CACTH24 • California Counselors and Therapists 2024-2025

Table of Contents

CACTH24 • California Counselors and Therapists 2024-2025

How to Receive Credit

NetCE 4 Hour Course #93010 • Maternal Health Disparities

93010 • Maternal Health Disparities

1. INTRODUCTION

2. EPIDEMIOLOGY

3. EXPLICIT AND IMPLICIT BIAS

4. INTERCULTURAL COMPETENCE AND CULTURAL IDENTITY

5. INTERVENTIONS TO REDUCE IMPLICIT BIAS AND RELATED MATERNAL HEALTH DISPARITIES

6. RESOURCES

7. CONCLUSION

8. GLOSSARY

Works Cited

Evidence-Based Practice Recommendations Citations

NetCE 6 Hour Course #77723 • Ethics for Counselors

77723 • Ethics for Counselors

1. INTRODUCTION

2. HISTORICAL CONTEXT OF COUNSELING ETHICS

3. COMMON TERMS USED IN THE DISCUSSION OF ETHICS

4. VALUES AND ETHICAL PRINCIPLES IN ETHICAL CODES

5. ETHICAL THEORIES

6. ETHICAL DECISION-MAKING FRAMEWORKS

7. ETHICAL SELF-REFLECTION

8. MANAGED CARE AND ETHICS

9. DIVERSITY AND MULTICULTURALISM: ETHICAL ISSUES

10. ONLINE COUNSELING

11. INTERPROFESSIONAL COLLABORATION AND ETHICS

12. CONCLUSION

13. RESOURCES

14. APPENDIX: THE ACA CODE OF ETHICS

Works Cited

NetCE 6 Hour Course #76442 • Suicide Assessment and Prevention

76442 • Suicide Assessment and Prevention

1. INTRODUCTION

2. EPIDEMIOLOGY OF SUICIDE

3. PATHOPHYSIOLOGY OF SUICIDAL BEHAVIOR

4. SUICIDE AND SPECIAL POPULATIONS

5. RISK AND PROTECTIVE FACTORS FOR SUICIDE

6. IMMINENT SUICIDE

7. SUICIDE ATTEMPTS

8. SCREENING AND ASSESSMENT OF SUICIDE RISK

9. MANAGEMENT OF SUICIDAL PATIENTS

10. SUICIDE PREVENTION

11. SUICIDE SURVIVORS: TREATMENT AND RESOURCES

12. CONCLUSION

Works Cited

Evidence-Based Practice Recommendations Citations

NetCE 10 Hour Course #78250 • Movement and Dance in Psychotherapy

78250 • Movement and Dance in Psychotherapy

1. INTRODUCTION

2. FOUNDATIONS: MOVEMENT AND HEALING

3. THE IMPACT OF MOVEMENT ON HEALING

4. SIMPLE MOVEMENT TECHNIQUES IN CLINICAL WORK

5. FURTHER TRAINING & COLLABORATION

6. CONCLUSION

7. APPENDIX 1: MULTICULTURAL AWARENESS AND COMPETENCE

8. APPENDIX 2: DANCE IN THE CONTEXT OF EXPRESSIVE GROUP THERAPY

Works Cited

Evidence-Based Practice Recommendations Citations

CACTH24 • California Counselors and Therapists 2024-2025

Mary Franks, MSN, APRN, FNP-C

Michele Nichols, RN, BSN, MA

Mark Rose, BS, MA, LP

www.netce.com

Copyright © 2026 NetCE, All rights reserved.

CACTH24 • California Counselors and Therapists 2024-2025

Expiration Date: 03/31/2026

How to Receive Credit

To complete this Special Offer for continuing education credit please go to http://www.netce.com/specials in your browser.

For assistance with receiving continuing education credit, please contact us at help@netce.com.

93010 • Maternal Health Disparities

Mary Franks, MSN, APRN, FNP-C

www.netce.com

Copyright © 2023 NetCE, All rights reserved.

There is no question that maternal health disparities are a significant problem in the United States. Inequalities have been noted associated with many factors, including education level, literacy, and socioeconomic status. However, the greatest disparities have been noted among racial/ethnic minority women and have been linked to explicit and implicit biases in healthcare providers and systems. It is of the utmost importance that those working in health care and caring for patients in the peripartum and postpartum period are committed on lowering the morbidity and mortality rates of all mothers of color. Promoting equity and cultural competence, effectively addressing modifiable risk factors, improving communication and monitoring, and engaging in regular training are needed to improve these maternal health disparities.

Table of Contents

93010 • Maternal Health Disparities

Course Overview

Audience

Accreditations & Approvals

Designations of Credit

Individual State Nursing Approvals

Individual State Behavioral Health Approvals

Special Approvals

Course Objective

Learning Objectives

Faculty

Faculty Disclosure

Division Planners

Division Planners Disclosure

Director of Development and Academic Affairs

Director Disclosure Statement

About the Sponsor

Disclosure Statement

Implicit Bias in Health Care

1. INTRODUCTION

2. EPIDEMIOLOGY

WORLDWIDE

UNITED STATES

NEW JERSEY

3. EXPLICIT AND IMPLICIT BIAS

POWER DYNAMICS

ORGANIZATIONAL FACTORS

STRATEGIES TO PROMOTE AWARENESS

IMPACT OF BIAS ON THE DELIVERY OF PERINATAL CARE

4. INTERCULTURAL COMPETENCE AND CULTURAL IDENTITY

BLACK PATIENTS

ASIAN PATIENTS

LATINO/A/X OR HISPANIC PATIENTS

NATIVE AMERICAN PATIENTS

WHITE AMERICAN PATIENTS

BARRIERS TO INCLUSION

CULTURALLY RESPONSIVE COMMUNICATION

RACIAL AND REPRODUCTIVE JUSTICE

5. INTERVENTIONS TO REDUCE IMPLICIT BIAS AND RELATED MATERNAL HEALTH DISPARITIES

PERSPECTIVE TAKING

EMPATHY INTERVENTIONS

INDIVIDUATION

MINDFULNESS

COUNTER-STEREOTYPICAL IMAGING

CHIEF EQUITY OFFICERS

6. RESOURCES

7. CONCLUSION

8. GLOSSARY

Works Cited

Evidence-Based Practice Recommendations Citations

93010 • Maternal Health Disparities

Education Category. Women's Health - Maternal / Child

Release Date. 11/01/2023

Expiration Date. 10/31/2026

Course Overview

There is no question that maternal health disparities are a significant problem in the United States. Inequalities have been noted associated with many factors, including education level, literacy, and socioeconomic status. However, the greatest disparities have been noted among racial/ethnic minority women and have been linked to explicit and implicit biases in healthcare providers and systems. It is of the utmost importance that those working in health care and caring for patients in the peripartum and postpartum period are committed on lowering the morbidity and mortality rates of all mothers of color. Promoting equity and cultural competence, effectively addressing modifiable risk factors, improving communication and monitoring, and engaging in regular training are needed to improve these maternal health disparities.

Audience

This course is designed for all healthcare providers who may intervene to improve peripartum and postpartum health care and reduce health disparities.

Accreditations & Approvals

In support of improving patient care, TRC Healthcare/NetCE is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team. NetCE has been approved by NBCC as an Approved Continuing Education Provider, ACEP No. 6361. Programs that do not qualify for NBCC credit are clearly identified. NetCE is solely responsible for all aspects of the programs. As a Jointly Accredited Organization, NetCE is approved to offer social work continuing education by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program. Organizations, not individual courses, are approved under this program. Regulatory boards are the final authority on courses accepted for continuing education credit. Continuing Education (CE) credits for psychologists are provided through the co-sponsorship of the American Psychological Association (APA) Office of Continuing Education in Psychology (CEP). The APA CEP Office maintains responsibility for the content of the programs. NetCE is accredited by the International Accreditors for Continuing Education and Training (IACET). NetCE complies with the ANSI/IACET Standard, which is recognized internationally as a standard of excellence in instructional practices. As a result of this accreditation, NetCE is authorized to issue the IACET CEU.

Designations of Credit

This activity was planned by and for the healthcare team, and learners will receive 4 Interprofessional Continuing Education (IPCE) credit(s) for learning and change. NetCE designates this enduring material for a maximum of 4 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. NetCE designates this continuing education activity for 4 ANCC contact hour(s). NetCE designates this continuing education activity for 4.8 hours for Alabama nurses. NetCE designates this continuing education activity for 1 NBCC clock hour(s). Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 4 MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit. Completion of this course constitutes permission to share the completion data with ACCME. Social workers participating in this intermediate to advanced course will receive 4 Clinical continuing education clock hours. Successful completion of this CME activity, which includes participation in the evaluation component, enables the learner to earn credit toward the CME and/or Self-Assessment requirements of the American Board of Surgery's Continuous Certification program. It is the CME activity provider's responsibility to submit learner completion information to ACCME for the purpose of granting ABS credit. Successful completion of this CME activity, which includes participation in the activity with individual assessments of the participant and feedback to the participant, enables the participant to earn 4 MOC points in the American Board of Pediatrics' (ABP) Maintenance of Certification (MOC) program. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABP MOC credit. Through an agreement between the Accreditation Council for Continuing Medical Education and the Royal College of Physicians and Surgeons of Canada, medical practitioners participating in the Royal College MOC Program may record completion of accredited activities registered under the ACCME's "CME in Support of MOC" program in Section 3 of the Royal College's MOC Program. NetCE is authorized by IACET to offer 0.4 CEU(s) for this program. AACN Synergy CERP Category B.

Individual State Nursing Approvals

In addition to states that accept ANCC, NetCE is approved as a provider of continuing education in nursing by: Alabama, Provider #ABNP0353 (valid through July 30, 2029); Arkansas, Provider #50-2405; California, BRN Provider #CEP9784; California, LVN Provider #V10662; California, PT Provider #V10842; District of Columbia, Provider #50-2405; Florida, Provider #50-2405; Georgia, Provider #50-2405; Kentucky, Provider #7-0054 through 12/31/2027; South Carolina, Provider #50-2405; West Virginia RN and APRN, Provider #50-2405.

Individual State Behavioral Health Approvals

In addition to states that accept ASWB, NetCE is approved as a provider of continuing education by the following state boards: Alabama State Board of Social Work Examiners, Provider #0515; Florida Board of Clinical Social Work, Marriage and Family Therapy and Mental Health Counseling, CE Broker Provider #50-2405; Illinois Division of Professional Regulation for Social Workers, License #159.001094; Illinois Division of Professional Regulation for Licensed Professional and Clinical Counselors, License #197.000185; Illinois Division of Professional Regulation for Marriage and Family Therapists, License #168.000190;

Special Approvals

This course is designed to meet the New Jersey requirement for implicit and explicit bias education for those healthcare professionals who provide perinatal treatment and care to pregnant persons. This course fulfills the Maryland requirement for 3 hours of anti-oppressive content, including cultural humility, social justice, racial equity, implicit bias, or anti-racism practices. NetCE is approved as a provider of continuing education by the California Consortium of Addiction Programs and Professionals. Provider Number 5-08-151-0626. NetCE is approved as a provider of continuing education by the California Association of DUI Treatment Programs (CADTP). Provider Number 185. This activity is designed to comply with the requirements of California Assembly Bill 1195, Cultural and Linguistic Competency. NetCE designates this continuing education activity for 4 continuing education hours for addiction professionals.

Course Objective

The purpose of this course is to provide healthcare professionals with the knowledge and skills necessary to improve maternal outcomes in all races, ethnicities, and marginalized groups.

Learning Objectives

Upon completion of this course, you should be able to:

1. Outline the epidemiology of maternal morbidity and mortality.

2. Discuss how explicit and implicit bias may contribute to pregnancy-related deaths and maternal and infant health outcomes.

3. Identify cultural identity across racial, ethnic, and other marginalized groups, including historical and contemporary exclusion and oppression.

4. Identify environmental, personal, interpersonal, institutional, and cultural barriers to inclusion.

5. Discover communicating more effectively across racial, ethnic, religious, and gender identities.

6. Review information about racial and reproductive justice.

7. Identify measures to decrease explicit and implicit bias at the interpersonal and institutional levels.

Faculty

Mary Franks, MSN, APRN, FNP-C, is a board-certified Family Nurse Practitioner and NetCE Nurse Planner. She works as a Nurse Division Planner for NetCE and a per diem nurse practitioner in urgent care in Central Illinois. Mary graduated with her Associate’s degree in nursing from Carl Sandburg College, her BSN from OSF Saint Francis Medical Center College of Nursing in 2013, and her MSN with a focus on nursing education from Chamberlain University in 2017. She received a second master's degree in nursing as a Family Nurse Practitioner from Chamberlain University in 2019. She is an adjunct faculty member for a local university in Central Illinois in the MSN FNP program. Her previous nursing experience includes emergency/trauma nursing, critical care nursing, surgery, pediatrics, and urgent care. As a nurse practitioner, she has practiced as a primary care provider for long-term care facilities and school-based health services. She enjoys caring for minor illnesses and injuries, prevention of disease processes, health, and wellness. In her spare time, she stays busy with her two children and husband, coaching baseball, staying active with her own personal fitness journey, and cooking. She is a member of the American Association of Nurse Practitioners and the Illinois Society of Advanced Practice Nursing, for which she is a member of the bylaws committee.

Faculty Disclosure

Contributing faculty, Mary Franks, MSN, APRN, FNP-C, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Division Planners

John M. Leonard, MD

Margo A. Halm, RN, PhD, NEA-BC, FAAN

Alice Yick Flanagan, PhD, MSW

Margaret Donohue, PhD

Division Planners Disclosure

The division planners have disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Director of Development and Academic Affairs

Sarah Campbell

Director Disclosure Statement

The Director of Development and Academic Affairs has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

About the Sponsor

The purpose of NetCE is to provide challenging curricula to assist healthcare professionals to raise their levels of expertise while fulfilling their continuing education requirements, thereby improving the quality of healthcare.

Our contributing faculty members have taken care to ensure that the information and recommendations are accurate and compatible with the standards generally accepted at the time of publication. The publisher disclaims any liability, loss or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents. Participants are cautioned about the potential risk of using limited knowledge when integrating new techniques into practice.

Disclosure Statement

It is the policy of NetCE not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners.

Implicit Bias in Health Care

The role of implicit biases on healthcare outcomes has become a concern, as there is some evidence that implicit biases contribute to health disparities, professionals' attitudes toward and interactions with patients, quality of care, diagnoses, and treatment decisions. This may produce differences in help-seeking, diagnoses, and ultimately treatments and interventions. Implicit biases may also unwittingly produce professional behaviors, attitudes, and interactions that reduce patients' trust and comfort with their provider, leading to earlier termination of visits and/or reduced adherence and follow-up. Disadvantaged groups are marginalized in the healthcare system and vulnerable on multiple levels; health professionals' implicit biases can further exacerbate these existing disadvantages.

Interventions or strategies designed to reduce implicit bias may be categorized as change-based or control-based. Change-based interventions focus on reducing or changing cognitive associations underlying implicit biases. These interventions might include challenging stereotypes. Conversely, control-based interventions involve reducing the effects of the implicit bias on the individual's behaviors. These strategies include increasing awareness of biased thoughts and responses. The two types of interventions are not mutually exclusive and may be used synergistically.

1. INTRODUCTION

Substantial differences in maternal morbidity and mortality among racial and ethnic groups exist in the United States. Black women are more than twice as likely to die related to maternal complications compared with White women [1]. The Centers for Disease Control and Prevention (CDC) reports that nearly 20% of surveyed women reported experiences of mistreatment during their pregnancy and/or the delivery of their child/children [2]. However, the reported rates were higher among Black (30%), Hispanic (29%), and multiracial (27%) patients.

Increasingly, research has shown that the quality of health care is an important lever for expanding positive outcomes for racial and ethnic minority women [1]. This course will identify underlying drivers of maternal disparities, review potential contributing factors (with the intention of supporting amelioration), and outline approaches to improve maternal outcomes. This course will also explore supportive measures, particularly in minority populations to reduce explicit and implicit bias in perinatal care.

2. EPIDEMIOLOGY

WORLDWIDE

The United Nations International Children's Emergency Fund (UNICEF) reports an overall global 34% decline in the maternal mortality rate, from 342 maternal deaths per 100,000 live births in 2000 to 223 maternal deaths per 100,000 live births in 2020 [3]. This decrease is consistent with achieving the sustainable development goal of 70 maternal deaths per 100,000 live births by 2030. However, the maternal mortality rates plateaued in Western Europe and North America between 2016 and 2022, and Latin America and the Caribbean noted an increase over the same period. The goal annual reduction rate is 15% for every country [3].

The location with the largest number of maternal deaths is sub-Saharan Africa, where the rate is 545 maternal deaths per 100,000 live births. Countries with the lowest rates of maternal mortality include Australia and New Zealand (with 4 maternal deaths per 100,000 live births) [3]. Among regions, women in sub-Saharan Africa face the highest lifetime risk of maternal death (1 in 41), which is approximately 268 times higher than in Western Europe (1 in 11,000), the lowest-risk region [3].

UNITED STATES

In the United States, maternal deaths represent the largest disparity among all populations within perinatal health measures. The maternal mortality rate in the United States is unacceptably high and rising. In 2021, 1,205 women died of maternal causes in the United States, compared with 861 in 2020 and 754 in 2019 [4]. The maternal mortality rate for 2021 was 32.9 deaths per 100,000 live births, compared with a rate of 23.8 in 2020 and 20.1 in 2019. More than 80% of all pregnancy-related deaths that occur in the United States are considered preventable [5].

Maternal mortality rates in the United States are higher among American Indian, Alaskan Native, Pacific Islander/Native Hawaiian, and Black women than among Asian, Hispanic, or White populations [6]. In 1933, the first time all states reported maternal deaths, the maternal mortality rate for Black women (1,000 deaths per 100,000 births) was 1.8 times greater than the rate for White women (564 deaths per 100,000 births). As of 2021, maternal death rates among Black women (69.9 per 100,000 births) had risen to 2.6 times higher than the rate noted for White women (26.6 per 100,000 births) [7].

Increases in maternal mortality rates are significantly greater among women 40 years of age and older. In this group, the mortality rate was 138.5 deaths per 100,000 live births in 2021 [7]. This represents an 83.4% increase compared with 2019. Data reported by the U.S. Government Accountability Office between 2020 and 2021 indicate the COVID-19 pandemic is a contributing factor to the increasing maternal mortality rate. This was believed to be linked to the chronic physiological stress present during pregnancy paired with severe illness from COVID-19 [8].

Evidence Based Practice Recommendation

The American College of Obstetricians and Gynecologists and Society for Maternal-Fetal Medicine recommend using two criteria to screen for severe maternal morbidity: transfusion of 4 or more units of blood and admission of a pregnant or postpartum patient to an intensive care unit.

https://www.acog.org/clinical/clinical-guidance/obstetric-care-consensus/articles/2016/09/severe-maternal-morbidity-screening-and-review

Last Accessed: October 16, 2023

Strength of Recommendation: Expert Opinion/Consensus Statement

The CDC considers the following diagnoses/procedures as indicators of delivery hospitalizations with severe maternal mortality [9]:

- Acute myocardial infarction

- Aneurysm

- Acute renal failure

- Acute respiratory distress syndrome (ARDS)

- Amniotic fluid embolism

- Cardiac arrest/ventricular fibrillation

- Conversion of cardiac rhythm

- Disseminated intravascular coagulation

- Eclampsia

- Heart failure/arrest during surgery or procedure

- Puerperal cerebrovascular disorders

- Pulmonary edema/acute heart failure

- Severe anesthesia complications

- Sepsis

- Shock

- Sickle cell disease with crisis

- Air and thrombotic embolism

- Hysterectomy

- Temporary tracheostomy

- Ventilation

Blood transfusion is not included on this list but is considered separately as a potential indicator.

In addition to mortality, obstetric morbidity is also associated with increased risk in the minority populations, particularly for non-Hispanic Black women. For every reported maternal death, 100 women experience a severe obstetric disease or life-threatening diagnosis during their hospitalization for delivery. Analysis of 2012–2015 data indicates that the incidence of severe maternal morbidity was significantly higher among deliveries to women in every racial and ethnic minority category compared with deliveries among non-Hispanic White women [10]. Severe maternal morbidity occurred at a rate of 231.1 per 10,000 delivery hospitalizations for non-Hispanic Black patients; the rate was 139.2 per 10,000 delivery hospitalizations among non-Hispanic White women. Racial and ethnic minority women have higher rates on most major morbidity indicators than White patients [1,9].

NEW JERSEY

In 2018, the New Jersey legislature enacted P.L. 2018, c.82, which requires the New Jersey Department of Health to issue a report on hospital maternity care. This report (often referred to as the maternal health report card for the state of New Jersey) gives insights into the evolution of the maternal population as well as trends in serious maternal morbidity and mortality [10]. Over time, the maternal population in New Jersey has become more diverse. In 2020, 54% of mothers identified as a race/ethnicity other than White, compared with 46% in 2000 [10]. There has also been a trend away from hospital births, with a 2% decrease in hospital deliveries between 2019 and 2020 [10].

The report assesses five measures to track maternal morbidities and delivery complications in the state: third- and fourth-degree perineal laceration, episiotomy, obstetric hemorrhage, post-admission infections, and severe maternal morbidity (a surrogate for other complications) [10]. In 2020, non-Hispanic Black mothers in New Jersey were noted to have the highest rate of obstetric hemorrhage, defined as cumulative blood loss greater than 1,000 mL regardless of the method of delivery (i.e., vaginal or cesarean birth) or blood loss accompanied by signs or symptoms of hypovolemia within 24 hours after the birth process. Risk factors for obstetric hemorrhage were Non-Hispanic Black or Hispanic race, cesarean delivery, placental or uterine disorders, nulliparity, premature gestational age, infection, pre-existing anemia, ICU admission, and pre-pregnancy overweight or obesity [10].

Non-Hispanic Black mothers in New Jersey also had the highest rate of severe maternal morbidity with need for blood transfusion, at a rate of 36.5 cases per 1,000 delivery hospitalizations. This represented a slight increase from the 2019 rate (35.6 cases per 1,000 delivery hospitalizations) [10]. Hispanic patients had the second highest rate (25.2 cases per 1,000 delivery hospitalizations). Non-Hispanic White mothers had the lowest documented transfusion rate (15.7 cases per 1,000 delivery hospitalizations)—a rate less than half that of Black mothers [10].

Asian mothers were identified to have the highest risk of third- and fourth-degree perineal tears without instrumentation (3.4 cases per 100 delivery hospitalizations). Hispanic and non-Hispanic Black mothers had the lowest rate of this complication (0.9 cases per 100 delivery hospitalizations) [10].

Asian mothers were also the most likely to experience episiotomies (11.6 cases per 100 delivery hospitalizations). The rate among this population is almost triple the next most likely group, Hispanic patients (4.3 cases per 100 delivery hospitalizations). Non-Hispanic Black mothers had the lowest episiotomy rate, at 2.8 cases per 100 delivery hospitalizations [10].

Postadmission infections were also most likely among Asian patients, who had a reported rate of 25.4 cases per 1,000 delivery hospitalizations. Hispanic mothers followed closely, with a rate of 21.8 per 1,000 delivery hospitalizations. The lowest rate occurred among non-Hispanic White mothers, who had a postadmission infection rate of 12.7 cases per 1,000 delivery hospitalizations (half the rate among Asian patients) [10].

Between 2016 and 2018, a total of 125 deaths with a temporal relationship to pregnancy (within 365 days) were reported in New Jersey [11]. Of these deaths, 44 (35%) were determined to be pregnancy-related, 74 (59%) were pregnancy-associated but not related, and 7 (6%) were unable to be determined. As in the rest of the country, the maternal mortality outcomes for non-Hispanic Black women continue to be largely disparate when compared to White women. The maternal mortality rate for Black women in New Jersey (39.2 deaths per 100,000 live births) is 6.6 times higher than the rate for White women (5.9 per 100,000 live births). The rate for Hispanic women (20.6 per 100,000 live births) is 3.5 times higher than the rate for White women [11].

3. EXPLICIT AND IMPLICIT BIAS

Bias plays a pivotal role in health care, especially patient care. Therefore, it is important to define the term. In a sociocultural context, biases are generally defined as negative evaluations of a particular social group relative to another group. Explicit biases are conscious, whereby an individual is fully aware of his/her attitudes and there may be intentional behaviors related to these attitudes [13]. For example, an individual may openly endorse a belief that women are weak, and men are strong. This bias is fully conscious and is made explicitly known. Implicit bias refers to the unconscious attitudes and evaluations held by individuals. These individuals do not necessarily endorse the bias, but the embedded beliefs/attitudes can negatively affect their behaviors [14,15,16,17]. Some have asserted that the cognitive processes that dictate implicit and explicit biases are separate and independent [17].

Implicit biases can start as early as 3 years of age. As children age, they may begin to become more egalitarian in what they explicitly endorse, but their implicit biases may not necessarily change in accordance with these outward expressions [18]. Because implicit biases occur on the subconscious or unconscious level, particular social attributes (e.g., skin color) can quietly and insidiously affect perceptions and behaviors [19]. According to Georgetown University's National Center on Cultural Competency, social characteristics that can trigger implicit biases include [20]:

- Age

- Disability

- Education

- English language proficiency and fluency

- Ethnicity

- Health status

- Disease/diagnosis (e.g., HIV/AIDS)

- Insurance

- Obesity

- Race

- Socioeconomic status

- Sexual orientation, gender identity, or gender expression

- Skin tone

- Substance use

An alternative way of conceptualizing implicit bias is that an unconscious evaluation is only negative if it has further adverse consequences on a group that is already disadvantaged or produces inequities [21,22]. Disadvantaged groups are marginalized in the healthcare system and vulnerable on multiple levels; health professionals' implicit biases can further exacerbate these existing disadvantages [21].

Implicit bias has been linked to a variety of health disparities [23]. Health disparities are differences in health status or disease that systematically and adversely affect less advantaged groups [24]. These inequities are often linked to historical and current unequal distribution of resources due to poverty, structural inequities, insufficient access to health care, and/or environmental barriers and threats [25]. As illustrated, health disparities have been clearly documented in maternal and perinatal care among racial/ethnic groups.

In an ideal situation, health professionals would be explicitly and implicitly objective, and clinical decisions would be completely free of bias. However, healthcare providers have implicit (and explicit) biases at a rate comparable to that of the general population [22,26]. It is possible that these implicit biases shape healthcare professionals' behaviors, communications, and interactions, which may produce differences in help seeking, diagnoses, and ultimately treatments and interventions [26]. They may also unwittingly produce professional behaviors, attitudes, and interactions that reduce patients' trust and comfort with their provider, leading to earlier termination of visits and/or reduced adherence and follow-up [15].

POWER DYNAMICS

Power dynamics are inevitable in many situations, including throughout the healthcare system, when two or more individuals are attempting to balance the power among themselves. These dynamics may look different in various situations. Seven types of power dynamics have been identified: coercive, expert, reward, informational, formal, referent, and connection [27]. When power is exerted differently between the parties, inequity can result. In practice, healthcare professionals may use power to protect their autonomy and exert their expertise. This can lead to problems in interprofessional collaboration and in a failure to focus on the patient's role in making healthcare decisions, advocating for their needs and preferences, and being an empowered member of the care team. Communication, competence, and role perceptions are common factors that influence power dynamics [28].

ORGANIZATIONAL FACTORS

Larger organizational, institutional, societal, and cultural forces contribute, perpetuate, and reinforce implicit and explicit biases, racism, and discrimination. Psychological and neuroscientific approaches ultimately decontextualize racism [17,29]. Sources of bias in organizations include internal politics, culture, leadership, organizational history, and team-specific structures. Organizational bias reaches far beyond individuals themselves; the language used or tasks identified influence how the organization functions daily [30]. Bias within an organization can detour patients from visiting if they feel they are being viewed or cared for as a "lesser" patient. One of the primary roles and responsibilities of health professionals is to analyze how institutional and organizational factors promote racism and implicit bias and how these factors contribute to health disparities. This analysis should extend to include one's own position in this structure.

STRATEGIES TO PROMOTE AWARENESS

It is important to promote awareness of bias—both explicit and implicit biases and at personal, organizational, and professional levels. Education and training are powerful tools to identify and address issues related to bias. Reflection exercises and role play can be used, as hands-on skills are necessary in order to apply theories to practice. Creating safe environments and using skill-building exercises are key components of any program designed to reduce biases and related health disparities [31].

Harvard University sponsors Project Implicit, a research project which monitors implicit biases. Project Implicit houses the Implicit Association Test (IAT), which can be used as a metric to assess professionals' level of implicit bias on a variety of subjects, and this presupposes that implicit bias is a discrete phenomenon that can be measured quantitatively [32]. When providers are aware that implicit biases exist, discussion and education can be implemented to help reduce them and/or their impact. The IAT is available at https://implicit.harvard.edu/implicit, and anyone may complete an assessment.

Another way of facilitating awareness of providers' implicit bias is to ask self-reflective questions about each interaction with patients. Some have suggested using SOAP (or subjective, objective, assessment, and plan) notes to assist practitioners in identifying implicit biases in day-to-day interactions with patients [33]. Integrating the following questions into charts and notes can stimulate reflection about implicit bias globally and for each specific patient interaction:

- Did I think about any socioeconomic and/or environmental factors that may contribute to the health and access of this patient?

- How was my communication and interaction with this patient? Did it change from my customary pattern?

- How could my implicit biases influence care for this patient?

When reviewing the SOAP notes, providers can look for recurring themes of stereotypical perceptions, biased communication patterns, and/or types of treatment/interventions proposed and assess whether these themes could be influenced by biases related to race, ethnicity, age, gender, sexuality, or other social characteristics. A review of empirical studies conducted on the effectiveness of interventions promoting implicit bias awareness found mixed results. At times, after a peer discussion of IAT scores, participants appeared less interested in learning and employing implicit bias reduction interventions. However, other studies have found that receiving feedback along with IAT scores resulted in a reduction in implicit bias. Any feedback, education, and discussions should be structured to minimize participant defensiveness [34].

IMPACT OF BIAS ON THE DELIVERY OF PERINATAL CARE

Worldwide, the maternal mortality has decreased 43% since 1993. However, the United States is the only developed country in which maternal mortality has increased [35]. As of 2023, the United States reports the highest maternal mortality of all developed countries. The rate in New Jersey (25.7 maternal deaths per 100,000 live births) is higher than the national average (23.5 deaths per 100,000 live births). The greatest rates tend to occur in the South [36].

What is further troubling is that most maternal deaths and cases of severe morbidity are preventable [35]. This then leads to the necessary question: Why are these deaths occurring? A review of maternal deaths across nine states found that the deaths were most commonly related to "clinician, facility, and system factors, such as inadequate training, missed or delayed diagnosis of complications, poor communication, and lack of coordination between clinicians" [37]. Improvements in clinician knowledge, skill, interprofessional collaboration, and bias could make inroads to improving maternal health care in the United States.

In a survey of 2,402 women regarding their maternal care, the following mistreatments were most commonly reported [2]:

- Receiving no response to requests for help

- Being shouted at or scolded

- Not having their physical privacy protected

- Being threatened with withholding treatment or made to accept unwanted treatment

About 30% of Black, Hispanic, and multiracial women reported mistreatment, with lower rates or reported mistreatment among White (19%), Native American/Alaska Native/Native Hawaiian/Pacific Islander (18%), and Asian (15%) patients. Mistreatment was most commonly reported by those with no insurance (28%) or public insurance (26%); only 16% of those with private insurance reported mistreatment. Patients most commonly reported discrimination and/or mistreatment during prenatal care related to age, weight, income, and race/ethnicity [2]. About 29% of women experienced discrimination, with the highest rates among Black (40%), multiracial (39%), and Hispanic (37%) women [2]. While satisfaction with maternity care overall was high (90%), satisfaction among those who reported mistreatment was considerably lower (75%). Mistreatment and discrimination impact experiences of care.

Social determinants of health are the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks. These circumstances are shaped by the distribution of money, power, and resources at global, national, and local levels. For example, historical economic stresses and restrictions on housing, jobs, and education have resulted in health inequalities for racial and ethnic minority groups. Healthy People 2030 groups social determinants of health into five categories [38]:

- Economic stability

- Education access and quality

- Health care access and quality

- Social and community context

- Neighborhood and built environment

These factors have a major impact on people's health, well-being, and quality of life. Social determinants contribute to maternal outcomes; however, they do not fully explain the large number of women of racial and ethnic backgrounds having higher than average maternal morbidity and mortality rates [37].

Implicit biases have been directly linked with lesser quality of care for certain patients, particularly those of minority groups. In some cases, this lower quality of care is triggered by stressful circumstances [35]. One explanation is that implicit biases are a heuristic, or a cognitive or mental shortcut. Heuristics offer individuals general rules to apply to situations in which there is limited, conflicting, or unclear information. Use of a heuristic results in a quick judgment based on fragments of memory and knowledge, and therefore, the decisions made may be erroneous. If the thinking patterns are flawed, negative attitudes can reinforce stereotypes [39].

Negative stereotyping can be a contributing factor to maternal health disparities. For example, healthcare providers may neglect to recognize the pain of non-Hispanic Black women or feel that this group's expressions of pain are more disproportionate than their actual experiences. One study found that a Black woman in New York City with a college education is nearly three times more likely to endure severe maternal morbidities compared with a White woman of similar age with less than a high school education [37]. In one study of patients following cesarean delivery, Black and Hispanic women were evaluated for pain less frequently, had higher pain scores, and received less pain medication than White women, even after controlling for other clinical factors, suggesting that these inequities are the result of different approaches to care delivery [40]. These implicit racial beliefs also have the potential to affect the way a patient is counseled about treatment options [35].

Evidence Based Practice Recommendation

In order to reduce Black maternal mortality, the Centers for Disease Control and Prevention recommends that healthcare providers:

- Ask questions to better understand their patient and things that may be affecting their lives.

- Help patients, and those accompanying them, understand the urgent maternal warning signs and when to seek medical attention right away.

- Help patients manage chronic conditions or conditions that may arise during pregnancy, like hypertension, diabetes, or depression.

- Recognize and work to eliminate unconscious bias in themselves and in their office on an ongoing basis.

- Respond to any concerns patients may have.

- Provide all patients with respectful quality care.

https://www.cdc.gov/healthequity/features/maternal-mortality

Last Accessed: October 16, 2023

Strength of Recommendation: Expert Opinion/Consensus Statement

Serious maternal complications, including hemorrhage, embolism, eclampsia, and stroke, occur in all racial and age groups; however, there is a clearly documented increased risk for racial or ethnic minority women. Failure to recognize these complications could be related to the high-stress environments in which they occur, but they may also be related to stereotypical unconscious thoughts related to minority groups [38].

Preconception counseling and care is critical to optimizing maternal health. This includes management of chronic diseases, maternal and fetal screenings, and lifestyle changes. Racial and/or ethnic minority women tend to have less accessibility to preconception and antenatal care [37]. Closing these access and engagement gaps could help address some of the disparities in birth complications.

Postnatal care is less emphasized but is a significantly important aspect of maternal care. During the eight weeks following delivery, the physical and emotional needs of the mothers should be assessed, including chronic health issues or complications that developed during the gestational period (e.g., gestational diabetes, hypertension, anemia, peripartum anxiety, peripartum depression). Unfortunately, it is reported that 16% to 36% of women do not attend a six-week follow-up visit following birth [36]. Furthermore, those who do attend the six-week visit report insufficient care and postnatal guidance, indicating a need to improve both adherence and provision of care during this period.

Healthcare professionals have a responsibility to repair biased systems that perpetuate racial health disparities. The American College of Obstetricians and Gynecologists has released a statement on racism in obstetrics and gynecology that reads, in part, [41]:

Racial and ethnic inequities in obstetrics and gynecology cannot be reversed without addressing all aspects of racism and racial bias, including sociopolitical forces that perpetuate racism. The actualization of an equitable health care system which serves all people can only occur through acknowledgment of the historical context from which modern health inequities grew, including reproductive injustices.

4. INTERCULTURAL COMPETENCE AND CULTURAL IDENTITY

Cultural identity is defined as the "shared characteristics of a group of people, which encompasses place of birth, religion, language, cuisine, social behaviors, art, literature, and music" [42]. Cultural identity is important as it influences how we respond to different situations. In health care, cultural identity can influence the behaviors one exhibits, the barriers upheld, and professional decisions, interactions, and performance. Cultural identity can evolve, and even if one does not consider their culture consciously, it is exhibited subconsciously [43]. It is important to remember that one's cultural identity should not impede the care provided to patients. For example, religion can influence one's practice but it should not determine how one practices or the type or quality of care given.

Providing culturally responsive care can help to avoid practice that is influenced by explicit or implicit biases. The U.S. Department of Health and Human Services has outlined steps important to incorporate in evaluation and treatment planning processes to ensure culturally competent clinical and programmatic decisions and skills [44]. The first step is to engage patients. When engaging in any patient teaching, remember that individuals may be new to the specific language or jargon and expectations of the diagnosis and care process. Patients should be encouraged to collaborate in every step of their care. Practitioners should also work to identify screening and assessment tools that have been translated into or adapted for other languages and have been validated for their particular population group(s). Typically, culturally responsive care establishes holistic treatment goals that include objectives to improve physical health and spiritual strength; utilizes strengths-based strategies that fortify cultural heritage, identity, and resiliency; and recognizes that treatment planning is a dynamic process that evolves along with an understanding of patient history and treatment needs.

As part of the cultural competence process and as a reflection of cultural humility, practitioners should strive to learn as much as possible about the specific racial/ethnic populations they serve. However, considerable diversity exists within any specific culture, race, or ethnicity [45]. Cultural beliefs, traditions, and practices change over time, both through generations and within an individual's lifetime. It is also possible for the differences between two members of the same racial/ethnic group to be greater than the differences between two people from different racial/ethnic groups. Within-group variations in how people interact with their environments and specific social contexts are also often present.

In addition to these general approaches, specific considerations may be appropriate for specific populations. While discussion of every possible patient subgroup is outside of the scope of this course, some of the most common factors are outlined in the following sections.

BLACK PATIENTS

"Black" or "African American" is a classification that serves as a descriptor; it has sociopolitical and self-identification ramifications. The U.S. Census Bureau defines African Americans or Black Americans as persons "having origins in any of the Black racial groups of Africa" [46].

Historical adversity and institutional racism contribute to health disparities in this group. For the Black population, patient assessment and treatment planning should be framed in a context that recognizes the totality of life experiences faced by patients. In many cases, particularly in the provision of mental health care, equality is sought in the provider-patient relationship, with less distance and more disclosure. Practitioners should assess whether their practices connect with core values of Black culture, such as family, kinship, community, and spirituality. Generalized or Eurocentric treatment approaches may not easily align with these components of the Black community [47]. Providers should also consider the impact of racial discrimination on health and mental health among Black patients. Reports indicate that expressions of emotion by Black patients tend to be negatively misunderstood or dismissed; this reflects implicit or explicit biases.

ASIAN PATIENTS

"Asian" is a single term widely used to describe individuals who have kinship and identity ties to Asia, including the Far East, Southeast Asia, and the Indian subcontinent. This encompasses countries such as China, Japan, Korea, Vietnam, Cambodia, Thailand, India, Pakistan, and the Philippines. Pacific Islander is often combined with Asian American in census data. The Pacific Islands include Hawaii, Guam, Samoa, Fiji, and many others [48]. There are more than 25 Asian/Pacific Islander groups, each with a different migration history and widely varying sociopolitical environments in their homelands [49].

As of 2019, 22.9 million Americans identified as Asian [50]. Between 2000 and 2019, Asians experienced the greatest growth compared with any other racial group at 81% [51,52]. The Chinese group represents the largest Asian subgroup in the United States, and it is projected that this population will grow to 35.7 million between 2015 and 2040 [53,54].

Recommended best practices when caring for Asian American patients include:

- Create an advisory committee using representatives from the community.

- Incorporate cultural knowledge and maintain flexible attitudes.

- Provide services in the patients' primary language.

- Develop culturally specific questionnaires for intake to capture information that may be missed by standard questionnaires.

- Emphasize traditional values and incorporate traditional practices (e.g., acupuncture) into treatment plans, when appropriate and desired.

- Explore patient coping mechanisms that draw upon cultural strengths.

While these approaches have been identified as useful for Asian patients, they may be broadly applicable across racial groups.

LATINO/A/X OR HISPANIC PATIENTS

In 2020, the Hispanic population in the United States numbered 60.6 million, comprising 18.7% of the U.S. population [55]. As such, they are the largest ethnic minority group in the United States. The majority of the Hispanic population in the United States (63.3%) identify themselves as being of Mexican descent [56]. Approximately 27% of the U.S. Hispanic population identify as Puerto Rican, Cuban, Salvadoran, Dominican, Guatemalan, Colombian, Honduran, Ecuadorian, or Peruvian [57].

When involved in the care of Latinx/Hispanic individuals, practitioners should strive to employ personalismo (warm, genuine communication) and recognize the importance of familismo (the centrality of the family). More flexible scheduling strategies may be more successful with this group, if possible, and some patients may benefit from culturally specific treatment and ethnic and gender matching with providers. Aspects of Latino culture can be assets in treatment: strength, perseverance, flexibility, and an ability to survive.

NATIVE AMERICAN PATIENTS

The Native American population is extremely diverse. According to the U.S. Census, the terms "Native American," "American Indian," or "Alaskan Native" refer to individuals who identify themselves with tribal attachment to indigenous groups of North and South America [58]. In the United States, there are 574 federally recognized tribal governments and 324 federally recognized reservations [59].

In 2020, it was reported that there were 7.1 million Native Americans in the United States, which is approximately 2% of the U.S. population. By 2060, this number is projected to increase to 10.1 million, or 2.5% of the total population [59].

Listening is an important aspect of rapport building with Native American patients, and practitioners should use active listening and reflective responses. Assessments and histories may include information regarding patients' stories, experiences, dreams, and rituals and their relevance. Interruptions and excessive questioning should be avoided if possible. Extended periods of silence may occur, and time should be allowed for patients to adjust and process information. Practitioners should avoid asking about family or personal matters unrelated to presenting issues without first asking permission to inquire about these areas. Native American patients often respond best when they are given suggestions and options rather than directions.

WHITE AMERICAN PATIENTS

In 2021, 76.3% of the U.S. population identified as White alone [60]. The U.S. Census Bureau defines White race as a person having origins in any of the original peoples of Europe, the Middle East, or North Africa [46]. While the proportion of the population identifying as White only decreased between 2010 and 2020, the numbers of persons identifying as White and another race/ethnicity increased significantly. The White population in the United States is diverse in its religious, cultural, and social composition. The greatest proportion of this group reports a German ancestry (17%), followed by Irish (13%), English (10%), and Italian (7%) [61].

Providers can assume that most well-accepted treatment approaches and interventions have been tested and evaluated with White American individuals, particularly men. However, approaches may need modification to suit class, ethnicity, religion, and other factors.

Providers should establish not only the patient's ethnic background but also how strongly the person identifies with that background. It is also important to be sensitive to a person's multiracial/multiethnic heritage, if present, and how this might affect their family relationships and social experiences. Assumption of White race should be avoided, as White-passing persons of color have their own unique needs.

BARRIERS TO INCLUSION

Culturally diverse patients experience a variety of barriers when seeking health and mental health care, including:

- Immigration status

- Lower socioeconomic status

- Language barriers

- Cultural differences

- Lack of or poor health insurance coverage

- Fear of or experiences with provider discrimination

- Mistrust of healthcare systems

Such obstacles can interfere with or prevent access to treatment and services, compromise appropriate referrals, affect compliance with recommendations, and result in poor outcomes. Culturally competent providers build and maintain rich referral resources to meet patients' assorted needs.

Encountering discrimination when seeking health or mental health services is a barrier to optimal care and contributor to poorer outcomes in under-represented groups. Some providers will not treat patients because of moral objections, which can affect all groups, but particularly those who are gender and/or sexual minorities, religious minorities, and/or immigrants. In fact, in 2016, Mississippi and Tennessee passed laws allowing health providers to refuse to provide services if doing so would violate their religious beliefs [62]. However, it is important to remember that providers are obligated to act within their profession's code of ethics and to ensure all patients receive the best possible care.

CULTURALLY RESPONSIVE COMMUNICATION

Styles of communication can be classified from high- to low-context [63]. High-context cultures are those cultures that disseminate information relying on shared experience, implicit messages, nonverbal cues, and the relationship between the two parties [64,65]. Members of these cultural groups tend to listen with their eyes and focus on how something was said or conveyed [63,66]. On the other hand, low-context cultures rely on verbal communication or what is explicitly stated in the conversation [64]. Consequently, low-context communicators listen with their ears and focus on what is being said [63,65,66]. Western culture, including the United States, can be classified as a low-context culture. On the other hand, groups from collectivistic cultures, such as Asian/Pacific Islanders, Hispanics, Native Americans, and Black Americans, are from high-context cultures [63].

Communicators from high-context cultures generally display the following characteristics [64,65,66,67]:

- Use of indirect modes of communication

- Use of vague descriptions

- Less talk and less eye contact

- Interpersonal sensitivity

- Use of feelings to facilitate behavior

- Assumed recollection of shared experiences

- Reliance on nonverbal cues such as gestures, tone of voice, posture, voice level, rhythm of speaking, emotions, and pace and timing of speech

- Assimilation of the "whole" picture, including visual and auditory cues

- Emotional speech

- Use of silence

- Use of more formal language, emphasizing hierarchy between parties

On the other hand, low-context communicators can typically be described as [64,65,66]:

- Employing direct patterns of communication

- Using explicit descriptions and terms

- Assuming meanings are described explicitly

- Utilizing and relying minimally on nonverbal cues

- Speaking more and often raising their voices (more animated, dramatic)

- Often being impatient to get to the point of the discussion

- Using more informal language; less emphasis on hierarchy, more equality between parties (more friendly)

- Being more comfortable with fluidness and change

- Uncomfortable using long pauses and storytelling as a means of communicating

Understanding the distinctions between individuals who come from high- and low-context cultures can promote cultural sensitivity. However, it is vital that practitioners take heed of several words of caution. First, it is important not to assume that two individuals sharing the same culture (e.g., low-context culture) will automatically have a shared script for communicating. Second, it is important to not immediately classify an individual into a low- or high-context culture because of their ethnicity. Third, a major criticism of the discussion of low-/high-context cultures is that they reinforce dualism and ultimately oversimplify the complexities and nuances of communication [68].

In this multicultural landscape, interpreters are a valuable resource to help bridge the communication and cultural gap between clients/patients and practitioners. Interpreters are more than passive agents who translate and transmit information back and forth from party to party. When they are enlisted and treated as part of the interdisciplinary clinical team, they serve as cultural brokers, who ultimately enhance the clinical encounter. In any case in which information regarding diagnostic procedures, treatment options, and medication/treatment measures are being provided, the use of an interpreter should be considered. Whenever possible, professional interpreters are preferred. Family interpreters should be avoided if at all possible.

Preferred language and immigration/migration status should be considered. Stressing confidentiality and privacy is particularly important for undocumented workers or recent immigrants, who may be fearful of deportation.

RACIAL AND REPRODUCTIVE JUSTICE

Racial biases in healthcare access, treatment, and outcomes and institutional racism embedded in healthcare institutions contribute to poorer health outcomes in minority populations. Many healthcare organizations are committing to the improvement of racial inequalities by dedicating resources and infrastructure to negating this problem. Healthcare organizations and practitioners have a vital role in acknowledging and dismantling structural racism [69].

Race Forward defines racial justice as "a vision and transformation of society to eliminate racial hierarchies and advance collective liberation, where Black, Indigenous, Latinx, Asian Americans, Native Hawaiians, and Pacific Islanders, in particular, have the dignity, resources, power, and self-determination to fully thrive" [70]. In the context of health care, this concept is related to eliminating race-related health disparities, ensuring access and quality of care for minority groups, and improving quality of life for all persons, regardless of race, color, or ethnicity. This requires that practitioners take a perspective of cultural humility and proactively move to dismantle harmful stereotypes and practices.

It is vital to actively listen and critically evaluate patient relationships. All practitioners should seek to educate themselves regarding the experiences of patients who are members of a community that differs from their own. Resources and opportunities to collaborate may be available from community organizations and leaders.

The term "reproductive justice" was coined by a group of Black women in 1994 [90]. This concept, linked to racial justice, is based on the core belief that sexual and reproductive justice exists when all people have the power and resources to make healthy decisions about their bodies, sexuality, and reproduction. Reproductive justice sheds light on the multiple combined forms of oppression that contribute to the reproductive oppression of women of color. This perspective asserts that intersecting systems of oppression (e.g., race, class, gender) result in the control and exploitation of women, girls, gender-expansive individuals, and others through their bodies, sexuality, labor, and/or reproduction [90]. Persons who experience multiple oppressions experience more severe maternal morbidity. Only addressing all of the systemic issues contributing to poorer maternal health outcomes in persons of color will resolve racial health disparities in the United States.

5. INTERVENTIONS TO REDUCE IMPLICIT BIAS AND RELATED MATERNAL HEALTH DISPARITIES

According to the CDC, interventions to address bias on multiple levels can reduce pregnancy-related deaths [2]. Healthcare systems should foster a respectful maternity culture by hiring and retaining a diverse labor force and training all healthcare staff to identify implicit bias and stigma. The CDC also recommends healthcare systems promote quality improvement measures, focusing on increasing the respectful maternity culture for all women, so all patients feel they are equal regardless of race, ethnicity, or socioeconomic status. It is also ideal for healthcare professionals to strive for all maternal patients to feel respected, understood, supported, and valued throughout their care [2].

The American College of Obstetricians and Gynecologists makes the following recommendations for obstetrician/gynecologists and other healthcare providers to improve patient-centered care and decrease inequities in reproductive health care by [71]:

- Inquiring about and documenting social and structural determinants of health that may influence a patient's health and use of health care

- Maximizing referrals to social services to help improve patients' abilities to fulfill these needs

- Providing access to interpreter services for all patient interactions when patient language is not the clinicians' language

- Recognizing that stereotyping patients using presumed cultural beliefs can negatively affect patient interactions, especially when patients' behaviors are attributed solely to individual choices without recognizing the role of social and structural factors

The CDC has also launched the Hear Her campaign to provide resources for practitioners and pregnant and postpartum women, with an emphasis on preventing pregnancy-related deaths by sharing potentially life-saving messages about urgent warning signs. The Hear Her campaign can be accessed online at https://www.cdc.gov/hearher.

Adherence to guideline-endorsed practice may also help to reduce health disparities. In a Ghanaian study, provider adherence to antenatal care guidelines beginning in the first visit improved delivery and neonatal outcomes [89]. In addition, racial and ethnic disparities in severe maternal morbidity and mortality may be at least partially explained by variation in hospital quality. The majority of Black women who deliver in the United States (75%) do so in only 25% of hospitals; only 18% of White women deliver in those same hospitals [1]. The hospitals more likely to serve Black communities have higher risk-adjusted severe maternal morbidity rates, regardless of the patient's race/ethnicity, than the national average. Improving access to high-quality maternal health care and adherence to antenatal and postpartum guidelines may thus effectively reduce racial disparities in maternal morbidity and mortality.

In addition to these strategies, practitioners should act to address their own implicit biases. Interventions or strategies designed to reduce implicit bias may be categorized as change-based or control-based. Change-based interventions focus on reducing or changing cognitive associations underlying implicit biases. These interventions might include challenging stereotypes. Conversely, control-based interventions involve reducing the effects of the implicit bias on the individual's behaviors [72]. These strategies include increasing awareness of biased thoughts and responses. The two types of interventions are not mutually exclusive and may be used synergistically.

PERSPECTIVE TAKING

Perspective taking is a strategy of taking on a first-person perspective of a person in order to control one's automatic response toward individuals with certain social characteristics that might trigger implicit biases [73]. The goal is to increase psychological closeness, empathy, and connection with members of the group [39]. Engaging with media that presents a perspective (e.g., watching documentaries, reading an autobiography) can help promote better understanding of the specific group's lives, experiences, and viewpoints. In one study, participants who adopted the first-person perspectives of Black Americans had more positive automatic evaluations of the targeted group [74].

EMPATHY INTERVENTIONS

Promoting positive emotions such as empathy and compassion can help reduce implicit biases. This can involve strategies like perspective taking and role playing [75]. In a study examining analgesic prescription disparities, nurses were shown photos of White or African American patients exhibiting pain and were asked to recommend how much pain medication was needed; a control group was not shown photos. Those who were shown images of patients in pain displayed no differences in recommended dosage along racial lines; however, those who did not see the images averaged higher recommended dosages for White patients compared with Black patients [76]. This suggests that professionals' level of empathy (enhanced by seeing the patient in pain) affected prescription recommendations.

In a study of healthcare professionals randomly assigned to an empathy-inducing group or a control group, participants were given the IAT to measure implicit bias prior to and following the intervention. The level of implicit bias among participants in the empathy-inducing group decreased significantly compared with their control group counterparts [77].

INDIVIDUATION

Individuation is an implicit bias reduction intervention that involves obtaining specific information about the individual and relying on personal characteristics instead of stereotypes of the group to which he or she belongs [39,73]. The key is to concentrate on the person's specific experiences, achievements, personality traits, qualifications, and other personal attributes rather than focusing on gender, race, ethnicity, age, ability, and other social attributes, all of which can activate implicit biases. When providers lack relevant information, they are more likely to fill in data with stereotypes, in some cases unconsciously. Time constraints and job stress increase the likelihood of this occurring [78].

MINDFULNESS

Mindfulness requires stopping oneself and deliberately emptying one's mind of distractions or allowing distractions to drift through one's mind unimpeded, focusing only on the moment; judgment and assumptions are set aside. This approach involves regulating one's emotions, responses, and attention to return to the present moment, which can reduce stress and anxiety [79]. There is evidence that mindfulness can help regulate biological and emotional responses and can have a positive effect on attention and habit formation [39]. A mindfulness activity assists individuals to be more aware of their thoughts and sensations. This focus on deliberation moves the practitioner away from a reliance on instincts, which is the foundation of implicit bias-affected practice [39,80].

Mindfulness approaches include yoga, meditation, and guided imagery. One approach to mindfulness using the acronym STOPP has been developed as a practical exercise to engage in mindfulness in any moment. STOPP is an acronym for [81]:

- Stop

- Take a breath

- Observe

- Pull back

- Practice

Mindfulness practice has been explored as a technique to reduce activation or triggering of implicit bias, enhance awareness of and ability to control implicit biases that arise, and increase capacity for compassion and empathy toward patients by reducing stress, exhaustion, and compassion fatigue [82]. One study examined the effectiveness of a loving-kindness meditation practice training in improving implicit bias toward Black and unhoused persons. One hundred one non-Black adults were randomized to one of three groups: a six-week loving-kindness mindfulness practice, a six-week loving-kindness discussion, or the waitlist control. The IAT was used to measure implicit biases, and the results showed that the loving-kindness meditation practice decreased levels of implicit biases toward both groups [83].

COUNTER-STEREOTYPICAL IMAGING

Counter-stereotypical imaging approaches involve presenting an image, idea, or construct that is counter to the oversimplified stereotypes typically held regarding members of a specific group. In one study, participants were asked to imagine either a strong woman (the experimental condition) or a gender-neutral event (the control condition) [84]. Researchers found that participants in the experimental condition exhibited lower levels of implicit gender bias. Similarly, exposure to female leaders was found to reduce implicit gender bias [85]. Whether via increased contact with stigmatized groups to contradict prevailing stereotypes or simply exposure to counter-stereotypical imaging, it is possible to unlearn associations underlying various implicit biases. If the social environment is important in priming positive evaluations, having more positive visual images of members in stigmatized groups can help reduce implicit biases. Some have suggested that even just hanging photos and having computer screensavers reflecting positive images of various social groups could help to reduce negative associations [86].

CHIEF EQUITY OFFICERS

Equity teams are encouraged to help with implicit bias in healthcare institutions. A chief equity officer has strong relationships in the delivery system and works to ensure health equity is prioritized. Those in this role are leaders with practical oversight of healthcare delivery and implementation. Equity officers are distinct from chief diversity officers, who focus more on internal recruiting, retention, and inclusion opportunities. An equity officer drives an agenda that addresses internal performance in quality and access for all patients, particularly vulnerable patients [87].

Chief equity officers often concentrate on staff preparation, responsibility, and biases, and work to assess and improve how staff regard and treat all patients, regardless of race, ethnicity, gender/sex, or socioeconomic status. Chief equity officers implement approaches to engage providers and the wider community to support and address medical and nonmedical (social determinants) risks to health outcomes [87].

6. RESOURCES

Maternal Mortality Review Committees

http://reviewtoaction.org/tools/networking-map

CDC Working Together to Reduce Black Maternal Mortality

https://www.cdc.gov/healthequity/features/maternal-mortality/index.html

American Bar Association Diversity and Inclusion Center

Toolkits and Projects

https://www.americanbar.org/groups/diversity/resources/toolkits

National Implicit Bias Network

https://implicitbias.net/resources/resources-by-category

New Jersey Maternal Care Quality Collaborative (NJMCQC)

https://www.nj.gov/health/maternal/mcqc

Ohio State University

The Women's Place: Implicit Bias Resources

https://womensplace.osu.edu/resources/implicit-bias-resources

Ohio State University

Kirwan Institute for the Study of Race and Ethnicity

http://kirwaninstitute.osu.edu

Partnership for Maternal and Child Health of Northern New Jersey

https://www.partnershipmch.org

University of California, Los Angeles

Equity, Diversity, and Inclusion: Implicit Bias

https://equity.ucla.edu/know/implicit-bias

University of California, San Francisco, Office of Diversity and Outreach

Unconscious Bias Resources

https://diversity.ucsf.edu/resources/unconscious-bias-resources

Unconscious Bias Project

https://unconsciousbiasproject.org

7. CONCLUSION

There is no question that maternal health disparities are a significant problem in the United States. Inequalities have been associated with many factors, including education level, literacy, age, and socioeconomic status. However, the greatest disparities have been noted among racial/ethnic minority women and have been linked to explicit and implicit biases in healthcare providers and systems. It is of the utmost importance that those caring for patients in the peripartum and postpartum period are committed to lowering the morbidity and mortality rates of all mothers of color. Promoting equity and cultural competence, effectively addressing modifiable risk factors, improving communication and monitoring, and engaging in regular training are needed to improve the health and outcomes of this population.

8. GLOSSARY

Pregnancy-associated death: A death during or within one year of pregnancy, regardless of the cause [88].

Pregnancy-related death: A death during or within one year of pregnancy, from a pregnancy complication, a chain of events initiated by pregnancy, or the aggravation of an unrelated condition by the physiologic effects of pregnancy [88].

Preventability: A death is considered preventable if there was at least some chance of the death being prevented by one or more reasonable changes to patient, family, provider, facility, system, and/or community factors. This definition is used by maternal mortality review committees to determine if a death they review is preventable [88].

Maternal death: The death of a woman while pregnant or within 42 days of termination of pregnancy, regardless of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental causes. This definition is used by the National Center for Health Statistics and the World Health Organization [88].

Maternal mortality ratio: The number of maternal deaths (as defined) per 100,000 live births. Also referred to as the maternal mortality rate [88].

Maternal mortality: Number of deaths during pregnancy, childbirth, and the postpartum period up to 365 days from the end of pregnancy [88].

Works Cited

1. Howell EA. Reducing disparities in severe maternal morbidity and mortality. Clin Obstet Gynecol. 2018;61(2):387-399.

2. Centers for Disease Control and Prevention. Many Women Report Mistreatment During Pregnancy and Delivery. Available at https://www.cdc.gov/vitalsigns/respectful-maternity-care/index.html. Last accessed October 2, 2023.

3. UNICEF. Maternal mortality. Available at https://data.unicef.org/topic/maternal-health/maternal-mortality. Last accessed October 5, 2023.

4. Hoyert DL. Maternal Mortality Rates in the United States, 2021. Available at https://www.cdc.gov/nchs/data/hestat/maternal-mortality/2021/maternal-mortality-rates-2021.htm. Last accessed October 5, 2023.

5. Trost S, Beauregard J, Chandra G, et al. Pregnancy-Related Deaths: Data from Maternal Mortality Review Committees in 36 U.S. States, 2017–2019. Available at https://www.cdc.gov/reproductivehealth/maternal-mortality/erase-mm/data-mmrc.html. Last accessed October 5, 2023.

6. Fleszar LG, Bryant AS, Johnson CO, et al. Trends in state-level maternal mortality by racial and ethnic group in the United States. JAMA. 2023;330(1):52-61.

7. Harris E. US maternal mortality continues to worsen. JAMA. 2023;329(15):1248.

8. U.S. Government Accounting Office. Maternal Health: Outcomes Worsened and Disparities Persisted During the Pandemic. Available at https://www.gao.gov/products/gao-23-105871. Last accessed October 5, 2023.

9. Centers for Disease Control and Prevention. How Does CDC Identify Severe Maternal Morbidity? Available at https://www.cdc.gov/reproductivehealth/maternalinfanthealth/smm/severe-morbidity-ICD.htm. Last accessed October 5, 2023.

10. Admon LK, Winkelman TNA, Zivin K, Terplan M, Mhyre JM, Dalton VK. Racial and ethnic disparities in the incidence of severe maternal morbidity in the United States, 2012–2015. Obstet Gynecol. 2018;132(5):1158-1166.

11. New Jersey Department of Health. New Jersey Hospital Maternity Care Report Card, 2020. Available at https://www.nj.gov/health/maternal/documents/hospital_report_card_mathodology_2020.pdf. Last accessed October 5, 2023.

12. New Jersey Department of Health. New Jersey Maternal Mortality Report 2016-2018. Available at https://www.nj.gov/health/fhs/maternalchild/documents/New%20Jersey%20Maternal%20Mortality%20Report%202016-2018.pdf. Last accessed October 5, 2023.

13. Georgetown University National Center for Cultural Competence. Conscious and Unconscious Biases in Health Care. Available at https://nccc.georgetown.edu/bias. Last accessed October 5, 2023.

14. Amodio DM. The social neuroscience of intergroup relations. Eur Rev Soc Psychol. 2008;19(1):1-54.

15. Blair IV, Steiner JF, Havranek EP. Unconscious (implicit) bias and health disparities: where do we go from here? Perm J. 2011;15(2):71-78.

16. Hall WJ, Chapman MV, Lee KM, et al. Implicit racial/ethnic bias among health care professionals and its influence on health care outcomes: a systematic review. Am J Public Health. 2015;105(12):e60-e76.

17. Matthew DB. Toward a structural theory of implicit racial and ethnic bias in health care. Health Matrix. 2015;5(1)61-85.

18. Baron AS, Banaji MR. The development of implicit attitudes: evidence of race evaluations from ages 6 and 10 and adulthood. Psychol Sci. 2006;17(1):53-58.

19. Ogungbe O, Mitra AK, Roberts JK. A systematic review of implicit bias in health care: a call for intersectionality. IMC Journal of Medical Science. 2019;13(1):1-16.

20. Georgetown University National Center for Cultural Competence. What the Literature Is Telling Us? Available at https://nccc.georgetown.edu/bias/module-2/2.php. Last accessed October 5, 2023.

21. FitzGerald C, Martin A, Berner D, Hurst S. Interventions designed to reduce implicit prejudices and implicit stereotypes in real world contexts: a systematic review. BMC Psychol. 2019;7(1):29.

22. FitzGerald C, Hurst S. Implicit bias in healthcare professionals: a systematic review. BMC Med Ethics. 2017;18(1):19.

23. Institute of Medicine Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care, Smedley BD, Stith AY, Nelson AR (eds). Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare. Washington, DC: National Academies Press; 2003.

24. Dehlendorf C, Bryant AS, Huddleston HG, Jacoby VL, Fujimoto VY. Health disparities: definitions and measurements. Am J Obstet Gynecol. 2010;202(3):212-213.

25. Centers for Disease Control and Prevention. Health Disparities Among Youth. Available at https://www.cdc.gov/healthyyouth/disparities/index.htm. Last accessed October 5, 2023.

26. Chapman EN, Kaatz A, Carnes M. Physicians and implicit bias: how doctors may unwittingly perpetuate health care disparities.J Gen Intern Med. 2013;28(11):1504-1510.

27. Hahn SD. What are Power Dynamics? Available at https://global.sacap.edu.za/blog/communication/what-are-power-dynamics. Last accessed October 5, 2023.

28. McDonald J, Jayasuriya R, Harris MF. The influence of power dynamics and trust on multidisciplinary collaboration: a qualitative case study of type 2 diabetes mellitus. BMC Health Serv Res. 2012;12:63.

29. Penner LA, Hagiwara N, Eggly S, Gaertner SL, Albrecht TL, Dovidio JF. Racial healthcare disparities: a social psychological analysis. Eur Rev Soc Psychol. 2013;24(1):70-122.

30. Dowsett C. It's Time to Talk About Organizational Bias in Data Use. Available at https://towardsdatascience.com/lets-talk-about-organizational-bias-in-data-use-92ba83bb2c59. Last accessed October 5, 2023.

31. Sabin JA. Tackling implicit bias in health care. N Engl J Med. 2022;387(2):105-107.

32. Sukhera J, Wodzinski M, Rehman M, Gonzalez CM. The Implicit Association Test in health professions education: a meta-narrative review. Perspect Med Educ. 2019;8(5):267-275.

33. Johnson R, Richard-Eaglin A. Combining SOAP notes with guided reflection to address implicit bias in health care. J Nurs Educ. 2020;59(1):59-59.

34. Zestcott CA, Blair IV, Stone J. Examining the presence, consequences, and reduction of implicit bias in health care: a narrative review. Group Process Intergroup Relat. 2016;19(4):528-542.

35. Saluja B, Bryant Z. How implicit bias contributes to racial disparities in maternal morbidity and mortality in the United States.Journal of Women's Health. 2021;30(2).

36. Centers for Disease Control and Prevention. Maternal Deaths and Mortality Rates: Each State, the District of Columbia, United States, 2018–2021. Available at https://www.cdc.gov/nchs/maternal-mortality/MMR-2018-2021-State-Data.pdf. Last accessed October 5, 2023.

37. Howell EA, Ahmed ZN. Eight steps for narrowing the maternal health disparity gap: step-by-step plan to reduce racial and ethnic disparities in care. Contemp Ob Gyn. 2019;64(1):30-36.

38. Leonard SA, Main EK, Scott KA, Profit J, Carmichael SL. Racial and ethnic disparities in severe maternal morbidity prevalence and trends. Annals of Epidemiology. 2019;33:30-36.

39. Edgoose J, Quiogue M, Sidhar K. How to identify, understand, and unlearn implicit bias in patient care. Fam Pract Manag. 2019;26(4):29-33.

40. Bixby Center for Global Reproductive Health. Racial Inequities in Treatment for Pain after Cesarean Birth. Available at https://bixbycenter.ucsf.edu/news/racial-inequities-treatment-pain-after-cesarean-birth. Last accessed October 5, 2023.

41. American College of Obstetricians and Gynecologists. Racism in Obstetrics and Gynecology. Available at https://www.acog.org/clinical-information/policy-and-position-statements/statements-of-policy/2022/racism-in-obstetrics-gynecology. Last accessed October 5, 2023.

42. National Geographic. Cultural Identity. Available at https://education.nationalgeographic.org/resource/resource-library-cultural-identity. Last accessed October 5, 2023.

43. Wilson V. What is Cultural Identity and Why is it Important? Available at https://www.exceptionalfutures.com/cultural-identity. Last accessed October 5, 2023.

44. Substance Abuse and Mental Health Services Administration. Improving Cultural Competence: Quick Guide for Clinicians. Available at https://store.samhsa.gov/sites/default/files/d7/priv/sma16-4931.pdf. Last accessed September 21, 2023.

45. Agency for Healthcare Quality and Research. Health Literacy Universal Precautions Toolkit, 2nd Edition. Available at https://www.ahrq.gov/health-literacy/improve/precautions/index.html. Last accessed October 5, 2023.

46. U.S. Census Bureau. About Race. Available at https://www.census.gov/topics/population/race/about.html. Last accessed October 5, 2023.

47. American Psychiatric Association. Working with African American/Black Patients. Available at https://www.psychiatry.org/psychiatrists/diversity/education/best-practice-highlights/working-with-african-american-patients. Last accessed October 5, 2023.

48. Lee E. Asian American families: an overview. In: McGoldrick M, Giordano J, Pearce JK (eds). Ethnicity and Family Therapy. 2nd ed. New York, NY: The Guilford Press; 1996: 227-248.

49. U.S. Census Bureau. We the People: Asians in the United States: Census 2000 Special Reports. Available at https://www.census.gov/prod/2004pubs/censr-17.pdf. Last accessed October 5, 2023.

50. U.S. Census Bureau. Asian American, Native Hawaiian and Pacific Islander Heritage Month: May 2023. Available at https://www.census.gov/newsroom/facts-for-features/2023/asian-american-pacific-islander.html. Last accessed October 5, 2023.

51. Budiman A, Ruiz NG. Asian Americans are the Fastest-Growing Racial or Ethnic Group in the U.S. Available at https://www.pewresearch.org/fact-tank/2021/04/09/asian-americans-are-the-fastest-growing-racial-or-ethnic-group-in-the-u-s. Last accessed October 5, 2023.

52. Pew Research Center. U.S. Hispanic Population Growth has Leveled Off. Available at https://www.pewresearch.org/fact-tank/2017/08/03/u-s-hispanic-population-growth-has-leveled-off. Last accessed October 5, 2023.

53. Pew Research Center. The Demographics of Asian Americans. Available at https://www.pewresearch.org/social-trends/2013/04/04/asian-groups-in-the-u-s. Last accessed October 5, 2023.

54. Ong P, Ong E. The Future of Asian America in 2040 Asian American Electorate to Double. Available at https://escholarship.org/content/qt5c07t9tk/qt5c07t9tk_noSplash_fd0688434f0006c3db86dc48f23c5857.pdf. Last accessed October 5, 2023.

55. U.S. Census Bureau. Hispanic Heritage Month 2023. Available at https://www.census.gov/newsroom/facts-for-features/2023/hispanic-heritage-month.html. Last accessed October 5, 2023.

56. Pew Research Center. 2015, Hispanic Population in the United States Statistical Portrait. Available at https://www.pewresearch.org/hispanic/2017/09/18/2015-statistical-information-on-hispanics-in-united-states-trend-data. Last accessed October 5, 2023.

57. Pew Hispanic Center. Hispanic Origin Profiles, 2010. Available at https://www.pewresearch.org/hispanic/2012/06/27/country-of-origin-profiles. Last accessed October 5, 2023.

58. U.S. Census Bureau. We the People: American Indians and Alaska Natives in the United States. Available at https://www.census.gov/library/publications/2006/dec/censr-28.html. Last accessed October 5, 2023.

59. U.S. Census Bureau. Facts for Features: American Indian and Alaska Native Heritage Month: November 2022. Available at https://www.census.gov/newsroom/facts-for-features/2022/aian-month.html. Last accessed October 5, 2023.

60. U.S. Census Bureau. QuickFacts: United States. Available at https://www.census.gov/quickfacts/fact/table/US/PST045221. Last accessed October 5, 2023.

61. U.S. Census Bureau. American Community Survey: B04006 People Reporting Ancestry. Available at https://data.census.gov/cedsci/table?q=ancestry&tid=ACSDT1Y2019.B04006. Last accessed October 5, 2023.

62. Wang T, Cahill S. Antitransgender political backlash threatens health and access to care. Am J Public Health. 2018;108(5):609-610.

63. Singh NN, Mckay JD, Singh AN. Culture and mental health: nonverbal communication. J Child Fam Stud. 1998;7(4):403-409.

64. Lynch EW, Hanson MJ (eds). Developing Cross-Cultural Competence: A Guide for Working with Children and Their Families. 4th ed. Baltimore, MD: Paul H. Brookes Publishing, Co.; 2011.

65. Manrai LA, Manrai AK, Lascu D, Friedeborn S. Determinants and effects of cultural context: a review, conceptual model, and propositions. Journal of Global Marketing. 2019;32(2):67-82.

66. Okun BF, Fried J, Okun ML. Understanding Diversity: A Learning-As-Practice Primer. Pacific Grove, CA: Brooks/Cole Publishing Co.; 1999.

67. Gudykunst WB. Asian American Ethnicity and Communication. Thousand Oaks, CA: Sage; 2001.

68. Chang H, Chen L. Commonalities as an alternative approach to analyzing Asian Pacific communication. Journal of Asian Pacific Communication. 2015;25(1):1-21.

69. Reid A, Brandes R, Butler-MacKay D, et al. Getting grounded: building a foundation for health equity and racial justice work in health care teams. NEJM Catalyst. 2022;3(1).

70. Race Forward. What Is Race Equity? Available at https://www.raceforward.org/what-racial-equity-0. Last accessed October 5, 2023.

71. ACOG Committee on Health Care for Underserved Women. ACOG Committee Opinion No. 729: Importance of social determinants of health and cultural awareness in the delivery of reproductive health care. Obstet Gynecol. 2018;131(1):e43-e48.

72. Wong Y-LR, Vinsky J. Beyond implicit bias: embodied cognition, mindfulness, and critical reflective practice in social work. Australian Social Work. 2021;74(2):186-197.

73. Devine PG, Forscher PS, Austin AJ, Cox WT. Long-term reduction in implicit race bias: a prejudice habit-breaking intervention. J Exp Soc Psychol. 2012;48(6):267-1278.

74. Todd AR, Bodenhausen GV, Richeson JA, Galinsky AD. Perspective taking combats automatic expressions of racial bias. J Pers Soc Psychol. 2011;100(6):1027-1042.

75. Sukhera J, Watling CA. A framework for integrating implicit bias recognition into health professions education. Acad Med. 2018;93(1):35-40.

76. Drwecki BB, Moore CF, Ward SE, Prkachin KM. Reducing racial disparities in pain treatment: the role of empathy and perspective-taking. Pain. 2011;152(5):1001-1006.

77. Whitford DK, Emerson AM. Empathy intervention to reduce implicit bias in pre-service teachers. Psychol Rep. 2019;122(2):670-688.

78. Chapman EN, Kaatz A, Carnes M. Physicians and implicit bias: how doctors may unwittingly perpetuate health care disparities. J Gen Intern Med. 2013;28(11):1504-1510.

79. Mayo Clinic. Consumer Health: Mindfulness Exercises. Available at https://www.mayoclinic.org/healthy-lifestyle/consumer-health/in-depth/mindfulness-exercises/art-20046356. Last accessed October 5, 2023.

80. Narayan MC. Addressing implicit bias in nursing: a review. American Journal of Nursing. 2019;119(7):36-43.

81. Goldstein E. The STOP Practice. Available at https://www.mindful.org/the-s-t-o-p-practice-for-stress. Last accessed October 5, 2023.

82. Burgess DJ, Beach MC, Saha S. Mindfulness practice: a promising approach to reducing the effects of clinician implicit bias on patients. Patient Educ Couns. 2017;100(2):372-376.

83. Kang Y, Gray JR, Dovidio JF. The nondiscriminating heart: lovingkindness meditation training decreases implicit intergroup bias.J Exp Psychol Gen. 2014;143(3):1306-1313.

84. Blair IV, Ma JE, Lenton AP. Imagining stereotypes away: the moderation of implicit stereotypes through mental imagery. J Pers Soc Psychol. 2001;81(5):828-841.

85. Dasgupta N, Asgari, S. Seeing is Believing: exposure to counterstereotypic women leaders and its effect on the malleability of automatic gender stereotyping. J Exp Soc Psychol. 2004;40(5):642-658.

86. National Center for States Courts. Addressing Implicit Bias in the Courts. Available at https://www.nccourts.gov/assets/inline-files/public-trust-12-15-15-IB_Summary_033012.pdf?q_DMMIVv0v_eDJUa1ADxtw59Zt_svPgl. Last accessed October 5, 2023.

87. Agrawal S, Enekwechi A. It's Time to Address the Role of Implicit Bias Within Health Care Delivery. Available at https://www.healthaffairs.org/content/forefront/s-time-address-role-implicit-bias-within-health-care-delivery. Last accessed October 5, 2023.

88. Review to Action. Definitions. Available at http://reviewtoaction.org/learn/definitions. Last accessed October 5, 2023.

89. Amoakoh-Coleman M, Klipstein-Grobusch K, Agyepong IA, Kayode GA, Grobbee DE, Ansah EK. Provider adherence to first antenatal care guidelines and risk of pregnancy complications in public sector facilities: a Ghanaian cohort study. BMC Pregnancy Childbirth. 2016;16(1):369.

90. National Black Women's Reproductive Justice Agenda, Interfaith Voices for Reproductive Justice, SisterLove, Inc. Black Reproductive Justice Policy Agenda: June 2021. Available at https://blackrj.org/blackrjpolicy. Last accessed October 17, 2023.

Evidence-Based Practice Recommendations Citations

1. American College of Obstetricians and Gynecologists, Society for Maternal-Fetal Medicine, Kilpatrick SK, Ecker JL. Severe maternal morbidity: screening and review. Am J Obstet Gynecol. 2016;215(3):B17-B22. Available at https://www.acog.org/clinical/clinical-guidance/obstetric-care-consensus/articles/2016/09/severe-maternal-morbidity-screening-and-review. Last accessed October 16, 2023.

2. Centers for Disease Control and Prevention. Working Together to Reduce Black Maternal Mortality. Available at https://www.cdc.gov/healthequity/features/maternal-mortality. Last accessed October 17, 2023.

77723 • Ethics for Counselors

Alice Yick Flanagan, PhD, MSW

Michele Nichols, RN, BSN, MA

www.netce.com

Copyright © 2022 NetCE, All rights reserved.

The purpose of this course is to increase the professional counselor's knowledge base about ethical theories, principles, and the application of these principles to counseling practice. A historical context of ethics in counseling and in the larger context of the helping professions, such as medicine, social work, and other human service areas, will be explored. The course will also examine the specific components of ethical theories, ethical decision-making processes, the psychological context of moral development, multiculturalism, and the field's two major codes of ethics.

Table of Contents

77723 • Ethics for Counselors

Course Overview

Audience

Course Objective

Learning Objectives

Faculty

Faculty Disclosure

Director of Development and Academic Affairs

Director Disclosure Statement

About the Sponsor

Disclosure Statement

Implicit Bias in Health Care

1. INTRODUCTION

2. HISTORICAL CONTEXT OF COUNSELING ETHICS

HISTORY OF COUNSELING IN THE UNITED STATES

HISTORY OF ETHICS

PHILOSOPHICAL HISTORY OF MODERN ETHICS

3. COMMON TERMS USED IN THE DISCUSSION OF ETHICS

VALUES

ETHICS

4. VALUES AND ETHICAL PRINCIPLES IN ETHICAL CODES

ACA CODE OF ETHICS

NBCC CODE OF ETHICS

5. ETHICAL THEORIES

VIRTUE ETHICS

TELEOLOGIC ETHICAL THEORIES

MOTIVIST ETHICAL THEORIES

NATURAL LAW ETHICAL THEORY

TRANSCULTURAL ETHICAL THEORY

FEMINIST ETHICS

RELATIONAL ETHICS

ASSESSING ETHICAL THEORIES

PRACTICAL APPLICATIONS OF ETHICAL THEORIES

6. ETHICAL DECISION-MAKING FRAMEWORKS

DECISION-MAKING MODELS FOR ETHICAL DILEMMAS

LIMITATIONS OF ETHICAL DECISION-MAKING FRAMEWORKS

7. ETHICAL SELF-REFLECTION

PSYCHOLOGICAL CONTEXT OF MORAL DECISION MAKING

8. MANAGED CARE AND ETHICS

9. DIVERSITY AND MULTICULTURALISM: ETHICAL ISSUES

DEMOGRAPHIC SHIFTS

MULTICULTURALISM IN RESEARCH

DEBATES WITHIN MULTICULTURALISM/DIVERSITY AND ETHICS

INFUSING DIVERSITY INTO THE ETHICAL DECISION-MAKING MODELS

MULTICULTURALISM/DIVERSITY AND THE ACA CODE OF ETHICS

MULTICULTURALISM/DIVERSITY AND THE NBCC CODE OF ETHICS

10. ONLINE COUNSELING

LIMITATIONS OF ONLINE COUNSELING

ONLINE COMMUNICATIONS AND DISTANCE COUNSELING: A SOCIOCULTURAL CONTEXT

ETHICAL AND LEGAL ISSUES

ACA CODE OF ETHICS AND DISTANCE COUNSELING

NBCC STANDARDS FOR THE PROVISION OF TELEMENTAL HEALTH SERVICES

11. INTERPROFESSIONAL COLLABORATION AND ETHICS

12. CONCLUSION

13. RESOURCES

14. APPENDIX: THE ACA CODE OF ETHICS

SECTION A: THE COUNSELING RELATIONSHIP

SECTION B: CONFIDENTIALITY AND PRIVACY

SECTION C: PROFESSIONAL RESPONSIBILITY

SECTION D: RELATIONSHIPS WITH OTHER PROFESSIONALS

SECTION E: EVALUATION, ASSESSMENT, AND INTERPRETATION

SECTION F: SUPERVISION, TRAINING, AND TEACHING

SECTION G: RESEARCH AND PUBLICATION

SECTION H: DISTANCE COUNSELING, TECHNOLOGY, AND SOCIAL MEDIA

SECTION I: RESOLVING ETHICAL ISSUES

Works Cited

77723 • Ethics for Counselors

Education Category. Ethics - Human Rights

Release Date. 05/01/2022

Review Date. 05/18/2023

Expiration Date. 06/30/2026

Course Overview

The purpose of this course is to increase the professional counselor's knowledge base about ethical theories, principles, and the application of these principles to counseling practice. A historical context of ethics in counseling and in the larger context of the helping professions, such as medicine, social work, and other human service areas, will be explored. The course will also examine the specific components of ethical theories, ethical decision-making processes, the psychological context of moral development, multiculturalism, and the field's two major codes of ethics.

Audience

This intermediate to advanced course is designed for counselors and related professionals.

Course Objective

The purpose of this course is to increase the professional counselor's knowledge base about ethical theories, principles, and the application of these principles to counseling practice. A historical context of ethics in counseling and in the larger context of the helping professions, such as medicine, social work, and other human service areas, will be explored. The course will also examine the specific components of ethical theories, ethical decision-making processes, the psychological context of moral development, multiculturalism, and the field's two major codes of ethics.

Learning Objectives

Upon completion of this course, you should be able to:

1. Discuss the historical context of ethics in counseling.

2. Define common terms such as ethics, values, morality, ethical dilemmas, and ethical principles.

3. Discuss the ethical principles in the American Counseling Association (ACA) Code of Ethics and the National Board for Certified Counselors (NBCC) Code of Ethics.

4. Differentiate between deontologic, teleologic, motivist, natural law, transcultural ethical, feminist, and multicultural theories.

5. Identify the different ethical decision-making models.

6. Discuss the psychological context of ethical decision making by applying Lawrence Kohlberg's theory of moral development.

7. Outline ethical issues that emerge with counseling in managed care systems.

8. Review issues that arise in online counseling, including sociocultural context, ethical and legal issues, and standards for ethical practice.

Faculty

Alice Yick Flanagan, PhD, MSW, received her Master’s in Social Work from Columbia University, School of Social Work. She has clinical experience in mental health in correctional settings, psychiatric hospitals, and community health centers. In 1997, she received her PhD from UCLA, School of Public Policy and Social Research. Dr. Yick Flanagan completed a year-long post-doctoral fellowship at Hunter College, School of Social Work in 1999. In that year she taught the course Research Methods and Violence Against Women to Masters degree students, as well as conducting qualitative research studies on death and dying in Chinese American families.

Previously acting as a faculty member at Capella University and Northcentral University, Dr. Yick Flanagan is currently a contributing faculty member at Walden University, School of Social Work, and a dissertation chair at Grand Canyon University, College of Doctoral Studies, working with Industrial Organizational Psychology doctoral students. She also serves as a consultant/subject matter expert for the New York City Board of Education and publishing companies for online curriculum development, developing practice MCAT questions in the area of psychology and sociology. Her research focus is on the area of culture and mental health in ethnic minority communities.

Michele Nichols, RN, BSN, MA, received her Associates Degree in Nursing in 1977, her Bachelor of Science Degree in Nursing in 1981 and obtained her Master of Arts Degree in Ethics and Policy Studies in 1990 through the University of Nevada, Las Vegas. She was Chief Nurse Executive at Valley Hospital Medical Center in Las Vegas, Nevada, and retired as the System Director for the Valley Health System University, a five hospital system in Las Vegas, Nevada. She is currently a volunteer nurse for Volunteers in Medicine of Southern Nevada.

Faculty Disclosure

Contributing faculty, Alice Yick Flanagan, PhD, MSW, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Contributing faculty, Michele Nichols, RN, BSN, MA, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Director of Development and Academic Affairs

Sarah Campbell

Director Disclosure Statement

The Director of Development and Academic Affairs has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

About the Sponsor

The purpose of NetCE is to provide challenging curricula to assist healthcare professionals to raise their levels of expertise while fulfilling their continuing education requirements, thereby improving the quality of healthcare.

Our contributing faculty members have taken care to ensure that the information and recommendations are accurate and compatible with the standards generally accepted at the time of publication. The publisher disclaims any liability, loss or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents. Participants are cautioned about the potential risk of using limited knowledge when integrating new techniques into practice.

Disclosure Statement

It is the policy of NetCE not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners.

Implicit Bias in Health Care

The role of implicit biases on healthcare outcomes has become a concern, as there is some evidence that implicit biases contribute to health disparities, professionals' attitudes toward and interactions with patients, quality of care, diagnoses, and treatment decisions. This may produce differences in help-seeking, diagnoses, and ultimately treatments and interventions. Implicit biases may also unwittingly produce professional behaviors, attitudes, and interactions that reduce patients' trust and comfort with their provider, leading to earlier termination of visits and/or reduced adherence and follow-up. Disadvantaged groups are marginalized in the healthcare system and vulnerable on multiple levels; health professionals' implicit biases can further exacerbate these existing disadvantages.

Interventions or strategies designed to reduce implicit bias may be categorized as change-based or control-based. Change-based interventions focus on reducing or changing cognitive associations underlying implicit biases. These interventions might include challenging stereotypes. Conversely, control-based interventions involve reducing the effects of the implicit bias on the individual's behaviors. These strategies include increasing awareness of biased thoughts and responses. The two types of interventions are not mutually exclusive and may be used synergistically.

1. INTRODUCTION

Ethical issues do not exist within a vacuum; rather, they emerge, evolve, and adapt within the sociocultural context of a particular society. In past decades, the field of professional ethics has received increased attention. Much of the discussion began in the 1960s in the medical field, where the blending of ethics, legalities, and medicine has become known as bioethics. Its emergence occurred because there was a need to talk about how research and healthcare decisions and regulations could be made, who could make them, and what their long-term implications would be. In the late 1960s, philosophers, theologians, physicians, lawyers, policy makers, and legislators began to write about these questions, hold conferences, establish institutes, and publish journals for the study of bioethics. Around the same time, many existing professional organizations and agencies, such as those for counseling, social work, and law enforcement, began implementing their own ethical codes. When a new institution is young, the creation of a formal code of ethics is standard practice to inform prospective members, unify, advise, and protect existing members, help resolve ethics issues, protect those who the profession serves, and help establish and distinguish an organization, agency, and its members.

2. HISTORICAL CONTEXT OF COUNSELING ETHICS

HISTORY OF COUNSELING IN THE UNITED STATES

Modern psychology began with the work of Sigmund Freud in the 1880s in Vienna. By the early and mid-20th century, Sigmund Freud's psychoanalytical theories were being challenged, most notably by American psychologist Carl Rogers. While Freud examined the effects of the unconscious mind upon patients, Rogers' work focused on environmental factors, the patient's experience in the world, and the person-centered approach [50]. It was during this same time period that advanced education in medicine and certification was becoming required for psychoanalysts, because in the United States, analysis of the mind was viewed as a medical endeavor [50]. Frank Parsons, often called the father of vocational guidance, had established the new field of career counseling between the years 1906 and 1908 [52]. Rogers borrowed Parson's label, "counselor," and extended it to individuals who were educated in and practiced behavioral health both outside of the field of medicine and toward different goals than medical psychoanalysis [50]. This helped remove some of the prejudice against non-medically trained professionals and shifted the emphasis away from treating clients purely as medical patients to helping individuals and groups realize their developmental goals. The relatively new field of counseling that stemmed from Parsons' vocational guidance movement and Rogers' work was of particular value during World War II, when the need for vocational training became acute, and after the war, when a large number of people were integrating back into a society that had become profoundly different [51,52]. Some returned with psychologic problems, and many were left with disabilities. Many more had come home to a country where they could not find jobs.

Around this time, the American Psychological Association (APA) and the Veterans Administration (VA) both formed counseling psychology branches. The post-war era was a defining period because the need for trained professionals was so great, and counselors were increasingly seen as critical human service providers in the fields of psychology and employment services. Guidance counseling, with a focus on educational and career advancement, was still seen as a somewhat separate profession. Today, each branch of counseling is considered a practical application of psychology because the focus on human development and wellness issues deals directly with strategies to enable personal and family growth, career development, and life enhancement [53]. In addition, counselors advocate for patients and clients and connect them to services.

HISTORY OF ETHICS

Ethics have been discussed in various arenas since ancient times. The ethics that most Western counselors are familiar with are derivatives of the virtue ethics system developed by Greek philosophers such as Socrates, Plato, and most notably, Aristotle, in the 5th century B.C.E. Virtue ethics were thought to be a way to make decisions in life that developed strong personal character, based on attaining permanent happiness through knowledge, reason, restraint, and striving for excellence in physical and intellectual pursuits [54]. The word ethics has evolved from the ancient Greek word ethikos, meaning moral character, and implies that a personal character is constructed. The ability to engage in the ethical decision-making process, or thinking analytically about how an action will be viewed in the context of the community by applying its upheld virtues, develops strong character. The action will be viewed by others who can determine that the decision-maker is a virtuous person if the outcome is in line with the values of society. The community will have positive feelings about the person, the person will have positive self-esteem, and the end result will be happiness.

The virtues (i.e., values) of a particular society are based on what has been deemed important to that society; for example, liberty and justice are among the most important American values. It could be said that one who upholds these values with the sole intention of being virtuous is acting in a righteous way according to Aristotelian virtue ethics [54]. In other words, virtues are values, and being virtuous is acting ethically. It must be acknowledged that not all societies have similar values and not all subgroups or individuals in a society have values similar to the mainstream. Therefore, codes of ethics must be developed to unify, guide, and protect individuals belonging to a group or institution and to protect the institution itself.

A familiar historical code of ethics, the Hippocratic Oath, also comes from Greece during the same time period as Aristotle's philosophies and embodies the values of ancient Greek ethics. A few of the oath's ethical principles, translated from the original text and listed here, relate to specific counseling ethical principles that will be discussed later in this course [55]:

I will use those dietary regimens which will benefit my patients according to my greatest ability and judgment, and I will do no harm or injustice to them. (Ethical principles of beneficence and nonmaleficence)

I will not use the knife, even upon those suffering from stones, but I will leave this to those who are trained in this craft. (Ethical principle of competence)

Into whatever homes I go, I will enter them for the benefit of the sick, avoiding any voluntary act of impropriety or corruption, including the seduction of women or men, whether they are free men or slaves. (Ethical principle of maintaining appropriate relationships)

Whatever I see or hear in the lives of my patients, whether in connection with my professional practice or not, which ought not to be spoken of outside, I will keep secret, as considering all such things to be private. (Ethical principles of confidentiality, trust, and privacy)

Although Hippocrates' wrote this oath roughly 2,500 years ago, the ideas remain pertinent to health care today. This is likely due to the fact that the Hippocratic Oath is based on principles that are universally applicable.

Because Aristotelian virtue ethics can be adapted to fit any society or institution by reprioritizing the values to achieve positive end goals congruent with "normal" community values, many offshoots of virtue ethics exist. With the rise of Christianity in the Middle Ages came theologic ethical systems derived from the Aristotelian notion of virtue ethics. St. Augustine, in the 4th century C.E., put forth the idea that a relationship with and love of God, in addition to acting from virtue, leads to happiness [54]. In the 13th century C.E., St. Thomas Aquinas developed another Christian system of ethics by simply adding the values of faith, hope, and charity to the established virtues of Aristotelian ethics [54].

These two ethical systems, Aristotelian virtue ethics and Christian ethics, form the foundation of most ethical systems and codes used in modern Western society. It should be understood that other ethical systems have contributed to Western philosophies and have shaped modern ethics; for example, one of the traditional Asian ethical systems, Confucian ethics, is very similar to Aristotelian ethics with an added emphasis on obligations to others [54].

Recent History

Prior to the 1960s, healthcare decisions were part of the paternalistic role of physicians in our society. Patients readily acquiesced health decisions to their physicians because they were regarded almost as family. What drove this resolve of patients to acquiesce their medical care and treatment decisions to their physicians? David Rothman, as discussed in his book Strangers at the Bedside: A History of How Law and Bioethics Transformed Medical Decision Making, believes physicians were given such latitude by their patients because they were well known and trusted by their patients and the community in which they practiced [56]. There were no specialists. One physician took care of a patient and family for a lifetime. The frontier physician often knew the patient from birth to adulthood, made house calls, and was a family friend who knew best what the patient should do with a healthcare concern [56]. Since the 1960s, physicians have become strangers to their patients, largely due to three factors. First, World War II experimentation and other medical research brought attention to humans as test subjects and the rights that should be recognized on their behalf. Second, the modern structuring and organization in healthcare delivery moved patients from their familiar surroundings of home and neighborhood clinics to the often intimidating large hospital. Third, the medical technologic boom brought life-saving interventions. In today's healthcare model, the patient is evaluated and educated by the professional and encouraged to make their own determination about the course of treatment.

Several medical research events in the 20th century served as catalysts to strengthen the codifying principles and behaviors that protect the rights of all individuals. This spurred the creation of codes of ethics in human service arenas, including counseling. The codes of ethics that were developed were designed to protect all individuals from harm and strived to be inclusive of age, race, ethnicity, culture, immigration status, disability, educational level, religion, gender, sexual orientation, gender identity or expression, and socioeconomic status.

One event was the atrocities exposed during the Nuremberg trials in Germany in 1945 and 1946. Because an ethical code (e.g., the Hippocratic Oath) would condemn the acts committed by Nazi medical researchers, it can be deduced that either no ethical code existed or that ethics did not extend to certain populations.

Another significant event occurred in the United States when, in 1932, the Public Health Service initiated a syphilis study on 399 black men from Tuskegee, Alabama, who were unaware of their diagnosis. The goal of the study was to observe the men over a period of time to examine how the disease progressed in people of African descent, because most of the clinical data on syphilis came from evaluating people of European descent. When the study began, there were no effective remedies; however, fifteen years into the study, penicillin was found to be a cure for syphilis. The research participants were never informed, and treatment was withheld, in spite of the fact that by the end of the experiment, in 1972, 128 men had died either from the disease or related complications [1].

Finally, in 1967, children with intellectual disability at the Willowbrook State School in New York were given hepatitis by injection in a study that hoped to find a way to reduce the damage done by disease. Although consent was obtained in this study, the consent sometimes had an element of coercion in that gaining admission to the school was difficult and parents were given a guarantee their child would be admitted if they consented to the participation of their child in the study.

It was events such as these that heightened the realization that organized standards of ethics were necessary to ensure that self-determination, voluntary consent, and informed consent, among other principles, were upheld and extended to all populations. In 1966, the Public Health Services established ethical regulations for medical research. In 1973, the first edition of the Hastings Center Studies pointed out the problems and the needs that would become paramount in developing healthcare research projects. Remarkable advances were projected in the areas of organ transplantation, human experimentation, prenatal diagnosis of genetic disease, prolongation of life, and control of human behavior. All of these had the potential to produce difficult problems, requiring scientific knowledge to be matched by ethical insight. This report laid the foundation for other disciplines to develop or revise their own ethics guidelines. In 1974, the National Commission for the Protection of Human Subjects was created by public law. Finally, in 1979, the Commission published The Belmont Report: Ethical Principles and Guidelines for the Protection of Human Subjects of Research. The Commission recommended that all institutions receiving federal research funding establish institutional review boards. Today, these boards, made up of researchers and lay people, review social science research proposals to ensure that they meet ethical standards for protecting the rights of the potential subjects. This was an initial entry into what would later be called bioethics.

Professional Ethics

In the 1970s, a new field of applied and professional ethics emerged, which had a dominant role in healthcare ethics. This new field emerged during a social and political climate that begged for answers to philosophical questions. For example, there were debates about welfare rights, prisoners' rights, and healthcare issues such as organ transplants, abortion, and end-of-life decisions.

It is within this backdrop that, in the 1980s, counselors began to further explore the profession's values. Drawing on ideas from philosophy and the newer field of applied ethics, counseling literature focused on ethical theories, ethical decision making, and ethical challenges confronted in direct practice, such as self-determination, informed consent, and the relationships among practitioners [6].

The federal government, private philanthropists and foundations, universities, professional schools, and committed professionals moved quickly to address these questions. A plethora of codes of ethical behaviors and guidelines have been set forth by many human service disciplines. Table 1 provides a summary of codes of ethics commonly utilized by mental health professionals, counselors, marriage and family therapists, social workers, and other helping practitioners [2,106,107,108,109].

Table 1: CODE OF ETHICAL BEHAVIORS UTILIZED IN HUMAN SERVICE DISCIPLINES

Association

Code

National Board for Certified Counselors

NBCC Code of Ethics

National Association of Social Workers

NASW Code of Ethics

American Association for Marriage and Family Therapy

AAMFT Code of Ethics

American Mental Health Counselors Association

Code of Ethics for Mental Health Counselors

Association for Specialists in Group Work

ASGW Best Practices Guidelines

American Psychological Association

Ethical Principles of Psychologists and Code of Conduct

American Counseling Association

Code of Ethics and Standards of Practice

American School Counselors Association

Ethical Standards for School Counselors

International Association of Marriage and Family Counselors

IAMFC Code of Ethics

Association for Counselor Education and Supervision

Ethical Guidelines for Counseling Supervisors

Commission on Rehabilitation Counselor Certification

Code of Professional Ethics for Rehabilitation Counselors

National Association of Alcoholism and Drug Abuse Counselors

NAADAC Code of Ethics

National Rehabilitation Counseling Association

Rehabilitation Counseling Code of Ethics

National Organization for Human Services

Ethical Standards for Human Services Professionals

International Society for Mental Health Online

Suggested Principles for the Online Provision of Mental Health Services

Source: [2]

Development of Ethical Codes in Counseling

The APA was the first mental health organization to publish a code of ethics. The code was published in 1953, but an ethics committee had been formed before World War II. The original APA ethical code was based on more than 1,000 submissions by psychologists regarding ethical decisions they had made in their practice to determine which ethical dilemmas were common [53]. The American Counseling Association (ACA), originally called the American Personnel and Guidance Association, was created in 1952, formed an ethics committee in 1953, and published its first code of ethics in 1961. The National Board for Certified Counselors (NBCC) was established in 1982 by an ACA committee to implement and monitor a national certification system for counseling professionals. The NBCC is now an independent, non-profit organization that maintains the certification of more than 65,000 counselors in more than 40 countries, and its members and those seeking certification are required to follow the NBCC Code of Ethics to maintain their certification [57,58].

Ford identifies several reasons that codes of ethics are developed [53]:

- To identify the purpose, goals, and values of an organization to members and those applying

- To give rights to and protect both clients and professionals

- To provide guidance for ethical decision making

- To influence public perception and ensure professionalism by showing that the organization will monitor itself for the public

- To send a message to law enforcement and government that the organization can enforce its own rules and regulate itself

- To help to establish an organization by differentiating it from similar institutions

- To establish a road toward being granted licensing of professionals in that field

Ethics and New Technologies

Internet technology has and will continue to have a tremendous impact on the economic, social, political, and cultural landscape. Not only has it affected commerce, but the fields of physical health, mental health, and counseling have also incorporated Internet technologies in the delivery of services and resources. As a result, the general public can access services from home within minutes at their convenience. Looking toward the future, as personal computers and computer software applications become less expensive and more accessible, an increasing number of agencies and organizations will be able to offer a diverse array of services via the Internet.

As a result, there has arisen a need for ethical standards for online counseling. Both the ACA and the NBCC have established practice guidelines for online counseling, which will be discussed in detail later in this course [100,101].

PHILOSOPHICAL HISTORY OF MODERN ETHICS

It is important to understand historical philosophical underpinnings in order to understand the evolution of the definition of ethics and how today's ethical principles emerged [3]. Ethics can be viewed as developing within two major eras in society: modernism and postmodernism.

Modernism

The term modernism refers to an era during which scholars were encouraged to shift from a basis of metaphysics to rationalism in analyzing the world and reality [3]. In a modernist world, it is believed that reasoning can determine truth on all subjects [3]. Just as science evolved from being religion- or faith-based, modernists sought to understand social phenomena by explicating universal ethical laws [3].

Modernist philosophy argues that all individuals are similar and individual rights are supreme [4]. This philosophy has permeated much of biomedical ethics, and as such, each of the four ethical principles that form the backbone of ethical codes—autonomy, beneficence, nonmaleficence, and justice—should be universally adhered to and applied [5]. Utilitarian ethical principles, rationalism, and evidence-based scientific applications are at the heart of modernism [116].

Postmodernism

Postmodernism is a reaction to the belief that there is "rational scientific control over the natural and social worlds" [3]. Postmodernism is characterized by diversity, pluralism, and questioning the belief that there are objective laws or principles guiding behavior [3]. Postmodernists argue that ethical principles must take into account historical and social contexts to understand individuals' behaviors [4]. This philosophical climate emphasizes situational ethics in which there are no black-and-white rules about principles of good and bad. Ultimately, a set of universal ethical principles cannot be easily applied [3].

Since 2015, there has been increasing discussion regarding the apparent shift to postmodernism in the ethical landscape [116,117]. In part spurred by the political environment in the United States during this period, the concept of a universal set of ethical principles appeared to be challenged; instead, ethical relativism appeared to move to the forefront. The growing use of social media and the Internet helped to present a highly individualized set of "truths" (or "alternative facts") [116].

Today, ethical codes and practices are also influenced by critical theory. Critical theorists focus on eliminating inequities and marginalization [112]. Ethics from this perspective explores the role of power and power inequalities, exploring who or what defines truth and whose voices are represented [112]. Reality is a socially and culturally shared experience and is shaped and navigated by both the practitioner and client [118]. Therefore, ethics is not a top-down experience, whereby ethical rules are unilaterally imposed. Rather, handling and negotiation of ethical challenges should be a collaboration [118].

3. COMMON TERMS USED IN THE DISCUSSION OF ETHICS

VALUES

Frequently, the terms values and ethics are employed interchangeably; however, the terms are not synonymous. Values are beliefs, attitudes, or preferred conceptions about what is good or desirable, that provide direction for daily living. They stem from our personal, cultural, societal, and agency values. Rokeach has argued that values may be organized into two categories: terminal values and instrumental values [9]. Terminal values describe the desired end-goal for a person's life. Some that are identified by Rokeach are happiness, inner harmony, wisdom, salvation, equality, freedom, pleasure, true friendship, mature love, self-respect, social recognition, family security, national security, a sense of accomplishment, a world of beauty, a world at peace, a comfortable life, and an exciting life. Instrumental values are those that help a person to achieve their desired terminal values; they are the tools one uses to work toward an end goal. Instrumental values include love, cheerfulness, politeness, responsibility, honesty, self-control, independence, intellect, broad-mindedness, obedience, capability, courage, strength, imagination, logic, ambition, cleanliness, helpfulness, and forgiveness. Ultimately, all of these types of values influence how a person will behave. Not all individuals will identify with all of these values; most will have a few terminal values that are most important to them. When there is conflict or tension between instrumental values, such as politeness and honesty, individuals will begin to prioritize [9].

It is important for counselors to have a high level of self-awareness and to understand the nature and origins of value conflicts and the impact of values on their decisions. Values include our life experiences, worldview, cultural outlook, professional values, societal values (e.g., equality, freedom, justice, achievement, self-actualization), and religious beliefs. Values are also based on knowledge, aesthetics, and morals [10].

Whether values can or should be completely removed from counseling sessions is a topic of debate. Core values are key to successful interventions; however, there are two extremes in a counseling relationship that should be avoided [59]:

- Counselors should not act as a moral authority and try to influence clients to change their personal values in favor of the counselors'.

- Counselors should not struggle to create a value-free environment, because this can cripple the intervention.

The professional counselor's duty is to help a client assess thoughts, feelings, and actions and, perhaps, to help clients to reprioritize values. When a counselor shows his or her own values through the choice of words, identification of problems, and treatment strategies, the client will usually pick-up on the implied values and may decide to adopt some [59].

ETHICS

Ethics are the beliefs an individual or group maintains about what constitutes correct or proper behavior or actions [13]. To put it simply, ethics are the standards of conduct an individual uses to make decisions. The term morality is often confused with ethics; however, morality involves the judgment or evaluation of an ethical system, decision, or action based on social, cultural, or religious norms [13,14]. The term morals or morality is derived from the Greek word mores, which translates as customs or values. The separation between ethics and values/morals is best illustrated in the following two examples.

Defense Lawyer W is representing a client who he knows has committed homicide because the client has admitted to the slaying in confidence. Murder goes against the values of American society and, more importantly for this example, against the values of the attorney, whose ethical duty is to defend the client to the best of his abilities, regardless of his feelings toward the client's action.

Counselor T is a high school counselor in Oregon who is against the termination of pregnancy due to her personal and religious values; she has had several miscarriages and is currently experiencing difficulty becoming pregnant. Student A, 15 years of age, enters Counselor T's office in tears; the student has not told anyone that she is 9 weeks pregnant. She is seeking help regarding obtaining an abortion. Counselor T learns that her client was the victim of sexual abuse by her first adoptive parents. Other foster children and individuals in support groups, which Student A has come to know, were also victims of physical and sexual abuse by their adoptive parents. She expresses fear of alienation from her friends, concern about falling behind in school, and anguish at not being able to remain active in sports, which are "her way of coping with life." The student has stated that she does not want to give birth to a child because she is too young to raise it properly and would not put her child up for adoption for fear that it too would become a victim. In fact, she states that she does not know if she "ever wants to bring a child into this world."

It is apparent that the student's values differ from the counselor's values. Counselor T's employer has made it clear in their code of ethics that promoting well-being and self-determination is the primary responsibility of counselors. While abortion does not fit with Counselor T's personal values, society as a whole values independence, self-determination, and equal rights. Given the student's history and values, taken in the context of societal values and laws, it would be unethical for the counselor to impose her own personal values upon Student A.

It is important to remember that ethics must prevail over a counselor's personal values when value conflicts exist. As discussed, counselors are bound to the ethical duty to not act as moral authorities and force their values upon others. The professional relationship exists to benefit the client and fulfill the client's needs. A counselor's needs, such as the need to feel adequacy, control, and clients' change toward values similar to one's own values, will harm the relationship [59]. It is unethical to put personal needs before clients' needs [59].

Ethical Dilemmas

An ethical dilemma presents itself to a counselor when he or she must make a choice between two mutually exclusive courses of action. The action may involve the choice of two goods (benefits) or the choice of avoiding two harms (problems). If one side of the dilemma is more valuable or good than the other side then there is no dilemma because the choice will lean toward the side that is more desirable [15].

Ethical Decision Making

The process of resolving an ethical dilemma is the ethical decision-making process. Ethical decision making is influenced by values and the ethical principles to which individuals and groups adhere. Counselors are encouraged to gather all available resources and consider all possible outcomes before making decisions; this will be discussed in detail later in this course.

Ethical Principles

Ethical principles are expressions that reflect people's ethical obligations or duties [10]. These principles of correct conduct in a given situation originated from debates and discussions in ancient times and became the theoretical framework upon which we base our actions as individuals and societies. Most prominently, it was the Bible and Greek philosophers, such as Plato and Aristotle, who created most of the familiar ethical principles in use today. The following are general ethical principles that counseling professionals recognize [10]:

- Autonomy: The duty to maximize the individual's rights to make his/her own decisions

- Beneficence: The duty to do good

- Confidentiality: The duty to respect privacy and trust and to protect information

- Competency: The duty to only practice in areas of expertise

- Fidelity: The duty to keep one's promise or word

- Gratitude: The duty to make up for (or repay) a good

- Justice: The duty to treat all fairly, distributing risks and benefits equitably

- Nonmaleficence: The duty to cause no harm

- Ordering: The duty to rank the ethical principles that one follows in order of priority and to follow that ranking in resolving ethical issues

- Publicity: The duty to take actions based on ethical standards that must be known and recognized by all who are involved

- Reparation: The duty to make up for a wrong

- Respect for persons: The duty to honor others, their rights, and their responsibilities

- Universality: The duty to take actions that hold for everyone, regardless of time, place, or people involved

- Utility: The duty to provide the greatest good or least harm for the greatest number of people

- Veracity: The duty to tell the truth

While ethical principles are seemingly similar to values, they pertain specifically to ethics. For example, in medicine, there are many infections that can be prevented simply by hand washing. Hence, the value of cleanliness pertains to the ethical principle of nonmaleficence, or the duty to cause no harm. Based on general values and ethical principles, professions develop ethical codes that embody the values and ethics of the institution and guide the behavior of members. Unfortunately, codes of ethics do not always provide clear direction, and in some cases, the tenets of the codes are in direct conflict with each other.

4. VALUES AND ETHICAL PRINCIPLES IN ETHICAL CODES

ACA CODE OF ETHICS

The ACA Code of Ethics is divided into nine sections and a preamble. Each section is well organized into various sub-sections; for example, working backward, "Section A.9.a. Screening" contains selection criteria for group counseling in the "A.9. Group Work" category of "Section A: The Counseling Relationship" [8]. It is laid out in a concise, easily accessible format, which makes it a helpful tool for any professional counselor to use when trying to resolve ethical issues. The Code of Ethics must be studied and utilized by ACA members and is recommended for all counselors.

The preamble of the ACA Code of Ethics states that embracing professional values ultimately provides a basis for ethical behavior and decision-making in practice. The Code identifies ACA's core values and requires that ACA ethics prevail over personal values. The following are section headings as they appear in the Code followed by a synopsis of the ethical guidelines and values expressed in each section [8]. Additionally, examples of related values and ethical principles are given. This synopsis of the ethical principles in the ACA Code of Ethics is meant to be an overview. Please refer to the full ACA Code of Ethics, available online at https://www.counseling.org/Resources/aca-code-of-ethics.pdf and in the Appendix.

Section A: The Counseling Relationship

Counselors should always work to serve the client's best interest in a manner that is culturally sensitive. The primary goals of the counselor are to help people in need, to advocate, and to link clients to services that best fit their needs. However, a counselor's commitment to these goals is tested when presented with a client who may be unable to afford services. The code encourages pro bono work, when possible.

Informed consent is a prominent issue in health care. It is especially important to make all information about evaluation results, treatments, and what to expect from the counseling relationship, including the benefits and limitations of counseling, available to clients. The counselor must honestly and accurately represent their training, abilities, and experience to clients.

When conducting group work, each client's needs must be met in a way that also benefits the group; in turn, the client should benefit the group. Counselors must always do no harm and should avoid imposing their personal values upon others. Sexual or romantic relationships with clients (and clients' family members/former partners) are strongly discouraged and are prohibited for a period of five years after the professional relationship is terminated.

Some of the ethical principles expressed in this section include autonomy, beneficence, nonmaleficence, and competency. The values are honesty, responsibility, self-control, and helpfulness.

Section B: Confidentiality and Privacy

Trust is perhaps the most important aspect of a counseling relationship. A client's trust is earned by maintaining boundaries and respecting privacy. Information relating to client care should be shared with other professionals only with the consent of the client. When counseling minors or people with diminished capacity, all local and federal laws must be obeyed and a third party should be consulted before sharing any private information.

The limits of confidentiality should be discussed with clients, and counselors should remain aware of situations that confidentiality must be breached in order to protect the client or others from serious and likely harm (e.g., intended violence, life-threatening disease). When doubts exist about breaching confidentiality, counselors have a duty to consult with other professionals. If the court orders disclosure of confidential and private information, counselors must make an effort to obtain informed consent from the client and to block disclosure or severely limit its reach (i.e., only provide essential information).

All records and correspondence, including e-mail, should be protected within reason. Clients have a right to access their records, but access should be limited when there is compelling evidence that the information may potentially harm the client. The fundamental ethical principles that apply to this section are fidelity and veracity.

Section C: Professional Responsibility

The responsible counselor values honesty and is competent. Professional competence is an ethical standard, meaning counselors should only practice in areas in which they have the requisite knowledge and abilities. One can only help if he or she has the proper tools and the skills to utilize them effectively; techniques, procedures, and modalities used in practice should have a solid foundation of theory, empiricism, and/or science. Counselors must also improve their knowledge and abilities so they can further assist clients and contribute to the advancement of their profession. Advocating for positive social change and engaging in self-care activities are also highly recommended, and pro bono work is encouraged. Self-monitoring for impairment (i.e., physical, mental, or emotional illness that interferes with practice) and not practicing while impaired is important. The principles represented in this section are nonmaleficence, ordering, and universality. An important value is self-awareness.

Section D: Relationships with Other Professionals

When a network of colleagues is developed both inside and outside of the counselor's field of practice, different perspectives can be gained and shared. Having a support system of professionals in related disciplines can help to inform decision making, and ultimately, clients can benefit from these interrelationships. Counselors are also encouraged to alert the proper entities to ethical concerns, and a professional attitude should be maintained toward someone who exposes inappropriate behaviors, policies, or practices. Deficiencies or ethical concerns regarding employer policies require intervention (e.g., voluntary resignation from the workplace, referral to appropriate certification, accreditation, or state licensure organizations). Fidelity and veracity are ethical principles that apply in this section.

Section E: Evaluation, Assessment, and Interpretation

Appropriate assessment instruments should be used when evaluating a client, and care should be taken that these instruments and evaluations are culturally appropriate. This includes educational, psychologic, and career assessment tools that provide qualitative and quantitative information about abilities, personality, interests, intelligence level, achievement, and performance. It is important not to use the results of any test to the client's detriment and to make the results known to the client. In addition, one should note that in many instances, these tests were standardized on a population that may be different from the client's population or identity. Informed consent and explanation of the goals of the assessment should be given in a language preferred by the client or his or her surrogate. Clients are to be given autonomy, and the counselor must apply the ethical principles of nonmaleficence and confidentiality.

Section F: Supervision, Training, and Teaching

Supervising counselors should have knowledge of supervisor models and be aware of supervisees' training, methods, and ethics while respecting their styles and values. Supervisors should foster an environment of openness and continued learning and should seek to minimize conflicts. Training sessions should be inclusive and positive. Romantic or sexual relationships with supervisees are prohibited; however, it may be beneficial in some circumstances to engage with supervisees in friendly or supportive ways (e.g., formal ceremonies, hospital visits, during stressful events). It is important to remember that the supervisor must also ensure client welfare; therefore, it is necessary to regularly assess supervisees' work and encourage their growth as counselors. Ethical principles that apply in this section are autonomy, respect, and universality.

Section G: Research and Publication

A main goal of research in counseling is to improve society, as many of the personal problems that counselors are enlisted to solve arise from clients' experiences in flawed social environments. Counselors should help with and participate in research. Research should not cause harm or interfere with participants' welfare. Informed consent must be maintained throughout the process, and all data must be kept private. Justice and confidentiality are paramount ethical concerns. When conducting research it is important to ensure that the benefits and risks are distributed equitably. Often, any benefits from research groups will only be short lived; it should be made clear that after the study has concluded, counseling interactions related to the study will cease. Also, participants must be confident that collected data will remain secure.

Section H: Distance Counseling, Technology, and Social Media

Counselors should have a good understanding of the evolving nature of the profession with regard to distance counseling, digital technology, and social media and how these resources can be used to better serve clients. Maintaining privacy and confidentiality in the digital world is more complex than with face-to-face counseling and maintaining hard-copy records. Every reasonable effort to protect digital client information should be made, and clients should be informed about the potential risks and limitations of distance counseling. The appropriateness of distance counseling should be considered for each client. The counselor's qualifications to provide the service are equally important. The laws and regulations of the counselor's location jurisdiction and of the client's location jurisdiction must be understood and followed. When counselors have a social media presence, the personal and professional presence should be separate and unmistakably distinct. Counselors are advised to avoid viewing clients' social media pages unless given expressed permission. Personal and confidential information should never be disclosed on public social media or forums. Confidentiality and nonmaleficence are especially important ethical principles in online and distance communications, and politeness, forethought, and clarity are especially critical when body and other nonverbal cues are unavailable because counseling is not face-to-face.

Section I: Resolving Ethical Issues

Counselors should be familiar with their agency's or institution's rules and regulations; these should be accepted and upheld or employment should be sought elsewhere. When ethical dilemmas arise, they should be resolved using communication with all those involved. When a conflict cannot be resolved among the parties involved, consultation with peers may be necessary. Ethical codes should be followed, but in some cases, this may conflict with laws (e.g., subpoena). It is advised that laws prevail over ethics when all other means of resolution are exhausted. Counselors who become aware of colleagues' ethics violations that are not able to be resolved informally are obligated to report them provided it does not violate client-counselor confidentiality. The ethical resolution of dilemmas or issues requires the application of the ethical principles of ordering, respect, reparation, and veracity. Values of honesty, courage, independence, and intellect, among many others, determine positive outcomes in adverse situations.

NBCC CODE OF ETHICS

The preamble of the NBCC's ethical code states that while counselors may work for agencies that also have their own ethical codes, all NBCC ethical guidelines must be followed to retain NBCC certification [58]. The Code is an assurance to other professionals, institutions, and clients that the certified counselor is expected to adhere to NBCC's ethical standards. While this code of ethics is intended for those who are certified by the NBCC, it is an excellent resource for all counselors. A synopsis of the directives contained in the Code of Ethics appears below [58].

Professional Responsibilities

Counselors have a responsibility to themselves, clients, and institutions to behave in an ethical manner consistent with the NBCC Code of Ethics. All applicable legal standards and professional regulations should be abided in all cases. Counselors speaking publicly should reflect their personal views and not those of an organization unless authorized to speak on its behalf.

As with the ACA Code of Ethics, the ethical principle of competency is stressed. Counselors should recognize their limitations in all areas of practice, keep up with reviews and advancements in the field, and seek to improve their knowledge base. Only proven, established techniques may be used without client consent. Competency is an ethical priority for those who supervise others, both self-competency and an understanding of the competency of supervisees.

Cultural competency is an important aspect of this directive, and counselors must ensure unbiased and nondiscriminatory practice. Beyond this, counselors are expected to demonstrate multicultural counseling competence.

Credentials and qualifications should be accurately represented, and it is the responsibility of the counselor to correct known misrepresentations. Counselors who are no longer able to competently practice shall seek professional assistance or withdraw from the practice of counseling. In addition, counselors who have reasonable cause to believe that another mental health professional has engaged in unethical behavior, must report the matter to NBCC except when State regulations require immediate reporting.

Professional influence should not be misused, either for personal gain or at the expense of clients and their welfare. Testimonials from family/friends or current clients are not permitted. Counselors have the duty not to provide a reference for a counselor known to be unqualified.

Counseling Relationships

Harms identified in this section include breach of confidentiality, privacy, and trust. Information learned in the counseling relationship (including test/assessment results and/or research data) may not be shared without client/legal guardian consent, barring the threat of imminent danger to self/others or court order. Out of the respect of privacy, only information that is pertinent to the counseling goals shall be solicited from clients. Steps must be taken to ensure that client records remain confidential, even following the incapacitation/death of the counselor; these include verbal communications, paper documents, test results, media recordings, and electronically stored documents.

Client records are to be maintained for a minimum of five years and disposed of in a manner that assures confidentiality. Client confidentiality should be a priority of every subordinate employee with access to client records. Prior to the court-ordered release of client records, a reasonable attempt should be made to notify clients and former clients. Upon retirement from the profession, current and former clients should be notified.

Before or during the initial session, clients must be informed about the goals, limitations, purposes, procedures, and the potential risks and benefits of services and techniques. Information regarding rights and responsibilities must also be provided, including the potential limitations of confidentiality, particularly when working with families or groups.

Consent should be obtained before initiating services. The goals of the counseling relationship and written plans should be developed collaboratively with the client. Clients must agree to changes to the plan and these changes should be documented. The record should also contain information regarding other relationships that exist between the client and other mental health professionals. Upon request, client records must be released to the client. There can be a discussion of the repercussions of release if the counselor believes the information may harm the counseling relationship, but the client record belongs to the client. Upon realization of a lack of benefit for the client, termination of services should be discussed within a reasonable period. Termination of services must not take place without a justified cause, and an appropriate referral should be made.

Supervision and Consultation

Consultation, supervisor assistance, or client referral is required if the services rendered are ineffective. A professional with whom consultation is sought must have the requisite experience to effectively respond to the issue. A written plan shall be agreed upon by the counselor and the consultant that identifies the specific issue, consultation goals, potential consequences of action, and evaluation terms. If no specific client information is shared between the consultant/consultee, it is not considered a consultation.

Counselors who act as educators or supervisors should avoid multiple relationships and specifically must refrain from sexual or romantic intimacy (in-person or electronic) with students or supervisees during and for at least five years following last academic/supervisory contact.

Supervisors must identify their qualifications and credentials to supervisees and provide information regarding the supervision process. Counselor supervisors should strive to establish a helpful and safe supervisory environment, always promoting the welfare and continued professional development of supervisees. This includes providing regular, substantive feedback and establishing procedures for responding to crisis situations.

Testing, Appraisal, and Research

Counselors should explain the ramifications of tests and results to clients and use assessments only for the client's benefit. Only current, reliable, and valid tests and assessments should be used. The results of a single test/assessment should never be used as the sole basis for a decision. It is a counselor's duty to recognize if the services provided will benefit a client or if they would be better served by another counselor or institution.

There are many assessment tools and techniques available to counselors, and counselors should be competent in the use and interpretation of each they intend to use. Consideration must be given to the fact that many tests/assessments are culturally biased; open-mindedness about test/assessment performance is valued. Tests and assessment administration and interpretation must comply with standard protocols. Identified security protocols for each must also be maintained.

Test results must be objectively and accurately interpreted, with consideration given to any irregularities in the administration of assessments or to any known unusual behavior or conditions (e.g., cultural factors, health, motivation) that may affect test results. Test results must be taken in the appropriate context. All communications with clients and colleagues, including those made electronically, are entered into the record. Clerical issues (e.g., change of address, appointment scheduling) are not an exception.

Counselors have an obligation to ensure that services or research are conducted in an ethical manner. It is unethical to use any tests or techniques that have the foreseen potential to cause harm. Informed consent is paramount when conducting research, and every precaution must be taken to ensure the safety and confidentiality of research participants. Replicable and unbiased data is the product of honest research practices.

All counselors should consider plagiarism a breach of the Code of Ethics and give credit to the work of others when publishing work or research. If ethics violations occur, it is the counselor's duty to withdraw from the profession.

Social Media and Technology

Social media must be used wisely and sensibly when communicating with clients or for sharing client information with other professionals; any means of consultation with other professionals must ensure client confidentiality. Policies must be in place to delineate the appropriate use of social media and other related digital technology as it relates to current and former clients. This policy should identify differences between private and professional accounts and measures to prevent confidentiality breaches. Professional accounts should only be used to post information related to professional services that does not create multiple relationships or violate client confidentiality.

Clients should be provided with instructions for how to securely and appropriately contact with their counselor, including the risks of inappropriate technology use. Counselors should become familiar with the privacy and security settings of social media and other electronic platforms used to provide services and how these settings can impact confidentiality.

Counselors should not access clients’ social media accounts without documented discussion, client permission, and a specific clinical purpose. The privacy of clients’ online activities and personas should be respected, and counselors must refrain from establishing non-professional online relationships with clients.

Counselors who are certified by the NBCC must follow the NBCC Code of Ethics. The Code may be reviewed online at https://www.nbcc.org/Assets/Ethics/NBCCCodeofEthics.pdf.

5. ETHICAL THEORIES

Ethical theories provide a framework that can be used to decide whether an action is ethical. These ethical systems are each made up of principles, precepts, and rules that form a specific theoretical framework, providing general strategies for defining the ethical actions to be taken in any given situation. In its most general and rudimentary categorization, ethics can be classified into two different headings: mandatory ethics and aspirational ethics [16]. When a counselor uses a mandatory ethics lens, he/she views the world in terms of polar opposites, in which one must make a choice between two behaviors. On the other hand, those who adopt aspirational ethics assume that there are a host of variables that play a role in benefiting the client's welfare [16]. For each ethical decision-making model, there is an underlying ethical theory that drives the model. Therefore, it is important to understand the various ethical theories.

VIRTUE ETHICS

As mentioned, virtue ethics developed from the Aristotelian philosophy that positive personal character is developed by acting based on the values of a particular society. According to Aristotle, there are two categories of virtues: intellectual and moral. Intellectual virtues include wisdom, understanding, and prudence; moral virtues encompass liberality and temperance [119]. A true virtue ethicist would act out of charity and good will rather than just following society's rules because they were expected to. Because virtues are "neither situation specific nor universal maxims," but instead are "character and community specific," virtue ethics allows an individual to have free will, both good and ill [54]. It is not a commandment that people must be benevolent and avoid doing evil; instead virtue ethics posits that if people uphold societal values then they will gain happiness. It is to this end that virtue ethical theory encourages people to act out of virtue. Virtue ethics forms the basis of religions throughout the world but is not inherently religious. This approach is different from deontologic ethics and teleologic ethics because rather than focusing on duty and consequences, respectively, virtue ethics' main focus is on the character of the person; it emphasizes the appraisal of the actor rather than the action [54].

DEONTOLOGIC ETHICAL THEORIES

Deontologic theories concentrate on considering absolutes, definitives, and imperatives [7]. Deontologic theories may also be referred to as fundamentalism or ethical rationalism [17]. The Greek word deon means duty or obligation, and the deontologic theorist would argue that values such as self-determination and confidentiality are absolute and definitive, and they must prevail whatever the circumstances (i.e., universally applicable) [17]. An action is deemed right or wrong according to whether it follows pre-established criteria known as imperatives. An imperative is viewed as a "must do," a rule, an absolute, or a black-and-white issue. This is an ethic based upon duty linked to absolute truths set down by specific philosophical schools of thought. Persons adhering to this perspective ask: What rules apply? What are the duties or obligations that provide the framework for ethical behavior [120,121,122]? As long as one follows the principles dictated by these imperatives and does his/her duty, one is said to be acting ethically.

The precepts in the deontologic system of ethical decision making stand on moral rules and unwavering principles. No matter the situation that presents itself, the purest deontologic decision maker would stand fast by a hierarchy of maxims. These maxims are as follows [18,121]:

- People should always be treated as ends and never as means.

- Human life has value.

- Always to tell the truth.

- Above all in practice, do no harm.

- All people are of equal value.

The counseling professionals making ethical decisions under the deontologic ethical system see all situations within a similar context regardless of time, location, or people. It does not take into account the context of specific cultures and societies [17]. The terminology used in this system of beliefs is similar to that found in the legal justice system. Of course, enforcement of the rights and duties in the legal system does not exist in the ethical system.

One of the most significant features of deontologic ethics is found in John Rawls' Theory of Justice, which states that every person of equal ability has a right to equal use and application of liberty. However, certain liberties may be at competition with one another. Principles within the same ethical theoretical system can also conflict with one another. An example of this conflict might involve a decision over allocation of scarce resources. Under the principle of justice, all people should receive equal resources (benefits), but allocation can easily become an ethical dilemma when those resources are scarce. For instance, in national disasters, emergency response personnel would be among those ranked first to receive immediate stockpiles of food and drugs. Although this is in opposition with the principle of justice, it is supported by the principle of utility (greatest good).

A framework of legislated supportive precepts, such as the ACA Code of Ethics, serves counseling professionals by protecting them in their ethical practice. Most ethical codes are said to be deontologic because they set forth rules that must be followed. However, even these systems of thought will not clearly define the right answer in every situation. Most professionals will not practice the concept of means justifying the end if the means are harmful to the client. When duties and obligations conflict, few will follow a pure deontologic pathway because most people do consider the consequences of their actions in the decision-making process.

Theologic Ethical Theories

Well-known deontologic ethical theories are based upon religious beliefs and are strongly duty-bound. The principles of these theories promote a summum bonum, or highest good, derived from divine inspiration. A very familiar principle is the Golden Rule. Its Christian phrasing is "do unto others as you would have them do unto you;" however, the Golden Rule is present in various wordings in almost all cultures and religions throughout written history. One would be viewed as ethically sound to follow this principle within this system of beliefs. The most prevalent theologic ethical systems/religious ethics in the world are Christian (31.4%), Muslim (23.2%), Hindu (15%), Buddhist (7.1%), folk religions (5.9%), Jewish (0.2%), and other (0.8%), with 16.2% unaffiliated with any particular religion [60]. The most prevalent in the United States are Protestant (51.3%), Roman Catholic (23.9%), unaffiliated (16.1%), Mormon (1.7%), other Christian (1.6%), Jewish (1.7%), Buddhist (0.7%), Muslim (0.6%), and other (2.5%); 4% claim no religion [60].

According to this data, it would seem that about 80% of people in the United States are using deontologic/theologic ethics as their primary decision-making framework. However, when it comes to actual, real-world decision making, it is easy to see that purely deontologic/theologic pathways are followed less often, because, as discussed, people usually consider the implications of their actions or decisions upon the lives of others. Accordingly, in the United States, a separation of church and state is required so the common good is upheld, and the democratic system is determined to be the best source of governance rather than any one religious entity.

A 2004 Gallup poll found that 71% of Protestants and 66% of Catholics supported capital punishment [61]. Though it would seem that execution is against theologic ethics, many religious individuals have decided that the death penalty better safeguards the common good, in spite of an 88% criminologist and law enforcement expert-consensus that the death penalty does not deter homicide and other violent crime [104]. A 2000–2001 survey asked 10,000 women who had obtained induced abortions at 100 different providers throughout the United States about their religious affiliation. The results were that 70% identified as Catholic, Protestant, or Evangelical ("born-again") Christians and that an additional 8% identified as belonging to other religions; 22% had no religious affiliation [62]. These two examples are given to show that pure theologic ethical decision-making pathways are followed less often when people are faced with extremely difficult ethical dilemmas.

Categorical Imperative

Another fundamental deontologic ethical principle is Immanuel Kant's categorical imperative. An imperative is something that demands action. The first rule in Kant's theory is to only act in a way that you would wish all people to act, which is essentially a variation of the Golden Rule. Other rules are to treat people as both a means and an end and to never act in a way so as to cause disruption to universal good.

Kant believed that rather than divine inspiration, individuals possessed a special sense that would reveal ethical truth to them. The idea is that ethical truth is inborn and causes persons to act in the proper manner. Some of the ethical principles to come from Kant include individual rights, self-determination, keeping promises, privacy, and dignity.

TELEOLOGIC ETHICAL THEORIES

Telos is a Greek word meaning end, and the teleologic ethical theories or consequential ethics are outcome-based theories [123]. It is not the motive or intention that causes one to act ethically, but the consequences of the act [7]. If the action causes a positive effect, it is said to be ethical. So here, the end justifies the means. From this perspective, the question is: What are the possible good and bad outcomes? What would be the most or least harmful [120,122,123,124]? Teleological theories focus more on societal effects of actions, while deontological theories emphasize effects on the individual [121]. Therefore, deontological theories may be more patient-centered.

Utilitarianism

Utilitarianism is the most well-known teleologic ethical theory. It is the principle that follows the outcome-based belief of actions that provide the greatest good for the greatest number of people [125]. So rather than individual goodness or rightness, this principle speaks for the group or society as a whole. Social laws in the United States are based upon this principle. The individual interests are secondary to the interest of the group at large. There are two types of utilitarianism: rule utilitarianism and act utilitarianism [125]. In rule utilitarianism, a person's past experiences are his influence toward achieving the greatest good. In act utilitarianism, the situation determines whether an action or decision is right or wrong. There are no rules to the game; each situation presents a different set of circumstances. This is commonly referred to as situational ethics. In situational ethics, if the act or decision results in happiness or goodness for the client and their social context, it would be ethically right.

Individuals may choose the utilitarian system of ethics over another because it fulfills their own need for happiness, in which they have a personal interest. It avoids the many rules and regulations that may cause a person to feel lack of control. One of the limitations of utilitarianism is its application to decision making in counseling. In developing policies for a nation of people based upon the principle of doing the greatest good for the greatest number, several questions arise. Who decides what is good or best for the greatest number: society, government, or the individual? For the rest of the people, are they to receive some of the benefits, or is it an all or nothing concept? How does "good" become quantified in counseling?

Existentialism

One modern teleologic ethical theory is existentialism. In its pure form, no one is bound by external standards, codes of ethics, laws, or traditions. Individual free will, personal responsibility, and human experience are paramount. Existentialism lends itself to counseling because one of the tenets is that every person should be allowed to experience all the world has to offer. A critique of the existential ethical theory is that because it is so intensely personal, it can be difficult for others to follow the reasoning of a counselor, making proof of the ethical decision-making process a concern.

Pragmatism

Another modern teleologic ethical theory is pragmatism. To the pragmatist, whatever is practical and useful is considered best for both the people who are problem solving and those who are being assisted. This ethical model is mainly concerned with outcomes, and what is considered practical for one situation may not be for another. Pragmatists reject the idea that there can be a universal ethical theory; therefore, their decision-making process may seem inconsistent to those who follow traditional ethical models.

MOTIVIST ETHICAL THEORIES

The motivist would say that there are no theoretical principles that can stand alone as a basis for ethical living. Motivist belief systems are not driven by absolute values, but instead by intentions or motives. It is not the action, but the intent or motive of the individual that is of importance. An example of a motivist ethical theory is rationalism. Rationalism promotes reason or logic for ethical decision making. Outside directives or imperatives are not needed as each situation presents the logic within it that allows us to act ethically.

NATURAL LAW ETHICAL THEORY

Natural law ethics is a system in which actions are seen as morally or ethically correct if in accord with the end purpose of human nature and human goals. The fundamental maxim of natural law ethics is to do good and avoid evil. Although similar to the deontologic theoretical thought process, it differs in that natural law focuses on the end purpose concept. Further, natural law is an element in many religions, but at its core it can be either theistic or non-theistic.

In theistic natural law, one believes God is the Creator, and the follower of this belief has his understanding of God as reflected in nature and creation. The nontheistic believer, on the other hand, develops his understanding from within, through intuition and reason with no belief rooted in God. In either case natural law is said to hold precedence over positive (man-made) law.

The total development of the person, physically, intellectually, morally, and spiritually, is the natural law approach. Therefore, ethical decision making should not be problematic, as judgment and action should come naturally and habitually to the individual follower of natural law. A shortcoming with natural law ethics is that what might be a virtue for one person might be another person's vice [53]. Like existentialism, if virtue ethics is dependent on personal character it may not consistently lead to decisions that many others agree with [63].

TRANSCULTURAL ETHICAL THEORY

Another ethical theory used in counseling is a relatively modern system of thought that centers on the diversity of cultures and beliefs among which we now live. At its core, this ethic assumes that all discourse and interaction is transcultural because of the differences in values and beliefs of groups within our society. This concept has developed into what has become known as the transcultural ethical theory [27].

The concept of care from a transcultural perspective focuses on a comparative analysis of differing cultures' health/illness values, patterns, and caring behavior. Decisions are made on the basis of the value or worth of someone by the quality of interrelationships. This transcultural context encourages individual and global communities to question and to understand each other's beliefs and values. It is only within this context of understanding that one can make sound ethical decisions in a culturally diverse society.

The advantage to the transcultural ethical system is that while it recognizes the uniqueness of different cultures, it is based on various precepts of other ethical systems [27]. The disadvantage might be that Western society largely follows the deontologic and teleologic principles that also make up its legal system. In a society that values decision-making based on hard facts, one may have some difficulty in making decisions based upon other cultural beliefs and values. Many professionals may have difficulty with transcultural ethics' reliance on close interrelationships and mutual sharing of differences that are required in this framework of ethical decision making.

Ethical Relativism/Multiculturalism

The ethical theory of relativism/multiculturalism falls under the postmodernist philosophical perspective and may be referred to as moral relativism [17]. Multiculturalism promotes the idea that all cultural groups be treated with respect and equality [19]. According to ethical relativists, ethical principles are culturally bound and one must examine ethical principles within each culture or society [17]. The question then becomes how ethical principles that are primarily deontologic and rooted in Western values are applicable in other societies. The challenge of ethical relativism is how to determine which values take precedent [17]. Greater detail will be focused on multiculturalism and diversity issues later in this course.

FEMINIST ETHICS

Feminist philosophy questions the origins, meanings, and implications of societal gender roles. Over the years, feminist ethics has focused on disputing three major patriarchal ideas [64]:

- Women's moral thinking is more contextual and less abstract than men's thinking.

- Values of empathy, caring, and nurturing are inherent in women, are more valued by women, and are shown more often by women.

- Values of free will and autonomy apply equally to men and women, not because of women's moral choice but because of the moral demands imposed on women as caretakers.

When the assumption is made that women are not able to engage in concrete thought, it is a short leap to assume that women are incapable of grasping complex, abstract ideas; this has been used as an argument against women participating in the professional world [65]. Feminist ethicists posit that, in general, women are forced to consider context because their moral priorities are focused differently than men, not because of an inherent difference in thinking style [65].

Of particular concern to feminist ethics in counseling and psychology are the perception of "female" moral priorities (e.g., benevolence, nonmaleficence, etc.) and the assignment of the values of caring, nurturing, and empathy to women. Because the duty of feeling goes against deontologic ethics (which fails to acknowledge sympathy, compassion, and concern as motives for decision making) reasoning based on these values can be seen as irrational [65]. It is a goal of feminist ethics to show that caring, nurturing, sympathy, empathy, benevolence, and concern, among other supposedly "female" values, are actually universal values that are simply discouraged in males. Ancient philosophers, such as Aristotle, have noted that relationships between men are impossible without such values [65]. It has been debated whether a counselor can be effective without a duty to feeling, whether or not it is acknowledged as such.

RELATIONAL ETHICS

A relational model of ethics focuses on the network of relationships and social connections rather than universal absolutes, as humans are embedded in a social web [113,114,126]. Cooperation and care are key in relational ethics. Gilligan's ethics of care is an example of relational ethics. At the heart of relational or care ethics is consideration of the care responsibilities of a practitioner [122].

ASSESSING ETHICAL THEORIES

It is important to remember a theory is not an absolute. Rothman encourages professionals to consider the following three questions when assessing ethical theories [15]:

- The authoritative question: Where does the theory turn to for validation of its basic assumptions or tenets—the Bible, law, philosophical constructs, or another source?

- The distributive question: Whose interest does the theory serve—the interests of every human being or only certain members of a community?

- The substantive question: What is the theory's ultimate goal—social justice, equality, happiness, or another desirable endpoint?

There are other indicators to assess ethical theories. First, a sound ethical theory must be clear and easily understood. It should be simple, with no more rules and principles than professionals are able to remember and apply to real-life professional situations. Second, it should be internally consistent. This means that the different parts of a theory should be in agreement and that different professionals applying the theory to similar circumstances should reach similar conclusions. Third, a good ethical theory should be as complete as possible, without major gaps or omissions. Finally, an ethical theory should be consistent with general daily experience and judgment. If an ethical theory is useful in helping to resolve moral dilemmas but is inconsistent with most or all our ordinary judgments, it will ultimately cause dissonance and will need to be modified.

PRACTICAL APPLICATIONS OF ETHICAL THEORIES

It is important to remember that ethical theories are just that—theories. They do not provide the absolute solutions for every ethical dilemma. They do provide a framework for ethical decision making when adjoined to the critical information we obtain from the clients and families. In other words, theories serve as lenses to how we approach the ethical dilemma or problem.

In reality, most counselors combine the theoretical principles that best fit the particular client situation. Whenever the professional relationship is established, a moral relationship exists. Moral reasoning is required to reach ethically sound decisions. This is a skill, not an inherent gift, and moral reasoning must be practiced so that it becomes a natural part of any counselor's life.

If a professional wears a deontologic lens, duty and justice are the underlying and unchanging moral principles to follow in making the decision. Wearing this theoretical lens, one argues that a person who becomes a helping professional accepts the obligations and duties of the role. Caring for clients who have contagious diseases, for example, is one of those obligations; therefore, refusal, except in particular circumstances, would be a violation of this duty. In the deontologic system, another unchanging moral principle, justice, would require healthcare professionals to provide adequate care for all patients. Refusing to care for a patient with HIV/AIDS would violate this principle.

Although all the ethical systems concern decisions about ethical problems and ethical dilemmas, the decision reached in regard to a specific conflict will vary depending on the system used. For example, a nurse working in a hospital setting assigned to a patient in the terminal stages of AIDS might have strong fears about contracting the disease and transmitting it to family. Is it ethical for him or her to refuse the assignment? If the nurse employs a utilitarian lens, they would weigh the good of the family members against the good of the patient. Based on the greatest good principle, it would be ethical to refuse working with the patient. In addition, because utilitarianism holds that the ends justify the means, preventing the spread of AIDS to the nurse's family would justify refusal of the assignment.

However, if the nurse adheres to the natural law system in shaping his or her ethical decisions, refusing to care for an AIDS patient would be unethical. One of the primary goals of the natural law system is to help the person develop to maximum potential. Refusing to have contact with the AIDS patient would diminish the patient's ability to develop fully. A good person, by natural law definition, would view the opportunity to care for an AIDS patient as a chance to participate in the overall plan of creation and fulfill a set of ultimate goals.

6. ETHICAL DECISION-MAKING FRAMEWORKS

The decision-making frameworks presented in this section are decision analyses. A decision analysis is a step-by-step procedure breaking down the decision into manageable components so one can trace the sequence of events that might be the consequence of selecting one course of action over another [23]. All ethical decision-making models include the steps of identifying the problem, identifying alternatives, consulting with others, and implementing and evaluating the decision [127]. Decision analysis frameworks provide an objective analysis in order to help professionals make the best possible decision in a given situation, build logic and rationality into a decision-making process that is primarily intuitive, and lay the potential outcomes for various decision paths [23]. They are also attempts to shift the process of moral decision making from the arena of the personal and subjective to the arena of an intellectual process, characterized by rigor and systematization [24]. They can be particularly helpful for novice practitioners to organize the information that surfaces when an ethical dilemma emerges [128]. The models assist in providing a linear series of steps to make an informed decision in order to reduce the likelihood of making a truncated decision [128].

Osmo and Landau note that there are two types of argumentation: explicit and implicit [25]. Implicit argumentation involves an internal dialogue, whereby the practitioner talks and listens to him/herself. This internal dialogue involves interpreting events, monitoring one's behavior, and making predictions and generalizations. It is more intuitive and automatic, and this type of dialoguing to oneself has tremendous value because it can increase the practitioner's level of self-awareness. However, Osmo and Landau also argue for the importance of counselors' use of explicit argumentation [25]. Research indicates that just because a professional code of ethics exists, it does not automatically guarantee ethical practice. Explicit argumentation involves a clear and explicit argumentation process that leads to the ethical decision. In other words, the counselor must provide specific and explicit justification of factors for a particular course of conduct regarding an ethical dilemma [25]. Explicit argumentation is like an internal and external documentation of one's course of action. One can explain very clearly to oneself and others why one made the choices.

Osmo and Landau employ Toulmin's theory of argumentation [25,26]. Toulmin defines an argument as an assertion followed by a justification. According to Toulmin, an argument consists of six components: (1) the claim, (2) data, evidence, or grounds for the claim, (3) a warrant, which is the link between the claim and the data (may include empirical evidence, common knowledge, or practice theory), (4) qualification of the claim by expressing the degree of confidence or likelihood, (5) rebuttal of the claim by stating conditions that it does not hold, and (6) further justification using substantiation. In essence, decision-making frameworks are an attempt of explicit argumentation.

In general, decision analyses typically include the following: acknowledging the decision, listing the advantages or disadvantages (pros or cons), creating the pathways of the decision, estimating the probabilities and values, and calculating the expected value [23].

DECISION-MAKING MODELS FOR ETHICAL DILEMMAS

Kenyon's Ethical Decision-Making Model

Kenyon has adapted an ethical decision-making model from Corey, Corey, and Callanan and from Loewenberg and Dolgoff (Table 2) [10]. The first step in Kenyon's decision-making model is to describe the issue [10]. Counselors should be able to describe the ethical issue or dilemma, specifically, by identifying who is involved and what their involvement is, what the relevant situational features are, and what type of issue it is. Next, they should consider all available ethical guidelines; professional standards, laws, and regulations; relevant societal and community values; and personal values relevant to the issue.

Table 2: KENYON'S ETHICAL DECISION-MAKING MODEL

1. Describe the issue.

2. Consider the ethical guidelines.

3. Examine the conflicts.

4. Resolve the conflicts.

5. Generate all possible courses of action.

6. Examine and evaluate the action alternatives.

7. Select and evaluate the preferred action.

8. Plan the action.

9. Evaluate the outcome.

10. Examine the implications.

Source: [10]

Any conflicts should be examined. Counselors should describe all conflicts being experienced, both internal and external, and then decide if any can be minimized or resolved. If necessary, they may seek assistance with the decision by consulting with colleagues, faculty, or supervisors, by reviewing relevant professional literature, and by seeking consultation from professional organizations or available ethics committees.

After all conflicts are resolved, counselors can generate all possible courses of action. Each action alternative should be examined and evaluated. The client's and all other participants' preferences, based on a full understanding of their values and ethical beliefs, must be considered. Alternatives that are inconsistent with other relevant guidelines, inconsistent with the client's and participants' values, and for which there are no resources or support should be eliminated. The remaining action alternatives that do not pass tests based on ethical principles of universality, publicity, and justice should be discarded. Counselors may now predict the possible consequences of the remaining acceptable action alternatives and prioritize them by rank. The preferred action is selected and evaluated, an action plan is developed, and the action is implemented.

Finally, counselors may evaluate the outcome of the action and examine its implications. These implications may be applicable to future decision making.

In Kenyon's ethical decision-making framework, there are five fundamental components to this cognitive process. They encompass naming the dilemma, sorting the issues, solving the problem, and evaluating and reflecting [10].

Naming the dilemma involves identifying the values in conflict. If they are not ethical values or principles, it is not truly an ethical dilemma. It may be a communication problem or an administrative or legal uncertainty. The values, rights, duties, or ethical principles in conflict should be evident, and the dilemma should be named (e.g., this is a case of conflict between client autonomy and doing good for the client). This might happen when a client refuses an intervention or treatment that the counselor thinks would benefit the client. When principles conflict, such as those in the example statement above, a choice must be made about which principle should be honored.

Sort the issues by differentiating the facts from values and policy issues. Although these three matters often become confused, they need to be identified, particularly when the decision is an ethical one. So, ask the following questions: what are the facts, values, and policy concerns, and what appropriate ethical principles are involved for society, for you, and for the involved parties in the ethical dilemma?

Solve the problem by creating several choices of action. This is vital to the decision-making process and to the client's sense of controlling his or her life. When faced with a difficult dilemma, individuals often see only two courses of action that can be explored. These may relate to choosing an intervention, dealing with family and friends, or exploring available resources. It is good to brainstorm about all the possible actions that could be taken (even if some have been informally excluded). This process gives everyone a chance to think through the possibilities and to make clear arguments for and against the various alternatives. It also helps to discourage any possible polarization of the parties involved. Ethical decision making is not easy, but many problems can be solved with creativity and thought. This involves the following:

- Gather as many creative solutions as possible by brainstorming before evaluating suggestions (your own or others).

- Evaluate the suggested solutions until you come up with the most usable ones. Identify the ethical and political consequences of these solutions. Remember that you cannot turn your ethical decision into action if you are not realistic regarding the constraints of institutions and political systems.

- Identify the best solution. Whenever possible, arrive at your decision by consensus so others will support the action. If there are no workable solutions, be prepared to say so and explain why. If ethics cannot be implemented because of politics, this should be discussed. If there are no answers because the ethical dilemma is unsolvable, the appropriate people also must be informed. Finally, the client and/or family should be involved in making the decision, and it is imperative to implement their choice.

Ethics without action is just talk. In order to act, make sure that you communicate what must be done. Share your individual or group decision with the appropriate parties and seek their cooperation. Implement the decision.

As perfect ethical decisions are seldom possible, it is important to evaluate and reflect. Counselors can learn from past decisions and try to make them better in the future, particularly when they lead to policy making. To do this [27]:

- Review the ramifications of the decision.

- Review the process of making the decision. For example, ask yourself if you would do it in the same way the next time and if the appropriate people were involved.

- Ask whether the decision should become policy or if more cases and data are needed before that step should occur.

- Learn from successes and errors.

- Be prepared to review the decision at a later time if the facts or issues change.

- It is important to remember that Kenyon's ethical decision-making framework is based on a rational model for ethical decision making. One of the criticisms of rational decision-making models is that they do not take into account diversity issues.

Ethical Principles Screen

Loewenberg and Dolgoff's Ethical Principles Screen is an ethical decision-making framework that differs slightly from the Kenyon model [28]. This method focuses on a hierarchy of ethical principles to evaluate the potential course of action for ethical dilemmas. The hierarchy rank prioritizes ethical principles; in other words, it depicts which principle should be adhered to first. The first ethical principle is more important than the second to the seventh [11]. Counselors should strive for the first ethical principle before any of the following ethical principles. In a situation where an ethical dilemma involves life or death, this ethical principle should be adhered to first before principle 6, which is adhering to confidentiality. When reading Loewenberg and Dolgoff's hierarchy, the counselor can see that only conditions to maintain the client's right to survival (ethical principle 1) or his/her right to fair treatment (ethical principle 2) take precedence to ethical principle 3, which is free choice and freedom or self-determination.

Collaborative Model for Ethical Decision Making

The Collaborative Model for Ethical Decision Making is relationally oriented and is based on values emphasizing inclusion and cooperation [27,29]. Essentially, it entails four steps [27]:

- Identify the parties involved in the ethical dilemma.

- Define the viewpoints and worldviews of the parties involved.

- Use group work and formulate a solution in which all parties are satisfied.

- Identify and implement each individual's proposed recommendations for a solution.

LIMITATIONS OF ETHICAL DECISION-MAKING FRAMEWORKS

One of the criticisms of ethical decision-making frameworks is that they portray decision making in a linear progression, and in real life, such prescriptive models do not capture what professionals do [30]. In essence, these frameworks stem from a positivist approach. Positivism values objectivity and rationality. In subjectivity, one's values, feelings, and emotions are detached from scientific inquiry. Research has indicated that practitioners having these linear ethical decision frameworks in their knowledge base do not necessarily translate them into ethical practice. Consequently, Betan argues for a hermeneutic (i.e., interpretive) approach to ethical decision making. The person making the decision is not a detached observer; rather, the individual is inextricably part of the process. Betan maintains that this is vital because "ethics is rooted in regards to human life, and when confronting an ethical circumstance, one calls into service a personal sense of what it is to be human. Thus, one cannot intervene in human affairs without being an active participant in defining dimensions of human conduct and human worth" [30]. This does not necessarily mean that professionals should discard the linear approaches to ethical decision making. Rather, professionals should work toward understanding how the principles fit within the therapeutic context as well as the larger cultural context. Furthermore, some maintain that even if practitioners follow a decision-making model, they are often prone to rationalizing their decisions despite ethical violations [128]. Many ethical decision-making models also fail to take into account diversity and culture [129].

7. ETHICAL SELF-REFLECTION

Mattison challenges mental health professionals to not only use decision-making models to infuse logic and rationality to the decision-making process, but to also incorporate a more reflexive phase [24]. In many ways, Mattison's assertion is similar to Betan's call for integrating a hermeneutic perspective to ethical decision making. This is referred to as ethical self-reflection. The process is to learn more about oneself as a decision maker or to better understand the lens one wears to make decisions [24]. It is impossible and unnecessary to remove one's character, conscience, personal philosophy, attitudes, and biases from the decision-making process [31]. Just as counseling emphasizes the person-in-situation perspective in working and advocating for clients, so too should the person-in-situation perspective be employed in increasing self-awareness as a decision maker in ethical situations [24]. The person-in-environment perspective argues that to understand human behavior, one must understand the context of the environment that colors, shapes, and influences behavior. Therefore, the counselor must engage in an active process by considering how their individual level (e.g., prior socialization, cultural values and orientations, personal philosophy, worldview), the client's domain (e.g., values, world views, beliefs), organizational context (i.e., organizational or agency culture, policies), professional context (i.e., values of the social work profession), and societal context (i.e., societal norms) all play a role in influencing moral decision making [24]. Supervision is also key in facilitating self-awareness and reflection when making ethical decisions [130].

PSYCHOLOGICAL CONTEXT OF MORAL DECISION MAKING

As discussed, ethical decision making does not operate within a vacuum. As Mattison acknowledges, there is an array of factors that influence the ethical decision-making process [24]. Consequently, it is impossible to talk about ethical decision making without looking at the psychology of moral development. Psychologists have looked at many of the same questions that philosophers have pondered but from their own professional perspective. Their theories of moral development permit us to learn something else about how moral disagreements develop and even how we may untangle them. Lawrence Kohlberg, a former professor at Harvard University, was a preeminent moral-development theorist. His thinking grew out of Jean Piaget's writings on children's intellectual development. Kohlberg's theories are based on descriptive norms (i.e., typical patterns of behavior) rather than on proven facts. Others in this field have taken issue with his categories, saying they are based too exclusively on rights-oriented ethical approaches, particularly those based on responsibility for others.

Kohlberg's stages of moral development theory presumes that there are six stages of moral development that people go through in much the same way that infants learn first to roll over, to sit up, to crawl, to stand, and finally to walk [32]. The following section is from Lawrence Kohlberg's theory on moral development. There are two important correlates of Kohlberg's system:

- Everyone goes through each stage in the same order, but not everyone goes through all the stages.

- A person at one stage can understand the reasoning of any stage below him or her but cannot understand more than one stage above.

These correlates, especially the latter one, are important when it comes to assessing the nature of disagreements about ethical judgments. Kohlberg has characterized these stages in a number of ways, but perhaps the easiest way to remember them is by the differing kinds of justification employed in each stage. Regarding any decision, the following replies demonstrate the rationale for any decision made within each stage level.

Stage 1: When a person making a stage 1 decision is asked why the decision made is the right one, he or she would reply, "Because if I do not make that decision, I will be punished."

Stage 2: When a person making a stage 2 decision is asked why the decision made is the right one, he or she would reply, "Because if I make that decision, I will be rewarded and other people will help me."

Stage 3: A stage 3 decision maker would reply, "Others whom I care about will be pleased if I do this because they have taught me that this is what a good person does."

Stage 4: At this stage, the decision maker offers explanations that demonstrate his or her role in society and how decisions further the social order (for example, obeying the law makes life more orderly).

Stage 5: Here, the decision maker justifies decisions by explaining that acts will contribute to social well-being and that each member of society has an obligation to every other member.

Stage 6: At this final stage, decisions are justified by appeals to personal conscience and universal ethical principles.

It is important to understand that Kohlberg's stages do not help to find the right answers, as do ethical theories. Instead, recognizing these stages helps counselors to know how people get to their answers. As a result, if you asked the same question of someone at each of the six levels, the answer might be the same in all cases, but the rationale for the decision may be different. For example, let us suppose that a counselor is becoming more involved in the life of his female client. He drives her home after Alcoholics Anonymous meetings and is talking with her on the weekends. Here are examples of the rationale for the counselor's decision and reply, in each stage, to the question of whether this relationship is appropriate.

Stage 1: "No, because I could lose my license if anyone found out that I overstepped the appropriate boundaries."

Stage 2: "No, because if I became known as a counselor who did that kind of thing, my colleagues might not refer clients to me."

Stage 3: "No, because that is against the law and professionals should obey the law," or, "No, because my colleagues would no longer respect me if they knew I had done that."

Stage 4: "No, because if everyone did that, counselors would no longer be trusted and respected."

Stage 5: "No, the client might benefit from our relationship, but it is wrong. I need to merely validate her as a human being."

Stage 6: "No, because I personally believe that this is not right and will compromise standards of good practice, so I cannot be a party to such an action."

These stages can give the counselor another viewpoint as to how ethical decisions can get bogged down. A person who is capable of stage four reasoning may be reasoning at any level below that, but he/she will be stymied by someone who is trying to use a stage six argument. Ideally then, if discussion is to be effective or result in consensus or agreement, the participants in that discussion should be talking on the same level of ethical discourse.

Whenever individuals gather to address a particular client's case, the members of the team must be sure that they are clear about what values they hold, both individually and as a group, and where the conflict lies. Is it between the values, principles, or rules that lie within a single ethical system? Is it between values, principles, or rules that belong to different ethical systems? When consensus has been reached, the members should be aware of the stage level of the decision.

Kohlberg's theory of moral development has been criticized for being androcentric. In other words, his moral dilemmas capture male moral development and not necessarily female moral development. Gilligan, backed by her research, argues that men and women have different ways of conceptualizing morality, and therefore, the decisions made will be different [33]. This does not necessarily mean that one conceptualization is better than the other. Brown and Gilligan maintain that men have a morality of justice while women have a morality of care [34]. Consequently, the goal is not to elevate one form of moral development as the scientific standard; rather, it is crucial to view feminine ethics of care as complementing the standard theories of moral development.

8. MANAGED CARE AND ETHICS

Managed care has changed the climate in the provision of health and mental health services, and a range of practitioners have been affected, including counselors. In part due to negative public perception, there has been a shift away from the term "managed care" and toward terms such as "behavioral health," "integrated behavioral health," and "behavioral mental health" to refer to managed mental health care [115]. This shift acknowledges that mental health issues are complex and involve physical, psychologic, and emotional components [20]. So, more coordinated and integrated services should ultimately benefit the consumer [20,115]. This section is not meant to be an exhaustive discussion of how managed care has impacted ethical practice but is meant to provide an overview of the ethical issues raised in a managed care climate that is complex and multifaceted.

Managed care is a system designed by healthcare insurance companies to curb the increasing costs of health care. A third party (utilization reviewer) reviews treatment plans and progress and has the authority to approve further treatment or to terminate treatment [16]. In addition, certain types of interventions are reimbursable while other types of care are not [36].

The ethical concerns in managed care revolve around the issue of whether a counselor or other practitioner should continue to provide services outside the parameter of the managed care contract [16]. Is early termination of services deemed on a probability that payment will not be obtained? In a cost-benefit analysis, what is the role of the client? How does the ethical principle of beneficence come into play? Certain diagnoses will be deemed reimbursable by the managed care organization. Is it beneficial for the client if a different diagnosis is given in order for services to continue [131]?

At the core, it is the ethical conflict of distributive justice versus injustice [37]. Distributive justice stresses the role of fairness in the distribution of services and states that, at minimum, a basic level of care should be provided. However, the principle of distributive justice may be compromised when services are allocated based on fixed criteria and not on individuals' needs [37]. Situations will then emerge in which the utilization reviewer indicates that the client is not approved for more services, and the counselor may find him or herself unable to provide services that are still necessary. In this case, it is suggested that counselors utilize their roles as advocates to encourage and coach their clients to go through grievance procedures for more services from their managed care provider [37].

Another ethical issue emerging within counseling practice in a managed care environment is that of the counselor's fiduciary relationship with their agency versus a fiduciary relationship with the client [37]. Each relationship has competing sets of loyalties and responsibilities. First, the counselor has a fiduciary relationship to the managed care company. The responsibility to the agency is to keep expenditures within budget. Yet, there is also the counselor's obligation to the client's best interests and needs [37]. One way of managing this conflict is for counselors to be involved in the advocacy and development of policies that allow some leeway for clients who may require additional services.

Confidentiality, which is founded on respect and dignity, is of paramount importance to the therapeutic relationship. However, managed care systems also present challenges to the ethical issue of client confidentiality, as they often request that clients' records be submitted for review for approval of services [38,131]. Consequently, counselors and other practitioners should explain up front and provide disclosure statements that establish the limits to confidentiality, what types of information must be shared, how this information is communicated, treatment options, billing arrangements, and other information [38,39].

Regardless of what counselors might think of managed care, the counselor bears the responsibility of upholding his/her respective professional ethical principles. In order to assist counselors and other practitioners in developing their own ethical standards, the following self-reflective considerations for those working in a managed care environment should be considered [16]:

- Reflect on one's therapeutic and theoretical orientation and its compatibility with the philosophies of managed care. Depending on the assessment, counselors may have to reassess their practices or obtain additional training to acquire the necessary competencies to work in a managed care environment.

- Reflect on one's biases and values regarding managed care and how these attitudes influence one's practice.

- Develop a network of colleagues to act as peer reviewers, as they may evaluate one's ethical practice within the managed care climate.

9. DIVERSITY AND MULTICULTURALISM: ETHICAL ISSUES

As noted, it has been argued that ethical principles may not be easily applied to different cultural contexts. The majority of established ethical principles and codes have been formulated within a Western context; therefore, these ethical principles may have been formulated without consideration for linguistic, cultural, and socioeconomic differences. Harper argues that a cultural context must be taken into account because many of these groups constitute vulnerable populations and may be at risk of exploitation [17]. In this course, an inclusive definition of diversity is utilized, encompassing age, race, ethnicity, culture, immigration status, disability, educational level, religion, gender, sexual orientation, gender identity or expression, and socioeconomic status [40].

DEMOGRAPHIC SHIFTS

Coupled with the ever-changing socioeconomic backdrop, demographic trends indicate increasing diversification and multiculturalism in U.S. society, including rapidly growing ethnic minority populations relative to the white population; a continual influx of documented and undocumented immigrants; a growing number of individuals with various gender and sexual identities (4% to 17% of the total population); an unprecedented increase in the older American population; and a vast number of Americans with disabilities (57 million individuals) [41,42,43,44,45,46]. This has profound implications for counselors, as culture (in a general sense) influences every aspect of our lives, including our social and psychologic reality [47]. Consequently, it is inevitable that counselors will work with more clients and settings than they are familiar or comfortable with. It is therefore advisable that counselors take into account cultural context and their clients' sociocultural identity when entering into a counseling relationship. Richmond writes that "counselors and clients are both emotionally invested in 'right living' issues. Since no therapy is value free, clients face the dilemma of finding a therapist with values similar to their own or having their values challenged. Therapists face the ethical issue of clarifying their own values and determining how to make them known" [66].

This is part of the ethical principle of competency. It is correct to admit to oneself that the knowledge/experience or willingness to effectively care for another individual is not currently possessed. When value conflicts are apparent from the start, it may be more ethical not to engage in a professional relationship with the client. Remember, multiculturalism is not a demand (i.e., one cannot be forced to apply the ethic); rather, it is the knowledge and understanding that cultures/social-groups operate on different value systems.

MULTICULTURALISM IN RESEARCH

It is important to note that culturally sensitive research is of particular value because many older studies, while perhaps not totally biased, may have been skewed due to a lack of cultural understanding. An example of this is a study of research conducted with elderly Japanese American populations in which participants signed agreements that they did not fully understand because they traditionally deferred judgment to their doctors regarding medical decisions; they also felt that not agreeing to participate would be disrespectful to their doctors and the researchers [67].

A positive example of a culturally appropriate study was one that was conducted within a Korean community in which research follow-ups took place at local ethnic grocery stores rather than in an institutional setting [68]. The businesses were identified as traditional gathering places whereas the institutions were identified as a source of fear or discomfort or were inconveniently located, which would have caused a reduction in willing participants. If the research had only been conducted in institutional settings, instead of getting a true cross section, the study would likely end up with participants who were of a certain type (e.g., more affluent, no mobility issues).

Both the ACA and the NBCC wish to further the goals of the field by encouraging counselors to give knowledge back to the profession through the release of culturally appropriate research [8,58]. Publishing culturally oriented or culturally inclusive research upholds the ethical principles of gratitude, publicity, and justice.

DEBATES WITHIN MULTICULTURALISM/DIVERSITY AND ETHICS

Much of the traditional ethical systems and philosophies that have influenced the United States stems from Christian-based and scientific empiricism [48]. Positivism assumes there is one universal that can be counted or measured. In addition, it postulates that reality is objective and value-free [48]. This positivistic approach to ethics was challenged by Joseph Fletcher in 1966 when he published Situation Ethics. He challenged the assumption made by many scholars in the 20th century that one resolved ethical dilemmas by turning to universally accepted principles. His work caused a paradigm shift from a universal approach to ethics to deconstructing it and developing a constructivist, contextual approach [48]. Consequently, in situation ethics, one takes the context (including culture and diversity) into account.

In our multicultural society, how one views good or bad will inevitably vary from group to group. Consequently, one of the struggles when dealing with multiculturalism and diversity issues while developing ethical guidelines is the question of how to develop one ethical guideline that can fully apply to the many diverse groups in our society. The complexity of defining multiculturalism and diversity is influenced by the tremendous differences within a group in addition to the differences between groups. Certainly religion, nationality, socioeconomic status, education, acculturation, and different political affiliations all contribute to this within-group diversity. To make matters even more complex, multiculturalism and diversity within a society are dynamic rather than static [49]. Consequently, the questions that arise in this debate are, should ethical guidelines be based on the uniqueness of groups, taking into account distinct values, norms, and belief systems, or should ethical guidelines be developed based on the assumption that all human beings are alike [49]?

INFUSING DIVERSITY INTO THE ETHICAL DECISION-MAKING MODELS

Several ethical decision-making models have been reviewed in this course. The major criticism of these models is that they do not take into account issues of diversity. Garcia, Cartwright, Winston, and Borzuchowska developed the Transcultural Integrative Model for Decision Making, which includes a self-reflective activity [27]. This allows practitioners to recognize how cultural, societal, and institutional factors impact their values, skills, and biases. Furthermore, the model stresses the role of collaboration and tolerance, encouraging all parties to be involved in the evaluation of ethical issues and promoting acceptance of diverse worldviews [27].

The authors of this model maintain that its strength lies in the fact that it is based on several underlying frameworks: rational, collaborative, and social constructivist. It employs a rational model in providing a sequential series of procedures. The collaboration model is used because it acknowledges the importance of working with all stakeholders involved, employing a variety of techniques to achieve consensus. Finally, the Transcultural Integrative Model employs social constructivist principles by acknowledging that meanings of situations are socially constructed [27]. No single theoretical framework can provide solutions to complex and multifaceted ethical solutions; therefore, an array of strengths from various frameworks is harnessed. The Transcultural Integrative Model consists of four major steps, with sub-tasks within each step [27].

Step 1: Interpreting the Situation through Awareness

First, the counselor examines his/her own competence, values, attitudes, and knowledge regarding a cultural group. The counselor then identifies the dilemma not only from his/her own perspective, but also from the client's perspective. Relevant stakeholders, or meaningful parties relevant to the client's cultural context and value systems, are identified. Finally, cultural information is garnered (e.g., value systems, immigration history, experiences with discrimination, prejudice).

Step 2: Formulating an Ethical Decision

In the second step, the dilemma is further reviewed within its cultural context. It is important to examine the professional ethical code for specific references to diversity. A list of possible culturally sensitive and appropriate actions is formulated by collaborating with all parties involved. Each action is then evaluated from a cultural perspective, examining the respective positive and negative consequences. Again, feedback from all parties is solicited. Consultation with individuals with multicultural expertise is sought to obtain an outsider perspective. Finally, a course of action is agreed upon that is congruent with the cultural values and is acceptable to all parties involved.

Step 3: Weighing Competing, Nonmoral Values

Counselors should reflect and identify personal blind spots that may reflect values different from that of the cultural values of the client. Larger professional, institutional, societal, and cultural values should also be examined.

Step 4: Implementing Action Plan

In the final step, cultural resources are identified to help implement the plan. Cultural barriers that might impede execution of the plan, such as biases, stereotypes, or discrimination, are identified. After the action is implemented, it should be evaluated for accuracy and effectiveness. Such an evaluation plan should include gathering feedback from multicultural experts and culturally specific and relevant variables.

MULTICULTURALISM/DIVERSITY AND THE ACA CODE OF ETHICS

In the 2005 revision of the ACA Code of Ethics, the emphasis on the multicultural/diversity issues in counseling reminds professionals to consider sociocultural context when making ethical decisions. For example, section A.1.d. of the Code was changed to "Support Network Involvement" from "Family Involvement," realizing that in many instances a client may be alienated from a traditional family due to a variety of factors, including sexual or gender identity, interracial marriage, or religious differences; this revision persists in the 2014 ACA Code of Ethics [8,69]. This is an example of the kind of sensitivity to diversity that must be applied in a professional relationship. It is not a new concept but is instead an increased awareness that informs applied ethics.

Other such examples are sections E.5.b. and E.5.c. of the Code, which remind counselors that in other cultures mental or emotional disorders may not be defined in the same ways they are in their culture [8,69]. Also, in the past, certain sociocultural differences were viewed by the hegemony as anomalies that required treatment, and the Code advises counselors to be aware of these past prejudices and to not perpetuate them.

MULTICULTURALISM/DIVERSITY AND THE NBCC CODE OF ETHICS

Directive 7 of the NBCC Code of Ethics states, "Counselors shall demonstrate multicultural counseling competence in practice. Counselors will not use counseling techniques or engage in any professional activities that discriminate against or show hostility toward individuals or groups based on gender, ethnicity, race, national origin, sex, sexual orientation, disability, religion, or any other legally prohibited basis" [58]. In addition to a working knowledge of a client's cultural norms, the counselor should have an understanding of the effect that discrimination and oversimplification have on various social groups.

Furthermore, Directive 66 states, "Prior to the use of a test or assessment with a client, counselors shall seek information about a test's normative groups and limitations of use that may affect the administration or interpretation of results" [58]. It has been noted that many assessments, standardized tests, and techniques were normalized based on research with white, middle class populations. This includes psychologic test procedures and instruments in addition to educational or career assessment tools. Sociocultural norms and biases should be accounted for when interpreting results.

In order to avoid perpetuating cultural disparities in research and care, the NBCC also requires that research conducted with under-represented groups must take into consideration their historical, diverse, and multicultural experiences, and only use techniques and approaches based on appropriate, established, clinically sound theories.

10. ONLINE COUNSELING

Despite the debate about the strengths and limitations of utilizing Internet technologies in the delivery of mental health services, there is a consensus that online counseling and mental health service will certainly become more popular, out of convenience and/or necessity [70]. Consequently, professionals must understand the clinical, legal, and ethical context of online counseling/therapy. Clinicians should be familiar with the empirical research in order to evaluate the strengths, challenges, and efficacy of online counseling and assist individuals who may be considering online counseling.

LIMITATIONS OF ONLINE COUNSELING

As a result of the relatively recent emergence of online counseling, some are concerned that established counseling theories apply specifically to face-to-face counseling and do not translate well to online counseling. It may not be easy to apply traditional theoretical frameworks and principles to online counseling [71]. However, as online practice becomes increasingly routine, more studies will be conducted to evaluate their effectiveness. Over time, a comprehensive knowledge base will be in place for clinicians, professionals, and researchers to utilize.

To date, one of the main challenges with the delivery of Internet counseling and mental health services involves the mechanisms for monitoring quality of services and accountability [72]. There is no established monitoring system to track the credibility and legitimacy of counselors' advertisements. There is also no accountability structure to review and monitor the quality and accuracy of information on websites [72]. These concerns may be amplified in cases of chat rooms or support groups, which may or may not involve a licensed and trained counselor. In some cases, these forums may open clients to a larger number of people who support a destructive behavior or lifestyle, as in the case of a number of pro-anorexia nervosa websites [73].

Another concern with online counseling is based on security and privacy issues. Computer hackers, for example, can access particular websites and compromise the confidentiality, privacy, and security of clients' disclosures as well as payment information, such as credit cards [72]. As online counseling websites become more sophisticated, there is a move toward using the same message security systems utilized by banking institutions [72].

Online counseling may not be conducive and appropriate for clients with severe emotional problems or who have serious psychiatric problems. In an emergency situation in which a client expresses suicidal or homicidal thoughts, counselors may not know where the client is located and be unable to implement emergency plans [72,74]. In addition, they may not be able to warn vulnerable third parties [75]. However, similar challenges exist with telephone counseling or crisis hotlines [74]. Counselors may also have difficulty referring clients to appropriate local resources and services [75]. Even when clients share their locations, counselors may be unfamiliar with the range and quality of services in any given geographic area.

Another concern is the absence of nonverbal cues in online environments, such as chatrooms, e-mails, discussion forums, and even with videoconferencing. Counselors have traditionally relied on nonverbal cues to assist in diagnosing. Due to the lack of nonverbal cues, there is a greater likelihood for counselors to misread and misinterpret text-based messages; therefore, counselors must be careful in interpreting latent meanings [74]. Crying, irritability, and other signs of distress may not be detected, and side effects of medications such as tremors or akathisia may not be evident, even in a video call [76]. The online environment for counseling may not be conducive for certain clients who require visual and auditory cues, including clients who have paranoid tendencies or poor ego strength [74]. The lack of nonverbal cues is also a concern in the formation of a therapeutic alliance and establishment of rapport between the counselor and client.

Some argue that the anonymity offered by online counseling offsets this concern, as anonymity can promote greater rapport building and self-disclosure. Others believe it is impossible for an effective working alliance to be developed in an online environment [72,77]. At this point, the results are mixed at best.

As noted, one of the potential advantages of the online environment is the time delay for both client and counselor responses [74]. It can provide both parties the opportunity to think before they converse. However, the downside of this time delay is that some clients may misinterpret the delay as abandonment or inattention, which can trigger anxiety [74]. Again, online counseling is not suited for everyone. Counselors must properly assess its applicability for each client.

Finally, there are many ethical and legal issues associated with online counseling. Because the Internet is available across state and national boundaries; state and legal jurisdictions by which the counselor practices may not apply [72].

Several states have passed legislation addressing the potential risks, consequences, and benefits to patients who decide to pursue counseling online. These laws generally require that patients must give both oral and written consent stating they are fully aware of the potential risks. In addition, counselors must document whether or not patients have the skills to truly benefit from counseling online [110].

The APA has developed guidelines for counselors who wish to provide telepsychology. These guidelines were created as a direct response to the growing use of technology, which ultimately helps to continue to reach more clients/patients. There are eight guidelines for counselors to consider [111]:

- Competence of the psychologist: Counselors should be competent with the use of the technologies needed and aware of the possible risks to online counseling.

- Standards of care in the delivery of telepsychology services: Counselors should make every effort to ensure that ethical and professional standards of care are followed throughout the duration of services.

- Informed consent: Counselors must obtain informed consent specific to the risks and benefits of telepsychology, including laws that may apply.

- Confidentiality of data and information: Counselors must protect client data and inform clients about the possible risks of using technology for telepsychology.

- Security and transmission of data and information: Counselors must use applicable security measures to protect client information.

- Disposal of data and information and technologies: Counselors should dispose of data and information in a way that reasonably protects it from unauthorized access.

- Testing and assessment: Counselors should be aware that screenings, tests, and other assessments used with clients may work in different ways when used online than when applied with clients face-to-face.

- Interjurisdictional practice: Counselors should be aware of laws that may exist when providing services outside one's jurisdiction or internationally.

ONLINE COMMUNICATIONS AND DISTANCE COUNSELING: A SOCIOCULTURAL CONTEXT

It is crucial to remember that technology is merely a tool to communicate and impart information. As with any form of communication, the sender and recipient of the message operate within a cultural context. Technologies are described as cultural tools that "transform, augment, and support cognitive engagement" [78]. The atmosphere of online groups, for example, is influenced by members' styles of participation, forms of interactions, roles assumed, and power sharing between members and the facilitator, all of which are influenced by the cultural, ethnic, and racial backgrounds of the members and the facilitator [78]. Race, culture, ethnicity, and gender influence communication patterns and attitudes toward technology usage.

Race, Culture, and Ethnicity

Johari, Bentley, Tinney, and Chia argue that reasoning pattern differentials and high- and low-context differentials must be taken into account in gaining an understanding of how ethnic minorities and individuals from other cultures assimilate information and communicate through computer technologies [79]. Thinking and reasoning patterns and approaches to problem solving, for example, vary from culture to culture. Individuals from Western countries like the United States tend to use linear reasoning, whereas individuals from Asia, the Mediterranean, and Latin America are characterized by more nonlinear or circular reasoning patterns [79].

Styles of communication can be classified from high-context to low-context [80]. High-context cultures are those cultures that disseminate information relying on shared experience, implicit messages, nonverbal cues, and the relationship between the two parties [81]. They tend to focus on "how" something was conveyed [55]. Low-context cultures rely on verbal communication and focus on what is explicitly stated in the conversation [81]. Western cultures, including the United States, can generally be classified as low-context. On the other hand, groups from collectivistic cultures such as Asian/Pacific Islanders, Hispanics, Native Americans, and African Americans are from high-context cultures [80].

Individuals from high-context cultures may require more social context in order to understand the meanings of the communication [79]. E-mail is a technology that can be viewed as more amenable to individuals from low-context cultures [79]. E-mails are perceived as a quick, easy way to communicate, in which the focus is on words to convey both content and meaning [79]. However, this form of communication can place ethnic minorities or individuals from other cultures at a disadvantage. Some experts recommend that when using technology in education and, by extension, counseling, the facilitator should attempt to increase contextual cues [82]. Counselors may choose to provide biographical information about themselves and encourage brief introductions from everyone in an online support group [82]. This process of setting up rich contextual cues will assist in building rapport as well.

High- and low-context culture differentials can also impact the amount of information that can be assimilated. Individuals from high-context cultures (e.g., Korea, Japan) may experience information overload compared to those individuals from low-context cultures (e.g., Germany, the United States) [83]. Counselors should be sensitive to the amount of information a client can process and assimilate.

Other cultural values can influence technology usage. Individuals' attitudes about appropriate uses of time vary from culture to culture [84]. Monochronism refers to preference to perform tasks one at a time; polychronism refers to a preference to parallel task, performing more than one task simultaneously [84]. Certain cultures (e.g., Egypt and Peru) tend to be less concerned with slower technologies with some delay because they adhere to more polychronistic attitudes toward time [83].

Instructors who use Internet technology are cautioned to remember that writing styles, writing structure, web design, and multimedia all influence how students process and assimilate information and that the learning process does not exist in a cultural vacuum [85]. The same applies to Internet counseling. Vocabulary and grammar have varying meanings from culture to culture and signify different levels of respect and politeness [85]. For example, some cultures use more formal language to convey respect. Sentence structures, particularly if they are translated from one language into another, can inadvertently convey a completely different message, or they might sound too direct, appearing to be offensive [85]. Web design is also important, and the design should reflect the language of the cultural group. The English language, for example, is read from left to right, but some cultures read right to left. Therefore, icons and images should reflect these norms [85]. It is also important to remember that images are culturally sensitive and can perpetuate stereotypes [85].

Finally, individuals' perceptions of computer technologies may be influenced by cultural and gender role norms, and understanding cultural differences in attitudes toward computers may have implications in online counseling [86]. One would surmise that some ethnic minority groups may have less favorable attitudes toward computer technology in part due to practical barriers, such as cost and access. One ethnographic study revealed that economics is not the only factor; psychosocial barriers can also affect ethnic minority adults' perceptions about computers [87]. Some participants, for example, did not see themselves as the type of person who used computers. Some thought that computers were a luxury item, and their subcultural identity did not include the image of a computer user [87]. Similarly, in Menard-Warwick and Dabach's case studies of two Mexican families, affective factors included fear in using computers and anxiety revolving around a sense of entitlement [88].

Culturally embedded perceptions about gender roles also color attitudes toward computers. Some Hispanic men stated that computers and typing were considered female subjects in school. In other cases, some participants stated that computers were equated with educational success, but educational achievement was not part of their life tasks and roles [87].

Gender

It has been said that Internet and computer usage is male-dominated and that the Internet was developed by men for men [89]. Yet, some argue that the Internet democratizes and minimizes patriarchal communications between men and women in part because there are less social cues in online communication [90]. Consequently, differential status based on gender may potentially be reduced, ultimately equalizing communication patterns [90].

Those who argue that the Internet is male-dominated and reinforces male patriarchy attribute this to early socialization processes favoring males in computer, math, and science subjects [89,91]. In the United States, men and women are roughly equal users of the Internet at home (79.4% and 78.5%, respectively) [103]. Yet, it is important to remember that examining the gender digital divide in terms of statistics of usage is misleading because the culture of gender and general societal expectations of men and women continue to influence attitudes toward Internet usage, computer technologies, and communication patterns and styles in online media.

In general, there are gender differences in how the Internet is used. Men have historically been more likely to use the Internet to find news, play games, seek information, and connect to audio broadcasts. Early on, men gained more sophisticated web skills, and were more comfortable and proficient in developing their own websites and changing preferences [89]. In one study, Weiser found gender differences in Internet patterns and applications [89]. Men had a tendency to use the Internet for entertainment and leisure such as pornography, games, and pursuing sexual relationships, while women were more likely to use the Internet for interpersonal communications and education [89].

Gender differences are also apparent in the content of Internet communications. When examining text of postings in online forums, women tend to gravitate toward topics that have practical ramifications and consequences and are less inclined to be drawn to topics that are abstract and theoretical [92]. They prefer to discuss personal issues, ask questions to solicit information, and give or garner information [92]. Men also may discuss personal issues, but prefer to focus on an issue, give or obtain information, ask questions, and discuss personal matters [92].

In a qualitative study examining gender differences and technology use, particularly women's experiences with the use of the Internet, women were most likely to discuss how e-mail has helped them to keep in touch with family and friends. Instant messaging was also used as a way to keep in touch with children, particularly for single mothers with children at home alone [93]. Men also discussed the ability of the Internet to connect them to family and friends; however, male communication predominantly consisted of providing information, while women connected on a personal level [93].

Male communications are characterized as being more power-conscious; that is, they are more assertive in conveying information and less focused on exchanging information and developing relationships [90]. On the other hand, female communications are described as less power-dominated, as they tend to ask more questions and apologize more often [93]. Postings by female participants in online groups are characterized by more support and encouragement compared to the postings of male participants, who seek and receive information (Table 3) [93,102]. Similarly, Rovai found that the majority of men in online forums tended to utilize an independent voice that was characterized as authoritative, impersonal, and assertive, while the majority of women used a connected voice described as supportive and helpful [94].

Table 3: GENDER DIFFERENCES IN COMMUNICATION PATTERNS IN ONLINE MEDIA

Women

Men

Attenuated assertions

Apologies

Explicit justifications

Questions

Personal orientation

Support for others

Strong assertions

Self-promotion

Presuppositions

Rhetorical questions

Authoritative orientation

Challenges to others

Use of humor and sarcasm

Source: [102]

Some scholars argue that by emphasizing these dichotomies, stereotypes about women will be reinforced. Instead, it is important to focus on how the Internet serves to equalize interactions and relationships. Others argue that it is too simplistic to maintain that online communications equalize gender relationships due to the promotion of anonymity, as it might actually heighten stereotypical behavior, promote group norms, and trigger an "us" versus "them" behavior [95]. Interestingly, in one study, researchers found that one way to reduce stereotypical behaviors was to reduce the depersonalization and the anonymity of the online environment. Simply having individuals post their photos and share biographies with other participants in the online environment can promote greater personalization [96].

Regardless of the side of the debate, it is impossible to disregard the power of gender in shaping Internet communications. While some might hail the Internet as democratizing and equalizing gender relations, it is crucial to recognize that gender norms and the effects of socialization may be equally if not more powerful in online media. It should be noted that gender differences in the use of information and communication technology among the younger generations are minimal [105]. However, there is still debate regarding the effect of socialization and generational differences on Internet use behavior; for example, the youngest generations of proficient Internet and social media users have not yet become parents, workers, or spouses. It is too early to know if or how gender will affect online behavior as these individuals transition to adulthood [105]. Clinicians should be aware of the effects of gender on communication patterns and styles in individual and group online counseling.

ETHICAL AND LEGAL ISSUES

Various ethical concerns have been raised regarding online counseling. There is some concern that beneficence cannot be fully upheld with the use of electronic communications because the counselor may find it difficult to ensure the client's safety. In part, this safety concern is linked to the issue of privacy and confidentiality. It is nearly impossible to ensure that another party will not intercept the client/counselor interaction or that encryption methods will be foolproof [97]. For example, a client who is accessing the Internet at home could be interrupted by another individual who might see what was written, or an e-mail could be read by other family members, compromising the client's privacy. If a client is using a computer in the workplace, there is a possibility that others may read the online communication. In the United States, an employer has the legal right to read their employees' e-mail communications [71]. In some situations, the compromise of the client's privacy could prove particularly dangerous. Consider a victim of family violence who is caught by the abuser communicating with a counselor or an abuser hacking into the victim's computer system to access private information [97].

Beyond merely ensuring the client's physical safety, some argue it may not be possible for counselors to truly extend beneficence to clients in an online environment because the essence of therapeutic change rests upon the formation of the client-counselor rapport and relationship. However, this argument is based on the belief that a relationship cannot truly be developed in an online environment, an issue that remains controversial [97].

At the heart of the client-counselor relationship is confidentiality. A counselor adheres to the ethical principle that the information provided by the client will remain confidential. Moreover, the Internet does not exist within state or international borders, which then brings legal jurisdictions into question. What regulations about patient/doctor confidentiality will be adhered to, particularly if the counselor resides in one state and the client in another [72]?

As noted, one of the limitations of online counseling is the fact that neither party can be fully confident of the other's identity [72]. The clients may not give their identity, contact information, or physical location. Again, this has implications regarding ensuring client safety. In a traditional counseling relationship, if the client expresses a desire to hurt him/herself or others, the counselor is obligated to report this to the appropriate authorities. If a client never discloses his/her full name or contact information, then the counselor's ability to intervene or report is limited [97,98]. Another concern revolves around minors who lie about their identity and age and who obtain treatment without parental consent [97]. Despite statements indicating that users must be older than 18 years of age or have parental consent, online counselors should still ask for age and birthdate during the intake process [98]. Although a minor could still lie, the online counselor has then done all that is possible to ensure that the client is not a minor [98].

There is also concern about the identity of counselors and their stated qualifications [97]. Online counselors' qualifications vary widely, from unlicensed therapists to licensed social workers, psychologists, and psychiatrists. Again, questions about licensing requirements across legal jurisdictions arise [99]. There is debate about which authorities and jurisdictions should be recognized for activities occurring on the Internet, as online counseling crosses geographical and governmental boundaries [71]. Normally, malpractice insurance is limited to the state(s) where the clinician is licensed to practice; online, the clinician may not be covered in "interstate" suits [76]. Some contend that if the client has accessed the clinician's website, then the client has actually "traveled" to the clinician's state [76]. These ethical and legal issues have not yet been firmly resolved.

ACA CODE OF ETHICS AND DISTANCE COUNSELING

Because online counseling has become increasingly popular, national counseling and other related professional organizations must develop ethical codes relating to online and other distance counseling. Clinicians should be familiar with the code of ethics for distance counseling in their professional organization as well as ethical codes in related professional disciplines.

Manhal-Baugus described two main ethical issues pertinent to distance counseling: information that is conveyed to the client about privacy/confidentiality and principles in establishing online relationships [100].

Information Privacy and Confidentiality

The ACA code of ethics highlights specific information that must be conveyed to the client and to the counselor. Counselors, for example, must clearly communicate to clients regarding their identity, qualifications, and areas of expertise. In turn, clients should also provide identification information at the beginning and throughout the relationship [8].

Information related to the inherent limitations of using computer technology and how privacy might be affected when transmitting information should be clearly communicated to clients [8]. Counselors must inform clients whether websites are secure and whether e-mail encryption is employed and should make every effort to ensure this is true. The client must acknowledge in a waiver that he/she understands that there are risks to confidentiality when information is disseminated over the Internet. Finally, all records and e-mail transcripts should be stored in a secure place [8].

Distance Counseling, Technology, and Social Media

Six principles related to establishing and maintaining distance counseling relationships are identified in the ACA's code of ethics [8]:

- Knowledge and legal considerations: Counselors should have clear understanding of the technical, legal, and ethical aspects of distance counseling, technology, and social media. The laws and regulations of the counselor's practice location and the client's location must be known. Counselors should only practice within their area(s) of expertise.

- Informed consent and security: Intervention plans should reflect the client's individual needs, and the client should decide whether to use alternatives to face-to-face counseling. The counselor must disclose her or his distance counseling credentials, physical location, and contact information; risks and benefits of distance counseling, technology, or social media; response times; and possible failure of technology and alternatives in this eventuality. Counselors discuss and the client acknowledges the security risks and confidentiality limitations involved with distance counseling.

- Client verification: Counselors must ensure that the client is who he or she purports to be. Steps must be taken to verify clients' identity throughout the relationship.

- Distance counseling relationship: Counselors should be sure that clients are completely able use the technology and that the client is suited to distance counseling. Clients should understand that misunderstandings are possible due to lack of nonverbal cues between both individuals in the relationship. If it is assessed and determined that distance counseling is not appropriate, counselors should first consider providing face-to-face services; referrals should be made to alternative services if this is not feasible.

- Records and web maintenance: Laws and statutes regarding electronic record storage dictate how counselors maintain and secure client files and personal information. Clients should be informed about the security measures and encryption used in their database. If transaction records are archived, counselors should disclose how long these are kept. A distance counselor's licensure and professional certification board information should be linked on their website or personal page, and these links should be regularly updated.

- Social media: Counselors must maintain separate personal and professional social media profiles and/or web pages. Disclosure of confidential information on public social media or web pages must be avoided. Clients' Internet presence should remain private (even publicly shared information) unless a counselor receives consent.

NBCC STANDARDS FOR THE PROVISION OF TELEMENTAL HEALTH SERVICES

In its most recent revision of its Code of Ethics, the NBCC added a section addressing telemental health. This section replaces the previous policy for the provision of distance professional services issued by the NBCC in 2016. The following standards are from the 2023 NBCC Code of Ethics [58].

91. Counselors shall provide only those telemental health services for which they are qualified by education and experience.

92. Counselors shall carefully adhere to legal requirements when providing telemental health services. This requirement includes legal regulations from the State(s) in which the counselor and client are located. Counselors shall document relevant State requirements in the relevant client record(s).

93. Counselors shall ensure that the electronic means used in providing telemental health services are in compliance with current Federal and State laws and regulatory standards concerning telemental health service.

94. Counselors shall ensure that all electronic technology communications with clients are encrypted and secure.

95. Counselors shall maintain records of all clinical contacts with telemental health service clients.

96. Counselors shall set clear expectations and boundaries with telemental health service recipients about the type(s) and timing of communications that will be included in service provision. These expectations and boundaries shall be communicated in writing in disclosure documents provided to clients.

97. Counselors shall provide written information to all telemental health clients regarding the protection of client records, accounts and related passwords, electronic communications, and client identity. This information should include a description of the nature of all communication security measures that are used by the counselor, including any risks or limitations related to the provision of telemental health services.

98. Counselors shall communicate information regarding security to clients who receive telemental health services. Telemental health service clients shall be informed of the potential risks of telemental health communications, including warnings about transmitting private information when using a public access computer or one that is on a shared network.

99. Counselors shall screen potential telemental health service clients to determine whether such services are appropriate. These considerations shall be documented in the client’s record. Counselors shall advise telemental health services clients that they must be intentional about protecting their privacy and confidentiality, including advice concerning viewing employer policies relating to the possible prohibitions concerning the use of work computer systems for personal communications, and not using “auto-remember” usernames and passwords.

100. During the screening or intake process, Counselors shall provide potential clients with a detailed written description of the telemental health counseling process and service provision. This information shall be specific to the identified service delivery type, and include relevant considerations for that particular client. These considerations shall include: the appropriateness of telemental health counseling in relation to the specific goal; the format of service delivery; the electronic equipment requirements such as the need for a computer with certain capabilities; the limitations of confidentiality; privacy concerns; the possibility of technological failure; anticipated response time to electronic communication; alternate service delivery processes; and, any additional considerations necessary to assist the potential client in reaching a determination about the appropriateness of the telemental health service delivery format for their needs. Counselors shall discuss this information throughout the service delivery process to ensure that this method satisfies the anticipated goals. The counselor will document such information and the discussion of alternative service options and referrals in the client’s record.

101. Counselors shall prevent the distribution of confidential telemental health client information to unauthorized individuals. Counselors shall discuss actions the client may take to reduce the possibility that such confidential information is sent to unauthorized individuals in error.

102. Counselors shall provide clients of telemental health services with information concerning their professional preparation and/or credentials related to telemental health, and identify the relevant credentialing organization websites.

103. Counselors, either prior to or during the initial session, shall inform clients of the purposes, goals, procedures, limitations, and potential risks and benefits of telemental health services and techniques. Counselors also shall provide information about rights and responsibilities as appropriate to the telemental health service. Counselors also shall discuss with clients the associated challenges that may occur when communicating through telemental health means, including those associated with privacy and confidentiality.

104. In the event that the client of telemental health services is a minor or is unable to provide legal consent, the counselor shall obtain a legal guardian’s consent prior to the provision of services unless otherwise required by State law. Counselors shall retain documentation indicating the legal guardian’s identity and consent in the client’s file.

105. Counselors will provide clients of telemental health services with specific written procedures regarding emergency assistance situations related to a client. This information shall include the identification of emergency responders near the client’s location. Counselors shall take reasonable steps to secure referrals for recipients when needed for emergencies. Counselors shall provide information to clients concerning the importance of identifying personal contacts in the event of identified emergency situations, and shall ask clients to identify such contacts. Counselors also shall identify to the clients the circumstances in which the counselor will communicate with emergency contacts, and the information that will be shared with emergency contacts.

106. Counselors shall develop written procedures for verifying the identity of each telemental health client, their current location, and readiness to proceed at the beginning of each contact. Examples of verification include the use of code words, phrases, or inquiries, such as “Is this a good time to proceed?”.

107. Counselors shall limit use of client information obtained through social media sources (e.g., Facebook, LinkedIn, Twitter) in accordance with established practice procedures provided to the client at the initiation of services and as adopted through the ongoing informed consent process.

108. Counselors shall retain telemental health service records for a minimum of five (5) years unless applicable State laws require additional time. Counselors shall limit the use of such client records to those permitted by law and professional standards, and as specified by the agreement terms with the respective telemental health services client.

As previously indicated, all professional organizations have their own codes of ethics, and many of these ethical principles overlap. It is important to remember that counselors are bound to their employer's code of ethics, but often, professional organizations will explicitly highlight principles directly related to online counseling. Counselors are encouraged to review and become familiar with other organizations' codes of ethics.

11. INTERPROFESSIONAL COLLABORATION AND ETHICS

Interprofessional collaboration is defined as a partnership or network of providers who work in a concerted and coordinated effort on a common goal for clients and their families to improve health, mental health, and social and/or family outcomes [132]. It involves the interaction of two or more disciplines or professions who work collaboratively with the client on an identified issue [133]. Providers come together to discuss and address the same client problem from different lenses, which can ultimately produce more inventive and effective solutions [134]. The client/patient is not excluded from the process; rather, shared decision making by all team members advances the goal of improving client/patient outcome(s) [132].

Interprofessional collaborations have been touted for multiple reasons. Positive outcomes have been demonstrated on individual and organizational levels. For example, on the client level, reduced mortality, increased safety and satisfaction, and improved health outcomes and quality of life have been demonstrated [135,136,137]. Practitioners also experience benefits, including increased job satisfaction, staff retention, improved working relationships, and more innovative solutions to problems [135,137,138].

There is a difference between the traditional model of professional ethics and interprofessional ethics [139]. The traditional model revolves around a single profession's unique code of ethics, which addresses the specific profession's roles, expertise, core values, and ethical behaviors. Each professional's code of ethics demands the practitioner's loyalty and commitment to the values, specialty, and expertise [139]. On the other hand, interprofessional ethics emphasizes the relationship and interactions of practitioners from different professions and the unique ethical issues that emerge from working with a diverse team (e.g., interpersonal conflict, misuse of power, respect) [139]. Practitioners in an interprofessional setting should engage in collective interprofessional ethics work, which is defined as "the effort cooperating professionals put into collectively developing themselves as good practitioners, collectively seeing ethical aspects of situations, collectively working out the right course of action, and collectively justifying who they are and what they do" [140].

12. CONCLUSION

The application of ethical theories and ethical decision making is challenging. Without a background of knowledge and understanding, counselors will struggle to make sound decisions about ethical problems and be unable to help clients and families in their decision making. Although every situation differs, decision making based upon ethical theories can provide a useful means for solving problems related to client situations. Hopefully, as a result of this course, you feel more prepared and confident in facing future ethical decision-making situations.

California LMFTs

An excerpt from the California Board of Behavioral Sciences Statutes and Regulations Relating to the Practice of Marriage and Family Therapy is available by clicking here.

California LPCCs

An excerpt from the California Board of Behavioral Sciences Statutes and Regulations Relating to the Practice of Professional Counseling is available by clicking here.

California LEPs

An excerpt from the California Board of Behavioral Sciences Statutes and Regulations Relating to the Practice of Educational Psychology is available by clicking here.

13. RESOURCES

Counselors play an important role in advocacy and education. To be more effective, counseling professionals may require additional resources.

American Association for Marriage and Family Therapy

https://www.aamft.org/Legal_Ethics/Code_of_Ethics.aspx

American Counseling Association Code of Ethics

https://www.counseling.org/Resources/aca-code-of-ethics.pdf

APA Ethics Office

https://www.apa.org/ethics

Center for the Study of Ethics in the Professions

This center was established in 1976 for the purpose of promoting education and scholarship relating to the professions.

https://www.iit.edu/center-ethics

Ethics and Compliance Initiative

The Ethics and Compliance Initiative aims to strengthen ethical leadership worldwide by providing leading-edge expertise and services through research, education and partnerships. Although this may not be completely targeted to counselors, there are some resources that may be appropriate.

https://www.ethics.org

Ethics Updates

Ethics Updates is designed primarily to be used by ethics instructors and their students. It is intended to provide updates on current literature, both popular and professional, that relates to ethics.

http://ethicsupdates.net

NASW Code of Ethics

A code of ethics for social workers that may be used as a resource for counselors.

https://www.socialworkers.org/About/Ethics/Code-of-Ethics

National Board for Certified Counselors: Ethics Policies and Procedures

https://www.nbcc.org/Ethics

W. Maurice Young Centre for Applied Ethics

https://ethics.ubc.ca

14. APPENDIX: THE ACA CODE OF ETHICS

This appendix contains the entirety of the ACA Code of Ethics. It is reprinted with permission from the American Counseling Association.

SECTION A: THE COUNSELING RELATIONSHIP

Introduction

Counselors facilitate client growth and development in ways that foster the interest and welfare of clients and promote formation of healthy relationships. Trust is the cornerstone of the counseling relationship, and counselors have the responsibility to respect and safeguard the client's right to privacy and confidentiality. Counselors actively attempt to understand the diverse cultural backgrounds of the clients they serve. Counselors also explore their own cultural identities and how these affect their values and beliefs about the counseling process. Additionally, counselors are encouraged to contribute to society by devoting a portion of their professional activities for little or no financial return (pro bono publico).

A.1. Client Welfare

A.1.a. Primary Responsibility

The primary responsibility of counselors is to respect the dignity and promote the welfare of clients.

A.1.b. Records and Documentation

Counselors create, safeguard, and maintain documentation necessary for rendering professional services. Regardless of the medium, counselors include sufficient and timely documentation to facilitate the delivery and continuity of services. Counselors take reasonable steps to ensure that documentation accurately reflects client progress and services provided. If amendments are made to records and documentation, counselors take steps to properly note the amendments according to agency or institutional policies.

A.1.c. Counseling Plans

Counselors and their clients work jointly in devising counseling plans that offer reasonable promise of success and are consistent with the abilities, temperament, developmental level, and circumstances of clients. Counselors and clients regularly review and revise counseling plans to assess their continued viability and effectiveness, respecting clients' freedom of choice.

A.1.d. Support Network Involvement

Counselors recognize that support networks hold various meanings in the lives of clients and consider enlisting the support, understanding, and involvement of others (e.g., religious/spiritual/community leaders, family members, friends) as positive resources, when appropriate, with client consent.

A.2. Informed Consent in the Counseling Relationship

A.2.a. Informed Consent

Clients have the freedom to choose whether to enter into or remain in a counseling relationship and need adequate information about the counseling process and the counselor. Counselors have an obligation to review in writing and verbally with clients the rights and responsibilities of both counselors and clients. Informed consent is an ongoing part of the counseling process, and counselors appropriately document discussions of informed consent throughout the counseling relationship.

A.2.b. Types of Information Needed

Counselors explicitly explain to clients the nature of all services provided. They inform clients about issues such as, but not limited to, the following: the purposes, goals, techniques, procedures, limitations, potential risks, and benefits of services; the counselor's qualifications, credentials, relevant experience, and approach to counseling; continuation of services upon the incapacitation or death of the counselor; the role of technology; and other pertinent information. Counselors take steps to ensure that clients understand the implications of diagnosis and the intended use of tests and reports. Additionally, counselors inform clients about fees and billing arrangements, including procedures for nonpayment of fees. Clients have the right to confidentiality and to be provided with an explanation of its limits (including how supervisors and/or treatment or interdisciplinary team professionals are involved), to obtain clear information about their records, to participate in the ongoing counseling plans, and to refuse any services or modality changes and to be advised of the consequences of such refusal.

A.2.c. Developmental and Cultural Sensitivity

Counselors communicate information in ways that are both developmentally and culturally appropriate. Counselors use clear and understandable language when discussing issues related to informed consent. When clients have difficulty understanding the language that counselors use, counselors provide necessary services (e.g., arranging for a qualified interpreter or translator) to ensure comprehension by clients. In collaboration with clients, counselors consider cultural implications of informed consent procedures and, where possible, counselors adjust their practices accordingly.

A.2.d. Inability to Give Consent

When counseling minors, incapacitated adults, or other persons unable to give voluntary consent, counselors seek the assent of clients to services and include them in decision making as appropriate. Counselors recognize the need to balance the ethical rights of clients to make choices, their capacity to give consent or assent to receive services, and parental or familial legal rights and responsibilities to protect these clients and make decisions on their behalf.

A.2.e. Mandated Clients

Counselors discuss the required limitations to confidentiality when working with clients who have been mandated for counseling services. Counselors also explain what type of information and with whom that information is shared prior to the beginning of counseling. The client may choose to refuse services. In this case, counselors will, to the best of their ability, discuss with the client the potential consequences of refusing counseling services.

A.3. Clients Served by Others

When counselors learn that their clients are in a professional relationship with other mental health professionals, they request release from clients to inform the other professionals and strive to establish positive and collaborative professional relationships.

A.4. Avoiding Harm and Imposing Values

A.4.a. Avoiding Harm

Counselors act to avoid harming their clients, trainees, and research participants and to minimize or to remedy unavoidable or unanticipated harm.

A.4.b. Personal Values

Counselors are aware of—and avoid imposing—their own values, attitudes, beliefs, and behaviors. Counselors respect the diversity of clients, trainees, and research participants and seek training in areas in which they are at risk of imposing their values onto clients, especially when the counselor's values are inconsistent with the client's goals or are discriminatory in nature.

A.5. Prohibited Noncounseling Roles and Relationships

A.5.a. Sexual and/or Romantic Relationships Prohibited

Sexual and/or romantic counselor-client interactions or relationships with current clients, their romantic partners, or their family members are prohibited. This prohibition applies to both in-person and electronic interactions or relationships.

A.5.b. Previous Sexual and/or Romantic Relationships

Counselors are prohibited from engaging in counseling relationships with persons with whom they have had a previous sexual and/or romantic relationship.

A.5.c. Sexual and/or Romantic Relationships with Former Clients

Sexual and/or romantic counselor-client interactions or relationships with former clients, their romantic partners, or their family members are prohibited for a period of 5 years following the last professional contact. This prohibition applies to both in-person and electronic interactions or relationships. Counselors, before engaging in sexual and/or romantic interactions or relationships with former clients, their romantic partners, or their family members, demonstrate forethought and document (in written form) whether the interaction or relationship can be viewed as exploitive in any way and/or whether there is still potential to harm the former client; in cases of potential exploitation and/or harm, the counselor avoids entering into such an interaction or relationship.

A.5.d. Friends or Family Members

Counselors are prohibited from engaging in counseling relationships with friends or family members with whom they have an inability to remain objective.

A.5.e. Personal Virtual Relationships with Current Clients

Counselors are prohibited from engaging in a personal virtual relationship with individuals with whom they have a current counseling relationship (e.g., through social and other media).

A.6. Managing and Maintaining Boundaries and Professional Relationships

A.6.a. Previous Relationships

Counselors consider the risks and benefits of accepting as clients those with whom they have had a previous relationship. These potential clients may include individuals with whom the counselor has had a casual, distant, or past relationship. Examples include mutual or past membership in a professional association, organization, or community. When counselors accept these clients, they take appropriate professional precautions such as informed consent, consultation, supervision, and documentation to ensure that judgment is not impaired and no exploitation occurs.

A.6.b. Extending Counseling Boundaries

Counselors consider the risks and benefits of extending current counseling relationships beyond conventional parameters. Examples include attending a client's formal ceremony (e.g., a wedding/commitment ceremony or graduation), purchasing a service or product provided by a client (excepting unrestricted bartering), and visiting a client's ill family member in the hospital. In extending these boundaries, counselor stake appropriate professional precautions such as informed consent, consultation, supervision, and documentation to ensure that judgment is not impaired and no harm occurs.

A.6.c. Documenting Boundary Extensions

If counselors extend boundaries as described in A.6.a. and A.6.b., they must officially document, prior to the interaction (when feasible), the rationale for such an interaction, the potential benefit, and anticipated consequences for the client or former client and other individuals significantly involved with the client or former client. When unintentional harm occurs to the client or former client, or to an individual significantly involved with the client or former client, the counselor must show evidence of an attempt to remedy such harm.

A.6.d. Role Changes in the Professional Relationship

When counselors change a role from the original or most recent contracted relationship, they obtain informed consent from the client and explain the client's right to refuse services related to the change. Examples of role changes include, but are not limited to:

1. Changing from individual to relationship or family counseling, or vice versa;

2. Changing from an evaluative role to a therapeutic role, or vice versa; and

3. Changing from a counselor to a mediator role, or vice versa.

Clients must be fully informed of any anticipated consequences (e.g., financial, legal, personal, therapeutic) of counselor role changes.

A.6.e. Nonprofessional Interactions or Relationships (Other Than Sexual or Romantic Interactions or Relationships)

Counselors avoid entering into non-professional relationships with former clients, their romantic partners, or their family members when the interaction is potentially harmful to the client. This applies to both in-person and electronic interactions or relationships.

A.7. Roles and Relationships at Individual, Group, Institutional, and Societal Levels

A.7.a. Advocacy

When appropriate, counselors advocate at individual, group, institutional, and societal levels to address potential barriers and obstacles that inhibit access and/or the growth and development of clients.

A.7.b. Confidentiality and Advocacy

Counselors obtain client consent prior to engaging in advocacy efforts on behalf of an identifiable client to improve the provision of services and to work toward removal of systemic barriers or obstacles that inhibit client access, growth, and development.

A.8. Multiple Clients

When a counselor agrees to provide counseling services to two or more persons who have a relationship, the counselor clarifies at the outset which person or persons are clients and the nature of the relationships the counselor will have with each involved person. If it becomes apparent that the counselor may be called upon to perform potentially conflicting roles, the counselor will clarify, adjust, or withdraw from roles appropriately.

A.9. Group Work

A.9.a. Screening

Counselors screen prospective group counseling/therapy participants. To the extent possible, counselors select members whose needs and goals are compatible with the goals of the group, who will not impede the group process, and whose well-being will not be jeopardized by the group experience.

A.9.b. Protecting Clients

In a group setting, counselors take reasonable precautions to protect clients from physical, emotional, or psychological trauma.

A.10. Fees and Business Practices

A.10.a. Self-Referral

Counselors working in an organization (e.g., school, agency, institution) that provides counseling services do not refer clients to their private practice unless the policies of a particular organization make explicit provisions for self-referrals. In such instances, the clients must be informed of other options open to them should they seek private counseling services.

A.10.b. Unacceptable Business Practices

Counselors do not participate in fee splitting, nor do they give or receive commissions, rebates, or any other form of remuneration when referring clients for professional services.

A.10.c. Establishing Fees

In establishing fees for professional counseling services, counselors consider the financial status of clients and locality. If a counselor's usual fees create undue hardship for the client, the counselor may adjust fees, when legally permissible, or assist the client in locating comparable, affordable services.

A.10.d. Nonpayment of Fees

If counselors intend to use collection agencies or take legal measures to collect fees from clients who do not pay for services as agreed upon, they include such information in their informed consent documents and also inform clients in a timely fashion of intended actions and offer clients the opportunity to make payment.

A.10.e. Bartering

Counselors may barter only if the bartering does not result in exploitation or harm, if the client requests it, and if such arrangements are an accepted practice among professionals in the community. Counselors consider the cultural implications of bartering and discuss relevant concerns with clients and document such agreements in a clear written contract.

A.10.f. Receiving Gifts

Counselors understand the challenges of accepting gifts from clients and recognize that in some cultures, small gifts are a token of respect and gratitude. When determining whether to accept a gift from clients, counselors take into account the therapeutic relationship, the monetary value of the gift, the client's motivation for giving the gift, and the counselor's motivation for wanting to accept or decline the gift.

A.11. Termination and Referral

A.11.a. Competence within Termination and Referral

If counselors lack the competence to be of professional assistance to clients, they avoid entering or continuing counseling relationships. Counselors are knowledgeable about culturally and clinically appropriate referral resources and suggest these alternatives. If clients decline the suggested referrals, counselors discontinue the relationship.

A.11.b. Values within Termination and Referral

Counselors refrain from referring prospective and current clients based solely on the counselor's personally held values, attitudes, beliefs, and behaviors. Counselors respect the diversity of clients and seek training in areas in which they are at risk of imposing their values onto clients, especially when the counselor's values are inconsistent with the client's goals or are discriminatory in nature.

A.11.c. Appropriate Termination

Counselors terminate a counseling relationship when it becomes reasonably apparent that the client no longer needs assistance, is not likely to benefit, or is being harmed by continued counseling. Counselors may terminate counseling when in jeopardy of harm by the client or by another person with whom the client has a relationship, or when clients do not pay fees as agreed upon. Counselors provide pre termination counseling and recommend other service providers when necessary.

A.11.d. Appropriate Transfer of Services

When counselors transfer or refer clients to other practitioners, they ensure that appropriate clinical and administrative processes are completed and open communication is maintained with both clients and practitioners.

A.12. Abandonment and Client Neglect

Counselors do not abandon or neglect clients in counseling. Counselors assist in making appropriate arrangements for the continuation of treatment, when necessary, during interruptions such as vacations, illness, and following termination.

SECTION B: CONFIDENTIALITY AND PRIVACY

Introduction

Counselors recognize that trust is a cornerstone of the counseling relationship. Counselors aspire to earn the trust of clients by creating an ongoing partnership, establishing and upholding appropriate boundaries, and maintaining confidentiality. Counselors communicate the parameters of confidentiality in a culturally competent manner.

B.1. Respecting Client Rights

B.1.a. Multicultural/Diversity Considerations

Counselors maintain awareness and sensitivity regarding cultural meanings of confidentiality and privacy. Counselors respect differing views toward disclosure of information. Counselors hold ongoing discussions with clients as to how, when, and with whom information is to be shared.

B.1.b. Respect for Privacy

Counselors respect the privacy of prospective and current clients. Counselors request private information from clients only when it is beneficial to the counseling process.

B.1.c. Respect for Confidentiality

Counselors protect the confidential information of prospective and current clients. Counselors disclose information only with appropriate consent or with sound legal or ethical justification.

B.1.d. Explanation of Limitations

At initiation and throughout the counseling process, counselors inform clients of the limitations of confidentiality and seek to identify situations in which confidentiality must be breached.

B.2. Exceptions

B.2.a. Serious and Foreseeable Harm and Legal Requirements

The general requirement that counselors keep information confidential does not apply when disclosure is required to protect clients or identified others from serious and foreseeable harm or when legal requirements demand that confidential information must be revealed. Counselors consult with other professionals when in doubt as to the validity of an exception. Additional considerations apply when addressing end-of-life issues.

B.2.b. Confidentiality Regarding End-of-Life Decisions

Counselors who provide services to terminally ill individuals who are considering hastening their own deaths have the option to maintain confidentiality, depending on applicable laws and the specific circumstances of the situation and after seeking consultation or supervision from appropriate professional and legal parties.

B.2.c. Contagious, Life-Threatening Diseases

When clients disclose that they have a disease commonly known to be both communicable and life threatening, counselors may be justified in disclosing information to identifiable third parties, if the parties are known to be at serious and foreseeable risk of contracting the disease. Prior to making a disclosure, counselors assess the intent of clients to inform the third parties about their disease or to engage in any behaviors that may be harmful to an identifiable third party. Counselors adhere to relevant state laws concerning disclosure about disease status.

B.2.d. Court-Ordered Disclosure

When ordered by a court to release confidential or privileged information without a client's permission, counselors seek to obtain written, informed consent from the client or take steps to prohibit the disclosure or have it limited as narrowly as possible because of potential harm to the client or counseling relationship.

B.2.e. Minimal Disclosure

To the extent possible, clients are informed before confidential information is disclosed and are involved in the disclosure decision-making process. When circumstances require the disclosure of confidential information, only essential information is revealed.

B.3. Information Shared with Others

B.3.a. Subordinates

Counselors make every effort to ensure that privacy and confidentiality of clients are maintained by subordinates, including employees, supervisees, students, clerical assistants, and volunteers.

B.3.b. Interdisciplinary Teams

When services provided to the client involve participation by an interdisciplinary or treatment team, the client will be informed of the team's existence and composition, information being shared, and the purposes of sharing such information.

B.3.c. Confidential Settings

Counselors discuss confidential information only in settings in which they can reasonably ensure client privacy.

B.3.d. Third-Party Payers

Counselors disclose information to third-party payers only when clients have authorized such disclosure.

B.3.e. Transmitting Confidential Information

Counselors take precautions to ensure the confidentiality of all information transmitted through the use of any medium.

B.3.f. Deceased Clients

Counselors protect the confidentiality of deceased clients, consistent with legal requirements and the documented preferences of the client.

B.4. Groups and Families

B.4.a. Group Work

In group work, counselors clearly explain the importance and parameters of confidentiality for the specific group.

B.4.b. Couples and Family Counseling

In couples and family counseling, counselors clearly define who is considered "the client" and discuss expectations and limitations of confidentiality. Counselors seek agreement and document in writing such agreement among all involved parties regarding the confidentiality of information. In the absence of an agreement to the contrary, the couple or family is considered to be the client.

B.5. Clients Lacking Capacity to Give Informed Consent

B.5.a. Responsibility to Clients

When counseling minor clients or adult clients who lack the capacity to give voluntary, informed consent, counselors protect the confidentiality of information received—in any medium—in the counseling relationship as specified by federal and state laws, written policies, and applicable ethical standards.

B.5.b. Responsibility to Parents and Legal Guardians

Counselors inform parents and legal guardians about the role of counselors and the confidential nature of the counseling relationship, consistent with current legal and custodial arrangements. Counselors are sensitive to the cultural diversity of families and respect the inherent rights and responsibilities of parents/guardians regarding the welfare of their children/charges according to law. Counselors work to establish, as appropriate, collaborative relationships with parents/guardians to best serve clients.

B.5.c. Release of Confidential Information

When counseling minor clients or adult clients who lack the capacity to give voluntary consent to release confidential information, counselors seek permission from an appropriate third party to disclose information. In such instances, counselors inform clients consistent with their level of understanding and take appropriate measures to safeguard client confidentiality.

B.6. Records and Documentation

B.6.a. Creating and Maintaining Records and Documentation

Counselors create and maintain records and documentation necessary for rendering professional services.

B.6.b. Confidentiality of Records and Documentation

Counselors ensure that records and documentation kept in any medium are secure and that only authorized persons have access to them.

B.6.c. Permission to Record

Counselors obtain permission from clients prior to recording sessions through electronic or other means.

B.6.d. Permission to Observe

Counselors obtain permission from clients prior to allowing any person to observe counseling sessions, review session transcripts, or view recordings of sessions with supervisors, faculty, peers, or others within the training environment.

B.6.e. Client Access

Counselors provide reasonable access to records and copies of records when requested by competent clients. Counselors limit the access of clients to their records, or portions of their records, only when there is compelling evidence that such access would cause harm to the client. Counselors document the request of clients and the rationale for withholding some or all of the records in the files of clients. In situations involving multiple clients, counselors provide individual clients with only those parts of records that relate directly to them and do not include confidential information related to any other client.

B.6.f. Assistance with Records

When clients request access to their records, counselors provide assistance and consultation in interpreting counseling records.

B.6.g. Disclosure or Transfer

Unless exceptions to confidentiality exist, counselors obtain written permission from clients to disclose or transfer records to legitimate third parties. Steps are taken to ensure that receivers of counseling records are sensitive to their confidential nature.

B.6.h. Storage and Disposal After Termination

Counselors store records following termination of services to ensure reasonable future access, maintain records in accordance with federal and state laws and statutes such as licensure laws and policies governing records, and dispose of client records and other sensitive materials in a manner that protects client confidentiality. Counselors apply careful discretion and deliberation before destroying records that may be needed by a court of law, such as notes on child abuse, suicide, sexual harassment, or violence.

B.6.i. Reasonable Precautions

Counselors take reasonable precautions to protect client confidentiality in the event of the counselor's termination of practice, incapacity, or death and appoint a records custodian when identified as appropriate.

B.7. Case Consultation

B.7.a. Respect for Privacy

Information shared in a consulting relationship is discussed for professional purposes only. Written and oral reports present only data germane to the purposes of the consultation, and every effort is made to protect client identity and to avoid undue invasion of privacy.

B.7.b. Disclosure of Confidential Information

When consulting with colleagues, counselors do not disclose confidential information that reasonably could lead to the identification of a client or other person or organization with whom they have a confidential relationship unless they have obtained the prior consent of the person or organization or the disclosure cannot be avoided. They disclose information only to the extent necessary to achieve the purposes of the consultation.

SECTION C: PROFESSIONAL RESPONSIBILITY

Introduction

Counselors aspire to open, honest, and accurate communication in dealing with the public and other professionals. Counselors facilitate access to counseling services, and they practice in a nondiscriminatory manner within the boundaries of professional and personal competence; they also have a responsibility to abide by the ACA Code of Ethics. Counselors actively participate in local, state, and national associations that foster the development and improvement of counseling. Counselors are expected to advocate to promote changes at the individual, group, institutional, and societal levels that improve the quality of life for individuals and groups and remove potential barriers to the provision or access of appropriate services being offered. Counselors have a responsibility to the public to engage in counseling practices that are based on rigorous research methodologies. Counselors are encouraged to contribute to society by devoting a portion of their professional activity to services for which there is little or no financial return (probono publico). In addition, counselors engage in self-care activities to maintain and promote their own emotional, physical, mental, and spiritual well-being to best meet their professional responsibilities.

C.1. Knowledge of and Compliance with Standards

Counselors have a responsibility to read, understand, and follow the ACA Code of Ethics and adhere to applicable laws and regulations.

C.2. Professional Competence

C.2.a. Boundaries of Competence

Counselors practice only within the boundaries of their competence, based on their education, training, supervised experience, state and national professional credentials, and appropriate professional experience. Whereas multicultural counseling competency is required across all counseling specialties, counselors gain knowledge, personal awareness, sensitivity, dispositions, and skills pertinent to being a culturally competent counselor in working with a diverse client population.

C.2.b. New Specialty Areas of Practice

Counselors practice in specialty areas new to them only after appropriate education, training, and supervised experience. While developing skills in new specialty areas, counselors take steps to ensure the competence of their work and protect others from possible harm.

C.2.c. Qualified for Employment

Counselors accept employment only for positions for which they are qualified given their education, training, supervised experience, state and national professional credentials, and appropriate professional experience. Counselors hire for professional counseling positions only individuals who are qualified and competent for those positions.

C.2.d. Monitor Effectiveness

Counselors continually monitor their effectiveness as professionals and take steps to improve when necessary. Counselors take reasonable steps to seek peer supervision to evaluate their efficacy as counselors.

C.2.e. Consultations on Ethical Obligations

Counselors take reasonable steps to consult with other counselors, the ACA Ethics and Professional Standards Department, or related professionals when they have questions regarding their ethical obligations or professional practice.

C.2.f. Continuing Education

Counselors recognize the need for continuing education to acquire and maintain a reasonable level of awareness of current scientific and professional information in their fields of activity. Counselors maintain their competence in the skills they use, are open to new procedures, and remain informed regarding best practices for working with diverse populations.

C.2.g. Impairment

Counselors monitor themselves for signs of impairment from their own physical, mental, or emotional problems and refrain from offering or providing professional services when impaired. They seek assistance for problems that reach the level of professional impairment, and, if necessary, they limit, suspend, or terminate their professional responsibilities until it is determined that they may safely resume their work. Counselors assist colleagues or supervisors in recognizing their own professional impairment and provide consultation and assistance when warranted with colleagues or supervisors showing signs of impairment and intervene as appropriate to prevent imminent harm to clients.

C.2.h. Counselor Incapacitation, Death, Retirement, or Termination of Practice

Counselors prepare a plan for the transfer of clients and the dissemination of records to an identified colleague or records custodian in the case of the counselor's incapacitation, death, retirement, or termination of practice.

C.3. Advertising and Soliciting Clients

C.3.a. Accurate Advertising

When advertising or otherwise representing their services to the public, counselors identify their credentials in an accurate manner that is not false, misleading, deceptive, or fraudulent.

C.3.b. Testimonials

Counselors who use testimonials do not solicit them from current clients, former clients, or any other persons who may be vulnerable to undue influence. Counselors discuss with clients the implications of and obtain permission for the use of any testimonial.

C.3.c. Statements by Others

When feasible, counselors make reasonable efforts to ensure that statements made by others about them or about the counseling profession are accurate.

C.3.d. Recruiting Through Employment

Counselors do not use their places of employment or institutional affiliation to recruit clients, supervisors, or consultees for their private practices.

C.3.e. Products and Training Advertisements

Counselors who develop products related to their profession or conduct workshops or training events ensure that the advertisements concerning these products or events are accurate and disclose adequate information for consumers to make informed choices.

C.3.f. Promoting to Those Served

Counselors do not use counseling, teaching, training, or supervisory relationships to promote their products or training events in a manner that is deceptive or would exert undue influence on individuals who may be vulnerable. However, counselor educators may adopt textbooks they have authored for instructional purposes.

C.4. Professional Qualifications

C.4.a. Accurate Representation

Counselors claim or imply only professional qualifications actually completed and correct any known misrepresentations of their qualifications by others. Counselors truthfully represent the qualifications of their professional colleagues. Counselors clearly distinguish between paid and volunteer work experience and accurately describe their continuing education and specialized training.

C.4.b. Credentials

Counselors claim only licenses or certifications that are current and in good standing.

C.4.c. Educational Degrees

Counselors clearly differentiate between earned and honorary degrees.

C.4.d. Implying Doctoral-Level Competence

Counselors clearly state their highest earned degree in counseling or a closely related field. Counselors do not imply doctoral-level competence when possessing a master's degree in counseling or a related field by referring to themselves as "Dr." in a counseling context when their doctorate is not in counseling or a related field. Counselors do not use "ABD" (all but dissertation) or other such terms to imply competency.

C.4.e. Accreditation Status

Counselors accurately represent the accreditation status of their degree program and college/university.

C.4.f. Professional Membership

Counselors clearly differentiate between current, active memberships and former memberships in associations. Members of ACA must clearly differentiate between professional membership, which implies the possession of at least a master's degree in counseling, and regular membership, which is open to individuals whose interests and activities are consistent with those of ACA but are not qualified for professional membership.

C.5. Nondiscrimination

Counselors do not condone or engage in discrimination against prospective or current clients, students, employees, supervisees, or research participants based on age, culture, disability, ethnicity, race, religion/spirituality, gender, gender identity, sexual orientation, marital/partnership status, language preference, socioeconomic status, immigration status, or any basis proscribed by law.

C.6. Public Responsibility

C.6.a. Sexual Harassment

Counselors do not engage in or condone sexual harassment. Sexual harassment can consist of a single intense or severe act, or multiple persistent or pervasive acts.

C.6.b. Reports to Third Parties

Counselors are accurate, honest, and objective in reporting their professional activities and judgments to appropriate third parties, including courts, health insurance companies, those who are the recipients of evaluation reports, and others.

C.6.c. Media Presentations

When counselors provide advice or comment by means of public lectures, demonstrations, radio or television programs, recordings, technology-based applications, printed articles, mailed material, or other media, they take reasonable precautions to ensure that:

1. The statements are based on appropriate professional counseling literature and practice,

2. The statements are otherwise consistent with the ACA Code of Ethics, and

3. The recipients of the information are not encouraged to infer that a professional counseling relationship has been established.

C.6.d. Exploitation of Others

Counselors do not exploit others in their professional relationships.

C.6.e. Contributing to the Public Good (Pro Bono Publico)

Counselors make a reasonable effort to provide services to the public for which there is little or no financial return (e.g., speaking to groups, sharing professional information, offering reduced fees).

C.7. Treatment Modalities

C.7.a. Scientific Basis for Treatment

When providing services, counselors use techniques/procedures/modalities that are grounded in theory and/or have an empirical or scientific foundation.

C.7.b. Development and Innovation

When counselors use developing or innovative techniques/procedures/modalities, they explain the potential risks, benefits, and ethical considerations of using such techniques/procedures/modalities. Counselors work to minimize any potential risks or harm when using these techniques/procedures/modalities.

C.7.c. Harmful Practices

Counselors do not use techniques/procedures/modalities when substantial evidence suggests harm, even if such services are requested.

C.8. Responsibility to Other Professionals

C.8.a. Personal Public Statements

When making personal statements in a public context, counselors clarify that they are speaking from their personal perspectives and that they are not speaking on behalf of all counselors or the profession.

SECTION D: RELATIONSHIPS WITH OTHER PROFESSIONALS

Introduction

Professional counselors recognize that the quality of their interactions with colleagues can influence the quality of services provided to clients. They work to become knowledgeable about colleagues within and outside the field of counseling. Counselors develop positive working relationships and systems of communication with colleagues to enhance services to clients.

D.1. Relationships with Colleagues, Employers, and Employees

D.1.a. Different Approaches

Counselors are respectful of approaches that are grounded in theory and/or have an empirical or scientific foundation but may differ from their own. Counselors acknowledge the expertise of other professional groups and are respectful of their practices.

D.1.b. Forming Relationships

Counselors work to develop and strengthen relationships with colleagues from other disciplines to best serve clients.

D.1.c. Interdisciplinary Teamwork

Counselors who are members of interdisciplinary teams delivering multifaceted services to clients remain focused on how to best serve clients. They participate in and contribute to decisions that affect the well-being of clients by drawing on the perspectives, values, and experiences of the counseling profession and those of colleagues from other disciplines.

D.1.d. Establishing Professional and Ethical Obligations

Counselors who are members of interdisciplinary teams work together with team members to clarify professional and ethical obligations of the team as a whole and of its individual members. When a team decision raises ethical concerns, counselors first attempt to resolve the concern within the team. If they cannot reach resolution among team members, counselors pursue other avenues to address their concerns consistent with client well-being.

D.1.e. Confidentiality

When counselors are required by law, institutional policy, or extraordinary circumstances to serve in more than one role in judicial or administrative proceedings, they clarify role expectations and the parameters of confidentiality with their colleagues.

D.1.f. Personnel Selection and Assignment

When counselors are in a position requiring personnel selection and/or assigning of responsibilities to others, they select competent staff and assign responsibilities compatible with their skills and experiences.

D.1.g. Employer Policies

The acceptance of employment in an agency or institution implies that counselors are in agreement with its general policies and principles. Counselors strive to reach agreement with employers regarding acceptable standards of client care and professional conduct that allow for changes in institutional policy conducive to the growth and development of clients.

D.1.h. Negative Conditions

Counselors alert their employers of inappropriate policies and practices. They attempt to effect changes in such policies or procedures through constructive action within the organization. When such policies are potentially disruptive or damaging to clients or may limit the effectiveness of services provided and change cannot be affected, counselors take appropriate further action. Such action may include referral to appropriate certification, accreditation, or state licensure organizations, or voluntary termination of employment.

D.1.i. Protection From Punitive Action

Counselors do not harass a colleague or employee or dismiss an employee who has acted in a responsible and ethical manner to expose inappropriate employer policies or practices.

D.2. Provision of Consultation Services

D.2.a. Consultant Competency

Counselors take reasonable steps to ensure that they have the appropriate resources and competencies when providing consultation services. Counselors provide appropriate referral resources when requested or needed.

D.2.b. Informed Consent in Formal Consultation

When providing formal consultation services, counselors have an obligation to review, in writing and verbally, the rights and responsibilities of both counselors and consultees. Counselors use clear and understandable language to inform all parties involved about the purpose of the services to be provided, relevant costs, potential risks and benefits, and the limits of confidentiality.

SECTION E: EVALUATION, ASSESSMENT, AND INTERPRETATION

Introduction

Counselors use assessment as one component of the counseling process, taking into account the clients' personal and cultural context. Counselors promote the well-being of individual clients or groups of clients by developing and using appropriate educational, mental health, psychological, and career assessments.

E.1. General

E.1.a. Assessment

The primary purpose of educational, mental health, psychological, and career assessment is to gather information regarding the client for a variety of purposes, including, but not limited to, client decision making, treatment planning, and forensic proceedings. Assessment may include both qualitative and quantitative methodologies.

E.1.b. Client Welfare

Counselors do not misuse assessment results and interpretations, and they take reasonable steps to prevent others from misusing the information provided. They respect the client's right to know the results, the interpretations made, and the bases for counselors' conclusions and recommendations.

E.2. Competence to Use and Interpret Assessment Instruments

E.2.a. Limits of Competence

Counselors use only those testing and assessment services for which they have been trained and are competent. Counselors using technology-assisted test interpretations are trained in the construct being measured and the specific instrument being used prior to using its technology-based application. Counselors take reasonable measures to ensure the proper use of assessment techniques by persons under their supervision.

E.2.b. Appropriate Use

Counselors are responsible for the appropriate application, scoring, interpretation, and use of assessment instruments relevant to the needs of the client, whether they score and interpret such assessments themselves or use technology or other services.

E.2.c. Decisions Based on Results

Counselors responsible for decisions involving individuals or policies that are based on assessment results have a thorough understanding of psychometrics.

E.3. Informed Consent in Assessment

E.3.a. Explanation to Clients

Prior to assessment, counselors explain the nature and purposes of assessment and the specific use of results by potential recipients. The explanation will be given in terms and language that the client (or other legally authorized person on behalf of the client) can understand.

E.3.b. Recipients of Results

Counselors consider the client's and/or examinee's welfare, explicit understandings, and prior agreements in determining who receives the assessment results. Counselors include accurate and appropriate interpretations with any release of individual or group assessment results.

E.4. Release of Data to Qualified Personnel

Counselors release assessment data in which the client is identified only with the consent of the client or the client's legal representative. Such data are released only to persons recognized by counselors as qualified to interpret the data.

E.5. Diagnosis of Mental Disorders

E.5.a. Proper Diagnosis

Counselors take special care to provide proper diagnosis of mental disorders. Assessment techniques (including personal interviews) used to determine client care (e.g., locus of treatment, type of treatment, recommended follow-up) are carefully selected and appropriately used.

E.5.b. Cultural Sensitivity

Counselors recognize that culture affects the manner in which clients' problems are defined and experienced. Clients' socioeconomic and cultural experiences are considered when diagnosing mental disorders.

E.5.c. Historical and Social Prejudices in the Diagnosis of Pathology

Counselors recognize historical and social prejudices in the misdiagnosis and pathologizing of certain individuals and groups and strive to become aware of and address such biases in themselves or others.

E.5.d. Refraining From Diagnosis

Counselors may refrain from making and/or reporting a diagnosis if they believe that it would cause harm to the client or others. Counselors carefully consider both the positive and negative implications of a diagnosis.

E.6. Instrument Selection

E.6.a. Appropriateness of Instruments

Counselors carefully consider the validity, reliability, psychometric limitations, and appropriateness of instruments when selecting assessments and, when possible, use multiple forms of assessment, data, and/or instruments in forming conclusions, diagnoses, or recommendations.

E.6.b. Referral Information

If a client is referred to a third party for assessment, the counselor provides specific referral questions and sufficient objective data about the client to ensure that appropriate assessment instruments are utilized.

E.7. Conditions of Assessment Administration

E.7.a. Administration Conditions

Counselors administer assessments under the same conditions that were established in their standardization. When assessments are not administered under standard conditions, as may be necessary to accommodate clients with disabilities, or when unusual behavior or irregularities occur during the administration, those conditions are noted in interpretation, and the results may be designated as invalid or of questionable validity.

E.7.b. Provision of Favorable Conditions

Counselors provide an appropriate environment for the administration of assessments (e.g., privacy, comfort, freedom from distraction).

E.7.c. Technological Administration

Counselors ensure that technologically administered assessments function properly and provide clients with accurate results.

E.7.d. Unsupervised Assessments

Unless the assessment instrument is designed, intended, and validated for self-administration and/or scoring, counselors do not permit unsupervised use.

E.8. Multicultural Issues/Diversity in Assessment

Counselors select and use with caution assessment techniques normed on populations other than that of the client. Counselors recognize the effects of age, color, culture, disability, ethnic group, gender, race, language preference, religion, spirituality, sexual orientation, and socioeconomic status on test administration and interpretation, and they place test results in proper perspective with other relevant factors.

E.9. Scoring and Interpretation of Assessments

E.9.a. Reporting

When counselors report assessment results, they consider the client's personal and cultural background, the level of the client's understanding of the results, and the impact of the results on the client. In reporting assessment results, counselors indicate reservations that exist regarding validity or reliability due to circumstances of the assessment or inappropriateness of the norms for the person tested.

E.9.b. Instruments with Insufficient Empirical Data

Counselors exercise caution when interpreting the results of instruments not having sufficient empirical data to support respondent results. The specific purposes for the use of such instruments are stated explicitly to the examinee. Counselors qualify any conclusions, diagnoses, or recommendations made that are based on assessments or instruments with questionable validity or reliability.

E.9.c. Assessment Services

Counselors who provide assessment, scoring, and interpretation services to support the assessment process confirm the validity of such interpretations. They accurately describe the purpose, norms, validity, reliability, and applications of the procedures and any special qualifications applicable to their use. At all times, counselors maintain their ethical responsibility to those being assessed.

E.10. Assessment Security

Counselors maintain the integrity and security of tests and assessments consistent with legal and contractual obligations. Counselors do not appropriate, reproduce, or modify published assessments or parts thereof without acknowledgment and permission from the publisher.

E.11. Obsolete Assessment and Outdated Results

Counselors do not use data or results from assessments that are obsolete or outdated for the current purpose (e.g., noncurrent versions of assessments/instruments). Counselors make every effort to prevent the misuse of obsolete measures and assessment data by others.

E.12. Assessment Construction

Counselors use established scientific procedures, relevant standards, and current professional knowledge for assessment design in the development, publication, and utilization of assessment techniques.

E.13. Forensic Evaluation: Evaluation for Legal Proceedings

E.13.a. Primary Obligations

When providing forensic evaluations, the primary obligation of counselors is to produce objective findings that can be substantiated based on information and techniques appropriate to the evaluation, which may include examination of the individual and/or review of records. Counselors form professional opinions based on their professional knowledge and expertise that can be supported by the data gathered in evaluations. Counselors define the limits of their reports or testimony, especially when an examination of the individual has not been conducted.

E.13.b. Consent for Evaluation

Individuals being evaluated are informed in writing that the relationship is for the purposes of an evaluation and is not therapeutic in nature, and entities or individuals who will receive the evaluation report are identified. Counselors who perform forensic evaluations obtain written consent from those being evaluated or from their legal representative unless a court orders evaluations to be conducted without the written consent of the individuals being evaluated. When children or adults who lack the capacity to give voluntary consent are being evaluated, informed written consent is obtained from a parent or guardian.

E.13.c. Client Evaluation Prohibited

Counselors do not evaluate current or former clients, clients' romantic partners, or clients' family members for forensic purposes. Counselors do not counsel individuals they are evaluating.

E.13.d. Avoid Potentially Harmful Relationships

Counselors who provide forensic evaluations avoid potentially harmful professional or personal relationships with family members, romantic partners, and close friends of individuals they are evaluating or have evaluated in the past.

SECTION F: SUPERVISION, TRAINING, AND TEACHING

Introduction

Counselor supervisors, trainers, and educators aspire to foster meaningful and respectful professional relationships and to maintain appropriate boundaries with supervisees and students in both face-to-face and electronic formats. They have theoretical and pedagogical foundations for their work; have knowledge of supervision models; and aim to be fair, accurate, and honest in their assessments of counselors, students, and supervisees.

F.1. Counselor Supervision and Client Welfare

F.1.a. Client Welfare

A primary obligation of counseling supervisors is to monitor the services provided by supervisees. Counseling supervisors monitor client welfare and supervisee performance and professional development. To fulfill these obligations, supervisors meet regularly with supervisees to review the supervisees' work and help them become prepared to serve a range of diverse clients. Supervisees have a responsibility to understand and follow the ACA Code of Ethics.

F.1.b. Counselor Credentials

Counseling supervisors work to ensure that supervisees communicate their qualifications to render services to their clients.

F.1.c. Informed Consent and Client Rights

Supervisors make supervisees aware of client rights, including the protection of client privacy and confidentiality in the counseling relationship. Supervisees provide clients with professional disclosure information and inform them of how the supervision process influences the limits of confidentiality. Supervisees make clients aware of who will have access to records of the counseling relationship and how these records will be stored, transmitted, or otherwise reviewed.

F.2. Counselor Supervision Competence

F.2.a. Supervisor Preparation

Prior to offering supervision services, counselors are trained in supervision methods and techniques. Counselors who offer supervision services regularly pursue continuing education activities, including both counseling and supervision topics and skills.

F.2.b. Multicultural Issues/Diversity in Supervision

Counseling supervisors are aware of and address the role of multiculturalism/diversity in the supervisory relationship.

F.2.c. Online Supervision

When using technology in supervision, counselor supervisors are competent in the use of those technologies. Supervisors take the necessary precautions to protect the confidentiality of all information transmitted through any electronic means.

F.3. Supervisory Relationship

F.3.a. Extending Conventional Supervisory Relationships

Counseling supervisors clearly define and maintain ethical professional, personal, and social relationships with their supervisees. Supervisors consider the risks and benefits of extending current supervisory relationships in any form beyond conventional parameters. In extending these boundaries, supervisors take appropriate professional precautions to ensure that judgment is not impaired and that no harm occurs.

F.3.b. Sexual Relationships

Sexual or romantic interactions or relationships with current supervisees are prohibited. This prohibition applies to both in-person and electronic interactions or relationships.

F.3.c. Sexual Harassment

Counseling supervisors do not condone or subject supervisees to sexual harassment.

F.3.d. Friends or Family Members

Supervisors are prohibited from engaging in supervisory relationships with individuals with whom they have an inability to remain objective.

F.4. Supervisor Responsibilities

F.4.a. Informed Consent for Supervision

Supervisors are responsible for incorporating into their supervision the principles of informed consent and participation. Supervisors inform supervisees of the policies and procedures to which supervisors are to adhere and the mechanisms for due process appeal of individual supervisor actions. The issues unique to the use of distance supervision are to be included in the documentation as necessary.

F.4.b. Emergencies and Absences

Supervisors establish and communicate to supervisees procedures for contacting supervisors or, in their absence, alternative on-call supervisors to assist in handling crises.

F.4.c. Standards for Supervisees

Supervisors make their supervisees aware of professional and ethical standards and legal responsibilities.

F.4.d. Termination of the Supervisory Relationship

Supervisors or supervisees have the right to terminate the supervisory relationship with adequate notice. Reasons for considering termination are discussed, and both parties work to resolve differences. When termination is warranted, supervisors make appropriate referrals to possible alternative supervisors.

F.5. Student and Supervisee Responsibilities

F.5.a. Ethical Responsibilities

Students and supervisees have a responsibility to understand and follow the ACA Code of Ethics. Students and supervisees have the same obligation to clients as those required of professional counselors.

F.5.b. Impairment

Students and supervisees monitor themselves for signs of impairment from their own physical, mental, or emotional problems and refrain from offering or providing professional services when such impairment is likely to harm a client or others. They notify their faculty and/or supervisors and seek assistance for problems that reach the level of professional impairment, and, if necessary, they limit, suspend, or terminate their professional responsibilities until it is determined that they may safely resume their work.

F.5.c. Professional Disclosure

Before providing counseling services, students and supervisees disclose their status as supervisees and explain how this status affects the limits of confidentiality. Supervisors ensure that clients are aware of the services rendered and the qualifications of the students and supervisees rendering those services. Students and supervisees obtain client permission before they use any information concerning the counseling relationship in the training process.

F.6. Counseling Supervision Evaluation, Remediation, and Endorsement

F.6.a. Evaluation

Supervisors document and provide supervisees with ongoing feedback regarding their performance and schedule periodic formal evaluative sessions throughout the supervisory relationship.

F.6.b. Gatekeeping and Remediation

Through initial and ongoing evaluation, supervisors are aware of supervisee limitations that might impede performance. Supervisors assist supervisees in securing remedial assistance when needed. They recommend dismissal from training programs, applied counseling settings, and state or voluntary professional credentialing processes when those supervisees are unable to demonstrate that they can provide competent professional services to a range of diverse clients. Supervisors seek consultation and document their decisions to dismiss or refer supervisees for assistance. They ensure that supervisees are aware of options available to them to address such decisions.

F.6.c. Counseling for Supervisees

If supervisees request counseling, the supervisor assists the supervisee in identifying appropriate services. Supervisors do not provide counseling services to supervisees. Supervisors address interpersonal competencies in terms of the impact of these issues on clients, the supervisory relationship, and professional functioning.

F.6.d. Endorsements

Supervisors endorse supervisees for certification, licensure, employment, or completion of an academic or training program only when they believe that supervisees are qualified for the endorsement. Regardless of qualifications, supervisors do not endorse supervisees whom they believe to be impaired in any way that would interfere with the performance of the duties associated with the endorsement.

F.7. Responsibilities of Counselor Educators

F.7.a. Counselor Educators

Counselor educators who are responsible for developing, implementing, and supervising educational programs are skilled as teachers and practitioners. They are knowledgeable regarding the ethical, legal, and regulatory aspects of the profession; are skilled in applying that knowledge; and make students and supervisees aware of their responsibilities. Whether in traditional, hybrid, and/or online formats, counselor educators conduct counselor education and training programs in an ethical manner and serve as role models for professional behavior.

F.7.b. Counselor Educator Competence

Counselors who function as counselor educators or supervisors provide instruction within their areas of knowledge and competence and provide instruction based on current information and knowledge available in the profession. When using technology to deliver instruction, counselor educators develop competence in the use of the technology.

F.7.c. Infusing Multicultural Issues/Diversity

Counselor educators infuse material related to multiculturalism/diversity into all courses and workshops for the development of professional counselors.

F.7.d. Integration of Study and Practice

In traditional, hybrid, and/or online formats, counselor educators establish education and training programs that integrate academic study and supervised practice.

F.7.e. Teaching Ethics

Throughout the program, counselor educators ensure that students are aware of the ethical responsibilities and standards of the profession and the ethical responsibilities of students to the profession. Counselor educators infuse ethical considerations throughout the curriculum.

F.7.f. Use of Case Examples

The use of client, student, or supervisee information for the purposes of case examples in a lecture or classroom setting is permissible only when (a) the client, student, or supervisee has reviewed the material and agreed to its presentation or (b) the information has been sufficiently modified to obscure identity.

F.7.g. Student-to-Student Supervision and Instruction

When students function in the role of counselor educators or supervisors, they understand that they have the same ethical obligations as counselor educators, trainers, and supervisors. Counselor educators make every effort to ensure that the rights of students are not compromised when their peers lead experiential counseling activities in traditional, hybrid, and/or online formats (e.g., counseling groups, skills classes, clinical supervision).

F.7.h. Innovative Theories and Techniques

Counselor educators promote the use of techniques/procedures/modalities that are grounded in theory and/or have an empirical or scientific foundation. When counselor educators discuss developing or innovative techniques/procedures/modalities, they explain the potential risks, benefits, and ethical considerations of using such techniques/procedures/modalities.

F.7.i. Field Placements

Counselor educators develop clear policies and provide direct assistance within their training programs regarding appropriate field placement and other clinical experiences. Counselor educators provide clearly stated roles and responsibilities for the student or supervisee, the site supervisor, and the program supervisor. They confirm that site supervisors are qualified to provide supervision in the formats in which services are provided and inform site supervisors of their professional and ethical responsibilities in this role.

F.8. Student Welfare

F.8.a. Program Information and Orientation

Counselor educators recognize that program orientation is a developmental process that begins upon students' initial contact with the counselor education program and continues throughout the educational and clinical training of students. Counselor education faculty provide prospective and current students with information about the counselor education program's expectations, including:

1. The values and ethical principles of the profession;

2. The type and level of skill and knowledge acquisition required for successful completion of the training;

3. Technology requirements;

4. Program training goals, objectives, and mission, and subject matter to be covered;

5. Bases for evaluation;

6. Training components that encourage self-growth or self-disclosure as part of the training process;

7. The type of supervision settings and requirements of the sites for required clinical field experiences;

8. Student and supervisor evaluation and dismissal policies and procedures; and

9. Up-to-date employment prospects for graduates.

F.8.b. Student Career Advising

Counselor educators provide career advisement for their students and make them aware of opportunities in the field.

F.8.c. Self-Growth Experiences

Self-growth is an expected component of counselor education. Counselor educators are mindful of ethical principles when they require students to engage in self-growth experiences. Counselor educators and supervisors inform students that they have a right to decide what information will be shared or withheld in class.

F.8.d. Addressing Personal Concerns

Counselor educators may require students to address any personal concerns that have the potential to affect professional competency.

F.9. Evaluation and Remediation

F.9.a. Evaluation of Students

Counselor educators clearly state to students, prior to and throughout the training program, the levels of competency expected, appraisal methods, and timing of evaluations for both didactic and clinical competencies. Counselor educators provide students with ongoing feedback regarding their performance throughout the training program.

F.9.b. Limitations

Counselor educators, through ongoing evaluation, are aware of and address the inability of some students to achieve counseling competencies. Counselor educators do the following:

1. Assist students in securing remedial assistance when needed,

2. Seek professional consultation and document their decision to dismiss or refer students for assistance, and

3. Ensure that students have recourse in a timely manner to address decisions requiring them to seek assistance or to dismiss them and provide students with due process according to institutional policies and procedures.

F.9.c. Counseling for Students

If students request counseling, or if counseling services are suggested as part of a remediation process, counselor educators assist students in identifying appropriate services.

F.10. Roles and Relationships Between Counselor Educators and Students

F.10.a. Sexual or Romantic Relationships

Counselor educators are prohibited from sexual or romantic interactions or relationships with students currently enrolled in a counseling or related program and over whom they have power and authority. This prohibition applies to both in-person and electronic interactions or relationships.

F.10.b. Sexual Harassment

Counselor educators do not condone or subject students to sexual harassment.

F.10.c. Relationships with Former Students

Counselor educators are aware of the power differential in the relationship between faculty and students. Faculty members discuss with former students potential risks when they consider engaging in social, sexual, or other intimate relationships.

F.10.d. Nonacademic Relationships

Counselor educators avoid nonacademic relationships with students in which there is a risk of potential harm to the student or which may compromise the training experience or grades assigned. In addition, counselor educators do not accept any form of professional services, fees, commissions, reimbursement, or remuneration from a site for student or supervisor placement.

F.10.e. Counseling Services

Counselor educators do not serve as counselors to students currently enrolled in a counseling or related program and over whom they have power and authority.

F.10.f. Extending Educator-Student Boundaries

Counselor educators are aware of the power differential in the relationship between faculty and students. If they believe that a nonprofessional relationship with a student may be potentially beneficial to the student, they take precautions similar to those taken by counselors when working with clients. Examples of potentially beneficial interactions or relationships include, but are not limited to, attending a formal ceremony; conducting hospital visits; providing support during a stressful event; or maintaining mutual membership in a professional association, organization, or community. Counselor educators discuss with students the rationale for such interactions, the potential benefits and drawbacks, and the anticipated consequences for the student. Educators clarify the specific nature and limitations of the additional role(s) they will have with the student prior to engaging in a nonprofessional relationship. Nonprofessional relationships with students should be time limited and/or context specific and initiated with student consent.

F.11. Multicultural/Diversity Competence in Counselor Education and Training Programs

F.11.a. Faculty Diversity

Counselor educators are committed to recruiting and retaining a diverse faculty.

F.11.b. Student Diversity

Counselor educators actively attempt to recruit and retain a diverse student body. Counselor educators demonstrate commitment to multicultural/diversity competence by recognizing and valuing the diverse cultures and types of abilities that students bring to the training experience. Counselor educators provide appropriate accommodations that enhance and support diverse student well-being and academic performance.

F.11.c. Multicultural/Diversity Competence

Counselor educators actively infuse multicultural/diversity competency in their training and supervision practices. They actively train students to gain awareness, knowledge, and skills in the competencies of multicultural practice.

SECTION G: RESEARCH AND PUBLICATION

Introduction

Counselors who conduct research are encouraged to contribute to the knowledge base of the profession and promote a clearer understanding of the conditions that lead to a healthy and more just society. Counselors support the efforts of researchers by participating fully and willingly whenever possible. Counselors minimize bias and respect diversity in designing and implementing research.

G.1. Research Responsibilities

G.1.a. Conducting Research

Counselors plan, design, conduct, and report research in a manner that is consistent with pertinent ethical principles, federal and state laws, host institutional regulations, and scientific standards governing research.

G.1.b. Confidentiality in Research

Counselors are responsible for understanding and adhering to state, federal, agency, or institutional policies or applicable guidelines regarding confidentiality in their research practices.

G.1.c. Independent Researchers

When counselors conduct independent research and do not have access to an institutional review board, they are bound to the same ethical principles and federal and state laws pertaining to the review of their plan, design, conduct, and reporting of research.

G.1.d. Deviation From Standard Practice

Counselors seek consultation and observe stringent safeguards to protect the rights of research participants when research indicates that a deviation from standard or acceptable practices may be necessary.

G.1.e. Precautions to Avoid Injury

Counselors who conduct research are responsible for their participants' welfare throughout the research process and should take reasonable precautions to avoid causing emotional, physical, or social harm to participants.

G.1.f. Principal Researcher Responsibility

The ultimate responsibility for ethical research practice lies with the principal researcher. All others involved in the research activities share ethical obligations and responsibility for their own actions.

G.2. Rights of Research Participants

G.2.a. Informed Consent in Research

Individuals have the right to decline requests to become research participants. In seeking consent, counselors use language that:

1. Accurately explains the purpose and procedures to be followed;

2. Identifies any procedures that are experimental or relatively untried;

3. Describes any attendant discomforts, risks, and potential power differentials between researchers and participants;

4. Describes any benefits or changes in individuals or organizations that might reasonably be expected;

5. Discloses appropriate alternative procedures that would be advantageous for participants;

6. Offers to answer any inquiries concerning the procedures;

7. Describes any limitations on confidentiality;

8. Describes the format and potential target audiences for the dissemination of research findings; and

9. Instructs participants that they are free to withdraw their consent and discontinue participation in the project at any time, without penalty.

G.2.b. Student/Supervisee Participation

Researchers who involve students or supervisees in research make clear to them that the decision regarding participation in research activities does not affect their academic standing or supervisory relationship. Students or supervisees who choose not to participate in research are provided with an appropriate alternative to fulfill their academic or clinical requirements.

G.2.c. Client Participation

Counselors conducting research involving clients make clear in the informed consent process that clients are free to choose whether to participate in research activities. Counselors take necessary precautions to protect clients from adverse consequences of declining or withdrawing from participation.

G.2.d. Confidentiality of Information

Information obtained about research participants during the course of research is confidential. Procedures are implemented to protect confidentiality.

G.2.e. Persons Not Capable of Giving Informed Consent

When a research participant is not capable of giving informed consent, counselors provide an appropriate explanation to, obtain agreement for participation from, and obtain the appropriate consent of a legally authorized person.

G.2.f. Commitments to Participants

Counselors take reasonable measures to honor all commitments to research participants.

G.2.g. Explanations After Data Collection

After data are collected, counselors provide participants with full clarification of the nature of the study to remove any misconceptions participants might have regarding the research. Where scientific or human values justify delaying or withholding information, counselors take reasonable measures to avoid causing harm.

G.2.h. Informing Sponsors

Counselors inform sponsors, institutions, and publication channels regarding research procedures and outcomes. Counselors ensure that appropriate bodies and authorities are given pertinent information and acknowledgment.

G.2.i. Research Records Custodian

As appropriate, researchers prepare and disseminate to an identified colleague or records custodian a plan for the transfer of research data in the case of their incapacitation, retirement, or death.

G.3. Managing and Maintaining Boundaries

G.3.a. Extending Researcher-Participant Boundaries

Researchers consider the risks and benefits of extending current research relationships beyond conventional parameters. When a nonresearch interaction between the researcher and the research participant may be potentially beneficial, the researcher must document, prior to the interaction (when feasible), the rationale for such an interaction, the potential benefit, and anticipated consequences for the research participant. Such interactions should be initiated with appropriate consent of the research participant. Where unintentional harm occurs to the research participant, the researcher must show evidence of an attempt to remedy such harm.

G.3.b. Relationships with Research Participants

Sexual or romantic counselor-research participant interactions or relationships with current research participants are prohibited. This prohibition applies to both in-person and electronic interactions or relationships.

G.3.c. Sexual Harassment and Research Participants

Researchers do not condone or subject research participants to sexual harassment.

G.4. Reporting Results

G.4.a. Accurate Results

Counselors plan, conduct, and report research accurately. Counselors do not engage in misleading or fraudulent research, distort data, misrepresent data, or deliberately bias their results. They describe the extent to which results are applicable for diverse populations.

G.4.b. Obligation to Report Unfavorable Results

Counselors report the results of any research of professional value. Results that reflect unfavorably on institutions, programs, services, prevailing opinions, or vested interests are not withheld.

G.4.c. Reporting Errors

If counselors discover significant errors in their published research, they take reasonable steps to correct such errors in a correction erratum or through other appropriate publication means.

G.4.d. Identity of Participants

Counselors who supply data, aid in the research of another person, report research results, or make original data available take due care to disguise the identity of respective participants in the absence of specific authorization from the participants to do otherwise. In situations where participants self-identify their involvement in research studies, researchers take active steps to ensure that data are adapted/changed to protect the identity and welfare of all parties and that discussion of results does not cause harm to participants.

G.4.e. Replication Studies

Counselors are obligated to make available sufficient original research information to qualified professionals who may wish to replicate or extend the study.

G.5. Publications and Presentations

G.5.a. Use of Case Examples

The use of participants', clients', students', or supervisees' information for the purpose of case examples in a presentation or publication is permissible only when (a) participants, clients, students, or supervisees have reviewed the material and agreed to its presentation or publication or (b) the information has been sufficiently modified to obscure identity.

G.5.b. Plagiarism

Counselors do not plagiarize; that is, they do not present another person's work as their own.

G.5.c. Acknowledging Previous Work

In publications and presentations, counselors acknowledge and give recognition to previous work on the topic by others or self.

G.5.d. Contributors

Counselors give credit through joint authorship, acknowledgment, footnote statements, or other appropriate means to those who have contributed significantly to research or concept development in accordance with such contributions. The principal contributor is listed first, and minor technical or professional contributions are acknowledged in notes or introductory statements.

G.5.e. Agreement of Contributors

Counselors who conduct joint research with colleagues or students/supervisors establish agreements in advance regarding allocation of tasks, publication credit, and types of acknowledgment that will be received.

G.5.f. Student Research

Manuscripts or professional presentations in any medium that are substantially based on a student's course papers, projects, dissertations, or theses are used only with the student's permission and list the student as lead author.

G.5.g. Duplicate Submissions

Counselors submit manuscripts for consideration to only one journal at a time. Manuscripts that are published in whole or in substantial part in one journal or published work are not submitted for publication to another publisher without acknowledgment and permission from the original publisher.

G.5.h. Professional Review

Counselors who review material submitted for publication, research, or other scholarly purposes respect the confidentiality and proprietary rights of those who submitted it. Counselors make publication decisions based on valid and defensible standards. Counselors review article submissions in a timely manner and based on their scope and competency in research methodologies. Counselors who serve as reviewers at the request of editors or publishers make every effort to only review materials that are within their scope of competency and avoid personal biases.

SECTION H: DISTANCE COUNSELING, TECHNOLOGY, AND SOCIAL MEDIA

Introduction

Counselors understand that the profession of counseling may no longer be limited to in-person, face-to-face interactions. Counselors actively attempt to understand the evolving nature of the profession with regard to distance counseling, technology, and social media and how such resources may be used to better serve their clients. Counselors strive to become knowledgeable about these resources. Counselors understand the additional concerns related to the use of distance counseling, technology, and social media and make every attempt to protect confidentiality and meet any legal and ethical requirements for the use of such resources.

H.1. Knowledge and Legal Considerations

H.1.a. Knowledge and Competency

Counselors who engage in the use of distance counseling, technology, and/or social media develop knowledge and skills regarding related technical, ethical, and legal considerations (e.g., special certifications, additional course work).

H.1.b. Laws and Statutes

Counselors who engage in the use of distance counseling, technology, and social media within their counseling practice understand that they may be subject to laws and regulations of both the counselor's practicing location and the client's place of residence. Counselors ensure that their clients are aware of pertinent legal rights and limitations governing the practice of counseling across state lines or international boundaries.

H.2. Informed Consent and Security

H.2.a. Informed Consent and Disclosure

Clients have the freedom to choose whether to use distance counseling, social media, and/or technology within the counseling process. In addition to the usual and customary protocol of informed consent between counselor and client for face-to-face counseling, the following issues, unique to the use of distance counseling, technology, and/or social media, are addressed in the informed consent process:

- Distance counseling credentials, physical location of practice, and contact information;

- Risks and benefits of engaging in the use of distance counseling, technology, and/or social media;

- Possibility of technology failure and alternate methods of service delivery;

- Anticipated response time;

- Emergency procedures to follow when the counselor is not available;

- Time zone differences;

- Cultural and/or language differences that may affect delivery of services;

- Possible denial of insurance benefits; and

- Social media policy.

H.2.b. Confidentiality Maintained by the Counselor

Counselors acknowledge the limitations of maintaining the confidentiality of electronic records and transmissions. They inform clients that individuals might have authorized or unauthorized access to such records or transmissions (e.g., colleagues, supervisors, employees, information technologists).

H.2.c. Acknowledgment of Limitations

Counselors inform clients about the inherent limits of confidentiality when using technology. Counselors urge clients to be aware of authorized and/or unauthorized access to information disclosed using this medium in the counseling process.

H.2.d. Security

Counselors use current encryption standards within their websites and/or technology-based communications that meet applicable legal requirements. Counselors take reasonable precautions to ensure the confidentiality of information transmitted through any electronic means.

H.3. Client Verification

Counselors who engage in the use of distance counseling, technology, and/or social media to interact with clients take steps to verify the client's identity at the beginning and throughout the therapeutic process. Verification can include, but is not limited to, using code words, numbers, graphics, or other nondescript identifiers.

H.4. Distance Counseling Relationship

H.4.a. Benefits and Limitations

Counselors inform clients of the benefits and limitations of using technology applications in the provision of counseling services. Such technologies include, but are not limited to, computer hardware and/or software, telephones and applications, social media and Internet-based applications and other audio and/or video communication, or data storage devices or media.

H.4.b. Professional Boundaries in Distance Counseling

Counselors understand the necessity of maintaining a professional relationship with their clients. Counselors discuss and establish professional boundaries with clients regarding the appropriate use and/or application of technology and the limitations of its use within the counseling relationship (e.g., lack of confidentiality, times when not appropriate to use).

H.4.c. Technology-Assisted Services

When providing technology-assisted services, counselors make reasonable efforts to determine that clients are intellectually, emotionally, physically, linguistically, and functionally capable of using the application and that the application is appropriate for the needs of the client. Counselors verify that clients understand the purpose and operation of technology applications and follow up with clients to correct possible misconceptions, discover appropriate use, and assess subsequent steps.

H.4.d. Effectiveness of Services

When distance counseling services are deemed ineffective by the counselor or client, counselors consider delivering services face-to-face. If the counselor is not able to provide face-to-face services (e.g., lives in another state), the counselor assists the client in identifying appropriate services.

H.4.e. Access

Counselors provide information to clients regarding reasonable access to pertinent applications when providing technology-assisted services.

H.4.f. Communication Differences in Electronic Media

Counselors consider the differences between face-to-face and electronic communication (nonverbal and verbal cues) and how these may affect the counseling process. Counselors educate clients on how to prevent and address potential misunderstandings arising from the lack of visual cues and voice intonations when communicating electronically.

H.5. Records and Web Maintenance

H.5.a. Records

Counselors maintain electronic records in accordance with relevant laws and statutes. Counselors inform clients on how records are maintained electronically. This includes, but is not limited to, the type of encryption and security assigned to the records, and if/for how long archival storage of transaction records is maintained.

H.5.b. Client Rights

Counselors who offer distance counseling services and/or maintain a professional website provide electronic links to relevant licensure and professional certification boards to protect consumer and client rights and address ethical concerns.

H.5.c. Electronic Links

Counselors regularly ensure that electronic links are working and are professionally appropriate.

H.5.d. Multicultural and Disability Considerations

Counselors who maintain websites provide accessibility to persons with disabilities. They provide translation capabilities for clients who have a different primary language, when feasible. Counselors acknowledge the imperfect nature of such translations and accessibilities.

H.6. Social Media

H.6.a. Virtual Professional Presence

In cases where counselors wish to maintain a professional and personal presence for social media use, separate professional and personal web pages and profiles are created to clearly distinguish between the two kinds of virtual presence.

H.6.b. Social Media as Part of Informed Consent

Counselors clearly explain to their clients, as part of the informed consent procedure, the benefits, limitations, and boundaries of the use of social media.

H.6.c. Client Virtual Presence

Counselors respect the privacy of their clients' presence on social media unless given consent to view such information.

H.6.d. Use of Public Social Media

Counselors take precautions to avoid disclosing confidential information through public social media.

SECTION I: RESOLVING ETHICAL ISSUES

Introduction

Professional counselors behave in an ethical and legal manner. They are aware that client welfare and trust in the profession depend on a high level of professional conduct. They hold other counselors to the same standards and are willing to take appropriate action to ensure that standards are upheld. Counselors strive to resolve ethical dilemmas with direct and open communication among all parties involved and seek consultation with colleagues and supervisors when necessary. Counselors incorporate ethical practice into their daily professional work and engage in ongoing professional development regarding current topics in ethical and legal issues in counseling. Counselors become familiar with the ACA Policy and Procedures for Processing Complaints of Ethical Violations and use it as a reference for assisting in the enforcement of the ACA Code of Ethics.

I.1. Standards and the Law

I.1.a. Knowledge

Counselors know and understand the ACA Code of Ethics and other applicable ethics codes from professional organizations or certification and licensure bodies of which they are members. Lack of knowledge or misunderstanding of an ethical responsibility is not a defense against a charge of unethical conduct.

I.1.b. Ethical Decision Making

When counselors are faced with an ethical dilemma, they use and document, as appropriate, an ethical decision-making model that may include, but is not limited to, consultation; consideration of relevant ethical standards, principles, and laws; generation of potential courses of action; deliberation of risks and benefits; and selection of an objective decision based on the circumstances and welfare of all involved.

I.1.c. Conflicts Between Ethics and Laws

If ethical responsibilities conflict with the law, regulations, and/or other governing legal authority, counselors make known their commitment to the ACA Code of Ethics and take steps to resolve the conflict. If the conflict cannot be resolved using this approach, counselors, acting in the best interest of the client, may adhere to the requirements of the law, regulations, and/or other governing legal authority.

I.2. Suspected Violations

I.2.a. Informal Resolution

When counselors have reason to believe that another counselor is violating or has violated an ethical standard and substantial harm has not occurred, they attempt to first resolve the issue informally with the other counselor if feasible, provided such action does not violate confidentiality rights that may be involved.

I.2.b. Reporting Ethical Violations

If an apparent violation has substantially harmed or is likely to substantially harm a person or organization and is not appropriate for informal resolution or is not resolved properly, counselors take further action depending on the situation. Such action may include referral to state or national committees on professional ethics, voluntary national certification bodies, state licensing boards, or appropriate institutional authorities. The confidentiality rights of clients should be considered in all actions. This standard does not apply when counselors have been retained to review the work of another counselor whose professional conduct is in question (e.g., consultation, expert testimony).

I.2.c. Consultation

When uncertain about whether a particular situation or course of action may be in violation of the ACA Code of Ethics, counselors consult with other counselors who are knowledgeable about ethics and the ACA Code of Ethics, with colleagues, or with appropriate authorities, such as the ACA Ethics and Professional Standards Department.

I.2.d. Organizational Conflicts

If the demands of an organization with which counselors are affiliated pose a conflict with the ACA Code of Ethics, counselors specify the nature of such conflicts and express to their supervisors or other responsible officials their commitment to the ACA Code of Ethics and, when possible, work through the appropriate channels to address the situation.

I.2.e. Unwarranted Complaints

Counselors do not initiate, participate in, or encourage the filing of ethics complaints that are retaliatory in nature or are made with reckless disregard or willful ignorance of facts that would disprove the allegation.

I.2.f. Unfair Discrimination Against Complainants and Respondents

Counselors do not deny individuals employment, advancement, admission to academic or other programs, tenure, or promotion based solely on their having made or their being the subject of an ethics complaint. This does not preclude taking action based on the outcome of such proceedings or considering other appropriate information.

I.3. Cooperation with Ethics Committees

Counselors assist in the process of enforcing the ACA Code of Ethics. Counselors cooperate with investigations, proceedings, and requirements of the ACA Ethics Committee or ethics committees of other duly constituted associations or boards having jurisdiction over those charged with a violation.

Works Cited

1. Monette DR, Sullivan TJ, DeJong CR. Applied Social Research: A Tool for Human Services. 9th ed. Fort Worth, TX: Harcourt College Publishers; 2013.

2. Capuzzi D, Gross DR. Counseling and Psychotherapy: Theories and Interventions. 6th ed. Upper Saddle River, NJ: Merrill; 2016.

3. Hugman R. Professional ethics in social work: living with the legacy. Australian Social Work. 2003;56(1):5-15.

4. Eliason MJ. Ethics and transcultural nursing care. Nurs Outlook. 1993;41(5):225-228.

5. Rashad AM, MacVane Phipps F, Haith-Cooper M. Obtaining informed consent in an Egyptian research study. Nurs Ethics. 2004;11(4):394-399.

6. Reamer FG. The evolution of social work ethics. Soc Work. 1998;43(6):488-501.

7. Congress EP. Social Work Values and Ethics: Identifying and Resolving Professional Dilemmas. Belmont, CA: Wadsworth; 1999.

8. American Counseling Association. 2014 ACA Code of Ethics. Available online at https://www.counseling.org/Resources/aca-code-of-ethics.pdf. Last accessed April 14, 2022.

9. Rokeach M. The Nature of Human Values. New York, NY: The Free Press; 1973.

10. Kenyon P. What Would You Do? An Ethical Case Workbook for Human Service Professionals. Pacific Grove, CA: Brooks/Cole Publishing Company; 1999.

11. Kirst-Ashman KK, Hull GH. Understanding Generalist Practice. 8th ed. Chicago, IL: Nelson-Hall, Inc.; 2017.

12. Trattner WI. From Poor Law to Welfare State: A History of Social Welfare in America. 6th ed. New York, NY: The Free Press; 1999.

13. Corey G, Corey MS, Callanan P. Issues and Ethics in the Helping Professions. 10th ed. Pacific Grove, CA: Brooks/Cole Publishing Company; 2018.

14. Gladding ST. Counseling: A Comprehensive Profession. 8th ed. Upper Saddle River, NJ: Merrill; 2017.

15. Rothman JC. From the Front Lines: Student Cases in Social Work Ethics. 4th ed. Needham Heights, MA: Allyn and Bacon; 2013.

16. Lucies C. Ethical challenges to counseling practice. In: Patrick PKS (ed). Contemporary Issues in Counseling. Boston: Pearson; 2007: 159-186.

17. Harper MG. Ethical multiculturalism: an evolutionary concept analysis. ANS Ad Nurs Sci. 2006;29(2):110-124.

18. Catalano JT. Critical care nurses and ethical dilemmas. Crit Care Nurse. 1991;11(1):20,22,24-25.

19. Macklin R. Ethical relativism in a multicultural society. Kennedy Inst Ethics J. 1998;8(1):1-22.

20. Reamer FG. Ethics and Integrated Behavioral Health. Available at https://www.socialworktoday.com/news/eoe_1117.shtml. Last accessed April 14, 2022.

21. Walker R, Staton M. Multiculturalism in social work ethics. J Soc Work Educ. 2000;36(3):449-463.

22. Libman KA. When "best interests of client" harms third party. In: Rothman JC (ed). From the Front Lines: Student Cases in Social Work Ethics. Needham Heights, MA: Allyn and Bacon; 1998: 37-44.

23. Cottone RR. Clause RE. Ethical decision-making models: a review of the literature. J Couns Dev. 2000;78(3):275-284.

24. Mattison M. Ethical decision making: the person in the process. Soc Work. 2000;45(3):201-213.

25. Osmo R, Landau R. The need for explicit argumentation in ethical decision-making in social work. Social Work Education. 2001;20(4):483-492.

26. Toulmin SE. The Uses of Argument. Cambridge, MA: Cambridge University Press; 1958.

27. Garcia J, Cartwright B, Winston S, Borzuchowska B. A transcultural integrative model for ethical decision making in counseling.J Couns Dev. 2003;81(3):268-277.

28. Loewenberg FM, Dolgoff R. Ethical Decisions for Social Work Practices. Itasca, IL: Peacock; 1996.

29. Davis AH. The ethics of caring: a collaborative approach to resolving ethical dilemmas. J Appl Rehabil Counsel. 1997;28(1):36-41.

30. Betan EJ. Toward a hermeneutic model of ethical decision making in clinical practice. Ethics Behav. 1997;7(4):347-365.

31. Abramson M. Reflections on knowing oneself ethically: toward a working framework for social work practice. Fam Soc. 1996;77: 195-202.

32. Kohlberg L. Stages in the Development of Moral Thought and Action. New York, NY: Holt, Rinehart and Winston; 1969.

33. Gilligan C. In A Different Voice: Psychological Theory and Women's Development. Cambridge, MA: Harvard University Press; 1982.

34. Brown LM, Gilligan C. Meeting at the Crossroads: Women's Psychology and Girls' Development. Cambridge, MA: Harvard University Press; 1992.

35. Freedberg S. Feminine ethic of care and the professionalization of social work. Soc Work. 1993;38(5):535-540.

36. Cohen J, Marecek J, Gillham J. Is three a crowd? Clients, clinicians, and managed care. Am J Orthopsychiatry. 2006;76(2):251-259.

37. Galambos C. Resolving ethical conflicts in a managed health care environment. Health Soc Work. 1999;24(3):191-198.

38. Glosoff H, Garcia J, Herlihy B, Remley T Jr. Managed care: ethical considerations for counselors. Couns Values. 1999;44(1):8-16.

39. Daniels J. Managed care, ethics, and counseling. J Couns Dev. 2001;79(1):119-122.

40. Weinrach SG, Thomas KR. The counseling profession's commitment to diversity-sensitive counseling: a critical reassessment.J Couns Dev. 1996;74(5):472-477.

41. Bernstein R. U.S. Census Bureau Projections Show a Slower Growing, Older, More Diverse Nation a Half Century from Now. Available at https://www.census.gov/newsroom/releases/archives/population/cb12-243.html. Last accessed April 14, 2022.

42. Baker B, Rytina N. Population Estimates: Estimates of the Unauthorized Immigrant Population Residing in the United States: January 2012. Available at https://www.dhs.gov/sites/default/files/publications/Unauthorized%20Immigrant%20Population%20Estimates%20in%20the%20US%20January%202012_0.pdf. Last accessed April 14, 2022.

43. Vincent GK, Velkoff VA. The Next Four Decades: The Older Population in the United States. Available at https://www.census.gov/content/dam/Census/library/publications/2010/demo/p25-1138.pdf. Last accessed April 14, 2022.

44. Gonsiorek JC, Sell RL, Weinrich JD. Definition and measurement of sexual orientation. Suicide and Life Threat Behav. 1995;25:40-51.

45. Colbridge TD. The Americans with Disabilities Act: the continuing search for meaning. FBI Law Enforcement Bulletin. 2002;71(8):27.

46. Brault MW. Americans with Disabilities, 2010. Available at https://www.census.gov/library/publications/2012/demo/p70-131.html. Last accessed April 14, 2022.

47. Das AK. Rethinking multicultural counseling: implications for counselor education. J Couns Dev. 1995;74(1):45-52.

48. Fried J. Changing ethical frameworks for a multicultural world. New Directions for Student Services. 1997;77:5-23.

49. Pedersen P. Developing multicultural ethical guidelines for psychology. International Journal of Psychology. 1989;24(5):643-653.

50. Mulhauser G. History of Counseling and Psychotherapy. Available at https://counsellingresource.com/therapy/types/history. Last accessed April 14, 2022.

51. Munley PH, Duncan LE, McDonnell KA, Sauer EM. Counseling psychology in the United States of America. Counseling Psychology Quarterly. 2004;17(3):247-271.

52. Jones LK. Frank Parsons' contribution to career counseling. Journal of Career Development. 1994;20(4):287-294.

53. Ford GG. Ethical Reasoning for Mental Health Professionals. Thousand Oaks, CA: Sage Publications, Inc.; 2006.

54. Houser R, Wilczenski FL, Ham MA. Culturally Relevant Ethical Decision-Making in Counseling. Thousand Oaks, CA: Sage Publications, Inc.; 2006.

55. National Institutes of Health. Greek Medicine: The Hippocratic Oath. Available at https://www.nlm.nih.gov/hmd/greek/greek_oath.html. Last accessed April 14, 2022.

56. Rothman DJ. Strangers at the Bedside: A History of How Law and Bioethics Transformed Medical Decision Making. New York, NY: Basic Books; 1991.

57. National Board for Certified Counselors. About Us. Available online at https://www.nbcc.org/about. Last accessed April 14, 2022.

58. National Board for Certified Counselors. NBCC Code of Ethics. Available at https://www.nbcc.org/Assets/Ethics/NBCCCodeofEthics.pdf. Last accessed May 18, 2023.

59. Corey G. Theory and Practice of Counseling and Psychotherapy. 10th ed. Belmont, CA: Thompson Brooks/Cole; 2020.

60. Central Intelligence Agency. The World Factbook. Available at https://www.cia.gov/the-world-factbook. Last accessed April 14, 2022.

61. Carroll J. Gallup Poll: Who Supports the Death Penalty? Available at https://deathpenaltyinfo.org/stories/gallup-poll-who-supports-the-death-penalty. Last accessed April 14, 2022.

62. Jones RK, Darroch JE, Henshaw SK. Patterns in the socioeconomic characteristics of women obtaining abortions in 2000–2001. Perspectives on Sexual and Reproductive Health. 2002;34(5):226-235.

63. Berstoff D. The virtue of principle ethics. The Counseling Psychologist. 1996;24:86-91.

64. Grimshaw J. Feminist Philosophers: Women's Perspectives on Philosophical Positions. Brighton: Wheatshelf Books; 1986.

65. Cole EB, Coultrap-McQuin SM. Explorations in Feminist Ethics: Theory and Practice. Bloomington, IN: Indiana University Press; 1992.

66. Richmond L. Counseling models and their impact on how therapists handle value issues. International Journal of Value-Based Management. 1996;9(1):29-43.

67. Saldov M, Kakai H, McLaughlin L, Thomas A. Cultural barriers in oncology: issues in obtaining medical informed consent from Japanese-American elders in Hawaii. J Cross Cult Gerontol. 1998;13(3):265-279.

68. Han H, Kang J, Kim KB, Ryu JP, Kim MT. Barriers to and strategies for recruiting Korean Americans for community-partnered health promotion research. J Immigr Minor Health. 2007;9(2):137-146.

69. Glosoff HL, Kocet MM. Highlights of the 2005 ACA Code of Ethics. In: Walz GR, Bleuer J, Yep RK (eds). VISTAS: Compelling Perspectives on Counseling. Alexandria, VA: American Counseling Association; 2006: 5-9.

70. Norcross JC, Hedges M, Prochaska JO. The face of 2010: a Delphi poll on the future of psychotherapy. Prof Psychol Res Pr. 2002;33(3):316-322.

71. Childress C. Ethical issues in providing online psychotherapeutic interventions. J Med Internet Res. 2000;2(1):e5.

72. Griffiths M, Cooper G. Online therapy: implications for problem gamblers and clinicians. Br J Guid Counc. 2003;31(1):113-135.

73. Zabinski MF, Celio AA, Jacobs MJ, Manwaring J, Wilfley DE. Internet-based prevention of eating disorders. Eur Eat Disord Rev. 2003;11(3):183-197.

74. Rochlen AB, Zack JS, Speyer C. Online therapy: review of relevant definitions, debates, and current empirical support. J Clin Psychol. 2004;60(3):269-283.

75. Finn J. MSW student perceptions of the efficacy and ethics of Internet-based therapy. J Soc Work Educ. 2002;38(3):403-419.

76. Recupero PR, Rainey SE. Informed consent to e-therapy. Am J Psychother. 2005;59(4):319-331.

77. Leibert T, Archer J, Munson J, York G. An exploratory study on client perceptions of Internet counseling and the therapeutic alliance. Journal of Mental Health Counseling. 2006;28(1):69-83.

78. Mcloughlin C. Culturally responsive technology use: developing an on-line community of learners. Br J Educ Technol. 1999;30(3):231-244.

79. Johari A, Bentley JPH, Tinney MV, Chia BH. Intercultural Internet-based learning: know your audience and what it values. Educational Technology Research and Development. 2005;53(2):117-127.

80. Singh NN, Mckay JD, Singh AN. Culture and mental health: nonverbal communication. J Child Fam Stud. 1998;7(4):403-409.

81. Lynch EW. Developing cross-cultural competence. In: Lynch EW, Hanson MJ (eds). Developing Cross-Cultural Competence: A Guide for Working With Children and Their Families. Baltimore, MD: Brookes Publishing Company; 1998: 47-89.

82. Gundling E. How to communicate globally. Train Dev J. 1999;53(6):28-31.

83. Leidner DE, Kayworth T. A review of culture in information systems research: toward a theory of information technology culture conflict. MIS Quarterly. 2006;30(2):357-399.

84. Hall ET. The Dance of Life: The Other Dimension of Time. New York, NY: Anchor; 1983.

85. Joo JE. Cultural issues of the Internet in the classrooms. Br J Educ Technol. 1999;30(3):245-250.

86. Irwin L. Gender inequities in technology in developing nations: females and computers in traditional cultures. Intercultural Education. 2000;11(2):195-199.

87. Stanley LD. Beyond access: psychosocial barriers to computer literacy. The Information Society. 2003;19(5):407-416.

88. Menard-Warwick J, Dabach DB. "In a little while I could be in front:" social mobility, class, and gender in the computer practices of two Mexican families. Journal of Adolescent and Adult Literacy. 2004;47(5):380-389.

89. Weiser EB. Gender differences in Internet use patterns and Internet application preferences: a two-sample comparison. Cyberpsychol Behav. 2000;3(2):167-178.

90. Rondino M. Breaking out of binaries: reconceptualizing gender and its relationship to language in computer-mediated communication. J Comput Mediat Commun. 1997;3(3).

91. Clark C, Gorski P. Multicultural education and the digital divide: focus on gender. Multicultural Perspectives. 2002;4(1):30-40.

92. Herring SC. Gender and democracy in computer-mediated communication. In: Kling R (ed). Computerization and Controversy Second Edition: Value Conflicts and Social Choices. San Diego, CA: Academic Press; 1996: 476-489.

93. Dickerson SS. Gender differences in stories of everyday Internet use. Health Care Women Int. 2003;24(5):434-451.

94. Rovai AP. Building classroom community at a distance: a case study. Educational Technology Research and Development Journal. 2001;49(4):33-48.

95. Rovai AP, Baker JD. Gender differences in online learning: sense of community, perceived learning, and interpersonal interactions. Quarterly Review of Distance Education. 2005;6(1):31-47.

96. Postmes T, Spears R, Sakhel I, de Groot. Social influence in computer-mediated communication: the effects of anonymity on group behavior. Pers Soc Psychol Bull. 2001;27(10):1243-1254.

97. Robson D, Robson M. Ethical issues in Internet counselling. Couns Psychol Q. 2000;13(3):249-257.

98. Shaw HE, Shaw SF. Critical ethical issues in online counseling: assessing current practices with an Ethical Intent Checklist.J Couns Dev. 2006;84(1):41-53.

99. Rochlen AB, Zack JS, Speyer C. Online therapy: review of relevant definitions, debates, and current empirical support. J Clin Psychol. 2004;60(3):269-283.

100. Manhal-Baugus M. E-therapy: practical, ethical, and legal issues. Cyberpsychol Behav. 2001;4(5):551-563.

101. National Board for Certified Counselors. NBCC Policy Regarding the Provision of Distance Professional Services. Available at https://www.nbcc.org/Assets/Ethics/NBCCPolicyRegardingPracticeofDistanceCounselingBoard.pdf. Last accessed April 14, 2022.

102. Okun BF, Fried J, Okun ML. Understanding Diversity: A Learning-As-Practice Primer. Pacific Grove, CA: Brooks/Cole Publishing Company; 1999.

103. U.S. Census Bureau. Computer and Internet Use in the United States: 2013. Available at https://www.census.gov/history/pdf/2013computeruse.pdf. Last accessed April 14, 2022.

104. Death Penalty Information Center. Facts About the Death Penalty. Available at https://deathpenaltyinfo.org/documents/FactSheet.pdf. Last accessed April 14, 2022.

105. Helsper E. Gendered Internet use across generations and life stages. Commun Res. 2010;37(2):352-374.

106. International Association of Marriage and Family Counselors. IAMFC Code of Ethics. Available at http://www.iamfconline.org/public/IAMFC-Ethical-Code-Final.pdf. Last accessed April 14, 2022.

107. Association for Specialists in Group Work. Best Practice Guidelines. Available at https://docs.wixstatic.com/ugd/513c96_93df348d51134a08b789df5374b6dfb7.pdf. Last accessed April 14, 2022.

108. Commission on Rehabilitation Counselor Certification. Code of Professional Ethics for Rehabilitation Counselors. Available at https://crccertification.com/code-of-ethics-4/. Last accessed April 14, 2022.

109. National Organization for Human Services. Ethical Standards for Human Services Professionals. Available at https://www.nationalhumanservices.org/ethical-standards-for-hs-professionals. Last accessed April 14, 2022.

110. American Psychological Association. Practicing Distance Therapy Legally and Ethically. Available at https://www.apa.org/monitor/2012/03/virtual.aspx. Last accessed April 14, 2022.

111. American Psychological Association. Guidelines for the Practice of Telepsychology. Available at https://www.apa.org/practice/guidelines/telepsychology. Last accessed April 14, 2022.

112. Weinberg M. The social construction of social work ethics: politicizing and broadening the lens. Journal of Progressive Human Services. 2010;21(1):32-44.

113. Koggel C, Orme J. Care ethics: new theories and applications. Ethics and Social Welfare. 2010;4(2):109-114.

114. Thompson LJ, Wadley DA. Countering globalisation and managerialism: relationist ethics in social work. International Social Work. 2018;61(5):706-723.

115. Hudson CG. Behavioral mental health: an emerging field of service or an oxymoron. Soc Work. 2018;63(1):27-36.

116. Kien G. Postmodernism trumps all: the world without facts. Qualitative Inquiry. 2021;27(3/4):374-380.

117. Santis EL, Zavattaro SM. Performative ethics in the Trump era: a postmodern examination. Public Integrity. 2019;21(5):503-511.

118. van Zyl I, Sabiescu A. Toward intersubjective ethics in community-based research. Community Development. 2020;51(4):303-322.

119. McBeath G, Webb SA. Virtue ethics and social work: being lucky, realistic, and not doing one's duty. British Journal of Social Work. 2002;32(8):1015-1036.

120. Price B. Ethical challenges in delivering person-centred care. Primary Health Care. 2020;30(2):34-41.

121. Tseng PE, Wang YH. Deontological or utilitarian? An eternal ethical dilemma in outbreak. International Journal of Environmental Research and Public Health. 2021;18(16):8565.

122. Reamer FG. Social Work Values and Ethics. 3rd ed. New York, NY: Columbia University Press; 2006.

123. Jibiliza X. The rationality of ethics: teleological theory reconciled in the context of abortion. Pharos Journal of Theology. 2021;102(2).

124. Deel SK, Amaral NB. Ethical behavior and decision-making: an interdisciplinary review. Journal of Multidisciplinary Research. 2019;11(2):51-72.

125. Savulescu J, Persson I, Wilkinson D. Utilitarianism and the pandemic. Bioethics. 2020;34(6):620-632.

126. van der Meiden J, Noordegraaf M, van Ewijk H. Relational ethics as enrichment of social justice: applying elements of contextual therapy to social work. Qualitative Social Work. 2020;19(1):125-141.

127. Barnett JE. The ethical practice of psychotherapy: clearly within our reach. Psychotherapy. 2019;56(4):431-440.

128. Miller BJ, Springer P. Ethics-based training for clinicians: moving beyond ethical decision-making models. Contemporary Family Therapy. 2020;42(4):370-380.

129. Diamond E, Whalen A, Kelly KK, Davis S. DECIDE: an ethical decision-making model supporting a socially just practice. Communique. 2021;49(8):4, 6-7.

130. McCarthy LP, Imboden R, Shdaimah CS, Forrester P. "Ethics are messy:" supervision as a tool to help social workers manage ethical challenges. Ethics & Social Welfare. 2020;14(1):118-134.

131. Seehusen C, Britton R, Duys D. Managed care organizations in counseling practice, research, and education. Journal of Counselor Preparation & Supervision. 2020;13(1):1-23.

132. Bridges DR, Davidson RA, Odegard PS, Maki IV, Tomkowiak J. Interprofessional collaboration: three best practice models of interprofessional education. Medical Education Online. 2011;16.

133. Solomon P. Inter-professional collaboration: passing fad or way of the future? Physiotherapy Canada. 2011;62(1):47-65.

134. Goodwin S, MacNaughton-Doucet L, Allan J. Call to action: interprofessional mental health collaborative practice in rural and northern Canada. Canadian Psychology. 2016;57(3):181-187.

135. Gilles I, Filliettaz SS, Berchtold P, Peytremann-Bridevaux I. Financial barriers decrease benefits of interprofessional collaboration within integrated care programs: results of a nationwide survey. International Journal of Integrated Care. 2020;20(1).

136. Hale GM, Joseph T, Maravent S, et al. Effect of interprofessional collaboration on quality of life in elderly patients with cardiovascular disease. Journal of Interprofessional Education & Practice. 2018;12:25-28.

137. Weinberg DB, Miner DC, Rivlin L. "It depends:" medical residents' perspectives on working with nurses. Am J Nursing. 2009;109:34-43.

138. Ndibu Muntu Keba Kebe N, Chiocchio F, Bamvita J, Fleury MJ. Variables associated with interprofessional collaboration: a comparison between primary healthcare and specialized mental health teams. BMC Family Practice. 2020;21(1):1-11.

139. Banks S. Interprofessional ethics: a developing field? Notes from the ethics and social welfare conference, Sheffield, UK, May 2010. Ethics and Social Welfare. 2010;4(3):280-294.

140. De Jong E, Gillet F. Interprofessional cooperation as collective ethics work. European Journal of Social Education. 2015;26/27:76-90.

76442 • Suicide Assessment and Prevention

Mark Rose, BS, MA, LP

www.netce.com

Copyright © 2023 NetCE, All rights reserved.

Suicide is a major preventable public health problem and cause of mortality. This course will review the major aspects of suicide assessment, management, and prevention, with a special focus on military veterans. Primary care contact may represent the last opportunity for intervention in the severely depressed suicidal patient, making the thorough comprehension of identification and treatment of depression and suicide risk imperative.

Table of Contents

76442 • Suicide Assessment and Prevention

Course Overview

Audience

Course Objective

Learning Objectives

Faculty

Faculty Disclosure

Division Planners

Division Planners Disclosure

Director of Development and Academic Affairs

Director Disclosure Statement

About the Sponsor

Disclosure Statement

Implicit Bias in Health Care

1. INTRODUCTION

2. EPIDEMIOLOGY OF SUICIDE

THE MISREPORTING OF DEATH BY SUICIDE

SUICIDE REPORTING IN THE MEDIA

3. PATHOPHYSIOLOGY OF SUICIDAL BEHAVIOR

4. SUICIDE AND SPECIAL POPULATIONS

WOMEN

YOUTH

OLDER ADULTS (65 YEARS OF AGE AND OLDER)

LESBIAN, GAY, BISEXUAL, AND TRANSGENDER (LGBT+) INDIVIDUALS

MILITARY SERVICE MEMBERS

HEALTHCARE PROFESSIONALS

5. RISK AND PROTECTIVE FACTORS FOR SUICIDE

PROTECTIVE FACTORS

RISK FACTORS

ACTIVE-DUTY MILITARY AND VETERANS

6. IMMINENT SUICIDE

WARNING SIGNS

7. SUICIDE ATTEMPTS

LETHAL MEANS

MOTIVES BEHIND SUICIDAL BEHAVIOR

8. SCREENING AND ASSESSMENT OF SUICIDE RISK

SCREENING IN THE PRIMARY CARE SETTING: EXPERT CONSENSUS

ASSESSMENT OF SUICIDE RISK

DETERMINING LEVEL OF RISK AND APPROPRIATE ACTIONS

DOCUMENTATION

9. MANAGEMENT OF SUICIDAL PATIENTS

PHARMACOTHERAPY TO REDUCE SUICIDE RISK

PSYCHOTHERAPY TO REDUCE SUICIDE RISK

MENTAL HEALTH REFERRAL

REFERRAL TO BE HOSPITALIZED

ADDITIONAL OPTIONS FOR CONTINUITY OF CARE

SAFETY PLANNING

CONSIDERATIONS FOR VETERANS

CONSIDERATIONS FOR HEALTHCARE PROFESSIONALS

10. SUICIDE PREVENTION

HISTORY OF SUICIDE PREVENTION IN THE UNITED STATES

SUICIDE PREVENTION THAT TARGETS AT-RISK POPULATIONS

STIGMA AND SUICIDE

11. SUICIDE SURVIVORS: TREATMENT AND RESOURCES

12. CONCLUSION

Works Cited

Evidence-Based Practice Recommendations Citations

76442 • Suicide Assessment and Prevention

Education Category. Psychiatric / Mental Health

Release Date. 04/01/2023

Expiration Date. 03/31/2026

Course Overview

Suicide is a major preventable public health problem and cause of mortality. This course will review the major aspects of suicide assessment, management, and prevention, with a special focus on military veterans. Primary care contact may represent the last opportunity for intervention in the severely depressed suicidal patient, making the thorough comprehension of identification and treatment of depression and suicide risk imperative.

Audience

This course is designed for physicians, nurses, pharmacists, and other healthcare professionals who may identify persons at risk for suicide and intervene to prevent or manage suicidality.

Course Objective

The purpose of this course is to provide health and mental health professionals with an appreciation of the impact of depression and suicide on patient health as well as the skills necessary to identify and intervene for patients at risk for suicide.

Learning Objectives

Upon completion of this course, you should be able to:

1. Review the epidemiology of suicide.

2. Describe the impact of suicide in the treatment of special populations, including among military veterans.

3. Identify risk and protective factors for suicide.

4. Discuss warning signs of imminent suicide and the importance of lethal means.

5. Evaluate tools available for the assessment and evaluation of suicide risk.

6. Outline key components of an effective suicide prevention plan.

Faculty

Mark Rose, BS, MA, LP, is a licensed psychologist in the State of Minnesota with a private consulting practice and a medical research analyst with a biomedical communications firm. Earlier healthcare technology assessment work led to medical device and pharmaceutical sector experience in new product development involving cancer ablative devices and pain therapeutics. Along with substantial experience in addiction research, Mr. Rose has contributed to the authorship of numerous papers on CNS, oncology, and other medical disorders. He is the lead author of papers published in peer-reviewed addiction, psychiatry, and pain medicine journals and has written books on prescription opioids and alcoholism published by the Hazelden Foundation. He also serves as an Expert Advisor and Expert Witness to law firms that represent disability claimants or criminal defendants on cases related to chronic pain, psychiatric/substance use disorders, and acute pharmacologic/toxicologic effects. Mr. Rose is on the Board of Directors of the Minneapolis-based International Institute of Anti-Aging Medicine and is a member of several professional organizations.

Faculty Disclosure

Contributing faculty, Mark Rose, BS, MA, LP, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Division Planners

Alice Yick Flanagan, PhD, MSW

Margaret Donohue, PhD

Division Planners Disclosure

The division planners have disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Director of Development and Academic Affairs

Sarah Campbell

Director Disclosure Statement

The Director of Development and Academic Affairs has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

About the Sponsor

The purpose of NetCE is to provide challenging curricula to assist healthcare professionals to raise their levels of expertise while fulfilling their continuing education requirements, thereby improving the quality of healthcare.

Our contributing faculty members have taken care to ensure that the information and recommendations are accurate and compatible with the standards generally accepted at the time of publication. The publisher disclaims any liability, loss or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents. Participants are cautioned about the potential risk of using limited knowledge when integrating new techniques into practice.

Disclosure Statement

It is the policy of NetCE not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners.

Implicit Bias in Health Care

The role of implicit biases on healthcare outcomes has become a concern, as there is some evidence that implicit biases contribute to health disparities, professionals' attitudes toward and interactions with patients, quality of care, diagnoses, and treatment decisions. This may produce differences in help-seeking, diagnoses, and ultimately treatments and interventions. Implicit biases may also unwittingly produce professional behaviors, attitudes, and interactions that reduce patients' trust and comfort with their provider, leading to earlier termination of visits and/or reduced adherence and follow-up. Disadvantaged groups are marginalized in the healthcare system and vulnerable on multiple levels; health professionals' implicit biases can further exacerbate these existing disadvantages.

Interventions or strategies designed to reduce implicit bias may be categorized as change-based or control-based. Change-based interventions focus on reducing or changing cognitive associations underlying implicit biases. These interventions might include challenging stereotypes. Conversely, control-based interventions involve reducing the effects of the implicit bias on the individual's behaviors. These strategies include increasing awareness of biased thoughts and responses. The two types of interventions are not mutually exclusive and may be used synergistically.

1. INTRODUCTION

In 2019, there were 47,511 reported suicide deaths in the United States, making it the 10th leading overall cause of mortality [1]. Every day, approximately 130 Americans take their own life, and one person dies by suicide every 11.2 minutes. An estimated 90% of persons who die by suicide have a diagnosable psychiatric disorder at the time of death, although only 46% have a documented diagnosis [2,3].

For the approximately 48,000 suicide deaths each year, an estimated 200,000 additional individuals are affected by the loss of a loved one or acquaintance by suicide [5,46]. This translate to about six survivors intimately affected per suicide. However, a 2019 study estimated that the rate is much higher, projecting a rate of 135 individuals exposed to a single suicide in addition to those intimately affected (equaling more than 6.9 million individuals) [13,14]. Among these, 20% (or more than 1 million individuals) reported that the experience had a devastating impact or caused a major-life disruption [4]. These figures do not take into account the physical and emotional pain and trauma endured by persons who survive suicide attempts [5].

The total economic burden of suicide is estimated to be $69 billion annually, with the costs falling most heavily on adults of working age [2]. Depression causes an estimated 200 million lost workdays each year at a cost to employers of $17 to $44 billion [6]. However, the accuracy of attempts to quantify such costs on a national scale is hampered by incomplete data, such as the under-reporting of suicides and an absence of reliable data on suicide attempts [5].

Among persons with a mood disorder, 12% to 20% will ultimately die by suicide. The first three months after diagnosis is the period of highest risk for a first attempt, with the three months following the first attempt being the highest risk period for a second attempt [7].

Case Scenario: Patient A

Two case studies will be referenced throughout the text to illustrate the challenges of assessing and treating patients with possible suicide attempt.

Patient A, 19 years of age, is brought to the local emergency department by ambulance after being found unconscious on the floor of her mother's living room, an empty pill bottle nearby. She exhibits quiet, shallow breathing but otherwise no spontaneous movement; she does react to deep, noxious stimuli by opening her eyes and moving her extremities but does not speak or respond to questioning. Her neck is supple, and a screening cranial nerve and motor exam shows no focal neurologic deficits. Her blood pressure is 110/70 mm Hg, pulse is 114 beats per minute, respiration 12 breaths per minute, and temperature 98.8°F; the lungs are clear. The empty bottle is a prescription for a tricyclic antidepressant made out to Patient A's mother. The friend who found her has followed and provides some context: she is not working at present, lives with a boyfriend who recently left her ("they fight a lot"), and has been living at her mother's home for several days. She is admitted to the intensive care unit and intubated, primarily to protect her airway from aspiration should she vomit.

2. EPIDEMIOLOGY OF SUICIDE

Every year, more than 700,000 people around the world die by suicide, with 77% occurring in low- and middle-income countries. The suicide rate has increased by more than 60% in the past 45 years, with suicide rates among young people increasing at alarming rates in both developed and developing countries [8]. Suicide is the 4th leading cause of death for people 15 to 29 years of age. However, since 2000, the overall rate appears to have decreased slightly.

Suicide rates vary according to race, ethnicity, sex, and many other factors, including age [8]. In almost every country, suicide is predominated by male victims, with the exception of China, which is the only country in which the female suicide rate (14.8 per 100,000) exceeds the male rate (13 per 100,000) [9]. In the United States, the number of deaths by suicide is nearly four times greater among men (37,256) than among women (10,255). Overall, suicide accounts for 1.7% of all deaths in the United States and a death rate of 13.9 per 100,000 [1].

From the mid-1950s to the late 1970s in the United States, the suicide rate tripled among men 15 to 24 years of age and doubled among women 15 to 24 years of age. The suicide rate reached a plateau during the 1980s and early 1990s and began decreasing during the mid-1990s [10]. However, the age-adjusted suicide rate increased 35% between 1999 and 2018, with increases in most groups younger than 75 years of age [11]. The suicide rate is consistently highest among men 75 years of age and older (40 deaths per 100,000). Among the elderly, the suicide rate peaked in 1987, at 21.8 per 100,000 people, and has since declined nearly 13% (to 19.2 per 100,000 in 2018) [11,13]. Despite the growing recognition of suicide as a problem demanding public health attention, the overall rates of suicide in the United States have increased over the last half-century [13].

Although official national statistics are not compiled on attempted suicide (i.e., nonfatal actions), it is estimated that 1.2 million adults (18 years of age and older) attempt suicide each year [13]. Overall, there are roughly 25 attempts for every death by suicide; this ratio changes to 100 to 200:1 for the young and 4:1 for the elderly [13,16]. The risk of attempted (nonfatal) suicide is greatest among women and the young, and the ratio of female-to-male nonfatal suicide attempts is 2 to 3:1 [2,10,13].

THE MISREPORTING OF DEATH BY SUICIDE

There is broad agreement that not all suicide deaths are accurately recorded and reported. Reasons for under-reporting include [5,18,19,20,21]:

- Families or family physicians may hide evidence due to the stigma of suicide.

- The determination of death is judged by local standards, which can vary widely.

- Ambiguous cases involving suicide may end up classified as "accidental" or " undetermined."

- Compared with the "accidental" or " undetermined" motive categories, a larger number of deaths are officially classified as "ill-defined and unknown causes of mortality," in which even the actual cause of death is uncertain and some of which are undoubtedly suicides.

- The frequency of physician-assisted suicide for the terminally ill is unknown but is probably both substantial and increasing.

In contrast, some ambiguous cases are classified as suicides, often in institutions such as prisons, hospitals, religious orders, and the military, where the verdict of suicide is likely to be less embarrassing than homicide. Other motivations for declaring a death a suicide, despite much doubt surrounding a case, are that homicides must be investigated and a murderer sought and accidental death may be the basis of negligence lawsuits [5].

SUICIDE REPORTING IN THE MEDIA

Suicide rates may temporarily spike with intense media coverage of a suicide, especially among youth, and both news reports and fictional accounts of suicide in movies and television can produce this effect [22,23,24]. Imitation is often the key factor and is most powerful with the highly publicized suicides of entertainment celebrities [5,25].

Media coverage of suicide can lead to misinformation, as when suicide is attributed to a single event, such as the loss of a job or a relationship, without mention of a broader context involving ongoing problems with depression, substance abuse, or lack of access to treatment for these conditions. On the other hand, responsible coverage of suicide can educate audiences about the causes, warning signs, and treatment advances and prevention of suicide [5].

Thirty-six hours after admission, Patient A has been extubated and is awake, sitting up, and talking to a young man (the boyfriend) at her bedside. As you approach, she smiles sheepishly and asks, "Can I go home now?" Before answering, which of the following management options would you consider appropriate at this juncture?

- Have physical therapy assess strength and ambulation. If normal, discharge her home to the care of her family.

- Ask the young man to step out, then take a careful medical and social history, exploring in detail her mindset, actions, and intent in the period leading up to admission.

- Anticipate transfer out of the intensive care unit and the need for an around-the-clock "sitter" in her room as a suicide prevention precaution.

- Request social service consult to assess her resources and support system and a psychiatry consult to assess the need for further inpatient care and recommend a plan for outpatient follow-up.

3. PATHOPHYSIOLOGY OF SUICIDAL BEHAVIOR

Although suicide is a potential complication of all psychiatric disorders, serious suicidal actions have a neurobiologic basis that is distinct from the psychiatric illnesses with which they are associated [26].

Alterations in several neurobiologic systems are associated with suicidal behavior, most prominently hyperactivity of the hypothalamic-pituitary-adrenal (HPA) axis, serotonergic system dysfunction, and excessive activity of the noradrenergic system. While the first and the last system appear to be involved in the response to stressful events, serotonergic dysfunction is thought to be trait-dependent and associated with disturbances in the regulation of anxiety, impulsivity, and aggression [27,28]. Altered functioning of these systems may stem from both genetic and developmental causes. Exposure to extreme or chronic stress during childhood has developmental consequences on these systems that persist into adulthood. Genetic differences may also contribute to alterations in the functioning of these neurobiologic systems, and the interactive effect of adverse childhood experiences, such as physical abuse, sexual abuse, or caregiver abandonment, with genetic vulnerability is increasingly believed to play a role in suicidal behavior [27,29].

Neurobiologic and psychologic perspectives have converged to identify the most prominent risk factors for suicidal behavior: dysregulated impulse control and a propensity to intense psychologic pain that includes hopelessness, often in the context of a mood disorder. These factors are believed to largely reflect serotonergic system dysregulation [30]. Investigation into the role played by serotonergic dysfunction in suicidal behavior has identified two prominent regions: the dorsal and median raphe nuclei in the midbrain, which host the main serotonergic cell bodies, and the prefrontal cortex, particularly the ventral prefrontal cortex, which is innervated by the serotonergic system. In vivo and postmortem examinations have revealed serotonergic hypofunction in these two brain systems in persons who have died by suicide or made serious suicide attempts. The deficient serotonergic input in the ventral prefrontal cortex stemming from this serotonin hypofunction can result in a breakdown in inhibitory function leading to a predisposition to impulsive and aggressive behavior. This vulnerability to deficient impulse control coupled with the development of psychiatric illness or other life stressors elevates the risk of acting on suicidal thoughts [31].

4. SUICIDE AND SPECIAL POPULATIONS

WOMEN

A woman takes her own life every 51.25 minutes in the United States [1]. Suicide is more common among women who are single, recently separated, divorced, or widowed, and the suicide rates for women peak between the ages of 45 to 64 years. Precipitating life events for women who attempt suicide often involve interpersonal losses or crises in significant social or family relationships. As noted, more women attempt suicide than men, and there is a 2 to 3:1 ratio of women versus men with a history of attempted suicide. The higher rates of attempted suicide among women are likely due to the higher rates of mood disorders such as major depression, persistent depressive disorder (dysthymia), and seasonal affective disorder. Factors that may contribute to the lower rates of suicide deaths in women relative to men include stronger social supports, feeling that their relationships are a deterrent to suicide, differences in preferred suicide method, and greater willingness to seek psychiatric and medical intervention [2,13].

YOUTH

In 2020, suicide was the third leading cause of death for young people 10 to 24 years of age, exceeded only by unintentional injury and homicide [32]. As noted, an estimated 100 to 200 attempts are made for every suicide completion in this age group. Between 2008 and 2015, encounters for suicide ideation and/or attempt at children's hospitals nearly doubled [51]. Risk factors for suicide among the young include suicidal thoughts, psychiatric disorders (e.g., depression, impulsive aggressive behavior, bipolar disorder, panic disorder), drug and/or alcohol abuse, and previous suicide attempts. The risk is further elevated with situational stress or access to firearms [2,13].

Children 10 to 14 Years of Age

In 2020, suicide was the second leading cause of death for children 10 to 14 years of age, with a rate of approximately 3 per 100,000 [11,32]. The rate of suicide and percentage of total deaths varies considerably by race (Table 1) [122].

Table 1: DEATHS BY SUICIDE AMONG U.S. CHILDREN 10 TO 14 YEARS OF AGE BY RACE IN 2020

Race

Rate Per 100,000 Population

Total Suicide Deaths

Percentage of Total Deaths

Alaska Native/Native American

6.3

21

35%

Asian

1.3

15

14.5%

Black/African American

3.0

93

11.5%

Multiracial

2.1

24

19.7%

White

2.8

424

18.4%

Source: [122]

College Students

More than 1,000 suicides occur each year on college campuses, and 1 in 10 college students have made a suicide plan [34]. A 2011 survey of 27,774 college students from 44 campuses found that 6.6% had seriously contemplated suicide and 1.1% had attempted suicide [16]. In the 12 months before the survey, 60.5% reported feeling very sad, 45.2% reported feeling hopeless, and 30.3% reported feeling so depressed they were unable to function [16]. More than 45% reported feelings of hopelessness; however, only 6.7% of men and 13.1% of women reported a diagnosis of depression, suggesting that many students are not receiving adequate diagnosis and/or treatment [16]. A 2015 follow-up survey including 93,034 college students from 108 campuses found a much higher rate of suicidality, with 24% of the survey population reporting seriously contemplating suicide, nearly 20% reporting self-injury, and 9% reporting a suicide attempt [33]. Rates of suicidality were highest among racial/ethnic, sexual, and gender minorities.

Students with a pre-existing mental health condition or who develop mental health conditions in college are at highest risk of suicide. In the 2015 study, 25% students were diagnosed with and/or received treatment for a mental health condition in the previous 12 months [33]. Risk factors for suicide among college students include depression, sadness, hopelessness, and stress [13].

Other Considerations in Youth Suicide

Most adolescent suicides occur at home after school hours. Adolescent nonfatal suicide attempters are typically girls who ingest pills, while those who die by suicide are typically boys who die from gunshot wounds. Intentional self-harm should be considered serious and in need of further evaluation because not all adolescent attempters admit their intent. Most adolescent suicide attempts are triggered by interpersonal conflicts and are motivated by the desire to change the behavior or attitude of others. Repeat attempters may use this behavior as a coping mechanism for stress and tend to exhibit more chronic symptomatology, worse coping histories, and higher rates of suicidal and substance abuse behaviors in their family histories [13]. The presence of multiple emotional, behavioral, and/or cognitive problems may be a more important predictor of suicide behavior risk than a specific type of problem (e.g., an addictive behavior or an emotional problem) [13,33]. The presence of acne is associated with social and psychologic problems, and certain acne medications have been linked with an increased risk of suicidal ideation [36].

OLDER ADULTS (65 YEARS OF AGE AND OLDER)

The elderly account for roughly 19.3% of suicides but only 16% of the population [13]. Suicide rates rise with age for men, especially after 65 years of age, and the suicide rate in elderly men is 5 times that of same-aged women; more than 85% of elderly suicides are among men [13,35]. The overall rate of elderly suicide is nearly 20 per 100,000. However, the rate is 40 per 100,000 among elderly White men and 51.8 per 100,000 among White men older than 85 years of age, a rate that is almost 2 times the rate for men of all ages. In contrast, the suicide rate of women declines after 60 years of age [13,35].

Although undiagnosed and/or untreated depression is the primary cause of suicide in the elderly, suicide completion is rarely preceded by only one factor. Risk factors for suicide in this population include a previous suicide attempt; mental illness; physical illness or uncontrollable pain; fear of a prolonged illness; major changes in social roles, such as retirement; loneliness and social isolation (especially in older men who have recently lost a loved one); and access to lethal means, such as firearms in the home [13].

LESBIAN, GAY, BISEXUAL, AND TRANSGENDER (LGBT+) INDIVIDUALS

The true incidence of suicide among lesbian, gay, bisexual, transgender, and other gender and sexual minority (LGBT+) youth is unknown, but research indicates higher rates of suicidal behavior among LGBT+ youth (15 to 24 years of age) compared with heterosexual youth [33,43]. Among adolescents and young adults, the lifetime prevalence of suicide attempts ranges from 20.5% to 52.4% among LGB individuals versus 4.2% to 24.8% among same-aged heterosexuals [39,40,42]. Among adolescents and young adults, past-year suicide attempts are more than 4.5 times higher among LGB youth than same-aged heterosexual youth [13,37,47].

Evidence Based Practice Recommendation

The American Academy of Child and Adolescent Psychiatry asserts that family connectedness, adult caring, and school safety are highly significant protective factors against suicidal ideation and attempts in gay, lesbian, and gender-variant youth.

https://jaacap.org/article/S0890-8567(12)00500-X/fulltext

Last Accessed: March 24, 2023

Level of Evidence: Expert Opinion/Consensus Statement

LGBT+ youth generally have more risk factors, more severe risk factors, and fewer protective factors, such as family support and safe schools, than heterosexual youth. There are also risks unique to this population related to sexual orientation, such as disclosure to family or friends [13]. The impact of stigma and discrimination against LGBT+ individuals is enormous and is directly tied to risk factors for suicide such as isolation, alienation and rejection from family, and lack of access to culturally competent care [43]. Family connectedness, perceived caring from other adults, and feeling safe at school were reported as significant protective factors in a survey of 6th-, 9th-, and 12th-grade LGBT+ students [37,38]. It has also been noted that LGBT+ adults have a two-fold excess risk of suicide than their heterosexual counterparts [37].

The effect of race/ethnicity and other demographic characteristics on suicidal behavior in the LGB population has also been studied little, but reports suggest high suicide attempt rates among African American gay/bisexual men, among gay/bisexual men of lower socioeconomic status, and among LGB Latinx [35].

Depression and suicide are also common among transgender individuals. One survey assessed transgender individuals' school experiences from kindergarten through grade 12. Of the individuals who were out as transgender during their school years, 77% reported at least one negative experience, including physical attacks, verbal abuse, and mistreatment by teachers and/or administrators. Among those with negative school experiences, 58% attempted suicide, compared with 37% of transgender individuals without negative school experiences. Among out transgender college students, 24% reported that they were physically, verbally, or sexually harassed. [38]. Across all age groups, 39% of transgender individuals reported experiencing serious psychologic distress in the past month, compared with 5% of the general U.S. population. Up to 82% of transgender persons have considered suicide in their lifetimes [124]. In addition, 40% of individuals reported attempting suicide, more than nine times the rate in the United States [38,47,124].

MILITARY SERVICE MEMBERS

Although the true incidence of suicide among military service members and veterans is difficult to estimate due to the lack of national suicide surveillance data, the U.S. Department of Veterans Affairs (VA) estimates that 18% of all deaths from suicide in the United States are in military war veterans [79]. Despite preventive measures taken by the military, the number of suicides in this population continues to increase [52,54,56,79]. Although the majority of military suicides occur among young men shortly after their discharge from military service, military women 18 to 35 years of age commit suicide nearly three times more frequently than civilian women of the same age group [57,58]. Servicewomen, in particular, experience high rates of interpersonal violence, including childhood abuse, intimate partner violence, and sexual trauma during adulthood (e.g., military sexual assault) [123].

Patient A is transferred to a regular floor and a sitter is assigned to her room. With the aid of additional clinical observation and consultations, a clearer picture emerges. In the presence of staff, Patient A appears open and optimistic and takes initiative; when her boyfriend or family are present, she becomes passive, more withdrawn, and demanding, expecting others to attend to her needs. Patient A's parents divorced when she was 11 years of age, and two years later, she came under psychiatric care, followed by counseling, because of depression and a brief period of suicide ideation. She had attended college but dropped out after two years. In recent months, her life had become more chaotic. She was unhappy in her job and subject to fits of anger and despondency. She was often at odds with her live-in boyfriend, who, on occasion, threatened to leave her and in fact did so four days prior to her admission. The decision to take an overdose of her mother's medication was judged to have been abrupt and impulsive, perhaps a "suicide gesture"—partly misdirected anger and partly designed to win back the attention of her boyfriend. Nevertheless, she almost succeeded in taking her life. The consultant's diagnosis is borderline personality disorder and likely major depression. She is transferred to the inpatient psychiatry service for further evaluation and care. Some days later, she is discharged to a mental health clinic for psychiatric and social service follow-up combined with ongoing counseling.

HEALTHCARE PROFESSIONALS

Some occupations are known to have higher rates of suicide than others. Job factors, including chronic stress, vicarious trauma, low job security, and low pay, can contribute to risk of suicide, as can easy access to lethal means (e.g., medications, firearms) among people at risk. Other factors that can influence the link between occupation and suicide include gender, socioeconomic status, economic environment, cultural factors, and stigma [115].

Healthcare workers have historically been at disproportionate risk of suicide, due to a variety of factors, including difficult working conditions, such as [115]:

- Long work hours

- Irregular shifts

- Emotionally difficult situations

- Risk for exposure to infectious diseases and other hazards on the job, including workplace violence

- Routine exposure to human suffering and death (vicarious or secondary trauma)

- Access to lethal means (e.g., medications) and knowledge about using them

In 2019, a large review of more than 60 scientific studies was conducted to address conflicting data on the nature of suicide among healthcare workers. The researchers found that physicians were at a significant and increased risk for suicide, with female physicians at particularly high risk [116]. A cross-sectional survey involving 7,378 nurses found that nurses were at increased risk for past-year suicidal ideation (5.5%) [117]. In addition, nurses with suicidal ideation were less likely to be willing to seek help (72.6%) than nurses without suicidal ideation (85%). Burnout was strongly associated with suicidal ideation, even after controlling for other personal and professional characteristics [117].

5. RISK AND PROTECTIVE FACTORS FOR SUICIDE

Suicide is now understood to be a multidimensional disorder stemming from a complex interaction of biologic, genetic, psychologic, sociologic, and environmental factors [59,60]. One of the first social scientists to empirically investigate contributing factors to suicide was Émile Durkheim. Instead of focusing only on shared traits among persons who had died by suicide, Durkheim compared one group with another and originated the scientific study of suicide risk factors [5,61]. Protective factors reduce suicide risk by enhancing resilience and counterbalancing risk factors, while risk factors increase the potential for suicidal behavior. Protective and risk factors may be biopsychosocial, environmental, or sociocultural in nature [5].

PROTECTIVE FACTORS

Several protective factors against suicide behavior have been identified [5,62]. These include:

- Access to effective clinical care for mental, physical, and substance use disorders, and support for help-seeking

- Restricted access to highly lethal means of suicide

- Strong connections to family and community support

- Emotionally supportive connections with medical and mental health providers

- Effective problem-solving and conflict-resolution skills

- Cultural and religious beliefs that discourage suicide and support self-preservation

- Reality testing ability

- Pregnancy, children in the home, or sense of family responsibility

- Life satisfaction

RISK FACTORS

Evidence Based Practice Recommendation

According to the American Psychiatric Association, the assessment and treatment of major depressive disorder should consider the impact of language barriers, as well as cultural variables that may influence symptom presentation, treatment preferences, and the degree to which psychiatric illness is stigmatized.

https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/mdd.pdf

Last Accessed: March 24, 2023

Strength of Recommendation: I (Recommended with substantial clinical confidence)

In addition to risk factors specific to special populations, there are many general risk factors common among most populations. General biopsychosocial risk factors include [2,5,62]:

- Psychiatric disorders

- Alcohol and other substance use disorders

- Hopelessness

- Impulsive and/or aggressive tendencies

- History of physical or sexual trauma or abuse, especially in childhood

- Medical illness involving the brain or central nervous system (CNS)

- Family history of suicide

- Suicidal ideas, plans, or attempts (current or previous)

- Lethality of suicidal plans or attempts

In addition, environmental factors can impact an individual's suicide risk. Attention to the presence of job or financial loss, relationship or social loss, easy access to lethal means, and local clusters of suicide (due to contagious influence) is necessary.

Lack of social support and sense of isolation are risk factors for suicide, along with cultural factors. Some cultural practices and/or beliefs can predispose an individual to suicide, such as stigma associated with help-seeking behavior; barriers to accessing mental health care and substance abuse treatment; certain cultural and religious beliefs (e.g., suicide as an honorable act); and media exposure to and the influence of others who have died by suicide [2,5,62].

Psychiatric Disorders

At least 90% of people who die by suicide have diagnosable psychiatric illness [2,3]. The psychiatric conditions with the greatest association with suicidal behavior are depression, bipolar disorder, substance abuse, schizophrenia, and personality disorders.

Depression

Major depression is the psychiatric diagnosis most commonly associated with suicide. The risk of suicide in persons with major depression is roughly 20 times that of the general population [13]. About 30% of all patients with major depression attempt suicide, half of whom ultimately take their own lives [63]. More than 60% of persons who die by suicide are clinically depressed at the time of their deaths, although this climbs to 75% when patients with comorbid depression and alcohol use disorder are added. Seven of every 100 men and 1 of every 100 women diagnosed with depression will die by suicide [13].

In one survey of adults who experienced depression in the previous year, 56.3% thought it would be better if they were dead during their worst or most recent episode, 40.3% contemplated suicide, 14.5% made a suicide plan, and 10.4% attempted suicide [65]. Among persons with depression, those with a history of multiple episodes of depression and those with an alcohol or other substance use disorder are at greatest risk [2]. Persons with depression who exhibit the following symptoms are at heightened risk for suicide [2,13]:

- Extreme hopelessness or desperation

- A lack of interest in previously pleasurable activities

- Intense anxiety and/or panic attacks

- Insomnia

- Talk of suicide or history of attempts

- Irritability, agitation, or enraged behavior

- Isolation

Feelings of hopelessness (e.g., belief that there is no solution) are more predictive of suicide risk than a diagnosis of depression per se. It is also important to remember that patients who desire an early death during a serious or terminal illness are usually experiencing a treatable depressive illness [2].

Bipolar Disorder

Between 5 and 10 million Americans currently have bipolar disorder. Of these, as many as 1 in 5 will die by suicide [67]. Like depression, bipolar disorder is treatable, and effective treatment decreases the risk of suicide.

Alcohol and Substance Abuse

Alcohol and drug abuse are second only to depression and other mood disorders as conditions most associated with suicide. Substance use disorders and disordered mood are often comorbid. The suicide risk among patients with alcohol use disorder is 50% to 70% higher than the general population. Alcohol abuse is a factor in roughly 30% of suicides, and about 7% of persons with alcohol dependence die by suicide [2,13,68].

In 2011, an estimated 228,366 emergency department admissions were made for alcohol- or drug-related suicide attempts. Almost all (94.7%) involved either a prescription drug or an over-the-counter medication [69]. Approximately 64.4% involved multiple drugs, and 29% involved alcohol [69].

As mentioned, comorbid psychiatric and substance use disorders substantially increase the risk of suicide behavior. Combined data from 2004 and 2005 indicated that 16.4 million adults 18 years of age and older experienced a major depressive episode in the previous year. Of these persons, more than 10% attempted suicide. But when alcohol abuse or illicit drug use occurred with major depression, the proportion of suicide attempts rose to nearly 14% for alcohol abuse and close to 20% for illicit drug use [65]. A 2017 study conducted among more than 10,000 individuals in a prison population showed that those with a documented substance abuse disorder or other psychiatric disorder had a higher rate of attempted suicide (2.0 and 9.2 greater odds, respectively) than those without a diagnosis [41].

There are several possible explanations for the association between alcohol/drug use and suicide. Alcoholism can cause loss of friends, family, or job, leading to social isolation; however, the reverse is equally plausible. Alcohol abuse and suicide may also both represent attempts to deal with depression and misery. Alcohol increases the sedating effects of some drugs that are frequently used in suicide attempts and may increase impulsive actions, making suicide attempts and completions more common [18,70]. To claim that alcoholism "causes" suicide is simplistic; while the association of alcohol and suicide is clear, a causal relationship is not. Both alcoholism and suicide may be responses to the same pain [18].

Schizophrenia

Suicide is the largest cause of premature death among individuals with schizophrenia, and young, unemployed men are at highest risk. Other risk factors include recurrent relapses; fear of deterioration, especially among persons with high intellectual ability; positive symptoms of suspiciousness and delusions; and depressive symptoms [59,60]. The suicide risk is highest during early stages of the illness, early relapse, and early recovery. The risk decreases with prolonging illness duration [59,60].

Personality Disorders

An estimated 20% to 50% of young people who die by suicide have a diagnosable personality disorder, with borderline personality and antisocial personality disorders being most frequently associated with suicide. Histrionic and narcissistic personality disorders and certain psychologic traits, such as impulsivity and aggression, are also associated with suicide [59,60].

Medical Disorders

Illnesses affecting the brain and CNS have a greater effect on suicide risk compared with other medical conditions. These conditions include epilepsy, AIDS, Huntington disease, traumatic head injury, and cerebrovascular accidents. In contrast, cancer and other potentially fatal conditions carry a more modest suicide risk [71].

Sociodemographic Factors

Suicide is an individual act that also occurs in the context of a broader culture, and specific sociodemographic factors are associated with suicide risk, including marital status, occupation, and previous suicide attempt(s) [59,60].

Marital Status

Divorced, widowed, and single people have a higher suicide risk. Marriage appears to be protective for men, but not so for women. Marital separation also increases the risk of suicide [59,60].

Occupation

Certain occupational groups, such as veterinary surgeons, pharmacists, dentists, farmers, and medical practitioners, have higher rates of suicide. Although obvious explanations are lacking, access to lethal means, work pressure, social isolation, and financial difficulties may account for the heightened risk [59,60].

Unemployment and suicide are also correlated, although the nature of the association is complex. Poverty, social deprivation, domestic difficulties, and hopelessness likely mediate the effect of unemployment, but persons with psychiatric illness and personality disorders are also more likely to be unemployed. Recent job loss is a greater risk factor than long-term unemployment.

Previous Suicide Attempt

Approximately 20% of people who kill themselves had made a previous attempt, making previous serious suicide attempts a very high risk factor for future attempts [2].

Incarceration

Suicide is the single most common cause of death in correctional settings, and collectively, inmates have higher suicide rates than their community counterparts. One study found that the rate of suicide among male prisoners is 5 to 6 times higher than in the general population and as much as 20 times higher among women prisoners. Also, for every suicide death there are many more suicide attempts [44,72].

Inmates at highest risk of suicide include young men, the mentally ill, the socially disenfranchised and socially isolated, substance abusers, previous suicide attempters, and juveniles placed in adult correctional facilities. Factors that increase the likelihood of suicidal behavior include the psychologic impact of arrest and incarceration; the stresses of prison life, including physical and sexual predation and assault from other inmates; and the absence of formal policies regarding managing suicidal patients, staff training, or access to mental health care [44,72].

Vicarious Trauma and Burnout

Compassion fatigue is comprised of two components: burnout and vicarious traumatic stress [118]. The first component consists of characteristic negative feelings such as frustration, anger, exhaustion, and depression. The second component, vicarious traumatic stress, may result when the professional is negatively affected through vicarious or indirect exposure to trauma material through their work. Compassion fatigue is associated with a variety of negative mental health repercussions, including increased risk for depression and suicidal ideation.

Being aware of the factors that increase a professional's risk of burnout is very valuable in contributing to a prevention strategy. Contributing factors may be individual/personal, systemic, or frequently a combination of both. It is important to know what does not work (or what makes a toxic environment) first in order to prevent exposure and the associated fallout from such exposure.

Creative Personalities

Anecdotes of famous painters, writers, and musicians who were depressed and died by suicide have occurred for centuries, but only recently has science been able to identify the underlying basis of vulnerability to depression and suicide among creative people. Treatment of major depressive or bipolar illness in artists presents unique problems, one of which is the concern that creativity and the disorder are so intertwined that treatment might suppress the artist's unique talent [73,74,76].

Holiday Suicide Myth

The idea that suicide occurs more frequently during the holiday season is a myth perpetuated in part by the media and has been debunked [2]. The National Center for Health Statistics of the Centers for Disease Control and Prevention (CDC) reports that the suicide rate is actually lowest in December, with peak rates in the spring and the fall. This pattern has remained constant for many years [77]. The holiday suicide myth has been considered important to counter because it provides misinformation about suicide that might ultimately hamper prevention efforts [78].

ACTIVE-DUTY MILITARY AND VETERANS

Protective Factors

Several general protective factors may be more prevalent among military service members and veterans, including strong interpersonal bonds, responsibilities/duties to others, steady employment, sense of belonging/identity, and access to health care [79]. Historically, the selection bias for healthy recruits, employment, purposefulness, access to health care and a strong sense of belonging were believed to be protective against suicide, but increasing rates have challenged this assumption [79]. In one study, having a service-connected disability was associated with a lower risk of suicide in veterans, likely due to greater access to VA health care and regular compensation payments [52]. It is interesting to note that many of these protective factors do not apply to discharged or retired veterans. Other potentially protective factors include older age, African American/Black race, and admission to a nursing home [79].

Risk Factors

Veterans and military members often possess many risk factors for attempting or completing suicide. This includes combat exposure (particularly deployment to a combat theater and/or adverse deployment experiences), combat wounds, post-traumatic stress disorder (PTSD) and other mental health problems, comorbid major depression, traumatic brain injury, poor social support, feelings of not belonging or of being a burden to others or society, acquired ability to inflict lethal self-injury, and access to lethal means [52,58,81,82,83]. There is conflicting evidence of the role of PTSD in suicide risk, with some studies finding PTSD diagnosis to be protective while others indicated it increased risk. Other possible risk factors include [79,123]:

- Disciplinary actions

- Reduction in rank

- Career threatening change in fitness for duty

- Perceived sense of injustice or betrayal (unit/command)

- Command/leadership stress, isolation from unit

- Transferring duty station

- Administrative separation from service/unit

- Military sexual trauma

Case Scenario: Patient B

Patient B is 56 years of age, married with one grown daughter. She consults a primary care physician because of a gradual decline in health over the past 12 to 18 months. She has come at the insistence of her daughter, who accompanies her. Her given purpose is vague: a "check-up" and perhaps laboratory work. Her daughter tells the nurse, "My mother's not well. She's home alone, doesn't get enough sleep, and won't eat right. She complains about her stomach and thinks she has food allergies; she has tried special diets, supplements, and herbal remedies and claims she's getting better, but she's not." The patient is petite, well-groomed, and smiles readily. She tells the physician, "I'll be okay, but I do want to be sure I'm not anemic or have a thyroid problem." She gives a history of chronic, recurrent abdominal discomfort, bloating, periodic constipation, and intolerance to many foods. As a young woman, she was told she has irritable bowel syndrome and was given trials of medication, but she reports being unable to take these medications and being "very sensitive to any prescription medication." She thinks she has lost maybe 5 pounds in the past year. Her examination is unrevealing, except she is thin and there is a hint of generalized muscle atrophy. Over the course of the interview, she appears tired and to have a slightly blunt affect. The following laboratory tests are ordered: complete blood count, chemistry profile, vitamin D and B12 levels, and thyroid function tests. She is given an appointment to return in five days to discuss the results and plan a course of treatment.

6. IMMINENT SUICIDE

While risk factors for suicide represent broader, durable, and ongoing factors, a suicide crisis is a time-limited event that signals an immediate danger of suicide. A suicide crisis can be triggered by a particularly distressing event, such as loss of a loved one or career failure, and involve an intense emotional state in addition to depression, such as desperation (anguish plus urgent need for relief), rage, psychic pain or inner tension, anxiety, guilt, hopelessness, or acute sense of abandonment. Changes in behavior or speech can suggest that suicide is imminent; speech may be indirect, with statements such as, "My family would be better off without me." Persons contemplating suicide may also talk as if they are saying goodbye or going away, exhibit actions ranging from buying a gun to suddenly putting one's affairs in order, or deterioration in social or occupational functioning, increasing use of alcohol, other self-destructive behavior, loss of control, or rage explosions [2].

WARNING SIGNS

Most people who are suicidal exhibit warning signs, whether or not they are in an acute suicide crisis. These warning signs should be taken seriously and include observable signs of serious depression, such as unrelenting low mood, pessimism, hopelessness, desperation, anxiety, psychic pain, and inner tension; withdrawal from friends and/or social activities; sleep problems; and loss of interest in personal appearance, hobbies, work, and/or school [2,13]. Other signs include:

- Increased alcohol and/or other drug use

- Recent impulsiveness and taking unnecessary risks

- Talk about suicide, death, and/or no reason to live

- Making a plan (e.g., giving away prized possessions, sudden or impulsive purchase of a firearm, or obtaining other means of killing oneself, such as poisons or medications)

- Unexpected rage, anger, or other drastic behavior change

- Recent humiliation, failure, or severe loss (especially a relationship)

- Unwillingness to "connect" with potential helpers.

The following expressions of thoughts, feelings, or behaviors may also be warning signs of suicidal behavior [13]:

- Can't stop the pain

- Can't think clearly

- Can't make decisions

- Can't see any way out

- Can't sleep, eat, or work

- Can't get out of the depression

- Can't make the sadness go away

- Can't see the possibility of change

- Can't see themselves as worthwhile

- Can't get someone's attention

- Can't seem to get control

A mnemonic device, IS PATH WARM, has been developed for use in identifying suicide risk [84]. This mnemonic device was derived from the consensus of internationally renowned clinical researchers held under the auspices of the American Association of Suicidology. It consists of the following [84]:

- Ideation

- Substance abuse

- Purposelessness

- Anxiety

- Trapped

- Hopelessness

- Withdrawal

- Anger

- Recklessness

- Mood change

Intentional Self-Harm

Intentional self-harm is behavior related to, but distinct from, suicide behavior and includes suicide attempts and nonsuicidal self-injurious behaviors, such as burning, cutting, and hair pulling, that does not have fatal intent [85]. Self-injurious behavior falls into three categories [85]:

- Major self-injury: Infrequent, usually associated with psychosis or intoxication

- Stereotypic self-injury: Repetitive and reflects a biologic drive of self-harm

- Superficial-to-moderate self-injury: The most common form and is used by self-mutilators to relieve tension, release anger, regain self-control, escape from misery, or terminate a state of depersonalization

Patients with a history of intentional and repetitive self-harm are likely to be highly impulsive with a diagnosis of borderline personality disorder, and distress over their inability to curtail the behavior may heighten suicide risk [85,86,87]. It is essential to recognize that previous nonlethal self-harm does not preclude the development of suicidal ideation or plans with serious intent and lethality [62]. It is important to assess the intent of self-harm behaviors during the risk assessment.

Five days after the initial visit, in anticipation of follow-up later that day, the physician reviews Patient B's laboratory results, all of which are normal. That afternoon, the patient is a "no-show," and no further action is taken. Some time the following week, the office nurse asks her colleague about Patient B, stating "Something about her really bothered me." She recommends that the physician call the patient to follow-up, which he does. The daughter answers with a mix of concern and relief. She states, "I'm really worried about my mother. She's not making sense at times, seems really down, and says we'd all be better off if she just went to sleep and didn't wake up…I didn't mention it last week, but she and my dad are not doing well. He's busy, on the road a lot, and I get the feeling she thinks he's unfaithful to her." At this juncture what do you do?

- Ask the daughter to bring her mother to the office today, along with all supplements and herbal medicines she may have been taking.

- Consider the key issue(s) and give some thought to your clinical approach (e.g., sequencing the encounter and useful tools that will help to identify major depression and assess suicide risk).

- Anticipate logistical barriers in relation to time of day and the possible need for immediate psychiatric consultation and/or hospitalization.

7. SUICIDE ATTEMPTS

LETHAL MEANS

In the United States in 2019, use of a firearm was the cause of death in 50.4% of suicides and is the number one means among all individuals 15 years of age and older. Gun use accounts for 47% of all suicide deaths in individuals 15 to 24 years of age, reaching a low of 42.1% in those 35 to 44 years of age, and increasing to 51.8% in those 55 to 64 years of age. Firearm use for suicide completion is extremely high among the elderly, with individuals 75 to 84 and 85 years of age and older having the highest rates, at 75.4% and 76.6%, respectively. Gun use is also the most common suicide method among youth, accounting for 31.5% of all suicide deaths [1,78].

Although most gun owners report keeping a firearm in their home for the purpose of protection or self-defense, 83% of gun-related deaths in these homes are the result of a suicide, usually by someone other than the gun owner. Guns are involved in more deaths by suicide than by homicide, and overall, death by firearm is the most common suicide method [12].

The suicide rates among youths 15 to 24 years of age by firearm increased from 5.3 per 100,000 in 2001 to 6.6 per 100,000 in 2019, while the suicide rates by suffocation (e.g., hanging) increased from 3.1 per 100,000 in 2001 to 5.0 per 100,000 in 2019. These trends among teens and young adults have been mirrored by children 5 to 14 years of age, in whom deaths by firearms and suffocation have been increasing since at least 2001 [1,78].

The most common method of suicide death among women in all age groups from 2001 to 2019 was poisoning (35.5%); however, in 2018, firearms surpassed poisoning for the first time since 2000 among female victims [15,78]. Although intentional overdose is the most common method for suicide attempts in women, it is much less likely to result in death. Many over-the-counter medications, prescription drugs, dietary supplements/herbal medications, or illicit drugs may be used to attempt suicide. Ibuprofen is a popular over-the-counter analgesic and a common drug of choice in intentional overdoses. There were more than 12,490 intentional overdose ingestions of ibuprofen reported by U.S. poison control centers in 2018, resulting in one death [89]. Opioid analgesics result in many deaths due to intentional overdose. In one study, researchers found that the percentage of individuals who died by suicide and had opioids in their system more than doubled, from 8.8% to 17.7%, between 2006 and 2017 [45].

Ingestion of other toxic substances (including bleach, poisons, and agricultural chemicals), jumps from tall heights, and exsanguination are also relatively common methods of suicide attempt and completion. When assessing risk, it is important to consider the patient's level of impulsivity and the potential lethality of available means (particularly firearms).

MOTIVES BEHIND SUICIDAL BEHAVIOR

Although thousands of books have explored the question of why people kill themselves, in most cases the answer can be summed up in three words: to stop pain. The pain may be physical, as in chronic or terminal illness, but is usually emotional. However, Stone has delineated a more elaborate description of the motivations for suicide, including [18]:

- Altruistic/heroic suicide: Occurs when someone (more or less) voluntarily dies for the benefit of the group. Examples include the Japanese kamikaze pilots in WWII and the Buddhist monks who burned themselves to death protesting the Vietnam war.

- Philosophical suicide: Various philosophical schools, such as the stoics and existentialists, have advocated suicide under some circumstances.

- Religious suicide: Often as martyrdom, this type of suicide has a long history that spans from early Christianity to the Branch Davidians in Waco, Texas, and some members at Jonestown, Guyana.

- Escape: This type of suicide represents an escape from an unbearable situation, such as persecution, a terminal illness, or chronic misery.

- Excess alcohol and other drug use

- Romantic suicide: This includes suicide pacts (dual suicide), which constitute about 1% of suicides in Western Europe. Participants are usually older than 51 years of age, except in Japan, where 75% of dual suicides are "lovers' pacts."

- "Anniversary" suicide: Suicide involving the same method or date as a deceased loved one.

- "Contagion" suicide: Occurs when one suicide appears to trigger others (e.g., "cluster" and "copycat" suicides), most often among adolescents.

- Manipulation: Usually involving the theme "If you don't do what I want, I'll kill myself." The word "manipulative" does not imply a lack of seriousness, as fatal suicide attempts can be made by people hoping to influence or manipulate the feelings of others even though they will not be around to witness the outcome. However, the intent of manipulative attempts is to produce guilt in the other person, and a nonfatal result is usually intended.

- Call for help: An expression of unbearable pain and misery that is more frequent in the young.

- "Magical thinking" and vengeance: Associated with a feeling of power and complete control. This motivation to attempt suicide is driven by a "you'll be really sorry when I'm dead" fantasy. A fatal outcome is intended, and this is sometimes called "aggressive suicide."

- Cultural approval: In some cultures, such as Japanese culture, society has traditionally accepted or encouraged suicide when matters of honor were concerned.

- Lack of an outside source to blame for one's misery: Evidence exists that rage and homicide is the extreme response when an external cause of one's unhappiness can be identified, and depression and suicide is the extreme response in the absence of a perceived or identifiable external source.

8. SCREENING AND ASSESSMENT OF SUICIDE RISK

Many persons who die by suicide have contact with healthcare providers in the time preceding their deaths. Roughly 45% of all persons who die by suicide had contact with a mental health professional in the year before their deaths, and 75% of elderly persons who die by suicide had visited their physician in the month before their death [2,5]. Although close to 90% of these cases had diagnosable psychiatric illness at the time of death, only 30% reported suicidal ideation or intent to a health professional before their suicide attempt [2]. These figures suggest a widespread inadequacy in identifying and assessing at-risk persons by healthcare professionals, and numerous studies have concluded that health professionals often lack sufficient training in the proper assessment, treatment, management, or referral of suicidal patients [2,5]. Many health professionals also lack training in identifying grieving family members of loved ones who have died by suicide [5]. Primary care providers occupy a niche in the healthcare system and have perhaps the greatest opportunity to impact suicidal persons through educational means [5,46,59,60,91].

SCREENING IN THE PRIMARY CARE SETTING: EXPERT CONSENSUS

Many organizations have issued consensus statements regarding screening for suicide risk in the primary care setting. The U.S. Preventive Services Task Force (USPSTF) states that although suicide screening is of high national importance, it is very difficult to predict who will die from suicide and has found insufficient evidence for routine screening by primary care clinicians to detect suicide risk and limited evidence of the accuracy of screening tools to identify suicide risk in the primary care setting[92,96]. The USPSTF recommends physicians screen all adolescents 12 to 18 years of age for major depressive disorder. The Canadian Task Force on Preventive Health Care found insufficient evidence for routine screening by primary care clinicians to detect depression and suicide risk[93].

However, the American Academy of Pediatrics (AAP) recommends universal screening for suicide risk throughout adolescence (12 years of age and older) and clinically indicated screening for children 8 to 11 years of age[94]. Screening should be performed in a developmentally and medically appropriate manner. The AAP notes that screening for depression is not the same as screening for suicide risk and that screening for depression alone misses 36% of patients at-risk for committing suicide [94]. Screening children younger than 8 years of age is not recommended, but warning signs or parental reports of self-harm or suicidal behaviors should be assessed further; these may include [94]:

- Talking about wanting to die or wanting to kill oneself

- Grabbing their throat in a "choking" motion, or placing their hand in the shape of a gun pointed toward their head

- Acting with impulsive aggression

- Giving away their treasured toys or possessions

The American Academy of Child and Adolescent Psychiatry recommends clinician awareness of patients at high risk for suicide (i.e., older male adolescents and all adolescents with current psychiatric illness or disordered mental state, particularly major depressive disorder), especially when complicated by comorbid substance abuse, irritability, agitation, psychosis, or previous suicide attempt[95,125]. Suicide risk should be assessed at each visit in patients with long-term SSRI use.

ASSESSMENT OF SUICIDE RISK

Initial Inquiry

Healthcare providers may encounter a patient they suspect is suicidal. This suspicion may be prompted by the presence of one or more of the risk factors for suicide described previously, patient history, a statement expressed by the patient, or by their intuition. This scenario may present a dilemma of how to proceed. Although some healthcare professionals are uncomfortable with suicidal patients, it is essential not to ignore or deny the suspicion of suicide risk. The first and most immediate step is to allocate adequate time to the patient, even though many others may be scheduled. Showing a willingness to help begins the process of establishing a positive rapport with the patient. Closed-ended and direct questions at the beginning of the interview are not very helpful; instead, use open-ended questions such as, "You look very upset; tell me more about it." Listening with empathy is in itself a major step in reducing the level of suicidal despair and overall distress [59,60]. It is helpful to lead into the topic gradually with a sequence of useful questions, such as [59,60]:

- Do you feel unhappy and helpless?

- Do you feel desperate?

- Do you feel unable to face each day?

- Do you feel life is a burden?

- Do you feel life is not worth living?

- Have you had thoughts of ending your own life?

It is important to ask these questions after rapport has been established, when the patient feels comfortable expressing his or her feelings, and when the patient is in the process of expressing negative feelings [59,60].

After the patient confirms an initial suspicion of suicidal ideation, the next step is to assess the frequency and severity of the ideation and the possibility of suicide. It is important to ask the patient about whether a method has been developed and planned, the accessibility to the means to attempt suicide, and the magnitude of lethal intent in a manner that is not demanding or coercive, but is asked in a warm and caring way that demonstrates empathy with the patient. Such general questions might include [59,60]:

- Have you made any plans for ending your life?

- How are you planning to do it?

- Do you have in your possession [pills/guns/other means]?

- Have you considered when to do it?

In general, the more an individual has thought about suicide, made specific plans, and intends to act on those plans, the greater the suicide risk. Thus, as part of the assessment of suicide risk it is essential to inquire specifically about the patient's suicidal thoughts, plans, behaviors, and intent. Such questions may often flow naturally from discussion of the patient's current situation, but in other cases they should be explicitly asked [62].

Other questions may help further elucidate suicidal thoughts, plans, or behaviors, including [62]:

Patient's Feelings about Living

- Have you ever felt that life was not worth living?

- Did you ever wish you could go to sleep and just not wake up?

Thoughts of Death, Self-Harm, or Suicide

- Is death something you've thought about recently?

- Have things ever reached the point that you've thought of harming yourself?

Follow-Up Questions

- When did you first notice such thoughts?

- What led up to the thoughts (e.g., interpersonal and psychosocial precipitants, including real or imagined losses; specific symptoms such as mood changes, anhedonia, hopelessness, anxiety, agitation, psychosis)?

- How often have those thoughts occurred (including frequency, obsessional quality, controllability)?

- How close have you come to acting on those thoughts?

- How likely do you think it is that you will act on them in the future?

- Have you ever started to harm (or kill) yourself but stopped before doing something (e.g., holding knife or gun to your body but stopping before acting, going to edge of bridge but not jumping)?

- What do you envision happening if you actually killed yourself (e.g., escape, reunion with significant other, rebirth, reactions of others)?

- Have you made a specific plan to harm or kill yourself? If so, what does the plan include?

- Do you have guns or other weapons available to you?

- Have you made any particular preparations (e.g., purchasing specific items, writing a note or a will, making financial arrangements, taking steps to avoid discovery, rehearsing the plan)?

- Have you spoken to anyone about your plans?

- How does the future look to you?

- What things would lead you to feel more (or less) hopeful about the future (e.g., treatment, reconciliation of relationship, resolution of stressors)?

- What things would make it more (or less) likely that you would try to kill yourself?

- What things in your life would lead you to want to escape from life or be dead?

- What things in your life make you want to go on living?

- If you began to have thoughts of harming or killing yourself again, what would you do?

For persons with previous suicidal or self-harm behavior, the following questions address the antecedents, methods, and aftermath [62]:

- Can you describe what happened (e.g., circumstances, precipitants, view of future, use of alcohol or other substances, method, intent, seriousness of injury)?

- What thoughts were you having beforehand that led up to the attempt?

- What did you think would happen (e.g., going to sleep versus injury versus dying, getting a reaction out of a particular person)?

- Were other people present at the time?

- Did you seek help afterward yourself, or did someone get help for you?

- Had you planned to be discovered, or were you found accidentally?

- How did you feel afterward (e.g., relief versus regret at being alive)?

- Did you receive treatment afterward (e.g., medical versus psychiatric, emergency department, inpatient versus outpatient)?

- Has your view of things changed, or is anything different for you since the attempt?

- Are there other times in the past when you've tried to harm (or kill) yourself?

Repeated Suicidal Thoughts or Attempts

- About how often have you tried to harm (or kill) yourself?

- When was the most recent time?

- Can you describe your thoughts at the time that you were thinking most seriously about suicide?

- When was your most serious attempt at harming or killing yourself?

- What led up to it, and what happened afterward?

Persons with Psychosis, Hallucinations, and Delusions

- Can you describe the voices (e.g., single versus multiple, male versus female, internal versus external, recognizable versus unrecognizable)?

- What do the voices say (e.g., positive remarks, negative remarks, threats)? If the remarks are commands, determine if they are for harmless versus harmful acts; ask for examples.

- How do you cope with (or respond to) the voices?

- Have you ever done what the voices ask you to do? What led you to obey the voices? If you tried to resist them, what made it difficult?

- Have there been times when the voices told you to hurt or kill yourself? How often? What happened?

- Are you worried about having a serious illness or that your body is rotting?

- Are you concerned about your financial situation even when others tell you there is nothing to worry about?

- Are there things that you have been feeling guilty about or blaming yourself for?

Potential to Harm Others

- Are there others who you think may be responsible for what you are experiencing (e.g., persecutory ideas, passivity experiences)? Are you having any thoughts of harming them?

- Are there other people you would want to die with you?

- Are there others who you think would be unable to go on without you?

When assessing for suicide, it is important to be cautious of misleading information or false improvement [59,60]. When an agitated patient suddenly appears calm, he or she may have made the decision to attempt suicide and feels calm after making the decision. Denial is another important consideration. Patients may deny harboring very serious intentions of killing themselves.

All patients at acute risk for suicide who are under the influence (intoxicated by drugs or alcohol) should be evaluated in an urgent care setting and be kept under observation until they are sober. If the patient is intoxicated when the initial assessment is completed, it should be repeated after he or she is sober [79].

Lethal Means

All persons at risk for suicide should be assessed for availability or intent to acquire lethal means, including firearms and ammunition, drugs, poisons, and other means in the patient's home [79].

Clinicians should always inquire about access to firearms and ammunition and how they are stored. For military members and veterans, this includes assessing privately owned firearms. In addition, medication reconciliation should be performed for all patients. For any current and/or proposed medications, consider the risk/benefit of any medications that could be used as a lethal agent to facilitate suicide. Consider prescribing limited supplies for those at elevated risk for suicide or with histories of overdose or the availability of a caregiver to oversee the administration of the medications. In addition to medications, the availability of chemical poisons, especially agricultural and household chemicals, should be assessed, as many of these are highly toxic [79].

DETERMINING LEVEL OF RISK AND APPROPRIATE ACTIONS

The formulation of the level of risk for suicide guides the most appropriate care environment in which to address the risk and provide safety and care needs. The first priority is safety. Patients assessed as having a clear intention of taking their lives will require higher levels of safety protection than those with less inclination toward dying. Patients who are at high risk for suicide may require inpatient care to provide for increased level of supervision and higher intensity of care. Those at intermediate and low acute risk may be referred to an outpatient care setting and, with appropriate supports and safety plans, may be able to be followed-up in the community (Table 2) [79].

Table 2: DETERMINE LEVEL OF RISK FOR SUICIDE AND APPROPRIATE ACTION

Risk of Suicide Attempt

Indicators of Suicide Risk

Contributing Factorsa

Initial Action Based on Level of Risk

High acute risk

Persistent suicidal ideation or thoughts

Strong intention to act or plan

Not able to control impulse

Recent suicide attempt or preparatory behaviorb

Acute state of mental disorder or acute psychiatric symptoms

Acute precipitating event(s)

Inadequate protective factors

Maintain direct observational control of the patient

Limit access to lethal means

Immediate transfer with escort to urgent/emergency care setting for hospitalization

Intermediate acute risk

Current suicidal ideation or thoughts

No intention to act

Able to control the impulse

No recent attempt or preparatory behavior or rehearsal of act

Existence of warning signs or risk factorsb and limited protective factors

Refer to behavioral health provider for complete evaluation and interventions

Contact behavioral health provider to determine acuity of referral

Limit access to lethal means

Low acute risk

Recent suicidal ideation or thoughts

No intention to act or plan

Able to control the impulse

No planning or rehearsing a suicide act

No previous attempt

Existence of protective factors and limited risk factors

Consider consultation with behavioral health to determine need for referral and treatment

Treat presenting problems

Address safety issues

Document care and rationale for action

aModifiers that increase the level of risk for suicide of any defined level include acute state of substance use, access to means (e.g., firearms, medications), and existence of multiple risk factors or warning signs or lack of protective factors.

bEvidence of suicidal behavior warning signs in the context of denial of ideation should call for concern (e.g., contemplation of plan with denial of thoughts or ideation).

Source: U.S. Department of Veterans Affairs. VA/DoD Clinical Practice Guideline for Assessment and Management of Patients at Risk for Suicide. Available at http://www.healthquality.va.gov/guidelines/MH/srb.

Risk Assessment Tools

Rating scales can be helpful in the assessment process. However, a clinical assessment by a trained professional is required to assess suicide risk. This professional should have the skills to engage patients in crisis and to elicit candid disclosures of suicide risk in a non-threatening environment. The assessment should comprise a physical and psychiatric examination, including a comprehensive history (with information from patient, parents, and significant others whenever possible) to obtain information about acute psychosocial stressors, psychiatric diagnoses, current mental status, and circumstances of prior suicide attempts. Assessment tools may be used to evaluate risk factors, in addition to the clinical interview, although there is insufficient evidence to recommend one tool over another.

High Acute Risk

Considering all the information gathered in the assessment, the clinician will formulate the level of risk in one of the following categories: high acute risk, intermediate acute risk, low acute risk, not at elevated risk [79].

High acute risk patients include those with warning signs, serious thoughts of suicide, a plan and/or intent to engage in lethal self-directed violence, a recent suicide attempt, and/or those with prominent agitation, impulsivity, and/or psychosis. In such cases, clinicians should ensure constant observation and monitoring before arranging for immediate transfer for psychiatric evaluation or hospitalization [79]. Patients at high acute risk should be immediately referred for a specialty evaluation with particular concern for ensuring the patient's safety and consideration for hospitalization.

Intermediate Acute Risk

Intermediate acute risk patients include those with suicidal ideation and a plan but with no intent or preparatory behavior. Combination of warning signs and risk factors to include history of self-directed violence (suicide attempt) increases a person's risk for suicide. Patients at intermediate risk should be evaluated by a behavioral health provider. The decision whether to urgently refer a patient to a mental health professional or emergency department depends on that patient's presentation. The patient who is referred may be hospitalized if further evaluation reveals that the level of illness or other clinical findings warrant it. The patient may be managed in outpatient care if patient and provider collectively determine that the individual is capable of maintaining safety by utilizing non-injurious coping methods and utilize a safety plan [79].

Low Acute Risk

Low acute risk patients include those with recent suicidal ideation who have no specific plans or intent to engage in lethal self-directed violence and have no history of active suicidal behavior. Consider consultation with behavioral health to determine need for referral to treatment addressing symptoms and safety issues. These patients should be followed up for reassessment. Patients at low acute risk should be considered for consultation with or referral to a behavioral health practitioner [79].

Not at Elevated Acute Risk or Risk Unknown

Persons with a mental disorder who are managed appropriately according to evidence-based guidelines and do not report suicidal thoughts are outside the scope of the classification of risk for suicide. Patients who at some point in the past have reported thoughts about death or suicide but currently do not have any of these symptoms are not considered to be at acute risk of suicide. There is no indication to consult with behavioral health specialty in these cases, and the patients should be followed in routine care, continue to receive treatment for their disorder, and be re-evaluated periodically for thoughts and ideation. Patients at no elevated acute risk should be followed in routine care with treatment of their underlying condition and evaluated periodically for ideation or suicidal thoughts. Patients for whom the risk remains undetermined (i.e., no collaboration of the patient or provider concerns about the patients despite denial of risk) should be evaluated by a behavioral health practitioner [79].

DOCUMENTATION

In order to ensure optimal patient care and to prevent miscommunication and litigation, the results of any suicide risk assessment should be fully documented. At a minimum, documentation should include the following points, noted by the mnemonic SUICIDE [17]:

- Suicide assessment: The results of suicide screening or assessment, including any relevant history (personal or family), access to lethal means, suicide plans, recent history of stressful events, and protective factors, should be noted.

- Unpredictable: Family members and/or other supportive third parties should be alerted that suicide can be unpreventable, even given the best efforts and plans.

- Interventions: All interventions planned and undertaken should be included in the patient's record.

- Clear and comprehensive: It is important to ensure that all documentation is clear and comprehensive, with specific notes regarding the patient's own words.

- Intent: The intentions of any suicide attempt(s) or intentional self-harm should be noted.

- Discussions with family members and/or other supportive third parties: Supportive third parties can be invaluable to the treatment process, and their inclusion in risk assessments and treatment planning should be documented.

- Educate, engage, empathize: Documentation should include notes regarding the patient's involvement in treatment planning and the creation of a safety plan.

Patient B arrives at the office with her daughter. She appears withdrawn and preoccupied, having a look of resignation and despair. Seated together, you begin the interview in a positive, affirming manner: "I'm pleased that all your laboratory work, including your thyroid tests, is normal. You know you told me you would be okay, and I believe if we work together, so as to know and understand better what you are going through, we can relieve many of your symptoms and get you to a much better place." She is receptive, and after further discussions, the following picture emerges: Patient B has been unhappy for "a very long time." There is little to add to the somatic complaints related on the first visit. She sleeps poorly and is tired all the time; she has lost interest in what was previously an active social life and rarely "goes out." There is a good deal of psychic stress and pain attached to the relationship with her husband, and a sense of hopelessness has been building for months. In recent days, she has not slept and has periods of confusion. She wishes not to be a burden to those closest to her and has thought often of ending her life. Recently she has been thinking about just how to do this, the options available to her, and how it might be done so as to mask her intent. At the conclusion of the interview, you glance at the nurse with an expression of appreciation, and shudder to think how easily you might have missed all this.

- Recall the mnemonic device IS PATH WARM. How many of the elements are positive for Patient B? Which ones?

- Would you rate Patient B's suicide risk as low? Intermediate? High?

- Which of the following management options is the LEAST appropriate at this juncture?

- Send the patient home with a prescription for an antidepressant and a plan for regular return psychotherapy sessions in your office.

- Refer her to a psychiatrist (appointment in 48 to 72 hours) and negotiate a "contract" with the patient that she is not to take matters into her own hands but will call you immediately if she has thoughts of doing so.

- Arrange admission to the hospital medical service with a "sitter" and place an urgent psychiatry consultation.

- Call your psychiatry consultant to summarize the case and request immediate consultation or admission to the inpatient psychiatry service.

9. MANAGEMENT OF SUICIDAL PATIENTS

The opportunity for an emotionally disturbed patient with vague suicidal ideation to vent his or her thoughts and feelings to an understanding health or mental health provider may bring a degree of relief such that no further intervention is needed. However, in all cases the encouragement of further contact and follow-up should be conveyed to the patient, especially when inadequate social support is present. Independent of the actual catalyst, most suicidal persons possess feelings of helplessness, hopelessness, and despair and a triad of three cognitive/emotional conditions [59,60]:

- Ambivalence: Most suicidal patients are ambivalent, with alternating wishes to die and to live. The healthcare provider can use patient ambivalence to increase the wish to live, thus reducing suicide risk.

- Impulsivity: Suicide is usually an impulsive act, and impulse, by its nature, is transient. A suicide crisis can be defused if support is provided at the moment of impulse.

- Rigidity: Suicidal people experience constricted thinking, mood, and action and dichotomized black-and-white reasoning to their problems. The provider can help the patient understand alternative options to death through gentle reasoning.

Healthcare professionals should assess the strength and availability of emotional support to the patient, help the patient identify a relative, friend, acquaintance, or other person who can provide emotional support, and solicit the person's help [59,60]. The engagement of supportive third parties in the patient's life can be a useful tool in preventing suicide completion.

Adherence to established best practices general assures that assessment and care will be ethical and legal. It is important to consider and document informed consent. Underlying key ethical principles include respect for persons, autonomy, and beneficence [121].

PHARMACOTHERAPY TO REDUCE SUICIDE RISK

Abundant evidence has demonstrated that lithium reduces the rate of suicidal behavior in patients with bipolar disorder and recurrent major depression and that clozapine reduces suicidal behavior in schizophrenia [97,98,99,100,101,102]. Both drugs reduce suicide risk independently of their effect on the primary psychiatric disorder. Although the exact anti-suicide mechanism of both drugs has yet to be identified, lithium enhances serotonergic activity and clozapine is a potent 5-HT2A antagonist. Serotonergic modulation is a likely explanation of the suicide-reducing effects of both medications, because aggression levels and suicide are correlated with prefrontal cortical 5-HT2A binding [71,104,105].

PSYCHOTHERAPY TO REDUCE SUICIDE RISK

In addition to pharmacotherapy, various psychotherapy approaches have been shown to decrease suicide risk in patients at low or intermediate risk for suicide [55]. Post-admission cognitive therapy is a cognitive-behavioral therapy approach designed to help patients who have suicide-related thoughts and/or behaviors. It consists of three phases of therapy for outpatients or inpatients [55]:

- The patient is asked to tell a story associated with her or his most recent episode of suicidal thoughts, behavior, or both.

- The patient is assisted with modifying underdeveloped or overdeveloped skills that are most closely associated with the risk of triggering a suicidal crisis.

- The patient is guided through a relapse-prevention task.

Another cognitive-behavioral approach is cognitive-behavioral psychotherapy for suicide prevention, which involves "acute and continuation phases, each lasting about 12 sessions, and includes a chain analysis of the suicidal event, safety plan development, skill building, psychoeducation, family intervention, and relapse prevention" [53].

Dialectical behavior therapy was originally designed to address the self-harm impulses of patients with borderline personality disorder, but it has good evidence for use in most suicidal individuals. Dialectical behavioral therapy is an adaptation of cognitive-behavioral therapy and is based on the theoretical principle that maladaptive behaviors, including self-injury, are attempts to manage intense overwhelming affect of biosocial origin. It consists of the two key elements of a behavioral, problem-solving approach blended with acceptance-based strategies and an emphasis on dialectical processes. Dialectical behavioral therapy emphasizes balancing behavioral change, problem-solving, and emotional regulation with validation, mindfulness, and acceptance of patients. Therapeutic targets are ranked in hierarchical order, with life-threatening behaviors addressed first, followed by therapy-interfering behaviors, and then behaviors that interfere with quality of life.

MENTAL HEALTH REFERRAL

Depending on the level of suicide risk, referral to a mental health professional (e.g., psychologist, counselor, therapist), psychiatrist, or hospitalization may be warranted. Long-term treatment and follow-up will be required for many patients, and appropriate referral to outpatient facilities is often necessary. If the person is currently in therapy, the therapist should be called and involved in the management decision. If the patient does not have a therapeutic relationship with a mental health professional, referral to one should be made. Suicidal patients should be referred to a psychiatrist when any of the following are present: psychiatric illness; previous suicide attempt; family history of suicide, alcoholism, and/or psychiatric disorder; physical illness; or absence of social support [59,60]. After deciding to refer a patient to a mental health professional, the clinician should explain to the patient the reason for the referral and help alleviate patient anxiety over stigma and psychotropic medications. It is also important to help the patient understand that pharmacologic and psychologic therapies are both effective and to emphasize to the patient that referral does not mean "abandonment." The referring clinician should also arrange an appointment with the mental health professional, allocate time for the patient following the initial appointment with the therapist or psychiatrist, and ensure the ongoing relationship with the patient [59,60].

REFERRAL TO BE HOSPITALIZED

Evidence Based Practice Recommendation

The Department of Veterans Affairs recommends choosing the appropriate care setting that provides the patient at risk of suicide maximal safety in the least restrictive environment. Despite insufficient evidence to demonstrate the effectiveness of acute hospitalization in the prevention of suicide, hospitalization is indicated in suicidal patients who cannot be maintained in less restrictive care settings.

https://www.healthquality.va.gov/guidelines/MH/srb

Last Accessed: March 24, 2023

Level of Evidence: Expert Opinion/Consensus Statement

Some indications for immediate hospitalization include recurrent suicidal thoughts, high levels of intent of dying in the immediate future (the next few hours or days), the presence of agitation or panic, or the existence of a plan to use a violent and immediate suicide method [59,60]. When hospitalizing a patient, she or he should not be left alone; the hospitalization and transfer of the patient by ambulance or police should be arranged and the family, and any appropriate authorities should be informed [59,60].

A patient may be discharged to a less restrictive level of care from an acute setting (emergency department/hospital/acute specialty care) after a behavioral health clinician evaluated the patient, or a behavioral health clinician was consulted, and all three of the following conditions have been met [79]:

- Clinician assessment indicates that the patient has no current suicidal intent.

- The patient's active psychiatric symptoms are assessed to be stable enough to allow for reduction of level of care.

- The patient has the capacity and willingness to follow the personalized safety plan (including having available support system resources).

ADDITIONAL OPTIONS FOR CONTINUITY OF CARE

It is important to ensure that the patient has follow-up contact even after discharge to another provider. At the point of discharge, information should be provided on crisis options (referred to as "crisis cards") and free, universally available help, such as hotlines. There is evidence that follow-up outreach in the form of letters or postcards expressing care and concern and continuing for up to three years may be helpful in suicide prevention [75]. These letters should generally be non-demanding, allowing the opportunity but not the requirement for patients to respond.

Alternatively, patients may be followed-up with phone calls from a mental health professional or suicide crisis volunteer [75]. If phone follow-up is preferred, calls should be made weekly or biweekly, in some cases supplemented with a home visit, and should continue for a period of three to six months.

In many cases, partnering with a community crisis center can be helpful [66]. Crisis call centers are a crucial resource in linking patients to services and providing emotional support. According to the Suicide Prevention Lifeline, crisis center follow-up before a service appointment is associated with improved motivation, a reduction in barriers to accessing services, improved adherence to medication, reduced symptoms of depression, and higher attendance rates [64].

SAFETY PLANNING

The VA recommends establishing an individualized safety plan for all persons who are at high acute risk for suicide as part of discharge planning, regardless of inpatient or outpatient status [79]. The safety plan is designed to empower the patient, manage the suicidal crisis, and engage other resources. Safety should also be discussed with patients at intermediate and low risk, with appropriate patient education and a copy of a safety plan handout [79].

Stressful events, challenging life situations, mental/substance use disorders, and other factors can precipitate a crisis of suicidal thoughts and behaviors leading directly to self-injury. Advance anticipation of challenging situations and envisioning how one can identify and break a cycle of suicidal crises can reduce risk of self-injury and enhance a patient's sense of self-efficacy. Open dialogue between patients and clinicians to establish a therapeutic alliance and develop strategies and skills supporting the patient's ability to avoid acting on thoughts of suicide (including minimizing access to lethal means) is an essential component of suicide prevention in clinical settings. Putting this thinking-through process in writing for the anticipation of a suicidal crisis and how to manage it constitutes a patient's safety (action) plan [79].

Safety planning is a provider-patient collaborative process—not a "no harm" contract. The safety planning process results in a written plan that assists the patient with restricting access to means for completing suicide, problem-solving and coping strategies, enhancing social supports and identifying a network of emergency contacts including family members and friends, and ways to enhance motivation. These plans are tailored to the patient by assisting with identifying his or her specific warning signs and past effective coping strategies [79].

The safety plan should include the following elements, as appropriate:

- Early identification of warning signs or stressors

- Enhancing coping strategies (e.g., to distract and support)

- Utilizing social support contacts (discuss with whom to share the plan)

- Contact information about access to professional help

- Minimizing access to lethal means (e.g., weapons and ammunition or large quantities of medication)

The safety plan should be reviewed and updated by the healthcare team working with the patient as needed and shared with family and other supportive third parties if the patient consents. Safety plans should be updated to remain relevant during changes in clinical state and transitions of care [79].

Providers should document the safety plan or reasons for not completing such a plan in the medical record. In addition, patients should receive a copy of the plan [79].

Limiting Access to Lethal Means

Restricting at-risk patients from access to lethal means is considered an essential part of suicide prevention and safety planning. Methods of ensuring persons with suicidal intent do not have access to lethal means include restriction of access to firearms and ammunition, safer prescribing and dispensing of medications to prevent intentional overdoses, and modifying the environment of care in clinical settings to prevent fatal hangings [79]. For military service members, concerns about firearms should include privately owned guns and ammunition. It is also important to educate caregivers, family members, and/or other supportive third parties regarding the potential dangers of lethal means and how to keep these items or substances from the patient.

Storing firearms away from suicidal individuals can reduce gun deaths [79]. It must be stressed that the firearms are still the property of the individual, and they are not "giving them away." Options for safe storage of firearms include removing ammunition from an individual's possession, asking a friend or relative to take possession of firearms, disassembling firearms and storing various parts in different locations, storing firearms at a storage unit or gun locker at a shooting range, storing firearms at a gun shop or pawn shop, asking law enforcement to take possession of firearms, or storing personal firearms at military unit arms rooms [79]. The least restrictive and most acceptable means of removing easy accesses to lethal means should be employed in order to assure an individual welcomes the intervention. It is important to avoid implying that an individual is incapable of firearm possession or that they are unfit in a legal sense.

CONSIDERATIONS FOR VETERANS

With military service members, the command element should also be involved in education, safety planning, treatment planning, and implementation of duty limitations. Additional areas to address are the patient's medical and other specific needs. These may be psychosocial, socioeconomic, or spiritual in nature [79].

The VA/DoD has made the following recommendations when creating a treatment plan for veterans and active service members [79]:

- Providers should take reasonable steps to limit the disclosure of protected health information to the minimum necessary to accomplish the intended purpose.

- Providers should involve command in the treatment plan of service members at high acute risk for suicide to assist in the recovery and the reintegration of the patient to the unit. For service members at other risk levels, the provider should evaluate the risk and benefit of involving command and follow service department policies, procedures, and local regulations.

- When performing a medical profile, the provider should discuss with command the medical recommendation and the impact on the service member's limitations to duty and fitness for continued service.

- Providers should discuss with service members the benefit of having command involved in their plan and assure them their rights to protected health information, with some exceptions, regarding to the risk for suicide.

- As required by pertinent military regulations, communicate to the service member's chain of command regarding suicidal ideation along with any recommended restrictions to duty, health and welfare inspection, security clearance, deployment, and firearms access. Consider redeployment to home station any service member deployed to a hazardous or isolated area.

- Service members at high acute risk for suicide who meet criteria for hospitalization and require continuous (24-hour) direct supervision should be hospitalized in almost all instances. If not, the rationale should specifically state why this was not the preferred action, with appropriate documentation.

- During operational deployment conditions or other extreme situations during which hospitalization or evacuation is not possible, "unit watch" may be considered as appropriate in lieu of a high level care setting (hospitalization), and service department policies, procedures, and local regulations should be followed.

- Because of the high risk of suicide during the period of transition, providers should pay particular attention to ensure follow-up, referral, and continuity of care during the transition of service members at risk for suicide to a new duty station or after separation from a unit or from military service.

CONSIDERATIONS FOR HEALTHCARE PROFESSIONALS

Although confidentiality is crucial when caring for any patient, this is heightened for healthcare providers who would potentially be seeking assessment and treatment in their workplace. All healthcare providers should be offered the opportunity for anonymous screening for depression and suicide. The healer education assessment and referral (HEAR) screening program is a sustainable suicide prevention program that uses an anonymous method to provide screening for untreated depression or suicide [119,121]. The American Foundation for Suicide Prevention also provides services specifically for healthcare providers, accessible at https://afsp.org/suicide-prevention-for-healthcare-professionals.

10. SUICIDE PREVENTION

Understanding the interactive relationship between risk and protective factors in suicidal behavior and how this interaction can be modified forms the basis of suicide prevention [5,106]. The characteristics shared by effective suicide prevention programs include clear identification of the intended population, definition of desired outcomes, use of interventions known to effect a particular outcome, and use of community coordination and organization to achieve an objective. Prevention efforts are based on a clear plan with goals, objectives, and implementation steps [5,45].

HISTORY OF SUICIDE PREVENTION IN THE UNITED STATES

In the United States, large-scale suicide prevention efforts began in 1958. Funding from the U.S. Public Health Service established the first suicide prevention center in Los Angeles, and other crisis intervention centers replicating this model were opened across the country [5]. The risk factor approach to suicide prevention was first implemented in 1966, and the American Association of Suicidology and the American Foundation for Suicide Prevention were established over the next two decades. Their activities included increasing the scientific understanding of suicide as the basis for effective prevention activities [5]. In 1983, the CDC established a violence prevention division that alerted the public to the disturbing increase in youth suicide rates.

In 1996, survivors of suicide loss mobilized to form the Suicide Prevention Advocacy Network USA (SPAN USA) and launched a campaign to advocate for the development of a national suicide prevention strategy [107]. In 2009, SPAN USA merged with the American Foundation for Suicide Prevention to raise awareness, fund research, and provide resources and aid to those affected by suicide [48].

The National Strategy for Suicide Prevention (NSSP) was released by the Surgeon General of the United States in 2001 and updated in 2012. The NSSP describes a series of goals and objectives designed to reduce the incidence of suicide behaviors in the United States [46]. Although activity in the field of suicide prevention has increased exponentially since publication of the NSSP, the overall rate of suicide since 2000 continues to increase [1].

SUICIDE PREVENTION THAT TARGETS AT-RISK POPULATIONS

College Students

Colleges and universities are increasingly challenged to identify and manage mental health and substance use problems in students. Because the risk and protective factors for suicide among young adults include substance abuse and interpersonal violence, suicide prevention may best be integrated within broader prevention efforts [5,108,109].

Inmates in Jails and Correctional Settings

As discussed, jails and juvenile justice facilities have exceptionally high suicide rates. The highest rates of jail suicide occur within the first 24 to 48 hours of arrest, suggesting an important role of medical assessment of substance abuse and suicide proneness at intake. Comprehensive prevention programs targeting inmate suicide include training, screening, effective communication methods, intervention, use of reporting protocols, and mortality review [5,110].

Elderly Persons

Almost 70% of elderly patients who take their own lives see their primary care physician within a few months of their death [111,112]. This represents an absolutely vital, yet narrow, window for accurate screening and assessment of suicide risk [2]. Unfortunately, healthcare and mental health professionals are not immune from harboring the stereotypes of the elderly often found among society in general. These can include attitudes that a depressive response to interpersonal loss, physical limitation, or changing societal role is an inevitable and even normal aspect of aging [111,113,114]. Suicidal thoughts may even be considered age-appropriate in the elderly [112]. When held by patients and family members, these erroneous beliefs can lead to under-reporting of symptoms and lack of effort on the part of family members to seek care for patients [114]. When held by clinicians, these beliefs can result in delayed or missed diagnoses, less effective treatment, or suicide in the elderly patient.

Because the elderly have the highest overall suicide rate of all age groups, organizations with special access to older persons have an important role in suicide prevention. State aging networks exist in every state, and these networks develop and fund a variety of in-home and community-based services. States organize the provision of such services through area agencies on aging, which coordinate a broad range of services for older people [5].

Patients with Bipolar Disorder

Although 20% of patients with bipolar disorder have their first episode during adolescence, diagnosis is often delayed for years, which can result in problems such as substance abuse and suicidal behaviors. Thus, early recognition and aggressive treatment may prevent years of needless suffering and death by suicide. In particular, lithium is effective in preventing suicidal behavior in patients with bipolar disorder. Maintaining treatment is essential in preventing suicide, and the suicide rate in the first year of discontinuation of lithium treatment is 20 times higher than during lithium treatment [103].

Patients with Schizophrenia

Approximately 0.9% of people in the United States are living with schizophrenia or a related disorder [49]. One study of patients with schizophrenia showed a lifetime prevalence of suicide attempt of 39.2%, versus 2.8% of nonafflicted individuals; furthermore, about 5% of patients with schizophrenia will eventually die by suicide [50,90]. Depression is the most important risk factor for suicide in patients with schizophrenia; only 4% of patients with schizophrenia who exhibit suicidal behavior do so in response to instructions from "command" voices. Clozapine is effective in reducing suicide and attempted suicide in patients with schizophrenia, and effective suicide prevention involves the early recognition and prompt treatment of schizophrenia and all comorbid conditions [2].

Military Veterans

Assessment of suicide risk and protective factors in military personnel is vital, particularly at times of transition (e.g., deployment, separation from service/unit). It is important to include life planning, referral information, and resources for patients who experience suicidal ideation, and there are military-specific resources available for current or former members of the military. The Veterans Crisis Line, https://www.veteranscrisisline.net or 988, is free to all active service members, including members of the National Guard and Reserve, and veterans, even if they are not registered with the VA or enrolled in VA health care [81].

STIGMA AND SUICIDE

The stigma of mental illness and substance abuse, both of which are closely linked to suicide, prevents many persons from seeking help out of a fear of prejudice and discrimination [88]. People who have a substance use disorder face additional stigma because many people believe that abuse and addiction are moral failings and that individuals are fully capable of controlling these behaviors if they want to [5,80]. The stigma of suicide, while deterring some from attempting suicide, is also a barrier to treatment for many persons who have suicidal thoughts or have attempted suicide. Family members of suicide attempters often hide the behavior from friends and relatives, because they may believe that it reflects badly on their own relationship with the suicide attempter or that suicidal behavior itself is shameful or sinful. Persons who attempt suicide may have many of these same feelings [5].

On a systems level, the stigma surrounding mental illness, substance use disorders, and suicide has contributed to inadequate funding for preventive services and inadequate insurance reimbursement for treatments. Substance use and mental health conditions, including those associated with suicide, will remain undertreated and services tailored to persons in crisis will remain limited as long as stigma persists, resulting in an unnecessarily high rate of suicidal behavior and suicide [5]. Additionally, the stigma associated with mental illness and substance abuse has led to separate systems for physical health and mental health care, a consequence being that preventive and treatment services for mental illness and substance abuse are much less available than for other health problems. This separation has also led to bureaucratic and institutional barriers between the two systems that impede and complicate access to care and service implementation [5].

11. SUICIDE SURVIVORS: TREATMENT AND RESOURCES

Family members and friends affected by the death of a loved one through suicide are referred to as "suicide survivors." Conservative estimates suggesting a ratio of six survivors for every suicide deaths indicate that an estimated 6 million Americans became suicide survivors in the past 25 years; however, as noted, many more individuals are affected by a single suicide [4,13,14].

The death of a loved one by suicide can be shocking, painful, and unexpected for survivors. The ensuing grief can be intense, complex, chronic, and nonlinear. Working through grief is a highly individual and unique process that survivors experience in their own way and at their own pace. Grief does not always move in a forward direction, and there is no timeframe for grief. Survivors should not expect their lives to return to their previous state and should strive to adjust to life without their loved one. The initial emotional response may be overwhelming, and crying is a natural reaction and an expression of sadness following the loss of a loved one [13].

Survivors often struggle with trying to comprehend why the suicide occurred and how they could have intervened. Feelings of guilt are likely when the survivor believes he or she could have prevented the suicide. The survivor may even experience relief at times, especially if the loved one had a psychiatric illness. The stigma and shame that surround suicide may cause difficulty among the family members and friends of survivors in knowing what to say and how to support the survivor and might prevent the survivor from reaching out for help. Ongoing support remains important to maintain family and other relationships during the grieving process [13].

Many survivors find that the best help comes from attending a support group for survivors of suicide in which they can openly share their own story and their feelings with fellow survivors without pressure or fear of judgment and shame. Support groups can be a helpful source of guidance, understanding, and support through the healing process [13]. The American Foundation for Suicide Prevention maintains an international directory of suicide bereavement support groups on their website, https://afsp.org.

12. CONCLUSION

Suicide is a major preventable public health problem and a significant cause of mortality. This course has reviewed the major aspects of suicide assessment, management, and prevention, with a special focus on military veterans. Primary care contact may represent the last opportunity for intervention in the severely depressed suicidal patient, making the thorough comprehension of identification and treatment of depression and suicide risk imperative.

Works Cited

1. Xu J, Murphy SL, Kochanek KD, Arias E. Deaths: final data for 2019.Natl Vital Stat Rep. 2021;70(8):1-86.

2. American Foundation for Suicide Prevention. Suicide Statistics. Available athttps://afsp.org/suicide-statistics. Last accessed March 21, 2023.

3. National Alliance on Mental Illness. Risk of Suicide. Available athttps://www.nami.org/About-Mental-Illness/Common-with-Mental-Illness/Risk-of-Suicide. Last accessed March 21, 2023.

4. Cerel J, Maple M, van de Venne J, et al. Exposure to suicide in the community: prevalence and correlates in one U.S. state.Public Health Rep. 2016;131(1):100-107.

5. U.S. Department of Health and Human Services, Office of the Surgeon General, and National Action Alliance for Suicide Prevention.2012 National Strategy for Suicide Prevention: Goals and Objectives for Action. Washington, DC: U.S. Department of Health and Human Services; 2012.

6. Centers for Disease control and Prevention. Depression Evaluation Measures. Available athttps://www.cdc.gov/workplacehealthpromotion/health-strategies/depression/evaluation-measures/index.html. Last accessed March 21, 2023.

7. Randall JR, Walld R, Finlayson G, Sareen J, Martens PJ, Bolton JM. Acute risk of suicide and suicide attempts associated with recent diagnosis of mental disorders: a population-based, propensity score-matched analysis.Can J Psychiatry. 2014;59(10): 531-538.

8. World Health Organization. Suicide. Available athttps://www.who.int/news-room/fact-sheets/detail/suicide. Last accessed March 21, 2023.

9. Värnik P. Suicide in the world.Int J Environ Res Public Health. 2012;9(3):760-771.

10. Xu JQ, Kochanek KD, Murphy SL, Tejada-Vera B. Deaths: final data for 2007.Natl Vital Stat Rep. 2010;58(19):1-135.

11. Hedegaard H, Curtin SC, Warner M. Increase in suicide mortality in the United States, 1999–2018.NCHS Data Brief. 2020;362:1-7.

12. Hoyert DL, Xu J. Deaths: preliminary data for 2011.Nat Vital Stat Rep. 2012;61(6):1-52.

13. American Association of Suicidology. Facts and Statistics. Available athttps://suicidology.org/facts-and-statistics. Last accessed March 21, 2023.

14. Cerel J, Brown MM, Maple M, et al. How many people are exposed to suicide? Not six.Suicide Life Threat Behav. 2019;49:529-534.

15. Centers for Disease Control and Prevention. Facts About Suicide. Available athttps://www.cdc.gov/suicide/facts/index.html. Last accessed March 21, 2023.

16. American College Health Association.American College Health Association-National College Health Assessment II: Reference Group Executive Summary Fall 2011. Hanover, MD: American College Health Association; 2012.

17. Francois D, Madva EN, Goodman H. How to document SUICIDE risk.Current Psychiatry. 2014;13(10):33-34.

18. Stone G.Suicide and Attempted Suicide. New York, NY: Carroll & Graf; 2001.

19. Clark DC, Horton-Deutsch SL. Assessment in absentia: the value of the psychological autopsy method for studying antecedents of suicide and predicting future suicides. In: Maris RW, Berman AL, Maltsberger JT, Yufit RI (eds).Assessment and Prediction of Suicide. New York, NY: Guilford Press; 1992: 144-182.

20. Hawton K, Saunders KE, O'Connor RC. Self-harm and suicide in adolescents.Lancet. 2012;379(9834):2373-2382.

21. Bebbington PE, Minot S, Cooper C, et al. Suicidal ideation, self-harm and attempted suicide: results from the British psychiatric morbidity survey 2000.Eur Psychiatry. 2010;25(7):427-431.

22. Schmidtke A, Schaller S. The role of mass media in suicide prevention. In: Hawton K, van Heeringen K (eds).The International Handbook of Suicide and Attempted Suicide. New York, NY: Wiley; 2000: 675-697.

23. Velting DM, Gould MS. Suicide contagion. In: Maris RW, Silverman MM, Canetto SS (eds).Review of Suicidology. New York, NY: Guilford Press; 1997: 96-136.

24. Zenere EFJ. Suicide clusters and contagion.Principal Leadership. 2009;10(2):12-16.

25. National Institute of Mental Health. Crisis and Suicide Prevention Services Struggle with Demand after Celebrity Suicides. Available athttps://www.nimh.nih.gov/news/science-news/2019/crisis-and-suicide-prevention-services-struggle-with-demand-after-celebrity-suicides.shtml. Last accessed March 21, 2023.

26. van Heeringen K, Mann JJ. The neurobiology of suicide.Lancet Psychiatry. 2014;1(1):63-72.

27. Mann JJ, Currier DM. Stress, genetics and epigenetic effects on the neurobiology of suicidal behavior and depression.Eur Psychiatry. 2010;25(5):268-271.

28. Costanza A, D'Orta I, Perroud N, et al. Neurobiology of suicide: do biomarkers exist?Int J Legal Med. 2014;128(1):73-82.

29. Fiori LM, Ernst C, Turecki G. Genetic and neurobiological approaches to understanding suicidal behaviors. In: Nock M (ed).The Oxford Handbook of Suicide and Self-Injury. Oxford: Oxford University Press; 2014: 155-182.

30. Joiner TE Jr, Brown JS, Wingate LR. The psychology and neurobiology of suicidal behavior.Annu Rev Psychol. 2005;56:287-314.

31. Ernst C, Mechawar N, Turecki G. Suicide neurobiology.Prog Neurobiol. 2009;89(4):315-333.

32. Centers for Disease Control and Prevention. Ten Leading Causes of Death and Injury. Available athttps://www.cdc.gov/injury/wisqars/leadingcauses.html. Last accessed March 21, 2023.

33. Liu CH, Stevens C, Wong SHM, Yasui M, Chen JA. The prevalence and predictors of mental health diagnoses and suicide among U.S. college students: implications for addressing disparities in service use.Depress Anxiety. 2019;36(1):8-17.

34. Wilcox HC, Arria AM, Caldeira KM, et al. Prevalence and predictors of persistent suicide ideation, plans, and attempts during college.J Affect Disord. 2010;127(1-3):287-294.

35. Centers for Disease Control and Prevention. WONDER Databases. Available athttps://wonder.cdc.gov. Last accessed March 21, 2023.

36. Halvorsen JA, Stern RS, Dalgard F, Thoresen M, Bjertness E, Lien L. Suicidal ideation, mental health problems, and social impairment are increased in adolescents with acne: a population-based study.J Invest Dermatol. 2011;131(2):363-370.

37. National LGBT Health Education Center. Suicide Risk and Prevention for LGBTQ People. Available athttps://www.lgbthealtheducation.org/wp-content/uploads/2018/10/Suicide-Risk-and-Prevention-for-LGBTQ-Patients-Brief.pdf. Last accessed March 21, 2023.

38. National Center for Transgender Equality. The Report of the 2015 U.S. Transgender Survey. Available athttps://transequality.org/sites/default/files/docs/usts/USTS-Full-Report-Dec17.pdf. Last accessed March 21, 2023.

39. Hatzenbuehler ML. The social environment and suicide attempts in lesbian, gay, and bisexual youth.Pediatrics. 2011;127(5):896-903.

40. Haas AP, Eliason M, Mays VM, et al. Suicide and suicide risk in lesbian, gay, bisexual, and transgender populations: review and recommendations.J Homosex. 2011;58(1):10-51.

41. 41. Gates ML, Turney A, Ferguson E, Walker V, Staples-Horne M. Associations among substance use, mental health disorders, and self-harm in a prison population: examining group risk for suicide attempt.Int J Environ Res Public Health. 2017;14(3):317.

42. Mustanski B, Liu RT. A longitudinal study of predictors of suicide attempts among lesbian, gay, bisexual, and transgender youth.Arch Sex Behav. 2013;42(3):437-448.

43. Kann L, Olsen EO, McManus T, et al. Sexual identity, sex of sexual contacts, and health-related behaviors among students in grades 9–12—United States and selected sites, 2015.MMWR. 2016;65(9):1-202.

44. Fazel S, Ramesh T, Hawton K. Suicide in prisons: an international study of prevalence and contributory factors.Lancet Psychiatry. 2017;4(12):946-952.

45. American Psychiatric Association. New Research: Opiates May Be Playing an Increasing Role in Suicides, Even Outside of Overdoses. Available athttps://www.psychiatry.org/newsroom/news-releases/new-research-opiates-may-be-playing-an-increasing-role-in-suicides-even-outside-of-overdoses. Last accessed March 21, 2023.

46. National Action Alliance for Suicide Prevention.Transforming Health Systems Initiative Work Group. Recommended Standard Care for People with Suicide Risk: Making Health Care Suicide Safe. Washington, DC: Education Development Center, Inc.; 2018.

47. Grant JM, Mottet LA, Tanis J, Harrison J, Herman JL, Keisling M. Injustice at Every Turn: A Report of the National Transgender Discrimination Survey. Available athttps://www.transequality.org/sites/default/files/docs/resources/NTDS_Report.pdf. Last accessed March 21, 2023.

48. American Foundation for Suicide Prevention. Available athttps://afsp.org. Last accessed March 21, 2023.

49. Schizophrenia and Psychosis Action Alliance. About Schizophrenia. Available athttps://sczaction.org/about-schizophrenia/. Last accessed March 21, 2023.

50. Fuller-Thomson E, Hollister B. Schizophrenia and suicide attempts: findings from a representative community-based Canadian sample.Schizophr Res Treatment. 2016;2016:3165243.

51. Plemmons G, Hall M, Doupnik S, et al. Hospitalization for suicide ideation or attempt: 2008–2015.Pediatrics. 2018;141(6):1-12.

52. Sundararman R, Panangala SV, Loster SA. CRS Report for Congress: Suicide Prevention Among Veterans. Available athttps://www.fas.org/sgp/crs/misc/RL34471.pdf. Last accessed March 21, 2023.

53. Stanley B, Brown G, Brent DA, et al. Cognitive-behavioral therapy for suicide prevention (CBT-SP): treatment model, feasibility, and acceptability.J Am Acad Child Adolesc Psychiatry. 2009;48(10):1005-1013.

54. Cogan J. US Military Suicide Rates at Record High. Available athttps://www.wsws.org/en/articles/2009/02/suic-f04.html. Last accessed March 21, 2023.

55. Ghahramanlou-Holloway M, Neely LL, Tucker J. A cognitive-behavioral strategy for preventing suicide.Curr Psychiatr. 2014;13(8):18-25, 28.

56. Sher L. Suicide in war veterans: the role of comorbidity of PTSD and depression.Expert Rev Neurother. 2009;9:921-923.

57. McFarland BH, Kaplan MS, Huguet N. Datapoints: self-inflicted deaths among women with U.S. military service: a hidden epidemic?Psychiatr Serv. 2010;61(12):1177.

58. Rozanov V, Carli V. Suicide among war veterans.Int J Environ Res Public Health. 2012;9(7):2504-2519.

59. World Health Organization. Preventing Suicide: A Resource for General Physicians.https://apps.who.int/iris/handle/10665/67165. Last accessed March 20, 2023.

60. World Health Organization.Preventing Suicide: A Resource for Primary Health Care Workers. Geneva: World Health Organization Department of Mental Health; 2000.

61. Durkheim E.Suicide: A Study in Sociology. New York, NY: Free Press; 1951.

62. American Psychiatric Association.Practice Guideline for the Assessment and Treatment of Patients with Suicidal Behaviors. Washington, DC: American Psychiatric Association; 2010.

63. Gotlib IH, Hammen CL (eds).Handbook of Depression. 3rd ed. New York, NY: Guilford Press; 2015.

64. National Suicide Prevention Lifeline. Crisis Center Guidance: Follow-up with Callers and Those Discharged from Emergency Department and Inpatient Settings. Available athttps://suicidepreventionlifeline.org/wp-content/uploads/2016/09/Lifeline-Follow-Up-Guidance1214.pdf. Last accessed March 21, 2023.

65. Office of Applied Studies.The OAS Report: Suicidal Thoughts, Suicide Attempts, Major Depressive Episode and Substance Use Among Adults. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2006.

66. Suicide Prevention Resource Center. Continuity of Care for Suicide Prevention: The Role of Emergency Departments. Available athttps://dev.sprc.org/resources-programs/continuity-care-suicide-prevention-role-emergency-departments. Last accessed March 21, 2023.

67. Depression and Bipolar Support Alliance. Bipolar Disorder Statistics. Available athttps://www.dbsalliance.org/education/bipolar-disorder/bipolar-disorder-statistics. Last accessed March 21, 2023.

68. Goldsmith SK, Pellmar TC, Kleinman AM, Bunney WE (eds).Reducing Suicide: A National Imperative. Washington, DC: National Academy Press; 2002.

69. Substance Abuse and Mental Health Services Administration.Drug Abuse Warning Network, 2011: National Estimates of Drug-Related Emergency Department Visits. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2013.

70. Miranda J, Schoenbaum M, Sherbourne C, Duan N, Wells K. Effects of primary care depression treatment on minority patients' clinical status and employment.Arch Gen Psychiatry. 2004;61(8):827-834.

71. Mann JJ. Neurobiology of suicidal behavior.Nat Rev Neuroscienc. 2003;4(10):819-828.

72. World Health Organization. Preventing Suicide in Jails and Prisons. Available athttps://apps.who.int/iris/handle/10665/43678. Last accessed March 21, 2023.

73. Tremblay CH, Grosskopf S, Yang K. Brainstorm: occupational choice, bipolar illness and creativity.Econ Human Biol. 2010;8(2):233-241.

74. Liu A, Werner K, Roy S, et al. A case study of an emerging visual artist with frontotemporal lobar degeneration and amyotrophic lateral sclerosis.Neurocase. 2009;15(3):235-247.

75. Brown GK, Green KL. A review of evidence-based follow-up care for suicide prevention: where do we go from here?Am J Prev Med. 2014;47(3 Suppl 2):S209-S215.

76. Figueroa CG. Virginia Woolf as an example of a mental disorder and artistic creativity [article in Spanish].Rev Med Chil. 2005; 133(11):1381-1388.

77. Annenberg Public Policy Center. Holiday-Suicide Link: The Myth Persists. Available athttps://www.annenbergpublicpolicycenter.org/holiday-suicide-link-the-myth-persists. Last accessed March 21, 2023.

78. Centers for Disease Control and Prevention. Injury Prevention and Control: Data and Statistics. Available athttps://www.cdc.gov/injury/wisqars/index.html. Last accessed March 20, 2023.

79. U.S. Department of Veterans Affairs. VA/DoD Clinical Practice Guideline for Assessment and Management of Patients at Risk for Suicide. Available athttps://www.healthquality.va.gov/guidelines/MH/srb. Last accessed March 21, 2023.

80. Murphy GE.Suicide in Alcoholism. New York, NY: Oxford University Press; 1992.

81. Veterans Crisis Line. Available athttps://www.veteranscrisisline.net. Last accessed March 21, 2023.

82. Selby EA, Anestis MD, Bender TW, et al. Overcoming the fear of lethal injury: evaluating suicidal behavior in the military through the lens of the Interpersonal-Psychological Theory of Suicide.Clin Psychol Rev. 2010; 30(3):298-307.

83. Boscarino JA. Posttraumatic stress disorder and mortality among U.S. Army veterans 30 years after military service.Ann Epidemiol. 2006;16(4):248-256.

84. Association of Suicidology. Know the Warning Signs of Suicide. Available athttps://suicidology.org/wp-content/uploads/2019/07/Warning-Signs-Flyer.pdf. Last accessed March 21, 2023.

85. Favazza A. Self-mutilation. In: Jacobs DG (ed).The Harvard Medical School Guide to Suicide Assessment and Intervention. San Francisco, CA: Jossey-Bass; 1999: 125-145.

86. Evans J, Platts H, Liebenau A. Impulsiveness and deliberate self-harm: a comparison of "first-timers" and "repeaters."Acta Psychiatr Scand. 1996;93(5):378-380.

87. Stanford S, Jones MP. Psychological subtyping finds pathological, impulsive, and "normal" groups among adolescents who self-harm.J Child Psychol Psychiatry. 2009;50(7):807-815.

88. Najt P, Fusar-Poli P, Brambilla P. Co-occurring mental and substance abuse disorders: a review on the potential predictors and clinical outcomes.Psychiatry Res. 2011;186(2-3):159-164.

89. Gummin DD, Mowry JB, Spyker DA, et al. 2018 annual report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 36th annual report.Clin Toxicol (Phila). 2019;57(12):1220-1413.

90. National Institute of Mental Health. Schizophrenia. Available athttps://www.nimh.nih.gov/health/statistics/schizophrenia. Last accessed March 21, 2023.

91. Kleespies PM (ed).Emergencies in Mental Health Practice: Evaluation and Management. New York, NY: Guilford Press; 2000.

92. U.S. Preventive Services Task Force.Screening for Suicide Risk in Primary Care: A Systematic Evidence Review for the U.S. Preventive Services Task Force: Evidence Synthesis, No. 103. Rockville, MD: Agency for Healthcare Research and Quality; 2013.

93. Canadian Task Force on Preventive Health Care. Recommendations on screening for depression in adults.CMAJ. 2013;185(9):775-782.

94. American Academy of Pediatrics. Screening for Suicide Risk in Clinical Practice. Availible at https://www.aap.org/en/patient-care/blueprint-for-youth-suicide-prevention/strategies-for-clinical-settings-for-youth-suicide-prevention/screening-for-suicide-risk-in-clinical-practice. Last accessed March 21, 2023.

95. American Academy of Child and Adolescent Psychiatry. Practice parameter for the assessment and treatment of children and adolescents with suicidal behavior.J Am Acad Child Adolesc Psychiatry. 2001;40(7 suppl):24S-51S.

96. U.S. Preventive Services Task Force, Mangione CM, Barry MJ, et al. Screening for depression and suicide risk in children and adolescents: U.S Preventive Services Task Force recommendation statement.JAMA. 2022;328(15):1534-1542.

97. Lewitzka U, Severus E, Bauer R, Ritter P, Müller-Oerlinghausen B, Bauer M. The suicide prevention effect of lithium: more than 20 years of evidence-a narrative review.Int J Bipolar Disord. 2015;3(1):32.

98. Tondo L, Baldessarini RJ. Long-term lithium treatment in the prevention of suicidal behavior in bipolar disorder patients.Epidemiol Psychiatr Soc. 2009;18(3):179-183.

99. Asenjo Lobos C, Komossa K, Rummel-Kluge C, et al. Clozapine versus other atypical antipsychotics for schizophrenia.Cochrane Database Syst Rev. 2010;(11):CD006633.

100. Kasckow J, Felmet K, Zisook S. Managing suicide risk in patients with schizophrenia.CNS Drugs. 2011;25(2):129-143.

101. Riesselman A, Johnson E, Palmer E. Lithium and clozapine in suicidality: shedding some light to get out of the dark.Ment Health Clin. 2015;5(5):237-243.

102. Cipriani A, Hawton K, Stockton S, Geddes JR. Lithium in the prevention of suicide in mood disorders: updated systematic review and meta-analysis.BMJ. 2013;346:f3646.

103. Rihmer Z, Gonda X. The effect of pharmacotherapy on suicide rates in bipolar patients.CNS Neurosci Ther. 2012;18(3):238-242.

104. Underwood MD, Kassir SA, Bakalian MJ, Galfalvy H, Mann JJ, Arango V. Neuron density and serotonin receptor binding in prefrontal cortex in suicide.Int J Neuropsychopharmacol. 2012;15(4):435-447.

105. Oquendo MA, Russob SA, Underwood MD, et al. Higher postmortem prefrontal 5-HT2A receptor binding correlates with lifetime aggression in suicide.Biol Psychiatry. 2006;59(3):235-243.

106. Wasserman D, Wasserman C.Oxford Textbook of Suicidology and Suicide Prevention: A Global Perspective. Oxford: Oxford University Press; 2009.

107. Suicide Prevention Resource Center, SPAN USA.Charting the Future of Suicide Prevention: A 2010 Progress Review of the National Strategy and Recommendations for the Decade Ahead. Washington, DC: Education Development Center, Inc.; 2010.

108. Brent DA, Johnson BA, Perper J, et al. Personality disorder, personality traits, impulsive violence, and completed suicide in adolescents.J Am Acad Child Adolesc Psychiatry. 1994;33(8):1080-1086.

109. Hunt J, Eisenberg D. Mental health problems and help-seeking behavior among college students.J Adolesc Health. 2010;46(1):3-10.

110. Pompili M, Lester D, Innamorati M, et al. Preventing suicide in jails and prisons: suggestions from experience with psychiatric inpatients.J Forensic Sci. 2009;54(5):1155-1162.

111. Substance Abuse and Mental Health Services Administration.The Treatment of Depression in Older Adults: Depression and Older Adults: Key Issues. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, US Department of Health and Human Services; 2011.

112. Fischer LR, Wei F, Solberg LI, Rush WA, Heinrich RL. Treatment of elderly and other adult patients for depression in primary care.J Am Geriatr Soc. 2003;51(11):1554-1562.

113. Mitchell AJ, Rao S, Vaze A. Do primary care physicians have particular difficulty identifying late-life depression? A meta-analysis stratified by age.Psychother Psychosom. 2010;79(5):285-94.

114. Law J, Laidlaw K, Peck D. Is depression viewed as an inevitable consequence of age? The "understandability phenomenon" in older people.Clinical Gerontologist. 2010;33(3):194-209.

115. Tiesman H, Weissman D, Stone D, Quinlan K, Chosewood LC. Suicide Prevention for Healthcare Workers. Available athttps://blogs.cdc.gov/niosh-science-blog/2021/09/17/suicide-prevention-hcw. Last accessed March 21, 2023.

116. Dutheil F, Aubert C, Pereira B, Dambrun M, Moustafa F, Mermillod M, et al. Suicide among physicians and health-care workers: a systematic review and meta-analysis.PLoS ONE. 2019;14(12):e0226361.

117. Kelsey EA, West CP, Cipriano PF, et al. Original research: suicidal ideation and attitudes toward help seeking in U.S. nurses relative to the general working population.Am J Nurs. 2021;121(11):24-36.

118. Stamm BH, Figley CR. Advances in the theory of compassion satisfaction and fatigue and its measurement with the ProQOL 5. Presented at the International Society for Traumatic Stress Studies Annual Conference. Atlanta, GA; 2009.

119. Davidson JE, Zisook S, Kirby B, DeMichele G, Norcross W. Suicide prevention: a healer education and referral program for nurses.J Nurs Adm. 2018;48(2):85-92.

120. American Nurses Association. Nurse Suicide Prevention/Resilience. Available athttps://www.nursingworld.org/practice-policy/nurse-suicide-prevention. Last accessed March 21, 2023.

121. Bernert RA, Roberts LW. Suicide risk: ethical considerations in the assessment and management of suicide risk.Focus. 2012;10(4):467-472.

122. Centers for Disease Control and Prevention. About Underlying Cause of Death, 2018–2021, Single Race. Available at https://wonder.cdc.gov/ucd-icd10-expanded.html. Last accessed March 21, 2023.

123. Monteith LL, Holliday R, Dichter ME, Hoffmire CA. Preventing suicide among women veterans: gender-sensitive, trauma-informed conceptualization.Curr Treat Options Psychiatry. 2022;9(3):186-201.

124. Austin A, Craig SL, D'Souza S, McInroy LB. Suicidality among transgender youth: elucidating the role of interpersonal risk factors.J Interpers Violence. 2022;37(5-6):NP2696-NP2718.

125. Walter HJ, Abright AR, Bukstein OG, et al. Clinical practice guideline for the assessment and treatment of children and adolescents with major and persistent depressive disorders.J Am Acad Child Adolesc Psychiatry. 2022;S0890-8567(22):01852-01854.

Evidence-Based Practice Recommendations Citations

1. Adelson SL, American Academy of Child and Adolescent Psychiatry Committee on Quality Issues. Practice parameter on gay, lesbian, or bisexual sexual orientation, gender nonconformity, and gender discordance in children and adolescents. J Am Acad Child Adolesc Psychiatry. 2012;51(9):957-974. Available at https://jaacap.org/article/S0890-8567(12)00500-X/fulltext. Last accessed March 24, 2023.

2. American Psychiatric Association. Practice Guideline for the Treatment of Patients with Major Depressive Disorder. 3rd ed. Arlington, VA: American Psychiatric Association; 2010. Available at https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/mdd.pdf. Last accessed March 24, 2023.

3. Assessment and Management of Risk for Suicide Working Group. VA/DoD Clinical Practice Guideline for Assessment and Management of Patients at Risk for Suicide. Washington, DC: Department of Veterans Affairs, Department of Defense; 2019. Available at https://www.healthquality.va.gov/guidelines/MH/srb/. Last accessed March 24, 2023.

78250 • Movement and Dance in Psychotherapy

Jamie Marich, PhD, LPCC-S, REAT, RYT-500, RMT

www.netce.com

Copyright © 2024 NetCE, All rights reserved.

For millennia, indigenous cultures around the globe have regarded dance and other movement-intensive activities like drumming to be highly valuable in emotional healing. Present-day discussions in the psychotherapeutic professions tend to label movement or dance therapy as an "innovative" approach. This course will explain how using basic movement strategies (which may or may not include dance) into clinical work represents a return to the roots of how healing arts have been classically used from a global perspective. Special attention is paid to the role of movement in the processing of unhealed emotional trauma. The work of pioneers in Western psychology will be surveyed, and an overview of dance and movement therapy as specific disciplines will be presented. Clinicians will acquire no fewer than five movement-related techniques that they can use alongside of their existing clinical training through reading this course. Options for further training, which also includes a discussion on scope of practice issues with movement, are also presented.

Table of Contents

78250 • Movement and Dance in Psychotherapy

Course Overview

Audience

Accreditations & Approvals

Designations of Credit

Individual State Behavioral Health Approvals

Special Approvals

Course Objective

Learning Objectives

Faculty

Faculty Disclosure

Division Planners

Division Planners Disclosure

Director of Development and Academic Affairs

Director Disclosure Statement

About the Sponsor

Disclosure Statement

Implicit Bias in Health Care

1. INTRODUCTION

2. FOUNDATIONS: MOVEMENT AND HEALING

A MULTICULTURAL VIEW OF MOVEMENT AS A HEALING ART FORM

EARLY IDEAS ON MOVEMENT IN THE HELPING AND DANCE PROFESSIONS

MARIAN CHACE AND THE DISCOVERY OF DANCE AND MOVEMENT THERAPY

THE CONSCIOUS DANCE MOVEMENT

3. THE IMPACT OF MOVEMENT ON HEALING

A BRIEF PRIMER ON UNHEALED TRAUMA AND THE LIMBIC BRAIN

HOW MOVEMENT AND RITUAL ENHANCE HEALING

THE ROLE OF MINDFULNESS, MOVEMENT, AND YOGA

4. SIMPLE MOVEMENT TECHNIQUES IN CLINICAL WORK

CLENCH-AND-RELEASE TECHNIQUE/PROGRESSIVE MUSCLE RELAXATION

BILATERAL MOVEMENTS FOR STRETCHING AND CLEANSING

USING HAND GESTURES AND POSTURING FOR TEACHING NEW BEHAVIORS

SITTING AND STANDING WITH INTENTION

RITUAL MOVEMENTS FOR LETTING GO AND RELEASE

DANCING MINDFULNESS

5. FURTHER TRAINING & COLLABORATION

IS FURTHER TRAINING RIGHT FOR MY CLINICAL PRACTICE?

COLLABORATING WITH OTHER PROVIDERS

6. CONCLUSION

7. APPENDIX 1: MULTICULTURAL AWARENESS AND COMPETENCE

BEST PRACTICES FOR CULTURALLY RESPONSIVE CARE

CREATING A WELCOMING AND SAFE ENVIRONMENT

8. APPENDIX 2: DANCE IN THE CONTEXT OF EXPRESSIVE GROUP THERAPY

Works Cited

Evidence-Based Practice Recommendations Citations

78250 • Movement and Dance in Psychotherapy

Education Category. Alternative Medicine

Release Date. 04/01/2024

Expiration Date. 03/31/2027

Course Overview

For millennia, indigenous cultures around the globe have regarded dance and other movement-intensive activities like drumming to be highly valuable in emotional healing. Present-day discussions in the psychotherapeutic professions tend to label movement or dance therapy as an "innovative" approach. This course will explain how using basic movement strategies (which may or may not include dance) into clinical work represents a return to the roots of how healing arts have been classically used from a global perspective. Special attention is paid to the role of movement in the processing of unhealed emotional trauma. The work of pioneers in Western psychology will be surveyed, and an overview of dance and movement therapy as specific disciplines will be presented. Clinicians will acquire no fewer than five movement-related techniques that they can use alongside of their existing clinical training through reading this course. Options for further training, which also includes a discussion on scope of practice issues with movement, are also presented.

Audience

This course is designed for professional clinicians who work with clients on a regular basis or who teach/supervise those working with clients who might benefit from the inclusion of movement in their therapy.

Accreditations & Approvals

NetCE has been approved by NBCC as an Approved Continuing Education Provider, ACEP No. 6361. Programs that do not qualify for NBCC credit are clearly identified. NetCE is solely responsible for all aspects of the programs. As a Jointly Accredited Organization, NetCE is approved to offer social work continuing education by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program. Organizations, not individual courses, are approved under this program. Regulatory boards are the final authority on courses accepted for continuing education credit. Continuing Education (CE) credits for psychologists are provided through the co-sponsorship of the American Psychological Association (APA) Office of Continuing Education in Psychology (CEP). The APA CEP Office maintains responsibility for the content of the programs. NetCE is accredited by the International Accreditors for Continuing Education and Training (IACET). NetCE complies with the ANSI/IACET Standard, which is recognized internationally as a standard of excellence in instructional practices. As a result of this accreditation, NetCE is authorized to issue the IACET CEU. NetCE is recognized by the New York State Education Department's State Board for Social Work as an approved provider of continuing education for licensed social workers #SW-0033. This course is considered self-study, as defined by the New York State Board for Social Work. NetCE is recognized by the New York State Education Department's State Board for Mental Health Practitioners as an approved provider of continuing education for licensed mental health counselors #MHC-0021. This course is considered self-study by the New York State Board of Mental Health Counseling. NetCE is recognized by the New York State Education Department's State Board for Mental Health Practitioners as an approved provider of continuing education for licensed marriage and family therapists. #MFT-0015.This course is considered self-study by the New York State Board of Marriage and Family Therapy. Materials that are included in this course may include interventions and modalities that are beyond the authorized practice of licensed master social work and licensed clinical social work in New York. As a licensed professional, you are responsible for reviewing the scope of practice, including activities that are defined in law as beyond the boundaries of practice for an LMSW and LCSW. A licensee who practices beyond the authorized scope of practice could be charged with unprofessional conduct under the Education Law and Regents Rules.

Designations of Credit

NetCE designates this continuing education activity for 3 NBCC clock hour(s). Social workers participating in this intermediate to advanced course will receive 10 Clinical continuing education clock hours. NetCE is authorized by IACET to offer 1 CEU(s) for this program. NetCE designates this continuing education activity for 10 credit(s).

Individual State Behavioral Health Approvals

In addition to states that accept ASWB, NetCE is approved as a provider of continuing education by the following state boards: Alabama State Board of Social Work Examiners, Provider #0515; Florida Board of Clinical Social Work, Marriage and Family Therapy and Mental Health Counseling, CE Broker Provider #50-2405; Illinois Division of Professional Regulation for Social Workers, License #159.001094; Illinois Division of Professional Regulation for Licensed Professional and Clinical Counselors, License #197.000185; Illinois Division of Professional Regulation for Marriage and Family Therapists, License #168.000190;

Special Approvals

NetCE is approved as a provider of continuing education by the California Consortium of Addiction Programs and Professionals. Provider Number 5-08-151-0626. NetCE is approved as a provider of continuing education by the California Association of DUI Treatment Programs (CADTP). Provider Number 185. NetCE designates this continuing education activity for 10 continuing education hours for addiction professionals.

Course Objective

The purpose of this course is to introduce movement therapy as a treatment option that practitioners can incorporate into their work with clients, with the goal of improvement outcomes.

Learning Objectives

Upon completion of this course, you should be able to:

1. Describe movement and dance in the context ofpsychotherapy.

2. Describe how various world cultures have used movement, dance, and ritual for emotional healing as a separate entity from modern psychology.

3. Outline the work of earlier pioneers in the psychotherapeutic and dance professions who used movement in healing.

4. Describe how the field of dance and movement therapy emerged as its own discipline.

5. Define conscious dance and explain its differences to dance therapy.

6. Discuss the importance of movement to healing the limbic area of the brain affected by trauma.

7. Summarize the psychotherapeutic profession's research findings and applications for working with mindfulness, movement, and yoga.

8. Describe how to assess clients for the appropriateness of movement-based adjuncts in clinical therapy.

9. Discuss how adding simple movement techniques can enhance traditional, talk-based therapy, and apply basic movement-related exercises to existing clinical work.

10. Decide whether or not further training in movement-related modalities is a good fit for one's own clinical repertoire.

11. Outline special considerations for movement- and dance-related modalities, including cultural competence and group therapy.

Faculty

Jamie Marich, PhD, LPCC-S, REAT, RYT-500, RMT, (she/they) travels internationally speaking on topics related to EMDR therapy, trauma, addiction, expressive arts, and mindfulness while maintaining a private practice and online education operation, the Institute for Creative Mindfulness, in her home base of northeast Ohio. She is the developer of the Dancing Mindfulness approach to expressive arts therapy and the developer of Yoga for Clinicians. Dr. Marich is the author of numerous books, including EMDR Made Simple, Trauma Made Simple, and EMDR Therapy and Mindfulness for Trauma Focused Care (written in collaboration with Dr. Stephen Dansiger). She is also the author of Process Not Perfection: Expressive Arts Solutions for Trauma Recovery. In 2020, a revised and expanded edition of Trauma and the 12 Steps was released. In 2022 and 2023, Dr. Marich published two additional books: The Healing Power of Jiu-Jitsu: A Guide to Transforming Trauma and Facilitating Recovery and Dissociation Made Simple. Dr. Marich is a woman living with a dissociative disorder, and this forms the basis of her award-winning passion for advocacy in the mental health field.

Faculty Disclosure

Contributing faculty, Jamie Marich, PhD, LPCC-S, REAT, RYT-500, RMT, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Division Planners

Alice Yick Flanagan, PhD, MSW

Margaret Donohue, PhD

Division Planners Disclosure

The division planners have disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Director of Development and Academic Affairs

Sarah Campbell

Director Disclosure Statement

The Director of Development and Academic Affairs has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

About the Sponsor

The purpose of NetCE is to provide challenging curricula to assist healthcare professionals to raise their levels of expertise while fulfilling their continuing education requirements, thereby improving the quality of healthcare.

Our contributing faculty members have taken care to ensure that the information and recommendations are accurate and compatible with the standards generally accepted at the time of publication. The publisher disclaims any liability, loss or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents. Participants are cautioned about the potential risk of using limited knowledge when integrating new techniques into practice.

Disclosure Statement

It is the policy of NetCE not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners.

Implicit Bias in Health Care

The role of implicit biases on healthcare outcomes has become a concern, as there is some evidence that implicit biases contribute to health disparities, professionals' attitudes toward and interactions with patients, quality of care, diagnoses, and treatment decisions. This may produce differences in help-seeking, diagnoses, and ultimately treatments and interventions. Implicit biases may also unwittingly produce professional behaviors, attitudes, and interactions that reduce patients' trust and comfort with their provider, leading to earlier termination of visits and/or reduced adherence and follow-up. Disadvantaged groups are marginalized in the healthcare system and vulnerable on multiple levels; health professionals' implicit biases can further exacerbate these existing disadvantages.

Interventions or strategies designed to reduce implicit bias may be categorized as change-based or control-based. Change-based interventions focus on reducing or changing cognitive associations underlying implicit biases. These interventions might include challenging stereotypes. Conversely, control-based interventions involve reducing the effects of the implicit bias on the individual's behaviors. These strategies include increasing awareness of biased thoughts and responses. The two types of interventions are not mutually exclusive and may be used synergistically.

1. INTRODUCTION

The various disciplines composing the psychotherapeutic profession look to Bessel van der Kolk as a prominent thought leader on issues connected to trauma. Originally from the Netherlands and based in the Boston area, Dr. van der Kolk is an outspoken advocate for the use of creative, innovative, and dynamically body-based interventions in the healing of traumatic stress. In a documentary entitled Trauma Treatment for the 21st Century, van der Kolk speaks on a plethora of issues related to trauma treatment in the modern era [1,46]. One statement in his interview jumps out as a summary position: "The purpose of trauma treatment is to help people feel safe in their own bodies" [1]. He goes on to explain in the interview that some people arrive at this safety through yoga or exercise, while for other people it comes through receiving bodywork, like massage or Reiki. For others, this safety is achieved through a combination of channels, particularly innovative approaches to psychotherapy that honor the mind-body connection.

van der Kolk and his contemporaries have raised awareness about the importance of using the body in the treatment of unhealed trauma and its manifestations, which may or may not include post-traumatic stress disorder, or PTSD. As will be explored in this course, unhealed traumatic memories and experiences generally get stored in the limbic brain, the part of the human brain that cannot be easily accessed using words. Thus, the challenge is to work with the parts of the human brain (i.e., the limbic brain and brain stem) that are deeper than the cerebral cortex, or our talking, thinking, and reasoning brain. If not words, what then?

Remember the adage you likely learned sometime in your youth: Actions speak louder than words. As described in the section of this course on trauma and the brain, there is a great deal of neurobiological wisdom in this statement. Many helping professionals in the modern era trained primarily in cognitive or talk therapy interventions are being asked to engage in a paradigm shift, informed by modern neuroscience. How can we more dynamically engage our clients in their healing, especially when we know that many of their problems are happening in a part of their brain that cannot be easily accessed by talking? The simple answer is to work more fully with action-oriented interventions, and these can include a wide range of movement strategies. Present-day discussions in the psychotherapeutic professions tend to label movement or dance therapy as an "innovative" approach. However, many world cultures have made use of dance, ritual ceremony, aerobic activity, and other forms of movement as part of their healing traditions. Thus, engaging in this paradigm shift of "actions speak louder than words" when it comes to fully healing the brain may involve, more than anything, a back-to-basics approach. As will be highlighted in this course, movement as a healing art is not a new idea—in fact, it is quite ancient. Even after the birth of modern psychology in the 19th century, early thinkers in the field made connections between movement and emotional wellness.

This course will present a brief overview of this history and to consider its relevance to modern-day helping and healing. This course assumes that treating emotional distress is more than a cognitive or medical pursuit. Rather, the optimal pursuit of emotional wellness is more than just treating disease or distress—it requires a holistic approach that looks at the whole person. After examining the history, the impact that movement can have on healing will be explored, especially when healing is framed through a holistic lens. Material on trauma and the brain will be presented, including research from the modern era on the use of movement approaches, specifically yoga. Step-by-step instructions on how clinicians of all backgrounds can implement simple movement strategies to their existing practice without formal or specialized training will also be provided. The course will conclude with information on the specialized training that is available, and learners will have a chance to evaluate if this specialized training is right for them and their practice.

This course offers an overview of many practices and principles that cultures around the globe have used for millennia. Although special attention is paid to highlighting what is most relevant for the modern clinician working in mainstream settings, please understand that if your interest is piqued by any one area of the course, there is more material that you can seek out to expand your knowledge. Throughout the course, recommendations are given for further reading and pursuit of these resources.

2. FOUNDATIONS: MOVEMENT AND HEALING

A MULTICULTURAL VIEW OF MOVEMENT AS A HEALING ART FORM

Eye movement desensitization and reprocessing (EMDR) is one of the most popular and researched therapies in the treatment of PTSD. In brief review, the therapy makes use of back-and-forth eye movements, audio tones, or tapping (of the feet, legs, or arms) to induce emotional and somatic processing more expeditiously. For dancers or drummers, as well as EMDR practitioners, the idea of EMDR and its bilateral mechanism of action makes a great deal of sense. In many Native American traditions, drumming and dancing, typically done in communal ceremony, have been the two most used approaches to treat warriors returning from battle. Many similarities exist in cultures on the Asian continent, from which the tribal nations of North America share a common origin. Traditions of dance as emotional empowerment or communal gathering occur globally: the Haka, a dance of the Maori of New Zealand, the Umoya of South Africa, and even the bouncy circle dances orkolosof Slavic traditions are known to many, even in the modern era.

Rabbi Miriam Maron, a dancer and psychotherapist, summarizes the role of dance and movement as healing art within Judaism [2]. She writes, "The word for dance and the word for illness, taught Rebbe Nachman of Breslav, are related:ma'cho'lfor dance,machah'lahfor illness or affliction. Not by accident do they both share the same root. After all, dancing brings one to a state of joy, and when the body is in a state of joy, the negative energies contributing to illness begin to dissipate" [2]. If one examines texts and traditions from a variety of world cultures, similar themes are evident, making a strong case for dance as a cultural healing universal. Summarizing global research on dance in her book Dance: The Sacred Art, Rev. Cynthia Winton-Henry states [3]:

At the beginning of nearly every culture, dance arose at the foundation of collective spiritual life. Just as inconceivable as separating out deities and goddesses from everyday activities, dancing was intrinsic to the religiosity of indigenous groups. It could not be extricated. It was manna, daily bread. More than mere expression, dancing served as a primary means of knowing and creating the world. It carried technologies of healing, entertainment, and most definitely praying.

Perhaps the most famous story of a Western-trained psychiatrist being affected by the power of indigenous healing traditions is that of Dr. Carl Hammerschlag. In his memoir The Dancing Healers: A Doctor's Journey of Healing with Native Americans, Hammerschlag, trained as a psychiatrist at Yale, relates that when he first traveled to Arizona to work with the Indian Health Services, he believed he was bringing a wealth of knowledge about the human brain to an "uncivilized" people [4]. He soon learned that they had more to teach him about healing than he could ever teach them. He relays a particularly touching story of a tribal elder who, after listening to Dr. Hammerschlag's credentials, asked him if he could dance. To appease him, the doctor did a little shuffle by his bedside. The elder chuckled, replying, "You must be able to dance if you are to heal people." Hammerschlag's memoir offers a glimpse into his own paradigm shift of being trained as a physician, in the traditional Western sense, to being a more holistically rounded healer. He calls for the adoption of the dances and ceremonial customs of indigenous and other cultures generally described as "non-Western" as a way to get clients and patients comfortable with cultivating their own insights. He observes, "Artists and other of creative mind know that the unconscious must be uninhibited to make the associations that produce new understanding" [4].

Gabrielle Roth (founder of the 5Rhythms practice and considered by many to be the mother of the modern conscious dance movement) summarized her work with Native American healers in this anthem of empowerment amongst holistic practitioners [5]:

In many shamanic societies, if you came to a medicine person complaining of being disheartened, dispirited, or depressed, they would ask one of four questions. When did you stop dancing? When did you stop singing? When did you stop being enchanted by stories? When did you stop finding comfort in the sweet territory of silence?

The National Institutes of Health recognize Native American healing approaches as a whole medical system [6]. This system encompasses a range of holistic treatments used by indigenous healers for a multitude of acute and chronic conditions and to promote total health and well-being. Many psychotherapists trained in Western traditions are honoring the holistic missions of their practices by incorporating approaches from the Native American and other healing traditions.

Incorporation of traditional forms of healing into clinical practice can be helpful, but it can be difficult to know where to start. One resource for this integration is Susan Pease Bannit's The Trauma Toolkit: Healing Trauma from the Inside Out [7]. A traditionally trained social worker who completed her internship in the Harvard medical system, Bannit proposes a taxonomy for healing using the five subtle bodies of yoga philosophy. She integrates movement and ceremonial techniques from yoga and Ayurveda (Indian systems of healing), in addition to Native American practices. Bannit's text is an excellent resource for the traditional practitioner working in a North American system wanting to incorporate these multicultural healing traditions in a safe and user-friendly way.

If exploring the cultural roots of dance as a healing art appeals, consider further reading the work of Bannit, Roth, Hammerschlag, Winton-Henry, and Maron. For many clients who have Native American roots, there can be great power in claiming the connection to their lineage, so encouraging them to explore dance and other Native American healing arts may serve as an important adjunct to treatment. This connection does not just apply for Native American clients—truly, encouraging a client to explore their cultural heritage's views on healing can be powerful, whatever that culture may be.

Here are some websites in the area of dance/movement, ceremony, culture, and healing that you and your clients may find useful:

- African healing dance: http://www.wyomadance.com/african-healing-dance.html

- Classical Indian dance: https://www.shaktibhakti.com

- National Center for Complementary and Integrative Health: https://www.nccih.nih.gov

- Various Indigenous cultures: http://www.healing-arts.org

EARLY IDEAS ON MOVEMENT IN THE HELPING AND DANCE PROFESSIONS

Professionals and scholars have been making the links between movement and emotional healing almost since the beginning of modern psychology. These links are not just attributed to psychologists and related psychological professionals—professional dancers and other artists also made connections that we can find valuable as helpers to this day. In this section, we will review some of these modern pioneers. In addition to Lowen, Fritz Perls, Frederick Alexander, Moshé Feldenkrais, Florence Noyes, and Martha Graham will be explored. Some of these leaders and their ideas overlapped, although most of their work represented independent thought that essentially worked with the same ideas: There is great capacity for emotional healing when the body moves itself. These overviews will dovetail into the next section on Marian Chase and the formal discovery of dance therapy, compared with the similar (yet related) conscious dance movement. Then, we will take a look at how the formal literature and practice standards view the use of dance and movement work, both formal and informal.

Alexander Lowen

Alexander Lowen was an American-born physician who originally studied under Wilhelm Reich, a second-generation Freudian psychoanalyst. Like another of Reich's students, Fritz Perls, Lowen added his own ideas to the work of Reich, resulting in the development of bioenergetic analysis (BA) (founding date credited as 1956). According to the International Institute for Bioenergetic Analysis, BA is a body-based psychotherapy rooted in the principles of mind-body connection taught to Lowen by Reich [8]. Some of the core tenants of this therapeutic approach include:

- BA basically combines a bodily, analytic, and relational therapeutic work, based upon an energetic understanding.

- BA helps to release chronic muscular tensions, manage affects, expand the capacity for intimacy, heal sexual trauma or dysfunction, and learn new, more fulfilling ways of relating to others. Tenderness, aggression, and assertion—and their confluence in sexuality—are seen as core life-saving forces. The therapeutic relationship provides a place of safety in which healing begins.

- The therapist reads the body, resonates with its energy, feels the emotions, listens, hears, and answers the words. The language of the body (i.e., posture/gesture, breathing, motility, expression) is the focus, as it indicates the status on the way to personhood, from the past to the present and future.

- Techniques are used to address the energetic aspect of the individual, including their self-perception, self-expression, and self-possession. These also include work with body contact, boundaries, grounding, and the understanding of muscular tensions as indications of somatic and psychological defenses against past trauma. The goal of therapy is more than the absence of symptoms. It is having aliveness, getting a taste of pleasure, joy, love—vibrant health.

- According to Lowen, wellness starts with the reality of the body and its basic functions of motility and expression.

BA is still being practiced throughout the world today, stemming from Lowen's work. During his lifetime, he wrote or co-wrote 14 books on various topics related to health and wellness, explained through the lens of BA. Because it has origins in Freudian psychoanalysis, many view BA as the most classical of the movement and body basic approaches to therapy. The International Institute for Bioenergetic Analysis keeps a catalogue of the latest research and conference presentations on the use of BA as a treatment and wellness approach. For more, visit http://www.bioenergetic-therapy.com.

Fritz Perls

Fritz Perls, regarded as the father of Gestalt Therapy, is typically a more recognizable name than Alexander Lowen, although they studied in the same tradition. Perls developed the Gestalt approach in collaboration with his wife Laura in the 1940s and 1950s, and he also lived in residence at the Esalen Institute in California during the 1960s, where Lowen also completed much of his work. Gestalt is generally considered one of the more classical psychotherapy approaches, with most graduate students in North America receiving some basic training in its principles. Toward the end of his life when an interviewer asked Perls to define the Gestalt approach, he struggled with putting words to it, preferring instead to demonstrate [9]. Perls set out to revise the classic psychoanalysis of his training, and one might observe the Gestalt approach as a more dynamic practice of psychoanalytic principles.

The Gestalt therapist is actively involved with the client, often engaging in their own disclosure, unlike the distance established in psychoanalysis [10]. The Gestalt therapist uses an active array of methods to engage the client, including promoting body awareness and making use of behavioral tools, like movement. Experimentation is encouraged to ultimately allow the client to work through unfinished trauma or issues. Yontef and Jacobs identify Gestalt psychotherapy as the first truly holistic approach to Western psychotherapy, making use of affective, sensory, interpersonal, and behavioral components [10]. The Gestalt approach draws from existential, humanistic, and Zen philosophy, and it can be common for a Gestalt session to work with body alignment, awareness, and movement. It is also common for Gestalt psychotherapists to also work with dance or movement modalities. For an example of a therapist who is integrating the two because of their obvious overlap, visit https://gestaltdance.com.

Although Gestalt psychotherapy is not typically discussed in the new wave of psychotherapies generating attention in the treatment of trauma, many modern approaches (e.g., EMDR therapy, dialectical behavior therapy, sensorimotor psychotherapy, somatic experiencing) draw on many time-honored Gestalt principles. Linda Curran, a psychotherapist, teacher, and director of several educational documentaries on trauma, refers to Gestalt psychotherapy as the "original trauma therapy" [11]. Indeed, many of the newer approaches to trauma and other mental health treatment that appear in the Substance Abuse and Mental Health Services Administration (SAMHSA) Evidence-Based Practices Resource Center make use of coping skills that simply represent a repurposing of many time-honored Gestalt approaches.

Moshé Feldenkrais

Moshé Feldenkrais, a Russian-Israeli engineer and practitioner of the Eastern martial arts, is another name associated with the movement practitioners who taught at the Esalen Institute in the 1960s and 1970s. Feldenkrais was inspired to develop his now trademarked method, described as a type of somatic education, after he was injured playing soccer in his young adulthood. He published his first book in 1949 describing his method. The method is something that anyone interested in learning more about their body and the information it gives them can study. Feldenkrais himself is well-known for giving lessons in his method to the prime minister of Israel. The training program to become a recognized Feldenkrais Method practitioner is extensive, and it is a training program that professionals from many disciplines (e.g., massotherapists, psychotherapists, dance teachers) pursue. Many of the popular conscious dance movements, most notably the Nia movement practice, draw on influences from Feldenkrias. To read more about the method and to pursue a catalogue of current research about the Feldenkrais method, please visit https://feldenkrais.com.

F.M. Alexander

Feldenkrais studied with F.M. Alexander, an Australian actor who explored the somatic connections between body, emotion, and performance decades before doing such became popular within psychotherapy. Despite his early work, Alexander is much less recognized among psychotherapists and counselors. However, many musicians and performing artists are familiar with Alexander's work. According to the public story published about his life, Alexander found himself struggling from chronic laryngitis, which clearly got in the way of his performance as an actor. His healthcare providers were unable to detect an organic cause, so he began engaging in his own inquiry. Alexander discovered that excess tension in his neck and back was causing the problems with his vocalization. Through trial and error, he began making modifications in his movement, which ultimately eradicated his laryngitis. So impressed were the doctors who were unable to help him, they encouraged him to begin teaching his method.

Research conducted on the Alexander technique spans a wide range of academic disciplines. Alexander was also known for promoting the idea of self-discovery with movement, which has led to many individuals engaging in the Alexander technique as a self-study method. Many of the available resources in this area are billed as "Alexander Self-Help." There are many resources available that can assist interested parties in this process. A good first resource to read more about the Alexander technique, its practice, and related research is https://alexandertechnique.com.

Florence Noyes

Like Alexander, Florence Noyes was a performer—a classically trained dancer who regularly performed at New York venues like Carnegie Hall. In her own work as a dance teacher, she began making links between movement and life. She created a system of study now called Noyes Rhythm, described as working with physical technique, improvisational exercises, and building internal awareness. From the days of Noyes, the approach was billed as a something that from which both dancers and non-dancers could derive benefit, if their goal was to open up to greater creativity and ease in life. The work of Noyes can be described as one of the forerunners of modern-day dance therapy. There is an active community of teachers working and sharing the original work of Noyes throughout the world. To read more about Noyes Rhythm and the work being done, please visit https://www.noyesrhythm.org.

Martha Graham

Many present-day teachers of conscious dance and dance therapists look to Martha Graham as a role model. Her inspirational sayings (e.g., "Dance is the hidden language of the soul") regularly make their way around social media pages and other promotional materials. Recognized as the mother of what is now referred to as modern or contemporary dance, Graham clearly extrapolated a great deal of psychological learning about mind-body connection from her own training and work with others. An alumnus of her dance company, Albert Pesso, is well-known in the mind-body circles of psychotherapy for his method, psychomotor psychotherapy, which will be briefly discussed later in this course.

Graham's 1991 autobiographyBlood Memorylargely reads like a study in mind-body-spirit connection, with tremendous insights provided about the role of breath in movement. One such insight about the role of breath can be beneficial to anyone working with the psychological process [12]:

Every time you breathe life in or expel it, it is a release or a contraction. It is that basic to the body. You are born with these two movements, and you keep both until you die. But you begin to use them consciously so that they are beneficial to the dance dramatically. You must animate that energy within yourself. Energy is that thing that sustains the world and the universe. It animates the world and everything in it. I recognized early in my life that there was this kind of energy, some animating spark, or whatever you choose to call it. It can be Buddha, it can be anything, it can be everything. It begins with the breath.

The role of linking breath with movement will be explored further later in this course. Many psychotherapeutic professionals do not realize the powerful connection between the two, yet teaching deep, full breath is a practice that is within our scope as clinical professionals.

MARIAN CHACE AND THE DISCOVERY OF DANCE AND MOVEMENT THERAPY

Although the use of dance as a therapeutic method for healing and wholeness was certainly not new to the 1960s, the founding of dance therapy as a distinct and separate discipline traces here. Marian Chace, like Martha Graham, was a student of Ruth St. Denis and the Denishawn School of Dance during the same era. Chace launched her own career as a dance teacher and was inspired by ideas from Carl Jung about the connection between mind and body. Chace discovered that many of her dance students became more interested in the psychology of movement rather than the technique of dance. Thus, she began further developing her ideas with the support of many in the local medical community of Washington, DC, her home teaching base. She launched into offering her own training programs in what she coined dance/movement therapy, and in 1966, she founded and became the first president of what is now called the American Dance Therapy Association (ADTA).

Although one does not have to be a fully credentialed dance/movement therapist to incorporate movement into the practice of psychotherapy, billing oneself as a dance/movement therapist, at least with the blessing of the ADTA and often credentialing boards, requires specialized training and accredited credentialing. There are now graduate degree programs specifically offered in dance and movement therapy that can count toward ADTA accreditation and toward professional licensure in the mainstream psychotherapy professions (e.g., social work, counseling, marriage and family therapy) in many states. Professionals with a standard Master's degree that is not specific to dance and movement therapy can still become an ADTA-accredited dance/movement therapist through extra training and supervision. Full details about this process can be obtained at https://www.adta.org.

The ADTA's official definition of dance/movement therapy, as stated in their promotional literature and on their website, is as follows [13]:

- Focused on movement behavior as it emerges in the therapeutic relationship. Expressive, communicative, and adaptive behaviors are all considered for group and individual treatment. Body movement, as the core component of dance, simultaneously provides the means of assessment and the mode of intervention for dance/movement therapy.

- Is practiced in mental health, rehabilitation, medical, educational, and forensic settings, and in nursing homes, day care centers, disease prevention, health promotion programs and in private practice.

- Is effective for individuals with developmental, medical, social, physical, and psychological impairments.

- Is used with people of all ages, races and ethnic backgrounds in individual, couples, family and group therapy formats.

The ADTA publishes its own peer-reviewed research journal in dance/movement therapy. Although there is a wide array of research documenting the use of dance and movement therapy approaches in a wide array of physical and medical conditions, the use of such approaches as stand-alone treatments for mental and emotional disturbances has not been fully established [14].

THE CONSCIOUS DANCE MOVEMENT

Those who practice conscious dance (sometimes referred to as ecstatic dance) are well-acquainted with the healing and therapeutic properties of dance, even if they are not practicing healing dance under the formal umbrella of credentialed dance therapy. Mark Metz, founder of the DanceFirst Association and editor of Conscious Dancer Magazine, jokingly states that when you try to define it, it is no longer "conscious dance." Yet for the sake of furthering the academic discussion, Metz offered this definition: movement with an intention toward higher awareness [15].

As noted, Gabrielle Roth is generally credited as the mother of the conscious dance movement. Like Lowen, Perls, and Feldenkrais, much of her work is traced to the Esalen Institute in Big Sur, California. She developed her own practice, which is now called 5Rhythms, because she was asked to put together a movement program for residents and retreatants at the institute while she resided there. In one of her books, Sweat Your Prayers: Movement as Spiritual Practice, Roth wrote (in describing her early years of developing the practice): "Sometimes two hours of moving are as powerful as two years on the couch. I discovered that the body can't lie; put it in motion and the truth kicks in" [5].

Conscious dance practices like 5Rhythms are often associated with places like the Esalen Institute and other retreat centers like the Kripalu School of Yoga and Health and The Omega Institute, as well as music and consciousness festivals like Burning Man. However, mainstream psychological and helping professions have been taking more and more notice of these practices. There are a plethora of dance practices, some developed independently of Roth's 5Rhythms, with most developing in the wake of her legacy, that can be described as conscious dance practices. Many conscious dance practitioners within the helping professions are integrating conscious dance practices as an adjunct to clinical work in clinical settings. Moreover, many professionals are also noticing the value of sending their clients to conscious dance classes as wellness and skills-building technique to help them better manage affect. Even the dance classes that are more fitness-based as opposed to conscious-based, like Zumba fitness, can serve this purpose.

In linking clients with dance resources in the community for their own health and wellness, conscious dance and fitness dance practices are generally more accessible and available than dance/movement therapy. Metz, recognizing this phenomenon, started the DanceFirst organization as a fellowship for those working in movement and dance, designed to be more inclusive than exclusive. This organization publishes a calendar including more than 100 modalities within the scope of conscious dance being taught around the world today and provides a search tool for finding local classes and programs on their website at https://consciousdancer.com.

3. THE IMPACT OF MOVEMENT ON HEALING

Reflection

F.M. Alexander is quoted as saying, “You translate everything, whether physical, mental or spiritual, into muscular tension.” Does this resonate with you and your practice? How might this manifest in your clients?

Recall the previous discussion in this course regarding the age-old adage that actions speak louder than words. When it comes to emotional healing, especially regarding those issues that are deeply entrenched in our more primitive brains, the saying carries a great deal of neurobiological wisdom. Many therapists reach a frustration point in working with traumatized clients because, even if these clients can talk about the trauma, they may not experience much forward movement with their healing. In fact, these clients may end up subjectively worse from talking so much about their trauma. A basic understanding of how unhealed trauma or other adverse life experiences can become stuck in the limbic brain suggests that when it comes to complete healing, talking is not enough.

A BRIEF PRIMER ON UNHEALED TRAUMA AND THE LIMBIC BRAIN

For survivors of trauma and other adverse life experiences, the effects in the neuronetworks of the brain tend to occur at the lower levels of the brain called the limbic brain and the brain stem. These two lower areas in the human brain structure are related to emotion, movement, and the basic functions of human life, but not with concepts like speech, higher-order thinking, or rational judgment. As complicated as the study of trauma neurobiology can get, the most basic concept to grasp in making sense of this material is the human brain is composed of three separate brains, also referred to as the triune brain model.

According to this model, each of the three areas (i.e., the R-complex brain or brainstem, the limbic brain, and the cerebral brain or neocortex) has their own separate functions and senses of time. This model was introduced by MacLean in 1990 and has been used by trauma specialists in the ensuing years to help describe the impact of trauma and trauma processing [16].

The base of the brain contains the cerebellum, and it directly connects to the spinal cord (the brainstem). MacLean terms this as the R-complex (his original name for the basal ganglia), sometimes referred to as the reptilian complex or the "lizard brain." This area is equated with animal instincts. Those basic functions of animal life originate in this lowest part of the brain: reflex behaviors, muscle control, balance, breathing, heartbeat, feeding/digestion, and reproduction. The brainstem is very reactive to direct stimulation.

The paleomammalian complex (limbic system), sometimes called the midbrain, is unique to mammals. According to MacLean, this center of emotion and learning developed very early in mammalian evolution to regulate the motivations and emotions now associated with feeding, reproduction, and attachment behaviors [16]. In MacLean's explanation, everything in the limbic system is either agreeable (pleasure) or disagreeable (pain/distress), and survival is based on the avoidance of pain and the recurrence of pleasure. The limbic brain contains the amygdala and hypothalamus and does not operate on the same rational sense of time we know as humans. The amygdala is a filter and determines if incoming input is dangerous or not [17]. If the amygdala classifies the information as not a threat, it can process through to the neocortex and is integrated with other useful or useless data that have been acquired over the years. In essence, the information integrates into one's existing experience without fallout. As will be discussed later in this course, for many people who go through experiences from which threat or danger is signaled, receiving help, support, or validation sooner rather than later can assist a person with this process of integration, thus decreasing the chances of long-term consequences.

If the amygdala signals threat/danger, other parts of the limbic brain are activated, specifically the survival part of the brain, or the thalamus. These activities can incite one of three reactions, fueled by the lower reptilian brain: the fight response, the flight response, or the freeze response. When these responses are activated and re-activated, the body will respond, regardless of what rational thought might be saying. Even after the danger has passed, the thalamus remains on high alert, activating the same responses if anything reminiscent of the original danger passes through again. Together, the thalamus and the reptilian brain may work extra hard to prevent a similar response the next time. Obviously, these problematic symptoms can keep occurring in a vicious cycle until the limbic-reptilian levels of the brain can return to balance.

The limbic brain has no sense of time. When traumatized people feel "stuck," it is as if their proverbial panic button is not fully functional. When crossed wires get stuck in the limbic brain, they take on a high level of significance, because material was not meant to be stored here long term. When the regulatory capacities of this brain are impaired, it works longer and harder than it was intended to, causing the symptoms associated with traumatic stress.

The goal of successful trauma processing is to move or to connect the charged material out of the limbic brain into a part of the brain that is more efficient in its long-term storage capacities. In the triune brain model, this is referred to as the neomammalian complex (or cerebral neocortex). This is unique to primates, and a more highly evolved version is unique to humans. The neocortex contains the prefrontal lobes of the brain frequently discussed in explaining human behavior. This brain regulates so much of what makes us human: executive functioning, higher-order thinking skills, reason, speech, meaning making, willpower, and wisdom.

Most working in the psychological and behavioral health professions are familiar with attempting to talk reason to people in crisis or to encourage people to leave the past in the past and focus on the present. These types of interventions are common in much of the cognitively focused modern-day training in human services; it is natural to confront a person's negative thinking or to encourage a client to see the "silver lining" or reason. However, talking reason to a person in crisis is often futile. Cognitive (or any reason-based) interventions primarily target the prefrontal regions of the brain. However, the limbic region of the brain was activated during the original trauma to help the person survive (through flight, fight, or freeze responses). Because the frontal lobes were not activated or involved, the individual was never able to link up that limbic activation with frontal lobe functions during the experience. For a person in crisis or intense emotional distress, this process is playing out in real time and/or triggers from earlier, unprocessed experiences fuel the distress.

To summarize, when the limbic brain is activated, the prefrontal lobes are not. For optimal healing to occur, all three brains must be able to work together. Neurologically, unprocessed trauma creates disconnection in the brain. However, it is important to keep in mind that complex interventions are not necessary to encourage whole-brain interaction. Consider that deep breathing is a whole-brain intervention. Breath originates in the primal, reptilian region of the brain. Any movement-based or body-based intervention automatically works with the limbic and reptilian brains. The action parts of one's experience (and conversely the inaction or freeze responses that can result from unhealed trauma) are regulated by the limbic brain and brain stem. Thus, some of the most basic interventions for healing involve taking action.

HOW MOVEMENT AND RITUAL ENHANCE HEALING

Many in Western cultures tend to assume that talking is the best way to process trauma. You may have heard or even used phrases like, "We have to get her talking about it so she doesn't hold it all in," or "Well, he's talking about it, so that's a good sign." In many mental health and addiction treatment cultures, talking is synonymous with processing, and talking can play a role in helping a person to process. However, talking is primarily a function of the frontal lobe. A person can talk about the trauma all he or she wants, but until the person can address it at the limbic level, traumas will likely stay stuck. Being psychologically stuck means that a memory fragment is too large for the brain to process. Thus, something additional is required to help dissolve the fragment. Other healthy modalities of processing that can help with this dissolution include exercise, breath work, imagery, journaling, drawing, prayer, dreaming, and of course, dancing and movement. These experiential modalities are more likely to address limbic-level activity when compared with the classic "talking it out" strategies.

van der Kolk offers a solid summary of how to engage a person in a multi-tiered approach to healing in The Body Keeps the Score [14]. He writes that there are three primary ways for helping survivors feel alive in the present and move on with their lives:

- Top-down methods: Talking, connecting with others, self-knowledge

- Medication and technology: Medications to shut down inappropriate alarm reactions, other therapies/technologies that change the way the brain organizes information

- Bottom-up methods: Allowing the body to have experiences that deeply and viscerally contradict the helplessness, rage, and collapse that result from trauma

Usually, a combination of the three approaches is needed. The movement-based strategies addressed throughout this course are designed to help a person work from the bottom up.

THE ROLE OF MINDFULNESS, MOVEMENT, AND YOGA

Evidence Based Practice Recommendation

The Department of Veterans Affairs has found insufficient evidence to recommend for or against dance therapy for the treatment of PTSD.

https://www.healthquality.va.gov/guidelines/MH/ptsd/VA-DoD-CPG-PTSD-Full-CPGAug242023.pdf

Last Accessed: March 25, 2024

Strength of Recommendation: Neither for nor against

Evidence supporting the role of holistic strategies like mindfulness and movement strategies, especially yoga, continues to mount. Research indicates that these modalities provide powerful adjuncts to traditional psychotherapy. Although the field of dance/movement therapy and yoga therapy has existed for quite some time—each with their own journals—van der Kolk made history in 2014 when a psychiatric journal published a study that he and his team completed on yoga and PTSD. Using empirical methodology to study 64 women with described "chronic, treatment-resistant PTSD," the study concluded that yoga significantly reduced PTSD symptomatology, with effect sizes comparable to well-researched psychotherapeutic and psychopharmacologic approaches. Yoga may improve the functioning of traumatized individuals by helping them to tolerate physical and sensory experiences associated with fear and helplessness and to increase emotional awareness and affect tolerance [14].

Many innovators have worked to bring yoga and movement strategies into their work with trauma survivors, recovering addicts, and others who are struggling with problems of living. One such innovator is Nikki Myers, founder of a growing program called Y12SR, the Yoga of 12-Step Recovery. Nikki, a recovering addict and survivor of multiple layers of trauma, launched the program in early 2000. Y12SR meetings are not affiliated with any specific 12-step fellowship; rather, they are independent gatherings that combine the essence of a 12-step discussion meeting with a yoga class. The guiding principle of Y12SR is that "the issues live in our tissues" [18]. As Nikki explains, when one is in the physical posture of a yoga pose or even a simple stretch outside of the context of yoga and they feel muscles quiver, the body is working something out. Myers remembers being a 9-year-old girl watching the news and seeing people of color, people who looked just like her, being hosed and gassed and beaten. She absorbed these images during the social upheaval of the Civil Rights movement, and although she was raised in the northern United States, seeing those images completely shook her sense of authority and self. As Nikki explains, [18]:

Something had to be wrong with me if these people who looked like me were being treated this way. Everything I'd learned in school taught me that government and authority was to be respected, so if government and authority was doing this to children like me, I must be flawed.

She discloses that, to this day, reflecting on that memory brings up a strong visceral reaction in her [18]. These visceral reactions that people experience can rarely be addressed by talking alone, which is why integrating holistic strategies, including movement, are important competencies to weave into clinical skill sets.

In addition to yoga, work with mindfulness meditation and mindful movement programs (some being within the scope of dance therapy) continues to expand in the helping professions. Barton's research on a program she designed called Movement and Mindfulness offers some interesting results and implications [19]. Movement and Mindfulness was a body-based curriculum introduced into a group rehabilitation setting for severely mentally ill clients, using a combination of dance/movement therapy techniques, yoga skills, and traditional group therapy with a focus on mindfulness/Eastern meditation. Using qualitative methods of evaluation, results indicated numerous examples of physical and psychological shifts and experiences of pro-social behavior [19].

Crane-Okada, Kiger, Sugerman, et al. investigated the use of dance/movement therapy paradigms and mindfulness with female cancer survivors [20]. In this randomized design of 49 female participants between 50 and 90 years of age, the program's major benefits included reducing fear and improving attitudes of mindfulness. Another study examined Vipassana meditation and dance as vehicles for promoting somatic and emotional coherence, concluding through empirical measures that the coherence between somatic and cardiac aspects of emotion was greater in those that had specialized training in meditation or dance, as compared with the control group [21].

Since the early 2000s, the field of traumatic stress studies has taken special notice of mindfulness and other Eastern practices like yoga and the martial arts as healing channels. A major reason for this interest relates to neurobiology. Mindfulness practices play a key role in activating the prefrontal cortex and promoting a greater sense of concentration; concentration problems are common among trauma survivors, with the DSM-5-TR identifying them as a heightened arousal symptom [22,23]. Mindfulness can calm a client's inner experience and promote greater introspection, an important feature considering that disorganized memory structure may be one process that impedes access to, and modification of, trauma-related cognitive schema [24,25]. Structured mindfulness practice can cause positive structural changes in the brain related to learning and memory (hippocampus) and can cause a thinning in the amygdala, lessening the charge of fear-based responses [26,27]. There is also evidence that mindfulness meditation practices lead to decreases in ruminative thinking, alter the neural expression of sadness, positively influence change in neural activity, and positively impact working memory capacity and affective experience [28,29,30,31].

In 2012, a task force assembled by the International Society for Traumatic Stress Studies (ISTSS) published a paper on best practices in the treatment of trauma-related disorders. One of the team's conclusions, supported by literature reviews, was that "optimization of outcomes also includes exploration of novel treatment approaches such as complementary medicine strategies that focus on somatosensory experience and the mind-body relationship, for which there is emerging evidence regarding efficacy" [32].

Considerations for Clients Who Fear the Body/Movement

While some clients will be very open to incorporating movement into their therapy, many clients get fearful, skeptical, or otherwise uncomfortable when interventions like yoga, meditation, dance, or other movement strategies are suggested. In trainings, learners often ask, "How do you pitch these interventions to clients? Won't they think they're weird?"

In general, when working with new clients, one can ask general questions about the role of exercise and/or spirituality in their life. If a client is already using exercise, begin discussing some of those benefits and how they can continue working with those as part of their recovery and goals for wellness. In talking about the importance of building coping skills to a treatment plan, also ask if they are open to using simple breathing and movement strategies in the work in the office. If they are amenable, then proceed, and if this results in positive feedback, one can become more proactive about working in yoga, movement, or dance strategies. Sometimes it may be within one's scope to do this in sessions, and other times, it may be appropriate to work to match the client with community resources where they can take classes in these areas.

When clients begin asking the "why" questions about strategies like the ones covered in this course, it can be helpful to respond in one of two ways. The first is to provide a description of the triune model of the human brain, as described earlier in this course, to explain why talking alone may not meet all of their needs. Another approach is to share the following demonstration. A common symptom of PTSD and other trauma-related issues is hypervigilience, or always being on guard for something bad to happen. When one is hypervigiliant, their shoulders tend to creep up a bit toward their ears. Try this now—let your shoulders move up toward your ears and hold them there for a few moments. What are you noticing about your breath when you do this?

If you've held your shoulders up by your ears for even a moment, you probably began to notice a shallowing of your breath. Indeed, when muscles are tense or we are otherwise on guard, we do not breathe as fully as we should. Thus, working on breath and muscle-release strategies can prove to be a radically new, life-changing intervention for people. Most clients are not aware that their muscles are tense or that their breathing is so affected until they do this exercise. This can be a good way to offer a physical/movement-based demonstration instead of just lecturing about the potential benefits.

Of course, clients in therapy have various degrees of receptivity about working with the spectrum of action-based and movement-based strategies, which is why it is important to gauge their readiness and meet them where they are at with interventions. In the next section, a wide range of options that clinicians have at their disposal for integrating breath, movement, and even yoga or dance-related strategies into their clinical work will be presented.

Perhaps the highest degree of resistance from clients will be related to dance. Of course, it is important not to force dance-based interventions on clients or to tell them that they have to seek out a dance class, although it may be worth exploring why a person may be open to other movement strategies like yoga (which is generally more structured) or simple stretching, but closed off when it comes to dance or other more creative movement modalities. Cynthia Winton-Henry, developer of the InterPlay technique and author of Dance the Sacred Art: The Joy of Movement as Spiritual Practice, identifies these primary reasons people tend to be blocked from giving dance a try [3]:

- It is too embarrassing to dance.

- There is no connection between dance and spirituality (a myth).

- The body is a Pandora's box and not to be trusted.

- Dancing is not important.

In some cases, a combination of these factors may be at play. Hence, even while respecting a person's right to say no to dance or creative movement interventions, it may be worth exploring the source of their "no" and using that as grist for the clinical mill.

For those who are scared of or unsure about creative or expressive movement, structured movement exercises can provide for comfort, at least when someone is new to the process of embodiment. Even in approaches in which the goal may be for the group to open up and to explore freely, some clearly show discomfort in this area so they may need more direct physical instruction that feels like stretching. For example, "Open up your arm to the right side, stretch it out away from you, then let the arm float back and across your body to the left side." For this reason, dance or fitness classes that are highly structured may be a better fit for newcomers to dance and movement than classes or techniques that encourage free creative movement.

For the hesitant client, whether in a dance class or group or in an office-based setting, relying on more structure and direction is a solid best practice. Even with the simple breath and movement strategies covered in the next section, letting a person go too long in silence is what causes many to become uncomfortable beyond their window of tolerance. Also, getting continuous feedback from a client is helpful. Let them know that in trying some of these movement and other holistic coping practices, you want to get a sense about what will work for them and what they are not able to handle. Thus, trying six to eight breaths at a time to start with may be too much, so scale it back to two to three. Using the arms for stretching may seem uncomfortable but working with gentle twists from the waist may be a better fit. An axiom that can be helpful in work with movement, either one-on-one or with groups, is that there is always a variation, an adaptation, and alternative movement that can be tried. Additionally, there are ways that movement can be subtly added into favorite, time-honored talk therapy, cognitive therapy, or traditional recovery therapy (e.g., 12-step programs) strategies.

4. SIMPLE MOVEMENT TECHNIQUES IN CLINICAL WORK

Reflection

Consider the following quote from Fritz Perls: “Fear is excitement without the breath.” Does this concept resonate with you? How might it present in your clients?

One of the classical techniques in the broad practice of cognitive-behavioral therapy is thought stopping. Typically practiced as a combination of visualization (e.g., a literal red octagon of a stop sign or any other symbol for stopping) and intentional thwarting of a negative belief (e.g., "I cannot succeed"), the thought stopping approach helps many. However, for some clients, it only goes so far. Many individuals are well aware of what their self-defeating negative cognitions are and even using intention, confrontation, or visualization cannot stop the flow of the negative thought into permeating their emotions and/or behavior.

In these cases, a simple variation on the thought stopping technique using movement can be attempted. Instead of or in addition to visualizing a stop sign, this time bring your hands into a motion that signals stop. For most people, this means raising one or both hands in front of their core body, making some style of barrier motion. By adding this simple movement into the classic technique, the client is automatically working with more functions of the human brain. Clients can continue to make this barrier motion with their hands over and over again, even if it is 50 repetitions, until the negative belief passes. This simple activity in and of itself may not resolve the core negative belief (more intensive processing or cathartic interventions may be needed for that), but as a body-responsive coping skill, it can work wonders for distress tolerance.

Many clinicians (and clients) do not realize that incorporating dance and movement strategies into their work with clients can be done in such a simple fashion. When many clinicians hear "dance and movement work," they fear that this means actually getting clients to dance and engage in other movement activities in the office. Although dance and movement work can involve such strategies, assuming that the clinician feels comfortable and qualified to lead them, they do not have to incorporate that level of intensity. Clinicians who are new to movement work can begin by adding a gesture to the thought stopping technique, see how that works, and then proceed from there.

This section will explore other simple movement activities that correspond well with time-honored counseling and recovery techniques. Specific instructions are given to guide. Clinicians are encouraged to weave them into work with clients in whatever order may make sense. It can also be helpful to try these strategies yourself first, as you read this course. The key to being able to effectively pass these techniques along to clients, whether in an individual context or in a group setting, is to make sure that you have tried and understand the motions.

CLENCH-AND-RELEASE TECHNIQUE/PROGRESSIVE MUSCLE RELAXATION

The time-honored hypnotherapy technique of progressive muscle relaxation dates back to the 1920s. In this technique, recipients are guided to clench and release one muscle group at a time. So, for instance, one may begin by first clenching the left fist, holding it for about 20 to 30 seconds, and then with a nice deep exhale, releasing the contraction. This isometric motion is continued throughout the entire body. There are variations. Some will start with the left fist, and then continue into contracting and releasing the left forearm, then the left upper arm. Some people may prefer, after contracting and releasing the left fist, to move over to the right fist, beginning a pattern of left-right alternation through the body. Some progressive muscle relaxation guided meditation can be very detailed (e.g., challenging you to work with even the smallest of muscular contractions), whereas others are very general.

A full progressive muscle relaxation exercise that covers the whole body, if done slowly and mindfully, can take upwards of 20 minutes to complete. Such an exercise can be an excellent technique for clients who struggle with sleep. However, in most arenas of life, going into a full 20-minute exercise, especially one that may result in complete relaxation and sleepiness, is not optimally realistic. Thus, clients can be encouraged to use the same spirit of isometric muscle contraction used in progressive muscle relaxation in a simplified, "express" format. The following is an example of how one might teach such a skill to a client and work with variations [33].

Have you ever been so angry or stressed you just want to make fists and hit something? In this exercise, you'll be able to make that first…and then practice mindfully, intentionally letting go. Here are the steps:

- Make fists.

- As you focus on your clenched fists, bring to mind something that stresses you out.

- As you reflect on the stressor, really notice the contraction of your muscles. Feel your fingernails dig into your skin, if possible.

- Whenever it feels too uncomfortable for you to keep holding on, know that you can slowly, mindfully let go at any time.

- Notice your fingers uncurling, and feel the trickle of letting go all through your arms, up to your shoulders.

- Notice how it feels to let go.

Clinicians can repeat this basic, core exercise with a client for as many repetitions as necessary and helpful. There is no right or wrong experience that said client should be feeling after the letting-go motion. Rather, this can be a way to help clients cultivate the practice of noticing how certain experiences feel in their body. Alternatively, the client's observations may be used as a channel for dialogue within a standard clinical skill set. For instance, one time I did this exercise with a client who struggled with letting go of things that no longer served her—old memories, old relationships, old beliefs about herself. I guided her through this exercise, using the standard line, "Whenever it feels too uncomfortable for you to keep holding on, know that you can slowly and mindfully let go." My client held on tightly for 15 minutes—the longest I have seen a client hold it. We rode out the experience for a few minutes in silence. She finally broke the ice declaring, "I guess I can really hold on to things for a long time." We ended up having one of the most productive dialogues in our clinical relationship about how holding on to things was a barrier to her health and wellness.

Prior to us doing this exercise, this client was very hesitant about doing anything too deep, explorative, or cathartic with her therapy. Within a few sessions using this simple clench-and-release technique, the client knew that she could no longer stall with her therapy if she wanted to reach her goals.

Clinicians very often talk with clients about the importance of letting go: letting go of the past, letting go of fear, letting go of anger or resentment. The 12-step recovery model places a great deal of emphasis on letting go of resentments. This extensive talk about the virtues of letting go can continue with no results, or clinicians can dynamically, experientially urge clients to work with the concept of letting go, hopefully allowing them to experience how good it can feel to do it.

There are extensive modifications and creative variations that can be made if the basic clench-and-release exercise does not seem to optimally resonate with a client. Some examples include:

- Any muscle group can be clenched and released, especially if clenching the fists is too painful or not possible due to context or physical limitations. Clenching and releasing the stomach and feet are other popular choices.

- A bilateral component can be added to the exercise. For instance, consider clenching the left fist first for a period of time, then move over to the right fist and repeat the motion. Continue alternating left-and-right, giving it a minimum of three sets. Notice if it gets more difficult to "clench" after each sequence of "release."

- Add a relaxing sound (e.g., nature sound, music) in the background or use an aromatherapy diffuser, particularly if using this exercise for sleep.

- The client can be instructed to write down a stressor, resentment, or thing that they wish to let go of on a slip of paper. For some, hearing the drop of the paper to the floor, or releasing it into a recipient (e.g., a trash can, the wind, a flowing river) makes the release experience even more powerful.

In a later section of this course, we will explore how this clench-and-release principle can be used as an actual dance exercise with a client or other recipient.

BILATERAL MOVEMENTS FOR STRETCHING AND CLEANSING

In the clench-and-release variations, adding a bilateral element is noted as a possible option that can be powerful for many. Most clients report a greater sense of relaxation doing the clench-and-release technique bilaterally as opposed to using both fists together. There is something special about the power of bilateral movement on the brain (i.e., back-and-forth/left-to-right), as evidenced by ancient spiritual/healing practices (e.g., drum circles) and modern approaches (e.g., EMDR). Modern research in neuroscience is beginning to support one of the core healing principles in Native American healing arts: moving back and forth has a transformative effect on the brain and the body [34].

Contrary to some misinformation, simply invoking bilateral eye movements or other forms of bilateral stimulation will not cause a person to go into a full-on trauma abreaction. As discussed in the book Trauma Competency, [1]:

Bilateral stimulation is not dangerous, nor is EMDR as a modality. If it were, wouldn't it follow that we should all abreact when walking, snapping our fingers, or playing Miss Mary Mac? However, when administered by clinicians without prerequisite knowledge to effectively address and treat trauma's sequelae, the EMDR protocol proves challenging, fear-inducing and, oftentimes, traumatizing for clinicians and re-traumatizing for clients.

Consider this: If you are pairing bilateral movements together with questions for digging deep into a person's past without training in trauma and its effects, you may be treading into dangerous territory. However, as a basic coping strategy, bilateral interventions themselves are not inherently harmful. It truly comes down to the intention of the movement. If paired with the intention to self-soothe or bring the brain back into balance, as opposed to the intention of inducing deep exploration or catharsis, most clinicians are well within their scope to bring them into the therapeutic context. Within the cannon of EMDR literature, master clinician Dr. Laurel Parnell first introduced the idea of using bilateral tapping, paired with positive imagery, as a self-help strategy [35]. Even the founder of EMDR therapy, Dr. Francine Shapiro, followed suit with a book on using basic EMDR techniques as self-help strategies [36]. Both works serve as excellent supplementary resources to the material provided in this course.

Many clinicians may note that clients who have never heard of EMDR therapy intuitively engage in bilateral "techniques" to help alleviate stress. For example:

Whenever a client feels stressed at work, he goes outside and takes a cigarette lighter and tosses it back and forth from one hand to another. Interestingly, he does not smoke cigarettes anymore; he just uses this self-created technique with the lighter.

Another client was intrigued when EMDR was first suggested to her because she said it seemed like a process she has used to help her calm down over the years. She wears a ring on which a bejeweled bumblebee is set on a spring hinge. When you touch the bee, it rapidly moves back and forth horizontally. This client would stare at the back-and-forth motion of the bee to calm herself whenever she felt agitated or triggered.

Think back to your own experiences in elementary school or preschool. Did your teachers ever use techniques like having the class get up and run in place for a minute or so to work out the stale energy and get the blood pumping? Maybe you have even used such an approach with your own children, telling them to go outside and burn off some of that energy. Conversely, when some are too lethargic or sluggish, engaging in a similar pursuit can generate more productive energy. Such activities bring a greater sense of equilibrium to the brain, opening them up for a greater sense of calm and enhanced learning.

Some of this same logic may resonate with clients. Consider the following cases:

- A client comes into the office. They are so high strung and anxious, they can barely sit down to even give voice to what is happening with them on that given day.

- The session "goes stale"—there is either nothing to talk about, or the client has "hit a wall" from talking too much about a specifically heavy emotion.

In either scenario, consider how bringing some simple movement into standard interventions can make a difference. The following approach may work in either scenario: Instruct the client to stand up tall and encourage them to rotate from the hips, letting their arms fall against the body on each side. The client can keep the motion gentle, especially if their mobility is restricted, simply moving the arms at waist-level from side to side. If the client wants to get more movement into the motion, they can make the hip rotation more vigorous, even moving on to the balls of the feet with each back-and-forth motion.

If you have the option in your setting to do "walking therapy" outside, especially in decent weather, you may take advantage of that experience. In his book The Wounds Within: A Veteran, a PTSD Therapist, and a Nation Unprepared, Mark Nickerson (with Goldstein) shared his experience using this approach with a returning veteran who had a serious case of PTSD [37]. The young man was not only unable to sit still to talk, he had a very difficult time making eye contact because of his intense shame. When the veteran client asked if they could take a walk, my colleague was willing to make some modifications to facilitate and found that the client opened up in a way he was not able to in the office. For many who work in the adventure or wilderness therapy model, similar experiences are regularly observed. Indeed, one of the guiding premises of adventure therapy is that there is healing potential in getting out there and doing instead of just sitting around and talking.

If stepping outside of the office is not a feasible option in addressing either of these two scenarios, or if the client is not open to overt physical movement, clinicians have the option of using only the hands. Some refer to this technique "energetic massage," although the title can be modified to best reach the client. The following is an example of how to teach the exercise [33].

Do you ever feel, quite literally like your brain hurts? Wouldn't it be great if you could give your brain a massage? With a simple exercise that harnesses the power of your own tactile (e.g., touch), you can.

- Rub your hands together for at least 30 seconds (or longer if you want). Really work up some heat!

- Pull your hands apart and bring them to your forehead. You can close your eyes, and place the base of your palms over your eyes; let the rest of your hands curl over your forehead to the top of the forehead. Or you can rest the base of your palms on your cheeks and go around your eyes. Choose a variation that is comfortable and helps facilitate relaxation.

- Settle in and feel the energy you generated in your hands move into your brain. Just allow the head to exist without judgement.

- Hold as long as you like.

This simple strategy, which you may already do inherently when you have a headache, can be used in many ways during therapy sessions. First, when the client comes into session and they seem to be talking rapidly and/or are unfocused, this exercise can be done as a simple ceremony to settling in before beginning talking. This can set a much calmer, more even pace for the session. A second option is as a session closer. If the client has been working on difficult material throughout the session, they may be feeling a little exhausted or too overwhelmed to leave. This option can be presented as a "brain massage" to return the client back to balance before leaving the session. As with many of the exercises discussed in this section, a third option is when/if the session "goes stale." If you've hit a wall with the session content or the client seems too exhausted to continue, this energetic massage movement technique can provide the much needed shift.

Other options and variations on this core exercise include:

- Bringing the energy from your hands to any part of your body that is feeling tense or anxious. Think about bringing the heat energy from your hands to your heart/chest or stomach if you are noticing any tension or pain.

- The "cranial hold" position is an option after generating the energy. To achieve this, horizontally bring one hand to your forehead and the other hand to the back of your head.

- Consider adding another sense into the process for optimal relaxation, like meditative music or an aromatherapy oil of your choice.

USING HAND GESTURES AND POSTURING FOR TEACHING NEW BEHAVIORS

So far in this section, we have covered how to bring the "stop" hand gesture into the classic thought stopping coping skills, how to use clenching and releasing to work with the concept of letting go, and how to use bilateral motion achieved via rubbing the hands together for a simple energetic massage. It should be becoming clear that incorporating movement in the context of traditional psychotherapy can be as simple as working with the hands. The next sections will present a few more ideas for how to bring gestures into therapeutic work to highlight certain principles and begin to explore how advocating certain changes in posture can achieve similar effects.

Regardless of one's primary approach to psychotherapy, clinicians are likely to have worked with clients on setting boundaries. Many clients struggle with boundaries, often as a result of trauma and abuse, with possible connection to codependency or co-addiction patterns. A simple exercise based on a yoga gesture (e.g., a mudra) may be included in this work. The following example is of the mudra of self-confidence, also known as the vajrapradama (or vajra) mudra:

- Interlace your two hands together, allowing your thumbs to point up and away from your body.

- Now bring these interlaced hands over your heart. If touching your body feels too invasive or uncomfortable for you, as a variation, you can bring the gesture over your heart without touching your hand to your skin.

- Hold this gesture over your heart for as long as you are able. Think about this gesture as a fence or a guard for your heart. Consider that you are in control of what comes into your heart, and you are in control of what flows from your heart.

- If you ever need to be reminded of this boundary and that you are powerful, come into this hand gesture and hold it, together with your breath, for as long as you need to.

If a client develops another hand gesture or posture that works better for them based on this original suggestion, this can be a great way of incorporating their feedback and creating a useful variation.

Coming into postures of confidence and power can have similarly positive results. Practitioners of yoga, yoga therapy, and many of the newer somatic therapy approaches that will be briefly discussed in the final section of this course are well-acquainted with this principle. How one sits, stands, and postures oneself overall, in relation to others, can tell a great deal about how one feels and/or perceives oneself in that relationship. For many individuals, having an awareness of this relationship dynamic is the first step of awareness that helps them to renegotiate their own perceptions of the relationship through making an adjustment in the posture. Such adjustments are well-known interventions within the Alexander technique.

Case Example

Client A presents to therapy with several goals, one of which is improved, positive assertiveness in her work setting. The client reports a high degree of stress about an abusive boss. Even after many years in his employ, she continually struggles with feeling heard by him, and she knows that the power dynamic he casts is reminiscent of how she related to a previous spouse with alcohol use disorder. Although she identifies that these older wound issues will need to be addressed and healed later in therapy, her therapist begins, during stabilization, to help her develop some skills to better cope in her work setting. The therapist asks Client A if she is sitting or standing during these difficult conversations with her boss. She replies that he always summons her into his office and that the available chair is lower than the boss's own. When the therapist asks her to visualize herself in this scenario and recall how it makes her feel, she reports that she feels small in his presence, and because of that, she has a natural tendency to curl or cower inward. Inspired by work with trauma-informed chair yoga, the therapist/client dyad spends some time in the session working on how to sit with confidence: sitting forward in the chair so that her feet can remain firmly planted and grounded on the floor, spine upright and straight, shoulders relaxed away from her ears. In the first part of the exercise, Client A simply practices this posture, specifically practicing coming into it from her natural position, which is to sit back in the big chair and cower inward while her shoulders are spiking up toward her ears. After the client feels confident with the posture, she then visualizes sitting in this more confident posture while in her boss's presence. As a homework assignment, the therapist advises her to practice coming into this seated posture every day, pairing it with some of the breath exercises, other safeguard visualizations, and other positive affirmations she is learning in her therapy/healing. When it comes time to actually speak to her boss again, Client A is able to use this simple shift in her posture, which she reports allows her to speak more confidently and feel less affected by the boss's natural critical countenance.

SITTING AND STANDING WITH INTENTION

If Client A had typically interacted with her boss while standing, the exercise could have been easily adjusted to target the standing posture and to practice standing with confidence. A common question in counseling and community settings is what skill can be used when talking to a difficult person. For these situations, it can be most effective to teach one of the foundational poses of yoga: mountain pose (tadasana). To a casual observer, mountain pose may not look very dynamic: it may appear that the practitioner is standing and looking out at the horizon. But there is power in standing with purpose and intention—embodying the power and grace of a mountain. Notice the full surface area of the foot connected to the earth below. Keeping one's gaze to the horizon can help support standing with purpose and confidence. Let the shoulders relax away from the ears, and feel the crown of the head extend to the sky. Allow the hands to rest gently at one's side if practicing this inconspicuously, or if practicing alone or with more intention, consider facing the palms out.

The simple motion of moving from sitting to standing may also be used as a technique for working with clients with movement. Rising from a seated position, assuming physical capacity, is something that most take for granted. Yet even this simple activity of life can be practiced mindfully, allowing one to build an even greater sense of body awareness and empowerment. One example of how this technique (referred to as full body rising) can be taught follows [33].

Whenever one does an activity that is normally automatic in a slow, mindful way, it is a perfect chance to cultivate the attitude of patience. Consider the following exercise:

- While in a sitting position, allow your upper body to fold over your seated, lower body. Your hands do not need to touch the ground, but aim there. Take a few moments and notice how it feels when the blood moves to your head as you fold over.

- Very slowly and carefully, allow your buttocks to lift off of the chair while remaining in the bent-over position. If your hands can touch your feet or the ground, do that; if not, just allow your hands to fall wherever they may on your legs.

- Stay in this folded over, "rag doll" position as long as you are able.

- Slowly, mindfully begin to unfold your spine and rise. Think one vertebra at a time; avoid just rushing up.

- When you have totally unfolded, let your shoulders roll back and keep your gaze straight ahead, with confidence. Notice how you feel.

As with all of the activities presented in this chapter, there are no "rights" or "wrongs" about what a person should (or should not) be feeling. Rather, use the feedback that clients give about the experience to elicit further dialogue within the existing therapeutic context, or use the feedback to make modifications. For instance, if a client is unable to stand, they can still achieve the benefits of this exercise by doing the first part of bending over and then unfolding the spine. The client can be encouraged to take the confidence stance with their upper body, even in a seated position. One can also incorporate music that creates a vibe of rising or emergence to enhance the mood of growing into confidence. This variation can be especially effective in engaging children.

A yogic breathing technique that can be coupled with a confident posture is an approach called lion breathing. Although many adult clients may be initially too self-conscious to try it, they often find benefit if they are eventually able to overcome their reticence, and it can be a useful coping approach for assertiveness training. The following script can be used to teach lion breathing [33].

Although taking on the full character of a lion is optional with this exercise, allowing yourself to make the face of a lion with this breath can help you with letting go of negativity:

- Begin with a healthy inhale with your nose that allows the belly to expand as fully as possible.

- Exhale vigorously, allowing the tongue to hang out. Feel the jaw and cheeks loosen. Open the eyes widely and let them roll back slightly to help with the sensation of letting go.

- Try at least three to five sets, taking time to adjust to the level of your physical comfort. With each set, see if you can allow your tongue to hang out further. Bring your hands up like lion paws to fully get into the character of the breath.

Following attempt of this exercise, individuals should experience a loosening in the jaw on both sides. We often discuss how important it is to stretch the joints, but the jaw, one of the most powerful joints in the human body, tends to be overlooked. It is often said that when a trauma or other stressor has silenced someone, it is felt somatically through jaw pain or throat tension. Doing an exercise like lion breathing, and practicing it with consistently, is a way to promote movement in the somatic and energetic body and resultantly serve as an aid in building confidence. After teaching lion breathing in the office setting, clients can be advised to craft a few minutes each day where they can practice the exercise on their own. As a variation option, adding a musical track that one finds empowering can take the exercise to a new dimension. Although going into a difficult conversation with a boss or other person while doing lion breathing is generally not advised, taking a few minutes to do some lion breaths before going into these types of interactions can make a significant difference.

With lion breathing or any of the strategies, you never want to engage in them to the point of physical pain. Hence, starting with a simple one or two sets of the breath is generally advised until you see how well a person will tolerate the technique. The same spirit of encouraging clients to listen to their body's own limits must also be taken into the next series of exercises.

RITUAL MOVEMENTS FOR LETTING GO AND RELEASE

There can be healing power for many in both ritual and ceremony. For many indigenous cultures, the idea of helping a person to heal without involving ceremony would not be possible. Although one could argue that there is a certain ceremony to the process of coming to an office and sitting down in the therapist's chair, it is a ceremony that has become more of a mindless ritual in modern society. For clinicians committed to bringing in more creativity and movement into their practice of psychotherapy, the essential question is: How can I make the process more dynamic and engaging for my clients?

Reflection

Scan your memory of your practice. What are some of the memories that stick out to you about when you’ve worked with the client to come up with a creative solution to a problem at hand? What role did creativity, specifically invoking some type of ritual or ceremony, play in that solution? Take time to make notes of how these approaches might inform work with your current clients.

A time-honored psychotherapy technique from the Gestalt tradition is the unsent letter technique. In this process, a person writes, in letter form, everything that s/he would like to say to a person who was a source of trauma or offense. When making use of this technique, clients are encouraged to get it all out—avoid censoring language or judging emotional content. Assuming that the client is stable and ready enough to handle this process, they should be supported in really letting it all out. Together, after they've released the emotions through the physical process of writing, devise a method for best releasing the unsent letter. This is where movement, ceremony, and ritual can be introduced to enhance the process. Some people choose to rip their letters up and leave them in the trash bin in the office (again, symbolizing letting go and leaving it behind), whereas others may choose to burn the letter, noticing the rising smoke as a symbolic releasing of the pain in the letter to God/Higher Power/nature. Others may choose to leave unsent letters at a cemetery, if the letter is to someone who has passed away. The options here are endless; the common denominator is that the physical processes involved with these activities powerfully activate the brain to help with the overall sense of release.

Such a ceremonial process may be particularly helpful if a person is struggling with complicated mourning issues, especially if there were words left unsaid or the client/mourner was unable to say goodbye in the way that they would have wished. Taking an unsent letter to a gravesite may be sufficient, but others may want to invite others in to witness the process. Perhaps bringing in the element of fire to burn the letter and setting the intention of it rising to the heavens with the smoke can add to the richness of the ceremony. Bringing in loved ones' favorite songs may also add a dimension to the ceremony.

Experts have also identified a variety of ideas for incorporation of elements of traditional ceremony and ritual into the Western counseling process [4,7]. This can include Native American customs and ceremonies, traditional Chinese medicine practices, and yogic traditions. For example, the text Yoga Skills for Therapists provides examples of how psychotherapists can weave elements of yoga into their own practices without formal training [38].

Although this course will cover direct dance strategies for letting go and release in the next section, a simple movement technique can also be useful as a ritual/ceremony for "shaking off" negativity or stress. Inspired by Cornelius Hubbard, this exercise is referred to as noodling. Like running in place, it can have a similar effect to getting a person whose attention has drifted or who has become overwhelmed to refocus. The following is a sample script for teaching noodling [33].

Haven't you ever envied a cooked noodle? The way it just moves free and easy, without stress, is an admirable quality that can teach us how to practice the attitude of letting go. Think of how fun, and potentially beneficial, it could be to take on the role of a noodle.

- For optimal benefit, rise to your feet (although you can also do this sitting or lying down).

- With your next breath, think of taking on the qualities of a noodle…it is suggested that you begin in your shoulders and then let the "noodling" move through the rest of your body.

- Keep noodling, in an intentional way, practicing beginner's mind, nonjudgment, and non-striving for at least three minutes.

- When you have completed this exercise, allow yourself to be still for a few moments longer (either standing, sitting, or lying down), and notice how it feels.

- Although you can do this in silence, one potential creative modification is to put on some music that can bring out your inner noodle. You can also bring scarves, ribbons, or others props into the action—this is an especially fun exercise to engage children.

As with many of the exercises covered thus far, the dialogue with clients following their attempts of these exercise can be powerful. Comments from clients following an attempt at noodling can lead to an amazing discussion about how hypervigilence plays a role in mental health and body sensations. Clients may begin to get a sense of the extent to which somatic hypervigilence is engrained and how it keeps them from fully "relaxing into" and ultimately enjoying life.

DANCING MINDFULNESS

In 2010, I worked to develop "dance-based" interventions that can be woven into traditional psychotherapy through the lens of a practice called Dancing Mindfulness. Dancing Mindfulness is an approach that uses the human activity of spontaneous dance as a mechanism for teaching and practicing mindfulness meditation. The practice adapts the classic practices of mindfulness in Eastern philosophy for a more Westernized audience using an expressive art form [39]. While various articles and writings within the field of dance therapy reference mindful movement, Dancing Mindfulness exists outside of the structured precepts of dance therapy. Whereas dance therapy approaches may draw upon mindfulness, Dancing Mindfulness is a modern approach to mindfulness meditation that draws on dance as the vehicle for practicing the present-focused meditation. Meditation is any activity that helps one systematically regulate attention and energy, thereby influencing and possibly transforming the quality of experience in service of realizing the full range of humanity and of relationships to others in the world [27]. There are numerous ways to meditate, with different approaches having nuanced effects for individual practitioners [40]. A study consisting of interviews with both nuns and laywomen led Buddhist teacher Batchelor to conclude that the specific techniques of meditation used do not seem to matter as much as one's sincerity in practicing the Dharma, or "the body of principles and practices that sustain human beings in their quest for happiness and spiritual freedom" [41].

Although the phrase Dancing Mindfulness has been coined to describe an approach to mindfulness meditation, cultures around the globe have collectively drawn on the power of dance and present-moment meditation since the dawn of time. Dancing Mindfulness is a wellness practice that grew from my clinical experiences working with trauma and addiction. It can be learned in a group class and practiced in community as well as individually; experience in yoga, meditation, or dance is not required to practice. Participants are simply asked to come as they are with attitudes of open-mindedness. Structured classes begin with a facilitator gently leading participants through a series of breathing and body awareness exercises. Following a mindful stretch series, the facilitator leads participants up to their feet for letting go and dancing with the freedom one might tap into by simply turning on some music and dancing around their houses. Many participants find this practice, especially when supported by the energy of other practitioners who are also taking risks, a cathartic experience. Although some find themselves overwhelmed and intimidated, they are encouraged to just acknowledge their experience, without judgment, and can choose to opt out of a certain dance or use their breath and movement as vehicles for moving through the discomfort. Safety is imperative to Dancing Mindfulness practice—facilitators emphasize that no one ought ever feel forced to participate in any component of the practice.

The primary attitudes cultivated by mindful practice, as identified by Kabat-Zinn in his synthesis of mindfulness research, are used as thematic guidelines in structuring classes: acceptance, beginner's mind, letting go, non-judging, non-striving, patience, and trust [27]. Any of these attitudes may be used as a thematic guide in choosing music for the class, or the facilitator may call upon a series of these attitudes in dancing with an element. The elements of Dancing Mindfulness are networks through which mindfulness can be practiced: breath, body, mind, spirit, sound, story, and fusion of all the elements. A facilitator may elect to start the class working with breath in silence, advising participants that when they use their bodies to come up to their feet and dance, their breaths are with them as a guiding force. Using breath to guide movement is a way, for example, to cultivate the attitude of trust.

Although Dancing Mindfulness was developed within a group context, the attitudes and elements of dancing mindfulness can be used as part of a daily wellness practice and in individual work with clients. Many Dancing Mindfulness facilitators use the practice as an adjunctive activity in clinical settings, bringing moving meditations inspired by Dancing Mindfulness into individual sessions with clients. The following sections will outline versions of some of these mindfulness-informed approaches. Learners are encouraged to try the interventions out first and then determine if they can or should be weaved into work within clients in their existing therapy setting and therapeutic approach. When it comes to physical safety, be sure to advise clients to listen to the feedback that their bodies give them about how far or how fast they are going. In terms of your own clinical scope of practice, if any of these exercises are going to be used for more of a cathartic experience, be sure that you feel comfortable addressing, within your existing therapeutic orientation, what may come up during the movement process.

Clench-and-Release Variation

One Dancing Mindfulness-inspired approach is to take the clench-and-release exercise (discussed previously) to a more dynamic, "dancey" place. The purpose of this dance is to consider whatever it is you are holding onto: anger, resentment, hatred. It is up to the individual to decide what they want to work with. After this selection is made, the dancer is instructed to take two stress balls and grip their hands tightly around them. As the music inspires, they should move through the space and notice the experience of holding on. It is important to allow time for this process. In addition, the choice of music is very important here; "angstier" music can generate more tension in dancers, which is useful here. When the song ends, the client should be instructed to release the stress balls, notice them leave their hands, and drop to the floor. Ask the client to take a moment to notice how good it can feel to let go and to let the earth absorb any of the negativity that arose in the room.

It is generally a good idea to choose the next song as a counterpoint, one that continues to work with the power of release. As a caution: Not everyone likes this dance; some may feel that it is "too much." For those attempting this facilitation in a group or within an individual counseling setting, remind your group or individual client that opting out is always an option. As a variation, the individual could do the same dance without stress balls—simply have people clench their fists and when you invite the release, have them notice how good it feels to release the grip on the hands. Encourage the opening of the hands to trickle into the rest of the body and then dance with that sense of release.

Mindful Music Listening

If an exercise like this seems too advanced or risky for your clients, consider working with the client in the context of a mindful listening exercise and then adding in some movement if it seems organic. Too often, music is in the background. In this exercise, the client can explore how really paying attention to the music in a nonjudgmental manner can usher in a new experience. Clinicians are encouraged to try all four parts of this exercise, in order, before attempting it with clients. It can be an excellent exercise for personal practice in addition to working on it with clients or students.

To start, ask clients to get into a comfortable yet alert position, as if about to do a seated or lying down meditation. Then, cue up a piece of music that the client has never heard before. For the length of the song, their only task is to pay attention to the song, listening mindfully. Just be with the experience.

After a few minutes of silence, cue up the song again and let the music connect with breath. Be open to movement should it happen, and just go with it. Some clients will only be inspired to sway and swivel a little bit; others may break out into a full-on dance routine. Whatever happens, just honor the experience.

Now, find a piece of music that the client knows very well, preferably something that they connect with emotionally. Instruct the listener to return to a sitting or lying meditative position and listen to this piece of music with total awareness, as if it is the first time they are hearing it. Once again, just be with the experience and notice what happens within when listening with mindful ears.

Finally, replay the song, only this time being open to movement. Just go with it, and notice what happens.

5. FURTHER TRAINING & COLLABORATION

Reflection

“Almost all creativity involves purposeful play.” –Abraham Maslow

Consider for a moment how purposeful play in the form of dancing and movement might inspire your clinical practice. How do your own experiences with movement inform your understanding of other individuals and cultures?

IS FURTHER TRAINING RIGHT FOR MY CLINICAL PRACTICE?

If the interventions outlined in this article excite you, there is a chance that you may want to pursue further training in dance and/or movement modalities as part of your continuing education. There are several avenues that you can explore—the conscious dance routes (e.g., 5Rhythms, Dancing Mindfulness); the more structured dance, movement, and expressive arts therapies routes; and finally, approaches to psychotherapy that typically are not viewed as dance/movement therapy, but certainly incorporate movement and somatic work (e.g., EMDR therapy, somatic experiencing). This section will provide a very brief overview of available avenues and resources for further information.

If you are interested in the conscious dance route, consider visiting https://consciousdancer.com, the official website of Conscious Dancer Magazine and the DanceFirst Association. Of particular interest may be the Upshift Guide, which lists summaries and training requirements for more than 100 conscious dance modalities operating around the world. The training lengths for each modality vary, although it is not unrealistic to complete full training in some modalities within several weekend modules. Conscious dance training is generally ideal for those who seek to bring movement practices into the larger community (e.g., yoga studios, churches, schools, wellness fairs, festivals) and not just in a clinical setting. In addition, those who work in a clinical setting that is open-minded to practices like this, having some training in a conscious dance form will generally suffice to support the incorporation of dancing approaches into clinical practice.

For those who are looking for a more structured experience in dance/movement or expressive arts therapy, there are options available through the ADTA (https://www.adta.org) and the International Expressive Arts Therapy Association (https://www.ieata.org). Both entities offer formal training programs, many of which come with continuing professional education. For the ADTA route, to become a registered dance and movement therapist, a period of working with an approved supervisor is required. The ADTA also lists Master's degree programs that they recognize in dance and movement therapy for fulfilling much of these requirements, although a post-Master's training route is available for those wishing to register as a dance/movement therapist after having completed a general clinical Master's degree. The IEATA model allows for individuals to become certified through both traditional and non-traditional models of demonstrating their training and education. These paths are recommended for clinicians who truly want to deepen their educational experience and those who are likely to work in settings where formal accreditations are expected and/or required.

A final, and perhaps the most career-advantageous, path could be to explore the newer wave modalities of psychotherapy that utilize somatic interventions and creative affect tolerance modalities. Many of these, like dialectical behavioral therapy and EMDR therapy, are recognized in the SAMHSA Evidence-Based Practices Resource Center. Others, such as sensorimotor psychotherapy, are increasingly gaining credibility based on their grounding in the latest findings in trauma-informed care and neurobiology. In addition to the traditional modalities in movement discussed in the first section of this course, clinicians should also consider checking out the regulatory websites of these modalities for information about training and formation:

- EMDR therapy: https://www.emdria.org

- Dialectical behavior therapy: https://dbt-lbc.org

- Somatic experiencing: https://traumahealing.org/professional-training

- Sensorimotor psychotherapy: https://sensorimotorpsychotherapy.org

- Psychomotor psychotherapy: https://pbsp.com

- Hakomi mindful somatic psychotherapy: https://hakomiinstitute.com

- Body psychotherapy: https://www.usabp.org

The imperative here is not that all persons interested in incorporating movement into their clinical practice must seek training in every one of these modalities. Rather, they offer a potential avenue for blending somatically informed movement work into a psychotherapy practice. Learners are encouraged to visit the sites, read about each, watch demonstration videos, and if possible, arrange to have some work in each modality done. This process of inquiry will provide a good idea of which approach best resonates and will likely prove to be the best fit for your practice.

COLLABORATING WITH OTHER PROVIDERS

After participating in this course, clinicians should be empowered to, at least, try out some of these movement practices themselves. Even those who do not foresee incorporating movement or dance approaches into work with clients are encouraged to experiment with making them a part of their own self-care. In between stressful meetings or client appointments, consider if you might incorporate a little movement to improve posture or to shake the stress away.

In addition, clinicians should consider the option of collaboration with other professionals. Even if pursuing formal training is not appealing, consider exploring some of the websites and organizations provided. They might be able to direct you to providers in your area who are willing to work with you collaboratively. Especially if it seems like you have exhausted the extent of your clinical repertoire with a certain client, sending them for some supplemental sessions in one of the modalities described here may be a good fit. Many conscious dance or yoga classes offered in communities have a healing spin that is appropriate for clients. Bringing these to clients' attention as resources they can seek out for coping can be helpful, as long as you check back in with them after they sought out the suggestion to make sure that it was not unproductively triggering in any way. This follow-up feedback can be used to continue working with them on wellness measures.

6. CONCLUSION

The intent of this course was to inspire creative thought processes related to how to work movement and dance modalities into an existing psychotherapy practice. There are many options available using various traditions and levels of movement engagement. The creative descriptions are intended to be resources to support work on some of these skills. Before passing them along to clients, it is important to have first tried them. If you have been able to incorporate movement or dance exercises into your daily life and wellness practice, you are in an even better position to be an ambassador for movement.

7. APPENDIX 1: MULTICULTURAL AWARENESS AND COMPETENCE

As discussed throughout this course, dance and movement have long cultural traditions around the world, and the healing properties of movement have been a staple in ancient and modern communities. With this in mind, all clinicians should be mindful of the role of clients' cultural identity, beliefs, and traditions as well as of the cultural roots of modalities.

In its Code of Ethics and Standards, the American Dance Therapy Association has established criteria for providing culturally competent dance/movement therapy [42]. Although this code applies to certified dance therapists, it provides a good guideline for all clinicians incorporating movement, dance, and/or somatic techniques into their practice. The Code includes the following requirements for clinicians [42]:

- Dance/movement therapists should consider the role of cultural context in the practice of therapy and continuously attend to developing the awareness, knowledge, and skills needed to competently work with diverse client groups.

- Dance/movement therapists examine the meaning of their ethnic and cultural backgrounds and how they may affect cross-cultural therapy dynamics.

- Dance/movement therapists develop awareness of their own worldviews, values, and beliefs and seek to understand the worldviews, values, and beliefs of their clients.

- Dance/movement therapists actively engage in broadening their knowledge of all cultures and in particular acquire information about the cultural group(s) with whom they are working, with attention to the inherent strengths of the cultural group. Dance/movement therapists seek this knowledge from multiple sources.

- Dance/movement therapists are sensitive to individual differences that exist within a cultural group and understand that individuals may have varying responses to cultural norms.

- Dance/movement therapists consider the impact of societal dynamics of power, privilege, and oppression on individual client experience and behavior.

- Dance/movement therapists inquire about client concerns, including perceptions of racism, language barriers, or cultural differences, which the client may experience as compromising trust and communication in the therapy relationship or treatment setting.

While these ethical standards do not vary significantly from the codes of ethics governing the various behavioral and mental health professions, there are unique considerations when considering the inclusion of culturally bound traditions. For example, tribal dance has been a vital component of many Native American communities, and clients from these backgrounds (and potentially beyond) may express interest in incorporating indigenous dance into mindfulness practices and/or therapeutic work. Behavioral health service providers should recognize that Native American tribes represent a wide variety of cultural groups that differ from one another in many ways [6]. Each Native American culture has its own specific healing practices, and not all of those practices are necessarily appropriate to adapt to behavioral health treatment settings. However, many traditional healing activities and ceremonies have been made accessible during treatment or effectively integrated into treatment settings. These practices include sacred dances (such as the Plains Indians' sun dance and the Kiowa's gourd dance) [6]. Clinicians from outside of these communities should seek consultation with a Native expert and/or refer clients to a culturally appropriate community or professional resource.

BEST PRACTICES FOR CULTURALLY RESPONSIVE CARE

The U.S. Department of Health and Human Services has outlined steps important to incorporate in evaluation and treatment planning processes to ensure culturally competent clinical and programmatic decisions and skills [6].

The first step is to engage clients. In nonemergent situations, it is important to establish rapport before asking a series of assessment questions or delving deeply into history taking. Providers should use simple gestures as culturally appropriate (e.g., handshakes, facial expressions, greetings) to help establish a first impression. The intent is that all clients feel understood and seen following each interaction. Culturally responsive interview behaviors and paperwork should be used at all times [6].

When engaging in any client teaching, remember that individuals may be new to the specific language or jargon and expectations of the diagnosis and care process. Clients should be encouraged to collaborate in every step of their care. This consists of seeking the client's input and interpretation and establishing ways they can seek clarification. Client feedback can then be used to help identify cultural issues and specific needs. If appropriate, collaboration should extend to include family and community members.

Assessment should incorporate culturally relevant themes in order to more fully understand clients and identify their cultural strengths and challenges. Themes include [6]:

- Immigration history

- Cultural identity and acculturation

- Membership in a subculture

- Beliefs about health, healing, and help-seeking

- Trauma and loss

In some cases, it may be appropriate and beneficial to obtain culturally relevant collateral information, with the client's permission, from sources other than the client (e.g., family or community members) to better understand beliefs and practices that shape the client's cultural identity and understanding of the world.

Practitioners should work to identify screening and assessment tools that have been translated into or adapted for other languages and have been validated for their particular population group(s). An instrument's cultural applicability to the population being served should be assessed, keeping in mind that research is limited on the cross-cultural applicability of specific test items or questions, diagnostic criteria, and concepts in evaluative and diagnostic processes [6].

Typically, culturally responsive care establishes holistic treatment goals that include objectives to improve physical health and spiritual strength; utilizes strengths-based strategies that fortify cultural heritage, identity, and resiliency; and recognizes that treatment planning is a dynamic process that evolves along with an understanding of client history and treatment needs. In addition to these general approaches, specific considerations may be appropriate for specific populations.

CREATING A WELCOMING AND SAFE ENVIRONMENT

Ensuring clients feel comfortable enough to participate in therapy, including movement and/or dance approaches, begins with client comfort. This can be facilitated, in part, by providing a welcoming environment. The basis of establishing a safe and welcoming environment for all clients is security, which begins with inclusive practice and good clinician-client rapport. Shared respect is critical to a client's feeling of psychological well-being. Security can also be fostered by a positive and safe physical setting. As such, therapy environments should be controlled in a way to minimize traumatic stress responses. Providers should keep this in mind when structuring the environment (e.g., lighting, arrangement of space), creating processes (e.g., layout of appointments or care systems, forms), and providing staff guidance (e.g., nonverbal communication, intonation, communication patterns). During each encounter, the client's perception of safety is impacted by caretakers and ancillary staff.

Experts recommend the adoption and posting of a nondiscrimination policy that signals to both clinicians and clients that all persons will be treated with dignity and respect [43]. Also, checklists and records should include options for the client defining their race/ethnicity, preferred language, gender expression, and pronouns; this can help to better capture information about clients and be a sign of acceptance to that person. If appropriate, providers should admit their lack of experience with client subgroups and seek guidance from clients regarding their expectations of the visit.

Front office staff should avoid discriminatory language and behaviors. For example, staff should avoid using gender-based pronouns, both on the phone and in person. Instead of asking, "How may I help you, sir?" the staff person could simply ask, "How may I help you?" Offices that utilize electronic health records should have a system to track and record the gender, name, and pronoun of all clients. This can be accomplished by standardizing the notes field to document a preferred name and pronoun for all clients [44]. Persons who identify as nonbinary (i.e., neither or both genders) or with dissociative identity disorder may prefer that plural pronouns (e.g., they) be used.

Questions should be framed in ways that do not make assumptions about a client's culture, gender identity, sexual orientation, or behavior. Language should be inclusive, allowing the client to decide when and what to disclose. Assurance of confidentiality should be stressed to the client to allow for a more open discussion, and confidentiality should be ensured if a client is being referred to a different healthcare provider. Asking open-ended questions can be helpful during a history and physical.

8. APPENDIX 2: DANCE IN THE CONTEXT OF EXPRESSIVE GROUP THERAPY

When practiced as a formal group modality, dance and movement therapy is included in the larger umbrella of expressive groups, which includes a range of therapeutic activities that allow clients to express feelings and thoughts—conscious or unconscious—that they might have difficulty communicating with spoken words alone. The purpose of expressive therapy groups is generally to foster social interaction among group members as they engage either together or independently in a creative activity. These groups therefore can improve socialization and the development of creative interests. Further, by enabling clients to express themselves in ways they might not be able to in traditional talking therapies, expressive therapies can help clients explore their substance abuse, its origins, the effect it has had on their lives, and new options for coping. These groups can also help clients resolve trauma that may have been a progenitor of their current presenting problem. For example, clinical observation has suggested benefits for female clients with substance use disorder involved in dance therapy [45]. Expressive therapy groups often can be "a source of valuable insight into clients' deficits and assets, both of which may go undetected by treatment staff members concerned with more narrowly focused treatment interventions" [45].

The actual characteristics of an expressive therapy group will depend on the form of expression clients are asked to use. Expressive therapy may use music, dance, or free movement. Expressive group leaders generally will have a highly interactive style in group. They will need to focus the group's attention on creative activities while remaining mindful of group process issues. The leader of an expressive group will typically need to be trained in the particular modality to be used (e.g., dance therapy). In some cases, expressive therapies can require highly skilled staff, and, if a program does not have a trained staff person, it may need to hire an outside consultant to provide these services. Any consultant working with the group should be in regular communication with other staff, because expressive activities need to be integrated into the overall program, and group leaders need to know about each client if they are to understand their work in the group. Expressive therapies can stir up very powerful feelings and memories. The group leader should be able to recognize the signs of reactions to trauma and be able to contain clients' emotional responses when necessary. Group leaders need to know as well how to help clients obtain the resources they need to work though their powerful emotions [45].

Finally, it is important to be sensitive to a client's ability and willingness to participate in an activity. To protect participants who may be in a vulnerable emotional state, the leader should be able to set boundaries for group members' behavior. For example, in a movement therapy group, participants need to be aware of each other's personal space and understand what types of touching are not permissible.

After clients have spent some time working on their creative activity (e.g., dance), the group comes together to discuss the experience and receive feedback from the group leader and each other. In all expressive therapy groups, client participation is a paramount goal. All clients should be involved in the group activity if the therapy is to exert its full effect [45].

Another point to consider is the role of touch. Touch in a group is never neutral. People have different personal histories and cultural backgrounds that lead to different interpretations of what touch means. Consequently, the leader should evaluate carefully any circumstance in which physical contact occurs, even when it is intended to be positive. In most groups, touch (handholding or hugs) as part of group rituals is not recommended, though in an expressive therapy or dance group, touch may be acceptable and normative. Naturally, group agreements always should include a clause prohibiting physical violence. Whenever the therapist invites the group to participate in any form of physical contact, individuals should be allowed to opt out without any negative perceptions within the group. All members uncomfortable with physical contact should be assured of permission to refrain from touching or having anyone touch them [45].

Leaders also should make sure that suggestions to touch are intended to serve the clients' best interests and not the needs of the therapist. Under no circumstances should a counselor ask for or initiate physical contact. Like their clients, counselors need to learn that such impulses affect them as well. It is wrong for those providing psychotherapy to allow feelings of attraction to dictate or influence their behavior [45].

Works Cited

1. Curran L.Trauma Competency: A Clinician's Guide. Eau Claire, WI: PESI, LLC; 2013.

2. Maron MA. The Healing Power of Sacred Dance. Available at http://www.miriamscyberwell.com/articles. Last accessed March 5, 2024.

3. Winton-Henry C.Dance–The Sacred Art: The Joy of Movement as a Spiritual Practice. Woodstock, VT: SkyLight Paths; 2009.

4. Hammerschlag CA.The Dancing Healers: A Doctor's Journey of Healing with Native Americans. New York, NY: HarperCollins Publishers; 1988.

5. Roth G.Sweat Your Prayers. New York, NY: Penguin Putnam, Inc; 1997.

6. Substance Abuse and Mental Health Services Administration. Improving Cultural Competence: Quick Guide for Clinicians. Available at https://store.samhsa.gov/sites/default/files/d7/priv/sma16-4931.pdf. Last accessed March 5, 2024.

7. Bannitt SP.The Trauma Tool Kit: Healing PTSD From the Inside Out. Wheaton, IL: Quest Books; 2012.

8. International Institute for Bioenergetic Analysis. What Is Bioenergetic Analysis? Available at http://www.bioenergetics-society.com/wp-content/uploads/2012/09/Reading-4.pdf. Last accessed March 5, 2024.

9. Gestaltkritik. What Is Gestalt Therapy? Available at http://www.gestalt.de/english/fritz_perls.html. Last accessed March 5, 2024.

10. Yontef G, Jacobs L, Bowman C. Gestalt therapy. In: Wedding D, Corsini RJ (eds).Current Psychotherapies. 11th ed. Boston, MA: Cengage; 2019: 309-348.

11. Marich J.EMDR Made Simple: 4 Approaches to Using EMDR with Every Client. Eau Claire, WI: Premier Publishing & Media; 2011.

12. Graham M.Blood Memory: An Autobiography. New York, NY: Doubleday; 1991.

13. American Dance Therapy Association. Frequently Asked Questions. Available at https://www.adta.org/become-a-dance-movement-therapist. Last accessed March 5, 2024.

14. van der Kolk BA, Stone L, West J, et al. Yoga as an adjunctive treatment for posttraumatic stress disorder: a randomized controlled trial.J Clin Psychiatry. 2014;75(6):559-565.

15. Marich J.Dancing Mindfulness: A Creative Path to Healing and Transformation. Woodstock, VT: Skylight Paths; 2015.

16. MacLean PD.The Triune Brain in Evolution: Role in Paleocerebral Functions. New York, NY: Springer; 1990.

17. Grey E.Unify Your Mind: Connecting the Feelers, Thinkers, & Doers of Your Brain. Pittsburgh, PA: CMH&W Inc; 2010.

18. Marich J.Trauma Made Simple: Competencies in Assessment, Treatment and Working with Survivors. Eau Claire, WI: PESI Publishing & Media; 2014.

19. Barton EJ. Movement and mindfulness: a formative evaluation of a dance/movement and yoga therapy program with participants experiencing severe mental illness.Am J Dance Ther. 2011;33(2):157-181.

20. Crane-Okada R, Kiger H, Sugerman F, et al. Mindful movement program for older breast cancer survivors: a pilot study.Cancer Nurs. 2012;35(4):1-13.

21. Sze JA, Gyurak A, Yuan JW, Levenson RW. Coherence between emotional experience and physiology: does body awareness training have an impact?Emotion. 2010;10(6):803-814.

22. Graham L.Bouncing Back: Rewiring Your Brain for Maximum Resilience and Well-Being. Novato, CA: New World Library; 2013.

23. American Psychiatric Association.Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Text revision. Washington, DC: American Psychiatric Publishing; 2022.

24. Porges SW.The Polyvagal Theory: Neurophysiological Foundations of Emotions, Attachment, Communication, and Self-Regulation. 1st ed. New York, NY: W.W. Norton & Company, Inc; 2011.

25. Harvey AG, Bryant RA. A qualitative investigation of the organization of traumatic memories.Br J Clin Psychol. 1999;11(38):401-405.

26. Chiesa A, Brambilla P, Serretti A. Functional neural correlates of mindfulness meditations in comparison with psychotherapy, pharmacotherapy and placebo effect. Is there a link?Acta Neuropsychiatr. 2010;22(3):104-171.

27. Kabat-Zinn J.Mindfulness for Beginners: Reclaiming the Present Moment and Your Life. Boulder, CO: Sounds True, Inc; 2012.

28. Ramel W, Goldin PR, Carmona PE, McQuaid JR. The effects of mindfulness meditation on cognitive processes and affect in patients with past depression.Cognit Ther Res. 2004;28(4):433-455.

29. Farb NA, Anderson AK, Mayberg H, Bean J, McKeon D, Segal ZV. Minding one's emotions: mindfulness training alters the neural expression of sadness.Emotion. 2010;10(1):25-33.

30. Lutz A, Greischar LL, Rawlings NB, Ricard M, Davidson RJ. Long-term meditators self-induce high-amplitude gamma synchrony during mental practice.Proc Natl Acad Sci USA. 2004;101(46):16369-16373.

31. Jha AP, Stanley EA, Kiyonaga A, Wong L, Gelfand L. Examining the protective effects of mindfulness training on working memory capacity and affective experience.Emotion. 2010;10(1):54-64.

32. International Society for Traumatic Stress Studies. The ISTSS Expert Consensus Treatment Guidelines for Complex PTSD in Adults. Available at https://istss.org/ISTSS_Main/media/Documents/ISTSS-Expert-Concesnsus-Guidelines-for-Complex-PTSD-Updated-060315.pdf. Last accessed March 5, 2024.

33. Marich J.Creative Mindfulness: 20+ Strategies for Wellness & Recovery. Warren, OH: Mindful Ohio; 2013.

34. Pagani M, Hogberg G, Fernandez I, Siracusano A. Correlates of EMDR therapy in functional and structural neuroimaging: a critical summary of recent findings.Journal of EMDR Practice and Research. 2013;7(1):29-38.

35. Parnell L.Tapping In: A Step-By-Step Guide to Activating Your Healing Resources Through Bilateral Stimulation. Boulder, CO: Sounds True, Inc; 2008.

36. Shapiro F.Getting Past Your Past: Take Control of Your Life with Self-Help Techniques from EMDR Therapy. New York, NY: Rodale; 2012.

37. Nickerson MI, Goldstein JS.The Wounds Within: A Veteran, a PTSD Therapist, and a Nation Unprepared. New York, NY: Skyhorse; 2015.

38. Weintraub A.Yoga Skills for Therapists: Effective Practices for Mood Management. 1st ed. New York, NY: W.W. Norton & Company; 2012.

39. Marich J, Howell T. Dancing mindfulness: a phenomenological investigation of the emerging practice.Explore. 2015;11(5):346-356.

40. Sauer S, Walsh E, Eisenlohr-Moul T, Lykins ELB. Comparing mindfulness-based intervention strategies: differential effects of sitting meditation, body scan, and mindful yoga.Mindfulness. 2013;4(4):383-388.

41. Bodhi B. What does mindfulness really mean? A canonical perspective.Contemporary Buddhism. 2011;12(1):19-39.

42. American Dance Therapy Association. The Code of Ethics and Standards of the American Dance Therapy Association (ADTA) and the Dance/Movement Therapy Certification Board (DMTCB). Available at https://www.adta.org/assets/DMTCB/Code-of-the-ADTA-DMTCB-Final.pdf. Last accessed March 5, 2024.

43. Committee on Health Care for Underserved Women. Committee Opinion #512: health care for transgender individuals.Obstet Gynecol. 2011;118(6):1454-1458.

44. National LGBT Health Education Center. Affirmative Care for Transgender and Gender Non-Conforming People: Best Practices for Front-line Health Care Staff. Available at https://www.lgbtqiahealtheducation.org/publication/affirmative-services-for-transgender-and-gender-diverse-people-best-practices-for-frontline-health-care-staff. Last accessed March 5, 2024.

45. Substance Abuse and Mental Health Services Administration. TIP 41: Substance Abuse Treatment: Group Therapy. Available at https://store.samhsa.gov/sites/default/files/sma15-3991.pdf. Last accessed March 5, 2024.

46. Premier Publishing and Media.Trauma Treatment: Psychotherapy for the 21st Century[DVD]. Ireland: Premier Publishing & Media; 2012.

Evidence-Based Practice Recommendations Citations

1. Management of Posttraumatic Stress Disorder Work Group.VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder. Washington, DC: Department of Veterans Affairs, Department of Defense; 2023. Available at https://www.healthquality.va.gov/guidelines/MH/ptsd/VA-DoD-CPG-PTSD-Full-CPGAug242023.pdf. Last accessed March 25, 2024.