VASW19 • Virginia Social Workers 2019

Table of Contents

VASW19 • Virginia Social Workers 2019

How to Receive Credit

NetCE 5 Hour Course #71500 • The Bisexual Client: Trauma-Focused Care

71500 • The Bisexual Client: Trauma-Focused Care

1. INTRODUCTION

2. FOUNDATIONS: IDENTIFYING BISEXUALITY AND RELATED DEFINITIONS

3. THE TRAUMA OF THE BISEXUAL EXPERIENCE

4. CULTURALLY RESPONSIVE TRAUMA TREATMENT PLANNING FOR BISEXUAL CLIENTS

5. CLINICAL COMPETENCE IN WORKING WITH BISEXUAL UMBRELLA CLIENTS

6. CONCLUSION

7. RESOURCES

Works Cited

NetCE 6 Hour Course #77040 • Setting Ethical Limits: For Caring and Competent Professionals

77040 • Setting Ethical Limits: For Caring and Competent Professionals

1. INTRODUCTION

2. COMPETENCE

3. CULTURAL COMPETENCE

4. THE THERAPEUTIC RELATIONSHIP

5. THE COSTS OF CARING

6. TRANSFERENCE AND COUNTERTRANSFERENCE

7. BOUNDARIES AND LIMITS

8. BOUNDARY CROSSINGS AND VIOLATIONS

9. MULTIPLE RELATIONSHIPS

10. GIFTS

11. TECHNOLOGY AND DISTANCE THERAPY

12. CONCLUSION

13. RESOURCES

Works Cited

NetCE 15 Hour Course #76430 • Mass Shooters and Murderers: Motives and Paths

76430 • Mass Shooters and Murderers: Motives and Paths

1. INTRODUCTION

2. HISTORICAL OVERVIEW

3. MASS SHOOTERS: CHARACTERISTICS

4. MASS SHOOTERS: PATHS TO VIOLENCE

5. EXTREMIST MASS VIOLENCE: THE PERPETRATORS

6. EXTREMIST MASS VIOLENCE: PATHWAYS

7. GUN VIOLENCE TRENDS, DATA, AND FACTORS

8. DISCUSSING GUN SAFETY AND RISKS WITH PATIENTS

9. RESOURCES

10. CONCLUSION

11. APPENDIX: UNDERSTANDING GUN CULTURE

Works Cited

Evidence-Based Practice Recommendations Citations

VASW19 • Virginia Social Workers 2019

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

Lisa Hutchison, LMHC

www.netce.com

Copyright © 2024 NetCE, All rights reserved.

VASW19 • Virginia Social Workers 2019

Expiration Date: 04/30/2020

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.

71500 • The Bisexual Client: Trauma-Focused Care

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

www.netce.com

Copyright © 2019 NetCE, All rights reserved.

There is an increasing interest in the health and human services professionals to better serve lesbian, gay, bisexual, transgender, and other gender/sexual minority (LGBT+) individuals. This course highlights the unique needs of bisexual clients or those who otherwise identify in a non-binary way in the realm of sexual identification and expression. Professionals will learn valuable tools and approaches for strengthening their rapport with bisexually identified clients, with an emphasis placed on evaluating one's own biases around sexual identify and expression. The course also presents a basic plan for addressing oppressive cognitions as part of trauma-focused care.

Table of Contents

71500 • The Bisexual Client: Trauma-Focused Care

Course Overview

Audience

Course Objective

Learning Objectives

Faculty

Faculty Disclosure

Division Planners

Division Planners Disclosure

About the Sponsor

Disclosure Statement

1. INTRODUCTION

2. FOUNDATIONS: IDENTIFYING BISEXUALITY AND RELATED DEFINITIONS

DEFINING BISEXUALITY

THE GROWING LGBT+ SPECTRUM AND OTHER NON-BINARY IDENTIFIERS

CONCERNS UNIQUE TO BISEXUAL CLIENTS

3. THE TRAUMA OF THE BISEXUAL EXPERIENCE

DEFINING TRAUMA

TRAUMA AND THE LGBT+ COMMUNITY

OPPRESSIVE COGNITIONS AND THE UNIQUE CONCERNS OF BISEXUALS

THE COMING-OUT PROCESS

4. CULTURALLY RESPONSIVE TRAUMA TREATMENT PLANNING FOR BISEXUAL CLIENTS

BEST PRACTICES FOR TRAUMA-INFORMED CLINICAL INTERACTIONS WITH BISEXUAL UMBRELLA CLIENTS

APPLYING THE THREE-STAGE CONSENSUS MODEL OF TRAUMA TREATMENT TO BISEXUAL CLIENTS

SAMPLE TREATMENT PLANNING STRATEGIES

5. CLINICAL COMPETENCE IN WORKING WITH BISEXUAL UMBRELLA CLIENTS

EXPLORING AND ADDRESSING BIASES AROUND SEXUAL IDENTITY, SEXUAL EXPRESSION, AND GENDER

6. CONCLUSION

7. RESOURCES

Works Cited

71500 • The Bisexual Client: Trauma-Focused Care

Education Category. Community Health

Release Date. 05/01/2019

Expiration Date. 04/30/2022

Course Overview

There is an increasing interest in the health and human services professionals to better serve lesbian, gay, bisexual, transgender, and other gender/sexual minority (LGBT+) individuals. This course highlights the unique needs of bisexual clients or those who otherwise identify in a non-binary way in the realm of sexual identification and expression. Professionals will learn valuable tools and approaches for strengthening their rapport with bisexually identified clients, with an emphasis placed on evaluating one's own biases around sexual identify and expression. The course also presents a basic plan for addressing oppressive cognitions as part of trauma-focused care.

Audience

This course is designed for behavioral and mental health professionals of any kind who work with clients on a regular basis or who teach/supervise those working with clients who identify as bisexual or non-binary.

Course Objective

The purpose of this course is to provide members of the interdisciplinary healthcare team with the knowledge and resources necessary to improve the care provided to bisexual or sexually fluid individuals.

Learning Objectives

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

1. Define bisexuality using several well-accepted definitions in the LGBT+ literature.

2. List and briefly define other identifiers generally described as non-binary that often get discussed alongside bisexuality.

3. Identify concerns unique to bisexual clients.

4. Discuss the concept of trauma and oppressive cognitions in LGBT+ clients and explain how such cognitions can complicate recovery for bisexual clients.

5. Articulate a basic trauma-focused treatment strategy for working with bisexual clients.

6. Evaluate one's own personal biases surrounding bisexuality and working with bisexual clients.

Faculty

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

Faculty Disclosure

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

Division Planners

Alice Yick Flanagan, PhD, MSW

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

There is an increasing interest in the health and human services professions to better serve lesbian, gay, bisexual, transgender, and other gender/sexual minority (LGBT+) individuals. At conferences, sessions on serving LGBT+ populations are more commonplace, usually justified under the conference's commitment to meet multicultural and diversity competencies. Organizations dedicated to promoting awareness of LGBT+ issues within clinical and public health settings are more visible than they were a generation ago. Yet two significant problems remain. First, many clinical organizations, from treatment settings to private practices, will declare that they specialize in working with LGBT+ clients because there is someone who identifies as LGBT+ on staff. Even worse, they may declare this competency because one or more staff members describe themselves as tolerant or liberal. A second major problem is that, despite the visibility, many courses and advocacy activities described as LGBT+ only focus on the gay or lesbian experience.

The LGBT abbreviation first came into use in the 1980s, and since then, criticism abounds that both the B (bisexual) and T (transgender) perspectives have been widely silenced. Although some general patterns connected to health care, mental health, and addiction recovery needs are ubiquitous throughout the larger LGBT+ community, the people represented by each individual "letter" have their own unique needs and perspectives that should be considered. In newer usage of the term, the plus (+) symbol has been added to include even more sexual or gender identity minorities who are seeking to find community and recognition in a heteronormative world. Intersex (formerly called androgynous or hermaphroditism), questioning, queer, and asexual individuals can all now be included under the growing scope of the LGBT+ community.

The purpose of this course is to give specific voice to the bisexual experience and to highlight the needs of bisexual clients presenting for clinical services. While there have been a variety of informal polls describing how Americans identify, many of the reputable polling organizations (e.g., Gallup) have thus far only measured the LGBT+ identifier as one population. Research from 2016 indicates that 4.1% of Americans identify as part of the LGBT+ community [1]. The most reputable statistical research measuring individual qualifiers shows that there are more identified bisexual individuals in the United States than there are gay and lesbian individuals combined. A 2011 report published by the Williams Institute at the UCLA School of Law indicated that approximately 9 million Americans identify as LGBT+. Of the total U.S. adult population, 1.7% identifies as either gay or lesbian; 1.8% of the total U.S. adult population identifies as bisexual [2]. When taking this reported data into account, one can assert that the population of bisexuals in America is greater than the number of gay men and lesbian women combined.

The chances are very high that, as a clinical professional, you have worked with a bisexual client. If you have not yet, you very likely will encounter such a client in the future. The goal of this course is to provide a basic knowledge and appreciation of bisexual clients' experiences and needs. At best, this article may empower you to further your competence in working with bisexual clients and providing them with the appropriate clinical services that they need while linking them with other resources available in the larger community.

2. FOUNDATIONS: IDENTIFYING BISEXUALITY AND RELATED DEFINITIONS

DEFINING BISEXUALITY

The American Institute for Bisexuality, formerly called the Klein Institute, was founded by Dr. Fritz Klein, a pioneer of bisexual visibility, in 1998. The Institute's mission is to educate the public, including human service professionals, about the needs of those who identify as bisexual. The Institute also seeks to promote and fund research on bisexuality and to engage in public discourse on bisexuality and issues of sexual identity. In his book, The Bisexual Option, Dr. Klein offers a set of concepts to describe bisexual identity and the bisexual experience [3]. In essence, a bisexual person has the capacity for romantic and/or sexual attraction to more than one gender. For most people, this means they can be attracted to both men and women. If one honestly feels he or she meets this criterion, then he or she is bisexual.

It is important to remember that bisexual persons are not required to feel the same kind or intensity of attraction to all genders. There is nothing for bisexual persons to prove, nothing to consummate, and no requirement to "maintain" their bisexuality. Understanding and acknowledging one's sexuality is a personal process and is about living with integrity and being true to oneself.

Bisexual and other non-binary sexual identity advocates have long embraced the Klein definition for its inclusivity and lack of emphasis on labels, categories, or boxes. The well-known Kinsey Scale was a step in the right direction, offering a continuum (on a scale of 0 to 6) as a measure for describing sexual identity (0 being exclusively heterosexual and 6 being exclusively homosexual, with various degrees expressed in between). However, Klein found the Kinsey scale too limiting and developed his own alternative—the Klein Sexuality Orientation Grid (KSOG), a more nuanced measure of the fluidity and complexity of sexual orientation (Table 1). The KSOG takes seven key variables into account—sexual attraction, sexual behavior, sexual fantasies, emotional preferences, social preferences, heterosexual/homosexual lifestyle, and self-identification (which can include sexual identity and political identity)—and recognizes that a person's preferences may change over time. According to Klein, recognizing that sexual orientation is an ongoing dynamic process is necessary in order to understand a person's orientation properly in its entirety [3]. After completion of the KSOG, a point score is issued that gives some insight into where an individual falls on the continuum (21 being exclusively heterosexual and 147 being exclusively homosexual), with more specific findings than the Kinsey Scale.

Table 1: KLEIN SEXUALITY ORIENTATION GRID

Variable

Past

Presenta

Ideal

A: Sexual attraction

B: Sexual behavior

C: Sexual fantasies

D: Emotional preference

E: Social preference

F: Heterosexual/homosexual lifestyle

G: Self-identification

The following points are assigned for each variable for the past, present, and ideal:

1 = Other sex or heterosexual only

2 = Other sex or heterosexual mostly

3 = Other sex or heterosexual somewhat more

4 = Both sexes, or heterosexual and gay/lesbian equally

5 = Same sex or gay/lesbian somewhat more

6 = Same sex or gay/lesbian mostly

7 = Same sex or gay/lesbian only

aThe present is defined as the most recent 12 months.

Source: [3]

Professionals and bisexual advocates also cite the definition of activist Robin Ochs. Ochs was one of the first individuals to declare herself a bisexual advocate in response to the little attention she witnessed being paid to the unique needs of bisexuals in LGBT+ discussions in the 1980s. The Ochs definition of bisexuality reads as follows [4]:

I call myself bisexual because I acknowledge that I have in myself the potential to be attracted—romantically and/or sexually—to people of more than one sex and/or gender, not necessarily at the same time, not necessarily in the same way, and not necessarily to the same degree.

In educating clients and clinicians about the bisexual experience, offering this definition is often a solid place to start.

The National Gay and Lesbian Task Force definition of bisexuality can be especially helpful for professionals new to learning about bisexuality. The Task Force notes that bisexuality is not an extension of homosexuality, and bisexuality does not require both male and female partners [5]. Behavior and identity can be, and often are, very different; a person can have a bisexual identity even if he or she is celibate or involved in a monogamous relationship with a person who identifies as gay, lesbian, heterosexual, or bisexual. Knowing whether a person identifies as heterosexual, gay, lesbian, or bisexual is not an accurate method of predicting sexual behavior.

THE GROWING LGBT+ SPECTRUM AND OTHER NON-BINARY IDENTIFIERS

Many bisexuals embrace a bisexual identity because, especially if one adheres to the Klein definition, it defies the concept of a binary. Being bisexual challenges larger societal messaging that everything must fit nicely into predetermined categories or labels. Klein commented on this phenomenon in The Bisexual Option [3]:

No matter what sexual orientation a person has, he or she lives on a continuum. Despite the certainty of eventual death, the life of an individual goes on until that time. During the course of a lifetime each individual plays a number of roles: father, mother, soldier, teacher, heterosexual, homosexual, and so on. We take comfort in the labels; they help define our relationship with one another and with the world at large. Yet with each label we acquire, we limit our infinite possibilities, our uniqueness. It is our insistence on labels that creates the "either-or" syndrome.

Oregon governor Kate Brown, America's first openly identified bisexual governor, described her experience of being bisexual as such: "Some days I feel like a have a foot in both worlds, yet never really belonging to either" [6]. Brown's experience resonates with many bisexual-identified individuals. Marich explained that such an identity and life experience poses a major problem when bisexuals seek clinical treatment services [7]:

Most mainstream treatment cultures rely on labeling; some, I would argue, are even obsessed with it. Making sure that clients are described by manualized, precise diagnostic categories is a form of labeling. Adopting pre-defined treatment curriculums for our programs and requiring our clients to respond to that curriculum (instead of modifying curriculum to respond to the needs of individual clients) is a form of labeling. When a recovery culture, especially formal treatment, relies on people fitting into neat boxes, I contend that a bisexual-identified client will have a more difficult time being validated by those who are there to help them.

Part of rejecting the damaging effects of labeling and categorizing is to also recognize that people who have traditionally been described as or have identified as bisexual may no longer find that term to fully embrace their identity and their experience. A growing momentum to change the traditional LGBT abbreviation to a more inclusive LGBT+ is one way this sea change is manifesting in larger discourse. As discussed, LGBT+ is an alternative to the traditional LGBT abbreviation that has come into popular use in the 2010s as a gesture of optimal inclusion to all individuals who may identify as being part of a sexual or gender minority group; this recognizes that the abbreviation could continue to expand indefinitely as understanding about the diversity of sexual identity and gender expression evolves. A running commentary is that if the LGBT community continued to embrace all sexual identity, gender identity, or lifestyle identity minorities into the abbreviation, it would read something like LGBTQQIAAFAGPBDSM. LGBT+ is a growing alternative to be inclusive for all persons who do not feel like they belong in the sexual identity or gender identity mainstream. Heteronormative refers to traditional norms and mores for sexual identity and expressions being assessed by the heterosexual ideal of how things should be; people who reject heteronormativity often identify with one or more descriptors embraced by the LGBT+ abbreviation.

There is also a growing movement of individuals who are rejecting the term or the label of bisexual as being too limiting. Because the nature of sexual identity is ever-evolving, many, particularly members of younger generations in the LGBT+ community, may choose less restrictive identities to challenge what it means to label and to identify. It is important that some of these identifiers be explored, as they may be more comfortable for clients. Queer is a term that has come into wider use in recent years as an umbrella term for sexual, gender, or lifestyle identity that defies heterosexual or mainstream norms. Originally used as an insult, many members of younger generations have reclaimed it as an empowering word, although those outside the community should be careful using it widely, as members of many older generations, especially gay men, still associate it as a term of insult and shaming.

Fluid is another term coming into wider use in recent years. In an open forum posed for readers, the American Institute for Bisexuality offers this useful description [8]:

The term fluid expresses the fact that the balance of a person's homosexual and heterosexual attractions exists in a state of flux and changes over time. Usually, but not always, people who describe their sexuality as fluid are bi people whose attractions skew very heavily toward one gender. The terms heteroflexible and homoflexible add a further level of specificity, by indicating whether the bisexual person's attractions skew almost exclusively toward same-sex or different-sex individuals.

The Institute explains that the term bisexual remains the more scientific identifier for describing sexual fluidity, especially when the intricacies of Klein's work are embraced [8].

In discussing the concept of heteroflexibility, the concept of straight men who have sex with men also arises. Several research studies have been conducted on this construct of men who identify as straight and have also disclosed encounters with men that are purely recreational in nature or in response to intoxication. As with many identifiers, it is important to refrain from judgment when men disclose such behaviors (e.g., do not assume that a client is a closeted or "in denial" gay man).

The American Institute for Bisexuality also explains that newer terms such as pansexual, polysexual, omnisexual, and ambisexual are now preferred by individuals who may have traditionally identified as bisexual. They offer this very succinct explanation [8]:

By replacing the prefix bi- (two, both) with pan- (all), poly- (many), omni- (all), ambi- (both, and implying ambiguity in this case), people who adopt these self-identities seek to clearly express the fact that gender does not factor into their own sexuality, or that they are specifically attracted to trans, genderqueer, and other people who may or may not fit into the mainstream gender categories of male and female. This does not mean, however, that people who identify as bisexual are fixated on traditional notions of gender.

The editors make an interesting link to the shifts that the larger community is making around gender identity.

Belous and Bauman conducted an academically rigorous content analysis of online content referencing pansexuality, attempting to make comparisons and contrasts between bisexual identity and pansexual identity [9]. They explore themes such as whether or not the term pansexual carries less stigma than the term bisexual (which may explain why many young people are opting for this identifier) and whether people are opting for the term pansexual because it is fundamentally more inclusive and not as binary. In an era in which wider acceptance is growing for gender fluidity and transition, such a term may be more relevant to certain experiences. Belous and Bauman challenge a long-held notion that pansexuality falls under the bisexual umbrella, suggesting that bisexuality may better be examined as a subset of the pansexual identity, and not the other way around [9].

Working with the needs of transgender clients is beyond the scope of this specific course, but it is worthy to note the similarities between the bisexual struggle and the problems with discrimination and alienation that many trans-identified individuals have experienced within the larger LGBT+ community. While bisexual individuals have often referred to themselves as the "silent B," transgender or other gender non-binary individuals have referred to themselves as the "silent T." The LGBTQIA Resource Center at the University of California, Davis, provides a succinct definition of transgender/trans/trans* [10]:

Adjective used most often as an umbrella term, and frequently abbreviated to "trans" or "trans*" (the asterisk indicates the option to fill in the appropriate label, e.g., trans man). It describes a wide range of identities and experiences of people whose gender identity and/or expression differs from conventional expectations based on their assigned sex at birth. Not all trans people undergo medical transition (surgery or hormones). Some commonly held definitions: (1) Someone whose determination of their sex and/or gender is not universally considered valid; someone whose behavior or expression does not "match" their assigned sex according to society, (2) A gender outside of the man/woman binary, (3) Having no gender or multiple genders.

Scholarship and advocacy around trans issues have brought an additional term—non-binary—into wider use. As it relates to gender, non-binary (often stylized as ENBY) is a gender identity and experience that embraces the full universe of expressions and ways of being that resonate for an individual. It may be an active resistance to binary gender expectations and/or an intentional creation of new unbounded ideas of self within the world. For some people who identify as non-binary, there may be overlap with other concepts and identities, like gender expansive and gender non-conforming [10]. While discussions around the fluidity of gender have shaped the terminology around experiences traditionally described as bisexual by ushering in the new terminology (e.g., pansexual, polysexual, omnisexual, ambisexual), many bisexual and sexually fluid individuals are choosing to adopt the term non-binary to describe their sexual identities as well. Non-monosexual is another option being utilized, a contrast to monosexual, or having sexual attractions/feelings to only one gender.

For professionals, it is important to respect the terminology that clients choose to embrace, if they choose any terminology at all. Professionals can get overly enthusiastic about getting clients to label themselves, but part of what the bisexual movement has always been about is embracing the nuances and fluidity of human experience. Other professionals, either implicitly or explicitly, are dismissive when a client, especially a young client, comes into session using a newly evolving term in identifying themselves. For instance, many individuals who historically identified as bisexual began using the term pansexual when it came into wider use, resonating with an increasingly popular axiom that "I am attracted to hearts, not parts." When this change in terminology became more noticeable, there was commentary (from both heteronormative people and others in the LGBT+ community) about how this term was another trend or a cry for attention. As a clinician, it is paramount, in the spirit of doing no harm, to educate oneself on the evolving terminology and to respect how clients describe themselves or identify. Many reputable websites are available for the purposes of educating oneself on evolving terminology (Resources).

Seeking to understand the perspectives of the younger generation, Flanders, LeBreton, Robinson, Bian, and Caravaca-Morera conducted an extensive, mixed-methods study of 60 identified bisexuals and pansexuals between 18 and 30 years of age [11]. The content analyses led them to overwhelmingly conclude that, for this sample, sexual behavior is not part of the comprehensive definition. Rather, identifying as either bisexual or pansexual has more to do with attraction and recognizing the fluidity of attraction over time. They also conclude, "The data do not support the stereotype that all bisexual people conceptualize gender as binary, or view their own sexuality as binary" [11].

For the sake of continuity and editorial clarity, the term bisexual or bisexual umbrella will be primarily used throughout this course. The bisexual umbrella is a term that has been in popular use for many years, although it is now gaining more ground in the academic literature to encompass all the related identities explained in this section [11,12,13]. Bisexuality still being the most widely recognized, scientifically validated term is the main reason for this decision. However, it is important to honor and recognize new identifiers as being valid paths of identity that clients may use to describe themselves, and also to acknowledge each person's right not to identify or label themselves.

CONCERNS UNIQUE TO BISEXUAL CLIENTS

A significant barrier for many bisexual individuals presenting for health care or clinical care is the fear of being truthful when asked certain questions. There can be a significant fear of being judged or further marginalized, especially when questions are asked about sexual history. Many individuals withhold truthful information that, in an ideal world in which the spectrum of sexuality is largely understood, may help professionals to better serve them. Biphobia (i.e., others' fear of bisexuality and misunderstanding about bisexuals) pushes many bisexuals further into the closet. This self-imposed isolation is generally to avoid ridicule and rejection, affecting well-being and sense of identity.

A 2015 study done in Scotland found that 48% of 518 individuals surveyed described receiving biphobic comments from healthcare professionals within the National Health Service (the United Kingdom's national healthcare network). Unwanted sexual advances by healthcare professionals were reported by 38% of the respondents. What is further compelling is that 66% of the respondents felt pressure to identify as straight and 42% of the participants found that it is was easier just to identify as gay when presenting for healthcare services [14].

Discriminatory messages that bisexuals are likely to receive can be further damaging when a helping professional makes them. While this will be explored later in this course, at this juncture, it is important to understand that barriers exist about being truthful with any healthcare or clinical professionals, originating from this fear of judgment, ridicule, or misunderstanding.

Bisexual individuals can have even greater struggles with depression, mental health symptoms, and suicidal ideas than individuals who identify solely as gay or lesbian. According to a 2016 study from Drexel University that included responses of 2,500 LGBT+-identified individuals between 14 and 24 years of age, bisexual and questioning girls/women endorsed significantly higher scores on the depression, anxiety, and traumatic distress subscales than heterosexual girls/women. Lesbians, bisexual females, and questioning females all exhibited significantly higher lifetime suicide scores than heterosexual females. Interestingly, bisexual females exhibited the highest current suicide scores. Gay and bisexual males endorsed significantly higher scores on the depression and traumatic distress subscales than heterosexual males. Gay males also exhibited higher scores on the anxiety subscale than heterosexual males, with bisexual males exhibiting a nonsignificant trend toward higher scores as well. The research conclusion is that LGBT+ mental health needs should be individualized, calling for specific attention to be paid to bisexual clients [15].

The findings of this article likely come as no surprise to those who have been researching bisexual mental health and social conditions for years. Research has consistently found poorer health outcomes, mental health outcomes, and poverty levels/income inequality among bisexuals when compared with monosexual peers [16,17,18,19,20].

3. THE TRAUMA OF THE BISEXUAL EXPERIENCE

DEFINING TRAUMA

Trauma derives from the Greek work traumatikos meaning "wound." Professionals and diagnosticians continue to develop labels and technical rubrics for studying trauma and its clinical manifestations. Many are well-acquainted with diagnoses like post-traumatic stress disorder (PTSD), acute stress disorder, reactive attachment disorder, and other clinical labels from the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) that generally suggest the presence of trauma. While many individuals who fall under the bisexual umbrella carry such diagnoses due to adverse life experiences, the problem with DSM-5 conceptualizations of trauma is that they are event-centric. In other words, trauma is only recognized if a traumatic incident that meets DSM-5 standards for an established condition occurred. This has created a barrier in recognizing and addressing adverse life events that may not meet the criteria for a formal diagnosis of a trauma-related disorder but that have had a serious impact on a client's life, mental health, and well-being.

From a humanitarian standpoint, trauma may be simply defined as a wound—physical, emotional, verbal, sexual, or spiritual—whether or not a precise DSM-5 definition is met for the suffering due to unhealed trauma. In the case of physical injury, there is often an initial wound, which may appear innocuous. However, if proper treatment is not received or if that wound continues to get agitated, further problems and complications can result. With physical injury, one large wound that gets treated properly may be less of an issue for a person in the long-run than a series of cuts or scrapes that continue to fester and infect.

According to the adaptive information processing model developed by Dr. Francine Shapiro, the creator of eye movement desensitization and reprocessing (EMDR) therapy, people learn things about themselves and the world as a result of adverse life experiences and wounding. The messages that come with these learnings are internalized and can result in either an enhanced ability to adapt (e.g., "I'm a survivor") or a paralyzing belief structure (e.g., "I am defective," "I am weak," or "I am permanently damaged"). Shapiro offers an interesting definition of trauma in the 2015 update to her adaptive information processing model [21]:

Trauma can include DSM-5 Criterion A events and/or the experience of neglect or abuse that undermines an individual's sense of self-worth, safety, ability to assume appropriate responsibility for self or other, or limits one's sense of control or choices.

In light of this definition, consider how the life experiences that LGBT+ people, specifically bisexual individuals, may qualify as traumatic, especially when the messaging that accompanies the experiences happens at developmentally vulnerable periods of life.

For many bisexuals, the messages themselves may cause the wounding, further crystallizing negative core beliefs in the limbic brain, the center of emotions and learning. These negative beliefs are also referred to as oppressive cognitions.

TRAUMA AND THE LGBT+ COMMUNITY

Any minority group, especially those traditionally discriminated against by family members, the community, faith organizations, and society at large, is extremely vulnerable to being traumatized or wounded. In some cases, these traumatic experiences are public and large, such as in the case of hate crimes, physical violence, or pointed vandalism. For each of these public experiences, there are hundreds more that have remained uncovered. Moreover, much of the wounding faced by LGBT+ persons is experienced in the form of bullying, snide comments, and spiritually abusive messages by religious leaders or parents. For members of the LGBT+ community, dismissals and invalidation of personal identity and selfhood make up a large part of their trauma histories. Many individuals who identify as LGBT+ have also been forced into "reparative therapy," or variations thereof. These damaging religious programs are used to try to force change upon the individuals and how they love and express themselves in the world. It is essential that clinicians validate these subtler, yet equally insidious, experiences as traumatic.

Two concepts that are widely discussed in the trauma scholarship over the last decade—complex trauma and developmental trauma—may further help in the process of working with any LGBT+ client.

Complex and Developmental Trauma

Complex trauma, first coined by Dr. Judith Hermann in 1992, refers to conditions of prolonged trauma or trauma that occurs at developmentally vulnerable times for an individual. Courtis and Ford describe complex traumas as having the following characteristics [22]:

- Repetitive or prolonged actions or inaction

- Involving direct harm and/or neglect or abandonment by caregivers or ostensibly responsible adults

- Occurring during developmentally vulnerable times in the victim's life, such as early childhood

- Great potential to severely compromise a child's development

Other scholars have made use of the term developmental trauma to specifically describe the role that trauma and adverse life experiences during early childhood development can play in personality development, behavior, and affect [23].

Complex trauma/PTSD and developmental trauma have emerged as constructs seeking to fill the gap between the event-centric diagnoses that appear in the DSM-5 (and previous versions) and the reality of how many survivors experience trauma. Developmental trauma is often compared to the slow drip or water torture experience of little bits of insult, degradation, and dismissal that happen each day, accumulating over time. This includes experiences like constantly being insulted by people close to you for something that cannot be helped—like who one is attracted to, how one loves, and how one sees oneself in the world. The impact of these experiences, and the messages that accompany them, can toxically accumulate over time. If left unhealed or unprocessed, mental health and various other social problems (e.g., unemployment, instability in relationships, disconnection from community/society, spiritual identity crisis) can result.

The Human Rights Campaign (HRC) conducts extensive surveys and data collections on the experiences of LGBT+ individuals in America. Their project, Growing Up LGBT in America, surveyed 10,000 LGBT+-identified youth 13 to 17 years of age [24]. According to this survey, 42% of LGBT+ adolescents say that the community in which they live is not accepting of LGBT+ individuals, and 92% of LGBT+ youth say that they hear negative messages about being LGBT+ from school, the Internet, and peers. LGBT+ youth are twice as likely as heterosexual youth to have been kicked, shoved, or physically assaulted [24].

OPPRESSIVE COGNITIONS AND THE UNIQUE CONCERNS OF BISEXUALS

The HRC conducted a follow-up survey of nearly 5,000 youth who identified as part of the bisexual umbrella [25]. According to this survey, 10% of bisexual youth report that they "fit in" in their community, with 58% believing that they will need to move away at some point to experience fulfillment. In addition, bisexual youth report having experimented with drugs and alcohol at a slightly higher rate (56%) than gay or lesbian youth (50%) and at a significantly higher rate than straight youth (22%) [25].

Bisexual youth who participated in this survey reported the following experiences of how their sexuality is misunderstood by others, as expressed in messages that are very common to the bisexual experience overall [25]:

- "I wish that more people inside the gay community itself would support my decision to call myself bisexual. I am not being selfish. I am not a liar. I am not gay. I am not straight. I am bisexual."

- "As a bisexual, I feel shunned by the gay and lesbian community."

- "I came out to my family, and they didn't believe me."

- "Being gay is understood in my family, but being bisexual is not."

- "The one time I brought up the issue with my mom she said that I would grow out of it. And then she ignored it."

- "I feel like if I were to come out as bisexual people would just think I am a slut."

- "My parents aren't homophobic, but when it comes to me they aren't accepting at all. They say I can't be bi. I have to be gay or straight."

- "When I tell males about my sexuality I get remarks like 'that's so hot,' which I feel fetishizes my sexual orientation."

- "I'm tired of being told it's a phase."

- "I've had people tell me that my life is worthless because I'm bisexual. That I am nothing."

- "Bisexuality isn't real."

- "They just think I'm confused."

- "I would like the pressure to 'pick a side' to stop. It's very frustrating."

These statements gleaned from the HRC survey reflect many of the struggles that bisexual clients presenting for services have voiced over the years. These and similar messages reflect a reality that bisexuality is misunderstood by the public, in the context of a larger society that has traditionally been discriminatory against any sexual minority in the first place. To understand how these wounding messages can crystallize for clients who identify as being part of the bisexual umbrella, it is important to explore a newer concept in the trauma literature: oppressive cognitions.

Levis and Siniego first published the concept of oppressive cognitions in 2016. This term emerged from Levis' work as a trauma specialist/EMDR therapist and as a specialist in multicultural issues and providing culturally attuned psychotherapy. In EMDR therapy, the construct of negative cognitions, or the maladaptive messages that people receive about themselves or how they are in the world because of traumatic experiences, is critical. Levis took this a step further to suggest that when these negative cognitions or messages are received due to oppression, cultural trauma, or bias, they can crystallize more insidiously. Oppressive cognitions may be relevant to both the individual and to the specific minority group [26]. Furthermore, oppressive cognitions are sociopolitically influenced and culturally reinforced in an ongoing and insidious manner by the dominant majority and the media.

Levis and Siniego contend that treatment of oppressive cognitions requires a broadening of therapeutic focus [26]. Successful resolution depends on an acknowledgment of the impact that historic and ongoing social oppression have upon the presenting problem. For clinicians working with bisexual clients, recognizing the damaging messages that have traditionally been received by individuals identifying as part of the bisexual umbrella is paramount. While all of the messages reported from the HRC survey could apply, in this course, four specific messages are isolated for further exploration as oppressive cognitions:

- There is no such thing as bisexuality.

- Bisexual people are just confused and have not figured things out yet.

- Bisexual people use their sexuality in deviant or manipulative ways.

- Bisexual people are not really a part of the LGBT+ community.

There is no such thing as bisexuality.

The wounding inherent in this message can be received in a variety of ways. Many bisexuals and others under the bisexual umbrella hear this comment expressed by family or friends who identify as straight, but it can feel even more hurtful coming from individuals who identify as gay or lesbian. The suggestion that comes with this message, either implicit or explicit, is that identifying as bisexual is simply a step on the way to identifying as fully gay or fully lesbian. Bisexual boys/men are particularly susceptible to receiving such commentary from others. Another message that seems more tolerant on the surface is, "Well, I just assume that everyone is bisexual. Sexuality is a spectrum, right?" The sting of invisibility can still accompany such a statement, as it suggests that how one legitimately identifies as loving in the world is "normalized" to the point of minimization.

For any of the messages that fall under the general theme of bisexuality being less than authentic, a core negative or oppressive cognition that can become installed is "I do not exist." While some bisexuals fully receive this message with power and intensity, others may also hear and internalize messages such as "How I love isn't valid," "Who I am isn't valid," and "I am invisible." Consider how many of these themes may come out in clinical work related to presenting issues like depression, anxiety, or other diagnoses in the trauma and stress disorders classification. With bisexual clients, it is imperative that professionals pause and consider how such themes may be best explained by the accumulated stress and wounding of hearing such messages about the self.

Bisexual people are just confused and have not figured things out yet.

The assumption that bisexual people are inherently confused or are simply on some path of discovery is prevalent in popular and clinical culture. While some people's sexual behavior, especially during points of developmental transition, may be described as experimental or bi-curious, it is very important that clinicians never shame individuals who are seeking to find their sexual voice or identity. While it is true that some people transition into and out of bisexual attractions and behaviors, it is vital not to assume that it is a phase for everyone who identifies as bisexual.

The oppressive cognition of bisexual confusion helps to perpetuate the myth that bisexuals are somehow the most "abnormal" of the sexual minorities and can drive home oppressive messaging such as "I am defective," "I am disgusting," "I am a disappointment," and "I am confused" as core beliefs, not just passing feelings.

In working with clients, it is useful to help them sort through how they may feel versus whether or not they have internalized negative or distressing feelings about the self. In many forms of trauma-focused therapy, such as EMDR therapy, feelings are identified as important although fundamentally transient. A client can feel like he or she is worthless, for instance, without believing at the core that he or she is worthless, especially if the feelings come and go. With oppressive cognitions, especially several of the major ones experienced by bisexuals, the belief is ingrained and impactful.

Bisexual people use their sexuality in deviant or manipulative ways.

The portrayal of bisexual characters in film and television as manipulative, deviant, or villainous is well-known. Two particular tropes recur. The first is the "emotional wrecking ball" trope, almost exclusively a woman, whose emotional instability wreaks havoc in the lives of all her monosexual (and therefore emotionally stable) friends [27]. This usually includes cheating, contributing to the social myth that bisexuals are sexually "greedy."

The second trope is of the criminally deviant bisexual. This bisexual is corrupt and morally irredeemable—often a femme fatale. At the root of these tropes is a belief that bisexuality is an event in itself; it drives the bisexual person's behaviors instead of being just one feature in a complex and multifaceted human.

The implications here for working with oppressive cognitions are clear. Negative messaging such as "I am deviant," "I am (inherently) a villain, and I will hurt people," and "I am damaged" are all examples of what bisexual clients may be carrying into their clinical work.

Bisexuals are not really a part of the LGBT+ community.

Many bisexuals describe feeling excluded from the gay and lesbian communities. Various reasons can exist for this exclusion, including fear of dating bisexuals because of perceptions that they are sexually greedy/more likely to cheat and the belief that bisexuals are really "closeted" gays/lesbians who are practicing internalized homophobia by identifying as bisexual. Bisexuals and others under the bisexual umbrella are often accused of wanting to present as sexually progressive and maybe even reaping the benefits of the fashionable aspects of gay culture without fully participating in the daily trials and social struggles of being out. These messages can internalize as oppressive cognitions (e.g., "I am defective/sexually deviant," "I am an attention monger," "I am a poser/inauthentic") and may be a part of many clients' experiences. The message that can create the biggest sting is the accusation that because bisexuals have passing privilege, they are not fully part of the LGBT+ community.

Passing privilege is a pejorative phrase suggesting that it is easier for bisexuals to "hide" in straight relationships and ultimately in mainstream society, especially compared with gay and lesbian individuals. Bisexual advocates respond to this criticism by highlighting that many people who eventually come out as gay or lesbian have also been in heterosexual marriages while they were closeted. Some marriages are a form of self-preservation to appear integrated in communities that are not fully accepting of LGBT+ people, regardless of how they may identify. To claim that it is easier for bisexuals to "hide out" in the mainstream simply reflects bias, fear, and judgment against bisexuals, part of insidious biphobia.

Clinical and human services professionals are on the front lines of being able to fight biphobia. The wounding of oppressive cognitions can be reversed simply by validating the legitimacy of bisexuality and embracing clients who identify as being part of the bisexual umbrella without trying to change them. In trauma-informed and trauma-focused care, the oppressive cognitions of minority groups, including bisexuals, may need to be evaluated through client history and addressed as treatment issues before memories related to other traumas can be processed. Clinicians should look for the links between presenting issues for treatment and possible oppressive cognitions.

Three aspects have been identified as a minimum of affirmative practice with LGBT+ clients [28]:

- Have a working knowledge of LGBT+ individuals

- Understand heterosexism and work to dispel it

- Acknowledge the possibility of one's own heterosexism

While principles of affirmative treatment will be further discussed in a later section that focuses on treatment strategies, this is a simple, evaluative starting point for clinicians wanting to improve their efficacy in working with bisexual clients. The focus on heterosexism, or the biased assumption that heterosexual identities and behaviors are the "norm" and everything else is deviant, merits attention. Oppression and thus the impact of oppressive cognitions exist because of such heterosexism in mainstream society.

THE COMING-OUT PROCESS

The concept of coming out is more widely recognized as a phrase and a concept in modern society. However, it is rarely simple to define. Coming out is typically described as the process of revealing one's non-heteronormative sexual or gender identity to others. While coming out is often portrayed as a rite of passage or a dramatic event in the lives of LGBT+ people, the reality is that people who identify as LGBT+ are "coming out" their entire life in a society that is still largely heteronormative: to new friends, in new relationships, and in new work settings. When an individual decides to come out, it is generally a multi-layered processed that usually begins with "coming out" to one's self first. People may then choose to come out to those closest to them, such as family, or may need to first come out to people they feel are safer than family, such as friends/a peer group, a school counselor, a clinical professional, or another ally. An ally is generally described in the LGBT+ community as someone who is affirmative, supporting, and accepting of diversity in sexuality and gender identity and does not attempt to change or steer the individual away from being who they are. Some people are outed without their consent or permission due to others in the community making assumptions about them or their behaviors. Such forced coming-out experiences generally qualify as traumatic or wounding for the individuals affected by this invasion of personal privacy.

It is important for medical, human services, and other clinical professionals to understand several key concepts about coming out. First, an individual identifying as LGBT+ must decide when and how to come out in health and mental health settings. In some cases, the coming-out process is unintentional and awkward, like when the provider asks about sexual preference and activity during the intake process. Clients may stammer with uncertainty about how to answer as they decide whether they feel safe enough to disclose important aspects of themselves, such as sexual orientation and gender identity. A client may also be uncertain about who they are and how they identify. In LGBT+ circles, the term questioning is often used to describe such individuals. Many questioning individuals present for clinical services to sort out their thoughts and feelings about how they identify and if/how to come out to others. Thus, being received by an affirmative (at minimum) and LGBT+-competent professional is imperative to making sure that therapy does not become a retraumatizing experience.

The coming-out process, even under positive and affirmative conditions offered by friends, family, and a faith community, can still be traumatic on some level, particularly when mainstream society is heteronormative and many people carry biases and hateful opinions. Realizing this second truth is a vital step for professionals. In working with bisexual clients, it is important to recognize how the previously discussed myths and biases against bisexuals can complicate the coming-out process. Many bisexuals choose to stay in the closet, fearing judgment from those in the mainstream while believing that they will find inadequate support among other LGBT+ people.

There is still a widespread assumption by many professionals and those in society at large that coming out as bisexual is just a step on the way to coming out as "fully" gay or lesbian, and some research suggests that coming out as bisexual may be a stepping stone for some, a construct referred to as transitional bisexuality [29]. However, professionals can do a great deal of damage by assuming that bisexuality is just a transition for everyone identifying as part of the bisexual umbrella. For many, being attracted to both or many genders and in various degrees is an accurate reflection of who they are and how they love in the world. It can be retraumatizing if a bisexual person seeking help encounters a professional who either minimizes or fails to appropriately validate their experience of coming out.

While a discussion of all of the issues connected to the coming-out process is beyond the scope of this course, there is one more vital issue to cover related to coming out for bisexual clients: the prospect of coming out again. Professionals who work in LGBT+-specific treatment routinely report the experience of educating their clients on bisexuality and hearing traditionally identified gay men or women state that they chose to be out as gay, rather than their actual bisexual identity, because everyone assumes they are gay. In particular, bisexual men are vulnerable to a great deal of prejudice and spiteful commenting, in some cases from gay men, about not being brave enough to admit that they are gay and come out of the closet fully [7].

For bisexuals across the gender spectrum, coming out to friends and their community as bisexual after initially coming out as gay or lesbian can be difficult. Consider the case of Client A, who initially came out as bisexual and was told by her family, "There is no such thing as bisexuality." Affected by this judgment, Client A chose to come out as a lesbian and ultimately to marry a woman. After her marriage ended, in exploring her relational dynamics in her own therapeutic process, Client A reclaimed her bisexual identity. Coming out as bisexual proved challenging, as she was still met with comments about "picking a side" and "switching teams." Yet, describing her sexuality authentically as a bisexual woman ushered in a new era of growth for her. Mental health professionals can help guide clients on this journey instead of keeping them stuck in those patterns of shame by practicing from a place of bias, assumption, or misinformation.

4. CULTURALLY RESPONSIVE TRAUMA TREATMENT PLANNING FOR BISEXUAL CLIENTS

While a great amount of research literature has gone into enlightening the evidence-based practice movement in recent years, it is worth noting that treatment research specific to LGBT+ populations has been minimal. A 2006 task force of the American Psychological Association concluded that "an evidence-based practice in psychology is the best available research with clinical expertise in the context of patient characteristics, culture, and preferences" [30]. Choosing a line of intervention for treatment never comes down to research alone. Other variables are important, and in working with minority groups such as bisexuals, contextual factors can take on even greater importance.

In his text on treating substance use disorders in LGBT+ populations, Michael Shelton emphasizes that treatment of LGBT+ individuals must be trauma-informed [5]. The phrase trauma-informed can be confusing to many professionals who assume that trauma-informed care is only for individuals with a PTSD diagnosis. As described, the impact of trauma can manifest in a variety of ways, not just in clinically obvious diagnoses. Shelton writes [5]:

Some LGBT individuals enter behavioral health treatment with insidious traumatization. Since childhood they may have been bombarded with messages that same-sex attraction and gender nonconforming behaviors are disgusting, sinful, or indicative of mental problems; these microaggressions are sufficiently traumatizing in themselves.

In addition to being affirming, being trauma-informed is an imperative bare minimum in working with bisexual clients and other sexual minorities. This imperative applies to all professionals, regardless of the setting in which they may work (e.g., treatment centers, private practices, hospitals, school settings, correctional settings, medical offices).

The Substance Abuse and Mental Health Services Administration (SAMHSA) provides guidelines on trauma-informed care in their Treatment Improvement Protocol. The trauma-informed movement can be characterized as embracing the paradigm shift of asking what happened to clients as opposed to what is wrong with clients. The SAMHSA defines a trauma-informed approach to the delivery of behavioral health services as including an understanding of trauma and an awareness of the impact it can have across settings, services, and populations. It involves viewing trauma through an ecologic and cultural lens and recognizing that context plays a significant role in how individuals perceive and process traumatic events, whether acute or chronic [31]. For providers working with bisexual clients, recognizing the inherently traumatic nature of being bisexual/part of the bisexual umbrella in a heteronormative mainstream is part of viewing clients through an ecologic and culturally informed lens.

The SAMHSA Treatment Improvement Protocol emphasizes specific ways that individuals working in human services can practice trauma-informed care, including [31]:

- Promote trauma awareness and understanding

- Recognize that trauma-related symptoms and behaviors originate from adapting to traumatic experiences

- View trauma in the context of individuals' environments

- Minimize the risk of retraumatization or replicating prior trauma dynamics

- Create a safe environment

- Identify recovery from trauma as a primary goal

- Support control, choice, and autonomy

- Create collaborative relationships and participation opportunities

- Familiarize the client with trauma-informed services

- Incorporate universal routine screenings for trauma

- View trauma through a sociocultural lens

- Use a strengths-based perspective and promote resilience

- Foster trauma-resistant skills

- Demonstrate organizational and administrative commitment to trauma-informed care

- Develop strategies to address secondary trauma and promote self-care

- Provide hope—recovery is possible

The Treatment Improvement Protocol, which expands upon each actionable point in more detail, is available for free online (Resources). All professionals are encouraged to obtain this document, at least as a means of personal or practice-wide evaluation to determine how well they are practicing trauma-informed principles in medical and behavioral health care.

BEST PRACTICES FOR TRAUMA-INFORMED CLINICAL INTERACTIONS WITH BISEXUAL UMBRELLA CLIENTS

Do not re-traumatize—clinicians most often do this by prodding for too many details too soon or coming across as interrogatory. This relates to both the general biopsychosocial history as well as gathering information about sexual orientation or identity. Do not ask questions out of morbid curiosity or simply with the urgency to fill out clinical forms.

Do consider that getting an exact, chronologic trauma history may be unsafe or impractical because of how the memories are stored. Instead, determining presenting issues and corresponding themes is of utmost importance. If the topic of sexuality comes up in an initial session, exploring issues related to the coming-out process as a theme (as an example) may be more useful than getting a detailed history around sexual development.

Do ask open-ended questions. Questions that start with the words "what" and "how" generally allow clients to provide as much or as little detail as they are ready to give. Questions such as, "What are you willing to share today about your sexual orientation or sexual identity?," or "How has coming out as bisexual impacted your life?" are examples of how to avoid limiting clients to yes/no answers.

Do be non-judgmental. This does not mean endorsing maladaptive or unhealthy behaviors, but it does mean respecting the dignity of the person at all times. For LGBT+-affirmative therapists, it is imperative not to explore a person's sexual identity or orientation as a "problem" or the maladaptive response. However, a person may disclose engaging in problematic or addictive behaviors to cope with internalized shame and homophobia. If these phenomena are explored in the treatment plan, take care not to make sexual identity/orientation the problem—the heterosexist mainstream is the problem. With bisexual clients, discrimination from the larger LGBT+ community may also be part of the problem, although identifying as bisexual and claiming a bisexual identity is not. If one finds that their own biases are getting in the way of practicing non-judgment, seek further supervision, consultation, or training.

Do be genuine and build rapport from the first greeting. Forging a solid therapeutic relationship is essential for clinical success, especially in trauma-informed clinical services. Again, internal biases about LGBT+, specifically bisexuality, impede this process and should be addressed through supervision, consultation, or training.

Do consider the role of shame in bisexual clients presenting for treatment of addiction, trauma, and/or grief. Most clients identifying as LGBT+ carry some type of internalized shame about who they are and/or what they may have done to deal with the pressure of being who they are in a heterosexist society (e.g., substance use, acting out, hurting others while closeted). Recognizing this reality is an important competency for professionals who are in positions of power to further shame clients by making assumptions and judgments about being bisexual. Instead, professionals should help clients to see new, healthier truths about themselves and their capacity to love.

Do make use of the "stop sign" when appropriate. Let clients know that they can opt out of answering questions in the history, with the possible exception of questions related to suicidality/harm to others. Some of the greatest harm that clinicians can do with all clients, especially clients who identify as LGBT+, is to prod for too many details out of curiosity or because it is believed to be required to meet all the standards with paperwork. Those working for a highly regulated agency should determine how often statements like "client chose not to disclose" or "defer to further assessment" may be used in paperwork. Much of the detail that certain assessment tools require from clients about sex and sexuality should only be obtained in the context of established trust and rapport; this can be very difficult to do in a first session. Assess how medically and psychologically necessary a piece of information is to address the issue at hand. Although the answer may be "yes," in certain contexts (e.g., in diagnosing and treating a sexually transmitted infection [STI]), in many contexts it is not. If the latter, avoid prying.

Do assure clients that they may not be alone in their experiences, but be mindful not to minimize. Examples of minimizing with a bisexual client include using statements like, "I think everyone is bisexual to a certain degree," or "Sexuality is a continuum after all; it is not black and white." While such statements can be delivered with good intention as a gesture of normalization, consider how they are inherently minimizing. In contrast, sharing with clients that one has worked with bisexual clients before and has learned from such clients about their experiences may be a better way to normalize or help new clients to see that they are not alone.

Do have closure strategies ready. Allow at least 10 minutes to close down and consider teaching a brief coping skill at the end of a first intake session. For all clients, it is important not to run any session to the last minute with questioning and content, especially about sexuality. If a client does have a big reveal that may have even taken them by surprise during an initial intake session, be sure to check in about how they are feeling for disclosing such information about their sexuality or sexual behavior before they leave and develop a plan for self-care between sessions. One can also preview for the client how treatment will help them and address any goals they may have around sexuality. The essential lesson here is to avoid ending the session immediately after the client has unloaded. The term "vulnerability hangover" has been coined to describe the feelings of shame and remorse that people may feel after a big reveal [32]. If clients are ill-equipped to handle the feelings that may come up, they may resort to default coping mechanisms that are self-destructive (e.g., substance use, acting out).

Do be mindful of how screening tools or devices are administered to clients. Be careful to adequately orient the client to the rationale for why the tool is being used. Also, avoid simply placing people in a crowded waiting room or small confined office if those environments may be too triggering/activating. If a tool like the KSOG is determined to be useful, it is imperative to fully explain the survey and to provide privacy. How answering these questions may serve the client and the overall treatment plan should be explained.

Consider that assessment is an ongoing process. Clinicians will not (and should not) obtain all the information that they need in the first session, especially about sex and sexuality. Information about sex and sexuality can be deeply personal and sacred to clients and is best shared when they feel sufficiently safe to disclose such information. Although some client-clinician interactions have that quality of rapport developing instantly, for most clients identifying as LGBT+, the process takes time. For bisexual clients, especially if they have been told unkind or untrue things about their sexuality by professionals before, this process may take even longer.

One final item to note is that another, deeper paradigm shift is happening with those who take the role of trauma and its impact on the human experience seriously. Although being trauma-informed is a good first step and should be a minimum of care for anyone who works with the public, being trauma-focused is required to bring about deeper healing, especially for those discriminated against by a heteronormative mainstream in their development.

Trauma-informed care recognizes the role that unhealed trauma plays in human behavior, provides a template for minimizing harm in the delivery of human services, and offers an education framework for human services systems [33]. In contrast, trauma-focused care assumes that unhealed trauma plays a major role in presenting issues, denotes greater action in the delivery of treatment services, and promotes proactive treatment planning to heal the legacy of trauma [33].

Professionals who believe that human suffering is caused or exacerbated by trauma will gravitate toward a trauma-focused approach. In working with bisexual clients, it is important to understand that trauma is insidious and plays a major role in causing or exacerbating the problems that LGBT+ clients report in presenting for services [5]. For bisexual clients, the inherent traumatization of being affected by oppressive cognitions can be salient, so adopting a trauma-focused treatment strategy for healing is imperative.

APPLYING THE THREE-STAGE CONSENSUS MODEL OF TRAUMA TREATMENT TO BISEXUAL CLIENTS

There are many theories, modalities, and approaches available for the treatment of mental health issues, substance use disorders, and psychopathology/problems of daily living specifically linked to traumatic stress. Approaches can include traditional modalities, like psychodynamic psychotherapy, Gestalt therapy, existential therapy, and cognitive-behavioral therapy (CBT), to newer interventions, like EMDR therapy and dialectical behavior therapy, both of which are listed as evidence-based practices by major clinical organizations like SAMHSA [31]. In addiction counseling, interventions like 12-step facilitation and motivational interviewing are still popularly used; when applied in the context of cultural considerations, both approaches are effective. Social justice counseling and therapy based on feminist theory are appealing choices for many LGBT+ clients. Newer wave, more somatically informed interventions for resolving trauma, like body-centered psychotherapy, sensorimotor psychotherapy, or somatic experiencing, are also viable options for engaging in trauma-focused care with bisexual clients.

The aim of this section is not to make a case that any one approach works best for bisexual clients. There has not been enough research done specific to bisexual populations to begin making a case for any one modality as the best. In addition, a culturally responsive approach to treatment dictates that clinicians should never force a preferred mode of intervention on a client. Rather, clinicians should blend their expertise and knowledge of effective practices with the cultural needs and preferences of the client. A culturally competent and proficient clinician is "aware of the importance of integrating services that are congruent with diverse populations and capable of meeting their needs. Diversity is valued. There is a willingness to be more transparent in evaluating current services and practices and in developing policies and practices that meet the diverse needs of the treatment population and community at large" [5]. This is in contrast to a culturally destructive clinician or organization that imposes attitudes from mainstream culture, including inflexible beliefs about "what works" for a client.

Clinical flexibility that honors clients' goals and preferences for treatment is critical, and much of this means not imposing rigidity about the method for treatment. Eclectic or integrated clinicians trained in several different modalities may be in a better position to work with LGBT+ clients. In trauma-focused treatment, practitioners can still be flexible and have a framework from which to operate: Pierre Janet's Stage Model for the Treatment of Traumatic Stress [34]. Tracing back to the late 19th century, this model is still relevant in the modern era because it carries a great deal of timeless common sense. Janet's original model goes by different names in the field today, including the three-stage model, the triphasic model, and the three-stage consensus model. In the century since Janet published his ideas, nearly every major scholar writing on post-traumatic stress, regardless of their clinical orientation, can agree on the three-tiered structure. Places of consensus in a field that can be divided are valuable sources of content and clinical applicability.

Janet's original stages were [34]:

- Stage 1: Stabilization, symptom-oriented treatment, and preparation for liquidation of traumatic memories

- Stage 2: Identification, exploration, and modification of traumatic memories

- Stage 3: Relapse prevention, relief of residual symptomatology, personality reintegration, and rehabilitation

Aristotelian simplicity dictates that there should be a beginning, a middle, and an end (even if this "ending" is better conceptualized as maintenance) to the healing structure of therapy. Of course, there is room for practitioners to add a personal spin and to focus on one stage more than the others based on client readiness and need. For instance, many clients present for services reasonably stabilized and ready to dive into the deeper work of stage 2. Other clients may need to engage in some stage 2 work relatively early in the treatment process before they can come close to stabilizing, a function typically described as part of stage 1 [35]. Although exceptions exist and stage 2 treatment may need to occur sooner than usual, an attuned clinician committed to affirming the client and ensuring safety before engaging in deeper clinical work can work with the client to build an individualized treatment plan [35]. Working with client context has always been vital to understanding the consensus model. In the case of bisexual clients, their presenting problems, where they are in the coming-out process, how they have been impacted by oppressive cognitions, and the nature of the developing practitioner-client relationship should all be evaluated within clinical context to determine how to apply the consensus model for treatment.

One of the greatest misconceptions about trauma-focused therapy is that catharsis, or the second component of Janet's structure (i.e., identification, exploration, and modification of traumatic memories), is paramount. However, if an individual engages in catharsis and is actively working on trauma without having a foundation of skills for tolerating emotion or affect, further damage can result. Part of this foundation and groundwork includes a solidly forged therapeutic alliance with an affirming practitioner.

Another misconception about trauma-focused care is that after something is processed or cleared, then it is fixed and gone. This mindset promotes a misconception that trauma can be cured, but a healthier approach is to look at trauma as something that can be healed. Even after a person has a breakthrough in treatment, the process of reintegrating or adjusting to regular life after healing can be another source of trauma and/or adjustment. If a person undergoes successful major surgery but no postoperative follow-up or rehabilitation is provided, he or she could be seriously harmed. The same logic applies to healing emotional trauma, especially in working with LGBT+ individuals who are likely returning to a mainstream that is still less than friendly or affirming as a whole.

Consider how the consensus model fits with the wound metaphor addressed earlier in this course. Stabilization is the immediate attention to a wound. For example, stabilization might mean cleaning out the wound and disinfecting the area. Then, a dressing is generally applied to stop the bleeding and prevent infection or contamination. However, the wound needs to be exposed to the light and air in order to fully heal. Healing occurs from the inside and can take a great deal of time. This process is stage 2. After a wound heals, it generally leaves a scar. In cases of relatively benign wounding, that scar may resolve completely. With more significant injuries, a person may live with a scar or whatever aftermath is left after the wound heals [36].

In 2012, an expert consensus panel of the International Society for Traumatic Stress Studies issued their recommendations for addressing complex post-traumatic stress. The panel still recommends the general sequence of the three-stage consensus model as the standard for trauma care [37]. The 2013 World Health Organization report on treating trauma also makes reference to similar themes, particularly the importance of psychologic first aid (or stabilization) as a standard of care for PTSD [38].

Trauma, grief, and how wounds manifest are not linear, especially for bisexual umbrella clients whose state of being can be qualified as traumatic experience. One concern with models for clinical intervention is that the more "steps," "numbers," or "components" they contain, the more likely clinicians are to be confused about how to deal with unpredictability. No model can capture the truly messy nature of unresolved trauma or grief, let alone offer the perfect solution for healing it. A simpler model allows for flexibility and the ebb and flow that characterizes human healing. As such, the consensus model is a framework. It is common sense to stabilize first—to make sure a person can deal with what may come up in the stage of deeper identification or exploration [36]. Affirmative practices and teaching basic skills for managing affect, feelings, and unpredictability (especially if a coming-out process happens during treatment) are imperative in stage 1 work with bisexual umbrella clients. However, if the exploration stage begins and it is evident that the client is not adequately prepared to engage in deeper work around oppressive cognitions or other traumatic causes of presenting symptoms, the treatment can steer back to a stabilization focus at any time. Even when actively working with clients doing stage 2 processing with any appropriate modality, it is wise to use skills acquired during stabilization (stage 1) to close sessions safely or to remind the client how to use these skills to stay as safe and as regulated as possible between sessions.

SAMPLE TREATMENT PLANNING STRATEGIES

As discussed, no single theory or modality is recommended for working with bisexual umbrella clients. Professionals should apply their chosen modality in a trauma-focused and culturally responsive manner; any modality or series of modalities can work well with bisexual clients in the context of the three-stage consensus model. In this section, a sample outline for tasks that could happen in each phase of treatment with bisexual umbrella clients is presented to aid in clinical decision making, with specific commentary on how to carry out these treatment tasks. The case of Client A, a bisexual woman, will be used as an example of how a clinician can work through each stage.

Stage 1: Stabilization and Laying the Foundation

In the first stage of treatment with bisexual clients, it is important to establish and cultivate therapeutic rapport, with special attention paid to affirming the client's bisexual umbrella identity, questioning identity, and (if applicable) coming-out process in a way that serves the client's goals. Professionals should not push an agenda or assumptions about coming out (e.g., "Coming out will be good for you right now") on the client. Work with their goals, needs, and preferences for treatment.

Clients should be linked with appropriate support in the community or, via virtual platforms, online. Having appropriate support is especially important if a bisexual client is choosing to come out during his/her treatment or therapy process. Some clients may be "out" in some aspects of their lives (e.g., with family and friends) but not in all areas of their lives (e.g., work, faith community). Obtaining support to take this next step in the journey can be critical. In working with minor clients or clients with active family ties, encouraging support for the family can be critical as well. Although parents of children are often presumed to be most affected by a coming-out process, spouses can also be profoundly affected by a partner's public coming out (especially if they did not know about the client's bisexual identity at the beginning of their relationship). Professionals should be prepared to make referrals for family members if they are open and willing to seeking this help for themselves.

Bisexual umbrella clients may be encouraged to talk with others who have also come out. This can normalize clients' experiences and set them up for greater success both in therapy and in other parts of their coming-out journey and living a meaningful life. Advocacy websites can also be useful stops for clients to see other people thriving as bisexuals.

If a client has a substance use disorder or other addiction issue, referral to a 12-step group or other mutual help group in the community can be important. Whenever possible, seek out LGBT+-specific meetings, often called "rainbow" meetings, in the area. Healthy meetings of this nature can be a good place for bisexual umbrella clients to meet sober role models and support figures in the community. In general, not all 12-step meetings are high quality and many are not a good fit for LGBT+ clients who can feel further marginalized, especially in religiously charged areas. As with many areas of human services work, asking around, networking, and searching online collaboratively with clients can be good places to start.

For many LGBT+ clients, getting involved as an advocate or with political work connected to an LGBT+ or specifically bisexual umbrella organization can be a helpful adjunct to the healing process. Promoting such involvement is a critical component of an approach called social justice counseling. While this engagement can be helpful for some clients who are working to find their voice as healthy bisexuals, be careful to avoid making assumptions that such advocacy work is helpful for every client.

Psychoeducation is a critical part of stage 1 work with all clients. Trauma-focused clinicians can do this by finding out if clients are lacking information in a certain area or if they may be operating on misinformation and assumptions given by others. Many clients who grew up in religious institutions that discriminated against LGBT+ persons are still seriously affected by this shame-based messaging. While clinicians are not expected to practice pastoral counseling if this is outside their scope of practice or comfort, pointing the client in the direction of LGBT+-accepting spiritual resources may be necessary. It can be helpful to identify which churches, spiritual communities, or other places of worship are LGBT+ affirming; many socially progressive churches promote this on their websites and in their literature. If a client is comfortable speaking with a leader at such a church, supportive religious teachings can supplement the therapy process.

Another aspect of psychoeducation for bisexual umbrella clients can involve sharing information on healthy sexuality and lifestyle. This can include the basics, like education on safer sex and STI screening for clients who are sexually active. Working with clients to determine what feels like healthy sexuality for them and developing a plan to achieve it is crucial. For bisexual clients, this generally involves connecting with and/or reading about how other bisexuals have managed to thrive and life healthy lives that honor the full expression of their sexuality. This task may include addressing the misconception that to fully claim bisexual identity, one must become polyamorous. Polyamory, literally "many loves" and sometimes referred to as ethical non-monogamy, is a lifestyle path in which multiple relationships or sexual connections are made, with the full knowledge and consent of all parties involved. Some bisexual umbrella clients find polyamory appealing, and others do not.

When conducting stage 1 treatment, it is important to evaluate whether basic needs, like food, water, shelter, and clothing, are being met. If there are deficits in these areas, be prepared to link clients with resources available in the community. This task can take on special importance when working with LGBT+ clients, many of whom have been shunned from their homes and families. Some clients may have lost jobs or financial security after coming out. All of these contingencies should be addressed, and clients should be assisted in developing a plan of action for getting these basic needs met, especially if they are running into barriers.

Coping skills and other approaches to work with heavy, intense, or unpredictable affect and feeling states should be taught, bolstered, or reviewed in stage 1 work. Clients who desire to do the deep digging of stage 2, especially if their goal is to heal the legacy of trauma created by oppressive cognitions and other stressors of the LGBT+ experience, should be prepared to reasonably handle what might surface emotionally. In stage 1, a variety of clinical methods and approaches may be used to help clients widen their affective window of tolerance, or the amount of emotional intensity and/or distress they can safely withstand and continue to adaptively and effectively function. Approaches like grounding, mindfulness strategies, breath work, guided visualizations, and expressive arts practices (e.g., writing, visual art making, engaging with music) are all dynamic ways to work with clients in stage 1.

Embodied practices like yoga/Pilates, dance, martial arts, or other safe forms of exercise can be especially fruitful in a client's trauma recovery process, as can receiving bodywork (e.g., massage) or energy work (e.g., Reiki). Such practices should be introduced on a case-by-case basis, depending on client willingness and access in the community. With all clients, it is important to brainstorm ways to build a healthier relationship with the body on some level, even if that starts as simply as taking a walk in the evening or engaging in a popular mindfulness meditation practice called body scan. Unhealed trauma manifests in the body and can be expressed as hypoarousal or shutting-down responses or as hyperarousal or anxious/"jumpy" responses. Trauma survivors often engage in addictive or other unhealthy behaviors, including avoidance and disconnecting from others, to either feel better or feel numb. Learning to live in one's body, adapt to stressors in a healthy way, and listen to the signals of the body are important in trauma-focused care. Many clients may not be able to fully engage with the body until some stage 2 work is done, but it is vital to begin teaching about listening to and working with the body in stage 1, no matter how slowly.

Client A: Stage 1

Client A presents for clinical services to address two primary life concerns: her escalating drinking/drug use (prescription pills) and her recent divorce. Client A had been prescribed a benzodiazepine medication (lorazepam) by a psychiatrist for years to deal with what she describes as chronic anxiety stemming from early childhood sexual abuse. The client was never properly evaluated for PTSD. Client A has grown concerned by how her drinking is starting to affect her work performance and seeks counseling to obtain further guidance on the matter. Client A's clinician begins by educating her on trauma and how her symptoms seem to meet the criteria for PTSD based on her early child sexual abuse experiences. In talking about trauma, Client A starts to connect the dots with other aspects of her life that also seem traumatic or wounding for her, including her sexuality.

Client A relays to her therapist, a trauma-focused eclectic, that she first knew she was bisexual around 14 years of age, when she became cognizant of the fact that she was attracted to both boys and girls. At the time, a therapist prodded Client A to come out to her conservative, Catholic parents. When Client A would not do it, her therapist outed her to her parents, justifying it as a safety measure. This premature disclosure ushered in several years of discord at home. Although Client A's parents never considered sending her for any kind of religious intervention (e.g., reparative therapy), they thought it was a phase she would outgrow. At 18 years of age, Client A's siblings told her that they would support her in coming out, but that there was no such thing as bisexuality. One sibling even encouraged her, "It's okay to come out as fully gay; I'm here for you."

While this support meant the world to her at the time and eventually helped her to live her life openly and publicly as a lesbian, now Client A is recognizing how invalidating and misinformed her sibling's statement was. Client A identifies that the stressors of her six-year marriage to a woman impacted her alcohol consumption, although by the time she presents for services she does not need to be convinced that she has a substance use problem and is open to a referral to attend a local 12-step group. Client A finds a sponsor at a local meeting that affirms her bisexual identity, and as she grows to trust that her therapist is not going to try to talk her out of being bisexual, the quality of her work begins to deepen. Client A also accepts a recommendation to attend a local "recovery yoga" class and begins working to develop a set of coping skills, like breathing and meditation. Client A is encouraged by her therapist's suggestion to begin exploring some stories of other bisexuals published online on advocacy websites. Every time Client A reads stories of people who were originally out as gay or lesbian and began to own the truth of their bisexual identity, she finds herself nodding her head in agreement.

Stage 2: Going Deeper and Modifying Traumatic Memories

As discussed, there are a variety of therapeutic modalities that can work to identify traumatic memories and other stressful issues that keep people stuck and to move them through to a more adaptive resolution. The approach collaboratively chosen for deeper work should be one with which the counselor/therapist feels confident and competent to guide a bisexual client in the work. For many clinicians, this is not a matter of just being trained technically; rather, it is about maintaining a calming presence if the client's affective output intensifies. Naturally, this also requires that clinicians working with bisexual umbrella clients be fully affirming and aware of their own biases at all times.

After a general modality or approach has been selected to work on the core wounds connected to the client's presenting issues, it is important to inventory the negative messages about the self that the client has internalized as true statements. The oppressive cognitions previously discussed can provide a solid framework from which to work on this task. Clients may also carry other negative cognitions from instances of abuse that are not specific to the bisexual experience, and clinicians should be prepared to work with this material as well. If a bisexual client has internalized an oppressive cognition like "I do not exist" connected to a society message like "There is no such thing as bisexuality," the identified approach or series of approaches may be used to help the client move/transform that belief to a more adaptive one, such as "I am valid and I exist."

Be mindful that there are a variety of grief issues that may arise for bisexual clients as they begin fully unpacking and exploring their experiences, especially experiences with oppressive cognitions. Many clients find themselves grieving the lives that they could have had and often feel the heavy emotions and sensations connected to deep regret had they come out at earlier points in their lives. Another reality for many LGBT+ clients who come out later in life is the gap in time that exists between the time they "knew" or identified the nature of their feelings and attractions and the age when they actually came out. If a client suspected at 11 years of age that she was bisexual but does not come out until 36 years of age, there is a 25-year gap in psychosexual development that should be explored to feel fully present in her identity and in herself. A variety of therapeutic approaches designed to help clients work through grief and loss can be beneficial in this process. Additionally, many bisexual umbrella clients are grieving the loss of family connections, spouses/past relationships, their faith community, or other connections that they lost because of coming out or coming out more fully. It should not be assumed that the coming-out process will immediately make bisexual clients feel better because they have chosen to live a more authentic life. A great deal of loss is part of many individuals' coming-out journeys, and therapy should provide a safe place for clients to grieve these losses.

In working with clients who are closely bound to family members (e.g., parents, spouses), advise the close individuals that engaging in stage 2 work can be emotionally exhausting for the client. As suggested in stage 1, making appropriate referrals for family members and educating them on the coming-out and working-through processes (if the client is open to this collaboration) can be helpful. When working with children and adolescents, it can be challenging to navigate the desired preferences and identity issues of the children alongside the parents' desired outcomes for treatment. Parents or guardians may pressure a counselor or therapist to convince the minor client that bisexual desires are "just a phase," or that they are "too young" to be sure of their sexuality. Using available data and resources, parents should be educated that a younger a child can be affirmed in their sexual identity, and that acceptance at this stage can result in a healthier and happier adulthood.

Client A: Stage 2

Client A's therapist is certified in EMDR in addition to being a registered expressive arts therapist, and she works with Client A in both modalities to help her target the oppressive cognition of "I do not exist." This oppressive cognition is connected to her siblings' comments invalidating her bisexual identity and her parents' treatment of her coming out as "a passing phase."

According to the World Health Organization [38]:

EMDR therapy is based on the idea that negative thoughts, feelings, and behaviors are the result of unprocessed memories. The treatment involves standardized procedures that include focusing simultaneously on (a) spontaneous associations of traumatic images, thoughts, emotions, and bodily sensations and (b) bilateral stimulation that is most commonly in the form of repeated eye movements. Like CBT with a trauma focus, EMDR aims to reduce subjective distress and strengthen adaptive beliefs related to the traumatic event. Unlike CBT with a trauma focus, EMDR does not involve (a) detailed descriptions of the event, (b) direct challenging of beliefs, (c) extended exposure, or (d) homework.

The EMDR process allows clients like Client A to make connections between memories that they did not consciously realize had an impact. In targeting the memories related to the cognition "I do not exist," and her siblings' invalidating comments, Client A also recognizes that her therapist outing her to her parents made her feel like she did not exist and that her feelings did not matter.

Through her engagement with EMDR therapy and visual art making, Client A fully embraces the beliefs of "I do exist, and I matter." She accepts these beliefs as they relate to her sexuality, and she translates them to other scenarios in her life as well. Client A also finds that making music playlists helps her reclaim her sexual identity, and sharing music that meaningfully expresses her journey of sexual development eventually helps her to share what it means for her to be bisexual with her mother.

Stage 3: Reintegrating to Society

Reintegration suggests that those who suffer from unhealed trauma traditionally feel cut off from mainstream society. While this truth can apply to all trauma survivors, it applies to LGBT+ clients almost universally. As discussed, bisexual clients may feel even more alienated when they encounter hurtful comments and lack of support from gay and/or lesbian communities.

Reintegration is not a perfect "step 3" in this framework. Clients in outpatient settings require some level of reintegration throughout the process in order to function as members of mainstream society. For many clients working collaboratively with therapists, the art of engaging in productive stage 3 work is to see the links between stage 1 resources and the necessity of carrying these resources into everyday life.

For many bisexual clients, the most difficult part of treatment can be learning to live as an out and proud LGBT+ person after they have engaged in deep work from the past. The client may be left with a sense of uncertainty about the future as they navigate what it means to date, to be in relationships, or to interact with family or work contacts in an authentic way. Bisexual clients who are still thwarted with stigma may find the hardest work comes in stage 3 and learning to adapt to change. The bisexual umbrella client may be fully out and more comfortable with his/her internal identity, but hatred, bigotry, and misunderstanding will continue to occur. As these problems are faced, clients will generally need to continue seeking support, especially if they are coping with a potentially chronic condition like substance use or PTSD. This may be more communal and support group in nature, or bisexual clients may need to continue accessing professional mental health care on a more long-term basis.

Continued work with embodiment and expression is highly recommended. If clients began exploring some of these resources in stage 1, their development and exploration should continue in stage 3.

Client A: Stage 3

After two years, Client A is two years sober, is working in a job that she loves, and is in a relationship situation that makes her happy. However, she has no plans to stop seeing her therapist. Their work together is largely maintenance at this point, but Client A finds it helpful to be able to work through the petty, spiteful comments she hears from others (especially old friends who knew her and her ex-wife) with professional assistance.

Another issue of navigation for Client A is being in a polyamorous relationship. Client A reports that engaging in this lifestyle is helpful and meaningful to her at this point in her journey of sexual development. She has a boyfriend, the first major relationship with a man she has enjoyed in her life, although he is open to her having relationships with other people.

While Client A is happy with this open and polyamorous arrangement for now, there are logistical issues and some jealousy to navigate, which she does with the help and support of her therapist. Moreover, Client A does not envision herself being polyamorous long-term, as she would like to settle down with a primary/exclusive partner (of any gender) and raise a family at some point. Client A is enjoying the journey of exploration for the moment and finds it very helpful to be guided by a non-judgmental, affirming therapist in the journey.

5. CLINICAL COMPETENCE IN WORKING WITH BISEXUAL UMBRELLA CLIENTS

One of the simplest things a professional of any kind can do when working with a bisexual client is to affirm their existence. This may sound like a given, but when how one identifies or loves in the world has been invalidated, teased, or mistrusted, simple attitudes like validation, acceptance, and non-judgment can be essential. Telling bisexual umbrella clients they are in a safe place is non-trauma-focused, because it tells them what they should be feeling. Instead, clients should be allowed to decide and to evaluate for themselves whether they feel adequately safe.

As with many skills in the behavioral and mental health professions, these approaches sound simple but may not be easy in practice. This section will explore the qualities of bisexual- and LGBT+-affirming professionals. Consider which qualities you possess and which qualities you may like to adopt. Is it an issue of improved training or understanding, or might it be better explained as a bias or blind spot?

Several qualities have been used to describe a bisexually aware professional:

- Believes that bisexuality is a valid lifestyle and is welcoming toward bisexual people

- Is aware of ways in which bisexuals' concerns differ from gays' and lesbians' concerns, and ways in which bisexuals' concerns differ from heterosexual peoples' concerns

- Actively participates in bisexual community events or forums

- Has read professional books or journal articles on bisexuality

- Attends professional workshops on the concerns of bisexual people

- Has worked professionally with several bisexual clients in the past

- Organizes bisexually oriented support or social groups or workshops

Shelton widens the scope slightly in describing the characteristics of LGBT+-affirming clinicians and treatment programs in general [5]. He states that practitioners should be aware of historical context and remain informed about sociocultural changes, both positive and negative. Training programs should increase LGBT+-specific knowledge in terms of theories and identity formation, minority stress, and the current state of the literature (which changes rapidly) about LGBT+-specific concerns and health disparities. On both training and independent practice levels, the awareness and application of LGBT+-specific culturally sensitive language across all forms of communication (e.g., call screening, forms used, assessment) should become standard practice. Clinicians should expand the discussion of confidentiality and documentation issues during their initial contact with LGBT+ clients, who may be concerned about being permanently labeled as LGBT+ within medical records and thus potentially "outed" to medical providers and others. Clinicians should attempt to understand whether a presenting problem is LGBT+-specific or whether it is one of several individual-difference factors that contributes to understanding a case and formulating a treatment plan, but is not central to treatment. Across training levels and throughout practice settings, clinicians should include appropriate assessment(s) of sexual orientation and gender identity that may better facilitate alliance and possibly improve response to treatment in their work with LGBT+ clients [5].

These qualities should form the basis of a bisexually aware and responsive practice. However, clinicians should continue educating themselves on how bisexual umbrella clients may experience trauma in the world and struggle when presenting for services.

EXPLORING AND ADDRESSING BIASES AROUND SEXUAL IDENTITY, SEXUAL EXPRESSION, AND GENDER

Those struggling with any of the concepts covered in this course may benefit from directly talking to a person who identifies as bisexual or as part of the bisexual umbrella. Many will be happy to discuss their experiences and to answer questions. Reputable organizations and websites (Resources) can be helpful for further exploration, particularly if other options are scarce in your community. It is important not to rely on popular films and television as a sole source of cultural information, as the overall portrayal of bisexuals in popular culture is flawed and potentially damaging.

Seeking supervision or consultation around issues that are clear blind spots in working with LGBT+ clients, specifically with bisexual clients, should be considered. Such supervision may be a necessary requirement if one is blocked from effectively working with a bisexual umbrella or other LGBT+ client because of one's personal beliefs. The ethical guidelines of the major clinical organizations that guide practice in the United States assert that professionals cannot discriminate against clients based on sexual orientation or gender identity [39,40,41]. If referral is not available, the duty falls on the professional to work with the client in as ethical a manner as possible.

6. CONCLUSION

This course has covered a variety of topics to support behavioral and mental health professionals, however they may serve the public, to work with clients who identify as bisexual or as part of the bisexual umbrella. The first section provided foundational material on defining bisexuality, identifying biases around bisexuality, expanding the scope of identities under the bisexual umbrella, and reviewing concerns that are unique to bisexual clients. The course then discussed and defined trauma and explored how LGBT+ individuals are especially susceptible to being affected by trauma. Specific attention was paid to the trauma of the bisexual experience as explained by the construct of oppressive cognitions and negative messages that bisexuals are likely to receive. Issues connected to the coming-out process were also discussed.

The course then transitioned to explaining the importance of trauma-informed and trauma-focused treatment for all LGBT+ clients, especially those identifying as part of the bisexual umbrella. The three-stage consensus model was used to provide a framework for explaining how professionals can best care for bisexual clients, especially in a clinical setting. A sample treatment plan and a sample case were offered to fully illustrate these points. The course then concluded with a challenge to self-assess one's own competency and awareness for working with bisexual clients. The most essential take-away message is not to let a client suffer or be retraumatized because of one's own biases or misunderstandings about the spectrum of sexual identity and expression.

7. RESOURCES

The American Institute of Bisexuality

https://bisexual.org

BiNet USA

http://www.binetusa.org

Bisexual Organizing Project

http://www.bisexualorganizingproject.org

Bisexual Resource Center

http://biresource.org

Coming Out: UCLA Resource Center

https://www.lgbt.ucla.edu/Resources/Coming-Out

Human Rights Campaign

https://www.hrc.org

Human Rights Campaign Report: Supporting and Caring for Our Bisexual Youth

https://www.hrc.org/youth-report/supporting-and-caring-for-our-bisexual-youth

The LGBTQIA Resource Center at the University of California, Davis

https://lgbtqia.ucdavis.edu

More Than Two: Polyamory Resources

https://www.morethantwo.com

The Association of Lesbian, Gay, Bisexual, Transgender Addiction Professionals and Their Allies (NALGAP)

http://www.nalgap.org

PFLAG

https://pflag.org

Substance Abuse and Mental Health Services Administration (SAMHSA)

A Treatment Improvement Protocol: Trauma-Informed Care in Behavioral Health Services

https://www.ncbi.nlm.nih.gov/books/NBK207201

The Trevor Project

https://www.thetrevorproject.org

Wellness Identity Sexuality Health (WISH) Research Lab

https://www.wishresearch.com

My LGBT Plus

http://www.mylgbtplus.org

Works Cited

1. Gates GJ. In U.S., More Adults Identifying as LGBT. Available at https://news.gallup.com/poll/201731/lgbt-identification-rises.aspx. Last accessed April 4, 2019.

2. Gates GJ. How Many People are Lesbian, Gay, Bisexual, and Transgender? Available at https://williamsinstitute.law.ucla.edu/research/census-lgbt-demographics-studies/how-many-people-are-lesbian-gay-bisexual-and-transgender. Last accessed April 4, 2019.

3. Klein F. The Bisexual Option. 2nd ed. New York, NY: Routledge; 2013.

4. Ochs R. The Definition of Bisexuality (According to Bi Organizations, Activists, and the Community). Available at https://robynochs.com/2016/04/18/the-definition-of-bisexuality-according-to-bi-2. Last accessed April 4, 2019.

5. Shelton M. Fundamentals of LGBT Substance Use Disorders: Multiple Identities, Multiple Challenges. New York, NY: Harrington Park Press; 2017.

6. Crary D. First Openly Bisexual Governor May Bring Visibility to Overlooked Group. Available at https://www.pbs.org/newshour/nation/first-openly-bisexual-governor-may-bring-visibility-overlooked-group. Last accessed April 4, 2019.

7. Marich J. Validate the bisexual client. Addiction Professional. 2015;13(4).

8. American Institute for Bisexuality. What is the Difference between Bisexual and Terms Like Pansexual, Polysexual, Omnisexual, Ambisexual, and Fluid? Available at https://bisexual.org/?qna=what-is-the-difference-between-bisexual-and-terms-like-pansexual-polysexual-omnisexual-ambisexual-and-fluid. Last accessed April 4, 2019.

9. Belous CK, Bauman ML. What's in a name? Exploring pansexuality online. J Bisex. 2016;17(1):58-72.

10. U.C. Davis Student Health and Resource Center. Why Pronouns Are Important. Available at https://shcs.ucdavis.edu/blog/archive/why-pronouns-are-important. Last accessed April 4, 2019.

11. Flanders C, LeBreton M, Robinson M, Bian J, Caravaca-Morera J. Defining bisexuality: young bisexual and pansexual people's voices. J Bisex. 2017;17(1):39-57.

12. Eisner S. Bi: Notes for a Bi Revolution. Berkeley, CA: Seal Press; 2013.

13. Flanders C. Under the bisexual umbrella: diversity of identity and experience. J Bisex. 2017;17(1):1-6.

14. Rankin S, Morton J, Bell M. Bisexual People's Experience of and Ideas for Improving Healthcare Services. Edinburgh: Equality Network Scotland; 2015.

15. Shearer A, Herres J, Kotish T, et al. Differences in mental health symptoms across lesbian, gay, bisexual, and questioning youth in primary care settings. J Adolesc Health. 2016;59(1):38-43.

16. Schick V, Dodge B. Introductions to the special issue: bisexual health: unpacking the paradox. J Bisex. 2012;12(2):161-167.

17. Bauer BR, Brennan DJ. The problem with "behavioral bisexuality:" assessing sexual orientation in survey research. J Bisex. 2013;13(2):148-165.

18. Flanders CE, Dobinson C, Logie C. "I'm never really my full self:" young bisexual women's perceptions of their mental health.J Bisex. 2015;15(4):454-480.

19. Flanders CE, Dobinson C, Logie C. Young bisexual women's perspectives on the relationship between bisexual stigma, mental health, and sexual health: a qualitative study. Crit Public Health. 2017;27(1):75-85.

20. Ross L, O'Gorman L, MacLeod M, Bauer G, McKay J, Robinson M. Bisexuality, poverty, and mental health: a mixed methods analysis. Soc Sci Med. 2016;156:64-72.

21. EMDR International Association. New Basic Training Requirements. Available at https://c.ymcdn.com/sites/www.emdria.org/resource/resmgr/BasicTraining/BTCRequirements.pdf. Last accessed April 2, 2019.

22. Courtois CA, Ford JD. Treating Complex Traumatic Stress Disorders: An Evidence-Based Guide. New York, NY: The Guilford Press; 2009.

23. van der Kolk BA. Developmental Trauma Disorder: Towards a Rational Diagnosis for Children with Complex Trauma Histories. Available at http://www.traumacenter.org/products/pdf_files/preprint_dev_trauma_disorder.pdf. Last accessed April 2, 2019.

24. Human Rights Campaign. Growing up LGBT in America. Available at https://www.hrc.org/youth-report/about-the-survey. Last accessed April 4, 2019.

25. Andre A, Brown J, Delpercio A, Kahn E, Nicoll A, Sherouse B. Supporting and Caring for Our Bisexual Youth. Washington, DC: The Human Rights Campaign Foundation; 2014.

26. Levis RV, Siniego LB. An integrative framework for EMDR therapy as an anti-oppression endeavor. In: Nickerson MI (ed).Cultural Competence and Healing Culturally-Based Trauma with EMDR Therapy: Innovative Strategies and Protocols. New York, NY: Springer Publishing Company; 2017.

27. Settinelli K. Not Your Villain: Bisexual Representation on Screen. Available at http://www.rabelais.com.au/2017/03/not-your-villian-bisexual-representation-on-screen. Last accessed April 4, 2019.

28. Kort J. Gay-Affirmative Therapy for the Straight Clinician. New York, NY: W.W. Norton; 2008.

29. Semon TL, Hsu KJ, Rosenthal AM, Bailey JM. Bisexual phenomena among gay-identified men. Arch Sex Behav. 2017;46(1):237-245.

30. American Psychological Association Presidential Task Force on Evidence-Based Practice. Evidence-based practice in psychology. American Psychologist. 2006;61(4):271-285.

31. Substance Abuse and Mental Health Services Administration. A Treatment Improvement Protocol: Trauma-Informed Care in Behavioral Health Services. Washington, DC: U.S. Department of Health and Human Services; 2014.

32. Miller TA. How shame affects writing. Undergraduate Research Journal. 2015;9(1).

33. Marich J, Dansiger S. EMDR Therapy and Mindfulness for Trauma-Focused Care. New York, NY: Springer Publishing Company; 2018.

34. van der Hart O, Brown P, van der Kolk B. Pierre Janet's treatment of post-traumatic stress. J Traumatic Stress. 1989;2(4):1-11.

35. De Jongh A, Resick P, Zoellner L, et al. Critical analysis of the current treatment guidelines for complex PTSD in adults. Depress Anxiety. 2016;33(5):359-369.

36. Marich J. Trauma Made Simple: Competencies in Assessment, Treatment, and Working with Survivors. Eau Claire, WI: Pesi Publishing & Media; 2014.

37. Cloitre M, Courtois CA, Ford JD, et al. The ISTSS Expert Consensus Treatment Guidelines for Complex PTSD in Adults. Available at https://www.istss.org/ISTSS_Main/media/Documents/ISTSS-Expert-Concesnsus-Guidelines-for-Complex-PTSD-Updated-060315.pdf. Last accessed April 4, 2019.

38. World Health Organization. Assessment and Management of Conditions Specifically Related to Stress: mhGAP Intervention Guide Module. Available at https://apps.who.int/iris/bitstream/handle/10665/85623/9789241505932_eng.pdf;jsessionid=C991B5240D3961905D37F44B44B992CB?sequence=1. Last accessed April 2, 2019.

39. American Counseling Association. 2014 ACA Code of Ethics. Available online at https://www.counseling.org/Resources/aca-code-of-ethics.pdf. Last accessed April 3, 2019.

40. National Board for Certified Counselors. NBCC Code of Ethics. Available at https://www.nbcc.org/Assets/Ethics/NBCCCodeofEthics.pdf. Last accessed April 3, 2019.

41. National Association of Social Workers. NASW Code of Ethics. Available at https://www.socialworkers.org/About/Ethics/Code-of-Ethics/Code-of-Ethics-English. Last accessed April 3, 2019.

77040 • Setting Ethical Limits: For Caring and Competent Professionals

Lisa Hutchison, LMHC

www.netce.com

Copyright © 2018 NetCE, All rights reserved.

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

Table of Contents

77040 • Setting Ethical Limits: For Caring and Competent Professionals

Course Overview

Audience

Course Objective

Learning Objectives

Faculty

Faculty Disclosure

Division Planners

Division Planners Disclosure

About the Sponsor

Disclosure Statement

1. INTRODUCTION

2. COMPETENCE

APA'S ETHICAL PRINCIPLES OF PSYCHOLOGISTS AND CODE OF CONDUCT

2014 ACA CODE OF ETHICS

CODE OF ETHICS OF THE NASW

3. CULTURAL COMPETENCE

CHARACTERISTICS OF A CULTURALLY COMPETENT COUNSELOR

4. THE THERAPEUTIC RELATIONSHIP

CONGRUENCE

EMPATHY

5. THE COSTS OF CARING

STRESS

COMPASSION FATIGUE, VICARIOUS TRAUMA, AND BURNOUT

MITIGATING THE COSTS OF CARING

6. TRANSFERENCE AND COUNTERTRANSFERENCE

REFLECTION

SELF-AWARENESS

7. BOUNDARIES AND LIMITS

BUILDING TRUST

THE VALUE OF FLEXIBILITY

EMPOWERING AND PROTECTING THE CLIENT

PROTECTING THE PROFESSIONAL

8. BOUNDARY CROSSINGS AND VIOLATIONS

9. MULTIPLE RELATIONSHIPS

BOUNDARY VIOLATIONS WITHIN MULTIPLE RELATIONSHIPS

10. GIFTS

THE GIFT OF SELF-DISCLOSURE

11. TECHNOLOGY AND DISTANCE THERAPY

LEGAL AND ETHICAL CONSIDERATIONS

SOCIAL MEDIA

12. CONCLUSION

13. RESOURCES

Works Cited

77040 • Setting Ethical Limits: For Caring and Competent Professionals

Education Category. Ethics - Human Rights

Release Date. 12/01/2018

Expiration Date. 11/30/2021

Course Overview

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

Audience

This course is designed for social workers, counselors, and marriage and family therapists in all practice settings.

Course Objective

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

Learning Objectives

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

1. Define professional competence.

2. Describe the importance of cultural competence.

3. Outline components of the therapeutic relationship.

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

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

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

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

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

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

Faculty

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

Faculty Disclosure

Contributing faculty, Lisa Hutchison, LMHC, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Division Planners

Alice Yick Flanagan, PhD, MSW

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

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

- The demands of clinical and professional responsibility

- The challenges of managing the client/counselor relationship

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

- Vulnerability to vicarious traumatization

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

- The intersection of personal and professional demands

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

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

2. COMPETENCE

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

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

APA'S ETHICAL PRINCIPLES OF PSYCHOLOGISTS AND CODE OF CONDUCT

2.01 Boundaries of Competence

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

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

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

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

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

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

2.03 Maintaining Competence

Psychologists undertake ongoing efforts to develop and maintain their competence.

2014 ACA CODE OF ETHICS

C.1. Knowledge of and Compliance with Standards

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

C.2. Professional Competence

C.2.a. Boundaries of Competence

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

C.2.b. New Specialty Areas of Practice

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

C.2.c. Qualified for Employment

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

C.2.d. Monitor Effectiveness

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

C.2.e. Consultations on Ethical Obligations

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

C.2.f. Continuing Education

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

C.4. Professional Qualifications

C.4.a. Accurate Representation

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

C.4.b. Credentials

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

C.4.c. Educational Degrees

Counselors clearly differentiate between earned and honorary degrees.

C.4.d. Implying Doctoral-Level Competence

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

C.4.e. Accreditation Status

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

C.4.f. Professional Membership

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

CODE OF ETHICS OF THE NASW

1.04 COMPETENCE

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

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

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

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

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

3. CULTURAL COMPETENCE

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

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

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

CHARACTERISTICS OF A CULTURALLY COMPETENT COUNSELOR

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

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

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

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

4. THE THERAPEUTIC RELATIONSHIP

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

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

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

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

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

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

CONGRUENCE

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

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

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

EMPATHY

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

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

- See the world as others see it.

- Be nonjudgmental.

- Understand another person's feelings.

- Communicate your understanding of that person's feelings.

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

Compassion-focused therapy is "an evidence-based form of psychotherapy that draws upon our evolved capacity for compassion to facilitate the alleviation of human suffering" [19]. According to Gilbert, the following are attributes of compassion-focused therapy [20]:

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

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

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

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

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

Empathic Boundaries

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

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

5. THE COSTS OF CARING

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

STRESS

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

- Headaches, muscle tension, neck or back pain

- Upset stomach

- Dry mouth

- Chest pains, rapid heartbeat

- Difficulty falling or staying asleep

- Fatigue

- Loss of appetite or overeating "comfort foods"

- Increased frequency of colds

- Lack of concentration or focus

- Memory problems or forgetfulness

- Jitters, irritability, short temper

- Anxiety

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

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

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

COMPASSION FATIGUE, VICARIOUS TRAUMA, AND BURNOUT

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

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

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

MITIGATING THE COSTS OF CARING

Disengage

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

Seek Support

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

Set Self-Care Boundaries

In addition to setting and maintaining boundaries with clients, counselors also should set and maintain self-care boundaries to avoid burnout. When setting self-care boundaries, counselors may consider some of the following habits [39,40]:

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

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

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

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

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

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

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

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

Practice Mindfulness

Helping professionals often feel like they have to fix others or have all the answers. This is a faulty cognition. Oftentimes, the most healing and powerful act a counselor can do is being in the moment with the client, holding the space for his or her feelings and thoughts. Mindfulness practice can facilitate this. The practice of mindfulness (i.e., present-focused attending to ongoing shifts in mind, body, and the surrounding world), integrated into daily life, can help counselors to develop enhanced patience, presence, and compassion [41]. It can help counselors to stay calmly focused and grounded, which allows them to be less reactive and engage with greater equanimity [41].

One study investigated how the use of dialectical behavioral therapy (DBT) in working with young, self-harming women with borderline personality disorder affected the occupational stress and levels of burnout among psychiatric professionals [42]. DBT was stressful in terms of learning demands, but it decreased the experience of stress in actual treatment of clients. Participants felt that mindfulness training, which was one aspect of DBT, improved their handling of work stressors not related to DBT [42]. Counselors were better able to accept feelings of frustration, cope with stress, and be more patient and relaxed [42]. Mindfulness has been found to decrease stress, increase concentration, and increase the counselor's ability to detach from the client's material. It also assists a counselor's empathy and boundary setting [43]. Mindfulness, attention, empathy, and counseling self-efficacy have been found to be significantly related to one another [43].

One study explored the impact of Buddhist mindfulness (meditation) practice on the attitude, work, and lived experience of counselors and their self-reported experiences of working with clients [44]. Findings suggest that a long-term mindfulness meditation practice can positively impact counselors' ability to distinguish their own experiences from their clients' experiences, can enrich clarity in their work with clients and may help them develop self-insight [44]. Mindfulness may also help to increase patience, intentionality, gratitude, and body awareness [45]. It is an excellent tool for caring, compassionate professionals to use to maintain their own energies and support their clients' growth.

Expand Your Professional World

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

6. TRANSFERENCE AND COUNTERTRANSFERENCE

The term transference was coined by Freud to describe the way that clients "transfer" feelings about important persons in their lives onto their counselor. As Freud said, "a whole series of psychological experiences are revived, not as belonging to the past but applying to the person of the physician at the present moment" [46]. The client's formative dynamics are recreated in the therapeutic relationship, allowing clients to discover unfounded or outmoded assumptions about others that do not serve them well, potentially leading to lasting positive change [47]. Part of the counselor's work is to "take" or "accept" the transferences that unfold in the service of understanding the client's experience and, eventually, offer interpretations that link the here-and-now experience in session to events in the client's past [48]. The intense, seemingly irrational emotional reaction a client may have toward the counselor should be recognized as resulting from projective identification of the client's own conflicts and issues. It is important to guard against taking these reactions too personally or acting on the emotions in inappropriate ways [49].

REFLECTION

It also is important to be reflective rather than reactive in words and actions. Use of the mindfulness technique can help counselors to become reflective rather than reactive and can help counselors unhook from any triggering material and maintain appropriate limits and boundaries. Reflection demands a reasonable level of awareness of one's thoughts and feelings and a sound grasp of whether they deviate from good professional behavior. Reflection includes [50]:

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

- The recognition that we all have blind spots

- An understanding that staff are affected by clients

- An understanding that clients are affected by staff behavior

- A recognition that clients often have strong feelings toward staff

Clients are more accepting of transference interpretations in an environment of empathy. Transference interpretation is most effective when the road has been paved with a series of empathic, validating, and supportive interventions that create a holding environment for the client [51].

Freud believed transference to be universal, with the possibility of occurring in the counselor as well as the client. He described this "countertransference" as "the unconscious counter reaction to the client's transference, indicative of the therapist's own unresolved intrapsychic conflicts" [52]. Freud felt that countertransference could interfere with successful treatment [47]. Since the 1950s, the view of countertransference has evolved. It is no longer believed to be an impediment to treatment. Instead, it is viewed as providing important information that the professional can use in helping the client [47].

Empathy allows the counselor to experience and thus know what the client is experiencing. Countertransference emerges when the client's transference reactions touch the counselor in an unresolved area, resulting in conflictual and irrational internal reactions [53]. Good indicators of countertransference are feelings of irritability, anger, or sadness that seem to arise from nowhere. Countertransference frequently originates in counselors' unresolved conflicts related to family issues, needs, and values; therapy-specific areas (e.g., termination, performance issues); and cultural issues [54]. When feelings have intensity or when they persist, this is an indicator for future work and healing.

The counselor's work is to bear the client's transferences and interpret them. When the counselor refuses the transference, there is often a mutual projective identification going on, in which both counselor and client project part of themselves onto the other. Refusal may also mean that one of the counselor's own blind spots has been engaged. As Shapiro explains, "a rough edge of our character has been 'hooked' by a bit of what the patient is struggling with, and we act out a bit of countertransference evoked in us by the transference" [55]. In a group therapy setting, family dynamic re-enactments can emerge as transferences. Managing these complex dynamics can raise the counselor's anxiety and mobilize his or her defenses, compromising a usually thoughtful stance. When counselors experience intense reactions in trauma groups that pull them out of the present moment, they should investigate whether they are responding to traumatic content, personal unresolved issues, or individual or collective transference [56]. Counselors who find themselves ruminating about a previous session's content, a client's welfare, or their own issues should talk with a trusted, objective colleague. Countertransference issues for the mental health professional should be resolved apart from the therapeutic environment to avoid burdening and potentially harming clients [52].

SELF-AWARENESS

Problems arise when the professional lacks awareness or refuses to devote the necessary time to process the personal emotions and thoughts that arise within the therapeutic relationship. Feelings of anger, grief, jealousy, shame, injustice, trauma, and even attraction can, when they touch a wound from the past, trigger reactions within even experienced professionals. Clients' experiences can replicate the professional's past relationships and trigger emotions that have not been worked on or addressed. If this occurs, the professional can, without disrupting the client's session, make a mental note of the feelings. This allows the professional to attend to the present moment. After the client's session has ended, the professional can arrange to talk to a colleague or supervisor for processing. If the countertransference continues, it may be necessary for the professional to seek counseling. Self-awareness helps the professional to reflect back to the client's true emotions. It also is an important component of training, development, and effectiveness [57]. Mental health professionals need to possess certain values, qualities, and sensitivities, and should be open-minded and have an awareness of their comfort levels, values, biases, and prejudices [58].

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

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

7. BOUNDARIES AND LIMITS

Generally speaking, a boundary indicates where one area ends and another begins. It indicates what is "out of bounds" and acts to constrain, constrict, and limit. In the therapeutic relationship, a boundary delineates the "edge" of appropriate behaviors and helps to rule in and out what is acceptable, although the same behaviors might be acceptable or even desirable in other relationships [59,60]. Boundaries have important functions in the therapeutic relationship, helping to build trust, empower and protect clients, and protect the professional.

BUILDING TRUST

An inherent power differential exists in the therapeutic relationship between the client, who is placed in a position of vulnerability as she or he seeks help, and the practitioner, who is placed in a position of power because of her or his professional status and expertise [60]. When the client sees the counselor sitting in a chair, with a diploma or licensure on the wall, it can be intimidating. To help mitigate these feelings with the client, it is important to maintain a sense of professionalism while working to build trust and rapport. Part of that professionalism includes setting limits and explaining what they are in the context of therapy.

The familiarity, trust, and intensity of the therapeutic relationship create a powerful potential for abuse that underscores the need for careful attention to the ethical aspects of professional care [60]. Trust is the cornerstone of the therapeutic relationship, and counselors have the responsibility to respect and safeguard the client's right to privacy and confidentiality [4]. Clients have expressed what they believe to be essential conditions for the development of trust in the therapeutic relationship. These include that the clinician [61]:

- Is perceived as available and accessible

- Tries to understand by listening and caring

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

- Maintains confidentiality

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

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

Only when satisfied that the clinician is sufficiently experienced, professional, flexible, and empathic can a foundation for therapy be laid. Clients acknowledge that this takes time and that the trustworthiness of the therapeutic relationship may be tested. If the relationship is perceived to be wanting, clients indicate that they would have difficulty continuing it [61].

THE VALUE OF FLEXIBILITY

Rigid boundaries can negatively reinforce the power differential that exists between the client and the counselor. Rigid boundaries may serve the fears and needs of counselors who are new to the profession and/or concerned with the implications of boundary violations. However, rigid boundaries can lead to harm for the client who perceives that the "rules" are more important than his or her welfare. While rigidity and remoteness on the counselor's part may help ensure that boundaries are intact, they do not accurately reflect the intended role of boundaries in clinical practice. Boundaries should never imply coldness or aloofness. As stated, clients value flexibility, caring, and understanding. Within conditions that create a climate of safety, flexible boundaries can accommodate individual differences among clients and counselors and allow them to interact with warmth, empathy, and spontaneity [62]. Firm, intractable boundaries may be a comfort to the helping professional; however, fixed rules cannot capture the complex reality of the therapeutic relationship [60].

EMPOWERING AND PROTECTING THE CLIENT

Boundaries and effective limit setting in sessions help to empower and protect clients by teaching and reinforcing the skills they need to become healthy. Boundaries set the parameters and expectations of therapy, so it is important to articulate them in such a way that each client's understanding of them is clear. Counselors should constantly and actively make judgements about where to draw lines that are in the client's best interests [63].

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

Clients often enter therapy with a history of prior boundary violations (e.g., childhood sexual abuse, domestic violence, inappropriate boundary crossings with another professional) that leave them with persisting feelings and confusion regarding roles and boundaries in subsequent intimate relationships [64]. Consequently, they may test the boundaries as children do. The counselor should recognize these boundary dilemmas and manage them by reiterating the boundaries calmly and clearly [63]. The counselor must also set and maintain boundaries even if the client threatens self-harm or flight from therapy. This can be extremely challenging when faced with a client's primitively motivated, intense demands. However, counselors should recall that one description of the tasks with clients with primitive tendencies is to resist reinforcing primitive strivings and to foster and encourage adult strivings [65]. Winnicott refers to this as a "holding relationship," wherein the counselor acts as a "container" for the strong emotional storms of the client. The act of holding helps reassure the client that the clinician is there to help the client retain control and, if necessary, assume control on his or her behalf [66].

Due to the potential issues and challenges that the client brings to therapy (e.g., cognitive deficits, substance abuse/addictions, memory issues, personality disordered manipulations), it is important to maintain a record of instances when the articulated boundaries and limits have been ignored or violated. For example, a client is habitually late, despite knowing that it is unacceptable to arrive more than 10 minutes late to session. The first instance of a late arrival might simply warrant a reminder of the 10-minute limit, whereas repeated instances would require that the limit be enforced. The clinician who overidentifies with a client might experience a need to do things for the client rather than help the client learn to do things for him- or herself. While this behavior may appear relatively harmless, it suggests overinvolvement with a client and potential boundary problems [67]. Such behavior inhibits the client's ability to learn personal responsibility and how to resolve conflict [68]. It also may impede the reflective and investigative character of an effective helping process [39]. Mental health professionals should take reasonable steps to minimize harm to clients where it is foreseeable and unavoidable [3,4]. They also should facilitate client growth and development in ways that foster the interest and welfare of the client and promote the formation of healthy relationships [4].

PROTECTING THE PROFESSIONAL

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

Some situations in therapy are clear with regard to boundaries (e.g., no sexual relationships with clients). Other situations may be not as clear or may be ambiguous (e.g., receiving gifts from clients). When faced with such situations, professionals should engage in an ethical decision-making process that includes an evaluation of the context of the situation and collaboration with the client to make decisions that promote the client's growth and development [4]. Supervision and colleague support also may be necessary to reach the best decision. Such a process helps clinicians maintain justice and equity and avoid implications of favoritism in dealing with all of their clients [69].

Professionals who deliver services in nontraditional settings, such as those who have home-based practices, face unique challenges related to boundaries and limit setting. As with office-based therapy, some situations cannot be prepared for and will need to be addressed in the moment. While delivering services in nontraditional settings may benefit some clients, when working in homes or residences, the professional is advised to emphasize informed consent, particularly with regard to therapeutic boundaries. Whenever possible, the impact of crossing boundaries on therapy and on the therapeutic relationship should be considered ahead of time [70].

8. BOUNDARY CROSSINGS AND VIOLATIONS

A boundary crossing is a departure from commonly accepted practices that could potentially benefit clients; a boundary violation is a serious breach that results in harm to clients and is therefore unethical [71]. Professional risk factors for boundary violations include [72]:

- The professional's own life crises or illness

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

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

- Feeling solely responsible for the client's life

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

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

Denial about the possibility of boundary problems (i.e., "This couldn't happen to me") also plays a significant role in the persistence of the problem [72]. Lack of self-care and self-awareness also can leave the mental health professional vulnerable to boundary crossings and/or violations.

Whatever the reason the professional has to cross a boundary, it is of utmost importance to ensure that it will not harm the client. Each boundary crossing should be taken seriously, weighed carefully in consultation with a supervisor or trusted colleague, well-documented, and evaluated on a case-by-case basis. Intentional crossings should be implemented with two things in mind: the welfare of the client and therapeutic effectiveness. Boundary crossing, like any other intervention, should be part of a well-constructed and clearly articulated treatment plan that takes into consideration the client's problem, personality, situation, history, and culture as well as the therapeutic setting and context [73]. Boundary crossings with certain clients (e.g., those with borderline personality disorder or acute paranoia) are not usually recommended. Effective therapy with such clients often requires well-defined boundaries of time and space and a clearly structured therapeutic environment. Dual or multiple relationships, which always entail boundary crossing, impose the same criteria on the professional. Even when such relationships are unplanned and unavoidable, the welfare of the client and clinical effectiveness will always be the paramount concerns [73].

Some counselors may consider a boundary crossing when it provides a better firsthand sense of the broader clinical context of their client, such as visiting the home of a client that is ailing, bedridden, or dying; accompanying a client to a medically critical but dreaded procedure; joining a client/architect on a tour of her latest construction; escorting a client to visit the gravesite of a deceased loved one; or attending a client's wedding [73]. Many mental health professionals will not cross these boundaries and will insist that therapy occur only in the office. Each professional should operate according to the parameters with which he or she is comfortable. As stated, the best interests of the client, including client confidentiality, and the impact to therapy should be of paramount importance when considering whether to cross a boundary.

To be in the best position to make sound decisions regarding boundary crossings, mental health professionals should develop an approach that is grounded in ethics; stay abreast of evolving legislation, case law, ethical standards, research, theory, and practice guidelines; consider the relevant contexts for each client; engage in critical thinking and personal responsibility; and, when a mistake is made or a boundary decision has led to trouble, use all available resources to determine the best course of action to respond to the problem [74]. The risk management strategy also should include discussions with supervisors, colleagues, and the client. Each step should be documented and should include supervisory recommendations and client discussion regarding the benefits versus the risks of such actions. Although minor boundary violations may initially appear innocuous, they may represent the foundation for eventual exploitation of the client. If basic treatment boundaries are violated and the client is harmed, the professional may be sued, charged with ethical violations, and lose his/her license [75].

9. MULTIPLE RELATIONSHIPS

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

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

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

The ethics code of the NASW defines dual or multiple relationships as occurring "when social workers relate to clients in more than one relationship, whether professional, social, or business" [5]. It also states that "social workers should not engage in dual or multiple relationships with clients or former clients in which there is a risk of exploitation or potential harm to the client. In instances when dual or multiple relationships are unavoidable, social workers should take steps to protect clients and are responsible for setting clear, appropriate, and culturally sensitive boundaries" [5].

The ACA ethics code states that [4]:

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

Mental health professionals who practice in small, rural communities face special problems in maintaining neutrality, fostering client separateness, protecting confidentiality, and managing past, current, or future personal relationships with clients [76]. Whether the practice is located in a small town or a big city, there will be times when counselors and clients will encounter one another outside the office. To ignore a client who is reaching out in a social setting may cause the client harm. However, it also is important to avoid violating the client's privacy. The best way to minimize the potential awkwardness of such an encounter is to prepare ahead of time. For example, a counselor might incorporate a conversation about such an encounter into the initial evaluation process by telling the client: "If I happen to be at a store or a restaurant and see you, I won't say hello because I respect your confidentiality and want to protect your privacy. However, if you want to smile or say hello to me, I will respond in kind." Explain to the client that the conversation or acknowledgment must be brief to prevent any violation of the client's privacy. After an encounter in public, address the event in your next session, discuss any feelings the client had about the encounter, and note the discussion in the client record. Such an encounter would not fall under the category of dual/multiple relationships unless, for example, the counselor and client went grocery shopping at the same time every week and interacted each time. In this instance, the counselor is advised to change his or her shopping day and/or time in order to avoid risking loss of client confidentiality.

BOUNDARY VIOLATIONS WITHIN MULTIPLE RELATIONSHIPS

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

- Bartering with clients

- Sexual relationships with students or supervisees

- Sexual intimacies with current or former clients

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

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

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

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

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

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

The safest course of action is to continue to maintain established boundaries and limits indefinitely after therapy ends. In addition to the noted relevant factors, counselors should keep in mind that the client may return for further treatment. If the counselor has become involved in a business or social relationship with a former client, he or she deprives the client of the opportunity to return for additional treatment. It is vital to be mindful of the potential to exploit the client's vulnerability in a post-termination relationship [77].

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

10. GIFTS

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

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

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

The National Board for Certified Counselors Code of Ethics: Directives #4 provides similar guidance to its members [6]:

National certified counselors (NCCs) shall not accept gifts from clients except in cases when it is culturally appropriate or therapeutically relevant because of the potential confusion that may arise. NCCs shall consider the value of the gift and the effect on the therapeutic relationship when contemplating acceptance. This consideration shall be documented in the client's record.

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

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

As noted in these excerpts, the effect on the therapeutic relationship should be a primary consideration when considering whether to accept a gift. Gifts can mean many things and also can fulfill social functions. The counselor's task is to identify the contextual meaning of the gift and determine when the gift is not merely a gift. To do so, the counselor must draw out from the client information to discern the possibility of a metaphorical or culturally significant meaning for the gift giving [78]. Counselors should consider the client's motivation for gift-giving as well as the status of the therapeutic relationship. Gifts that may seem intended to manipulate the counselor are probably best refused, whereas rejection of a gift intended to convey a client's appreciation may harm the relationship [79].

If the counselor is most comfortable with a "no-gift policy," it is best that the policy be discussed at the beginning of therapy. To wait until a client is presenting a gift to state that it is your policy to decline gifts may harm the client and damage the therapeutic relationship. Clear communication, both written and spoken, of the policy with clients as they enter therapy may help avert difficult later interactions around gifts. If clients have an understanding as they begin therapy what the counselor's approach will be, misunderstandings may be avoided [80]. While restrictive guidelines might be unhelpful, confusion surrounding gifts seems to be exacerbated by a lack of professional discussion about the topic [81].

Many professionals try to keep gifts "alive" throughout client sessions. This often involves putting the gift "on hold" (including decisions about acceptance and rejection) until the best moment for exploration with the client occurs. This allows that gifts given during therapy (where possible) remain part of therapy (i.e., they stay in the room and are available for future sessions) [81]. When considering whether to discuss the gift as part of therapy, the counselor should evaluate pertinent factors, such as the client's time in therapy, the context and frequency of gifts, and client dynamics. While not all gifts warrant full discussion (e.g., those given to show appreciation or of modest financial value), some, such as repeated or expensive gifts, do. Although counselors should be careful not to make too much of a gift, especially those that clients at least initially see as being given simply as a way to say thank you, such conversations may enable both members of the dyad to attain greater insight into the gift's intention and meaning and thereby prove helpful to the continued therapy work [82].

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

Professionals who work with children have unique challenges regarding gifts. Rejecting a child's gift or trying to explain a "no-gift policy" can cause the child to feel confused or rejected; children do not have the same levels of cognition and understanding that adults have. For play counselors, potential compromises include incorporating the gift into the other materials and toys in the playroom or directly sharing the gift with the child [82]. An important factor affecting the decision to accept a gift is the kind of gift presented by the child. Artwork or something created by the child is an extension of the child and therefore can be viewed as an extension of emotional giving. Accepting non-purchased items (e.g., a flower picked by a child or a child's drawing) would be acceptable in most cases [83].

Clients with personality disorders present unique challenges regarding the issue of gifts. Generally, these clients exhibit manipulation, poor boundaries, and fixed or rigid patterns of relating, and gift giving can be a feature of the clinical picture for such clients. Accepting a gift from such a client may reinforce patterns of manipulative or self-debasing behaviors that are symptomatic of the problematic levels of functioning. In such instances, counselors should discern which course of action is truly in the client's best interests [78].

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

THE GIFT OF SELF-DISCLOSURE

Self-disclosure can be considered another type of gift; however, it is best saved for a special occasion, shared deliberately, and always with the client's welfare first and foremost in mind. Self-disclosure is useful when it benefits the client, not the counselor. Although self-disclosure may cause no problems in therapy, it may intrude on the client's psychic space or replace a client's rich and clinically useful fantasy with dry fact, stripped of meaningful affect [72].

Humanistic theorists openly embrace counselor self-disclosure, asserting that such interventions demonstrate counselors' genuineness and positive regard for clients [84]. It is not surprising that professionals with behavioral and cognitive orientations view professional self-disclosures positively, especially when these interventions are intended to serve as a model for client self-disclosure [85]. And there will be times that self-disclosure is helpful in therapy. For example, it may serve as a vehicle for transmitting feminist values, equalizing power in the therapy relationship, facilitating client growth, fostering a sense of solidarity between counselor and client, helping clients view their own situations with less shame, encouraging clients' feelings of liberation, and acknowledging the importance of the real relationship between counselor and client. It also may enable clients to make informed decisions about whether or not they choose to work with a counselor [85].

According to one study, the content areas clinical social workers felt most comfortable self-disclosing about were loneliness, relationship status, aging, and other developmental issues of adulthood. Many talked freely about their marital status, the composition of their families, their parenting, their education, and their work. The most significant content area for sharing was grief work around significant losses either through separation, divorce, or death [86]. In these cases, counselor self-disclosure can help clients feel less alone and can normalize an emotional experience. It can give a client hope to learn that a trusted counselor has gone through the same situation.

Cautions Regarding Self-Disclosure

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

No matter how on guard one is, there will be times when personal information makes its way to clients. Accidental self-disclosures may include extra-therapeutic encounters, slips of the tongue, or public notices of events or lectures. Personal aspects of the counselor's life may come to light if he or she calls a client by another client's name, a newspaper prints an obituary of the counselor's spouse, or the counselor is seen entering a place of worship [87]. Most clients who learn a bit of personal information about their counselor will mention it only to express care or concern, as when they learn of a death. Clients are generally satisfied with a brief acknowledgement of the disclosure and an appreciation for the client's expressed feelings about it.

As stated, mental health professionals' primary concern is to avoid burdening or overwhelming clients. Professionals should generally avoid using disclosures that are for their own needs, that remove the focus from the client, that interfere with the flow of the session, that burden or confuse the client, that are intrusive, that blur the boundaries between the professional and client, or that contaminate transference [85].

11. TECHNOLOGY AND DISTANCE THERAPY

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

The APA has created guidelines to address the developing area of psychologic service provision commonly known as telepsychology [88]. The APA defines telepsychology as the "provision of services using telecommunication technologies, including but not limited to: telephone, mobile devices, interactive videoconferencing, email, chat, text, and Internet (e.g., self-help websites, blogs, and social media)" [88]. The APA guidelines are informed by its ethics code and record-keeping guidelines as well as its guidelines on multicultural training, research, and practice. The guidelines allow that telecommunication technologies may either augment traditional in-person services or be used as stand-alone services. The guidelines also acknowledge that telepsychology involves "consideration of legal requirements, ethical standards, telecommunication technologies, intra- and interagency policies, and other external constraints, as well as the demands of the particular professional context" [88]. When one set of considerations may suggest a different course of action than another, the professional should balance them appropriately, with the aid of the guidelines [88]. The complete guidelines are available online at https://www.apa.org/practice/guidelines/telepsychology.aspx.

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

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

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

The National Board for Certified Counselors (NBCC) recognizes that distance counseling presents unique ethical challenges to professional counselors; related technology continues to advance and be used by more professionals; and that the use of technology by professionals continues to evolve. In light of this information, the NBCC revised its Internet counseling policy and developed the NBCC Policy Regarding the Provision of Distance Professional Services [89]. This policy replaces previous editions.

The revised policy includes use of the term "distance professional services" to include other types of professional services that are being used more in distance formats. The policy addresses telephone-, email-, chat-, video-, and social network-based distance professional services that may be conducted with individuals, couples, families, or group members. The policy also identifies specific actions that NCCs should take when providing distance services. The policy supplements the directives identified in the NBCC Code of Ethics [6,89]. The policy is available at https://www.nbcc.org/Assets/Ethics/NBCCPolicyRegardingPracticeofDistanceCounselingBoard.pdf.

Professionals interested in providing online interventions also should consider the possible boundary issues involved. For example, instant message systems can alert clients each time the professional is online, allowing the client to send chat requests. Clients might access a professional's personal webpage or sign onto online discussion groups to which the professional also belongs. Some may continue to send the professional emails after the termination of the relationship. E-counselors should consider their response to such ongoing contact. Potentially more seriously, clients may use the Internet to harass or stalk current or former counselors [92]. The best way to prevent potential problems is to discuss the boundaries with clients during the initial assessment. Being up front and clear with clients about limits and policies regarding the use of technology and social networking is recommended [93].

Miscommunication is a commonplace occurrence in the online world. Even the simplest things (e.g., punctuation marks) can be misinterpreted. Studies reveal that 7% of any message is conveyed through words, 38% through certain vocal elements, and 55% through nonverbal elements (e.g., facial expressions, gestures, posture) [94]. Some technology-based forms of communication can result in the loss of important nonverbal and vocal cues, leading to an increased risk for miscommunication between client and counselor. Interactive communication, such as texting and email, involves the loss of nonverbal social cues that provide valuable contextual information and interpretation of meaning. Loss of these physical social cues may also increase the client's tendency to project personal psychologic material onto the blankness of the communication. While this may be helpful in some forms of psychotherapeutic interventions and it may offer advantages over in-person communication, it also presents a potential risk for increased miscommunication [92].

The compassionate professional strives to communicate nonverbally to clients that he or she is listening to and in the moment with the client. Physical cues, such as nodding and eye contact, have been shown to be positively associated with the degree that clients feel the counselor is respectful and genuine [95,96]. Much attention also is paid to the voice, as it carries the verbal message and people often believe the voice to be a more reliable indicator of one's true feelings [97]. Because research exploring how empathy is experienced in an online environment is minimal, counselors should check with their clients to determine if the empathy is being transmitted in their text-based communications [12].

No matter what type of counseling is offered, a thorough initial evaluation should be completed to assess whether a client is appropriate for distance counseling. Practicing within recommended guidelines does not release counselors from the personal responsibility to be aware of, and to independently evaluate, the variety of ethical issues involved in the practice of online therapy [92]. Certain clients (e.g., those with suicidal, homicidal, or substance abuse history, clients with personality disorders) would not be suited to online therapy.

LEGAL AND ETHICAL CONSIDERATIONS

The challenges of online therapy lead to legal and ethical concerns associated with the delivery of mental health services via the Internet. Those opposed to online or distance therapy worry about licensure issues related to doing therapy across jurisdictional boundaries, legal responsibility in the event of a crisis, and the appropriateness of client anonymity [90].

Providing services across state lines is one of the biggest unresolved issues. Although communication technologies allow counselors to reach clients anywhere, state licensing laws generally do not permit out-of-state counselors to provide services via these methods. Some states offer guest licensure provisions, but most states require that the counselor hold a license in his or her own state and in the client's state. Three states—California, Vermont, and Kentucky—have passed laws specifying psychologists' legal obligations in online therapy [91]. Providing distance therapy within one's own state is simpler, and it allows mental health professionals to reach people who would not otherwise have access to services (e.g., rural residents, people with certain disabilities) as well as those who want to receive services from home. To confidently provide distance services [91]:

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

- Understand the technology being used.

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

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

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

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

SOCIAL MEDIA

With the advent of social media, clients can now search for and find the Facebook or Twitter page of their counselor, if one exists. Counselors who accept a client's "friend request" are in essence agreeing that the counselor and client are now friends, creating a multiple relationship. When clients have access to their counselor's social media sites, both intentional and unintentional self-disclosures can occur. Modern social networking systems (e.g., Facebook, Instagram) exemplify intentional self-disclosure without a particular client focus. In contrast, Internet search engines (e.g., Google, LexisNexis) may allow unintended disclosure of personal details of the professional's life. Professionals should be aware and cognizant of social media involvement, including what information is public. Many sites offer ways to post minimal information if a connection to other professionals is desired. Avoid posting a profile photo that includes your family or other personal details, as these are public [87].

12. CONCLUSION

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

California LCSWs

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

California LMFTs

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

California LPCCs

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

California LEPs

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

13. RESOURCES

Administration for Community Living

Diversity and Cultural Competency

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

Office of Minority Health

Cultural and Linguistic Competency

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

Health Resources and Services Administration

Culture, Language and Health Literacy

https://www.hrsa.gov/cultural-competence

APA Ethical Principles of Psychologists and Code of Conduct

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

ACA Code of Ethics

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

NAADAC Code of Ethics

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

NBCC Code of Ethics

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

NASW Code of Ethics

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

Substance Abuse and Mental Health Services Administration Cultural Competence

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

HelpGuide: Benefits of Mindfulness

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

Mindfulnet.org

http://www.mindfulnet.org

Plum Village Mindfulness Practice Center

https://plumvillage.org/mindfulness-practice

Works Cited

1. APA Practice Organization. Professional Health and Well-Being for Psychologists. Available at https://www.apapracticecentral.org/ce/self-care/well-being.aspx. Last accessed October 3, 2018.

2. Positive Psychology Program. How to Set Healthy Boundaries: 10 Examples + PDF Worksheets. Available at https://positivepsychologyprogram.com/great-self-care-setting-healthy-boundaries. Last accessed October 3, 2018.

3. American Psychological Association. Ethical Principles of Psychologists and Code of Conduct. Available at https://www.apa.org/ethics/code. Last accessed October 3, 2018.

4. American Counseling Association. 2014 ACA Code of Ethics. Available at https://www.counseling.org/resources/aca-code-of-ethics.pdf. Last accessed October 3, 2018.

5. National Association of Social Workers. Code of Ethics of the National Association of Social Workers. Available at https://www.socialworkers.org/About/Ethics/Code-of-Ethics. Last accessed October 3, 2018.

6. National Board of Certified Counselors. National Board for Certified Counselors (NBCC) Code of Ethics. Available at https://www.nbcc.org/Assets/Ethics/NBCCCodeofEthics.pdf. Last accessed October 3, 2018.

7. Association for Addiction Professionals. NAADAC/NCC AP: The National Certification Commission for Addiction Professionals Code of Ethics. Available at https://www.naadac.org/assets/2416/naadac-code-of-ethics-033117.pdf. Last accessed October 3, 2018.

8. Fairburn CG, Cooper Z. Therapist competence, therapy quality, and therapist training. Behav Res Ther. 2011;49(6-7):373-378.

9. Sue DW, Sue D. Counseling the Culturally Different: Theory and Practice. 7th ed. New York, NY: John Wiley and Sons; 2015.

10. Bernstein DM. Therapist-patient relations and ethnic transference. In: Tseng W-S, Streltzer J (eds). Culture and Psychotherapy: A Guide to Clinical Practice. Washington, DC: American Psychiatric Press; 2001: 103-121.

11. Bandura A. Self-Regulation. Available at http://professoralbertbandura.com/albert-bandura-self-regulation.html. Last accessed October 3, 2018.

12. Rogers CR. A Way of Being. Boston, MA: Houghton Mifflin; 1980: 115-116.

13. Gendlin ET. Subverbal communication and therapist expressivity: trends in client-centered therapy with schizophrenics. In: Rogers CR, Stevens B (eds). Person to Person: The Problem of Being Human: A New Trend in Psychology. Lafayette, CA: Real People Press; 1967: 121-122.

14. Jordan JV. Relational Development: Therapeutic Implications of Empathy and Shame. Wellesley, MA: Wellesley College; 1989.

15. Elliott R, Bohart AC, Watson JC, Greenberg LS. Empathy. Psychotherapy. 2011;48(1):43-49.

16. Watson JC. Role of empathy is psychotherapy: theory, research and practice. In: Cain DJ, Seeman J (eds). Humanistic Psychotherapies: Handbook of Research and Practice. 2nd ed. Washington, DC: American Psychological Association; 2002: 445-472.

17. Wiseman T. A concept analysis of empathy. J Adv Nurs. 1996;23(6):1162-1167.

18. Kirschenbaum H, Jourdan A. The current status of Carl Rogers and the person-centered approach. Psychother Theory Res Pract Training. 2005;42(1):37-51.

19. Compassion-Focused Therapy. Available at http://www.compassionfocusedtherapy.com. Last accessed October 3, 2018.

20. Gilbert P. Introducing compassion-focused therapy. Adv Psychiatr Treat. 2009;15(3):199-208.

21. Arnold K. Behind the mirror: reflective listening and its tain in the work of Carl Rogers. Humanistic Psychol. 2014;42(4):354-369.

22. Abendroth M, Flannery J. Predicting the risk of compassion fatigue: a study of hospice nurses. J Hosp Palliat Nurs. 2006;8(6):346-356.

23. American Psychological Association. Listening to the Warning Signs of Stress. Available at https://www.apa.org/helpcenter/stress-signs.aspx. Last accessed October 3, 2018.

24. Newell JM, MacNeil GA. Professional burnout, vicarious trauma, secondary traumatic stress, and compassion fatigue.Best Pract Ment Health. 2010;6(2):57-68.

25. Jenkins SR, Baird S. Secondary traumatic stress and vicarious trauma: a validation study. J Trauma Stress. 2002;15(5):423-432.

26. Tend. What is Compassion Fatigue? Available at https://www.tendacademy.ca/what-is-compassion-fatigue. Last accessed October 3, 2018.

27. Espeland KE. Overcoming burnout: how to revitalize your career. J Contin Educ Nurs. 2006;37(4):178-184.

28. Maslach C, Schaufeli WB. Historical and conceptual development of burnout. In: Schaufeli WB, Maslach C, Marek T (eds). Professional Burnout: Recent Developments in Theory and Research. New York, NY: Routledge; 2017: 1-16.

29. Figley CR. Compassion Fatigue: Coping with Secondary Traumatic Stress Disorder in Those who Treat the Traumatized. Levittown, PA: Brunner/Mazel; 1995.

30. Figley CR. Compassion fatigue: psychotherapists' chronic lack of self-care. J Clin Psychol. 2002;58(11):1433-1441.

31. Wilson JP, Lindy JD. Empathic strain and countertransference. In: Wilson JP, Lindy JD (eds). Countertransference in the Treatment of PTSD. New York, NY: Guilford; 1994: 5-30.

32. Abendroth M. Overview and summary: compassion fatigue: caregivers at risk. Online J Issues Nurs. 2011;16(1):1-3.

33. Sherman DW. Nurses' stress and burnout: how to care for yourself when caring for patients and their families experiencing life-threatening illness. Am J Nurs. 2004;104(5):48-56.

34. Bennett-Levy J, Beedie A. The ups and downs of cognitive therapy training: what happens to trainees' perception of their competence during a cognitive therapy training course? Behav Cogn Psychother. 2007;35(1):61-75.

35. Trippany R, White Kress VE, Wilcoxon SA. Preventing vicarious trauma: what counselors should know when working with trauma survivors. J Couns Dev. 2004;82(1):31-37.

36. Potter B. Overcoming Job Burnout: How to Renew Enthusiasm for Work. Berkeley, CA: Ronin Publishing; 1998.

37. Pearlman LA, Saakvitne KW. Treating therapists with vicarious traumatization and secondary traumatic stress disorders. In Figley CR (ed). Brunner/Mazel Psychological Stress Series, No. 23. Compassion Fatigue: Coping with Secondary Traumatic Stress Disorder in Those Who Treat the Traumatized. New York, NY: Routledge; 1995: 23, 150-177.

38. Harrison RL, Westwood MJ. Preventing vicarious traumatization of mental health therapists: identifying protective practices. Psychotherapy. 2009;46(2):203-219.

39. Rønnestad MH, Skovholt TM. The journey of the counselor and therapist: research findings and perspectives on professional development. J Career Dev. 2003;30(1):5-44.

40. Newell JM, MacNeil GA. Professional burnout, vicarious trauma, secondary traumatic stress, and compassion fatigue. Best Pract Ment Health. 2010;6(2):57-68.

41. Harrison RL, Westwood MJ. Preventing vicarious traumatization of mental health therapists: identifying protective practices. Psychotherapy. 2009;46(2):203-219.

42. Perseius KI, Kåver A, Ekdahl S, Åsberg M, Samuelsson M. Stress and burnout in psychiatric professionals when starting to use dialectical behavioural therapy in the work with young self‐harming women showing borderline personality symptoms.J Psychiatr Ment Health Nurs. 2007;14(7):635-643.

43. Greason PB, Cashwell CS. Mindfulness and counseling self-efficacy: the mediating role of attention and empathy. Couns Education Supervision. 2009;49(1):2-19.

44. Dreifuss A. A phenomenological inquiry of six psychotherapists who practice Buddhist meditation. Diss Abstr Int. 1990;51(5):2617.

45. Rothaupt JW, Morgan MM. Counselors' and counselor educators' practice of mindfulness: a qualitative inquiry. Couns Values. 2007;52(1):40-54.

46. Freud S. Fragment of an analysis of a case of hysteria (1905 [1901). In: Freud S, Strachey J, Freud A, Strachey A, Tyson A (eds). Complete Psychological Works of Sigmund Freud. Volume VII, 1901–1905, A Case of Hysteria. London: Hogarth Press; 1953: 7-122.

47. Reidbord S. Countertransference: An Overview. Available at https://www.psychologytoday.com/us/blog/sacramento-street-psychiatry/201003/countertransference-overview. Last accessed October 3, 2018.

48. Plakun EM. Making the alliance and taking the transference in work with suicidal patients. J Psychother Pract Res. 2001;10(4):269-276.

49. Murdoch L. Psychological consequences of adopting a therapeutic lawyering approach: pitfalls and protective strategies.Seattle UL Rev. 2000;24(2):483.

50. Hughes P, Kerr I. Transference and countertransference in communication between doctor and patient. Adv Psychiatr Treat. 2000; 6(1):57-64.

51. Gabbard GO, Horowitz MJ. Insight, transference interpretation, and therapeutic change in the dynamic psychotherapy of borderline personality disorder. Am J Psychiatry. 2009;166(5):517-521.

52. Slakter E. Countertransference. Northvale, NJ: Jason Aronson; 1988.

53. Peabody SA, Gelso CJ. Countertransference and empathy: the complex relationship between two divergent concepts in counseling.J Counseling Psychol. 1982;29(3):240-245.

54. Hayes JA, McCracken JE, McClanahan MK, Hill CE, Harp JS, Carozzoni P. Therapist perspectives on countertransference: qualitative data in search of a theory. J Counseling Psychol. 1998;45(4):468-482.

55. Shapiro ER, Carr W. Lost in Familiar Places: Creating New Connections Between the Individual and Society. New Haven, CT: Yale University Press; 1991.

56. Ziegler M, McEvoy M. Hazardous Terrain: Countertransference Reactions in Trauma Groups. Available at http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.578.2804&rep=rep1&type=pdf. Last accessed October 3, 2018.

57. Timm TM, Blow AJ. Self-of-the-therapist work: a balance between removing restraints and identifying resources. Contemp Fam Ther. 1999;21(3):331-351.

58. Godfrey K, Haddock SA, Fisher A, Lund L. Essential training components of curricula for preparing therapists to work with lesbian, gay, and bisexual clients: a Delphi study. J Marital Fam Ther. 2006;32(4):491-504.

59. Sommers-Flanagan R, Elliott D, Sommers-Flanagan J. Exploring the edges: boundaries and breaks. Ethics Behav. 1998;8(1):37-48.

60. Austin W, Bergum V, Nuttgens S, Peternelj-Taylor C. A re-visioning of boundaries in professional helping relationships: exploring other metaphors. Ethics Behav. 2006;16(2):77-94.

61. Langley GC, Klopper H. Trust as a foundation for the therapeutic intervention for patients with borderline personality disorder.J Psychiatr Ment Health Nurs. 2005;12(1):23-32.

62. Gabbard GO. Boundaries and Boundary Violations in Psychoanalysis. 2nd ed. Washington, DC: American Psychiatric Publishing; 2016.

63. Hermansson G. Boundaries and boundary management in counselling: the never-ending story. Br J Guid Counc. 1997;25(2):133-146.

64. Sonne JL. Nonsexual Multiple Relationships: A Practical Decision-Making Model for Clinicians. Available at https://kspope.com/site/multiple-relationships.php. Last accessed October 3, 2018.

65. Gutheil TG. Boundaries, blackmail, and double binds: a pattern observed in malpractice consultation. J Am Acad Psychiatry Law. 2005;33(4):476-481.

66. Winnicott DW. The Maturational Processes and the Facilitating Environment; Studies in the Theory of Emotional Development. New York, NY: International Universities Press; 1965.

67. Walker R, Clark JJ. Heading off boundary problems: clinical supervision as risk management. Psychiatr Serv. 1999;50(11):1435-1439.

68. Whitfield CL. Boundaries and Relationships: Knowing, Protecting, and Enjoying the Self. Deerfield Beach, FL: Health Communications; 1993.

69. Spence SA. Patients bearing gifts: are there strings attached? BMJ. 2005;331(7531):1527-1529.

70. Knapp S, Slattery JM. Professional boundaries in nontraditional settings. Prof Psychol Res Pr. 2004;35(5):553-558.

71. Corey G, Corey MS, Corey C. Issues and Ethics in the Helping Professions. 10th ed. Stamford, CT: Brooks/Cole Cengage Learning; 2018.

72. Norris DM, Gutheil TG, Strasburger LH. This couldn't happen to me: boundary problems and sexual misconduct in the psychotherapy relationship. Psychiatr Serv. 2003;54(4):517-522.

73. Zur O. To cross or not to cross: do boundaries in therapy protect or harm? Psychother Bull. 2004;39(3):27-32.

74. Pope KS, Keith-Speigel P. A practical approach to boundaries in psychotherapy: making decisions, bypassing blunders, and mending fences. J Clin Psychol. 2008;64(5):638-652.

75. Simon RI. Treatment boundary violations: clinical, ethical, and legal considerations. Bull Am Acad Psychiatr Law. 1992;20(3):269-288.

76. Simon RI, Williams IC. Maintaining treatment boundaries in small communities and rural areas. Psychiatr Serv. 1999;50(11):1440-1446.

77. Gabbard GO. Patient-therapist boundary issues. Psychiatr Times. 2005;22(12).

78. Gerig MS. Receiving gifts from clients: ethical and therapeutic issues. J Ment Health Couns. 2004;26(3):199-210.

79. Herlihy B, Corey G. Boundary Issues in Counseling: Multiple Roles and Responsibilities. 3rd ed. Alexandria, VA: ACA Press; 2014.

80. Knox S. Gifts in psychotherapy: practice review and recommendations. Psychotherapy. 2008;45(1):103-110.

81. Spandler H, Burman E, Goldberg B, Margison F, Amos T. "A double-edged sword:" understanding gifts in psychotherapy.Eur J Psychother Couns. 2000;3(1):77-101.

82. Knox S, Dubois R, Smith J, Hess S, Hill CE. Clients' experiences giving gifts to therapists. Psychotherapy. 2009;46(3):350-361.

83. Landreth G. Play Therapy: The Art of the Relationship. 3rd ed. New York, NY: Routledge Taylor and Francis Group; 2012.

84. Robitschek CG, McCarthy PR. Prevalence of counselor self-reference in the therapeutic dyad. J Couns Dev. 1991;69(3):218-221.

85. Hill CE, Knox S. Self-disclosure. In: Norcross JC (ed). Psychotherapy Relationships That Work: Therapist Contributions and Responsiveness to Patients. New York, NY: Oxford University Press; 2002: 255-265.

86. Borenzweig H. The self-disclosure of clinical social workers. J Sociol Soc Welfare. 1981;8(2):15.

87. Gutheil TG. Ethical aspects of self-disclosure in psychotherapy. Psychiatr Times. 2010;27(5):39-41.

88. American Psychological Association. Guidelines for the Practice of Telepsychology. Available at https://www.apa.org/practice/guidelines/telepsychology.aspx. Last accessed October 3, 2018.

89. National Board for Certified Counselors. NBCC Policy Regarding the Provision of Distance Professional Services. Available at https://www.nbcc.org/Assets/Ethics/NBCCPolicyRegardingPracticeofDistanceCounselingBoard.pdf. Last accessed October 3, 2018.

90. Rochlen AB, Zack JS, Speyer C. Online therapy: review of relevant definitions, debates, and current empirical support. J Clin Psychol. 2004;60(3):269-283.

91. DeAngelis T. Practicing Distance Therapy, Legally and Ethically. Available at https://www.apa.org/monitor/2012/03/virtual.aspx. Last accessed October 3, 2018.

92. Childress CA. Ethical issues in providing online psychotherapeutic interventions. J Med Internet Res. 2000;2(1):e5.

93. Novotney A. A new emphasis on telehealth: how can psychologists stay ahead of the curve—and keep patients safe? Am Psychol Assoc. 2011;42(6):40.

94. Mehrabian A. Silent Messages: Implicit Communication of Emotions and Attitudes. 2nd ed. Belmont, CA: Wadsworth Pub Co; 1980.

95. Hill CE, Stephany A. Relation of nonverbal behavior to client reactions. J Counseling Psychol. 1990;37(1):22-26.

96. Kelly EW Jr, True JH. Eye contact and communication of facilitative conditions. Percept Mot Skills. 1980;51(3):815-820.

97. Hall JA, Harrigan JA, Rosenthal R. Nonverbal behavior in clinician-patient interaction. Appl Prev Psychol. 1996;4(1):21-37.

76430 • Mass Shooters and Murderers: Motives and Paths

Mark Rose, BS, MA, LP

www.netce.com

Copyright © 2019 NetCE, All rights reserved.

Mass shootings at schools and other public settings are distressingly familiar, but their close relationship to extremist violence and domestic homicide is largely unknown. Mass shootings are part of a larger public health concern of gun violence that includes homicide, suicide, and gunshot injury. These violent acts are not impulsive, but are endpoints of a pathway beginning with grievance and alienation. Interaction with other factors influences movement on a pathway to mass violence (usually, but not always, involving guns) and whether the culmination is fueled by personal or ideologic motive; the marked similarities of perpetrators and pathways in both erase many previous distinctions. Clinicians are not immune to the false narratives surrounding mass shooting and extremist violence (a more accurate term than "terrorism") and benefit from understanding the evidence on mass and domestic violence, gun violence in general, their aggravating and mitigating factors, and preventive approaches. This course will make greater use of case histories, which are illustrative given the very small perpetrator population.

Table of Contents

76430 • Mass Shooters and Murderers: Motives and Paths

Course Overview

Audience

Course Objective

Learning Objectives

Faculty

Faculty Disclosure

Division Planners

Division Planners Disclosure

About the Sponsor

Disclosure Statement

1. INTRODUCTION

2. HISTORICAL OVERVIEW

ANARCHISTS: THE FIRST VIOLENT EXTREMISTS

MASS MURDER AT A SCHOOL

MASS SHOOTINGS

THE MEDIA AND PUBLIC PERCEPTION

3. MASS SHOOTERS: CHARACTERISTICS

PSYCHOPATHOLOGY OF MASS SHOOTERS/MURDERERS

CULTURAL INFLUENCES

4. MASS SHOOTERS: PATHS TO VIOLENCE

THE PATHWAY TO VIOLENCE MODEL

THE WARNING BEHAVIORS MODEL

PATHWAY TO TARGETED VIOLENCE IN THE WORKPLACE

5. EXTREMIST MASS VIOLENCE: THE PERPETRATORS

CORE CONCEPTS

EXTREMIST IDEOLOGIES

ISLAMIST AND FAR-RIGHTIST VIOLENCE IN THE UNITED STATES

MEDIA AND CULTURAL NARRATIVES OF EXTREMIST VIOLENCE

6. EXTREMIST MASS VIOLENCE: PATHWAYS

MORAL EMOTIONS AND INTERGROUP VIOLENCE

RADICALIZATION PATHWAYS: THE U.S. DEPARTMENT OF JUSTICE REPORT

SIMILARITIES OF VIOLENT EXTREMISTS AND OTHER MASS SHOOTERS

IMPLICATIONS FOR SUCCESSFUL COUNTERING OF VIOLENT EXTREMISM

7. GUN VIOLENCE TRENDS, DATA, AND FACTORS

AGGRESSION, WEAPONS, AND VIOLENCE

DOMESTIC HOMICIDE AND MASS SHOOTINGS

MASS SHOOTINGS AND OTHER GUN VIOLENCE

8. DISCUSSING GUN SAFETY AND RISKS WITH PATIENTS

RATIONALE AND BARRIERS

GENERAL GUIDANCE

CONSIDERATIONS TO AVOID STIGMATIZING PATIENTS WITH MENTAL ILLNESS

CONSIDERATIONS FOR NON-ENGLISH-PROFICIENT PATIENTS/CLIENTS

9. RESOURCES

10. CONCLUSION

11. APPENDIX: UNDERSTANDING GUN CULTURE

THE LEGAL CONTEXT OF GUN RIGHTS

MEDIA DEPICTION AND SYMBOLISM

GUN CULTURE

Works Cited

Evidence-Based Practice Recommendations Citations

76430 • Mass Shooters and Murderers: Motives and Paths

Education Category. Psychiatric / Mental Health

Release Date. 04/01/2019

Expiration Date. 03/31/2022

Course Overview

Mass shootings at schools and other public settings are distressingly familiar, but their close relationship to extremist violence and domestic homicide is largely unknown. Mass shootings are part of a larger public health concern of gun violence that includes homicide, suicide, and gunshot injury. These violent acts are not impulsive, but are endpoints of a pathway beginning with grievance and alienation. Interaction with other factors influences movement on a pathway to mass violence (usually, but not always, involving guns) and whether the culmination is fueled by personal or ideologic motive; the marked similarities of perpetrators and pathways in both erase many previous distinctions. Clinicians are not immune to the false narratives surrounding mass shooting and extremist violence (a more accurate term than "terrorism") and benefit from understanding the evidence on mass and domestic violence, gun violence in general, their aggravating and mitigating factors, and preventive approaches. This course will make greater use of case histories, which are illustrative given the very small perpetrator population.

Audience

This course is designed for all healthcare professionals who may intervene to identify persons at risk for committing acts of mass violence.

Course Objective

The purpose of this course is to provide health and mental health professionals with the knowledge and skills necessary to identify persons on paths to extreme violence and to intervene to prevent mass shooting events.

Learning Objectives

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

1. Outline the history of mass violence and media coverage of these events in the United States.

2. Identify psychopathology that is uncommon in mass shooters.

3. Describe psychopathology that is common in mass shooters and discuss how different pathologies act synergistically.

4. Analyze cultural factors that influence perpetrators of mass violence.

5. Distinguish targeted and affective violence and the role of pathways in identifying persons at risk for mass violence.

6. Evaluate components of the Pathways to Violence Model.

7. Describe the proximal warning behaviors outlined in the Warning Behaviors Model.

8. Discuss the distal characteristics of targeted violence as defined in the Warning Behaviors Model.

9. Define core concepts associated with perpetration of extremist violence, including radicalization and terrorism.

10. Analyze current and historic extremist ideologies common in the United States.

11. Outline the role of Islamist and far-rightist violence in the United States, including media and cultural narratives.

12. Evaluate models used to describe the common pathways to extremist violence.

13. Review general gun violence trends and data.

14. Describe the barriers to and rationale for gun safety discussions with patients.

15. Discuss considerations for avoiding stigmatizing patients with mental illness and appropriately meeting the needs of non-English-proficient patients in conversations regarding gun safety.

Faculty

Mark Rose, BS, MA, LP, is a licensed psychologist in the State of Minnesota with a private consulting practice and a medical research analyst with a biomedical communications firm. Earlier healthcare technology assessment work led to medical device and pharmaceutical sector experience in new product development involving cancer ablative devices and pain therapeutics. Along with substantial experience in addiction research, Mr. Rose has contributed to the authorship of numerous papers on CNS, oncology, and other medical disorders. He is the lead author of papers published in peer-reviewed addiction, psychiatry, and pain medicine journals and has written books on prescription opioids and alcoholism published by the Hazelden Foundation. He also serves as an Expert Advisor and Expert Witness to law firms that represent disability claimants or criminal defendants on cases related to chronic pain, psychiatric/substance use disorders, and acute pharmacologic/toxicologic effects. Mr. Rose is on the Board of Directors of the Minneapolis-based International Institute of Anti-Aging Medicine and is a member of several professional organizations.

Faculty Disclosure

Contributing faculty, Mark Rose, BS, MA, LP, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Division Planners

Alice Yick Flanagan, PhD, MSW

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

Mass shootings at schools and other public settings are distressingly familiar, but their close relationship to extremist violence and domestic homicide is largely unknown. Mass shootings are part of a larger public health concern of gun violence that includes homicide, suicide, and gunshot injury. These violent acts are not impulsive, but are endpoints of a pathway beginning with grievance and alienation. Interaction with other factors influences movement on a pathway to mass violence (usually, but not always, involving guns) and whether the culmination is fueled by personal or ideologic motive; the marked similarities of perpetrators and pathways in both erase many previous distinctions.

Extreme beliefs drive ideologic mass violence, but it is important to remember that few with extreme beliefs progress to extreme behaviors (violence). Hate is an extreme belief that can lead to extremist violence and motivate intergroup violence when cultural or economic changes perceived as threats are blamed on another group. In the United States, ideologic violence is primarily perceived as a problem from Muslims, but more acts of fatal mass violence are committed by far-right extremists than Islamist extremists [108].

More than half of mass shootings (generally defined as at least four persons killed in an incident) are domestic homicide events. During domestic violence, the risk of homicide increases 500% when a gun is present, and gun access is also a factor in public mass shootings [176].

Mass shootings, extremist violence, and domestic homicides are closely related. Gun violence, gun rights, and gun control are contentious subjects, but also require attention. Health and mental health providers play a key role in preventing gun violence by initiating conversations with patients, but they often lack training and guidance. Understanding the beliefs and perspectives of gun culture allows for effective gun safety counseling.

Clinicians are not immune to the false narratives surrounding mass shooting and extremist violence (a more accurate term than "terrorism") and benefit from understanding the evidence on mass and domestic violence, gun violence in general, their aggravating and mitigating factors, and preventive approaches.

Please note that all information contained in this course is specific to the United States, except when explicitly stated.

2. HISTORICAL OVERVIEW

Discussions of mass shootings and extremist violence may give the impression of an American public in an era of unique and unprecedented threat, but these phenomena are not recent. The following overview describes the historical antecedent events and perpetrators of personal and ideologically motivated mass violence. Over the past 140 years, the patterns and themes are recurrent, while cultural framing of individuals as predisposed to mass violence has changed over time [253].

ANARCHISTS: THE FIRST VIOLENT EXTREMISTS

The anarchist wave of extremist violence spread from Europe to the United States in the later 1800s. Similarities to recent Islamist extremist violence are evident. Borne of extreme income inequality, anarchist ideology advocated class warfare against capitalism and government oppression through violent revolution, including bombing and assassination [1,2].

The United States in the later 1800s was described as the Gilded Age. The richest 2% owned 60% of the wealth, 35,000 workers died in industrial accidents every year, and striking for better work conditions resulted in violent reprisals. Under these conditions, anarchism spread to the industrial hubs of the United States [1,2].

Chicago became a center of anarchism and anarchist leaders who endorsed violence to fight capitalist oppression. A Chicago newspaper printed instructions on how to use dynamite and other terrorism-related pieces. In 1886, 40,000 workers went on strike for an eight-hour workday in Chicago. Riots ensued, a bomb thrown at a group of policemen killed seven officers, and several anarchists were prosecuted and convicted [2,3].

The level of population-level terror caused by anarchists was substantial. Bomb attacks ripped through underground subways, theaters, cafes, parades, and other crowded settings in London, Barcelona, Paris, Moscow, Melbourne (Australia), and other major cities. Between 1894 and 1900, the heads of state in Russia, France, Spain, Austria, and Italy were assassinated [4,5].

In the United States, an anarchist assassinated President William McKinley in 1901. Industrialists were targeted for murder. In 1920, a bomb exploded on Wall Street, killing 38 people and seriously wounding 143, the most destructive act of terrorism on American soil until the Oklahoma City bombing in 1995. In 1908, President Theodore Roosevelt stated that "compared with the suppression of anarchy, every other question sinks into insignificance" [4,5].

Anarchist terrorism coincided with the onset of mass journalism, and a mutually reinforcing relationship developed. Tabloid-style reporting that sensationalized the terrorist acts and vilified the anarchists drove sales and profits. This attracted new recruits, ignorant of anarchist theory but interested in the notoriety and publicity. Media coverage fed into anarchists' grandiosity and vanity, and many were obsessed with their press. The nature of reporting elevated and spread public fears and perceptions of threat disproportionate to their true levels [2,4].

The racist anarchist profile popularized by the media fueled ethnic tensions, triggering indiscriminate deportation programs that targeted immigrant communities and other vicious backlashes against immigrants that went far beyond the perpetrators. Ethnic tensions peaked in 1927 when Sacco and Vanzetti, recent Italian immigrants, were put on trial for anarchism [2,4]. A presidential commission warned this crackdown only validated anarchist rhetoric about a police state and made violent resistance against police brutality seem necessary to young, disaffected men in targeted immigrant communities. Instead, the commission stressed the importance of addressing severe income inequality and other root structural causes of the violence [2,4].

Following the onset of the Great Depression in the early 1930s, severe civil unrest and frequent, violent clashes between foreclosed farmers and unemployed industrial workers and strikebreakers, police, and the National Guard were common.

On February 15, 1933, anarchist Giuseppe Zangara attempted to assassinate President-elect Franklin D. Roosevelt (FDR). Standing 30 feet away, Zangara fired five shots at FDR, hitting persons next to FDR, one of whom died [6]. By the mid-1930s, the mass unrest dissipated as social and economic policies began addressing the root causes [5].

MASS MURDER AT A SCHOOL

The deadliest school attack killed 44 and wounded 58 in Bath, Michigan, in 1927, but this event is regularly missing from depictions of mass murder in America. The Bath Consolidated School (BCS) was attacked by Andrew Kehoe, who moved to Bath in 1912 and later became treasurer of the local school board. The BCS opened in 1922, vehemently opposed by Kehoe because its funding required property tax increases. This led to conflicts with other board members. In a public defeat, he lost his seat on the school board in 1926 [7,8].

Kehoe stopped paying the mortgage on his farm and received a letter of foreclosure. His wife was severely ill with tuberculosis. Neighbors thought Kehoe had become suicidal or was planning murderous revenge. Kehoe, a mechanic, had keys to access the BCS for repairs and rigged explosives throughout the school in the months before the attack [7,8].

The morning of the attack, Kehoe murdered his wife, firebombed his farm, and then detonated the first bomb at BCS. The timer to the second 500-lb bomb failed, so he drove his truck into rescuers and detonated dynamite inside it, killing himself and several others. His motive was vengeance against the school board and community for increasing his taxes to pay for the BCS [7,8]. He left a final communication, "Criminals are made, not born," reflecting externalized blame and long-held grievance [9].

The story made national headlines, but quickly disappeared. Men of Northern European heritage in small towns, like Kehoe, did not fit the prevailing terrorist narrative during a period when the public greatly feared bombing by "anarchist foreigners;" Sacco and Vanzetti were executed three months after the Bath bombing. Without an obvious political motive, the media quickly reached for mental illness to rationalize the incomprehensible, and news headlines widely described Kehoe as a "maniac." Then, as now, this approach stigmatizes people with mental illness, but serves to comfort a public that wants to see mass murderers and terrorists as insane, because viewing them as rational actors makes them a far greater threat [10].

MASS SHOOTINGS

The First Public Shooting Incident

Many reviews of mass shooting events in the United States cite the 1966 incident perpetrated by Charles Whitman at the University of Texas at Austin (UTA) as the first such offense. This is true of the modern era, but the first true incident occurred 63 years earlier, on August 13, 1903 [11].

That evening, an estimated 1,000 to 5,000 concert-goers packed into downtown Winfield, Kansas, for an outdoor music event. Gilbert Twigg opened fire on the crowd with a shotgun, killing 9 people and injuring at least 25. Twigg's seemingly indiscriminate choice of victims is considered the first of its nature in the United States, an archetype of mass shootings prevalent later in the century [11].

In 1889, the 19-year-old Twigg moved to Winfield with an uncle. He was reportedly viewed as bright and good-looking, with a favorable future. In 1894, a woman broke off an engagement to him. Demoralized, he joined the army in 1896, and was sent to fight in the Philippines for three years during a bloody insurrection that saw excessive brutality by both sides. During this period, an ongoing conflict with two superior officers developed into a severe grievance [11].

Returning to Winfield in 1903, his deterioration was obvious. Twigg's former employer, and other businesses, refused to hire him. Others noted that he muttered of plots against him and of being jilted. A search of his belongings after the massacre found a rambling, paranoid note warning that vengeful annihilation of all who conspired against him was imminent [11].

The University of Texas at Austin and South Chicago Community Hospital in 1966

On August 1, 1966, 25-year-old student Charles Whitman climbed to the top of the high campus tower at UTA and began shooting at people below, killing 15 and wounding 31 before the police shot and killed him. This horrific event occurred just two weeks after Richard Speck committed one of the most notorious mass murders in American history when he gained entrance to a dormitory at night and killed eight nursing students at the South Chicago Community Hospital [12].

Both murders were thought to profoundly influence the public's fear of crime, with Speck shattering people's perceptions of safety in their own homes and Whitman having an equally damaging effect on beliefs of safety in public places. The two crimes significantly shaped the perception of mass murder [12].

Head injury and brain dysfunction are thought to be highly prevalent among mass murderers, with 10% a conservative estimate and considerably higher than in the general population. Brain injury may interact with adverse psychosocial factors to increase individual predisposition, suggested in the histories of Richard Speck, who sustained a head injury falling from a tree; Andrew Kehoe, who was in a coma for two weeks from a severe head injury sustained in a fall in early adulthood; and Charles Whitman, with severe headaches, changes in personality, and violent, intrusive ideation possibly from a large brain tumor found at autopsy [9,13].

The 2017 Las Vegas Mass Murder

Detailed case analyses of mass violence perpetrators show similar distal and proximal patterns leading to the incident; this will be discussed later in this course. The Las Vegas mass murderer Stephen Paddock has remained an enigma. In the worst mass shooting in U.S. history, 58 people were killed and more than 420 were wounded by gunshots on October 1, 2017. Paddock erased his digital trail leading to the meticulously planned attack [14,15].

The first hint of possible motivation came in documents released seven months later. Multiple witnesses gave statements of their contacts with Paddock shortly before the attack. These described his angry, agitated tirades about the deadly standoffs at Ruby Ridge, Idaho, in 1992, Waco, Texas, in 1993, and the involved agencies (Federal Bureau of Investigation [FBI], Bureau of Alcohol, Tobacco, Firearms, and Explosives [ATF]); the federal government in general, gun control, and the Federal Emergency Management Agency (FEMA) "camps" for gun owners; the 25th anniversary of Ruby Ridge; and that "sometimes sacrifices have to be made" [16; 17]. While not conclusive, the statements align with the beliefs of anti-government extremists, a segment of the far-right [18].

In the 11 months before the attack, Paddock purchased more than 55 guns (mostly assault weapons). Found in the hotel room where he shot into the crowd were 24 weapons, mostly AR-15 rifles or variants with 100-round magazines and bump stocks to enable high firing rates. Hundreds of child pornography images were found on his laptop computer. Paddock's father was a bank robber once on the FBI's Most Wanted List, whom the FBI classified as a "psychopath." Psychopathic traits can be inherited, and while they do not account for the motivation, they may explain the detachment and cruelty necessary to commit such an act [14,15].

THE MEDIA AND PUBLIC PERCEPTION

As mentioned, public perceptions of mass murder and murderers have changed over time. The framing of individuals and subgroups as predisposed to mass violence is shaped by culturally prevailing political, race, and class anxieties, which are propagated by the media. This is bidirectional, as the media also shapes prevailing political, race, and class anxieties. The stigma linked to gun violence and mental illness is itself complex, politicized, and influenced by changing views of race, gender roles, violence, and conceptions of psychiatric illness [19].

News media depictions have long been the primary information source of mass murder for the public, journalists, academics, interest group activists, and criminal justice professionals. The media has fundamentally influenced the narratives and perceptions of mass murder/murderers, and research has consistently shown that the news media presents a distorted image of crime. The need to attract a larger audience and greater advertising revenue has shaped media selection and presentation of violent crime [12,20].

Mass shootings and murders in public spaces naturally evoke horror and outrage. The nature of media coverage and commentary amplifies public fears of their safety and promotes anger and blame directed at individuals portrayed as predisposed to mass violence. Oversimplified discussions often reduce complex phenomena to a single factor.

False information can also spread by media efforts to lead the reporting in breaking news situations. Within hours of the Parkland, Florida, shooting in February 2018, Republic of Florida leader Jordan Jereb claimed credit for training perpetrator Nikolas Cruz as a joke that he posted online in alt-right fora. The media began reporting that Cruz was a violent white supremacist, and the spread of this hoax made Jereb a celebrity in trolling subcultures [21,22]. (Trolling is defined as deliberately trying to disrupt, upset, attack, or offend others online.) Following mass shootings, alt-right trolls also float the names of innocent individuals to "bait" mainstream media uptake. After the Parkland shooting, a hoax of this nature was re-posted on Twitter by prominent figures, including the President of the United States [21].

Some widespread misperceptions and erroneous beliefs discussed in this course include [9,23,24,25,26]:

The perpetrator "snapped."

In this case, the premise is that nobody who reflected on such an act would engage in behavior so horrifying. Unlike impulsive violence, which is the most prevalent type overall, mass shootings almost always reflect targeted, or instrumental, violence. This subtype of violence is planned and methodically prepared over time.

The perpetrator must have been Muslim.

The catastrophic attack on September 11, 2001, by violent Islamist extremists continues to shape public and law enforcement perception of Muslims as uniquely terrorism-prone. As discussed later in this course, Islamist extremist violence has become infrequent in the United States and other extremist subgroups present a higher level of threat.

The assailant must have been mentally ill.

In mass shootings that capture media attention, perpetrators are often depicted as schizophrenic, psychotic, or "psycho." Mental illness has long been used to explain why these rampages occur, in part because it rejects the idea that a sane person could do something so horrific. Mass violence is very rare by persons experiencing serious mental illness (as it is among those without mental illness).

Mass shootings are just a fact of life.

The randomness of these events and inability to predict their perpetration can promote the view that future victims, law enforcement, and society are helpless and powerless. This is challenged by research showing that mass violence cannot be predicted but may be prevented.

3. MASS SHOOTERS: CHARACTERISTICS

A variety of psychopathologic, social, and interpersonal factors interact to increase the likelihood an individual will move to a path to mass violence.

PSYCHOPATHOLOGY OF MASS SHOOTERS/MURDERERS

In mass shooters with psychiatric diagnoses, perpetration is motivated by long-standing, pervasive feelings of extreme anger, persecution, violent revenge, and severe narcissism, and not by formal symptoms of the psychiatric disorder [27]. These abnormalities reflect character pathology traits or symptoms of personality disorders, which differ from serious mental illness [26].

Personality disorders are enduring, pervasive, inflexible patterns of behaviors. With typical onset in adolescence or early adulthood, these disorders of maladaptive attitudes, behaviors, and thought patterns remain stable over time. Such individuals may conclude that violence is an acceptable or necessary response to their problems, but they are not disengaged from reality and are capable of logistical and rational processes necessary for long-term planning [26].

Mass shooters frequently feel compelled to leave some type of final communication; others have been caught and extensively evaluated. Nearly all "leak" their pre-attack intent or thought process. These sources provide a more complete understanding of perpetrator motives, mental state, and psychologic disturbances [24,28,29,30].

Psychiatric Disorders Not Associated with Mass Shooting

Schizophrenia/Serious Mental Illness

The umbrella term "serious mental illness" refers to psychoses, schizophrenia (including paranoid type), bipolar disorder, and severe major depression. Active delusions and psychotic symptoms, such as command hallucinations, acutely elevate the risk of violent behavior, especially if substance abuse or cognitive impairments are present. Some persons with serious mental illness who are non-adherent to their medication have a higher risk of violence, either against others or self-directed (e.g., suicidal behavior) [31]. Overall, however, persons with serious mental illness and other psychiatric disorders are not more violent than individuals without psychiatric conditions. Importantly, mass shootings committed during episodes of serious mental illness are rare [9].

Despite this, mass shootings that capture media attention are often followed by depictions of the perpetrator as mentally ill and by calls for improved mental health care [32]. For example, following the 1999 Columbine and the 2012 Newtown school massacres came high-profile warnings—some by psychiatrists—that half of mass shooters/murderers were experiencing serious mental illness, mostly schizophrenia, and their treatment would have prevented such incidents [19]. The criminology literature contributes to these misperceptions by recycling obsolete and incorrect statistics on mass shooters/murderers [20].

Since 1950, the public perception of persons with mental illness as violent or frightening have increased; persons with serious mental illness are more feared today than they were half a century ago [9,33]. In a 2013 Gallup poll designed to assess public perception of factors associated with mass shootings, 80% of respondents attributed a "great deal" (48%) or "fair amount" (32%) of blameto the failure of the mental health system to identify individuals who are a danger to others [34]. This opinion, often echoed by researchers, may appear supported by evidence that many mass shooters had received a psychiatric diagnosis at some point [25,28]. However, these assertions of causality or heightened risk are overwhelmingly discredited by evidence that persons with serious mental illness commit less than 3% of all violence. Most of this violence does not involve guns. The relationship between psychiatric disorders and violence in any form is minimal when substance abuse is absent, and suicide—not homicide—is the most significant public health concern with mental illness and guns [9,35,36].

Although mass shooters with active serious mental illness are rare, they do occur. In 2009, a 41-year-old man killed 13 people and wounded another 4 in Binghamton, New York. In the two weeks before the incident, the man's father reported that his son had stopped eating dinner and became withdrawn. A local news station received a letter from the offender, mailed the day of the shootings, that reflected chronic paranoid, persecutory delusions with the shooter describing resentment over his perceived persecution by "undercover cops" who destroyed his chances of assimilating and working in the United States. The case material suggested active psychosis and severe depression [9,29].

Substance Use Disorders

Mass shooters seldom use substances, probably to avoid impairing effects on planning, preparation, and maximizing the casualty rate. The exceptions were two cases in which therapeutic amounts of sedating drugs were ingested [37].

In contrast, other violence commonly involves substance use, especially alcohol. With intimate partner homicide, the victim, perpetrator, or both are often intoxicated [37]. Alcohol and drug use increase the risk of violent crime as much as seven-fold, even in persons without a history of mental illness [38]. This is especially concerning in states with laws that allow persons to bring loaded handguns into bars and nightclubs. A history of childhood abuse, binge drinking, and male sex are predictive factors for serious (but not mass) violence [19,39].

Limitations of the Standard Diagnostic Systems

Limitations of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) have interfered with efforts to identify the psychopathology of mass shooters [40]. The DSM-5 uses a categorical diagnostic system, whereby personality and other psychiatric disorders are determined as present or absent, based on whether the number of diagnostic criteria meets the diagnostic threshold [41]. Dimensionality is a truer measure of personality pathology, because personality traits fall on a spectrum of trait dimensions that may be present in differing degrees. Destructive narcissistic or paranoid traits may be present in an individual, but when the number of symptom criteria are insufficient to meet DSM-5 diagnostic criteria, important dimensional aspects of the psychopathology are missed [24].

Extremes of character and temperamental traits do not fit easily into the categorical diagnostic system of the DSM-5 and can require more complicated formulations and assessments. The DSM has also contributed to checklist-style psychiatric examinations that may blur important diagnostic distinctions [41].

The DSM-5 classifies psychiatric disorders by symptom-based criteria and not by underlying cause. This modern DSM system increases diagnostic reliability, but some argue at the expense of validity. This is most relevant in pathologic personality traits; the dimensional aspects of mental structure and functioning and pathologic disturbances in cognition, ideation, fantasy, affect, psychologic defenses, object relating, moral functioning, and impulse control are better understood and evaluated using psychodynamic concepts [40].

Media and behavioral health specialists commonly (but usually erroneously) ascribe mass shootings and terrorist attacks to delusional, psychotic beliefs [42]. The DSM-5 classification of psychotic disorders invites interpretation of rigid but non-delusional beliefs as psychotic-spectrum conditions [41].

An extreme overvalued belief is a core concept in understanding ideologic violence and mass shootings. Extreme overvalued beliefs are rigidly held, non-delusional beliefs shared by one's subgroup. The belief is often defended, becoming more dominant, refined, and resistant to challenge over time. The individual develops an intense emotional commitment to the belief and may act violently in its service—justified by a sense of moral superiority [42].

Extreme overvalued beliefs are not psychotic delusions, which are defined as fixed, false idiosyncratic beliefs not shared by others. Extreme overvalued beliefs also are not obsessional beliefs, recognized by an individual as their own but resisted due to the intrusive unpleasant nature. The DSM-5 adds confusion by describing overvalued ideas as not shared by others in one's subcultural group, which is often not the case [42].

The 9/11 terrorists, Unabomber Ted Kaczynski, the Oklahoma City bomber, and perpetrators of Islamist and antiabortionist violence all possessed extreme overvalued beliefs that promoted a view of their moral superiority that justified violence [41]. During the criminal responsibility evaluations of Anders Breivik (the Norwegian mass shooter responsible for the deaths of 77 people), the initial team of psychiatrists erroneously concluded his beliefs reflected paranoid schizophrenia. A second team correctly defined his bizarre, extreme beliefs as extreme overvalued beliefs shared by other right-wing extremist groups in Norway [42].

One subgroup with shared extreme overvalued beliefs are "sovereign citizens." Believing the U.S. government is illegitimate, they wage war against it and those in authority through harassment, refusal to pay taxes, intimidation, and occasionally violence. When challenged, sovereign citizens espouse idiosyncratic legal theories and political beliefs that may appear delusional but are shared by these adherents and are best understood as an extremist political philosophy and not as a psychotic belief system [41].

Psychopathology Associated with Mass Shooters

As discussed, psychiatric disorders alone do not cause individuals to commit mass shootings. But psychiatric symptoms may exacerbate other problems, making it more difficult to deal with family, work or school problems, peer relationships, or personal crises [43]. Mass shooters may report their acts of violence were precipitated by anger over blocked goal achievement (e.g., being expelled from school or fired from work) or negative social interactions (e.g., peer bullying, rejection, humiliation) [43]. The disproportionality and perceived basis of their rage and vengeance is not adequately explained by psychologic conditions (e.g., depression, psychosis, antisocial personality) or social experiences (e.g., being bullied) [44,45].

Instead, this requires contribution from other conditions. With narcissism, psychopathy, or paranoia present, one's perspective and interpretation of the world readily distorts, which promotes irrational and exaggerated perceptions of one's victimization and persecution, ultimately leading to the targeting of those perceived to represent their persecutors [25,43]. The interaction of paranoid ideation and narcissistic pathology captures the psychopathology of mass shooters.

Paranoia

Paranoia begins as a profound disturbance in the sense of trust—a sense of self under attack. This develops from an intense insecurity related to some deep sense of inferiority. The intensity of this perceived insecurity and constant intrusion into awareness generates anxiety. Convinced the defect is perceived by others and cannot be disguised, chronic feelings of shame and humiliation develop [45]. A belief one is special enough to be singled out for persecution reflects the narcissistic dimensions of paranoia [46].

Individuals with paranoia are hypersensitive to perceived slights. Obsessed with revenge, they justify the revenge as "payback" for a perceived injustice. They often react disproportionately to perceived slights, and their "mistreatment" by others may not have been extreme or unusual. Eric Harris (one of the Columbine killers) left a diary describing a hatred of his bullying, persecutory peers; this was unsubstantiated after extensive interviewing of Columbine students [47]. The final writings of Virginia Tech shooter Seung-Hui Cho portrayed other students (whom he barely knew) as having "raped my soul" and having "crucified" him [46].

Rejection or "disrespect" is perceived as showing others are on attack, consider them inferior, or expect them to submit to external control. Paranoid persons become obsessed with social rank and status in social settings and despise weakness. Self-justifying and entitled, they view their behavior as necessitated by their unique plight caused by the ill will of others [45].

The nature of paranoia self-exacerbates, because the paranoid individual withdraws and his or her thought processes are not amenable to corrective feedback. The individual ruminates angrily on his or her humiliation by others. This becomes magnified with isolation, explaining the build-up of rage and planned annihilation and how the personality pathology of mass shooters devolves over time [45,48].

The obsession with rejection or "disrespect" that progresses into rage and planned annihilation usually stems from paranoid thinking and not psychopathy [49]. Purely psychopathic individuals do not form or desire to form emotional bonds, are unlikely to obsess about rejection by others, and are likely to dismiss the others out of hand. While Harris and some other mass shooters possessed prominent psychopathic traits, their psychopathy was not the main driver of murderous vengeance over perceived social rejection [45].

Studies of mass murderers describe paranoid conditions as pervasive, falling on a spectrum from traits to delusion. Paranoid themes seldom rise to the level of psychosis in these offenders, but virtually all share common themes of preoccupation with feelings of social persecution, alienation, and/or perceived injustice; severe envy; and fantasies of revenge against their perceived tormentors for the cumulative perceived maltreatment [9,24,50]. It is important to remember that feeling persecuted and being persecuted are not the same thing [45].

Narcissistic Pathology

Narcissism is a dimensional personality trait that, in more pronounced cases, involves an inflated and grandiose regard of self, extremely low regard of others, and inability to experience empathy, concern, or compassion for others' suffering [51]. With a grandiose and unstable sense of self, hypersensitivity to ego threats results in retaliatory aggression and violence to perceived social rejection and insult [52]. In pathologic narcissism, destructive rage is an externalized defense reaction against intolerable feelings of shame or powerlessness and aversive self-awareness of defect [23].

Narcissistic injury occurs when the pathologic narcissist perceives a threat to their self-esteem that reveals to others their hidden, "true" defective self [44]. Narcissistic injury can provoke narcissistic rage, an ego preservation response that serves to restore a sense of safety and power by destroying a threat, to satisfy the need for revenge, and to right a wrong by inflicting pain on another [13,53]. When present with paranoid traits, the interaction can produce a severe reaction with excessive retaliation and disproportionate transfer of pain to perceived persecutors believed to be the only resolution [23,24].

The interaction of paranoid cognition with narcissistic traits over time increases the propensity for targeted violence. This is most evident in the diaries or "manifestos" of mass shooters discovered post-event. A central theme is feeling rejected, dismissed, disrespected, and devalued by an "in-group" and of wanting vengeance for this mistreatment. The in-group is despised for being "superficial" and for their undeserved status. The "rejecting" peer group becomes an obsession; the shooter cannot let go and move on [45].

Malignant narcissism, a syndrome with core components of pathologic narcissism, antisocial features, paranoid traits, and unconstrained aggression, may also be present. Malignant narcissism is psychoanalytically described as a level of personality fracture or disorganization—a disturbance of object relations—whereby a profoundly fragile sense of self is compensated by antisocial grandiosity ("I am above the rules") and preoccupation with mistreatment and disrespect by others [52,53].

Autism Spectrum Disorder

The role of autism spectrum disorder (ASD) in mass shooters is controversial but significant and only recently identified [54]. ASD encompasses the neurodevelopmental disorders previously termed autism and Asperger syndrome. The range of potential symptoms and severities makes ASD a spectrum disorder [55].

ASD is not a mental illness or personality disorder in the usual sense, but is considered an impairment of early brain development leading to personal, social, academic, or occupational difficulties [55]. ASD is usually identified in early childhood by pervasive deficits in social communication and interactions, restricted and repetitive patterns of behavior or activities, and intense but non-bizarre special interests [54].

Marked social impairment and anxiety, lack of empathy, highly rigid thought processes, and very literal interpretation of written and verbal material typify ASD [43]. Persons with ASD can have good technical skills and may be drawn to computers, which are logical and syntax-guided, unlike social interactions, which are guided by semantics and can be confusing and anxiety-provoking [56].

ASD is differentiated from other disorders that may present with social-interaction abnormalities and restricted interests. Unlike schizoid personality disorder, persons with ASD often have a desire to make friends or have intimate relationships, but profound social-skills deficits make them unable to appropriately engage, empathize with, or respond to others. Unlike schizotypal personality disorder, social-interaction impairments in ASD are rooted in empathic and perspective-taking deficits [57].

Core problems faced by individuals with ASD include impairments in interpersonal reciprocity and understanding the effects of their actions on others [54]. Common comorbidities of anxiety, mood, and personality disorders or attention-deficit/hyperactivity disorder (ADHD) may intensify impaired coping ability. Early comorbidity may further impair later social adjustment in youths with ASD, highlighting the importance of early diagnosis and treatment [43].

ASD alone does not increase the risk for mass violence; this requires the presence of additional factors that interact with ASD features, such as deficits in social cognition and empathy, emotion-regulation deficits, and intense restricted interests [57,58]. History of childhood neglect or abuse correlate with later criminal behavior. Comorbid psychopathy with ASD is rare but potentially very serious and a significant violence risk and threat assessment issue. At first assessment, it may be difficult to distinguish between the two because lack of empathy is characteristic of both disorders, but the underlying reasons differ [54,57,59,60]. An increased intensity of preoccupations with disturbing or violent content is a possible warning sign [43].

Research suggesting ASD may be over-represented in mass shooters was investigated using the Mother Jones database of mass shootings (as noted, defined as at least four deaths in a single event). Evidence of ASD was evaluated in 75 cases, and 8% of perpetrators had a pre-event ASD diagnosis; this increased to 9% after adding Elliot Rodger, the Santa Barbara mass shooter [43]. An additional 21% of the cases had ASD traits or symptoms [43].

CULTURAL INFLUENCES

Mass shooting incidents have increased since the 2000s. With mental disorders alone negligibly related to mass shooting and not useful for predicting violent acts, researchers have looked to other explanations in the culture.

Culture of Celebrity, Narcissism, and Perverse Incentive

Since the 1990s, mass murders have not just increased, but have arguably taken on a different quality, especially mass shootings. With an American culture that promotes an influential value system centered on celebrity and fame, narcissism has been described as the classic American pathology. An upswing in the narcissistic values of American culture since the 1990s has also been documented [61,62,63].

Some critics have suggested that media attention makes mass killers into celebrities. A comparison of media coverage given to celebrities versus seven perpetrators of mass killings during 2013–2017 found the murderers received roughly $75 million in media coverage value. Some received more high-value coverage during their attack months than some of the most famous American celebrities, and media coverage exceeded the public interest, as reflected in online searches and Twitter use [64].

Contagion, Copycat, and Columbine as Cultural Script

The idea of a "cultural script" has also been examined. A "cultural script" describes a schema, or a prescription, for behavior. Media and sociocultural factors have propagated a "script" of mass shootings that points to armed attack as a model for problem-solving—a "masculine" solution to lessen an inferior social position, especially for altering the shooter's reputation from a socially marginalized loser to a notorious antihero [27,50]. Media attention to mass murder may perversely glamorize the act in the eyes of subsequent perpetrators; the instant notoriety feeds narcissistic pathology [9,65].

Social media is an important contributing factor to this disturbing finding, given the appeal of fame, or rather infamy, without achievement other than successfully killing innocents [66]. Performative violence, a related concept, describes the construction of identity or position through a violent act that, by demanding audience attention and compelling the audience to look intently at the perpetrator and his or her act, fulfills perpetrator needs for recognition and acknowledgement of their existence and uniqueness [67].

Contagion and copycat effects are related but distinct. Contagion is imitation of the violent act, an effect active over days or weeks. Copycat is identification with the actor, an effect that may remain active for months or even years. Copycats can aggregate over time to become a cultural script [50]. School shooters are more likely than other types of mass murderers to commit copycat violence for achieving notoriety [28].

Perpetrators and plotters looked to past attacks for inspiration and operational details to cause even greater damage [68,69]. The FBI examined 160 mass shootings committed after Columbine and found a copycat effect that was stronger and more pervasive than previously understood.

The 1999 Columbine shooting was a landmark event; the planning of this mass shooting was driven by rage and narcissistic desire for immortality. The perpetrators, Eric Harris and Dylan Klebold, uploaded videos of themselves firing guns, yelling into the camera about killing hundreds and starting a "revolution," and other content fantasizing about Hollywood directors fighting over their story. At the dawn of the Internet era, the Columbine offenders created a script for mass shooting [68,69].

Mother Jones analyzed 74 plots and attacks by perpetrators claiming inspiration by Columbine. Of these, 53 plots were thwarted and 21 were completed and resulted in the deaths of 89 victims and injury of 126. Of these [68,69]:

- The suspects often planned the attack on the anniversary of Columbine (≥14 cases).

- The goal was to outdo the Columbine body count (13 cases).

- The suspects referred to Harris/Klebold as heroes, idols, martyrs, or God (at least 10 cases).

- At least three suspects made pilgrimages to Columbine High School, two of which carried out rampages after returning home.

The "Columbine effect" describes this cultural script of aggregated copycats; mass shootings are ritualized and self-referential, with perpetrators identifying with past shooters. This expands beyond the Columbine legacy, with mass shooters citing many others before them. The Internet has propagated this script by increasing the ease by which perpetrators can study and idolize previous mass killers [27].

A universal reporting code has been recommended for appropriately covering these incidents and reducing "copycat" effects. This media guidance suggests avoiding emphasis on perpetrators and neither glorifying nor demonizing them, and emphasizing victim and community recovery efforts [9,70].

Violent Video Game Consumption

The consumption of violent media, in particular violent first-person shooter video games, has been suggested as a factor contributing to a likelihood of committing violent acts. The shoot-to-kill style of first-person shooter games is considered highly arousing and violent.

This theory can be traced back to Columbine shooters Harris and Klebold, whose writings indicated they had used the video game Doom to prepare for their attack. Similarly, Anders Breivik claimed to have used the video game Modern Warfare 2 during his preparation phase [71]. There is some evidence that exposure to media violence is a risk factor for aggressive behavior in youth, including violent criminal behavior [72]. However, other studies have found no link between video game violence and aggressive behaviors or reduced empathy in youth [73]. There is even less evidence of effects on adults, including adults with ASD [74].

It is important to note that most video game players do not commit violence, and most mass shooters have no documented history of violent media consumption. It has been suggested that player motivations, frustration, and the social context of play may influence the possible risks associated with violent video games [75].

Hegemonic Masculinity

It is important to note that masculinity, like all expressions of gender, is fluid, and each culture may have many types of masculinity available [252]. Hegemonic ("toxic") masculinity has not been clinically defined, but it is generally understood to mean "a set of values, established by men in power, that functions to include and exclude, and to organize society in gender unequal ways. It combines several features: a hierarchy of masculinities, differential access among men to power (over women and other men), and the interplay between men's identity, men's ideals, interactions, power, and patriarchy" [252]. This conceptualization of masculinity, based on the idea that men are inherently more powerful than women and some other men, is common in alt-right and far-right ideologies.

4. MASS SHOOTERS: PATHS TO VIOLENCE

Mass shootings are followed by a collective frustration, even anguish, over the inability to stop these incidents from recurring. Evidence from research on suicide and violence prediction and prevention can help explain why standard methods fail in thwarting mass shooters.

Suicide reduction has long relied on suicide prediction using risk factors to place patient suicide potential as low, moderate, or high. However, this approach fails to consider the fluidity of proximal factors that drive acute suicide behaviors. Today, experts believe suicide cannot be predicted but can be prevented, and this paradigm shift has transformed suicide prevention efforts [76].

Predicting future violence is likewise difficult. Predictive methods of assessing violent antisocial behavior rely on risk assessment, whereby risk factors are measured and used to statistically predict future violence. To examine the value of risk assessment, 409 patients detained for violent criminal behavior were evaluated and followed 12 months after discharge to the community. Risk assessment had little value in predicting future violence and could not identify essential risk factors that should be targeted to prevent violence [77].

Thus, predictive methods fail to identify future violence in mass shooters because predictor risk variables (e.g., criminal history, psychiatric diagnosis, drug history) are static factors that are causally and temporally unrelated to violence [77]. Standard prediction and profiling methods cannot identify individuals posing a high, increasing, or imminent threat. Profiling is helpful in identifying perpetrators who have already acted violently, such as serial murderers, but is not useful with future mass shooters [66,78].

Evidence Based Practice Recommendation

The National Collaborating Centre for Mental Health recommends using a multidisciplinary approach that reflects the care setting when assessing and managing the risk of violence and aggression. Take into account previous violent or aggressive episodes, because these are associated with an increased risk of future violence and aggression.

https://www.nice.org.uk/guidance/ng10

Last Accessed: March 19, 2019

Level of Evidence: Expert Opinion/Consensus Statement

One approach, based on the concept that targeted violence is distinct from affective violence, is already showing promise in interrupting mass shooters before they act [69,78,79,80,81,82]. Targeted violence (also referred to as instrumental or predatory violence) is methodically planned against individuals, groups, or locations. Affective violence (also referred to as impulsive or emotional violence) is emotionally charged, impulsive, and reactive and typifies intimate partner violence (IPV). While affective violence is the most common subtype of violence, it does not accurately describe mass shootings. Mass shootings are considered an example of targeted violence, the endpoint of an understandable process of thinking and behavior that is neither spontaneous nor impulsive. Potential offenders on a pathway to targeted violence can be identified and prevented, but not usually predicted.

Two models have been developed and applied to describe, identify, and impede those on a pathway to acts of targeted violence. The Pathway to Violence Model was developed by the U.S. Secret Service from studying assassins and school shooters [78]. It describes a progression from grievance to violent attack and helps differentiate individuals who threaten and menace a target from those truly intent on committing violence. This model describes the underlying interaction of emotional and psychosocial factors [83,84].

The Warning Behaviors Model uses pattern recognition of dynamic variables proximally related to violence that reveal pre-attack behaviors and violent intent. Unlike static risk factors, dynamic proximal factors are the best short-term indicators of targeted violence, because they point to intra-individual behavioral, cognitive, and emotional processes that signify decreasing, increasing, or imminent threat [40,82,85].

The Warning Behaviors Model captures superordinate behavioral and psychologic patterns that may represent changing or accelerating risk. This model is used extensively in targeted violence of school shooters and other public mass shooters, including violent extremists [40,79,80,81,85,86].

Both models are complementary and overlapping, because state of mind and outward behaviors are inextricably intertwined. Understanding the pathways to targeted violence of mass shooters facilitates their disruption and prevention [26,78,79,80,81]. As discussed, prevention does not require prediction.

THE PATHWAY TO VIOLENCE MODEL

The Pathway to Violence Model does not suggest that all, or even many, people with a grievance will move to violent action [87]. However, the FBI states that among threat-management models, Pathway to Violence is best-suited to address the question of why persons perpetrate targeted violence [26].

Stages of the Pathway to Violence Model

Grievance

The first stage of the Pathway to Violence Model is a perceived injustice, threat, or loss of a highly personal significance. In this context, grievance refers to the cause of the offender's distress or resentment—a perception of having been wronged or treated unfairly or inappropriately. More than a feeling of anger, grievance can result in a desire, even a sense of mission, to right the wrong and achieve a measure of deserved justice. Grievance is more than a feeling of discontent or a short-lived, even explosive, expression of anger or frustration; it is a conclusion reached about the reason for the offender's suffering. A grievance is external to the offender, and by externalizing blame, the offender creates a target for retribution. The grievance becomes an organizing principle as the offender seeks to address the unjust treatment causing the anguish [87].

The grievance is exacerbated by a robust narcissism laced with an inflated sense of entitlement, privilege, or ability that, when perceived as unrecognized or insulted by others, results in an intolerable state, whereby the only compensatory relief to their sense of humiliation comes from rage and violent fantasy (i.e., ideation) [78]. However, few who are aggrieved progress to committing targeted violence.

Ideation

Those who become violent move from grievance to ideation as they realize violence is the appropriate means to address their grievance and make a conscious choice to violently harm others [83,87].

Unable to find satisfaction or repair outside of violent fantasy, a "pseudocommando" warrior mentality may consume their thinking while simultaneously inflaming their narcissistic grandiosity. Revenge fantasies become inflexible and persistent because they provide desperately needed nourishment to injured self-esteem. A sense of (pseudo) power and control is gained by ruminating on vengeance [29]. Subjects often begin a fascination with previous attacks and attackers during the ideation stage, underscoring the notoriety and attention that often accompanies high-profile targeted violence [88].

Many persons who harbor profound grievances and violent revenge fantasies do not progress to violence and withdraw into an omnipotent fantasy of violent retribution [24]. Others become so enthralled by violent ideation and psychologically consumed by the compensatory relief it affords their fractured ego that they lose the desire or ability to pursue nonviolent means of resolution [78].

Research and Planning

Eventually, fantasy may escalate beyond ideation into action; research and planning bridges the gap between idea and action. During this stage, the offender takes concrete steps toward an attack and dedicates effort and energy toward the goal, which can include selecting and gathering information on the target, stalking the target, photographing targeted areas (e.g., classrooms, hallways, theaters), and charting out areas for explosive devices. Other behaviors can include Internet searches and conversing with likeminded others on social media or online [26,78].

Preparation

During the preparation stage, the individual is accumulating the necessary weapon(s), ammunition, clothing, or other practical materials needed for an attack; the offender is also becoming psychologically prepared [78]. Other behaviors can include assembling equipment, confirming transportation routes, and/or attack rehearsal [26]. Kimveer Gill played a video game that re-enacted Columbine (considered a rehearsal) before killing one person and injuring 19 at Dawson College in Montreal in 2006 [45].

Breach

The offender assesses the level of security and barriers that must be defeated to gain close physical proximity to the target in the breach stage. Without normal access to a targeted facility, the offender may breach by conducting a "dry run" penetration test, intruding into a facility where he or she does not have legitimate access to identify security countermeasures. Breaching can also involve the smuggling of weapons into a classroom or theater, and then waiting to attack, or dressing as a security guard or package delivery person for a non-forcible entry [78,89].

Attack

The final stage is the attack. The offender launches a destructive, nihilistic assault, attempting to completely dominate the targeted institution or person. The attack typically represents the manifestation of two desired states [78,90]:

- Perceived infamy and notoriety from the inevitable media coverage

- A sense of omnipotent—but transient—control

The offender's depleted narcissism fuels an overwhelming desire for omnipotent control over the target. The offender may realize the attack will result in his or her arrest or death, but the fleeting experience of control is perceived as transformative [78,90].

The Pathway to Violence Model in Research

The initial Pathway to Violence stages have been applied to analysis of the progression of paranoid cognitions observed in mass murderers. Threat perception occurs when perceived personal inadequacy interacts with real or imagined perception of threat and expectations of persecution. Threats typically involve some form of social or peer rejection (i.e., a grievance). Whether delusional or not, this perception triggers feelings of humiliation and anger, if not hatred, contempt and disgust for the perceived persecutors [24].

Manifestos and other written communications of mass shooters show recurrent themes of persecution, alienation, envy, and vengefulness. These were identified by psycholinguistic analysis of pre-attack communications from 12 mass shooters (Table 1) [28,46].

Table 1: THEMES IN PRE-ATTACK COMMUNICATIONS OF 12 MASS SHOOTERS

Theme

Description

Nihilism

An extreme form of self-centeredness

An utterly intolerable narcissistic injury becomes nihilistic—nothing matters, everything is meaningless

Ego survival and revenge

The seeking of vengeance as a way of broadcasting one's pain

Heroic revenge fantasy

The conviction that, by performing an act of violence, an individual will be freed from persecution

Pseudocommando mindset

A cognitive perspective incorporating innate distrust and a persecutory worldview, creating a combination of narcissism and paranoia with persecution, envy, and obliteration

Entitlement

A dimension of destructive narcissism with extreme lack of empathy, whereby the individual feels he or she has a right to what others have and is thus justified in engendering harm

Envy

An aspect of pathologic narcissism whereby the individual not only wants what others have, but is willing to destroy their enjoyment of the coveted thing or the state of this enjoyment

Source: [28,29,46,86]

THE WARNING BEHAVIORS MODEL

The Warning Behaviors Model has two components: proximal warning behaviors and distal characteristics. Some proximal and distal items reflect the original development for use in terrorism, but the model has been applied to all forms of mass violence.

Proximal Warning Behaviors

Pathway Behavior

Any behavior described in the Pathway to Violence Model is defined in the Warning Behaviors Model as a pathway behavior, including research, planning, preparation, or implementation of a targeted attack [83].

Sirhan Sirhan assassinated Senator Robert F. Kennedy on June 5, 1968, the first anniversary of the Six-Day War. Sirhan was not Muslim but identified closely with the Palestinians and saw Kennedy's vote to sell 50 combat jets to Israel in January 1968 as a betrayal of his people. In the five months leading to the attack, Sirhan secured a handgun, practiced at a shooting range, and made at least four approaches to Kennedy in public venues before shooting him in the pantry at the Ambassador Hotel in Los Angeles, California. This assassination began the U.S. Secret Service's practice of protecting aspiring presidential candidates [79]. Each of the actions he took would be categorized as a pathway behavior.

Fixation

Fixation is defined as an extreme preoccupation with another person, activity, or idea, often involving a grievance and a personal cause. With increasingly pathologic preoccupation comes social and occupational deterioration. Fixation is observed by increasing perseveration on persons or cause; increasingly strident opinion, negative characterization of the object of fixation, and angry emotional undertone; and impact on family or associates of the object of fixation, if present and aware [50].

In 2007, during his psychiatric residency, Nidal Hasan, the 2009 Fort Hood, Texas, mass killer, gave a psychiatric presentation titled, "The Koranic World View as it relates to Muslims in the Military." Note the disconnect between topic and context of the lecture in some of these quotes [79]:

- "We love death more than you love life!"

- "Fighting to establish an Islamic state to please God, even by force, is condoned by Islam."

- "Muslim soldiers should not serve in any capacity that renders them at risk to hurt/kill believers unjustly."

Hasan became increasingly vocal in his opposition to the Afghanistan and Iraq wars and gave a subsequent psychiatric presentation titled, "Why the War on Terror is a War on Islam." In late 2008, Hasan sent 18 emails to Anwar al-Awlaki in Yemen asking whether killing American soldiers and officers was religiously legitimate. His fixation was a cause, but it became deeply personal because his grievance against the wars in the Middle East went unheeded [79].

Identification

Mass shooters often have behavior demonstrating a warrior mentality or psychologic desire to be a pseudocommando. These individuals identify with military or law enforcement weapons, uniforms, or paraphernalia, or with previous attackers. They may self-proclaim as agents to advance a cause or belief system [79].

Fixation is what one constantly thinks about, and identification is what one becomes. Fixation and identification are key warning behaviors; the evolution from preoccupation to self-identity distinguishes (with a large effect size) attackers from persons of concern without violent intent [50].

An example of this type of behavior is Anders Breivik, who in 2011 bombed several Norwegian government buildings (killing 8 people) and hours later shot and killed 69 young people. Breivik identified himself as a reincarnated Knights Templar, the militant spear of the 12th-century Christian Crusades against the Muslims, and saw himself as a soldier fighting to free his people from Muslim immigrants and multiculturalism. In photos, Breivik wore homemade uniforms emblematic of his identification. He developed an affinity for American terrorists Ted Kaczynski (and plagiarized his writings) and Timothy McVeigh, writing that McVeigh probably felt as he did when making his bombs [79].

As noted, school shooters recurrently identify with the Columbine perpetrators. This is exemplified by the assailant who killed 10 victims and injured at least another 10 at his high school in Santa Fe, Texas, in 2018. On the day of the attack, he wore a black trench coat in 90-degree weather [91].

Novel Aggression

Novel aggression is an act of violence that appears unrelated to any pathway behavior and is committed for the first time. This behavior tests the perpetrator's ability to become violent and can be thought of as experimental aggression [37].

Energy Burst

Mass shooters often display an increase in frequency, duration, or variety of warning behaviors related to a target, even if the behaviors appear innocuous, in the days or weeks before an attack [37]. For example, Jared Loughner, in the 12 hours before his attack on U.S. Representative Gabrielle Giffords and bystanders in a supermarket in 2011, engaged in the following, according to police reports [79]:

Drops off 35-mm film at Walgreen's before midnight, checks into motel shortly after midnight…searches web for 'assassins' and 'lethal injection'…at 02:19 picks up photos, makes a purchase, leaves telephone message with friend…at 04:12 posts to Myspace page a photo of his Glock pistol and the words 'Goodbye friends.'

At 06:00, visits Walmart and Circle K stores, unable to purchase ammunition at first Walmart, purchases 9-mm full metal jacket ammo and diaper bag at 07:27…stopped by police officer for running a red light…went home but was confronted by father, runs away...returns to Circle K, gets a cab, goes to supermarket where he insists on getting correct change for cab ride to the shopping center where Congresswoman Giffords was speaking…16 minutes later at 10:10, opens fire, killing 6 and wounding 13 people. Tackled by three senior citizens when he attempts to reload.

Leakage

Leakage is defined as intentions or plans of violence expressed to another person or posted on the Internet that raise concern. Leakage may be overt (e.g., ''I'm going to kill my supervisor and his cohorts tomorrow.") or covert (e.g., ''Don't come to work tomorrow, but watch the news.'') [37].

This warning behavior is one of the strongest warning signs an individual intends to commit targeted violence [40]. Leakage is nearly ubiquitous across all targeted violence offender groups, including juvenile and adult mass murderers, attackers of public figures, school shooters, and lone actor terrorists. Grievance is strongly correlated with leakage, but no single mass shooter "profile" is more likely than others to leak intent [87]. Threat assessment professionals should not expect leakage based on a subject type (e.g., young, with criminal history) and be reassured by its absence, or be surprised by its presence with a subject type (e.g., well-educated professional, no criminal record) and discount its potential significance [87].

Would-be offenders frequently express threats or intentions to others verbally or in writing, posting a manifesto or on online fora. In most school shootings, at least one person knew about the killers' intentions [28,40,92,93].

Leakage before a planned attack was acknowledged by Tucson offender Loughner in his writings: "Of course, I kept a journal. Don't people like me always keep a journal? It's part of the whole thing. It was me against the world" [28].

On December 20, 2010—19 days before the attack—Loughner wrote on his MySpace page: ''I HAVE THIS HUGE GOAL AT THE END OF MY LIFE: 165 rounds fired in a minute!'' A week earlier, Loughner wrote: ''I'll see you on National TV! This is a foreshadow…why doesn't anyone talk to me?'' [37].

Numerous mass shootings have been prevented because people reported hearing or observing oral or written threats of violence [69,94]. In 57 cases of thwarted attacks, manifestos were frequently posted online by the would-be offenders who made highly credible threats [94].

In many other cases, persons aware of the threatened mass violence did not alert anyone in authority. By reporting such advance communications, individuals can help prevent planned acts of mass violence. To encourage adolescents to speak out, many school administrators have provided anonymous avenues for students to make reports without fear of repercussion. The U.S. Department of Homeland Security implemented the "If You See Something, Say Something" campaign as a nationwide means of encouraging citizen reporting and community safety [28,86,95,96,250].

Many health and mental health professionals are governed by a duty to warn if they are aware that a patient may be a risk to others. This applies to cases of mass shooters just as it does in cases of intimate partner or family violence.

Directly Communicated Threat

Some perpetrators will make an unambiguously stated or written threat to either a target or to law enforcement expressing intent to commit violence. For decades, law enforcement academies taught that explicit threats were a precursor to violence [66]. This is valid in the context of a current or past sexual intimate; in these cases, directly communicated threats indicate heightened risk of violence against the target, referred to as the "intimacy effect." However, in targeted violence, this is disproven, and directly communicated threats are rare.

Last Resort

Last resorts are communications or actions indicating a "violent-action imperative" or time imperative and increasing desperation or distress, forcing the subject into a position of last resort. No alternative to violence is perceived, and the individual believes the consequences are justified; the subject feels trapped [79,85].

Days after white supremacist Dylann Roof perpetrated his mass murder in a South Carolina church in 2015, his website and manifesto were discovered. These writings provide a good example of last resort thinking. Roof had written [79]:

I have no choice. I am not in the position to, alone, go into the ghetto and fight. I chose Charleston because it is [the] most historic city in my state, and at one time had the highest ratio of blacks to Whites in the country. We have no skinheads, no real KKK [Ku Klux Klan], no one doing anything but talking on the Internet. Well, someone has to have the bravery to take it to the real world, and I guess that has to be me.

Evidence of Validity

The Terrorist Radicalization Assessment Protocol-18 (TRAP-18) combines the 8 proximal warning behaviors and 10 distal characteristics into a single assessment instrument for mental health providers, law enforcement, and intelligence/security professionals. Developed for threat assessment of violent extremists, use of TRAP-18 has expanded to all potential lone-actor perpetrators of targeted violence [81].

The validity of TRAP-18 was examined in 111 violent Islamist, right-wing, and single-issue extremist cases in 1990–2014 [81]. Researchers found that 70% demonstrated at least half of the 18 TRAP variables and more than 77% showed all four warning behaviors (i.e., pathway, fixation, identification, and leakage). Leakage (85%) was the most frequent proximal warning behavior. Less frequent proximal warning behaviors were directly communicated threat (22%), novel aggression (17%), and energy burst (8%). Few differences were observed among extremist ideology groups. The authors concluded the TRAP-18 appeared useful across the spectrum of ideologies that drive targeted violence [81].

A separate study examined 33 mass murderers in Germany from 2000–2010. An average of 6.11 warning behaviors were present in each perpetrator. The authors concluded a pattern of proximal warning behaviors can be expected to precede targeted mass murder [80,81].

An FBI analysis found the observable behaviors that are most suggestive of pre-attack planning of targeted mass violence include [26]:

- Novel or greatly increased interest in guns and/or explosives

- Recent, significant real or perceived personal loss or humiliation

- Surveillance behaviors

- Sudden changes in social media behavior

- Statements or farewell writings

Indicators of potential imminence include [26]:

- Energy burst, end-of-life planning, and/or last resort behavior

- Sudden cessation of medications or other substance use

- Sudden withdrawal from routine life pattern

Distal Characteristics of Targeted Violence

While proximal warning behaviors are signs of growing or imminent threat of targeted violence, distal characteristics are long-term psychodynamic and psychosocial factors that may be necessary but not sufficient for targeted violence [66]. The most frequently identified distal characteristics in the TRAP-18 validation study were framed by an ideology (100%), changes in thinking and emotion (88%), failure of sex-pair bonding (84%), and personal grievance and moral outrage (78%) [81].

Personal Grievance and Moral Outrage

Many perpetrators express a personal grievance (typically a major loss in love or work, with anger, humiliation, and blaming others) combined with moral outrage over historical or contemporaneous religious or political events. This characteristic largely overlaps with stage 1 in the Pathway to Violence Model [66].

Moral outrage can develop via vicarious identification with a victimized group when the offender has not personally experienced the victimized suffering. An example of this type of thinking is evidenced by Timothy McVeigh, the Oklahoma City bomber. He displayed superior intelligence, hypervigilant narcissist characteristics, and "ultimate warrior" identification. He was humiliated by rejection from the Special Forces (i.e., the grievance). He was also abandoned by his mother and distrusted women, with a sexualized interest in weapons. McVeigh saw himself as the first hero of a second American revolution. His research, planning, and preparation began following moral outrage over the Branch Davidian compound assault by the FBI and the ATF.

Framed by an Ideology

The presence of an ideology or belief system that justifies the intent to act is a common characteristic of mass shooters [66]. The intent to commit an act of mass violence is framed by an ideology or belief system. Violence is sanctioned by an external moral authority, but the ideology is often selectively evaluated for words and phrases that justify targeted violence. Morality becomes a simplistic choice between good and evil.

Ideologic violence is perpetrated against a perceived enemy to advance a specific belief system and frequently to purify in religious or racial extremism. Purification may not be the only goal for violence, but it is often central to the paranoid belief that one is surrounded by contaminants and toxins, including women as "temptresses." A consistent theme in the thinking of anti-abortion terrorists (e.g., James Kopp, Eric Rudolph, Robert Dear, Paul Hill) is female sexual promiscuity as the cause of desire for abortion [90].

Failure to Affiliate with an Extremist Group

Rejection by an extremist group the actor wants to join, due to either lifelong interpersonal problems or beliefs seen as too extreme by others in the group, is a distal characteristic of violent extremists. The rejection further isolates and may harden the belief system and violent intent. In one study, all 10 violent extremists (i.e., Timothy McVeigh, Joseph Franklin, John Salvi, Eric Rudolph, Buford Furrow, Ted Kaczynski, Benjamin Smith, Paul Hill, Michael Griffin, and Terry Nichols) attempted to affiliate with an extremist group, but their rejection led to further hardening of radical position and violent intent [66]. In the specific case of Paul Hill, he was a minister of a Presbyterian Church in Florida, but was excommunicated for his radicalization in the anti-abortion extremist movement. Three years after his excommunication, Hill shot and killed Paul Britton, MD, and his bodyguard James Barrett.

Dependence on Virtual Communities

In early studies of violent extremists, online support was noted to be greater than off-line contact with other extremists. However, this item is now believed to be obsolete, with online connectivity the norm for much of the population.

Thwarted Occupational Goals

Thwarted success is endemic for many young people. The distinction is that future offenders become disillusioned with the surrounding social order; resentful of narcissistic wounding from a history of slights, rejections, and failures; and find a target for their intense grievance and hatred [40].

Changes in Thinking and Emotion

Over time, the thoughts of mass shooters and their expression become more strident, simplistic, and absolute. Prior to a violent attack, argument, persuasion, and critical thinking ceases, and dogmatic preaching and imposition of one's beliefs on others begins. Beliefs become more rigid, simplistic, and absolute; a "moral authority" is embraced. Violence is cloaked in self-righteousness and the pretense of superior belief.

Fixation warning behavior may be apparent during these changes, but fixation relates to thought content, and this distal characteristic relates to changing interpersonal expression of that content. Expressiveness may suddenly diminish when the subject enters later stages of the pathway [66]. The individual may appear happier and/or more at peace after having made the decision to act.

Failure of Sexual Pair Bonding

The failure to form a sexually intimate relationship from puberty until the violent offense and death or incarceration is a common characteristic [81]. Incels (involuntary celibate men) are individuals who, having failed to find women they can talk or coerce into sex, radicalize their anger into calls of violence [97]. More than believing they are entitled to sex but unable to find a willing partner, their hatred of women stems from believing women are (or should feel) required to give them sex but purposefully withhold it. This distinction is crucial to understanding the disproportionality of rage against women [98]. Several mass shooters/murderers since 2015 have been identified as incels, including Elliot Rodger, Alek Minassian, Chris Harper-Mercer, and Scott Beierle.

In addition to the many school shooters mentioned, the 84% prevalence of failure of sex-pair bonding among 111 violent extremists is striking and may represent a sensitive indicator of distal risk [81]. None of the following perpetrators had any evidence of normal sexually intimate relationships: Anders Breivik, Eric Rudolph, Buford Furrow, Malik Hasan, Mohamed Atta, Marwan al-Shehhi, Ted Kaczynski, or Timothy McVeigh [40].

Mental Disorder

The presence of a mental disorder by history or at the time of the offense is common. However, with violence and mental illness, it is essential to address the behavior, not the diagnosis [26].

Greater Creativity and Innovation

Operating outside the structure of extremist groups may promote greater innovation [79,80,81]. One example of this characteristic is found in Bruce Ivins, a prominent anthrax researcher in the U.S. government. In the Fall of 2001, Ivins is believed to have killed 5 people and injured 17 in two waves of anthrax attacks. His motives included revenge, need for personal validation, career preservation, and professional redemption. Ivins was also obsessed with a sorority house, which he stalked. (Note: Ivins committed suicide before he could be charged or tried for these crimes, and the FBI's conclusions have ben contested since it concluded its investigation.)

History of Criminal Violence

A history of instrumental criminal violence before the act of targeted violence is considered a distal characteristic of mass violence perpetrators.

Warning Behaviors Model Case Illustration: Nikolas Cruz

In the case documents of Cruz, who perpetrated the 2018 Marjory Stoneman Douglas High School shooting in Parkland, Florida, pre-attack communications or manifestos are not mentioned, but observations by others are replete with distal risk characteristics and proximal warning behaviors of targeted violence [99].

Cruz was diagnosed with developmental delays at 3 years of age and, subsequently, with autism, depression, ADHD, and emotional behavioral disability. Obsessive-compulsive and anger issues were also noted. Over 10 years, the Broward Sheriff's Office responded to 23 calls by his mother for help when Cruz was violent.

In 8th grade, Cruz was placed in a school for students with emotional problems. In 10th grade, his grades were good, but he was fascinated by guns and death. Weeks after transferring to Marjory Stoneman Douglas High School to begin 11th grade, Cruz posted on social media that he planned to "shoot up" the school. He had become preoccupied with wars, death, and killing. Cruz had trouble making friends, and his peers saw him as peculiar and socially awkward.

Investigated after cutting his arms on social media, Cruz stated he planned on buying a gun. A month after quitting mental health treatment in January 2017, he assaulted a classmate and was expelled from the high school. Cruz purchased the AR-15 used in the massacre one year later. Later that year, he was reported to the FBI after stating he wanted to be a professional school shooter on a YouTube page.

In November 2017, Cruz went to live with neighbors after his mother died. Within weeks, the neighbors called the County Sheriff when kicking Cruz out for violent behavior, stating they feared him because he had eight guns he kept with a friend and that he had put a gun to the head of someone several times. The police received a call the next day that Cruz was collecting guns and knives and could be a "school shooter in the making."

Another family in Parkland took him in. In early January 2018, a caller told the FBI she wanted to get her fears about Cruz's potential for violence off her chest. Citing his social media statements and photos and seeing his behaviors with guns, "It's alarming to see these pictures, to know what he's capable of doing, and what could happen."

In the two weeks before the shooting, Cruz told the family he was living with that he was happier than he had ever been before. On February 14, 2018, Cruz arrived at Marjory Stoneman Douglas High with his AR-15 at 2:06 p.m., when school was letting out for the day, and killed 17 classmates and staff and injured another 17 before surrendering.

Discussion:What risk characteristics and proximal warning behaviors did Cruz exhibit?

Warning Behaviors in Practice

The Warning Behaviors Model is used by professionals trained in threat assessment and management to detect and disrupt targeted violence, as shown in the following case summaries [69,78,82].

The Threat Assessment and Management Unit of the Los Angeles Police Department (LAPD) described a firefighting recruit, enraged when dismissed from the academy, told another trainee, "When they fire me, I'm coming back here to f***ing massacre everyone." The trainee informed the academy, which alerted the LAPD, and a search warrant was obtained. Finding an explosive device and a dozen assault-style rifles and handguns, the impression was of "someone absolutely geared to go to war." The Threat Unit leader stated had there not been rapid intervention, an imminent mass shooting was certain.

Police in Keizer, Oregon, received a tip about high school junior from another student who the student had told he was angry at other students and was bringing a gun to school. The student of concern was interviewed and admitted being unhappy, but denied intent to harm others. Two months later, the student was admitted to a psychiatric facility for a suicide attempt. The school district's threat assessment and management team of psychologists, counselors, and police interviewed his friends, family, and teachers before the student's release from the facility and found additional warning signs in notebooks in which he raged about grievances toward a girl who rejected him and students he despised; he included both on a hit list. He had also attempted to buy a gun.

The threat assessment and management team determined the student lacked access to a gun and launched a "wraparound intervention" of counseling, in-home tutoring, and helping him pursue his interests in music and computers. Over the next 18 months, The student's outlook improved, the warning signs dissipated, he graduated high school, and his case was transferred to the county adult threat assessment and management team. A psychologist on the threat assessment and management team stated they largely helped redirect his focus onto his strengths while maintaining close but casual and supportive contact.

Use of threat assessment and management is demonstrably effective in preventing targeted mass violence. However, threat assessment and management remains largely unknown in mental health, law enforcement, education, and social service professional communities.

Psychiatrist Jerome Knoll, an expert in mass murderers and targeted violence, states that mass shootings will diminish only to the extent that society takes the following meaningful actions [24]:

- Third-party reporting of concerns or leaked intent

- Sensible nationwide gun control laws

- Media responsibility

When a person is believed to be on a path to violence, health and mental health professionals should act decisively. The American Psychological Association (APA) has identified several approaches to effective gun violence prevention at the individual and societal levels [251]. At the individual level, this involves addressing underlying issues that are triggering desperation, including referring the person to or providing mental health services and other sources of support. As discussed, psychiatric hospitalization may be needed to address despondence and suicidality. Nonpsychiatric resources can also help alleviate the individual's problems or concerns and include conflict resolution, credit counseling, job placement assistance, academic accommodations, veterans' services, pastoral counseling, and disability services [251]. At the macro, or societal, level, the APA recommends a comprehensive approach that engages the many stakeholders involved, including community and public safety officials, schools, workplaces, neighborhoods, mental health and public health systems, and faith-based groups, to develop laws, policies, and community outreach programs [251].

Warning Behaviors and Impulsivity

In some cases, perpetrators of targeted violence act impulsively in response to a triggering event of loss and humiliation. These precipitous attacks fail to include the often-considerable planning and preparations already carried out. Such cases are the exception, but point to the complexity and fluidity of factors and their interaction that move an individual from grievance to perpetration [100].

PATHWAY TO TARGETED VIOLENCE IN THE WORKPLACE

Mass shooters who target their current or former workplace largely resemble other targeted violence perpetrators. These offenders are almost always aggrieved or disgruntled employees or ex-employees whose explosion of murderous rage is the culmination of a perceived rejection, a felt injustice, and determination to seek revenge. They are typified by paranoid and/or narcissistic traits, blame others for their problems, and feel unjustly wronged. Strong persecutory themes reflect an amplified narcissistic injury [9,24].

The failed Atlanta day trader Mark Barton, who killed 12 people and injured 13 more in 1999, left a suicide note stating "I don't plan to live very much longer, just long enough to kill as many of the people that greedily sought my destruction" [9,24].

Perpetrators of targeted workplace homicide progress through the Pathway and Warning Behaviors stages [79,80]:

- Begins with a grievance, a thinking pattern that blames everyone else, and an angry, ashamed emotional state.

- The humiliating event (e.g., loss of status, perceived rejection at home or work) is delusional, reality-based or both.

- Vengeful thoughts develop into violent fantasies. Most individuals do not go further; their grievance and vengeful fantasies eventually resolve.

- Very few see violence as the only solution; a decision to act is captured by the acronym JACA:

- The act is Justified.

- There is no Alternative.

- I accept the Consequences.

- I am Able to do this.

- From this point, the perpetrator progresses to research, planning, and preparation.

5. EXTREMIST MASS VIOLENCE: THE PERPETRATORS

Mass violence may be committed for personal or ideologic motive, but many former distinctions between the two have dissolved. The Warning Behaviors Model, initially applied to ideologic terrorism, was later found similarly reliable and valid with non-ideologic targeted mass violence, and mass shootings fueled by personal or ideologic motive often appear identical. The paths to targeted violence of both offender types largely overlap, and both originate from grievance and alienation. Extremist violence purported to advance an ideology is frequently grievance-driven violence cloaked in ideology.

Most persons with extreme beliefs do not commit extremist violence, as can be demonstrated with a pyramid model. The large base represents the masses of aggrieved, alienated individuals; the substantially narrow midpoint represents the aggrieved who develop extreme beliefs; and the tiny tip of the pyramid represents individuals with extreme beliefs who commit extremist violence [101].

CORE CONCEPTS

The way that threat is understood and addressed is profoundly influenced by how the threat is defined. The literature on radicalization, extremism, and terrorism includes inconsistent and incorrect use of key terms and concepts, and no two countries define "radicalization" the same [102,103].

Radicalism, Extremism, and Violent Extremism

Radicalization is a process that intends to transform thinking, belief, and perception from socially normative to extremist, but this term frequently conflates extremism, radicalism, and terrorism. Radicalism describes intent to overthrow a status quo, not necessarily using illegal or violent means. Extremism refers to deviation from a norm. Radicalism and extremism are not societal threats unless connected to violence or inciting hatred; neither automatically leads to violence, and almost all of those with radical extreme ideas never act on them [101,102,104].

Essential distinctions are extremist ideology versus behavior and movement from non-violence to violence [101,105]. "Violent ideology" and "violent extremist beliefs" are misnomers. Most individuals who harbor extreme beliefs/extremist ideologies do not commit violence to advance the belief or ideology [101]. Individual factors, not ideology, largely influence extremist violence (as will be discussed later in this course).

"Lone actors" self-radicalize without formal terrorist network affiliation, support, or influence. Social movement theory historically viewed lone-actor terrorism as an anomaly, but this long-standing paradigm is mostly obsolete [106]. Radicalization is a distinctly social process, now primarily online instead of offline. Predating the Internet, Unabomber Ted Kaczynski is one of few truly self-radicalized terrorists [107].

Terrorism

The terrorist attack on September 11, 2001, murdered 2,969 people in New York, Virginia, and Pennsylvania. Thousands more, including many first responders, lost their lives to health complications from proximity to Ground Zero in New York City. This attack by Islamist extremists caused almost 18 times the fatalities of the 1995 Oklahoma City bombing, America's second deadliest terrorist attack. From the extreme loss of life and physical destruction, 9/11 has eclipsed all other terrorist events in U.S. history and continues to shape perceptions of terrorism and its perpetrators [108].

Terrorism is defined by the Central Intelligence Agency (CIA) and U.S. State Department as premeditated, politically motivated violence against noncombatant targets by non-state actors, usually intended to influence an audience. Counterterrorism experts consider this definition accurate, in contrast to the description used by other U.S. governmental agencies of "coercion through fear or intimidation" [109].

Islamist terrorists often intend to incite anger, not fear. By provoking aggressive over-reaction that victimizes Muslims previously unsympathetic to Islamist extremist violence, the goal of increasing future support and vulnerability to radicalization is achieved [109]. Solely defining fear as the objective perpetuates the idea that not appearing terrorized by terrorism is to overcome it. This promotes aggressive over-reach and civil rights violations, which feed terrorist propaganda and recruitment efforts [110].

Terrorism is not defined by lethality, and violence includes property destruction. For example, terrorist acts by far-left animal-rights and environmentalist extremists in the 1990s and 200s targeted property and not people. Horrific mass violence is not terrorism when ideologic goals or motives are absent [111,112].

The distinguishing feature of terrorism is the mens rea, or intent, of the perpetrated act [113]. Terrorist acts are synonymous with extremist violence, but terrorism is not synonymous with extremist ideology. Acts of terrorism/extremist violence can be motivated or inspired by extremist ideology.

Ambiguous Motivation

Violent attacks with ambiguous or multiple goals are challenging to define. In the 2015 mass shooting in San Bernardino, the perpetrators radicalized to Islamist extremist violence during Mideast travel but were familiar to the victims of this workplace massacre, making personal grievance impossible to rule out as a motive. A hypothetical middle-aged white man attacking a Planned Parenthood clinic could be terrorism inspired by extremist anti-abortion ideology or IPV against his wife employed by the clinic; a hypothetical young Muslim woman attacking an office building could be inspired by radical Islamism or by personal retribution [111].

Assigning terrorist, criminal, or personal motivation to targeted violence is inherently subjective. Research demonstrates that some attackers cloak their motives with political rhetoric to construct a narrative that legitimizes their acts, and so taking statements about political motivation at face value should be avoided. Described as "murderers in search of a cause," such actors may "upgrade" their violence by flavoring it with a political motive, when in fact it is driven by grudges or other personal motives [67,114]. Many attacks in 2016–2017 appeared linked to Islamism, but open source reporting indicated the purported religiosity of attackers was suspect [113].

An example is the 2017 murder of a Denver security guard by Joshua Cummings, a white man who had recently converted to Islam. When captured, he stated his allegiance to the Islamic State of Iraq and the Levant (ISIS) but committed the murder for the "pleasure of Allah," and not on behalf of ISIS [115]. Placed on a terrorism watch list after leaders of a local mosque reported him as suspicious and possibly radicalized, Cummings had a long history of threatening violence to police. No contact or connection with any Islamist group was found. The Denver Chief of Police concluded Cummings was "looking for attention" with his ISIS-related statements [116].

Violence can also be motivated by extreme beliefs that are denied by the assailant. Following his assassination attempt on FDR, Giuseppe Zangara rejected any anarchist influence or inspiration, but repeatedly mentioned his sympathy for poor people everywhere and a bitter resentment of capitalists and heads of state for their money that drove his desire to kill [6].

EXTREMIST IDEOLOGIES

In the post-9/11 era, Islamist extremism has defined public perceptions of terrorism and governmental targeting of counter-terrorism efforts in both the United States and European Union [105]. However, over the last 100 years in the United States, extremist violence has been perpetrated to advance a broad range of extreme ideologies, the nature of which has changed over time. The temporal appearance of extremist violence in Europe and the United States shows that broader political and economic changes have influenced the changing nature of terrorist motivation, with these factors transcending national borders.

Temporal Appearance of Extremism in the United States and Europe

Researchers examining terrorist motivation in response to broader sociocultural and geopolitical changes have identified five terrorism "waves" in the United States and Europe beginning in the 19th century [1,3,113].

The evolution of terrorism in the United States began in the 1880s with the anarchist wave, which lasted roughly 40 years, followed in the 1920s by an anti-colonial wave, which lasted to the 1960s, then a new left wave, which in turn faded as the religious wave formed [113].

The Anarchist Wave

The anarchist terrorists and assassins of heads of state in the late 1800s and early 1900s committed extreme acts to advance an ideologic/political goal, but had virtually no interaction with each other, and a shared understanding of a common purpose was improbable. On these dimensions, the anarchists were the precursors of current "lone-actor" violent extremists [113].

The Anti-Colonial Wave (Nationalist-Separatist)

The anti-colonial wave began in the 1920s in reaction to the vast international reorganization and technologic innovation following WWI, described by some as the onset of globalization. Extremist violence during anti-colonial and new left waves was coordinated and group-led [113].

This wave was typified by groups such as Fatah and the Irish Republican Army, joined by members who continued the mission of their parents as minority groups seeking liberation from their colonial oppressors or from ruling majorities in their country [1,3].

The New Left Wave (Social-Revolutionary)

Extremist groups of the new left wave are typified by groups such as the Weather Underground, the Symbionese Liberation Army, the Red Army Faction in Germany, and other far-left extremist groups in the 1960s and 1970s, who rebelled against their parents' generation's loyalty to the regime or ruling structure [1,3].

The former Soviet Union was the bastion of Communism and backer of many leftist terrorist-sponsor nations. Its collapse substantially contributed to the demise of the new left wave and rise of the religious wave. It also propelled, as an unforeseen consequence of support to the Mujahideen, resistance in Afghanistan [113].

The Religious Extremism Wave

The religious wave of transnational Islamism emerged in the 1980s and can be divided into four sub-waves [113,117]. The initial sub-wave propagated beliefs of an international oppression of Muslims, which drew religiously inspired fighters to join the Mujahideen in the Afghanistan conflict against the Soviet Union. This sub-wave included Osama bin Laden and other original al-Qaeda members. The second sub-wave involved the Bosnia, Chechnya, and Kashmir conflicts and the 9/11 attacks. These violent Salafi extremists were generally middle class and educated; hardened criminals were nearly absent. The third sub-wave emerged in the wake of the Iraq War as "homegrown" rather than international extremists. The fourth sub-wave emerged in 2010–2014 with ISIS leaders and members substantially lower in education and higher in criminal histories than prior sub-waves, and with sole actors in the United States inspired by violent Salafi extremist leaders.

In each successive sub-wave, the "religiosity" of participants noticeably declined from the preceding sub-wave. Anti-terrorist experts described this pattern as an "extremist social trend," with individuals radicalized to violence by extremist interpretation of Islam replaced by what are best described as "Islamized radicals." In the fourth wave, 90% were motivated for personal reasons, including looking for a fight, adventure, or revenge against perceived rejection. Religion was not the primary driver of this movement [118,119]. Corroboration came from recent interviews of former al-Qaeda members, describing being attracted to terrorism motivated primarily by a pre-existing anger and alienation related to childhood abuse or trauma, lack of integration and assimilation, and/or socioeconomic grievances. Foreign policy grievances were described as a channel for releasing deeply held tensions, instead of a primary motive [113].

This decline in "religiosity" is indicative of a wider change in the "extremist social trend" extending far beyond Islamism. In aggregate, these factors indicate the religious wave is dissipating, with the Western world progressing into terrorism's fifth wave [113].

The Lone Actor Wave

The emerging terrorist actors are motivated by the rhetoric of extreme ideologies through online exposure, instead of affiliation with extremist groups offline. Lone actors, typified by Dylann Roof and Anders Breivik, have much in common with the first wave Anarchists [1,3]. The Internet alone is not driving radicalization but serves as a catalyst with wider societal changes the root cause [103].

Individuals with a grievance can find previously inaccessible ideologies that may provide "frame alignment" to their grievances and failures. They may not fully understand the ideology but can latch onto it in ways not previously possible. The far-reaching societal changes echo the conditions during the anarchist wave. It is premature to determine if the next phase of terrorism represents a new wave, or a loop that continues to mirror, at least in part, the anarchist ancestors [113].

Current Extremist Ideologies in the United States

Far-Left Extremism

This group is traditionally class-oriented, with individuals and groups that adhere to anti-imperialist, anarchist, or Marxist beliefs and seek to overthrow the capitalist system, including the U.S. government, for replacement with decentralized, non-hierarchical systems. During the 1960s and 1970s, far-left extremist groups were motivated by anti-war, anti-capitalism, and social justice issues. Far-left extremists were responsible for 68% of terrorist attacks and 58% of fatalities in the United States during the 1970s [120,121].

Terrorist attacks by violent left-wing groups dissipated in the 1980s. However, environmental activism and terrorism emerged in the 1990s and remains the current ideology associated with the far-left. In the 1990s and 2000s, groups like the Animal Liberation Front (ALF) and Earth Liberation Front (ELF) have been responsible for many terrorist attacks against property, but all have been non-lethal and non-injurious. Incidents by these groups dropped off during the 2010s [121].

Single-Issue Extremism

Individuals motivated primarily by a single issue rather than a broad ideology have beliefs that may fall anywhere on the political spectrum [121]. Examples include members of the Puerto Rican independence movement and the Jewish Defense League in the 1960s and 1970s, and extremists with idiosyncratic ideologies, like Unabomber Ted Kaczynski.

Several armed attacks against law enforcement officers were perpetrated in 2014–2016 by assailants whose stated motivation was deadly use-of-force incidents involving the police and blacks during this period. The deadliest year was 2016, with attacks in Dallas that killed five and wounded nine law enforcement officers; in Baton Rouge that killed three law enforcement officers and injured three; and in Philadelphia that killed one civilian and injured five law enforcement officers. A 2014 attack in New York City killed two officers. In several other incidents, assailants opened fire on police without officer or civilian fatalities. These extremists, perhaps most accurately described as black supremacists, do not neatly fall into other broad groupings [121].

Anti-abortion extremists not motivated by traditional far-right issues (e.g., anti-government, race superiority) are single-issue extremists. Between 1973 (when abortion was nationally legalized) and 2007, more than 200 abortion clinics were bombed or set on fire and more than 4,000 acts of violence were perpetrated (including homicide) or threatened against abortion providers or clinic workers [89,120].

Islamist Extremism

Islamists are violent Salafi Sunni Muslim extremists. Salafism is a highly conservative fundamentalist movement within Sunni Islam that originated in the Arabian Peninsula and is adhered to by a minority of Sunni Muslims [122].

Violent Salafis engage in extremist violence to advance their beliefs against perceived enemies. Influential figures include al-Qaeda leaders Osama bin Laden and Anwar al-Awlaki, an American-born radical Islamic cleric who led al-Qaeda of the Arabian Peninsula. al-Awlaki was killed by a 2011 U.S. military drone strike in Yemen, but his videos persist. ISIS is considered a violent Salafi movement [122].

Salafism is not monolithic but highly fractured by differences among Salafi groups. Nonviolent Salafis are often outspoken in their criticisms about the actions of violent Salafis [122]. Violent radical Salafi ideology is only one of six branches of Salafi Islam, an important distinction to avoid confusing the violent radical ideology with a larger mass of ideologies that have different nonviolent visions for the role of Islam in society [105].

The first Islamist extremist attack in the United States was the 1993 truck bomb in a garage under the World Trade Center in New York, killing 6 people and injuring more than 1,000. On September 11, 2001, four passenger jets were hijacked by members of al-Qaeda and flown into both World Trade Center towers and the Pentagon, with the fourth plane crashed into an empty field after the passengers gained control. With nearly 3,000 people killed and thousands more injured, the lethality and long-term impact of 9/11 were extraordinary [121].

Following 9/11, attacks perpetrated by foreign Islamist extremists became rare. They were replaced by individuals born or raised from childhood in the United States, whose self-identified radicalization to Islamist extremist violence occurred through Internet exposure to material from al-Qaeda or ISIS [120]. Attacks during the 2010s by al-Qaeda- or ISIS-inspired perpetrators decreased but did not disappear. In 2013, Dzhokhar and Tamerlan Tsarnaev detonated bombs near the finish line of the Boston Marathon, killing three and injuring several hundred others in an attack motivated by extremist Islamic views (although not connected to any group specifically). Ahmad Khan Rahami was arrested for three ISIS-inspired explosive device attacks in New Jersey and New York City injuring 31 [123].

The Zebra Killers were a Nation of Islam offshoot of black Muslims who, in San Francisco during 1973–1974, committed 20 attacks of randomly targeted whites, killing 15 victims and injuring 8. The primary motive may have been racial rather than religious extremism [123].

Traditional Far-Right Extremism

Modern far-right extremism ideology is generally exclusivist, favors social hierarchy, and seeks an idealized future favoring a specific group or group identity (often based on racial traits). The extremist far right is commonly hostile to the political left and the federal government and includes radical individuals linked to extremist religious groups (e.g., Identity Christians), non-religious racial supremacists (e.g., Creativity Movement, National Alliance), tax protesters, sovereign citizens, militias, and militant gun rights advocates. Some advocate violence based on beliefs that a personal and/or national way of life is under attack and already lost or the threat is imminent [120,121].

The increasing anti-Muslim sentiment of the far-right correlates with rising populism and nationalism throughout the West. The far-right has expanded from ethno-racial to cultural-ideologic forms of extremism, opposing not just ethnic and religious differences in society but the supporting ideologies and philosophies of multiculturalism and diversity. The idea of differences itself is opposed [103,124].

The Alternative Right ("Alt-Right")

An emerging far-right extremist infrastructure, the term "alt-right" was coined by white nationalist leader Richard Spencer to describe a younger, better-educated movement than traditional white supremacists like the KKK, with right-wing views at odds with the conservative establishment. "Alt-right" re-brands long-standing racist, misogynist, and white nationalist beliefs for appeal to younger people [125,126].

The sprawling alt-right universe envelops neo-Nazis, white supremacists, male supremacists, misogynists, conspiracy theorists, techno-libertarians, white nationalists, anarcho-capitalists, and Dark Enlightenment adherents through a loosely affiliated aggregation of blogs, fora, podcasts, Twitter/Gab, and YouTube personalities united by a hatred of feminism, multiculturalism, and liberalism, and the belief that "political correctness" threatens individual liberty [97,125,127].

The alt-right movement is largely traced to 2012–2014, with the killing of black teenager Trayvon Martin and the "Gamergate" harassment campaign that targeted female game developers and journalists for entering the male-dominated space. Using 4chan and other platforms to organize, the targets were "doxxed" (i.e., had their personal information published online) and systematically threatened with rape and death by anonymous abusers. Gamergate was formative in the development of the alt-right; young men from right-wing online spaces came together in a shared campaign against liberal "politically correct" culture [126,127]. Male supremacy was fundamental to the formation of the racist alt-right [97]. Alt-right, white supremacist, and male supremacist circles tightly overlap to reinforce shared narratives of dispossessed, oppressed white men, blamed on minorities, women, and immigrants [97]. Gamergate crystalized the "manosphere" of misogynist websites that encourage harassment of women and launched the incel movement.

Antisemitism is another common belief of far-right and alt-right extremists. In these groups, Jewish persons are commonly blamed for promoting progressive (and perceived anti-white and/or anti-Nationalist) policies such as civil rights, immigration, and diversity. Antisemitic conspiracy theories (e.g., Holocaust denial, banking/Hollywood control) are used to justify violent behaviors. Several shootings committed by far-right or alt-right perpetrators have occurred outside or in synagogues or Jewish community centers over the past 20 years, including in Kansas in 2014 (resulting in three deaths), at the U.S. Holocaust Memorial Museum in 2009 (resulting in one death), and Los Angeles in 1999 (resulting in five injuries). The mass shooting at the Tree of Life (Or L'Simcha Congregation) Synagogue in 2018 resulted in 11 deaths and 6 injuries. The shooter in this case, Robert Gregory Bowers, had a history of participation in alt-right extremist social media. Before entering the Synagogue on October 27, 2018, Bowers posted the following on the website Gab (a Twitter-like social media site frequented by alt-right extremists): "HIAS [Hebrew Immigrant Aid Society] likes to bring invaders in that kill our people. I can't sit by and watch my people get slaughtered. Screw your optics, I'm going in." He had also made statements online indicating his desire to "kill Jews" [128].

ISLAMIST AND FAR-RIGHTIST VIOLENCE IN THE UNITED STATES

Attacks and Fatalities

Following 9/11, non-Islamist extremism has often been ignored, but threats posed by far-right extremism are significant. Table 2 shows Islamist and far-rightist violence; 9/11 and the Oklahoma City bombing are excluded as outliers [108,129,130].

Table 2: EXTREMIST IDEOLOGY AND VIOLENCE IN THE UNITED STATES

Target and Timeframe

Far-Rightist

Islamist

Attacks

Deaths

Attacks

Deaths

Civilian fatalities from attacks, 1990–2017a

N/A

272

N/A

136

Civilian fatalities from attacks, 9/12/2001–2017

N/A

158

N/A

119

Civilian fatalities from attacks, 2008–2018b

N/A

71%

N/A

26%

Attacks on law enforcement officers and fatalities, 1990–2015

46

57

5

7

Attacks on military personnel and fatalities, 1990–2015

0

0

3

18c

aExcludes September 11 and Oklahoma City attacks

b3% of deaths by Black Supremacists

cIncludes 13 killed in the 2009 Fort Hood attack

N/A = not available.

Source: [108,115,129,130]

After 2008, Islamist extremists were responsible for a small number of high-casualty mass shootings, including 49 killed in the 2016 Pulse nightclub attack and 14 killed in the 2015 San Bernardino attack. During that same period, far-right extremists committed more numerous, lower-casualty attacks [115]. After 9/11, deaths from far-right attacks exceeded Islamist attacks in 10 of the 15 years and were the same in 3 of the years [108,129,130].

Black supremacists committed 15% of extremist homicides in 2017, including the shooting spree of Kori Ali Muhammad, who killed four white victims in Fresno. This followed eight police officers killed in Dallas and Baton Rouge by black supremacists in 2016, the most homicides perpetrated by this extremist subgroup since the early 1980s. More time is needed to determine if black supremacists represent a durable problem [115].

Law enforcement officers killed or injured in targeted attacks doubled after 9/11 (vs. pre-9/11). Far-rightist attacks on law enforcement officers escalated during 2009–2013, motivated by anti-government and white supremacist anger, some focused on the nation's first African American president [108,129,130].

All Islamist extremist attacks on military personnel occurred during 2009–2011 by offenders motivated by anger over the Iraq and Afghanistan wars. Far-right extremists are sympathetic to the military but often hold anti-government views and have a higher likelihood of escalating routine law enforcement contacts into fatal encounters. These extremists present a unique risk to local law enforcement officers, who are disproportionately targeted [108,129,130].

Emerging Trends in Far-Rightist Violence

Analysis of 108 far-right homicides from 1990 to 2008 concluded far-right terrorism was primarily a white male phenomenon fueled by a need to re-establish their perceived threatened dominant position in society [131]. In 2015, the FBI issued an intelligence bulletin that Muslims and Islamic religious institutions were new targets for harassment and violence by far-right militia groups, and that given the broader trends of Islamophobia and sharp increases in hate crimes targeting Muslims, anti-Muslim violence by militias had the potential to worsen [132].

The FBI forecast was prescient. Looking at events in early 2018, three men were charged with bombing a mosque in Minnesota (no deaths or injuries); a sting operation foiled a planned mass-shooting of a Florida mosque; a Muslim mayoral candidate in Minnesota received death threats from a militia group; and three defendants, disrupted before they detonated four car bombs to demolish a Kansas apartment that housed Somali Muslim immigrants, were all found guilty of conspiring to use a weapon of mass destruction and conspiracy against rights, a hate crime. The bombing was planned for November 9, 2016, the day of the presidential election [133,134]. Sikhs have also been killed by perpetrators unaware that Sikhs are not Muslims, including a Sikh temple massacre that killed six worshipers in 2012 [135].

The Southern Poverty Law Center identifies the 2014 rampage of Elliot Rodger that killed 7 and injured 14 as the first alt-right-inspired mass murder. As an incel, Rodgers' grievance against women was amplified to murderous hatred by immersion in violent misogynist fora [126]. In 2018, another deadly incel attack killed 10 Toronto pedestrians and injured 16 more, most of whom were women. Before his vehicular rampage, Alek Minassian posted "All hail the Supreme Gentleman Elliot Rodger!" on social media [98].

Among cases cited by the Southern Poverty Law Center in 2017, the alt-right anti-Muslim radicalization of Alexandre Bissonnette preceded his mass shooting in a Quebec City mosque killing 6 worshipers and injuring 19 others, and Lane Davis, who murdered his liberal father after accusing him of pedophilia, solely from believing the alt-right conspiracy that liberals are secretly operating pedophilia rings (e.g., #Pizzagate) [126].

Similarities of Far-Right and Islamist Extremists

The radicalization pathways and outcomes of far-right and Islamist extremists are markedly similar, the issues leading to a path highly overlap, and both should be regarded as similarly problematic [103,136]. The following case suggests how similar factors may influence radicalization to either extremism.

In 2016, nine young people were fatally shot in Munich by David Sonboly, an 18-year-old man born in Germany to Iranian refugee parents. At first, the attack appeared to be a violent incident by a radicalized Islamist. However, various personal, psychologic, and political motivations led Sonboly (born Ali Sonboly) to embrace a "pure racial identity" that transcended his cultural, immigrant, and minority background, and that of his family and friends. Sonboly idolized far-right terrorist Anders Breivik and timed his mass murder on the fifth anniversary of the Breivik attacks in Norway [103,137].

The specifics of this case are unusual, but the issues at the margins of society similarly affect young people challenged by their cultural and ethnic identities, leading a few to radicalization and violence. Sonboly did not feel comfortable in his own skin, radicalizing and murdering others over insecurities surrounding his ethnic and cultural identity [103].

With industrial capitalism ending and being replaced by neoliberal globalization, the pace of de-industrialization has accelerated. The political, religious, and cultural societal changes and broader globalization have left many communities with a sense of alienation. "Left behind" white working classes and Muslim minorities both face social, psychologic, economic, and structural issues that can thwart the formation of identities and realization of individual potential. Both are apprehensive over multiculturalism, dislocation, and identity conflict [103]. Anomie is a term to describe the alienation and instability that can follow rapid social change and an increasing inability to achieve what society appears to promise, which may lead to weakened group ties, non-adherence to social norms, fragmentation of identity, and loss of purpose [125,138].

The emotional consequences of losing hope leave many of these young men vulnerable, exposed, and pliable to external influences that exploit feelings of marginalization and loss of significance [103]. For example, young white men who feel disenfranchised and alienated are vulnerable to radicalization from exposure to alt-right elements [120,125].

A crisis of masculinity is an issue faced by youth in marginalized communities and a vulnerability factor to both Islamist and far-right radicalization. It is created by a lack of social mobility, persistent unemployment, anomie, and disenfranchisement. The consequences can encourage young people to prove themselves—to seek recognition and become somebody—using whatever means necessary [103].

MEDIA AND CULTURAL NARRATIVES OF EXTREMIST VIOLENCE

Mass violence is followed by questions of whether the act was terrorism. Public perception of terrorist acts and actors has far-reaching consequences that influence governmental and mental health policy and how citizens treat each other. In essence, media reporting shapes this perception [139].

A 2018 study examined the media attention of terrorist attacks in the United States from 2006 to 2015. All 136 attacks (81.6% non-fatal) were controlled for target, fatalities, and arrests. Attacks by Muslim perpetrators received an average 357% more media coverage than comparable attacks by non-Muslims. During this period, Muslims perpetrated 12.5% of attacks but received 50.4% of all news coverage [135].

Several terrorist attacks received substantially less media coverage than researchers expected. These include attacks on a Sikh Temple in Wisconsin that killed six people in 2012; on a Kansas synagogue that killed three people in 2014; and the 2015 attack that killed nine African Americans in a Charleston church. All three cases had white male perpetrators and religious or ethnic minority targets, highlighting the disparity in media coverage of domestic terrorism [135].

Some terrorist attacks are sensationalized and extensively covered, but most receive little to no media attention [140]. A terrorist attack receives less coverage when framed as a crime, while crime reports of incidents committed by Muslims are more likely to be labeled as terrorism [141]. Events are considered more newsworthy if they can be typified as reflecting current beliefs and social structures and can be scripted in ways that reinforce stereotypes. Media framing of terrorism as a specifically Muslim problem is the dominant narrative [142].

Media coverage increases when terrorist perpetrators are members of an out-group, or "others." Social identity research highlights in-group and out-group dynamics, whereby people perceived as "others" are portrayed and perceived more negatively. The biased portrayal of Muslims and Arabs as "others" in entertainment and news media may explain why people implicitly connect terrorism and Islam, Muslims as threats to national security, and an incident as "terrorism" when the perpetrator is Muslim [135,143,144,145]. The substantially greater media attention to extremist attacks by Muslims reinforces the cultural narrative of who should be feared. Framing this type of event as more prevalent helps explain why 42% of Americans are very or somewhat fearful that they or someone they know will be a victim of terrorism and implicitly link terrorism and Islam [145,146].

Political decisions can reinforce Muslim-terrorist stereotypes. In 2009, the U.S. Department of Homeland Security released an intelligence brief stating the economic downturn and election of the first African American president were fueling a resurgence in far-right extremism. A severe backlash (incorrectly) claiming the report painted conservatives as potential domestic terrorists led to withdrawal of the report and defunding of the DHS unit that produced it [147,148]. Following the white supremacist mass murder of nine black churchgoers in 2015, the FBI Director stated the offense was not an act of terror [139]. These misperceptions and lack of will to consider extremist violence by non-Muslims fuel prejudice and discrimination, prevent other pressing security threats from being addressed, and invite consequences [135,149].

6. EXTREMIST MASS VIOLENCE: PATHWAYS

Distinguishing nonviolent from violent extremists and understanding what generates the difference is a foremost concern that is only recently appreciated [150]. As with mass shooters, terrorist acts have been ascribed to mental illness, which became a focus of terrorist prevention. However, looking to psychologic characteristics and psychopathology to explain extremist violence has been generally unhelpful [151].

Extremist violence, as with all forms of targeted violence, cannot be disrupted using prediction. Realizing terrorist acts are too difficult to predict, the focus turned to radicalization as a proxy for pre-empting terrorism, because radicalized individuals are substantially greater in number and easier to detect than individuals who commit extremist violence [101].

This logic is compelling but flawed, and around 2010, the value of disrupting radicalization became questioned. Viewing ideas as threats can lead to a war on ideas, and government over-reaction to terrorist threat often creates a backlash, with new threats [101]. Decades of social psychology research demonstrates extreme beliefs are largely or mostly unrelated to extreme actions [101,120].

The Profiles of Individual Radicalization in the United States (PIRUS) database was developed to address these shortcomings [120,150]. PIRUS contains information on 1,473 violent and nonviolent extremists across the ideologic spectrum from 1948 to 2013 and is the first U.S. extremist database with size and case detail sufficient for longitudinal (pathway) and quantitative analyses [120,150].

MORAL EMOTIONS AND INTERGROUP VIOLENCE

As discussed, social identity theory distinguishes the group one identifies with and belong in (in-group) from groups one does not identify with nor belong in (out-group). Group members can share emotions about their in-group and out-groups. Group emotions motivate group behaviors and provide the bases for in-group and out-group attributions. Negative attributions of an out-group by leaders of ideologic groups can motivate hostile or violent in-group behaviors against out-group members. Hate crimes, massacre, and genocide against out-groups have been incited by leaders who, from positions of moral superiority, evoke moral outrage, devaluation, and a need to protect in-group "purity" from out-group contamination [90,152,153].

The ANCODI Emotions

Anger, contempt, and disgust (ANCODI) are moral emotions associated with violations of ethics, morality, and divinity. Disgust is also an evolved defense to ward off contaminants and purge the environment of toxins [90]. A highly relevant body of research demonstrates how ANCODI emotions can combine to drive ideologically motivated intergroup violence [153,154,155].

Research on aggression has focused on anger, but disgust transforms aggression into hostility and anger into hatred. Directed at a despised out-group, anger motivates action, contempt motivates devaluation, and disgust motivates dehumanization and elimination. Thus, the ANCODI emotions work in a sequence (or pathway) that starts with a perceived injustice and evolves to elimination [155].

ANCODI works through serial narrative by in-group leaders. An unjust incident that evokes outrage is attributed to the out-group (anger), re-framed from a position of moral superiority that links similar behaviors to the morally inferior out-group (contempt) that threatens in-group purity with contamination and must be removed (disgust). Cultural narratives can facilitate hatred across generations by propagating ANCODI emotions [152,155].

The validity of ANCODI emotions as instrumental in inciting ideologically motivated violence has been demonstrated by speech and video analysis of leaders of ideologically motivated groups, and by clinical research involving members of ideologically motivated groups. Hitler, Osama Bin Laden, Slobodan Milošević, and Virginia Tech mass shooter Seung-Hui Cho (among others) showed escalation of disgust preceding mass violence. Studies evaluating ANCODI showed cross-cultural, cross-language, and cross-generational validity [153,155].

People normatively react to spoiled food, filthy environments, and insects not with anger or contempt, but with disgust and a desire to cleanse, sometimes through violence, so they do not continue to poison [153,156]. In a mass psychology context, the Nazis equated the Jews with vermin and other contaminants, and thus found an emotional accelerant for the Holocaust. Propaganda in the Rwandan genocide states it was "cockroaches," and not humans, that were killed. These ideologies argue that purification takes a step forward if toxins and contaminants are obliterated [90,157].

For ideologic extremists, the path to violence advances when anger, fear, or contempt of the perceived enemy is replaced by equating the enemy with a toxin (disgust). The impulse is to be rid of it, to exterminate, to kill [90]. Far-right groups vehemently defend a sense of identity, the purity of which is seen threatened with destruction or dilution by emerging racial, ethnic, and religious minority groups [103]. Calls by ISIS to violently cleanse society of impure elements incited the annihilation of Shia and moderate Sunni Muslims to rid their "pure" Islamic caliphate of these "contaminants" [105].

Anger, contempt, and disgust compressed together become dangerous in the processes of dehumanization and extremist violence across all languages and cultures. Monitoring communications for expression of ANCODI emotions directed at out-groups may provide an early-warning mechanism of impending violence [153,155]. The same is true of the language used by individuals encountered in a health or mental health setting.

Dehumanization

Dehumanization is directly related to ANCODI emotions of contempt and disgust, but its valid measurement remained elusive until introduction of a novel scale using the Ascent of (Hu)Man (AoM) diagram. With AoM, a diagram is presented, with five images depicting the evolution of humans, from primitive quadrupedal ancestor to modern human. The subject places each person/group on a continuum from 0 (primitive pre-human) to 100 (fully human). Lower scores indicate dehumanization, and higher scores represent humanization [158]. For comparison, the average American in 2014 rated ISIS at 54 [158]. The AoM scale and other measures were given to alt-right adherents and a control group to understand the psychologic profile of this emergent group (Table 3) [159].

Table 3: DEHUMANIZATION RATINGS OF VARIOUS TARGET GROUPS BY SUPREMACISTS AND OTHER ALT-RIGHT ADHERENTS

Target Groups

Supremacists

All Alt-Right

Control Group

Blacks

51.4

64.7

89.1

Democrats

52.1

60.4

88.9

Mainstream media

51.5

58.6

84.2

Feminists

46.9

57.0

86.9

Muslims

44.8

55.4

83.2

Hillary Clinton

N/A

54.8

85.1

Source: [159]

Supremacists perceived Blacks as half-way between the primitive ape-like human ancestor and "full" human, and similarly dehumanized democrats and the mainstream media, with feminists and Muslims closer to primitive pre-humans than fully human. The combined ratings by supremacists and populists increased somewhat, but these entities were still perceived as less than fully human.

The alt-right group perceived that certain historically advantaged groups are superior to other groups and need their interests protected, with their social positions under threat. They also expressed a level of hostility toward religious/national out-groups and political opposition groups considered extremist [159].

The supremacist subgroup reported very high motivations to express prejudice, extreme dehumanization of out-groups and opposition groups, very high levels of callous and manipulative behavior, and more frequent aggressive behavior. The populist subgroup showed lower extremist tendencies [159].

Radicalization

As discussed, radicalization is a gradual process that intends to change the beliefs, feelings, and behaviors of individuals with the objective of aligning them against the core values of societies they inhabit and preparing them for intergroup conflict against an out-group that must be fought [117]. Social factors influence this process and the progression from extremist beliefs (non-violence) to extremist violence [151]. The radicalization process may be linear or nonlinear, but it starts with social or political grievances and perceived injustices, a subsequent identity crisis, and the search for significance, identity, or purpose that follows [105].

Radicalization should be understood in the context of "push" and "pull" factors. Push factors refer to negative social, political, economic, or cultural root causes that influence individuals to affiliate with extremist organizations. Pull factors are the perceived positive characteristics and benefits of extremist organizations that lure vulnerable individuals, such as feelings of significance and belonging [105].

Mental illness history, although very uncommon in the PIRUS data, may likewise "pull" individuals by increasing their susceptibility to ideologic narratives or extremist group coercion, or "push" individuals labeled, stigmatized, and excluded from conventional society and forced to seek acceptance through antisocial means [150].

Following alienation from the status quo of perceived unjust society, contextual factors set the stage for radicalization. These include political, economic, ideologic, and psychosocial drivers [105].

Significance Quest Theory of Radicalization to Extremist Violence

The Significance Quest Theory, also termed the 3-N (Need, Narrative, and Network) Model, explains radicalization and movement on a path to extremist violence using principles from social psychology and criminology that combine into three core, inter-related components [149,151,160].

The Need

The actor, or the ethnic, religious, or national group they identify with, experiences perceived oppression from a regime or social group; systemic discrimination, stigma, and/or abuse; or personal circumstances of trauma, failure, a significant loss, or reversal. Perceiving themselves as rejected, divested of control, or victimized by injustice, the actor feels belittled, disrespected, and humiliated. The specifics of the experience are less important than the psychologic effects [149,151,161].

A feeling of significance is the fundamental human need to feel worthy and to feel important, valued, and respected in the eyes of others. Humiliating and shameful experiences create a discrepancy between the positive way one wishes to view oneself, and the negative self-perception suggested by the circumstances. This discrepancy induces an aversive arousal and motivates action. The actor searches for routes that can remedy this state of insignificance and restore feelings of value and worth [151].

The Narrative

Some individuals with feelings of alienation and perceived injustice will search for the means to improve their condition. Unable to resolve or improve their grievance, feelings of anger and frustration accumulate. Extremist groups exploit these vulnerabilities by convincing the individual his or her frustration is attributable to a specific enemy [105,162].

Regardless of where it falls on the political spectrum, the task of extremist ideology is to advance radicalization by identifying an entity to blame for the humiliation, justifying aggression against the entity on moral grounds, and indoctrinating the individual into simplistic thinking that sees the world in black and white. This narrative greatly appeals to those striving for significance [151].

Political, economic, or social grievances can lead to a "cognitive opening," when individuals in crisis become prone to altering their previously held beliefs and perceptions. Instead of relying on individuals' identity crises to spread their ideology, extremist recruiters actively trigger cognitive openings through different communication strategies intended to create a "moral shock" [105].

Through frame alignment, the individual examines whether the narrative of an extremist group aligns with his or her experiences and views. If frame alignment is not achieved, the process may be abandoned. If the frame makes sense, a process of socialization begins, and the individual adopts the ideology and becomes committed to it [105].

The Network

Through exposure to the extremist network, the realities of the individual undergo reconstruction. Alternative frames through which to interpret one's grievances are introduced. These frames are variations of existing cultural or religious frames that rework the schemata of interpretation to affect the meaning attached to events [117]. The individual increasingly identifies with the extreme ideology and network, leading to support of, or engagement in, extremist violence [105].

The network makes a violence-justifying narrative cognitively accessible; their support of the narrative validates it and proves its soundness. The network may convince the individual that, under present circumstances, violence is an acceptable and legitimate means. Violence becomes perceived as less extreme and more normative, making it easier to deviate from broad societal norms without the burden of guilt [149,161].

Radicalization starts with an individual recognizing an unfavorable condition as "not right." This condition is then framed as "not fair" and attributed to a target entity. The enemy is demonized, and violence is validated. Dehumanization is a key psychosocial factor in extremist violence that contributes to "moral disengagement," the process which develops a moral justification to use violence [105,163]. Reinforcement of an "us versus them" mentality brings the individual fully into the extremists' fold [117].

PIRUS Research and Radicalization Pathways

The PIRUS database was analyzed to identify nonviolent and violent radicalization pathways. (Note: The most recent data entry in PIRUS dates to 2013, which prevents analysis of alt-right extremism and makes some data on Internet activities and group affiliation dated. Nonetheless, studies using PIRUS data advance the understanding of extremist violence and its prevention.) Researchers found that factors that are necessary for nonviolent extremism are not sufficient for moving to violent extremism [120,150]. A sense of community victimization and cognitive frame realignment are both necessary for radicalization to violent extremism. These factors combine with psychologic and emotional vulnerabilities from lost significance or thwarted efforts to gain significance, personal trauma, and collective crises to produce sufficient pathways to violent extremism. Radicalization to violence is unlikely in the absence of a cognitive frame realignment or the absence of feeling one is a member of a collectively victimized community. When present, neither factor ensures movement to violence, but they set the environment where it is possible.

Pathways that combine loss of significance and other individual-level vulnerabilities with perceptions of community victimization are particularly important for explaining shifts from nonviolent to violent extremism. Personal vulnerabilities can fuel identity-seeking behaviors in individuals who then find direction and meaning in extremist narratives. Individual-level factors interact with social identity dynamics, and individuals are persuaded that their personal deficits largely result from their membership of a collectively victimized or threatened community.

As individuals and groups become more insular, common mechanisms of cognitive bias (e.g., groupthink, rule compliance, dehumanizing rhetoric, diffusion of responsibility) increase, convincing individuals that alleviation of community grievances and threats to community survival can only occur through violent action.

Analysis of historical data from PIRUS identified four correlates of extremist violence [164]:

- Absence of stable employment

- Radical peers

- Mental illness history

- Pre-radicalization criminal record

The correlations were significant and additive. Individuals with none of the characteristics had a 41.3% chance of engaging in extremist violence; those with one factor had a 59.8% chance of violent behavior; with two factors, a 67.0% chance; and with three factors, an 84.8% chance. Documented mental illness was uncommon, and its influence on extremist violence was difficult to identify [164]. Of note, 41.3% of violent extremists lacked all four risk factors, highlighting the limited predictive capacity of static distal factors.

RADICALIZATION PATHWAYS: THE U.S. DEPARTMENT OF JUSTICE REPORT

In 2015, the U.S. Department of Justice published their findings of radicalization pathways among post-9/11 extremists unaffiliated with terrorist groups. The pathway was common across Islamist and far-right ideologies [129]. The pathway begins with personal and political grievances combined. This mirrors personal grievance and moral outrage outlined among the distal characteristics of targeted violence discussed previously in this course. These grievances formed the basis for an affinity with online sympathizers and ideologic validation of their beliefs (the second stage).

In the third stage, an "enabler" is identified—someone providing inspiration for terrorism (nearly all are indirect). The most frequent enablers identified were:

Islamists

- Osama bin Laden

- Anwar al-Awlaki

White Supremacists and Anti-Government Extremists

- William Pierce (National Alliance founder and author of The Turner Diaries)

- Internet personality Alex Jones

Nearly all extremists then engaged in broadcasting of terrorist intent. Finally, a triggering event occurs and acts as the catalyst for extremist violence that was personal, political, or some combination. The prompt to violence may be immediate or may accumulate slowly through a series of "escalation thresholds."

Example 1

The triggering event superseded all other facets of radicalization by fusing the personal proclivity for anger and violence with political grievance over the abuse of Muslims by U.S. military forces. This defining event allowed the subject to dehumanize his victims while elevating himself to a position of moral sanctity as a self-identified holy warrior.

Example 2

A series of escalation thresholds were influenced by a combination of personal grievances over a lack of employment prospects and paranoid political beliefs that intensified through affinity with online sympathizers. Along this pathway, discharge from military service was the triggering event for his self-identification as an armed warrior that precipitated an assassination.

SIMILARITIES OF VIOLENT EXTREMISTS AND OTHER MASS SHOOTERS

Evidence Based Practice Recommendation

The National Collaborating Centre for Mental Health cautions against making negative assumptions based on culture, religion, or ethnicity when assessing risk of violence. Unfamiliar cultural practices and customs can be misinterpreted as being aggressive, and clinicians should ensure that the risk assessment is objective and takes into account the degree to which the perceived risk can be verified.

https://www.nice.org.uk/guidance/ng10

Last Accessed: March 19, 2019

Level of Evidence: Expert Opinion/Consensus Statement

A comparison of 115 mass murderers (at least four victims) with 71 lone actor terrorists from 1990 to 2013 concluded both groups were very similar in behaviors, and similar threat assessment frameworks may be applied to both offender types. Instead of prediction based on static factors, prevention identifies patterns of behavior in both offender types that increases or decreases across time in a lead-up to perpetration; these trends statistically differ from random behavior [89].

Severe grievance is a common starting point among mass shooters and violent extremists. Both offender groups share pathologic narcissism, whereby sensitivity to shame and humiliation is activated by actual or perceived loss and public exposure of self as deficient. This, in turn, fuels the development of grievance against the humiliating entity. The path to violence diverges, but finally converges against a persecutory entity and past humiliation is undone through contempt, devaluation, and violence [90].

IMPLICATIONS FOR SUCCESSFUL COUNTERING OF VIOLENT EXTREMISM

In the final report of the PIRUS data analysis, the authors state that erroneous assumptions drive policies to protect against Islamist extremism. These policies are counterproductive and are likely to inflame instead of mitigate the conditions that promote extremism [112,120].

Complex psychologic and emotional processes, driven by feelings of lost significance and community victimization, play a central role in radicalization. Countering violent extremism programs should take this into account and should not place undue pressure or surveillance on specific communities, because this may amplify feelings of community victimization and alienation.

Efforts to counter extremist narratives and recruitment efforts should address perceptions of community victimization by challenging myths or misperceptions. Legitimate grievances should be acknowledged, with a focus on alternatives to address these grievances. Those countering violent extremism should be aware that cognitive biases make members less responsive to the disconfirming evidence central to counter-narratives.

Successful programs to counter violent extremism address underlying psychologic and emotional vulnerabilities that make individuals open to extremist narratives. These may result from traumatic experiences and losses, or personal and community marginalization. Programs that emphasize the acquisition of job-relevant skills may be effective for promoting sustained employment of at-risk individuals.

FBI statistics show that, in 2001, anti-Muslim hate crime incidents increased 1,600% from 2000. In 2002, hate crimes against Muslims decreased 67%, a drop credited, in part, to the leadership of President George W. Bush [148]. Leaders and advocates should keep this in mind when providing care or doing outreach.

7. GUN VIOLENCE TRENDS, DATA, AND FACTORS

The identification and interruption of individuals on a pathway to targeted mass violence is often performed by professionals with specialized training in threat assessment and management. However, mass shootings are part of the broader public health concern of gun violence. There is overwhelming recognition that health and mental health professionals can take critically important actions to reduce gun violence and increase the safety of their patients.

Clinician effectiveness in helping prevent gun violence requires understanding the following [32,165,166]:

- The nature and extent of mass shootings and the gun violence problem in general, including what it is, whom it affects, where it occurs, how patterns have changed over time, and the factors contributing to these changes

- The facts on gun safety and risks, gun owner subculture, and how to have gun conversations with patients

It is vitally important for clinicians to understand the dynamics of domestic violence and victim danger with perpetrator access to a gun. The strong association between domestic violence and mass shootings is largely unappreciated.

AGGRESSION, WEAPONS, AND VIOLENCE

The understanding of gun violence and risk reduction is well-informed by briefly reviewing aggression, aggressive behavior, and potential interaction with gun presence.

General Contributors to Aggression

The I-3 Model, a general framework to understand aggression, identifies three factors that influence the likelihood and intensity of aggressive behavioral response: instigation, impellance, and inhibition [167].

Instigation

Instigation is defined as the immediate environmental provocation that normatively affords an aggressive response. For example, in most contexts, witnessing another man try to seduce one's wife normatively renders aggression. Other normative instigations may include social rejection and verbal/physical provocation.

Impellance

Impellance encompasses the situational or dispositional qualities that influence how strongly the instigator fosters a proclivity to aggress. Factors that increase impellance strength include trait aggressiveness, Dark Tetrad personality traits (i.e., Machiavellianism, narcissism, psychopathy, and sadism), trait anger, hostile rumination, and presence of a weapon.

Inhibition

The situational or dispositional qualities that influence how strongly an individual is likely to enact an aggressive response are over-ridden with disinhibition. Inhibition is weakened by intoxication and strengthened by self-control, frontal lobe functioning, and emotional commitment to the relationship with the potential target of aggression.

Hostile Attributional Bias

Hostile attributional bias describes the tendency to perceive hostility in ambiguous situations. These individuals show a pattern of hypervigilance to threat and reactive aggression to perceived provocation. Hostile attributional bias is connected to personality traits involving hostile beliefs and reactive aggression, including narcissism and psychopathy [168,169].

Some subcultures promote hostile attributional bias [169]. A unique "culture of honor" in some areas of the United States (particularly in the South) promotes vigilance toward provocateurs, perceptual readiness to attribute hostile intent to others, and retaliatory aggression in response to being dishonored. Violence among urban minority men is promoted by the premium placed on retaliation when disrespected ("dissed"). Recent "stand your ground" laws in some states permit lethal retaliation against a perceived provocateur [170].

The "Weapons Effect"

In the I-3 model of aggression, the presence of a weapon increases the proclivity for aggressive response to provocation [167]. This "weapons effect" was first described more than 50 years ago following observations that the mere presence of a weapon increased aggression, especially in angered individuals. In response to a specific situation, whether a person behaves aggressively is greatly influenced by how they interpret, or appraise, the situation [171].

Research demonstrates that the presence of weapons increases aggressive thoughts and hostile appraisals, which in turn increases the aggressive behavior. These effects are significantly stronger for men than women [171].

Weapons can make people more aggressive even when they are concealed instead of visible. In a nationally representative sample of adults, motorists with a concealed weapon in their car were more likely to drive aggressively (e.g., tailgate, make obscene gestures) than motorists without weapons in their car, even after controlling for other factors related to aggressive driving (e.g., gender, age, urbanization, census region, driving frequency) [171,172].

DOMESTIC HOMICIDE AND MASS SHOOTINGS

As discussed, mass shootings/murders are generally defined as four or more people killed over a brief duration in close proximity. Many are domestic homicides, excluded from public mass shooting databases because they were not perpetrated in public and/or the perpetrator was known to the victims [173]. Unlike targeted violence, domestic violence homicides are typically impulsive acts perpetrated in highly charged emotional states. The terms "domestic violence" and "intimate partner violence" (IPV) are often used interchangeably.

During the 1920s and 1930s, mass murders (mostly familicides and crime-related gun massacres) were nearly as common as in the post-1960s era. Familicide describes mass murder, typically a man killing his partner (spouse or ex-spouse, girlfriend or ex-girlfriend), their children, relatives, or some combination. Then, as now, these acts were less likely to receive widespread news coverage. The long-standing view of domestic violence as a private family matter has undermined taking domestic violence as seriously as other potentially fatal violence [12,20]. Public and clinician attention to the lethality of domestic violence is vital.

Domestic Violence as a Driving Factor in Mass Shootings

Some are quick to link Islam or mental illness to the actions of mass shooters, but the strong association with domestic violence/IPV goes largely unaddressed [174]. Domestic violence mass murders comprise more than 50% of all mass murders. Everytown for Gun Safety (Everytown) is a non-profit organization involved in research, education, and policy related to gun violence prevention. Because domestic mass shootings are often excluded from public mass shooting databases, Everytown examined the prevalence of mass shootings (defined as at least four people killed with a firearm, shooter excluded) during 2009–2017 [175,176]. They found that in 173 mass shooting incidents, 1,001 people were killed and 792 were injured. Fifty-four percent of mass shootings were domestic violence incidents, during which 491 intimate partners or other family members were killed, 39% of whom were children. In these incidents, 65% ended when the perpetrators killed themselves. Women make up 15% of all deaths from gun violence, but 64% of mass shooting victims are women and children [175,176]. In total, 16% of attackers had previously domestic violence charges, and 59% of incidents took place entirely in private residences.

Women are 16 times more likely to be killed by gunfire in the United States than in other high-income countries [176,177,178,179]. A woman is 500% more likely to be killed in a domestic violence event when a gun is present. Nearly 1 million women alive today have been shot, or shot at, by an intimate partner. Abusers use guns to threaten and control their victims, even if they never pull the trigger. Around 4.5 million American women alive today have been threatened with a gun by an intimate partner [176,177,178,179].

Of female victims of homicide, 90% are killed by a person they know, and half of these offenders are current or former intimate partners [180]. In contrast, a 2017 analysis places the annual risk of being killed by a stranger with severe psychoses at 1 in 14 million [32]. Most suicides that follow homicide occur in the context of IPV; the perpetrators are motivated by dependency on, and/or desire to be reunited with, the victim(s) [181].

Warning Signs

Before the incident, 42% of mass shooters showed "red flag" warning signs for dangerous gun behaviors indicating they posed a danger to themselves or others, including [176]:

- A recent threat of violence

- An act (or attempted act) of violence toward self or others

- A conviction for certain firearms offenses (e.g., unlawful and reckless use, display or brandishing)

- Violation of a protective order

- Ongoing substance abuse

The "red flags" overlap with factors that place women at greatest risk of being killed in abusive relationships, including [80,178]:

- Perpetrator access to a gun

- Previous threat with a weapon

- Escalation in severity or frequency of violence

- Recent estrangement, especially from a controlling partner

- Being stalked by a former sexual partner

Domestic Violence Histories of Mass Shooters

As noted, a history of domestic violence is common among perpetrators of mass violence. One example is Devin Kelley, who killed 26 people and injured 20 in the November 2017 church massacre in Sutherland Springs, Texas. Kelley was consumed by a grievance against his mother-in-law and attacked the church his in-laws attended, although the mother-in-law was not present [182]. In the Air Force during 2012, Kelley was court-martialed and served 12 months in a military jail for assaulting his first wife and infant stepson, fracturing the boy's skull. While awaiting sentencing, he was detained at a mental health clinic for bringing weapons on base and making death threats against his superiors [182,183]. His domestic violence record never appeared in the background check required of licensed gun dealers because the Air Force did not file the paperwork. Kelley legally purchased the AR-15 used in the massacre. Dishonorable discharges, but not bad conduct discharges, which Kelley received, enter the background check to block gun sales [182].

Other examples include Omar Mateen, who killed 49 people in the Pulse nightclub in 2016 and frequently battered his former wife, and Tamerlan Tsarnaev, one of the Boston Marathon bombers, who had been previously been arrested for domestic assault and battery. Anti-abortion extremist Robert Dear, who killed three people in a Colorado Planned Parenthood clinic in 2015, had an extensive history of violence against women, domestic abuse, and an arrest for rape. Seung-Hui Cho, who killed 32 people at the Virginia Polytechnic Institute in 2007, had a history of stalking and harassing female students [184].

IPV Dynamics

IPV describes attempts to harm or control current or former romantic partners against their will through physical violence, psychologic aggression, sexual violence, or stalking. Men and women tend to show equivalent rates of IPV perpetration, but women are disproportionately injured and killed by IPV. De-humanization of women (i.e., women viewed as sex objects and not people) has implications for violent behavior directed toward them. The extent to which men objectify women is related to their IPV behaviors toward those women [185].

Domestic violence is driven by a desire by the abuser to exert power and control over the victim. The perpetrator's sense of losing that control is when violence is more likely, including domestic mass murder. The psychology of mass shooters also points to violence as the means to gain power and control [186]. Beyond potential use to kill and wound, batterers use guns in a variety of ways to coerce and control their victims. They may threaten to kill the women, themselves, the children, or a pet. During an argument, other methods of gun intimidation include cleaning, holding or loading a gun, and going outdoors and shooting the gun [187,188].

Domestic abusers and mass killers often possess patriarchal, highly traditional views of male-female relationships and may use domestic violence to impose traditional gender roles on the female partner [174,184]. This view also makes fundamentalist belief systems of major religions that advocate restrictive attitudes toward gender appealing and encourage men to punish women for their own failings. ISIS infamously noted this, with promises of young female sex slaves in its recruiting material. An IPV history may help neutralize the natural barriers to attempting mass murder [184].

MASS SHOOTINGS AND OTHER GUN VIOLENCE

Firearm injuries encompass fatal and non-fatal outcomes of interpersonal violence, self-directed violence, and accidental discharge. Around 100,000 Americans are injured or killed by guns each year, and since 1968, more civilians have been murdered with guns than American soldiers have been killed in combat by any means in all wars combined [189,190]. Firearm injuries are disproportionately a problem affecting men and boys, who account for 86% of deaths and 89% of non-fatal injuries; and a problem afflicting the South, where 46% of all gun-related homicides and 45% of suicides occur [165].

The definitions for mass shooting exclude assailants in counting the death toll, but otherwise vary. In 2005, the FBI defined mass murder as a purposeful homicidal act resulting in the deaths of four or more people. Following the 2012 Sandy Hook shooting, the defining minimum number of lives lost was lowered from four to three during the same event [191].

FBI Supplementary Homicide Reports, widely used for homicide data, rely on voluntary reporting by local law enforcement agencies nationwide. Problems with persistent under-reporting led to several independent homicide research databases, with Mother Jones and Everytown the two most widely cited [20,28].

Most mass shooting databases exclude murders committed against family members, during robbery or burglary, or resulting from gang or drug activity [192]. This has excluded some of the worst incidents, including [193]:

- A 1983 robbery of a Seattle gambling club, in which 13 victims were executed by gunfire

- The largest family annihilation in U.S. history, when in 1987 an Arkansas man murdered his 14 family members, then drove to other locations to kill a former coworker, and then a woman who had spurned his romantic advances

According to the Mother Jones mass shooting database, during 2007–2013, active shooting and mass murder incidents increased 150% compared with 2000–2006 [66,194]. Mass shootings occurred, on average, every 200 days in 1982–2010, increasing to every 64 days in 2011–2014. The average victims per year increased more than 200% after the federal ban on assault weapons and large-capacity magazines expired (i.e., 65.7 victims per year in 2005–2016 vs. 21.1 victims per year in 1995–2004) [195].

The Gun Violence Archives (GVA) reported the following numbers of mass shooting incidents annually [196]:

- 2014: 271

- 2015: 333

- 2016: 383

- 2017: 346

- 2018: 340

The FBI examined active shooter incidents, defined as one or more individuals actively engaged in killing or attempting to kill people in a populated area. In total, 200 active shooter incidents were identified between 2000 and 2015 [197,198]. The average annual frequency increased from 2000–2006 (6.4) and 2007–2013 (16.4) to 2014 and 2015 (20 incidents each). In 2000–2013, there were 160 incidents with 1,043 casualties (486 killed and 557 wounded). In contrast, in 2014–2015 alone, there were 40 incidents with 231 casualties (92 killed and 139 wounded). During 2014–2015, the FBI noted two incidents in which a citizen with a gun permit exchanged gunfire with a shooter before the assailant was restrained and arrested, and a third incident in which a citizen pursued the shooter inside a store, but was shot and killed before he fired his weapon.

In sum, public mass shootings show an increasing frequency since roughly 2007–2010.

Homicides

As a subtype of homicide, discussion of trends in mass shooting also requires discussion of broader trends in gun homicide. Beginning in 1996, Congress prohibited gun injury research by the Centers for Disease Control and Prevention (CDC), and FBI data are used to analyze gun contribution to total homicides (Table 4) [199,200].

Table 4: HOMICIDE RATES BY MEANS, 2012–2016

Type of Homicide (Weapon Used)

2012

2013

2014

2015

2016

Firearms

8,897

8,454

8,312

9,778

11,004

Knives, cutting instruments

1,604

1,490

1,595

1,589

1,604

Blunt objects

522

428

446

450

472

Personal weapons (hands, fists, etc.)

707

687

682

659

656

Weapon type not stated

802

850

872

873

903

All Homicides

12,888

12,253

12,270

13,750

15,070

Source: [200]

The National Institute of Justice (NIJ) published an analysis of homicide increases in November 2017 [201]. Homicides increased nationwide from 2014 to 2015 (11.4%) and 2015 to 2016 (8.2%); and in big cities (≥250,000 population) from 2014 to 2015 (15.2%) and 2015 to 2016 (10.8%).

Despite 2016 homicide rates 35.4% lower nationwide and 45.7% lower in big cities than in 1995, the abrupt 2015–2016 increase is concerning. A closer look by NIJ found that most big cities with large homicide increases in 2015 or 2016 saw far smaller increases or large decreases in the opposite (2016 or 2015) year [201]. In all, 10 big cities accounted for 67.5% of homicide increases in 2015 and 95.5% in 2016 [201].

Most homicide increases are concentrated in a fraction of big cities and are time-limited. This suggests factors driving these increases may also be short-lived. The Department of Justice linked homicide increases in 2015–2016 to two proximal factors: the opioid epidemic and the "Ferguson effect." They did not identify the underlying (root) causal factors [201].

The Opioid Epidemic

The illicit opioid epidemic concentrates in white populations, but not in big cities. In 2015, fatal heroin overdose rates among whites were 74% higher than Blacks and 135% higher than Hispanics. Racial differences in fatal fentanyl overdoses were even larger [201].

In 2015–2016, there were larger increases in drug-related homicides than all other homicide types involving white offenders and victims. The increasing demand for illicit opioids attracts more sellers into the market, which escalates conflicts between sellers over customers and territory; increases disputes between buyers and sellers over price, purity, quantity, or related factors; and draws other criminals who intend to rob sellers or buyers of drugs or money [201].

The "Ferguson Effect"

The "Ferguson effect" describes a cascade of effects that followed a series of high-profile, deadly use-of-force incidents involving the police and black Americans in big cities during 2014–2016, beginning in Ferguson, Missouri [201].

A ripple effect of these incidents activated a police "legitimacy crisis" in urban black communities already experiencing elevated levels of violent crime. With increased community alienation from the police, contact is avoided and violent crime is not reported by witnesses or victims, and violent retaliation increases. Following highly publicized violent police encounters, calls for police assistance significantly decline in nearby black neighborhoods, taking about a year to return to pre-incident levels [201,202]. Another effect is increasing concerns among police for their safety, resulting in reduced proactive policing, fewer arrests, and reduced stopping and questioning for suspicious behaviors and activities [201].

Cities most troubled by conflict between police and black communities experienced the greatest one-year homicide increases (in either 2015 or 2016), including Cleveland, Chicago, Baltimore, St. Louis, and Milwaukee [201].

Suicide and Suicide Attempts

Suicide is self-directed violence, and it is often overlooked in gun violence discussions. Guns are used in 5% of suicide attempts, but are responsible for more suicide deaths (>50%) than all other methods combined [203]. Around two-thirds of the annual 33,000 gun-related fatalities in the United States are suicide. In 2012, 75% of all gun suicides were white men, with the highest rates among those 70 years of age or older [165,204,205,206].

During an acute suicidal crisis, lethality of the method available can be a critical determinant of fatal or nonfatal outcome. The fatality rate of suicide attempts using guns (85%) is much higher than most other methods (cutting/slashing: 0.7%; intentional overdose: 2.5%; jumping: 20%); hanging is the exception (70%). People usually do not substitute a different method when a highly lethal method is unavailable or difficult to access [165,207].

Most suicidal impulses are overwhelming but short-lived, and suicidal individuals are often ambivalent about killing themselves [188]. The time between deciding on suicide and attempting suicide can be 10 minutes or less; more people begin a suicide attempt and stop mid-way than continue and complete it [205,208,209]. Cutting and overdose, unlike guns, offer a window for rescue [165]. More than 90% of those who attempt suicide and survive do not later die by suicide, but suicide attempts with a gun are usually fatal [205].

8. DISCUSSING GUN SAFETY AND RISKS WITH PATIENTS

The key role of primary care clinicians in preventing gun-related mortality and morbidity by initiating gun conversations with their patients is established. Clinicians should know what approaches to use and how to speak with patients, especially members of gun culture. Judgemental approaches and telling patients their fears of mass shootings/violent strangers and their urge to defend themselves are irrational are unlikely to be effective [210].

RATIONALE AND BARRIERS

Gun safety counseling is a key component in preventing firearm injury and deaths, including IPV and mass shootings, but healthcare professionals have a longstanding reluctance in addressing gun risks in their patients. Efforts by the American College of Physicians, the American Academy of Pediatrics, the National Association of Social Workers, the APA, and many other health and mental health organizations are helping to overcome this resistance [211,212]. Asking patients about firearms, counseling them on safe firearm behaviors, and taking further steps with high-risk patients are some critically important actions to help prevent gun violence and accidents [212].

General Barriers

The healthcare team strives to prevent important health and mental health problems at the individual and population levels, but in general, does poorly at gun injury prevention. Members of the team infrequently ask about firearms and counsel poorly, if at all, despite awareness that the high lethality of guns makes prevention efforts particularly important [213].

In a 2014 survey of 573 internal medicine physicians, 58% reported never discussing with their patients whether there were guns in the home, 80% never discussed whether the patient used guns, 77% never discussed ways to reduce the risk for gun-related injury or death, and 62% reported never discussing the importance of keeping guns away from children [214].

In a survey study of 339 psychologists, 78.2% reported having no systems in place for identifying patients with access to firearms [215]. Only 51.6% of those surveyed indicated they would initiate firearm safety counseling if the patients were assessed as at risk for self-harm or harm to others, and 46% reported not receiving any information on firearm safety issues [215].

Many barriers exist. Perhaps the most important is an unfamiliarity with firearms themselves, with the benefits and risks of firearm ownership, and with what to say during firearm safety counseling and how to say it. Some may worry that asking questions that seem intrusive may invite discord or damage the patient relationship. They may feel uncomfortable asking about firearms, even when they are well-informed, or worry that patients will not be truthful. Some may believe that firearm counseling is outside their scope of practice or infringes on patients' Second Amendment rights [213].

Gun Culture and Clinician Barriers

Fully grasping and appreciating the perspectives, beliefs, and values of gun culture members is vital for providers who are not part of the culture (Appendix: Understanding Gun Culture). Now considered culture blindness, this may lead to failures in engaging the patient, understanding their interests, and communicating useful information to them or their family [32,216,217]. Effective work with gun owners is considered a cross-cultural issue that requires the integration of gun violence evidence with the culture and interests of gun owners [32,218].

Patient-centered care, a guiding principle in many disciplines, requires cultural competence for patient populations diverse by ethnic heritage, religious beliefs, sexual orientation, and other factors. Cultural competence includes respect for cultural variation, awareness of diverse beliefs and practices, interest in learning about other cultures and skills that enhance cross-cultural communication, and acknowledgment that practicing cultural competence enhances the delivery of quality health care [218]. Healthcare providers should view gun ownership as linked to membership of a subculture, with cultural competence for gun safety counseling requiring the recognition of multiple gun owner subpopulations with differing perspectives and motivations [218].

Health and mental health providers should recognize and work to reduce their knowledge gaps or biases, while taking steps to optimize patient education and communication. This approach is used in counseling patients on other controversial behaviors with potential health consequences, like using helmets and seat belts, accepting childhood vaccinations, and reliance on naturopathic remedies. Clinicians may feel uncomfortable or uninformed when discussing certain subjects and may disagree with patient choices or beliefs, but discomfort or disagreement cannot justify condescension or silent inaction [218].

Gun Culture and Patient Barriers

The limited availability and recognized need for healthcare provider training on firearm-related issues has invited patient misunderstanding, as clinicians often enter gun discussions with limited comfort and competence [32]. Some gun-owning patients have interacted with providers who seemed unaware of the issues or intolerant of their perspective and may not view healthcare providers as trustworthy resources for information or concerns about gun safety [218].

Viewpoints of the broader gun owner community have shifted over time, and the current trend shows increased identification and perception as a persecuted group [219]. Some gun owners perceive medical and mental health clinicians as hostile to their interests, values, and rights [32]. This highlights the importance for clinicians to reach across a cultural divide by understanding the perspective of patients in gun culture.

Prohibitions on Asking About Firearms

Some states have enacted laws with the stated intent to protect patient privacy and prevent intrusive questioning of gun ownership. Florida passed a law in 2011, the Firearm Owners' Privacy Act (FOPA), imposing disciplinary sanctions for clinicians who ask about or document patient gun ownership. A clause permitted this when relevant to safety, but many providers believed questioning was illegal under any circumstances and refrained from doing so. Key provisions were overturned in 2017 [32,220,221].

While there is presently no state or federal statute that should interfere with initiating gun conversations with patients, the impact of actual or perceived threat of professional sanctions on gun discussions with patients may be substantial [32,218,220]. Concerned clinicians can find the status of gun laws in their state by visiting https://lawcenter.giffords.org/search-gun-law-by-state.

GENERAL GUIDANCE

Patients are more open to firearm safety counseling that is tailored to their context, focused on well-being and safety, and involves the family in discussions. The following section provides suggestions on how to approach gun discussions [211,213,218,220].

Individualize and provide health context for questions. Explain the context for asking about guns when routinely assessing gun safety, such as part of routine household hazard screening for parents of toddlers and risk behaviors for teens. With counseling, use different educational messages for parents of young children, family members of patients with cognitive impairment, and suicidality. Acknowledge local cultural norms.

Avoid accusatory questions. If a patient is struggling with suicidal thoughts, instead of asking "Do you have a gun?", consider "Some of my patients have guns at home, and some gun owners with suicidal thoughts choose to make their guns less accessible. Are you interested in talking about that?"

Start with open-ended questions. To avoid sounding judgmental, instead of starting with, "Is your gun safely secured?", ask "Do you have any concerns about the accessibility of your gun?"

Avoid being overly prescriptive. Meet patients where they are. When risk is present, instead of prescribing one specific solution, consider brainstorming. Removing the gun may be objectively optimal but when resisted by the patient, turn to making the gun less accessible by discussing various options (e.g., surrendering the gun, disposing of ammunition, storing the gun outside the home). This is consistent with the principles of shared decision-making.

Health and mental health professionals have an opportunity to educate patients about safe storage, household risk factors, and risk mitigation, which is particularly important when increased risk factors apply. Educate patients on firearm safety and include statistics on risks of injury or death, conveyed as less judgmental by written educational material with resources. To refine the patient education approach, professionals should collaborate with gun-owner community members. The suggestion, "Don't just ask, inform" emphasizes patient education and not just information gathering.

The three basics of gun safety assessment and counseling are [211,213]:

- Ask

- Assess

- Counsel (regarding safe storage and decreased access)

Ask first, "Are any firearms kept in or around your home?" If "yes," ask two follow-up questions:

- "Do any of these firearms belong to you personally?"

- "Are any of these firearms stored loaded and not locked away?"

Assess gun access by high-risk household members (e.g., those with history of violence, children or teenagers, suicidal or depressed, IPV survivors or perpetrators, alcohol abuse, cognitive impairment). With guns in the home, ask about the "5 Ls" risk factors (Locked, Loaded, Little children, feeling Low, Learned owner) and ask if the operator has cognitive impairment.

Counsel patients that the safest storage at home is unloaded and securely locked, with ammunition locked in a separate container. To decrease gun access, consider storage at a remote location, ammunition disposal (or stored separately), or deactivation by removing a functional part. Providing an educational handout with information on gun storage devices may also be helpful.

If advisability of having guns at home enters discussion, clinicians can point to the abundant evidence establishing that guns at home, and purchasing a handgun, are associated with a substantial, long-lasting increased risk for violent death [213].

Counseling patients on gun safety and risks may involve advising a patient their safest action is to remove guns from the home. If this is resisted, safe storage practices are introduced as a compromise. The conflict between safest approach and compromise approach may create an ethical challenge [220].

Patients with Safety Concerns

For patients with acute risk of gun violence and/or whose information or behaviors suggests suicidal or homicidal ideation or intent, immediately determine access to lethal means and promptly reduce access with patient cooperation if possible (i.e., lethal means counseling). Temporarily relinquishing guns may be needed; use a gun violence restraining order or red flag law, family members, gun shops, or law enforcement (as allowed by state laws). Disclose to others who can reduce risk (e.g., family, law enforcement, psychiatric services). Hospitalize when necessary; bed availability should be long enough to significantly reduce suicide/homicide risk. Those with prescriptive authority should avoid prescribing disinhibiting medication, such as benzodiazepines [205,213,222].

Remember that patient demographics increase the risks of gun-related injury. Middle-aged and older white men and those with children and adolescents in the household are at greater risk. These individuals may be counseled on safe storage and risk reduction [213]. For patients with two or more high-risk factors, counsel on safe storage and risk reduction. In patients with diminished cognitive capacity, disclose to others who can reduce the risk [213].

Laws Addressing Gun Removal from Owner/Possessor

Some laws address individuals at high risk for harming self or others who already possess a gun, by allowing petition for a court order that respondents relinquish their gun(s).

Domestic violence restraining orders (DVROs), with or without gun restrictions, have little effect on intimate partner homicides. DVROs reduce gun intimate partner homicides only when expanded to cover dating partners and ex parte orders (temporary until court hearing with respondent appearance) [224].

Some states have laws that restrict gun purchase and possession from those convicted of misdemeanor crimes of domestic violence and minimally reduce intimate partner homicide. However, misdemeanor crimes of domestic violence laws expanded to restrict gun purchase/possession from those convicted of any violent misdemeanor crime substantially reduce overall intimate partner homicides (-23%) and gun intimate partner homicides (-25%) [224].

Gun violence restraining orders are court orders to temporarily prevent gun access of high-risk individuals in crisis, independent of psychiatric history. Some state gun violence restraining orders allow gun removal if not voluntarily surrendered [225,226].

Red flag laws (or extreme risk protection orders, in some states) provide a legal means for gun removal when other mechanisms are absent. Two states enacted red flag laws after being powerless to disarm individuals with warning signs of danger before they committed gun massacres. Florida passed its law after the Parkland shooting in 2018, and California passed its law in 2014 after the mass murder by Elliot Rodger [91].

Laws that explicitly require gun surrender or grant law enforcement officers authority to remove guns more effectively reduce gun violence than laws that leave enforcement unaddressed. Gun relinquishment may not occur just because it is ordered. Although enforcement of court orders can be done effectively, efforts to ensure implementation or enforcement by state and local jurisdictions have varied [224,227].

IPV and Guns

In patients with suspected IPV from a current or former intimate, clinicians should ask about abuser gun ownership regardless of co-habitation status. In addition to lethality threat, the psychologic impact of merely displaying or handling a gun can facilitate coercive control. As a situation of chronic and escalating abuse, coercive control involving a gun portends ill for the woman [179,223]. Patients injured by, or exposed to, gun violence are at risk for developing post-traumatic stress disorder or risky self-medication [222].

Duty to Warn

Patient disclosures to mental health professionals are typically protected by federal and state laws covering doctor/patient privilege and by practitioners' ethics rules governing confidentiality. Duty to warn is the exception, summarized to mean that privacy and privilege end where danger to the public begins [26]. This includes potential mass violence.

Tarasoff law states that therapists, clinicians, and other mental health counselors have the duty to protect third parties from harm. As a result of this legislation, clinicians have a duty to protect the third party by warning the targeted victim or others who can then warn the intended victim, notifying law enforcement, and implementing other steps to protect the potential victim [228]. These laws are state-specific and the professions affected vary.

CONSIDERATIONS TO AVOID STIGMATIZING PATIENTS WITH MENTAL ILLNESS

Mental health interventions to prevent mass shootings are based on the supposition that psychiatric evaluations can predict and thus prevent mass shootings. Such proposals are the logical conclusion of ascribing blame to untreated serious mental illness [9,229]. However, most mass murderers do not have identifiable serious mental illness; most have maladaptive personality configurations. As such, gun access, not serious mental illness, determines most gun homicides [230].

The framing of mass violence as a serious mental illness problem persists, despite the statistically improbable odds of dying from gunshot by a stranger with psychotic illness [32]. The behavior and motives of mass shooters should be distinguished from psychiatric diagnoses [9].

Mass shooters are typified by long-standing, pervasive anger, persecution, violent revenge, and egotism—psychopathology for which the mental health field has no immediate, quick-acting "treatment." Mental health professionals can help troubled individuals willing to engage in psychotherapy, medication therapy, and/or substance abuse counseling, but the persecutory narcissistic pathology of mass shooters subverts such willingness, and they usually shun mental health treatment [9].

Psychiatric diagnosis is largely an observational tool, not an extrapolative one. A psychiatric diagnosis is not predictive of violence, and predictions of future dangerousness based on psychiatric judgement are not much better than chance alone. Even the overwhelming majority of psychiatric patients who superficially match the profile of mass shooters (i.e., gun-owning, angry, paranoid white men) do not commit crimes [19].

Some mass shooters (e.g., Cho, Harris, Breivik, Holmes, Lanza, Rodger) had been evaluated by psychiatrists prior to committing violence. Their assessments seemed cursory and focused on obvious symptoms, like anger. Without looking further into their personality pathology, the disproportionality of grievances and rage remained undetected and they went on to perpetrate [45]. Expecting psychiatrists, mental health workers, or primary care providers to prevent mass shootings imposes an impossible, ineffective burden [229].

CONSIDERATIONS FOR NON-ENGLISH-PROFICIENT PATIENTS/CLIENTS

As a result of the evolving racial and immigration demographics in the United States, interaction with patients for whom English is not a native language is inevitable. Because patient education is such an important aspect of the care of patients at risk for gun violence, it is each practitioner's responsibility to ensure that information and instructions are explained in such a way that allows for patient or caregiver understanding. When there is an obvious disconnect in the communication process between the practitioner and patient due to the patient's lack of proficiency in the English language, an interpreter is required. (In many cases, the terms "interpreting" and "translating" are used interchangeably, but interpreting is specifically associated with oral communication while translating refers to written text.) Frequently, this may be easier said than done, as there may be institutional and/or patient barriers.

Depending upon the patient's language, an interpreter may be difficult to locate. Or, an organization may not have the funds to bring in an interpreter. Also, bringing in an interpreter creates a triangular relationship with a host of communication dynamics that must be negotiated [231]. Many view interpreters merely as neutral individuals who communicate information back and forth. However, another perspective is that the interpreter is an active agent, negotiating between two cultures and assisting in promoting culturally competent communication and practice [232,233]. In this more active role, the interpreter's behavior is also influenced by a host of cultural variables such as gender, class, religion, educational differences, and power/authority perceptions of the patient [232,233]. Consequently, an intricate, triangular relationship develops between all three parties. Another factor affecting the communication process is the fact that many interpreters are not adequately trained in the art of interpretation in mental health and general health settings, as there are many technical and unfamiliar terms. An ideal interpreter goes beyond being merely proficient in the needed language/dialect [234]. Interpreters who are professionally trained have covered aspects of ethics, impartiality, accuracy, and completeness [235]. They are also well-versed in interpreting both the overt and latent content of information without changing any meanings and without interjecting their own biases and opinions [235]. Furthermore, knowledge about cross-cultural communication and all the subtle nuances of the dynamics of communicating in a mental health or general health setting is vital [233,234].

On the patients' side, they may be wary about utilizing interpreters for a host of reasons. They may find it difficult to express themselves through an interpreter [236]. If an interpreter is from the same community as the patient, the client/patient may have concerns about sharing private information with an individual who is known in the community and the extent to which the information disclosed would remain confidential. In some cases, raising the issue of obtaining an interpreter causes the client/patient to feel insulted that their language proficiency has been questioned. Finally, if an interpreter is from a conflicting ethnic group, the patient may refuse having interpreter services [231]. The ideal situation is to have a well-trained interpreter who is familiar with health and mental health concepts.

If an interpreter is required, the practitioner must acknowledge that an interpreter is more than a body serving as a vehicle to transmit information verbatim from one party to another [236]. Instead, the interpreter should be regarded as part of a collaborative team, bringing to the table a specific set of skills and expertise [236]. Several important guidelines should be adhered to in order to foster a beneficial working relationship and a positive atmosphere.

A briefing time between the practitioner and interpreter held prior to the meeting with the client/patient is crucial. The interpreter should understand the goal of the session, issues that will be discussed, specific terminology that may be used to allow for advance preparation, preferred translation formats, and sensitive topics that might arise [234,236,237]. It is important for the client/patient, interpreter, and practitioner to be seated in such a way that the practitioner can see both the interpreter and client/patient. Some experts recommend that the interpreter sit next to the client/patient, both parties facing the practitioner [235].

The practitioner should always address the client/patient directly. For example, the practitioner should query the client/patient, "How do you feel?" versus asking the interpreter, "How does she feel?" [235]. The practitioner should also always refer to the client/patient as "Mr./Mrs. D" rather than "he" or "she" [236]. This avoids objectifying the client/patient.

At the start of the session, the practitioner should clearly identify his/her role and the interpreter's role [236]. This will prevent the client/patient from developing a primary relationship or alliance with the interpreter, turning to the interpreter as the one who sets the intervention [234]. The practitioner should also be attuned to the age, gender, class, and/or ethnic differences between the client/patient and the interpreter [236]. For example, if the client/patient is an older Asian male immigrant and the interpreter is a young, Asian female, the practitioner must be sensitive to whether the client/patient is uncomfortable given the fact he may be more accustomed to patriarchal authority structures. At the conclusion of the session, it is advisable to have a debriefing time between the practitioner and the interpreter to review the session [234,236,237].

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

9. RESOURCES

American College of Physicians

Commitment to discuss gun safety with patients.

http://go.annals.org/commit-now

American Psychological Association

https://www.apa.org/topics/violence/gun-violence-prevention

American Public Health Association

https://www.apha.org/topics-and-issues/gun-violence

Annals of Internal Medicine

To help healthcare providers become knowledgeable of gun safety and risks, the Annals of Internal Medicine has made gun-related content available for free.

https://annals.org/aim/pages/firearm-related-content

Coalition to Stop Gun Violence

https://www.csgv.org

Everytown for Gun Safety

https://everytown.org

Giffords Law Center to Prevent Gun Violence

Comprehensive information on federal and state gun laws.

https://lawcenter.giffords.org

Office for Victims of Crime

Victims of Mass Violence and Terrorism Toolkit

https://www.ovc.gov/pubs/mvt-toolkit

10. CONCLUSION

Mass shooting incidents have become overfamiliar to health and mental health providers and the public. The close associations between public mass shooters, extremists who commit mass violence, and domestic mass shooters are largely unknown. Mass shootings are acts of targeted violence fueled by personal or ideologic motive. For both offender types, the pathway to violence begins with grievance and alienation. Contrary to common misperception, mass violence is rarely committed by offenders experiencing serious mental illness or by offenders who "snap." In addition, most recent victims in the United States have been killed by far-right extremists rather than Islamist extremists. Mass shootings are typically defined as at least four persons killed over a brief period, and a large proportion of public mass violence perpetrators have histories of domestic violence. Mass shootings and domestic homicides are part of the larger public health concern of gun violence. Health and mental health providers are encouraged to initiate gun conversations with their patients. However, knowledge of gun injury statistics and gun culture that many gun owners are a part of are required for clinicians to play an effective role in reducing gun violence.

11. APPENDIX: UNDERSTANDING GUN CULTURE

Households with guns have demonstrably greater risk for homicide, suicide, and/or accidental firearm death of a household member. For providers devoted to preserving life and promoting health, this can make advising patients in risk situations to remove guns from their home seem ethically self-evident [220,222].

However, a cultural divide can exist between gun-owning patients and clinicians. For many patients who own guns, gun ownership is a core element of a deeply rooted system of beliefs and values referred to as gun culture. Clinicians who are not part of this culture benefit from an understanding of the perceptions, beliefs, and values of gun culture members before initiating gun safety conversations with their patients. Although difficult for some clinicians, this reflects cross-cultural competence, a core element of patient-centered care. Understanding gun culture can make the difference between reaching versus alienating a patient.

THE LEGAL CONTEXT OF GUN RIGHTS

Ratified into law in 1791, the Second Amendment to the U.S. Constitution reads, "A well-regulated Militia, being necessary to the security of a free State, the right of the people to keep and bear Arms, shall not be infringed." The U.S. Supreme Court has affirmed the right to bear arms was the right for the individual, attachment to a militia was not relevant, and the protection expressly extended to firearms well-suited for self-defense [32].

MEDIA DEPICTION AND SYMBOLISM

In the United States, guns are bestowed with powerful symbolism that conveys empowerment, self-defense, self-sufficiency, and virility [34,238]. The extent that guns are literally and symbolically enshrined in American culture is beyond the scope of this course. It is worth mentioning that guns are powerfully associated with masculinity. The images conveyed in American movies of guns as signifiers of virility and power are especially potent for disempowered white, working-class men. Guns figure prominently in the socialization of men from a very early age [239].

Media depictions of guns for self-protection conflict with objective evidence that gun access is more likely to facilitate than prevent violence [188]. The United States is one of very few countries relaxing instead of tightening access to guns. Diverse cultural aspects reinforce the idea that firearms are invaluable for self-defense in a dangerous world, despite evidence that guns heighten the risk of suicide and homicide [188,204].

GUN CULTURE

Gun culture and its members represent a unique cultural subgroup. Many gun owners intensely resist public policy or clinician efforts that might limit gun access or ownership in some way and perceive such efforts as threats to their culture, values, and way of life. Gun culture and its members can be difficult for outsiders to understand [218]. Formal study of gun culture has been sparse, but recent research has been published to shed light on the values, attitudes, and beliefs of gun culture members. An important point is that research tends to report averages, but the circumstances and experiences of each individual and family are unique [188]. Also, the few available studies may not be representative of the universe of gun culture members.

Firearm ownership and use for recreation and personal defense have long been an integral part of the broader U.S. culture. In many parts of the country, social norms include participation in social activities around gun ownership [240]. In general, there is a sense of identity among gun owners and enthusiasts, often anchored in a shared enjoyment of owning and using firearms and tied to family traditions, personal beliefs, and social relationships [32]. Exposure to gun culture is robustly associated with gun ownership and both are mutually reinforcing [188,240].

The First-Person Perspective

For those not raised in homes with firearms, gun ownership can begin from an awareness of threat and of one's vulnerability given the delay in police response that increases in rural areas. The first gun purchase is followed by instructions and practice, which brings an exciting thrill of mastering a powerful tool. The gun at home increases the feeling of confidence and sense of safety from the protection it affords. Wanting that sense of safety and confidence away from home, a concealed-carry permit is obtained. Carrying the weapon feels empowering, and no longer depending on the state for one's personal security and safety feels liberating. The enthusiasm continues as one enters the social networks of other gun owners. A changing worldview becomes noticeable [241].

Gun owners tend to believe that government regulation should deny guns to the dangerous while protecting the rights of access for the law-abiding. From this perspective, criminals and the dangerously mentally ill are believed to make the nation more violent, while law-abiding gun owners save and protect lives. Gun owners insist the government enforce existing laws, largely support existing background checks, and tend to be open to solutions that specifically target troubled individuals for intervention, such as gun violence restraining orders. Proposals such as bans on assault weapons and large-capacity magazines are opposed, as they are believed to punish the innocent and briefly inconvenience the lawless [241].

Gun Ownership and Empowerment

Guns carry powerful symbolic meaning that can promote gun owner attachment to their weapons extending beyond their self-defense utility. To better understand this relationship, 577 gun owners were administered the Gun Empowerment Scale. White men in economic distress showed greatest attachment to their guns, as a means to re-establish a sense of individual power [242,243].

With changing economic realities, many working-class white men have lost, or perceive they are losing, their advantage and benefits from previous power and economic hierarchies. With expectation of status and power in their communities frustrated, the gun becomes a symbol through which to regain a lost sense of empowerment, nostalgic masculinity, and sense of self [242,243].

Gun owners can be emotionally and spiritually attached to the weapon, but owners highly involved in their religious community are less likely to feel empowered by their guns. This suggests that white men most attached to their guns may use firearms to substitute for other cultural sources of meaning and identity. Women and nonwhites who have suffered economic setbacks were not more likely to find empowerment in guns and tended to look elsewhere [242,243].

Many working-class white men feel embittered over real or perceived economic setbacks. Searching for explanations of their circumstances, some find solace in narratives that cast blame at external forces designed to undermine the white working class. Such narratives reinforce the longstanding media messages that the government is interested in taking their guns and money. In one study, many described feeling highly patriotic through their gun ownership. Owners most attached to their guns were politically conservative and felt that violence against the government is sometimes justified, reflecting beliefs that developed from exposure to these and related narratives [242,243].

Most gun owners support some gun legislation and do not support the idea of arming everyone. Gun owners who score high on the Gun Empowerment Scale show the strongest pro-gun policy attitudes, viewing that arming teachers and the public would make schools and citizens safer. This is thought to reflect avoidance of cognitive dissonance, an aspect of normal psychology whereby individuals who highly value their benefits from a source are disinclined to objectively examine that source [242,243].

Beliefs of Self-Defense

Violent crime statistics cannot explain the relationship between threat perception and motivation for owning/carrying guns for self-protection. Instead, a social-cognitive perspective is used to examine how threat perception influences motivations to purchase a handgun and endorse broad gun rights. Long guns (i.e., rifles, shotguns) are owned mainly for hunting, target shooting, and similar activities. Self-protection is typified by handgun ownership [188].

Two distinct types of perceived threats were measured in a nationally representative sample of 899 male gun owners and non-owners [244]:

- Belief in a dangerous world: A diffuse, abstract belief of the world as a dangerous unpredictable place

- Perceived lifetime risk of assault: A specific, concrete threat that one may become a victim of violent assault

Belief in a dangerous world reflects a worldview that sees the world as an inherently dangerous, unpredictable, and threatening place. High belief in a dangerous world is strongly associated with political conservatism and right-wing authoritarianism and correlates with a subtle bias toward minorities (termed symbolic racism) [245,246,247,248]. High belief in a dangerous world was the strongest predictor of need for protection/self-defense. Only handgun owners perceived greater threats than non-owners, with higher perceived lifetime risk of assault and belief in a dangerous world than both non-owners and owners of long guns only. Perceived lifetime risk of assault was influenced by previous victimization experience. Belief in a dangerous world was mainly determined by a politically conservative orientation, but not previous victimization [244].

The belief in a dangerous worldview that motivates handgun purchase also shapes beliefs about how handguns can and should be used. These include the rights of gun owners to shoot or kill other people in self-defense, the fundamentality of Second Amendment rights and opposition to laws infringing on gun rights, strong gun rights advocacy, and belief that a well-armed society is a safe society [244].

The belief in a dangerous world reflects a worldview that forms during early socialization, making it very difficult to influence. Worldviews are coherent belief systems, and changing any one specific belief would make it inconsistent with many other beliefs [249]. Efforts to dissuade handgun owners with a high belief in a dangerous world from needing a gun for self-defense are more likely to alienate than succeed. When specific risk perception drives the need for self-defense, persuasion could be aimed at reducing perceived threat (when inconsistent with actual threat) [244].

Other Sociocultural Factors

Today, efforts to increase gun control have been fiercely resisted primarily by white Americans, but this has not always been the case. During the civil rights movement of the late 1960s, Black Panthers and other black activists exercised their right to carry loaded firearms for protection against the police and other perceived threats (e.g., violent white opponents). Californians responded by demanding stricter gun control, and Governor Ronald Reagan signed a law in 1967 that prohibited carrying loaded firearms in public [248].

The reasons for gun ownership and gun control opposition are complex, but a link is established between racial considerations, gun ownership, and gun control views. Research indicates that racial resentment is integral to National Rifle Association (NRA) discourse and identity of many white gun owners. Among whites, a strong negative correlation was found between racial resentment and endorsement of gun control policy [247,248].

Symbolic racism is not overt racism but is implicit bias—a subtle, subconscious form usually not linked to consciously held racist attitudes. Symbolic racism develops as a belief structure through early exposure to negative racial stereotypes. Individuals with high levels of symbolic racism respond negatively to issues perceived to involve a racial component, including policy preferences. In a large study of white Americans, higher symbolic racism increased the odds of having a gun in the home and greater opposition to gun control, after crime victimization and other explanatory factors were controlled [248]. However, while some gun ownership experiences are specific to white Americans, especially in rural areas, the enticement of guns to men cuts across racial lines.

Works Cited

1. Post JM. Terrorism and right-wing extremism: the changing face of terrorism and political violence in the 21st century: the virtual community of hatred. Int J Group Psychother. 2015;65(2):243-271.

2. Hari J. Blood, Rage and History: The World's First Terrorists. Available at https://www.independent.co.uk/news/world/politics/blood-rage-history-the-worlds-first-terrorists-1801195.html. Last accessed March 11, 2019.

3. Post JM, McGinnis C, Moody K. The changing face of terrorism in the 21st century: the communications revolution and the virtual community of hatred. Behav Sci Law. 2014;32(3):306-334.

4. Sparrow J. In the End, We Forget the Anarchists, Bombers and "Lone Wolves," but the Hysteria They Provoke Stays With Us. Available at https://www.theguardian.com/commentisfree/2015/jan/02/in-the-end-we-forget-the-anarchists-bombers-and-lone-wolves-but-the-hysteria-they-provoke-stays-with-us. Last accessed March 11, 2019.

5. Ketcham C. When Revolution Came to America: A Brief History of Violence Against Wall Street and its Accomplices. Available at https://www.vice.com/en_us/article/8gd3px/kill-the-banker-0000525-v21n12. Last accessed March 11, 2019.

6. Florida Department of Corrections. 1933–1935. Available at http://www.dc.state.fl.us/oth/timeline/1933-1935.html. Last accessed May 16, 2018.

7. Bernstein A. Bath Massacre: America's First School Bombing. Ann Arbor, MI: University of Michigan Press; 2009.

8. Dozier V. Bath School Disaster: 89th Anniversary of the Deadliest Act of Mass Murder in a School in the U.S. Available at https://www.lansingstatejournal.com/story/news/local/2016/05/18/bath-school-disaster-89th-anniversary-deadliest-act-mass-murder-school-us/84498214/. Last accessed March 11, 2019.

9. Knoll JL, Annas GD. Mass shootings and mental illness. In: Gold LH, Simon RI (eds). Gun Violence and Mental Illness. Arlington, VA: American Psychiatric Association Publishing; 2016.

10. Gulliver K. Why We Have Forgotten the Worst School Attack in U.S. History? Available at http://time.com/4492872/kehoe-attack-history. Last accessed March 11, 2019.

11. Weinman S. Massacre on Ninth and Main. Available at https://www.buzzfeed.com/sarahweinman/how-a-forgotten-1903-killing-spree-became-the-first-modern-m. Last accessed March 11, 2019.

12. Duwe G. A circle of distortion: the social construction of mass murder in the United States. West Crim Rev. 2005;6(1):59-78.

13. Allely CS, Minnis H, Thompson L, Wilson P, Gillberg C. Neurodevelopmental and psychosocial risk factors in serial killers and mass murderers. Aggress Violent Behav. 2014;19(3):288-301.

14. Las Vegas Metropolitan Police Department. Preliminary Investigation Report 1: October/Mass Casualty Shooting. Available at https://www.lvmpd.com/en-us/Documents/1_October_FIT_Report_01-18-2018_Footnoted.pdf. Last accessed March 11, 2019.

15. Follman M. The Las Vegas Shooter Didn't Just "Snap." They Never Do. Available at https://www.motherjones.com/crime-justice/2017/10/the-las-vegas-shooter-didnt-just-snap-they-never-do. Last accessed March 11, 2019.

16. Ritter K, Price ML. Vegas Shooting Papers Hint Some May Have Encountered Gunman. Available at https://apnews.com/29e426a2ec014c0492cd5aef40f579b4. Last accessed March 11, 2019.

17. Dalrymple J. The Las Vegas Shooter Went on an Anti-Government Rant Weeks Before His Deadly Attack. Available at https://www.buzzfeednews.com/article/jimdalrympleii/las-vegas-shooter-witness-statements. Last accessed March 11, 2019.

18. Southern Poverty Law Center. Antigovernment Movement. Available at https://www.splcenter.org/fighting-hate/extremist-files/ideology/antigovernment. Last accessed March 11, 2019.

19. Metzl JM, MacLeish KT. Mental illness, mass shootings, and the politics of american firearms. Am J Public Health. 2015;105(2):240-249.

20. Duwe G. The patterns and prevalence of mass public shootings in the United States, 1915–2013. In: Wilson LC (ed). The Wiley Handbook of the Psychology of Mass Shootings. Hoboken, NJ: John Wiley and Sons; 2017.

21. Barrouquere B, Janik R. Lessons to be Learned from the ROF Florida Shooting Hoax. Available at https://www.splcenter.org/hatewatch/2018/02/20/lessons-be-learned-rof-florida-shooting-hoax. Last accessed March 11, 2019.

22. Barrouquere B. ROF Leader's Comments About Florida School Shooting Basis for Search Warrant for Home. Available at https://www.splcenter.org/hatewatch/2018/04/03/rof-leader%E2%80%99s-comments-about-florida-school-shooting-basis-search-warrant-home. Last accessed March 11, 2019.

23. Knoll JL IV. The "pseudocommando" mass murderer: a blaze of vainglory. Psychiatr Times. 2012;29(1):1-11.

24. Knoll JL IV. How to Prevent Mass Shootings. Available at https://truthout.org/articles/how-to-prevent-mass-shootings-a-case-in-point. Last accessed March 11, 2019.

25. Rocque M, Duwe G. Rampage shootings: an historical, empirical, and theoretical overview. Curr Opin Psychol. 2018;19:28-33.

26. Amman M, Gibson KA, Bowlin M, et al. Making Prevention a Reality: Identifying, Assessing, and Managing the Threat of Targeted Attacks. Available at https://www.fbi.gov/file-repository/making-prevention-a-reality.pdf. Last accessed March 11, 2019.

27. Knoll JL, Pies RW. Mounties, cowboys, avengers—and the cultural script of gun violence. Psychiatric Times. 2016;33(1).

28. Hamlett LE. Common Psycholinguistic Themes in Mass Murderer Manifestos. Available at https://scholarworks.waldenu.edu/dissertations/3493. Last accessed March 11, 2019.

29. Knoll JL IV. The "pseudocommando" mass murderer: part II, the language of revenge. J Am Acad Psychiatry Law. 2010;38(2):263-272.

30. Smith S, Shuy R. Forensic psycholinguistics: using language analysis for identifying and assessing offenders. FBI Law Enforcement Bulletin. 2002;71(4):16-21.

31. Davenport L. Psychiatrists the Most Common Victims of Physician Homicide. Available at https://www.medscape.com/viewarticle/895220. Last accessed March 11, 2019.

32. Rozel JS, Mulvey EP. The link between mental illness and firearm violence: implications for social policy and clinical practice. Annu Rev Clin Psychol. 2017;13:445-469.

33. Phelan J, Link B, Stueve A, Pescosolido BA. Public conceptions of mental illness in 1950 and 1996: what is mental illness and is it to be feared? J Health Soc Behav. 2000;41(2):188-207.

34. Fan MD. Disarming the dangerous: preventing extraordinary and ordinary violence. Indiana Law Journal. 2015;90(1):151-178.

35. Fazel S, Grann M. The population impact of severe mental illness on violent crime. Am J Psychiatry. 2006;163(8):1397-1403.

36. Martone CA, Mulvey EP, Yang S, Nemoianu A, Shugarman R, Soliman L. Psychiatric characteristics of homicide defendants.Am J Psychiatry. 2013;170(9):994-1002.

37. Meloy JR. The seven myths of mass murder. Violence Gend. 2014;1(3):102-104.

38. Van Dorn R, Volavka J, Johnson N. Mental disorder and violence: is there a relationship beyond substance use? Soc Psychiatry Psychiatr Epidemiol. 2012;47(3):487-503.

39. Monahan J, Steadman H, Silver E, et al. Rethinking Risk Assessment: The MacArthur Study of Mental Disorder and Violence. New York, NY: Oxford University Press; 2001.

40. Meloy JR, Yakeley J. The violent true believer as a "lone wolf:" psychoanalytic perspectives on terrorism. Behav Sci Law. 2014;32(3):347-365.

41. Rahman T, Resnick PJ, Harry B. Anders Breivik: extreme beliefs mistaken for psychosis. J Am Acad Psychiatry Law. 2016;44(1):28-35.

42. Rahman T. Extreme overvalued beliefs: how violent extremist beliefs become "normalized." Behav Sci. 2018;8(1):10.

43. Allely CS, Wilson P, Minnis H, Thompson L, Yaksic E, Gillberg C. Violence is rare in autism: when it does occur, is it sometimes extreme? J Psychol. 2017;151(1):49-68.

44. Baumeister RF, Smart L, Boden JM. Relation of threatened egotism to violence and aggression: the dark side of high self-esteem. Psychol Rev. 1996;103(1):5-33.

45. Dutton DG, White KR, Fogarty D. Paranoid thinking in mass shooters. Aggress Violent Behav. 2013;18(5):548-553.

46. Knoll JL, Meloy JR. Mass murder and the violent paranoid spectrum. Psychiatr Ann. 2014;44(5):236-243.

47. Steffgen G, Recchia S, Viechtbauer W. The link between school climate and violence in school: a meta-analytic review. Aggress Violent Behav. 2013;18(2):300-309.

48. Rosen IC. Revenge—the hate that dare not speak its name: a psychoanalytic perspective. J Am Psychoanal Assoc. 2007;55(2):595-620.

49. Menninger WW. Uncontained rage: a psychoanalytic perspective on violence. Bull Menninger Clin. 2007;71(2):115-131.

50. van der Meer B, Meloy JR, Hoffmann J. The Adult Mass Murderer in Europe and North America: Available at http://drreidmeloy.com/wp-content/uploads/2017/08/ATAP2017.pdf. Last accessed March 11, 2019.

51. Cascio CN, Konrath SH, Falk EB. Narcissists' social pain seen only in the brain. Soc Cogn Affect Neurosci. 2015;10(3):335-341.

52. Chester DS, DeWall CN. Sound the alarm: the effect of narcissism on retaliatory aggression is moderated by dACC reactivity to rejection. J Pers. 2016;84(3):361-368.

53. Terman DM. Aggression and narcissistic rage: a clinical elaboration. Annals of Psychoanalysis. 1975;3:239-255.

54. White SG, Meloy JR, Mohandie K, Kienlen K. Autism spectrum disorder and violence: threat assessment issues. Journal of Threat Assessment and Management. 2017;4(3):144-163.

55. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013.

56. Harrington and Mahoney Law Firm. Asperger's Syndrome and the Criminal Law: The Special Case of Child Pornography. Available at https://www.harringtonmahoney.com/content/Publications/AspergersSyndromeandtheCriminalLawv26.pdf. Last accessed March 11, 2019.

57. Im DS. Template to perpetrate: an update on violence in autism spectrum disorder. Harv Rev Psychiatry. 2016;24(1):14-35.

58. Volkmar FR, McPartland JC. From Kanner to DSM-5: autism as an evolving diagnostic concept. Annu Rev Clin Psychol. 2014;10:193-212.

59. Bjørkly S. Risk and dynamics of violence in Asperger's syndrome: a systematic review of the literature. Aggress Violent Behav. 2009;14(5):306-312.

60. Kawakami C, Ohnishi M, Sugiyama T, Someki F, Nakamura K, Tsujii M. The risk factors for criminal behavior in high-functioning autism spectrum disorders (HFASDs): a comparison of childhood adversities between individuals with HFASDs who exhibit criminal behavior and those with HFASD and no criminal histories. Res Autism Spectr Disord. 2012;6(2):949-957.

61. Twenge JM, Konrath S, Foster JD, Campbell WK, Bushman BJ. Egos inflating over time: a cross-temporal meta-analysis of the Narcissistic Personality Inventory. J Pers. 2008;76(4):875-902.

62. Twenge JM, Campbell WK, Freeman EC. Generational differences in young adults' life goals, concern for others, and civic orientation, 1966–2009. J Pers Soc Psychol. 2012;102(5):1045-1062.

63. Knoll JL. Mass Shootings: Research and Lessons. Available at https://www.psychiatrictimes.com/disaster-psychiatry/mass-shootings-research-and-lessons. Last accessed March 11, 2019.

64. Lankford A. Do the media unintentionally make mass killers into celebrities? An assessment of free advertising and earned media value. Celebr Stud. 2018;9(3):340-354.

65. Mullen PE. The autogenic (self-generated) massacre. Behav Sci Law. 2004;22(3):311-323.

66. Meloy JR. Threat assessment: scholars, operators, our past, our future. Journal of Threat Assessment and Management. 2015;2(3-4):231-242.

67. Liem M, van Buuren J, de Roy van Zuijdewijn J, Schönberger H, Bakker E. European lone actor terrorists versus "common" homicide offenders: an empirical analysis. Homicide Stud. 2018;22(1):45-69.

68. Follman M, Lurie J, Lee J, West J. True Cost of Gun Violence in America. Available at https://www.motherjones.com/politics/2015/04/true-cost-of-gun-violence-in-america. Last accessed March 11, 2019.

69. Follman M. How the Media Inspires Mass Shooters and 7 Ways News Outlets Can Help Prevent Copycat Attacks. Available at https://www.motherjones.com/politics/2015/10/media-inspires-mass-shooters-copycats. Last accessed March 11, 2019.

70. Etzersdorfer E, Sonneck G. Preventing suicide by influencing the mass media reporting: the Viennese experience, 1980–1996.Arch Suicide Res. 1998;4(1):67-74.

71. National Science Foundation. Youth Violence: What We Need to Know. Alexandria, VA: National Science Foundation; 2013.

72. Bushman BJ, Newman K, Calvert SL, et al. Youth violence: what we know and what we need to know. Am Psychol. 2016;71(1):17-39.

73. Ferguson CJ, Barra H, Figueroa G, et al. Digital poison? Three studies examining the influence of violent video games on youth. Computers in Human Behavior. 2015;50:399-410.

74. Engelhardt CR, Mazurek MO, Hilgard J, Rouder JN, Bartholow BD. Effects of violent-video-game exposure on aggressive behavior, aggressive-thought accessibility, and aggressive affect among adults with and without autism spectrum disorder. Psychol Sci. 2015;26(8):1187-1200.

75. Ferguson CJ, Bowman ND, Kowert R. Is the link between games and aggression more about the player, less about the game? In: Sturmey P (ed). The Wiley Handbook of Violence and Aggression. London: Wiley-Blackwell; 2017.

76. Pisani AR, Murrie DC, Silverman MM. Reformulating suicide risk formulation: from prediction to prevention. Acad Psychiatry. 2016;40(4):623-629.

77. Coid JW, Kallis C, Doyle M, et al. Identifying causal risk factors for violence among discharged patients. PLoS One. 2015;10(11):e0142493.

78. Simons A, Meloy JR. Foundations of threat assessment and management. In: Van Hasselt VB and Bourke ML (eds). Handbook of Behavioral Criminology. Cham: Springer; 2017.

79. Meloy JR. Perspective: Identifying Warning Behaviors of the Individual Terrorist. Available at https://leb.fbi.gov/articles/perspective/perspective-identifying-warning-behaviors-of-the-individual-terrorist. Last accessed March 11, 2019.

80. Meloy JR. Contemporary Threat Assessment and Management. Presented at: University of Texas Health Science Center; December 5–6, 2016; Houston, TX.

81. Meloy JR, Gill P. The lone actor terrorist and the TRAP-18. Journal of Threat Assessment and Management. 2016;3(1):37-51.

82. Association of Threat Assessment Professionals. Threat Assessment: Defining an Approach for Evaluating Risk of Targeted Violence. Body of Knowledge Summaries. Available at https://c.ymcdn.com/sites/atapworldwide.site-ym.com/resource/resmgr/summaries/12-Threat-Assessment-Definin.pdf. Last accessed March 11, 2019.

83. Calhoun FS, Weston SW. Contemporary Threat Management: A Practical Guide for Identifying, Assessing, and Managing Individuals of Violent Intent. San Diego, CA: Specialized Training Services; 2003.

84. Calhoun FS, Weston SW. Perspectives on threat management. Journal of Threat Assessment and Management. 2015;2(3-4):258-267.

85. Meloy JR, Hoffmann J, Guldimann A, James D. The role of warning behaviors in threat assessment: an exploration and suggested typology. Behav Sci Law. 2012;30(3):256-279.

86. Knoll JL IV. Mass murder: causes, classification, and prevention. Psychiatric Clin North Am. 2012;35(4):757-780.

87. Silver J, Horgan J, Gill P. Foreshadowing targeted violence: assessing leakage of intent by public mass murderers. Aggress Violent Behav. 2018;38:94-100.

88. Meloy JR, Mohandie K, Knoll J, Hoffmann J. The concept of identification in threat assessment. Behav Sci Law. 2015;33(2-3):213-237.

89. Horgan JG, Gill P, Bouhana N, Silver J, Corner E. Across the Universe? A Comparative Analysis of Violent Behavior and Radicalization Across Three Offender Types with Implications for Criminal Justice Training and Education. Available at https://www.ncjrs.gov/pdffiles1/nij/grants/249937.pdf. Last accessed March 11, 2019.

90. Meloy JR. Sexual desire, violent death, and the true believer. Contemp Psychoanal. 2018;54(1):1-20.

91. Everytown for Gun Safety. Moms Demand Action, Gun Violence Survivor, Everytown Respond to Mass Shooting at Santa Fe High School. Available at https://everytown.org/press/moms-demand-action-gun-violence-survivor-everytown-respond-to-mass-shooting-at-santa-fe-high-school. Last accessed March 11, 2019.

92. Bondü R, Scheithauer H. Leaking and death-threats by students: a study in German schools. Sch Psychol Int. 2014;35(6):592-608.

93. Madfis E. Triple entitlement and homicidal anger: an exploration of the intersectional identities of American mass murderers.Men Masc. 2014;17(1):67-86.

94. Sarteschi CM. An examination of thwarted mass homicide plots and threateners. Aggress Violent Behav. 2016;30:88-93.

95. Fox JA, Levin J. Extreme Killing: Understanding Serial and Mass Murder. 3rd ed. Thousand Oaks, CA: Sage Publications; 2015.

96. Schildkraut J, Elsass HJ. Mass Shootings: Media, Myths, and Realities. Santa Barbara, CA: Praeger; 2016.

97. Southern Poverty Law Center. Male Supremacy. Available at https://www.splcenter.org/fighting-hate/extremist-files/ideology/male-supremacy. Last accessed March 11, 2019.

98. Southern Poverty Law Center. For Incels, It's Not About Sex. It's About Women. Available at https://www.splcenter.org/news/2018/05/04/weekend-read-incels-its-not-about-sex-its-about-women. Last accessed March 11, 2019.

99. Wallman B, McMahon P, O'Matz M, Bryan S. School Shooter Nikolas Cruz: A Lost and Lonely Killer. Available at https://www.sun-sentinel.com/local/broward/parkland/florida-school-shooting/fl-florida-school-shooting-nikolas-cruz-life-20180220-story.html. Last accessed March 11, 2019.

100. Meloy JR, Pollard JW. Lone-actor terrorism and impulsivity. J Forensic Sci. 2017;62(6):1643-1646.

101. McCauley C, Moskalenko S. Understanding political radicalization: the two-pyramids model. American Psychologist. 2017;72(3):205-216.

102. van de Weert A, Eijkman QAM. Subjectivity in detection of radicalization and violent extremism: a youth worker's perspective. Behavioral Sciences of Terrorism and Political Aggression. 2018; [Epub ahead of print].

103. Abbas T. Ethnicity and politics in contextualizing far right and Islamist extremism. Perspectives on Terrorism. 2017;11(3):54-61.

104. Borum R. Radicalization into violent extremism I: a review of social science theories. Journal of Strategic Security. 2011;4(4):7-36.

105. Bondokji N, Wilkinson K, Aghabi L. Understanding Radicalization: A Literature Review of Models and Drivers. Available at http://wanainstitute.org/en/publication/understanding-radicalisation-literature-review-models-and-drivers. Last accessed March 11, 2019.

106. Kaplan J, Lööw H, Malkki L. Introduction to the special issue on lone wolf and autonomous cell terrorism. Terrorism and Political Violence. 2014;26(1):1-12.

107. Schuurman B, Bakker E, Gill P, Bouhana N. Lone actor terrorist attack planning and preparation: a data-driven analysis. J Forensic Sci. 2018;63(4):1191-1200.

108. Parkin W, Klein B, Gruenewald J. Threats of Violent Islamist and Far-Right Extremism: What Does the Research Say? Available at https://www.start.umd.edu/publication/threats-violent-islamist-and-far-right-extremism-what-does-research-say. Last accessed March 11, 2019.

109. McCauley C, Moskalenko S. Another Look at Jujitsu Politics. Available at https://www.start.umd.edu/news/another-look-jujitsu-politics. Last accessed March 11, 2019.

110. Braniff W. Recasting and Repositioning CVE as a Grand Strategic Response to Terrorism. Available at https://www.start.umd.edu/publication/recasting-and-repositioning-cve-grand-strategic-response-terrorism. Last accessed March 11, 2019.

111. Miller E. Is This Terrorism? Why Does It Matter? Available at https://www.start.umd.edu/news/terrorism-why-does-it-matter. Last accessed March 11, 2019.

112. Jensen M, LaFree G. Final Report: Empirical Assessment of Domestic Radicalization (EADR). Available at https://www.ncjrs.gov/pdffiles1/nij/grants/250481.pdf. Last accessed March 11, 2019.

113. Gallagher MJ. The 2016 "lone wolf" tsunami: is Rapoport's "religious wave" ending? Journal of Strategic Security. 2017;10:60-76.

114. van Buuren J. Performative violence? The multitude of lone wolf terrorism. Terrorism: An Electronic Journal & Knowledge Base. 2012;1:1-25.

115. Anti-Defamation League. Murder and Extremism in the United States in 2017. Available at https://www.adl.org/resources/reports/murder-and-extremism-in-the-united-states-in-2017. Last accessed March 11, 2019.

116. Bergen P. Terrorism in America After 9/11. Part IV: What is the Threat to the United States Today? Available at https://www.newamerica.org/in-depth/terrorism-in-america/what-threat-united-states-today. Last accessed March 11, 2019.

117. Al Raffie D. Social identity theory for investigating Islamic extremism in the diaspora. Journal of Strategic Security. 2013;6(4):67-91.

118. Cruickshank P. A View from the CT Foxhole: An Interview with Alain Grignard, Brussels Federal Police. Available at https://ctc.usma.edu/a-view-from-the-ct-foxhole-an-interview-with-alain-grignard-brussels-federal-police. Last accessed March 11, 2019.

119. Coolsaet R. Facing the Fourth Foreign Fighters Wave: What Drives Europeans to Syria, and to Islamic State? Available at http://www.egmontinstitute.be/facing-the-fourth-foreign-fighters-wave. Last accessed March 11, 2019.

120. Jensen M, LaFree G. Empirical Assessment of Domestic Radicalization (EADR). Available at https://www.start.umd.edu/research-projects/empirical-assessment-domestic-radicalization-eadr. Last accessed March 11, 2019.

121. National Consortium for the Study of Terrorism and Response to Terrorism. Ideological Motivations of Terrorism in the United States, 1970–2016. University of Available at https://www.start.umd.edu/pubs/START_IdeologicalMotivationsOfTerrorismInUS_Nov2017.pdf. Last accessed March 11, 2019.

122. National Consortium for the Study of Terrorism and Response to Terrorism. Debates among Salafi Muslims About Use of Violence. Available at https://www.start.umd.edu/publication/debates-among-salafi-muslims-about-use-violence. Last accessed March 11, 2019.

123. National Consortium for the Study of Terrorism and Response to Terrorism. Global Terrorism Database. Available at https://www.start.umd.edu/gtd/search/Results.aspx?country=217. Last accessed March 11, 2019.

124. Hafez F. Shifting borders: Islamophobia as common ground for building pan-European right-wing unity. Patterns Prejudice. 2014;48:479-499.

125. Marwick A, Lewis R. Media Manipulation and Disinformation Online. Available at https://apo.org.au/sites/default/files/resource-files/2017/05/apo-nid135936-1217806.pdf. Last accessed March 11, 2019.

126. Hankes K, Amend A. The Alt-Right is Killing People. Available at https://www.splcenter.org/20180205/alt-right-killing-people. Last accessed March 11, 2019.

127. Southern Poverty Law Center. McInnes, Molyneux, and 4chan: Investigating Pathways to the Alt-Right. Available at https://www.splcenter.org/20180419/mcinnes-molyneux-and-4chan-investigating-pathways-alt-right. Last accessed March 11, 2019.

128. U.S. Department of Justice. Additional Charges Filed in Tree of Life Synagogue Shooting: Robert Bowers Charged with 63 Counts Including Hate Crimes Resulting in Death. Available at https://www.justice.gov/opa/pr/additional-charges-filed-tree-life-synagogue-shooting. Last accessed March 11, 2019.

129. Hamm M, Spaaj R. Lone Wolf Terrorism in America: Using Knowledge of Radicalization Pathways to Forge Prevention Strategies. Available at https://www.ncjrs.gov/pdffiles1/nij/grants/248691.pdf. Last accessed March 11, 2019.

130. U.S. Government Accountability Office. Countering Violent Extremism: GAO-17-300. Available at https://www.gao.gov/products/GAO-17-300. Last accessed March 11, 2019.

131. Gruenewald J, Pridemore WA. A comparison of ideologically-motivated homicides from the new Extremist Crime Database and homicides from the supplementary homicide reports using multiple imputation by chained equations to handle missing values.J Quant Criminol. 2011;28(1):141-162.

132. Federal Bureau of Investigation Domestic Terrorism Analysis Unit, Counterterrorism Division. Militia Extremists Expand Target Sets to Include Muslims. Available at https://info.publicintelligence.net/FBI-MilitiaTargetingMuslims.pdf. Last accessed March 11, 2019.

133. Southern Poverty Law Center. Hatewatch. Available at https://www.splcenter.org/hatewatch. Last accessed March 11, 2019.

134. Smith M. Kansas Trio Convicted in Plot to Bomb Somali Immigrants. Available at https://www.nytimes.com/2018/04/18/us/kansas-militia-somali-trial-verdict.html. Last accessed March 11, 2019.

135. Kearns EM, Betus A, Lemieux A. Why Do Some Terrorist Attacks Receive More Media Attention Than Others? Available at https://papers.ssrn.com/sol3/papers.cfm?abstract_id=2928138. Last accessed March 11, 2019.

136. Pisoiu D. Subcultural theory applied to Jihadi and right-wing radicalization in Germany. Terrorism and Political Violence. 2015;27(1):9-28.

137. Berntzen LE, Sandberg S. The collective nature of lone wolf terrorism: Anders Behring Breivik and the anti-Islamic social movement. Terrorism and Political Violence. 2014;26(5):759-779.

138. Marks SR. Durkheim's theory of anomie. Am J Sociology. 1974;80:329-363.

139. Huff C, Kertzer J. How the public defines terrorism. Am J Pol Sci. 2018;62(1):55-71.

140. Chermak SM, Gruenewald J. The media's coverage of domestic terrorism. Justice Q. 2006;23(4):428-461.

141. West K, Lloyd J. The role of labeling and bias in the portrayals of acts of "terrorism:" media representations of Muslims vs. non-Muslims. Journal of Muslim Minority Affairs. 2017;37(2):1-12.

142. Powell KA. Framing Islam: an analysis of U.S. media coverage of terrorism since 9/11. Communication Studies. 2011;62(1):90-112.

143. Allouche J. A Research Synthesis Exploring the Trends and Gaps in Knowledge. Available at https://esrc.ukri.org/files/public-engagement/public-dialogues/executive-summary-public-attitudes-to-global-uncertainties. Last accessed March 11, 2019.

144. Park J, Felix K, Lee G. Implicit attitudes toward Arab-Muslims and the moderating effects of social information. Basic Appl Soc Psych. 2007;29(1):35-45.

145. Saleem M, Anderson CA. Arabs as terrorists: effects of stereotypes within violent contexts on attitudes, perceptions, and affect. Psychol Violence. 2013;3(1):84-99.

146. Gallup. Concern About Being a Victim of Terrorism. Available at https://news.gallup.com/poll/4909/terrorism-united-states.aspx. Last accessed March 11, 2019.

147. U.S. Department of Homeland Security. Rightwing Extremism: Current Economic and Political Climate Fueling Resurgence in Radicalization and Recruitment. Available at https://fas.org/irp/eprint/rightwing.pdf. Last accessed March 11, 2019.

148. Cohen JR. Testimony of J. Richard Cohen, President, Southern Poverty Law Center before the Subcommittee on Oversight, Agency Action, Federal Rights and Federal Courts Committee on the Judiciary United States Senate. Willful Blindness: The Consequences of Agency Efforts to Deemphasize Radical Islam in Combatting Terrorism. Available at https://www.splcenter.org/sites/default/files/richardcohen_testimony-radicalright-6-28-16.docx.pdf. Last accessed March 11, 2019.

149. Kruglanski AW, Jasko M, Webber D, Chernikova M, Molinario E. The making of violent extremists. Rev Gen Psychol. 2018;22(1):107-120.

150. LaFree G, Gruenewald J. The intersection of homicide, terrorism, and violent extremism. Homicide Stud. 2018;22(1):3-7.

151. Webber D, Kruglanski AW. The social psychological makings of a terrorist. Curr Opin Psychol. 2018;19:131-134.

152. Matsumoto D, Hwang HS, Frank MG. The Role of Emotions in Predicting Violence. Available at https://leb.fbi.gov/articles/featured-articles/the-role-of-emotion-in-predicting-violence. Last accessed March 11, 2019.

153. Matsumoto D, Hwang HC, Frank MG. Emotion and aggressive intergroup cognitions: the ANCODI hypothesis. Aggress Behav. 2017;43(1):93-107.

154. Matsumoto D, Hwang HC, Frank MG. Emotions expressed by leaders in videos predict political aggression. Behavioral Sciences of Terrorism and Political Aggression. 2014;6(3):212-218.

155. Matsumoto D, Frank M, Hwang H. The role of intergroup emotions in political violence. Curr Dir Psychol Sci. 2015;24(5):369-373.

156. Matsumoto D, Hwang HC, Frank MG. Emotional language and political aggression. J Lang Soc Psychol. 2013;32(4):452-468.

157. Elbert T, Schauer M, Moran JK. Two pedals drive the bi-cycle of violence: reactive and appetitive aggression. Curr Opin Psychol. 2018;19:135-138.

158. Kteily NS, Bruneau E, Waytz A, Cotterill S. The ascent of man: theoretical and empirical evidence for blatant dehumanization.J Pers Soc Psychol. 2015;109(5):901-931.

159. Forscher PS, Kteily NS. A Psychological Profile of the Alt-Right. Presented at: The Society for Personality and Social Psychology 2018 Annual Convention; March 3, 2018; Atlanta, GA. Available at https://spsp2018.zerista.com/event/member/438154. Last accessed March 11, 2019.

160. Webber D, Kruglanski AW. Psychological factors in radicalization: a "3N" approach. In: LaFree G, Freilich JD (eds). The Handbook of the Criminology of Terrorism. West Sussex: Wiley Blackwell; 2017: 33-46.

161. Jaśko K, LaFree G, Kruglanski A. Quest for significance and violent extremism: the case of domestic radicalization. Polit Psychol. 2016;38(5):815-831.

162. Taylor M, Horgan J. A conceptual framework for addressing psychological process in the development of the terrorist. Terrorism and Political Violence. 2006;18(4):585-601.

163. Bandura A. Moral disengagement in the perpetration of inhumanities. Pers Soc Psychol Rev. 1999;3(3):193-209.

164. LaFree G, Jensen MA, James PA, et al. Correlates of violent political extremism in the United States. Criminology. 2018;56(2):233-268.

165. Fowler KA, Dahlberg LL, Haileyesus T, Annest JL. Firearm injuries in the United States. Prev Med. 2015;79:5-14.

166. Wilson HL. Gun Politics in America: Historical and Modern Documents in Context. Santa Barbara, CA: ABC-CLIO; 2016.

167. Finkel EJ, Hall AN. The I3 Model: a metatheoretical framework for understanding aggression. Curr Opin Psychol. 2018;19:125-130.

168. Law H, Falkenbach DM. Hostile attribution bias as a mediator of the relationships of psychopathy and narcissism with aggression. Int J Offender Ther Comp Criminol. 2018;62(11):3355-3371.

169. Paulhus DL, Curtis SR, Jones DN. Aggression as a trait: the Dark Tetrad alternative. Curr Opin Psychol. 2018;19:88-92.

170. Dodge KA, Malone PS, Lansford JE, et al. Hostile attributional bias and aggressive behavior in global context. Proc Natl Acad Sci. 2015;112(30):9310-9315.

171. Benjamin AJ Jr, Bushman BJ. The weapons effect. Curr Opin Psychol. 2018;19:93-97.

172. Hemenway D, Vriniotis M, Miller M. Is an armed society a polite society? Guns and road rage. Accid Anal Prev. 2006;38(4):687-695.

173. Stroebe W, Leander NP, Kruglanski AW. The impact of the Orlando mass shooting on fear of victimization and gun-purchasing intentions: not what one might expect. PLoS One. 2017;12(8):e0182408.

174. Durkee A. Domestic Violence is a Link among Most Mass Shooters—but America Continues to Ignore It. Available at https://mic.com/articles/185866/domestic-violence-is-a-link-among-most-mass-shooters-but-america-continues-to-ignore-it. Last accessed March 11, 2019.

175. Everytown for Gun Safety. Mass Shootings in the United States: 2009–2017. Available at https://everytownresearch.org/reports/mass-shootings-analysis. Last accessed March 11, 2019.

176. Everytown for Gun Safety. Guns and Domestic Violence. Available at https://everytownresearch.org/guns-domestic-violence. Last accessed March 11, 2019.

177. Grinshteyn E, Hemenway D. Violent death rates: the U.S. compared with other high-income OECD countries, 2010. Am J Med. 2016;129(3):266-273.

178. Campbell JC, Webster D, Koziol-McLain J, et al. Risk factors for femicide in abusive relationships: results from a multisite case control study. Am J Public Health. 2003;93(7):1089-1097.

179. Sorenson SB, Schut RA. Nonfatal gun use in intimate partner violence: a systematic review of the literature. Trauma Violence Abuse. 2018;19(4):431-442.

180. Catalano S, Smith E, Snyder H, Rand M. Selected Findings: Female Victims of Violence. Available at https://www.bjs.gov/index.cfm?ty=pbdetail&iid=2020. Last accessed March 11, 2019.

181. Liem M. Homicide followed by suicide: a review. Aggress Violent Behav. 2010;15(3):153-161.

182. Grinberg E, McLaughlin EC. Texas Church Shooter Devin Patrick Kelley's Troubled Past Emerges. Available at https://www.cnn.com/2017/11/06/us/devin-kelley-texas-church-shooting-suspect/index.html. Last accessed March 11, 2019.

183. King S. In Life and in Death, White Privilege Protected Texas Shooter Devin Kelley. Available at https://theintercept.com/2017/11/08/texas-shooting-devin-kelley-white-privilege. Last accessed March 11, 2019.

184. Freeman H. What Do Many Lone Attackers Have in Common? Domestic Violence. Available at https://www.theguardian.com/commentisfree/2017/mar/28/lone-attackers-domestic-violence-khalid-masood-westminster-attacks-terrorism. Last accessed March 11, 2019.

185. Chester DS, DeWall CN. The roots of intimate partner violence. Curr Opin Psychol. 2018;19:55-59.

186. National Coalition Against Domestic Violence. Dynamics of Abuse. Available at https://ncadv.org/dynamics-of-abuse. Last accessed March 11, 2019.

187. Sorenson SB, Wiebe DJ. Weapons in the lives of battered women. Am J Public Health. 2004;94(8):1412-1417.

188. Hemenway D. Risks and benefits of a gun in the home. Am J Lifestyle Med. 2011;5(6):502-511.

189. Smith VM, Siegel M, Xuan Z, et al. Broadening the perspective on gun violence: an examination of the firearms industry, 1990–2015. Am J Prev Med. 2017;53(5):584-591.

190. Lee LK, Fleegler EW, Farrell C, et al. Firearm laws and firearm homicides: a systematic review. JAMA Intern Med. 2017;177(1):106-119.

191. Huff-Corzine L, McCutcheon JC, Corzine J, et al. Shooting for accuracy: comparing data sources on mass murder. Homicide Stud. 2014;18(1):105-124.

192. Lankford A. Are America's public mass shooters unique? A comparative analysis of offenders in the United States and other countries. Int J Comp Appl Crim Justice. 2016;40(2):171-183.

193. Fox JA, Levin J. Mass confusion concerning mass murder. Criminologist. 2015;40(1):8-11.

194. Cohen AP, Azrael D, Miller M. Rate of Mass Shootings Has Tripled Since 2011, Harvard Research Shows. Available at https://www.motherjones.com/politics/2014/10/mass-shootings-increasing-harvard-research. Last accessed March 11, 2019.

195. Follman M, Aronsen G, Pan D. U.S. Mass Shootings, 1982–2018: Data from Mother Jones' Investigation. Available at https://www.motherjones.com/politics/2012/12/mass-shootings-mother-jones-full-data. Last accessed March 11, 2019.

196. Gun Violence Archive. Mass Shootings in 2018. Available at https://www.gunviolencearchive.org/past-tolls. Last accessed March 11, 2019.

197. Blair JP, Schweit KW. A Study of Active Shooter Incidents in the United States Between 2000 and 2013. Available at https://www.fbi.gov/file-repository/active-shooter-study-2000-2013-1.pdf/view. Last accessed March 11, 2019.

198. Federal Bureau of Investigation. Active Shooter Incidents in the United States in 2014 and 2015. Available at https://www.fbi.gov/file-repository/activeshooterincidentsus_2014-2015.pdf/view. Last accessed March 11, 2019.

199. Kellermann AL, Rivara FP. Silencing the science on gun research. JAMA. 2013;309(6):549-550.

200. Federal Bureau of Investigation Criminal Justice Information Services Division. Expanded Homicide Data Table 4: Murder Victims by Weapon, 2012–2016. Available at https://ucr.fbi.gov/crime-in-the-u.s/2016/crime-in-the-u.s.-2016/tables/expanded-homicide-data-table-4.xls. Last accessed March 11, 2019.

201. Rosenfeld R, Gaston S, Spivak H, Irazola S. Assessing and Responding to the Recent Homicide Rise in the United States. Available at https://www.ncjrs.gov/pdffiles1/nij/251067.pdf. Last accessed March 11, 2019.

202. Desmond M, Papachristos AV, Kirk DS. Police violence and citizen crime reporting in the black community. Am Soc Rev. 2016;81(5):857-876.

203. Law Center to Prevent Gun Violence. Confronting the Inevitability Myth. Available at https://lawcenter.giffords.org/wp-content/uploads/2017/09/The-Inevitablity-Myth-Report.pdf. Last accessed March 11, 2019.

204. Cukier W, Eagen SA. Gun violence. Curr Opin Psychol. 2018;19:109-112.

205. Sarai SK, Abaid B, Lippmann S. Guns and suicide: are they related? Prim Care Companion CNS Disord. 2017;19(6).

206. Anestis MD, Selby EA, Butterworth SE. Rising longitudinal trajectories in suicide rates: the role of firearm suicide rates and firearm legislation. Prev Med. 2017;100:159-166.

207. Hawton K. Restricting access to methods of suicide: rationale and evaluation of this approach to suicide prevention. Crisis. 2007;28(Suppl 1):4-9.

208. Drum D, Brownson C, Denmark A, Smith S. New data on the nature of suicidal crises in college students: shifting the paradigm. Prof Psychol Res Pract. 2009;40(3):213-222.

209. Deisenhammer EA, Ing CM, Strauss R, Kemmler G, Hinterhuber H, Weiss EM. The duration of the suicidal process: how much time is left for intervention between consideration and accomplishment of a suicide attempt? J Clin Psychiatry. 2009;70(1):19-24.

210. Webster DW. The true effect of mass shootings on Americans. Ann Intern Med. 2017;166(10):749-750.

211. Massachusetts Medical Society. Talking to Patients about Gun Safety. Available at http://www.massmed.org/firearmguidanceforproviders. Last accessed March 11, 2019.

212. Frellick M. More than 1000 Doctors Pledge to Talk to Patients About Guns. Available at https://www.medscape.com/viewarticle/893307. Last accessed March 11, 2019.

213. Wintemute GJ, Betz ME, Ranney ML. Yes, you can: physicians, patients, and firearms. Ann Intern Med. 2016;165(3):205-213.

214. Butkus R, Weissman A. Internists' attitudes toward prevention of firearm injury. Ann Intern Med. 2014;160(12):821-827.

215. Traylor A, Price JH, Telljohann SK, King K, Thompson A. Clinical psychologists' firearm risk management perceptions and practices. J Community Health. 2010;35(1):60-67.

216. Radant LJ, Johnson TM. The Wisconsin Research Network Firearm Safety Survey. WMJ. 2003;102(4):46-50.

217. Shaughnessy AF, Cincotta JA, Adelman A. Family practice patients' attitudes toward firearm safety as a preventive medicine issue: a HARNET study. Harrisburg Area Research Network. J Am Board Fam Pract. 1999;12(5):354-359.

218. Betz ME, Wintemute GJ. Physician counseling on firearm safety: a new kind of cultural competence. JAMA. 2015;314(5):449-450.

219. Somerset AJ. Arms:The Culture and Credo of the Gun. Windsor: Biblioasis; 2015.

220. McCourt AD, Vernick JS. Law, ethics, and conversations between physicians and patients about firearms in the home. AMA J Ethics. 2018;20(1):69-76.

221. Wolk CB, Jager-Hyman S, Marcus SC, et al. Developing implementation strategies for rearm safety promotion in pediatric primary care for suicide prevention in two large U.S. health systems: a study protocol for a mixed-methods implementation study. BMJ Open. 2017;7(6):e014407.

222. Moffic HS. The Psychology of Guns: 12 Steps Toward More Safety. Available at https://www.psychiatrictimes.com/blogs/couch-crisis/psychology-guns-12-steps-toward-more-safety. Last accessed March 11, 2019.

223. Sorenson SB. Guns in intimate partner violence: comparing incidents by type of weapon. J Womens Health. 2017;26(3):249-258.

224. Zeoli AM, McCourt A, Buggs S, Frattaroli S, Lilley D, Webster DW. Analysis of the strength of legal firearms restrictions for perpetrators of domestic violence and their association with intimate partner homicide. Am J Epidemiol. 2018;187(7):1449-1455.

225. Benedek EP, Gold LH, Simon RL. Gun violence and mental illness. J Am Acad Psychiatry Law. 2016;44(3)402-404.

226. Frattaroli S, McGinty EE, Barnhorst A, Greenberg S. Gun violence restraining orders: alternative or adjunct to mental health-based restrictions on firearms? Behav Sci Law. 2015;33(2-3):290-307.

227. Wintemute GJ, Frattaroli S, Claire BE, Vittes KA, Webster DW. Identifying armed respondents to domestic violence restraining orders and recovering their firearms: process evaluation of an initiative in California. Am J Public Health. 2014;104(2):e113-e118.

228. Borum R, Reddy M. Assessing violence risk in Tarasoff situations: a fact-based model of inquiry. Behav Sci Law. 2001;19(3):375-385.

229. Malina D, Morrissey S, Campion EW, Hamel MB, Drazen JM. Rooting out gun violence. N Engl J Med. 2016;374(2):175-17.

230. Dudley MJ, Rosen A, Alpers PA, Peters R. The Port Arthur massacre and the National Firearms Agreement: 20 years on, what are the lessons? Med J Aust. 2016;204(10):381-383.

231. Ayonrinde O. Importance of cultural sensitivity in therapeutic transactions: considerations for healthcare providers. Dis Manage Health Outcomes. 2003;11(4):233-248.

232. Hwa-Froelich DA, Westby CE. Considerations when working with interpreters. Commun Disord Q. 2003;24(2):78-85.

233. National Council on Interpreting in Health Care, Inc. National Standards for Healthcare Interpreter Training Programs. Available at https://www.ncihc.org/assets/documents/publications/National_Standards_5-09-11.pdf. Last accessed March 11, 2019.

234. Lynch EW. Developing cross-cultural competence. In: Lynch EW, Hanson MJ (eds). A Guide for Working with Children and their Families: Developing Cross-Cultural Competence. 4th ed. Baltimore, MD: Paul H. Brookes Publishing, Co.; 2011: 41-78.

235. Tribe R. Working with interpreters in mental health. Int J Cult Ment Health. 2009;2(2):92-101.

236. Dysart-Gale D. Clinicians and medical interpreters: negotiating culturally appropriate care for patients with limited English ability. Fam Community Health. 2007;30(3):237-246.

237. Raval H, Smith J. Therapists' experiences of working with language interpreters. Int J Ment Health. 2003;32(2):6-31.

238. Lemieux F. Effect of gun culture and firearm laws on gun violence and mass shootings in the United States: a multi-level quantitative analysis. International Journal of Criminal Justice Sciences. 2014;9(1):74-93.

239. Page E. Men, Masculinity and Guns: Can We Break the Link? Available at http://iansa-women.org/sites/default/files/newsviews/iansa_wn_masculinities_paper-2009.pdf. Last accessed March 11, 2019.

240. Kalesan B, Villarreal MD, Keyes KM, Galea S. Gun ownership and social gun culture. Inj Prev. 2016;22(3):216-220.

241. French D. What Critics Don't Understand About Gun Culture. Available at https://www.theatlantic.com/politics/archive/2018/02/gun-culture/554351. Last accessed March 11, 2019.

242. Mencken FC, Froese P. Gun culture in action. Social Problems. 2019:66(1):3-27.

243. Moyer MW. Do Money, Social Status Woes Fuel the U.S. Gun Culture? Available at https://www.scientificamerican.com/article/do-money-social-status-woes-fuel-the-u-s-gun-culture. Last accessed March 11, 2019.

244. Stroebe W, Leander NP, Kruglanski AW. Is it a dangerous world out there? The motivational bases of American gun ownership.Pers Soc Psychol Bull. 2017;43(8):1071-1085.

245. Altemeyer B. Enemies of Freedom: Understanding Right-Wing Authoritarianism. San Francisco, CA: Jossey-Bass; 1988.

246. Duckitt J. A dual-process cognitive-motivational theory of ideology and prejudice. Adv Exp Soc Psychol. 2001;33:41-113.

247. Filindra A, Kaplan NJ. Racial resentment and white's gun policy preferences in contemporary America. Polit Behav. 2016;38(2):255-275.

248. O'Brien K, Forrest W, Lynott D, Daly M. Racism, gun ownership and gun control: biased attitudes in U.S. whites may influence policy decisions. PLoS One. 2013;8(10):e77552.

249. Kruglanski AW, Stroebe W. Attitudes, goals and beliefs: issues of structure, function and dynamics. In: Aberracin D, Johnson B, Zanna MP (eds). Handbook of Attitudes. Mahwah, NJ: Erlbaum; 2005.

250. Madfis E. Averting school rampage: student intervention amid a persistent code of silence. Youth Violence Juv Justice. 2014;12(3):229-249.

251. American Psychological Association. Gun Violence: Prediction, Prevention, and Policy. Available at https://www.apa.org/pubs/info/reports/gun-violence-report.pdf. Last accessed March 28, 2019.

252. Jewkes R, Morrell R, Hearn J, et al. Hegemonic masculinity: combining theory and practice in gender interventions. Cult Health Sex. 2015;17(Suppl 2):S112-S127.

253. Harris-Hogan S. Terrorism, 1888–2018: some change, but mostly the same. Journal of Threat Assessment and Management. 2018;5(4):245-247.

Evidence-Based Practice Recommendations Citations

1. National Collaborating Centre for Mental Health. Violence and Aggression: Short-Term Management in Mental Health, Health and Community Settings. Available at https://www.nice.org.uk/guidance/ng10. Last accessed March 19, 2019.