Counseling Students: Perceptions of Problematic Behaviors, Self-Care and Related Training by Amanda Marie Thomas A dissertation submitted to the Graduate Faculty of Auburn University in partial fulfillment of the requirements for the Degree of Doctor of Philosophy Auburn, Alabama August 9, 2010 Keywords: problematic behaviors, self-care, duty to warn Copyright 2010 by Amanda Marie Thomas Approved by Jamie Carney, Chair, Professor of Special Education, Rehabilitation, Counseling/School Psychology David Shannon, Professor of Educational Psychology Program Karen Rabren, Associate Professor of Special Education, Rehabilitation, & Counseling/School Psychology ii Abstract The purpose of this study was to examine student awareness and frequency of self- reported problematic behaviors, self-care practices, and related training experiences. Participants were randomly selected from regionally represented community and school counseling programs through a faculty representative. Eighty-four subjects from CACREP and Non-CACREP accredited programs completed the Awareness of Problematic Behavior survey, created by Dr. Jamie Carney. The survey focused on counseling students self-report related to issues including problematic behaviors, self-care practices, and related training experiences. Responses were analyzed and subjected to reliability assessment, correlation analysis, and descriptive review to determine significance. Although no significant differences resulted related to problematic behaviors and self-care or problematic behaviors and exposure to training programs, there was a relationship in reported self-care training and problematic training experiences suggesting that subjects who received self-care training, likely received problematic behavior training. All subjects reported practicing self-care. Qualitative responses obtained in this study offers information related to self-reported behavioral indicators. Findings from this study provide new and current information related to problematic behaviors, self-care practices, and academic training program trends. iii Acknowledgments If I am part of all that I have met, then I would like to take this opportunity to thank the people who have contributed. First and foremost, thanks to my soul-mate and soon-to-be husband, Chad who reminds me to follow God?s plan, think before I speak, and to be grateful for what I have. To my parents, Fred and Marilyn, who nourished and encouraged my potential before I ever knew it even existed. Thank you for helping me to reach for the stars! I also want to express my gratitude and deep appreciation to Dr. Jamie Carney who is my advisor, professor and most importantly my mentor. Dr. Carney has showed me how to be the kind of professional woman that I aspire to be. Thank you also to Dr. David Shannon and Dr. Karen Rabren who offered help and support in every step of this dissertation process. I could not have asked for a better or more knowledgeable team of advisors. From the bottom of my heart - thank you. iv Table of Contents Abstract ......................................................................................................................................... ii Acknowledgments........................................................................................................................ iii List of Tables ................................................................................................................................ v I. Introduction ....................................................................................................................... 1 Rationale ........................................................................................................................... 1 Significance of Study ........................................................................................................ 2 Purpose of Study ............................................................................................................... 3 Research Questions ........................................................................................................... 4 Operational Definition ...................................................................................................... 4 Summary ........................................................................................................................... 5 II. Literature Review .............................................................................................................. 6 Introduction ....................................................................................................................... 6 Problematic Behaviors in the Profession .......................................................................... 9 Problematic Behaviors in Academia ............................................................................... 15 Self-Care and Academia ................................................................................................. 22 Summary ......................................................................................................................... 26 III. Methodology .................................................................................................................. 27 Introduction ..................................................................................................................... 27 Research Questions ......................................................................................................... 27 v Participants ...................................................................................................................... 27 Instruments ...................................................................................................................... 28 Procedures ....................................................................................................................... 30 Data Analysis .................................................................................................................. 31 Summary ......................................................................................................................... 32 IV. Results............................................................................................................................. 33 Introduction .................................................................................................................... 33 Participants ..................................................................................................................... 34 Reliabilities .................................................................................................................... 36 Results ............................................................................................................................ 36 Summary ........................................................................................................................ 50 V. Discussion ...................................................................................................................... 51 Introduction .................................................................................................................... 51 Quantitative Analysis ..................................................................................................... 52 Qualitative Analysis ....................................................................................................... 53 Limitations ..................................................................................................................... 54 Recommendations for Future Research ......................................................................... 55 Implications.................................................................................................................... 56 Summary ........................................................................................................................ 60 References ................................................................................................................................. 61 Appendix A Hippocratic Oath ................................................................................................ 70 Appendix B American Counseling Association Code of Ethics ............................................ 72 vi Appendix C Published Studies on Common Factors Associated with Student Unsuitability in Social Science Programs ..................................................................................... 92 Appendix D American Personnel and Guidance Association Code of Ethics ......................... 95 Appendix E Awareness of Problematic Behavior Survey ..................................................... 101 Appendix F Information Sheet.............................................................................................. 108 Appendix G Auburn University Institutional Review Board Approval to Conduct Study Email ........................................................................................................ 110 Appendix H Lenoir-Rhyne Institutional Review Board Approval to Conduct Study Email .................................................................................................................. 112 Appendix I Recruitment Email ............................................................................................. 114 vii List of Tables Table 1 Demographic Information Overall............................................................................ 35 Table 2 Descriptive Information Self-Care Practices ............................................................ 37 Table 3 Descriptive Information Experienced Problematic Behavior ................................... 40 Table 4 Coded Behavioral Indicators Associated with Problematic Behaviors .................... 42 Table 5 Descriptive Information on Received Self-Care Training ........................................ 46 Table 6 Descriptive Information on Received Problematic Training .................................... 47 Table 7 Bivariate Correlations between Self-Care Practices, Self-Care Training, Problematic Behavior Training and Problematic Behaviors ......................................................... 48 Table 8 Regression Analysis of Predictors Self-Care, Self-Care Training and Problematic Training with Criterion Problematic Behavior .......................................................... 49 Table 9 Correlation Coefficients of Self-Care, Self-Care Training and Problematic Training ...................................................................................................................... 49 1 CHAPTER I. INTRODUCTION This study explored student self reports of problematic behaviors, self-care practices and training experiences. Analysis was conducted to assess masters-level graduate student?s ability to identify problematic behaviors within themselves. The purpose was to explore whether counselors-in-training possess the knowledge and training to demonstrate self-awareness in an effort to prevent problematic behaviors. Individual self-care is a skill necessary in preventing harm to oneself, clients, and society-at-large. Assessing graduate students? ability to demonstrate self-care and self-awareness of problematic behaviors will be helpful in program development and advocacy initiatives. Rationale The Hippocratic Oath (see Appendix A), ?above all, do no harm,? has been adopted by the counseling profession and may be found in the American Counseling Association?s (ACA) Code of Ethics (see Appendix B). In adherence to this concept of nonmaleficence, one of the five moral principles to ethical counseling practice (Kitchener, 1986), several ethical guidelines have been developed to identify and promote the avoidance of harm within the profession (ACA, 2005). This no harm concept, in many cases, is first introduced to students during graduate instruction as counselors-in-training become more acquainted with the counseling profession. Oftentimes, graduate students are advised to avoid legal infractions by becoming aware of their responsibility to attend to a client who poses a threat to one self or others as this is an ethical 2 concern whereby the practitioner is bound by a duty to warn the appropriate authorities (Gross & Robinson, 1987). This duty to avoid harm also extends personally to the counselor who is ethically obligated to monitor their own and their peers behaviors and report if needed (ACA, 2005). All professionals within the counseling community are required by ethical standards to identify and intervene when problematic behaviors arise whether these behaviors are presented by the individual themselves or a colleague. Counselors-in-training and professionals alike may struggle with their role as a gatekeeper and can be resistant to report a problematic peer because of the potential for negative repercussions. In response to this pressure, Kitchener (1986) advised educators to model appropriate behaviors so that students can observe the difficult choices associated with behaving ethically. Demonstration of ethical decision-making and related behaviors, allows students to increase their understanding of the gatekeeper role. Additionally, course content that exposes students to healthy and appropriate self-care practices may function as a preventive measure to reduce the persistence of problematic behaviors during academic enrollment. ?The need is not for more unethical behavior charges brought up for punishment, but for an awareness and a willingness to support ways to treat early signs? (Emerson & Markos, 1996, p. 110). Significance of Study Currently there is a dearth of research on self-reported problematic behaviors; however, there is some research available that considers faculty and supervisor evaluations of said behaviors. Previous research has indicated that problematic behaviors have been noted in graduate students, practitioners, supervisors and educators by colleagues and peers (Burgress, 1995; Lamb & Swerdlik, 2003; Mearns & Allen, 1991). In regard to self-perceived deficiencies, 3 student perception of problematic behaviors related to the self has not been considered. Although there is some evidence of research applicable to the study of problematic students from the perspective of educator and peers, many of these significant findings were published between five and ten years ago suggesting that this specific topic would benefit from more recent research (see Appendix C). In response to the absence of current research, this study focused on student self-reports of problematic behaviors, self-care practices, and related training experiences. This study obtained data in an effort to explore individual self-reports related to problematic behaviors. This topic is especially significant when considering program development and advocacy initiatives. As counselors-in-training are learning to become clinical practitioners, it only seems natural that students are introduced to problematic behaviors and the ethically sanctioned regulations to prevent harm. This study assessed student knowledge and current academic training practices. Upon analysis of the data, all subjects reported practicing self-care behaviors to some degree. Results indicated that there is not a significant relationship between the practice of self-care and the presence of problematic behaviors. However, there is a significant relationship between problematic behavior training as a predictor variable on self- reported problematic behaviors. The data did report a significant relationship between self-care training and problematic behavior training suggesting that students who received training on one of the topics likely received training on the other. It is believed that the outcome data obtained in this study will provide additional information regarding indicators associated with problematic behaviors, the frequency of experienced problematic behaviors, and current training practices. Purpose of Study The purpose of this study was to: (1) examine counselors-in-training self-reported experiences related to problematic behaviors; (2) consider the frequency of self-care practices 4 utilized by counselors-in-training; and (3) explore whether graduate students are receiving training related to self-care and problematic behaviors. Research Questions In an attempt to explore counseling students? awareness of problematic behaviors, self- care practices, and related training experiences, the following questions will be investigated. 1. What self-care behaviors do counselors-in-training use? 2. What is the nature of problematic behaviors that counselors-in-training identify personally? 3. What behavioral indicators do counselors-in-training identify as experiencing problematic behavior? 4. What training have counselors-in-training received on self-care? 5. What is the relationship between self-care practices, self-care training and problematic behavior training with the number of reported problematic behaviors? Operational Definitions To facilitate general comprehension, the specific terminology used within this study will be defined. These terms are consistent with generally accepted definitions within the scholarly literature available. Problematic behavior: when a practitioner is functioning at a below acceptable standard influenced by either deficient clinical skills or psychological limitations potentially causing damage to clients, students, supervisees, colleagues or society-at-large (Kress & Protivnak, 2009). 5 Self-monitoring: the realistic awareness of one?s own abilities. A higher level of competence implies that the individual makes more accurate assessments of oneself (Snyder, 1974). Self-care: ?a holistic approach toward preserving and maintaining our own wellness across domains? (ACA, 2004, http://www.counseling.org/wellness_taskforce/tf_wellness_ strategies.htm). Summary In closing, this study explored problematic behaviors using masters-level counselor-in- training student self-reports. Counseling students were prompted to disclose information regarding personal experiences of problematic behaviors, self-care practices utilized, and if they had received training on identifying problematic behaviors. Ultimately assessing graduate students? ability to demonstrate self-care and self-awareness of problematic behaviors can assist in initiatives to train and evaluate students. 6 CHAPTER II. LITERATURE REVIEW Introduction The Hippocratic Oath, ?above all, do no harm,? has been adopted by the counseling profession as a basic tenant to ethical therapeutic practice (ACA, 2005B; NBCC, 2005) and academic instruction (CACREP, 2009; ACES, 1991). This concept, in many cases, is first introduced during graduate instruction as students become more acquainted with the counseling profession. Due to prior litigation, a client who poses a threat to one self or others is an especially serious liability, as the practitioner is bound by a duty to warn the appropriate person(s) (Gross & Robinson, 1987). This duty to warn concept also extends to the counselor who is ethically obligated to report and monitor their own and peers behaviors (ACA, 2005). Researchers have transitioned from using the term impaired to problematic. The term problematic is preferred because it suggests that the individual is functioning at a below acceptable standard potentially causing damage to clients, students, supervisees, colleagues or society-at-large (Kaslow, Mitnick, & Baker, 2002; Kress & Protivnak, 2009; Rosenberg, Getzelman, Arcinue, & Oren, 2005). Previously, research employed the term impaired which seemed to imply that the individual-in-question could be remediated (Kaslow, et al., 2002; Lawson & Vernart, 2005; Rosenburg, Getzelman, Arcinue, & Oren, 2005; Sheffield, 1996; Wilkinson, 2006). Not all problematic behavior can be eliminated and there are times when a counselor is ill-advised in providing continued counseling services (Frame & Stevens-Smith, 1995, Lamb, Presser, Pfost, Baum, Jackson, & Jarvis, 1987). Thus, the use of the word impaired 7 seemed to misrepresent a sample of individuals. Not to mention, the term impaired may also suggest that the individual has a disability. According to the Americans with Disabilities Act, (ADA, 1990) individuals who are impaired should receive the necessary accommodations in order to provide competent care. Overlooking a counselor?s negative professional behavior or excusing problematic behavior as a disability could potentially lead to harm, thereby causing a serious ethical violation. Thus, the term problematic has been selected in an effort to delineate from the concept of impairment that was previously confusing. In this context, the presence of a problematic behavior proposes that the individual functions as a liability and is thereby not a suitable candidate for the counseling profession. Harm may be conceptualized as damage to the client or society-at-large. For example, a counselor-in-training who refuses to work with a specific client population because the group represents a non-preferred client demographic may choose to not offer services based on their individual, moral convictions. This action could potentially cause harm through abandonment (4.11.a), personal values (A.4.b), and appreciation of diversity (B.1.a.) (ACA, 200b). Huprich and Rudd (2004) noted that problematic behaviors in clinicians are an increasing concern as the profession continues to develop because a formalized method to evaluate negative behaviors is not readily available. One especially challenging issue regarding this topic is that the terms self- monitor or evaluate can be perceived as ambiguous because a consensually accepted definition is not yet available (Hermon & Hazler, 1999; Welfel, 2005). As researchers continue to identify and address problematic behaviors that can interfere with the counseling process, valuable information can be gleaned that could lead to the provision of improved counseling services. Furthermore, it seems that the counseling professions relationship with problematic behaviors at this time is more rehabilitative than preventative in function (Frame & Stevens-Smith, 1995; 8 Olsheski & Leech, 1996; Emerson & Markos, 1996; Young & Lambie, 2007). This suggests that action in response to a problematic behavior takes place once the damage has occurred and been disclosed to regulating bodies which seems counterproductive to the basic tenants of the counseling profession of avoiding harm. Examining these empirical findings encourages more professionally supported ethical-decision making practices, advocacy initiatives and preventative measures to assure that the Hippocratic Oath is upheld on the front end. Some problematic behaviors are more damaging than others. For example, a counselor who engages in a sexual relationship with a client is considered to have violated the ethical standards and would likely receive legal and professional consequences for their inappropriate behavior (ACA, 2005). Despite severity, some behaviors may be considered problematic but are not as damaging as the previously described sexual/dual relationship. Such examples of a less serious ethical infraction may be when a counselor discusses with a non-counseling friend information regarding a client (i.e., presenting problem, personal experiences) in the absence of a collaborative/consultative relationship (Welfel, 2005). Research conducted by Sherry, Teschendorf, Anderson and Guzman (1991) found that the majority of polled mental health professionals admitted to committing an ethical infraction either deliberately or unknowingly. Although these negative behaviors may interfere with the counseling process, a standardized method to prevent their occurrence is not available. ?It is the subtle, but nonetheless damaging impairments that puzzle us, make us wonder when to speak up, when to confront, and when to mind our own business? (Emerson & Markos, 1996, p. 109). Counselors are to self-monitor against problematic behaviors despite the degree of client harm (ACA, 2005). In this context, self-monitoring will be described using Synder?s (1974) definition and considers the awareness of one?s own knowing. The capacity to self-monitor 9 connotes a high level of competence and suggests that the individual is able to make accurate assessments of their own abilities. Thus, an individual who does not engage in self-monitoring practices exhibits a lower level of proficiency and lacks the requisite knowledge to assess their skills (Synder, 1974). In consideration of the knowledge associated with self-monitoring, it seems ideal for counselors to practice techniques associated with regulating and identifying problematic behaviors. Problematic Behaviors in the Profession First examined in the 1970s, impairment within the field of psychology was identified as difficulties exhibited by the practitioner that compromised clinical abilities causing legal and ethical intervention (Olsheski & Leech, 1996). Over the past thirty years, several professional organizations have expressed an interest in remediating impaired clinicians within the mental health field and include social workers, the American Counseling Association (ACA), the American Psychological Association (APA) and the American Medical Association (AMA) (Farber, Gilibert, Aboff, Collier, Weiner & Boyer, 1989). Consistency amongst professions as identified by Tarvydas, Leahy, and Saunders (2004) indicate that both Rehabilitation Counselors and Nationally Certified Counselors (NCC) agree that behaviors associated with professional competency warrant unethical practices. Behaviors commonly associated with professional incompetence include providing therapeutic services when not prepared, practicing while intoxicated, or not sharing the limits of confidentiality with the client. Although the discussed organizations have all worked independently to explore clinician deficiencies within the mental health field in an effort to avoid harm, there appears to be some general similarities between the recognition of professionally ethical and unethical behaviors. 10 The American Counseling Association, previously known as the American Association for Counseling and Development (AACD) and the American Personnel and Guidance Association (APGA); developed a committee concerned with providing ethical support within its first year of conception in 1952 and disseminated its first published APGA Ethical Code in 1961 (Gibson & Pope, 1993; Ponton & Duba, 2009) (see Appendix D). As evidenced in ACA?s historical origins, the counseling profession has adopted an active position in ethical advocacy and guidance. Olshenski and Leech (1996) noted that ACA (nationally) and related state credentialing programs historically had a unique relationship because they worked together to improve their knowledge and awareness of problematic behaviors in the profession. This is noted by the preparation and consensually distributed ACA Code of Ethics, (2005) which identifies specific criteria related to ethical practice including professional responsibility to self- monitor and avoid harm. ?Without a code of established ethics, a group of people with similar interests cannot be considered a professional organization? (Allen, 1986, p. 293). More specifically, the ACA Code of Ethics addresses impairment in a variety of ways. First, the professional is reminded that they are to avoid harm (A.4.a; A.8.b). This means that counselors should not intentionally or negligently make their clients vulnerable to personal, emotional or psychological damage. Also, counselors should be aware of the symptoms associated with impairment and are to regulate their own and others behaviors if it is damaging (C.2.g). Clinicians, educators, students, and researchers all serve as gatekeepers to the profession and must uphold the ethical standards (F.1,a.; F.6.a). Additionally counselors are to monitor their own effectiveness and seek intervention as needed (C.2.d.; F.7.b.; F.8.b.). During academic matriculation, counselor educators are to inform and remind counselors-in-training of the ethical standards which include continual evaluation both academically and interpersonally 11 (F.9.a.). Throughout this continual evaluation, students who are unable to exhibit counseling skill competency must be remediated as indicated in the code (F.9.b.). ACA developed this ethical code to serve as a guideline for professional behavior; however, critics report that the wording at times appears ambiguous or confusing. Thoroughly understanding these guidelines can make ethical decision-making difficult because practitioners may only be able to rely upon individual interpretation. A professional who is presenting with problematic behaviors might experience compromised judgment in regard to self-regulation as their skewed perception can lead to distorted interpretations and ethical disobedience. Before merging ethical guidelines with ACA, the Association for Counselor Education and Supervision (ACES, 1991) advised supervisors to protect the welfare of clients by providing counselors-in-training with a knowledge of ethical codes when monitoring supervisee performance (1:01; 1:06; 2.a). Additionally, supervisors were to remind counselors of the ethical and legal implications associated with the profession (2.03). When faced with a student/supervisee with deficient skills, ACES recommended that the supervisor suggest professional development activities to promote growth (3.18); however, these activities to encourage self-awareness for the counselor-in-training were not to be provided by the supervisor so that they were able to continually evaluate student progress. In this system, the role of the supervisor is one of accountability for the counselors-in-training?s decision making can be a liability to the supervisor. The national board of certified counselors (NBCC), a credentialing agency that certifies professional counselors, has also developed an ethical code that strives to promote ethical behavior within the counseling profession. In these guidelines, certified counselors are reminded that they are to monitor peer behavior in accordance with the ethical standards (NBCC, 2005, 12 A:3). Thus, if a colleague is not acting in an ethical manner, the peer is to make the appropriate arrangements to protect the client?s welfare. Section A:13 reports that counselors are to act in morally and legally appropriate manners in an effort to protect the profession. Furthermore, these guidelines stipulate that NBCC certified counselors are not to provide counseling services if they are not emotionally or mentally able to uphold a professional relationship or if they have breached an ethical infraction (NBCC, 2005, A:15). One particularly noteworthy ethical violation in the NBCC code occurs when the client?s welfare is not protected as both the counselor (B:1) and/or supervisor (C:i) can be held responsible. In summary, it appears that NBCC endorses practitioner promotion of client welfare and requests that problematic clinicians discontinue providing services ? whether that be self or peer regulated. Despite the presence of several codes of ethics for counselors, the guidelines continue to appear vague and require additional interpretation. Although these guidelines were developed to assist in decision making, it appears that interpreting the code into realistic situations does not increase practitioner confidence (Gibson & Pope, 1993). Supporting this claim, research conducted by Walden, Herlihy, and Ashton (2003) of 15 former ACA Ethics Committee chairs found that, ?respondents reported a sense of awe at the pervasiveness and complexity of ethical issues in the areas of ethical issues in counseling practice. They made frequent references to the constant blending of moral, value, and legal issues in the area of ethics? (Walden et al., 2003, p. 108). The ambiguous nature of the counseling code(s) of conduct can be quite challenging to new or inexperienced counselors-in-training who are attempting to navigate through the professional realm. Not to mention, ethical decision making may be further compromised if the counselor-in-training is unable to manage their own needs through continued self-monitoring. Complicating this matter is that ACA requires clinicians to monitor themselves against 13 impairment, however, protocol for managing a problematic counselor are not available (Sheffield, 1996). Within the field of psychology, 39% of polled practitioners reported knowing of a fellow psychologist who suffered from substance addiction and 63%, of that same sample, stated that they knew a colleague who was presently experiencing symptoms associated with burnout (Wood, Klein, Cross, Lammers, & Elliott, 1985). Of polled practicing psychologists, 90% reported experiencing emotional distress related to their occupation (Guy & Liaboe, 1986). In psychology training programs, Vacha-Haase, Davenport, and Kerewsky (2004) found that the most frequently reported occurrences of problematic behaviors in students included deficient clinical skills (65%), resistance toward supervision feedback (52%), and interpersonal aversiveness (42%). Huprich and Rudd (2004) found that problematic students in clinical psychology are more frequently reported and dismissed in doctoral programs than internship. In consideration of substance use, of 158 polled faculty 25% reported knowing of a student who had, or currently has a substance abuse addiction (Scott & Stevens, 1998). These research studies seem to suggest that problematic behaviors in the profession and classroom are prevalent and a real concern to practitioners. Although undesirable professional have been identified, interventions to reduce these occurrences are less available. In 1996, researchers projected that approximately 6,000 mental health counselors within the United States experienced impairment either mentally or emotionally (Kotler & Hazler, 1996). To further explore this phenomena within the profession, in 2003 ACA appointed a task force that focused on problematic behaviors in an effort to identify critical issues related to this ethical concern. Research participants were randomly selected ACA members (Lawson & Vernart, 2005). Survey responses indicated that 64% of participants had personal experience 14 with an impaired colleague (ACA, 2004). The study?s results indicated that there is a need for a growing awareness of impairment within the profession; thereby three general categories were developed to address problematic behaviors within the profession (Lawson & Vernart, 2005). These three categories are (1) impairment prevention and resiliency education, (2) resources, interventions, and treatment for impaired counselors and (3) advocacy (Lawson & Vernart, 2005). Research suggests that professionals are hesitant to confront a problematic peer (Scott & Stevens, 1998) due to a variety of reasons including the fear for negative repercussions, differing sensitivities amongst professionals making problematic behaviors more detectable to some, or difficulties interpreting one?s role in the ethical guidelines (Kitchener, 1986). ?Most colleagues in any profession are hesitant to report behavior that seems to be unethical or the result of impairment for fear of retribution or for the simple reason that they may be wrong? (Sheffield, 1996, p. 100). This aversion to monitoring problematic behaviors can be quite damaging to the profession as noted by 76% of polled professional counselors who reported an unwillingness to report a peer. Additionally, 83% of those studied were unaware of available, state-wide professional development activities to provide awareness of problematic behaviors (ACA, 2004). These findings seem to suggest that problematic counselor may not be able to regulate him or herself and intervene to avoid causing harm. Consequently the impaired practitioner?s colleagues may be resistant to address the problematic behavior due to fear of negative consequences. This chaotic cycle seems further aggravated by unavailable professional support and unclear, despite numerous, ethical guidelines. 15 Problematic Behaviors in Academia While counselor education faculty are not ethically permitted to perceive their students as clients, they do maintain a significant responsibility in monitoring student problematic behaviors and related gatekeeping concerns (Gaubatz & Vera, 2002; Gizara & Forrest, 2004). In the counseling profession, the appropriate governing bodies (ACA, 2005; CACREP, 2009) suggest that college and university faculty are to educate and demonstrate appropriate professional behaviors while consistently evaluating students. ?Counselor education is an academic discipline that focuses on promoting the training of competent professional counselors. Counselors and counselor educators have a philosophical commitment to promoting the growth, development, and holistic experiences of themselves, clients, and students? (Hill, 2004, p. 135). In essence, students must be well suited for the profession by being both willing and able (Owen, 1993). Students should be evaluated on both academic and interpersonal paradigms. This implies that successful academic work alone does not indicate student success within the counseling profession. In a study conducted by Gaubatz and Vera (2002) of 118 surveyed counselor education faculty members, approximately 10.4% of enrolled masters? students were ill-suited for the profession. Contrary to these findings, Forest, Elman, Gizara and Vacha-Haase (1995), found that an estimated 5% of graduate students are remediated or dismissed each year and Burgess (1995) estimated that 3?4% of counseling students within a five year period are problematic. These differences in figures suggest that although 10.4% of students are ill-suited, only 5% receive remediation or dismissal from masters-level programs implying that academia lacks formal gatekeeping procedures and allows unsuitable counseling students successful candidacy despite negative presentation. 16 There is not a general consensus of what constitutes problematic behaviors (Burgess, 1995; Huprich & Rudd, 2004; Woodyard, 1997). This lack of agreement may cause difficulties when attempting to study the significance of problematic behaviors in counseling graduate students, and also leads to confusion as when it is appropriate to confront problematic behaviors. Moreover, it is important to note that problematic behaviors exhibited by a student does not mean that the student has violated an ethical code; however, the violation of an ethical code indicates the presence of a problematic behavior. In an effort to identify specific problematic student critical indicators, a study conducted by Li, Trusty, Lampe, and Lin (2007) polled 35 CACREP accredited faculty and discussed 86 different cases of problematic peers. Through the administration of the Behavioral Indicators of Student Impairment Survey, problematic behaviors identified were lying, addiction, refusal to participate in counseling, inappropriate boundaries, acting seductively toward clients, inability to demonstrate multicultural sensitivity, psychological impairment, engagement in sexual relationships with clients, harassing peers, and interpersonal deficiencies (Li, et al., 2007). These constructs are some of the most recent contributions to the field of impairment and suggest that the profession continues to identify the presence of these destructive behaviors. Out of 10 identified behavioral indicators of problematic students, six of these were considered psychological issues by students (Hill, 2005). This suggests that the terminology associated with problematic behaviors is unclear and differs between academic and student opinion. Kaslow et al. (2002), suggested that students may exhibit personal factors that increase their vulnerability toward experiencing problematic behaviors and include: (a) experienced abuse as a child, (b) have a persistent substance addiction, (c) are diagnosed with an axis I or II disorder, (d) feel the need to present a false sense of self, (e) is a ?wounded healer? (Goldberg, 17 1986), and/or (f) experiences attachment difficulties. Additionally, Kaslow et al., identified a continuum of student behaviors ranging from model (motivated, reliable), to less than desirable (resistant to graduate school time commitments, unreliable), and finally to disruptive (verbally combative within the classroom, demonstrating deceptiveness toward other students, frequently unprepared for class activities) for use within the counseling profession. This range provides professionals more substantial indicators when attempting to determine problematic student behaviors by rating the severity. Academic institutions are encouraged to develop evaluation measures based on these behavioral markers. In consideration of the Kaslow et al., continuum of student behaviors, greater consistency throughout the profession can be promoted and attained through a standardized evaluation method. ?Counselor educators who are concerned about the fitness of a particular trainee are faced with navigating a formidable maze of student, institutional, and client rights? (Gaubatz & Vera, 2002, p. 295). Counselor educators are confronted with the reality that the demands of pursuing a graduate counseling degree can be quite stressful leading to the presence of problematic behaviors (Lamb & Swerdlik, 2003). In consideration of these issues, defining and identifying problematic behaviors when working with institutional policies and student dynamics can be complicated. It is not surprising that some students with problematic behaviors are not addressed. More specifically, there is much speculation that a portion of students who demonstrate problematic behaviors while attending graduate school may not be confronted by faculty despite the evidence of problematic behaviors. These students are termed ?gate slippers? as the gatekeeping process was not implemented in an effort to remediate the student. One cause for the lack of confronting problematic behaviors may be the difficulties associated with 18 remediating and dismissing students as it can be quite litigious causing faculty to ?heed with caution? (Cole & Lewis, 1993; McAdams III, Foster, & Ward, 2007; Lamb, et al., 1987). Problematic peers can be an especially frustrating experience for counseling students. As found by Mearns and Allen (1991), approximately 95% of 73 polled graduate students reported experience with a problematic peer. Graduate students stated a desire to uphold the ACA ethics and wished to intervene when confronted with an unethical peer (Mearns & Allen, 1991) but lack the knowledge to do so. A survey of clinical psychology students regarding impaired peers found that students reported the topic of problematic peers was not discussed during course enrollment (Oliver, Bernstein, Anderson, Blashfield & Roberts, 2004). Additionally, the number one behavioral indicator associated with problematic behaviors that students felt compelled to inform faculty was related to interpersonal issues as opposed to academic or ethical deficiencies (Oliver, et al., 2004). Students function in a different role with peers as opposed to faculty and the persistence of problematic behaviors may be more noticeable through the frequency of student interactions. Not to mention, a problematic student may mask or maintain ?impression management? in the classroom to avoid remediation services although these behaviors may not be upheld amongst the student body (Bradley & Post, 1991; Myers, Mobely, & Booth, 2003; Rosenberg, et al., 2005). Despite the presence of problematic behaviors in a peer, students are not likely to confront the individual. Rather students are more likely to avoid interactions with the problematic peer and this can potentially cause decreased motivation within the classroom impacting the non-problematic student academic and emotional functioning (Rosenberg, et al., 2005). Rosenberg et al. found in their study of counseling psychology students, that a majority reported having a negative experience with a problematic peer during course enrollment. Of 129 19 polled students in this study, only 5% reported experiencing no impact on the persistence of a problematic student within their graduate program. Furthermore, 95% of reported disturbances with a problematic peer included (a) disruption of class time, (b) difficulties applying the cohort model during supervision, (c) challenges related to individual student learning (Oliver, et al., 2005). Research indicates that non-problematic students are impacted by a problematic student in the following areas: experienced negative feelings emotionally, encountered difficulties within the classroom environment, decreased confidence in the mental-health profession, and decreased confidence in faculty (Oliver et al., 2004, Mearns & Allen, 1991). Rosenberg et al., (2005) found that students believed that they were more aware of problematic peers than faculty. Furthermore, students stated that they were unsure if faculty would be responsive if they approached them regarding a deficient fellow student (Mearns & Allen, 1991; Rosenberg, et al., 2005). The educational climate can be negatively affected if a problematic student is present within a program. Some of the most commonly reported student responses to a problematic student was gossiping about the peer or withdrawing from the student (Mearns & Allen, 1991; Rosenberg, et al., 2005). These studies represent the available literature regarding student responses to problematic peers and seem to suggest that students are unsure of appropriate gatekeeping procedures or their role within academia to prevent the practice of deficient practitioners. As previously noted, academia holds a large responsibility in preparing counselors to function in an ethical and effective manner. However, academia must also serve as a gatekeeper, in an effort to prevent problematic students from practicing as a counselor. As faculty identify and attempt to implement remediation plans, it is mandatory that the student?s confidentiality be upheld causing fellow graduate students to be unaware of faculty intervention. Since students are unaware of 20 faculty actions, it can be frustrating for both staff and student morale. Not to mention, a student may demonstrate problematic behaviors while maintaining a high academic performance, thereby seeming contradictory as the student must be remediated despite classroom success. Student motivation to enroll in counseling graduate programs includes a variety of stimuli, for example, exhibiting a willingness to help others, demonstrating a desire to become more acquainted with the human psyche, et cetera. Not all motives to join the counseling profession are well-intentioned though, one potentially disturbing cause is to enroll in a counseling program is to remedy one?s own personal problems (Lumadue & Duffey, 1999). Of studied counselors-in-training, White and Franzoni (1990) found that a large number of counseling graduate students experienced adjustment or personality difficulties at a higher rate than the average population, which may suggest that problematic students may be attracted to the mental health profession to address personal issues. The process of evaluating students begins as early as the admissions process (Koerin & Miller, 1995). At this time, students are prompted to provide letters of reference, grade point averages, and (depending of the university) may engage in formal interviews. In an effort to monitor student progress, continual evaluation seems to be the recommendation to prevent harm (Wilkerson, 2006; Witmer & Young, 1996). Levy (1983) suggested incorporating a variety of evaluative methods in course curriculum including both formative and summative measures in an effort to provide continual feedback in a variety of formats. The utilization of several types of evaluation methods allows educators to assess past performance and identify future objectives in an effort to remediate questionable student behaviors. Similar to treatment planning, evaluation measures can support professionals during documentation procedures and may assist in the development of measureable goals. Bradley and Post (1991) found that out of 113 polled 21 counseling programs only 65% reported continued student evaluation during graduate matriculation. Despite the best of intentions to introduce evaluative measures when monitoring student progress, if programs are not adhering to a continual appraisal process ? then the best measure will not be effective. If, despite intervention, the student continues to demonstrate problematic behaviors, a remediation plan can be prepared. Interventions may include: additional coursework, recommendation to participate in therapy, requests to receive additional supervision, advisement to attend professional development activities, and more significantly a suggestion to remove oneself from the program (Biaggio, Gasparikova-Krasnes & Bauer, 1983; Kutz, 1986; Olkin & Gaughen, 1991). Huprich and Rudd (2004) found that faculty who encountered a personal experience with a problematic clinical psychology student who required remediation procedures, reported that students complied to the remediation plan at a rate of 67% consistently, 26% partially, and 7% not at all. Currently, there is not a professionally accepted remediation procedure, thus formal practices are not yet available (Huprich & Rudd, 2004). One consideration recommended by Wilkerson (2006) is that the remediation process should be executed with specific thoughtfulness on time limitations, documentation, and the students? ability to successfully achieve the desired goal. Students who have successfully navigated through the admission selection process are increasingly difficult to terminate because due process and documentation procedures are not consistently upheld throughout academic institutions. This makes a formal procedure for remediation unavailable. A mistake in documenting the student?s problematic behavior can cause the student to remain in the program despite the evidence of a problem. Thus, it is extremely important for staff and students to be knowledgeable on the ethical and academic 22 guidelines related to problematic behaviors. Research suggests that student?s who receive ethics training infused within the graduate program, are less likely to commit an ethical infraction (Butler & Williams, 1985). An approach as identified by ACA and ACES, focuses on students who show interpersonal aversiveness, substance abuse/chemical dependency, mental health illnesses, and other pervasive difficulties (Lawson & Vernart, 2005; Mearns & Allen, 1991) whereby the individual is encouraged to maintain a remediation plan in an effort to unlearn the problematic issue(s); however, this is a professional recommendation and not a requirement meaning that the student corrects the behaviors not from a personal standpoint, but rather a professional one. Burgess (1995) found that remediation over termination was the preferred intervention when confronted with an impaired peer at 77%. As faculty are ethically bound to provide support services to problematic students, remediation plans appear to be a tool that can assist during this sensitive time (Enouchs & Etzbach, 2004). Students, who are personally experiencing problematic behaviors, are encouraged by the code of ethics to monitor themselves in an effort to avoid causing harm to clients (ACA, 2005). As experiencing weaknesses toward a preferred profession or deficiencies can be disheartening, the academic climate is encouraged to provide students with support (O?Connor, 2001). This willingness to provide assistance to an impaired peer does not mean that the student remains in the program despite the persistence of behaviors not suitable for the counseling profession, but rather peers and faculty are aware of the difficulties associated with being identified as a problematic peer. This willingness to provide support toward a peer can be achieved by educating students and through faculty modeling of appropriate professional behaviors (Rosenberg, et al., 2005). Self-Care and Academia 23 As the potential for negative consequences in relation to counseling and problematic behaviors has been highlighted in the professional literature, it seems very practical that self-care has garnered increasing attention (Kaslow, et al., Kress & Protivnak, 2009; Lawson & Vernart, 2005; Roach & Young, 2007; Rosenburg, et al., 2005; Sheffield, 1996; Wilkinson, 2006; Yager & Tovar-Blank, 2007). For this study, self-care will be defined, ?as a holistic approach toward preserving and maintaining our own wellness across domains? (ACA, 2004). According to the Task Force (2004), self-care activities should be maintained by counselors to achieve wellness. Self-care strategies as identified by the Task Force include; meditation, journaling, reading for pleasure, hobbies, volunteering, going to the movies, visiting with friends, laughing, going to see a counselor, crying, exercising, drinking plenty of water, sleeping enough, eating regular meals, yoga, et cetera (ACA, 2004). Task Force committee members noted that it is not of importance what specific self-care activity(s) were selected rather it is more important that the counselor has participated in appropriate self-care practices. The specific concept of wellness was first introduced by a physician named Dr. Halbert Dunn in 1961 who believed that a combination of personal accountability and understanding of the environment promoted the attainment of psychological and physical health (E-AWR, 2006). This suggests that despite physical sickness, an individual can remain well if they maintain a general satisfaction, achieved through self-care practices. This understanding has been hypothesized by the counseling profession to mean that wellness and self-care reduces ethical violations and the persistence of problematic behaviors (Kaslow, et al., Kress & Protivnak, 2009; Lawson & Vernart, 2005; Roach & Young, 2007; Rosenburg, Getzelman, et al., 1996; Wilkinson, 2006; Yager & Tovar-Blank, 2007). 24 ACA, ACES, and CACREP endorses self-care and encourages academic programs to educate students on wellness and self-care (Roach & Young, 2007). ?The continued healthiness of the profession depends on individual awareness of personal wellness? (Olsheski & Leech, 1996, p. 135). At this time, there is not a consensually standardized professional training practice for counseling programs on self-care and wellness. Bradley and Post (1991) suggested that the absence of standardization may be an accidental professional endorsement to promote problematic behaviors. Despite the self-care methods utilized, it appears that wellness (if achieved) saturates all components of one?s lifestyle (Roach & Young, 2007). Thus, the counseling profession stresses the need for counselors to be able to balance personal and professional stressors when needed. Once students begin to experience stress, they may exhibit a range of symptoms including anxiety, fatigue, and decreased motivation (Hill, 2009; Theriault & Gazzola, 2005). These feelings appear to compromise an individual?s motivation and potentially lead to problematic behaviors. It seems that masters-level students are especially vulnerable to stress and report lower levels of wellness than their doctoral counterparts (Myers, et al., 2003). These results suggest that matriculation through counseling programs may promote greater levels of wellness although the cause for this is not known (Myers, et al.). ?One of the most important skills counselors can learn in guarding against impairment is the regular practice of self monitoring and self care activities? (Lawson & Vernart, 2005, p. 6). Oftentimes, self-care and wellness training are first introduced during graduate enrollment. Suggestions to introduce and incorporate wellness and self-care training in counseling programs might include (1) initiate wellness discussions (2) link professional development practices to wellness (3) faculty modeling of appropriate behaviors (4) shatter the concept of the perfect 25 counselor (5) remind students of the holistic nature of wellness (6) promote student participation in personal counseling (7) educate using the ACA Code of Ethics standards (8) infuse self-care practices into all courses (9) creatively remind students of wellness and self-care (10) endorse positive relations with society (Yager & Tovar Blank, 2007). The theme in these ideas considers the importance of introducing and reintroducing the many opportunities to utilize resources to maintain self-care for graduate students. Interestingly, counselors reported that they do not seek counseling as a self-care resource (Kottler, 1993). Despite research that indicates individuals who sought personal counseling reported decreased feelings associated with burnout and increased personal growth, the majority of clinicians are not seeking counseling services (Linley & Joseph, 2007). Periodically, students should be evaluated during graduate study for problematic behavior and self-care practices (ACA, 2005; CACREP, 2009; Roach & Young, 2007). At this time consensually agreed methods to assess, evaluate, and promote student accountability are not available (Myers, et al., 2003). Academic faculty maintain an important responsibility when evaluating students. Based on their role, it is proposed that faculty should contribute to the adoption of wellness practices for counseling students (Hill, 2004). Austin and Rice (1990) believed that faculty who practice self-care as evidenced in the academic milieu, modeled and supported student growth toward wellness. In response to the literature on problematic behaviors and impairment, the counseling profession endorsed self-care and wellness practices (ACA, 2004). Although self-care is supported by the professional bodies, there is not yet a consensually supported evaluation or training approach to monitor wellness and self-care. Researchers suggest that academic 26 programs implement training considerations that promote self-care and utilize faculty as models of appropriate behaviors. Summary All professionals within the counseling community are required by ethical standards to identify and intervene when problematic behaviors arise whether that occurs within oneself or a colleague. Counselors-in-training, and professionals alike, struggle with their role as a gatekeeper and may be resistant to report a problematic peer because of the potential for negative repercussions. In response to the literature on problematic behaviors, the counseling profession has endorsed self-care practices to achieve wellness. Kitchener (1986) indicated that educators should model appropriate behaviors so that students can observe the difficult choices associated with acting ethically. This demonstration of ethical behaviors, allows students to increase their knowledge of problematic behaviors, gatekeeping, self-monitoring, and self-care. Additionally, course content and training that exposes students to acceptable, professional practices may serve as an intervention to reduce the presence of problematic behaviors during academic matriculation. 27 CHAPTER III. METHODOLOGY Introduction This section addresses the procedures and methodology related to this specific research as the study was developed to empirically investigate student self-perceptions related to problematic behaviors. Included within this chapter is the study?s research questions, instrument description, the process for which the data was collected and selected data analysis methods. Research Questions In an attempt to explore counseling students? perceptions of problematic behaviors, self- care and related training experiences the following questions were investigated. 1. What self-care behaviors do counselors-in-training use? 2. What is the nature of problematic behaviors that counselors-in-training identify personally? 3. What behavioral indicators do counselors-in-training identify as experiencing problematic behavior? 4. What training have counselors-in-training received on self-care? 5. What is the relationship between self-care practices, self-care training and problematic behavior training with the number of reported problematic behaviors? Participants Participants in this study were recruited from masters-level counselor training programs and included a regional representation of schools throughout the United States. Programs 28 solicited included CACREP and non-CACREP Community and/or School Counseling degree seeking candidates. Participation was restricted to students who were currently enrolled in a graduate program. Subjects were randomly selected. Participants received a survey package which included the Awareness of Problematic Behavior Survey (see appendix E) and Information Sheet (see appendix F). In accordance to research related to statistical power analysis, the projected participant pool was 75 (Cohen, 1988). Instruments The Awareness of Problematic Behavior survey was developed by Dr. Jamie Carney. At the beginning of the survey, participants were prompted to answer a series of demographic questions such as gender, degree program enrolled in, and number of credit hours completed. Participants were then asked questions related to self-care practices, recognition of problematic behaviors as evidenced within oneself, and whether the individual had received training related to identifying problematic behaviors. The Awareness of Problematic Behavior survey was first used for this study and is based on research disseminated by Li, et al. (2007) and Rosenberg, et al. (2005) who have attempted to identify behavioral indicators associated with problematic behaviors. According to Li et al., (2007) individuals who exhibit non-academic behavioral indicators of impairment may include: 1) lies 2) exhibits addictive behavior 3) refuses to consider personal counseling when recommended 4) touches clients inappropriately 5) has inappropriate boundaries 29 6) is seductive toward clients 7) displays anger toward a specific gender, race, sexual orientation, etc 8) displays psychotic symptoms 9) misrepresents his or her skill level 10) engages in sexual contact with a client 11) is doing therapy/ attending classes under the influence of drugs or alcohol 12) is sexually harassing clients/other students 13) has suicidal attempts/ideation 14) has a personality disorder 15) has deficient interpersonal skills 16) has difficulty receiving supervision 17) displays academic dishonesty. The behavioral indicators as developed by Li et al., assisted in the development of the ?have you experienced any of the following problematic behaviors,? checklist. Although in this case, students were prompted to self-report as opposed to CACREP academic unit leaders reporting whether they had observed the behavior in others as in the Li et al. study. Although Rosenthal et al. (2005) was noted as a contributor to the survey design, the specific questions designed from the research was not used for this study. Rosenthal studied the impact of problematic peers and this concept was beyond this study?s scope. The survey consisted of 12 questions. The first five questions focused on the subjects personal experiences with problematic behaviors and self-care practices. The final seven questions asked subjects about the persistence of problematic behaviors within peers. For this study, only the first five questions were used as the objective to gather information on self- 30 reported problematic behaviors. For question one, participants were prompted to check the self- care behaviors that they practiced. Questions two and three inquired whether the student had received training on self-care and assessing personal problematic behaviors. Question four was an open-ended question that asked subjects to identify behavioral indicators that they would use to determine if they were experiencing problematic behaviors. Question number five was another checklist that asked the subject if they had experienced any of the problematic behaviors listed. These constructs were obtained from the research disseminated by Li, et al. Finally, question number six asked the subject whether they had ever received remediation and if so, would they please describe their experiences. Procedures The data collected for this research study was facilitated through one researcher-designed survey on student self-reports. After approval from Auburn University?s Institutional Review Board (IRB) was received (see Appendix G), 104 Community and/or School Counseling Faculty were contacted (one from each institution) via email requesting their assistance in disseminating the research (see Appendix I). From the 104 faculty contacted, twelve faculty representatives agreed to disseminate the surveys to their graduate students. Of the twelve faculty, five faculty representatives were from the Council for Accreditation of Counseling and Related Education Programs (CACREP) and seven faculty represented Non-CACREP programs. A total of 292 surveys were sent through standard mail with an accompanying mailing envelope and information sheet. Evaluation packets consisted of the IRB letter of approval to conduct research and the Awareness of Problematic Behaviors Survey. Both items were individually attached to a self-addressed stamped envelope. 31 Potential subjects were made aware that their willingness to participate was noted through the completion of the included measure. All participants were instructed that they were to return the measure in the provided envelope, and to seal the envelope. All responses received were anonymous, as identifiable information was not collected. Data Analysis Generally, the scope of this study was to collect information on problematic behaviors, self-care and training experiences. More specifically, masters-level student?s self-report of personal experiences with problematic behaviors. This study also aimed to explore counseling students? self-care practices and training experiences in relation to problematic behaviors and self-care. Participants were also polled to provide personal behavioral indicators as associated with problematic behaviors. Collected data was analyzed using the Statistical Package for Social Services (SPSS) version 17.0 computer software. In order to address research questions 1, 2 and 4, descriptive statistics were calculated. A qualitative analysis was considered for question number 3 as it was an open-ended question which related to the behavioral indicators counselors-in-training identify if they had ever experienced any problematic behaviors. This question can provide useful information related to student self-monitoring and awareness of problematic behaviors based on the participants responses. Statements were coded for emergent themes, content analysis support and qualitative support of the quantitative analysis. Researcher bias and predisposition of the data were coded based on a key word identification with the groupings including (1) academic, (2) anger, (3) avoidant, (4) eating, (5) emotional, (6) interactions, (7) personality, (8) professional responsibility, and (9) physical which are consistent with the primary topics identified from the Li et al., research and the informational organization of this study. Finally, 32 question number 5 was addressed using bivariate correlations and multiple linear regression. For the bivariate correlation, all variables were considered to determine if a relationship existed. Furthermore, for the multiple linear regression the independent variables of ?self-care?, ?self- care training?, and ?problematic training? were used to predict the dependent variable of problematic behaviors. Summary In this chapter, an overview of the research study was provided with a focus on participant recruitment, instrument selection, assessment distribution practices, and data analysis procedures. In summary, graduate students who were currently enrolled in Counselor Education programs were encouraged to participate. The instrument utilized for this student is entitled the Awareness of Problematic Behavior Survey developed by Dr. Jamie Carney. The surveys were disseminated by a faculty representative and sampled student bodies were regionally comprised within the United States. Collected data was analyzed using various statistical methods including bivariate correlation, multiple linear regression, descriptive and qualitative analysis. 33 CHAPTER IV. RESULTS Introduction The purpose of this research study was to explore masters-level counseling graduate student?s awareness of problematic behaviors. To conduct this research, 104 regionally representative universities were contacted throughout the United States and twelve School and Community programs agreed to participate in the study. One survey was disseminated to all participating programs to collect data. The survey evaluated student reports of self-care, problematic behaviors and if program services were available. The survey was developed due to a dearth in available research on problematic students. This chapter will present the results of the data analysis collected with an emphasis on demographic considerations, self-care practices, and the presence of reported problematic behaviors. Additionally, the study?s methodology will be considered including a focus on the statistical analyses selected and data trends. Information in this section will be offered according to the research questions examined. The research questions developed for this study were: 1. What self-care behaviors do counselors-in-training use? 2. What is the nature of problematic behaviors that counselors-in-training identify personally? 3. What behavioral indicators do counselors-in-training identify as experiencing problematic behavior? 34 4. What training have counselors-in-training received on self-care? 5. What is the relationship between self-care practices, self-care training and problematic behavior training with the number of reported problematic behaviors? As these questions examined problematic behaviors, self-care practices and training experiences for counselors-in-training, the sample of participants captured represented this specific population. All participants for this study were adult students who were currently enrolled in counseling masters granting programs. Participants Demographic information collected for this study was obtained from community and school counseling masters-level students. Information related to demographics included (1) gender, (2) degree program enrolled in e.g., masters or doctoral, (3) credit hours completed in the program, and (4) specialty area. All 84 subjects who participated in this study completed the demographics questions found at the top of the survey (see Appendix E) and the demographic results are presented in Table 1. The subjects in this study consisted of 14 male students and 70 female students. All 84 participants were enrolled in master-level degree seeking programs. Twenty-one percent (21%) reported that they had completed 0?12 credit hours, 33% stated that they had completed 13?24 credit hours, 26% said that they completed 25?40 credits and 19% reported 41+ credit hours. Of the 84 subjects, 52 identified their specialty area as Community Counseling with 22 students reporting that were on the School Counseling track. 35 Table 1 Demographic Description Overall Descriptor Variable Overall N (n %) Gender Male 14 (16.7%) Female 70 (83.3%) Degree Program Masters 84 (100%) Doctoral 0 Credit Hours Completed 0?12 18 (21.4%) 13?24 28 (33.3%) 25?40 22 (26.2%) 41+ 15 (19%) Specialty Area Community 10 (11.9%) School 22 (26.2%) Accreditation CACREP 44 (52.4%) Non-CACREP 40 (47.6%) In conjunction with the demographic data, subjects were placed in groups as to whether they had national accreditation with the Council for Accreditation of Counseling & Related Educational Program (CACREP). CACREP is the nationally recognized special accrediting body for counseling programs whose curriculum is in compliance with professionally supported standards (CACREP, 2009). If the program was not accredited, they were identified as Non- CACREP. Of the 84 subjects, 44 reported attending a CACREP program. Inversely, 40 subjects reported that they attended a Non-CACREP program. These demographic constructs set the 36 basis for analysis of how the demographic factors impact student?s ability to assess and monitor problematic behaviors. Reliabilities Using Cronbach?s Alpha, an internal consistency analysis was utilized to assess reliability coefficients and determine consistency within the survey questions or how well the construct survey questions measured for intended outcomes. Reliability coefficients for the four construct questions ranged from a low -.482 to .618. For this study self-care practices resulted in a coefficient of .233, self-care training resulted in a -.482, problematic training .601 and problematic behavior at .618. Results Research Question 1 Research Question 1 focused on the procedures used to identify which self-care behaviors counselors-in-training use. Based on the participants? responses overall, 100% masters-level students utilize self-care practices. This indicates that all subjects from CACREP and Non- CACREP programs equally use self-care. Upon further consideration, specific self-care practices appeared to be utilized more frequently. Table 2 provides a closer examination of the frequency of self-care practices. Respondents reported a high frequency of spending time with friends (97.1%), discussing concerns with peers (79.8%), exercising (67.9%) and spending time with hobbies (66.7%). 37 Table 2 Descriptive Information Self-Care Practices Self Care Behaviors Engaged Overall CACREP Non-CACREP n (%) n(%) n(%) Exercise 57 (67.9%) 32 (72.7%) 25 (62.5%) Meditation 17 (20.2%) 7 (15.9%) 10 (25%) Spending time with friends 77 (91.7%) 40 (90.9%) 37 (92.5%) Seeking consultation 21 (25%) 10 (22.7%) 11 (27.5%) Discussing concerns with supervisors 24 (28.6%) 14 (31.8%) 10 (25%) Spending time with hobbies 56 (66.7%) 30 (68.2%) 26 (65%) Discussing concerns with peers 64 (76.2 %) 34 (77.3%) 30 (75%) Relaxation exercises 17 (20.2%) 10 (22.7%) 7 (17.5%) Listening to music 67 (79.8%) 37 (84.1%) 30 (75%) Seeing a counselor for personal issues 14 (16.7%) 8 (18.2%) 6 (15%) Other 13 (15.5%) 8 (18.2%) 5 (12.5%) Journaling 1 (1.19%) 1 (2.5%) Spending time with family 1 (1.19%) 1 (2.27%) Pray 1 (1.19%) 1 (2.27%) 1 (2.5%) Dog park with dogs 1 (1.19%) 1 (2.27%) Spending time with bible 1 (1.19%) 1 (2.27%) Pampering 2 (2.38%) 1 (2.27 %) Yoga 1 (1.19%) 1 (2.5%) 38 (table continues) Table 2 (continued) Self Care Behaviors Engaged Overall CACREP Non-CACREP n (%) n(%) n(%) Watching television 1 (1.19%) 1 (2.27%) Reading 1 (1.19%) 1 (2.27%) Cooking/eating healthy 1 (1.19%) 1 (2.27%) Surfing the net 1 (1.19%) 1 (2.5%) Dinner and a movie with the spouse 1 (1.19%) 1 (2.5%) M 5 5.2 4.92 SD 1.5 1.61 1.36 Research Question 2 Research Question 2 examined the nature of problematic behaviors that counselors-in- training personally experienced. Of the 84 subjects, 50 (59.5%) reported having experienced problematic behaviors on the survey?s checklist. The most commonly reported problematic behavior was emotional problems or concerns at 34 (40.5%). Table 2 further explores the frequency of reported problematic behaviors. Upon a closer look at the descriptive statistics, there appears to be some disparaging differences between CACREP and Non-CACREP programs. One interesting discrepancy between the programs was the 20% of respondents from CACREP programs who reported academic limitations, while 5% of Non-CACREP students reported this as a difficulty. Another interesting difference is the spread between CACREP respondents at 38.6% of students who 39 reported experiencing avoidant or withdrawal behaviors in comparison to 25% of Non-CACREP students. Finally, 27.3% of CACREP subjects who experienced problematic behaviors reported experience with inappropriate dual relationship, whereas Non-CACREP students reported 2.5%. A follow-up question to the problematic behavior checklist was an inquiry if the subject had ever experienced remediation and if so, what the remediation included. Of the 84 subjects, 8 (9.5%) reported receiving remediation. Of the 44 CACREP subjects, 2 (4.5%) reported receiving remediation. In these cases the participants reported ?I met with key faculty members to disclose items outside of school that was affecting my academic performance. I tried to, with the help of faculty develop a strategic plan for overcoming pressing obstacles,? and ?supervision,? as remediation received. For the 40 Non-CACREP students, 6 (15%) reported receiving remediation. Examples of remediation received included, ?Able to share issues with faculty member?, ?discuss problems with professor ? I was having reactions to classmates that concerned me (in regards to their professional behavior?, ?discussions?, ?encouraged to make personal art and see campus counselor?, ?professor noticed disengaged behavior in class; peer noticed behavior and told professors?, and ?within class?. 40 Table 3 Descriptive Information Experienced Problematic Behaviors Overall CACREP Non-CACREP n (%) n (%) n (%) Engagement in unprofessional behavior 4 (4.8%) 2 (4.5%) 2 (5%) Emotional problems or concerns 34 (40.5%) 20 (45.5%) 14 (35%) Academic limitations or deficiencies 11 (13.1%) 9 (20.5%) 2 (5%) Eating disordered behavior 16 (19%) 7 (15.9%) 9 (22.5%) Counseling skill limitations or deficiencies 7 (8.3%) 6 (13.6%) 1 (2.5%) Substance abuse 2 (2.4%) 2 (4.5%) 0 (0%) Difficulties maintaining appropriate and professional boundaries 2 (2.4%) 1 (2.3%) 1 (2.5%) Personality problems or concerns 9 (10.7%) 6 (13.6%) 3 (7.5%) Unprofessional behavior 3 (3.6%) 1 (2.3%) 2 (5%) Avoidant or withdrawal behavior 27 (32.1%) 17 (38.6%) 10 (25%) Anger or aggressive behavior 14 (16.7%) 9 (20.5%) 5 (12.5%) Problems in interactions with peers 9 (10.7%) 6 (13.6%) 3 (7.5%) Inappropriate dual relationships 1 (1.2%) 12 (27.3%) 1 (2.5%) Problems in using or responding to supervision 2 (2.4%) 1 (2.3%) 1 (2.5%) Inappropriate sexual behavior 2 (2.4%) 2 (4.5%) 0 (0%) M 1.28 1.18 1.36 SD .605 .529 6.58 41 Research Question 3 In addition to the quantitative items on the Awareness of Problematic Behavior Survey, the survey also asked the participants to offer their personal report related to behavioral indicators if they were experiencing problematic behaviors. Responses were coded based on several general themes including (1) Academic limitations, (2) Anger, (3) Avoidant, (4) Eating, (5) Emotional, (6) Interactions, (7) Personality, (8) Professional Responsibility, and (9) Physical. The academic components include performance related to academic limitations or deficiencies. The anger component, similar to the anger or aggressive behavior construct on the survey, noted behavioral indicators consistent with feeling angry. The avoidant component included those statements which were avoidant or withdrawal related. The eating component was reserved for statements that either reported decreased or increased eating habits and or weight gain/loss. The emotional component included statements linked to feeling and emotional problems/concerns. The interactions component was extended beyond friendships and included statements that mentioned any notice of change in relationships or interactions as a behavioral indicator. The personality component included statements that mentioned mood changes or more pervasive attitudinal changes. The professional responsibility component, although not included on the survey checklist, included statements where the participant reported their problematic behavior interfering with the provision of counseling services. The final component, physical, which was also not included in the survey?s checklist, included statements with physical references either to sleep, sickness, and headaches. Table 4 lists the theme coded response to question number three which asked what behavioral indicators do counselors-in-training identify who were experiencing problematic behaviors. 42 Table 4 Behavioral Indicators Coding Behavioral Indicators Participants? Responses Theme: Academic Limitations Academic limitations Academic limitations or deficiencies Decline in academic functioning Decrease in grades Difficulty keeping up with assignments Late assignments Poor attendance in class Poor school performance Theme: Anger Anger Frustration Irritable Mild anger Short tempered Snapping at loved ones Tension Unreasonable resentment Theme: Avoidant Ability to complete assignments Allowing my living space to get noticeably messy Avoidance Concentration problems Decrease in time spent on religious observance Disengaging in class Disengagement from work Distractibility Feeling procrastinating If I stop doing my ?normal? activities such as going to the gym, gardening, or cooking Lack of desire to complete activities I normally enjoy doing Lack of interest in social activities or things I typically enjoy doing Lack of social interests Losing motivation Losing interest in hobbies Not happy with daily routine No motivation to do enjoyable activities Problem focusing Time management Withdrawal 43 Table 4 (continued) Behavioral Indicators Participants? Responses Theme: Eating Changes in appetite Eating more or less Not eating correctly Overeating Unhealthy eating Weight gain Theme: Emotional Anxiety Anxious Anxious feelings Anxiety and stress become a huge factor Depression Depressed Dwelling on problems Emotional distress Emotional Excessive stress Feelings out of balance Feelings of anxiety more often than normal Feeling burnout Feeling burned out Feeling down Feeling uncomfortable Feeling uncomfortable with actions Feeling of worthlessness Feel stress General level of anxiety Helplessness Lack of motivation Lowered confidence Overwhelmed Overwhelmed with smallest tasks Sadness Stress levels Stress Stressed all the time Suicidal ideation and/or intent Uneasy feelings 44 Table 4 (continued) Behavioral Indicators Participants? Responses Theme: Interactions Behaviors negatively influencing my relationship with friends and family Discussing issues with a colleague or supervisor Feedback from friends in the program and instructors Feedback from significant other Feedback from others Friends notice change in behavior Interacting with peers Other people?s reactions toward me Talking with supervisor or advisor Wife would tell me Withdrawal from friends and family Theme: Personality Abnormal mood swings Attitude change Changes in mood Changes in demeanor Feeling out of control Mood swings Negative attitude Mood swings, crying for an extended period of time (more than 2 days) Theme: Professional Responsibility Lack of effectiveness in meeting needs of my clients Minor boundary violations Not being able to focus on my clients issues, not able to be present The amount of time spent thinking about circumstances outside of the session Theme: Physical Being tearful Body aches Cannot get out of bed Changes in body health (headache, tired, etc) Changes in physical experience Changes in sleep Changes in sleep pattern Crying easily Fatigue Feel tired Frequently crying 45 Headaches Table 4 (continued) Behavioral Indicators Participants? Responses Theme: Physical (cont?d) Illness Insomnia Lack of sleep Level of physical discomfort Loss of sleep Low energy Not being able to sleep Physical sensations Physically sick Restlessness Skin problems Sleep disturbances Sleeping hours a night When I am smoking Research Question 4 Research Question 4 explored the training counselor-in-training students received on self- care (see Table 5). Of 84 subjects, 46 (54.8%) confirmed that they had received self-care training. Of the 46 subjects, 42 (50%) stated that their training was integrated into a course, 12 (14.3%) reported receiving the training during supervision, and 2 (2.4%) of respondents marked academic advising as the vehicle for which they received training in self-care. Finally, 2 (2.4%) of subjects indicated that they had received self-care training in the form of a wellness workshop. In consideration of CACREP programs, of the 44 participants, 22 (50 %) stated that they had received self-care training. Respondents reported receiving the training at 20 (45.5%) integrated into course, 7 (15.9%) supervision, 2 (4.5%) advisement and 2 (4.5%) from a wellness workshop. For Non-CACREP programs, of the 40 participants, 24 (60%) indicated that they had received training on self-care. 22 (55%) reported the training was received through course integration, 5 (12.5%) supervision, and 4 (10%) received the training during advisement. 46 Table 5 Demographic Information Self-Care Training Self-Care Training Overall CACREP Non-CACREP n (%) n (%) n (%) Have Received 46 (54.8%) 22 (50%) 24 (60%) Integrated in Course 42 (50%) 10 (45.5%) 22 (55%) Supervision 12 (14.3%) 7 (15.9%) 5 (12.5%) Advising 6 (7.1%) 2 (4.5%) 4 (10%) Other 2 (2.4%) 2 (4.5%) 0 M 1.35 5.23 4.92 SD .566 1.612 1.457 Although not a specific question, subjects were also polled as to whether they had received training on identifying self problematic behavior (see Table 6). Out of 84 respondents, 39 (46.4%) indicated that they had indeed received training on this construct. Thirty-four (40.5%) stated they experienced the training as integrated into their course(s), 11 (13.1%) indicated they had received the training during supervision and 5 (6%) during advisement. Subjects representing CACREP programs stated 17 (38.6%) received training on self-identifying problematic behaviors. Subjects indicated that 14 (31.8%) received the training integrated into course(s), 5 (11.4%) during supervision, and 1 (2.3%) during advisement. Finally, Non- CACREP students reported 22 (55%) reported training of indentifying self problematic behaviors. 20 (50%) indicated that they had received the training within a course, 6 (15%) in supervision, and 4 (10%) in advisement. 47 Table 6 Demographic Information Problematic Training Problematic Behavior Training Overall CACREP Non-CACREP n(%) n(%) n(%) Training Received 39 (46.4%) 17 (38.6%) 22 (55%) Integrated into Course 34 (40.5%) 14 (31.8%) 20 (50%) Supervision 11 (13.1%) 5 (11.4%) 6 (15%) Advising 5 (6%) 1 (2.3%) 4 (10%) M 1.28 1.41 1.29 SD .605 .503 .624 Research Question 5 Research Question 5 investigated the relationship between self-care practices, self-care training and problematic training with the number of reported problematic behaviors. A bivariate correlation was conducted between the three independent variables; self-care practices, self-care training and problematic behavior training. A p value less than .05 was required to indicate a statistically significant relationship. Results of the bivariate correlation are presented in Table 7. Results of the bivariate indicates that out of four correlations there are three correlations that are not statistically significant. There does appear to be one statistically significant relationship with self-care training and problematic behavior training suggesting that subjects who received the one training may likely receive the other (r (82) = .754, p < .01); likewise, if the subject did not receive one of the trainings, there was a possibility that they would not receive the other. 48 Table 7 Bivariate Correlations between Self-Care Practices, Self-Care Training, Problematic Behavior Training, and Problematic Behaviors Measure Self-Care Train Score Prob Train Score Prob Score Self Care ??? .201 .273 -.136 Train Score .201 ??? .754** -.044 Prob Train Score .273 .754** ??? -.248 Prob Score -.136 -.044 -.248 ??? ** Correlation is significant at the 0.01 level (2-tailed). A multiple regression analysis was conducted to evaluate how well self-care practices, self-care training, problematic training predict problematic behavior. The predictor variables were entered into a simultaneous regression model predicting problematic behavior. The three constructs self-care, self-care training, and problematic training were the predictor variables. The results, shown in Table 8, indicate that the model was significant. The linear combination of measures was significantly related to problematic behaviors R2 = .461, F(3, 12) = 3.426, p < .01. The sample multiple correlation coefficient .68, indicating that approximately 46% of the variance of problematic behavior index in the sample can be accounted for by the linear combination of criterion measures. At the 5% significance level, the model is useful for predicting the response at p =.52. There exists enough evidence to conclude that at least one of the predictors is useful for predicting problematic behaviors, thus the model is useful. 49 Table 8 Regression Analysis of Predictors Self-Care, Self-Care Training and Problematic Training with Criterion Problematic Behavior Predictor variable Beta p Self-Care -.125 .511 Self-Care Training -.541 .406 Problematic Training -1.933 .049 Table 9 shows the indices to demonstrate the strength of the individual predictors. The bivariate correlations represented negative and positive correlations. Three indices were statistically significant (p < .05). The predictor variable problematic training was significant as it was negatively correlated with problematic behavior. This may suggest that fewer problematic behaviors were reported if the participant reported receiving problematic training. The other predictor variables were not statistically significantly. There seemed to be a positive correlation between self-care and problematic behavior. This implies that the more self-care practices identified the more problematic behaviors were equally reported. Table 9 Correlation Coefficients of Self-Care, Self-Care Training and Problematic Training Predictors Correlation Predictor/Criterion Correlation Self-Care .090 -.144 Self-Care Training -.490 -.182 Problematic Training -.628 -.465 50 Summary This section analyzed the data collected through dissemination of the Awareness of Problematic Behavior survey. Demographic information in the form of gender, credits in program, and specialty area were noted. Descriptive analysis presented information as related to self-care practices as reported by subjects, problematic behaviors experienced by participants and experiences with training programs in self-care and problematic behaviors. Some qualitative information was presented in consideration of specific behavioral indicators as recorded by subjects. Finally, a bivariate correlation and multiple regression considered the possible influence of self-care practices, self-care training, and problematic behavior training on reported problematic behaviors. 51 CHAPTER V. DISCUSSION Introduction Counselors are to ?do no harm,? as outlined in the ACA Code of Ethics (2005). Additionally noted is the mention that counselors are to monitor their effectiveness (C.2.d.) and are to be aware of their own signs of impairment (C.2.g.). As cited in ACA (2005), counselors- in-training are equally responsible in warding against signs associated with impairment (F.8.b). Typically the ACA Code of Ethics are first introduced to graduate students during their academic matriculation as infused in classroom instructions, supervision opportunities, and experiential activities (Bowman, Bowman, &DeLucia, 1990). This begs the question, are counseling students aware of problematic behaviors as related to the self? As previously noted, there is a dearth of research on self-reported problematic students; although there is some research available that considers educators and supervisors responses to the persistence of problematic students published years ago. When deliberating over self- perceived deficiencies, student perception?s of individual problematic behaviors has not yet been considered. In response to the absence of research, this study focused on student self-reports of problematic behaviors and self-monitoring techniques. In consideration of the study?s purpose, a survey research design was identified as an appropriate assessment method (Heppner, Wampold, & Kivlighan, 2008). In an effort to explore the frequency of identified variables including self- care practices and presence of problematic behaviors within the field of counseling a survey, 52 developed by Dr. Jamie Carney, was selected. The goal of this study was to explore a previously unexamined phenomena within the counseling profession as related to counselors-in-training. In the previous chapter, data collected from regionally represented counselor-in-training graduate students were presented and analyzed. This chapter will provide a more thorough discussion of the results as related to the obtained data, limitations of this specific research study and implications for the counseling profession as gleaned from the noted findings. Quantitative Analysis Upon review of the data, it appears that the most significant finding is that participants who receive training on self-care frequently also receive training on problematic behaviors. As all subjects reported self-care practices, this variable became a constant in this study and the most frequently reported activities were spending time with friends, discussing concerns with peers and exercising. Sixty percent of respondents indicated that they had experienced problematic behaviors and the most frequently reported problematic behavior was emotional concerns at 41%. Finally, there was not a statistically significant relationship between self-care practices, self-care training, and problematic training. Upon a closer examination through a multiple regression analysis of the predictor variables, the predictor variable of problematic training was negatively correlated with problematic behaviors and suggests that the respondents who received problematic training reported experiencing less problematic behaviors. The other predictor variables did not yield significant results. As training and self-care have traditionally been recommended to combat the pervasiveness of problematic behaviors, the study?s absence of significance in regard to these variables is notable. 53 Qualitative Analysis The descriptive analysis identified no differences between CACREP and Non-CACREP programs between surveyed groups. A review of the means does indicate a general agreement that both sub-groups practice self-care, experienced problematic behaviors and received training on self-care and problematic behaviors. Qualitative responses obtained from the participants were consistent with the professional research. The themes that emerged from the coding included (1) academic, (2) anger, (3) avoidant, (4) eating, (5) emotional, (6) interactions, (7) personality, (8) professional responsibility, and (9) physical. Subjects reported behavioral indicators that included a range of problematic behaviors from academic deficiencies, angry outbursts, avoidant behaviors, emotional disturbances, interruption in social interactions, personality changes, deficiencies in professional responsibility and physical limitations. These codes overlap previously disseminated research (Emerson & Markos, 1996; Huprich & Rudd, 2004; Li, et al, 2007; Koerin & Miller, 1995; Oliver, et al., 2004; Theriault & Gazzola, 2005). The respondents listed a number of behaviors consistent with problematic behaviors suggesting an understanding of problematic behaviors. Participants reported that the components presented in this question are behavioral indicators when experiencing problematic behaviors. This translates into a more global issue related to a counselor?s ability to practice self-monitoring skills and awareness of personal deficiencies. Whatever the case, counselors-in-training are aware of problematic behaviors and have identified behavioral indicators associated with this potentially damaging construct. This suggests that despite an awareness of problematic behaviors, counselors-in-training continue to remain in counseling programs. Generally, the information obtained through this question is 54 critical for the counseling profession and academia as students are self-reporting problematic behaviors. As evidence of a professionally supported definition to self-monitoring responsibilities is not available, the themes as found within this study although not ethically condemning ? are concerning. Limitations As with all studies, this study has several limitations. Information collected from this study was obtained via student self-report thereby suggesting that the data is more subjective in nature. The use of self-report measures may be influenced by social desirability, thus respondents may have inflated the correlations amongst variables (Graham, McDaniel, Douglas, & Snell, 2002). Furthermore, in consideration of the Superiority and Goal Instability Scales (Robbins, 1989), it is important to be careful when interpreting research findings when using one instrument. The survey?s design was prepared in consideration of the noted problematic behaviors in previous research (Li et al., 2007; Rosenberg et al., 2005). The Awareness of Problematic Behavior Survey was developed primarily for this study and has not previously been used to collect data thus there is insufficient information available regarding the survey?s validity. The constructs identified as problematic and self-care are by no means exhaustive and reflect factors commonly associated in popular society. This is a limitation because other factors identified as problematic and self-care have unknowingly been omitted. The sample of counseling students captured for this study represented Community Counseling and School Counseling programs. As many CACREP schools are beginning to transition toward Mental Health Counseling Programs to meet the 2009 objectives, it may have been advantageous to sample from these programs as well. Additionally, sampling from 55 counseling programs that offered degrees in Additions Counseling, Student Affairs, College Counseling, and other related programs may have made the sample size more robust. For this study, faculty representatives were contacted as the spring semester was in its final weeks thereby potentially limiting the availability of subjects. Some faculty representatives reported that they were unable to disseminate surveys as the semester had already ended or that they would not be teaching a summer counseling course load. This limited the study?s ability to increase the number of participants as well as number of faculty representatives willing to disseminate surveys. Additionally, the surveys collected data on problematic behaviors, as students were preparing for the end of the spring semester or beginning of the summer semester. These times within the semester could impact student responses as they may have experienced increased stress and workload demands based on the time of the semester or condensed summer scheduling. Recommendations for Future Research While discussing the study?s limitations, specific considerations for future research became evident. A future study of this nature should consider including additional objective methods to measure problematic behaviors and self-monitoring skills of students to reduce subjective bias. Pairing counselor-educator and/or supervisor reports with graduate student reports is one example. Also when contacting faculty representatives and disseminating surveys to graduate students a different time in the semester when subjects may not be directly impacted by final semester preparations or condensed summer schedules is recommended. Another consideration is to offer the survey to licensed counselors, counselor educators and supervisors to capture a more thorough conceptualization of problematic behaviors within the counseling 56 profession at different levels. Additionally, disseminating surveys to counselors from various counseling disciplines is recommended. Future research should also focus on a larger sample of counseling graduate students. This study included 84 counselors-in-training, 14 males and 70 females. In consideration of the large number of both CACREP and Non-CACREP counseling graduate programs within the United States, a larger sample size to explore trends may also be beneficial. Implications This is one of the first studies that examined student?s report on self-identified problematic behaviors. Previously, researchers have examined behavioral indicators associated with problematic students (Lamb, et al., 1991; Li, et al., 2007; Rosenberg, et al., 2005; Scott & Stevens, 1998) educators identification of the persistence of problematic behaviors in graduate students (Mearns & Allen, 1991), clinical programs reported frequency of impaired students (Frame & Stevens, 1995; Lumadue & Duffy, 1999; Vacha-Haase, 1995) and impaired colleagues (Olsheski & Leech, 1996; Rosenberg, et al., 2005). In consideration of the variety of noted topics, Wilkerson (2006) suggested that academia, predominately faculty, conceptualize graduate students with a therapeutic lens. This would allow professionals to work with students in a capacity whereby the student?s progress, limitations, and consent would be up for discussion; however, this approach, much like the previous literature, depends upon gatekeepers to assist in remediating the individuals? deficiencies. For this particular study, data indicated that there is a relationship between self-care training received and problematic behavior training. Furthermore, 100% of respondents reported practicing self-care and 60% consequently reported problematic behaviors. This implies that counselors-in-training possess self-awareness and suggests the possibility of personal 57 responsibility when regulating problematic behaviors. The themes associated with this study are comparable to similar implications as noted by the ACA Task Force in 2003 when they studied impaired counselors. In their study, the ACA Task Force found that counselors may be more vulnerable to impairment than the average American population and have highlighted three main objectives in an effort to reduce the persistence of problematic behaviors: (1) preventative/ educational measures, (2) providing necessary resources if a problematic behavior occurs, and (3) promoting advocacy based initiatives at the state and national levels (Lawson & Venart, 2005). According to the Task Force, clinicians could be conceptualized across a spectrum from ?well-balanced? to ?problematic? (ACA, 2004). These constructs are fluid in nature and can be experienced by counselors throughout their career, thus a discussion that considers prevention, support and advocacy seems essential. ?It would be useful for counselors to know what places them at risk for progressing along the spectrum and to better equip them with activities and strategies that promote health? (Lawson & Vernart, 2005, p. 3). The Task Force noted that preventative measures with an emphasis on self-monitoring is an important skill (ACA, 2004). In response to these findings, ACA prepared an online web resource for counselors to assess their own self-care. This website includes self-scoring instruments to determine care practices, factors associated with impairment, and other resources that may assist in self-monitoring. It is important to keep in the mind that the website has not been updated since 2005, so some previously available resources have become outdated. Nonetheless, clinicians are able to access the self-assessment measures. Research that evaluates training experiences and counselor knowledge is necessary in an effort to promote self-monitoring skills. ?Education efforts build on counselors? strengths, help counselors identify areas of vulnerability, and provide strategies to promote wellness? (Lawson 58 & Vernart, 2005, p. 2). If a problematic behavior arises, research indicates that supporting the clinician is needed (ACA, 2004; Welfel, 2005). From a pedagogy perspective, it seems valuable to introduce practitioners early in their stages of counselor development to ethical decision- making models that simulate real life occurrences and experiential learning as a support for future ethical dilemmas (Bernard & Goodyear, 2004; Choate & Granello, 2006; Cottone, 2001; Garcia, Cartwright, Winston, Borzuchowska, 2003; Rest, 1984). If counselors fit between a fluid continuum of well-balanced and problematic, educational opportunities that promote the identification and clarification of problematic behaviors is ideal. This toolbox, if you will, of a more concrete understanding of both the ACA Ethics Code (2005) and counselor expectations may assist in the decreased need for peer gatekeeping as well as increase personal responsibility. Considering this format, training should include educating counselors-in-training in becoming acquainted with professional mistakes, personal concerns related to ethical slip-ups (i.e., regret, remorse), and assessing possible rehabilitative measures (Reynolds-Welfel, 2005). A method to support supervisees is through self-monitoring techniques and appropriate professional relationships. Within the literature, supportive relationships are noted as an intervention that reduces impairment and stress (Lamb, et al., 1987). Thus, an encouraging supervisor could introduce self-reflection skills to further develop the practitioner?s own abilities including personal strengths and limitations relevant to professional counseling (Bernard & Goodyear, 2004). As most counselors perceive themselves as highly competent, the awareness of a personal ethical infraction can be quite difficult (Welfel, 2005). By introducing methods that can assist clinicians without minimizing the action would be beneficial. Welfel (2005) identified a four element model that may be relevant when a professional encounters an ethical infraction. This model includes: (1) recognition of the error, (2) experience of regret or remorse, 59 (3) evaluation of the possibilities of restitution, (4) rehabilitation to prevent recurrence. In the final stage of rehabilitation, the counselor is asked to reexamine the ethical misstep and consider available resources in an effort to prevent the infraction?s occurrence in the future. Preventative measures may include counseling, becoming aware of one?s own responses to stress, and continuing education opportunities. Most notably is the freedom for the counselor to tailor the rehabilitation to their specific needs. Theriault and Gazzola (2005) suggest that a life-long model for clinicians throughout their careers to increase practitioner coping skills as well as assist in feelings of incompetence would improve therapist self-care initiatives. Approaches like these found in within counseling literature help to increase professional awareness of problematic behaviors and encourages responsible behavior. One objective as identified by the Task Force is advocacy at the state and national levels to assist professionals in defining problematic behaviors, clarifying the ACA Code of Ethics (2005) and increasing professional confidence in managing the presence of problematic behaviors. Lawson and Vernart (2005) noted that one common misconception in the professional field of counseling is that counselors are highly self-actualized and must therefore be mentally healthy in order to provide competent care. The reality is the counselors are vulnerable to difficulties and may present with problematic behaviors. One method to decrease the persistence of problematic behaviors that lead to ethical infractions is by lessening the stigma associated with counselor impairment. A climate that promotes counselor accountability, personal care and minimization to honestly report a personal ethical misdeed is one such consideration (Welfel, 2005). Most recently related to this topic, the ACA Ethics Committee prepared an article that presented tips on self-identifying problematic behaviors and available resources for professional counselors (Thomas & Levitt, 2010). This is one step toward 60 decreasing the stigma associated with problematic behaviors in an effort to promote honest dialogue within the counseling profession and reduce harm. Summary The purpose of this research study was to explore whether counselors-in-training possess the knowledge and training to demonstrate self-awareness in an effort to prevent problematic behaviors. Of the variables studied, significant findings implied that oftentimes students who receive training in self-care, likely receive training in identifying problematic behaviors. Additionally, the predictor variable of problematic training is negatively correlated with the frequency of reported problematic behaviors. Results from this study are novel for the counseling profession as previous research has not considered individual self-reports of problematic behaviors. The presence of problematic behaviors does not imply that a counselor has committed an ethical violation, thus increased opportunities for counselors to increase their understanding of this construct is essential. 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I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone. I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan; and similarly I will not give a woman a pessary to cause an abortion.. But I will preserve the purity of my life and my arts. I will not cut for stone, even for patients in whom the disease is manifest; I will leave this operation to be performed by practitioners, specialists in this art. In every house where I come I will enter only for the good of my patients, keeping myself far from all intentional ill-doing and all seduction and especially from the pleasures of love with women or with men, be they free or slaves. All that may come to my knowledge in the exercise of my profession or in daily commerce with men, which ought not to be spread abroad, I will keep secret and will never reveal. If I keep this oath faithfully, may I enjoy my life and practice my art, respected by all men and in all times; but if I swerve from it or violate it, may the reverse be my lot. *Since its original inception, the Hippocratic Oath, has encountered several modifications including the exclusion of the previously forbidden practices of abortion, euthanasia, other surgery practices. 72 APPENDIX B AMERICAN COUNSELING ASSOCIATION CODE OF ETHICS 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 APPENDIX C PUBLISHED STUDIES ON COMMON FACTORS ASSOCIATED WITH STUDENT UNSUITABILITY IN SOCIAL SCIENCE PROGRAMS 93 94 Chart obtained from the work of Brear (2008) 95 APPENDIX D AMERICAN PERSONNEL AND GUIDANCE ASSOCIATION CODE OF ETHICS 96 97 98 99 100 101 APPENDICES E AWARENESS OF PROBLEMATIC BEHAVIOR SURVEY 102 Problematic behavior is defined as a practitioner who may be functioning below an acceptable standard. This may be influenced by either deficient clinical skills or psychological sensitivities potentially causing damage to clients, students, supervisees, colleagues or society-at-large (Kress & Protivnak, 2009). Among counselors-in-training this may include problematic behavior in the areas of academic, clinical skill development, intra/interpersonal behavior or psychological/emotional difficulties. These are behaviors that interfere in overall development, functioning and growth as a professional counselor. The following survey addresses issues related to self-care and problematic behavior. This includes examining self-care and self/peer problematic behavior. The survey should take no more than 20 minutes to complete. Demographics ______ Male _____ Female Degree Program: _____Masters _____Doctoral Credit Hours Completed in Program: _____0-12 _____13-24 _____25-40 _____41+ Specialty Area (fill in): __________________________________________________ Self-Care 1. Self-care is defined as behaviors that one engages in to maintain professional and personal well-being. What type of self-care behaviors do you engage in? Check all that apply: _____Exercise _____Meditation _____Spending time with friends _____Seeking consultation _____Discussing concerns with supervisors _____Spending time with hobbies _____Discussing concerns with peers _____Relaxation exercises _____Listening to music _____Seeing a counselor for personal issues 103 Other: ______________________________________________________________________________ ______________________________________________________________________________ 2. Have you had training in your counselor education program on self-care? _____ Yes _____ No 2a. If you answered yes what was the nature of the training? Check all that apply. _____Integrated into course(s) _____Supervision _____Academic advisement/meeting Other:________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 3. Have you had training in your counselor education program on identifying self problematic behavior? _____Yes _____No 3a. If you answered yes what was the nature of the training? Check all that apply. _____Integrated into course(s) _____Supervision _____Academic advisement/meeting Other:________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 4. What are the behavioral or personal indicators you would use to determine if you were having challenges or experiencing problematic behaviors? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 104 5. Have you experienced any of the following problematic behaviors? Check all that apply: _____Engagement in unprofessional behavior _____Emotional problems or concerns _____Academic limitations or deficiencies _____Eating disordered behavior _____Counseling skill limitations or deficiencies _____Substance abuse _____Difficulties maintaining appropriate and professional boundaries _____Personality problems or concerns _____Unprofessional behavior _____Avoidant or withdrawal behavior _____Anger or aggressive behavior _____Problems in interactions with peers _____Inappropriate dual relationships _____Problems in using or responding to supervision _____Inappropriate sexual behavior If you answered yes, did you receive any remediation within your program? _____Yes _____No If you received remediation please describe: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Peer Concerns and Issues These questions pertain to observation and or experiences of problematic behavior with peers 1. Does your program have a policy/procedure that addresses remediation and problematic behavior? _____Yes _____ No 105 2. Have you had training on identifying problematic behavior among colleagues when you are a professional counselor? _____Yes _____ No 2a. If you answered yes what was the nature of the training? Please check all that apply. _____Integrated into course(s) _____Supervision _____Academic advisement/meeting Other:________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 3. Have you observed any peer related problematic behaviors while in your program? _____Yes _____No 3a. If you answered yes, estimate what percentage of students in your program you believe have experienced problematic behavior? _____1-5% _____6-10% _____11-15% _____16% or higher 3b. If you answered yes, what types of problematic behaviors have you observed? Check all that apply: _____Difficulty in collaborating or working with others _____Problems in self-awareness _____Difficulties in interpersonal skills _____Engagement in unprofessional behavior _____Emotional problems or concerns _____Academic limitations or deficiencies _____Eating disordered behavior _____Counseling skill limitations or deficiencies _____Substance abuse 106 _____Difficulties maintaining appropriate and professional boundaries _____Personality problems or concerns _____Unprofessional behavior _____Difficulty in identifying or responding to social cues _____Avoidant or withdrawal behavior _____Anger or aggressive behavior _____Problems in interactions with peers _____Inappropriate dual relationships _____Problems in using or responding to supervision _____Inappropriate sexual behavior _____Maturity problems Other: ______________________________________________________________________________ ______________________________________________________________________________ 4. What concerns or problems have your experienced relating to peer problematic behavior? Check all that apply: _____Disruption of class _____Difficulty completing group projects _____Needed to avoid contact with the peer(s) _____Concerns about ability to self-disclose _____Challenging social interactions with peers _____Problems participating in class discussions _____Concerns that they may harm or hurt clients _____Frustration that faculty/program did not address problem _____Disruption of group cohesion in classes or group supervision _____Motivates me to address my own issues or concerns _____Frustration that the program did not screen out the peer or identify the problem _____Peer disrupts the learning process _____The problematic behavior has not had a direct effect on me Other:________________________________________________________________________ ______________________________________________________________________________ 5. Have you ever discussed a peer?s problematic behavior with: (Please check all that apply) _____ Faculty Member _____ Peers 107 _____ University Supervisor _____ Site Supervisor _____ Counselor _____ Department Head/Chair 6. To what extent are each of the following a concern(s) when considering reporting a peer?s problem? Circle the response that is most appropriate for you. Scale: 1 2 3 4 5 Not a Concern Somewhat of Concern Neutral A Concern Significant Concern Faculty are not aware of student problematic behavior 1 2 3 4 5 Faculty are not receptive to reports about peer problematic behavior 1 2 3 4 5 The environment in the program is not conducive to reporting 1 2 3 4 5 I have not been prepared to identify or report 1 2 3 4 5 There is no policy or procedure for reporting 1 2 3 4 5 I am not comfortable reporting on peers 1 2 3 4 5 I do not feel competent to decide if I need to report behavior 1 2 3 4 5 I am not confident that the problem will be addressed 1 2 3 4 5 Other: ______________________________________________________________________________ ______________________________________________________________________________ 7. Discuss your experiences with faculty intervening or addressing problematic behavior among peers in your program: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 108 APPENDICES F INFORMATION SHEET 109 110 APPENDICES G AUBURN UNIVERSITY INSITUTIONAL REVIEW BOARD APPROVAL TO CONDUCT STUDY EMAIL 111 Dear Ms. Thomas, Your revisions to your protocol entitled "The Influence of Problematic Behaviors on Counseling Students Ability to Self-Monitor" have been reviewed. The protocol has now been approved as "Exempt". We will be forwarding your approval documents to you to your Wisconsin address. If you need your stamped information letter quickly, please let us know. Please note that you may not begin your research that involves human subjects until your information letter with an IRB approval stamp applied has been returned to you. You must use copies of that document when you consent participants, and provide a copy for them to keep. Your protocol will expire on January 11, 2011. Put that date on your calendar now. About three weeks before that time you will need to submit a final report or renewal request. If you have any questions, please let us know. Best wishes for success with your research! Office of Research Compliance 307 Samford Hall Auburn University, AL 36849 (334) 844-5966 hsubjec@auburn.edu 112 APPENDIX H LENOIR-RHYNE INSTITUTIONAL REVIEW BOARD APPROVAL TO CONDUCT STUDY EMAIL 113 114 APPENDIX I RECRUITMENT EMAIL 115 Greetings Counseling Faculty, This email was developed to request assistance in accessing your graduate community and school counseling program students regarding The Influence of Problematic Behaviors on Counseling Students Ability to Self-Monitor. If interested, we are asking that you a) identify a class of either school and/or community counseling students, b) respond to this email (amt0004@auburn.edu) with an approximate number of students in your identified class c) pass out the survey to students once received via U.S. mail. If you agree to permit us access to your student body, I will then send you a large envelope that includes consent to participate and the surveys. Please expect this packet within 8-10 business days. Thank you for your assistance in this effort. Feel free to contact us with any questions or comments at carnejs@auburn.edu or amt0004@auburn.edu. Thank you for the consideration, Dr. Jamie Carney and Amanda M. Thomas