OHSW20 • Ohio Social Workers 2020-2021

Table of Contents

OHSW20 • Ohio Social Workers 2020-2021

How to Receive Credit

NetCE 10 Hour Course #76773 • A Review of Psychiatric Emergencies

76773 • A Review of Psychiatric Emergencies

1. INTRODUCTION

2. EMERGENCY DEPARTMENTS

3. ASSESSMENT OF PSYCHIATRIC PATIENTS IN THE EMERGENCY SETTING

4. PSYCHIATRIC COMPONENTS OF MEDICAL EMERGENCIES

5. IMMINENT DANGERS

6. AN OVERVIEW OF PSYCHIATRIC ILLNESSES

7. PSYCHIATRIC ILLNESSES IN CHILDREN AND ADOLESCENTS

8. ENVIRONMENTAL BIOLOGY

9. MANAGEMENT OF PSYCHIATRIC EMERGENCIES

10. APPROPRIATE DISCHARGE PLANNING

11. OFFICE EMERGENCIES

12. LEGAL ISSUES

13. CONCLUSION

14. RESOURCES

Works Cited

Evidence-Based Practice Recommendations Citations

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

77040 • Setting Ethical Limits: For Caring and Competent Professionals

1. INTRODUCTION

2. COMPETENCE

3. CULTURAL COMPETENCE

4. THE THERAPEUTIC RELATIONSHIP

5. THE COSTS OF CARING

6. TRANSFERENCE AND COUNTERTRANSFERENCE

7. BOUNDARIES AND LIMITS

8. BOUNDARY CROSSINGS AND VIOLATIONS

9. MULTIPLE RELATIONSHIPS

10. GIFTS

11. TECHNOLOGY AND DISTANCE THERAPY

12. CONCLUSION

13. RESOURCES

Works Cited

NetCE 5 Hour Course #77790 • Domestic and Sexual Violence

77790 • Domestic and Sexual Violence

1. INTRODUCTION

2. AN OVERVIEW OF THE ISSUE

3. SIGNS OF ABUSE/VICTIMIZATION

4. HEALTH EFFECTS AND IMPLICATIONS OF DOMESTIC VIOLENCE

5. HEALTH EFFECTS AND IMPLICATIONS OF SEXUAL VIOLENCE

6. IMPLICATIONS ON PREGNANCY AND PRENATAL CARE

7. HEALTH EFFECTS AND IMPLICATIONS OF CHILDREN EXPOSED TO DOMESTIC VIOLENCE

8. DOMESTIC VIOLENCE AND SEXUAL VIOLENCE IN SPECIAL POPULATIONS

9. PERPETRATORS OF DOMESTIC/SEXUAL VIOLENCE

10. ASSESSMENT AND SCREENING METHODS

11. BEST PRACTICES IN FOLLOW-UP CARE FOR VICTIMS OF VIOLENCE

12. BUILDING EFFECTIVE COMMUNITY PARTNERSHIPS AND COLLABORATIONS WITH COMMUNITY-BASED AGENCIES

13. APPROPRIATE RESPONSES AND DOCUMENTATION

14. RESOURCES

Works Cited

Evidence-Based Practice Recommendations Citations

NetCE 5 Hour Course #71610 • Integrating Religion and Spirituality into Counseling

71610 • Integrating Religion and Spirituality into Counseling

1. INTRODUCTION

2. MULTICULTURAL ISSUES IN THE PROVISION OF MENTAL HEALTH SERVICES

3. INCREASING DEMAND FOR MENTAL HEALTH SERVICES

4. ETHICAL SUPPORT FOR INTEGRATING SPIRITUALITY AND RELIGION INTO COUNSELING

5. ASERVIC: HISTORY AND COMPETENCIES

6. CULTURE AND WORLDVIEW

7. COUNSELOR SELF-AWARENESS

8. HUMAN AND SPIRITUAL DEVELOPMENT

9. COMMUNICATION

10. ASSESSMENT

11. DIAGNOSIS AND TREATMENT

12. CONCLUSION

Works Cited

Evidence-Based Practice Recommendations Citations

OHSW20 • Ohio Social Workers 2020-2021

James Trent, PhD

Lisa Hutchison, LMHC

John M. Leonard, MD

www.netce.com

Copyright © 2024 NetCE, All rights reserved.

OHSW20 • Ohio Social Workers 2020-2021

Expiration Date: 04/30/2021

How to Receive Credit

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

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

76773 • A Review of Psychiatric Emergencies

James Trent, PhD

www.netce.com

Copyright © 2020 NetCE, All rights reserved.

This course introduces professionals to the issue of psychiatric emergencies. Psychiatric illnesses that may require emergency treatment are divided between those involving adults and children. Within each of these categories, individual illnesses are presented with a short description of the presenting symptoms and possible areas of differential diagnosis before treatment is started. However, this course does not attempt to teach psychiatric diagnosis, as such is beyond the limits of the course. Common treatment approaches are provided for each psychiatric illness described. In addition to the illnesses and possible treatments, professionals are introduced to potential dangers and ways to minimize the possibility of injury to either medical personnel or the patient.

Table of Contents

76773 • A Review of Psychiatric Emergencies

Course Overview

Audience

Course Objective

Learning Objectives

Faculty

Faculty Disclosure

Division Planner

Division Planner Disclosure

Director of Development and Academic Affairs

Director Disclosure Statement

About the Sponsor

Disclosure Statement

Implicit Bias in Health Care

1. INTRODUCTION

2. EMERGENCY DEPARTMENTS

MISUSE OF EMERGENCY SERVICES AND OVERCROWDING

3. ASSESSMENT OF PSYCHIATRIC PATIENTS IN THE EMERGENCY SETTING

MEDICAL EVALUATION

PSYCHIATRIC ASSESSMENT

4. PSYCHIATRIC COMPONENTS OF MEDICAL EMERGENCIES

5. IMMINENT DANGERS

SUICIDE

HOMICIDE

INABILITY TO AVOID COMMON DANGERS

6. AN OVERVIEW OF PSYCHIATRIC ILLNESSES

SUBSTANCE USE DISORDERS

DELIRIUM, DEMENTIA, AND AMNESTIC DISORDERS

SCHIZOPHRENIA AND RELATED DISORDERS

MOOD DISORDERS

ANXIETY DISORDERS

PERSONALITY DISORDERS

ADJUSTMENT DISORDERS

7. PSYCHIATRIC ILLNESSES IN CHILDREN AND ADOLESCENTS

SUICIDE

SUBSTANCE USE DISORDERS

ACTING OUT OR IMPULSIVE BEHAVIOR

8. ENVIRONMENTAL BIOLOGY

9. MANAGEMENT OF PSYCHIATRIC EMERGENCIES

AGITATION

SUICIDE

DELIRIUM AND DEMENTIA

FUNCTIONAL DISORDERS

HOMICIDAL PATIENTS

MANAGING INTENSE EMOTIONS

10. APPROPRIATE DISCHARGE PLANNING

11. OFFICE EMERGENCIES

12. LEGAL ISSUES

13. CONCLUSION

14. RESOURCES

Works Cited

Evidence-Based Practice Recommendations Citations

76773 • A Review of Psychiatric Emergencies

Education Category. Psychiatric / Mental Health

Release Date. 03/01/2020

Expiration Date. 02/28/2023

Course Overview

This course introduces professionals to the issue of psychiatric emergencies. Psychiatric illnesses that may require emergency treatment are divided between those involving adults and children. Within each of these categories, individual illnesses are presented with a short description of the presenting symptoms and possible areas of differential diagnosis before treatment is started. However, this course does not attempt to teach psychiatric diagnosis, as such is beyond the limits of the course. Common treatment approaches are provided for each psychiatric illness described. In addition to the illnesses and possible treatments, professionals are introduced to potential dangers and ways to minimize the possibility of injury to either medical personnel or the patient.

Audience

This course is designed for mental and behavioral health professionals who may intervene in psychiatric emergencies.

Course Objective

The purpose of this course is to help mental and behavioral health personnel recognize psychiatric emergencies, identify common psychiatric illnesses that may share symptoms with physical illness, and improve the management of psychiatric emergencies.

Learning Objectives

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

1. Outline the history and appropriate use of the emergency department (ED).

2. Cite statistics regarding ED utilization.

3. Describe the medical evaluation of psychiatric patients in the emergency setting.

4. Discuss components of a psychiatric assessment in the ED.

5. Review common medical conditions that may be linked to psychiatric issues.

6. Define imminent danger.

7. Identify common psychiatric conditions that may precipitate emergencies in adults.

8. Recognize psychiatric illnesses in children and adolescents that may necessitate emergency intervention.

9. Describe the appropriate management of psychiatric emergencies, including the necessity for providing information in the patient's native language.

10. Outline appropriate discharge planning for patients who have been treated for psychiatric emergencies.

11. List interventions that should be utilized in the case of a psychiatric emergency in an office setting.

12. Discuss legal issues associated with psychiatric emergencies.

Faculty

James Trent, PhD, earned his doctorate in clinical psychology from the University of Mississippi in 1977. He has worked in rural community mental health, where psychiatric emergencies were managed without the benefit of adjacent inpatient psychiatric facilities. He has managed an independent practice of psychology since 1979, a practice that has included managing patients presenting with psychiatric emergencies. Dr. Trent taught at Middle Tennessee State University and Capella University, lecturing graduate students on psychopathology and psychotherapy. He supervised practicum students and interns at the VAMC Nashville, Tennessee, and at the Vanderbilt University Psychological and Counseling Center. In 2017, Dr. Trent retired from the Charleston, South Carolina, VAMC Home Based Primary Care program, where he provided psychological services to elderly veterans with chronic, comorbid illnesses that precluded their ability to receive care at the hospital and managed psychiatric emergencies among home-based veterans. Dr. Trent also acts as the Psychology Division Planner at NetCE.

Faculty Disclosure

Contributing faculty, James Trent, PhD, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Division Planner

Alice Yick Flanagan, PhD, MSW

Division Planner Disclosure

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

Director of Development and Academic Affairs

Sarah Campbell

Director Disclosure Statement

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

About the Sponsor

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

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

Disclosure Statement

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

Implicit Bias in Health Care

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

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

1. INTRODUCTION

Hospital emergency departments (EDs) were initially used to provide immediate care for patients experiencing acute medical conditions or trauma. Their role expanded to provide more extensive management of people with other types of conditions that require immediate care, including people experiencing psychiatric emergencies. Now, EDs are experiencing increased use by people who do not have a primary care physician and use EDs for routine medical care, causing stress on available healthcare resources.

A psychiatric emergency has been defined as, "any behavior that cannot be dealt with as rapidly as needed by the ordinary mental health, social service, or criminal justice system in a community" [1]. A consensus definition developed by a task force of the American Psychiatric Association (APA) has indicated that a psychiatric emergency is "an acute disturbance of thought, behavior, or social relationship that requires an immediate intervention as defined by the patient, the family, or the community" [2]. Psychiatric illnesses, some of which have the potential of becoming emergencies, occur in adults, adolescents, and children. Each diagnosis is based on the presence of certain symptoms; however, symptoms are not unique markers for each diagnosis. As such, some symptoms overlap into more than one diagnosis. It is helpful for healthcare professionals who do not work closely with psychiatric patients, but who may come into contact with them in various settings, to recognize common and overlapping symptoms of psychiatric disorders.

As with physical conditions, psychiatric episodes may become emergencies. It is important for the professional staff in various settings (e.g., correctional facilities, nursing homes, clinics, offices) to recognize a psychiatric emergency when it occurs and know how to manage it based on available resources.

Psychiatric emergencies can manifest in different ways and places. The emergency with the most potential for damage to the patient and others involves a person who is suicidal, homicidal, or unable to avoid common dangers. Managing any of these problems involves both general and specific actions.

2. EMERGENCY DEPARTMENTS

As noted, the emergency department evolved from the emergency room, which was used to stabilize and provide immediate care to patients experiencing a medical emergency. Once stabilized, patients could either be discharged to another unit for additional evaluation and treatment or to their home, if appropriate.

EDs now offer many more resources than the original emergency rooms. In addition to stabilizing and treating the patient in need of immediate care, the ED has more diagnostic and treatment options than were previously imagined. As EDs became self-sufficient units within larger medical centers, they became an integrated part of the patient's continuum of care. In-house specialty physicians are usually immediately available to consult with the ED physicians, nurses, and medical social workers. The presence of a psychiatrist or psychiatric resident, when a training component is available, facilitates the development of a working diagnosis and immediate treatment for patients experiencing a psychiatric emergency. Of course, psychiatric patients are not impervious to other medical emergencies. The existence of a comorbid psychiatric condition may complicate the diagnosis and treatment of medical problems. In such cases, consultation with a psychologist or psychiatrist may help the ED physician and staff distinguish psychologic issues from medical problems that may be present [3].

MISUSE OF EMERGENCY SERVICES AND OVERCROWDING

The misuse of emergency services by patients who do not have primary care physicians and use the ED for routine office visits is a continuing problem in the United States and can contribute to ED crowding. According to an analysis by the Centers for Disease Control and Prevention (CDC), the foundation of the overcrowding problem is that the demographics of the U.S. population have changed over time (e.g., a greater number of older Americans, higher incidence of obesity and diabetes) and there are fewer EDs [76,84].

Trends in Emergency Department Use

An increase in the use of emergency services has continued over the last several decades. Between 1995 and 2010, the percentage of adults in the United States visiting the ED one time each year remained consistent (approximately 20%); however, the number of adults with two or more visits increased 34%. Over this same period, the number of EDs decreased by 11% [76,84]. One in five people visited the ED at least once each year, but frequent users (i.e., four or more visits in two years) are a dilemma. They represent 1% of all users, but are responsible for 18% of all visits [76]. These individuals typically have poor general health and chronic conditions, lower socioeconomic status, and are older than 65 years of age.

Between 2011 and 2017, the percentage of adults in the United States visiting the ED each year has remained consistent, at about 18.5% [84]. However, there were 5,686 hospitals and 1 million beds available in 2017, and significant decrease compared with 1975, when there were 7,156 hospitals and 1.5 million beds [23,85]. In the last few decades, overcrowding and misuse of EDs has received more attention, resulting in new guidelines, protocols, and action plans being developed to address the issue [23,47].

Myths in Emergency Department Use

There are many myths regarding ED usage. It is often asserted that most visits to EDs are for non-urgent conditions, but the reality is much different. Based on 2015 CDC National Hospital Ambulatory Medical Care Survey data (gathered in 2014–2015), 55.9% of adult and pediatric ED visits nationwide were classified as urgent or semi-urgent and only 5.5% were classified as nonurgent [4]. The remainder were classified as emergent. It is also often reported that Medicaid patients or the uninsured are using EDs as primary care; however, in 2015, the number of adult visits classified as emergent, for example, was higher for privately insured (7.9%) than publicly insured (6.9%) and uninsured (4.4%) patients [4]. The prevailing belief is that poor, uninsured/publicly insured individuals are the problem, when in fact there has been a disproportionate increase in ED use as primary care among privately insured individuals [75,76].

Misuse of emergency services is an expensive aspect of medical care. Treatment in EDs is 12 times more expensive than in primary care offices and 10 times more expensive than urgent care centers; even so, the nonurgent use of emergency rooms continues to grow [76,19]. Many of these nonurgent visits may be avoided if patients are able or willing to receive care (and preventive care) from a primary physician. Research has shown that people are more likely to use emergency services if they do not have a regular healthcare provider [75,19]. This is unfortunate because primary care providers will typically have the patient's history as a resource, avoiding unnecessary tests. However, it has also been shown that many individuals visit the ED with what turns out to be non-life-threatening conditions because they are experiencing symptoms that mimic those of more serious conditions (e.g., chest pain) [67,76].

In addition to the financial cost, crowded waiting areas, long waiting times, actual or potential delays in receiving medical care, and exacerbation of psychiatric conditions are serious problems in hospitals. Crowded, busy, noisy, and frightening EDs become sources of stress for the psychiatric patient having difficulty maintaining tenuous contact with reality. A situation that begins as a decompensating process, which is upsetting to the patient and family, deteriorates into agitation and eventual loss of control. This process leads to a dangerous situation for both the patient and others, as the patient becomes more frightened and agitated.

3. ASSESSMENT OF PSYCHIATRIC PATIENTS IN THE EMERGENCY SETTING

According to the CDC, 5.5 million visits to EDs were attributed to mental, behavioral, and neurodevelopmental disorders as the primary diagnosis [86]. Because persons with psychiatric symptoms and disorders will often be encountered in the ED, understanding the clinical features and differential diagnoses for various disorders that commonly present in a medical setting is vital. There are several aspects of assessing an apparent psychiatric emergency. In all cases, physical illness should be considered, both as a causal and a comorbid condition. Management of acute behavioral problems may be necessary at this point in order to gain an accurate history and examination. After medical conditions have been investigated, a psychiatric evaluation is essential. In all stages, the patient's potential for violence and/or self-harm should be assessed and taken into consideration.

MEDICAL EVALUATION

Thorough medical evaluation is clearly indicated for patients with psychiatric emergencies, although the feasibility and extent of screening may differ. The American College of Emergency Physicians (ACEP) has developed policies that address the diagnosis and management of adult psychiatric patients in the ED [5]. There are three elements of the initial assessment of a psychiatric patient in an emergency setting [5,79]:

- Assess and differentiate patients with depression and agitation, evaluate patients with depression for risk of harm to self and/or others, and determine if patients with agitation require sedation, seclusion, or restraint.

- Establish whether the patient's symptoms are caused or exacerbated by a medical illness (e.g., toxidrome, delirium, medical disease) and treat any acute medical condition.

- Determine if the patient is intoxicated.

Patients with suggestive histories, abnormal vital signs, and/or abnormal physical examinations should be cleared of medical illnesses during their evaluation [5]. This generally requires more intensive diagnosis utilizing laboratory and radiologic screening. Several groups have been identified as necessitating further medical evaluation if presenting with psychiatric symptoms, including the elderly, those with substance abuse problems, those with pre-existing or new medical complaints, and those of lower socioeconomic status [6,7]. In addition, patients without a prior psychiatric history should be carefully evaluated for possible physiologic causes of the behavioral changes [6].

Several areas should be addressed when taking the history of these patients. If the patient is unable to respond coherently, available family, friends, or law enforcement personnel may be questioned. Specific areas of importance include premorbid functioning, previous psychiatric history, alcohol use, substance abuse, recent injury, medical history, and medication use [8]. In addition, clinicians should determine if neurologic symptoms are present, including recent headaches, slurred speech, confusion, or ataxia [9].

As with all patients who present in the ED, vital signs should be taken. Abnormal vital signs indicate the need for further medical testing. A brief assessment of the head and neck for signs of trauma may also be indicated [8]. If possible, a brief neurologic exam may help elucidate causes of the behavioral abnormalities. The neurologic exam should include assessment of motor strength, speech quality, and reflexes [9].

Although some studies have indicated the use of laboratory and radiologic evaluation of all patients presenting with psychiatric disturbances in the ED, evidence does not support these interventions for most patients [5]. For alert, cooperative patients with no signs of physical distress whose primary complaint is psychiatric, the ACEP has recommended that diagnostic evaluation be directed by the history and physical examination. Routine laboratory testing is not necessary, because it usually does not change the management or disposition of the patient [5]. However, there are several life-threatening medical conditions that may precipitate a psychotic emergency, including central nervous system or systemic infection, collagen vascular disease, drug overdose or intoxication, head trauma, hypertensive crisis, hypoglycemia, hypoxemia, sedative-hypnotic agent withdrawal, and thyrotoxicosis [8,10]. If the cause of psychosis is unclear, these etiologies should be investigated.

In many cases, identification of alcohol and/or drug intoxication is necessary prior to psychiatric evaluation, as intoxication will complicate the assessment and treatment of both medical and psychiatric conditions. Many psychiatric facilities require toxicology screening prior to the transfer of an acutely intoxicated individual [79]. Although identifying intoxication in these patients is helpful, studies have indicated that routine urine toxicologic screens for drugs of abuse in alert, cooperative patients do not affect ED management and therefore need not be performed as part of the ED assessment [5,65,79]. The ACEP also has noted that there is no blood alcohol level at which it has been established that adequate cognitive functioning and decision-making capacity returns; thus, cognitive impairment secondary to intoxication should be individually assessed [79].

PSYCHIATRIC ASSESSMENT

Evidence Based Practice Recommendation

The American Psychiatric Association recommends that the initial psychiatric evaluation of a patient include assessment of the patient's need for an interpreter and cultural factors related to the patient's social environment.

https://psychiatryonline.org/doi/pdf/10.1176/appi.books.9780890426760

Last Accessed: February 17, 2020

Level of Evidence: 1C (Recommendation based on low confidence that the evidence reflects the true effect)

A full psychiatric assessment is complex, the details of which are beyond the scope of this course. According to the APA, the purpose of an emergency psychiatric assessment is to [11]:

- Assess and enhance the safety of the patient and others.

- Establish a provisional diagnosis (or diagnoses) of the mental disorder(s) most likely to be responsible for the current emergency, including identification of any general medical condition(s) or substance use that is causing or contributing to the patient's mental condition.

- Identify family or other involved persons who can provide information that will help determine the accuracy of reported history, particularly if the patient is cognitively impaired, agitated, or psychotic and has difficulty communicating a history of events. If the patient is to be discharged back to family members or other caretaking persons, their ability to care for the patient and their understanding of the patient's needs should be addressed.

- Identify any current treatment providers who can provide information relevant to the evaluation.

- Identify social, environmental, and cultural factors relevant to immediate treatment decisions.

- Determine whether the patient is able and willing to form an alliance that will support further assessment and treatment, what precautions are needed if there is a substantial risk of harm to self or others, and whether involuntary treatment is necessary.

- Develop a specific plan for follow-up, including immediate treatment and disposition; determine whether the patient requires treatment in a hospital or other supervised setting and what follow-up will be required if the patient is not placed in a supervised setting.

Psychiatric assessments in an emergency setting differ in length and may last up to several hours. If possible, the medical and psychiatric assessments should be conducted in cooperation, as additional medical evaluation may be necessary during or after a psychiatric assessment. The clinician administering the psychiatric evaluation may also order certain tests to determine etiology or appropriate treatments (Table 1). Confidentiality may be an issue; however, necessary information may be conveyed to the ED staff in an emergency situation [11].

Table 1: TESTS THAT MAY BE INDICATED AS PART OF A PSYCHIATRIC EVALUATION

Test

Purpose

Basic laboratory tests (e.g., complete blood count; blood chemistries, including lipid profile, B12, folate; urinalysis)

Used to screen for general medical conditions or provide baseline measures prior to treatment. Recommended frequency of screening may vary with health status and specific ongoing treatments (e.g., second-generation antipsychotics, lithium).

Medication levels

Used to monitor therapeutic levels of medications.

Pregnancy test

Some psychiatric conditions and treatments may entail risks to a pregnant woman or her fetus.

Fasting blood glucose or hemoglobin A1c

Used to diagnose diabetes or help determine risk. Patients prescribed second-generation antipsychotics may be at increased risk of developing diabetes.

Lyme serology, syphilis serology, HIV test

May assist in evaluation of cognitive and behavioral changes. Individuals with behavioral problems, such as impulsivity or drug use, may be at increased risk for HIV infection.

Thyroid function tests

May be important for patients with suspected mood disorder, anxiety disorder, or dementia. Used to monitor lithium effects.

Toxicology screen, blood alcohol level

Used to screen for substance use or abuse. Individuals with a mental disorder are at increased risk for substance abuse.

Electrocardiogram

Used to assess effects of medications that may influence cardiac conduction (e.g., tricyclic antidepressants, some antipsychotics). May also be indicated depending on age and health status.

Chest x-ray

Used to diagnose cardiopulmonary disorders (e.g., pneumonia, tuberculosis) that may contribute to delirium. May also be part of a pre-electroconvulsive therapy (ECT) evaluation depending on age and health status.

Imaging studies

Structural studies, such as computed tomography (CT) and magnetic resonance imaging (MRI), and functional studies, such as positron emission tomography (PET), single photon emission computed tomography (SPECT), electroencephalogram (EEG), and functional magnetic resonance imaging (fMRI), may indicate regional brain abnormalities related to a psychiatric illness and its management.

Lumbar puncture

Used to diagnose central nervous system infection (e.g., meningitis, herpes, toxoplasmosis, syphilis, Lyme disease). May be important for differential diagnosis of delirium.

Polysomnography

Used to diagnose sleep disorders, including sleep apnea. May be important for differential diagnosis of depression, psychosis, or other cognitive or behavioral changes.

Psychologic testing

May be requested when cognitive deficits are suspected or there is need to grade for severity or progression of symptoms over time. May also be helpful in establishing a diagnosis (e.g., dementia, mental retardation) or in delineating specific deficits that affect thought processes, treatment, or vocational planning.

Source: Reprinted with permission from the Psychiatric Evaluation of Adults: A Quick Reference Guide. Am J Psych. Copyright 2004. American Psychiatric Association.

Risk for Suicide

During the evaluation of the suicidal patient, a number of significant questions should be asked and answered. The following questions should be asked, although additional items may be added as needed to develop a more thorough understanding of the patient's status.

Questions for Patients

- Have you ever attempted suicide?

- How long have you thought about suicide before coming here?

- What has happened to lead you to such a thought?

- Have you had any losses in the last few months?

- How would you complete suicide if you decide to try to do it?

Evaluation of Patient Responses

- Has the patient described a detailed suicide plan, or is it more of a casual thought?

- If there is a plan, is it well thought out and potentially lethal?

- Does the patient have the means available to carry out the plan?

- Is there anything (e.g., religious belief) that will stop a suicide attempt?

Evidence Based Practice Recommendation

The Department of Veterans Affairs recommends an assessment of risk factors as part of a comprehensive evaluation of suicide risk, including but not limited to: current suicidal ideation, prior suicide attempt(s), current psychiatric conditions (e.g., mood disorders, substance use disorders) or symptoms (e.g., hopelessness, insomnia, and agitation), prior psychiatric hospitalization, recent biopsychosocial stressors, and the availability of firearms.

https://www.healthquality.va.gov/guidelines/MH/srb/VADoDSuicideRiskFullCPGFinal5088212019.pdf

Last Accessed: February 17, 2020

Strength of Recommendation: Strong for

The interview of the potentially suicidal patient provides valuable information to determine the degree of risk present. Those who have a plan that either protects the feelings of others or is designed to cause as much emotional pain to others as possible are at much higher risk than individuals who have passive thoughts about suicide. Clinicians should consider the degree of planning as an indication of the seriousness of a potential attempt. Impulsive people present a more dangerous situation than those who are not impulsive; therefore, substance misuse increases the risk for suicidal behavior. The use of suicide predictive tools will be discussed later in this course.

Risk for Violence

Until the 1990s, assessment of a patient's risk for violent behavior depended almost singularly on the experience and intuition of the clinician, and individual judgment is still an important factor. Several factors have since been identified as increasing the risk for violent behaviors. An intense feeling about harming others increases the risk, as does a well-developed plan and/or availability of a weapon. Impulsivity and substance abuse may further increase the urgency of the situation. Despite this knowledge, various studies have shown that clinicians' ability to predict violence falls somewhere between 14% and 53% [12]. Therefore, tools have been developed to assist in the assessment of the potential for violence in psychiatric patients.

The Historical, Clinical, Risk Management-20 (HCR-20) has been developed to assist in quantifying a psychiatric patient's risk for violent behavior. The 20-item checklist is divided into three sections: historical, clinical, and risk management [13]. The checklist may be administered regularly to identify any changes in risk. In several small-scale studies and meta-analyses, the HCR-20 has been shown to positively predict the level of danger in persons with mental illness; however, this tool offers better predictive accuracy for low-risk patients versus average- or high-risk patients [12,14,66]. Despite possible shortcomings, diagnostic accuracy is improved compared to not using an assessment tool. HCR-20 is now in its 3rd version. The Rating Sheet for Version 3 of the HCR-20 is available online at http://hcr-20.com/hcr/wp-content/uploads/2013/03/HCR-V3-Rating-Sheet-1-page-CC-License-16-October-2013.pdf.

Another available resource is the Violence Risk Appraisal Guide (VRAG), which analyzes 12 variables to provide a probability of whether the patient will engage in violent behavior within a specified time [14]. Because the VRAG is an actuary tool, it does not require that the patient complete a checklist. Rather, the patient's psychosocial history is appraised, particularly childhood conduct, family background, antisocial and criminal behavior, and psychologic problems. Although the VRAG was originally developed for the assessment of inmates and violent crime offenders, researchers have suggested that it may also be of use in assessing psychiatric patients [14,15].

The Classification of Violence Risk (COVR) program, developed by researchers involved with the MacArthur Violence Risk Assessment Study, is software designed to allow clinicians to assess adult patients' risk for violent behavior based on approximately "40 individualized questions, generated by computer algorithms in response to answers to previous questions" [12]. The COVR analyzes 106 variables, which the publisher contends may be ascertained from a chart review and a 10-minute interview with the patient [12].

More research is necessary to evaluate the usefulness of these tools in the ED. However, given the pressures and poor predictive values of clinician assessment for violence risk, the incorporation of an assistive tool may be warranted.

4. PSYCHIATRIC COMPONENTS OF MEDICAL EMERGENCIES

Common medical emergencies seen in the ED include chest pain, asthma attacks, motor vehicle accidents, intoxication, animal bites, suicide attempts, and trauma from physical assaults. While each of these emergencies has physical components that require treatment, almost all may involve psychiatric causes that should be treated as psychiatric emergencies.

It is normal for healthcare professionals to make decisions based on experience and observation of physical symptoms. This is valuable, especially when decisions must be made quickly to save a life or minimize injury to a patient. However, the most common emergencies may have hidden psychiatric reasons that cause or exacerbate the presenting complaint. For example, patients who complain of chest pain should be evaluated to rule out cardiac or other physical causes. It is when physical causes are ruled out that a different set of problems should be addressed. The ED staff may quickly reassure the patient that the chest pain is not signaling an impending heart attack and discharge him or her to a private physician for follow-up evaluation and care. Despite reassurance from the ED staff, the patient may feel sure that the chest pain is a precursor to a heart attack or other major problem. A crowded ED can be overwhelming to the ED staff, making it difficult for them to provide the additional reassurance that may be helpful. It is possible, perhaps even probable, that the patient complaining of chest pain without support of a physical diagnosis is having a panic attack. The diagnosis and treatment of this can easily be lost in the hectic ED. The presence of a consulting psychologist or psychiatrist may help diagnose and provide care for the patient.

In addition to chest pain, several other seemingly medical conditions may be linked to psychiatric issues. Asthma attacks certainly have a physical component, but they are also exacerbated by psychologic issues, particularly anxiety and fear. Intoxication can be a complicated and potentially dangerous condition that involves self-medication for an untreated or poorly controlled psychiatric disorder. Hopelessness has been found to be a feature in irritable bowel syndrome [16]. It is important to recognize that time constraints may lead professionals to depend on experience when the time to reflect on and investigate other possibilities is not available.

EDs in large medical centers frequently have specialized personnel, equipment, and technology. While psychiatric emergencies do not rely on specialized surgical procedures or technology, they do require a thorough understanding of the causes and events around the emergent situation. Knowledge of available psychotropic medications allows for a better decision about the type and dose to use. In small hospitals, psychiatric expertise may not be available to help the agitated psychiatric patient. Thus, the patient's behavior and the staff's response may escalate until the patient requires a stronger intervention to resolve the problem.

5. IMMINENT DANGERS

It is the responsibility of the professional staff, whether in an ED or elsewhere, to recognize and understand the types of imminent dangers that require immediate action. Every state and commonwealth has specific laws mandating how these situations are to be handled. It is important both to read the pertinent laws and post them where professional staff may refer to them when necessary. The specific laws of each state and commonwealth share basic characteristics, such as the three types of imminent danger: suicide, homicide, and the inability to avoid common danger. Despite the recommended approach associated with each, there are significant subjective decisions that should be made by the responsible medical personnel.

SUICIDE

EDs frequently are the first line of treatment for people with suicidal thoughts or behaviors. The increased attention that suicide research has received has been helpful to mental health professionals, crisis center workers, and others involved in suicide prevention. The ED professional staff should be able to determine the presence or absence of imminent danger.

Imminent danger is characterized by a patient describing or manifesting self-destructive behavior that shows a reasonable probability of happening in the immediate hours rather than days, weeks, or months later. Subjectivity comes into play with each professional's interpretation of the patient's statements. The time period for imminent danger may be modified depending on the patient's suicide plan.

There are two suicidal types: passive and active. Persons considering passive suicide will put themselves into harm's way. The goal of this action is to allow an accident to be the cause of death. When passive suicide attempts are treated in the ED, it is unlikely that the ED staff will identify them as suicide attempts, as the staff is focused on treating the injuries from the accident. An active suicide attempt requires a direct action by the suicidal person toward ending his or her life; it is not an accident or a mistake. The suicidal person is directly involved in setting up and causing the action that is intended to end his or her life. Some active suicide attempts are clearly self-inflicted and obvious to the ED staff. At other times, there may be enough doubt about the cause of the injury to make it difficult to determine whether it was self-inflicted or an accident. If in doubt, healthcare professionals should evaluate for the presence of suicidal behavior, as this may be one of a series of increasingly dangerous actions.

Suicidal Ideation

There are several levels to suicidal behavior (Table 2). The first level is suicidal ideation. People experiencing personal or financial duress commonly have passing thoughts about "not waking up," "just leaving the mess," or other fleeting thoughts of death. Suicidal ideation, though, is a much more significant pattern of thinking. Instead of transient thoughts when distressed or fatigued, an individual with suicidal ideation experiences frequent and specific thoughts about dying and possible plans of action. No longer is the thought about "not waking up;" it is about how to accomplish that end and either insulate family or friends or blame them for the suicidal decision. At the point of suicidal ideation, the person may not have a firm plan for suicide but instead thinks about it when driving, cutting vegetables with a knife, or engaging in a potentially dangerous activity.

Table 2: LEVELS OF SUICIDAL BEHAVIOR

Level

Characteristics

Ideation

Frequent and specific thoughts of death and ways to die

Planning

A logical and well-prepared suicide plan with a good likelihood of success

Gesture

Behavior or activity that is dangerous and/or harmful, but not potentially lethal

Attempt

Clear, self-destructive actions with a good probability or expectation of lethality that do not result in death

Completed suicide

Destructive and harmful action that results in one's own death

Source: Compiled by Author

Suicide Plan

If not interrupted, suicidal ideation can gel into a suicide plan. A suicide plan is one that is evidenced by specific strategies to end one's life. While fleeting ideation may suggest an impulsive action that might result in suicide, a suicide plan includes a logical and well-prepared action that has good likelihood of success. Instead of impulsively driving a car off the road, the person with a plan will know when and where to do so to increase the probability that it will be completed. Suicide plans may change the definition of imminent danger as well. Planning may not meet the definition of imminent danger, as it may not be immediately executed. However, careful planning and the need to complete the action via a predetermined series of steps in order to conceal intention are indicative of imminent danger.

Both suicidal ideation and suicide plans should be taken very seriously. Impulsive actions by these individuals can end in unexpected death. The decision about how to manage a patient with suicidal ideation or a suicide plan is affected by several variables. If the person is currently in therapy, the therapist should be called and involved in the management decision. This may involve immediate telephone or face-to-face conversations while the patient is in the ED. A follow-up appointment the next day is usually necessary. If the patient does not have a therapeutic relationship with a mental health professional, referral to one should be made before discharge. Individuals presenting with suicidal ideation may be discharged to home if there are responsible adults available who are willing to take on the responsibility of supervising the patient until treatment is started. If medication is provided to a suicidal patient, a responsible adult should be present to administer it. The entire quantity available should not be enough to reach a lethal dose.

Suicide Gestures

Persons with suicidal gestures are frequently brought to the ED. A gesture shows more behavioral activity than a plan, but less than an attempt, and is not potentially lethal. For example, a person takes a few pills (not enough to be lethal), tells someone about it, and identifies it as a suicide attempt. Two things make this a gesture but not an attempt. First, the person has not taken enough pills to cause death, although it may make the person sick or unintentionally cause other problems. Secondly, a second party has been notified about the action and the motivation, thereby allowing intervention. Patients who engage in suicidal gestures may show increasing lethality in future gestures. Depending upon the person's history and the severity of the current gesture, discharge to involuntary hospitalization for a period of evaluation and observation may be necessary. It is also appropriate, at times, for the ED to discharge the person to a responsible adult pending psychologic treatment.

Suicide Attempts

Suicide attempts involve clear, self-destructive actions. The actions provide a strong probability for lethality or the expectation for lethality. One example is an individual who takes an overdose of pills, with the belief that those pills in that quantity will be lethal, but lives because the pills are ineffective or the necessary quantity is incorrect. Because this person expects the action to be fatal, it is considered an active suicide attempt. Discharge from the ED will likely require inpatient psychiatric treatment.

Involuntary hospitalization is usually preferred to voluntary hospitalization for these patients because they are required to remain for observation and evaluation even if they change their mind. This period of observation and evaluation provides an opportunity to address the suicide attempt and the reasons behind it. After the period of imminent danger has passed, the person may be discharged with a recommendation to start outpatient therapy. It is important for the ED staff to recognize that the danger continues even after the physical condition has been stabilized or treated.

Professional staff should remember that the actions of suicidal people can be deceiving. In some cases, persons manifesting the symptoms of severe depression, including suicidal ideation, suddenly appear to be better. They no longer feel depressed, or at least not as depressed, and look calm or happy. It is at this point that the person may seem calm enough to be discharged to family or friends pending a mental health appointment the next day. However, patients who are discharged may seem calmer because they have resolved how and when to end their lives.

An investigation of suicide in older adults found that in addition to mental conditions these individuals are at high risk for suicide due to a variety of physical conditions [17]. Common health problems cited as possible precursors to suicide include cancer (particularly gastrointestinal cancer and brain cancer), liver disease, epilepsy, cerebrovascular diseases, cataract, heart disease, chronic obstructive pulmonary disease (COPD), osteoporosis, and arthritis. Multiple illnesses greatly increase suicide risk [17]. Mental conditions that may increase the risk for self-harm include anxiety, bipolar disorder, psychosis, and depression. When an elderly person is treated for medical conditions, healthcare professionals should also evaluate the patient for suicidal potential, as it may coexist with the health problems but may not be mentioned when treatment is sought.

HOMICIDE

Homicidal thoughts or attempts are another aspect of imminent danger that may be encountered in an emergency setting. It is usually the victim of the psychiatric patient who presents in the ED; however, contact with the perpetrator does occur. The major decision to make is determining whether the person with homicidal thoughts or behaviors is a criminal who should be dealt with by law enforcement or whether the person may be assisted solely through psychiatric treatment. As with suicide, various levels of homicidal ideation or action present differing risks.

A key to correctly assessing and treating patients with homicidal ideation is understanding the motive. If the motive is due to involvement in criminal activity (e.g., a drug deal), it is a matter for law enforcement. It becomes a psychiatric emergency when the action is based on a psychotic disorder. For example, loss of contact with reality and the presence of paranoid thinking can lead to a dangerous situation in which homicidal ideation is present. In a psychiatric emergency, the thoughts of hurting someone are based on irrational beliefs that the patient is in danger from others and assault is the only protective alternative available. Irrational thinking may lead to a dangerous situation for others in the vicinity. For example, if the patient believes that someone wearing blue scrubs is dangerous, it is likely that everyone wearing blue scrubs will be seen as dangerous. Homicidal ideation due to psychiatric instability or illness requires involuntary hospitalization to protect both the patient and those whom the patient fears.

In the case of psychiatric patients, a homicidal attempt is comparable to a suicide attempt in that the actions are directed outward toward the perceived threat. When a homicidal attempt is based on a psychiatric condition, discharge from the ED should be to involuntary hospitalization for the protection of both the patient and others. While the patient is being treated in the ED, it is important to separate the patient from others in order to reduce stimulation and excitement and prevent the patient from becoming agitated and dangerous. Weapons should be removed, and the patient should wait in a room that does not contain items that could be used for harm (e.g., scalpels, syringes, blunt objects, glass cabinet doors). It is necessary to have someone wait with the patient. This can be a responsible adult or a member of the ED staff. It is often better not to have security wait with the patient, as the presence of a uniform and the accoutrements of law enforcement can upset a paranoid person. Nonetheless, security should be notified of the potentially dangerous situation and the actions being taken. Depending on the resources available at a particular hospital or medical center, it may be necessary to seek the assistance of community law enforcement officials to transport the patient to a secured unit.

INABILITY TO AVOID COMMON DANGERS

Another source of imminent danger is found among people who are unable to avoid common dangers. Psychotic, demented, or substance-impaired people may enter dangerous situations without understanding the associated risks. For example, persons with delusions of invincibility may walk into ongoing traffic without understanding that the traffic can kill them. When these patients are brought to the ED, it is usually because others are unable to manage their behavior. The patient's psychologic state may be so disrupted that he or she becomes a threat to others out of fear and confusion. Healthcare professionals should recognize the danger to the patient and others and take responsibility to initiate involuntary hospitalization.

ED physicians have the authority in all states to order involuntary hospitalizations [18]. Additionally, depending on state laws, clinical psychologists meeting certain criteria (e.g., doctoral degree, health service provider status, special training) are permitted to initiate involuntary hospitalizations. Some states require the receiving hospital to meet other requirements before a patient can be hospitalized involuntarily. Thus, it is the responsibility of psychologists and physicians to evaluate the data and determine if there is sufficient evidence to warrant involuntary hospitalization. A serious complication for psychologists and physicians arises when the patient has been in similar situations and is still able to minimize the outward symptoms or effects, thereby avoiding admission to a secured unit. This can make it difficult to decide whether the patient requires hospitalization.

6. AN OVERVIEW OF PSYCHIATRIC ILLNESSES

Aside from conditions that are sources of imminent danger, many psychologic conditions are commonly encountered in the ED. Although these conditions may not carry the risk of harm associated with suicide or homicide, they do have the potential to escalate to a psychiatric emergency. An understanding of the various psychologic states that can precipitate an emergency, including signs that the state may be a source of imminent danger, is a vital tool for any healthcare professional.

There is overlap between the symptoms associated with different adult psychiatric illnesses and possible medical conditions. It is therefore important for healthcare professionals, especially those who are not familiar with mental health problems, to realize that the differential diagnosis is based on a combination of reported or observed symptoms, underlying personality characteristics, and external circumstances. It is not necessary for all healthcare professionals to be experts on the diagnoses of various mental illnesses. However, it is important to recognize the factors related to diagnoses and consider them in the treatment and discharge plans. It is easy to accept that hallucinations are due to a thought disorder, such as schizophrenia, without considering the possibility of substance abuse. Careful and thorough diagnosis helps to identify and manage psychiatric emergencies.

In various studies, researchers have found that 4% of pediatric patients and up to 9% of all patients seeking medical treatment at EDs for nonpsychiatric reasons experienced suicidal ideation, suicide attempt, or self-harm; another 2% of patients had definite suicide plans [19,82,83]. Among those experiencing suicidal ideation or plans, 97% had depression, anxiety, or substance abuse problems. Thus, there may be a psychiatric emergency among people who do not initially present with psychiatric complaints. Because the reason for seeking treatment at an ED may not be psychiatric, it can be easy to overlook the risk of imminent danger.

Despite a comprehensive knowledge of behavioral emergencies, healthcare professionals continue to rely heavily on subjective judgment to make important decisions. For example, the presence of agitation has been identified as an important symptom to recognize when assessing psychiatric emergencies, yet the lack of an operational definition of agitation has resulted in a wide variation in its diagnosis [20]. The same is true for many other symptoms.

SUBSTANCE USE DISORDERS

Substance use disorders can involve alcohol, prescription medications, or illegal drugs. The misuse of any of these substances may lead to a medical emergency. Each type of substance use disorder presents with symptoms common for the specific substance and the level of abuse. Acute intoxication and the effects of chronic ingestion can both result in medical and psychiatric emergencies.

Intoxication refers to ingesting enough of a substance to impair functional ability in motor, cognitive, or physiologic behavior. The pattern of use may be one of infrequency; however, excessive use during periods of intoxication can be quite dangerous to intoxicated persons and those around them. Regular use of a substance that results in negative consequences in social, health, or occupational areas is defined as substance abuse or substance use disorder [21,26]. Individuals diagnosed with substance use disorder continue to use a substance despite the serious negative effects. Dependence is diagnosed when substance misuse escalates beyond occasional use that might lead to problems and regular abuse that causes continuing deleterious effects on the person's life. Dependence is characterized by the use of a substance such that it is necessary for daily functioning; the dependent individual experiences serious physiologic or psychologic symptoms of withdrawal without it.

Alcohol Abuse

Alcohol is a common cause of psychiatric emergencies. Symptoms of alcohol intoxication are the presence of the odor of alcohol, slurred speech, confusion, and staggering gait. Depending on the amount of alcohol ingested, patients may develop inattention and memory loss and can progress to a stuporous state or coma. These symptoms can vary from a minor inconvenience to a truly dangerous medical emergency. Aside from the medical conditions that require treatment, there are behavioral changes that may make intervention difficult and risky. Alcohol reduces inhibitory control, which may lead to silly or embarrassing behavior. Of more concern for the medical staff and others working with and around the intoxicated person is the disinhibition of aggressive control. Some intoxicated people become very aggressive and may physically assault those around them.

Managing angry and aggressive intoxicated patients is difficult. They are not generally good candidates for reasoning or calming conversations. In some cases, a friend or family member can calm the aggressive patient. In a medical setting, the professional staff should decide if there is a coexisting medical condition that requires immediate medical care. If so, the staff must control the patient's agitation in order to treat the condition. For example, it may not be possible to suture lacerations while the patient is thrashing around. If acute alcohol intoxication is determined to be present, administration of metadoxine may be useful [22,23,24,25]. If an antidote is used, it is important to monitor the patient for signs of withdrawal or adverse cardiovascular effects.

The potential interaction between the quantity of alcohol consumed and psychotropic medications may preclude calming the person with a sedative, although it is often the first-line approach. In extreme situations, it may be necessary to use physical restraints to diagnose or treat medical problems. Intoxicated patients who are irrational and aggressive are a threat to others and should, therefore, be as isolated as possible.

In inpatient facilities, it may be necessary to have security personnel control the patient and call for law enforcement to manage the patient after discharge. Of course, if the person has become sober enough to remain calm and allow a friend or family member to take him or her home, it may not be necessary to involve law enforcement. In outpatient settings, it must be determined whether the person requires medical care for observable symptoms or injuries. If the answer is yes, the appropriate response is to call 911. If there is no obvious need for medical care, the management of the intoxicated and aggressive person should fall to law enforcement personnel who have both the training and expertise to cope with this type of situation. It is dangerous for the intoxicated patient and those working in an outpatient facility if appropriate emergency resources are not used.

Stimulants

Amphetamines and other stimulants present a dangerous situation due to the cognitive and motor changes associated with their use. These substances can be prescription medicines, such as methylphenidate (Ritalin), or illegal substances, including cocaine and methamphetamine. An illegal substance is believed to represent a greater risk to mental and general health because the actual content and ingredients of the substance are unknown. Patients intoxicated with these substances may experience euphoria, hypervigilance, hypersensitivity, paranoia, psychomotor retardation, agitation, anxiety, anger, and poor judgment. They may misconstrue events taking place around them and be sensitive to physiologic changes, which can cause significant fear and distress. Those abusing these substances may also experience perceptual disturbances. Withdrawal from stimulants can be quite dangerous, as the person may experience frightening dreams, hypersomnia or insomnia, psychomotor retardation, or agitation in the context of poor judgment and aggression before reaching a period of stability.

Hallucinogenic Drugs

Hallucinogenic drugs alter the user's perception of reality, mimicking psychosis. The resulting behavior may be dangerous to the user as well as those around the user. Examples of these substances are d-lysergic acid diethylamide (LSD), phencyclidine (PCP), peyote, and hallucinogenic mushrooms. Patients under the influence of hallucinogens often experience periods of anxiety, during which aggressive behavior toward others may be seen, or depression, during which suicide is a serious risk. Paranoia is present along with impaired judgment. Hallucinogenic drugs produce ideas of reference, often influenced by mood prior to ingestion of the substance, in which the user reads personal messages in common events. For example, a song on the radio may be perceived as a special message. Because this is perceived as real, individuals may react protectively or follow orders from an auditory hallucination.

Inhalants

Individuals abusing various substances via inhalation, including glue, gasoline, and medical gases, present difficult situations to manage. The behavior of the inhalant abuser is frequently characterized by belligerence, assault, apathy, cognitive impairment, mood disturbance, and poor judgment [26]. It is often difficult to distinguish acute inhalant intoxication from other causes; furthermore, the symptoms of chronic abuse (e.g., dizziness, headaches, irritability, fatigue, cough) are nonspecific, especially in adolescent patients [27,28,29]. Withdrawal symptoms are rare, but when they do occur, they are similar to those seen in cases of alcohol withdrawal [26]. Efforts to assist the patient to stand or walk may be difficult due to poor coordination, unsteady gait, and diplopia or other visual disturbances. Attempts to help are often rebuffed, and the patient may respond quite violently.

Opioids

As with other abused substances, opiate misuse results in changes in cognition, mood, and judgment. Moods may range from euphoria and agitation to dysphoria and apathy. Opiate abusers who are euphoric are fairly cooperative, although some may be agitated and unwilling to follow any suggestions or orders. During periods of intoxication, ability to make rational decisions and use good judgment is impaired. The withdrawal syndrome from opioid abuse varies from patient to patient. Usually, it involves unpleasant physiologic changes that are not generally life-threatening; however, there are two withdrawal symptoms that should be followed particularly closely: anxiety and depression. Because judgment is impaired, anxiety may lead to dangerous attempts to acquire more of the drug to alleviate the withdrawal. Criminal behavior, including prostitution, is frequently engaged in to acquire more drugs. When depression is present, the patient may become suicidal.

DELIRIUM, DEMENTIA, AND AMNESTIC DISORDERS

Dementia, delirium, and amnestic disorders are included under the broader category of cognitive disorders. These disorders are based on medical, neurologic, or biochemical factors, generally organic in nature, that adversely affect brain functioning. Delirium and dementia are the primary psychiatric emergencies in this category. Patients experiencing acute or active phases of delirium or dementia require immediate medical care. As such, patients with these disorders are often assessed in EDs. Behavioral manifestations include disorientation, hallucinations, illusions, delusions, and personality changes. A normally mild-mannered person may become quite aggressive and assaultive.

Delirium is first and foremost a medical emergency, as without immediate medical treatment the patient is susceptible to injury or harm. If the condition has a rapid onset, the etiology is usually physiologic in nature. The behavioral symptoms of delirium may interfere with needed medical care. Confused, agitated, and frightened patients should be calmed or restrained to allow appropriate treatment. Distinguishing between the behavioral manifestations of delirium and those caused by methamphetamine abuse requires appropriate laboratory testing and thorough interviewing of knowledgeable family members or friends. Unlike those with substance use disorders, patients with delirium may benefit from a small dose of an antipsychotic medication.

Patients with dementia share some characteristics with people with delirium, and both may be present in one patient. However, delirium, when present, should be resolved before a diagnosis of dementia can be made. Patients with dementia experience disorientation and confusion, but they may also display hallucinations, poor judgment, and poor impulse control. Impaired cognition may be focused or diffused, depending on the type of dementia. The sense of immediacy seen in patients with dementia is not as great in those with delirium. Nonetheless, the person with dementia presents a difficult management challenge as a result of the associated symptoms. The management goal for patients with dementia is to prevent harm to the patient and those who are in the patient's proximity.

Patients suffering from delirium or dementia cannot participate in healthcare decisions while actively impaired by their illness. In an emergency, family and knowledgeable friends can be valuable sources of information about the patient's health. However, the Health Insurance Portability and Accountability Act (HIPAA) regulations may complicate acquiring helpful information, as discussion of the patient's condition with other individuals may be restricted or impossible.

No figures have been reported about the incidence or prevalence of amnestic disorder in part because it often accompanies a variety of conditions and disorders. Amnestic disorder may be characterized and diagnostically categorized by memory impairment resulting from: a general medical condition (e.g., stroke, head trauma, hypoglycemia); or the persisting effects of a toxin or substance (e.g., alcohol, sedative, hypnotic). When the etiology is unclear, a diagnosis of amnestic disorder not otherwise specified is used [9,21,30].

SCHIZOPHRENIA AND RELATED DISORDERS

Psychosis is a term commonly used to describe schizophrenia and the associated diagnoses. The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) considers the group of schizophrenias to include the initial episode of schizophrenia, diagnosed as schizophreniform disorder, and schizoaffective disorder, which is a manifestation of schizophrenic and affective symptoms [26]. There are also subtypes of schizophrenia (e.g., paranoid, disorganized, catatonic, undifferentiated) according to the predominant symptoms. Additional psychotic disorders include delusional disorder, brief psychotic disorder, shared psychotic disorder (i.e., folie à deux), and psychotic disorder not otherwise specified.

The diagnoses related to schizophrenia share a common symptom: loss of self. These patients are alienated from others and have lost a sense of personal identity. In some cases, even their body parts may be seen as not belonging to them. Those diagnosed with schizophrenic disorders experience hallucinations and delusions. Thoughts and speech are impoverished, and they may be unable to carry on a meaningful conversation. Words may be fabricated, making language incomprehensible to others. Motor behavior may be agitated or withdrawn.

Some diagnosed with schizophrenia exhibit catatonia, in which they are unresponsive to external stimulation. There is also an agitated form of catatonia in which the patient may exhibit incredible strength compounded with the loss of contact with reality. People diagnosed with the catatonic subtype of schizophrenia share an overall negativism, which can certainly interfere with any professional help.

People diagnosed with the disorganized subtype of schizophrenia manifest inappropriate affect and disorganized speech and motor behavior. Affect is incongruent with the content of their speech. For example, a disorganized person may talk about a serious loss while giggling or laughing about it. Motor behavior may seem unrelated to goal-directed action. It is the confusion and lack of organized thinking, feeling, and behaving that makes the disorganized type of schizophrenia difficult to manage in an open ED, private practice setting, or clinic. These patients may not present direct danger or risk, but they may get hurt or harm others due to the lack of inhibitory control and overall disorganization in their behavior.

Perhaps the most well-known type of schizophrenia is the paranoid type. The essence of this subtype is the attribution of harm or threat from others. Patients with the paranoid subtype of schizophrenia are very sensitive to the actions of people around them. For example, a couple laughing nearby may be perceived as sharing a disparaging joke or conspiracy against the paranoid person. Because this is believed to be real, the laughing couple may be confronted or attacked by the paranoid person. Paranoid hallucinations and delusions complicate treatment. A healthcare provider approaching the paranoid person with a syringe may be seen as a real threat, if the medicine in the syringe is considered poison. The person trying to inject the medicine may be seen as an assassin. The paranoid person simply takes defense to an irrational and potentially dangerous level.

Delusional Disorders

Another dangerous psychotic disorder that is difficult to diagnose is delusional disorder, which is defined according to the subtypes erotomanic, grandiose, persecutory, jealous, and somatic. The DSM-5 categorizes delusional disorder as part of the schizophrenia spectrum [26]. Those with delusional disorders have a fixed belief that is usually based partially on reality. Of course, that reality is seriously distorted in patients with a delusional disorder. Outside the delusion, the patient may appear quite normal and maintain effective work and school activities as long as the activities do not involve the delusion. Erotomania, the distortion of a real or imagined love object, may also develop. There is no actual relationship between erotomanic persons and the object of their love and attention. Celebrities are not the only people affected by erotomania; a simple smile from a clerk can lead to erotomania. Usually, there is a power differential between the weaker (erotomanic) person and the stronger (love object) person. Patients with this type of delusional disorder are unlikely to present with a psychiatric emergency unless they are seen as a danger to others as a result of their delusions.

The persecutory, jealous, and somatic delusional disorder subtypes are more likely to be seen as psychiatric emergencies. Persecutory and jealous types focus on a particular person instead of the more generalized thoughts seen in schizophrenia. Unless one is the focus of persecutory delusions or the object of delusional jealousy, these patients may not appear to be dangerous. If a patient with one of these types of delusional disorders is brought to an ED, it is generally because he or she has either acted on a delusion or is perceived by a victim to be threatening. Unless the psychosis is obvious, law enforcement may handle the problem without involving medical professionals.

Patients diagnosed with the somatic type of delusional disorder are frequent visitors to the ED, physicians' offices, and clinics. The delusion is focused on physical symptoms and conditions, so these patients are more likely to seek treatment from healthcare professionals rather than a psychologist or mental health professional. While these patients can be quite frustrating to physicians, they are generally more of a distraction and disruption than a danger.

MOOD DISORDERS

Patients with mood disorders frequently present in the ED with severe depression and suicidal behavior or because of manic behavior. The depressive symptoms that require emergency treatment include unremitting crying, severe loss of appetite and weight, suicidal ideation, self-criticism, and overwhelming guilt. Many of these patients lose interest in and energy for activities they once enjoyed; it is common for them to show anger and irritation when family or friends are trying to cheer them up or persuade them to do something. Attention and concentration are impaired, memory is fogged, and simple activities may be dangerous due to poor attention and concentration.

Major Depressive Disorder

Major depressive disorder can manifest either as a single episode or a recurring condition. Severity can range from mild to severe, and other factors, including postpartum depression and psychosis, may be present. At least five of the symptoms of this disorder (e.g., depressed mood, loss of pleasure or interest in activities, significant change in weight, sleep disturbance, psychomotor symptoms, fatigue, feeling of worthlessness or inappropriate guilt, diminished ability to think or concentrate, suicidal ideation) must be present nearly every day for at least two weeks for the diagnosis to be made [26]. Psychiatric emergencies with major depressive disorder are the result of the unremitting nature of the symptoms and the intensity with which they are felt. If treatment has either not worked or has not been undertaken for sufficient time, patients with major depressive disorder may become despondent and suicidal, as continuing life is perceived as too painful. Some become extremely withdrawn and experience catatonia, becoming so unresponsive to events around them that they stop eating and begin suffering the physical changes of malnutrition. This is more likely to happen when the person lives alone and does not see others on a frequent basis. Worried family and friends can be the reason that this person is brought to the ED or other professional setting.

Some patients with major depressive disorder experience psychosis, which may take the form of auditory hallucinations. This often includes a voice or voices telling the person how despicable he or she is and how much guilt should be felt. However, the differential diagnosis should rule out schizophrenia [26]. In some cases, the voices tell the person to complete suicide because he or she does not deserve to live. If the person has a weapon, or if other means of suicide are present, the patient is experiencing a life-threatening emergency that should be dealt with by professionals.

Persistent Depressive Disorder

Persistent depressive disorder (dysthymia) differs from major depressive disorder by its duration. Individuals suffering from dysthymia have experienced it for at least two years but may not experience the symptoms every day [26]. Unlike patients with major depressive disorder, patients with persistent depressive disorder have periods of feeling better in the context of overall depressive symptoms, although they do experience depressed mood for more days than not. People with persistent depressive disorder experience different degrees of depression, including hopelessness. These periods of hopelessness may lead to suicidal ideation or attempts. After years of living with painful depression, some people decide that it is not worth living that way [31]. However, despite the relationship between milder persistent depressive disorder and hopelessness, dysthymia is less likely to lead to suicidal behavior than major depression or bipolar disorder.

Bipolar Disorder

Bipolar disorder accounts for approximately 18% of all psychiatric emergencies [32]. It typically appears in the late teens or early 20s and affects men and women equally [33]. The disorder is characterized by manic phases of extreme activity, poor judgment, and loss of contact with reality, and depressive phases, in which the patient becomes depressed, lethargic, and possibly suicidal. Bipolar disorder is categorized as bipolar I or bipolar II disorder.

People diagnosed with bipolar I disorder typically experience extreme mood swings. The transition from a normal mood to hypomania and mania may be slow or may cycle rapidly from one mood state to another. When the patient is manic, psychosis may be exhibited through grandiose ideas or behaviors, poor judgment, impulsivity, or paranoia. Efforts to calm manic patients may produce irritability, anger, and aggressiveness. Rational individuals are seen as negativistic obstacles to the manic person's grandiose goals. An investigation of impulsivity and its impact on suicidal ideation or attempts found that as the number of suicide attempts increased, so did the level of impulsivity [34]. Although a laboratory method of studying impulsivity was used in this investigation, the relationship between clinical bipolar I disorder and impulsivity was relatively clear. A study that included data gathered from 21 countries has confirmed this relationship [35]. In another study, violence toward others was reported to be more likely seen in patients with psychosis, while those with severe depression or anxiety tended to be suicidal [36]. Thus, patients with mania are more of a threat to others, while depressed people are a threat to themselves. Of course, both mania and depression require treatment.

Bipolar II disorder differs from bipolar I primarily by the degree of mania experienced. There must be at least one instance of a bipolar episode and no history of manic episode. Patients with bipolar II disorder typically experience a less intense version, hypomania, which is characterized by increased energy, elated mood, expansive plans, and an increase in enjoyable behavior with some negative consequences. Sleep patterns change, and the patient requires much less sleep than is normal. Speech is often pressured, and there is more intensity toward goal-directed activities. During hypomania, the person's energy leads to more productivity. Hypomania coexists with recurring major depressive behavior in patients with bipolar II disorder. As with bipolar I disorder, the level of intensity can vary from mild to severe, with some individuals experiencing psychotic episodes. Mood swings may occur in rapid cycles in some and in slower cycles in others.

The issue that is most important when these disorders become psychiatric emergencies is the presence of behaviors associated with psychomotor agitation and retardation. When mood is elevated, the patient will show poor judgment, and behavior can be both self-defeating (e.g., sexual promiscuity) and potentially fatal (e.g., excessive use of a mixture of drugs and alcohol). If psychosis is present, the patient will display the effects of a loss of contact with reality. For example, a rational discussion to dissuade a manic person from pursuing a grandiose idea or spending large amounts of money may be perceived as an enemy getting in the way of a great idea. On the other hand, the depressive phase of the mood swings can lead to helpless and hopeless thinking. If one believes that he or she cannot do anything right and there is no hope that things will change for the better, suicidal ideation is likely to occur. This possibility changes into a probability if the person experiences psychosis, including any commanding hallucinations associated with guilt and worthlessness.

It is important to protect patients with mood disorders from self-destructive behavior. It is also important to protect others from patients' acting-out behavior.

ANXIETY DISORDERS

Patients with anxiety disorders generally experience symptoms that do not result in a psychiatric emergency, although there are times when emergencies occur. Anxiety disorders range from mild to pervasive and may have specific forms. There are also types of anxiety that can be caused by life events and may unpredictably recur. Generalized anxiety disorder (GAD) is experienced as anxiety throughout many of life's events and places. Patients with GAD often focus on real or perceived threats and dangers present in their lives. They may feel threatened around strangers or in situations in which their performance may be evaluated, often experiencing uncomfortable physical changes that may result in contact with emergency medical personnel. Heart rate, blood pressure, and startle reflexes may increase, and concentration is impaired. These patients worry excessively about things that they cannot control; the worry is disabling. The anxiety is present in addition to other symptoms, including sleep disturbances, inability to concentrate, irritability, and being on edge. People with GAD may be called "uptight" by friends and family. It is important to realize that a psychiatric emergency may develop when anxiety coexists with another serious stressor [37].

Phobias

Phobias are irrational fears regarding an object or situation. While they can be quite inconvenient, they are not usually disabling to the point of becoming emergencies. For example, a fear of snakes may keep someone from hiking or farming, but it has little effect on someone who is working or shopping in a city. More difficult in both urban and rural areas is social phobia. Social phobia is experienced when an individual is afraid of public performance or criticism from others. Unfamiliar people cause much anxiety for those with social phobia; criticism from those they know also increases the anxiety. Some with social phobia are vulnerable to panic attacks, which can lead to avoiding important and necessary activities. Those who do not avoid these situations may endure them, but with extreme anxiety.

Panic Attacks

Panic attacks often occur without any discernible trigger. They initiate with little warning and are characterized by intense feelings of anxiety, including rapid heart rate, chest pain or tightness, difficulty breathing, sudden increases and decreases of blood pressure, and intense fear. Patients experiencing a panic attack may believe that they are having a stroke, a heart attack, or "going crazy," and in many cases they do seek medical care. If the medical examination for a cardiac event is negative, these patients may be reassured and discharged to home. Usually, this is not acceptable for the patient because the symptoms are so intense. As a result, patients may experience anticipatory anxiety, as they worry about having another episode. This, of course, makes them more likely to have additional panic attacks.

An investigation into personality disorders, panic disorder, and suicide led to the discovery that persons with panic disorder and coexisting personality disorders have more severe degrees of impulsivity, depression, and hopelessness [38]. The participants with panic disorder were more likely to report suicide attempts and attempted suicide at a younger age than those without panic disorder.

Post-Traumatic Stress Disorder

Patients with post-traumatic stress disorder (PTSD) are frequently treated in EDs, whether the cause of the trauma was an individual event or a mass disaster. Although many people may have experienced the same traumatic event, not all are adversely affected in the long term. The causal event for those who develop PTSD may involve physical damage to the body or psychologic damage caused by observing or experiencing the trauma without being physically hurt. The consequences of the trauma may be experienced immediately (acute) or may occur much later (delayed). PTSD can be a chronic condition if the individual does not receive the necessary treatment.

The influence of PTSD on suicide ideation and suicide attempts was investigated using the National Comorbidity Survey [39]. The results indicated that people with PTSD were significantly more likely than those without PTSD to seriously think about or attempt suicide. Thus, if treatment solely focuses on the observable injuries, the life-threatening psychiatric factors may be left untreated. It becomes important for professionals to examine PTSD patients for suicidal ideation during the initial treatment and in the discharge planning, including follow-up treatment by a mental health professional.

PTSD and Veterans

PTSD secondary to deployment to a military conflict or war is another consideration when assessing patients, particularly due to the military operations in Afghanistan and Iraq. Individuals who have served in a war may develop PTSD due to several unique factors, including exposure to severe combat; having personally killed enemy combatants and, possibly, innocent bystanders; exposure to unpredictable, life-threatening attacks; postcombat exposure to the consequences of combat; exposure to the sights, sounds, and smells of dying men and women; and observation of refugees, devastated communities, and homes destroyed by combat [40]. Certain factors have been identified in veterans of the current conflicts that indicate a greater risk for development of PTSD, including [40,41,42]:

- Stigma

- Deployment with a National Guard or military reserve unit

- Military sexual trauma

- Survival after serious injury

Due to the perceived stigma against psychiatric disorders and PTSD, these patients may not seek treatment; this stigma appears to increase among symptomatic patients [43]. Furthermore, documentation of a psychiatric disorder can have an adverse effect on military advancement. As a result, veterans with mental health conditions may be seen more often in the ED or civilian healthcare settings [40].

Anxiety and Suicide

A study examining suicidal ideation and attempts among women with human immunodeficiency virus (HIV) and histories of intimate partner violence indicated that those with coexisting depression were 12 times more likely to have suicidal ideation or attempts. If anxiety coexisted with HIV or violence, suicide ideation or attempts were five times more likely than those without anxiety [44]. This clearly indicates an important area for assessment, as the presenting complaint in the ED or medical center may be HIV or partner violence.

Researchers have found that anxiety is one of the intense affective states associated with suicide ideation and that social phobia, specifically, is associated with suicide attempts [45]. Anxiety disorders have the highest prevalence of all psychiatric disorders. Although suicidal behavior is less likely to occur in patients with anxiety disorders than in patients with other psychiatric disorders, patients with anxiety disorders can be at risk for suicidal behavior, especially when comorbid conditions are present. Professionals providing treatment to anxious patients should assess the degree of suicidality present.

PERSONALITY DISORDERS

Personality disorders are divided into three major clusters based on similarities in associated symptomatology. Cluster A encompasses individuals who are suspicious and possibly experiencing transient psychotic episodes, including those with paranoid, schizoid, or schizotypal types. Cluster B personality disorders are more dramatic and include borderline, histrionic, antisocial, and narcissistic types. Finally, cluster C disorders are typified by avoidant, obsessive-compulsive, and dependent personalities. Cluster C personality disorders are also characterized by anxiety.

Cluster A Personality Disorders

Patients diagnosed with cluster A personality disorders are unlikely to present psychiatric emergencies. However, paranoid personality disorders are mainly associated with unreasonable suspiciousness toward other people, and patients with this type of disorder may counterattack or defend themselves against people whom they perceive as threatening. They are less likely to act out in a violent and dangerous manner than patients with schizophrenia or paranoid delusional disorders, as the suspiciousness does not reach a high level. A person with schizoid personality disorder neither wants nor needs contact with other people. Their isolation is one of choice rather than anxiety or fearfulness. Those diagnosed with schizotypal disorder may have periods of transient psychotic episodes that are seen as magical thinking or a belief that they can see or predict the future.

Cluster B Personality Disorders

Emergencies are more likely to develop from cluster B patients rather than cluster A due to the presence of dramatic and exaggerated behavior. Antisocial personality disorder patients are potentially dangerous because of the ease with which they are frustrated and their likelihood to respond in aggressive and assaultive ways. These patients do not have any regard for other people or their rights. Alcohol and drug abuse are often components of their behavior, which exacerbates the potential of acting out dangerously. Professionals providing treatment for antisocial patients should be aware of the dangers of aggressive behavior, as that is the likely emergency.

Patients with borderline personality disorder are likely to experience suicidal ideation and behavior. These individuals have extreme mood swings and conflictual relationships with others. They are dramatic in their behavior and may attempt suicide in order to seek attention. They may become physically aggressive, but it is more likely that they will be combative due to impulsivity and irritability. Suicide and other self-destructive behaviors among those with borderline personality disorder are prominent reasons for receiving medical treatment and are clear psychiatric emergencies. These patients may utilize the ED on a regular basis.

Histrionic personality disorder is also characterized by dramatic behavior, usually as a means to seek attention at any cost. Individuals with this disorder place great importance on physical appearance and use sexually provocative behavior to get attention. They are unlikely to present with physically aggressive or disfiguring suicidal behavior. However, other suicidal gestures, such as an overdose of medication, may be engaged in and should be taken seriously.

Finally, narcissism is the last of the cluster B personality disorders. These patients have an exaggerated sense of importance and entitlement, and because they see themselves as special and important, they are unlikely to manifest suicidal ideation or attempts. However, if combined with antisocial characteristics, they can be a threat to others. For example, if the narcissistic patient expects to be treated by staff with a certain level of respect and then decides that this expectation is not being met, he or she can become quite dangerous, as their thinking precludes empathy or appropriate interactions. Of course, the addition of substance abuse exacerbates the dangerousness associated with these patients.

Cluster C Personality Disorders

Cluster C personality disorders, which include dependent, obsessive-compulsive, and avoidant individuals, share anxiety as a symptom. Among patients with these disorders, the risk for suicide or harmful behavior usually emerges at the end of a chronic and painful mental illness. Dependent individuals seek the acceptance and approval of others; they will go to great lengths to avoid contradicting someone if they think it would make them angry or unhappy. When an emergency develops, it is because the cluster C personality is finally tired of being dependent on others. It is this sense of hopelessness that may ultimately lead to suicidal behavior.

An obsessive-compulsive person is overly meticulous and strives for perfection; failure to reach perfection leads to disappointment and frustration. These patients are rigid and dogmatic; flexibility is not part of their lives. Falling short of their personal expectations leads to anxiety. Before they reach a point of desperation, obsessive-compulsive individuals become unpleasant and make unreasonable demands of those around them. As relationships unravel and perfection is frustrated, loneliness and hopelessness sets in. Some patients will reach a point at which they believe that life is no longer worth living.

Avoidant personality disorder involves the inability to have close personal relationships with other people. Unlike schizoid personality disorder, the avoidance associated with this disorder is due to anxiety and fear of embarrassment or being hurt by an intimate personal relationship. Yet, avoidant persons desperately want friendships and the ability to comfortably interact with others. The risk for these patients comes from the chronic anxiety that they experience in anticipation of interaction or from real or imagined insults they receive from people around them. Because they have limited coping skills, they may feel hopeless when they experience failure around others. Eventually, these individuals may progress to suicidal ideation or attempts because their life is so unhappy.

Personality disorders are not usually the primary reason for seeking emergency treatment. They are, however, an underlying factor behind seeking help in some cases. For example, an overdose may be the reason for going to the ED and the primary focus of treatment; but, borderline personality disorder may be the psychologic cause of the overdose. The presence of personality disorders reportedly increases the clinical severity of patients with panic disorder and suicidal behavior [38]. Of all of the personality disorders, paranoid and borderline types are associated with the greatest risk for suicidal behavior. Although treatment of personality disorders is not necessary during emergency or crisis intervention, the diagnosis will help guide treatment and discharge planning. Consequently, the focus in the ED and crisis intervention should include an assessment of imminent danger, whether directed toward self or others. Treating the personality disorder will require long-term therapy by a nonemergency mental health professional.

ADJUSTMENT DISORDERS

Adjustment disorders occur after the experience of a distressing event. These events are often nontraumatic, such as losing a job or being diagnosed with a serious illness, and are considered common experiences for most people. Symptoms of adjustment disorders begin within three months of the event and end within six months after the stressor has been resolved [26]. Most individuals learn to cope with the event and adjust to a new life. Those who are unable to adjust to the changes are diagnosed with another disorder.

It is easy to assume that adjustment disorders are either minor or easily resolved. Unfortunately, that is not always the case. There are individuals who cannot make the necessary adjustment and suffer severe disruptions in their lives. It is this group that may present with a psychiatric emergency.

Adjustment disorder is an umbrella diagnosis for several subtypes: depressed mood, anxiety, mixed anxiety and depressed mood, disturbance of conduct, mixed disturbance of emotions and conduct, and unspecified type [26]. The symptoms associated with this diagnosis are usually mild. Nonetheless, they may become severe and debilitating for some patients.

Treatment of an adjustment disorder emergency requires recognizing the stressful event that caused the symptoms and determining if the patient is dangerous as a result of the condition. If imminent danger is present, immediate action is necessary in order to protect the patient and/or others. It is not the responsibility of the emergency staff to provide counseling or reassurance for an individual suffering from a major loss. However, it is important to recognize the loss and its relationship to the patient's behavior. The causal event provides some direction for assessing danger when it is present.

Individuals experiencing job or financial loss, divorce, or the death of a loved one may be driven to suicide, homicide, or both. If there is reasonable belief that the event could have been caused or exacerbated by another person, it is important to ascertain whether the patient harbors any assaultive or homicidal ideation. In situations where blame is placed on others, patients with adjustment disorders often exhibit strong personalization of the event.

Internalized blame can also lead to suicidal behavior. In these cases, there may be little or no blame directed toward others, and if the person's depression is severe enough, suicide may be perceived as the best option. Professionals involved in the treatment of these patients should not try to treat the self-blame but should intercede to stop self-destructive behavior. A discharge plan should also be developed that includes referring the individual to an appropriate, long-term treatment resource.

7. PSYCHIATRIC ILLNESSES IN CHILDREN AND ADOLESCENTS

Child and adolescent psychiatric illnesses parallel those found in adults. However, there are certain changes in the symptoms that reflect the developmental stages of youth, including the continuing development of personality through late adolescence. Some psychiatric disorders, in conjunction with the developmental phase, can present a unique challenge in children and adolescents. This section of the course addresses the effects of psychiatric illnesses in children and adolescents that present a significant risk of danger. It should be noted that managing an aggressive child or adolescent criminal is often the responsibility of law enforcement, not that of the physicians, nurses, psychologists, social workers, or others working in healthcare facilities.

The issue of the management of children and adolescent psychiatric patients presenting in the ED or other healthcare setting is at least as significant as for adults. The prevalence of pediatric patient ED visits for psychologic emergencies continues to increase (from 4.4% in 2001 to 7.2% in 2011) and has become a worrying contribution to ED use [46]. One study of nearly 200,000 pediatric patients showed a 45% increase of mental health visits to the ED between 2010 and 2016, compared with a 13% increase in among non-mental health visits [87]. This group of patients (and psychiatric patients in general) has been identified as being among those that need emergency department services the most [67].

It has been suggested that improper diagnosis and treatment for mental health issues in the pediatric population, in which approximately 20% suffer from a major psychiatric illness with at least some impairment, has precipitated the increase in emergency services utilization [48,49]. This is particularly true in patients with public insurance, who typically have limited access to mental health services and fewer treatment options [50]. Additionally, there has been a reduction in the number of inpatient beds available at state psychiatric hospitals, where less than half are allocated for acute care, while at the same time funding for outpatient mental health services has not increased to offset the losses [67]. Of pediatric ED visits for psychiatric illnesses, approximately 70% are made by adolescents, and more than 66% of these are classified as urgent [50]. For children and adolescents, the first symptoms of psychiatric illness may result in presentation to the ED, making accurate assessment and referral vital.

As with adult patients, the primary factor in assessing a pediatric patient for psychiatric emergency is determination of imminent danger. A classification system exists to measure risk for harm or other adverse events among pediatric patients [51]. According to this system, patients who exhibit suicidal or homicidal behaviors (actions that are potentially life-threatening) are considered class I. Class II designates patients who are in a "heightened state of disturbance" and require immediate assistance (e.g., rape victims) [51]. Serious but not life-threatening conditions, such as verbal threats of violence, are categorized as class III. Patients with class III conditions should be treated as soon as possible, but not necessarily immediately. Class IV refers to conditions or situations that require attention, but are not considered psychiatric emergencies, including misuse of emergency services or lack of a mental health provider. Classification based on this metric allows healthcare professionals to quickly assess the patient and determine the level of intervention that is warranted. Triage tools (e.g., the Mental Health Triage Scale, Emergency Severity Index, Ask Suicide Screening Questions [ASQ]) that may be incorporated into practice also have been developed based on this system [48,88,89]. All classifications require action, whether it is immediate psychiatric intervention or referral to the appropriate resource. This tool may also be helpful for social work, general health, and allied professionals who are attempting to determine if emergent treatment is indicated.

SUICIDE

Suicide is the second leading cause of death in the United States among persons 10 to 24 years of age, accounting for 19.2% of deaths [81]. In the 12 months prior to the 2017 Youth Behavior Risk Survey, 17.2% of high school students seriously considered suicide and 7.4% attempted suicide [54]. Suicidal ideation and attempt among high school students is much higher in girls (22.1% and 9.3%, respectively) than in boys (11.9% and 5.1%, respectively). Overall, planning and attempting suicide peaks for girls during the 10th grade and boys during the 12th grade. Suicide ideation and attempt among girls increased significantly between 2009 and 2017 after many years of steady decline [54]. Psychosocial factors that have been identified as heightening the risk for suicidal behavior in children and adolescents include [55]:

- Social isolation

- Abuse and neglect

- Poor school performance

- Parental psychopathology

- Family history of completed suicide

- History of nonadherence with psychiatric treatment

It is common for suicidal youth to engage in risky behavior and ingest various substances for recreational use, self-medication, or as the primary vehicle for suicide. Young people who experience suicidal ideation, engage in risky behavior, or attempt suicide often feel lonely, neglected, and hopeless [80]. Those with severe symptoms of depression are more likely to engage in acts of nonsuicidal self-injury (e.g., burning, cutting) and suicidal ideation. Life becomes a struggle for many youths with depression, and insults may be exaggerated, which further leads to a sense of hopelessness. It is not uncommon for people, young or old, to compare themselves to others. As hard as the comparisons are for adults, they are even more difficult for children and, especially, adolescents. Humiliating rejection can lead some to internalize or externalize intense feelings.

Children and adolescents also try to "save face" by not expressing how hurt or distressed they are by treatment from adults or peers. It may be important for the professional staff to carefully coach these patients to reveal some of their feelings, especially about other people. The presence of dramatic or intense emotional changes should cue professionals to further assess for the presence of causal factors. Internal factors may indicate a risk for suicidal behavior, while external factors may lead to aggressive acting out. A combination of both may result in an initial period of acting out followed by suicidal behavior. It is the responsibility of healthcare providers in contact with these children and adolescents to protect them and others from the poorly controlled anger or aggressiveness that they may exhibit.

There is some evidence that cues of suicidality vary among male and female children and adolescents. One study has indicated that male children and adolescents experience suicidal behavior in combination with depression and hopelessness, while females feel suicidal only in the presence of hopelessness [52]. Both males and females felt anxious, depressed, and suicidal in the absence of family support. Not surprising, these factors can lead to a sense of loneliness and worthlessness. If an individual believes that no one cares, development of hopelessness and suicidal ideation becomes easy. Engaging in many different types of (but not more frequent) nonsuicidal self-injury is strongly associated with suicide attempt, as are polysubstance abuse and aggression [80].

A 2013 study noted that although 0.6% of ED visits (in patients of all ages) are due to overt suicidal behavior, suicidal ideation is found in 3% to 11.6% of patients [69]. Additionally, a 2019 study indicated that in the year after their visit individuals who presented to EDs with deliberate self-harm had a 56.8 times increased risk of suicide than those of demographically similar individuals. Those who presented with suicidal ideation had 31.4 times greater suicide rates in the next year than demographically similar patients [90]. The Suicide Prevention Resource Center, the American Association of Suicidology, and the U.S. Substance Abuse and Mental Health Services Administration recommend that EDs use a screening method (including a screening instrument) appropriate for their particular setting and that suicide screening should become standardized in the same manner as screening for child abuse, intimate partner violence, and fall risk [70,71]. They also recommend reviewing The Joint Commission's National Patient Safety Goals. After reviewing several instruments, the ASQ, the Manchester Self-Harm Rule, the Risk of Suicide Questionnaire, the Patient Safety Screener, and the Suicide Affect-Behavior-Cognition Scale have been recommended by the Emergency Nurses Association for use in the ED to assess patients' potential for self-harm/suicide [68].

SUBSTANCE USE DISORDERS

Patients who misuse substances constitute a considerable number of the potentially dangerous encounters in the healthcare system. Drug use by adolescents, particularly polysubstance use, is directly related to suicidal behavior [80]. It is also a factor in the development of anxiety, depression, and hopelessness, which influence suicidal ideation or attempts [52]. Young people using or abusing substances experience an impairment of inhibitory control that may already be weak, which leads to poor judgment and bad decisions and contributes to aggressive, physically harmful, or suicidal behaviors. Substance abuse in children or adolescents is part of an overall risk-taking pattern that can be perpetuated or exacerbated as a result of continued use [80]. While intoxicated, there is a danger of acting out in ways that may harm others as well as themselves. The danger, however, is less clear when the child or adolescent is not actually intoxicated, although there is a persistence of negative feelings and thoughts that cause the repeated desire to become intoxicated [80].

Researchers investigated adolescents assigned to suicidal-only, suicidal-violent, and violent-only experimental groups, and a control group [53]. All of the teenagers in the experimental groups showed more internalized problems, risk-taking, and aggressiveness than the control group. Risk-taking behavior in this study included substance abuse. Those in the suicidal-only group showed high levels of depression, anxiety, and covert aggression. Suicidal-violent teenagers had the highest levels of depression, somatization, covert and overt aggression, and risk-taking behavior. Adolescents in the violent-only group had high levels of overt aggression, risk-taking behavior, failure to recognize or perceive risk, and use of marijuana. All of the participants in the experimental groups showed some risk of becoming a danger. Those showing overt aggression and disregard of the rights or lives of others were usually more easily managed as they clearly represented a risk to others. Less clear were the teenagers in the suicidal-only or suicidal-violent groups, as their danger was more likely concealed by withdrawal from others or complaints of physical problems. When the inhibitory controls fail, these adolescents may attempt suicide or harm someone else.

Substance abuse in children and adolescents can affect behavior as it does in adults. Depending on the substance used, behavior may include hallucinations, violence, agitation, or confusion. Substances, whether prescribed or illegal, present their own degrees of dangerousness from overdose, due to the toxicity inherent in the chemicals used. Medical treatment for the physical problems caused by substance abuse should be conducted in the context of someone who may be agitated, psychotic, or aggressive. Thus, the patient's psychiatric condition should be managed at the same time that health problems are addressed.

ACTING OUT OR IMPULSIVE BEHAVIOR

Acting out and impulsive behavior are the terms used to describe a variety of actions based on poor judgment and poor impulse control. Examples of these behaviors include shoplifting, driving too fast, and promiscuous sex. While these actions may have negative consequences for children and adolescents, they are not psychiatric emergencies. Joining a gang, vandalizing public and private property, robbing or assaulting people, and homicide can all be considered impulsive behavior or examples of acting out. Psychiatric emergencies are behaviors that are based on poor judgment or poor impulse control due to psychologic disturbances or abuse of mind-altering substances; they usually are not the result of logical and planned activity.

As noted, violent behavior occurs when strong emotions of anger and aggressiveness are displaced onto other people. Displacement serves to punish an individual or group considered responsible for losses or mistreatment. Hallucinations and delusions may influence the direction and focus of the aggression. At other times, persons are targeted because of low inhibitory control; this is based on the assumption that the patient would not be aggressive if he or she were in a normal state of mind. Thus, treating children and adolescents in these circumstances involves managing both immediate risks and delayed ones.

Thought disorders and psychosis are clear psychiatric emergencies for both adults and youths, impairing their ability to interact appropriately with the world. Those experiencing a psychotic episode represent a risk for both the people treating them and others. The challenge for healthcare professionals is identifying the danger during the treatment process and preventing or minimizing the harm to others. Equally important, but sometimes more difficult, is identifying the danger to others in general. If a psychotic person identifies a potential victim, then medical, psychologic, and mental health personnel have an obligation to protect or warn the intended victim. Professional opinion is formed depending on the type and amount of information provided by the patient and allows a determination about how much truth to place on the statements. Children and adolescents make many statements about hating or killing someone else without ever meaning what they say. If healthcare professionals took every such statement at face value, an exorbitant amount of time would be spent with people who are not dangerous. Thus, there should be enough information to lend credibility to a threatening statement.

Children and adolescents who are depressed and anxious are usually considered threats for self-destruction rather than aggressive acting out. However, peers who humiliate and reject the child may become foci of retribution. Parents who are abusive or strict may be attacked in response to real or perceived mistreatment. These are the dangerous situations that the professional staff should ascertain during the assessment of depressed or anxious youth. Overlooking the potential for serious harm can lead to disastrous consequences.

Oppositional defiant disorder (ODD) and conduct disorder represent two diagnoses for children and adolescents that address acting out and impulsiveness. ODD is characterized by talking back, refusing to follow instructions, deliberately irritating others, and becoming more negativistic and hostile. While youths with ODD are hard to tolerate, they do not usually cause harm to others. Youths diagnosed with conduct disorder present a much greater risk than those with ODD. Those who are diagnosed with conduct disorder are willing to use weapons to coerce or attack other people. Stealing is usually part of their behavior and, given the choice, they confront victims rather than stealing without confrontation. These children and adolescents display similar behavioral traits to adults with antisocial personality disorder. When brought into a hospital setting or ED, they may steal medications or equipment if the opportunity is present. These patients may use violence to intimidate or coerce hospital employees. As with the adult with antisocial personality disorder, this behavior may be difficult to distinguish from criminal behavior.

8. ENVIRONMENTAL BIOLOGY

Psychiatric illnesses can be considered organic or functional depending on etiology. Those caused by organic dysfunction have a physiologic basis, such as the irreversible changes in brain functioning that are associated with dementia. Those who are acutely intoxicated experience a change in brain functioning because of alcohol ingestion. Behavior that is based on organic changes can be either permanent or temporary, depending on the causal factor.

Psychiatric illnesses based on functional factors are either caused by experiences or learned. For example, individuals who have not had a history of an anxiety disorder may develop one after a traumatic event. The assumption is that the anxiety was developed after the trauma and would not have occurred otherwise.

Management and treatment approaches vary based on the etiology of the illnesses. This is particularly true if the organic changes are the result of a medical condition.

Research has shown a strong biologic component in disorders that were previously thought to be based on psychosocial factors [21]. Schizophrenia and bipolar disorder are two examples of mental illnesses that were once considered functional disorders but have since been recognized as organic in basis [56]. Researchers have suggested that the relationship between psychosocial and biologic factors be considered through the concept of "environmental biology" [21]. There are three subtypes involved in this system: biologic trauma from the environment; psychosocial trauma inducing biologic changes; and genotypes and phenotypes.

Biologic trauma from the environment involves the effects of environmental changes in the development of biologic factors. An example of this is fetal alcohol syndrome, whereby the presence of alcohol in the prenatal environment influences fetal brain development. While this example focuses on child development, the principle applies to adults as well, as when biologic changes occur after psychosocial traumas. Extended periods of psychologic strain can lead to changes in brain physiology, and continued periods of uncontrollable environmental stress may change brain functioning, leading to chronic depression or anxiety. Enduring psychosocial trauma leads to biologic changes unless the individual has made an effective adaptation to the cause of the strain.

It is hoped that the success of the Human Genome Project (HGP) will lead to better information and research about the effect of genetic makeup on mental illness. Even without the HGP, there is evidence to support a genetic component to some disorders. Whether the disorder will be manifested (phenotype) depends on environmental and psychologic factors. Genetic makeup may predispose some individuals to anxiety or mood disorders, while others can handle adversity with little or no sequelae. Severe environmental or psychologic factors can influence basic genetic predisposition.

Regardless of the type of facility (e.g., ED, private practice office), professionals should determine the cause of a psychiatric condition in order to provide the most appropriate plan for treatment and discharge. It is certainly correct to focus on the more specific and accurate diagnostic terms when approaching psychiatric illnesses and emergencies. However, that degree of precision may not be practically achieved when the goal is to provide immediate care, stabilize the patient's psychiatric condition, and refer to appropriate follow-up care. If follow-up care becomes more of a long-term process, the healthcare provider can develop as much precision as necessary to effectively treat the patient. An emergency setting does not usually require that degree of precision; instead, defining the psychologic trauma as either organic or functional may be helpful when referring a patient after stabilization.

9. MANAGEMENT OF PSYCHIATRIC EMERGENCIES

Management of psychiatric emergencies in the ED is largely in the form of pharmacotherapy, due to the risks for violence and self-harm. Long-term treatment and follow-up will be required for many patients, and appropriate referral to outpatient facilities is often necessary. However, the management approach varies widely among the different types of mental illness that present in an emergency setting. The ACEP has encouraged clinicians to make every effort to establish whether the potential for violence can be managed at a verbal or behavioral level prior to turning to pharmacotherapy, with its risk of undesirable side effects [5,79].

AGITATION

Evidence Based Practice Recommendation

When managing the risk of violence and aggression, the National Institute for Health and Care Excellence recommends using a multidisciplinary team that includes a psychiatrist and a specialist pharmacist to develop and document an individualized pharmacologic strategy for using routine and when needed medication to calm, relax, tranquillize, or sedate service users who are at risk of violence and aggression as soon as possible after admission to an inpatient psychiatric unit.

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

Last Accessed: February 17, 2020

Level of Evidence: Expert Opinion/Consensus Statement

In many cases, agitation is the most treatable manifestation of a psychiatric emergency. Furthermore, treatment of agitation and/or aggression can facilitate the opportunity for a more thorough analysis and diagnosis. Agitated patients should be thoroughly examined for both physical and psychologic causes for the agitation. Organic conditions that may cause agitation range from infections, such as urinary tract infections in the elderly or HIV, to substance abuse [57,58]. Many of these patients will require pharmacologic intervention to calm them quickly and effectively. The recommendation is to start with a low dose of the medication and slowly increase the amount if the required benefit is not achieved.

For the acutely agitated, undifferentiated patient in the ED, benzodiazepines (e.g., lorazepam or midazolam) or first-generation antipsychotics (e.g., haloperidol) have been suggested as effective therapy for initial drug treatment; ketamine may also be considered [5,79]. Recommended initial therapy consists of combination haloperidol and lorazepam [78]. The addition of benztropine or diphenhydramine may reduce the risk of extrapyramidal symptoms. Second-generation antipsychotics, such as ziprasidone and olanzapine, may also be used for initial drug treatment and have fewer short term side effects than haloperidol [59,91]. Agitated but cooperative patients may be treated orally with olanzapine, sublingual asenapine, or a combination of lorazepam and risperidone [79,91]. For the patient with known psychiatric illness for which antipsychotics are indicated, the ACEP has recommended treatment with an antipsychotic (typical or atypical) as effective monotherapy both for management of agitation and initial drug therapy. In 2022, the U.S. Food and Drug Administration (FDA) approved orally dissolving sublingual dexmedetomidine for agitation in patients with schizophrenia or bipolar disorder, and this may be an option for cooperative patients [92].

In addition or as an alternative to pharmacologic intervention, agitated patients require a safe and quiet room to limit stressors; this is especially true of intoxicated patients, in whom medication (e.g., benzodiazepines) may enhance respiratory depression, or when agitation is secondary to alcohol intoxication [72]. Family members or friends who do not cause upset should join the patient in a calm room to reassure safety and provide support. If family or friends are not a viable option, it is necessary to have a nonthreatening staff person sit quietly with the patient to ensure that he or she does not become frightened or agitated again. Conversations should be respectful and supportive, as condescending or controlling statements may stimulate agitation or combativeness. Members of law enforcement or a facility security department may also be required to protect the patient and others from the agitated and potentially aggressive behavior.

SUICIDE

Patients who present in the ED as a result of injuries that may have been self-inflicted should be thoroughly evaluated. A psychosocial assessment of suicidal patients should not be delayed until after medical treatment is complete, unless life-saving medical treatment is needed or the patient is unconscious or otherwise incapable of being assessed [60]. If treatment is delayed, the patient should be offered an environment that is safe, supportive, and quiet. These patients should be constantly supervised. The initial assessment should determine if the patient has any underlying medical or psychiatric conditions that should be addressed. Patients experiencing distress due to anxiety or depression may benefit from administration of alprazolam [61].

Although patients with suicidal ideation, gestures, or attempts benefit from treatment with a combination of pharmacologic and psychosocial interventions, acute treatment in the ED is generally limited to symptom alleviation and prevention of further injury. The APA has recommended that patients experiencing acute depressive episodes receive antidepressant therapy unless somatic therapy is planned [62]. It is advised that clinicians select an antidepressant with a low risk of overdose, such as a selective serotonin reuptake inhibitor (SSRI) or other newer antidepressant, and prescribe conservative doses. According to the APA, benzodiazepines may be the best choice for the treatment of agitation, panic attacks, or psychic anxiety [62]. Other possible pharmacologic options include some second-generation antipsychotics and some anticonvulsants, such as gabapentin or valproic acid. The FDA warns that valproic acid/valproate/divalproex should not be given during pregnancy, due to decreased IQ in children whose mothers took these anticonvulsants while pregnant [73]. For psychotic patients, particularly those with schizophrenia, treatment with clozapine may be effective [62].

Patients who have been diagnosed as suicidal should be provided with both verbal and written explanations of their care plan, including medications and instructions for follow-up care. If possible, this information should be provided in their native language to ensure comprehension and adherence. Possible delays in the actions of antidepressant medications should also be discussed [62].

DELIRIUM AND DEMENTIA

Evidence Based Practice Recommendation

The American Psychiatric Association recommends that nonemergency antipsychotic medication should only be used for the treatment of agitation or psychosis in patients with dementia when symptoms are severe, are dangerous, and/or cause significant distress to the patient.

https://psychiatryonline.org/doi/pdf/10.1176/appi.books.9780890426807

Last Accessed: February 17, 2020

Level of Evidence: 1B (Recommendation based on moderate confidence that the evidence reflects the true effect)

Delirium and dementia are considered organic conditions, meaning that these conditions generally stem from biologic and/or physiologic causes. Patients with either disorder will require follow-up care. Because these patients can become agitated and combative, it is important to administer a fast-acting sedative. Perphenazine and haloperidol may be used to treat agitated individuals, including children and the elderly [61]. Examples of medications used in the treatment of patients with dementia are donepezil and rivastigmine [61].

It is important not to assume that a patient's confusion is due to long-term dementia or other mental handicap [74]. The most common causes of delirium are infections, medications, or drug withdrawal. A well-documented cause of delirium/dementia symptoms in the elderly patient is urinary tract infection, especially in women, and these infections are often "silent" in older individuals (i.e., no discomfort or other symptoms). It is important to ascertain if the patient has a history of dementia symptoms or if the confusion and/or unusual behaviors are acute. The family/caregivers can provide a patient history.

The ED is an especially important resource for immediate treatment of the delirious patient, and roughly 15% to 20% of patients presenting in the ED will be delirious [74]. An outpatient clinic may or may not have the resources and professional staff to appropriately treat this medical emergency. Inpatient settings should have the necessary resources for treating patients experiencing delirium and should be the treatment location of choice. Delirium, if appropriately treated, should be expected to resolve completely; dementia may be managed pharmacologically, but the patient will not regain full cognitive functioning.

After the delirious or demented patient is stabilized, a referral for continued short-term treatment or long-term therapy should be made. A delirious patient who returns to a normal mental state should be referred to a physician who can further investigate the cause of the delirium and continue treating it. Depending on the expected reason for the dementia, the demented patient should be referred to the appropriate specialist.

FUNCTIONAL DISORDERS

Patients with functional disorders, for which no physiologic or anatomic cause can be identified, may be seen in EDs, outpatient facilities, and inpatient facilities. Initial treatment of a patient who is experiencing agitation, disorientation, confusion, severe withdrawal, suicidal or homicidal behavior, or other potentially life-threatening behaviors should be immediate and effective to avoid harm to the patient or others. If a facility is unable to appropriately intervene, it is imperative to direct or transfer the agitated person to the closest available facility that is able to manage the problem.

Those with functional illnesses also may require medication to calm them, particularly patients with a history of psychiatric illnesses for which they may or may not be receiving treatment [63]. If a patient is currently receiving treatment for a psychiatric condition, assessment should address medication compliance. Re-establishing the medication may result in recovery of behavioral control and resolve the emergency.

Patients with certain personality disorders who may show agitation, including those with borderline, narcissistic, and antisocial personality disorders, may present in the ED. However, these patients are often taken to the ED by family, friends, or law enforcement rather than presenting for voluntary treatment. Medications can be used to address the symptoms of agitation [63].

HOMICIDAL PATIENTS

Homicidal patients represent a different and unique challenge. As with any psychiatric patient, the professional staff should determine if imminent danger is present. Individuals with antisocial personality disorders are a special case as their behavior is, by definition, criminal. Children diagnosed with conduct disorder manifest assaultive or homicidal behavior and can be as dangerous as adults. Any patient believed to be a danger to others should be isolated and, if necessary, sedated and/or restrained. Discharge planning may include involuntary hospitalization. Law enforcement personnel may also be involved if a victim is identified.

MANAGING INTENSE EMOTIONS

There are effective, nonpharmacologic methods that can be used in the ED to help establish trust and calm patients experiencing a psychologic emergency. Although interactions in the ED can be a frightening and agitating experience for all parties, it is critical that staff remain aware of their own mood, attitude, and emotions at each interaction and keep them in control. The Substance Abuse and Mental Health Services Administration offers the following guide on managing intense emotions [77]:

- Communicate calmly; use the acronym SOLER.

- Sit squarely or stand using the L-stance (shoulder 90 degrees to the patient's shoulder)

- Open posture

- Lean forward

- Eye contact

- Relax

- Communicate warmth.

- Use a soft tone.

- Smile.

- Use open and welcoming gestures.

- Allow the patient to dictate the distance between you.

- Establish a relationship.

- Introduce yourself if he/she does not know you.

- Ask the patient what he/she would like to be called.

- Do not shorten a name or use a first name without permission.

- In some cultures, it is important to always address the patient as Mr. or Mrs.

- Use concrete questions to help the patient focus.

- Use closed-end questions.

- Explain why you are asking the question.

- Come to an agreement on something.

- Establish a point of agreement that will help solidify your relationship and gain their trust.

- Active listening will help you find a point of agreement.

- Speak to the patient with respect.

- Use words like "please" and "thank you."

- Do not make global statements about the patient's character.

- Lavish praise is not believable.

- Use positive language.

If the patient becomes agitated, he or she may:

- Challenge or question authority

- Answer the question calmly.

- Repeat your statement calmly.

- Refuse to follow directions

- Do not assert control; let the patient gain control of self.

- Remain professional.

- Restructure your request in another way.

- Give the patient time to think about your request.

- Lose control and become verbally agitated

- Reply calmly.

- State that you may need assistance to help them.

- Become threatening

- If the patient becomes threatening or intimidating and does not respond to your attempts to calm them, seek immediate assistance.

10. APPROPRIATE DISCHARGE PLANNING

In a large group practice or ED, it is beneficial to have an on-call mental health professional available to advise regarding psychiatric emergencies, mental health referrals, and discharge planning. This is more easily found in urban areas with psychiatric residency programs, where on-call duty is built into the training program. Facilities without available psychiatric residency programs should arrange a practical on-call procedure with local mental health professionals. The extent to which state law and hospital rules allow mental health professionals who are not physicians to provide emergency on-call mental health services affects the availability of these services in hospital settings.

The discharge of patients seen in EDs and other facilities should include the consideration of hospitalization or outpatient treatment after the patient is stabilized. Hospitalization is necessary for patients exhibiting imminent danger to themselves or others. Inpatient treatment for other patients may be provided on a voluntary basis. Patients who do not acquiesce will be discharged home.

The goal of the professional staff is to stabilize the patient and refer to someone for follow-up treatment. A decision about the most appropriate and effective way of treating psychiatric patients should be made on an individual basis.

As discussed, each state or commonwealth has its own laws pertaining to involuntary hospitalization. Healthcare professionals working with and around psychiatric patients should know the applicable laws or have quick access to that information. Usually, the signatory officer for an order of involuntary hospitalization is a physician or clinical psychologist. The signatory officer should interview the patient and, exercising professional opinion, determine that imminent danger is present and hospitalization is necessary to protect the patient from self-harm. Some states or commonwealths require two signatures. One signature initiates the order to hospitalize the patient, and the other is from the physician at the receiving hospital. Of course, both must agree that imminent danger is present.

Inpatient treatment can be quite beneficial for patients who are starting a new medication or require close observation to monitor efficacy and adherence to treatments. Those who do not respond to medication may need inpatient treatment to determine the best combination of drugs and dosages, particularly if they cannot function effectively on an outpatient basis. Patients who are withdrawn because of the psychiatric condition may be hospitalized to provide more intense treatment, including involvement with other people. When the inpatient is able to function, he or she can be discharged for outpatient follow-up treatment.

Suicidal patients will usually require close supervision after discharge. It may not be possible for family and friends to meet that demand. Therefore, these patients will likely need inpatient treatment to establish better control over their thinking and behavior before returning home. When a patient does return home, responsible adults should be present to supervise activities of daily living, manage the correct usage of all medications, and ensure safety from wandering away or engaging in other activities that might be potentially dangerous. The degree of cognitive impairment helps determine the amount of danger present. Mild cognitive impairment may allow the patient to live with minimal supervision, while severe cognitive impairment will require close supervision.

11. OFFICE EMERGENCIES

Office emergencies can be challenging, as offices frequently do not have the range of resources present even in small EDs. Large group practices should establish procedures to protect professional and administrative staff from an agitated or acting-out patient. The procedures should also instruct the staff on how to protect others who may be present in the facility, especially those in the waiting room or offices.

Facilities with a speaker system can announce an emergency requiring assistance by using an innocuous message. The message should not frighten others or increase the agitation of the person who is causing the announcement. It should also provide the location by code where help is needed. Protection of the professional staff may include a hidden button that, when operated, notifies the administrative staff that help is needed and where the problem is occurring. The staff, especially front desk staff, should have a similar procedure to signal the need for help. A written policy should be reviewed and practiced by everyone on a regular basis to be certain that any emergency can be managed without having to refer back to the policy. The policy and procedures should include how and when to call for law enforcement.

Protecting staff and others from potentially dangerous patients involves physical means as well as warning systems. The administrative staff should be protected by separating their work area from the waiting room. Patients may make appointments or complete insurance claims without entering the separate administrative area. A locked door between the waiting room and the rest of the office may also provide some protection. Only authorized people should be able to open the door, providing another obstacle for patients who are agitated and acting out.

When in the therapy side of the office, a helpful, but more expensive, choice is a small quiet room. These are routinely found in inpatient psychiatric facilities but are less common in outpatient settings. The quiet room should be built similarly to those seen in hospital settings. When in this room, the patient should be protected from his or her own behavior. If any furniture is present, it should be soft. There should also be a way to monitor the person in the quiet room. Some facilities utilize video cameras with appropriately discreet monitors; others have a small window in the door to allow the responsible employee(s) to observe the patient without having to enter the room. Using a quiet room to help calm and control an agitated or acting-out patient helps protect the staff from being hurt but requires frequent monitoring to ensure that the patient is also safe.

Independent practices usually do not have the staff or other resources to implement strategies that may be found in large group practices. Nonetheless, independent practitioners should also plan for the possibility of a psychiatric emergency occurring in their office. Some independent practices have receptionists, at least on a part-time basis, and, in these settings, the communication between the professional and the receptionist is critical. Without violating any confidentiality rules, the receptionist should know any patient(s) whom the professional considers potentially dangerous. As with other types of practices, it is important to formulate plans and policies addressing how to specifically manage patients if agitated or acting-out behavior is observed. The most likely first step is to contact the psychologist or other provider. The professional should then decide how to best manage the situation. This, of course, will be affected by circumstances such as the presence or absence of others in the office, the location of the office, and its proximity to other businesses. The goal should be to protect innocent people from the behavior of a patient who presents a dangerous situation. At the very least, the office should be designed in such a way that there is a physical barrier between the waiting room and the administrative and therapy area(s).

Individual practices without an administrative staff or other professionals working in the office are at particular risk in the case of a psychiatric emergency. Again, a locked door that separates the therapy offices from the waiting room and a safe exit from the offices should be installed. Some may invest in a video camera system to monitor who enters the waiting room and what is occurring. Practitioners should decide how to best protect themselves and any patients with them if an emergency occurs.

Only medical professionals are able to administer medication to calm a patient; therefore, other methods are necessary in mental health practices. Every practice, whether group or independent, should determine the type of patients they are best able to treat and plan how to manage the emergencies that their patients may present. Even when patients who are likely to be dangerous are not included in the practice, staff members should be aware that emergencies may occur and it is their responsibility to manage them.

12. LEGAL ISSUES

A psychiatric emergency may raise legal issues, and legislation can affect the provision of care. The Tarasoff Rule, passed in 1985, influences how medical and mental health professionals are required to address violent or homicidal threats [64]. The rule was instigated by the case of a young man who told his psychologist, in the confidence of psychotherapy, that he was going to kill a young woman. The psychologist reported the threat to campus security. The young man was interviewed but not detained. He stopped seeing the psychologist and subsequently killed the young woman. The young woman's parents filed a lawsuit against the psychologist saying that he had not done enough to protect their daughter. The courts agreed that the psychologist's response was insufficient.

The Tarasoff Rule requires mental health professionals to: notify law enforcement when they become aware of a threat against someone else; inform the identified target; and provide both law enforcement and the target with the name of the threatening person. It has been recommended that professionals seek legal counsel regarding the requirements in specific states about notifying others of a patient's threat.

State and local laws may vary regarding notification of child abuse and elder abuse. Specific information about abuse should be sought from the jurisdiction in which the professional practices.

13. CONCLUSION

Emergency rooms were initially designed to treat acute medical conditions and stabilize patients before transfer to the appropriate treatment resource. In larger, urban areas, emergency rooms have evolved into EDs that provide more extensive services. Unfortunately, EDs have also become a place to seek treatment for many people who do not have a family physician. As a result, the number of emergency visits has increased, although the reasons for the visits often are not emergencies. Thus, nonemergent visits are causing a huge backlog of real emergency patients and increasing the amount of money spent on health care. Misuse of EDs also complicates the diagnosis and treatment of people with psychiatric emergencies. As the emergency staff becomes overwhelmed with demands, they are less capable of providing the necessary time and attention to understand the psychiatric problems that bring some patients to the EDs.

Psychiatric conditions are comprised of many symptoms. There is considerable overlap in the presence of particular symptoms in different psychiatric diagnoses. The effective and accurate diagnosis of psychiatric conditions requires assessment beyond the presence or absence of symptoms; it involves examining the psychosocial and biologic aspects of a patient's life as well. Common psychiatric emergencies carry many similar characteristics, including agitation, disorientation, confusion, fear, and acting out. These symptoms are experienced by patients with both organic mental disorders, such as delirium and dementia, and functional mental disorders, including intense anxiety, major depression, and certain personality disorders. Management of psychiatric emergencies, both organic and functional, may involve fast-acting sedative medication, physical restraint, careful diagnosis, and stabilizing treatment before discharge planning.

A psychiatric emergency can present a serious threat to the professional staff, administrative staff, patients, and others who are present during the emergency. It is important to calm psychiatric patients in order to protect them from harming themselves or others. Usually, the most effective way to calm the person is by using a fast-acting medication. It is also helpful to have a quiet and safe place for psychiatric patients to wait before receiving treatment. A thorough physical and mental examination is necessary to determine the most appropriate discharge plan. Discharge from the ED may lead either to inpatient treatment or outpatient follow-up. Discharge planning for facilities other than EDs should also consider the range of options from inpatient treatment to outpatient follow-up.

Whether it is an ED or another facility, policies and procedures should be in place to protect both the patient and staff in the case of a psychiatric emergency. Law enforcement is a valuable resource, as most mental health professionals have no training or expertise in physically managing people who are acting out. EDs, large group practices, and small independent practices should establish systems of warning others about a developing emergency.

Emergencies that involve the threat of imminent danger, such as suicide, homicide, and the inability to avoid common danger, can occur in well-staffed EDs as well as in an individual practitioner's office. A patient who is believed to be an imminent danger should be evaluated to determine the degree of risk. In the opinion of the professional evaluating the patient (e.g., physician, clinical psychologist), a decision should be made regarding the appropriateness of involuntary hospitalization. In addition, a patient who is believed to constitute a real threat to others forfeits confidentiality, and the professional has an obligation to inform both law enforcement and the identified victim(s) of the threat.

Although individual practices may not focus on people who are likely to experience an emergency, the potential is still present, and a plan is necessary to prevent harm to others when it occurs.

14. RESOURCES

American Foundation for Suicide Prevention

199 Water Street, 11th Floor

New York, NY 10038

(888) 333-2377

https://www.afsp.org

Provides extensive information about suicide prevention. Part of its mission is to address the impact of suicide on a survivor's life.

American Psychiatric Association

800 Maine Avenue SW, Suite 900

Washington, DC 20024

(202) 509-3900

https://www.psychiatry.org

Provides information about psychiatric practice, education, research, advocacy, and career development.

American Psychological Association

750 First Street NE

Washington, DC 20002

(800) 374-2721

https://www.apa.org

The professional and scientific organization for psychologists. Part of the website is for members only and part is open to consumers.

American Society of Addiction Medicine

11400 Rockville Pike, Suite 200

Rockville, MD 20852

(301) 656-3920

https://www.asam.org

Provides medical training and education for physicians and medical students on state of the art science in addiction medicine.

Association for Behavioral and Cognitive Therapies

305 7th Avenue, 16th Floor

New York, NY 10001

(212) 647-1890

http://www.abct.org

An interdisciplinary organization for those interested in behavioral and cognitive therapy.

National Association of Social Workers

750 First Street NE, Suite 800

Washington, DC 20002

(202) 408-8600

https://www.socialworkers.org

The professional organization for social workers.

National Association of State Mental Health Program Directors

66 Canal Center Plaza, Suite 302

Alexandria, VA 22314

(703) 739-9333

http://www.nasmhpd.org

Provides names and email addresses for state mental health program directors, from state agencies to directors of specific hospitals or programs. It also provides current information on important mental health laws in each state or commonwealth.

National Empowerment Center

(800) 769-3728

https://www.power2u.org

Offers support to individuals with mental illness.

National Institute of Mental Health

6001 Executive Boulevard

Room 6200, MSC 9663

Bethesda, MD 20892

(866) 615-6464

https://www.nimh.nih.gov

A government website with a variety of resources pertaining to mental health issues, policy and research topics, and funding opportunities.

National Institute on Alcohol Abuse and Alcoholism

(301) 443-3860

https://www.niaaa.nih.gov

Provides information and publications pertaining to alcohol use and abuse. Sources for grant funding are included.

National Institute on Drug Abuse

6001 Executive Boulevard

Room 5213, MSC 9561

Bethesda, MD 20892

(301) 443-1124

https://www.drugabuse.gov

A government website with a wide range of topics pertaining to drug abuse and treatment of addiction. Sections are provided for professionals, researchers, and consumers.

Substance Abuse and Mental Health Services Administration

5600 Fishers Lane

Rockville, MD 20857

(877) 726-4727

https://www.samhsa.gov

Government resource providing information about substance abuse and mental illness information for a wide range of ages and circumstances.

Training Institute for Suicide Assessment and Clinical Interviewing

https://www.suicideassessment.com

Provides training to all professionals who may assess or treat suicidal patients. This website is not for people who are suicidal and seeking help.

U.S. Drug Enforcement Administration

8701 Morrissette Drive

Springfield, VA 22152

(202) 307-1000

https://www.dea.gov

Government agency that provides valuable information about prescription and illegal drugs and law enforcement efforts to interdict illegal drug use.

U.S. National Library of Medicine

8600 Rockville Pike

Bethesda, MD 20894

(301) 594-5983

https://www.nlm.nih.gov

A vast source of publications in medicine, psychology, and education.

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48. Edelsohn GA. Urgency counts: the why behind pediatric psychiatric emergency visits. Clin Ped Emerg Med. 2004;5(3):146-153.

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50. Pittsenbarger ZE, Mannix R. Trends in pediatric visits to the emergency department for psychiatric illnesses. Acad Emerg Med. 2014;21(1):25-30.

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52. Thompson EA, Mazza JJ, Herting JR, Randell BP, Eggert LL. The mediating roles of anxiety depression, and hopelessness on adolescent suicidal behaviors. Suicide Life Threat Behav. 2005;35(1):14-34.

53. Vermeiren R, Schwab-Stone M, Ruchkin VV, King RA, Van Heeringen C, Deboutte D. Suicidal behavior and violence in male adolescents: a school-based study. J Am Acad Child Adolesc Psychiatry. 2003;42(1):41-48.

54. Kann L, McManus T, Harris WA, et al. Youth risk behavior surveillance—United States, 2017. MMWR. 2018;67(8):1-114.

55. Gould MS, Greenberg T, Velting DM, Shaffer D. Youth suicide risk and preventive interventions: a review of the past 10 years. J Am Acad Child Adolesc Psychiatry. 2003;42(4):386-405.

56. Van Os J, Kapur S. Schizophrenia. Lancet. 2009;374(9690):635-645.

57. Husebo BS, Ballard C, Cohen-Mansfield J, Seifert R, Aarsland D. The response of agitated behavior to pain management in persons with dementia. Am J Geriatr Psychiatry. 2014;22(7):708-717.

58. MedlinePlus. Agitation. Available at https://medlineplus.gov/ency/article/003212.htm. Last accessed January 30, 2020.

59. Rund DA, Ewing JD, Mitzel K, Votolato N. The use of intramuscular benzodiazepines and antipsychotic agents in the treatment of acute agitation or violence in the emergency department. J Emerg Med. 2006;31(3):317-324.

60. National Institute for Health and Care Excellence. Self-Harm in Over 8s: Short-Term Management and Prevention of Recurrence. Available at https://www.nice.org.uk/guidance/cg16/chapter/1-Guidance. Last accessed January 30, 2020.

61. Physicians' Desk Reference. PDR Drug Guide for Mental Health Professionals. 3rd ed. New York, NY: Thomson Reuters; 2007.

62. American Psychiatric Association. Practice Guideline for the Treatment of Patients with Major Depressive Disorder. 3rd ed. Arlington, VA: American Psychiatric Association; 2010.

63. Mayo Clinic. Personality Disorders. Available at https://www.mayoclinic.org/diseases-conditions/personality-disorders/symptoms-causes/syc-20354463. Last accessed February 3, 2020.

64. Tarasoff v Regents of Univ of Calif. 551 P.2d 334 (Cal 1976).

65. Kroll DS, Smallwood J, Chang G. Drug screens for psychiatric patients in the emergency department: evaluation and recommendations. Psychosomatics. 2013;54(1):60-66.

66. Yang M, Wong SC, Coid J. The efficacy of violence prediction: a meta-analytic comparison of nine risk assessment tools. Psychol Bull. 2010;136(5):740-767.

67. Dolan MA, Fein JA, Committee on Pediatric Emergency Medicine. Pediatric and adolescent mental health emergencies in the emergency medical services system. Pediatrics. 2011;127(5):e1356-1366.

68. Emergency Nurses Association. Clinical Practice Guideline: Suicide Risk Assessment. Available at https://www.ena.org/docs/default-source/resource-library/practice-resources/cpg/cpgsuicide.pdf?sfvrsn=409a64fe_14. Last accessed February 3, 2020.

69. Allen MH, Abar BW, McCormick M, et al. Screening for suicidal ideation and attempts among emergency department medical patients: instrument and results from the Psychiatric Emergency Research Collaboration. Suicide Life Threat Behav. 2013;43(3):313-323.

70. Suicide Prevention Resource Center. Continuity of Care for Suicide Prevention: The Role of Emergency Departments. Available at http://www.sprc.org/sites/sprc.org/files/library/ContinuityCare_Suicide_Prevention_ED.pdf. Last accessed February 3, 2020.

71. Knesper DJ, American Association of Suicidology, Suicide Prevention Resource Center. Continuity of Care for Suicide Prevention and Research: Suicide Attempts and Suicide Deaths Subsequent to Discharge from the Emergency Department or Psychiatry Inpatient Unit. Newton, MA: Education Development Center, Inc.; 2010.

72. Nordstrom K, Zun LS, Wilson MP, et al. Medical evaluation and triage of the agitated patient: consensus statement of the American Association for Emergency Psychiatry Project Beta Medical Evaluation Workgroup. West J Emerg Med. 2012;13(1): 3-10.

73. U.S. Food and Drug Administration. Valproate Anti-Seizure Products Contraindicated for Migraine Prevention in Pregnant Women Due to Decreased IQ Scores in Exposed Children. Available at https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-valproate-anti-seizure-products-contraindicated-migraine-prevention. Last accessed January 30, 2020.

74. Patient information Publications (PiP). Delirium. Available at https://patient.info/doctor/delirium-pro. Last accessed January 30, 2020.

75. Reuters. Who's Packing ERs? Not the Uninsured. Available at https://www.reuters.com/article/us-usa-health-emergencies/whos-packing-ers-not-the-uninsured-idUSTRE64I78X20100520. Last accessed January 15, 2020.

76. Centers for Disease Control and Prevention. Health, United States 2015. Available at https://www.cdc.gov/nchs/data/hus/hus15.pdf. Last accessed January 15, 2020.

77. Substance Abuse and Mental Health Services Administration. Psychological First Aid for First Responders. Available at https://www.acep.org/globalassets/sites/acep/media/crowding/empc_crowding-ip_092016.pdf. Last accessed February 3, 2020.

78. Brown HE, Stoklosa J, Freudenreich O. How to stabilize an acutely psychotic patient. Curr Psych. 2012;11(12):10-16.

79. Wiler JL, Brown A, Chanmugam AS, et al. Care of the Psychiatric Patient in the Emergency Department: A Review of the Literature. Available at https://www.acep.org/globalassets/uploads/uploaded-files/acep/clinical-and-practice-management/resources/mental-health-and-substance-abuse/psychiatric-patient-care-in-the-ed-2014.pdf. Last accessed January 15, 2020.

80. Stewart JG, Esposito EC, Glenn CR, et al. Adolescent self-injurers: comparing non-ideators, suicide ideators, and suicide attempters. J Psychiatr Res. 2017;84:105-112.

81. Heron M. Deaths: leading causes for 2017. Natl Vital Stat Rep. 2019;68(6):1-77.

82. Horowitz LM, Bridge JA, Teach SJ, et al. Ask Suicide-Screening Questions (ASQ): a brief instrument for the pediatric emergency department. Arch Pediatr Adolesc Med. 2012;166(12):1170-1176.

83. Betz ME, Arias SA, Segal DL, Miller I, Camargo CA Jr, Boudreaux ED. Screening for suicidal thoughts and behaviors in older adults in the emergency department. J Am Geriatr Soc. 2016;64(10):e72-e77.

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87. Hoffmann JA, Stack AM, Samnaliev M, Monuteaux MC, Lee LK. Trends in visits and costs for mental-health emergencies in a pediatric emergency department, 2010–2016. Acad Pediatr. 2019;19(4):386-393.

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Evidence-Based Practice Recommendations Citations

1. American Psychiatric Association. Practice Guidelines for the Psychiatric Evaluation of Adults. 3rd ed. Arlington, VA: American Psychiatric Association; 2015. Available at https://psychiatryonline.org/doi/pdf/10.1176/appi.books.9780890426760. Last accessed February 17, 2020.

2. Assessment and Management of Risk for Suicide Working Group. VA/DoD Clinical Practice Guideline for Assessment and Management of Patients at Risk for Suicide. Washington, DC: Department of Veterans Affairs, Department of Defense; 2019. Available at https://www.healthquality.va.gov/guidelines/MH/srb/VADoDSuicideRiskFullCPGFinal5088212019.pdf. Last accessed February 17, 2020.

3. National Collaborating Centre for Mental Health. Violence and Aggression: Short-Term Management in Mental Health, Health and Community Settings. London: National Institute for Health and Care Excellence; 2015. Available at https://www.nice.org.uk/guidance/ng10. Last accessed February 17, 2020.

4. American Psychiatric Association. The American Psychiatric Association Practice Guideline on the Use of Antipsychotics to Treat Agitation or Psychosis in Patients with Dementia. Arlington, VA: American Psychiatric Association; 2016. Available at https://psychiatryonline.org/doi/pdf/10.1176/appi.books.9780890426807. Last accessed February 17, 2020.

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

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77790 • Domestic and Sexual Violence

Alice Yick Flanagan, PhD, MSW

John M. Leonard, MD

www.netce.com

Copyright © 2019 NetCE, All rights reserved.

Victims of domestic and sexual violence suffer emotional, psychologic, and physical abuse, all of which can result in both acute and chronic signs and symptoms of physical and mental disease, illness, and injury. Frequently, the injuries sustained require abused victims to seek care from healthcare professionals immediately after their victimization. Subsequently, physicians and nurses are often the first healthcare providers that victims encounter and are in a critical position to identify victims in a variety of clinical practice settings where victims receive care. Accordingly, each healthcare professional should educate himself or herself to enhance awareness of the presence of abuse victims in his or her particular practice or clinical setting.

Table of Contents

77790 • Domestic and Sexual Violence

Course Overview

Audience

Course Objective

Learning Objectives

Faculty

Faculty Disclosure

Division Planner

Division Planner Disclosure

About the Sponsor

Disclosure Statement

1. INTRODUCTION

2. AN OVERVIEW OF THE ISSUE

DEFINING DOMESTIC VIOLENCE

DEFINING SEXUAL VIOLENCE

CONTRACEPTIVE COERCION

3. SIGNS OF ABUSE/VICTIMIZATION

DOMESTIC VIOLENCE

SEXUAL VIOLENCE

4. HEALTH EFFECTS AND IMPLICATIONS OF DOMESTIC VIOLENCE

5. HEALTH EFFECTS AND IMPLICATIONS OF SEXUAL VIOLENCE

NON-GENITAL BODILY INJURY

GENITAL INJURY

LONG-TERM PSYCHOSOCIAL IMPACT

SEXUALLY TRANSMITTED INFECTION

6. IMPLICATIONS ON PREGNANCY AND PRENATAL CARE

7. HEALTH EFFECTS AND IMPLICATIONS OF CHILDREN EXPOSED TO DOMESTIC VIOLENCE

8. DOMESTIC VIOLENCE AND SEXUAL VIOLENCE IN SPECIAL POPULATIONS

ELDERLY

LESBIAN, GAY, BISEXUAL, AND TRANSGENDER VICTIMS

HOMELESS INDIVIDUALS

PEOPLE WITH PHYSICAL AND/OR COGNITIVE DISABILITIES

PEOPLE WITH BEHAVIORAL HEALTH PROBLEMS

CHILDREN AND ADOLESCENTS

LOW-INCOME POPULATIONS

PEOPLE LIVING IN RURAL COMMUNITIES

IMMIGRANTS AND REFUGEES

PEOPLE OF COLOR

9. PERPETRATORS OF DOMESTIC/SEXUAL VIOLENCE

10. ASSESSMENT AND SCREENING METHODS

SCREENING

ASSESSMENT

11. BEST PRACTICES IN FOLLOW-UP CARE FOR VICTIMS OF VIOLENCE

12. BUILDING EFFECTIVE COMMUNITY PARTNERSHIPS AND COLLABORATIONS WITH COMMUNITY-BASED AGENCIES

13. APPROPRIATE RESPONSES AND DOCUMENTATION

LEGAL INTERVENTIONS

CASE MANAGEMENT

SHELTERS

14. RESOURCES

Works Cited

Evidence-Based Practice Recommendations Citations

77790 • Domestic and Sexual Violence

Education Category. Ethics - Human Rights

Release Date. 06/01/2019

Expiration Date. 05/31/2022

Course Overview

Victims of domestic and sexual violence suffer emotional, psychologic, and physical abuse, all of which can result in both acute and chronic signs and symptoms of physical and mental disease, illness, and injury. Frequently, the injuries sustained require abused victims to seek care from healthcare professionals immediately after their victimization. Subsequently, physicians and nurses are often the first healthcare providers that victims encounter and are in a critical position to identify victims in a variety of clinical practice settings where victims receive care. Accordingly, each healthcare professional should educate himself or herself to enhance awareness of the presence of abuse victims in his or her particular practice or clinical setting.

Audience

This course is designed for a wide range of behavioral and mental health professionals, including social workers, mental health counselors, and marriage and family therapists.

Course Objective

The purpose of this course is to provide professionals with the skills and confidence necessary to identify victims of sexual or domestic violence and to intervene appropriately and effectively.

Learning Objectives

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

1. Identify common types of domestic and sexual violence.

2. Outline signs of abuse or victimization.

3. Describe the health effects and implications of domestic violence and/or sexual assault, including effects on pregnancy, developing fetuses, and child witnesses.

4. Evaluate the unique risk factors for and consequences of domestic and sexual violence in special populations.

5. Discuss traits of perpetrators of domestic and/or sexual violence.

6. Analyze screening and assessment methods to identify victims of abuse.

7. Describe appropriate responses to domestic and sexual violence, including best practices for follow-up care.

Faculty

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

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

John M. Leonard, MD, Professor of Medicine Emeritus, Vanderbilt University School of Medicine, completed his post-graduate clinical training at the Yale and Vanderbilt University Medical Centers before joining the Vanderbilt faculty in 1974. He is a clinician-educator and for many years served as director of residency training and student educational programs for the Vanderbilt University Department of Medicine. Over a career span of 40 years, Dr. Leonard conducted an active practice of general internal medicine and an inpatient consulting practice of infectious diseases.

Faculty Disclosure

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

Contributing faculty, John M. Leonard, MD, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Division Planner

James Trent, PhD

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

Domestic violence continues to be a prevalent problem in the United States today. Because of the number of individuals affected, it is likely that most healthcare professionals will encounter patients in their practice who are victims. Accordingly, it is essential that healthcare professionals are taught to recognize and accurately interpret behaviors associated with domestic violence. It is incumbent upon the healthcare professional to establish and implement protocols for early identification of domestic violence victims and their abusers. In order to prevent domestic violence and promote the well-being of their patients, healthcare professionals in all settings should take the initiative to properly assess all women for abuse during each visit and, for those women who are or may be victims, to offer education, counseling, and referral information.

Victims of domestic violence suffer emotional, psychologic, and physical abuse, all of which can result in both acute and chronic signs and symptoms of physical and mental disease, illness, and injury. Frequently, the injuries sustained require abused victims to seek care from healthcare professionals immediately after their victimization. Subsequently, physicians and nurses are often the first healthcare providers that victims encounter and are in a critical position to identify domestic violence victims in a variety of clinical practice settings where victims receive care. Accordingly, each healthcare professional should educate himself or herself to enhance awareness of the presence of abuse victims in his or her particular practice or clinical setting.

Specifically, healthcare professionals should be aware of the signs and symptoms associated with domestic violence. In addition, when family violence cases are identified, there should be a plan of action that includes providing information on, and referral to, local community resources related to legal aid, sheltering, victim counseling, batterer counseling, advocacy groups, and child protection.

2. AN OVERVIEW OF THE ISSUE

DEFINING DOMESTIC VIOLENCE

Domestic violence, termed spousal abuse, battering, or intimate partner violence (IPV), refers to the victimization of an individual with whom the abuser has or has had an intimate or romantic relationship. The Centers for Disease Control and Prevention (CDC) defines IPV as, "physical violence, sexual violence, stalking, and psychologic aggression (including coercive tactics) by a current or former intimate partner (i.e., spouse, boyfriend/girlfriend, dating partner, or ongoing sexual partner)" [1].

Domestic violence can consist of any of many behaviors or combination of behaviors, falling under physical, psychologic, verbal, sexual, and financial/economic abuse (Table 1).

Table 1: DOMESTIC VIOLENCE BEHAVIORS

Physical Abuse

Psychologic/Verbal Abuse

Sexual Abuse

Financial/Economic Abuse

Kicking, punching, biting, slapping, strangling, choking, abandoning in unsafe places, burning with cigarettes, throwing acid, throwing objects, refusing to help when sick, stabbing, shooting

Intimidation, humiliation, put-downs, ridiculing, control of victim's movement, stalking, threats, threatening to hurt victim's family and children, social isolation, ignoring needs or complaints

Rape, forms of sexual assault (such as forced masturbation, fellatio, or oral coitus), sexual humiliation, perpetrator refuses to use contraceptives, coerced abortion

Withholding of money, refuse to allow victim to open bank account, all property is in the perpetrator's name, victim is not allowed to work

Source: Compiled by Author

It is important for healthcare professionals to understand that domestic violence, in the form of emotional and psychologic abuse and physical violence, is prevalent in society. Unfortunately, domestic violence and abuse has become a fact of life for many Americans. This course will use the terms "domestic violence" and "IPV" interchangeably.

DEFINING SEXUAL VIOLENCE

According to the Massachusetts Coalition Against Sexual Assault and Domestic Violence, sexual violence is defined as "a multi-layered oppression that occurs at the societal and individual level and is connected to and influenced by other forms of oppression, in particular, sexism, racism, and heterosexism…On an individual level, sexual violence is a wide range of sexual acts and behaviors that are unwanted, coerced, committed without consent, or forced either by physical means or through threats" [2].

Whether out of impulse, compulsion, anger, or the assertion of power, sexual assault is a criminal act of violence imposed on the vulnerable and the innocent, causing immediate physical and emotional suffering and often having long-lasting adverse psychologic effects. Rape is the legal term for a sexual assault during which there is penetration of a body orifice (vagina, anus, or mouth) involving force, the threat of force, or incapacity and nonconsent of the victim.

It is important to consider that there is a wide range of sexual violence that can manifest in many different ways. For example, reproductive coercion (e.g., forced abortion, forced pregnancy) is considered a form of sexual violence [2].

CONTRACEPTIVE COERCION

Control of reproductive or sexual health is also a recognized trend in IPV. This type of abuse includes trying to impregnate or become pregnant against a partner's wishes, refusal to use birth control (e.g., condoms, oral contraceptives), preventing or forcing abortion, or stopping a partner from using birth control [3]. Research indicates that this form of violence is relatively common. A study of young women (16 to 29 years of age) presenting to family planning clinics in California found that 53% of respondents reported physical or sexual partner violence, 19% reported experiencing pregnancy coercion, and 15% reported birth control sabotage [4]. Of those who reported being victims of partner violence, 35% reported reproductive control. Studies suggest that reproductive control and unintended pregnancy may disproportionately affect women of color [5].

According to the American College of Obstetricians and Gynecologists (ACOG), interventions that focused on awareness of reproductive and sexual coercion and provided harm-reduction strategies reduced pregnancy coercion by 71% among women who experienced IPV [6]. The ACOG recommends the following screening questions:

- Has your partner ever forced you to do something sexually that you did not want to do or refused your request to use condoms?

- Has your partner ever tried to get you pregnant when you did not want to be pregnant?

- Are you worried your partner will hurt you if you do not do what he wants with the pregnancy?

- Does your partner support your decision about when or if you want to become pregnant?

Interventions targeted to protect victims of contraceptive coercion include helping conceal contraceptives, placement of an intrauterine device or other implanted birth control, and appropriate referrals [6].

3. SIGNS OF ABUSE/VICTIMIZATION

DOMESTIC VIOLENCE

It is imperative that healthcare professionals work together to establish specific guidelines that will facilitate identification of batterers and their victims. In a 2016 study of 288 healthcare facilities in Florida, 78% understood the importance of IPV screening and had some type of IPV screening policy institute in their setting [7]. However, many of the respondents did not know which screening tool was used or the types of screening questions asked. These guidelines should review appropriate interview techniques and should also include the utilization of screening tools, such as intake questionnaires. The following is a review of certain signs and symptoms that may indicate the presence of abuse. Although victims of domestic violence do not display typical signs and symptoms when they present to healthcare providers, there are certain cues that may be attributable to abuse. The obvious cues are the physical ones. Injuries range from bruises, cuts, black eyes, concussions, broken bones, and miscarriages to permanent injuries such as damage to joints, partial loss of hearing or vision, and scars from burns, bites, or knife wounds. In addition to physical signs and symptoms, domestic violence victims also exhibit psychologic cues that resemble an agitated depression.

Unfortunately, healthcare professionals may respond to these women by diagnosing the patient to be neurotic or irrational [8]. Healthcare professionals should cast aside these misperceptions of abused victims and work within their respective practice settings to develop screening mechanisms to detect women who exhibit these symptoms. In addition, it is important to recognize that vulnerable populations, including lesbian, gay, bisexual, transgender, and other gender/sexual minority (LGBT+) individuals, those with HIV, individuals with disabilities, and veterans are also at risk and should be screened for IPV [9].

SEXUAL VIOLENCE

Although most cases of sexual violence are accompanied by physical force and/or active resistance, visible injuries are rare. Possible signs of sexual violence victimization include [10]:

- Unwanted touching

- Rape (i.e., actual or attempted unwanted vaginal, oral, or anal penetration by an object or body part)

- Being forced or manipulated into doing unwanted, painful, or degrading acts during intercourse

- Being taken advantage of while one is drunk or otherwise not likely to give consent

- Being denied contraception or protection against sexually transmitted infections

- Taking any kind of sexual pictures or film without consent

- Being forced to perform sexual acts on film or in person for money

- Threatening break up when sex is refused

4. HEALTH EFFECTS AND IMPLICATIONS OF DOMESTIC VIOLENCE

As is clear, victims of domestic violence experience a wide range of physical and psychologic injuries. Typical injury patterns include contusions or minor lacerations to the head, face, neck, breast, or abdomen. These are often distinguishable from accidental injuries, which are more likely to involve the periphery of the body. In one hospital-based study, domestic violence victims were 13 times more likely to sustain injury to breast, chest, or abdomen than accident victims. Abuse victims are also more likely to have multiple injuries than accident victims. When this pattern of injuries is seen in a patient, particularly in combination with evidence of old injury, physical abuse should be suspected [11].

As a result of prolonged stress, victims often manifest various psychosomatic symptoms that generally lack an organic basis. For example, they may complain of backaches, headaches/migraines, and gastrointestinal problems. Often, they will complain of chronic pain, fatigue, restlessness, insomnia, or loss of appetite. Great amounts of anxiety, guilt, and depression or dysphoria are also typical [11,12]. In many women, this constellation of symptoms has been labeled "battered women's syndrome."

The long-term health implications should also be considered. In a study conducted by MORE magazine and the Verizon Foundation, 88% of women who have experienced sexual abuse and 81% of women who have experienced any form of domestic violence report having chronic health conditions (compared with 62% among women who experienced no domestic violence) [13]. In this study, the most common chronic health conditions among victims were low back pain (35%), headaches (32%), difficulty sleeping (30%), and depression/anxiety (30%). Victims of violence were also found to have increased incidences of diabetes, cervical pain, gastroesophageal reflux disease, irritable bowel syndrome, and post-traumatic stress disorder.

5. HEALTH EFFECTS AND IMPLICATIONS OF SEXUAL VIOLENCE

Research indicates that victims of sexual violence experience a range of acute and long-term physical and psychologic injuries as a result of the violence [14].

NON-GENITAL BODILY INJURY

Non-genital bodily injury is seen in more than half of all rape victims presenting to emergency departments [15,16]. In one study of 162 women examined between 2002 and 2006, signs of bodily injury were found in 61% of patients, with genital injury present in 39% [17]. Most common were bruises (56%) and abrasions (41%), followed by lacerations, penetrating injury, and bites. Evidence of injury was higher in the 137 cases examined within 72 hours of assault (66% vs. 33%) and in cases in which the assaults occurred outdoors (79% vs. 52%).

On examination, one should inspect carefully for evidence of blunt traumatic injury to the head, neck, arms, legs, and torso, looking for signs of penetrating injury, lacerations, and bite marks. Bruising may be evident on the neck (attempted strangulation), hands, arms, breasts, or thighs. Signs of bodily injury are more prevalent in women younger than 30 years of age. Other factors showing a strong positive association with bodily injury include alcohol consumption, history of prior assault, and assault by strangers [15].

GENITAL INJURY

Signs of genital traumatic injury are not always found after sexual assault, and in such cases should not be taken as evidence that sexual assault did not occur [17]. When routine inspection is combined with additional examination techniques, such as colposcopy and toluidine blue staining, the rate for identifying genital injury approaches 70% [18]. Observed rates of genital injury are highest in women examined within 72 hours (40% vs. 7%), in those of virginal state (60% vs. 33%), and in cases involving assault by strangers or multiple assailants [19].

The common types and location of genital injuries, and thus the areas to be examined most closely, are:

- Bruises and abrasions to the labia, fossa navicularis, or perianal area

- Ecchymoses, tears, or lacerations of the hymen

- Abrasions and/or tears of the posterior fourchette

- Tears/lacerations in the perianal area

LONG-TERM PSYCHOSOCIAL IMPACT

The impact of sexual assault leads to immediate and long-term physical and mental health consequences. In addition to the potential risk for acquiring a sexually transmitted disease (STD), approximately 1% to 5% of rape victims become pregnant [20]. The National Violence Against Women Survey (NVAWS) found that 33% of women and 24% of men received counseling from a mental health professional as a direct result of their last assault; 28% and 10%, respectively, lost time from work [21]. Survivors of sexual assault are also at increased risk for re-victimization and experience higher rates of depression, post-traumatic stress disorder, substance abuse, and suicide.

In the aftermath of sexual assault, a variety of chronic somatic, cognitive, and emotional sequelae have been observed in sexual assault victims (Table 2). The individual's response and subsequent ability to cope with the trauma of the assault are influenced by a number of related factors. These include the nature and severity of the assault itself, age of the victim, relationship between the victim and assailant, prior history of abuse, and the person's own ambient life stress and coping mechanisms. For some, the impact of a sexual assault experience is severe and long-lasting, often resulting in difficulty with interpersonal relationships and tasks of daily living, sexual dysfunction, loss of work-time, and increased utilization of healthcare resources [22,23,24].

Table 2: LONG-TERM PHYSICAL AND EMOTIONAL IMPACT OF SEXUAL ASSAULT

Chronic Somatic Disorders

Psychosocial Disorders

Pelvic pain, dyspareunia

Functional gastrointestinal disorder

Fibromyalgia

Multisystem physical complaints

Headaches

Abdominal pains

Anxiety, depression, phobias

Post-traumatic stress disorder

Sexual dysfunction

Sleep disturbance

Anorexia

Work absenteeism

Source: [22,23,24,25,26,27]

A meta-analysis of clinical studies published between 1980 and 2002 revealed a significant association between prior sexual assault and the lifetime diagnosis of fibromyalgia, chronic pelvic pain, and functional gastrointestinal disorders [25]. In a cross-sectional, randomly selected study of 219 women followed in a Veterans Administration (VA) primary care clinic, a history of prior sexual assault was found to be associated with a significant increase in somatization scores, multisystem physical complaints, anxiety, work absenteeism, and health care utilization [26]. Among another cohort of women receiving VA medical and mental health care, the prevalence of post-traumatic stress disorder was found to be seven to nine times higher in women who had experienced a prior sexual assault, compared with those having no assault history [27].

To summarize, the priorities of acute care counseling are to provide emotional support, assure a plan for patient safety, and assess coping skills and strength of support system post-discharge. When possible, arrangements should be made for ongoing counseling through sexual assault crisis programs. In anticipation of the long-term adverse effects of sexual assault, arrangements should be made for primary care follow-up and patients and families should be offered information and access to mental health services.

SEXUALLY TRANSMITTED INFECTION

The infections commonly reported in women after sexual assault are Chlamydia, gonorrhea, trichomoniasis, bacterial vaginitis, and pelvic inflammatory disease (PID) [28]. The possible exposure to hepatitis B virus and human immunodeficiency virus (HIV) is also an important consideration. In general, the risk of infection is relatively low; published estimates are 3% to 16% for chlamydia, 7% for trichomoniasis, and 11% for PID [29]. The risk, however, does vary directly with the degree of genital trauma, associated bleeding (sustained by the victim or assailant), and the number of assailants. The CDC has published guidelines for the assessment, counseling, and preventive treatment of infection following sexual assault, including common pelvic infections, hepatitis B, human papillomavirus (HPV), and HIV [28].

Follow-up within one to two weeks after the initial evaluation provides the opportunity to review previous test results, complete an assessment for STDs, and ensure safety and adherence to prescribed medication. CDC guidelines advise that a follow-up examination at one to two months should be considered to re-evaluate for development of anogenital warts, especially in patients who received a diagnosis of other STDs following the assault. If initial tests were negative and infection in the assailant could not be ruled out, serologic tests for syphilis can be repeated at four to six weeks and three months. To exclude acquisition of HIV, tests for acute infection should be repeated at six weeks, three months, and six months after the assault [28].

6. IMPLICATIONS ON PREGNANCY AND PRENATAL CARE

Because a gynecologist or obstetrician is frequently a woman's primary care physician, these healthcare providers should be particularly sensitive to domestic violence issues [30]. According to the CDC, IPV affects as many as 324,000 pregnant women each year [31]. This represents approximately 8% of all pregnant women in the United States. As with all domestic violence statistics, this number is presumed to be lower than the actual incidence as a result of under-reporting and lack of data on women whose pregnancies ended in fetal or maternal death. This makes IPV more prevalent among pregnant women than some of the health conditions included in prenatal screenings, including pre-eclampsia and gestational diabetes [31]. Because 96% of pregnant women receive prenatal care, this is an optimal time to screen for domestic violence and develop trusting relationships with the women. Possible factors that may predispose pregnant women to IPV include young maternal age, unintended pregnancy, delayed prenatal care, lack of social support, and use of tobacco, alcohol, or illegal drugs [31,32].

The overarching problem of violence against women cannot be ignored, especially as both mother and unborn child are at risk. One study found that pregnant women who had been treated at a hospital after a violent incident had an eight-fold increased risk of fetal death [33]. At this particularly vulnerable time in a woman's life, an organized clinical construct leading to immediate diagnosis and medical intervention will ensure that therapeutic opportunities are available to the pregnant woman and will reduce the potential negative outcomes [11,34]. Healthcare professionals should also be aware of the possible psychologic consequences of abuse during pregnancy. There is a higher risk of stress, depression, and addiction to alcohol and drugs in abused women, and victims are less likely to obtain prenatal care and to develop postpartum depression [33,35,36].

Low birth weight can result from either preterm birth or growth restriction in utero, both of which can be directly linked to stress. Living in an abusive and dangerous environment marked by chronic stress can therefore be an important risk factor for maternal health, as well as affecting birth weight [37].

The risk of becoming pregnant after vaginal rape is estimated to be 5% [16]. It is generally recommended that rape victims of childbearing age have a baseline urine or serum pregnancy test performed, in anticipation of offering prophylaxis against pregnancy if the result is negative.

Postexposure emergency contraceptive treatment options are available for preventing pregnancy after unwanted intercourse [38]. The simplest and best-studied product is levonorgestrel (Plan B), an oral progestin-only medication developed for this purpose. The dosage regimen is 1.5 mg (two 0.75-mg tablets) administered as a single oral dose. It is considered to be most effective when administered within 12 hours of the assault. In one carefully conducted study, the success rate (prevention of pregnancy) exceeded 95% when administered up to 120 hours after unprotected intercourse [39]. This medication is safe and well tolerated, even if given to someone who is pregnant. Systemic side effects, such as headache, nausea, fatigue, and gastrointestinal/abdominal complaints, occur in less than 10% of patients. Transient vaginal bleeding in the days following treatment is more common (25% to 30%).

7. HEALTH EFFECTS AND IMPLICATIONS OF CHILDREN EXPOSED TO DOMESTIC VIOLENCE

Children may be victims of domestic violence either directly (if victims of the perpetrator) or indirectly (if witnessing the violence or suffering the fallout). However, there is evidence that child abuse and intimate partner violence often occur within the same household and that exposure to violence in childhood may increase the risk of experiencing or perpetrating different forms of violence later in life [40].

Children exposed to family violence are at high risk for abuse and for emotional damage that may affect them as they grow older. The Department of Justice estimates that of the 76 million children in the United States, 46 million will be exposed to some type of violence during their childhood [12]. Results of the National Survey of Children's Exposure to Violence indicated that 11% of children were exposed to IPV at home within the last year, and as many as 26% of children were exposed to at least one form of family violence during their lifetimes [41]. Of those children exposed to IPV, 90% were direct eyewitnesses of the violence; the remaining children were exposed by either hearing the violence or seeing or being told about injuries [41].

A number of studies indicate that child witnesses are at increased risk for post-traumatic stress disorder, impaired development, aggressive behavior, anxiety, difficulties with peers, substance abuse, and academic problems than the average child [43,44,45]. Children exposed to violence may also be more prone to dating violence (as a perpetrator or a victim), and the ability to effectively cope with partnerships and parenting later in life may be affected, continuing the cycle of violence into the next generation [46,47].

In addition to witnessing violence, various studies have shown that these children may also become direct victims of violence, and children who both witness and experience violence are at the greatest risk for adverse psychosocial outcomes [48]. Research indicates that between 30% and 60% of husbands who batter their wives also batter their children [49]. Moreover, victims of abuse will often turn on their children; statistics demonstrate that 85% of domestic violence victims abuse or neglect their children. According to the U.S. Department of Justice, between 1980 and 2008, 17.5% of all homicides against female adolescents 12 to 17 years of age were committed by an intimate partner [8]. Among young women (18 to 24 years of age), the rate is 42.9%. Abused teens often do not report the abuse. Individuals 12 to 19 years of age report only 35.7% of crimes against them, compared with 54% in older age groups [50]. Accordingly, healthcare professionals who see young children and adolescents in their practice (e.g., pediatricians, family physicians, school nurses, pediatric nurse practitioners, community health nurses) should have the tools necessary to detect these "silent victims" of domestic violence and to intervene quickly to protect young children and adolescents from further abuse. Without such critical intervention, the cycle of violence will never end.

8. DOMESTIC VIOLENCE AND SEXUAL VIOLENCE IN SPECIAL POPULATIONS

ELDERLY

Abused and neglected elders, who may be mistreated by their spouses, partners, children, or other relatives, are among the most isolated of all victims of family violence. In a national study conducted by the National Institute of Justice in 2010, 4.6% of participants (community dwelling adults 60 years of age or older) were victims of emotional abuse in the past year, 1.6% physical abuse, 0.6% sexual abuse, 5.1% potential neglect, and 5.2% current financial abuse by a family member [51]. The estimated annual incidence of all elder abuse types is 2% to 10%, but it is believed to be severely under-measured. According to one study, only 1 in 14 cases of elder abuse are reported to the authorities [52].

The prevalence rate of elder abuse in institutional settings is not clear. However, in one nonprobability study, 36% of nursing and aide staff disclosed to having witnessed at least one incident of physical abuse by other staff members in the preceding year. When asked whether they themselves perpetrated physical abuse against an elderly resident, 10% admitted they had [53]. In a random sample survey, 24.3% of respondents reported at least one incident of elder physical abuse perpetrated by a nursing home staff member [54].

It is important to understand that the needs of older patients will increase, as will the numbers of elder victims of domestic violence. Because elder abuse can occur in family homes, nursing homes, board and care facilities, and even medical facilities, healthcare professionals should remain keenly aware of the potential for abuse. When abuse occurs between elder partners, it is primarily manifested in one of two ways, either as a long-standing pattern of marital violence or as abuse originating in old age. In the latter case, abuse may be precipitated by issues related to advanced age, including the stress that accompanies disability and changing family relationships [55].

Evidence Based Practice Recommendation

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

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

Last Accessed: May 7, 2019

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

It is important to understand that the domestic violence dynamic involves not only a victim but a perpetrator as well. For example, an adult son or daughter who lives in the parents' home and depends on the parents for financial support may be in a position to inflict abuse. This abuse may not always manifest itself as violence, but can lead to an environment in which the elder parent is controlled and isolated. The elder may be hesitant to seek help because the abuser's absence from the home may leave the elder without a caregiver [55]. Because these elderly victims are often isolated, dependent, infirm, or mentally impaired, it is easy for the abuse to remain undetected. Healthcare professionals in all settings should remain aware of the potential for abuse and keep a watchful eye on this particularly vulnerable group.

LESBIAN, GAY, BISEXUAL, AND TRANSGENDER VICTIMS

Domestic violence exists in LGBT+ communities, and the rates are thought to mirror those of heterosexual women—approximately 25% [56]. However, women living with female intimate partners experience less IPV than women living with men. Conversely, men living with male intimate partners experience more IPV than do men who live with female intimate partners. In addition, 77% of IPV homicide victims reported in 2015 were transgender women or cisgender men [57]. This supports other statistics indicating that IPV is perpetrated primarily by men. A form of abuse specific to the gay community is for an abuser to threaten or to proceed with "outing" a partner to others [56].

Transgender individuals appear to be at particular risk for violence. According to a large national report, transgender victims of IPV were 1.9 times more likely to experience physical violence and 3.9 times more likely to experience discrimination than other members of the LGBT+ community [57].

Because of the stigma of being LGBT+, victims may be reticent to report abuse and afraid that their sexual orientation or biologic sex will be revealed. In one study, the three major barriers to seeking help were a limited understanding of the problem of LGBT+ IPV, stigma, and systemic inequities [58]. Many in this community feel that support services (e.g., shelters, support groups, crisis hotlines) are not available to them due to homophobia of the service providers. Unfortunately, this results in the victim feeling isolated and unsupported. Healthcare professionals should strive to be sensitive and supportive when working with homosexual patients.

Twenty-six percent of transgender and gender non-conforming individuals have been physically assaulted and 10% have been sexually assaulted [59]. In a study of transgender women, 78.1% experienced gender-related psychologic abuse and 50% experienced gender-related physical abuse [60]. The Transgender Day of Remembrance is held in November of each year to memorialize those who were killed due to anti-transgender hatred or prejudice. In total, 717 murders have been documented between 1970 and 2012 [61]. The National Center for Transgender Equality recommends that ending violence against transgender people should be a public health priority, because of the direct and indirect negative effect violence has on both victims and on the healthcare system that treats them.

HOMELESS INDIVIDUALS

The intersection of homelessness and domestic and/or sexual violence is bidirectional and complex. Studies indicate up to 92% of homeless women have experienced severe physical or sexual abuse at some point in their lives, and as many as 57% of all homeless women report domestic violence as the immediate cause of their homelessness [62,63,64]. Homeless domestic violence victims face unique barriers to accessing help, including affordable housing, as a result of actions of their perpetrator. They may face housing discrimination, lack stable employment histories, and have poor credit as a result of their abuse histories [62]. In addition, a study published by the National Online Resource Center on Violence Against Women found that homeless women are "particularly vulnerable to multiple forms of interpersonal victimization, including sexual and physical assault at the hands of strangers, acquaintances, pimps, sex traffickers, and intimate partners on the street, in shelters, or in precarious housing situations" [63]. The sexual assault experiences of homeless women are more likely to be violent and include multiple sexual acts than women with housing [65].

Because homeless victims of violence face specific barriers to seeking and receiving services, interventions and assistance should be targeted to their specific needs. It is also important to remember that additional marginalizing factors (e.g., gender/sexual minority status, geographic isolation) compound the problems experienced by survivors.

PEOPLE WITH PHYSICAL AND/OR COGNITIVE DISABILITIES

Research indicates that disability predicts recent intimate partner violence victimization in both men and women [66]. National data indicate that women with a disability are significantly more likely to report experiencing every form of intimate partner violence, including rape, other sexual violence, physical violence, stalking, psychologic aggression, and control of reproductive or sexual health [66]. Stalking and psychologic aggression by an intimate partner are more likely in men with disabilities. Most perpetrators are acquaintances of the victim [67].

The type of disability may also be an indicator or risk. In a national sample of victims of sexual assault who were disabled, the majority (60.5%) had a psychiatric disability and 25% had an intellectual/developmental disability; the smallest percentage (15.6%) had physical/sensory disabilities [67]. People with intellectual disabilities are sexually assaulted at a rate seven times higher than those without disabilities [68].

Although persons with disabilities are more likely to be victimized, it can be difficult for them to seek and obtain help. Legal action was taken in only 13.6% of cases [67]. Differently able individuals may be less likely to be believed when they report abuse or may be unable to effectively communicate their experiences [69]. Police and prosecutors are often reluctant to take these cases because they are difficult to win in court [68]. In addition, there is a lack of coordinated community services and supports for disabled survivors of sexual assault [67].

PEOPLE WITH BEHAVIORAL HEALTH PROBLEMS

Behavioral health problems, including substance use disorders, eating disorders, and compulsive behaviors, commonly co-occur with intimate partner violence and sexual violence. According to the American Society of Addiction Medicine, substance abuse co-occurs in 40% to 60% of IPV incidents, with several lines of evidence suggesting that substance use/abuse plays a facilitative role in IPV by precipitating or exacerbating violence [70]. Both victims and abusers are 11 times more likely to be involved in domestic violence incidents on days of heavy substance use [71].

It is unclear if substance abuse precedes the violence, or vice versa. However, victimization is considered a positive risk factor for substance use disorders, and women in abusive relationships have often reported being coerced into using alcohol and/or drugs by their partners [70].

Women with a history of eating disorders are also at increased risk for intimate partner violence [72]. In a study of undergraduate women, recent (i.e., last three months) sexual assault was associated with more severe eating disorder symptoms [73,74].

CHILDREN AND ADOLESCENTS

Dating Violence

Perpetrators of dating violence among young adults include witnessing interparental violence, experiencing child abuse, alcohol abuse, adherence to traditional gender roles, and relationship power dynamic issues [75]. Female perpetrators are more likely than men to display internalizing symptoms (e.g., depression), trait anger and hostility, and to be victims of past dating violence; young male perpetrators are more likely than women to report lower socioeconomic status and educational attainment, antisocial personality characteristics, and increased relationship length [75]. Sexting has also been identified as a unique risk factor for dating violence in young adulthood [76].

Young women are more likely than men to experience dating violence, as is the case among most subgroups. However, nonsexual violence in dating relationships is more likely to involve the reciprocal use of violence by both partners (mutual aggression) than adult abusive relationships [77].

Sexual Assault

In contrast to sexual victimization of adolescents and adults, who usually present in the aftermath of an assault, pre-pubertal victimization of children tends to be "discovered" when the child is found to have signs of physical or sexual abuse (e.g. genital injury or scarring) or when a sexually transmissible infectious agent is identified. Gonorrhea, syphilis, and HIV (not linked to prior blood transfusion or maternofetal transmission) acquired during the postnatal period of childhood are indicative of sexual abuse. Chlamydia infection might be indicative of sexual abuse in children 3 years of age of older. Sexual abuse should be suspected when genital herpes, Trichomonas vaginalis, or anogenital warts are diagnosed [28]. In cases in which any STD has been diagnosed in a child, further evaluation for other STDs and for the possibility of sexual assault/abuse should be made in consultation with a specialist.

Just as the identification of a sexually transmissible infection in a child raises suspicion for prior sexual assault/abuse, so too does known or suspected childhood sexual assault/abuse warrant an assessment for STDs. The decision to perform a diagnostic evaluation and to collect vaginal or other specimens should be made on an individual case basis. Among factors to consider in the decision to screen a child for STDs are [28,78]:

- Child has experienced penetration or has evidence of recent or healed penetrative injury.

- The perpetrator of the abuse is a stranger.

- The perpetrator is known to have an STD or is at high risk for STDs.

- Child has a relative or another person in the household with an STD.

- Child has symptoms or signs of active infection (e.g., vaginal discharge or pain, genital itching or odor, genital lesions or ulcers).

- Child or parent requests STD testing.

The physical examination and collection of vaginal specimens is often frightening or uncomfortable for a child and should be conducted by an experienced clinician. The CDC and the American Society of Pediatrics provide updated guidance for healthcare providers involved in the evaluation of childhood sexual assault/abuse.

LOW-INCOME POPULATIONS

As with most sociodemographic risk factors for domestic and sexual violence, the correlation between lower socioeconomic status and violence is potentially bidirectional. Economic abuse (considered a form of intimate partner violence) may precede more severe forms of physical and sexual violence. Women who are financially dependent on their abusers are less able to leave and more likely to return to an abusive relationship [79]. Greater economic dependence is associated with more severe abuse.

Financial instability is also a potential adverse effect of intimate partner violence. Current or past exposure to violence has been found to negatively affect ability to sustain stable employment, and women in abusive relationships frequently lose their jobs, experience high job turnover, are forced to quit, or are fired [80].

Victims of sexual violence also experience short- and long-term economic consequences, and low-income individuals are more vulnerable. Victims exceed non-victims in the average number and cost of medical care visits. Beyond medical costs, there are productivity costs and other long-term costs to victims and their families such as pain and suffering, trauma, disability, and risk of death. Sexual violence and the trauma resulting from it can have an impact on the survivor's employment in terms of time off from work, diminished performance, job loss, or being unable to work. These impacts disrupt earning power and have a long-term effect on the economic well-being of survivors [81].

PEOPLE LIVING IN RURAL COMMUNITIES

A large national study found that lifetime intimate partner violence victimization rates in rural areas (26.7% in women, 15.5% in men) are similar to the prevalence found among men and women in non-rural areas [82]. There is some evidence that intimate partner homicide rates may be higher in rural areas than in urban or suburban locales [83].

Substance use disorders and unemployment are more common among IPV perpetrators in rural areas [83]. It has been suggested that IPV in rural areas may be more chronic and severe and may result in worse psychosocial and physical health outcomes. Poverty in rural areas is also associated with an increased risk for IPV victimization and perpetration for both men and women [84]. Residents of rural areas are less likely to support government involvement in IPV prevention and intervention than urban residents [83].

Although the rates are similar, the risk factors, effects, and needs of rural victims are unique. For example, research indicates that rural women live three times further from their nearest IPV resource than urban women. In addition, domestic violence programs serving rural communities offer fewer services for a greater geographic area than urban programs [85].

It is important to assess victims' proximity to available resources and to help in times of crisis. Rural victims may benefit from improved access to services, including technology-based outreach (e.g., videoconferencing, telehealth programs) [86].

IMMIGRANTS AND REFUGEES

A variety of persons migrate to the United States, including legal immigrants granted the indefinite or time-limited right to live in the United States by immigration authorities; undocumented immigrants who have not been granted such a right; and refugees who are unable or unwilling to return to their country of origin due to fears of persecution based on their race or ethnicity, religion, nationality, political opinion, or gender identity or sexual orientation. For simplicity, all three groups are referred to as immigrants [87].

Recent immigrants are at increased risk for violence victimization. In one study of Chinese immigrants in the United States, acculturation and socioeconomic status were associated with severity, frequency, length, and type of abuse [88]. Persons who are displaced due to conflict in their home countries are also vulnerable to sexual violence. Studies indicate that approximately one in five refugees or displaced women in complex humanitarian settings have experienced sexual violence, but this is likely an underestimation [89]. Refugees may also experience torture and sexual violence prior to being displaced. Among male survivors, sexual torture is substantially under-reported, and estimates indicate that 5% to 15% of male survivors were sexually abused by threats of castration or rape, being raped or forced to perform sex in view of others, or receiving electric shock or mutilation to the genitals [90,91]. Fewer women than men are tortured in aggregate, but around 50% of female torture survivors report sexual torture, typically by rape and sometimes in front of family members [92,93,94].

Immigrants tend to underuse health services, especially undocumented immigrants, who typically lack health insurance and may avoid seeking medical attention out of fear of being deported. Immigration status and the inability to understand domestic violence within given cultural norms are major barriers to help-seeking among recent immigrants [95]. The Violence Against Women Act puts some protections in place for noncitizen women, including the ability to self-petition for citizenship (instead of requiring a citizen sponsor) and immigration relief to victims of sexual/other violence or human trafficking [96]. Access to bilingual and culturally appropriate services is also a major concern.

PEOPLE OF COLOR

In the United States, intimate partner violence disproportionately affects women of color [97]. Black and multiracial non-Hispanic women have significantly higher lifetime prevalence of rape, physical violence, or stalking by an intimate partner [98]. Black, American Indian or Alaska Native, and multiracial non-Hispanic men have a significantly higher lifetime prevalence of rape, physical violence, or stalking compared with white non-Hispanic men. These findings may be a reflection of the many stressors that racial and ethnic minority communities continue to experience. For example, a number of social determinants of mental and physical health, such as low income and limited access to education, community resources, and services, likely play important roles. These factors and medical mistrust, historical racism and trauma, perceived discrimination, and immigration status may affect help seeking and the assessment of victims [97].

When race and ethnicity are considered, it is important to remember that there is great diversity within these groups. Certain factors may be generally applicable, but there may be unique contributions by ethnic sub-group [99].

9. PERPETRATORS OF DOMESTIC/SEXUAL VIOLENCE

Abuser characteristics have been studied far less frequently than victim characteristics. Some studies suggest a correlation between the occurrence of abuse and the consumption of alcohol. A man who abuses alcohol is also likely to abuse his mate, although the abuser may not necessarily be inebriated at the time the abuse is inflicted [100]. Domestic violence assessment questionnaires should include questions that explore social drinking habits of both victims and their mates.

Other studies demonstrate that abusive mates are generally possessive and jealous. Another characteristic related to the abuser's dependency and jealousy is extreme suspiciousness. This characteristic may be so extreme as to border on paranoia [101]. Domestic violence victims frequently report that abusers are extremely controlling of the everyday activities of the family. This domination is generally all encompassing and often includes maintaining complete control of finances and activities of the victim (e.g., work, school, social interactions) [101].

In addition, abusers often suffer from low self-esteem and their sense of self and identity is directly connected to their partner [101]. Extreme dependence is common in both abusers and those being abused. Due to low self-esteem and self-worth, emotional dependence often occurs in both partners, but even more so in the abuser. Emotional dependence in the victim stems from both physical and psychologic abuse, which results in a negative self-image and lack of self-worth. Financial dependence is also very common, as the abuser often withholds or controls financial resources to maintain power over the victim [102].

In some cases, a perpetrator and victim will seek help together (joint or couples counseling) to resolve issues in their relationship. Some domestic-violence focused joint counseling approaches have been described [103]. However, many organizations, including the National Domestic Violence Hotline, the Department of Justice, the American Bar Association, and Futures Without Violence, recommend against joint counseling for violent couples due to the risk of additional harm to and isolation of the victim [104,105]. A better option for abusive partners is battering intervention and prevention programs.

10. ASSESSMENT AND SCREENING METHODS

SCREENING

There is no universal guideline for identifying and responding to domestic violence, but it is universally accepted that a plan for screening, assessing, and referring patients of suspected abuse should be in place at every healthcare facility. Guidelines should review appropriate interview techniques for a given setting and should also include the utilization of assessment tools. Furthermore, protocols within each facility or healthcare setting should include referral, documentation, and follow-up. This section relies heavily on the guidelines outlined in the Family Violence Prevention Fund's National Consensus Guidelines on Identifying and Responding to Domestic Violence Victimization in Health Care Settings; however, protocols should be customized based on individual practice settings and resources available [49]. The CDC has provided a compilation of assessment tools for healthcare workers to assist in recognizing and accurately interpreting behaviors associated with domestic violence and abuse, which may be accessed at https://www.cdc.gov/violenceprevention/pdf/ipv/ipvandsvscreening.pdf [106].

Several barriers to screening for domestic violence have been noted, including a lack of knowledge and training, time constraints, lack of privacy for asking appropriate questions, and the sensitive nature of the subject [49]. Although awareness and assessment for IPV has increased among healthcare providers, many are still hesitant to inquire about abuse [107]. At a minimum, those exhibiting signs of domestic violence should be screened. Typical injury patterns include contusions or minor lacerations to the head, face, neck, breast, or abdomen and musculoskeletal injuries. These are often distinguishable from accidental injuries, which are more likely to involve the extremities of the body. Abuse victims are also more likely to have multiple injuries than accident victims. When this pattern of injuries is seen, particularly in combination with evidence of old injury, physical abuse should be suspected [100].

As a result of prolonged stress, various psychosomatic symptoms that generally lack an organic basis often manifest. For example, complaints of backaches, headaches, and digestive problems are common. Often, there are reports of fatigue, restlessness, insomnia, or loss of appetite. Great amounts of anxiety, guilt, and depression or dysphoria are also typical. Women who experience IPV are also more likely to report asthma, irritable bowel syndrome, and diabetes [3]. Healthcare professionals should look beyond the typical symptoms of a domestic violence victim and work within their respective practice settings to develop appropriate assessment mechanisms to detect victims who exhibit less obvious symptoms.

Trauma-informed screening is an essential part of the intake evaluation and the treatment planning process. Trauma-informed practices include [108]:

- Reflecting an understanding of trauma and its many effects on health and behavior

- Addressing both physical and psychologic safety concerns

- Using a culturally informed, strengths-based approach

- Helping to illuminate the nature and effects of abuse on victims' everyday experience

- Providing opportunities for patients to regain control over their lives

Screening processes can be developed that allow staff without advanced degrees or graduate-level training to conduct them, whereas assessments for trauma-related disorders require a mental health professional trained in assessment and evaluation processes. The most important domains to screen among individuals with trauma histories include [109]:

- Trauma-related symptoms

- Depressive or dissociative symptoms, sleep disturbances, and intrusive experiences

- Past and present mental disorders, including typically trauma-related disorders (e.g., mood disorders)

- Severity or characteristics of a specific trauma type (e.g., forms of interpersonal violence, adverse childhood events, combat experiences)

- Substance abuse

- Social support and coping styles

- Availability of resources

- Risks for self-harm, suicide, and violence

- Health screenings

In addition to broad screening tools that capture various traumatic experiences and symptoms, other screening tools, such as the Intimate Partner Violence Screening Tool, focus on acknowledging a specific type of traumatic event [109]. These tools may be used to screen and assess for the presence of adverse or traumatic life experiences. However, it is not necessary to use a formal tool to screen for trauma and exploration of trauma should be done by trained, experienced, and skilled staff. This process requires a safe, comfortable, and respectful environment and a trusting, caring relationship. As mentioned previously, it is not necessary for an individual to disclose painful experiences to be helped. By using universal precautions and treating all people as if they have been exposed to trauma and by using trauma-informed approaches, healing and recovery can be promoted [110].

Universal Trauma-Informed Education

A trauma-informed approach to screening and care of victims of violence creates a space that is supportive, safe, and conducive to healing. Universal trauma-informed education focuses less on formalized screening tools and checklists and more on creating spaces in which traumatic experiences are freely discussed. In this approach, the practitioner conveys universal information about intimate partner violence, in some cases tailored to the specific setting or patient population [111]. These settings "facilitate disclosure for victims of IPV and meet disclosure with empathy, competence, and appropriate referrals" [111]. This approach can be used in any healthcare or human services setting.

ASSESSMENT

Healthcare providers have reported that even if routine screening and inquiry results in a positive identification of IPV, the next steps of assessing and referring are often difficult, and many feel that they are not adequately prepared [107]. According to the Family Violence Prevention Fund, the goals of the assessment are to create a supportive environment, gather information about health problems associated with the abuse, and assess the immediate and long-term health and safety needs for the patient to develop an intervention [49].

Assessment of domestic violence victims should occur immediately after disclosure of abuse and at any follow-up appointments. Assessing immediate safety is priority. Having a list of questions readily available and well-practiced can help alleviate the uncertainty of how to begin the assessment (Table 3). If the patient is in immediate danger, referral to an advocate, support system, hotline, or shelter is indicated [49].

Table 3: ASSESSMENT OF IMMEDIATE SAFETY FOR DOMESTIC VIOLENCE VICTIMS

Are you in immediate danger?

Is your partner at the health facility now?

Do you want to (or have to) go home with your partner?

Do you have somewhere safe to go?

Have there been threats or direct abuse of the children (if s/he has children)?

Are you afraid your life may be in danger?

Has the violence gotten worse or is it getting scarier? Is it happening more often?

Has your partner used weapons, alcohol or drugs?

Has your partner ever held you or your children against your will?

Does your partner ever watch you closely, follow you or stalk you?

Has your partner ever threatened to kill you, him/herself or your children?

Source: [49]

If the patient is not in immediate danger, the assessment may continue with a focus on the impact of IPV on the patient's mental and physical health and the pattern of history and current abuse [49]. These responses will help formulate an appropriate intervention.

Culturally Sensitive Assessment

Many trauma-related symptoms and disorders are culture specific, and a patient's cultural background should be considered in screening and assessment [109]. During the assessment process, a practitioner should be open and sensitive to the patient's worldview, cultural belief systems and how he/she views the illness [112]. Assessment tools should be culturally appropriate for the patient, whenever possible. This may reduce the tendency to over-pathologize or minimize health concerns of ethnic minority patients.

Pachter proposed a dynamic model that involves several tiers and transactions [113]. The first component of Pachter's model calls for the practitioner to take responsibility for cultural awareness and knowledge. The professional should be willing to acknowledge that he/she does not possess enough or adequate knowledge in health beliefs and practices among the different ethnic and cultural groups he/she comes in contact with. Reading and becoming familiar with medical anthropology is a good first step.

The second component emphasizes the need for specifically tailored assessment [113]. Pachter advocates the notion that there is tremendous diversity within groups. For example, one cannot automatically assume that a Cuban immigrant adheres to traditional beliefs. Often, there are many variables, such as level of acculturation, age at immigration, educational level, and socioeconomic status, that influence health ideologies. Finally, the third component involves a negotiation process between the patient and the professional [113]. The negotiation consists of a dialogue that involves a genuine respect of beliefs. It is important to remember that these beliefs may affect symptoms or appropriate interventions in the case of domestic violence.

Culturally sensitive assessment involves a dynamic framework whereby the practitioner engages in a continual process of questioning. By incorporating cultural sensitivity into the assessment of individuals with a history of being victims or perpetrators of domestic violence, it may be possible to intervene and offer treatment more effectively.

Sexual Assault Victims

Given the societal context of sexual assault reporting, the practitioner should accept the person's account of his or her traumatic experience without investigating the authenticity of the claims. Victims/survivors may anticipate disbelief and denial from the clinician due to past negative responses to their disclosures from friends, family, or the criminal justice system.

Practitioner gender should also be considered when working with sexual assault survivors. Avoid assuming that a female or male patient will prefer a practitioner of either the same or the opposite gender. Instead, discuss this issue with the patient and, if possible, let him or her choose the provider gender [114].

The proper clinical assessment of a person who has been sexually assaulted requires a systematic, patient, and thorough approach. It is of necessity time-consuming and should be conducted with sensitivity and respect for the patient's emotional state. Preferably, providers who have been specifically trained for this task should perform the initial clinical examination. More than 500 hospitals and other health facilities in the United States have now addressed this need by adopting the Sexual Assault Nurse Examiner (SANE) program. A SANE is a trained nurse specialist who works within an interdisciplinary team to carry out a general and forensic clinical examination of the sexual assault patient and to develop a strategy for support and after-care [115].

The evaluation and treatment of sexual assault victims should incorporate the following components [115,116]:

- General assessment and treatment of physical injuries, with special attention to the genitalia

- Forensic evaluation, where indicated and with informed consent

- Pregnancy risk assessment and prevention

- Evaluation, treatment, and prevention of STDs

- Psychologic assessment, crisis intervention, and follow-up referral for counseling

As discussed, when appropriate, a trauma-informed approach should be used for victims of sexual violence—during both physical and psychologic assessments.

Ending Assessments and Safety Planning

Evidence Based Practice Recommendation

The World Health Organization asserts that women who disclose any form of violence by an intimate partner (or other family member) or sexual assault by any perpetrator should be offered immediate support.

https://www.who.int/reproductivehealth/publications/violence/9789241548595/en

Last Accessed: May 7, 2019

Level of Evidence: Strong/Indirect Evidence

In some contexts of repeated trauma exposure, victims presenting for treatment may remain vulnerable to ongoing threat and further trauma. With victims of domestic violence and victims of sexual assault perpetrated in their current job setting or by an intimate partner, treatment may be affected by returning to unsafe environments. In the presence of ongoing risk, interventions should initially focus on ensuring safety, stabilization, and symptom management, instead of initiating the trauma-focused components of treatment. Ensure, to the extent possible, the safety, security, and survival needs of the patient by helping secure food, hydration, clothing, hygiene, and shelter. This will include promoting patient stabilization and the importance of sleep and replacing medications that are destroyed or lost. Patients also benefit from education on the process they are experiencing. Patients should be counseled regarding limiting ongoing harm by reducing the use of alcohol, tobacco, caffeine, and illicit psychoactive substances, if needed. Family, friends, and community resources should be identified. From the initial point of contact onward, it is vital to establish a working treatment alliance with the patient and maintain a supportive, non-blaming, non-judgmental stance [114,117].

It is important to note that general safety planning does not take into account the specific needs of victims who fall into vulnerable populations or affected children [118]. Because these individuals are at higher risk of marginalization and oppression, they may feel powerless to execute a safety plan. It is important for practitioners to assess each victim and his/her readiness to change, circumstances, resources, and needs in order to tailor a specific safety plan [119].

11. BEST PRACTICES IN FOLLOW-UP CARE FOR VICTIMS OF VIOLENCE

It is imperative that healthcare professionals document all findings and recommendations regarding domestic violence in the victim's medical record, including a patient's denial of abuse, if applicable. If domestic violence is disclosed, documentation should include relevant history, results of the physical examination, findings of laboratory and other diagnostic procedures, and results of the assessment, intervention, and referral. The medical record can be an invaluable document in establishing the credibility of the victim's story when seeking legal aid [49].

Healthcare professionals should offer a follow-up appointment if disclosure of past or current abuse is present. Reassurance that assistance is available to the patient at any time is critical in helping to break the cycle of abuse [49].

In addition to providing acute care and scheduling follow-up appointments, providers should connect victims of violence with available resources. After identifying victims and their abusers, healthcare professionals should immediately implement a plan of action that includes providing a referral to a local domestic violence shelter to assist the victim and the victim's family. The acute situation should be referred immediately to local law enforcement officials. Other resources in an acute situation include crisis hotlines and rape relief centers.

After a victim is introduced into the system, counseling and follow-up is generally available by individual counselors who specialize in the care of domestic/sexual violence victims. These may include social workers, psychologists, psychiatrists, other mental health workers, and community mental health services. The goals are to make the resources accessible and safe and to enhance support for victims who are unsure of their options.

12. BUILDING EFFECTIVE COMMUNITY PARTNERSHIPS AND COLLABORATIONS WITH COMMUNITY-BASED AGENCIES

Domestic and sexual violence impact many domains of a victim's life, and collaboration between health, mental health, social service, law enforcement, and community-based agencies is vital to providing the best possible care and support. Community agencies provide services such as 24-hour hotlines, shelter, support groups, counseling, and legal advocacy. These agencies and the specialized services they provide for victims of sexual and domestic violence are essential [120].

13. APPROPRIATE RESPONSES AND DOCUMENTATION

Healthcare and mental health professionals involved in the care of patients who have been victims of abuse should fully document suspected abuse, assessment results, any evidence of abuse, and interventions/safety planning in the patient's record or clinical notes. All aspects of patient assessment, documentation, safety planning, communication, intervention, and follow-up should take into account the immediate and long-term safety of the victim and any dependents [123].

All practitioners who deal with domestic and/or sexual violence should periodically review safety planning with victims. Homicide is of high risk for victims; therefore, safety planning is crucial. When advocating a safety plan, it is important to:

- Encourage the victim to be aware of weapons in the residence.

- Have victims make a plan of what to do if violence escalates and where to go if leaving is an option.

- If children are old enough, they should be instructed about the safety plan and assigned roles.

- When possible, victims should save some money in a private bank account or hide money for escape. Victims should be informed that if the abuser finds out about a separate bank account, they could be in danger.

- Encourage victims to keep a bag packed with necessities and stored in a safe place in the event leaving must be immediate.

- Advise victims to work out a code word or signal with the children so they will know when to implement an escape plan.

- Encourage victims to keep a list of important phone numbers in their packed bag. Memorizing important numbers provides more safety.

- Recommend that copies of important documents and necessary items be available.

Although safety planning may be advocated, it does not necessarily mean victims will employ safety planning guidelines.

Ideally, the victim of a sexual or physical assault should be offered a formal forensic evaluation; this requires written documentation of informed consent. Injuries should be documented in photographs, diagrams, or sketches. A growing number of hospitals now employ dedicated forensic nurses, including SANEs, as part of a multispecialty sexual assault team [115].

SANEs have completed specialized training in the medical forensic care of the patient who has experienced physical violence, abuse, or sexual assault. An important component of the care offered by the SANE is the medical forensic examination. This consists of a medical forensic history, a detailed physical and emotional assessment, written and photographic documentation of injuries, and collection and management of forensic samples. The SANE is trained to ensure that evidence is collected and documented according to established protocol and local jurisdiction procedures and that the "chain of custody" is properly maintained in the event of later legal proceedings. Evidence collection kits designed for this purpose are available commercially or, in some states, may be obtained through designated distribution centers. Medically trained rape crisis advocates typically accompany SANEs to provide support, information, and follow-up guidance to victims [123].

Often, however, these trained specialists are not the first professionals to interact with the patient. Consequently, all healthcare professionals, particularly those in an emergency care setting, should have an understanding of the principles that govern proper collection and preservation of evidence during the examination of an assault victim. At stake is the successful prosecution of the assault perpetrator, which often is compromised by insufficient or improperly collected evidence or by not following evidence through the chain of custody.

LEGAL INTERVENTIONS

Domestic violence victims can obtain protective orders through a civil proceeding [42]. Until the enactment of Pennsylvania's Protection of Abuse Act in 1976, only two states had protective order legislation [42]. Protective orders prohibit the abuser from communicating with the victim and/or other family members in a threatening manner. The order also prohibits the abuser from going to the home or place of employment of the victim or family members. Violations of protective orders can result in fines, imprisonment, or a combination of both [42].

Victims can file for a temporary or permanent protective order. A temporary protective order does not require the abuser to be present. These orders last about 30 days or until a court date is scheduled. A permanent protective order requires both the victim and abuser to be present in court. Permanent protective orders last for about 12 months [121].

Laws for dating violence are different. All 50 states and the District of Columbia have state laws related to dating violence. However, the term "dating violence" is not used. Instead, the following terms are used: "sexual assault," "domestic violence," and "stalking" [122]. Only 39 states and the District of Columbia offer the option of protective orders for dating violence victims. The National Center for Victims of Crime is a resource to obtain additional information about state laws.

For more information about legal interventions, state coalitions for domestic violence can be contacted. The American Bar Association has compiled a list of domestic violence state coalitions. Although, the American Bar Association Commission on Domestic and Sexual Violence suggests victims do Internet searches for local domestic violence resources, they caution them to use a local library or go to a friend's home where they can access a computer without the abuser being able to track Internet and email activities [123].

CASE MANAGEMENT

Because abused women often suffer physical injuries, they will likely seek care from a healthcare professional who can make referrals to counseling services. Some women seek counseling on their own. After identifying victims and their abusers, mental health professionals should immediately implement a plan of action that includes providing referrals for available community services and safe havens to assist the victim and the victim's family.

Most abused women are in ongoing danger when seeking help. If they decide to leave, the risk factors increase significantly [124]. Accordingly, if the victim consents, acute situations should be referred immediately to local law enforcement officials. Other resources include crisis hotlines and rape relief centers. After victims are in the system, counseling and follow-up is generally available through victims of crime programs. A list of approved services is provided and includes social workers, marriage and family therapists, psychologists, psychiatrists, other mental health workers, and community mental health services. The goals are to make resources accessible and safe and to enhance support for crime victims who are unsure of their options [125].

Assisting crime victims is essential. Coordinating and accessing an array of social service benefits, which include mental health counseling, healthcare, legal and advocacy services, and other public benefits, is crucial. Consequently, it is vital for professionals to establish relationships with community organizations and be acquainted with appropriate contact persons. When working with diverse cultural and ethnic groups, it is also important to develop relationships with culturally sensitive and bilingual professionals who can provide appropriate interventions.

SHELTERS

Shelters provide a haven for domestic violence victims and their children. They provide temporary emergency housing and a range of services to help victims "get back on their feet." Services vary but may include job training, support groups, skills development groups, and counseling.

To access shelter information by geographic region, there is a valuable website sponsored by the Office for Victims of Crime Resources Center. The Directory of Crime Victim Services is available at https://ovc.ncjrs.gov/findvictimservices. This is a search engine that allows resources and services to be located by state.

14. RESOURCES

MilitaryOneSource

https://www.militaryonesource.mil/leaders-service-providers/child-abuse-and-domestic-abuse

National Coalition Against Domestic Violence

https://ncadv.org

National Domestic Violence Hotline

1-800-799-7233

1-855-812-1011 (VP)

1-800-787-3224 (TTY)

https://www.thehotline.org

Rape, Abuse, and Incest National Network (RAINN)

1-800-656-4673

https://www.rainn.org

National Center for Victims of Crime

https://victimsofcrime.org

The Network/La Red

https://tnlr.org

Matahari Women Workers' Center

https://www.mataharijustice.org

Victim Rights Law Center

https://www.victimrights.org

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Evidence-Based Practice Recommendations Citations

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71610 • Integrating Religion and Spirituality into Counseling

Katherine Greig, MSW, PhD

www.netce.com

Copyright © 2020 NetCE, All rights reserved.

There is a growing recognition of the importance of the spiritual domain in the counseling process and the need for training materials and strategies for integrating the Association of Spiritual, Ethical, and Religious Values in Counseling (ASERVIC) competencies into the field of counseling. Although many counselors and educators endorse the spiritual competencies, there is little evidence that these competencies are being systematically and comprehensively addressed in counselors' training. This course summarizes the revised ASERVIC competencies, their relevance, and application in the counseling process, explaining why it is important for counselors to be proficient in each area before working with spiritual and religious issues in counseling. These competencies will enable counselors, social workers, mental health professionals, and allied professionals to develop a framework to assist them in understanding and working effectively with clients' spiritual and religious lives.

Table of Contents

71610 • Integrating Religion and Spirituality into Counseling

Course Overview

Audience

Course Objective

Learning Objectives

Faculty

Faculty Disclosure

Division Planners

Division Planners Disclosure

Director of Development and Academic Affairs

Director Disclosure Statement

About the Sponsor

Disclosure Statement

Implicit Bias in Health Care

1. INTRODUCTION

2. MULTICULTURAL ISSUES IN THE PROVISION OF MENTAL HEALTH SERVICES

3. INCREASING DEMAND FOR MENTAL HEALTH SERVICES

4. ETHICAL SUPPORT FOR INTEGRATING SPIRITUALITY AND RELIGION INTO COUNSELING

5. ASERVIC: HISTORY AND COMPETENCIES

BACKGROUND

THE SPIRITUAL COMPETENCIES

6. CULTURE AND WORLDVIEW

SIMILARITIES AND DIFFERENCES BETWEEN SPIRITUALITY AND RELIGION

POSITIVE AND NEGATIVE ASPECTS OF SPIRITUALITY AND RELIGION

MAJOR WORLD RELIGIONS

7. COUNSELOR SELF-AWARENESS

EVALUATING THE INFLUENCE OF ONE'S SPIRITUAL AND/OR RELIGIOUS BELIEFS AND VALUES ON THE CLIENT AND THE COUNSELING PROCESS

RECOGNIZING LIMITS

8. HUMAN AND SPIRITUAL DEVELOPMENT

ALLPORT'S MODEL

FOWLER'S STAGES OF FAITH

OSER'S RELIGIOUS JUDGMENT MODEL

GENIA'S FIVE-STAGE FAITH DEVELOPMENT MODEL

WASHBURN'S THEORY OF PSYCHOSPIRITUAL DEVELOPMENT

LIMITATIONS OF MODELS OF RELIGIOUS/SPIRITUAL DEVELOPMENTAL

9. COMMUNICATION

10. ASSESSMENT

11. DIAGNOSIS AND TREATMENT

12. CONCLUSION

Works Cited

Evidence-Based Practice Recommendations Citations

71610 • Integrating Religion and Spirituality into Counseling

Education Category. Community Health

Release Date. 06/01/2020

Expiration Date. 05/31/2023

Course Overview

There is a growing recognition of the importance of the spiritual domain in the counseling process and the need for training materials and strategies for integrating the Association of Spiritual, Ethical, and Religious Values in Counseling (ASERVIC) competencies into the field of counseling. Although many counselors and educators endorse the spiritual competencies, there is little evidence that these competencies are being systematically and comprehensively addressed in counselors' training. This course summarizes the revised ASERVIC competencies, their relevance, and application in the counseling process, explaining why it is important for counselors to be proficient in each area before working with spiritual and religious issues in counseling. These competencies will enable counselors, social workers, mental health professionals, and allied professionals to develop a framework to assist them in understanding and working effectively with clients' spiritual and religious lives.

Audience

This course is designed for social workers, mental health counselors, therapists, and other allied health professionals who work in clinical practice settings.

Course Objective

The purpose of this course is to assist social workers, counselors, and mental health professionals in raising their level of expertise when working with clients who present with spiritual and religious issues.

Learning Objectives

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

1. Explain the relationship between clients' spiritual/religious beliefs, worldviews, and psychosocial functioning.

2. Outline the history and current role of the incorporation of spirituality and religion in counseling.

3. Describe the similarities and differences between spirituality and religion, including the basic beliefs of various spiritual systems and major world religions.

4. Discuss the influence of the counselor's beliefs, attitudes, and values on clients and the counseling process.

5. Describe and apply various models of spiritual and religious development and their relationship to human development.

6. Respond to client communication about spirituality and/or religion with acceptance and sensitivity.

7. Consider clients' spiritual and/or religious perspectives when gathering information for the intake and assessment processes.

8. Recognize when making a diagnosis that clients' spiritual and/or religious perspectives can: enhance well-being, contribute to client problems; and exacerbate symptoms.

9. Set goals with clients that are consistent with their spiritual and/or religious perspectives.

Faculty

Katherine Greig, MSW, PhD, is the CEO of New Perspective Counseling Center LLC in Cleveland, Ohio. She is a trainer, consultant, and retired professor of social work. She received her Bachelor of Arts in Education and a Master’s in Counseling Education from Cleveland State University. Later, she received a Master’s in Social Work and a PhD in Social Administration from Mandel School of Applied Social Sciences at Case Western Reserve University.

Dr. Greig has worked in the fields of social work and counseling for more than 30 years. Her specialty areas include depression, anxiety, relationship issues, and Christian counseling. Dr. Greig is a certified Critical Incident Stress Management (CISM) consultant, Substance Abuse Professional (SAP), and Employee Assistance Program (EAP) specialist.

Faculty Disclosure

Contributing faculty, Katherine Greig, MSW, PhD, 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.

Director of Development and Academic Affairs

Sarah Campbell

Director Disclosure Statement

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

About the Sponsor

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

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

Disclosure Statement

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

Implicit Bias in Health Care

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

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

1. INTRODUCTION

Over the past few decades, the number of books and journal articles on the role of religion and spirituality in the field of counseling and psychotherapy has increased significantly. At the same time, mental and behavioral health professionals have become more aware of the importance of the spiritual domain in the field of counseling. This renewed interest in the spiritual domain is an indication that something is missing when spirituality is not included in health and wellness models [1,2]. When the spiritual dimension is not incorporated into care, the whole person is not being addressed—the component that has to do with giving life meaning and purpose and connecting to self, others, and a Higher Power/Ultimate/God is missing [1,3,4,5,6]. Moreover, one could be overlooking the heart of what it means to be human, because spirituality is a vital component of being human [3].

Diverse theories emphasize the importance of the holistic approach to wellness, and concepts related to holistic wellness continue to inform best practices for counselors, social workers, and other mental health professionals [7]. Accordingly, the counseling wellness model includes a commitment to promoting holistic health throughout the entire lifespan; the spiritual domain is considered an important factor in this model. The holistic perspective recognizes human multidimensionality and therefore takes into account the physical, mental, emotional, and spiritual dimensions of clients when they present for treatment. As a result, the individual is perceived as a unified whole. Of the various dimensions, the spiritual dimension may have the greatest impact on overall personal health [8].

Research has supported relationships between spirituality and physical and mental health [5,9,10,11,12,13,14,15]. In particular, spirituality/religion has been found to have a positive effect on positive coping, resilience, psychosocial competence, self-esteem, and recovery from severe mental disorders [16,17,18,19,20]. Likewise, religious engagement is correlated with decreased perception of pain and reduced incidences of suicidal ideation and substance abuse [1,21,22].

Although there are numerous studies on the positive impact of spirituality and/or religion on physical health, the impact of spirituality and/or religion on mental health has been more widely studied [10]. Mental disorder is the main cause of disability in the United States, and it affects all areas of life, including finances, work and leisure, daily functioning, relationships, self-esteem, and spiritual functioning [23]. As of 2018, there were approximately 48 million adults with mental disorders, including 7.7 million youth between 6 and 17 years of age and 9 million people with co-occurring substance use and mental illness [24].

Moreover, mental disorder is considered the costliest medical condition in this country [25]. It is estimated that the costs for substance abuse and mental health services were approximately $201 billion in 2013 [25]. Both the pervasiveness of mental illness and the cost of treatment have made this one of the main contributors to rising healthcare costs [23,25]. As such, prevention and treatment of mental illnesses would reduce the financial burden on the healthcare system while also improving community health. In this regard, the spiritual domain may be a valuable resource for professionals working with persons with mental disorders [23].

Although counselors and mental health professionals agree about the need to integrate the spiritual domain into the counseling process, there is less agreement as to how this may be best done [26,27]. Educators have explored strategies for fusing the spiritual domain into the curriculum of education programs, which may be the best option to train students regarding the Association of Spiritual, Ethical, and Religious Values in Counseling (ASERVIC) competencies [28,29,30]. However, continuing education activities are also helpful [23].

The purpose of this course is to increase mental and behavioral health professionals' knowledge and skills when addressing spiritual and religious issues in counseling. To this end, the course will discuss why spirituality and/or religion should be integrated into the counseling process; the origin of ASERVIC; the ASERVIC competencies and their relevance; and why it is important to be proficient in each of the competencies prior to working with the spiritual domain in the counseling process.

2. MULTICULTURAL ISSUES IN THE PROVISION OF MENTAL HEALTH SERVICES

As noted, counseling has become more multiculturally aware in past decades due to the multicultural movement and its attention to issues of diversity [31]. The movement began in the early 1960s in response to a recognition that the United States had become increasingly diverse in race, culture, and language [31]. Racial segregation and discriminatory practices were widespread, which led to the Civil Rights Act of 1964 [31]. The movement had a significant impact on the counseling profession, because it changed the way counselors related to their clients [23].

The 1980s witnessed the development of the Multicultural Counseling Competencies (MCC). The primary focus of the MCC was to provide guidance to counselors working with racially and ethnically diverse clients [23,32]. In 1991, the MCC was approved by the Association for Multicultural Counseling Development (AMCD) as standards for counselors' training and practice [33]. Initially, the MCC focused primarily on racial and ethnic aspects of diversity; religion, spirituality, and other aspects of diversity were added later. However, spirituality and religion, along with other aspects of diversity, continue to be under-represented in the MCC, raising doubt as to whether a multiculturally competent counselor is necessarily spiritually competent [23,27].

Immigration to the United States was at an all-time high during the last half of the 20th century [34]. In 2020, immigrants comprised approximately 12% of the U.S. population, and this percentage has been steadily increasing [34]. Consequently, the cultural landscape of the United States is becoming even more diverse [35]. Hispanics and Asians have the highest growth in population when compared with black/African Americans, Native Americans, and white/European Americans [36]. Unlike previous generations, immigrants today are better educated, have greater financial resources, and do not find it necessary to assimilate fully into the dominant culture [23,33,37]. Accordingly, new immigrants are more likely to maintain their cultural traditions and heritage, which include their spiritual and religious traditions [23,27].

3. INCREASING DEMAND FOR MENTAL HEALTH SERVICES

It is well documented that when individuals face psychologic distress they are likely to turn to existing religious resources (e.g., prayer, faith, trusting in God's will, the clergy) to cope [5]. As such, many individuals seeking counseling services want their spiritual beliefs included in their counseling experience [27,38,39]. In a study of 655 individuals diagnosed with a mental illness, 65% stated they wanted to talk about spiritual issues with their therapist, whereas 35% said they did not feel comfortable doing so [40].

Individuals consistently identify spiritual and/or religious needs as important issues in their lives [20,22,41]. Clients and counselors agree that religion and/or spirituality should be included in counseling and are open to discussing such issues [42,43,44,45,46]. However, many mental and behavioral health professionals have not received the necessary training to do so appropriately, effectively, and confidently.

According to a Pew Research Center survey, approximately 90% of Americans believe in some kind of higher power [41]. Around 56% believe in God as described in the Christian Bible, and 33% said they believe in another type of higher power or spiritual force. Roughly 11% said they do not believe in God or a higher power of any kind. Based on these findings, it is safe to assume that spiritual and/or religious issues are important to many individuals seeking counseling services. Neglecting these aspects of diversity in counseling or therapy denotes a failure to respect the individual as a whole and could be viewed as an ethical violation [47].

4. ETHICAL SUPPORT FOR INTEGRATING SPIRITUALITY AND RELIGION INTO COUNSELING

Based on studies validating the positive correlation between religion and health, professional organizations have increased their efforts to infuse spirituality and religion into counseling, training and practice [6,10]. Both the American Psychological Association (APA) and the American Counseling Association (ACA) have formally acknowledged religion in their ethical guidelines as an issue for counselors to consider in their practice [48,49]. Additionally, the APA has authorized a division (36 Society for the Psychology of Religion and Spirituality) specifically for the study of the psychology of spirituality and religion [10].

The Council for Accreditation of Counseling and Related Educational Programs (CACREP) requires the inclusion of spirituality and religion issues in counselor education programs [50]. The Joint Commission asserts that spiritual services are important aspects of health care and daily life [51]. In 2001, the Joint Commission revised its standards and now mandates a spiritual assessment for patients. Such recognition validates the importance of spiritual care for clients seeking health services [11,52].

5. ASERVIC: HISTORY AND COMPETENCIES

ASERVIC was established in 1951 through the merging of three Catholic counseling organizations [27]. It is currently a division of the American Counseling Association and consists of counselors who believe spiritual, ethical, and religious values are essential to the overall development of a person [6]. Its primary mission is the integration of spiritual, ethical, and religious values into the counseling profession. Accordingly, ASERVIC plays a central role in the incorporation of spirituality and religion into counseling practice and counselor education programs [52].

BACKGROUND

The first Summit on Spirituality was a major event in ASERVIC's history. For this Summit, a group of experts in spirituality and counseling convened in the fall of 1995 in order to discuss how the organization could guide the profession toward spiritual competency [27]. It became evident that the construct of "spirituality" presented a challenge to define, and a review of the literature confirmed this struggle [53]. Therefore, ASERVIC's leadership commissioned a task force to develop a description of spirituality and a set of competencies that would support counselors in serving clients from various religious and spiritual traditions [27,53].

Outcome of Summit I

After a series of town hall meetings at professional conferences over several years, the Summit group developed a description of spirituality and a set of competencies [27,53]. The development of counselors' competencies gave structure to the discussion that had been taking place and provided data to be included in curricula and accreditation standards. The summit initially produced 23 competencies, which later became 10 guidelines and finally resulted in 9 items. ASERVIC endorsed the 9 items in 1996, and these items have since been endorsed by the ACA Governing Council [27,54].

Outcome of Summit II

Summit II convened in the summer of 2008 with various leaders and scholars in spirituality and counseling. The primary focus of this summit was the revision of the competencies developed at the previous summit. The counseling profession strongly endorsed the spiritual competencies, and it was recommended that the competencies be used to inform curriculum development [27]. In spite of the effort that went into the development of the competencies, spiritual and religious material continues to be neglected in counselor training programs.

Counselor educators supported the inclusion of the revised competencies in curricula. However, it was not clear whether educator training was needed or if training would accomplish outcome measures of increased knowledge, skills, and attitudes needed to assist clients with their spiritual and religious concerns [27]. It became apparent that a formal measurement tool was needed, and the Spiritual Competency Scale (SCS) was developed to meet this need [23]. A pilot study of the SCS was conducted with 602 participants, and the findings supported the use of the SCS to "inform curriculum development, as a measure of training outcomes, and as a tool for the certification of spiritually competent counselors" [23].

THE SPIRITUAL COMPETENCIES

The ASERVIC competencies continue to serve as a guideline for addressing spiritual and religious issues in counseling and are intended to be used with traditional counseling techniques that are evidence-based and coincide with best practices. The 14 competencies are grouped under six primary categories [6]:

- Culture and worldview

- Counselor self-awareness

- Human and spiritual development

- Communication

- Assessment

- Diagnosis and treatment

6. CULTURE AND WORLDVIEW

At the beginning of each section, the ASERVIC competencies for the category will be listed [6].

Competency 1

The professional counselor can describe similarities and differences between spirituality and religion, including the basic beliefs of various spiritual systems, major world religions, agnosticism, and atheism.

Competency 2

The professional counselor recognizes that the client's beliefs (or absence of beliefs) about spirituality and/or religion are central to his or her worldview and can influence psychosocial function.

SIMILARITIES AND DIFFERENCES BETWEEN SPIRITUALITY AND RELIGION

The word spirituality is derived from the Latin root spiritus, which means breath of life [1,55]. Due to the elusive nature of the concept of spirituality, leaders attending the first Summit on Spirituality found it difficult to define. Instead, they chose to describe it as [6]:

Spirit may be defined as the animating life force, represented by such images as breath, wind, vigor, and courage. Spirituality is the drawing out and infusion of spirit in one's life. It is experienced as an active and passive process. Spirituality is also defined as a capacity and tendency that is innate and unique to all persons. This spiritual tendency moves the individual toward knowledge, love, meaning, peace, hope, transcendence, connectedness, compassion, wellness, and wholeness.

Spirituality includes one's capacity for creativity, growth, and the development of a value system. Spirituality encompasses a variety of phenomena, including experiences, beliefs, and practices. Spirituality is approached from a variety of perspectives, including psychospiritual, religious, and transpersonal. While spirituality is usually expressed through culture, it precedes and transcends culture.

The word religion is derived from the Latin word religio, which means a bond between humanity and greater-than-human power [56]. Many people use the terms religion and spirituality interchangeably; however, they are two separate concepts that often overlap [10,39,57]. Spirituality is a personal connection with the universe, whereas religion is an organized community of faith that has a written doctrine and codes that regulate behavior [14]. Although they are two separate concepts, both incorporate a sense of transcendence—a belief in something greater than oneself [58].

As noted, there has been much discussion and confusion regarding the definition of religion and spirituality, and the majority of people (74% and 88%) do not distinguish between the two [27]. However, it is important to understand that there is a continuum of religiousness and spirituality, and it is essential to recognize where each client falls on this continuum. Clients will present for counseling services with different perspectives regarding religion, spirituality, and the relationship between the two concepts [27]. For example, some clients will say they are religious but not spiritual. These individuals go through the motions of following the practices of the group. They do so out of a sense of duty or obligation, or they fear the consequences of not participating from family members or punishment from God [27]. There are clients who say they are spiritual and not religious. These individuals are not affiliated with a particular religion or belief system but still feel connected to something greater than themselves. They are primarily concerned with their own personal spiritual journey. The number of individuals in this category is growing [27]. Clients can be both religious and spiritual. To these individuals, religion and spirituality are intertwined and they strengthen each other [27]. There are also clients who are religiously tolerant and indifferent. These persons are tolerant of others' religion but are not committed to organized religion [27]. Lastly, there are clients who are religiously antagonistic. These individuals often consider themselves spiritual but have negative feelings toward organized religion. Usually, these individuals have had negative experiences with organized religion or grew up in families that were prejudiced toward organized religion [27]. Regardless of where clients happen to fall on the continuum, it is important to understand each client's perspective, as well as each client's readiness and willingness to discuss his or her spiritual/religious beliefs, or lack thereof [27].

POSITIVE AND NEGATIVE ASPECTS OF SPIRITUALITY AND RELIGION

Like any intervention, spirituality and religion have beneficial as well as adverse effects [5,10] [21]. According to Jones and colleagues, one's spiritual or religious beliefs have a significant impact on physical and mental health outcomes [21]. Negative spiritual beliefs are related to poorer health outcomes, whereas positive spiritual beliefs are related to better health outcomes. It is estimated that 10% of the population has negative spiritual beliefs [21].

A study of 200 individuals was conducted to determine how their spiritual beliefs impacted their health outcomes [21]. Individuals in the study had a range of health conditions, including traumatic brain injury, chronic pain, and cancer. Individuals who held negative spiritual beliefs (e.g., feeling punished or abandoned by God) had poorer physical and mental health outcomes and an increased perception of pain. Individuals who held positive spiritual beliefs (e.g., feeling loved and forgiven by God) had better health outcomes and a decreased perception of pain.

Other examples of negative spiritual beliefs include [59,60]:

- God is not supportive.

- One should rely on faith alone for healing.

- Crises are punishment from God.

- Turning to medicine shows a lack of faith.

- Lifesaving medical treatment should be refused for self and family members.

Negative spiritual and religious beliefs can impair health and well-being because they create a toxic environment, lowering immune system functioning and increasing both stress hormones and blood pressure [21]. Additionally, negative spiritual beliefs diminish hope and optimism, potentially increasing mental health problems such as depression and anxiety. In short, positive or healthy spiritual beliefs may enhance well-being, while negative or unhealthy spiritual beliefs contribute to the problem by diminishing hope and instilling fear, which may exacerbate symptoms.

MAJOR WORLD RELIGIONS

The following section provides a brief overview of the beliefs and practices of the major Western and Eastern religions. It is hoped that counselors and mental health professionals will gain an understanding and appreciation of diverse religious and spiritual beliefs and practices. As a result, counselors and mental health professionals will be better prepared to meet clients' needs and enhance their well-being. This overview is meant only to give a simple, brief summary of the general ideology of each religion. By no means are all of the rites or beliefs described practiced by all members of each religion; likewise, not all religious rites or beliefs are discussed for each religion. As always, individualized assessment is encouraged.

Before discussing the various religious and spiritual beliefs and practices, it is important to have an understanding of the concept of "worldview" [61]. Worldview refers to one's total outlook on life. Clients' worldviews are shaped by their culture, religion and/or spirituality, race, ethnicity, sociopolitical factors, age, ability, sexuality, gender expression, family, and other variables. These variables interact to form clients' total worldviews, which influence the way they think, feel, and behave [14,15,27]. Wiggins-Frame writes that, "counselors must be aware that our clients bring to us not only their problems and their pain but also their views of the world molded by culture, religion, and the intersection of the two" [53].

The three major Western religions are Judaism, Christianity, and Islam. All three are monotheistic, meaning their followers believe in one Supreme Being or God who created and sustains the universe. The major Eastern religions include Hinduism, Buddhism, Confucianism, Taoism, and Shintoism. These religions are typically polytheistic (worshiping more than one God) or pantheistic (God is manifested in the forces and laws of the universe). A separate group of religions may be described as atheistic or agnostic [15]. Atheism is the disbelief in the existence of a god or gods; agnosticism holds that the existence of God is unknown and unknowable [27,53,62].

Western Religions

Judaism

Judaism emerged in the Southern Levant (an area in the Middle East) in about 2000 B.C.E. [63]. The word Jew is derived from the term yehudah, or Judah, the Southern Kingdom of Israel that existed from 922 to 586 B.C.E. [64]. There are approximately 13 million Jewish people in the world—6 million in North America, 4.3 million in Asia and 2.5 million in Europe [62]. Jewish descent is traced through the maternal line, but the choice to practice Judaism is made by the individual. Persons who are not born to Jewish mothers may convert to Judaism through a procedure specific to the sponsoring denomination [64]. In Jewish tradition, the Torah is believed to be the word of God and the ultimate authority.

There are three tenets of Judaism. The first tenet is monotheism; there is one God who created the universe and continues to rule. In Jewish tradition, the name of God is revealed to Moses as the Hebrew consonants yhwh. This is often stylized as Yahweh, but Jewish individuals traditionally do not pronounce it. Yahweh is described as "eternal, omniscient, omnipotent, and holy" [53]. The second tenet is that the Jews were chosen to receive the law of Yahweh and to serve as role models for humankind [53]. The third tenet refers to the covenant, which is a contractual agreement between God and the Jews. According to the agreement, they will be rewarded if they obey God and keep his commandments; failing to do so would result in divine retribution. Also, they believe that studying the Torah and faithfulness to God and his commandments may hasten the arrival of the Messiah [27,53].

Jewish law focuses on dietary practices, the Sabbath, and annual holidays or festivals. Observing the dietary laws is called keeping kosher. One's home is considered the table of the Lord, and therefore certain animals considered unclean (e.g., pork, shellfish) are not to be eaten. However, animals with split hooves and animals that chew their cud are acceptable. Acceptable animals must be slaughtered correctly, must have the blood drained from them, and must not be served with dairy products. Those who adhere to kosher laws have separate sets of dishes and utensils for preparing and serving meat, dairy products, and Passover meals [53,65].

Sabbath is a day of rest and rejuvenation. Observance of the Sabbath usually takes place on Saturdays. Passover, Hanukkah, Rosh Hashanah, and Yom Kippur are major festivals observed by members of the faith. Passover is the festival celebrating the exodus from Egypt and liberation from bondage. Hanukkah celebrates the triumph of the Maccabees over the Syrian King Antiochus IV in 165 B.C.E. [27,53]. Rosh Hashanah marks the beginning of the two-day celebration of the Jewish New Year. Yom Kippur, also known as the Day of Atonement, is the holiest day of the year in Judaism and occurs eight days after Rosh Hashanah. Its central themes are atonement and repentance.

Christianity

Christianity emerged in the 1st century C.E. It is the largest religion in North America, and there are approximately 2 billion followers worldwide [27]. There are three major divisions in Christianity: Roman Catholicism, Eastern Orthodoxy, and Protestantism [27,53]. Christianity is based on the life and teachings of Jesus Christ, a Jew who was born in Bethlehem (in modern-day Palestine) and was believed to be God's promised Messiah. In Hebrew, Jesus means "God saves" and Christ means "Messiah" [62]. Accordingly, they believe that salvation and eternal life can be obtained through their belief in Jesus [62]. Most Christians believe Jesus was crucified and later resurrected by God and that he continues to live and reign with God. At the end of time, Christians believe Jesus will return to earth and establish his Kingdom, which he began during his earthly existence [27].

Christians also believe Jesus is both human and divine or God in human form [65]. As an ongoing source of comfort and guidance, God offered them the Holy Spirit [65,66]. Christians believe God's grace is a gift and that it saves them from evil, sin, and death. Moreover, grace is earned not by doing good deeds or obedience to the law, but through living by the teachings of Jesus Christ [27,65]. The concept of the Trinity is also basic to Christian belief. Although God is perceived as one, God is also expressed in three roles: Father (Creator), Son (Redeemer), and the Holy Spirit (Sustainer) [53,65].

Baptism and the Eucharist or Holy Communion are the primary sacraments celebrated in most Christian churches [53]. Baptism symbolizes the forgiveness of sins, new life, and initiation into the Christian church. During the baptism, persons are either immersed in water or water is sprinkled or poured over them. Eucharist or Holy Communion is a ritual meal in which bread and wine are taken in remembrance of the body and blood of Jesus that was broken and shed at the cross [27]. Major Christian holidays include Easter (commemorating the death and resurrection of Jesus Christ) and Christmas (celebrating the birth of Jesus).

Christians consider the Bible to be the word of God. It is composed of 66 to 81 separate books (depending on denomination). The Bible is comprised of the Hebrew scriptures (Old Testament) and the New Testament, which consists of the four gospels (Matthew, Mark, Luke, and John), Acts, the letters of the apostle Paul, and Revelation [53]. Christians hold various perspectives on the nature, purpose, and approaches to the interpretation of the Bible.

Islam

Islam is the fastest-growing religion in the United States and throughout the world [41]. Members of Islam are called Muslims, and approximately 3.45 million live in the United States [41]. Islam means "to surrender" in Arabic. However, from a religious perspective, Islam means "to surrender to the will of God" [67]. Islam began in Arabia around 570–632 C.E. and was founded by the prophet Muhammad. It is a monotheistic religion whose followers believe there is one God and that Muhammad was his last Prophet. They believe the Qur'an (or Koran) is the literal word of God (or Allah in Arabic) that was revealed to Muhammad and mediated by Gabriel, the angel of revelation [67]. Arabic is the language used in Islamic prayer/liturgy [62]. Major festivals or holidays include Al-Hijra, Milad un Nabi, Ramadan, Eid al-Fitr, Eid al-Adha, Day of Ashura, and Laylatul Qadr.

Most Muslims are of one of two denominations: Sunni and Shia. While various denominations may have slightly different beliefs or translations, Islam has six major doctrines. The first is the belief in divine unity, or tawhid [27,53]. The second is the belief in angels as agents of God. Angels have many functions, such as carrying messages to prophets and watching over and keeping track of people. The third is a belief in prophecy as revealed in the Qur'an. The fourth involves belief in scripture (Qur'an), and the fifth is the belief in Judgment Day and life after death [27,53]. On the Last Day (or final judgment), both the living and the dead will be judged. The faithful will be rewarded, and the unfaithful will be cast into hell. Finally, the sixth doctrine is the Divine Decree and Predestination. It suggests that Allah has already determined who will receive eternal salvation [27,53].

The Five Pillars are the core beliefs and practices of Islam. The first is the Shahada (profession of faith)—the belief that there is no god but Allah and Muhammad is his messenger [27]. The second pillar is the Salat (ritual prayer). Muslims pray facing Mecca five times every day: at dawn, noon, mid-afternoon, sunset, and evening [53]. The prayers are usually performed on a rug or mat specifically for this purpose. Zakat (almsgiving) is the third pillar of Islam. Muslims are expected to donate a certain portion of their income to community members in need [68]. Sawm (or fasting) is the fourth pillar of Islam. During the daylight hours of Ramadan, healthy adult Muslims are expected to abstain from food, drink, and sexual relations. This is a time of reflecting, renewing faith, and being grateful for everything Allah has given [68]. The fifth pillar of Islam is Hajj (pilgrimage). After 16 years of age, every Muslim in good health and whose finances permit is expected to visit the holy city of Mecca, located in present-day Saudi Arabia.

Eastern Religions

Hinduism

Hinduism is one of the world's oldest religions, dating back to about 1500 B.C.E. [69]. Unlike other major religions, it was not founded by a single person but was born of many religious beliefs and philosophies [70]. Hinduism originated in India, and today it is the third-largest religion in the world. There are approximately 1.1 billion adherents worldwide and 2.3 million adherents in the United States [71]. Hinduism is a polytheistic religion with three major deities: Shiva, Vishnu, and Brahma [69].

Hindus believe there are four paths, or yogas, leading to a spiritual life and that each person must choose the path that best fits his or her temperament. One path is Jnana Yoga, which appeals to intellects who travel the path of knowledge. Another path is Bhakti Yoga, which is the path of love and devotion as a way to god. Individuals on this path utilize mantras as a means of altering one's consciousness. Another path is Karma Yoga, which is the path of performing daily activities or work instead of contemplation. Finally, the path of Raja Yoga is the path of psychologic experimentation and meditation as a way to one's true nature [72].

In addition to the four paths toward God, there are four stages (or ashramas) in life leading to moksha or liberation. The stages involve duties boys/men have throughout their lives. The first stage is the student stage (brahmachari). It involves the study of the religion under the guidance of a teacher. Grahasthin, the second stage, is referred to as the householder. It involves maintaining a home and family and giving alms to those who have reached a different karmic stage [70]. The third stage is called the forest dweller (vanaprasthin). It consists of elderly men who perform rituals honoring their ancestors. Finally, the fourth stage, referred to as sannyasin or renunciation, involves giving up the material world entirely to experience liberation [70].

Two concepts are central to Hinduism: karma and reincarnation. Karma refers to the spiritual principle of cause and effect. In short, people's circumstances are the result of present and past-life actions of good or evil [27]. Hindus also believe in the continuous cycle of life, death, and rebirth (reincarnation) that continues until the soul "transcends all pain and pleasure and release itself from all fears and attachments" [53]. This state is called samsara or transmigration [53].

The caste system is traditionally central to Hinduism as well. Historically, it divided people into four hierarchical categories [53]:

- Brahmans (seers)

- Kshatriyas (administrators)

- Vaishya (businesspersons)

- Shudra (laborers)

Later, a fifth category of untouchables emerged, and people in this category were subject to discriminatory practices [53]. This discrimination is now illegal in India. Marriage is typically expected to be within the caste (jati), and the hope is for male heirs [69].

The Hindu temple is a cultural center where people come to sing, read sacred texts, and perform rituals [27]. The chanting of mantra called pathas is a traditional Hindu practice and is believed to have transformative power. Puja or daily worship is an important aspect of Hinduism. It entails the offering of food, incense, flowers, fruits, ashes, and other articles to an image of a deity [72]. Tirthas refer to pilgrimage sites and holy places in Hinduism [72].

There are many sacred texts in Hinduism, including The Ramayana, an epic tale of Lord Rama's victory over the 10-headed demon Ravana, and The Mahabharata, the world's longest epic poem that is an historical account of the birth of Hinduism along with a code of ethics for the faithful [27]. Major Hindu festivals include Makar Sankranti, Holi, Diwali, Mahashivratri, Vasant Panchami, Rama Navami, and Janmashtami/Krishna Jayanti.

Buddhism

There are approximately 3 million Buddhists in the United States and about 488 million worldwide [71]. Buddhism was founded in northeastern India by Siddhartha Gautam, whose name was later changed to the Buddha or Enlightened One. Around the year 563 B.C.E., Buddha was born into a wealthy family as a prince in present-day Nepal. He was saddened by the suffering in the world and the emptiness of his life [73]. He later realized that he could be subjected to different forms of human suffering (e.g., death, disease) as well. Consequently, at 29 years of age, he left his home and became a wandering monk seeking a resolution to suffering and death.

He sought knowledge from several forest yogis and learned meditation techniques. He joined the five yogis and practiced extreme forms of asceticism and almost starved to death [73]. That is when he realized that neither extreme pleasure nor self-denial was the path to nirvana (release from suffering). After six years, Buddhists believe Gautama found enlightenment while meditating under a Bodhi tree and was released from the cycle of rebirths [73]. He began promoting the idea of a middle path that focused on purity of thought and deed. Buddha believed awareness was the path to overcoming death [104]. He did not want to be worshiped as a god or savior. Instead, he believed his role was to help people find their path to freedom and enlightenment.

The Four Noble Truths and the Eightfold Path are essential to understanding Buddhism. The Four Noble Truths have been identified as the first teaching given by Buddha. They are considered one of the most important teachings in Buddhism because they instruct followers on how to end suffering [27,62]. Within the Four Noble Truths is found the Eightfold Path. The Four Noble Truths are [62]:

- There is suffering in life.

- Human desire is the cause of suffering.

- The end of human suffering is possible.

- The Eightfold Path is how one achieves nirvana.

Collectively, the Four Noble Truths explain why humans suffer and how to overcome suffering. Wangu describes the Eightfold Path as consisting of the right opinion, right intentions, right speech, right conduct, right livelihood, right effort, right mindfulness, and right concentration [74]. These eight paths are grouped into three key elements of Buddhist practice: morality, wisdom, and concentration [73]. Buddha taught the Eightfold Path in all of his discourses. Buddha understood that everyone is not suited to be a monk, so his followers were given the Five Precepts to learn and practice. The Five Precepts or moral codes are to be undertaken by lay followers of Buddhism in order to develop mind and character, which leads to enlightenment [73].

The Five Precepts for everyday behavior are "to refrain from killing, from taking what is not mine, from sensual misconduct, from false speech, and from using intoxicating substances that cloud the mind" [74]. Similar to Hinduism, karma is a key component of Buddhism. Accordingly, good deeds are rewarded and evil deeds are punished. Karma is viewed as a universal law that "determines one's destiny—whether one is reborn as a human, animal, or some other creature, such as a god or the devil" [73].

Buddhists also engage in rituals such as chanting and placing flowers, candles, and incense before an image of Buddha. Flowers represent the impermanence of life, incense assists followers in remembering moral virtue, and fire denotes enlightenment [75]. Buddhists celebrate many holidays and festivals, most of which commemorate important events in the life of the Buddha. Every year, Buddhists celebrate Vesak, a festival that commemorates Buddha's birth, enlightenment, and death. During each quarter of the moon, followers of Buddhism participate in a ceremony called Uposatha [75]. This observance allows Buddhists to renew their commitment to their teachings. Buddhist New Year is a time for reflection of past lives and identifying and rectifying mistakes [27].

Confucianism

Confucianism is described as a way of life, philosophy, religion, or ethical code by which to live [53]. It was developed from the teachings of Confucius, who was born around 551 B.C.E. [76]. These teachings focus on good conduct, wisdom, and proper social relationships. Confucius has had a great influence on Chinese culture. Although temples were built to honor him, he is not perceived as a god. The temples are used for public ceremonies only and not as places of worship [77].

Confucianism advocates eight key concepts. The first is Jen, which translates as love, human-heartedness, and goodness [77]. Jen refers to "a feeling of humanity toward others and respect for oneself, an indivisible sense of the dignity of human life…" [76]. The second concept is Chun-tzu, which refers to a state of centeredness whereby one exhibits Confucians' values effortlessly and without the need for self-monitoring. The third concept is Li, or a sense of order in one's life that coincides with social convention. The fourth concept is Te, or the appropriate use of power by leaders and authority figures. Confucius believed leaders should lead by example and not by force. They should be honorable and benevolent, which will lead to people being respectful and obedient. The fifth concept is Wen, which refers to the cultural arts (e.g., music, drama, poetry) that help to maintain unity in society [76]. The remaining concepts are Chi (the wisdom of proper action), Hsin (integrity), and Yi (righteousness or justice).

Taoism

Taoism (pronounced DOW-ism) is a Chinese philosophy and religion dating back to the fourth century B.C.E. [27]. Tao means "the way," and it has no founder or central figures. Taoists do not worship a god. Instead, they focus on coming into harmony with Tao, the cosmic energy that blows through everything. Taoism emphasizes what is natural and going with the flow of life. Today, there are about 20 million Taoists, and most followers live in China, Taiwan, or Southeast Asia [27].

The word Tao has three different meanings. First, Tao refers to the ultimate reality; therefore, it is "unspeakable and transcendent, the ground of all existence" [53]. Second, Tao is the cycles of nature and constant change that are evidence of the universal force [78]. Third, Tao implies the way to peace is through synchronizing one's life with the natural rhythm of the universe [76]. Being in concert with Tao means doing nothing stressful, artificial, or unnatural. Taoists seek balance and harmony in life, particularly in their approach to diet and exercise. Meditation is an important practice, and the goal of meditation is to come into harmony with the universe [27]. The philosophy is found in a text, the Tao-te-Ching (Classic Way and Its Power), dating back to the third century B.C.E. and attributed to Lao Tzu [53].

Shintoism

Shintoism began during prehistoric times on the Japanese islands [79]. Today, Shinto is the religion of Japan, and it has approximately 112 million followers; more than 75% of them follow Buddhism as well [79]. Like Taoism, Shinto has no founder or central figure. It teaches that all things in the world are imbued with a spirit (kami). Therefore, Shinto followers revere nature in all forms [78].

Most of the deities associated with Shinto are related to nature, such as the sky, earth, heavenly bodies, and storms [80]. However, deities are not different from humans, because everything is imbued with spirit. Everything is connected, including rocks, trees, dust, water, animals, and humans [81]. Shinto focuses on "simplicity and cleanliness as signs of inner goodness" [53].

Shinto has no fixed doctrine and no scripture or sacred text. However, ancient prayers are passed down via oral tradition. Shinto followers worship primarily individually rather than in groups, and followers engage in purification rituals (e.g., handwashing) [79]. Worship occurs outside the shrine, and worshipers usually bring offerings of food or coins for the spirit (kami). These offerings are not given as sacrifices but as signs of gratitude [79]. Some followers write prayers on slips of paper and leave them nearby.

New Age Spirituality

The New Age movement became popular in Western society in the 1970s [82]. The precise definition of the term differs among scholars largely due to its highly eclectic range of spiritual beliefs and practices [82,83]. The movement takes many shapes and is continually changing. However, there are some common features that distinguish it from other religions, such as followers who [27]:

- Look forward to a society that reunites the wisdom of both science and religion

- Adopt holistic and alternative healing methods

- Embrace a wide array of traditional and nontraditional spiritual beliefs and practices

- Accept the existence of a universal energy that undergirds and permeates all of existence

Adherents believe healing can occur when individuals connect with this universal energy and learn to use it. This energy has been called by many names by different cultures, including chi (Chinese), ki (Japanese), prana (Sanskrit), mana (Pacific Islander), or the use of self as a final authority [27].

7. COUNSELOR SELF-AWARENESS

Competency 3

The professional counselor actively explores his or her own attitudes, beliefs, and values about spirituality and/or religion.

Competency 4

The professional counselor continuously evaluates the influence of his or her own spiritual and/or religious beliefs and values on the client and the counseling process.

Competency 5

The professional counselor can identify the limits of his or her understanding of the client's spiritual and/or religious perspective and is acquainted with religious and spiritual resources and leaders who can be avenues for consultation and to whom the counselor can refer.

Most models of psychotherapy require the enhancement of self-awareness and knowledge on the part of mental health professionals. To function effectively as a counselor, mental health professionals need to know themselves [84,85,86]. Accordingly, counselors should be aware of their own biases, values, beliefs, and assumptions prior to working with culturally diverse clients [27]. Kotter asserts that counselors devalue their profession when they are unable to practice in their own lives what they ask of their clients [85].

McLennan and colleagues identify four integrated processes to assist counselors in becoming more self-aware [27,87]. The first process involves reflecting on how one's attitudes, values, and beliefs have developed over the lifespan. The second process involves the exploration of personal prejudices, biases, doubts, and fears [27]. The third process consists of exploring spirituality/religion and assimilating it into the counseling process through examining the relationship between mind, body, and spirit [27]. The final process involves continuous assessment of one's comfort levels while exploring the spiritual domain with clients, especially when clients' beliefs differ greatly from one's own [27].

EVALUATING THE INFLUENCE OF ONE'S SPIRITUAL AND/OR RELIGIOUS BELIEFS AND VALUES ON THE CLIENT AND THE COUNSELING PROCESS

A counselor has the potential to intentionally or unintentionally influence a client toward his/her own worldview [27]. Therefore, counselors should be mindful and monitor how their values and beliefs might influence the interventions they use in their professional work. If counselors have clarity regarding their values and beliefs, they are less likely to lead their clients toward adopting their values and beliefs. The counselor's task is to provide a nonjudgmental and accepting environment for clients to discuss their religious and spiritual concerns. Counseling does not entail making decisions for the client, teaching them "appropriate" values, or steering clients toward accepting the counselor's perspective [27]. Instead, counselors should keep in mind that the client is responsible for determining which values to maintain, discard, replace, or modify [27].

McLennan et al. suggest counselors engage in self-exploration to determine how their religious and spiritual values and beliefs might impact the therapeutic process [87]. Not doing so could lead to negative consequences, such as [27]:

- Clients feeling their spiritual experiences are not validated

- Counselors overlooking clients' important issues that should be addressed

- Counselors failing to recognize clients' positive spiritual coping resources

In short, counselors must first feel comfortable with their own spiritual and religious values and beliefs before working with clients who want to address spiritual and/or religious issues in counseling [27].

RECOGNIZING LIMITS

The first and most basic limitation for counselors to consider is whether they can work with clients around spiritual or religious concerns [27]. Some counselors may have their own spiritual concerns due to past experiences and may not feel comfortable discussing religious and spiritual issues with clients [27]. Acknowledging any reluctance to address spiritual and/or religious matters is an important step toward understanding one's limitations. Upon noting one's reluctance, growth in comfort and competence is necessary [27].

The second professional limitation to consider involves the assessment of clients' spectrum of spiritual concerns. A client's presenting concern is often related to his/her current spiritual beliefs and practices (e.g. "How can God allow me to feel so much pain in this situation?"). Other times, presenting concerns are influenced by the client's spiritual beliefs and practice (e.g., "Should I have a sexual relationship with my girlfriend?") [27].

A third limitation is clients being challenged by their own or others' beliefs and practices [27]. Some clients may be having a crisis of faith, have experienced spiritual abuse, or may feel unable to achieve the standards of their religion.

Lastly, it is important for counselors to avoid crossing professional boundaries and adopting the role of a religious leader; doing so would interfere with the therapeutic process [27]. Counselors who are self-aware know when to refer a client to spiritual and/or religious community resources. For example, if a client's concern is related to religious doctrine or scripture, a referral to a clergy might be necessary. Counselors should also be familiar with their referral sources and with the spiritual resources in the community [27].

8. HUMAN AND SPIRITUAL DEVELOPMENT

Competency 6

The professional counselor can describe and apply various models of spiritual and/or religious development and their relationship to human development.

Spiritual development has been identified as a normal part of the human development process [27]. To become competent in this area, counselors should be familiar with the various models of spiritual development. Spiritual development models differ in form and usually imply a process of growth over time [27,53]. Some theorists view spiritual development as a continual process, instead of a process of moving from one stage to another [88]. However, most spiritual development models are linear and hierarchical, and each stage of development builds on the previous stage [53]. Usually, individuals must complete each stage successfully before moving to the next stage. Further, each stage is designed to follow a chronologic sequence based on age or life stage [53]. These models are useful because they assist counselors in understanding how clients integrate faith into their lives [53]. Furthermore, they give counselors an idea as to where clients are in their spiritual and religious development [53]. This section will discuss a variety of models of spiritual development, including Allport's theory of faith development, Fowler's Stages of Faith, Oser and Gmunder's religious judgment model, Genia's faith development model, and Washburn's theory of transpersonal development.

ALLPORT'S MODEL

Gordon Allport presented the first model of faith development in 1950 [53]. This model focused on "religious sentiments," which he defined as "religious beliefs (empowered by effective energies) that lead to consonant religious and secular behavior" [89,90]. According to Allport, religious sentiments or beliefs occur in three stages.

Stage 1 of Allport's model is raw credulity. This stage is referred to as authority-based, because persons in this stage (traditionally, prepubescent children) tend to believe whatever their parents or adult authority figures tell them about religion and spirituality [90]. Such blind acceptance of religious doctrine fulfills an individual's need to belong and be accepted by an "in-group" [89]. Many children move into adulthood without questioning the faith they acquire as children, and these beliefs are considered juvenile and illogical [89].

Stage 2 is satisfying rationalism. This usually begins during the turbulence of adolescence. During this stage, individuals start questioning what they have been taught about religion and spirituality and begin to seek an identity separate from their parents [90]. Many individuals enter this stage in their teenage years, becoming rebellious and starting to reject parental values, including religious and/or spiritual ones [89].

Stage 3 is religious maturity. This stage is characterized by the movement between uncertainty and faith [53]. Mature religious sentiment occurs when individuals remain connected to a religious or spiritual tradition but approach it critically [53]. Individuals in this stage discern which beliefs are useful to them and which are not. Useful beliefs are kept, and harmful or non-useful beliefs are discarded [53].

FOWLER'S STAGES OF FAITH

Fowler perceived faith development as an innate part of human development [27]. His theory of faith development is grounded in cognitive development theory. Fowler defines faith as "loyalty to a transcendent center of value and power" and "the force field of life" [91]. Fowler's faith development model was based on a qualitative study of 359 individuals who were interviewed between 1972 and 1981 about religion, values, and life-altering experiences [27,53]. Each interview lasted about 2.5 hours, and participants ranged from 3.5 to 84 years of age. Fowler's theory of faith development is comprised of seven stages.

Stage 1 of Fowler's model is referred to as primal faith, and it occurs during infancy and before language development. At this stage, children experience faith as a connection between themselves and their caregivers. Infants are learning to trust their caregivers to meet their needs. If their needs are met, they gain hope, love, courage, and trust; however, unfulfilled needs lead to narcissism or isolation [91].

Stage 2 is intuitive-projective faith. Children at this stage are between 3 to 7 years of age. Language is emerging, but cognitive processes have not fully developed—these children are incapable of thinking logically and seeing the world from another person's perspective [27,53]. Their internal world centers around fantasy, imagination, and emotions [27]. At this stage, children's images of God are very similar to their parents and other significant others [27].

Stage 3 is mythic-literal faith. Children at this stage are usually elementary and middle-school age. Their cognitive processes are emerging; therefore, their thinking is more logical and they are able to see the world through other people's perspectives. They are now capable of separating fantasy from reality [53]. Children at this stage begin to incorporate the values and beliefs of their culture as guidelines for living [27]. God is perceived as anthropomorphic and the ruler of the universe—one who is fair and rewards good and punishes evil [27].

Stage 4 is synthetic-conventional faith. The majority of persons at this stage are adolescents. These persons can think abstractly, engage in self-reflection, and see themselves through the eyes of others [53]. At this stage, individuals find meaning through group identification. Therefore, they seek belonging through religious institutions, spiritual traditions, family, and ethnic groups [27].

Stage 5 is individuative-reflective faith. This stage is generally comprised of persons in late adolescence to early adulthood [27]. Persons at this stage start to question assumptions around their faith tradition. No longer do they blindly accept the faith of their parents. Some persons leave their religious community to search for answers to their questions. Faith becomes a conscious decision based on critical examination. In the end, the person starts to take greater ownership of his or her faith journey [53].

Stage 6 is conjunctive faith. Persons who arrive in this stage are usually in their 30s [27]. Many have found answers to some of their questions and have learned that two or more truths can exist simultaneously [27]. They have developed their own faith through struggling and questioning. They now acknowledge and embrace multiple perspectives of faith while remaining grounded in their own.

Stage 7 is universalizing faith, and very few people reach this stage. Persons at this stage are committed to universal values such as peace and justice [53]. Moreover, they are "grounded in oneness with the power of being or God" [91].

OSER'S RELIGIOUS JUDGMENT MODEL

Oser's religious judgment model is universal and is based on a cognitive approach to spiritual development [92]. The model occurs in five stages and explains how people understand their relationship with God or the Ultimate Being. According to the model, crisis situations provoke individuals to explore their relationship with God or the Ultimate [65]. Crises usually create disequilibrium in the lives of individuals, causing them to question their relationship with the Ultimate [65]. Consequently, they decide to be open to uncertainty and the opportunity to reconsider this relationship [65]. This is a continuous process whereby people undergo a transformation of faith as they age due to their life experiences [53].

Stage 1 is referred to as the orientation of heteronomy. Persons (usually children) at this stage view God or the Ultimate Being as all-powerful and the cause of everything that happens (good and bad).

Stage 2 is the orientation of do et des. Do et des translated from Latin means "I give and you give" [27]. God continues to be perceived as all-powerful but can be influenced through prayers, vows, rituals, and good deeds [27,65].

Stage 3 is the orientation of ego autonomy and one-side responsibility. In this stage, God or the Ultimate (if such a being exists) is placed within an independent realm of influence separated from human autonomy and responsibility. Thus, both the individual and the Ultimate are independent and free to make decisions.

Stage 4 is mediated autonomy. In this stage, individuals perceive God as having power over all things and as being present in the world. The Ultimate and the individual work in concert according to God's predetermined divine plan [53].

Stage 5 is the orientation of unconditional religiosity. Persons at this stage are aware of the all-pervasiveness of God. They recognize that God "informs each moment and commitment in life, however profane and insignificant" [53].

GENIA'S FIVE-STAGE FAITH DEVELOPMENT MODEL

Genia's Five-Stage Faith Development Model has its origin in psychoanalytic theory. The model depicts the progression of faith through five stages, beginning with egocentric faith and ending with transcendent faith. According to this theory, the progression of faith development is not always linear nor does it always run smoothly [53]. When individuals are undergoing crises or when their needs have not been met for a period of time, they tend to regress to less mature coping strategies [93]. Emotional difficulties can cause persons to seek out toxic forms of faith, and traumatic experiences can prevent them from progressing to the next stage [93].

Stage 1 of Genia's model is egocentric faith. In this stage, one's religion is rooted in fear and a need for comfort [53]. Usually, adults in this stage have survived abuse or neglect and have difficulty forming trusting relationships with others or with God [53,65]. Disappointments or emotional pain cause these persons to feel tormented by God. Adults at this stage typically use prayer as a means of seeking God's favor and manipulating God to protect them [65].

Stage 2 is dogmatic faith. Persons at this stage are continually trying to earn the approval of God [65]. They adhere to religious and spiritual laws out of fear of disappointing God and forfeiting the reward of eternal blessing.

Stage 3 is transitional faith. Persons in this stage are critically examining their faith. They may experiment with different spiritual paths, trusting their own conscience instead of religious dogma. During this period of experimenting with various spiritual paths, individuals often feel alone and disconnected [65]. People at this stage of faith might switch religious denominations or might investigate a variety of other spiritual experiences prior to adopting a meaningful spiritual orientation [53,65].

Stage 4 is reconstructed faith. Persons at this stage have matured and have chosen a faith that provides meaning and purpose and suits their spiritual needs. Because they are driven by their own morals and ideas, they perceive God as a reliable friend and source of sustenance [53,65]. Therefore, they are grateful, acknowledging their wrongdoings, seeking forgiveness, and making amends when possible [65].

Stage 5 is transcendent faith; most individuals do not reach this stage. Persons who do reach this stage are usually more mature spiritually and are committed to universal ideals and are devoted to truth and goodness [53]. They feel a sense of connection with others of diverse faiths, have a relationship with God, and apply spiritual principles to their lives [53].

WASHBURN'S THEORY OF PSYCHOSPIRITUAL DEVELOPMENT

Washburn's theory of psychospiritual development is based on psychoanalytic theory and transpersonal psychology [27,94,94]. According to Washburn, the primary aim of human development is spiritual fulfillment [27]. He envisioned spiritual fulfillment resulting from the interplay between the ego (personal aspect) and the Dynamic Ground (spiritual aspect), which is a lifelong process. During this interplay, the ego functions receptively (moves closer to the Ground) or actively (moves away from the Ground) [27]. The interplay between the ego and the Dynamic Ground continues throughout the developmental process as both evolve through the three stages [27].

Stage 1 of Washburn's theory is the pre-egoic phase. This stage begins at birth and continues to pre-latent childhood [27]. At this stage, the ego is totally immersed in the Dynamic Ground and, therefore, in the receptive mode of functioning. After birth, the ego becomes more active, as it begins to differentiate itself from the Dynamic Ground through repression [27]. During latency, the ego has completely separated itself from the Dynamic Ground.

Stage 2 is the egoic phase. During this stage, the ego functions primarily in the active mode, as it becomes more autonomous while the Dynamic Ground recedes into unconsciousness. Persons may remain in this stage for their entire lives. Around midlife, individuals with highly evolved egos feel less threatened and begin to relax repression of the Dynamic Ground. Once relaxed and secure, the ego begins to reconnect with the Ground for the purpose of transcendence.

Stage 3 is called the transegoic phase. During this stage, reconnection with the Ground leads to emotional and functional difficulties, which brings about a spiritual awakening [27]. If the transegoic stage is allowed to proceed, the ego begins mastering both receptive and active functioning, sometimes simultaneously. This occurs through drawing from the Dynamic Ground and becoming increasingly empowered [27]. The individual who has learned to integrate opposites (i.e., active and receptive) is said to be demonstrating advanced development potential [27].

LIMITATIONS OF MODELS OF RELIGIOUS/SPIRITUAL DEVELOPMENTAL

No models of religious and/or spiritual development are all-encompassing. A major criticism of these models is that they tend to promote the notion of "developmental progression" [53]. While some assert that the stages in these models are simply ways of organizing shared traits, to some theorists the stage-wise approach seems to imply that individuals at higher stages in the models are more valued than those at a lower stage [53]. In structures that are linear and hierarchical, it is difficult not to conclude that higher stages are more valued [53].

Nevertheless, understanding the various spiritual developmental models can be of great value in the counseling process. Such models can serve as a reference point for both the counselor and the client and can help both parties anticipate and even facilitate the client's developmental progress [27].

9. COMMUNICATION

Competency 7

The professional counselor responds to client communication about spirituality and/or religion with acceptance and sensitivity.

Competency 8

The professional counselor uses spiritual and/or religious concepts that are consistent with the client's spiritual and/or religious perspective and are acceptable to the client.

Competency 9

The professional counselor can recognize spiritual and/or religious themes in client communication and is able to address these with the client when they are therapeutically relevant.

Most mental health professionals agree that discussing religious and spiritual matters in counseling, when appropriate, is desirable and "a necessary component of holistically addressing clients' needs" [27]. However, the best way to communicate with clients about religion and spiritual matters remains under-explored [27]. Counselor training programs have historically neglected spiritual issues due to the belief that religion and education should be separated [27]. Consequently, students did not receive vital training to address spiritual matters in counseling. This lack of knowledge can hinder effective communication, which may cause the client to feel that the counselor is insensitive or not receptive to discussing religious or spiritual matters [27].

The ability to intensify clients' exploration of their spirituality relies on the counselor's communication skills [27]. Spirituality is very personal, and deeper exploration of a client's spirituality can be very therapeutic, especially when counselors express genuine interest in client beliefs [27]. Effective communication regarding spiritual and religious issues involves avoiding four common barriers to miscommunication. The first type of miscommunication occurs when counselors do not accurately convey spiritual or religious content discussed in the session [27]. Second, counselors may also be inconsistent or incongruent with their communications. Third, counselors may struggle with limitations and complexities inherent in the language clients use when discussing their religious and/or spiritual beliefs [27]. Finally, counselors may inappropriately express judgment or disapproval of clients' beliefs and values [27]. Avoiding these four types of miscommunication will lead to a more trusting therapeutic relationship. Clients may feel discouraged from discussing spiritual or religious issues when counselors are not consistent in their communication of being open to exploring client spirituality [27]. Openness and consistency should start at the beginning of the counseling session, preferably during the intake process [53].

Another key element of effective communication is matching the client's language or terminology [27]. For example, if a client uses Allah in reference to God, counselors should do the same rather than using another comparable term, such as Higher Power [27]. Using words outside of the client's frame of reference during counseling can damage the therapeutic relationship [27]. Often, clients will not feel comfortable initiating discussion about spiritual concerns in counseling and will use indirect messages of spirituality instead [27]. Therefore, counselors should listen for spiritual themes, which can take many forms. These themes may be centered around ideas of the sacred, a belief in a just universe, death or loss, and/or finding meaning and purpose [27].

Other factors that influence spiritual communication and the developmental process include gender, age, race, ethnicity, family, and sexuality [27]. Both explicit and implicit gender-laden messages can affect how individuals' spiritual and religious identities develop. Religious teachings may conflict with a client's sexual orientation and present a spiritual concern for the client. [27]. Also, clients of different ages may be in different stages of spiritual development. For example, older adults may use faith to cope when considering their own mortality [27].

10. ASSESSMENT

Competency 10

During the intake and assessment processes, the professional counselor strives to understand a client's spiritual and/or religious perspective by gathering information from the client and/or other sources.

Both spiritual assessments and informed consents are needed prior to incorporating spirituality or religion into therapy. A primary function of a spiritual assessment is to determine whether religious or spiritual issues are germane to the client's presenting problem or to ascertain if the presenting problem is spiritual or religious in nature [62]. There are a variety of purposes to assess the client's religious and spiritual perspective, including to [15]:

- Understand the client's worldview

- Obtain knowledge as to how healthy the client's perspective is and how it is related to counseling issues

- Identify positive resources of beliefs and support

- Determine possible interventions that can be used in counseling

- Clarify the level of need to address spiritual or religious views in counseling

The intake process and the clinical interview are usually the first steps in the spiritual assessment process [53]. Both the intake and the clinical interview give counselors the opportunity to learn about the client, the client's concerns, and the client's worldview (including spiritual and religious perspectives) [27,53]. Information gathered during the intake process usually includes demographic information, a description of the presenting problem, current problem-solving techniques, medical history, mental health status, and family background [53]. When conducting an assessment of the client's spiritual and/or religious perspective, certain factors should be considered, such as family religious and/or spiritual history, its impact on the client's upbringing, and the client's past experiences with spiritual or religious issues [62,95].

Counselors can assess their clients' spirituality utilizing intake questionnaires or counseling interviews [96]. Questions one might consider asking at intake include [96]:

- Would you like to discuss spiritual matters in counseling when relevant?

- Do you believe in God or a higher power?

- What is God like to you?

- Is spirituality important to you?

- Do you have a religious affiliation? If so, how important is it?

- Do you attend a place of gathering, such as a church, mosque, temple, or synagogue?

- How closely do you, and your family, follow the teachings of your religion?

- How do you personally experience God's guidance?

- Do you have any concerns related to your spirituality or religious community?

When gathering spiritual information about the client, it is important to remember that the focus should be on the whole person and not just on the client's presenting problem or spiritual concerns [27]. Humans are multidimensional; therefore, a client's physical, emotional, spiritual, and environmental dimensions should all be taken into consideration during an assessment [27]. Information gathering should include verbal and nonverbal communication. For example, counselors may obtain some information through observing client appearance (e.g., head coverings, religious symbols, wedding rings) [27].

A spiritual genogram is another way of assessing the spiritual domain in families. It gives clients a multigeneration view by enabling clients to understand their families' religious/spiritual heritage and recognize ways in which their families' experiences impact current issues in their lives [53,103]. Spiritual ecomaps can also be used with clients to assess the spiritual domain of the client's immediate family when necessary [95]. Usually, a family's spiritual genogram is located in the center of the spiritual ecomap, with other subsystems relevant to the family located outside of the family circle [95].

11. DIAGNOSIS AND TREATMENT

Competency 11

When making a diagnosis, the professional counselor recognizes the client's spiritual and/or religious perspective can a) enhance well-being, b) contribute to client problems, and/or c) exacerbate symptoms.

Competency 12

The professional counselor sets goals with the client that are consistent with the client's spiritual and/or religious perspectives.

Competency 13

The professional counselor is able to a) modify therapeutic techniques to include a client's spiritual and/or religious perspectives, and b) utilize spiritual and/or religious practices as techniques when appropriate and acceptable to a client's viewpoint.

Competency 14

The professional counselor can therapeutically apply theory and current research supporting the inclusion of a client's spiritual and/or religious perspectives and practices.

When making a diagnosis, it is important to remember that positive or healthy spiritual beliefs may enhance well-being while negative or unhealthy spiritual beliefs can contribute to the problem by diminishing hope and instilling fear. When working in the realm of spirituality and mental health, the risk of misdiagnosis increases [27]. Counselors who are spiritually and religiously oriented tend to be more inclined to underdiagnose clients, while counselors who adhere to a biomedical model may overlook spiritual influences and/or diagnose them as treatable disorders [27]. A counselor who lacks understanding of transformative processes may pathologize spiritual experiences rather than contextualizing them as spiritual and/or religious [27]. Conversely, counselors who shy away from diagnosing clients may be more likely to label a diagnosable disorder as a spiritual experience [27]. Essentially, it is vital for counselors to be able to discern diagnosable mental disorders/symptoms and spiritual experiences [27].

A diagnostic category V62.89 Religious and Spiritual Problems was proposed by transpersonal clinicians to address this concern and subsequently added to the fourth revised edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) and carried over to the fifth edition (DSM-5) [97,102]. Examples of religious and spiritual problems include [97]:

- Crisis of faith

- Conversion to a new faith

- Life-threatening or terminal illness

- Guilt and shame resulting from membership in a religious cult

In some cases, spiritual or religious problems co-occur with a psychiatric disorder [27,97]. For example, obsessive-compulsive disorder may manifest as religious or spiritual [27]. An extreme version of this is moral or religious scrupulosity, an obsessive concern with one's sins and moral behavior [27]. Treatment of this disorder is difficult, as practitioners often feel torn between addressing the pathology of the disorder and respecting the patient's religious beliefs or practices.

In some instances, spiritual or religious concerns are merely due to psychopathology. Patients with psychotic disorders may experience delusions and hallucinations with religious content, and focusing on religion might exacerbate symptoms of disorganized thought and potentially promote injury to self or others [98,99,100].

Counseling goals should be clear, observable, measurable, and attainable so sessions do not appear aimless. Moreover, these goals should be consistent with the client's belief system [27]. Clients' participation in goal setting is very important, and goal setting for spiritual and religious matters should come primarily from the client. There are three types of outcome goal settings to keep in mind throughout the counseling process: collaborative goals, counselor process goals, and spiritual and religious goals [27]. Collaborative goals are developed by the client and the counselor together [27]. Counselor process goals are developed by the counselor for their work with clients, the therapeutic relationship, and the process [27]. Usually, these goals are not shared directly with the client. Spiritual and religious goals are developed for the client's spiritual and/or religious growth. These goals tend to be less specific or behavioral, which makes outcomes difficult to measure [27].

Evidence Based Practice Recommendation

The American Academy of Child and Adolescent Psychiatry recommends clinicians consider consulting and collaborating with traditional healers (e.g., curanderos, santeros, or shamans) and including rituals and ceremonies in psychotherapy with children from more traditional backgrounds.

https://www.aacap.org/App_Themes/AACAP/Docs/practice_parameters/Cultural_Competence_Web.pdf

Last Accessed: May 19, 2020

Level of Evidence: Consensus Statement/Expert Opinion

Competently treating spirituality concerns requires counselors to modify therapeutic techniques to include clients' spiritual and religious perspectives [27]. One way to do this is through experiential focusing, a process developed by Gendlin to access and integrate spiritual experiences [27,101]. Encouraging adjunctive spiritual practices (e.g., spiritual journaling, mindfulness techniques, meditation, prayer) can be useful as well, depending on the client's belief system. Counselors can also encourage the use of spiritual practices during sessions by leading clients through a guided meditation [27]. There are many presenting problems and situations in which spiritual or religious exploration would be beneficial, including clients who present with depression, substance abuse, and terminal illness [27]. However, it is always important to consider clients' beliefs and comfort levels using spiritual or religious techniques and practices in the counseling setting.

12. CONCLUSION

There is a growing recognition of the importance of the spiritual domain in the counseling process and the need for training materials and strategies for integrating the ASERVIC competencies into the field of counseling. Although many mental health professionals and educators endorse the spiritual competencies, additional resources can help clarify the role of these competencies in everyday practice.

This course has summarized the revised ASERVIC competencies, their relevance, and application in the counseling process. It is important for counselors to be proficient in each area before working with spiritual and religious issues with clients. These competencies will enable counselors, mental health professionals, and allied health professionals to develop a framework to assist them in understanding and working effectively with clients' spiritual and religious lives.

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Evidence-Based Practice Recommendations Citations

1. Pumariega AJ, Rothe E, Mian A, et al. Practice parameter for cultural competence in child and adolescent psychiatric practice. J Am Acad Child Adolesc Psychiatry. 2013;52(10):1101-1115. Available at https://www.aacap.org/App_Themes/AACAP/Docs/practice_parameters/Cultural_Competence_Web.pdf. Last accessed May 19, 2020.