ectives on Com
and Alternative Therapies for Children
Journal of Asia Pacific Counseling
ⓒ 2022 The Korean Couns eling Association
2022, Vol. 12, No.1, 17- 3
Doi : 10 .18401/2022.12.1.2
There is a growing popularity for complementary and alternative therapies available for families of children with
intellectual disabilities. The purpose of this phenomenological study was to examine the perspectives of counselors
towards the utilization of complementary and alternative therapies (CAT) for children with intellectual disabilities. The
methods used were focus groups, individual interviews, and critical incident responses. Results of this study revealed six
themes relating to the perspectives of counselors: confidence in CAT; increased parental involvement in CAT; CAT’s
ability to be calming and relaxing; building productive relationships; professional development; and creating a safe space
for children with intellectual disabilities. Recommendations for further research and implications for parents of childre
with intellectual disabilities, along with implications to the field of counselor education and supervision, are discussed.
eywords: complementary and alternative therapies, perspectives, intellectual disabilities, children, counselors
Families of children with disabilities have a greater interest in complementary and alternative therapies
(Searight et al., 2012). A high prevalence of complementary and alternative therapy use is seen among
children in industrialized countries (Gottschling et al., 2013). Increase in the number of researchers in nursing
and other allied health professions also reflects the acceptance of complementary and alternative therapies
(Johannessan & Garvik, 2016); however, there is limited research in the counseling field concerning the use
of complementary and alternative therapies by counselors in their clinical practice. In addition, there is
widespread use of complementary and alternative therapies in pediatrics. Specifically, parents of young
children with intellectual disabilities who are reluctant to use psychotropic drugs rely on complementary and
alternative therapies for the behavioral and emotional problems that may arise. This study will provide insight
to practicing counselors, both for those working in a clinical setting and at school, as well as for parents of
children with intellectual disabilities. The gaps in the literature are addressed by exploring counselors’
1Northern State University
2North Carolina Agricultural & Technical State University
Shalini Mathew, Millicent Atkins School of Education, Northern State University, 1200 S. Jay St. Aberdeen, SD -
18 SHALINI MATHEW, MICHAEL BROOKS
perspectives towards the use of complementary and alternative therapies for children with intellectual
The National Center for Complementary and Integrative Health (2017) defines complementary and alternative
therapies (CAT) as a group of therapies, systems of treatment, practices or products that do not fall under the
category of mainstream conventional medicine. Complementary and alternative therapies generally include
herbs and dietary supplements, play therapy, massage, acupuncture, yoga, mindfulness-meditation, naturopathy,
Ayurveda homeopathy, etc. Many families prefer CAT over conventional medicine for children and adolescents,
because they believe that these are natural and environmentally friendly methods to use. Presently, there are
several new therapeutic models of CAT being used for children and adolescents with intellectual disabilities.
Still, families who often choose CAT for their children are not always willing to disclose this information to
their providers (Faith et al., 2013). A systematic review and meta-analysis conducted on the reasons behind
this lack of disclosure revealed that a provider’s disapproval, belief that the provider would not have relevant
knowledge of CAT, lack of time during consultation, previous experiences of negative responses from
conventional providers and the client’s own beliefs that all CAT would be safe and would not interfere with
conventional treatment (Foley et al., 2019) was found. International data (Salomone et al., 2015) showed that
CAT is used for children in a wide spectrum of developmental disabilities, such as intellectual disability,
cerebral palsy, autism, learning disabilities, ADHD, and epilepsy (Italia et al., 2014).
Professional counselors depend on the foundation of counseling theories in their practice (Corey, 2013).
While counseling theories often focus on ‘talk therapy’, the use of CAT indicates the presence of new trends
in the counseling profession (Bastemur et al., 2016). Indeed, most of the therapies that come under the
umbrella of CAT have a rich and varied history. These are used in industrialized nations, such as the United
States, Canada, the United Kingdom, Australia, and Europe; additionally, many of these CAT have their
origin in developing nations, like China or India, or among the indigenous peoples of industrialized nations.
Moreover, these CAT are considered traditional medicine rather than alternative medicine (Gale, 2014).
Numerous Americans, namely, more than thirty percent of adults and approximately twelve percent of
children, use health care approaches developed outside of mainstream Western, or conventional approaches to
medicine (National Center for Health Statistics, 2015). According to DSM-5 (2013), the diagnostic criteria for
an intellectual disability includes two main areas: deficits in intellectual functioning and deficits in adaptive
functioning. Compared to other children, children diagnosed with intellectual disabilities have a greater
probability of experiencing learning and development at a slower pace. Children with intellectual disabilities
may also take a longer time to learn language, with increased difficulty with self-care skills and social skill
development. Although children with intellectual disabilities have limitations, they can achieve their maximum
potential with the help and support by trained professionals.
According to Grant and Osanloo (2014), a theoretical framework is a blueprint that serves as a guide and
foundation from which all knowledge is constructed for a proposed research study. The phenomenon in this
Counselors’ Perspectives on Complementary and Alternative Therapies for Children 19
study is CAT. CAT is studied based on the Theory of Planned Behavior (TPB), a well-validated theory, often
used as a decision-making model (Ajzen, 1991; Wilson et al., 2013; Wilson & White, 2011). A robust theory,
Theory of Planned Behavior, helps researchers predict human behavior guided by three kinds of underlying
beliefs (Ajzen, 1991): Behavioral beliefs delineate the consequences of behavior and therefore evaluations of
those consequences. In this study, the behavioral beliefs noted specifically refer to counselors’ attitudes
toward CAT. Normative beliefs refer to expected norms, and the efforts to adhere to these expectations are
termed normative beliefs. In this study, normative beliefs are the ethical considerations of CAT. Control
beliefs mention the perceived control, or the power that promotes or declines performance of the behavior.
The Theory of Planned Behavior was specifically selected for this study to understand what motivated counselors
to use or not use CAT, alongside traditional counseling methods. Our findings suggested that depending on
how favorable the attitudes to CAT are determines a counselor’s use of CAT. Additionally, knowledge of
ethical considerations helps counselors make decisions on whether CAT is appropriate for the client.
. An illustration of the Theory of Planned Behavior.
Figure 1. Theory of Planned Behavior
Using a qualitative approach, and through the lens of the Theory of Planned Behavior, interpretative
phenomenology was used for data collection and analysis of data. The study explored and gained insight on
counselors’ perspectives toward the use of CAT for children with intellectual disabilities. The research was
used to answer three questions. The first one was what are counselors’ perspectives towards complementary
and alternative therapies for children with intellectual disabilities? The second question was what are the
implications of counselors’ perspectives towards complementary and alternative therapies in this study for the
field of counselor education? And finally, the third research question was what implications do the
perspectives of counselors towards complementary and alternative therapies in this study have for the support
of children with intellectual disabilities?
20 SHALINI MATHEW, MICHAEL BROOKS
Participants included counselors who use CAT for children with intellectual disabilities. Using a
phenomenological design, data collection consisted of in-depth and multiple interviews with the participants.
In a phenomenological study, the number of participants could be anywhere between five and twenty-five,
depending on which stage data saturation is achieved (Creswell, 2017). There were ten participants in this
study; the transcripts revealed the appearance of similar codes. As a result, data saturation was reached. Data
was collected from nine licensed professional counselors (LPC’s) and one licensed clinical social worker
(who maintained a strong counselor identity). This study used network sampling, where the participants were
selected intentionally to understand the phenomenon under study. Network sampling is usually used when the
population is rare (Lavrakas, 2008). Though the population in this study is very general and easily accessible,
samples are considered to be a rare group.
Data Collection Procedures
To address the research questions, data collection was carried out using three different techniques, including
two focus groups, in-depth follow up interviews and the use of Enhanced Critical Incident Technique (ECIT)
by Butterfield and colleagues (2009). Participants were initially asked to complete a demographic survey via
Qualtrics. Before downloading the survey and entering their details, participants were asked to sign their
consent forms, which were included in the demographic survey.
A demographic survey was conducted via Qualtrics. Questions related to gender, age, state of residence,
race/ethnicity, training in CAT, highest degree, special certifications in CAT, counseling track and experience
of working with children with intellectual disabilities were asked. Although thirteen participants gave consent,
only ten completed the demographic survey.
A focus group is generally a group discussion or a dialogue on a subject of interest (Gill et al., 2008).
In this research study, the subject of interest was the use of CAT for children with intellectual disabilities.
There were two virtual focus group discussions conducted through Zoom. Zoom has the power to guard all
audio, video and screen sharing data using end-to-end encryption. Encryption is enabled using a unique
Advanced Encryption Standard (AES) with a 2-bit key generated and securely distributed to all or any
participants at the beginning of every session, thus ensuring confidentiality.
For follow up interviews open ended questions were asked, and responses were recorded. Collected data
were then transcribed and made ready for analysis. Interviews were one-on-one to ensure maximum
confidentiality, which gave more autonomy to participants to process their feelings. Each follow up interview
Counselors’ Perspectives on Complementary and Alternative Therapies for Children 21
lasted between 35- 40 minutes. An interview protocol was used to carry out the follow-up interview. The
interview had two parts; the first part examined general perspectives and the second part was specifically
focused on critical incidents using Enhanced Critical Incident Technique.
Enhanced Critical Incident Technique
Critical Incident Technique (CIT) by Flanagan (1954) is a well-established qualitative research tool used in
many areas of the health sciences. As its name suggests, the Enhanced Critical Incident Technique (ECIT) is
an enhanced version of CIT. The ECIT consists of a flexible set of principles which can be modified and
adapted to meet a specific situation at hand. ECIT focuses on critical events, incidents or factors that help
promote the understanding of an experience or perspective on a deeper level (Butterfield et al., 2009). ECIT
was chosen for this study because of its ability to capture counselors’ perspectives on a more profound level.
ECIT can be employed in both the data collection and analysis stages. In this study, ECIT was used for data
collection. ECIT provides a framework for data interpretation by determining the frame of reference, forming
the categories, and determining the level of specificity in data reporting (Butterfield et al., 2005). The
researcher infused ECIT into the personal interviews and identified the critical incident component. In
addition, the researcher tracked the emergence of new categories by member checking using the table of
Helpful Critical Incidents (HE), Hindering Critical Incidents (HI) and Wish List Items (WL), as suggested by
Butterfield et al., (2009).
Credibility, Trustworthiness, and Validation
Qualitative research is typically non-replicated and cannot be generalized because the findings are specific
to the chosen group (Leung, 2015). To ensure trustworthiness, the researcher minimizes threats to credibility,
transferability, dependability, and confirmability by triangulating the data sources and data analysis methods
(Forero et al., 2018). In this study, the researcher used four different methods to ensure credibility,
trustworthiness, and validation. These included triangulation, bracketing, member checking and peer review.
Triangulation was achieved using data source triangulation and data analysis triangulation. Different methods
were used for data collection and a multi-step coding process was used to analyze the data. Data collection
included three different methods: focus group discussions; individual follow-up interviews, and enhanced
critical incident techniques. During data analysis three different coding methods were selected for the initial
cycle, and one was chosen for the second cycle. Synthesized results of enhanced critical incident technique were
used for member checking. The peer review was performed by a counselor educator and a counselor who
uses CAT along with counseling. Additionally, a researcher’s diary kept track of all activities related to research,
all the while keeping check on personal biases, which in turn helped with bracketing (Mathew, 2019).
Statistical Procedures Used and Data Analysis
The data for this study included the focus group (n = 10), follow-up individual interviews (n = 10), the
critical incident technique (n = 10), and member-checking feedback for the critical incident questionnaire (n
= 9). Focus group and interview data was transcribed by the researcher to ensure confidentiality and in-depth
22 SHALINI MATHEW, MICHAEL BROOKS
understanding of the data.
Thematic Analysis is a “method for identifying, analyzing and reporting patterns within data” (Braun &
Clarke, 2006, p.79). Thematic Analysis is a very flexible method because it might be used with any theory
that the researcher chooses to examine. Thematic Analysis was chosen for this study due to its flexibility to
adapt to Interpretative Phenomenological Data (Braun& Clarke, 2006). Interpretative Phenomenology was the
methodology chosen for this research, whereas Thematic Analysis was the method of choice for data analysis.
Thematic analysis was primarily used as a way to identify recurring themes in counselors’ perspectives
towards the use of CAT for children with intellectual disabilities. Secondly, Thematic Analysis was used as
a way to make sense of (i.e., interpret) those experiences. As Interpretative Phenomenological Analysis (IPA)
is a qualitative approach which aims to provide detailed examinations of personal lived experience, using
Thematic Analysis helped add more meaning to these experiences through its detailed six-step process.
The six-step process of Thematic Analysis, which includes familiarizing data, generating initial codes,
searching for themes, reviewing, defining and naming themes, and presentation of emerging themes and
subthemes, was used. During the step of searching for themes, a concept map was used. A concept map is
a schematic device, which is employed to collapse qualitative data in order to highlight categories (Daley,
2004). A snapshot of the concept map is shown below.
Note. Concept map with different categories identified.
Figure 2. Concept Map
Counselors’ Perspectives on Complementary and Alternative Therapies for Children 23
In the final step of thematic analysis, the six major themes followed by their sub themes are presented.
The six themes are: Theme 1: Confidence in CAT, Theme 2: Increased parental involvement in CAT, Theme
3: CAT is calming and relaxing, Theme 4: Building productive relationships, Theme 5: Professional
development, and Theme 6: Creating a safe space for children with intellectual disabilities.
. Thematic map with the different themes and subthemes identified
Figure 3. Thematic Map
Participants in this study offered valuable insights into the perspectives of counselors towards the use of
CAT for children with intellectual disabilities. Among all participants within the study, the common shared
value was their responsible behavior towards their clients. There have been times of uncertainty but unless
they exhibited a strong faith in the use of CAT, counselors did not use it for their clients. Participants
showed a strong commitment to the counseling profession, as well as to their clients. Value for relationships
was another important factor seen consistently throughout. Counselors took it as their responsibility to build
strong therapeutic relationships to ensure the best experience for their clients. The parent engagement aspect
offered another means of striking evidence of how families were included in the treatment of children with
intellectual disabilities. Participants suggested that CAT provided more opportunities for involving, engaging,
and educating parents. Participants also shared their views on the importance of training and professional
development. That is, lack of opportunities for training made them uncomfortable and handicapped when they
wanted to use CAT for children with intellectual disabilities. Participants also made valuable
24 SHALINI MATHEW, MICHAEL BROOKS
recommendations to the field of counselor education for providing training opportunities in CAT at the
graduate level, so that recent graduates enter the counseling field with more options for professional practice.
This research adds emphasis to the importance of child-friendly therapies in the literature. In general, CAT
can be used alongside conventional therapies for children with intellectual disabilities in specific cases and
with all children, if needed.
Theme 1-Confidence in CAT
Most of the time children’s problems are exacerbated by their inability to verbally communicate their
presenting symptoms. CAT provides a better platform for counselors to communicate with children. When
counselors are more open and willing to use CAT, non-verbal interactions become easier. Participant # 1 very
passionately stated that, “I truly do believe in alternative therapies for children and adults.” She continued by
saying that she wasn’t quite sure how children would react to CAT, but to her surprise she was really
impressed by their interest in CAT. Participant # 3 supported this by stating that, all these alternative
therapies are extremely useful not only just for kids with disabilities but also for all children. Participant #
6 expressed a similar opinion, commenting that “CAT is different, and it feels more real, as it brings out
more emotion and peacefulness.” In general, all the participants had confidence the use of CAT, not only for
children with intellectual disabilities, but for all children.
Counselors’ confidence in CAT can be helpful for parents and caregivers of children alike with intellectual
disabilities. Counselors who have confidence in CAT provide encouragement and support to clients. This
encouragement motivates clients to discuss their experiences using CAT. One of the advantages of having
confidence in CAT among counselors is to strengthen the therapeutic relationship, thereby offering a better
treatment approach for the client. This theme had three sub themes which were identified as supporting pillars
to increase confidence in counselors who used CAT. Subthemes were as follows, motivated to incorporate
CAT with counseling, seeing CAT as an effective strategy, and perceiving CAT as a safe therapy for
Theme 2-Increased Parental Involvement in CAT
Children with intellectual disabilities tend to be more comfortable in the presence of their parents; in turn,
parents can act as a catalyst for their children to reach treatment goals (Mohsin et al., 2011). From the
response of the participants in this study, it is evident that parental involvement is easier to incorporate in
CAT, when compared to talk therapy. This theme had two subthemes; the first subtheme is the way in which
CAT can engage and educate families, and the second subtheme is the view of parents acting as catalysts.
Parents and teachers are often the firsthand resources of information about a child with a disability. They can
provide different information about the developmental and educational characteristics of their children
(Mohsin et al., 2011). Therefore, it is beneficial for parents to be involved at different stages of the treatment
process. Since intellectual disabilities are invisible, well-informed parents are more able to identify early signs
of disability, as well as detect the slightest improvement in their children. Participants highlighted the
Counselors’ Perspectives on Complementary and Alternative Therapies for Children 25
importance of educating parents and integrating them in treatment. Parents need to be involved to make a
change, which may also result in a lasting effect. Parents often help in the treatment process by acting as a
catalyst. They help maintain a hopeful, positive attitude about the treatment process and its possible outcomes.
It is very important for parents to have confidence in the treatment and to trust the therapist. Having parents
attend sessions provides counselors with more flexibility within which to engage and educate parents while
using CAT. Participants expressed their feelings on how it helped when parents acted as catalysts in CAT
and how parental involvement is always viewed as a strength in the treatment process.
Theme 3-CAT is Calming and Relaxing
Although it could not be empirically proven, the participants of this study suggested that CAT is calming
and relaxing for children. Participant # 3 said that children beg her to do meditation and mindfulness,
“meditation and mindfulness can calm them and help them regulate themselves. And so, children begged for
it. Although I don’t have quantitative data to prove, I can see their behavior in class improves.” This theme
had three subthemes: CAT helps children to slow down, CAT is child-friendly, and CAT helps children to
focus better. All ten participants shared the opinion of the calming and relaxing nature of CAT in children.
They explained how CAT transforms the natural setting of the child by helping the children to calm down.
As counseling children is often not an easy task, it may take a great deal of a counselor’s effort, especially
when working with children with intellectual disabilities. Counselors use different kinds of techniques and
activities to assess and treat children with intellectual disabilities. Counselors also try to make the sessions as
child-friendly as possible. To make the counseling sessions child-friendly, some counselors engage parents
and/or families, some focus on creating a playful atmosphere, while others integrate CAT into their
counseling sessions. Participants in this study also suggested that since CAT is child-friendly, this
characteristic is one of the reasons they use CAT when working with children. Children with intellectual
disabilities need special assistance to focus better. Using CAT can help foster increased focus, which
precisely is one of the advantages of CAT; that is, whether it may be yoga, meditation or mindfulness, once
children are actually taught how, they are able to do it by themselves.
Theme 4-Building Productive Relationships
When working with children, it is crucial to build a positive relationship early on in treatment and to
maintain a strong relationship throughout the course of treatment. However, this is not an easy task. To build
productive relationships, participants have tried different strategies; they concluded that CAT is an effective
medium to use to build productive relationships. This theme had three sub themes, namely, that CAT is
interactive, CAT is creative, and CAT is a strength when connecting with children. Since most of the CAT
is non-verbal in nature, they are interactive in their own distinctive way. Some of the participants expressed
their opinion in regards to the non-verbal interactive nature, by connecting it to the language of children.
Using CAT helps children have a better communication system, which in turn can assist counselors have a
better understanding of how their mind works.
26 SHALINI MATHEW, MICHAEL BROOKS
Every child comes in with a different language and as a counselor, one works at attempting to crack the
code and help them. Again, CAT is very interactive and not threatening at all. CAT is perceived as a
creative technique by the participants. As such, they spoke about their responsibility to be creative and
consequently, to instill creativity in children. It is crucial to be creative, in order to find ways to give
children what they need. Participants shared that CAT helps children be more creative and expressive.
Theme 5-Professional Development
Ongoing professional development is vital in every career. Many counselors who participated in this
research were of the opinion that using CAT along with counseling helped them acquire additional
opportunities of professional development. For example, they were motivated to learn new techniques to
enhance their practice in different ways. This theme has three sub themes, which included having different
therapeutic options, more room for continuing education and equipping the counselor’s toolbox. One of the
interesting aspects of using CAT along with counseling is having different therapeutic options. Participants
shared that using CAT allowed them to choose from different options. More specifically, they believe that
having various options at their disposal helps them meet the child where they are. Continuing education is
a part and parcel of professional development. In terms of CAT, all participants asserted that they would
appreciate more opportunities for training and development. The participants of this study believed that
knowing CAT enriches their existing knowledge by equipping their toolbox with a variety of techniques from
which to choose.
Theme 6-Creating a Safe Space for Children with Intellectual Disabilities
This theme has three subthemes, understanding children with intellectual disabilities, acknowledging that
these children are mostly non-verbal and a feeling of protection. First and foremost in the treatment plan is
for a counselor to understand the child in treatment and his or her disabling conditions. This will give the
counselor an insight into the child’s strengths and weaknesses and work from there. For instance, some
children find it difficult to follow instructions. In addition, most of the time, children need more time to
process, which includes comprehending, and getting insight about what counselors are saying. In CAT,
instructions are normally given at the beginning of a session and while most of it is non-verbal, it easily
works with children.
Participants were very sensitive to the special challenges of children with intellectual disabilities. This
shows a genuine interest in trying to understand each child in the best possible way. As demonstrated in
several previous themes, CAT helps build productive and meaningful therapeutic relationships. Trust becomes
an important factor in these relationships and in turn offers a sense of security to the client. Participants in
the study view this as a feeling of protection.
Counselors’ Perspectives on Complementary and Alternative Therapies for Children 27
Interpretation of Findings and Discussion
Results and findings from the data generated on counselors’ perspectives on the use of CAT for children
with intellectual disabilities opens new directions in counseling children. The present results indicate that
integrating CAT with counseling for children with intellectual disabilities offers multiple benefits. Several of
the specific CAT forms commonly used by the participants included yoga, mindfulness, play therapy,
theraplay and hypnotism. The theme that supports the calming and relaxing nature of CAT along with its sub
themes underscores the soothing nature of CAT. Yoga has always been a calming influence for children with
intellectual difficulties (Cooper, 2010). Participants shared similar views about several of the CAT forms,
especially since yoga and mindfulness help children slow down and focus better. Breathing and stretching
exercises also help students rely on an internal locus of control and to function at a higher cognitive level,
thus facilitating increased blood flow to the brain (Bellhouse, 2010). Results of the present study supports the
study of Bellhouse (2010), which suggested that yoga also has the potential to calm children with intellectual
disabilities when they get overwhelmed from the stress of learning challenges and trying to cope. Although
yoga is beneficial, the American Counseling Association’s (ACA) ethics’ updates by Natwick (2018)
mandates counselors to be “cognizant of their scope of practice regulations, their level of competency, the
risks and benefits to client welfare, appropriate informed consent and proper management of boundary
extensions,” while incorporating CAT into traditional counseling (p. 12).
Children with intellectual disabilities tend to experience spelling tests and arithmetic lessons as
pressuresome; as a result, mindfulness has been found to be an effective tool in helping them to be calm and
happier, allowing them to deal with their stress effectively (McMahon, 2014). Results of the present study
supports previous literature by recommending CAT for an increased focus, creativity, and calmness in
children with intellectual disabilities.
Parental involvement is a key factor in counseling, as parents are the first counselors and advocates for
their children. Parents are equal partners with providers in the support programs for children with intellectual
disabilities, which makes education and engagement an inevitable part of parental involvement (Machalicek et
al., 2015). Studies reveal that parents play an important role in the lives of children with disabilities (John
et al., 2017); therefore, strategies that increase parental involvement in counseling will be an added advantage
in extending support services for children with intellectual disabilities. Studies also indicated a gradual shift
in parents increasingly selecting CAT over mainstream treatment options for their children with intellectual
disabilities (John et al., 2017). The theme which discusses increased parental involvement, along with the sub
themes, adds to the existing literature by showing that integrating CAT with counseling is one of the ways
to increase parental involvement in the support services for children with intellectual disabilities.
CAT integration in different health care professions have been studied previously. A study on predicting
psychologists’ intentions to integrate CAT using the theory of planned behavior revealed that psychologists
found CAT offered an advantage when used in combination with psychotherapeutic measures (Wilson et al.,
2013). Similarly, a study on nurses’ beliefs and experiences regarding CAT also revealed an increased interest
in nurses to incorporate CAT into their practice (Smith & Wu, 2012). The theme that suggests the confidence
in CAT is consistent with previous literature that highlights the advantages of CAT integration in counseling
28 SHALINI MATHEW, MICHAEL BROOKS
and a counselor’s confidence in the efficiency of using CAT for children with intellectual disabilities.
Often, there is a poor conceptualization of young children’s issues (Cleary& Scott, 2011). Hence it
becomes important that “counselors working with children adapt their counseling skills to fit the child client”
(Velsor, 2004, p.7). Relationship building is an essential step in the initial stage of counseling. Most of the
time the focus of this relationship is building trust between the therapist and the client (Young, 2013). One
of the emergent themes in the present study supports the importance of therapeutic relationships and
relationship building. Participants stressed the social and interactive nature of CAT and suggested further that
it could be a strength in building relationships with children when integrated with counseling.
While looking at the contributions of the findings to the field of counseling and counselor education,
participants suggested that CAT opens more space for professional development. Continuing education is very
crucial in all professional fields, which is noteworthy in counseling because it enhances the skills and
effectiveness of practicing counselors (Foster, 2012). As the profession of counseling is in the process of
continuous growth and evolution, counseling professionals are also obliged to keep up with professional
growth and development (Foster, 2012). Through the theme of professional development, participants have
specifically identified CAT as a means for professional development by offering different therapeutic options,
thus allowing more room for continuing education and equipping the counselor’s toolbox.
This research provides multiple options in the treatment and training for children with intellectual
disabilities. Counselors need to establish a safe and comfortable environment during counseling that works
better with young children (Erdman& Lampe, 1996). Previous literature provides evidence that CAT creates
a sense of safety for clients (Vincent, 1996; Dunlop & Tsantefski, 2018). Results of this study is in
accordance with previous literature by providing participants a voice towards ensuring the safe environment
provided by CAT when used with counseling for children with intellectual disabilities. This is evident through
the theme that discusses CAT’s ability to provide a safe space for children with intellectual disabilities.
Safety is crucial for children in counseling, as it gives children the freedom to interact in a protected
space. The participants of this study shared the common viewpoint that safety could be established by
integrating CAT with counseling.
This study examined an innovative aspect of counseling, namely, integrating CAT with traditional methods
of counseling for children. This study could be beneficial for practicing counselors who work with children
with intellectual disabilities, their parents, counselor educators, and clinical supervisors. Implications of this
study related to parental awareness, counselor education, clinical practice, and clinical supervision within the
counseling profession, is addressed in the following section.
Counselors’ Perspectives on Complementary and Alternative Therapies for Children 29
Implications for Parents of Children with Intellectual Disabilities in Relation to the Counseling
According to the National Institutes of Health, the National Center for Complementary and Integrative
Health (NCCIH) healthcare professionals began integrating CAT into their treatment approaches and clinical
practice since early to mid-19th century (Ventola, 2010). Although mental health professionals have started
thinking about integrating CAT into counseling, there is a great deal more to be accomplished in terms of
clinical training (Berger, 2011). Counselors are always engaged in ongoing efforts to better meet the clinical
needs of their clients. This research has shown the importance and effectiveness of integrating CAT into
counseling for children with intellectual disabilities. Participants of this research have a positive attitude
towards CAT for children and expressed their views on how CAT is more child-friendly and acceptable
among children and families. Results of this research need to be strengthened by increasing research on CAT
in counseling. Additionally, every practicing counselor is obligated to have a working knowledge of CAT and
its different modalities, uses, strengths, limitations, and contraindications. The ethical dilemmas and challenges
which counselors may face when working with CAT include those related to safety, scope of practice and
cultural diversity. Consequently, counselors need to address these ethical challenges, in addition to
determining when the use of CAT may be appropriate for clients, either through integration of CAT into
ongoing counseling or through referrals to appropriately trained CAT practitioners. Counseling works on a
wellness model (Berger, 2011); this factor could be further explored to include more CAT research in
counseling. As there is an increased interest in CAT among all ages of people (NHIS 2012 & 2017), this
research could be expanded to adolescent and youth counseling.
Implications for Counselor Education and Supervision
Results of this study indicate that there are several CAT modalities appropriate for children. Counselors
can integrate these into practice with appropriate training and credentialing. The ACA Code of Ethics Practice
Section C.2.b (2014) suggests that counselors take steps to ensure the competence of their work and protect
others from possible harm, while developing skills in new specialty areas. The field of counselor education
is committed to establishing and maintaining multicultural competence and social justice (ACA Code of
Ethics Preamble, 2014).
The immigrant population is on the rise in the United States (Elewonibi & Belue, 2016), which paves the
way for an increased emphasis on multicultural competency among counselors in training. Other professions
like social work, psychology and nursing have already incorporated CAT into their treatment delivery and
training programs. Therefore, it is of critical importance that the field of counseling keeps up with this
growing trend in the health industry through research, training and scholarship. One of the categories
identified in this research is professional development. Participants shared a common view when they spoke
of the lack of training opportunities in their profession. At the same time, this study identified that a general
awareness of the helpfulness of CAT modalities needs to be given. However, it is the responsibility of the
counselors in training to decide and learn further, if needed; yet there was no direction as to go forth as
30 SHALINI MATHEW, MICHAEL BROOKS
revealed by the study’s participants. There needs to be a change. Previous research in other health professions
pointed out that there are several ethical issues related to the use of CAT (Barnett & Shale, 2012). Therefore,
counselor educators and supervisors may want to consider how counselors in training be made aware of the
ethical issues that must be addressed before integrating CAT or making referrals in order to provide the
highest standard of care. This research also opens a new direction in the field of rehabilitation counselor
education; rehabilitation counselors in training are obligated to understand the diverse needs of children with
intellectual disabilities and their increased needs in counseling.
Implications for Research and Scholarship
In the area of research and scholarship, current scholars can use the results of this study to build on
integrative models in counseling. This can be achieved by conducting empirical research on the CAT
modalities that among the general population has been received the most. Funding opportunities are available
from NCCIH (National Center for Complementary and Integrative Health), to conduct research in the field of
CAT. Current and future scholars can take advantage of these resources and explore the different emergent
themes of this study.
Although measures of credibility were identified in the research, there is still room for attention directed
to limitations and improvements. There are five primary limitations to this study. First, the National Center
for Complementary and Integrative Health (NCCIH) identified different categories and forms of CAT, yet
only some of the forms were mentioned by the participants. Therefore, additional research should be
conducted to explore the perspectives of counselors using other forms of CAT. Second, the absence of male
counselors is a limitation for transferability to the general population of counselors.
The third limitation is that the researcher has approximately eleven years of experience working with
children with intellectual disabilities and using some form of complementary and alternative therapies. This
could be a potential limitation, although the researcher took special care to bracket these experiences earlier
in the research to prevent their influence or bias on the data collection and analysis. This was accomplished
by triangulation, bracketing, member checking and peer review. In this study, triangulation was achieved
using data source triangulation and data analysis triangulation. Different methods were used for data
collection and a multi-step coding process was used for analyzing the data. Member checking was performed
using the results of an enhanced critical incident technique; a peer reviewer who is a counselor and uses
CAT with children served as the external support for peer review. The fourth limitation is due to the
purposeful sampling (network sampling) technique used. This limited the representation of counselors by
restricting them to the researcher’s network of professionals. The fifth limitation is with the member checking
process itself. The researcher used only the synthesized result of the data for member checking. This could
be improved by using additional sources of data, such as the interview transcripts and focus group transcripts
Counselors’ Perspectives on Complementary and Alternative Therapies for Children 31
for member checking in the future.
Recommendations for Current Practice
Children with intellectual disabilities need assistance from childhood on because impairments and
inadequacies in academic performance as early as the preschool years can lay the ground for risky behaviors
in adolescence and adulthood. The findings of this study can be used to increase awareness among practicing
counselors by networking and offering a team treatment approach. As in the findings, these can be
incorporated, starting from intake documentation. Counselors can then monitor their client’s involvement in
CAT. Counselors can be open to discussions on CAT with their clients, if that is something the clients would
prefer. As suggested in previous literature (Berger, 2011), counselors can start networking with integrative
therapy practitioners, as well as CAT practitioners by having dialogues and/or referrals. Interested counselors
can receive additional training in CAT forms and start integrating those with counseling, specifically for
children as the findings of this research supports integrating CAT forms for counseling children. Additionally,
the support system for children with intellectual disabilities can be informed about the immense possibilities
of incorporating CAT into counseling. These could be communicated by conducting parent information
sessions. Counselors with a thorough understanding of children with intellectual disabilities and who have
special competence for working with these groups, can conduct parent information workshops. In addition,
school counselors can provide collaborative sessions targeted for educators and school personnel.
The importance of a multidisciplinary treatment team approach is one of the outcomes of this research.
Findings of this study suggest that incorporating CAT is one way to improve counseling competence, while
working for children with intellectual disabilities. Because there is more room in CAT to validate the feelings
of children with intellectual disabilities, it is recommended for counselors to stay informed about the
possibilities of using CAT for children with intellectual disabilities. The findings of this study can also be
used as a source of information for practicing counselors, counselor educators, supervisors, and the immediate
social support system of children with intellectual disabilities for further training and development.
Recommendations for Future Research
Based on the limitations of this study, future lines of research can explore more CAT forms and study
each one to explore which one offers a better fit for children with intellectual disabilities or for children in
general. A more representative group of counselors can be selected including both male and female
counselors, and the study could be replicated. A quantitative research design could be developed with an
increased sample size to validate and generalize the findings. Other options are to have a special focus placed
on the specific themes that emerged from this study. Research can also be conducted on the perspectives of
counselor education faculty as well, which may differ from counselors’ perspectives. A replicated study could
32 SHALINI MATHEW, MICHAEL BROOKS
address the lived experiences of school counselors, mental health counselors and rehabilitation counselors
separately and then compare and contrast the findings. Another replication of this study could explore the
perspectives of parents of children with intellectual disabilities who are using complementary and alternative
therapies. Additionally, there is a lack of standardized measurement scales to measure the skills, perspectives,
knowledge, and attitudes on CAT in counselors, so developing standardized tools could be another area of
Keeping in mind the rising numbers of people using CAT (NCCAM, 2014), counselors are obligated to
act wisely to meet the diversified needs of their clientele. Whether the client is a child or an adult, counselors
may want to be intentional and prepared to take up the unique challenges and preferences of each of their
clients. Counselors can incorporate CAT use in three different ways by networking, cross functioning and
becoming educated (Berger, 2011). The networking aspect involves networking with CAT practitioners and
providing a team treatment approach. Being cross functional is another way by which a counselor can
identify colleagues with treatment expertise in CAT and associate with them by referring clients who might
be interested to work with counselors who integrate CAT in counseling. Continuing education and training in
CAT will help integrate CAT into counseling. Also, as more research comes out in the area of CAT, all
training programs in counselor education and supervision will need to incorporate training on CAT into their
curriculum, either through coursework or supervised practicum and internship, thereby promoting CAT
competence in future counselors. Findings of this study indicated that counselors who participated in this
study have a positive attitude toward integrating CAT in counseling and were also recommending that CAT
be integrated into counselor education and training programs.
Counselors’ Perspectives on Complementary and Alternative Therapies for Children 33
Ajzen, I. (1991). The theory of planned behavior. Organizational Behavior and Human Decision Processes,
50, 179-211. doi.org/10.1016/0749-5978(91)90020-T
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).
American Counseling Association. (2014). 2014 ACA code of ethics. https://www.counseling.org/docs/default-
Bastemur, S., Dursun-Bilgin, M., Yildiz, Y., & Ucar, S. (2016). Alternative therapies: New approaches in
counseling. Procedia - Social and Behavioral Sciences, 217(1), 1157-1166. https://doi.org/10.1016/j.
Barnett, J. E., & Shale J. A. (2012). The integration of complementary and alternative medicine (CAM)
into the practice of psychology: A vision for the future. Professional Psychology: Research &
Practice, 43(6), 576-585. https://doi.org/10.1037/a0028919
Bellhouse, B. (2010). Yoga for mind, body, soul, and school. Physical & Health Education Journal, 76(2),
Berger, C. C. (2011). Integrative mental health and counseling: Research considerations and best practices.
Retrieved from http://counselingoutfitters.com/vistas/vistas11/Article_.pdf
Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in
Psychology, 3:2, 77-101. https://doi.org/10.1191/1478088706qp0oa
Butterfield, L., Borgen, W., Maglio, A., & Amundson, N. (2009). Using the enhanced critical incident
technique in counselling psychology research. Canadian Journal of Counselling, 43(4), 265-282.
Retrieved from https://cjc rcc.ucalgary.ca/article/view/58863
Cleary, M. J., & Scott, A. J. (2011). Developments in clinical neuropsychology: Implications for school
psychological services. Journal of School Health, 81(1), 1-7. https://doi.org/10.1111/j.1746-1561.2010.
Cooper C. (2010). A calming influence. Nursing standard (Royal College of Nursing Great Britain: 1987),
24(50), 24-25. https://doi.org/10.7748/ns.24.50.23.s26
Corey, G. (2013). Student manual for theory and practice of counseling and psychotherapy (9th ed. ed.).
Belmont, CA: Brooks/Cole.
Creswell, J. W., & Crewell J. D. (2017). Research design: Qualitative, quantitative, and mixed method
approaches (5th ed.). Thousand Oaks, CA: Sage.
Daley, B. (2004). Using concept maps in qualitative research. Proc. of the First Int. Conference on Concept
Mapping Pamplona, Spain.
Dunlop, K., & Tsantefski, M. (2018). A space of safety: Children’s experience of equine-assisted group
therapy. Child & Family Social Work, 23(1), 16-24. https://doi.org/10.1111/cfs.12378
Elewonibi, B. R., & Belue, R. (2016). Prevalence of complementary and alternative medicine in
immigrants. Journal of Immigrant and Minority Health, 18(3), 600-607. https://doi.org/10.1007/s10903-
34 SHALINI MATHEW, MICHAEL BROOKS
Erdman, P., & Lampe, R. (1996). Adapting basic skills to counsel children. Journal of Counseling &
Development, 74, 374-377. https://doi.org/10.1002/j.1556-6676.1996.tb01882.x
Faith, J., Thorburn, S., & Tippens, K. M. (2013). Examining CAM use disclosure using the Behavioral
Model of Health Services Use. Complementary Therapies in Medicine, 21(5), 501-508. https://doi.org/
Foley, H., Steel, A., Cramer, H., Wardle, J., & Adams, J. (2019). Disclosure of complementary medicine
use to medical providers: a systematic review and meta-analysis. Scientific reports, 9(1), 1573.
Forero, R., Nahidi, S., De Costa, J., Mohsin, M., Fitzgerald, G., Gibson, N., McCarthy, S., &
Aboagye-Sarfo, P. (2018). Application of four-dimension criteria to assess rigour of qualitative
research in emergency medicine. BMC health services research, 18(1), 120. https://doi.org/10.1186/
Foster, L. H. (2012). Professional counselor credentialing and program accreditation in the United States:
A historical review. Journal for International Counselor Education, 4, 42-56. Retrieved from
Gale, N. (2014). The sociology of traditional, complementary, and alternative medicine. Sociology Compass,
8(6), 805-822. https://doi.org/10.1111/soc4.12182
Gill, P., Stewart, K., Treasure, E., & Chadwick, B. (2008). Methods of data collection in qualitative
research: Interviews and focus groups. British Dental Journal, 204(6), 291-295. https://doi.org/
Gottschling, S., Gronwald, B., Schmitt, S., Schmitt, C., Längler, A., Leidig, E., Meyer, S., Baan, A.,
Shamdeen M.G., Berrang, J., & Graf, N. (2013). Use of complementary and alternative medicine in
healthy children and children with chronic medical conditions in Germany. Complementary Therapies
in Medicine, 21(SI), 61-69. https://doi.org/10.1016/j.ctim.2011.06.001
Grant, C.A., & Osanloo, A.F. (2014). Understanding, selecting, and integrating a theoretical framework in
dissertation research: Creating the blueprint for your “house”. Administrative Issues Journal, 4, 12-26.
Italia, S., Wolfenstetter, S., & Teuner, C. (2014). Patterns of complementary and alternative medicine
(CAM) use in children: A systematic review. European Journal of Pediatrics, 173, 1413-1428.
Johannessen, B., & Garvik, G. (2016). Experiences with the use of complementary and alternative medicine
in nursing homes: A focus group study. Complementary Therapies in Clinical Practice, 23(10),
John, A., Bailey, L., & Jones, J. (2017). Culture and context: Exploring attributions and caregiving
approaches of parents of children with an intellectual disability in urban India. Child & Family Social
Work, 22(2), 670-679. https://doi.org/10.1111/cfs.12282
Lavrakas, P. J. (2008). Encyclopedia of survey research methods Thousand Oaks, CA: SAGE Publications
Leung, L. (2015). Validity, reliability, and generalizability in qualitative research. Journal of Family
Counselors’ Perspectives on Complementary and Alternative Therapies for Children 35
Medicine and Primary Care, 4(3), 324-327. https://doi.org/10.4103/2249-4863.161306
Machalicek, W., Lang, R., & Raulston, T. J. (2015). Training parents of children with intellectual
disabilities: trends, issues, and future directions. Current Developmental Disorders Reports, 2(2),
Mathew, S. J. (2019). A Phenomenological Inquiry of Counselors’ Perspectives Toward the Use of
Complementary and Alternative Therapies for Children with Intellectual Disabilities (Order No.
13811010) [Doctoral dissertation, North Carolina Agricultural and Technical State University].
Available from ProQuest Dissertations & Theses Global. (2238752945).
McMahon, B. (2014). Mindfulness for children: How to make them calmer and happier. The Times, 6, 6-6.
Mohsin, M. N., Khan, T. M., Doger, A. H., & Awan, A. S. (2011). Role of parents in training of children
with intellectual disability. International Journal of Humanities and Social Sciences, 9(1), 78-88.
National Center for Complementary and Alternative Medicine. (2014). What is complementary and
alternative medicine? (NCCAM Publication No. D3). Retrieved from http://nccam.nih.gov/health/
National Center for Health Statistics (2018). Survey Description, National Health Interview Survey, 2017.
Natwick, J. (2018, September). Counselors are doing what now? Exploring the ethics of complementary
methods. Counseling Today, 9(1), 10-12.
Salomone, E., Charman, T., McConachie, H., Warreyn, P., & Working Group 4, COST Action ‘Enhancing
the Scientific Study of Early Autism’ (2015). Prevalence and correlates of use of complementary and
alternative medicine in children with autism spectrum disorder in Europe. European journal of
pediatrics, 174(10), 1277-1285. https://doi.org/10.1007/s00431-015-2531-7
Searight, H. R., Robertson, K., Smith, T., Perkins, S., & Searight, B. K. (2012). Complementary and
Alternative Therapies for Pediatric Attention Deficit Hyperactivity Disorder: A Descriptive Review.
ISRN Psychiatry, 2012, 1-8. https://dx.doi.org/10.5402/2012/804127
Smith, G., & Wu, S. (2012). Nurses’ beliefs, experiences, and practice regarding complementary and
alternative medicine in Taiwan. Journal of Clinical Nursing, 21(17-18), 2659-67.
Velsor, P. V. (2004). Revisiting basic counseling skills with children. Journal of Counseling and
Development, 82(3), 313-318. https://doi.org/10.1002/j.1556-6678.2004.tb00316.x
Ventola, C. L. (2010). Current Issues Regarding Complementary and Alternative Medicine (CAM) in the
United States: Part 1: The Widespread Use of CAM and the Need for Better-Informed Health Care
Professionals to Provide Patient Counseling. P & T: a peer-reviewed journal for formulary management,
Vincent, S. (1996). Emotional safety in adventure therapy programs: Can it be defined? Australian Journal
of Outdoor Education, 2(2), 3-9.
Wilson, L., & White, K. (2011). Integrating complementary and alternative therapies into psychological
practice: A qualitative analysis. Australian Journal of Psychology, 63(4), 232-242. https://doi.org/10.
Received June 09, 2021
Revision received January 05, 2022
Accepted January 22, 2022
36 SHALINI MATHEW, MICHAEL BROOKS
Wilson, L., White, K., & Hamilton, K. (2013). Predicting psychologists’ intentions to integrate complementary
and alternative therapies into their practice. Australian Psychologist, 48, 149-158. https://doi.org/10.
Young, M. E. (2013). Learning the art of helping: Building blocks and techniques (5th ed.). Boston, MA: