Monday, May 9, 2016

The Political Beliefs of Mental Health Counselors

On more than a few occasions, I've heard clients and prospective clients talk about avoiding counseling because they expected the counselor to impose a biased worldview.  This has been particularly notable among politically or religiously conservative clients.  Apparently, some of them have been exposed to the same stereotypes about counselors that those of us who work in the profession have been exposed to; the image of a liberal intellectual--perhaps formerly a hippie--who is vaguely spiritual but clearly opposed to organized religion, espousing a worldview of moral relativism.  

But is there any truth to these stereotypes?  If so, is there any evidence that they impact the quality or nature of the therapeutic relationship between counselor and client?

To find out, I started by looking for research published in peer-reviewed professional journals that might shed light on the political beliefs of mental health professionals.  I discovered that in previous studies the majority of social workers, clinical and counseling psychologists, school counselors, and professional counselors and counselor educators identified as politically liberal, which wasn't very surprising.

What I was surprised to discover is how little research I could find on the implications of this correlation.  How does the dominance of liberal political ideology impact the field of mental health counseling?  How does it affect interactions between counselor and client?  How does it manifest in the classrooms of counseling students?  How does it influence what and how counseling researchers explore?

I decided these might be some interesting questions to explore, so I designed the first in what may be a series of studies designed to at least partially answer these questions.  I started with exploring the question of how political ideology might influence counseling sessions.  I wanted to see if there was any connection between the political beliefs of Licensed Mental Health Counselors and their preferred counseling theories.

Basically, counseling theories are beliefs and assumptions about people and their problems, and more specifically how to help people accomplish their goals.  For readers who are not already familiar with them, let me offer a brief summary of theses approaches:

  • Cognitive-Behavioral: Teach people strategies to identify unhealthy thoughts and behaviors and replace them with healthier alternatives.
  • Experiential: Provide people with therapeutic experiences that help them to resolve emotional problems.
  • Humanistic, Existential, and Constructivist: Help people tap into their internal resources by finding meaning or purpose, identifying what they really want or need, and/or adopting strategies or stories that help them accomplish their goals.
  • Mindfulness-Based: Teach people to be aware in the present moment of their thoughts and emotions without judging them.
  • Psychodynamic: Help people develop insight into the developmental experiences and subconscious processes that contribute to their present suffering so that those patterns can be interrupted.
  • Systems: Help people to understand the role each member of a system (e.g., family or relationship) plays in the functioning of that system as a whole and interrupt processes that negatively affect the system.

To date, I have found only one study that examined the relationship between the political beliefs of mental health professionals and their preferred counseling theories, but the study was conducted with psychologists rather than counselors, the sample size was too small to carry a strong effect size, and I also didn't like that the study used a unidimensional approach to categorizing political ideology ranging from liberal to conservative.  I prefer a bi-dimensional approach that includes labels for political ideologies that mix conservative and liberal beliefs (e.g., libertarianism).  For example, on the traditional unidimensional spectrum ranging from conservative on one of the spectrum to liberal on the other, a libertarian who is economically conservative but socially liberal falsely appears moderate or centrist, when in fact he or she tends to take extreme positions depending on the whether the issue is social or economic in nature. A bidimensional approach eliminates this type of illusion.  Finally, I wanted to know more about some of the more specific political beliefs of counselors than the previous study explored.  

For my study, I surveyed 490 Licensed Mental Health Counselors in Florida, asking them how they identified their political ideology (conservative, liberal, moderate, libertarian, communist, etc.), how much they believed their political beliefs influenced their counseling theories, and which political party they last registered with.  I then asked them to rank-order the six counseling theories above from least to most preferred.  Lastly, I asked them to rate how much they agreed or disagreed with 14 political statements related to social and economic freedom on an individual level.  

I developed five hypotheses about what I would find and reported on whether or not the data collected supported those hypotheses.  I created a manuscript of my findings and submitted it to the Journal of Mental Health Counseling in hopes that it would be published.  As of this writing, I'm still awaiting a response.

Hypothesis 1: Mental health counselors are more likely to identify as liberals than as conservatives.

This hypothesis was supported by the data.  Nearly 52% of counselors described themselves as liberal, and only 20% of the sample described themselves as conservative.  Also, 54% of counselors reported that they were registered Democrats, whereas 23% were registered as Republicans.

Hypothesis #2: A majority of mental health counselors will report a perception that their political ideology influences their counseling theory.

Only about 30% of mental health counselors reported that they don't think their political ideology influences their counseling theory at all.  The remaining 70% believe that their political beliefs at least partially influence their counseling theory.

Hypotheses 3 and 4: Liberal mental health counselors will be more likely to prefer humanistic and experiential counseling theories, and conservative counselors will be more likely to prefer cognitive behavioral theory.

The first thing I learned when I explored preferred counseling theories is that cognitive behavioral theory was the most preferred counseling theory among the six options I gave counselors.  The bar graph you see below provides the average rating given by counselors in my sample on a scale of 1 to 6.  As you can see, cognitive behavioral theory was most popular, followed by humanistic/existentialist/constructivist, mindfulness-based, systemic, psychodynamic, and experiential theories in that order.

Next, I used statistical procedure called a chi square test for independence to try and determine whether or not there was any statistically significant relationship between political ideology and each counseling theory.  This test demonstrated a significant relationship with only two of the counseling theories; cognitive-behavioral and mindfulness-based.  As a rule of thumb, in the social sciences we consider a relationship between two variables to be significant if we can obtain a Pearson chi-square value of 0.05 or less, which literally means that the probability that two variables are unrelated is 5% of less.  The value I obtained for cognitive behavioral theory and political ideology was 0.00, meaning that there is approximately a 0% likelihood that the two variables are not related.  The value I obtained for mindfulness-based theory and political ideology was 0.009, meaning that the probability that the two variables are unrelated is less than 1%.

To find out exactly what that relationship was, I had to dig a little deeper and look at ratios.  I discovered that of the 232 counselors who describe themselves as liberal, 159 (68.5%) selected cognitive behavioral theory as their first or second most preferred counseling theory compared to 81 of 89 (91%) conservative counselors.  Twenty (8.6%) liberal counselors and three (3.37%) conservative counselors least preferred cognitive behavioral theory.  In other words, although cognitive behavioral theory was the most popular theory among both conservatives and liberals, conservatives preferred it much more than liberals on average.

I also discovered that 34 of the 232 (14.66%) liberal counselors most preferred mindfulness-based counseling theories, compared to 3 of the 89 (3.37%) conservative counselors.  Four of the 232 (1.72%) liberal counselors least preferred mindfulness-based counseling theories, compared to 3 of 89 (3.37%) conservative counselors.  In other words, liberal counselors tended to prefer mindfulness-based counseling theories more than conservative counselors.

When I examined the relationship between political party affiliation and cognitive behavioral theory, I found similar results.  The probability that the two were unrelated was approximately 0%.  Eighty-seven of the 102 (85.29%) counselors who reported that they were registered Republicans selected cognitive behavioral theory as their first or second preferred theory, compared to 176 of 241 (73.03%) counselors who were registered Democrats.  Six of the 102 (5.88%) Republican counselors least preferred cognitive behavioral theory, compared to 16 of the 241 (6.64%) Democrat counselors.  In other words, although both Democrats and Republicans favored cognitive behavioral theory, Republicans favored it much more than Democrats.

Surprisingly, I did not find that Democrats were any more likely to prefer mindfulness-based counseling theories than Republicans, despite that liberal counselors were more likely than conservative counselors to prefer it.

I did not find any significant relationship between any other counseling theory and political ideology nor party affiliation (i.e., humanistic/existentialist/constructivist, psychodynamic, experiential, and systemic theories).

Hypothesis #5: Mental health counselors will be more likely to support political statements reflective of high levels of individual social freedom than those reflective of high levels of individual economic freedom.

I asked counselors to rate how much they agree with 14 political statements on a scale of 1 to 5.  Seven of those statements were designed to support high levels of individual economic freedom, and the other seven were designed to support high levels of individual social freedom.  These statements are similar to items in The Political Compass and The World's Smallest Political Quiz.  Below, you'll see the average rating counselors gave each item on that scale from 1 to 5.

As I anticipated, counselors were more likely to endorse items supporting social freedom (freedom to make lifestyle choices without government interference) than economic freedom (freedom to make choices about how to spend one's income).

I used the data obtained from these 14 items to create a Nolan Chart, which is essentially a scatter plot providing a graphical representation of where each counselor stands on a bi-dimensional spectrum that separates counselors into four quadrants based on endorsement of beliefs supportive of freedom on an individual level.

(1) Communitarian Quadrant: low social freedom and low economic freedom;

(2) Liberal Quadrant: high social freedom and low economic freedom;
(3) Conservative Quadrant: low social freedom and high economic freedom;
(4) Libertarian Quadrant: high social freedom and high economic freedom.

When I grouped all of those data points into just one point on the same chart that represented the average counselor's position, I came up with the chart below, which depicts the average counselors as a moderate liberal:

Limitations and Flaws of the Study

My study has several limitations and flaws.  First, any study that relies on email responses to a survey runs the risk of sampling bias and volunteer bias.  Basically, any counselor who doesn't have access to email or who did not report his or her email address to the licensing board did not receive the invitation to participate.  What if those counselors, few as they may be, would have made a difference in my results?  Also, what if the counselors who chose not to participate in the study are substantially different from those who took the time to participate?  What if, for example, the counselors who participated are more passionate about politics (and possibly less moderate)?  

Second, this study tells us nothing about causation, it only tells us about correlation.  In other words, we don't know if conservative political ideology causes a stronger preference for cognitive behavioral counseling theories; We only know the two variables are strongly related somehow.  Personally, I suspect that both counseling theory and political ideology are subsets of a broader concept of worldview--a person's overall philosophies of life, or beliefs in how and what people and the world are or should be like.

Third, it's possible that counselors aren't very accurate in applying labels that describe their political beliefs.  What if, for example, the counseling profession tends to attract people who are less politically-informed or politically neutral, and such individuals don't know enough to accurately self-report on their political beliefs?  Personally, I strongly doubt this possibility is true, as counselors tend to be educated individuals who care a lot about society, but I can't say that I know for certain that this is the case.

Lastly, it could be argued that the 14 items I selected and the model I employed to divide counselors into four quadrants is flawed, irrelevant, or perhaps biased.  I think this is a valid perspective in the sense that by definition models are ways of conceptualizing phenomena that are often rooted in preference and are therefore at least partially subjective in nature.  Also, the Nolan Chart that I used to illustrate responses was created by the founder of the Libertarian Party, and as such could raise questions as to whether the model is biased to favor libertarians.

That being said, I certainly uncovered a great deal of evidence that many in the political science field support bidimensional models like the model I used over the traditional unidimensional model that rates political ideology on one spectrum from liberal to conservative (e.g., Feldman & Johnston, 2014; Treier & Hillygus, 2009), and my reasoning for avoiding this reductionist approach seems sound and reasonable (see paragraph 8).  Also, my experience thus far is that at first glance most people who pay a great deal of attention to politics look at the 14 items I selected and consider them to be relevant in terms of understanding an individual's political ideology, and the items were based on items in popular political surveys, suggesting face validity.  And at the very least, these 14 items tell us something about the political beliefs of counselors.

What Might These Findings Say About the Counseling Profession?

I have several theories bout why most of my hypotheses were supported by the data, and what they mean.  First, several researchers have asserted that conservatives may be more attuned to threat than liberals and may prefer order and structure as a means of countering chaos, whereas liberals may have a greater preference for openness and novelty-seeking.  

If these findings are accurate, then one might expect conservatives to be attracted to the structured, orderly, and methodical approach of cognitive behavioral therapy, in which cognitive distortions, irrational thoughts, and maladaptive behaviors can be identified, targeted, extracted, countered, and/or replaced.  Conversely, liberals may be somewhat more likely to spread their preferences out over a variety of counseling theories with less regimented approaches.  They may be attracted to the idea of acknowledging and accepting unpleasant thoughts and feelings with a nonjudgmental stance, as mindfulness-based approaches emphasize.

Also, because cognitive behavioral therapy is so well-researched and popular in counselor education programs, conservative counselors may view it as a "safe bet" of sorts, preferring it to other approaches with less empirical support.

Are there benefits to liberal bias in the counseling profession?  Do liberals tend to make better counselors somehow?  Why does the profession attract more liberals than conservatives?  These are interesting questions to explore, although they may also feel threatening to conservative counselors, counseling students, and counselor educators.  But even if there were advantages to the liberal lean in the counseling profession, there may also be several drawbacks.  

A popular team of researchers on moral reasoning recently published a position paper asserting that the field of social psychological science has progressively become less politically diverse (i.e., more politically liberal) over time, and that this lack of political diversity contributes to bias that sometimes harms the profession.   

Could the same be true for the counseling profession?  I believe that the following research questions related to political homogeneity may be useful in exploring this further: 

  1. (How might the relationship between counseling theory and political ideology manifest in the therapy room (e.g., whether or not clients tend to have better outcomes when matched with a counselor with a similar political ideology or worldview, differences in decision-making or case conceptualization by counselors with varying political ideologies); 
  2. Does the lack of political diversity in our field negatively impact research in mental health counseling (e.g., biased questionnaires or experimental research, lack of research in areas more likely to be appealing to conservative counselors and researchers, confirmation bias, etc.)? 
  3. How might this lack of political diversity impact counselor education (e.g., intentional or unintentional gate-keeping by liberal educators, fear of genuine disclosure by counseling students with a minority political belief system, biased education on topics with a strong connection to political issues)?
  4. How might political homogeneity impact the actions and positions of counseling associations?

To illustrate this fourth question, when the Affordable Care Act was passed into legislation, the American Counseling Association (ACA), the largest professional association representing counselors, released a statement to its members entitled The Affordable Care Act: What Counselors Should Know.  The flyer described several ways the legislation would benefit counselors and clients. Concurrently, several news stories, briefs, articles, and books were published with information on how the legislation could also adversely impact mental health counselors, especially those working in private practice (e.g., Hixson, 2013; Nordal, 2012; Rasmussen, 2013; Rodriguez, 2014; Varney, 2013).  Given that private practice was the second most prevalent work setting among the ACA’s membership in 2011, it is reasonable to question why the ACA did not inform its members of the potential drawbacks of the legislation and whether this intentional or unintentional omission may be related to political bias resulting from the lack of political diversity in the profession.  

Don't counselors deserve for their professional associations to give them objective and balanced information about issues that face them?  If counseling associations fail to do so, will legislators begin to view them as biased mouthpieces of political parties?  If they lose credibility, do they lose influence on important issues of professional advocacy?  These are important questions to explore in a profession that lacks political diversity.

As I mentioned earlier, I anticipate that I will be conducting a few more studies to explore some of the questions I posed above.  I'm also hoping that others will design similar studies so that we can learn more about benefits and drawbacks of political diversity in the counseling profession.  If you're interested in this line of research, stay tuned. 

Update 8/19/16

My manuscript was not selected for publication by the Journal of Mental Health Counseling, primarily because they did not think I had gone far enough in my statistical analysis.  I resubmitted the manuscript to Counseling Values, which may be a more appropriate fit in terms of content and am still awaiting a response.

In an attempt to increase the validity of my findings, I performed some additional analysis on the 14 political statements that I asked counselors to respond to. A one-way analysis of variance was conducted to evaluate the relationship between scores on the economic freedom and social freedom scales of the political beliefs questionnaire and the reported political ideology of participants. The independent variable, the reported political ideology of the participants, included six categories: communist, socialist, liberal, moderate, conservative, and libertarian. The dependent variables include the scores on the economic freedom and social freedom scales. The ANOVA was significant, F (5, 394) = 4.79, p =0.00. This result indicated that the economic freedom and social freedom scores among these six political groups were different.  In other words, counselors who report different political ideologies were likely to respond differently on the 14 items I selected.

Update 10/9/18

I partnered with Dr. Tony Tan at the University of South Florida to improve the statistical analyses of this study, and our manuscript has since been published in the American Journal of Orthopsychiatry.  We are helpful that it will be useful in furthering discussion and research in this are of inquiry.