CACTH26 • California Counselors and Therapists 2026-2027

Table of Contents

CACTH26 • California Counselors and Therapists 2026-2027

How to Receive Credit

NetCE 15 Hour Course #76183 • Anxiety Disorders

76183 • Anxiety Disorders

1. INTRODUCTION

2. BACKGROUND

3. OVERALL PREVALENCE, RISK FACTORS, AND CLINICAL COURSE

4. ETIOLOGY AND PATHOPHYSIOLOGY

5. CLINICAL AND DIAGNOSTIC FEATURES

6. ASSESSMENT

7. GENERAL TREATMENT CONSIDERATIONS

8. TREATMENT OF GENERALIZED ANXIETY DISORDER

9. TREATMENT OF PANIC DISORDER

10. TREATMENT OF AGORAPHOBIA

11. TREATMENT OF SOCIAL ANXIETY DISORDER

12. TREATMENT OF SPECIFIC PHOBIA

13. TREATMENT OF SEPARATION ANXIETY DISORDER

14. EMERGING THERAPIES AND NOVEL TREATMENT APPROACHES

15. COMPLEMENTARY/ALTERNATIVE THERAPIES

16. CONCLUSION

Works Cited

Evidence-Based Practice Recommendations Citations

NetCE 6 Hour Course #77630 • Codes of Ethics for Counselors and Marriage and Family Therapists

77630 • Codes of Ethics for Counselors and Marriage and Family Therapists

1. INTRODUCTION

2. HISTORICAL PERSPECTIVES

3. FOUNDATIONS AND SHARED BELIEFS

4. ETHICAL DECISIONS

5. CURRENT ETHICAL CODES

6. SUMMARY OF THE NBCC CODE OF ETHICS

7. A SUMMARY OF THE ACA CODE OF ETHICS

8. SUMMARY OF THE AAMFT CODE OF ETHICS

9. ETHICAL DECISION-MAKING

10. EVALUATING ETHICAL PRACTICE

11. SERVICE DELIVERY THROUGH TECHNOLOGY AND SOCIAL MEDIA

12. CONVERSION/REPARATIVE THERAPY

13. DUAL RELATIONSHIPS

14. CONFIDENTIALITY AND DUTY TO WARN

15. CASE STUDIES

16. SUMMARY OF THE HEALTH INSURANCE PORTABILITY ACCOUNTABILITY ACT (HIPAA) PRIVACY RULE

17. GLOSSARY

18. RESOURCES

19. CONCLUSION

Works Cited

NetCE 5 Hour Course #97364 • Cultural Meanings of Death and Dying

97364 • Cultural Meanings of Death and Dying

1. INTRODUCTION

2. THE UNITED STATES: A MULTICULTURAL LANDSCAPE

3. CULTURAL COMPETENCE AT THE END OF LIFE

4. CULTURAL ORIENTATIONS AND HEALTH DECISION MAKING

5. DEATH AND DYING: WESTERN MEANINGS

6. ISSUES OF DEATH AND DYING: CULTURAL CONSIDERATIONS

7. CULTURALLY SENSITIVE COMMUNICATION STRATEGIES

8. CULTURALLY SENSITIVE PRACTICE AT THE END OF LIFE: ETHICAL CONSIDERATIONS

9. CONCLUSION

Works Cited

Evidence-Based Practice Recommendations Citations

CACTH26 • California Counselors and Therapists 2026-2027

Mark Rose, BS, MA, LP

Deborah Converse, MA, NBCT

www.netce.com

Copyright © 2026 NetCE, All rights reserved.

CACTH26 • California Counselors and Therapists 2026-2027

Expiration Date: 06/30/2027

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.

76183 • Anxiety Disorders

Mark Rose, BS, MA, LP

www.netce.com

Copyright © 2025 NetCE, All rights reserved.

Anxiety disorders are characterized by states of chronic, excessive dread or fear of everyday situations. The fear and avoidance can be life-impairing and disabling. Anxiety disorders result from the interaction of biopsychosocial factors, whereby genetic vulnerability interacts with situations, stress, or trauma to produce clinically significant syndromes. The influence from hereditary factors and adverse psychosocial experiences on anxiety disorder pathogenesis and pathophysiology is complex, but neuroscience advances have greatly improved the understanding of the underlying factors in the development and maintenance of anxiety disorders.

Table of Contents

76183 • Anxiety Disorders

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. BACKGROUND

SAFETY BEHAVIORS AND SIGNALS

PRIMARY FEATURES OF ANXIETY AND RELATED DISORDERS

3. OVERALL PREVALENCE, RISK FACTORS, AND CLINICAL COURSE

PAST YEAR AND LIFETIME PREVALENCE

OVERALL RISK FACTORS

CLINICAL COURSE

COMORBID DEPRESSION

SPECIFIC DISORDERS

4. ETIOLOGY AND PATHOPHYSIOLOGY

ANXIETY DISORDERS IN GENERAL

GENERALIZED ANXIETY DISORDER

PANIC DISORDER

AGORAPHOBIA

SOCIAL ANXIETY DISORDER

SPECIFIC PHOBIA

ADULT SEPARATION ANXIETY DISORDER

5. CLINICAL AND DIAGNOSTIC FEATURES

GENERALIZED ANXIETY DISORDER

PANIC ATTACKS

PANIC DISORDER

AGORAPHOBIA

SOCIAL ANXIETY DISORDER

SPECIFIC PHOBIA

SEPARATION ANXIETY DISORDER

SELECTIVE MUTISM

6. ASSESSMENT

SCREENING FOR ANXIETY DISORDERS IN THE PRIMARY CARE SETTING

SCREENING TOOLS

IDENTIFYING PATIENTS WHO REQUIRE TREATMENT

PATIENT HISTORY

PHYSICAL EXAMINATION

DIFFERENTIAL DIAGNOSIS

7. GENERAL TREATMENT CONSIDERATIONS

PREDICTORS OF WORSE TREATMENT RESPONSE AND OUTCOMES

OVERLAPPING PSYCHOLOGIC AND DRUG THERAPY MECHANISMS

PSYCHOTHERAPIES: OVERVIEW

PHARMACOTHERAPY: OVERVIEW

CLINICAL ISSUES

8. TREATMENT OF GENERALIZED ANXIETY DISORDER

PSYCHOTHERAPY

PHARMACOTHERAPY

9. TREATMENT OF PANIC DISORDER

PSYCHOTHERAPY

PHARMACOTHERAPY

SSRI/SNRI

10. TREATMENT OF AGORAPHOBIA

PSYCHOTHERAPY

PHARMACOTHERAPY

CONTRIBUTING FACTORS TO PANIC DISORDER WITH AGORAPHOBIA TREATMENT RESPONSE

11. TREATMENT OF SOCIAL ANXIETY DISORDER

PSYCHOTHERAPY

PHARMACOTHERAPY

12. TREATMENT OF SPECIFIC PHOBIA

PSYCHOTHERAPY

PHARMACOTHERAPY

A NOVEL APPROACH COMBINING MEDICATION AND EXPOSURE THERAPY

13. TREATMENT OF SEPARATION ANXIETY DISORDER

PSYCHOTHERAPY

PHARMACOTHERAPY

14. EMERGING THERAPIES AND NOVEL TREATMENT APPROACHES

NEUROENHANCING AGENTS TO AUGMENT EXPOSURE THERAPY

CAPNOMETRY-ASSISTED RESPIRATORY TRAINING

NEUROMODULATION THERAPIES

NEW OR NOVEL ANXIOLYTIC AGENTS

15. COMPLEMENTARY/ALTERNATIVE THERAPIES

HERBAL PRODUCTS AND SUPPLEMENTS

EXERCISE THERAPY

YOGA

16. CONCLUSION

Works Cited

Evidence-Based Practice Recommendations Citations

76183 • Anxiety Disorders

Education Category. Psychiatric / Mental Health

Release Date. 05/01/2025

Expiration Date. 04/30/2028

Course Overview

Anxiety disorders are characterized by states of chronic, excessive dread or fear of everyday situations. The fear and avoidance can be life-impairing and disabling. Anxiety disorders result from the interaction of biopsychosocial factors, whereby genetic vulnerability interacts with situations, stress, or trauma to produce clinically significant syndromes. The influence from hereditary factors and adverse psychosocial experiences on anxiety disorder pathogenesis and pathophysiology is complex, but neuroscience advances have greatly improved the understanding of the underlying factors in the development and maintenance of anxiety disorders.

Audience

This course is designed for behavioral and mental health providers involved in the identification, treatment, and care of patients with anxiety disorder.

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 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 6.5 NBCC clock hour(s). Social workers participating in this intermediate to advanced course will receive 15 Clinical continuing education clock hours. NetCE designates this continuing education activity for 15 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

This course has been approved by NetCE, as a NAADAC Approved Education Provider, for educational credits, NAADAC Provider #97847. NetCE is responsible for all aspects of their programming. 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 is approved as a provider of continuing education by the California Association for Alcohol/Drug Educators. Provider Number CP40 889 H 0626. NetCE designates this continuing education activity for 15 continuing education hours for addiction professionals.

Course Objective

The purpose of this course is to provide mental health professionals with the knowledge and skills necessary to appropriately identify and treat patients with anxiety disorders, addressing knowledge gaps, enhancing clinical skills, and improving patient outcomes.

Learning Objectives

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

1. Review basic concepts related to anxiety disorders, including safety behaviors/signals and primary features.

2. Outline the epidemiology of anxiety disorders in the United States.

3. Describe general risk factors for and comorbidities of anxiety disorders.

4. Describe risk factors for and the clinical course of specific anxiety disorders.

5. Discuss the pathogenesis of anxiety disorders in relation to contributing genetic, physiologic, and psychologic factors.

6. Review the pathophysiology of specific anxiety disorders, including social anxiety disorder, agoraphobia, and specific phobia.

7. Apply the clinical and diagnostic criteria for anxiety disorders presented in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

8. Analyze key components of screening and select appropriate screening tools for identification of anxiety disorders.

9. Conduct an informed clinical evaluation and select laboratory testing, in consideration of the differential diagnosis of anxiety disorders.

10. Describe general treatment considerations for anxiety disorders, including predictors of response or nonresponse to therapy.

11. Discuss the role and efficacy of psychotherapy approaches in the treatment of anxiety disorders.

12. Select a pharmacotherapy option appropriate to a given patient's specific diagnosis, age, and comorbidities.

13. Devise a strategy for management and follow-up designed to improve outcomes.

14. Provide patient education more effectively, in relation to specific anxiety disorders.

15. Address the efficacy, safety and limitations of novel, emerging, and alternative/complementary approaches to the treatment of anxiety disorders.

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

Anxiety is an extreme form of worry, life's adaptative response to perceived impending physical and emotional threats both large and small; as such, anxiety focuses attention and, if necessary, prompts one to prepare for "fight or flight." Small moments of anxiety are useful and expected in the course everyday life; such experiences are transient, having no significant impact on social and occupational activities. Anxiety disorders are maladaptive forms of excessive apprehension and fearfulness—taxing, counter-productive, robbing life of its productivity and joy.

Anxiety disorders are characterized by several distinct clinical patterns that share a common refrain: acute exacerbation and chronic states of excessive worry and apprehension around otherwise normal circumstance and everyday situations. Anxiety syndromes include fearfulness in response to social and performance expectations, situational and triggered panic attacks, general (anticipatory) anxiety states, and avoidance (safety) behaviors. The diagnosis of anxiety disorder requires that the patient has experienced a certain number of symptoms or symptomatic episodes for more than a minimum specified period, causing significant personal distress and impairing everyday function [3,350].

Anxiety disorders are thought to develop from the interaction of genetic predisposition in the face of perceived overwhelming challenges to self—biopsychosocial stress or trauma that leads to clinically significant syndromes. The influence of hereditary factors and adverse psychosocial experiences on pathogenesis and pathophysiology is complex, but neuroscience advances have greatly improved the understanding of the underlying factors in the development and maintenance of anxiety disorders.

2. BACKGROUND

SAFETY BEHAVIORS AND SIGNALS

Safety behaviors are coping tactics used by persons with anxiety disorders to prevent, escape from, or diminish the severity of a perceived threat. Safety behaviors are particularly common in persons with panic disorder, agoraphobia, and social anxiety disorder. These behaviors emerge in response to external (e.g., situations, persons, activities) and/or internal (e.g., thoughts, emotions, memories) foci of perceived threat and are either anticipatory (avoidant) or consequential (escape) [1]. While safety behaviors may provide some measure of immediate relief, they have no impact on the individual's propensity for anxiety, nor do they diminish the frequency and severity of future symptomatic events. However, assessment of safety behavior provides guidance for implementing targeted interventions, and accurate assessment and elimination of safety behaviors is often necessary to maximize treatment of clinical anxiety [351].

Another coping mechanism observed in persons with anxiety disorder is safety signals, defined as the people or objects used to diminish distress in situations that elicit anxiety. Safety signals are also potentially counterproductive; they offer immediate relief but facilitate persistence of the anxiety disorder over time by preventing direct confrontation of feared stimuli in the absence of "safe" objects/people and by maintaining perceptions of risk/harm and coping inability. A patient's continued use of safety signals impedes therapeutic progress, in particular the response to exposure therapy. However, safety behaviors may be helpful early in treatment by making exposure therapy more tolerable and less threatening [1].

PRIMARY FEATURES OF ANXIETY AND RELATED DISORDERS

The distinguishing features of specific anxiety disorders are summarized in the following section. Related conditions of post-traumatic stress disorder (PTSD) and obsessive-compulsive disorder (OCD) are included because, although no longer classed as anxiety disorders by the 2013 Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), they are often included in research that pre-dates 2013 and can co-occur with anxiety disorders [2]. Situations or objects that evoke intense anxiety in patients with agoraphobia, social anxiety disorder, or specific phobia are either avoided or endured with significant personal distress.

Generalized Anxiety Disorder

Generalized anxiety disorder (GAD) is characterized by repetitive thinking and intrusive worrying about potentially harmful future events that is persistent (lasting more than a few months) and not restricted to circumstances [3]. While recognizing that some degree of worry may be helpful, patients with GAD report experiencing excessive, uncontrollable worry causing distress or impairment. These patients have physical anxiety symptoms and key psychologic symptoms (i.e., restlessness, fatigue, difficulty concentrating, irritability, muscle tension, and disturbed sleep). GAD is often comorbid with major depression, panic disorder, phobic anxiety disorders, health anxiety, and OCD [3].

Panic Disorder

Panic disorder is characterized by recurrent unexpected surges of severe anxiety ("panic attacks"), with varying degrees of anticipatory anxiety between attacks [3]. Panic attacks are characterized by sudden onset of intense fear (terror) accompanied by such symptoms as uncontrollable trembling, sweating, palpitations, dizziness, shortness of breath, numbness and tingling, and chest pain. These attacks are often incapacitating, typically peak within 10 minutes and last around 30 to 45 minutes. Most patients also develop a fear of having future panic attacks, which is considered a key element in classifying such episodes as panic disorder [3].

Agoraphobia

Around two-thirds of patients with panic disorder develop agoraphobia, defined as fear or avoidance of places or situations from which escape might be difficult or where help might not be available in the event of a panic attack [3]. These places or situations can include crowds, public transportation, or being alone outside of the home [2].

Social Anxiety Disorder

Social anxiety disorder (SAD) is characterized by excessive worry and apprehension in anticipation of social interactions and situations, specifically a fear of being negatively evaluated/judged by others (resulting in embarrassment or humiliation) in social group settings [3]. It is associated with physical and psychologic anxiety symptoms.

Specific Phobia

Specific, simple, or isolated phobia is excessive and unreasonable fear/avoidance of specific objects or situations such as animals (e.g., snakes, insects); the natural environment (e.g., heights, storms); closed spaces (e.g., elevators, caves); or procedures (e.g., venipuncture, dental examination) [3]. Individuals with specific phobia disorder recognize that their specific fear/avoidance reaction is unreasonable but find it intensely distressing or interfering with everyday life. The most common phobias reported by adults involve animals, heights, and flying.

Separation Anxiety Disorder

Adult separation anxiety disorder (SEPAD) is characterized by fear or anxiety concerning separation from those to whom an individual is attached. Common features include excessive distress when experiencing or anticipating separation from home and persistent and excessive worries about potential harms to attachment figures or untoward events that might result in separation [3].

Post-Traumatic Stress Disorder

PTSD is the persistent fear or episodic severe emotional distress that follows actual or threatened death, serious injury, or psychological shock to the physical integrity of self or others (the trauma), with ongoing intrusive symptoms related to the traumatic event. Exacerbations are often triggered by recollections, flashbacks, or dreams; manifestations include avoidance symptoms (e.g., efforts to avoid activities or thoughts associated with the trauma), negative alterations in cognition and mood, and hyper-arousal symptoms (e.g., disturbed sleep, hypervigilance, exaggerated startle response) [2].

Obsessive-Compulsive Disorder

OCD is characterized by recurrent uncontrollable thoughts and ruminations (obsessions) that lead to restlessness and anxiety, followed by impulsive/repetitive physical or mental rituals (compulsions) to alleviate distress. The obsessive-compulsive behaviors are destressing and time-consuming, which impedes normal social and occupational function. Common obsessions relate to fear of personal contamination, accidents, and religious or sexual matters; common rituals include washing, checking, cleaning, counting, and touching [3].

Illness Anxiety Disorder

Illness anxiety disorder is a somatic-symptom related disorder characterized by excessive or disproportionate preoccupations with having or acquiring a serious illness. This includes excessive health-related behaviors and high levels of alarm about personal health status [3].

3. OVERALL PREVALENCE, RISK FACTORS, AND CLINICAL COURSE

Taken together, anxiety disorders (DSM-5 plus PTSD and OCD) have a 12-month prevalence of approximately 19% in the United States, and a lifetime prevalence of approximately 29% [4,5]. The pattern of sex distribution is consistent among anxiety disorders, and the prevalence of any anxiety disorder is higher for girls/women (23%) than for boys/men (14%) [5,6]. Anxiety disorder is more prevalent among adolescents 13 to18 years of age (32%) but less severe, with only 8% having experienced severe impairment. The prevalence of anxiety disorder gradually declines with age, from a high of 23% among all persons 30 to 44 years of age to 9% among those older than 60 years of age. Among surveyed adults having any anxiety disorder, the proportional severity of impairment associated with symptomatic episodes occurring in the previous year was 43% mild, 34% moderate, and 23% serious [5].

PAST YEAR AND LIFETIME PREVALENCE

The reported data on anxiety disorders in the United States include 12-month prevalence, lifetime prevalence, and lifetime morbid risk (Table 1). The two lifetime measures differ. Lifetime prevalence measures the proportion of the population currently or previously diagnosed with the disorder, while lifetime morbid risk measures the proportion who may develop the disorder at some point, independent of their lifetime history at the time of assessment. By including future cases, lifetime morbid risk is believed to be more accurate. Lifetime prevalence and lifetime morbid risk are usually equivalent for disorders with early-life onset, but diverge for disorders with increasingly later onset. The ratio of lifetime prevalence to lifetime morbidity risk falls below 1.0 in disorders with increasingly later onset; the further the ratio values fall below 1.0, the later the median age of onset [7].

Table 1: COMPARISON OF PREVALENCE, MORBID RISK, AND RATIO OF LIFETIME PREVALENCE TO MORBID RISK FOR ANXIETY DISORDERS

Anxiety Disorder

12-month

Lifetime

Lifetime Morbid Risk

Lifetime/Lifetime Morbid Risk

Generalized anxiety disorder

2.0%

4.3%

9.0%

0.5

Panic disorder

2.4%

3.8%

6.8%

0.5

Agoraphobia

1.7%

2.5%

3.7%

0.7

Social anxiety disorder

7.4%

10.7%

13.0%

0.8

Specific phobia

12.1%

15.6%

18.4%

0.8

Separation anxiety disorder

1.2%

6.7%

8.7%

0.8

Source: [7]

Anxiety disorders with earlier median age of onset are phobias and separation anxiety disorder (15 to 17 years of age), and those with latest age of onset are panic disorder and generalized anxiety disorder (23 to 30 years of age). Lifetime morbid risk is considerably higher than lifetime prevalence for most anxiety disorders, with magnitude of difference much higher for disorders with later than earlier age of onset. Also, the ratio of 12-month to lifetime prevalence roughly reflects persistence but varies meaningfully in ways consistent with differential persistence of these disorders [7].

OVERALL RISK FACTORS

Demographic

The odds for a lifetime diagnosis of any anxiety disorder were calculated, and the same pattern was found for past 12 month diagnosis [8]. These odds are organized according to sex, socioeconomic status, education level, and age. Overall, the risk of developing an anxiety disorder is greater for women/girls than men/boys.

Persons in lower income brackets also incur an increased odds of developing an anxiety disorder compared with those in higher income brackets (48% increased risk with $35,000 to $69,000; 52% with $20,000 to $34,000; 100% with $19,000 or less). Lower educational attainment is also a risk factor. Compared with college graduates, the odds of developing an anxiety disorder are increased 44% with 13 to 15 years of education, 76% with 12 years of education, and 86% with 0 to 11 years of education. These disorders are also 40% more likely in persons 15 to 24 years of age compared with older adults (45 to 54 years of age) [8].

Behavioral Inhibition and Temperament

Behavioral inhibition has been defined as a childhood temperament characterized by high levels of caution, avoidance, and fearful response to unfamiliar people, objects, and situations [352]. Children who display behavioral inhibition may exhibit limited ability to handle stress as they mature and are at increased risk of developing anxiety disorders later in life. A study of heightened anxiety in young adults during the COVID-19 pandemic found that behavioral inhibition in childhood was linked to worry dysregulation in adolescence, which in turn predicted elevated anxiety during the pandemic when participants had reached young adulthood [352,353]. Behavioral inhibition and introversion are also strongly linked to later development and severity of situational avoidance, which is a core feature and risk factor in agoraphobia and SAD [9].

CLINICAL COURSE

Anxiety disorders in the aggregate show a U-shaped age of onset—higher in childhood and young adulthood and lower in adolescence. The greatest concentration occurs during transition to early adulthood. Unlike biologically driven pubertal transitions, adulthood transitions involve distinct psychosocial events (e.g., independent living, full-time employment), and this represents a key period for understanding the development of adult anxiety disorders such as panic disorder and agoraphobia [10].

Community studies of persons with sub-diagnostic anxiety symptoms over time often show episodic symptoms and prolonged periods of remission, with symptoms reappearing or worsening during adverse life events and psychosocial stressors. In contrast, studies of clinical anxiety disorder populations typically show a chronic course with fluctuating symptom severity between periods of remission and relapse, with long-term course varying by disorder [3].

Healthcare Utilization

Distressing anxiety symptoms oftentimes consist of somatic complaints, prompting patients to visit an emergency facility or seek out a primary care provider. If anxiety disorder goes unrecognized or is considered a secondary issue, costly medical testing and delay in effective care may result. Societal costs resulting from misdiagnosis, ineffective treatment and work absenteeism attributable to anxiety disorders are substantial. The direct medical expenditure associated with anxiety in adults, including inpatient visits, prescription costs, and office-based visits is estimated at $33.7 billion annually [354]. Recognition of the patient with a pattern of subjective worrying and anxiety, coupled with validated screening, targeted examination and selective testing enhances diagnosis. Effective treatment with pharmacotherapy or cognitive-behavioral therapy (CBT) can be expected to relieve symptoms and minimize costs [2,3].

COMORBID DEPRESSION

Anxiety symptoms often co-occur with other psychologic symptoms. Depressive symptoms are highly prevalent with more severe anxiety symptoms, with anxiety and depressive symptom severity strongly correlated. Patients with anxiety disorder have high comorbidity rates of major depressive disorder (almost 50%), schizophrenia, substance use disorders, and physical illness [3,11]. Overlapping symptoms of anxiety and depression, such as sleep disturbance, fatigue, and difficulty concentrating, make differentiation challenging. Depressive disorders are sometimes termed "anxious-misery" when high levels of sadness and anhedonia are present [2]. Suicidal ideation and rates of suicide attempts are elevated in persons with anxiety disorders, and the suicide risk among patients has been reported as increased by a factor of 10 compared with the general population [54].

SPECIFIC DISORDERS

Generalized Anxiety Disorder

Epidemiology

Studies show that GAD has a 6.2% lifetime prevalence and a 2.0% to 3.1% past-year prevalence in the U.S. population [350]. The lifetime and past-year prevalences are 3.6% and 2.0% in men/boys and 6.6% and 4.3% in women/girls. Most persons with GAD diagnoses are female. The reported prevalence for GAD in primary care patient panels range 3.7% to 14.8% [54]. Childhood or adolescent onset was found in more than 50% of those seeking help for anxiety, reflecting the chronicity of the disease [2].

Risk Factors

No single etiology has been identified for GAD, but it likely involves the interaction of multiple familial/genetic and environmental risk factors. A review of twin and family studies found significant associations between GAD, other anxiety disorders, and depression, suggesting a common underlying genetic basis. A significant number of patients and their first-degree relatives develop GAD (odds ratio 6:1) [12]. Civilian trauma (e.g., motor vehicle accidents, physical or sexual assault, sudden unexpected loss of a loved one, bullying or peer victimization in childhood or adolescence) is a risk factor for GAD [13]. The presence of another anxiety disorder (e.g., panic disorder, SAD, specific phobia) is another possible factor. Panic disorder is comorbid in 25% of patients with GAD [13].

Older adults are the fastest-growing age demographic in the United States. Although late-onset GAD (on or after 65 years of age) is uncommon, clinicians should bear in mind that age-related propensity for anxiety, including the emergence of anxiety disorder, may change over the course of a lifetime. The concerns of aging that may lead to excessive worrying include personal health, the welfare of loved ones, dwindling income, loss of independence, and ability to manage one's affairs at home. The primary predictors of anxiety in the elderly include female sex, recent adverse life events, and chronic physical (e.g., respiratory and cardiac disorders, dyslipidemia, cognitive impairment) or mental health (e.g., depression, phobia, past GAD) disorders. Other risk factors include poverty, parental loss/separation or low emotional support during childhood, and history of parental mental health problems. Late-onset GAD is described as a multifactorial, stress-related affective disorder resulting from proximal and distal risk factors of which some are potentially modifiable by healthcare intervention [14].

Clinical Course

The course of GAD tends to be chronic with fluctuating symptom severity, and GAD may "switch" to other diagnoses, particularly depression and somatoform disorders [15,16]. GAD is associated with impairments in psychosocial functioning, role functioning, work productivity, and health-related quality of life comparable to major depressive disorder or panic disorder. Patients with GAD and comorbid major depression show significantly greater impairment in health-related quality of life than in either disorder alone. Primary care patients with GAD showed significantly higher annual medical costs than patients without GAD (median $2,375 versus $1,448) and higher mean annual medical costs ($2,138) than patients with other anxiety disorders. GAD is frequently under-recognized in primary care, and only 20% to 32% of patients receive adequate treatment. Suboptimal treatment adds to the health-related quality of life burden of this disorder [17].

Panic Disorder

Epidemiology

In the United States, 4% to 28% of the population experience panic attacks at some time during life. The 2.4% 12-month prevalence of panic disorder in the United States is among the highest worldwide [7,18].

Panic disorder prevalence in primary care is approximately 7%, and substantially higher in patients presenting with cardiac or gastrointestinal symptoms. Relative to white patients, the odds of developing panic attacks and panic disorder are higher in Native Americans, and lower in Asian, Hispanic, and black patients [18,19].

Panic attacks are most likely to develop in patients who are in their mid-20s and slightly earlier in men than women. Panic disorder age of onset is usually between late adolescence and 35 years of age, while the age of onset for panic disorder with agoraphobia spans the early 20s to early 30s. Panic disorder is more common among women, with a 2:1 ratio and increasing to 3:1 with panic disorder with agoraphobia. Panic symptoms during adolescence elevate risks for other anxiety and mood disorders in adulthood. Depressive disorders are highly comorbid (33% to 85%), especially among those with agoraphobia [2,20]. Panic disorder is highly comorbid with other anxiety, mood, and substance use disorders, including nicotine dependence, and cigarette smoking may increase the risk for later-onset panic disorder [21].

Risk Factors

As with GAD, the etiology of panic disorder probably results from a combination of risk factors. There is a five-fold greater risk of developing panic disorder when the disorder is present in first-degree relatives. Shared genetic factors account for 30% to 40% of panic disorder heritability [12]. In addition, major adverse life events, especially those involving physical threat (e.g., physical abuse, sexual assault, military service in a combat zone), precede the onset of panic attacks in roughly 80% of patients. Trauma history is prevalent in patients with panic disorder, especially women [22].

Behavioral inhibition may contribute to panic risk in adulthood. Learned escape and avoidance behaviors can maintain the condition and worsen functional impairment over time. Anxiety sensitivity, or the tendency to catastrophically misinterpret physical symptoms as dangerous, is a risk factor for panic disorder. Personality pathology, particularly avoidant and dependent personality traits, are predictors of panic disorder or agoraphobia development [23,24].

Asthma severity is associated with an incremental risk for panic disorder, and respiratory variability may also increase risk for later onset panic disorder [25]. Baseline respiratory abnormalities are specific to panic disorder pathophysiology [6]. As noted, cigarette smoking and nicotine dependence is disproportionately high among patients with panic disorder and may be temporally related to elevated risk for developing panic disorder [26]. Additionally, panic attacks may be related to poorer cessation outcome during smoking treatment among patients with cancer [27]. Caffeine use is also positively correlated with increased anxiety symptoms and risk of inducing panic attacks in patients with panic disorder [28].

Clinical Course

Prospective studies of panic disorder show high rates of symptom chronicity, relapse after remission, and "switching" to other diagnoses [29,30]. Panic disorder symptoms remain persistent for 50% to 80% of cases even after treatment, increasing disability and impaired quality of life [31].

Agoraphobia

Epidemiology

Agoraphobia usually, but not always, occurs with panic disorder. In community populations, about 25% of those with panic disorder also have agoraphobia, but the proportion is substantially higher in clinical populations [20].

Agoraphobia was made an independent diagnostic entity in the DSM-5, and accordingly, epidemiologic and clinical data that consider agoraphobia in the absence of panic disorder are pending. In the DSM-IV-TR, panic disorder could be specified with or without agoraphobia. Lifetime and 12-month prevalence of panic disorder with agoraphobia were 1.0% and 0.5%, respectively [32].

Risk Factors

Much of the published agoraphobia research assumes panic disorder causation or comorbidity. As such, many of the known risk factors are the same. Comorbid panic disorder and agoraphobia aggregate in families, while agoraphobia without panic disorder is non-familial but may enhance familial transmission of panic disorder [33]. The risk of agoraphobia development in patients with panic disorder is elevated with female sex, more severe dizziness during panic attacks, cognitive factors, dependent personality traits, and SAD. Panic disorder with agoraphobia is associated with greater severity and worse prognosis [34].

Longitudinal studies show low remission rates (0% to 23%) over time in panic disorder or agoraphobia, and subjects with panic disorder with agoraphobia or agoraphobia with panic attacks at baseline were more likely to develop agoraphobia, panic attacks, and other anxiety disorders and experience greater severity (e.g., impairment, disability, treatment-seeking, comorbidity) than subjects with panic disorder without agoraphobia or agoraphobia without panic attacks at baseline [35].

A late-life subtype of agoraphobia (onset at or after 65 years of age) was identified through assessing elderly patients at baseline and four years later. Baseline agoraphobia prevalence was 10.4%, and 11.2% developed agoraphobia during the four-year follow-up. Agoraphobia in the elderly, unlike younger populations, was not more common in women and not associated with panic attacks. Risk factors for late-onset agoraphobia include severe depression, trait anxiety, and poor visuo-spatial memory [36]. Incident anxiety also appears to develop in response to subjective memory complaints independent of depressive symptoms [37].

Patients with panic disorder who experience their first panic attack while driving or using public transportation had higher rates of comorbid agoraphobia. Those with first panic attack at home had higher fear-of-dying rates than with first panic attack outside of the home and felt more severe distress from their first panic attack independent of whether agoraphobia developed. Treatment of patients with panic disorder whose first panic attack was at home should address secondary aspects of fear and distress elicited by the attack [38].

Clinical Course

In persons with panic disorder with or without agoraphobia, the strongest predictors of incidence and relapse were history of panic attacks, GAD/major depression, nicotine dependence, female sex, younger age, and major financial crises. Most predictor variables were similar between panic disorder and panic disorder with agoraphobia. Clinicians should bear in mind the characteristic relapsing-remitting nature of panic disorder/panic disorder with agoraphobia in order to avoid prematurely reducing or eliminating effective treatments. Close attention should be paid to concurrent factors linked to relapse that can be clinically addressed, such as comorbid major depression, GAD, and nicotine dependence [39].

One study followed 711 participants with anxiety disorder diagnoses over 15 years. At baseline, those with early-onset (≤20 years of age) panic disorder were more likely to have comorbid major depressive disorder, GAD, and SAD. Those with early-onset panic disorder with agoraphobia were less likely to be married and more likely to have comorbid GAD and SAD. During follow-up, persons with panic disorder with agoraphobia were significantly more likely to have illness recurrence after periods of recovery, while findings for the other disorders failed to reach significance. This was thought to reflect differences in typical age of onset among anxiety disorders. The onset of panic disorder with or without agoraphobia is usually early adulthood; earlier onsets are relatively uncommon and may signal a particularly pernicious form of illness. The results further support the particularly adverse effects of early-onset psychiatric illness [40].

Social Anxiety Disorder

Epidemiology

SAD can develop at any time during a lifespan, but the average age of onset is during late childhood and adolescence. The prevalence of SAD in pre-adolescence is 3.5%, with rates increasing to about 14% during adolescence [41]. The lifetime prevalence of SAD is 13%, and the prevalence in primary care settings (7%) is high compared with that of other anxiety disorders encountered in general practice [19,350]. Gender distribution is generally equal during pre-adolescence and becomes increasingly more common in girls/women through adolescence and adulthood. An estimated 70% to 80% of individuals with SAD have comorbid anxiety, mood, or substance use disorders. There are cultural variants in Asian and Eastern cultures that involve fears of offending others or making others uncomfortable [2].

Risk Factors

A combination of biologic, familial, environmental, and cultural risk factors drive the development of SAD. Life transitions, personal loss, poverty, and experiences of humiliation or embarrassment contribute to SAD risk [42]. Compared with data from the general population, first-degree relatives are as much as six times more likely to be at risk of SAD. Concordance rates are 24% in monozygotic twins and 15% in dizygotic twins [43].

Behavioral inhibition, shyness, introversion, and anxiety sensitivity are all common among patients with SAD. Emerging early in life, behavioral inhibition is a heritable trait, and 15% to 20% of young children with behavior inhibition exhibit extreme signs. Relative to children without behavioral inhibition, these patients are typically shy, fearful, and cautious and show elevated physiologic arousal signs at rest, such as higher heart rate, increased pupil dilation, and higher cortisol levels. Brain profiles of children with behavioral inhibition show distinct patterns, including electroencephalography asymmetry, functional differences in amygdala response to facial expression challenge, and structural differences in the ventral prefrontal cortex. Roughly 40% of children with behavioral inhibition eventually develop SAD, and childhood behavioral inhibition is a primary predictor of SAD. Other components of SAD probably appear later in development, including social-evaluative concerns and coping skills deficits that contribute to functional impairment [44,45].

A bi-directional relationship exists between parenting style and childhood anxiety. Parenting styles of criticism, over-protection, over-control, and lack of warmth can create insecure attachment and risk for SAD. Likewise, temperamentally introverted and anxious children may shape and change parenting styles, with parents becoming over-protective or over-controlling [42]. Studies suggest that challenging parenting behavior (especially in fathers) may play a protective role in anxiety development in the most vulnerable children [46,47].

Early childhood anxiety disorders, especially separation anxiety and other phobias, are associated with elevated SAD risk in adulthood. SAD is highly comorbid with other anxiety disorders, mood disorders, and substance use disorders; substance abuse is often used to regulate anxiety symptoms and social skills [48].

Multiple social cues can develop the capacity to elicit anxiety-related symptoms. Learned escape and avoidance behaviors maintain anxiety, interfere with skill development, and can lead to functional impairment and disability over time. Similarly, safety behaviors, such as only entering social situations with a trusted companion, averting eye contact, and staying on the periphery of social gatherings, may maintain anxiety-related impairments. Selective attention to social cues of negative evaluation and internal cues supporting danger perception may develop [49,50].

Primary Prevention

Childhood presence of fearfulness and behavioral inhibition can lead to chronic, disabling SAD. Early recognition of childhood impairments and evidence-based treatment intervention may offset the SAD trajectory of persisting into and through adulthood. Educational-behavioral interventions involving older children/adolescents, parents, school staff, and healthcare providers have been found to reduce the development of social anxiety [51,52,53].

Clinical Course

SAD tends to run a chronic course of long duration, associated with substantial impairment of work productivity, and has a reported recovery rate of only 38% [54].

Specific Phobia

Epidemiology

Women are two to three times more likely than men to develop phobias, with the exception of blood-injection-injury phobia, which is evenly distributed by sex. Roughly 70% of individuals with specific phobia report more than one clinically relevant fear. Animals and heights are the most common stimuli, followed by flying, enclosed spaces, and blood-injection-injury. The average period of onset is 7 to 10 years of age, with declining probabilities of onset into later adulthood. Most animal phobias develop before 8 years of age [2,41,56]. The average age of treatment engagement is 31 years, although only 8% of persons with specific phobia are reported to seek treatment [56].

The odds of developing phobias are significantly less in Hispanic and Asian individuals and greater in white individuals. Animal fears are prevalent in Japan and Hong Kong [56,57].

Risk Factors

For specific phobias, familial concordance rates among first-degree relatives are moderate. The greatest heritability indices are found in animal and blood-injection-injury phobias [58,59,60].

Intense anxiety or unexpected panic responses in the presence of specific objects or situations can mark phobia onset but are not the sole causal route. Disgust, either alone or combined with fear, may trigger the onset and maintenance of animal (particularly spiders, snakes, and worms) or blood-injection-injury phobias. Onset can occur indirectly by observing others reacting fearfully. Some stimuli are more likely to induce phobias than others (e.g., animals vs. electrical outlets) through evolutionary threat relevance.

Phobia onset can be precipitated by relationship problems, relocation, employment loss, or economic difficulties. In addition, anxiety, mood, or substance use disorders can co-occur with or predate phobia onset. Substance use disorder can maintain phobic symptoms. Phobia symptoms in adolescence predict adult symptoms but are not a risk factor for developing other anxiety, mood, or substance use disorders.

Adult Separation Anxiety Disorder

Epidemiology

The lifetime prevalence of adult SEPAD is 6.6% in the general population, 12% to 40% in psychiatric clinic settings, and more than 75% among those seeking treatment at anxiety disorder clinics [61]. In adults with lifetime SEPAD, 22.5% have childhood age of onset that persisted into adulthood, while 77.5% had adult onset. Girls/women show higher overall prevalence than boys/men and substantially higher rates of childhood-onset SEPAD persisting into adulthood [62]. SEPAD and panic disorder are highly comorbid in clinical settings. Among adult patients with panic disorder, 53.2% were diagnosed with SEPAD. Patients with panic disorder and SEPAD (versus no SEPAD) were more commonly female and younger and showed higher rates of childhood SEPAD and greater lifetime prevalence of mood disorder spectrum symptoms [63].

Risk Factors

Children of adults with anxiety disorders have higher rates of anxiety disorders. Early, traumatic separation from attachment figures and a positive family history of anxiety or depressive disorders may also elevate risk of SEPAD, school phobia, and depressive-spectrum disorders during adolescence or adulthood. Early, traumatic separation can include prolonged severance of contact with the primary caregiver during the neonatal period; later sudden hospitalization; early loss of attachments from death or divorce; or an interactive pattern with an over-protective, needy, or depressed parent [64].

Clinical Course

In one study, children with SEPAD were 3.5 times more likely to later develop panic disorder and more than twice as likely to develop any anxiety disorder but did not significantly differ in later development of depression or substance use disorder. These findings were considered supportive of a developmental psychopathology model of anxiety disorders [65].

4. ETIOLOGY AND PATHOPHYSIOLOGY

ANXIETY DISORDERS IN GENERAL

Anxiety disorders are characterized by diverse neuroendocrine, neurotransmitter, and neuroanatomical disruptions, the result of interactions between multiple genetic, environmental, and social factors. Although each disorder may have unique features, this group shares some underlying pathophysiology.

Pathologic Alterations in Brain Structure and Function

Fear and anxiety are thought to involve two major brain circuits: the limbic system and the prefrontal cortex. In the limbic system, which consists of the amygdala, hippocampus, central nucleus of the amygdala, insular cortex, and cingulate cortex, emotion-processing brain structures generate primitive innate responses to simple, overtly threatening stimuli. Functions of limbic structures include processing emotionally important external stimuli and initiating behavioral responses; mediating expressions of fear, aggression, and defensive behavior; and forming and retrieving emotional and fear-related memories [66,67]. The prefrontal cortex, comprised of the orbitofrontal cortex and the prefrontal, ventromedial, and dorsomedial prefrontal cortex, dampens emotional responses to anxiety-inducing stimuli. The prefrontal cortex functions to regulate impulses, emotions, and behavior via inhibitory "top-down" control of emotional-processing structures; this works to control impulses and regulate mood [66,67].

Altered limbic and prefrontal cortex functioning characterize anxiety disorders, with amygdala hyper-responsivity to threatening stimuli and impaired ventromedial prefrontal contex inhibitory control over limbic-generated, anxiety-inducing signals, associated with aberrant communication and functional connectivity between the amygdala and the prefrontal cortex [67].

Narrowing brain region contribution, amygdala and insula hyperactivation contribute to anxiety disorders triggered by specific stimuli (e.g., panic disorder, specific phobia). The insula integrates sensory, emotional, and cognitive information through extensive connections between the lateral prefrontal cortex, ventromedial prefrontal cortex, orbitofrontal cortex, cingulate, amygdala, bed nucleus of the stria terminalis, and ventral striatum. Changes in the level of insula activation influence anxiety level [66].

Amygdala-medial prefrontal cortex functional connectivity shows a developmental trajectory, and early temperamental risk for anxiety is associated with disruption of these circuits. Aberrant amygdala-prefrontal cortex connectivity is found in patients with adult-onset anxiety disorders who showed childhood temperament risk factors but did not develop early-onset anxiety. This suggests aberrant connectivity is a lingering biomarker of risk [68].

Familial and Environmental Contribution

Persons with anxiety and mood disorders show a shared genetic predisposition, with specific manifestation the product of genetic and environmental interactions. A developmental dynamic pattern of genetic influence on individual differences in anxiety and depression symptoms is apparent. Genetic influence on psychopathology changes over the lifespan, with different developmental stages associated with a unique pattern of risk factors [67].

Significant early-life stress (e.g., maternal deprivation) may degrade prefrontal cortex functional connectivity with subcortical panic-generating circuits, elevating risks of anxiety disorders and other psychopathology. Many significant early-life stress events (e.g., child abuse, neglect, parental loss from death or abandonment) are receiving heightened attention as contributing factors to anxiety disorders and trauma pathology, as in PTSD. Previous childhood or adult trauma is considered a predisposing/contributing factor to panic disorder and SEPAD as well as major depressive disorder and PTSD that may be primary or comorbid with other anxiety disorders [69]. Aversive experiences can lead to complex behavioral adaptations, including increased levels of anxiety and fear generalization.

Alterations in Brain Transmitter Chemicals

Neurotransmitters allow communication between brain regions. Alterations in neurotransmitter systems implicated in anxiety disorder pathogenesis include the monoamines serotonin (5-hydroxytryptamine or 5-HT), norepinephrine, and dopamine. Aberrant limbic signaling is associated with decreased inhibitory signaling by gamma-amino-butyric acid (GABA) or increased excitatory neurotransmission by glutamate. Many other neurotransmitter systems participate in the modulation of fear and anxiety, including the neuropeptide substances P, N, and Y; corticotropin-releasing factor (CRF); and endocannabinoids. Abnormalities in these systems are associated with structural and functional alterations in specific brain areas, such as the amygdala, prefrontal cortex, locus coeruleus, and hippocampus, and represent the therapeutic targets of drug therapy [70].

Gene products that regulate monoamine signaling may be critical in facilitating antidepressant effect. Monoaminergic regulators include transmitter receptors; vesicular monoamine transporter, which packages monoamines into vesicles; oxytocin and vasopressin; transmitter-specific reuptake transporters, such as the serotonin transporter, norepinephrine transporter, and dopamine transporter; monoamine oxidase, which degrades monoamines; and catecholamine-O-methyltransferase, which degrades norepinephrine and dopamine [67]. However, the cause of anxiety disorders is not simply a deficiency of one neurotransmitter or excess of another. The networks governed by these transmitters are extensively inter-related, with multiple feedback mechanisms and complex receptor structures. This complexity contributes to unpredictable and sometimes paradoxical medication responses [70].

GENERALIZED ANXIETY DISORDER

Neuronal circuits implicated in GAD are distinct from panic disorder, likely involving much greater frontal and prefrontal lobe than amygdala involvement. GAD is characterized by abnormalities in frontal and limbic structures and in the connectivity between these regions. The most frequently implicated frontal regions are the prefrontal cortex and the anterior cingulate cortex; in the limbic region, the amygdala and possibly the hippocampus are involved. Structural abnormalities and decreased structural and functional connectivity between frontal and limbic regions have repeatedly been documented in GAD [71,72]. Functional neuroimaging suggests that GAD is characterized by inefficient biologic mechanisms associated with emotion regulation. Worry induction increases prefrontal cortex activation and decreases amygdala activity in patients with GAD and non-anxious controls, but unlike non-anxious subjects, patients with GAD are unable to normalize this neural activity afterward. The results from studies using tasks that require conflict monitoring and emotion regulation support a model of GAD characterized by hypoactivation in the prefrontal cortex and anterior cingulate cortex indicative of deficient "top-down" emotional control [73].

PANIC DISORDER

Core Pathophysiology

Genetic, developmental, hormonal, and environmental factors interact to impair the ventromedial prefrontal cortex's ability to inhibit panic impulses generated by limbic regions. This underlies the pathogenesis of the initial onset of unexpected panic attacks. This pathology is further compounded by recurrent panic attacks with repeated activation of panic-generating subcortical sites, leading to recruitment and plasticity within extended amygdala fear-hippocampus-cortical circuits. This in turn facilitates the development of situational and anticipated panic attacks and agoraphobia. Imaging studies have demonstrated ventromedial prefrontal cortex structural abnormalities in patients with panic disorder, reflecting the loss of inhibitory control over panic-generating sites. CBT enhances medial prefrontal cortex activity in subjects with anxiety disorders, which may explain its efficacy in treating panic disorder [69].

Other Pathophysiologic Models

In addition to ventromedial prefrontal cortex inhibition, other alterations in brain function have been suggested in panic disorder. Involvement of the central nuclei of the amygdala and activation of other fear centers in the thalamus, hypothalamus, and hippocampus may dysregulate respiratory control in the brainstem [74,75]. Additionally, it has been proposed that genetic risk variants partly drive fear network activity [76]. Exaggerated hypothalamic-pituitary-adrenal axis reactivity to environmental stimuli may be involved in panic disorder etiology [77,78].

In patients with panic disorder, CBT significantly reduces left interior frontal gyrus region activation, and reduced activity is correlated with reduced agoraphobic symptoms [79]. This reduced activation appears to be a specific substrate of CBT effects in patients with panic disorder/agoraphobia without comorbid depressive disorders [80]. Functional magnetic resonance imaging (MRI) shows that pre-treatment activation of the bilateral insula and left dorsolateral prefrontal cortex during threat processing is associated with rapid response to CBT [81].

AGORAPHOBIA

Patients with panic disorder and agoraphobia who are anticipating agoraphobia-specific stimuli have shown stronger region-specific activations in the bilateral ventral striatum and left insula versus controls. Patients processed these stimuli more intensively based on individual salience, and this activation is stronger than found in patients with panic disorder alone. Ventral striatum and insula hyperactivation when anticipating agoraphobia-specific situations may be a key neurofunction modulator in agoraphobia [82].

In patients with panic disorder/agoraphobia, fear conditioning has shown enhanced activation of the bilateral dorsal inferior frontal gyrus. Simple conditioning, safety signal processing, and anxiety sensitivity correlate with the extent of midbrain activation. These findings suggest alterations in "top-down" and "bottom-up" processes during fear conditioning, interpreted within a neural framework of defensive reactions that mediate threat through distal (forebrain) versus proximal (midbrain) brain structures. This network may play a key role in panic disorder pathogenesis [83].

Genetic polymorphism (variation) may influence panic disorder with agoraphobia treatment response. Serotonin transporter gene promoter polymorphism (5-HTTLPR) is conclusively linked to emotion regulation and related patterns of brain connectivity. During functional MRI imaging, the patient subgroup that showed inhibitory anterior cingulate cortex-amygdala coupling during fear conditioning predominantly possessed the L/L genotype of 5-HTTLPR polymorphism. This activation of inhibitory function, the normal function in non-anxious persons, suggests an intermediate connectivity phenotype that modulates response to exposure-based CBT [84].

Expanding on these results, patients with panic disorder/agoraphobia and the low-expression allele of 5-HTTLPR showed more favorable exposure therapy response than patients with other 5-HTTLPR genotypes. This genetic contribution to exposure therapy outcome implicates the serotonergic system as a response mediator to exposure treatments [85].

Balance System Abnormalities

Patients with panic disorder/agoraphobia have shown subclinical abnormalities in balance system function that seemed to influence agoraphobia severity and contribute to dizziness and disorientation symptoms in complex sensory environments (e.g., shopping malls, traffic, crowds). These patients also display greater balance control reliance on non-vestibular, proprioceptive, visually dependent cues and greater balance system reactivity to peripheral visual stimulation. These possibly link to a more active visual alarm system involving visual, vestibular, and limbic areas. Patients with panic disorder/agoraphobia also show high sensitivity to light or brightness stimuli with photophobic behavior and abnormal retinal and pupillary reflex responses possibly linked to serotonergic and/or dopaminergic dysfunction. This overall amplified sensitivity to environmental stimuli suggests that agoraphobia involves activation of complex systems beyond panic attack fear and behavioral avoidance, including emotional responses to destabilizing/distressing environmental stimuli and operant-learning avoidance of experiences that provoke this distress [86].

SOCIAL ANXIETY DISORDER

Patients with SAD have shown hyper(re)active limbic, frontal, and parietal brain regions involved in emotional and attentional processes. Compared to healthy subjects, patients with SAD display increased cortical thickness in frontal, parietal, and other brain areas. CBT treatment success and symptom improvement have been associated with changes in prefrontal regions involved in emotion regulation [87].

Persons with SAD and GAD share core features of persistent, debilitating focus on negative or potentially threatening experience. This negative affective bias is characterized by increased threat processing at the neural, psychologic, and behavioral levels, with engagement of the dorsal medial prefrontal cortex-amygdala circuit during aversive processing. Anxiety disorder subtypes frequently co-occur, and while abnormal activation of this neural circuitry that mediates bias toward threats is diagnosis-independent, it also represents a cardinal feature of SAD and GAD [88].

SAD pathophysiology includes heightened autonomic arousal to social cues and novelty. Fear processing appears mediated by the amygdala, in which neuroimaging studies show exaggerated activations with exposure to novel facial stimuli. Amygdala activation to novelty is also found in persons with a behavioral inhibition temperament. Other pathophysiologic models suggest that exaggerated hypothalamic-pituitary-adrenal axis reactivity to environmental stimuli may be involved in SAD [89,90,91,92].

SPECIFIC PHOBIA

Amygdala, anterior cingulate cortex, and insula hyperactivity is believed to be the underlying pathophysiology of specific phobia. Neuroimaging studies have shown increased amygdala activation with exposure to phobic-relevant cues, and heightened activity in thalamic, insula, and dorsal anterior cingulate cortex regions [93,94,95]. Meta-analyses suggest the left amygdala/globus pallidus, left insula, right thalamus, and cerebellum regions are all more active among patients with a phobia compared with controls when exposed to phobic-relevant stimuli. Acute, exaggerated parasympathetic nervous system activity with exposure to stimuli is thought to underlie the vasovagal syncope experienced by up to 80% of people with blood-injection-injury phobia [96]. Exposure-based therapy leads to deactivation in the right frontal cortex, limbic cortex, basal ganglia, and cerebellum, and increased activity in the thalamus [97].

ADULT SEPARATION ANXIETY DISORDER

SEPAD etiology is thought to arise during childhood by disrupted caregiving environments that promote greater hypothalamic/pituitary stress responsivity. Neuroimaging research has focused on brain circuitry that shows abnormal activity at single time points during anxiety from close attachments. The underlying neural circuitry that mediates separation-hypersensitive attachment includes subcortical areas (amygdala, hippocampus, striatum) and cortical limbic areas (insula, cingulate). Predisposing endophenotypes may interact with circuitry involved in attention, learning, and executive control (medial prefrontal cortex, superior temporal sulcus, and temporoparietal junction). With social interaction central to separation anxiety, neural circuitry involved in separation-sensitive social representations that predict danger when separation occurs may include the anterior temporal cortex [98]. SEPAD is associated with hypersensitivity to inhaled carbon dioxide, with a similar pattern to patients with panic disorder, suggesting SEPAD and panic disorder may share a common pathophysiologic basis [99,100].

5. CLINICAL AND DIAGNOSTIC FEATURES

As with other psychiatric disorders, the treatment of anxiety disorders is guided by conceptualization of the disorder and theoretical basis for disorder/treatment relationships. The understanding of anxiety disorders has changed over time with input of new evidence. In the United States, the DSM, published by the American Psychiatric Association, is the authoritative reference in defining and diagnosing psychiatric disorders. In the modern era, revised DSM editions have been published in 1980, 1994, 2000, and most recently in 2013 with the DSM-5.

To better reflect current thinking on anxiety disorders, the DSM-5 made several important changes from the 1994 DSM-IV and its 2000 text revision [32,101]. As noted, the chapter on anxiety disorders no longer includes OCD, PTSD, and acute stress disorder. New sections were added for these conditions: obsessive-compulsive and related disorders and trauma- and stressor-related disorders. Duration criteria for several anxiety disorders were extended to six months or longer to minimize overdiagnosis of transient symptoms, applied to all ages.

With agoraphobia, specific phobia, and SAD, the requirement that patients recognize their anxiety as excessive or unreasonable has been eliminated. This change was based on evidence that individuals with such disorders often overestimated the danger in "phobic" situations and that older individuals often misattributed "phobic" fears to aging. Instead, the anxiety must be out of proportion to the actual situational danger or threat, with consideration of cultural contextual factors [102].

The DSM-5 (and previous DSM editions) has been criticized for emphasis on reliability at the expense of diagnostic validity and for use of symptom-based diagnosis when symptoms alone may not best inform treatment selection. In response, the National Institute of Mental Health is developing the Research Domain Criteria, a new taxonomy for mental disorders that draws from genetics, neuroscience, and behavioral science [103]. Additionally, the DSM-5-TR, which was released in March 2022, includes the addition of prolonged grief disorder; the inclusion of symptom codes for suicidal behavior and nonsuicidal self-injury; refinement of criteria; and comprehensive literature-based updates to the text [104].

GENERALIZED ANXIETY DISORDER

GAD is characterized by excessive and inappropriate worrying that is persistent and not restricted to circumstance or situation. Patients have physical anxiety symptoms and key psychologic symptoms. GAD is often comorbid with major depressive disorder, panic disorder, phobia, health anxiety, and OCD [3]. The DSM-5 diagnostic criteria for GAD remain unchanged from previous editions [2,102]:

- Excessive anxiety and worry (apprehensive expectation) over a number of everyday concerns (e.g., school/work performance)

- Individual finds it difficult to control the worry

- Excessive anxiety and worry are associated with three or more of the following six symptoms, with at least some occurring more days than not for at least six months:

- Restlessness, feeling "on edge"

- Easily fatigued

- Difficulty concentrating

- Irritability

- Muscle tension

- Sleep disturbance (difficulty falling or staying asleep, restless sleep)

- The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning

- Symptoms not better explained by another mental disorder

- The disturbance is not attributable to the physiologic effects of a substance or another medical condition

Patients with GAD in the absence of current or lifetime comorbidity are uncommon, and patients with GAD typically present to primary care with comorbid depression, anxiety disorders, or substance use disorders. The presence of comorbidity complicates diagnosis and treatment [2].

PANIC ATTACKS

Panic attacks are abrupt, unexpected periods of intense fear or discomfort with multiple physical or psychologic anxiety symptoms, often peaking by 10 minutes and lasting around 30 to 45 minutes. Panic disorder is characterized by recurrent unexpected surges of severe anxiety (panic attacks). As noted, most patients develop a fear of having further panic attacks. The extent of anticipatory anxiety between attacks varies, and patients may alter their behavior to reduce the recurrence risk [2,3].

The essential features of panic attacks are unchanged in the DSM-5, but the complicated DSM-IV terminology for describing different types of panic attacks (i.e., situational-bound/cued, situational-predisposed, and unexpected/uncued) is replaced with unexpected and expected panic attacks. Panic attacks function as a marker and prognostic factor for severity of diagnosis, course, and comorbidity across an array of disorders, including but not limited to anxiety disorders. Hence, panic attack can be listed as a specifier, applicable to almost all DSM-5 disorders [102]. The DSM-5 criteria for panic attacks specify an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes and includes four or more of the following symptoms [2]:

- Palpitations, pounding heart, or accelerated heart rate

- Sweating

- Trembling or shaking

- Sensations of shortness of breath or smothering

- Feelings of choking

- Chest pain or discomfort

- Nausea or abdominal distress

- Feeling dizzy, unsteady, light-headed, or faint

- Chills or heat sensations

- Paresthesias (numbness or tingling sensations)

- Derealization (feelings of unreality) or depersonalization (being detached from oneself)

- Fear of losing control or going crazy

- Fear of dying

Physical symptoms predominate.

Panic attack is not classified as a mental disorder and does not have a diagnostic code. Instead, an attack can occur with other mental disorders, such as depressive and anxiety disorders, and also be extant with physical disorders. While panic attack is a specifier for both mental and physical disorders, the elements of panic attack are contained within the criteria for panic disorder, making the specifier unnecessary for that diagnosis.

PANIC DISORDER

Panic disorder in the DSM-5 has an added criterion for unexpected panic attacks. This implies that expected panic attacks exist and that anticipated, situationally triggered panic attacks are somehow less pathologic than spontaneous panic attacks. This assumption is challenged on the basis that panic attacks are inherently pathologic, regardless of context or lack thereof, and individuals with panic disorder can have unexpected and expected panic attacks [18,105]. Regardless, the DSM-5 diagnostic criteria for panic disorder require [2]:

- Recurrent unexpected panic attacks

- One or more of the attacks followed by at least one month of one or both of the following:

- Persistent concern or worry about additional panic attacks or their consequences

- Significant maladaptive change in behavior related to the attacks

The symptoms must not be attributable to substance-related effects, other medical conditions, or other psychiatric disorders. Up to 70% of patients report a history of at least one nocturnal panic attack [106]. Patients may present with symptoms suggestive of heightened sympathetic nervous system activity such as palpitations, increased systolic blood pressure, hyperventilation, sweating, or flushing. Other common symptoms include chest pain and discomfort, dizziness, and paraesthesias, while gastrointestinal symptoms such as nausea and vomiting are more common among men [2,107].

The severity of distress during panic attacks by patients with panic disorder with or without agoraphobia is increasingly seen as traumatic. Panic attacks are frequently experienced as life threatening, and patients with panic disorder can experience PTSD symptoms in relation to their panic attacks. Patients with panic disorder/agoraphobia or PTSD were found to relive their trauma or panic attacks with equal frequency, report comparable bodily reactions and distress associated with trauma or panic attack memories, and avoid trauma or panic attack reminders (i.e., places and things associated with trauma or panic attacks). Trauma-like symptoms surrounding panic attacks are common, and panic attacks may be processed similarly to trauma in PTSD [108].

Intense, disorganized recollections, a core symptom of PTSD, are thought to result from inadequate processing of trauma information. A first panic attack resembles trauma; both are unexpected, frightening, and subjectively life-threatening events. Like PTSD, panic disorder with agoraphobia also involves fear conditioning after the first event. Therefore, panic attack and trauma processing may be similar, with panic attack and PTSD trauma memories sharing the characteristics of reliving and disorganization. A comparison of panic memories and PTSD trauma memories did not find differences between groups in reliving intensity and disorganization levels, suggesting that panic attacks may affect information processing similarly to a traumatic event [109,110].

Patients with panic disorder exhibit considerably worse overall mental well-being than individuals with cancer, diabetes, heart disease, arthritis, hypertension, and other chronic physical conditions [111]. Current panic disorder is also related to worse quality of life and physical function and an elevated risk of attempting suicide [112]. These effects are similar to or greater than those associated with major depression. A study found that nearly 33% of these patients in primary care had seen three or more healthcare professionals and almost 20% had visited emergency departments [113]. Another study found that although the majority of individuals with panic disorder first present to the primary care setting, only 38% of those with panic disorder with agoraphobia and 24% of those with panic disorder without agoraphobia were receiving appropriate treatment, and the use of empirically supported interventions was rare [114].

AGORAPHOBIA

Agoraphobia is defined as the fear of panic attacks occurring in places or situations from which escape might be difficult or embarrassing or where help may not be available. These situations can include crowds, going outside the home, or using public transportation and are either avoided or endured with significant personal distress [3]. Agoraphobia can become severely disabling, and more than 33% of patients diagnosed with agoraphobia cannot endure leaving their home environment. Roughly 66% of patients with panic disorder develop agoraphobia [2].

In the DSM-5, agoraphobia was de-aggregated from panic disorder and is now classed as a separate diagnostic entity. The former DSM-IV diagnoses of panic disorder with agoraphobia, panic disorder without agoraphobia, and agoraphobia without history of panic disorder are now replaced by two diagnoses with separate criteria: panic disorder and agoraphobia. Co-occurring panic disorder and agoraphobia are also coded as two diagnoses. This change recognizes that a substantial number of individuals with agoraphobia do not experience panic symptoms, although clinical prevalence is much lower than community prevalence. The diagnostic criteria for agoraphobia are derived from the DSM-IV descriptors, with endorsement of fears from two or more agoraphobia situations now required to more effectively distinguish agoraphobia from specific phobias. The criteria for agoraphobia are also extended to concord with criteria sets for other anxiety disorders [102]. Diagnosis is based on marked fear or anxiety about two or more of the following [2]:

- Public transportation (e.g., traveling in planes, automobiles, buses, trains, ships)

- Open spaces (e.g., parking lots, market places, bridges)

- Being in shops, theatres, or stadiums

- Standing in line or being in a crowd

- Being outside of the home alone in other situations

The individual with agoraphobia fears or avoids these situations due to thoughts that escape might be difficult or help might not be available in the event of panic-like symptoms. These situations almost always provoke fear or anxiety and are actively avoided, require presence of a companion, or are endured with marked fear or anxiety. The fear or anxiety is out of proportion to the actual threat posed by an agoraphobic situation. The fear, anxiety, or avoidance is persistent, typically lasting at least six months, and causes clinically significant distress or impaired functioning. Avoidance symptoms in PTSD differ in that the situations avoided are trauma-associated, such as a park or street where an assault occurred or riding in a car after a motor vehicle accident [2].

Major personality dimensions, such as introversion and neuroticism, have been studied for contribution to the risk of developing agoraphobia and other anxiety disorders. Genetic factors that influence individual variation in extraversion and neuroticism have been found to account entirely for genetic liability in SAD and agoraphobia but not animal phobia, emphasizing the importance of both introversion (low extraversion) and neuroticism as risk factors [115]. Situational avoidance is the most disabling aspect of agoraphobia. Temperament is shown to influence agoraphobia severity, with introverted temperament significantly associated with the presence and severity of agoraphobic situational avoidance [9].

The longitudinal relationship between personality disorder traits and panic disorder (with or without agoraphobia) is important for understanding agoraphobia etiology. A large-scale study that assessed community-dwelling adults at baseline and again 12 to 15 years later found that after excluding participants with baseline panic attacks, baseline timidity with avoidant, dependent, and related traits predicted the onset of panic disorder or panic disorder with agoraphobia during the follow-up period. These results suggest that avoidant and dependent personality traits are predisposing factors, or markers of risk, for panic disorder or panic disorder with agoraphobia, and not simply epiphenomena [24]. Additionally, personality and temperament traits may be potentially related to poor treatment response [116].

SOCIAL ANXIETY DISORDER

SAD is often misconstrued as mere shyness but can be considerably disabling and produce much greater distress and more severe symptoms. SAD is characterized by a marked, persistent, and unreasonable fear of being observed or evaluated negatively by other people in social or performance situations, which is associated with physical and psychologic anxiety symptoms. Feared situations, such as speaking to unfamiliar people or eating in public, are either avoided or are endured with significant distress [3]. Social phobia has been renamed SAD to reflect a new, broader understanding of the condition in a variety of social situations.

Previously, social phobia was primarily diagnosed in patients reporting extreme discomfort or fear when performing in front of others. Research indicates this definition is too narrow, and SAD in the DSM-5 can be diagnosed based on patient response to a variety of social situations. For example, the patient may be so uncomfortable engaging in conversation he or she is unable to talk to others, especially strangers. A patient with anxiety regarding being observed may be unable to go out to dinner over fears of being watched while eating and drinking [102].

The defining features of SAD diagnosis remain unchanged. However, some modifications in require features have been made, including deletion of the requirement that individuals older than 18 years of age must recognize their fear or anxiety is excessive or unreasonable, and addition of a duration criterion. A more significant change is that the "generalized" specifier has been deleted and replaced with a "performance only" specifier. The DSM-IV-TR generalized specifier was problematic in that "fears include most social situations" was difficult to operationalize. Individuals who fear only performance situations (i.e., speaking or performing in front of an audience) appear to represent a distinct subset of SAD in terms of etiology, age at onset, physiologic response, and treatment response. The DSM-5 establishes the following diagnostic criteria for SAD [2]:

- Marked fear or anxiety about social situations in which the person may be exposed to scrutiny by others

- Fear that actions or showing anxiety symptoms will cause negative evaluation (e.g., embarrassment, humiliation) or offend others

- The social situation:

- Almost always provokes fear or anxiety

- Is actively avoided or endured with marked fear or anxiety

- The fear, anxiety, or avoidance:

- Is disproportionate to actual threat posed by the social situation

- Is persistent, typically at least six months

- Causes significant distress or functional impairment

- If another medical condition is present (e.g., stuttering, obesity), the disturbance is unrelated or out of proportion to it

If the fear is restricted to speaking or performing in public, diagnosis should specify "performance only." Other diagnostic features of SAD include [2]:

- Post-event processing: Tendency to replay social encounters in a negative, self-critical manner

- Attentional bias: Heightened attention to negative evaluative threat cues and lack of attention to positive or benign cues

- Social skills deficits: Poor eye contact, closed stance, quiet tone of speech, and difficulties initiating conversations

Patients with SAD highly inflate perceived social costs from committing hypothetical blunders. Accounting for much of this social cost inflation are concerns about revealing self-flaws and, in particular, concerns over appearing socially incompetent [117].

SPECIFIC PHOBIA

Specific, simple, or isolated phobia describes excessive or unreasonable fear in the presence of phobic stimuli, typically involving specific animals, objects, or situations (e.g., dentists, spiders, elevators, flying, seeing blood). Phobic stimuli are either avoided or are endured with significant personal distress [3]. This fear or anxiety must be markedly stronger than the actual threat of the object or situation (e.g., likelihood of being stuck on a well-maintained elevator) [2]. The core features and different types of specific phobia remain unchanged from the DSM-IV, but the requirement was removed that individuals older than 18 years of age must recognize their fear and anxiety as excessive or unreasonable. The duration requirement of longer than six months now applies to all ages [102].

Specific phobias can develop after a traumatic event or from witnessing traumatic events. The fear or anxiety happens every time the person is exposed to the stimulus and may include panic attack symptoms.

The median age of onset with specific phobia is 13 years [2]. According to the DSM-5, specific phobia is diagnosed when the following criteria are met [2]:

- Marked fear or anxiety about a specific object or situation (e.g., flying, seeing blood)

- Phobic object or situation almost always provokes immediate fear or anxiety and is actively avoided or endured with marked fear or anxiety

- Fear or anxiety out of proportion to the actual danger posed by the specific object or situation

- The fear, anxiety, or avoidance is persistent, typically at least six months

- Marked distress or functional impairment

Specific phobia subtypes are organized by phobia categories:

- Animal: Dogs, snakes, insects

- Natural environment: Storms, heights, dark

- Blood-injection-injury: Injections, blood draws, medical procedures

- Situational: Driving, flying, enclosed spaces

- Other: Choking, vomiting, clowns

Specific Phobia Coding

Approximately 75% of individuals diagnosed with specific phobia fear more than one object. In the past, when this occurred, more than one ICD-10 code was given [2]. However, the ICD-11 eliminated this component. When individuals experience panic attacks in response to their phobia, clinicians should add "with panic attacks" to the diagnosis.

SEPARATION ANXIETY DISORDER

Separation anxiety is a basic human fear and readily observable in children. Close attachment to nurturing parental figures during infancy is necessary for survival, and close relationships throughout life are an important source of support in times of stress. Separation anxiety does not vanish with development and maturation, but persistant separation anxiety in adulthood should not become an issue of clinical importance. Manifestations of pathologic separation anxiety include uncontrollable apprehension over losing important attachment figures, intense fears of leaving home or going out unaccompanied, and nightmares around themes of separation. Persons with SEPAD have substantial impairments in many aspects of community life, although not all individuals show problems in attachment [118,119].

Pathologic early childhood attachments can have far-reaching consequences in adulthood. These patients often have a grossly impaired ability to experience and internalize positive relationships or to develop mental capacities for self-soothing, anxiety tolerance, affect modulation, and individuation. Adults with SEPAD feel unable to function in the absence of a mother surrogate. Separation anxiety has long been considered the distal antecedent to panic disorder. In adults, separation anxiety may reflect excessive activation of fear circuits in response to separation and over-activation of reward circuits with reunion, likely the result of abnormalities or deficits in underlying social representation and cognition systems [98].

SEPAD is characterized by fear or anxiety concerning separation from those to whom an individual is attached. Common features include excessive distress when experiencing or anticipating separation from home, and persistent and excessive worries about potential harms to attachment figures or untoward events that might result in separation [3].

The core features of SEPAD are mostly unchanged from DSM-IV, but the wording is modified to more adequately represent SEPAD expression in adulthood. For example, attachment figures may include the children of adults, and avoidance behaviors may occur in the workplace as well as at school. Diagnostic criteria no longer require childhood history of SEPAD or onset before 18 years of age, because a substantial number of adults report onset later in life. Adults with the condition include those with adult-onset and those with childhood onset and symptom persistence into adulthood. A duration criterion of six months or longer was added [64,102]. For a diagnosis of SEPAD, the persistent and excessive anxiety related to separation or impending separation from a major attachment figure (e.g., spouse, close family member) must be evidenced by at least three of the following criteria [2]:

- Recurrent excessive distress when anticipating or experiencing separation

- Persistent and excessive worry about losing a major attachment figure or about possible harm to him or her

- Persistent and excessive worry about experiencing an untoward event (e.g., getting lost, kidnapped, into an accident) that causes separation from a major attachment figure

- Persistent reluctance or refusal to go out, away from home, to school, to work, or elsewhere because of fear of separation

- Persistent and excessive fear of or reluctance about being alone or without a major attachment figure

- Persistent reluctance or refusal to sleep away from home or to go to sleep without major attachment figure near

- Repeated nightmares involving the theme of separation

- Repeated complaints of physical symptoms (e.g., headaches, stomachaches, nausea, vomiting) when separation occurs or is anticipated

To meet the criteria for this disorder, the symptoms must cause clinically significant distress or impairment in social, academic, occupational, or other important areas of functioning. Symptoms must not be better explained by another mental disorder (e.g., delusions or hallucinations concerning separation in psychotic disorders); refusal to go outside without a trusted companion (as in agoraphobia); worries about ill health or other harm befalling significant others (as with generalized anxiety disorder); or concerns about having an illness (as in illness anxiety disorder) [2]. Panic attacks commonly occur with youth and adult SEPAD.

Differential Diagnosis

In the past, adult SEPAD was often diagnosed as panic disorder, and it shares features with other psychiatric conditions. Excessive attachment toward others is a feature of a dependent personality, and avoidance behavior is a predominant feature of agoraphobia. With SEPAD, the focus involves key attachment figures, unlike dependent personality disorder, which is more indiscriminate. Panic and phobic-like behavior in SEPAD is specific to fears of separation from, or harm to, attachment figures and not spontaneous or triggered by other factors. Social and occupational function is frequently impaired, but individuals with SEPAD do not show impaired function in family life compared to controls and often function well in family environments. Borderline personality disorder differs by pervasive mood and relationship instability uncharacteristic of SEPAD [61].

A study exploring whether SEPAD in patients with panic disorder/agoraphobia was a manifestation of anxious attachment, a form of agoraphobia, or a specific condition with clinically significant consequences found that patients with SEPAD had greater panic symptom severity and quality of life impairment than those without separation anxiety. A greater rate of symptoms suggestive of anxious attachment was found among patients with panic disorder and SEPAD versus those without SEPAD. However, the relationship between SEPAD and attachment style was weak, and SEPAD occurred in some patients who reported secure attachment style. There was also little evidence SEPAD was a form of agoraphobia. SEPAD was found to be a distinct condition associated with impairment in quality of life and should be better recognized and treated in patients with comorbid panic disorder [119].

SELECTIVE MUTISM

Separation anxiety disorder and selective mutism were included in the DSM-IV section Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence, but were classed as anxiety disorders and moved to the anxiety disorder section in the DSM-5 [102]. The majority of children with selective mutism are anxious, and while selective mutism is now considered an anxiety disorder, it remains a disorder primarily of childhood and is beyond the scope of this course [102].

6. ASSESSMENT

Effective anxiety disorder treatment relies on accurate diagnosis. Diagnosis is made when diagnostic criteria for a specific disorder are established and symptoms cannot be better explained by the effects of the patient's other medical conditions, medications, substances, or pre-existing mental disorders [2].

Evidence Based Practice Recommendation

The American Psychiatric Association recommends that the initial psychiatric evaluation of a patient include assessment of anxiety and panic attacks.

https://psychiatryonline.org/doi/10.1176/appi.books.9780890426760.pe02

Last Accessed: April 27, 2025

Strength of Recommendation/Level of Evidence: 1C (Recommendation with low confidence that the evidence reflects the true effect)

The management of patients presenting with anxiety symptoms should initially follow the flow of these five components [120]:

1. Screen for anxiety and related symptoms.

2. Consider differential diagnosis and severity, impairment, and comorbidity.

3. Identify specific or multiple anxiety disorder(s), often in consultation with trained specialists using structured interview techniques.

4. Initiate psychologic and/or pharmacologic treatment.

5. Perform follow-up.

Evidence suggests that in primary care, patient tendency to ascribe pathologic anxiety symptoms to physical causes contributes to high rates of missed diagnoses and the misdiagnosis of GAD and panic disorder. To offset this requires a broad differential and caution to identify confounding variables and comorbid conditions [121].

SCREENING FOR ANXIETY DISORDERS IN THE PRIMARY CARE SETTING

Lifetime prevalence of anxiety in the general population is estimated 30%, and anxiety disorders are among the most common mental health syndromes encountered in general medical practice. In a study of 965 randomly selected patients across 15 primary care clinics, 19.5% had at least one anxiety disorder; of the four common disorders assessed in the study, 8.6% of patients had PTSD, 7.6% had GAD, 6.8% panic disorder, and 6.2% had SAD [55]. Each disorder was associated with functional impairment that became more substantial as the number of co-occurring anxiety disorders increased. The GAD-7 diagnostic scale was seen to perform well as screening tool for all four anxiety disorders studied [55]. Other studies in primary care settings have found that the prevalence of co-occurring GAD is 68% for patients with panic disorder and 38.6% for those with a diagnosis of major depression [34,122].

The American Academy of Family Physicians and other physician groups have noted that rates of failed diagnosis of anxiety disorder and misdiagnosis of GAD and panic disorder are high in primary care settings, in part because of time constraints, lack of a defining presentation, and the resemblance of symptoms to common somatic disorders [54,55,121]. Primary care clinicians have noted that patients with somatic complaints, sleep disturbance, or psychosocial distress are often unaware that anxiety disorder is the root cause of their symptoms. A study of older patients with GAD found that accurate referencing of symptoms to the onset of anxiety was low (34%), as was the rate of anxiety disorder diagnosis (9%), despite a high level of healthcare utilization [123]. In the current managed care environment, anxiety is usually treated in primary care settings, and given the increasing time constraints imposed on primary care providers, it is not surprising that anxiety disorders are under-recognized and undertreated [70].

Many patients with anxiety and depressive symptoms do not seek help, and in those who do, anxiety symptoms are often not the presenting complaint. Patients and providers often have difficulty initiating discussion of emotional problems and distress. Primary care providers with greater sensitivity to nonverbal communications have been found more likely to detect and diagnose anxiety, while those tending to "blame" patients make fewer psychologic inquiries and are less accurate in detecting distress [3,124].

SCREENING TOOLS

The American Academy of Family Physicians suggests using diagnostic screening and monitoring scales, such as the Generalized Anxiety Disorder 7-Item Scale (GAD-7) and the Severity Measure for Panic Disorder, to aide in diagnosis and monitor response to treatment [121]. The Primary Care Evaluation of Mental Disorders (PRIME-MD) was originally developed as a physician-administered screening tool for identifying mental disorders. It contained 12 different mental health disorder modules and required lengthy administration time, limiting its clinical usefulness [133]. Developers of the PRIME-MD subsequently crafted a self-administered version of the PRIME-MD, the Patient Health Questionnaire (PHQ). The PHQ includes mood, anxiety, alcohol, eating, and somatoform modules as covered in the original PRIME-MD [134]. In addition to its value in identifying anxiety and mood disorders, including depressive symptoms, panic disorder and other anxiety disorders, the PRIME-MD-PHQ is efficient for use in primary care settings; most clinicians can analyze the results in three minutes or less [134].

The GAD-7 scale is a brief, validated screening tool specifically designed to identify anxiety disorders. The patient with symptoms is asked to rate severity and frequency of occurrence over the previous two weeks. Each item is rated on a four-point scale (0 to 3), yielding a maximum score of 21. A score of 10 or greater is the cut-off point for diagnosis of anxiety disorder (sensitivity 87%; specificity 82%) [135]. The degree of distress/functional impairment varies directly with the total score. The GAD-7 scale is available online at https://adaa.org/sites/default/files/GAD-7_Anxiety-updated_0.pdf.

In theory, patients and providers should benefit from screening tools designed to detect anxiety disorders. However, regular use may require adjustments to practice structure, and it is uncertain to what extent routine screening (of all patients) and disclosure to "screened positive" patients improves clinical outcomes.

In 2022, the U.S. Preventive Services Task Force recommended screening all children older than 7 years of age for anxiety [349]. Primary care providers can improve anxiety detection skills by first acknowledging patients may be reluctant to discuss psychological and emotional distress early in the physician-patient relationship. This can be offset with greater sensitivity to nonverbal expression of distress and by allowing repeated patient encounters and deepening understanding to develop the rapport required for exploring the presence and depth of anxiety symptoms [3].

Healthcare providers can create a more comfortable environment for a patient of another culture by acknowledging the impact of culture and cultural differences on physical and mental health. The nature and expression of symptoms are influenced by cultural factors, and in some cultures anxiety is expressed through a heavy focus on somatic symptoms, such as musculoskeletal pain and fatigue. Providers may consider starting the clinical encounter by exploring such symptoms patiently and in greater depth. The concept of anxiety also varies across cultures, and patients may not seek medical treatment unless symptoms manifest as psychosis, conversion disorders, or significant physical ailments.

IDENTIFYING PATIENTS WHO REQUIRE TREATMENT

The potential chronicity and disability of anxiety disorders indicates that most patients meeting diagnostic criteria should receive psychologic and/or pharmacologic treatment. Treatment selection is guided by severity, duration, patient distress and impairment, the presence of depression and other comorbid disorders, previous treatment response or contraindication, patient preference, provider experience, and treatment availability [3,126]. However, many patients with anxiety disorder who could benefit do not receive treatment; fewer than one in five receive appropriate medication, improving to one in three for patients with comorbid depression [127].

Treatment quality is improved with accurate diagnosis and regular monitoring. Inadequate dosage and treatment duration were found common in the primary care treatment of patients with panic disorder, but improved outcomes were more likely with enhanced patient education and follow-up contact than with physician education [3,128]. Worth noting is the contrast between concerning media reports of medicalization and inappropriate psychotropic prescribing for "normal" anxiety, shyness, or situational stress, and the repeated findings in primary care studies of inadequate or no prescribing and a high level of unmet patient need [3].

General Use Screening Questions

Clinical care providers may consider incorporating a simple question format into the routine clinical encounter, asking patients if they have recently felt excessively nervous, anxious, or on edge, and if worrying is ever uncontrollable or otherwise distressing. The DSM-5-TR suggests the following questions for identifying anxiety-related symptoms [2]:

During the past two weeks, how much have you been bothered by the following problems:

- Feeling nervous, anxious, frightened, worried, or on edge

- Feeling panic or being frightened

- Avoiding situations that make you anxious

A positive history of anxiety symptoms should be explored with screening questions for specific anxiety disorders.

Screening for Specific Anxiety Disorders

In addition to the general questions suggested for all patients with complaints of anxiety, it is important to inquire regarding disorder-specific symptoms. This will allow for more specialized assessment and diagnosis.

Generalized Anxiety Disorder

- During the past four weeks, have you been bothered by feeling worried, tense, or anxious most of the time?

- Are you frequently tense or irritable, or do you have trouble sleeping?

If the patient acknowledges in the positive, then follow with the GAD-7 screening tool.

Panic Disorder

- Do you have sudden, unexpected episodes/spells/attacks of intense fear or discomfort? If yes, then continue.

- Have you had more than one of these attacks?

- Does the worst part of these attacks usually peak within several minutes?

- Have you ever had one of these attacks and spent the next month or more living in fear of having another attack or worrying about the consequences of the attack?

Agoraphobia

- Do you avoid certain situations or places where panic attacks have occurred or may occur?

Social Anxiety Disorder

- Does fear of embarrassment cause you to avoid doing things or speaking to people?

- Do you avoid activities where you are, or may be, the center of attention?

- Is being embarrassed or looking stupid among your worst fears?

Specific Phobia

- Do you feel intense anxiety or fear when confronted by certain animals, objects, or situations?

- Are you avoiding these animals, objects, or situations because of your fear?

- In what ways has this anxiety or fear interfered with your life?

- How would you react if you were exposed to the animal, object, or situation right now?

- Have you ever fainted or almost fainted around blood, injuries, or needles?

Separation Anxiety Disorder

- Do you feel anxious, fearful, or upset thinking about separation, or being away from, your (spouse, partner, primary support person)?

Evidence Based Practice Recommendation

If an adult with possible social anxiety disorder finds it difficult or distressing to attend an initial appointment in person, the National Collaborating Centre for Mental Health recommends making the first contact by phone or Internet, but aiming to see the person face to face for subsequent assessments and treatment.

https://www.nice.org.uk/guidance/cg159/resources/social-anxiety-disorder-recognition-assessment-and-treatment-pdf-35109639699397

Last Accessed: April 27, 2025

Level of Evidence: Expert Opinion/Consensus Statement

Positive responses to screening questions is followed by a formal assessment.

PATIENT HISTORY

A patient history is performed to assess patient and family history for clinically relevant information. Patients should be assessed for onset of anxiety symptoms, duration (remission or persistent), association with life events or trauma, level of distress, and effect on current functioning (academic, occupational, relationships, leisure activities, role functioning). Also inquire about a personal history of physical or emotional trauma, anxiety or mood disorders, medications or therapies, and patient response. Family history should be assessed for anxiety, mood, and substance use disorders [2]. Screening for depression is very important, given its high comorbidity rate and associated risk of suicidal behavior [129].

A thorough list of prescribed, over-the-counter, and herbal medications should be obtained [2]. Furthermore, substance use should be assessed, including:

- Current and past tobacco use

- Current and past alcohol use

- Current and past use of illicit drugs (e.g., cannabis, cocaine, heroin, methamphetamine)

- Current and past use of pharmaceutical drugs (e.g., opioids, stimulants, benzodiazepines)

- Current and past use of "legal high" or novel drugs (e.g., club drugs, "bath salts," "synthetic cannabis")

- Having been told their substance use is a problem

- Having received counseling or treatment for a substance use problem

PHYSICAL EXAMINATION

The physical examination of most patients evaluated for anxiety is usually unrevealing but necessary in order to assess the possibility of primary disorders and conditions associated with anxiety. Careful measurement and recording of resting pulse rate and blood pressure (including postural effect) are important. Patients may be uncomfortable discussing their anxiety, but physical signs of heightened sympathetic nervous system activity (e.g., tachycardia, hyperventilation, sweating, flushing) are absent in the context of a reassuring clinical encounter (excepting acute examination of a patient following panic attack). Routine examination of adolescents and young adults with recent-onset anxiety should prompt careful assessment for signs of hyperthyroidism (e.g., the stare of early proptosis; fine tremor of outstretched hands; tachycardia; brisk deep tendon reflexes). Patients with observed (or history of) vasovagal fainting, especially those suspected of specific phobia disorder, should be assessed for other medical conditions associated with fainting risk (including blood glucose levels and orthostatic hypotension) [2].

Diagnosis is made through self-report, clinical interview, and behavioral observation of impairments in personal, social, or occupational domains; no laboratory testing is necessary. Several empirically validated self-report questionnaires are available to assess baseline functioning and track treatment response. Assessment of anxiety symptoms and associated impairments optimally includes key informant interviews with family members or close friends [2].

DIFFERENTIAL DIAGNOSIS

Differential diagnosis is performed to eliminate potential underlying causes that, if present, would better account for patient anxiety complaints. As noted, screening for other anxiety, mood, and substance-related disorders should be routinely conducted due to high comorbidity rates.

Other Mental Disorders

Evidence Based Practice Recommendation

When assessing an adult with possible social anxiety disorder, the National Collaborating Centre for Mental Health recommends that clinicians be aware of comorbid disorders, including avoidant personality disorder, alcohol and substance misuse, mood disorders, other anxiety disorders, psychosis, and autism.

https://www.nice.org.uk/guidance/cg159/resources/social-anxiety-disorder-recognition-assessment-and-treatment-pdf-35109639699397

Last Accessed: April 27, 2025

Level of Evidence: Expert Opinion/Consensus Statement

To confirm or rule out the presence of comorbid anxiety or related disorders, determine the nature and focus of patient apprehension/anxiety. It may be [2]:

- Diffuse, non-specific (GAD)

- Discrete, intense anxiety episodes (panic disorder)

- Fear of one's panic attacks and avoidance of places or situations where they may occur (agoraphobia)

- Embarrassment in public (SAD)

- Fear of specific objects or situations (specific phobia)

- Attachment figure separation (separation anxiety)

- Contamination (OCD)

- Weight gain (anorexia nervosa)

- Multiple physical complaints (somatization disorder)

- Serious illness (hypochondriasis)

- Strictly trauma-related (PTSD)

A diagnosis of SAD should rule out avoidant personality disorder. Some symptoms of avoidant personality disorder resemble SAD, such as a pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation. However, avoidant personality disorder is distinguished by non-social avoidance that extends to novel situations and positive affect. Roughly 36% of patients with SAD are comorbid for avoidant personality disorder, and some believe avoidant personality disorder is a more severe variant of SAD [130,131].

Medication or Substance Use

It is important to rule out medication side effects as the underlying cause of anxiety by obtaining a complete list of currently used prescribed, over-the-counter, and herbal medications. Examples of common medications with anxiety side effects are asthma medications (e.g., albuterol, theophylline), herbal medicines (St. John's wort, ginseng, ma huang), corticosteroids, and antidepressants [2].

Patients should also be assessed for current use of alcohol, nicotine, stimulants, benzodiazepines, and opioids, because the direct, adverse, or withdrawal effects can mimic anxiety or panic symptoms [132]. Illicit or illicitly used drugs with acute effects most commonly associated with anxiety include cocaine, methamphetamine, prescription amphetamines (e.g., lisdexamfetamine), methylphenidate, and MDMA ("Ecstasy") [2]. Caffeine may also provoke anxiety in sensitive patients, including those with anxiety disorders [28]. Alcohol use disorder is highly prevalent among persons with anxiety disorders. Acute anxiety relief may powerfully reinforce alcohol use, but frequent or heavy drinking commonly exacerbates the anxiety disorder symptoms. When these two disorders co-occur, treatment can be complicated.

Medical Conditions

Careful history taking and physical examination are warranted for all patients to rule out medical causes of anxiety symptoms. Conditions that can mimic or cause anxiety complaints include hyperthyroidism and hypothyroidism, asthma, cardiac arrhythmias, pheochromocytoma, and temporal lobe epilepsy. As noted, screening for depression is very important, given its high comorbidity rate and associated risk of suicidal behavior [129].

Laboratory Tests and Imaging

Although usually negative in the absence of other suggestive evidence, laboratory testing or imaging studies may be indicated to help rule out medical cause. For example, a routine blood panel with thyroid-stimulating hormone and blood glucose levels may help to identify or rule out conditions such as hyperthyroidism or hypoglycemia that may be responsible for intense, persistent anxiety and panic. Toxicology screening may also be indicated to determine whether illicit substances are contributing to the clinical presentation. An electrocardiogram is required in all patients presenting with chest pain (to exclude cardiac causes), and pulmonary function tests are used to rule out pulmonary disease in patients with shortness of breath. It is important to note that cardiopulmonary disorders can co-occur with anxiety disorders [2].

7. GENERAL TREATMENT CONSIDERATIONS

Information in this section is derived from published research, meta-analyses, and clinical practice guidelines. The most recent anxiety disorder guideline (on panic disorder) by the American Psychiatric Association was published in 2009. The 2014 Anxiety Disorders Association of Canada (ADAC) guidelines are the most recent and comprehensive North American publication and are emphasized accordingly [120]. Successful treatment requires tailoring options to individuals and may often include a combination of modalities [121]. When selecting a treatment regimen, clinicians should consider current and prior treatments, comorbid conditions, age, cost of and access to care, and patient preference [350].

The two recommended first-line modes of therapy for anxiety disorder are psychotherapy (principally CBT) and pharmacotherapy. CBT, which includes an exposure therapy component when there are triggered episodes (e.g., SAD, specific phobia), is designed to work through maladaptive beliefs and avoidance behaviors that reinforce pathology surrounding fear-eliciting stimuli. CBT with some variant of exposure is the first-line psychotherapy approach for most adult patients and all childhood cases of anxiety disorder. Selecting CBT as treatment option has two limitations: it requires patient willingness to engage in therapy and the availability of well-trained therapists. Pharmacotherapy is also considered a first-line treatment option for anxiety disorders. While many medications have received FDA approval to treat anxiety, antidepressants have proven to be the most effective. Either a selective serotonin reuptake inhibitor (SSRI) or serotonin-norepinephrine reuptake inhibitor (SNRI) is recommended initial treatment of GAD, SAD, and panic disorder [350]. Benzodiazepines, which once served as a first-line option, are now best reserved for short-term use or as a supplement to the primary treatment regimen.

Advances in anxiety disorder neuroscience have increasingly pointed to the necessary role of fear extinction learning (through exposure therapy) in addressing underlying pathophysiology. While efficacy is shown with CBT and exposure, patients can have difficulty with the demanding and exhausting therapy process, and many who do manage to complete therapy respond partially and relapse with time. Efforts to improve CBT/exposure outcomes have led to the investigation of augmenting agents. In contrast to standard anti-anxiety drugs, these agents are not anxiolytic but are used to promote and accelerate long-term adaptive changes in brain function initiated by successful exposures [137].

Any review of treatment efficacy for anxiety disorders, and pharmacotherapy in particular, requires a disclaimer. Most treatment outcomes were based on studies using methodologies that excluded those with additional anxiety disorders and comorbid psychiatric or medical disorders. Patients seeking care for anxiety problems in primary care and other real-world settings often differ from carefully screened study participants. The extent that efficacy, response, and remission rates reported in the published research generalize to typically more complex clinic patients has been questioned [138].

Treatment refusal and attrition are significant problems. Patients with anxiety disorders show treatment refusal rates of 25% to 30% and treatment dropout rates of 10% to 82% [139]. Treatment dropout is very high in exposure therapy, as patients repeatedly confront (with graded intensity) the situations or objects that trigger their greatest fear or panic response. The intensity of distress during exposure can overwhelm patients, and with avoidance the hallmark feature of most anxiety disorders, attrition is significant [2,139]. Attrition can interfere with evaluating treatment efficacy (or the lack thereof), and unless explicit in study reporting, can be misleading. Attrition is also a clear concern in the clinical care of patients with anxiety.

PREDICTORS OF WORSE TREATMENT RESPONSE AND OUTCOMES

SEPAD

Severe forms of SEPAD are associated with a pervasive negative influence on treatment response. Comorbid SEPAD is highly correlated with poor treatment response and patient outcomes across a range of anxiety and mood disorders. SEPAD negatively impacts response to major depression treatment and is linked to worse symptom chronicity and quality of life. SEPAD decreases CBT response and predicts worse outcomes in patients treated for panic disorder, GAD, or SAD. SEPAD also predicts nonresponse to selective serotonin re-uptake inhibitors (SSRIs) or tricyclic antidepressants (TCAs) in patients with panic disorder with agoraphobia [98,140].

Chronic Pain

Uncontrolled pain is also increasingly recognized to negatively impact anxiety disorder treatment outcomes. In primary care patients with a GAD or panic disorder diagnosis treated for severe anxiety and followed for one year, patients with moderate or greater pain levels were found to show significantly lower rates of clinical improvement [141]. A cohort of 1,122 individuals with remitted anxiety or depressive disorders were followed up to four years, and pain (but not chronic disease) was associated with recurrence during follow-up [142].

Social Drinking

Problematic, excessive drinking clearly disrupts treatment response, but social drinking can also aggravate panic disorder and probably other anxiety syndromes. The short-acting effects of alcohol wear off rapidly, followed by rebound to a state of hyper-excitability that may be more problematic for patients with anxiety. This can occur with one to two drinks in some patients, who often do not even consider this a contributing factor to their anxiety complaint. Explaining the simple physiology of rebound excitation after profound neuronal inhibition will often convince patients that alcohol may be sensitizing the neural circuits subserving their anxiety and that a trial period of abstinence is indicated [28].

Other Anxiety Disorders

Highly symptomatic panic inhibits benefit from interpersonal psychotherapy, either alone or combined with SSRIs. The presence of any anxiety disorder impairs response to treatment of comorbid major depression [98]. Patients with major depressive disorder and a comorbid anxiety disorder demonstrate longer time to recovery and greater risk of early treatment termination. Patients with comorbid anxiety and depressive disorders generally have worse outcomes than patients with either disorder alone. Patients with comorbid GAD and major depression are significantly more likely to remain symptomatic than those with depression or GAD alone [143]. When anxiety symptoms are present within a dominant depressive disorder, antidepressant drugs are often effective in reducing anxiety [144]. However, depression that follows or is comorbid with an anxiety disorder usually indicates greater severity and worse prognosis [145].

Among treatment-seeking patients with panic disorder, SAD, or GAD followed over two years, symptom changes in GAD were most specifically related to changes in impairment, suggesting that treatment of patients with multiple anxiety disorders should initially focus on GAD symptoms or employ trans-diagnostic modalities [146].

Patients with panic disorder/agoraphobia who display the low-expression allele of the serotonin transporter gene promoter show more favorable exposure therapy response than patients with other 5-HTTLPR genotypes. This genetic contribution to exposure therapy outcome implicates the serotonergic system as a response mediator to exposure treatments [85].

OVERLAPPING PSYCHOLOGIC AND DRUG THERAPY MECHANISMS

Emerging evidence is challenging conventional wisdom by showing that antidepressant therapeutic action may begin with the first dose and that psychologic and drug therapy approaches share common mechanisms. In one study, a single dose of norepinephrine reuptake inhibitor reboxetine reduced negative affective bias in depression by increasing recognition of positive facial expressions and enhancing memory for positive vs. negative information [147]. These early changes in emotional processing reflect changes in frontolimbic circuitry involved in detection and response to biologically salient information. These findings were replicated following seven days of escitalopram treatment [148]. Changes in neurocognitive processing that precede clinical improvement predict later antidepressant response [149]. A 2013 study found that the initial session of CBT administered for panic disorder/agoraphobia led to reduced threat processing the following day, with the magnitude of early effect predictive of the therapeutic response after four weeks [150]. These findings challenge assumptions that psychologic therapies address conscious thought processes before automatic information processing and suggest a greater similarity between early effects of pharmacologic and psychologic treatments for anxiety than previously thought [149].

PSYCHOTHERAPIES: OVERVIEW

Psychologic treatments play an integral role in the management of anxiety disorders, and efficacy is established for several modalities. Most broadly effective are exposure-based and other CBT approaches. When choosing psychologic treatments for individual patients, the forms of therapy developed for the specific anxiety disorder should be used first.

Cognitive and Behavioral Approaches

Psychotherapy can be as effective as medication for GAD and panic disorder, and CBT has the best level of evidence [121]. CBT is the most extensively evaluated psychologic therapy in anxiety disorders and contains elements of cognitive and behavioral therapy approaches.

Behavior therapy consists of using exposure to modify dysfunctional behaviors that may contribute to the development and persistence of psychologic symptoms [151]. Cognitive therapy involves cognitive restructuring, a psychotherapeutic process of learning to identify and modify irrational or maladaptive thoughts using strategies such as Socratic questioning, thought recording, and guided imagery [34].

CBT is not a single treatment approach but a process that addresses factors that caused and maintain patient anxiety symptoms. The classic CBT approach involves disorder-specific treatment protocols that target the symptoms and the cognitive, behavioral, and emotional vulnerabilities that underlie development and maintenance of each disorder. This approach reflects the assumption that each form of psychopathology has a distinct cognitive profile, to which CBT is tailored accordingly. Disorder-specific CBT is the standard of care for anxiety and depressive disorders [152]. However, there are common components of CBT used in anxiety disorders (Table 2) [120].

Table 2: COMMON COMPONENTS OF CBT USED IN THE TREATMENT OF ANXIETY DISORDERS

Cognitive Strategies

Cognitive restructuring, behavioral experiments, and related strategies target exaggerated perception of danger (e.g., fear of negative evaluation in SAD).

Therapy provides corrective information regarding the level of threat and can also target self-efficacy beliefs.

Arousal Management

Relaxation and breathing control skills help control increased anxiety levels.

Exposure

Encourage patients to face fears.

Patients learn corrective information through experience.

Extinction of fear occurs through repeated exposure.

Successful coping enhances self-efficacy.

Safety Response Inhibition and Surrender of Safety Signals

Patients wean from and relinquish use of their usual anxiety-reducing safety signals and behaviors (e.g., presence of a companion, need for reassurance, knowing the location of nearest exit or toilet), which decreases negative reinforcement.

Coping with anxiety without using anxiety-reducing behavior enhances self-efficacy, allowing patients to learn adaptive self-efficacy beliefs.

Source: [120]

There is some debate regarding whether the efficacy of CBT that targets common underlying factors would be comparable to standard diagnosis-tailored CBT. Support for CBT that addresses common underlying factors includes frequent comorbidities in anxious patients, such as major depressive disorder, which some studies found present in close to 50% of patients with anxiety [153]. The frequent co-presence of mood and anxiety disorders, substantial overlap in dimensional symptom ratings, and extensive evidence of shared vulnerability factors enabled identification of common underlying factors that represent targets for CBT. These include [152]:

- Motivational enhancement

- Psychoeducation and understanding emotions

- Emotional awareness training

- Cognitive reappraisal

- Attenuation of emotional and behavioral avoidance

- Awareness and tolerance of physical sensations

- Interoceptive and situational exposure

- Relapse prevention

Psychotherapy and drug therapy show similar efficacy in most anxiety disorders. There is variability and conflicting data on outcome measures from studies of psychotherapy in combination with drug therapy; current evidence does not support routine combination therapy as initial treatment. However, patients lacking response to either CBT or drug therapy may benefit from adding the other modality [120].

Delivery of effective CBT is versatile. Individual or group delivery is effective in most anxiety disorders. A variety of self-directed or minimal intervention formats (e.g., bibliotherapy/self-help books, Internet/computer-based CBT with or without minimal therapist contact) have shown significant improvements in anxiety symptoms, and exposure therapy can be effective using a virtual reality format. These strategies can be very useful when real-life exposure is made difficult by inconvenience or patient reluctance [120].

Third-Wave Therapies

Mindfulness-based cognitive therapy, acceptance and commitment therapy, compassionate mind training, extended behavioral activation, metacognitive therapy, and schema therapy are diverse approaches originating from CBT. These modalities place greater importance on the form rather than content of patient cognitions. These third-wave therapies help patients develop more adaptive emotional responses to situations by focusing on the function of cognition. Mindfulness and acceptance are used in anxiety disorders to help patients observe symptomatic processes without overly identifying with or reacting to them in ways that perpetuate distress [154].

Mindfulness

Mindfulness involves attending to relevant aspects of experience in a non-judgmental manner. The goal of mindfulness is to maintain moment-by-moment awareness; disengage oneself from strong attachment to beliefs, thoughts, or emotions; and develop a greater sense of emotional balance and well-being. An aim of mindfulness practice is to take greater responsibility for one's life choices. Some evidence supports the efficacy of this approach in GAD and panic disorder [155,156,157].

Mindfulness versus active control was compared in ability to reduce negative thought intrusions activated by a worry-induction procedure. Negative thought intrusions significantly increased with progressive muscle relaxation and focused attention but not with brief mindfulness meditation, suggesting mindfulness might target anxiety by reducing negative elaborative processes that maintain worry [158].

Acceptance and Commitment Therapy

Acceptance and commitment therapy views psychologic events as a set of ongoing interactions between whole organisms and contexts defined historically and situationally. Acceptance and commitment therapy states that analyzing problematic behaviors but excluding the contexts that participate in the event misses the nature of the problem and pathways for its solution. This approach promotes a conscious posture of openness and acceptance of all psychologic events, including those deemed "negative" or "irrational." In acceptance and commitment therapy, when patients feel frustrated, afraid, angry, or anxious, this represents an opportunity to examine how powerful events in the present can become barriers to growth [159]. Some evidence suggests acceptance and commitment therapy may be as effective as CBT in anxiety disorder treatment, including panic disorder [151,160,161].

Acceptance-based skill training differs from traditional coping skills training by de-emphasizing control (over physiology or thoughts) to focus on acceptance of panic-related sensations and cognitions as they occur from moment to moment. Patients learn to pay nonjudgmental attention to thoughts, feelings, images, and bodily sensations. Thoughts are viewed as an ongoing process distinct from self, rather than events with literal meaning (cognitive defusion). Efficacy of acceptance approaches has been shown in patients with panic disorder/agoraphobia [162].

Education and Support

Psychoeducation states that providing information to patients with anxiety about their anxiety symptoms and theories of psychologic therapy may help reduce these symptoms. By increasing the patient's sense of control, psychoeducation may reduce catastrophic thoughts and emotions. This is especially relevant to patients with panic disorder, whose cognitive coping mechanisms are disrupted and whose anticipatory anxiety may cause additional attacks [151].

Supportive psychotherapy uses encouragement, rationalizing/reframing, and anticipatory guidance to reduce symptoms and maintain, restore, or improve self-esteem, ego function, and adaptive skills. This approach views the therapeutic alliance as the most important element. The archetype of supportive psychotherapy is the Rogerian client-centered approach; a warm, empathic, and non-directive therapeutic relationship helps clients become aware of their true feelings and achieve full self-acceptance. This approach may benefit patients with agoraphobia, but efficacy in panic disorder is unclear [151].

Physiologic Therapy

Physiologic therapies involve physical training (e.g., breathing retraining, relaxation techniques, biofeedback) to help patients control physiologic anxiety symptoms. Hyperventilation and hypocapnia are identified factors in panic disorder development and maintenance; panic attacks can be caused by acute hypocapnia states in a positive feedback loop between hyperventilation and anxiety. Breathing training is used to ameliorate panic symptoms, but it shows mixed efficacy in panic disorder [162]. Progressive muscle relaxation teaches patients with panic to reduce general tension and achieve a body state that lowers the risk for panic-inducing stressors. Applied relaxation teaches patients to observe the first signs of a panic attack and apply a rapid and effective relaxation technique to cope with and abort panic symptoms before escalation into a panic attack. Applied relaxation is comparable to progressive muscle relaxation in reducing panic attacks [151].

Psychodynamic Approaches

Psychodynamic therapies differ in length and depth, influenced by Freudian psychoanalysis and later refinements. Psychodynamic psychotherapy views mental symptoms as manifestations of intrapsychic and unconscious conflicts; treatment involves uncovering, interpreting, and resolving such conflicts using analysis of unconscious contents, dreams, past experiences, parental relationships, transference, and/or resistances [151]. A brief panic-focused psychodynamic psychotherapy, derived from psychodynamic theories, utilizes emotion-focused therapy, whereby the therapist is viewed as an "emotion coach" who works to enhance emotion-focused coping by helping patients become aware of, accept, and make sense of their emotional experience [163].

One psychodynamic psychotherapy approach is derived from the proposition that fearful parental dependency in childhood may lead to anger toward the parent. A vicious cycle is created; anger threatens the needed tie to the parent and increases fearful dependency, which promotes further frustration and rage at the parent. This cycle may recur in adulthood when threats to attachment trigger intense feelings of abandonment, anger, and anxiety, promoting the development of pathologic anxiety. The goal is to address such underlying psychologic factors to decrease panic symptoms. Some evidence suggests this approach is a valid therapeutic option, especially when SEPAD is present [98,151].

Exposure Therapies

Exposure therapy is defined as any treatment that encourages patients to systematically confront feared stimuli, which can be external (e.g., feared objects, activities, situations) or internal (e.g., feared thoughts, physical sensations) [136]. Exposure therapy is an effective, empirically supported treatment modality for anxiety disorders and a core component of CBT. Variants of exposure therapy include:

- In vivo exposure: Exposure that involves real-world confrontation of feared stimuli

- Imaginal exposure: Vividly imagining and describing the feared stimulus, including details about external (sights, sounds) and internal (thoughts, emotions) cues

- Virtual reality exposure: Patient immersion into a software-generated virtual world that allows them to confront their fears

The success of exposure therapy occurs by targeting maladaptive learning and fear conditioning, core mechanisms implicated in anxiety disorder etiology and maintenance. Standard exposure therapy involves exposure to feared objects or situations and gradual elimination of safety behaviors—the subtle avoidance behaviors that temporarily diminish distress in feared situations but interfere with long-term anxiety reduction. Patients are encouraged to continue confronting the feared situations through exposure until substantive reductions in fear occur. Exposure therapies facilitate extinction learning by diminishing the association between the avoided situation and fear and promoting new learning of the true nonthreatening nature of the situation [164,165].

Exposures are graded in intensity, with the same process used for weaning safety signals. For instance, a patient with panic disorder and agoraphobia can initially practice walking through a congested shopping mall with a family member; on the next exposure, he or she may practice walking separately through the shopping mall and eventually walk through the congested mall alone. Patients are taught that treatment setbacks are common and to distinguish between expected treatment lapses and relapses. Symptom flare-ups do not mean treatment failure, but instead are opportunities to revisit psychoeducation, cognitive restructuring, or exposure, and work toward regaining progress [166].

A substantial number of patients fail to achieve substantive symptom relief from exposure-based therapies or experience fear relapse following exposure therapy. This results from deficits in the mechanisms considered central to extinction learning (e.g., poor medial prefrontal cortex inhibition of amygdala-generated fear impulses) that contributed to the development of pathologic anxiety and avoidance in the first place. Because of this, effort is underway to optimize exposure therapies to improve significant and durable patient response [167]. This effort includes the therapeutic alliance as a potential prognostic indicator [168].

PHARMACOTHERAPY: OVERVIEW

The first-generation antidepressants monoamine oxidase inhibitors (MAOIs) and TCAs were introduced in the late 1950s and early 1960s, and the first report of antidepressant use in anxiety treatment was published in 1962. In this account, patients with agoraphobia who were given the TCA imipramine showed reductions in panic attacks and improved exposure to feared situations [169]. The benzodiazepine chlordiazepoxide (Librium) was introduced to the U.S. market in 1960. This was followed by diazepam (Valium) in 1963, which became the most prescribed drug in the United States from 1969 to 1982; in 1978, more than 2.3 billion diazepam doses were sold in the United States [170]. Panic disorder was first formalized as a psychiatric disorder in the 1980 DSM-III, and alprazolam (Xanax) became the first U.S. Food and Drug Administration (FDA)-approved drug for panic disorder treatment in 1981, remaining the most-prescribed benzodiazepine to date [171].

In the past two decades, antidepressant drugs, specifically SSRIs, have displaced benzodiazepines as the most widely prescribed and recommended anxiety disorder pharmacotherapy. Efforts to improve safety, efficacy, and tolerability led to introduction of the second-generation antidepressants, with trazodone (Oleptro) in 1982, bupropion (Wellbutrin) in 1985, and fluoxetine (Prozac)—the first domestically marketed SSRI—in 1987.

Antidepressants are generally recommended as first-line therapy for panic disorder because, unlike benzodiazepines, antidepressants treat comorbid depression and lack abuse risk and potential side effects of excessive sedation, cognitive impairment, and ataxia. All major antidepressant classes are comparably effective, but SSRIs and, increasingly, SNRIs are recommended over TCAs and MAOIs due to better safety and tolerability [172].

Tricyclic Antidepressants

Norepinephrine, serotonin (5-HT), and dopamine are termed monoamines. Monoamine reuptake transporters retrieve monoamines released into the synaptic cleft to terminate their activation of post-synaptic monoamine receptors. TCAs act by inhibiting norepinephrine and 5-HT reuptake transporters. This increases synaptic levels of norepinephrine and 5-HT by preventing their clearance, which increases post-synaptic receptor activation and signaling. TCAs generally have greater norepinephrine than 5-HT reuptake transporter potency. TCAs also act as histamine H1/H2, muscarinic acetylcholine, and alpha-adrenergic receptor antagonists, resulting in a range of undesirable side effects associated with patient intolerance and discontinuation, including [173]:

- Anticholinergic: Dry mouth, blurred vision, constipation, urinary hesitancy and retention, confusion, precipitation of glaucoma, delayed ejaculation, sweating

- Alpha-1-adrenoceptor antagonism: Postural hypotension, increased heart rate, dizziness

- Antihistaminergic: Sedation, psychomotor slowness, weight gain

- Cardiac sodium channel blockade: QTc prolongation, decreased cardiac conduction, fatal cardiac arrest in overdose

TCAs have comparable efficacy to SSRIs in panic disorder and GAD [174,175]. TCAs are lethal in overdose and, compared to SSRIs, have a markedly broader, more problematic, and less tolerable side effect profile [172]. Nonetheless, TCAs may work when first-line agents do not [136]. Also, some patients with panic disorder are sensitive to both beneficial and adverse effects of TCAs, so they cannot tolerate imipramine doses >10 mg/day but may still experience panic blockade [172].

Monoamine Oxidase Inhibitors

MAOIs inhibit MAO, an enzyme that degrades and inactivates 5-HT, norepinephrine, and dopamine, thereby increasing monoamine levels and activity. The earlier MAOIs—phenelzine (Nardil) and tranylcypromine (Parnate)—are characterized by irreversibility and nonselectivity. Irreversibility refers to tenacious drug binding to the MAO enzyme for the 14- to 28-day lifespan of the drug molecule. Nonselectivity refers to phenelzine and tranylcypromine binding to both A and B isoenzymes of MAO. While tyramine and dopamine are metabolized by both MAO-A and MAO-B, MAO-A inhibition is established as the precursor to hypertensive crises [176].

During phenelzine or tranylcypromine therapy, dangerous and potentially fatal hypertensive reactions can result from co-ingestion of drugs with monoamine activity or foods high in tyramine content (e.g., cheese, beer, wine). Concurrent use of serotonergic agents or supplements such as St. John's wort can cause potentially lethal serotonin syndrome. Common side effects include orthostatic hypotension, weight gain, sexual dysfunction, sedation, headache, and insomnia. To avoid drug interactions, washout periods are required before an MAOI is started (≥5 days) or stopped before switch to another medication (≥14 days) [136].

Moclobemide is a reversible inhibitor of monoamine oxidase type A (RIMA). With reversibility, MAO enzyme detachment and/or displacement readily occur, greatly improving safety. Compared to tranylcypromine, it takes eight times the tyramine level (8 mg vs. 63 mg) with moclobemide to induce a 30 mm Hg rise in diastolic blood pressure; dietary and co-medication concerns are greatly reduced. No washout period is required for switching anti-depressants. Moclobemide is safe in overdose, and 20,000 mg has been ingested without fatality. Common side effects include nausea, insomnia, tremor, and lightheadedness. Orthostatic hypotension is uncommon, even in the elderly [176]. Moclobemide lacks the cholinergic and histaminergic side effects of TCAs and the sexual side effects of SSRI/SNRIs. Depressive patients more commonly reported improved libido, erection/ejaculation, and orgasm with moclobemide. Weight gain or lowered seizure threshold are not side effects [177]. Moclobemide was slated for introduction in the United States in 1992. It was withdrawn from the application process because SSRI popularity cast doubts on its profit potential. This drug is available in Canada and throughout Europe and Asia [176,178].

MAOIs and RIMAs are effective for panic disorder and SAD and are thought by some to be superior options for severe, treatment-resistant anxiety disorders. As noted, MAOIs have a substantial side effect profile and impose the greatest safety burden of all antidepressants. Therefore, they are usually reserved as the last treatment option after other drug therapies have failed to achieve remission [179]. Clinicians do not routinely prescribe MAOIs for anxiety disorders, although they are probably not considered often enough in treatment-resistant patients [136].

SSRIs

SSRIs are considered first-line therapy for GAD and panic disorder [121,172]. SSRI mechanism is thought to involve serotonin transporter (SERT) inhibition at the presynaptic axon terminal of 5-HT neurons. SERT inhibition also occurs at the somatodendritic end of the neuron, where the increase in 5-HT causes 5-HT1A autoreceptors to downregulate, desensitize, and over time lose the ability to inhibit 5-HT release. The resultant increase in synaptic 5-HT level mediates the therapeutic action. SSRIs were termed "selective" because, unlike TCAs, they were believed to have little-to-no interaction with non-serotonin receptors and transporters [136,180].

It is now recognized that SSRIs differ in pharmacologic effect, including activity beyond SERT inhibition [179,180]:

- Fluoxetine: Antagonist at 5-HT2C receptors, which enhances norepinephrine and dopamine release. Therapeutic effects may emerge more slowly than other SSRIs.

- Sertraline (Zoloft): A weak dopamine transporter inhibitor, sigma-1 receptor activity. Along with fluoxetine, increases cortex monoamine levels to possibly explain patient reports of improved energy, motivation, and concentration.

- Paroxetine (Paxil): A weak norepinephrine transporter inhibitor, which contributes to antidepressant effects. Muscarinic cholinergic receptor activity may underlie some sedative and anxiolytic effects.

- Fluvoxamine (Luvox): Along with sertraline, has sigma-1 receptor activity that possibly contributes to the anxiolytic effects of both agents.

- Citalopram (Celexa): Mild antihistamine properties not observed with escitalopram.

- Escitalopram (Lexapro): Is considered the only SSRI without pharmacologic activity beyond SERT inhibition.

The atypical SSRIs vilazodone (Viibryd) and vortioxetine (Brintellix) display expanded serotonergic and other monoaminergic activity beyond those of standard SSRIs. Vilazodone and vortioxetine are likely to be treatment options for patients who do not respond to or cannot tolerate typical SSRIs/SNRIs.

Side effects associated with SSRI treatment include gastrointestinal upset (nausea, vomiting, diarrhea), activation/insomnia (restlessness, agitation, anxiety, akathisia, sleep disturbances), sexual dysfunction (loss of erectile or ejaculatory function in men, loss of libido and anorgasmia in both sexes), headache, fatigue, and weight gain. Many side effects dissipate over time. Sertraline is particularly associated with diarrhea, and paroxetine with weight gain. Discontinuation syndrome from paroxetine is more severe and protracted than other SSRIs [181]. To avoid relapse, medication should be continued for at least 12 months after symptom improvement before tapering [121].

Vilazodone

Approved by the FDA in 2011, vilazodone primarily acts as a serotonin reuptake inhibitor and 5-HT1A receptor partial agonist, with modest action as a dopamine and norepinephrine reuptake inhibitor, with 5-HT4 receptor activity [173]. This profile resembles the combination of SSRI and buspirone, and GAD efficacy of both agents suggests a potential role for vilazodone in anxiety disorder treatment. Two eight-week randomized controlled trials of vilazodone treatment of GAD have been published. One using a flexible-dose design found nominal clinical improvement with vilazodone compared with placebo, while the other study using a fixed-dose design found statistically significant reduction in anxiety scores (vs. placebo) with vilazodone 40 mg but not 20 mg [182,183]. Vilazodone does not appear to improve efficacy over drugs already in use, but it does have advantages of earlier onset of clinical response (beginning by two weeks) and little evidence of sexual dysfunction or weight gain. Vilazodone should be taken with food, which increases its absorption and bioavailability by 72% [184].

Vortioxetine

Approved by the FDA in 2013, vortioxetine is a multimodal antidepressant and potential anxiolytic with activity as an antagonist in 5-HT1D/3A/7 receptors, a 5-HT1A receptor agonist, 5-HT1B partial agonist, serotonin transporter inhibitor, and weak norepinephrine transporter inhibitor. This multiple receptor activity modulates serotonergic, noradrenergic, dopaminergic, and histaminic systems to produce clinical effect [185]. Results from four randomized controlled trials suggest vortioxetine may have potential efficacy in the treatment of severe GAD, but effects in patients with more moderate GAD were minimally improved compared with placebo. Nausea, the most common side effect, was dose dependent [186]. Sexual dysfunction rates were similar to placebo across the 5–20 mg/day dose range, and vortioxetine can be taken without regard for meals [187].

SNRIs

Venlafaxine, the first SNRI approved in the United States, was introduced as immediate release (IR) in 1993 and extended release (XR) in 1997. This was followed by the introduction of duloxetine in 2004, desvenlafaxine in 2008, milnacipran in 2009, and levomilnacipran in 2013. SNRIs increase synaptic concentrations of 5-HT and norepinephrine by blocking reuptake of these neurotransmitters by their respective transporters. SNRIs lack significant affinity for adrenergic, cholinergic, histaminergic, opioid, glutamate, or GABA receptors and transporters [136,188].

SNRIs differ in proportion of 5-HT/norepinephrine reuptake inhibition. Venlafaxine is the most serotonergic SNRI, followed by duloxetine and desvenlafaxine. Milnacipran shows relatively equal influence on 5-HT and norepinephrine reuptake inhibition, and levomilnacipran is a greater norepinephrine than 5-HT reuptake inhibitor. Such differences suggest that SNRIs are dissimilar from one another. Venlafaxine and duloxetine exhibit dose-related sequential effects on reuptake inhibition, while desvenlafaxine, milnacipran, and levomilnacipran act simultaneously on 5-HT and norepinephrine reuptake inhibition with proportionality intact with dose escalation [189].

Side effects from SNRIs overlap with SSRIs but can also include adrenergic effects of increased pulse rate and blood pressure, dilated pupils, dry mouth, and excessive sweating. Venlafaxine has a greater incidence of nausea and vomiting than SSRIs and may be associated with an increased risk for cardiovascular events [181]. Sexual side effects associated with SNRIs include decreased response to sexual stimuli, loss of interest in sex, anorgasmia, and much less frequently, genital anesthesia. Discontinuation syndrome from venlafaxine is markedly worse than other SNRIs and SSRIs [188].

Relative to SSRIs and TCAs, the SNRIs have relatively short half-lives, and few or no active metabolites for simpler overall pharmacology. In contrast to venlafaxine and duloxetine, desvenlafaxine, milnacipran, and levomilnacipran largely bypass the hepatic cytochrome P450 isoenzyme system, making drug interactions less likely. Of the five available SNRIs, only venlafaxine has an active metabolite (desvenlafaxine). Dosing with venlafaxine IR and milnacipran is twice daily; the remaining SNRIs are dosed once daily [184].

The impairing effects from synaptic plasticity induced by conditioned psychologic stress were found reversed by SNRI treatment. Long-term venlafaxine and milnacipran use suppressed long-term potentiation in hippocampal CA1 via 5-HT1A receptor and a1-adrenoceptor activity, contributing to reversal in synaptic plasticity-related impairment induced by conditioned fear stress. Increased responsiveness of a1-adrenergic and dopaminergic D3 systems, decreased responsiveness of 5-HT2 systems, and development of adaptive changes occurred despite lack of SNRI affinity for these neurotransmitter receptors [188,190,191].

Venlafaxine

Venlafaxine IR was introduced in 1993 but from the outset was plagued with side effects, leading to the 1997 introduction of venlafaxine XR. The XR formulation has become a widely prescribed agent with established efficacy in several anxiety disorders. In addition to the dose-related reuptake inhibition of 5-HT and norepinephrine mentioned, weak dopamine reuptake inhibition may appear at dosages greater than 300 mg/day. This sequential activity is mirrored by the initial predominant serotonergic side effects (headache, nausea, fatigue, sexual dysfunction), with noradrenergic effects at higher doses (activation effects, dry mouth, night sweats) [184].

Desvenlafaxine

Desvenlafaxine (Pristiq) shows a 10-fold higher selectivity for serotonin over norepinephrine reuptake inhibition at 50 mg/day, with selectivity unchanged by dose increase to 100 mg/day [184]. A primary advantage of desvenlafaxine over venlafaxine involves metabolic pathways and drug interactions. Venlafaxine is extensively metabolized by the hepatic CYP2D6 isoenzyme to desvenlafaxine, while desvenlafaxine is metabolized primarily via glucuronidation and minimally through CYP3A4 [178]. Venlafaxine, but not desvenlafaxine, clearance in patients with polymorphic 2D6 can be accelerated or delayed, resulting in non-efficacy or greater side effects/toxicity. This makes desvenlafaxine preferable to venlafaxine for these patients. The desvenlafaxine metabolic pathway also eliminates adverse drug interactions with 2D6 substrates that require consideration with venlafaxine prescribing [188,192]. However, few trials have evaluated desvenlafaxine in anxiety disorder treatment [184]. A comparison of the efficacy and safety of desvenlafaxine and escitalopram for treatment of depression with anxiety found that both drugs reported similar efficacy, but escitalopram was better tolerated with fewer adverse effects [193].

Duloxetine

Duloxetine (Cymbalta) has greater potency in 5-HT reuptake inhibition than fluoxetine. It has an elimination half-life of roughly 12.5 hours, steady-state is usually achieved after three days, and metabolism occurs mainly through hepatic CYP 2D6 and 1A2 [178,194]. Common adverse effects of duloxetine include nausea, headache, and weight loss. Certain adverse effects, including xerostomia, drowsiness, and fatigue, are dose related [178].

Milnacipran

Milnacipran (Savella) has been marketed in France since 1997 for the treatment of major depression, but it is indicated for use by the FDA solely for fibromyalgia [178]. Milnacipran is not available in a generic formulation, and the expiration of the patent is not imminent. Anxiolytic effects of milnacipran are at least partially mediated by 5-HT2A receptor agonism [188,195]. Results of a systematic review were inconclusive regarding the comparative efficacy, acceptability, and tolerability of milnacipran versus other antidepressive agents; however, milnacipran reportedly was more favorable than TCAs in terms of acceptability and tolerability [196].

Levomilnacipran

Levomilnacipran (Fetzima) differs from other SNRIs in that it is a more potent and selective inhibitor of norepinephrine than serotonin, especially at low doses. Alcohol may disrupt the extended-release mechanism to release large amounts of drug over a brief period, and co-ingestion should be avoided. With reports of milnacipran increasing hepatic transaminases to cause fulminant hepatitis, levomilnacipran should be avoided in patients with a history of alcoholism or chronic liver disease. Levomilnacipran is not associated with weight gain [173,178]. Levomilnacipran ER 40–120 mg daily was found to be effective in preventing relapse in patients with major depressive disorder [197].

Other Antidepressants

Bupropion

Bupropion (Wellbutrin) lacks effect on serotonin neurotransmission either presynaptically (through serotonin release or reuptake inhibition) or postsynaptically (acting on serotonin receptors). Instead, bupropion inhibits the reuptake of norepinephrine and dopamine without affecting release or transport of other neurotransmitters and without binding to other neurotransmitter receptors. This unique pharmacologic profile makes bupropion the only approved antidepressant that increases dopamine neurotransmission in the nucleus accumbens and prefrontal cortex. The side effect profile, distinct from other antidepressants, lacks sexual dysfunction, weight gain, and sedation. The activating effects of bupropion can increase insomnia and anxiety, leading to its infrequent use in anxiety disorders [179,198].

Trazodone and Nefazodone

The anxiolytic effects of trazodone are mediated by activity as a highly potent 5-HT2A receptor antagonist and moderately potent 5-HT1A partial agonist, with additional activity in SERT and 5-HT2C receptor inhibition. The combined actions of 5HT2A/5HT2C antagonism and SERT inhibition only occur at moderate-to-high doses, with doses lower than effective for antidepressant action frequently used for the effective treatment of insomnia [178,179,199]. Nefazodone (Serzone) is highly similar in pharmacologic activity to trazodone, but it is rarely prescribed due to liver toxicity concerns [179].

Mirtazapine

Mirtazapine (Remeron) is a tetracyclic compound with a unique mechanism of action, leading to description as a noradrenergic antagonist-specific serotonin antagonist antidepressant. Pharmacologically, mirtazapine is a 5-HT1 receptor agonist, and antagonism of 5-HT2A/C receptors increases cortical serotonin, dopamine, and norepinephrine modulation. Inhibition of norepinephrine alpha-2 autoreceptors allows greater norepinephrine release from neuron terminals. Also antagonized are receptors of 5-HT3, 5-HT5, and H1 histamine. This unique profile helps account for earlier onset of action than SSRI/SNRIs. Mirtazapine tends to promote sleep or drowsiness, and the most frequent side effect of daytime sedation can be a beneficial effect in highly anxious patients [178,179,188].

Mirtazapine is found beneficial in patients with GAD, SAD, OCD, panic disorder, and PTSD [200]. It is relatively safe in overdose. Mirtazapine is particularly useful in patients with sexual dysfunction from other antidepressants and is a good choice in patients with significant insomnia. Weight gain is a side effect, and if the risks for elevated lipid levels and rare agranulocytosis are a concern, mirtazapine may be reserved as a third-line choice [200,201].

Agomelatine

Agomelatine is approved for clinical use in Europe, Australia, and a total of 40 countries overall, but not by the FDA. It is discussed in light of its novel mechanism and particular benefit in GAD [202].

Agomelatine is a synthetic melatonin analog with activity as a melatonin MT1/MT2 receptor agonist and 5-HT2C receptor antagonist. Unique to agomelatine, and one of its most important properties, is a sleep-promoting and pro-chronobiologic effect. Its 5-HT2C antagonism promotes dopaminergic firing in the ventral tegmental area, frontal cortex, hypothalamus, hippocampus, medulla, pons, and retina by enhancing norepinephrinergic activity in the locus coeruleus [185,203].

With a unique non-monoaminergic mechanism of action, clinical trials have shown a low risk of sexual dysfunction, lack of weight gain or withdrawal symptoms, and overall side effect profile similar to placebo. However, reports of liver injury require patients to receive liver enzyme monitoring [204].

Anti-Epileptic Drugs

Gabapentinoids

Pregabalin (Lyrica) and gabapentin (Neurontin) are structurally analogous GABA analogs, with pregabalin more extensively evaluated in anxiety disorders. The anxiolytic, antinociceptive, and antiseizure properties of pregabalin are mediated through binding to presynaptic α2δ subunits of central nervous system (CNS) voltage-gated calcium channels, which decreases calcium influx at presynaptic channels and inhibits neurotransmission of excitatory glutamate, norepinephrine, and substance P [185,205].

The relative efficacy and early onset of effect of pregabalin versus benzodiazepines may represent a new therapeutic intervention for GAD as mono- and augmentation therapy. Pregabalin has a low risk of drug interactions, lacks withdrawal or physical dependence risk, is associated with minimal adverse effects (e.g., dizziness, weight gain, insomnia), and is safe and well tolerated. A potential role for pregabalin in patients with GAD tapering off long-term benzodiazepine therapy has been suggested [185].

Benzodiazepines have been the only anxiolytic agents that rapidly reduce anxiety, but trials conducted in the last decade have also found this effect with pregabalin. In 89 patients with moderate-to-severe dental anxiety (without anxiety disorder diagnosis) given single-dose pregabalin 150 mg, alprazolam 0.5 mg, or placebo four hours before a dental procedure, the onset of anxiolytic effects began within three to four hours after pregabalin and within two hours after alprazolam. The magnitude of anxiety reduction and tolerability were equivalent between pregabalin and alprazolam [206].

Common GAD comorbidities of insomnia, gastrointestinal symptoms, and depression do not impair efficacy and are specifically improved by pregabalin. Pregabalin is generally well tolerated; the adverse event profile includes dizziness, somnolence, incoordination, dry mouth, headache, and weight gain. Risk of withdrawal symptoms is low when tapered over one week [205].

Levetiracetam (Keppra) is an analog of the nootropic drug piracetam and structurally unrelated to other anti-epileptic drugs. It has a novel mechanism of action that involves binding to synaptic vesicle protein SV2A, a protein that modulates neurotransmitter release including GABA. Metabolism has no effect on the cytochrome P450 enzyme system. The most common side effects include somnolence, dizziness, and weakness [207]. In one study, adjunctive levetiracetam (mean: 1,969 mg/day for 9.3 weeks) in highly symptomatic patients with treatment-refractory anxiety disorders led to clinically and statistically significant improvement in illness severity [208]. Further research involving patients with panic disorder with or without agoraphobia given levetiracetam for 12 weeks showed significant improvement in panic attack frequency, anxiety, and global severity ratings. Clinical benefits were apparent by one to two weeks for most patients, and side effects were minimal [209]. Patients with SAD initially administered levetiracetam 250 mg/day and flexibly titrated up to 3,000 mg/day over eight weeks showed significant improvements on measures of social anxiety, overall anxiety, and illness severity [210]. In contrast to the anti-epileptic agents zonisamide and topiramate, levetiracetam has not shown decrements in neuropsychologic performance on tests of cognitive impairment in patients with seizure disorder [211].

Atypical Antipsychotics

Olanzapine, risperidone, aripiprazole, and quetiapine are dopamine D2 receptor antagonists, as with all antipsychotic drugs, but differ from typical (first-generation) antipsychotics by also acting as 5-HT2A receptor antagonists (minimizing development of extrapyramidal effects), 5-HT1A receptor partial agonists (producing anxiolytic effects), and histamine receptor antagonists (further augmenting sedative and anxiolytic effects) [185].

Quetiapine

Quetiapine (Seroquel) is the most-studied atypical in anxiety disorder treatment and has greatest efficacy in GAD. A review of quetiapine in GAD found efficacy and tolerability in all acute and long-term monotherapy trials and statistically significant changes in anxiety and symptom severity in three of five adjunct therapy studies. Quetiapine is a treatment option for patients unresponsive to first-line therapy, and potential benefits may outweigh risks with appropriate monitoring and side effect management [212]. While the unique efficacy of quetiapine monotherapy in GAD is supported by a Cochrane review, quetiapine was denied FDA approval for GAD, likely due to its tendency for inducing lipid abnormalities, weight gain, and glucose intolerance, and concerns over widespread use in primary care without careful consideration of alternatives or monitoring adverse metabolic effects during follow-up [136,213].

Buspirone

Introduced in 1986, buspirone (BuSpar) was the first anxiety-specific medication unrelated to benzodiazepines or barbiturates in pharmacology, effect, and abuse potential. The 5-HT1A receptor partial agonism mediates the anxiolytic effects. Buspirone acts as a weak presynaptic dopamine D2, D3, and D4 receptor antagonist and alpha-1 agonist [214]. Buspirone is primarily used in the treatment of GAD and to augment antidepressants for improved response.

Hydroxyzine

Hydroxyzine (Vistaril) acts mechanistically as a potent H1 receptor inverse agonist, and as a 5-HT2A, D2, and alpha-1-adrenergic receptor antagonist. The serotonergic activity of hydroxyzine is more potent than its dopaminergic and adrenergic activity and likely accounts for its anxiolytic efficacy, as other antihistamines lacking this property have not been effective in the treatment of anxiety [178,216]. Hydroxyzine efficacy in anxiety disorders is limited to GAD, for which anxiety-reducing efficacy is demonstrated [217,218,219].

Benzodiazepines

Since their introduction in the early 1960s, benzodiazepines have been the most prescribed drugs for anxiety over the majority of the past half-century. Although SSRI/SNRI agents have replaced benzodiazepines as the top-prescribed anxiolytics, benzodiazepine prescribing remains common. In 2020, alprazolam, clonazepam, and lorazepam were among the top 25 most frequently prescribed psychotropic medications in the United States; alprazolam ranked ninth, clonazepam ranked 12th, and lorazepam ranked 16th [220,221].

Pharmacology and Short-Term Effects

Numerous benzodiazepines are available and have similar pharmacodynamic properties and clinical actions; they mainly differ in pharmacokinetic properties (absorption, distribution, metabolism, elimination). Benzodiazepines bind to a specific receptor site in the GABA-A receptor complex. GABA is the primary inhibitory neurotransmitter in the CNS, and benzodiazepines cause non-selective GABA-A inhibitory effects throughout the brain that include drowsiness, cognitive impairment, dampening of fear and anxiety, memory impairment, anticonvulsant actions, and impairment of balance, motor control, muscle tone, and coordination. Adverse reactions to alprazolam also include amnesia, aggression, mood changes, and hostility. The newer Z drugs (e.g., zolpidem, zopiclone) have similar actions to benzodiazepines but are marketed for insomnia due to their pharmacokinetic profile, with high doses required for anxiolytic effects. There is evidence the Z drugs share similar risks to benzodiazepines [222,223].

Meta-analyses suggest alprazolam, lorazepam, and diazepam are effective but comparable in GAD efficacy, while clonazepam shows much greater efficacy in the treatment of panic disorder than alprazolam, lorazepam, and diazepam, which all have modest efficacy [224].

Appropriate Prescribing

Benzodiazepine treatment of anxiety disorders is controversial. While effective in rapid anxiety reduction, the potential drawbacks with long-term use are substantial. These agents are indicated when potent, short-term anxiolytic effects are necessary to permit infrequent exposure to feared stimuli and potentially severe anxiety, such as airplane travel [121,129,136]. Clonazepam, lorazepam, and alprazolam are effective for short-term use in panic disorder, GAD, and SAD, but ineffective for, and potentially worsening, comorbid depression [28]. The rapid anxiolytic effects make benzodiazepines highly appealing to patients with anxiety, but aside from this specific context, benzodiazepine prescribing for as-needed use is discouraged [136,225,226]. Benzodiazepines can reinforce pill taking, serve as a safety signal that undermines self-efficacy, and become incorporated into conditioned fear responses; these concerns are heightened with as-needed use. On-demand dosing links pill taking to rapid anxiety reduction, powerfully reinforcing avoidance in anxiety-provoking situations and encouraging longer-term reliance on the drug. This iatrogenic effect also contributes to poor CBT response.

The current recommended prescribing is for time-dependent use, instead of panic response-dependent use, to minimize the risks [121]. This would also seem to maximize risk of withdrawal syndrome from uninterrupted versus intermittent drug exposure.

Benzodiazepines are also useful in the initial weeks of SSRI/SNRI initiation, to rapidly reduce anxiety and possible early anxiogenic medication side effects before the onset of SSRI/SNRI anxiolytic effects [121,129,136]. However, patients may discontinue the antidepressant when co-prescribed a rapidly effective benzodiazepine, believing the benzodiazepine's symptom relief makes the SSRI/SNRI unneeded. Supportive therapy with regular visits or phone contacts may also help patients remain adherent until the delayed onset of antidepressant benefits appears or early antidepressant side effects lessen [227].

Another indication for benzodiazepine use is for the short-term relief (two to four weeks only) of anxiety that is severe, disabling, or subjecting the individual to unacceptable distress. Perhaps the greatest prescribing challenge with benzodiazepines is preventing short-term use from insidiously developing into long-term use. Patients with the most severe anxiety may obtain the greatest relief and become most hesitant to discontinue use [228]. In many cases, clinicians ignore the recommended two- to four-week prescribing limit, mainly because alternative options with superior anxiolytic effects are not available [229]. Clinicians intending to prescribe alprazolam should carefully consider the likelihood that its use will remain restricted to the very short term—a few days to a couple weeks—to see the patient through a crisis [228].

Benzodiazepines may be prescribed to augment SSRI/SNRI therapy for improved response in select patients with significant residual anxiety or non-response. In one study, patients with SAD and sertraline nonresponse after 10 weeks were given sertraline plus clonazepam (≤3 mg/day), venlafaxine (≤225 mg/day), or sertraline plus placebo for 12 weeks. Those with sertraline augmented by clonazepam showed greatest reduction in SAD symptoms and a better overall response rate than comparator groups, although remission rates did not differ significantly [230]. These agents are third- or fourth-line treatment in patients unresponsive or intolerant to other anxiolytic drugs who remain highly symptomatic [121,129,136]. Generally, patients with a history of substance abuse, personality disorder, or chronic pain should not be treated with benzodiazepines because of the high risk for overuse of these medications [129]. While benzodiazepines should usually be reserved for patients lacking response to at least two treatments (i.e., non-response to an SSRI/SNRI and a psychologic treatment), concerns about potential problems in long-term use should not prevent their use in patients with persistent, severe, distressing, and impairing anxiety symptoms [231].

It seems the most appropriate guidance for benzodiazepine prescribing involves occasional, context-specific use or cautious use during SSRI/SNRI initiation [3,231]. Otherwise, benzodiazepines should be reserved for patients lacking response to three or more treatments, such as an SSRI, an SNRI, and a psychologic intervention, who remain highly symptomatic.

Risks/Drawbacks

While alprazolam remains the most-prescribed benzodiazepine for anxiety disorders, evidence suggests that relative to other benzodiazepines, alprazolam is no more effective and may have specific drawbacks [171]. Alprazolam may have greater potential for dependence than other benzodiazepines due to its rapid onset of anxiolysis and short half-life. With the short half-life, persons prescribed fixed-interval alprazolam (e.g., every six to eight hours) can experience morning withdrawal symptoms following the last nighttime dose. This is frequently mistaken as relapse in anxiety for which the drug was originally prescribed, confirming the continuing need for the drug [228]. The alprazolam product monograph states that such emergence of interdose symptoms reflect insufficient plasma levels, best managed by adding the same dose for four times daily administration (but breakthrough anxiety and alprazolam withdrawal are not differentiated). The document also states that alprazolam treatment of panic disorder differs from sub-syndromal anxiety, in that recommended dosing is as close to around-the-clock as possible, or three or four times per day [232].

Long-term benzodiazepine use can result in added symptoms during stable-dose maintenance, including increasing anxiety and withdrawal-associated symptoms such as perceptual disturbances and paresthesia. This emerging withdrawal syndrome despite ongoing benzodiazepine use is much more likely with highly potent and rapidly eliminated alprazolam or lorazepam and is temporarily alleviated by dose escalation. As craving, dysphoria, and other withdrawal symptoms develop over time between doses, the motivation to continue benzodiazepine use for anxiolysis gradually merges with the need to avoid withdrawal symptoms [233].

Benzodiazepine prescriptions are associated with nonmedical use and the development of benzodiazepine use disorder unrelated to co-occurring drug use or anxiety disorder diagnosis/severity [221]. Acute cognitive-impairing side effects are drowsiness, increased reaction time, ataxia, motor incoordination, and anterograde amnesia. In one study, long-term use of an average 17 mg/day diazepam equivalent led to substantial cognitive decline that did not resolve three months after cessation [234]. Motor vehicle accident risks during benzodiazepine therapy are comparable to driving with a blood alcohol concentration of 0.050% to 0.079% [235]. Hip fracture risk is increased by ≥50% in older persons who take benzodiazepines; with zolpidem, the risk is increased 200% in persons older than 65 years of age [236]. The risk of overdose is particularly great when benzodiazepines are combined with sedative drugs such as opioids or alcohol.

Personality traits associated with long-term use, emotional dependence, and more severe/protracted benzodiazepine withdrawal have been described. Long-term benzodiazepine users often have poor stress coping abilities. Benzodiazepines compensate for these deficits, but their use interferes with learning stress coping strategies, including behavioral therapy for agoraphobia. Passive-dependent personality traits and lack of internal and external stress coping resources increases vulnerability to withdrawal symptoms and motivation for continued use. In these patients, benzodiazepine deprivation renders them unprotected from stress and re-exposes their coping deficits. Chronically anxious people have been found innately hypersensitive to punishing stimuli and punishment; benzodiazepines can be described as "depunishing" drugs [233].

Withdrawal

Withdrawal symptoms following benzodiazepine cessation are appropriately concerning and a liability of this drug class that all prescribers should understand. In patients with panic disorder discontinuing alprazolam following 1.5 to 22 months of treatment, 33% to 100% were unable to completely taper [181]. These data did not include the 50% of long-term benzodiazepine users who do not consent to withdrawal studies or who later quit the study. The experience of benzodiazepine withdrawal is known to deter patients from future attempts [237]. An estimated 25% to 76% of patients prescribed benzodiazepines are long-term users. Defining high-dose benzodiazepine varies, but users of high-dose benzodiazepines commonly have comorbid disorders and are unlikely to benefit from current discontinuation and withdrawal strategies that expose them to greater risk of impairment and injury [237].

Despite comparable dosing, patients with panic disorder often show greater difficulty tapering than patients with GAD. Problems during alprazolam tapering are most severe during the last half of the taper. Patients with panic disorder receiving diazepam or alprazolam had fewer problems during taper of the top 50% of daily dose. However, with abrupt discontinuation of the remaining dose, alprazolam caused significantly more anxiety, relapse, and rebound. This may reflect greater problems withdrawing from short half-life, high-potency benzodiazepines like alprazolam [181].

The patient experience of benzodiazepine withdrawal was studied in 41 high-dose benzodiazepine-using inpatients deciding to withdraw (median dosage: 70 mg/day diazepam equivalent; median duration: six years) [237]. Driving this decision were health concerns of cognitive and physical impairments; feeling addicted; belief benzodiazepine use was a moral burden that limited autonomy; and pressure or coercion by relatives or institutional or governmental bodies to change benzodiazepine consumption patterns. The patients had long histories of repeated unsuccessful attempts to stop taking benzodiazepines and disappointment and frustration by the outcomes. However, many wanted to withdraw completely, with abstinence the goal. Most subjects described benzodiazepine withdrawal symptoms as severe, unpredictable, diverse in manifestation, and of duration difficult to anticipate. Common symptoms included chills, weakness, headache, muscle pains, abdominal pain, nausea, vomiting, diarrhea, tachycardia, dizziness, vision disorders, irritability, nervousness, restlessness, difficulties sleeping, depression, anxiety, tickling sensations, dissociation, complete loss of appetite, and epileptic seizures. Most experienced prolonged post-withdrawal symptoms. Many initially tried withdrawing by abruptly stopping benzodiazepine usage at home; most stated this resulted in perceived epileptic seizures. All favored gradual, long-term tapering over abrupt withdrawal [237].

Normally used to reverse benzodiazepine overdose and post-surgery sedation, flumazenil has shown effects that diminish benzodiazepine withdrawal severity and duration and improve abstinence rates. Dosage and infusion rates vastly differ between these two indications [238]. Flumazenil requires IV or subcutaneous infusion, because its brief half-life and extensive gastric metabolism prohibit oral use [239].

In a study of flumazenil IV infusion, 29 patients stopped benzodiazepines and began flumazenil 1.6 mg/day and oral clonazepam 2–6 mg/day. Antidepressants were started three weeks before the trial or were maintained. Clonazepam was tapered during outpatient follow-up. No patient dropped out, withdrawal severity showed significant linear reduction through the seven-day infusion, and 53% remained free of clonazepam and other benzodiazepines at six-month follow-up [240]. In patients with protracted withdrawal at 47 weeks, IV flumazenil significantly reduced aggression and hostility compared with placebo [241].

In research focused on subcutaneous infusion of flumazenil, patients were switched to oxazepam, began a 48-hour taper, and started flumazenil 16 mg over 96 hours. Subcutaneous infusion significantly reduced psychologic distress and benzodiazepine withdrawal symptoms during treatment. Patients with the highest initial withdrawal severity showed greatest improvement. Patients reported high treatment comfort, willingness to receive the treatment again, and likelihood to recommend it to a friend [239].

Flumazenil attenuates chronic benzodiazepine withdrawal symptoms by up-regulating benzodiazepine receptor binding sites to reverse uncoupling between benzodiazepine and GABA binding sites on the GABA-A complex. This reversal of GABA-A functional alteration helps explain its effect on benzodiazepine withdrawal and reports of positive effects on mood, memory, cognition, and motor performance [229].

CLINICAL ISSUES

Poor Treatment Response or Nonresponse

An estimated 30% to 60% of patients with anxiety disorders do not achieve meaningful symptom reduction or remission with initial therapy [242]. Decades of psychopharmacologic research have yielded safer, more tolerable side-effect profiles, but without improved efficacy in anxiety disorders. With poor or non-response, clinicians and patients then must decide how treatment should proceed, but research that best informs this clinical dilemma is only beginning to emerge. Given the limitations of SSRIs and benzodiazepines, investigators are pursuing novel treatment approaches and molecular targets [136].

With apparent patient nonresponse to treatment, clinicians should explore other factors before deciding the next therapy approach. The two broad causes of treatment resistance are pseudo-resistance and true treatment resistance [28].

Treatment Pseudo-Resistance

Pseudo-resistant patients have not actually received sufficient treatment, because of ineffective treatment matching for the anxiety diagnosis, insufficient medication dose or psychotherapy delivery, or patient non-adherence. Treatment pseudo-resistance may be the result of ineffective drug therapies, such a bupropion, beta-blockers (except in performance anxiety), buspirone and trazodone (except in GAD), and TCAs in SAD. Insufficient dosages and waiting an inadequate period for onset are also factors. The time for treatment onset is often longer for anxiety than depression. Patients may not fully respond until 8 to 12 weeks, and response may further increase in the second 6 months. Waiting an adequate time for response may be difficult for patients and healthcare providers, who may feel a need to change prescriptions or the regimen if a patient is distressed over his or her continued anxiety symptoms [28].

Poor patient adherence may also present as apparent treatment resistance. Only half of patients refill their first prescription, and many patients discontinue their drug in the first six months of treatment [136,185]. Nonadherence may result from medication intolerance or side effects. Even if patients with troubling side effects do not stop the drug, the inherent distress avoidance and anticipatory anxiety with anxiety disorders can delay achieving adequate dose or taking medication long enough for response. Therapeutic skills can help to gain patient trust and overcome their anxiety of medication; adherence improves with medication counseling [136,185]. Medication beliefs or attitudes that contribute to poor adherence include [28]:

- Unrealistic expectations

- Negative beliefs of perceived harmful effects

- Stigma

- Not "buying in" to treatment rationale or difficulty believing that treatment will work

- Psychologic conflicts over dependence and fear of becoming "addicted" to the medication

- Preference for psychotherapy over medication (as patients are less likely to adhere to a treatment modality they prefer less)

Following adherence and remission or large improvement, some patients will become non-adherent, and relapse follows. This may be addressed by explaining that the disorder requires ongoing treatment, like diabetes or any other chronic disease.

Overlooked Diagnosis, Comorbid Conditions, or Psychosocial Contributors

When established that adequate treatment was delivered and received, factors contributing to treatment resistance can include misdiagnosis or overlooked comorbidities or psychosocial factors. The following should be revisited [28]:

- Primary diagnosis accuracy

- Presence and contribution of unrecognized substance use disorder, psychiatric comorbidity, and/or complicating medical condition

- Psychosocial or lifestyle factors (e.g., caffeine overuse, sleep deprivation, interpersonal or family conflict)

Necessary Treatment Duration for Evidence of Response or Dose Escalation

Compared with treatment of simple depression, SSRI/SNRI treatment of anxiety disorder typically requires somewhat higher dosage and longer initial treatment duration before realizing a therapeutic effect. With duloxetine and escitalopram, a satisfactory response is unlikely without some degree of clinical benefit within four weeks of initiating therapy. With pregabalin, onset of clinical effect within two weeks is associated with a 5.3-fold increased likelihood of treatment response; 25% of patients not showing clinical effect at two weeks will ultimately respond to treatment. A pregabalin dosage of 150 mg/day is suboptimal; a dose-response effect usually requires 300–600 mg/day [243].

In clinical trials of venlafaxine XR, therapeutic benefits usually diverged from placebo at four to six weeks. However, the percentage remitted from panic disorder in one trial increased from 18% at 6 weeks to 50% at 12 weeks [244].

SSRIs/SNRIs usually take two to six weeks to show an initial "partial" response, often defined as ≥25% improvement (i.e., beyond random noise or natural symptom fluctuations). Full benefit may not appear for another four to six weeks or longer. Data from patients with depression, and some uncontrolled data with anxiety, suggest that about 20% of patients may need 10 to 12 weeks or longer before responding. Thus, dose escalation to highest level tolerated is recommended for patients with incomplete response before adequate time has passed [245]. In contrast to depression, antidepressant efficacy in anxiety disorders appears to be lost soon after stopping, with anxiety recurrence being the rule rather than the exception [228].

Patient Education

Successful medication treatment often involves dosage adjustments and/or trials of a different medication at some point in order to maximize response and minimize side effects. Because patient adherence is the essential pre-condition for maximum clinical benefit, the following messages should be communicated to the patient to encourage and support ongoing medication adherence [246]:

- Side effects often precede therapeutic benefit and typically recede over time.

- It is important to expect some discomfort prior to the benefit.

- Successful treatment may involve dose adjustments and/or trials of different medications to maximize response and minimize side effects.

- Most people must be on medication at least 6 to 12 months after adequate response, and patients may show improvement at two weeks but need a longer length of time to really see response and remission.

- It is important to take the medication as prescribed, even after feeling better, because early discontinuation is associated with high rates of relapse/recurrence.

- Do not stop taking the medication without calling the provider.

- Side effects can often be managed by changing the dose or dosage schedule.

A novel approach to improve patient understanding of their anxiety disorder and treatment rationale incorporates anxiety neuroscience. A core concept is that anxiety disorders/symptoms with amygdala origin (e.g., panic disorder, phobias) require different approaches than anxiety of cortical origin (e.g., SAD, GAD). Educating patients of the brain-based source of their anxiety can improve treatment adherence and empower patients to modify these areas of brain function. For example, patients with cortex-related symptoms such as obsessions, perfectionism, and chronic worry benefit from an approach termed "Question Your Cortex." They can be encouraged to identify anxiety-generating thoughts in the cortex and use cognitive restructuring methods to exploit cortical neuroplasticity by modifying their thoughts. However, cortex-based interventions are not effective at reducing or managing anxiety with amygdala-mediated symptoms; for these patients, exposure to feared situations is stressed. Most patients benefit from a combination of cortex- and amygdala-focused interventions, with the rationale and order of interventions differing by disorder and individual patient [247].

Antidepressant Withdrawal

Evidence Based Practice Recommendation

The National Collaborating Centre for Mental Health asserts that all patients prescribed antidepressants should be informed that, although the drugs are not associated with tolerance and craving, discontinuation/withdrawal symptoms may occur on stopping or missing doses or, occasionally, on reducing the dose of the drug.

https://www.nice.org.uk/guidance/cg113

Last Accessed: April 27, 2025

Level of Evidence: Expert Opinion/Consensus Statement

In reference to withdrawal of SSRI therapy, "withdrawal syndrome" has been largely replaced by the term "discontinuation syndrome" with industry support to convey the message that SSRIs do not cause addiction, dependence, or withdrawal syndrome as one might experience following cessation of benzodiazepines. This has been challenged, given the potential seriousness of SSRI post-cessation symptoms, as a false dichotomy that minimizes the vulnerabilities induced by SSRIs. For the purposes of this course, the term "withdrawal syndrome" will be used [248]. Clinicians should be aware of these withdrawal syndromes, as misdiagnosis may result in inappropriate diagnostic tests and treatment and unnecessary patient distress and morbidity [248].

A 2015 meta-analysis found SSRI withdrawal symptoms can occur with any SSRI but are exceedingly more frequent with paroxetine [248]. Common symptoms include dizziness, nausea, headache, confusion, low energy, weakness, sleep disturbance, flu-like symptoms, restlessness, agitation, anxiety, panic, anger, and irritability. Less common and more severe symptoms include electric-shock sensations, vertigo, paresthesias, intensified suicidal ideation, aggression, derealization, depersonalization, and visual/auditory hallucinations. Symptoms do not greatly differ between patients with anxiety versus mood disorders. The authors concluded that the typical SSRI withdrawal syndrome begins within a few days of cessation and lasts two to three weeks [248]. Variations include late onset and protracted duration up to one-year follow-up. Several cases of persistent postwithdrawal disorders induced by paroxetine have been described.

Gradual tapering is a reasonable strategy but does not prevent the onset of SSRI withdrawal [248]. Patient characteristics that predict increased vulnerability are not known. Recognition of withdrawal symptoms requires careful exploration, as they can be misidentified as signs of impending relapse. Even when withdrawal symptoms are recognized, clinical management is hindered by the lack of research.

SSRI cessation may trigger complex phenomena related or unrelated to the onset of withdrawal, such as hypomania, mania, and persistent postwithdrawal disorders. Iatrogenic comorbidity describes the lasting effects from treatment well beyond their time of administration, such as mood instability and high reactivity to environmental stimuli in persistent postwithdrawal disorders [248].

Among 20 patients with remitted panic disorder with agoraphobia followed over one year after SSRI cessation, nine experienced SSRI withdrawal syndrome that subsided within one month [249]. Exceptions were three patients taking paroxetine, who experienced worsened mood, fatigue, and emotional lability with trouble sleeping, irritability, and hyperactivity. One patient prescribed clonazepam after three months of symptom persistence improved considerably but was later unable to discontinue clonazepam. A second patient did not improve with clonazepam or fluvoxamine, and symptoms subsided only with paroxetine reinstatement. In a third patient, clonazepam had little benefit, paroxetine reinstatement was refused, and symptoms persisted unchanged over one year [249].

Following SSRI/SNRI cessation, the rates of withdrawal syndrome range from 17.2% to as high as 78% (with venlafaxine). Among SSRI/SNRIs, venlafaxine XR may have the worst withdrawal syndrome. In addition to serotonergic withdrawal symptoms, palinopsia (persistent visual images) and sensory disturbances are frequently reported. These symptoms are described as sensations affecting the brain and head that feel like electrical shocks or the sensation of the brain shivering. This sensory disturbance, often accompanied by dizziness, headache, and disorientation, is distressing to patients and has been reported to persist for months after venlafaxine XR cessation [244,250]. Other unexpected withdrawal symptoms that may emerge include gait difficulties, delirium, suicidal ideation, and hypomania or mania. The onset of withdrawal is usually one to four days post-venlafaxine XR cessation; dose reduction can also trigger withdrawal [251].

The etiology and treatment of these highly distressing sensory symptoms are unknown. However, contribution from noradrenergic dysregulation is suggested theoretically and by reports of positive treatment response to noradrenergic agents. Abrupt cessation of venlafaxine XR 37.5 mg led to a sensation that "felt like the brain was shaking inside the skull," with anhedonia, anxiety, tinnitus, headache, nausea, and increased noise sensitivity. A trial of the norepinephrine transporter inhibitor atomoxetine 40 mg/day led to immediate improvement in "brain shivers" two to three hours from the first dose [250]. Post-venlafaxine XR electric shock-like sensations and dizziness were greatly reduced by low-dose clonidine (0.05 mg twice/day), a central α-2 adrenergic agonist. The positive response suggests an underlying noradrenergic rebound mechanism [244].

Interdose withdrawal symptoms have been reported with venlafaxine XR, probably resulting from the "ultrarapid metabolizer" genetic variant of 2D6, the hepatic cytochrome P450 isoenzyme that metabolizes venlafaxine. Occurring in 3% to 5% of white individuals, this polymorphism accelerates venlafaxine elimination, causing interdose withdrawal [251].

Antidepressant Lethality in Overdose

In some patients with anxiety disorder, and especially those with depressive comorbidity, consideration of overdose fatality is necessary when deciding on therapy options. Lethality rates from intentional overdose involving single medication ingestions of agents commonly prescribed for depression and anxiety were calculated from data obtained during the period 2000–2014 [252]. TCAs remain the most lethal antidepressants, with fatality rates from 31–142 per 10,000 ingestions. Amitriptyline is associated with the greatest lethality in overdose and alone accounted for 37% of all deaths from antidepressants [252]. Lithium, bupropion, venlafaxine, quetiapine, and valproic acid had rates of 6.9–12.0 per 10,000 ingestions, while citalopram and fluvoxamine had rates of 3.9–4.1 per 10,000. Fluoxetine, sertraline, paroxetine, and escitalopram had the lowest overdose lethality rates at 0.79–1.34 per 10,000 ingestions [252].

Substance Use Disorder

Anxious patients often use alcohol or anxiolytics to regulate general anxiety, distressing panic symptoms, or social anxiety and social skills deficits. Substance use disorder is highly prevalent in patients with anxiety disorders and interferes with treatment response and leads to poor outcomes [28]. More than 33% of patients with GAD have an alcohol use disorder, and patients with SAD have a lifetime substance use disorder prevalence of roughly 40%. Nicotine dependence is also disproportionately high among patients with panic disorder [253,254,255].

Self-medication of anxiety disorder symptoms has been conclusively identified as a significant predictor for later development of alcohol or drug dependence. This is consistent with the self-medication hypothesis, which posits that the specific substance used for anxiety relief/control tends to be the substance to which the person develops a substance use disorder [256]. Ongoing substance use problems are abundantly linked to worse outcomes in comorbid anxiety disorders. Long-term effects of substance use negatively interact with anxiety symptoms, and quitting substances may improve anxiety in some patients. A trial of abstinence will usually answer this question. The duration must be several months to evaluate the link between anxiety and substance use, and there should be ongoing treatment, preferably in a 12-step program. Twelve-step programs have been shown to have anxiolytic effects themselves due to the support and empowerment they offer. Residual anxiety then should be treated with either medication or CBT [28].

If substance use is suspected, patients should be screened during diagnosis. A motivational interviewing approach is recommended to frame the rationale for substance abuse in a non-judgmental manner and explore patient desire and readiness for change. For patients initiating efforts to decrease substance use, concurrent treatment with an SSRI or venlafaxine is reasonable; benzodiazepines should be avoided due to the abuse liability [257]. Detoxification from alcohol or benzodiazepines is indicated if signs of substance withdrawal appear, and referral to a formal substance abuse treatment is recommended. Recognition and treatment of underlying substance abuse is an essential component in the overall treatment plan [13,28].

Anxiety Disorder Treatment Effect Sizes

A 2015 meta-analysis of panic disorder, GAD, and SAD assessed treatment efficacy [224]. Studies published through 2012 were used to calculate medication, psychologic, or combination treatment efficacy. Effect sizes were calculated from pre- versus post-treatment and treatment versus control comparisons (Table 3) [224]. A significantly higher average pre-post effect size was found for medication outcomes than psychotherapy outcomes. Side effects, contraindications, drug interactions, and efficacy should all guide drug selection. Benzodiazepine abuse, dependence, and withdrawal potential; TCA side effects; and quetiapine metabolic risks make these agents second- to fourth-line options and not first-line options, as suggested by effect sizes alone [224].

Table 3: EFFECT SIZES OF TREATMENTS FOR PANIC DISORDER, GENERALIZED ANXIETY DISORDER, AND SOCIAL ANXIETY DISORDER

Treatment Modality

Effect Sizea

Medications

SNRIs

2.25

Benzodiazepines

2.15

SSRIs

2.09

Tricyclic antidepressants

1.83

Psychotherapy

Mindfulness therapies

1.56

Relaxation

1.36

Individual CBT/exposure therapy

1.30

Group CBT

1.22

Psychodynamic therapy

1.17

Internet and self-directed therapies

1.11

Eye movement desensitization and reprocessing

1.03

Interpersonal therapy

0.78

Other approaches

CBT/drug combination therapy

2.12

Exercise

1.23

aAn effect size greater than 0.80 is considered large, indicating that the treatment is effective.

CBT = cognitive-behavioral therapy, SNRI = serotonin-norepinephrine reuptake inhibitor, SSRI = selective serotonin re-uptake inhibitor.

Source: [224]

8. TREATMENT OF GENERALIZED ANXIETY DISORDER

The goals of GAD treatment are reduction in severity of ambient symptoms followed by prevention of symptoms and relief of disability. Pharmacotherapy (SSRIs and SNRIs) is considered the mainstay of therapy; psychotherapy (CBT or cognitive therapy) is also highly effective and may be preferred during pregnancy and by patients who cannot tolerate or wish to avoid medication [54,258]. GAD is associated with specific biases for mood-congruent information. Patients with GAD are vigilant for threatening stimuli and tend to misinterpret ambiguous information as threat. These cognitive biases diminish with successful psychologic or drug treatment [243].

PSYCHOTHERAPY

First-Line Options

CBT

Evidence Based Practice Recommendation

According to the National Collaborating Centre for Mental Health, the recommended high-intensity psychological intervention for persons with generalized anxiety disorder is cognitive-behavioral therapy (CBT) or applied relaxation.

https://www.nice.org.uk/guidance/cg113

Last Accessed: April 27, 2025

Level of Evidence: Expert Opinion/Consensus Statement

CBT for GAD uses some combination of psychoeducation (understanding safety behaviors), worry exposure, applied relaxation, and re-structuring common automatic thoughts (e.g., catastrophizing). Meta-analyses clearly demonstrate that CBT significantly reduces GAD symptoms and is markedly more effective than placebo or wait-list control conditions [120]. Sessions should occur at least weekly over 6 to 12 weeks and involve 12 to 20 sessions. While fewer than eight sessions is as effective as eight or more sessions for anxiety symptoms, more intense regimens are more effective in improving worry and depression symptoms [258,259,260]. Individual and group CBT seem equally effective in anxiety symptom reduction, but individual therapy may lead to earlier improvement in worry and depression symptoms [120].

Cognitive Therapy

Cognitive therapy teaches patients to evaluate their anxious thoughts objectively. Variants include pure cognitive therapy, cognitive restructuring, meta-cognitive therapy, and uncertainty intolerance therapy. Cognitive therapy typically involves 15 to 20 individual sessions [261].

As discussed, effective cognitive therapy/CBT treatment helps patients develop new, alternative strategies to manage worries and habits and cope with life stressors, which reduces the symptoms of anxiety. Cognitive therapy/CBT helps patients to understand [261]:

- They cannot control their fears but can control their worrying behavior as a fear response.

- Worrying has no protective value, reinforces negative thinking, and increases the risk of escalating anxiety levels in the future.

- Worrying does not assist in managing negative future scenarios, and patients are equipped to handle whatever future challenges appear.

Cognitive therapy/CBT techniques may be especially helpful for generalized anxiety in later life [120].

Internet-Based CBT

Internet-based CBT is delivered by patient-administered media interventions. Components include cognitive restructuring, exposure, problem solving, and applied relaxation, usually over six to eight sessions [261,262]. Efficacy is demonstrated, with benefits maintained at long-term follow-up. A peer-to-peer cognitive self-therapy program has been found as effective as treatment-as-usual, with a decreased need for therapist contact [120].

Applied Relaxation

Applied relaxation teaches the patient a coping skill that will enable him or her to relax rapidly in order to counteract and eventually abort the anxiety reactions. This therapy is different from simple relaxation alone, which is not helpful. Applied relaxation entails having patients relax in actual anxiety-provoking situations. Achieving effective applied relaxation technique requires around 15 individual sessions [261].

Second-Line Options

Acceptance and commitment therapy and mindfulness are CBT variants with promising initial results. They teach patients to focus on the present moment and follow actions guided by their values rather than by emotions and anxiety. Effective acceptance and commitment therapy usually involves 10 to 15 individual sessions [261].

Short- and long-term psychodynamic psychotherapy has a degree of efficacy and may be useful when CBT/cognitive therapy is unavailable. Specific psychotherapy targets in GAD include intolerance of uncertainty, poor problem-solving confidence, and positive and negative metacognitive beliefs concerning the value or utility of worry [263].

Adjunctive Approaches

Additional modalities can be added to psychotherapy and/or drug therapy. Exercise is not widely studied in GAD, but available data have shown reduction in anxiety symptoms [264]. Meditation training is an option for patients unable or unwilling to receive psychotherapy [265]. Applied relaxation is effective as adjunctive therapy and uses relaxation techniques that are self-monitoring without the use of in-depth psychotherapy [266]. In addition, physical activity has been noted as a cost-effective treatment for GAD [121].

Sleep disturbances are highly prevalent in patients with GAD. Sleep hygiene education can be a useful tool in primary care, used with CBT in GAD to ensure the best possible sleep efficiency and quality. Patients can be counseled to improve sleep hygiene by going to bed and waking up at the same time each day, eliminating alcohol after 6 p.m., avoiding caffeine after 3 p.m., and getting out of bed if unable to fall asleep to avoid development of negative associations with the bed environment [267,268]. Long-term follow-up data from a meta-analysis and randomized controlled trials suggest that benefits of psychologic treatments are maintained one to three years following treatment [120].

PHARMACOTHERAPY

In addition to demonstrated efficacy, the selection of initial drug therapy for GAD is based on illness severity (degree of distress and disability), medical and psychiatric comorbidities, substance abuse profile, patient preference, and side effect profile. In general, an SSRI or SNRI is preferred for initial pharmacological treatment. These agents have been shown to be moderately effective in multiple controlled clinical trials, and no single agent has proved more effective than others. The choice of an SNRI or SNRI over an older antidepressant (e.g., TCA) is due more to increased tolerability (side effects and toxicity) than to difference in efficacy [54].

First-Line Options

The ADAC and the Anxiety and Depression Association of America (ADAA) have created guidelines for the selection of appropriate pharmacotherapy in the treatment of GAD with differing recommendations regarding first- and second-line medications [120,261]. The ADAC recommends agomelatine, pregabalin, venlafaxine XR, duloxetine, escitalopram, paroxetine, or sertraline as first-line options, while the ADAA suggests venlafaxine XR, duloxetine, paroxetine, escitalopram, sertraline, or fluoxetine [120,261].

Pregabalin

Two randomized, placebo- and active comparator-controlled, double-blind studies evaluated the efficacy of pregabalin versus lorazepam for the treatment of GAD. The pregabalin and lorazepam groups experienced greater reductions in Hamilton Anxiety Rating Scale (HAM-A) score by week 4 compared with placebo, with no observed statistically significant differences among the active-treatment groups. Relative to placebo, pregabalin 600 mg significantly reduced psychic and somatic anxiety, while lorazepam significantly reduced somatic anxiety symptoms only. Anxiety reduction with pregabalin and lorazepam was evident within one week [185].

A four-week trial randomized 451 patients with GAD to alprazolam 1.5 mg/day; pregabalin 300, 450, or 600 mg/day; or placebo. As measured by HAM-A scores, psychic anxiety symptoms were significantly reduced (vs. placebo) with all pregabalin doses and alprazolam by weeks 1 and 4. Somatic anxiety symptoms were significantly reduced by 300 and 600 mg pregabalin, but not by 450 mg pregabalin or 1.5 mg alprazolam (vs. placebo). Pregabalin produced an early onset (≤1 week) of clinically relevant anxiety reduction comparable to alprazolam and anxiety reduction over a broader range of GAD symptoms than alprazolam by four weeks [269].

Data was combined from six placebo-controlled trials of patients with GAD randomized to pregabalin 150 mg, 300–450 mg, or 600 mg; lorazepam 6 mg/day; alprazolam 1.5 mg/day; or placebo. Pregabalin 300–600 mg significantly improved HAM-A psychic and somatic anxiety factor scores, but pregabalin 150 mg showed significance in psychic anxiety only. Of the 14 HAM-A items, significant improvement was shown on 13 with pregabalin 300–450 mg, 10 with pregabalin 600 mg, and 5 with benzodiazepines. A dose-response effect was evident for pregabalin [270].

Along with SSRIs/SNRIs, pregabalin is considered a first-line agent for long-term GAD treatment by the World Federation of Societies of Biological Psychiatry. Head-to-head studies with SSRIs/SNRIs are lacking, but pregabalin augmentation of SSRI/SNRI therapy has been found more effective than SSRI/SNRI alone [205].

Sleep dynamics were evaluated in healthy volunteers randomized to pregabalin (150 mg three times per day), alprazolam (1 mg three times per day), or placebo for three days. Pregabalin and alprazolam modestly but significantly reduced sleep-onset latency (compared with placebo). Pregabalin significantly increased the proportion of slow-wave sleep to total sleep period, and the slow-wave sleep duration of stage 4 sleep. Alprazolam significantly reduced slow-wave sleep. Rapid eye movement (REM) sleep latency with pregabalin did not differ from placebo and was significantly shorter than with alprazolam. Pregabalin and alprazolam similarly reduced the REM sleep proportion to total sleep (vs. placebo), while pregabalin significantly reduced the number of awakenings longer than one minute. Ease in getting to sleep and sleep quality were subjectively rated as improved with both active treatments. Pregabalin effects on sleep and sleep architecture were distinct from benzodiazepines. Enhancement of slow-wave sleep was relevant to frequent reports of reductions in slow-wave sleep in patients with fibromyalgia or GAD [271].

Clinical trials have reported euphoria, which emphasizes the need for careful and continuing evaluation of any potential for abuse. Reports of pregabalin abuse have appeared, usually involving individuals with a history of psychotropic medication abuse [243]. Discontinuation symptoms were reported after abruptly stopping pregabalin and were more prominent with higher daily doses. However, significantly fewer withdrawal symptoms were found after stopping pregabalin compared with lorazepam, and when tapered over one week, pregabalin withdrawal symptoms are minimal. Tentative evidence suggests pregabalin may be beneficial in withdrawal from benzodiazepines and related compounds [243].

Agomelatine

Agomelatine studies have mostly investigated its efficacy in GAD. Three randomized controlled trials have been performed. One trial with an escitalopram arm found that agomelatine led to comparable efficacy in GAD and significantly improved sleep restoration with fewer side effects and no discontinuation symptoms compared with escitalopram [202]. The low discontinuation rate reflected good tolerability, and laboratory results showed a low incidence of transient elevations in liver enzymes. Another trial that measured therapeutic response as 50% or greater reduction in HAM-A score found response rates of 66.7% with agomelatine, compared with 46.6% with placebo. Agomelatine was noted to improve sleep quality, with a lack of sexual side effects or discontinuation syndrome. Dizziness (8%) and nausea (5%) were more frequent than placebo [202,272]. Agomelatine was superior to placebo in symptom reduction beginning at six weeks and in relapse prevention at six-month follow-up [203].

Second-Line Options

When treatment with SSRIs/SNRIs proves to be ineffective or intolerable, alternative choices with demonstrable efficacy include TCAs (e.g., imipramine) or a second-generation antipsychotic agent (quetiapine or pregabalin). Pregabalin is also effective for augmenting other first- and second-line agents in patients showing partial response. Internationally, pregabalin is regarded as a first-line option for GAD, but U.S. guidelines have not yet integrated this agent into the first-line tier [185].

Several options as second-line agents have efficacy in GAD comparable to first-line agents but possess potential side effects or other risks that preclude first-line use [120]. Benzodiazepines would be considered first in most cases, except where there is a risk of substance abuse, while bupropion XL would likely be reserved for later. Quetiapine XR remains a good choice in terms of efficacy, but given the metabolic concerns associated with this atypical antipsychotic, it should be reserved for patients who lack response or cannot tolerate antidepressants or benzodiazepines [120]. It is important to note that drugs such as beta-blockers (e.g., propranolol) prescribed to address the physical symptoms of anxiety are ineffective in the treatment of GAD [243].

Quetiapine

In three 10-week randomized controlled trials of patients with GAD, quetiapine monotherapy showed clinically and statistically significant improvements in anxiety reduction and remission rates versus placebo [185]. Meaningful separation from placebo in anxiety reduction began as early as four to seven days after initiation of treatment. Somnolence, dizziness, and fatigue were more frequent with quetiapine, and sexual function improved slightly in quetiapine groups. Quetiapine has shown decreased symptom recurrence and improved sleep quality during maintenance treatment. However, quetiapine is not recommended for patients with nonresponding GAD because efficacy is inconsistent [185]. One literature review included three studies that evaluated the use of quetiapine extended-release (XR) as monotherapy for acute GAD treatment, one study that evaluated quetiapine XR monotherapy for maintenance treatment of GAD, and five studies that evaluated quetiapine (2 XR, 3 immediate release) as adjunct therapy for acute GAD treatment [273]. Quetiapine displayed both efficacy and tolerability in all monotherapy trials evaluating its use for acute and long-term treatment of GAD. Despite limitations to and heterogeneity among the five adjunct therapy studies, three studies showed that quetiapine resulted in statistically significant changes in the HAM-A scores [273].

Imipramine

While TCA use has become disfavored because of tolerability and safety issues, compelling support of imipramine efficacy for GAD came from a landmark study comparing the anxiolytic effects of imipramine, trazodone, diazepam, and placebo in non-depressed patients with GAD. Imipramine resulted in moderate-to-marked improvement between weeks 2 and 8 of therapy in 73% of patients, compared with 69% for trazodone, 66% for diazepam, and 44% for placebo [274].

Vortioxetine

Multiple randomized controlled trials involving patients with GAD found clinical improvement and symptom reduction with vortioxetine marginally greater or similar to placebo. With vortioxetine, discontinuation from side effects was modestly greater than placebo, with incidence of sexual dysfunction comparable. Patients with severe baseline GAD did show significantly greater benefit from vortioxetine [186,275,276].

Comorbid Major Depression

With a few caveats, treatment of GAD is generally the same whether comorbid major depression is present or absent. Use of buspirone and pregabalin is not recommended, while duloxetine has shown efficacy in comorbid anxiety disorder and major depressive disorder [277]. Patients with comorbid major depression and GAD prescribed benzodiazepines, sedating medications, or TCAs should be monitored for suicide risk; those with severe depression and suicidal ideation may require hospitalization while therapy is initiated [278].

Relapse Prevention

Relapse-prevention studies randomized patients showing response to acute treatment to placebo or the same medication/dose. Results in GAD showed significant advantages with continuing the active medications agomelatine, duloxetine, escitalopram, paroxetine, quetiapine, venlafaxine, or vortioxetine versus switching to placebo for periods of 6 to 18 months [243].

9. TREATMENT OF PANIC DISORDER

Evidence Based Practice Recommendation

The National Collaborating Centre for Mental Health asserts that people who have panic disorder and their families and carers need comprehensive information, presented in clear and understandable language, about the nature of their condition and the treatment options available.

https://www.nice.org.uk/guidance/cg113

Last Accessed: April 27, 2025

Level of Evidence: Expert Opinion/Consensus Statement

Treatment of panic disorder is directed at prevention of panic attacks and reducing preoccupation and anxiety around possibility of impending attacks. SSRIs and SNRIs are effective in preventing panic attacks and relieving anxiety but have no impact on acute symptoms associated with an attack. A treatment duration of four to eight weeks is generally required to see a significant reduction in symptoms. A meta-analysis of 54 psychotherapy studies found that eight standard interventions, including supportive psychotherapy, behavioral therapy, cognitive therapy, and CBT, were equally efficacious for managing panic disorder, independent of accompanying agoraphobia [125]. Another meta-analysis found that combined psycho- and pharmacotherapy was superior to single-mode therapy, with efficacy verses placebo twice as large as pharmacotherapy alone [279]. The results also suggest that the effects of pharmacotherapy and psychotherapy are largely independent from each other and roughly equal in contribution to the effects of combined treatment. The effects remain strong and significant up to two years post-treatment.

PSYCHOTHERAPY

Behavior Therapy

Behavior therapy for panic disorder consists of graded exposure to body sensations that accompany panic (interoceptive exposure), to situations perceived as threatening (in vivo exposure, imagery exposure, virtual reality exposure), or both, in order to progressively reduce apprehensive reaction toward them by the patient. Although exposure strategies alone can be effective in the treatment of panic disorder, they do not appear to be a valid alternative to CBT as a first-line treatment [151].

Cognitive Therapy

In cognitive therapy for panic disorder, panic attacks are thought to result from the catastrophic misinterpretation of certain bodily sensations. The patient perceives the sensations of normal anxiety response as much more dangerous than they are, such as palpitations viewed as evidence of impending heart attack. Cognitive therapy identifies these negative interpretations of the bodily sensations experienced in panic attacks, suggests alternative non-catastrophic interpretations, and helps the patient test the validity of these alternative interpretations. While cognitive therapy is often combined with behavioral techniques, there is some evidence that training in cognitive procedures in isolation from exposure and behavioral procedures is efficacious in reducing some aspects of panic [151,280,281,282,283].

CBT

CBT assumes that cognitions, behaviors, and emotions are interrelated and combines behavior therapy and cognitive therapy to reduce emotional distress and psychologic symptoms. CBT for panic disorder consists of psychoeducation, breathing retraining, progressive muscle relaxation, cognitive restructuring, behavioral experiments, interoceptive exposure, and in vivo exposure. A consistent body of evidence supports the efficacy of CBT for panic disorder in individual or group sessions. There is also growing evidence that supports CBT efficacy when therapist-supported and self-administered via the Internet [151,284,285]. A network meta-analysis found that the most effective combination of CBT components for treatment of panic disorder was face-to-face administration and graded interoceptive exposure to physiological aspects of the panic response, while muscle relaxation and virtual-reality exposure were the least effective components [286].

Patient Education

An essential step after diagnosis of panic disorder is to review with patients their fears of medical illness and expectations of medical testing and treatment. More than 80% of patients with panic disorder present with a medical symptom, and most are fearful of having a serious condition, such as a stroke. Clinical experience suggests that patients benefit from education about panic disorder as the cause of their symptoms and the mechanism by which a mental disorder may provoke physical symptoms. Educational materials for patients may be obtained from the ADAA (https://adaa.org) and the National Institute of Mental Health (https://www.nimh.nih.gov) [129].

PHARMACOTHERAPY

The first-line drugs recommended for the treatment of panic disorder are SSRIs or venlafaxine XR [120]. Research suggests that the largest effect size is found with clonazepam, followed by venlafaxine and fluoxetine [224]. Despite a sizeable number of pharmacologic options, less than 50% of patients with panic disorder experience full and sustained remission to first-line medication therapy [287].

SSRI/SNRI

The SSRI safety/side effect profile relative to TCAs, MAOIs, and benzodiazepines led to their recommendation as first-line drug options for patients with panic disorder. SSRI side effects occur early in treatment before the therapeutic effects. Many patients with panic disorder are highly sensitive to side effects, and SSRIs should be started at low doses, with dose titration every five to seven days, as tolerated [129].

Following 10 weeks of venlafaxine treatment for panic disorder, patients with few dissociative symptoms during panic attacks showed significantly greater treatment response than patients with greater presence of panic attack-associated dissociative symptoms. These findings suggest that dissociative symptoms accompanying panic disorder negatively impact pharmacologic treatment response. Re-evaluation of dissociative symptoms at the beginning and end of treatment would help in personalizing therapy [288].

Benzodiazepines

A meta-analysis was performed of randomized controlled trials comparing alprazolam to other benzodiazepines in the treatment of panic disorder with or without agoraphobia [289]. In the pooled results, there were no significant differences in efficacy between alprazolam and comparator benzodiazepines on improvements in panic attack frequency, anxiety rating scores, or proportion of patients panic attack-free at final evaluation. To date, the evidence fails to demonstrate alprazolam superiority to other benzodiazepines for panic disorder treatment [289]. Additionally, while alprazolam is one of the most widely prescribed benzodiazepines for the treatment of panic disorder, its clinical use is contentious due to its potential for misuse [290].

10. TREATMENT OF AGORAPHOBIA

Almost all agoraphobia studies reported treatment outcomes of patients with co-occurring panic disorder, as they were not separated into distinct diagnostic entities until the DSM-5 was published in 2013.

PSYCHOTHERAPY

CBT is the most empirically supported psychosocial treatment for panic disorder with agoraphobia, with a central focus of repeated exposure to feared situations and sensations and application of skills learned in therapy. These include cognitive skills to control negative thoughts and somatic skills to control dysregulated physiology during exposure. While CBT has clearly been established as an effective treatment for panic disorder with agoraphobia, the effect sizes are smallest among the anxiety disorders and a large percentage of treatment completers are not panic free or do not reach responder status after treatment. The largest randomized controlled trial to date for panic disorder with agoraphobia found only 32% of those assigned to CBT alone demonstrated strong treatment response at 12 months post-treatment [162]. A small 20-year follow-up of patients with panic disorder with agoraphobia found that completion of medication-free, integrated exposure and psychodynamic treatment resulted in excellent very long-term outcomes for these patients [291].

The relevance of process variables in patient response and outcomes with CBT have been studied. Among 301 patients with panic disorder/agoraphobia, changes in panic symptoms were preceded by changes in catastrophic appraisal and agoraphobic avoidance in all treatment phases, anxiety sensitivity during generalization and follow-up, and psychologic flexibility during exposure therapy. Changes in functioning were preceded by changes in agoraphobic avoidance and psychologic flexibility in all treatment phases, fear of bodily symptoms during generalization/follow-up, and anxiety sensitivity during exposure. The effects of process variables on outcomes differed across treatment phases and outcomes. Agoraphobic avoidance and psychologic flexibility should be therapeutically targeted in addition to cognitive variables [292].

Low remission rates in patients with panic disorder/agoraphobia following CBT-based therapies has led to the development and evaluation of novel psychotherapies, adjunctive drug therapies, and cognitive enhancer drugs to improve exposure therapy response and remission rates.

Novel Psychotherapies

The intervention for patients with panic disorder/agoraphobia who are nonresponsive to CBT has generally been pharmacotherapy, with few studies evaluating a switch to psychotherapy. In one study, patients with previous unsuccessful state-of-the-art treatment were randomized to immediate acceptance and commitment therapy or four-week waiting list with delayed acceptance and commitment therapy; they were then followed for up to six months. Significantly greater changes in functioning and symptomatology were found in patients who received immediate acceptance and commitment therapy versus those on the waiting list, and medium-to-large effect sizes were maintained for six or more months. Acceptance and commitment therapy may be a viable treatment option for treatment-resistant panic disorder with agoraphobia [293].

A long-term study of patients with panic disorder and agoraphobia found catastrophic beliefs to be an important mediator of change. Of 46 patients with panic disorder/agoraphobia randomized to cognitive or guided mastery therapy, 31 (67.4%) medication-free patients who completed treatment were followed up to 18 years post-treatment. Both groups showed a large effect size for avoidance of situations when alone, and 56.5% no longer met diagnostic criteria for panic disorder or panic disorder with agoraphobia. Patient outcomes between the two treatments were comparable, although guided mastery was associated with greater beneficial changes in catastrophic beliefs and self-efficacy. Greater reduction in panic-related beliefs about physical and mental catastrophes predicted lower anxiety level at follow-up [294].

Combination Therapy

Following paroxetine plus CBT (once weekly for 12 weeks), paroxetine plus CBT and virtual reality exposure (four sessions), or paroxetine only, the six-month follow-up of 99 patients with panic disorder/agoraphobia showed reduced anxiety levels in all three groups and greatest reduction in both CBT groups. The virtual reality exposure group showed greater improvement in confronting agoraphobic stimuli, although medication cessation and dropout were high [295].

The one-year follow-up of patients with panic disorder with and without agoraphobia treated with CBT, SSRI, or CBT and SSRI found that panic attack frequency significantly declined in all groups and both SSRI groups improved significantly faster than CBT [296]. The SSRI gains were maintained after tapering. Panic frequency in patients with moderate-to-severe agoraphobia decreased more rapidly with CBT plus SSRI than either sole treatment. With CBT alone, improvement was slower than with SSRI or CBT plus SSRI. SSRI monotherapy was concluded sufficient for patients with panic disorder with no or mild agoraphobia, while patients with panic disorder and moderate-to-severe agoraphobia should receive CBT plus SSRI [296].

PHARMACOTHERAPY

An efficacy analysis of drug therapy trials in the treatment of panic disorder with agoraphobia was published in 2011 [86]. It concluded that panic attack recurrence worsens agoraphobic behaviors in panic disorder with agoraphobia and disrupts agoraphobia remission. This suggests that using panic attack-blocking medication in patients with panic disorder/agoraphobia at risk of panic attack recurrence is more appropriate than CBT alone.

The meta-analysis also found that paroxetine displayed high efficacy in panic and phobic symptoms and agoraphobia severity reduction. This efficacy was similar to CBT in reducing agoraphobic behaviors and superior to CBT in reducing panic attacks during acute treatment phase [86]. Adding paroxetine to CBT in patients with poor CBT response is significantly more effective in improving agoraphobic behaviors than adding placebo, so it is strongly suggested to add paroxetine for patients lacking adequate response or panic attack reduction with CBT [86]. Sertraline, citalopram, and escitalopram are also effective in the treatment of panic disorder/agoraphobia.

A randomized controlled trial compared treatment with an SSRI (paroxetine or citalopram) to continued treatment with CBT in a sample of 68 individuals with panic disorder (with or without agoraphobia) who had not responded to an initial course of CBT [297]. Participants were randomized to three months of treatment and then followed for an additional nine months. Those who responded to treatment after 3 months were maintained on the treatment until 12-month follow-up. Participants receiving an SSRI showed significantly lower panic disorder symptoms compared with continued CBT at three months, suggesting a greater improvement in panic disorder symptoms when patients are switched to an SSRI after failure to respond to an initial course of CBT [297].

The TCA clomipramine has similar panic/phobic efficacy to paroxetine and sertraline. Imipramine is more effective than placebo in long-term maintenance, but less effective than sertraline in short-term outcomes. Venlafaxine is effective in reducing panic and phobic symptoms [86]. Reboxetine is more effective in the treatment of panic/phobia than placebo. It has similar efficacy to paroxetine in phobic avoidance and anticipatory anxiety, but lower efficacy in reducing panic attacks.

Fluvoxamine has only inconsistent efficacy in the treatment of panic disorder/agoraphobia, and while fluoxetine may be used to address panic attacks, it has limited efficacy for panic disorder/agoraphobia [86].

These results suggest noradrenergic system involvement in modulating panic disorder with agoraphobia avoidance behaviors, but serotonergic system targeting is important to decrease panic attacks. Re-analysis of prior pharmacologic randomized controlled trial data found higher efficacy with sertraline and clomipramine in reducing agoraphobic symptoms than paroxetine, fluvoxamine, or citalopram. This may reflect the added dopaminergic modulation of these agents beyond their primary serotonergic activity [86].

A novel treatment approach is based on multiple findings of balance system dysfunction in patients with panic disorder/agoraphobia. An open study found citalopram influenced the balance system in these patients by improving postural stability, as measured by static posturography. Compared with baseline scores, most patients whose balance system function improved were no longer agoraphobic, while those whose posturography scores remained abnormal continued to be agoraphobic. These findings suggest the involvement of balance system dysfunction in panic disorder with agoraphobia and serotonergic system relevance in mediating the connection between balance and agoraphobia [298]. The authors suggest that real abnormal body functioning (primarily involving cardiorespiratory and balance systems), which leads to reduced overall physical fitness, may be a primary cause of panic disorder and that the anxiety and fear it induces is sustained by repeated signals of impaired body functioning [299].

In one study, patients with panic disorder/agoraphobia received alprazolam plus exposure, alprazolam plus progressive muscle relaxation, placebo plus exposure, or placebo plus progressive muscle relaxation. The highest rate of improvement at follow-up was observed in the placebo/exposure (71%) and alprazolam/exposure (71%) groups; alprazolam/progressive muscle relaxation (51%) and progressive muscle relaxation/placebo (25%) groups were less improved [300]. Alprazolam showed no benefit over placebo when added to exposure therapy as treatment for panic disorder/agoraphobia [300].

CONTRIBUTING FACTORS TO PANIC DISORDER WITH AGORAPHOBIA TREATMENT RESPONSE

Pronounced safety behaviors during exposure therapy, but not at baseline, have been associated with poor treatment response in patients with panic disorder/agoraphobia. This underscores the importance of rigorous safety behavior assessment during therapy [301].

During 13 to 21 years post-treatment follow-up, major depression at baseline predicted worse improvement in agoraphobic avoidance in the first year. Employment and marriage/cohabitation at baseline predicted greater improvement at 1-year, 2-year, and 13- to 21-year follow-up [302].

A substantial number of patients with panic disorder/agoraphobia fail to improve following CBT. Agoraphobic avoidance is the most consistent predictor of decreased improvement, followed by low expectancy for change, high levels of functional impairment, and Cluster C personality pathology [303].

11. TREATMENT OF SOCIAL ANXIETY DISORDER

PSYCHOTHERAPY

CBT is the criterion-standard psychologic treatment for SAD. Cognitive restructuring techniques are used to challenge assumptions and maladaptive thoughts (i.e., "I will embarrass myself"), while the behavioral component centers on patient exposure to anxiety-provoking situations. Over time and with repeated exposure sessions, the goal is to reduce anxiety symptoms and to demonstrate that the situational anxiety is tolerable and without substantial risk. The efficacy of CBT is supported by many randomized controlled trials, with outcomes that vary but are typically similar to pharmacotherapy. Some reports suggest that, after treatment discontinuation, gains achieved with CBT may persist longer than those achieved with pharmacotherapy. CBT for SAD can be administered in group or individual formats. Although some studies have reported that individual CBT is superior to group CBT, meta-analyses have failed to find significant differences in efficacy between the two modalities. There is evidence to support the effectiveness of exposure therapy alone, but efficacy compared with CBT is equivocal [120].

Several CBT variants have been examined. Videotaped feedback was not shown to enhance the effects of exposure-based treatment. However, CBT with virtual reality exposure was found more effective than wait-list control and as effective as CBT with imaginal or in vivo exposure according to two meta-analyses [120].

A form of CBT focused on interpersonal behavior found similar improvements in social anxiety compared to standard CBT and also increased relationship satisfaction and social approach behaviors. Evidence to support interpersonal therapy in SAD is conflicting; while some results are negative, interpersonal therapy is probably more effective than wait-list control, but less effective than traditional CBT [120].

With Internet CBT for SAD, patients with an avoidance and depression profile showed lower remission after treatment, higher levels of social anxiety at follow-up assessments, and typically remained highly symptomatic. In patients with SAD, high levels of social avoidance and depressive symptoms constitute a risk profile for poor treatment response [304].

PHARMACOTHERAPY

Pharmacotherapy of SAD is effective but varies considerably, with room for further improvement [305]. Placebo-controlled clinical trials have shown that SSRIs and SNRIs are the most effective class of pharmacologic treatment. The ADAC recommends escitalopram, fluvoxamine (immediate- or controlled-release), paroxetine (immediate- or controlled-release), pregabalin, sertraline, or venlafaxine XR for first-line treatment of SAD [120]. Citalopram has less evidence but is likely as effective as other SSRIs. Phenelzine efficacy is established in multiple randomized controlled trials but is recommended as a second-line option due to concerns over dietary and medication restrictions that, if not strictly adhered to, can lead to hypertensive crisis [120].

Abnormalities in brain GABA and glutamate systems have been studied in patients with SAD, including whether these changed following eight weeks of levetiracetam. Compared to healthy controls, patients with SAD at baseline showed significantly higher whole brain levels of glutamate and glutamine (but not GABA) and significantly higher thalamic glutamine and lower GABA levels. Following treatment, these patients showed significant reduction in thalamic glutamine. These findings support the role of impaired GABAergic and overactive glutamatergic function in SAD and may explain the anxiolytic effects of levetiracetam [306].

12. TREATMENT OF SPECIFIC PHOBIA

Patients with specific phobias generally do not consult medical professionals when able to avoid the specific feared situations or objects. Exposure therapy is effective in treating specific phobia and is the favored approach.

PSYCHOTHERAPY

Exposure-based therapies are the treatments of choice and show a high degree of successful remission for all phobias. In vivo exposure and virtual reality exposure to phobic stimuli or situations are both effective, with in vivo exposure superior to imaginal and virtual reality exposure at post-treatment but not at follow-up [307]. The effectiveness of exposure-based therapy is enhanced when exposure sessions are grouped closely together; when exposure is prolonged, real (not imagined), and provided in different settings; and when there is some degree of therapist involvement instead of being entirely self-directed. A greater number of sessions have been shown to predict more favorable outcomes. There is no evidence that flooding is more effective, and patients usually find graded, progressive exposures more tolerable [307].

A variety of psychotherapeutic options have been found effective for the treatment of specific phobias, with some approaches recommended for particular phobias (Table 4) [120]. For blood-injection-injury phobias, an effective approach is combining exposure therapy with muscle tension exercises (applied tension) designed to prevent fainting. Using stress-reducing medical devices, such as decorated butterfly needles and syringes, has significantly reduced needle phobia and stress in pediatric and adult patients. With dental phobias, use of CBT can reduce avoidance of oral injections and decrease patient anxiety [120,307].

Table 4: PSYCHOLOGIC TREATMENTS EFFECTIVE IN SPECIFIC PHOBIA

Treatment Approach

Phobia(s)

Exposure-based treatments

All specific phobias

Virtual reality exposure

Heights, flying, spiders, claustrophobia

Computer-based self-help programs

Spiders, flying, small animals

Applied muscle tension (i.e., exposure with muscle tension exercises)

Blood-injection-injury type

Cognitive therapy and exposure

Dental, flying

Source: [120]

Evidence Based Practice Recommendation

The National Collaborating Centre for Mental Health recommends against routinely offering computerized CBT to treat specific phobias in adults.

https://www.nice.org.uk/guidance/cg159/resources/social-anxietydisorder-recognition-assessment-and-treatmentpdf-35109639699397

Last Accessed: April 27, 2025

Level of Evidence: Expert Opinion/Consensus Statement

Long-term treatment of specific phobia is rare. CBT and exposure therapies show sustained benefits at long-term follow-up assessments following a time-limited course of treatment [120].

PHARMACOTHERAPY

Pharmacotherapy has a minimal role in specific phobia treatment, largely from the lack of drug therapy research and the success of exposure therapies. Alprazolam benefit was studied in 28 women with flying phobia during two air travel exposures, one week apart. Compared with subjects given pre-flight placebo for both flights, those receiving alprazolam before the first flight had less anxiety and symptoms but greater heart and respiratory rates. Those given alprazolam had a substantial increase in panic attacks during the second flight compared with the first flight (71% vs. 7%), greater overall anxiety, and further elevation in heart rate. Alprazolam increased physiologic activation under acute stress conditions and hindered the therapeutic effects of exposure therapy for flying phobia [120,308]. These findings require replication to determine clinical utility.

Some benefit is suggested by small trials of paroxetine or escitalopram. However, there is too little evidence to recommend any drug treatment of specific phobias [224].

A NOVEL APPROACH COMBINING MEDICATION AND EXPOSURE THERAPY

In 2015, a potential landmark study of 45 subjects with spider phobia was published. A pre-treatment two-minute tarantula exposure was followed four days later by randomization to propranolol without exposure or to exposure and then propranolol 40 mg or placebo (within 10 minutes). All three groups went through tarantula exposure 9 days, 16 days, 90 days, and one year later [309].

After nine days, all exposure/propranolol subjects touched the tarantula, while the other two groups barely touched its container. By 16 days, all exposure/propranolol subjects further progressed in approach, while the two other groups did not progress. Approach behavior remained stable for all three groups throughout one year. Most interestingly, significant reduction in self-reported spider fear lagged several months behind the instant behavioral transformation in the exposure/propranolol group [309].

This study is the first to identify optimal drug and timing for durable remission of phobic anxiety and avoidance. The results challenge the fundamental tenet of CBT that changes in cognition are necessary for behavioral change. Such a novel approach is clearly needed, and similar trials enrolling subjects with agoraphobia and social phobia are expected in the future [309].

13. TREATMENT OF SEPARATION ANXIETY DISORDER

PSYCHOTHERAPY

As mentioned, the presence of pathologic separation anxiety has a pervasive negative influence on treatment response in patients with diverse anxiety and mood disorders receiving standard therapies. Patients with SEPAD show poor response to standard CBT and exposure-based therapies. This poorer treatment response may reflect the difficulties these patients experience forming and maintaining attachments, including therapeutic relationships. Growing evidence points to the incompatibility in applying the prevailing fear extinction model of anxiety to patients with SEPAD. This pathophysiologic model emphasizes desensitization to threatening stimuli. While theoretically and empirically supported in other anxiety disorders, this model does not consider the role of earlier childhood SEPAD in adult panic disorder and other anxiety disorders [98].

The unmet need for SEPAD-specific treatment has led to psychotherapies that focus on relationships and separation anxiety. These approaches use the therapist-patient relationship to recapture and better understand important elements of earlier pathologic parent-child relationships. Panic-focused psychodynamic psychotherapy is an affect-focused therapy that specifically targets separation anxiety as a core component of panic disorder. Preliminary efficacy is shown in patients with prominent separation anxiety symptoms across different anxiety and mood disorders. High separation anxiety levels constitute a central organizing element in patient self-perception as incompetent and unable to manage developmentally normative tasks without the presence of their central attachment figures. Panic-focused psychodynamic psychotherapy emphasizes free association, centrality of transference, unconscious thoughts that underlie physical sensations of panic, and difficulty with separation and autonomy. The therapist focuses on these processes as they relate to panic symptoms. Common themes of difficulty with separations and unconscious rage inform interpretive interventions. The pre-determined 24-session, 12-week time limit enhances the opportunity to work with separation anxiety and permits the re-experiencing and better understanding [98].

PHARMACOTHERAPY

With adult SEPAD becoming formalized in 2013 as a distinct diagnostic entity and anxiety disorder, little pharmacotherapy research has been performed specifically addressing this condition.

14. EMERGING THERAPIES AND NOVEL TREATMENT APPROACHES

NEUROENHANCING AGENTS TO AUGMENT EXPOSURE THERAPY

Some neuroenhancers, especially D-cycloserine (DCS), are promising for treating anxiety disorders because these agents improve extinction learning efficacy, integral in exposure therapy. They facilitate learning new memories through habituation and extinction, and these safe memories will over-ride the previous fear memories. Use of neuroenhancers to augment CBT represents a promising translational effort—taking neuroscience discovery into clinical practice. In contrast, use of anxiolytics and CBT in anxiety disorders did not originate from a theoretical basis for the mechanism of action, and overall effectiveness leaves substantial room for improvement [164].

D-Cycloserine

The most extensively studied exposure augmentation agent is DCS, an N-methyl-D-aspartate (NMDA) receptor partial agonist. Findings that extinction learning is modulated, in part, by the glutamatergic NMDA receptor complex prompted interest in the role of glutamatergic transmission in anxiety disorders. Clinical trials began to study the potential efficacy of low-dose DCS for enhancing memory consolidation and thereby improving the effectiveness of exposure therapies for anxiety disorders [165]. DCS studies of patients with specific phobia (e.g., heights, snakes), OCD, panic disorder with agoraphobia, PTSD, or SAD have been published, showing a marginal benefit when combined with exposure therapy. Following promising early findings, more recent studies have reported inconsistent results, including findings that DCS resulted in faster rates of improvement but not higher response or remission rates in SAD and even more symptoms at post-treatment in PTSD. These inconsistent trials have informed the understanding of limitations and indications of DCS augmentation of exposure therapy [310,311,312,313].

Dosing and dose timing of DCS is essential. Most trials reporting positive results used low-dose DCS (50–250 mg) one to two hours before three to five exposure sessions. Studies with negative results often used higher doses (≥250 mg), chronically (before 12 exposures), and more than one to two hours before an exposure. Higher-dose DCS shows weaker NMDA partial agonist or antagonist effects. Key extinction learning processes occur hours following exposure, and DCS blood concentration peaking at four to six hours makes it more effective taken within one to two hours before exposure for peak activity to coincide with key extinction processes. Repeated DCS use can desensitize the NMDA receptor complex, leading DCS to effectively work as an NMDA antagonist. Long-term antidepressants can induce neurochemical changes at the glycine binding site of the NMDA receptor complex, which alters the action of DCS. Therefore, use of DCS should consider the narrow therapeutic window and the need to be administered without concomitant medication, acutely, and at low doses one to two hours pre-exposure [310].

DCS is associated with serious risks. DCS not only enhances cognitive processes during fear extinction learning but also during fear memory reconsolidation, thus improving good exposures and worsening bad exposures. If fear-inducing stimulus re-exposure during fear memory reactivation is too brief relative to the strength of fear conditioning or if fear decrease during exposure is inadequate, little extinction is induced and DCS can augment the process of fear memory reconsolidation to worsen symptoms [310].

These findings led to DCS administered post-exposure, contingent on the level of fear reduced (i.e., extinction learning achieved) by the end of the exposure session. Preliminary evidence shows that this approach may be effective in capitalizing on the benefits while minimizing the risks of DCS use to augment exposure therapy [310].

Yohimbine Hydrochloride

Yohimbine hydrochloride (YOH) is a selective competitive alpha2-adrenergic receptor antagonist currently only approved for veterinary use. This compound increases extracellular norepinephrine in humans by blocking autoreceptor inhibition of norepinephrine release. This mechanism potentially facilitates extinction learning in exposure therapies. Placebo-controlled trials have been performed in specific phobia and SAD. Subjects with claustrophobia given YOH 10.8 mg before two 60-minute exposures of sitting in a closed, dark chamber showed more robust reductions in claustrophobia symptoms. Patients with SAD given YOH 10.8 mg before four exposure sessions showed accelerated treatment improvement and lower levels of social anxiety symptoms. More research is needed, but these results suggest YOH may have a role in augmenting exposure therapy [164].

Glucocorticoids

Glucocorticoids have shown enhancement of virtual reality-based exposure therapy for fear of heights and were investigated for possible outcome enhancement in exposure-based group therapy for spider phobia. In one randomized controlled trial, cortisol 20 mg or placebo was orally administered one hour before each therapy session and patients were assessed at one-month post-therapy follow-up. Compared to placebo, cortisol led to significantly greater reduction in fear of spiders at follow-up but not immediately post-treatment, as measured psychometrically and by exposure to live spiders. Groups did not differ in phobia-unrelated state-anxiety before and after exposure sessions and at follow-up [314].

Another randomized controlled trial investigated the role of hydrocortisone as an adjunct to brief CBT for specific (spider) fear [315]. Spider-fearful participants were randomized to receive either 20 mg hydrocortisone or placebo one hour prior to single-session, predominantly computerized, exposure-based CBT. Participants' fear of spiders was assessed using self-report and approach behaviors measured at baseline and at one-day and one-month follow-up. Threat processing was assessed at baseline and at one-day follow-up. Cortisol and cortisone levels from hair and saliva samples were analyzed at baseline. All measures improved following CBT. Augmentation with hydrocortisone resulted in greater improvement in self-reported fear and approach behavior but not threat bias. Neither threat bias nor endogenous glucocorticoids predicted symptom change. Evidence indicates that higher hair cortisone predicts a stronger threat bias reduction [315].

Methylene Blue

Methylene blue is a nitric oxide synthase inhibitor, central MAO inhibitor, and cerebral metabolic enhancer. A placebo-controlled trial of subjects with severe claustrophobic fear found that participants displaying low fear at the end of extinction training showed significantly less fear at follow-up if they received methylene blue post-training relative to placebo. In contrast, participants displaying moderate-to-high levels of post-training fear tended to fare worse at follow-up with methylene blue compared with placebo. Similar to the profile of DCS, methylene blue enhanced memory and retention of fear extinction when administered after a successful exposure session, but it may have deleterious effects on extinction when administered after an unsuccessful session [316].

CAPNOMETRY-ASSISTED RESPIRATORY TRAINING

Panic disorder and sensitivity to increased carbon dioxide (CO_2) levels common in patients with panic disorder may represent pathologically amplified survival mechanisms. Panic disorder reflects a "fight-or-flight" response, and CO_2 hypersensitivity is an evolutionary carry-over from when alarm response to dwindling oxygen helped ensure survival. Panic attacks that awaken people at night only occur during non-REM sleep, when deep relaxation and slowed breathing lead to rising CO_2 levels that trigger a false suffocation alarm [317].

Capnometry-assisted respiratory training (CART) is an intervention that addresses CO_2 fluctuation and its role in panic attacks for some people. CART targets respiratory dysregulation and hypocapnia through a four-week training using immediate feedback of end-tidal CO_2 pressure (PCO_2). Patients are taught how to raise subnormal PCO_2 levels (caused by hyperventilation) to control dysfunctional respiratory patterns and related panic symptoms of shortness of breath and dizziness. CART uses novel technologies that allow precise assessment and monitoring of core respiratory variables. A portable capnometer offers breath-by-breath feedback of expired CO_2 and breathing rate, as measured via nasal cannula.

In one study, four weeks of CART led to reductions in panic symptom severity and frequency comparable to standard CBT, maintained at 12-month follow-up. Patients with panic disorder/agoraphobia randomized to four weeks of CART or cognitive therapy showed significant and comparable reductions in panic symptom severity and panic-related cognitions [281]. Across studies in patients with panic disorder with agoraphobia and asthma, compliance with the 17-minute, twice-daily exercises was high, and compliance correlated with the extent of panic symptom reduction [281,318]. Changes in PCO_2 mediated and preceded changes in fear of panic sensations, cognitive reappraisal of symptoms, and perceived control. Reductions in respiration rate were unrelated to outcome [281,319]. These findings strengthen the idea that panic symptom reduction can be achieved through different mechanisms [162].

NEUROMODULATION THERAPIES

Brain stimulation (also referred to as neuromodulation, neurostimulation, or somatic therapy) for the treatment of neuropsychiatric disorders was developed as an option for patients with severe disorders refractory to multiple treatments. Electroconvulsive therapy, introduced more than 75 years ago, has been historically the only widely used somatic treatment of psychiatric disorders. This was changed by the development and FDA approval of several minimally or non-invasive brain stimulation modalities with much greater specificity than electroconvulsive therapy. Other modalities are undergoing evaluation and possible market entry [320]. This approach shifts the treatment focus from altering synaptic neurotransmission to altering or modulating the function of entire neural circuits, the dysfunction of which underlies anxiety disorders [120].

Repetitive Transcranial Magnetic Stimulation

The most studied neurostimulation approach in the United States is repetitive transcranial magnetic stimulation (rTMS). As discussed, patients with panic disorder often lack response or only partially respond to drug or psychologic treatments, which increases the risk of the disorder becoming chronic and disabling. Transcranial magnetic stimulation delivers non-invasive stimulation to the cerebral cortex, with currents induced by powerful, extremely brief magnetic fields. Administration in a rhythmic, repetitive form is rTMS. Modulation of cortical excitability uses high-frequency rTMS to increase cortical excitability or low-frequency rTMS to inhibit cortical excitability of targeted areas. rTMS can also affect remote brain areas connected to the stimulated site [321].

Early studies of rTMS in anxiety disorders often found no difference between active vs. sham rTMS, reflecting the inability to stimulate brain regions deeper than superficial cortical layers and inadequate treatment duration or post-treatment follow-up [322]. Subsequent technical refinements show treatment efficacy.

A randomized controlled trial treated 28 patients with panic disorder and major depression with active or sham rTMS to the right dorsolateral prefrontal cortex. Response was defined as reduction by ≥40% in panic disorder severity and ≥50% in depression ratings. After four weeks, panic disorder response rate was 50% with active and 8% with sham rTMS, with no difference in depression. After eight weeks of active rTMS, response rates were 67% for panic and 50% for depressive symptoms. Significant improvements occurred in panic disorder, major depression, clinical global impression, and social adjustment. Clinical improvements were maintained at six months post-treatment. While four weeks of rTMS was sufficient to significantly reduce panic symptoms, a longer course led to better outcomes for both panic disorder and major depression. These data suggest that inhibitory rTMS to the right dorsolateral prefrontal cortex affects symptom expression in comorbid anxiety and depressive disorder [323]. Another study found that inhibitory rTMS to the left dorsolateral prefrontal cortex showed therapeutic effects in patients with major depressive disorder [324].

NEW OR NOVEL ANXIOLYTIC AGENTS

Cannabidiol

Cannabidiol is the second most abundant cannabinoid in Cannabis plants and lacks the consciousness-altering effects of delta-9-tetrahydrocannabinol (THC), the primary psychoactive compound in Cannabis. Cannabidiol is a pharmacologically broad-spectrum drug that has drawn increasing interest as a treatment for a range of neuropsychiatric conditions, including anxiety disorders. Preclinical evidence supports cannabidiol as a treatment for GAD, panic disorder, SAD, OCD, and PTSD when administered acutely, but few studies have investigated chronic cannabidiol dosing. Randomized controlled trials showed that, relative to placebo, cannabidiol significantly reduced anxiety in patients with SAD and GAD [136,325].

In a series of randomized controlled trials using fear-conditioning paradigms, subjects who received cannabidiol (vs. placebo) all showed successful conditioning, extinction, and recall. When given after resolution of symptoms, cannabidiol enhanced consolidation of extinction learning. Cannabidiol administered pre- or post-extinction reduced the reinstatement of autonomic contextual responding. No acute effects of cannabidiol were found on extinction. These results are the first evidence that cannabidiol may enhance consolidation of extinction learning in humans, suggesting cannabidiol may have potential as an adjunct to extinction therapies for anxiety disorders [326].

Brain imaging cannabidiol trials in patients with GAD or SAD consistently showed changes in functional activity in limbic and paralimbic cortical areas implicated in anxiety pathophysiology, with effects in the left para-hippocampal gyrus, the hippocampus, and the right posterior cingulate gyrus. Cannabidiol was found safe and tolerable, with few side effects and without major side effects during acute treatment. Cannabidiol administered chronically in oral doses of 10–1,280 mg/day to healthy volunteers and patients with schizophrenia, bipolar affective disorder, Parkinson disease, or Huntington disease did not find significant side effects or induction of any new neurologic, psychiatric, or general clinical conditions [136,327]. Overall, evidence indicates cannabidiol has considerable potential as a treatment for several anxiety disorders, with further study of chronic and therapeutic effects in relevant clinical populations needed [325,328].

Etifoxine

Etifoxine (also known as etafenoxine) is a non-benzodiazepine anxiolytic and anticonvulsant not yet approved in the United States. Clinical effects are mediated by GABA-Aα2 receptors, similar to benzodiazepines, and etifoxine appears to produce anxiolytic effects directly by binding to β2 or β3 subunits of the GABA-A receptor complex. The effects of etifoxine are not completely reversed by the benzodiazepine antagonist flumazenil. Etifoxine also stimulates neurosteroid production, which contributes to anxiolytic and neuroprotective effects. Several randomized controlled trials comparing etifoxine to lorazepam found vigilance, psychomotor performance, and free recall significantly impaired by lorazepam but not etifoxine. Superior anxiolytic effect and memory recall were noted with etifoxine, with fewer withdrawal symptoms than with lorazepam. Etifoxine appears promising as a non-benzodiazepine anxiolytic agent that lacks many shortcomings with benzodiazepines and SSRIs, although acute liver toxicity has been reported [329,330].

Asenapine

Asenapine is a newer atypical antipsychotic drug. Its dominant mechanism of action is mediated through 5HT2A and D2 receptor antagonism and also by antagonism of 5HT2B, 5HT2C, 5HT6, and 5HT7 serotoninergic; α1A, α2A, α2B and α2C adrenergic; and D3/D4 dopaminergic receptors [178]. Clinical efficacy in anxiety and mood disorders is predicted by its serotoninergic profile. This agent lacks affinity for muscarinic receptors and induces fewer anticholinergic side effects than other second-generation antipsychotics [331]. Asenapine is FDA-approved for schizophrenia and bipolar disorder; its use for anxiety disorders is off-label [178].

Tandospirone

Closely related to buspirone, tandospirone (also known as metanopirone) is a 5-HT1A receptor partial agonist used in China and Japan. Its efficacy was compared to sertraline in an eight-week randomized controlled trial in adolescents with SAD. Both drugs significantly improved anxiety scores from baseline, showed similar overall response and anxiety symptom-specific response rates (≥50% reduction), and resulted in significant and comparable improvements in social phobia symptoms. Tandospirone appeared non-inferior to sertraline treatment of SAD in adolescents. The drug is not FDA-approved [332].

15. COMPLEMENTARY/ALTERNATIVE THERAPIES

HERBAL PRODUCTS AND SUPPLEMENTS

Myo-Inositol

Myo-inositol is a glucose isomer and essential component of the phosphatidylinositol second messenger system critically linked to several CNS receptor-signaling systems [333]. Myo-inositol anxiolytic and antidepressant activity is mediated by a serotoninergic 5-HT2A/5-HT2C receptor-signaling pathway [334].

Several randomized controlled trials have been conducted using placebo or active controls. In 21 patients with panic disorder with or without agoraphobia given inositol 12 g/day or placebo for four weeks, significant decreases were found in the frequency and severity of panic attacks and agoraphobia severity with inositol relative to placebo [335]. Another randomized controlled trial compared myo-inositol 18 g/day with fluvoxamine 150 mg/day in patients with panic disorder with or without agoraphobia. Both drugs led to significant but comparable improvements in anxiety symptoms/severity, agoraphobia symptoms/severity, and global impression. In the first month, reduction in the number of panic attacks per week was significantly greater with inositol than fluvoxamine (4.0 vs. 2.4). Nausea and fatigue were significantly more common with fluvoxamine [336].

Other randomized controlled trials found that myo-inositol 12 g/day in 28 patients with major depression significantly reduced Hamilton Depression Rating Scale scores (vs. placebo) after four weeks; and 18 g/day given to patients with OCD for six weeks led to significant reductions in OCD symptom scores (vs. placebo) [335]. A review of supplements and herbal therapies with purported anxiolytic efficacy concluded myo-inositol was one of very few with demonstrated effectiveness [337]. The published research needs larger trials but is intriguing in light of a study in which patients with severe depression receiving treatment with rTMS showed significantly elevated prefrontal cortex myo-inositol levels, and this elevation correlated with extent of clinical improvement [338]. A meta-analysis of inositol for depression and anxiety disorders found that the agent may be particularly beneficial for treatment of depression [339].

The effective dose is 12–18 g per day, and inositol is free of side effects other than loose stools and drowsiness [335]. A drawback is the large amount required for therapeutic benefit, necessary to compensate for poor blood-brain barrier penetration. An Italian pharmaceutical company has developed a more concentrated myo-inositol formulation, with dose comparability to standard myo-inositol at 25% the dose level [338].

Overall, inositol is a natural compound with few side effects and may be an attractive option for patients with panic disorder who are ambivalent about taking psychiatric medication [336]. Myo-inositol is one of nine inositol isomers, but unless another inositol isomer is specified, inositol sold at retail is almost always myo-inositol.

Kava

Kava (Piper methysticum) extract has been used for anxiolytic effects, mediated through GABA channel modulation and weak GABA binding, β-adrenergic downregulation, and MAO-B inhibition. Efficacy studies in GAD showed superiority to placebo and comparability to buspirone. However, distribution and use of kava dropped off when reports of liver toxicity surfaced in the early 2000s [340,341,342].

Lavender Oil

A six-week randomized controlled trial compared silexan, a lavender oil capsule preparation, with lorazepam in GAD treatment efficacy. Both treatment groups showed similar reductions on the primary anxiety measure (HAM-A) and similar and comparable reductions on measures of somatic anxiety, psychic anxiety, anxiety self-rating, impression of illness severity, sleep quality, and other scales. Silexan appears to be an effective and well-tolerated alternative to benzodiazepines for GAD treatment [343]. A 10-week randomized controlled trial compared silexan with paroxetine and placebo in GAD treatment efficacy. Participants received 80 mg or 160 mg silexan, 20 mg paroxetine, or placebo once daily for 10 weeks [344]. The primary outcome measured was HAM-A total score reduction between baseline and treatment end. A total of 60.3% of participants in the silexan 160 mg group showed a HAM-A total score reduction greater than 50% of the baseline value compared with 51.9% in the silexan 80 mg group, 34.1% in the paroxetine group and 37.8% in the placebo group. Silexan additionally showed a pronounced antidepressant effect and improved general mental health and health-related quality of life. Rates of adverse effects were comparable among the silexan and placebo groups and lower for the paroxetine group [344].

EXERCISE THERAPY

Resistance exercise (i.e., strength training) includes a broad group of activities that evoke repeated muscle action against resistances above those encountered in daily life. A growing body of literature has identified anxiolytic effects of resistance exercise after both single sessions and long-term training. This research has shown that resistance training at a low-to-moderate intensity produces the most reliable and robust decreases in anxiety. Higher intensity has shown either no change or increased anxiety from baseline. One caveat is most of this research involved participants with state (not trait) anxiety [345].

YOGA

Yoga is an ancient mind/body practice that involves different techniques in physical postures, controlled breathing, deep relaxation, and meditation that have positive and specific influences. Research on yoga has demonstrated significant improvements in emotional self-regulation with consequent reductions in depression, stress, and anxiety levels and improvements in mood, quality of life, and well-being [346]. Several studies have found significant anxiolytic effects with yoga in patients with GAD or panic disorder, and it is considered the complementary therapy with strongest evidence of safety and efficacy in anxiety disorders.

One randomized controlled trial compared patients with panic disorder who received yoga or CBT plus yoga weekly over two months. Both treatment groups showed significant decreases from baseline in anxiety levels associated with panic disorder, panic-related beliefs, and panic-related body sensations, although the CBT/yoga combination group led to greater reductions over yoga alone [346].

A group of patients with GAD lacking response to pharmacotherapy received a five-day, 22-hour yoga course. Compared with baseline, follow-up at four weeks found a 73% response rate and 41% remission rate and significant reductions in HAM-A total score and psychic subscale score. Attrition was 25% [347].

Combining yoga with CBT integrates yoga and meditation with traditional and alternative CBT methods to enhance restructuring of the destructive cognitive and emotional patterns associated with physical and psychologic anxiety symptoms. Given in 90-minute sessions once per week for six weeks, CBT/yoga consisted of yoga/meditation, instruction and experiential cognitive restructuring using traditional and alternative CBT interventions, and group discussion with processing. In a group of patients with GAD receiving CBT/yoga, post-treatment scores were compared to baseline. The patients showed significant improvements on measures of state and trait anxiety, depression, panic, suicidality, sleep disturbance, sexual function, and quality of life [348].

16. CONCLUSION

Anxiety disorders are among the most prevalent mental health disorders encountered in primary care settings, yet these disorders often go under-recognized and undertreated for a variety of reasons, including reluctance to discuss emotional and psychological distress; clinic and practitioner time constraints; and attribution of symptoms to somatic conditions. Chronicity and episodic exacerbations often lead to ongoing personal distress and functional disability, resulting in excessive healthcare utilization and societal costs. Screening tools are available for diagnostic purposes, and effective pharmacotherapy and psychotherapy regimens specific to each anxiety disorder have been developed. The prevalence, distress/disability, potential for comorbidity, and management complexities associated with anxiety disorders emphasize the need for understanding (and paying attention to) the clinical presentation, differential diagnosis, and appropriate treatment selection in these patients.

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309. Soeter M, Kindt M. An abrupt transformation of phobic behavior after a post-retrieval amnesic agent. Biol Psychiatry. 2015;78(12):880-886.

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312. Mataix-Coils D, Fernandez de la Cruz L, Monzani B, et al. D-cycloserine augmentation of exposure-based cognitive behavior therapy for anxiety, obsessive-compulsive, and posttraumatic stress disorders: a systematic review and meta-analysis of individual participant data. JAMA Psychiatry. 2017;74(5):501-510.

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314. Soravia LM, Heinrichs M, Winzeler L, et al. Glucocorticoids enhance in vivo exposure-based therapy of spider phobia. Depress Anxiety. 2014;31(5):429-435.

315. Steudte-Schmiedgen S, Fay E, Capitao L, Kirschbaum C, Reinecke A. Hydrocortisone as an adjunct to brief cognitive-behavioural therapy for specific fear: endocrine and cognitive biomarkers as predictors of symptom improvement. J Psychopharmacol. 2021;35(6):641-651.

316. Telch MJ, Bruchey AK, Rosenfield D, et al. Effects of post-session administration of methylene blue on fear extinction and contextual memory in adults with claustrophobia. Am J Psychiatry. 2014;171(10):1091-1098.

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318. Meuret AE, Wilhelm FH, Ritz T, Roth WT. Feedback of end-tidal pCO2 as a therapeutic approach for panic disorder. J Psychiatr Res. 2008;42(7):560-568.

319. Meuret AE, Rosenfield D, Hofmann SG, Suvak MK, Roth WT. Changes in respiration mediate changes in fear of bodily sensations in panic disorder. J Psychiatric Res. 2009;4(6)3:634-641.

320. Schlaepfer TE, George MS, Mayberg H. WFSBP guidelines on brain stimulation treatments in psychiatry. World J Biol Psychiatry. 2010;11(1):2-18.

321. Li H, Wang J, Li C, Xiao Z. Repetitive transcranial magnetic stimulation (rTMS) for panic disorder in adults. Cochrane Database Syst Rev. 2014;9:CD009083.

322. Paes F, Machado S, Arias-Carrión O, et al. The value of repetitive transcranial magnetic stimulation (rTMS) for the treatment of anxiety disorders: an integrative review. CNS Neurol Disord Drug Targets. 2011;10(5):610-620.

323. Mantovani A, Aly M, Dagan Y, Allart A, Lisanby SH. Randomized sham controlled trial of repetitive transcranial magnetic stimulation to the dorsolateral prefrontal cortex for the treatment of panic disorder with comorbid major depression. J Affect Disord. 2013;144(1-2):153-159.

324. Kang JI Lee H, Jhung K, et al. Frontostriatal connectivity changes in major depressive disorder after repetitive transcranial magnetic stimulation: a randomized sham-controlled study. J Clin Psychiatry. 2016;77(9):e1137-e1143.

325. Blessing EM, Steenkamp MM, Manzanares J, Marmar CR. Cannabidiol as a potential treatment for anxiety disorders. Neurotherapeutics. 2015;12(4):825-836.

326. Das RK, Kamboj SK, Ramadas M, et al. Cannabidiol enhances consolidation of explicit fear extinction in humans. Psychopharmacology (Berl). 2013;226(4):781-792.

327. Crippa JA, Derenusson GN, Ferrari TB, et al. Neural basis of anxiolytic effects of cannabidiol (CBD) in generalized social anxiety disorder: a preliminary report. J Psychopharmacol. 2011;25(1):121-130.

328. Mandolini GM, Lazzaretti M, Pigoni A, Oldani L, Delvecchio G, Brambilla P. Pharmacological properties of cannbidiol in the treatment of psychiatric disorders: a critical overview. Epidemiol Psychiatr Sci. 2018;27(4):327-335.

329. Choi YM, Kim KH. Etifoxine for pain patients with anxiety. Korean J Pain. 2015;28(1):4-10.

330. do Rego JL, Vaudry D, Vaudry H. The non-benzodiazepine anxiolytic drug etifoxine causes a rapid, receptor-independent stimulation of neurosteroid biosynthesis. PLoS One. 2015;10(3):e0120473.

331. Samalin L, Charpeaud T, Llorca PM. Asenapine in bipolar I disorder: evidence and place in patient management. Ther Adv Chronic Dis. 2013;4(1):5-14.

332. Huang X, Li C, Li WH, et al. Clinical evaluation of the efficacy and safety of tandospirone versus sertraline monotherapy for social anxiety disorder: a randomized open-label trial. Hum Psychopharmacol. 2013;28(6):594-599.

333. Vadnal R, Parthasarathy L, Parthasarathy R. Role of inositol in the treatment of psychiatric disorders. CNS Drugs. 1997;7(1):6-16.

334. Einat H, Clenet F, Shaldubina A, Belmaker RH, Bourin M. The antidepressant activity of inositol in the forced swim test involves 5-HT(2) receptors. Behav Brain Res. 2001;118(1):77-83.

335. Levine J. Controlled trials of inositol in psychiatry. Eur Neuropsychopharmacol. 1997;7(2):147-155.

336. Palatnik A, Frolov K, Fux M, Benjamin J. Double-blind, controlled, crossover trial of inositol versus fluvoxamine for the treatment of panic disorder. J Clin Psychopharmacol. 2001;21(3):335-339.

337. Saeed SA, Bloch RM, Antonacci DJ. Herbal and dietary supplements for treatment of anxiety disorders. Am Fam Physician. 2007;76(4):549-556.

338. Zheng H, Zhang L, Li L, et al. High-frequency rTMS treatment increases left prefrontal myo-inositol in young patients with treatment-resistant depression. Prog Neuropsychopharmacol Biol Psychiatry. 2010;34(7):1189-1195.

339. Mukai T, Kishi T, Matsuda Y, Iwata N. A meta-analysis of inositol for depression and anxiety disorders. Hum Psychopharmacol. 2014;29(1):55-63.

340. De Sousa A. Herbal medicines and anxiety disorders: an overview. J Med Plants Stud. 2013;1(6):18-23.

341. Sarris J, Byre GJ, Bousman CA, et al. Kava for generalized anxiety disorder: a 16-week double-blind, randomised, placebo-controlled study. Aust N Z J Psychiatry. 2020;54(3):288-297.

342. Ooi SL, Henderson P, Pak SC. Kava for generalized anxiety disorder: a review of current evidence. J Altern Complement Med. 2018;24(8):770-780.

343. Woelk H, Schläfke S. A multi-center, double-blind, randomised study of the lavender oil preparation silexan in comparison to lorazepam for generalized anxiety disorder. Phytomedicine. 2010;17(2):94-99.

344. Kasper S, Gastpar M, Muller WE, et al. Lavender oil preparation silexan is effective in generalized anxiety disorder: a randomized, double-blind comparison to placebo and paroxetine. Int J Neuropsychopharmacol. 2014;17(6):859-869.

345. Strickland JC, Smith MA. The anxiolytic effects of resistance exercise. Front Psychol. 2014;5:753.

346. Vorkapic CF, Rangé B. Reducing the symptomatology of panic disorder: the effects of a yoga program alone and in combination with cognitive-behavioral therapy. Front Psychiatry. 2014;5:177.

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Evidence-Based Practice Recommendations Citations

1. American Psychiatric Association. Practice Guidelines for the Psychiatric Evaluation of Adults. 3rd ed. Arlington, VA: American Psychiatric Association; 2015. Available at https://psychiatryonline.org/doi/10.1176/appi.books.9780890426760.pe02. Last accessed April 27, 2025.

2. National Collaborating Centre for Mental Health. Social Anxiety Disorder: Recognition, Assessment and Treatment. London: National Institute for Health and Care Excellence; 2013. Available at https://www.nice.org.uk/guidance/cg159/resources/social-anxiety-disorder-recognition-assessment-and-treatment-pdf-35109639699397. Last accessed April 27, 2025.

3. National Collaborating Centre for Mental Health, National Collaborating Centre for Primary Care. Generalised Anxiety Disorder and Panic Disorder (with or without Agoraphobia) in Adults: Management in Primary, Secondary and Community Care. London: National Institute for Health and Clinical Excellence; 2020. Available at https://www.nice.org.uk/guidance/cg113. Last accessed April 27, 2025.

77630 • Codes of Ethics for Counselors and Marriage and Family Therapists

Deborah Converse, MA, NBCT

www.netce.com

Copyright © 2026 NetCE, All rights reserved.

This course provides a comprehensive review of ethical standards and professional responsibilities for counselors and therapists based on the NBCC, ACA, and AAMFT Codes of Ethics. Participants will explore key topics including professional competence, informed consent, confidentiality and its exceptions, recordkeeping requirements, and ethical considerations in working with diverse populations. The course also addresses decision-making frameworks, duty to warn, standards for working with minors and vulnerable individuals, the use of technology in practice, and guidelines related to advocacy and prohibited practices. Additionally, learners will gain insight into the ethical complaint process and potential sanctions for violations, supporting ethical and compliant practice across settings.

Table of Contents

77630 • Codes of Ethics for Counselors and Marriage and Family Therapists

Course Overview

Audience

Accreditations & Approvals

Designations of Credit

Individual State Behavioral Health Approvals

Special Approvals

Course Objective

Learning Objectives

Faculty

Faculty Disclosure

Division Planner

Division Planner Disclosure

Director of Development and Academic Affairs

Director Disclosure Statement

About the Sponsor

Disclosure Statement

Implicit Bias in Health Care

1. INTRODUCTION

2. HISTORICAL PERSPECTIVES

3. FOUNDATIONS AND SHARED BELIEFS

CLIENT FOCUS

RIGHT OF INFORMED CONSENT

CONFIDENTIALITY

DUTY TO WARN

MULTICULTURAL ISSUES

TECHNOLOGY-ASSISTED SERVICES

4. ETHICAL DECISIONS

5. CURRENT ETHICAL CODES

6. SUMMARY OF THE NBCC CODE OF ETHICS

CORE VALUES IN THE NBCC CODE OF ETHICS

NBCC ETHICS STANDARDS

DISTANCE SERVICES THROUGH TECHNOLOGY

OVERVIEW OF THE NBCC ETHICAL COMPLAINT PROCESS

7. A SUMMARY OF THE ACA CODE OF ETHICS

ACA CODE OF ETHICS PREAMBLE

MISSION

CORE VALUES

PRINCIPLES

PURPOSE

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

THE ACA POLICIES AND PROCEDURES FOR PROCESSING COMPLAINTS OF ETHICAL VIOLATIONS

8. SUMMARY OF THE AAMFT CODE OF ETHICS

PREAMBLE

HONORING PUBLIC TRUST

SEEKING CONSULTATION

ETHICAL DECISION-MAKING

BINDING EXPECTATIONS

ASPIRATIONAL CORE VALUES

ETHICAL STANDARDS

A SUMMARY OF THE AAMFT ETHICS COMPLAINT PROCESS

9. ETHICAL DECISION-MAKING

10. EVALUATING ETHICAL PRACTICE

11. SERVICE DELIVERY THROUGH TECHNOLOGY AND SOCIAL MEDIA

TELETHERAPY AND TELESUPERVISION GUIDELINES II

EMERGENCY PLANS TO SAFEGUARD TELEMENTAL HEALTH SERVICES

HIPAA STANDARDS FOR MOBILE DEVICES

ACA SOCIAL MEDIA TIPS

12. CONVERSION/REPARATIVE THERAPY

13. DUAL RELATIONSHIPS

BARTERING: A COMMON BOUNDARY ISSUE

SEXUAL DUAL RELATIONSHIPS

14. CONFIDENTIALITY AND DUTY TO WARN

ETHICAL QUESTIONS: TARASOFF CASE ON DUTY TO WARN

ETHICAL DECISIONS: KEY POINTS FROM THE TARASOFF CASE

RECORD ACCESS BY FAMILY MEMBERS

15. CASE STUDIES

REPARATIVE/CONVERSION THERAPY

DUAL RELATIONSHIPS

DUTY TO WARN

RECORD ACCESS BY FAMILY MEMBERS

16. SUMMARY OF THE HEALTH INSURANCE PORTABILITY ACCOUNTABILITY ACT (HIPAA) PRIVACY RULE

17. GLOSSARY

18. RESOURCES

19. CONCLUSION

Works Cited

77630 • Codes of Ethics for Counselors and Marriage and Family Therapists

Education Category. Ethics - Human Rights

Release Date. 05/01/2026

Expiration Date. 12/31/2027

Course Overview

This course provides a comprehensive review of ethical standards and professional responsibilities for counselors and therapists based on the NBCC, ACA, and AAMFT Codes of Ethics. Participants will explore key topics including professional competence, informed consent, confidentiality and its exceptions, recordkeeping requirements, and ethical considerations in working with diverse populations. The course also addresses decision-making frameworks, duty to warn, standards for working with minors and vulnerable individuals, the use of technology in practice, and guidelines related to advocacy and prohibited practices. Additionally, learners will gain insight into the ethical complaint process and potential sanctions for violations, supporting ethical and compliant practice across settings.

Audience

This course is designed for counselors and therapists in all practice settings.

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. 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 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.

Designations of Credit

NetCE designates this continuing education activity for 6 NBCC clock hour(s). NetCE is authorized by IACET to offer 0.6 CEU(s) for this program. This course meets the qualifications for 6 hours of continuing education credit for LMFTs, LPCCs, and LEPs in the area of Law and Ethics as required by the California Board of Behavioral Sciences.

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 fulfills the Florida requirement for 3 hours of Professional Ethics and Boundaries education. This course has been approved by NetCE, as a NAADAC Approved Education Provider, for educational credits, NAADAC Provider #97847. NetCE is responsible for all aspects of their programming. 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 for Alcohol/Drug Educators. Provider Number CP40 889 H 0626. NetCE designates this continuing education activity for 6 continuing education hours for addiction professionals.

Course Objective

The purpose of this course is to provide counselors and therapists with a comprehensive understanding of ethical standards and professional responsibilities outlined by NBCC, ACA, and AAMFT, including competence, confidentiality, informed consent, multicultural considerations, and ethical decision-making across diverse practice settings.

Learning Objectives

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

1. Identify and define the standards of the NBCC, ACA, and AAMFT codes of ethics for professional competence, informed consent, confidentiality, dual relationships, and duty to warn.

2. Discuss fundamental principles of the ACA Code of Ethics.

3. Explain the requirements for client records in the NBCC, ACA, and AAMFT codes of ethics.

4. Identify exceptions that allow disclosure of confidential information.

5. Discuss assessment guidelines in the NBCC Code of Ethics.

6. List and define competencies for multicultural diversity sensitivity from the ACA and AAMFT codes of ethics.

7. Explain the term "foreseeable harm" related to confidentiality of client disclosures.

8. Discuss components of ethical decision making in therapy and counseling.

9. List ethical standards specific to minor clients and incapacitated or incompetent individuals.

10. Explain standards that guide long-distance counseling or therapy using technology and social media from the NBCC, ACA, AAMFT, Code of Ethics, and AMFTRB guidelines.

11. Discuss the NBCC, ACA, and AAMFT directives opposing conversion-reparative therapy and counseling.

12. Identify standards for advocacy from the ACA and AAMFT codes of ethics.

13. List the complaint process and sanctions for ethics violations.

Faculty

Deborah Converse, MA, NBCT, holds an MA in Education for Emotionally Disabled Students from the University of Central Florida, a BA and MA in Psychology, and was awarded National Board Certification in 2000 as an Exceptional Needs Specialist, Birth-21+ endorsement. She has dedicated her career to building knowledge and acceptance of individuals with special needs within their families, schools, and communities, and has addressed education and employment issues for students facing challenges that include developmental, emotional and behavioral challenges, mental illness, mobility, and chemical dependency within the public school system setting. She has authored numerous instructional programs and presented them at state, national, and international conferences on education and mental health.

Faculty Disclosure

Contributing faculty, Deborah Converse, MA, NBCT, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Division Planner

Scott Deatherage, PhD

Division Planner Disclosure

The division planner 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

Mental health professionals today face complex ethical considerations related to a host of factors. Increasing client diversity, changing family dynamics, and new methods of providing counseling and therapy through digital technology and social media bring new ethical challenges. Ethical practice requires counselors and therapists to reconsider issues of confidentiality, informed consent, multiple relationships, patient privacy, and records security.

The practitioner must keep pace with revised ethical standards of practice and the needs of an increasingly diverse population. A working knowledge and daily application of revised ethical guidelines are required of all mental health counselors, therapists, and staff to provide the highest level of service to their clients.

- "Ethics" refers to the beliefs that individuals hold about what is right and what is wrong.

- "Morals" are similar and have been described as a person's individual values that guide their behavior based on their beliefs of right and wrong.

- "Ethical conduct" refers to the behaviors exhibited by the counselor and the therapist. Good ethical conduct in counseling and therapy is grounded in moral principles, professional standards, decision making skills, understanding ethical codes, and a commitment to client welfare.

Both laws and ethical codes regulate the practice of therapists and counselors. Professional organizations do not enforce laws; rather, they develop standards and guidelines to assist the practitioner in delivering services based on ethical principles. Laws are defined and enforced by governmental definitions of the minimum standards of conduct that are acceptable to society.

Common types of ethical violations that occur in the counseling profession include errors in informed consent, breach of confidentiality, inappropriate relationships with clients, false or misrepresented statements, fraudulent billing practices, and boundary violations.

In order to educate and guide counselors and therapists, professional associations have developed codes of ethics as resources, as well as processes to review ethics complaints to protect clients. Recent revisions to these codes will be discussed, with policies and procedures to address ethical complaints if a violation is alleged.

The "Standards for Privacy of Individually Identifiable Health Information," or the Privacy Rule, establishes a set of national standards to protect health information. The U.S. Department of Health and Human Services (HHS) issued the Privacy Rule to implement the requirement of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The Privacy Rule addresses the use and disclosure of individuals' health information by professionals subject to the Privacy Rule [1].

The major goal of the Privacy Rule is to ensure that health information is properly protected while allowing the flow of information to promote quality healthcare and protect the public's health. The HIPAA Privacy Rule and the codes of ethics for mental health practitioners complement each other and were developed to ensure privacy, confidentiality, and the well-being of individuals and society.

This course reviews the codes of ethics and guidelines from several different organizations, including:

- The National Board for Certified Counselors (NBCC)

- The American Counselors Association (ACA)

- The American Association of Marriage and Family Therapy (AAMFT)

- The Association of Marital Therapy Regulatory Board (AMFTRB)

The codes and guidelines for each of these associations will be summarized. Some codes have been recently revised, and all should be reviewed in their entirety on their respective websites included in the resource section at the end of this course.

2. HISTORICAL PERSPECTIVES

Standards of practice and the idea of accountability can be traced back to ancient Egypt. The code of Hammurabi was established as far back as 2000 B.C.E. It contained a description of physicians' responsibilities and the consequences and punishments if a patient's health did not improve.

The Hippocratic Oath, written in 400 B.C.E., can be viewed as an early example of a code of ethics to guide the practice of medical professionals and define obligations to their profession, practice, and patients. This ancient oath is the foundation for the values and ethical principles in our current codes of ethics.

The writings of Aristotle concluded that ethics provided guidelines for virtuous and moral action. In his rule, the "Gold Mean," Aristotle defined an ethical choice as one that falls in the middle of two extremes, one of excess and the other of deficiency [2].

After World War II, the American Psychological Association (APA) saw the need to develop a code of ethics due to a change in the type of professional activity requested of its members. Psychologists were called to address the mental health needs of soldiers returning home from the war and were responsible for developing psychological assessments to determine eligibility for the draft. A committee was formed to identify ethical issues to effectively guide psychologists' practice. It covered concepts that included the psychologists' responsibilities when treating clients, training students, and consulting colleagues as well as ethical research practices [3].

Throughout the years, other mental health organizations developed codes of ethics and enacted subsequent revisions to address the continuing changes in society and the needs of their clients.

The ACA can trace its roots to 1952 when independent member associations held a joint convention. These associations included the National Vocational Guidance Association (NVGA); the National Association of Guidance and Counselor Trainers (NAGCT); the Student Personnel Association for Teacher Education (SPATE); and the American College Personnel Association.

They established the American Personnel and Guidance Association (APGA) to form a professional group that united all counselors. A Code of Ethics was first developed and adopted in 1963. In 1983, the association adopted the name American Association of Counseling and Development. It was changed again on July 1, 1992, to the American Counseling Association (ACA). This new membership association unified the various counseling professions into one entity that reflected shared goals, purpose, and commitment to ethical practice.

The ACA developed a professional Code of Ethics that has been adopted by licensing boards who use the code as the basis in counseling decision-making on ethical issues. The ACA Code has been revised every 7 to 10 years: The recent revision adopted in 2014 replaces the 2005 edition. The American Counseling Association now services professional counselors in the United States and in 50 other countries in Europe and Latin America, as well as the Philippines and the Virgin Islands. In addition, the ACA is associated with a comprehensive network of 19 divisions and 56 branches [4].

The American Association for Marriage and Family Therapy (AAMFT) was founded in 1942 to address the needs and changing demands of couples and family relationships. This membership association supports research and provides education, tools, and resources to provide effective services in the field of marriage and family therapy. The AAMFT's goal is to ensure that trained, ethical professionals meet the needs of clients and society. This association is now the professional membership association for the field of marriage and family therapy, with more than 50,000 marriage and family therapists throughout the United States, Canada, and around the world.

The National Board for Certified Counselors, Inc. and Affiliates (NBCC) is a not-for-profit, independent certification organization that was established in 1982 [5]. The organization was founded to create a voluntary national certification system and to identify certified counselors by maintaining a registry of membership. Since then, NBCC divisions and affiliates have expanded their commitment to include advancement of the profession with the goal of improving mental health around the world.

Today, there are more than 69,000 National Certified Counselors (NCCs) in more than 40 countries. These counselors volunteer to obtain certification through a rigorous program to achieve national standards, set by the profession, based on research, written dissertations, and examinations. Certified NCCs are encouraged to mentor other counselors to improve their practice and obtain certification as an NCC. NCCs may be members of associations such as ACA and AAMFT, depending on their area of expertise.

3. FOUNDATIONS AND SHARED BELIEFS

Trust appears to be the common thread throughout ethical counseling and marriage and family therapy practice. Therapists, patients, and students view trust as fundamental to psychotherapy [6].

One shared belief among therapists and counselors is that professionals must do the right thing and make ethical decisions that are in the best interest of the client.

The counselor-client relationship impacts ethical decision making and must consider the cultural context of the professional relationship along with ethical principles. The structure of common therapeutic relationship factors includes confidence in the therapist and confidence in the treatment plan, which is built on trust [7].

Confidentiality is essential in developing an effective relationship between mental health practitioners and their clients. Research supports the ethical principle in counseling and therapy that asserts effective practice is based on trust and confidentiality between the practitioner and client. The client may approach a counselor or therapist feeling vulnerable and seeking assistance in times of crisis. The client may be fearful, ashamed, or unwilling to share feelings at first. If the client believes that the information shared will be kept confidential, there is a greater possibility of developing an effective collaborative relationship with the therapist and a positive outcome for the client.

Over the last decade, ethical issues faced by counselors have received increased attention in counseling literature, and no area of study is more important in the practice of counseling [8]. Counselors are often confronted with situations that require sound ethical decision-making. Determining the appropriate course of action when faced with difficult ethical conflicts can be challenging and should never be done in isolation.

Codes of conduct are designed to protect clients and society. Counselors and therapists encounter ethical issues and challenges that require complex decisions, and they must be familiar with the ethical codes for their association. They must know what areas and issues are problematic to avoid potential risks of ethical violations that may harm clients and families.

Ethics in counseling and therapy focuses on ideals rather than obligatory rules. It emphasizes professionals' character and their relationships with their clients. The study of ethics is more than solving a specific ethical or legal dilemma. Although ethics codes speak to many issues, the counselor must recognize that codes are broad and do not cover every ethical issue faced by counselors and therapists. The professional's ethical awareness, behavior, and problem-solving skills will determine how they translate and apply these general guidelines to professional practice. Ethics codes do not provide explicit instructions for every possible situation.

CLIENT FOCUS

Counselors and therapists must be aware that their focus on their clients' welfare takes precedence over their own. Practitioners must understand their own needs, as well as their potential for imposing personal values and biases that may impact service to clients. Professionals have a responsibility to continually expand self-awareness and recognize areas of biases, prejudices, and vulnerabilities.

RIGHT OF INFORMED CONSENT

Informed consent is an ethical and legal requirement and an integral part of any counseling plan and therapeutic process. Providing clients with information they need to make informed choices promotes the active participation of clients and families in the counseling plan and is critical to achieve a positive outcome. Informed consent educates clients about their rights and responsibilities and builds empowerment for a trusting, collaborative relationship with the therapist or counselor.

Informed consent is not a single form or procedure and must be revisited throughout the counseling/therapeutic process whenever changes or new components are introduced.

CONFIDENTIALITY

Confidentiality is a standard of conduct that prevents the professional from disclosing information concerning clients. State and federal statutes, administrative codes, regulations, and case law interpret rulings by the court and include components of confidentiality. Confidentiality is fundamental to the counseling and therapeutic relationship, and professionals must not disclose client information without prior consent. The ethics codes, as well as state and federal laws, provide some exceptions to confidentiality standards that will be discussed.

Confidentiality is based on our society's belief that individuals have a right to privacy and to decide what information they will share and with whom. Confidentiality is an ethical principle that holds the practitioner responsible for respecting the client's privacy and protecting information disclosed during therapy. Both the Code of Ethics and the HIPAA Privacy Rule provide explicit, detailed provisions that cover client consent for disclosure of information and which entities can receive information. Privileged communication, resulting from a therapy or counseling session, is a legal concept that protects the client from having confidential information disclosed without their consent.

Confidentiality in the professional–client relationship is consistent with the obligation to serve as an advocate for the client and for the greater society. Confidentiality, as addressed in ethics codes and case study examples of violations, will be presented in this course. The Tarasoff v. University of California case and its resulting legal actions led to revisions to the codes of ethics [9]. This precedent-setting case has led to changes in many state laws concerning the release of confidential information, duty to warn, and protection from harm.

Confidentiality in Group Counseling

Providing services to a family or group presents ethical challenges when the practitioner works with multiple clients at the same time. The counselor or therapist must inform all members of the group of their rights to confidentiality at the onset of services and include a statement that the practitioner will not disclose any information that one family member offered in a private discussion. Some practitioners decide to address this situation by meeting only in a group setting with the family and never with one member individually.

The practitioner working with a family or a group may need to assess progress frequently as new issues may emerge that must be addressed and added to the written services agreement. Interventions that were planned for one member of the family may not be appropriate for others or may have a negative effect on some members. The practitioner must always maintain their view of the family as a unit and not appear to focus on one member of the group. The practitioner must also keep everyone informed of their obligation to maintain confidentiality. Informed consent is an ongoing process as the treatment plan or service agreement evolves.

In most cases, the initial contact to the therapist or counselor's office for assistance is made by one of the group members. The other members may not share this desire or commitment to participate in the treatment plan. Informed consent by all group members is particularly important in these situations, especially with minors who cannot legally provide consent. The reluctance on the part of some members may complicate the delivery of effective services, including maintaining confidentiality. The therapist or counselor must avoid being viewed as biased toward one member over another and must work to establish the trust of all members. Establishing trust is important to encourage sharing, communication, and participation among members, and respect for confidentiality rules. The therapist or counselor should avoid contact with any members outside of the professional setting to avoid any appearance of favoritism and potential ethical boundary violations.

When counseling groups or families, confidentiality may be difficult to accomplish. Each client has different behaviors, levels of maturity, affiliations, loyalties, and attitudes toward the counseling or therapy. There are also levels of varying commitments to keep information from the group sessions private. In all codes of ethics, there are statements that guide the counselor to build commitment to confidentiality:

- Inform all clients in the group of the rules of confidentiality.

- Define ground rules and parameters for the group to support positive, productive discussions among members.

- Identify who the client is in the counseling setting.

- Discuss how confidentiality matters will be addressed.

- Determine how information by one member may be disclosed to other members by the counselor.

- Discuss how to disclose information that was previously held as secret in the group counseling session.

- Provide rules for communication, fairness, and respect in the group.

- Explain that confidentiality cannot be guaranteed in the group setting.

- Identify and discuss the impact of distance counseling regarding confidentiality.

The ACA suggests that counselors clearly explain the importance and parameters of confidentiality as it applies to members of the group [10].

Additionally, the AAMFT notes, as with other information shared in a counseling setting, that marriage and family therapists [11]:

- Do not disclose client confidences except by written authorization, waiver, or when mandated by law.

- Do not take verbal authorization except when permitted in an emergency situation or when ordered by law.

- Do not disclose information outside the treatment context without a written authorization from each individual competent to execute the waiver.

- Disclose the nature of confidentiality to clients, as well as the possible limitations of the clients' right to confidentiality.

- Review with clients the circumstances where confidential information may be requested and when it can be disclosed.

- Understand the circumstances that may necessitate repeated disclosures.

- Do not reveal any individual's confidences to others in the client group without the prior written permission of that individual.

The foregoing information serves as a guideline only and it is recommended that the entire AAMFT Code of Ethics be reviewed to understand the complex nature of confidentiality in group therapy.

The NBCC 2023 Standards include the following directives:

- Counselors shall clearly identify in writing the primary client in the record.

- Counselors will also identify in the record those individuals who are receiving related professional services in connection with such client relationship.

- In the context of couple, family, or group counseling, the counselor shall not reveal any individual client's confidences to others without the prior written permission of that individual.

Confidentiality Laws with Minors or Incapacitated Clients

Federal and state laws mandate the reporting of suspected child abuse or neglect. Additionally, statutes require the protection of others who may not have the ability to protect themselves, such as elderly individuals or those who are residing in institutions. Counselors and therapists who work with these clients are mandated reporters and must study applicable state laws that detail procedures for reporting abuse, including the required time limits, representatives to contact and their phone numbers.

Counselors and therapists must provide informed consent to minor or incapacitated clients as well. They must also take care to discuss the rules of confidentiality at their clients' developmental or cognitive levels. The language used must be appropriate so that clients will understand that there are times when parents, guardians, or other officials must be notified concerning the information that they share.

The NBCC 2023 Code of Ethics contains the following standards in this area:

- Counselors working with minors, incapacitated adults, or other persons unable to give legal consent to release confidential and privileged information, shall protect the confidentiality of information received in the counseling relationship as specified by Federal and State laws, written policies, and applicable ethical standards. In all cases, the counselor shall discuss with the client and their legal representative the limits of confidentiality and the rules concerning the release of any information.

- Counselors respect and honor the inherent and legal rights of the parents and legal guardians of minors and incapacitated adults who are legally incapable of giving informed consent. As appropriate, the counselor shall collaborate with the parent(s) or legal guardian, discussing the role of counseling, the confidential nature of the counseling relationship, and the autonomy of the client as required by the NBCC Code of Ethics, State and Federal law, and other applicable ethical standards. When working with minors or incapacitated adults who are legally incapable of giving informed consent, the counselor shall consider the custody agreement, power of attorney document, or legal agreement that may impact the rights of a parent or legal guardian.

The practitioner should have expertise in working with these clients and should be competent in communication with them. A statement should be included in the plan of service that indicates (1) what was told to the client, and (2) that the practitioner took steps to inform them of disclosure in the following situations:

- If they report they are being abused;

- If they say they plan to hurt themselves; and

- If they say they plan to hurt others.

If the practitioner believes any of the three indicators of harm are credible, the practitioner must follow the appropriate steps to report abuse or neglect and to warn others if the threat is deemed a serious one. The rules that govern the actions to take in these cases vary from state to state; therefore, the practitioners must follow the mandates within their jurisdictions of practice and licensure, as well as the code of ethics. Case studies and additional considerations will be covered in subsequent sections.

DUTY TO WARN

The confidentiality requirement of nondisclosure does not apply when imminent danger to the client or others exists. This duty to warn was a result of the Tarasoff case in California and has been added to many states'' laws across the nation. The laws may vary across the states concerning the therapist's obligation to warn and include such terms as:

- Whether the practitioner "must" warn of imminent danger or "may" warn of imminent danger.

- What constitutes a serious, foreseeable, and imminent danger?

- Which individuals must be given a warning of imminent danger and when?

- What circumstances warrant the therapist's obligation to warn of imminent danger?

- Must the practitioner need to have firsthand information of the danger, or can a credible source inform them?

- Who is a credible source?

- What is the practitioner's assessment of danger conflicts with opinions from medical or law enforcement personnel?

- Is the practitioner legally accountable if they issue a warning and danger was not imminent?

It is imperative that any counselor or therapist confronted with a potential duty to warn situation seeks legal consultation for the best course of action.

The ACA's general requirement that counselors keep information confidential does not apply when [10]:

- Disclosure is required to protect clients or identified individuals from serious and foreseeable harm;

- Legal requirements demand that confidential information must be revealed;

- The counselor is in doubt as to the validity of the exception and must consult with other professionals; and when

- Additional considerations apply to address end-of-life and child welfare issues.

The foregoing statements are addressed in detail in the ACA Code of Ethics, which must be studied in its entirety to understand the complexities of confidentiality between the client and the counselor.

The NBCC 2023 Code of Ethics provides the following standards [12]:

- Counselors shall take proactive measures to avoid harming their clients and avoid imposing personal values on those who receive their professional services. Counselors will seek to minimize unavoidable or unanticipated harm, and where possible seek to address unintentional harm.

- Counselors shall not share client information that is obtained through the counseling process without specific written consent by the client or legal guardian except when necessary to prevent serious and foreseeable harm to the client or others, or when otherwise mandated by federal or state law or regulation.

- Counselors who provide clinical supervision services shall keep accurate records of supervision goals and the supervisee's progress. All supervision-related information shall be treated as confidential, except to prevent serious and foreseeable harm to a client or others, or when legally required to do so by a court or government agency order.

The AAMFT Code of Ethics includes the following standards [11]:

- Marriage and family therapists disclose to clients and other interested parties at the outset of services the nature of confidentiality and possible limitations of the client's right to confidentiality.

- Therapists review with clients the circumstances where confidential information may be requested and where disclosure of confidential information may be legally required. Circumstances may necessitate repeated disclosures.

- Marriage and family therapists do not disclose client confidences, except by written authorization or waiver or where mandated or permitted by law.

- Verbal authorization will not be sufficient except in emergency situations, unless prohibited by law.

MULTICULTURAL ISSUES

A major focus of the ACA Code of Ethics' expanded revision in 2014 was multicultural diversity competency. Multicultural diversity is a major component of the NBCC and AAMFT ethics codes as well. As the population increases and becomes more diverse, increased proficiency in multicultural diversity must be considered, and therapists and counselors must consider their personal values and biases.

Cultural influences must be recognized and appreciated in order to build trust and collaboration for effective counseling and therapeutic relationships. These influences are complex, and counseling and therapy methods must be individualized and specific to the diverse needs of the client. Counselors and marriage and family therapists may work with client groups that represent multiple sexual orientations, genders, cultures, ethnic, racial, generational, and religious groups; therefore, multicultural diversity awareness and acceptance is central to effective therapy.

Ethical challenges in multicultural diversity may begin with the validity of assessments because appropriate evaluation tools must be used. It is crucial to locate a culture fair or a culture-free method of assessment. The APA defines a culture-fair test and cross-cultural testing as follows [13]:

- A test based on common human experience and considered to be relatively unbiased with respect to special background influences. Unlike some standardized intelligence assessments, which may reflect predominantly middle-class experience, a culture-fair test is designed to apply across social lines and to permit equitable comparisons among people from different backgrounds.

- Cross-cultural testing is the assessment of individuals from different cultural backgrounds. The use of instruments that are free of bias is essential to valid cross-cultural testing, as it provides for the measurement equivalency necessary to ensure that outcomes have the same meaning across diverse populations of interest. For example, scores on a coping questionnaire that possesses bias may be a legitimate measure of coping if they are compared within a single cultural group, whereas cross-cultural differences identified on the basis of this questionnaire may be influenced by other factors, such as translation issues, item inappropriateness, or differential response styles.

Therapists should strive to be culturally aware and learn about the cultural identities they serve. The client's cultural identity impacts assessment, communication, client goals, and methods of service, and counselors must expand their strategies and skills to be effective in a variety of cultural contexts.

Problems may also arise when making a diagnosis in a multicultural context when using the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition Text Revision (DSM-5-TR). There are many cultural beliefs and experiences that influence diagnosis, and the DSM-5-TR revision in 2022 incorporated greater cultural sensitivity and understanding in the diagnostic process [14]. Some changes implemented in DSM-5-TR include language that challenges the view that races are discrete and natural entities:

- The term "racialized" is used instead of "race/racial" to highlight the socially constructed nature of race.

- The term "ethnoracial" is used in the text to denote the U.S. Census categories, such as Hispanic, White, or African American, that combine ethnic and racialized identifiers.

- The terms "minority" and "non-White" are avoided because they describe social groups in relation to a racialized "majority," a practice that tends to perpetuate social hierarchies.

- The emerging term "Latinx" is used in place of Latino/Latina to promote gender-inclusive terminology.

- The term "Caucasian" is not used because it is based on obsolete and erroneous views about the geographic origin of a prototypical pan-European ethnicity.

- Prevalence data on specific ethnoracial groups were included when existing research documented reliable estimates based on representative samples.

In addition, information is provided on variations in symptom expression, attributions for disorder causes or precipitants, and factors associated with differential prevalence across demographic groups. Cultural norms that may affect the level of perceived pathology are also reported. Attention was paid to the risk of misdiagnosis when evaluating individuals from socially oppressed ethnoracial groups.

Clearly, it is impossible to be an expert in working with all cultures. Many researchers in this field report that it is important to look at the universal principles and standards that are at the core of therapy and counseling. These are basic human rights, and promoting an individual's mental health to reach full potential is fundamental. A counselor should work beyond their cultural beliefs and social systems and strive to understand clients from their viewpoints. A counselor must be aware of a client's external influences that may impact the development of service plans.

There are many training and educational programs to help build competence in multicultural diversity and to help the practitioner appreciate the social and cultural influences that shape a client's view of the world. Practitioners who do not consider these influences may incorrectly evaluate, or label, the client. They risk diagnosing behavior as pathological or impaired, although it may be an accepted and normal practice in the client's culture.

Multicultural awareness in counseling and therapy is critical for the counselor or therapist to communicate effectively in a way that is culturally sensitive. The practitioner must consider the effects of the client's culture in all phases of the service plan to deliver effective, individualized service.

In addition to training and educational programs, practitioners should increase their own multicultural competencies through hands-on experiences with local cultures in their communities of practice. This could include attending special events; volunteering; consulting professionals in the community; and participating in workshops, advocacy programs, and discussion groups along with consulting supervisors or other colleagues who have experience with the community. These activities, combined with guidelines from the code of ethics, may help practitioners develop competencies to further serve clients from diverse cultures.

Practitioners must identify and understand their own cultural perspective as it impacts their practice with diverse populations.

While there may be situations that show blatant discrimination toward others or ignorance of other cultures, many cultural insensitivities or negative behaviors have been termed "micro-aggressions," which are defined as, "A comment or action that subtly and often unconsciously or unintentionally expresses a prejudice" [15]. Well-meaning therapists who believe that they are culturally sensitive and open minded may offend members of another culture without being aware that they are doing so.

Micro-aggressions are linked to implicit bias (see glossary) that may be subtle, unconscious, and unintentional as well. According to the APA, [16]:

- Implicit bias is thought to be shaped by experience and based on learned associations between particular qualities and social categories, including race and/or gender.

- Individuals' perceptions and behaviors can be influenced by the implicit biases they hold, even if they are unaware they hold such biases.

- Implicit bias is an aspect of implicit social cognition: the phenomenon that perceptions, attitudes, and stereotypes can operate prior to conscious intention or endorsement.

Therapists and counselors must be careful to identify their potential for bias and stereotyping clients from other cultural backgrounds and should complete implicit bias training as part of their professional preparation for practice.

Nontraditional Family Groups

Today's professional will encounter a variety of nontraditional families and groups. Same-sex or transgender parents; same-sex family members; and biological, surrogate, and stepparents and -children are all within these nontraditional family groups. There is no "typical" family group, and each person in the family may face issues related to their unique family composition. These issues may include discrimination, bullying, loss of employment, child custody issues, antigay prejudices or violence, feeling ostracized or isolated in the community, and feeling devalued by society.

The family or group counselor or therapist should acquire specialized skills and experiences to understand the complexities of nontraditional family groups in order to practice in a nonjudgmental, supportive manner. The following issues may present:

- Sexual or gender orientation within the family group may lead to prejudice, discrimination, or bias in the community.

- Minority sexual orientation or gender issues may be the focus in custody issues the family is facing.

- Co-parenting and blended families may present added stress to all family members.

- Children may face issues at school or within the community due to their family composition.

- Same-sex or transgender couples may experience discrimination related to adoption or conceiving a child through the use of a surrogate.

- There may be conflicts between the biological parent and a stepparent who now has custody of the child.

- Extended families may not accept the nontraditional family members.

- Parents may need support to help their children feel confident and comfortable with a lifestyle that contradicts what they see and experience outside of their homes. The parents may require strategies to help their children face discrimination, isolation, and any negative stereotypes that they may encounter.

- Teens and children may face challenges due to their sexual or gender identity.

- It may take additional time to build trusting, collaborative relationships with members of the group to overcome their reluctance to share their feelings due to negative, judgmental experiences that they may have had in the past.

- A member of the family may be questioning sexual orientation or gender or may be in transition and need support through the process. The family may need services to help them adjust to the changes within the family.

Microaggressions that are related to gender expression and sexual identity can occur when working with members of the LBGTQ community. For example, the counselor or therapist should ask in their first session which gender pronoun the client prefers.

TECHNOLOGY-ASSISTED SERVICES

The computer age has presented new areas of ethical concerns that have affected every mental health organization today. Computers and other forms of technology are now the standard methods for recording, storing, retrieving, and transmitting patient information, clinical records, session notes, insurance information, evaluation results, and all other data involved in a client's case.

Massive amounts of information can now be stored on increasingly smaller, faster, and more portable electronic devices. Audio and visual records of every part of the therapeutic and counseling service can now be easily recorded and accessed. The convenience, ease of use, and portability of these systems can unfortunately lead to confidential information being stolen, lost, or transmitted accidentally. The constant upgrades and expansions among these systems lead to increasing possibilities of privacy violations and other ethical concerns for confidentiality maintenance in cyberspace.

Email interception by unauthorized parties is a widespread problem and is a violation of a client's privacy. Some companies and agencies feel justified in monitoring worksite email accounts and Internet usage because they view these employee email accounts as the company's property and a part of the company's technological infrastructure. Another justification is that they claim to determine whether personal business is being conducted on work time or if inappropriate Internet sites have been accessed. An example of this is within school systems where specific words and content are regularly flagged to monitor student and faculty use. If a school counselor or therapist reports that a child threatened to kill themself, the word "kill" may be red flagged in email correspondence by a county technology official who is monitoring the account in an office in another city and may trigger an investigation by individuals outside of the counseling relationship. This type of monitoring is a common practice in many public-school systems for all students and staff.

Technology has taken therapy and counseling out of the office and moved it across geographic borders. It allows a practitioner to work with clients from any location any time of day or night. This may be convenient for both parties; however, it opens many opportunities for confidentiality breaches and privacy right violations that will be covered in detail in subsequent sections.

In addition to crossing geographic boundaries, technology leads to boundary issues that cross the line from professional to personal with clients. Counselors and therapists may have websites and social media pages that are professional, in addition to personal online pages. These two types of social media must be kept separate at all times to maintain appropriate boundaries with clients. An example of this might be a Facebook page that can be used for professional purposes; however, the profile can also include personal information that may include interactions with friends.

A greater concern is the publishing or posting of information and photos by others that the therapist is unable to control. The counselor or therapist should always be aware of information or pictures online that can be accessed by the public, and the lack of security of online postings.

Practitioners must use caution with online communication including emails, text messages, blogs, tweets, photos, and other social media posts. Their online presence must be professional and cannot cause harm to a client or anyone viewing the information. Professional counselors and therapists may not cross boundaries and interact as friends in real life; however, clients and others may become confused online with terms like "friending" on Facebook. This is something that the professional should never do. If personal information or a status with someone is posted on Facebook, it is open to be reposted and viewed by anyone who is associated with the person that reposted the information, unless specific privacy settings are in place.

Any counselor or therapist with a professional website, networking site, or social media page should review their code of ethics as well as any state or federal laws that regulate technology or practice in and outside the state boundaries of the professional license.

In recent years, many systems have been compromised, hacked, or cracked. These violations have resulted in lost or stolen personal, medical, and financial information. The practitioner can never be completely confident that they can protect the privacy rights of their clients when using technology for communication or distance services. Practitioners must follow numerous safeguards and be vigilant when using technology in their practice.

Revisions to the code of ethics have addressed the benefits and the risks of technology use and the provision of distance services. The use of technology affects the components of confidentiality, privilege, legal jurisdiction, client safety, duty to warn, and quality of the practitioner–client relationship. HIPAA laws provide extensive regulation of any information gathered, transmitted, and stored using all forms of technology including audio, visual, computer, fax, and phone.

The expanded use of technology and social media in service delivery brought many ethical conflicts to the forefront. The revised codes in this course contain guidelines in this area; however, as the technology continues to change the therapist and counselor must remain vigilant, review the sections on ethical technology use, and collaborate with other professionals to make sound ethical decisions. The course will address the guidelines in codes of ethics and the requirements defined within the HIPAA Privacy Rule, which governs the use of new technology and social media to prevent unintentional, or accidental, violations of privacy.

In addition, the counselor and therapist must maintain close contact with their professional associations and stay abreast of any code revisions and guidance. They must also stay informed to identify changes in state and federal laws related to informed consent, confidentiality, duty to warn, and privacy when using technology.

4. ETHICAL DECISIONS

Ethical decision-making is a process that involves the informed judgment of the counselor and the therapist. The codes advise that there will be issues with clients that contain ethical questions with no simple answers. The practitioner should consider how their actions would be judged in a peer review process and what ethical standards would apply. The codes stress that the practitioner should seek consultation from professionals in their employing organizations, state board, or professional associations regarding ethical decisions. When in doubt, it is important to seek collaboration and never to act alone.

The practitioner must review ethical principles and standards in their decision-making process. They must apply knowledge from the code of ethics for their association, the standards and principles of their employing organization, and state and federal statutes that apply.

When codes do not contain information on a particular issue, the practitioner is still responsible for making correct ethical decisions to protect the welfare of the client. The responsibility for making the correct ethical decision is complex, with serious ramifications for the client and practitioner. A sound ethical decision-making process must be applied to lead the practitioner, with assistance from other professionals, to resolve the ethical conflict in accordance with the code of ethics. Reasonable differences of opinion may exist among professionals as they seek to apply values, principles, and ethical standards to resolve a conflict.

Appropriate time and resources should be given so that all stakeholders in the process feel confident in the decision to resolve the ethical issue. At any point, professionals should discuss the issue with their supervisors, administrators, or professional associations to include them in the process.

According to the NBCC 2023 revised Code of Ethics: Counselors shall not share client information that is obtained through the counseling process without specific written consent by the client or legal guardian except when necessary to prevent serious and foreseeable harm to the client or others, or when otherwise mandated by federal or state law or regulation.

AAMFT Standard 2.2 advises:

- Marriage and family therapists do not disclose client confidences, except by written authorization or waiver or where mandated or permitted by law. Verbal authorization will not be sufficient except in emergency situations, unless prohibited by law.

- See the subsequent sections on theTarasoff v. Regent's case for further details.

5. CURRENT ETHICAL CODES

A revision of the ACA Code of Ethics was completed in 2014. Changes were made that impacted professional counselors across all settings and specialties. The revised 2014 ACA Code of Ethics was the first new edition of the Code of Ethics since 2005. The AAMFT Code was revised on January 1, 2015; the NBCC Code was revised May 15, 2023. Major changes in the new codes involve distance counseling using technology and social media for client communication. These codes cover guidelines to address ethical considerations for confidentiality, client verification, safeguards, and effectiveness of therapy that must be considered while using these new forms of service delivery with clients.

Other new additions in the codes provide guidance in order to avoid any influence or bias toward clients based on the imposition of the counselor's personal values. The revised codes replace all others and provide additional guidelines for ensuring confidentiality, maintaining boundaries in dual relationships, increasing focus on multicultural diversity, safeguarding methods for record-keeping and securing information, assessing and diagnosing mental illness, as well as the selection of interventions.

The growing population of clients older than age 60 led to the inclusion of guidelines in the codes to handle counseling issues and ethics related to end-of-life care, managed care, and Medicaid/Medicare. Service payments for these clients are particularly complex. Although some of the services have been expanded through the federally mandated Affordable Care Act, some states have opted out of paying for additional services that are not covered under this Act. Some states with a large population of citizens older than 65 years of age have opted out of additional Medicaid and Medicare program funding. As a result, this has affected payments for mental health services, including counseling and therapy.

A review of the ethics codes for the National Board for Certified Counselors (NBCC), the American Counseling Association (ACA), the American Association of Marriage and Family Therapists (AAMFT), and the Association of Marital Therapy Regulatory Boards (AMFTRB) reveals similarities in the values, principles, and standards that guide the counseling professions. All of these organizations' missions seek to enhance human development and well-being, recognize diversity, and promote self-worth, dignity, potential, and independence for all people within their social and cultural contexts. These associations have ethics codes that apply to scientific, educational, and professional roles. They share common terms and definitions and are based on the premise that the client's welfare always has the highest priority.

These codes clarify the ethical responsibilities of professional practice and provide guidelines when professional obligations conflict or ethical uncertainties arise. The code for each association includes information in the following areas:

- Building trust for effective, collaborative client relationships

- Communication, informed consent, privacy, and confidentiality

- Multicultural diversity in practice

- Professional responsibility for ethical behavior and practice

- Evaluation, assessment, and interpretation of data

- Ethical use of technology and social media

- Training, teaching, and supervision

- Research and publication

- Relationships, consultation, and ethical responsibilities with colleagues and other professionals

- Ethical responsibilities to society

- Resolving ethical issues, complaints, or inquiries.

This course reviews and discusses key elements of the codes of ethics for marriage and family therapy and professional counseling, ethical decision-making, and associations' policies and procedures for addressing ethical complaints. It is not a comprehensive guide for compliance or a source of legal information or advice. The codes of ethics state that they are not able to address every possible ethical dilemma that therapists or counselors may face in their practice. The practitioner must seek professional assistance and collaboration as directed by their association, or employing agency, and refer to code guidelines on a regular basis. In addition, all professional associations can assist with questions related to ethical practice; therefore, contact information will be included.

6. SUMMARY OF THE NBCC CODE OF ETHICS

The National Board for Certified Counselors (NBCC) certifies licensed counselors who volunteer to enter the program from a variety of specialty areas and professional associations. NBCC offers general counselor certification as well as a choice of specialty areas in accordance with the counselor's specific practice. The NBCC Code of Ethics is applicable to all NBCC applicants and National Certified Counselors (NCCs) regardless of their area of practice or their choice of professional association membership [12].

According to the organization, the NBCC's Code represents the standards for ethical behaviors and seeks to provide an assurance of ethical behavior among counselors that provide professional practice as an NCC. The code's standards provide directives for ethical behavior and practice, and all NCC are expected to follow the code in their service to clients. The code serves as a resource for the professional counselor and provides recourse for clients who suspect an ethical violation has been committed by an NCC.

Applicants and credentialed NCC holders under this code will be sanctioned by the NBCC if the association determines that any directive or standard in the NBCC Code of Ethics has not been followed, which constitutes an ethical violation.

The NBCC is available to assist in ethical decisions and can be contacted by phone at 336-547-0607 or by email at nbcc@nbcc.org.

CORE VALUES IN THE NBCC CODE OF ETHICS

The following information is from the most recent revision of the of the code. It may be further viewed in its entirety on the NBCC website (https://nbcc.org) [12].

- Counselors will be civil in their actions and words, avoiding arrogance, assumptions, and hubris. Counselors seek to listen to others with intention and respond with respect. When engaged in challenging dialogues, counselors do so to seek answers not confrontations or harm. Counselors strive to be sensitive to differences in attitudes and culture. Counselors always seek to minimize undue harm and take particular care of those who are vulnerable or in anguish. With respect to all clients and work, counselors seek to be mindful of their humanity as they fulfill their counseling duties.

- Counselors strive to enhance the social and mental well-being of their clients while supporting the overall physical health of each client. Counselors must engage in self-care and self-reflection.

- Access and equity are essential to the profession of counseling and fundamentally important for the success of any society. Counseling services should be provided to achieve the best mental health outcomes. Counselors provide services to all of those in need, utilizing available resources, and advocating for the expansion of resources in underserved communities.

- Certified counselors and candidates demonstrate their commitment to ethical behaviors by demonstrating, and representing to their clients, sensitivity to multicultural issues, avoiding discrimination, oppression, and/or any form of social injustice.

NBCC ETHICS STANDARDS

The following standards are from the 2023 revision and are summarized [12]. You can review them in their entirety at https://www.nbcc.org/assets/ethics/nbcccodeofethics.pdf.

Professional Responsibilities

- Counselors shall perform only those professional services for which they are qualified by training, education, and supervised experience.

- Counselors shall accurately represent their current professional qualifications and credentials in counseling or closely related disciplines.

- Counselors shall identify only earned educational degrees in counseling or another mental health discipline with regard to all counseling work, including publications.

- Counselors shall seek professional assistance or withdraw from the practice of counseling if their mental or physical condition makes it so that they are unable to provide appropriate services.

- Counselors shall obtain supervision or consultation with other qualified professionals when unsure about client treatment and/or professional practice responsibilities.

- Counselors shall clearly distinguish honorary educational degrees from earned degrees.

- 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.

- Counselors shall not misuse their professional influence or meet their own needs at the expense of a client's welfare, including, but not limited to, the promotion of services or products.

- Counselors shall not solicit testimonials from current clients or their families and friends. Recognizing the possibility of future requests for services, counselors shall not solicit testimonials from former clients within 5 years from the date of service termination.

- 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.

- Counselors shall discuss service termination with clients when there is a reasonable belief that the clients are no longer benefiting from, or are unlikely to benefit from, future services, and provide appropriate referrals.

- Counselors shall comply with all NBCC policies, procedures, and agreements, including all disclosure requirements and related instructions.

- Counselors shall adhere to legal standards and requirements, including State licensure regulations.

- Counselors shall not engage in unlawful discrimination.

- Counselors, who make public statements inconsistent with this code or other professional counseling standards, shall state that their opinions represent their personal views.

- Counselors providing professional counseling presentations shall ensure that the content is consistent with this code of ethics.

Counseling Relationships

- Counselors shall take proactive measures to avoid harming their clients, avoid imposing personal values on those who receive their professional services, seek to minimize unavoidable or unanticipated harm, and address unintentional harm.

- Counselors shall respect each client's privacy and shall solicit only information that contributes to the identified counseling goals or facilitates the counseling process and is also consistent with counseling protocols.

- Counselors shall not share client information that is obtained through the counseling process without specific written consent by the client or legal guardian except when necessary to prevent serious and foreseeable harm to the client or others, or when otherwise mandated by federal or state law or regulation.

- Counselors generally shall not accept goods or services from clients in return for counseling services in recognition of the possible negative effects, including perceived exploitation. Counselors may accept goods or services only in cases where: no referrals are possible; the arrangement is discussed with the client in advance; they are of a reasonable equivalent value; they do not place the counselor in an unfair advantage; they are not harmful to the client and documented in the counseling services agreement.

- Counselors shall not accept gifts from clients except in cases when it is culturally appropriate or therapeutically relevant and shall consider the value of the gift and the effect on the therapeutic relationship before accepting.

- Counselors shall be mindful of engaging in counseling relationships with those individuals with whom another relationship, such as a community connection, friendship, or work relationship exists (i.e., multiple relationships). If a multiple relationship develops in an unforeseen manner, the counselor shall discuss the potential effects with the client, and take reasonable steps to resolve the situation, including termination and the provision of referrals.

- Counselors will exercise caution and avoid exploitation or the appearance of exploitation before entering into a non-counseling relationship with a former client. A period of 5 years is recommended, and counselors shall exercise caution and avoid exploitation of former clients.

- Counselors will not engage in any form of sexual or romantic contact with a client or former client for at least 5 years following the date of counseling service termination.

- Counselors will not engage in any type of harassing behavior towards clients, defined as any verbal, nonverbal, electronic, or physical act that is known, or reasonably understood, to be unwelcome or that reasonably would be perceived as harassment.

- Counselors will take proactive measures to avoid interruptions of counseling services due to illness, vacations, or unforeseen circumstances. To prevent the harm that may occur if clients are unable to access professional assistance, identify other qualified professionals with whom the counselor has a working agreement or local emergency service agencies that can respond to a client in a mental health crisis.

- Counselors shall protect against unauthorized access to confidential client information in all formats. Counselors will inform and ensure all other persons with access to confidential information will observe confidentiality procedures and protocols.

- Counselors shall create and follow written procedures regarding client confidentiality rules and the handling of client records in the event of the counselor's death, incapacitation, unforeseen and lengthy interruption of services, and end of employment.

- Counselors shall discuss with prospective clients and document the appropriateness of counseling services offered. If there is cause to believe a client will not benefit from counseling services, counselors will explore alternative forms of treatment and/or discuss and/or facilitate a referral to another provider.

- Counselors working independently will retain and protect client records as directed by State or Federal law.

- Counselors shall make efforts to inform clients and former clients of the court-ordered release of confidential client information prior to such release in a prompt and timely manner. The counselor may request that a court withdraw any order to release confidential information, due to the potential harm to the client or the counseling relationship, and release only that information required by the court or agency and document the release.

- Counselors shall inform clients of the purposes, goals, procedures, limitations, and potential risks and benefits of services and techniques either prior to or during the initial counseling session. Counselors also will provide information about client's rights and responsibilities, billing arrangements, collection procedures, confidentiality and its limitations, and records and service termination policies. Information will be provided to the client in verbal and written forms and counselors will confirm that the client understands the information. Counselors will obtain written informed consent to participate in counseling and document any client concerns related to the information provided in the client's record.

- Counselors understand that clients own the content of their clinical records, and counselors work to provide reasonable access to the content of the records when requested in a timely manner. If there is a reasonable basis to believe that direct review of the record will cause the client harm, the counselor will discuss the request and possible effects. In the case of minors, counselors may limit access to the minor client or responsible guardian if there is compelling evidence that other access may cause harm.

- Counselors shall obtain a client's written consent prior to the provision of services.

- Counselors shall work collaboratively with clients in the creation of written plans of treatment that offer attainable goals and use appropriate techniques consistent with the client's psychological and physical needs and abilities.

- Counselors shall update and modify the client's record throughout the counseling relationship when changes occur in the treatment plan, including changes relating to goals, roles, techniques, and diagnoses. Counselors shall obtain each client's written approval for such changes.

- Counselors shall clearly identify in writing the primary client in the record and record those individuals who are receiving related professional services in connection with such client relationship. In the context of couple, family or group counseling, the counselor shall not reveal any individual client's confidences to others, without the prior written permission of that individual.

- Counselors working with minors, incapacitated adults, or other persons unable to give legal consent to release confidential and privileged information, shall protect the confidentiality of information received in the counseling relationship as specified by Federal and State laws, written policies, and applicable ethical standards. In all cases, the counselor shall discuss with the client and their legal representative the limits of confidentiality and the rules concerning the release of any information.

- Counselors respect and honor the inherent and legal rights of the parents and legal guardians of minors and incapacitated adults who are legally incapable of giving informed consent. As appropriate, the counselor shall collaborate with the parent(s) or legal guardian, discussing the role of counseling, the confidential nature of the counseling relationship, and the autonomy of the client as required by the NBCC Code of Ethics, state and federal law, and other applicable ethical standards. When working with minors or incapacitated adults who are legally incapable of giving informed consent, the counselor shall consider the custody agreement, power of attorney document, or legal agreement that may impact the rights of a parent or legal guardian.

- Counselors are encouraged to consult with both parents or other family members prior to delivery of services in joint custody arrangements to ensure agreement with treatment planning and record sharing. Counselors will seek permission of an appropriate parent or legal guardian to disclose information and obtain voluntary and informed consent to release confidential information when counseling minors or adults who are legally incapable of providing consent.

Supervision

- Counselors who provide clinical supervision shall obtain appropriate training, including continuing education concerning current clinical trends, in order to meet the needs of their supervisees and the clients they serve.

- Counselors who provide supervision services shall provide accurate written information to supervisees regarding the counselor's credentials, as well as information regarding the process of supervision.

- Counselors who act as counselor educators, field placement supervisors, or clinical supervisors shall not engage in sexual or romantic intimacy, in-person or electronically, with current and former students or supervisees for at least 5 years from the date of the last academic and/or supervision contact, whichever is later.

- Counselors who provide clinical supervision services shall keep accurate records of supervision goals and the supervisee's progress confidential except to prevent serious and foreseeable harm to a client or others, or when legally required to do so by a court or government agency order.

- Counselors who provide clinical supervision services shall intervene in situations where a supervisee is impaired or incompetent and potentially placing the client(s) at risk. The supervisor also may take steps to end the supervisee's services to protect the client and may only resume services after the completion of any recommended or required remediation.

- Counselors who provide clinical supervision services shall not have multiple relationships with a supervisee that may interfere with the supervisor's professional judgment or exploit the supervisee. Supervisors shall not supervise friends, family, or relatives.

- Counselors who provide supervision services shall provide supervisees with regular and substantive feedback through-out the supervision process.

- Counselors shall promote the welfare and continued education of supervisees by discussing ethical and legal standards and practices related to supervision.

- Counselors who provide clinical supervision services shall establish procedures for responding to crisis situations related to supervisees and the supervisee's clients. These procedures shall be provided both verbally and in writing to their supervisees. A clear protocol and guidelines shall be made available and communicated to the supervisee in the event of the supervisor's absence. Contact information for an alternative supervisor shall be provided to the supervisee in the absence of the supervisor.

Consultation

- Counselors who seek or receive case consultation services from another professional shall document consultation in the relevant client records.

- Counselors who seek clinical supervision and consultation (consultees) shall promote the welfare of the client by selecting qualified professionals.

- Counselors who provide supervision services to supervisees who are practicing under the supervision of more than one supervisor shall exchange contact information and communicate about the shared supervisee's performance.

- Counselors who act as a university, field placement, or clinical supervisor shall ensure that supervisees provide accurate information to clients about the supervisee's professional status.

- Counselors who seek consultation (consultees) shall protect the client's identity and confidential information, and unnecessary invasion of privacy, by providing only the client information relevant to the consultation.

- Counselors who provide consultative services (consultants) shall establish a written plan with the professional seeking assistance.

- Counselors who provide consultative services (consultants) shall use and provide to consultees accurate information regarding their consultation qualifications and credentials related to the identified concerns or situations.

- Counselors who act as university, field placement, or clinical supervisors shall require that supervisees provide the supervisor's name, credentials, and contact information to the supervisee's clients.

Testing and Appraisal

- Counselors shall protect the confidentiality and security of client related tests, assessments, reports, data, and any transmission of client-related information in any form.

- Counselors shall not release any information related to the client, to any party other than the client without prior written consent, except as required to prevent clear and imminent danger to the client or others; when authorized by written agreement with the client; or, when legally required to do so by a court order or governmental agency.

- Counselors shall use or interpret only the specific tests and assessments for which they are qualified, including meeting the qualification of having the required education and supervised experience.

- Counselors shall only use current, valid tests and assessments specifically necessary for the provision of quality services, and that have been carefully considered in terms of the instrument's validity, reliability, psychometric limitations, and appropriateness for use with regard to a particular population or client.

- Counselors shall recognize results that are clinically significant for a given client test and assessment and shall document in the client's record how the results will be appropriately used in the counseling process.

- Counselors who develop tests or assessments for measuring personal characteristics, development, diagnoses, goal attainment, or other appropriate clinical uses shall provide test users with written valid, information regarding the benefits and limitations of test instruments, including appropriate use, test results, and interpretation.

- Counselors who develop tests and assessments for measuring personal characteristics, development, diagnoses, goal attainment, or other appropriate clinical uses shall identify other potential sources of comparable information.

- Prior to the use of a test or assessment, counselors shall provide complete information to a client regarding the format of each test and assessment, purpose, outcome, risks, and limitations.

- 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. If appropriate, the counselor may provide a referral to another qualified professional who specializes in the evaluation of individuals with similar conditions.

- Counselors shall follow administration and interpretation protocols for all tests and assessments, including the use of appropriate computer software.

- Counselors shall comply with identified information and data security protocols identified by test publishers when using published tests and assessments.

Research

- Counselors shall protect the welfare of research participants by taking all appropriate precautions to prevent negative psychological or physical effects.

- Counselors shall protect the identities of research participants by appropriately disguising data, except when there is a specific written client authorization for an identified appropriate reason.

- Counselors conducting research with underrepresented groups must take into consideration their historical, diverse, and multicultural experiences, and only use techniques and approaches based on established, clinically sound theory applicable to underrepresented populations.

- Counselors shall take credit only for research activities they have performed or authored.

- Counselors shall provide appropriate disclosures prior to research participation, and appropriately report to and debrief participants regarding the subject and features of the study after research data is collected.

- Counselors shall provide critical information, through a written informed consent process, to potential research subjects that will assist them in reaching a determination about participation. This information shall include the research purpose, process, duration, risks, potential consequences, and procedures, as well as the participant's right to refuse or withdraw from participation.

- Counselors shall accurately report results of research, including limitations and variables that may have impacted the findings.

- Counselors shall not employ deceptive techniques in research unless there are no alternatives and there is significant prospective scientific, educational, or clinical value to the research, and will not use any techniques that can be reasonably expected to cause harm.

- Prior to conducting research with students, counselors shall carefully follow ethical standards, including requirements regarding participant, supervisee, and client confidentiality and multiple relationships.

- Counselors shall comply with applicable guidelines when designing, conducting, or reporting research, including those of the relevant institutional review board.

- Counselors shall credit the work of contributors, including students who have contributed to research or publication either by joint authorship, acknowledgment, or other appropriate means.

- Counselors shall comply with intellectual property laws and accepted publication guidelines.

Counselor Education

Competence

- Counselor educators shall stay current with, and be well informed about, counseling-related professional issues and developments.

- Counselor educators shall engage in teaching and student supervision activities only with respect to their areas of professional knowledge and competence.

- Counselor educators shall ensure that all teaching activities are based on current research and evidence-based practices.

- Counselors who are counselor educators shall maintain professional licensure and/or certification consistent with their practice and teaching activities, including specialization areas, such as school, clinical mental health, rehabilitation counseling.

- Counselors who are counselor educators shall maintain competency in the delivery models and tools they use for teaching, supervision, and research.

Multiple Relationships:

- Counselor educators shall avoid non-academic relationships with counseling students during the student's participation in the educator's training program.

- Counselor educators shall not engage in intimate or sexual relationships with current students or individuals who were students enrolled in the counselor's program within the past 5 years. Prohibited sexual or romantic intimacy engagements include physical contact and electronic interactions.

Gatekeeping

Counselor educators shall serve as professional gatekeepers and assume responsibilities related to the evaluation of their students' professional behaviors and dispositions. Counselor educators shall establish clear, written behavioral and dispositional expectations for students, including student remediation.

Advocacy

Counselor educators shall advocate for counseling students to address programmatic barriers and obstacles that hinder student academic growth and development.

Cultural Identity

Counselor educators will practice cultural responsiveness in their teaching, and respect the cultural identity, values, sexual orientation, and gender identity, of their students.

DISTANCE SERVICES THROUGH TECHNOLOGY

The Board of Directors for NBCC addressed the potential impact of computers on the counseling profession beginning in 1997. The NBCC adopted the Standards for the Ethical Practice of Web Counseling, which was the first time a national association in the mental health profession had addressed standards in this critical area. Technology is constantly changing, so the NBCC Board of Directors continues to review and revise the standards and policies. The Board approved the current revision in 2023 to guide the practice of online counseling. The entire document should be reviewed at the NBCC website before proceeding with distance services. The NBCC 2023 revised Code of Ethics continues as follows:

Telemental Health

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

- 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 and document relevant State requirements in the relevant client record(s).

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

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

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

- 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 shall be communicated in writing in disclosure documents provided to clients.

- 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.

- Counselors shall communicate information regarding security to clients who receive telemental health services.

- 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 on computer systems for personal communications, and not using "auto-remember" usernames and passwords.

- 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 including:

- 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, and document such information and the discussion of alternative service options and referrals in the client's record.

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

- 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.

- Counselors, either prior to or during the initial session, shall inform clients of the purposes, goals, procedures, limitations, potential risks and benefits of telemental health services and techniques, and information about rights and responsibilities as appropriate to the telemental health service.

- 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.

- 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.

- 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?"

- 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.

- Counselors shall retain telemental health service records for a minimum of 5 years unless applicable state laws require additional time.

Social Media and Technology

- Counselors shall provide services pursuant to an appropriate written policy which regulates the use of social media and other related digital technology with respect to current and former clients. Policy shall also identify that client and counselor personal accounts are distinct from social media accounts used for professional purposes.

- Counselors shall be familiar with the use of privacy and security settings of social media and other electronic platforms utilized for telemental health service provision.

- Counselors shall not publish confidential client information on any social media platform, including updates, and blogs, without the consent of the client. To facilitate the secure provision of information, counselors shall inform clients prior to or during the initial session about secure and appropriate ways to communicate with them. Counselors also shall advise clients about the potential risks of sending messages through digital technology and social media sources.

- Counselors who use digital technology for professional purposes shall only post information related to professional services, such as information concerning advocacy, educational purposes, and marketing, that does not create multiple relationships or threaten client confidentially.

- Counselors shall respect the privacy of a client's social media material and accounts and shall not access client social media accounts without specific client permission, a related discussion with the client, documentation of potential risks and benefits, and a specific clinical purpose.

- Counselors shall avoid non-professional relationships with clients online. This restriction includes connecting with or following client social media accounts.

OVERVIEW OF THE NBCC ETHICAL COMPLAINT PROCESS

The NBCC developed a process to review alleged ethics violations by their NCCs and administer discipline if warranted. NCCs are bound by the decisions of NBCC. NCCs should have complete knowledge of these procedures and should visit the nbcc.org website to review the entire ethics section.

The complaint process is very detailed, and for the purpose of this course, they are summarized as follows from the 2023 website on filing an ethics complaint [17].

If you wish to file a complaint against a National Certified Counselor (NCC), you may do so by completing an Ethics Complaint Statement, including all information required by the form, and submitting it to the NBCC Department of Ethics. The Ethics Complaint Statement is a formal written communication from a complainant describing in detail the concerns regarding an NBCC certificant or candidate and is the only form of complaint submission accepted [17].

Overview of Complaint Procedures

1. The complainant (person filing the complaint) must complete an Ethics Complaint Statement, including all information required by the form, and email it to the NBCC Department of Ethics at ethics@nbcc.org.

2. When a completed Ethics Complaint Statement is received by NBCC, the NBCC Director of Ethics will (a) review the material received and assign a case number to the matter; (b) review the complaint(s) made; (c) determine whether the complaint(s) is presented in sufficient detail to permit NBCC to conduct a preliminary inquiry; and, if necessary, (d) contact the complainant and request additional factual material.

3. The NBCC Director of Ethics will send a letter to the complainant and respondent stating whether the complaint(s) submitted is accepted or rejected for a formal ethics review.

4. If an ethics complaint is accepted for a formal inquiry, the NBCC Director of Ethics will issue an Ethics Complaint Summary identifying each term that may have been violated and the basis for each. This notification will be delivered to the respondent and the complainant at the last known address(es) by regular mail, email, or other verifiable delivery service.

5. Within 30 days of the mailing date of an Ethics Complaint Summary, the respondent must submit an Ethics Complaint Response according to the instructions in the Summary. The Ethics Complaint Response must include the following: (a) a full answer to each item identified in the Ethics Complaint Summary, (b) the identification and a copy of each document that the respondent believes to be relevant to the resolution of the ethics complaint, and (c) any other information that the respondent believes will assist NBCC in considering the ethics complaint fairly.

6. The NBCC Director of Ethics will forward a copy of the submitted Ethics Complaint Response to the complainant within approximately 10 days following its receipt by NBCC. The complainant may submit a Reply to the Response by letter or similar document within 14 days of the complainant's receipt of the Response. If submitted, this Reply must fully explain any additional information that the complainant wishes to present to the Director of Ethics concerning the Ethics Complaint Response. The optional Reply will be provided to the respondent, who may submit a Final Response to NBCC within 14 days of the respondent's receipt of the Reply.

7. For questions about the complaint process and to submit a completed Ethics Complaint Statement, email ethics@nbcc.org.

7. A SUMMARY OF THE ACA CODE OF ETHICS

Members are committed to serve all clients and recognize and appreciate multicultural diversity. They work across cultures with the goal of increasing opportunities to maximize the potential in all people. The code was not written to mandate how the counselor will practice; rather, it serves as a guide for professional behavior and ethical practice based on their commitment, values, and dedication to ethical counseling.

The 2014 revision, the most current one, will be summarized in this section. The complete ACA Code of Ethics should be studied and can be found at https://www.counseling.org/resources/ethics.

ACA CODE OF ETHICS PREAMBLE

The American Counseling Association (ACA) is an educational, scientific, and professional organization whose members work in a variety of settings and serve in multiple capacities. Counseling is a professional relationship that empowers diverse individuals, families, and groups to accomplish mental health, wellness, education, and career goals.

MISSION

The mission of the American Counseling Association is to enhance the quality of life in society by promoting the development of professional counselors, advancing the counseling profession, and using the profession and practice of counseling to promote respect for human dignity and diversity [10].

CORE VALUES

The following are core professional values of the counseling profession according to the ACA, and are detailed in the Code of Ethics:

- Enhance human development throughout the life span.

- Honor diversity and embrace a multicultural approach in support of the worth, dignity, potential, and uniqueness of people within their social and cultural contexts.

- Promote social justice.

- Safeguard the integrity of the counselor-client relationship.

- Practice in a competent and ethical manner.

PRINCIPLES

These core values provide the foundation for the ACA ethical principles that will be outlined in this section. The fundamental principles of professional ethical behavior as determined by the ACA are as follows:

- Autonomy, fostering the right to control the direction of one's life.

- Nonmalfeasance or avoiding actions that cause harm.

- Beneficence, or working for the good of the individual and society by promoting mental health and well-being.

- Justice, treating individuals equitably and fostering fairness and equality.

- Fidelity, honoring commitments and keeping promises, including fulfilling one's responsibilities of trust in professional relationships.

- Veracity, dealing truthfully with individuals with whom counselors come into professional contact.

PURPOSE

The ACA Code of Ethics contains the following:

- The code sets forth the ethical obligations of members and provides guidance intended to inform the ethical practice of professional counselors.

- The code identifies ethical considerations relevant to professional counselors and counselors-in-training.

- The code enables the association to clarify for current and prospective members, and for those served by members, the nature of the ethical responsibilities held in common by its members.

- The code serves as an ethical guide designed to assist members in constructing a course of action that best serves those utilizing counseling services and establishes expectations of conduct with a primary emphasis on the role of the professional counselor.

- The code helps to support the mission of ACA.

- The standards contained in the code serve as the basis for processing inquiries and ethics complaints concerning ACA members.

The ACA Code of Ethics includes nine sections that serve as a guide to the counselor in the following areas:

- The counseling relationship

- Confidentiality and privacy

- Professional responsibility

- Relationships with other professionals

- Evaluation, assessment, and interpretation

- Supervision, training, and teaching

- Research and publication

- Distance counseling, technology, and social media

- Resolving ethical issues

SECTION A. THE COUNSELING RELATIONSHIP

Counselors facilitate client growth and development in ways that foster the interest and welfare of clients and promote the formation of healthy relationships. This section covers:

- Client welfare, primary responsibility

- Records and documentation

- Counseling plans

- Support network involvement

- Informed consent in the counseling relationship

- Inability to give consent

- Mandated clients

- Avoiding harm and imposing values

- Prohibited non-counseling roles

- Personal virtual relationships with current clients

- Managing and maintaining boundaries and professional relationships

- Role changes in the professional relationship

- Roles and relationships at individual, group, institutional, and societal levels

- Confidentiality and advocacy

- Multiple clients and group work

- Fees and business practices

- Self-referral

- Unacceptable business practices, bartering, and receiving gifts

- Termination and referral

SECTION B. CONFIDENTIALITY AND PRIVACY

Counselors recognize that trust is a cornerstone of the counseling relationship. This section provides details in the following areas:

- Respecting client rights

- Multicultural diversity considerations

- Explanation of limitations and exceptions

- Serious and foreseeable harm and legal requirements

- Confidentiality regarding end-of-life decisions

- Contagious, life-threatening diseases.

- Court-ordered disclosure

- Minimal disclosure and release, sharing and transmission of information

- Subordinates and interdisciplinary teams

- Confidential settings

- Third-party payers

- Deceased clients

- Groups and families

- Clients lacking capacity to give informed

- Parents and legal guardians

- Records and documentation

- Permission to record and observe

- Client access, assistance with records

- Storage and disposal after termination

- Case consultation, privacy, and disclosure.

When addressing a client's HIV status, counselors may need to determine if they are permitted to disclose that a client is HIV-positive, especially if the client confides that unsafe sexual activity has occurred. Standard B.2.b of the ACA Code of Ethics addresses contagious, life-threatening diseases as follows:

- 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.

Additionally, counselors must refer to state laws regarding disclosure: Some states allow counselors to disclose HIV-positive statuses to identifiable third parties, although the majority may assign this responsibility to medical professionals.

SECTION C. PROFESSIONAL RESPONSIBILITY

Counselors aspire to open, honest, and accurate communication when dealing with the public and other professionals. The following topics are covered in detail in the code:

- Knowledge and compliance with standards

- Professional competence and boundaries

- New specialty areas of practice and qualifications for employment

- Monitoring effectiveness

- Consultations on ethical obligations

- Continuing education

- Impairment, counselor incapacitation, death, retirement, or termination of practice

- Advertising, soliciting clients, testimonials, or products

- Recruiting through employment

- Professional qualifications, credentials, educational degrees, accreditation status and professional membership

- Public responsibility

- Reports to third parties

- Media presentations

SECTION D. RELATIONSHIPS WITH OTHER PROFESSIONALS

Counselors develop positive working relationships and systems of communication with colleagues to enhance services to clients. This section discusses the following components:

- Relationships with colleagues, employers, and employees

- Different approaches

- Interdisciplinary teamwork

- Establishing professional and ethical obligations and confidentiality

- Personnel selection and assignment

- Employer policies

- Protection from punitive action

- Provision of consultation services and competency

- Informed consent in formal consultation

- Contributing to the public good (pro bono publico)

SECTION E. EVALUATION, ASSESSMENT, AND INTERPRETATION

Counselors promote the well-being of individual clients or groups of clients by developing and using appropriate educational, mental health, psychological, and career assessments.

- Assessment services and security, scoring, interpretation, and reporting results;

- Competence to use and interpret assessment instruments;

- Informed consent in assessment;

- Release of data to qualified personnel;

- Diagnosis of mental disorders;

- Referral information;

- Technological administration;

- Historical and social prejudices in the diagnosis of pathology;

- Multicultural issues and diversity in assessment;

- Forensic evaluation for legal proceedings; and

- Avoid potentially harmful relationships.

SECTION F. SUPERVISION, TRAINING, AND TEACHING

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. The code contains details on the following components:

- Counselor supervision and client welfare

- Supervisor and student responsibilities

- Counselor supervision competence

- Emergencies and absences

- Standards for supervisees

- Termination of the supervisory relationship

- Supervisory relationship and student welfare

- Counseling supervision evaluation, remediation, and endorsement

- Responsibilities of counselor educators

- Evaluation and remediation

- Multicultural/diversity competence in counselor education and training programs

SECTION G. RESEARCH AND PUBLICATION

Counselors who conduct research are encouraged to contribute to the knowledge base of the profession and promote understanding of conditions that will lead to a healthy and just society.

- Research responsibilities

- Roles and relationships between counselor educators and students

- Rights of research participants

- Student/supervisee participation

- Client participation

- Confidentiality of information

- Informing sponsors

- Research records custodian

- Managing and maintaining boundaries

- Reporting results

- Replication studies, publications, and presentations

- Student research

- Professional review

SECTION H. DISTANCE COUNSELING, TECHNOLOGY, AND SOCIAL MEDIA

Counselors understand that the profession of counseling may no longer be limited to face-to-face interactions. They understand the evolving nature of the profession with regard to distance counseling, technology, and social media and how resources may be used to better serve their clients. Counselors understand concerns related to the use of distance counseling, technology, and social media and make every attempt to protect confidentiality and meet legal and ethical requirements for the use of such resources.

- Knowledge and legal considerations

- Laws and statutes

- Informed consent, security, and disclosure

- Confidentiality maintained by the counselor

- Acknowledgment of limitations

- Client verification

- Distance counseling relationship

- Benefits and limitations

- Professional boundaries in distance

- Effectiveness of services

- Access

- Communication differences in electronic media

- Records and web maintenance

- Client rights

- Electronic links

- Multicultural and disability considerations

- Social media

- Virtual professional presence

- Social media as part of informed consent

- Client virtual presence

- Use of public social media

SECTION I. RESOLVING ETHICAL ISSUES

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 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 [10]. This section includes details in the following categories:

- Standards and the law

- Ethical decision-making

- Conflicts between ethics and laws

- Suspected violations

- Informal resolution

- Reporting ethical violations

- Consultation

- Organizational conflicts

- Unwarranted complaints

- Unfair discrimination against complainants and respondents

- Cooperation with ethics committees

THE ACA POLICIES AND PROCEDURES FOR PROCESSING COMPLAINTS OF ETHICAL VIOLATIONS

The ACA Governing Council approved these policies and procedures in 2005, and they were revised July 31, 2020. The ACA's directives for processing complaints of alleged violations, and resolving an ethical complaint, are detailed and extensive. This course includes a summary as follows, and the complete ACA policies and procedures should be downloaded and reviewed at https://www.counseling.org/docs/default-source/bylaws-and-policies/aca-policies-procedures-9-2022.pdf.

General

- The American Counseling Association, hereafter referred to as the "Association" or "ACA," is dedicated to promoting the professional development of counselors, advocating for the profession, and ensuring ethical, culturally inclusive practices that protect those using counseling services.

- The Association, in furthering its objectives, administers the ACA Code of Ethics, hereafter referred to as the "ACA Code," which has been approved by the ACA Governing Council.

- This ACA Policies and Procedures for Processing Complaints of Ethical Violations (the "Procedures") document provides guidance and procedures for handling and resolving ethics complaints brought against Charged Members under the ACA Code. It specifies the procedures for processing complaints and for the work of the ACA Ethics Committee ("Committee"). It sets forth: the standards and options for judging the ethical conduct of members, and as appropriate, imposing sanctions, and identifies appeals procedures.

Jurisdiction

To be accepted, an ethics complaint must pertain to a "Charged Member," meaning an individual who:

a. Is a current member of the American Counseling Association; or

b. Was an ACA member when the alleged violations occurred.

Eligibility to File Complaints

The following individuals may file complaints (i.e., serve as "Complainants"):

- Any individual(s) who have reason to believe that an ACA member has violated the ACA Code.

- The Co-Chair(s) of the Committee on behalf of the ACA membership when the Co-Chair has reason to believe through information received by or otherwise available to the Committee that an ACA member may have violated the ACA Code.

Ethics Committee Members

- The Ethics Committee is a standing committee of the Association with 9 appointed members, which includes 2 Co-Chairs.

- Generally, three Committee members are appointed each year by the President-Elect for 3-year terms, subject to confirmation by the ACA Governing Council.

Timelines

- The timelines set forth in these standards are guidelines only and have been established to provide a reasonable time framework for processing complaints.

- The Committee may consider complaints received less than five years after the alleged conduct either occurred or was discovered by the complainant.

- The Co-Chairs have the authority, in their discretion when justified by circumstances, to grant extensions of deadlines upon request by a Complainant or Charged Member.

- The Co-Chairs have the latitude to adjust procedures for good cause as they deem necessary to protect any party, participant, or subject of a complaint.

- Adjudication of the complaint shall correspond with the version of the ACA Code of Ethics in effect at the time of the alleged violation.

Nature of Communication

- Communications and complaints must be legibly printed or typed.

- Correspondence related to ethical complaints may be provided by hard copy via certified means or electronic means, but complaints and Committee decisions must be signed.

- Correspondence related to ethical complaints are to be addressed to the ACA Staff Liaison at the ACA Headquarters and marked "confidential," if provided by certified mail.

Intake and Finalizing of Submitted Complaints

- Complainants are required to contact the ACA Staff Liaison prior to filing a formal complaint.

- Complainants must identify who the complaint is about so that the ACA Staff Liaison can determine whether the person is subject to the jurisdiction of the ACA Ethics Code.

- Complainants are sent a copy of these Policies and Procedures, the ACA Ethics Complaint Form, and a copy of the ACA Code. They are told that they will have to provide authorization for the release of information to and from the Charged Member about the complaint, in order for the complaint filing to proceed (as this is not an anonymous process).

- If there is jurisdiction, the Complainant describes the reason for the complaint to the ACA Staff Liaison, who sends a formal Ethics Complaint form for the Complainant to identify: (a) the name and last known address of the Complainant, the Charged Member, and anyone who has knowledge of the facts involved; and (b) an explanation of how the code was violated.

- The Complainant then works with the ACA Staff Liaison in order to accurately identify the ACA Ethics Code sections that apply, as necessary, to identify any evidence and witnesses the Complainant wants to offer. To then finalize the complaint, steps will be taken in setting forth into separate charges according to the sections of the ACA Ethics Code that were allegedly violated.

- The Complainant maintains the right to approve or make any or none of the suggested changes made by the ACA Staff Liaison.

- Once the Complainant is satisfied with the contents of the completed formal complaint, Complainants must sign the complaint to begin the formal adjudication process.

- If the ACA Staff Liaison is unable to obtain a response from potential complainants for 45 business days after repeated attempts, those are treated as incomplete cases and are reported to the Co-Chairs and subsequently to the Committee as administratively dismissed but can be refiled by the Complainant in accordance with this policy.

Sanctions to address ethical violations may include letters of reprimand, suspension, or revocation of membership in the association. Documentation from the complaint process outlined previously may be obtained through subpoena and become part of a legal action against the counselor. If a violation of state or federal law occurs, criminal sanctions may result if convicted in a court of law. This may result in fines, suspension, or revocation of the license to practice, and/or criminal adjudication depending on the offense.

8. SUMMARY OF THE AAMFT CODE OF ETHICS

Counseling and therapy practice emphasize evidence-based interventions and methods of service, often using integrated therapies tailored to the needs of a specific set of clients. The practice of marriage and family therapy continues to be influenced by societal and cultural changes as well as politics and economics, such as the Affordable Care Act, managed care, and the increasing number elderly and disabled citizens who rely on Medicaid or Medicare. The trend toward research-based models that integrate several approaches may be more effective for families than one specific approach. Therapy that involves an integrated model for intervention requires the therapist to match the therapeutic approach to the specific members of the family. This process increases the number of interventions for the therapist to consider and may make the decisions and judgments more complex and dynamic as the therapy progresses. The complexity of group therapy increases the ethical considerations for confidentiality and informed consent.

Multicultural, generational, and developmental factors, as well as lifestyles, belief sets, sexual orientations, race, ethnicity, gender, religious affiliation, group affiliation, and intrafamilial issues impact the group approach to marriage and family therapy. The nature of the group therapy process involves an infinite number of variables and ethical issues to consider.

Complicating this process further is the growing application of technology for distance therapy with multiple clients, jurisdictional requirements, licensing restraints, state and federal laws, and organizational mandates that must be reviewed if services are delivered across state lines.

The following section is taken from the American Association for Marriage and Family Therapy's (AAMFT) Code of Ethics and is only a summary of the major components [11]. The entire code should be reviewed to ensure best ethical practice guidelines are followed.

PREAMBLE

The Board of Directors of the American Association for Marriage and Family Therapy (AAMFT) hereby promulgates, pursuant to Article 2, Section 2.01.3 of the Association's bylaws, the Revised AAMFT Code of Ethics, effective January 1, 2015.

HONORING PUBLIC TRUST

The AAMFT strives to honor the public trust in marriage and family therapists by setting standards for ethical practice as described in this code. The ethical standards define professional expectations and are enforced by the AAMFT Ethics Committee.

Commitment to Service, Advocacy, and Public Participation

Marriage and family therapists are defined by their dedication to professional and ethical excellence, which includes the following components:

- Commitment to service, advocacy, and public participation.

- Participation in activities that contribute to a better community and society, regardless of financial return.

- Concern with developing laws and regulations pertaining to marriage and family therapy and altering laws and regulations that are not in the public interest.

- Professional competence in these areas is essential to the character of the field, and the well-being of clients and their communities.

SEEKING CONSULTATION

The standards are not exhaustive and marriage and family therapists uncertain about the ethics of a particular course of action are encouraged to seek counsel from consultants, attorneys, supervisors, colleagues, or other appropriate authorities.

ETHICAL DECISION-MAKING

- Therapists must consider the AAMFT Code of Ethics and applicable laws and regulations.

- If the AAMFT Code of Ethics prescribes a standard higher than the law, therapists must meet the higher standard of the AAMFT.

- Therapists must comply with the mandates of law, maintain their commitment to the AAMFT Code of Ethics and try to resolve any conflict between the code, the law, and the mandates of their employment organization.

- The AAMFT supports legal mandates for reporting of alleged unethical conduct.

- Therapists must remain accountable to the AAMFT Code of Ethics at all times.

BINDING EXPECTATIONS

- The AAMFT Code of Ethics is binding on members of AAMFT.

- AAMFT members have an obligation to be familiar with the AAMFT Code of Ethics and its application to their professional services.

- The process for filing, investigating, and resolving complaints of unethical conduct is described in the current AAMFT Procedures for Handling Ethical Matters.

ASPIRATIONAL CORE VALUES

These core values are aspirational in nature and are distinct from ethical standards.

- Acceptance, appreciation, and inclusion of a diverse membership.

- Excellence in training, knowledge, and expertise in systemic and relational therapies.

- Excellence in service to members.

- Diversity, equity, and excellence in clinical practice, research, education, and administration.

- Integrity evidenced by a high threshold of ethical and honest behavior within Association governance and by members.

- Innovation and the advancement of knowledge of systemic and relational therapies.

ETHICAL STANDARDS

Ethical standards are rules of practice upon which the marriage and family therapist is obliged and judged.

Standard I. Responsibility to Clients

Marriage and family therapists advance the welfare of families and individuals and make reasonable efforts to find the appropriate balance between conflicting goals within the family system. This standard includes a discussion of the following categories:

- Non-discrimination;

- Informed consent;

- Multiple relationships;

- Sexual intimacy with current and former clients is prohibited;

- Reports of unethical conduct;

- Abuse of the therapeutic relationship;

- Client autonomy in decision-making;

- Relationship beneficial to the client;

- Referrals;

- Non-abandonment;

- Written consent to record; and

- Relationships with third parties.

Standard II. Confidentiality

Marriage and family therapists have unique confidentiality concerns because the client in a therapeutic relationship may be more than one person. Therapists respect and guard the confidences of each individual client. This standard defines the following components:

- Disclosing limits of confidentiality;

- Written authorization to release client information;

- Client access to records;

- Confidentiality in non-clinical activities;

- Protection of records;

- Preparation for practice changes; and

- Confidentiality in consultations.

Standard III. Professional Competency and Integrity

Marriage and family therapists maintain high standards of professional competence and integrity.

- Maintenance of competency;

- Knowledge of regulatory standards;

- Seeking assistance;

- Conflicts of interest;

- Maintenance of records;

- Development of new skills;

- Harassment;

- Exploitation;

- Gifts;

- Scope of competence;

- Public statements; and

- Professional misconduct.

Therapists may be in violation of this Code and subject to termination of membership or other action if they are:

- Convicted of a felony;

- Convicted of a misdemeanor related to their qualifications or functions;

- Engaged in conduct leading to conviction of a felony, or misdemeanor related to their qualifications or functions;

- Expelled or disciplined by other professional organizations;

- Disciplined by regulatory bodies or have their licenses or certificates suspended or revoked;

- Practicing marriage and family therapy while no longer competent due to physical or mental impairment, abuse of alcohol or other substances;

- Not cooperating with the association throughout proceedings regarding a complaint.

Standard IV. Responsibility to Students and Supervisees

Marriage and family therapists do not exploit the trust and dependency of students and supervisees.

- Exploitation;

- Therapy with students or supervisees;

- Sexual intimacy with students or supervisees is prohibited;

- Oversight of supervisee competence and professionalism;

- Confidentiality with supervisees; and

- Payment for supervision.

Standard V. Research and Publication

Marriage and family therapists do not exploit the trust and dependency of students and supervisees. This standard includes information on the following areas:

- Therapists respect the dignity and protect research participants, are aware of applicable laws, regulations, and standards of research;

- Institutional approval;

- Informed consent to research;

- Right to decline or withdraw participation;

- Confidentiality of research data;

- Publication;

- Authorship of student work;

- Plagiarism; and

- Accuracy in publication.

Standard VI. Technology-Assisted Professional Services

This standard addresses basic ethical requirements of offering therapy, supervision, and related professional services using electronic means.

- Technology assisted services;

- Consent to treat or supervise;

- Clients and supervisees must be made aware of the risks and responsibilities associated with technology-assisted services;

- Confidentiality and professional responsibilities;

- Technology and documentation;

- Location of services and practice; and

- Training and use of current technology.

Standard VII. Professional Evaluations

Marriage and family therapists aspire to the highest of standards in providing testimony in various contexts within the legal system.

- Performance of forensic services;

- Testimony in legal proceedings;

- Competence;

- Informed consent;

- Avoiding conflicts and dual roles;

- Separation of custody evaluation from therapy;

- Professional opinions;

- Changes in service; and

- Familiarity with rules.

Standard VIII. Financial Arrangements

Marriage and family therapists make financial arrangements with clients, third-party payers, and supervisees that are reasonably understandable and conform to accepted professional practices.

- Financial integrity;

- Disclosure of financial policies;

- Notice of payment recovery procedures;

- Truthful representation of services;

- Bartering;

- Withholding records for non-payment.

Standard IX. Advertising

Marriage and family therapists engage in appropriate informational activities, including those that enable the public, referral sources, or others to choose professional services on an informed basis.

- Accurate professional representation;

- Promotional materials;

- Professional affiliations and identification;

- Educational credentials;

- Employee or supervisee qualifications;

- Specialization; and

- Correction of misinformation.

All practitioners must study the entire code, which is available online on the AAMFT website at https://aamft.org/Legal_Ethics/Code_of_Ethics.aspx.

A SUMMARY OF THE AAMFT ETHICS COMPLAINT PROCESS

The AAMFT Ethics Committee, hereafter the Committee, investigates ethical complaints made against AAMFT members as described in the AAMFT Procedures for Handling Ethical Matters [18]:

Initiating a Complaint

- Complaints must be initiated by someone with personal knowledge of the alleged behavior or by someone in a position to supply relevant reliable testimony or evidence on the subject.

Preliminary Review of a Complaint

- AAMFT staff review the complaint materials for jurisdiction and completeness.

- Complainants must waive therapist-client confidentiality and permit AAMFT to use their name and forward a copy of the allegations to the member, if charged with a violation of the AAMFT Code of Ethics.

Determining Whether to Open a Case

- The Chair, in consultation with AAMFT's legal and ethics staff, determines whether the allegations, if factual, constitute a violation of the Code.

Consideration by the Full Committee

- The case will be submitted to the full Committee at its next meeting.

- If the Committee determines that a violation has occurred, they will recommend an appropriate sanction based on the severity of the violation.

Appeal to Judicial Committee

- The member will be notified and given the opportunity to appeal the Committee's findings and recommendations to the Judicial Committee.

- The member must provide a written request for a hearing within 15 days after receiving notice of the Ethics Committee's findings and recommendations. If the member does not appeal within the allotted time, the Ethics Committee's decision becomes final.

Manner of Judicial Committee Hearing

- The member may choose either an in-person hearing or a written review process. In-person hearings are typically held in Alexandria, VA before a Judicial Committee Panel.

- The Judicial Committee panel is required to render its decision within 30 days of the hearing. If the member requests a written review process, the member and the Ethics Committee will provide written submissions to a Judicial Committee Panel, which will review the materials and render its decision within 30 days of the review.

Appeal to AAMFT Board of Directors

- A member may make a final appeal to the AAMFT Board of Directors if the member believes that a procedural violation substantially impaired the member's ability to defend against the charges.

- The Board will review the appeal at its next scheduled meeting and will render a decision within 30 days of the meeting.

Confidentiality of Ethics Matters

- All information obtained by the Ethics Committee and all case proceedings are confidential with limited exceptions.

- At this time, termination of membership with a permanent bar to readmission is the only sanction that is routinely published in AAMFT's Family Therapy Magazine. In cases that involve a finding of no violation(s) and cases that involve lesser sanctions, typically the only notification is to the member and complainant. The Procedures permit AAMFT to provide a limited report on an ethics case to a regulatory body or another professional association upon request. If such a report is provided, a copy of the report is sent to the member.

Professional association ethics committees, such as the one described previously, as well as any peer review, consultant, or decision-making team, can be viewed as a "third party." When disclosing confidential material, the guidelines from the code and HIPAA rules regarding confidentiality and disclosure to third parties are applicable in these situations. Counselors, therapists, and other members of professional associations related to the case have a duty to respond as required by the ethics committee, licensing board, courts, or other regulatory agencies; however, they must always follow basic procedures for confidentiality, privacy, and informed consent.

If the ethics committee asks for confidential information, or for a statement from the practitioner in reference to a client, the practitioner should ask for a copy of the consent or waiver of confidentiality from the complainant before responding to the request. The ethics committee cannot conduct a review or require a response concerning client record without signed waiver of consent from the client, and that document serves as a waiver of the practitioner's duty to maintain confidentiality.

A complaint packet may be obtained via email to ethics@aamft.org. Contact AAMFT by phone at 703-838-9808. If a therapist needs assistance or information regarding an ethical question, they can consult with an AAMFT Ethics Case Manager at ethics@aamft.org or 703-253-0471. Members may obtain a formal ethical opinion from the AAMFT Ethics Committee [18].

9. ETHICAL DECISION-MAKING

Ethical decision-making is a process that involves the informed judgment of the therapist or counselor. There are many situations where simple answers are not available for ethical questions, or where the complexity of the situation crosses several standards with different possible interpretations. Ethics related to diversity, discrimination, privacy, confidentiality, privilege, informed consent, dual relationships, and duty to warn may overlap as these are all areas where ethical violations may occur. The practitioner should consider how the issues would be judged in a peer review process where ethical standards would be applied. In all cases, the practitioner must review values, principles, and ethical standards relevant to the situation. They should have thorough knowledge of ethics codes for their organization or employer, and applicable state and federal statutes.

Again, even when codes do not contain specific guidelines covering a particular issue, the practitioner is responsible for making correct ethical decisions. If practitioners are faced with ethical dilemmas that are difficult to resolve, they are expected to engage in an ethical decision-making process that aligns with ethics codes. This process may involve consulting outside resources and collaboration with other professionals. Reasonable differences of opinion may exist among individual counselors or therapists in respect to values, principles, directives, and how standards would be applied when they conflict.

There is no specific ethical decision-making model identified to be most effective. Professionals should be familiar with evidence-based models of decision-making that involve a professional team and will stand up to public scrutiny. In the absence of a clear answer to the particular ethical issue, or when conflicts arise among the team concerning interpretation, the team must implement an ethical decision-making model. Through the decision-making processes counselors and therapists can make ethical decisions for the welfare of clients.

Most decision-making models include the following components in some form:

- Identify the problem and ethical issue(s).

- Consult relevant professional association and organizational codes of ethics for guidance.

- Review state and federal statutes that regulate ethical practice.

- Consult professionals from several sources to obtain multiple, objective perspectives.

- Identify relevant client communications or concerns.

- Brainstorm potential strategy options, considering all suggestions and opinions.

- Discuss potential outcomes or consequences for each option.

- Develop the action plan with roles, responsibilities, and timelines for stakeholders.

- Be sure the plan aligns with all ethics codes, legal statutes, and regulations.

- Implement the plan and assess progress.

- Revise the plan as needed.

After the team has agreed on a course of action and a plan to move forward, they should review the plan to see if it presents any new considerations involving ethics and client welfare. Stadler suggests applying three simple tests to the course of action to be sure it is appropriate [19]. These tests are referenced in current ACA guidelines [20].

The three tests are:

- Justice: This test assesses fairness by asking if the decision and treatment would be extended to other clients in similar situations.

- Publicity: Would the practitioner allow the ethical decision or course of action to be reported by the press?

- Universality: Could they recommend the same decision and course of action to another counselor in the same situation?

If the team believes that they can meet these three tests, they should feel confident that their decision is ethically sound. The practitioner can then move forward with the client. When one or more of the tests cannot be answered in the affirmative, the team should analyze the reasons why the decision has failed in that test. They can then revisit the decision-making process to review the part of the test that has not been met and identify the part of the plan that is not just, would not meet public scrutiny, or lacked universality, for example.

If the course of action presents new ethical issues, the counselor or team will go back to the beginning and reevaluate each step of the process to address that issue.

Practitioners should periodically apply formative assessment methods to monitor and judge the effectiveness of their plan as they progress through sessions. This is especially important when implementing a new decision or a plan to resolve an ethical issue. The evaluation may be informal; it should answer the following questions:

- Did the course of action, based on the decision, result in the anticipated effect?

- Did positive consequences result from the decision or course of action?

- Was the decision or course of action aligned with the plan of service?

- Was client assessment culture fair?

- Did the decision or course of action promote the client's goals?

- Is the course of action in the best interest of client's welfare?

- Is the client positive and participating in the course of action?

- Is there anything that should change in method or practice to be more effective for the client?

When making any practice decisions about a counseling plan, with or without an identified ethical issue, it is important to follow an organized, thorough, collaborative process for decision making. The process must be grounded in skills of professional competence and knowledge of client needs that will inform the appropriate method(s) of practice. Applying the decision-making process, based on these skills, can inform the appropriate counseling method and plan.

Clients should be included whenever possible in decisions about their counseling and therapy plan. They should be informed about the process and encouraged to be active participants in all sessions. The following the components should be part of the planning and delivery process with clients:

- Discuss with the client the problem or dilemma that prompted them to seek assistance.

- Identify potential barriers to progress including any language or cultural considerations. Use an objective translator as needed, not a family member or friend.

- Discuss assessment measures and explain the rationale for use prior to conducting them. Always explain the results of assessment and how they inform delivery of services.

- Include the client in the decision-making process, when possible, to build ownership and autonomy skills.

- Identify and discuss various courses of action and consequences of each.

- Form a plan and set goals with the client, check for understanding and agreement through the informed consent process.

- Implement the course of action with clear objectives and timelines for progress.

- Provide resources and to support the client in reaching their goal.

- Review the plan, assess progress, and revise the plan as necessary. Any changes to the plan must be reflected in the informed consent document.

- Seek consultation from more than one source to gain multiple perspectives.

Counselors and therapists should be vigilant in their practice to identify potential ethical concerns and areas that require consultation, review effectiveness of the service, and employ a decision-making model when warranted. This may include the practitioner's self-evaluation to ensure they are maintaining clarity, objectivity, competence, and appropriate boundaries, free of bias, to prevent ethical violations in practice.

10. EVALUATING ETHICAL PRACTICE

How can counselors or therapists self-monitor to know if they are practicing in an ethical manner? They may not encounter an ethical issue in their practice that necessitates the need for a decision-making team process but want assurances that they are following the ethics codes and practicing ethically.

Van Hoose and Paradise suggested a process for judging professional practice against ethical standards [21]. Their work has stood the test of time and serves as the basis for significant research on ethical practice today as referenced in current ACA publications [20]. The counselor or therapist is probably acting ethically by evidence that they:

- Maintained personal and professional honesty.

- Can demonstrate they have acted in the best interest of the client's welfare as their priority.

- Acted without malice or personal gain.

- Consulted with other professionals in the field.

- Can demonstrate fair and just actions.

- Would be comfortable with a peer review process to evaluate their practice.

- Could publicly report and defend their action.

- Can support their actions based on the best practice of the profession.

- Can show documentation of appropriate informed consent procedures and record keeping.

- Maintained client confidentiality following ethical and legal requirements.

- Employed a sound decision making model.

- Consistently followed their code of ethics.

It is also important for counselors and therapists to consider the following components in, addition to the foregoing, when assessing their practice related to ethics:

- Issues related to the specific client including levels of comprehension, informed consent, participation, cultural factors, goal achievement, and satisfaction of the client through the service delivery.

- Appropriate formative and summative assessment of client needs and progress to inform and guide the plan of service.

- Counselor bias, emotions, personality, and other factors specific to the counselor that may have impacted their practice during the service delivery.

- The dynamics of the counselor/client relationship.

- Review of evaluations, goal achievement, and client satisfaction with the outcomes and success of the service plan.

11. SERVICE DELIVERY THROUGH TECHNOLOGY AND SOCIAL MEDIA

The major area of revision in the ethics codes involves the use of technology in delivering counseling and therapy services. Technology has led to many complicated ethical issues in mental health service delivery in and beyond the office setting. Virtually every office and agency have sophisticated databases that contain an infinite amount of sensitive personal information. These systems collect, file, preserve, search, share, tabulate, track, transmit, and store information at incredible speeds with no geographic boundaries. A review of the literature reveals that even before the Internet, mental health professionals in the 1960s expressed concerns about the potential risks to individual privacy and confidentiality inherent in computerized data systems.

Computer networks are used to manage records concerning assessment and evaluation, treatment, billing/payments, and communications between therapists and their clients. Many practitioners deliver services via real-time distance technology. The ever-expanding use of new technology systems, such as mobile media devices, computers, e-mail, faxes, cell phones, video conferencing, and social media may lead to breaches in confidentiality and potential ethical dilemmas.

Technology in counseling settings requires ongoing security considerations to avoid new risks for unintentional confidentiality breaches. Counselors must carefully review their association's and employing agency's ethical guidelines prior to implementing technology-based therapy or counseling.

Technology is continually changing, increasingly varied, complex, and in demand by many clients and practitioners who prefer audio/video conferencing with increased speed capacities for information transmitting, and storing, over traditional methods of service. Skype, instant messaging, face time, e-mail, social media, mobile media using iPad and iPhone, and other technology methods for delivering distance practice expand the access to counseling and may make it more convenient for the client and professional.

Many clients are more comfortable with online distance services than with traditional, in-person counseling because they provide more anonymity and privacy, avoiding the stigma of going to an office for services. These individuals may access and continue online counseling when they would not have done so in a face-to-face setting, which may increase that number of clients receiving services.

Technology presents many challenges to the counselor or therapist, including the following:

- Counselors, therapists, staff, and clients may lack competence in using technology. Training must take place prior to service delivery requiring additional time.

- Frequent system failures may block or interrupt services altogether.

- During a time of crisis, it can be stressful and dangerous if a connection is lost, or service is unavailable. This may cause the counselor to lose all contact with the client.

- The practitioner may receive multiple messages from different clients simultaneously.

- Guidelines and boundaries must be established concerning times, length, and frequency of contact between the practitioner and client.

- Communicating at a distance, especially on devices that do not have a video component, may impact the client's authentic response and interfere with relationship development between practitioner and client.

- Third parties may hear or see interactions, which erodes privacy and privilege.

All of the professional counseling and therapy associations in this course detail their ethical and legal obligation to keep records secure and have developed guidelines specific to technology, social media, and distance service delivery.

In addition to the ethics codes, practitioners must comply with the HIPAA Privacy Rule. This rule dictates the "who, what, when, where, why, and how" of storage, transmission, disclosure, right of privacy, and the duty to safeguard confidential information under penalty of federal law.

Distance technology includes other challenges when compared to conventional therapy. The professional may have more difficulty assessing body language including facial expressions, gestures, voice quality, tone, mood, and other subtle cues that do not translate well, if at all, depending on the technology being used. The practitioner and the client should discuss and agree on a plan to evaluate the therapy's effectiveness in the treatment plan. Either party may determine that long-distance service may be terminated or altered if not effective or if the welfare of the client is at risk. Service delivery may include a combination of distance and face-to-face methods.

Ethical concerns and potential risks associated with technology cannot be completely avoided in practice today. The ethical codes, state and federal regulations, and case studies described in this course, serve as a starting point for counselors and therapists to deepen their understanding of ethical use of technology and social media in their specific area of practice. All practitioners must review their state statutes, employer guidelines, revised association codes, and HIPAA requirements specific to technology use and distance services. Remember that distance services across state lines mandates compliance with all state statutes for ethical practice and licensure requirements for all jurisdictions.

TELETHERAPY AND TELESUPERVISION GUIDELINES II

In addition to the guidelines previously covered from the NBCC, ACA, and AAMFT, one of the most current and detailed set of teletherapy guidelines, Teletherapy and Telesupervision Guidelines II, was published by the Association of Marital and Family Therapy Regulatory Boards (AMFTRB) in 2021. These guidelines incorporate reference information from research in the fields of counseling, social work, marriage and family therapy, and the HIPAA Privacy Rule.

Due to the length of the guidelines, they will be summarized here and should be viewed in their entirety at https://amftrb.org/wp-content/uploads/2021/09/AMFTRB-Teletherapy-Guildelines-9-21.pdf [22,23,24].

Teletherapy and Telesupervision Glossary

- Asynchronous: Communication is not synchronized or occurring simultaneously.

- Electronic communication: Using Web sites, cell phones, e-mail, texting, online social networking, video, or other digital methods and technology to send and receive messages, or to post information so that it can be retrieved by others or used later.

- HIPAA compliant: The Health Insurance Portability and Accountability Act (HIPAA), sets the standard for protecting sensitive patient data. Any company that deals with protected health information (PHI) must ensure that all the required physical, network, and process security measures are in place and followed. This includes covered entities (CE), anyone who provides treatment, payment and operations in healthcare, and business associates (BA), anyone with access to patient information and provides support in treatment, payment, or operations. Subcontractors, or business associates of business associates, must also comply.

- HITECH: Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 addresses the privacy and security concerns associated with the electronic transmission of health information through several provisions that strengthen the civil and criminal enforcement of the HIPAA rules in the revised HITECH Act Enforcement of Interim Final Rule, 2016.

- Synchronous: Communication which occurs simultaneously in real time.

- Telesupervision: Refers to the practice of clinical supervision through synchronous or asynchronous two-way electronic communication including but not limited to telephone, videoconferencing, email, text, and instant messaging, for the purposes of developing trainee marital and family therapists, evaluating supervisee performance, ensuring rigorous legal and ethical standards within the bounds of licensure, and as a means for improving the profession of marital and family therapy.

- Teletherapy/technology-assisted services: Refers to the practice of marriage and family therapy of diagnosis, evaluation, consultation, intervention, and treatment of behavioral, social, interpersonal disorders through synchronous or asynchronous two-way electronic communication including but not limited to telephone, videoconferencing, email, text, and instant messaging.

AMFTRB Guidelines for the Regulation of Teletherapy Practice

1. Adhering to Laws and Rules in Each Jurisdiction

1. Therapists of one state who are providing marriage and family therapy to clients in another state must comply with the laws and rules of both jurisdictions.

2. Treatment, consultation, and supervision utilizing technology-assisted services will be held to the same standards of appropriate practice as those in traditional (in person) settings.

2. Training and Continuing Competency Requirements

1. Therapists must adhere to their jurisdiction's training requirements for teletherapy prior to initiating teletherapy.

2. Therapists must review their discipline's definitions of "competence" prior to initiating teletherapy to ensure that they maintain recommended technical and clinical competence for the delivery of care in this manner.

3. Therapists must have completed basic education and training in suicide prevention.

4. Therapists must assume responsibility to continually assess both their professional and technical competence when providing teletherapy services.

5. Therapists must demonstrate competence in a variety of ways (e.g., encryption data, HIPAA compliant connections). Areas to be covered in training must include, but not be limited to, the following seven telebehavioral health competency domains as researched and identified by Maheu et al. and Hertlein et al. [25,26]:

1. Clinical Evaluation and Care

2. Virtual Environment and Telepresence

3. Technology

4. Legal and Regulatory Issues

5. Evidence-Based and Ethical Practice

6. Mobile Health Technologies Including Applications

7. Telepractice Development

6. Therapists conducting teletherapy must demonstrate continuing competency in each license renewal cycle in their jurisdiction.

3. Diversity, Bias, and Cultural Competency

1. Therapists must be aware of and respect clients from diverse backgrounds and cultures and have basic clinical competency skills providing treatment with these populations.

2. Therapists must be aware of, recognize, and respect the potential limitations of teletherapy for diverse cultural populations.

3. Therapists must remain aware of their own potential projections, assumptions, and biases.

4. Therapists must select and develop appropriate online methods, skills, and techniques that are attuned to their clients' cultural, bicultural, or marginalized experiences in their environments.

5. Therapists must know the strengths and limitations of current electronic modalities, process, and practice models, to provide services that are applicable and relevant to the needs of culturally and geographically diverse clients and of members of vulnerable populations.

6. Therapists must be cognizant of the specific issues that may arise with diverse populations when providing teletherapy and make appropriate arrangements to address those concerns (e.g., language or cultural issues; cognitive, physical, or sensory skills or impairments; or age may impact assessment).

7. Therapists must recognize that sensory deficits, especially visual and auditory, can affect the ability to interact over a videoconference connection. Therapists must consider the use of technologies that can help with visual or auditory deficit. Techniques should be appropriate for a client who may be cognitively impaired or find it difficult to adapt to the technology.

4. Establishing Consent for Teletherapy Treatment

1. A therapist who engages in teletherapy services must provide the client with their license number and information on how to contact the board by telephone, electronic communication, or mail, and must adhere to all other rules and regulations in the relevant jurisdiction(s). The consent must include all information contained in the consent process for in-person care including discussion of the structure and timing of services, record keeping, scheduling, privacy, potential risks, confidentiality, mandatory reporting, and billing.

2. A clinical treatment relationship is clearly established when informed consent documentation is signed.

3. Therapists must communicate any risks and benefits of the teletherapy services to be offered to the client(s) and document such communication.

4. Screening for client technological capabilities is part of the initial intake processes. (e.g., This type of screening could be accomplished by asking clients to complete a brief questionnaire about their technical and cognitive capacities).

5. As appropriate teletherapy services must have accurate and transparent information about the website owner/operator, location, and contact information, including a domain name that accurately reflects the identity.

6. The therapist and/or client must use connection test tools (e.g., bandwidth test) to test the connection before starting their videoconferencing session to ensure the connection has sufficient quality to support the session.

5. Identity Verification of Client

1. Therapists must recognize the obligations, responsibilities, and client rights associated with establishing and maintaining a therapeutic relationship.

2. The therapist is responsible for assessing and documenting the client's appropriateness for teletherapy treatment.

3. It is the therapist's responsibility to document appropriate verification of the client's identity.

4. The therapist must take reasonable steps to verify the location and identity of the client(s) at the onset of each session before rendering therapy using teletherapy.

5. Therapists must develop written procedures for verifying the identity of clients, their current location, and their appropriateness and readiness to proceed at the beginning of each contact. Examples of verification means include the use of code words, phrases, or inquiries. For example, "is this a good time to proceed?"

6. Informed Consent: Availability of Professional to Client

1. The therapist must document the provision of informed consent in the record prior to the onset of therapy.

2. In addition to the usual and customary protocol of informed consent between therapist and client for in-person therapy the following issues, unique to the use of teletherapy, technology, and/or social media, must be addressed in the informed consent process:

1. Confidentiality and the limits to confidentiality in electronic communication

2. Teletherapy training and/or credentials, physical location of practice, and contact information

3. Licensure qualifications and information on reporting complaints to appropriate licensing bodies

4. Risks and benefits of engaging in the use of teletherapy, technology, and/or social media

5. Possibility of technology failure and alternate methods of service delivery

6. Process by which client information will be documented and stored

7. Anticipated response time and acceptable ways to contact the therapist

1. Agreed upon emergency procedures

2. Procedures for coordination of care with other professionals

3. Conditions under which teletherapy services may be terminated and a referral made to in-person care

8. Time zone differences

9. Cultural and/or language differences that may affect delivery of services

10. Possible denial of insurance benefits

11. Social media policy

12. Specific services provided

13. Pertinent legal rights and limitations governing practice across state lines or international boundaries, when appropriate

14. Information collected and any passive tracking mechanisms utilized.

3. The information must be provided in language that can be easily understood by the client. This is particularly important when discussing technical issues like encryption or the potential for technical failure.

4. Local, regional, and national laws regarding verbal or written consent must be followed. If written consent is required, electronic signatures may be used if they are allowed in the relevant jurisdiction.

5. Therapists may be offering teletherapy to individuals in different states at any one time, the therapists must meet each jurisdiction's regulations and rules related to informed consent and document that in the respective record(s). The therapist is responsible for knowing the correct informed consent forms for each applicable jurisdiction.

6. Therapists must provide clients clear mechanisms to:

1. Access, supplement, and amend client-provided personal health information (PHI)

2. Provide feedback regarding the site and the quality of information and services; and register complaints, including information regarding filing a complaint with the applicable state licensing board(s).

7. Working with Children

1. Therapists must determine if a client is a minor and, therefore, in need of parental/guardian consent. Before providing teletherapy services to a minor, the therapist must verify the identity of the parent, guardian, or other person consenting to the minor's treatment.

2. In cases where conservatorship, guardianship, or parental rights of the client have been modified by the court, therapists must obtain and review a written copy of the custody agreement or court order before the onset of treatment.

8. Acknowledgement of Limitations of Teletherapy

1. Therapists must:

1. Determine that teletherapy is appropriate for clients, considering clinical, relational, cultural, cognitive, intellectual, emotional, and physical needs

2. Inform clients of the potential risks and benefits associated with teletherapy

3. Ensure the security of the therapist's communication medium

4. Only commence teletherapy after appropriate education, training, or supervised experience using the relevant technology

2. Therapists are to advise clients in writing of the risks and of both the therapist's and clients' responsibilities for minimizing such risks.

3. Therapists must consider nonverbal and verbal communication cues and how these may affect the teletherapy process. Therapists must educate clients on how to prevent and address potential misunderstandings arising from the lack of visual cues and voice intonations when communicating electronically.

4. Therapists must recognize the members of the same family system may have different levels of competence and preference using technology. Therapists must acknowledge power dynamics when there are differing levels of technological competence within a family system.

5. Before therapists engage in providing teletherapy services, they must conduct an initial assessment to determine the appropriateness of the client(s) for teletherapy service. An assessment should include examination of the potential risks and benefits to provide teletherapy services for the client's particular needs, the multicultural and ethical issues that may arise, and a review of the most appropriate medium (e.g., video conference, text, email, etc.) or best options available for service delivery.

6. It is incumbent on the therapist to engage in a continual assessment of the client's appropriateness for teletherapy services throughout the duration of treatment.

9. Confidentiality of Communication

1. Therapists utilizing teletherapy must meet or exceed applicable federal and state legal requirements of health information privacy, including HIPAA (https://www.hhs.gov/hipaa/for-professionals/privacy/index.html) and HITECH (https://www.hhs.gov/hipaa/for-professionals/special-topics/hitech-act-enforcement-interim-final-rule/index.html and https://www.hipaajournal.com/new-hipaa-regulations).

2. Therapists must assess the remote environment in which services will be provided, to determine what impact there might be to the efficacy, privacy and/or safety of the proposed intervention offered via teletherapy.

3. Therapists must understand and inform their clients of the limits to confidentiality and risks to the possible access or disclosure of confidential data and information that may occur during service delivery, including the risks of access to electronic communications.

10. Professional Boundaries Regarding Virtual Presence

1. Reasonable expectations about contact between sessions must be discussed and verified with the client at the start of treatment. The client and therapist must discuss whether the provider will be available for contact between sessions and the conditions under which such contact is appropriate. The therapist must provide a specific time frame for expected response to a between session contact. This must also include a discussion of emergency and crisis management between sessions.

2. To facilitate the secure provision of information, therapists must provide in writing the appropriate ways to contact them.

3. Therapists are discouraged from knowingly engaging in a personal virtual relationship with clients (e.g., through social and other media). Therapists must document any known virtual relationships with clients/associated with clients.

4. Therapists must discuss, document, and establish professional boundaries with clients regarding the appropriate use and/or application of technology and the limitations of its use within the therapy relationship (e.g., lack of confidentiality, circumstances when not appropriate to use).

5. Therapists must be aware that personal information they disclose through electronic means may be broadly accessible in the public domain and may affect the therapeutic relationship.

6. Virtual sexual interactions are prohibited.

7. Therapists must be aware of statutes and regulations of relevant jurisdictions regarding sexual interactions with current or former clients or with known members of the client's family system.

11. Impact of Social Media and Virtual Presence on Teletherapy

1. Therapists must develop written procedures for the use of social media and other related digital technology with clients that provide appropriate protections against the disclosure of confidential information and identify that personal social media accounts are distinct from any used for professional purposes.

2. Therapists separate professional and personal web pages and profiles for social media use to clearly distinguish between the two kinds of virtual presence.

3. Therapists who use social networking sites for both professional and personal purposes must review and educate themselves about the potential risks to privacy and confidentiality and consider utilizing all available privacy settings to reduce these risks.

4. Therapists must respect the privacy of their clients' presence on social media unless given consent to view such information.

5. Therapists must avoid the use of public social media sources (e.g., tweets, blogs, etc.) to provide confidential information.

6. Therapists must refrain from referring to clients generally or specifically on social media.

7. Therapists who engage in online blogging must be aware of the effect of a client's knowledge of their blog information on the therapeutic relationship and place the client's interests as paramount.

12. Documentation/Record Keeping

1. All client-related electronic communications must be stored and filed in the client's record, consistent with standard record-keeping policies and procedures.

2. Written policies and procedures for teletherapy must be maintained at the same standard as in-person services for documentation, maintenance, and transmission of records.

3. Services must be accurately documented as remote services and include dates, place of both therapist and client(s) location, duration, and type of service(s) provided.

4. Requests for access to records require written authorization from the client with a clear indication of what types of data and which information is to be released. If therapists are storing video or audio recorded data from sessions, these cannot be released unless the client authorization indicates specifically that this is to be released.

5. Therapists must maintain policies and procedures for the secure destruction of data and information and the technologies used to create, store, and transmit data and information.

6. Therapists must 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.

7. Clients must be informed in writing of the limitations and protections offered by the therapist's technology.

8. The therapist must obtain written permission prior to recording any part of the teletherapy session. The therapist must request that the client(s) obtain written permission from the therapist prior to recording the teletherapy session.

13. Payment and Billing Procedures

1. Prior to initiating teletherapy, the client must be informed of any and all financial charges that may arise from the services to be provided. Payment arrangements must be established prior to beginning teletherapy.

2. All billing and administrative data related to the client must be secured to protect confidentiality. Only relevant information may be released for reimbursement purposes as outlined by HIPAA.

3. Therapist must document who is present and use appropriate billing codes.

4. Therapist must ensure online payment methods by clients are secure.

14. Emergency Management

1. Each jurisdiction has its own involuntary hospitalization and duty-to-notify laws outlining criteria and detainment conditions. Professionals must know and abide by the rules and laws in the jurisdiction where the therapist is located and where the client is receiving services.

2. At the onset of the delivery of teletherapy services, therapists must make reasonable effort to identify and learn how to access relevant and appropriate emergency resources in the client's local area, such as emergency response contacts (e.g., emergency telephone numbers, hospital admissions, local referral resources, a support person in the client's life when available and appropriate consent has been authorized).

3. Therapists must have clearly delineated emergency procedures and access to current resources in each of their client's respective locations; simply offering 911 may not be sufficient.

4. If a client repeatedly experiences crises emergencies the therapist must reassess the client's appropriateness for teletherapy and if in-person treatment may be more appropriate. The therapists must take reasonable steps to refer a client to a local mental health resource or begin providing in-person services.

5. Therapists must prepare a plan to address any lack of appropriate resources, particularly those necessary in an emergency, and other relevant factors which may impact the efficacy and safety of teletherapy service. Therapists must make reasonable effort to discuss with and provide all clients with clear written instructions as to what to do in an emergency (e.g., where there is a suicide risk).

6. Therapists must be knowledgeable of the laws and rules of the jurisdiction in which the client resides and the differences from those in the therapist's jurisdiction, as well as document all their emergency planning efforts.

7. In the event of a technology breakdown, causing disruption of the session, the therapist must have a backup plan in place. The plan must be communicated to the client prior to commencement of treatment and may also be included in the general emergency management protocol.

15. Synchronous Versus Asynchronous Contact with Client(s)

1. Communications may be synchronous with multiple parties communicating in real time including interactive videoconferencing, telephone, or asynchronous including email, online bulletin boards, storing and forwarding information.

2. Technologies may augment traditional in-person services including psychoeducational materials online after an in-person therapy session, or be used as stand-alone services, such as therapy provided over videoconferencing. Different technologies may be used in various combinations and for different purposes during the provision of teletherapy services.

3. The same medium may be used for direct and non-direct services. For example, videoconferencing and telephone, email, and text may also be utilized for direct service while telephone, email, and text may be used for non-direct services or scheduling.

4. Regardless of the purpose, therapists must be aware of the potential benefits and limitations in their choices of technologies for particular clients in particular situations.

16. HIPAA Security, Web Maintenance, and Encryption Requirements

1. Videoconferencing applications must have appropriate verification, confidentiality, and security parameters necessary to be properly utilized for this purpose.

2. Video software platforms must not be used when they include social media functions that notify users when anyone in contact list logs on skype or g-chat.

3. Capability to create a video chat room must be disabled so others cannot enter at will.

4. Personal computers used must have up-to-date antivirus software and a personal firewall installed.

5. All efforts must be taken to make audio and video transmission secure by using point-to-point encryption that meets recognized standards.

6. Videoconferencing software must not allow multiple concurrent sessions to be opened by a single user.

7. Session logs stored by third party locations must be secure.

8. Therapists must conduct analysis of the risks to their practice setting, telecommunication technologies, and administrative staff, to ensure that client data and information is accessible only to appropriate and authorized individuals.

9. Therapists must encrypt confidential client information for storage or transmission and utilize such other secure methods as safe hardware and software and robust passwords to protect electronically stored or transmitted data and information.

10. When documenting the security measures utilized, therapists must clearly address what types of telecommunication technologies are used, such as email, telephone, videoconferencing, or text, how they are used, and whether teletherapy services used are the primary method of contact or to augment in-person contact.

17. Archiving/Backup Systems

1. Therapists must retain copies of all written communications with clients. Examples of written communications include email/text messages, instant messages, and histories of chat-based discussions even if they are related to housekeeping issues such as change of contact information or scheduling appointments.

2. PHI and other confidential data must be backed up to or stored on secure data storage location.

3. Therapists must have a plan for the professional retention of records and availability to clients in the event of the therapist's incapacitation or death.

18. Standardized and Non-standardized Testing for Assessment

1. Therapists must familiarize themselves with the tests' psychometric properties, construction, and norms in accordance with current research. Potential limitations of conclusions and recommendations that can be made from online assessment procedures should be clarified with the client prior to administering online assessments.

2. Therapists must consider the unique issues that may arise with test instruments and assessment approaches designed for in-person implementation when providing services.

3. Therapists must maintain the integrity of the application of the testing and assessment process and procedures when using telecommunication technologies. When a test is conducted via teletherapy, therapists must ensure that the integrity of the psychometric properties of the test or assessment procedure, including reliability and validity, and the conditions of administration indicated in the test manual are preserved when adapted for use with such technologies.

4. Therapists must be cognizant of the specific issues that may arise with diverse populations when administering assessment measures and make appropriate arrangements to address those concerns, such as language or cultural issues; cognitive, physical, or sensory skills or impairments; or age may impact assessment. In addition, therapists must consider the use of a trained assistant, or proctor, to be on premise at the remote location in an effort to help verify the identity of the client(s), provide needed on-site support to administer certain tests or subtests, and protect the security of the testing and/or assessment process.

5. Therapists must use test norms derived from telecommunication technologies administration if such are available. Therapists must recognize the potential limitations of all assessment processes conducted via teletherapy and be ready to address the limitations and potential impact of those procedures.

6. Therapists must be aware of the potential for unsupervised online testing, which may compromise the standardization of administration procedures and take steps to minimize the associated risks. When data are collected online, security should be protected by the provision of usernames and passwords. Therapists must inform their clients of how test data will be stored and the electronic database that is backed up. Regarding data storage, ideally secure test environments use a three-tier server model consisting of an internet server, a test application server, and a database server. Therapists should confirm with the test publisher that the testing site is secure and that it cannot be entered without authorization.

7. Therapists must be aware of the limitations of "blind" test interpretation, that is, interpretation of tests in isolation without supporting assessment data and the benefit of observing the test taker. These limitations include not having the opportunity to make clinical observations of the test taker, such as test anxiety, distractibility, or potentially limiting factors such as language, disability, or to conduct other assessments or interviews that may be required to support the test results.

19. Telesupervision

1. Therapists must hold supervision to the same standards as all other technology-assisted services. Telesupervision must be held to the same standards of appropriate practice as those in in-person settings.

2. Before using technology in telesupervison, supervisors must be competent in the use of those technologies.

3. Supervisors must take the necessary precautions to protect the confidentiality of all information transmitted through any electronic means and maintain competence.

4. The type of communications used for telesupervision must be appropriate for the types of services being supervised, the clients and the supervisee needs.

5. Telesupervision is provided in compliance with the supervision requirements of the relevant jurisdiction(s). Supervisors must review state board requirements specifically regarding face-to-face contact with supervisee as well as the need for having direct knowledge of all clients served by their supervisee.

6. Supervisors must:

1. determine that telesupervision is appropriate for supervisees, considering professional, cognitive, cultural, intellectual, emotional, and physical needs

2. inform supervisees in writing of the potential risks and benefits associated with telesupervision and of both the supervisor's and supervisees' responsibilities for minimizing such risks.

3. ensure the security of their communication medium

4. only commence telesupervision after appropriate education, training, or supervised experience using the relevant technology.

7. Supervisors must be aware of statutes and regulations of relevant jurisdictions regarding sexual interactions with current or former supervisees.

8. Communications may be synchronous or asynchronous. Technologies may augment traditional in-person supervision, or be used as stand-alone supervision. Supervisors must be aware of the potential benefits and limitations in their choices of technologies for particular supervisees in particular situations.

EMERGENCY PLANS TO SAFEGUARD TELEMENTAL HEALTH SERVICES

Contingency plans must be developed, written, and signed that give consent to service as well as outline procedures to handle technical difficulties and/or crisis situations. If the counselor or therapist is not in the same location as the client or family, then there must be a plan to handle emergency situations in the client's home or employment area. This requires that the practitioner identifies and collaborates with professional contacts in facilities that are immediately available to assist the client, if needed. These resources should include professional colleagues' contact information, crisis hotlines, mental health outreach programs, clinics, hospitals, mental health facilities, and law enforcement agencies. These contacts must also be shared with clients and included in their treatment or counseling plans. Procedures that effectively outline when and how to contact these resources, as well as when to call 911, must be written out and discussed with the client. Crisis contingency plans must also be included in the informed consent documents signed by the client. Any informed consent would include the client's understanding of all of the risks involved in technology, long-distance service, and the implementation of the crisis plan.

HIPAA STANDARDS FOR MOBILE DEVICES

HIPAA outlines the national standards developed by the Department of Health and Human Services to secure electronic protected health information (ePHI) that is "created, received, used, or maintained by a covered entity" [24]. The security of a client's health information may be at risk when using mobile devices because the data is stored within the device in its onboard memory through the use of a security information module (SIM) card. This card identifies the owner and stores data and can be removed from the cellular device. The device may also have a memory chip, which is a microchip that can be plugged into a computer to provide more memory. An eSIM card is hardwired into the phone so it cannot be removed or stolen, making it more secure.

Mobile devices may not have the capability to restrict access to data by encryption and authentication, so practitioners must be cautious when sharing ePHI using mobile devices. Sending or receiving information through publicly available Wi-Fi, or unsecured cellular networks, risks exposing ePHI to anyone. To ensure that ePHI is not compromised or stolen when using a mobile device, the practitioner must use a secure website or a virtual private network (VPN) that encrypts information as it is received and sent from the device.

Another risk is that mobile devices are small, light, and portable so they can be easily lost or stolen, with theft as a primary form of security breach.

Ethical codes and the HIPAA Privacy Rule will continue to be revised but may not keep pace with the constant changes in these technologies. Therapists are always responsible for protecting client privacy and information disclosed to them in confidence. Telemental health delivery requires sophisticated equipment and safety precautions for various technology systems. It is advisable to contact a technology consultant to design an appropriate system with privacy and security safeguards that will meet all requirements of the jurisdictions being served.

ACA SOCIAL MEDIA TIPS

Practitioners must be cautious to avoid the negative effects of social media and the inherent ethical concerns when using these platforms. It should be noted that cyber bullying on social media is a major problem and has been linked to severe psychological distress and suicide among youth [27].

Social Media: 10 Tips for Professional Counselors

1. Make sure professional social media accounts are separate from personal accounts. It is a good idea to keep personal accounts private (ACA Code of Ethics H.6.a.).

2. Learn everything about social media platforms prior to use. Be sure to understand the various platforms' purposes and operations, including their privacy controls (H.1.a.).

3. Do not share confidential information on social media, even in closed/private settings. Nonprofessionals may have access to that information (H.6.d.).

4. Do not disclose/identify individuals in social media posts, even if they are public figures.

5. If you would not say it in real life, do not post it online. Statements have weight (C.6.c.). Keep in mind that values and beliefs shared online may be viewed by clients, employers, counseling education programs, membership organizations, other professionals, and the general public.

6. Be accurate and appropriate in the portrayal of education, licensure, accreditation, expertise, and memberships. The ACA advertising/promotion ethical standards apply to social media, too (C.3.).

7. Do not view a client's social media profile without permission, even if it is public (H.6.c.). Keep in mind that personal virtual relationships with current clients are prohibited (A.5.e.).

8. Counselors and counseling-related organizations must develop a social media policy. Information about this policy must be included in informed consent documents for clients and should be posted on professional social media pages and websites (A.2.b.).

9. Social media policies should cover the risks, especially to confidentiality, and benefits of interacting with counselors on social media, as well as the expectations clients should have when interacting with a counselor's professional social media account (H.6.b.).

10. Follow all of the social media guidelines listed in the 2014 ACA Code of Ethics.

12. CONVERSION/REPARATIVE THERAPY

In the last few years, the second largest area of revision to the ethics codes has been the opposition by ACA, AAMFT, and NBCC to the practice of conversion/reparative therapy.

Many counselors have consulted ACA staff and leaders concerning the ethics involved in the practice of conversion therapy, also known as reparative therapy. Many state and federal initiatives have enacted proposals to ban the practice entirely. The ACA ethics committee shared its formal interpretation of specific sections of the Code of Ethics concerning the practice of conversion therapy, which is a practice designed to change sexual orientation from homosexual to heterosexual [28]. The ACA published the following information on their website in 2015 and republished it in 2023:

Dr. David Kaplan, ACA's Chief Professional Officer, testified before the Washington, D.C. Committee on Health in support of a bill banning conversion therapy for minors. "The American Counseling Association has adopted an unequivocal policy against reparative therapy. Reparative therapy is not congruent with the American Counseling Association's Code of Ethics as the effects of efforts to change sexual orientation have been found to cause damage to individuals who have been exposed to it," Dr. Kaplan said. Additionally, the American Psychological Association has found the practice to be "unlikely to be successful and involve some risk of harm." In his testimony, Dr. Kaplan also said the following: "The word 'therapy' should really not be used when talking about sexual orientation change efforts. 'Therapy' is a clinical word and refers to a mental health intervention. 'Reparative therapy' is not a mental health intervention since it does not address the diagnosis of a mental disorder. The mental health field has concluded that same-sex attraction is not a deficit and therefore homosexuality is not categorized as a psychiatric disorder in the Diagnostic and Statistical Manual (DSM)."

The ACA will assist any parties in their efforts to ensure all Americans are protected from these dangerous and unethical mental health practices, and the association commended the White House for speaking out on this topic [28].

AAMFT has also spoken out against the practice of conversion/reparative therapy. Like the ACA's opinion on the topic, AAMFT's policy, adopted in 2009 by their Board of Directors, states that homosexuality is not considered a disorder that requires treatment, so there is no basis for therapy. AAMFT advises members to conduct therapy based on the best research and clinical evidence available following their Code of Ethics. The following information was obtained from the 2015 AAMFT website, and reprinted on the 2023 website, and shows the commitment and action of the association to support same-sex couples [29]:

AAMFT has joined with the American Psychological Association and other mental health associations in filing briefs in federal court that support the right of same-sex couples to marry under state law. For example, on March 6, 2015, AAMFT, along with the Michigan Association for Marriage and Family Therapy, joined in a brief filed with the U.S. Supreme Court that is in support of parties who are challenging laws in four states that deny the status of marriage to same-sex couples. The purpose of these briefs, known as an amicus brief, is to alert a court of issues relevant to the lawsuit that parties in the lawsuit might not adequately address.

Many professional mental health associations file such briefs concerning issues of importance to their members. These briefs are written by individuals not involved in a legal case who have expertise to offer the court in support of a specific cause.

The NBCC provides the following directives from their code in response to this topic [12,30]:

- 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.

- Counselor educators will practice cultural responsiveness in their teaching, and respect the cultural identity, values, sexual orientation, and gender identity, of their students.

- Sexual Orientation Change Content Restriction: The program content of continuing education providers cannot present or include information promoting Sexual Orientation Change Efforts as a therapeutic method.

13. DUAL RELATIONSHIPS

When reviewing revised codes of ethics, considerable information addresses dual relationships that counselors may have with the client. Mental health professionals must have guidelines, often referred to as boundaries, which are designed to minimize the opportunity for therapists to use clients for their own gain and to ensure the welfare of clients who disclosed confidential information to the therapist. Dual relationships are sometimes referred to as "multiple-role relationships," which occur when the counselor assumes two or more concurrent or sequential roles that involve the client in and out of the professional relationship. The dual relationship may include a second role that could be social, financial, educational, or professional.

In all codes of ethics, there are key elements in the guidelines that relate to dual relationships. These key elements are summarized as follows:

- A dual relationship exists when a mental health practitioner is in a counseling relationship at the same time that they are in a relationship with the client outside of counseling.

- Guidelines also govern a promise or an agreement to enter into another relationship in the future with the client, or a person associated with the client.

- The mental health practitioner should not take on a dual role with the client if it would impair the practitioner's assessment, objectivity, competence, effectiveness, communication, or confidentiality as a therapist.

- The mental health practitioner should not enter into a dual relationship if the possibility exists that it could exploit or harm the client.

- Mental health practitioners are responsible for establishing clear, appropriate, sensitive, and ethical boundaries prior to entering into any dual relationship with the client.

- If the mental health practitioner becomes aware that potential harm may occur, or if unintentional harm has already occurred due to a multiple relationship, the practitioner must take immediate action and present evidence that they have attempted to remediate the harm.

- Clients may be harmed in counseling relationships if professional boundaries are crossed, and sexual conduct with clients is strictly prohibited.

BARTERING: A COMMON BOUNDARY ISSUE

Current revisions summarized in this code advise against bartering. These revisions provide exceptions, however, as long as the bartering causes no harm. Therapists generally enter bartering arrangements with clients with good intention of offering services to those with limited finances, yet potential problems may exist. If the intent is to help a client with limited funds, delivering services pro bono, without bartering, may be an option.

Although bartering with the client for goods or services is not directly prohibited, it is not recommended as a customary practice. The therapist should carefully review the ethics code for their association. Some sections include regulations surrounding bartering or inappropriate relationships with clients that refer to trading or exchanging services in lieu of payment but do not use the term "bartering."

There is much disagreement among practitioners about whether or not bartering is ethical. Client services may not equal the monetary value of the hourly rate for therapy. Clients fall further behind in the amount owed for therapy or counseling and may feel trapped or resentful. The quality of barter services might also become problematic as the therapist or the client may feel shortchanged resulting in resentment and damage to the therapeutic relationship.

The exchange of goods, instead of traditional payments, may result in disputes over negotiating the equivalent number of therapy sessions for the bartered goods.

The following list provides general guidelines that are summarized and commonly held from the various ethical codes for mental health practitioners:

- Bartering arrangements create the potential for conflicts of interest and inappropriate boundaries with clients.

- Bartering should occur only in limited circumstances and if it is an accepted practice in the community.

- The mental health practitioner assumes the full burden of demonstrating that this arrangement will cause no harm to the client.

- Bartering arrangements should not put the mental health practitioner at an unfair advantage.

- Bartering agreements should be discussed, and the counselor and client should sign a clear written contract.

Establishing a friendship or a social relationship due to bartering may produce a conflict of interest that impairs objectivity for professional judgment. The dual relationship and/or friendship forms a special interest for the counselor or therapist beyond the professional one. For example, a therapist may hesitate to raise a certain issue with the client who is also a friend due to concerns of damaging the friendship.

SEXUAL DUAL RELATIONSHIPS

One of the oldest ethical mandates in the healthcare profession is the prohibition of sexual intimacies with clients. Clients may suffer reactions similar to victims of rape, spousal abuse, incest, abandonment, and post-traumatic stress disorder. Additionally, feelings of guilt, rage, isolation, confusion, and an impaired ability to trust may occur.

Harm from sexual relationships with the practitioner is universally accepted and easy to prove. There are no credible opinions in the profession that defend sexual relationships with clients.

The codes of ethics for all mental health organizations include established moratoriums, timeframes, and strict regulations concerning sexual contact with clients. The mental health practitioner must review the sections of their association's and employing organization's code of ethics and regulations that govern sexual contact with clients in their entirety.

The following list contains information held in common among major codes of ethics regarding regulations for sexual contact between mental health practitioners and clients:

- Mental health practitioners do not engage in sexual intimacies with current therapy clients/patients.

- Mental health practitioners do not engage in sexual contact with former clients, according to the limits set in their organization's code of conduct.

- Sexual intimacy with former clients is likely to be harmful.

- Even after the appropriate time period allowed in the professional's code of conduct, the burden shifts to the therapist to demonstrate there has been no exploitation or injury to the client or the client's immediate family.

- Whether such contact is consensual or forced, under no circumstances will the counselor engage in sexual activities or sexual contact with current clients.

- Mental health practitioners should not engage in sexual activity with anyone associated directly with the client, such as friends, family members, or colleagues.

The indecency of sexual conduct with clients is widely acknowledged. Clients who sue for damages have an excellent chance of winning their lawsuits if allegations are true. Civil lawsuits by clients in these cases may include the following allegations against practitioners:

- Malpractice

- Negligent infliction of emotional distress

- Battery

- Intentional infliction of emotional distress

- Fraudulent misrepresentation

- Breach of contract

- Breach of warranty

- Spousal loss of consortium

Some state legislators have passed laws that automatically make it illegal for mental health professionals to engage in sexual relationships with their clients. These laws encourage victimized clients to sue.

Clients who sue must still prove the sexual relationship harmed them, but harm is broadly defined as mental, emotional, financial, or physical. Sexual dual relationships will always be clear ethical violations. Nevertheless, these relationships continue to occur.

Counselors and therapists must be aware that even the smallest form of physical contact, or even close proximity, may be perceived as threatening, suggestive, an invasion of privacy, or offensive to some clients. A client who has been sexually assaulted may be revulsed by even a tap on the back; handshake, certain gestures, or close contact may be offensive to certain cultural groups. It may become an ethical boundary violation if it is harmful, rejected by the client, or is determined to be the result of the counselor's personal needs.

14. CONFIDENTIALITY AND DUTY TO WARN

Anyone familiar with the previous 1995 ACA Code of Ethics will notice the omission of "clear and imminent danger" and the substitution of "serious and foreseeable harm" in the revisions. This change was a direct outcome from the legal case Tarasoff v. Regents of the University of California.

This landmark case from 1969 involved a counselor working with a client who admitted he intended to murder his partner. The study of confidentiality in the mental health field must include a thorough review of Tarasoff v. Regents of the University of California. Analysis of the legal case has been the subject of much historical literature in the field of mental health ethics. A brief summary follows.

Prosenjit Poddar, a student from India, was born into the Harijan, or the "untouchable" caste. He came to UC Berkeley as a graduate student in September 1967 and briefly dated a fellow student named Tatiana Tarasoff. Ms. Tarasoff was not interested in a serious, exclusive, relationship, and that during the summer of 1969, she went to South America. Poddar felt betrayed, became depressed, and sought counseling with a psychologist at UC Berkeley University's Health Service Department.

During counseling, Poddar confided his intent to buy a gun and kill his former girlfriend. His psychologist concluded Poddar posed a significant danger. This conclusion came not only from Poddar's statements but also from assessment results that indicated a pathological attachment to Tarasoff. The psychologist consulted with professional colleagues and notified police, both orally and in writing, of his belief that Poddar posed a significant danger to Tarasoff. The psychologist believed that Poddar was suffering from acute, severe, paranoid schizophrenia. The psychologist also told the police of Poddar's plans to shoot and kill Tarasoff. The psychologist requested that the campus police detain Poddar and also requested that the police take Poddar to a facility for hospitalization so that an evaluation under California's civil commitment statutes could be administered in order to commit him as a dangerous person.

Poddar was detained but shortly thereafter released because he appeared rational, and the police believed he was not a significant danger to his girlfriend. Poddar agreed that he would stay away from Ms. Tarasoff, but Poddar then befriended Tatiana's brother and even moved in with him. Poddar stopped seeing his psychologist, and neither Tatiana nor her parents received any warning of the threat he revealed to the psychologist. Poddar carried out his plan and killed Tatiana Tarasoff by stabbing her with a kitchen knife.

Poddar was sentenced to second degree murder for manslaughter and served four years of a five-year sentence. Poddar's original sentence was overturned because the jury was not adequately informed of his mental illness. He was allowed to avoid a second trial by agreeing to return to India, and reports indicate he is married and living happily in India today.

Tatiana Tarasoff's parents sued the psychologist, the University of California, and the health center staff involved in the consultation, as well as the police. Both trial and appeals courts initially dismissed the case because, at that time, no legal basis existed under California law concerning the duty to warn. The Tarasoff family appealed their case to the Supreme Court of California. The court ruled the defendants knew of the danger prior to the tragedy and had a duty to warn Ms. Tarasoff, or her family, of Poddar's potential for significant danger due to his severe mental illness and stated plans to kill their daughter. The family believed that the mental health professionals should have insisted on Poddar's confinement and should have taken steps to ensure he was hospitalized to protect their daughter.

In 1974, the court ruled that the therapists did have a duty to warn Ms. Tarasoff. The defendants and several organizations responded and petitioned the court for a new hearing. This petition was granted, and the second hearing in 1976 resulted in the ruling that released the police from liability. It established, however, that mental health therapists were responsible and placed them under obligation to warn by imposing a duty that they use reasonable care to protect third parties against any dangers posed by a patient.

The ruling included the following indicators on the duty to warn to protect the intended victim [9]:

- If the therapist concludes, or should have concluded based on the professional standards, that the client was a serious, violent danger to society, they had the duty to warn.

- The therapist had an obligation to use reasonable care, based on what he knew, to protect the intended victim from danger.

- Depending on the specifics of the case, the therapist may have had to make numerous contacts to notify and warn the potential victim(s), notify law enforcement, contact medical or psychiatric facilities, or persist in taking all steps necessary to warn and protect.

ETHICAL QUESTIONS: TARASOFF CASE ON DUTY TO WARN

Since the Tarasoff case, many laws and association standards and codes of ethics have changed to mandate the duty to warn. There are still a number of issues to consider related to ethics today:

1. Was the counselor competent to deal with the cultural aspects and the mental health diagnoses?

2. What information concerning cultural contexts existed?

3. Was the counselor competent to deal with dangerous or violent clients?

4. Can the counselor violate this ethical standard of confidentiality if they are no longer seeing the client?

5. What should be done if clients pose a significant danger to others and need therapy but do not return to therapy, placing the client and society at increased risk?

6. What if clients avoid therapy because the therapist may disclose their shared information to law enforcement?

7. What if clients are not forthcoming with their true feelings and intentions because they believe the counselor will disclose them to law enforcement or mental health facilities?

8. What is the responsibility of the therapist or counselor, who believes the client poses a danger, to follow up after a client is released from a facility? For how long?

Hint: To answer these questions, remember what exceptions to confidentiality rules are allowed in HIPAA and association standards in cases of foreseeable harm to self or others.

Resulting court opinions form the basis for a general acceptance of the notion that treating professionals have a duty to protect if they know there are intended victims. This is important and relates to the general principles of beneficence, meaning "striving to benefit," and nonmalfeasance, meaning to do no harm.

In Tarasoff v. Regents of the University of California, it was ruled that if the patient poses a significant risk of violence to another party, the therapist "bears a duty to exercise reasonable care to protect the foreseeable victim of the danger." States differ in their requirements for identifying foreseeable danger or intended victims, as well as the scope or the degree of possible danger. These are important factors to be considered and acted on to protect both individuals and society.

ETHICAL DECISIONS: KEY POINTS FROM THE TARASOFF CASE

The following precedents were set, following this case, that altered legal statutes and professional standards for ethical practice.

- Therapists have specialized knowledge due to the therapeutic relationship of the therapist and client that should inform the duty to protect in this case.

- The Tarasoff case, and cases that followed, support the therapist's duty to warn/protect intended victim(s), not the community at large.

- Counselors must be competent to identify and evaluate clients' potential for violent behavior and assess their potential to commit dangerous acts.

- If a patient poses a significant risk of violence to another party, the therapist "bears a duty to exercise reasonable care to protect the foreseeable victim of danger."

- One standard by which the breach of confidentiality and the duty to warn will be judged is the standard of what a reasonable professional in the community under the circumstances would do. This is supported by laws and professional standards.

- Counselors must be competent to work with clients with those diagnoses that may include violent behavior or refer those clients to other professionals. Counselors and therapists work only within their area of expertise.

- Client records are critical to document that the therapist understood the nature of the situation in relation to the client's diagnosis.

- Counselors must take reasonable steps based on their knowledge of the facts.

- Counselors should consult with colleagues if they are unsure of how to proceed according to their code of ethics and the law of their state.

- A therapist is liable for a negative outcome if their actions fall below the expected level of care.

Only supporting professional standards from the ethics codes are listed subsequently, so the identifying numbers will not be consecutive:

ACA Standards

- 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.

- 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.

- 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.

- 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.

NBCC Standards

- 1. Counselors shall perform only those professional services for which they are qualified by training, education, and supervised experience.

- 19. Counselors shall not share client information that is obtained through the counseling process without specific written consent by the client or legal guardian except when necessary to prevent serious and foreseeable harm to the client or others, or when otherwise mandated by Federal or State law or regulation.

AAMFT Standard

- 1. Marriage and family therapists do not disclose client confidences except by written authorization or waiver, or where mandated or permitted by law. Verbal authorization will not be sufficient except in emergency situations, unless prohibited by law.

- 3.2 Knowledge of Regulatory Standards. Marriage and family therapists pursue appropriate consultation and training to ensure adequate knowledge of and adherence to applicable laws, ethics, and professional standards.

- 3.10 Scope of Competence. Marriage and family therapists do not diagnose, treat, or advise on problems outside the recognized boundaries of their competencies.

Components of the Tarasoff case judgement were expanded in subsequent cases involving confidentiality, disclosure, informed consent, and duty to warn and protect. It is important to review the state and federal laws and administrative codes for each state of practice for direct or distance counseling. States differ in requirements concerning identifying victims and determining the scope of the danger. The following examples show some of the resulting changes from the case.

- Some cases have recognized the duty to warn all foreseeable victims, not just those clearly identified.

- Legislative and regulatory bodies have attempted to clarify and define this duty across numerous states.

- All 50 states have mandatory reporting requirements for child abuse.

- In cases of communicable diseases, such as HIV, the counselor may attempt to diffuse the risks to the client before making an exception to the confidentiality rule if the level of risk or level foreseeable harm allows it. Examples would be to:

- Have the client present when the partner is notified

- Include this in part of the therapy

- Have the partner or a client voluntarily divulge the disclosure

- Have the parties participate in other partner notification programs.

Other circumstances dictate that the counselor must legally report information in the following cases as outlined by law [1]:

- Counselors believe a client younger than 16 years of age is a victim of incest, rape, or some other crime.

- Counselors believe the client needs hospitalization to prevent harm to self or others.

- information is required as an issue in a court action.

- Clients request that their records be released to themselves or to a third party.

RECORD ACCESS BY FAMILY MEMBERS

The ACA 2014 Code of Ethics includes exceptions to the confidential information that include end of life care as follows:

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.

The NBCC Code of Ethics provides the following directives [12]:

- Counselors working with minors, incapacitated adults, or other persons unable to give legal consent to release confidential and privileged information, shall protect the confidentiality of information received in the counseling relationship as specified by Federal and State laws, written policies, and applicable ethical standards. In all cases, the counselor shall discuss with the client and their legal representative the limits of confidentiality and the rules concerning the release of any information.

- Counselors respect and honor the inherent and legal rights of the parents and legal guardians of minors and incapacitated adults who are legally incapable of giving informed consent. As appropriate, the counselor shall collaborate with the parent(s) or legal guardian, discussing the role of counseling, the confidential nature of the counseling relationship, and the autonomy of the client as required by the NBCC Code of Ethics, State and Federal law, and other applicable ethical standards. When working with minors or incapacitated adults who are legally incapable of giving informed consent, the counselor shall consider the custody agreement, power of attorney document, or legal agreement that may impact the rights of a parent or legal guardian.

AAMFT includes these sections related to disclosure of information [11]:

1. Standard I: Responsibility To Clients

1. Marriage and family therapists advance the welfare of families and individuals and make reasonable efforts to find the appropriate balance between conflicting goals within the family system.

2. 1.2 Informed Consent
When persons, due to age or mental status, are legally incapable of giving informed consent, marriage and family therapists obtain informed permission from a legally authorized person, if such substitute consent is legally permissible. The content of informed consent may vary depending upon the client and treatment plan; however, informed consent generally necessitates that the client: (a) has the capacity to consent; (b) has been adequately informed of significant information concerning treatment processes and procedures; (c) has been adequately informed of potential risks and benefits of treatments for which generally recognized standards do not yet exist; (d) has freely and without undue influence expressed consent; and (e) has provided consent that is appropriately documented.

2. Standard II: Confidentiality

1. Marriage and family therapists have unique confidentiality concerns because the client in a therapeutic relationship may be more than one person. Therapists respect and guard the confidences of each individual client.

2. 2.1 Disclosing Limits of Confidentiality.
Marriage and family therapists disclose to clients and other interested parties at the outset of services the nature of confidentiality and possible limitations of the clients' right to confidentiality. Therapists review with clients the circumstances where confidential information may be requested and where disclosure of confidential information may be legally required. Circumstances may necessitate repeated disclosures.

3. 2.2 Written Authorization to Release Client Information.
Marriage and family therapists do not disclose client confidences except by written authorization or waiver, or where mandated or permitted by law. Verbal authorization will not be sufficient except in emergency situations, unless prohibited by law.

4. 2.3 Client Access to Records.
Marriage and family therapists provide clients with reasonable access to records concerning the clients. When providing couple, family, or group treatment, the therapist does not provide access to records without a written authorization from each individual competent to execute a waiver. Marriage and family therapists limit client's access to their records only in exceptional circumstances when they are concerned, based on compelling evidence, that such access could cause serious harm to the client. The client's request and the rationale for withholding some or all of the records should be documented in the client's file. Marriage and family therapists take steps to protect the confidentiality of other individuals identified in client records.

15. CASE STUDIES

The following section summarizes case studies and includes legal judgements and rationales. This information should not be construed as legal reference material or guidance. Professionals should always seek the assistance of their professional association and consult employing agency legal counsel for any questions regarding ethical/legal issues.

REPARATIVE/CONVERSION THERAPY

During the third session of counseling, a 30-year-old client reported that he was gay and stated that he no longer wanted to follow this lifestyle. He wanted to participate in conversion therapy so that he no longer felt an attraction to men. His goal was to become attracted to a woman and have a traditional marriage with children.

At the suggestion of a friend, the client read about reparative/conversion therapy and researched the approach on the Internet. Even after his research, he was convinced this is the route he wants to take.

The counselor listened and asked questions in a clinically appropriate manner. The counselor informed the client that although she felt that she could be effective in counseling with him, she could not ethically engage in reparative/conversion therapy and felt it would not be effective in reaching his desired goals. She explained that she could find no scientific evidence or support for the approach; she even consulted her association, who advised her that it was not a supported form of therapy. The client understood but indicated he was disappointed that the counselor could not help him through that type of counseling.

He then asked for a referral to another counselor or therapist who would help him change his sexual orientation and reach his goals. Ethical question: Should the counselor make a referral for conversion therapy?

Analysis

The ACA Ethics Committee considered many factors and arrived at a consensus opinion that addressed several sections of the Code of Ethics and moral principles of practice presented in this scenario.

They started with the basic goal of reparative/conversion therapy: to change an individual's sexual orientation from homosexual to heterosexual. Counselors who conduct this type of therapy view same-sex attraction and its behavior as abnormal, unnatural, or immoral. They also believe that a change, or a "cure," can be achieved through the use of therapy.

The belief that same-sex attraction and behavior is abnormal and in need of treatment is in opposition to the position taken by national mental health organizations, including the ACA, APA, and AAMFT. The ACA Governing Council resolution specifically noted that the ACA opposes the portrayals of lesbian, gay, and bisexual individuals as mentally ill due to their sexual orientation. This resolution supported dissemination of accurate information about sexual orientation, mental health, and appropriate interventions and instructed counselors to report research accurately and in a manner that minimizes the possibility that results may be misleading.

The ACA found that the majority of the studies on this topic had been expository in nature and had no scientific evidence published in psychological peer-reviewed journals that stated the effectiveness of conversion therapy. They did not find any longitudinal studies conducted to follow the outcomes of those individuals who had engaged in this type of treatment. They concluded that research published in peer-reviewed counseling journals indicated that conversion therapy may harm clients.

These findings bring several questions to the forefront:

1. Is a counseling professional who offers conversion therapy practicing ethically?

2. Since ACA has taken the position that it does not endorse reparative therapy as a viable treatment option, is it ethical to refer a client to someone who does engage in conversion therapy?

3. If the client insists on obtaining a referral, what guidelines can a counselor follow?

4. What are the conditions that allow the professional counselor to refer this case to another counselor?

ACA committee members agreed that it is of primary importance to respect the client's autonomy to request a referral for services which are not offered by the counselor. If counselors determine an inability to be of professional assistance to clients, they avoid entering or continuing the counseling relationship. Counselors act to avoid harming their clients, trainees, and research participants and to minimize or to remedy unavoidable or unanticipated harm [10].

Referring a client to a counselor who engages in a treatment modality not endorsed by the profession may in fact cause harm, does not promote the welfare of clients, and opposes the basic purpose of the code.

There is no professional training condoned by ACA, ACA, AAMFT, APA, or other prominent mental health association that would prepare counselors and therapists to provide conversion therapy. Additionally, all professional associations and related mental health agencies have spoken out against any form of conversion therapy or counseling. The counselor or therapist would be practicing outside the boundaries of their expertise because there is no professional training for conversion therapy. This would violate the ethics code.

The ACA Code requires counselors to "recognize history and social prejudices in the misdiagnosis and determination of pathology of certain individuals and groups and the role of mental health professionals in perpetuating these prejudices through diagnosis and treatment" [10].

Today, some religions and segments of the population in the United States continue to view same-sex relationships as immoral sexual behavior that is pathological, sinful, and in need of therapy and counseling. In the past decade, increasing acceptance of same-sex lifestyle choices has been noted, including the number of states that recognize marriages between same-sex partners.

Referring a client to someone who engages in conversion therapy signifies to the client that same-sex attraction and behaviors are deviant and need to be changed. This would violate the ACA Code of Ethics, The AAMFT Code of Ethics, the NBCC Code of Ethics, and the APA Diagnostic and Statistical Manual; therefore, the ethical decision would be to refuse the referral request.

DUAL RELATIONSHIPS

Case 1

A professional artist complained to an ethics committee that his therapist's actions caused him stress and anxiety when she did not carry out her promises. The therapist had treated the artist for over one year, during which time the therapist complimented the client's artwork, attended art shows with him, and promised to introduce her art gallery contacts to her client. The client stated he began to feel so self-confident that he terminated therapy and expected the therapist's interest in his career to continue. The therapist stopped returning the ex-client's phone calls, which left the client frantic. An ethics committee contacted the therapist. She explained that she always provided unconditional positive regard to her clients; however, since this particular individual was no longer a client, she felt no further obligation to him.

Analysis

The ethics committee found in favor of the client. They determined that the therapist had maintained a dual relationship by combining their professional and private lives outside of counseling together. This caused confusion and harm to the client, and the therapist did nothing to resolve the client's distress and dependency and chose to ignore him, which increased his anxiety.

Case 2

The therapist and her ex-client decided they would become friends because the past therapeutic relationship was very harmonious. A month into the friendship, the ex-client perceived that the therapist was controlling and overbearing in their new relationship. He then questioned the therapist's overall competence and stability, to the point of distancing himself from the post-therapeutic friendship. The ex-client decided that the therapist had caused him to feel exploited, hurt, and confused. He then consulted another therapist who advised him to press charges against the previous therapist.

Analysis

An ethics committee determined that incompetence could not be conclusively proven; however, both the complainant and respondent were surprised by the findings of a dual role violation.

The investigation uncovered that the therapist planned their developing relationship and a longer-term continuation while the client was still in active therapy. The therapist had actually presented these facts as a defense against the client's accusations.

This case shows how personas may change from one context to another, and the resulting change may be viewed as negative. The client responded well to the therapist's authoritative personality in therapy but not in a social context. This case shows the problems that occur when personal and professional boundaries are crossed and the resulting ethical issue that harmed both client and counselor.

Case 3: Bartering

A counselor provided services to a man with anxiety that adversely affected his work and personal life. He eventually lost his job and his health insurance due to his anxiety. The counselor agreed to hire the client to do maintenance on his house and yard work to help him earn some money while he looked for a job. The counselor paid him minimum wage but continued the counseling sessions at no charge. A month later, the man attempted suicide and was admitted to an inpatient mental health facility. He was assigned to a psychiatrist who learned of the exchange of work for counseling services. The psychiatrist questioned the ethics of the relationship and considered it a boundary violation and an inappropriate dual relationship that caused harm to the client. He reported it to the state licensing board, and they opened an investigation.

Analysis

The therapist was not paying the fair market value for the labor being performed, so the relationship was not a beneficial one for the client, even though he was able to continue counseling for free. The quality and the effectiveness of the counseling services were called into question in light of the firing and subsequent suicide attempt.

The ethics committee ruled in favor of the client.

Professional liability insurance policies may exclude coverage pertaining to business relationships with clients. Liability insurance carriers may view bartering arrangements between mental health professionals and clients as business relationships and therefore refuse to defend a covered therapist if complications arise in therapy that leads to litigation. Bartering arrangements have the potential for client exploitation, impaired professional judgement and objectivity, conflicts of interest, damage to the therapeutic relationship, and unsatisfactory outcomes to both parties.

Case 4: Sexual Boundary Violation

A therapist had delivered services to a client for two months and felt an attraction to her. He decided to invite her to go with him to a presentation on autism because her nephew had been recently diagnosed with the disorder. The client believed that it was not a date but rather an educational event, so she accepted. After the lecture, they went to dinner at the invitation of the therapist.

When the client went to the next therapy session, she was given a DVD for the nephew that was produced by the speaker from the presentation. Following a subsequent therapy session, they again went to dinner, and after a few drinks, they returned to the client's house, where they engaged in sexual intercourse. The relationship continued for a month and ended when the therapist started dating a previous girlfriend again.

The client was hurt and angry. She ended the therapy sessions and brought a malpractice suit against the therapist on the grounds that he was unprofessional and that the relationship violated professional boundaries. She claimed that the relationship caused her such mental distress that she was unable to sleep, which subsequently affected her work. The review board ruled in favor of the client and awarded a large damage award as a result of her civil malpractice complaint.

Analysis

The therapist has the burden of proving that no exploitation took place in relation to the client's mental status and severity of their presenting issues, the ability to comprehend the risk, a level of independence, and the autonomy to act in their best interest. As a professional with inherent power in the relationship due to the potential to coerce or influence a client, therapists may have difficulty defending themselves against a claim of sexual misconduct Any diagnosis, such as depression, previous abuse, or various personality or emotional disorders, suggests vulnerability or susceptibility to exploitation and would influence the case against a therapist The therapist or counselor must, in all ways, put the client's welfare above his or her own. Sexual relationships with current, former, or potential clients are always an ethical violation.

DUTY TO WARN

Case 1

M.K. was a 15-year-old client of a New Jersey psychiatrist for two years. The client was open with the therapist about his use of illegal drugs and his violent thoughts about a fantasy to threaten people with a knife to control and rob them. He also told the therapist about his sexual relationship with a 20-year-old neighbor. It was clear that he had a strong emotional attachment to the young woman; however, M.K. often expressed his anger and jealousy that the woman was dating other men.

The therapist observed that M.K. showed symptoms of severe anxiety when he spoke of the woman. In a subsequent session, M.K. told the therapist that he once fired a BB gun at her car as she drove by his house.

M.K. stole a prescription pad from the therapist and attempted to forge his signature in an attempt to purchase 30 Xanax pills. The pharmacist noticed that M.K. was acting suspiciously and, because of his age, called the therapist. The therapist told the pharmacist to disregard the prescription, and M.K. went home. He later stole a gun and shot the young woman to death.

The therapist had attempted to reach M.K. by phone to discuss the stolen prescription forms but did not reach him before the woman was shot. The woman's father had heard of the Tarasoff case, and the family hired an attorney to bring a civil suit against the therapist. The suit charged him with the wrongful death of their daughter and his failure to warn and protect her.

The therapist hired an attorney who argued to dismiss the suit claiming that the Tarasoff principle should not apply in New Jersey based on the following:

- The ability to predict danger is unreliable.

- Violating the client's confidentiality would have interfered with effective treatment.

- Instituting the Tarasoff principle might deter therapists from treating potentially violent patients.

- A ruling on the Tarasoff principle could lead to unwarranted commitments to institutions.

Analysis

The court rejected all these arguments and declined to dismiss this case. The court instead ruled that the duty to warn is valid under New Jersey law. The court decision stated that even though therapists could not be expected to accurately predict danger or harm in 100 percent of the situations, they have the ability to make a professional judgment in the relationships of the client with others. This therapist observed several warning signs, and the client's own statements and actions of a violent nature should have provided the therapist with enough evidence to decide that a warning concerning the potential of danger was in order.

The court made an analogy and compared the situation with the responsibility to warn communities and individuals about carriers of a contagious disease. The court stated that the client/therapist confidentiality must be secondary to the greater welfare of the community. In cases of imminent or potential danger, the therapist has the duty to warn. The therapist faced the jury and was not held liable for damages, but the Tarasoff principle of duty to warn and protect was adopted in New Jersey.

Case 2

A PhD and marriage and family therapist (MFT) had treated a client, a former policeman, for three years. The therapy centered on work-related injuries and the breakup of a 17-year relationship with a woman who began to date someone else. The client allegedly told the therapist that he was having suicidal thoughts in early June. The therapist recommended hospitalization and asked for permission to speak with the client's father. The father told the therapist that his son was deeply depressed, had lost his desire to live, and had mentioned harming the man his former girlfriend was currently dating.

The client checked himself into the hospital as a voluntary patient on June 17. The therapist received a phone call from the client's father the next morning stating that the hospital would soon release his son. The therapist then called the admitting physician and urged him to maintain the client's hospitalization for further observation through the weekend. The psychiatrist disagreed and released the client. The client did not contact his therapist after he was released from the hospital.

No one from the hospital contacted the therapist after releasing the client. On June 23, the client shot the boyfriend of his ex-partner and then killed himself with the same handgun.

The parents of the new boyfriend filed a wrongful death lawsuit and named the therapist as one of the defendants. The lawsuit claimed the therapist had a duty to warn their son of the risk from the client. A judge dismissed the case against the therapist, who asserted that his client did not disclose a threat to the new boyfriend directly to him.

Ultimately, the California Court of Appeals reinstated the case, explaining, "When the communication of a serious threat of physical harm is received by a therapist from the patient's immediate family and is shared for the purpose of facilitating and furthering the patient's treatment, the fact that the family member is not technically the patient is not crucial."

Analysis

The court expressed that psychotherapy does not occur in a vacuum and that for therapy to be effective, therapists must be aware of the context of a client's history and their personal relationships. The court advised that communications from clients' family members in the context comprised a "patient communication." Mental health professionals, however, must use caution when accepting the warnings of third parties, such as parents or spouses, who are emotionally involved as they may have ulterior motives. This ruling required that if the therapist determines that individuals have credible information, then that constitutes patient communication and necessitates the duty to warn.

RECORD ACCESS BY FAMILY MEMBERS

Case 1: Record Access by Family Members

D.C. battled cancer for many years and received the assistance of a counselor on several occasions. She did not have regularly scheduled sessions, but D.C. would consult the counselor when she faced medical issues and treatments that intensified her anxiety and depression.

During a planned surgery, there were complications, and D.C. had to be resuscitated. This left her in a coma on life support. Her physicians informed her family of the possibility that she would remain on life support and her prognosis for recovery was bleak, at best. Members of her family decided to approach the court for authorization to take D.C. off of life-support.

The family was instructed by the court to locate any information they could find that would shed some light on D.C.'s wishes concerning end-of-life issues. The family asked the counselor if any of the records from her counseling sessions might help to provide some guidance to the court concerning D.C.'s end of life plans in order to make decisions about her treatment. The counselor refused and decided to consult a colleague. The family turned to the court for an order to compel the counselor and the counselor's colleague to release all information and communication concerning D.C.'s end-of-life wishes. The courts issued a subpoena for all records and communications. The counselor eventually complied to avoid sanctions by the court.

Analysis

Family members have many reasons to seek access to the records of other family members. Some are legitimate; others have the potential to harm the client or lead to an ethical violation if mistakes are made in disclosing information to the wrong party.

In this situation, the client was incapacitated and could not make her wishes known. In these cases, the courts recognize a surviving line of consent as follows:

- The first in line in the chain to grant consent is the spouse. This is true even if they are estranged and living apart, but not divorced.

- Next would be the children of legal age: each child would be given equal weight in the decision.

- Next are parents or grandparents, followed by siblings, each having equal weight.

- If there are no family members, the courts may appoint the next closest relative or close friend.

The ethics codes are clear that in cases with clients who are minors, or clients who meet criteria as legally incompetent, that parents or legal guardians will be given full access to records. Therapists must understand the complex nature of confidentiality, informed consent, and privacy when serving minors and their families. Even if a client is a minor or is incompetent to understand at the expected level, the therapist should make every attempt to communicate in a way that can be understood at their developmental or cognitive level.

The practitioner must be sensitive to the needs and feelings of these clients and must realize that the client may understand more than is readily apparent or may have an inability to respond. At the beginning of any counseling or therapeutic relationship, each member should receive information about confidentiality in the treatment relationship. A legal parent or guardian must be established before services begin so that the practitioner knows who may be contacted, consulted, and involved in the client's treatment.

Counselors and therapists may be reluctant to provide access to records and notes to clients, parents, and guardians because they may believe they will not understand or may misconstrue the information. Misunderstandings could cause harm to the client, impede the treatment plan, or result in a lawsuit. The ethics codes of the NBCC, AAMFT, and ACA provide guidelines concerning the rights of the client and the obligation of the provider in this area. When information is shared, the practitioner must take the time to be sure the client understands the information and must involve interpretation and explanation. Records should never be turned over to the client or guardian without a conference that includes all parties that have any legal authority to review the information so that the therapist or counselor can explain the contents and answer questions.

Case 2: Privilege Applied to Child Safety and Custody

The laws that govern mandatory reporting of child abuse will always take precedence over client privilege laws in all states. In cases of child abuse or neglect, the therapist or the counselor may be compelled to testify in court for the welfare of the child.

The following case from the Alabama Supreme Court (Marks v. Tenbrunsel) demonstrates these important facts [31]:

- Client Marks consulted a psychologist, Dr. Tenbrunsel, for mental health services. It was the client's understanding that anything he shared with the therapist would be confidential information that would never leave the office. He believed the therapist told him that there would be protection under client privilege when they initially met.

- During a subsequent therapy setting, Marks confided that he had sexually abused two girls under the age of 12 years.

- The therapist consulted a professional colleague and made the decision to tell Marks that as a mandated reporter he was compelled to report the incident to child protective services and that the confidentiality agreement would be void in this case.

- Marks alleged malpractice, hired an attorney, and filed a civil case against the therapist as well as the colleague he consulted. He also claimed in the lawsuit that the therapist caused him to be prosecuted, lose his job, suffer mental anguish, and ruined him financially.

- The therapist's counsel filed a motion to have the case dismissed, which was granted. Marks appealed the judgment of dismissal; however, the Alabama Supreme Court upheld the dismissal.

Analysis

The court, after reviewing rulings in other cases, found when a person issues a report of child abuse or neglect in good faith, or is called to testify in the judicial process related to the report, the person would have "immunity from any liability, civil or criminal, that might otherwise be incurred or imposed."

The court stated, "because Marks admitted to the abuse of the two children the psychologists had reasonable causes to suspect that children were being abused and therefore were acting in good faith when they determined that a report should be made."

In the review of other cases, the court found decisions that the psychotherapist-client privilege was second to the child abuse reporting statute and that child abuse statutes, "vitiated the privilege and the therapist could be compelled to reveal the alleged sexual abuser's medical records in a civil action for damages."

The court found, in most cases, that the child abuse reporting statute abrogates a privilege that may otherwise be applicable with respect to proceedings involving child abuse or neglect.

Some states allow information in the report of child abuse to be disclosed, along with all other privileged information; others simply act on the fact that the report was made and substantiated in these cases of privilege brought against the therapist or counselor. For prosecution of the alleged abuser, all privileged information would be discovered.

In situations of child custody, there are a number of positions of privilege taken by the courts depending on the jurisdiction. Some courts will deny privilege to allow every piece of information to be reviewed to make the best possible custody decision. Some courts will strictly adhere to rulings of privilege. The courts will have to resolve any conflicts that may result based on these two positions and the circumstances of each case.

In cases of custody disputes, the mental health of one or both parents and the effects that this may have on the child may come into question. The court will decide based on the particular evidence regarding the mental health of the parents or the child. Again, states vary on their positions of privilege in these cases depending on the severity of the mental health issues of the parents or child. Today, states recognize privilege in the relationships of clients and mental health practitioners. Counselors and therapists should consult state statutes or case law in the state of their licensure and/or jurisdiction of practice to be familiar with the concept of privilege in their state.

Case 3: Court Access to Records

J.D. is a licensed MFT who found herself in an ethical dilemma when faced with a court order to release certain client records from her files. J.D. refused to release treatment notes as ordered by the courts as part of a custody dispute involving a young client. She believed that there were two exceptions to the confidentiality and client privilege, including knowledge of child abuse or if the client threatens suicide or homicide.

J.D. stated that the notes were sometimes just phrases of her interpretations, thoughts, and topics to refresh her memory and would not be understood by anyone but herself. She believed that it was unethical to disclose her notes and decided to provide only a general summary. The attorney brought the summary to the judge who issued an order for the complete set of notes, but J.D. decided to defy the court order.

J.D. was arrested and fined $2,000 on a contempt charge, which cost her $900 in bail in lieu of being incarcerated. In the end, J.D. decided to disclose the notes to the court.

Analysis

J.D.'s personal views and her misinterpretation of the AAMFT's Code of Ethics point to a lack of understanding in many areas. Here are the key features:

- If J.D. had referred to the Code, she would know that she was wrong to defy the courts in this case.

- She made a mistake by not seeking assistance from other professionals or her administrator when faced with a situation as serious as a court order in a child custody case. In fact, she viewed her own opinion, not based on sound decisions following the code, as more significant than the opinion of the court.

- She was not focusing on the best interest of her client by delaying the case and refusing to turn over her notes to inform the court's decision. The delay added to the stress and fear felt by her young client, who was unable to give consent or waive the obligation of confidentiality to disclose the notes.

- If a subpoena duces tecum, or subpoena for production of evidence, is issued that requests all files documents, notes, reports, photographs, and recordings in any form, it is clear that case notes are part of that request. The subpoena in this case would have a release signed by the parent in cases with a minor child.

- A court order is issued as the result of a hearing before a judge and demands a set of records be disclosed and delivered to the court representative, unless there is an appeal to a higher court. It is the court, not the practitioner, which will ultimately decide what qualifies as protected information.

If the therapist is ordered to testify and the client requests that the therapist should not disclose privileged information, the therapist may explain to the court the possible harm to the therapeutic relationship if a disclosure is made. If the judge requires the therapist to testify, they should disclose only the information related to the request. Under court order, the counselor or therapist is not in violation of privacy rules or privilege because they are complying with the judge's order. The court order is defense against any charge of ethical wrongdoing if the counselor is later sued over a breach of confidentiality.

16. SUMMARY OF THE HEALTH INSURANCE PORTABILITY ACCOUNTABILITY ACT (HIPAA) PRIVACY RULE

The Standards for Privacy of Individually Identifiable Health Information established a set of national standards for the protection of certain health information. The U.S. HHS issued the Privacy Rule to implement the requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

The Privacy Rule standards address the use and disclosure of individuals' health information called "protected health information" by organizations under the Privacy Rule called "covered entities." According to the Privacy Rule, as well as all of the Administrative Simplification rules, the term "covered entities" applies to health plans, health care clearinghouses, and to any healthcare provider who transmits health information in electronic form in connection with services or transactions.

HIPAA also includes standards for individuals' privacy rights to understand and control how their health information is used. A major goal of the Privacy Rule is to ensure that individuals' health information is properly protected while allowing sharing of health information to provide high-quality health care and to protect public health.

Therapists and counselors must adhere to directives of the HIPAA Privacy Rules that apply to all healthcare providers. The rule permits the use of information, while protecting the privacy of people who seek care and treatment. Psychotherapy notes are treated in a different way from other records under the HIPAA Privacy Rule. According to HIPAA:

"Psychotherapy notes" means notes recorded, in any medium, by a health care provider who is a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session and that are separated from the rest of the individual's medical record. Psychotherapy notes excludes medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests, and any summary of the following items: diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date.

Release of this information requires a HIPAA compliant release form signed by the client with a few exceptions:

1. To carry out the following treatment, payment, or health care operations:

1. Use by the originator of the psychotherapy notes for treatment;

2. Use or disclosure by the covered entity for its own training programs in which students, trainees, or practitioners in mental health learn under supervision to practice or improve their skills in group, joint, family, or individual counseling; or

3. Use or disclosure by the covered entity to defend itself in a legal action or other proceeding brought by the individual; and

2. A use or disclosure that is required by another law, such as reporting abuse or disclosures to avoid harm to patient or others.

The mention of "another law" exception covers the mandatory duty to report child abuse in all 50 states and the laws governing duty to warn.

Counselors should be aware that 2013 brought important changes to HIPAA and that September 23, 2013, was the compliance deadline for many of these regulatory requirements. Any counselor or therapist who is not sure if they are considered a "covered entity" under HIPAA should immediately access the online decision-making tool available at the website of the Centers for Medicare and Medicaid Services. All counselors who are covered entities should move quickly to come into compliance or risk very stiff monetary penalties [10].

With more than 800 pages, the entire HIPAA document and Privacy Rule is extensive. Covered entities regulated by the rule are obligated to comply with all of its requirements and should not rely on this summary as the source of legal information or advice. Professionals should receive specialized training and continuing education on HIPAA regulations related to their practice. To view the entire rule, and for other information about how it applies, review the website at https://www.hhs.gov/hipaa/for-professionals/privacy/index.html.

17. GLOSSARY

Professional counseling and marriage and family therapist associations, such as the NBCC, ACA, and AAMFT, have terms and definitions in common that are seen throughout their ethical codes. Some of the most commonly used terms and their definitions are as follows:

Abandonment: The ending or termination of a counseling or therapeutic relationship that harms a client or puts the client at risk.

Advocacy: Actions to promote the welfare of individuals and groups to remove barriers and increase access to reach their full potential. Advocacy includes supporting policy changes to promote these goals for all individuals.

Assent: Actions that indicate or demonstrate agreement when a person is not capable or competent to give informed consent.

Bartering: Goods or services that are accepted from clients in exchange for counseling or therapy services.

Client: Individuals or groups at the point where they make contact and ask for services.

Client record: The paper or electronic system containing all information gathered and stored throughout service delivery. This may include written, electronic audio, and video records.

Clinical supervision: Guidance, mentoring, education, coaching, and monitoring by a practicing professional to enable the development of professional skills and facilitate learning in application of skills to practice settings.

Competency: Therapists and counselors provide services only within the boundaries of their expertise based on education, training, license, certification, and experience.

Confidentiality: The ethical duty of counselors to protect client identity, communications, or any information related to the relationship with clients.

Consultation: A professional collaboration that includes advice, information, assistance, support, or testimony. The codes promote professional consultation.

Counseling: A professional relationship that aids diverse individuals, families, and groups of all ages to enhance mental health, wellness, education, and career goals.

Counselor educator: A professional counselor engaged in developing, implementing, supervising, monitoring, and evaluating the educational preparation of professional counselors.

Counselor services agreement: Written document that informs the client of the terms and conditions of the counseling or therapeutic service. It includes potential benefits and risks.

Counselor supervisor: A licensed, practicing counselor in a formal professional relationship with a student counselor or a counselor-in-training to oversee the individual's counseling work or clinical skill development.

Culture: The customary beliefs, social norms, institutions, behavior patterns, values, and lifestyles of a particular community or group.

Deceptive methods: Any methods used in which clients are unaware, misinformed, or denied informed consent.

Digital technology: Digitized information recorded in a binary code of combinations of the digits 0 and 1, called bits, which represent words and images. Digital technology enables immense amounts of information to be compressed on small storage devices that can be easily preserved and transported including the Internet, digital mobile devices, and systems used in communication and social media.

Discrimination: To make distinctions or to differentiate based on preference or prejudicial views of an individual or group.

Distance counseling: The therapeutic or counseling services delivered without physical proximity to the client by using technology as the point of access.

Diversity: The differences and distinct qualities within cultures and social groups.

Documents: Written, digital, or audio/visual records of client information within the counseling or therapeutic relationship with clients.

Encryption: Process of encoding information to protect identity and to block access by unauthorized parties.

Examinee: The client who is being assessed for the purpose of determining psychological, educational, or developmental levels to inform the counseling or therapeutic process.

Exploitation: Unethical actions for one's own advantage.

Fee splitting: The division of payment for referrals or services.

Forensic evaluation: An assessment to inform professional knowledge to prepare for testimony legal proceedings. These reports do not fall under HIPAA guidelines and may cover evaluations for determining child custody decisions, competency to stand trial, and criminal culpability.

Harmful multiple relationships: Relationships developed outside of the professional relationship that do not protect the welfare of the client and erode the ethical practice of counseling and therapy.

Implicit bias: Also called implicit prejudice, is a negative attitude, of which one is not consciously aware, against a specific social group [32].

Impairment: Diminished strength, value, fitness, and quality that renders the professional incapable of delivering ethical services to clients.

Informed consent: A process of advising clients on all aspects of the counseling or therapeutic process prior to services. This includes all benefits, risks, rights and responsibilities, and explanations required by the client to understand all phases of the treatment and decide to consent or to decline the service. Adjustments may be required as the service progresses so consent must be revisited.

Intellectual property: An original work, invention, or creation to which one has the rights of ownership.

Interdisciplinary teams: Teams of professionals who collaborate to serve clients from a variety of applicable areas of expertise. The team should agree with the counselor and therapist regarding confidentiality.

Marriage and family therapist: Marriage and family therapists (MFTs) are mental health professionals trained in psychotherapy and family systems and licensed to diagnose and treat mental and emotional disorders within the context of marriage, couples, and family systems.

Minors: Individuals younger than 18 years of age; however, this age will vary according to state statutes. In some jurisdictions, minors may have the right to consent to counseling or therapy independent of a parent or a guardian.

Multicultural/diversity competence: An approach to counseling or therapy from the context of the personal culture of the client.

Multicultural/diversity counseling: Professional services that accommodate differences in religion, spirituality, sexual orientation, gender, age and maturity, socioeconomic class, and family history and emphasize the worth, dignity, potential, and uniqueness of individuals.

Non-counseling relationships: All relationships that exist outside of the context of the professional counseling practice.

Personal virtual relationship: A relationship that exists through technology or social media that is outside the professional boundaries for therapy or counseling. These relationships should be avoided as they may lead to unethical practices.

Privacy: The right of an individual to control their personal information to avoid unauthorized disclosure.

Privilege: A legal term denoting the protection of confidential client information in a legal proceeding, including subpoena, deposition, and testimony.

Pro bono publico: Contributing professional services without regard for financial gain.

Professional virtual relationship: Using technology and/or social media in the delivery of professional, ethical services to clients.

Psychosocial: Interrelation of social factors with individual thoughts and behaviors.

Records custodian: The person responsible for keeping records in an ordinary course of practice. In some organizations, the custodian is responsible for the accuracy and the security of records, as well as adherence to all ethical guidelines and legal requirements.

Self-growth: A process of self-examination and professional development to enhance professional competence.

Serious and foreseeable: A concept used in negligence tort law to limit the liability of a party to those acts that carry a risk of foreseeable harm, meaning a reasonable person would be able to predict or anticipate the harmful consequence of their actions.

Sexual harassment: Unwanted and offensive physical, verbal, or nonverbal sexual conducts in a workplace, professional, or social situation.

Social justice: Equity for all people, including the distribution of wealth, opportunities, and privileges within a society to end oppression and to provide access to communities, schools, workplaces, governments, and other social or institutional systems.

Social media: Websites and applications that enable users to create and share content, communicate, or participate in social networking.

Subpoena duces tecum: A writ ordering a person to appear before the court and bring relevant documents and other tangible evidence for use at a hearing or trial.

Telemental health: Counseling and therapy services delivered through two-way electronic communication including but not limited to telephone, videoconferencing, email, text, and instant messaging.

18. RESOURCES

American Association of Marriage and Family

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

American Counseling Association

https://www.counseling.org/docs/default-source/default-document-library/ethics/2014-aca-code-of-ethics.pdf

American Mental Health Counselors Association

https://www.amhca.org

American Psychological Association

https://www.apa.org/ethics/code

Association for Child and Adolescent Counseling (ACAC)

https://acachild.org

Association for Lesbian, Gay, Bisexual and Transgender Issues in Counseling (ALGBTIC)

https://www.counseling.org/about-us/governance-bylaws/candidate-profiles/divisions-and-regions/association-for-lesbian-gay-bisexual-and-transgender-issues-in-counseling

Association for Multi-Cultural Counseling and Development

https://www.multiculturalcounselingdevelopment.org

HIPAA Privacy Rule

https://www.hhs.gov/hipaa/for-professionals/privacy/index.html

International Association of Marriage and Family Counselors (IAMFC)

https://www.iamfconline.org

National Board for Certified Counselors

https://www.nbcc.org

19. CONCLUSION

Clearly the major counseling and therapy associations and regulatory divisions agree on the standards, principles, and guidelines that dictate and govern ethical practice.

Today, ethical practice requires competence that goes beyond basic professional foundational standards and involves knowledge of ethical decision making, multicultural awareness and sensitivity, self-awareness to address implicit bias including microaggressions, telemental health practices, ethics codes, and state and federal laws that are continuously evolving.

It is the counselors' and therapists' obligation to stay current with research and revisions in the knowledge, guidelines, and laws that govern their profession.

Many resources are available, and the professional must rely on colleagues, supervisors, associations, and state and local agencies for collaboration on decisions to address complicated ethical dilemmas that may arise. There are no codes or guidelines to address every ethical issue a professional may face, and no decision-making model will apply to all cases. The practitioner must be familiar with the procedures of decision making and include the client when possible to build rapport and participation in the counseling or therapy process.

In addition to collaboration with other professionals, there are case studies, legal statutes, state administrative codes, and considerable research to consider when making ethical decisions. Always apply tests to evaluate the decision before putting the plan into action.

Best practice to ensure the delivery of ethical service relies on the professional acquiring competencies to deliver new methods of telemental health services, continuing self-awareness, knowledge of changing cultures and family dynamics, and culture-fair assessment to inform practice. The professional must continually evaluate their services to ensure they are delivering ethical practice. Every action must be based on the primary focus of client welfare that includes identification of foreseeable harm and taking appropriate measures for prevention.

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.

Works Cited

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2. Eldridge S. Golden Mean. Available at https://www.britannica.com/topic/golden-mean. Last accessed April 3, 2026.

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97364 • Cultural Meanings of Death and Dying

Alice Yick Flanagan, PhD, MSW

www.netce.com

Copyright © 2024 NetCE, All rights reserved.

Service delivery, assessing, intervening and communicating must reflect cultural respect and meet families' and patients' needs. Understanding the cultural lenses by which patients and family members hold about death and dying is a critical component to successful outcomes in clinical encounters in the health, mental health, and social service arenas and the design of culturally sensitive service delivery models. This course will address how race, ethnicity, and culture impact issues of dying, including attitudes toward death, death rituals, grieving and bereavement, advance directives, and palliative care to ensure that culturally responsive care is provided at the end of life. In addition, best practices for interventions and service delivery will be framed within both a culturally relevant and ethical context.

Table of Contents

97364 • Cultural Meanings of Death and Dying

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. THE UNITED STATES: A MULTICULTURAL LANDSCAPE

AFRICAN AMERICANS

ASIAN AMERICANS

HISPANICS/LATINOS

NATIVE AMERICANS

3. CULTURAL COMPETENCE AT THE END OF LIFE

4. CULTURAL ORIENTATIONS AND HEALTH DECISION MAKING

COMMUNICATION

SPACE

BIOLOGIC VARIATIONS

TIME

ENVIRONMENTAL CONTROL

SOCIAL ORGANIZATION

5. DEATH AND DYING: WESTERN MEANINGS

6. ISSUES OF DEATH AND DYING: CULTURAL CONSIDERATIONS

DELIVERING BAD NEWS AND DISCUSSING END-OF-LIFE ISSUES

BELIEFS REGARDING DEATH

THE NOTION OF A GOOD DEATH

DEATH OF A CHILD

DEATH RITUALS

MOURNING, GRIEF, AND BEREAVEMENT

ADVANCE DIRECTIVES

PALLIATIVE CARE

7. CULTURALLY SENSITIVE COMMUNICATION STRATEGIES

ASSESSMENTS

THE ROLE OF INTERPRETERS

INTERPROFESSIONAL COLLABORATION

8. CULTURALLY SENSITIVE PRACTICE AT THE END OF LIFE: ETHICAL CONSIDERATIONS

9. CONCLUSION

Works Cited

Evidence-Based Practice Recommendations Citations

97364 • Cultural Meanings of Death and Dying

Education Category. Ethics - Human Rights

Release Date. 09/01/2024

Expiration Date. 08/31/2027

Course Overview

Service delivery, assessing, intervening and communicating must reflect cultural respect and meet families' and patients' needs. Understanding the cultural lenses by which patients and family members hold about death and dying is a critical component to successful outcomes in clinical encounters in the health, mental health, and social service arenas and the design of culturally sensitive service delivery models. This course will address how race, ethnicity, and culture impact issues of dying, including attitudes toward death, death rituals, grieving and bereavement, advance directives, and palliative care to ensure that culturally responsive care is provided at the end of life. In addition, best practices for interventions and service delivery will be framed within both a culturally relevant and ethical context.

Audience

This course is designed for physicians, nurses, social workers, therapists, mental health counselors, and other members of the interdisciplinary team who work with diverse racial and ethnic minority groups and their families during the end of life.

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. NetCE is approved to offer continuing education through the Florida Board of Nursing Home Administrators, Provider #50-2405. 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 approved as a provider of online continuing education for certified nursing assistants through the California Department of Public Health Licensing and Certification Division. Nurse Aide Certification (NAC) Provider #7005. 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. 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. 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.

Designations of Credit

This activity was planned by and for the healthcare team, and learners will receive 5 Interprofessional Continuing Education (IPCE) credit(s) for learning and change. NetCE designates this enduring material for a maximum of 5 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 5 ANCC contact hour(s). NetCE designates this continuing education activity for 6 hours for Alabama nurses. NetCE designates this continuing education activity for 2.5 NBCC clock hour(s). Social workers participating in this intermediate to advanced course will receive 5 Cultural Competency continuing education clock hours. Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 5 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 5 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. This activity has been approved for the American Board of Anesthesiology’s® (ABA) requirements for Part II: Lifelong Learning and Self-Assessment of the American Board of Anesthesiology’s (ABA) redesigned Maintenance of Certification in Anesthesiology Program® (MOCA®), known as MOCA 2.0®. Please consult the ABA website, www.theABA.org, for a list of all MOCA 2.0 requirements. Maintenance of Certification in Anesthesiology Program® and MOCA® are registered certification marks of the American Board of Anesthesiology®. MOCA 2.0® is a trademark of the American Board of Anesthesiology®. This activity has been designated for 5 Lifelong Learning (Part II) credits for the American Board of Pathology Continuing Certification Program. 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. This home study course is approved by the Florida Board of Nursing Home Administrators for 5 credit hour(s). AACN Synergy CERP Category B. NetCE is authorized by IACET to offer 0.5 CEU(s) for this program. NetCE designates this continuing education activity for 5 credit(s).

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 fulfills the Maryland requirement for 3 hours of anti-oppressive content, including cultural humility, social justice, racial equity, implicit bias, or anti-racism practices. This activity is designed to comply with the requirements of California Assembly Bill 1195, Cultural and Linguistic Competency.

Course Objective

With the ever-increasing multicultural diversity in the landscape of the United States, culturally competent and sensitive practice is essential for practitioners. The purpose of this course is to increase clinicians' knowledge and awareness of the impact of culture on issues of death and dying in order to improve the provision of care and patients' quality of life.

Learning Objectives

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

1. Discuss the changing demographic trends that contribute to the United States' multicultural landscape.

2. Define the importance of cultural competence when working with patients and families around end-of-life issues.

3. Compare and contrast Western and non-Western sociocultural values surrounding end-of-life topics.

4. Describe cultural belief systems, values and norms for various racial and ethnic minority groups around death and dying issues including discussing death, attitudes towards death and dying, death rituals, grieving and bereavement, advance directives, palliative care, and other end-of-life issues.

5. Discuss culturally sensitive communication strategies when discussing death and dying and end-of-life issues with racial and ethnic minority patients and families, including the role of interpreters.

6. Identify best practice guidelines that reflect ethical cultural competence and sensitivity when working with racial and ethnic minority patients and families around issues related to the end of life.

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.

Faculty Disclosure

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

Division Planners

John M. Leonard, MD

Mary Franks, MSN, APRN, FNP-C

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

When patients and their families are confronted with a terminal illness and issues of death and dying, it is undoubtedly a time of grief and stress. Although patients and families require support during this period, practitioners may be uncomfortable witnessing grief, as it may raise personal issues about their own mortality. This is further complicated when the issue of culture intersects with this highly emotional topic.

Culture is defined as the values and knowledge of groups in a society; it consists of approved behaviors, norms of conduct, and value systems as well as attitudes and beliefs that are passed from generation to generation within a group [1]. Culture is the lens by which individuals view the world and interact with others, the natural environment, and higher power(s) [2]. It is dynamic, and the shared meanings influence day-to-day interactions with other individuals and their own behaviors [11]. Although these definitions of culture are frequently presented as if there is a universal consensus, in practice, culture is a challenging concept to measure [8].

On the other hand, ethnicity is a marker of culture. Both cultural values and ethnicity influence death and dying and decisions regarding end-of-life issues [3].When there is a discrepancy between the linguistic and cultural value systems of the practitioner and patient, this increases the risk for cross-cultural miscommunication [4]. When communication styles, patterns, and differences are perceived to be irreconcilable, patients are more likely to become dissatisfied with services and to terminate treatment prematurely. This course will address how race, ethnicity, and culture impact issues of dying, including attitudes toward death, death rituals, grieving and bereavement, advance directives, and palliative care to ensure that culturally responsive care is provided at the end of life. In addition, best practices for interventions and service delivery will be framed within both a culturally relevant and ethical context.

2. THE UNITED STATES: A MULTICULTURAL LANDSCAPE

The U.S. Census utilizes a variety of ways to measure diversity. One approach is the diversity index, which is a calculation that "tells us how likely two people chosen at random will be from a different race and ethnicity groups" [17]. The index ranges from 0 to 100, with 0 signifying a lack of diversity and 100 indicating greater diversity. The diversity index for the total population in the United States in 2020 was 61.1%, which means there is 61.1% chance that any two people chosen at random were from different racial or ethnic groups [17]. In 2010, the national diversity index was 54.9%, indicating that diversity increased over the past decade. By 2044, more than half of the U.S. population will identify as a racial minority [10]. This group is also a young population. By 2060, the minority population is expected to increase to 241 million, with the Hispanic population growing by 142%, the Asian population by 116%, and African American population by 50% [5].

Hawaii, New Mexico, California, the District of Columbia, and Texas are regions in the United States that consist of a "majority-minority," meaning that more than half of the areas' populations consist of individuals who are an ethnicity other than non-Hispanic white [6]. In California and Texas, the diversity index among those 35 to 44 years of age is 69.9% and 68%, respectively [17]. With the increase of immigration and the slower birth rate in white families, it is anticipated that the United States is rapidly moving toward becoming a majority minority [6]. The Hispanic or Latino population are expected to increase from 19.1% in 2022 to 26.9% in 2060 [21].

It is important to remember that ethnic/racial minority groups are highly diverse, even among persons from the same area or group. One factor to take into consideration when assessing and caring for members of minority groups is the practice of religion, which is not always culturally bound. Table 1 contains a brief overview of religious beliefs related to death and bereavement among the major religious groups in the United States. These religious customs may be practiced by any person, regardless of race or ethnicity.

Table 1: AN OVERVIEW OF MAJOR RELIGIOUS IDEOLOGY AS IT RELATES TO DEATH AND BEREAVEMENTa

Topic

Buddhism

Catholicism

Hinduism

Islam

Judaism

Protestantism

Death

It is very important that everything be done to provide a quiet and calm environment for patients for whom death is imminent, as it is believed that calmness of mind at death translates to a better rebirth.

A priest should be called to give the Sacrament of the Sick if death is imminent. Last confession (Sacrament of Penance and Reconciliation) is made to a priest. Cremation is allowed; scattering of ashes is not.

A Hindu priest or Guru may be summoned for last rites. As the soul (jiva) is reincarnated until karmic absolution, death is seen as an opportunity to continue the spiritual journey.

Dying patients may request to face Mecca. Burial usually takes place as soon as possible, and there are special washing and shrouding procedures.

Emphasis on sanctity of life.It is believed that one should not go into death alone; therefore, the dying individual will receive as much attention as possible. A confessional and shema (statement of faith) is read when death is imminent.

Traditions regarding death are also diverse. Some traditions require prayer and liturgies.

Bereavement

Prayers for an auspicious rebirth are said for the 49 days following an individual's death. Meditation on impermanence is also important.

The presence of a priest may be necessary for support during this time. Prayers for the deceased soul may be said, informally and/or formally (Mass and/or the Rosary).

Remorse for the deceased is believed to inhibit the spirit from leaving the body. Therefore, excessive mourning is discouraged, though not always avoided.

The head should be covered when speaking of the deceased. Continuous prayers are recited in the home for three days following an individual's death. Guilt is a common component of grieving.

Bereavement does not formally begin until the burial, after which there is generally a seven-day period of mourning (shiva).

Among Protestants, bereavement is less structured than in other religions. Each person should be individually assessed.

aThis overview is meant only to give a simple, brief summary of general death/dying ideology of each religion. By no means are all of the rites or beliefs described practiced by all members of each religion; likewise, not all religious rites or beliefs are listed for each religion. As always, individualized assessment is encouraged.

Source: [94,111,152,153,154,155]

AFRICAN AMERICANS

"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 blacks as persons "having origins in any of the Black racial groups of Africa" [7].

According to the Pew Research Center, Black Americans numbered 47.9 million in 2022, with the greatest concentration living in New York City (3.6 million) [156]. By 2060, it is projected African Americans and Black immigrants will comprise one-third of the U.S. population [215].

This group tends to be young. In 2022, the median age for this group was 32.1 years, which was much lower than the median of 38 years for the United States [156]. In terms of educational attainment, 87.9% of African Americans 25 years of age or older had a high school diploma or completed college in 2019 [20]. Approximately 26% of Black Americans have attained a Bachelor's degree [156].

ASIAN AMERICANS

As of 2021, 24 million Americans identified as Asian [189]. Between 2000 and 2019, Asians experienced the greatest growth compared with any other racial group at 81% [157]. In 2017, this group had the highest growth rate, at 3.0% [15]. 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 [110]. In 2021, Chinese Americans (excluding Taiwanese Americans) numbered at 5.2 million [189]. They also have the highest educational attainment; 55.1% of Asians 25 years of age or older have a bachelor's degree or higher in 2021 [189].

"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 [12]. 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 [12]. There are more than 25 Asian/Pacific Islander groups, each with a different migration history and widely varying sociopolitical environments in their homelands [13].

Asian American groups have differing levels of acculturation, lengths of residency in the United States, languages, English-speaking proficiency, education attainment, socioeconomic statuses, and religions. For example, there are approximately 32 different languages spoken among Asian Americans, and within each Asian subgroup (e.g., Chinese), multiple dialects may be present [13,14]. In 2019, California had the largest Asian American and Pacific Islander population, totaling 6 million [190].

HISPANICS/LATINOS

In 2020, the Hispanic population in the United States numbered 62.1 million [191]. The majority of the Hispanic population in the United States (35.9 million) identify themselves as being of Mexican descent [192]. Approximately 27% of the U.S. Hispanic population identify as Puerto Rican, Cuban, Salvadoran, Dominican, Guatemalan, Colombian, Honduran, Ecuadorian, or Peruvian [16].

In 2020, the Hispanic population comprised 19% of the U.S. population [191]. As such, they are the largest ethnic minority group in the United States. By 2060, Hispanics are expected to represent 31% of the U.S. population [8]. They are also a young group, with a median age of 29.8 years [158]. In 2019, the three states with the largest Hispanic population growth were Texas (2 million), California (1.5 million), and Florida (1.4 million); these three states have the largest Hispanic populations overall [159].

NATIVE AMERICANS

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 [19]. In the United States, there are 574 federally recognized tribal governments and 324 federally recognized reservations [193].

In 2020, it was reported that there were 9.7 million Native Americans in the United States [193]. By 2060, this number is projected to increase to 10.1 million, or 2.5% of the total population [160]. The largest group are those who identify as Cherokee [193].

In general, this group is young, with a median age of 31 years, compared with the general median age of 37.9 years [112]. In 2018, the states with the greatest number of residents identifying as Native American are Alaska, Oklahoma, New Mexico, South Dakota, and Montana [113]. In 2016, this group had the highest poverty rate (26.2%) of any racial/ethnic group [112].

3. CULTURAL COMPETENCE AT THE END OF LIFE

Evidence Based Practice Recommendation

According to the National Coalition for Hospice and Palliative Care, members of the palliative care team should recognize that the provision of quality palliative care requires an understanding of the patient's and family's culture and how it relates to their decision-making process, and their approach to illness, pain, psychological, social, and spiritual factors, grief, dying, death, and bereavement.

https://www.nationalcoalitionhpc.org/wp-content/uploads/2020/07/NCHPC-NCPGuidelines_4thED_web_FINAL.pdf

Last Accessed: August 28, 2024

Strength of Recommendation/Level of Evidence: Guideline (Expert opinion)

Although there is no universally agreed upon definition of cultural competency, three main themes are generally included in any discussion of the topic: cultural sensitivity, cultural knowledge, and cultural skills [2]. The goal of cultural competency is to reduce the differences between the institutional cultural norms of service delivery agents and the belief systems of patients from diverse cultural groups. Ultimately, this will help to minimize the disparities that exist in the current mental health and healthcare systems [22].

Cultural sensitivity consists of promoting trust and mutual respect for cultural differences between providers and patients [2]. In end-of-life care, an understanding of cultural differences in beliefs about grieving is necessary. In Western culture, grieving is expected to be time-limited, and extended grieving can be considered pathologic [23]. However, in other cultures, extended periods of grieving are socially sanctioned. For example, Egyptian parents who have lost a child are allowed a grieving period that lasts up to seven years [24]. Some cultural and religious groups avoid talking about death and are therefore reluctant to discuss end-of-life planning, believing that to do so communicates defeat [194]. In terms of program planning, cultural sensitivity can be expressed in the design and implementation of physical layouts of space. For example, some cultures (e.g., Native American) revolve around extended family and the community. The physical environment in which a patient receives care should take into account this collectivistic orientation. Rooms large enough to accommodate the many extended family members who come to visit would be needed [25]. In Muslim culture, a patient and his/her family members might request that the patient's bed face Mecca [114]. Many Hmongs practice rituals, such as using charms to ward off evil spirits [161].

Cultural knowledge is an important component of cultural competency, as practitioners should have a foundational understanding of different cultural worldviews, beliefs systems, and practices [2]. The United States and other Western countries, for example, are guided by cultural values of individualism, which focus on autonomy and independence. In the healthcare system, practitioners emphasize that patients have the right to make their own decisions regarding care. Consequently, informed consent, whereby practitioners will convey information to individuals so that they can make an informed decision about their care, is the backbone of health decision-making processes in the United States [26]. However, other cultural groups have a more collectivist orientation, which emphasizes group decision making with the family rather than individual autonomy [26,162]. Key family decisions about treatment and lifesaving measures are discussed by the family, which decides together what will be done [163]. Practitioners who do not understand this may feel that a family is undermining the patient's autonomy or that the patient is overly dependent. At the same time, there is no one piece of cultural knowledge that fits all. There is tremendous heterogeneity within groups, some of which can be can attributed to generational differences [194].

Finally, the ability to integrate and apply cultural sensitivity and knowledge in one's day-to-day practice with patients is referred to as cultural skill [2]. Cultural groups adhere to culturally laden beliefs about death rituals, death symbols, language, gender roles, advanced care planning, end-of-life directives, and bereavement and grief. As a result, a provider's level of cultural competence will influence how he or she interacts with patients and family members during the end of life, ultimately influencing how patients and families perceive the end-of-life experience [135]. In traditional Asian families, for example, the eldest son may be designated to make key health and end-of-life decisions [114]. Various cultural groups will have specific norms about the expression of emotion during funerals. White Protestant individuals, for example, may value stoicism, while the Chinese equate the amount of wailing to the amount of respect paid to the deceased [27]. Crying that involves shaking of the body is considered cathartic and a normal reaction in some cultures [28].

Conveying bad news is another culturally specific practice. In Western cultures, truth telling and honesty are generally highly valued and are considered essential parts of the informed consent process. However, some Asian patients may consider a direct statement conveying bad news (e.g., a poor prognosis) to be rude and inappropriate [135]. For these patients, a more indirect approach using euphemisms may be preferred [29]. Outside of the United States, practitioners often conceal serious diagnoses because disclosure is viewed as disrespectful and harmful to the patient [30]. Practitioners who are not aware of these cultural differences may inadvertently label behaviors as problematic or pathologic.

For many cultural groups, dying is viewed as a process, and within this process, there are social events, preparations, and many relationships involved. Family members respond to these events dynamically. Consequently, healthcare providers should understand that the wishes of the patient and family may change or evolve [164]. Ultimately, cultural competence in the area of illness and death involves adopting a holistic and phenomenologic perspective, which asserts that "the subjective experience of illness, rather than physiologic descriptions of disease, should take priority. If care is to be 'person-centered,' it is necessary to enter the patient's world, to see the illness through the patient's eyes. A phenomenologic approach which attempts to understand the experience of illness 'from the inside' is therefore highly appropriate" [115].

It is also important to consider intersectionality in discussions of cultural competence. Individuals do not belong in one category in terms of their identity. Often, patients have overlapping identities (e.g., sex/gender, socioeconomic status, religion, class, sexual orientation, racial/ethnic minority group). This contributes to discrimination and marginalization, which influences how one experiences death and dying [136]. Some experts assert that the word "competence" in cultural competence is a misnomer, because it implies that providers can obtain a "rational mastery and application of knowledge" [165]. Instead, some argue for the need of cultural humility, which requires continuous self-reflection and a mindset that is interwoven into all aspects of clinical care [195]. Asking open-ended questions about one's own implicit biases, stereotypes, and prejudices can help to foster healthy end-of-life communications with families and patients. End-of-life care planning is complex, and cultural competence entails being reflective and accessing one's intuition.

4. CULTURAL ORIENTATIONS AND HEALTH DECISION MAKING

Giger and Davidhizar's Transcultural Assessment Model is often used to provide a framework to conceptualize the role of cultural orientations and belief systems in shaping health decision making. The Model identifies six cultural phenomena that practitioners must understand and incorporate into practice when working with culturally diverse patients and families. These six domains are [31]:

- Communication

- Space

- Biologic variations

- Time

- Environmental control

- Social organizations

Issues may arise in any or all of these categories. This is particularly true when addressing a complex issue such as end-of-life care.

COMMUNICATION

Communication, the process of sending a message from one party to another, consists of both verbal and nonverbal components. Verbal and nonverbal communications are embedded within the culture of the parties disseminating the information and within the culture of the parties receiving the information. Communication is complex and multilayered because it involves unstated, implicit rules regarding a variety of factors, including physical distance between parties, tone of voice, acceptable topics of discussion, physical contact, and amount of eye contact [32]. Each of these variables is influenced by the perception of the level of formality/informality of the situation. Frequently, misunderstandings occur because the decoding and interpretation of nonverbal cues are not accurate.

The verbal component of communication is just as complicated. Certainly, similarity in language shared by both parties enhances communication, but assuming that both parties in a conversation speak the same language, how the information is interpreted is still influenced by a host of factors. Linguists have posited that approximately 14,000 different meanings and interpretations can be extracted from the 500 most common English words [33]. Consequently, practitioners must be aware of the different communication styles held by diverse ethnic minority patients, as the clinical communication process is the primary vehicle by which problems and solutions are identified and conveyed [34].

Styles of communication can be classified from high- to low-context [35]. High-context cultures rely on shared experience, implicit messages, nonverbal cues, the environment, and the relationship between the two parties to disseminate information [33,196]. Members of these cultural groups tend to listen with their eyes and focus on how something was said or conveyed [32,35]. On the other hand, low-context cultures rely on verbal communication, or what is explicitly stated in the conversation [33]. Consequently, low-context communicators listen with their ears and focus on what is being said [32,35,196]. 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 African Americans, are considered high-context [35]. In one study, older immigrant Korean elders reported minimal communication with a healthcare provider about end-of-life issues [116]. This trend may be because practitioners assume that Korean and other Asian elders are not comfortable talking about death and dying, based on the cultural belief that discussing death openly invites bad events [166]. Asian elders tend not to explicitly raise the topic; practitioners should watch for nonverbal cues and resist ascribing this belief to all members of the Asian community. The Western biomedical culture emphasizes clear, concise, and precise communications, but this may appear to be brusque and insensitive to patients and families from high-context cultures [196]. Furthermore, there are some groups, like many Asian groups, who emphasize emotional restraint. Coupled with both a reliance on high-context communication styles and an avoidance in discussing end-of-life issues, it brings additional complexities to palliative care and discussion of end-of-life issues [197]. Clearly, adherence to cultural values influences communication styles. Cross-cultural communication is by no means simple, and there is no set of rules by which to abide. Instead, promoting culturally sensitive communication is an art that requires practitioners to self-reflect, be self-aware, and be willing to learn. Therefore, as practitioners become skilled in noticing nonverbal behaviors and how they relate to their own behaviors and emotions, they will be more able to understand their own level of discomfort and comprehend behavior from a cultural perspective [32].

SPACE

The amount of social space or physical distance between two communicating parties is culturally charged as well. Depending upon the social context, Westerners tend to maintain a distance of about 3 feet, or an arm's length, in conversations [33]. In a public setting, where both parties are engaged in a neutral, nonpersonal topic, Westerners will feel encroached upon and uncomfortable if an individual maintains a closer conversational distance. However, in other cultures, such as Latino and Middle Eastern, a closer distance would be the norm [33]. Asians tend to prefer more space between the two conversational parties until they have developed a relationship. Chung recommends that in a clinical setting, the practitioner allow Asian patients to set the tone and social distance [36]. The practitioner can sit first and permit the patient to select where he/she would like to sit.

BIOLOGIC VARIATIONS

Biologic variations are differences in food preferences, physical development, and physical appearance. Cultural groups have unique beliefs about food and its place in society and one's life. For example, the concepts of the yin and yang and "hot" and "cold" are very common among Asian, Indian, Muslim, and some Latino cultures [37]. Foods are identified as "cold" or "hot," with the goal of balancing one's consumption of each type; too much of one can trigger illness. Similarly, medications may be considered "hot" or "cold." If an illness is believed to have been caused by "hot" foods or energy, the treatment would be "cold." Some patients who are reluctant to follow a course of treatment may be concerned regarding this balance. Practitioners should explore the underlying reason for this reluctance rather than simply categorizing a patient as "resistant" or "difficult."

TIME

Time and time orientations, or how individuals view the past, present, and future, are also culturally laden. Americans tend to have a monochronic orientation, meaning they prefer to do one thing at a time and are focused on the efficient management of time [36]. However, other groups, such as Native Americans and Hispanics, are more present-oriented, viewing time as rhythmic and circular [38,39]. Some cultural groups are also polychronic, preferring to work on multiple activities simultaneously. Depending upon a group's orientation, some may believe that it is more important to be attuned with nature and go with the "flow" than to follow a schedule [36]. These time orientations have implications for health decision making and the practitioner/patient relationship. Members of cultural groups that are more present-oriented will not necessarily adhere to time tables and appointments and may find it less amenable to plan advance directives [39]. This may be perceived as lackadaisical or rude by those who are not familiar with the group's cultural norms about time [37].

ENVIRONMENTAL CONTROL

Environmental control refers to one's perceived ability to control external factors in the environment [37]. In many Western countries, the cultural principles of individualism and the Protestant work ethic pervade. In these cultures, the belief in personal responsibility is vital; one is expected to take control of destiny and exert control over the external environment. By extension, Western medicine focuses on curative and preventive medicine, which again emphasizes autonomy and control. However, some groups have a more fatalistic view, attributing outcomes to chance, destiny, or fate [37]. These groups have externalizing explanations of disease etiologies, focusing on possible causes that are rooted in either the environment or specific circumstances. In cultural groups with externalizing explanatory systems, disease may be attributed to an individual who is believed to hold a grudge or an angry ancestor.

SOCIAL ORGANIZATION

The networks and groups (e.g., family, church, tribes, community, religion) with which individuals identify and derive their identity, social support, and frames of reference are considered a culture's social organization. These social organizations play an important role in individuals' decision making and health behaviors. For example, in Hispanic families, the cultural values of familismo (emphasizing the family over the individual), respeto (respect for older persons), and dignidad (maintaining dignity and not asking for help) impact family members' decisions regarding the use of nursing homes and hospice care [40]. Respect for the patient's religious and spiritual beliefs is also vital. For example, Muslim patients and their families may require prayer mats in the rooms. Care of female patients in certain racial/ethnic minority groups should take into consideration the gender of the practitioner and minimize unnecessary touching [167].

Traditional Asian beliefs and values are often centered around Confucian thought, which focuses on harmony, unity, and family [36]. Children are expected to obey their parents and demonstrate filial piety and to repay their parents for all the sacrifices they have made for them. Members of Asian families that emphasize the role of filial piety may feel that the family should provide the care to the patient or that family members should be active decision-makers for the patient's care while the patient assumes a more passive role in decision-making [135,198]. Asai and Kameoka further argue that it may not necessarily be filial piety that influences the Japanese to provide caregiving, but rather the cultural value of sekentei[41]. Sekentei refers to social dignity, reputation, and social appearance in public. It taps into the notion of individuals behaving in a certain way in order to influence the public's perception of them. In terms of caregiving, sekentei comes into play because individuals are concerned about what others may think of them if they do not provide caregiving [41].

5. DEATH AND DYING: WESTERN MEANINGS

The Victorian Age (1837–1901) shaped much of the modern norms of death and grieving [199]. Queen Victoria of England had lost her husband, Prince Albert, in 1861, and the public witnessed her extensive mourning and death rituals. More elaborate coffins and carriages were required, and originally carpenters by trade, they grew into the role of funeral directors [199].

Western notions of death, dying, and grief have also been shaped by the Western biomedical model and Sigmund Freud's theoretical paradigm outlined in the publication Mourning and Melancholia [42]. In general, Western traditions believe that life begins and ends, and death is primarily viewed as the cessation of the individual's bodily organs [117]. In Western cultures, death is generally considered a topic that should not be discussed. When death occurs, particularly for those who have been ill, members of this culture tend to assume that the biomedical model has failed. Some experts have referred to this Western concept as "death denying" [137,138,200]. Overall, in Western culture, individuals tend to remove or detach themselves from the death and dying process [168]. This detachment from death and dying has been linked to two social trends. The first is that as technology became increasingly advanced, medical facilities had the equipment to help patients stay alive, and therefore, hospitals became the place where people eventually died [199]. Second, the notion of a "good death" became prevalent in the 20th century. This included the belief that dying should be pain-free [199]. The biomedicalization of aging has also conveyed the message that aging and, in many ways, death and dying can be controlled with modern medicine [200].

When it comes to grief, Freud distinguished between normal and pathologic grief, defining pathologic grief as the inability to "decathect" from the relationship with the deceased. Freud believed individuals who could detach themselves and move on were experiencing "normal" grief. According to this paradigm, the "normal" grief period is an intensely emotional time, but it is time-limited, with an expectation that the bereaved should return to normal functioning as quickly as possible [23]. If an individual is unable to detach in an "acceptable" period of time, then pathologic symptoms will emerge. Freud's theoretical assumptions were based on Western cultural beliefs that mourning is a private affair and that death is final [43]. If an individual experiences pathologic grief, according to this definition, grief work with a mental health professional may be undertaken. However, in Western cultures, individuals are generally expected to "work through" their grief alone [23].

In the United States, there are generally no post-funeral rituals to facilitate grieving or assist surviving family members and friends to reintegrate into life without the deceased [44]. There are concrete tasks that must be completed, such as filing life insurance and social security claims, closing bank accounts, and executing wills, that keep family members busy, but they do not allow for advancement of the grief process [44]. As a result, surviving family members may struggle with how to express or experience grief. In Western cultures, public displays of grief after a funeral signal pathologic grief and make others uncomfortable [44]. Grief is to be regulated by oneself, and if this is not possible, particularly over a period of time, the grieving individual is expected to obtain help through a professional or self-help group [118,138]. Ultimately, grief is meant to be worked in a limited amount of time [118]. This is manifested in terms of the amount of leave time (e.g., three days) a workplace allows for bereavement [137].

In the United States and Northern Europe, mourning practices may have shifted during World War I [45]. Prior to this, during the Victorian period, there were prolonged and complex mourning practices, some of which lasted for more than two years. However, because of the high death toll in the war, it has been posited that society psychologically distanced itself from the mourning and grieving process. Instead of expending time and effort with death and mourning rituals, energy was expended on working and patriotic efforts [44]. This may have formed the foundation of modern Western views of death and dying.

6. ISSUES OF DEATH AND DYING: CULTURAL CONSIDERATIONS

It is important to remember that the following discussion about the role of culture in issues related to death and dying is not prescriptive. It is not meant to be applied universally across racial and ethnic minority groups, as there is a tremendous amount of diversity within each of these groups. Age, gender, educational level, age at immigration, immigration status, socioeconomic status, and acculturation level all contribute to this rich heterogeneity.

DELIVERING BAD NEWS AND DISCUSSING END-OF-LIFE ISSUES

Bad news has been defined as any information that would negatively affect their views of the future [119]. Unfortunately, the delivery of bad news and end-of-life planning cannot be avoided. When necessary, adhering to culturally sensitive practice can ensure patient satisfaction, as truth telling is culturally influenced. As discussed, the Western biomedical model emphasizes the full disclosure of information to allow for informed decisions [29]. This model assumes that patient autonomy is paramount and that patients want to hear a realistic assessment of their prognosis, which may not be true in all cultures [29,139,166]. For example, some Native American groups, such as the Navajos, believe that language can dictate reality and therefore outcomes [46]. Traditional Japanese cultural beliefs maintain that language has a soul of its own, referred to as kotodama, a term meaning word and soul [47]. Chinese culture also includes a belief that talking about death will attract evil spirits, bad luck, or ghosts, which can bring about bad fortune or even death itself [197]. In these cases, language is believed to be so powerful that it can dictate the course of events [47]. This is also the case in some Pacific Islander groups (e.g., Maori) who believe that words can transform the thought into reality [120]. Some who adhere to this belief may avoid talking about death and serious illnesses [48]. Others may prefer that communication be more indirect, relying on nonverbal means, inferences, and euphemisms [29]. These patients may want information but prefer that it be delivered in an indirect manner [166].

The amount of family participation is another consideration in the disclosure of bad news, particularly in collectivistic cultures. In some collectivistic cultures, the family can supersede the individual's decisions and preferences [121]. Collectivistic cultures emphasize the importance of other people and the community versus personal autonomy [49]. In one qualitative study comparing non-Hispanic whites' and Hispanics' perspectives regarding hospice care, death, and terminal prognoses, the cultural value of familism appeared to play a dominant role. Among the Hispanic participants, family members felt that it was their duty to protect the patient as well as other family members [50]. In some cultures (Hispanic/Latino, Asian Indian), telling the truth to a family member is frowned upon because they believe this can destroy a person's hope, expediting death [140,141]. Some Chinese physicians and nurses refrained from using the words "cancer" and "tumor," preferring instead the word "disease" [198]. This was not as common a theme among white participants. In another qualitative study that focused on the perspectives of oncologists working with immigrant families and patients, oncologists stated that the families were the biggest barrier to "truthful" communication [121]. Some participants indicated that family members would attempt to "ambush" or "catch" the doctor before they had a chance to speak to the patient [121]. Similarly, in Chinese cultures, especially those adhering to Confucian principles, strict truth-telling goes against the cultural value of striving toward family harmony and the belief that the family knows best [140]. In some cases, family members may serve as interpreters. When this occurs, family members are put in the position of delivering bad news. Some providers choose family interpreters because they feel that family will be in a better position of knowing the patient's needs [169]. However, it raises serious ethical and professionals issues.

Practitioners may feel torn between upholding Western ethics of autonomy and respecting the desires of the family members and being culturally sensitive [121]. Again, keep in mind that the cultural values underpinning the concepts of patient autonomy and collectivism will guide decisions regarding the delivery of bad news and discussions of death and dying. Assumptions should not be made based on a dichotomous categorization.

BELIEFS REGARDING DEATH

All cultures attribute specific meanings and significance to death and dying, and these meanings are influenced by the group's religious, philosophical, and cultural belief systems. Although it is beyond the scope of this course to provide a comprehensive discussion of all of the beliefs of racial and ethnic minority groups, this section will provide a very broad overview based on a sampling of various cultural groups.

Many Hispanic cultures normalize death as part of the course of life and part of God's will (fatalism) [142]. In Mexican culture, death is often portrayed in art, literature, and history, leading some to claim that Mexicans have a "cultural familiarity with death" [51]. In Hispanic cultures, familismo plays a prominent role in the remaining life of the patient. All individuals who are considered family members, including children, have a place in the dying process [122]. Family members often come from afar and drop their day-to-day responsibilities to be with the patient [122].

For African Americans, there is tremendous diversity in views about death depending upon individuals' religious affiliations. For example, African Americans with a Baptist tradition generally believe in heaven as an afterlife where the deceased will see God [51]. Some African Americans believe cremation inhibits entry into heaven [170]. A growing number of African Americans are Muslim, and Muslim tradition emphasizes spiritual progression in the afterlife.

It is important to remember that there is no single monolithic culture among Native Americans, and they are very diverse in their beliefs regarding death. The concept of death for Native Americans is defined by beliefs regarding balance and harmony. In many Native American traditions, the worlds of the living and the dead are not separate but are believed to exist simultaneously. The bodies of the deceased help the earth to produce new life, thereby extending the cycle of life [52]. Some tribes in North America believe that the spirit and body are separate and when someone dies, the spirit leaves the body and travels in the land of the dead and can communicate with ancestors [201]. In a qualitative study with 27 participants from the Creek tribe, the individuals described transitions as being circular—not beginnings or finalities [52]. According to this belief system, death is an essential part of the cycle of life. However, not all Native American groups hold these same beliefs [53].

Chinese views about death are influenced by Confucianism, Taoism, traditional Chinese medicine, and Buddhism [54]. Similarly, Japanese views of death are influenced by Shintoism, Confucianism, and Buddhism. In general, death is considered a taboo topic and to talk about death is to potentially bring about misfortune [27]. In a study in China, nurses discussed how they would incorporate traditional Chinese customs (e.g., placing a red apple at the nursing station to signify safety) [202]. Sometimes, they encouraged family members to pass out red envelops to ward off bad luck after certain medical procedures [202]. In Chinese and Japanese cultures, the soul is believed to remain in the body after death [123]. This belief informs various traditions surrounding death. For example, in Japan, after the physician officially declares the death, the nurses clean the body and apply makeup to the face of the deceased. A "seeing-off ceremony" involving the physicians, nurses, and family members is then done during the transfer of the body to the mortuary [123]. Similarly, Hmongs believe that the soul of the deceased individual requires help transitioning to the next life. Shamans, funeral singers, and soul guides may be invited to assist in this endeavor [163].

The Chinese adhere to specific rules regarding treatment of the dead that reflect back to principles of propriety and filial piety. This includes ancestor worship, which consists of surviving family members honoring the dead by performing certain rituals (e.g., bringing and burning food and paper money at gravesites during an annual holiday to commemorate the dead) [27]. Ancestor worship rituals perpetuate the bond between the living and the dead [54]. Some Chinese individuals adhere to "memorial piety," or demonstration of remembrance through ancestor worship [171]. Not adhering to these traditions can cause displeasure among the ancestors and result in bad luck. This belief is partially an extension of the Chinese belief in evil spirits or qi (i.e., the flow of energy, in this case bad energy) [55]. In many Asian cultures, the ghosts of the dead can cause bad luck, ill health, or even death, as early deaths are considered the result of evil or angered spirits [55]. Widows are considered bad luck, and during the first year of mourning, they are expected not to join in weddings, birthdays, and other celebrations [124].

THE NOTION OF A GOOD DEATH

The concept of a good death is prevalent in many cultures and is reflective of societal views about both a good life and a good death [172]. These beliefs influence treatment and end-of-life care decisions. From a Western perspective, patients who die with dignity, pain-free, and with an opportunity to communicate openly with family members and make decisions regarding end-of-life care are believed to have had a good death [56,125]. This is the underlying notion of Western palliative care [172]. In one study, older patients defined a good death as having family and friends by their bedside and having advance knowledge of their imminent death [143]. This conception of a "good death," in which one controls the activities and environment, is congruent with Western values of individualism [144].

Although many racial and ethnic minority groups share similar definitions to Western views of a good death, there are some cultural variations. For African Americans, the concept of a good death is dependent on the amount of control an individual has over his/her dying process and the amount of closure in his/her life [57]. Spirituality and religion are paramount in many African Americans' lives, and African American focus group participants stated that the deceased having a relationship with their Lord is a defining dimension of a good death [126]. In a systematic review, African Americans and Hispanics identified spiritual support as key to a good death [164]. Koreans have a specific term, ho sang, meaning good death or blessed death, used to describe death following a long and a prosperous life [58]. One study of older Korean individuals found that they defined a good death as having the following components [59,173]:

- Having their children outlive them

- Dying with their children around them

- Having lived life without being a burden to their children

- Fulfilling their parental duties

- Dying without pain

- Completing the natural order of life

- Being prepared for death

These components clearly reflect the Asian cultural values of filial piety and family. In a qualitative study of Chinese cancer patients in Hong Kong, participants defined a good death to include positive relationships with family members, control of one's life and symptoms/pain, and acceptance and awareness of death [60]. In a study with Asian Buddhists, the two main components of a good death were lack of suffering/being free of pain and having family around [94]. Additional factors that contribute to a good death in Chinese cultures include good relationships with family, independence, positive mental status, and physical and environmental comfort prior to death [125].

DEATH OF A CHILD

The death of a child, regardless of how old, is a tremendous crisis to families. It can bring into question the order of life and trigger unique family dynamics [126]. The challenge to processing this grief lies in constructing meaning of the traumatic event and integrating the loss. Again, it is impossible to provide a comprehensive cultural analysis, as variations exist within cultural groups.

The Chinese have a saying that black hair should not precede white hair. In other words, the death of a child should not occur before the death of a parent, because, among other reasons, this would prevent the child from fulfilling obligations of filial piety [145]. Similarly, the Korean culture has an adage that when a parent or spouse dies, one buries them underground, but when a child dies, they are buried in the loved one's heart [61]. In many cultures, the death of a child is viewed as bad luck caused by evil spirits, perhaps as punishment for some past misdeed [27,55]. Many traditional Chinese families will not hold a burial or funeral for children in part because the death of a child is considered a bad death (i.e., shameful) and because the hierarchal family roles dictate deceased children should not be worshipped by adult living family members [62,124]. If one is held, it is not elaborate, and parents and grandparents are not expected to attend because their presence could bring about more misfortunes [62]. In these cases, only children, accompanied by their parents to watch and supervise them, will be present; it is not customary for elders to pay their respects to children [63]. In some cases, children will precede the coffin while the older generation follows, with the parents at the end [63]. Cultural norms dictate that parents should not overly mourn the death of their children, as this goes against the hierarchal order [145].

In Puerto Rican families, a child who dies is dressed in white as a symbol of innocence [170]. For Catholic families, a novena (a type of worship held over nine days with special prayers asking for forgiveness) may not be needed because the child is considered free of sin [170]. Attendants at these services wear lighter colors rather than black [170]. In Native American cultures, some tribes do not name an infant until after his/her first year, in part due to historically high infant mortality rates. In other traditions, the name of the child may be changed to confuse the spirits, preventing them from making the child ill. Many Native Americans believe that when an infant or young child dies, the child will be reincarnated in another family through another birth [38].

DEATH RITUALS

To many people, death is considered a major life event, in some cases the last, and is marked as such by rites of passage. A rite of passage consists of a series of cultural practices that help transition a group or an individual from one phase of life to another [44,203]. Rituals are practiced as a group or as an individual, and they often have strong symbolic meaning [44]. Neimeyer, Prigerson, and Davies state that rituals "serve both integrative and regulatory goals by providing a structure for the emotional chaos of grief, conferring a symbolic order on events, and facilitating the construction of shared meanings among members of the family, community, or even nation" [64]. During a time of crisis and grief, rituals can be healing and provide structure to chaos [174,203]. Rituals help to acknowledge a change in status, serve as a mechanism to deal with feelings of powerlessness, and maintain a connection to the person who has passed [146,147,174,175]. These behaviors are not always rational, as they involve a high degree of emotion and sensory stimulation [175]. Rituals also bring people together to mourn and enhance relationships [148,203]. Five factors common to funerals or death rituals across all cultures are [127]:

- Symbols that convey culture, trigger emotions, and help recognize the deceased

- Gathered community to offer support to those left behind

- Ritual action to bring everyone together but also help them to move on with their loss

- Connection to heritage

- Transition of the corpse

Death rituals have order and meaning, but there are other components of these rituals that may be confusing and difficult to explain [63]. It is this incomprehensible dimension that allows for expressions of grief that are consistent with the group's cultural belief system. Understanding death rituals of various cultural groups provides a glimpse into how groups give meaning to life and death [65]. Rituals also provide insight regarding the role of surviving family members in relation to their family, community, and the deceased. Death rituals assist mourners to make the transition to their new identity (e.g., husband to widower) [175]. All of this is influenced by cultural value and belief systems and religion [65].

In Hispanic culture, death rituals are influenced by Catholicism and cultural norms. There is a preference for burials versus cremation, novenas (religious devotion through prayer, usually for nine days), lighting of candles for the deceased for a period of time, and a Mass said for the deceased during the first year and annually thereafter [51,66,176]. Elaborate wakes and large extended family gatherings are common, with food and many family members [176]. Loud wailing is common among the women, but men remain more stoic, conforming to Hispanic cultural values of machismo [51,66].

African American death rituals vary widely as a function of religious affiliation and geographic region. In general, the funeral often involves a large gathering of family and friends to pay respect to the deceased. They are also viewed as "home-going" celebrations, and therefore, the mood is not necessarily somber [177]. In the past, African Americans in the South had a viewing of the deceased in the house before the funeral, but this has largely been abandoned [51]. In some cases, "flower girls" (actually adult women) may walk with the pallbearers during the funeral procession. In Afro-Caribbean cultures, open caskets are common. Laying of hands and touching are common gestures of communicating one's grief [146]. Food is served and memories are shared [146]. In Haiti, funeral and death rituals have elements of Catholicism and Vodou, stemming from Haitian history and West African diaspora resulting from slavery [177].

Death rituals among Native American tribes are also diverse. In one study, 27 Muscogee Creeks were interviewed about their death ritual practices [67]. Sixteen of the participants indicated that the body of the deceased was not left alone until the burial, because the spirit is believed to remain on Earth for four days. During this four-day period, it is believed that the deceased person's spirit visits the different places he/she lived on earth. Family members and friends may leave favorite items and food in the casket, so the spirit will be well provided for during the journey to the afterlife. Other Native American groups place the deceased's belongings in the casket or destroy them, so the spirit does not return looking for his/her things [38]. Native Americans primarily on the West Coast in the United States mark the mourning period with ceremonies involving wailing to provide an opportunity for family members, friends, and the community to come together to grieve. The ceremony ends with a potlatch, which is a lavish feast [201].

In Chinese culture, it is important that the soul of the deceased travels safely, with adequate provisions for the afterlife. After the funeral, it is common to light incense, burn paper money, and have a whole chicken and wine placed at the gravesite [145]. It is believed that the deceased should be provided for, which reflects cultural beliefs about filial piety [27]. After the burial, a meal is offered and attendees are invited to partake as a token of the family's appreciation [148]. The Chinese emphasize the importance of following the customs of death rituals properly as a reflection of one's respect for a parent or elderly relative [68]. The Qingming Festival is a holiday in the spring during which families visit cemeteries to sweep the tombs of their family members, bring food and flowers, and burn incense [178].

Similarly, the Japanese bring "incense money" (koden) to funerals [69]. Survivors place money in an envelope labeled with their name, and the family of the deceased keeps a careful record of who brings koden. Approximately 49 days later, a gift is reciprocated to the donor. In this way, social networks and bonds are reinforced and family members have a clear sense of communal attachment [69]. Throughout the year, rituals are performed in order to connect with the deceased and to provide comfort to the living, particularly the elderly [149].

For Asian Indian Hindus, families will perform various rituals to ensure a good death for the patient. For example, they will bring prasada (food from the temple offered to the deity), placing holy water in the mouth of the patient to wash away sins, and placing sanctified bracelets to help ward off evil [204]. Cremation is common; burials are contrary to cultural belief systems [204]. Hindu adults who pass away are cremated, and this process is considered necessary purification. Hindu children have not fully developed and have not become impure, and therefore, they do not need to undergo the purification rites after death [70]. Traditionally, male relatives will attend the cremation, and the oldest son will light the fire for the cremation ritual. (Women are not permitted to attend.) The mourning period generally lasts 10 to 16 days. During this time, the family is perceived to be tainted, and friends and distant relatives do not visit [70].

MOURNING, GRIEF, AND BEREAVEMENT

Mourning has been defined as specific cultural norms, behaviors, or practices associated with the sorrow or grief experienced by family members and friends of the deceased, while grief is the affective and cognitive experience resulting from loss [71]. The period of mourning and grief following a loss is referred to as bereavement, and this period varies from individual to individual and from culture to culture [72].

As described, Western culture views grief and bereavement as time-limited in part because death is viewed as a finality. The fifth revised edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) introduced a new diagnosis of prolonged grief disorder. One of the key features is a preoccupation with the deceased at least one year after the death [205]. However, in some cultures, there continues to be a bond between the deceased and family members. When a culture has an extended death ritual, it conveys the belief that the bereavement process is not easy or quick [44]. Rather than relying solely on a model that espouses "closure" and "moving on," an alternative model of mourning that emphasizes a continuing bond with the deceased may be more appropriate [73]. Instead of letting go of the representation, memories, and/or events associated with the deceased, family members may continue to integrate, identify with, and create bonds with objects that serve as a representation of the deceased [74,178]. This process is not time-limited nor is it considered pathologic. This model appears to be more consistent with cultural norms among many racial and ethnic minority groups.

In Asian cultures, ancestor worship helps to maintain a bond with the deceased, and family members will regularly burn offerings to the deceased. In the Chinese tradition of han san (which translates to "walking the mountain"), family members visit the cemetery annually and bring food and paper money to continue providing for the deceased in the afterlife [27]. In a study of 10 Chinese parents who had lost a child, the majority indicated they kept a photo of their deceased child in their home to share memories with friends and family members; some burned incense near the photo [62].

Many South Asian Muslims participate in elaborate death ritual over three days that involves bathing the body, reciting the Quran, holding a funeral, and following specific procedures and processes for the burial [128]. There are also specific holidays, such as Ramadan and Eid, during which the deceased are remembered [128].

African Americans also emphasize an ongoing connectedness or bond with the deceased despite the end of their physical presence [68]. In a study comparing African American and white college students who had experienced bereavement, African Americans reported a closer bond with the deceased compared with their white counterparts [68]. The African American students reported they sought out certain activities to remind themselves of the deceased or had conversations with the deceased.

Continuing the bonds with the deceased is also a part of Hispanic/Latino cultures. The underlying cultural norms include personalismo, which emphasizes close personal relationships, and familismo, which centers placing family over the individual, are inherent in many of the mourning rituals. Extended wakes are held for family and friends to convene, and during this time, there is food, games, and prayer [206]. Storytelling, keepsakes, religious rituals, and pictures may be used to remember lost loved ones [75]. Other practices include wearing mourning clothes (including dark colors), performing a novena with rosaries for nine days, and holding a mass on the first anniversary of the individual's death [206]. Cooking favorite food items of the deceased on the Día de los Muertos (the Day of the Dead) and using a certain flower to tempt the spirit of the deceased back home are cultural practices designed to stay connected with the deceased.

It is important not to adhere to cultural generalizations. While many collectivistic cultures emphasize the continuation of bonds with the deceased, there are subgroups (e.g., Wahabi Muslims) who argue that death is part of God's will [128]. Consequently, this subgroup discourages ritualized mourning. Some argue that this tradition has less to do with cultural beliefs and is more due to economic pressures [128].

Expressions of grief and bereavement also vary from culture to culture. In Chinese tradition, wailing and weeping at a funeral are common. Family members and friends wear black or plain-colored clothing at the funeral and for a period of time after. During the grieving period, other happy celebrations, such as weddings and birthdays, are avoided [62]. In Vietnamese culture, the vocal expression of grief and the number of mourners is equated with the level of importance of the deceased [76]. Because of this, mourners may be hired to join in funeral processions. Instead of black, white is the color of death in the Vietnamese culture. Close family members wear simple white apparel, and guests may be given white headbands to wear [76]. In Chinese culture, the bereaved wear mourning apparel of different colors, signifying the relationship to the deceased [148]. However, public expression of emotion (including crying) is taboo in Chinese culture, especially among Taiwanese communities. In these groups, suppressing emotions is believed to facilitate the transition to the afterlife, as the deceased will not feel burdened to remain with the living [179].

In African American culture, explicit outward demonstrations of emotion are common, particularly among women and children who identify as Southern Baptists or are recent African immigrants [77]. This practice has been called "falling out" and is a culture-bound syndrome recognized in the DSM-5-TR as a dissociative experience involving fainting and emotional distress [77].

In some cultures, grieving is not as public. Many Native American and aboriginal people view outward expressions of grief to be inappropriate. Some may consult with traditional healers, while others use sharing circles [78]. In the United States, non-Hispanic whites tend to grieve with less display of emotion [129].

ADVANCE DIRECTIVES

Advance directives, living wills, and other documents detailing an individual's wishes regarding care are deliberate processes designed to allow the individual to control end-of-life decisions, such as life-sustaining interventions, or to designate a proxy to make these decisions in the event of incapacitation [79]. In the United States, the Patient Self-Determination Act (PSDA) requires that hospitals, nursing homes, and other healthcare facilities provide information about advance directives to adult patients [80]. The goal of the PSDA is to increase individuals' control and autonomy in making informed decisions and obtaining the care they desire [80].

Western institutions, such as the PSDA and advance directives, are based on the beliefs that autonomy and individualism are desirable, truth telling is important, and individuals should have control over their deaths [80]. It is also based on the values and norms of the Western biomedical model, which is not necessarily consistent with other health belief systems (e.g., Ayurvedic medicine) [204]. However, these assumptions are not universally accepted and may be culturally dissonant with the belief systems of non-Western groups. This is reflected in the different practices worldwide. In countries such as India, advance directives are not recognized as valid legal documents, while in other countries, like Turkey, advance directives are formally recognized but not uniformly followed [79]. In some cultures, avoidance of talk about death makes advance directive use impractical, as conversations about advance planning could be considered a personal affront or an assault on the person's well-being [79,81]. Instead, language should promote harmony and positivity. For some Native American groups, advance directives are considered a violation of tribal belief systems [46].

There is some evidence that specific ethnic minority groups are less familiar with or have more misconceptions about advance directives compared with whites. For example, in a study of 112 Korean American and 105 white elders, only 5% of the Korean Americans had advance directives compared with 59% of their white counterparts [82]. In this study, it was not necessarily lack of knowledge that contributed to the disparity. Rather, Korean culture's adherence to family involvement in decision making was identified as a major barrier. Again, it is important to recognize that there is tremendous within-in group differences, influenced by acculturation and generational differences, and providers should not make blanketed assumptions [207].

In a study with three groups of Japanese individuals (i.e., English-speaking Japanese Americans, Japanese-speaking Japanese Americans, and Japanese living in Japan), there were no significant differences among the groups in terms of having discussed advance directives with their physicians [83]. In addition, they all preferred a group decision-making model, conforming to Asian values emphasizing the collective. In a study with elderly Chinese patients, participants were resistant to the idea of advanced directives. They did not see a necessity for formal advanced directives as family are expected to intercede [180]. It is also important to remember that advanced directives help remove the burden on families having to make difficult decisions on behalf of the patient. However, for many cultural groups, family-based decision-making is at the heart of their cultural belief systems [207,208]. For example, many Asian Indians who practice Hinduism not only consult with immediate family members but multiple extended family members when making decisions [204].

In one study, Hispanics were less likely to complete advance directives compared with white Americans [130]. For some, religious beliefs can be a barrier to setting up advance directives. If one believes that God has ultimate control, actively planning one's death will feel incongruent [150]. In qualitative interviews with ethnic minorities, Hispanic participants indicated that they did not want to sign advance directive forms for fear of deportation [131]. O'Mara and Zborovskaya assert that healthcare providers are in a unique position to help educate Hispanic/Latino patients about advance directives by taking advantage of the cultural value of jerarquismo, which emphasizes respect for hierarchy [142].

Compared with White Americans, African Americans are also less likely to plan for end of life and use advance directives [84,132]. In one study, white participants were more likely to identify benefits of end-of-life planning, while African Americans were more likely to identify barriers [132]. In a study with Black Americans living in Alabama, older participants reported they were reluctant to talk about end-of-life care planning with health providers [209]. An analysis of a secondary dataset examining racial and ethnic differences in formal and informal advance care planning among U.S. adults found that both Hispanic and Black Americans were 1.77 times as likely to lack advance care plans compared with White Americans [210]. This was also the case with any informal advance care planning.

Although advance directives, living wills, and power of attorney directives are less common, African Americans tend to choose more aggressive lifesaving interventions than whites [85]. While they are less likely to rely on formal written advanced directive documents, they are more likely to discuss end-of-life issues and planning with family members. Consequently, end-of-life planning for African Americans are more family-oriented, informal, and collectivistic [181].

Some speculate that African Americans' experiences with institutional oppression, racism, and discrimination play a role in these trends. Examples of medical abuses (e.g., the Tuskegee experiment) may make African Americans more likely to aggressively protect themselves, which manifests as taking steps to prolong life [209]. Experiences of oppression, which are rooted in slavery and the Jim Crow laws, may result in African Americans being fearful of giving up control, particularly to those representing the dominant culture [86]. As with the sociopolitical backdrop of oppression in African American culture, some immigrant and refugee groups who have been politically persecuted and exploited in their home countries may be wary of signing legal documents [87]. Among these groups, advance directives are often viewed with skepticism.

Another factor in the non-adoption of advance directives is the role of religiosity and spirituality. Some have suggested that the disparity of advance directive use between whites and African Americans may be related to differences in beliefs regarding God's role in controlling life and death [208]. Furthermore, cultural values about individualism/collectivism and future/present orientation appear to influence older individuals. In one study, older White individuals spoke more often about individualism/self-reliance and tended to have a future orientation while their older African American counterparts, who focused on collectivism/interconnectedness and tended to have a present orientation [132].

PALLIATIVE CARE

Palliative care is the noncurative care provided to patients to relieve symptoms and improve quality of life [88]. The goal of palliative care is to not only meet patients' physical needs but also address their psychologic, social, religious/spiritual, and cultural needs [89]. Even across cultures, there appear to be common denominators for effective palliative care. In an analysis of studies on palliative care in various ethnic/racial minority groups, researchers found common cultural themes that cut across all groups in the area of palliative care [90]. These included:

- Pain management

- Support to achieve closure (i.e., resolve social and emotional concerns that are hindering well-being)

- Spiritual and religious care

- Support to family and friends

- Focus on the quality of life

The priorities set by patients and healthcare professionals were considered carefully in the structuring of clinical practice guidelines for high-quality palliative care developed by the National Consensus Project for Quality Palliative Care. These guidelines are organized according to eight domains [91]:

- Structure and process of care

- Physical aspects

- Psychologic and psychiatric aspects

- Social aspects

- Spiritual, religious, and existential aspects

- Cultural aspects

- Care of the imminently dying patient

- Ethical and legal aspects

In its proposed national framework for palliative and hospice care, the National Quality Forum set forth 38 preferred practices based on these eight domains [91]. Of these preferred practices, six refer directly to the spiritual and cultural care of the dying patient (Table 2).

Table 2: PREFERRED PRACTICES FOR PALLIATIVE AND HOSPICE CARE RELATED TO SPIRITUAL AND CULTURAL DOMAINS

Develop and document a plan based on an assessment of religious, spiritual, and existential concerns using a structured instrument, and integrate the information obtained from the assessment into the palliative care plan.

Provide information about the availability of spiritual care services, and make spiritual care available either through organizational spiritual care counseling or through the patient's own clergy relationships.

Specialized palliative and hospice care teams should include spiritual care professionals appropriately trained and certified in palliative care.

Specialized palliative and hospice spiritual care professionals should build partnerships with community clergy and provide education and counseling related to end-of-life care.

Incorporate cultural assessment as a component of comprehensive palliative and hospice care assessment, including but not limited to locus of decision making, preferences regarding disclosure of information, truth telling and decision making, dietary preferences, language, family communication, desire for support measures such as palliative therapies and complementary and alternative medicine, perspectives on death, suffering, and grieving, and funeral/burial rituals.

Provide professional interpreter services and culturally sensitive materials in the patient's and family's preferred language.

Source: [91]

At the end of life, palliative care is delivered most effectively through hospice, and the use of hospice care has been increasing in the United States [92]. Despite these trends, hospice/palliative care remains underused, particularly among racial and ethnic minorities. For example, fewer than 9% of hospice care recipients are African Americans [93].

The National Hospice and Palliative Care Organization, which provides data on patterns of hospice and palliative care service use in the United States, estimates that 1.7 million Medicare patients received services from hospice in 2021 [211]. Among those who died who were Medicare recipients and who used hospice, 50% were White [211]. As with much of Westernized health care, the values underlying palliative care are based on the ethical notions of autonomy, informed consent, and capacity, which may be culturally dissonant to many groups [88].

Many African Americans perceive the use of hospice care as giving up, and given their experiences with adversity, this is considered weak and unacceptable [93,126]. In focus groups, African American participants disclosed that hospice meant "imminent death," "giving up," and a place for family members to "come and watch you die" [126].

African Americans also tend to have extensive social networks, including family, church, and the community, that they historically rely on in times of crisis [95]. Similarly, Asian Americans and immigrants have strong cultural values regarding the role of the family at the end of life. As a result of this cultural emphasis, many view hospice as a form of abandonment of the sick and dying. Hospice is often considered a sign that family members are unable to fulfill their responsibilities of filial piety, which is shameful [96]. Like other Asian groups, Asian Indians tend to prefer for terminally ill family to die at home in order to ensure a good death. The Hindu culture has many end-of-life rituals that are performed by family members; dying at home is more conducive to this process [70]. However, because much of hospice care is now delivered to patients at home, it may become a more desirable option to these groups in the future.

In a focus group study of Mexican Americans, participants indicated providing medical care for the terminally ill was the responsibility of the family and that the family should assist the patient to die with dignity [97]. Many participants also stressed the importance of having priests available at the end of life, as Catholicism is a significant aspect of most traditional Mexican and Latino families.

In many Asian families, the responsibility of care is believed to be the responsibility of the family. Providers can respect this belief by assuming the role of educator. For example, a nurse can instruct family members how to safely change the patient's positioning [135].

7. CULTURALLY SENSITIVE COMMUNICATION STRATEGIES

Most health communications can be classified as patient-centered or family-centered. Patient-centered communications consist of practitioners discussing decisions with the patient first, emphasizing autonomy and individuality. On the other hand, family-centered communication relies on group discussions involving the patient and his or her (self-defined) family. This type of communication is based on collectivistic cultural values and entails conducting a thorough assessment of the family's cultural, religious, and spiritual preferences and documenting that all members of the team have access to this information [37,182].

If health communication is viewed on a continuum with patient-centered and family-centered as two end-points, practitioners can assess the patient's and the family members' stance by asking two questions [37]:

- Do you want us to tell you (the patient) everything about your illness or do you want us to tell your family? Both? Neither?

- Do you (the patient) want to make decisions about your treatment or do you want others to make decisions?

Some experts recommend using the "ask-tell-ask" communication strategy to ensure a two-way conversation between the patient, family members, and providers [141]. This approach involves the provider encouraging the patient and family to provide their perspectives of the illness and health care. The provider may then offer assistance and/or information. Finally, the provider should ask the patient/family what information they can practically apply and what other concerns they have. Such conversations cannot be rushed, as family stories are complex and establishing rapport takes time [151]. Asking open-ended questions and reflexive listening are crucial [182].

ASSESSMENTS

Evidence Based Practice Recommendation

The National Coalition for Hospice and Palliative Care asserts that the palliative care team should recognize that culture can influence the approach to illness, reporting of symptoms, preferences around treatment and decision-making process.

https://www.nationalcoalitionhpc.org/wp-content/uploads/2020/07/NCHPC-NCPGuidelines_4thED_web_FINAL.pdf

Last Accessed: August 28, 2024

Strength of Recommendation/Level of Evidence: Guideline (Expert opinion)

Communicating effectively about palliative care and assessing patients' needs requires both cultural sensitivity and skills specific to the end-of-life setting [80]. The following questions may be helpful when assessing patients' and families' cultural, linguistic, and spiritual needs at the end of life:

- What language does the family speak when discussing health issues?

- How open are they in talking about diagnoses, prognosis, and death? With whom will they be open to talking about these issues?

- Who appears to be the decision maker (e.g., the patient or another family member)? How do gender roles influence decision making?

- What are the patient's and family's views about death and the role of each person in the family and healthcare team in relation to death?

- What is the patient's and family members' level of fatalism regarding the illness and prognosis?

- How do religiosity and spirituality influence views about death?

- Are additional sources of culturally sensitive information (e.g., interpreters, community workers, persons with expertise regarding a specific culture) necessary?

- What role does hope play for the patient and family?

In 2011, the Joint Commission implemented assessment standards for healthcare providers working with patients from culturally diverse backgrounds in hospitals. The following questions are specific for healthcare professionals caring for patients at the end of life [114]:

- Which cultural background does the patient identify with?

- Are there cultural beliefs or traditions that the patient adheres to?

- What is the role of the family in the patient's care?

- Does the patient want family involved in the treatment plan?

- Who makes the decisions about advance directives and treatment options at the end of life? Is it the family, patient, or someone else?

- Does the patient have any religious or spiritual beliefs?

- What is the role of religion in making decisions about illness and treatment?

- Would the patient prefer a visit from a religious leader or clergy member?

- Who can be present for the death?

- What does the patient believe about the body after death? In addition, how is the body to be treated?

- How does the patient want to manage comfort and pain?

- How does the patient want to say goodbye?

- Does the patient want to die at home or in the hospital?

- Who will make final plans?

- How can the healthcare professional honor the patient's spiritual beliefs as death approaches?

- Who will communicate between the patient and healthcare professional?

It is important for practitioners to be open and curious about diversity and cultural issues and to consider patients and families to be experts of their own culture [90]. Practitioners can then take this information and attempt to apply it within the context of dying and palliative care. According to Bosma et al., "deliberately assuming a clinical position of 'not-knowing' establishes a non-threatening tone for engagement with culturally diverse patients and families, which can evoke descriptions of their individual understanding, needs and goals at end of life" [90]. This "not-knowing" position is in stark contrast to the biomedical model, which positions the practitioner as the expert.

Practitioners should not make assumptions about the preferences of the patient or family on the basis of cultural beliefs. Even within a single culture or ethnicity, the level of information desired, preferences for treatment, role of other family members in decision making, and goals of care differ among patients and families [98,99]. Assessment is continuous and requires careful observation [140].

THE ROLE OF INTERPRETERS

Evidence Based Practice Recommendation

When patients and families do not speak or understand English, or prefer communicating in a language other than English, the National Coalition for Hospice and Palliative Care recommends that palliative care providers use qualified medical interpreter services, either in person or via telephone or video.

https://www.nationalcoalitionhpc.org/wp-content/uploads/2020/07/NCHPC-NCPGuidelines_4thED_web_FINAL.pdf

Last Accessed: August 28, 2024

Strength of Recommendation/Level of Evidence: Guideline (Expert opinion)

In clinical situations in which there are language barriers between practitioners and the patient and/or family members, miscommunication, dissatisfaction with care, and premature termination of services can occur. When terminal illnesses and end-of-life issues are part of the discussion, communication can be even more difficult. In these cases, interpreters may be needed. It is important to differentiate between informal/ad-hoc versus trained interpreters. Informal and ad-hoc interpreters are often used by health professionals because it may be difficult to access an interpreter who can speak a specific language and/or dialect. Time pressures may also result in providers turning to any family or friends present for interpretation [169]. However, this is not ideal, because they lack medical knowledge and language and may not fully communicate needed information to their family members [194].

Many view interpreters merely as neutral individuals who communicate information back and forth. This approach to interpretation, common in healthcare settings, is referred to as the "interpreter as a conduit" model. Practitioners adopting this perspective view interpreters as tools to relay information back and forth, discounting their human nature, emotions, and independent knowledge [100]. Consequently, some interpreters feel they are placed in a challenging position because the family may end up getting mixed messages from the various health providers. The interpreter who is viewed merely as a conduit and not an active agent gets caught up in the clash of mixed messages, cultural differences, and general confusion [212].

Another approach is to view interpreters as active agents, negotiating between two cultures and assisting in promoting culturally competent communication and practice [101]. This role is closer to that of a co-diagnostician, as interpreters decide which medical information is valuable, seek illness-related information independently, and participate in the diagnostic process by identifying signs or symptoms [102]. Healthcare providers actively engage interpreters and utilize their insights about their understanding to the cultural dynamics in interacting with families during the difficult end-of-life conversations [212].

Medical interpreters also often perform cultural brokering, providing cultural information to health providers and gauging if information is conveyed too directly. Using culturally appropriate words in the target language helps to contextualize the medical terminology [183].

In a study conducted with 43 medical interpreters, the participants confirmed that they were active agents in the clinical encounter [103]. In addition, the interpreters identified specific qualities that improve end-of-life communications between practitioners and patients/families who speak different languages. These qualities include [103]:

- Balancing between interpreting word-for-word versus being an advocate, cultural broker, and/or educator

- Acknowledging that language and culture are different (i.e., the interpreter and the patient/family members may speak the same language but may not share the same culture)

- Allowing enough time with family members and the patient

- Addressing any religious or spiritual issues that arise in the clinical encounter

- Being aware of personal discomforts that may arise given the sensitive and stressful nature of the encounter

Word-for-word interpretation can lead to confusion or anxiety in certain contexts. For example, if the word "hospice" is translated to hospicio in Spanish, it could be understood as an orphanage or an asylum [135]. Therefore, it is important to understand how words like "palliative," "death," "hospice," and "advanced directive" translate literally and what underlying cultural meanings they have [212].

Because interpreters carry heavy emotional burden when interpreting end-of-life conversations, it is also recommended that practitioners meet with interpreters prior to and after the delivery of bad news to family members and patients. The meeting prior to the delivery of bad news will allow interpreters to provide culturally specific information to practitioners, if appropriate. In addition, it should be established whether practitioners expect interpreters to merely interpret or to help with cultural brokering. After the delivery of bad news, it is equally vital to have the opportunity to debrief, as they can experience moral distress and emotional conflict [103,213].

When considering the use of interpreters, it is often conceptualized as a binary choice—to use or not use [133]. However, it may be more useful to conceptualize interpreter participation along a continuum [133]. If a patient does not speak English, then it is vital to call upon the services of an interpreter. However, an over-reliance on an interpreter can inadvertently minimize client's or patient's sense of self-efficacy. When a patient has the ability to switch back and forth between English and his or her native language, an interpreter can assist in elaborating on thoughts [133].

INTERPROFESSIONAL COLLABORATION

Interprofessional collaboration is defined as a partnership or network of providers who work in a concerted and coordinated effort for the common goal of improving patients' health, mental health, and social and/or family outcomes [184]. Positive outcomes have been demonstrated on the individual and organizational levels with interprofessional collaboration [185,186,187]. When the patient and family desire home-based care for the end of life, this will more likely occur when there is interprofessional collaboration among all the different healthcare professionals, including nurses, palliative care specialists, social workers, and case managers [214]. When there is coordination and a palliative care specialist is integrated in the support services, it will be more likely the patient will remain at home [214]. However, implementing and promoting this approach can be challenging. Not understanding each other's roles is another barrier.

8. CULTURALLY SENSITIVE PRACTICE AT THE END OF LIFE: ETHICAL CONSIDERATIONS

Health care in the United States is based primarily on the Western ethical principles of respect for persons and beneficence [18]. The underlying premise of respect for persons is autonomy, or the belief that patients should be able to make their own decisions about their health care. In order for patients to make an informed decision, truth-telling and full disclosure are necessary. In terms of death and dying, patients are given all of the information available regarding their terminal condition and prognosis (even estimates of time left to live) because it is believed to be moral and ethical [104]. Truth-telling is based on the deontological perspective that expressing truths is a universally good and moral behavior [203]. It is also premised on the view that truth-telling is absolute and objective; however, some argue it is rarely achieved in medicine [203]. However, as discussed, truth telling as it is practiced in Western medicine is not universally accepted in all cultural groups. Some argue that autonomy is not necessarily a dichotomous principle; rather, it can be demonstrated on a continuum [188]. Relational autonomy is more suited to working with racial and ethnic minorities in end-of-life care. This concept entails taking into account the cultural, social, and familial contexts of patients and their decision-making and incorporates compassion, hope, empathy, and responsibility [188]. To address this possible gap, practitioners can review informed consent with patients, following the principles of respect for persons and autonomy, and follow up by inquiring whether the patient would like other family members to be involved in decision making. This allows the patient to act as an autonomous agent in a culturally sensitive way [30].

Consent forms are also an essential part of health care and the legal system in the United States. A signed informed consent form indicates that appropriate information was given or communicated and the patient acknowledges having received and comprehended the information and/or agrees with a prescribed course of action [105]. However, in many cultures, consent is not considered to occur until the family has been informed [18]. Informed consent is a process and should not be viewed as a one-time event. Rather, informed consent should be viewed as a continuous process of evaluating what the patient and family want to know and the extent to which they comprehend the information [105].

As discussed, the notion of "self" is at the heart of Western ideologies of individualism. The challenge comes when working with patients and family members from racial and ethnic minority groups whose cultural value systems focus on collectivism rather than individualism. Focusing on Western principles of autonomy can lead to isolating and disempowering the patient [134].

Assessments can be conducted to determine patients' decision-making patterns (i.e., patient-centered vs. family-centered). This information can then be communicated with practitioners who are responsible for obtaining informed consent [106].

The ethical principle of beneficence, or the duty to do good, is also the foundational basis of most healthcare professionals' codes of ethics. Johnstone and Kanitsaki observe the following [107]:

Providers are also often bewildered and frustrated by what they see as a negative attitude and at times hostile resistance toward advance care planning by patients and involved families of diverse cultural backgrounds and their apparent inability to understand and accept the intended benefits (and benevolence) of advance care planning and related respecting patient choices programs. Patients and involved families, meanwhile, are often left bewildered and frustrated by the inability of providers to understand and accept the benevolence and justice of their actions, which have as their sole objective protecting the life and well-being of their loved ones—whatever the medical prognosis.

Family members should not be viewed as intrusive but as an integral part of the clinical process [107]. As important members of the healthcare team, their beliefs regarding the best course of action for the patient are to be respected. They may be involved in the decision-making process, if the patient wishes for this to be the case [107].

The ethical principle of distributive justice (i.e., ensuring equal access to health and end-of-life services) can be promoted by healthcare providers by being sensitive and discerning when mitigating the barriers immigrants and refugees often experience [134]. For example, when using interpreters, it is crucial to determine if interpreters are developing multiple roles. For example, if the interpreter is also an immigrant or refugee living in the same ethnic community as the patient, this can cause discomfort for both parties [9]. The fear that the interpreter will disclose sensitive information to others in the community can impede patients from continuing with services [9].

9. CONCLUSION

According to Nkongho, "human growth and development take place within all cultural groups, and the cultural group's influence on personality is continuous through life" [108]. Given the ever-changing demographics of the United States and the growing role of multiculturalism, it is certain practitioners will encounter cultural diversity in their patients and their family members. Healthcare disciplines are calling for more holistic care that encompasses physical, psychologic, social, spiritual/religious, and emotional components. As such, it is essential to take into account the cultural background of patients and families when conducting assessments and creating care plans at the end of life [109].

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Evidence-Based Practice Recommendations Citations

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