self-reported growth (Frazier et al., 2001). “Growth”
is not surprising given that positive reappraisal that does not last would not seem to reflect actual
involves finding benefits in difficult events. growth. Finally, research in other domains suggests
The Helgeson et al. (2006) meta-analysis also that people generally are not very accurate in assess-
addressed the important question of the relation ing the degree to which they have changed over time.
between measures of PTG and more traditional For example, assessments of perceived personality
measures of distress and well-being posttrauma. If change have small correlations with actual person-
PTG is an adaptive response to trauma one would ality change in longitudinal studies (e.g., Robins,
expect individuals who report more growth to report Noftle, Trzesniewski, & Roberts, 2005). Such assess-
less distress. Conversely, if growth is more likely fol- ments of change are what measures of PTG require.
lowing more stressful events, and arises from dealing Several methods have been used to assess the
with event-related distress, one might expect posi- validity of self-reported PTG and studies using
tive relations between PTG and distress. Or, growth these methods generally do not find strong evidence
and distress may be separate outcomes that are essen- that reports of growth reflect actual life change.
tially unrelated to each other. Helgeson et al., in fact, For example, studies that assess whether significant
found complicated relations between measures of others corroborate growth reports show only modest
PTG and distress and well-being in their meta- concordance between trauma survivors and their
analysis. For example, PTG was negatively related to significant others (McMillen & Cook, 2003; Park,
depression (r = –.09), unrelated to anxiety (r = –.02), Cohen, & Murch, 1996). If individuals have truly
and positively related to the PTSD symptoms of changed, significant others should recognize and
intrusion and avoidance (r = .18). Moreover, these report the change as well. Another approach involves
effects differed significantly across studies and were comparing the well-being of individuals who expe-
moderated by several variables, including time since rienced a trauma to a matched comparison group
the trauma occurred. For example, intrusive thoughts of individuals who did not experience a trauma.
were more related to PTG in studies in which the A variation of this approach involves comparing the
trauma was more recent (r = .23) than in studies in well-being of individuals who reported growth from
which the trauma was less recent (r = .08). a trauma to that of their counterparts who reported
Helgeson et al. (2006) concluded that one reason no growth. Frazier and Kaler (2006) used both
for the inconsistent relations between measures of approaches and found little evidence to support the
PTG and distress was the lack of clarity regarding validity of self-reported PTG. For example, there
what PTG measures actually assess. That is, does were no significant differences in well-being between
self-reported PTG reflect actual change in people’s undergraduate students who said that something
lives, or does it reflect a cognitive strategy of coping positive had come out of their worst stressor and
with distress not necessarily reflective of actual those who reported no positives. Finally, a recent
change? Because virtually all data on PTG consist of study found only modest (r’s = .04 to .22) correla-
survivors’ reports that they have experienced various tions between self-reported PTG and actual change
positive life changes, concerns about whether these from pre- to post-cancer treatment (Ransom,
reports reflect actual life changes are increasingly Sheldon, & Jacobsen, 2008). If self-reported PTG
being raised. reflects actual positive change, one would expect
There are several reasons to suspect that reports a stronger correlation.
of PTG may not represent actual life changes. First, Although these studies yield useful information
people may describe the positive things that came about the correlates of perceived growth, the best
out of a trauma because they want to appear to be way to assess whether perceived growth corresponds
coping well or because they think that is what others to actual growth is to conduct a prospective study
want to hear. This cultural script may be particularly in which self-reported growth is compared to actual
prevalent in the United States (Steger, Frazier, & growth from pre- to posttrauma. Such a study recently
Zacchanini, 2008). Second, reports of growth may was conducted, which is the first in the literature
reflect motivated illusions. McFarland and Alvaro (Frazier, Tennen, et al., 2009). To assess pretrauma
(2000) presented convincing evidence that people functioning, a large group of undergraduate stu-
report that they have changed as a result of traumatic dents was assessed at baseline and 2 months later.
events not because they have actually grown but The expectation was that a small percentage would
because they derogate their past selves. Third, some experience a major trauma over that time period.

828 tr aum a psych o lo g y

If a participant reported a traumatic event during future research on trauma. Issues related to each of
that time, their pre- and posttrauma scores on the broad topics reviewed previously will be high-
various PTG-related domains (to measure actual lighted. This list is by no means exhaustive but does
growth) were compared to their scores on a self-report provide some directions for future research.
measure of PTG (to measure perceived growth) after
the trauma. The self-report measure used was the Trauma Prevalence
Posttraumatic Growth Inventory (PTGI; Tedeschi & As mentioned previously, trauma prevalence rates
Calhoun, 1996). If the PTGI measures actual growth, depend greatly on how traumatic events are mea-
the two scores should be at least moderately corre- sured and defined. One definition of a “traumatic”
lated. However, the correlation between actual post- event is that contained in PTSD Criterion A in the
traumatic growth and PTGI scores was fairly small DSM-IV, which focuses on whether the event was
(r = .22). In addition, higher scores on the PTGI life-threatening. However, there is considerable
(perceived growth) were related to greater increases debate in the literature regarding whether events
in distress from pre- to posttrauma and more posi- need to meet Criterion A to lead to PTSD (see
tive reappraisal coping posttrauma, suggesting that Rosen & Lilienfeld, 2007, for a review). In fact, sev-
the PTGI may be measuring coping as opposed to eral studies have found that events that do not meet
actual growth. In contrast, actual growth from pre- to Criterion A1 are just as likely (Anders et al., 2011;
posttrauma (e.g., improved relationships) was associ- Green et al., 2000) or more likely (e.g., Gold, Marx,
ated with decreases in distress from pre- to posttrauma. Soler-Baillo & Sloan, 2005) to lead to PTSD than
In a follow-up study, there were much stronger rela- are Criterion A1 events. Thus, Criterion A1 may
tions between perceived and actual growth among be changed, or even eliminated, in the upcom-
trauma survivors who were less distressed posttrauma ing DSM-V. Criterion A2 (experiencing fear, help-
than in those who were more distressed posttrauma, lessness, or horror) also is problematic and may
supporting the notion that reporting PTG may be a be changed or eliminated because other emotions
strategy for coping with distress (Gunty, Frazier, (e.g., guilt, shame, anger) may be as or more impor-
Tennen, Tashiro, & Tomich, 2011). tant in predicting who develops PTSD (Brewin,
The previous section should not be taken to Andrews, & Rose, 2000). Unless researchers assess
imply that some people do not grow following trau- non-Criterion A1 events and emotions besides fear,
matic events. Clearly they do. In the prospective helplessness, or horror, we will not have a complete
study described above (Frazier, Tennen, et al., 2009), picture of which events are most distressing or
25% of the sample reported reliable increases in life which peritraumatic emotions are most important.
satisfaction from pre- to posttrauma (although those One category of event that deserves further atten-
increases were not necessarily due to the trauma). tion is the category of interpersonal traumas, such
The accumulating data do suggest, however, that ret- as ostracism, discrimination, and betrayal. Even
rospective self-reports of growth following trauma though these typically do not involve life-threat,
do not necessarily reflect actual growth from pre- to there is a great deal of evidence suggesting that they
posttrauma. As a result, some researchers have com- are very distressing and threaten basic belonging-
mented that propagating the notion that most people ness needs (see Smart Richman & Leary, 2009).
experience actual growth can have adverse effects on Researchers also need to take into account the fact
trauma survivors (e.g., Wortman, 2004). This is that there are cultural variations in what is consid-
illustrated in a book, written by a cancer survivor, ered traumatic. For example, in one study of Tibetan
who said “For at least a year after I had breast cancer, refugees, the destruction of religious sites (e.g., tem-
my friends would ask me what I’d learned from it. ples) and signs was rated as the worst possible event
And I admit I fell prey to the media hype a little. I that could ever happen (Terheggen, Stroebe, &
did think there ought to be something I could point Kleber, 2001). Such an event would not count as a
to . . . I hated to let everyone down” (Lewis, 2008, trauma according to Western definitions.
p. 9). This is not another burden we want to add
to individuals struggling to cope with traumatic life Risk of Trauma Exposure
events. The previous review focused on demographic differ-
ence in risk for trauma exposure. This review
Future Directions in Trauma Research revealed a need for more research on risk for trauma
This final section outlines some of the most pressing exposure among specific ethnic groups and research
questions and issues that need to be addressed in exploring the reasons behind the counterintuitive

fr azie r 829
finding that younger individuals report more life- movements of the heart (e.g., “heart flying out”)
time traumas than do older individuals. Additional (Rasmussen, Smith, & Keller, 2007).
studies also are needed that move beyond the assess-
ment of demographic differences in risk of trauma Risk Factors for Posttraumatic
exposure. Prospective studies in which risk factors Stress Disorder
are assessed prior to trauma exposure are most One conclusion drawn by several authors who have
useful. When “risk” factors are assessed at the same reviewed the literature on PTSD risk factors is that
time as lifetime trauma exposure, the risk factors more complex models of the development of PTSD
(e.g., neuroticism) may influence the reporting of need to be developed and tested (Brewin, Andrews,
past traumatic events. Further research also is needed & Valentine, 2000; Elwood et al., 2009; Ozer
that explores risk factors for different types of events. et al., 2003; Ozer & Weiss, 2004). These models
For example, the predictors of traumatic events in could involve either interactions (moderator effects)
childhood differ from the predictors of traumatic among risk factors or the posttrauma mechanisms
events in adulthood (Breslau, Davis, & Andreski, (mediator effects) by which pretrauma risk factor
1995). Hatch and Dohwenrend (2007) distin- are associated with greater symptom severity. The
guished between fateful events and events that may need for examining moderator effects was illustrated
have been brought about by the behavior of the by the findings of both meta-analyses (Brewin,
individual, which also may have different predic- Andrews, & Valentine, 2000; Ozer et al., 2003) that
tors. Finally, we need effective interventions for the relations between risk factors and PTSD symp-
preventing traumatic events, particularly those that, tom depended on (i.e., were moderated by) other
like sexual assault, carry a high risk for PTSD. Most factors (e.g., gender, type of trauma). For example,
sexual assault prevention programs focus on chang- McKeever and Huff (2003) have developed a diath-
ing attitudes on the assumption that changed atti- esis-stress model of PTSD in which biological (e.g.,
tudes will result in changed behavior but few genetic) and ecological (e.g., personal history, social
programs have been shown to reduce the actual risk support) factors interact with each other and with
of perpetration or victimization (Anderson & trauma severity in predicting PTSD (see also Olff
Whiston, 2005). et al., 2007). With regard to mediators, the mecha-
nisms by which pretrauma factors (ideally measured
Effects of Trauma prior to the trauma) are related to the development
The 2008 and 2009 conferences of the ISTSS of PTSD need to be identified (see Engelhard, van
contained a great deal of programming related to den Hout, Kindt, Arntz, & Schouten, 2003; Frazier,
possible changes to the PTSD criteria in the DSM-V. Gavian, et al., 2011; Lengua, Long, & Meltzoff,
These changes include whether PTSD will continue 2006, for examples).
to be classified as an anxiety disorder or whether
there will be a new category of trauma-related disor- Interventions
ders. Given that the DSM is a diagnostic classifica- As mentioned, several treatments have been identi-
tion scheme used around the world, one recurring fied that are effective in treating PTSD, such as
theme in these discussions was the need for cross- exposure therapy and CBT. Bradley et al. (2005)
cultural research on the effects of trauma that described some of the limitations of existing PTSD
assesses both universal and cultural-specific symp- treatment efficacy studies. One limitation is the lack
toms. According to Miller (2006), “a strict reliance of systematic data on comorbidity in patient sam-
on the language and constructs of Western psychia- ples. Given that comorbidity is the rule rather than
try risks inappropriately prioritizing psychiatric syn- the exception in individuals with PTSD (Breslau,
dromes that are familiar to Western practitioners, 2002), lack of data on this issue makes it difficult to
such as . . . PTSD, but that may be of secondary assess the generalizability of treatment findings.
concern or simply lack meaning to non-Western Rather than review the limitations of existing
populations for whom local idioms of distress are treatment outcome studies, the need for innovative
more salient” (p. 423). For example, studies that treatments and service delivery formats that can
move beyond Western paradigms have identified reach individuals who may not be interested in tradi-
unique symptoms of distress among Africans that tional psychotherapy is highlighted. This includes
differ from those recognized in Western psychology veterans who may find seeking help too stigmatizing,
including “crawling” beneath or on the scalp, intense individuals from cultures in which psychotherapy
heat in the body or head, and perceived sudden is not commonly used, or individuals who have

830 tr aum a psych o lo g y

experienced traumas they may not wish to disclose, practice are going to see clients who have experi-
such as sexual assault. All the best treatments in the enced traumatic events. Thus, it is imperative that
world will not help if the barriers to using them counseling psychologists are aware of research related
are too great. For example, the Department of to trauma and are trained to work with trauma sur-
Defense and the Veteran’s Administration have vivors. According to Courtois and Gold (2009),
funded a project to develop and implement an training in trauma-related topics has been largely
Internet-based intervention for veterans that reduces ignored in psychology or offered in specialty courses
many of the barriers to treatment-seeking among this outside of the main curricula. Given the prevalence
group (e.g., stigma). The ISTSS treatment guidelines and effects of trauma, Courtois and Gold decry this
for PTSD (Foa et al., 2009a) concluded that techno- situation, stating that “the noninclusion of informa-
logical innovations in service delivery (e.g., virtual tion in psychology about trauma as a major aspect
reality, Internet-based interventions) show promise of human experience and as a substantive contribu-
in making treatments more readily available. The tor to derailment of normative development and
National Institute on Drug Abuse has funded a study the development of psychopathology defies logic”
to evaluate the effectiveness of brief video-based (p. 12). They propose that basic information about
interventions for sexual assault survivors in the trauma be integrated throughout the psychology
emergency room, one of which has been found to curriculum, beginning at the undergraduate level
be effective in a previous study (Resnick, Acierno, and continuing through all aspects of graduate train-
Holmes, Kilpatrick, & Jager, 1999). Because many ing (e.g., coursework, practica, research). Their arti-
sexual assault survivors do not return for follow-up cle also provides information on existing training
services (Rosenberger, Frazier, & Moore, 2000), the programs and resources.
emergency room may be the one chance to inter- As argued at the beginning of the chapter, coun-
vene with survivors. Finally, a qualitative study with seling psychology is particularly well-suited to
Somali refugees is being conducted to understand contribute to the understanding and treatment of
the reasons behind the low service utilization rates trauma-related problems. As shown in this chapter,
for this group and to develop more culturally appro- these events happen to almost everyone, and most
priate interventions. For example, even though many people recover from them without developing diag-
Somali refugees have been tortured, very few (less nosable psychological disorders such as PTSD.
than 1%) requested or accepted referrals for Western Thus, trauma psychology fits well within counseling
mental health services (Jaranson et al., 2004). psychology’s emphasis on normal human function-
ing and positive adaptation. However, at this point,
Posttraumatic Growth trauma research is not well-represented in counsel-
As suggested by the previous review of research on ing journals. Hopefully, this chapter will serve to
PTG, one of the most important tasks is to further encourage more counseling psychologists to con-
explore what scores on PTG inventories actually rep- tribute to this important area of research and prac-
resent. Frazier and Kaler (2006) outlined a future tice and to focus on the normative processes of
research agenda for PTG that included the need for resilience following traumatic life events.
studies in which data are collected prospectively prior
to the trauma to assess actual change from pre- to
References
posttrauma, studies that assess whether self-reports of
Adams, R. E., & Boscarino, J. A. (2006). Predictors of PTSD
growth are evident in actual behaviors either in labo- and delayed PTSD after disaster: The impact of exposure
ratory or real-life situations, and studies that examine and psychosocial resources. Journal of Nervous and Mental
whether individuals who report that they have grown Disease, 194, 485–493.
from a traumatic event are better able to cope with American Psychiatric Association (APA). (1952). Diagnostic
future traumas. Research also is needed on the ante- and statistical manual of mental disorders. Washington, DC:
Author.
cedents and consequences of both perceived and American Psychiatric Association (APA). (1968). Diagnostic and
actual growth, which may very well differ. Even if statistical manual of mental disorders (2nd ed.). Washington,
measures of perceived growth do not measure actual DC: Author.
growth, they still may predict important outcomes. American Psychiatric Association (APA). (1980). Diagnostic and
statistical manual of mental disorders (3rd ed.). Washington,
DC: Author.
Conclusion American Psychiatric Association (APA). (1987). Diagnostic and
Given that almost everyone experiences a traumatic statistical manual of mental disorders (3rd ed., text rev.).
event in their lifetime, counseling psychologists in Washington, DC: Author.

fr azie r 831
American Psychiatric Association (APA). (1994). Diagnostic and Brewin, C. R., Andrews, B., & Rose, S. (2000). Fear, helpless-
statistical manual of mental disorders (4th ed.). Washington, ness, and horror in posttraumatic stress disorder: Investigating
DC: Author. the DSM-IV Criterion A2 in victims of violent crime. Journal
American Psychiatric Association (APA). (2000). Diagnostic and of Traumatic Stress, 13, 499–509.
statistical manual of mental disorders (4th ed., text rev.). Brewin, C. R., Andrews, B., & Valentine, J. D. (2000). Meta-
Washington, DC: Author. analysis of risk factors of posttraumatic stress disorder in
Amir, M., & Sol, O. (1999). Psychological impact and preva- trauma-exposed adults. Journal of Consulting and Clinical
lence of traumatic events in a student sample in Israel: The Psychology, 68, 748–766.
effect of multiple traumatic events and physical injury. Brewin, C., Dalgleish, T., & Joseph, S. (1996). A dual represen-
Journal of Traumatic Stress, 12(1), 139–154. tation theory of posttraumatic stress disorder. Psychological
Anders, S., Frazier, P., & Frankfurt, S. (2011). Variations in Review, 103, 670–686.
Criterion A and PTSD prevalence rates in a community Bryant, R., & Guthrie, R. (2005). Maladaptive appraisals as
sample of women. Journal of Anxiety Disorders, 26, 176–184. a risk factor for posttraumatic stress: A study of trainee
Anderson, L. A., Whiston, S. C. (2005). Sexual assault education firefighters. Psychological Science, 16, 749–752.
programs: A meta-analytic examination of their effectiveness. Cahill, S. P., & Foa, E. B. (2007). Psychological theories of
Psychology of Women Quarterly, 29(4), 374–388. PTSD. In M. J. Friedman, T. M. Keane, & P. A. Resick
Beck, J. G., Coffey, S. F., Palyo, S. A., Gudmundsdottir, B., (Eds.), Handbook of PTSD: Science and practice (pp. 55–77).
Miller, L. M., & Colder, C. R. (2004). Psychometric proper- New York: Guilford Press.
ties of the Posttraumatic Cognitions Inventory (PTCI): Card, J. (1987). Epidemiology of PTSD in a national cohort of
A replication with motor vehicle accident survivors. Vietnam veterans. Journal of Clinical Psychology, 43, 6–17.
Psychological Assessment, 16, 289–298. Charuvastra, A., & Cloitre, M. (2008). Social bonds and post-
Bedard-Gilligan, M., & Zoellner, L. A. (2008). The utility of the traumatic stress disorder. Annual Review of Psychology, 59,
A1 and A2 criteria in the diagnosis of PTSD. Behavior 301–328.
Research and Therapy, 46, 1062–1069. Courtois, C. A., & Gold, S. N. (2009). The need for inclusion of
Benish, S. G., Imel, Z. E., & Wampold, B. E. (2008). The psychological trauma in the professional curriculum: A call
relative efficacy of bona fide psychotherapies for treating to action. Psychological Trauma: Theory, Research, Practice, and
post-traumatic stress disorder: A meta-analysis of direct Policy, 1, 3–23.
comparisons. Clinical Psychology Review, 28(5), 746–758. Cox, B. J., MacPherson, P. S. R., Enns, M. W., &
Bernat, J. A., Ronfeldt, H. M., Calhoun, K. S., & Arias, I. McWilliams, L. A. (2004). Neuroticism and self-criticism
(1998). Prevalence of traumatic events and peritraumatic associated with posttraumatic stress disorder in a nationally
predictors of posttraumatic stress symptoms in a nonclinical representative sample. Behaviour Research and Therapy, 42,
sample of college students. Journal of Traumatic Stress, 11, 105–114.
645–664. Creamer, M., Burgess, P., & McFarlane, A. C. (2001). Post-
Bisson, J. I., Ehlers, A., Matthews, R., Pilling, S., Richards, D., traumatic stress disorder: Findings from the Australian
& Turner, S. (2007). Psychological treatments for chronic National Survey of Mental Health and Well-being. Psycho-
post-traumatic stress disorder: Systematic review and meta- logical Medicine, 31, 1237–1247.
analysis. British Journal of Psychiatry, 190(2), 97–104. Daugherty, T. K. (1998). Childhood trauma and current anxiety
Bodkin, J. A., Pope, H. G., Detke, M. J., & Hudson, J. I. (2007). among college men. Psychological Reports, 83, 667–673.
Is PTSD caused by traumatic stress? Journal of Anxiety Davis, C., Nolen-Hoeksema, S., & Larson, J. (1998). Making
Disorders, 21, 176–182. sense of loss and benefiting from the experience: Two con-
Bradley, R., Greene, J., Russ, E., Dutra, L., & Westen, D. (2005). struals of meaning. Journal of Personality and Social Psychology,
A multidimensional meta-analysis of psychotherapy for 75, 561–574.
PTSD. American Journal of Psychiatry, 162(2), 214–227. Dunmore, E., Clark, D. M., & Ehlers, A. (2001). A prospective
Bramsen, I., Dirkzwager, A. J. E., & van der Ploeg, H. M. investigation of the role of cognitive factors in persistent
(2000). Predeployment personality traits and exposure to Posttraumatic Stress Disorder (PTSD) after physical or sexual
trauma as predictors of posttraumatic stress symptoms: assault. Behaviour Research and Therapy, 39, 1063–1084.
A prospective study of former peacekeepers. American Journal Ehlers, A., & Clark, D. M. (2000). A cognitive model of post-
of Psychiatry, 157, 1115–1119. traumatic stress disorder. Behaviour Research and Therapy, 38,
Breslau, N. (2002). Epidemiologic studies of trauma, posttrau- 319–345.
matic stress disorder, and other psychiatric disorders. Ehlers, A., Mayou, R. A., & Bryant, B. (1998). Psychological
Canadian Journal of Psychiatry, 47, 923–929. predictors of chronic posttraumatic stress disorder after
Breslau, N., Davis, G. C., & Andreski, P. (1995). Risk factors motor vehicle accidents. Journal of Abnormal Psychology, 107,
for PTSD-related traumatic events: A prospective analysis. 508–519.
American Journal of Psychiatry, 152(4), 529–535. Elliott, D. M. (1997). Traumatic events: Prevalence and delayed
Breslau, N., Davis, G. C., Andreski, P., & Peterson, E. (1991). recall in the general population. Journal of Consulting and
Traumatic events and posttraumatic stress disorder in an Clinical Psychology, 65, 811–820.
urban population of young adults. Archives of General Elwood, L. S., Hahn, K. S., Olatunji, B. O., & Williams, N. L.
Psychiatry, 48, 216–222. (2009). Cognitive vulnerabilities to the development of
Breslau, N., Kessler, R. C., Chilcoat, H. D., Schultz, L. R., PTSD: A review of four vulnerabilities and the proposal of an
Davis, G. C., & Andreski, P. (1998). Trauma and posttrau- integrative vulnerability model. Clinical Psychology Review,
matic stress disorder in the community: The 1996 Detroit 29(1), 87–100.
area survey of trauma. Archives of General Psychiatry, 55, Engelhard, I. M., Huijding, J., van den Hout, M. A., & de Jong,
626–632. P. J. (2007). Vulnerability associations and symptoms of

832 tr aum a psych o lo g y

 posttraumatic stress disorder in soldiers deployed to Iraq. Frazier, P., Steward, J., & Mortensen, H. (2004). Perceived con-
Behaviour Research and Therapy, 45, 2317–2325. trol and adjustment to trauma: A comparison across events.
Engelhard, I. M., van den Hout, M. A., Kindt, M., Arntz, A., & Journal of Social and Clinical Psychology, 23, 303–324.
Schouten, E. (2003). Peritraumatic dissociation and post- Frazier, P., Tennen, H., Gavian, M., Park, C., Tomich, P., &
traumatic stress after pregnancy loss: A prospective study. Tashiro, T. (2009). Does self-reported post-traumatic growth
Behaviour Research and Therapy, 41, 67–78. reflect genuine positive change? Psychological Science, 20,
Foa, E. B., Cashman, L., Jaycox, L., & Perry, K. (1997). The 912–919.
validation of a self-report measure of posttraumatic stress Friedman, M. J., Cohen, J. A., Foa, E. B., & Keane, T. M.
disorder: The Posttraumatic Diagnostic Scale. Psychological (2009). Integration and summary. In E. B. Foa, T. M. Keane,
Assessment, 9, 445–451. M. J. Friedman, & J. A. Cohen (Eds.), Effective treatments for
Foa, E. B., Ehlers, A., Clark, D. M., Tolin, D. F., & Orsillo, S. M. PTSD: Practice guidelines from the International Society for
(1999). The Posttraumatic Cognitions Inventory (PTCI): Traumatic Stress Studies (2nd ed., pp. 617–642). New York:
Development and validation. Psychological Assessment, 11(3), Guilford Press.
303–314. Friedman, M., Resick, P., & Keane, T. (2007). Twenty-five years
Foa, E. B., & Jaycox, L. H. (1999). Cognitive-behavioral theory of progress and challenge. In M. Friedman, T. Keane, &
and treatment of posttraumatic stress disorder. In D. Spiegel P. Resick (Eds.), Handbook of PTSD: Science and practice
(Ed.), Efficacy and cost-effectiveness of psychotherapy (pp. 23–61). (pp. 3–18). New York: Guilford Press.
Washington, DC: American Psychiatric Press. Gold, S. D., Marx, B. P., Soler-Baillo, J. M., & Sloan, D. M.
Foa, E. B., Keane, T. M., Friedman, M. J., & Cohen, J. A. (2005). Is life stress more traumatic than traumatic stress?
(2009a). (Eds.). Effective treatments for PTSD: Practice guide- Anxiety Disorders, 19, 687–698.
lines from the International Society for Traumatic Stress Studies Goodman, L. A., Corcoran, C., Turner, K., Yuan, N., &
(2nd ed.). New York: Guilford Press. Green, B. L. (1998). Assessing traumatic event exposure:
Foa, E. B., Keane, T. M., Friedman, M. J., & Cohen, J. A. General issues and preliminary findings for the stressful life
(2009b). Introduction. In E. B. Foa, T. M. Keane, M. J. events screening questionnaire. Journal of Traumatic Stress,
Friedman, & J. A. Cohen (Eds.), Effective treatments for 11, 521–542.
PTSD: Practice guidelines from the International Society for Green, B. L., Goodman, L. A., Krupnick, J. L., Corcoran, C. B.,
Traumatic Stress Studies (2nd ed., pp. 1–20). New York: Petty, R. M., Stockton, P., & Stern, N. M. (2000). Outcomes
Guilford Press. of single versus multiple trauma exposure in a screening
Foa, E. B., & Kozak, M. J. (1986). Emotional processing of fear: sample. Journal of Traumatic Stress, 13, 271–286.
Exposure to corrective information. Psychological Bulletin, Gunty, A., Frazier, P., Tennen, H., Tomich, P., Tashiro, T., &
99, 20–35. Park, C. (2011). Moderators of the relation between per-
Foa, E. B., Zinbarg, R., & Rothbaum, B. O. (1992). Uncontrollability ceived and actual posttraumatic growth. Psychological Trauma:
and unpredictability in posttraumatic stress disorder: An animal Theory, Research, Practice, and Policy, 3, 61–66.
model. Psychological Bulletin, 112, 218–238. Hatch, S. L., & Dohrenwend, B. P. (2007). Distribution of trau-
Frans, Ö, Rimmö, P.-A., Åberg, L., & Fredrickson, M. (2005). matic and other stressful life events by race/ethnicity, gender,
Trauma exposure and post-traumatic stress disorder in the SES and age: A review of the research. American Journal of
general population. Acta Psychiatrica Scandinavica, 111, Community Psychology, 40, 313–332.
291–299. Helgeson, V. S., Reynolds, K. A., & Tomich, P. L. (2006).
Frazier, P., Anders, S., Perera, S., Tomich, P., Tennen, H., A meta-analytic review of benefit finding and growth. Journal
Park, C., & Tashiro, T. (2009). Traumatic events among of Consulting and Clinical Psychology, 74, 797–816.
undergraduate students: Prevalence and associated symp- Hodgins, G. A., Creamer, M., & Bell, R. (2001). Risk factors for
toms. Journal of Counseling Psychology, 56, 450–460. posttrauma reactions in police officers: A longitudinal study.
Frazier, P., Berman, M., & Steward, J. (2002). Perceived control Journal of Nervous and Mental Disease, 189, 541–547.
and posttraumatic stress: A temporal model. Applied & Horowitz, M. J. (1986). Stress response syndromes (2nd ed.).
Preventive Psychology, 10, 207–223. Northvale, NJ: Aronson.
Frazier, P., Conlon, A., & Glaser, T. (2001). Positive and negative Janoff-Bulman, R. (1992). Shattered assumptions: Towards a new
life changes following sexual assault. Journal of Consulting psychology of trauma. New York: Free Press.
and Clinical Psychology, 69, 1048–1055. Jaranson, J., Butcher, J., Halcon, L., Johnson, D., Robertson, C.,
Frazier, P., Gavian, M., Hirai, R., Park, C., Tennen, H., Savik, K., et al. (2004). Somali and Oromo refugees:
Tomich, P., & Tashiro, T. (2011). Prospective predictors of Correlates of torture and trauma. American Journal of Public
PTSD symptoms: Direct and mediated relations. Psychological Health, 94, 591–598.
Trauma: Theory, Research, Practice, and Policy, 3, 27–36. Joseph, S., & Linley, P. A. (2005). Positive adjustment to
Frazier, P. A., & Kaler, M. E. (2006). Assessing the validity of threatening events: An organismic valuing theory of
self-reported stress-related growth. Journal of Consulting and growth through adversity. Review of General Psychology, 9,
Clinical Psychology, 74, 859–869. 262–280.
Frazier, P., Keenan, N., Anders, S., Perera, S., Shallcross, S. & Keane, T. M., Brief, D. J., Pratt, E. M., & Miller, M. W.
Hintz, S. (2001). Perceived past, present, and future control (2007). Assessment of PTSD and its comorbidities in adults.
and adjustment to stressful life events. Journal of Personality In M. J. Friedman, T. M. Keane, & P. A. Resick (Eds.),
and Social Psychology, 100, 749–765. Handbook of PTSD: Science and practice (pp. 279–305).
Frazier, P., Mortensen, H., & Steward, J. (2005). Coping strate- New York: Guilford Press.
gies as mediators of the relations among perceived control Keane, T. M., Zimering, R. T., & Caddell, J. M. (1985).
and distress in sexual assault survivors. Journal of Counseling A behavioral formulation of posttraumatic stress disorder.
Psychology, 52, 267–278. Behavior Therapist, 8, 9–12.

fr azie r 833
Kessler, R. C., Berglund, P., Demler, O., Jin, R., Merikangas, K. R., Miller, K., Omidian, P., Quraishy, A., Quraishy, N., Nasiry, M.,
& Walters, E. E. (2005). Lifetime prevalence and age-of-onset et al. (2006). The Afghan symptom checklist: A culturally
distributions of DSM-IV disorders in the National Comorbidity grounded approach to mental health assessment in a
Survey Replication. Archives of General Psychiatry, 62, 593–602. conflict zone. American Journal of Orthopsychiatry, 76,
Kessler, R. C., Chiu, W. R., Demler, O., Walters, E. E. (2005). 423–233.
Prevalence, severity, and comorbidity of 12-Month DSM-IV Munley, P. H., Pate, W. E., II, & Duncan, L. E. (2008).
disorders in the National Comorbidity Survey Replication. Demographic, educational, employment, and professional
Archives of General Psychiatry, 62, 617–627. characteristics of counseling psychologist. The Counseling
Kessler, R. C., Sonnega, A., Bromet, E., Hughes, M., & Psychologist, 36, 250–280.
Nelson, C. B. (1995). Posttraumatic stress disorder in the National Collaborating Centre for Mental Health. (2005). Post-
National Comorbidity Survey. Archives of General Psychiatry, traumatic stress disorder: The management of PTSD in adults
52, 1048–1060. and children in primary and secondary care. London: National
Kirk, A., & Dollar, S. C. (2002). Prevalence of traumatic events Institute for Clinical Excellence (NICE).
and PTSD symptomatology among a selected sample of Nemeroff, C. B., Bremner, J. D., Foa, E. B., Mayberg, H. S.,
undergraduate students. Journal of Social Work in Disability North, C. S., & Stein, M. B. (2006). Posttraumatic stress
& Rehabilitation, 1, 53–65. disorder: A state-of-the-science review. Journal of Psychiatric
Krinsley, K. E., Gallagher, J. G., Weathers, F. W., Kutter, C. J., & Research, 40(1), 1–21.
Kaloupek, D. G. (2003). Consistency of retrospective report- Norris, F. H. (1992). Epidemiology of trauma: Frequency and
ing about exposure to traumatic events. Journal of Traumatic impact of different potentially traumatic events on different
Stress, 16, 399–409. demographic groups. Journal of Consulting and Clinical
Krupnick, J. L., Green, B. L., Stockton, P., Goodman, L., Psychology, 60, 409–418.
Corcoran, C., & Petty, R. (2004). Mental health effects of ado- Olff, M., Langeland, W., Draijer, N., & Gersons, B. P. R. (2007).
lescent trauma exposure in a female college sample: Exploring Gender differences in posttraumatic stress disorder. Psycholo-
differential outcomes based on experiences of unique trauma gical Bulletin, 133(2), 183–204.
types and dimensions. Psychiatry, 67, 264–279. Owens, G. P., & Chard, K. M. (2006). PTSD severity and
Lahey, B. (2009). Public health significance of neuroticism. cognitive reactions to trauma among a college sample:
American Psychologist, 64, 241–256. An exploratory study. Journal of Aggression, Maltreatment,
Lengua, L. J., Long, A. C., & Meltzoff, A. N. (2006). Preattack & Trauma, 13, 23–36.
stress-load, appraisals, and coping in children’s responses to Oxlad, M., & Wade, T. D. (2008). Longitudinal risk factors for
the 9/11 terrorist attacks. Journal of Child Psychology and adverse psychological functioning six months after coronary
Psychiatry, 47, 1219–1227. artery bypass graft surgery. Journal of Health Psychology, 13,
Lengua, L. J., Long, A. C., Smith, K. I., & Meltzoff, A. N. (2005). 79–92.
Preattack symptomatology and temperament as predictors of Ozer, E., Best, S., Lipsey, T., & Weiss, D. (2003). Predictors
children’s responses to the September 11 terrorist attacks. of posttraumatic stress disorder and symptoms in adults:
Journal of Child Psychology and Psychiatry, 46, 631–645. A meta-analysis. Psychological Bulletin, 129, 52–73.
Lensvelt Mulders, G., van Der Hart, O., van Ochten, J. M., van Ozer, E. J., & Weiss, D. S. (2004). Who develops posttraumatic
Son, M. J. M., Steele, K., & Breeman, L. (2008). Relations stress disorder? Current Directions in Psychological Science, 13,
among peritraumatic dissociation and posttraumatic stress: A 169–172.
meta-analysis. Clinical Psychology Review, 28(7), 1138–1151. Park, C. L., Cohen, L. H., & Murch, R. L. (1996). Assessment
Lewis, S. (2008). Five lessons I didn’t learn from breast cancer and prediction of stress-related growth. Journal of Personality,
(and one big one I did). New York: New American Library. 64, 71–105.
Litz, B. T., & Maguen, S. (2007). Early intervention for trauma. Parslow, R., Jorm, A., & Christensen, H. (2006). Associations
In M. J. Friedman, T. M. Keane, & P. A. Resick (Eds.), of pretrauma attributes and trauma exposure with
Handbook of PTSD: Science and practice (pp. 306–329). screening positive for PTSD: Analysis of a community-based
New York: Guilford Press. study of 2085 young adults. Psychological Medicine, 36,
Luszczynska, A., Benight, C. C., & Cieslak, R. (2009). Self- 387–395.
efficacy and health-related outcomes of collective trauma: Peirce, J. M., Burke, C. K., Stoller, K. B., Neufeld, K. J., &
A systematic review. European Psychologist, 14(1), 51–62. Brooner, R. K. (2009). Assessing traumatic event exposure:
McFarland, C., & Alvaro, C. (2000). The impact of motivation Comparing the traumatic life events questionnaire to the
on temporal comparisons: Coping with traumatic events by structured clinical interview for DSM-IV. Psychological
perceiving personal growth. Journal of Personality and Social Assessment, 21(2), 210–218.
Psychology, 79, 327–343. Perkonigg, A., Kessler, R. C., Storz, S., & Wittchen, H. (2000).
McKeever, V. M., & Huff, M. E. (2003). A diathesis-stress model Traumatic events and post-traumatic stress disorder in the
of posttraumatic stress disorder: Ecological, biological, and community: Prevalence, risk factors and comorbidity. Acta
residual stress pathways. Review of General Psychology, 7(3), Psychiatrica Scandinavica, 101(1), 46–59.
237–250. Ransom, S., Sheldon, K., & Jacobsen, P. (2008). Actual change
McMillen, J. C., & Cook, C. L. (2003). The positive and inaccurate recall contribute to posttraumatic growth
by-products of spinal cord injury and their correlates. following radiotherapy. Journal of Clinical and Consulting
Rehabilitation Psychology, 48, 77–85. Psychology, 76, 811–819.
McMillen, J. C., Smith, E., & Fisher, R. (1997). Perceived Rasmussen, A., Smith, H., & Keller, A. (2007). Factor structure
benefit and mental health after three types of disaster. Journal of PTSD symptoms among West and Central African refu-
of Consulting and Clinical Psychology, 65, 733–739. gees. Journal of Traumatic Stress, 20, 271–280.

834 tr aum a psych o lo g y

Resnick, H., Acierno, R., Holmes, M., Kilpatrick, D., & a community survey. American Journal of Psychiatry, 154,
Jager, N. (1999). Prevention of post rape psychopathology: 1114–1119.
Preliminary evaluation of an acute rape treatment. Journal Tedeschi, R., & Calhoun, L. (2004). Posttraumatic growth:
of Anxiety Disorders, 13, 359–370. Conceptual foundations and empirical evidence. Psychological
Resnick, H. S., Kilpatrick, D. G., Dansky, B. S., Saunders, B. E., Inquiry, 15, 1–18.
& Best, C. L. (1993). Prevalence of civilian trauma and post- Tedeschi, R. G., & Calhoun, L. G. (1996). The Posttraumatic
traumatic stress disorder in a representative national sample Growth Inventory: Measuring the positive legacy of trauma.
of women. Journal of Consulting and Clinical Psychology, 61, Journal of Traumatic Stress, 9, 455–472.
984–991. Terheggen, M., Stroebe, M., & Kleber, R. (2001). Western
Robins, R. W., Noftle, E. E., Trzesniewski, K. H., & Roberts, B. W. conceptualizations and Eastern experience: A cross-cultural
(2005). Do people know how their personality has changed? study of traumatic stress reactions among Tibetan refugees in
Correlates of perceived and actual personality change in young India. Journal of Traumatic Stress, 14(2), 391–403).
adulthood. Journal of Personality, 73, 489–521. Tolin, D. F., & Foa, E. B. (2006). Sex differences in trauma
Roemer, L., Litz, B. T., Orsillo, S. M., Ehlich, P. J., & and posttraumatic stress disorder: A quantitative review of
Friedman, M. J. (1998). Increases in retrospective accounts 25 years of research. Psychological Bulletin, 132, 959–992.
of war-zone exposure over time: The role of PTSD symptom Turner, R. J., & Avison, W. R. (2003). Status variations in stress
severity. Journal of Traumatic Stress, 11, 597–605. exposure: Implications for the interpretation of research on
Rosen, G. M., & Lilienfeld, S. O. (2007). Posttraumatic race, socioeconomic status and gender. Journal of Health and
stress disorder: An empirical evaluation of core assumptions. Social Behavior, 44, 488–505.
Clinical Psychology Review, 28, 837–868. Turner, R. J., & Lloyd, D. A. (2004). Stress burden and the life-
Rosenberger, S., Frazier, P., & Moore, N. (2000, August). time incidence of psychiatric disorder in young adults.
Correlates of service utilization among sexual assault survivors. Archives of General Psychiatry, 61, 481–488.
Poster presented at the annual meeting of the American van der Kolk, B. A. (2007). The history of trauma in psychiatry.
Psychological Association, Washington, DC. In M. J. Friedman, T. M. Keane, & P. A. Resick (Eds.),
Rubin, D. C., Berntsen, D., & Bohni, M. K. (2008). A memory- Handbook of PTSD: Science and practice (pp. 19–36).
based model of posttraumatic stress disorder: Evaluating New York: Guilford Press.
basic assumptions underlying the PTSD diagnosis. Psycho- Vrana, S., & Lauterbach, D. (1994). Prevalence of traumatic
logical Review, 115(4), 985–1011. events and post-traumatic psychological symptoms in a non-
Scarpa, A. (2001). Community violence exposure in a young clinical sample of college students. Journal of Traumatic Stress,
adult sample. Journal of Interpersonal Violence, 16, 36–53. 7, 289–302.
Scarpa, A., Fikretoglu, D., Bowser, F., Hurley, J. D., Pappert, C. A., Watson, S. B., & Haynes, S. N. (2007). Brief screening for
Romero, N., & Van Voorhees, E. (2002). Community vio- traumatic life events in female undergraduate health service
lence exposure in university students. Journal of Interpersonal patients. International Journal of Clinical and Health
Violence, 17, 253–272. Psychology, 7, 261–282.
Sears, S. R., Stanton, A. L., & Danoff-Burg, S. (2003). Weathers, F. W., Keane, T. M., & Foa, E. B. (2009). In E. B. Foa,
The yellow brick road and the emerald city: Benefit finding, T. M. Keane, M. J. Friedman, & J. A. Cohen (Eds.), Effective
positive reappraisal coping, and posttraumatic growth in treatments for PTSD: Practice guidelines from the International
women with early-stage breast cancer. Health Psychology, 22, Society for Traumatic Stress Studies (2nd ed., pp. 23–61).
487–497. New York: Guilford Press.
Siegel, K., & Schrimshaw, E. W. (2003). Reasons for adopting Wilson, J. P., & Keane, T. M. (2004). Assessing psychological
celibacy among older men and women living with HIV/ trauma and PTSD (2nd ed.). New York: Guilford Press.
AIDS. Journal of Sex Research, 40, 189–200. Wortman, C. B. (2004). Posttraumatic growth: Progress and
Skinner, E. A. (1996). A guide to constructs of control. Journal of problems. Psychological Inquiry, 15, 81–90.
Personality and Social Psychology, 71, 549–570. Yehuda, R. (2004). Risk and resilience in posttraumatic stress
Smart Richman, L., & Leary, M. R. (2009). Reactions to dis- disorder. Journal of Clinical Psychiatry, 65, 29–36.
crimination, stigmatization, ostracism, and other forms of Zatzick, D., Rivara, F., Nathens, A., Jurkovich, G., Wang, J.,
interpersonal rejection: A multimotive model. Psychological Fan, M., et al. (2007). A nationwide US study of post-
Review, 116, 365–383. traumatic stress after hospitalization for physical injury.
Steger, M., Frazier, P., & Zacchanini, J. L. (2008). Terrorism in Psychological Medicine, 37, 1469–1480.
two cultures: Stress and growth following September 11th Zoellner, T., Rabe, S., Karl, A., & Maercker, A. (2008).
and the Madrid train bombings. Journal of Loss and Trauma, Posttraumatic growth in accident survivors: Openness and
13, 511–527. optimism as predictors of its constructive or illusory sides.
Stein, D. J., Ipser, J. C., & Seedat, S. (2006). Pharmacotherapy Journal of Clinical Psychology, 64, 245–263.
for post traumatic stress disorder (PTSD). Cochrane Database
of Systematic Reviews, 1, Art. No.: CD002795. DOI:
10.1002/14651858.CD002795.pub2. Further Reading
Stein, M. B., Hofler, M., Perkonigg, A., Lieb, R., Pfister, H., Bradley, R., Greene, J., Russ, E., Dutra, L., & Westen, D. (2005).
Maercker, A., et al. (2002). Patterns of incidence and psychi- A multidimensional meta-analysis of psychotherapy for
atric risk factors for traumatic events. International Journal of PTSD. American Journal of Psychiatry, 162, 214–227.
Methods in Psychiatric Research, 11(4), 143–153. Breslau, N., Kessler, R. C., Chilcoat, H. D., Schultz, L. R.,
Stein, M. B., Walker, J. R., Hazen, A. L., & Forde, D. R. (1997). Davis, G. C., & Andreski, P. (1998). Trauma and posttrau-
Full and partial posttraumatic stress disorder: Findings from matic stress disorder in the community: The 1996 Detroit

fr azie r 835
 area survey of trauma. Archives of General Psychiatry, 55, McKeever, V. M., & Huff, M. E. (2003). A diathesis-stress model
626–632. of posttraumatic stress disorder: Ecological, biological, and
Foa, E., Keane, T., Friedman, M., & Cohen, J. (2009). (Eds.). residual stress pathways. Review of General Psychology, 7,
Effective treatments for PTSD: Practice guidelines from the 237–250.
International Society for Traumatic Stress Studies (2nd ed.). Ozer, E., Best, S., Lipsey, T., & Weiss, D. (2003). Predictors
New York: Guilford Press. of posttraumatic stress disorder and symptoms in adults:
Friedman, M., Keane, T., & Resick, P. (Eds.). (2007). A meta-analysis. Psychological Bulletin, 129, 52–73.
Handbook of PTSD: Science and practice. New York: Rubin, D. C., Berntsen, D., & Bohni, M. K. (2008).
Guilford Press. A memory-based model of posttraumatic stress disorder:
Kessler, R. C., Sonnega, A., Bromet, E., Hughes, M., & Evaluating basic assumptions underlying the PTSD diagnosis.
Nelson, C. B. (1995). Posttraumatic stress disorder in the Psychological Review, 115, 985–1011.
National Comorbidity Survey. Archives of General Psychiatry,
52, 1048–1060.

836 tr aum a psych o lo g y

 CHAPTER

32 Counseling Psychologists As Consultants

Stewart E. Cooper and Sandra L. Shullman

Abstract
The new American Psychological Association (APA) guidelines on education and training (Rodolfa,
Bent, Eisman, Nelson, Rehm, & Ritchie (2005) list consultation as one of the five key competencies
for applied psychologists in general. All counseling psychologists engage in consultation as one of their
primary work activities, with the specifics being influenced by setting, population, and particular job
responsibilities. The purpose of this chapter is to enhance understanding of the concepts and skills
associated with the professional role, type of consultation, and focus of consulting processes for
counseling psychologists serving as consultants. Additionally, suggested direction for further
development of consultation for counseling psychologists is presented.
Keywords: consultant, consulting, consultation, mental health consultation, school consultation,
organizational consultation

Psychologically based consultation is a primary pro- key roles, and requisite skills for counseling psychol-
fessional activity, engaged in by virtually all counsel- ogists as consultants. The second section focuses on
ing psychologists, whether or not they consciously consultation theory and research. The third addresses
consider and/or label the activity as consulta- multicultural issues and the practice of consultation.
tion. Moreover, consultation as an expected profes- The fourth presents a generic model of consultation,
sional role for psychologists is now more formally along with three specific applied models of con-
considered as a highly significant professional activ- sultation: mental health consultation, school con-
ity. For example, consultation and education has sultation, and organizational consultation. The fifth
been recently recognized as one of seven core com- section presents the current status (and dearth) of
petencies needed by all professional psychologists, training on this key professional psychology compe-
along with relationship, assessment, intervention, tency. Finally, the last section presents some best
research and evaluation, management and supervi- practices for counseling psychologists who aspire to
sion, and diversity (Rodolfa, Bent, Eisman, Nelson, engage or are currently engaged in psychologically
Rehm, & Ritchie, 2005). based consultation and suggests some needed steps
The purpose of this chapter is to assist counseling for the immediate future of this area of practice.
psychologists in learning more about consultation as
a professional role and about the range of possible Essentials of Psychologically Based
consultation types and focus areas. The chapter is Consultation: Common Characteristics,
divided into six sections. The first section covers the Roles, and Skill Sets of Consultation
essentials of psychologically based consultation and Common Characteristics
examples of counseling psychologists working as con- Dougherty (2009a) presents ten common aspects or
sultants. This incorporates common characteristics, characteristics of psychologically based consultation

837
that can be used to differentiate this service modal- for an upper-level manager (consultee) by a large
ity from other modalities: the role of a human ser- corporation also has client relationship responsi-
vices professional; a focus on a problem-solving bilities with the upper-level manager’s boss and
process; work that is triadic in nature; a helping the organization. In this situation, the consultant
relationship; work done either internally or exter- ensures that the information emerging from the
nally; efforts involving all voluntary parties; rela- work with the consultee (upper-level manager) ben-
tionships of peers; marked collaboration, regardless efits not only that individual but the organization
of what consultation role best fits the needs of the as well. This requires clarification at the beginning
consultee and client system; temporary rather than with all parties.
ongoing engagement; and focus on either remedial Consultations can be internal or external to the con-
or developmental needs. The following illustrate sultee or can be a hybrid of the two. For example, a
each of these ten characteristics as they might play counseling center director does team building with
out for counseling psychologists in consultation the staff of the career center at the same university.
roles. The director, who is a counseling psychologist, is an
Consultation by a human services professional internal consultant in that the director and the career
differs from consultation by other professions in the need center staff both work at the same university and
for flexible adaptation of the interventions based on an both are in the student affairs division. Yet, the psy-
interactive process between the consultant and the con- chologist is an external consultant, as the career center
sultee. For example, a counseling psychologist who and its staff is a distinct unit, with only a moderate
had delivered several team building consultations number of cross-referrals and interactions.
to the leadership team of a non-profit organization Consultation is engaged in on a voluntary basis. For
going through significant expansion and change example, a counseling psychologist employed in an
shifted to working on developing and revising job employee assistance program (EAP) is contacted by
descriptions and to supporting the onboarding pro- a line manager having a problem with a staff member.
cess for new hires to the team. The need from this The human resources (HR) office suggested that the
shift emerged from a series of discussions with the manager contact the EAP office, but it was an option
CEO based on the progress already made through offered to the manager to pursue voluntarily. This
the previous consultations in the face of new chal- example shows how easy it can be to intentionally or
lenges that had emerged for the organization. unintentionally put significant pressure on an indi-
Consultation involves a focus on the care-taking/ vidual or a team to become a consultee by using
work-related role of the consultee rather than their “recommended” consulting services.
mental health issues. For example, a counseling psy- Consultation is a relationship of peers. In consulta-
chologist meets four times with a teacher who would tion, although the consultee and the consultant may
appear to be having control-based frustrations with have different knowledge and skills, both come
an oppositional student. Instead of focusing on the together as equals to develop and select interven-
history and dynamics of the teacher and the teach- tions to benefit the client system and then to imple-
er’s need for control, the psychologist could work ment these interventions with adjustments to meet
with the teacher to develop new strategies that give these goals. The consultee often brings a much better
options to the student as well, putting emphasis on awareness of the client system and its context than
increasing the cooperation level of the student with does the consultant, whereas the consultant often
the teacher. has specific in-depth expertise in processes to assist
Consultation typically involves a triadic and indi- the consultee in achieving success and/or profes-
rect connection, in which the consultant relates through sional growth. For example, a counseling psycholo-
the consultee to the client system. For example, a direc- gist working in the defense industry works with a
tor of a number of community behaviorally oriented section chief to develop ways to be a more effective
group homes for developmentally delayed adults leader. The work is sufficiently complicated, and the
participates in a 3-day intensive training experience section manager may have a good deal of informa-
in advanced behavior modification strategies, taught tion that cannot be shared due to national security
by three counseling psychologists with expertise in concerns. The consultant can focus on effective lead-
these methods. ership processes and rely on the client to apply learn-
Consultation is fundamentally a helping rela- ing without revealing protected information.
tionship. For example, a counseling psychologist Consultation is marked by collaboration, regard-
employed as a leadership development specialist less of consultation role and fit with consultee/client

838 coun seling p s ych o lo gis ts as co n s u ltants

system needs. This point can be confusing because For example, a counseling psychologist who has
consultation and collaboration are related yet dis- developed a school safety program provides semi-
tinct professional activities. As discussed earlier, nars to administrators, teachers, and professional
consultation, regardless of consultant role taken and staff in districts within a large regional area. The
consulting approach used, must be collaborative to psychologist employs an educational approach.
be successful. This is due to several of the character- A developmentally focused program helps the
istics described above, including the concepts of administrators, teachers, and professional staff apply
relationship between peers and viewing consulta- what they have learned to create new and creative
tion as a voluntary relationship. In this sense, the approaches to school safety within their specific
collaboration inherent in consultation is somewhat schools. In contrast, a remedial program helps them
different than the relationship between supervisor identify previous deficiencies in their school safety
and supervisee and between teacher and student. programs to bring them up to minimum standards.
Both of these latter relationships involve a power
differential and an evaluative component. (A profes- Consultation Roles
sional gatekeeping function is often present as well.) Counseling psychologists delivering psychologically
In contrast, for example, a counseling psychologist based consultation typically take on one or more
is hired to do a program evaluation of a community of six roles: expert, trainer/educator, collaborator,
methadone clinic. Although the consultant has the fact-finder, process specialist, advocate (Dougherty,
expertise needed to do such program evaluation, 2009a).
a good deal of discussion and collaboration is needed During the time of their training and subsequent
between the consultant and the director of the pro- to graduation, counseling psychologists typically
gram to identify the components to be evaluated develop, by plan or circumstances, several areas of
and the staff resources available to gather and assem- expertise, thereby becoming an expert. These areas
ble the data. of early expertise often become the basis of future
Consultation is temporary rather than ongoing. professional work. Furthermore, it is common to
Some consultation projects, particularly those that develop consultation activities in areas of expertise.
are complex and involve teams of consultants with A few examples of such a transition to expert are
specialized expertise areas, can continue for a sus- provided to further explain this process. For exam-
tained period of time. Similarly, executive coaching, ple, a counseling psychologist trained in a Veterans
due to its nature, can go on for several months or Administration (VA) internship to do therapy for
years. Most consultation, however, is short term, veterans with posttraumatic stress disorder (PTSD)
focused on specific problems, and is done when the is asked to give testimony at a congressional com-
goals are satisfactorily met or when no additional mittee meeting on what is needed to successfully
resources can be used to support further work. For assist such persons. As a second example, a coun-
example, a counseling psychologist is hired to pro- seling psychologist who has done a good deal of
vide coaching to the director of a large urban hospi- student suicide prevention work on campus goes
tal with 2,000 employees, a great deal of complexity, on to develop and deliver workshops to campus
and major economic challenges. The psychologist administrators. Third, a counseling psychologist with
consultant and the director agree that a 3-month advanced business training works with corporate
contract for weekly consultation should provide leadership teams within a company to enhance suc-
some needed support to make changes helpful to cess in areas for which individual team leaders have
the hospital organization and its very diverse con- responsibility.
stituencies, each with its own focus. They may also Counseling psychologists who use the expert role
agree to review where they are at the end of each as their primary role in a particular consultation sit-
month and at the end of the 3-month period. uation do so when the consultee believes they have a
Consultation is focused on either remedial or devel- clearly identified need, requiring specialized knowl-
opmental needs. Remedial needs would represent edge and experience that the consultant possesses.
situations in which moderate or more serious con- Often, however, the need they have identified may
cerns exist about the current performance level of not be either the best or only need, and other, more
client system and/or the consultee. Developmental important needs emerge as the consultation process
needs represent situations in which the goal is to develops. Additionally, consultees who are seeking
anticipate or prevent a problem or to learn to func- expert consultants do not develop their own prob-
tion at a higher or different level of effectiveness. lem-solving skills when sometimes doing so would

coope r, shullm an 839

be to their advantage. There is perhaps a potential decision making. It is the consultee who determines
parallel here to the situation in which mental health the course of action selected and the responsibility
clients may look for experts to tell them how to fix for its implementation. The benefit of the collabora-
their mental health issues rather than learning to tor approach to consultation is that it maximizes the
handle these issues themselves. It is incumbent on consultee’s professional growth. The caution is that
the consultant to clearly define and clarify areas of the consultant can overestimate the level of the con-
expertise for potential consultees. sultee’s knowledge and skills, especially if he or she is
The trainer/educator consultation role is one that talented interpersonally. As an example, a counseling
is close to the expert role just described. It is perhaps psychologist assists a mental health counselor in
the most common consultation role that counsel- making choices about which therapy interventions
ing psychologists use (Cooper, 2003). The goal is for are most likely to be successful, subsequent to assist-
the consultant to assist the consultee in the develop- ing the consultee in conducting an interpersonally
ment of new knowledge and skills, to help the client based treatment formulation. For a second example,
systems with whom they work. Training and educa- a counseling psychologist engages in collaborative
tion can be formal or informal, and training requires consultation with the CEO of a local YMCA and its
the counseling psychologist consultant to have spe- leadership team to optimize the opportunities pro-
cific skills, expertise, and facilitation/teaching skills. vided by their move to a new facility. Or, a counsel-
Education requires the counseling psychologist con- ing psychologist working in a school district consults
sultant to possess a high-level knowledge base and collaboratively with the special education team in
strong teaching ability. For example, a counseling one of the area high schools. The purpose of this col-
psychologist provides ongoing training to a police laborative consultation is to help this team evaluate
department to help line officers better respond to the quality of the services they provide, with the
situations involving a person with significant mental intention of using the results to improve the services
illness. As a second example, a counseling psycholo- received by students and their families.
gist provides a workshop on behavioral strategies The fact-finder is another role that counseling
and then follows-up with group consultation to psychologist consultants can use to help consultees
bachelors’ level staff at group homes for emotion- assist their own client systems. The background and
ally disabled children. Or, a counseling psycholo- training experiences in assessment and program
gist delivers a half-day workshop to campus student evaluation that counseling psychologists receive in
affairs administrators on campus strategies for sui- their doctoral studies and postdoctoral professional
cide prevention. The trainer/educator approach is development are well suited to this fact-finder role.
most useful when the information or skills imparted The most common process is for the consultant in
to the consultee can be easily implemented and put the fact-finder role to gather, analyze, and synthesize
into practice to support the client system. Typically, information and to provide feedback to the consul-
however, formal assessment of such implementation tee (Dougherty, 2009a). Such information can be
does not take place (Dougherty, 2009a). simple or complex, take a long or short time, and
The collaborator role of consultation is likely can focus information gathering on an individual,
to be one of the two consultation roles of most individuals, a group, or the entire organization.
familiarity and preference for counseling psycholo- Sources of information range over a wide variety of
gists (Cooper, 2003; Pryzwansky & White, 1983). topics and are selected depending upon the pur-
The collaborator role requires that the consultee poses and needs of the consultation. Both naturalis-
has the requisite knowledge and skills to be able tic and standardized methods can be employed
to bring these to bear in meeting the needs of the cli- (Cooper & O’Connor, 1993). Naturalistic tech-
ent system, yet needs the assistance of the consultant, niques may include nonintrusive observation, use of
for various reasons, to have the best outcomes. Typi- existing records, interviews, and informal assess-
cally, the consultant first solicits the consultee’s per- ments. Standardized methods would consist of vali-
spectives about his or her direct service issues and dated and reliable inventories and substantiated
goals, and his or her ideas about how to achieve qualitative methods. An excellent initial question
them. The consultant then provides assistance in for the consultant being asked to take on a fact-
generating and tentatively suggesting solutions, finding role is to discern why they, rather than the
determining the promoting and restraining influ- consultee, is being asked to collect, analyze, and
ences on these options, and facilitating consultee evaluate the results. Often, consultation is requested

840 coun seling p s ych o lo gis ts as co n s u ltants

because of lack of existing expertise or lack of time consultants’ roles, developed in the 1970s, includes
or other resources (Schein, 1999). task roles (those related to expertise) at one end of a
The process specialist consultation role is one that continuum and process roles (those related to facilita-
is a strong fit with the training of counseling psy- tion at the other; Margulies & Raia, 1972; Schein,
chologists. It is the least directive of all the six roles 1999). Consultation roles often appear to be cate-
(Lippit & Lippit, 1986). In the process specialist gorized by the balance of involvement and control
role, the consultant focuses more on the questions in the process between the consultant and the con-
of “how” rather than “what,” and on process rather sultee (Dougherty, 2009a). There is an obvious par-
than content. Edgar Schein was the architect of allel here to the counseling process, in which the
this approach (Schein, 1969, 1978, 1987, 1988, counseling psychologist’s role of involvement and
1999). Two subcomponents of process consultation control is balanced in interaction with the counsel-
were defined—a process observer role and a process ing client’s psychological and situational resources.
facilitator role (Kormanski & Eschbach, 1997). The There are several key factors in selecting the pri-
relative balance of these two for the counseling psy- mary, secondary, and perhaps tertiary roles to be
chologist engaged in consultation depends on the assumed in a particular consultation situation
needs, goals, and preexisting skills of the consultees (Dougherty, 2009b). These key factors involve the
with whom they are working. For example, a coun- nature of the problem itself, the purpose of the con-
seling psychologist is brought into a large company sultation and its desired outcomes, and the consul-
to assist a mid-level team that is exhibiting difficul- tant’s and consultee’s skill sets (Dougherty, 2009b).
ties in communication and decision making during Given the enhanced complexity of the triadic nature
their weekly 2-hour meetings. As a second example, of consultation relative to the complexities of dyadic
a large firm that has a high rate of dissatisfaction services, such as individual counseling, it is often
among its front-line employees hires a counseling helpful to have co-consultants or a “shadow consul-
psychologist to observe front-line manager behavior tant” brainstorm about best roles and approaches to
and to meet with each one to discuss observations. particular consultation situations (Kilburg, 2002).
A third example might involve a counseling psy-
chologist who is brought into a large community Consultant Skill Sets
mental health center to facilitate discussion among Recent efforts have been made to define specific
group therapy leaders and administrators, following competencies and skill sets for psychologists in
discovery that the group program is evaluated as not consultation roles (O’Roark, 1999). Specifically,
working well. For counseling psychologists, their Division 13 of the American Psychological
education and experience in working with groups Association (APA), the Society for Consulting
provides them with a strong skill set for using this Psychology, developed a set of consulting compe-
process specialist role in consultation (Corey, Corey, tencies for training consulting psychologists, which
& Corey, 2010). A common pitfall in such a process were adopted as APA Guidelines (APA, 2007;
consultation role, however, can occur when consul- O’Roark, Lloyd, & Cooper, 2005). These are pre-
tants put too much focus on resolving interpersonal sented in Table 32.1. Shullman (2002) discussed
issues (Schein, 1988). It is critical to know when to the relationship of the consulting competencies for
make referrals for therapy rather than moving over training consulting psychologists with the training
that boundary in the consulting process (Schein, of counseling psychologists. Although several
1990). attempts have been made to define essential skill
Other paradigms for categorizing consulting sets for consultants (Cooper, Monarch, Serviss,
roles exist; these are helpful and often utilize a roles Gordick, & Skipton, 2007), Dougherty (2009) has
continuum (Dougherty, 2009a). The most popu- developed a set of seven skill domains, each of which
lar categorization approach still used was devel- is composed of nine skills (see Dougherty, 2009a,
oped earlier by Lippit and Lippit (1986). In their pp. 25–31 for a more detailed description of these
approach, the consultants’ roles lie on a continuum 63 skills). The seven domains are communications
ranging from directive to nondirective roles. In direc- skills, interpersonal skills, problem-solving skills,
tive roles, the consultant is something of a techni- organization analysis skills, group work, cultural
cal expert, whereas in nondirective roles, consultants competence skills, and ethical/legal knowledge
tend to facilitate the consultee’s expertise. (Lippitt & and competency. The overlap between essential skill
Lippitt, 1986). Another popular approach to sets for counseling psychologists as therapists and

coope r, shullm an 841

Table 32.1. Competencies for Postdoctoral level Organizational Consulting Psychologists
A. Primarily Individual-Level Core Competencies
(1) Individual assessment for purposes of career and vocational assessment
(2) Individual assessment for purposes of employee selection or development
(3) Job analysis for purposes of individual assessment
(4) Executive and individual coaching
(5) Individual-level intervention for job and career-related problems
B. Primarily Group-Level Core Competencies
(1) Group assessment
(2) Assessment of the functional and dysfunctional group behavior
(3) Assessment and development of teams
(4) Creating group level teams in organizations (e.g., self-directed work groups)
(5) Inter-group assessment and intervention
(6) Group boundary assessment and intervention
(7) Identity group (racial, gender, ethnic) management in the organizational context
C. Primarily Organizational/Systemic-Level Core Competencies
(1) Organizational diagnosis including systemic assessment of the entire organization
or large component parts of the organization
(2) Attitude, climate, and satisfaction surveys
(3) Evaluation of corporate management philosophy, organizational culture and nature
of systemic stressors
(4) Work-flow and project planning activities
(5) Identification of aggregate performance measures
(6) Assessment of organizational values and management practices
(7) Organizational level interventions
(8) Change management of organizational systems

counseling psychologists as consultants is signifi- One approach involved revising the cube to become
cant. The largest differences are in focus when a more systems and interactional model (Pace,
applying these skills and in attention to organiza- Stamler, Yarris, & June, 1996). Kurpius and Fuqua
tional context (Shullman, 2002). (1993) advanced the field when they served as
authors and editors of a double special issue of
Essentials of Consultation Theory and the Journal of Counseling & Development entitled
Research Understanding Psychologically “Consultation: A Paradigm for Helping.” Atkinson,
Based Consultation Thompson, and Grant (1993) articulated eight
A number of counseling psychologists have identi- roles for counseling psychologists. They also pre-
fied psychologically based consultation as an impor- sented their work as a cube-like model, in which
tant role. In 1974, Morrill, Oetting, and Hurst consultation was one of these eight roles. Similarly,
developed a three-dimensional “cube” model for the community psychology model placed a large
categorizing a broad range of counseling interven- emphasis on the use of consultation as an indirect
tions. They identified one to four possible targets (triadic) service mode (Lewis, Lewis, Daniels, &
of intervention (individual, primary group, associa- D’Andrea, 2003). Caplan’s mental health consulta-
tion group, and institution or community); one of tion model (1970) has also received significant
three possible purposes (remediation, prevention, attention. In his model, mental health consultation
and development); and one of three possible meth- was considered an alternative means of delivering
ods of intervention (direct service, consultation, primary care interventions, with a large emphasis
and media). Thus, their model explicitly cited con- on a power-free relationship between consultant
sultation as one of the three counseling interven- and consultee and a focus on the client’s ecological
tion methods listed. The cube model stimulated system. The mental health collaboration approach
further work having a direct bearing on consultation. later emerged to address some of the control and

842 coun seling p s ych o lo gis ts as co n s u ltants

responsibility issues questioned in the original culars of the content and focus of consultation can
model. (Caplan, Caplan, & Erchul, 1994). Thus, differ tremendously. Additionally, the major dis-
the mental health consultation approach was con- tinction in consultation focuses on whether the pri-
siderably revised later as a result of critiques of the mary emphasis of the consultation is on the
model based on resulting research (Caplan & consultee’s work-related role versus a caretaking-
Caplan, 1993). related role. (Dougherty, 2009a). An example of
Although the various forms of consultation a counseling psychologist helping a consultee with
employed by psychologists have not received a great a work-related role could be an executive coach-
deal of attention, several texts clarify both the over- ing situation. In such a situation, an upper-level
lap and distinctiveness of consultation in relation to administrator may help an individual redirect
counseling and psychotherapy (e.g., Bellman, 1990; leadership behaviors that are likely interfering
Dougherty, 2009a; Lippitt & Lippitt, 1986). To with the direction and effectiveness of those who
understand these commonalities and differences, it work for them. Such situations are dexribed in detail
is helpful to distinguish consultation terms from elsewhere (Kampa-Kokesch & Anderson, 2001).
related clinical terms. Dougherty (2009a) presents Alternatively, an example of a counseling psycholo-
concise definitions of four critical terms, designated gist helping a consultee with a caretaking role could
as the “4 Cs”: consultation, consultee, consultant, be a consultant hired to conduct a program evalua-
and client system. tion of a campus suicide prevention effort, working
with and through a task force created to address this
• Consultation: A type of helping relationship
issue. In this situation, the consultant and task force
in which a human service professional (consultant)
might meet to discuss the results of the evaluation,
delivers assistance to another person (consultee)
and the task force may make decisions concerning
so as to solve a work-related or caretaking-related
changes in the program, based on the interaction
problem the consultee has with a client system
with the consultant.
(a person, group, organization, or community).
The idea of a triadic relationship is common to
• Consultant: A person, typically a human
most concepts of psychologically based consultation
service professional, who delivers direct service
(Bell & Nadler, 1985). The consultant interacts
to another person (consultee) who has a
directly with the consultee who, in turn, is seeking
work-related or caretaking-related problem with
to enhance a targeted area of functioning of the
a client system.
individual, the group, or the organization. Often,
• Consultee: The person, often a human service
the effectiveness of the consultant with the client
professional or a caretaker (for example, a parent,
system is indirect, via the actions of the consultee
teacher, or supervisor), to whom the consultant
(Knoff, Hines, & Kromrey, 1995). At times, how-
provides assistance with a work-related or
ever, the consultant may interact directly with
caretaking-related problem. One of the goals of
the client system (Peterson, 2010). For example,
consultation is to improve the current and future
the counseling psychologist consultant may con-
functioning of the consultee.
duct an assessment of a person for selection or
• Client system: The person, group,
may assist him or her with leadership development.
organization, or community with whom the
Such selection and/or leadership development will
consultee is having work-related or caretaking-
likely have a considerable effect on the individual’s
related problem. One of the goals of consultation
team, agency, or organization. Systems evaluation
is to improve the functioning of the client system
and observation are other examples of direct contact
(Dougherty, 2009a).
between the consultant and the client system. Such
Dougherty (2009a) views consultation as deal- limited direct contact of the consultant with the
ing exclusively with the consultee’s work-related or client system differs from what is labeled collabora-
caregiving-related problems, and is collaborative. tion (Caplan et al., 1994). This distinction will be
The consultant and consultee work together in solv- addressed later in this chapter.
ing the problems defined by consultation. The word Psychologically based mental health, school-
“challenge” rather than “problem” may convey a based, and organizational consultation offer differ-
more positive connotation that could be helpful to ential approaches to mental health therapy. Mental
the consultee (Foster & Lloyd, 2007). health–focused consultation differs from psycho-
Although nearly all consultation involves a con- therapy not so much in the goal of change for the
sultant, consultee, and a client system, the parti- client system, but in the triadic nature of how this is

coope r, shullm an 843

accomplished (Caplan & Caplan, 1993). For exam- of consultation in organizational settings focuses on
ple, a consultant with expertise in PTSD may be individual work issues, although often the focus for
brought in to help mental health workers better organizational consultation is on teams and the
assist those affected by trauma. In this situation, the organization as a whole. Even when the focus of
consultant does not work directly with those in the consultation is on an individual, the goals of
need of services, but with those who are trying to the individual’s organization are at least equal or
help them. perhaps more important than the goals of the indi-
The differences between mental health therapy vidual person. Thus, compared to the individual
and school-based consultation focus on the priority making an occupational choice, counseling psy-
given to the student’s educational attainment over chologists engaged in organizational consultation
other areas of his or her life functioning and on the focus on enhancing the functioning of the organiza-
triadic rather than dyadic/direct nature of the ser- tion itself, by improving the functioning of indi-
vice (Rosenfield, 2002). For example, a counseling viduals and groups within the organization or by
psychologist with additional training as a school changing the organization’s structures and processes.
psychologist may gather information from formal- Thus, although the consultation work may be being
ized testing of the student, from the informal and done with an individual—as in executive coaching
behavioral assessments and observations of others, or talent development—the objective of the work in
and from interviews with parents and teachers. The organizational consultation is primarily about how
psychologist, as consultant, then makes recommen- the organization benefits (and hopefully the indi-
dations on class placement and educational inter- vidual, too) (Levinson, 2009).
ventions that others will implement. Research by counseling psychologists on consul-
The differences between mental health therapy tation process or practice is far less than for psycho-
and organizational consultation provide perhaps the therapy. Plus, the majority of articles that counseling
largest contrast (Schein, 2006).The overall goal of psychologists have authored are conceptual in app-
organizational consultations is to assist the organi- roach rather than being quantitative- or qualitative-
zation in achieving its goals. A consultant who based research (Cooper, 2008). Perhaps the main
focuses too heavily on the mental health issues of reason for this paucity of investigation is that con-
a consultee, at the cost of focusing on his or her sulting psychology is currently neither a specializa-
work functioning and the organizational context, tion nor proficiency, and most working in the field
could quite possibly cause damage to that individual are practitioners (Blanton, 2000). To find existing
and the organization. This error of overfocusing on literature, the most likely psychology journal outlets
the individual and his mental health issues is one for these publications are the Consulting Psychology
that trained counseling psychologists need to guard Journal, Journal of Educational and Psychological
against, given the many experiences they have had Consultation, Journal of Consulting and Clinical
in analyzing and diagnosing mental health issues in Psychology, Journal of School Psychology, the School
persons and then intervening to assist them. One Counselor, Elementary School Guidance and Coun-
particular model utilizes a process approach to con- seling, and the Journal of Applied Behavioral Science.
sultation, relying on counseling skills but focusing Several nonpsychology journals may contain articles
the content much differently than in personal coun- on psychologically based consultation. They include
seling (Schein, 1999). the Harvard Business Review, Journal of Manage-
Psychologically based consultation differs from ment, the Leadership and Organizational Develop-
vocational therapy in the scope of its focus and the ment Journal, and the Training and Development
nature of who is served and why (Blustein, 2006). Journal.
Specifically, vocational therapy has primarily empha- The Journal of Counseling and Development pub-
sized the study of vocational development and the lished a double special issue on consultation
phases of occupational decision making. Decades of (Kurpius & Fuqua, 1993). The first part focused on
research and practice have focused on this, and it conceptual, structural, and operational definitions.
remains a vibrant area of research (Dawis, 1996; The second part focused on prevention, prepara-
(Fouad, 2007). More recently, this focus has been tion, and key issues. These special issues were
expanding as more is understood about the life-long updates of earlier articles published in the Personal
nature of changes in the work people do, changes and Guidance Journal.
some make by choice, and, more and more, because Two main domains of scholarship on consulta-
of circumstances (Wasylyshyn, 2001). A good deal tion are of relevance to counseling psychologists.

844 coun seling p s ych o lo gis ts as co n s u ltants

The primary one is conceptual and applied. As illus- in the Journal of Counseling Psychology and The
trations of such scholarship, Consulting Psychology Counseling Psychologist have some element of
Journal has released a number of special issues on multiculturalism as a central focus or variable in the
select topics such as executive coaching (Diedrich, study. Other APA Divisions such as the Society for
2008); leadership (Leonard, 2003; Quick & Nelson, the Psychological Study of Ethnic Minority Issues
2008); workplace mobbing (Sperry, 2009); and cul- (Division 45), the Society for the Psychological
ture, race, and ethnicity in organizational consult- Study of Lesbian, Gay, Bisexual, and Transgender
ing psychology (2008). Issues (Division 44), the Society for the Psychology
Empirical research on consultation has a 40-year of Women (Division 35), and the Division of
history, but the methods of investigation used International Psychology (Division 52) have been
have not been sophisticated (Dougherty, 2009a). equally active.
Lowman (2008) calls for high-quality literature The case can easily be made that working with
reviews, avoidance of authoritatively presented issues of diversity and multiculturalism in consulta-
hypotheses, and both theoretical and empirical rigor tion is inherently even more complicated due to its
in both data-based and case studies. Given the triadic nature. There is an added component when
highly applied nature of consultation and that most the diversity of the consultant, the diversity of the
reports come from practitioners, case studies and consultee, and the diversity of the client system
quasi-scientific studies have been the dominant all have to come together. For example, such issues
form of research, with less work that is scientifically are being addressed in the training of those working
or meta-analysis based (Armenakis & Burdg, 1988). in community mental health centers (Parker-Taylor,
Consultation appears to result in moderately posi- Kim, Budianto, Laidlaw, Sakurai & Pfeifer, 2009).
tive outcomes (Gibson & Chard, 1994) in approxi- When there are multiple consultants, multiple con-
mately three-fourths of the studies (Sheridan, sultees, and a complex client system, the importance
Welch, & Orme, 1996). of attending to multicultural issues is geometrically
significant.
Essentials of Psychologically Based Steward (1996) called for consultants to attend
Consultation: Multiculturalism to workplace diversity issues. He affirmed that
in Consultation important progress could be accomplished by
Racial, ethnic, religious, and national diversity is focusing on organizational infrastructure, job satis-
increasing rapidly in the United States and many faction, relationships among staff, and work pro-
other countries of the world (Cooper & Leong, ductivity. Similarly, Plummer (1998) argued that
2008). This results from a number of factors, such attending to diversity consultation is a must, given
as immigration and emigration and from differen- the increasing diversity in the workplace. Deal-
tial birthrates among different populations. The ing with issues of awareness, sociopolitical implica-
increased interaction among diverse persons in a tions, open dialogue, cultural competence, and
global, flat world is increasing even more rapidly. cultural norms is vital if organizations are to accom-
Additionally, more organizations and industries are plish enhanced diversity functioning. Unfortu-
operating cross-culturally and internationally. The nately, relatively little empirical work has been
sharing of information around the world via the conducted in this area to date Cooper & Leong,
Internet and other form of electronic communica- 2008). Yet, the presses of internationalization and
tion has grown exponentially (Cooper & Leong, diversity within and external to organizations
2008). continue to push for consultants to incorporate a
A combination of these factors has led to applied “multicultural and racially sensitive consultation
psychology’s growing attention to professionals approach” (Cooper, Wilson-Stark, Peterson, &
who work with clients who are different from them- O’Roark, 2008, p. 200).
selves and the need to provide competent and Although few empirical studies have been con-
helpful consultation. Counseling psychology has ducted, some of the literature provides prescriptive
been a leader in the multicultural movement in psy- suggestions to the consultant. Dougherty (2009a)
chology. For example, Division 17 was one of the noted nine skills related to incorporating the salience
co-founding APA divisions of the National Multi- of multicultural factors into successful consultation.
cultural Conference and Summit (Sue, Bingham, Several additional frameworks exist that can assist
Porsche-Burke & Vasquez, 1999). A significant pro- the consultant and the consultee in functioning
portion of the scholarly articles published recently with cultural competence. Hofstede (2005) has

coope r, shullm an 845

conducted a long-term study of cultural differences Similar to Hofstede’s approach, the Center for
around the globe. His model includes five factors Creative Leadership (CCL, 1998) has developed a
(2005): seven-factor model (Prince & Hoppe, 2007). The
seven factors CCL uses in leadership training are:
• Power distance reflects the extent to which
source and expression of identity (collective vs. indi-
the less powerful members of institutions and
vidual), source and expression of authority (equal vs.
organizations within a country expect and accept
unequal), means and goals of achievement (tender–
that power is distributed unequally. Individualism
work to live vs. tough–live to work), response to
pertains to societies in which the ties between
uncertainty and change (dynamic vs. stable), means
individuals are loose: Everyone is expected to look
of knowledge acquisition (reflective vs. active),
after himself or herself and his or her immediate
orientation to time (scarce–linear vs. plentiful–
family.
cyclical), and response to natural and social envi-
• Collectivism, the opposite of individualism,
ronment (being–harmony vs. doing–mastery).
pertains to societies in which people from birth
Like Hofstede’s work, researchers using the CCL
onward are integrated into strong in-groups,
model have collected data regarding where different
which throughout people’s lifetimes continue to
countries fall on a continuum of each of these fac-
protect them in exchange for unquestioning
tors. Consultants can utilize these factors to help the
loyalty.
consultant work better with consultees or client sys-
• A masculine society has gender roles that are
tems that are multiculturally different, whether
clearly distinct: Men are supposed to be assertive,
these differences of diversity are within the United
tough, and focused on materials success, whereas
States or occur cross-nationally.
women are supposed to be nonassertive, tender,
Another significant resource to assist consul-
and concerned with the quality of life. In contrast,
tants to consult with multicultural competence is
a feminine society has emotional gender roles that
the Guidelines on Multicultural Education, Train-
overlap: Both men and women are supposed to be
ing, Research, Practice, and Organizational Change
modest, tender, and concerned with the quality
for Psychologists (APA, 2003). The latter two sec-
of life.
tions of this document are particularly appropri-
• Uncertainty avoidance is defined as the
ate. Guideline 5 pertains to practice. The Guideline
extent to which the members of a culture feel
states: “Psychologists strive to apply culturally
threatened by ambiguous or unknown
appropriate skills in clinical and other applied
situations.
psychological practices” (APA, 2003, p. 390). Spe-
• A long-term orientation focuses on the
cifically, “culturally appropriate psychological appli-
fostering of virtues oriented toward future
cations assume awareness and knowledge about
rewards—in particular, perseverance and thrift.
one’s worldview as a cultural being and as a profes-
Its opposite, a short-term orientation, stands for
sional psychologist, and the worldview of others’
the following of virtues related to the past and
particularly as influenced by ethnic/racial heritage”
present—in particular, respect for tradition,
(APA, 2003, p. 390). This Guideline refers to apply-
preservation of “face,” and fulfilling social
ing that awareness and knowledge in psychological
obligations.
practice.
Hofstede’s research has explored a nation-based It is not necessary to develop an entirely new rep-
analysis of differences on these dimensions in areas ertoire of psychological skills to practice in a
such as work life, personal beliefs, student–teacher culture-centered manner. Rather, it is helpful for
relationships, etc. On a general, “emic” (universal) psychologists to realize that there will likely be situ-
perspective, knowing the ratings for a given country ations in which culture-centered adaptations in
can help the consultant work more effectively in interventions and practices will be more effective
that country or with people who came from that (Cooper & Leong, 2008). Psychological practice is
country. Always, however, an individual, “etic” defined here as the use of psychological skills in a
(group) approach must be kept in mind by the con- variety of settings and for a variety of purposes,
sultant for both the consultee and the client sys- encompassing counseling, clinical, school, consult-
tem. Although Hofstede’s model was developed ing, and organizational psychology. This guideline
primarily for international application, it is useful further suggests that, regardless of our practice site
for addressing within-country diversity as well and purview of practice, psychologists are respon-
(Hofstede, 2005). sive to the Ethics Code (APA, 1992; 2002). In the

846 coun seling p s ych o lo gis ts as co n s u ltants

Preamble to the Ethics Code is language that advo- • Theme 3: Use of language between the
cates behavior that values human welfare and basic consultant and consultee may be a challenge
human rights. Most of the initial work on Guideline or an issue when diversity is greater.
5 was on clinical work, but it would appear to be • Theme 4: Combining an emic (universal),
equally, if not more, suitable for consulting activity. etic (group), and unique (person) approach to
Guideline 6 advocates significant use of orga- organizational consulting with consultees is
nizational consultation as a means of achieving recommended.
meaningful change. The Guideline reads “psycholo- • Theme 5: It is best to bring up differences
gists are encouraged to use organizational change of culture, race, and ethnicity directly and into
processes to support culturally informed organi- the open.
zational (policy) development and practices” (APA, • Theme 6: It takes concentrated effort to avoid
2003, p. 392). Guideline 6 is based on the advocate cultural myopia and colonialism.
role of the consultant, in which the consultant is • Theme 7: When the consultant and the
assisting organizations as consultees/client systems consultee are of differing culture, race, or ethnicity,
to develop new ways of functioning that are con- more time is likely to be needed to build trust and
gruent with a pluralistic work and social environ- to develop the consulting relationship. (Cooper,
ment. Specifically, Guideline 6 is designed to inform Wilson-Stark, Peterson, & O’Roark, 2008,
psychologists about the following: the contempo- pp. 199–200)
rary and future contexts that provide motivators
for psychologists’ proactive behavior with organiza- With effort, study, practice and mentoring,
tional change processes, perspectives about psy- organizational consultants can gain knowledge,
chologists in transition, frameworks and models to attitude, and behavioral skills needed to have
facilitate multicultural organizational development, reasonable and effective cultural competence when
and examples of processes and practices reflective consulting with consultees and client systems that
of psychologists’ leadership in the development of differ culturally, racially or ethnically from the
culture-centered organizations (APA, 2003). consultant. With further scientific study, we can
Given the paucity of literature on this topic, deepen our understanding of consulting effectively
Cooper and Leong (2008) co-edited a special issue in this increasingly multicultural world. The need for
of the Consulting Psychology Journal entitled “Cul- enhancement of both practice and science on this
ture, Race, and Ethnicity in Organizational Con- topic is great.
sulting Psychology.” This special issue adopted a (Cooper et al., 2008, p. 200)
qualitative approach to the topic from leaders in this
field, as well as an article summarizing themes A Transtheoretical Model for
(Cooper, Wilson-Stark, Peterson, & O’Roark, 2008) Psychologically Based Consultation
and a detailed bibliography with sections on general Dougherty (2009) has developed a detailed generic
diversity issues, diversity management and intercul- approach to consulting that counseling psycholo-
tural communication, culture specific issues, racism gists might find very useful in the consultation work
and prejudice, and cross-cultural and international they do—mental health, school, behavioral, or orga-
issues (Leong, Cooper, & Huang, 2008). nizational consultation. It also works well whether it
is a relatively simple consultation (i.e., one consultee
Cooper et al. (2008) employed a consensual
and one client), or a very complex consultation with
qualitative research method of developing sum-
multiple consultants, consultees, and client system
maries of findings based on narratives from consul-
targets at the individual, group, and organizational
tants’ perspectives of integrating attention and
levels.
priority to diversity issues within their work and
Dougherty’s generic approach is divided into
then presenting these back to those who contrib-
four phases: entry, diagnosis, implementation, and
uted for affirmation, change, or addition. The final
disengagement. Furthermore, each phase is divided
seven consultation themes developed by this reitera-
into four stages. Although his approach appears to
tive process were:
be a linear process, there is interaction and overlap
• Theme 1: Culture, race, and ethnicity matters. among the stages in each phase and among the
• Theme 2: Networking and mentoring are phases as well, especially the first three. The amount
more challenging for nonmajority managers and of time and detail needed varies tremendously
leaders to obtain. depending on the nature of the problem to be

coope r, shullm an 847

resolved and the dynamics of each particular psy- teams, or organizations, the role of the consul-
chologically based consultation. For most consulta- tant during the implementation phase typically
tions that counseling psychologists do, relatively involves those of being a resource person and/
little time is needed to go through the entire pro- or trainer (Dougherty, 2009a). In the implementa-
cess, but for some, the opposite is the case. tion stage, the counseling psychologist consultant
Entry occurs when the consultant develops a pro- focuses on four phases: choosing an intervention,
fessional relationship with the consultee and explores which involves selection (Gutkin & Curtis, 1999)
the presenting problem, along with formulating and modality, for example, third-party peacemaking
a formal or informal contract. This involves begin- (Gelembiewski & Rauschenberg, 1993); formulat-
ning to physically and psychologically enter the ing a plan (Egan, 1985); implementing the plan;
system of the consultee and his or her agency or and evaluating the plan.
organization. Dougherty defines entry as “the gen- The final phase of Dougherty’s generic model,
eral process by which the consultant enters the disengagement, constitutes a winding down process.
system in which consultation is to occur” The more involved the consultation, in terms of
(Dougherty, 2009a, p. 53). In the entry stage, the length and intensity, the more length of time and
counseling psychologist consultant focuses on four effort is needed to end the consultation successfully.
phases: exploring organizational needs (McLean, Disengagement typically starts with collection and
2006; Stroh & Johnson, 2006), contracting (APA, discussion of the summative evaluation data. Prior
2003 see Ethical Code Standard 3.11); physically to this, the evaluations conducted throughout and
entering the system (Gallessich, 1982; McLean, at the end of the entry, diagnosis, and implementa-
2006), and psychologically entering the system. tion phases were process-oriented and often brief
According to Dougherty (2009a), the diagnostic and qualitative in nature.
stage involves the process of defining and specifying As with counseling and therapy, disengagement
the work-related or care-taking problem to be is a critical part of the helping process and one that
resolved. This initially involves gathering, analyzing, is far too often done badly. The effects of such a
and discussing information and data. The consulta- badly done disengagement process can adversely
tee and consultant move on to goal setting and affect a consultation that has gone very well through
brainstorming of implementation strategies. Similar all the first three stages. When done very poorly, the
to counseling and therapy, diagnosis is essential in consultant–consultee relationship is irreparably
determining the course of action to be taken, in this damaged, and there can be intense negative emo-
case by the consultant and consultee. The thorough- tions for the consultee(s). The disengagement stage
ness of the diagnostic process depends on the pur- proceeds through evaluating the process of consul-
pose of the consultation and, in some consultations, tation, using both summative and process evalua-
feedback about the results of the diagnosis is the tion methods; postconsultation planning; reduced
main outcome. In other consultations with a differ- contact; follow-up (see Myrick, 2003, for a listing
ent goal, there are interrelationships among diag- of benefits); and termination (Teyber & McClure,
nosis, data collecting, and intervention. In the 2011). Much greater detail on Dougherty’s generic
diagnostic stage, the counseling psychologist con- model is available in part II of his book, Psychological
sultant focuses on four phases: gathering informa- Consultation and Collaboration in School and
tion (Dougherty, 2009a), defining the problem, Community Settings (5th ed.).
setting goals (Curtis & Stollar; Egan, 2006; Locke The relationship between counseling psycholo-
& Latham, 2002), and generating possible inter- gists using the integrative model of consultation
ventions (Egan, 2006, 2007). versus use of a specific model or particular approach
The third phase of Dougherty’s generic model is to consultation is identical to the relationship
implementation and begins with the selection of between counseling psychologists who use systemic,
interventions. This is followed by the consultee eclectic, or transtheoretical models of counseling
engaging in action with the support of the consul- versus those who choose use of a specific theoretical
tant. A reiterative process is involved with the plan. model or approach. Generally, most counseling psy-
Changes are made depending on the level of goal chologists engaging in consultation will find the
attainment for the client system. Whereas the major generic approach to be more flexible to adapt to the
purpose of the first two stages of the consultation particular consultation needed. However, some
process is to set the stage for action for the consultee consultants find it easier working within a specific
or consultees to make change to help their client(s), model or with any of the approaches that are part of

848 coun seling p s ych o lo gis ts as co n s u ltants

that model. Sometimes, the parameters of a sit- this model: case (Bergin & Kratochwill, 1990),
uation or setting may elicit the use of a particular technology training (Vernberg & Reppucci, 1986),
consultation approach. One difference between con- and system (Lewis & Newcomer, 2002).
sultation and counseling is the relatively smaller In behavioral case consultation, the counseling
number of current models and approaches. For psy- psychologist consultant helps a consultee apply
chologically based consultation, four main models behavioral technology to a case (Kratochwill, 2007).
are mental health, behavioral, school, and organiza- In behavioral technology training, the counseling
tional (Dougherty, 2009a). psychologist consultant trains consultees to improve
their general and/or specific skill areas of behavioral
technology. In behavioral system consultation, the
Mental Health Consultation counseling psychologist consultant assists an orga-
For counseling psychologists who engage in con- nization in being more effective by using behavioral
sulting, the closest consultation model is the mental technology.
health consultation model developed by Caplan For the school consultation model, there are
(1970, 1993). The focus of mental health consulta- three main approaches. These approaches include:
tion is to help the therapist or the administrator Adlerian (Carlson, Watts, & Maniacci, 2006;
work more effectively with clients and programs, Dinkmeyer, 2006), instructional (Rosenfield, 2002),
respectively. Although some of the above may seem and organizational development change (Cowan,
identical to clinical supervision (particularly when 2007; Dougherty, 2009a; Flashpohler, 2007).
the focus is on helping a counselor be more help- In Adlerian consultation, the counseling psycholo-
ful to their client), there are a number of differ- gist consultant uses Adlerian principles to help
ences between consultation and clinical supervision teachers individually or, in a C-group, to assist a stu-
(Haynes, Corey, & Moulton, 2003). Supervision dent or students. In instructional consultation, the
involves a hierarchical relationship that addresses counseling psychologist consultant focuses on mod-
evaluation of the student. ifying the teacher’s behavior to create a better learn-
Within the mental health model, there are four ing environment. In organizational development
main approaches: client-centered case, consultee- change consultation, the counseling psychologist
centered case, program-centered administrative, and consultant helps the school improve its functioning
consultee-centered administrative (Caplan, 1970). on a system-wide basis.
A two-dimensional figure can be visualized, in The organizational model of consultation
which one dimension is the target of the consulta- emerged outside the mental health and school fields
tion (an individual vs. a program) and the other of study, but it has influenced both profoundly.
dimension is focus (more on the client or more on Dougherty (2009a), based on earlier work by Schein
the consultee). (1988, 1999, 2006), describes four approaches
In client-centered case consultation, the coun- within the organizational model: educational/train-
seling psychologist consultant focuses on helping ing (Arredondo, 1996), program consultation
a consultee with a client (with the consultant hav- (Gallesich, 1982), doctor–patient (Schein, 1990),
ing no or minimal contact with the consultee). In and process (Schein, 1990).
consultee-centered case consultation, the counsel- In educational/training consultation (Arredondo,
ing psychologist consultant considers work-related 1996), the counseling psychologist consultant trains
problems to reside in the consultee and helps the or educates consultees to be more effective in some
consultee by focusing on a specific case. In program- area. In program consultation (Staton, Bensen,
centered administrative consultation, the counsel- Briggs, Cowen, Echterling, Evans, et al., 2007), the
ing psychologist consultant helps an administrator counseling psychologist consultant assists a pro-
fix a program-related problem. Caplan and Caplan gram, frequently via program evaluation. In doctor–
(1993) added a fifth approach, ecological, which patient consultation (Schein, 1990), the counseling
aims at the human–environment interface, a sys- psychologist consultant enters an organization,
temic perspective. diagnoses a problem, and prescribes a solution.
The behavioral model of consultation is based on In process consultation (Schein, 1990), the counsel-
various behavioral models, but especially on social ing psychologist consultant assists consultees in
learning, instrumental conditioning, and cognitive- becoming better decision makers and problem solv-
behavioral therapy (CBT) theories (Dougherty, ers in the future. See Table 32.2 for a summary of
2009a). There are three main approaches within these four approaches.

coope r, shullm an 849

Table 32.2. Consultation Approaches and The Status of Training and Research on
Areas of Emphasis Psychologically Based Consultation
Mental Health Consultation is recognized as one of six main func-
tional competency domains for counseling psy-
Client-Centered Helping a consultee with a client chologists (Rodolfa, et al., 2005). Yet, graduate
Case (with minimal contact with the counseling psychology programs place very limited
consultee)
curricular time toward instruction on consultation.
Consultee- Considers work-related problem to The authors of this chapter conducted an e-survey
Centered Case reside in the consultee; helping of the directors of APA-accredited programs in
consultee by focusing on case counseling psychology in July 2009. Although the
Program- Helping an administrator fix a number of respondents was not large ( N = 13), half
Centered program-related problem of the programs were consistent in how content
Administrative on psychologically based consultation was covered.
Specifically, half of these programs provided a com-
Consultee- Helping an administrator and other
bined supervision/consultation course. One program
Centered consultees develop their skills to
Administrative improve the mental health aspects of
focused on consultation in rural settings and com-
the organization and its programs bined this with a course on program evaluation.
Another program combined consultation-focused
Ecological Changing the human–environment content in a course on community prevention and
interface intervention, and yet another incorporated consulta-
Behavioral tion into their professional development and assess-
ment courses. Two of the responder schools offered
Case Helping a consultee apply behavioral
no coursework in consultation, and one school,
technology to a case
which has historically offered a combined supervi-
Training Training consultees to improve their sion/consultation class, is in the process of moving
general and/or specific skill areas of toward a standalone consultation course.
behavioral technology The APA Guidelines and Principles for Accred-
System Assisting an organization in being itation of Programs in Professional Psychology
more effective by using behavioral ( http://www.apa.org/ed/accreditation/qrg_
technology doctoral.html, 2009) list specific criteria that all
accredited programs must meet. Standard B.3 (c) is
School
the standard that most directly addresses the consul-
Adlerian Using Adlerian principles to help tation area. “Diagnosing or defining problems
teachers individually or in a C-group through assessment and implementing interven-
Instructional Focuses on modifying the teacher’s tion strategies (including empirically supported
behavior to create a better learning procedures) including exposure to the current body
environment. of knowledge in at least the following areas: (a) The-
ories and methods of assessment and diagnosis,
Organizational Helping the school improve its
(b) Effective intervention, (c) Consultation and
Development functioning on a system-wide basis
Change
supervision, and (d) Evaluating the efficacy of inter-
ventions.” Given the increasing importance of con-
Organizational sultation as a key competency, the limited amount of
Educational/ Training or educating consultees to be attention current programs build into their required
Training more effective in some area curriculum seems insufficient (Rodolfa, Bent,
Eisman, Nelson, Rehm, & Ritchie, 2005).
Program Assisting a program, frequently The APA accreditation standards for internship
evaluation
sites reflect the increased attention to consulta-
Doctor–Patient Entering an organization, diagnosing tion given in the current program accreditation
a problem, and prescribing a solution standards (see APA, Guidelines and Principles
Process Assisting consultees in becoming for Accreditation of Programs in Professional
better decision makers and problem Psychology, 2009). Specifically, Standard 4 (c) reads
solvers in the future “In achieving its objectives, the program requires
that all interns demonstrate an intermediate to

850 coun seling p s ych o lo gis ts as co n s u ltants

advanced level of professional psychological skills, consultation over the curriculums of the other “clin-
abilities, proficiencies, competencies, and knowl- ically focused” graduate programs (Shullman,
edge in the areas of: (c) Theories and/or methods 2002). What would most be needed for counseling
of consultation, evaluation, and supervision;” (APA, psychology programs to better prepare their stu-
http://www.apa.org/ed/accreditation/intern. dents to provide high-quality consultation would
html, 2009). Each program is required to document be to find textbook and in-class examples of consul-
how this standard is being met via the expectations tations within organizational settings, to be pre-
and experiences that are built into the training sented along with the clinical setting examples that
requirements. Given the combination of consulta- currently prevail in both book resources and class-
tion, evaluation, and supervision that are all com- room discourse. Additionally, programs moving
bined in this single standard, however, it is unlikely toward a standalone consultation course instead
that significant attention is given to enhancing con- of the combined supervision/consultation course,
sultation knowledge and skill acquisition at most required currently by many programs, would dou-
internship sites. ble the attention paid to the development of con-
sultation as a core competency. Furthermore, most
Best Practices for Enhancing counseling psychology programs do not focus on
Psychologically Based Consultation the organizational level of intervention, despite a
Education and Training strongly held value within counseling psychology
Although neither counseling psychology nor other toward prevention and community enhancement
branches of applied psychology have focused signif- (Shullman, 2002). Expansion of the curriculum to
icant resources on education, training, and research include this molar emphasis could best be achieved
on the practice of consultation, sufficient work via a curriculum infusion process rather than by the
has been done to be able to suggest best practices development of new courses to be taught by already
for enhancing education and training, as well as overstretched counseling psychology faculty.
research. Suggestions for counseling psychologists Cooper (2002) edited a special issue of the
who want to become or are engaged in psychologi- Consulting Psychology Journal on “Training and Edu-
cally based consultation are given first. This is fol- cation in Organizational Consulting Psychology.”
lowed by suggestions on improving research-related This special issue included reaction pieces from sev-
to consultation. eral counseling psychologists. Fuqua and Newman
The seven skill sets that effective consultants use (2002) focused on doctoral-level curricula. They
were described earlier (Dougherty, 2009a). The stated that the Guidelines provide four important
micro-skills in each of these skills sets could serve as advantages: They focus on competencies rather than
the basis for educational curriculum and outcomes on course activities; they place an emphasis on the
assessment. Another valuable conceptual framework utilization of applied research skills; they prioritize
for developing best practices is the organizational process and summative evaluation; and they endorse
consultation competencies that were passed as offi- the scientist–practitioner approach to professional
cial APA Guidelines in 2005 (APA, 2007). These work (now reframed as the evidence-based practice
consist of a number of different competency areas model). In their reaction piece, Fuqua and Newman
nested respectively under individual, group, and (2002) questioned the level of actual attention that
organizational levels. As official APA-approved would be paid to developing a solid, underlying sci-
guidelines, these represent work that involved a ence for consulting, and expressed concern about
highly reviewed and quality-controlled process. The practices being taken without sufficient foundation.
outcomes are considered to represent best practice. They also questioned the level of distinctiveness of
In general, APA has approved only a handful of such consultation from therapy focused skills. Concerning
guidelines, as they represent officially sanctioned this distinctiveness, the concept of two overlapping
perspectives. Venn diagrams, in which consultation and counsel-
The educational curriculum of most counseling ing share many of the same skills sets, yet differ in
psychology programs already targets the acquisition how these are utilized, would seem to portray the
of several of the individual- and group-level core most accurate picture. The main difference that
competencies that are part of these Guidelines. For offsets consultation is that it is triadic, indirectly
counseling psychologists, the historical inclusion of targeting improvement in the client, group, or orga-
vocational counseling as a root of counseling psy- nization; it has a work- or caretaking-related focus;
chology gives the field a significant advantage for and the consultant–consultee relationship differs

coope r, shullm an 851

from the therapist–client relationship. Fuqua and needing to fit into a developmental model for those
Newman (2002) presaged the current discussion of doing consultation, with the stages increasing from
changes in the APA Model Professional Psychology beginning to entry to mid-level to senior psycholo-
Practice Act by speculating about what the future gists. These suggestions cross the developmental
might bring in the relationship of the Guidelines to level of the psychologist with the individual-group-
professional practice and licensure. As currently organizational consultation competencies model.
proposed, the APA Model Practice Act will encom- A report presenting each of these suggestions is
pass the work of all professional psychologists, both available from the Society of Consulting Psycho-
clinical and applied. Practice within the domain of logy’s website at http://www.div13.org/Reports/
one’s demonstrated competencies, as acquired by PresidentialTaskForce.htm. The report was a prod-
curricular and applied experiences, is a central com- uct of a Presidential Task Force on Professional
ponent of the proposed act. Preparation and Continuing Education for Begin-
Shullman (2002) supported a congruence of ning, Entry, Mid-level, and Senior Consulting
most counseling psychology doctoral curriculum Psychologists.
with the individual and group levels of the Guid-
elines. Yet, she also described several aspects of the
Best Practices for Enhancing
consulting competencies in which counseling psy-
Psychologically Based Consultation
chology students could benefit from greater expo-
Research
sure. An example at the individual level is a greater
Several best practices targeted at improving consul-
utilization of a strengths-based rather than solely a
tation-focused research emerge from the work
deficits-based approach, an approach typically used
done by APA on evidence-based psychology
in counseling vocational psychology. Examples at the
practice (APA, 2005). Specifically, the recommen-
group level are uses of tools to assess and assist work-
dations generated by the APA Task Force on
groups and to facilitate intergroup problem solving,
Empirically Based Practice provide a context for
to identity groups and intergroup relations, and to
examining research on consultation process and
align groups with organizational objectives. Shullman
practice (APA, 2005). In relation to the method-
(2002) asserted that the largest area of deficit in the
ologies used to study consultation, the primary
training of counseling psychologists is at the organi-
methodologies scholars have employed have been
zational/systemic level. She articulated that counsel-
clinical observation, qualitative research (most
ing psychology’s emphases on person–environment
of which have been very simplistic and have not used
fit and multiculturalism provide the basis for a
contemporary rigorous qualitative methods), and
broader individual-group-organizational model that
studies of interventions as delivered in naturalistic
could incorporate therapy, consultation, and the
settings. Some consultation studies (e.g., Cooper &
other four core applied psychology domains.
Newbold, 1994) have employed single-case experi-
These suggestions would take place within the
mental designs. Such single-case design studies are
doctoral program of studies. A best practice that
more prevalent in behavioral (see Kratochwill, Elliot,
would assist the development of consultation com-
& Callan-Soiber, 2002) and school-based consulta-
petency at the practicum and predoctoral levels
tions (Rosenfield, 2002). A few meta-analyses of
would be the creation of communication networks
organization-wide interventions (e.g., Gibson &
among these sites that share trainee expectations
Chard, 1994) have been conducted. Systematic case
and developmental experiences that aim to improve
study, process outcome studies, and randomized
the student’s understanding and skills in consult-
clinical trail studies have rarely been employed
ing. Use of organizations such as the Association
(Dougherty, 2009a). With randomized controlled
of Psychology Postdoctoral and Internship Centers
trials, both lack of funding and the highly idio-
(APPIC) that already have extensive networking
graphic nature of consultation have been barriers.
among the training coordinators would require
Few studies of consultation with diverse consultees
relatively little effort.
or client populations have been carried out (Cooper
Cooper, Monarch, Serviss, Gordick, and Leonard
& Leong, 2008). Rodney Lowman, the current
(2007) focused on post-degree learning experiences
editor of Consulting Psychology Journal, wrote:
that psychologists wanting to work as consultants
could seek as a means of acquiring the requisite The Society’s [APA Div.13] flagship journal:
knowledge, skills, and supervised applied experi- Consulting Psychology: Practice and Research is one
ences. These learning experiences were viewed as outlet for creating the new knowledge base but it is

852 coun seling p s ych o lo gis ts as co n s u ltants

 far from the only one. Consulting Psychology will American Psychological Association (APA). (2009). Guidelines
need carefully to note and master the research that and principles for accreditation of programs in professional psy-
chology. Retrieved from http://www.apa.org/ed/accreditation/
is published in related disciplines on our field’s areas
qrg_doctoral.html.
of special expertise (e.g., coaching, assessment and Armenakis, A. A., & Burdig, H. B. (1988). Consultation
group-organizational interventions). Needed research: Contributions to practice and directions for
are “bread and butter” studies that do the necessarily improvement. Journal of Management, 14, 339–365.
detailed work to validate operating premises such Arredondo, P. (1996). Successful diversity management initiatives.
Thousand Oaks, CA: Sage.
as approaches to assessment and intervention.
Atkinson, D. R., Thompson, C. E., & Grant, S. K. (1993).
Unfortunately we have very few graduate training A three-dimensional model for counseling racial/ethnic
programs in consulting psychology so there is not minorities. The Counseling Psychologist, 21, 257–277.
a large amount of research and theory emanating Bell, C. R., & Nadler, L. (1985). Clients and consultants. Houston,
from the usual sources and with the usual support TX: Gulf.
Bellman, G. M. (1990). The consultants calling. San Francisco:
mechanisms. If we wish as a profession to expand
Josey-Bass.
the research base of our discipline we must support Bergin, J. R., & Kratochwill, T. R. (1990). Behavioral consulta-
the expansion of such graduate programs, to create tion and therapy. New York: Plenum.
internships and post-docs in these areas with Blanton, J. S. (2000). Why consultants don’t apply psychological
research expectations and we must facilitate the research. Consulting Psychology Journal: Practice and Research,
52, 235–247.
expansion of journals and other publication outlets.
Blustein, D. L. (2006). The psychology of working: A new perspec-
By promoting jobs in this area of psychological tive for career development, counseling, and public policy.
practice and reasonable methods of licensure, Mahwah, NJ: Lawrence Erlbaum Associates.
we may be able to attract more graduate programs Caplan, G., & Caplan, R. B. (1993). Mental health consultation
and more students and in turn more faculty and collaboration. San Francisco: Josey-Bass.
Caplan, G., Caplan, R. B., & Erchul, W. P. (1994). Caplanian
and research. Encouraging consulting firms
mental health consultation: Historical background and
to take on research agendas also provide an outlet. current status. Consulting Psychology Journal: Practice and
(Personal communication, Lowman, 2009) Research, 46, 2–12.
Civiello, C. L. (2009). Introduction to the special issue on orga-
Conclusion nizational consulting in national security contexts. Consulting
Consulting psychology is a major area of psycho- Psychology Journal: Practice and Research, 61(1), 1–4.
logical practice that is currently neither a specialty Cooper, S. E. (2002). Training and education in organizational
consulting psychology. Consulting Psychology Journal: Practice
or proficiency. Although longstanding in practice,
and Research (special issue), 54, 211–278.
consulting psychological practice is still lacking in Cooper, S. E. (2003). College counseling centers as internal
empirical rigor. To paraphrase the language of the organizational consultants to universities. Consulting Psy-
2005 APA Task Force on Evidence-Based Practice chology Journal: Practice and Research, 55, 230–238.
in Psychology (APA, 2005), evidence-based practice Cooper, S. E. (2008, August). Enhancing the practice, craft, and
science of psychologically-based consultation. Presidential
is the integration of the best available research with
Address for Division 13 at the annual convention of the
consultant expertise in the context of consultee and American Psychological Association. Boston, Massachusetts.
individual, group, and organizational client charac- Cooper, S. E., & Leong F. T. L. (2008). Introduction to the spe-
teristics, culture, and preferences. A fertile field is cial issue on culture, race, and ethnicity in organizational
open to counseling psychologists for developing consulting psychology. Consulting Psychology Journal: Practice
and Research: Special Issue on Culture, race and ethnicity in
both the science and the practice components of
organizational consulting psychology, 60(2), 133–138.
this equation. Cooper, S. E., Monarch, N., Serviss, S. T., Gordick, D., &
Skipton, L. H. (2007). Professional preparation and continu-
References ing education for beginning, entry, midlevel, and senior con-
American Psychological Association (APA). (2003). Guidelines sulting psychologists. Consulting Psychology Journal: Practice
on multicultural education, training, research, practice, and and Research, 59, 1–16.
organizational change for psychologists. American Psychologist, Cooper, S. E., & Newbold, R. C. (1994). Combining external
58, 377–402. and internal behavioral system consultation to enhance plant
American Psychological Association (APA). (2005). American safety. The Consulting Psychologist, 46, 32–41.
Psychological Association policy statement on evidence-based Cooper, S. E., & O’Connor, R. M. (1993). Standards for organi-
practice in psychology. Retrieved from http://search.apa.org/ zational consultation assessment and evaluation instruments.
search?query=evidence-based%20practice. Journal of Counseling & Development: Special issue on
American Psychological Association (APA). (2007). Guidelines Consultation: A paradigm for helping: Consultation I: Conceptual,
for education and training at the doctoral and postdoctoral structural, and operational dimensions, 71, 651–660.
levels in consulting psychology/organizational consulting Cooper, S. E., Wilson-Stark, K., Peterson, D., O’Roark,
psychology. American Psychologist, 62, 980–992. A. M. & Pennington, G. (2008). Consulting competently in

coope r, shullm an 853

 multicultural contexts. Consulting Psychology Journal: Practice Levinson, H. (2009). Reciprocation: The relationship between
and Research, 60, 186–202. man and organization. In H. Levinson, A. M. Freedman
Corey, M. S., Corey, G., & Corey, C. (2010). Groups: Process (Ed.), & K. H. Bradt (Ed.). Consulting psychology: Selected
and Practice (8th ed.). Pacific Grove, CA: Brooks/Cole. articles by Harry Levinson (pp. 31–47). Washington, DC:
Dawis, R. V. (1996). Vocational psychology, vocational adjust- American Psychological Association.
ment, and the workforce: Some familiar and unanticipated Lewis, V. A., Lewis, M. D., Daniels, J. A., & D’Andrea, M. J.
consequences. Psychology, Public Policy, and Law, 2(2), (2003). Community counseling: Empowerment strategies for
229–248. a diverse society (3rd ed.). Pacific Grove, CA: Brooks/Cole
Diedrich, R. C. (Ed.). (2008). More about executive coaching: Publishing.
Practice and research. Special issue. Consulting Psychology Lippit, G. L., & Lippit, R. (1986). The consulting process in prac-
Journal: Practice and Research, 60(1), 4–131. tice. (2nd ed.). La Jolla, CA: University Associates.
Dinkmeyer, D. Jr. (2006). School consultation using individual Locke, E. A., & Latham, G. P. (2002). Building a practically
psychology. Journal of individual psychology, 62, 180–187. useful theory of goal setting and task motivation: A 35 year
Dougherty, A. M. (2009a). Psychological consultation and collabo- odyssey. American Psychologist, 57, 705–717.
ration in school and community settings (5th ed.). Belmont, Lowman, R. L. (2008). Editorial policy of the Consulting
CA: Brooks/Cole. Psychology Journal: Practice and Research. Consulting
Dougherty, A. M. (2009b). Psychological consultation and collabo- Psychology Journal: Practice and Research, 60, 1–3.
ration in school and community settings: A casebook (5th ed.). McCauley, C. D., Moxley, R. S., & Van Vesslor, E. (Eds.).
Pacific Grove, CA: Brooks/Cole. (1998). Center for Creative Leadership handbook of leadership
Foster, S. L., & Lloyd, P. (2007). Positive psychology principles development. San Francisco: Jossey-Bass.
applied to consulting psychology at the individual and group McLean, G. N. (2006). Organization development. San Francisco:
level. Journal of Consulting Psychology, 59(1), 30–40. Berrett-Koehler Publishers.
Fouad, N. A. (2007). Work and vocational psychology: Theory, National Council of Schools and Programs in Professional
research, and applications. Annual Review of Psychology, 58, Psychology. (2008). Competency developmental achievement
543–564. doi:10.1146/annurev.psych.58.110405.085713. levels (DALs) of the National Council of Schools and Programs
Gallesich, J. (1982). The profession and practice of consultation. in Professional Psychology. Retrieved July 25, 2009, from
San Francisco: Josey-Bass. http://www.ncspp.info/.
Gibson, G., & Chard, K. M. (1994). Quantifying the effects of O’Roark, A. M. (1999). A History of Division 13 initiatives on
community mental health consultation interventions. education and training in consulting psychology. Consulting
Consulting Psychology Journal: Practice and Research, 46, Psychology Journal: Practice and Research, 51(4), 218–225.
13–25. O’Roark, A. M., Lloyd, P. J., & Cooper, S. E. (2005, February
Haynes, R., Corey, G., Moulton, P. (2003). Clinical supervision 20). Guidelines for education and training at the doctoral and
in the helping professions. Pacific Grove, CA: Thompson postdoctoral level in consulting psychology/organizational con-
Brooks/Cole. sulting psychology. Retrieved August 14, 2009, from http://
Hofstede, G. (2005). Cultures and organizations: Software of www.apa.org/governance/cpm/div13guidelines.pdf.
the mind. Columbus, OH: McGraw-Hill. Pace, D., Stamler, V. L., Yarris, E., & June, L. (1996). Rounding
Kampa-Kokesch, S., & Anderson, M. Z. (2001). Executive out the cube: Evolution to a global model for counseling cen-
coaching: A comprehensive review of the literature. ters. Journal of Counseling & Development, 74, 321–325.
Consulting Psychology Journal: Practice and Research, 53(4), Park-Taylor, J., Kim, G. S., Lina, B., Gary, P., Phillip, L.,
205–228. Mariko, S., & Jessica, P. (2009). Toward reflective practice:
Kilburg, R. R. (2002) Shadow consultation: A reflective approach A multicultural competence training model from a commu-
for preventing practice disasters. Consulting Psychology nity mental health center. Professional Psychology: Research
Journal: Practice and Research, 54, 75–92. and Practice, 4(1), 88–95.
Knoff, H. M., Hines, C. V., & Kromrey, J. D. (1995). Finalizing Peterson, D. B. (2010). Executive coaching: A critical review and
the Consultant Effectiveness Scale: An analysis and valida- recommendations for advancing the practice. In S. Zedeck
tion of the characteristics of effective consultants. School (Ed.), APA handbook of industrial and organizational psychol-
Psychology Review, 24, 480–496. ogy: Vol. 2. Selecting and developing members for the organiza-
Kratochwill, T. R. (2007). Preparing psychologists for evidence- tion (pp. 527–566). Washington, DC: American Psychological
based school practice: Lessons learned and challenges ahead. Association.
American Psychologist, 62(8), 829–843. Prince, D. W., & Hoppe, M. H. (2007). Communicating across
Kratochwill, T. R., Elliot, S. N., & Callan-Stoiber, K. (2002). cultures (J-B CCL Center for Creative Leadership). Greensboro,
Best practices in school-based problem-solving consultation. NC: Center for Creative Leadership.
In A. Thomas and J. Grimes (Eds.), Best practices in school Pryzwansky, W. B., & White, G. W. (1983). The influence of
psychology (4th ed., pp. 583–608). Washington, DC: National consultee characteristics on preferences for consultation
Association of School Psychologists. approaches. Professional Psychology: Research and Practice,
Kurpius, D. J., & Fuqua, D. R. (1993). Fundamental issues in 14(4), 457–461.
defining consultation. Journal of Counseling & Development, Quick, J. C., & Nelson, D. L. (2008). Emerging issues in leader-
71, 598–600. ship development consultation. Special issue. Consulting
Leonard, H. S. (2003). Leadership development: New perspec- Psychology Journal: Practice and Research, 60(4).
tives. Consulting Psychology Journal. 55(1). Rodolfa, E., Bent, R., Eisman, E., Nelson, P., Rehm, L., &
Leong, F. T. L., Cooper, S., & Huang, J. L. (2008). Selected bib- Ritchie, P. (2005). A cube model for competency develop-
liography on diversity consulting: psychology. Consulting ment: Implications for psychology educators and regulators.
Psychology Journal: Practice and Research, 60, 215–226. Professional Psychology: Research and Practice, 36, 347–354.

854 coun seling p s ych o lo gis ts as co n s u ltants

Schein, E. H. (1969). Process consultation: Its role in organization for the practice of counseling psychology. Consulting
development (1st ed.). Reading, MA: Addison-Wesley. Psychology Journal: Practice and Research, 54(4), 242–251.
Schein, E. H. (1978). The role of the consultant: Content expert Sperry, L. (2009). Workplace mobbing and bullying. Special
or process facilitator? Personnel and Guidance Journal, 56, issue. Consulting Psychology Journal, 61(3).
339–343. Steward, R. J. (1996). Training consulting psychologists to
Schein, E. H. (1987). Process consultation: Lessons for managers be sensitive to multicultural issues in organanizational con-
and consultants (Vol. 2). Reading, MA: Addison-Wesley. sultation. Consulting Psychology Journal: Practice and Research,
Schein, E. H., (1988). Process consultation: Its role in organization 48, 180–189.
development (Vol 1, 2nd ed.). Reading, MA: Addison-Wesley. Sue, S. (1998). In search of cultural competence in psychother-
Schein, E. H. (1999). Process consultation revisited: Building the apy and counseling. American Psychologist, 53, 440–448.
helping relationship. Reading, MA: Addison-Wesley. Sue, D. W., Bingham, R. P., Porché-Burke, L., Vasquez, M.
Schein, E. H. (2006). Consultation and coaching revisited. (1999). The diversification of psychology: A multicultural
In M. Goldsmith, & L. S. Lyons (Eds.), Coaching for leader- revolution. American Psychologist, 54, 1061–1069.
ship (2nd ed., pp. 17–25). San Francisco: Wiley. Teyber, E. & McClure, F. H. (2011). Interpersonal Process in
Sheridan, S. M., Welch, M., & Orme, S. F. (1996). Is consulta- Therapy: An Integrative Model. (6th ed.). Belmont, CA:
tion effective? A review of outcome research. Remedial and Brooks/Cole.
Special Education, 17, 341–354. Wasylshyn, K. M. (2001). On the full actualization of psychol-
Shullman, S. L. (2002). Reflections of a counseling psychologist: ogy in business. Consulting Psychology Journal: Practice and
Implications for the principles for education and training at Research, 53, 10–21.
the doctoral and postdoctoral level in consulting psychology

coope r, shullm an 855

 CHAPTER

33 Social Justice in Counseling Psychology

Nadya A. Fouad and Jeffrey P. Prince

Abstract
This chapter traces the historical roots of social justice in counseling psychology and reviews social
justice in counseling psychology practice, training, and research. Social justice advocacy in counseling
psychology urges counseling psychologists to use their knowledge and expertise to actively create new
opportunities for clients, to change the systems that perpetuate injustice, and to advocate for new
policies that will institutionalize equity and fairness. We also identify the challenges and barriers to
conducting social justice work, and we highlight some of the ethical issues and dilemmas of social
justice work. Finally, we make some recommendations for policy and legislation, and suggest next
steps for counseling psychologists to be social justice agents.
Keywords: social justice, multicultural training, multicultural counseling, multicultural research,
advocacy

Counseling psychology, as a discipline, has long for the role that psychologists can, and should play
placed an emphasis on prevention, on understand- in the redistribution of resources in the United
ing the role that individual and cultural differences States. A review of that history is well beyond the
play in clients’ lives, and on normal, developmental scope of this chapter, but readers are referred to Fox,
concerns. For example, counseling psychologists Prilleltensky, and Austin (2009) and Prilleltensky
have proposed prevention interventions (Romano (in press). This chapter will briefly trace the histori-
& Netland, 2008), have sought to understand racial cal roots of social justice in counseling psychology
identity development for black youth (Nicolas, and review social justice in counseling psychology
Helms, Jernigan, Sass, Skrzypek, & DeSilva, 2008), practice, training, and research. In each area, we will
and have examined individuals’ work and career- also identify the challenges and barriers to conduct-
related decisions (Blustein & Fouad, 2008). The ing social justice work. We conclude the chapter by
underlying philosophical assumption, that counsel- highlighting some of the ethical issues and dilemmas
ing psychology research and practice can help to of social justice work, make some recommendations
make conditions more equitable and fair, coincides for policy and legislation, and finally suggest next
with philosophical premises underlying social jus- steps for counseling psychology.
tice work that dates back to Greek philosophers. Social justice advocacy in counseling psychology
More recently, social workers and community urges counseling psychologists to use their knowl-
psychologists have written extensively about the edge and expertise to actively create new opportuni-
philosophical underpinnings determining fair distri- ties for clients, to change the systems that perpetuate
bution of resources. Counseling psychologists owe a injustice, and to advocate for new policies that
great deal to the scholars who have eloquently argued will institutionalize equity and fairness. Vera and

856
Speight (2003) argued that counseling psychologists External funding agencies were much more likely to
need to do more than examine factors that contrib- focus on problems and areas of remediation, rather
ute to, or are the results of, injustice. Rather, coun- than on prevention or community partnerships.
seling psychologists need to actively work for societal Many journal editors were concerned about studies
change. Goodman, Liang, Helms, Latta, Sparks, with high internal validity, and generalizability and
and Weintraub (2004a) defined social justice as practical implications were less important consider-
“scholarship and professional action designed to ations. Community partnerships take time to build
change social values, structures, policies, and prac- and sustain, and faculty spent less time on collabo-
tices” (p. 795). Fouad, Gerstein, and Toporek (2006) ration and more time on individual studies that
characterized social justice in counseling psychol- led to peer-reviewed publications. The net effect
ogy as “helping to ensure that opportunities and was less focus on community work, more focus on
resources are distributed fairly and helping to ensure studies that were easy to conduct, and less interdis-
equity when resources are distributed unfairly” ciplinary work.
(p. 1). Using these definitions, activities that may be Social justice has, though, been very much in the
viewed as social justice actions for counseling psy- forefront of the field for the past 10 years. A number
chologists include using individual therapy to of initiatives have come together to highlight the
empower clients struggling with racism, sexism, or need for counseling psychologists to play a more
homophobia; intervening to ameliorate institutional active role in advocating for social change. One of
barriers to equal opportunities; and advocating these factors has been the increased emphasis on
to influence legislation. To successfully accomplish contextual influences of behavior. Researchers have
social justice actions like these, counseling psycho- moved away from the uniformity myth that all indi-
logists must understand and work to systemically viduals are the same, regardless of gender or culture,
change the root causes of societal problems that or treating gender, race, or sexual orientation as
affect the well-being of clients and their families. nuisance variables. Rather, scholars have begun to
Counseling psychology’s commitment and examine individuals’ behavior as shaped by the
involvement in social justice activities may be traced context that includes many dimensions of diversity
back to its earliest days, but the field’s commitment (e.g., gender, race/ethnicity, sexual orientation, reli-
to social justice has been uneven. For example, early gion, disability, social class). Another factor was the
pioneers of counseling psychology, such as Frank increased emphasis in universities and funding agen-
Parsons, advocated for social change through career cies on interdisciplinary collaboration and commu-
guidance, believing that work could serve as a social nity partnerships. Faculty began to be rewarded for
equalizer (O’Brien, 2001). Counseling psycholo- building and sustaining social justice programs.
gists continued to advocate for social change in their Another factor in the renewed focus on social
work with veterans after World War II. Counseling justice has been successful organizational initia-
psychologists campaigned actively for civil rights tives within the American Psychological Associa-
during the 1960s, and vigorously worked to create tion (APA), the American Counseling Association
equal opportunities for women in the 1970s. But, (ACA), and the Society of Counseling Psychology
although some counseling psychologists continued (Division 17 of APA). For example, counseling psy-
to advocate for change, particularly highlighting chologists played key roles in writing the Multi-
the effects of racism, sexism, and homophobia, the cultural Guidelines on Education and Training,
market forces of managed care in the 1980s changed Research, Practice, and Organizational Change that
the reward structures for counseling psychologists. were adopted as policy by APA in 2003 (APA,
Individual therapy and remediation were rewarded, 2003), and to develop Advocacy Competencies that
whereas prevention and social advocacy were not. were adopted as policy by ACA in 2002 (Lewis,
Managed care companies required clients to have a Arnold, House, & Toporek, 2002). The ACA
diagnosis and treatment plan in order for psycholo- and Psychologists for Social Responsibility have
gists to be reimbursed. As Speight and Vera (2008) co-sponsored the development of an electronic
note, prevention care is rarely, if ever, reimbursed by journal, called the Journal for Social Action in Coun-
a third party. seling and Psychology, highlighting the work that
Reward structures in universities also changed counselors and psychologists may play as commu-
during the 1980s, with more pressure for faculty to nity change agents. These initiatives have given an
publish rigorous empirical articles in journals with impetus to encouraging counseling psychologists to
high-impact ratings and to secure external funding. be agents of social change.

fouad, p r ince 857

 At the same time that counseling psychologists not labeled their efforts specifically as social justice
were involved in these organizational initiatives, work.
they were planning for the 2001 National Coun- More recently, there has been renewed attention
seling Psychology Conference. The theme of the paid to highlighting social justice as a central com-
conference was “Making a Difference,” with social ponent to the practice of counseling psychology.
action groups focusing on a number of social advo- For example, as noted in the introduction, counsel-
cacy plans (Fouad, McPherson, Gerstein, Blustein, ing psychologists were instrumental in guiding
Elman, Helledy, & Metz, 2004). One of the out- the development of APA practice guidelines for
comes of the conference was the development of the marginalized and underserved populations, such as
Handbook of Social Justice in Counseling Psychology the Guidelines on Multicultural Education, Train-
(Toporek, Gerstein, Fouad, Roysircar, & Israel, ing, Research, Practice and Organizational Change
2006). Another outcome was the decision by Robert (American Psychological Association [APA], 2003)
Carter, the editor of The Counseling Psychologist, to and the Guidelines for Psychotherapy with Lesbian,
create a social justice forum, encouraging major Gay and Bisexual Clients (APA, 2000). The develop-
contributions on social justice. A third outcome was ment of multicultural counseling competencies
the development of the Social Justice Award, spon- (Arredondo et al., 1996) has been an especially
sored by the authors of the Handbook, awarded for important contribution from counseling psychol-
“a sustained commitment to the specialty, to com- ogy. These competencies provide guidance for coun-
munity involvement, to recognizing diversity, and selors working with racial and ethnic minority
to demonstrating evidence of achieving community clients. The development of these competencies has
or organizational change that supports disenfran- been in itself an important step toward the practice
chised, disempowered, less privileged, or oppressed of social justice. However, a number of authors
groups and has a larger impact on practice, research, (Constantine, Hage, Kindaichi, & Bryant, 2007;
and scholarship in the field.” The first award was Toporek & Reza, 2001; Vera & Speight, 2003) have
presented in 2007 to Maria de Lourdes Prendes- argued that the implementation of multicultural
Lintel for her community work with immigrant and competencies is not sufficient; that there is a need
refugee families in Nebraska. Finally, under William for a stronger emphasis on linking multicultural
Parham’s presidency of the Society, a committee was counseling to a broader commitment of practicing
formed to give back to the communities in which social justice. They have emphasized a need to
the annual APA convention is held. Community expand beyond competencies in individual counsel-
activities, such as serving at a homeless shelter, were ing to the full range of counseling psychology prac-
sponsored in San Francisco in 2007 and in Boston tice, and to function as an advocate and social
in 2008. Thus, the past decade has seen renewed change agent at organizational, institutional, and
emphasis on social justice in counseling psychol- societal levels. Martin-Baro (1994) stated even more
ogy, with articles, committees, books, awards, and strongly that psychologists motivated to address
a journal calling for counseling psychologists to be social justice need to go beyond understanding the
more active as agents of change. This chapter will world to seeking to transform it.
focus on social justice activities of counseling psy- As we noted earlier, such directions are not new
chologists, and highlight that work in practice for the practice of counseling psychology. The pro-
settings, training, and research. fession’s philosophical foundation emphasizes pre-
vention, the development of strengths, and a holistic
Social Justice Practice view of a person interacting within an environment.
The practice of social justice in counseling psychol- Similarly, the skill sets of counseling psychologists
ogy builds on decades of work from other areas of have routinely included functions that are critical to
psychology, such as community and social psychol- the work of social justice, such as group facilitation,
ogy, as well as from the long history of the practice of consultation, assessment, program evaluation, and
social justice in other disciplines such as social work, the integration of science and practice. Recently,
law, medicine, religion, education, and economics. however, counseling psychologists have begun to
Counseling psychologists have developed models of define the skills and actions needed to practice social
practice that integrate key concepts of social justice justice, and several theoretical models have been
into the core domains of counseling psychology to proposed to organize and guide practice in this
address inequities encountered by a wide range of domain. These models are in their early theoretical
marginalized populations. However, often, they have stage of development and have limited empirical

858 social justice

support at this time, but they provide useful guid- carried out with vigilance for the environmental
ance for conceptualizing and counseling clients, forces that may be contributing to the problem.
particularly those from marginalized populations.
Each role involved takes into account three
They share a common framework for addressing
factors: client level of acculturation, locus of the
both the individual and contextual forces that are
etiology of client’s presenting concerns (i.e., stem-
critical to understanding and changing the lives and
ming from internal, dynamic sources or from envi-
situations of marginalized individuals.
ronmental sources), and goals or desired outcomes
of the intervention. This model was the first to
models of social justice practice specify methods of incorporating cultural variables
Atkinson, Thompson, and Grant (1993) were pio- into counseling to ensure that services would be
neers in developing a model for the practice of social more effective and relevant to clients from diverse
justice. They offered a model for working with cultures.
diverse populations that argued for expanding the Goodman et al. (2004a) built on Atkinson,
roles of counseling psychologists beyond the tradi- Thompson and Grant’s model by adding a theo-
tional functions of counselor and psychotherapist. retical structure derived from feminist and multi-
They identified the following eight roles for broad- cultural counseling models to guide how a counselor
ening the repertoire of counseling psychologists: might take on the expanded roles needed for social
justice work. Their model emphasizes that the prac-
• Facilitator of indigenous healing methods.
tice of social justice occurs on three levels: micro
Counselors need to consider referring clients to
(i.e., individuals), meso (communities and organiza-
healers from the clients’ culture or apply these
tions), and macro (social structures and policies).
healing methods directly if trained appropriately.
They proposed the following set of principles to
• Facilitator of indigenous support systems. It is
assist counseling psychologists in attending to each
important for counselors to know what support
level:
systems are available in the client’s culture and
how to assist the client in using them. • Ongoing self-examination: To engage in critical
• Advisor. Counselors at times need to offer self-assessment and to acknowledge hidden biases
direct advice to clients on how to remedy potential and preconceived notions toward clients from
problems and to describe how others have culturally diverse populations. This principle
managed to address them. stresses the need for counselors and practitioners
• Advocate. Sometimes counselors need to to recognize the role that power plays in how they
speak on behalf of clients, especially those who are perceived across interpersonal interactions and
are low in acculturation or have limited English- practice settings, particularly given the variation in
language skills, to remediate problems that result power attached to social position, race, gender,
from discrimination. and culture.
• Change agent. Counselors need to work • Sharing power: To engage in consensual
toward changing environments that are oppressive decision making where possible. The practitioner’s
and discriminatory, whether or not a particular contribution is presented as just one source of
client is involved. information, not the expert or best source. The
• Consultant. Counselors can help clients to goal of this principle is for both partners to gain
anticipate and strategize how to minimize effects from the interaction through a collaborative,
of discrimination and racism in various co-learning relationship, and to avoid the
environments. practitioner behaving as the only expert who
• Counselor. This role is one of traditional directs, teaches, or controls the client.
counseling that focuses on preventing problems • Giving voice: To amplify the needs,
and on addressing developmental and educational perspectives, and strengths of oppressed groups
needs of clients. It incorporates an awareness of the by advocating for them both within and outside
influence of cultural and environmental factors the counseling office.
that contribute to clients’ clients needs. • Consciousness raising: To help clients
• Psychotherapist. The traditional understand the role of historical, political, and
psychotherapist role is deemed appropriate only to social forces—such as discrimination, racism,
clients with high acculturation who want relief sexism, and homophobia—that contribute to
from an existing problem; this role needs to be an individual’s difficulties. The goal of this

fouad, p r ince 859

principle is to empower clients through Advocacy competencies that follow from this
identifying the source of distress outside of model were endorsed by the American Counseling
themselves in social institutions and norms. Association (Lewis et al., 2002). Competencies were
• Focus on strengths: To facilitate growth and classified according to three types of practice: indi-
development through helping clients to recognize vidual counseling, community work, and social
their competencies, skills, and talents, and their change. Furthermore, they were organized accord-
capacity to find solutions to their problems. ing to six domains of advocacy, varying from a focus
• Leaving clients tools: To avoid dependence on micro- to macro-level actions, and according to
and to emphasize indigenous strengths and whether they are carried out either in action with
support systems that will continue to develop the client or in action on behalf of the client.
and sustain self-determination, empowerment, Individual practice is represented at the micro level
and growth after the relationship ends and of advocacy, community work at the middle level,
over time. and social change at the macro level. Advocacy may
take place at all three levels through acting either
One criticism of this model is its limited scope with agents (e.g., working with clients or with a
(Kiselica, 2004; Palmer, 2004; Thompson & Shermis, community agency) or on behalf of agents (e.g., sys-
2004). It places a strong emphasis on helping indi- tems advocacy). Thus, this classification results in
viduals but it does not fully address changing broader six domains for practicing advocacy: client empow-
systems and communities. erment, client advocacy, community collaboration,
Another model for practicing social justice has systems advocacy, public information, and social/
been proposed by Toporek and colleagues (Toporek political advocacy. Each of the six domains has
& Chope, 2006; Toporek & Liu, 2001). This model specific competencies.
complements the models previously described Client empowerment begins with an under-
through its emphasis on the knowledge base that standing of the influences of social, political, eco-
practitioners need to acquire to effectively carry out nomic, and cultural contexts on individual clients.
the roles and principles of social justice. Furthermore, Counseling psychologists must be able to identify
this model expands upon previous models with its the client’s strengths and resources, identify his or
strong emphasis on the need for practitioners to her contextual factors, and understand the role that
engage in a broad range of advocacy roles, functions internalized oppression may play in a client’s life.
that have not been traditionally part of the reper- The psychologist must then be able to help the client
toire of counseling psychologists. identify external barriers, help him or her develop
These authors highlight four particular areas self-advocacy skills and action plans, and help the
of knowledge that form the foundation of social client to carry out the action plan.
justice practice: Client advocacy goes beyond helping a client
develop self-advocacy skills to acting as an advocate
• Interdisciplinary contributions: Becoming on behalf of the client. Competencies include nego-
familiar with social justice work in other disciplines tiating services on behalf of clients, helping clients
and developing partnerships with other access resources, identifying barriers to the well-
community professionals with similar goals. being of clients, developing an action plan for con-
• Cultural competence: Developing an fronting these barriers, identifying potential allies
awareness of personal beliefs, values, and biases to for confronting the barriers, and carrying out the
understand how they influence interventions and action plan.
to ensure that they are directed toward the best The third domain of advocacy is community
interest of the client. collaboration, in which the counseling psycholo-
• Complex roles: Gaining an understanding gist helps to identify barriers within communities
of how a practitioner’s role may vary along a and serves as an ally to facilitate systemic change.
continuum from individual empowerment to Competencies include the ability to identify recur-
social action depending on the situation and the ring themes within a community, skills to alert
strengths of the psychologist and client. community groups to the concerns, and mecha-
• Social justice resources: Becoming adequately nisms to facilitate that change. The latter includes
familiar with resources that can address clients’ skills to develop alliances within the community,
needs, such as financial resources, legal resources, and skills to listen and respect the group’s goals
and others. while still advocating for change.

860 social justice

 Systems advocacy, the fourth competency, includes school, health care, and work settings have been
the skills to facilitate systemic change, thereby alter- implemented with a wide array of disenfranchised
ing the status quo. In this domain, counseling psy- communities. They have demonstrated the commit-
chologists are able to identify factors influencing ment and potential that counseling psychologists
clients’ development, help gather and interpret data bring to combating oppression through action.
to support their findings, and help community
stakeholders develop a vision for change. Embedded Schools
in systems advocacy is the ability to analyze the polit- Davidson, Waldo, and Adams (2006) have pointed
ical and social sources of power within the commu- out that elementary and secondary school systems
nity, build alliances to facilitate change, and help are ideal settings for the practice of social justice
communities develop a plan to implement change. given the existence of schools within every geo-
Counseling psychologists also need to be able to ana- graphic area and across all social and economic levels.
lyze potential sources of resistance to change and They have stressed the importance of both the con-
know how to overcome that resistance. nection and the distinction between social justice
The fifth competency is the ability to communi- and prevention. For example, prevention efforts typ-
cate publicly about systemic areas of oppression. ically attempt to reduce risks for individuals or
Counseling psychologists develop skills to recognize groups, but many do not address the broader context
oppression, identify environmental factors that may of underlying societal inequities and hierarchies that
help to ameliorate oppression, and prepare materi- are the target of social justice efforts. These authors
als that help to publicize these. This includes the have implemented interventions that achieved social
ability to communicate in ways ethical for the com- changes in public school environments though
munity and collaborating with allies to help dis- implementing service learning activities, educating
seminate information broadly. teachers, and training school personnel.
Finally, the last competency is social and political Similarly, Thompson, Alfred, Edwards, and Garcia
advocacy, in which counseling psychologists act as (2006) have presented a framework for racial-social
agents to change public policies. This includes rec- activism based on Helms’ racial identity interaction
ognizing which problems may be addressed by social model (Helms, 1995) to address racial injustice
or political action, identifying ways to address those through a school-based effort within one commu-
problems, establishing relationships with allies, pre- nity. This project, the Heritage Project, was designed
paring rationales for change, and lobbying policy to address racism constructively with parents, teach-
makers to facilitate change. ers, students, and community members, and to
facilitate the racial identity development of students
practice arenas in a predominantly white school system. Strategies
To practice counseling psychology—and to deliver for effecting change included a wide array of activi-
mental health services generally—in a way that ties including classroom instruction, community
addresses social justice requires an acknowledgment consultations, and workshops.
that accessibility to services is itself a critical con-
cern. Seeking counseling and psychotherapy for Health Care
many cultural groups is highly stigmatized and a Many counseling psychologists practice within
violation of cultural norms. Even if individuals seek hospitals and health centers that are located within
out these services, they may not be accessible due poor and disenfranchised communities. However,
to location or cost. Furthermore, services may be location alone does not guarantee adequate care.
viewed with distrust due to past practices of discrim- The U.S. Surgeon General’s report in 2001 (U.S.
ination or inadequate care (Vera, Daly, Gonzales, Department of Health and Human Services, 2001)
Morgan, & Thankral, 2006). Consequently, the documented significant disparities in mental health
practice of counseling psychology, in any setting, care for racial and ethnic groups in the United
frequently needs to be carried out in nontradi- States. The report showed that minorities had less
tional ways if it is to serve the needs of oppressed access to services, were less likely to receive care, and
communities. received poorer quality care. The practice of social
Counseling psychologists have translated princi- justice within health care settings requires focused
ples of social justice through the development of attention to these inequities and active collabora-
interventions and programs in a number of core tion with the communities in which counseling
practice areas. A number of model programs in psychologists work. Furthermore, the integration

fouad, p r ince 861

of indigenous beliefs and health practices is impera- specifically address discrimination and harassment
tive to ensure that the community interests are being on both an individual and institutional level. These
served (Roysicar, 2006). authors caution that interventions appropriate to the
One example of how social justice can be culture of one community may be inappropriate for
addressed within this setting was illustrated by a different community. They have illustrated this
Huynh and Roysircar (2006). They described a pilot point in documenting vocational intervention pro-
program designed by the Harvard Program in grams in San Francisco that targeted homeless-
Refugee Trauma that addressed the psychological ness and poverty. Juntunen, Cavett, Clow, Rempel,
health of Southeast Asian refugees by promoting a Darrow, and Guilmino (2006) have provided a simi-
biopsychosocial health education model to help larly detailed description of a welfare-to-work pro-
maximize available resources. This effort involved gram that stresses the importance of refocusing the
building working alliances with civic organizations responsibility for change from individuals to employ-
and local ethnic community leaders to develop ers, policy makers, and community leaders. Some
services and clinical competencies that were appro- counseling psychologists (e.g., Fassinger & Gallor,
priate to the clients’ cultural context. Similarly, 2006) have argued that such efforts are not enough,
Schmidt, Hoffman, and Taylor (2006) described a however, and have advocated for a full dismantling
social justice approach to working with individuals and rebuilding of the occupational structure within
with HIV/AIDS that illustrated the impact that the United States to remedy the patriarchal hierar-
counseling psychologists can have not only with chies that maintain workplace inequities. Obviously
individuals, but with global communities. They their goal is idealistic. Nevertheless, these authors
stressed the importance of collaborating with com- emphasize the parallel to remodeling a house one
munity agencies to better understand sexual behav- plank at a time. Oppressive structures in the work-
iors, substance use, stigma, and sexual orientation, place and in schools can be remodeled to address
among other variables, to develop reciprocal, mutu- inequities across gender, sexuality, race, and abilities
ally beneficial opportunities for social justice work. through collaborations and coalitions that target
legal, policy, and professional changes a step at a
Work time.
Counseling psychology has a long history of attend-
ing to the vocational and career development needs challenges and barriers to social
of disenfranchised groups. In fact, many of the stron- justice practice
gest examples of social justice work within counsel- Although much work has been done to guide and
ing psychology have occurred within the vocational develop the practice of counseling psychology toward
domain. Early efforts that set the groundwork for an emphasis on social justice, this focus remains lim-
current practice include Frank Parsons’ vocational ited within the field overall. The practice of social
interventions with poor boys in Boston in the early justice, for a number of reasons, has yet to be fully
1900s (Pope, 2000) and post-World War II voca- emphasized and integrated into the broad practice of
tional guidance programs that attended to the needs counseling psychology. One barrier to the practice
of returning veterans and the changing roles of of social justice is simply economic. Insurance pay-
women in the workplace (Sundberg & Littman, ments, for example, will typically reimburse practi-
1994; Thompson, Super, & Napoli, 1955). More tioners for individual psychotherapy, but not for the
recently, vocational counseling psychologists have expanded functions of prevention, advocacy, and
advocated for equal access and higher-quality career community work that a social justice perspective
development services for a number of underserved entails (Vera & Speight, 2003). Even in those prac-
and marginalized populations, including women tice settings that do not rely on third-party payments
(Betz & Fitzgerald, 1987; Fitzgerald & Harmon, from insurance companies, such as college and uni-
2001), racial and ethnic minorities (Fouad & versity counseling centers and community mental
Bingham, 1995; Leong 1995), gays and lesbians health clinics, rarely are social justice models inte-
(Chung 2003; Croteau, Anderson, Distefano, & grated into practice models. The missions of these
Kampa-Kokesch, 2000), and poor and working-class agencies may be to serve the broad psychological and
individuals (Blustein, 2006; Fouad & Brown, 2000). developmental needs of all the members of their
Toporek and Chope (2006) have described common communities, but in recent times, most of these
examples of workplace injustice; they have detailed services have reduced their focus on prevention
strategies that counseling psychologists can use to and advocacy. Instead, many have redirected their

862 social justice

limited resources toward responding to increasing social justice was often included as an objective in
demands for individual clinical care, to reducing the course, but few of the instructors included
wait-lists, and to remaining accessible to individuals exploration of actual strategies for social change. In
in crisis (Gallagher, 2007; Ivey & Collins, 2003). this section, we will review the literature on social
Prevention work and programs that address the justice training and highlight challenges and barri-
needs of under-represented groups may be funded ers for social justice training. The two questions of
instead through secondary income sources such as concern in social justice training are what knowl-
time-limited and competitive government grants edge and skills students need to learn and how to
(Davidson, Waldo, & Adams, 2006). include this knowledge acquisition in training.
Perhaps the most significant challenge to integrat-
ing social justice into the core practice of counseling social justice knowledge and
psychology is the call for of expanding the scope of advocacy competence
our discipline beyond its historic emphasis on help- What exactly is social justice training? In general,
ing individuals, couples, families, and small groups. there is a consensus that social justice training
Only recently have counseling psychologists begun builds on training for multicultural competence
to define the guiding principles of social justice work; (Arredondo & Rosen, 2007; Goodman et al., 2004a;
we have yet to fully develop and refine the skill sets McWhirter & McWhirter, 2007; Toporek et al.,
needed for working with communities and larger sys- 2006; Vera & Speight, 2003). Students must have
tems through interdisciplinary collaborations self-awareness and must have knowledge of cultural
(Davidson et al., 2006; Goodman et al., 2004a). groups, but training for social justice involves more
Social justice work can be extremely rewarding action on the part of the student. Students must
personally and professionally. At the same time, it learn to conceptualize structural explanations for
challenges practitioners emotionally in ways that clients’ concerns and know how to systemically
traditional counseling and consulting do not. The intervene to ameliorate their concerns.
work can be time-consuming and draining, and the Consistent with the first and second APA (2003)
outcomes can be small compared to the large social Guidelines on Multicultural Education, Training,
problems being addressed. Helms (2003) highlighted Research, Practice and Organizational Change for Psy-
how often social justice work relies on volunteer chologists, students need to learn an appreciation and
work and is conducted in addition to a psychologist’s respect for diversity, gain knowledge about margin-
full-time job duties. To sustain social justice work, alized and oppressed groups, and learn an under-
practitioners need the availability of strong profes- standing of oppression. Indeed, Toporek and
sional support structures and supportive colleagues Pope-Davis (2005) found that students with multi-
or supervisors. These supports can provide needed cultural training were more likely to have structural,
encouragement, recognition, and consultation. Most rather than individual, explanations for poverty.
importantly, they can help combat the common cor- Beyond attitude change, however, Toporek et al. rec-
ollaries of this work, such as burnout, hopelessness, ommended that social justice training helps students
and anger. to learn about roles for counseling psychologists
other than that of individual therapy. Thus, students
Social Justice Training need to learn to collaborate with other profession-
Scholars writing about social justice have frequently als, learn advocacy skills, learn to ethically conduct
given specific suggestions for training (e.g., research in community-based settings, and to ethi-
Aldarondo, 2007; Ali, Liu, Mahmood, & Arguello, cally build and sustain community partnerships.
2008; Lee, 2007; Toporek et al., 2006). The sugges- One of the questions about social justice training
tions and recommendations range from overhau- is how to help students build competencies needed
ling the entire training program, to adding specific for ethical advocacy. Advocacy is a core competency
components to training, to providing concrete sug- for psychologists defined as “Actions targeting the
gestions of activities or projects that may be incor- impact of social, political, economic or cultural fac-
porated into a class. Each defines social justice tors to promote change at the individual (client),
somewhat differently, but most define social justice institutional, and/or systems level” (Fouad et al.,
training as different from training in multicultural 2009, p. S24).
competence. However, Pieterse, Evans, Risner- Two essential components comprise the advocacy
Butner, Collins, and Mason (2009) reviewed multi- competence: empowerment and systems change.
cultural counseling course syllabi and found that Students need to learn how to empower their clients

fouad, p r ince 863

and how to promote systems change. Developmen- services other than remedial interventions” (p. 269),
tally, training begins with building students’ aware- and students need to be trained to think more sys-
ness of the need for empowerment and systems temically about their work as psychologists. They do
change and then builds their competence in contex- not specifically suggest that students should not be
tual analysis and finally, helping students to develop trained to be competent at remedial, individually
skills to intervene appropriately. focused interventions. Rather, they discuss the
Skills for advocacy are developed sequentially potential for student stress and burnout when stu-
across levels of training. At the first developmental dents emphasize therapy as the avenue for change,
level for empowerment, students are expected to be when clients are embedded in a social context that
able to articulate social, political, economic, or cul- needs to be changed. They recommended that train-
tural factors that may have an impact on human ing activities foster a passion for social justice
development and functioning. By the time students (an affective component), provide students with
are ready for internship, they should know how to knowledge of history of oppression and the psycho-
use that awareness in the context of service provi- logical affects of oppression (intellectual compo-
sion, as evidenced by their ability to identify specific nent), and most critically, provide students with the
barriers to client improvement, such as lack of access skills and tools to effectively intervene as social
to resources or exposure to discrimination, and to change agents (a component that moves them to
assist clients in the development of self-advocacy action).
plans. By the time students are ready to enter the
profession, they should be able to intervene with social justice training models
clients to promote action on those barriers, know- The second question in social justice training is how
ing how to promote client self-advocacy and how to programs can help students to develop these skills.
assess the client’s implementation and outcome of Several authors have described the development of
that self-advocacy. social justice–oriented training programs in coun-
The second essential component in advocacy is seling psychology. Goodman et al.’s (2004a) six core
systems change. Early in their training, students are themes were described more fully in the previous
expected to understand the differences between section on practice; Goodman et al. also applied
individual- and institutional-level interventions and these to training. Briefly, these themes include help-
systems level change. This is evidenced by their abil- ing students to build an awareness of power dynam-
ity to articulate the role of therapist as a change ics; understand how to share power and foster
agent outside of direct patient contact. By the time empowerment; learn how to “give voice” to others’
they are ready for internship, students should be experiences, particularly to those with less power;
able to promote change to enhance the functioning raise clients’ consciousness of the extent to which
of individuals. Students are able to specify the difficulties are embedded in societal contexts; learn
concern, formulate and engage in a plan for action, how to foster clients’ strengths and resources; and
and demonstrate an understanding of appropriate leave clients with the tools to continue growing.
boundaries to advocate on behalf of the client.
At the final level of training, students should be Training Models
qualified to promote change at the level of institu- McWhirter and McWhirter (2007) described the
tions, community, or society. This will be evidenced counseling psychology program at the University of
by their ability to develop alliances with relevant Oregon. They outlined the shift in the program over
individuals and groups and by their ability to engage the last 10 years from training students to do indi-
with groups with differing viewpoints around issues vidual interventions to giving students the skills
to promote change. to be systemic change agents. They help students
Thus, in addition to learning the traditional build these skills through practica designed to help
skills to be a counseling psychologist (e.g., building them understand contextual influences on clients,
relationships, conducting assessment and interven- including a practicum in which students conduct
tions), students are encouraged to learn advocacy home and school visits. Specifically, they assume
skills. Some authors suggest that social justice train- that “counseling psychologists are responsible for
ing must de-emphasize developing the skills to be working to reduce or eliminate risk factors, develop
an individual therapist. For example, Vera and protective interventions that contribute to resil-
Speight (2003) argued that “clients need more than ience . . . and support and strengthen aspects of the
[individual] counseling and communities need community” (p. 395). The authors delineate various

864 social justice

readings that are integrated into courses, the infu- additional course load for students. Although stu-
sion of multicultural competence throughout the dents and faculty at Boston College valued a social
curriculum, and ways that students are engaged in justice curriculum, this curriculum was in addition
the community through practica and community- to the activities of the typical counseling psychology
based research. training expected in an APA-accredited program.
Burns and Manese (2008) described implemen- Ali, Liu, Mahmood, and Arguello (2008) com-
tation of social justice training as part of an APA- mented on the importance of social justice training
accredited internship located at the University of in counseling psychology as a philosophical stance,
California-San Diego University Counseling Center. as well, and described two concrete methods for
The internship provides opportunities for interns to teaching social justice, through courses that offer
engage in consultation, outreach, and preventative service learning (e.g., community-based experi-
activities outside the campus community, in addi- ences as part of a course) or through focused pra-
tion to the individual and group counseling typical cticum experiences that emphasize social justice
of internship training. The authors analyzed their work. Goodman et al. (2004a) also described ser-
program within the six tenets identified by Goodman vice learning as a mechanism for teaching social jus-
et al. (2004a), providing perspectives from both the tice and having students participate in extended
training director and a previous intern. The authors community–faculty partnerships. Green, McCollum,
conclude with several recommendations for intern- and Hays (2008) suggested several ways to teach
ship programs, including: select interns who have students the skills for advocacy counseling, includ-
an interest in social justice activities, assess the com- ing helping students to develop an advocacy plan
mitment of training staff to social justice activities, for a community need, or having students partici-
provide training and support for staff on an ongoing pate in the orientation sessions of local community
basis, and develop training opportunities that are organizations.
commensurate with the interns’ skills. Interns with
higher levels of skills are able to develop, imple- challenges and barriers
ment, and evaluate their own programs, whereas The central difficulty in social justice training is that
interns with less developed skills are able to observe community needs and training needs do not always
workshops or participate in discussion. The authors coincide. Traditional training programs help stu-
noted, in particular, the need to use a strengths- dents build competence in quarter- or semester-
based perspective to avoid putting interns into posi- long intervals. But the need for advocacy within the
tions in which they feel inadequate, or staff in community may occur at any time of the year, and
positions in which they feel burned out. not necessarily when the faculty believe that the stu-
The training programs described above are, them- dents are ready to be advocates. Clearly, community
selves, examples of systemic change in the training and client needs for advocacy may not coincide with
programs. Common across these examples are key the training schedule. Ethically, training programs
leaders who articulated the need to shift to a social cannot extend opportunities for advocacy for the
justice training model and invested a great deal semester, and then abandon efforts until the next
in developing strong community partnerships that semester starts. Thus, many programs find that they
benefited both the university and the community can build awareness of the need for social justice
site. Training activities were designed to provide stu- and build knowledge of ways to implement social
dents with the opportunities to learn advocacy skills justice, but may not be able to build social justice
in a real-life setting. Each model also described the skills.
difficulties in creating such change. The authors Ali et al. (2008) also acknowledged the practical
delineate the importance of lengthy faculty/staff difficulty of implementing a social justice agenda,
discussions of how and what to change in the cur- particularly the very real problem of asking faculty to
riculum, of faculty/staff engagement, and faculty/ add to their workload. As mentioned above, creating
staff commitment. Implementing a program-wide and sustaining community partnerships take a great
commitment to social justice training begins with a deal of faculty time. Time is needed to listen to
deep faculty commitment to establishing and main- community concerns, and time is needed to create
taining strong community partnerships. Goodman, training models and activities that meet commu-
Liang, Weintraub, Helms, and Latta (2004b) noted nity needs. These activities must also help students
not only the intensive amount of time to deve- become competent psychologists. Faculty must often
lop and sustain community partnerships, but the rethink their courses and instructional strategies,

fouad, p r ince 865

which also takes time. Faculty may not want to invest Counseling psychologists have a number of skills to
the time in these changes for a variety of reasons. collect and analyze data that can be of great help to
They may not agree with the philosophical shifts to a communities. For example, counseling psychologists
social justice model, they may have their own pres- may help to document the existence of a problem,
sures to publish to be successful, and they may, may help to design systems of data collection to argue
themselves, be fatigued with community efforts. the need for more resources, or to help community
Talleyrand, Chung, and Bemak (2006) had partners evaluate and document the effectiveness of
several suggestions to help programs that were services. Fassinger and Gallor (2006) suggest that
interested in incorporating social justice training, research documenting fiscal need for services may be
including holding faculty retreats, ensuring addi- the most important advocacy tool we have. But, the
tional training for adjunct faculty and supervisors, most critical issue is to ask questions that are impor-
empowering students to have a voice in the program, tant to the community. This requires time and
partnering with local community-based services, patience to understand what issues are important to
and ensuring consistent assessment and evaluation community partners, who may not be versed in the
of the training. But, Burns and Manese (2008) also language of operational definitions that translate into
point out the difficulty of mandating that faculty research studies. In other words, community partners
and staff participate in social justice activities if they are knowledgeable about the work they are doing, the
are not prepared or are burned out or have compas- problems of the community, and the possible solu-
sion fatigue. Also, programs may be in danger of tions, but may not know how to create a way to
marginalizing faculty or staff who have not devel- examine these problems or solutions. Counseling
oped those skills, or who do not want to engage in psychologists can bring their skills to help develop
community service. Thus, program faculty and staff evaluation or research studies, but it must be a col-
need to determine if their training mission includes laborative process (Vera & Speight, 2003). Listening
the development of advocacy skills, in addition to and developing socially relevant questions is best done
awareness and knowledge related to advocacy. as part of a systemic partnership that will benefit all
parties involved. As we have noted several times in
Social Justice Research this chapter, this takes time, persistence, and patience.
Social justice research may be viewed in two ways: Toporek et al. (2006) suggest, as well, that we need
research on the effectiveness of social justice practice to develop new and collaborative multidisciplinary
or training, and research that, as Sedlacek (2007) sug- mechanisms of doing research, including participa-
gested, “[is] making a difference in bringing about tory action research. They recommend that counsel-
social change” (p. 223). Few studies have been done ing psychologists can learn from community-centered
on the former at this point, and clearly this is an area research paradigms that have been developed by social
for future research. How do we know that we are, in workers and community psychologists.
fact, making a difference by integrating a social jus- It is also important to be broad in the dissemina-
tice perspective in our practice or training? Are some tion of social justice research. Developing sound
activities more helpful than others in creating advo- methodological research will help enable studies to
cacy skills in students? Are some attitudes so essential be published in counseling psychology journals, but
in developing social justice skills that training pro- community partners are not likely to read and be
grams need to select students on those attitudes? influenced by those journals. Identifying outlets to
What traditional and nontraditional healing practices write about the practical implications for the com-
are the most critical in helping empower clients? munity is important. This is similar to the call for
Speight and Vera (2008) note that research on factors translational research in health sciences, to bridge
leading to mental health disparities (and ways to the gap between basic research and the clinical
redress this) are a type of social justice research, and implications. Counseling psychologists also need to
Toporek et al. (2006) suggest that research could learn to write succinct summaries of their research
focus on factors that lead to perpetuating injustice, to provide information to legislators and policy
including studies on oppressors, rather than the makers.
oppressed. Research results may guide program devel-
opment to help ensure that a social justice perspective challenges and barriers
does no harm to clients or communities. The collaborative nature of social justice research
Much more has been written about developing also brings a few dilemmas. When research does
mechanisms to use research for social justice purposes. not support the community partner’s perspective,

866 social justice

the question may arise, who owns the data? Do taking on nontraditional roles in nontraditional set-
counseling psychologists have an obligation to pub- tings, counseling psychologists may need to cau-
lish the results of studies that may not be in favor of tiously engage in dual roles with clients and to work
community initiatives? Do they have an obligation within a broader definition of professional boundar-
to support the community partner’s perspective, ies. Practitioners need to actively and consistently
even if the data do not support it? This becomes seek out supervision and peer consultation to help
more of a concern when considering the pressure identify and negotiate these challenges. Similarly,
that many academic counseling psychologists are training programs need to incorporate case studies
under to publish. Whose needs are met when and offer supervision in social justice practice to
research results cause a conflict? assist students in identifying and responding to these
Academic psychologists may also be in universi- unique ethical dilemmas.
ties in which community work is not supported, or We highlighted earlier some of the ethical dilem-
in which community partnerships are expected, but mas that counseling psychologists confront when
are not rewarded. Tenure policies that emphasize they incorporate social justice into their training
publications in academic journals with high impact and research, particularly the ethical dilemma when
ratings may differentially reinforce scholarship in training or research needs conflict with the advocacy
narrow avenues of research and not reward faculty needs of a community. The ethical mandates from
who are involved in community-based partnerships. our professional codes of practice require doing no
By the same token, programs that try to protect harm to clients, ensuring competence, and provid-
junior faculty from community-based partnerships ing informed consent. These principles become even
may overburden senior faculty and may prevent more critical when students are involved in advo-
community partners from benefiting from new cacy work with vulnerable populations. Consider
faculty perspectives and ideas. the potential ethical dilemmas in social justice train-
ing. Faculty may have a conflict between training
Ethics students to be competent and doing no harm to
The practice of social justice requires an understand- clients. What happens when the best solution for
ing of underlying ethical considerations and carries clients is to pull a student from the training site, but
with it unique ethical challenges. Social justice work the best solution for students is to keep them at the
is complex work and is often filled with ethical site to develop their skills? Whose needs are best met
dilemmas. It involves an ongoing process of self- in this situation? What happens when students are
examination, of power dynamics and negotiating not yet competent to provide services in a commu-
multiple levels of individual, organizational, and nity partnership, but the site is depending on those
community interactions. A number of authors services? Whose needs are met in this situation,
(Goodman et al., 2004a; Kiselica, 2004), drawing particularly if the university wants to continue the
from feminist and multicultural psychology, have partnership in the future, or the faculty member is
emphasized two broad ethical mandates for the conducting research at the site? Clearly, these ethical
practice of social justice: to reflect our personal dilemmas need to be considered when faculty are
values and those values of the organizations and creating partnerships to enable their students to
systems in which we operate, and to empower and develop advocacy competencies.
collaborate rather than to exploit and objectify. Toporek and her colleagues have written exten-
Carrying out such mandates is not straightfor- sively on the topic of ethics in social justice work
ward; difficult self-reflection and ethical conflicts are (Toporek & Chope, 2006; Toporek & Williams,
necessary components. For example, clashes 2006). They have identified three practical ethical
can occur when the cultural values and worldviews issues that are related to both research and practice:
of psychologists are incongruent with the cultural the need for psychologists to provide informed con-
values of their clients or client groups. Such conflicts sent not only to individuals, but to communities
underscore the need for psychologists to be attentive as well; the need to acknowledge limits to a psy-
to their motives as well as to their positions of power chologist’s competence with community work, and
and privilege compared to those of their clients, and the necessity of working collaboratively with other
the need to avoid acting in ways that are paterna- agencies and professionals to ensure the client’s
listic and reinforcing of clients’ feelings of helpless- needs are best addressed; and the importance of
ness. Similarly, Kiselica and Robinson (2001) have balancing conflicting goals, such as a clash between
cautioned that since social justice work often requires the goals of a client and the need for social change.

fouad, p r ince 867

For example, there is an ethical responsibility to begin to influence policy and legislation? Coun-
maintain a client’s goal as foremost, when a client seling psychology training programs have not yet
chooses to not take action in the face of injustice. routinely addressed the teaching and practicing of
Toporek and Williams (2006) have called for an specific skills that would enable new professionals
expansion of the APA’s ethical standards (APA, to influence large organizations, social policies, and
2002), so that attention to social justice is embed- legislatures.
ded in the fundamentals of all ethical psychological Nevertheless, counseling psychologists have
practice. They have distilled a number of themes an array of core proficiencies, including interper-
specific to social justice from the ethical standards of sonal relations, research, counseling, administra-
a number of professions and organizations, and tion, teaching, and consultation, that have vast
have recommended that the following three themes potential for influencing policy makers and legisla-
be incorporated into the current APA ethical prin- tors. Furthermore, numerous counseling psycholo-
ciples and code of conduct (APA, 2002): gists have shown through their writings and by
example how to influence macro-level social and
• Respect. Psychologists need to acquire
political changes through their exercise of the
adequate knowledge of a culture’s customs and
knowledge and skills that are central to our field.
structures before engaging in any work with a
For example, Haldeman (2003) has made signifi-
community. This knowledge should serve as a base
cant contributions to inform national leaders on
for identifying a community’s strengths and as a
misguided and discriminatory programs in conver-
guide for the psychologist’s behavior within that
sion therapy for gays and lesbians; Winerman
community.
(2004) has helped to oppose discrimination against
• Responsibility. Not only do psychologists
same-sex parents and to support same-sex marriage;
need to recognize that all persons are entitled to
and several authors have outlined ways to address
equal access and equal quality of psychological
workplace inequities (Blustein, 2006; Fassinger &
services; psychologists also need to work toward
Gallor, 2006; Toporek & Reza 2001). Counseling
ending discrimination, oppression, and other
psychologists have advocated for changes in social
forms of social justice. Furthermore, psychologists
policy through a variety of roles, including drafting
have a responsibility to engage in research and
legislation to promote funding for mental health of
practice that serves oppressed groups and
college students (Ablasser, 2004), testifying before
eliminates oppression.
legislative bodies to advocate for equal rights for
• Social action. Psychologists should be
women, and even serving as an elected public offi-
expected to confront injustice, to correct
cial, as did Ted Strickland, the first psychologist
discriminatory and unjust practices, and to
(counseling psychologist) elected to the U. S.
expand opportunities for vulnerable,
Congress (Shullman, Celeste, & Strickland, 2006).
disadvantaged, and oppressed people.
Counseling psychologists also have been instru-
mental in influencing social policies in international
Policy and Legislation arenas. For example, Norsworthy and her colleagues
Advocates of social justice point out how essential it have described their consulting and peace-building
is for counseling psychologists to network, to lobby, efforts in Southeast Asia, and have stressed the impor-
and to actively work toward modifying policies tance of counseling psychologists working with
and structures that create inequities and oppression nonpsychologist, international partners to success-
in the United States and globally. Nevertheless, fully address justice worldwide (Norsworthy, 2006).
many counseling psychologists, although commit- Similarly, Gerstein and Kirkpatrick (2006) have iden-
ted to the values of social justice, are uncomfortable tified through their efforts in Tibet some critical roles
becoming involved at the macro level of organiza- that counseling psychologists can assume to reduce
tional and political action. For some, this may international violence. For example, counseling psy-
reflect a personal preference, disillusionment with chologists can serve as group leaders, program plan-
the lengthy process of social change, or perhaps a ners, trainers, and evaluators on multidisciplinary
desire to avoid dual relationships within specific teams to help integrate indigenous strategies toward
communities. For many, however, reluctance may peaceful solutions. Furthermore, many nonprofit and
be due largely to not knowing how to do such work. international organizations hire psychologists to
Where and how does a counseling psychologist study and address the reasons and consequences for
trained and skilled in the helping of individuals violence.

868 social justice

 These examples underscore the innumerable • Help policy makers prepare materials and
opportunities for counseling psychologists to frame arguments through serving as a staff member
become involved and to commit to action in a tan- or advisor to public officials or through an
gible way. Although most counseling psychologists appointment to public policy boards, committees,
will not run for office or create international pro- and commissions.
grams, we can begin to influence social policies • Support and encourage other psychologists
through becoming more informed about basic legis- who are involved in public debates about social
lative and policy-making structures, learning how justice.
state and federal bills are introduced and passed, • Engage in lobbying and raising money for
and sending letters of support for bills that address candidates and political action committees that
social injustice to representatives in state and federal support social justice causes.
legislatures. • Educate and prepare psychologists for social
The APA and the ACA have a number of divi- advocacy work through professional seminars that
sions, sections, committees, and task groups that address real-world ethical dilemmas in shaping and
work toward supporting and educating psycholo- forming public policy.
gists interested in influencing social policy. The APA
has a Public Policy Office that actively engages in The challenges to influencing policies and
shaping federal policy, as well as a Directorate for legislators from local to global levels are immense.
Public Interest that promotes the advancement of Nevertheless, as larger numbers of counseling
human welfare. In addition, the APA formed a psychologists become engaged in such advocacy,
coalition for social justice in 1999, Divisions for large-scale social and political changes will occur.
Social Justice, that is comprised of representatives The potential for counseling psychology to contrib-
from a number of APA divisions and focuses on ute to social change and to address community,
supporting and encouraging social justice initiatives societal, and global injustices has only begun to
across divisions through sponsoring symposia and be recognized.
town hall meetings at conventions. Similarly, the
ACA has formed a division devoted to addressing Conclusion
social justice issues. Both organizations have created Future Directions
a range of opportunities for members to lobby legis- Strengthening the practice of social justice in coun-
lative bodies and to share data and research findings seling psychology will require efforts on a number
with legislators that can be used to craft and support of fronts. Counseling psychology has only begun
bills that address social justice needs. to develop culturally sensitive and internationally
Shullman et al. (2006) offered these nine sugges- effective models related to various forms of social
tions for different ways in which counseling psy- oppression. Incorporating theories from other disci-
chologists can become more involved in the political plines such as anthropology, sociology, and political
and policy making process: science, among others, will be a challenge but an
essential component to developing our knowledge
• Support social advocacy efforts of national base and to creating more culturally informed,
professional organizations, such as APA, ACA, interdisciplinary, and systemically focused models.
the Association of Black Psychologists, the Latino/ Some training programs have incorporated social
Latina Psychological Association, and the justice as part of the curriculum, but as Pieterse
Association of Asian Psychologists. et al. (2009) have shown, many programs combine
• Support public policy efforts of professional social justice training with training in multicul-
organizations of psychologists at state and local tural competence. More information is needed
levels. on minimal competencies for social justice effective-
• Support independent political action groups ness. Stronger collaborative partnerships in research,
that support social justice issues. training, and practice between universities and
• Become directly involved in dialogues with community agencies need to be developed across
policy makers through sharing professional domains of psychology, across professional disci-
knowledge on social justice issues. plines, and across communities and nations. For
• Focus efforts on getting to know specific both practical and ethical reasons, these collabora-
policy makers and on influencing a specific social tions need to be developed with an eye toward
justice topic. respecting the strengths of community stakeholders

fouad, p r ince 869

affected by oppression and with the assumption that Betz, N. E., & Fitzgerald, L. F. (1987). The career psychology of
these stakeholders hold the knowledge that will lead women. San Diego: Academic Press.
Blustein, D. L. (2006). The Psychology of working. Mahwah NJ:
to solutions. Counseling psychologists can begin to Lawrence Erlbaum Associates.
develop such collaborative relationships through Blustein, D. L., & Fouad, N. A. (2008). Changing face of
becoming more involved in established interdisci- vocational psychology: The transforming world of work.
plinary organizations working toward social justice, In W. B. Walsh (Ed.), Biennial review of counseling psychology
such as the United Nations, diplomatic services, Vol. 1 (pp. 129–155). New York: Routledge/Taylor & Francis
Group.
and human rights groups. Burnes, T. R., & Manese, J. E. (2008). Social justice in an accred-
Most importantly, a shift in our professional ited internship in professional psychology: Answering the
standards is needed to ensure that our practice set- call. Training and Education in Professional Psychology, 2,
tings embrace social justice and that our training 176–181. doi: 10.1037/1931–3918.2.3.176.
programs mirror the broader roles required for social Chung, Y. B. (2003). Career counseling with lesbian, gay,
bisexual, and transgendered persons: The next decade. Career
justice work. Accreditation standards for our aca- Development Quarterly, 52, 78–85.
demic and training programs, for example, need Constantine, M. G., Hage, S. M., Kindaichi, M. M., &
revision to ensure they include courses, experiences, Bryant, R. M. (2007). Social justice and multicultural issues:
and interventions specific to developing social jus- Implications for the practice and training of counselors
tice skills. Similarly, professional licensure require- and counseling psychologists. Journal of Counseling and
Development, 85, 24–29.
ments need to be expanded if practitioners are to be Croteau, J. M., Anderson, M. Z., Distefano, T. M., & Kampa-
held accountable for incorporating social justice Kokesch, S. (2000). Lesbian, gay and bisexual vocational
into the fabric of their work. The field of counseling psychology: Reviewing foundations and planning construc-
psychology is at a crossroads. The work of a handful tion. In R. M. Perez, K. A. DeBord, & D. J. Bieschke (Eds.),
of counseling psychologists has paved the way for a Handbook of counseling and psychotherapy with lesbian, gay
and bisexual clients (pp. 383–408). Washington, DC:
transformation of our profession, one that encom- American Psychological Association.
passes a broader, more direct and more collaborative Davidson, M. M., Waldo, M., & Adams, E. M. (2006).
approach to confronting social injustice. Promoting social justice through preventive interventions
in schools. . In R. L. Toporek, L. Gerstein, N. A. Fouad,
References G. Roysircar, & T. Israel (Eds.), Handbook for social justice
Ablasser, C. (2004). Creating healthy campuses: APA members in counseling psychology: Leadership, vision, and action
successfully promote psychological services at colleges and (pp. 117–129). Thousand Oaks, CA: Sage.
universities. APA Monitor on Psychology, 5(10), 66–67. Fassinger, R. E., & Gallor, S. M. (2006). Tools for remodeling
Aldarondo, E. (Ed.). (2007). Advancing social justice through the master’s house: Advocacy and social justice in education
clinical practice. Mahwah, NJ: Lawrence Erlbaum Associates. and work. In R. L. Toporek, L. Gerstein, N. A. Fouad,
Ali, S. R., Liu, W. M., Mahmood, A., & Arguello, J. (2008). G. Roysircar, & T. Israel (Eds.), Handbook for social justice
Social justice and applied psychology: Practical ideas for in counseling psychology: Leadership, vision, and action
training the next generation of psychologists. Journal for (pp. 256–275). Thousand Oaks, CA: Sage.
Social Action in Counseling and Psychology, 1(2), 1–13. Fitzgerald, L. F., & Harmon, L. W. (2001). Women’s career
American Psychological Association (APA). (2000). Guidelines development: A postmodern update. In F. T. L. Leong, &
for psychotherapy with lesbian, gay and bisexual clients. A. Barak (Eds.), Contemporary models in vocational psychol-
American Psychologist, 55, 1440–1451. ogy: A volume in honor of Samuel H. Osipow (pp. 207–230).
American Psychological Association (APA). (2002). Ethical Mahwah, NJ: Lawrence Erlbaum.
principles of psychologists and code of conduct. American Fouad, N. A., & Bingham, R. (1995). Career counseling with
Psychologist, 57, 1060–1073. racial/ethnic minorities. In B. Walsh, & S. Osipow (Eds.),
American Psychological Association (APA). (2003). Guidelines Handbook of vocational psychology (2nd ed., pp. 331–366).
on multicultural education, training, research, practice, and Hillsdale, NJ: Lawrence Erlbaum.
organizational change for psychologists. American Psychologist, Fouad, N. A., & Brown, M. T. (2000). The role of race and class
58, 377–402. in development: Implications for counseling psychology.
Arredondo, P., Toporek, R., Brown, S. P., Jones, J., Sanchez, J., & In S. D. Brown, & R. W. Lent (Eds.), Handbook of counseling
Stadler, H. (1996). Operationalization of the multicultural psychology (3rd ed., pp. 379–408). New York: Wiley.
counseling competencies. Journal of Multicultural Counseling Fouad, N. A., Grus, C. L., Hatcher, R. L., Kaslow, N. L.,
and Development, 24, 42–78. Hutchings, P. S., Madson, M., et al. (2009). Competency
Arredondo, P., & Rosen, D. C. (2007). Applying principles of benchmarks: A developmental model for understanding and
multicultural competencies, social justice, and leadership in measuring competence in professional psychology. Training
training and supervision. In E. Aldarondo (Ed), Advancing and Education in Professional Psychology, Vol. 3 (4, Suppl),
social justice through clinical practice (pp. 443–458). Mahwah, S5–S26.
NJ: Lawrence Erlbaum Associates. Fouad, N. A., McPherson, R. H., Gerstein, L., Blustein, D. L.,
Atkinson, D. R., Thompson, C. E., & Grant, S. K. (1993). Elman, N., Helledy, K. I., & Metz, A. J. (2004). Houston,
A three-dimensional model for counseling racial/ethnic 2001: Context and Legacy. Counseling Psychologist, 32,
minorities. The Counseling Psychologist, 21(2), 257–277. 15–77.

870 social justice

Fouad, N. A., Gerstein, L. H., & Toporek, R. L. (2006). Kiselica, M. S., & Robinson, M. (2001). Bringing advocacy
Social justice and counseling psychology in context. counseling to life: The history, issues, and human dramas of
In R. L. Toporek, L. Gerstein, N. A. Fouad, G. Roysircar, & social justice work in counseling. Journal of Counseling &
T. Israel (Eds.), Handbook for social justice in counseling psy- Development, 70, 387–397.
chology: Leadership, vision, and action (pp. 1–16). Thousand Lee, C. C. (Ed.). (2007). Counseling for social justice (2nd ed.).
Oaks, CA: Sage. Alexandria, VA: American Counseling Association.
Fox, D., Prilleltensky, I., & Austin, S. (Eds.). (2009). Critical Leong, R. T. L. (Ed.). (1995). Career development and vocational
psychology: An introduction (2nd ed.). London: Sage. behavior of racial and ethnic minorities. Hillsdale, NJ:
Gallagher, R. (2007). National survey of counseling center direc- Lawrence Erlbaum.
tors 2006. Washington DC: International Association of Lewis, J., Arnold, M., House, R., & Toporek, R. (2002).
Counseling Services Inc. American Counseling Association advocacy competencies.
Gerstein, L. H., & Kirkpatrick, D. (2006). Counseling psychol- Alexandria, VA: American Counseling Association.
ogy and non-violent activism: Independence for Tibet!. Martin-Baro, I. (1994). War and mental health. In A. Aron, &
In R. L. Toporek, L. Gerstein, N. A. Fouad, G. Roysircar, & S. Corne (Eds.), Writings for liberation psychology: Ignacio
T. Israel (Eds.), Handbook for social justice in counseling Martin-Baro (pp. 108–121). Cambridge, MA: Harvard
psychology: Leadership, vision, and action (pp. 442–471). University Press.
Thousand Oaks, CA: Sage. McWhirter, E. H., & McWhirter, B. T. (2007). Grounding
Goodman, L. A., Liang, B., Helms, J. E., Latta, R. E., Sparks, E., clinical training and supervision in an empowerment model.
& Weintraub, S. R. (2004a). Training counseling psycholo- In E. Aldarondo (Ed.), Advancing social justice through
gists as social justice agents: Feminist and multicultural clinical practice (pp. 417–442). Mahwah, NJ: Lawrence
principles in action. Counseling Psychologist, 32, 793–837. Erlbaum Associates.
doi: 10.1177/0011000004268802. Nicolas, G., Helms, J. E., Jernigan, M. M., Sass, T., Skrzypek, A.,
Goodman, L. A., Liang, B., Weintraub, S. R., Helms, J. E., & & DeSilva, A. M. (2008). A conceptual framework for
Latta, R. E. (2004b). Warts and all: Personal reflections on understanding the strengths of Black youths. Journal of Black
social justice in counseling psychology. Reply to Kiselica, Psychology, 34, 261–280. doi: 10.1177/0095798408316794.
Palmer, Thompson and Shermis, and Watts. Counseling Norsworthy, K. L. (2006). Bringing social justice to international
Psychologist, 32, 886–899. practices of counseling psychology. In R. L. Toporek,
Green, E. J., McCollum, V. C., & Hays, D. G. (2008). Teaching L. Gerstein, N. A. Fouad, G. Roysircar, & T. Israel (Eds.),
advocacy counseling within a social justice framework: Handbook for social justice in counseling psychology:
Implications for school counselors and educators. Journal for Leadership, vision, and action (pp. 421–441). Thousand
Social Action in Counseling and Psychology, 1(2), 14–30. Oaks, CA: Sage.
Haledman, D. C. (2003). The practice and ethics of sexual orien- O’Brien, K. M. (2001). The legacy of Parsons: Career counselors
tation conversion therapy. In L. D. Garnets, & D. C. Kimmel and vocational psychologists as agents of social change.
(Eds.), Psychological perspectives on lesbian, gay, and bisexual The Career Development Quarterly, 50, 66–76.
experiences (2nd ed., pp. 681–698). New York: Columbia Palmer, L. K. (2004). The Call to Social Justice: A Multidiscipline
University Press. Agenda. The Counseling Psychologist, 32, 879–885.
Helms, J. E. (1995). An update of Helm’s White and people of Pieterse, A. L., Evans, S. A., Risner-Butner, A., Collins, N. M., &
color racial identity models. In J. Ponterotto, J. M. Casas, Mason, L. B. (2009). Multicultural competence and social
L. A. Suzuki, & C. M. Alexander (Eds.), Handbook of multi- justice training in counseling psychology and counselor edu-
cultural counseling (pp. 181–198). Thousand Oaks, CA: cation: A review and analysis of a sample of multicultural
Sage. course syllabi. The Counseling Psychologist, 37, 93–115.
Helms, J. E. (2003). A pragmatic view of social justice. Pope, M. (2000). A brief history of career counseling in the
The Counseling Psychologist, 31, 305–313. United States. Career Development Quarterly, 48, 194–211.
Huynh, U. K., & Roysircar, G. (2006). Community health pro- Prilleltensky, I. (in press). Justice in the helping professions:
motion curriculum: A case study of Southeast Asian refugees. A brief guide. In M. Constantine (Ed.), Social justice and
In R. L. Toporek, L. Gerstein, N. A. Fouad, G. Roysircar, & empowerment initiatives in psychology and education.
T. Israel (Eds.), Handbook for social justice in counseling Washington DC: American Psychological Association.
psychology: Leadership, vision, and action (pp. 338–357). Romano, J. L., & Netland, J. D. (2008). The application of the
Thousand Oaks, CA: Sage. theory of reasoned action and planned behavior to preven-
Ivey, A. E., & Collins, N. M. (2003). Social justice: A long- tion science in counseling psychology. Counseling Psychologist,
term challenge for counseling psychology. The Counseling 36, 777–806.
Psychologist, 31, 290–298. Roysicar, G. (2006). Counseling Health Psychology’s
Juntunen, C. L., Cavett, A. M., Clow, R. B., Rempel, V., Collaborative Role in the Community. In R. L. Toporek,
Darrow, R. E., & Guilmino, A. (2006). Social justice through L. Gerstein, N. A. Fouad, G. Roysircar, & T. Israel (Eds.),
self-sufficiency: Vocational psychology and the transition Handbook for social justice in counseling psychology:
from welfare to work. In R. L. Toporek, L. Gerstein, Leadership, vision, and action (pp. 313–317). Thousand
N. A. Fouad, G. Roysircar, & T. Israel (Eds.), Handbook for Oaks, CA: Sage.
social justice in counseling psychology: Leadership, vision, and Schmidt, C. K., Hoffman, M. A., & Taylor, N. (2006). Social
action (pp. 294–309). Thousand Oaks, CA: Sage. justice related to working with HIV/AIDS from a counseling
Kiselica, M. S. (2004). When duty calls: The implications of health psychology perspective. In R. L. Toporek, L. Gerstein,
social justice work for policy, education, and practice in the N. A. Fouad, G. Roysircar, & T. Israel (Eds.), Handbook for
mental health professions. The Counseling Psychologist, 32, social justice in counseling psychology: Leadership, vision, and
838–854. action (pp. 44–58). Thousand Oaks, CA: Sage.

fouad, p r ince 871

Sedlacek, W. E. (2007). Conducting research that makes a Toporek, R. L., Gerstein, L., Fouad, N. A., Roysircar, G., &
difference. In C. C. Lee (Ed.), Counseling for social justice Israel, T. (Eds.). (2006). Handbook for social justice in counsel-
(2nd ed., pp. 223–237). Alexandria, VA: American ing psychology: Leadership, vision, and action. Thousand Oaks,
Counseling Association. CA: Sage.
Shullman, S. L., Celeste, B. L., & Strickland, T. (2006). Toporek, R. L., & Liu, W. M. (2001). Advocacy in counseling:
Extending the Parsons legacy: Applications of counseling Addressing race, class, and gender oppression. In D. B. Pope-
psychology in pursuit of social justice through the develop- Davis, & H. L. K. Coleman (Eds.), The intersection of race,
ment of public policy. In R. L. Toporek, L. Gerstein, class and gender in multicultural counseling (pp. 285–413).
N. A. Fouad, G. Roysircar, & T. Israel (Eds.), Handbook for Thousand Oaks, CA: Sage.
social justice in counseling psychology: Leadership, vision, and Toporek, R. L., & Pope-Davis, D. B. (2005). Exploring the rela-
action (pp. 499–513). Thousand Oaks, CA: Sage. tionships between multicultural training, racial attitudes,
Speight, S. L., & Vera, E. M. (2008). Social justice and and attributions of poverty among graduate counseling train-
counseling psychology: A challenge to the profession. ees. Cultural Diversity and Ethnic Minority Psychology, 11,
In S. D. Brown, & R. W. Lent (Eds.), Handbook of counseling 259–271. doi: 10.1037/1099–9809.11.3.259.
psychology (4th ed., pp. 54–67). New York: Wiley. Toporek, R. L., & Reza, J. V. (2001). Context as a critical
Sundberg, N. D., & Littman, R. A. (1994). Leona Elizabeth dimension of multicultural counseling: Articulating per-
Tyler (1906–1993). American Psychologist, 49(3), 211–212. sonal, professional, and institutional competence. Journal of
Talleyrand, R. M., Chi-yung, R., & Bemak, F. (2006). Multicultural Counseling and Development, 29(1), 13–30.
Incorporating social justice in counselor training programs: Toporek, R. L., & Williams, R. A. (2006). Ethics and
A case study example. In R. L. Toporek, L. Gerstein, professional issues related to the practice of social justice
N. A. Fouad, G. Roysircar, & T. Israel (Eds.), Handbook for in counseling psychology. In R. L. Toporek, L. Gerstein,
social justice in counseling psychology: Leadership, vision, and N. A. Fouad, G. Roysircar, & T. Israel (Eds.), Handbook for
action (pp. 44–58). Thousand Oaks, CA.: Sage. social justice in counseling psychology: Leadership, vision, and
Thompson, C. E., Alfred, D. M., Edwards, S. L., & Garcia, P. G. action (pp. 17–34). Thousand Oaks, CA: Sage.
(2006). Transformative endeavors: Implementing Helms’s U.S. Department of Health and Human Services. (2001). Mental
racial identity theory to a school-based heritage project. health: Culture, race and ethnicity–a supplement to mental
In R. L. Toporek, L. Gerstein, N. A. Fouad, G. Roysircar, & health: A report of the Surgeon General. Rockville, MD: U. S.
T. Israel (Eds.), Handbook for social justice in counseling Department of Health and Human Services, Public Health
psychology: Leadership, vision, and action (pp. 100–116). Office, Office of the Surgeon General.
Thousand Oaks, CA: Sage. Vera, E. M., & Speight, S. L. (2003). Multicultural compe-
Thompson, C. E., & Shermis, S. S. (2004). Tapping the Talents tence, social justice, and counseling psychology: Expanding
Within: A Reaction to Goodman, Liang, Helms, Latta, our roles. Counseling Psychologist, 31, 253–272. doi:
Sparks, and Weintraub. The Counseling Psychologist, 32, 10.1177/0011000003031003001.
866–878. Vera, E., Daly, B., Gonzales, R., Morgan, M., & Thakral, C.
Thompson, A. S., Super, D. E., & Napoli, P. J. (1955). (2006). Prevention and outreach with underserved popula-
Developing a VA counseling psychology training program: tions: Building multisystemic youth development programs
A case history of university-hospital cooperation. American for urban youth. In R. L. Toporek, L. Gerstein, N. A. Fouad,
Psychologist, 10, 283–288. G. Roysircar, & T. Israel (Eds.), Handbook for social justice
Toporek, R. L., & Chope, R. C. (2006). Individual, program- in counseling psychology: Leadership, vision, and action
matic, and entrepreneurial approaches to social justice. (pp. 86–99). Thousand Oaks, CA: Sage.
In R. L. Toporek, L. Gerstein, N. A. Fouad, G. Roysircar, & Winerman, L. (2004). Timely action. APA Monitor on Psychology,
T. Israel (Eds.), Handbook for social justice in counseling 35(1), 48.
psychology: Leadership, vision, and action (pp. 276–293).
Thousand Oaks, CA: Sage.

872 social justice

 CHAPTER
Internationalization of Counseling
34 Psychology

Lawrence H. Gerstein and Stefanía Ægisdóttir

Abstract
This chapter discusses the consequences of exporting U.S. models and strategies of counseling to other
countries, and it presents a few ethical issues linked with the internationalization of the field.
Additionally, an in-depth discussion and analysis of specific lines of cross-cultural research in psychology
and counseling (i.e., emotions, coping, and psychological help-seeking) is included and evaluated in
terms of its cross-cultural validity and applicability to diverse cultures. Methodological challenges of
cross-cultural research, theory, and practice are also highlighted, as are alternative approaches to
performing cross-cultural research. The chapter ends with a brief discussion about the importance of
cross-cultural collaboration and future opportunities for counseling professionals.
Keywords: cross-cultural research, cross-cultural validity, internationalization, emotions, coping,
help-seeking, culture, methodology, collaboration

From almost its very inception, the discipline of Leung, and Norsworthy (2009a) and Heppner et al.
psychology in the United States has been connected (2008a) provided an in-depth discussion of the
to some degree with professionals outside the U.S. history of this interest for the counseling and psy-
borders. In the 1800s, for instance, there was a close chology professions in the United States.
association between U.S. and European psycholo- In this chapter, we discuss the consequences
gists (Brehm, 2008). The interest of U.S. counseling of exporting U.S. models and strategies of counsel-
psychologists in international issues can be traced to ing to other countries, and we present a few ethical
the 1940s. At this time, a number of pioneers in the issues linked with the internationalization of the
early days of the profession engaged in work outside field. Additionally, an in-depth discussion and anal-
the United States. Such luminaries in the profession ysis of specific lines of cross-cultural research in
as H. Borow, L. Brammer, W. Lloyd, D. Super, and psychology and counseling is included (i.e., emo-
E. G. Williamson collaborated with education fac- tions, coping, and psychological help-seeking) and
ulty in Japan in helping to establish counseling evaluated in terms of its applicability to diverse cul-
services. In the 1960s, other leaders of the profes- tures. Methodological challenges of cross-cultural
sion (e.g., F. Robinson, C. G. Wrenn) assisted with research, theory, and practice are also highlighted,
launching the counseling profession in England as are alternative approaches to performing cross-
(Heppner, Leong, & Chiao, 2008a), while Donald cultural research. The chapter ends with a brief
Super and his associates began conducting interna- discussion about the importance of cross-cultural
tional research on work values and career choice. collaboration and future opportunities for counsel-
The U.S. counseling profession’s interest in interna- ing professionals.
tional topics blossomed, however, in the first decade Before discussing these topics, it is essential to
of the 21st century. Gerstein, Heppner, Ægisdóttir, first define four terms that appear throughout this

873
chapter, to provide clarity and uniformity in their counseling professionals, especially recently, as more
use. Frequently, these terms are either not defined or persons have pursued international work both in
are inconsistently defined in the counseling litera- and outside the United States. Counseling profes-
ture. The concept of internationalization has been sionals engaged in such work have wondered whether
defined in many ways in the counseling literature to call their activities multicultural or cross-cultural
(Gerstein et al., 2009a). Here, the definition offered counseling. In trying to resolve this confusion,
by Leung, Clawson, Tena, Szilagyi, and Norsworthy Gerstein et al. (2009a) introduced a new, unique
(2009) will be employed. These scholars claimed definition of cross-cultural counseling in order to
that internationalization is an ongoing process of differentiate this concept from multicultural coun-
synthesizing research and information derived from seling. These authors defined cross-cultural counsel-
counseling practices tied to various cultures. The ing as the “pursuit and application of universal and
knowledge gained from this endeavor is used to indigenous theories, strategies (e.g., direct service,
solve issues locally and globally. Furthermore, inter- consultation, training, education, prevention), and
nationalization involves taking steps to indigenize research paradigms of counseling and mental health
counseling worldwide, so that theories, practices, help-seeking grounded in an in-depth examination,
and systems are developed and grounded in the understanding, and appreciation of the cultural and
local culture. Globalization is another term incon- epistemological underpinnings of countries located
sistently used in the counseling literature, with its worldwide” (p. 6). Gerstein et al. (2009a) also intro-
use varying with the context of analyses. In this duced another new term, cross-national counseling, to
chapter, it refers to interdependent transactions capture a unique set of specific international activi-
across borders that affect economic, social, cultural, ties apart from those linked with cross-cultural
and political aspects of life (United Nations ESSAP, counseling. They defined cross-national counseling
1999). as “collaborative professional activities (e.g., program
In the late 1980s and early 1990s, the multicul- development and implementation, training, teach-
tural counseling movement, first called the cross- ing, consultation) jointly pursued by mental health
cultural counseling movement (see Gerstein et al., professionals residing in at least two countries”
2009a), emerged as an important focus in the coun- (p. 6). Heppner et al. (2009) introduced another new
seling profession. Historically, since the terms mul- term, cross-national movement, to help further crys-
ticultural and cross-cultural counseling have been tallize and clarify the international nomenclature in
used synonymously and often defined inconsistently the U.S. counseling profession. They defined cross-
(Gerstein et al., 2009a; Heppner, Ægisdóttir, Leung, national movement as “the evolution of thought
Duan, Helms, Gerstein, & Pedersen, 2009), it is about culturally sensitive collaboration about all
essential to also clarify their definitions for the aspects of the counseling profession among counsel-
purposes of this chapter. Basically, multicultural ing professionals across countries” (pp. 33–34).
counseling involves helping individuals, groups, Clearly, many terms are associated with cultural
organizations, and communities through the use and international counseling activities. Regardless
of universal and cultural specific strategies that are of the term or its definition, however, the more
consistent with the cultural values and experiences recent increased interest in international topics in
of the target clientele (Sue & Torino, 1994). More the counseling profession can be traced to numer-
specifically, the multicultural counseling movement ous innovative developments in the multicultural
emphasizes the importance of offering a host of counseling movement and many professionals who
appropriate and effective services to diverse groups were either directly or indirectly affected by this
of people including persons of various ethnic and movement (Heppner et al., 2009). Although serv-
racial origins, socioeconomic status, sexual orienta- ing international domestic populations has been
tion, and physical ability. Serving international perceived by most U.S. counseling professionals to
populations in and outside the United States was be a component of the multicultural movement,
also emphasized early on in the movement, although activities involving populations in other countries
it was not a high priority or central to the mission. frequently have not been considered under the
As mentioned above, in the initial stages of rubric of multicultural counseling.
the emergence of the multicultural counseling It not surprising, therefore, that a certain degree
movement, the terms multicultural counseling and of tension has existed between the U.S. multicultural
cross-cultural counseling were frequently used inter- and cross-national counseling movements (Gerstein,
changeably. This has led to some confusion among Heppner, Stockton, Leong, & Ægisdóttir, 2009b;

874 intern ation al iz atio n

Heppner et al., 2009), or between the counseling Furthermore, some counseling professionals have
professionals interested in domestic versus interna- assumed these paradigms can be employed to accu-
tional cultural issues. In general, members affiliated rately conceptualize the emotions, cognitions, and
with both movements are concerned, albeit to differ- behaviors of individuals living in other countries, and
ing degrees, about resource allocation, educational also used to design and implement effective interven-
opportunities, and meeting the needs of diverse and tions. There is a growing awareness among counseling
large populations (Gerstein et al., 2009b; Heppner professionals worldwide (Gerstein et al., 2009a;
et al., 2009). Heppner et al. (2009) provided an Ægisdóttir, Gerstein, Leung, Kwan, & Lonner, 2009),
extensive discussion about the tensions, similarities, however, that such assumptions are inaccurate and
and differences between the two movements, and potentially harmful to the cultural integrity and sur-
also the benefits of strengthening collaboration vival of countries around the globe.
between the two groups. Other scholars have voiced even stronger con-
cerns about the exportation and importation of U.S.
Clashing Cultural and Counseling counseling models to other countries, claiming that
Paradigms this was yet another example of Western Eurocentric
The internationalization of the U.S. counseling pro- domination, psychological hegemony (control or
fession has led to many new lines of research, col- domination of one person or group over another,
laborative cross-national relationships, consulting particularly one society or nation over others), cul-
opportunities, developments in methodology, and tural imperialism (a more powerful nation or society
intervention strategies. It has also resulted in a stron- enforces its stance of superiority through domina-
ger network of counseling professionals worldwide, tion and control; Said, 1993), and/or neocolonial-
and a deeper understanding and respect for cultural ism (dominance, usually by a Western nation, over
diversity and uniqueness. Although the U.S. cross- another nation that is politically independent but
national counseling movement has enriched numer- weak economically and dependent on trade with the
ous professionals and others in the United States more powerful nation) that could deepen inequities
and abroad, and has helped meet the needs of among countries and destroy indigenous cultures
various international clientele, many scholars (Norsworthy, Heppner, Ægisdóttir, Gerstein, &
(Gerstein et al., 2009a; Gerstein & Ægisdóttir, Pedersen, 2009a). Lugones and Spelmann (1983)
2005a, 2005b; Gerstein & Ægisdóttir, 2007; went so far as to state that Western psychologists
Heppner, 2006; Heppner et al., 2008a; Leong & working outside of the West were inclined to engage
Ponterotto, 2003; Leong & Blustein, 2000; Leung, in a type of psychological colonization (system of
2003; Pedersen, 2003; Pedersen & Leong, 1997) domination depicted by social patterns or mecha-
have seriously questioned the appropriateness, valid- nisms of control that maintain oppression and that
ity, relevance, and impact of countries embracing vary from context to context; Moane, 1994) or
U.S. paradigms of counseling. Historically, these neocolonialism.
paradigm have been either exported to other coun- To overcome the ethnocentric, U.S.-centric, or
tries by U.S. counseling professionals and interna- Anglo-centric exportation and importation of U.S.
tional scholars and international students returning counseling paradigms, and the potential for psycho-
home, or imported by non-U.S. professionals enam- logical hegemony, imperialism, colonialism, and
ored of the presumedly scientific, theoretical, and neocolonialism, it is essential that U.S. counseling
applied superiority of the U.S. models. professionals become more mindful of the implica-
In fact, these paradigms and those linked with tions of employing their paradigms elsewhere, and
U.S. psychology have been called ethnocentric most importantly, that they learn how, by recogniz-
(Cheung, 2000; Heppner, 2006; Heppner et al., ing internalized attitudes and behaviors linked with
2008a; Heppner, Leong, & Gerstein, 2008b; Leong positions of privilege and oppression, they can avoid
& Leach, 2007; Leung, 2003; Marsella, 1998; perpetuating dominant–subordinate relationships
Norsworthy, 2006; Pedersen & Leong, 1997; (Norsworthy et al., 2009a). This also requires coun-
Takooshian, 2003; Stevens & Wedding, 2004), U.S.- seling professionals to respect, listen, and learn from
centric (Leong & Ponterotto, 2003), or Anglo-centric each other; commit to distributing and sharing
(Cheung, 2000; Trimble, 2001) because they are power, and establish and maintain equitable rela-
grounded in U.S. cultural values, beliefs, and behav- tionships with one another worldwide. This can
iors, and assume that persons and contexts from lead to greater understanding of various cultures
other countries and cultures share this background. around the world, and a deeper appreciation of the

ge r st e in, ægisdót t ir 875

similarities and unique differences in how people greatly worldwide. For instance, in some countries
think, feel, and behave. It also can potentially facili- (e.g., Sweden, Portugal), the title psychologist only
tate a clearer understanding for counseling profes- refers to professors teaching psychology and/
sionals of the “conscientization” process (Freire, or researchers conducting psychological studies. In
1970). That is, these therapists can develop an other countries (e.g., United States, Canada), the title
awareness and comprehension about the dynamics of psychologist can characterize individuals engaged
of colonization, domination, and subordination, in clinical, counseling, educational, or industrial
and their own attitudes, feelings, and behaviors work, for example, as well as persons who teach and/
linked with such dynamics (Norsworthy et al., or conduct research.
2009a). Acquiring this awareness and genuine There is also variation in the role and function
conscientization requires counseling professionals of counseling psychologists in countries where the
to enact solutions to change existing oppressive con- title exists (Gerstein et al., 2009a; Heppner et al.,
ditions. Additionally, it requires professionals to 2008b; Savickas, 2007). In the United States, coun-
learn how to liberate themselves from a colonized seling psychologists’ “participate in a range of activi-
mentality and set of behaviors so that they may cre- ties including teaching, research, psychotherapeutic
atively collaborate and partner with one another and counseling practice, career development, assess-
(Norsworthy et al., 2009a). ment, supervision, and consultation. They employ a
Although taking the steps outlined above cannot variety of methods closely tied to theory and research
ensure that U.S. models of counseling will no lon- to help individuals, groups and organizations func-
ger be indiscriminately exported and imported tion optimally as well as to mediate dysfunction.
around the world, it is likely that following this Interventions may be either brief or long-term; they
path will increase counseling professionals’ cultural are often problem-specific and goal-directed. These
sensitivity and understanding, deepen their recogni- activities are guided by a philosophy that values
tion of being culturally encapsulated (Wrenn, individual differences and diversity and a focus on
1962), and increase the potential that they can be prevention, development, and adjustment across
liberated from a colonized mentality (Norsworthy the lifespan, which includes vocational concerns”
et al., 2009a). Taking this path should also enhance (see www.div17.org/students_defining.html ).
professionals’ awareness, knowledge, and respect for Counseling psychologists in the United States
diverse, rich, and unique models of counseling are employed in a many settings (e.g., universities,
embraced worldwide, including indigenous para- independent practice, mental health centers, medi-
digms. In so doing, there is a much greater prob- cal facilities, rehabilitation agencies, business and
ability that counseling professionals will rely on industrial organizations, and consulting firms).
culturally appropriate, valid, and effective theories A somewhat similar definition can be found
and strategies of counseling when assisting diverse in Australia. The Australian Psychological Society
clientele around the world. (2007a) reported, “Counselling psychologists employ
a wide range of therapeutic methods, each of which
Professional Issues Worldwide places a significant emphasis on the quality of the
Definition, Role, and Function relationship between the client and the psychologist.
of Counseling They assist individuals, families, and groups in areas
Although the terms psychologist and counselor are related to personal well-being, interpersonal relation-
somewhat common throughout the world, Abi- ships, work, recreation, and health. They are also
Hashem (1997) claimed that, when these terms do trained to assist people experiencing both acute and
exist, they are defined differently than in Western chronic life crises.” These professionals are employed
countries. The title counseling psychologist and the in health and community agencies, educational insti-
counseling psychology field, in contrast, exists in tutions, property and business organizations, and
only a few nations (e.g., United States, Canada, government and administrative offices (Australian
Hong Kong, South Africa, Australia, Taiwan, Bureau of Statistics, 2003).
Thailand, Puerto Rico), and is thought to be unique The definition of counseling psychology in
to the United States. In fact, counseling psychology Canada is also quite specific. Young and Nicol (2007)
cannot be found in most European countries and in stated the Colleges of Psychologists of Ontario
the Southern Hemisphere. (CPO) defined this term as “the fostering and
The role and function of a counselor and improving of normal human functioning by helping
psychologist (see Rosenzweig, 1982) also varies people solve problems, make decisions, and cope

876 intern ation al iz atio n

with stresses of everyday life” (p. 21). The CPO is governmental agencies, and instead, they work in
the organization that licenses psychologists. Similar schools, universities, health care settings, social ser-
to counseling psychologists in the United States, vice agencies, private enterprises, and in business
Canadian professionals are engaged in many activi- (Leung et al., 2007).
ties (e.g., counseling, prevention, research, training, Regardless of the country or the specific psycho-
supervision, policy development and implementa- logical title (e.g., clinical psychologist, counseling
tion) with a diverse clientele (e.g., individuals, fami- psychologist, school psychologist) employed, psy-
lies, groups, organizations) that vary in their concerns chologists in many locations are involved in some
and needs. These professionals are employed in a type of professional activity closely connected to
host of settings (e.g., educational institutions, social psychology and not some other discipline or con-
service agencies, government offices, private practice, tent area. Furthermore, to become a psychologist,
business and industry) (Young & Nicol, 2007). an individual must complete some form of academic
In contrast to the employment opportunities training. In the United States, a psychologist must
available to counseling psychologists in the coun- earn a doctoral degree, whereas in most other coun-
tries already discussed, in South Africa, very few tries a master’s degree or an equivalent diploma is
work settings are available to these professionals required for a practicing psychologist (Europe,
(Naidoo & Kagee, 2009). Almost all these individu- South Africa, Taiwan, China, Korea, Japan, Uganda),
als are affiliated with a private practice. Some are and a doctoral degree for an academic psycholo-
employed, however, by nongovernmental organiza- gist (Gerstein et al., 2009a). In many regions of the
tions that offer counseling services (e.g., career world (South, Latin, and Central America), it is pos-
interventions, health development, prevention, and sible to become a practicing psychologist with the
economic empowerment) to economically disad- equivalent of a bachelor’s degree (Gerstein et al.,
vantaged individuals living with HIV/AIDS, or to 2009a).
those who have survived trauma, rape, or crime. There is even greater divergence in how the title,
The definition of a counselling psychologist in role, and function of a counselor are defined world-
South Africa is somewhat vague as compared to the wide, and in the case of the title, how it is used
one adopted in the United States and Australia. (Gerstein et al., 2009a; Heppner & Gerstein, 2008).
According to the scope of practice statement issued In some countries (e.g., India), the title counselor
by the Health Professions Council of South Africa is utilized by indigenous healers, and by persons
(2011), “Counselling psychologists assist relatively who offer financial advice (e.g., bankers), legal ser-
well-adjusted people in dealing with normal prob- vices (i.e., lawyers), or medical care (e.g., physicians,
lems of life concerning all stages and aspects of a nurses). In other countries, only individuals engaged
person’s existence in order to facilitate desirable in psychological activities employ the title. For
psychological adjustment, growth, and maturity.” example, professional counselors offering psycho-
South African counselling psychologists engage in logical services exist in Taiwan, China, Japan, South
assessment, intervention, policy development, pro- Korea, Thailand, Malaysia, Hong Kong, Singapore,
gram design, research, training, and supervision. the Philippines, Israel, Lebanon, Saudi Arabia,
In Hong Kong, the recently formed Division of Egypt, Jordan, Kuwait, the United Arab Emirates
Counseling Psychology of the Hong Kong Psycho- (UAE), the Palestinian territory, Turkey, Iran, Greece,
logical Society introduced a new definition of coun- Uganda, Ghana, Kenya, Nigeria, Botswana, South
seling psychology. Like South Africa, this definition Africa, Italy, The Netherlands, Ireland, Great Britain,
is somewhat general: “the application of psychologi- Ukraine, Slovakia, Portugal, France, Hungary, South
cal knowledge, psychotherapeutic skills, and pro- Korea, and New Zealand.
fessional judgment to facilitate enhanced human To become a professional counselor in different
functioning and quality of life” (Leung, Chan, & countries, similarly to becoming a psychologist, an
Leahy, 2007, p. 53). This definition assumes coun- individual must complete some type of academic
seling psychologists assist diverse populations, work training. In the United States, a professional coun-
in a host of settings, employ growth- and strengths- selor must earn a master’s degree, whereas in many
oriented strategies linked to psychotherapeutic and other countries a bachelor’s degree is sufficient to
developmental perspectives, consider context and become a counselor (e.g., Australia, United Arab
systems, use preventive interventions, and conduct Emirates). There are also some countries where a
research (Leung et al., 2007). In Hong Kong, coun- person can become a professional counselor with
seling psychologists are infrequently employed by less than a college education (e.g., the Ukraine).

ge r st e in, ægisdót t ir 877

 Finally, it should be mentioned that worldwide, principles for psychologists” (see http://www.iupsys.
some amount of advanced academic coursework is org/ethics) to promote ethical ideals in the psychol-
required to be a professional counselor or psycholo- ogy profession. These principles are based on shared
gist. For both occupations, however, countries vary global values (e.g., respect for dignity, maximize
in their requirements to complete counseling prac- benefits and minimize harm to individuals, families,
tica or field experiences, and/or an internship as part and communities, integrity, and being responsible
of the training program. Licensure requirements to society) that are moral and aspirational, without
also vary greatly worldwide. Some countries license prescribing specific behaviors that are influenced by
counselors (e.g., Japan, Lebanon, United States, cultural values and laws (Gauthier, 2008).
Malaysia) and psychologists (e.g., Taiwan, Greece, Although many countries have ethical codes and
South Africa, Iceland, Portugal, Ireland, Canada, regulations guiding counseling professionals’ work
United States, Colombia, Venezuela, Argentina, in general, fewer have specific guidelines regarding
Puerto Rico), whereas others (e.g., New Zealand, psychological tests and testing (Iliescu, Ispas, &
Fiji, Turkey, Iran, Uganda, Ghana, Italy, Great Harris, 2009). Leach and Oakland (2007) compared
Britain, Slovakia, South Korea, Turkey, Greece, ethical standards affecting the development of tests
Nigeria, United Arab Emirates) have no laws to and their use across 31 ethical codes in 35 countries.
regulate these titles or the services provided by indi- They discovered that these standards were valuable
viduals in such professions. in that they provided mental health professionals
with guidelines for practicing with competence.
Ethics of International Work Some specific policies have been influential with
A growing number of counseling organizations respect to the ethics of testing. In this regard, the
worldwide have adopted an ethical code. These codes APA has continuously pursued the creation of such
were developed and endorsed by counseling and policies, with the latest being the “Standards for
psychology organizations to provide guiding princi- Educational and Psychological Testing” (AERA,
ples and standards, in part, for the ethical practice of APA, NCME, 1999). Yet, in spite of this policy’s
counseling, and to promote the conducting of cross- wide reach and importance, it is “tributary to local
culturally and culturally valid research. Ethical codes values, customs, and practices and do [sic] not bring
are expressions of values (Diener & Grandall, 1978; about adherence from psychologists around the
Gerstein et al., 2009c) and are constructed in a world” (Iliescu et al., 2009, n.p.). An important
specific cultural context. For instance, Pedersen step, however, was taken by the International Test
(1995, 1997) argued the ethical codes endorsed Commission (ITC) when addressing the unique test-
by U.S. counseling and psychology associations ing issues faced by professionals outside the United
(i.e., American Psychological Association [APA], States. Three documents in this regard are of great
American Counseling Association) were based on a importance. First, the ITC International Guidelines
dominant U.S. cultural perspective, and therefore on Test Use (International Test Commission, 2000)
ignored or minimized the cultural context in ethical focuses on the fair and ethical use of tests worldwide
decision-making regarding minority groups in the and the competence of test users. Second, the ITC
United States Several books have emphasized the Guidelines on Test Adaptation (e.g., van de Vijver &
importance of considering cultural factors in ethical Hambleton, 1996) addresses the selection, transla-
decision making (e.g., Houser, Wilczenski, & Ham, tion, adaptation, and interpretation of psychological
2006). These books offer counseling professionals tests employed outside their culture/country of
information on how different worldviews can influ- origin. And the third document, the ITC Guidelines
ence and guide this process. on Computer-based and Internet Delivered Testing
Many counseling and psychology organizations (Bartram & Coyne, 2005), focuses on issues and best
around the world have developed ethical codes and practices in the use of technology in test administra-
guidelines for the practice of psychology in their tion, the security of tests and test results, and the
country (see e.g., Leach, 2008) grounded in their control over the testing process.
unique cultural context. Yet, in other countries, no Given the contextual influence on ethical prac-
ethical code exists. To address this gap, the General tices, the ITC International Guidelines for Test Use
Assembly of the International Union of Psychologi- (Bartram, 2001) and the Universal Declaration of
cal Science (IUPsyS), and the International Ethical Principles for Psychologists (Gauthier, 2008)
Association of Applied Psychology (IAAP) devel- are extremely valuable documents for counseling
oped and adopted a “universal declaration of ethical professionals engaged in psychological testing in an

878 intern ation al iz atio n

international arena for several reasons. For example, individuals, couples, families, and groups. In fact,
countries differ greatly in the degree, if any, of legal an overwhelming number of our U.S. graduate-level
control over psychological testing and those tested. master’s training programs in counseling continue
Therefore, the ethical guidelines outlined in these to emphasize the acquisition of basic helping skills
documents may offer a degree of support to national linked with the recognition and reflection of clients’
associations interested in developing such standards emotions. Developing these skills is also considered
where they are lacking. These guidelines also may important to the establishment of an effective coun-
help provide direction to professionals practicing in seling relationship with all clients, regardless of their
countries where no statutory control exists. Consis- ethnic, cultural, racial, and/or national background.
tent with this observation, we concur with Iliescu Furthermore, displaying these skills is thought to be
et al. (2009), who stated that, in a situation in which an essential prerequisite for learning theories and
there are few if any laws about psychological tests, strategies tied to most all therapeutic approaches.
and where none is internationally binding, for a Although emotions have occupied a central role
test or testing procedure to be considered ethical, in the counseling profession throughout the world,
it should adhere to the Universal Declaration of the profession itself has not given much thought to
Ethical Principles for Psychologists. the generalizability and cross-cultural validity of
U.S. theories designed to explain these constructs,
Relevance of Cross-cultural Research nor has it focused much attention on the role of such
to Counseling constructs in individuals’ everyday life. Instead, the
Along with having an influence on ethical practices prevailing assumption in the field basically has been
worldwide, context and culture also may differen- that all individuals experience and express emotions
tially impact important variables of interest to in a similar fashion, and that these constructs serve a
counseling professionals. As a result, it is critical to similar role across cultures and countries.
discuss a few lines of research and the correspond- Interestingly, the broader profession of psy-
ing relevant potential challenges. Here, we will chology in the United States and elsewhere has a
focus on emotions, coping, and help-seeking to long history of both exploring and questioning
highlight what is known about these topics from an these assumptions. Perhaps, Darwin was the first to
international perspective, the challenges connected investigate this topic and provide a foundation for
with each, and possible solutions that counseling the study of emotional expressions across culture
professionals might pursue to conduct culturally (Matsumoto, 2009). Darwin argued, “the commu-
and cross-culturally valid and appropriate research. nication of emotion, both its expression and its rec-
Each of these topics is salient to both the practice ognition, is part of our biological heritage” (Russell,
and science of counseling worldwide. 1991, p. 427). He also claimed that people through-
out the world were consistent in how they expressed
Culture and Emotions: An Overview some emotions and that this could be understood
In the United States and many other countries, by looking at their faces (Matsumoto, 2009).
emotions have been central to the science and prac- Numerous social scientists later questioned
tice of counseling. From the early days of the pio- Darwin’s observations. According to Matsumoto
neers in psychotherapy (e.g., Freud, Jung, Rank, (2009), Margaret Mead and Ray Birdwhistell were
Reich, Adler) to the more contemporary giants of vocal critiques of Darwin, claiming that expressive
our profession (e.g., Rogers, Perls, Frankl), the emo- behaviors across cultures varied greatly, and as such,
tional life of individuals has occupied much of our it was not possible to consider facial expressions
training, practice, and pursuit of research. Even universal. Mead and Birdwhistell thought emotional
theorists (e.g., Beck, Ellis) whose psychotherapeutic expressions were learned differently in every culture.
approaches were grounded in understanding and Moreover, they stated that “just as different cultures
changing cognition placed great importance on have different languages, they must have different
comprehending the role of emotion, particularly languages of the face” (Matsumoto, p. 264). Since
as it effected cognition. Without a doubt, a large the time of Darwin’s work, and Mead and
number of counseling professionals worldwide con- Birdwhistell’s pointed criticism, there has been an
tinue to structure their work whether it be, for enormous amount of research on the universality
instance, direct service, prevention, training, or of the expression of emotion and the correspond-
research, around the identification, assessment, con- ing facial behavior of individuals across cultures.
ceptualization, and/or treatment of the emotions of The early work of psychologists investigating the

ge r st e in, ægisdót t ir 879

relationship between culture and emotions was also attention to the sociocultural or cross-cultural facets
driven by an interest in determining if facial expres- of emotion. A summary of this line of research is
sions for specific “basic” emotions were universal presented later.
(Soto, Levenson, & Ebling, 2005). Before summa- There are several components of emotions, includ-
rizing the extensive research on this topic, it is nec- ing self-awareness, self-expression, self-regulation,
essary to highlight the current discussion in the and the recognition and identification of emotions in
psychology literature on the operational definition others. Emotional responding through expressive
of emotion. behavior serves an essential function of communica-
tion in that it helps regulate interpersonal interac-
Definitions and Precursors of Emotions tions (Matsumoto et al., 2008a). The expression of
According to Matsumoto, Yoo, Fontaine et al. emotion is an aspect of emotional behavior defined
(2008a), “emotions are neurophysiological and psy- as outward expressions and actions linked with
chological reactions that aid in adapting to social emotional experience (Mesquita & Frijda, 1992;
coordination problems” (p. 58) that incorporate Mesquita, Frijda, & Scherer, 1997). Emotional regu-
intra- and interpersonal functions (Keltner & Haidt, lation, on the other hand, “is the ability to manage
1999; Levenson, 1999). Matsumoto (2009) also and modify one’s emotional reactions to achieve goal-
claimed the fundamental system of emotions people directed outcomes” (Matsumoto, 2006, p. 421).
possess at birth operates as a central processor, Some writers (Menon, 2000) have indicated that
modified for a variety of functions within specific emotions are cognitive appraisals derived from cul-
cultures. Put another way, emotions are critical tural values, beliefs, and norms. As such, culture
to “‘managing relationships with other persons, shapes what persons should feel and experience, and
defining the self, maintaining the self ’s worth or dig- emotions are culturally relative and affect individu-
nity and organizing appropriate action in many als’ relationships. Individuals’ cognitive appraisals of
social situations’” (Kitayama, Markus, & Matsumoto situations and relationships determine what emo-
1995, p. 442). Some researchers (Matsumoto) tions they experience (Lynch, 1990; Menon, 2000).
claimed that, in the early years of life, individuals Cultures also establish rules, guidelines, and norms
learn to have emotions linked with situations they about the regulation of emotions since emotions,
encounter. These emotions are thought to be specific for example, play a critical role in social interactions
to the persons’ culture and themselves. Consequently, (Keltner, Ekman, Gonzaga, & Beer, 2003).
there are cultural and individual differences in the Cultural psychologists offer another perspective
experience and expression of emotions, although on the nature of emotions. These psychologists
some investigators have claimed there are seven (plus (e.g., Menon, 2000; Shweder, 1991, 1993) are
or minus two) basic universal emotions (e.g., happi- inclined to perceive emotions as scripts or narratives
ness, fear, anger, disgust, sadness). Matsumoto fur- comprised of several features. Such scripts are consid-
ther stated, “One of the functions of culture, for ered appraisals of specific events or situations (Menon,
instance, is to ascribe meaning to the various events 2000). From this viewpoint, Shweder (1993) argued
that occur in our lives that are not part of our evolu- that, when conducting cross-cultural research on
tionary past” (p. 275). emotional functioning, it is beneficial to separate an
Mesquita and Walker (2003) also argued that, by emotion-script into its specific narrative features.
nature, emotions were sociocultural and biological. This strategy renders it possible to draw comparisons
Galati, Schmidt, Sini et al. (2005) claimed, in the between the differences and similarities in the spe-
late 1970s, that many investigators (e.g., Boucher, cific features of individuals’ emotional script. In so
1979, 1983) were interested in distinguishing uni- doing, it also permits an assessment of the common-
versal antecedents of the fundamental emotions alities in the pattern of how persons from various
such as joy, surprise, fear, anger, disgust, and sadness cultures evaluate different events or circumstances.
as a way to show that emotions were based in biol- Matsumoto et al. (2008a) also argued that
ogy, and as such, that they were basically innate culture shapes the norms connected to the experi-
responses. Some researchers (Kitayama & Markus, ence and expression of emotions, and consequently,
1994; Mesquita & Frijda, 1992; Mesquita & informs the display rules guiding emotional expres-
Walker) have reported that most of the cross- sions (see also Ekman & Friesen, 1969; Izard, 1980).
cultural research on emotions has centered on the Some investigators (e.g., Eid & Diener, 2001) have
universal, biological features of the construct. In argued, however, that there have been a limited
contrast, until recently, psychology has paid little number of quantitative cross-cultural studies on the

880 intern ation al iz atio n

norms for experiencing emotions. Some highlights vocabulary of languages varies in how well it
of various aspects of this line of research follow. captures the expression of emotional concepts.
For instance, for native English speakers the verb
display rules “to feel” is linked with emotions and intimately
Ekman and Friesen (1969) introduced the concept associated with emotional expression and experi-
of display rules more than 35 years ago. According ence (Menon, 2000). In contrast, there is no exact
to Ekman and Friesen and others (Saarni, 1999), equivalent for the verb “to feel” in most South Asian
individuals learn display rules early in their life. languages, and yet, South Asians do not miss this
Once emotions are elicited, these rules inform and verb when they experience and express their emo-
guide people in how they might express themselves tions (Lynch, 1990).
emotionally, given specific social situations. Inves- Not only are there differences in the presence of
tigators often rely on these rules when characteriz- the verb “to feel” in some languages, there are also
ing cultural differences in the display of emotions major differences in whether certain feeling or emo-
(Matsumoto, 2009). In fact, in the 1980s, research- tion words appear in various languages, and if the
ers started to assess cultures and ethnicities in terms concept of emotion even exists in all cultures (Russell,
of their display rules (Matsumoto, 1990, 1993), 1991). In a study by Brandt and Boucher (1986),
although Ekman and Friesen had earlier argued that for example, it was discovered that the concept emo-
such rules could be used to explain variations in tion and a term for this concept existed in the tar-
facial expressions of emotions across cultures. The geted languages of the study (Indonesian, Japanese,
most recent extensive study on this topic (Matsumoto Korean, Malay, Spanish, and Sinhalese). Matsuyama
et al., 2008a) examined display rules in more than et al. (1978), however, discovered something very
30 cultures worldwide. The overall results indicated different for the Japanese language. They reported
that display rule norms of less expressivity were that, in this language, the word for emotion, jodo,
more common in collectivistic as compared to includes being angry, happy, sad, and ashamed,
individualistic cultures. Based on these findings, and also includes terms not considered emotions
Matsumoto et al. concluded that the regulation of (e.g., considerate, motivated, lucky). Other investi-
expressing all emotions was vital to preserving the gators, in contrast, have claimed that some cultures
social order in these cultures. have no concept or word for emotion. For instance,
In addition to display rules, some writers have this was reported to be the case for the Tahitians
discussed similar rules known as feeling rules. (Levy, 1973), the Bimin-Kuskusmin of Papua, New
Hochschild (1983) claimed these rules represent Guinea (Poole, 1985), the Gidjingali aborigines of
social norms prescribing how persons should feel in Australia (Hiatt, 1978), the Ifalukians of Micronesia
specific situations (e.g., wedding or funeral). Clearly, (Lutz, 1980, 1983), the Chewong of Malaysia
these rules also can vary by culture. There are numer- (Howell, 1981), and the Samoans (Gerber, 1975).
ous cultural differences in the display or expression Although the concept or word emotion might
of emotions. Matsumoto (2009) claimed that two not exist in certain cultures, there is evidence that
processes are responsible for this variation. First, a in some of these cultures the concept is implicit
culture’s display rules or differences in the cultural (Russell, 1991). Furthermore, similar words may be
norms linked with managing and regulating the used, or words not recognized by English speakers
expression of emotion contributes to this variation. might be employed to communicate the term emo-
And second, cultural differences in the antecedent tion (Russell, 1991). Moreover, as Russell stated,
circumstances that elicit emotions contribute to “Some English emotion words have no equivalent
cultural variations in how individuals will express in some other language” (p. 430), words such as
their emotions. love, anger, sadness, and fear. Similarly, some emo-
tion words in non-English languages have no equiv-
the language of emotion alent word in the English language.
One of the most important aspects and challenges Even if the concept or word emotion appears in
of understanding emotions across cultures is exam- a particular culture, researchers have discovered
ining the vocabulary or language structure used by a major differences in how such concepts or words are
culture to capture and convey the experience and interpreted and understood. For example, Hupka,
expression of feelings and emotions. Therefore, it is Lenton, and Hutchison (1999) reported that for
not surprising that researchers (e.g., Matsumoto & approximately 20% of the world’s languages, no dis-
Assar, 1992; Russell, 1991) have reported that the tinction is made between envy and jealousy. In these

ge r st e in, ægisdót t ir 881

languages, one word captures both concepts. Other researchers have reported that there is
Similarly, Leff (1973) claimed that only one word no single word for depression in certain cultures.
described anger and sadness in some African lan- This is true, for instance, for the Yoruba of Nigeria
guages, whereas Russell (1991) stated this was also (Leighton et al., 1963), some North American
the case for the Ilongot in the Philippines and the Indian Nations (Termansen & Ryan, 1970), the
Ifaluk who reside on a coral atoll in the Caroline Malay (Resner & Hartog, 1970), the Chinese
Islands. A number of cultures also do not distin- (Chan, 1990; Tseng & Hsu, 1969), the Eskimos
guish between shame and other emotions such (Leff, 1973), the Fulani in Africa (Riesman, 1977),
as fear (Gidjingali aborigines of Australia; Hiatt, the Kaluli of Papua New Guinea (Schieffelin, 1985),
1978) and embarrassment (Japanese: Lebra, 1983; and the Xhosa of Southern Africa (Cheetham &
Tahitians: Levy, 1973; Ifalukians:- Lutz, 1980; Cheetham, 1976).
Indonesians: Keeler, 1983; Newars of Nepal: Levy, Along with depression, a fair amount of cultural
1983). In other cultures (e.g., Ilongot, Javanese, research has been conducted on semantic structures
Pintupi), one word captures shame and other emo- of emotions. Russell (1991) reported on an exten-
tions (e.g., timidity, embarrassment, awe, obedi- sive review of this literature, stating, among other
ence, respect, guilt, shyness) at the same time (see observations, that words for emotions in different
Geertz, 1959; Myers, 1979; M. Z. Rosaldo, 1983). languages cannot be accurately translated one-to-
Cultures also vary in their cognitive schemas of one. Russell cautioned, however, that this conclu-
emotions (Levy, 1983, 1984; Mesquita & Frijda, sion needed to be further explored since the earlier
1992). research had been based on ethnographic methods.
The concept of depression has posed challenges Interestingly, two later studies on the cultural uni-
for cultural investigations as well. Researchers have versals in the semantic structure of emotion terms,
faced difficulties with defining this concept and in general, found that emotion concepts were com-
understanding its meaning (Marsella, 1980). In parable across cultures (Church, Katigbak, Reyes,
fact, when summarizing cross-cultural studies of & Jensen, 1998; Romney, Moore, & Rusch, 1997).
depression, some writers (Marsella, 1980; Kleinman, Similarly, when studying 25 emotional clusters
1977) have suggested that the ethnocentric concep- (e.g., adoration, agony, anger, depression, envy, guilt,
tualization of depression has led to challenges when pride, relief ) across 64 languages, Hupka et al.
conducting research. Other researchers (e.g., Brandt (1999) discovered the “naming of emotion catego-
& Boucher, 1986; Marsella, 1980), when reviewing ries was relatively uniform across languages when
previous studies, have concluded that a number of English terms were used as the referents and when
non-Western societies have no emotion terms simi- the establishment of the universal developmental
lar to the concept of depression used in the English sequence of the emotion lexicon was based on emo-
language. In their study of this observation, Brandt tion category terms that all sampled languages had
and Boucher discovered that, as an organizing con- encoded” (p. 260).
cept, depression was present in one of three Western Regardless of these findings, it is rather difficult
(United States) and three of five non-Western to accurately investigate how language depicts the
(Indonesia, Japan, and Sri Lanka) countries. The emotions of various cultures. Complicating this task
researchers concluded from this “that the broad even further is the fact that criteria are lacking to
classification of cultures into dichotomous groups— judge the equivalence of words to describe emo-
Western vs. non-Western—cannot account for the tions, making it difficult to compare the equivalence
occurrence (and nonoccurrence) of depression clus- or nonequivalence of emotions between cultures
ters” (p. 330). Furthermore, they reported that for (Mesquita & Frijda, 1992). This task is further
the countries just mentioned, “depression was a complicated by the recognition that languages vary
sufficiently salient semantic organizing concept . . . in the number of words they use to classify emo-
despite their cultural and linguistic differences” tions (Russell, 1991). For instance, Wallace and
(p. 341). Last, Brandt and Boucher argued that, unlike Carson (1973) reported that over 2,000 words in
the Diagnostic and Statistical Manual (DSM-III) the English language were used to classify emotions,
that described a depressive episode as “either a dys- whereas Hoekstra (1986) discovered 1,501 words
phoric mood or loss of interest or pleasure in in Dutch, Boucher (1979) found 750 words in
usual activities and pastimes,” their “samples did Taiwanese Chinese and 230 words in Malay, and
not view depression as an either-or-phenomenon” Howell (1981) reported seven words in Chewong
(p. 343). linked with categories of emotion.

882 intern ation al iz atio n

 Additionally, it has been discovered that there situations that give rise to it, then it is likely that
is the possibility that emotions “may lose some of there are subtle differences in the way interdepen-
their meaning across cultural boundaries” (Elfenbein dent and independent cultures engage in talking
& Ambady, 2002, p. 228). Consistent with this about emotions” (p. 26). Moreover, they stated that
assumption, Menon (2000) reported, “Glossing emo- their results suggested emotion-talk has greater
tion terms across cultural and linguistic boundaries implications for action in an interdependent cul-
will rarely make the emotional experiences they rep- ture (i.e., pursue or do something collaboratively) as
resent intelligible” (p. 48). As stated earlier, Menon compared to in an independent culture, in which
argued that if we want to comprehend the similari- emotion-talk might just be analytic in nature. Semin
ties and differences in emotional functioning et al. urged investigators to further research these
between cultures, we must separate emotion scripts conclusions.
into their specific elements. Finally, it is important to note that, in some
Moore, Romney, Hsia, and Rusch (1999) did cultures, emotions are exclusively linked with physi-
exactly this when examining the structure of emo- cal sensations or specific bodily organs (Mesquita
tion terms for Chinese, English, and Japanese. They & Frijda, 1992), and as such, the language used to
found a similar structure for emotion terms for describe an emotion is associated with a physical
the three languages. These researchers, like others attribute. Rosaldo (1980), for example, reported
(Romney et al., 1997; Rusch, 1996), also reported that the Ilongot of the Philippines depicted motions
that Chinese, English, and Japanese shared a similar of the heart when describing emotions, whereas
cognitive semantic structure of emotion terms. Soto et al. (2005) proposed that the Chinese dis-
Kim and Hupka (2002), on the other hand, played emotions as physical symptoms linked with
investigated the cross-cultural comparability of illness, and as such, they somatisized their emotions.
emotions from a different perspective. They studied In general, researchers have claimed that there are
the free associations to five emotion concepts of cultural differences in the salience of physical sensa-
university students in Korea and the United States. tions when describing and experiencing emotions
Although they discovered some minor differences, and also the number of physical responses linked
for both samples there were similarities in about with reports of emotions (Mesquita & Frijda).
one-third of the associations to anger, envy, fear,
jealousy, or sadness. Kim and Hupka concluded methods for studying emotion
there might be universals in the primary structural Before discussing in further detail the cross-cultural
components of the language of emotion. They also research on the experience, expression, regulation,
thought their results corroborated earlier findings of and recognition of emotions, it is important to
universals in, for instance, semantics (Herrmann & briefly highlight a few of the major methodologies
Raybeck, 1981; Ullman, 1963/1966), phonology, employed to investigate these topics. Historically,
grammar, lexicon, kinship terminology (Greenberg, the most common strategy employed by researchers
1966), the utilization of antonyms (Raybeck & has been extrapolating emotions from facial expres-
Herrmann, 1996), the appraisal process linked with sions and movements. In the early 1970s, a number
emotions (Scherer, 1997a), and the conceptual of investigators introduced observational coding
organization of emotion terms (Russell, 1983). systems to distinguish facial expressions, in general,
Looking at emotion terms from yet another and to varying degrees specific facial movements
perspective, based on the results of two mixed- assumed to be linked with different emotions.
methods studies, Semin, Görts, Nandram, and Ekman, Friesen, and Tomkins (1971) were the first
Semin-Goossens (2002) discovered emotion terms to do this when they developed the Facial Action
served as relationship-markers, and emotion events Scoring Technique. Soon thereafter, Ekman and
were symbolized by employing concrete linguistic Friesen (1976, 1978) constructed the Facial Action
terms in cultures that valued relationships and inter- Coding System (FACS). Following this, a number
dependence, as contrasted with cultures emphasiz- of other methods were introduced, including the
ing the value of the individual. In the latter cultures, Maximally Discriminative Facial Movement Coding
emotion terms were also found to operate mainly System (Izard, 1979), Monadic Phases (Tronick,
as self-markers symbolized by the greater use of, for Als, & Brazelton, 1980), Emotion FACS (EMFACS;
instance, adjectives and nouns. Semin et al. con- Ekman & Friesen, 1982), and A System for
cluded, “If the manner in which emotion is marked Identifying Affect Expressions by Holistic Judgment
(relationship vs. self ) differs systematically, as do the (Izard, Dougherty, & Hembree, 1983). It should be

ge r st e in, ægisdót t ir 883

noted the EMFACS is a technique for employing established reliability (e.g., inter-rater, interobserver)
the FACS to specifically assess facial movements based on the unique data collected in their own
presumed to be connected to identifying emotions. studies.
Strategies to investigate the relationship between As mentioned earlier, researchers have often also
electrical activity in the muscles of the face and assessed display rules. Such rules have been mea-
emotions also have been developed (Ekman, 1993). sured in many ways, but only a few of the techniques
Ekman (1982) provided an excellent review of the employed have been rendered sound in terms of
early work on the various methodologies to measure their psychometrics (Matsumoto, Yoo, Hirayama,
facial movements considered to be relevant to emo- & Petrova, 2005). In some of the earliest research
tional activity. designed to investigate display rules, the investiga-
To date, the FACS is the most frequently used tors (Ekman, 1972; Friesen, 1972) did not actually
and researched methodology for assessing and assess the rules with a psychometric instrument.
describing facial expressions in many diverse fields Instead, differences in facial responses of individuals
(e.g., computer vision and graphics; neuroscience; from two cultures were assessed and compared, and
developmental, social, and clinical psychology), and interpretations of the findings were guided by theory
it is considered the “criterion measure of facial and not an empirical construct (Matsumoto et al.,
behavior” (Sayette, Cohn, Wertz, Perrott, & Parrott, 2005).
2001, p. 168). This technique offers a framework to Much of the early work (e.g., Saarni, 1979) on
assess all visually distinctive, observable facial move- assessing display rules was conducted with children
ments. It also can be used to identify the “‘basic by exposing them to stories about social situations
emotions’” of happiness, sadness, surprise, disgust, that would elicit their emotional responses. Until
anger, and fear through coding specific muscles in recently, the measures employed in such studies
the face tied to facial behaviors (Ekman & Friesen, were not validated. In the early part of this century,
1978). Ekman and Friesen referred to each facial two devices with sound psychometric properties
movement as an action unit (AU) (Ekman, Friesen, were introduced and employed to examine the emo-
& Hager, 2002). It appeared from the most current tional expressivity of children: Children’s Sadness
FACS manual that there are 46 AUs (Ekman et al., Management Scale (CSMS; Zeman, Shipman, &
2002); however, over the years, investigators have Penza-Clyve, 2001) and the Emotion Expression
generated a range of AUs (e.g., 30–58) based on the Scale for Children (EESC; Penza-Clyve & Zeman,
purpose of their projects and the data obtained. 2002). The CSMS measures the inhibition of the
Since its introduction, the FACS has been used expression of sadness, emotion regulation coping,
to investigate thousands of photographs, films, and and dysregulated expression, whereas the EESC
videotapes of facial expressions (Ekman, 2003). assesses two components of deficiencies in express-
Reliability and validity for the system has been ing emotions: lack of emotion awareness and lack
established by Ekman and his colleagues (see Ekman of motivation to express negative emotion.
et al., 2002). Reliability also has been shown in con- A number of adult measures of display rules
junction with hundreds of other projects designed and the management of emotional expressions with
to study a host of topics linked with facial behavior. satisfactory psychometric qualities began to appear
Perhaps the most comprehensive examination of in the 1980s. However, like the devices designed
the FACS’s reliability was conducted by Sayette for children, almost all of these instruments were
et al. (2001), who reported good to excellent reli- constructed to investigate individual differences in
ability for various aspects of the system. the emotional expressivity, emotional control, or
As stated above, the EMFACS identifies spe- emotion regulation of adults along a single dimen-
cific AUs that are thought to be connected to facial sion of expression management, such as suppres-
expressions linked with emotions. According to sion or inhibition (Matsumoto et al., 2005). Some
Matsumoto and Willingham (2006), the validity for examples of these adult scales include the Cour-
this system has been supported by investigations of tauld Emotional Control Scale (Watson & Greer,
spontaneous expression and judgments of expres- 1983) that assesses the emotional control of Anger,
sions (Ekman, Davidson, & Friesen, 1990; Ekman Depressed Mood, and Anxiety; the Emotion Control
& Friesen, 1971; Ekman, Friesen, & Ancoli, 1980; Questionnaire (Roger & Najarian, 1989; Roger &
Ekman, Friesen, & Ellsworth, 1972; Ekman, Friesen, Nesshoever, 1987) that measures the inclination
& O’Sullivan, 1988; Ekman, Sorenson, & Friesen, to inhibit the expression of emotional responses
1969). Investigators employing the EMPACS have (i.e., emotional inhibition, aggression control, and

884 intern ation al iz atio n

benign control); the Emotional Expressiveness Because of how it was constructed, it was not possi-
Questionnaire (King & Emmons, 1990) that assesses ble to perform a factor analysis on participants’
emotional expressiveness in terms of the expression responses. Instead, the researchers conducted multi-
of positive emotion, expression of intimacy, and dimensional scaling. Although the six expected strat-
expression of negative emotion; the Emotional egies to manage emotions were obtained from this
Expressivity Scale (Kring et al., 1994) that simply process, this study failed to provide extensive evi-
measures emotional expressiveness; the Berkeley dence for the validity of the DRAI, and it did not
Expressivity Questionnaire (BEQ) (Gross & John, measure the scale’s reliability.
1995, 1997) that assesses emotional expressivity Matsumoto et al. (2005) conducted two studies
with regard to general expressivity, impulse strength, to more closely investigate the psychometric proper-
positive expressivity, and negative expressivity; and ties of the DRAI. In the first, participants were from
the Emotion Regulation Questionnaire (Gross & the United States, Russia, and Japan. Based on factor
John, 2003) that measures the reappraisal and sup- analysis, five factors were retained: express, deam-
pression of emotion or the ability to control the plify, amplify, mask, and qualify. The investigators
expression and experience of emotions. Matsumoto argued this result was the first to empirically support
et al. (2005) provided a fairly comprehensive review Ekman and Friesen’s (1969) theoretical assumption
of all the child and adult instruments constructed to about various unique expressive modes for facial
assess display rules and emotional expressivity. expressions. Convergent validity and internal reli-
Matsumoto, Takeuchi, Andayani, Kouznetsova, ability were also explored and found to be satisfac-
and Krupp (1998) introduced a different type of tory. The second study further investigated the
scale to measure display rules. Their device, the validity and reliability of the measure with a sample
Display Rule Assessment Inventory (DRAI), unlike of U.S. and non-U.S. participants. The findings sup-
previous measures, was designed to capture the ported the scale’s convergent and predictive validity,
complexity of the behavioral repertoire linked with and also its internal and test-retest reliability.
display rules instead of simply the suppression or
inhibition of emotions. As such, it attempted to Cross-cultural Research on Emotions: Some
account for various behavioral responses when indi- Themes Relevant to Counseling Psychology
viduals experience different emotions in a host of By now, it is rather apparent how daunting the
social relationships. Seven emotions considered uni- challenge is for psychologists to operationally define
versally displayed in the face (i.e., anger, contempt, the recognition, experience, and expression of emo-
disgust, fear, happiness, sadness, and surprise along tions; to understand how language is used in the
with a synonym for each) were linked with four types context of identifying, labeling, and communicat-
of social relationships (family members, close friends, ing emotion; and to employ valid and reliable meth-
work colleagues, and strangers). Participants were ods designed to capture the complexity of this
asked to report what they might do in terms of seven construct, especially across cultures. An even more
behavioral responses if they experienced each of these insurmountable task, however, is to effectively and
emotions in each social relationship. Six of the accurately summarize the enormous amount of
behavioral responses corresponded with Ekman and research conducted worldwide on various cultural
Friesen’s (1969; 1975) original assumptions about and cross-cultural features of emotions. This is par-
how expressions might be managed when emotions ticularly difficult given the extensive, inconsistent
are aroused: Express the feeling as is with no inhibi- results reported in this body of literature. In fact,
tions (express); express the feeling, but with less attempting to discuss this entire line of research is
intensity than one’s true feelings (deamplify); express beyond the scope of this chapter. Instead, some
the feeling, but with more intensity than one’s true highlights of a few important themes found in this
feelings (amplify); try to remain neutral, express literature that are relevant to counseling profession-
nothing (neutralize); express the feeling, but together als will be presented.
with a smile to qualify one’s feelings (qualify); and
smile only, with no trace of anything else, in order to experiencing emotions
hide one’s true feelings (mask). The seventh option Perhaps the most frequently researched topic appear-
allowed participants to share some other response. ing in this literature is whether there are similarities
This measure was given to four different populations and/or differences in how individuals from various
worldwide, and it was written in four languages cultures experience, express, and recognize emotions.
(i.e., English, Japanese, Russian, and Korean). Stated another way, investigators have explored the

ge r st e in, ægisdót t ir 885

universality versus uniqueness of the experience, differ based on culture, thus supporting the univer-
expression, and recognition of emotions across and sality of emotional expressions found in the large
within cultures. One of the first to study this topic body of laboratory research on this topic. For exam-
was Ekman, whose often-cited project ple, when receiving their medals, the athletes smil-
in New Guinea (Ekman, 1972) suggested that the ing behavior seemed consistent across cultures even
expression and recognition of emotion was universal though this expression was displayed in an emotion-
(Matsumoto, 2009). Other studies by Ekman and ally charged, naturalistic setting.
his colleagues further supported this conclusion As will be discussed later in the chapter, although
(Ekman & Friesen, 1971; Ekman et al., 1969) by a substantial amount of research documents the cross-
discovering that persons from a host of diverse cul- cultural similarity of facial expressions and emotions,
tures were able to correctly and consistently identify there is also research indicating cross-cultural differ-
emotions (e.g., anger, disgust, fear, happiness, sad- ences. Commenting on this, Matsumoto reported,
ness, and surprise) displayed in facial expressions and “cultural differences in emotional expressions are pro-
that individuals from different cultures could spon- duced because members of different cultures learn to
taneously exhibit the same expressions when these have different emotional reactions to different cultur-
emotions were generated (Matsumoto). According ally available events in the first place” (p. 276).
to Matsumoto, Keltner, O’Sullivan, and Frank
(2006), approximately 74 studies since Ekman’s antecedents of emotions
(1972) seminal investigation have basically con- Many studies have examined the factors that elicit
firmed the facial configurations first theorized by emotions across cultures (Soto et al., 2005). Galati
Darwin and later verified by Ekman and his associ- and associates found similarities in the antecedents
ates (Ekman, 2003; Ekman & Friesen, 1971, 1975, of emotions for Africans and Italians (Galati, 1989)
1986; Ekman et al., 1969). and persons from Northern and Southern Italy
Matsumoto (2009) argued, however, that simply (Galati & Sciaky, 1995). Cultural differences in the
because facial expressions of emotion appeared to be antecedents of emotions (e.g., anger, disgust, fear,
universal, this discovery did not account for the root joy, sadness, surprise) also have been reported, as
of this universality. Matsumoto theorized the source have individuals’ beliefs about when and how emo-
of this universality could be attributed to “culture tions should be experienced and shared (e.g., Ekman,
constant learning,” whereby individuals worldwide 1972; Galati et al., 2005; Hochschild, 1979;
learn to spontaneously display similar facial features Mesquita & Frijda, 1992; Shweder, 1993). Some
for the same emotions. A second source for the uni- researchers (van Hemert, Poortinga, & van de Vijver,
versality of facial expressions of emotion proposed 2007) have claimed that persons from cultures with
by Matsumoto (2009) is biology and evolution. fewer restrictions on behavior and with more open
Matsumoto claimed, and others have discovered, social norms are more likely to freely express their
that facial configurations connected to emotions emotions. As an example, Rosenblatt, Walsh, and
for persons throughout the world are innately bio- Jackson (1976) reported that, during the entire
logical. This association also has been found for mourning time after a loved one had died, persons
nonhuman primates (de Waal, 2003). from Bali were not permitted to cry. Others have
It should be noted that the extensive research on found that, in certain cultures, displaying intense
the universality of facial expressions of emotions emotions (e.g., crying) was condemned or only
performed by Ekman and his associates prior to permitted in specific situations (e.g., Becht &
2003 was based on controlled laboratory studies. Vingerhoets, 2002; Georges, 1995; Wellenkamp,
Therefore, the findings from these studies might not 1995). For the Utku Eskimos, for example, it is
generalize to naturalistic environments (Matsumoto, socially inappropriate to express anger (Briggs,
2009). To address this limitation, Matsumoto and 1970). In contrast, the Kaluli of Papua New Guinea
Willingham (2006) conducted a study with athletes are expected to display their anger (Schieffelin,
who were participating in the 2004 Athens Olympic 1983).
Games. The spontaneous facial expressions of emo-
tions of 84 athletes when receiving their medals were interpreting emotions
investigated. These athletes represented 35 countries According to Yuki, Maddux, and Masuda (2007),
and six continents. Overall, the results paralleled researchers have also discovered cultural differences
emotions predicted by the EMFACS dictionary and in how emotions are interpreted (Elfenbein &
suggested that the expression of emotion did not Ambady, 2002, 2003; Elfenbein, Mandal, Ambady,

886 intern ation al iz atio n

Harizuka, & Kumar, 2004; Marsh, Elfenbein, & Therefore, it is not surprising that some research-
Ambady, 2003; Matsumoto, 1989; Matsumoto & ers have discovered that guilt is of greater impor-
Ekman, 1989) although other investigators (e.g., tance in collectivistic as compared to individualistic
Matsumoto & Kishimoto, 1983; Russell, 1991; van cultures (Eid & Diener, 2001). It should be noted,
Bezooijen, Otto, & Heenan, 1983) have claimed though, that Matsumoto et al. (2009) reported a
that facial expressions (e.g., smiles, frowns) are different result. They discovered that greater intensi-
attributed the same meaning across cultures and ties of shame or guilt were not linked with collectiv-
languages. For instance, Wilkins and Gareis (2006) istic cultures. Furthermore, in one study, unlike
in an exploratory study found that stating “I love what would have been expected, Americans as com-
you” varied between cultures. In some cultures, the pared to Chinese college students were found to
phrase was uttered only in romantic relationships, experience greater degrees of shame in certain situa-
whereas in others it was expressed with friends, tions (Tang, Wang, Qian, Gao, & Zhang, 2008).
family, lovers, and others. Furthermore, non-native Cultural differences in the experience of pride
English-speaking persons reported saying, “I love also have been reported. For instance, Stipek (1998)
you” more frequently in English than their native found differences in the experience of pride between
language. U.S. and Chinese persons. For the Chinese partic-
ipants, pride was considered more acceptable for
individualistic versus collectivistic achievements benefiting others as compared to
cultures and emotions achievements resulting from personal accomplish-
Mesquita and Walker (2003) claimed that, in ments. Eid and Diener (2001) in their cross-cultural
general, cultural differences in the occurrence of study of 1,846 participants from two individualistic
emotional expressions and behaviors reflected varia- (United States, Australia) and two collectivistic
tions in cultural structures. In fact, a good deal of (China, Taiwan) countries also discovered that pride
research has explored differences in the expression was more important in individualistic versus collec-
of emotions in individualistic versus collectivistic tivistic cultures.
cultures. Investigators have reported that in indi- Additionally, based on the results of their study,
vidualistic cultures, it is more common for persons Eid and Diener (2001) reported larger cross-cultural
to directly and explicitly express their emotions differences in the self-conscious or self-reflective
(e.g., Markus & Kitayama, 1991), whereas in col- emotions (i.e., emotions connected to an individual’s
lectivistic cultures (e.g., Japan, China, and Korea) own actions). The investigators stated, in part, that
individuals control and subdue their emotional individualistic cultures believe self-reflective emo-
expressions since to do so is to help maintain har- tions about persons performing well are good,
monious relationships (Heine et al., 1999; Markus whereas collectivistic cultures, such as Confucian
& Kitayama; Yuki et al., 2007) or because there is cultures of the Pacific Rim, think self-reflective
little social significance attached to expressing emo- emotions conveying individuals’ controllable actions
tions (Potter, 1988). In one collectivistic culture, are wrong or insufficient. The latter conclusion is
Mexico, however, researchers have theorized (Garza, considered desirable as well.
1978; Guerra, 1970; Ramirez & Castaneda, 1974) Eid and Diener’s (2001) findings also indicated
and discovered (Tsai & Levenson, 1997) that emo- that both culture-specific and universal kinds of
tions are openly expressed, accepted, and valued. norms were connected to the experience of emo-
In Western individualistic cultures, to express tions. Furthermore, collectivistic cultures were found
one’s emotions is also considered being true to one’s to have intranational variability in their norms for
self (Heine et al., 1999; Markus & Kitayama, 1991). emotions, whereas individualistic cultures were very
Yuki et al. (2007) claimed that the findings in the consistent in such norms, especially in terms of pleas-
literature on facial expressions supported the results ant emotions. More specifically, Australia and the
just highlighted in the previous paragraphs. That is, United States were found to be relatively tight
individuals from collectivistic cultures suppressed nations in terms of their norms for positive affect.
their negative emotions in the presence of others According to Eid and Diener, the norms in cultures
more so than did persons from individualistic cul- that are tight are very homogeneous, and persons in
tures. Matsumoto et al. (1998) also discovered that such cultures are pressured to adhere to the norms.
Japanese persons, when compared to Americans, In contrast, loose cultures lack such homogeneous
engaged in greater control of both their expression of norms, and they tolerate variations in behavior.
negative emotions and their feelings of happiness. Given this explanation, Eid and Diener claimed

ge r st e in, ægisdót t ir 887

individuals in the United States and Australia may in their own versus another culture. Furthermore,
experience pressure to be happy, joyful, and full of persons from individualistic cultures were more
love and pride. Furthermore, they might “make use likely to endorse expressivity norms, especially those
of their constitutional right to the pursuit of happi- related to the expression of positive emotions.
ness” (p. 880). When unhappy, Eid and Diener Individuals from collectivistic cultures, in contrast,
argued, persons from these countries would be were less inclined to express their emotions to people
expected to become happy through, for example, in their own culture. Additionally, the researchers
seeking counseling. Eid and Diener’s results also sug- discovered that interindividual variability (“indi-
gested that the collectivistic cultures in their study, vidual differences in overall expressivity norms
China and Taiwan, were looser in their norms for across contexts and emotions” p. 59) was negatively
positive emotions. They found China to have a wide linked with individualistic cultures. That is, the
range of norms. For instance, they reported some increased freedom to express emotions in such cul-
Chinese might find being unhappy acceptable, tures was correlated with a smaller (not larger)
whereas others would not since they perceived posi- continuum of possible ways that individuals could
tive emotions as undesirable. Similarly, many of the express themselves. One conclusion that Matsumoto
Chinese and Taiwanese in their study viewed pride as et al. presented was that the expression of emotions
undesirable, but others thought it was acceptable. across cultures fluctuated as a result of the specific
Another set of findings from Eid and Diener’s emotion, the type of interactants, and the degree
study with regard to Taiwan must be mentioned. of emotional expressivity sanctioned by a particu-
In terms of almost every positive emotion investi- lar culture. This conclusion was consistent with
gated except pride, Taiwan was quite similar to Eid and Diener (2001), who urged cross-cultural
Australia and the United States. With respect to the researchers to pay careful attention to both within
frequency of negative emotions, however, Taiwan and between cultural differences in the variability
was similar to Australia and the United States, but associated with the norms connected to emotion.
differed from these countries in the intensity of Based on their results, these investigators claimed
negative emotions. The Taiwanese experienced less that even when norms are similar, emotional experi-
intense negative emotions than did individuals from ences vary by nation. Given this, Eid and Diener
Australia and the United States. concluded, “it appears that factors such as genetics
Eid and Diener’s findings, in part, contradicted or life circumstances also influence emotional expe-
an earlier less well-designed and smaller study con- riences beyond the influence of norms” (p. 882).
ducted by Sommers (1984). Sommers found the Perhaps another explanation for the inconsistent
emotions of love, happiness, and joy were valued results reported thus far in terms of the emotions
across the cultures investigated (United States, experienced by persons in individualistic versus
China, Greece, and West Indies), whereas hate, collectivistic cultures is related to the role of harmo-
terror, and rage were viewed as dangerous and nious relationships in various cultures. Numerous
destructive, and guilt, frustration, fear, shame, and writers have reported that most Asian cultures deeply
embarrassment were perceived as aversive in these value harmonious relationships between people
cultures. Sommers also discovered differences in rather than pursuits that are self-fulfilling at the
the experience of emotions between the cultures. expense of such relationships. Mesquita and Walker
Persons from the United States greatly treasured (2003) even claimed that these cultures frown on
enthusiasm, individuals from Greece prized respect, persons “occupying too much space in the relation-
and West Indians valued pride, whereas the Chinese ship, both figuratively and literally” (p. 786). These
viewed more negative emotions as useful and con- researchers also argued that in cultures valuing
structive as compared to respondents from the other harmonious relationships the expression of happi-
three cultures. ness is discouraged. The expression of anger is also
The results of a more recent large-scale, carefully seen in some cultures as disrupting social relation-
designed study by Matsumoto et al. (2008a) on the ships (Bender, Spada, Seitz, Swoboda, & Traber,
topic of emotions might help explain the inconsis- 2007). Bender et al. discovered that persons from
tency in these results. In this project, the responses Tonga expressed less anger than did individuals
of 5,000 individuals from 32 countries were investi- from Western countries for this very reason.
gated. In general, the findings revealed that persons Cultures within nations also have been found
from both individualistic and collectivistic cultures to vary in emotional expressivity. For example,
were more inclined to express emotions to people European Americans typically value expressing

888 intern ation al iz atio n

emotions (Kim & Sherman, 2007; Matsumoto, (Morling, Kitayama, & Miyamoto, 2003; Taylor,
1990), whereas Asian Americans consider such Sherman, Kim, Jarcho, & Takagi, 2004; Tweed,
expressions less acceptable with their acquaintances White, & Lehman, 2004; Yeh & Inose, 2002);
(Matsumoto, 1993). U.S. males and females of and display rules, which are linked to suppression
European, African, Asian, and Hispanic descent (Matsumoto, 1990, 1993; Matsumoto et al., 1998,
have been found to also vary in their emotional 2005). A substantial amount of previous research
expressivity. Results of three studies conducted also has discovered that the suppression of emotions
by Durik, Hyde, Marks, Roy, Anaya, and Schultz was linked with increased physiological responding
(2006) indicated that stereotypes embraced by for European Americans (Butler et al., 2003; Gross
European American men suggested they expressed & Levenson, 1993, 1997). In contrast, suppressing
more pride than women, whereas stereotypes of emotions was found to be relatively normative and
African American men indicated that they were automated for Asian American women (Butler, Lee,
similar to women in their expression of this emo- & Gross, 2007, 2009).
tion. Furthermore, smaller gender differences were In a direct study of the emotional regulation
discovered between Hispanic and Asian Americans components of reappraisal and suppression in
in terms of their expression of love as compared to 23 countries, Matsumoto, Yoo, Nakagawa et al.
European Americans, in whom women, as con- (2008b) found cultures valuing social order (i.e.,
trasted with men, were thought to display greater long-term oriented, embeddedness, and hierarchy)
degrees of this emotion. Other studies have discov- like China, Japan, and Korea were more inclined
ered gender differences in the emotional responses to have higher suppression scores, and a positive
of Japanese and European Americans (Frymier, correlation between suppression and reappraisal.
Klopf, & Ishii, 1990; Zahn-Waxler, Friedman, On the other hand, cultures emphasizing affective
Cole, Mizula, & Hiruma, 1996). Based on their autonomy and egalitarianism (e.g., United States,
own findings and those of others, Durik et al. con- Canada, Italy) were more likely to have lower sup-
cluded that “different norms may pose challenges pression scores, and a negative correlation between
for inter-cultural interactions, and they point to these two components of emotional regulation.
the importance of considering both gender and eth- Differences in the expected direction in suppres-
nicity simultaneously in the study of emotions” sion, reappraisal, and a more general assessment of
(p. 429). emotional regulation were also found in a study com-
paring Japanese and U.S. respondents (Matsumoto,
emotional regulation 2006). Of particular interest is the fact that Matsumoto
In addition to examining cultural differences in the discovered that the personality traits of extraversion,
experience and expression of emotions, researchers neuroticism, and conscientiousness mediated the
have investigated cultural variations in the regula- differences in the three emotion regulation variables
tion of emotions. Recall that emotional regulation for the target populations. Matsumoto concluded
has been defined as being able to manage and change that these differences might not be related to culture,
emotional reactions to fulfill specific outcomes but to the possibility that persons in the United
(Matsumoto, 2006). According to Gross and associ- States have personalities with a greater likelihood to
ates (1998; Gross & John, 2003), reappraisal and engage in reappraisal, whereas the Japanese were more
suppression are components of emotion regulation. inclined to have personalities that employ suppres-
Reappraisal is defined as the way persons construe sion. Assuming the results of Matsumoto’s study are
an emotion-eliciting situation to modify its effect replicated and extended, it would seem critical that
on their emotional experience, whereas suppres- future research includes personality variables when
sion is thought to inhibit emotionally expressive investigating potential cross-cultural differences in
behaviors. emotional regulation.
Several studies have discovered cross-cultural Universal norms for emotional expression regu-
differences in processes and factors linked with lation also have been reported in the literature. In a
emotional regulation. For instance, cultural differ- large-scale study involving the facial display rules in
ences have been found for emotion-related apprais- 32 countries, Matsumoto et al. (2008a) discovered
als (Matsumoto, Kudoh, Scherer, & Wallbott, little variation in the overall facial expression of
1988; Mauro, Sato, & Tucker, 1992; Roseman, emotions, leading the researchers to conclude that
Dhawan, Rettek, & Naidu, 1995; Scherer, 1997a, there was a universal norm for the regulation of
1997b); coping, which is connected to reappraisal emotional expressions.

ge r st e in, ægisdót t ir 889

recognition of emotion designed to examine whether 548 observers (U.S.-
Cultural variations and similarities in the recogni- born and -raised Americans, immigrants to the
tion of emotion is another topic widely investigated. United States, Japanese, and British) of spontane-
Researchers have focused on examining facial ous displays of emotion could accurately recognize
expressions since they are considered a basic way of emotions, the participants were asked to assess the
communicating emotions (Yuki et al., 2007). Much emotional expressions of the athletes involved in
of the extensive evidence, including meta-analytical Matsumoto and Willingham’s (2006) study discussed
studies (Elfenbein & Ambady, 2002, 2003), has earlier. A unique aspect of this study, as compared to
indicated, in general, a universal recognition of previous research, was its focus on the spontaneous
emotions based on facial expressions (Ekman, 1989, display of facial expressions rather than a still photo-
1992; Matsumoto, 2001, 2009; Yuki et. al., 2007). graph. Another unique feature was that it was the
Even so, researchers have also reported cross-cultural first to investigate cross-cultural spontaneous facial
differences in emotion recognition explained by expressions of emotion assessed by persons from dif-
moderators (see Mesquita & Frijda, 1992; Russell, ferent cultures. In general, the findings suggested
1994; Scherer, 1997a; Scherer & Wallbott, 1994), that observers, regardless of their cultural back-
such as exposure between cultures, majority or ground, were able to accurately and consistently
minority status in the culture, attributes of studies, recognize the emotions expressed by the Olympic
and demographics (Elfenbein & Ambady). medal–winning athletes representing the various
More specifically, in their meta-analysis, Elfen- countries.
bein and Ambady (2002) discovered it was easier
for persons to identify the basic emotions of indi- summary of research on emotions
viduals from their own as compared to another eth- Although it is impossible to draw any definitive con-
nicity, nationality, or regional group. This finding, clusions about the extensive cross-cultural research
however, seemed to be connected to the accuracy of on various aspects of emotions, based on a meta-
individuals judging the emotions of persons from analysis of 190 published studies from 1967 to 2000,
their same culture. In this regard, investigators have van Hemert et al. (2007) claimed that any differ-
discovered that the greater the knowledge about ences in emotional expression, types of emotions,
ones’ culture, or exposure to a particular culture, the and the recognition of facial expressions might be
more accurate persons are in identifying emotions in overestimated due to statistical artifacts and method-
that culture (Elfenbein & Ambady, 2002, 2003; related factors. The investigators discovered, how-
Elfenbein et al., 2004; Marsh et al., 2003; Shimoda, ever, differences in “broad patterns in emotions”
Argyle, & Ricci Bitti, 1978). van Hemert et al. connected to positive and negative emotions, and
(2007), in their meta-analytic study, discovered emotional recognition. In an earlier publication,
somewhat similar results, reporting that differences Russell (1991) reached a somewhat similar conclu-
in emotions were greater in cross-national as com- sion as a result of reviewing a large body of literature
pared to intranational studies. on emotions. He reported “studies on what is similar
Based on their findings, Elfenbein and Ambady in how emotions are understood across cultures
(2002) concluded that specific aspects of emotions point principally to bipolar dimensions: pleasure-
are universal and probably biological, and that the displeasure surely, arousal-sleepiness and dominance-
expression of emotions can lose some meaning submissiveness probably” (p. 440).
across cultures. Furthermore, they concluded that Based on the results of their study, Matsumoto
the ability of persons from various cultures to com- et al. (2009) reached a different conclusion. They
prehend the emotions of other individuals is not reported that the variance explained by country or
consistently symmetric. Drawing on their findings, culture in their study was not very large and best
Elfenbein and Ambady indicated that members of a attributed to differences in individuals instead of
minority group displayed greater accuracy when cultures. Furthermore, they claimed that when
judging the emotions of majority group members differences in emotions by country did exist, such
than did majority group persons when assessing the differences could be linked with a specific culture.
emotions of individuals from a minority group. In a thorough recent review of the cross-cultural
One other methodologically sophisticated emo- literature on emotions, Matsumoto (2009) elo-
tion recognition cross-cultural study needs to be quently captured the essence of the complex, incon-
mentioned. In this large-scale study (Matsumoto, sistent previously reported findings when he stated,
Olide, Schug, Willingham, & Callan, 2009) “Because different events occur in different cultures

890 intern ation al iz atio n

or have different meanings in different cultures, the literature a few global and general sugges-
individuals learn to have different emotional reac- tions that can provide a framework for the field to
tions across cultures, thus producing different embrace a more focused and informed perspective
expressions” (p. 271). on the complexity of emotions, especially across
Consistent with one of Matsumoto et al’s cultures. Obviously, given their job responsibilities,
(2009) conclusions, Mesquita and Frijda (1992), in it behooves counseling professionals and students to
another extensive literature review on emotions cau- further enhance their knowledge of the psychologi-
tioned that, “global statements about cross-cultural cal and cross-cultural literature on emotions.
universality of emotion, or about their cultural As pointed out previously, it is critical that
determination, are inappropriate. Rather, any evalu- counseling professionals and students be extremely
ation of biological or cultural determinants should cautious in assuming that all people experience the
start from an analytical approach of the emotion same emotions; report the same antecedents for
process, distinguishing the determinants for differ- their emotions; express, regulate, and interpret their
ent components. Within each component, more- emotions in a similar fashion; and are compara-
over, differences in level of analysis of the phenomena ble in their ability to recognize emotions in other
also appear to be decisive for the kind of conclu- persons. Although the literature suggested that uni-
sions drawn” (p. 198). The authors also concluded, versal features of emotions exist, it also suggested
however, that there are universal features of emo- unique components to this concept in particular
tions, such as emotional reactions (i.e., modes of cultures and countries. It was discovered that the
action readiness), specific types of responses (e.g., structure of the culture (i.e., collectivistic vs. indi-
facial expressions, voice intonations, physiological vidualistic) has a great influence on what emotions
responses, inhibition), antecedents arousing emo- are experienced, expressed, and/or recognized, and
tions (e.g., loss of close individual, rejection of social how emotions may be interpreted. The literature
group), and methods of appraising and reappraising also indicated there could be differences in compo-
emotions (e.g., self-blame, hope, other-blame, out- nents of the emotional phenomena depending upon
come uncertainty, controllability, and modifiabil- the nature of this structure. Regardless of the struc-
ity). Mesquita and Walker (2003), in their literature ture, however, the research revealed that culture
review, reached a very different conclusion about shapes the norms linked with all aspects of emotions
emotional responses. Drawing on the research of including, for example, whether it is appropriate to
other investigators (Mesquita, 2003; Mesquita et al., express anger or sadness. The norms of a culture, in
1997), they claimed, “there are cultural differences general, influence not only the experience of specific
in the prevalent, modal, and normative emotional emotions, but also the regulation of emotions in
responses” (p. 777). This observation was thought terms of emotional suppression and reappraisal.
to have important implications for assessing emo- One other study not reported earlier might help
tional disturbances defined as “‘excesses’ in emo- illustrate the importance of culture with respect to
tions, ‘deficits’ in emotions, or the lack of coherence norms associated with emotions. In this study, self-
in emotional components” (Kring, 2001, p. 337). report data were gathered from over 4,000 males
Perhaps the best way to summarize the numerous and females residing in 30 countries (Becht &
lines of inconsistent results linked with various Vingerhoets, 2002). Based on the results of a regres-
aspects of emotions is to recognize that communi- sion analysis, as expected, it was discovered that
cating emotions is central to being a human being, masculinity–femininity, national income, shame,
regardless of membership in a specific culture and the frequency of crying predicted changes in
(Russell, 1991). As Russell (1991) stated, to con- mood. Extrapolating from these results, Becht and
clude anything else is to embrace findings that are Vingerhoets concluded that how individuals feel
open to a range of interpretations. after crying is a function of how common crying
is in a person’s culture and also in an individual’s
implications for the counseling feelings of shame about crying.
profession The literature reviewed earlier also suggested
Given the breadth, complexity, and inconsistency that various features of emotions differ by gender,
in the literature on emotions, it is impossible to ethnicity, and personality characteristics, and these
offer the counseling profession highly specific, con- variables may interact with the structure of the
crete recommendations concerning practice, train- culture, affecting how emotions are, for instance,
ing, and research. Rather, we can extrapolate from experienced and expressed. It is essential, therefore,

ge r st e in, ægisdót t ir 891

that counseling professionals and students under- their emotions might be noticed and displayed
stand the structure of their client’s culture, the func- through physical cues or symptoms that these
tion of emotions in that culture, and also the universal individuals and their mental health providers’ rec-
and potentially unique ways that emotions are expe- ognize. A study mentioned earlier in this chapter
rienced, expressed, regulated, and interpreted by illustrates this possibility. Butler et al. (2009) inves-
males, females, persons with different personality tigated whether expressing emotions raised or low-
characteristics, and individuals of different ethnicities ered blood pressure for 32 European Americans
in the client’s culture. and Asian Americans. Their results indicated that
To strengthen counseling professionals cultural expressing emotions was inversely related to blood
understanding of emotions, it seems beneficial for pressure for European American dyads, but posi-
graduate counseling training programs to teach stu- tively related for Asian American dyads. Therefore,
dents the different methods (e.g., observations and they concluded that cultural context might moder-
rating systems of facial expressions, self-report inven- ate this relationship. The investigators also con-
tories) of studying emotions and the host of available cluded that the expression of emotion “is culturally
tools (e.g., FACS, EMFACS) to accomplish this condoned in most European American contexts but
objective. Acquiring knowledge about the literature may be socially problematic for Asian Americans,
on display rules and the instrumentation and strate- and that this results in different physiological
gies (e.g., DRAI, Emotional Expressivity Scale, response patterns when such expression does occur”
Emotion Regulation Questionnaire) to investigate (p. 514).
these rules, for instance, could greatly enrich students’ Because the language or vocabulary of emotion
basic repertoire of counseling skills, particularly their varies worldwide, it is also critical that counseling
cross-cultural and multicultural counseling skills. professionals and students become knowledgeable
Possessing this knowledge and demonstrating the about how their client’s culture or country employs
skills linked with understanding the complexity of language to convey, understand, and interpret emo-
display rules, including how they were shaped by the tions. Professionals and students do not necessarily
client’s culture would certainly strengthen students’ need to learn their client’s language, although that
ability to accurately and effectively recognize, code, would be ideal. Instead, they need to understand
assess, conceptualize, and reflect their clients’ emo- how the client’s native language communicates
tions. Furthermore, it would enhance students’ ability emotions and how this might be different or similar
to correctly interpret excesses and deficits in emotions, to the language being used in the co