NYSW19B • New York Social Workers 2019 - 2020

Table of Contents

NYSW19B • New York Social Workers 2019 - 2020

How to Receive Credit

NetCE 4 Hour Course #76522 • Dream Work: A Psychoanalytic Perspective

76522 • Dream Work: A Psychoanalytic Perspective

1. INTRODUCTION

2. THE MEANING AND ORIGIN OF DREAMS

3. A HISTORY OF FREUD AND THE PSYCHOANALYTIC TRADITION

4. FREUD'S APPROACH TO DREAMS

5. SHARED CONCEPTS WITHIN PSYCHOANALYSIS

6. MODERN DREAM RESEARCH

7. PSYCHOANALYSTS: AN OVERVIEW

8. THE INFLUENCE OF CULTURE/ETHNICITY ON DREAMING

9. THE IMPACT OF TECHNOLOGY ON DREAMS AND DREAM ANALYSIS

10. THE DREAMER'S ROLE IN INTERPRETING SYMBOLS IN DREAMS

11. DREAM SPECIMENS

12. CONCLUSION

13. RESOURCES

Works Cited

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

71500 • The Bisexual Client: Trauma-Focused Care

1. INTRODUCTION

2. FOUNDATIONS: IDENTIFYING BISEXUALITY AND RELATED DEFINITIONS

3. THE TRAUMA OF THE BISEXUAL EXPERIENCE

4. CULTURALLY RESPONSIVE TRAUMA TREATMENT PLANNING FOR BISEXUAL CLIENTS

5. CLINICAL COMPETENCE IN WORKING WITH BISEXUAL UMBRELLA CLIENTS

6. CONCLUSION

7. RESOURCES

Works Cited

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

77040 • Setting Ethical Limits: For Caring and Competent Professionals

1. INTRODUCTION

2. COMPETENCE

3. CULTURAL COMPETENCE

4. THE THERAPEUTIC RELATIONSHIP

5. THE COSTS OF CARING

6. TRANSFERENCE AND COUNTERTRANSFERENCE

7. BOUNDARIES AND LIMITS

8. BOUNDARY CROSSINGS AND VIOLATIONS

9. MULTIPLE RELATIONSHIPS

10. GIFTS

11. TECHNOLOGY AND DISTANCE THERAPY

12. CONCLUSION

13. RESOURCES

Works Cited

NYSW19B • New York Social Workers 2019 - 2020

Suzanne Saldarini, MA, LPC, NCPsyA

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

www.netce.com

Copyright © 2024 NetCE, All rights reserved.

NYSW19B • New York Social Workers 2019 - 2020

Expiration Date: 11/30/2021

How to Receive Credit

To complete this Special Offer for continuing education credit please go to http://www.netce.com/specials in your browser.

For assistance with receiving continuing education credit, please contact us at help@netce.com.

76522 • Dream Work: A Psychoanalytic Perspective

Suzanne Saldarini, MA, LPC, NCPsyA

www.netce.com

Copyright © 2019 NetCE, All rights reserved.

More than 100 years ago, Sigmund Freud's pioneering work with dreams revealed a hidden world of unconscious thoughts and wishes. Freud's theories and methods continue to speak to mental health professionals. This course is intended to give clinicians a basic understanding of Freud's theory of dream interpretation, to explain practical techniques for use with patients, and to describe the therapeutic gains obtainable with dream work. It will begin with brief summations of Freud's contribution to the search for dreams' significance and the impact of his development of psychoanalysis. Connections to contemporary dream research are established. Issues surrounding specimens, including Freud's dreams, the clinician's own, and those of patients, are discussed.

Table of Contents

76522 • Dream Work: A Psychoanalytic Perspective

Course Overview

Audience

Course Objective

Learning Objectives

Faculty

Faculty Disclosure

Division Planner

Division Planner Disclosure

About the Sponsor

Disclosure Statement

1. INTRODUCTION

2. THE MEANING AND ORIGIN OF DREAMS

3. A HISTORY OF FREUD AND THE PSYCHOANALYTIC TRADITION

4. FREUD'S APPROACH TO DREAMS

THE ROUTE FROM WISH TO DREAM

MANIFEST AND LATENT DREAM CONTENT

THE MECHANISMS OF DREAM WORK

5. SHARED CONCEPTS WITHIN PSYCHOANALYSIS

6. MODERN DREAM RESEARCH

PSYCHOLOGY

NEUROPSYCHOLOGY

PSYCHOANALYSIS

NEUROSCIENCE

7. PSYCHOANALYSTS: AN OVERVIEW

TRAINING

ESSENTIAL TECHNIQUE

8. THE INFLUENCE OF CULTURE/ETHNICITY ON DREAMING

CULTURE IN THE PSYCHOANALYSIS OF DREAMS

9. THE IMPACT OF TECHNOLOGY ON DREAMS AND DREAM ANALYSIS

10. THE DREAMER'S ROLE IN INTERPRETING SYMBOLS IN DREAMS

PERSONAL DREAM STUDY

EDUCATING CLIENTS

RECOMMENDATIONS FOR CLINICIANS

11. DREAM SPECIMENS

DREAM I

DREAM II

DREAM III

DREAM IV

12. CONCLUSION

13. RESOURCES

Works Cited

76522 • Dream Work: A Psychoanalytic Perspective

Education Category. Psychiatric / Mental Health

Release Date. 02/01/2019

Expiration Date. 01/31/2022

Course Overview

More than 100 years ago, Sigmund Freud's pioneering work with dreams revealed a hidden world of unconscious thoughts and wishes. Freud's theories and methods continue to speak to mental health professionals. This course is intended to give clinicians a basic understanding of Freud's theory of dream interpretation, to explain practical techniques for use with patients, and to describe the therapeutic gains obtainable with dream work. It will begin with brief summations of Freud's contribution to the search for dreams' significance and the impact of his development of psychoanalysis. Connections to contemporary dream research are established. Issues surrounding specimens, including Freud's dreams, the clinician's own, and those of patients, are discussed.

Audience

This course is designed for mental health clinicians across disciplines, including counselors, social workers, and other professionals who provide psychotherapy. It is written for clinicians without formal training in dream interpretation as well as for those seeking review of the material.

Course Objective

The purpose of this course is to provide a basic understanding of Freud's theory of dream interpretation, to explain practical techniques for use with clients, and to describe therapeutic gains obtainable with dream work.

Learning Objectives

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

1. Outline Freud's contributions to the psychoanalytic tradition.

2. Describe Freud's approach to dreams.

3. Identify psychologic mechanisms involved in building a dream.

4. Identify shared concepts within psychoanalysis.

5. Describe an example of modern dream research.

6. Explain the key differences between psychoanalysts and other mental health clinicians.

7. Discuss the influence of culture, ethnicity, and technology on dreaming.

8. Describe the dreamer's role in interpreting symbols in dreams

Faculty

Suzanne Saldarini, MA, LPC, NCPsyA, is a certified psychoanalyst and licensed professional counselor in private practice in Ramsey, New Jersey. She sees individuals, couples, children, and adolescents in both long and short-term psychotherapy. She earned psychoanalytic certification at the New Jersey Institute for Training in Psychoanalysis, where she has taught The Interpretation of Dreams and served as Curriculum and Membership chairs; she continues at NJIT as a faculty member and control analyst. Ms. Saldarini began formal study of dreams as an analytic candidate but first read Freud as a psychology undergraduate at Drew University. Her graduate career in psychology began with basic research in observation of child behavior in natural settings at the University of Kansas. A certified School Psychologist, she completed many years of practice in schools and agencies both public and private before her return to Freudian study and finally psychoanalytic training and practice. She has made continuing education presentations on Freud’s approach to dreams at annual conferences for both the New Jersey Counseling Association and the International Association for the Study of Dreams. Ms. Saldarini has also authored two children's books on dreaming, About Dreams and Harry's Dream.

Faculty Disclosure

Contributing faculty, Suzanne Saldarini, MA, LPC, NCPsyA, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Division Planner

Alice Yick Flanagan, PhD, MSW

Division Planner Disclosure

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

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

The nature and meaning of dreams has been an area of interest throughout history. However, Sigmund Freud elevated the study of dreams to a type of science. His contributions, including the concept of the unconscious, remain relevant to researchers and mental health professionals today. With the publication of Freud's The Interpretation of Dreams, the field of psychoanalysis was born, and serious clinical inquiry into the basis and creation of the mind (i.e., Freud's "theory of the mind") began. Freud labeled the ethereal parts of the mind (i.e., the conscious, subconscious, and unconscious) that make us human, and he established the foundation for how we think about the brain. His theory of the mind led to the understanding that our dreams are both purposeful and meaningful [1].

2. THE MEANING AND ORIGIN OF DREAMS

While sleeping, dreams seem real. On waking, however, the memory of the dream, especially in comparison with waking thoughts and feelings, may seem alien or other-worldly [2]. Freud connected these impressions to the explanation that dreams are messages that begin outside ourselves. Literature is filled with examples of dreams explained as communications from supernatural or divine sources, understood as warnings or predictions [3,4,5,6,7]. Cryptic dreams have been explained as needing only the wisdom of a gifted interpreter to decode the message [6,7,8]. Conceptualizing dreams as supernatural messages means that questions of the dream's origin, content, meaning, and function are quickly answered. However, this discourages the pursuit of scientific study and dismisses dreaming as unimportant meandering of the mind [9]. Freud asserted that dreams are meaningful, and that, although their meanings are hidden, a replicable method for uncovering their meanings is possible. His confidence in the value of dreams echoes the attitude expressed throughout history: rather than simply being contrasts to waking life, dreams have value, command attention, and deserve efforts to find their meanings.

Many contemporary experts support Freud's assertions about the meaning of dreams, detailing neuroscientific findings consistent with basic psychoanalytic concepts, including the hypothesis that dream content is disguised by censoring operations in the mind. As Solms states, "We are beginning to understand something about the neurological correlates of the censoring function, and we know at least that the structures which are most likely to be implicated are indeed highly active during dreaming sleep" [9]. Others, while acknowledging that dreams have purpose, argue against interpreting dreams. They have abandoned the concept of hidden meaning, attending only to a dream's literal narrative and the feelings it induces [10]. Regardless of one's position on the meaning of dreams, critics and supporters alike have evolved from Freud's scientific approach to the study of dreams, an approach that was influenced by Charles Darwin, Ernst von Brücke, and other great scientific minds.

3. A HISTORY OF FREUD AND THE PSYCHOANALYTIC TRADITION

Freud was an accomplished neurologist with 28 publications to his credit before he began psychoanalytic work, but in spite of his achievements, he was frustrated in his efforts to gain an appointment as full professor at the University of Vienna. He was Jewish, and anti-Semitism stifled academic and professional advancement in 19th century Vienna. Eager to marry, and pressed by financial responsibilities, Freud needed a reliable income. His colleagues advised private practice. Unprepared for clinical work, however, he returned to study, traveling to Paris to work under renowned neurologist and psychiatrist Jean Martin Charcot.

Charcot was a commanding and masterful teacher, challenging prevailing theories of the day. In an era when hysterical symptoms were dismissed as a form of malingering, Charcot experimented, and obtained remarkable results, with hypnosis. He recognized hysteria as a real ailment afflicting both men and women. His methods also demonstrated that hypnotic states were genuine phenomena that could be used to heal otherwise intractable complaints. Charcot insisted that everything about his clients' hypnotic reactions was significant, including a peculiar "magnetic passion" developed for the hypnotist. (Freud eventually understood and named this behavior, transference, one of the most powerful of psychoanalytic phenomena.) What interested Freud most about Charcot, however, was his confidence in plain, observable facts as opposed to dogma. Charcot taught Freud that the "scientist's submissive obedience to facts is not the adversary, but the source and servant of theory" [11]. Returning from Charcot's clinic in 1886, Freud began a practice in neuropathology. With it began discoveries that would change the scientific understanding of human behavior.

Like any young physician, Freud looked to established colleagues, such as Josef Breuer, for referrals. Breuer was a reputable neurologist (credited with discovering the role of the vagus nerve in controlling respiration) who, like Freud, had abandoned the laboratory for private practice. Breuer and Freud also shared interests in psychopathology. Their 1895 publication Studies On Hysteria introduced the cathartic "talking cure," which gradually evolved into psychoanalysis. Another physician friend, Wilhelm Fliess, became increasingly important to Freud. Fliess (an ear, nose, and throat specialist) was indispensable to Freud, especially as Freud was writing The Interpretation of Dreams. Fliess had a sound understanding of Freud's theories as well as an appreciation for psychologic themes common across cultures. Freud prized Fliess' ability to accept as scientific evidence all types of human behavior, including folklore, legends, and dreams [11].

With experience in private practice in hand, Freud began lecturing and writing on the origin and treatment of psychoneuroses and hysteria. In an 1896 presentation for Vienna's Society of Psychiatry and Neurology, he confidently announced that all hysterias are founded in repression, always with a sexual content. Expanding this argument, Freud declared that hysterical illnesses originate with a passive sexual experience (i.e., a seduction) that occurs before puberty, usually at 3 or 4 years of age. He based his conclusion on 13 successful cases, all carefully documented. He stated that students of hysteria are like explorers discovering the remains of an abandoned city, and when obscured inscriptions (i.e., clients' repressed memories and feelings) can be uncovered and read, then the truth and symptom relief will follow. Freud found much criticism and little support for this assertion, however. Dismayed, angered, and discouraged, Freud experienced a period of pessimism. He continued treating neurotic clients successfully and maintained his belief in the sexual origin of their illnesses. Bolstered by Fliess and spurred by his own practice of observation and common sense, Freud eventually re-examined his initial conclusions and found a deeper truth. He recognized that his clients' reports were serious but not literal communications, and he began to listen more intently. He came to read these reports as messages that were coded: distorted, censored, and meaningfully disguised [11]. Helping his clients to discover and meaningfully illuminate these unconscious activities formed the basis for Freud's theory of the mind.

Spurred by the death of his father in 1896, Freud began an intense self-analysis. He knew that what he was learning from his work with clients revealed information basic to all human psychologic development, and he realized that his own development could be no exception. Armed with the same objectivity that he brought to dissections in von Brücke's laboratory, Freud analyzed his dreams, his physical symptoms, his inhibitions, and his wishes. In this way, he became a model for future psychoanalysts and set the standard for competency: to analyze, one must first submit to analysis.

4. FREUD'S APPROACH TO DREAMS

Freud's approach to dreams includes the assertion that their meanings are hidden; they are disguised expressions of suppressed wishes [1,2]. Exploring unconscious mental activity was at the heart of Freud's approach. In his view, dreams are the direct result of unconscious activity that helps determine a dream's production and its final form. It is by uncovering these unconscious thoughts that a dream's meaning can be revealed, a process that requires the dreamer to willingly suspend self-criticism and censorship.

Censorship is the agency that watches critically during sleep, rejecting many thoughts and forbidding expression. It regulates which thoughts and wishes are permitted to reach consciousness. Wishfulness is the psychologic agency that presses for expression against censorship. A third psychologic agency, the ego, evolves. Sleep dulls the censor, allowing ideas that have been rejected in waking hours to slip through, finding disguised expression in dreams. Dreams answer the ego's wish to sleep; dreams sometimes fail, however, and the dreamer awakens. Physical stimuli that occur in sleep must be interpreted by the brain in a way that will not wake the sleeper. Occasionally, the sensations are too intense or the disturbing ideas are too poorly disguised to permit sleep to continue. Anxiety dreams—those frightening visitations that jolt dreamers awake—are partly explained in this way.

Freud considered dreams to be "the royal road to the unconscious" [2]. One of the first dreams that Freud understood to be meaningful was his own "Dream of Irma's Injection." Freud described his dream in this way [2]:

A great hall—a number of guests, whom we were receiving—among them Irma whom I immediately take aside, as though to answer her letter and to reproach her for not accepting my "solution." I say to her: "If you still have pains, it is really only your fault." She answers: "If you only knew what pains I have now in the throat, stomach, and abdomen – I am choked by them." I am startled and look at her. She looks pale and puffy. I think to myself that after all I must be overlooking some organic affection. I take her to the window and look into her throat. She offers some resistance to this, like a woman who has a set of false teeth. I think, surely she doesn't need them. The mouth then opens wide and I find a large white spot on the right, and elsewhere I see extensive grayish-white scabs adhering to curiously curled formations, which are evidently shaped like the turbinal bones of the nose. I quickly call Dr. M, who repeats the examination and confirms it…Dr. M looks quite unlike his usual self; he is very pale, he limps, and his chin is clean-shaven…Now my friend, Otto, too, is standing beside her, and my friend, Leopold, percusses her covered chest and says: "She has a dullness below, on the left," and also calls attention to an infiltrated portion of skin on the left shoulder (which I can feel in spite of the dress)…M says: "There's no doubt it's an infection, but it doesn't matter; dysentery will follow and the poison will be eliminated." We know, too, precisely how the infection originated. My friend, Otto, not long ago, gave her when she was feeling unwell, an injection of a preparation of propyl, propyls…propionic acid…trimethylamin (the formula of which I saw before me, printed in heavy type)…One doesn't give injections of that sort ought so rashly…Probably, too, the syringe was not clean.

THE ROUTE FROM WISH TO DREAM

Freud discussed his associations to the Irma dream in The Interpretation of Dreams, in which he examines the dream image by image, ponders the meaning of the various thoughts that come to his mind in connection with each image, and begins to notice a recurrent theme. Although the dream presents a number of different explanations for Irma's pains, it portrays Freud as utterly blameless. Freud concludes that the dream shows how he wishes things were (i.e., blameless for Irma's pains). Thus, the wish was the dream's motive, and the dream represents the wish fulfilled. The "secret" revealed to Freud through the Irma dream is that dreams are the fulfillment of wishes. In response to opponents who questioned how a terrifying nightmare could possibly be the fulfillment of a wish, Freud responded that it was important to distinguish between the dream's manifest content and its latent content [1,12,13].

MANIFEST AND LATENT DREAM CONTENT

Freud asserted that dreams embody two levels of meaning or content: manifest and latent. He defined manifest content as that which the dream relates; it is the dream as dreamt and consciously remembered by the dreamer. Manifest content more often consists of visual images than thoughts and words. It is the surface meaning of the dream that is reported on waking (e.g., you dream you are running, but when you look behind you, no one is there); it is a disguised representation of the true thoughts underlying the dream. These underlying thoughts are what Freud called latent content, consisting of unconscious wishes and fantasies that have been denied gratification. Latent content is the deeper, hidden, symbolic meaning of the dream. It is the disguised, repressed part that translates threatening, underlying impulses (e.g., unconscious sexual, aggressive impulses) into the more acceptable manifest content. Latent content is disguised by a censorship process into manifest content. Because latent content is repressed, and therefore unobtainable by the dreamer's consciousness, it is accessible only by the analysis of ideas. The process of transforming unconscious latent content into acceptable manifest content is called dream work [14,15,16,17,18].

THE MECHANISMS OF DREAM WORK

Dream work takes the raw material of dreams (e.g., memories, feelings, wishes, events of the day) and combines it to analyze a dream [1,13,18]. This is carried out through three primary types of transformation: condensation, displacement, and secondary revision. Condensation refers to dreams' compression of many associated thoughts, memories, fantasies, and images into a single figure. There are different types of condensation, each with an everyday application. Videos that combine two images into a new composite image, disparate individuals that form groups based on a commonality, slips of the tongue, and double entendre jokes are examples of condensation at work in everyday life.

Displacement occurs when an emotion associated with one idea or experience is detached from it and attached to another idea. It describes the dreaming tendency to hide an important idea or feeling in something trivial, allowing objectionable ideas to pass censorship. A type of displacement that is of particular importance to the formation of dreams is what Freud termed "considerations of representability." This involves turning underlying abstract dream thoughts into pictorial, concrete language before the abstract thoughts can be used in the dream. Freud likened the process to writing poetry; in order to combine thoughts as succinctly as possible, they are translated into concrete, imagistic language. Freud asserted that displacement and condensation were the "two governing factors to whose activity we may in essence ascribe the form assumed by dreams" [13].

Secondary revision occurs as a result of the natural tendency to organize disconnected elements into a coherent whole. It is the application of conscious thought processes to the dream material. It polishes the disparate, poorly organized contents of a dream so that it approximates conscious thought (e.g., a coherent daydream). Secondary revision attempts to produce sense and order—a comprehensible narrative [1,13,18].

Freud demonstrated that psychologic understanding can make a substantial difference in the lives of troubled individuals and an important contribution to the whole of civilization. His pioneering work established the foundation of contemporary dream research [1,19].

5. SHARED CONCEPTS WITHIN PSYCHOANALYSIS

Freud's study of dreams founded over a century of psychoanalytic research and practice. It marked the beginning of his drive theory, which began with the premise that human behavior is determined by biologic drives that operate outside consciousness. Freud concluded that the greater part of psychologic life is unconscious. Sexual and aggressive strivings, he found, are central motives throughout life; illnesses can begin with their repression. He described the sexual life of children, including the Oedipus complex, and noted that childhood sexual fantasies and experiences have a determining effect on adult character and personality. Each of these tenets is rooted in clinical observation and in the analysis of dreams.

In addition to Freud's formulations, at least four additional, distinctive psychologies exist within psychoanalysis, each emphasizing specific aspects of human development and function. Ego psychology, closest to Freud's drive theory, describes adaptations developed in response to conflicts between internal drives and external realities. Freud's daughter, Anna, a gifted analyst in her own right, named these adaptations "defense mechanisms" and created the terminology so familiar today (e.g., denial, repression, projection, identification). Ego psychologists emphasize the importance of studying normal ego functioning, defined as efforts "to achieve the maximum degree of drive satisfaction consistent with the limitations imposed by the environment" [20]. These theorists point to the ego's functions in the outside world (e.g., thinking, learning, impulse control) and note that sexual and aggressive drives can be redirected. Like Freud, ego psychologists value dreams for their revelations of thoughts hidden in waking life.

Object relations theorists believe that individuals develop prototypes of interpersonal relationships that are repeated throughout life. Objects achieve internal psychic representation as well as external influence. The theorist might argue, "There is no such thing as a baby…There is only a baby with a mother" [21]. Total dependency characterizes the early years of human development, and the resulting attachments have an enduring influence. Object relations theorists describe deficits that can develop if early objects are inadequate; they also describe corrective (e.g., therapeutic) experiences that create change. An object relations approach gives special attention to dream references that describe clients' reactions to their analyst.

Eminent psychoanalyst Heinz Kohut identified the self as the all-important structure of personality. Self develops from one's experiences both in subjective and interrelated situations. It is a concept more directly related to individual experience than are the concepts of drive, ego, or object. Self psychologists emphasize the importance of achieving a cohesive sense of identity and autonomy; threats to this secure sense of self bring fear of personal disintegration. The experience of empathy, both in the course of early development and later in therapeutic relationships, is central to healthy self-development. Like Freud, Kohut felt that most dreams hold wishes, but he added the concept of self-state dreams. Self-state dreams are generally believed to be an effort to master or integrate threatening psychologic material, much in the way that traumatic dreams are processed.

Dream work is a departure from classical dream interpretation, which explores the images and emotions evoked without focusing on a single meaning of the dream. Through dream work, one learns about oneself, often with the help of others. Sharing dreams in small, empathic groups has been shown to increase dreamers' associations and insights and promote healing [22,23]. Dreamers and listeners are equally capable of accurate understanding. Dream workers use ideas from many sources, including Freud and Jung; they do not necessarily feel that therapists are required. Dream workers' contributions include group techniques, methods for recalling and recording dreams, and validation of dreamers' interpretive expertise. Many also include spiritual discussion in their approach [24].

Differences within psychoanalysis need not challenge its validity. Rather, bringing diverse approaches to dream analysis supports the validity of psychoanalysis while adding value to the practice of dream analysis. In one study, analysts with four different orientations each interpreted a patient's dream. Although their interpretations differed, all were found to be correct and all indicated the existence of a major psychodynamic issue that emerged over the course of the patient's seven-year analysis [25].

6. MODERN DREAM RESEARCH

Researchers remain challenged by the psychologic issues identified in Freud's time and before. Determining the meaning and origin of dreams, addressing the problem of recall, unraveling the mystery of content, and accounting for dream function are all issues that continue to be researched and discussed. Research examples come from psychology, neuropsychology, psychoanalysis, and neuroscience.

PSYCHOLOGY

In a 2010 study examining the meaning and content of dreams, researchers used sophisticated quantitative methods to organize dream data [26]. They hypothesized that dream content could be read in a way that would accurately reveal the dreamer's daytime interests, personality traits, aspects of relationships, and overall emotional well-being. They predicted that dreams would echo waking life and that their meaning could be found by examining manifest content (i.e., the dream as recalled by the dreamer) without additional interpretation. The investigators examined dreams using a combination of the Hall/Van de Castle (HVdC) system, a content coding system that provides normative data for the content of adult dreams, and a related but newer, computerized word-search method. The data were drawn from 192 reports collected in a journal over a two-year period, contributed by one dreamer, a male volunteer 23 years of age. The young man, a journalist, contacted one of the researchers and requested help interpreting his dreams. Dream reports, recorded in a Word document, were loaded into a computer dream bank and analyzed for content using HVdC categories and the researchers' previously published word strings (40 categories of words and phrases known to capture dream content). One of the researchers was designated to make blind inferences from the data; he did not read the dreams nor was he privy to any biographical information about the dreamer, beyond age and sex. He produced 14 inferences about the dreamer based entirely on frequencies derived from the computer's sorting. Each of these inferences was expressed in descriptive sentences and given to the dreamer for comment. For example, "He is socially active and competent, not reclusive or shy;" "He is an even-tempered person, not prone to emotional outbursts;" and "He is closer to his brothers G and J than brother C or sister A" [26]. The dreamer confirmed 12 of the 14 inferences. The researchers concluded that a blind analysis of dreams based only on the results of word searches could accurately predict many aspects of an individual's waking life (e.g., personality attributes, relationships, activities, cultural preferences) [26].

The researchers also included discussion of the erroneous inferences. One, a conclusion that the subject "has many nightmares," based on a high frequency of words relating to fear, physical aggression, falling, animals, and death, was corrected by the dreamer this way: "One man's nightmare is another's fantasy…Where I'm stranded and fighting for my life on an island, I consider that a pleasant adventure dream and wake up stimulated." A second inference that the subject is equally close to his mother and father, based on equal frequencies of these two words was also disputed by the dreamer, who stated, "I'm much closer to my mother than my father. The dreams may be skewed because during the middle of the time frame that I was recording them I was spending much more time with my father than was normal" [26]. Finally, in a series of follow-up questions about whether anything obvious about his life or personality was absent from the inferences, the young man responded: "I'm a pretty adventurous guy, with a higher attraction to danger than a lot of people…Most people who know me would use those facts as descriptors." He also said, "If I were reading my dreams, I might be curious about why a variety of women come and go, without a mainstay. You might have been able to infer, 'He doesn't have a steady girlfriend.'" [26].

Certain findings from this study are of psychoanalytic interest. First, the recovery and quantification of manifest dream content appears to be achievable, and blind analysis of the data can lead to accurate inferences about the dreamer. Second, dream content, even with sophisticated methodology, does not yield to analysis easily. Third, analysis of manifest content alone in this case missed and misinterpreted significant material (i.e., the young man's fondness for danger), led away from an important truth (i.e., his closeness to his mother), and left other matters in obscurity (i.e., his lack of a steady girlfriend). Each of these was an area important to the dreamer. The limitations of manifest content analysis are consistent with Freud's emphasis on hidden, latent material.

A second study published in 2012 reported similar findings [46]. By applying the blind analysis and word-search method to 223 dreams from the diaries of a single volunteer subject, the researcher was able to produce 15 inferences about her waking life, 11 of which were confirmed by the subject. This study again lends support to claims that dream content reflects waking interests and emotional concerns (i.e., the continuity hypothesis). A psychoanalytic viewpoint argues that manifest content reflects residue of the day as well as enduring emotional themes and conflicts [46].

NEUROPSYCHOLOGY

Memory, an issue central to dream study, has been scrutinized by neuropsychologists who have explored the acceptability of data from dreamers' reports, the best setting for collecting dream specimens, and the role of rapid eye movement (REM) sleep in dreaming [27]. The goal of one meta-analysis was to determine whether the methods researchers use to study dream recall affect the outcome or whether recall is innately difficult [27]. Dream recall measured with self-rating scales found average frequencies of two to three dreams per week; however, the results were not consistent. (This is partly because the term "recall" can be interpreted differently.) Indeed, when taking into account so-called "white dreams" (i.e., the certainty of having dreamed but not being able to recall the dream content), the rate of dream recall was an average of 5.1 dreams per week (up to 72.9% of spontaneous awakenings) [27]. This indicates that people are regularly aware of their dream experiences, irrespective of their ability to recall dream content.

Dreaming during non-REM sleep has been confirmed in the presence of separate physiologic correlates. Consequently, dream researchers have been encouraged to turn away from sleep laboratories in favor of natural settings because intrusive elements (e.g., noise, electrodes, unfamiliar beds) can affect dreaming. Dream journals or simple instructions about how to recall dreams on waking have been shown to help a majority (90%) of sleep study participants increase dream recall within as little as three nights [27]. This seems to indicate retrieval of dream content is not as difficult as predicted, especially when appropriate guidelines for facilitating dream recall are provided. Even in the presence of neurologic injury, dreams persist due to the brain's ability to retrieve forgotten information through a variety of cues.

PSYCHOANALYSIS

As described previously, Freud's discoveries about dreams began as he treated clients. Psychoanalytic theory and practice continue to evolve from clinical work, such as work done with clients who have had post-traumatic nightmares [28]. Freud, and many theorists since, excluded these nightmares from the analytic attention given to other dreams. The nightmares were understood as instigated by trauma, as representations of the essence of that experience, and as free of hidden meaning. Freud suggested that their repetition might represent either an attempt at mastery or at restoration of psychologic balance. Treated more like emotionally charged memories than "real" dreams, post-traumatic nightmares were excluded from any wish-fulfilling function.

Lansky challenged these assumptions and argued that post-traumatic nightmares belong in treatment as do other dreams [28]. He asserted that they can be analyzed for hidden content, they are related to conflicts and previous trauma in the dreamer's life, they recur in response to events in the dream day, and they fulfill wishes [28]. Noting trauma victims' increased vulnerability and need for environmental support, he emphasized their fractured sense of self (i.e., feeling disassociated, disorganized) and included shame as a prominent, painful, and often underemphasized result of trauma [28]. He argued that post-traumatic nightmares are not simply a replay of the traumatic event. Typically, significant discrepancies appear between the patient's report of the trauma and the dream scenario. For example, a veteran dreamed of being captured and beaten in a prisoner-of-war camp. Analysis revealed that although the veteran had witnessed horrifying atrocities, he was never taken prisoner. In childhood, however, he was a victim of brutal beatings from his father. "Replaying" the horrors of war protected him from the more threatening helplessness, rage, and shame he felt at the hands of his father. Lansky also found that post-traumatic nightmares often cast the dreamer as an intact, competent person who, although in danger, is neither disintegrated nor shamefully out of control; the nightmare fulfils the dreamer's wish for psychologic survival and sanity in the face of adversity [28]. This illustrates that careful, clinical observation can lead to important changes in treatment. It also supports the extension of Freud's wish-fulfilling function to dreams such as these.

NEUROSCIENCE

Investigators find that aspects of Freud's account of the dreaming mind remain consistent with the available neuroscientific data [28]. Contemporary laboratory methods demonstrate that dreams occur with the activation of brain pathways that govern goal-seeking and appetitive behaviors. (REM sleep often triggers this pathway, but dreaming can occur during other sleep periods as well.) Dreaming occurs only with activation of the motivational pathway, characterized by Freud as "wishes" (i.e., activation of goal-seeking impulses). Activation of brain mechanisms capable of creating a dream can cause arousal during sleep. Freud posed the argument that dreams are a response to something that disturbs sleep. Dreaming requires both a trigger and an activated motivational pathway. Freud metaphorically described dreams as similar to a new business: both entrepreneur (i.e., a stimulus or a trigger) and capital (i.e., wishful impulses or goal-seeking activity) are required.

Neuroscientists describe dreaming as a regressive process. That is, dream images result from information or stimuli traveling backward in the perceptual system. (Sleep blocks passage forward and prevents motor activity.) These images are fed into the cortex as if they were coming from the outside. The brain system that processes incoming stimuli responds to this reversal by converting the information into visual images instead of waking thoughts. Because critical or reflective functions are inactive in sleep, the images are mistaken for real perceptions. Freud wrote extensively about the regressive nature of dreams. He acknowledged that science in his time could not trace precise pathways for dream activity but stated confidently that "deeper research will one day trace the path further and discover an organic basis for the mental event" [2].

7. PSYCHOANALYSTS: AN OVERVIEW

Psychoanalysts generally share an approach that includes free association (i.e., the patient's unreserved report of ideas, memories, feelings), dream interpretation, interpretation of resistance, and interpretation of transference. Resistance refers to both the conscious and unconscious efforts that clients make to counter therapeutic progress. Transference recognizes the patient's tendency to perceive the analyst as an important figure from the patient's past. Analysts also consider countertransference (i.e., both conscious and unconscious feelings stirred in the analyst by the patient). Creating a therapeutic alliance, respecting and understanding the ego's defense mechanisms (characteristic and/or transient means of adjustment), and strengthening ego functions are additional common aims. Many psychotherapists recognize these processes and use this language.

TRAINING

As with many mental health disciplines, psychotherapists' preparation includes years of postgraduate study and hours of supervised practice. Course content and supervisory requirements vary by university, by discipline, and by professional license. Psychoanalytic candidates, regardless of professional license or previous study, have an additional requirement to complete a personal analysis before earning the title of psychoanalyst. Psychoanalytic training institutes define their own curricular and supervisory standards, but all demand a personal analysis, which is unique to this profession. The National Association for the Advancement of Psychoanalysis (NAAP) requires its members to have a minimum of 450 hours of course work, 1,500 hours of supervised clinical experience, 200 hours of psychoanalytic case supervision, and 300 hours of individual analysis. The requirements of individual institutions often exceed NAAP requirements [29].

Dream Work

The International Association for the Study of Dreams (IASD) is a nonprofit, multidisciplinary organization established in 1984 to encourage research and dream study. The IASD has adopted recommendations for the training of dream study practitioners, including those whose practice is mainly or exclusively focused on dream work as well as those who include dream work as part of their overall practice. According to the IASD, training programs for dream study practitioners should [30]:

- Have a clear ethics statement, including a disclaimer that while dream work can be therapeutic, it is not a replacement for psychotherapy

- Clearly assign the authority of dream work to the dreamer and not to an outside person, including a therapist. The dreamer is ultimately in charge of interpreting thoughts, feelings, and associations about their dreams.

- Include both supervised one-on-one and group practice

- Include written goals and learning objectives

- Include protocol to avoid projection

- Require students to do their own dream work

- Require faculty to be sufficiently trained in the ethics of dream work

- Be aware of cultural differences between teachers and students

- Contain recommendations for continued study

- Contain the hours necessary to be sufficiently trained

- Record the training levels of all graduates

In addition to the ethical guidelines of each clinician's discipline, the IASD requires that dream work practitioners recognize the dignity and integrity of the dreamer. The dreamer is the decision-maker regarding the significance of the dream and may or may not share any part of the dream he or she chooses. The hour belongs to the patient; therefore, the patient's lead supersedes the clinician's interest. Ethical dream work guides the dreamer to more fully experience, appreciate, and understand the dream. It also recognizes the validity of approaches from many traditions and cultures [30].

ESSENTIAL TECHNIQUE

The patient-therapist relationship is the essential treatment tool in psychoanalysis. The analyst listens with an uncommon empathy, a situation in which the analyst's own unconscious engages as a "third ear." Personal analysis prepares the analyst for this work in three ways. First, the analyst learns analytic technique by experiencing the methods as a patient. Second, knowledge of personal idiosyncrasies and blind spots arms the analyst against overlooking or exaggerating those of his or her clients. Finally, and most importantly, even when bombarded by the strong feelings expressed by clients, the analyst avoids reacting with personal feelings (whether conscious or unconscious) and abstains from meeting personal emotional needs, which the patient's behavior may stimulate. The analyst's focus at all times is to help the patient observe self-behavior.

8. THE INFLUENCE OF CULTURE/ETHNICITY ON DREAMING

Dreams are an integral part of daily life across cultures. Although the biologic and physiologic framework of dreams is consistent throughout the world, the importance, validity, and value placed on dreams differs [31,32,33,34]. Research indicates that although both Eastern and Western cultures place certain validity on dreams, Western cultures more readily determine dreams to be a product of the brain without having greater meaning [34,35]. Western cultures often view dreams, and the act of dreaming, as unreal and unimportant, viewing waking life as the only true "reality" [36]. Many contemporary psychologists hold this to be true, asserting that dreams merely sort memories. They believe that dreams are a reflection of the organization of an individual's thoughts and daily experiences and how these thoughts and experiences relate to the individual's physical, emotional, and social life [37].

In contrast, many Eastern cultures view dreaming either as an opportunity to connect with another realm of "reality" or as a tool to spiritually progress [36]. Tibetan Buddhists practice a meditative dream state called dream yoga, whereby they use their dreams to assess inner sources of suffering [38]. Dream yoga is a meditative practice in which the dreamer maintains a dream state while being lucid. Both dreaming and waking states are considered equally real or unreal; thus, dream yoga practitioners are able to use these dreams to assess individual sources of unhappiness. By determining the source, they are able to address their own discontent and ultimately live a happier life with a greater sense of peace [38].

Other cultures view dreams as spiritual phenomena connecting the dreamer to spirits, nature, and other dimensions outside their waking reality. In Native American cultures, dreaming connects the individual to spirits, providing a compassionate understanding of dimensions outside present reality [38]. In the Ese Eja community in the Peruvian Amazon, dreamers "see" the names of their unborn children in dreams, showing a direct indication of the importance placed on the dreams themselves. The Ese Eja perception is that reality and dreams are intertwined and overlapping in time and space [39]. In some instances, the lack of adequate dreaming is seen as a detriment to a community and its livelihood. In the Andamanese hunter-gatherer culture in India, dream sharing is practiced within the community in order to form a consensus on the meaning of an individual's dreams. Once they have arrived at a consensus, these dreams determine actions taken by the community in waking life. Andamanese people believe that more modern sleeping arrangements, with less time devoted to the understanding and recollection of dreams, is the reason for their declining hunting success [40].

CULTURE IN THE PSYCHOANALYSIS OF DREAMS

Culture plays an integral part in how an individual interprets dreams and how much significance is placed on the dream [35]. When analyzing a patient's dream, the psychoanalyst should understand that interpretation can be affected by the patient's motivation to extend pre-existing beliefs or ideas or to enhance existing attitudes. Although dreaming occurs in all cultures, each individual will respond differently to the act of dreaming and the interpretation of dreams; cultural variations in the narrative content will exist. The psychoanalyst should be aware of the patient's cultural assumptions and should set aside judgmental biases in order to obtain a nonbiased assessment [41]. Assessing and interpreting dreams should be an open, communicative process between the analyst and the dreamer [42].

Without diminishing the significance of culture, studies do show similarities in dream themes and manifest content across cultures. In 2013, a study of dreams in Iranian and American students showed marked similarities [47]. For example, the distribution of male and female characters in dreams was nearly equal, as was the incidence of aggressive social interactions in dreams. Differences that were noted (e.g., Iranian students increased likelihood to dream of family members) were primarily attributed to cultural factors (e.g., Iranian collectivist orientation) [47].

Similarity in the human experience of dreaming appears to outweigh any differences [48]. Any serious search for a dream's meaning will consider the influence of culture, but only in connection with the interplay of individual experience and fundamental, shared human needs and reactions [48].

9. THE IMPACT OF TECHNOLOGY ON DREAMS AND DREAM ANALYSIS

Another component of dream analysis is the connection between how an individual interacts with virtual media (e.g., videos, MP3 players, video games) and how the images of these media can affect the individual's dreams. Research indicates that the more an individual interacts with a specific type of virtual media, the more that media will affect and be present in the individual's dreams. The most direct connections between virtual technology and dreams are seen in clients who regularly watch films and/or play video games. Body systems simulate movement and establish spatial orientation function during dreaming as they do when viewing a film or playing a video game [43]. The greater the degree of interactivity and clarity of the images in the media, the greater the likelihood that those images will appear in dreams [43,44]. Also, the more regular the participation in virtual reality media, the stronger the connection between waking life and dream life emotions. Researchers have also documented specific connections between media and manifest dream content. A survey of nearly 1,300 Turkish dreamers revealed that those who consumed violent or sexual media were more likely to produce dreams with violent or sexual content and experienced greater dream frequency [49]. A pilot study of persons experiencing nightmares found that treatment combining virtual reality technologies with imagery rehearsal and rescripting was effective in reducing anxiety, nightmare frequency, and post-traumatic stress symptoms [50]. Media is a ubiquitous element of both waking and dreaming life. As such, clinicians should be aware of patients’ media activities and should acknowledge the potential role of technology as a therapeutic tool [43,44].

10. THE DREAMER'S ROLE IN INTERPRETING SYMBOLS IN DREAMS

PERSONAL DREAM STUDY

Those who study their own dreams are in good company. Both Freud and Jung recorded and studied their dreams, a practice continued by contemporary experts. Dream study can be done alone, but therapists often see concerns or painful connections otherwise missed. Dream recall can usually be established and improved simply with conscious intent. Using a notebook or other record upon waking (even if only a few images are recalled at first) can help to recapture the dream.

Freud chose to demonstrate his methods with analysis of his own dreams. He set out to articulate psychologic processes that characterize normal development and functioning. He had analyzed thousands of clients' dreams at the time he wrote The Interpretation of Dreams, but they were all potentially attributed to clients' pathologies. Freud recorded many of his own dreams, so he had data from a healthy source. Freud's example of self-study is a model for clinicians. Anyone hoping to help others understand dreams should start with their own.

EDUCATING CLIENTS

Some clients spontaneously offer dreams; others do not, which may indicate that they devalue their internal lives, including dreams. Questions asked early in treatment, including inquiry about recurrent dreams, memorable childhood dreams, and recent dreams, can signal their importance [45]. Freud's instructions were simple and direct: consider the dream's circumstances, suspend self-criticism, and report all thoughts associated with dream elements. Dream work gains may include: the production of new material, including memories, associations, fears, and conflicts; opportunities for empathy, respect, and collaboration (i.e., advances in the therapeutic alliance); and opportunities to engage the patient's resources in problem solving, thereby increasing self-observation, insight, and ego strength. All of these are therapeutic goals shared by most forms of psychotherapy.

RECOMMENDATIONS FOR CLINICIANS

Freud's analysis of the Irma dream can be intimidating. However, his recommendations for clinicians just beginning dream interpretation can mitigate concern [30]:

- Do not expect dream interpretation to come easily.

- If blocked, stop and begin another day.

- It is not possible to interpret all dreams; however, it is always possible to make enough progress to know that a dream is a structure with a meaning.

- One satisfactory interpretation does not preclude a second; allegorical dreams require a second interpretation. Series and/or consecutive dreams have common ground and should be interpreted in connection with one another.

- Focus attention on a single dream element; abandon the purposive approach that usually characterizes thought.

- Perfection is not required; incomplete interpretation can be helpful.

11. DREAM SPECIMENS

Few clinicians will approach Freud's virtuosity, and this level is not required to achieve useful insights. The following are examples of ordinary dreams and ordinary, but important, applications. Dreams I and II are the author's; dreams III and IV belong to clients in the author's practice.

DREAM I

I am walking along a path in the snow. I can feel cool air on my face and see snowflakes falling. I meet D and exclaim several times, "I'm so happy to see you again!" We embrace; I feel happy and excited.

Precipitating Events

On the previous evening, old friends, E and F, arrived for a visit. I greeted them happily with the words repeated in the dream. During the work week, my thoughts had been unhappily occupied with criticisms leveled against a friend and colleague by others in our organization. I had also been targeted by these same faultfinders. Recently, one of the women in this group had been in the office as I passed through. I suppressed angry feelings, nodded in what I perceived to be a civil, but hypocritical fashion, and went my way.

Associations

- Snow and cool air: The evening of the dream was warm; I had turned on the air conditioner before going to sleep.

- D: A colleague from a previous workplace and a skillful politician who often advised me on internal political matters. D sided with me in disputes. We also often spoke about our teenaged sons, both of whom played high school soccer. Days before the dream, as my husband watched a televised soccer game, I had remarked, "Too bad you didn't get to know D; he loved soccer."

- "I'm so happy to see you again:" As noted, the dream took these words from the previous evening.

Analysis

At first, this dream seems simple and obvious. Associations emerged readily. Its thoughts and wishes appeared to be innocent and sentimental: during a time of collegial quarreling, I wished for the advice, wisdom, and support of my old friend. If only he could return as had E and F! Still, something incomplete nagged away. I was fond of D, but the dream's joyful reunion exaggerated my feelings. Something seemed phony. My thoughts returned to the criticism I had endured and to the critic, a person I was not "so happy to see again." Then, they again turned to D and that favorite topic of ours—soccer.

Soccer is a homophone of "sock her." A suppressed impulse to strike back angrily and aggressively was the dream's latent wish, disguised in affectionate, picture-pretty content. The dream's feelings, words, and images were hypocritical. The figure of an old trusted male colleague, recent words of a friendly greeting, and feelings of affection combined to conceal their opposites: a distrusted female, a curt nod, and angry aggression. Everything led away from my real sleeping thoughts. (Freud called dreams like this "red herrings.")

DREAM II

I am in a kitchen, somehow located upstairs and with many big windows. I am preparing a large meal. Other people (unknown to me) are around me. I look out a window and see L (and her sister?) approaching. L is smiling broadly. I greet her enthusiastically; she must walk upstairs to join me, which she does. I invite her to stay, hoping she will accept.

Precipitating Events

I dreamed this while napping after an early morning medical procedure, a colonoscopy. I had spent the previous afternoon and evening fasting and cleansing. The morning was routine except for a telephone call from my husband's wealthy cousin, A. At A's request, I had found a therapist for someone close to her. I had chosen carefully and recommended a colleague whom I admire. A was calling back to ask that I negotiate a low fee. I was surprised, angry, and embarrassed at the idea. I also felt used. Did she want expertise or a discount? I stifled my irritation, however, and simply explained that payment is arranged between patient and therapist.

Associations

- Kitchen upstairs with big windows: The colleague to whom I had referred A's son has an upstairs office with big windows. Also, on the previous day, my building manager told me that an upstairs office I had inquired about was rented.

- Preparing a large meal: I had fallen asleep still hungry from my medical fast.

- People all around me: While waiting for the colonoscopy, I had felt anxious and wished for company, a feeling I quickly rejected as silly.

- L: Both the name and the image referenced a friend from high school days. She was a sweet, good-natured girl, first cousin to my high school boyfriend, B, who was competitive with C, L's boyfriend.

Both B and C were candidates for admission to military academies. C won an appointment, while B was only a first alternate. I remembered, too, that my father had once had a friend named L; both of my parents sometimes made playful teasing references to the "sweet L" of his youth (possibly my mother's rival).

- She must walk upstairs: I had no associations, but my analyst provided an interpretation (discussion to follow).

Analysis

A large meal is this dream's first promise; it allowed me to sleep on in spite of hunger pangs. "People all around me" fulfilled another lingering wish: to have company and not be alone. L's role is more disguised. What wishes prompted the appearance of my old friend? In our adolescent social circle, L gained boyfriend status over me through C's achievement. The dream reverses that nicely; she must climb stairs to join me. Furthermore, L's smiling, compliant presence is a comforting replacement for A, the cousin whose demanding ways and higher socioeconomic status had so irritated me. A mostly forgotten, decades-old affront to my pride links up with a fresh insult and suppressed wish (i.e., to have a richer husband than A) and appears in the teenage image of an old friend. Another wishful thought appears: if I am with L, I am young again, safely away from any need for colonoscopies. Finally, the upstairs kitchen with large windows grants another wish: to be like my admired colleague and have a better office.

More could be said. The dream's origin has been explained (i.e., preserving sleep in spite of hunger) and its raw material (i.e., suppressed feelings, memories, trivial events from the day), but questions remain. For example, why no associations to "she must walk upstairs?" Given the context of ambitious wishes and aggressive feelings (i.e., to have a better office, to eliminate rivalry with cousin A), is some conflict suggested? A look at history may be warranted. Is it important that memory shows my mother to be playful (not competitive or aggressive) in response to her rival? Dreams open the way to new material and also to a deeper understanding of familiar issues.

DREAM III

Client W is an anxious man 54 years of age. His dream occurred the night before his therapy session.

I'm in bed, and I know I'm trying to sleep. I feel something on my head tugging or touching or hitting. I can't see it, but I put my hand up and feel it to pull it down. I know it's a small demon. I can feel it, like its little arm or something. I want to grab it, pull it down, and look at it. I get hold of it, but when I look at it—this is the crazy part—it is one of those transparent plastic salad containers! It's empty—just a bit of residue of dressing on the bottom.

Associations

- Salad container: Eating salad is healthy, and an empty container indicates it has been eaten.

- Touch on the head: Client W's wife, A, touches his head when he snores to wake him up, but he was sleeping in the other room because she was sick. It is very important to Client W to stay healthy.

- Demon: Client W has often said he continues therapy to stay mentally healthy and to "get the demons out" of his head. He recalls that, in childhood and adolescence, his dreams were filled with frightening fiery demonic images associated with priests' warnings about the evils of masturbation. He dreaded sleep. He continues with current worries (e.g., conflicts he feels about the many demands made by his recently widowed mother).

Analysis

In this case, the wish filled was to exchange demons for good health. "Head" could be understood as "penis" and a wish to have it touched. (Client W often expresses unhappiness about A's disinterest in sex.) W's wish to pull the little demon seems linked to boyhood masturbatory wishes. Oedipal themes also remain to be explored.

DREAM IV

The client, S, is a woman 50 years of age who feared becoming "just like" her mother. Obese, controlling, and reclusive, her unhappy mother demanded constant attention and offered S little except rules and criticism. S's early and disastrous marriage brought four children and years of self-doubt about her own mothering. S opens the session remarking:

I had this amazing dream about my mother; I haven't dreamed about her in 40 years! I dreamt I saw her, and it was her, but she was so different! She was still heavy, kind of like me—well, heavier than I am but not obese. She looked good! Her hair was done and pretty, and she was wearing make-up. She smiled, and she saw me. She really looked at me!

Precipitating Events

The dream took place Sunday night after a difficult weekend. S described a problem her troubled adult son struggled with, her efforts to help, and her worries that the matter might ruin him.

Associations

- An improved mother: S's mother had always been a source of anxiety, but in the dream, she is healthy and pleasant.

Analysis

The wishes fulfilled in this dream were to have a healthy mother and to appreciate and see her own healthy self. For quite some time, S discusses the problems her son is having and his progress. She relates to her desire to be a good mother. After a few moments, she rather abruptly goes on to discuss a project of her own repairing a small garden statue for a neighbor. She describes the difficulty of "restructuring the Madonna" and the surprise discovery of a previously concealed serpent and apple at the statue's feet. When she pauses, the term "restructuring the Madonna" is pointed out and a link is made to the dream image of the improved mother. S recognizes that seeing her mother healthy and a positive figure in the dream means she can be those things as well.

12. CONCLUSION

Freud affirmed that dreams are meaningful and that they originate within the dreamer. He explained that a dream results from a struggle between an unconscious wish and forces opposing that wish. A dream occurs because its disguise—its manifest content—hides latent objectionable thoughts from the mind's censoring operations. Disguised, nonsensical content reduces disturbance and permits sleep to continue. Analysis uncovers the dream's latent meaning and reveals motives, thoughts, feelings, and memories otherwise unknown to the dreamer. With publication of The Interpretation of Dreams, Freud demonstrated his method, introduced psychoanalytic theory, and launched decades of research and clinical innovation.

Research supports the meaningful nature of dreams, finds neurologic evidence of wishful brain activity during dreaming, and suggests that even traumatic dreams have a wish-filling function. Divergent views within psychoanalysis enrich therapeutic work and stimulate thought. Freud's analysis of his own dreams set a standard still central to psychoanalytic training: to analyze, one must first undergo analysis.

When interpreting a client's dream, the clinician should consider the effects that culture, race, and technology have on the images present in dreams as well as on interpretation of the individual's dream. Assessing and interpreting dreams should always be an open, communicative process between the psychoanalyst and the dreamer. It is important to note that dream work is not limited to psychoanalysts or therapists; any dreamer can use Freud's method (i.e., suspend self-criticism, collect thoughts and associations clinging to dreams). Dream work can advance the therapeutic alliance, produce new insights, and build clients' ego strength. Analysis of one's own dreams sharpens clinical skill and promotes essential self-knowledge. Technique calls for candor from the dreamer, self-restraint from the clinician, and patience, curiosity, and hard work from both.

13. RESOURCES

National Association for the Advancement of Psychoanalysis

850 7th Avenue, Suite 800

New York, NY 10019

212-741-0515

https://naap.org

International Association for the Study of Dreams

PO Box 206

Novato, CA 94948

209-724-0889

http://www.asdreams.org

American Psychoanalytic Association

309 East 49th Street

New York, NY 10017

212-752-0450

http://www.apsa.org

Works Cited

1. American Psychoanalytic Association. Interview with Leon Hoffman, MD: Questions and Answers about The Interpretation of Dreams. Available at http://www.apsa.org/content/interpretation-dreams. Last accessed December 21, 2018.

2. Freud S. The Interpretation of Dreams. 3rd ed. New York, NY: The Macmillan Company; 1913.

3. Matthew 3.13 (RSV).

4. Bulkeley K. Dreaming in the World's Religions: A Comparative History. New York, NY: New York University Press; 2008.

5. Grunebaum GE, Caillois R (eds). The Dream and Human Societies (No. 4). Oakland, CA: University of California Press; 1966.

6. Tedlock B. Dreaming: Anthropological and Psychological Interpretations. Santa Fe, NM: School of America Research Press; 1992.

7. Mittermaier A. Dreams that Matter: Egyptian Landscapes of the Imagination. Berkeley, CA: University of California Press; 2010.

8. Genesis 41 (RSV).

9. Solms M. Freud returns. Sci Am Mind. 2006;290(5):82-88.

10. Solms M. The interpretation of dreams and the neurosciences. Psychoanal Hist. 2001;3(1):79-91.

11. Gay P. Freud: A Life for Our Time. 1st ed. New York, NY: WW Norton & Company Ltd.; 2006.

12. Bulkeley K. An Introduction to the Psychology of Dreaming. 2nd ed. Westport, CT: Praeger Publishers; 2017.

13. Freud Museum London. Interpretation of Dreams. Available at https://www.freud.org.uk. Last accessed December 21, 2018.

14. Freud S. A General Introduction to Psychoanalysis. New York, NY: Horace Liveright; 1920.

15. Jones-Smith E. Theories of Counseling and Psychotherapy: An Integrative Approach. 2nd ed. Thousand Oaks, CA: Sage Publications, Inc.; 2014.

16. Barrett D, McNamara P (eds). The New Science of Dreaming [3 Volumes]. Westport, CT: Praeger Publishers; 2007.

17. Langs R. Freud on a Precipice: How Freud's Fate Pushed Psychoanalysis Over the Edge. Lanham, MD: Rowman, Littlefield Publishing Group, Inc.; 2010.

18. Van De Castle RL. Our Dreaming Mind. New York, NY: Ballantine Books; 1994.

19. American Psychoanalytic Association. About Psychoanalysis. Available at http://www.apsa.org/content/about-psychoanalysis. Last accessed December 21, 2018.

20. Brenner C. An Elementary Textbook of Psychoanalysis. New York, NY: International Universities Press, Inc.; 1974.

21. Fine R. TheHistory of Psychoanalysis. New York, NY: Jason Aronson, Inc.; 1990.

22. Goelitz A. Exploring dream work at end of life. Dreaming. 2007;17(3):159-171.

23. Kinney CK, Rodgers DM, Nash KA, et al. Holistic healing for women with breast cancer through a mind, body, and spirit self-empowerment program. J Holist Nurs. 2003;21(3):260-279.

24. Hartmann E. Dreams and Nightmares: The Origin and Meaning of Dreams. Cambridge, MA: Ernest Hartmann; 1998.

25. Alperin R. Toward an integrated understanding of dreams. Clin Soc Work J. 2004;32(4):451-469.

26. Bulkeley K, Domhoff GW. Detecting meaning in dream reports: an extension of a word search approach. Dreaming. 2010;20(2): 77-95.

27. Yu CKC. Dream recall and the dissociation between dream cessation and neurological memory disorders. Neuropsychoanalysis. 2007;9(2):213-221.

28. Lansky MR. Posttraumatic Nightmares: Psychodynamic Explorations. Hillsdale, NJ: Routledge; 1995.

29. National Association for the Advancement of Psychoanalysis. About Psychoanalysis. Available at https://naap.org/naap-membership-requirements. Last accessed December 21, 2018.

30. International Association for the Study of Dreams. About IASD. Available at http://www.asdreams.org/about-iasd. Last accessed December 21, 2018.

31. Glaskin K. Dreams, memory, and the ancestors: creativity, culture, and the science of sleep. J Royal Anthropological Institute. 2011;17(1):44-62.

32. King DB, DeCicco TL. Dream relevance and the continuity of hypothesis: believe it or not? Dreaming. 2009;19(4):207-217.

33. Glaskin K, Chenhall R (eds). Sleep Around the World: Anthropological Perspectives (Culture, Mind, and Society). New York, NY: Palgrave MacMillan; 2013.

34. Wax ML. Dream sharing as social practice. Dreaming. 2004;14(2-3):83-93.

35. Morewedge CK, Norton MI. When dreaming is believing: the (motivated) interpretation of dreams. J Pers Soc Psychol. 2009;96(2):249-264.

36. Wallace BA. Buddhism and Science: Breaking New Ground. 2nd ed. Chichester, NY: Columbia University Press; 2003.

37. Hollan D. The anthropology of dreaming: selfscape dreams. Dreaming. 2004;14(2-3):170-182.

38. Rinpoche G, Khandro S. Meditation, Transformation, and Dream Yoga. Ithaca, NY: Snow Lion Publications; 2002.

39. Peluso DM. That which I dream is true: dream narratives in an Amazonian community. Dreaming. 2004;14(2-3):107-119.

40. Pandaya V. Forest smells and spider webs: ritualized dream interpretation among Andaman Islanders. Dreaming. 2004;14(2-3): 136-150.

41. Lohmann RI, Barrett D. Dreams and ethnography. In: Barrett D, McNamara P (eds). The New Science of Dreaming. Westport, CT: Praeger; 2007: 35-69.

42. Tedlock B. Bicultural dreaming as an intersubjective communicative process. Dreaming. 2007;17(2):57-72.

43. Cook RF. Correspondence in visual imaging and spatial orientation in dreaming and film viewing. Dreaming. 2011;21(2):89-104.

44. Gackenback J. Electronic media and lucid-control dreams: morning after reports. Dreaming. 2009;19(1):1-6.

45. McWilliams N. Psychodynamic Psychotherapy: A Practitioner's Guide. New York, NY: The Guilford Press; 2004.

46. Bulkeley K. Dreaming in adolescence: a "blind" word search of a teenage girl's dream series. Dreaming. 2012;22(4):240-252.

47. Mazandarani AA, Aguilar-Vafaie ME, Domhoff GW. Content analysis of Iranian college students' dreams: comparison with American data. Dreaming. 2013;23(3):163-174.

48. Yu CKC. One hundred typical themes in most recent dreams, diary dreams, and dreams spontaneously recollected from last night. Dreaming. 2015;25(3):206-219.

49. Van den Bulck J, Çetin Y, Terzi Ö, Bushman BJ. Violence, sex, and dreams: violent and sexual media content infiltrate our dreams at night. Dreaming. 2016;26(4):271-279.

50. McNamara P, Moore KH, Papelis Y, Diallo S, Wildman WJ. Virtual reality-enabled treatment of nightmares. Dreaming. 2018;28(3):205-224.

71500 • The Bisexual Client: Trauma-Focused Care

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

www.netce.com

Copyright © 2019 NetCE, All rights reserved.

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

Table of Contents

71500 • The Bisexual Client: Trauma-Focused Care

Course Overview

Audience

Course Objective

Learning Objectives

Faculty

Faculty Disclosure

Division Planners

Division Planners Disclosure

About the Sponsor

Disclosure Statement

1. INTRODUCTION

2. FOUNDATIONS: IDENTIFYING BISEXUALITY AND RELATED DEFINITIONS

DEFINING BISEXUALITY

THE GROWING LGBT+ SPECTRUM AND OTHER NON-BINARY IDENTIFIERS

CONCERNS UNIQUE TO BISEXUAL CLIENTS

3. THE TRAUMA OF THE BISEXUAL EXPERIENCE

DEFINING TRAUMA

TRAUMA AND THE LGBT+ COMMUNITY

OPPRESSIVE COGNITIONS AND THE UNIQUE CONCERNS OF BISEXUALS

THE COMING-OUT PROCESS

4. CULTURALLY RESPONSIVE TRAUMA TREATMENT PLANNING FOR BISEXUAL CLIENTS

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

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

SAMPLE TREATMENT PLANNING STRATEGIES

5. CLINICAL COMPETENCE IN WORKING WITH BISEXUAL UMBRELLA CLIENTS

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

6. CONCLUSION

7. RESOURCES

Works Cited

71500 • The Bisexual Client: Trauma-Focused Care

Education Category. Community Health

Release Date. 05/01/2019

Expiration Date. 04/30/2022

Course Overview

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

Audience

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

Course Objective

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

Learning Objectives

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

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

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

3. Identify concerns unique to bisexual clients.

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

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

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

Faculty

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

Faculty Disclosure

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

Division Planners

Alice Yick Flanagan, PhD, MSW

James Trent, PhD

Division Planners Disclosure

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

About the Sponsor

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

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

Disclosure Statement

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

1. INTRODUCTION

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

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

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

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

2. FOUNDATIONS: IDENTIFYING BISEXUALITY AND RELATED DEFINITIONS

DEFINING BISEXUALITY

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

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

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

Table 1: KLEIN SEXUALITY ORIENTATION GRID

Variable

Past

Presenta

Ideal

A: Sexual attraction

B: Sexual behavior

C: Sexual fantasies

D: Emotional preference

E: Social preference

F: Heterosexual/homosexual lifestyle

G: Self-identification

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

1 = Other sex or heterosexual only

2 = Other sex or heterosexual mostly

3 = Other sex or heterosexual somewhat more

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

5 = Same sex or gay/lesbian somewhat more

6 = Same sex or gay/lesbian mostly

7 = Same sex or gay/lesbian only

aThe present is defined as the most recent 12 months.

Source: [3]

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

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

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

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

THE GROWING LGBT+ SPECTRUM AND OTHER NON-BINARY IDENTIFIERS

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

CONCERNS UNIQUE TO BISEXUAL CLIENTS

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

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

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

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

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

3. THE TRAUMA OF THE BISEXUAL EXPERIENCE

DEFINING TRAUMA

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

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

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

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

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

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

TRAUMA AND THE LGBT+ COMMUNITY

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

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

Complex and Developmental Trauma

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

- Repetitive or prolonged actions or inaction

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

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

- Great potential to severely compromise a child's development

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

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

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

OPPRESSIVE COGNITIONS AND THE UNIQUE CONCERNS OF BISEXUALS

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

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

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

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

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

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

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

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

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

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

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

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

- "Bisexuality isn't real."

- "They just think I'm confused."

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

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

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

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

- There is no such thing as bisexuality.

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

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

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

There is no such thing as bisexuality.

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

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

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

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

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

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

Bisexual people use their sexuality in deviant or manipulative ways.

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

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

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

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

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

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

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

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

- Have a working knowledge of LGBT+ individuals

- Understand heterosexism and work to dispel it

- Acknowledge the possibility of one's own heterosexism

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

THE COMING-OUT PROCESS

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

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

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

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

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

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

4. CULTURALLY RESPONSIVE TRAUMA TREATMENT PLANNING FOR BISEXUAL CLIENTS

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

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

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

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

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

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

- Promote trauma awareness and understanding

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

- View trauma in the context of individuals' environments

- Minimize the risk of retraumatization or replicating prior trauma dynamics

- Create a safe environment

- Identify recovery from trauma as a primary goal

- Support control, choice, and autonomy

- Create collaborative relationships and participation opportunities

- Familiarize the client with trauma-informed services

- Incorporate universal routine screenings for trauma

- View trauma through a sociocultural lens

- Use a strengths-based perspective and promote resilience

- Foster trauma-resistant skills

- Demonstrate organizational and administrative commitment to trauma-informed care

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

- Provide hope—recovery is possible

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Janet's original stages were [34]:

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

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

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

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

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

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

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

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

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

SAMPLE TREATMENT PLANNING STRATEGIES

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

Stage 1: Stabilization and Laying the Foundation

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

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

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

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

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

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

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

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

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

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

Client A: Stage 1

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

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

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

Stage 2: Going Deeper and Modifying Traumatic Memories

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

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

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

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

Client A: Stage 2

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

According to the World Health Organization [38]:

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

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

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

Stage 3: Reintegrating to Society

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

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

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

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

Client A: Stage 3

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

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

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

5. CLINICAL COMPETENCE IN WORKING WITH BISEXUAL UMBRELLA CLIENTS

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

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

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

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

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

- Actively participates in bisexual community events or forums

- Has read professional books or journal articles on bisexuality

- Attends professional workshops on the concerns of bisexual people

- Has worked professionally with several bisexual clients in the past

- Organizes bisexually oriented support or social groups or workshops

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

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

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

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

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

6. CONCLUSION

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

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

7. RESOURCES

The American Institute of Bisexuality

https://bisexual.org

BiNet USA

http://www.binetusa.org

Bisexual Organizing Project

http://www.bisexualorganizingproject.org

Bisexual Resource Center

http://biresource.org

Coming Out: UCLA Resource Center

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

Human Rights Campaign

https://www.hrc.org

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

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

The LGBTQIA Resource Center at the University of California, Davis

https://lgbtqia.ucdavis.edu

More Than Two: Polyamory Resources

https://www.morethantwo.com

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

http://www.nalgap.org

PFLAG

https://pflag.org

Substance Abuse and Mental Health Services Administration (SAMHSA)

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

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

The Trevor Project

https://www.thetrevorproject.org

Wellness Identity Sexuality Health (WISH) Research Lab

https://www.wishresearch.com

My LGBT Plus

http://www.mylgbtplus.org

Works Cited

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

77040 • Setting Ethical Limits: For Caring and Competent Professionals

Lisa Hutchison, LMHC

www.netce.com

Copyright © 2018 NetCE, All rights reserved.

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

Table of Contents

77040 • Setting Ethical Limits: For Caring and Competent Professionals

Course Overview

Audience

Course Objective

Learning Objectives

Faculty

Faculty Disclosure

Division Planners

Division Planners Disclosure

About the Sponsor

Disclosure Statement

1. INTRODUCTION

2. COMPETENCE

APA'S ETHICAL PRINCIPLES OF PSYCHOLOGISTS AND CODE OF CONDUCT

2014 ACA CODE OF ETHICS

CODE OF ETHICS OF THE NASW

3. CULTURAL COMPETENCE

CHARACTERISTICS OF A CULTURALLY COMPETENT COUNSELOR

4. THE THERAPEUTIC RELATIONSHIP

CONGRUENCE

EMPATHY

5. THE COSTS OF CARING

STRESS

COMPASSION FATIGUE, VICARIOUS TRAUMA, AND BURNOUT

MITIGATING THE COSTS OF CARING

6. TRANSFERENCE AND COUNTERTRANSFERENCE

REFLECTION

SELF-AWARENESS

7. BOUNDARIES AND LIMITS

BUILDING TRUST

THE VALUE OF FLEXIBILITY

EMPOWERING AND PROTECTING THE CLIENT

PROTECTING THE PROFESSIONAL

8. BOUNDARY CROSSINGS AND VIOLATIONS

9. MULTIPLE RELATIONSHIPS

BOUNDARY VIOLATIONS WITHIN MULTIPLE RELATIONSHIPS

10. GIFTS

THE GIFT OF SELF-DISCLOSURE

11. TECHNOLOGY AND DISTANCE THERAPY

LEGAL AND ETHICAL CONSIDERATIONS

SOCIAL MEDIA

12. CONCLUSION

13. RESOURCES

Works Cited

77040 • Setting Ethical Limits: For Caring and Competent Professionals

Education Category. Ethics - Human Rights

Release Date. 12/01/2018

Expiration Date. 11/30/2021

Course Overview

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

Audience

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

Course Objective

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

Learning Objectives

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

1. Define professional competence.

2. Describe the importance of cultural competence.

3. Outline components of the therapeutic relationship.

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

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

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

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

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

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

Faculty

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

Faculty Disclosure

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

Division Planners

Alice Yick Flanagan, PhD, MSW

James Trent, PhD

Division Planners Disclosure

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

About the Sponsor

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

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

Disclosure Statement

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

1. INTRODUCTION

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

- The demands of clinical and professional responsibility

- The challenges of managing the client/counselor relationship

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

- Vulnerability to vicarious traumatization

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

- The intersection of personal and professional demands

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

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

2. COMPETENCE

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

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

APA'S ETHICAL PRINCIPLES OF PSYCHOLOGISTS AND CODE OF CONDUCT

2.01 Boundaries of Competence

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

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

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

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

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

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

2.03 Maintaining Competence

Psychologists undertake ongoing efforts to develop and maintain their competence.

2014 ACA CODE OF ETHICS

C.1. Knowledge of and Compliance with Standards

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

C.2. Professional Competence

C.2.a. Boundaries of Competence

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

C.2.b. New Specialty Areas of Practice

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

C.2.c. Qualified for Employment

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

C.2.d. Monitor Effectiveness

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

C.2.e. Consultations on Ethical Obligations

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

C.2.f. Continuing Education

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

C.4. Professional Qualifications

C.4.a. Accurate Representation

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

C.4.b. Credentials

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

C.4.c. Educational Degrees

Counselors clearly differentiate between earned and honorary degrees.

C.4.d. Implying Doctoral-Level Competence

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

C.4.e. Accreditation Status

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

C.4.f. Professional Membership

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

CODE OF ETHICS OF THE NASW

1.04 COMPETENCE

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

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

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

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

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

3. CULTURAL COMPETENCE

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

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

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

CHARACTERISTICS OF A CULTURALLY COMPETENT COUNSELOR

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

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

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

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

4. THE THERAPEUTIC RELATIONSHIP

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

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

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

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

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

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

CONGRUENCE

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

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

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

EMPATHY

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

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

- See the world as others see it.

- Be nonjudgmental.

- Understand another person's feelings.

- Communicate your understanding of that person's feelings.

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

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

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

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

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

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

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

Empathic Boundaries

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

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

5. THE COSTS OF CARING

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

STRESS

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

- Headaches, muscle tension, neck or back pain

- Upset stomach

- Dry mouth

- Chest pains, rapid heartbeat

- Difficulty falling or staying asleep

- Fatigue

- Loss of appetite or overeating "comfort foods"

- Increased frequency of colds

- Lack of concentration or focus

- Memory problems or forgetfulness

- Jitters, irritability, short temper

- Anxiety

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

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

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

COMPASSION FATIGUE, VICARIOUS TRAUMA, AND BURNOUT

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

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

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

MITIGATING THE COSTS OF CARING

Disengage

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

Seek Support

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

Set Self-Care Boundaries

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

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

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

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

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

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

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

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

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

Practice Mindfulness

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

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

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

Expand Your Professional World

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

6. TRANSFERENCE AND COUNTERTRANSFERENCE

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

REFLECTION

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

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

- The recognition that we all have blind spots

- An understanding that staff are affected by clients

- An understanding that clients are affected by staff behavior

- A recognition that clients often have strong feelings toward staff

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

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

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

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

SELF-AWARENESS

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

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

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

7. BOUNDARIES AND LIMITS

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

BUILDING TRUST

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

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

- Is perceived as available and accessible

- Tries to understand by listening and caring

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

- Maintains confidentiality

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

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

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

THE VALUE OF FLEXIBILITY

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

EMPOWERING AND PROTECTING THE CLIENT

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

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

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

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

PROTECTING THE PROFESSIONAL

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

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

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

8. BOUNDARY CROSSINGS AND VIOLATIONS

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

- The professional's own life crises or illness

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

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

- Feeling solely responsible for the client's life

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

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

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

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

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

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

9. MULTIPLE RELATIONSHIPS

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

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

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

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

The ACA ethics code states that [4]:

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

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

BOUNDARY VIOLATIONS WITHIN MULTIPLE RELATIONSHIPS

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

- Bartering with clients

- Sexual relationships with students or supervisees

- Sexual intimacies with current or former clients

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

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

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

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

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

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

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

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

10. GIFTS

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

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

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

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

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

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

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

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

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

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

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

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

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

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

THE GIFT OF SELF-DISCLOSURE

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

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

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

Cautions Regarding Self-Disclosure

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

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

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

11. TECHNOLOGY AND DISTANCE THERAPY

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

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

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

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

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

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

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

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

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

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

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

LEGAL AND ETHICAL CONSIDERATIONS

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

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

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

- Understand the technology being used.

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

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

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

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

SOCIAL MEDIA

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

12. CONCLUSION

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

California LCSWs

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

California LMFTs

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

California LPCCs

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

California LEPs

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

13. RESOURCES

Administration for Community Living

Diversity and Cultural Competency

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

Office of Minority Health

Cultural and Linguistic Competency

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

Health Resources and Services Administration

Culture, Language and Health Literacy

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

APA Ethical Principles of Psychologists and Code of Conduct

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

ACA Code of Ethics

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

NAADAC Code of Ethics

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

NBCC Code of Ethics

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

NASW Code of Ethics

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

Substance Abuse and Mental Health Services Administration Cultural Competence

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

HelpGuide: Benefits of Mindfulness

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

Mindfulnet.org

http://www.mindfulnet.org

Plum Village Mindfulness Practice Center

https://plumvillage.org/mindfulness-practice

Works Cited

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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