SW18B • Social Workers

Table of Contents

SW18B • Social Workers

How to Receive Credit

NetCE 3 Hour Course #97662 • Online Professionalism and Ethics

97662 • Online Professionalism and Ethics

1. INTRODUCTION

2. INTERNET AND DIGITAL TECHNOLOGY TRENDS

3. REVIEW OF INTERNET COMMUNICATION TOOLS

4. USES OF INTERNET TOOLS IN CLINICAL PRACTICE

5. OVERVIEW OF PROFESSIONALISM AND ETHICS

6. INTERNET TECHNOLOGIES AND PROFESSIONALISM AND ETHICS

7. ONLINE SELF-DISCLOSURES

8. ONLINE SEARCHES FOR INFORMATION ON PATIENTS OR CLIENTS

9. BEST PRACTICE GUIDELINES

10. CONCLUSION

Works Cited

NetCE 5 Hour Course #97823 • Elder Abuse: Cultural Contexts and Implications

97823 • Elder Abuse: Cultural Contexts and Implications

1. HISTORICAL OVERVIEW

2. DEFINITIONS OF ELDER ABUSE AND CONTROVERSIES

3. CULTURE, RACE, AND ETHNICITY AND ELDER ABUSE

4. ASSESSMENTS, INTERVENTIONS, AND MANDATORY REPORTING LAWS FOR ELDER ABUSE

5. RESOURCES FOR PRACTITIONERS WORKING WITH THE ELDERLY AND ABUSE VICTIMS

Works Cited

Evidence-Based Practice Recommendations Citations

NetCE 7 Hour Course #78041 • Integrating Mindfulness into Clinical Practice

78041 • Integrating Mindfulness into Clinical Practice

1. INTRODUCTION

2. HISTORICAL BACKGROUND

3. SEVEN ATTITUDES OF MINDFULNESS

4. MINDFULNESS PRACTICES OF DAILY LIFE

5. MINDFULNESS AS A CLINICAL CONCEPT

6. WAYS TO CULTIVATE MINDFULNESS

7. MINDFULNESS IN THE CLINICAL SETTING: TREATMENT PLAN STRATEGIES

8. MINDFULNESS IN CONTINUING CARE

9. CONCLUSION

10. RESOURCES

Works Cited

Evidence-Based Practice Recommendations Citations

SW18B • Social Workers

Alice Yick Flanagan, PhD, MSW

www.netce.com

Copyright © 2025 NetCE, All rights reserved.

SW18B • Social Workers

Expiration Date: 04/30/2021

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.

97662 • Online Professionalism and Ethics

Alice Yick Flanagan, PhD, MSW

www.netce.com

Copyright © 2018 NetCE, All rights reserved.

Internet technology has become an integral part of American life, and it is crucial for practitioners to determine how technology impacts their professional lives. The course will review the different forms of Internet technologies that are commonly employed in both the professional and personal arenas and how these various online vehicles can have both positive and negative influences on professionalism and clinical practice. The concept of professionalism and how practitioners' online identity can impact boundaries, self-disclosure, privacy/confidentiality, and client/practitioner relationships will be reviewed.

Table of Contents

97662 • Online Professionalism and Ethics

Course Overview

Audience

Course Objective

Learning Objectives

Faculty

Faculty Disclosure

Division Planners

Division Planners Disclosure

About the Sponsor

Disclosure Statement

1. INTRODUCTION

2. INTERNET AND DIGITAL TECHNOLOGY TRENDS

SOCIAL NETWORKING

3. REVIEW OF INTERNET COMMUNICATION TOOLS

ELECTRONIC MAIL (E-MAIL)

CHATROOMS

BLOGS OR MICROBLOGS

INSTANT AND TEXT OR PHOTO MESSAGING

SOCIAL NETWORKING WEBSITES

PHOTO OR VIDEO SHARING

WIKIS

4. USES OF INTERNET TOOLS IN CLINICAL PRACTICE

5. OVERVIEW OF PROFESSIONALISM AND ETHICS

DEFINING PROFESSIONALISM

ETHICS AND CODES OF ETHICS

6. INTERNET TECHNOLOGIES AND PROFESSIONALISM AND ETHICS

SOCIAL NETWORKING SITES

E-MAIL DISTRIBUTION LISTS

CELL PHONES

BLOGS AND ONLINE DISCUSSION GROUPS

7. ONLINE SELF-DISCLOSURES

8. ONLINE SEARCHES FOR INFORMATION ON PATIENTS OR CLIENTS

9. BEST PRACTICE GUIDELINES

USE PRIVACY FILTERS

POST CAUTIOUSLY

THE "FRIEND" DILEMMA

SEARCH WISELY

SOCIAL MEDIA AND TECHNOLOGY IN INFORMED CONSENT

10. CONCLUSION

Works Cited

97662 • Online Professionalism and Ethics

Education Category. Ethics - Human Rights

Release Date. 05/01/2018

Expiration Date. 04/30/2021

Course Overview

Internet technology has become an integral part of American life, and it is crucial for practitioners to determine how technology impacts their professional lives. The course will review the different forms of Internet technologies that are commonly employed in both the professional and personal arenas and how these various online vehicles can have both positive and negative influences on professionalism and clinical practice. The concept of professionalism and how practitioners' online identity can impact boundaries, self-disclosure, privacy/confidentiality, and client/practitioner relationships will be reviewed.

Audience

This course is designed for physicians, nurses, social workers, psychologists, therapists, and mental health counselors who wish to increase their knowledge of how their online presence can affect their professional practice in terms of professionalism, ethics, and professional identity.

Course Objective

As Internet technologies increasingly become ingrained in our professional and personal lives, the issues of professionalism and ethics should be considered carefully. The purpose of this course is to increase practitioners' level of awareness and knowledge of how Internet tools impact professionalism and ethics in clinical practice.

Learning Objectives

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

1. Define Internet usage patterns and common Internet technologies.

2. Analyze how various Internet technologies are utilized in clinical practice.

3. Define professionalism.

4. Evaluate how the use of specific Internet technologies can affect professionalism and ethics.

5. Discuss how the use of Internet technologies can impact issues of boundaries, self-disclosure, privacy/confidentiality, and professional relationships.

6. Identify best practices for using Internet technologies as a clinical practitioner.

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 V. Jurica, MD, MPH

Jane C. Norman, RN, MSN, CNE, PhD

James Trent, PhD

Division Planners Disclosure

The division planners have 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.

1. INTRODUCTION

Professionals are increasingly entering the digital world to network both socially and professionally. Internet technology can be a powerful tool when job searching and developing and expanding professional networks; however, it is important for individuals to use discretion and judgment in the types of information they post, as the casual and informal nature of social networking sites can make it easy to inadvertently cross professional boundaries. The term "digital footprint" has been used to refer to the digital content and evidence left behind as a result of posting on discussion boards, social networking sites, blogs, and other Internet platforms [1]. These digital footprints can affect how the public, colleagues, supervisors, and employers will perceive an individual in the future. In fact, it is becoming increasingly commonplace for individuals to search online for information about another individual, particularly for professional reasons. For example, 19% of online adults in one study had searched the Internet for information about an individual with whom they had a professional relationship [1]. Some universities and colleges will look up their applicants on social media as part of the admission process [7]. What might a photo of an applicant partying, drinking, or using substances convey to the admissions panel?

One of the hallmarks of curricula in graduate professional degree programs is to socialize novice professionals about the profession's identity, ethical practice within the field, and sense of professionalism. However, with the advent of technology and the era of online venues, the notion of professional identity and boundaries can become blurred. A review found that 63% of employers decided to reject potential employees after finding inappropriate or unprofessional content in their profiles on social networking sites [2]. A nurse in Sweden was dismissed after she posted a photo of herself holding a piece of flesh during a brain operation [3].

In professions such as medicine, psychology, social work, mental health counseling, family therapy, and nursing, unprofessional online identities can have negative repercussions for both the client and practitioner. In addition, practitioners searching for information about clients on the Internet can result in damaged relationships and impact care. The Internet can be a powerful tool, but it is important to consider how appropriate it is to access information about a client who has not disclosed the information within the therapeutic setting. For example, what is the practitioner's ethical obligation if a client posts depressive thoughts that might be indicative of suicidal risk on a social networking site [5]? In one scenario, a clinician conducted an Internet search of a young client because the grandfather refused to elaborate about the trauma experienced as a result of the client's parents' plane crash [4]. When the clinician utilized the information during the search in the therapeutic process, the grandfather terminated the sessions. The grandfather perceived this as a violation of privacy, and ultimately the working alliance was adversely affected. Even something as seemingly innocuous as sending out an e-mail correspondence from an Internet hotspot or public terminal to a client or a clinical supervisor with the client's name could potentially violate issues of privacy [6].

The goal of this course is to raise awareness and build the knowledge base of psychologists, social workers, mental health counselors, family therapists, physicians, and nurses regarding the impact of Internet technology on professionalism and ethics [14]. Technology has become an integral part of the American lifestyle, and it is crucial for practitioners to determine how it impacts their professional lives.

2. INTERNET AND DIGITAL TECHNOLOGY TRENDS

In order to understand the pervasive social, psychologic, and cultural impact of the Internet on the lives of individuals, it is important to obtain a brief glimpse of Internet and digital technology usage and consumption. In 2015 in the United States, it was estimated that 78% of households had Internet access [65]. In a 2018 study conducted by the Pew Research Center with adults 18 years of age and older, 89% reported Internet use, compared with 52% in 2000 and 76% in 2010 [8]. Individuals 18 to 29 years of age are the most likely to utilize the Internet (98%), while adults 65 years of age and older are the least likely (66%) [8]. There is no doubt that Internet technology has become a ubiquitous part of the American landscape. Although data published in the last several years is among the most current, the Internet landscape changes so rapidly that obtaining accurate data is nearly impossible.

SOCIAL NETWORKING

A huge number of individuals are using online social networking sites like Facebook and Google+. As of 2010, the average American spends 6 hours and 35 minutes on blogs and social networking sites every month [9]. As of 2018, an estimated 68% of Americans 18 years of age and older used Facebook, 35% had an Instagram profile, 29% used Pinterest, 27% use Snapchat, 25% reported using LinkedIn, and 24% used Twitter [76]. Women and girls tend to use Facebook at a slightly higher rate than men and boys [76].

The general belief is that social networking users are adolescents and young adults. While the percentage of adolescents and young adults using online social networking sites like Facebook and Google+ is higher compared to older adults, this is beginning to change. In 2018, 41% of adults 65 years of age and older used Facebook [76]. Older adults report using social networking technology to connect with people by sharing photos, personal news and updates, and links.

3. REVIEW OF INTERNET COMMUNICATION TOOLS

Before discussing how Internet technologies may impact professional ethics and conduct, it is important to have a clear understanding of the tools and terminology used. Each of the following applications presents unique benefits and challenges.

ELECTRONIC MAIL (E-MAIL)

E-mail is a form of electronic communication that involves sending messages over the Internet. It is one of the most commonly used Internet applications. It allows for the delivery of a message to another person or to a group of individuals rapidly, conveniently, and without incurring any per message charges (as with text messaging) [12].

CHATROOMS

A chatroom or chat group is a virtual community or venue in which a group of individuals can "dialogue" and share information about a common interest asynchronously (non-real time) or synchronously (real time). Chatrooms are often organized by specific topics or interests, such as a hobby, an illness, mental health disorders, or personal interests. For example, it is possible to find an online chatroom devoted to the discussion of depression.

BLOGS OR MICROBLOGS

Blogs are analogous to a website journal and generally consist of a log of entries displayed in chronologic order. Entries might include commentary, information about events, graphics, or videos posted by an individual or group. Blogs have become relatively popular and may be attractive to many partly because they require little technical expertise, are inexpensive, allow users to archive and refer back to previous entries, and facilitate connections with others, who may read and comment on entries [13]. There are many free services to develop and search for blogs, including Blogger, Google, Tumblr, WordPress, Wix, Weebly, Blogspot, SquareSpace, and LiveJournal [77]. Microblogging is similar to blogging, but with a limit on the number of characters that may be used. Twitter, for example, is limited to 140 characters [5]. According to Nielsen, women are more likely than men to blog, and one in three bloggers is a mother [10]. As of 2015, the top three blogging sites are Blogger, WordPress, and Tumblr [10].

INSTANT AND TEXT OR PHOTO MESSAGING

Instant messaging and text messaging are forms of synchronous communication whereby individuals communicate through text and/or photos using computers, cellular phones, or other devices. Text messaging has become one of the most popular forms of electronic communication, especially among adolescents and young adults. More than three-quarters of adults own a smartphone as of 2016 [78]. In a 2014 survey conducted by the Pew Research Center, 78% of cell phone owners in emerging countries use their phone for texting [58]. In 2015, among adolescents 13 to 17 years of age, the median number of texts sent in a typical day was 30 [79].

Applications that allow users to send photos or videos (usually modified with text and/or drawings) have also gained popularity since 2010. One popular example of this platform is Snapchat, which allows users to send images or videos and limit the amount of time they are available; after the set time, the file can no longer be accessed. Teens are also likely to use apps such as Snapchat to send messages to friends (in lieu of or in addition to texting). Among cell phone owners 18 to 24 years of age, 78% were using this application as of 2018 [76].

SOCIAL NETWORKING WEBSITES

Social networking is a form of online communication that is comprised of "web-based services that allow individuals to construct a public or semi-public profile within a bounded system, articulate a list of other users with whom they share a connection, and view and traverse their list of connections and those made by others within the system" [15]. Examples of social networking sites include YouTube, Facebook, Google+, LinkedIn, VK, Pinterest, Twitter, Instagram, Snapchat, Tumblr, and WhatsApp. Almost three-quarters of Internet users use two or more social media sites [76].

PHOTO OR VIDEO SHARING

Posting original photos and videos online is a common Internet activity, and there are a variety of ways that users may upload their images online. Most social media users include personal photos and videos on their online profiles; it is estimated that half of all persons using the Internet post original photos online [76]. A variety of photo- and video-based applications have been adopted by users, including Instagram, YouTube, and Flickr.

WIKIS

Wikis, derived from the Hawaiian word for quick, are collaborative websites on which anyone with access can add, revise, or remove the content published [16]. The most popular wiki is Wikipedia, which is similar to a collaborative encyclopedia, but there are many specific wikis focusing on a single topic, such as suicide prevention or a video game. Often, access is not restricted, but in some cases, editing may be password restricted [16]. Wikis have grown tremendously popular, as they can be a vehicle to quickly access and share information [17]. Wikis have been developed in healthcare communities to promote continuing education and professional development [16].

4. USES OF INTERNET TOOLS IN CLINICAL PRACTICE

In addition to affecting personal life, recreation, and the dissemination of information, Internet technologies have also impacted the provision of health and mental health care. E-mail is one of the most commonly utilized web-based interventions in clinical practice [18]. E-mail-based counseling consists of asynchronous interactions between a counselor and client using text-based communications sent electronically. E-mail communications allow the client to provide brief narratives, and the counselor can structure the communication for exploration of the described symptoms with a problem-solving focus [19]. Some practitioners will use e-mail as a mechanism to provide support. The premise is that the opportunity to interact with another individual, even in writing, can help to mitigate maladaptive responses to stressors [20]. This may be the most useful for clients who cannot easily see a practitioner due to transportation issues or residing in remote areas. In addition, e-mail counseling or any type of counseling involving text-based communication may be cathartic for the client and allow him or her to control how much information to disclose and when to disclose it [80].

In one study of abuse survivor care, nurse practitioners reported that e-mail technology allowed for immediate referrals, education, support, information, and guidance, improving their practice and level of care [20]. E-mails have also been used as a supplement for supervision, and they can serve as a journal of thoughts and questions between an intern and a supervisor to stimulate reflection [21]. Due to the convenience of e-mails and the ability to aggregate lists of e-mail addresses (e-mail distribution lists), forming groups in which participants interact through e-mail has proliferated [12]. A single individual can physically set-up distribution lists and send mass e-mails, or the distribution of the e-mails can be moderated through special software. E-mail software application systems are available to handle the task of subscribing or unsubscribing persons from the e-mail distribution list (LISTSERV) [12]. Such applications are often developed for the purpose of disseminating information or providing support for a specific issue [22]. They can be particularly helpful in keeping practitioners abreast of current information and connected with colleagues. These distribution lists may also be beneficial for training and continuing professional development [23]. In a study conducted by Cook and Doyle about the motivations of using e-mail-based counseling, many of the participants indicated that they preferred it to face-to-face counseling because it was less embarrassing and they had the ability to read and reread e-mails and reflect on the counseling sessions [59].

Online chatting, texting, and instant messaging refers to the exchange of brief written messages in quasi-real time (i.e., quasi-synchronously) between two phones or computers [80]. Common platforms for online counseling may include MSN, WhatsApp, SMS, or IMessage [81]. While online chatting is slower than talking, clients appear to disclose the problem more quickly, which may be attributable to characteristics of chatting that promote disinhibition [82]. In a qualitative study examining counselor/client e-mails and online chats, clients tended to get to the point of the problem more quickly in chats, while in e-mail counseling, clients wrote longer narratives with greater detail [82]. In e-mail counseling, there was more interactional space, while in online chat, there was more real-time interaction.

Chatrooms or discussion groups may be established to address specific topics or interests (e.g., surviving cancer, coping with depression). Ideally, these websites will have experienced practitioners acting as facilitators who may observe and guide the "conversations" [24,25]. Benefits of discussion groups include lasting documentation of discussions (in the form of archived transcripts), the creation of a supportive environment, and a minimization of isolation. In a study of a real-time chatroom offering peer counseling on a variety of emotional issues, the online peer counseling was found to be person-centered [60]. The youths who participated were satisfied with their counselor's ability to provide support. However, the counselors had difficulty providing solutions and assisting participants to think critically and generate solutions.

Blogs have traditionally been used in clinical practice in one of two ways [26]. First, they may be used as an online journal of life events, feelings or emotions, and personal views or belief systems. A community of readers and fellow bloggers may comment and share their life experiences with each other. These responses can be empathic and sincere, giving the blogger a sense of community, understanding, and support. In this way, the blog can act as a record of symptoms and triggers and also as a support group of sorts. Second, blogs may be used by professionals to discuss a particular topic, with readers or other bloggers providing recommendations and feedback [26]. In a 2005 study, researchers found that half of all evaluated blog posts were written with the purpose of self-help or self-therapy [27]. Third, blogs may be used as a form of social justice activism, encouraging people into social action and change [83].

A 2010 study analyzing 951 blogs related to health during a two-year period found that women wrote more than half of blogs, and almost half of the blogs were written by those in the health professions [28]. Typically, the blogs included links, archives, and comments sections, and most of the topics revolved around mental health. For example, more than one-quarter focused on autism, while another quarter concentrated on bipolar disorders. The blogs were informational but also contained personal experiences. They obtain support and help patients and caregivers cope. However, it could also be a cathartic mechanism for health professionals dealing with workplace stress to share challenges experienced in the healthcare sector.

Social networking sites are being used in the health and mental health fields to build and connect members within a community. These sites often collect information about their members by having them create profiles. Members then connect with each other based on information from their profiles [29].

Because social support is an essential factor in helping people cope with medical conditions, social networking may be an important tool. The U.S. Department of Health and Human Services and the National Suicide Prevention Lifeline partnered with Facebook in an initiative to prevent suicide. As part of this program, if a Facebook user notices that a "friend" posted a suicidal comment or a post that alluded to suicidal intent, the comment could be reported to the National Suicide Prevention Lifeline, with the "friend" then contacted via e-mail or an instant chat [61]. The Italian Service for Online Psychology (SIPO) also employs Facebook as a means to provide free online psychologic consultations [84]. Between November 2011 and June 2014, 284 individuals used Facebook for 30-minute consultations with an SIPO clinician. Depression was the most common reported presenting problem. In this example, Facebook chat offers a convenient and non-stigmatizing way to access mental health assistance, thereby eliminating barriers to access to traditional mental health care [84].

Video technology may be used to facilitate long-distance therapeutic interventions as well as to share repetitive therapeutic information. Real-time video conferencing, using secure networks or online technology like Skype, Google Hangouts, or FaceTime, can allow practitioners to provide care in underserved areas or to persons who are unable to travel even small distances to receive therapy [81].

Using technology, people can more easily provide both emotional and informational support to each other regardless of geographic or other barriers. One example of a social networking site for patients focusing on health and medical conditions is PatientsLikeMe (https://www.patientslikeme.com). There are also social networking sites specifically developed to allow healthcare professionals to connect with each other and share information. One such example is AllNurses (http://allnurses.com).

5. OVERVIEW OF PROFESSIONALISM AND ETHICS

DEFINING PROFESSIONALISM

As noted, one of the hallmarks of curricula in graduate professional degree programs is to acquaint novice professionals about the profession's identity, ethical practice within the field, and sense of professionalism. Professional identity has been defined as a "frame of reference for carrying out work roles, making significant decisions, and developing as a professional" [30]. The developmental process of a practitioner's professional identity is a continual process involving attitudinal, behavioral, and structural changes that result in an understanding and acceptance of what is involved in being a professional. The development of a practitioner's professional identity begins in graduate school, and the process continues to affect future professional behaviors [30]. This dynamic process includes teaching knowledge, development of a professional identity, and socialization into the group or profession's norms and values [62].

To be even more exact, it is important to have a clear definition of what constitutes a profession. A profession is defined as involving, "the application of general principles to specific problems, and it is a feature of modern societies that such general principles are abundant and growing" [31]. Professions are characterized by two major dimensions: the substantive field of knowledge that the specialist professes to command, and the technique of production or application of knowledge over which the specialist claims mastery [31]. Therefore, professionals have or claim to have knowledge and apply this knowledge to specific problems.

Professionalism is defined as a set of norms endorsed by a collective community and is characterized by "a personal high standard of competence," including "the means by which a person promotes or maintains the image" of a profession [32]. Professionalism involves a set of qualities, including not only knowledge and clinical skills but commitment, integrity, altruism, individual responsibility, compassion, and accountability [33]. In health care, professionalism often involves employing and applying a unique set of clinical skills and scientific knowledge base [85]. In the helping professions, professionalism is designed to promote patient/client autonomy, protect the public, improve access to care, distribute constrained resources in a just and equitable manner, and ensure professional accountability to the public [34,35].

In the past, and to some degree today, professional organizations defined specific behaviors and characteristics that conformed to the standards of a particular profession. Consequently, many graduate programs selected and screened students determined to be the "right kind" of person, one who met a set list of characteristics and behaviors that conformed to the standards of competence, ethics, and professionalism within the field [36]. In addition, there are codes of conduct to regulate behavior and supervisory processes to ensure appropriate use of autonomy [86]. Therefore, many argue that merely compiling a list of behaviors and characteristics does not allow for the fact that professionalism is field- and context-independent. The standards of professionalism, ethics, and competence are influenced by a range of external factors, such as the social, political, economic, and cultural goals of the professional institutions and organizations, social norms, and the experiences of clients/patients and their families [36]. There are also factors in the presentation of professionalism that can be more easily controlled. First impressions can be extremely influential in how a professional is perceived [37]. Professional appearance (e.g., clothing, hygiene, presentation) and behavior (e.g., language use, nonverbal cues, etiquette) are vital components of a positive first impression [37,85]. Ultimately, professionalism forms the foundation of trust between the client/patient and practitioner [63].

ETHICS AND CODES OF ETHICS

It is not possible to talk about professionalism without a discussion of ethics. The code of ethics in a profession has been said to be the "hallmark of professionalism" [64]. Codes of ethics provide guidance to the public and professionals regarding the responsibilities of professionals. They also serve as vehicles for accountability in the profession and as a means for practitioners to self-monitor and enhance practice [87].

Ethics are beliefs about what constitutes correct or proper behavior, the principles of right conduct and how to live as a good person [38]. Ethical principles are statements that reflect one's obligations or duties [39]. General ethical principles common to the helping profession include [39]:

- Autonomy: An individual's right to make his or her own decisions

- Beneficence: The duty to do good

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

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

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

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

- Nonmaleficence: The duty to cause no harm

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

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

- Reparation: The duty to make up for a wrong

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

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

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

- Veracity: The duty to tell the truth

Based on these ethical principles, professions develop ethical codes that embody the values of the profession and guide behaviors of members. In an analysis of the codes of ethics of diverse professions, researchers were able to classify the codes into four domains [40]:

- The professional's qualities and characteristics

- Behaviors toward other professionals and colleagues

- Behaviors of professionals in a range of situations

- The responsibility of the profession and the professional to society and the common good

Although ethics and professionalism are different, there is considerable overlap. Acting professionally entails adhering to accepted codes of conduct and ethics within a given field, and acting in an ethical manner in online interactions is a good first step in ensuring online professionalism.

The International Society for Mental Health Online (ISMHO), established in 1997, formulated the Suggested Principles for the Online Provision of Mental Health Services in 2000 [88]. Many professional organizations have attempted to keep abreast advances in digital technology and its impact, and many have begun to revise their ethical standards to reflect the ubiquitous nature of technology in modern society. The American Counseling Association (ACA) added an addendum to their code of ethics in 1999 and, in 2005, finalized comprehensive guidelines for Internet counseling [88]. In the field of psychology, Guidelines for the Practice of Technology were developed by the American Psychological Association (APA), the Association of State and Provincial Psychology Boards, and the APA Insurance Trust [89]. In 2017, the National Association of Social Workers (NASW) Delegate Assembly approved updates to the NASW Code of Ethics, including new guidance regarding the role of technology in informed consent, privacy, confidentiality, competency, supervision, and client records [90]. In addition, in 2017 the NASW, in conjunction with the Association of Social Work Boards, the Council on Social Work Education, and the Clinical Social Work Association, published specific guidance in its publication Standards on Technology and Social Work Practice [91]. The American Nurses Association and the American Medical Association have developed opinion statements and toolkits for the appropriate use of technologies such as social media in their respective professions [92,93].

6. INTERNET TECHNOLOGIES AND PROFESSIONALISM AND ETHICS

Internet technologies can be powerful tools when job-searching, developing and growing professional networks, and providing support to clients. As a result, e-professionalism, or professionalism in the Internet world, should be instilled in practitioners [3,94]. Some maintain that e-professionalism, the application of ethics online, and digital literacy should be essential components of the knowledge and skill of practitioners [83]. It is important, for example, to use discretion and judgment in the types of information made public online. The casual and informal nature of social networking sites, for example, can cause practitioners to inadvertently cross professional boundaries, which can negatively affect their professional identity and may breach ethical standards. If practitioners discuss work-related problems (e.g., difficult clients, conflicts with colleagues) on social media, it could disclose confidential information or qualify as abuse [95]. Not everyone considers how the image or persona portrayed online may be perceived in the future. Because the Internet can be a public forum, viewers do not necessarily avoid viewing personal, intimate, and/or embarrassing behaviors [41]. The issue may not be the ever-growing presence of Internet communications, but rather the seeming mindlessness or carelessness with which information is shared; this has been referred to as the diminishing of intentionality of online communication [42]. Practitioners may adhere to strict guidelines for self-disclosure in "real" life, but the Internet may defy practitioners' best intentions. Some have likened the Internet to a clinical practice in a rural area, where practitioners inevitably have unplanned encounters with their clients/patients due to the size of the community [42]. In some cases, individuals may inaccurately believe that the privacy settings will ensure confidentiality [95]. With the Internet, practitioners have minimal control over when and how clients encounter information about them online [42]. The Internet has no expiration date, and anything posted online should be assumed to be permanent [66]. Unfortunately, many codes of ethics in fields such as medicine, psychology, social work, nursing, and counseling have struggled to keep up with these technologic changes [41]. In some cases, standards have been established for the provision of technology-assisted services (such as online counseling), but not for online professional conduct [43].

SOCIAL NETWORKING SITES

The use of social networking platforms can affect professional relationships and boundaries. In a 2013 survey of psychologists, social workers, and physicians, 59% of the practitioners indicated they maintained a Facebook account and 75% of users reported using a privacy setting [67]. Similarly, in a survey study with 695 psychology students and psychologists, 77% indicated they had an account on a social networking site, and of these users, 85% used privacy settings [42]. In a 2018 study with nursing students, 96.6% reported having a Facebook account [96]. However, practitioners were ambivalent about what to do when clients contacted them through a social networking site. It may appear to be an innocuous request, but it can bring up many ethical issues. If the practitioner accepts the client as a friend, the client may have access to personal information, blurring professional boundaries. If the practitioner does not accept the request, the client might misconstrue this as rejection, potentially harming the therapeutic relationship.

Similar issues may arise if information about a client is gleaned from a social networking site. In a study of 302 graduate psychology students, 27% had reported actively seeking out client information on the Internet; most stated they wanted to verify the clients' claims [41]. In a study with 346 undergraduates, participants were asked to evaluate their likelihood of posting different types of "problematic" information in their Facebook profiles and their perceptions of how others would view their image after seeing their profiles [44]. Gender differences were found; specifically, undergraduate men were more likely to report that their Facebook profile contained an image that was sexually appealing, wild, or offensive. Men were also more likely to post "problematic" content in their profiles compared to their female counterparts. In a qualitative study of 813 medical students and residents, 44% were found to have an account and only 33% of these profiles were made private [45]. Of the profiles that were not private, the researchers found that more than half included overt mentions of personal and/or ideologic views, such as political affiliation (50%), sexual orientation (52%), and relationship status (58%). In some cases, the medical students and residents had uploaded photos that could be interpreted negatively (e.g., photos with alcohol, excess drinking, drug use). In the study of graduate psychology students, 81% confirmed having some sort of online profile, with 37% reporting having a social networking page [46]. Of the students who used social networking, more than 65% used their real names and 13% stated they posted photos they would not want their faculty members to see. Nearly 30% stated they posted photos they would not want their clients to see, and 37% posted information they would not want to their clients to read. A study of first-year nursing students, participants reported ambivalence regarding patients seeing their posts in Facebook, perhaps because they lack clinical experiences [96]. In a content analysis of Facebook profiles of nurses in the United Kingdom and Italy, the researcher looked at photos posted and classified them according to the content [68]. Approximately 18.5% of the profiles included photos of the nurse engaged in unhealthy behavior, including smoking and drinking alcohol [68]. The representations of professionals' behaviors on social networking sites could inadvertently have a negative effect on the integrity of the profession [69].

Therapeutic boundaries are established to promote client beneficence and define the client/practitioner relationship. Informed consent, single-role relationship, and confidentiality support these boundaries [70]. The boundaries of the client-practitioner relationship will get blurred as online friendship interactions can lead to sharing of private information on the part of both parties, which may negatively impact the professional relationship [47]. If practitioners find sensitive or embarrassing information about clients, they may be conflicted regarding the appropriate way to use this information. For example, a practitioner may be working with a client on abstaining alcohol, and in the session, the client denies having used alcohol in the past 24 hours. However, if the client and practitioner are linked on a social networking site, the practitioner may stumble onto a photo of the client at a party holding a beer bottle. There is no clear correct course of action. Should the practitioner utilize this information in the next clinical session? If the practitioner does bring it up, does it violate privacy issues? Will it affect the clinical rapport and relationship?

In some cases, social media profiles have been used by law enforcement or social service providers to guide their interactions with clients. For example, there have been reports of social workers "friending" a youth in foster care in order to keep track of them, using a client's social media post to demonstrate his/her lack of progress or faulty character, or using an online profile picture to search for someone [94].

A good first step is to consider the ethical ramifications of each action utilizing the ethical principles identified in many of the professional codes of ethics [41]:

- Beneficence (the duty to do good): How would the information obtained from a social networking site promote the well-being and welfare of the client?

- Fidelity (the duty to keep one's promises): How would the information gleaned about a client on a social networking site help promote trust?

- Nonmaleficence (the duty to do no harm): What harm might emerge from using social networking sites to find information about the client? How might this unintentionally harm the client?

- Autonomy (the individual's right to make his or her own decisions): How does the information found on a social networking site help to promote the client's ability to make his or her own choices about what to share or not in the clinical sessions? Will seeking information on the Internet without the client's consent violate autonomy and respect for the client?

- Justice (the duty to treat everyone fairly): How will the practitioner's being able to find information (or not) on a social networking site provide clues to the client's gender, race, sexual orientation, socioeconomic status, religion, ability, etc.? How might this information affect how the practitioner treats the client?

The same questions can be asked when practitioners use social networking sites to create profiles and post information. How might this information harm the client or jeopardize trust, credibility, and the working the relationship? If a practitioner is a supervisor, what issues of subtle coercion may arise [5]? Of course, each practitioner's behavior on social networking sites must be in accordance with the profession's ethical codes. Befriending a client or patient on a social networking site could potentially violate standards regarding multiple relationships or dual relationships [48].

Practitioners should use their self-reflective skills to ask themselves the following questions in order to guide the information they post on social networking sites [71,95]:

- What information do you want to share? Is this information important, harmful, protected?

- Why do you want to share this information? What are the benefits and consequences of sharing the information?

- Who needs to see this information? Why?

- Where do I want to share this information?

- What professional boundary issues might "friending" someone pose?

- How might any "off-duty" conduct be perceived?

- How might a photo or post be taken out of context?

- How does my professional code of ethics or other organizational policies guide sharing this information?

E-MAIL DISTRIBUTION LISTS

The main ethical issues associated with e-mail distribution lists concern risks to confidentiality and privacy. Mass e-mail communications can be intercepted at four different points: prior to being e-mailed from the originating computer, during transmission, upon receipt, and when subpoenaed [24]. In one study, 10% of social workers reported having e-mailed something to the wrong person [97]. Some practitioners may utilize this technology to solicit professional consultation from their colleagues. If this is the case, they may describe a case in detail. Even if the client's name and specific identifying information are excluded, the details provided could increase the risk to violating confidentiality. This risk is further increased with the advent of data mining software, which can analyze and search e-mails for certain content or key words [23].

In addition, there is no insurance that the sender or receiver is the person whom they claim to be. A best practice to reduce these risks is to encrypt the e-mail, to alert the client that an e-mail will be sent, or to ask for a phone confirmation that the e-mail has been received [97].

One of the main applications of the ethical principle of respect for persons is informed consent. When seeking consultation from another colleague on the phone or face-to-face, practitioners obtain informed consent from their clients; the same is true when using e-mail distribution lists for this purpose. Practitioners should inform clients they plan to use e-mail for the purpose of consultation and that certain details of the case will be provided. The potential for violations of privacy and confidentiality using this technology should be outlined [23].

CELL PHONES

Cell phones and smartphones are commonplace, and it is important to carefully consider the possible benefits and consequences before providing a personal cell phone number to a patient or client. First, conversations on cell phones cannot be guaranteed confidentiality, as it possible that the conversation will be intercepted by another device (e.g., baby monitor) [70]. Perhaps more importantly, cell phones can imply some level of personal familiarity that goes beyond the client/practitioner relationship [70]. Finally, giving a cell phone number may imply that the practitioner will be available at any time, including after professional hours. To create boundaries, practitioners may inform the client that messages will only be checked during work hours [97].

It is important to be upfront with clients regarding the use of a cell phone in order to clarify the policies and to obtain informed consent form [70]. Practitioners should explicitly discuss the circumstances under which a client may call the practitioner on his/her cell phone, when he/she would not be available, any additional fees involved, and the amount of time he/she will spend on the cell phone with the client.

BLOGS AND ONLINE DISCUSSION GROUPS

Concerns about privacy and confidentiality also apply to blogs and online discussions. Practitioners who write or comment on blogs must be sensitive to revealing personal identifiers of clients, which could violate practitioner/client confidentiality and privacy. Practitioners in the health fields should keep the Health Insurance Portability and Accountability Act (HIPAA) in the forefront of their minds when blogging or posting in online discussion groups. HIPAA privacy rules protect any identifiable health data, including any past, present, or future health information that can be used to identify an individual [49]. For example, a practitioner might blog about a difficult client who was treated at his or her workplace at a particular time and date [50]. Even if the client's name is not provided in the blog, if the blog author is not anonymous, it is possible that the workplace could be traced and the identity of the client linked back to the appointment book. Or a practitioner could post a message to his or her friends on a discussion board describing clinical experiences, but in doing so, express enough information about a client to be identifiable [49,72]. It is also important to be careful of how clients or patients are depicted, including the tone and content of postings, so as not to threaten or damage the integrity of the professional field or discipline [51].

Conflict of interest is another ethical issue that may arise when using blogs or discussion boards. A practitioner should be cautious of openly endorsing any products or services. Some blogging software platforms, particularly free ones, automatically display advertisements along with the platform. It is vital to avoid dual relationships or have the appearance of having a conflict of interest with service providers. Some experts recommend limiting blog content to announcements about conferences, events, and professional organizations that represent the practitioner's field [26].

In a 2008 study involving 271 medical blogs, individual patients were described in 42% of the blogs, and 16.6% of these had sufficient identifiers, revealing the identity of physicians or patients [51]. The researchers found that 17.7% of the blogs depicted patients in a negative manner (by tone or content), and 11.4% contained product promotions, either by images or direct content. There is a definite need for practitioners to practice self-regulation and self-monitoring, carefully considering ethics and professionalism while blogging, so the ethical principles of respect for persons and beneficence are not compromised.

7. ONLINE SELF-DISCLOSURES

Much of science and medicine in Western culture is premised on the tenets of logical positivism, advocating for quantification and objectivity [52]. The psychology, counseling, mental health, and social work fields have followed suit, and as a result, paternalism has become the backbone of the patient/client and practitioner relationship. For example, the physician/patient relationship is typically characterized as hierarchical, with the physician viewed as the "expert." Many counseling and social work models, with the exception of feminist and humanistic orientations, similarly espouse this hierarchical relationship. Traditionally, practitioners are positioned as the "objective" experts, disclosing very little about themselves. However, the extent to which practitioners self-disclose has changed with the growth of the Internet. With the prevalent use of Internet technologies, the client/patient is now an active consumer of health and mental health services, and they are more likely to use the Internet to research or share information about practitioners, services, and facilities [53]. Therefore, the question is not to what extent practitioners should disclose private information to their clients, but rather how to manage the Internet-driven self-disclosure that has become almost inevitable [54]. It is ultimately the practitioner's responsibility to develop the tone of the professional relationship [66]. Therefore, when disclosing information on social networking sites, the practitioner should take time to reflect on how it may affect the client and the therapeutic relationship.

There are three main types of self-disclosures, and the Internet can affect each of these types [53]:

- Deliberate self-disclosure: The practitioner intentionally discloses certain information, verbally or nonverbally. Internet examples include uploading a photo on LinkedIn, a professional social networking site, or posting information on a commercial website about one's professional background, training, and experiences.

- Accidental self-disclosure: Personal information about the practitioner is inadvertently revealed to the client. For example, a client sees his or her therapist at a boutique, which may reveal information that the practitioner had no plan of sharing. On the Internet, accidental self-disclosures can occur when clients inadvertently come across photographs of their practitioner in a non-professional setting or personal blog posts on a social networking site.

- Unavoidable self-disclosure: These types of revelations are not deliberate but are related to information conveyed by conducting the normal affairs of life. For example, wearing a wedding ring indicates one's marital status. Of course, one can argue whether this is deliberate or unavoidable. Again, photos uploaded on a website or a professional social networking account can reveal information that the practitioner has no control over.

The most typical disclosures via Facebook profiles are of one's age, gender, education, and relationship status [98]. In the past, if a client asked about a practitioner's background, this could be used as an opportunity to understand the underlying dynamics of the client's interest. Ultimately, practitioners must be diligent in managing their images in both the face-to-face and Internet worlds. Issues of self-disclosure and transparency have moved outside the therapeutic encounter and onto the Internet, and online posts, blogs, threads in discussion forums, and mass e-mails will for the most part stay "alive" in the virtual world [54].

8. ONLINE SEARCHES FOR INFORMATION ON PATIENTS OR CLIENTS

Conducting online searches, commonly referred to as "Googling," is a common part of modern Internet use. Some practitioners engage in patient-targeted Googling, searching for a specific patient or client on the Internet [73]. In a 2014 study involving counseling graduate students, 75% reported using the Internet to search for information about a client, with 29.2% using Google and 19.5% using a social networking site. Of those who searched, more than 80% stated that they did not obtain informed consent from the client, did not document the search in the client's file, and did not consider this to be a confidentiality issue [73]. In a 2016 survey study, 39.4% of psychotherapists reported having looked online for additional information about their clients; 75% had not obtained client consent to do an online search [99].

There are cases in which patient-targeted Googling may have yielded fruitful clinical outcomes, such as locating family members of a patient with dementia after all other venues have been exhausted [73]. Searching online to obtain information about an individual's home has become a common Internet activity, but there may not be a place for such activity in the clinical encounter. It is vital for practitioners to draw a line between voyeurism and a clinical constructive goal [11; 73]. Although the Internet is considered public, for practitioners to make an active decision to search for additional information not given by the client may be a violation of his or her rights [74]. This continues to be an issue when considering what to do with information obtained online. If search results are documented in the client's record, it may impact their future care or insurance coverage [73].

The following questions may be useful when considering searching for client information on the Internet [94]:

- Why do I want to conduct this search?

- How will the information obtained from the search affect engagement and treatment?

- Is an informed consent needed from the client before searching?

9. BEST PRACTICE GUIDELINES

In today's environment of technology and information proliferation, it is important to balance the amount of information available to clients and to carefully consider one's online persona as an extension of one's professional identity [55]. Practitioners must now actively manage their virtual identities and reputations. In order to do so, the following best practice guidelines have been established for practitioners when using Internet technologies for both personal and professional reasons.

USE PRIVACY FILTERS

When using social networking sites and/or blogs, practitioners should use a pseudonym, check their privacy filters, and research the restrictions in place for their online profiles in order to exercise control over who can access the information. Most social networking sites and blog platforms have some kind of privacy filter available, but even when in use, clients may be able to view limited information (e.g., a profile picture). Practitioners should remember that privacy controls are subject to change at the discretion of the social media company [66].

POST CAUTIOUSLY

Practitioners should be cautious regarding posting client/patient information. The Internet has made the world smaller, and it is not difficult to trace the identity of the author of online postings. Furthermore, it is easy to inadvertently post information online that may violate a client's/patient's confidentiality and privacy [5]. Along these same lines, think twice about sharing personal information or photos online. The concept of digital footprints should be at the forefront of practitioners' minds. If any uploaded photos can be professionally compromising, they should not be posted. Consider the underlying message any information might convey [56]. Certainly, photos that could endanger the privacy of clients or violate HIPAA rules should not be uploaded. Carefully weigh the costs and benefits of posting various information [46].

It is also important for practitioners not to use online platforms as mechanisms to vent about professional issues. Venting feelings of frustrations with clients, employers, supervisors, salaries, or an agency/organization are likely to be perceived negatively by colleagues and conveys a message of unprofessionalism [50]. Reflect on how information posted on the Internet could undermine one's professional credibility as well as the legitimacy of the professional field [46].

THE "FRIEND" DILEMMA

As discussed, the issue of dual relationships is at the heart of deciding whether or not to accept patients/clients as "friends" on social networking sites [66]. The risks and the benefits should be weighed. If a patient or client invites a practitioner to be an online "friend," the practitioner can discuss dual relationships and the reasons why this is unprofessional and unethical; this request could become part of the clinical work [46,47]. If the client becomes angry that the practitioner has "rejected" him or her or ignored the invitation, this could be discussed within the context of the client's previous experiences with loss, rejection, and self-esteem [97].

Consider crafting a professional statement about why accepting patients/clients as online friends is inappropriate. If this is an issue affecting your practice, spend time writing a standard statement to send to clients/patients regarding the professional policy not to accept clients as online friends [50]. This statement can be friendly but firm and should indicate the reasons it is not wise to establish this online relationship due to privacy and confidentiality issues. However, clients should be encouraged to discuss any issues with the practitioner during a scheduled session within the context of the therapeutic setting.

SEARCH WISELY

Practitioners should reflect on the underlying motivations for searching for client information on the Internet and how this information could be used positively. Therefore, searching for information about a client or patient is not necessarily unethical. Rather, consider how clients or the therapeutic relationship could ultimately be negatively affected by any information found and how the information can help the client [11,46]. In general, it is best to avoid searching for client information online.

However, practitioners should search for themselves on the Internet. Many professionals believe that everyone experiences some level of privacy through online obscurity, and in general, individuals take the path of least resistance in monitoring their online presence [57]. This can be detrimental and may limit the practitioner's ability to control disclosures. Practitioners should conduct Internet searches regularly to monitor the information available about themselves and to have better control of the content [42]. Furthermore, if clients raise information they found on the Internet in a clinical session, this will prevent practitioners from being caught unaware.

SOCIAL MEDIA AND TECHNOLOGY IN INFORMED CONSENT

The content of informed consent forms should reflect the changing technologic times. The following points should be incorporated into informed consent forms [70,72,75]:

- How cell phones, e-mails, and social media will be used with the patient/client

- Whether the practitioner will search for information about the patient/client on the Internet

- How the practitioner will respond if contact is made by the patient/client on a social media site

- If the practitioner will take cell phone calls and, if so, parameters for use

- Whether there will be additional fees if the client makes contact with the practitioner via phone, e-mail, and/or social networking site

- Whether therapeutic issues will be discussed via e-mail

- If the practitioner does respond via e-mail, expected response turnaround time

- Risks and benefits of clients using social media within the therapeutic context

10. CONCLUSION

The landscape of professional practice has changed with the increasing use of Internet technology by both practitioners and clients/patients. The opportunities that the Internet affords are endless, and practitioners should reflect on how information posted online can have implications on their professional practice and their relationships with clients/patients. The codes of ethics and professional standards may not have necessarily kept up with the technologic changes, and therefore, there may not be clear guidelines on how to behave online. Ultimately, more education is needed for professionals entering the fields to prepare to make the complex ethical decisions they will face using new technologies. Clinical supervisors should initiate conversations with their supervisees regarding how online personas and identities can affect professional identities, credibility, and roles. Finally, psychologists, social workers, counselors, therapists, physicians, and nurses must take an active role in shaping the development of professional standards for the provision of services in the new online environment, conforming to the ethical and professional best practices in their respective fields.

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97823 • Elder Abuse: Cultural Contexts and Implications

Alice Yick Flanagan, PhD, MSW

www.netce.com

Copyright © 2020 NetCE, All rights reserved.

According to the National Center on Elder Abuse, it is estimated that 1 in 10 Americans older than 60 years of age has been the victim of abuse. There are some studies that indicate that women are more likely than men to be victims of elder abuse. Other demographic factors that contribute to risk include unmarried status and non-white ethnic origin. Consequently, practitioners will need to become more culturally aware and sensitive to the cultural norms, belief systems, and needs of culturally diverse patients in order to provide culturally relevant services and interventions for this population. There has been a growing interest in the perceptions of elder abuse among ethnic minority populations. This reflects a recognition that culture, race, and ethnicity can influence what constitutes elder abuse, particularly because definitions of elder abuse reflect a white, middle-class perspective. This course will outline the impact of culture, race, and ethnicity on elder abuse and help seeking patters for abuse and provide tools for identifying and intervening in cases of elder abuse.

Table of Contents

97823 • Elder Abuse: Cultural Contexts and Implications

Course Overview

Audience

Course Objective

Learning Objectives

Faculty

Faculty Disclosure

Division Planners

Division Planners Disclosure

Director of Development and Academic Affairs

Director Disclosure Statement

About the Sponsor

Disclosure Statement

Implicit Bias in Health Care

1. HISTORICAL OVERVIEW

EMERGENCE AND SOCIAL CONSTRUCTION OF FAMILY VIOLENCE

EMERGENCE AND SOCIAL CONSTRUCTION OF ELDER ABUSE

PREVALENCE AND SCOPE OF ELDER ABUSE

SCOPE AND TRENDS OF ELDER ABUSE IN ETHNIC MINORITY COMMUNITIES

2. DEFINITIONS OF ELDER ABUSE AND CONTROVERSIES

CASE STUDIES

GENERAL PROFILE OF ELDER ABUSE VICTIMS

TYPOLOGY OF ABUSERS

CONTROVERSIES IN THEORETICAL CONCEPTUALIZATION

3. CULTURE, RACE, AND ETHNICITY AND ELDER ABUSE

CULTURAL NORMS AND VALUES REGARDING FAMILY AND THE ELDERLY

ROLE OF CULTURE, RACE, AND ETHNICITY IN ELDER ABUSE

4. ASSESSMENTS, INTERVENTIONS, AND MANDATORY REPORTING LAWS FOR ELDER ABUSE

ASSESSING FOR ELDER ABUSE

CULTURALLY SENSITIVE ASSESSMENT: CONSIDERATIONS AND GUIDELINES

INTERVENTIONS FOR ELDER ABUSE

ETHICAL ISSUES

5. RESOURCES FOR PRACTITIONERS WORKING WITH THE ELDERLY AND ABUSE VICTIMS

Works Cited

Evidence-Based Practice Recommendations Citations

97823 • Elder Abuse: Cultural Contexts and Implications

Education Category. Ethics - Human Rights

Release Date. 02/01/2020

Expiration Date. 01/31/2023

Course Overview

According to the National Center on Elder Abuse, it is estimated that 1 in 10 Americans older than 60 years of age has been the victim of abuse. There are some studies that indicate that women are more likely than men to be victims of elder abuse. Other demographic factors that contribute to risk include unmarried status and non-white ethnic origin. Consequently, practitioners will need to become more culturally aware and sensitive to the cultural norms, belief systems, and needs of culturally diverse patients in order to provide culturally relevant services and interventions for this population. There has been a growing interest in the perceptions of elder abuse among ethnic minority populations. This reflects a recognition that culture, race, and ethnicity can influence what constitutes elder abuse, particularly because definitions of elder abuse reflect a white, middle-class perspective. This course will outline the impact of culture, race, and ethnicity on elder abuse and help seeking patters for abuse and provide tools for identifying and intervening in cases of elder abuse.

Audience

This course is targeted to physicians, nurses, social workers, and other allied health professionals who may identify and intervene in cases of elder abuse.

Course Objective

The purpose of this course is to increase the knowledge base of social workers, nurses, physicians and other allied health professionals about elder abuse, assessment, and intervention. This curriculum will focus on abuse against elders in domestic settings perpetrated by family members.

Learning Objectives

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

1. Summarize the historical context and scope of elder abuse.

2. Define elder abuse and the different forms of elder abuse.

3. Identify the general profile of the elder abuse victim.

4. Analyze the different classifications of perpetrators of elder abuse.

5. Discuss the various theoretical models to help explain the causes of elder abuse in domestic settings.

6. Explain how culture, race, and ethnicity color views about family and aging and definitions of and attitudes toward elder abuse and help seeking.

7. Discuss assessments for elder abuse victims.

8. Describe general mandatory laws for and ethical issues associated with elder abuse.

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

Jane C. Norman, RN, MSN, CNE, 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. HISTORICAL OVERVIEW

EMERGENCE AND SOCIAL CONSTRUCTION OF FAMILY VIOLENCE

To understand the emergence of elder abuse as a social problem, it is helpful to examine it within the historical context of family violence. It is often assumed that family violence is a recent phenomenon, perhaps because of the amount of media coverage to which we are exposed. However, it is not a recent development. Infanticide, for example, has been practiced since prehistoric times [1].

Spector and Kitsuse assert that a condition (e.g., family violence) becomes a social problem only when individuals and groups make claims that a condition is problematic and argue that the condition should be eradicated or that it is in need of intervention [2]. Child abuse, for example, came to the public's attention in the 1870s when the abuse of a specific young girl was "discovered." The Society for the Prevention of Cruelty to Animals asserted that this young girl should not be abused because, technically, she is an animal [3]. The focus on child abuse waned until the 1960s when Henry Kemp "rediscovered" child abuse, and his article "The Battered Child Syndrome" legitimized it as a social problem [4,5]. The characteristics of this medical syndrome included traumatic injuries to the heads of young children, typically younger than 3 years of age. It became a serious medical problem warranting medical as well as legislative intervention [4].

Similarly, we tend to associate domestic violence with the 1960s, when the feminist movement brought this issue onto the national stage. However, assaults against women by their husbands or intimate partners were not a new social issue. Dobash and Dobash argue that domestic violence has always existed [6]. As recently as the 1970s, a Pennsylvania town had an ordinance that prohibited a husband from beating his wife after 10 p.m. on Sundays [7].

Until the feminist movement focused on the plight of battered women, minimal empirical attention was given to this condition [8]. In 1981, the first National Day of Unity was observed, and since 1984, Domestic Violence Awareness Week has been observed each October [7]. It is against this backdrop that elder abuse emerged in the 1980s as a recognized social problem.

EMERGENCE AND SOCIAL CONSTRUCTION OF ELDER ABUSE

As a form of family violence, elder abuse has existed for millennia, although it did not gain public attention until fairly recently. Anthropologists have described some cultures and societies that abandoned or killed the elderly during times of structural inequalities and tensions [9]. In cultures predominated by agriculture, the need for laborers and disputes over land inheritance fueled family conflict [10,11]. In general, throughout the ages and certainly today, cultural norms dictate what is considered "productive" during the various cycles of the life span [9].

Burston, a physician, published an article about "granny-bashing" in the British Medical Journal in 1975, which promulgated the notion of elder abuse, and the media then began to use the term, which helped to reinforce the seriousness of the problem [12,20]. By the mid-1980s, the gerontology literature began including works on elder abuse, and in 1980 the House Select Committee on Aging heard testimony about the "social problem" of elder abuse in the United States [13]. Shocking testimony was given about elderly seniors who were beaten, neglected, left in filth, and financially exploited by children, grandchildren, or caregivers [14].

In the United States, the conception of elder abuse was closely linked with the concept of child abuse [20]. The picture of a frail elderly parent dependent upon their adult child caregiver was disseminated, and because there was no statute for elder abuse at that time, lawmakers and service providers turned to the child abuse model with its mandatory reporting laws [15,20]. In 1974, an amendment to the Social Security Act created the Adult Protective Services (APS) [22]. At that time, the purpose of APS was to protect adults with physical and/or mental limitations. However, the APS system became the solution when elder abuse became a public issue, allowing action on the matter without having to call on additional state funds [15]. Consequently, policies and programs were tailored to look like the child abuse and neglect model. For example, both child abuse and elder abuse models require the reporting of incidences of abuse through specific channels, the designation of certain professionals to report if incidences of abuse are learned, and penalties for violations. In both forms of family violence, a third party can intervene if there is suspected child or elder abuse [16].

In 1978, the Older Americans Act was amended to include the responsibility of each state to develop long-term care ombudsman programs to deal with elder abuse in nursing homes [17]. By the 1980s, research tended to focus on elder abuse rather than adult protective services, likely because elder abuse sounded like a more dramatic social problem [105]. In 1987, with the increased public interest in elder abuse, the National Center on Elder Abuse was developed by the federal government to more clearly define elder abuse and neglect as well as to promote awareness and formulate educational programs for elder abuse [17]. By 1991, there were mandatory reporting laws in 42 states; however, a study by the Government Accounting Office found that these laws were not effective in reducing elder abuse [105].

In 2003, Louisiana Senator John Breaux introduced the Elder Justice Act [115]. The title of the Act was meant to support the notion of elder abuse as a human rights issue—the right of all elders to be free from abuse and mistreatment [115]. In March 2010, the Elder Justice Act was passed. The goal of this act is to "provide federal resources to prevent, detect, treat, understand, intervene in, and, where appropriate, prosecute elder abuse, neglect, and exploitation" [18]. As a part of its activities, the Department of Health and Human Services will implement forensic centers to develop elder abuse services, enhance long-term care services by providing more staff training, provide funds to states' Adult Protective Services for more research, detection, and prosecution of cases of elder abuse, and provide funds to long-term care ombudsman programs to respond to elder abuse in care facilities [18]. In 2015, the White House Conference on Aging was held, and elder abuse was identified as one of the four priorities in promoting the well-being of older adults [132].

The interest in elder abuse increased in the 1980s and continues today, partially due to the growth of the elderly population. According to the U.S. Census, in 2016, there were 49.2 million adults who were 65 years or older [184]. By 2060, it is estimated that there will be 94.7 million adults 65 years of age and older in the United States [210]. By 2020, there will be 1.6 billion persons 65 years of age and older worldwide [184]. In the United States, persons 85 years of age and older are projected to number 19.7 million in 2060 [19]. This rapid growth is attributed to the aging of the baby-boomer generation, and the youngest baby boomer will be 96 years of age in 2060 [19]. In addition, life expectancy has continued to increase. It is projected that by 2036, the number of persons 85 years of age and older in the United States will double, with the number tripling by 2049 [211].

Similarly, the ethnic minority elderly population is growing rapidly. By 2030, individuals who identify as racial/ethnic minorities will represent 28% of the U.S. population [21]. Between 2014 and 2030, the white population is expected to increase by 46%, compared with 110% for older racial and ethnic minority populations, including Hispanics (137%), African Americans (90%), American Indian/Native Alaskans (93%), and Asians (104%) [21]. The percentage of older persons who are non-Hispanic white is anticipated to fall from 77% (in 2018) to 55% (in 2060) [212]. These demographic trends have opened the eyes of policy makers and service providers to the needs of the elderly, and the specific needs of minority elderly populations.

Elder abuse remains a largely invisible problem, which is due in part to the fact that the elderly are frequently isolated. Frail elders often do not leave the house, perhaps seen only by a caregiver, allowing their abuse to remain behind closed doors [10]. Also, our society has some misconceptions about this period of life. We generally view the elderly years as "golden," as a period when one retires, travels, and spends time pursuing leisurely activities. Additionally, we believe that the family is a private domain, free from public scrutiny. These factors allow elder abuse to continue to occur in both domestic and institutional settings.

PREVALENCE AND SCOPE OF ELDER ABUSE

In a systematic review that represented 28 different countries, the overall prevalence rates of elder abuse was assessed at 15.7%; 11.6% had experienced psychologic abuse [213]. It is estimated that approximately 1 in 10 Americans older than 60 years of age has been the victim of abuse, including physical abuse, psychologic or verbal abuse, sexual abuse, financial exploitation, and neglect [23,24,214]. According to data from the National Intimate Partner and Sexual Violence Survey (NISVS), 14% of adults 70 years of age and older had experienced some form of abuse in the past year [215].

Epidemiologic studies to detect the prevalence of elder abuse indicate a prevalence of between 2% and 10% [25]. According to a national telephone survey, 1.6% of elderly respondents reported experiencing physical abuse in the past year; 5.2% recounted financial abuse, 5.1% neglect, and 4.6% emotional abuse [26]. In another survey study with 3,005 adults between 57 and 85 years of age, researchers found that only 0.2% disclosed physical abuse in the last year, 9% reported verbal abuse, and 3.5% indicated financial abuse [27]. In a national study conducted by the National Center on Elder Abuse in 2004, there were 565,747 reports of elder abuse to APS in the United States. This was an almost 15% increase from the 483,000 reports in 2000 [28]. A study conducted by the state of New York found that for every case of known (reported) elder abuse, 24 were unknown (unreported) [23].

The prevalence and scope of elder abuse in institutional settings, such as nursing homes, is not clear, in part due to lack of agreement about definitions [23]. Elderly neglect is typically conveyed as poor care; however, this is a very simplistic definition and does not take into account clinical and legal ramifications [29]. For example, is patient neglect due to staff's poor attitudes, medical negligence, human error, or some other factor?

In two studies on elder abuse in institutions, Buzgová and Ivanová reported that 54% of the staff from 12 different residential homes in the Czech Republic self-disclosed to having perpetrated some form of abuse on their elderly patients in the previous year; 65% of the staff witnessed another employee committing some form of elder abuse [30]. When patients were asked, only 11% reported having experienced some form of abuse by staff, and 5% witnessed another patient being abused by a staff member. In a study of 441 individuals living in nursing homes in Michigan, 21% of family members reported some type of elder neglect experienced by their relative in the last year [31]. The most significant predictor of neglect was the patient's ability to carry out activities of daily living, with more limitation correlating to greater likelihood for neglect. In a 2019 systematic review, 33.4% of older adults in institutional settings reported psychologic abuse, and 14.1% reported physical abuse [216]. Strikingly, 64.2% of staff disclosed to abusing an elder resident.

In a study with 1,002 relatives of elderly residents of long-term-care facilities, 16.2% stated their family member had experienced neglect, 13% reported emotional abuse, and 12.7% reported caregiving abuse, which was defined as mistreatment that stemmed from caregiving activities such as withholding or delaying drugs, over administration of drugs, inappropriate uses of physical restraints and forced feeding [32]. The authors noted the limitations of using family relatives as proxies; however, family members are often keen observers of abuse, and because the victim would not be identified in the study, the researchers felt that the relatives could be more truthful [32].

This was consistent with another telephone survey study of individuals who had an adult family member 65 years of age or older living in a long-term care facility [33]. Researchers found that 86% of participants reported that their elder family member experienced neglect, such as staff's failure to ensure personal safety and to provide food, water, and/or medications. Emotional or psychologic mistreatment, defined as the elder family member being treated disrespectfully, not being allowed to talk or see family members, or being given the silent treatment, was reported by 79% of participants. In telephone survey of 452 adults with elderly relatives in nursing homes, 24.3% indicated that their relative experienced at least one incident of physical abuse by a staff member [217].

In a 2004 study conducted in Germany, using a multi-data collection technique with surveys of residents, staff, and professional caregivers of nursing homes, interviews with staff revealed interesting findings [34]. A majority (70%) of the staff disclosed to having acted abusively or neglectfully on at least one occasion; more than half witnessed another staff or caregiver verbally abuse nursing home residents, and 20% had observed inappropriate use of chemical restraints. Substance abuse on the part of staff, physically aggressive behavior by residents, caregiver burnout, and the ratio of residents to registered nurses were predictors of abuse and neglect [34].

Sexual abuse experienced by elders in institutional care facilities has been minimally studied. The literature has documented that sexual offenders who sexually abuse elders in care facilities include employees, other residents, family members, and visitors to the facilities [35]. Perpetrators generally target victims who have mental or physical impairments. In one study, researchers found that the largest group of alleged sexual offenders consisted of employees of the facilities (43%) [35]. The majority of these employees provided direct care to the elder residents. The second largest group was other residents of the facility (41%).

As stated, problems in obtaining prevalence rates stem from a lack of a definition of elder abuse [36]. For example, should the definition focus on acts of physical, psychologic, verbal, sexual, and/or financial abuse? Some differentiate between different types of neglect: passive and active [36]. Passive neglect or benign neglect refers to when the caregiver is not aware they are injuring or causing harm to the elder, while active neglect is intentional harm [36]. Although the National Center on Elder Abuse (NCEA) recognizes the value of each existing definition, using different definitions will affect the outcome of the scope of elder abuse [23].

Methodologic issues, such as sampling and recruiting participants, are complicated because elder abuse is a private and sensitive topic matter. When race, culture, and ethnicity are added to the equation, it becomes even more complicated. Issues of translating and back-translating instruments, ensuring linguistic equivalence of constructs, and hiring linguistic and culturally proficient interviewers are some issues that arise with cross-cultural research. Consequently, to get a sense of the scope of elder abuse in ethnic minority communities, this course will focus on nonprobability sample studies.

SCOPE AND TRENDS OF ELDER ABUSE IN ETHNIC MINORITY COMMUNITIES

There are few empirical studies that look at the scope of elder abuse in ethnic minority communities. In a large-scale study with a representative sample of 5,777 older Americans obtained through random digit dialing, there were no racial or ethnic differences in rates of emotional and sexual elder abuse among whites and non-whites (self-classified as black, Pacific Islander, Native American or Alaska Native, Asian, Hispanic, or other). There were slightly higher rates of physical elder abuse for non-whites compared to whites (3.0% vs. 1.4%, respectively) [37]. In another study with 200 Latino individuals 65 years of age and older, researchers found that 40.4% of the participants had experienced some form of abuse or neglect in the previous year; 25% disclosed experiencing psychologic abuse, 10.7% physical abuse, 9% sexual abuse, and 16.7% financial abuse [38]. Finally, using a convenience sample of persons of Mexican origin who were 60 years of age or older, Sanchez recruited a total of 62 participants who obtained services from community centers in Michigan and Nevada [39]. Thirty-three percent of the Mexican elders reported awareness of at least one incident of elder abuse in the Mexican American community. When broken down into the types of abuse, 40% reported that they knew of someone who was denied shelter by family members; 22.6% neglect; 12.9% financial abuse; and 11.3% physical abuse. Again, these figures are not necessarily representative given the small sample size and the convenience sample employed. In addition, these are only indirect accounts of elder abuse; however, the study does indicate that elder abuse among Hispanics/Latinos deserves further examination.

There have been very few studies of Native American elders and victimization. A 2018 study found that financial abuse was the most common form of elder abuse among this population [218]. A chart review of 550 urban American Indian and Alaskan Indian elders (defined as 50 years of age and older) living in Washington state was conducted to examine the effect of abuse on this population [40]. The researchers found that 10% of the cases indicated definite physical abuse, and another 7% were suggestive of abuse; that is, the alleged cause was not consistent with the location of the injury. Being female, depressed, or dependent on others for food were predictors of being physically abused [40].

One study found that 63% of African Americans with impaired decisional capacity experienced some form of financial exploitation [219]. Another study found that the rate of past-year financial exploitation was two to three times higher among African American elders than the national rate [220]. In a telephone survey in Pennsylvania, 693 non-African American and 210 African American persons 60 years of age and older were asked about their experiences with financial and psychologic abuse perpetrated by a spouse, child, family member, or another trusted individual [41]. Twenty-three percent of the African American respondents indicated they had experienced financial exploitation since turning 60 years of age compared to 8.4% of their non-African American counterparts. The figures were higher for African Americans regarding psychologic abuse (24.4%) compared to the non-African American respondents (13.2%). In another study, Dimah and Dimah examined gender differences among African American elder abuse victims and perpetrators [42]. Forty-eight cases of substantiated elder abuse in a service agency were examined. They found that male elder abuse victims experienced more physical abuse (85%) than their female counterparts (42.9%). African American perpetrators of elder abuse were found to be more often related to their victims. Finally, financial exploitation was a common form of elder abuse, affecting 53% of the male victim cases and 54% of the female victim cases.

Chang and Moon conducted a study with 100 Korean immigrant elders and found that 34% had witnessed or heard about elder abuse that occurred among friends, family members, or acquaintances [43]. Financial abuse was the most common form. A common example of financial abuse cited from this study was a son stealing from his parents' Supplemental Security Income checks [44]. In a 2019 quantitative study, two groups of older Koreans between 60 and 79 years of age—those residing in Korea and those in the United States—reported similar rates of abuse (23% and 26%, respectively) [221]. In both groups, declining health was correlated with abuse.

In Asia, the topic of elder abuse is receiving increased empirical attention. In a study of Korean caregivers and their elderly family members with various types of physical and cognitive abilities, the most common forms of elder abuses were psychologic abuse and neglect [45]. Almost one-fifth of respondents (18%) disclosed to confining the elder family member in a room and 10% admitted to having hit the elder. In a large-scale study conducted in China, 2,039 individuals 60 years of age and older were interviewed, and 36% of the participants indicated they experienced elder mistreatment [46]. Specifically, the prevalence of physical elder abuse was 4.9%, psychologic abuse was 27.3%, caregiver neglect was 15.8%, and financial mistreatment was 2% [46]. Risk factors for abuse included having depression, being alone (e.g., divorced, widowed), and having a labor intensive job. In another survey study of individuals 60 years of age and older living in an urban area in China, 35% of the sample (32% men and 42% women) reported elder abuse and neglect [47]. Caregiver neglect was the most common form (16.9%), followed by financial exploitation at 13.6%. In Hong Kong, Yan and Tang conducted a survey study on the risk factors of elder abuse with 276 elder Chinese individuals, 27.5% of whom admitted to having experienced at least one type of abusive behavior perpetrated by a caregiver during the past year [48]. The findings of the study also found that verbal abuse was the most prevalent, at 26.8%, while violation of personal rights (5.1%) and physical abuse (2.5%) were less common. Participants who had visual or memory problems and who were dependent on their caregivers were more at risk of general abuse and verbal abuse [48].

In a study of 3,157 older Chinese immigrants, 15% reported experiencing mistreatment by a family member [222]. In a separate study of 2,713 older Chinese Americans, the overall abuse rate was 8.8% [223]. In a study of Chinese women older than 60 years of age, 15.8% experienced mistreatment [224]. In each of these studies, poorer health status and/or deteriorating health were associated with mistreatment.

It is crucial to remember that the lack of research in this area does not imply that elder abuse does not exist in ethnic minority communities. Unfortunately, cross-cultural research in this area requires considerable funding to obtain adequate sample sizes, the development of culturally sensitive instruments, and the hiring and training of interviewers who can meet the tremendous diversity within the many ethnic minority groups.

2. DEFINITIONS OF ELDER ABUSE AND CONTROVERSIES

In general, elder abuse literature has identified three basic categories of abuse and neglect: domestic elder abuse; institutional abuse; and self-neglect or self-abuse. The World Health Organization (WHO) defines elder abuse as "a single or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust that causes harm or distress to an older person" [225]. However, one of the biggest difficulties in the field of family violence revolves around the definition of the problem. Defining social problems is controversial because the definition determines the prevalence rate of who is counted as abused and who is not. It determines what legislation does and does not cover, and it directs programs regarding the eligibility criteria of who does and does not receive services.

What constitutes elder abuse, mistreatment, and neglect? Must elder abuse include a component of trust between the victim and perpetrator [218]? Often, the terms "abuse," "mistreatment," and "neglect" are used interchangeably. Yet, the definition is extremely important, as it sets the stage for measurement in empirical studies, reporting of incidences by practitioners, and development of policies and programs. In some cases, "abuse in later life" is used interchangeably with "elder abuse," but the former term is usually specific to domestic violence or sexual abuse of an older adult. "Crimes against older adults" refers to burglary, financial scams, and/or theft of older individuals [218].

Abuse is generally perceived as more serious because it is viewed as a deliberate or intentional act to harm [10]. Conversely, neglect has generally been viewed as less serious because the intent of the perpetrator is not necessarily deliberate. That is, neglect is an act of omission—not doing something because of ignorance or some situational factor (such as stress) [10]. The Centers for Disease Control and Prevention, the NCEA, and other organizations include both an intentional act and a failure to act in their definitions of elder abuse [23,49].

Other definitions have focused on the types and categories of abusive acts. The NCEA and the Administration on Aging have defined seven different types of elder abuse, which are based on state and federal definitions [49,50,218]:

- Physical abuse: Use of physical force that results in injury, pain, and impairment. Examples include slapping, punching, kicking, and restraining.

- Sexual abuse: Nonconsensual contact of any form.

- Emotional abuse: Infliction of distress, anguish, and/or pain through verbal or nonverbal acts.

- Financial/material exploitation: Illegal or improper use of the elder's resources, property, funds, and/or assets, without the consent of the elder.

- Neglect: Refusal or failure to provide goods or services to the elder, such as denying food or medical-related services.

- Caregiver neglect/abandonment: Desertion of an elderly person by the individual who has physical custody or who is the primary caretaker of the elderly person.

- Self-neglect: Behaviors of the elderly person that jeopardize his/her own safety and/or physical health.

The types of elder abuse in nursing homes, categorized as institutional abuse, include physical abuse, psychologic abuse, neglect, and financial abuse as identified above [23]. Other forms of nursing home abuse include use of inappropriate restraints, substandard care, overcrowding, authoritarian practices, denying residents' daily activity choices, and labeling troublesome individuals, which results in depersonalized treatment [51]. In a qualitative study of elderly nursing home residents and staff in the Czech Republic, one of the recurrent themes was the violation of rights to make decisions and free choice [52]. Due to the restrictive environment in institutional settings, freedom to make decisions regarding activities of daily living becomes important. The lack of respect for elderly residents' dignity and privacy were also noted as dimensions of abuse in institutional settings.

Another form of elder abuse in nursing homes that has been the subject of limited research is nursing home theft. In a study of 47 nursing homes, 6% of the nursing home staff members reported witnessing colleagues stealing from elderly patients [53]. Another 19% suspected coworkers of stealing.

It is important to remember that these forms of abuse are not mutually exclusive. An older individual who experiences one type of abuse will often be the victim of another form of abuse as well. A study of 842 women 60 years of age and older found they often experienced multiple abuses [54]. For example, 69% of the women who had been abused physically also experienced psychologic abuse or controlling abuse.

Overall the definition and conceptualization of elder abuse has been fraught with challenges. Anetzberger offers an updated typology of elder abuse that may be used when assessing the components of abuse [55]:

- Perpetrator: Self, trusted other, or stranger or acquaintance

- Setting: Domestic or institutional

- Form: Neglect and/or abuse

- Perpetrator motivation: Intentional or unintentional

- Locus of harm: Physical, psychologic, social, financial, and/or sexual

CASE STUDIES

Read each of the following case scenarios and try to determine what type of abuse was sustained.

Case Study 1

For several weeks, church members noticed that Mr. L, 82 years of age, had bruises, cuts, and scrapes on his face, hands, and arms. Mr. L always had some plausible explanation and, knowing that he was the sole caretaker for his very ill wife of 61 years, they did not press the issue. A hospital social worker finally contacted APS after Mr. L drove himself to the hospital emergency room, over 20 miles from his home, with multiple fractures to his left arm. The APS social worker eventually discovered that Mr. L was being attacked by his wife, who was suffering from undiagnosed Alzheimer disease and had become combative. Mr. L did not know that his wife's behavior was a part of her illness and was protecting her.

Case Study 2

Mrs. J, a long time insulin-dependent diabetic, was admitted to the hospital after being brought to her physician's office by a neighbor who became concerned after not seeing Mrs. J for several days. Mrs. J finally told hospital staff members that she had run out of insulin several days ago and had given her grandson all the money she had to go and refill her prescription. He did not return, and Mrs. J did not call family members because she did not want to get him in trouble.

Case Study 3

Mr. B, 74 years of age, complains with increasing frequency of pain. His physician is puzzled by the complaints because the methadone she has prescribed should be controlling the pain. She has already increased the dosage a couple of times and is reluctant to do so again. She finally asked a family member to bring in all of Mr. B's medications so that she could check for drug/drug interactions or perhaps prescribe another medication. Examination of the methadone tablets revealed that someone had switched most of the methadone with over-the-counter potassium tablets, which are nearly the same size and color. Mr. B's failing eyesight prevented him from being able to tell the difference between the very similar tablets. Questioning revealed that Mr. B's niece, a former drug addict, had been living with him in exchange for his care, and that she prepared his medications each day. The family suspected that she was using drugs again, but was reluctant to probe too deeply because there was no one else to care for Mr. B.

GENERAL PROFILE OF ELDER ABUSE VICTIMS

There are some studies that indicate that women are more likely than men to be victims of elder abuse [56]. Other demographic factors that contribute to risk include unmarried status and non-white ethnic origin [57]. Elders who reside with a caregiver or family with a history of substance abuse, mental illness, and violence are more at risk of abuse [56]. One study found that elders who have short-term memory problems, psychiatric diagnoses, and/or alcohol problems are more vulnerable to elder abuse [58]. Elders who have poor health and low income also appeared to be at risk of elder abuse [55,57].

TYPOLOGY OF ABUSERS

Several different typologies have been suggested for abusers. In their 2017 study, DeLiema, Yonashiro-Cho, Gassoumis, Yon, and Conrad identified four different abuser categories [226]. The first category is "caregiver abusers," and as the name indicates, these are the individuals are responsible for the care of an older adult. These abusers provide the most support, but may lack sufficient caregiving knowledge and skills. The second category is "temperamental abusers." These persons are caregivers who have difficulty controlling their tempers. The third category is "dependent caregivers." These abusers have challenges maintaining a job and rely on the victim's financial support. The last classification is "dangerous abusers," because they exhibit high levels of aggression, substance abuse problems, and financial dependence on the victim.

Similarly, Ramsey-Klawsnik has formulated a classification or typology of perpetrators of elder abuse [59]. This typology provides a description of overall characteristics of abusers.

The Overwhelmed Offender

This is an individual who is responsible for providing day-to-day care for the elder, and the amount of caregiving that is needed exceeds the caregiver's ability. This type of offender realizes that his/her behaviors are abusive but has difficulty asking for or seeking help. This type of abuser is the most often depicted [55]. However, the caregiver stress theory does not completely explain elder abuse.

The Impaired Offender

This is an individual who has a physical or mental impairment that makes caregiving difficult. This type of offender tends to be neglectful, administer medications inappropriately, and use restraints. Impaired offenders often do not realize that their behaviors are abusive. Research seems to indicate that perpetrators of elder abuse tend to have substance abuse and mental health issues [55].

The Narcissistic Offender

This type of offender does not want to provide caregiving and is only doing so to exploit the elder. Oftentimes, the abuse involves neglect and financial abuse.

The Bullying Offender

This offender has little empathy or compassion for elders. Bullying offenders want to exert power and control over their victims. Their victims are too frightened to disclose the abuse and will merely attempt to placate the abuser. These offenders employ a range of abusive behaviors that includes physical, sexual, verbal, emotional, and financial.

The Sadistic Offender

This type of perpetrator enjoys humiliating and inflicting terror on the elder and experiences no guilt or remorse for abusive actions.

These different typologies do not necessarily contradict each other. Rather, they can be used supplementally to assist in developing targeted interventions for elder abuse perpetrators [226].

CONTROVERSIES IN THEORETICAL CONCEPTUALIZATION

How a social problem is conceptualized or defined greatly influences the perceptions of the problem, its attributes, etiology, and the policies and interventions. Although the social problem of elder abuse has existed for thousands of years, there has been an absence of a coherent theory. The field has borrowed and/or adapted many theories from other fields, including child abuse, intimate partner violence, and criminology [218]. Wolf identified six broad theoretical models to explain how practitioners and researchers have conceptualized why elder abuse occurs [60,61]. These models are:

- Situational model (i.e., the overburdened caregiver)

- The dependent victim and abuser

- The impaired abuser

- Social learning theory (i.e., childhood of abuse and neglect)

- Feminist theory (i.e., imbalance of power in male/female relationships)

- Political economic theory (i.e., macro structures and conditions that lead to violence and conflict)

The Overburdened Caregiver

This overburdened caregiver perspective is perhaps the only theory specific to elder abuse [218]. It argues that elder abuse is caused by a family member who assumes the caregiver role and who is exhausted, stressed, and burdened with the caregiver tasks revolving around the elderly individual who has functional and/or cognitive impairments [10,62]. In other words, there are external or situational stressors that precipitate the abuse. Because the locus of caring is shifting from institutions to the family, families are expected to provide care and support to impaired elders [10]. The caregiver stress theory is one of the most frequently cited to explain elder abuse. However, empirical findings suggest that stress and dependency do not explain or predict perpetrating elder abuse; they merely contribute to abuse [55]. To rely on the caregiver stress theory to predict elder abuse can inadvertently result in blaming the victim for "being difficult" or "recalcitrant" and minimize the perpetrator's accountability [63].

The pressures of caregiving are very real. Caregiver stress is caused when the demands of providing care for the elderly individual are perceived as exceeding available resources [64]. Caregiver burden comprises the range of physical, psychologic, social, and financial strains or problems experienced by family members who have a family member with a chronic illness and who assume the primary caregiver role [65].

The literature has identified two types of caregiver burden or stress experienced: objective and subjective burden. Objective burden is characterized by tangible, external stressors. This includes providing physical care, financial stressors, employment, and overcrowding. Subjective burden is defined by the emotions that result from caregiver stresses [66]. In one study, the average length of caregiving was seven years [67]. Elders with dementia, for example, often require extensive assistance with bathing, feeding, and bladder and bowel incontinence [10].

Studies have shown that the severity of abuse often increases as elders' cognitive functioning level decreases [45]. Furthermore, family caregivers who have sufficient economic resources are less likely to report using some sort of abuse on the elder family member. Those who experience higher levels of caregiver burden are more likely to abuse their elder family member.

Typically, overburdened caregivers are female, middle age, and have families of their own. They provide much of the caregiving with minimal assistance from other family members. They have very little respite and are taxed with the responsibilities of caregiving and providing for their own families [68]. In in-depth interviews with 11 married and employed Japanese women who were caregiving for an elderly parent, researchers found that many of these women, despite their own career and professional aspirations, placed a higher priority of taking care of their elder family members due to deeply ingrained cultural beliefs about gender roles and filial piety [69]. The women initially took on the task of providing care to their elder parents or parents-in-law because this was the cultural norm. Over time, they felt oppressed as the caregiving duties became overwhelming. Their spouses often adhered to traditional beliefs that caregiving is a female responsibility. The multiple demands and strains these women experienced led to feelings of anger, loss of self-esteem, lack of self-worth, shame, and guilt. The majority of modern elder abuse prevention interventions (e.g., reducing caregiver stress) stem from this theory [218].

Case Scenario

Mr. R, 54 years of age, and Mrs. R, 49 years of age, work full time in very demanding jobs. About one year ago, Mr. and Mrs. R built an apartment addition onto their home, depleting their savings, to accommodate Mrs. R's mother, Mrs. D. Mrs. R is the oldest of three siblings and care for her aging mother had become primarily her responsibility. The 90-minute drive to her mother's apartment in a nearby city each weekend had become increasingly taxing, and her mother's care had become more time consuming. When Mrs. D's long-time physician announced his intent to leave private practice, it became reasonable to make the move. Mrs. D, while not enthusiastic, was agreeable. Mrs. R's brother and sister, who rarely visited or helped with her mother's growing needs, became angry about the move and stated that they had no intention of making such a trip. Now, in addition to working 9 to 10 hours per day, Mrs. R goes home to find numerous messages from her mother with various requests and demands. Additionally, because her mother can see her car drive up, the phone is usually ringing by the time she gets into the house to begin dinner for the three of them. There is an in-home aide who comes three days per week to help with bathing and light cleaning, but lately Mrs. R has questioned whether this is worth the added burden of mediating disputes between the aide and her mother. Each morning before work, Mrs. R prepares her mother's medications for the day and makes sure she has something available for breakfast. She longs for a vacation, but the routine continues seven days per week. Besides, all her vacation and sick leave must be devoted to taking care of her mother's medical appointments and treatments. Lately, Mrs. R has been having difficulty sleeping with disturbing dreams of having forgotten some major task. She feels tired all of the time. She has also noticed that she snaps at her spouse and friends often and that her anxiety level is increasing. Her own household chores are piling up because she does not have the time or energy to do them. Last week she noticed a red rash on her thigh and wonders when she might find the time to see her own doctor.

Early theoretical models proposed that caregiver stress was a contributing factor to elder abuse; however, stress alone does not explain the phenomenon. Researchers tend now to look at stress in the wider context of the overall quality of the relationship between abused and abuser. The nature of the pre-abuse relationship between the caregiver and the care recipient may be an important predictor of future abuse [15,70].

Dependency Theory

Early theories on elder abuse sought to associate dependency with increased risk of abuse [70]. This is based on Family Power-Dependent Relationship Model and social exchange theory. In the Family Power-Dependent Relationship Model, the child caregiver perceives that there is a reduction of power because the elder has become more frail and dependent. By using aggression, The caregiver uses aggression to claim more power [218]. Similarly, social exchange theory posits that the interaction between two or more persons will be positively evaluated if all persons involved benefit equally from the relationship [36,218]. An imbalance or unequal exchange in the relationship will be viewed negatively, and this imbalance will result in abuse. Initially, the focus of research was on the increasing dependency of the elder victim on the caregiver or abuser, often an adult child [36,70]. The increasing cost to the caregiver of providing emotional, economic, and physical care to the elderly parent without the positive mutual exchange in the relationship might be viewed as unfair to the caretaker, leading to relationship imbalance and increased risk of elder abuse [36]. Interestingly, Baumann argued that the picture of the frail, weak, and dependent elderly made it easy to call national attention to elder abuse and to justify allocating resources to this social problem [13]. However, Pillemer argues that there is no empirical evidence that elder dependency causes elder abuse [71]. In fact, elder abuse only occurs in a small percentage of the elderly population, and in a study of patients with Alzheimer disease, only 5% of the caregivers became abusive [72]. In addition, Pillemer and Wolf maintain that the problem with this perspective is that it rests on an ageist assumption that all people automatically become dependent and powerless as they age [73]. Thus, they assert that the dependency may lie elsewhere.

Later case work identified abusers who were dependent on the older person (e.g., an adult child dependent on an elderly parent for housing or financial assistance) [70]. Because of the sense of imbalance in the relationship and the violation of social expectations regarding independent adult behaviors, the perpetrator attempts to restore some sense of control by using violence [36]. However, some have a critical view of exchange theory, arguing that to use exchange theory for elder abuse "reproduces assumptions of market economics, independence, and value in the present that reproduce instrumental attitudes to relationships rather than focusing on altruism and life-course interdependence" [74]. However, Wolf and Pillemer found that in many instances of elder abuse, a large number of abusers were financially and emotionally dependent on the elder [75]. In some instances, a "web of interdependency"—a strong emotional attachment between the abused and the abuser—made intervention efforts difficult [70]. To date, no interventions have been developed based on this theory [218].

This dependency is illustrated in the following vignette.

Case Scenario

Mr. J had returned to live with his mother, Mrs. J, a widow of ten years, after his wife insisted he leave their house. During this time, he became depressed and started to drink. Mrs. J's neighbors became concerned that Mrs. J had lost a tremendous amount of weight and looked sad and disheveled lately. One day, Mrs. J confided to one of her neighbors that ever since her son returned to live with her, he had been pilfering her Social Security checks. Initially, she noticed that small amounts of money were missing from her pocketbook, but now, Mr. J threatens her both verbally and physically. He would smash and throw china at her until Mrs. J handed her signed Social Security check to him.

The Impaired Abuser

The focus of this theory is on the abuser's behavioral characteristics; however, there is minimal research evaluating this theory, as it is difficult to conduct research with elder abuse perpetrators [58]. Substance abuse and psychiatric illnesses are risk factors for elder abuse. In one study of the relationship between reported instances of elder abuse and regional levels of substance abuse, researchers found that elder abuse was related to higher rates of illicit drug use in the past month by either the victim or the perpetrator [76].

The Abuser was Abused/Neglected When Young

The social learning theory argues that individuals' learning patterns occur through observations of others [77]. When applied to the area of family violence, some researchers have coined the term "intergenerational transmission of violence," which maintains that abusive behaviors are learned. The intergenerational transmission theory argues that the dynamics of abusive behavior get perpetuated, and this is the reason why some abused children become abusers themselves [3,218]. A study conducted by Hotaling et al. found that abused children are more likely to exhibit aggressive behavior toward family members and to engage in crime outside the family [78]. The intergenerational theory is very popular and makes intuitive sense; however, empirical research does not indicate that abusers of the elderly are more likely to have been raised in families that were violent [36].

Feminist Theory

Feminist theorists argue that violence against women is broadly defined as male coercion of women [79]. In other words, patriarchy and male domination contribute to violence against women [80,81]. Patriarchy is perpetuated and reinforced by cultural ideologies, existing social institutions, gender socialization, and socioeconomic inequalities [80,81]. Thus, the root of violence against women stems from power imbalances in male/female relationships and male domination in the family, which is reinforced through current economic structures, social institutions, and the sexist division of labor [81].

Some argue that feminist theory is not useful to addressing elder abuse, because it does not necessarily explain the different types of elder abuse or the typologies of abusers [218]. However, feminist theory has relevance to elder abuse because elderly abused women are often not thought of as battered women or domestic violence victims. In other words, we do not think of elderly women being abused by their spouses. Studies on domestic violence, for example, have typically excluded women older than 59 years of age [82]. Vinton argues that service providers and scholars have traditionally dichotomized the terms "battered women" and "elder abuse victims" [12]. Each of these terms conjures up images for us; for example, rarely do we associate a battered woman or domestic violence victim with an elderly woman. Instead, we might use the label "elder abuse" because we have inscribed in us a mental picture of an elder abuse victim as a frail elderly person being abused by a caretaker. However, domestic violence does occur throughout a woman's lifespan [83]. Band-Winterstein and Eisikovits argue that intimate partner or domestic violence does not necessarily "age out" and that this notion is a myth [84]. In a study of 620 middle-aged and older women recruited from emergency rooms in an urban setting, 5.5% had experienced intimate partner violence within the last 2 years [85]. Forms of abuse included sexual abuse and verbal threats or use of physical force to make them have sex. It may be that abuse among older couples can be better understood by the abuser-victim dynamics of the domestic violence model than the elder abuse model, which is based on the concept of caregiver stress [86,87]. For example, older women's inability to leave an abusive marital relationship is very similar to their younger female counterparts, such as fear of reprisal [82]. However, for older women, concerns of finances and economic resources stem from their ability to obtain a job, lack of pension, and health and physical limitations [84].

This type of dichotomous thinking has implications for interventions. On one hand, a battered woman will be referred to a shelter, and an elderly female victim of abuse will be referred to Adult Protective Services [88]. In part, this dichotomous conceptualization has been shaped by the historical legacy of the domestic violence and elder abuse movements. Domestic violence, or the battered women's movement, emerged in the late 1960s when second-wave feminism and social activism were active. Then, in the mid-1980s, elder abuse emerged as a separate, distinct social problem and was primarily depicted as a social problem where the perpetrators were caretakers.

Political Economic Theory

This theoretical perspective maintains that American societal norms and attitudes may contribute to elder abuse. First, negative attitudes about the elderly create an atmosphere that breeds elder abuse [10]. Ageism is defined as "any attitude, action, or institutional structure that subordinates a person or group because of age or any assignment of roles in society purely on the basis of age" [89]. Our stereotypical views of the elderly include images of elders losing their memory, being less flexible and resilient, and being grouchy and unproductive. Although there is no empirical research that directly links ageism to elder abuse, the argument is that these stereotypes and myths play a role in dehumanizing elders. The process of devaluing and dehumanizing a particular group lends to and perhaps even provides justification for certain discriminatory and/or abusive behaviors [90]. Ageism promotes apathy towards the treatment of elders, and consequently, social problems, including elder abuse and neglect, do not receive the same attention as other problems [10,90].

Disengagement Theory

Disengagement theory was proposed by social scientists in 1961 and was the first social science theory of aging. It describes a process of disengagement from social life that people experience as they age. The theory states that, over time, elderly people withdraw from the social roles and relationships that were central to their life in adulthood. This process is deemed necessary and beneficial to maintaining societal stability and order [91]. The theory caused controversy as soon as it was published. Opponents argued that it ignored many aspects of aging and that it failed to capture the complex and rich social lives of the elderly and the many forms of engagement that follow retirement. The authors of one paper developed a profile of the social integration of older adults that included nine dimensions of connectedness [92]. Using data from the National Social Life, Health, and Aging Project (NSHAP), they conducted a population-based study in 2005–2006 of noninstitutionalized Americans 57 to 85 years of age. Their findings suggested that age was negatively related to network size and closeness to network members but positively related to frequency of socializing, religious participation, and volunteering. The authors concluded that late life transitions (e.g., retirement, bereavement) may prompt greater connectedness.

3. CULTURE, RACE, AND ETHNICITY AND ELDER ABUSE

Why is it necessary to put on a cultural lens when we talk about elder abuse? First, the United States is becoming increasingly diverse in terms of ethnic composition. According to U.S. Census data, there were 43 million foreign-born individuals in the United States in 2017 [93]. The majority (51.2%) are from Latin America (including the Caribbean, South America, and Central America) [93]. By 2050, it is expected that Hispanics will represent 29% of the U.S. population [94]. As a result, it is inevitable that race, culture, and ethnicity will have a profound effect on how we think, feel, and act. Race, culture, and ethnicity become the lens through which we view the world and touch on all aspects of human life [95]. Consequently, practitioners will need to become more culturally aware and sensitive to the cultural norms, belief systems, and needs of culturally diverse patients in order to provide culturally relevant services and interventions. In other words, it is inevitable that we talk about cultural competency. Cross-cultural competency is defined as a dynamic attribute that professionals develop in the areas of attitude, knowledge and skills to work with an increasingly multi-ethnic and diverse society [95]. Ultimately, the goal of cultural competence is to reduce the differences between the belief systems of clients and patients from diverse cultural groups and the institutional cultural norms of service delivery agents. This will then mitigate the disparities that exist in the current mental health and healthcare systems [96].

Second, cultural values and belief systems influence norms about family life and structure. It is vital to examine various ethnic groups' norms of family life, as every family system shapes and guides rules, obligations, roles, and labor divisions [97]. Because one's family of origin is the foundational building block to socialization, understanding general views about gender roles, beliefs about family authority, and views about elderly family members will assist us in understanding the intersection of culture, race, and ethnicity and family norms on elder abuse.

A third reason to take into account culture, race, and ethnicity in the study of elder abuse is that these factors influence the labeling or the perception of the social problem. Diller argues that human beings relate to their world through cognitive worldviews or paradigms [98]. These worldviews and paradigms provide individuals with rules and assumptions about how the world works. Culture and ethnicity provide the content of these worldviews [98]. Consequently, how a group labels or constructs abuse or maltreatment is influenced by their cultural beliefs and values, which ultimately affect how domestic violence is perceived, exhibited, and reported [99]. Furthermore, the social realities of the lives of older abused immigrant women may be uniquely different from their younger counterparts as a result of generation, acculturation, and gender role socialization differences. These factors may distinguish how elder abuse victims label their situations and what services they may seek [100].

Fourth, it has been postulated that certain ethnic minority groups may be more vulnerable to violence because of the existence of environmental risk factors such as poverty, racism, oppression, and discrimination. For example, the sociocultural backdrop of slavery, oppression, and economic deprivation may have contributed to any violent behavior seen in the African American community [101].

Finally, culture, race, and ethnicity influence help-seeking patterns. There are a host of factors that influence ethnic minority families and elders in seeking outside professional assistance. This might include financial limitations, suspiciousness or wariness of professionals, or inconvenience in locating and traveling to agencies [102]. However, help-seeking behavior is in part influenced by the individual's definition and understanding of the phenomenon, which is ultimately influenced by culture. For example, an ethnic minority elder who is being abused by another family caretaker may not seek help because he/she does not label the event as a problem. Instead, the victim believes that the event must be something that should be persevered. In other words, the victim shares a "cognitive map" or explanatory model about the explanations and expectations regarding illness, symptoms, or other events like violence [102].

Despite these benefits, it is important to be careful not to overemphasize the role of cultural differences or to inadvertently attribute deficits or adverse outcomes to cultural practices [227]. There are often other contextual factors that should be factored into understanding elder abuse.

CULTURAL NORMS AND VALUES REGARDING FAMILY AND THE ELDERLY

This section will briefly review cultural values and norms about family structure and views about the elderly within each of the four ethnic groups: African Americans, Asian Americans, Hispanics/Latinos, and Native Americans. It is crucial that, as helping professionals, we understand cultural values because they are the driving forces guiding daily behavior [103]. Cultural norms about family life and the role of elderly family members will have an impact on how the elderly are treated within society and the family and, ultimately, how elder abuse is perceived.

It is important to remember that there is tremendous diversity within groups. In other words, factors such as acculturation, age at immigration, education level, socioeconomic status, and religion all contribute to the heterogeneity within each subgroup. Falicov cautions against static descriptions of ethnic groups because they are merely social science simplifications rather than true portraits of the complexities of culture, race, and ethnicity [104]. Consequently, bear in mind that the following information is intended to present general themes to guide practice and not indicate hard and fast rules.

African Americans: Family and Elders

According to the U.S. Census, African Americans constitute 13.6% of the U.S. population as of 2015, numbering 46.3 million [228]. By 2060, it is projected they will comprise 17.9% of the U.S. population.

The family is very important in African American history, and values related to the family are rooted in African traditions. It has been said that the African American family structure is what enabled African Americans to survive during slavery and the challenging times of the Jim Crow era [106,229]. Terms such as "my family," "my folks," and "my kin" refer to both blood relatives and those who are not related, such as special friends and cared for individuals [5]. This was confirmed in a qualitative study in which African American family therapists discussed the roles of African American families' strengths in therapy [107]. The therapists all identified the strong kinship bonds that existed in African American families and noted these bonds extended beyond nuclear family members into extended family members and into the community. Similarly, marriage is viewed among African Americans as a "sacred vow" and covenant [106]. During the slavery period, when family life was severely disrupted, kinship bonds were highly relied on for support. Young children of slaves, for example, were often cared for by older women or children [5]. Parents attempted to discipline and raise their children to the best of their ability given the constraints of life in slavery.

Extended family networks are common in African American families. Many African American family structures are multigenerational and interdependent. In a study conducted by Martin and Martin, it was found that an extended family network might consist of five or more households centered around a base unit, where the "family leader" resides [108]. This extended family network system pools resources to help during hard times. These strong kinship networks are the key element in helping African American families cope with economic stressors as well as structural issues such as racism, oppression, and discrimination [108]. Similarly, Goode notes that the value of group effort for the common interest is highly valued [5]. There is an expectation that one shares with the larger African American community, and this value orientation is part of that strategy for survival. Simultaneously, the value of independence is emphasized, which focuses on the ability to stand on one's own feet and to have one's own focus [5]. It revolves around the ability to earn a living, care for one's family and provide for them, and have some left over to help others in the extended family [5]. Jackson observed that African American families have demonstrated an elastic quality, assuming flexible roles to adapt to change and stress [109]. Family therapists have noted the amazing resilience and creativity of African American family members in utilizing internal and external resources in handling the challenges that emerge [107]. Economic reasons are not the only reasons why African Americans share households. They also adhere to cultural beliefs about closeness and connectedness [110].

The elderly are highly valued in African American families [229]. Dating back to Western African traditions, the provision of care of elders is embedded in the belief that it is the responsibility of the kin group and care is a collective process [111]. Even during slavery, slave communities provided care to elderly slaves who could no longer work. Although times and the structure of families have changed, many African American families still abide by these cultural norms. African Americans have the lowest utilization rates of nursing homes; tasks of caregiving in African American families are often spread out to different family members rather than having one identified primary caregiver assuming all responsibilities [111].

Elders are viewed as the repository of wisdom and hindsight, termed "elder educators" [5,112]. In traditional African religions, the oldest family members are believed to have special status and an ability to communicate with God [5]. Harper and Alexander note an interesting and unique trend about African American elders [113]. African American elders tend to live in multigenerational households; however, they do not go to live with their children. Rather, it is their children who move in with them. For example, daughters who are divorced, widowed, or separated commonly return with their children to live with their parents [113]. It is very common for grandmothers to help in rearing the children of single mothers [114].

Asian Americans: Family and Elders

In the 1990s, the number of Asian Americans in the United States increased tremendously due to high levels of immigration from Asian countries. In 2015, 21 million Americans identified solely as Asian [230]. It is projected that this number will reach 41 million by the year 2050, which would be 9% of the total population [94]. More than half (58%) were foreign-born in 2005, but by 2050, fewer than half (47%) will be foreign-born [94].

Approximately one-third (31%) reside in California; however, a greater dispersion of Asian Americans to other states has begun. This trend reflects the refugee groups that immigrated during the 1980s and the 1990s and more recent immigrants from India and Pakistan [116].

Generally, traditional Asian families can be characterized as hierarchical. In other words, family authority and structure is defined by family position, which is determined by age and gender [117]. Older family members have higher status than the young, and men hold higher positions than women [117]. Family harmony and equilibrium are valued, and one way to maintain this balance is to adhere to the hierarchical structure. In addition, traditional Asian American families are patriarchal in nature; the father maintains authority, and the sons are more desired and valued because they symbolically carry on the family line and care for their parents when they become old [117].

Mutual support, cooperation, and interdependence also characterize the family [118]. As a result of the close-knit nature of Asian American families, there is a strong sense of obligation and duty to others [119]. Problems are generally solved within the family, and a sense of family honor and pride limits outside information to be shared by counselors or other professionals [118].

The term "family" can be defined in multiple ways in the Asian American community and can include a wide network of kinship. In many Filipino families, for example, trusted friends serve as godparents to children and play a vital role in their socialization process [119].

Elders are generally venerated in Asia. China, for example, has been described as a gerontocracy because of the overall attitude of respect and veneration toward the elderly [120]. Filial piety refers to a series of obligations of the child to the parent for providing emotional and economic support and bringing honor to the parent by doing well educationally and occupationally. These obligations are dictated by Confucian values and have governed many generations of Asian families [121]. In India, children are socialized early to respect elders as an intricate part of the family system [122]. Unlike American society, which encourages independence to maintain self-esteem, Asian elders encourage their children to operate under a framework of mutual dependency [123]. Old age signifies wisdom, status, and power in the traditional Asian family system [124].

Due to westernization and modernization, many Asian countries are experiencing rapid shifts in cultural norms. It is speculated that in countries that have moved toward more capitalistic and market-driven economies, the values of family and collectivism have shifted more to individualism. These changing social norms may have impacted the family structure and how families care for their elders [125]. For example, in Japan, more women have returned to the work force, perhaps due to the economic recession as well as shifts in gender role perceptions [125]. Some have noted that traditional and modern cultural beliefs are becoming more fused, including beliefs regarding filial piety [126]. In focus groups with Taiwanese university students, students' beliefs of filial obligation were found to be deeply rooted in their belief systems; they believed that it was their duty to care for their parents [126]. The participants acknowledged the deeply rooted traditions of filial piety that were passed down in their families. However, for some of the students, filial piety was not necessarily demonstrated by living with their parents. They argued by not living with their parents, they would have a greater chance of achieving intergenerational harmony. Furthermore, they stated it was not completely clear how they will actually practice the day-to-day dimensions of filial piety as circumstances are never constant. Therefore, filial piety is dependent on circumstances [126,231].

Loneliness and social isolation experienced by elders have been identified to be predictors of elder abuse. This might be more salient with ethnic minority elderly immigrants. In one study, the researchers found high rates of loneliness, ranging from 24% to 50%, among elder immigrants from China, Africa, the Caribbean, Bangladesh, and Pakistan [127]. Kao and Lam maintain that when Asian immigrants age in the United States, what they experience is very different from how they were socialized [123]. It is a more demanding task to age in a society where their contributions are devalued, compared to a society where elders are treated with deference. This is demonstrated by the fact that loneliness is a significant predictor to elder abuse. In a survey study of 410 elderly Chinese patients (60 years of age and older), elders with higher reported levels of loneliness were four times as likely to experience elder mistreatment compared to elders with lower scores [128]. It is possible the rapid industrial changes in China have created tension between the older and younger generations in their prescriptions of familial responsibilities and roles.

Hispanic/Latinos: Family and Elders

The Hispanic/Latino population is also a very diverse ethnic group. They hail from Mexico, Puerto Rico, Cuba, and Central and South America. Ramirez has observed that mestizaje contributes to these complex within-group differences [129]. Mestizo refers to the genetic mixture that evolved from amalgamation due to European colonization and the intermingling that occurred between the European population and the indigenous people of the Americas as well as within the various indigenous tribes [129]. The term "Latino" is the preferred term as one that is self-applied, and the term "Hispanic" is a category used by the U.S. Census [103]. Latino describes people whose ancestors come from the Spanish-speaking countries of Latin America as well as those of Spanish and Indian descent whose ancestors have always lived in areas of the Southwest United States, which was once part of Mexico [130]. The word Latino describes diverse ethnic cultural groups, not a singular religious or racial group. Latinos engage in a variety of religious and spiritual practices, and may be white, black, Indian, or Asian. Latinos most often identify themselves by their national origin, for instance, as Dominicans or Mexicans. According to the U.S. Census, 63.4% Hispanic Americans originated from Mexico in 2015 [131].

Hispanics are the largest minority group in the United States, numbering 56.5 million in 2015 [232]. It is estimated that the Latino/Hispanic population will increase to 128 million by the year 2050 [94]. In 2016, California, Texas, and Florida had the largest concentration of Hispanic residents [233].

The family is of paramount value, which is influenced by both the Spaniards' Catholic religion as well as the values stemming from the indigenous people of the Americas [103]. In Hispanic culture, familismo, defined as putting the needs of the family before those of the individual, is a paramount cultural value [133,234]. The emphasis is on family reciprocity, including financial support, shared day-to-day activities and child rearing, and support related to the challenges of immigration [134].

It is both matrilineal and patrilineal, as there was a mixture of both matrilineal and patrilineal tribal governances among the indigenous people of the Americas [103]. However, in traditional Puerto Rican culture, there is a hierarchy of authority based on gender and age. Men and older family members are ascribed authority [135]. Similarly, patriarchal gender roles exist among many Mexican American families [104]. These differences reinforce the notion that there is tremendous heterogeneity within this ethnic group.

The family is an extended system that includes blood relations, those related by marriage, and fictive kin adopted through compadrazgo [136]. Compadres (i.e., godparents or co-parents) and extended family have very strong and close relationships with family members, providing financial and emotional support [137]. Padrinos is the relationship between godparents and godchildren [135]. It is not uncommon to transfer children from one family to another during times of hardship and crises, and mutual help, protection, and caregiving are provided [136].

Community is another value that is emphasized. Unlike individualism, which is the hallmark of many of the values in the United States, Hispanics/Latinos focus on the collective, which extends to valuing community life [103]. Consequently, fictive kinship is a part of the fabric of life. Stemming from this value of community is the emphasis of the value of cooperation versus competition. Latino families teach children the importance of sharing resources [103].

In the Hispanic/Latino culture, self-sufficiency is not expected for the elderly [138]. Because of the values of respect, cooperation, and family, elders expect to receive emotional assistance from their children. Elders are believed to be the storehouse of tradition, wisdom, and tradition [139]. They are viewed as advisors and it is not uncommon for family members to seek the advice of elders for parenting, childrearing, and other aspects of family life. Children are obligated to provide care and to respect their elderly parents [104]. They play important roles when they live with their adult children. Hispanic elders' attitudes about old age and well-being were contingent on their interactions and their sense of connectedness within the family unit [139]. This is one reason threatening to send elderly parents to a nursing home is perceived as a form of abuse in some Hispanic families [234]. Hispanic immigrant parents view these cultural values as important as they strive to teach their children the importance of respecting the elderly and addressing elders with the proper titles. Some lament the challenge of instilling these values to their children as they become Americanized [140].

Native Americans: Family and Elders

Native Americans, or American Indians, like other minority groups, encompass people with many different languages, religions, organizations, and relationships with the U.S. government [141]. They identify themselves as belonging to a specific tribe, each with unique customs and values. Again, readers are cautioned to regard the themes highlighted below merely as general cultural themes and to keep in mind the tremendous diversity within the Native American population.

The Native American/Alaska Native population grew 18% between 2000 and 2010 [142]. As of 2015, this population numbered 6.6 million, or approximately 2.0% of the U.S. population. It is projected that by 2060, this number will increase to 10.2 million, 2.4% of the total population [143]. As of 2019, in the United States, there are 573 federally recognized tribes and 335 federally recognized reservations [143].

In 2015, this group was more likely to live in Arizona, California, Texas, or Oklahoma [143]. The largest tribes are the Cherokee and Navajo. They are also a younger group, with a median age of 30.2 years compared to the median of 37.8 years for non-Hispanic whites [143]. In 2015, this group had the highest poverty rate (26.6%) compared with any other racial/ethnic group [235].

The family is regarded as the cornerstone for emotional, social, and economic well-being for individuals [144]. The composition of the family is very different from the dominant Anglo culture in the United States. For some tribes, the term "family" goes beyond the nuclear family and includes everyone in the tribe or clan. The terms "brother" and "sister" are used to refer to cousins in Native American families [145]. Therefore, family members encompass both blood relatives and tribe members with no distinctions, which is consistent with cultural values that emphasize interconnectedness and harmony [146].

The primary relationship is not necessarily with the parents, but instead with the grandparents, who assume the caregiver and disciplinarian role [141]. For example, among the Native Americans from the Navajo tribe, it is common for grandchildren to be sent to live with their grandparents, which benefits both the child (by ensuring that care and traditional values are passed down to the younger generation) and the elder (by ensuring a means to provide assistance to older individuals) [147]. In addition, the term "grandparent" is not limited to the dominant culture's role of a grandparent, but instead grandparents for Native Americans can also include other relations, such as aunts, great aunts, and godparents. Similarly, parental roles are assumed not only by the biologic parents but also by siblings of the parents [141].

Elderly family members are highly regarded. The aged are believed to be the repository of wisdom, and their role is to teach the young the traditions, customs, legends, and myths of the tribe [148,236]. In addition, the view of reciprocity is woven into the inter-relationships between elders and the young. Typically, elders help raise children, and caring for the elderly is considered "returning the favor" [149]. Consequently, in their old age they are taken care of by the tribe. This family orientation is reinforced by the cultural value of collectivism; that is, the value of being part of a group. Joe and Malach note that consensus is often the goal, and in decision-making processes, individuals often spend a lot of time trying to achieve consensus and harmony [150].

ROLE OF CULTURE, RACE, AND ETHNICITY IN ELDER ABUSE

Definitions and Perceptions of Elder Abuse

There has been a growing interest in the perceptions of elder abuse among ethnic minority populations. This reflects a recognition that culture, race, and ethnicity can influence what constitutes elder abuse, particularly because definitions of elder abuse reflect a white, middle-class perspective [151]. In addition, as noted previously, there is controversy about the definition of elder abuse and how to view the etiology of the problem.

Some studies employ cross comparisons among ethnic groups to identify similarities and differences regarding definitions of elder abuse. In a study that included African Americans, Korean Americans, and white elderly women, the participants were presented with scenarios of potentially abusive situations [152]. These scenarios included thirteen situations that covered various dimensions of elder abuse and mistreatment, such as physical, psychologic, verbal, sexual, medical, and financial abuse and neglect [152]. They found that the Korean elderly women were more tolerant of potentially abusive situations compared to the other two groups. In other words, Korean elderly women perceived fewer of the situations (50%) to be elder abuse as compared to white elderly women (who perceived 67% to be abusive) and African American elderly women (73%). It is plausible that the Korean elderly women were more sensitive to hierarchy and traditional gender roles as espoused by traditional Korean culture. There are rigid role differentiations between husband, wife, and children in Korean culture; males are valued, and, therefore, hierarchy and patriarchy are emphasized in Korea [153]. These values affect the Korean elderly women's beliefs about what is acceptable behavior and what is not.

These findings were replicated in a study conducted by Moon and Benton [151]. The study consisted of 100 African Americans, 95 Korean Americans, and 90 white elderly individuals 60 years of age or older, all living in Southern California. All participants were interviewed face-to-face. In general, the majority of the participants, regardless of ethnicity, disapproved of obvious, blatant forms of physical abuse, such as hitting an elder. Interestingly, some participants stated that it might be tolerated depending upon the circumstances. For example, 9.5% of the Koreans, 5.6% of the whites, and 2% of the African Americans indicated that it was acceptable to restrain an elderly parent in bed depending upon the circumstances. In addition, findings indicated that the Korean Americans and African Americans were more willing to tolerate medical mistreatment of elderly individuals. When asked about the causes of elder abuse, Korean Americans demonstrated a significantly different perception than either whites or African Americans. Korean Americans, for example, felt that elder abuse was primarily perpetrated by those with a mental illness or problems with substance abuse.

In a study comparing elders living in Korea and Korean immigrant elders in the United States, 90% of both groups agreed that scenarios that depicted physical and financial abuse were mistreatment. However, there was a lower percentage of agreement (37% to 40%) regarding the scenarios that portrayed neglect [154]. Both groups were more likely to seek help in cases of elder abuse, though the likelihood was lower for cases of neglect. However, Korean immigrants were 17 times more likely to seek help in cases of physical abuse compared to their Korean counterparts. Furthermore, women and more educated individuals were more willing to seek help [154]. In one study, older Korean immigrants were less likely to perceive psychologic or emotional abuse as elder abuse [221]. For example, silent treatment and name calling were not perceived as elder abuse.

In another similar study, four groups were recruited—whites, African Americans, Puerto Ricans, and Japanese Americans—for focus groups [99]. In general, the Puerto Rican respondents were more likely to label a situation as elder abuse without qualification, and the white and Japanese American focus group participants were least likely to label a situation as elder abuse. Meanwhile, African Americans tended to look at the context or circumstances to assist in understanding whether a situation was considered abusive or not. They were also asked what was "the worst thing that a family member can do to an elderly person." The white focus group participants stated psychologic neglect was the worst thing, the Japanese Americans listed psychologic abuse, and African Americans stated psychologic abuse and exploitation. Although most studies report differences among ethnic groups about the definitions and perceptions of elder abuse, it is not always clear how cultural values and norms play a role in these differences. Therefore, the specific cultural context can influence definitions.

Modernization in India has negatively impacted the social status of the elderly. Along with modernization come shifts in power structures and dynamics in the family system [155]. Like many other Asian cultures, Asian Indian elders are highly respected, as age is a valued social status [155]. Using a series of research methodologies to collect data about elder abuse within an Asian Indian context, some interesting results emerged. First, the cultural context does influence perceptions and definitions of elder abuse. Psychologic/emotional abuse goes beyond insults, criticisms, and pejorative statements. In the Indian context, elders perceive behaviors that go against their religious or philosophical beliefs as constituting psychologic abuse. For example, many Hindus have day-to-day dietary restrictions, and when elders live with their children who do not observe the same dietary restrictions, the elders may change their lifestyle to the extent that they perceive it as abuse or neglect. In a study focusing on Tamil and Punjabi immigrants in Canada, daughters-in-law were often identified as perpetrators of elder abuse in multigenerational households [156]. Nagpaul describes an elderly Indian woman who has stopped eating in the family kitchen because her daughter-in-law uses the same utensils to cook meat as in her vegetarian dishes. She now survives on bananas. She feels she has no other residential living options than to live with her son and daughter-in-law [155].

Financial exploitation may also fail to be viewed as abusive. In many cases, cultural norms may influence definitions and perceptions of financial elder abuse [237]. Behaviors such as family members taking small amounts of money from an elder, taking advantage of an elder for housing, or pressuring an older family member to provide excessive or inappropriate childcare may be common but not necessarily viewed as abusive.

Elder Abuse and Cultural and Social Contexts

While examining cross-cultural differences can be helpful in highlighting the differences and similarities between groups, some researchers have focused on studying one group in order to understand specifically how the qualitative details of their social realities might influence perceptions of elder abuse [157]. Again, because the sample sizes in such studies are frequently small, it is important to be cautious about generalizing findings to entire populations.

Using a review of the literature and the author's research with African Americans in North Carolina, Griffin noted that the generally accepted definition of elder abuse and the common profile of elder abuse victims and perpetrators may not necessarily apply for African Americans [157]. The general profile developed by Kosberg describes an elder abuse victim as older than 75 years of age, middle-class, widowed, white, and female, with mental or physical disabilities [158]. The perpetrator is described as a caregiver, typically a middle-aged adult woman who resides in the home of the elder.

Griffin argues that elder maltreatment and abuse in African American communities takes place in a markedly different social context [157]. As previously noted, African American elderly individuals frequently live in multigenerational family households, and unlike white elders who leave their homes and live with their children, children come live with them [157]. This situation provides a unique set of stressors that may contribute to elder abuse and maltreatment in this community.

Much has been written and speculated about the culture of violence in African American communities and whether this plays a role in risk factors for elder abuse among this group. Some suggest that historical violence against African Americans, perpetrated by individuals as well as institutions, is partially responsible for violent behavior among African Americans [159]. In a qualitative study of 30 older African American women, some women mentioned the spill-over effect of violence in the streets into the home as a trigger to family violence [160]. However, these arguments are not conclusive. Some have noted that the family structure of African Americans (that is, multigenerational households) can place elders at risk in their homes [101]. As described previously, adult children, as well as grandchildren and other relatives, are more likely to move into an elder's home. The strength of such multigenerational households is that it has allowed generations of poor African American families to pool their resources during hardships [159]. It can be argued that support from multigenerational living arrangements as well as from the church can be protective factors to elder abuse. However, Benton argues that the circumstances that contribute to relatives moving into an elder's home are typically due to stressors such as divorce, unemployment, or drug problems, all of which are risk factors for elder abuse [159].

The social or economic contexts also play a role in elder abuse among Native Americans. Dependency has become a variable studied in the field of elder abuse. Interestingly, in the mainstream literature on elder abuse, the research focuses on the elder becoming dependent on family members, which is believed to play a role in elder abuse. Boudreau observed that the direction of financial dependency is opposite for Native Americans; many young Native Americans are dependent upon their elderly family relatives for financial support [36]. Many elderly receive monthly paychecks from pensions, Social Security, or welfare, and because of the high rates of unemployment, many younger Native American adults rely on their elderly family members' funds [161]. Consequently, many Native American elders are at risk of financial abuse [238]. The economic stressors on many Indian reservations have also adversely impacted the family kinship system. Many have had to leave the reservations in order to find employment, leaving elders behind. Some service providers have asserted that this leaves elderly family members isolated, without family to provide for the care they might need [161]. Furthermore, years of social and historical forces that reinforce racism (e.g., failure to recognize tribal groups, relocations, forcible removal of children to boarding schools, and exploitation of Indian land) have negatively impacted the traditional Native American family system. Family ties and traditional values that emphasize the collective unit have both been disrupted [162].

Forces of social change impacting the traditional family structure have also affected Chinese elderly in Hong Kong. In recent years, the primary social support system for the elderly has been impacted by small public housing units, which have not encouraged multigenerational households [124]. Consequently, many young adult children move to new towns outside Hong Kong, leaving elderly parents behind. Elders who have been socialized to expect to be comfortable and cared for in their old age instead find themselves isolated. Some in the younger generations have also redefined what filial piety is to them. For example, paying nursing care fees for an elderly family member may be considered a demonstration of filial piety in some families or communities [231]. Consequently, principles of filial piety are challenged.

The theme of respecting elders and filial piety surfaced in a qualitative study with Asian American immigrants. Participants in the study stated that adult children should support their elderly parents, especially if they have a successful life, and this value should be passed down [163]. Interestingly, Korean immigrants in Chang and Moon's study identified elder abuse in terms of "abrogation of filial piety" [43]. These acts included adult children not wanting to live with elderly parents, placing their elderly parents in a nursing home, or not showing adequate or proper respect. Many Korean adult children may have acculturated to new value systems that minimize familial responsibilities, particularly to parents. Pang found a similar theme surfacing among Korean elderly immigrants [164]. Many resented living with their adult children and having to watch children, cook, and clean the house. They felt they had become full-time childcare providers. Because many elders did not regard discussing and negotiating these matters appropriate, the situation merely worsened. They classified these scenarios as abuse.

Similarly, in a study with Vietnamese elders, Le found that some elders stated that their daughters-in-law did not want them to learn English or how to use the transportation systems [165]. Therefore, they were confined at home to do household chores as free laborers. They classified these behaviors as elder abuse. Interestingly, emotional abuse was pervasive, and it not only included threats of putting the elder in a nursing home, but the use of silent treatment and blatantly ignoring their presence.

In a study using focus groups with home care workers who worked with Chinese elderly, the theme of disrespect emerged prominently. Disrespect encompassed actions and attitudes that go against cultural norms of obedience, conformity, and filial piety. Such behaviors might include being bossy or rude, ordering an elderly person to leave the room for no reason, scolding, or being demeaning [166]. Disrespect led to social isolation among the elderly, and for some of these immigrant Chinese elderly, the social isolation was exacerbated by financial dependency or dependency on family members due to their low level of English proficiency. The dissonance experienced by the Chinese elders stemmed from their expectations of filial piety and being taken care of in their old age. When this did not happen, this led to loneliness and depression; in the elders' minds, this was a type of "abuse" [166].

This concept of disrespect is not specific to Asian culture. A qualitative study of African American, Hispanic, and white custodial grandfathers found that the men discussed their grandchildren and children being disrespectful. Not listening and not appreciating them, which ultimately made them feel devalued and in their eyes, fell into the category of emotional abuse [167].

Cultural values and norms of family and family obligations also color elder abuse and how victims perceive the abuse. Sanchez noted that in the Latino/Hispanic culture, particularly for Mexican Americans in the study, la familia may play a role in the sanctioning of family violence [39]. A majority of the Mexican American elderly participants justified the violence, stating they had instigated it and that it was best dealt with within the family. The needs of la familia are considered paramount and are more valued than the needs of the individual [39]. Therefore, incidences of elder abuse would not be disclosed to authorities; rather, they would be kept within the confines of the family. Related to this is the theme of verguenza, which emerged during the study. The word means shame or losing face. Disclosing that one's child has mistreated a parent brings shame to the family and violates norms about la familia [39]. Yet, one study found that length of residence in the United States predicted caregiver neglect among elders in Latino families [38]. This raises the question of whether immigrants' emphases on family and family obligation decay with acculturation. The role of family in the maintenance of elder abuse warrants more empirical attention.

Tomita discusses similar themes in the examination of elder abuse within a Japanese cultural context [168]. The Japanese have a strong sense of "we-self" or "familial self," which is markedly different from the Western/American "I" centered self. Again, the elder abuse victim may feel it is necessary to relegate his/her individual needs so as not to jeopardize group harmony. Cultural norms of perseverance, silent suffering, and quiet endurance are valued, but these are also associated with victimization; consequently, victims do not necessarily perceive and label themselves as victims of abuse. For many Japanese, it is more important to protect the family and the community by not discussing with outsiders anything that is shameful and dishonorable [169].

Although there are few research studies focusing on ethnic minority families and elder abuse, there is a growing recognition that more scholarly empirical work is needed to increase the knowledge base in this area. Practitioners and scholars realize that understanding and highlighting the cultural context of elder abuse will shed light on formulating culturally sensitive interventions for ethnic minority families and their elderly family members.

Role of Culture, Race, and Ethnicity in Help-Seeking Patterns

It has been said that ethnic minority elders experience multiple jeopardy. In other words, they are vulnerable to life stressors because of their age, being an ethnic and class minority, not being proficient in the English language, being unfamiliar with American institutions, and not having transportation or social support networks [170]. Furthermore, most ethnic minority elderly do not voluntarily seek out social, community, and mental health services. For example, in a study with elderly Korean immigrants from Los Angeles County, there was a disconnect with their views and their intention to seek help, even when they classified various scenarios as elder abuse [171]. For example, 91% of the elders stated the financial abuse scenario constituted elder abuse, but only 63.7% stated they would seek help. Consequently, it is important to step back and examine reasons for their reluctance because these factors are in part social and cultural, and lessons learned can be used to develop culturally sensitive interventions and programs for the ethnic minority elderly.

Language Barriers

Many ethnic minority elders may not be proficient in the English language. If the helping professional cannot communicate with the immigrant elder, the patient is less likely to disclose personal problems, particularly sensitive topics such as abuse [172]. However, many helping professionals in social services are not multilingual despite the efforts to recruit professionals who are both bilingual and bicultural. This becomes even more problematic in certain ethnic groups, such as the Chinese, who have numerous dialects.

Geographic and Operational Accessibility of Services

Often, social service and community agencies are located in areas that are not easily accessible to elderly individuals who may not be able to drive themselves. Thus, they find themselves relying on public transportation, which may not be reliable or convenient. In addition, many agencies operate traditional hours of service—weekdays, from 9 a.m. to 5 p.m. Again, because they must rely on their adult children who may be working, elderly individuals may find it difficult to gain assistance.

Financial Difficulties

Some elderly face increasing financial difficulties as they age. They are typically living on fixed incomes; some do not have Medicare, Social Security, or receive pensions [170]. Consequently, many elderly immigrants not only avoid seeking services but also put off seeking medical services and other necessities until the situation becomes extremely severe [123].

Stigma/Shame in Asking for Help

As mentioned earlier, the concept of shame in many ethnic minority cultures is very different from that of Western notions. In traditional Asian culture, for example, shame or loss of face extends to the collective unit, such as the family and community. Therefore, not only is the individual embarrassed, but the shame is also experienced by the entire family system, including one's ancestors [239,240]. This similar theme appeared in Sanchez's study with Mexican American elders [39]. They revealed that incurring shame to the family is to be avoided at all cost, and only on rare occasions, when someone's life is in jeopardy, should outside agencies be involved. In a study comparing Koreans and Korean immigrants in the United States, both groups indicated that physical and financial elder abuse was the most severe form of abuse compared to other forms of maltreatment [154].

Attitudes and Definitions of Abuse

Some victims may view a behavior some identify as abusive as a normal part of life [239]. In a 2019 study, some participants perceived problematic behaviors as family conflict rather than abusive, and thus did not see a need for formal support [241]. In another study of African American elders, the participants tended to accept abuse as an implicit agreement or exchange for caregiving or for being allowed to remain at home (versus a nursing home) [242].

Importance of Keeping Individual Problems from Outsiders

Tomita's qualitative interviews with Japanese adult immigrants revealed the importance of not discussing problems with outsiders [169]. They emphasized that it was unacceptable to make any disclosures about any unpleasantness to outsiders, but instead they must always maintain and present a happy and untroubled countenance to the public. Incidences of abuse would bring dishonor to the community and should be hidden at all costs. Along with the belief that it is shameful to discuss family matters, some consider abuse to be a part of one's fate [243].

Mistrust of Mainstream Services

Many ethnic minority immigrant elders are simply mistrustful of Western mainstream services. In a study of 124 Korean immigrant elders, one of the themes that emerged was mistrust of third-party interventions as a deterrent in seeking help [173]. Elders who adhered to traditional values were less likely to seek formal help. Coupled with unfamiliarity with Western notions of mental health and health and institutional procedures, many prefer to rely on traditional healers. For example, some Mexican American elders seek curanderos (folk healers) for healing and spiritual guidance [172]. African Americans are often wary of government and legal entities, and African American elders tend to be more likely to seek help from spiritual leaders, family, and the community than from mainstream services [244]. Furthermore, many African Americans with strong ethnic affiliations are more likely to use prayer and forms of spirituality when they need help instead of seeking formal services [174].

Ambivalence Toward the Legal System

Another issue among many ethic/racial minority groups is ambivalence or fear of the established legal system. In one study, many of the participants (older African American, Hispanic, and white women) identified fear of police as a major barrier to seeking help through legal channels. Concerns that the police would not understand, demean the victim, and even trigger police brutality were expressed. There was also a perception that restraining orders or protective orders were ineffective and could exacerbate the abuse [175]. Since the 1980s, more tribes have developed legal codes for elder abuse [176]. However, these legal remedies mirror Euro-American legal standards, and they appear to go counter to tribal cultural values of collectivism, harmony, and healing. Legal punishment of the abuser may therefore be less effective, and some Native Americans may be reluctant to seek help through the legal system [176].

This is not an exhaustive list of barriers experienced by ethnic minority elders. It does provide readers a glimpse into their social realities. Abuse and mistreatment take on a host of connotations, and then given the layers of barriers, many elders are reluctant to seek assistance from mental health professionals, physicians, and other authority figures.

4. ASSESSMENTS, INTERVENTIONS, AND MANDATORY REPORTING LAWS FOR ELDER ABUSE

This section will provide readers an overview of various assessments and interventions for practitioners when working with elder abuse patients, particularly with those from ethnic minority groups. An emphasis will be placed upon gleaning cultural values and belief systems and incorporating them into assessments and interventions so that delivery of services can be both culturally sensitive and relevant.

ASSESSING FOR ELDER ABUSE

Evidence Based Practice Recommendation

The U.S. Preventive Services Task Force concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for abuse and neglect in all older or vulnerable adults.

https://jamanetwork.com/journals/jama/fullarticle/2708121

Last Accessed: January 29, 2020

Strength of Recommendation: I (Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.)

Assessing for elder abuse does not merely involve asking the possible victim questions. It also involves asking oneself difficult self-evaluative questions such as: Do I hold ageist attitudes? How are these attitudes translated when I conduct an assessment? Do I believe that elders can be abused, even sexually abused? Because of pervasive ageist attitudes, practitioners often fail to acknowledge that some forms of elder abuse occur [177]. This may impact whether certain assessment questions are asked.

Sengstock and Barrett recommend a two-step process in the identification of elder abuse [178]. The first step revolves around identifying elders who may be at risk for elder abuse, and the second step involves verifying instances of abuse. According to Sengstock and Barrett, certain situations may make some elders more vulnerable to elder abuse [178]. Any elder, for example, who is incapable of taking care of his/her own daily needs and is dependent on another person is automatically in an at-risk situation.

Evidence Based Practice Recommendation

The American Academy of Family Physicians recommends that screening for cognitive impairment should be performed before screening for abuse in older persons.

https://www.aafp.org/afp/2014/0315/p453.html

Last Accessed: January 29, 2020

Level of Evidence: C (Consensus)

To screen elders who may be at risk, Sengstock and Barrett recommend that practitioners assess the following domains [178]:

- Reason for visit to practitioner: Presence of acute or chronic psychologic or physical disability, elder's inability to participate independently in activities of daily living, reluctance of caregiver to give information about the elder's condition, delay in elder's seeking professional or medical assistance, and inappropriate caregiver's reaction to practitioner's concern may indicate an at-risk situation or potential abuse.

- Family history: Elders who grew up in violent homes, children who have antagonistic relationships with the elder, children's excessive dependence on the elder, use of substances such as alcohol or drugs by children, and children who were abused by the elder may indicate an at-risk situation or potential elder abuse.

- Elder's personal/social circumstances: Caregivers who have unrealistic expectations of the elder, elders who are socially isolated, and conflict in the family system may also warrant further questioning by the practitioner.

- History of accidents: Patterns of accidents that do not make sense should alert practitioners to potential abuse.

- Healthcare utilization: Health care "shopping," in which the victim does not have a regular physician because of the perpetrator's fear of detecting abuse. Infrequent visits to physicians and caregivers overanxious to have elders hospitalized may also be signs of an at-risk situation.

Jayawardena and Liao also encourage practitioners to inquire about the domestic relationship between the elder and caregiver and underlying issues and dynamics of control [179]. For example, the practitioner should ask about the duration and nature of the relationship and how much responsibility the caregiver is assuming. In trying to gauge control and power dynamics, the practitioner may want to ask about financial resources, power of attorney, and how decisions are made [179].

The presence of any of the above does not necessarily mean that the elder is a victim of elder abuse. Rather, the presence of these factors warrants further questioning and observations on the part of practitioners. Assessment is a dynamic and holistic process, taking into account both individualistic and environmental factors. Given the legal nature of abuse, it is also important for practitioners to determine whether they are conducting an assessment or an investigation; an investigation implies an adversarial component, while assessment is a collaborative process [180].

Another screening device is the Hwalek-Sengstock Elder Abuse Screening Test (H-S/EAST). This is a 15-item tool that measures three aspects of abuse: violation of personal rights or direct abuse, characteristics of vulnerability, and potentially abusive situations. These 15 items were eventually reduced to six items, which were found to be as effective in identifying abuse as the original 15 items [60,181]. Practitioners can easily incorporate these six questions into their assessment, and positive responses should raise a "red flag" [60,181]:

- Has anyone close to you tried to hurt or harm you recently?

- Do you feel uncomfortable with anyone in your family?

- Does anyone tell you that you give him or her too much trouble?

- Has anyone forced you to do things that you did not want to do?

- Do you feel that nobody wants you around?

- Who makes decisions about your life, how you should live or where you should live?

The Elder Abuse Suspicion Index (EASI) is a five-item tool that provides practitioners with a very quick sense of whether there is potential presence of elder abuse [182]. It was originally developed for use by physicians and has been recommended by the U.S. Preventive Services Task Force, but it can be used by practitioners in diverse disciplines [245]. The following items comprise the index [182]:

- Have you relied on people for any of the following: bathing, dressing, shopping, banking, or meals?

- Has anyone prevented you from food, clothes, medication, glasses, hearing aids, or medical care, or from being with people you wanted to be with?

- Have you been upset because someone talked to you in a way that made you feel shamed or threatened?

- Has anyone tried to force you to sign papers or use your money against your will?

- Has anyone made you afraid, touched you in ways that you did not want, or hurt you physically?

The Brief Abuse Screen for the Elderly (BASE) consists of only five questions and takes less than one minute to complete [183]. It is not meant to be administered to the client, but is designed to determine the practitioner's level of suspicion. It is ideally suited to be used in conjunction with a tool that assesses for actual elder abuse [183].

The Centers for Medicare and Medicaid reporting includes the Elder Maltreatment Screen and Follow-Up Plan, which assesses the percentage of patients 65 years of age and older with a documented elder maltreatment screen and follow-up plan noted on the date of positive screen. This measure was created for the Physician Quality Reporting System and has been collecting data since 2009 [185]. Statistics from the first six months of 2012 indicated that there were more than 53.9 million reported cases of individuals who were eligible to receive a maltreatment screen when visiting their physician. Of these nearly 54 million reported cases, only 1,438 individuals were actually screened for maltreatment. The cases were reported by psychologists, geriatricians, and occupational therapists, among others [185].

Other guidelines for effective screening include [186]:

- Ask open-ended questions.

- Normalize the questions by stating to the patient that practitioners normally or routinely ask these types of questions.

- Ask specific and behaviorally oriented questions. For example, if you ask a patient if he or she has been abused, you will likely receive a negative response. Instead, ask specific questions, such as:

- Has anyone ever hurt you?

- Has anyone ever touched you when you did not want to be touched?

- Has anyone ever taken anything that was yours without your permission?

- Does anyone ever talk or yell at you in a way that makes you feel lousy or bad about yourself?

- Has anyone ever threatened you?

- Explore any affirmatives to the above types of questions. Find out more about frequency, severity, what precipitates the violence, and the outcomes of the violence. Can the patient protect him/herself? What does the patient want to happen now?

Evidence Based Practice Recommendation

The American Academy of Family Physicians asserts that patients and caregivers should be interviewed separately when screening for elder abuse.

https://www.aafp.org/afp/2014/0315/p453.html

Last Accessed: January 29, 2020

Level of Evidence: C (Usual practice)

Welfel, Danzinger, and Santoro encourage practitioners to interview family members separately [16]. This is more likely to elicit honest disclosures than interviewing elders and their family members together. An elder might feel embarrassed or intimidated and will refrain from disclosing abuse in the presence of family members. No family members should be discounted as possible perpetrators.

If the practitioner finds an elder is at risk, the next step is to investigate, report, and possibly verify the abuse [178]. A comprehensive assessment includes an examination of physical, psychologic, and social characteristics of the elder and his/her family members and other significant others. It is important to note that physical abuse injuries are likely to be located in an upper extremity (e.g., arm, hand) or the maxillofacial, dental, and neck area [187].

CULTURALLY SENSITIVE ASSESSMENT: CONSIDERATIONS AND GUIDELINES

Many ethnic minority groups such as Hispanics/Latinos, Native Americans, and Asian Americans emphasize the collective unit. Tomita, in her work with Japanese elder abuse victims, discusses their strong sense of "we-self" and "familial self" which causes some elders to relegate their individual needs for the good of the group [168]. Consequently, they are less likely to discuss or complain about elder mistreatment. If they do complain, they will make certain that there are no negative ramifications to the family member or the perpetrator [188]. Tomita recommends the following tasks be incorporated into assessment when working with ethnic minority elders who subscribe to cultural norms emphasizing group collectivity [188]:

- Explore the elder's level of collective self or commitment to the perpetrator. The practitioner, for example, can ask the elder if any of their finances, such as their pension, is shared with other family members and how they feel about this.

- Examine the cultural context of abuse.

- Assess the likelihood of employing outside interventions. Many ethnic minority families do not believe that family matters should be discussed with outsiders.

- Assess for subtle signs of psychologic abuse and neglect. The practitioner can ask the elder about their relationships with family members and then listen closely to the elder's choice of words. Chang and Moon, in their study with Korean elders, found that when asked if the elder gets enough to eat, the elder may not directly say "no" [43]. Rather, they might say in a roundabout way that the daughter-in-law often says: "You don't really need that second helping of rice, do you?"

The practitioner's choice of words is also vital during the assessment process. The term "abuse" is often unfamiliar or may be considered taboo. In some ethnic minority groups, this term is difficult to translate. Therefore, it is more helpful to ask specific behaviorally oriented questions. For example, practitioners can inquire about a wide range of potentially abusive behaviors, such as intense child care duties, stealing money, silent treatment, and disrespect. Tomita also suggests that practitioners find culturally acceptable terms for assessment [188]. When working with Asian immigrants, the terms "sacrifice," "suffering," and other related terms may be more meaningful because the cultures maintain that life has much suffering and stress the need to persevere. It may also be beneficial for practitioners to ask if an older patient/client has heard or seen any instances of elder abuse [231]. This could engage the individual in a more in-depth conversation.

It is important for practitioners to remember that the elderly population is not a homogenous group [183]. Racial and ethnic diversity contribute to their heterogeneity, but there are other dimensions that practitioners may not consider, including sexual orientation.

INTERVENTIONS FOR ELDER ABUSE

Mandatory Reporting Laws

All 50 states have enacted legislation dealing with elder abuse, and they share many features with child abuse statutes. Elder abuse laws are also called APS laws because many states combine the protection of elders and disabled adults under one law [189]. They provide legal definitions of elder abuse, establish administrative channels for the investigation of and intervention in elder abuse, define who is mandated to report, and designate penalties for violations [16]. However, the specifics of state laws vary, and elder abuse laws may be ambiguous. Individual states are responsible for their own interpretations of the laws [190].

What follows is a brief review of the administrative channels for the investigation of elder abuse cases. It is important to remember that each state has different elder abuse statutes and they differ along three major areas: mandatory versus voluntary reporting; the targeted elder population to be served (e.g., some states focus on cognitively impaired or incapacitated elders); and the authority granted to elder abuse workers to investigate cases (e.g., some states require that the worker seek consent from the elder) [189].

In all 50 states and the District of Columbia, an APS agency has been designated to investigate reports of elder abuse [246]. This is the principal public agency that is responsible for both investigating reported cases of elder abuse and for providing victims and their families with treatment and protective services. Title XX of the Social Security Act makes it a federal requirement for states to implement APS in order to receive funds [191]. In most jurisdictions, the county departments of social services maintain an APS unit that serves the need of local communities [192]. In general, APS offers case management, emergency medical services, alternative housing arrangements, and help in obtaining Medicare, Medicaid, and aging services [191]. It is important to remember that, unlike the child abuse, older adults can refuse services or accept only partial services, even if APS substantiates an incident of abuse [246,247]. In some cases, APS can petition the court for assistance after it has demonstrated probable cause [247].

As noted, elder abuse laws differ from state to state, and definitions, procedures, and training can likewise vary [248]. Tennessee, Virginia, and Texas uphold the principle of autonomy in that elders can refuse services. In other states, authorities can be called to intervene if elders refuse services [190]. Unlike child abuse statutes that mandate professionals in all states to report incidences of child abuse, there is less consistency among the states regarding mandatory reporting for elder abuse [16,56,192]. For example, practitioners may be mandated to report only in cases in which the elder is residing in institutional settings [16,56]. The definition of elderly may also differ [56].

Those people who are designated as mandated reporters vary from state to state. In Illinois, for example, licensed counselors are specifically named as mandated reporters [192]. Twenty-one states and protectorates required mental health professionals to report; 17 required psychologists to report; 5 required family and marriage counselors to report; and 30 required social workers to report elder abuse [192]. All states except New York, the District of Columbia, and Puerto Rico require healthcare professionals to report, and failing to do so can result in penalties [249]. As with child abuse statutes, the practitioner does not have to prove that the abuse occurs before reporting; the practitioner must report even if he/she only suspects abuse. Only 75% of the state laws on elder abuse include a criminal penalty for failure to report [16]. To locate the number to call for specifics about your state's elder abuse laws or to report elder abuse, visit the NCEA's website at https://ncea.acl.gov/Resources/State.aspx [193].

Frequently, practitioners are reluctant to report elder abuse. It is estimated that less than 2% of suspected elder abuse cases are reported by physicians [194]. There are several barriers to reporting. First, many practitioners do not have a clear understanding of how APS operates. Many are not familiar with the elder abuse reporting laws, how they work, and/or who to contact if they were to report, and time constraints make it difficult to do additional research to locate the information. Second, practitioners fear they will make a bad situation worse or that nothing will change if they report the abuse [179,194,195]. Third, practitioners may also feel threatened for their own safety, and in some instances, it may be necessary to contact law enforcement as well [179,195]. Some are also concerned that they are breaking the confidentiality of the elderly individual [194,195]. Practitioners may be unsure due to lack of preparedness. There is a shortage of services for elders, particularly in rural areas, making it difficult to make proper referrals. In some rural areas, transportation barriers make it even more complex [196].

Ultimately, the effectiveness of mandatory reporting laws remains unclear. There does not appear to be a difference in the number of reports in states with and without mandatory reporting laws [226].

Education

Healthcare professionals can play a significant role in education and information dissemination. It is important to educate the victim by providing him/her with information about the nature of the problem, their options, and assuring the victim that he/she is not responsible for what has happened. Distribute literature about elder abuse when appropriate, and provide a list of emergency community resources (e.g., lock replacements, counseling, hotlines, shelters, meals-on-wheels, visiting nurse, adult day care). Family members also require education. The key is coordination of various professionals and organizations in order to provide education, technical assistance, and services [247].

Safety Planning

Practitioners should review safety planning with the elder. Components of safety planning involve encouraging the patient to have emergency numbers on hand; being able to identify warning signals that the violence might escalate; having bags packed in the event that the elder needs to leave immediately; and forming an escape plan by identifying all the exits. The elder should be encouraged to replace locks if necessary. Remember, older women and men do experience domestic violence or spousal abuse; and therefore, it is important to review safety planning. Again, safety planning should be done in such a way that it does not contradict the ethical principle of respect for persons; it should help keep elders safe but simultaneously empower them to change their situations [197].

Legal Assistance and Orders of Protection

Elders may require legal assistance to establish guardianships, revoke powers of attorney, and obtain orders of protection. Every state offers orders of protection for domestic violence. These orders are available for victims of provable violence perpetrated by a person to whom the victim is married or was formerly married, has a child in common, or is related by blood [198]. Some states extend the availability of orders of protection to include vulnerable adults [198]. Orders of protection essentially stipulate that the abuser must stay away from the victim and his/her home, vacate the home, and/or refrain from abuse or threats. Practitioners must be aware of the limitations of orders of protection and seek legal consultation for elder abuse victims. More states are expanding their definition of domestic violence to include other forms of family violence, including elder abuse [199].

Alternative Housing

Practitioners can discuss options for alternative living arrangements with elderly individuals. Depending on the situation, domestic violence shelters might be appropriate; in other cases, temporary stays in care facilities, senior housing, or shelters for victims of abuse may be preferred [200]. However, domestic shelters are not always suitable for elders, especially if they have limited mobility or require assistance with activities of daily living [218]. Always begin with the least restrictive arrangements. For example, does the elder have someone to stay with him/her? In addition, explore options such as home care arrangements and the issue of temporary or permanent alternative residences (e.g., a senior citizen residence, nursing home, shelters).

Providing services to elders at risk of abuse or who are victims of elder abuse is complicated. Practitioners must wrestle with issues of self-determination, mental competency, and, as discussed previously, inconsistency of elder abuse statutes from state to state. The concept of self-determination refers to the right of individuals to make their own decisions [201]. To truly self-determine, each person must have several alternatives that are feasible and appropriate to their situation. To complicate matters, in working with elder abuse victims, practitioners also must examine patients' levels of "learned helplessness," fear, and mental competency, all of which affect their ability to self-determine [201]. Consequently, working with elders requires a long-term casework approach—the building of a trusting relationship with the patient, referring, linking, and coordinating appropriate services, and providing counseling and support to the individual [201].

Prevention

Healthcare facilities often conduct background checks on their care providers. Families who hire care providers for their elder relatives should also conduct comprehensive background checks to reduce the risk of abuse. Family members may do some background checks themselves by calling references and verifying employment dates. With Internet technology, there are businesses that will conduct background reports for a nominal fee. Red flags that could indicate potential problems include [202]:

- Unsigned applications

- Gaps in employment that are not or are poorly reconciled

- Unanswered questions regarding criminal background

- References are friends or family members as opposed to previous employers/supervisors

- Names of past supervisors cannot be recalled

- Poor explanations for leaving other positions

- Excessive cross-outs and changes made on the employment application

- Background questions not answered

In some states, banks are mandated to report incidences of financial abuse of their elderly clients through APS [203]. However, many banks are concerned about legal liability despite the fact that there are immunity clauses for those who report in good faith.

In terms of general prevention, social services and other outreach programs can help with early detection and overcoming the barrier of isolation [231].

State of Elder Abuse Interventions

Although elder abuse has been the subject of intense research and debate for several decades, there remains little consensus about the effectiveness of any one particular intervention [250]. Studies that evaluate elder abuse interventions often have small sample sizes, lack methodologic rigor, and tend to rely on poor-quality evidence, making it challenging to definitively identify effective intervention and prevention services [250,251,252].

ETHICAL ISSUES

There are unique ethical issues for practitioners when dealing with cases of elder abuse. Practitioners should consider the following ethical issues.

Autonomy and Self-Determination

Autonomy is defined as an ability to control one's own life and is based on independence and freedom [204]. On the other hand, self-determination is characterized by the ability to make informed decisions and plans to fulfill personal goals [205]. Both autonomy and self-determination are important aspects of care and should be protected. In some cases, the violation of clients' autonomy and self-determination is very subtle. For example, practitioners should consider whether the role of the practitioner's expert status inadvertently reinforces or mimics the power dynamic in an abusive relationship [206]. The abused elder should feel free to make decisions regarding his or her life or care.

The state may intercede when an individual cannot protect him/herself from harm. Referred to as parens patriae, the state's intervention allows agencies, such as APS, to provide voluntary and involuntary services for at-risk elders [207].

The balance between promoting self-determination and ensuring the welfare of the individual is a delicate issue. Practitioners should keep in mind that an elder's level of autonomy is not static. It will constantly change due to altering medical conditions and level of functioning. Therefore, is important to periodically evaluate the individual's level of autonomy to determine the balance between supporting self-determination and beneficence [197,253].

It is important that practitioners be supportive of patients' decisions regarding care [205]. To this end, the National Association of APS Administrators and others have identified best practice guidelines to promote principles of autonomy and self-determination [207,208,253]:

- Seek informed consent from the elder.

- Discuss values and preferences with the elder.

- Avoid imposing one's own personal values on the elder, and support the client's values and preferences regardless of whether they conflict with one's own value system.

- Recognize the elder's individual cultural and personal differences.

- Involve the elder as much as possible with the intervention plan.

- Evaluate care plans that take into account physical safety, independence, and the client's values and preferences.

- Employ the least restrictive services first.

- Respect the elder's decisions.

Informed Consent

The issues of self-determination and an individual's mental capacity are components of assuring informed consent. Although protecting a client's self-determination is important, there will be times when a person cannot give informed consent. If a client's capacity may be compromised, there are three courses of action that may be taken. A surrogate caregiver, ideally identified by the client via a durable health care power of attorney, could provide consent. Alternatively, the surrogate caregiver may give informed consent while the elder gives assent. Finally, the client may have created documents indicating consent for certain procedures or wishes (e.g., living wills, do not resuscitate orders) prior to incapacitation [209].

Confidentiality

The practitioner's duty to respect a patient's or client's privacy of information is referred to as confidentiality. Because a victim's trust has been violated, he/she may have difficulty trusting practitioners and may be reluctant to accept help [253]. If during any patient assessment abuse is suspected, the necessary steps of action will be dictated by the state laws regarding elder abuse [253]. Effective collaboration involving sharing information across various agencies to coordinate services to protect the elder is vital, as is the protection of the client's right to confidentiality. Ultimately, the promotion of confidentiality should not breed inaction [175].

Capacity

It is unethical to assume that all elders do or do not have the capacity to make decisions. If an elder abuse victim does not take action against the perpetrator or to end the abusive relationship, this does not indicate lack of capacity [198].

It is often assumed that with old age comes diminished intellectual ability, which is an ageist attitude [198]. Normal aspects of aging, such as hearing loss, may make communication difficult, which may in turn be misinterpreted as diminished capacity. Therefore, each patient's physical limitations should be taken into account and communication modified as necessary. This allows important information to be accurately conveyed and ensures that all decisions are appropriately informed [198]. It may be necessary to take more breaks or otherwise accommodate the elder's needs during appointments [218].

5. RESOURCES FOR PRACTITIONERS WORKING WITH THE ELDERLY AND ABUSE VICTIMS

The following resources are provided for practitioners to gain more information about various aspects of elder abuse as well as resources to get additional information about services to which to refer elders.

Administration for Community Living

https://acl.gov

Center of Excellence on Elder Abuse and Neglect

http://www.centeronelderabuse.org

Eldercare Locator

https://eldercare.acl.gov

Elder Justice Coalition

http://www.elderjusticecoalition.com

Futures Without Violence

https://www.futureswithoutviolence.org

National Long-Term Care Ombudsman Resource Center

https://ltcombudsman.org

National Academy of Elder Law Attorneys, Inc.

https://www.naela.org

National Adult Protective Services Association

https://www.napsa-now.org

National Center on Elder Abuse

https://ncea.acl.gov/

National Center for Victims of Crime

https://victimsofcrime.org

National Clearinghouse on Abuse in Later Life

https://www.ncall.us

National Coalition Against Domestic Violence

http://www.ncadv.org

National Institute of Justice

https://nij.ojp.gov

National Organization for Victim Assistance

https://www.trynova.org

National Online Resource Center on Violence Against Women

https://www.nsvrc.org/organizations/115

The U.S. Government Guide for Seniors

https://www.usa.gov/features/usagovs-guide-for-seniors

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78041 • Integrating Mindfulness into Clinical Practice

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

www.netce.com

Copyright © 2019 NetCE, All rights reserved.

Mindfulness is the ancient meditation practice of staying in the moment and noticing life absent of judgment. Mindfulness has been a buzzword in the helping professions in recent years, and with good reason. Evidence continues to suggest that clinical applications of mindfulness principles can have a direct impact on client health and wellness. In this course, participants will learn about the basics of mindfulness meditation, consider its applications for enhancing quality of life, read about advances in the field regarding the use of mindfulness alongside a plethora of existing practices, and learn specific, simple ways to incorporate mindfulness principles into clinical practice with clients.

Table of Contents

78041 • Integrating Mindfulness into Clinical Practice

Course Overview

Audience

Course Objective

Learning Objectives

Faculty

Faculty Disclosure

Division Planner

Division Planner Disclosure

Director of Development and Academic Affairs

Director Disclosure Statement

About the Sponsor

Disclosure Statement

Implicit Bias in Health Care

1. INTRODUCTION

2. HISTORICAL BACKGROUND

THICH NHAT HANH AND THE MIRACLE OF MINDFULNESS

MINDFULNESS: EAST MEETS WEST

3. SEVEN ATTITUDES OF MINDFULNESS

4. MINDFULNESS PRACTICES OF DAILY LIFE

SEATED AWARENESS

BELLY BREATHING

MUSCLE CLENCH AND RELEASE

MINDFUL WALKING

IMPORTANCE OF PRACTICE

5. MINDFULNESS AS A CLINICAL CONCEPT

MINDFULNESS-BASED STRESS REDUCTION

MINDFULNESS-BASED COGNITIVE THERAPY

DIALECTICAL BEHAVIOR THERAPY

ACCEPTANCE AND COMMITMENT THERAPY

EYE MOVEMENT DESENSITIZATION AND REPROCESSING (EMDR)

12-STEP TRADITIONS

CANCER CARE

RESEARCH SUMMARY AND NEW DIRECTIONS

6. WAYS TO CULTIVATE MINDFULNESS

BREATH WORK

MEDITATION: SEATED AND WALKING

YOGA

DANCING MINDFULNESS

MINDFUL EATING

MINDFUL LISTENING

MINDFULNESS IN ALL ACTIVITIES OF LIFE

7. MINDFULNESS IN THE CLINICAL SETTING: TREATMENT PLAN STRATEGIES

INTEGRATING MINDFULNESS INTO ANY APPROACH

TO BE WITH THE EMOTION/WORD/SOMATIC EXPERIENCE

ANXIETY AND TRAUMA-RELATED DISORDERS

ADDICTION

DEPRESSION AND GRIEF

8. MINDFULNESS IN CONTINUING CARE

STRATEGIES FOR REINTEGRATION USING MINDFULNESS

ACCESSING RESOURCES WITHIN THE COMMUNITY

9. CONCLUSION

10. RESOURCES

WEBSITES

BOOKS

Works Cited

Evidence-Based Practice Recommendations Citations

78041 • Integrating Mindfulness into Clinical Practice

Education Category. Alternative Medicine

Release Date. 10/01/2019

Review Date. 09/15/2022

Expiration Date. 09/30/2023

Course Overview

Mindfulness is the ancient meditation practice of staying in the moment and noticing life absent of judgment. Mindfulness has been a buzzword in the helping professions in recent years, and with good reason. Evidence continues to suggest that clinical applications of mindfulness principles can have a direct impact on client health and wellness. In this course, participants will learn about the basics of mindfulness meditation, consider its applications for enhancing quality of life, read about advances in the field regarding the use of mindfulness alongside a plethora of existing practices, and learn specific, simple ways to incorporate mindfulness principles into clinical practice with clients.

Audience

This course is designed for professional clinicians, including counselors, social workers, and therapists, who work with clients on a regular basis who may benefit from the integration of mindfulness into their treatment plans.

Course Objective

The purpose of this course is to provide mental health professionals with an appreciation of the benefits of mindfulness approaches. Many therapeutic mindfulness techniques will be presented that can be safely and effectively incorporated into clinical practice.

Learning Objectives

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

1. Outline the history of modern mindfulness.

2. Define mindfulness and the underlying attitudinal and theoretical concepts.

3. Describe the utility of mindfulness in clinical practice and evidence supporting its use for specific clients.

4. Discuss the practice of breath work and potential uses for clients and professionals.

5. Compare and contrast various approaches to mindful meditation, including seated, walking, yoga, and dancing styles.

6. Evaluate the use of mindfulness in the treatment of anxiety, depression, and substance use disorders.

7. Describe how mindfulness techniques may be used in continuing care.

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 Planner

Alice Yick Flanagan, PhD, MSW

Division Planner Disclosure

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

Director of Development and Academic Affairs

Sarah Campbell

Director Disclosure Statement

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

About the Sponsor

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

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

Disclosure Statement

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

Implicit Bias in Health Care

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

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

1. INTRODUCTION

Many professionals have heard the term mindfulness used a great deal in clinical or education culture but may not quite sure what it means or how to apply it. Others are students of mindfulness, either as a meditative practice or as a clinical practitioner looking for relevant ways to apply it in clinical life. This course should be useful for both of these types of learners.

Following an introductory section exploring the history of mindfulness, its foundations and principles, specific recommendations for cultivating or practicing mindfulness will be provided. To optimally benefit from this course, readers should attempt each skill described, particularly before teaching these skills to clients.

After a thorough description of mindfulness practices, the course will explore how to integrate mindfulness skills into clinical treatment planning. It will describe how mindfulness works well in addressing specific clinical conditions, such as depression, anxiety, trauma and stressor-related disorders, and addiction.

Furthermore, this course will demonstrate how mindfulness can complement a chosen approach to psychotherapy. In addition, mindfulness as a continuing care strategy will be examined. Numerous mindfulness-based skills and strategies will be offered that can be used for client wellness even after therapy terminates.

2. HISTORICAL BACKGROUND

THICH NHAT HANH AND THE MIRACLE OF MINDFULNESS

Thich Nhat Hanh, Zen Buddhist author, teacher, and often referred to as the father of mindfulness in the West, states [1]:

Mindfulness is the miracle by which we master and restore ourselves. Consider, for example: a magician who cuts his body into many parts and places each part in a different region—hands in the south, arms in the east, legs in the north, and then by some miraculous power lets forth a cry that reassembles whole every part of his body. Mindfulness is like that—it is the miracle that can call back in a flash our dispersed mind and restore it to wholeness so that we can live each minute of life.

Nhat Hanh's manual The Miracle of Mindfulness, published in 1975, lays out the basic principles of what he calls "engaged Buddhism" [1]. These guidelines first appeared in a long letter of support and advice to a fellow Buddhist monk during the Vietnam War. Writing from exile in France, Nhat Hanh wanted to encourage young Buddhist students in the social work school he founded in the 1960s.

Refusing to align with any political group, these social workers and students were kidnapped, imprisoned, and killed. It was during this time that Nhat Hanh urged them to continue to work in a spirit of compassion and of reconciliation, to not give in to despair. He emphasized the essential discipline of following the breath and cultivating calm mindfulness, of staying aware and present in the moment [1].

Although mindfulness has been practiced for many centuries by Buddhists and other spiritual traditions, its use as a therapeutic tool in Western medicine is a fairly recent phenomenon. Since the 1970s, several mindfulness-based clinical approaches have been developed and have inspired a wave of scientific and scholarly investigation.

In Western medical practice, mindfulness is described as a psychologic state, a practice of mindfulness meditation, and a mode of awareness. The current understanding of mindfulness in clinical psychology is that mindfulness is an awareness of experience in the moment, without judgment, and with acceptance. However, it is important to note that acceptance is not a passive, docile, or hopeless state—it means experiencing an event without having an extreme reaction or suppressing it [2].

MINDFULNESS: EAST MEETS WEST

Interest in mindfulness started in America with the growth of Zen Buddhism in the 1950s and 1960s. Psychotherapists began to integrate meditation techniques into their practice, and researchers experimented with ways to heighten awareness and explored levels of consciousness, including through drugs and meditation [3].

One of the most famous of these researchers was Dr. Richard Alpert, who became known as Ram Dass. He was a psychology professor who worked with Dr. Timothy Leary at Harvard University in the 1960s. Their controversial teachings on the use of lysergic acid diethylamide (LSD) and other psychedelics for expanding consciousness and achieving spiritual awakening are notorious in the field. Ultimately, Leary and Alpert were dismissed from Harvard and mainstream academia.

Ram Dass: Be Here Now

In 1971, Ram Dass published a pamphlet, which has since become a classic book in the world of meditation and metaphysical studies, called Remember, Be Here Now [4]. The teaching of "be here now" was given to Ram Dass from his spiritual teacher, Bhagavan Das, who studied in both Buddhist and Hindu traditions. The lessons of mindfulness are potently encapsulated in the phrase "be here now," and the book contains writings, drawings, and musings on the idea of finding peace through present-moment living. The book became a mission statement for a generation of individuals who sought spiritual enlightenment outside the boundaries of conventional religions.

Some people in Western cultures have preconceived notions of mindfulness as being linked to a specific religion or practice. The reality is that mindfulness can be practiced through a variety of outlets: Mindfulness is not only a meditative technique; it also includes yoga stretches or postures as a way to energize and relax the body. Yoga in and of itself has many mental and physical health benefits. Furthermore, mindfulness can be practiced through a variety of ways: walking, eating, dancing, singing, or in making the simple choices of daily living. The practice of mindfulness comes from the Eastern concept of smriti, a Sanskrit word meaning awareness, or in a more nuanced translation, to come back to awareness.

Buddhist in Origin, Universal in Application

In Jon Kabat-Zinn's seminal work Wherever You Go, There You Are, he defines mindfulness as "paying attention in a particular way, on purpose, in the presence of the moment, and non-judgmentally" [5,6]. In later writings, he adds the qualifier "as if your life depended on it" [7]. Thus, the challenge of mindful practice is to be totally in the moment with whatever one is doing as if nothing else mattered, whether that "doing" is the act of sitting down and meditating or moving through the tasks of one's day. By focusing on the here and now, the "being" instead of the "doing," one is capable of both reducing stress levels and developing attitudes that will promote overall wellness.

As a meditation practice, mindfulness is Buddhist in its origins. In fact, mindfulness is considered to be the heart of Buddhist meditation. However, Kabat-Zinn and others who write on mindfulness continue to reiterate that there is nothing exclusively Buddhist about practicing mindfulness. It is a universal approach that can be practiced alongside other philosophies, religious traditions, or even in a secular sense. One can be totally aware and in the moment with Christian or Jewish practices or with facets of nature or with secular elements of living. If one keeps an open mind and applies the concept in the context of his/her own worldview, mindfulness may be healing [8].

3. SEVEN ATTITUDES OF MINDFULNESS

According to Kabat-Zinn, there are seven primary attitudes that may be acquired and further cultivated through regular practice of mindfulness [7]. These attitudes are non-judging, patience, beginner's mind, non-striving, trust, acceptance, and letting go. Consider what each of these attitudes mean and how each attitude may apply to overall wellness for professionals and clients.

Being non-judgmental of one's internal processes is at the heart of mindfulness practice. Non-judging refers to thinking, feeling, or responding without the influence of an internal sensor or critic. Non-judging is an attitude of "just noticing" thoughts, emotions, or whatever may surface as relevant. Non-judgment, however, does not endorse behaviors that put oneself or others in harm's way. For instance, consider a recovering addict who is experiencing an intense craving to use a substance following a stressful day. Non-judgment does not advocate that the person should just go out and use, which would certainly be harmful. Rather, non-judgment encourages the person to just notice the craving, pay attention to it, and be with it in a spirit of non-judgment.

By doing this, one is more likely to make the healthier choice to handle something like a craving instead of beating oneself up for having the craving. This scenario plays out time and again with recovering people: negative judgments for having an unhealthy thought or craving lead to shame, which can be the biggest trigger for unhealthy behaviors.

Mindfulness, especially if practiced regularly, helps us to become more patient with ourselves. Patience, which derives from the Latin root (patientia) meaning to undergo, suffer, or bear, is the art of deferring gratification. Patience teaches how to wait with grace. By cultivating this attitude, one can not only learn to defer instant gratification, but also to be gentler with oneself when shame-based responses attempt to sabotage. Thus, mindfulness practice is a way to retrain maladaptive cognitive and emotional responses while being gentle with oneself.

The mindfulness attitude that can significantly impact this retraining of the brain is "beginner's mind." Beginner's mind is approaching each new task with an open mind. Think of the sense of wonder that a child attempting a task for the first time may experience. With this attitude, one can remove an expert's mindset and refrain from living on metaphorical autopilot. Skills like walking meditation are wonderful strategies to work with beginner's mind because one is challenged to take an activity that tends to be automatic, like walking, and break it down to appreciate each individual part as if one is walking for the first time.

Practicing any activity with a beginner's mind is also a very effective way to practice non-striving: thinking, feeling, or acting with focus on the process, not just the outcome. The name of this skill confuses many people, because Western culture tends to associate non-striving with giving up. Non-striving does not imply laziness or sloth. Non-striving is an attitude that encourages one, even in work, to refrain from fighting so hard. In non-striving, whatever happens, happens. Consider the saying, "life is about the journey, not the destination," which epitomizes the spirit of non-striving.

The final three attitudes of mindfulness are also ideal for enjoying the journey without letting the stress of reaching the destination trouble us. First, there is the attitude of trust, or having belief in some unseen entity, such as another person or group or the internal self. One can also practice trust in an outcome that may not be obvious during the journey by believing it is there and it will be reached when it is supposed to be reached.

The next attitude is acceptance, or coming to terms with reality no matter how harsh or unpleasant it may be. Practicing acceptance can be a pathway to peace, and it does not imply one must "like" the reality in order to discontinue fighting. Acceptance is internalizing the attitude of "it is what it is." Finally, there is the attitude of letting go, or releasing one's "grip" on a situation, emotion, person, thing, or outcome. Letting go generally results in a freeing response (or at least the beginnings of one). This response can clear the path for wellness and growth.

According to Kabat-Zinn, these seven primary attitudes are the foundational fruits of mindfulness practice [7]. By internalizing them, a variety of other attitudes can flow into our lives. Kabat-Zinn identifies friendliness, gratitude, gentleness, curiosity, non-attachment, non-reactivity, happiness, and creativity as possible outcomes. Others can include attunement, persistence, confidence, and willingness. Attunement, or being in harmony with another human or entity, is an especially vital skill for helping professionals. By practicing attunement, professionals are able to more effectively read a client's nonverbal signals and sense any subtle shifts in energy or relational dynamics.

4. MINDFULNESS PRACTICES OF DAILY LIFE

In many of his books on mindfulness, Jon Kabat-Zinn recalls meeting a master of Chan (a school of Chinese Buddhism) who espoused, "There are an infinite number of ways in which people suffer. Therefore, there must be an infinite number of ways in which Dharma is available to people" [7]. The English translations of dharma from Sanskrit are numerous, but the one that seems to most resonate for the purpose of helping others with suffering is to think of dharma as the stability and harmony of the universe [9].

People suffer in so many ways, so it is good common sense to have a variety of approaches to help people. One of the foundational principles of trauma-informed, person-centered counseling is meeting people where they are. Because mindfulness can be practiced in a variety of ways, there are numerous exercises available to help any number of clients develop a program of coping skills.

This section will present four separate skills that can encourage the practice of mindfulness through a variety of channels that are a part of daily life: sitting, breathing, relaxing muscles, and walking. As a reminder, it is important to try these skills before teaching them to clients.

SEATED AWARENESS

Instructions

- Shift around in your chair a little bit, or in a seated position on the ground, until you find a position that, for you, symbolizes paying attention.

- Be careful not to slouch your shoulders, but also be aware not to sit so straight that it hurts you to be in this sitting posture.

- Spend some time paying attention to your body and make a mental note of what this posture of awareness feels like for you.

- If your head starts to wander or you feel that you have stopped paying attention, this is an opportunity to practice non-judgment and beginner's mind. When you catch yourself, use this as a chance to bring your attention back to the body posture of awareness.

- Work up to practicing this in three-minute increments. This practice is an effective way to cultivate the attitude of patience.

Modifications

If three minutes is attempted and simply cannot be done, consider adding in another sensory element and practice paying attention to that element (e.g., a scent, a simple sound, or a tactile sensation, like holding a rock). If sitting is not accessible, this same exercise can also be done standing or lying down. Remember to keep the emphasis on awareness [8].

BELLY BREATHING

Instructions

- Put one or both hands on the upper area of your stomach so you can pay attention to the motions you are engaging with your diaphragm.

- As you inhale with your nose, allow your belly to expand as far as it will go.

- Exhale with your mouth, allowing the belly to pull back in.

- Continue this inhale-exhale pattern and your own pace, giving it at least six to seven sets to find a rhythm and style that works. Curiosity and non-judgment are key.

- After finding your rhythm, consider puckering your mouth and really exaggerating your exhale, striving to make it somewhat longer than your inhale. This should help facilitate relaxation.

Modifications

If you feel awkward, or in any way out of control with this suggested pattern, consider starting with an exhale instead of the inhale. If paying attention to the breath on its own is not working, consider adding a count to it (e.g., In-2-3-4…hold…Out-2-3-4). A word or a special phrase (e.g., Sat Nam, amen, peace, help me) may also be added.

Children may be engaged in this practice by having them put something like a bean bag or a flatter stuffed animal on their stomach so they have a focus point while they observe the rise and fall of the belly [8].

MUSCLE CLENCH AND RELEASE

Instructions

- Make fists.

- As you focus on your clenched fists, bring to mind something that causes stress in your life.

- As you reflect on the stressor, really notice the contraction of your muscles. Feel your fingernails dig into your skin, if possible.

- Whenever it feels too uncomfortable for you to keep holding on, know that you can slowly, mindfully let go at any time.

- Notice your fingers uncurling, and feel the trickle of letting go all through your arms and up to your shoulders.

- Notice how good it feels to let go.

Modifications

Any muscle group can be clenched and released, especially if clenching the fists is too painful or not possible due to context or physical limitations. Clenching and releasing the stomach and feet are other popular choices.

For help with sleep and deeper relaxation, clench and release one muscle group at a time (holding each clench 20 to 30 seconds and then slowly releasing). The entire exercise, known as progressive muscle relaxation, should take about 20 minutes. A relaxing sound (e.g., nature sound, music) may be added in the background or an aromatherapy diffuser may be used to further relaxation [8].

MINDFUL WALKING

Instructions

- Think about looking toward the horizon during the walk instead of down at your feet.

- Consider the art of breaking this walk down into slow motion, as if you are experiencing it for the first time (i.e., beginner's mind).

- Standing tall, let your heel connect with the earth and allow the front part of your foot to point towards the sky.

- Very slowly step down, shifting the weight from your heel to the ball of the foot.

- Shift the weight from the ball to the toes.

- Deliberately repeat this same motion on the other foot.

- Continue taking this walk in this slow, deliberate fashion, observing each sensation with a new awareness. Let your walk truly be an exercise in mindful meditation.

Modifications

This exercise can be done inside or outside. If the exercise is being taught to a client, it is recommended to start at a slow pace. However, the same exercise can be done in the spirit of silence and meditation at a faster pace. A faster pace is good when teaching the idea that one can still achieve mindful awareness even at the regular pace of life.

Reflection

Consider the four exercises covered in this section and think about how "being in the moment" can be practiced with each activity. At this point, what are some other ideas for practicing mindfulness in activities of daily living?

IMPORTANCE OF PRACTICE

In working these exercises oneself, or teaching them to clients, it is important to remember the word "practice." No one can be ideally in the moment the first time she or he tries these exercises. As with learning any activity, mindfulness takes practice, especially in order for it to internalize and become a more automatic part of daily living. In working with clients, it is important to highlight the practice element, because many clients abandon an activity if they do not experience instant results.

It is normal for clients not to experience an effect right away, which is why starting with a three-minute goal is important. In addition, it may be advisable to teach at least three different mindfulness skills at first, because one usually resonates most strongly in terms of causing a positive response. If a person can find a core skill to work with initially, then he or she may be encouraged to start working with some of the others.

The challenge of mindfulness is that, while it seems so simple on the surface, practicing it can be quite challenging. This is partially because Western society is the very essence of mindlessness—fast-paced and result-oriented, with a focus on "doing" rather than "being." As Kabat-Zinn articulates, the work of mindfulness is some of the hardest work in the world [7].

5. MINDFULNESS AS A CLINICAL CONCEPT

Where Ram Dass served as a vital figure in leading people to consider the power of mindfulness, Jon Kabat-Zinn pioneered the meditative benefits of mindfulness and developed a systematic program for helping people with stress, physical illness, and mental disorders. His academic background is in molecular biology, but his work has been widely influential in the medical and mental health professions. A student of Buddhist meditation practices, Kabat-Zinn, then a professor at the University of Massachusetts, introduced his program in 1979 [5].

Several therapeutic approaches have been developed based on mindfulness meditation precepts. Approaches like mindfulness-based stress reduction (MBSR) and mindfulness-based cognitive therapy (MBCT) have gained prominence. Other innovative approaches to therapy, like dialectical behavior therapy (DBT) and acceptance and commitment therapy (ACT), make use of mindfulness in their approaches. Indeed, all of these approaches are part of the larger umbrella of mindfulness-based interventions.

MINDFULNESS-BASED STRESS REDUCTION

The history of Kabat-Zinn's program, which came to be known as MBSR, and its teaching protocols are explained in his book Full Catastrophe Living: Using the Wisdom of the Body and Mind to Face Stress, Pain, and Illness [5]. This book is considered a classic in the area of mind-body medicine. While Kabat-Zinn was unlikely the first professional to use mindfulness principles with clients and patients, the results of his program generated attention within his own medical center. MBSR then expanded into the psychologic and medical fields at large, cementing his status as a pioneer of modern mindfulness.

It is important to remember that mindfulness practice and MBSR are not synonymous [10]. MBSR programs must follow the eight-week protocol and ideally be presented by an individual who received training directly from Kabat-Zinn and his team. The MBSR structure contains work in breathing, seated meditation, walking meditation, gentle yoga, and body scanning. Participants are encouraged to practice these skills as homework, and the hope is that over the course of the program, changes in attitudes toward oneself and one's health will change.

Most of the mindfulness research available at present is related to formal MBSR and MBCT, also a systematized program that uses mindfulness practice to help people readjust their negative schema.

Comprehensive meta-analytic research demonstrates a strong effect of the completion of a formal MBSR program on overall psychologic well-being, especially in clinical populations [11]. The same review found that general mindfulness meditation practices outside the scope of a systematized MBSR program have the strongest effect for subclinical populations, especially connected to the attitudes of mindfulness and wellness variables. The increased effect sizes for MBSR could be related to the components of the program that are not directly tied to mindfulness meditation [11].

MINDFULNESS-BASED COGNITIVE THERAPY

MBCT is a fairly new approach that combines cognitive-behavioral techniques with the mindfulness skills of MBSR. It was originally developed as a treatment of recurrent depression and has been used for several years in the treatment of depression with good results. MBCT was developed by Segal, Williams, and Teasdale, with the first clinical trial published in 2000. Since then, scientific evidence indicates that MBCT may also be effective in other conditions such as bipolar disorder, anxiety, food and eating issues, and psychosis. Like MBSR, the MBCT protocol calls for an eight-week course during which participants learn how to use cognitive methods and mindfulness meditation tools to combat the processes that trigger depression. Better understanding of the association between thoughts and feelings and how to interrupt and change these processes to achieve better mental health are at the core of this therapeutic technique [12].

A meta-analysis to determine the efficacy of MBCT to prevent depression relapse confirmed that the approach had positive results, especially for those with more severe symptoms [13]. One study explored whether MBCT was superior to maintenance antidepressants and found MBCT to be as effective as medication in reducing re-occurrence of symptoms—both MBCT and medication had positive outcomes [14].

Other very popular clinical approaches within the helping professions make use of mindfulness principles in their foundational philosophy. While many have been influenced by the contributions of Kabat-Zinn and his work with MBSR, there is recognition that MBSR's structure may be limiting when working with certain populations in certain clinical settings.

DIALECTICAL BEHAVIOR THERAPY

Dr. Marsha Linehan is best known for her development of the ground-breaking therapy DBT, which is now a first-line option in the treatment of borderline personality disorder. Linehan found that the discipline of behaviorism was not enough to create change in patients with suicidal ideation or attempt—a population that has tried multiple times to change without success. DBT is based on two core principles [15]:

- The need to accept life as it is, not as one believes it should be

- The need to make changes in life, despite and because of the above

DBT is based on the philosophic principle that two things can be true at the same time. This important concept is used to change the black-and-white thinking that defines borderline personality disorder and other personality disorders.

Also, in working with patients with borderline personality disorder, traditional cognitive methods are often missing the necessary component of self-soothing or regulating affect. Linehan found that mindfulness and other meditation strategies worked well to fill in many of the gaps in the cognitive approach. DBT addresses this need with its focus on emotional management and regulation in treatment. Traditional DBT involves a combination of techniques including mindfulness, cognitive-behavioral therapy, relaxation, and breathing exercises [15].

Popular DBT skills that are especially rooted in mindfulness include "radical acceptance," or total acceptance of an experience or situation over which one has no control without trying to change or resist it. Other similar mindfulness concepts used in DBT include "turn the mind" (to accept and to simply be) and "letting go" (to detach from outcomes). It is very common for DBT to be taught in the form of skills groups, recognizing that clients or patients should learn and cultivate skills for tolerating intense affect and practice how to apply them [15].

To date, DBT is the most well-researched treatment for borderline personality disorder and is considered to be a first-line treatment by many clinical entities [17]. The most consistent finding is that DBT is effective in reducing parasuicidal behavior in patients with borderline personality disorder. In addition, these studies found a reduction in anger behavior and better social adjustment. There are also promising research results for DBT with patients with eating disorders and elderly patients with depression [18].

ACCEPTANCE AND COMMITMENT THERAPY

Another popular approach in the helping professions today is ACT, developed by Stephen Hayes and his team in the late 1980s. This modality also blends traditional cognitive analysis strategies with mindfulness principles. Two popular acronyms used to summarize this approach are FEAR and ACT [19]. Distress is caused by FEAR:

- Fusion with your thoughts

- Evaluation of experience

- Avoidance of your experience

- Reason-giving for your behavior

To address this maladaptive response, the healthy alternative is ACT:

- Accept your reactions and be present

- Choose a valued direction

- Take action

ACT has been suggested as a promising approach to treating PTSD and other trauma-based mental health issues. The approach has six core ACT components: creative hopelessness, the problem of control, willingness and defusion, self as context, valued living, and committed action [20].

Further reading in ACT is recommended for those looking to blend mindfulness-approaches with cognitive-behavioral work. As an approach, ACT has a great deal of empirical validation to date [15].

EYE MOVEMENT DESENSITIZATION AND REPROCESSING (EMDR)

Although MBSR, MBCT, DBT, and ACT are the most popular modalities in modern psychology that relate to mindful practice, there is evidence of mindful practice in many other approaches to psychotherapy and helping, even if mindfulness does not seem to be presented as a major focus.

For instance, some may have been introduced to the benefits of mindfulness through eye movement desensitization and reprocessing (EMDR) therapy. Francine Shapiro, who created EMDR in 1987, was a student of mindfulness and wove many mindfulness concepts into her EMDR protocol [8]. In EMDR, the client is invited to just notice or observe something, such as a thought, a body feeling, a memory, or an emotion, without judgment. Where so many approaches to therapy confront irrational beliefs or promote analysis, mindfulness approaches in therapy encourage clients to just notice [8].

12-STEP TRADITIONS

Even 12-step programs of recovery introduce concepts like living in today (as opposed to projecting to the future or dwelling in the past) and practicing acceptance as a pathway to peace [21]. Many newer approaches, like DBT and ACT, contain elements of 12-step recovery, which traces back to the 1930s. Newer approaches add to the tradition by teaching the path to mindfulness instead of just telling people to live in today or practice acceptance. A hallmark of trauma-informed addiction treatment is not just to rely on slogans and platitudes, but also to work with clients on learning how to put these helpful ideas into practice. [22]

CANCER CARE

In oncology settings, mindfulness training is often offered through MBSR or mindfulness-based cancer recovery. These are usually eight-week programs with weekly meetings and home practice of mindfulness techniques and yoga exercises. Issues addressed include loss of control, uncertainty about the future, depression, anxiety, fatigue, pain, and sleep problems.

A 2017 review of 13 studies of various cancer types found consistent positive effects for anxiety, stress, depression, and overall quality of life [23]. A few studies have shown that mindfulness training has greater improvement than other interventions, such as nutrition education and expressive group therapy, and with more long-term sustained benefits [23].

Reflection

Think about your existing paradigm, or approach, to psychotherapy. How might you weave some mindfulness principles into what you already do?

RESEARCH SUMMARY AND NEW DIRECTIONS

There is a vast amount of scholarly research on the use of mindfulness-based interventions in mental health and general health care. In 2012 alone, more than 500 studies were published demonstrating the positive impact of mindful practice on recovery from a wide variety of mental health, addiction, and physical disease conditions. According to Shonin, Van Gordon, and Griffiths, a definitive conclusion about all mindfulness research is difficult because of the imprecise parameters with operational definitions (e.g., some programs have structured protocols, like MBSR and MBCT, whereas others, like DBT, ACT, and mindfulness-based relapse prevention [MBRP] therapy, make use of mindfulness strategies as part of their larger scope).

Another problem exists, at least for the more scientifically minded, in reconciling the precisions of empirical language with the more imprecise, spiritual concepts often used in mindfulness writing that may not lend themselves to specific empirical measure. Nonetheless, Shonin, Van Gordon, and Griffiths conclude that [43]:

Interest and supporting evidence for the clinical application of mindfulness-based interventions has increased substantially in the last decade. [Mindfulness-based interventions] appear to represent cost-effective, acceptable, and non-invasive means for treating a broad spectrum of psychological and somatic illnesses.

A proliferation of research and writing has also emerged addressing the changes that occur in the human brain during the practice of mindfulness. In a 2011 article, Kabat-Zinn summarizes the findings [7]:

It is now becoming apparent that MBSR training also results in structural changes in the brain in the form of thickening of certain brain regions, such as the hippocampus, which plays important roles in learning and memory, and thinning in other regions, for instance, the right amygdala, a structure in the limbic system that regulates our fear-based reactions such as to perceived threats of one kind or another, including the thwarting of our desires.

Evidence Based Practice Recommendation

The Department of Veterans Affairs recommends considering mindfulness-based therapy, delivered by trained professionals, for patients with chronic multisymptom illness.

https://www.healthquality.va.gov/guidelines/MR/cmi/VADoDCMICPG2014.pdf

Last Accessed: September 25, 2019

Strength of Recommendation: Weak

A 2015 meta-analysis involving 21 studies found that eight regions of the brain consistently changed in experienced meditators [44]:

- Postrolateral prefrontal cortex (awareness of the thinking process, introspection)

- Sensory cortices and insular cortex (tactile information, pain, body awareness)

- Hippocampus (memory, emotional responses)

- Anterior cingulate cortex and mid-cingulate cortex (self-control, emotional regulation, attention)

- Superior longitudinal fasciculus and corpus callosum (communication between and within brain hemispheres)

While research into mindfulness and meditation is in the early stages, their findings suggest that mindfulness practices are promising in the treatment of clinical disorders as well as supporting better mental health and increased well-being for the general population [44].

6. WAYS TO CULTIVATE MINDFULNESS

For clinical counselors and helping professionals strongly committed to meeting clients where they are along the journey, the wisdom of Jon Kabat-Zinn's Chan master is sage guidance: Just as there are many ways that people suffer in this world, there are many ways to overcome suffering. Mindfulness is universal, and working with clients on mindful practice is a trial-and-error process to help them find the avenue or avenues that will work best to help them stay in the moments of life. There are several mindfulness outlets that people can use in combination to help bring about overall lifestyle change.

The key is in motivating clients to consistently practice their chosen outlets. This section will build upon the four skills covered in the previous section by offering even more options for mindful practice. Then, other physical outlets, like yoga, dance, and other exercises, will be considered, followed by instruction on how to eat mindfully, how to listen mindfully, and how to carry mindful practice into all areas of life. Once again, attempting to practice these skills will enhance one's ability to teach them to clients and may provide good options for self-care.

BREATH WORK

This section will present some additional breath work ideas to work on alone or with clients, building on the foundations of diaphragmatic breathing. Be advised that in the traditions of yoga and mindfulness meditation, there are many more breath exercises to attempt if they are proving useful. Additional resources for breath work techniques and instructions are provided at the end of this course. Whichever specific breath strategy works best, the key when incorporating breath work as a practice in mindfulness is to develop the habit of focusing totally on the breath. The goal is to breathe with single-pointed attention and focus, no matter how much practice it takes to get there. Cultivating this practice makes deeper breathing a more automatic, healthy response in daily life when one is met with a stressor.

Complete Breathing

Instructions

- Begin with a diaphragmatic breath but continue the inhale into the ribs and then the chest. Placing a hand on the chest can help with awareness.

- At the top of the inhale, cradle the breath in your awareness for a moment; this is a more meditative way to conceptualize holding your breath.

- Gradually release the breath with your exhale, allowing the chest, the ribs, and the belly to pull back in.

- Continue this inhale-exhale pattern at your own pace, completing at least six to seven sets to find a rhythm and style that works for you. Curiosity and non-judgment are key, as with any other breath.

Modifications

The standard pattern with exhales is to keep them slow and deliberate. However, a very powerful variation is a fast, dramatic exhale, like a "sigh of relief." Practitioners should feel free to be as dramatic as they like on the exhale, perhaps bringing the hand to the forehead. This breath is a chance to put letting go of negative energy into practice. When you expand your chest on the inhale, you can bring up "superhero" imagery (especially fun with children) to further the empowering motion.

Breath Controls the Mind

Teaching clients how to mindfully breathe is paramount to clinical practice. So many clinicians trained in cognitive-behavioral approaches to therapy learned that changing behaviors requires a person to change the way that he or she thinks. The traditions of yoga and mindfulness teach that in order to change thoughts, one must first change the breath. One guiding principle comes from the Indian yogi B.K.S. Iyengar, one of the primary figures responsible for bringing yoga to the West. Iyengar advised that the mind controls the body, but the breath controls the mind [24]. Thus, where cognitive approaches to therapy advise to change the thinking in order to change the behavior, Iyengar proposes that to change the thinking, one must first change the breath.

Start with Three Minutes per Day

When breath work is incorporated into clinical practice, it should be one of the first areas covered. In order to be effective, it should become an essential part of one's routine. Giving one's brain some time each morning and each evening to receive deep, mindful breaths is like metaphorically brushing your teeth or washing your face; breath practice delivers the brain the proper oxygen it needs to clear out and balance. This metaphor can be shared with clients to explain the value of regularly practicing breath. Committing to 3 minutes of breath work per day, working up to 10 minutes, will initiate changes in functioning and gives people a reachable starting goal.

These three minutes may be worked on together in sessions or clients can begin practicing breath work in their everyday life, even while waiting at a traffic light or standing in line at a store. While structured approaches to mindfulness training (e.g., MBSR) recommend longer periods of breath practice, many clients will be overwhelmed by the notion of breathing for 20 or 30 minute stretches at a time; however, 3 minutes is feasible. From a consistency standpoint, people breathing mindfully for 3 minutes at various points in the day can be more helpful, especially as a coping mechanism, than allotting 20 to 30 minutes for mindful breathing and then going on mindless autopilot for the rest of the day.

Some clients will be resistant to doing breath work and will give a variety of excuses and reasons these exercises do not work for them, some of which are legitimate. Clinicians should be prepared with responses to help work through the resistance (Table 1).

Table 1: RESISTANCE TO BREATH WORK AND HOW TO ADDRESS IT

Comment/Resistance

Clinical Response(s)

"I just can't stay focused on my breath."

"It's okay; a lot of people report they can't focus on the breath at first. Are you willing to give it a try again? Whenever you notice your mind start to wander, just notice that it is wandering and bring your attention back to your breath. Even if you have to do this 10 times every minute, just practice bringing your attention back to your breath. Mindfulness is practice, and this is part of what practice means."

Revisit the modifications suggested for belly breathing and complete breathing. Starting with the exhale or adding a count to the breath often helps people improve their focus. For others, music or ambient sound may help maintain focus on the breath.

"Breathing just doesn't work for me."

Engage clients in a dialogue about how they've tried or been exposed to breathing in the past. From there, inform them about how your approach to mindful breathing may be different and see if they are willing to try again.

There is likely a chance that if a client has tried breathing before, he/she gave it less than one minute and, if an effect was not noticed immediately, gave up. To counter this, issue the three-minute challenge. Let the client know that you will breathe with him or her as encouragement (and modeling).

If a client has been exposed to clinical breath work in the past, it was most likely diaphragmatic breath. Consider teaching another breathing technique (e.g., complete breathing).

If a client still has a mental barrier about breathing, try a more direct body intervention, like clench and release/progressive muscle relaxation. Suggesting this as an alternative to breath work automatically makes it more appealing, and as you are guiding a client through these exercises you can insert gentle reminders about noticing the breath as she or he moves or works the muscles.

"I just can't relax when I breathe. It makes me more tense because I worry if I'm doing it right."

Suggest that the client start with the exhale. Starting with an exhale can create negative pressure on the lungs, making the subsequent inhale automatically relaxing.

One of Jon Kabat-Zinn's teachings is: "If you are breathing, there is more right with you than wrong with you." This wisdom serves as an excellent coaching statement for people with hesitation about technique.

"Getting that relaxed makes me nervous. I don't feel comfortable letting my guard down. What if someone sneaks up on me?"

Make sure the client knows that he/she does not have to close the eyes in order to do breath work. Closed eyes during breath work can increase trauma-related claustrophobic responses.

Take the breath work very slowly and gradually. Start with just one or two breaths, and then have the client look around the room, perhaps repeating an affirmation (e.g., "I'm here now. I'm safe."). When the client feels ready, he/she can resume with deeper breathing. Encourage the client to be aware of his or her surroundings, even while doing breath work, and check in at any time.

"I am prone to fainting spells." (Other medical reasons may also be given as reasons or concerns.)

Obtain a release from the client's medical provider. This may help with the client's and clinician's peace of mind.

Take shorter breathing sets (two to three inhale/exhale repetitions) instead of standard sets of five to six repetitions, and instruct the client check in with his or her body after each attempt. Learning to listen to the body is an important skill in and of itself.

Begin with diaphragmatic (belly) breathing first to determine if the client tolerates the breath work before moving on to some of the fuller breath exercises.

Source: Compiled by Author

Ocean or Ujjayi Breathing

Instructions

- Pucker your mouth as if you are sucking through a straw or about to kiss someone. Attempt to contract the back of your throat slightly.

- Inhale through your nose, expanding your diaphragm and belly.

- Exhale through your nose. Although air may flow out of your mouth, think about doing the work with your nose.

- If your mouth is puckered and throat is contracted, each breath should produce a sound similar to the ocean.

- Attempt to keep the inhales and exhales even in length, especially when first learning the breath.

- Do not attempt more than five full sets during first attempts.

- It is normal if you feel somewhat light headed, but it should be a "good" light-headed. If it does not feel good, this indicates that the inhales and exhales were uneven or that too many sets were attempted.

Modifications

Some clients benefit from envisioning different characters with this breath, like Darth Vader or a charging bull. It can also be helpful to use a mirror to see the steam of the breath makes, attuning one to the idea of breath as a force. Some clients also like to visualize breathing in a calming or soothing color and breathing out a color that represents stress [8].

Lion Breathing

Instructions

- Begin with a healthy inhale (as in complete breathing, start with expansion of the stomach and then the chest).

- Exhale vigorously, allowing the tongue to hang out. Feel the jaw and cheeks loosen. Open the eyes wide to facilitate a feeling of letting go.

- Try at least five sets, although you can continue with this breath as long as it is physically comfortable for you.

Modifications

This is a good exercise to teach to children (or adults who are not too self-conscious to try it). Instruct clients to think of making this face when ugly thoughts about trauma or stress come up, embodying the strength of a lion in the wake of a painful trigger.

MEDITATION: SEATED AND WALKING

The practicing awareness strategy introduced earlier in this course is a form of meditation. Mindfulness meditation is about being in the here and now, however it is practiced. By strict definition, meditation is extended thought, reflection, or contemplation. Contrary to popular misconception, meditation is not about erasing thoughts, but about learning how to be with them more effectively. The word meditation comes from the same Greek root as the words mediate or medicine, which simply imply bringing order back into natural balance.

Misconceptions

There are many misconceptions about meditation, and these misconceptions can be barriers to clients engaging in the practice. Some people equate meditation with blanking the mind and believe that this can allow negative or evil influences to creep in. Others, particularly devoutly Christian individuals, may feel that meditation is specifically Eastern (i.e., only for persons who practice Buddhism). As such, one of the first steps when incorporating meditation into practice is to address any misconceptions that the client may have. Some of this bias comes from legitimately publicized meditation groups that took on cult-like characteristics (a risk with any spiritual tradition), but much of it comes from misinformation. For example, clients may be reassured that meditation is a non-denominational practice. It can be engaged in as a part of any spiritual journey, including Christianity. In fact, there are 41 references to meditation in the Christian bible. [25]

Difference Between Prayer and Meditation

Many religious traditions make use of meditation in one form or another. In addition, step 11 in the classic 12-step program reads: "Sought through prayer and meditation to improve our conscious contact with God as we understood God, praying only for a knowledge of God's will for us and the power to carry it out." One of the most potent distinctions at a 12-step meeting is that prayer is when one talks to a chosen deity or Higher Power, and meditation is when one sits quietly and listens for the response. When meditation is conceptualized this way, few people argue with its value.

Health Benefits of Meditation

The health benefits of meditation continue to be supported by both case and research evidence. A comprehensive meta-analysis examined 163 studies of various meditation traditions (including mindfulness meditation) and found a strong effect size for meditation in helping with emotionality and relational issues and a moderate effect size for issues related to attention. The effects were similar regardless of the specific meditation tradition practiced [26].

Another meta-analysis specifically compared MBSR and general mindfulness meditation practice on various psychologic variables. Researchers found that while MBSR practice shows a greater effect on psychologic well-being, general mindfulness practice had a larger effect with subclinical populations as they related to the variables measured in the study (e.g., the attitudes of mindfulness) [12]. In a review of the research available on mindfulness meditation, Bauer-Wu determined that mindfulness meditation is very safe and has few associated risks [27].

Some people may experience a transient increase in anxiety when initially attempting meditation, as they let go of usual busy-ness and distractions and become aware of unsettling thoughts and feelings, but this is generally short lived. In addition, mindfulness meditation and mindfulness-based clinical interventions are low-cost and low-risk mind-body practices that have been shown to positively affect quality of life and biologic outcomes in many different populations, including healthcare professionals and individuals with cancer [27].

The MBSR program makes use of both seated and walking meditation, often alternating between the two in the protocol to encourage clients to experience mindfulness in both planes. The basics of a seated awareness exercise and a walking meditation were outlined previously in this course, and both can be easily practiced in clinical or community settings.

YOGA

If one is open to it, meditation can also be carried into a more dynamic plane of movement and exercise. The ancient practice of yoga is one of the primary components of traditional MBSR. However one practices yoga, whether it is part of a structured MBSR program or as part of a personal fitness and wellness regimen, it is a physical and mental practice that can help cultivate mindfulness.

Yoga is a Sanskrit word meaning union, or more specifically, to yoke. A yoke is a device for bringing two parts together. In yoga, the yoke is the spiritual realm, bringing together body and mind. In psychotherapy and the helping professions, attention has been focused on the importance of holistic care and integrating the human elements of mind, body, and spirit. The practice of yoga is designed to create this union and has been doing so for thousands of years.

Yoga: The Eight-Limbed Path

In the West, yoga is commonly associated with stretching and breathing, although these are only two of the limbs or paths of yoga. Yoga is a true folk practice, passed down through the generations of practitioners in ancient India. Patanjali, who lived in the second century B.C.E., recorded the first writings on yoga, the Yoga Sutras. In its fullest form, yoga is an eight-part path that includes moral or ethical principles such as nonviolence, compassion, and truthfulness. Other limbs or paths are concerned with breath control, poses, and four levels of meditation.

An entire discourse on yoga philosophy is beyond the scope of this course; if this is an area of interest, please use the recommended resources given at the end of this course.

Scientific Research on Yoga

The Harvard Medical School reports that in the past decade, the research on yoga has tripled—as of 2014 there have been a total of 312 randomized controlled trials of yoga published [28]. Yoga was found to make a positive improvement in health in more than 90% of these studies. With many newer scientific methods, like measurement of biochemical levels in the brain, magnetic resonance imaging (MRI), and DNA analysis, researchers are able to show how yoga changes the body [28].

Role in Treatment of Psychologic Disorders

There is mounting evidence to demonstrate yoga's effectiveness as both a complementary and stand-alone treatment in addressing a variety of mental health disorders, including bipolar disorder, post-traumatic stress disorder, and obsessive-compulsive disorder [29,30,31]. Comprehensive literature reviews of yoga in the treatment of neuropsychologic disorders concluded that evidence from randomized trials supports the efficacy of yoga for depression and sleep disorders as a complementary therapy to traditional forms of treatment (e.g., cognitive-behavioral therapy) [32].

Yoga as Treatment of Trauma and Stress-Related Disorders

Bessel van der Kolk, a pre-eminent scholar and practitioner in the field of post-traumatic stress, advocates for the inclusion of yoga in the treatment of trauma- and stress-related disorders [33]. At his treatment center, the Trauma Center at the Justice Resource Institute in Boston, enrollment in one of the Center's trauma-sensitive yoga classes is compulsory. Furthermore, the Center's research initiatives are committed to studying how yoga and complementary therapies can be best integrated into trauma treatment. van der Kolk was one of a team of experts assembled by the International Society for Traumatic Stress Studies (ISTSS) to establish an "expert consensus" on the effective treatment of complex post-traumatic stress disorder [34].

One of the team's conclusions, supported by literature reviews, is that "optimization of outcomes also includes exploration of novel treatment approaches such as complementary medicine strategies that focus on somatosensory experience and the mind-body relationship, for which there is emerging evidence regarding efficacy" [34]. Many large addiction centers in the United States have been offering adjunctive classes in yoga for decades, and this trend is translating now to smaller, community-based treatment centers.

How Yoga Differs From Other Exercise

It is true that all forms of physical exercise can prove beneficial for helping with overall health and wellness. However, so many forms of sports and exercise in Western cultures are mindless and/or result-oriented. Many people in gyms watch television while walking or running on a treadmill or elliptical machine, with primarily aesthetic goals. In theory, all exercise has the potential to be engaged in mindfully, and runners have shared experiences of mindfulness and spiritual fulfillment when running [35].

As long as physical activity is focused on being in the present, without obsessing about the end result, it can be part of a mindfulness practice. However, Eastern forms of exercise like yoga, tai chi, qi gong, and the martial arts directly promote mindful attention to the physical movements and may be an easier fit. These practices can result in a heightened sense of body awareness and the associated therapeutic benefits, especially for people struggling with trauma, addiction, and eating disorders.

General Health Benefits

According to a Harvard Medical School report, 90% of patient visits may be contributed to stress-related problems. It is the third highest source of healthcare costs, after heart disease and cancer. Yoga has been proven to reduce stress symptoms in healthy people as well as those with depression and anxiety. Other proven areas of benefit include cardiovascular health (lowers blood pressure, heart rate, cholesterol levels), sleep hygiene, and immune health. In addition, yoga increases natural antioxidants, helps in weight management, and increases body strength, flexibility, and balance. Moreover, research suggests yoga can improve or maintain cognitive health in older adults [28].

Even helping professionals who are not convinced that mindful movement practices like yoga can stand alone as treatment for mental disorders should recognize their potency as adjunctive, healthy, complementary activities for clients, as stated by the ISTSS. When working with clients on accessing healthy coping skills and developing a social network support of their recovery, local yoga studios can be a great resource. Yoga studios are set up to offer classes in many different levels of yoga, and many offer other programs, like MBSR, specialty wellness workshops, drum circles, or healthy dance activities (e.g., Zumba, Nia). In addition, fitness centers and gyms often offer yoga classes.

Holy Yoga: A Christianity-Based Yoga Practice

As discussed, some people are resistant to take up Eastern practices, even for exercise, because they somehow feel that they are violating their religious traditions (e.g., Judeo-Christian, Islamic). One response to this concern has been the development of the program Holy Yoga, which takes the breathing and stretching benefits of mindful yoga and practices them alongside Christian spiritual principles [36]. It is unclear if the wider availability of programs like these (and expansion to other religions), along with a growing body of research supporting the efficacy of yoga, will address the concerns of critics.

DANCING MINDFULNESS

In the 1970s, the conscious dance movement began on the West Coast. This approach promotes the gathering of people to dance in a "come as you are" format. Conscious dance classes are not focused on learning specific steps, but rather encouraging dancers to connect their breath to movement in a mindful way.

One such approach is dancing mindfulness, which draws on research from mindfulness work and trauma competency, using the art of dance as the primary medium of discovering mindful awareness. Participants are encouraged to access their body's healing resources while dancing through seven primary areas of mindfulness in motion: breath, sound, body, story, mind, spirit, and integrated experience, with a respect to the attitudes of mindfulness [8]. A small study of women who engaged in a dancing mindfulness practice found improvements in overall health and well-being and growth in emotional and spiritual domains [37].

Instructions

- Spend some time with a mindful breath of your choice, working your way into a body scan.

- Introduce some music into your experience. You can do this by turning on a radio, starting your personal music device, or starting a playlist made in advance along a theme.

- Begin moving organically in a way that connects your breath to the music and to the body. The key is to move with intention and focus on staying in the moment with your movements.

- For your practice to truly be dancing mindfulness, regardless of how long it is, it is important to spend some time in body stillness at the end, letting your breath, the music, and your body integrate the fruits of your practice.

Modifications

Dancing mindfulness can be practiced as an activity with friends or as an activity within a therapeutic setting, as long as people keep a commitment to safe physical and emotional practice. Having a leader to keep the group experience organized and on task with mindful focus is recommended.

Before recommending yoga, dancing, wellness workshops, or even community-led MBSR, it is important to do research regarding local offerings. If one has doubts about whether certain yoga studios would understand the needs of clients, call and ask to speak to the director of the studio or the teacher in question and get a feel for his or her comfort in working with clinical populations.

MINDFUL EATING

In Western culture, especially in the United States, eating is often done automatically or while distracted, and this mindless eating has been linked to obesity and gastrointestinal problems [38]. One solution is to practice mindful eating, an approach used by many eating disorder and weight-loss programs to help participants reorient their relationship to food. The art of mindful eating includes:

- Slowing down

- Carefully paying attention to the food and the sensations it creates in the body

- Being attuned to each sense in order to fully savor the experience

Mindful eating, like other channels of mindfulness, requires practice. Popular food items for completing this exercise include almonds, raisins, and dark chocolate. MBSR, for instance, makes use of raisins as its instruction method. One can also use an item that comes with a wrapper for extra sensory dimensions [8].

Instructions

- Find an edible item that comes in a wrapper, like a starlight mint or a chocolate.

- Hold the item in your hand. Look at it and really observe it. Notice every detail of what you see.

- Roll the item in your hands and notice what the wrapper feels like and what it sounds like.

- As slowly as you are physically able, begin to unwrap the packaging, paying attention to every sense along the way, especially the sound. Place the wrapper aside.

- Look at the edible item in your hand, noticing what it looks like, rolling it in your hand and bringing it up to your nose to smell it.

- Very slowly, bring the item to your mouth and rub it over your lips, noticing whatever you notice, then put it in your mouth. Just allow the item to sit on your tongue for a few minutes. Be curious. Bring the item to the roof of your mouth and roll it around the sides of your mouth.

- Before biting into or ingesting the object, be sure to take some swallows and notice any juiciness or other tastes coming from the item.

- Mindfully take your first bite into the item, noticing what it sounds like, what it feels like, what it tastes like, and even a surge in the smell.

- Continue at this slow pace, savoring each sensation, down to the last swallow.

Modifications

Individuals may practice mindful eating for an entire meal, noting if they are satiated earlier. If trying this with a whole meal seems like too much to handle for now, consider focusing on one item (e.g., committing to eating the mashed potatoes mindfully).

MINDFUL LISTENING

Not feeling heard or listened to is one of the great causes of distress in humans today. This suffering is no surprise when a culture is heavy on talking and slim on actually listening.

To become a better listener, actually making time to practice listening is paramount. In Western culture, music and sounds are more background noise than anything, almost like a soundtrack for fast-paced multitasking. Teaching (and practicing) mindful listening can help build listening skills and be used as a valuable stress reliever.

Instructions

- Start with finding a simple nature sound or series of sounds. This may be a sample recording or ambient sounds in nature (e.g., the park).

- Begin practicing single-pointed concentration on that sound. For the next three minutes, your only job is to listen to that sound. Once again, if your attention wanders, be patient and gentle with yourself. Use these moments as opportunities to draw your attention back to the sound.

- Notice what happens. If a first sound choice is not effective, persist and keep experimenting. There are thousands of sounds and sound combinations you can try until you find what works for you.

Modifications

For some, actual pieces of music may work better than nature sounds. Simple, hypnotic/meditative music may do the trick; for others, more dynamic sounds may engage them more fully. Some may benefit most from music with lyrics. Individuals should try different sounds to find a listening experience that clears any manifestations of stress. For hearing-impaired clients, the benefits of this exercise can be achieved by sitting close to large speakers and feeling the vibrations.

The Internet and online applications make accessing music and nature sounds easy. Even individuals in offices or cities far from the sounds of nature can use modern technology to practice this technique. One smartphone application makes the tranquil sound of a Tibetan singing bowl at random or predetermined intervals to remind the listener to pay attention—quite literally a call to mindful awareness. Even taking a few moments to really absorb the sound of the singing bowl can make a powerful difference.

MINDFULNESS IN ALL ACTIVITIES OF LIFE

One of the most powerful lessons of mindfulness is a resistance to multitasking. This is reflected by a simple approach to everyday tasks. For example, if you are going to do the laundry, really do the laundry. After everything presented so far in this course, consider what this might mean. One of the core lessons of mindfulness in daily living is to be in the moment for every task, giving it total focus. So, for instance, when one is doing the laundry, this will capture one's sole attention, instead of having other projects going on as well.

Those in the high-pressured, multi-tasking generation are likely to fight this wisdom. Yet, in practice, they will often find that staying focused on the task at hand results in less stress. The idea of practicing mindfulness in every activity of daily life can serve as a means for stress relief and overall wellness; living in this manner is a worthy point to discuss with clients. Be prepared to process or coach through any resistances that may come up, because doing the tasks of the day in a mindful fashion can seem impossible to clients at first. As with teaching any mindful practice, it is imperative to advise clients to start small and avoid getting frustrated if the practice is not immediately conquered.

Reflection

Think about one of your activities of daily living that you seem to do on autopilot, like doing the laundry, brushing your teeth, or cooking dinner. The next time you do that activity, do it with single-pointed concentration and notice what happens for you. Practice the art of mindfulness in daily living. Try it for at least one week with three different activities.

7. MINDFULNESS IN THE CLINICAL SETTING: TREATMENT PLAN STRATEGIES

INTEGRATING MINDFULNESS INTO ANY APPROACH

It is very common for beginning helpers to struggle with the concept of silence, interpreting it as a sign that they have done something wrong or that the session has stalled due to their incompetence. However, with practice, one will find it is in the silence where clients do their best work. When words are removed, even for a moment, tremendous insight can emerge. Giving a client permission to be silent, to just sit with something (e.g., a thought, a feeling, a body sensation), is a solid technique. If there is a silent halt in a session, one should honor it and encourage clients to be comfortable when silent and still with their experience; the session will move on when it is supposed to.

This is a way to subtly interweave mindfulness into work with clients. Silence is one of the microskills of counseling that is inherently mindful, and it is one of the simplest ways to integrate mindfulness into clinical work, regardless of one's primary orientation. Giving clients the permission or encouragement to be with that silence and notice what comes up in a non-judgmental way transforms the potency of the skill. The following is an example of how this might play out in a session:

Client P is 26 years of age, a white gay man who is in counseling for issues connected to depression and low self-esteem. He and his counselor have just engaged in an emotional discussion about his father's non-acceptance of his sexual orientation and choices that he has made about his career. The session has gone silent, and by practicing the skill of attunement through reading Client P's nonverbal communication, the counselor chooses to invite the silence.

Counselor : It's okay. You don't have to say anything right now. Why don't you just sit with the silence and notice whatever may come up in you? Don't censor whatever you may get; just go with it.

Client P : (takes a breath) Okay.

For the next several minutes, the two sit in silence, with only the sound of both of their breathing patterns audible. Client P expresses a series of winces and eventually starts to cry.

Client P : Sad. I'm just really sad.

Counselor : Okay, sad. Let's not judge that sadness, P. Just be with that feeling; don't judge it.

TO BE WITH THE EMOTION/WORD/SOMATIC EXPERIENCE

Too often, clinical work gets stifled because, just like modern society, counselors and clients think that there must always be something to say or think about. Therapy has come to be associated with analysis and breaking things down, a place clients come to be called out on their dysfunctional thought patterns and behaviors. While these can be important features of therapy, their excess can thwart the emergence of emotional or somatic material that needs to come to the surface in order to be cleared. One intervention that may be used to counter this tendency, regardless of the modality used in a session, is to invite a client to just "sit with" an emotion, a word, or a somatic experience. Giving her/him permission to just be with something without an internal critic can make room for movement within the session, especially movement of the insight-oriented nature.

Reflection

How comfortable are you with silence in your clinical sessions? What barriers may exists that keep you from being comfortable with silent moments?

Mindfulness approaches may be incorporated in treatment planning with a variety of conditions commonly encountered in clinical work. In general treatment planning, a three-tiered structure that is seen as a consensus in the literature, especially when it comes to addressing trauma- or stressor-related disorders, may be followed.

Stage one begins with stabilizing the client and preparing him or her for deeper healing work. The teaching of coping skills and affect regulation techniques is a vital component of stage one work, and this is an ideal time to begin the introduction of mindfulness strategies for coping.

In stage two, the client is assisted to more deeply process emotional disturbances or issues that he or she is stuck on, blocking optimal health.

Finally, in stage three, reintegration, the client takes the skills that he/she has acquired as part of their therapy into life following termination.

ANXIETY AND TRAUMA-RELATED DISORDERS

Although the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) contains a category of trauma- and stressor-related disorders separate from anxiety disorders, for the purposes of discussing clinical mindfulness, anxiety and trauma may be examined together. Not all trauma meets criteria for PTSD. The term "trauma" is from the Greek word meaning wound, and clinically significant trauma may be conceptualized as unhealed emotional wounds that continue to cause functional impairment. In some cases, the result is a PTSD diagnosis, but other times the unhealed wounds manifest as other diagnoses, including anxiety, depression, and adjustment disorders.

Strategies

If the unhealed emotional wound is what the clinician is entrusted to clinically treat, mindfulness strategies are powerful bandages in stage one work. Before any clinician can proceed with the cathartic work of reprocessing associated with healing trauma, it is important to ensure that a client is reasonably able to tolerate the emotional intensity that goes with such work. Developing a coping skills plan with an individual client is usually a trial-and-error process—what works for one client may not necessarily work for another. When helping a client devise his or her coping plan, the following strategies may be helpful:

- Breath work (diaphragmatic first, followed by others)

- Clench and release technique

- Mindful listening (with other sensory variations, if needed)

- Body cuing and/or tactile mindfulness

Body Cue

A skill that may be helpful in the early stage of therapy for any condition, especially anxiety and trauma-related disorders, is the body cue; traditional MBSR and yoga traditions refer to this skill as the body scan. The intention is to encourage the client to begin paying attention to her or his body and to listen to the cues it gives. Whereas traditional, meditative body scans can take a very long time to do properly, use of the body cue is intended to teach clients how to check in with their visceral responses at a moment's notice [8].

Instructions

- Bring to mind something that causes you stress. It does not have to be a major trauma, but something that you identify as stressful.

- Spend a few moments reflecting on that stressor. What does it look like? Does it have a sound or any other sensory qualities?

- Now, notice what is happening in your body. Does the stress seem to be felt in one part of your body or in one organ specifically? Or is the stress felt all over your body? There are no right or wrong answers, just practicing acceptance of what is going on in your body right now. Spend a few moments just sitting with the stressor, noticing the body response in a spirit of non-judgment.

- Begin describing the presence of that stressor in your body: If it had a color, what color would it be? If it had a shape, what shape would it be? If it had a texture, what would that texture be? Are there any other qualities, like temperature, sound, or smell?

- Ask yourself, what does my body need the most right now to help the presence of this body stress? Even if your gut-level answer does not seem to be the healthiest response, practice non-judgment; just notice what your body needs.

Modifications

It can be interesting to consider drawing the experience of stress in one's body. Young people in particular may find this approach more appealing or accessible then having to describe it. Colored pencils, crayons, markers, or other crafting elements can be employed.

Tactile Mindfulness

Unresolved trauma and fears that cause anxiety can produce powerful, visceral responses at the body level. This is a major reason for the strong connection between trauma-related disorders and addiction problems—the physical pleasure of addictive behaviors is soothing. The challenge in working with anxiety, trauma, and addiction is to teach clients healthier ways to work with their bodies. In addition to breath work and muscle work, another strategy that uses an outside object to promote mindful practice, especially through the tactile channel, can be a useful tool. Popular objects to use for this activity include marbles, stones, and gems or crystals [8].

Instructions

- Imagine that this is the first time you are ever looking at this type of object; approach it with the spirit of a beginner's mind. Take the object in your hand and observe the color. Practice patience and spend several minutes just noticing what you notice about the colors and patterns.

- Notice the weight of the object in your hand. Try moving it from hand to hand and notice if there are any differences.

- Roll the object around in your hands. Observe the texture of the object against your skin.

- Notice if you hear any sounds.

- Repeat as many times as necessary, practicing curiosity with each set.

Modifications

Any object can be used for this exercise, especially objects that are meaningful to a client. The key is to think of an object that is ordinarily taken for granted, yet upon examination, contains new wonder. Popular alternatives include thimbles, small toys that might have special significance to a child, and 12-step recovery coins, chips, or tags.

Stage One: Stabilization

It is important to coach clients to use these skills outside of the office setting. It is great if a skill works in the office, but it is important for clients to put them to the test in their outside lives. If they are an inpatient or incarcerated, it is important that they test these skills when they are not with a counselor. As a stabilization approach, it may also be good practice to determine if a formal MBSR program or other mindfulness meditation program is available in the community for a client to access as an adjunct to psychotherapy. Stage one stabilization may also be a good time to explore referring a client to yoga or other wellness-based exercise programs, also as a complement to psychotherapy.

Stage Two: Stabilization

If a client becomes accustomed to listening to his or her body responses and honoring them in stage one work, it widens the potential of stage two work. When practicing catharsis-oriented reprocessing stages of therapy, one may observe a major difference between clients who practice mindfulness and those who do not. The clients who practice mindfulness are aware of their own body responses and are willing to notice them in a spirit of non-judgment. The tendency to overanalyze in a cognitive sense falls away, and these clients, quite simply, process more efficiently.

Regardless of the modality used to process trauma, a barrier that many clinicians experience when it comes to trauma is fear of destabilizing clients or making clients feel worse. However, if a client is properly stabilized and equipped with dynamic coping skills for addressing intense emotional responses, the chances of destabilizing a client are significantly decreased.

Helping clients become more mindful of their internal world during stabilization increases the likelihood that they will be able to stop if they have gone too far with processing emotional material in any given session. As such, being mindful helps with both physical and emotional safety. By beginning sessions orienting clients to what mindfulness means and how to listen to and honor the messages of one's physical body and emotional needs, clients become simultaneously aware of their possibilities and limitations.

ADDICTION

In many cases, approaches effective for the treatment of trauma triggers are also effective for the treatment of addiction cravings and responses. As discussed, there is a connection between unresolved trauma and addiction responses because it is a natural tendency to practice avoidance (one of the specific criteria of the PTSD diagnosis) when viscerally threatened. Self-soothing with an instantly gratifying chemical or behavior is a sure way to calm the body, but the escape is only temporary, and for many, the vicious cycle escalates. However, a full discussion of the intricacies and debates of trauma-addiction interaction is beyond the scope of this article.

G. Alan Marlatt, a major figure in the area of treating addictive disorders, and his colleagues developed MBRP, an approach designed as an aftercare program following primary addiction treatment that follows a flow similar to MBCT, with specific focus on relapse prevention [39]. The major goals of MBRP are to:

- Develop awareness of personal triggers and habitual reactions, and learn ways to create a pause in this seemingly automatic process.

- Change one's relationship to discomfort, learning to recognize challenging emotional and physical experiences and responding to them in skillful ways.

- Foster a non-judgmental, compassionate approach toward oneself and one's experiences.

- Build a lifestyle that supports both mindfulness practice and recovery.

Even when not using MBRP's specific protocol, the goals for therapy with recovering addicts are similar. The coping skills developed for both trauma and addiction are centered on working with body-level responses and practicing self-compassion. The definition of non-judgment provided previously in this course essentially outlines the mindful approach in working those in recovery. Similar to work with trauma, addiction work can begin with teaching the following coping skills with a mindful focus:

- Breath work

- Clench and release

- Mindful listening

- Tactile mindfulness

- Body cuing

When working with body cuing during recovery, it is important for clients to begin noticing and describing not only how stress manifests in the body, but how to work with how cravings manifest in the body as well. The following is a script that one can use as a guideline (modified and personalized) to help a client identify his or her cravings and address them in a healthy way using body cuing.

Bring to mind your drug of choice or whatever stressor makes you want to use your drug (or behavior) of choice. Spend a moment being totally aware of that drug or stressor. Notice any sensory details you may notice about it. What does it look like? Does it have any other sensory details, like a sound or a smell? Just notice, non-judgmentally, anything that is connected to this drug or stress.

Take a moment to notice what is happening in your body. There are no right or wrong answers; just notice whatever you may notice. Maybe you feel something in one particular area of your body or maybe you feel something all over. Whatever it is, just honor it and be with it. If whatever is coming up in your body had a color, what color would it be? If it had a shape, what shape would it be? Maybe it has a texture. Maybe it has a sound or a smell. Whatever it is, just notice it and pay attention to it.

Now I would like you to think about one of your healthy coping skill s— maybe breathing, working with your muscles, or getting up and taking a walk. Ask your body what healthy outlet it most needs right now. Then, honor your body by engaging in that healthy coping skill and notice what happens. Whatever skill you choose, remember to breathe mindfully and fully throughout the exercise. Just keep noticing what happens.

Learning to listen to one's body and train it to respond in a healthy way is a prime skill for recovering addicts to foster, as the body will give clues before one's mind consciously recognizes an issue. Mindfulness is about responding to stress instead of reacting to stress. A Kabat-Zinn axiom is that while one cannot stop the stress of life (or in this case, the cravings of addictive responses), one can learn how to surf the stresses [6].

DEPRESSION AND GRIEF

A common saying in mindfulness-based classes is that anxiety is about living in the future and depression is about living in the past. The solution is to develop a practice of living in the present moment. However, this can be difficult. In working simple mindfulness strategies with depression and conditions related to unresolved grief, the primary goal is to help a person become more present-focused even while exploring unresolved trauma from the past.

As discussed, one strategy for interweaving mindfulness into a session is to begin and end with three minutes of mindful breathing (of the client's choosing). Even if cognitively oriented methods are used for processing, incorporating this simple breath work will prepare the brain for the work.

A common complaint with depressive disorders is poor energy or motivation. Clients may express mental fatigue, saying "My head hurts from thinking so hard," or "These thoughts running around in my head just will not stop." Mindfulness techniques such as energetic massage and guided imagery can be used to help energize or reorient a client [8].

Energetic Massage

Instructions

- Rub your hands together for at least 30 seconds. Really work up some heat.

- Pull your hands apart and bring them to your forehead. You can close your eyes and place the base of your palms over your eyes, letting the rest of your hands curl to the top of the forehead. Or you can rest the base of your palms on your cheeks and let your fingers go around your eyes.

- Settle in and feel the energy you generated in your hands move into your brain. Just let go and let the energy work in you. Practice non-striving.

- Hold as long as you like.

Modifications

One can bring the energy from the hands to any part of the body that is feeling tense or anxious. Think about bringing the heat energy from the hands to the chest or stomach if any tension or pain is present in those areas.

The "cranial hold" position is an option after generating the energy. To achieve this, horizontally bring one hand to the forehead and the other hand to the back of the head. Consider adding another sense into the process for optimal relaxation, like meditative music or aromatherapy.

Guided Imagery

Guided imagery is another very popular coping skill. While many guided imageries may not work well with mindfulness because they promote using one's imagination as an escape (e.g., safe place, spiral staircase), there are some guided imageries that use the body and can be practiced very mindfully. One such exercise to use for this purpose is called light stream [4].

Instructions

- Imagine that a bright and healing light has begun to form overhead. This light can be whatever color you want it to be, whatever you associate with healing, happiness, goodness, or any of the other attitudes of mindfulness. If you do not like the idea of a light, you can think of it simply as a color or an essence.

- Now, think about this light beginning to move through or over your body, from the top of your head, moving inch-by-inch, slowly, until it reaches the bottom of your feet. This light can be seen as grounding you safely into the earth, if this is comfortable.

- Allow a few moments to just spend time with the presence of this light or essence in your body. Notice if it has any other qualities besides color, like a texture, a sound, or a smell.

- Draw your attention back to where you first cued your body stress. If the distress is still there on some level in your body, think about deepening your breathing so it makes the light or essence more brilliant and intense—so intense that the distress cannot exist within it.

- Keep practicing the exercise, in the attitude of patience, if you do not notice much of a shift the first time.

Modifications

The light/essence can enter anywhere in the body. For instance, if one's anxiety is felt mainly in the chest, it may feel more appropriate to have the light enter there. If the light stream image alone is hard to keep in focus, add another sensory element to enhance the focus (e.g., smell, simple sound or music, tactile sensation). Although most light-stream imagery approaches make use of the language of calming, the client may choose a color or light stream that represents an empowering or energizing quality.

Persons with a spiritual belief system may imagine that the light comes from a spiritual source (e.g., heaven, God/Allah, the universe). Using the variations with spiritual dimensions can be powerful when working with individuals struggling to process an unresolved grief or people who have been wounded by religion or spirituality in the past. The light-stream imagery makes use of the body domain and the spirit domain, if a client wants to go there.

In working with trauma, depression, and grief, it is good practice to start guided imagery with a light-stream exercise, which is naturally more mindful because it is rooted in the body (compared with "place" imageries). As discussed, any intervention done in the spirit of mindfulness is generally safer. If a client tolerates this exercise well, one can progress to incorporation of guided place imageries that may naturally be more emotionally charged and bring up material that is well-suited for stage two processing. Light-stream imagery is also a good skill to bring closure to a session after a client has engaged in emotionally evocative work.

A Note About Grief

Grief is a normal part of the human experience that, if not adapted to sufficiently, can lead to functional impairments. Many clinicians are rightfully tentative to pathologize grief. In the DSM-5, there is a special note in the depressive disorder diagnosis criteria cautioning professionals that some expressions of grief may manifest as clinical depression, and in these cases a diagnosis can be made. Professionals are advised to use their discretion about what constitutes a depressive episode compared to, in DSM-5 terms, a typical grief response [40].

However, some find the terms "typical" and "normal" to be problematic clinical constructs. Worden favors the term "adaptation" when describing how people respond in the aftermath of a loss, indicating that one will never be the same after a loss and recognizing that certain people will adapt more healthfully to the experience of loss than others, based on a wide variety of individual and situational variables [41]. These variables can include the nature of the relationship, the value placed on what was lost, an individual's internal resources for coping, and frames of reference for meaning-making and/or spiritual integration of the experience.

Although not a solution for every client, mindfulness strategies can be helpful for many struggling to adapt in the aftermath of a loss. These approaches can be applied in whatever combination will best help the individual more fully embrace the foundational attitudes of mindfulness, especially acceptance, trust, and letting go. The simple strategies covered throughout this course can help an individual endure the proverbial waves of grief when they come.

In some cases, coping with grief is made more difficult by the internal judgments that clients experience, often in reflection of others. Shame obviously plays a significant role in addiction and trauma, but it can be just as significant in complicated grief presentations when a person feels he or she should somehow be over the experience. A mindfulness practice can provide individuals with the tools to deal with whatever emerges emotionally in a non-judgmental manner. Resultantly, the adaptation becomes more effective and ultimately healthier.

Reflection

If you have experienced issues with depression, anxiety, trauma, or addiction, what worked best for you in terms of healing? Looking back on what worked, could any of these activities be described a part of the mindfulness spectrum covered in this course?

8. MINDFULNESS IN CONTINUING CARE

STRATEGIES FOR REINTEGRATION USING MINDFULNESS

Reintegration, the third stage in the three-tiered model for trauma processing, is about equipping clients with the skills they need to live life healthily and happily. Although certain exceptions may apply for clients with chronic mental illness, in general, the goal is to help a client work through his or her issues and adopt the necessary skills to no longer require regular therapy—a lifestyle change.

Mindfulness as a Lifestyle Choice

Originally coined by Alfred Adler, the concept of lifestyle is important to overall mental health and wellness [42]. Lifestyle is the series of choices and patterns that individuals live that are formed in reaction to early life experiences. Lifestyle can be changed at any time, an idea that is easier said than done for most. Mindful practice can play a major role in this area, especially with the focus on responding to stressors of life rather than reacting to them. If mindfulness is practiced in small ways and gradually evolves to embrace the idea that everything in life can be engaged in mindfully, the possibilities for shifts in outlook and overall lifestyle choices are infinite.

Revisit Skills and Reframe Focus

When working with clients, it is important to allow for many sessions to talk about termination, or life after therapy. This can include encouraging dialogue highlighting what has worked during the clinical process and to develop a plan for how clients continue working with these positives in their daily lives. For example, if a client said that learning how to breathe properly really helped him during the process, discuss how he can continue working with breath every day, both in structured practice time and as needed when stressed. If a client credits mindful listening with being a significant stress reliever, discuss how to continue using these strategies in daily life. The great secret to stage three work in the three-tiered approach is to revisit many of the same skills that were built during stage one stabilization and reframe their focus for use in continued lifestyle wellness and development.

ACCESSING RESOURCES WITHIN THE COMMUNITY

Exploring wellness resources available in the community is an imperative part of reintegration work. If a client mentions following through with a recommendation during therapy (e.g., yoga, dance, community meditation group) and finding some benefit, he or she should be encouraged to continue. Although clients may not need therapy for the rest of their lives, everyone can benefit from support, especially support that comes from a community of people who are focused on wellness.

The first step in identifying local mindfulness resources is often a simple Internet search. Because MBSR, as a structured program, has shown results in promoting psychological well-being, make a point to find out where those programs are offered in the local community. In addition, many socially conscious yoga studios offer at least some classes as sliding scale or donation-based in order to bring programming to those who may need it most. Some Veterans Affairs hospitals offer free yoga classes for veterans and their families, and some programs are available in inner city areas to teach yoga and meditation to underprivileged youth.

Reflection

On the Internet, go to a search engine and enter terms like "MBSR" or "yoga," paired with the name of your city or region. What are the results? Are you willing to try these opportunities or attend the classes before sending your clients there?

9. CONCLUSION

When people begin to study mindfulness, many discover that it is a coping response they have automatically used in the past. This course has outlined some approaches to practicing mindfulness in every aspect of life in order to achieve mental health and well-being. Bernhard identifies six primary outcomes that can flow from practicing mindfulness as a guideline for living, even outside of formal meditation [16]:

- Mindfulness gives the mind a rest from a fixation on discursive thinking.

- Mindfulness takes us out of ourselves.

- Mindfulness turns a boring activity into an adventure.

- Mindfulness frees us from judgment.

- Mindfulness enables us to make wise choices.

- Mindfulness opens our hearts and minds to the world unfolding before us.

The goal of this course has been to provide practitioners with ideas on how to practice mindfulness in order to experience these outcomes and pass them along to clients, beginning with the foundations of mindfulness, the attitudes of mindfulness practice, and the history of mindfulness and how it emerged as a powerful force in modern health care. Specific techniques for practicing mindfulness in all life activities were provided, including breathing, walking, eating, exercising, listening, and dancing. Next, strategies for integrating mindfulness practice into treatment across the spectrum were explored, especially with conditions like anxiety, trauma-related disorders, depression, and unresolved grief. Finally, ideas for how to help clients continue using mindfulness after they formally terminate therapy were considered, with special attention paid to helping clients access community resources.

10. RESOURCES

WEBSITES

Dr. Andrew Weil

https://www.drweil.com

Center for Healthy Minds

https://centerhealthyminds.org

The Greater Good Science Center at UC Berkeley

https://greatergood.berkeley.edu

American Mindfulness Research Association

https://goamra.org

Trauma Made Simple

https://www.traumamadesimple.com

BOOKS

Bays JC. Mindful Eating: A Guide to Rediscovering a Healthy and Joyful Relationship withFood. Boston, MA: Shambhala Publications; 2009.

Baxter B, Zolotow, N. Yoga for Healthy Aging: A Guide to Lifelong Well-Being. Boulder, CO: Shambala Publications, Inc.; 2017.

Catton T. The Mindful Addict: A Memoir of the Awakening of a Spirit. Las Vegas, NV: Central Recovery Press; 2010.

Dass R. Be Here Now, Remember. San Francisco, CA: The Lama Foundation; 1971.

Dayton T. Trauma and Addiction: Ending the Cycle of Pain Through Emotional Literacy. Deerfield Beach, FL: HCI Communications; 2000.

Emerson D, Hopper E. Overcoming Trauma Through Yoga: Reclaiming Your Body. Berkeley, CA: North Atlantic Books; 2011.

Hanh TK, Cheung L. Savor: Mindful Eating, Mindful Life. New York, NY: Harper One; 2011.

Hanson R. Resilient: How to Grow an Unshakable Core of Calm, Strength, and Happiness. New York, NY: Penguin Random House LLC; 2018

Hawk K. Yoga and the 12-Step Path. Las Vegas, NV: Central Recovery Press; 2012.

Jacobs-Stewart T. Mindfulness and the 12 Steps. Center City, MN: Hazelden; 2010.

Marich J, Paintner CV. Dancing Mindfulness. Woodstock, VT: SkyLight Paths Publishing; 2016.

Marich J. Trauma and the Twelve Steps: A Complete Guide to Enhancing Recovery. Warren, OH: Cornersburg Media; 2012.

Najavits L. Seeking Safety: A Treatment Manual for PTSD and Substance Abuse. New York, NY: Guilford Press; 2002.

Roth G. Women, Food, and God: An Unexpected Path to Almost Everything. New York, NY: Scribner; 2011.

Ryan T. A Mindful Nation: How a Simple Practice Can Help Us Reduce Stress, Improve Performance, and Recapture the American Spirit. Carlsbad, CA: Hay House; 2012.

Tang Y-Y. The Neuroscience of Mindfulness Meditation: How the Body and Mind Work Together to Change Our Behavior. New York, NY: Springer International Publishing; 2017.

Wei M, Groves J. The Harvard Medical School Guide to Yoga: 8 Weeks to Strength, Awareness, and Flexibility. Boston, MA: Da Capo Press; 2017.

Weintraub A. Yoga Skills for Therapists: Effective Practices for Mood Management. New York, NY: W.W. Norton; 2012.

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Evidence-Based Practice Recommendations Citations

1. Management of Chronic Multisymptom Illness Guideline Working Group. VA/DoD Clinical Practice Guideline for the Management of Chronic Multisymptom Illness. Washington, DC: Department of Veteran Affairs, Department of Defense; 2014. Available at https://www.healthquality.va.gov/guidelines/MR/cmi/VADoDCMICPG2014.pdf. Last accessed September 25, 2019.