NYSW26B • New York Social Workers 2026-2027

Table of Contents

NYSW26B • New York Social Workers 2026-2027

How to Receive Credit

NetCE 6 Hour Course #77042 • Setting Ethical Limits: For Caring and Competent Professionals

77042 • Setting Ethical Limits: For Caring and Competent Professionals

1. INTRODUCTION

2. COMPETENCE

3. CULTURAL COMPETENCE

4. THE THERAPEUTIC RELATIONSHIP

5. THE COSTS OF CARING

6. TRANSFERENCE AND COUNTERTRANSFERENCE

7. BOUNDARIES AND LIMITS

8. BOUNDARY CROSSINGS AND VIOLATIONS

9. MULTIPLE RELATIONSHIPS

10. GIFTS

11. TECHNOLOGY AND DISTANCE THERAPY

12. CONCLUSION

13. RESOURCES

Works Cited

NetCE 3 Hour Course #91450 • AI in Health Care

91450 • AI in Health Care

1. INTRODUCTION

2. AN OVERVIEW OF ARTIFICIAL INTELLIGENCE (AI)

3. BENEFITS OF AI IN HEALTH AND MENTAL HEALTH CARE

4. APPLICATIONS OF AI IN HEALTH AND MENTAL HEALTH CARE

5. BARRIERS, LIMITATIONS, AND ETHICAL CONSTRAINTS

6. COLLABORATION BETWEEN PRACTITIONERS AND AI

7. CONCLUSION

Works Cited

NetCE 5 Hour Course #76703 • Understanding and Treating Spiritual Abuse

76703 • Understanding and Treating Spiritual Abuse

1. INTRODUCTION

2. FOUNDATIONS: DEFINING SPIRITUAL ABUSE

3. COMMON THEMES IN SPIRITUAL ABUSE

4. ASSESSING FOR SPIRITUAL ABUSE

5. TREATING SPIRITUAL ABUSE

6. PROFESSIONAL DEVELOPMENT ISSUES

7. CONCLUSION

8. GLOSSARY

Works Cited

NYSW26B • New York Social Workers 2026-2027

Lisa Hutchison, LMHC

www.netce.com

Copyright © 2026 NetCE, All rights reserved.

NYSW26B • New York Social Workers 2026-2027

Expiration Date: 08/31/2027

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.

77042 • Setting Ethical Limits: For Caring and Competent Professionals

Lisa Hutchison, LMHC

www.netce.com

Copyright © 2024 NetCE, All rights reserved.

Without proper self-care, boundaries, and awareness (transference), therapists become vulnerable to burnout and vicarious traumatization. This can result in a risk of therapeutic effectiveness, loss of trust with clients, and possible ethical crossings or violations. This course supports professionals practicing competence, while utilizing self-care and boundaries to minimize burnout while practicing compassion for the clients that they serve.

Table of Contents

77042 • Setting Ethical Limits: For Caring and Competent Professionals

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. COMPETENCE

APA'S ETHICAL PRINCIPLES OF PSYCHOLOGISTS AND CODE OF CONDUCT

2014 ACA CODE OF ETHICS

CODE OF ETHICS OF THE NASW

3. CULTURAL COMPETENCE

CODE OF ETHICS OF THE NASW

CHARACTERISTICS OF A CULTURALLY COMPETENT COUNSELOR

4. THE THERAPEUTIC RELATIONSHIP

CONGRUENCE

EMPATHY

5. THE COSTS OF CARING

STRESS

COMPASSION FATIGUE, VICARIOUS TRAUMA, AND BURNOUT

MITIGATING THE COSTS OF CARING

6. TRANSFERENCE AND COUNTERTRANSFERENCE

REFLECTION

SELF-AWARENESS

7. BOUNDARIES AND LIMITS

BUILDING TRUST

THE VALUE OF FLEXIBILITY

EMPOWERING AND PROTECTING THE CLIENT

PROTECTING THE PROFESSIONAL

8. BOUNDARY CROSSINGS AND VIOLATIONS

9. MULTIPLE RELATIONSHIPS

BOUNDARY VIOLATIONS WITHIN MULTIPLE RELATIONSHIPS

10. GIFTS

THE GIFT OF SELF-DISCLOSURE

11. TECHNOLOGY AND DISTANCE THERAPY

LEGAL AND ETHICAL CONSIDERATIONS

SOCIAL MEDIA

12. CONCLUSION

13. RESOURCES

Works Cited

77042 • Setting Ethical Limits: For Caring and Competent Professionals

Education Category. Ethics - Human Rights

Release Date. 12/01/2024

Expiration Date. 11/30/2027

Course Overview

Without proper self-care, boundaries, and awareness (transference), therapists become vulnerable to burnout and vicarious traumatization. This can result in a risk of therapeutic effectiveness, loss of trust with clients, and possible ethical crossings or violations. This course supports professionals practicing competence, while utilizing self-care and boundaries to minimize burnout while practicing compassion for the clients that they serve.

Audience

This course is designed for social workers, counselors, and marriage and family 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. Continuing Education (CE) credits for psychologists are provided through the co-sponsorship of the American Psychological Association (APA) Office of Continuing Education in Psychology (CEP). The APA CEP Office maintains responsibility for the content of the programs. NetCE is accredited by the International Accreditors for Continuing Education and Training (IACET). NetCE complies with the ANSI/IACET Standard, which is recognized internationally as a standard of excellence in instructional practices. As a result of this accreditation, NetCE is authorized to issue the IACET CEU. NetCE is recognized by the New York State Education Department's State Board for Social Work as an approved provider of continuing education for licensed social workers #SW-0033. This course is considered self-study, as defined by the New York State Board for Social Work. NetCE is recognized by the New York State Education Department's State Board for Mental Health Practitioners as an approved provider of continuing education for licensed mental health counselors #MHC-0021. This course is considered self-study by the New York State Board of Mental Health Counseling. NetCE is recognized by the New York State Education Department's State Board for Mental Health Practitioners as an approved provider of continuing education for licensed marriage and family therapists. #MFT-0015.This course is considered self-study by the New York State Board of Marriage and Family Therapy. Materials that are included in this course may include interventions and modalities that are beyond the authorized practice of licensed master social work and licensed clinical social work in New York. As a licensed professional, you are responsible for reviewing the scope of practice, including activities that are defined in law as beyond the boundaries of practice for an LMSW and LCSW. A licensee who practices beyond the authorized scope of practice could be charged with unprofessional conduct under the Education Law and Regents Rules.

Designations of Credit

NetCE designates this continuing education activity for 2.5 NBCC clock hour(s). Social workers participating in this intermediate to advanced course will receive 6 Ethics continuing education clock hours. NetCE designates this continuing education activity for 6 credit(s). NetCE is authorized by IACET to offer 0.6 CEU(s) for this program.

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 meets the requirement for 3 hours of Ethics continuing education as required by the Pennsylvania State Board of Social Worker, Marriage and Family Therapists and Professional Counselors. 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 5-08-151-0624. NetCE is approved as a provider of continuing education by the California Association of DUI Treatment Programs (CADTP). Provider Number 185. NetCE designates this continuing education activity for 6 continuing education hours for addiction professionals.

Course Objective

The purpose of this course is to educate helping professionals on how to provide compassionate care ethically to those they serve without causing burnout.

Learning Objectives

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

1. Define professional competence.

2. Describe the importance of cultural competence.

3. Outline components of the therapeutic relationship.

4. Define empathy and describe the difference between empathy and sympathy.

5. Identify compassion fatigue, vicarious trauma, and burnout and describe their impact on mental health professionals.

6. Define transference and countertransference and discuss their implications for the mental health professional.

7. Identify the functions of professional boundaries in the therapeutic relationship and multiple relationships.

8. Discuss the guidance on giving and receiving gifts provided by professional ethics codes.

9. Discuss the legal and ethical considerations of providing distance therapy.

Faculty

Lisa Hutchison, LMHC, has more than 20 years of experience providing individual and group counseling with adults. She specifically focuses on teaching assertiveness, stress management, and boundary setting for empathic helpers. Ms. Hutchison graduated from the University of Massachusetts, Boston, with a Master’s degree in education for mental health counseling.

Faculty Disclosure

Contributing faculty, Lisa Hutchison, LMHC, 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

Counselors can make a significant, positive impact in the lives of those with whom they work, and the practice of therapy can be highly rewarding and gratifying. However, it can also be emotionally demanding, challenging, and stressful. Counselors are at risk for occupational stress from a variety of sources, including[1]:

- The demands of clinical and professional responsibility

- The challenges of managing the client/counselor relationship

- The role characteristics that make counselors prone to burnout (e.g., high level of involvement)

- Vulnerability to vicarious traumatization

- The changing standards and business demands of the profession (e.g., increased documentation requirements, increased intrusion of legal/business concerns into therapeutic practice)

- The intersection of personal and professional demands

Healthy boundaries are a critical component of self-care. Setting boundaries can help counselors manage occupational stressors and maintain the delicate balance between their personal and professional lives. Boundaries also demonstrate competency in clinical practice and help counselors avoid ethical conflicts [2].

Please note, throughout this course the term "counselor" is used to refer to any professional providing mental health and/or social services to clients, unless otherwise noted.

2. COMPETENCE

Professional associations representing the various fields of clinical practice have codes of ethics that provide principles and standards to guide and protect both the mental health professional and the individuals with whom they work. For example, the American Psychological Association (APA), the American Counseling Association (ACA), the National Association of Social Workers (NASW), the National Board of Certified Counselors (NBCC), and the National Certification Commission for Addiction Professionals (NCCAP) each has an ethics code created to identify core values, inform ethical practice, support professional responsibility and accountability, and ensure competency among its members [3,4,5,6,7].

Competency is defined as "the extent to which a therapist has the knowledge and skill required to deliver a treatment to the standard needed for it to achieve its expected effects" [8]. It is the scope of the professional's practice. According to the ethics codes of the APA, the ACA, and the NASW, members are to practice only within their boundaries of competence [3,4,5].

APA'S ETHICAL PRINCIPLES OF PSYCHOLOGISTS AND CODE OF CONDUCT

2.01 Boundaries of Competence

(a) Psychologists provide services, teach, and conduct research with populations and in areas only within the boundaries of their competence, based on their education, training, supervised experience, consultation, study, or professional experience.

(b) Where scientific or professional knowledge in the discipline of psychology establishes that an understanding of factors associated with age, gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, language, or socioeconomic status is essential for effective implementation of their services or research, psychologists have or obtain the training, experience, consultation, or supervision necessary to ensure the competence of their services, or they make appropriate referrals, except as provided in Standard 2.02, Providing Services in Emergencies.

(c) Psychologists planning to provide services, teach, or conduct research involving populations, areas, techniques, or technologies new to them undertake relevant education, training, supervised experience, consultation, or study.

(d) When psychologists are asked to provide services to individuals for whom appropriate mental health services are not available and for which psychologists have not obtained the competence necessary, psychologists with closely related prior training or experience may provide such services in order to ensure that services are not denied if they make a reasonable effort to obtain the competence required by using relevant research, training, consultation, or study.

(e) In those emerging areas in which generally recognized standards for preparatory training do not yet exist, psychologists nevertheless take reasonable steps to ensure the competence of their work and to protect clients/patients, students, supervisees, research participants, organizational clients, and others from harm.

(f) When assuming forensic roles, psychologists are or become reasonably familiar with the judicial or administrative rules governing their roles.

2.03 Maintaining Competence

Psychologists undertake ongoing efforts to develop and maintain their competence.

2014 ACA CODE OF ETHICS

C.1. Knowledge of and Compliance with Standards

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

C.2. Professional Competence

C.2.a. Boundaries of Competence

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

C.2.b. New Specialty Areas of Practice

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

C.2.c. Qualified for Employment

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

C.2.d. Monitor Effectiveness

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

C.2.e. Consultations on Ethical Obligations

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

C.2.f. Continuing Education

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

C.4. Professional Qualifications

C.4.a. Accurate Representation

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

C.4.b. Credentials

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

C.4.c. Educational Degrees

Counselors clearly differentiate between earned and honorary degrees.

C.4.d. Implying Doctoral-Level Competence

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

C.4.e. Accreditation Status

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

C.4.f. Professional Membership

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

CODE OF ETHICS OF THE NASW

1.04 Competence

(a) Social workers should provide services and represent themselves as competent only within the boundaries of their education, training, license, certification, consultation received, supervised experience, or other relevant professional experience.

(b) Social workers should provide services in substantive areas or use intervention techniques or approaches that are new to them only after engaging in appropriate study, training, consultation, and supervision from people who are competent in those interventions or techniques.

(c) When generally recognized standards do not exist with respect to an emerging area of practice, social workers should exercise careful judgment and take responsible steps (including appropriate education, research, training, consultation, and supervision) to ensure the competence of their work and to protect clients from harm.

(d) Social workers who use technology in the provision of social work services should ensure that they have the necessary knowledge and skills to provide such services in a competent manner. This includes an understanding of the special communication challenges when using technology and the ability to implement strategies to address these challenges.

(e) Social workers who use technology in providing social work services should comply with the laws governing technology and social work practice in the jurisdiction in which they are regulated and located and, as applicable, in the jurisdiction in which the client is located.

3. CULTURAL COMPETENCE

A general (aspirational) principle articulated in the APA's ethics code addresses respect for people's rights and dignity. The principle states, in part, that [3]:

Psychologists are aware of and respect cultural, individual, and role differences, including those based on age, gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, language, and socioeconomic status and consider these factors when working with members of such groups. Psychologists try to eliminate the effect on their work of biases based on those factors, and they do not knowingly participate in or condone activities of others based upon such prejudices.

CODE OF ETHICS OF THE NASW

1.05 Cultural Competence

(a) Social workers should demonstrate understanding of culture and its function in human behavior and society, recognizing the strengths that exist in all cultures.

(b) Social workers should demonstrate knowledge that guides practice with clients of various cultures and be able to demonstrate skills in the provision of culturally informed services that empower marginalized individuals and groups. Social workers must take action against oppression, racism, discrimination, and inequities, and acknowledge personal privilege.

(c) Social workers should demonstrate awareness and cultural humility by engaging in critical self-reflection (understanding their own bias and engaging in self-correction), recognizing clients as experts of their own culture, committing to lifelong learning, and holding institutions accountable for advancing cultural humility.

(d) Social workers should obtain education about and demonstrate understanding of the nature of social diversity and oppression with respect to race, ethnicity, national origin, color, sex, sexual orientation, gender identity or expression, age, marital status, political belief, religion, immigration status, and mental or physical ability.

(e) Social workers who provide electronic social work services should be aware of cultural and socioeconomic differences among clients' use of and access to electronic technology and seek to prevent such potential barriers. Social workers should assess cultural, environmental, economic, mental or physical ability, linguistic, and other issues that may affect the delivery or use of these services.

Although counselors are not expected to know about every nuance of each culture they serve, it is important to be open to learning about diverse cultural backgrounds in order to provide empathic, competent care. It is also important to be aware of culture-specific religious or spiritual practices that are regarded as healing forces in the client's world. Achieving this awareness may involve researching the client's culture and inquiring about their culture-specific healing practices in a manner that respects the client's dignity and privacy [3]. It is always the professional's goal to do no harm. As previously stated, professionals must "try to eliminate the effect on their work of [their] biases" and address them outside the therapeutic time with a trusted colleague or supervisor [3].

CHARACTERISTICS OF A CULTURALLY COMPETENT COUNSELOR

Three characteristics of a culturally competent counselor have been described. First, a culturally competent counselor is actively engaged in the process of becoming aware of his or her assumptions about human behavior, values, biases, preconceived notions, and personal limitations [9]. This is an ongoing process of self-discovery that requires the willingness to address any issues that may arise. For example, because the concept of boundaries varies across cultures, therapeutic elements related to boundaries should be modified to adapt to this variance. The expectation of confidentiality also varies, so the counselor should not assume that confidentiality is implicitly restricted to the counselor and client. In many cultures, confidentiality is neither expected nor therapeutic [10]. Being culturally competent also requires vigilance and an understanding that referral to another counselor might be necessary in some circumstances (i.e., when working with a particular client is beyond the counselor's boundaries of competence) [9].

Next, a culturally competent counselor actively attempts to understand the worldview of a culturally different client by employing empathy and avoiding negative judgments [9]. This involves becoming familiar with the culture, subculture, and political history of the client when these differ from those of the counselor. This yields valuable rewards and is useful in avoiding the common therapeutic blunder of overgeneralization [10]. For example, knowing the client's ethnicity, political affiliation in their country of origin, religious beliefs, and expectations of gender roles all contribute to providing the counselor a more precise framework from which therapy can be applied. Clients usually recognize and appreciate the counselor's attempts to learn about their culture, which can enhance the therapeutic alliance [10]. It is also important to recognize that the client is part of a larger cultural system that may include family members, societal elders, or others of significance to the client. These others can impact the client's therapy, with positive or negative outcomes, depending on whether they are enlisted as therapeutic allies or alienated [10].

Last, a culturally competent counselor actively develops and practices appropriate, relevant, and sensitive intervention strategies and skills when working with culturally different clients. In order to keep abreast of new interventions and strategies, the counselor may need to acquire additional education, training, and supervised experience (Resources) [9].

Common issues in the therapeutic relationship (e.g., gifts, touch, eye contact, medication compliance, choice of vocabulary) are all influenced by culture. Rather than adhere to a rigid theoretical approach to dealing with these issues, it is best to seek out their cultural meaning on a case-by-case basis. Enlist the expertise of a "cultural informant" if one is available. This person is generally from the same culture as the client, is not an active participant in the therapy, and functions as a consultant to the professional by interpreting or identifying culture-specific issues. The therapeutic paradigm should be flexible. The degree of active intervention by the mental health professional, definition of therapeutic goals, techniques used, and outcome measures should all be modified to reflect cultural differences in the therapy. Also, transference and countertransference interactions influenced by culture will occur and require that professionals become familiar with the types of culturally influenced reactions that can occur in therapy. Phenomena such as cultural stereotyping often occur even when the counselor and client share the same ethno-cultural background [10].

4. THE THERAPEUTIC RELATIONSHIP

Many situations that occur in the counseling office are not written about in text books or taught in a classroom setting. Counselors learn through hands-on experience, intuition, ongoing supervision, and continuing education. One constant is the therapeutic relationship. Every therapeutic relationship is built on trust and rapport. Counselors teach their clients what a healthy relationship is through the compassionate care and limit setting that occurs within the therapeutic context. Counselors model acceptable behavior in the office so their clients are equipped to emulate and apply that behavior in the outside world. In many cases, counselors are teaching self-regulation to clients who are learning how to control impulses or regulate behavior in order to improve their connection to other people.

Bandura has described self-regulation as a self-governing system that is divided into three major subfunctions [11]:

- Self-observation: We monitor our performance and observe ourselves and our behavior. This provides us with the information we need to set performance standards and evaluate our progress toward them.

- Judgment: We evaluate our performance against our standards, situational circumstances, and valuation of our activities. In the therapeutic setting, the counselor sets the standard of how to interact by setting limits and upholding professional ethics. The client then compares the counselor's (i.e., "the expert's") modeled behavior with what they already have learned about relationship patterns and dynamics (i.e., referential comparisons).

- Self-response: If the client perceives that he or she has done well in comparison to the counselor's standard, the client gives him- or herself a rewarding self-response. The counselor should reinforce this response by delivering positive reinforcement and affirmation for the newly learned behavior. For example, if the client arrives to therapy habitually late and then makes an effort to arrive on time, the counselor can remark, "I notice that you are working hard to arrive on time for session. That is great." The counselor's positive reinforcement and acknowledgment can have a positive impact on the client's self-satisfaction and self-esteem.

According to Rogers, "individuals have within themselves vast resources for self-understanding and for altering their self-concepts, basic attitudes, and self-directed behavior" [12]. To facilitate a growth-promoting climate for the client, the counselor should accept, care for, and prize the client. This is what Rogers refers to as "unconditional positive regard," and it allows the client to experience whatever immediate feeling is going on (e.g., confusion, resentment, fear, anger, courage) knowing that the professional accepts it unconditionally [12]. In addition to unconditional positive regard, a growth-promoting therapeutic relationship also includes congruence and empathy.

CONGRUENCE

Trust is built and sustained over time through consistent limits that are maintained within the sacred space of each therapeutic hour. When a counselor is observed as consistent and congruent, the client notices. Being authentic is part of being compassionate and empathic. Clients know when a counselor's words and actions do not match. These actions can be overt, such as cutting short the therapeutic time or going over the time allotted. They also can be subtle, as when leaked out and expressed through a stressed vocal tone, facial expression, or other body language indicator (e.g., arms folded across the chest). To the highly aware client, these actions can result in a loss of trust.

Nevertheless, counselors are not perfect and can err from time to time. This is why it is important for counselors to be self-aware, acknowledge when their words and actions do not match, and discuss that within the therapeutic relationship. If a client notices one of these cues of incongruence and expresses it to the counselor, it is essential that the counselor listen openly and validate the client's experience. Any defensiveness on the part of the counselor will decrease relationship trust. Conversely, this admission of human failure can actually build a stronger bond of trust. Clients see that counselors are, like themselves, human and imperfect. This presents an opportunity for clients to learn and then model this type of integrity in their own relationships. "Congruence for the therapist means that he (or she) need not always appear in a good light, always understanding, wise, or strong" [12]. It means that the therapist is his or her actual self during encounters with clients. Without façade, he or she openly has the feelings and attitudes that are flowing at the moment [12]. The counselor's being oneself and expressing oneself openly frees him or her of many encumbrances and artificialities and makes it possible for the client to come in touch with another human being as directly as possible [12]. As discussed, this involves self-observation and self-awareness on the counselor's part.

This does not mean that counselors burden clients with overt expression of all their feelings. Nor does it mean that counselors disclose their total self to clients. It means that the counselor is transparent to the client so that the client can see him or her within the context of the therapeutic relationship [13]. It also means avoiding the temptation to present a façade or hide behind a mask of professionalism, or to assume a confessional-professional attitude. It is not easy to achieve such a reality, as it involves "the difficult task of being acquainted with the flow of experiencing going on within oneself, a flow marked especially by complexity and continuous change" [12].

EMPATHY

There is great power in empathy. It breaks down resistance and allows clients to feel safe and able to explore their feelings and thoughts. It is a potent and positive force for change [12]. Empathy serves our basic desire for connection and emotional joining [14]. Empathy may be defined as the action of understanding, being aware of, being sensitive to, and vicariously experiencing the feelings, thoughts, and experience of another. It is a deeper kind of listening in which the counselor senses accurately the feelings and personal meanings that the client is experiencing and communicates this understanding to the client [12]. Empathy is not parroting back the client's words or reflecting only the content of those words. It entails capturing the nuances and implications of what the client is saying, and reflecting this back to the client for their consideration using clear, simply connotative language in as few words as possible [15]. Counselors also can show empathy in nonverbal ways to their clients by, for example, looking concerned, being attentive, leaning forward, and maintaining eye contact [15].

Empathy is a multi-level process of relating to others. It encompasses both an emotive experience and a cognitive one. It includes an intellectual component (namely, understanding the cognitive basis for the client's feelings), and it implies the ability to detach oneself from the client's feelings in order to maintain objectivity [16]. While engaged in empathic listening, mental health professionals should remain responsive to feedback and alter their perspective or understanding of the client as they acquire more information [16]. Empathy may be summarized by the ability to [17]:

- See the world as others see it.

- Be nonjudgmental.

- Understand another person's feelings.

- Communicate your understanding of that person's feelings.

Empathy should not be confused with sympathy, which may be defined as an affinity, association, or relationship between persons wherein whatever affects one similarly affects the other. Compared with empathy, sympathy is a superficial demonstration of care. With sympathy, you feel sorry for the client; with empathy, you feel the client's pain. Although a counselor can get caught up in the client's feelings, he or she should always strive to empathically understand what the client is experiencing while maintaining emotional detachment. This potentially provides a broader perspective that extends beyond the client's situational distress. Mental health professionals want to employ the best tools in order to affect change in their clients without causing harm, and empathy surpasses sympathy in terms of effectiveness. Research has validated the importance of empathy, unconditional positive regard, and congruence for achieving an effective therapeutic relationship [18].

Compassion-focused therapy is a rapidly growing, evidence-based form of psychotherapy that pursues the alleviation of human suffering through psychological science and engaged action [19]. According to Gilbert, the following are attributes of compassion-focused therapy [20]:

- Sensitivity: Responsive to distress and needs; able to recognize and distinguish the feelings and needs of the client.

- Sympathy: Being emotionally moved by the feelings and distress of the client. In the therapeutic relationship, the client experiences the counselor as being emotionally engaged with their story as opposed to being emotionally passive or distant.

- Distress tolerance: Able to contain, stay with, and tolerate complex and high levels of emotion, rather than avoid, fearfully divert from, close down, contradict, invalidate, or deny them. The client experiences the counselor as able to contain her/his own emotions and the client's emotions.

- Empathy: Working to understand the meanings, functions, and origins of another person's inner world so that one can see it from her/his point of view. Empathy takes effort in a way that sympathy does not.

- Nonjudgment: Not condemning, criticizing, shaming, or rejecting. It does not mean nonpreference. For example, nonjudgment is important in Buddhist psychology, which emphasizes experiencing the moment "as it is." This does not mean an absence of preferences.

Empathic Boundaries

Counselors strive to achieve empathy with their clients while maintaining boundaries that protect their own energies. Professionals should ''sense the client's private world as if it were [their] own, without ever losing the 'as if' quality,'' and while not becoming entangled with their perception of the client [12; 21]. It takes work to maintain a healthy distance emotionally while feeling and intuiting what the client is saying.

Too much sympathy, or working with empathy without proper boundaries in the therapeutic relationship, drains the counselor of energy and leads to burnout. In a study of 216 hospice care nurses from 22 hospice facilities across Florida, it was found that trauma, anxiety, life demands, and excessive empathy (leading to blurred professional boundaries) were key determinants of compassion fatigue risk [22]. In other words, there can be too much of a good thing. In order to motivate client change, there should be a limit to the use of empathy in therapy. Empathy is but one tool that a compassionate mental health professional can use to ensure client growth.

5. THE COSTS OF CARING

Humans need humans and heal best with compassionate care. However, mental health professionals must guard against caring too much. While hearing about and sharing the joyous parts of a client's life is wonderful, most therapeutic work involves listening to a client's emotional pain, which can take its toll on even the most seasoned professional.

STRESS

Stress is a warning sign that indicates that self-care needs to be increased. Stress tells you that something is not right. It is like the "check engine" light on your car's dashboard, which, if ignored, can lead to major engine malfunction. Stress that is left unchecked or poorly managed is known to contribute to high blood pressure, heart disease, obesity, diabetes, and suicide [23]. Stress reminds us that we are human and that we have limits. The symptoms of stress include [23]:

- Headaches, muscle tension, neck or back pain

- Upset stomach

- Dry mouth

- Chest pains, rapid heartbeat

- Difficulty falling or staying asleep

- Fatigue

- Loss of appetite or overeating "comfort foods"

- Increased frequency of colds

- Lack of concentration or focus

- Memory problems or forgetfulness

- Jitters, irritability, short temper

- Anxiety

Other warning signs that more self-care is needed include outbursts, depression, anxiety, and lowered tolerance to frustration. Fatigue, whether physical, emotional, mental, or spiritual, can lead to reactivity and poor judgment. Little or no self-care can contribute to burnout, illness, and even addiction. It can also leave the professional vulnerable to crossing or violating boundaries.

A counselor's job is stressful for many reasons, including working in isolation; shouldering the burden of a client's depression, anxiety, apathy, and suicidality; witnessing slow, gradual progress in the therapeutic process; and managing increasing administrative demands (e.g., insurance claims, documentation). These demands can often lead to increased stress and frustration for the counselor.

Self-care includes stress management and vice versa. Self-care should be part of your preventative wellness routine, not instituted only when signs of illness or breakdown are already occurring. Activities that one recommends to clients to decrease their stress will also work for professionals. This includes healthy eating, time management, relaxation techniques, adequate sleep, and maintaining hobbies and outside interests.

COMPASSION FATIGUE, VICARIOUS TRAUMA, AND BURNOUT

When work-related stress is combined with a lack of self-care and support, more serious stress reactions can occur. Compassion fatigue can develop when a mental health professional cares too much or carries too much material [24]. Chronic day-to-day exposure to clients and their distress (e.g., sexual and physical abuse, military combat, community disaster) can be emotionally taxing for the helping professional and can result in compassion fatigue, vicarious trauma, or, ultimately, professional burnout [24,25]. Vicarious trauma describes a profound shift in worldview that occurs in helping professionals when they work with clients who have experienced trauma; the professional's fundamental beliefs about the world are altered by repeated exposure to traumatic material. Burnout describes the physical and emotional exhaustion that helping professionals can experience when they have low job satisfaction and feel powerless and overwhelmed at work. It is not the same as being depressed or overworked. It is a subtle process in which an individual is gradually caught in a state of mental fatigue and is completely drained of all energy. However, burnout does not necessarily indicate a change in worldview or a loss of the ability to feel compassion for others [26,27,28].

The chronic use of empathy combined with day-to-day bureaucratic hurdles (e.g., agency stress, billing difficulties, balancing clinical work with administrative work) can generate the experience of compassion fatigue [29,30]. This type of listening and exposure can take its toll on mental health professionals, particularly when combined with the need to maintain strong limits and boundaries both inside and outside the office. Yet, no matter how well-defined the boundaries are, there will be times when the professional will be affected by listening to what the client has lived through in order to survive; it can be very difficult to hear. This is why peer supervision is necessary. The professional benefits from having a place to offload and receive support following an intense client session in order to mitigate the risk of negative consequences, such as post-traumatic stress disorder, which can be an indirect response to clients' suffering. Compassion fatigue can also cause professionals to lose touch with their own empathy. Strong emotions, as evoked by traumatic material, may strain the empathic ability of the therapist [31]. Symptoms of compassion fatigue result in a loss of interest toward holding empathic response to others due to feeling overwhelmed and burdened by the client's trauma and illnesses. Caregivers with compassion fatigue may develop a preoccupation with re-experiencing clients' trauma; they can develop signs of persistent arousal and anxiety as a result of this secondary trauma. Examples of this arousal can include difficulty falling or staying asleep, irritability or outbursts of anger, and/or exaggerated startle responses. Most importantly, these caregivers ultimately experience a reduced capacity for or interest in being empathic toward the suffering of others [32]. Overlap can occur between compassion fatigue, vicarious trauma, and burnout, with the mental health professional experiencing more than one emotional state.

Some causes of burnout and compassion fatigue can result in part from the personality characteristics of the professional (e.g., perfectionism, overinvolvement with clients) [33]. Because burnout is largely identified in young, highly educated, ambitious professionals, many consider the conflict between an individual's expectations and reality as one of the main characteristics of burnout [27]. Additionally, the professional's attitudes, beliefs, and assumptions can have an impact on performance (e.g., "I must get all my clients better'') and may lead to irritation, a sense of failure, or burnout. Some attitudinal issues are specific to particular client groups (e.g., people who get hostile or perpetrators of sexual assault) or to particular elements of the therapy process (e.g., "I must be available for all of my clients all the time'') [34]. In order to prevent or decrease cases of burnout, compassion fatigue, and vicarious traumatization among professionals, it is important that they receive education on the signs and symptoms of each and that they have access to an open and supportive environment in which to discuss them.

MITIGATING THE COSTS OF CARING

Disengage

As noted, counselors are at increased risk for compassion fatigue, burnout, and/or vicarious trauma when the majority of their caseload involves trauma cases; when there is a lack of balance between work, rest, and play; and when there is a lack of attention to spiritual needs. To reduce their risk, counselors should learn to let go and leave work at work—they should learn to disengage. Disengagement can lower or prevent compassion stress by allowing counselors to distance themselves from the ongoing misery of clients between sessions. The ability to disengage demands a conscious, rational effort to recognize that one must "let go" of the thoughts, feelings, and sensations associated with client sessions in order to live one's own life. Disengagement is the recognition of the importance of self-care and of the need to carry out a deliberate program of self-care [30]. When counselors employ self-care, they model for their clients what mental health looks like. When clients know that counselors have done their own therapeutic or healing work, it instills in them a sense of hope. They see results that indicate the process can work for them, too.

Seek Support

Research indicates that encouraging peer support groups, providing education on the impact of client traumas on mental health professionals, diversifying caseloads, encouraging respite and relaxation, and encouraging a sense of spirituality and wellness are several means of providing support for at-risk professionals [35]. Counselors can be more resilient, accomplish more, and feel more worthwhile when they have close, supportive relationships. Support acts as a buffer against the effects of stress and burnout [36]. Counselors with a larger sense of meaning and connection who practice self-care and work in collaboration with others are less likely to experience vicarious traumatization [37,38].

Set Self-Care Boundaries

In addition to setting and maintaining boundaries with clients, counselors also should set and maintain self-care boundaries to avoid burnout. When setting self-care boundaries, counselors may consider some of the following habits [24,39]:

- Leave work at the office. Avoid conducting research, making telephone calls, and catching up on record keeping at home. Set office hours, publish them on your answering machine, and adhere to those hours.

- Have a procedure for after-hours emergency calls. For example, many counselors instruct clients to call the nearest hospital or go to the local emergency room. Other offices may have an on-call clinician dedicated to responding to emergency calls. The important thing is that there be a clear policy in place for after-hours calls and that clients are aware of and understand the policy.

- Do not skip meals to see an extra client. Include regularly scheduled breaks as part of each work day.

- Schedule and take vacations. Do not check your messages while on vacation. Ask another counselor to see clients in cases of emergency. Most clients can tolerate their counselor's absence for a week or two.

- Live a well-rounded life beyond the office. Make time for friends and family and engage in interests that renew you.

- Educate yourself about trauma and its effects. If you are a supervisor, consider using instruments that measure stress with supervisees. The Maslach Burnout Inventory (MBI) and the Professional Quality of Life (ProQOL) scale should be administered on a regular basis to assess both organizational and individual risk of burnout and trauma-related conditions in high-risk settings.

- Increase your capacity for awareness, containment, presence, and integration. Awareness can be encouraged through meditation, visualization, yoga, journal keeping, art, other creative activities, and personal psychotherapy. Containment abilities can be built through self-care efforts and a balanced life that includes time spent in activities unrelated to work.

Mental health professionals should strive to maintain a balance between giving and getting, between stress and calm, and between work and home. These stand in clear contrast to the overload, understaffing, over-commitment, and other imbalances of burnout. To give and give until there is nothing left to give means that the professional has failed to replenish his or her resources [28].

Practice Mindfulness

Helping professionals often feel like they have to fix others or have all the answers. This is a faulty cognition. Oftentimes, the most healing and powerful act a counselor can do is being in the moment with the client, holding the space for his or her feelings and thoughts. Mindfulness practice can facilitate this. The practice of mindfulness (i.e., present-focused attending to ongoing shifts in mind, body, and the surrounding world), integrated into daily life, can help counselors to develop enhanced patience, presence, and compassion [38]. It can help counselors to stay calmly focused and grounded, which allows them to be less reactive and engage with greater equanimity [38].

One study investigated how the use of dialectical behavioral therapy (DBT) in working with young, self-harming women with borderline personality disorder affected the occupational stress and levels of burnout among psychiatric professionals [40]. DBT was stressful in terms of learning demands, but it decreased the experience of stress in actual treatment of clients. Participants felt that mindfulness training, which was one aspect of DBT, improved their handling of work stressors not related to DBT [40]. Counselors were better able to accept feelings of frustration, cope with stress, and be more patient and relaxed [40]. Mindfulness has been found to decrease stress, increase concentration, and increase the counselor's ability to detach from the client's material. It also assists a counselor's empathy and boundary setting [41]. Mindfulness, attention, empathy, and counseling self-efficacy have been found to be significantly related to one another [41].

One study explored the impact of Buddhist mindfulness (meditation) practice on the attitude, work, and lived experience of counselors and their self-reported experiences of working with clients [42]. Findings suggest that a long-term mindfulness meditation practice can positively impact counselors' ability to distinguish their own experiences from their clients' experiences, can enrich clarity in their work with clients and may help them develop self-insight [42]. Mindfulness may also help to increase patience, intentionality, gratitude, and body awareness [43]. It is an excellent tool for caring, compassionate professionals to use to maintain their own energies and support their clients' growth.

Expand Your Professional World

Symptoms of burnout or compassion fatigue can be signs of a need to grow professionally. This might mean branching out from individual therapy sessions to include group therapy, teaching at local colleges, supervising other professionals, developing continuing education units, or providing consultations. In some instances, it might mean changing careers or exploring other ways to use your licensure and experience.

6. TRANSFERENCE AND COUNTERTRANSFERENCE

The term transference was coined by Freud to describe the way that clients "transfer" feelings about important persons in their lives onto their counselor. As Freud said, "a whole series of psychological experiences are revived, not as belonging to the past but applying to the person of the physician at the present moment" [44]. The client's formative dynamics are recreated in the therapeutic relationship, allowing clients to discover unfounded or outmoded assumptions about others that do not serve them well, potentially leading to lasting positive change [45]. Part of the counselor's work is to "take" or "accept" the transferences that unfold in the service of understanding the client's experience and, eventually, offer interpretations that link the here-and-now experience in session to events in the client's past [46]. The intense, seemingly irrational emotional reaction a client may have toward the counselor should be recognized as resulting from projective identification of the client's own conflicts and issues. It is important to guard against taking these reactions too personally or acting on the emotions in inappropriate ways [47]. Therapists' emotional reactions to their patients (countertransference) impact both the treatment process and the outcome of psychotherapy.

REFLECTION

It also is important to be reflective rather than reactive in words and actions. Use of the mindfulness technique can help counselors to become reflective rather than reactive and can help counselors unhook from any triggering material and maintain appropriate limits and boundaries. Reflection demands a reasonable level of awareness of one's thoughts and feelings and a sound grasp of whether they deviate from good professional behavior. Reflection includes [48]:

- A questioning attitude towards one's own feelings and motives

- The recognition that we all have blind spots

- An understanding that staff are affected by clients

- An understanding that clients are affected by staff behavior

- A recognition that clients often have strong feelings toward staff

Clients are more accepting of transference interpretations in an environment of empathy. Transference interpretation is most effective when the road has been paved with a series of empathic, validating, and supportive interventions that create a holding environment for the client [50].

Freud believed transference to be universal, with the possibility of occurring in the counselor as well as the client. He described this "countertransference" as "the unconscious counter reaction to the client's transference, indicative of the therapist's own unresolved intrapsychic conflicts" [51]. Freud felt that countertransference could interfere with successful treatment [45]. Since the 1950s, the view of countertransference has evolved. It is no longer believed to be an impediment to treatment. Instead, it is viewed as providing important information that the professional can use in helping the client [45].

Empathy allows the counselor to experience and thus know what the client is experiencing. Countertransference emerges when the client's transference reactions touch the counselor in an unresolved area, resulting in conflictual and irrational internal reactions [52]. Good indicators of countertransference are feelings of irritability, anger, or sadness that seem to arise from nowhere. Countertransference frequently originates in counselors' unresolved conflicts related to family issues, needs, and values; therapy-specific areas (e.g., termination, performance issues); and cultural issues [53]. When feelings have intensity or when they persist, this is an indicator for future work and healing.

The counselor's work is to bear the client's transferences and interpret them. When the counselor refuses the transference, there is often a mutual projective identification going on, in which both counselor and client project part of themselves onto the other. Refusal may also mean that one of the counselor's own blind spots has been engaged. As Shapiro explains, "a rough edge of our character has been 'hooked' by a bit of what the patient is struggling with, and we act out a bit of countertransference evoked in us by the transference" [54]. In a group therapy setting, family dynamic re-enactments can emerge as transferences. Managing these complex dynamics can raise the counselor's anxiety and mobilize his or her defenses, compromising a usually thoughtful stance. When counselors experience intense reactions in trauma groups that pull them out of the present moment, they should investigate whether they are responding to traumatic content, personal unresolved issues, or individual or collective transference [55]. Counselors who find themselves ruminating about a previous session's content, a client's welfare, or their own issues should talk with a trusted, objective colleague. Countertransference issues for the mental health professional should be resolved apart from the therapeutic environment to avoid burdening and potentially harming clients [51]. One study of countertransference found that therapists' self-reported disengaged feelings over a treatment period adversely impacted the effect of transference work for all patients, but especially for patients with a history of poor, nonmutual, complicated relationships [48].

SELF-AWARENESS

Problems arise when the professional lacks awareness or refuses to devote the necessary time to process the personal emotions and thoughts that arise within the therapeutic relationship. Feelings of anger, grief, jealousy, shame, injustice, trauma, and even attraction can, when they touch a wound from the past, trigger reactions within even experienced professionals. Clients' experiences can replicate the professional's past relationships and trigger emotions that have not been worked on or addressed. If this occurs, the professional can, without disrupting the client's session, make a mental note of the feelings. This allows the professional to attend to the present moment. After the client's session has ended, the professional can arrange to talk to a colleague or supervisor for processing. If the countertransference continues, it may be necessary for the professional to seek counseling. Self-awareness helps the professional to reflect back to the client's true emotions. It also is an important component of training, development, and effectiveness [56]. Mental health professionals need to possess certain values, qualities, and sensitivities, and should be open-minded and have an awareness of their comfort levels, values, biases, and prejudices [57].

As stated in the ethics codes of the ACA [4]:

Therapists are aware of—and avoid imposing—their own values, attitudes, beliefs, and behaviors. They respect the diversity of clients, trainees, and research participants and seek training in areas in which they are at risk of imposing their values onto clients, especially when their values are inconsistent with the client's goals. They refrain from initiating an activity when they know or should know that there is a substantial likelihood that their personal problems will prevent them from performing their work-related activities in a competent manner. When they become aware of personal problems that may interfere with their performing work-related duties adequately, they take appropriate measures, such as obtaining professional consultation or assistance and determine whether they should limit, suspend, or terminate their work-related duties.

7. BOUNDARIES AND LIMITS

Generally speaking, a boundary indicates where one area ends and another begins. It indicates what is "out of bounds" and acts to constrain, constrict, and limit. In the therapeutic relationship, a boundary delineates the "edge" of appropriate behaviors and helps to rule in and out what is acceptable, although the same behaviors might be acceptable or even desirable in other relationships [58,59]. Boundaries have important functions in the therapeutic relationship, helping to build trust, empower and protect clients, and protect the professional.

BUILDING TRUST

An inherent power differential exists in the therapeutic relationship between the client, who is placed in a position of vulnerability as she or he seeks help, and the practitioner, who is placed in a position of power because of her or his professional status and expertise [59]. When the client sees the counselor sitting in a chair, with a diploma or licensure on the wall, it can be intimidating. To help mitigate these feelings with the client, it is important to maintain a sense of professionalism while working to build trust and rapport. Part of that professionalism includes setting limits and explaining what they are in the context of therapy.

The familiarity, trust, and intensity of the therapeutic relationship create a powerful potential for abuse that underscores the need for careful attention to the ethical aspects of professional care [59]. Trust is the cornerstone of the therapeutic relationship, and counselors have the responsibility to respect and safeguard the client's right to privacy and confidentiality [4]. Clients have expressed what they believe to be essential conditions for the development of trust in the therapeutic relationship. These include that the clinician [60]:

- Is perceived as available and accessible

- Tries to understand by listening and caring

- Behaves in a professional manner (evidenced by attributes such as honesty in all interactions)

- Maintains confidentiality

- Relates to the client as another adult person rather than as an "expert"

- Remains calm and does not over-react to the issue under discussion

Only when satisfied that the clinician is sufficiently experienced, professional, flexible, and empathic can a foundation for therapy be laid. Clients acknowledge that this takes time and that the trustworthiness of the therapeutic relationship may be tested. If the relationship is perceived to be wanting, clients indicate that they would have difficulty continuing it [60].

THE VALUE OF FLEXIBILITY

Rigid boundaries can negatively reinforce the power differential that exists between the client and the counselor. Rigid boundaries may serve the fears and needs of counselors who are new to the profession and/or concerned with the implications of boundary violations. However, rigid boundaries can lead to harm for the client who perceives that the "rules" are more important than his or her welfare. While rigidity and remoteness on the counselor's part may help ensure that boundaries are intact, they do not accurately reflect the intended role of boundaries in clinical practice. Boundaries should never imply coldness or aloofness. As stated, clients value flexibility, caring, and understanding. Within conditions that create a climate of safety, flexible boundaries can accommodate individual differences among clients and counselors and allow them to interact with warmth, empathy, and spontaneity [61]. Firm, intractable boundaries may be a comfort to the helping professional; however, fixed rules cannot capture the complex reality of the therapeutic relationship [59].

EMPOWERING AND PROTECTING THE CLIENT

Boundaries and effective limit setting in sessions help to empower and protect clients by teaching and reinforcing the skills they need to become healthy. Boundaries set the parameters and expectations of therapy, so it is important to articulate them in such a way that each client's understanding of them is clear. Counselors should constantly and actively make judgements about where to draw lines that are in the client's best interests [62].

Boundaries begin the moment a client enters the room. Indicate which chair is yours and where it is acceptable for the client to sit. Take note of where your seat is in relation to the door should an emergency arise. Be sure to maintain an appropriate amount of space between yourself and the client. Too much space can feel impersonal and too little can feel invasive. Consider the décor of the setting. Clients may become distracted by the counselor's personal artifacts and family photographs and may place their focus on the counselor rather than on their own therapeutic work. Some clients with poor boundaries may become preoccupied with the counselor's family, which can become a source of transference.

Clients often enter therapy with a history of prior boundary violations (e.g., childhood sexual abuse, domestic violence, inappropriate boundary crossings with another professional) that leave them with persisting feelings and confusion regarding roles and boundaries in subsequent intimate relationships [63]. Consequently, they may test the boundaries as children do. The counselor should recognize these boundary dilemmas and manage them by reiterating the boundaries calmly and clearly [62]. The counselor must also set and maintain boundaries even if the client threatens self-harm or flight from therapy. This can be extremely challenging when faced with a client's primitively motivated, intense demands. However, counselors should recall that one description of the tasks with clients with primitive tendencies is to resist reinforcing primitive strivings and to foster and encourage adult strivings [64]. Winnicott refers to this as a "holding relationship," wherein the counselor acts as a "container" for the strong emotional storms of the client. The act of holding helps reassure the client that the clinician is there to help the client retain control and, if necessary, assume control on his or her behalf [65].

Due to the potential issues and challenges that the client brings to therapy (e.g., cognitive deficits, substance abuse/addictions, memory issues, personality disordered manipulations), it is important to maintain a record of instances when the articulated boundaries and limits have been ignored or violated. For example, a client is habitually late, despite knowing that it is unacceptable to arrive more than 10 minutes late to session. The first instance of a late arrival might simply warrant a reminder of the 10-minute limit, whereas repeated instances would require that the limit be enforced. The clinician who overidentifies with a client might experience a need to do things for the client rather than help the client learn to do things for him- or herself. While this behavior may appear relatively harmless, it suggests overinvolvement with a client and potential boundary problems [66]. Such behavior inhibits the client's ability to learn personal responsibility and how to resolve conflict [67]. It also may impede the reflective and investigative character of an effective helping process [39]. Mental health professionals should take reasonable steps to minimize harm to clients where it is foreseeable and unavoidable [3,4]. They also should facilitate client growth and development in ways that foster the interest and welfare of the client and promote the formation of healthy relationships [4].

PROTECTING THE PROFESSIONAL

As stated, professional associations that represent the various fields of clinical practice have codes of ethics that provide principles and standards to guide and protect the professional and the individuals with whom they work [3,4,5,6,7]. Client welfare and trust in the helping professions depend on a high level of professional conduct [3,4]. Professional values, such as managing and maintaining appropriate boundaries, are an important way of living out an ethical commitment [4].

Some situations in therapy are clear with regard to boundaries (e.g., no sexual relationships with clients). Other situations may be not as clear or may be ambiguous (e.g., receiving gifts from clients). When faced with such situations, professionals should engage in an ethical decision-making process that includes an evaluation of the context of the situation and collaboration with the client to make decisions that promote the client's growth and development [4]. Supervision and colleague support also may be necessary to reach the best decision. Such a process helps clinicians maintain justice and equity and avoid implications of favoritism in dealing with all of their clients [68].

Professionals who deliver services in nontraditional settings, such as those who have home-based practices, face unique challenges related to boundaries and limit setting. As with office-based therapy, some situations cannot be prepared for and will need to be addressed in the moment. While delivering services in nontraditional settings may benefit some clients, when working in homes or residences, the professional is advised to emphasize informed consent, particularly with regard to therapeutic boundaries. Whenever possible, the impact of crossing boundaries on therapy and on the therapeutic relationship should be considered ahead of time [69].

8. BOUNDARY CROSSINGS AND VIOLATIONS

A boundary crossing is a departure from commonly accepted practices that could potentially benefit clients; a boundary violation is a serious breach that results in harm to clients and is therefore unethical [70]. Professional risk factors for boundary violations include [71]:

- The professional's own life crises or illness

- A tendency to idealize a "special" client, make exceptions for the client, or an inability to set limits with the client

- Engaging in early boundary incursions and crossings or feeling provoked to do so

- Feeling solely responsible for the client's life

- Feeling unable to discuss the case with anyone due to guilt, shame, or the fear of having one's failings acknowledged

- Realization that the client has assumed management of his or her own case

Denial about the possibility of boundary problems (i.e., "This couldn't happen to me") also plays a significant role in the persistence of the problem [71]. Lack of self-care and self-awareness also can leave the mental health professional vulnerable to boundary crossings and/or violations.

Whatever the reason the professional has to cross a boundary, it is of utmost importance to ensure that it will not harm the client. Each boundary crossing should be taken seriously, weighed carefully in consultation with a supervisor or trusted colleague, well-documented, and evaluated on a case-by-case basis. Intentional crossings should be implemented with two things in mind: the welfare of the client and therapeutic effectiveness. Boundary crossing, like any other intervention, should be part of a well-constructed and clearly articulated treatment plan that takes into consideration the client's problem, personality, situation, history, and culture as well as the therapeutic setting and context [72]. Boundary crossings with certain clients (e.g., those with borderline personality disorder or acute paranoia) are not usually recommended. Effective therapy with such clients often requires well-defined boundaries of time and space and a clearly structured therapeutic environment. Dual or multiple relationships, which always entail boundary crossing, impose the same criteria on the professional. Even when such relationships are unplanned and unavoidable, the welfare of the client and clinical effectiveness will always be the paramount concerns [72].

Some counselors may consider a boundary crossing when it provides a better firsthand sense of the broader clinical context of their client, such as visiting the home of a client that is ailing, bedridden, or dying; accompanying a client to a medically critical but dreaded procedure; joining a client/architect on a tour of her latest construction; escorting a client to visit the gravesite of a deceased loved one; or attending a client's wedding [72]. Many mental health professionals will not cross these boundaries and will insist that therapy occur only in the office. Each professional should operate according to the parameters with which he or she is comfortable. As stated, the best interests of the client, including client confidentiality, and the impact to therapy should be of paramount importance when considering whether to cross a boundary.

To be in the best position to make sound decisions regarding boundary crossings, mental health professionals should develop an approach that is grounded in ethics; stay abreast of evolving legislation, case law, ethical standards, research, theory, and practice guidelines; consider the relevant contexts for each client; engage in critical thinking and personal responsibility; and, when a mistake is made or a boundary decision has led to trouble, use all available resources to determine the best course of action to respond to the problem [73]. The risk management strategy also should include discussions with supervisors, colleagues, and the client. Each step should be documented and should include supervisory recommendations and client discussion regarding the benefits versus the risks of such actions. Although minor boundary violations may initially appear innocuous, they may represent the foundation for eventual exploitation of the client. If basic treatment boundaries are violated and the client is harmed, the professional may be sued, charged with ethical violations, and lose his/her license [74].

9. MULTIPLE RELATIONSHIPS

Examples of multiple relationships include being both a client's counselor and friend; entering into a teacher/student relationship; becoming sexually involved with a current or former client; bartering services with a client; or being a client's supervisor. Even when entering into a multiple relationship seems to offer the possibility of a better connection to a client, it is not recommended. Multiple relationships can cause confusion and a blurring of boundaries and risk exploitation of the client.

The issue of multiple relationships is addressed by the codes of ethics of mental health professions. According to the APA's ethics code [3]:

A multiple relationship occurs when a psychologist is in a professional role with a person and (1) at the same time is in another role with the same person, (2) at the same time is in a relationship with a person closely associated with or related to the person with whom the psychologist has the professional relationship, or (3) promises to enter into another relationship in the future with the person or a person closely associated with or related to the person. A psychologist refrains from entering into a multiple relationship if the multiple relationships could reasonably be expected to impair the psychologist's objectivity, competence or effectiveness in performing his or her functions as a psychologist, or otherwise risks exploitation or harm to the person with whom the professional relationship exists.

The ethics code of the NASW defines dual or multiple relationships as occurring "when social workers relate to clients in more than one relationship, whether professional, social, or business. Dual or multiple relationships can occur simultaneously or consecutively." [5]. It also states that "social workers should not engage in dual or multiple relationships with clients or former clients in which there is a risk of exploitation or potential harm to the client. In instances when dual or multiple relationships are unavoidable, social workers should take steps to protect clients and are responsible for setting clear, appropriate, and culturally sensitive boundaries" [5]. The code further states that it is the professional's responsibility to "be alert to and avoid conflicts of interest that interfere with the exercise of professional discretion and impartial judgment" and that counselors should "inform clients when a real or potential conflict of interest arises and take reasonable steps to resolve the issue in a manner that makes the clients' interests primary and protects clients' interests to the greatest extent possible" [5]. In some instances, this may require "termination of the professional relationship with proper referral of the client" [5].

The ACA ethics code states that [4]:

Counselors are prohibited from engaging in counseling relationships with friends or family members with whom they have an inability to remain objective. . .They also are prohibited from engaging in a personal virtual relationship with individuals with whom they have a current counseling relationship (e.g., through social and other media). . .When a counselor agrees to provide counseling services to two or more persons who have a relationship, the counselor clarifies at the outset which person or persons are clients and the nature of the relationships the counselor will have with each involved person. If it becomes apparent that the counselor may be called upon to perform potentially conflicting roles, the counselor will clarify, adjust, or withdraw from roles appropriately.

Mental health professionals who practice in small, rural communities face special problems in maintaining neutrality, fostering client separateness, protecting confidentiality, and managing past, current, or future personal relationships with clients [75]. Whether the practice is located in a small town or a big city, there will be times when counselors and clients will encounter one another outside the office. To ignore a client who is reaching out in a social setting may cause the client harm. However, it also is important to avoid violating the client's privacy. The best way to minimize the potential awkwardness of such an encounter is to prepare ahead of time. For example, a counselor might incorporate a conversation about such an encounter into the initial evaluation process by telling the client: "If I happen to be at a store or a restaurant and see you, I won't say hello because I respect your confidentiality and want to protect your privacy. However, if you want to smile or say hello to me, I will respond in kind." Explain to the client that the conversation or acknowledgment must be brief to prevent any violation of the client's privacy. After an encounter in public, address the event in your next session, discuss any feelings the client had about the encounter, and note the discussion in the client record. Such an encounter would not fall under the category of dual/multiple relationships unless, for example, the counselor and client went grocery shopping at the same time every week and interacted each time. In this instance, the counselor is advised to change his or her shopping day and/or time in order to avoid risking loss of client confidentiality.

BOUNDARY VIOLATIONS WITHIN MULTIPLE RELATIONSHIPS

Mental health professionals are forbidden to exploit any person over whom they have supervisory, evaluative, or other similar authority. This includes clients/patients, students, supervisees, research participants, and employees [3,4]. Professional ethics codes outline specific instances of behaviors and actions (some that are expressly prohibited) that have exploitative potential, including [3,4,5]:

- Bartering with clients

- Sexual relationships with students or supervisees

- Sexual intimacies with current or former clients

- Sexual intimacies with relatives/significant others of current therapy clients

- Therapy with former sexual partners or partners of a romantic relationship

- Romantic interactions or relationships with current clients, their romantic partners, or their family members, including electronic interactions or relationships

- Physical contact with clients (e.g., cradling or caressing)

There are times when a client has an emotional session and hugs the counselor unexpectedly before leaving the office. This physical contact should be noted in the client's record along with what precipitated it. It should be revisited with the client at the next session, with this discussion recorded in the client's record. While you may prefer no physical contact, you can try to respond positively to the desire for closeness. For example, make personal contact with your hand as you hold the client at a distance, make eye contact, and tell the client that while physical reaching out is positive and welcome, you cannot allow it [12].

The ACA ethics code prohibits sexual and/or romantic counselor/client interactions or relationships with former clients, their romantic partners, or their family members for a period of five years following the last professional contact. This prohibition applies to both in-person and electronic interactions or relationships [4]. The APA ethics code indicates that this period should be "at least two years after cessation or termination of therapy," and that "psychologists do not engage in sexual intimacies with former clients/patients even after a two-year interval except in the most unusual circumstances" [3]. Mental health professionals who choose to engage in relationships with former clients have the burden of demonstrating that there has been no exploitation, in light of all relevant factors [3]. Factors to consider include the amount of time passed since termination of therapy; the client's personal history and mental status; the likelihood of an adverse impact on the client; and statements or actions made by the counselor during therapy suggesting or inviting a possible sexual or romantic relationship with the client [3].

Standards regarding sexual relationships and physical contact also are addressed by the NASW ethics code [5]:

1.09 Sexual Relationships

(a) Social workers should under no circumstances engage in sexual activities, inappropriate sexual communications through the use of technology or in person, or sexual contact with current clients, whether such contact is consensual or forced.

(b) Social workers should not engage in sexual activities or sexual contact with clients' relatives or other individuals with whom clients maintain a close personal relationship when there is a risk of exploitation or potential harm to the client. Sexual activity or sexual contact with clients' relatives or other individuals with whom clients maintain a personal relationship has the potential to be harmful to the client and may make it difficult for the social worker and client to maintain appropriate professional boundaries. Social workers—not their clients, their clients' relatives, or other individuals with whom the client maintains a personal relationship—assume the full burden for setting clear, appropriate, and culturally sensitive boundaries.

(c) Social workers should not engage in sexual activities or sexual contact with former clients because of the potential for harm to the client. If social workers engage in conduct contrary to this prohibition or claim that an exception to this prohibition is warranted because of extraordinary circumstances, it is social workers—not their clients—who assume the full burden of demonstrating that the former client has not been exploited, coerced, or manipulated, intentionally or unintentionally.

(d) Social workers should not provide clinical services to individuals with whom they have had a prior sexual relationship. Providing clinical services to a former sexual partner has the potential to be harmful to the individual and is likely to make it difficult for the social worker and individual to maintain appropriate professional boundaries.

1.10 Physical Contact

Social workers should not engage in physical contact with clients when there is a possibility of psychological harm to the client as a result of the contact (such as cradling or caressing clients). Social workers who engage in appropriate physical contact with clients are responsible for setting clear, appropriate, and culturally sensitive boundaries that govern such physical contact.

The safest course of action is to continue to maintain established boundaries and limits indefinitely after therapy ends. In addition to the noted relevant factors, counselors should keep in mind that the client may return for further treatment. If the counselor has become involved in a business or social relationship with a former client, he or she deprives the client of the opportunity to return for additional treatment. It is vital to be mindful of the potential to exploit the client's vulnerability in a post-termination relationship [76].

Mental health professionals who find themselves attracted to a client should seek supervision around this issue. It is normal for feelings to develop in any type of relational context. It is not the feelings of attraction that are the problem, but rather actions taken. Mental health professionals should never act on these feelings, but instead discuss them with a trusted supervisor or colleague, exploring the possibility of countertransference as well as the potential trigger for the attraction. If the attraction causes intense feelings, it is advisable to seek personal therapy. If the feelings interfere with one's ability to treat a client, the client should be transferred to another professional, and work with the client terminated.

10. GIFTS

It is not unusual during the course of therapy for a client to present a counselor with a token of appreciation or a holiday gift, and receiving gifts from clients is not strictly prohibited by professional ethics codes. Instead, the ethics codes advise professionals to consider a variety of factors when deciding whether to accept a client's gift.

Section A.10.f (Receiving Gifts) of the 2014 ACA Code of Ethics states that [4]:

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

The National Board for Certified Counselors Code of Ethics: Directive #21 provides similar guidance to its members [6]:

Counselors shall not accept gifts from clients except in cases when it is culturally appropriate or therapeutically relevant. Counselors shall consider the value of the gift and the effect on the therapeutic relationship before accepting. Acceptance of a gift shall be documented in the client's record.

In the code of ethics of the Association for Addiction Professionals, Principle I-40: The Counseling Relationship states that [7]:

Addiction professionals recognize that clients may wish to show appreciation for services by offering gifts. Providers shall take into account the therapeutic relationship, the monetary value of the gift, the client's motivation for giving the gift, and the counselor's motivation for wanting to accept or decline the gift.

As noted in these excerpts, the effect on the therapeutic relationship should be a primary consideration when considering whether to accept a gift. Gifts can mean many things and also can fulfill social functions. The counselor's task is to identify the contextual meaning of the gift and determine when the gift is not merely a gift. To do so, the counselor must draw out from the client information to discern the possibility of a metaphorical or culturally significant meaning for the gift giving [77]. Counselors should consider the client's motivation for gift-giving as well as the status of the therapeutic relationship. Gifts that may seem intended to manipulate the counselor are probably best refused, whereas rejection of a gift intended to convey a client's appreciation may harm the relationship [78].

If the counselor is most comfortable with a "no-gift policy," it is best that the policy be discussed at the beginning of therapy. To wait until a client is presenting a gift to state that it is your policy to decline gifts may harm the client and damage the therapeutic relationship. Clear communication, both written and spoken, of the policy with clients as they enter therapy may help avert difficult later interactions around gifts. If clients have an understanding as they begin therapy what the counselor's approach will be, misunderstandings may be avoided [79]. While restrictive guidelines might be unhelpful, confusion surrounding gifts seems to be exacerbated by a lack of professional discussion about the topic [80].

Many professionals try to keep gifts "alive" throughout client sessions. This often involves putting the gift "on hold" (including decisions about acceptance and rejection) until the best moment for exploration with the client occurs. This allows that gifts given during therapy (where possible) remain part of therapy (i.e., they stay in the room and are available for future sessions) [80]. When considering whether to discuss the gift as part of therapy, the counselor should evaluate pertinent factors, such as the client's time in therapy, the context and frequency of gifts, and client dynamics. While not all gifts warrant full discussion (e.g., those given to show appreciation or of modest financial value), some, such as repeated or expensive gifts, do. Although counselors should be careful not to make too much of a gift, especially those that clients at least initially see as being given simply as a way to say thank you, such conversations may enable both members of the dyad to attain greater insight into the gift's intention and meaning and thereby prove helpful to the continued therapy work [81].

Gifts can range from physical objects, to symbols or gestures. As stated, consider the monetary value of the gift, the client's motivation for giving the gift, and the counselor's motivation for wanting to accept or decline the gift [4,5,7]. If there are concerns about any of these factors, it may be best to explore the intent of the gift in session. If a gift is deemed inappropriate, the counselor is advised to decline to accept it. In these cases, counselors should express appreciation for the thought and gesture, explain why they are unable to accept the gift, return it with kindness, and note the encounter in the client's record.

Professionals who work with children have unique challenges regarding gifts. Rejecting a child's gift or trying to explain a "no-gift policy" can cause the child to feel confused or rejected; children do not have the same levels of cognition and understanding that adults have. For play counselors, potential compromises include incorporating the gift into the other materials and toys in the playroom or directly sharing the gift with the child [81]. An important factor affecting the decision to accept a gift is the kind of gift presented by the child. Artwork or something created by the child is an extension of the child and therefore can be viewed as an extension of emotional giving. Accepting non-purchased items (e.g., a flower picked by a child or a child's drawing) would be acceptable in most cases [82].

Clients with personality disorders present unique challenges regarding the issue of gifts. Generally, these clients exhibit manipulation, poor boundaries, and fixed or rigid patterns of relating, and gift giving can be a feature of the clinical picture for such clients. Accepting a gift from such a client may reinforce patterns of manipulative or self-debasing behaviors that are symptomatic of the problematic levels of functioning. In such instances, counselors should discern which course of action is truly in the client's best interests [77].

Often, a small token may be given or received at the termination of therapy for a long-term client. A touchstone that has meaning for the client, such as a meditation CD, book, or greeting card, is appropriate. As with all gifts, the gift and the context in which the gift was given or received should be noted in the client's record, along with your own intent and how you think the client perceived the gift.

THE GIFT OF SELF-DISCLOSURE

Self-disclosure can be considered another type of gift; however, it is best saved for a special occasion, shared deliberately, and always with the client's welfare first and foremost in mind. Self-disclosure is useful when it benefits the client, not the counselor. Although self-disclosure may cause no problems in therapy, it may intrude on the client's psychic space or replace a client's rich and clinically useful fantasy with dry fact, stripped of meaningful affect [71].

Humanistic theorists openly embrace counselor self-disclosure, asserting that such interventions demonstrate counselors' genuineness and positive regard for clients [83]. It is not surprising that professionals with behavioral and cognitive orientations view professional self-disclosures positively, especially when these interventions are intended to serve as a model for client self-disclosure [84]. And there will be times that self-disclosure is helpful in therapy. For example, it may serve as a vehicle for transmitting feminist values, equalizing power in the therapy relationship, facilitating client growth, fostering a sense of solidarity between counselor and client, helping clients view their own situations with less shame, encouraging clients' feelings of liberation, and acknowledging the importance of the real relationship between counselor and client. It also may enable clients to make informed decisions about whether or not they choose to work with a counselor [84].

According to one study, the content areas clinical social workers felt most comfortable self-disclosing about were loneliness, relationship status, aging, and other developmental issues of adulthood. Many talked freely about their marital status, the composition of their families, their parenting, their education, and their work. The most significant content area for sharing was grief work around significant losses either through separation, divorce, or death [85]. In these cases, counselor self-disclosure can help clients feel less alone and can normalize an emotional experience. It can give a client hope to learn that a trusted counselor has gone through the same situation.

Cautions Regarding Self-Disclosure

The power differential in the therapeutic relationship gives the professional access to a great deal of information about the client, which is transmitted in a one-way direction from client to counselor. Occasionally, a client will ask personal questions of the counselor. The questions may arise simply out of curiosity, but they also may arise when a client is attempting to gain a feeling of control, as seen in individuals with personality disorders. Personal questions also may signal a client's wish to avoid feeling uncomfortable with emerging feelings/thoughts. Acknowledging and showing compassion for the client's curiosity while maintaining professional boundaries will satisfy most clients. While it is normal for clients to be curious, it is important to remind them that they are the focus of session. Gently redirect the conversation with comments such as, "Let's get back to you," or "What were you thinking or feeling before you asked me about myself?" It is important that professionals keep their sharing limited, even when the client asks for them to self-disclose.

No matter how on guard one is, there will be times when personal information makes its way to clients. Accidental self-disclosures may include extra-therapeutic encounters, slips of the tongue, or public notices of events or lectures. Personal aspects of the counselor's life may come to light if he or she calls a client by another client's name, a newspaper prints an obituary of the counselor's spouse, or the counselor is seen entering a place of worship [86]. Most clients who learn a bit of personal information about their counselor will mention it only to express care or concern, as when they learn of a death. Clients are generally satisfied with a brief acknowledgement of the disclosure and an appreciation for the client's expressed feelings about it.

As stated, mental health professionals' primary concern is to avoid burdening or overwhelming clients. Professionals should generally avoid using disclosures that are for their own needs, that remove the focus from the client, that interfere with the flow of the session, that burden or confuse the client, that are intrusive, that blur the boundaries between the professional and client, or that contaminate transference [84].

11. TECHNOLOGY AND DISTANCE THERAPY

We live in a rapidly changing world, especially where technology is concerned. In the past, therapy was offered only through in-person interaction in an office setting. Then, gradually, some professionals began to offer telephone sessions. Today, counseling is offered through video conferencing and other forms of telepsychology, and paper client records are being replaced with electronic records. Competent counseling includes maintaining the knowledge and skills required to understand and properly use treatment tools, including technology, while adhering to the ethical code of one's profession.

The APA has created guidelines to address the developing area of psychologic service provision commonly known as telepsychology [87]. The APA defines telepsychology as the "delivery of psychological services using telecommunication technologies…Telecommunication technologies include, but are not limited to synchronous (i.e., live and real-time interaction, e.g., videoconferencing, audio-only telephone) and asynchronous (i.e., store-and forward, non-live; e.g., text, email, messaging program, data-tracking smartphone applications) methods of healthcare-related communication and transmission of healthcare-related information. Transmitted information may include text, image, audio, interactive videoconferencing, remote patient monitoring, or other data related to patient care" [89]. The APA guidelines are informed by its ethics code and record-keeping guidelines as well as its guidelines on multicultural training, research, and practice.

The guidelines allow that telecommunication technologies may either augment traditional in-person services or be used as stand-alone services. However, the guidelines are intended to "help psychologists apply best professional practices when using telecommunication technologies" and not to "contravene any limitations set on psychologists' activities based on ethical standards; federal, state, provincial, and territorial laws; and other organizational regulations" [87]. When one set of considerations may suggest a different course of action than another, the professional should balance them appropriately, with the aid of the guidelines, while holding to all current legal and ethical standards of practice [87]. The complete guidelines are available online at https://www.apa.org/about/policy/telepsychology-revisions.

The 2014 ACA Code of Ethics also addresses distance counseling, technology, and social media. It states [4]:

Counselors understand that the profession of counseling may no longer be limited to in-person, face-to-face interactions. Counselors actively attempt to understand the evolving nature of the profession with regard to distance counseling, technology, and social media and how such resources may be used to better serve their clients. Counselors strive to become knowledgeable about these resources. Counselors understand the additional concerns related to the use of distance counseling, technology, and social media and make every attempt to protect confidentiality and meet any legal and ethical requirements for the use of such resources.

The ACA code also addresses legal considerations, informed consent and disclosure, confidentiality, security, and multicultural and disability considerations as they relate to technology.

The NBCC recognizes that distance counseling presents unique ethical challenges to professional counselors; related technology continues to advance and be used by more professionals; and that the use of technology by professionals continues to evolve. In light of this information, the NBCC Code of Ethics includes an updated and expanded section on telemental health, social media, and technology. The revised policy advises in detail about privacy concerns, legal considerations, obtaining the necessary information and consent from the client, and social media best practices [6].

According to the NASW ethics code, "Social workers should take reasonable steps to protect the confidentiality of electronic communications, including information provided to clients or third parties. Social workers should use applicable safeguards (such as encryption, firewalls, and passwords) when using electronic communications such as e-mail, online posts, online chat sessions, mobile communication, and text messages" [5]. Professionals are advised to "comply with the laws governing technology and social work practice in the jurisdiction in which they are regulated and located and, as applicable, in the jurisdiction in which the client is located" [5]. In general, the NASW Code of Ethics advises that "Social workers should develop and inform clients about their policies, consistent with prevailing social work ethical standards, on the use of electronic technology" [5]. Professionals who are involved in discoverable (by the client) "electronic communication with groups based on race, ethnicity, language, sexual orientation, gender identity or expression, mental or physical ability, religion, immigration status, and other personal affiliations may affect their ability to work effectively with particular clients" [5].

Professionals interested in providing online interventions also should consider the potential for boundary confusion, inappropriate dual relationships, or harm to clients [5]. For example, instant message systems can alert clients each time the professional is online, allowing the client to send chat requests. Clients might access a professional's personal webpage or sign onto online discussion groups to which the professional also belongs. Some may continue to send the professional emails after the termination of the relationship. E-counselors should consider their response to such ongoing contact. Potentially more seriously, clients may use the Internet to harass or stalk current or former counselors [88]. The best way to prevent potential problems is to discuss the boundaries with clients during the initial assessment. Being up front and clear with clients about limits and policies regarding the use of technology and social networking is recommended [89].

Miscommunication is a commonplace occurrence in the online world. Even the simplest things (e.g., punctuation marks) can be misinterpreted. Studies reveal that 7% of any message is conveyed through words, 38% through certain vocal elements, and 55% through nonverbal elements (e.g., facial expressions, gestures, posture) [90]. Some technology-based forms of communication can result in the loss of important nonverbal and vocal cues, leading to an increased risk for miscommunication between client and counselor. Interactive communication, such as texting and email, involves the loss of nonverbal social cues that provide valuable contextual information and interpretation of meaning. Loss of these physical social cues may also increase the client's tendency to project personal psychologic material onto the blankness of the communication. While this may be helpful in some forms of psychotherapeutic interventions and it may offer advantages over in-person communication, it also presents a potential risk for increased miscommunication [88].

The compassionate professional strives to communicate nonverbally to clients that he or she is listening to and in the moment with the client. Physical cues, such as nodding and eye contact, have been shown to be positively associated with the degree that clients feel the counselor is respectful and genuine [91,92]. Much attention also is paid to the voice, as it carries the verbal message and people often believe the voice to be a more reliable indicator of one's true feelings [93]. Because research exploring how empathy is experienced in an online environment is minimal, counselors should check with their clients to determine if the empathy is being transmitted in their text-based communications [12].

No matter what type of counseling is offered, a thorough initial evaluation should be completed to assess whether a client is appropriate for distance counseling. Practicing within recommended guidelines does not release counselors from the personal responsibility to be aware of, and to independently evaluate, the variety of ethical issues involved in the practice of online therapy [88]. Certain clients (e.g., those with suicidal, homicidal, or substance abuse history, clients with personality disorders) would not be suited to online therapy.

LEGAL AND ETHICAL CONSIDERATIONS

The challenges of online therapy lead to legal and ethical concerns associated with the delivery of mental health services via the Internet. Those opposed to online or distance therapy worry about licensure issues related to doing therapy across jurisdictional boundaries, legal responsibility in the event of a crisis, and the appropriateness of client anonymity [94].

Providing services across state lines is one of the biggest unresolved issues. Although communication technologies allow counselors to reach clients anywhere, state licensing laws generally do not permit out-of-state counselors to provide services via these methods. Some states offer guest licensure provisions, but most states require that the counselor hold a license in his or her own state and in the client's state. Providing distance therapy within one's own state is simpler, and it allows mental health professionals to reach people who would not otherwise have access to services (e.g., rural residents, people with certain disabilities) as well as those who want to receive services from home. To confidently provide distance services [95]:

- Abide by all applicable licensing requirements and professional standards of care.

- Understand the technology being used.

- Periodically check your state legislature's website for the latest telehealth laws and regulations.

- Check for a board policy statement that provides guidance on telepractice.

- Check whether your state licensing board has issued policies related to telepractice.

- Confirm that telehealth services (both in-state and across jurisdictional lines) are covered under your malpractice policy.

The COVID-19 public health emergency increased demand for mental and behavioral health services while driving most of those services to telehealth platforms. In response to this, in 2020, the APA led a campaign to maximize the availability of telepsychology services [96]. In March 2020, the federal government designated psychologists as critical, essential workers, and the Centers for Medicare and Medicaid Services (CMS) improved access to care for Medicare beneficiaries. CMS issued further guidance to waive key telehealth requirements. Because the new legislation cannot supersede state licensing laws (e.g., those that prohibit psychologists from using telehealth to provide services across state lines), the APA drafted letters to governors in all 50 states urging them to temporarily suspend state licensing laws and regulations regarding telepsychology services to ensure continuity of care. Within weeks of receiving the APA letter [96]:

- 12 states issued executive orders calling for expansion of telehealth service rates.

- 14 states issued executive orders allowing patients to receive telehealth services in their own homes.

- 16 states temporarily lifted licensing requirements.

- 22 states either expanded their policies for out-of-state providers to temporarily practice in their states or instituted emergency expedited registration for out-of-state providers.

However, the COVID-19 public health emergency ended in August 2023, and professionals offering telehealth services must use fully HIPAA-compliant software. Some options include Skype for Business, Updox, VSee, Zoom for Healthcare, and others [97]. More information can be found at https://www.hhs.gov/hipaa/for-professionals/security/laws-regulations/index.html [98]. The APA also advises professionals to review individual payer's policies to confirm what telehealth services are covered and to determine the requirements for coding and billing telehealth services. Depending on the state, telehealth services may be limited to videoconferencing or include asynchronous communications or audio-only phone. It is also important to determine if there are originating site restrictions for where the patient may receive services or if coverage of telehealth services is limited to in-network providers or telehealth-only providers [97]. Emergency licensing provisions enacted during the COVID-19 pandemic have also ended.

SOCIAL MEDIA

With the advent of social media, clients can now search for and find the Facebook or Twitter page of their counselor, if one exists. Counselors who accept a client's "friend request" are in essence agreeing that the counselor and client are now friends, creating a multiple relationship. As discussed, when clients have access to their counselor's social media sites, both intentional and unintentional self-disclosures can occur. Modern social networking systems (e.g., Facebook, Instagram) exemplify intentional self-disclosure without a particular client focus. In contrast, Internet search engines (e.g., Google, LexisNexis) may allow unintended disclosure of personal details of the professional's life. Professionals should be aware and cognizant of social media involvement, including what information is public. Many sites offer ways to post minimal information if a connection to other professionals is desired. Avoid posting a profile photo that includes your family or other personal details, as these are public [86].

12. CONCLUSION

Competent counselors are well-educated and well-versed in the ethics of their profession. They understand that trust is built over time in the therapeutic relationship, with the help of limits and boundaries, and that it is reinforced by empathic response. Competent, compassionate professionals are both self- and other-aware and able to seek appropriate supervision and consultation when necessary. They establish self-care boundaries in order to protect their own compassionate, empathic response as well as their physical, emotional, and spiritual well-being. This enables counselors to most effectively help their clients.

13. RESOURCES

Administration for Community Living

Diversity and Cultural Competency

https://www.acl.gov/programs/strengthening-aging-and-disability-networks/diversity-and-cultural-competency

Office of Minority Health

Cultural and Linguistic Competency

https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=1&lvlid=6

Health Resources and Services Administration

Culture, Language and Health Literacy

https://www.hrsa.gov/about/organization/bureaus/ohe/health-literacy/culture-language-and-health-literacy

APA Ethical Principles of Psychologists and Code of Conduct

https://www.apa.org/ethics/code

ACA Code of Ethics

https://www.counseling.org/docs/default-source/default-document-library/ethics/2014-aca-code-of-ethics.pdf

NAADAC Code of Ethics

https://www.naadac.org/code-of-ethics

NBCC Code of Ethics

https://www.nbcc.org/Assets/Ethics/NBCCCodeofEthics.pdf

NASW Code of Ethics

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

Substance Abuse and Mental Health Services Administration Cultural Competence

https://www.samhsa.gov/capt/applying-strategic-prevention/cultural-competence

HelpGuide: Benefits of Mindfulness

https://www.helpguide.org/harvard/benefits-of-mindfulness.htm

Mindfulnet.org

http://www.mindfulnet.org

Plum Village Mindfulness Practice Center

https://plumvillage.org/mindfulness-practice

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91450 • AI in Health Care

Alice Yick Flanagan, PhD, MSW

www.netce.com

Copyright © 2025 NetCE, All rights reserved.

Artificial intelligence (AI) is a buzzword and is the considered the "big thing" in health care. It is touted as holding tremendous promise in health and mental healthcare systems. In general, many healthcare and mental health professionals are not familiar with AI, are distrustful of AI, or may be skeptical of its application in health and mental health care. The purpose of the course is to familiarize participants with AI and its potential applications in health and mental health care. The merits and limitations of AI will be reviewed as well as factors that will aid in facilitating and impeding the integration of AI in service delivery. Ethical concerns will be reviewed as well.

Table of Contents

91450 • AI in Health Care

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. AN OVERVIEW OF ARTIFICIAL INTELLIGENCE (AI)

DEFINITION

MARKET OVERVIEW

HISTORICAL EVOLUTION OF AI USE

ATTITUDES TOWARD AI

3. BENEFITS OF AI IN HEALTH AND MENTAL HEALTH CARE

INCREASE SERVICE ACCESS

ENHANCED DIAGNOSTIC ACCURACY

PERSONALIZED TREATMENT AND SUPPORT

PROMOTE PUBLIC HEALTH SURVEILLANCE

INCREASE EFFICIENCY AND PRODUCTIVITY

IMPROVED DATA ANALYSIS

4. APPLICATIONS OF AI IN HEALTH AND MENTAL HEALTH CARE

ASSESSING, DIAGNOSING, AND INTERPRETING IMAGES

PREDICTIVE ANALYSIS

TREATMENT AND INTERVENTION PLANNING

PROMOTE PATIENT MONITORING AND SUPPORT

AUTOMATING OF CLINICAL PROCESSES

ANALYSIS OF DATA AND EVIDENCE-BASED LITERATURE

EDUCATION AND TRAINING

5. BARRIERS, LIMITATIONS, AND ETHICAL CONSTRAINTS

PRIVACY, SECURITY, AND CONFIDENTIALITY ISSUES

PERPETUATING BIAS

LESS THAN OPTIMAL SOLUTION TO REDUCING DISPARITIES

LACK OF TRANSPARENCY, ACCOUNTABILITY, AND POLICIES/REGULATIONS

RISKS/SAFETY, PROFESSIONAL LIABILITY, AND COMPETENCE

OVER-RELIANCE ON AI AND PERCEPTION OF CLIENT/PATIENT ABANDONMENT

6. COLLABORATION BETWEEN PRACTITIONERS AND AI

7. CONCLUSION

Works Cited

91450 • AI in Health Care

Education Category. Management

Release Date. 04/01/2025

Expiration Date. 03/31/2028

Course Overview

Artificial intelligence (AI) is a buzzword and is the considered the "big thing" in health care. It is touted as holding tremendous promise in health and mental healthcare systems. In general, many healthcare and mental health professionals are not familiar with AI, are distrustful of AI, or may be skeptical of its application in health and mental health care. The purpose of the course is to familiarize participants with AI and its potential applications in health and mental health care. The merits and limitations of AI will be reviewed as well as factors that will aid in facilitating and impeding the integration of AI in service delivery. Ethical concerns will be reviewed as well.

Audience

This course is designed for all members of the interprofessional healthcare team who interact with AI technologies.

Accreditations & Approvals

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

This activity was planned by and for the healthcare team, and learners will receive 3 Interprofessional Continuing Education (IPCE) credit(s) for learning and change. NetCE designates this enduring material for a maximum of 3 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 3 ANCC contact hour(s). NetCE designates this continuing education activity for 3.6 hours for Alabama nurses. NetCE designates this continuing education activity for 1 NBCC clock hour(s). Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 3 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. NetCE designates this activity for 3 ACPE credit(s). ACPE Universal Activity Number: JA4008164-0000-25-027-H99-P. Social workers participating in this intermediate to advanced course will receive 3 Non-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®. Successful completion of this CME activity, which includes participation in the activity with individual assessments of the participant and feedback to the participant, enables the participant to earn 3 MOC points in the American Board of Pediatrics' (ABP) Maintenance of Certification (MOC) program. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABP MOC credit. This activity has been designated for 3 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. NetCE is authorized by IACET to offer 0.3 CEU(s) for this program. NetCE designates this continuing education activity for 3 credit(s). AACN Synergy CERP Category C.

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 activity is designed to comply with the requirements of California Assembly Bill 1195, Cultural and Linguistic Competency.

Course Objective

The purpose of the course is to familiarize participants with AI and its potential applications in health and mental health care.

Learning Objectives

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

1. Outline the development and potential uses of AI in the context of health and mental health.

2. Outline practice considerations related to AI use, including barriers, limitations, ethical concerns, and collaboration.

3. Assess the limitations and the barriers of AI in day-to-day practice for providers.

4. Explain ethical concerns of the use of AI in health and mental health care.

5. Discuss collaborations between AI and practitioners.

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

Randall L. Allen, PharmD

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

Artificial intelligence, or AI, is an umbrella term that refers to a field of computer sciences that focuses on the use of computers, technology, and intelligence systems to simulate human thinking activities and execute human-level problem-solving [1,2]. AI has been employed to improve diagnosis, facilitate and expedite the discovery of new drugs, organize and manage healthcare data, and perform surgery [3]. In the area of mental health care, AI can be used to enhance the patient experience by automating schedule reminders, sending out personalized health tips and recommendations, offering chatbots and virtual assistants to talk to individuals who may be in distress or in crisis, and performing risk assessments [3,4].

Despite AI's growth, many health and mental health professionals are not familiar with AI applications and how they can be specifically integrated and applied in their day-to-day practices. Furthermore, it is often viewed with ambivalence.

The goal of the course is to provide health and mental healthcare professionals a basic overview of artificial intelligence and its current applications in the health mental health sectors. A discussion of the facilitators and barriers to its use will be presented. In addition, the array of limitations and challenges presented by AI technology will be explored.

2. AN OVERVIEW OF ARTIFICIAL INTELLIGENCE (AI)

DEFINITION

As noted, AI is an umbrella term that generally refers to the use of computers, technology, and intelligence systems to perform tasks that typically require human intelligence, such as learning, problem-solving, and decision-making [1,2,5]. AI technology gives computers cognitive abilities to complete tasks that humans generally perform, such as perceiving, learning, recognizing, predicting, and generating rules [6]. For example, when the AI application ChatGPT is provided with a prompt (i.e., "Outline the differences between ice cream and sorbet"), it will generate the outline based on research conducted via Internet search. It can also help authors with their writing tone. For example, an author can upload several paragraphs to ChatGPT, which can then edit the paragraphs so that they sound less technical and more informal and humorous. Voice-activated searches on smartphones are also an example AI—a search task that once required human performance but now can be conducted via technology that is activating via voice. It is estimated that half of cell phone users use voice-activated searches daily [7].

MARKET OVERVIEW

The AI market is projected to grow to $407 billion by 2027, a huge increase compared with the $86 billion revenue reported in 2022 [7]. In 2024, it was estimated that AI in the healthcare market was worth $14.9 billion; by 2030, it is projected to grow to $164 billion [8]. In 2020, 90% of healthcare organizations indicated they use AI for automation [9]. In the area of mental health, the growth of AI is also expected to increase rapidly. In 2023, in the United States, mental health app market revenue was estimated to be $5.72 billion, with a projected growth to $16.5 billion by 2030 [10]. It is expected that hospitals and clinics will be the largest users of AI in the mental health market, primarily driven by the prevalence rates of mental health conditions and the need for diagnoses and treatments [11]. As of 2024, North America is the dominant player in the global AI market [11].

HISTORICAL EVOLUTION OF AI USE

On the surface, it seems as if AI recently emerged in the health and mental health care, but this is not true. In the 1950s, Alan Turing developed a test for intelligence in a computer, requiring that a human should be unable to distinguish the machine from another human by using the replies to questions put to both [12]. This has become known as the Turing test [13]. In 1951, Christopher Strachey developed the first AI program, and at that same time, it was John McCarthy who then employed the term artificial intelligence to refer to the use of science and engineering to make machines intelligent [13,14]. In 1956, McCarthy organized the Summer Dartmouth Conference on AI, which drew leading scientists, researchers, mathematicians, and engineers to start a dialogue about AI and its practical uses. Some say that this conference laid the foundation to the inception of AI [12]. In terms of initial applications of AI, the first industrial robot appeared in General Motor's assembly line in 1961, and three years later, the first chatbot by the name of ELIZA emerged on the scene, which was developed by Joseph Weizenbaum at MIT [13]. ELIZA followed the tenets of Carl Roger's person-centered therapy, which would rephrase and repeat in order to mimic a human conversation [15]. Over the years, there were other chatbots, including A.L.I.C.E. and Apple's Siri, which laid the foundation for AI personal assistants [15].

Many historians have labeled the 30-year time period between 1970 and 2000 as the AI winter, because it was a time of fewer AI developments [13]. The first AI winter was in the late 1970s, during which time many doubted the practical uses of AI. The second AI winter occurred during the late 1980s into the early 1990s, when there was an AI lag prompted by the financial cost of AI development and maintenance of expert digital databases [13]. However, there were still some noteworthy developments. Deep Blue, a chess-playing computer, played against the world champion in chess in 1997 and won [16]. In 2011, Watson, another computer, won a Jeopardy gam played against the two leading rival players [16].

Between 2010 and 2020, electronic health records and large-scale healthcare databases became more prominent, and the question of how to leverage AI with health data emerged. In 2000, the da Vinci Surgical System was introduced as the first robotic surgical platform approved by the FDA [17]. As noted, Apple introduced Siri, a virtual assistant, into iPhones in 2011, and then in 2014, Alexa, another virtual assistant was released by Amazon [13]. Today, ChatGPT and Copilot are used in many arenas, and this has led to the surfacing of many potential implications and ethical conflicts associated with AI use in various fields/disciplines, including in health and mental health care. One of the main concerns is that many AI applications (e.g., ChatGPT) are not Health Insurance Portability and Accountability Act (HIPAA) compliant and content shared with AI applications is generally added to the associated database and shared.

ATTITUDES TOWARD AI

Overall, AI is viewed with ambivalence and concern. A bit more than half of Americans are concerned about the use of AI in day-to-day life; only 10% express more excitement than concern, and 36% are ambivalent [18]. As of 2023, an estimated 58% of adults in the United States had heard of ChatGPT while 42% were not familiar at all [18]. Pew Research conducted a survey about the public's attitudes and knowledge of AI in 2022 and 2023. Those who had heard about AI in 2022 were 16 points more likely to express more concern than excitement over AI one year later [19]. Another survey conducted in the United Kingdom found that twice as many of those surveyed thought that AI would bring more benefits than risks (28% vs. 14%). Almost 33% believed it would have a positive impact in the area of health care [20]. In a separate survey study with 427 U.S. participants, respondents were concerned that AI proliferation would result in loss of human contact and personal interactions with healthcare providers, with clinicians ending up as passive decision-makers [21].

In general, it appears that many health and mental health professionals are not familiar with AI, are distrustful of AI, and perhaps even skeptical in its application in health and mental health care. Elsevier, a leading academic publishing company, conducted a global online survey with a sample of 1,999 respondents comprised of clinicians and researchers from 123 countries [22]. This study found that 54% of respondents had used AI, and 31% had utilized it for work. Slightly more (39%) respondents in China are using AI applications compared to the United States (30%) or India (22%) [22]. When asked to identify an AI product, ChatGPT was the most frequently cited [22]. In a 2024 national Chinese study involving 1,243 nursing students, nursing professionals, and other healthcare professionals, 57% reported very little knowledge about AI and almost 66% indicated that they were not familiar with the role of AI in nursing [2]. Almost all (95%) believed that there could be imminent concerns with AI in health care and that more work will be needed in the area of ethics in AI in health care.

Most individuals as well as health and mental health providers prefer to have a human provider, even when they were told that the AI could perform the same task better or more accurately. While many professionals appreciate the benefits of AI, they believe it should be used as a supplement to a human provider [23]. Overall, while there is a good amount of empirical research on the role of AI in health care and medicine, much of the work is descriptive and experimental [24]. In a bibliometric analysis of 100 of the most commonly cited articles about AI in medicine, researcher found that the majority were published after 2000 and that oncology appears to be at the forefront in implementing AI in practice, with cardiovascular medicine lagging [25].

3. BENEFITS OF AI IN HEALTH AND MENTAL HEALTH CARE

Many have posited that AI will revolutionize the health and mental health fields, offering multiple benefits. Its potential benefits are briefly summarized here; however, specific applications will be discussed in the next section, which will further illustrate AI's practical uses.

INCREASE SERVICE ACCESS

AI-based health and mental health delivery of services can promote equity and justice, particularly for those underserved and marginalized populations that may not have easy access to services. These technologies could enhance remote monitoring and the provision of telehealth and mental health services [26]. Some have argued that AI could play a role in democratizing health and mental health disparities, reducing long wait lists, costs, and other systemic barriers [27].

ENHANCED DIAGNOSTIC ACCURACY

AI has been found to increase the accuracy of detection and identification of various conditions, which can then facilitate improved prevention or early intervention efforts [23].

PERSONALIZED TREATMENT AND SUPPORT

AI can tailor treatments and interventions to individual patients'/clients' needs based on the synthesis of clinical data, history, and demographics [14]. Individuals can also receive personalized reminders and support to assist in treatment adherence.

PROMOTE PUBLIC HEALTH SURVEILLANCE

AI can rapidly aggregate, synthesize, and analyze large public health datasets to track and predict health and mental health trends. This can be used to guide decisions related to public health policy and prevention efforts [14].

INCREASE EFFICIENCY AND PRODUCTIVITY

AI platforms can automate and streamline clinical day-to-day administrative tasks, reducing costs and time burdens [28].

IMPROVED DATA ANALYSIS

AI platforms can also rapidly aggregate large volumes of data from multiple datasets. This can be used to identify patterns and obtain the most up-to-date best evidence recommendations quickly and implement these approaches into practice [4,29].

4. APPLICATIONS OF AI IN HEALTH AND MENTAL HEALTH CARE

In 2020, 90% of healthcare organizations indicated they use AI for automation; this has likely increased in the years since [9]. As noted, AI has been employed to improve diagnosis, facilitate and expedite the discovery of new drugs, organize and manage healthcare data, and perform surgery [3]. The consensus is that AI applications have potential to improve health and mental healthcare delivery, reduce costs, and enhance efficiency and possibly efficacy from the diagnosis to treatment/intervention stages. This section will explore a few examples. When specific AI applications are mentioned, these examples are merely used as illustrative purposes and does not indicate endorsement.

ASSESSING, DIAGNOSING, AND INTERPRETING IMAGES

AI has been used to assess, diagnose, and interpret health and mental health conditions via a variety of methods, but perhaps the most obvious is through the analysis of imaging. AI applications can analyze images such as x-rays, computed tomography (CT) scans, and magnetic resonance imaging (MRI) to detect abnormal patterns. This approach can decrease human error and make more accurate diagnoses. For example, in a dataset of mammograms, an AI system was able to interpret the mammograms and make diagnoses of breast cancer, with a reduction in false positives of 5.7% and of false negatives of 9.4% [14]. In this case, the AI system was more sensitive and accurate compared to the radiologists (90% vs. 78% accuracy rates, respectively) [14]. In a systematic review and meta-analysis, researchers concluded that AI demonstrated a high level of accuracy in detecting lung cancer, which has positive implications for early diagnosis [30]. AI platforms can also assist with the differential diagnosis of certain disorders that present similar clinical symptoms, such as types of dementia or depression. AI systems can help to differentiate between these disorders by examining brain imaging and structural MRI scans [31]. Ultimately, accurate diagnosis is the lynchpin to effective treatment planning, and the use of AI technology to improve diagnosis is an exciting advancement on this front.

Voice data can be analyzed using AI technology to examine for volume, tone, breathing patterns, and vocal cord vibrations to assess and screen for type 2 diabetes, stroke, Parkinson disease, depression, post-traumatic stress disorder (PTSD), schizophrenia, heart conditions, larynx cancer, speech disorders, and autism [32]. In these cases, the human voice can be a digital biomarker to detect disorders that can affect the voice. In one systematic literature review involving 145 studies, Parkinson disease was the most common condition that used voice data as a digital biomarker [33]. However, the researchers found that the studies included in their review had limited and unbalanced data sets and focused primarily on diagnostic detection versus longitudinal monitoring [33].

AI-integrated virtual realities can mimic real life and provide health and mental health practitioners an opportunity to virtually assess patients/clients for various health and mental health conditions. When patients/clients enter the virtual environment, they respond and behave to stimuli as if in real life, and practitioners can observe and measure for physiological changes and symptoms, such as anxiety, fear, paranoia, and other emotional reactions [34].

AI-trained chatbots can perform triage to assess if certain symptoms and/or the severity of symptoms warrant emergent care. The chatbot can determine if the patient must see a professional and book an appointment [35].

Risk assessments are critical in health and mental health systems, and AI technologies are being employed in this arena as well. The Mayo Clinic has developed an AI model that can detect patients with a weak heart pump where no symptoms were present. The AI model can detect risk of stroke or myocardial infarction for patients in the years to come [36].

PREDICTIVE ANALYSIS

Clinical prediction and analysis integrated with AI algorithms can rapidly analyze data in order to identify patterns and correlations with precision and accuracy [37]. As a result, it can predict patient readmission, relapse, and/or complications risks. AI algorithms are able to analyze medical history, demographic, patient/client records and charts, and lifestyle information to predict health and mental health problems with some precision [14]. This technology can forecast disease and psychosocial problems and identify at-risk populations to inform public health surveillance initiatives [37]. One example is UCLA's California Policy Lab, where researchers aggregated data from 90,000 individuals who were users of various social services. Their AI algorithm was able to predict who might end up unhoused [38].

AI has also been used to analyze content from social media posts, blogs, online forums, and other online forums to assess mental health public sentiment and trends [39]. At the University of Denver, School of Social Work, an AI algorithm was developed to predict substance use disorder by analyzing Facebook posts. The algorithm was 80% accurate in predicting substance use, compared with 30% accuracy using traditional statistical models [40].

Personal sensing, defined as collecting and analyzing data from sensors embedded in the context of daily life with the aim of identifying human behaviors, thoughts, feelings, and traits, often with the aid of AI, has the potential to predict, measure, and monitor individuals' mental health [41]. For example, AI technology can evaluate content from social media posts and data from smart watches, smartphones, and other wearable health devices to identify behavioral patterns and changes and correlate them with specific health and mental health conditions [35,41]. Natural language processing algorithms can monitor conversations from texts messages, emails, and social media posts to identify key words and changes in language semantics and syntax (e.g., length of messages, longer intervals between texts, posts, or calls) that might indicate an increased risk of depression, suicide, or anxiety [35,41].

TREATMENT AND INTERVENTION PLANNING

Today, AI is widely used for the delivery of care and treatment/intervention planning. For example, AI is incorporated with robotic systems to work alongside surgeons performing complicated surgical procedures. The Da Vinci Surgical System provides real-time guidance to surgeons to increase accuracy and precision in cardiac, gynecological, pediatric, urologic, and general surgeries [17]. As of 2025, approximately 75% of prostate cancer surgeries are performed using the da Vinci system.

Robots have also been utilized to assist patients requiring rehabilitation, given the rising costs hiring a professional caregiver to help with activities of daily living for patients with dementia or recovering from stroke or other health conditions [42]. Because of their memory loss, patients with Alzheimer disease or other dementias are at increased risk of malnutrition and dehydration. With the help of AI-driven robots, caregivers can monitor patients' behaviors in real time and generate audio reminders [42].

Virtual reality interventions using AI platforms have been used in both the mental health and physical rehabilitation fields. Immersive body system feedback powered by AI can provide a tracking system for movements and engage patients in physical activity [42]. Personalization is often key to physical therapy planning, and these tools allow patients to receive real-time guidance, education, resources, and support. Furthermore, patients who may have limited access to services due to geographic or transportation constraints can use these interventions in their home.

AI can be used to predict the treatments or interventions that are likely to be successful for an individual by analyzing available data, circumstances, clinical history, and treatment context [23]. AI algorithms can provide risk estimates for each treatment option and, based on decision models, offer recommendations for the most appropriate approach to treatment for the specific patient [43]. As discussed, chatbots are able to collect patient/client data and assess symptoms and then synthesize this data to recommend treatment and interventions. If a patient presents an imminent safety risk, the chatbot can notify a health or mental health professional for immediate intervention [4]. The AI-driven small data platform CURATE.AI is one example of an AI system that evaluates individual patient data and to customize dose recommendations [44,45]. These tools do not remove final decision-making from the clinician, but acts as a tool and supplement to traditional practice [45].

Mental health digital apps supported by AI-automated conversational agents can provide emotional support and psychoeducation, with immediate real-time interaction for individuals who may be fearful, embarrassed, and/or reluctant to speak to a real-life counselor or therapist [46]. One example is Youper, an AI-driven app developed by a psychiatrist that uses a decision tree for each user and chatbots to provide emotional support using cognitive-behavioral therapy techniques to manage depression, anxiety, and other emotional issues [47,48]. Woebot is another example of an AI-powered app that delivers cognitive-behavioral counseling thorough AI conversations using a chatbot. It can track mood patterns by analyzing voice tones and tailoring interaction to the client [47]. Woebot has also been adapted for use in the management of substance use disorders by adding components of motivational interviewing, dialectical behavioral therapy, psychoeducation, and craving and pain monitoring [46]. Woebot has been examined for preliminary feasibility, efficacy, and acceptability [46]. Using a pre -and post-test design with 101 users with an average age of 38 years, researchers found confidence to resist substances increased and cravings, past-month substance use, and anxiety decreased in Woebot users compared with usual care.

Practitioners can incorporate AI-facilitated treatments, interventions, and therapies to supplement traditional treatments/interventions. These AI-driven treatments have been defined as being "digital and fully automated," with the use of a conversational interface, real-time, and personalized, and tailored to an individual's need [48]. It is critical to emphasize that AI is not a substitute for a practitioner's expertise, skills, and clinical judgment [42].

PROMOTE PATIENT MONITORING AND SUPPORT

Chatbots, virtual assistants, and assistive robots can also be used to enhance the patient/client experience by automating schedule reminders, sending out personalized health tips and recommendations, and monitoring progress and treatment response and adherence [3,4,5]. Virtual assistants can assume some of the administrative responsibilities of healthcare providers by reminding patients of their appointments and their treatment plan as well as collecting patient information to monitor progress and sending the progress check in reports their provider(s) [14]. Assistive robots can serve as helpers and companions to certain populations, particularly those who have limited mobility or disabilities who might benefit from increased companionship and support to reduce loneliness [35]. For example, pet bots have been created with sensors to respond to touch, sounds, and visual cues [35].

AUTOMATING OF CLINICAL PROCESSES

As noted, AI platforms can be used to reduce the burden of daily administrative procedures, such as billing, authorizations, and charting [23]. Information from provider notes can be extracted in order to assign medical codes for billing, authorization approvals, and insurance claim processing [28,35]. Other administrative tasks that AI may help to can automate and streamline include [28]:

- Scheduling appointments

- Managing by organizing, categorizing, and processing patient records and documents

- Billing

- Sending reminders and communications

- Improving data security and compliance by monitoring data breaches and reviewing administrative process to ensure compliance with regulations and laws

ANALYSIS OF DATA AND EVIDENCE-BASED LITERATURE

AI applications are able to aggregate, analyze, and interpret large amounts of data and literature to offer evidence-based recommendations [4,12]. Because it can be challenging for practitioners to sift through and aggregate, synthesize, and analyze multiple and large data sources, AI technology can be used to rapidly retrieve clinical literature and information from different sources in order to recommend treatment or diagnostic approaches [14]. AI applications are able to graph information from multiple databases quickly, which can give practitioners an accurate overview of the available knowledge base [49]. AI can even conduct social network analyses to identify a patient's social support network, allowing the practitioner to assess and determine how to use or enhance this social support system [49].

EDUCATION AND TRAINING

AI has potential application in the education of both patients/clients and practitioners. Using chatbots other AI assistants, health- and/or mental health-related materials can be generated and easily disseminated for patient education, disease prevention, and awareness building. Chatbots can be programmed to answer patients'/clients' questions quickly, and in certain circumstances, individuals may feel less embarrassed to seek guidance for certain conditions that may be perceived as stigmatizing [4,14].

Education, training, and continuing education can be enhanced using AI platforms. Consider new medical students who can practice certain clinical skills with AI avatars in real-life simulated situations, or mental health counselor trainees practicing assessment and rapport-building skills with virtual clients [35]. A systematic review examined the role of AI in medical education, including potential strengths and limitations [50]. Researchers analyzed articles published between 2017 and 2022, and a total of 25 articles met the inclusion criteria. Overall, current application of AI in medical education was focused primarily on specialty training and continuing education. AI application has been employed in radiology, surgery, cardiology, diagnostics, and dentistry. Accreditation standards have generally not yet addressed the appropriate use of AI applications, and more empirical research is needed to examine its effectiveness [50].

5. BARRIERS, LIMITATIONS, AND ETHICAL CONSTRAINTS

Although there are clear promises of AI applications, many have expressed concerns about the use of AI in health and mental healthcare service delivery.

PRIVACY, SECURITY, AND CONFIDENTIALITY ISSUES

Health and mental health data are sensitive, and there are concerns about how secure data are when using AI-driven platforms. One of the main questions is the extent to which are there risks of breaches of security, compromising privacy and confidentiality [4]. Patients'/clients' health records, therapy/counseling session notes, clinical histories, and behavioral data are required to comply with HIPAA regulations in order to ensure patient/client confidentiality [51]. In datasets, patient data are required to be de-identified; however, sophisticated algorithms are able to re-identify the data [52]. In one study, an algorithm was able to re-identify data from 85% of adults and 70% of children in a physical activity cohort study [53].

Informed Consent

At the heart of informed consent and client autonomy is the ability of clinicians to provide sufficient and understandable information to allow individuals to make an informed decision about their care. Patients/clients should be informed about the potential risks and benefits of AI in the delivery of their care. For example, AI algorithms can generate or perpetuate biases, create hallucinations (inaccuracies when the AI misperceives patterns), and introduce cyber-risks (e.g., data breaches) [54,55,56]. When a practitioner has employed AI for clinical decision-making without oversight, the patient/client should be made aware of this [56]. Furthermore, they should understand how their clinical/medical/behavioral data may be used beyond their clinical treatment planning [4,56].

PERPETUATING BIAS

AI algorithms are trained on existing datasets, and the validity and reliability of the original data are influenced by the original data collection procedures [57]. If the original data are not representative of certain demographic groups and if it ultimately makes inaccurate predictions, health and mental health disparities, biases, and inequities can be perpetuated [4,23,58]. This is known as algorithmic bias, which has been defined as, "the instances when the application of an algorithm compounds existing inequities in socioeconomic status, race, ethnic background, religion, gender, disability, or sexual orientation to amplify them and adversely impact inequities in health systems" [59]. Some have advocated for rigorous peer review feedback of AI algorithms to help counteract this potential problem [55]. The following strategies have been proposed to address algorithmic bias [60]:

- Including experts who are diversely represented to review AI algorithms

- Employing methods to manage situations in which there is not enough available information

- Introducing algorithms gradually in order to test their outcomes

- Creating mechanisms to collect feedback

LESS THAN OPTIMAL SOLUTION TO REDUCING DISPARITIES

Although AI has been proposed as a potential solution to reduce or mitigate health and mental health disparities, this may be an oversimplistic view. Many macro systemic factors will continue to exist and will exacerbate issues related to the digital divide, which continues to affect the general utilization of AI [27]. As of 2024, 80% of U.S. adults had broadband Internet access at home. However, there are significant differences in among racial/ethnic groups. While 83% of White American and 84% of Asian American adults have home broadband access, this reduces to 68% for Black adults and 75% for Hispanic adults [61]. It is plausible that AI will actually increase the disparities because the user demographics will be reflected back to users [27].

LACK OF TRANSPARENCY, ACCOUNTABILITY, AND POLICIES/REGULATIONS

AI algorithms have been compared to black boxes, because it is not always clear how the algorithm was designed, developed, tested, and validated [58]. Private commercial companies are often wary of releasing too much information or risking their intellectual property [62]. This is counter to the transparency regarding the validity and reliability and safety and risks of AI-derived clinical information health and mental health professionals require in order to make sound clinical decisions for their patients/clients. Similarly, patients/clients should understand the nature of the information in order to make informed decisions about their care [58]. In a 2024 study assessing public documentation on 14 AI-based radiology products, researchers employed a self-designed instrument to measure the transparency of the AI products in different domains, including ethics, safety and risks, training of the AI algorithm, and performance limitations [58]. Overall, they found very little publicly available information about the products, particularly on safety and risks. Most of the products did not disclose how the AI was trained to evaluate for algorithmic biases. Unfortunately, because AI technology has grown and changed so rapidly, regulations and policies have not kept pace.

RISKS/SAFETY, PROFESSIONAL LIABILITY, AND COMPETENCE

Data error is a challenge to the integrity of AI applications. If there are any algorithmic inaccuracies and/or biases, false clinical decisions could be made and result in harm to patients/clients. This in turn can impact professional liability [4]. Hallucinations are relatedly common with most AI applications; these events occur when AI software misperceives patterns that are do not exist, and it then produces nonsensical, inaccurate, and fabricated data and outcomes [63]. Ultimately, hallucinations can result in misdiagnoses, medical errors, inaccuracies in medical documentation, and data inaccuracies, leading to faulty and potentially harmful conclusions [54]. The following strategies may be incorporated in order to build trust and mitigate the impact of AI hallucinations [54]:

- Continual validation and evaluation of AI-powered platforms to detect hallucinations and employ diverse datasets

- Human oversight by healthcare and mental health professionals to review AI results to ensure clinical accuracies

- Provide training and continuing education to practitioners about the use of AI

- Delineate explainable and transparent AI models and protocols so practitioners understand how AI algorithms are developed

- Establish ethical and legal governance committees to provide oversight

Questions about liability may arise with the involvement of AI, including who or what is liable and accountable for outcome(s) [4,54]. Because AI is new and developing quickly, many health and mental healthcare professionals have not been fully trained on how to utilize AI nor are they fully aware of the latest evidence-based practice guidelines [55]. This raises the ethical issue of professional competency. The heart of clinical decision-making and judgment have traditionally revolved around the expertise of the professional, and a shift to an AI "expert" system requires practitioners to be fully trained and feel competent and comfortable with the operation of AI systems [26]. Practitioners who are interested in using AI in their clinical practice may refer to the Association for the Advancement of Artificial Intelligence (https://aaai.org) for guidance and to keep up to date on new developments [55].

OVER-RELIANCE ON AI AND PERCEPTION OF CLIENT/PATIENT ABANDONMENT

On a macro level, some have argued that overreliance on AI tools in health and mental health can result in practitioners becoming complacent in continuing to build and enhance their skills [62]. In other words, this could ultimately lead to the de-skilling of the health and mental healthcare workforce [62]. Some providers may also feel pressure to follow AI recommendations, instead of using the AI recommendations to supplement their clinical judgment [64].

On a micro level, patients/clients whose providers use AI extensively may feel that their practitioners are abandoning them [55]. While chatbots can offer immediate support, some patients/clients will prefer direct human interaction that cannot be obtained from a bot. At the heart of the provider-patient/client relationship is human empathy, conveyed through verbal and nonverbal communication and human interaction. Ultimately, AI does not have emotional intelligence to employ clinical wisdom, intuition, and empathy [27]. An over-reliance on AI can lead to an impersonal and dehumanizing experience for patients/clients [64].

6. COLLABORATION BETWEEN PRACTITIONERS AND AI

Some are skeptical of the use of AI in the health and mental health fields, and others are wholly enthusiastic. The reality is that optimal outcomes will come from a partnership of AI and practitioners. In an ideal world, AI would serve as a complement to humans, enhancing and supporting clinical decision-making but with practitioners providing oversight [29]. The American Medical Association coined the term "augmented intelligence" to refer to the ideal relationships between humans and AI applications [36]. The following ideal outcomes can result from an AI partnership with practitioners [27]:

- Combined insights to better understand the needs of the patient/client

- Timely interventions, with the practitioner providing oversight to ensure the interventions are tailored to specific needs and handle new issues that emerge real time

- Combined AI efficiency and practitioner empathy help to promote patient/client trust

- Reduce diagnostic errors by combining precision from AI and clinical wisdom and intuition of the practitioner

- Improved ethical decision-making by the AI objective analysis with the practitioner's experience, wisdom, and insights

However, this partnership is still tenuous. Some research indicates that team members' sense of trust does not necessarily grow over time in human-AI teams (HATs or HAIT) [65]. Incorporating AI team members does not necessarily enhance communication and coordination, perhaps because human team members have excessively high of expectations of AI team members. Alternatively, human team members may lack the training and understanding necessary for clear and optimal communication and collaboration with AI team members [65]. Ultimately, more training and continuing education are needed to improve the relationship between AI and practitioners and to explore how specific skills can merge and complement each other [27].

7. CONCLUSION

The technology of AI is growing at a rapid pace, and it can be difficult to keep up. While many remain skeptical and mistrustful of the application of AI in day-to-day life, practitioners in the health and mental health fields are called on to recognize that AI will continue to be a part of the professional landscape. In order for a positive synergistic relationship to develop between AI and practitioners, practitioners require an understand of AI systems and an opportunity to take part in AI-powered clinical decision-making, rather than passive relegation of clinical practice to AI. All professionals should feel empowered to take control and supervise AI systems. Future research is needed to evaluate the effectiveness of AI driven assessments, diagnoses, treatments, and interventions, so there is a larger body of evidence-based practice evidence.

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76703 • Understanding and Treating Spiritual Abuse

Jamie Marich, PhD, LPCC-S, REAT, RYT-500, RMT

www.netce.com

Copyright © 2024 NetCE, All rights reserved.

Spiritual abuse is not just relevant for those who have been members of cults. It is a very real condition that often occurs in individuals who have been abused or who struggle with addiction issues. In this course, theories of spiritual abuse and approaches to understanding it are explored through pastoral, developmental, and clinical lenses. Generally defined as the use of God/a higher power or religion as a tool to gain power and control by the abuser, spiritual abuse is one of the most overlooked forms of abuse in clinical settings. However, the willingness to address it will give clinicians added insight into many of their clients and how to more effectively and holistically address treatment. Case studies, personal reflection, and other critical thinking activities will help participants understand how the construct of spiritual abuse is relevant to clinical practice and apply this knowledge to assessment and treatment planning.

Table of Contents

76703 • Understanding and Treating Spiritual Abuse

Course Overview

Audience

Accreditations & Approvals

Designations of Credit

Individual State Behavioral Health Approvals

Course Objective

Learning Objectives

Faculty

Faculty Disclosure

Division Planners

Division Planners Disclosure

Director of Development and Academic Affairs

Director Disclosure Statement

About the Sponsor

Disclosure Statement

Implicit Bias in Health Care

1. INTRODUCTION

2. FOUNDATIONS: DEFINING SPIRITUAL ABUSE

SOCIOLOGIC PERSPECTIVES

PASTORAL PERSPECTIVES

DEVELOPMENTAL PERSPECTIVES

CLINICAL PERSPECTIVES

3. COMMON THEMES IN SPIRITUAL ABUSE

TRAITS OF SPIRITUAL ABUSERS

TRAITS OF SPIRITUAL ABUSE VICTIMS

CASE EXAMPLE

4. ASSESSING FOR SPIRITUAL ABUSE

CASE EXAMPLE

5. TREATING SPIRITUAL ABUSE

GENERAL FRAMEWORK FOR TRAUMA TREATMENT

CULT RECOVERY

HEALTHY SPIRITUALITY AND SPECIFIC RECOVERY STRATEGIES

CASE EXAMPLE

6. PROFESSIONAL DEVELOPMENT ISSUES

7. CONCLUSION

8. GLOSSARY

Works Cited

76703 • Understanding and Treating Spiritual Abuse

Education Category. Psychiatric / Mental Health

Release Date. 09/01/2024

Expiration Date. 08/31/2027

Course Overview

Spiritual abuse is not just relevant for those who have been members of cults. It is a very real condition that often occurs in individuals who have been abused or who struggle with addiction issues. In this course, theories of spiritual abuse and approaches to understanding it are explored through pastoral, developmental, and clinical lenses. Generally defined as the use of God/a higher power or religion as a tool to gain power and control by the abuser, spiritual abuse is one of the most overlooked forms of abuse in clinical settings. However, the willingness to address it will give clinicians added insight into many of their clients and how to more effectively and holistically address treatment. Case studies, personal reflection, and other critical thinking activities will help participants understand how the construct of spiritual abuse is relevant to clinical practice and apply this knowledge to assessment and treatment planning.

Audience

This course is designed for professional clinicians of any kind who may encounter victims of spiritual abuse, including counselors, social workers, therapists, and psychologists.

Accreditations & Approvals

NetCE has been approved by NBCC as an Approved Continuing Education Provider, ACEP No. 6361. Programs that do not qualify for NBCC credit are clearly identified. NetCE is solely responsible for all aspects of the programs. As a Jointly Accredited Organization, NetCE is approved to offer social work continuing education by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program. Organizations, not individual courses, are approved under this program. Regulatory boards are the final authority on courses accepted for continuing education credit. Continuing Education (CE) credits for psychologists are provided through the co-sponsorship of the American Psychological Association (APA) Office of Continuing Education in Psychology (CEP). The APA CEP Office maintains responsibility for the content of the programs. NetCE is accredited by the International Accreditors for Continuing Education and Training (IACET). NetCE complies with the ANSI/IACET Standard, which is recognized internationally as a standard of excellence in instructional practices. As a result of this accreditation, NetCE is authorized to issue the IACET CEU. NetCE is recognized by the New York State Education Department's State Board for Social Work as an approved provider of continuing education for licensed social workers #SW-0033. This course is considered self-study, as defined by the New York State Board for Social Work. NetCE is recognized by the New York State Education Department's State Board for Mental Health Practitioners as an approved provider of continuing education for licensed mental health counselors #MHC-0021. This course is considered self-study by the New York State Board of Mental Health Counseling. NetCE is recognized by the New York State Education Department's State Board for Mental Health Practitioners as an approved provider of continuing education for licensed marriage and family therapists. #MFT-0015.This course is considered self-study by the New York State Board of Marriage and Family Therapy. Materials that are included in this course may include interventions and modalities that are beyond the authorized practice of licensed master social work and licensed clinical social work in New York. As a licensed professional, you are responsible for reviewing the scope of practice, including activities that are defined in law as beyond the boundaries of practice for an LMSW and LCSW. A licensee who practices beyond the authorized scope of practice could be charged with unprofessional conduct under the Education Law and Regents Rules.

Designations of Credit

NetCE designates this continuing education activity for 2 NBCC clock hour(s). Social workers participating in this intermediate to advanced course will receive 5 Clinical continuing education clock hours. NetCE designates this continuing education activity for 5 credit(s). NetCE is authorized by IACET to offer 0.5 CEU(s) for this program.

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;

Course Objective

The purpose of this course is to provide clinicians with an appreciation for the impact of spiritual abuse on clients and the skills necessary to assess and address the experience of spiritual abuse.

Learning Objectives

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

1. Define spiritual abuse from a pastoral, developmental, and clinical perspective.

2. Identify the common traits among spiritually abusive persons and religious denominations as well as victims of spiritual abuse.

3. Assess for commonly encountered negative cognitions acquired by those who have been spiritually abused in the context of clinical symptomology.

4. Develop and implement treatment plans that are sensitive to the needs of clients who have experienced spiritual abuse.

5. Identify components of healthy spirituality that will assist in the recovery process.

6. Determine one's own strengths and weaknesses in clinically addressing spiritual abuse and its various clinical manifestations.

Faculty

Jamie Marich, PhD, LPCC-S, REAT, RYT-500, RMT, (she/they) travels internationally speaking on topics related to EMDR therapy, trauma, addiction, expressive arts, and mindfulness while maintaining a private practice and online education operation, the Institute for Creative Mindfulness, in her home base of northeast Ohio. She is the developer of the Dancing Mindfulness approach to expressive arts therapy and the developer of Yoga for Clinicians. Dr. Marich is the author of numerous books, including EMDR Made Simple, Trauma Made Simple, and EMDR Therapy and Mindfulness for Trauma Focused Care (written in collaboration with Dr. Stephen Dansiger). She is also the author of Process Not Perfection: Expressive Arts Solutions for Trauma Recovery. In 2020, a revised and expanded edition of Trauma and the 12 Steps was released. In 2022 and 2023, Dr. Marich published two additional books: The Healing Power of Jiu-Jitsu: A Guide to Transforming Trauma and Facilitating Recovery and Dissociation Made Simple. Dr. Marich is a woman living with a dissociative disorder, and this forms the basis of her award-winning passion for advocacy in the mental health field.

Faculty Disclosure

Contributing faculty, Jamie Marich, PhD, LPCC-S, REAT, RYT-500, RMT, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Division Planners

Alice Yick Flanagan, PhD, MSW

Margaret Donohue, PhD

Division Planners Disclosure

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

Director of Development and Academic Affairs

Sarah Campbell

Director Disclosure Statement

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

About the Sponsor

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

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

Disclosure Statement

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

Implicit Bias in Health Care

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

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

1. INTRODUCTION

In clinical discussions, we are used to talking about issues of sexual, physical, emotional, verbal, and even financial abuse, but the idea of spiritual abuse tends to be overlooked. Many professionals do not realize that spiritual abuse exists or are confused by its definition. Shortly, spiritual abuse is the use of God or religion as a tool to gain power and control by the abuser. Clients may relate their struggles with God or spirituality resulting from negative experiences with abusive religious leaders or parents/caregivers, and these struggles may keep them from accessing spiritual resources they inherently want to access for wellness. Dealing with "spiritual hang-ups" can enhance treatment of any clinical condition if a client is willing to have them addressed. If clinicians are serious about holistic, "body-mind-spirit" approaches to treatment, assessing for and addressing the experience of spiritual abuse and its impact on an individual is imperative.

This course will consider the foundations of spiritual abuse by first defining it through clinical, developmental, and pastoral lenses, then exploring the common themes in spiritually abusive dynamics that transcend religion or denomination. Next, the course will discuss how to assess for the presence of spiritual abuse in clients and how to provide in-depth treatment strategies, informed by trauma-sensitive treatment approaches, for healing the wounds of spiritual abuse. Finally, the course examines issues of professional development as it relates to spiritual abuse. This examination includes, but is not limited to, exploring one's own spiritual identities, hesitancies to address spirituality with clients, and strategies to help clients access the best healing possible.

A major premise in this course is that no religion, no denomination, and no spiritual practice is immune to the devastating effects of spiritual abuse. It can happen anywhere––in yoga schools, convents, Catholic churches, devout households, Evangelical "megachurches," tiny country church houses, synagogues, yeshivas, ashrams, temples, radical sects, meditation groups, and small community Bible studies. Whenever a leader or members usurp their power and use spiritual-based threats to keep people in place or wield power over vulnerable members of a group, then spiritual abuse is present. The notion that spiritual abuse does not discriminate is a key assumption of this course. In studying spiritual abuse, there is a chance that you will read something about your denomination or chosen belief system that is upsetting, but no offense is intended. With the exception of few groups that clearly meet the definition of a cult (explored later in this course) or an extremist sect that promotes hate speech, no denominations or spiritual practices are condemned. Rather, as a clinician who treats trauma, it is important to identify those individual groups, leaders, or members who use their power over people or the spiritual practices inherent in their faith system in an abusive way.

2. FOUNDATIONS: DEFINING SPIRITUAL ABUSE

Completing a literature search on spiritual abuse will not uncover as many entries as a search on sexual abuse or physical abuse. Many articles examine the spiritual implications of abuse or see spiritual wounding as a clear symptom of more "obvious" abuse that is more likely to present as a treatment issue. For example, there is clear documentation in scholarly literature discussing the spiritual implications of sexual abuse, and in the popular forum, many online support groups for spiritual abuse exist in conjunction with sexual abuse sites[1]. Another facet of the literature examines spiritual abuse as an issue in cultures in which forced assimilation and other religious discrimination occurred (e.g., Aboriginal, other indigenous cultures) [2]. The issue of spiritual abuse within subsystems meeting the definition of a cult is another major area of exploration, as is the examination of those who have survived clergy abuse [3,4,5].

It is important to realize that spiritual abuse is not limited to these more prominent examples—alongside sexual abuse or cases of religious persecution or cultic involvement. According to Dehan and Levi, spiritual abuse should be considered a separate category of abuse because its presence keeps the victim from realizing total spiritual fulfillment [6]. Spiritual abuse or other religious "hang-ups" can act as a barrier to people getting the help they need in terms of mental wellness [7]. In contrast, a healthy spiritual focus can be a major source of strength for a person seeking mental wellness, which makes resolving emotional issues connected to spiritual abuse imperative [8]. Literature findings regarding the treatment of spiritual abuse will be explored later in this course.

The vast majority of general literature on the topic of spiritual abuse is qualitative and experiential in nature. Books from multiple perspectives explore spiritual abuse and its effect. These writings are too numerous to catalogue in the scope of this article. Explanatory and definitional highlights from pastoral, developmental, and clinical perspectives are covered in this section.

SOCIOLOGIC PERSPECTIVES

As with many issues in psychology and religion, definitions are often personal and diverse. For the purposes of setting definitions in this course, it is imperative to explore the definition of a cult because much of the talk surrounding spiritual abuse is connected to cultic brainwashing and working to reintegrate people who escape from cults. The entomologic root of the word "cult" is the Latin cultus, simply meaning to tend or to worship; the same root also spawned the English word "cultivate," a verb that typically has positive connotations. In the modern era, the term "cult" has come to have a negative connotation. A succinct definition from the Oxford English Dictionary on modern usage is, "a new religious movement or other group whose beliefs or practices are considered abnormal or bizarre" [9]. This general definition, although accurate overall, is still open to interpretation and can even be used by spiritual abusers to denigrate other groups who are seen as a threat to their denominational superiority (e.g., in the Evangelical Church, Catholicism, Hinduism, Judaism, and Buddhism may all be considered negatively connoted cults). Thus, it is imperative to examine commonly agreed upon traits or characteristics of a cult.

An authority on cultic definition is Michael Langone, founder of the International Cultic Studies Association (ICSA). The ICSA does not publish a list of groups that they label to be cultic. Rather, they encourage those evaluating cultic behavior to make judgments for themselves, using certain criteria as a guideline to determine if a group is destructive or harmful to the people involved. Based on the work of Langone, Lalich and Tobias established the following list as an evaluative guideline [10]:

- The group displays excessively zealous and unquestioning commitment to its leader (whether alive or dead) and regards his/her belief system, ideology, and practices as the truth or law.

- Questioning, doubt, and dissent are discouraged or even punished.

- Mind-altering practices (such as meditation, chanting, speaking in tongues, denunciation sessions, and debilitating work routines) are used in excess and serve to suppress doubts about the group and its leader(s).

- The leadership dictates, sometimes in great detail, how members should think, act, and feel. For example, members may be required to obtain permission to date, change jobs, or marry—or leaders may prescribe what types of clothes to wear, where to live, whether or not to have children, how to discipline children, and so forth.

- The group is elitist, claiming a special, exalted status for itself, its leader(s), and its members. For example, the leader may be considered the Messiah, a special being, or an avatar, or the group and/or the leader may be on a special mission to save humanity.

- The group has a polarized us-versus-them mentality, which may cause conflict with the wider society.

- The leader is not accountable to any authorities (unlike, for example, teachers, military commanders, or ministers, priests, monks, and rabbis of mainstream religious denominations).

- The group teaches or implies that its supposedly exalted ends justify whatever means it deems necessary. This may result in members participating in behaviors or activities they would have considered reprehensible or unethical before joining the group (e.g., lying to family or friends, collecting money for bogus charities).

- The leadership induces feelings of shame and/or guilt in order to influence and/or control members. Often, this is done through peer pressure and subtle forms of persuasion.

- Subservience to the leader or group requires members to cut ties with family and friends and radically alter the personal goals and activities they had before joining the group.

- The group is preoccupied with bringing in new members.

- The group is preoccupied with making money.

- Members are expected to devote inordinate amounts of time to the group and group-related activities.

- Members are encouraged or required to live and/or socialize only with other group members.

- The most loyal members (the "true believers") feel there can be no life outside the context of the group; they believe there is no other way to be. Members often fear reprisals to themselves or others if they leave (or even consider leaving) the group.

In the spirit of ICSA's "evaluate for yourself" mentality, there is no certain number of criteria that should be fulfilled in order for the definition to be met. Rather, this list is offered as an evaluative guideline that can be especially useful for clinicians. The "evaluate for yourself" approach is a trait of healthy spirituality, a concept that will be discussed in greater depth in the section on treatment.

A critical aspect of working with spiritual abuse is to understand that it does not only occur in what society considers to be cults. It is easy to accept that a person emerging from a dangerous cult would be a clear victim of spiritual abuse, but what of the more subtle, yet equally dangerous manifestations? Hobson, although writing primarily from the pastoral perspective, offers a comprehensive definition of spiritual abuse [11]. Admitting that spiritual abuse is impossible to define in a sentence or two, he makes as concise of an attempt as possible [11]:

Spiritual abuse is the gross dereliction or neglect of a spiritual leader's responsibility to protect the basic rights of anyone under that leader's care. These basic rights include parishioners' spiritual, psychological, financial, and physical well-being. Spiritual abuse occurs when any spiritual leader violates these sacred trusts in any way, form, or fashion, thus causing any harm in regards to the aforementioned rights. Abuse occurs whenever a leader injures or takes advantage of anyone under his or her care at any time, in the following manner: physically, sexually, financially, emotionally, or psychologically, and any other similar acts…It occurs so frequently, most victims of it aren't even aware it has happened to them.

As explained, it is paramount to realize that spiritual abuse is a global phenomenon that transcends religious denomination or religious practice. Throughout history, if one person has been in the position to wield power over another person and chooses to use God, enlightenment, salvation, the threat of damnation, the promise of enlightenment, or other spiritual promise/threat to exert that power, a spiritually abusive relationship can exist. This relationship can occur between a spiritual leader (e.g., pastor, priest, guru, imam, rabbi) and his or her congregation, between parents/grandparents and their children, or between mentors/gurus and their disciples.

The term "guru" is worth exploring as well. Guru is the Sanskrit word meaning "teacher" or "master," literally translated as "one who casts out darkness." Although originating in Hinduism, many in the modern era use the term in reference to anyone whose teachings attract followers. For example, some consider the Dalai Lama to be a guru, and notable leaders in other disciplines not related to religion have even been referred to as gurus. Because of well-publicized scandals involving guru misconduct in the last several decades, especially in the areas of financial and sexual exploitation, many people in the United States attribute a negative connotation to the word "guru," similar to the negative, exploitative connotation associated with the term "cult."

One of the most well-known books on abusive power dynamics within Eastern and other spiritual practices that are not specifically Christian is The Guru Papers: Masks of Authoritarian Power [12]. In this book, "guru" (with editorial quotation marks) refers to anyone who manipulates others under the guise of knowing what is best for them. In this broad definition, almost anyone can meet the definition, whether it is a spiritual leader, a 12-step sponsor, a parent, a friend, a teacher, or a romantic partner.

PASTORAL PERSPECTIVES

Although spiritual abuse occurs in every religious denomination and no spiritual practice is immune to its effects, the greatest body of writing on the problem, from a religious perspective, is within Christianity. This section will explore how some of these seminal works define and explain spiritual abuse. Christian pastors or those in a position of ministry are the sources of all of these works, unless otherwise noted. Despite the overt Christian focus of this section, consider how any denomination, religion, or spiritual grouping could be inserted into these definitions and notice the similarities.

In their revolutionary work The Subtle Power of Spiritual Abuse, Jeff VanVonderen and former pastor David Johnson defined spiritual abuse as "the mistreatment of a person who is in need of help, support, or greater spiritual empowerment, with the result of weakening, undermining, or decreasing that person's spiritual empowerment" [13]. Many abuse survivors, with spiritual abuse being no exception, have a tendency to feel that they are somehow uniquely "crazy" for feeling a certain way. This doubt about the validity of experience can be an even greater factor with spiritual abuse because a great many people do not realize it is an actual form of abuse, as much as physical or sexual abuse.

Another leader in the pastoral community on the issue of spiritual abuse, Christian sociologist Ronald Enroth writes [14]:

Unlike physical abuse that often results in bruised bodies, spiritual and pastoral abuse leaves scars on the psyche and soul. It is inflicted by persons who are accorded respect and honor in our society by virtue of their role as religious leaders and models of spiritual authority. They base their authority on the Bible, the Word of God, and see themselves as shepherds with sacred trust. But when they violate that trust, when they abuse their authority and when they misuse ecclesiastical power to control and manipulate the flock, the results can be catastrophic.

Another Christian leader whose work emerged in the early 1990s was Ken Blue. He also drew comparisons between spiritual abuse and other types of abuse [15]:

Abuse of any type occurs when someone has power over another and uses that power to hurt. Physical abuse means that someone exercises physical power over another, causing physical wounds. Sexual abuse means that someone exercises sexual power over another, resulting in sexual wounds. And spiritual abuse happens when a leader with spiritual authority uses that authority to coerce, control, or exploit a follower, thus causing spiritual wounds.

Dale and Juanita Ryan, who worked closely with Ken Blue, put it in the simplest terms: "Spiritual abuse is a kind of abuse that damages the central core of who we are. It leaves us spiritually disorganized and emotionally cut off from the healing love of God" [16].

DEVELOPMENTAL PERSPECTIVES

The fields of psychology and related helping professions have a variety of developmental models to describe the human experience. A specific psychologic model of faith development also exists, attributed to developmental psychologist James W. Fowler and based on the works of Piaget, Erickson, and Kohlberg (who introduced the stages of moral development in human being) [17]. Examine this Faith Development Model and consider where spiritually abusive experiences might have their greatest impact [17]:

- Stage 0: Primal or undifferentiated faith (birth to 2 years of age) is characterized by an early learning of the safety of one's environment (i.e., warm, safe, and secure vs. hurt, neglect, and abuse). If consistent nurturing is experienced, one will develop a sense of trust and safety about the universe and the divine. Negative experiences will cause one to develop distrust with the universe and the divine.

- Stage 1: Intuitive-projective faith (3 to 7 years of age) is characterized by the psyche's unprotected exposure to the Unconscious.

- Stage 2: Mythic-literal faith (mostly school-age children) is characterized by a strong belief in the justice and reciprocity of the universe. During this stage, deities are almost always anthropomorphic (i.e., personified).

- Stage 3: Synthetic-conventional faith (12 years of age to adulthood) is characterized by conformity to religious authority and the development of a personal identity. Any conflicts with one's beliefs are ignored at this stage due to the fear of threat from inconsistencies.

- Stage 4: Individuative-reflective faith (usually mid-twenties to late thirties) is characterized as a stage of angst and struggle. The individual takes personal responsibility for his or her beliefs and feelings. As one is able to reflect on one's own beliefs, there is openness to a new complexity of faith, but this also increases the awareness of conflicts in one's belief.

- Stage 5: Conjunctive faith (mid-life) is characterized by the acknowledging of paradox and transcendence relating to the reality behind the symbols of inherited systems. The individual resolves conflicts from previous stages by a complex understanding of a multidimensional, interdependent "truth" that cannot be explained by any particular statement.

- Stage 6: Universalizing faith, or what some might call "enlightenment," is characterized by the individual treating any person with compassion as he or she views people as from a universal community and worthy of being treated with the universal principles of love and justice.

No perfect models exist within the psychologic professions, and this model is no exception. For instance, the quality of spiritual role models and sociocultural contexts can significantly impact the way a person moves through these stages. Moreover, the ages are meant to be approximate. Some would argue that the faith crises of the individuative-reflective stage are much more likely to happen in adolescence today than when the model was initially proposed in 1981. Despite its imprecisions, Fowler's model is highly regarded within the psychologic professions because its construction was strongly influenced by luminaries in developmental psychology and because empirical research supporting the model is extensive [18]. Having an understanding of this model becomes important when assessing for spiritual abuse because having a spiritually exploitative experience at an earlier stage can have different implications than abuse at a later stage. Moreover, healthy development in earlier stages may serve as a safeguard against the ill effects of a spiritually abusive experience in later stages.

Stein points to the role of disorganized attachment as a factor in the development or perpetuation of spiritual abuse [51]. In disorganized attachment, a person does not know what to expect, leading to a tendency to withdraw and to be anxious about attachment needs being met. Disorganized attachment styles can develop in highly vulnerable people, and if a spiritual abuse victim does not already operate in this style from early childhood wounding, a cultic or spiritually abusive system will work to create it [51].

CLINICAL PERSPECTIVES

Scholarly articles on spiritual abuse, as a clinical issue, began surfacing in the 1990s. The idea of spiritual abuse as an issue of clinical attention is not unique to the 1990s, but it is apparent that people began to speak up more about being spiritually abused during this period. Helping professionals who were savvy to working with the spiritual dimension of a human being continued the conversation and inquiry. One such author, Boyd Purcell, writes from two perspectives as a minister and as a doctoral-level clinical counselor. Purcell's insights on defining spiritual abuse are multifarious, and some are highlighted here to facilitate a discussion of clinical perspectives [19].

Purcell's succinct definition of spiritual abuse is "any unhealthy, mind-altering relationship with the God of a person's conception that has life-harmful consequences" [19]. He defines spiritual abuse among people as existing on a continuum from zero to terrorism.

Most people have experienced some form of spiritual abuse in their lifetime; however, the people who tend to suffer from it to the extent that clinical attention is required fall in the moderate-to-terrorism range. Purcell explains that when he began teaching the spiritual abuse continuum in the early 1990s, most clinicians responded that they had never heard of the terms or considered them to exist. But the ideas resonated and continue to be used today.

Purcell has identified three causes of spiritually abusive dynamics. Although he writes primarily from a Christian perspective, these causes clearly apply to abuse dynamics within other belief systems as well [19]:

- Legalism: A religious belief that people can please God or any chosen deity, even earning their way into heaven or an afterlife, by obeying specific rules. This is commensurate with a reward and punishment mentality, the lowest stage in Kohlberg's stages of moral development.

- Literalism: The belief that the Bible or other sacred texts must be interpreted literally, not symbolically, to be properly understood.

- Mixed messages: Receiving two contrasting viewpoints about God or spirituality (e.g., "God loves you unconditionally," vs. "But God will only love and accept you if you follow all of the rules").

Considering these dynamics, it becomes clear that people are often afraid to come forward to report spiritual abuse, fearing that they are somehow breaking the rules or displeasing God if they seek help. Although fear of speaking up is a common dynamic in many forms of abuse, it can take on a more damning implication for people if they believe that their soul may be in jeopardy.

Mixed messages are a causal factor in many issues presenting for clinical attention, and many people with personality disorders grow up in environments with severe mixed messaging. Clinicians who work in the field of recovery may know the colloquial expression "mixed messages are a recipe for crazy-making."

In terms of literalism and legalism, a parallel can be made to "living within the letter of the law" versus "living within the spirit of the law." People who have grown up with literalism and legalism often suffer from rigidity or black-and-white thinking. This type of thinking is difficult to work with and should be addressed as a treatment issue. If a client struggles with black-and-white thinking, consider exploring whether or not he or she grew up with legalism or literalism in their home of origin. Even if the client long abandoned the church or spiritual beliefs, the impact of such an upbringing on his or her thought system may be present.

Another causal factor is what is referred to as clericalism [52]. By definition, clericalism is when a small group of highly regarded leaders identified as special make all of the most important decisions in the organization. Although input might be taken from member of the congregation, it is not seriously regarded. Clericalism has been identified as a major causal and exacerbating factor in the abuse scandals within the Roman Catholic Church [52].

Another newer term is child abuse linked to faith or belief, or CALFB [53]. Child protective services workers may encounter this phenomenon used to justify other forms of abuse. In one survey of 1,300 child protective service workers, a need for further training in phenomenon around spiritual abuse and religious trauma was identified. The National Domestic Violence Hotline has also worked to raise awareness about the dynamics of spiritual abuse in intimate partner or other family violence.

Case Example

Client D grew up in a strict Baptist home. Her father was a Baptist minister who died when she was very young; her mother went on to remarry another Baptist minister. One of the teachings rigidly instilled in her developing mind was that she would "go to hell" if she had sex before marriage. So, after she chose to have sex with her boyfriend when she was 19 years of age, she felt that because she was doomed anyway, she might as well go all the way with her "sinning." D clearly identifies that this belief of being damned was a major factor in her developing sexual addiction and eventual dependency on food, alcohol, and cocaine. When she presented for treatment at 40 years of age, a significant belief that blocked her successful participation in treatment was, "I am unworthy of getting better because I am undeserving of God's love." In reflecting back on her treatment experience, eye movement desensitization and reprocessing (EMDR) therapy was needed to help her work on deservability issues, which were instilled by a spiritually abusive upbringing.

3. COMMON THEMES IN SPIRITUAL ABUSE

A desire for or a need to control is a common trait in those who abuse, typically because they are lacking an internal sense of security and stability. Those who work with trauma survivors typically assume that those who abuse others have been abused or mistreated themselves on some level. A trauma-sensitive perspective informs that if the original wound is not resolved, a person may act out in a maladaptive attempt to heal. The likelihood of a maladaptive, or unhealthy, response increases if the person is never shown healthier ways to resolve his or her wounding. This section will explore the traits of those who are likely to spiritually abuse—traits that are common regardless of the religious denomination or spiritual practice in question. In addition, some of the traits of those vulnerable to spiritual abuse will be discussed. Finally, the section will end with a discussion of the similarities and differences between those abuses that occur in religious or spiritual settings (e.g., churches, temples, ashrams) and those that occur within the home or family.

TRAITS OF SPIRITUAL ABUSERS

There are three major traits of those who spiritually abuse others:

- Narcissistic traits/tendencies, resulting from deep insecurity

- Usually a genuine belief that one is doing "the right thing" (rarely an intent to harm)

- Skilled in the language of love, emotions, trust, and intimacy

Narcissistic Traits/Tendencies

Just as clinicians tend to assume that those who abuse have been abused themselves, the assumption is often made that those with narcissistic traits and tendencies (even if criteria for full-blown narcissistic personality disorder are not met) are reacting to a deep sense of insecurity. For many who spiritually abuse, having spiritual knowledge to hold over people becomes a way to meet their need for inner security or self-esteem.

Genuine Belief in One's Righteousness

With the exception of a few extremists who fall into what might be considered cult leaders or who engage in what Purcell labels spiritual terrorism, there rarely is intent to harm [19]. Many who act out in spiritually abusive ways genuinely believe they have found some type of "answer" and desire to share it with others, likely unaware of the subconscious insecurities that drive them. In the case of Client D, discussed in the previous section, her parents likely believed they were doing the right thing by instructing her in the ways of their faith. The phrase, "I'm doing this for your own good" is a common statement uttered by those who spiritually abuse [11,19,50].

Skilled in the Language of Love, Emotions, Trust, and Intimacy

A very cynical way to explain this common trait is to think of manipulation. If abusers are not directly cruel, they are typically very manipulative, using the nuanced appeal of "I have what you really want deep down" to meet their own needs. Those who have experiences with abusive systems typically state that the church or spiritual community had a certain appeal to it, promising good things like love, camaraderie, or even healing and enlightenment. These positive appeals are fundamentally good and have nearly universal appeal. Those who spiritually abuse are masters at luring people in with these good points, but after spending some time with the church or faith community, followers are likely to become acquainted with the ugly realities of the system. In essence, all of this promised love, joy, and bliss comes with a price.

Certain gurus or spiritual teachers come across as very appealing at first, often attracting schools of followers. Then, the initial appeal of the practice may wear off when disciples realize that the leaders are asking more of them in terms of devotion or money than they initially presented. Or, in the worst cases, leaders may take advantage of their followers' desires for intimacy, motivation, and/or self-realization by promising it for a price, often one that is financial, sexual, or emotional in nature.

TRAITS OF SPIRITUAL ABUSE VICTIMS

People who are spiritually abused genuinely desire love, acceptance, intimacy, and the positive attributes of spiritual experiences. Many have been hurt in other areas of life and are seeking a spiritual connection. Abusers tend to sense this and take advantage of or exploit it. Commonly observed traits in people who are prone to being spiritually abused include:

- Deep insecurity and emotional sensitivity

- A genuine intent to pursue truth

- Deep longing for love, emotions, trust, and intimacy

- A belief that love is earned

- Periods of crisis or major life change

Insecurity, Sensitivity, and Longing

As discussed, those who spiritually abuse are often insecure. Those who are prone to being abused typically have the added dynamic of extreme sensitivity. Such sensitivity is like a fire in a fireplace. If it rages out of control, it can burn the house down, but if the fire dies (i.e., sensitive tendencies are numbed), the house will be freezing. The key is to keep a balance. Many sensitive people have the purest of intentions, as the traits suggest, to do the right thing and to live in truth, love, trust, and deep intimacy. Yet if this is not managed, it can make them vulnerable to a host of negative responses (e.g., addictive responses) or to being exploited emotionally, sexually, financially, physically, and spiritually.

Looking at these traits through the lens of Fowler's Faith Development Model, it is important to re-examine stage 0, or primal/undifferentiated faith. This period, from birth to 2 years of age, is characterized by an early learning of the safety of one's environment [17]. If consistent nurturing is experienced, one will develop a sense of trust and safety. Negative experiences will cause one to develop distrust with the universe and the divine. One could argue that people who have these negative experiences at this vulnerable, preverbal period are prone to developing insecurity, emotional sensitivity, and a longing for truth and intimacy.

Earned Love

The common belief that love is earned ties in to Purcell's descriptions of legalism and literalism [19]. This is exemplified by the idea that obedience results in God's love, entrance into heaven, a spiritual reward, or spiritual enlightenment (i.e., the truth, intimacy, and love one has been seeking). However, it is important to remember that even people who do not grow up in religious homes may develop this belief system. For example, in some homes the message of earning parental love through obedience is either implicitly or explicitly delivered. In alcoholic homes, young children may believe, albeit maladaptively, that their good behavior could stop their parent from drinking. Whenever a person receives any message along the lines of "love is earned" in the formative years and a newer, more adaptive message is never installed in its place, they are vulnerable to being abused, especially in a spiritual sense, later in life.

Periods of Crisis or Major Life Change

Abusers tend to prey on the weak, and people are most likely to feel weak during periods of crisis or life change, especially when an element of self-doubt is involved. In the popular understanding about cults, this trait is recognized in charismatic cult leaders: they prey on the weak. However, it does not take an extremist cult leader for this dynamic to take place.

In discussing spiritual abuse, it is not hard to see how it can manifest in spiritual systems (e.g., churches, communities) in which an abusive leader or leaders are at the helm. However, it is just as important to discuss when the abusive "leader" is a parent or family member. Research indicates that spiritual abuse is often perpetrated by a family member, commonly a parent who follows a literal, legalistic interpretation of fundamentalist religious teachings. Consider the case of Client D from the case example in the previous section. The messages she received about hellfire and damnation came in the home. One could argue that such messages are even more damaging to children when they come from a parent or primary attachment figure as opposed to a pastor or religious leader.

CASE EXAMPLE

Client J is a woman, 35 years of age. During a counseling session, J relates a key negative belief she received in childhood and internalized: "I am Satan's child." This belief was given to her by her father, a man whom she genuinely loved, in his attempt to "save her soul." Another negative message she received, one that accelerated her addictive responses, was that if she did not follow God's laws as written in her father's denomination's interpretation of the Bible, then the people who were close to her would be taken away. This message was relayed when she was 19 years of age, after her high school guidance counselor, a woman to whom she was very close, died unexpectedly of complications of pneumonia. Her death affected J very much, and her father's response to it was that her death was God's "warning sign" to Client J. Her father said that if she did not "straighten up" her ways (which meant getting back to church, an activity she abandoned when going to college), then God would begin to remove more people from her life, starting with her brother and mother. These words were very damaging, setting off a deep depression that lasted years.

4. ASSESSING FOR SPIRITUAL ABUSE

There is a very active online community of spiritual abuse survivors, discussion boards, and forums for people to share their stories about wounding and recovery. These online communities are usually the first places that spiritual abuse victims go in the modern era because of the anonymity they provide [20]. Such communities can provide victims with the initial validation of their experiences needed to begin recovery and transform into a survivor. One popular community, Kingdom Grace, offered the following insights regarding spiritual abuse [21]: Spiritual abuse is trauma. The three characteristics of trauma are:

- An external cause—Someone does it to you.

- Violation—You are violated by an unwelcome intrusion.

- Loss of control—It is unexpected and beyond your control.

The result is a shattering of the basic assumptions the person held about their world.

Trauma, which is based on a Greek word meaning wound, is defined as any experience a person endures that leaves a life-threatening or life-altering impact. If left unresolved, the effects can be devastating. Some experiences of trauma manifest as clinical post-traumatic stress disorder (PTSD). However, the helping professions are growing increasingly savvy to the notion that an event or experience does not have to meet PTSD criteria to be relevant. Many conditions that present for clinical attention, including, but not limited to, depression and mood disorders, anxiety disorders, adjustment disorders, and personality disorders, can have clear roots in traumatic experiences or can be exacerbated by the presence of unresolved trauma.

The same approaches that helping professionals use to assess for PTSD and trauma-related conditions can be used to assess for spiritual abuse, if spiritual abuse is accepted as a trauma like any other form of abuse. This section will focus on direct and indirect methods for assessing spiritual abuse as a trauma.

Providers who are not experienced in assessing for PTSD or trauma should start with a semi-standardized interview tool such as the Primary Care PTSD Screen (Table 1) [22]. The Primary Care PTSD Screen is not meant to be a diagnostic tool, but it is an effective screening tool, indicating whether or not further assessment is necessary. If a client answers "yes" to any of these questions, the results of the screening should be considered positive. A list of other screening tools or psychometric measures and instructions on their use in clinical settings is available at https://www.ptsd.va.gov/professional/provider-type/doctors/screening-and-referral.asp. Any trauma-related tool can be used to assess for the presence of spiritual abuse as long as it is appropriately modified.

Table 1: PRIMARY CARE PTSD SCREEN

In your life, have you ever had any experience that was so frightening, horrible, or upsetting that in the past month you:

1. Have had nightmares about it or thought about it when you didn't want to?

2. Tried hard not to think about it or went out of your way to avoid situations that remind you of it?

3. Were constantly on guard, watchful, or easily startled?

4. Felt numb or detached from others, activities, or your surroundings?

If you want to specifically tailor the tool to assess for spiritual abuse, you can modify the opening statement: In your life, have you ever had any spiritual or religious experiences that were so frightening, horrible, or upsetting?

Source: [22]

One of the sub-criteria of PTSD in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) is persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., "I am bad," "No one can be trusted," "The world is dangerous") [23]. Alternatively, this might be expressed as "I've lost my soul forever," or "My whole nervous system is permanently ruined." Although this symptom is officially listed under the criterion of negative alterations in cognitions and mood associated with the traumatic event(s) beginning or worsening after the traumatic event(s) occurred, this description has long been accepted as a part of trauma-related injuries.

These negative belief examples are one way to assess for trauma and its impact. In a clinical setting, a 30-item list called The Greatest Hits List of Negative Beliefs may be helpful [24]. This list contains 30 of the most common negative cognitions those who have been traumatized tend to believe about themselves. Common examples include:

- I am not good enough.

- I am permanently damaged.

- It is my fault.

- My body is ugly.

- I have to be perfect.

- I cannot trust anyone.

- I am not worthy.

- I am not safe.

- I cannot show my emotions.

These beliefs are rather general, but when identified, exploring them can lead to valuable clinical information. When working with survivors of spiritual abuse, a similar greatest hits list, specific to spiritually charged beliefs about the self, may be more helpful. Some of these beliefs include:

- I have to be perfect.

- I am defective.

- I am not deserving (of God's love/grace).

- I am a disappointment (in God's eyes).

- I cannot trust my judgment.

- I am demonic/possessed/"Satan's child."

- I am not safe in the world.

- I am cursed.

This list is not exhaustive, as it is not possible to capture every negative slur that a person received, with spiritual charge, from an abuser. However, it provides a solid place to begin. In some cases, the core event(s) causing the spiritual abuse reveal themselves during assessment with a general list, but if the trauma is suspected to be more spiritual or existential in nature, a simplified and specific list may be more helpful.

First, let the client see the list and ask if any of the eight beliefs on the list apply to him or her. Let the client know that he or she may have one, two, or even all eight beliefs that resonate. If more than two beliefs are checked, ask the client to re-review the list and try to rank or identify the one or two worst. In order to obtain additional information about a spiritually abusive experience, consider asking follow-up questions. For example, if a client's most charged cognition is "I'm a disappointment in God's eyes," ask:

- Thinking back over the course of your whole life, when did you first start to believe "I am a disappointment in God's eyes?" Or, thinking back over the course of your whole life, when did you first receive the message "I am a disappointment in God's eyes?"

- Thinking back over the course of your whole life, when was the worst time you believed "I am a disappointment in God's eyes?" Or, thinking back over the course of your whole life, when was the worst time you received the message "I am a disappointment in God's eyes?"

- Thinking back over the course of your whole life, when was the most recent time you believed "I am a disappointment in God's eyes?" Or, thinking back over the course of your whole life, when was the most recent time you received the message "I am a disappointment in God's eyes?"

The answers to these questions can provide a wealth of information to guide treatment planning. The decision of when during the treatment process to ask these questions is up to the clinician's discretion and the quality of the therapeutic relationship. These questions may be asked during an initial assessment if sufficient rapport has been established, or if a spirituality-related abuse issue arises, the questions may be used later in the treatment process.

The idea of observing and reacting to issues that come up during the treatment process is an important part of assessing for spiritual abuse. Many forms of trauma are not evident in the first session. Even if they are, it is generally not prudent to ask clients detailed questions about the trauma until sufficient rapport has been established and the client has sufficient stabilization, or coping, skills to deal with the distress that may manifest in his or her disclosures. Few clients will identify spiritual abuse as being a trauma or a form of abuse, even if asked during an initial assessment, because many people continue to be unaware of the possibility of this type of abuse. One potential avenue in the initial assessment is to ask a question about religious and/or cultural upbringing. Clients may respond with, "I grew up in a very devout (insert denomination or religion) home, so I was given a lot of negative messages about sex." Such responses provide an opportunity to follow-up or even educate clients on spiritual abuse.

Issues of spiritual abuse may also reveal themselves when working with a client to develop spiritual resources. This is a standard part of the treatment process in traditional substance use disorder treatment, especially those following a 12-step model. Founded in 1935, the 12 steps of Alcoholics Anonymous (AA) have been developed by many treatment centers as a philosophical approach. Part of 12-step philosophy is, after a person admits powerlessness over drugs or alcohol, to begin exploring a relationship with a Higher Power or power greater than oneself and to turn one's will and life over to the care of this power. The steps are not intended to demand devotion to a specific God or religion, but rather to allow addicts to develop their own conceptualization of God. Although many people find 12-step spirituality to be user-friendly and easily accessible to those who desire spirituality and not religion, others resist the 12-step model as being too "God-oriented." Others are able to express their belief in God, but find the idea of trusting a God of their understanding or turning their life over to a Higher Power scary. These resistances may be a natural part of addiction recovery, or they may be a sign that spiritual abuse occurred and is unresolved.

In 2022, Koch and Edstrom debuted a Spritual Abuse and Harm Scale [54]. They developed this tool from surveying over 3,000 Evangelical Christians, so the tool is limited to people from this experience. Six thematic factors comprise the 27-item scale: maintaining the system, internal distress, embracing violence, controlling leadership, harmful God image, and gender discrimination.

CASE EXAMPLE

Consider the case of Client E [24]. Several years ago, E presented for treatment services related to unresolved sexual trauma. She knew that she had PTSD, although the religious themes connected to her PTSD did not come to light immediately. One day, E declared, "There is something in me that is inherently spiritual. I want to be spiritual, but I resist, probably because of what happened to me growing up."

This statement may be viewed as a trigger. When a person say things like "I'm inherently spiritual, but…," or talks about wanting to do spiritual things (e.g., yoga class, church) without taking steps to do these activities, it is a sign that spiritual abuse may exist and should be explored further.

Upon questioning, E revealed she was raised in an Evangelical home with a strictly religious father and an alcoholic mother. She was sexually assaulted by another student at her father's church school as a pre-teen, and the school did not care to address it. In addition, she was sexually assaulted at one of her mother's AA meetings as a teenager, which understandably gave her a very low opinion of going to meetings in the community, even after she developed an issue with cannabis abuse in adulthood. E realized she was a lesbian during adolescence, and her father condemned her to hell when her same-sex desires came to the surface. For E, anything connected to God or religion had become equated with pain. Although she expressed interest in trying activities like yoga or meditation, Eastern practices that she knew would be more agreeable with her temperament, she resisted.

After being educated about the reality of spiritual abuse, E had no problem identifying as a spiritual abuse survivor, in addition to being an emotional abuse survivor. The next step was determining how to move forward with this knowledge.

5. TREATING SPIRITUAL ABUSE

As is the case when treating all forms of trauma, forging a solid therapeutic alliance is absolutely imperative when working with victims of spiritual abuse [19]. The importance of a solid therapeutic alliance is well-established by research in the field, and its implication in treating trauma is even more significant [25,26]. The literature addressing general traumatic stress indicates that the quality of the therapeutic alliance, as rated by clients, is the greatest predictor of facilitating meaningful change in clients with complex PTSD [27,28,29]. The Anaïs Nin quote,"Shame is the lie that someone told you about yourself" is often used to illustrate the effects of abuse on young children. Helping professionals are in a position of power, and this power may be used to continue reinforcing negative self-talk or to help a person start to see a new truth about himself or herself, which can hopefully assist that person in developing a healthier relationship with spirituality. The modeling process is the very essence of setting a crucible for change through the therapeutic alliance.

There are many possible approaches to treating spiritual abuse. Regardless of the chosen approaches, which should be tailored to meet the client where he or she is upon coming in to treatment, a strong therapeutic alliance is a constant. This section will review a general framework for treating all trauma and consider how spiritual abuse treatment can fit into this model. The available literature and evidence supporting spiritual abuse treatment approaches will be explored, including specific techniques that can be implemented into practice, regardless of the specific therapeutic modality.

GENERAL FRAMEWORK FOR TRAUMA TREATMENT

There is a general consensus in the traumatic stress literature that addressing trauma should occur in three stages [30,31,32,33]:

- Stabilization

- Working through of the trauma (reprocessing)

- Reintegration/reconnection with society

These stages are referred to by many names, including the consensus model, the three-stage consensus model, and the triphasic model.

Stage 1: Stabilization

During the stabilization stage, clients are equipped with the skills to make sure that they can regulate intense affect and remain stable when working on the past. One possible error is immediately attempting to address past issues/memories. When clients explore the past before they are ready to deal with it, more damage can result. Thus, stage one is just as important as stage two in trauma treatment; it provides clients with the skills necessary to stabilize and cope. Forging the therapeutic alliance and cultivating coping mechanisms (which may or may not include spiritual pathways) are essential parts of treatment.

Stage 2: Reprocessing

In stage two, a variety of therapeutic techniques or approaches can be implemented to help a person work through and resolve the trauma in a holistic, experiential way. It will not be enough to confront the negative thoughts and self-talk about the trauma(s), spiritual or not. Rather, the approach should help the person truly transform on all levels of the self, body, mind, and spirit. For example, if a client has the negative spiritual cognition "I'm a disappointment in God's eyes," a successful course of stage two treatment would allow her or him to develop a more positive core belief like "I am precious in God's eyes" in a total sense.

No one specific therapy is considered the most effective for reprocessing trauma [34,35]. The decision of which approach to use is based on a combination of factors, including the needs and strengths of the client, the experience and strengths of the therapist, the therapeutic alliance, and the choice of a method that engages and inspires the participants [25]. A wide variety of methods and approaches can help a person resolve trauma, including, but not limited to, psychoanalysis, experiential therapy, EMDR, trauma-focused cognitive-behavioral therapy, exposure therapy, stress inoculation therapy, somatic experiencing, narrative therapy, Gestalt therapy, and more innovative approaches like art therapy, music therapy, yoga therapy, dance therapy, and animal- or equine-assisted therapy. A combination of modalities is often necessary to help a client optimally heal, especially when issues connected to core identity are involved.

Stage 3: Reintegration

Reintegration is perhaps the most "common sense" stage of the entire consensus model, yet it is one that is often missed. The purpose of reintegration is to help clients transition into living their lives without the symptoms of trauma. At some point during treatment, clients often relate feeling like a burden has been lifted. Too often, work stops here, without considering that, after carrying a weight for such a long time, it may feel incredibly weird or even uncomfortable to maneuver through life without it. Continuing care and maintenance strategies are imperative.

There will be a great deal of overlap between stage 3 and stages 1 and 2, especially when trauma work is being done with a client in an outpatient setting. In fact, when working outpatient, reintegration is incorporated throughout treatment. The three-stage model is not meant to be a stepwise approach. If a client is working on trauma in stage two and finds him- or herself overwhelmed to the point of regressing dangerously, it is likely that he or she will need to step back to stage one work for a while. Whole sessions may be spent working on stage two material, but it can be good practice to close each session with stabilization strategies.

CULT RECOVERY

Interestingly, the literature on cult recovery offers a similar three-tiered model. Langone proposed the following three stages of recovery, with associated tasks for each stage [36]:

- Re-evaluation (focus on the past)

- Re-evaluate cult affiliation.

- Learn how one was under the influence of mind control.

- Help client to understand trauma and how to deal with "floating" or flashback episodes.

- Begin re-evaluating beliefs and value system before, during, and after the cult involvement.

- Reconciliation (focus on the present)

- Allow and encourage client to grieve losses.

- Expect emotional volatility, normalize, and offer support.

- Let the past re-emerge.

- Deal with arrests in the maturation process.

- Help the client regain purpose.

- Reintegration (focus on the future)

- Help plan and focus on the future.
-Encourage recovery of the whole self.

- Help clients integrate cult experience into their permanent identities.

The level of distress of those exiting cults has been noted to be comparable to patients in inpatient psychiatric treatment, so clinicians understanding these stages and how to work within them is important [37]. Although written for cult recovery, many of these suggestions can be applied to any manifestation of spiritual abuse that occurred within an unhealthy system; modifications will need to be made depending on the systems and, of course, the person.

Singer and Ofshe assert that it is important to normalize the sense of anxiety and trepidation a survivor experiences; it is further important to allow for a period of adjustment following abuse [38]. They discourage the use of hypnosis, cautioning that it may trigger dissociative experiences. Keeping this in mind, it is important to proceed with caution, even with guided meditations or relaxation techniques that may trigger a dissociative flashback. Trauma expert Judy Herman, who coined the term complex PTSD, states that clinicians should empower clients so they feel in control of their own recovery [39]. She also stresses the importance of screening for depression, anxiety, suicidality, and possible returns to the cult, especially in early treatment. Clinicians should refrain from making assumptions about those who enter a cult; for example, not all members have highly dependent personalities [40]. It is important to help victims recognize that they were ethically and morally wronged as a first step toward recovering their mental and emotional dignity [40].

Therapists who are accustomed to treating the whole person will be in a good position when it comes to treating spiritual abuse. Because spiritual abuse can affect multiple dimensions of a person's life, including physical, psychologic, emotional, relational, educational, vocational, sexual, financial, and spiritual realms, it is critical to assess which areas have been affected and address them accordingly within the three-stage consensus model [11,41]. First, clinicians should practice within a spiritually sensitive, reflective framework and not dismiss spiritual issues in the counseling process [42]. Second, especially in working with women, clinicians should help survivors connect with the full range of their emotional experience, which may be difficult because many traditional, orthodox religious groups promote emotional repression [43]. In the cases of spiritual abuse that happened as a result of oppression (e.g., in indigenous cultures), it can be critically important to bring in the respective culture's healing rituals, if the client is willing [2]. Narrative counseling, or affording oppressed survivors the chance to share their stories, is also a helpful tool [44].

One qualitative study specifically addressed the question of effective treatment for spiritual abuse recovery [20]. In this study, 100 spiritual abuse survivors in the Christian tradition from English-speaking countries throughout the world participated. The researcher concluded that four main steps were necessary in order for these survivors to heal from spiritual abuse:

- Sufficient time to grieve

- Forgiveness and release of the situation to God

- A suitable faith community

- Moving forward in Christ with the help of the Holy Spirit

Obviously, these steps can be modified to remove the Christian language if applied to other situations, and additional research investigating if similar dynamics are found in other denominations or faiths is necessary.

The definition of recovery may vary from survivor to survivor [20]. Regardless of how survivors choose to define their recovery, it becomes imperative that clinicians help them to define and work toward healthy spirituality as part of the treatment process.

HEALTHY SPIRITUALITY AND SPECIFIC RECOVERY STRATEGIES

The definition of spiritual abuse recovery can vary depending on the goals of each client and his or her situational factors, and the goals of recovery should be clearly delineated. Simply offering a client this choice of defining recovery can be a liberating gesture that enhances the therapeutic alliance; any chance to offer choice to a client is an opportunity for empowerment. There are various definitions of healthy spirituality and spiritual recovery available, but their often overtly Christian focus can be limiting for broader recovery. Much of the Christian pastoral literature on spiritual abuse, although revolutionary to jumpstarting the discussion on spiritual abuse, defines recovery in Christian-only terms. In a more liberal clinical view, attraction to other spiritual practices (e.g., Eastern, New Age) may be a manifestation of recovery; all practices that offer authentic expressions of religiosity/spirituality and yield healthy fruits for their followers are valid choices [45].

Spiritually and culturally inclusive counselors may appreciate the following list of traits of healthy spirituality and/or religion:

- Realization that spirituality is simply the search for meaning in everyday life

- Compassion, forgiveness, respect, and unconditional love as its foundation

- Individuals encouraged to look within to find the source of wisdom and knowledge

- Each person's path is accepted as right for them, and paths that are different from their own are not devalued

- Acknowledgement that each person alone contains everything needed for a fulfilling and successful spiritual existence

- The belief that spirituality arises from a personal relationship with God/the Universe and not from a relationship with any religious institution

- The spiritual/intuitive gifts of all individuals are recognized as divinely empowered

- Releasing judgment and acceptance of the connectedness and unity of all

If it is helpful, this list may be shared with clients.

Another way to conceptualize healthy spirituality is to look at the natural opposites of the negative beliefs covered in the previous section. These beliefs of healthy spirituality would read as such:

- It is okay to make mistakes.

- I am fine just as I am.

- I am deserving.

- I am perfect in God's/the Universe's eyes.

- I can trust my judgment/intuition.

- I am a child of God/the Universe/Earth.

- I can create safety in my world.

- I am blessed.

In working with clients, it is a solid first step, as part of stabilization, to determine if they have any of these positive beliefs, even if negative beliefs are also present. Time may then be spent working with that positive cognition.

If a client struggles with believing that he or she is shameful or undeserving, yet is somehow able to accept the belief that she is blessed, this positive cognition can be built on as a stabilization technique. Many clients with shame-based spiritual ideology are at least able to accept the "I am blessed" belief on some level, especially if they have worked steps two and three of a 12-step program (i.e., believing that Higher Power can restore to sanity and turning one's will and life over to the care of the Higher Power). Even if these steps have not been worked, "I am blessed" may be able to be accepted on gratitude alone. If this is the case, consider stating the following:

Right now, I would like you to just focus in on the statement "I am blessed." Stay with your breath, notice your body, and just say "I am blessed" either to yourself or aloud. Notice what that feels like in your body, to be blessed. If you can, bring up something in your mind that makes you connect with the statement "I am blessed." Maybe it is a song, or perhaps it is a memory, either in the distant past or recently, that really helped you to believe the truth that you are blessed.

At this point, the memory, the song, or any other information that comes up can be used to complete a spiritual guided imagery or guided meditation, inviting the client to stay focused on the positive elements of what is emerging, especially if he or she starts to entertain any negative spiritual cognitions.

Working with music, be it spiritual music or secular music with a spiritual theme, can be a powerful technique. If a client is clearly able to identify a special song that helps him or her to feel connected with a Higher Power, sense of spirit, or the universe, it can be incorporated into spiritual guided imagery or used as a focusing meditation technique. Encourage the client to stay attuned to any body sensations that may emerge as the song plays. Tuning in to these positive visceral sensations and inviting the client to really be with and notice them can be useful in the healing process. The client can then be encouraged to use this song (e.g., listening to it, singing it) as a coping skill to access when needed. Guided imagery and its multiple variations incorporating other sensory material can also help to build healthy spirituality. These techniques allow clients to begin experimenting with and rebuilding their own sense of spirituality.

Clinicians who are devout in the beliefs of one specific faith should feel free to tailor or modify the approaches discussed in this section, as long as it is clear that they are healthy for the client. It is only healthy for a clinician to be specific with her or his religion or faith if the client is seeking that specific care (e.g., Christian counseling). If a client is seeking a counselor of a specific faith, this is a way of indicating a desire to continue in that faith, so counselors should incorporate the healthiest elements of that faith. However, if a practitioner is working in a secular setting, it is her or his responsibility to refrain from pushing a specific faith and keep an open mind to the client's spiritual needs.

Some clients may be so scarred by spiritually abusive experiences that they want nothing to do with reconnection to a spiritual source. If this viewpoint is voiced, it should be respected. However, many who are spiritually abused have an innate drive to be spiritual. Thus, avoiding that part of the person is usually not optimal, and inquiry, curiosity, and experimentation should be encouraged, as appropriate. It can be healing for the client to find what works and is healthy and to make a connection that only spirituality will likely fulfill. A major part of recovery for any kind of abuse, but especially spiritual abuse, is negotiating what is healthy and authentic.

For some survivors of spiritual abuse, the process of recovery through discovery happens over a period of years and seasons of life. Even when survivors begin to find a path that feels genuine and healing for them, old messages, either directly or subtly delivered, must be confronted.

Because spiritual abuse is a form of trauma, it is clear that treatment will need to include reprocessing and reintegration components. As discussed, there is no gold-standard approach for reprocessing trauma. The keys are to make sure that proper stabilization is in place before proceeding with reprocessing activities and to discover with the client which methods or approaches will work best. For certain cases, EMDR can be a good fit [46]. Some specific pastoral techniques (e.g., transformational prayer) may also be used to treat spiritual abuse.

There are several techniques from the Gestalt approach that are useful for addressing spiritual abuse and its manifestations [47]. As long as a qualified professional who is comfortable dealing with trauma and intense affect uses these techniques with clients who are properly stabilized, they are generally safe. It is rarely productive for a survivor of abuse to confront the abuser (the only exceptions being when the abuser is in some form of active recovery and has an awareness of how they victimized others, or if the survivor is well-prepared to simply say what he/she has to say without engaging in extended attempts at reasoning). However, the empty chair technique can help survivors to release the feelings they have been holding in a dynamic, experiential way by imagining the abuser in an empty chair across from them.

Another similar technique is that of the unsent letter. In this approach, the client writes a letter to the person who abused him or her, or even to a Higher Power. The intention is not to send the letter to the abuser, but rather for the client to release his or her pain in a dynamic way, without censor. The client then decides how he or she is going to release the letter. Some will want to share the letter with their counselors so someone can witness their pain. Other clients may find it too dangerous to keep such a letter, so they destroy it after it is written, an act that can be very healing. Some may want to burn the letter, perhaps while saying some type of prayer or intention for release. Just as symbol and ritual can be used to hurt, it can also be used to heal.

Giving clients permission to vent their anger at the churches, groups, or entities that abused them is an important part of reprocessing the trauma of spiritual abuse. Anger toward God or the divine is an issue in treating all types of trauma (e.g., "How could God let this happen?"). Clearly, that anger can have an even more pervasive impact for survivors of spiritual abuse, as their trauma was perpetrated "in the name of God." Allowing clients to work through their anger with the abuser, Higher Power, or spiritual organization in a supportive manner is an effective component of stage two reprocessing. This spirit of non-judgment, even if the client seems stuck in her or his anger and resentment for quite a while, is critical when working with survivors of spiritual abuse.

Not all helping professionals can work with stage two reprocessing. Many clinicians are well-suited to deal with stage one and stage three work, but recognize that they cannot handle stage two. Comfort with trauma and intense affect is perhaps the most important quality of an effective trauma therapist [48,49]. The missing piece for many helping professionals is not lack of specific, technical training, but a general uneasiness with trauma in general. Often, this uneasiness results from unresolved countertransference issues or an unwillingness to address one's own traumatic wounds as a helping professional. The proverb "Healer, heal thyself" should be embraced in order for a clinician to work with trauma in an optimally effective manner.

Recovery from spiritual abuse can be a long-term process that continues to take place after formal counseling terminates, which is why the reintegration process is a necessary part of the healing process. Clinicians should work with clients on using the skills they developed in therapy to continue addressing pain as it arises in life, especially pain connected to spirituality. Clients who are able to foster connection with a healthier spiritual system, be that in the form of a new church group, a meditation group, yoga studio, Bible study, faith-sharing group, or simply a solid group of friends that honors tolerant, integrated approaches to spirituality, are at an advantage when it comes to reintegration. If contextually appropriate (based on clinical discretion), clinicians may work with the new spiritual group or that group's leader (with appropriate consent from the client) for enhanced, collaborative care.

CASE EXAMPLE

Let's return to Client E, the young woman discussed in a previous section. E knew immediately that she desired to be spiritual, but any time she tried, the images and early memories from her negative experiences at home and in the church blocked her. Although it became clear that reprocessing some of these memories would be an important part of her treatment, it was also critical to first build on the positive cognition, "There is something in me that wants to be spiritual."

Her counselor begins working with E on using some standard breathing, lightstream visualization, and muscle relaxation techniques. These helped her to achieve a sense of visceral calm and ease sitting in the office. Upon relaxing, the counselor asks E to keep an open mind to the spiritual realm and invites her to notice what emerges in terms of a spiritual figure or a spiritual source. Almost instantaneously, E smiles. She reports that she began to see a little creature that looked half like the character Yoda from the Star Wars movies and half like Mr. Miagi from The Karate Kid movies. The counselor prompts E to stay with that image and notice what happens. With a continued smile, she explains that he was playing a drum, and when he stopped, he invited her to come and sit with him and the two of them talked about all things related to life. As she stays with this experience, she reports feeling a sense of total love and acceptance. Clearly, this figure is a Higher Power that worked for her. As a take away, her counselor encourages E to continue working with this image on a daily basis. He also suggests that she begin by working with her breath, as she had in the office, and then allow the image to come up and notice what happens the longer she stays with the image. This technique is one that allows her to keep building her relationship with her Higher Power and her newfound spirituality.

6. PROFESSIONAL DEVELOPMENT ISSUES

Many helping professionals are reticent to explore issues of spirituality with clients, especially spiritual abuse, because they have not explored their own spiritual identities or are afraid of being perceived as "pushing spirituality" on clients. Although pushing spirituality is never appropriate, counselors are committing a disservice if they do not at least ask questions about the client's spiritual self. If clients are uninterested in addressing spirituality in counseling, that is their choice. If a client is willing to explore it, counselors should be willing to guide him or her.

This is why it is important for clinicians to assess their own spirituality. Some do not identify as a spiritual person or understand why anyone would be drawn to spirituality, and knowing this is a first step. These counselors should determine if this state of being inhibits them from being effective with clients who deeply desire to be spiritual. If a clinician dismisses spiritual abuse as related to church corruption or religious superstition, clinical relationships can be damaged.

Many counselors who work with spiritual abuse or trauma have had negative personal experiences with spirituality. If unresolved, this state tends to manifest as not wanting to explore spirituality with clients. If addressed, it can make counselors more effective in working with survivors. Not only can this effectiveness be used to help clients, but it can help to raise awareness about the realities of spiritual abuse. As discussed, many people are unaware that spiritual abuse exists, including colleagues, and education is important. Helping professionals may also be hesitant to address spiritual abuse because they are unsure of what to do with the issues that may come up in sessions. Thus, education about the experiences of people who go through spiritual abuse and trauma is a valuable part of enhancing treatment. This education should be more than just technical; it should include information about what people experience and how to build the understanding, empathetic relationships that can facilitate people growing into their authentic selves.

Part of being an effective helper is recognizing when one is beyond his or her area of competence or comfort. Having a referral network is vital. An Internet search of spiritual abuse counselors by geographical area may not retrieve a great deal of results. Instead, a pastor or religious leader who is known for her or his tolerance may be a good source. Working through one of the many books on the topic of spiritual abuse and personally reflecting upon the content may also provide guidance. For many clients, acknowledging that spiritual abuse is real can be a powerful validation.

7. CONCLUSION

Just as the specific definitions of spiritual abuse differ, so can the varieties of the recovery experience. Above all, helping professionals should realize that spiritual abuse is a form of abuse. Spiritual abuse is trauma, and it can manifest and cause problems in human experiences. Helping professionals can help clients to heal from its wounds. As discussed, having spiritual abuse validated as a legitimate form of abuse by a helping professional can commence the healing process in a very powerful way.

This course has outlined spiritual abuse, in general, as the use of God or religion as a tool to gain power and control. The primary assumption is that spiritual abuse is not unique to any one religion or faith; it can happen in every faith and in every spiritual practice. The specific definitions of and literature on spiritual abuse were explored from sociologic, pastoral, developmental, and clinical perspectives. Common themes apparent in spiritual abuse, specifically commonalities between those who abuse and those who are vulnerable to being spiritually abused, were outlined. Issues in assessing spiritual abuse, specifically assessing it as a trauma issue, were described, followed by issues in treatment. The three-stage consensus model of trauma treatment was presented as a framework for healing spiritual abuse in a clinically sensitive manner. Finally, the course concluded with issues of professional development and honing one's own sense of spiritual awareness in order to optimally serve clients.

8. GLOSSARY

12-step model: The 12-steps of Alcoholics Anonymous have been developed by many treatment centers as a philosophical approach. Part of the 12-step philosophy is to begin exploring a relationship with a power greater than oneself and to turn one's will and life over to the care of this power.

CALFB: Child abuse linked to faith or belief.

Conjunctive faith: Stage 5 in Fowler's Faith Development Model (mid-life), characterized by acknowledging paradox and transcendence relating to the reality behind the symbols of inherited systems. The individual resolves conflicts from previous stages by a complex understanding of a multidimensional, interdependent "truth" that cannot be explained by any particular statement.

Cult: From the Latin meaning "to worship," in the modern era, the definition takes on a negative connotation, generally described as a new religious movement or other group whose beliefs or practices are considered abnormal or bizarre [9]. Various organizations and scholars have published lists or guidelines to identify cultic groups, a common consensus being that cults have a destructive impact on their members.

Disorganized attachment: An attachment style characterized from unpredictable tendencies to withdraw and then to anxious engage with an attachment figure. Largely caused by inconsistency in attachment needs being met.

Fowler's Faith Development Model: A seven-stage model explaining faith development in humans across the lifespan, influenced by the work of Piaget, Erickson, and Kohlberg [17].

Guru: A Sanskrit word meaning "teacher" or "master," literally one who can cast out the darkness. Although originating in Hinduism, many in the modern era use the term in reference to anyone whose teachings attract followers. It has negative connotation in some circles because of scandals involving financial or sexual exploitation.

Individuative-reflective faith: Stage 4 in Fowler's Faith Development Model, characterized as a stage of angst and struggle. The individual takes personal responsibility for his or her beliefs and feelings. As one is able to reflect on one's own beliefs, there is an openness to a new complexity of faith, but this also increases the awareness of conflicts in one's belief.

Intuitive-projective faith: Stage 1 in Fowler's Faith Development Model, characterized by the psyche's unprotected exposure to the Unconscious.

Legalism: A religious belief that people can please God or any chosen deity, even earning their way into heaven or an afterlife, through obeying the rules.

Literalism: The belief that the Bible or other sacred text(s) must be interpreted literally, not symbolically, to be properly understood.

Mixed messages: Receiving two contrast viewpoints.

Mythic-literal faith: Stage 2 in Fowler's Faith Development Model, characterized by a strong belief in the justice and reciprocity of the universe; deities are almost always anthropomorphic (i.e., personified).

Primal or undifferentiated faith: Stage 0 in Fowler's Faith Development Model, characterized by an early learning of the safety of one's environment. If consistent nurturing is experienced, one will develop a sense of trust and safety about the universe and the divine; negative experiences will cause one to develop distrust.

Ritual abuse: An extreme, sadistic form of abuse of children and nonconsenting adults. It is methodical, systematic sexual, physical, emotional, and spiritual abuse, which often includes mind control, torture, and highly illegal and immoral activities such as murder, child pornography, and prostitution. The abuse is justified by a religious or political ideology.

Spiritual abuse: Succinctly described as the use of God or religion as a tool to gain power and control.

Synthetic-conventional faith: Stage 3 in Fowler's Faith Development Model, characterized by conformity to religious authority and the development of a personal identity. Any conflicts with one's beliefs are ignored at this stage due to the fear of threat from inconsistencies.

Three-stage (or triphasic) consensus model: refers to the three main stages that should guide trauma treatment—stabilization, reprocessing (working through of the trauma), and reintegration/reconnection with society. This model has emerged from a general consensus in the trauma literature of how treatment should be framed.

Universalizing faith: Stage 6 in Fowler's Faith Development Model, what some might call "enlightenment." Characterized by the individual believing everyone should be treated with the universal principles of love and justice.

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