NJCTH19 • New Jersey Counselors and Therapists 2019-2020

Table of Contents

NJCTH19 • New Jersey Counselors and Therapists 2019-2020

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 #77722 • Ethics for Counselors

77722 • Ethics for Counselors

1. INTRODUCTION

2. HISTORICAL CONTEXT OF COUNSELING ETHICS

3. COMMON TERMS USED IN THE DISCUSSION OF ETHICS

4. VALUES AND ETHICAL PRINCIPLES IN ETHICAL CODES

5. ETHICAL THEORIES

6. ETHICAL DECISION-MAKING FRAMEWORKS

7. ETHICAL SELF-REFLECTION

8. MANAGED CARE AND ETHICS

9. DIVERSITY AND MULTICULTURALISM: ETHICAL ISSUES

10. ONLINE COUNSELING

11. CONCLUSION

12. RESOURCES

13. APPENDIX: THE ACA CODE OF ETHICS

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

NJCTH19 • New Jersey Counselors and Therapists 2019-2020

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

Michele Nichols, RN, BSN, MA

www.netce.com

Copyright © 2024 NetCE, All rights reserved.

NJCTH19 • New Jersey Counselors and Therapists 2019-2020

Expiration Date: 02/28/2022

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

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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.

77722 • Ethics for Counselors

Alice Yick Flanagan, PhD, MSW

Michele Nichols, RN, BSN, MA

www.netce.com

Copyright © 2019 NetCE, All rights reserved.

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

Table of Contents

77722 • Ethics for Counselors

Course Overview

Audience

Course Objective

Learning Objectives

Faculty

Faculty Disclosure

About the Sponsor

Disclosure Statement

1. INTRODUCTION

2. HISTORICAL CONTEXT OF COUNSELING ETHICS

HISTORY OF COUNSELING IN THE UNITED STATES

HISTORY OF ETHICS

PHILOSOPHICAL HISTORY OF MODERN ETHICS

3. COMMON TERMS USED IN THE DISCUSSION OF ETHICS

VALUES

ETHICS

4. VALUES AND ETHICAL PRINCIPLES IN ETHICAL CODES

ACA CODE OF ETHICS

NBCC CODE OF ETHICS

5. ETHICAL THEORIES

VIRTUE ETHICS

DEONTOLOGIC ETHICAL THEORIES

TELEOLOGIC ETHICAL THEORIES

MOTIVIST ETHICAL THEORIES

NATURAL LAW ETHICAL THEORY

TRANSCULTURAL ETHICAL THEORY

FEMINIST ETHICS

RELATIONAL ETHICS

ASSESSING ETHICAL THEORIES

PRACTICAL APPLICATIONS OF ETHICAL THEORIES

6. ETHICAL DECISION-MAKING FRAMEWORKS

DECISION-MAKING MODELS FOR ETHICAL DILEMMAS

LIMITATIONS OF ETHICAL DECISION-MAKING FRAMEWORKS

7. ETHICAL SELF-REFLECTION

PSYCHOLOGIC CONTEXT OF MORAL DECISION MAKING

8. MANAGED CARE AND ETHICS

9. DIVERSITY AND MULTICULTURALISM: ETHICAL ISSUES

DEMOGRAPHIC SHIFTS

MULTICULTURALISM IN RESEARCH

DEBATES WITHIN MULTICULTURALISM/DIVERSITY AND ETHICS

INFUSING DIVERSITY INTO THE ETHICAL DECISION-MAKING MODELS

MULTICULTURALISM/DIVERSITY AND THE ACA CODE OF ETHICS

MULTICULTURALISM/DIVERSITY AND THE NBCC CODE OF ETHICS

10. ONLINE COUNSELING

LIMITATIONS OF ONLINE COUNSELING

ONLINE COMMUNICATIONS AND DISTANCE COUNSELING: A SOCIOCULTURAL CONTEXT

ETHICAL AND LEGAL ISSUES

ACA CODE OF ETHICS AND DISTANCE COUNSELING

NBCC STANDARDS FOR DISTANCE PROFESSIONAL SERVICES

11. CONCLUSION

12. RESOURCES

13. APPENDIX: THE ACA CODE OF ETHICS

SECTION A: THE COUNSELING RELATIONSHIP

SECTION B: CONFIDENTIALITY AND PRIVACY

SECTION C: PROFESSIONAL RESPONSIBILITY

SECTION D: RELATIONSHIPS WITH OTHER PROFESSIONALS

SECTION E: EVALUATION, ASSESSMENT, AND INTERPRETATION

SECTION F: SUPERVISION, TRAINING, AND TEACHING

SECTION G: RESEARCH AND PUBLICATION

SECTION H: DISTANCE COUNSELING, TECHNOLOGY, AND SOCIAL MEDIA

SECTION I: RESOLVING ETHICAL ISSUES

Works Cited

77722 • Ethics for Counselors

Education Category. Ethics - Human Rights

Release Date. 05/01/2019

Expiration Date. 04/30/2022

Course Overview

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

Audience

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

Course Objective

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

Learning Objectives

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

1. Discuss the historical context of ethics in counseling.

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

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

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

5. Identify the different ethical decision-making models.

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

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

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

Faculty

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

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

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

Faculty Disclosure

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

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

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

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

2. HISTORICAL CONTEXT OF COUNSELING ETHICS

HISTORY OF COUNSELING IN THE UNITED STATES

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

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

HISTORY OF ETHICS

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

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

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

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

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

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

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

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

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

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

Recent History

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

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

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

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

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

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

Professional Ethics

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

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

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

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

Association

Code

National Board for Certified Counselors

NBCC Code of Ethics

National Association of Social Workers

NASW Code of Ethics

American Association for Marriage and Family Therapy

AAMFT Code of Ethics

American Mental Health Counselors Association

Code of Ethics for Mental Health Counselors

Association for Specialists in Group Work

ASGW Best Practices Guidelines

American Psychological Association

Ethical Principles of Psychologists and Code of Conduct

American Counseling Association

Code of Ethics and Standards of Practice

American School Counselors Association

Ethical Standards for School Counselors

International Association of Marriage and Family Counselors

IAMFC Code of Ethics

Association for Counselor Education and Supervision

Ethical Guidelines for Counseling Supervisors

Commission on Rehabilitation Counselor Certification

Code of Professional Ethics for Rehabilitation Counselors

National Association of Alcoholism and Drug Abuse Counselors

NAADAC Code of Ethics

National Rehabilitation Counseling Association

Rehabilitation Counseling Code of Ethics

National Organization for Human Services

Ethical Standards for Human Services Professionals

International Society for Mental Health Online

Suggested Principles for the Online Provision of Mental Health Services

Source: [2]

Development of Ethical Codes in Counseling

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

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

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

- To give rights to and protect both clients and professionals

- To provide guidance for ethical decision making

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

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

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

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

Ethics and New Technologies

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

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

PHILOSOPHICAL HISTORY OF MODERN ETHICS

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

Modernism

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

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

Postmodernism

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

Today, ethical codes and practices are also influenced by critical theory. Critical theorists focus on eliminating inequities and marginalization [112]. Ethics from this perspective explores the role of power and power inequalities, exploring who or what defines truth and whose voices are represented [112].

3. COMMON TERMS USED IN THE DISCUSSION OF ETHICS

VALUES

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

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

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

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

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

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

ETHICS

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

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

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

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

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

Ethical Dilemmas

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

Ethical Decision Making

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

Ethical Principles

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

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

- Beneficence: The duty to do good

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

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

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

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

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

- Nonmaleficence: The duty to cause no harm

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

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

- Reparation: The duty to make up for a wrong

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

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

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

- Veracity: The duty to tell the truth

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

4. VALUES AND ETHICAL PRINCIPLES IN ETHICAL CODES

ACA CODE OF ETHICS

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

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

Section A: The Counseling Relationship

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

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

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

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

Section B: Confidentiality and Privacy

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

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

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

Section C: Professional Responsibility

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

Section D: Relationships with Other Professionals

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

Section E: Evaluation, Assessment, and Interpretation

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

Section F: Supervision, Training, and Teaching

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

Section G: Research and Publication

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

Section H: Distance Counseling, Technology, and Social Media

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

Section I: Resolving Ethical Issues

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

NBCC CODE OF ETHICS

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

Prevent Harm

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

All relationships should be non-exploitive. Gifts from clients are generally not acceptable. When a gift is offered, careful judgment and documentation of the gift should be made. Physical, romantic, or sexual relationships are prohibited during and for a period of two years after termination of a professional relationship.

Provide Only Those Services for Which One Has Education and Qualified Experience

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

There are many assessment tools and techniques available to counselors, and counselors should be competent in the use and interpretation of each they intend to use. Consideration must be given to the fact that many tests/assessments are culturally biased; open-mindedness about test/assessment performance is valued.

Promote the Welfare of Clients, Students, or Supervisees

Counselors should explain the ramifications of tests and results to clients and use assessments only for the client's benefit. Only current, reliable, and valid tests and assessments should be used. The results of a single test/assessment should never be used as the sole basis for a decision.

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

Communicate Truthfully

Credentials and qualifications should be accurately represented, and it is the responsibility of the counselor to correct known misrepresentations. Supervisors must identify their qualifications and credentials to supervisees and provide information regarding the supervision process.

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

Act with Integrity to Preserve Trust

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

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

Encourage Active Participation of Clients, Students, or Supervisees

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

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

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

Adhere to Recognized Professional Standards and Practices

The underlying theme in this directive is that counselors have a responsibility to themselves, clients, and institutions to behave in an ethical manner consistent with the NBCC Code of Ethics. All applicable legal standards and professional regulations should be abided in all cases. Counselors speaking publicly should reflect their personal views and not those of an organization unless authorized to speak on its behalf. Tests and assessment administration and interpretation must comply with standard protocols. Identified security protocols for each must also be maintained.

Comply with Intellectual Property Laws

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

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

5. ETHICAL THEORIES

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

VIRTUE ETHICS

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

DEONTOLOGIC ETHICAL THEORIES

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

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

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

- Human life has value.

- Always to tell the truth.

- Above all in practice, do no harm.

- All people are of equal value.

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

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

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

Theologic Ethical Theories

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

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

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

Categorical Imperative

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

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

TELEOLOGIC ETHICAL THEORIES

The teleologic ethical theories or consequential ethics are outcome-based theories. It is not the motive or intention that causes one to act ethically, but the consequences of the act [7]. If the action causes a positive effect, it is said to be ethical. So here, the end justifies the means.

Utilitarianism

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

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

Existentialism

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

Pragmatism

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

MOTIVIST ETHICAL THEORIES

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

NATURAL LAW ETHICAL THEORY

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

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

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

TRANSCULTURAL ETHICAL THEORY

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

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

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

Ethical Relativism/Multiculturalism

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

FEMINIST ETHICS

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

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

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

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

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

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

RELATIONAL ETHICS

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

ASSESSING ETHICAL THEORIES

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

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

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

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

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

PRACTICAL APPLICATIONS OF ETHICAL THEORIES

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

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

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

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

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

6. ETHICAL DECISION-MAKING FRAMEWORKS

The decision-making frameworks presented in this section are decision analyses. A decision analysis is a step-by-step procedure breaking down the decision into manageable components so one can trace the sequence of events that might be the consequence of selecting one course of action over another [23]. Decision analysis frameworks provide an objective analysis in order to help professionals make the best possible decision in a given situation, build logic and rationality into a decision-making process that is primarily intuitive, and lay the potential outcomes for various decision paths [23]. They are also attempts to shift the process of moral decision making from the arena of the personal and subjective to the arena of an intellectual process, characterized by rigor and systematization [24].

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

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

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

DECISION-MAKING MODELS FOR ETHICAL DILEMMAS

Kenyon's Ethical Decision-Making Model

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

Table 2: KENYON'S ETHICAL DECISION-MAKING MODEL

1. Describe the issue.

2. Consider the ethical guidelines.

3. Examine the conflicts.

4. Resolve the conflicts.

5. Generate all possible courses of action.

6. Examine and evaluate the action alternatives.

7. Select and evaluate the preferred action.

8. Plan the action.

9. Evaluate the outcome.

10. Examine the implications.

Source: [10]

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

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

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

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

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

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

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

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

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

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

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

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

- Review the ramifications of the decision.

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

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

- Learn from successes and errors.

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

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

Ethical Principles Screen

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

Collaborative Model for Ethical Decision Making

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

- Identify the parties involved in the ethical dilemma.

- Define the viewpoints and worldviews of the parties involved.

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

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

LIMITATIONS OF ETHICAL DECISION-MAKING FRAMEWORKS

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

7. ETHICAL SELF-REFLECTION

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

PSYCHOLOGIC CONTEXT OF MORAL DECISION MAKING

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

8. MANAGED CARE AND ETHICS

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

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

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

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

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

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

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

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

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

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

9. DIVERSITY AND MULTICULTURALISM: ETHICAL ISSUES

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

DEMOGRAPHIC SHIFTS

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

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

MULTICULTURALISM IN RESEARCH

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

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

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

DEBATES WITHIN MULTICULTURALISM/DIVERSITY AND ETHICS

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

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

INFUSING DIVERSITY INTO THE ETHICAL DECISION-MAKING MODELS

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

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

Step 1: Interpreting the Situation through Awareness

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

Step 2: Formulating an Ethical Decision

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

Step 3: Weighing Competing, Nonmoral Values

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

Step 4: Implementing Action Plan

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

MULTICULTURALISM/DIVERSITY AND THE ACA CODE OF ETHICS

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

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

MULTICULTURALISM/DIVERSITY AND THE NBCC CODE OF ETHICS

Directive 26 of the NBCC Code of Ethics states that nationally certified counselors "shall demonstrate multicultural competence and shall not use techniques that discriminate against or show hostility towards individuals or groups based on gender, ethnicity, race, national origin, sexual orientation, disability, religion or any other legally prohibited basis" [58]. In addition to a working knowledge of a client's cultural norms, the counselor should have an understanding of the effect that discrimination and oversimplification have on various social groups.

Furthermore, Directive 48 states that counselors "shall accurately report test and assessment results and limit conclusions to those based on evidence, taking into consideration any influences that may affect results such as health, motivation and multicultural factors." It has been noted that many assessments, standardized tests, and techniques were normalized based on research with white, middle class populations. This includes psychologic test procedures and instruments in addition to educational or career assessment tools. Sociocultural norms and biases should be accounted for when interpreting results.

10. ONLINE COUNSELING

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

LIMITATIONS OF ONLINE COUNSELING

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

ONLINE COMMUNICATIONS AND DISTANCE COUNSELING: A SOCIOCULTURAL CONTEXT

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

Race, Culture, and Ethnicity

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

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

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

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

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

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

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

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

Gender

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

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

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

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

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

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

Table 3: GENDER DIFFERENCES IN COMMUNICATION PATTERNS IN ONLINE MEDIA

Women

Men

Attenuated assertions

Apologies

Explicit justifications

Questions

Personal orientation

Support for others

Strong assertions

Self-promotion

Presuppositions

Rhetorical questions

Authoritative orientation

Challenges to others

Use of humor and sarcasm

Source: [102]

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

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

ETHICAL AND LEGAL ISSUES

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

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

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

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

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

ACA CODE OF ETHICS AND DISTANCE COUNSELING

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

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

Information Privacy and Confidentiality

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

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

Distance Counseling, Technology, and Social Media

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

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

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

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

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

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

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

NBCC STANDARDS FOR DISTANCE PROFESSIONAL SERVICES

The NBCC has issued a document, separate from their ethical code, containing guidelines for ethical behavior specific to e-mail, chat, and video based Internet counseling.

The following standards are from The NBCC Policy Regarding the Provision of Distance Professional Services, ©2016 National Board for Certified Counselors, Inc. and Affiliates. Reprinted with the permission of the National Board for Certified Counselors, Inc.™ and Affiliates; 3 Terrace Way, Greensboro, NC 27403-3660. In this section, "nationally certified counselor" is abbreviated as NCC.

1. NCCs shall adhere to all NBCC policies and procedures, including the Code of Ethics.

2. NCCs shall provide only those services for which they are qualified by education and experience. NCCs shall also consider their qualifications to offer such service via distance means.

3. NCCs shall carefully adhere to legal regulations before providing distance services. This review shall include legal regulations from the state in which the counselor is located as well as those from the recipient's location. Given that NCCs may be offering distance services to individuals in different states at any one time, the NCC shall document relevant state regulations in the respective record(s).

4. NCCs shall ensure that any electronic means used in distance service provision are in compliance with current regulatory standards.

5. NCCs shall use encryption security for all digital technology communications of a therapeutic type. Information regarding security should be communicated to individuals who receive distance services. Despite the use of precautions, distance service recipients shall be informed of the potential hazards of distance communications. Not the least of these considerations is the warning about entering private information when using a public access or computer that is on a shared network. NCCs shall caution recipients of distance services against using "auto-remember" user names and passwords. NCCs shall also inform recipients of distance services to consider employers' policies relating to the use of work computers for personal communications.

6. To prevent the loss of digital communications or records, NCCs who provide distance services shall maintain secure backup systems. If the backup system is also a digital mechanism, this too shall offer encryption-level security. This information shall be provided to the recipient of professional services.

7. NCCs shall screen potential distance service recipients for appropriateness to receive services via distance methods. These considerations shall be documented in the records.

8. During the screening or intake process, NCCs shall provide potential recipients with a detailed written description of the distance counseling process and service provision. This information shall be specific to the identified service delivery type and include considerations for that particular individual. These considerations shall include the appropriateness of distance counseling in relation to the specific goal, the format of service delivery, the associated needs (i.e., computer with certain capabilities, etc.), the limitations of confidentiality, the possibility of technological failure, anticipated response time to electronic communication, and any additional considerations necessary to assist the potential recipient in reaching a determination about the appropriateness of this service delivery format for their need(s). NCCs shall discuss this information at key times throughout the service delivery process to ensure that this method satisfies the anticipated goals, and if not, the NCC will document the discussion of alternative options and referrals in the client's record.

9. Because of the ease in which digital communications can inadvertently be sent to other individuals, NCCs shall adopt behaviors to prevent the distribution of confidential information to unauthorized individuals. NCCs shall discuss actions the recipient may take to reduce the possibility that they will send information to other individuals by mistake.

10. NCCs shall provide recipients of distance professional services with information concerning their professional credentials and links to the respective credentialing organization websites.

11. NCCs, either prior to or during the initial session, shall inform recipients of the purposes, goals, procedures, limitations, potential risks, and benefits of services and techniques. NCCs also shall provide information about rights and responsibilities as appropriate to the distance service. As a part of this type of service provision, NCCs shall discuss with recipients the associated challenges that may occur when communicating through distance means, including those associated with privacy and confidentiality.

12. In the event that the recipient of distance services is a minor or is unable to provide legal consent, the NCC shall obtain a legal guardian's consent prior to the provision of distance services. Furthermore, NCCs shall retain copies of documentation indicating the legal guardian's identity in the recipient's file.

13. NCCs shall avoid the use of public social media sources (e.g., tweets, blogs, etc.) to provide confidential information. To facilitate the secure provision of information, NCCs shall provide in writing the appropriate ways to contact them.

14. NCCs shall discuss with recipients the importance of identifying recipient-named contacts in the event of emergency situations. As a part of this discussion, NCCs will identify the circumstances in which these individuals will be contacted and what information will be shared with emergency contacts. NCCs will provide recipients of distance services with specific written procedures regarding emergency situations. This information shall include emergency responders near the recipient's location. Given the increased dangers intrinsic to providing certain distance professional services, NCCs shall take reasonable steps to secure reasonable referrals for recipients when needed.

15. NCCs shall develop written procedures for verifying the identity of the recipient, his or her current location, and readiness to proceed at the beginning of each contact. Examples of verification means include the use of code words, phrases, or inquiries. (For example, "Is this a good time to proceed?")

16. NCCs shall limit use of information obtained through social media sources (e.g., Facebook, LinkedIn, Twitter, etc.) in accordance with established practice procedures provided to the recipient at the initiation of services or adapted through ongoing informed consent process.

17. NCCs shall provide information concerning locations where members of the public may access the Internet free of charge or provide information regarding the location of complimentary Web communication services. In such cases, the informed consent process shall include the required discussion items, including how this affects confidentiality and privacy.

18. NCCs shall retain copies of all written communications with distance service recipients. Examples of written communications include e-mail/text messages, instant messages and histories of chat-based discussions even if they are related to housekeeping issues such as change of contact information or scheduling appointments.

19. At a minimum, NCCs shall retain distance service records for a minimum of five years unless state laws require additional time. NCCs shall limit the use of records to those permitted by law, professional standards, and as specified by the agreement with the respective recipient of distance services.

20. NCCs shall develop written procedures for the use of social media and other related digital technology with current and former recipients. These written procedures shall, at a minimum, provide appropriate protections against the disclosure of confidential information and the creation of multiple relationships. These procedures shall also identify that personal social media accounts are distinct from any used for professional purposes.

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

11. CONCLUSION

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

California LMFTs

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

California LPCCs

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

California LEPs

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

12. RESOURCES

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

American Counseling Association Code of Ethics

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

APA Ethics Office

https://www.apa.org/ethics

Center for the Study of Ethics in the Professions

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

https://ethics.iit.edu

Ethics Resource Center

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

https://www.ethics.org

Ethics Updates

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

http://ethicsupdates.net

NASW Code of Ethics

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

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

National Board for Certified Counselors: Code of Ethics and Provision of Distance Professional Services

https://www.nbcc.org/Ethics

W. Maurice Young Centre for Applied Ethics

https://ethics.ubc.ca

13. APPENDIX: THE ACA CODE OF ETHICS

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

SECTION A: THE COUNSELING RELATIONSHIP

Introduction

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

A.1. Client Welfare

A.1.a. Primary Responsibility

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

A.1.b. Records and Documentation

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

A.1.c. Counseling Plans

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

A.1.d. Support Network Involvement

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

A.2. Informed Consent in the Counseling Relationship

A.2.a. Informed Consent

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

A.2.b. Types of Information Needed

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

A.2.c. Developmental and Cultural Sensitivity

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

A.2.d. Inability to Give Consent

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

A.2.e. Mandated Clients

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

A.3. Clients Served by Others

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

A.4. Avoiding Harm and Imposing Values

A.4.a. Avoiding Harm

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

A.4.b. Personal Values

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

A.5. Prohibited Noncounseling Roles and Relationships

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

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

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

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

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

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

A.5.d. Friends or Family Members

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

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

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

A.6. Managing and Maintaining Boundaries and Professional Relationships

A.6.a. Previous Relationships

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

A.6.b. Extending Counseling Boundaries

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

A.6.c. Documenting Boundary Extensions

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

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

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

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

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

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

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

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

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

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

A.7.a. Advocacy

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

A.7.b. Confidentiality and Advocacy

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

A.8. Multiple Clients

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

A.9. Group Work

A.9.a. Screening

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

A.9.b. Protecting Clients

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

A.10. Fees and Business Practices

A.10.a. Self-Referral

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

A.10.b. Unacceptable Business Practices

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

A.10.c. Establishing Fees

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

A.10.d. Nonpayment of Fees

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

A.10.e. Bartering

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

A.10.f. Receiving Gifts

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

A.11. Termination and Referral

A.11.a. Competence within Termination and Referral

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

A.11.b. Values within Termination and Referral

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

A.11.c. Appropriate Termination

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

A.11.d. Appropriate Transfer of Services

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

A.12. Abandonment and Client Neglect

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

SECTION B: CONFIDENTIALITY AND PRIVACY

Introduction

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

B.1. Respecting Client Rights

B.1.a. Multicultural/Diversity Considerations

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

B.1.b. Respect for Privacy

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

B.1.c. Respect for Confidentiality

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

B.1.d. Explanation of Limitations

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

B.2. Exceptions

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

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

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

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

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

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

B.2.d. Court-Ordered Disclosure

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

B.2.e. Minimal Disclosure

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

B.3. Information Shared with Others

B.3.a. Subordinates

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

B.3.b. Interdisciplinary Teams

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

B.3.c. Confidential Settings

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

B.3.d. Third-Party Payers

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

B.3.e. Transmitting Confidential Information

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

B.3.f. Deceased Clients

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

B.4. Groups and Families

B.4.a. Group Work

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

B.4.b. Couples and Family Counseling

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

B.5. Clients Lacking Capacity to Give Informed Consent

B.5.a. Responsibility to Clients

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

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

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

B.5.c. Release of Confidential Information

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

B.6. Records and Documentation

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

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

B.6.b. Confidentiality of Records and Documentation

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

B.6.c. Permission to Record

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

B.6.d. Permission to Observe

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

B.6.e. Client Access

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

B.6.f. Assistance with Records

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

B.6.g. Disclosure or Transfer

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

B.6.h. Storage and Disposal After Termination

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

B.6.i. Reasonable Precautions

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

B.7. Case Consultation

B.7.a. Respect for Privacy

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

B.7.b. Disclosure of Confidential Information

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

SECTION C: PROFESSIONAL RESPONSIBILITY

Introduction

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

C.1. Knowledge of and Compliance with Standards

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

C.2. Professional Competence

C.2.a. Boundaries of Competence

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

C.2.b. New Specialty Areas of Practice

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

C.2.c. Qualified for Employment

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

C.2.d. Monitor Effectiveness

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

C.2.e. Consultations on Ethical Obligations

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

C.2.f. Continuing Education

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

C.2.g. Impairment

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

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

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

C.3. Advertising and Soliciting Clients

C.3.a. Accurate Advertising

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

C.3.b. Testimonials

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

C.3.c. Statements by Others

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

C.3.d. Recruiting Through Employment

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

C.3.e. Products and Training Advertisements

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

C.3.f. Promoting to Those Served

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

C.4. Professional Qualifications

C.4.a. Accurate Representation

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

C.4.b. Credentials

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

C.4.c. Educational Degrees

Counselors clearly differentiate between earned and honorary degrees.

C.4.d. Implying Doctoral-Level Competence

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

C.4.e. Accreditation Status

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

C.4.f. Professional Membership

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

C.5. Nondiscrimination

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

C.6. Public Responsibility

C.6.a. Sexual Harassment

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

C.6.b. Reports to Third Parties

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

C.6.c. Media Presentations

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

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

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

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

C.6.d. Exploitation of Others

Counselors do not exploit others in their professional relationships.

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

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

C.7. Treatment Modalities

C.7.a. Scientific Basis for Treatment

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

C.7.b. Development and Innovation

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

C.7.c. Harmful Practices

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

C.8. Responsibility to Other Professionals

C.8.a. Personal Public Statements

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

SECTION D: RELATIONSHIPS WITH OTHER PROFESSIONALS

Introduction

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

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

D.1.a. Different Approaches

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

D.1.b. Forming Relationships

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

D.1.c. Interdisciplinary Teamwork

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

D.1.d. Establishing Professional and Ethical Obligations

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

D.1.e. Confidentiality

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

D.1.f. Personnel Selection and Assignment

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

D.1.g. Employer Policies

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

D.1.h. Negative Conditions

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

D.1.i. Protection From Punitive Action

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

D.2. Provision of Consultation Services

D.2.a. Consultant Competency

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

D.2.b. Informed Consent in Formal Consultation

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

SECTION E: EVALUATION, ASSESSMENT, AND INTERPRETATION

Introduction

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

E.1. General

E.1.a. Assessment

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

E.1.b. Client Welfare

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

E.2. Competence to Use and Interpret Assessment Instruments

E.2.a. Limits of Competence

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

E.2.b. Appropriate Use

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

E.2.c. Decisions Based on Results

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

E.3. Informed Consent in Assessment

E.3.a. Explanation to Clients

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

E.3.b. Recipients of Results

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

E.4. Release of Data to Qualified Personnel

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

E.5. Diagnosis of Mental Disorders

E.5.a. Proper Diagnosis

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

E.5.b. Cultural Sensitivity

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

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

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

E.5.d. Refraining From Diagnosis

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

E.6. Instrument Selection

E.6.a. Appropriateness of Instruments

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

E.6.b. Referral Information

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

E.7. Conditions of Assessment Administration

E.7.a. Administration Conditions

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

E.7.b. Provision of Favorable Conditions

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

E.7.c. Technological Administration

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

E.7.d. Unsupervised Assessments

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

E.8. Multicultural Issues/Diversity in Assessment

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

E.9. Scoring and Interpretation of Assessments

E.9.a. Reporting

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

E.9.b. Instruments with Insufficient Empirical Data

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

E.9.c. Assessment Services

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

E.10. Assessment Security

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

E.11. Obsolete Assessment and Outdated Results

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

E.12. Assessment Construction

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

E.13. Forensic Evaluation: Evaluation for Legal Proceedings

E.13.a. Primary Obligations

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

E.13.b. Consent for Evaluation

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

E.13.c. Client Evaluation Prohibited

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

E.13.d. Avoid Potentially Harmful Relationships

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

SECTION F: SUPERVISION, TRAINING, AND TEACHING

Introduction

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

F.1. Counselor Supervision and Client Welfare

F.1.a. Client Welfare

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

F.1.b. Counselor Credentials

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

F.1.c. Informed Consent and Client Rights

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

F.2. Counselor Supervision Competence

F.2.a. Supervisor Preparation

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

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

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

F.2.c. Online Supervision

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

F.3. Supervisory Relationship

F.3.a. Extending Conventional Supervisory Relationships

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

F.3.b. Sexual Relationships

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

F.3.c. Sexual Harassment

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

F.3.d. Friends or Family Members

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

F.4. Supervisor Responsibilities

F.4.a. Informed Consent for Supervision

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

F.4.b. Emergencies and Absences

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

F.4.c. Standards for Supervisees

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

F.4.d. Termination of the Supervisory Relationship

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

F.5. Student and Supervisee Responsibilities

F.5.a. Ethical Responsibilities

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

F.5.b. Impairment

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

F.5.c. Professional Disclosure

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

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

F.6.a. Evaluation

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

F.6.b. Gatekeeping and Remediation

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

F.6.c. Counseling for Supervisees

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

F.6.d. Endorsements

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

F.7. Responsibilities of Counselor Educators

F.7.a. Counselor Educators

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

F.7.b. Counselor Educator Competence

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

F.7.c. Infusing Multicultural Issues/Diversity

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

F.7.d. Integration of Study and Practice

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

F.7.e. Teaching Ethics

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

F.7.f. Use of Case Examples

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

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

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

F.7.h. Innovative Theories and Techniques

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

F.7.i. Field Placements

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

F.8. Student Welfare

F.8.a. Program Information and Orientation

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

1. The values and ethical principles of the profession;

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

3. Technology requirements;

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

5. Bases for evaluation;

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

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

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

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

F.8.b. Student Career Advising

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

F.8.c. Self-Growth Experiences

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

F.8.d. Addressing Personal Concerns

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

F.9. Evaluation and Remediation

F.9.a. Evaluation of Students

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

F.9.b. Limitations

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

1. Assist students in securing remedial assistance when needed,

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

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

F.9.c. Counseling for Students

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

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

F.10.a. Sexual or Romantic Relationships

Counselor educators are prohibited from sexual or romantic interactions or relationships with students currently enrolled in a counseling or related program and over whom they have power and authority. This prohibition applies to both in-person and electronic interactions or relationships.

F.10.b. Sexual Harassment

Counselor educators do not condone or subject students to sexual harassment.

F.10.c. Relationships with Former Students

Counselor educators are aware of the power differential in the relationship between faculty and students. Faculty members discuss with former students potential risks when they consider engaging in social, sexual, or other intimate relationships.

F.10.d. Nonacademic Relationships

Counselor educators avoid nonacademic relationships with students in which there is a risk of potential harm to the student or which may compromise the training experience or grades assigned. In addition, counselor educators do not accept any form of professional services, fees, commissions, reimbursement, or remuneration from a site for student or supervisor placement.

F.10.e. Counseling Services

Counselor educators do not serve as counselors to students currently enrolled in a counseling or related program and over whom they have power and authority.

F.10.f. Extending Educator-Student Boundaries

Counselor educators are aware of the power differential in the relationship between faculty and students. If they believe that a nonprofessional relationship with a student may be potentially beneficial to the student, they take precautions similar to those taken by counselors when working with clients. Examples of potentially beneficial interactions or relationships include, but are not limited to, attending a formal ceremony; conducting hospital visits; providing support during a stressful event; or maintaining mutual membership in a professional association, organization, or community. Counselor educators discuss with students the rationale for such interactions, the potential benefits and drawbacks, and the anticipated consequences for the student. Educators clarify the specific nature and limitations of the additional role(s) they will have with the student prior to engaging in a nonprofessional relationship. Nonprofessional relationships with students should be time limited and/or context specific and initiated with student consent.

F.11. Multicultural/Diversity Competence in Counselor Education and Training Programs

F.11.a. Faculty Diversity

Counselor educators are committed to recruiting and retaining a diverse faculty.

F.11.b. Student Diversity

Counselor educators actively attempt to recruit and retain a diverse student body. Counselor educators demonstrate commitment to multicultural/diversity competence by recognizing and valuing the diverse cultures and types of abilities that students bring to the training experience. Counselor educators provide appropriate accommodations that enhance and support diverse student well-being and academic performance.

F.11.c. Multicultural/Diversity Competence

Counselor educators actively infuse multicultural/diversity competency in their training and supervision practices. They actively train students to gain awareness, knowledge, and skills in the competencies of multicultural practice.

SECTION G: RESEARCH AND PUBLICATION

Introduction

Counselors who conduct research are encouraged to contribute to the knowledge base of the profession and promote a clearer understanding of the conditions that lead to a healthy and more just society. Counselors support the efforts of researchers by participating fully and willingly whenever possible. Counselors minimize bias and respect diversity in designing and implementing research.

G.1. Research Responsibilities

G.1.a. Conducting Research

Counselors plan, design, conduct, and report research in a manner that is consistent with pertinent ethical principles, federal and state laws, host institutional regulations, and scientific standards governing research.

G.1.b. Confidentiality in Research

Counselors are responsible for understanding and adhering to state, federal, agency, or institutional policies or applicable guidelines regarding confidentiality in their research practices.

G.1.c. Independent Researchers

When counselors conduct independent research and do not have access to an institutional review board, they are bound to the same ethical principles and federal and state laws pertaining to the review of their plan, design, conduct, and reporting of research.

G.1.d. Deviation From Standard Practice

Counselors seek consultation and observe stringent safeguards to protect the rights of research participants when research indicates that a deviation from standard or acceptable practices may be necessary.

G.1.e. Precautions to Avoid Injury

Counselors who conduct research are responsible for their participants' welfare throughout the research process and should take reasonable precautions to avoid causing emotional, physical, or social harm to participants.

G.1.f. Principal Researcher Responsibility

The ultimate responsibility for ethical research practice lies with the principal researcher. All others involved in the research activities share ethical obligations and responsibility for their own actions.

G.2. Rights of Research Participants

G.2.a. Informed Consent in Research

Individuals have the right to decline requests to become research participants. In seeking consent, counselors use language that:

1. Accurately explains the purpose and procedures to be followed;

2. Identifies any procedures that are experimental or relatively untried;

3. Describes any attendant discomforts, risks, and potential power differentials between researchers and participants;

4. Describes any benefits or changes in individuals or organizations that might reasonably be expected;

5. Discloses appropriate alternative procedures that would be advantageous for participants;

6. Offers to answer any inquiries concerning the procedures;

7. Describes any limitations on confidentiality;

8. Describes the format and potential target audiences for the dissemination of research findings; and

9. Instructs participants that they are free to withdraw their consent and discontinue participation in the project at any time, without penalty.

G.2.b. Student/Supervisee Participation

Researchers who involve students or supervisees in research make clear to them that the decision regarding participation in research activities does not affect their academic standing or supervisory relationship. Students or supervisees who choose not to participate in research are provided with an appropriate alternative to fulfill their academic or clinical requirements.

G.2.c. Client Participation

Counselors conducting research involving clients make clear in the informed consent process that clients are free to choose whether to participate in research activities. Counselors take necessary precautions to protect clients from adverse consequences of declining or withdrawing from participation.

G.2.d. Confidentiality of Information

Information obtained about research participants during the course of research is confidential. Procedures are implemented to protect confidentiality.

G.2.e. Persons Not Capable of Giving Informed Consent

When a research participant is not capable of giving informed consent, counselors provide an appropriate explanation to, obtain agreement for participation from, and obtain the appropriate consent of a legally authorized person.

G.2.f. Commitments to Participants

Counselors take reasonable measures to honor all commitments to research participants.

G.2.g. Explanations After Data Collection

After data are collected, counselors provide participants with full clarification of the nature of the study to remove any misconceptions participants might have regarding the research. Where scientific or human values justify delaying or withholding information, counselors take reasonable measures to avoid causing harm.

G.2.h. Informing Sponsors

Counselors inform sponsors, institutions, and publication channels regarding research procedures and outcomes. Counselors ensure that appropriate bodies and authorities are given pertinent information and acknowledgment.

G.2.i. Research Records Custodian

As appropriate, researchers prepare and disseminate to an identified colleague or records custodian a plan for the transfer of research data in the case of their incapacitation, retirement, or death.

G.3. Managing and Maintaining Boundaries

G.3.a. Extending Researcher-Participant Boundaries

Researchers consider the risks and benefits of extending current research relationships beyond conventional parameters. When a nonresearch interaction between the researcher and the research participant may be potentially beneficial, the researcher must document, prior to the interaction (when feasible), the rationale for such an interaction, the potential benefit, and anticipated consequences for the research participant. Such interactions should be initiated with appropriate consent of the research participant. Where unintentional harm occurs to the research participant, the researcher must show evidence of an attempt to remedy such harm.

G.3.b. Relationships with Research Participants

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

G.3.c. Sexual Harassment and Research Participants

Researchers do not condone or subject research participants to sexual harassment.

G.4. Reporting Results

G.4.a. Accurate Results

Counselors plan, conduct, and report research accurately. Counselors do not engage in misleading or fraudulent research, distort data, misrepresent data, or deliberately bias their results. They describe the extent to which results are applicable for diverse populations.

G.4.b. Obligation to Report Unfavorable Results

Counselors report the results of any research of professional value. Results that reflect unfavorably on institutions, programs, services, prevailing opinions, or vested interests are not withheld.

G.4.c. Reporting Errors

If counselors discover significant errors in their published research, they take reasonable steps to correct such errors in a correction erratum or through other appropriate publication means.

G.4.d. Identity of Participants

Counselors who supply data, aid in the research of another person, report research results, or make original data available take due care to disguise the identity of respective participants in the absence of specific authorization from the participants to do otherwise. In situations where participants self-identify their involvement in research studies, researchers take active steps to ensure that data are adapted/changed to protect the identity and welfare of all parties and that discussion of results does not cause harm to participants.

G.4.e. Replication Studies

Counselors are obligated to make available sufficient original research information to qualified professionals who may wish to replicate or extend the study.

G.5. Publications and Presentations

G.5.a. Use of Case Examples

The use of participants', clients', students', or supervisees' information for the purpose of case examples in a presentation or publication is permissible only when (a) participants, clients, students, or supervisees have reviewed the material and agreed to its presentation or publication or (b) the information has been sufficiently modified to obscure identity.

G.5.b. Plagiarism

Counselors do not plagiarize; that is, they do not present another person's work as their own.

G.5.c. Acknowledging Previous Work

In publications and presentations, counselors acknowledge and give recognition to previous work on the topic by others or self.

G.5.d. Contributors

Counselors give credit through joint authorship, acknowledgment, footnote statements, or other appropriate means to those who have contributed significantly to research or concept development in accordance with such contributions. The principal contributor is listed first, and minor technical or professional contributions are acknowledged in notes or introductory statements.

G.5.e. Agreement of Contributors

Counselors who conduct joint research with colleagues or students/supervisors establish agreements in advance regarding allocation of tasks, publication credit, and types of acknowledgment that will be received.

G.5.f. Student Research

Manuscripts or professional presentations in any medium that are substantially based on a student's course papers, projects, dissertations, or theses are used only with the student's permission and list the student as lead author.

G.5.g. Duplicate Submissions

Counselors submit manuscripts for consideration to only one journal at a time. Manuscripts that are published in whole or in substantial part in one journal or published work are not submitted for publication to another publisher without acknowledgment and permission from the original publisher.

G.5.h. Professional Review

Counselors who review material submitted for publication, research, or other scholarly purposes respect the confidentiality and proprietary rights of those who submitted it. Counselors make publication decisions based on valid and defensible standards. Counselors review article submissions in a timely manner and based on their scope and competency in research methodologies. Counselors who serve as reviewers at the request of editors or publishers make every effort to only review materials that are within their scope of competency and avoid personal biases.

SECTION H: DISTANCE COUNSELING, TECHNOLOGY, AND SOCIAL MEDIA

Introduction

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

H.1. Knowledge and Legal Considerations

H.1.a. Knowledge and Competency

Counselors who engage in the use of distance counseling, technology, and/or social media develop knowledge and skills regarding related technical, ethical, and legal considerations (e.g., special certifications, additional course work).

H.1.b. Laws and Statutes

Counselors who engage in the use of distance counseling, technology, and social media within their counseling practice understand that they may be subject to laws and regulations of both the counselor's practicing location and the client's place of residence. Counselors ensure that their clients are aware of pertinent legal rights and limitations governing the practice of counseling across state lines or international boundaries.

H.2. Informed Consent and Security

H.2.a. Informed Consent and Disclosure

Clients have the freedom to choose whether to use distance counseling, social media, and/or technology within the counseling process. In addition to the usual and customary protocol of informed consent between counselor and client for face-to-face counseling, the following issues, unique to the use of distance counseling, technology, and/or social media, are addressed in the informed consent process:

- Distance counseling credentials, physical location of practice, and contact information;

- Risks and benefits of engaging in the use of distance counseling, technology, and/or social media;

- Possibility of technology failure and alternate methods of service delivery;

- Anticipated response time;

- Emergency procedures to follow when the counselor is not available;

- Time zone differences;

- Cultural and/or language differences that may affect delivery of services;

- Possible denial of insurance benefits; and

- Social media policy.

H.2.b. Confidentiality Maintained by the Counselor

Counselors acknowledge the limitations of maintaining the confidentiality of electronic records and transmissions. They inform clients that individuals might have authorized or unauthorized access to such records or transmissions (e.g., colleagues, supervisors, employees, information technologists).

H.2.c. Acknowledgment of Limitations

Counselors inform clients about the inherent limits of confidentiality when using technology. Counselors urge clients to be aware of authorized and/or unauthorized access to information disclosed using this medium in the counseling process.

H.2.d. Security

Counselors use current encryption standards within their websites and/or technology-based communications that meet applicable legal requirements. Counselors take reasonable precautions to ensure the confidentiality of information transmitted through any electronic means.

H.3. Client Verification

Counselors who engage in the use of distance counseling, technology, and/or social media to interact with clients take steps to verify the client's identity at the beginning and throughout the therapeutic process. Verification can include, but is not limited to, using code words, numbers, graphics, or other nondescript identifiers.

H.4. Distance Counseling Relationship

H.4.a. Benefits and Limitations

Counselors inform clients of the benefits and limitations of using technology applications in the provision of counseling services. Such technologies include, but are not limited to, computer hardware and/or software, telephones and applications, social media and Internet-based applications and other audio and/or video communication, or data storage devices or media.

H.4.b. Professional Boundaries in Distance Counseling

Counselors understand the necessity of maintaining a professional relationship with their clients. Counselors discuss and establish professional boundaries with clients regarding the appropriate use and/or application of technology and the limitations of its use within the counseling relationship (e.g., lack of confidentiality, times when not appropriate to use).

H.4.c. Technology-Assisted Services

When providing technology-assisted services, counselors make reasonable efforts to determine that clients are intellectually, emotionally, physically, linguistically, and functionally capable of using the application and that the application is appropriate for the needs of the client. Counselors verify that clients understand the purpose and operation of technology applications and follow up with clients to correct possible misconceptions, discover appropriate use, and assess subsequent steps.

H.4.d. Effectiveness of Services

When distance counseling services are deemed ineffective by the counselor or client, counselors consider delivering services face-to-face. If the counselor is not able to provide face-to-face services (e.g., lives in another state), the counselor assists the client in identifying appropriate services.

H.4.e. Access

Counselors provide information to clients regarding reasonable access to pertinent applications when providing technology-assisted services.

H.4.f. Communication Differences in Electronic Media

Counselors consider the differences between face-to-face and electronic communication (nonverbal and verbal cues) and how these may affect the counseling process. Counselors educate clients on how to prevent and address potential misunderstandings arising from the lack of visual cues and voice intonations when communicating electronically.

H.5. Records and Web Maintenance

H.5.a. Records

Counselors maintain electronic records in accordance with relevant laws and statutes. Counselors inform clients on how records are maintained electronically. This includes, but is not limited to, the type of encryption and security assigned to the records, and if/for how long archival storage of transaction records is maintained.

H.5.b. Client Rights

Counselors who offer distance counseling services and/or maintain a professional website provide electronic links to relevant licensure and professional certification boards to protect consumer and client rights and address ethical concerns.

H.5.c. Electronic Links

Counselors regularly ensure that electronic links are working and are professionally appropriate.

H.5.d. Multicultural and Disability Considerations

Counselors who maintain websites provide accessibility to persons with disabilities. They provide translation capabilities for clients who have a different primary language, when feasible. Counselors acknowledge the imperfect nature of such translations and accessibilities.

H.6. Social Media

H.6.a. Virtual Professional Presence

In cases where counselors wish to maintain a professional and personal presence for social media use, separate professional and personal web pages and profiles are created to clearly distinguish between the two kinds of virtual presence.

H.6.b. Social Media as Part of Informed Consent

Counselors clearly explain to their clients, as part of the informed consent procedure, the benefits, limitations, and boundaries of the use of social media.

H.6.c. Client Virtual Presence

Counselors respect the privacy of their clients' presence on social media unless given consent to view such information.

H.6.d. Use of Public Social Media

Counselors take precautions to avoid disclosing confidential information through public social media.

SECTION I: RESOLVING ETHICAL ISSUES

Introduction

Professional counselors behave in an ethical and legal manner. They are aware that client welfare and trust in the profession depend on a high level of professional conduct. They hold other counselors to the same standards and are willing to take appropriate action to ensure that standards are upheld. Counselors strive to resolve ethical dilemmas with direct and open communication among all parties involved and seek consultation with colleagues and supervisors when necessary. Counselors incorporate ethical practice into their daily professional work and engage in ongoing professional development regarding current topics in ethical and legal issues in counseling. Counselors become familiar with the ACA Policy and Procedures for Processing Complaints of Ethical Violations and use it as a reference for assisting in the enforcement of the ACA Code of Ethics.

I.1. Standards and the Law

I.1.a. Knowledge

Counselors know and understand the ACA Code of Ethics and other applicable ethics codes from professional organizations or certification and licensure bodies of which they are members. Lack of knowledge or misunderstanding of an ethical responsibility is not a defense against a charge of unethical conduct.

I.1.b. Ethical Decision Making

When counselors are faced with an ethical dilemma, they use and document, as appropriate, an ethical decision-making model that may include, but is not limited to, consultation; consideration of relevant ethical standards, principles, and laws; generation of potential courses of action; deliberation of risks and benefits; and selection of an objective decision based on the circumstances and welfare of all involved.

I.1.c. Conflicts Between Ethics and Laws

If ethical responsibilities conflict with the law, regulations, and/or other governing legal authority, counselors make known their commitment to the ACA Code of Ethics and take steps to resolve the conflict. If the conflict cannot be resolved using this approach, counselors, acting in the best interest of the client, may adhere to the requirements of the law, regulations, and/or other governing legal authority.

I.2. Suspected Violations

I.2.a. Informal Resolution

When counselors have reason to believe that another counselor is violating or has violated an ethical standard and substantial harm has not occurred, they attempt to first resolve the issue informally with the other counselor if feasible, provided such action does not violate confidentiality rights that may be involved.

I.2.b. Reporting Ethical Violations

If an apparent violation has substantially harmed or is likely to substantially harm a person or organization and is not appropriate for informal resolution or is not resolved properly, counselors take further action depending on the situation. Such action may include referral to state or national committees on professional ethics, voluntary national certification bodies, state licensing boards, or appropriate institutional authorities. The confidentiality rights of clients should be considered in all actions. This standard does not apply when counselors have been retained to review the work of another counselor whose professional conduct is in question (e.g., consultation, expert testimony).

I.2.c. Consultation

When uncertain about whether a particular situation or course of action may be in violation of the ACA Code of Ethics, counselors consult with other counselors who are knowledgeable about ethics and the ACA Code of Ethics, with colleagues, or with appropriate authorities, such as the ACA Ethics and Professional Standards Department.

I.2.d. Organizational Conflicts

If the demands of an organization with which counselors are affiliated pose a conflict with the ACA Code of Ethics, counselors specify the nature of such conflicts and express to their supervisors or other responsible officials their commitment to the ACA Code of Ethics and, when possible, work through the appropriate channels to address the situation.

I.2.e. Unwarranted Complaints

Counselors do not initiate, participate in, or encourage the filing of ethics complaints that are retaliatory in nature or are made with reckless disregard or willful ignorance of facts that would disprove the allegation.

I.2.f. Unfair Discrimination Against Complainants and Respondents

Counselors do not deny individuals employment, advancement, admission to academic or other programs, tenure, or promotion based solely on their having made or their being the subject of an ethics complaint. This does not preclude taking action based on the outcome of such proceedings or considering other appropriate information.

I.3. Cooperation with Ethics Committees

Counselors assist in the process of enforcing the ACA Code of Ethics. Counselors cooperate with investigations, proceedings, and requirements of the ACA Ethics Committee or ethics committees of other duly constituted associations or boards having jurisdiction over those charged with a violation.

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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.

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Evidence-Based Practice Recommendations Citations

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