Course Articles

Ethics Beyond Professional Codes: Wisdom from Buddhist Traditions for Behavioral Health Professionals

Allan Barsky, JD, MSW, PhD

This material is for educational purposes and does not replace clinical judgment or local policy.

Course overview

Professional codes of ethics and Western philosophical traditions form the backbone of ethics training for behavioral health professionals, yet these frameworks are not the only sources of ethical wisdom available to clinicians. Buddhist traditions offer a complementary set of concepts, compassion, mindfulness, impermanence, and non-harming, that align closely with existing professional obligations while adding useful language and practice tools. This article sets these four principles alongside familiar Western frameworks, including virtue ethics, deontology, and the ethics of care, and then applies them to three practice scenarios involving suicidal ideation, refugee resettlement, and end-of-life care. The treatment here is introductory rather than comprehensive, and clinicians working with Buddhist clients or communities are encouraged to pursue further reading, to participate in a local or online Buddhist community, and to practice cultural humility by learning directly from clients about what they see as Buddhist values and beliefs and how those beliefs affect their own decision-making.

Learning Outcomes

After completing this course, participants will be able to:

Describe at least three Buddhist principles: compassion (karuṇā), mindfulness (sati), impermanence (anicca), and non-harming (ahiṃsā).
Apply at least two Buddhist concepts: compassion (karuṇā), mindfulness (sati), impermanence (anicca), and non-harming (ahiṃsā) in ethical decision-making in mental health practice.
Evaluate how mindfulness and compassion practices may enhance ethical sensitivity, reduce bias, and support client well-being.

Limitations/Risks

Ethical and legal obligations may vary significantly between different regions and cultures. This training focuses on general principles and is not intended to be a substitute for consultation with your professional code of ethics, local laws, supervisors, or legal counsel.

Cultural Perspectives on Ethical Fidelity: This course provides a broad framework for ethical fidelity in mental health practice, but does not fully address how cultural values, norms, and traditions may influence ethical decision-making. Clinicians should consider culturally responsive approaches and seek guidance when working with clients from diverse backgrounds to ensure ethical fidelity aligns with both professional standards and cultural contexts.

Bias and Ethical Interpretation: Ethical dilemmas and concepts of fidelity may be interpreted differently based on cultural perspectives, systemic influences, and lived experiences. This training does not offer an exhaustive review of how implicit bias, power dynamics, and privilege may affect ethical decision-making. Clinicians are encouraged to engage in ongoing cultural humility training, supervision, and consultation to navigate these complexities effectively.

The specific answer to an ethical question depends on the ethical and legal obligations in a clinician's particular practice context, including local law and the cultural background of the people being served. Buddhist ethical principles, discussed in this article across behavioral health professions, should always be considered alongside, rather than as a substitute for, a clinician's own applicable code of ethics, since differences between professions depend on a clinician's particular professional background.

Ethics Codes

Several major behavioral health professions publish codes of ethics, and clinicians are reminded to always refer to the applicable code for their profession. The American Association for Marriage and Family Therapy publishes a code of ethics governing marriage and family therapists (American Association for Marriage and Family Therapy, 2015). The American Counseling Association publishes the 2014 ACA Code of Ethics for professional counselors (American Counseling Association, 2014). The American Psychological Association publishes ethical principles and a code of conduct for psychologists (American Psychological Association, 2017). The National Association of Social Workers publishes a code of ethics for social workers (National Association of Social Workers, 2021). Links are also provided to codes for certified counselors, alcohol and drug abuse counselors, and Ohio's administrative rules for counselor, social worker, and marriage and family therapist licensure.

Agenda

This article proceeds through five parts. The first part introduces key concepts in Buddhist ethics. The second part compares Buddhist ethics with the ethics typically embedded in professional codes and training for behavioral health professionals. The third part addresses application and evaluation, meaning how a clinician might apply these principles in practice and subsequently evaluate how well the principles were applied. The fourth part works through three case scenarios. The fifth part addresses common clinical questions and closes with concluding observations.

Buddhist and Western ethical traditions are sometimes treated as entirely separate or even opposed, but a closer comparison reveals several clear overlaps between Buddhist ethics and the professional ethics commonly taught to behavioral health professionals in the United States and other Western-dominant societies.

Concepts

Each Sanskrit term discussed below is paired with an English translation that is necessarily approximate; some nuance of meaning is inevitably lost in translating a concept from one language and tradition into another, even though the English terms chosen here aim to stay as close as possible to the original meaning. Readers are not expected to know the Sanskrit terms themselves, only the underlying English concepts.

Buddhist Ethics

Buddhist ethics refers to moral principles grounded in the teachings of the Buddha and in the writings of Buddhist leaders, teachers, and scholars, including the Dalai Lama and other more recent scholars who have expanded on these teachings (Egan et al., 2017; Koh, 2024). Several features distinguish this tradition from some Western frameworks.

Buddhist ethics emphasizes a middle way, a deliberate avoidance of extremes in either direction, a logic comparable to Aristotle's principle of the golden mean. Ethical disagreements are sometimes resolved not by moving toward one extreme position or another but by identifying a middle path that can bring differing parties together.

Morality in this tradition is determined primarily by intent rather than outcome, aligning it most closely with deontological, or duty-based, ethics rather than teleological approaches that judge an act primarily by its consequences. A teleological framework asks not only whether an actor intended good but whether the outcome actually produced was good, whereas Buddhist ethics places its primary emphasis on the intent behind an act, for example, the intent to be non-violent, respectful, and oriented toward the good, while not disregarding outcomes altogether.

The principle of karma holds that wholesome actions tend to lead to good outcomes. Although morality is determined by intent rather than outcome, the tradition holds that good intentions, when expressed through action, are more likely to yield beneficial results over time.

Finally, the tradition emphasizes universal responsibility. Ethical obligation is not limited to a particular professional role or situation. Every person is expected to strive to act well in all circumstances, regardless of role or status in life.

Interest in Buddhist ethics has grown in the United States in part because of a march undertaken by Buddhist monks from Texas to Washington, D.C., intended to spread the principles of non-violence and peace beyond Buddhist communities to the wider society.

Compassion (Karuṇā)

Compassion, or karuṇā, is the first specific principle addressed in this article. The English translation is approximate, and the concept carries nuances beyond the ordinary English use of the word compassion. Three components define it: care and concern, empathy paired with a desire to act, and a heartfelt wish to relieve suffering (Avci, 2025).

Care and concern denote an awareness of another person's situation accompanied by an emotional response to that awareness, a sense that the situation matters. Empathy and desire to act extend this awareness into motivation, meaning that compassion is not simply an accurate understanding of where another person stands, including their grievances, pain, sorrow, or happiness, but also a wish to have a positive effect on that person's circumstances. A heartfelt wish to relieve suffering distinguishes compassion from pity or mere sympathy. Karuṇā is concern for the well-being of all people, paired with a readiness to act, oriented toward healing, freedom from illness or problems, or relief from something painful in another person's life.

Mindfulness (Sati)

Mindfulness, or sati, is closely related to the awareness cultivated through yoga practice, one common route toward this kind of attentiveness (Berger et al., 2024; Monteiro et al., 2015; Shulman, 2025).

Awareness in this context has three related targets: the body, thoughts, and feelings. Awareness of the body means noticing bodily sensations, such as tension in the shoulders or head, as well as physical signs of nervousness or excitement. Awareness of feelings means noticing emotional states such as stress, happiness, or joy. Awareness of thoughts means noticing the cognitions running through the mind at a given moment, and recognizing how thoughts and feelings are connected. A clinician experiencing anger may perceive another person as threatening or difficult, even when the underlying issue is the clinician's own state of distress or fear; calming that emotional state can change how the clinician perceives and responds to the other person.

Four qualities characterize mindfulness practice: proceeding without judgment, reflecting, meditating, and centering. Without judgment means observing thoughts, feelings, and sensations as they are, without labeling them as good or bad. Anger is simply anger, happiness is simply happiness, a wish to be lazy on a given day is simply a thought that arises, not something to be judged, and physical pain in the legs after a hard day of exercise is simply acknowledged as present rather than judged as good or bad. This kind of non-judgmental awareness cultivates wisdom, can reduce suffering, and can feel liberating; it applies not only to concerns about oneself but also to concerns about friends, colleagues, and clients. Reflecting means considering an experience, either in the moment or after the fact, and noticing which elements produced hope or enthusiasm and which produced doubt or discomfort. Meditating can take many forms beyond seated stillness, including yoga, deliberate walking, tracing a labyrinth, or engaging in reflective drawing or art, each intended to calm the mind, reduce distraction, and deepen focus while avoiding a scattered, monkey mind quality of attention, all while maintaining a non-judgmental stance. Centering refers to pausing between activities, such as between client sessions, to set aside residual thoughts, feelings, and stress from a prior interaction before engaging with the next client. Even five to ten minutes between sessions devoted to this kind of centering can help a clinician return to a clear sense of professional role before the next session begins, supporting more deliberate, ethical, and mindful engagement with each subsequent client.

Mindfulness also underlies the emphasis, found across ethics trainings, on deliberation, the requirement that sound ethical decisions rest on engaged, reflective thinking rather than automatic or reactive responses. This connects to dialectical behavior therapy, which shares meaningful overlap with these principles, since helping clients manage difficult feelings, become aware of past trauma, and practice letting go or recognizing that a current difficult experience is impermanent is broadly consistent with the framework developed here. Models of practice should be informed not only by research evidence but also by the values and ethical commitments that underlie a clinician's approach to treatment. A structured daily routine, such as scheduled fifteen-minute breaks, offers a practical way to build a personal mindfulness practice into a clinical workday.

Impermanence (Anicca)

Impermanence, or anicca, is the recognition that nothing is fixed or eternal. All phenomena, including thoughts, feelings, bodies, possessions, relationships, and the world itself, arise and eventually pass away, much as a fragile object will eventually break. Professionals themselves will not always be young, will not always be early in their careers, and will not always carry the same level of energy. Life, clients, and social and political circumstances change continually. Recognizing this can allow a person to hold experiences and possessions more lightly; if a person breaks a fancy dish or a vase, the disappointment may be softened by recognizing that the dish or vase was going to break eventually, regardless. This same recognition applies not only to possessions but to all phenomena, thoughts, feelings, bodies, relationships, and the world itself, which arise, are sometimes destroyed or lost, and are continually replaced by new things coming into and passing out of a person's life.

Mindfulness can be used to raise awareness of impermanence by examining why a particular loss or ending feels difficult, and by approaching that difficulty without judgment. A therapeutic relationship, for example, may end through termination even when both clinician and client experienced the relationship as valuable, and framing that ending within the concept of anicca helps normalize the sense of loss that accompanies termination as an expected part of a relationship that was never intended to be permanent. If something about an ending continues to feel difficult, asking why it is bothering oneself, without judging that difficulty, is itself part of the practice, since something that mattered a great deal at the time may still need to be let go of gradually, without the letting go itself being judged as good or bad.

This principle extends naturally to caregiving contexts, such as a family caring for a relative living with dementia, including Alzheimer's disease. Focusing solely on the suffering, hardship, confusion, and anxiety associated with the condition can intensify a caregiver's own sense of suffering. Recognizing impermanence, including the impermanence of a person's capacities and memory, does not deny that suffering exists, but it may offer a way to hold that suffering with somewhat greater ease. This does not mean the suffering must be resolved; if it stays with a person, that is acceptable as well, without further self-judgment for the difficulty of letting go.

Non-Harming (Ahiṃsā)

Non-harming, or ahiṃsā, is the avoidance of causing harm to others, whether physical, emotional, or spiritual (Avci, 2025; Benerjee, 2024).

Physical harm in a clinical context could involve something as direct as getting into a physical altercation with someone or setting another person up for a physical confrontation, and it could also involve something more indirect, such as a referral for medication with side effects; the clinician's obligation is to ensure the client understands both the potential benefits and the potential harms of a given intervention, and to reconsider that intervention if the harms outweigh the benefits. Emotional harm might arise in the course of discussing trauma, sadness, or other difficult material with a client; the purpose of raising such material is to help the client work through it and move toward greater functioning, not to cause distress for its own sake. Spiritual harm concerns a person's sense of meaning and purpose, which they may define through religion, faith, volunteer work, parenting, or other sources of significance, and clinical practice should support rather than undermine that sense of purpose.

Ahiṃsā is sometimes translated as non-violence, which does not mean an absence of assertiveness or advocacy. A clinician may advocate strongly for something important, but should do so honestly, respectfully, and persuasively without seeking to harm or demean others in the process. This principle connects directly to compassion, since caring about a client's well-being should not come at the expense of others, including agencies or insurers for whom a clinician may be advocating.

Parallels with Professional Ethics of MHPs

The four Buddhist principles already discussed align closely with concepts embedded in the ethical training and codes of behavioral health professionals (Barsky, 2023; Garg & Dahia, 2024; Koh, 2024; Muncaster, 2021; Shonin et al., 2014; Wallace, 2001).

A focus on a person's character parallels virtue ethics. Aristotle's account of virtue ethics emphasizes enduring personality traits, such as respectfulness, caring, and compassion, and this framework overlaps substantially with the Buddhist emphasis on cultivating virtuous character to generate good karma.

Universal duty, with an emphasis on intent, parallels deontology. Immanuel Kant's principle of treating people as ends rather than as means, echoed by later deontologists such as Bernard Gert, requires that a clinician not exploit one person to benefit another, but instead treat all people with respect. This connects to the virtue of conscientiousness, an awareness of one's responsibilities across all roles in life, not only as a professional but also as a parent, friend, neighbor, and citizen, reflecting the universal scope of Buddhist ethical responsibility.

Compassion, or karuṇā, parallels fidelity with clients and, in social work specifically, the profession's primary ethical obligation toward the people it serves. Codes of ethics for psychologists and other professions may not use the word compassion directly, but the underlying expectation, that clinicians view situations from the client's perspective and act with empathy, reflects the same principle. This aligns with the ethics of care associated with feminist ethicists such as Carol Gilligan, who emphasize attentiveness to others' needs and argue that caring must be expressed through action, not only through feeling. Compassion in this sense can be summarized as care plus action, and it also reflects the framing of the helping professions as service professions oriented toward improving mental health, social well-being, and a client's overall sense of purpose.

Mindfulness, or sati, including what might be described as an ethics of tension, parallels self-awareness and other-awareness, conscious use of self, reiterative empathy, and attention to one's own biases. Self- and other-awareness means being aware of one's own beliefs, biases, and habitual ways of doing things, so as not to stereotype, judge, or discriminate against the people being served. For example, a clinician who personally places a high value on punctuality and getting things done within a set time frame may be working with clients who hold a more flexible orientation toward time; mindfulness of this difference allows the clinician to be accommodating of the client's own approach rather than imposing the clinician's own time-related values. Conscious use of self means being deliberate about what personal information a clinician chooses to share with a client, disclosing only what will help the client feel understood and connected, rather than information that might undermine the client's confidence in the clinician. Reiterative empathy refers to the practice of shifting attention back and forth between awareness of the client and awareness of oneself, particularly important when working with families or groups, where full simultaneous awareness of every person, including the clinician, is not possible. A brief period of centering or mindfulness before a session can help a clinician set aside extraneous concerns, allowing more attention to be directed toward the client during the session. Attention to one's own biases means recognizing the limits of one's understanding when working with clients from different backgrounds, for example, a client who is blind or a client with Parkinson's disease, and engaging in cultural humility by treating the client as the expert on their own experience rather than relying on the clinician's own assumptions. This finally connects to the emphasis, found across ethics trainings, on deliberation, the requirement that sound ethical decisions engage the deliberative, executive part of the mind rather than resting on an automatic, gut-level reaction.

Buddhist concept	Professional ethics parallel
Focus on the character of the person	Virtue ethics
Universal duty, intent	Deontology
Compassion (Karuṇā)	Fidelity with clients, primary duty to the client, ethics of care, plus action, service
Mindfulness (Sati), including "ethics of tension"	Self- and other-awareness, conscious use of self, reiterative empathy, attention to own biases, deliberation in ethical decisions

Parallels with Professional Ethics of MHPs

The comparison continues with the two remaining Buddhist principles (Barsky, 2023).

Impermanence, or anicca, parallels the professional belief that people can change, as well as related concepts such as hope, strengths-based practice, and loss theory. Although no code of ethics explicitly uses the term impermanence, the theories that inform professional practice reflect a very similar orientation. Positive expectations for a client's outcomes are associated with better outcomes, and a client's own sense of hope or hopelessness likewise affects the client's capacity for change, paralleling the core conditions long associated with positive therapeutic relationships, empathy, genuineness, and unconditional positive regard, together with a belief that current difficulties are not fixed. A client may be in a genuinely difficult situation, having lost a house or a job, or living with chronic pain, and impermanence does not deny that difficulty; rather, it points toward the possibility that even a condition that cannot be cured might still be controlled, and that a person's perspective on pain can shift even when the pain itself does not disappear. A strengths-based approach, in which a clinician asks a client who has struggled in school to recall an example of doing better, or asks a client dissatisfied with a marital relationship to recall a positive memory from years earlier, embodies this same recognition of impermanence, showing that a difficult present state is not necessarily a permanent one. Loss theory, similarly, recognizes that grief moves through phases; rather than telling a client that they will get over their grief, which is not an appropriate message, accepting the grief as it is may itself be what allows a person to return to functioning over time.

Non-harming, or ahiṃsā, parallels the Hippocratic principle of non-maleficence, above all, do no harm, and the broader professional practice of risk management. Risk management training addresses the same underlying question that ahiṃsā raises: how to maximize benefit and minimize harm from a given intervention, and how to avoid interventions where the potential harm is too severe. This principle also parallels respect for the dignity and worth of all people, with the caveat that respect must be assessed from the client's own perspective, since an action intended as respectful by the clinician may be experienced differently by the client.

Buddhist concept	Professional ethics parallel
Impermanence (Anicca)	Belief that people can change, hope, strengths, loss theory (acceptance)
Non-Harming (Ahiṃsā)	Hippocratic oath, do no harm, risk management, respect for the dignity and worth of all

Application & Evaluation

Application

Four practical steps support the application of these principles in day-to-day work.

Practice mindfulness. This might involve yoga, a five-minute centering period, journaling, or another routine that builds attentiveness to one's own thoughts, feelings, and bodily sensations, as well as mindful awareness of the other people being served.

Integrate Buddhist principles with principles from professional codes of ethics. This integration does not necessarily require a clinician to do something entirely new, but may involve applying familiar practices in a slightly different way, or adopting new terminology that reinforces existing habits.

Consult others with deeper knowledge of Buddhist ethics. This treatment offers only an introduction, and does not equip a clinician to teach yoga practice, Buddhist chanting, or prayer in any depth. Clinicians working with clients who practice these traditions should seek out consultation or further learning rather than relying solely on this article. A clinician does not need to personally practice Buddhist ethics in order to serve clients who do, but should be prepared to learn from those clients, from local or online Buddhist communities, and from further independent reading, approaching that learning with the same cultural humility discussed throughout this article.

Remain open to changes in oneself and others during ethics discussions. Clinicians and the people they work with can become frustrated when others do not share the same view of what is ethically correct. Recognizing that one's own frame of mind is impermanent and may shift with further experience, learning, or interaction with others can support more productive ethical discussion. A clinician's own attitude toward a contested issue, such as medical aid in dying, for example, might change considerably over the course of a career.

Evaluation: How well did I apply Buddhist ethics in this situation?

Mindfulness. To what extent was I aware of my thoughts, emotions, and bodily sensations?

Impermanence. To what extent was I able to accept change, including how my ideas about the ethical situation may evolve?

Compassion. To what extent did I show care and concern toward the client, myself, and others?

Non-harming. To what extent was I able to avoid harm to the client, myself, and others?

This evaluation extends the reflective practice already described under mindfulness, and clinicians are encouraged to revisit these four questions periodically, perhaps using them as a personal checklist after a difficult session or interaction. For mindfulness, this might mean asking what could have been done differently to respond with more awareness and less reactivity, verbally or nonverbally, during a tense meeting. For impermanence, this might mean recognizing that even a very strong conviction or religious belief can evolve over time, without necessarily changing completely. For compassion, this might mean examining a situation that went well and identifying whether attentiveness to the other person was balanced with attentiveness to one's own role as a helping professional. For non-harming, harm sometimes occurs without intention, through accident, an unavoidable circumstance, or negligence, and the evaluative question is not only whether harm occurred but whether it was avoidable and whether anything should be done differently going forward; some harms cannot be avoided altogether, and a clinician can remain aware of that harm without judging themselves negatively for it.

Scenarios

Thoughts of Suicide

Consider a client with severe depression who states, I don't want to live anymore. Please don't hospitalize me. I can't stand the idea of being locked up.

Mindfulness in this situation requires attention to the clinician's own attitudes toward hospitalization and clarity about what the client is actually requesting, whether the client wants support to remain at home or is raising the topic of medical aid in dying, together with awareness of the clinician's own automatic reaction, professional judgment, and personal beliefs in response.

Compassion involves exploring what a higher level of care could offer while also taking the client's fear of being confined seriously and empathizing with it, rather than addressing only the potential benefits of hospitalization. Non-harming involves considering options short of hospitalization, such as staying with friends or family, adjusting medication, or clarifying that any hospitalization would be brief rather than prolonged.

Impermanence involves validating the client's current thoughts and feelings while helping the client understand that, with support and the exploration of different options, these thoughts may not persist in the same form. Mindfulness techniques grounded in the five senses can help a client set aside broader existential concerns and remain present, consistent with research showing that mindfulness practices can be helpful for people experiencing depression.

Ahiṃsā, or non-harming, in this context also includes reassuring a client that having thoughts of suicide or self-harm does not mean the client will act on those thoughts, and that it is preferable for the client to discuss such thoughts openly with a clinician rather than keep them hidden.

Refugee

Consider a client from a Buddhist culture who is seeking refugee status in the United States and receiving services for post-traumatic stress disorder. During intake, the client requests that Buddhist chanting be incorporated into treatment, while the agency maintains a policy prohibiting religious practice during therapy sessions.

Compassion in this situation can be expressed through motivational interviewing, and mindfulness can be expressed through a breathing exercise framed as a general practice rather than explicitly as a Buddhist practice, or by allowing the client to chant while the clinician mindfully bears witness to the practice. Chanting has a physiological basis: it can activate the vagus nerve and support a parasympathetic response, a framing that can help reconcile a clinician's professional standing with a client's request. This physiological basis can also be used to help educate an agency that the practice is not simply religious but has a scientific, evidence-based rationale. Grounding techniques using counting or sound offer additional options that may satisfy both the client's preference and the agency's policy.

Mindfulness in this scenario also applies to the clinician's own reaction, prompting questions such as whether the clinician is comfortable with Buddhist chanting, and if not, whether that discomfort stems from unfamiliarity with the practice or from uncertainty about how an agency might respond, for example, concerns about insurance reimbursement. A clinician uncertain about the reasoning behind an agency policy can ask directly what specific concern the policy is meant to address, since the underlying concern, once clarified, may be addressed in a way that does not require excluding the client's request altogether. Giving the client a moment before beginning the formal portion of an interview, or taking a brief pause during the interview itself, offers another way to accommodate the client's request without necessarily contravening the letter of an agency's policy.

End-of-Life Care

Consider a palliative care therapist supporting a family whose loved one is dying. The family asks the therapist to advocate for the medical team to do everything to prolong life, while the medical team indicates that further treatment will increase suffering without meaningful benefit.

Compassion here is oriented toward relieving suffering for both the client and family members and requires self-awareness of the clinician's feelings about language, such as the phrase "do everything" (Avci, 2025). Medical and mental health professionals sometimes use language, such as describing a situation as beyond help or not worth pursuing further, that does not land well with family members, and part of the clinician's role is to use validating language and help the family clarify what do everything is actually meant to achieve, whether that goal is prolonging life specifically, or whether other goals, informed by the family's own beliefs, such as closure or the reduction of pain, might also be relevant.

Mindfulness in this context means being as present as possible with the time that remains, and choosing acceptance over spending limited remaining time resisting what cannot be changed, connecting directly to the principle of impermanence. Compassion toward a client does not require agreement with the client's choices, only genuine care, concern, and empathy, and this same compassion can be extended to family members, helping them explore what compassion toward their dying relative might mean to them.

Q&A

Questions for Discussion

Several recurring questions arise when applying these principles in practice. One concerns the relationship between yoga philosophy and the concepts discussed here, particularly the yamas and niyamas, which structure ethical conduct within yoga traditions and overlap substantially with the practices described above.

A second concern is the emphasis on intent over outcome, and the concern that outcome-focused judgment can unfairly characterize a person's motives; deontological reasoning does not disregard consequences altogether, but it recognizes that acting well according to duty may sometimes produce a less favorable short-term outcome while still serving the good of the wider system or society over the longer term. A third concerns how Buddhist philosophy relates to other religious traditions, such as Christianity, Judaism, or Islam, and whether adopting Buddhist-derived practices might conflict with a client's own faith; many elements discussed in this article are not mutually exclusive with other religious traditions, and a clinician can start by working within whichever mindfulness framework is consistent with a client's own religious beliefs, potentially introducing yoga or other Buddhist-derived practices later if appropriate, without requiring the client to adopt Buddhism itself or feel that doing so would offend their own faith.

A final and recurring question concerns how a clinician should think about holding contradictions, such as when a client holds beliefs that appear to conflict with other deeply held cultural values. Much of ethical practice involves holding two things as true at the same time. A client's belief may differ from a clinician's own view, and the client remains the clinician's primary obligation. The clinician does not need to impose a personal belief on the client, nor does the clinician need to adopt the client's belief personally. Ethical practice sometimes calls for a stance of yes, and rather than either-or, meaning that a clinician can build on what a client says without necessarily contradicting it, can validate the client's perspective while still holding a different personal view, and can respect a client's right to self-determination and the client's dignity and worth even while disagreeing with a particular choice. When this kind of tension becomes difficult for a clinician to manage internally, supervision, professional consultation, or, in some circumstances, the clinician's own therapy, may be an appropriate next step.

Conclusion

Key Takeaways

Integrating Buddhist principles can enhance ethical decision-making and conduct
Mindfulness is an ongoing practice
Compassion = Empathy + Action
Accepting impermanence may lead to creative problem-solving
Ethics is not just about doing right, but also about avoiding harm

Ethics training often focuses narrowly on a clinician's own conduct, but encouraging clients and others to adopt similar principles in everyday life extends the reach of these values, including the broader aspiration of spreading non-violence throughout society. Mindfulness is not a state that a clinician achieves once and then sets aside, but an ongoing practice that continues throughout a career, including with clients who are themselves learning mindfulness skills on an ongoing basis. The question of which mindfulness practice is best resembles the question of which exercise is best, in that the most effective practice for a given person is generally whichever practice, whether taking walks in the park, journaling, or sitting peacefully in meditation, that person is actually more likely to sustain. Compassion is not only about understanding or thinking about another person's situation but requires empathy paired with helpful action. Accepting impermanence can help clinicians and clients move past a sense of being stuck in an unresolved disagreement or an unsolved problem, supporting more creative approaches to problem-solving.

Finally, ethical practice is not only about identifying and doing the right thing, but also about identifying and avoiding potential harm, including asking what steps can reduce the risk of harm in interventions that carry some degree of risk. In practice, this often calls for the same qualities emphasized under mindfulness throughout this article, slowing down, breathing, taking the time to think, and remaining aware of oneself, applied to one's own conduct as a professional and not only to the situations of the clients being served.

References

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Nov 3, 2026

1 CE Credit

The Sociology of Child Abuse & Evidence-Based Prevention

Sophie Nathenson, PhD

Course overview

This article develops a sociological perspective on child abuse and neglect, shifting the frame of analysis from the individual to the societal level. It examines how culture, norms, technology, economics, social relations, and policy shape the prevalence and distribution of child maltreatment across populations. The discussion moves from foundational definitions of abuse and neglect, through mandatory reporting obligations for health and behavioral health professionals, national and state-level trends and statistics, and an ecological model that situates individual and family risk within broader social conditions, before turning to evidence-informed prevention strategies at the policy, community, and practice levels. The material is intended for health, behavioral health, and social service professionals who want to integrate a population-level, contextual understanding of child maltreatment into direct practice with individuals and families. As structured, the activity is designed to occupy approximately one hour of independent study time, consistent with a single continuing education contact hour.

Course information

Limitations/Risks

This presentation does not cover the entirety of research, statistics, or variation in types and prevalence of child abuse
All research is at the population level and should not be applied to all groups or individuals as a whole
Research seeking to explain the motivation and function of child abuse should not be interpreted as condoning behavior
Research on social factors should not be interpreted as obscuring personal responsibility and individual choice
All research is at the population level and should not be applied to all groups or individuals as a whole.

Learning Outcomes

After this course, participants will be able to:

Explain the Child Abuse and Neglect Reporting Act as it relates to your professional role.
Identify four community-level factors in child abuse and neglect.
Describe two evidence-based approaches to preventing child abuse in communities.

Introduction

The Sociological Perspective

Sociology, like psychology, economics, political science, and anthropology, is a discipline concerned with human behavior. What distinguishes the sociological perspective is its unit of analysis. Rather than asking what makes a particular individual behave in a particular way, sociology examines rates of behavior and compares outcomes across groups, looking for patterns that suggest something about a group, a location, or a social experience that may be influencing the behavior in question, rather than something occurring to only a few isolated individuals.

That societal lens applies directly to child abuse and neglect. Any measurable characteristic of how a society functions can be examined for its relationship to social problems, including culture, which the United States contains many overlapping forms of. Norms are the expected ways of behaving within a given community. Technology represents a substantial influence on society as a whole, and the nature and pace of technological change differ from one society to another. Economic structure, including how an economy is organized and how resources are distributed, has effects that trickle down to shape individual lives. Social relations rank among the most significant influences on mental health, and policy, meaning laws and the workings of social institutions such as the healthcare system, the educational system, and the criminal justice system, represent another layer through which society shapes individual outcomes.

Most clinical, behavioral health, and social work training curricula focus heavily on preparing practitioners to work directly with individuals, leaving comparatively little curricular space for analyzing the social factors and environmental conditions that shape a client's life circumstances. Bringing a population-level, big-picture perspective to frontline practitioners is not offered here as a replacement for individual clinical skill, but as a complementary lens that can be folded into direct practice with clients and families, since the institutional and structural pieces of society, including the healthcare, education, and criminal justice systems, are what allow sociology to complement, rather than replace, the individually focused work done in psychology, social work, and other helping professions. That framing recurs throughout the sections that follow, each of which takes a phenomenon often understood primarily as an individual failing or an individual pathology and asks what group-level, environmental, or structural conditions might also be contributing to it.

This dual focus matters because clinical training and sociological training tend to answer different questions. A clinician trained to work one-on-one with a client is well equipped to ask what is happening for this particular person, in this particular family, at this particular moment. A sociologist is better equipped to ask why rates of a given outcome differ across neighborhoods, states, or demographic groups, and what that difference might reveal about shared conditions rather than shared personality traits. Neither question subsumes the other. A practitioner who can hold both questions at once, treating the individual in front of them with clinical attention while also recognizing the community-level patterns that individual's circumstances reflect, is in a stronger position to identify appropriate referrals, anticipate systemic barriers, and avoid mistaking a structural problem for a personal one.

Child Maltreatment

Child maltreatment is generally categorized into several forms, including physical abuse, emotional abuse, sexual abuse, neglect, and exposure to violence. Childhood emotional maltreatment (CEM) is defined as not receiving love and support, and may also involve verbal assault or demeaning treatment, such as being repeatedly called names (Massullo et al., 2023; Finkelhor et al., 2023). This category of abuse carries long-term effects comparable to those associated with physical or sexual abuse.

General neglect is defined as the failure to provide basic needs, including food, shelter, water, and medical care (Massullo et al., 2023; Finkelhor et al., 2023). A sense of belonging and community is also part of what a child requires to be well in society, although the formal definition of general neglect used in most research and policy contexts is limited to the basic survival needs listed above. A recurring theme in the literature is that most research attention is directed toward sexual abuse and fatal abuse, even though neglect is statistically the most common form of maltreatment affecting children (Massullo et al., 2023; Finkelhor et al., 2023).

Impact of Abuse on Wellbeing

Childhood maltreatment is associated with a wide range of adverse outcomes across the lifespan. On the physical health side, documented associations include diabetes, lung disease, vision problems, poor nutrition, sleep problems, and sexual difficulties. On the mental health side, associations include attachment difficulties, impaired executive functioning, posttraumatic stress disorder, depression, anxiety, suicidal ideation or attempts, self-harm, and body image issues (Daníelsdóttir et al., 2024). Some researchers characterize adverse childhood experiences as among the most impactful known contributors to diagnoses listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM; Daníelsdóttir et al., 2024).

The adverse childhood experiences (ACEs) framework offers a structured assessment of experiences occurring between birth and age seventeen, including the various forms of child maltreatment described above as well as household exposure to substance use, domestic violence, and mental illness in a caregiver. An accumulation of these experiences is associated with substantially elevated risk of physical, mental, emotional, and social difficulties later in life. That elevated-risk trajectory reflects outcomes observed in the absence of intervention, and it is longitudinal research comparing groups with differing levels of childhood adversity that first allows the pattern to be identified at the population level. Impaired executive functioning is of particular interest because it may also play a role in the intergenerational continuation of abuse, insofar as adults who were themselves maltreated as children may carry functional impairments that affect their own parenting.

Impact on Youth Social Life

Childhood maltreatment also affects children's social functioning and relationships, including social cognition, emotional regulation, and sense of belonging. Research indicates that any type of maltreatment negatively affects sociality, popularity (measured by asking peers to name their friends), and social cohesion, while physical neglect specifically was found to affect all of these outcomes (Kamis & Copeland, 2024). In the sample referenced, more than 28 percent of children had experienced physical abuse, more than 4 percent had experienced sexual abuse, more than 17 percent had experienced emotional abuse, and more than 10 percent had experienced physical neglect (Kamis & Copeland, 2024).

These findings connect naturally to the concept of trauma-informed care: children experiencing abuse at home do not necessarily experience school as a place of reprieve, since the effects of maltreatment on emotional regulation and social functioning tend to follow a child into other settings. When children carrying these difficulties display behavioral or regulatory challenges at school, awareness of trauma-informed approaches can shift how educators and other professionals interpret and respond to that behavior. Trauma-informed care, as a practice framework, is not addressed in depth here, but the relationship flagged above warrants further professional development on its own terms.

Mandatory Reporting

Role of Health Professionals

Health professionals are mandatory reporters of suspected or confirmed child abuse. Social workers and behavioral health professionals, in particular, work with vulnerable populations, a term referring to groups that, compared with other groups in society, systematically have less access to resources, may be treated differently, or may experience a different life course that affects their ability to meet basic needs and maintain mental and emotional health. The existence of the social work profession reflects a societal response to these disparities, distributing support services to populations that need them, including children and individuals experiencing abuse.

Cultural competency, often required for professional licensure, follows naturally from this point. Cultural competency training has not been shown to have a large direct effect on patient outcomes on its own, in part because outcomes are also shaped by the structural and economic issues taken up later in this article. Cultural competency does not require a practitioner to become an expert on every culture encountered, nor does it require adopting the beliefs, practices, or attitudes of a given cultural group. Rather, it means recognizing that group and individual differences exist, avoiding assumptions, remaining open-minded, and making an effort to understand a client's context. That awareness can strengthen the therapeutic alliance between a practitioner and the people served, regardless of whether the practitioner shares the client's cultural background.

Child Abuse Reporting Act

Child abuse and neglect reporting requirements vary by state law. The general purpose of these statutes is to protect children from harm, and they require covered professionals to report suspected or confirmed cases of child abuse, whether encountered at work or outside of work. Reporting is required upon reasonable suspicion; a mandated reporter need not have witnessed the abuse directly or confirmed that it occurred before making a report.

Penalties for failing to report vary by state. As an illustrative example, the penalty in California for a mandated reporter who fails to report suspected abuse is up to six months of confinement in a county jail, a fine of up to $1,000, or both. Reporting laws of this kind are designed to place "eyes" on children across a wide range of settings by requiring a broad group of professionals who come into regular, close contact with children to receive training in recognizing and reporting suspected abuse. Worth noting as an editorial aside, not tied to a specific citation: certain settings associated with elevated abuse risk, such as some workplaces connected to trafficking, and certain professional roles that also work closely with youth outside of the categories below, are not explicitly named as covered professions, even though contact with children in those settings can be substantial.

Covered professionals

The category of mandated reporters is broad and includes the following groups, as identified on the accompanying slide:

Physicians, dentists, medical residents or interns, hospital personnel and administrators, nurses, health care practitioners, chiropractors, osteopaths, pharmacists, optometrists, podiatrists, emergency medical technicians, ambulance drivers, undertakers, coroners, medical examiners, alcohol or drug treatment personnel, and persons performing a healing role or practicing the healing arts
Psychologists, psychiatrists, and mental health professionals
Social workers, and licensed or unlicensed marriage, family, and individual counselors
Teachers, teacher's aides or assistants, school counselors and guidance personnel, school officials, and school administrators
Child care workers and administrators
Law enforcement personnel, probation officers, criminal prosecutors, and juvenile rehabilitation or detention facility employees
Foster parents
Commercial film and photo processors

Awareness of and training on suspected abuse indicators among frontline professionals, such as physicians and teachers, is a recognized element of early identification systems (Röders et al., 2024).

Trends & Variation

Stats

National data provide a sense of the scale of child abuse and neglect in the United States. In the most recent reporting year discussed on the slides, more than 3,081,715 children received some form of child protective services response, at a rate of approximately 7.4 children per 1,000, with the highest rate among children younger than 1 year of age. There were 546,159 confirmed victims of child abuse and neglect, of whom 64 percent experienced neglect only. Approximately 2,000 children died as a result of abuse or neglect in that year, and there were 422,117 identified perpetrators, an increase of nearly 20 percent compared with 2019. Approximately one in four cases involved a substance use factor, and approximately one in four involved a domestic violence factor. More than 1.76 million children received prevention services during the year. The overall prevalence of child abuse and neglect has not meaningfully decreased since the mid-1990s, despite increased investment in prevention efforts and expanded child protective services capacity.

The following table reproduces the core national statistics presented on the slide.

Measure	Value
Children with a child protective services response	3,081,715
Rate per 1,000 children	7.4
Confirmed victims of abuse and neglect	546,159
Share of victims who experienced neglect only	64%
Child fatalities	2,000
Identified perpetrators	422,117
Increase in perpetrators since 2019	~20%
Cases with a substance use factor	25%
Cases with a domestic violence factor	25%
Children receiving prevention services	1,762,516

These figures likely underrepresent true prevalence, since many cases never come to the attention of any reporting authority, particularly when a child who is being controlled or coached by an abuser does not feel able to disclose what is happening.

State Differences

Reported rates of child abuse and neglect vary considerably by state. Massachusetts has the highest reported rate, at 16.5 per 100,000 (22,075 cases), followed by West Virginia, Iowa, Maine, and Alaska. New Jersey has the lowest reported rate, at 1.6 (3,146 cases), preceded by Pennsylvania, Washington, Virginia, and Kansas. Measured by raw number of cases rather than rate, Texas has the highest count, at 54,207, while Vermont has the lowest, at 672.

Several explanations account for this variation. States may define, count, and report child abuse differently, which limits the direct comparability of raw statistics across jurisdictions. Better-funded child protective services systems may also identify and record more cases simply because they have greater capacity to do so, meaning that a higher reported rate in a well-resourced state does not necessarily indicate a higher true prevalence of abuse. Legal treatment of practices such as corporal punishment also differs by state; in some states, including Oklahoma, corporal punishment such as spanking or slapping is treated as a matter of parental discretion unless it crosses into an excessive or injurious level, which is itself a subjective threshold.

Beyond definitional and administrative differences, sociological factors identified in connection with state and community "hotspots" of child abuse include housing instability, a lower volume of available services, unemployment, and substance abuse, particularly involving opioids and methamphetamine.

Digging Deeper

Self-report surveys that ask children directly about their own experiences provide an additional, and in some respects more complete, picture than administrative case data. According to national surveys of children's exposure to violence, 38.1 percent of children had experienced some form of maltreatment by age 17, with some sources placing the figure as high as half of all children. Of this experienced maltreatment, approximately 75 percent was neglect, 17 percent was physical abuse, 11 percent was sexual abuse, 4 to 7 percent was emotional abuse, and 0.2 percent involved trafficking.

Data drawn from the DHHS National Child Abuse and Neglect Data System for 2023 indicate that 90 percent of sexual abusers are known to the child, that one in four girls and one in twenty boys will experience sexual abuse in their lifetime, that 10.6 percent of children experience physical abuse only, that 7.5 percent experience sexual abuse only, and that 3.5 percent experience psychological maltreatment only.

The statistic that the large majority of sexual abusers are known to the child is sociologically significant on its own terms. Media coverage of child sexual abuse often emphasizes cases involving strangers or abduction, which are important but comparatively rare relative to abuse committed by someone already trusted by the child or the child's family, such as a relative, babysitter, or teacher. That pattern suggests that prevention efforts benefit from attention to family and other trusted relationship systems, in addition to stranger-danger messaging, even though this focus can feel uncomfortable or counterintuitive. Public attention to child abuse tends to concentrate heavily on cases involving a stranger or an abductor, coverage that is important and merited in its own right, but coverage of this kind can create a skewed public impression of where risk actually concentrates, since babysitters, teachers, relatives, and other trusted adults account for the substantial majority of sexual abuse cases.

Taken together, the scope of these figures supports the sociological argument that child abuse should be understood as what the discipline terms a public issue, meaning a problem so widespread that societal or environmental conditions are implicated, rather than solely a personal trouble affecting a small number of individuals. A personal trouble is an individual's private struggle or suffering; a public issue is a pattern that recurs across a large enough share of the population to suggest something happening at the level of the community, institution, or society, rather than only within a small number of disturbed or ill-intentioned individuals. That shift, from viewing child abuse as a personal trouble to viewing it as a public issue, is the central conceptual move underlying the analysis that follows, since it is this shift that justifies looking to community, economic, and cultural conditions, rather than exclusively to individual psychology, for both explanation and prevention.

Introduction

Ecological Model

The ecological model is a theoretical framework that integrates personal history, family systems, and societal-level factors to explain outcomes such as child abuse perpetration and victimization (Jip et al., 2025). At the individual level, the model considers a person's personal history and individual characteristics, including biological factors. At the family level, it considers the household's dynamics and functioning. At the societal level, it considers the broader social, economic, and cultural conditions in which individuals and families are embedded.

Effective prevention, under this framework, depends on a holistic and contextual understanding of a case or a population, rather than an exclusive focus on any single level of analysis (Jip et al., 2025). Existing research and intervention efforts tend to carry a bias toward individual risk factors, which can obscure the societal conditions that also underlie abuse rates (Jip et al., 2025). Socioeconomic conditions, cultural norms, and broader social problems contribute in layered ways to abuse rates (Jip et al., 2025). Consider a town whose economy depends heavily on a single large employer: when that employer closes or substantially reduces its workforce, subsequent community-level increases in substance use, depression, and anxiety can be observed, illustrating how an event affecting an entire community can raise risk across many individuals simultaneously, distinct from any one person's individual psychology.

Social Determinants

Individual/Psychopathological

At the individual level, mental health factors specific to a given person do not reliably predict whether that person will perpetrate abuse, and such factors are not generalizable to populations as a whole. Personality disorders, severe substance use, impulse-control difficulties, impaired cognitive functioning, low self-esteem, and needs related to power and control are among the individual-level factors that can contribute to the perpetration of abuse. Psychosocial comorbidities can also increase a child's risk of victimization. Carrying any of these individual risk factors does not mean that abuse will occur; these are population-level associations rather than deterministic predictions about any one person.

The sociological approach builds on this individual-level picture by analyzing the social conditions that can influence these same risk factors, effectively asking what is happening in a person's environment that may be shaping the individual vulnerabilities described above, rather than treating those vulnerabilities as freestanding or unexplained.

Focusing on Society

Reframed at the societal level, child abuse is best understood as a public health issue rather than solely an individual problem (Korbin, 1994; Luo et al., 2025). This framing is analogous to how public health has approached other large-scale problems, such as the opioid crisis or the COVID-19 pandemic, in which the effects extend well beyond any single affected individual, influencing healthcare costs, education costs, and social services spending across a population.

Addressing upstream factors, meaning the social and economic conditions that precede a crisis event such as a fatality, injury, or confirmed abuse case, is the most impactful point of intervention, since it affects the largest number of people before harm occurs, in contrast to downstream responses such as emergency services, removal of a child from the home, or punishment of a perpetrator after the fact. Individual development takes place within families, neighborhoods, and the broader sociocultural environment, meaning that all of these settings shape a child's outcomes, not the family alone (Korbin, 1994; Luo et al., 2025).

Social Factors

Certain social statuses are associated with increased risk of child maltreatment, including low socioeconomic status, low educational attainment, young parental age, single parenthood, having multiple dependent children, and low income (Hong et al., 2023; Nadan, Spilsbury, & Korbin, 2015). A social gradient is observed across these factors, meaning that differences in income, race, ethnicity, and LGBTQ+ status are all associated with differing levels of risk (Hong et al., 2023; Nadan, Spilsbury, & Korbin, 2015). Lower social status is associated with chronic stress arising from external conditions and unmet basic needs (Hong et al., 2023; Nadan, Spilsbury, & Korbin, 2015).

These comparisons are made at the group level and do not imply that individuals sharing a given social status are alike in other respects, nor that any one person in a higher-risk category will necessarily experience or perpetrate abuse. Rather, the purpose of identifying these statistically elevated-risk categories is to direct attention toward the structural conditions, such as educational access or income support, that may underlie the observed differences, rather than toward the individuals themselves.

Race & Social Statuses

Research on race and child abuse identification produces mixed results. Some studies find that Black and Hispanic children are overrepresented in the child welfare system and in hospitalization for abuse-related injury, indicating greater risk of family separation and higher associated healthcare costs (Salimi-Jazi et al., 2024). When socioeconomic status and other relevant variables are statistically controlled for, Black race continues to show an independent effect on these outcomes, while Hispanic ethnicity appears to serve as a buffer, a pattern attributable in part to cultural factors (Salimi-Jazi et al., 2024).

Assumptions made by reporters, clinicians, or other professionals about families from non-dominant racial or ethnic groups can themselves contribute to higher rates of reporting, independent of any underlying difference in the true prevalence of abuse. The concept of intersectionality, referring to the co-occurrence of multiple social statuses such as race, class, gender, and sexuality, is also relevant, since overlapping statuses can compound vulnerability to abuse and affect a family's access to protective resources.

Community Factors

A set of evidence-based community-level factors has been identified in research examining why some communities show markedly higher rates of child abuse than others (Sampson, Raudenbush, & Earls, 1997). These factors include the level of violence and crime in a community, the number of mandated reporters present, the availability of social support services, the concentration of children relative to adults (a higher concentration is linked to higher rates of abuse), low food access, social cohesion and integration, neighborhood disadvantage, and residential instability (Sampson, Raudenbush, & Earls, 1997). The overall level of social support available in a community, including help with childcare and positive role modeling, also affects maltreatment rates (Sampson, Raudenbush, & Earls, 1997).

Neighborhood disadvantage often follows a self-reinforcing pattern: higher crime and reduced business investment can lead to declining property values and lower property tax revenue, which in turn reduces funding available for local education and other public services, further compounding disadvantage over time. Because property tax revenue in most jurisdictions funds schools directly, this cycle also touches the concentration of mandated reporters described above, since schools and school-based staff are among the settings where sustained daily contact with children makes early identification of abuse most feasible; a neighborhood losing school funding is, in effect, also losing some of its reporting infrastructure at the same time that its other risk factors are increasing.

Culture: Norms & Socialization

Culture encompasses a society's beliefs, values, and norms, meaning its expected ways of behaving, and socialization is the process through which individuals learn to behave and express themselves within their given culture. Norms surrounding corporal punishment, gender roles, and stigma or silence around disclosure all affect both the prevalence and the reporting of abuse. State-level differences in the legal and normative treatment of corporal punishment, discussed above, illustrate how cultural norms shape what is considered acceptable parenting versus abuse.

Collectivist and individualist societies may differ in reporting patterns. The United States is generally described as an individualist society, whereas other societies or subgroups may be more collectivist. A collectivist orientation can serve as a protective buffer through greater social cohesion, but it may also be associated with lower reporting rates, as community reputation can create pressure against disclosure. Victim blaming, in which the person harmed is held responsible for the abuse, is also a cultural phenomenon, and abuse can become internalized by victims as a result.

Early Development & Abuse

Emotional bonds and attachment patterns formed early in life can increase the likelihood that a person will later perpetrate abuse, and low empathy and emotional awareness can impair a caregiver's ability to respond appropriately to a child's emotional needs. This perspective frames abuse as shaped, at least in part, by skill deficits or developmental gaps rather than exclusively as a product of deliberate ill intent.

That framing is offered as one lens among several, not as an excuse for abusive behavior. Consider a mother with attachment-related deficits, co-occurring substance use difficulties, and shame following the removal of her child: a skills-and-deficits framework applied to a case of this kind can identify additional points for intervention, such as building emotional regulation and parenting skills, without minimizing the seriousness or impact of the abuse itself.

Economic Drivers

Economic inequality, as distinct from the overall size or growth rate of an economy, is a major predictor of social problems generally, because it influences stress, social status, social trust, and the distribution of resources. Poverty and unemployment can lead to chronic stress, substance use, and erosion of mental and cognitive functioning, while housing instability and food insecurity directly undermine a family's ability to meet a child's basic needs. Poverty is one of the most consistently identified risk factors for child abuse and neglect in the broader research literature (Bywaters et al., 2022), and periods of economic insecurity have a documented temporal relationship with subsequent child maltreatment (Conrad-Hiebner & Byram, 2020).

Consider a parent facing simultaneous stressors, such as unemployment, housing precarity, and food insecurity: accumulated pressures of this kind can erode a parent's capacity to manage a child's ordinary behavioral challenges, without in any way excusing resulting harm. These economic conditions are best understood as contributing factors layered atop other individual and social factors, consistent with the ecological model discussed above. Human children have an unusually long period of developmental dependency compared with most other species, requiring near-constant care during infancy and early childhood; that extended dependency period helps explain why economic and housing instability during a child's earliest years carries disproportionate weight for outcomes such as neglect, and why the highest reported rates of child abuse and neglect response occur among children younger than one year of age, as noted in the Stats section above.

Social Isolation

Social isolation is one of the most significant risk factors affecting health and mortality outcomes generally, with some research suggesting its effect on premature death is comparable to or greater than that of heavy smoking, active alcohol use disorder, or a sedentary lifestyle. Weak social ties and disconnection from the community are associated with increased risk of perpetrating child abuse.

Societal disruptions such as the COVID-19 pandemic intensified social isolation and economic stress simultaneously. A study conducted only two weeks after the onset of the pandemic found that one in five adults in a broadly distributed sample had hit their child, with employment loss and isolation identified as risk factors net of other variables such as depression, income, and demographic characteristics (Lee, Ward, Lee, & Rodriguez, 2022). Perceived isolation, meaning an individual's own sense of being isolated, was also associated with changes in disciplinary behavior, including increased spanking and hitting, even among parents who reported that they would not otherwise have used these behaviors (Lee, Ward, Lee, & Rodriguez, 2022). Investigations conducted in specific jurisdictions during the pandemic period similarly documented shifts in the volume and pattern of child maltreatment investigations coinciding with pandemic-related disruption (Zhang, 2023).

Social Media & Technology

Image-based sexual abuse (IBSA) refers to harm caused through the creation, distribution, or misuse of explicit images, and is more commonly reported among sexual minority youth (Mitchell et al., 2025). More broadly, media content can normalize violence and exploitation, and experiencing abuse increases the likelihood of problematic social media use as well as body image dissatisfaction (Kircaburun, Griffiths, & Billieux, 2020). Problematic social media use associated with childhood maltreatment has also been linked to attachment difficulties and depression (Worsley et al., 2018).

Independent of other forms of sexual abuse or adversity, experiencing image-based sexual abuse specifically increases the odds of drug overdose, suicide attempt, and self-injury among affected youth (Mitchell et al., 2025). This area of risk receives comparatively little attention in standard psychology and social work curricula, despite its documented impact, and it warrants the same practitioner attention given to more traditional categories of abuse.

Prevention

Prevention: Policy

At the policy level, several categories of intervention are identified as evidence-relevant approaches to reducing child abuse and neglect. These include universal health care, the Earned Income Tax Credit (EITC), Temporary Assistance for Needy Families (TANF), and Department of Housing and Urban Development Community Development Block Grant funding that supports low-rent, stable housing in low-poverty areas. Additional systems-level change involves child welfare systems engaging more directly with income, employment, and housing conditions rather than operating in isolation from other social service systems. Reviews of potential structural solutions to reducing rates of child abuse and neglect similarly point toward income- and housing-focused policy levers as high-value targets for intervention (Heil, 2025).

Policies that improve family socioeconomic status have the greatest health impact on children because they increase a family's ability to meet basic needs and improve overall well-being. Many of the relevant systems, such as education, welfare, and criminal justice, tend to operate with limited coordination or communication, even though none of the underlying problems can be fully addressed within a single institutional silo.

This siloing has practical consequences for how prevention is funded and evaluated. A housing program and a child welfare program may each be judged by outcomes specific to their own mandate, housing stability on one hand and confirmed maltreatment cases on the other, without either program's evaluation capturing the interaction between the two. Yet the research summarized above suggests that the two are causally linked: stable housing reduces the chronic stress and instability associated with neglect, and a child welfare system that engages proactively with a family's housing and income situation is addressing a root cause rather than only a downstream symptom. Structural reviews of this problem point to the same conclusion: policy levers targeting income and housing consistently outperform narrowly targeted, abuse-specific interventions when measured by population-level impact (Heil, 2025).

Prevention: Community

At the community level, nurse family partnership programs are close to the gold standard among evidence-based interventions with a demonstrated impact on family outcomes (Levey et al., 2017). These programs typically involve home visitation, in which a nurse or trained case manager visits a family, often beginning before a child is born, and brings resources and support directly into the home. This model removes many practical barriers to service access, including transportation, comfort with clinical settings, and professionals' limited direct knowledge of home conditions, by bringing the intervention to the family rather than requiring the family to seek it out.

Additional community-level strategies include neighborhood representative groups and meetings focused on programs such as foster care, community organizing efforts that share information and resources directly among residents, and a broad range of support services, including parenting classes, mentoring, childcare, and healthcare support (Levey et al., 2017). Communities with high rates of child abuse often also have a low density of these support services, which reinforces the importance of considering service availability alongside other risk factors when planning prevention efforts.

Awareness & Advocacy

Awareness and advocacy strategies include media campaigns, integration of relevant content into school curricula, early childhood interventions such as preschool programming, and inclusion of child abuse as a topic in political and national news coverage, including coverage that uses individual cases to illustrate systemic problems. A further strategy involves explicitly linking the public issue of child abuse to economic, social, and healthcare policy discussions, since media coverage of child abuse is heavily weighted toward sexual abuse and trafficking, important topics in their own right, while economic and structural contributors to abuse receive comparatively little attention in public discourse.

Practice Applications

For professionals working directly with individuals and families, this material translates into several practical applications. These include looking beyond the individual to gain a fuller understanding of the motivations and context behind a case, identifying community resources that can help parents meet their children's basic needs, and attending to skills, emotional intelligence, and physiological or psychological impairments that may stem from a caregiver's own history of past abuse.

An open question worth sitting with: when a child is removed from a home following a confirmed or suspected abuse incident, it is often unclear how much support, whether recovery services, economic assistance, or mental health treatment, is subsequently directed toward the parent or caregiver involved, as opposed to resources directed solely toward the child. A parent with a substance use disorder or untreated mental health condition may lose custody following an incident, and in the absence of coordinated support for that parent's own recovery and economic stability, may experience worsening shame, isolation, and hardship that further compounds the underlying difficulties rather than resolving them. This is less an argument for a single fix than for a more coordinated, wraparound approach that considers the needs of the whole family system, including the parent, rather than treating removal of the child as the endpoint of intervention.

Identifying and connecting families to such resources is one of the more direct and achievable applications of this material for practitioners working at the individual and family level. Attending to physiological and psychological impairments that may stem from a caregiver's own history of past abuse expands a practitioner's understanding of a case beyond a simple moral judgment about a parent's fitness, without excusing harmful behavior, by bringing brain-based and skill-based factors explicitly into the clinical picture alongside social and economic context.

Closing Thoughts…

Several summary points follow from the analysis above. Professionals are cautioned against making assumptions about individuals based on group-level social statuses, since population-level research findings do not predict outcomes for any specific person. Social change is needed both in how child abuse is covered publicly and in how prevention efforts are targeted "upstream," toward conditions that precede abuse rather than only toward crisis response after abuse has occurred. Redistribution of resources stands out as an especially high-impact practice for reducing rates of abuse. Finally, perpetrators of abuse have complex, overlapping intentions and motivations, shaped by social, economic, physiological, and psychological factors together, rather than by any single cause.

None of this displaces individual accountability. Recognizing a social pattern behind an individual act is not the same as excusing that act, and the limitations stated at the outset of this article apply with full force here: population-level findings describe groups, not any single perpetrator's culpability, and a sociological account of why abuse clusters in certain conditions is a tool for prevention, not a defense. Held together, the individual, family, and societal levels of the ecological model give practitioners, policymakers, and researchers a shared vocabulary for locating where an intervention is likely to do the most good, whether that intervention is a single family's treatment plan or a state's housing policy.

Q&A

Questions arising from this material, comments, or requests for collaboration may be directed to info@widespreadwellness.org.

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Nov 3, 2026

1 CE Credit

Principles and Practices in Culturally Competent Supervision

Giselle Levin, PsyD

Disclosures

Presenter disclosure. Financial disclosures: Dr. Giselle Levin, PsyD, received an honorarium for presenting this course. Dr. Levin has published articles on transgender healthcare, sex therapy, multiple minority stress, and adapting evidence-based interventions for marginalized populations. Non-financial disclosures: Dr. Levin has no relevant non-financial relationships to disclose.

Content disclosure. This learning event does not focus exclusively on any specific product or service.

Sponsor disclosure. There is no external sponsor for this course.

Course overview

This course examines the principles and practices that support effective clinical supervision, with particular attention to the supervisor-trainee relationship, the frameworks that structure multicultural supervision, and practical techniques supervisors can use to strengthen the supervisory alliance. Content is drawn from a continuing education webinar presented by Giselle Levin, PsyD, and is organized to follow the original presentation's structure. The course reviews several established supervision frameworks, including competency-based clinical supervision, the multidimensional ecological comparative approach, the integrated supervision framework, and the SuperVISION model, and introduces concrete techniques such as the worldview genogram and the ADDRESSING framework. The course also reviews how systemic factors within the mental health field, including diagnostic frameworks and institutional norms, can shape both clinical practice and psychology training more broadly, and it closes with a discussion of several frequently asked questions related to this material. Readers should come away with a clearer understanding of how supervisory relationships are built, structured, and evaluated, and how self-awareness and self-disclosure function within that relationship. This version of the course has been adapted to align with Florida's qualified supervisor training requirements, and the discussion of supervision research has accordingly been reframed to center on the supervisor-trainee relationship rather than on diversity, equity, and inclusion training specifically; the rationale for this adaptation, along with a full list of editorial adaptations made to the original presentation materials, is described in the editor's note at the end of the article.

Learning Outcomes

After this course, participants will be able to:

Describe the fundamentals of culturally responsive supervision.
Compare two different frameworks or models of multicultural supervision with regard to focus and impact on supervisors, supervisees, and clients.
Explain the significance of systemic oppression in mental health care systems and how systemic oppression shows up in clinical supervision.

Limitations/Risks

Information in the presentation is generalized and may not apply to specific patients. Refer or consult as needed.
Ethical and legal standards may differ from state to state. Ensure that you are familiar with the laws and ethics specific to your state.
Individual and cultural considerations should be explored prior to pursuing treatment and interventions.

Introduction

Culturally responsive supervision rests on a supervisor's willingness to bring their whole self into supervision, and into clinical work generally, and to model that practice for trainees. Identity, in this framework, is not fixed or determinative; rather, it serves as a reference point for exploring what a given identity means to a particular person and how that meaning manifests in both the supervisory and client-therapist relationships. This framing previews a distinction that recurs across later sections of this article, between having knowledge about a given identity or cultural group and having the awareness and relational skill to work with a specific individual who holds that identity in their own particular way.

My Cultural Self

Levin's own personal and professional identities offer a working example of this practice. These identities are organized below into two categories, reflecting how they were presented in the original course materials.

Professional and background identities	Personal identities
Psychologist (PsyD)	Non-binary
Gender specialist and sex therapist	Bisexual and queer
From New York	Polyamorous
Living in the Bay Area, California	Kinky
White	Neurotypical
Ashkenazi Jewish	Able-bodied
Raised Orthodox Jewish	U.S. citizen
	Middle class
	Millennial

Some identities, such as sexual orientation and race or ethnicity, tend to be more visible and more commonly disclosed by supervisors and psychology leadership, while others, such as kink community membership, HIV or sexually transmitted infection status, and religious identity, are rarely disclosed. Naming these less commonly disclosed identities is one way to reduce stigma and to model bringing one's full self into supervisory and clinical relationships.

A case example illustrates the potential impact of supervisor self-disclosure. As a trainee, Levin was open about being queer and was working with a bisexual, cisgender woman client who was in a relationship with another woman and who was experiencing a domestic violence dynamic within that relationship. Levin spent a substantial portion of a training year processing feelings related to the client's identity and their own identity as a queer trainee, having assumed the supervisor was heterosexual because the supervisor had never indicated otherwise. On the final day of that supervisory relationship, during termination proceedings, the supervisor disclosed that she was married. Levin later reflected that earlier disclosure of this identity would have provided meaningful support during the year of work with that client.

This experience points to a general principle: self-disclosure of identity is a personal decision, and no supervisor or clinician should feel pressured to disclose any particular identity to a trainee or client. At the same time, supervisors are well served by deliberately considering the reasons for disclosing or withholding an identity, weighing the potential advantages and disadvantages of each choice, and considering the impact that choice may have on the trainee and the supervisory relationship.

Goals for This Presentation

This course is organized around three goals.

Adopt a critical consciousness and social justice lens (Cadenas & McWhirter, 2022).
Think about decolonizing both clinical practice and psychology training and supervision.
Move away from an overemphasis on knowledge and focus instead on awareness, attitudes, and competence or skill.

Critical consciousness refers to the capacity of marginalized individuals to analyze systems of oppression, to act toward social justice, and to develop a sense of agency and hope. Consistent with this framing, this course emphasizes reflective thinking over simple content delivery throughout.

The Need for Culturally Competent Supervision

Reflecting on supervisory training experiences

Approaches to supervisory training vary considerably by training program, region, and trainee generation, and supervisors and trainees frequently differ in how well prepared they feel by that training. A systematic review of training approaches found a wide range of instructional methods in use, including lecture, group discussion, case scenarios, immersion experiences, role-play, structured contact with individuals from diverse backgrounds, self-reflection on clinical interactions, journaling, and service learning, and found that these approaches covered a similarly wide range of topics (Benuto et al., 2018). That review found that these training methods reliably improved trainees' knowledge but produced mixed results regarding trainees' attitudes, self-awareness, and clinical skill (Benuto et al., 2018).

This finding carries a direct implication for supervisors: training that only transmits information is unlikely, by itself, to change how a trainee behaves in the room with a client. Structured, ongoing supervision, rather than one-time didactic training, appears better positioned to help trainees translate knowledge into applied skill.

Experiences within the supervisory relationship

Research on the supervisory relationship indicates that trainees generally want more structured discussion of a client's background and more explicit conversation about power, privilege, and the broader diversity of client and trainee experience, and that this held true across a sample of eighteen interns and forty supervisors surveyed in one study (Adams et al., 2023). The same study found that a large majority of trainees, 77%, reported experiencing harassment based on some aspect of their identity during training, and that a substantial majority of supervisors, 69%, reported the same (Adams et al., 2023). These figures indicate that establishing and protecting relational safety within supervision is not a peripheral concern but a central one, relevant to both members of the supervisory dyad.

Supervisors, for their part, have reported wanting more structured opportunities for self-reflection and self-examination, as well as more conceptual support for addressing dynamics that arise in supervision (Adams et al., 2023). Supervisor responsiveness to trainees has also been found to vary: some research indicates that supervisors do not always engage with a given topic in a consistent way across different trainees, and that this variability can affect how supported a trainee feels within the relationship (Burkard et al., 2006; Hird et al., 2004).

Two case examples illustrate the practical stakes of these dynamics. In the first, a trainee was assigned a teenage client who had been referred to therapy after drawing a swastika on a school wall; the supervisor who assigned the case did not disclose this detail before the assignment, despite knowing that the trainee is Jewish and has family members who survived the Holocaust. The trainee later described feeling blindsided by this omission, noting that, had the information been shared at the time of assignment, there would have been an opportunity to raise concerns about working with that client, including safety concerns related to a distinctly Jewish surname. This example points to a general recommendation: supervisors who assign clients to trainees should consider the trainee's relevant identities and experiences, share information that may bear on the trainee's capacity to work with a given client, and give the trainee the opportunity to participate in that assignment decision.

In a second example, an early-career, non-binary supervisor, who is generally perceived as a woman, observed a trainee move, without hesitation, to sit in the chair typically reserved for the supervisor. This small but notable moment raises questions about how seating position, body language, and other nonverbal behavior can communicate assumptions about power and space within the supervisory relationship, independent of whether any harassment was intended.

Current state of clinical supervision training

A 2019 systematic review of training approaches for multicultural or diversity-related supervision, conducted before the COVID-19 pandemic, found substantial variation in how such training was delivered, spanning the instructional methods described above, and concluded that there was insufficient evidence at that time to recommend any one training strategy over another (Benuto et al., 2018). The review's authors found that training reliably increased trainee knowledge, but evidence for improvements in trainee attitudes, self-awareness, or applied skills was considerably weaker and less consistent (Benuto et al., 2018).

How far does knowledge go?

For a period, cultural competence training was often organized around three components: knowledge, attitude or awareness, and skill or competency. An overemphasis on knowledge carries a specific risk, namely oversimplification and stereotyping. Learning that a cultural group is broadly associated with a particular trait does not mean that the trait will apply, or apply in the same way, to any given individual from that group; how a person understands and expresses that trait can vary widely. For this reason, exploring personal bias and building self-awareness, the attitude component of the framework, may produce the most meaningful gains, and process-oriented techniques, which involve working with material as it arises in the moment rather than only through prepared content, may help build both awareness and skill (Chege et al., 2023).

Role of supervision in trainee development

Supervision occupies a distinct position relative to didactic training because it works directly with the specific scenarios and dilemmas a trainee brings from an actual client relationship, giving the supervisor an opportunity to extrapolate general principles and applied skills from a concrete case. Didactic instruction, such as lectures or workshops, has value, but supervision has been identified as the setting best positioned to teach trainees how to work with a diverse range of clients, in part because it can be tailored to many different training objectives and because supervision quality has been found to relate to trainees' overall satisfaction with their broader training experience (Benuto et al., 2018).

Cultural humility is closely related to this discussion: it describes a stance that balances what a supervisor or clinician knows with genuine curiosity about what they do not know, and recognizes that the trainee is generally the expert on their own experience, just as the client is the expert on theirs.

Systemic Oppression & Decolonization

This section addresses a central question: how does the field of psychology, and by extension the broader mental health field, contribute to systemic oppression, both in clinical practice and within psychology training itself?

Yikes, Psychology Is Problematic!

Several patterns within the mental health field warrant critical examination.

Pathologization of gender diversity is reflected in the continued inclusion of a gender-related diagnosis in the DSM-5.
Pathologization of sexual diversity is reflected in how paraphilias and sexual dysfunctions are classified.
An emphasis on the individual, rather than on the surrounding society, as the locus of a mental health problem.
An emphasis on the responsibility of marginalized communities to heal from oppression, relative to the responsibility placed on those who oppress.
A predominance of Western views of healing that de-emphasize the role of community, spirituality, culture, and tradition, and that favor verbal, cognitive approaches such as talk therapy over other healing modalities, including indigenous healing practices.

Diagnostic practice with transgender clients illustrates this tension directly. Because insurance-based access to care generally requires a diagnosis, one approach is to use the ICD-11 diagnosis of gender incongruence, which is not classified under mental health conditions in that system, rather than the DSM-5's gender dysphoria diagnosis, while discussing the significance of that diagnostic choice directly with clients. A parallel critique applies to how sexual dysfunction diagnoses are structured: certain diagnoses place a strong emphasis on specific physiological markers, such as erection or orgasm, that are not in fact necessary for sexual satisfaction, and the continued inclusion of transvestic disorder in the DSM-5 offers a further example of the pathologization of a form of sexual expression.

Diagnostic criteria also frequently condition a diagnosis on the presence of clinically significant distress or impairment in social or occupational functioning, and this framing can obscure the role of an unsupportive or non-affirming society in producing that distress or impairment. A transgender person may experience clinically significant distress connected to gender identity, and this distress may, in some cases, be better understood as arising from a non-affirming social environment or from barriers to accessing transition-related care rather than from gender identity itself.

This pattern of pathologization is also applied inconsistently. Consensual kink and consensual non-monogamy are not, in themselves, diagnosable conditions, and most paraphilia diagnoses in the DSM-5 specify that the behavior in question is only considered a mental health concern when it occurs in a non-consensual context. By contrast, behaviors that are inherently non-consensual in a different sense, such as infidelity within a monogamous relationship, lying, or stealing, do not carry a corresponding mental health diagnosis, despite arguably causing comparable relational harm. This comparison illustrates how diagnostic categories have historically concentrated scrutiny on sexual and gender diversity specifically, rather than on non-consensual conduct as a general category.

Research on neurodivergent communication offers a related example: autistic individuals often communicate effectively with one another, suggesting that differences between neurodivergent and neurotypical individuals reflect differences in communication style rather than inherent deficits, even though diagnostic frameworks often characterize such differences as deficits.

Systemic Oppression in Psychology Training

Systemic oppression can manifest within psychology training programs in several specific ways.

Power dynamics between supervisors and trainees.
Professional wardrobe policies, which disproportionately affect individuals with larger body sizes and individuals, often Black and Brown women, whose hair or clothing choices are more likely to be subject to scrutiny.
The blank slate approach to therapy, in which a clinician discloses little about themselves while expecting extensive disclosure from a client, embeds a significant power differential into the therapeutic relationship.
A mismatch between who holds psychology leadership positions, which tends to be disproportionately White, male, and cisgender, and who is represented among trainees.
The financial cost of training, which limits who can enter the mental health field; psychologists are generally compensated more than social workers, even though overall compensation across the mental health field remains comparatively low.

Decolonizing Psychology Training

Addressing these dynamics within training programs calls for several concrete steps.

Remain aware of the power dynamics inherent in the supervisor-trainee relationship.
Include training material that explores the harmful effects of colonialism (De Angelis, 2023).
Consider the Euro-Christian-centric influence embedded in prevailing models of change and healing, and make an effort to teach alternative models of healing drawn from other cultural traditions (De Angelis, 2023).

Social Justice Lens

A social justice lens involves attending to how power differentials, economic inequity, and unequal access to education contribute to marginalization, and connecting mental health outcomes to social oppression more broadly. Minority stress theory is a well-researched framework in this area, originally developed to explain disparities in mental health outcomes between queer and heterosexual, cisgender populations. The theory distinguishes between distal stress factors, such as direct experiences of prejudice, violence, or discrimination, and proximal stress factors, such as internalized shame, internalized homophobia, or a sense of isolation that develops as those external stressors become internalized over time. Applied to supervision, this distinction is useful because it separates what a trainee or client experiences from the outside, through discrimination or non-affirmation, from what that experience becomes once it is internalized, and it suggests that a supervisor's response may need to differ depending on which type of stressor is most active for a given client or trainee at a given time.

Intersectionality

Intersectionality is a framework recognizing that identity is not reducible to any single category and that multiple identities and experiences combine and interact to produce a particular experience of privilege or oppression. The term is often attributed to legal scholar Kimberle Crenshaw, writing in 1989. The corresponding slide illustrated this concept with six example identity categories that interact to shape a person's position with respect to privilege and oppression. Applied within supervision, an intersectional lens cautions against treating any single identity category, such as race alone or gender alone, as fully explanatory of a trainee's or client's experience; a trainee who is, for example, a Black, queer, disabled woman experiences these identities together, in combination, rather than as separate, additive factors.

Intersecting identity category
Race
Age
Class
Sexuality
Dis/ability
Gender

Frameworks & Models of Multicultural Supervision

Foundations of Culturally Competent Supervision

Culturally competent supervision rests on three foundational elements.

The supervisor's own self-exploration of attitudes, biases, strengths, and areas for growth.
A focus on process, including relational safety, power dynamics, and parallel process, meaning the ways that dynamics present in the client-therapist relationship can recur in the supervisor-trainee relationship, and in the broader systems surrounding both.
A critical examination of systems of colonization embedded within the psychology field.

Taken together, these three foundations describe a supervisor who is willing to examine their own position before examining the trainee's, who treats the supervisory hour as a space to be actively managed rather than a passive container for case discussion, and who is willing to situate individual client and trainee experiences within larger historical and institutional context rather than treating every difficulty as purely personal or idiosyncratic. These three elements function as a starting point for evaluating any specific model or technique a supervisor might adopt, since a model that neglects self-exploration, process, or historical context is likely to fall short regardless of its other strengths.

The focus on process described above extends beyond the two-person supervisory dyad. Dynamics involving power, safety, and relational rupture can appear simultaneously in the client-therapist relationship, in the supervisor-trainee relationship, and within the broader organizational system surrounding both, such as a training clinic, hospital, or larger healthcare system. Supervisors who work within large healthcare systems, in particular, may find that institutional dynamics, such as those between a supervisor and their own director, filter down through the levels of a training hierarchy and ultimately shape what happens between a supervisor and a trainee, or between a trainee and a client. Attending to process, in this sense, means attending to more than one relational layer at once.

Models: Overview

Four models of multicultural supervision are summarized below; two of these, along with a supervision technique, are discussed in more detail in the sections that follow. No single model is presented as superior; rather, each offers a different entry point for structuring supervision, and a supervisor may draw on more than one depending on the trainee, the setting, and the presenting concern.

Model	Citation
Multidimensional Ecological Comparative Approach (MECA)	Falicov, 2014
Competency-Based Clinical Supervision	Discussed in the presentation materials
Integrated Supervision Framework (ISF)	Peters et al., 2022
SuperVISION	Garrett et al., 2001

Competency-Based Clinical Supervision

Competency-based clinical supervision is described as meta-theoretical, meaning it can be layered onto other supervision models rather than functioning as a stand-alone approach. It incorporates a self-assessment of competencies, focuses on areas of strength, and addresses the development of the supervisory relationship, including relationship ruptures and repairs. The model also explicitly addresses supervisee vicarious trauma, recognizing that a trainee's own history, such as a personal history of sexual trauma, can be activated when working with a client processing similar material, and multicultural considerations are described as infused throughout the model rather than treated as a separate topic. Because the model is meta-theoretical, a supervisor already working from another framework, such as the Multidimensional Ecological Comparative Approach or the Integrated Supervision Framework described below, can layer a competency self-assessment and explicit attention to relationship ruptures and repairs on top of that framework rather than adopting an entirely separate model. The model's attention to supervisee vicarious trauma also connects directly to the case example described earlier in this article, involving a trainee who was not informed in advance that an assigned client had drawn a swastika on a school wall. A trainee's own history, whether related to religious or ethnic identity, personal trauma, or another significant experience, can be activated by a client's material in ways that are not always anticipated at the point a case is assigned, which is part of why this model treats vicarious trauma as a standing area of supervisory attention rather than an occasional exception.

MECA

The Multidimensional Ecological Comparative Approach moves away from broad generalizations about cultural groups and instead integrates culture into every training topic as specific scenarios arise, helping the trainee view each client within a comparative sociocultural context (Falicov, 2014). The model is organized around a both-and stance toward generalization, meaning that knowledge about a cultural group may apply to a given individual in some respects but not others, and a knowing-not-knowing stance, meaning that the supervisor gathers relevant information while maintaining ethical curiosity rather than certainty. The model attends to both cultural diversity among clients and broader questions of social justice.

Integrated Supervision Framework

The Integrated Supervision Framework integrates discrimination theory and ecological theory and is organized around three focus areas, intervention, conceptualization, and personalization; three supervisor roles, teacher, counselor, and consultant; and four domains, person, process, context, and time (Peters et al., 2022). Within this framework, intervention concerns the trainee's clinical skill development, including social justice advocacy, such as helping a trainee name culture, microaggressions, or injustice as they arise in a session. Conceptualization concerns helping the trainee build case formulations from a culturally informed framework, and personalization concerns helping the trainee process their own internal reactions and build self-understanding. The three supervisor roles describe different modes of engagement: a teacher role built on instruction, modeling, and feedback; a counselor role built on helping the trainee explore, process, and reflect; and a consultant role built on helping the trainee brainstorm and develop their own solutions. The four domains address the individual trainee's experience, what is occurring in the room in the moment, the various systems within which the trainee is situated, and time considered at multiple scales, from the immediate supervisory session to the trainee's broader training trajectory to the extended historical period within which training occurs (Peters et al., 2022).

SuperVISION Model

The SuperVISION model organizes supervision around the acronym VISION (Garrett et al., 2001). The table below summarizes each component along with an illustrative question a supervisor might use to explore it.

Component	Focus	Illustrative question
Values	Explore values and belief systems, for both trainee and supervisor	What is important to you, and why?
Interpreting experiences and applying meaning	Understand how internal and external stimuli are interpreted and made meaningful	How does the trainee's cultural background influence how they make meaning of an experience?
Structure	Understand how the trainee and supervisor structure their world	How does the trainee structure their relationships with clients and with the supervisor?
Interaction	Attend to communication style, including verbal and nonverbal communication, body language, and eye contact	How do trainee and supervisor interact with social groups and their environment?
Operational strategies	Identify goals for supervision and how to move toward them	Do the supervisor's and trainee's goals for supervision align?
Needs	Identify physical, spiritual, and environmental needs	Does the trainee want a more directive or a less directive supervisory approach?

Both supervisor and trainee bring their own goals to supervision. Making those goals explicit and discussing them directly, including the trainee's preference for a more or less directive supervisory style, is a practical starting point for applying this model.

Techniques for Supervisors

Worldview Genogram

The worldview genogram is a three-generation genogram technique designed to de-emphasize psychopathology and instead surface the overarching organizing principles of a family's worldview and culture (Chege et al., 2023). Use of the technique has been associated with improvements in trainees' knowledge, skills, and self-awareness, rather than knowledge alone (Chege et al., 2023).

A worked example illustrates the technique in practice: a three-generation genogram that includes Levin's grandmother, a Holocaust survivor who had been held at Auschwitz, extending to Levin's own generation. In the original presentation, this example was drawn as a family-tree diagram, spanning two grandparent couples, their children, and nine grandchildren in Levin's own generation; the same relationships are reproduced below in tabular form, which preserves the generational structure without requiring a visual diagram.

Generation	Individual	Relationship
Grandparents	Miriam and David; Paola and Michael	Two married couples
Parents	Chaya (daughter of Miriam and David) and Meir (son of Paola and Michael)	Married couple; Chaya's siblings are Frumy and Yossi
Grandchildren	Chanania, Giselle, Chana, Chaim, Dovi, Yekusiel, Mendel, Rachel, and Yehudis	Children of Chaya and Meir

The corresponding slide also included two personal photographs: the presenter's grandmother and the presenter at a Pride event; these are not essential to understanding the technique and are not reproduced here.

ADDRESSING Framework

The ADDRESSING framework was developed to help clinicians and supervisors systematically consider how different identities may carry privilege or oppression for a given individual (Hays, 2008). The framework's nine identity domains are listed below.

Identity domain
Age and generational influences
Disability, developmental
Disability, acquired
Religion
Ethnicity
Socioeconomic status
Sexual orientation
Indigenous heritage
National origin and gender

Age illustrates the framework's both-and quality well, since both older and younger individuals can experience oppression related to age, through ageism directed at older adults or through dismissiveness directed at younger trainees and clients, depending on context. In practice, a supervisor can use the nine domains as a checklist when helping a trainee build a case conceptualization, working through each domain briefly to consider whether it carries privilege, oppression, or some combination of both for a given client, rather than addressing identity only when a crisis or disclosure makes it unavoidable.

Self-Disclosure?!

Building on the earlier discussion of identity disclosure, three concrete recommendations for supervisors (DeAngelis, 2023) apply.

Recommendation	Description
Bring	Bring one's whole self into the supervisory relationship.
Share	Share a personal cultural genogram with the trainee.
Model	Model both self-awareness and appropriate self-disclosure, including awareness of one's own identities and associated power and privilege.

Appropriate self-disclosure does not mean using supervision time to process a supervisor's own unrelated stressors, but rather sharing oneself intentionally and in ways that model awareness of identity, power, and privilege for the trainee.

Advocacy & Activism

Social work training has historically placed more emphasis on advocacy and activism than psychology training has. Three reflective questions follow from this observation.

How does a supervisor advocate for their trainee within their own system?
How does a supervisor help their trainee advocate for their clients within that system?
How does a supervisor engage in activism within their communities and as a healthcare professional?

A case example illustrates a missed opportunity for advocacy within a supervisory system: in one training group, a Black trainee who was also a military veteran consistently received more negative feedback than peers, without anyone in the group naming or discussing how that trainee's identity and experience as the only Black veteran in the group might be relevant to that pattern. Advocacy operates at multiple levels simultaneously: a supervisor can advocate for an individual trainee within a specific training system, help that trainee build their own capacity to advocate for clients within larger institutional systems, and engage in advocacy or activism as a healthcare professional within their broader community. Supervisors are well served by considering all three levels rather than treating advocacy as a single, undifferentiated task.

Questions and Discussion

This section addresses several questions commonly raised in connection with this material.

Does harassment based on identity, reported by seventy-seven percent of trainees in one study, come specifically from supervisors? The underlying data describe harassment more generally, without specifying the source in every instance, though supervisor-perpetrated harassment is one documented source among others (Adams et al., 2023). Readers seeking a more granular breakdown should consult the original source directly.

Does the DSM adequately account for cultural differences? Many diagnostic categories condition a diagnosis on clinically significant distress or impaired social or occupational functioning, and this framing can obscure whether the underlying difficulty stems from an individual's condition or from a broader society that has not created conditions for diverse individuals to function well. This concern applies broadly across diagnostic categories, not only to those most closely associated with gender and sexual diversity discussed earlier in this article.

How can clinicians in rural areas be more intentional in practice and supervision? Rural practice presents particular difficulties: clinicians in rural areas are often preoccupied with basic access-to-care concerns and may have fewer opportunities to focus on the kind of culturally responsive supervision discussed in this course. Supervisors can nonetheless discuss directly with trainees what it is like to live and work in a rural area, including how contemporaneous political and social events, such as an election, may affect different trainees differently depending on where they live and what legal protections are or are not in place locally. Naming these regional and political considerations openly within supervision, rather than leaving them unaddressed, is a practical starting point regardless of jurisdiction.

What course or certification is required to become a supervisor? Within psychology, supervisory competence is generally developed through training rather than through a separate certification requirement; many psychologists begin supervising more junior trainees while still trainees themselves. A clinician who has not received formal training in supervision is well served by taking a course in clinical supervision and researching whether a relevant certification exists for their discipline and jurisdiction, since requirements outside of psychology, including under Florida's qualified supervisor rules, may differ.

How can clinicians incorporate cultural or spiritual practices relevant to a client's background without engaging in cultural appropriation? Discussing this directly with the client, rather than assuming a practice is relevant based on the client's apparent background, is the central recommendation. A case example involves a Native client grieving a sibling's death by overdose, with whom indigenous healing practices were incorporated at the client's own request, after the clinician asked directly whether the client wished to incorporate such practices, approached the topic with cultural humility, and checked in with the client both during and after incorporating the practice.

Summary and Key Takeaways

This course opened with a personal illustration of how a supervisor's own identity and self-disclosure choices can shape a trainee's experience, and returned to that theme repeatedly across the four major sections that followed. Several points are worth drawing together for practical use.

Regarding the fundamentals of culturally responsive supervision, the course described three foundational elements: a supervisor's ongoing self-exploration of their own attitudes, biases, strengths, and areas for growth; sustained attention to process within the supervisory relationship, including relational safety, power dynamics, and parallel process; and a willingness to examine how the broader psychology field, including its diagnostic frameworks and institutional norms, can embed systemic oppression into everyday practice and training. Supervisors who wish to build culturally responsive supervision into their own work can use these three elements as a working checklist, periodically asking whether their supervision attends to all three, rather than only to case content.

Regarding the comparison of frameworks, this course reviewed four models in varying depth. The Multidimensional Ecological Comparative Approach and the Integrated Supervision Framework were discussed in the greatest detail. The Multidimensional Ecological Comparative Approach is distinguished by its both-and stance toward generalization and its knowing-not-knowing stance toward cultural knowledge, and by its practice of integrating culture into every supervisory topic rather than treating it as a separate unit of training (Falicov, 2014). The Integrated Supervision Framework is distinguished by its explicit three-role structure for the supervisor, teacher, counselor, and consultant, and by its attention to time at multiple scales, from the immediate session to the historical period surrounding training (Peters et al., 2022). Compared with one another, the Multidimensional Ecological Comparative Approach places more weight on how the supervisor and trainee jointly interpret a given client's cultural context session by session, while the Integrated Supervision Framework places more weight on the supervisor's shifting role and on structuring the relationship itself, with implications for supervisors, supervisees, and, ultimately, the clients whose care depends on both.

The remaining two models reviewed in this course, competency-based clinical supervision and the SuperVISION model, serve a somewhat different function than the Multidimensional Ecological Comparative Approach and the Integrated Supervision Framework. Competency-based clinical supervision is meta-theoretical and is designed to be layered onto whichever primary framework a supervisor is already using, contributing a structured self-assessment of competencies and explicit attention to relationship ruptures and repairs. The SuperVISION model, by contrast, offers a discrete six-part structure, organized around the acronym VISION, that a supervisor can use directly to organize an individual supervisory relationship from the outset, making explicit each party's values, goals, and preferred degree of directiveness. A supervisor new to structured multicultural supervision might reasonably begin with the SuperVISION model to establish the relationship, then add competency-based self-assessment once that relationship is underway, before deciding whether the Multidimensional Ecological Comparative Approach or the Integrated Supervision Framework better fits their setting and caseload over time.

Regarding systemic oppression, the course traced several concrete mechanisms by which the mental health field, and psychology training specifically, can reproduce broader patterns of marginalization, including diagnostic frameworks that locate distress within the individual rather than within an unsupportive social environment, professional norms such as wardrobe policies that disproportionately burden certain trainees, and a persistent gap between who holds leadership positions in the field and who is represented among trainees. The course also offered concrete responses to these patterns, including deliberate attention to power dynamics in the supervisor-trainee relationship, incorporation of training material on the history and effects of colonialism, and active advocacy by supervisors on behalf of trainees and by trainees on behalf of clients.

Supervisors seeking to apply this material directly in their own practice may find it useful to begin with the ADDRESSING framework and the worldview genogram as concrete entry points, since both provide a structured way to open conversation about identity and background with a trainee, before moving toward the more comprehensive supervision models discussed above as the supervisory relationship develops. Read together, the course's four major sections suggest a progression that supervisors can revisit over time: understanding the supervisory relationship itself, examining the systemic context surrounding that relationship, selecting a framework or combination of frameworks to structure ongoing work, and applying concrete techniques session by session.

Course Completion

Participants who complete this course may proceed to the corresponding examination through their account, by navigating to pending courses and selecting the option to take the exam.

References

Adams, L. J., MacLean, R. R., Portnoy, G. A., Beauvais, J., & Stacy, M. A. (2023). Psychology trainee and supervisor perspectives of multicultural supervision. Psychological Services, 20(S1), 78. https://doi.org/10.1037/ser0000686

American Psychological Association. (2015). Guidelines for clinical supervision in health service psychology. The American Psychologist, 70(1), 33-46. https://doi.org/10.1037/a0038112

Benuto, L. T., Casas, J., & O'Donohue, W. T. (2018). Training culturally competent psychologists: A systematic review of the training outcome literature. Training and Education in Professional Psychology, 12(3), 125-134. https://doi.org/10.1037/tep0000193

Burkard, A. W., Johnson, A. J., Madson, M. B., Pruitt, N. T., Contreras-Tadych, D. A., Kozlowski, J. M., & Knox, S. (2006). Supervisor cultural responsiveness and unresponsiveness in cross-cultural supervision. Journal of Counseling Psychology, 53(3), 288-301. https://doi.org/10.1037/0022-0167.53.3.288

Cadenas, G. A., & McWhirter, E. H. (2022). Critical consciousness in vocational psychology: A vision for the next decade and beyond. Journal of Career Assessment, 30(3), 411-435. https://doi.org/10.1177/10690727211064805

Chege, C. N., Fu, M., Bustrum, J. M., & Jenks, E. H. (2023). The Worldview Genogram: A process model for enhancing diversity responsiveness and competence in education, training, and clinical supervision. Psychological Services, 20(2), 219-226. https://doi.org/10.1037/ser0000674

De Angelis, T. (2023). Increasing supervisor savvy around culture, race, and identity: Culturally responsive supervision includes learning about employees' perspectives, experts say. American Psychological Association. https://www.apa.org/monitor/2023/05/news-supervision

Falicov, C. J. (2014). Psychotherapy and supervision as cultural encounters: The multidimensional ecological comparative approach framework. In C. A. Falender, E. P. Shafranske, & C. J. Falicov (Eds.), Multiculturalism and diversity in clinical supervision: A competency-based approach (pp. 3–28). American Psychological Association. https://doi.org/10.1037/14370-001

Garrett, M. T., Borders, L. D., Crutchfield, L. B., Torres‐Rivera, E., Brotherton, D., & Curtis, R. (2001). Multicultural supervision: A paradigm of cultural responsiveness for supervisors. Journal of Multicultural Counseling and Development, 29(2), 147-158. https://doi.org/10.1002/j.2161-1912.2001.tb00510.x

Hays, P. A. (2008). Entering another's world: Understanding clients' identities and contexts. In C. A. Falender & E. P. Shafranske (Eds.), Diversity and multiculturalism in supervision (pp. 135–147). American Psychological Association. https://doi.org/10.1037/14370-005

Hird, J. S., Tao, K. W., & Gloria, A. M. (2004). Examining supervisors' multicultural competence in racially similar and different supervision dyads. The Clinical Supervisor, 23(2), 107-122. https://doi.org/10.1300/J001v23n02_07

Peters, H. C., Bruner, S., Luke, M., Dipre, K., & Goodrich, K. (2022). Integrated supervision framework: A multicultural, social justice, and ecological approach. Canadian Psychology/Psychologie canadienne, 63(4), 511-523. https://doi.org/10.1037/cap0000311

Additional Current References

Please note. The following resources have been included for members to view additional resources associated with this topic area. These resources were not used by the presenter when creating this course.

Childs, A. W., Crusto, C. A., & Miller, R. (2024). Getting Racism Out of Our Work (GROW): Design, deployment, and early outcomes for a program to increase psychology supervisor's multicultural competence. Training and Education in Professional Psychology, 18(4), 305–313. https://doi.org/10.1037/tep0000478

Chydenius, H., Ukkonen-Mikkola, T., & Fonsén, E. (2024). Supervisory discussions during the early childhood education and care student teacher practicum period – The cultural scripts, phases, and discourses. Early Years: An International Journal of Research and Development, 44(3-4), 845–859. https://doi.org/10.1080/09575146.2023.2252997

Hunt, T. T. (2024). The impact of clinical supervision on the authenticity of African American counselors in training. Dissertation Abstracts International Section A: Humanities and Social Sciences, 85(12-A).

Jury, R. T. (2024). Cultural considerations when working with Jewish students and supervisees. The Clinical Supervisor. Advance online publication. https://doi.org/10.1080/07325223.2024.2413060

Pyland, C. P., Williams, M. G., & Mollen, D. (2024). Ethical and diversity considerations of mandatory reporting: Implications for training. Training and Education in Professional Psychology, 18(4), 297–304. https://doi.org/10.1037/tep0000485

Nov 3, 2026

1 CE Credit

Elder Abuse and Child Abuse: Know the Signs and Your Role
Kathleen Weissberg, OTR/L, OTD
Editor’s note: This text-based course is a transcript of the webinar, Elder Abuse and Child Abuse: Know the Signs and Your Role, presented by Kathleen Weissberg, OTD, OTR/L.
Learning Outcomes
- After this course, participants will be able to recognize possible clinical, behavioral, and physical indicators of suspected elder and child abuse and neglect.
- After this course, participants will be able to list possible risk factors related to elder and/or child abuse and neglect.
- After this course, participants will be able to describe the reporting procedure for abuse and neglect.
- After this course, participants will be able to list resources that can be utilized for state-specific procedures.
Elder Abuse
Today, we are going to talk about elder abuse and child abuse, and sadly this is more common than you might think. Our goal for today is to learn to spot those warning signs and then to know what your responsibilities are or could possibly be with regard to reporting.
Some Statistics
- According to the U.S. Government Accountability Office (GAO), elder abuse is a widespread and growing problem
- Data reporting is a challenge
- Recent studies indicate that elder abuse incidence rates are far higher than once thought
According to a study by the United States Government Accountability Office, the GAO, elder abuse is really a widespread and growing problem. The data reporting in this area is a challenge, but despite that, recent studies indicate that elder abuse incident rates are far higher than we probably thought. This slide show includes a few different stories that have come up in the public sector.
- In NYS, incidence rates nearly 24X greater than the number of cases referred to authorities who can help (Lifespan of Greater Rochester et al., 2011)
- One in five Americans older than age 65 had been defrauded (Kiplinger’s Personal Finance, 2011)
- In most cases, the adult children of abused elders were unaware that their mother or father had received solicitations for money (Olson, 2011)
A collaborative public-private report on elder abuse in New York State, for example, found an incident rate of elder abuse nearly 24 times greater than the number of cases referred to social service, law enforcement, or legal authorities who have the capacity and the responsibility to assist adult older victims. And, as a nation, our response is disjointed. The minimal federal investment is only about 12 million dollars, give or take, and it is spread sparsely across eight agencies and two departments with very little coordination. I am going to digress for a second and say that recently the Office of Inspector General came out with a report related to elder abuse. I am not going to go through a lot of the details, but basically they found that a lot of individuals were coming into the emergency room and had diagnosis codes or situations indicative of abuse that was never reported to state authorities. I think we are going to see a little more oversight in the near future on this topic and probably some additional training from some of these government agencies. An Investors Protection Trust Survey found that one in five Americans older than the age of 65 had been defrauded. This is something that we are hearing about quite a bit about in the news. The conservative estimates of the personal cost to victims of financial abuse are easily three billion dollars annually. These reported cases only hint at the extent of the problem. We are not hearing a lot of the other stories that are probably out there. And, in a New York Times article, they talked about financial exploitation and the knowledge of adult children. Many are unaware that their mother or father had even received solicitations for money. Even attentive children, as involved as you can be with your parents, sometimes miss the warning signs. In that particular article, they highlighted the story of Dr. Robert Parker. He is the chief of community geriatrics at the University of Texas Health Medical Center in San Antonio. He failed to notice that his own mother was a victim of financial abuse. So, no matter how involved you are, sometimes you still miss some of these things.
A Chilling Example of Neglect
Before we get into some of the definitions, I wanted to share this story. It was a widely publicized case in Michigan. An elderly female nursing home resident began coughing one night. Her caretakers were busy, and she continued to just cough throughout the night. A couple of staff observed "white things" in her sputum and near her trach collar. It was not until the next morning that somebody actually checked into her mouth, and they found maggots. The maggots had created a partial airway obstruction causing her to suffer abnormal blood oxygen levels and labored breathing. The emergency medical services staff said that they could not even suction because of the very active maggots in the airway. This is just a terrible example and there is no evidence that that staff was disciplined for clearly neglecting this woman so severely.
Definitions
“Acts of omission or commission by a person who stands in a trust relationship that result in harm or threatened harm to the health and/or welfare of an older adult.”
Abuse Defined
- Willful infliction of injury
- Unreasonable confinement/Involuntary seclusion
- Intimidation with resulting physical harm, or pain, or mental anguish
- Punishment with resulting physical harm, or pain, or mental anguish
- Deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, or psychosocial well-being
- Corporal punishment & any physical or chemical restraint not required
- Abuse that includes that which is facilitated or enabled through the use of technology
I think the biggest piece here is that it is willful infliction. It can also include things like unreasonable confinement or involuntary seclusion, and that could happen in the home environment or in an institution. It might be where we are separating an individual from other individuals, from their room, or from another area where they want to go. This can be against their will or even against the will of that person's legal representative. It also could include intimidation or punishment with resulting physical harm, pain, or mental anguish. It could include things like deprivation by an individual, including a caretaker, of goods or services that are necessary to attain physical, mental, or psychosocial well-being. These are all the things that that person needs to be well. It can include corporal punishment or physical or chemical restraints that are not really required to treat that individual's symptoms or their issues. Again, it is anything that would cause pain or an issue, and it can also include things that are enabled through the use of technology. The individual acts deliberately.
- Elder abuse includes physical, emotional, or sexual harm inflicted upon an older adult, their financial exploitation, or neglect of their welfare by people who are directly responsible for their care
- Elder abuse tends to take place where the senior lives: where their abusers are often adult children, other family members such as grandchildren, or a spouse or partner. Elder abuse can also occur in institutional settings.
Now elder abuse includes, as we just said, physical, emotional, sexual harm potentially inflicted upon an older adult. It can also include financial exploitation and neglect of their welfare. It is done by somebody who is directly responsible for their care. And in the United States alone, more than half a million reports of elder abuse reach authorities every year, and many more go unreported. Now as older adults become more physically frail, they are less able to take care of themselves. They cannot stand up to bullying, and they cannot fight back a lot of times if they are attacked in some way.
The mental or physical ailment that they have can make them more trying to companions for those who live with them. They may not see, hear, or think as clearly as they used to. This leaves them open, unfortunately, for unscrupulous people to take advantage of them, and we definitely see that. The other thing to keep in mind is that elder abuse tends to take place where that individual lives. We hear stories of elder abuse that occurs somewhere out in the community, but typically, the senior lives with their abusers. The abusers can be adult children, other family members like grandchildren, a spouse, a partner, or a very good friend. The sad reality is that elder abuse can also occur in institutional settings especially long-term care facilities, that is where we hear about it most.
Forms of Abuse
- Verbal
- Physical
- Sexual
- Mental/Emotional
- Neglect
- Abandonment
- Financial exploitation
- Self-neglect
What are the different forms? Abuse of elders takes a lot of different forms. Some involve intimidation or threats against the elderly, some involve neglect and other financial trickery. The most common types are listed above. We will go through each one of these in a little more detail and look at some of the warning signs.
Verbal Abuse
- Oral, written or gestured language that includes disparaging and derogatory terms to the residents or their families to describe the resident within their hearing distance, regardless of their age &/or ability to comprehend or disability
This is almost like bullying. It is talking about that person in such a negative way so that they overhear it. The person feels, based upon this blame, diminished self-worth, or diminished ego, et cetera. This is, obviously, not something that we would want to do.
Physical Abuse
- The non-accidental use of force against an elderly person that results in physical pain, injury, or impairment. Such abuse includes not only physical assaults such as hitting or shoving but the inappropriate use of drugs, restraints, or confinement.
Physical abuse is pretty straightforward. This does not just include physical assault such as hitting or shoving, but it can also include things like the inappropriate use of drugs or medications, restraints, or even confinement. This can be in an institutional or home setting. The more common types of physical abuse that we see are things like hitting, slapping, pinching, scratching, spitting, holding that person roughly, holding them in their chair, or forcing them into their wheelchair. It also includes controlling behavior through corporal punishment. Unfortunately, we continue to see this in some of our settings. This a corporal type punishment of influence.
Sexual Abuse
- Contact with an elderly person without their consent. Includes but is not limited to humiliation, harassment, coercion, or sexual assault. Activities such as showing an elderly person pornographic material, forcing the person to watch sex acts, or forcing the elder to undress are also considered sexual elder abuse.
Again, you hear these outrageous stories on the news, and it makes you scratch your head. Sexual abuse includes but is not limited to things like humiliation, harassment, coercion, or even sexual assault. It is non-consensual sexual contact of any type with an individual. It is contact with that elderly person without their consent. It can involve physical sexual acts, but it can also involve other things like showing an elderly person pornographic materials and making them watch it or forcing the person to watch other sex acts or something else occurring in the environment. It can even include forcing the elder to undress in front of you. This would not be part of an ADL or helping them to use the restroom. This is forcing them to undress outside of those normal scenarios.
Emotional/Mental Abuse
- The treatment of an older adult in ways that cause emotional or psychological pain or distress, including:
  - Intimidation through yelling or threats
  - Humiliation and ridicule
  - Habitual blaming or scapegoating
  - Ignoring the elderly person
  - Isolating an elder from friends or activities
  - Terrorizing or menacing the elderly person
  - Harassment
  - Threats of punishment or deprivation.
This is the treatment of an older adult in ways that cause emotional or psychological pain or distress. It can be intimidation through yelling or threats, humiliation or ridicule, habitual blaming, or scapegoating. It can also be ignoring that elderly person or ignoring their requests, isolating an elder from their friends or their activities, and terrorizing or menacing the elderly person. You may not think that some of these things are necessarily emotional elder abuse, but they could be under the right set of circumstances. For example, if you take a photograph, and that person does not want to be photographed, that could constitute mental, physical, or some sort of abuse. Again, we should not be doing that in any of our settings or doing anything that might be considered humiliating toward an individual. During the delivery of care, depending on what we are doing with that individual, we need to make sure that we are keeping the person from public view like undressing to do an ADL. We need to make sure that we prevent any unnecessary exposure of body parts. That is what we do all the time normally, but if we did not, it could be potentially considered emotional or mental abuse.
My aunt, who has since passed away, was in a nursing home many years ago. She had dementia but she still knew enough to say I need to use the restroom when she truly needed to go. She had a urinary tract infection at the time was going much more frequently. I remember her saying, "I have to use the bathroom." She did not want me to take her and that was fine. She called for a nurse who came in and said, "Don't you realize you just went about an hour ago? You couldn't possibly need to go again. If you need to go, you're just going to have to go in your diaper." And I sat there and thought, "That's emotional abuse. That's humiliating to say to a person." And, this is in a premier community. There are the things that we need to look out for as they can certainly lead to emotional types of abuse. Whether that mental abuse has occurred or not is really determined by a reasonable person's standard and does not require a specific response from the individual. What I mean by that is a reasonable person would think that that is completely unacceptable. It does not necessarily have to have a response from the individual because that individual may have dementia or something else going on and cannot respond in an appropriate manner. We always use that "reasonable person standard" as our litmus test against whether or not something would be considered emotional or mental abuse.
Medication Diversion
- Knowingly, or intentionally, interrupting, obstructing, or altering the delivery, or administration of a prescription drug.
The next one is medication diversion. This is an interesting one. This is one we are hearing more and more about, but I think particularly in a home environment by a companion or caregiver (not necessarily paid) who might be looking to steal those medications for their own personal or financial gain. We are seeing a little bit more of this out in the community.
Elder Neglect
- Failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. This constitutes more than half of all reported cases of elder abuse. It can be intentional or unintentional.
This is quite simply the failure to fulfill a caretaking obligation. Unfortunately, this constitutes more than half of all reported cases of elder abuse. It can be intentional or unintentional based on factors such as ignorance or denial that an elderly charge needs as much care as they do. Again, it is really just that failure to provide goods and services that are necessary for that person to avoid harm, and we will talk more about that in just a little bit.
Financial Exploitation
- The unauthorized use of an elderly person’s funds or property, either by a caregiver or an outside scam artist
  - Misuse an elder’s personal checks, credit cards, or accounts
  - Steal cash, income checks, or household goods
  - Forge the elder’s signature
  - Engage in identity theft
  - Scams targeting the elderly
Another one that we are hearing a lot about now in the news is financial exploitation. This is the unauthorized use of an elderly person's funds or property either by a caregiver or by some outside person, a scam artist. It is deliberate misplacement, exploitation, wrongful temporary or permanent use of an individual's belongings or money without their consent. The important distinction is without their consent. An unscrupulous caregiver might do things like misuse a person's personal checks, their credit cards, or their accounts. They may steal cash, income checks, household goods, or get access to their accounts. They may be under the guise of helping the client with their bills, but they are skimming out of their accounts without that elder knowing. Forging the elder's signature and engaging in identity theft is very common. Another example is an announcement of a prize that the elderly person has won, but they have to pay money to claim. There can be phony charities and investment fraud. I have even heard of scammers showing up on an elder's doorstep. They claim to be from the utility company, or what have you, and they tell the homeowner that they need to pay their bill in cash.
Healthcare Fraud and Abuse
- Not providing healthcare, but charging for it
- Overcharging or double-billing
- Getting kickbacks for referrals
- Overmedicating or under medicating
- Recommending fraudulent remedies for illnesses
- Medicaid fraud
You may not think of this as elder abuse but it really is. This is carried out by unethical individuals like doctors, nurses, hospital personnel, and other professional providers. This includes not providing healthcare but charging for it, overcharging or double-billing from medical care or services, getting kickbacks for referrals to other providers, prescribing certain drugs, over-medicating or under-medicating, or recommending fraudulent remedies for illnesses or other medical conditions. This is anything that benefits the medical professional, not the client.
Elder Self-Neglect
- Physical or mental impairment or diminished capacity can mean that an older adult is no longer able to perform essential self-care
- May lack basic personal hygiene, appear malnourished, live in dirty conditions, be unable to pay bills or manage medications
- Can be a sign of depression, grief, dementia, or other medical problem
We already talked about neglect, but this is self-neglect. This is a common form of elder abuse that we see in healthcare. Physical or mental impairment or diminished capacity can mean that an older individual is no longer able to perform essential self-care, and we see that very commonly with cognitive decline, dementia, et cetera. They may lack basic personal hygiene, appear dehydrated, malnourished, underweight, or what have you. This can be a sign of depression, grief, dementia, some other medical problem, and in many cases, the older person refuses to seek assistance. They, oftentimes, are in denial. They feel ashamed about needing help or feel worried about losing their independence. If you see this self-neglect, this could be indicative of some other larger systemic issue going on with the elder.
Signs of elder abuse can, unfortunately, be very difficult to recognize, mistaken for symptoms of dementia, the elder person's frailty, or again the caregivers may explain them to you in that way and just pass them off. In fact, many of the signs and symptoms of elder abuse do overlap with symptoms of mental deterioration, but that does not mean that we want to dismiss them on the caregiver's say-so.
Warning Signs
If you suspect abuse but you are not sure, look for the warning signs. We are going to go through these quickly as it relates to each of the types of abuse.
Physical Abuse Warning Signs
- Unexplained signs of injury, such as bruises, welts, or scars
- Broken bones, sprains, or dislocations
- A report of drug overdose or an apparent failure to take medication
- Broken eyeglasses or frames
- Signs of being restrained, such as rope marks on wrists
- Caregiver’s refusal to allow you to see the elder alone
These can include unexplained signs of injury such as bruises, welts, scars, especially if they appear symmetrically on both sides of the body, broken bones, sprains, or dislocations, or fractures that are unexplained. Another warning sign is a report of either a drug overdose or an apparent failure to take their medication. When you go in to do your visit, you may see that there is a lot more of that prescription remaining than should be. They may have broken eyeglasses, broken frames, signs of being restrained, like rope marks on their wrists, or things maybe that came from a zip tie. The caregiver may refuse to allow you to see the elder alone. There can also be signs of burns, internal injuries, and abrasions. These are injuries that are unexplained or somebody is giving you an explanation and that explanation is just really not plausible.
Emotional Abuse Warning Signs
- Threatening, belittling, or controlling caregiver behavior
- Behavior from the elder that mimics dementia
- Depression, sleep and appetite disturbances
- Decreased social contact
- Evasiveness, anxiety, hostility
When we look at emotional abuse warning signs, these are things like threatening, belittling, or controlling caregiver behavior. You may observe the caregiver and what they are saying may not ring true. Your "spidey sense" may be alerted. Behavior from the elder that mimics dementia such as rocking, sucking, or mumbling to themselves. Depression, sleep and appetite disturbances, decreased social contact, loss of interest in their own self, apathy, suicidal ideation, evasiveness, anxiety, hostility, or any of those changes can be potential warning signs. This person who has always wanted to go to activities and been very involved suddenly does not want to go and have isolated themselves would be a big red flag.
Sexual Abuse Warning Signs
- Bruises around breasts or genitals
- Unexplained vaginal or anal bleeding
- Torn, stained, or bloody underclothing
- Fear of being touched
- Inappropriate modesty on evaluation
You may notice some of these things while doing an ADL. Other issues would be unexplained vaginal or anal bleeding, torn, stained, bloody underclothing, fear of being touched, or an inappropriate modesty when you are delivering standard treatment or evaluation. You might have draped that person appropriately, but they still just do not want you to see them.
Neglect Warning Signs
- Unusual weight loss, malnutrition, dehydration
- Untreated physical problems, such as bed sores
- Unsanitary living conditions
- Being left dirty or unbathed
- Unsuitable clothing or covering for the weather
- Unsafe living conditions
- Desertion of the elder at a public place
- Eccentric or idiosyncratic behavior, self-imposed isolation, marked indifference
Elder neglect or even self-neglect have some warning signs. These are things like unusual weight loss without a weight loss program, malnutrition, dehydration, untreated physical problems like bedsores or something else that should be treated, unsanitary living conditions, so dirt, bed bugs, or soiled bedding and clothing. They may be dirty or unbathed, or have unsuitable clothing or covering for the weather. For example, it could be cold outside yet the person has no coat. There may be no heat or running water, faulty electrical wiring, other fire hazards, or maybe they have been deserted at a public place. Another indication is the misuse or the absence of medication or an assistive device. You can also see things like eccentric or idiosyncratic behavior, self-imposed isolation, and a marked indifference to anything that is going on around them. All of those can be signs of neglect.
Financial Exploitation Warning Signs
- Significant withdrawals from the elder’s accounts
- Sudden changes in the elder’s financial condition
- Items or cash missing from the senior’s household
- Suspicious changes in wills, power of attorney, titles, and policies
- Addition of names to the senior’s signature card
- Financial activity the senior couldn’t have undertaken
- Unnecessary services, goods, or subscriptions
- The disparity between assets and appearance and general condition
Some of the warning signs here include significant withdrawals from that person's account, a sudden change in their financial condition, and items or cash missing from their household. Maybe, there have been changes in the will, in the power of attorney, and in titles and policies. They may have signed over these items to someone that just makes you scratch your head. There may be new additions of names to a signature card for the bank or other accounts. There may be financial activity that the person could not have possibly undertaken. For example, an ATM withdrawal when the account holder is bedridden or paying an account online when the person does not even have a computer. There could be unnecessary services, goods, or subscriptions. The client may also display fear, vague answers, or anxiety when asked about their personal finances. You may see a disparity between their assets and their appearance and their general condition.
Healthcare Fraud/Abuse Warning Signs
- Duplicate billings for the same medical service or device
- Evidence of overmedication or under-medication
- Evidence of inadequate care when bills are paid in full
- Problems with the care facility
Duplicate billings for the same medical service or device, evidence of overmedication or under-medication, evidence of inadequate care when the bills are truly paid in full are some warning signs in this category. All of their medical bills are paid, but they do not look like they are cared for. This could also happen in an institution where there are problems with the care facility. The staff could be poorly trained, poorly paid, insufficient staff, or overcrowding.
Risk Factors
- Caregiver stress
- Depression in the caregiver
- Lack of support from other potential caregivers
- Substance abuse by the caregiver
- The intensity of the elderly person’s illness or dementia
- Social isolation
- The elder’s role, at an earlier time, as an abusive parent or spouse
- A history of domestic violence in the home
- The elder’s own tendency toward verbal or physical aggression
Taking care of a senior who has a lot of different care needs can be difficult. Both the demands of caregiving and the needs of that elder can create situations in which abuse is more likely to occur. Many nonprofessional caregivers, spouses, adult children, other relatives, and friends find taking care of an elder to be really satisfying and enriching, but the responsibilities and demands of caregiving can escalate and cause stress as that person's condition deteriorates. The stress of elder care can lead to mental and physical health problems that leave the caregiver burned out, impatient, and more susceptible to neglecting or lashing out at the elder in their care. Even caregivers in institutional settings can experience that stress that can lead to elder abuse. Nursing home staff particularly may be prone to elder abuse if they lack training, have too many responsibilities, are unsuited to caregiving, or they work under poor conditions. In addition to that caregiver's inability to manage stress, some other significant risk factors for elder abuse include depression in the caregiver and lack of support from other caregivers. The caregiver's perception that taking care of the elder is burdensome without any sort of emotional reward is another problem. Other risk factors include substance abuse by the caregiver, the intensity of the elderly person's illness or their dementia, social isolation, meaning that the elder and the caregiver are alone most of the time together, the elder may have been an abusive parent or a spouse, a history of domestic violence in the home, and the elder's own tendency toward verbal or physical aggression.
Federal Reporting Requirements
- Elder Justice Act (EJA): designed to address crimes committed against older persons, raise national awareness of elder justice issues and apply resources to the efforts of those confronting elder abuse and neglect on the front lines in healthcare settings
These reporting requirements come from the Elder Justice Act. The purpose of that act is to detect, prevent, and prosecute elder abuse, neglect, and exploitation. The Elder Justice Act is designed to address crimes committed against older persons, raise national awareness of elder justice issues, and then apply resources to the efforts of those confronting elder abuse and neglect on the front lines in our healthcare settings. The Elder Justice Act as well adds new elder justice provisions and very specific provider requirements particularly in long-term care by amending various sections of several titles of the Social Security Act.
- Section 1150B of the Social Security Act (the Act), as established by section 6703(b)(3) of the Patient Protection and Affordable Care Act of 2010 (Affordable Care Act), requires specific individuals in applicable long-term care facilities to report any reasonable suspicion of crimes committed against a resident of that facility
- Facilities are required to conspicuously post, in an appropriate location, a notice for its employees specifying the employees’ rights, including the right to file a complaint under this statute. The notice must include a statement that an employee may file a complaint with the SA against an LTC facility that retaliates against an employee.
Section 1150B of the Social Security Act, as established by the Patient Protection and Affordable Care Act, requires that very specific individuals in applicable long-term care facilities report any reasonable suspicion of crimes committed against an individual of that facility. Now, this is required of any facility that receives at least $10,000 in federal funds under the act in the preceding year. That community is required to notify every covered individual of their obligation to report to the Secretary of Health and Human Services, known as the Secretary, and at least one local law enforcement entity, for any reasonable suspicion of a crime. A covered individual, in this case, is an owner, an operator, an employee, a manager, an agent, or a contractor. It includes pretty much everybody. Additionally, communities are required to post in a very conspicuous place a notice for employees specifying their rights including the right to file a complaint, and the notice also has to have a statement in it that an employee can file a complaint with the Secretary and they cannot be retaliated against.
- You have a duty to report any suspected acts involving mistreatment, neglect, abuse, etc.
- Facilities must report any reasonable suspicion of a crime against a resident or patient to:
  - The Secretary of the U.S. Department of Health and Human Services (HHS), and
  - The law enforcement authorities in the political subdivision where the facility is located.
You do have a duty to report any suspected acts involving individual mistreatment, neglect, abuse, crimes, misappropriation of resident property, injuries of an unknown source, et cetera. Again, these are healthcare facilities again that are receiving federal aid. These facilities need to report any reasonable suspicion of a crime against an individual or a patient, number one, to the Secretary of the United States Department of Health and Human Services, and then also to the law enforcement authorities in the political subdivision where that facility is located. There are two specific federal reporting requirements, and most of these apply to the long-term care segment of the industry as that is where most of our elders reside.
- Two-time limits for the reporting of reasonable suspicion of a crime
  - Serious Bodily Injury – 2 Hour Limit
    Shall report the suspicion immediately, but not later than 2 hours after forming the suspicion
  - All Others – Within 24 Hours
    If no serious bodily injury shall report the suspicion not later than 24 hours after forming the suspicion
- “Serious bodily injury” is one involving extreme physical pain or substantial risk of death; or an injury involving protracted loss or impairment of the function of a bodily member, organ, or mental faculty; or an injury requiring medical intervention such as surgery, hospitalization, or physical rehabilitation.
There are two-time limits for reporting reasonable suspicions of crime depending on the seriousness of the event that leads to that suspicion. The first is whether or not there is a serious bodily injury. Now under the Elder Justice Act, serious bodily injury is one involving extreme physical pain, substantial risk of death, or an injury involving protracted loss or impairment of the function of a bodily member, organ, or mental faculty. This is an injury requiring medical intervention such as surgery, hospitalization, or physical rehabilitation. If the events that cause a reasonable suspicion of harm or abuse and there is serious bodily injury, people are required to report immediately but no later than two hours after forming a suspicion to both local law enforcement and the Secretary of Health and Human Services. All others need to be reported within 24 hours. That is federal guidance.
State Reporting Requirements
- Each state may have specific reporting requirements related to abuse
- It is important that you familiarize yourself with the requirements for the state in which you work/provide services
- Report as required by state law
This is where it gets tricky because every state is different. Each state may have specific reporting requirements related to the abuse. And for you, it is important that you familiarize yourself with the requirements for the state where you work and where you provide the services. If you feel or have a reason to believe that somebody is being abused, you need to report this. As every state is different and you need to report as required by your state law.
Resources
- State Adult Protection Statutes:
  - https://www.stetson.edu/law/academics/elder/home/adult-protection-statutes.php
- State Mandatory reporting Statutes:
  - https://www.stetson.edu/law/academics/elder/home/media/Mandatory-reporting-Statutes-for-elder-abuse-2016.pdf
Here are a couple of resources. One is the State Adult Protection Statutes, and the second link here is for State Mandatory Reporting Statutes. The second one specifically will tell you where to report, how to report, who is required to report, and what those timeframes are for your specific state. Hopefully, you can take the time to look those up as well.
Child Abuse
Federal Definition of Child Abuse
- Federal Child Abuse Prevention and Treatment Act (CAPTA) (42 U.S.C.A. § 5106g) defines child abuse and neglect as at minimum:
  - "Any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation"; or
  - "An act or failure to act which presents an imminent risk of serious harm."
According to the United States Department of Health and Human Services, federal legislation provides guidance to states by identifying a minimum set of acts or behaviors that define child abuse and neglect. The Federal Child Abuse Prevention and Treatment Act or CAPTA, as amended by a Reauthorization Act in 2010, defines child abuse and neglect at a minimum to any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation, and an act or failure to which presents an immediate or an imminent risk of serious harm.
Definitions
- A "child" generally means a person who is younger than age 18 or who is not an emancipated minor
- CAPTA does not provide specific definitions for types of maltreatment such as physical abuse, neglect, or emotional abuse
- Federal legislation sets minimum standards for States that accept CAPTA funding, each state provides its own definitions of maltreatment within civil and criminal statutes
Under these definitions, this definition refers very specifically to parents and other caregivers. A child under this definition generally means a person who is younger than the age of 18 or who is not an emancipated minor. And while CAPTA provides definitions for sexual abuse and the special cases of neglect related to withholding or failing to provide medically indicated treatment, it does not provide specific definitions for other types of maltreatment or things like physical abuse, neglect, or emotional abuse. While federal legislation sets those minimum standards for states that accept CAPTA funding, each state is going to go out on its own and provide its own definitions of maltreatment within civil and criminal statutes.
State Statutes
- Definitions of child abuse and neglect are typically located in two places within each State's statutory code:
  - Civil statutes provide definitions of child maltreatment for mandated reporters
  - Criminal statutes define those forms of child maltreatment subject to arrest and prosecution
The federal definition is out there, but the state has to be accepting CAPTA funding for that federal definition to apply. More often than not, each state is going to have its own set of statutes related to child abuse. We will talk about this on another slide, but that is again where it is up to you to figure out the requirements in your specific state. Are you a mandatory reporter? What are your training requirements? I gave you some resources to do that, and we will talk about that in a minute. The definitions of child abuse are going to be located typically in two places within each state's statutory code. The first statutory code will be the civil statutes, and these will provide those definitions of what is child maltreatment. It also will help to guide the mandatory reporters and other individuals as well as to identify and report suspected child abuse and determine the grounds for intervention by the state child protection agencies and the civil courts. This is the overarching area of what is abuse, who reports, how do you report, and what do we do when you report. The criminal statutes, on the other hand, will define those forms of child maltreatment that can subject an offender to arrest and prosecution in criminal courts. Most of them will list out very specifically the types of things that are absolutely positively against the law and what would warrant an arrest, prosecution, jail time, community service, or whatever it would happen to be.
Types of Abuse
- Many states recognize four major types of maltreatment
  - Neglect
  - Physical abuse
  - Sexual abuse
  - Emotional abuse or neglect
Many states recognize four major types of maltreatment in their definitions and these include neglect, physical abuse, sexual abuse, and emotional abuse or neglect. Let's look at these in a little more detail. I think the first step in helping an abused or neglected child is learning those warning signs. The presence of a single sign does not prove that child abuse is occurring but it could be. But, when you look at the situation a little bit more closely, you may see signs appear repeatedly or in combination. When you see a pattern, that is when you want to take notice. If you do suspect at any time that a child is being harmed, you have to report your suspicions because that is going to help protect that child and get some help for the family. We will talk about reporting in a second, but any person can report suspicions of child abuse and neglect. Mandatory reporters need to report under very specific circumstances defined by the state. Healthcare providers with very few exceptions would be considered mandatory reporters in those states.
Recognizing Child Abuse
- The Child:
  - Shows sudden changes in behavior or school performance
  - Has not received help for physical or medical problems
  - Has learning problems that cannot be attributed to specific causes
  - Is always watchful
  - Lacks adult supervision
  - Is overly compliant, passive, or withdrawn
  - Comes to school or other activities early, stays late, and does not want to go home
These are the signs in a child that may signal child abuse or neglect. They show sudden changes in behavior or school performance. They were a wonderful student and now they are not. They have not received help for a physical or a medical problem that has been brought to the parent's attention. They have learning problems or difficulty concentrating in the classroom that cannot be attributed to a very specific physical or psychological cause. Or, maybe that child is always watchful as though they are always preparing for something bad to happen. They are looking for that other shoe to drop or looking over their shoulder. They lack adult supervision when they are not of an age to be unsupervised. They are overly compliant or very passive or withdrawn. They say yes ma'am or no sir to all requests. They come to school or to other activities early, they stay late, and they do not really want to go home when it is time for dismissal.
- The Parent:
  - Shows little concern for the child
  - Denies the existence of—or blames the child for—the child’s problems in school or at home
  - Asks teachers to use harsh physical discipline
  - Sees the child as entirely bad, worthless, or burdensome
  - Demands a level of physical or academic performance the child cannot achieve
  - Looks primarily to the child for care, attention, and satisfaction of emotional needs
This parent shows little concern for the child. They pass off some of the things that are happening with their child as not being important. They deny the existence of or even blame the child for the child's own problems in school or at home. They ask a teacher or a caregiver to use harsh physical discipline if that child misbehaves. It is okay to do X, Y, and Z if the child misbehaves. "This is what we do at home." They see the child as bad, worthless, or burdensome. They demand a level of physical or academic performance that the child cannot possibly achieve. This is different from encouraging them to be a better student or athlete. This is forcing something that they could not possibly achieve or do not have the physical or mental capacity to do. They look at the child primarily for care, attention, and satisfaction of their own emotional needs rather than providing the care to the child for the child's needs.
- The Parent and Child:
  - Rarely touch or look at each other
  - Consider their relationship entirely negative
  - State that they do not like each other
We can also look at the parent and child dyad together. They rarely touch each other or look at each other. You do not see that bond or connection between the two of them. They consider their relationship entirely negative, and they may just flat out state that they do not like each other and truly mean that. We talked about the types of maltreatment that are generally defined in the state statute, and now, we are going to go through now some of the signs that are associated with the types of child abuse and neglect. It is important to note however that these types of abuse are typically found in combination rather than alone.
You will not typically just see physical abuse without also some sort of emotional or mental anguish as well. For example, a child who is sexually abused may also be neglected. You want to look for these in combination and look for some of those signs. And again, a lot of these are going to be very similar to what we just talked about with elder abuse.
Physical Abuse
- Has unexplained burns, bites, bruises, broken bones, or black eyes
- Has fading bruises or other marks noticeable after an absence from school
- Seems frightened of the parents and protests or cries when it is time to go home
- Shrinks at the approach of adults
- Reports injury by a parent or another adult caregiver
They may have unexplained burns, bites, bruises, broken bones, and black eyes. They may be consistently in the emergency room for some sort of treatment. They have fading bruises or other marks that are noticeable after an absence from school. They seem frightened of the parents. They protest or they cry when it is time to go home. They shrink at the approach of an adult and are wary of adults who are around them. They report injuries by a parent or another adult caregiver, or they report an injury and the explanation of that injury is just not plausible. The proverbial "I fell down the stairs" type of excuse.
- Consider physical abuse when the adult:
  - Offers conflicting, unconvincing, or no explanation for the child’s injury
  - Describes the child as “evil,” or in some other very negative way
  - Uses harsh physical discipline with the child
  - Has a history of abuse as a child
We might want to consider physical abuse if they are offering conflicting, unconvincing, or no explanation for the child's injury. "have no idea how that happened." Or, "Don't worry about it. It's no big deal." They describe the child as evil in some way, or they are very negative in their description of the child. They use harsh physical discipline with the child even when it is not warranted. Another one is that they themselves may have a history of abuse as a child.
Neglect
- The child is frequently absent from school
- Begs or steals food or money
- Lacks needed medical or dental care
- Is consistently dirty
- Lacks sufficient clothing for the weather
- Abuses alcohol/drugs
- States that there is no one at home to provide care
You want to consider the possibility of neglect when the child is frequently absent from school again without a reason. This is when they are not on vacation, not sick and at the physician, and not visiting their grandparents. They may beg or steal food in the cafeteria. They may lack the necessary medical or dental care that they should be having at their age. They may not have their immunizations not necessarily related to the opinions of the parent but because the parent refuses to give them. Maybe they need glasses, but they do not have glasses. They are consistently dirty and do not look well-kept. They have severe body odor or their hair is very dirty. They may have consistent issues with lice or other types of bugs. They may lack sufficient clothing for the weather, again very similar to elder abuse. It is cold outside but they do not have a coat. It is raining but they do not have anything to protect them from the elements. The child may be abusing alcohol, drugs, or other things more consistent in an older child. They may state that there is no one home to provide care for them. They may say, "I cook my own meals all the time." Another clue is, "I take care of a younger sibling."
- Consider neglect when the adult:
  - Appears to be indifferent to the child
  - Seems apathetic or depressed
  - Behaves irrationally or in a bizarre manner
  - Is abusing alcohol or other drugs
You also want to consider the possibility of neglect again when we look at the parent or the adult caregiver and they are indifferent to that child. They are apathetic and do not seem to care. They themselves are depressed and not in a position to care appropriately for that child. They behave irrationally or in a bizarre type of manner. Or, they may be abusing alcohol or other drugs themselves.
Sexual Child Abuse
- Has difficulty walking or sitting
- Suddenly refuses to change for gym
- Reports nightmares or bedwetting
- Experiences a sudden change in appetite
- Demonstrates bizarre, sophisticated, or unusual sexual knowledge
- Becomes pregnant or contracts a venereal disease
- Runs away
- Reports sexual abuse by a parent or another adult caregiver
Consider the possibility of sexual child abuse when that child has difficulty walking or sitting. You see that they have pain in their genital area. It is observable that they are very uncomfortable. They suddenly refuse to change for the gym, participate in physical activities, or maybe participate in your treatment session. They may report having nightmares or bedwetting. Their appetite may have gone down or up, and they may also have sleep disturbances. They have bizarre, sophisticated, or even unusual sexual knowledge or behavior for their age. Things that they should not know but they do. They may become pregnant or have a sexually transmitted infection, particularly at younger ages. They run away or they report some sort of sexual abuse by a parent or another adult or caregiver. You have to take these comments very seriously.
- Consider sexual abuse when the adult:
  - Is unduly protective of the child or severely limits the child’s contact with other children, especially of the opposite sex
  - Is secretive and isolated
  - Is jealous or controlling with family members
We also want to consider the possibility of sexual abuse when the parent, adult caregiver, or older sibling is really protective of that child. This severely limits the child's contact with other children or other individuals, especially of the opposite sex. They are secretive and isolated. They look like they have an unhealthy type of family bond. They are very jealous and controlling with other family members.
Emotional Maltreatment
- Shows extremes in behavior
- Is either inappropriately adult or inappropriately infantile
- Is delayed in physical or emotional development
- Has attempted suicide
- Reports a lack of attachment to the parent
Signs of emotional maltreatment is when you see a child showing extremes in behavior. They may be overly demanding, extremely passive, or extremely aggressive. They are either inappropriately adult-like or infantile as examples. They may be delayed in their physical, emotional development, and cognitive development. Perhaps, they have attempted suicide or have even talked about suicide. They feel like their life is not worthy or unsatisfactory. They may report a lack of attachment to the parent. If we interact with that parent or caregiver, we may see that the adult constantly blames, belittles, or berates that child. They are really unconcerned about the child, their whereabouts, their well-being, and those sorts of things. They do not consider the offers of help for the child's problem.
How to Report Suspicions
- Suspected Child Maltreatment
  - If in serious danger, call 911
  - National and local resources are available to provide assistance and information about reporting suspected maltreatment.
- Suspected child abuse or neglect?
  - Contact your local child protective services office or law enforcement agency
  - Know the statutes if you are a mandatory reporter
If you see suspicions, what do you do? If you or someone else is in immediate danger, call 911. That is the best thing to do because there are both national and local resources that are available to provide immediate assistance to that child and family. You would want to report that information about suspected maltreatment. Again this is very state-specific, but at a bare minimum, you would contact your local Child Protective Services office or law enforcement agency. If you are a mandatory reporter in your state, you are going to need to know what their requirements are. I can tell you that I am licensed in a couple of states, and I look at my licensing requirements. There are very specific rules that you need to follow about timeframes, phone calls, and specific people to contact. Unfortunately, in the scope of this presentation, we cannot go into that level of detail, but you need to know what the statutes are for your specific state.
Who Can Report?
- Anyone can report suspected child abuse or neglect
- All U.S. States and territories have laws identifying mandatory reporters
- Mandatory reporters may include social workers, teachers, and other school personnel, childcare providers, physicians, and other health-care workers, mental health professionals, and law enforcement officers
Again all states have laws that identify persons who are mandatory reporters like social workers, teachers, school personnel, childcare providers, physicians, mental health professionals, and law enforcement officers. They are all identified in those state statutes, However, any person who suspects child abuse and neglect can and should report.
What Happens Next?
- Report a complete, honest account of what you observed that led you to your suspicion. Any reasonable suspicion is sufficient.
- Reports are sent to child protective services (CPS) for review
- If an investigation is deemed needed, CPS may talk with the family, the child, or others to help determine what is making the child unsafe
- For more information about where and how to file a report, contact your local child protective services agency or police department
You need to provide a completely honest account of what you observed that led you to suspect the occurrence of child abuse or neglect and any reasonable suspicion is sufficient. Do not make up details or leave out details - be clear, be honest about what you saw, what you heard, or what you observed. Do not base that on hearsay. It should only be based on your own report. This report is going to be sent over to Child Protective Services or CPS for review. Generally speaking, again for states, when they receive that report, the worker will review the information and determine if an investigation is necessary. That CPS worker may talk to the family, the child, or other individuals to help determine what possibly is making this child unsafe. They can also help parents and other caregivers get services, get an education, and get other assistance to help them through the situation.
Resources
- Childhelp National Child Abuse
  - Call or text 1.800.4.A.CHILD (1.800.422.4453). Professional crisis counselors are available 24 hours a day, 7 days a week, in over 170 languages.
- National Center for Missing and Exploited Children’s CyberTipline
  - Report online sexual exploitation of a child or if you suspect that a child has been inappropriately contacted online at the CyberTipline.
There are national resources that are available. For the Childhelp National Child Abuse resource, there are professional crisis counselors there 24 hours a day, seven days a week available in 170 different languages. Every call that is placed is completely confidential, and the hotline offers things like crisis intervention, information, referrals out to other emergency services, social services, and other sorts of resources that are available in the community. There is also the National Center for Missing and Exploited Children's Cyber. This is an online reporting if you suspect any sort of sexual exploitation of a child, and that would include human trafficking. You can also report if you suspect that a child has been inappropriately contacted online. Information again is made available to law enforcement in order to conduct that investigation.
- State Statutes for Child Protective Services:
  - https://www.childwelfare.gov/topics/systemwide/laws-policies/state/
- State reporting Phone Numbers:
  - https://www.childwelfare.gov/organizations/?CWIGFunctionsaction=rols:main.dspList&rolType=custom&rs_id=5
Here are two resources for your states. The first one is the state statutes for Child Protective Services, and the second is the state reporting phone numbers. Now, these are not necessarily the end all be all. Again go back to your Practice Act, your licensure, etc. But, these are some good starting points so that you can start to read about what is required.
Citation
Weissberg, K. (2019). Elder abuse and child abuse: Know the signs and your role. Continued - Counseling, Article 20. Available at www.continued.com/counseling
Oct 29, 2026
Assessing and Treating Non-Suicidal Self-Injury
Patrice Berry, LCP, PsyD
Editor's Note: This text-based course is a transcript of the webinar, Assessing and Treating Non-Suicidal Self-Injury, presented by Patrice Berry, PsyD, LCP.
Learning Outcomes
- After this course, participants will be able to explain non-suicidal self-injury, discuss different types of self-injury, and dispel common myths about self-injury.
- After this course, participants will be able to identify ways to assess for non-suicidal self-injury, safety plan, and common reasons why people engage in this behavior.
- After this course, participants will be able to identify clinical approaches to consider when treating non-suicidal injury.
Introduction
- Why is this important for psychologists?
  - Learning how to address non-suicidal self-injury applies to psychologists in all settings (School/Education, Justice System, Medical/Hospital Settings, Community Programs, Outpatient Clinics, Residential/Group Homes, etc.)
I am excited to be here, as this is a topic for which I am passionate. This topic is essential for psychologists to learn how to address non-suicidal self-injury across all settings, from schools, justice systems, both juvenile and adults, medical and hospital settings, community-based programs, outpatient clinics, and also residential and group homes. I have worked in many settings throughout my career, and I have seen individuals present with self-injury in each one. Knowing what to look for and how to help individuals is essential. We need to see things from their perspective and connect with them.
Limitations
- Some of the treatments listed in this presentation require additional training, and this training is not a comprehensive review of these treatment protocols.
- Mental Health professionals are responsible for reviewing scope of practice, including activities that are beyond the boundaries of practice in accordance with and in compliance with your professional standards.
Here are a few limitations of this presentation. Some of the discussed treatments require additional training. Today's training will not comprehensively review all of those treatment protocols. For example, I will mention dialectical behavior therapy (DBT), but training is needed to be proficient in that treatment.
Mental health professionals are responsible for reviewing the scope of practice, only engaging in behaviors within their scope of practice, recognizing the boundaries, and complying with their area's ethical and professional standards.
Terms Defined
- Suicidal Ideation-Thoughts of wanting to die
- Suicide Attempt-Acting on thoughts of wanting to die
- Thoughts of Self-harm-Thoughts about harming self
- Non-Suicidal Self-Injury (NSSI)-Acting on thoughts of harming self
(Donath, C., Bergmann, M. C., Kliem, S., Hillemacher, T., & Baier, D., 2019)
I want to define some terms. Suicidal ideation is thoughts of wanting to die, and a suicide attempt is acting on those thoughts. Thoughts of self-harm include thoughts of engaging in any self-harm, which could be related to a possible suicide attempt, or might not. Non-suicidal self-injury is acting on those thoughts of self-harm.
We are differentiating between a suicide attempt and non-suicidal self-injury because you will approach these in very different ways. I will have a different approach with an individual who presents with non-suicidal self-injury versus somebody who is presenting to a hospital after a suicide attempt. We will get more into this a little bit later. I will also be using the acronym NSSI for non-suicidal self-injury.
Examples of Types of Self-injury
- Cutting
- Scratching
- Head banging
- Pinching
- Hair pulling (Trichotillomania)
- Biting nails to the point of bleeding
- Punching self or objects
- Carving words or images into skin
- Burning
- Rubbing sharp objects
- Teeth Pulling
- Eating sharp or dangerous things (not pica)
- Putting needles or objects under the skin
- Breaking bones
- Intentionally reopening healed wounds
https://www.healthyplace.com/abuse/self-injury/10-ways-people-self-harm-self-injure
Here are some examples of different types of self-injury that come from healthyplace.com. There is a long list of ways an individual might engage in self-harm. The most common that we hear about is engaging in cutting. Self-harm can also include scratching, head banging, pinching, hair pulling, biting nails to the point of bleeding, punching to feel pain, carving words or images, burning oneself, rubbing self until it hurts, rubbing sharp objects, teeth pulling, eating sharp or dangerous things (not associated with pica), putting needles or objects under the skin, breaking bones, or intentionally reopening healed wounds. When a client presents with injuries, I assess if it is an accident or from self-harm. Being able to differentiate between those is very important for treatment.
Special Note
- NSSI is in the DSM 5 listed as a "condition requiring further study."
- Criteria if the person does not meet criteria for depression, anxiety, eating disorder, substance abuse, or trauma-related disorder
- NSSI common symptom within Borderline Personality Disorder, along with suicidal self-injury, suicidal gestures, and/or suicide attempts
- Cultural Formation Interview
(Hooley, J. M., Fox, K. R., & Boccagno, C., 2020; Lewis-Fernández, R., Aggarwal, N. K., Hinton, L., Hinton, D. E., & Kirmayer, L. J. (Eds.), 2016)
In the DSM 5, they have listed non-suicidal self-injury (NSSI) as a condition for further study, and the references are listed there. You will only use that particular diagnosis if the person does not meet the criteria for depression, anxiety, or eating disorders or if symptoms are not better understood within another diagnosis. Non-suicidal self-injury, along with making suicidal statements, gestures, or attempts, are also very common with a borderline personality disorder. Sometimes, people do this as a way to regulate their emotions. Practitioners with this education and understanding use a non-judgmental approach to connect with the person to help them find other ways to express those intense feelings.
The Cultural Formation Interview within the DSM 5 might be helpful if you are working with somebody from a different culture. You need to know how this behavior is seen within their culture. We do not want to pathologize something if it is part of certain spiritual or religious rituals. The Cultural Formation Interview has some great questions within the DSM 5 about how you can understand things from a client's perspective.
Common Myths About NSSI
- Self-injury is rare
- Self-injury always requires hospitalization
- Self-injury is only for attention
- If they really wanted to die, they would cut deeper
- Self-injury is only cutting
- Tattoos and piercings are a form of self-injury
- Nothing helps/there is no treatment
(Klonsky, E. D., Victor, S. E., & Saffer, B. Y., 2014)
https://health.usnews.com/health-news/health-wellness/articles/2014/12/26/myths-and-facts-about-self-injury
(Solís-Bravo, M. A., Flores-Rodríguez, Y., Tapia-Guillen, L. G., Gatica-Hernández, A., Guzmán-Reséndiz, M., Salinas-Torres, L. A., Vargas-Rizo, T. L., & Albores-Gallo, L. 2019)
There are common myths about non-suicidal self-injury.
Myth #1
Some people feel that it is rare when it is pervasive, especially among adolescents. Different studies say anywhere between 30 to 40% of adolescents have attempted some form of self-harm. They must have the proper treatment and professionals, primarily because by the time the behavior comes to light, the person has often engaged in it for a while. It could be anywhere from a few months to a year or more.
Myth #2
The second myth is that self-injury always requires hospitalization or that you would automatically seek hospitalization with any form of self-injury. Research has shown that maintaining them on an outpatient basis and not sending them to the hospital is a better option. Sometimes hospitalization can worsen their symptoms. You will do your standard safety planning if somebody engages in this behavior, and we will discuss it in depth, including the specific questions to ask. If the person has an injury that requires medical attention, we will refer them to the appropriate doctor or ER for treatment. Still, they do not automatically need to go to the hospital.
Myth #3
Something that I often hear from parents is the myth that self-injury is only for attention or so that other people see it. Self-injury is often a hidden and private act and is always a negative coping skill. It is always a way to cope with pain, what the person is going through, or meeting an unmet need. If a teenager is looking for additional attention, we want to help them find healthy and appropriate ways to get attention or uncover what is under that pain. We see the best success when we address the pain underlying the behavior. Often, I see people overreact to the behavior and not try to understand what the person is going through. We want to help teach them skills to get their needs met.
Myth #4
Number four is that they would have cut deeper if they wanted to die. I have heard people say things like this. This statement is very dismissive and puts the behavior aside instead of taking the self-injury seriously. Even though I say do not immediately hospitalize, we still need to pay attention to the behavior and get some treatment. We should pay attention because there are often other things going on within the individual, and we want to be able to meet those needs.
Myth #5
The next one is that self-injury is only cutting. We discussed this myth previously when we went over that self-injury can include many different things. I have even had some people intentionally antagonize a pet so that the pet would scratch them. The goal was they wanted to cause some form of pain to be able to cope, and that was a form of self-injury for them.
Myth #6
Myth six is that tattoos and piercings are a form of self-injury. Tattoos and piercings can be a form of expression. You need to determine if the client felt like harming themselves when participating in those activities.
Myth #7
It is not an all-or-nothing thing but rather a gray thing, which is why we will talk about dialectical behavior therapy a little bit later in this training. Some people will feel like nothing helps or there is no treatment. I think why this myth exists because it is not a linear behavior. It is not like somebody starts and stops. For some people, it can be a cycle. The person can be in treatment for a while, and then they might engage in the behavior again. We then need to come back and treat it again. There are evidence-based approaches that are extremely helpful, and this is something that can be treated. We will talk about some treatments a little bit later.
Signs of Self-Harm
- Unexplained marks or injuries/bandages or injury does not match explanation
- Long sleeves when it is warm outside
- Marks in private areas (breasts/chest, upper thighs, etc.)
- Covering wrists or forearms
- Injury does not match explanation
- Posting pictures of self-harm on social media
(Pritchard, T. R., Lewis, S. P., & Marcincinova, I., 2021).
Some signs that somebody may be engaging in self-harm include unexplained marks or injuries, bandages, or if the damage does not match the explanation. If you have a good rapport with them, they may tell you. Clients may wear long sleeves when warm outside or long pants and hoodies instead of their typical shorts and t-shirts. You can check with them to see if they have engaged in self-harm. Some people have chronic thoughts of self-harm, while others have thoughts and behavior. It is essential to work on safety planning and help them feel safe enough in sessions so they are honest about the thoughts and feelings that they are having.
They may have marks on private areas, which is not something that I typically ask. However, a client may say that they intentionally did self-harm in a place where a parent or somebody is not going to see it or is covered by clothes. This is where you can see some of the guilt and shame that can come up about engaging in these behaviors. You want to stay grounded and connect with them to have a therapeutic, non-judgmental relationship. My face is very expressive, so I am mindful of my expressions when asking these questions or when clients self-report this behavior. I try to understand what is happening instead of focusing on the behavior. I want to know what happened before the self-harm. How was the person's day, sleep, or what led to this? Often, there is a buildup that has been happening over time.
Somebody may cover their wrists or forearms if that is where the injury has occurred. The injury may also not match the explanation. For example, they may say it was their cat, but there are precise marks. You need to use your clinical judgment to determine how to create a safe relationship.
Recently, I have seen individuals posting pictures of self-harm on social media. I see this mostly with teenagers. It can start as early as childhood, and research has shown it as early as eight or earlier. Typically, eight to 18 are peak times for kids and teens engaging in this behavior and then posting it online. A parent or relative will see this and inform the therapist or the school psychologist.
Assessing for NSSI
- Informal
  - Nonverbal
  - Verbal
- Formal
  - Critical item endorsement of actions ("When things get tough, I normally do something to harm myself)
  - Critical item endorsement of thoughts ("Thoughts of hurting myself)
  - DSM 5 Clinician-Rated Severity of Non-suicidal Self-Injury (Level 0 - Level 4)
Gratz, K. L., Dixon-Gordon, K. L., Chapman, A. L., & Tull, M. T. (2015). Diagnosis and characterization of DSM-5 non-suicidal self-injury disorder using the clinician-administered non-suicidal self-injury disorder index. Assessment, 22(5), 527–539.
You must assess what has been happening and how we best help this individual. My goal is to help first instead of stopping this behavior. If we only focus on stopping the behavior, the person might start to engage in another negative coping skill. Non-suicidal self-injury is closely tied with that lack of ability to manage emotions appropriately and intense feelings of overwhelming within their life.
Here are some tips for assessing for non-suicidal self-injury. There is an informal assessment where you ask during your intake. I am going to go over example questions in a moment. I often send them a document, a nonverbal tool, that asks about self-injury. A parent also may report that their child is engaging in this behavior. Other questions asked are about thoughts of harm to self and others, hallucinations, and other pertinent things. I always want to check in on this, especially for somebody that is presenting for therapy with significant depression, anxiety, bullying at school, and different things like that.
Verbally, I will ask questions related to this topic. You can work with somebody for a while, and they do not disclose this. However, it can come up later on. As I said earlier, there is often guilt and shame, which leads to secrecy. They must have a calming, safe person. I want to make a special note that when you work with kids and teens, you must ensure that they know what you need to disclose to parents. Ethically, it is anything related to safety. You must all partner together, so the client feels safe enough to let you know if they have engaged in the behavior. Let's say the client engaged in the conduct a year ago, and the parents are aware. However, they might not know the specifics of your confidentiality agreement. This agreement should include what you share with parents and what you are not communicating. And if you are working with an adult engaging in self-harm, have another person in that safety planning process.
There are also formal assessments. The DSM 5 has a clinician-rated severity of non-suicidal self-injury, with zero being the lowest level and four being the highest. This is a clinician-rated scale that you can use to track behavior over time, which might be helpful. Personality assessments, like the MMPI, the Personality Assessment Inventory, the PAI, and an assessment within the BASC, have questions about self-harm. An example may be, "I normally do something to harm myself." If somebody acknowledges that, I want to ask additional questions like, "What do you do?" to get an idea of the thoughts behind that. Was it to relieve pain, or was this an attempt? They may take a different approach if it is a past attempt versus non-suicidal self-injury.
Example Questions to Ask During Assessment and Safety Planning
- Are you having thoughts about harming yourself?
- Are you having thoughts about dying?
- How have you harmed yourself in the past? (Give examples to lower the shame, cutting, punching walls, banging head, etc.)
- If you are feeling unsafe, what are some things that you should have access to?
- Do any of your friends know that you engage in self-injury, and do any of them engage in self-injury?
(Franzen, M., Keller, F., Brown, R. C., & Plener, P. L., 2020).
Here are some example questions to ask during the assessment and safety planning process. I like to ask, "Are you having any thoughts of harming yourself?" If the therapist is uncomfortable asking the question, the client can sense this and might not be as comfortable sharing. This is where I think normalizing it is imperative. And if the therapist is not comfortable working with somebody that does engage in self-harm, refer the client to somebody that is equipped. If you are taking this training, I believe you want to feel more comfortable working with clients with these thoughts.
Other questions to ask are, "Are you having thoughts about dying or not wanting to be here?" and "Have you ever harmed yourself in the past?" We also want to lower the shame associated with self-injury. We may need to ask more specific questions or give examples because they may say no, they do not self-injure but do something like pull out their eyelashes or engage in other behavior.
We need to take some of the shame out of that from a clinician's perspective and ask questions such as, "If you are feeling unsafe, what are some things you shouldn't have access to? "This is part of the safety planning when the client is calm. The person may say something like a razor, knife, et cetera, and those are the things that I want to make sure to safety plan around.
We will discuss this more, but if somebody wants to engage in self-harm, it is hard to protect them from everything. I have had people self-harm with pencils. In the school system, they had an accommodation where they used pens while we worked on getting them to a safer place. But, they could get a pencil from a peer. We need to assess their method and access and make a safety plan.
I also like to ask if any of their friends also engage in self-harm. Peer groups will often talk about it. It can be supportive, where a friend can talk another friend out of doing it, or it can be triggering. Thus, a safety plan can include that if one of their friends talks to them about engaging in self-harm, ways they can then protect themselves. Make sure to include adults in the safety planning process, so that young kids or teenagers are not feeling emotionally responsible for one another. We can assess many behaviors by asking some of these questions.
Reasons Why People Engage in NSSI
- Self-injury ALWAYS serves a purpose for the individual. We need to LOCATE their PAIN.
- Important to understand the function of the behavior before removing the negative coping:
- Distraction (emotions, painful memories/thoughts, environmental issues)
- Manage Emotions (emotional numbing, or to feel when they feel numb)
- Self-punishment
- Control-maintain control or feel control over their minds and bodies
(Hooley, J. M., Fox, K. R., & Boccagno, C. 2020; Laye-Gindhu, A. & Schonert-Reichl, K.A., 2005; van der Kolk, B.A., Perry, J.C., & Herman, J.L., 1991)
Again, it is crucial to understand the why behind NSSI. Sometimes the person might not know. In general, self-injury is always serving a purpose for the individual. There is a reason for this behavior, whether they are using their frontal lobe and are aware of it, or it is a survival response triggered in the amygdala, as a fight, flight, or freeze response.
It might be more of a survival response, but we want to locate their pain because the behavior will not go away, or if the behavior does go away, they may replace it with something else that might be more harmful. For example, they may be at a higher risk of using substances or engaging in risky behaviors. And so being able to help locate that pain is significant.
Before removing this negative form of coping, I want to add something like a distraction. It might distract from negative emotions, painful memories or thoughts, or specific environmental issues. I have had many clients who self-harm if their parents argue. Adults may do so if they have a conflict with people and may use it to help them calm down.
It can be a way of emotionally numbing yourself. When we talk about parent education, I may dig a little bit deeper into the fact that engaging in self-harm can have a numbing effect on people. This can help me to figure out what tools this person might need.
For some people, it is about self-punishment. Non-suicidal self-injury often correlates with low self-esteem, negative thoughts about their body, and body dysmorphia. They may have a distorted perception of their body. Others may use it as a way to control their emotions.
- Express things that they cannot put into words (emotions, feelings of loneliness/misunderstood/isolation)
- Relieve tension and/or anxiety
- Relieve and/or fully express a negative emotion (e.g., anger, depression, etc.)
- To feel real by feeling the pain or seeing the injury
- Purify self
- Punish self
- Nurture self or receive nurturing
- Boredom
  - Often more of a cycle than linear behavior
(Hooley, J. M., Fox, K. R., & Boccagno, C. 2020; Franzen, M., Keller, F., Brown, R. C., & Plener, P. L., 2020).
For some people, it is a way to see or express things they cannot say. You cannot see depression on someone's body or if somebody has been through a lot. A trauma survivor may not have a physical mark, especially for something emotional. It is a way to see their pain, and that gives them relief.
Self-harm behaviors can also relieve tension or anxiety or fully express a negative emotion like anger or depression. Emotions can get so big, and engaging in this behavior helps them come back down.
Self-harm may help someone feel real. I see this a lot with individuals who also have dissociation, who are kind of disconnected. They can be at a higher risk of self-harm, especially when in a dissociative or disconnected state.
It can be a way to purify or punish some unrelated to a spiritual or religious ceremony. It is a way of acting out self-hatred or that shame within themselves. For some people, it is a way to get nurturing from somebody else.
One that is most surprising for people is boredom. If somebody already engages in this behavior, thoughts of self-harm might get very strong if they are bored. We may recommend that they are not alone when they are bored. They need to be with family or go somewhere. You can make an activity jar with ideas for when their thoughts get dark. With non-suicidal self-injury, it is often that cycle where the person engages in the behavior, stops for some time, is triggered, and starts again. This cyclical behavior can be very frustrating for parents. We need to educate parents that this is normal behavior.
Comorbid Presenting Issues
- Low self-esteem and feelings of shame/worthlessness
- Trauma and dissociative symptoms/disorders
- Relationship problems and/or bullying
- Less dense social networks
- Mood Disorders/Depression/Anxiety
- Psychosis
- Mood Disorders
- Substance Abuse
- Borderline Personality Disorder
(Hooley, J. M., Fox, K. R., & Boccagno, C. 2020; Franzen, M., Keller, F., Brown, R. C., & Plener, P. L., 2020).
Some comorbid presenting issues are pervasive, like low self-esteem and feelings of shame and worthlessness. An intervention would be helping them build their self-esteem and address their shame and worthlessness. The behavior will continue or worsen if I do not address these issues.
Research has also shown that trauma and dissociative disorders and symptoms are common. Self-harm might have been a way that they coped with a situation they did not have control over. After the trauma has ended, they might still engage in the behavior as a survival technique and response. For some, it can be hard to let go of because they might feel safer when engaging in self-harm. Thus, addressing that sense of safety can be incredibly important.
Relationship problems or bullying are also widespread. People take that stress out on themselves. Parents must be mindful of what is happening on social media or within certain text groups. Cyberbullying can be relentless. Twenty years ago, bullying was mostly at school or in your neighborhood, but now with kids having access to phones, the bully can have unlimited access to them. Parents need to set up certain safety precautions. Every state is different. I worked with some clients who had to do "no contact" agreements with a particular student or where we encouraged them to block specific numbers as they were not engaging in a safe and healthy relationship.
For individuals that engage in non-suicidal self-injury, research also shows that they typically have less dense social networks and are in a group of lower emotionally functioning individuals. Often in a lower-functioning group, other individuals within that group are also engaging in similar behaviors. With clients that present with non-suicidal self-injuries, I always want to know about their friends. We want to connect with them with other healthy peers at some point if we can. Again, we do not want to take away those people because it might be all they have, but we also want to try to add in some healthier people to expand their network.
Mood disorders, depression, anxiety, and psychosis are prevalent with non-suicidal self-injury. We also see substance abuse, either people using when they have the urge to use or possibly engaging in the behavior while using. I have seen it both ways. Sometimes with cannabis, I will see people not engage in the behavior when they are using, and then for other substances, they might be more likely to engage in the behavior while using.
As I mentioned earlier, a borderline personality disorder is common. I view that diagnosis as an inability to manage emotions and a skills deficit. Dialectical behavior therapy helps the person break some black-or-white thinking and address some underlying attachment issues. Fear of rejection or being left can sometimes trigger thoughts or engagement in non-suicidal self-injury.
Safety Planning (Harm Reduction)
- Identify an adult that the client will tell if they are having thoughts of self-injury
- Discuss if anyone else in the client's friend group engages in self-injury and encourage client/family to set boundaries in those relationships
- Identify what things the client should not have access to when upset
- Door open when upset
- Typical safety planning (lock up sharps)
- Identify their positive coping and discuss the times they are able to abstain from self-injury
(Dickens, Geoffrey & Hosie, Leah, 2018)
With safety planning, we take a harm reduction approach. In the next slide, we will talk more about educating clients, parents, and families, but with a harm reduction approach, the goal will always be zero self-harm. However, if I am working with somebody currently engaging in the behavior four times a week, I want to see that number or urge to engage in self-harm to be reduced. I also want to know if they have used skills because I want the client to feel some success along the way. I also do not wish to villainize them if they engage in the behavior.
Many clients will talk about non-suicidal self-harm as feeling like an addiction. If a client uses that language, I also use it with them. First, we want to identify an adult the client can tell if they have these thoughts. And whatever adult that is, I want to prepare that person to support the client, as some things can help and others can worsen it. I say an adult because kids going to kids or teens going to teens can be very triggering for the other individual.
Discuss if anyone in the client's friend group is currently engaging in it, and then set some boundaries within those relationships. I have seen a teen dumping their problems on another without checking in to say, "Hey, are you in a good space where you can hear this?" Setting some emotional boundaries with their friends can be incredibly important.
Identifying what things the client should not have access to when upset is part of safety planning. Something that I have commonly instituted, especially for kids and teens, is if they are upset, their door is open. So if they go upstairs fuming and upset, they must leave the door open.
The next one is part of typical safety planning. We need to lock up sharp objects to help increase safety. I continually reaffirm that this is about safety and is not to punish them or because they did something wrong. What things do they already possess? Even within an initial session, if somebody is engaging in self-harm, I also want to hear about a time they had that thought and did not do it. We want to help them feel resilient and capable. You can also discuss how it may have been different at other times. They may have been under too much stress or were hungry and not sleeping well. These things can pile up. Identifying positive strengths within this individual can be so impactful as they are often very hard on themselves with some perfectionism and rigid thinking.
Educating Clients, Parents, and Families
- Reviewing the myths, facts, and common reasons why other people engage in self-injury
- Start from place of understanding why and locating the pain (often families only want the behavior to stop)
- Addictive Quality
- Appropriate emotional expression (often comes from overly expressive or invalidating environments)
- Skills deficit versus manipulation
(Dickens, Geoffrey & Hosie, Leah, 2018; Nielsen, E., Sayal, K., & Townsend, E, 2017)
When educating clients, parents, and families throughout this process, I want to review some myths and facts about self-harm and common reasons why people engage in it. One of the biggest things I like to do is explain its biology. When we harm ourselves, our body releases happy thoughts. For example, if I fall and hurt my knee, my brain's coping mechanism is to release happy thoughts. Parents often struggle with this concept and do not understand how their children can do this. I do this in a one-on-one session with the individual and the parents because unless you have a good sense that this would work well, I will avoid doing it as a family session. I want the parents to ask certain questions to help them not react when the person does come to them with these thoughts or behaviors. Then we make a plan. I often encourage them to fake it. "You will be freaking out, but if you freak out on the outside, it will make them feel unsafe in the moment."
It is essential to get those needs met. We want the parents to start from a place of understanding and locating the pain. Families often want the behavior to stop, and that is where I explain that stopping the behavior may allow another negative response to occur. There is something under this, and it is not just a phase. Some people grow out of it, but others do not.
It can have that addictive quality that I mentioned earlier. A person can get into the cycle of use. People will talk about being clean from self-harm for three months, four months, or only one day. If they do like that addictive quality, language that is used in substance abuse treatment can be helpful. You want to help them find other ways to express their emotions.
They may come from environments where emotions are expressed in very big ways, and they may feel like their feelings are getting too big. Or they may come from an invalidating environment where emotions are seen as dumb or weak. We can teach parents, families, and clients how to validate their emotions. Depression and emotions are not good or bad; it is what we do with them. We want to talk about it from that perspective.
I also like to educate on the difference between a skills deficit versus manipulation. 'Parents may say they are being manipulative. I see manipulation as trying to get your needs met in inappropriate ways. It is always about a need, but they are not going about it correctly. Let's teach them healthier ways to get those needs met.
- Severe and Most Common Risks
  - Infection
  - Link between self-harm and suicide
  - Accidently harming self more than intended/lethal
- To hospitalize or not hospitalize (psychiatric)
  - Clinical decision with client, family, and mental health provider
  - Consider potential for increased negative behaviors in psychiatric hospital
  - May require medical attention if significant physical injury
- Help client and family set appropriate boundaries
(Donath, C., Bergmann, M. C., Kliem, S., Hillemacher, T., & Baier, D., 2019; Stanley, B., Brown, G. K., Brenner, L. A., Galfalvy, H. C., Currier, G. W., Knox, K. L., ... & Green, K. L., 2018; Lloyd-Richardson, E. E., Lewis, S. P., Whitlock, J. L., Rodham, K., & Schatten, H. T., 2015).
The severe and most common risk with non-suicidal self-injury is infection. There is also a link between self-harm and suicide that has been shown in research. There is a difference between somebody that is practicing, trying to get used to the sight of blood, to be able to then complete a suicide versus somebody that is engaging in self-harm as a way to cope with emotions. The latter group has plans for the future. Another risk is that they might accidentally harm themselves when they did not intend to do so.
To hospitalize or not hospitalize is a clinician's decision with the client, family, and other mental health providers. Considering the potential for increased negative behaviors in the psychiatric setting is crucial. I have had clients go into psych hospitals for short-term stabilization and come out way worse. They learn new behaviors and connect with very low-functioning peers. We need to weigh if there is a way to maintain them at home safely. But if they require supervision or medical attention, a psychiatric stay may be appropriate. Individuals might also require medical treatment if they have a physical injury from engaging in the behavior.
We want to help the client and family set appropriate boundaries. I have seen a very entangled family where the child was taking on the parent's emotions and vice versa. We need to set some emotional boundaries.
Addiction
- Although there is conflicting research about whether non-suicidal self-harm is a behavioral addiction, many clients will describe it as addictive.
- Possible Treatment Interventions
  - Motivational Interviewing
  - 12 Steps
- Harm Reduction instead of harm elimination
(Blasco-Fontecilla, Hilario & Fernández-Fernández, Roberto & Colino, Laura & Fajardo Simón, Lourdes & Perteguer-Barrio, Rosa & de Leon, Jose, 2016)
When looking at self-harm through the lens of addiction, there is conflicting research about whether non-suicidal self-harm is a behavioral addiction. Many clients describe it as addictive, so some possible interventions might be motivational interviewing. A client may not intend to stop the behavior or see anything wrong with it. They may be seeing you because their parents want them to be there. With motivational interviewing, I want to take them through those stages of change. In the example, the individual is pre-contemplative and does not view their actions as a problem. There are also 12 steps programs if they identify with the language. Harm reduction versus harm elimination may also work.
The goal is always for the behavior to stop, but knowing it will be a process. We want them to reduce the harm by drawing with Sharpie where they would like to harm or using less harmful things like ice. Once again, they do less harm and not to the point where they are causing damage to the skin. The practitioner will partner to see what will work best for that client as it will differ between clients. It is partnering with them and saying, "Through this process, I might recommend something. It might not work, but we are going to keep trying. I have a lot of tools in my toolbox, and I will be able to support you in stopping." This is about their behavior, and they have to want to stop. In the resource section, there is a book that supports this message.

Grounding Techniques
- Trauma symptoms, including dissociation
- Examples of Grounding Techniques
  - Using the Senses: 5 Things you see, 4 things you feel, 3 things you hear, 2 things you smell, and 1 thing you taste
  - Butterfly Technique (also works with other animals, images, or name of someone in their family they care about)
  - Apps (e.g., Calm Harm)
(Grattan, R. E., Lara, N., Botello, R. M., Tryon, V. L., Maguire, A. M., Carter, C. S., & Niendam, T. A.; 2019)
An intervention that can be helpful is using grounding techniques. If a person feels emotionally overwhelmed, doing some grounding technique can often help them self-rescue and calm down. One example is using the 5, 4, 3, 2, 1 technique using the senses. I often explain to clients that the thinking brain is shut down when they are emotionally activated. We can calm the amygdala, the emotional part of the brain, by using our senses. This is where grounding techniques can be helpful, especially for individuals that have trauma symptoms like dissociation. The butterfly technique is where you fold your fingers, put your hands together, and tap back and forth like a butterfly hug. Another butterfly technique is where the client draws a butterfly or something on the place where they want to engage in self-harm. They can also use the name of a person that they care about in that spot. This externalizes it because the person will often not mind hurting themselves, but they do not want to hurt others or are protective of others. Some apps can be helpful. My clients have found the best apps, but Calm Harm is one example by the same company that does the Calm app.
Dialectical Behavioral Therapy
- DBT was Developed by Marsha Linehan
- DBT Skills Training
  - Mindfulness Skills
  - Emotion Regulation Skills
  - Distress Tolerance Skills
  - Interpersonal Effectiveness Skills
- Full DBT program
  - Individual therapy, Group Therapy, & Crisis intervention
(Kothgassner, O., Goreis, A., Robinson, K., Huscsava, M., Schmahl, C., & Plener, P., 2021)
https://behavioraltech.org/resources/faqs/dialectical-behavior-therapy-dbt/
Dialectical Behavioral Therapy, DBT, was developed by Dr. Marsha Linehan. The skills training includes mindfulness, being present in the moment, regulating emotions, and distress tolerance. DBT also means being less judgemental of yourself and looking at facts versus our perception or interpretation of things. It also includes interpersonal effectiveness skills. The ones I have taught the most are mindfulness, emotion regulation, and distress tolerance.
Skills training is very different from a full DBT program. Some individuals need a full DBT program that includes individual therapy, group therapy, and crisis intervention, where if they are feeling suicidal, there is a therapist on call to be able to support them in those moments.
Other Types of Treatment
- Cognitive Behavior Therapy
- Applied Behavior Analysis (individuals with autism, developmental disorders, or intellectual disabilities)
- Eye Movement Desensitization and Reprocessing (EMDR)
- Psychotropic medication (refer to a psychiatrist or discuss concerns with a medical doctor)
(Bahji A, Pierce M, Wong J, Roberge JN, Ortega I, Patten S., 2021; Gonzales AH, Bergstrom L, 2013)
Other types of treatment are cognitive behavior therapy and applied behavior analysis (ABA). ABA might be helpful if an individual has autism developmental disorders or intellectual disabilities, but we want to replace it and find ways to calm the individual. One example is an individual banging their head, but now there is a pillow. We are gradually shifting the behavior to something that is not causing harm. Eye Movement Desensitization and Reprocessing (EMDR) can be helpful for this. Lastly, we can refer to a psychiatrist or medical doctor for a medication evaluation and psychotropic medication if needed.
Resources
- Free guide through SAMHSA Treatment for Suicidal Ideation, Self-Harm, and Suicide Attempts Among Youth https://store.samhsa.gov/sites/default/files/SAMHSA_Digital_Download/PEP20-06-01-002.pdf
- Treating Self-Injury, Second Edition: A Practical Guide Second Edition by Barent W. Walsh
- Helping Teens Who Cut, Second Edition: Using DBT Skills to End Self-Injury by Michael Hollander
- Healing Self-Injury: A Compassionate Guide for Parents and Other Loved Ones 1st Edition by Janis Whitlock, Elizabeth E. Lloyd-Richardson
- Stop Walking on Eggshells: Taking Your Life Back When Someone You Care About Has Borderline Personality Disorder by Paul T. T. Mason MS, Randi Kreger
- Stopping the Pain: A Workbook for Teens Who Cut and Self Injure by Lawrence E. Shapiro PhD
- Non-suicidal Self-Injury, in the series Advances in Psychotherapy, Evidence Based Practice by E. David Klonsky, Jennifer J. Muehlenkamp, et al.
- Freedom from Self-harm: Overcoming Self-Injury with Skills from DBT and Other Treatments by Kim Gratz, Alexander Chapman, Barent Walsh (Foreword)
Here are some additional resources. There is a free guide through SAMHSA called Treatment for Suicidal Ideation, Self-Harm, and Suicide Attempts in Youth. I also mentioned the book, "Helping Teens Who Cut: Second Edition Using DBT Skills to End Self-Injury," and the other is stopping the pain. It is a workbook that I have frequently used. I always keep a list of resources to see what is a good fit for your clients. "Stop Walking on Eggshells" can often be a helpful book for teen clients and parents to set boundaries.
Summary/Review of Learning Outcomes
Thank you so much for attending this training. My goal is that you now know how to explain non-suicidal self-injury, discuss different types of self-injury, and dispel common myths about it. I also want you to identify ways to assess for non-suicidal self-injury and have a safety plan. And then lastly, I hope you can identify clinical approaches to consider when treating non-suicidal self-injury.
Online References
References
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Citation
Berry, P. (2022). Assessing and treating non-suicidal self-injury. Continued Psychology, Article 193. Available from www.continued.com/psychology.
Oct 28, 2026

Group Supervision

Carla D'Agostino-Vigil, LPC, MA

Disclosures

Presenter disclosure. Financial disclosures indicate that Carla D'Agostino-Vigil received an honorarium for presenting this course and is an approved clinical supervisor. Non-financial disclosures indicate that Carla D'Agostino-Vigil has no relevant non-financial relationships to disclose.

Content disclosure. This learning event does not focus exclusively on any specific product or service.

Sponsor disclosure. There is no external sponsor for this course.

Limitations/Risks

Confidentiality Concerns: Group supervision involves multiple supervisees discussing cases and clinical experiences, which may lead to potential breaches of client confidentiality if not managed properly. Ensuring that all participants understand and adhere to strict confidentiality agreements is crucial to mitigating this risk.

Varying Levels of Experience: Participants in group supervision may have differing levels of clinical experience and expertise, which can create challenges in meeting the diverse needs of all members. Less experienced participants might feel intimidated or overshadowed by more seasoned professionals, potentially hindering their learning and contribution.

Group Dynamics and Participation: The effectiveness of group supervision can be influenced by group dynamics and interpersonal relationships. Issues such as dominant personalities, conflicts, or lack of engagement from some members can impede the overall learning experience and the ability to provide equitable support and feedback to all participants.

Individual and Cultural Considerations: Individual and cultural differences should be taken into account when developing supervision plans.

Workshop Objectives

This course addresses group supervision from the perspective of the clinical supervisor who is designing, launching, and sustaining a group format for counselors, social workers, marriage and family therapists, and other behavioral health professionals in training or seeking ongoing consultation. The course opens with an overview of the session's objectives and agenda before moving into what a supervisor needs to know before beginning group supervision, including supervision style, contracting, and informed consent. From there, the course turns to establishing group norms, a topic that includes strategies for setting clear expectations so that the group functions as a safe and productive supervisory environment. Building on that foundation, the course addresses how supervisors establish expectations for member involvement and evaluate supervisee competency. The course then examines the supervisor's role as a leader who must navigate group dynamics, power differentials, diversity, and ethical considerations that surface uniquely in a group context. A dedicated discussion of cultural considerations follows, addressing strategies for incorporating cultural competence and attending to diversity within group supervision. The course closes with a sample process flow and agenda for conducting a group supervision session and a summary of key takeaways and next steps.

Course overview

Group supervision is an increasingly common structure for delivering clinical oversight to counselors and other behavioral health professionals who are accruing supervised hours or engaging in ongoing consultation. Group supervision offers efficiencies in supervisor time while also exposing supervisees to peer perspectives, multiple theoretical lenses, and a wider range of clinical presentations than individual supervision alone can provide (Valentino et al., 2016). At the same time, a group format introduces layers of complexity that individual supervision does not, including group dynamics, confidentiality across multiple parties, and the need to evaluate several supervisees with differing developmental needs at once. This course walks through the practical tools a supervisor needs before beginning group supervision, the process of establishing group norms and expectations, and the supervisor's ongoing role in navigating group dynamics, ethical dilemmas, and cultural considerations. Throughout the course, references are provided to sample forms, self-assessments, and process guides that a supervisor can adapt for use in individual, group, or agency settings.

Learning Outcomes

After this course, participants will be able to:

Identify their supervision style and craft a supervision contract.
Describe group norms, including expectations for involvement and evaluation of supervisee competency.
Explain effective leadership, ethical decision-making, and cultural competence in a group supervision setting.

Group Supervision - What to Know before You Go

Your Supervision Style

Before convening a group, a supervisor benefits from understanding their own supervision style, since supervisors typically develop their approach through a combination of formal professional training, prior supervision experiences that modeled effective practice, and, at times, difficult experiences that clarified what a supervisor does not want to replicate. A supervision style self-assessment offers a structured way to reflect on this development. Such a self-assessment typically walks a supervisor through several domains, beginning with self-reflection on personal biases, values, and worldview, and moving into attitudes toward supervisees from diverse backgrounds. Working through these domains reveals how a supervisor's biases and worldview may interact within the supervisory relationship, a reflection that is foundational to culturally competent supervision.

Among current supervisory frameworks, the empowerment model represents a recent addition, alongside more established developmentally focused, competency-based, and integrated models. Supervisors commonly draw on a blend of these frameworks rather than adhering to a single model exclusively. The Treatment Improvement Protocol (TIP) Series 52 from the Substance Abuse and Mental Health Services Administration, along with the American Psychological Association's guidelines for clinical supervision, provide a foundation for this self-assessment work and for supervision practice generally (Center for Substance Abuse Treatment, 2009; American Psychological Association, 2014). A supervision-style self-assessment handout, structured around these domains, provides a supervisor with a starting point for this reflection and can be revisited periodically as a supervisor's practice matures.

Among practicing supervisors polled during this course, a little under half identified the empowerment model as the style they most align with in current practice, with the remaining respondents describing a mix of developmentally focused, competency-based, and integrated approaches. This distribution illustrates that supervisors rarely operate from a single theoretical lens in isolation; rather, most blend elements of several frameworks depending on the supervisee's developmental level, the clinical setting, and the specific competencies being addressed in a given session. The empowerment model itself represents one of the newest additions to the field of supervisory models, developed in part by clinicians based in Colorado, and it emphasizes shared responsibility between supervisor and supervisee for identifying growth areas rather than positioning the supervisor as the sole evaluator of competence. Regardless of which supervisory model a supervisor favors, the self-assessment process described above remains a useful starting point, since every supervisory model still requires the supervisor to understand their own biases and default habits before attempting to apply it consistently across a group of supervisees.

The Supervision Contract and Informed Consent

A supervision contract and informed consent process are foundational tools for both individual and group supervision. This process has two components: an informed consent document and a supervisory mandatory disclosure. The mandatory disclosure communicates the supervisor's background, training, and supervisory experience, while the informed consent establishes an agreement between the supervisor and each supervisee. A group-specific version of this contract also addresses matters unique to a group format, including how the group will manage conflict among members, how confidentiality will be handled when multiple supervisees are present, and how emergent or crisis situations will be addressed. The contract functions much like an initial session with a counseling client: it establishes the supervisor's approach, clarifies expectations, and defines how communication will flow between supervisor and supervisees. A sample group supervision contract, which incorporates the additional supervisor disclosure, covers contact information, licensure and credentialing details, employer and hours worked, the identity of any individual supervisor, and consent for the group supervisor to contact a supervisee's existing individual supervisor. The original handout organizes this information into several categories, summarized in the table below in place of the original form layout.

Contract category	Information collected
Contact information	Full name, address, phone, email, today's date
Education and credentials	Highest degree, school, year of graduation, job title
Employment and hours	Employer or agency, number of hours worked each week, current license held
Licensure in progress	Whether the supervisee is acquiring hours for licensure, and which license is being pursued
Individual supervisor	Name and contact information for any existing individual supervisor, with the supervisee's consent for the group supervisor to make contact

Collecting this information at the outset gives the supervisor a documented record of each supervisee's professional standing and reduces ambiguity about the scope of practice, credential status, and lines of communication once group supervision is underway.

Documentation practices of this kind align with guidance from the American Psychological Association on both the substantive content of a supervision agreement and the sample forms a supervisor can adapt for use in practice (American Psychological Association, 2014, 2024). Establishing this contract before group supervision begins gives every participant a shared understanding of scope, fees where applicable, and expectations, and it reduces the likelihood of later miscommunication about roles or confidentiality.

Client Consent to Record

Because group supervision frequently relies on reviewing recorded sessions, it is important that a supervisee's clients be fully informed of and consent to any recordings used for supervisory purposes. A sample consent-to-record form addresses this need directly. Such a form specifies whether the client is consenting to an audio recording only or to a combined video and audio recording, and it clarifies that the recording will be used solely for educational and clinical purposes, including review by a clinical supervisor and, in some circumstances, discussion with the broader group of clinical interns for training purposes.

A data protection protocol should accompany this consent process. Clients should also sign and submit a release of information where applicable. In practice, this means storing recordings behind a secure, encrypted system, sharing with clients how the recording will be used and by whom, and specifying when and how the recording will ultimately be disposed of or deleted. Group practice electronic health record systems that meet HIPAA compliance standards and are positioned behind an encrypted firewall offer a practical mechanism for meeting this obligation. Building recording consent and data protection into the informed consent process protects both the client and the supervisee and gives the supervisor a defensible basis for using recorded material in a group setting.

Consent element	Purpose
Scope of recording	Specifies whether the client consents to audio only, or to combined video and audio recording
Permitted use	Limits use of the recording to the supervisee's clinical development, including review with the group, where applicable
Data protection protocol	Describes secure storage, encryption, and eventual disposal of the recording
Release of information	Where applicable, documents the client's additional signed release supporting the recording's use

Reviewing these elements with the client directly, rather than relying solely on a general intake signature, gives the client a clear understanding of how a recording will be handled before it is ever made.

Regulation for clinical supervision & continuing education requirements

Clinical supervision is typically regulated by the state licensing board, and continuing education requirements typically include accumulating a certain number of clinical supervision training hours before a clinician may serve as an approved supervisor. Supervision recording forms, sometimes referred to as a record of supervision completed, are typically required for both individual and group supervision as documentation for licensure or audit purposes (Regulation of LPC Supervisors in Colorado, 2020).

Regulatory requirements in this area vary considerably by state and by license type. In some states, a supervisor may pursue a national credential, such as the Approved Clinical Supervisor designation, even where the state's own regulatory board does not maintain a formal supervisor designation. Some states have more recently enacted requirements that supervisors complete a defined number of continuing education hours specific to supervision before providing ethical supervision to licensed professional counselors, while requirements for other license types, including licensed clinical social workers and licensed master social workers, may differ and should be confirmed directly with the relevant state board and national professional association. A supervisor is well served by maintaining clarity on what their state requires, and on what documentation would be expected in the event of an audit of their supervisory experience or the supervisory hours they have overseen. A professional practice self-assessment developed for counselors licensed in Colorado illustrates one state-level example of how a regulatory body frames expectations for supervised practice and professional competency documentation (Professional Practice Survey and Self-Assessment, 2020).

Colorado offers one illustrative example of how uneven this regulatory landscape can be. The state's regulatory agency for the professions does not maintain a formal designation specific to clinical supervision, which means a supervisor who wants a recognized credential must pursue one voluntarily, such as the national Approved Clinical Supervisor designation, even though that credential is not required by the state itself and is not recognized uniformly across every state. At the same time, more recent state legislation has begun to require that supervisors of licensed professional counselors complete a defined number of continuing education hours specific to supervision before they may provide ethical supervision, reflecting a broader trend toward formalizing supervisor qualifications even where a full licensing designation does not yet exist. A supervisor practicing in a different state, or supervising a different license type, such as a licensed clinical social worker or licensed master social worker, should not assume that Colorado's framework applies to their own jurisdiction; the appropriate next step is to consult that state's own licensing board directly, and, where relevant, the corresponding national professional association for further guidance.

Establishing Group Norms and Expectations

Establishing group norms begins with defining a group vision. Before starting a group, a supervisor benefits from clarifying the group's goals and focus, including whether the group is intended for general clinical supervision or organized around a specific treatment modality, such as trauma-focused work or cognitive behavioral therapy. This early clarification should also consider the group's long-term aims and how the group is expected to evolve as membership changes over time.

Group development is a second consideration. Like other clinical or professional groups, a supervision group tends to move through recognizable stages of development, often described as forming, norming, storming, and performing. Understanding which stage a given group occupies helps a supervisor anticipate and guide the group's dynamics rather than being caught off guard by shifts in cohesion, conflict, or engagement. A group that includes both newcomers and long-standing members, for example, may need explicit conversation about these stages so that all participants understand what to expect from one another and can agree on shared norms and conduct.

A structured group norms and expectations guide gives a supervisor a tool for having this conversation directly with the full group of supervisors and supervisees. Such a guide typically prompts the group to articulate a group vision statement and long-term goals, and to clarify roles and responsibilities so that every group member understands their part in the group's success. This conversation is best held with the full group present at the outset of group supervision, and it can be revisited periodically, particularly when new members join or leave the group.

Understanding group dynamics is essential to leading group supervision effectively. A supervisor benefits from continually observing several questions across sessions: what group dynamics are present, including member roles, communication patterns, and the group's current developmental stage; what leadership skills the supervisor is employing, such as scanning the room, linking one member's contribution to another's, offering confrontation when needed, and building trust; whether the group's goals were accomplished in a given session and why or why not; how the supervisor is assessing the group's overall progress; what process goals follow for the next session, given the group's stage and observed dynamics; what questions or comments the supervisor wishes to raise with a consulting colleague or instructor; and how the scope and acuity of cases being presented is being managed within the group. Attending to these questions across sessions allows a supervisor to adjust facilitation in ways that are responsive to where the group actually is, rather than assuming the group's needs are static.

The value that supervisors place on this kind of explicit structure is not merely theoretical. Among supervisors polled during this course, roughly two-thirds indicated that establishing clear group norms and expectations is extremely important to their own group supervision practice. This finding is consistent with broader research identifying explicit structure, defined roles, and protected time for discussion as enablers of effective clinical supervision, whereas unclear expectations and unmanaged group dynamics function as barriers to effective supervision in workplace settings (Rothwell et al., 2021). Framed this way, a group norms and expectations guide is not simply an administrative formality; it is one of the more direct levers a supervisor has for shaping whether a group functions as an effective supervisory environment or an inconsistent one.

Establishing Group Norms

Group Supervision Process Flow and Agenda

A sample process flow gives structure to an individual group supervision session. In this structure, a supervisee identifies questions about a client or brings forward a recorded segment of a session and requests specific feedback about their performance. Peers within the group are then assigned, or choose, particular roles, perspectives, or tasks for reviewing the recorded segment. These tasks may include observing the counselor generally or a particular counseling skill specifically; assuming the role of the counselor, the client, or another significant person in the client's life, such as a parent, spouse, coworker, friend, or teacher; viewing the session through a specific theoretical perspective; creating a metaphor for the client, the counselor, or the counseling process; or representing the counseling process or relationship visually, through a drawing, graph, or sand tray exercise.

The counselor then presents the preselected recorded segment to the group. Peers give feedback from their assigned roles or perspectives, keeping in mind the goals and questions the presenting counselor identified beforehand. During this feedback exchange, the presenting supervisee typically remains silent, though they may take notes on the comments offered, thereby preserving the flow of peer feedback without immediate back-and-forth. The session concludes with an opportunity for final reflections from the group.

In practice, a supervisor overseeing this process typically establishes a rotation among supervisees for who will present in a given session. Sessions commonly allocate roughly five minutes to case conceptualization, then thirty to forty-five minutes to reviewing the recorded segment and gathering peer feedback, within a one-hour group supervision block. This structure provides every presenting supervisee with a consistent, predictable process and defines peers' roles in contributing meaningfully to that supervisee's development.

When supervisors were polled on how closely they follow a structured process flow of this kind during their own group supervision sessions, there was no single dominant answer, though roughly half reported following such a structure often, with most of the remaining respondents reporting sometimes, and a smaller number reporting always, rarely, or never. This spread suggests that while a defined process flow is a useful default, supervisors reasonably adapt how rigidly they apply it based on the group's stage of development, the acuity of the cases being presented, and the time available in a given session.

Group Supervision Format for Presenter

A group supervision presentation format gives the presenting supervisee and the group as a whole a consistent structure for what the presenter is expected to cover. This format is typically distributed to supervisees well in advance of their scheduled presentation so that they can prepare. The format asks the presenter to briefly describe the client's presenting problem; describe the dynamics of the session, including the supervisee's own reactions to the client and the interactions between the supervisee and the client; describe other important information learned during the session, including relevant contextual information; describe relevant cultural or developmental information as it relates to the presenting problem; offer an initial conceptualization of the client's issues, grounded in sound theoretical reasoning; list relevant diagnostic impressions, including code and axis where applicable; describe, to the extent possible, the initial treatment plan for the client; identify objectives for the next session based on that treatment plan; share any personal reflections on the session; and raise any questions for the supervisor and the group. Providing this structure in advance sets the presenting supervisee up for a productive and focused presentation rather than an unstructured recounting of the session.

Group Supervision - What to Know before You Go

Presenter Evaluation

A supervisor evaluation form for the case presented in group supervision offers a baseline tool for assessing a supervisee's clinical performance, though its formality can be adapted to the needs of a given group. This evaluation form typically uses a five-point rating scale, where a rating of one indicates an area needing improvement, a rating of two indicates an adequate level of performance, a rating of three indicates a good level of performance, a rating of four indicates a strength of the supervisee, and a rating of five indicates an area in which the supervisee excels.

The evaluation addresses several domains. Relationship and attending skills are assessed through items such as whether the supervisee listens carefully and communicates an understanding of the client, whether the supervisee is genuine and warm with the client, whether the supervisee demonstrates immediacy with the client, whether the supervisee is respectful of and validates the client, and whether the supervisee is appropriate regarding the cultural context of the client. Additional sections of a fuller evaluation form typically extend into the assessment and professional skills domains, which evaluate the supervisee's ability to accurately conceptualize a case and apply that conceptualization professionally. These additional domains connect directly back to the presenter format checklist described above, since a supervisee who has already practiced describing diagnostic impressions, treatment plan objectives, and case conceptualization within their presentation is, in effect, rehearsing the same competencies the evaluation form later rates. Used together, the presenter format and the evaluation form provide a supervisor with a consistent thread from how a supervisee prepares a case presentation to how that same supervisee's clinical competence is ultimately assessed. This evaluation is most valuable when conducted one-on-one with the supervisee directly, rather than shared broadly with the rest of the group, since it can surface material the supervisee may not be comfortable disclosing in front of peers. Delivered privately, the evaluation becomes a foundation for an in-depth developmental conversation between supervisor and supervisee.

Ethics Codes

A supervisor should always refer to their own profession's governing ethical code, and should be prepared to direct supervisees to the code that governs their specific license type as well. The following resources provide access to ethics codes for several major behavioral health professions.

American Association for Marriage and Family Therapy: https://www.aamft.org/Legal_Ethics/Code_of_Ethics.aspx
American Counseling Association: https://www.counseling.org/resources/aca-code-of-ethics.pdf
American Psychological Association: https://www.apa.org/ethics/code
National Board for Certified Counselors: https://nbcc.org/assets/ethics/nbcccodeofethics.pdf
National Association for Alcoholism and Drug Abuse Counselors: https://www.naadac.org/code-of-ethics
National Association of Social Workers: https://www.socialworkers.org/About/Ethics/Code-of-Ethics/Code-of-Ethics-English
Florida Laws and Administrative Codes: https://floridasmentalhealthprofessions.gov/laws-rules/

Because clinical supervision is regulated at the state level, a supervisor practicing in Florida should consult Florida Statutes Chapter 491 and the corresponding Florida Administrative Code provisions governing clinical social work, marriage and family therapy, and mental health counseling, in addition to whichever national ethics code applies to the supervisor's own license type. State-specific laws and administrative rules take precedence over any general guidance in this course, and a supervisor should confirm current requirements directly with their state board before relying on any single source.

A group supervision setting frequently brings together supervisees licensed, or pursuing licensure, in more than one profession, such as licensed professional counselors alongside licensed clinical social workers or marriage and family therapists. In this situation, a supervisor cannot assume that a single ethics code covers every group member. A supervisor licensed as a professional counselor, for example, may be most familiar with the American Counseling Association code, while a supervisee working toward social work licensure is bound by the National Association of Social Workers code instead. Naming this distinction directly within the group and confirming that each supervisee knows which code governs their practice avoids a situation in which supervisees mistakenly assume that guidance appropriate for one profession applies uniformly to all.

Supervisor as Leader in Navigating Ethical Considerations

An ethical decision-making model provides a supervisor with a consistent process for addressing ethical dilemmas that arise in group supervision. That process begins by allowing group members to contribute their own thinking first, with the supervisor adding perspective only after a round-table peer discussion has taken place. From there, the group consults the relevant ethical code directly, and the supervisor seeks consultation from a colleague or professional community when needed.

This sequencing reflects a broader leadership stance: a supervisor benefits from establishing, at the outset of group formation, how the group will handle disagreement when it arises, since supervisees inevitably bring different opinions and worldviews to an ethical question. In practice, a supervisor may allow some disagreements to be resolved outside the group session, while recognizing that other disagreements are valuable for the full group to witness, since a respectful debate can demonstrate healthy diversity of perspective and generate a productive learning opportunity for everyone present. A supervisor exercises discernment in distinguishing a fruitful, diversity-affirming discussion from a genuine oversight in ethical judgment. When a true oversight has occurred, the supervisor steps in more directly, leading the group through the relevant section of the applicable code of ethics and clarifying how the situation should be handled going forward. Framed this way, discord over an ethical dilemma need not be treated as inherently negative; it can be a substantial learning opportunity, provided the group has agreed in advance on the structure and rules of engagement for working through disagreement.

A related leadership responsibility involves managing deviations or distractions that surface during group supervision, including situations in which the group's attention drifts toward one member's unresolved personal issue rather than the clinical topic at hand. A useful strategy here is to lean on the group norms established at the outset, including an agreed norm around staying on topic. A "parking lot" technique, borrowed from organizational practice, allows the group to set aside a tangential issue for follow-up outside the session rather than letting it consume group time. A supervisor should also watch for a related pattern in which group discussion drifts from evaluating a supervisee's clinical competence to assessing the client presented. Naming this shift directly and redirecting the group's attention back to the supervisee's development helps keep group supervision focused on its intended purpose.

A supervisor's facilitation choices also shape how ethical and clinical discussions unfold. Rather than offering feedback immediately, a supervisor benefits from waiting until group members have had the chance to discuss an issue and offer their own thoughts, which encourages critical thinking and peer learning. A practical technique for maintaining this discipline is for the supervisor to jot down their own observations as the discussion unfolds, while purposefully facilitating and linking peers to one another so they can provide peer support to the presenting supervisee. Peer contributions often surface much of what the supervisor has already noted or build on it in ways the supervisor had not considered, reinforcing the value of allowing the group's collective expertise to lead before the supervisor adds a final layer of guidance. This approach to corrective feedback, which privileges peer voice and positions the supervisor's input as a supplement rather than the primary source of correction, aligns with contemporary guidance on delivering culturally sensitive corrective feedback within supervision (Holstun & Bohecker, 2024). Structural enablers of this kind, including clear norms, defined facilitation roles, and protected time for peer discussion, are consistent with broader research identifying the conditions that support effective clinical supervision in workplace settings, rather than those that function as barriers to it (Rothwell et al., 2021).

Making ethics code content engaging is a related leadership skill. Code of ethics content is not always the most captivating material for a group to review, yet it is essential for growing clinicians to know where to find this information when a question arises. One technique for building this familiarity in a low-stakes way is an online scavenger hunt, in which supervisees are given access to the relevant code of ethics and asked a question that requires them to locate a specific rule or regulation, with a small incentive, such as a gift card, for whoever locates the answer first. The underlying rationale for this technique is that a supervisor is not expected to know every law, rule, or ethical provision by memory; rather, the supervisor's role is to model for supervisees how to locate authoritative information when faced with a question mark about their own skill set. Building this practice into group supervision on a recurring basis, whether monthly or quarterly, helps normalize the habit of consulting primary regulatory and ethical sources rather than relying on memory or assumption.

When supervisors polled during this course were asked to identify their typical first course of action when facing an ethical dilemma, a little over a third indicated that they would consult the relevant clinical code first, followed by discussing the matter with the group and seeking peer consultation. This response pattern is consistent with the ethical decision-making sequence described above, in which peer discussion and direct reference to the governing code precede the supervisor's input, reinforcing that supervisors who follow this sequence in practice are aligning with what many of their peers report doing.

Co-supervision arrangements introduce an additional layer of coordination. Where two supervisors alternate leading group sessions, clarity about how they will hand off responsibilities, communicate about supervisee progress between sessions, and present a unified approach to the group is important for maintaining consistency for supervisees experiencing two supervisory styles across sessions.

Group Supervision - What to Know before You Go

Multicultural Awareness: Supervisee assessment of supervisor's cultural competence

Modeling cultural competence is a stated commitment within the American Counseling Association Code of Ethics, and this commitment applies to group dynamics both between supervisees and between supervisor and supervisee. Two provisions are particularly relevant here: the code's guidance on developmental and cultural sensitivity, and its guidance on multicultural and diversity considerations.

A structured self-assessment gives a supervisor a way to hold themselves accountable to this commitment. Guidance developed within this domain, often described as a supervisor's focused personal development, calls for supervisors to actively explore and challenge their own biases, values, and worldview and how these relate to conducting supervision; to actively explore and challenge their attitudes and biases toward supervisees from diverse backgrounds; to be knowledgeable about their own cultural background and its influence on their attitudes, values, and behaviors; to possess knowledge about the background, experiences, worldview, and history of culturally diverse groups; and to be knowledgeable about alternative helping approaches beyond those grounded in a North American or Northern European context (Center for Substance Abuse Treatment, 2009, p. 91). This last point in particular represents an ongoing challenge for any supervisor, since it requires continually building familiarity with helping traditions and worldviews outside one's own frame of reference.

A multicultural supervision inventory, developed in 2000, offers a structured way for a supervisee to evaluate the cultural or racial competence of a supervisor they have worked with, capturing information such as the ethnic or racial identity of both parties, the nature of the clinical setting, the length and level of the supervisory relationship, and the supervisee's rated experience of that supervisor's cultural competence. This tool is particularly useful in a supervision-of-supervision context, as it provides a supervisor with a structured, low-stakes way to reflect on blind spots in their own cultural competence as a supervisor, distinct from the direct feedback they might solicit from their current supervisees.

Because any self-assessment tool reflects the cultural knowledge available at the time it was written, a supervisor should expect that older inventories will not capture every dimension of identity or difference relevant to a contemporary group. Conversations around neurotypical bias and around the experience of able-bodied versus non-able-bodied group members illustrate this point. These dimensions of difference are not always top of mind for supervisors, and inventories developed in the early 2000s typically do not address neurodivergence or ableism directly, even as conversations around accommodating, respecting, and understanding these dimensions of identity have grown substantially in recent years. When supervisors polled during this course rated their confidence in incorporating cultural competence into their group supervision practice, nearly 60% described themselves as confident, somewhat confident, or very confident. This level of reported confidence is worth examining critically rather than accepting at face value, since confidence in this domain can mean two very different things. One meaning is a supervisor's confidence in their own ability to assess their blind spots, seek feedback, and maintain an active learning plan for their own cultural competence development. A second, less productive meaning is a supervisor's belief that they have already learned everything relevant and have no further growth required. Only the first kind of confidence supports genuinely culturally competent supervision; the second kind can place a supervisor at greater risk of overlooking something important to a supervisee or client from a cultural background different from the supervisor's, precisely because that overconfidence forecloses the ongoing self-examination that cultural competence requires. A supervisor is better served by treating confidence in this domain as a marker of having a good learning plan and a willingness to seek feedback, rather than as a marker of having finished the work.

A supervisor who does not personally hold a given identity, such as neurodivergence, may be more prone to overlooking how that identity shapes group dynamics or a colleague's presentation style, without this necessarily reflecting an intentional bias. A supervisor is well served by supplementing an existing multicultural inventory with additional, self-generated questions that reflect current conversations around identity, and by treating this as an ongoing area of professional development rather than a box to check once. Attending to these evolving dimensions of cultural competence and delivering related feedback with sensitivity to power and difference within the group reflects the broader humanistic approach to corrective feedback in supervision described by Holstun and Bohecker (2024).

Questions and Discussion

Several themes raised during the live question-and-answer portion of this course extend the material covered above and warrant direct attention.

Managing a supervisor's own anxiety during group supervision is a recurring concern, particularly when a supervisor notices a group member who is hanging back and not participating. One practical response is to acknowledge the anxiety directly and plan for it through simple regulation strategies, such as breathing techniques, brief doodling, or muscle-tension relaxation exercises, and, when appropriate, invite the whole group to pause and engage in mindful breathing together before continuing a particularly heated conversation. A supervisor can also address disengagement directly by checking in with a quiet member by name and inviting their input, which both addresses the immediate concern and reinforces the group norm that everyone's voice is expected to be heard.

Building individual rapport with each supervisee before group supervision begins, and continuing to hold periodic one-on-one conversations alongside group sessions, gives a supervisor useful information about how each supervisee prefers to engage, what makes them anxious about presenting in front of peers, and how the supervisor might adapt their approach for that individual within the group setting. This individual relationship-building can be especially valuable for a newer supervisor working with a group of more seasoned supervisees, since it establishes rapport and credibility before the group encounters more difficult group-dynamics conversations. Being transparent with supervisees that the supervisor is continually learning, rather than presenting themselves as an authority with every answer, supports a collegial, rather than hierarchical, group culture and models the kind of continual learning and self-reflection the supervisor hopes supervisees will also practice.

When two supervisors alternate facilitating group sessions and clarify how they will divide facilitation responsibilities and maintain continuity of information across sessions, this supports a more consistent supervisee experience. Related documentation questions frequently arise regarding what information a supervisor should collect from a supervisee, particularly when supervising outside the context of an integrated group practice. At a minimum, a supervisor should maintain a copy of the supervisee's professional liability insurance, obtain the supervisee's consent to review relevant case notes, and, where the supervisee is not part of the same practice, obtain the supervisee's permission to communicate with their clinical director or supervisor of record regarding performance. Reviewing case notes directly within a shared electronic health record system, with the supervisee's consent, is a practical mechanism for maintaining this oversight. Group supervision generally carries a different liability profile for the supervisor than individual supervision, particularly when supervisees are not operating under the supervisor's license. However, maintaining oversight of supervisee notes and a communication channel with each supervisee's direct clinical supervisor remains good practice regardless.

Some participants asked about applying these self-assessment tools within a supervision-of-supervision arrangement, in which a more experienced clinician supervises the supervisory work of another supervisor rather than the direct clinical work of a frontline counselor. In this context, tools such as the multicultural supervision inventory described earlier can be used reflectively by the supervisor themselves, distinct from how that same tool might be used by a frontline supervisee evaluating their own supervisor. This use case underscores that professional development in cultural competence and group facilitation does not end once a clinician becomes a supervisor; the same self-assessment habits that a supervisor encourages in supervisees remain relevant to the supervisor's ongoing growth.

Requirements and available tools can differ meaningfully across license types, including between licensed master social workers and licensed clinical social workers, and a supervisor without direct experience in a given license type is encouraged to review that license's specific requirements with the relevant state board and corresponding national professional association. Even where specific requirements differ, the underlying skills addressed in this course, including group dynamics, self-assessed multicultural competency, and structured evaluation, apply broadly across the counseling, social work, and psychology professions represented in group supervision settings.

Course Completion

Participants should complete the examination for this course after the live event concludes; it becomes available shortly thereafter. To access it, log into the applicable account, navigate to pending courses, and select the option to take the exam. Where live continuing education credit is being sought, the examination should be completed within seven days of the event.

References

American Psychological Association. (2014). Guidelines for clinical supervision in health service psychology. http://www.apa.org/about/policy/guidelinessupervision.pdf

American Psychological Association. (2024, August 2). Preparing for supervision: Sample forms and other materials. Syracuse University. https://soe.syr.edu/about/accreditation/cacrep/resources/modules/supervision/samples/#supervisor

Center for Substance Abuse Treatment. (2009). Clinical supervision and professional development of the substance abuse counselor (Treatment Improvement Protocol Series 52; HHS Publication No. SMA 14-4435). Substance Abuse and Mental Health Services Administration.

Holstun, V. P., & Bohecker, L. (2024). Humanistic principles for providing culturally sensitive corrective feedback in supervision. Journal of Humanistic Counseling, 1–13. https://doi.org/10.1002/johc.12215

Professional Practice Survey and Self-Assessment | Professional Counselor [Google Doc]. (2020, July). Colorado Department of Regulatory Agencies, Division of Professions and Occupations. https://drive.google.com/file/d/0BzKoVwvexVATZnVNTHo4eXJrOWc/view

Regulation of LPC Supervisors in Colorado, C.R.S. §§ 12-245-222(2), 12-245-224(1)(n) (2009 & rev. 2020).

Rothwell, C., Kehoe, A., Farook, S. F., et al. (2021). Enablers and barriers to effective clinical supervision in the workplace: A rapid evidence review. BMJ Open, 11(9), e052929. https://doi.org/10.1136/bmjopen-2021-052929

Valentino, A. L., LeBlanc, L. A., & Sellers, T. P. (2016). The benefits of group supervision and a recommended structure for implementation. Behavior Analysis in Practice, 9(4), 320–328.

Additional Current References

Please note: The following resources have been included for members to view additional resources associated with this topic area. These resources were not used by the presenter when creating this course.

Debiak, D. (2024). Review of Self-supervision: Psychodynamic strategies [Review of the book Self-supervision: Psychodynamic strategies, by M. Lubin & J. Yalof]. Psychoanalytic Psychology, 41(3), 147–148. https://doi.org/10.1037/pap0000505

Harris, V., Glover, R., & Philbin, M. (2024). Revealing the unknown: Supervisors' perspectives on using creative techniques in supervision. Journal of Creativity in Mental Health, 19(3), 368–382. https://doi.org/10.1080/15401383.2023.2247330

Smith, H. (2024). Too hot to handle? Unthought anxiety and parallel process in social work supervision. Journal of Social Work Practice. Advance online publication. https://doi.org/10.1080/02650533.2024.2377761

Oct 23, 2026

1 CE Credit

Implicit Bias: Impact on Maternal Health in Minority Populations
Calista Kelly, ACEEAA, Cert. MDT, PT, DPT
Disclosures:
Presenter Disclosure:
- Financial: Calista Kelly is employed by Continued.com.
- Non-Financial: Calista Kelly has no non-financial disclosures.
Content Disclosure: This learning event does not focus exclusively on any specific product or service.
Sponsor Disclosure: There is no external sponsor for this course.
Limitations/Risks
- Awareness is not impact. Reading about bias can raise knowledge and self-awareness, but it does not reliably change clinical behavior or patient outcomes on its own; completion should not be mistaken for improvement in practice.
- DEI and cultural competency. Cultural-competency framing can drift toward checklist "mastery" of groups and reinforce the very stereotyping it aims to reduce, so it must be paired with cultural humility; learners should also remember that implicit bias, structural racism, cultural competency, and DEI are often separate licensure requirements, and that this is a contested space where defensiveness can undermine engagement.
- Format and assessment. As a self-paced written activity assessed by a multiple-choice test, the course measures knowledge rather than skill or team behavior, and it can only model interprofessional collaboration rather than have learners practice it.
- Data currency and fit. The statistics are time-sensitive and will need updating. Reliable data for some high-risk populations are limited or suppressed, and national figures may not reflect a learner's local patients or setting.
Learning Outcomes
After this course, participants will be able to:
- Describe implicit and explicit bias, explain how each develops through lifespan socialization and can influence interprofessional team members’ interactions with childbearing patients, and identify at least two resources team members can use to examine their own biases.
- Recognize how bias and power differentials between clinicians and patients can affect the patient and the patient and team relationship.
- Describe structural racism and how it forms, explain its impact on maternal health, and identify risk factors for and patterns of maternal morbidity and mortality across five racial and ethnic populations in the United States.
- Describe infant mortality in the United States and its ties to maternal health, and explain the interprofessional team’s role in reducing the impact of implicit bias and structural racism for pregnant patients.
Introduction: Why This Topic Belongs to the Whole Team
Pregnancy and the year that follows it are among the most medically and socially intensive periods in a person’s life, and they are also a period in which the United States performs poorly relative to its wealth. Maternal deaths in this country have remained stubbornly high, and they fall unequally. In 2023, the national maternal mortality rate was 18.6 deaths per 100,000 live births, but the rate for Black women was 50.3 per 100,000, more than three times the rate for White women (Hoyert, 2025). These differences are not explained away by income or education, nor are they a recent accident. They are the visible surface of two deeper and interacting forces: the everyday operation of bias inside clinical encounters, and the long history of structural racism that shapes who gets sick, who is believed, and who survives.
This course is written for an interprofessional audience. The perinatal team is larger than many clinicians assume. It includes obstetric and nursing staff, but it also includes behavioral health clinicians who treat perinatal mood and anxiety disorders, physical therapists who manage pelvic floor dysfunction and musculoskeletal pain in pregnancy and postpartum, occupational therapists who support feeding, infant development, and a parent’s return to daily activities, speech-language pathologists and audiologists who screen and treat newborns and follow infants at developmental risk and respiratory therapists who manage the breathing support that premature and medically fragile newborns depend on and who help care for mothers facing respiratory complications of pregnancy. Each of these professionals interacts with childbearing patients and their families, often at moments of vulnerability, and each carries the same human cognitive machinery that produces bias. A course built for only one discipline would miss the central point of this material: that bias and its consequences are a team problem and a team responsibility.
The interprofessional framing also matters because the evidence base points toward team-level change rather than individual heroics. Education planned by and for the healthcare team, in the language of Joint Accreditation, is designed to change how team members work together, not simply to update one clinician’s knowledge. The four competency domains commonly used to organize interprofessional practice, namely values and ethics, roles and responsibilities, interprofessional communication, and teams and teamwork, will recur throughout this material because reducing the harm of bias depends on all four. A physical therapist who notices that a patient’s pain reports are being dismissed, an occupational therapist who hears a colleague describe a family in stereotyped terms, or a behavioral health clinician who recognizes that a patient has stopped trusting the care team, each holds a piece of the solution, but only if the team has the shared values, role clarity, and communication habits to act on it.
This is sensitive material. Discussions of racism, bias, and preventable death can be uncomfortable, and discomfort is an expected part of learning in this area (Campbell, 2025). The goal here is not to assign guilt but to build accurate understanding and practical skill. Bias is a feature of normal human cognition, present in well-intentioned people, and the question is not whether a clinician has biases but what the team does about them. With that framing in mind, the course moves from the psychology of bias to how bias forms and operates in clinical relationships, to the structural forces surrounding those relationships, to the maternal and infant outcomes at stake, and finally to what the interprofessional team can actually do.
A word about how to engage with this material will help. The most useful posture for a learner here is neither defensiveness nor self-flagellation, but curiosity. The aim is to leave with a more accurate model of why a group of well-meaning professionals can nonetheless participate in a pattern of unequal outcomes, and with a concrete sense of which of one’s own habits and which of the team’s routines are worth changing. Where the course presents numbers, it presents the most recent national figures available and names their source, so that a reader can see that the disparities described are not rhetorical but measured. Where it makes a claim about how bias operates, it ties that claim to the research literature rather than to anecdote. And throughout, it keeps returning to the same practical question that interprofessional education is designed to answer: not what should I, alone, believe, but how should we, together, work, so that the next patient is heard, believed, and kept safe regardless of who she is.
Section 1: Implicit and Explicit Bias Defined and Differentiated
A bias, in the most general sense, is a tendency to favor or disfavor a person, group, or idea in a way that interferes with fair judgment. In healthcare, the term usually refers to attitudes about social groups that shape how a clinician perceives, communicates with, and treats a patient. Two broad categories are useful to distinguish at the outset, because they form and operate differently and call for different responses.
Explicit bias refers to attitudes and beliefs that a person holds consciously and can report. A clinician who openly believes that members of a particular group are less reliable historians of their own symptoms holds an explicit bias. Explicit biases are, by definition, available to introspection, which means they can be stated, defended, argued with, and, in many settings, socially discouraged. Most clinicians sincerely endorse the value of treating every patient equally, and on explicit measures, healthcare professionals tend to report egalitarian attitudes (FitzGerald & Hurst, 2017). That sincerity is real and part of what makes the second category so important.
Implicit bias refers to attitudes and associations that operate outside of conscious awareness and intention. These are automatic mental shortcuts: learned associations between a social group and a set of traits, evaluations, or expectations that activate quickly and without deliberate thought. Because they are unconscious, implicit biases can run contrary to a person’s consciously held, explicitly egalitarian values, and a person can be entirely unaware that the bias is influencing a decision (Campbell, 2025). This is the crucial difference. A clinician can honestly believe that they treat all patients the same and still, in the rushed and cognitively demanding environment of clinical care, act on associations they would reject if asked about them directly.
The mechanism is rooted in ordinary brain function. Implicit associations are formed through repeated exposure to messages and patterns in the surrounding culture, and they can be rapidly activated when the brain encounters socially relevant cues, producing a fast, automatic evaluation before slower, deliberate reasoning has a chance to engage (Campbell, 2025; Josiah et al., 2023). This speed is adaptive in many contexts because the brain must constantly categorize and predict, but it becomes a liability when learned associations are inaccurate and attach negative expectations to a patient based on race, ethnicity, language, body size, age, disability, or other group membership.
A widely used research tool for detecting implicit associations is the Implicit Association Test, which measures how quickly people pair concepts, on the premise that more strongly associated concepts are paired more quickly. Research using such measures has repeatedly found that healthcare professionals, as a group, show levels of implicit bias similar to those of the general population, and a systematic review of this literature concluded that such bias among healthcare professionals is associated with measurable differences in the care patients receive (FitzGerald & Hurst, 2017; Hall et al., 2015). In other words, entering a caring profession does not exempt a person from the associations absorbed from the broader culture. It is worth noting that individual scores on these tests are not a diagnosis of a clinician’s character and do not perfectly predict any single decision; the value of the research lies in establishing, at the population level, that the phenomenon is real and pervasive.
Why does the distinction between explicit and implicit bias matter for the interprofessional team? Because the two require different countermeasures. Explicit bias can sometimes be addressed through policy, accountability, and direct feedback, since the attitude is available to the person holding it. Implicit bias is not reachable in the same way, because the person is not aware of it. Telling a team to simply try harder to be fair is therefore an incomplete strategy, since the biases most likely to slip through are the ones no one intends. Effective approaches, discussed in Section 7, work by changing the conditions under which automatic associations get a chance to drive behavior, for example, by slowing decisions at high-stakes moments, by standardizing how symptoms are assessed, and by building team habits that catch what an individual misses.
It also helps to see how an implicit association becomes a clinical decision, because the pathway is rarely dramatic. Clinical reasoning depends heavily on rapid pattern recognition, the experienced clinician’s ability to size up a situation quickly, and that same speed is what allows an unexamined association to enter the judgment unnoticed. The bias does not announce itself as prejudice. It shows up as a slightly lower index of suspicion for one patient than another, a quicker readiness to attribute a complaint to anxiety or drug-seeking, a marginally shorter visit, less eye contact, fewer open-ended questions, or a faster move to reassurance rather than investigation. Any one of these is small, and any one could have an innocent explanation, which is exactly why bias is so difficult to catch in the moment and so consequential in the aggregate. Across thousands of encounters, small differences in suspicion, attention, and effort accumulate into measurable differences in the care that groups of patients receive (Campbell, 2025; FitzGerald & Hurst, 2017).
A further nuance is that implicit and explicit attitudes can point in different directions within the same person, and the relationship between what a clinician sincerely believes and how a clinician automatically reacts is loose rather than fixed. A clinician may hold strong, genuine egalitarian commitments and still carry implicit associations absorbed from the surrounding culture, and under ordinary conditions of fatigue, time pressure, and cognitive load, it is the automatic system that often wins (Campbell, 2025). This is why the sincerity of a team’s stated values, though real and important, cannot be the whole of its safeguard. Values shape the explicit layer; they do not automatically reach the implicit one. Recognizing this gap is not cynicism about clinicians’ character. It is an accurate account of how the mind works, and it points toward solutions that do not depend on individuals simply wanting to be fair.
It is also worth being precise about what implicit-bias measures can and cannot tell us, because misunderstanding this point has fueled both overclaiming and backlash. Tools such as the Implicit Association Test are research instruments that reliably detect automatic associations at the group level, and the body of evidence using them demonstrates that clinicians, like everyone else, hold such associations (FitzGerald & Hurst, 2017). What these tools do not do well is predict, with precision, what a particular clinician will do with a particular patient on a particular day. A clinician should therefore neither treat a personal test result as proof of guilt nor dismiss the entire phenomenon because the prediction at the individual level is imperfect. The defensible reading of the science is the moderate one: implicit bias is real, common among well-intentioned clinicians, and capable of influencing care, while remaining only one of several forces acting in any given encounter (Campbell, 2025; FitzGerald & Hurst, 2017).
For every profession on the perinatal team, the practical translation is the same. The audiologist interpreting a parent’s response to a newborn hearing screen, the speech-language pathologist judging whether a feeding concern warrants follow-up, the physical therapist deciding how seriously to take a postpartum patient’s report of pain, the occupational therapist assessing a parent’s engagement with an infant, and the behavioral health clinician forming an impression of a patient’s risk, are all making rapid judgments under time pressure and uncertainty, which are exactly the conditions in which implicit associations exert the most influence. None of these clinicians is choosing to be unfair, and most would be distressed to learn that an outcome had turned on an association they never endorsed. That is precisely the point. Recognizing that these everyday, well-meant judgments are vulnerable is the first step toward protecting them, and protecting them is a task that the following sections show is best carried out by the team rather than left to the individual.
It is worth naming explicitly the conditions under which an automatic association is most likely to slip past a clinician’s better judgment, because those conditions describe ordinary clinical life rather than rare exceptions. Bias tends to exert the greatest influence when a decision is made quickly, when the clinician is fatigued or stressed, when cognitive load is high, when the information available is ambiguous, and when the clinician must rely on first impressions rather than accumulated knowledge of the individual patient (Campbell, 2025). Each of these is a routine feature of perinatal care: the triage decision made in a busy unit, the late-shift assessment by a tired clinician, the brief first encounter with a patient whose history is incomplete. This matters for the team because it means that the moments of greatest vulnerability to bias are predictable, and predictable vulnerabilities can be designed around. If the team knows that the rushed, ambiguous, first-impression decision is where bias is most likely to enter, it can build in the deliberate pause, the second look, and the standard protocol precisely at those points, rather than relying on individuals to summon extra fairness at the very moments when their capacity to do so is most depleted (Campbell, 2025; Hagiwara et al., 2024; Kirwan Institute, 2013).
Bias also comes in more than one form, and a shared vocabulary helps a team recognize the particular pattern at work in a given encounter. Beyond the racial and gender bias most often discussed, the cognitive-science and healthcare literatures describe a family of related tendencies: affinity bias, the pull toward people who resemble us; confirmation bias, the tendency to notice and weight information that fits an expectation already formed; anchoring, the overreliance on the first piece of information encountered; attribution bias, the tendency to explain another person’s behavior in terms of character rather than circumstance; the halo and horns effects, in which one salient trait colors the whole impression; and name bias and bias based on perceived weight, body type, age, education, or socioeconomic status (Kirwan Institute, 2013). These are not separate phenomena from implicit bias but specific shapes it takes, and in the perinatal setting, each has a concrete cost. Anchoring on an initial impression of a patient as anxious can crowd out later physical signs; confirmation bias can lead a clinician to register findings that fit a benign explanation and discount those that do not; and weight or age bias can quietly lower the seriousness with which a symptom is treated. Naming the specific pattern is useful precisely because the countermeasure differs: confirmation bias calls for deliberately seeking disconfirming evidence, while anchoring calls for revisiting the initial assessment as new information arrives.
Section 2: How Bias Forms: Socialization, Stereotypes, Prejudice, and "Isms" Across the Lifespan
If implicit biases are learned associations, the natural question is where they are learned. The short answer is that they are absorbed over a lifetime from the social world a person grows up in and lives in. No one is born with a fully formed set of biases, and no one chooses them deliberately. They accumulate through the ordinary process of socialization, the lifelong process by which a person takes in the norms, categories, images, and expectations of family, community, schooling, media, language, and institutions (Campbell, 2025). Understanding this process helps the team see bias as a product of the environment rather than a personal moral failing, which, paradoxically, makes it easier to confront it honestly.
Several related terms are useful to define here, because they are often used loosely. A stereotype is a generalized belief about the characteristics of a group, applied to individuals who belong to it. Stereotypes are cognitive: they are the brain’s categories and the traits it attaches to them. Prejudice is an attitude or feeling, usually negative, directed toward a group or its members. Where a stereotype is a belief, prejudice is the affective charge, the liking or disliking, that often accompanies it. Discrimination is behavior: the differential treatment of people based on their group membership. The suffix “ism,” as in racism, sexism, ageism, ableism, or classism, names a system in which stereotypes and prejudice become organized and reinforced at the level of institutions and culture, so that the disadvantage no longer depends on any single biased individual. These distinctions matter because an intervention aimed at a belief, a feeling, a behavior, or a system will look different in each case.
The lifespan dimension is important. Children absorb associations from the earliest years, often before they have the language to question them, simply by noticing patterns in who is present, who is praised, who is feared, and who is absent in their environment. These associations are then reinforced across decades by repeated exposure to the same patterns in entertainment, news, professional training, and the structure of the institutions a person passes through (Campbell, 2025). For healthcare professionals, there is a specific occupational layer to this story. Clinical training and longstanding medical literature have at times transmitted inaccurate beliefs about biological differences between racial groups, and such beliefs, once learned, can persist and distort clinical judgment, for example, in the historically documented tendency to underestimate the pain of Black patients (Josiah et al., 2023). A clinician, therefore, arrives at the bedside carrying both the general biases of the surrounding culture and any specific misconceptions transmitted through professional socialization.
It is worth dwelling on each of the key terms, because precise language helps a team diagnose what it is actually facing. A stereotype can be positive in valence and still cause harm; the belief that a particular group is unusually resilient or tolerant of pain is a stereotype, and in maternity care, a stereotype of toughness can translate directly into undertreatment. Prejudice need not be intense hostility; a faint, automatic discomfort or a reflexive lowering of warmth toward members of a group is prejudice in the sense that matters clinically, and it shapes the emotional tone of an encounter that the patient feels even when nothing is said. Discrimination, the behavioral layer, includes not only overt acts but also the quiet differentials described in Section 1, the shorter visit and the lower suspicion. And the “ism” layer is what makes the problem self-sustaining: once stereotypes and prejudice are built into curricula, guidelines, institutional routines, and the surrounding culture, they reproduce themselves in each new cohort of professionals without anyone deciding to pass them on (Campbell, 2025; Njoku et al., 2023). A team that can identify which layer it is dealing with is better positioned to choose an appropriate response.
The developmental account also explains why exhortation alone fails. By the time a person reaches professional training, decades of socialization have already laid down the associations, and a sincere adult decision to be fair operates on top of that foundation rather than erasing it (Campbell, 2025). This is not a counsel of despair. Associations that were learned can be weakened and counteracted, and the surrounding environment that produced them can be changed. But it does mean that the goal of self-examination is not to reach a state of being bias-free, which the evidence does not support as a realistic endpoint, but to become reliably aware of one’s vulnerabilities and to build the personal and team habits that keep those vulnerabilities from reaching patients (Campbell, 2025; Hagiwara et al., 2024).
The occupational layer deserves particular emphasis for a clinical audience, because it is the part of socialization that professional training is directly responsible for. Historically, medical and clinical education transmitted false beliefs about biological differences between racial groups, including the durable and damaging myth that Black patients experience or tolerate pain differently, and such beliefs, absorbed during training, can persist into practice and distort assessment and treatment long after they have been formally discredited (Josiah et al., 2023). The maternal health literature treats this history as directly relevant to present-day disparities, because pain and symptom assessment are exactly the judgments through which warning signs of serious complications are recognized or missed (Josiah et al., 2023; Montalmant & Ettinger, 2024). A team that understands this history is less likely to be surprised when a patient’s reported pain is discounted and more likely to build checks to catch such discounting.
Turning to resources, several categories support honest self-examination, and they work best in combination. Validated self-assessment and program-level instruments allow individuals and teams to measure awareness of and mitigation of bias in maternity care and to track change over time, replacing impressions with data and enabling assessment of whether anything is actually improving (Bower et al., 2023). Structured reflective practice, in which clinicians examine specific encounters and their own emotional reactions to particular patients, helps surface associations that stay hidden under the smooth surface of routine. Continuing education, including activities like this one, provides the shared vocabulary and evidence that allow a team to discuss bias without each conversation collapsing into defensiveness or blame. Confidential implicit-association measures can be a useful prompt for personal reflection, provided they are framed as conversation-starters rather than verdicts. And cultural humility, the disposition to approach each patient as the authority on their own life and to remain a learner rather than assume expertise about a patient’s experience, gives self-examination a durable orientation rather than a finish line.
Putting these resources into practice is itself a skill, and a few principles make the effort more honest and more durable. Reflection is most useful when it is specific rather than general: examining an actual encounter that left a clinician uneasy, or a particular patient toward whom the clinician felt an unexplained reluctance, surfaces more than an abstract intention to be fair. It is also most useful when it is routine rather than occasional, because the associations being examined are themselves the product of constant, lifelong reinforcement and will not be undone by a single sitting (Campbell, 2025). Carrying the work out in the company of colleagues, in a setting where it is safe to name discomfort without fear of judgment, tends to be more sustainable than solitary effort, both because others can see patterns a clinician cannot see in themselves and because shared reflection builds the team culture in which raising the subject of bias is normal rather than threatening. The aim of all of this is not the impossible one of becoming a person with no associations, but the achievable one of becoming a clinician who knows where their judgment is most likely to slip and who has built, with their team, the habits that catch it before it reaches a patient (Campbell, 2025; Hagiwara et al., 2024).
A word of realism is appropriate here, because it will recur in Section 7. The mere act of measuring or naming one’s biases does not, by itself, reliably change behavior, and some popular training approaches rest on weak evidence and have not demonstrated lasting effects on practice (Hagiwara et al., 2024). Self-examination is necessary but not sufficient. Its value lies in opening the door to the structural and team-level changes that do the heavy lifting, and in sustaining the personal vigilance those changes require. For the interprofessional team, the shared goal of this section is a common understanding: that every member arrived with biases they did not choose, that some of those biases were transmitted by the professions’ own training, that these biases are knowable through honest and repeated reflection supported by validated tools, and that naming them is the beginning of the work rather than the end of it.
Section 3: Bias, Power Differentials, and the Patient
Bias does not operate in a vacuum. It operates within a structurally unequal relationship. In almost every clinical encounter, the clinician holds more power than the patient: more specialized knowledge, control over access to tests, referrals, medications, and documentation, the authority to define what counts as a legitimate concern, and the social standing conferred by a professional role. The patient, by contrast, is often unwell, anxious, undressed, in pain, or afraid, and is dependent on the clinician’s goodwill and judgment. This asymmetry is the power differential, the amplifier that turns a clinician’s private associations into consequences for a real person (Campbell, 2025).
The amplification works in several ways. First, because the clinician controls the interpretation of the encounter, a biased expectation can quietly become the official account. If an implicit association leads a clinician to expect that a particular patient is exaggerating symptoms, the clinician may document the visit in those terms, and that documentation then follows the patient through the system, shaping how the next clinician approaches them. Second, the power differential makes it costly for patients to push back. A patient who senses that they are not being believed may hesitate to insist, precisely because they depend on the clinician and fear being labeled difficult, which can further reduce the information the clinician receives and confirm the original misjudgment. Third, the differential is steeper for patients who already occupy a marginalized social position, so that a Black patient, a patient with limited English proficiency, a patient with a disability, or a patient with a low income may face a compounded gap in power that makes the effects of bias harder to resist (Njoku et al., 2023).
It is useful to trace how a small interpersonal moment can cascade into a clinical outcome, because the chain is what makes the power differential a safety issue rather than merely a matter of courtesy. Consider a patient whose report of severe pain or unusual symptoms is met with a subtly skeptical response shaped by an implicit association. The immediate effect is that the symptom is investigated less thoroughly. The patient, sensing skepticism and aware of the cost of being labeled difficult, may soften or withdraw the complaint, thereby removing the very information that might have prompted action. The encounter is then documented in language that reflects the original skepticism, and that documentation primes the next clinician to view the patient the same way. The patient, having learned that raising concerns is unproductive, discloses less at the next visit, attends less reliably, and waits longer before seeking help when something is genuinely wrong. In the perinatal period, where the difference between a good outcome and a catastrophe can hinge on whether a warning sign is acted on early, this cascade is not abstract. It is a plausible route from an unexamined association to a preventable harm, and it runs entirely through the power differential (Campbell, 2025; Josiah et al., 2023).
The maternal health literature describes precisely these effects. Implicit bias among clinicians has been linked to differences in communication, in the patient’s experience of care, in treatment decisions, and ultimately in outcomes, and perceived discrimination is repeatedly associated with erosion of the trust that childbearing patients place in their care teams (Josiah et al., 2023; Montalmant & Ettinger, 2024). Studies that ask patients directly find the same pattern from the other side of the encounter: Black and Latino patients have reported lower ratings of provider communication, trust in the provider, patient-centeredness, collaboration in decision-making, and the clinician’s contextual knowledge of them as a person (Blair et al., 2013). Trust is not a sentimental concern in this setting; it is functionally load-bearing. A patient who trusts the team tells the team things, returns to the team, and follows through with the team. A patient whose trust has been damaged, often by an accumulation of small dismissals rather than a single dramatic insult, may do none of these, and the resulting gaps in information and engagement are themselves risks. Because trust is built and broken across many encounters with many professionals, it is inherently a team property, which is part of why the response has to be a team response.
A particularly common channel through which bias reaches patients is the microaggression, a term for the everyday slights, dismissals, and subtle verbal or nonverbal behaviors that communicate a hostile, demeaning, or diminishing message to members of marginalized groups, often without the speaker’s awareness or intent (Sue et al., 2007). If implicit biases are the unconscious associations, microaggressions are among the behaviors that flow from them. In a clinical setting, they take recognizable forms: a comment that presumes a patient’s family structure, a term of endearment used in place of a name in a way that infantilizes, an expression of surprise at a patient’s competence, or a documentation choice that subtly casts doubt on a patient’s account. Language is central here because subtle word choices can carry biased assumptions and because the effects of biased language extend beyond a single bruised feeling, shaping health outcomes and reinforcing the belief systems behind discriminatory practices (American Medical Association, 2021). Nonverbal behavior matters as well, since bias can register in reduced eye contact, greater physical distance, or a colder tone that the patient perceives even when nothing overt is said. For the interprofessional team, the practical point is that respectful, person-centered language and attentive nonverbal communication are not merely courtesies but are themselves part of safe care, because they protect the trust on which a patient’s willingness to disclose depends.
The differential is also not uniform across patients, and the concept of intersectionality helps explain why. A patient may occupy several marginalized positions at once, for example, as a Black woman with a low income and limited English proficiency, and the disadvantages do not simply add; they interact, producing a steeper and more complex power gap than any single characteristic would predict (Njoku et al., 2023). A clinician who is attentive to race but not to language, or to disability but not to class, may still leave large blind spots. The practical implication is not that clinicians must catalog every dimension of a patient’s identity, which is impossible in the moment, but that they should hold their confident first impressions loosely, especially for patients whose social position differs most from their own, and lean on the structures and the team that the rest of this course describes.
The interprofessional lens makes the power differential more visible because different team members sit at different points in the hierarchy and see different parts of the patient’s experience. A patient may feel unable to question a physician but may speak more freely with a physical therapist during a longer hands-on session, with an occupational therapist working in the patient’s own environment, or with a behavioral health clinician whose role is explicitly to listen. These professionals often function as the team’s early warning system, hearing concerns that the patient did not feel safe raising elsewhere. Audiologists and speech-language pathologists, who frequently have repeated contact with families during newborn screening and developmental follow-up, occupy a similar position of trust. The value of this distributed vantage point is lost, however, if the team lacks the communication channels and the shared sense of permission to escalate what these members hear. A concern that a patient confides to the one clinician she trusts is worth little if that clinician has no reliable way to convey it to the people who can act, or no confidence that doing so is welcome. Recognizing the power differential, therefore, points directly to a teamwork solution: structures that flatten the hierarchy enough for patient concerns to travel, regardless of which team member first receives them, and a culture in which raising another professional’s possible blind spot is treated as good care rather than as an affront.
It is worth dwelling on trust as a clinical resource because it is easy to file under bedside manner and thereby underestimate it. In the perinatal period, the patient is often the first, and sometimes the only, person who can detect that something is wrong in her own body, and the system’s ability to act on that early signal depends entirely on whether she reports it and is believed. Trust is what makes the reporting happen. A patient who trusts her care team will mention the headache, the swelling, the strange breathlessness, the dark mood, and will do so early, when intervention is easiest; a patient whose trust has been worn away by accumulated small dismissals may say nothing until a crisis forces the issue, by which point the window for easy intervention may have closed. The maternal health literature links perceived discrimination to this erosion of trust and treats the resulting disengagement as a contributor to worse outcomes rather than as a mere matter of patient satisfaction (Josiah et al., 2023; Montalmant & Ettinger, 2024). Because trust is built and spent across many encounters with many different professionals, no single clinician owns it, and no single clinician can repair it alone, which is one more reason that protecting it is a shared, interprofessional responsibility rather than an individual courtesy.
A final point concerns the patient’s own account of being treated unfairly. Patients are often accurate observers of how they are treated, and a patient’s report of feeling dismissed or disrespected is clinical information, not a complaint to be managed away (Campbell, 2025). Treating such reports as data and responding to them with curiosity rather than defensiveness is one of the most direct ways an individual clinician can reduce the harm that flows from the power differential. It is also a behavior that any member of the team can model, regardless of discipline or seniority, making it one of the few high-value responses that do not require a system change to begin.
Section 4: Structural Racism: What It Is, How It Forms, and Its Impact on Maternal Health
The bias discussed so far lives inside individuals and the relationships they form. Structural racism is different in kind. It refers to the way that laws, institutional policies, established practices, and cultural norms work together, often without any individual intending harm, to produce and maintain disadvantage for racially and ethnically minoritized groups (Sonderlund et al., 2022). The defining feature of structural racism is that it does not require a biased person in the room. It is built into the systems themselves, so that ordinary institutional functioning automatically reproduces inequity. For this reason, structural racism is increasingly described in the health sciences as a fundamental, upstream cause of health inequities rather than as one factor among many (Sonderlund et al., 2022; Njoku et al., 2023).
How does a structure like this form? It accumulates historically. Practices established in one era, such as residential segregation, unequal access to education and employment, discriminatory lending, and concentrated policing and incarceration, become embedded in the geography and institutions of a society and continue to shape opportunity long after the original policies are formally ended (Sonderlund et al., 2022). One useful way to operationalize the concept for research is to trace specific structural domains and the pathways by which they affect health. For example, scholars have examined how the spatial and racialized clustering of incarceration, itself a product of structural racism, is associated with adverse birth outcomes in the surrounding communities, illustrating how a structure seemingly remote from the delivery room can reach into pregnancy and birth (Sonderlund et al., 2022). The general lesson is that structural racism operates through many intermediate channels, including where people can afford to live, the quality of the hospitals accessible to them, the chronic stress of navigating discrimination, and the resources their neighborhoods do or do not contain.
In maternal health specifically, several pathways are well described, and it helps to walk through them, because each suggests a different point of intervention. One is differential access to high-quality care. Because of residential and economic segregation, Black patients in the United States are disproportionately likely to give birth in a concentrated set of hospitals, and care quality across such facilities is, on average, lower on multiple measures, so that two patients with similar needs can receive systematically different care depending on where structural forces have routed them (Montalmant & Ettinger, 2024). This is a clear example of how a structure produces a disparity without any individual at the bedside intending it: the segregation that determines neighborhood, the economics that determine which hospital serves that neighborhood, and the resourcing that determines that hospital’s quality are all upstream of the delivery room, yet they shape what happens in it.
A second pathway is the cumulative physiological toll of living with chronic stress and discrimination over the life course, sometimes described through a weathering framework, in which the sustained wear of stress contributes to earlier onset and greater severity of the chronic conditions, such as hypertension and cardiovascular disease, that drive maternal risk (Njoku et al., 2023). The idea of weathering is important because it dissolves false comfort. It is tempting to assume that a patient who is educated, insured, and financially secure has escaped the effects of racism, but the weathering framework predicts, and the data confirm, that the bodily costs of navigating a discriminatory society accumulate regardless of achievement. This is one reason the Black and White disparity in maternal mortality persists, and in some analyses widens, across higher levels of education and income, with Black women who hold a college degree experiencing worse maternal outcomes than White women with far less education (Kaiser Family Foundation, 2025). If the disparity were simply a matter of poverty or schooling, it would close as those improve. It does not, which points to racism rather than race as the operative force (Njoku et al., 2023).
A third pathway connects structural racism back to the interpersonal bias of earlier sections. Structural and interpersonal racism are not separate problems but two expressions of the same system, and they reinforce each other. Structures determine who ends up in front of which clinician, under what time pressures, and with what prior documentation, and the clinician’s implicit biases then operate within those structurally shaped encounters (Montalmant & Ettinger, 2024). A patient routed by segregation to an under-resourced, overstretched facility meets clinicians who are more rushed, which, as Section 1 noted, is exactly the condition under which automatic associations exert the most influence. The structural and the interpersonal thus compound one another, and an account that addresses only one will leave the other in place. A comprehensive understanding of maternal health disparities, therefore, has to hold both levels at once. Addressing only individual bias while leaving the structures intact will leave most of the problem in place; addressing only structures while ignoring the daily encounters in which patients are believed or disbelieved will miss the mechanism by which much harm is delivered.
The history matters because it explains why the structures are so durable. Researchers operationalizing structural racism for empirical study stress that present-day inequities are the continuation of arrangements built over generations, and that structures established in one era persist through the institutions and geography they shaped long after the original policy is formally repealed (Sonderlund et al., 2022). The illustrative case of the spatial and racialized clustering of incarceration is instructive: incarceration patterns, themselves a product of structural racism, are associated with adverse birth outcomes in the surrounding communities, showing how a structure that has nothing obviously to do with pregnancy reaches into birth through the stress, instability, economic loss, and disrupted social ties it imposes on whole neighborhoods (Sonderlund et al., 2022). The general lesson for the team is that the causes of a disparity visible in the delivery room frequently lie far outside it, in domains, housing, criminal justice, education, and employment that no clinician controls but that together determine the health a patient brings to pregnancy.
A further structural pathway operates through the simple geography of where care is available. Access to maternity services is not evenly distributed, and communities that have been disinvested through the same historical processes of segregation and economic exclusion are also those most likely to face closures of obstetric units, shortages of perinatal providers, and long travel distances to the nearest facility capable of managing a complication (Montalmant & Ettinger, 2024). A patient who must travel far for care, or who has no nearby provider she trusts, is more likely to enter prenatal care late, to attend fewer visits, and to reach a higher level of care only after a complication has advanced. These access barriers are commonly described as social determinants of health, but it is important to see that they are not random misfortunes; they are the predictable products of the structural arrangements described in this section, which is why they fall along the same racial and economic lines as the outcomes they help to produce. For the interprofessional team, this pathway is a reminder that a patient’s pattern of engagement with care, how early she came, how reliably she attends, how quickly she seeks help, reflects the structure of access around her at least as much as it reflects any choice of her own, and that interpreting missed appointments or late presentation as a personal failing repeats the very error this course is meant to correct.
It is worth stating plainly what this section does and does not claim. It does not claim that any particular clinician is racist, nor that race is a biological cause of poor outcomes. The claim, grounded in the literature, is that a system built over generations distributes risk unequally by race, that this system is a major driver of the maternal health disparities documented in the next section, and that it continues to function through ordinary institutional practice unless it is deliberately changed (Sonderlund et al., 2022; Njoku et al., 2023). For the interprofessional team, the importance of naming structure is that it widens the field of possible action beyond the individual encounter, toward the policies, referral patterns, hiring, data practices, and institutional habits that the team and its organization can influence. It also guards against a demoralizing misreading of the earlier sections. If bias were purely a matter of individual minds, the persistence of disparities despite decades of good intentions would be baffling and discouraging. Once the structure is in view, the persistence makes sense, and so does the strategy: change the systems, not only the minds.
Section 5: Maternal Morbidity and Mortality: Risk Factors and Patterns Across Populations
To act on maternal health disparities, the team needs a clear picture of the outcomes themselves. Two related terms anchor this section. Maternal mortality refers to the death of a person while pregnant or within a defined period after the end of pregnancy from causes related to or aggravated by the pregnancy or its management. Severe maternal morbidity refers to unexpected outcomes of labor and delivery that result in significant short-term or long-term consequences to a person’s health, a broader category that includes the many patients who survive a life-threatening event. Morbidity is far more common than mortality, and the two share many of the same risk factors and the same disparities, so that mortality, though rarer, serves as a visible index of a much larger burden of harm.
The clinical risk factors for maternal morbidity and mortality are reasonably well established and will be familiar to many on the team. They include cardiovascular conditions and hypertensive disorders of pregnancy, such as preeclampsia, hemorrhage, infection, venous thromboembolism, and complications of chronic conditions, such as diabetes and obesity, as well as mental health conditions and substance use disorders that contribute substantially to deaths in the year after birth (Njoku et al., 2023). Older maternal age raises risk, and access-related factors, including late entry into prenatal care or no prenatal care, lack of insurance, and limited access to facilities, compound clinical risk (Kaiser Family Foundation, 2025). Several features of these risk factors are worth emphasizing for an interprofessional audience. Many of the conditions are chronic and predate the pregnancy, which means the window for prevention opens long before conception and stays open well after delivery. Many of the deaths occur not during the dramatic hours of labor but in the weeks and months that follow. And the mental health and substance use contributions place behavioral health clinicians squarely among the disciplines whose work bears directly on maternal survival, not at the margins of it.
It is important to connect these risk factors back to the preceding sections rather than to read them as a list of individual patient failings. The chronic conditions that drive maternal risk are themselves unequally distributed by the structural forces of Section 4, and the weathering framework predicts their earlier onset among populations exposed to sustained discrimination (Njoku et al., 2023). The access-related factors are likewise structural rather than personal: whether a patient enters prenatal care early depends on insurance, transportation, work flexibility, the availability of nearby providers, and prior experiences of being treated with respect, far more than on individual motivation. And whether a developing complication is caught in time depends on the interpersonal dynamics of Section 3, on whether the patient’s early reports are believed and acted on. The risk factors, in other words, are where the structural and interpersonal forces described earlier become concrete clinical events.
The way these forces show up in maternity care has been documented directly. In obstetric anesthesia, for example, Black women have been found more likely than White women to receive general anesthesia for cesarean delivery, which carries greater risk than neuraxial anesthesia, and more likely to receive no analgesia for vaginal delivery (Tangel et al., 2020). This is exactly the kind of differential that the earlier sections predict: not a dramatic act of overt discrimination, but a pattern of treatment decisions that diverges by race in ways that accumulate into disparate risk. The same pattern appears in the management of pain more broadly, where Black and Hispanic patients have been shown to receive less effective pain treatment across a range of conditions, a disparity rooted partly in the historical and durable misconceptions about pain described in Section 2 (Aronowitz et al., 2020). For the perinatal team, these findings are not distant statistics but a description of the specific clinical decisions, about anesthesia, analgesia, and the seriousness with which pain is treated, through which bias becomes a measurable difference in the care a childbearing patient receives.
The timing data make this concrete and have direct implications for the team. Among pregnancy-related deaths, roughly one in five occur during pregnancy, nearly a quarter occur during labor or in the first week after birth, and more than half occur between one week and one year postpartum (Kaiser Family Foundation, 2025). The postpartum year, in other words, is not an afterthought but the period in which the majority of these deaths happen, which is precisely the period when physical therapists, occupational therapists, behavioral health clinicians, and pediatric-facing audiologists and speech-language pathologists are often the professionals a family sees most. A patient who has been discharged from obstetric care may still be in active contact with these disciplines, which positions them to notice the warning signs, severe headache, shortness of breath, chest pain, heavy bleeding, signs of severe mood disturbance, that can herald a late and preventable death. Equally important, the great majority of these deaths are considered preventable. Estimates indicate that more than eight in ten pregnancy-related deaths could be prevented (Kaiser Family Foundation, 2025). Preventability is the hopeful core of this material: these are not inevitable tragedies but outcomes that better systems, communication, and follow-up can avert, meaning the team’s vigilance is not a mere formality but a determinant of survival.
It is worth being concrete about what preventability means, because the abstract statistic can obscure the practical opportunity. When review committees judge a maternal death preventable, they identify points at which a different action could have changed the outcome, and those points are distributed across the system rather than concentrated in a single dramatic moment. They include missed or delayed recognition of warning signs, gaps in communication and coordination among clinicians, failures to escalate care in a timely manner, and breakdowns in follow-up after discharge, alongside patient and community factors and the access barriers discussed elsewhere in this course (Kaiser Family Foundation, 2025). Most of these are precisely the failures that an attentive, well-coordinated interprofessional team is positioned to catch. A warning sign recognized during a physical therapy session and escalated promptly, a postpartum mood disturbance identified by a behavioral health clinician and acted on, a feeding or developmental visit that becomes an occasion to ask a recovering parent how she is truly doing, each of these is a potential point of prevention. Seen this way, the preventability finding is not a distant policy abstraction but a description of the everyday clinical opportunities that the team already encounters, and a strong argument that improving how the team recognizes, communicates, and escalates is among the most direct contributions any discipline can make to maternal survival.
The patterns across populations are stark and the empirical heart of this course. In 2023, the overall United States maternal mortality rate was 18.6 deaths per 100,000 live births, a decline from 22.3 in 2022, with 669 maternal deaths recorded in 2023 compared with 817 in 2022 (Hoyert, 2025). That overall improvement, however, masks a persistent and severe racial disparity. In 2023, the maternal mortality rate for Black women was 50.3 per 100,000 live births, while the rates for White, Hispanic, and Asian women were 14.5, 12.4, and 10.7 per 100,000, respectively (Hoyert, 2025). The Black rate was more than three times the White rate and more than four and a half times the lowest group rate. While rates declined significantly for White and Hispanic women between 2022 and 2023, the rate for Black women did not improve and remained the highest by a wide margin (Hoyert, 2025). It is worth pausing on what these numbers represent. A rate of 50.3 per 100,000 is not an abstraction; it means that the everyday experience of pregnancy and birth carries a categorically different level of danger for Black women in the United States than for their White, Hispanic, and Asian counterparts, and that this has remained true even as the overall picture improved.
American Indian and Alaska Native populations require specific attention, both because the relevant learning outcome names them and because the standard reporting can render them invisible. National vital statistics typically report stable rates only for the largest race and Hispanic-origin groups, and for 2023, the data were insufficient to publish a reliable maternal mortality rate for American Indian and Alaska Native and for Native Hawaiian and Other Pacific Islander populations (Kaiser Family Foundation, 2025). This statistical suppression is itself a manifestation of how systems can obscure the populations at highest risk, since small population counts lead to fewer cells being detected, and the groups most affected become the hardest to see in the headline figures. Earlier data make the stakes clear: in 2021, American Indian and Alaska Native and Native Hawaiian and Other Pacific Islander people had pregnancy-related mortality rates of 118.7 and 111.7 per 100,000, respectively, the highest of any groups (Kaiser Family Foundation, 2025). Any honest account of maternal mortality across the five populations named in this course must therefore include the caveat that the groups facing some of the gravest risk are also the ones most often missing from the published rates, and that the absence of a number is not the absence of a problem.
It also bears emphasizing that mortality, however grave, is the narrow tip of a far larger burden. For every maternal death, many more patients survive a severe maternal morbidity event, a near miss in which hemorrhage, eclampsia, sepsis, cardiac failure, or another life-threatening complication is survived but often at the cost of lasting physical and psychological harm. These survivors carry the consequences into the postpartum year and beyond, where they intersect directly with the work of the rehabilitation and behavioral health professions: the patient recovering from an emergency hysterectomy, the patient managing the aftermath of a stroke or cardiac event, the patient whose traumatic birth has left both a physical injury and a mental health sequela. Severe maternal morbidity follows the same racial gradient as mortality, so that the populations dying at higher rates are also those surviving complications at higher rates, which means the inequity reaches a far wider group of patients than the mortality figures alone suggest (Njoku et al., 2023; Montalmant & Ettinger, 2024). For an interprofessional team, this is a reminder that addressing disparities is not only about preventing the rare death but about the much more common experience of harm that falls short of death and shapes a family’s health for years.
Two further facts about the disparity deserve emphasis because they shape how the team should think about causes. First, as noted in Section 4, the Black-White gap persists across education and income levels and is not explained by socioeconomic status, which directs attention to racism rather than individual patient characteristics (Kaiser Family Foundation, 2025; Njoku et al., 2023). This finding is worth repeating because it is the single most effective counter to the common but mistaken assumption that the disparity is really about class. Second, the persistence of the disparity in a period when overall rates improved suggests that whatever drove the general improvement did not reach Black patients equally, a pattern consistent with structurally unequal access to the gains. For the interprofessional team, the central message of this section is that maternal mortality is racially patterned, largely preventable, and concentrated in a postpartum window during which many team members are actively involved, which makes the team’s vigilance and coordination directly relevant to whether a patient lives.
Section 6: Infant Mortality and Its Ties to Maternal Health
Maternal and infant health are bound together, biologically and socially, and the disparities in one are mirrored in the other. Infant mortality is defined as the death of an infant before the first birthday, and it is widely used as an indicator of the underlying health of mothers, the quality of perinatal care, and the social conditions in which families live (Ely & Driscoll, 2025). When a population’s mothers are sicker, less well cared for, and more stressed before and during pregnancy, its infants die at higher rates, which is why infant mortality cannot be understood apart from maternal health.
The national figures provide the baseline. In 2023, the United States infant mortality rate was 5.61 deaths per 1,000 live births, essentially unchanged from 2022, with 20,162 infant deaths recorded, a 2 percent decrease from the prior year (Ely & Driscoll, 2025). The leading causes of infant death are closely tied to the course of pregnancy: congenital malformations, disorders related to preterm birth and low birth weight, sudden infant death syndrome, injuries, and maternal complications of pregnancy (Kaiser Family Foundation, 2025). Several of these causes, particularly those stemming from preterm birth and low birth weight, are direct downstream consequences of maternal health and the conditions of pregnancy, which is the mechanical link between the two outcomes. An infant born too early or too small because of an inadequately managed maternal condition, a stressful pregnancy, or barriers to timely care begins life at a disadvantage that the best neonatal care cannot always overcome.
The racial patterning of infant mortality parallels the maternal data. Infants born to Black mothers die at more than twice the rate of infants born to White mothers, with Black infant mortality reported at roughly 10.9 per 1,000 live births compared with about 4.5 for White infants and 3.4 for Asian infants (Ely & Driscoll, 2025). American Indian and Alaska Native infants also experience elevated mortality relative to White and Asian infants. The leading contributors to the Black and White gap are the higher rates of preterm birth and low birth weight among Black infants, which again routes the explanation back through maternal health and the structural and interpersonal forces that shape it (Kaiser Family Foundation, 2025). The same disparities, the same upstream causes, and the same persistence across socioeconomic lines that characterize maternal mortality reappear in infant mortality data, providing strong evidence that the two are manifestations of a single underlying problem rather than two separate ones.
For the interprofessional team, this connection is not abstract. The infants who survive complicated pregnancies and difficult births are precisely the population that occupational therapists, physical therapists, speech-language pathologists, and audiologists follow most closely. A preterm infant may need feeding support from a speech-language pathologist, developmental and motor support from occupational and physical therapists, hearing surveillance from an audiologist, and respiratory support managed by a respiratory therapist while the parent navigates the physical recovery and the mental health consequences of a high-risk pregnancy and a fragile newborn, often with behavioral health involvement. These professionals therefore meet the downstream effects of maternal health disparities every day, frequently without naming them as such. Understanding that an infant’s developmental risk and a parent’s distress can both trace back to the same structural and interpersonal forces gives the team a more accurate picture of the family in front of them and a stronger rationale for coordinated, respectful, and vigilant care. It also reframes the team’s work as part of the prevention story: supporting maternal recovery, catching warning signs early, and sustaining a family’s trust in the care system all contribute, however indirectly, to better outcomes for the next pregnancy and the next generation.
The preterm birth pathway deserves a closer look because it is the mechanical hinge connecting maternal health to infant survival and because it carries the same disparity. Preterm birth and low birth weight are among the leading contributors to infant death, and they are more common among Black infants, which accounts for much of the Black and White gap in infant mortality (Kaiser Family Foundation, 2025). The forces that drive preterm birth are not separate from the forces described in earlier sections. The chronic stress captured by the weathering framework, the differential access to high-quality prenatal care produced by structural segregation, and the interpersonal dynamics that determine whether an emerging complication is caught and treated all feed into whether a pregnancy reaches term. An infant born too early because a maternal condition went unrecognized or untreated enters a neonatal course that the most skilled team can only partly rescue. Understanding this chain helps every discipline see that the infant outcomes they manage downstream were partly written upstream, in the quality and equity of the care the mother received, and that improving maternal care is, in a direct sense, infant care as well.
There is also a reciprocal direction to the maternal and infant relationship that matters for the postpartum team. A medically fragile newborn intensifies the stress, sleep disruption, and emotional strain on a recovering parent, raising the risk of perinatal mood and anxiety disorders at exactly the time when the parent is also managing their own physical recovery and the infant’s complex needs. Behavioral health clinicians supporting these parents, and the rehabilitation professionals helping both parent and infant regain function, are therefore working on two interlocking recoveries at once. Recognizing the dyad as a single unit of care, rather than treating mother and infant as separate cases, is consistent with the interprofessional emphasis on coordinated, whole-person care and positions the team to support the family in ways that fragmented, discipline-by-discipline attention cannot.
It is also worth stepping back to see why infant mortality carries such weight as a measure. Because an infant’s first year of life is so sensitive to the health of the mother, the quality of perinatal care, and the social conditions surrounding the family, the infant mortality rate is widely treated as a barometer of the underlying well-being of a whole population, not merely as a count of individual losses (Ely & Driscoll, 2025). When that barometer shows a rate for one group more than double the rate for another, and when the gap traces back through preterm birth and low birth weight to the same maternal health and structural forces examined throughout this course, the disparity is best read as a signal that the conditions supporting healthy pregnancy and infancy are themselves unequally distributed. For the interprofessional team, this reinforces a theme that runs through the entire course: the outcomes that appear at the very end of the causal chain, an infant lost, a mother dead, a complication survived with lasting harm, are produced by forces that operate long before and far upstream, many of which the team’s everyday practice can influence. Improving the equity of maternal care is therefore not a separate project from improving infant survival; it is, in large part, the same project viewed from a different point in the lifespan.
Section 7: The Interprofessional Team's Role in Reducing Bias and Structural Racism
The preceding sections describe a problem with two levels, the interpersonal and the structural, and the response has to operate at both. This section turns to what the interprofessional team can actually do, with attention to what the evidence supports and what it does not.
Begin with a note of humility about training. Implicit bias training has become widespread and is now legally required for healthcare professionals in several states (Shah & Bohlen, 2023). Yet a systematic review of implicit bias training for healthcare providers and trainees found that such training is frequently characterized by methodological weaknesses and translational gaps, often diverging from the underlying science and lacking strong evidence of internal, face, and external validity, which means a single training module cannot be assumed to change behavior on its own (Hagiwara et al., 2024). This finding should not be read as a reason to abandon education, which builds the shared understanding this very course aims to provide, but rather as a reason to embed education within a larger system of change and to be skeptical of any claim that a single workshop has fixed the problem. The honest message to a team is that awareness is a starting point and that durable change requires ongoing reflection and structural support (Campbell, 2025; Hagiwara et al., 2024).
At the level of the individual encounter, several evidence-informed strategies can reduce the influence of automatic associations. Honest self-assessment is the starting point, and a widely used entry point is a confidential implicit-association measure, such as those hosted by Project Implicit, which can prompt reflection by making a clinician’s automatic associations visible, provided the result is treated as a conversation starter rather than a verdict (Kirwan Institute, 2013). Counter-stereotypic imaging and the deliberate practice of individuating, that is, focusing on the specific person rather than the group category, can weaken the grip of stereotypes, and perspective-taking and structured reflection can increase a clinician’s self-awareness and empathy, with simulation-based and reflective approaches showing some of the more consistent positive effects in the literature (Campbell, 2025). Practices that reduce cognitive load and stress, including mindfulness and emotional regulation techniques, can help because bias exerts the most influence precisely when a clinician is rushed, tired, and overwhelmed, which is the ordinary condition of much clinical work (Campbell, 2025). Underpinning all of these is the disposition of cultural humility, defined as the ability to maintain an other-oriented stance that remains open to the aspects of cultural identity most important to the patient rather than assuming expertise about the patient’s experience (Hook et al., 2013). None of these is a cure, and measured effects on implicit-association scores tend to be modest and may fade, which is why they work best as habits sustained over time rather than as one-time exercises (Campbell, 2025).
Closely related is the team’s and the organization’s capacity for cultural and linguistic competence. Cultural competence has been defined as a set of congruent behaviors, attitudes, and policies that come together in a system or among professionals to enable effective work in cross-cultural situations (Cross et al., 1989), while linguistic competence is the capacity of an organization and its staff to convey information in a way that is readily understood by patients of limited English proficiency, low literacy, or sensory disability (National Center for Cultural Competence, n.d.). The stakes are concrete: without it, encounters produce incomplete or inaccurate histories, misunderstandings of diagnoses and treatment, problems with medication and informed consent, and avoidable repeat visits. A practical, high-yield example is the use of trained, qualified medical interpreters rather than family members or friends, with attention to difficult-to-translate terms and to the physical arrangement of the encounter. For a perinatal team serving diverse families, including the audiologists and speech-language pathologists whose work centers on communication itself, building cultural and linguistic competence into routine practice is one of the more tangible ways to prevent bias and miscommunication from reaching patients.
The more powerful levers are at the team and system levels, where the interprofessional framing pays off. Standardizing assessment and decision processes, for example, using consistent protocols for evaluating and escalating warning signs such as postpartum pain, bleeding, or mood changes, reduces the room for unexamined judgment to determine who is taken seriously. Validated instruments allow a team or organization to measure awareness and mitigation of bias and to track whether interventions are actually changing practice rather than assuming they are (Bower et al., 2023). Building communication channels that allow concerns to travel across the hierarchy means that what a physical therapist or occupational therapist hears during a long session, or what a behavioral health clinician learns about a patient’s eroding trust, can reach the people who can act on it. Treating patient reports of disrespect or dismissal as safety data and reviewing adverse outcomes with an explicit eye to whether bias or unequal access played a role turns individual events into system learning. Each of these maps onto the interprofessional competency domains: shared values and ethics that center equity; clear roles and responsibilities so that no warning sign is anyone’s blind spot; communication that crosses disciplinary lines; and genuine teamwork that distributes the work of vigilance.
First Domain: Values and Ethics for Interprofessional Practice
It is worth taking each of those four domains in turn because they give the team a practical structure for organizing its response and convert a broad commitment to equity into specific, assignable behaviors. The first domain, values and ethics for interprofessional practice, asks the team to place the patient’s interest and dignity at the center of its shared work and to treat equity as a professional obligation rather than an optional virtue. In concrete terms, this means the team agrees that a patient’s report of pain or distress is to be believed and investigated regardless of the patient’s race, language, body size, or insurance status, and that respectful communication is held as a standard of care rather than a matter of individual temperament. When equity is named as a shared value, an individual clinician who slows down to take a dismissed concern seriously is acting on team policy rather than swimming against the current, and a clinician who treats a patient curtly can be understood to have departed from an agreed standard rather than merely having an off day.
Second Domain: Roles and Responsibilities
The second domain, roles and responsibilities, asks each profession to understand both its own contribution and those of the others well enough that important observations do not fall through the cracks between disciplines. In the perinatal context, this means that the physical therapist knows that the postpartum pain she is hearing about could signal a complication that belongs to the obstetric team, that the speech-language pathologist understands that a parent’s flat affect during a feeding session may be relevant to the behavioral health clinician, and that everyone knows who is responsible for escalating a warning sign and how. Role clarity is a safeguard against bias because much of the harm described in this course occurs in the spaces between professionals, where each assumes someone else has noticed and acted. A team that has mapped its roles explicitly leaves fewer such spaces.
Third Domain: Interprofessional Communication
The third domain, interprofessional communication, asks the team to communicate in a manner that is responsive, respectful, and sufficiently structured to reliably carry concerns across the hierarchy. The relevance to bias is direct, because the distributed vantage point described earlier, in which the patient confides in the clinician she trusts most, is useless if that clinician has no dependable way to convey what she heard to the people who can act, or no confidence that doing so is welcome. Structured handoffs, shared documentation that travels with the patient, and an explicit norm that raising a colleague’s possible blind spot is an act of good care rather than an accusation all serve this domain. Communication is also where trust is protected or damaged, so the team’s communication habits with the patient, not only among its members, fall under this domain.
Fourth Domain: Teams and Teamwork
The fourth domain, teams and teamwork, asks the team to apply the values, the role clarity, and the communication into a coordinated practice that performs better than the sum of its individuals. This is the domain in which the standardized protocols, the measurement of bias awareness, the review of adverse outcomes, and the flattening of hierarchy live, because each of these is a property of how the team works together rather than of any one member’s knowledge or goodwill. The evidence reviewed throughout this course points consistently toward this conclusion: because bias is a feature of normal cognition that no amount of individual effort fully eliminates, and because structural forces operate above the level of any single encounter, the durable protections are the ones built into the team’s shared routines (Campbell, 2025; Hagiwara et al., 2024; Bower et al., 2023).
Structural racism, by definition, is not solved at the bedside, but the team and its organization are not powerless before it. Within their sphere, teams can examine their own referral patterns and access barriers, advocate for the data practices that make high-risk populations visible rather than suppressed, support workforce diversity and culturally responsive care, and align with institutional and policy efforts aimed at the upstream causes (Montalmant & Ettinger, 2024; Sonderlund et al., 2022). The point is not that an audiologist or a physical therapist can dismantle structural racism single-handedly, but that the structures are made of countless ordinary practices, many of which a team can influence, and that naming the structural level keeps it from being treated as someone else’s problem.
Measurement
Measurement deserves a place of its own in the team’s response, because without it good intentions cannot be distinguished from good results. A team that wishes to know whether it is reducing the harm of bias has to look at data, and several kinds are available. Validated instruments can assess awareness of and mitigation of bias within a maternity care setting, providing a team with a baseline and a way to detect change over time, rather than relying on the assumption that training or a policy must have helped (Bower et al., 2023). Stratifying clinical and experience measures by race and ethnicity, for example, examining whether pain is assessed and treated equally, whether warning signs are escalated equally, and whether patients of different groups report equivalent respect and trust, can make a hidden disparity visible and turn it into an actionable target. Reviewing severe morbidity and mortality events with an explicit question about whether bias or unequal access contributed converts individual tragedies into system learning. None of these measurements is punitive in spirit; its purpose is to replace the comfortable assumption that a team is doing well with evidence about whether it actually is, and to direct effort toward the points where the data show the largest gaps. This emphasis on measurement also guards against the documented risk of mistaking a single educational intervention for a solution, since the data will make it plain whether practice has changed (Hagiwara et al., 2024).
Care Models and Programs That Have Reduced Maternal Harm
The strategies in this section are not only theoretical; they are embodied in established programs whose results have been measured. The leading national example is the Alliance for Innovation on Maternal Health (AIM), a federally funded program coordinated through the American College of Obstetricians and Gynecologists that develops and disseminates maternal patient safety bundles, which are standardized, evidence-based sets of practices aimed at the leading preventable causes of maternal death and severe morbidity, including obstetric hemorrhage, severe hypertension and preeclampsia, sepsis, and perinatal mental health and substance use conditions. As of early 2025, AIM bundles were being implemented in roughly 2,000 birthing facilities across 49 states, the District of Columbia, and Puerto Rico (Health Resources and Services Administration, 2025). Each bundle is organized around the domains of readiness, recognition, response, reporting, and respectful care, and the deliberate inclusion of respectful and equitable care places the trust and bias concerns of this course within the safety framework rather than beside it (American College of Obstetricians and Gynecologists, n.d.).
This model has a measurable track record. The California Maternal Quality Care Collaborative (CMQCC) pioneered bundle-based perinatal quality improvement, and in a peer-reviewed evaluation of 99 collaborative hospitals, patients experiencing obstetric hemorrhage showed a 20.8 percent reduction in severe maternal morbidity compared with a 1.2 percent reduction in non-participating comparison hospitals, with a larger 28.6 percent reduction in hospitals that had prior collaborative experience (Main et al., 2017). At the state level, California’s maternal mortality rate fell by roughly 65 percent between 2006 and 2016, a period when the national rate was rising, a decline that CMQCC attributes substantially to these collaborative quality-improvement efforts (California Maternal Quality Care Collaborative, n.d.).
Two features make these programs directly relevant to this course. First, the gains are produced through precisely the team and system mechanisms described above, namely standardized recognition and escalation, rehearsed emergency response, and the routine review of data, rather than through individual exhortation; the bundles have since been revised to embed respectful and equitable care, and collaboratives increasingly stratify outcomes by race and ethnicity so that improvements reach the patients at highest risk (American College of Obstetricians and Gynecologists, n.d.; Montalmant & Ettinger, 2024). Second, they give the interprofessional team a concrete picture of what success looks like: a patient is less likely to die or to suffer severe harm when every discipline recognizes the warning signs, the team has practiced its response, and the data are watched to see who is being left behind. For the disciplines represented in this activity, these programs are the structural counterpart to the individual habits of listening and believing, and they show that the layered response this course recommends is not aspirational but already at work.
Finally, every team member's role includes the conduct of individual relationships, where evidence and ethics converge. Listening to patients, believing their reports of their own bodies, communicating respectfully, and protecting trust are not soft additions to clinical care but, in a period when most maternal deaths are preventable, and many depend on a patient’s warning being heard, are themselves safety interventions. The interprofessional team’s role in reducing the impact of implicit bias and structural racism for pregnant and postpartum patients is therefore both modest and essential: modest because no single profession or person controls the outcome, and essential because the outcome is built from exactly the encounters, hand-offs, and habits that the team controls together.
Pulling these threads together, the response the evidence supports is layered rather than singular. At the level of the individual clinician, it asks for honest, sustained self-examination and for the everyday discipline of listening to patients and believing their reports of their own bodies. At the level of the team, it asks for shared values that center on equity, clear roles so that warning signs are no one’s blind spot, communication that carries concerns reliably across the hierarchy, and coordinated routines that perform better than the sum of their members. At the level of the system, it calls for standardized processes, measurements that reveal disparities rather than hide them, and engagement with structural and access barriers that route patients to unequal care. No single layer is sufficient on its own: individual goodwill without team structure leaks; team structure without individual listening has nothing to carry; and both together still operate within structures that must be named and addressed. One way to hold these layers together is the image of a cycle that can turn in either direction: structural determinants and biased decision-making can feed a vicious cycle of diminished care and worse outcomes, while sound decision-making and supportive structures can feed a virtuous cycle of improved care and better outcomes, with the clinician and the team positioned at the point where the cycle can be redirected (Vela et al., 2022). What makes this an interprofessional rather than a single-discipline task is that each of these layers depends on contributions from every profession that touches the childbearing family, from behavioral health to audiology, and that the safety of the patient emerges from how those contributions are coordinated. The hopeful conclusion, grounded in the finding that the great majority of maternal deaths are preventable, is that this is a problem largely within the team’s power to influence, provided the team takes it up together rather than leaving it to the conscience of individuals (Campbell, 2025; Hagiwara et al., 2024; Bower et al., 2023; Kaiser Family Foundation, 2025).
Application to Team-Based Practice
The material in this course reaches each represented profession differently, and naming those connections helps every reader locate their own role. Behavioral health clinicians often hold the relationships in which a patient feels safe enough to disclose distrust, perceived discrimination, or worsening symptoms, and they treat the perinatal mood and anxiety disorders that contribute to maternal deaths in the postpartum year, which places them at the center of both the trust and the clinical-risk dimensions of this material. Physical therapists frequently spend extended, hands-on time with patients managing pelvic floor dysfunction, musculoskeletal pain, and postpartum recovery, and that time is an opportunity both to hear concerns that were not voiced elsewhere and to model the practice of believing a patient’s report of pain, a domain with a documented history of biased underestimation. Occupational therapists support feeding, infant development, and a parent’s return to daily roles, often in the patient’s own environment, where they can observe context that the clinic never sees and where the power differential may relax enough for honest exchange. Speech-language pathologists and audiologists conduct newborn feeding and hearing screenings and follow developmentally at-risk infants across repeated visits, which makes them trusted longitudinal contacts for families navigating the downstream consequences of high-risk pregnancies and positions them to notice and escalate parental concerns over time. Respiratory therapists manage the ventilation and oxygen support that medically fragile newborns rely on and assist with the maternal respiratory complications that can arise during pregnancy and the postpartum period, which places them among the clinicians most likely to encounter warning signs such as shortness of breath and to act on them quickly.
Across all of these roles, the shared behaviors are the same. Each profession makes rapid judgments under pressure that are vulnerable to implicit associations, each occupies a position in a power differential relative to the patient, each meets families who carry the effects of structural forces they did not choose, and each can either protect or undermine a patient’s trust in the care system. The interprofessional opportunity is to ensure that the distinct vantage points add up to more than their sum, so that a concern heard by one discipline reaches the whole team, and so that the values, role clarity, communication, and teamwork that reduce the harm of bias are built into how the team works rather than left to individual goodwill.
A few illustrative situations show how these principles become concrete and how the team functions as a single safeguard. Consider a postpartum patient who mentions to her physical therapist, during a session for pelvic pain several weeks after delivery, that she has also been having headaches and some shortness of breath, symptoms she has not raised with anyone else because a previous clinician seemed to brush off her concerns. The physical therapist who has absorbed this material recognizes two things at once: that these symptoms can signal a serious late postpartum complication, and that the patient’s reluctance to report them is itself a product of an eroded trust that bias can cause. The values domain tells the therapist to take the report seriously; the roles domain tells her that escalation belongs to the obstetric or emergency pathway; the communication domain gives her a reliable way to convey the concern; and teamwork ensures the handoff is received rather than lost. The same chain could begin with an occupational therapist noticing a parent’s distress during a home visit, a speech-language pathologist observing that a parent seems disengaged during a feeding session, or a behavioral health clinician learning that a patient has stopped trusting her care team. In each case, the discipline that first receives the information is not expected to manage the complication alone, but to recognize its significance and to move it into the team’s shared field of action.
These scenarios also illustrate why the individual relationship and the team structure are complementary rather than competing. The therapist’s decision to believe the patient and to respond with curiosity rather than dismissal is an individual behavior, available to any clinician without waiting for a system change, and it is exactly the behavior that keeps a patient willing to disclose. But whether that disclosure leads to timely care depends on the team structures around it, the channels, the role clarity, and the shared norms that carry the concern to the people who can act. A clinician with excellent personal habits embedded in a team that has no way to escalate her observations will still watch concerns evaporate, and a well-structured team staffed by clinicians who do not listen will have nothing worth escalating. The interprofessional response to bias, therefore, asks for both at once: the individual disposition to listen, believe, and respect, and the collective structures that turn what is heard into what is done.
Summary
This course examined implicit bias and its impact on maternal health in minority populations, building from individual psychology toward structural forces and the outcomes at stake, and it returns now to each learning outcome. It differentiated implicit bias, which operates automatically and outside awareness, from explicit bias, which is consciously held, and explained how both can shape clinical interactions even in well-intentioned clinicians (LO1). It described how stereotypes, prejudice, and “isms” form and evolve through lifespan socialization, and identified self-assessment instruments, reflective practice, and continuing education as resources for examining one’s own biases, while noting that awareness is a beginning rather than an end (LO1). It examined how bias and power differentials affect the patient and the patient-team relationship, eroding communication and trust in ways that pose safety concerns in the perinatal period (LO2). It gave examples of structural racism, described how it forms and accumulates historically, and explained its impact on maternal health through pathways such as differential access to quality care and the cumulative toll of chronic stress (LO3). It identified the major risk factors for maternal morbidity and mortality and described the patterns across populations, including a 2023 Black maternal mortality rate more than three times the White rate, the persistence of that disparity across education and income, and the elevated and often statistically suppressed rates among American Indian and Alaska Native and Native Hawaiian and Other Pacific Islander populations (LO3). Finally, it described United States infant mortality and its ties to maternal health and pregnancy-related complications, and summarized the interprofessional team’s role in reducing the impact of implicit bias and structural racism for pregnant patients, a role that is modest at the level of any one profession and essential at the level of the team’s shared encounters, hand-offs, and habits (LO4). The through-line is that most maternal deaths are preventable, that the harm is racially patterned and structurally produced, and that the perinatal team, working as a team, holds many of the levers that determine whether a patient is heard, believed, and kept safe.
References
Please see the additional handout.

Kelly, C. (2026). Implicit Bias: Impact on Maternal Health in Minority Populations. Counseling.com, Article 132. Available at www.continued.com/counseling.
Jul 8, 2026
1 CE Credit
A Comprehensive Introduction to the Diagnosis and Treatment of Obsessive Compulsive Disorder
Johann D'Souza, LP, PhD
This text-based course is an edited transcript of the webinar, A Comprehensive Introduction to the Diagnosis and Treatment of Obsessive-Compulsive Disorder, presented by Johann D'Souza, PhD, LP, on January 5, 2026.

Course Overview
Obsessive-compulsive disorder (OCD) is a widely misunderstood condition, frequently reduced in popular culture to quirks of tidiness or orderliness. This course provides a clinically grounded introduction to the disorder, moving from common misconceptions through formal diagnostic criteria, symptom subtypes, and evidence-based assessment tools, before arriving at a thorough examination of the gold-standard treatment: Exposure and Response Prevention (ERP). Developed for mental health practitioners and other healthcare professionals seeking continuing education, the material draws on current DSM-5-TR criteria, published research, and clinical examples to build practical competence. By the end of this course, participants will understand what OCD is, how it differs from superficially similar conditions, and how to implement the fundamental stages of ERP with individuals across the lifespan.
This material is for educational purposes and does not replace clinical judgment or local policy.
Limitations/Risks
- OCD is a highly complex disorder that shares symptoms with several other disorders. This webinar is not a replacement for supervision, consultation, and specialized professional training for the diagnosis and treatment of OCD.
- This webinar does not constitute a clinical credential and does not include all OCD subtypes, comorbid conditions, treatment options, or treatment complexities.
- Treatment protocols and diagnostic criteria continue to evolve; this webinar represents current knowledge at the time of presentation.
- The stigma associated with mental health issues and specific beliefs about mental health and treatment vary widely across cultures. In some cultures, seeking mental health treatment is highly stigmatized, leading to reluctance in seeking treatment and/or participating fully in treatment. Therefore, practitioners should exercise cultural humility at all times with all clients.
Learning Outcomes
After this course, participants will be able to:
1. List the two primary symptoms of OCD.
2. Describe the differences between OCD, anxiety, and other disorders.
3. Explain three fundamental stages of Exposure & Response Prevention.
Common Myths
Before defining OCD precisely, it is useful to examine what OCD is not — because misunderstanding is widespread not only among the general public but within professional communities as well. Several persistent myths shape how people with OCD experience their disorder and the kind of help they seek.
One of the most pervasive myths is the idea that everyone is "a little OCD." There is a kernel of truth embedded here: many people experience recurring, intrusive thoughts from time to time. However, to receive a diagnosis of OCD, an individual must meet a clinical threshold of symptom severity and functional impairment that is uncommon for most people. The casual colloquial use of "OCD" to describe everyday preferences for order or cleanliness trivializes a condition that can be profoundly disabling.
A related and equally common myth is that OCD is always about hand washing, cleaning, or neatness. While contamination concerns and cleaning compulsions are among the more visible manifestations of OCD, they represent only one slice of the disorder's full range. OCD can present in ways that are entirely unrelated to cleanliness — for example, intrusive thoughts about harming a loved one, fears related to morality or religious transgression, or a vague but distressing sensation that something is "not quite right." Someone can meet full diagnostic criteria for OCD without ever engaging in cleaning behaviors at all.
Another myth holds that people with OCD are simply neurotic, eccentric, or beyond help. It is important to separate the person from the disorder: the unusual or distressing behaviors associated with OCD are products of the condition, not character flaws. With appropriate, evidence-based treatment, individuals with OCD can achieve substantial — often dramatic — symptom reduction and lead fulfilling, functional lives.
Perhaps the most clinically consequential myth is the belief that OCD can be treated by directly disputing or arguing against the dysfunctional beliefs driving it. Intuitively, it might seem that if a person is afraid of contamination, demonstrating that their fears are irrational should help. In practice, the act of counter-arguing, debating, or seeking logical reassurance tends to perpetuate OCD rather than relieve it. The obsessional cycle is not fundamentally a problem of faulty logic; it is a problem of avoidance and reinforcement — a distinction that becomes central to understanding why ERP is the treatment of choice.
Similarly, OCD is not simply a reflection of unresolved psychodynamic conflicts or childhood trauma. Stressful or traumatic experiences can certainly exacerbate symptoms or trigger their onset, but the current evidence base indicates a strong genetic predisposition that is primary to the disorder's development (American Psychiatric Association, 2022). Stressors can make it worse; they are not the root cause.
Finally, clinicians should be aware of how perfectionism can interact with OCD in treatment itself. Individuals with OCD tend to exhibit high rigidity and a low tolerance for uncertainty, and these traits can affect the treatment process. A patient may feel compelled to complete exposure homework "perfectly," inadvertently generating a new OCD cycle within the therapeutic work. Developing insight into this pattern — in both the patient and the clinician — is an important clinical competency.
Defining OCD
DSM-5 TR Definition
The formal definition of OCD in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision is straightforward at its core (American Psychiatric Association, 2022). Three criteria must be met:
- The obsessions or compulsions are time-consuming and/or cause clinically significant distress or functional impairment.
- The obsessive-compulsive symptoms are not attributable to the effects of a substance or another medical condition.
- The disturbance is not better explained by the symptoms of another mental disorder.
What this definition leaves open is precisely what obsessions and compulsions are — and here the clinical literature departs significantly from everyday usage of these words.
Differentiating Disorders
Obsessions
In everyday speech, describing oneself as "obsessed" with a hobby or interest typically implies enthusiasm and pleasure. In the clinical context of OCD, the term means something nearly opposite. An obsession, as defined in the OCD literature, is a thought, image, or urge that is unwanted, intrusive, persistent, and irrational.
Each element of this definition carries diagnostic weight. The thought component refers to verbal content in one's mind — for example, the phrase "I am going to harm my child" entering awareness without the individual having invited it. An image refers to a mental picture, such as a vivid visualization of violence against a loved one. The third component, urge, is more nuanced and not universally experienced by people with OCD. It refers to a vague, uncomfortable somatic or perceptual sense that something is "not just right" — that a shirt sleeve is positioned incorrectly, that shoelaces are unevenly tightened, or that a symmetry has been disrupted. This phenomenon has been labeled "not just right OCD," and it is experientially distinct from cognitive worry.
The quality of being unwanted distinguishes OCD obsessions from ordinary preoccupations. The teenager who thinks about cars constantly is not experiencing obsessions in the clinical sense, because those thoughts are welcomed. Intrusive means the thought enters awareness without being sought; persistent means it returns repeatedly despite efforts to suppress or ignore it. The final criterion — irrational or unrealistic — is what most cleanly separates obsessions from the anxious worries seen in other disorders. Even exaggerated everyday worries bear some relationship to realistic events. OCD obsessions frequently carry a superstitious or magical quality that crosses into the clearly implausible: "If I do not wash my hands exactly five times, my grandmother will become ill and die." This irrational character is not a moral failing; it is the signature of the disorder.
The distinction between urge and fear of urge deserves particular attention for clinicians. A patient who reports "an urge to stab my spouse" when chopping vegetables is almost certainly not experiencing an actual drive to harm. What the patient experiences is an unwanted thought or image, accompanied by intense fear that they might act on it. The internal drive to harm is absent — that is precisely what makes the thought OCD rather than intent. Part of effective treatment involves helping patients develop insight into this distinction.
Compulsions
If obsessions are the internal, involuntary dimension of OCD, compulsions are the behavioral dimension — the things the person does in response. Compulsions are repetitive behaviors or mental acts that an individual feels compelled to perform in response to an obsession in order to reduce or prevent anxiety or distress, prevent a feared outcome, or make something feel "just right." Critically, they are either not connected in a realistic way to what they are intended to prevent or are clearly excessive in nature (American Psychiatric Association, 2022).
Compulsions may be overt and behavioral — hand washing, checking locks, arranging objects — or they may be entirely covert mental acts, such as silently counting, reviewing memories, or generating counter-thoughts. The compulsion is a choice, even when it feels automatic or overwhelming to resist. When working with children, clinicians should note that younger patients may be unable to articulate the connection between their obsession and their compulsive behavior. Helping these patients map the relationship between trigger, obsession, anxiety, compulsion, and temporary relief — the OCD cycle — is an important early phase of treatment.
The most universal category of compulsion is avoidance: any behavior the person engages in to steer clear of the feared thought, image, or situation. Reassurance-seeking is the next most common, in which the person repeatedly seeks confirmation from a spouse, parent, or clinician that the feared outcome has not occurred or is unlikely to occur. Providing reassurance, while immediately comforting, feeds the OCD cycle in exactly the same way a compulsion does. Confessing, checking, and rechecking, and mental reviewing are additional common compulsion types.
Insight
A critical clinical concept in OCD is the role of insight (Steinberg et al., 2025). Insight refers to the degree to which an individual recognizes that their obsessional fears are not realistic — that what they are experiencing is OCD, not an accurate perception of the world.
Image: The insight spectrum in OCD ranges from absent/delusional (firm belief that fears are real) through poor to good/fair (recognition that symptoms reflect OCD), with lower insight associated with poorer treatment outcomes (Steinberg et al., 2025).

At one extreme is good or fair insight: the person recognizes that feared thoughts are symptoms of a disorder and are not realistic, even if they still feel compelling. At the other extreme is absent or delusional insight: the individual is firmly convinced their fears are real. This rare but severe presentation — in which a person may be unable to leave the home because they are certain a harmed child is concealed somewhere in the building, despite living alone — begins to approximate a psychotic-spectrum disorder in its phenomenology.

More clinically common is poor insight, found in approximately one-fifth to one-third of individuals with OCD (Steinberg et al., 2025). These individuals oscillate: most of the time, they suspect they have OCD, but a persistent doubt remains — "maybe this time it really is true." Poor insight is more prevalent in OCD than in other anxiety-related conditions and carries significant treatment implications. Lower insight is one of the strongest predictors of poorer treatment response, making its assessment and its gradual improvement through treatment a clinical priority. One mechanism by which ERP improves insight is through repeated, successful fear-facing: when a person repeatedly confronts feared situations and observes that nothing catastrophic occurs, they accumulate experiential evidence that progressively weakens catastrophic beliefs.
Common OCD Subtypes
OCD can manifest in a remarkable variety of ways, and the specific content of obsessions is highly idiosyncratic. Nonetheless, research and clinical observation have identified common groupings or subtypes that help practitioners recognize and assess the full range of the disorder's presentations (Jalal et al., 2023).
Image: OCD subtypes mapped by obsession type and associated compulsions, illustrating the breadth of presentations beyond contamination and cleaning (Jalal et al., 2023).

Contamination OCD involves fears of germs, chemical contaminants, or substances with aversive sensory qualities, such as greasy or sticky textures. The corresponding compulsions typically center on washing, cleaning, or avoidance of perceived contaminants.
Scrupulosity involves an excessive fear of offending God, acting immorally, or being in a state of spiritual transgression. This subtype is of particular clinical importance because the symptom content intersects with the patient's deepest personal values. A patient with scrupulosity may engage in constant mental review of their words and actions, wondering whether an ambiguous statement was a lie or whether a momentary lapse placed them in spiritual jeopardy. Effective treatment requires a clinician who understands and respects the patient's religious and moral framework rather than pathologizing it wholesale.
Harm OCD involves recurrent, unwanted thoughts about causing harm to others or being harmed oneself. As noted in the section on obsessions, patients with harm OCD do not experience an internal drive to harm — they experience an overwhelming fear that they might. Taboo OCD is closely related, encompassing thoughts of a sexual nature, including fears of being attracted to children or committing sexual abuse. Because of the profound shame associated with these thoughts, patients are frequently reluctant to disclose them even to their therapist. Clinicians who do not directly and non-judgmentally inquire about this symptom domain may be treating a patient with significant taboo OCD without realizing it.
Just-right OCD involves the pervasive sense that things are not in their correct state — not perfectly symmetrical, not properly ordered, not adequately arranged. The discomfort is more somatic or aesthetic than cognitive; patients often struggle to articulate what specifically is wrong, only that something is not right.
On the compulsion side, avoidance is so universal that it can serve as a summary category for all compulsive behavior. Reassurance-seeking, confessing, checking and rechecking, repeating behaviors, and mental compulsions (internal reviews, counter-thoughts, neutralizations) round out the most common presentations (Jalal et al., 2023).
Other Related Disorders
OCD belongs to a broader family of conditions classified in the DSM-5-TR as obsessive-compulsive and related disorders, a grouping that reflects both phenomenological similarities and genetic relationships (Brierley et al., 2021). Understanding these related conditions helps clinicians think about comorbidity, differential diagnosis, and the broader context of a patient's presentation.
Image: OCD-related disorders sharing genetic and phenomenological features with OCD, including body dysmorphic disorder, tic disorders, illness anxiety disorder, body-focused repetitive behaviors, and hoarding (Brierley et al., 2021).

Tic disorders, including Tourette's syndrome, are among the most genetically proximate conditions to OCD. Vocal and motor tics — such as throat clearing or repetitive movements — are frequently comorbid with OCD, a pattern reflecting shared genetic architecture rather than coincidence.
Illness anxiety disorder (formerly hypochondriasis, often called health anxiety) involves excessive, disproportionate fear of having or developing a serious illness. This can present as a distinct disorder or as an OCD subtype, and careful assessment is needed to determine the most appropriate conceptualization.
Hoarding disorder may present as one symptom among many in a person with OCD or as a standalone condition. Similarly, body dysmorphic disorder — characterized by preoccupation with perceived flaws in physical appearance — shares important features with OCD and is treated with many of the same approaches.
Body-focused repetitive behaviors (BFRBs), including trichotillomania (hair pulling) and excoriation disorder (skin picking), are the most prevalent conditions in this category. They share a driven, repetitive behavioral quality with OCD compulsions and present similar treatment challenges.
OCD vs. Generalized Anxiety Disorder
The condition most frequently confused with OCD in clinical and general settings is generalized anxiety disorder (GAD). The two disorders share a surface-level quality — both involve excessive, unwanted mental activity that causes distress — but differ in several important ways (American Psychiatric Association, 2022).
The ego-dystonic nature of OCD obsessions is particularly diagnostic. A person with OCD is distressed by their thoughts precisely because those thoughts conflict with who they are and what they want. A person with harm OCD who fears harming their child is not someone who wishes to harm their child — the thought is alien to their identity. By contrast, GAD worries, while excessive, are connected to things the person genuinely cares about: finances, relationships, health, and performance. The person with GAD worries about things they wish would go well; the person with OCD is horrified by things they desperately wish would not happen.
Additionally, the behavioral responses differ. OCD generates highly specific, often ritualized compulsive patterns — particular sequences, numbers, or types of behaviors tied to the specific obsessional content. GAD generates more varied behavioral attempts to cope, primarily reassurance-seeking and preparation.
A note on perfectionism: Perfectionism itself is not a DSM diagnostic criterion, but individuals with OCD tend strongly toward rigidity, a high need for certainty, and discomfort with ambiguity. A person can be highly perfectionistic without having OCD and can have OCD without being a perfectionist, but the two frequently co-occur. This overlap has clinical relevance because perfectionism can become a vehicle through which OCD infiltrates the treatment itself, as patients attempt to perform their exposure homework "correctly" in a way that becomes its own compulsion.
Assessing OCD
When Does OCD Appear?
OCD can emerge at virtually any point across the lifespan, from preschool through adulthood. Research identifies two particularly common onset windows: between ages 8 and 12 and between late adolescence and early adulthood (Stein et al., 2025; Ziegler et al., 2021). The stress-diathesis model offers a useful framework for understanding this pattern: individuals with a genetic predisposition to OCD will typically not develop the full disorder until they encounter a meaningful life stressor. For most people, the physiological and psychosocial changes of puberty represent sufficient stress to trigger symptom onset, even without any specifically traumatic experience. Parents of children later diagnosed with OCD often report noticing precursor traits — rigidity, perfectionism, difficulty with transitions — from early in their child's development, long before those traits crystallized into clinically significant OCD.
The gap between symptom onset and formal diagnosis presents a significant public health challenge. On average, individuals wait approximately 13 years from the emergence of their first OCD symptoms to receiving a diagnosis (Ziegler et al., 2021). The interval from diagnosis to treatment is further extended, averaging approximately a year and a half (Ziegler et al., 2021). The combined effect is that individuals with OCD may spend a decade and a half or more living with a treatable condition before accessing an effective intervention. Contributing factors to this delay include the disorder's stigma, the private nature of obsessional content, and widespread lack of OCD-specific training even among mental health professionals.
Assessment
The gold-standard instrument for OCD assessment is the Yale-Brown Obsessive Compulsive Scale (Y-BOCS), a clinician-administered tool consisting of a detailed symptom checklist followed by a severity scale with established research-validated diagnostic cutoffs (Scahill et al., 1997). The Y-BOCS is broadly accepted within the field as the preferred assessment tool — a degree of consensus unusual in mental health assessment, where many comparable disorders have numerous competing instruments. Administering the full Y-BOCS takes between 30 and 60 minutes, depending on the clinical context.
Image: Standard OCD assessment framework including clinical interviews, the Yale-Brown Obsessive Compulsive Scale (Y-BOCS), and its child version (CY-BOCS), the latter validated by Scahill et al. (1997).

The Y-BOCS serves two distinct functions. The symptom checklist component comprehensively surveys the full range of OCD symptom types, frequently helping patients recognize the breadth and interconnectedness of their symptoms — an exercise that is itself therapeutically valuable, since many patients have not previously understood their disparate experiences as manifestations of a single disorder. The severity scale component quantifies the impact of the obsessions and compulsions on the patient's daily life, providing a baseline against which treatment progress can be tracked. Re-administering the severity scale every few weeks allows clinicians and patients to monitor symptom reduction in a concrete, measurable way.
For younger patients, the Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS) provides a developmentally appropriate parallel instrument (Scahill et al., 1997). The CY-BOCS is child-assessed rather than purely clinician-administered, accommodating the developmental differences in how children report and understand their symptoms.
Comprehensive assessment goes beyond the Y-BOCS alone. Clinical interviews help identify comorbid diagnoses (which are common in OCD), assess the family environment (particularly important when working with children and adolescents), and develop a neuropsychological profile of the individual's cognitive and emotional functioning. For clinicians who need a briefer initial screen, shorter instruments such as the Florida Obsessive Compulsive Inventory (FOCI) can be administered quickly, though they do not replace the Y-BOCS for comprehensive assessment purposes.
Treatment
Research on OCD treatment is unusually well-organized and convergent. There is broad expert consensus that cognitive behavioral therapy (CBT) incorporating Exposure and Response Prevention (ERP) is the most effective treatment currently available (American Psychiatric Association, 2022). ERP alone produces symptom reductions of 60 to 80 percent. Pharmacotherapy, primarily using selective serotonin reuptake inhibitors (SSRIs), produces symptom reductions of approximately 40 to 60 percent. A third evidence-based option, particularly relevant for children, is Supportive Parenting for Anxious Childhood Emotions (SPACE), a parent-based approach found to be efficacious, comparable, and non-inferior to direct CBT (Lebowitz et al., 2020).
Image: Evidence-based OCD treatments including CBT with ERP (60-80% symptom reduction), SSRI pharmacotherapy (40-60% reduction), and the SPACE parent-based program (non-inferior to CBT; Lebowitz et al., 2020).

The relative advantages of ERP over pharmacotherapy deserve elaboration. While ERP and SSRIs are both effective, ERP yields benefits that persist beyond the treatment period, whereas pharmacotherapy produces benefits primarily while the medication is being taken. Withdrawal from medication typically results in symptom return. Additionally, SSRIs carry side effects and, in some cases, risks of physiological dependence. Clinical guidance generally favors initiating ERP as the first-line intervention. Medication is considered when: symptom severity significantly interferes with daily functioning; ERP alone has not produced an adequate response; symptoms are so severe that they prevent meaningful engagement with ERP; or the patient declines ERP.
The question of combined treatment has been examined in meta-analyses. The evidence suggests that ERP combined with SSRIs is marginally more effective than ERP alone, but the magnitude of the advantage is small and, in many studies, does not reach statistical significance. This evidence supports a stepwise approach: begin with ERP, add medication if needed, rather than defaulting to combination treatment from the outset.
The SPACE program merits particular mention because it inverts the conventional assumption that treating a child requires the child to be present in therapy. SPACE is a parent-based treatment in which the clinician works directly with parents — teaching them how to reduce accommodation of OCD symptoms and support the child's tolerance of anxiety — without necessarily seeing the child. Research has demonstrated that its effectiveness is comparable to direct CBT for childhood anxiety and OCD (Lebowitz et al., 2020).
ERP
Exposure + Response Prevention
Exposure and Response Prevention is a two-component protocol, and both components are essential. Removing either significantly reduces the intervention's effectiveness.
The exposure component involves deliberately and repeatedly confronting the thoughts, images, urges, situations, or stimuli that provoke obsessional distress. This is not passive or accidental contact with feared stimuli; it is intentional, purposeful, and structured. Exposures are most effective when designed to generate genuine discomfort, not a sterile or intellectualized approximation of it.
The response prevention component involves actively choosing not to perform the compulsion in response to the triggered anxiety. Rather than washing, checking, seeking reassurance, counting, or engaging in mental rituals, the person allows the anxiety to persist and observes that it naturally diminishes over time without any intervention. This process of riding the discomfort — commonly described as "riding the wave" — is the mechanism through which OCD loses its power. Performing the compulsion, even once, "spoils" the exposure by interrupting the anxiety's natural decline and reinforcing the false belief that the compulsion was necessary.
ERP Treatment
The ERP treatment protocol follows a structured, sequenced process (American Psychiatric Association, 2022):
- Psychoeducation about the diagnosis and treatment — helping the patient understand what OCD is, what ERP is, and why it works.
- Establishing treatment goals — clarifying what the patient wants their life to look like without OCD.
- Developing a treatment plan collaboratively — ensuring the patient has genuine ownership and investment in the process.
- Creating an exposure hierarchy or menu — listing the patient's fears in order from least to most anxiety-provoking, providing a structured roadmap for treatment.
- Practicing exposures in session — building the patient's confidence and correct technique before independent practice begins.
- Between-session practice (homework) — the primary driver of improvement, in which the patient independently conducts exposures in their daily life.
- Response prevention plans — developing specific strategies for managing compulsive urges when practicing independently.
Psychoeducation is not merely introductory. For patients who have never received an accurate conceptualization of their disorder, learning about OCD is itself a significant intervention. Clinicians often observe that patients experience relief simply from understanding that their seemingly bizarre or alarming experiences are recognized symptoms of a well-characterized disorder with effective treatment.
Establishing the exposure hierarchy is a collaborative process. The hierarchy typically begins with situations or stimuli that provoke only mild to moderate anxiety and progresses toward the most feared scenarios. This graduated approach (as opposed to flooding, which begins with the most difficult exposures) is the standard clinical recommendation. While flooding may produce faster results, most patients find a graduated approach more tolerable and are more likely to engage and persist in treatment.
The bulk of therapeutic change occurs outside the session, in the patient's independent practice. If the patient does not conduct exposures between sessions, symptom improvement will be minimal. This reality requires clinicians to invest significantly in building motivation, providing a clear homework structure, troubleshooting obstacles, and monitoring adherence.
The final stage — relapse prevention — is as important as the active treatment phase. Patients need a clear plan for responding when symptoms return, as they often do during periods of stress. A patient who understands that symptom recurrence does not mean treatment failure and who knows how to restart the exposure process independently has a fundamentally different prognosis than one who is discharged without this preparation.
Examples: Fear Learning and Safety Learning
The rationale for ERP rests on two contrasting models of how anxiety changes over time in response to feared triggers.
Image: Fear learning: repeated avoidance of a feared trigger causes the baseline anxiety level to rise over time, as each encounter-and-escape cycle reinforces the threat value of the stimulus.

Image: Safety learning: when feared triggers are faced without avoidance or compulsion, anxiety peaks and then naturally declines; with repeated exposures, each successive peak is lower, reflecting the acquisition of safety information.

When a feared trigger is encountered, and the response is avoidance or compulsion, anxiety spikes and then falls — but incompletely, returning to a baseline somewhat higher than before. Over time, repeated cycles of avoidance produce a gradual escalation of overall anxiety, so that the disorder becomes progressively more impairing. This is fear learning: the nervous system learns that the trigger is genuinely threatening because the person keeps running from it.
Safety learning is the alternative process, and it is the mechanism ERP is designed to cultivate. When a trigger is encountered, and the person does not avoid or engage in compulsion, anxiety spikes and may even increase briefly. But without escape, anxiety reaches its maximum and then declines naturally, following the physiological arc of an anxiety response. The next time the trigger is encountered, the anxiety peak is somewhat lower. Over many repeated exposures, the baseline anxiety associated with the trigger diminishes substantially. The nervous system has learned that the trigger is not genuinely dangerous — that the feared catastrophe did not occur. This is the informational foundation on which recovery is built.
ERP for OCD Hierarchy: Sample Case
The application of the exposure hierarchy is illustrated in the following example from a patient with harm OCD centered on the fear of poisoning a family member.
Image: Sample exposure hierarchy for harm OCD (fear of poisoning): steps progress from low-responsibility food contact (watching others cook) to high-responsibility direct cooking for family members, illustrating graduated exposure from least to most fear-provoking.

At the bottom of this hierarchy — the point of least anxiety — is watching a video of someone else cooking. This presents the feared context (food preparation) with minimal personal responsibility. As they progress upward through the hierarchy, the patient eventually reaches the highest level: cooking for their own family. At this level, the patient is directly responsible for the safety of loved ones — the maximal feared outcome. The hierarchy allows the clinician and patient to incrementally build evidence of safety, with each successful step reducing the overall threat valence of the feared scenario.
A critical clinical consideration is whether to use in-vivo (real-life) or imaginal exposures. In vivo exposures are more ecologically valid and closely replicate real-world conditions. However, some feared scenarios are impractical, impossible, or unethical to replicate in real life. A patient with a fear of harming a loved one cannot be asked to simulate that harm; a patient with a fear of jumping from a window cannot safely practice that fear literally. In these cases — which are common in harm OCD, taboo OCD, and other subtypes — imaginal exposures are used. In an imaginal exposure, the clinician guides the patient to vividly imagine the feared scenario in detail, using all five senses, sometimes incorporating a written script or trance techniques to deepen immersion. Imaginal exposures have several advantages: they can be conducted at any time, varied and extended beyond what real life allows, and adapted to feared scenarios that have no real-world analog. According to the presenter, imaginal exposures comprise the majority of exposures used in clinical practice.
Obstacles to Proper Diagnosis and Treatment
Despite the availability of highly effective treatment, many individuals with OCD go years or decades without receiving it. Multiple overlapping barriers account for this gap (Ziegler et al., 2021).
Stigma is a primary obstacle, especially when symptoms fall into taboo categories. A patient who is terrified that they might harm a child, commit incest, or act on a sexual thought they find abhorrent is profoundly unlikely to disclose that symptom without assurance of a non-judgmental clinical environment. The secrecy this engenders delays both diagnosis and treatment.
Lack of public awareness compounds stigma. Even when individuals suspect that their experiences might be symptoms of a diagnosable condition, they may not have access to accurate information about what OCD looks like, how it is diagnosed, or where to find help. Cultural context is relevant here as well: in communities where seeking mental health treatment is itself stigmatized, individuals may face significant social pressure against disclosure or help-seeking.
Lack of proper training among health professionals is a particularly consequential barrier. Research indicates that primary care physicians are no more likely than untrained laypersons to correctly identify OCD when it presents in their practice. This level of diagnostic miss among front-line healthcare providers means that many individuals who do seek care receive incorrect diagnoses or inappropriate treatment. Clinicians who work with OCD are encouraged to seek out specialty training rather than applying general anxiety treatment protocols, because the clinical presentation and the effective intervention differ meaningfully.
Difficulty finding specialists and financial constraints are interconnected practical barriers. OCD specialists with adequate training are not evenly distributed geographically, often have long waiting lists, typically charge higher fees, and frequently do not accept insurance. These structural factors disproportionately affect individuals with fewer resources, creating inequitable access to effective care.
Summary
OCD is a potentially debilitating mental health condition that affects approximately 2 to 3 million adults and approximately half a million children in the United States (Stein et al., 2025). Despite its severity and prevalence, it is highly treatable. CBT with ERP produces symptom reductions of 60 to 80 percent, making it one of the most effective interventions in all of mental health treatment. SSRIs and parent-based treatments offer additional evidence-based options that expand the range of patients who can benefit. At the same time, numerous barriers — stigma, limited professional training, geographic and financial constraints — prevent many individuals from accessing the care that could substantially relieve their suffering.
The goals of this course have been to provide participants with a foundation in what OCD is: its diagnostic definition, its two primary symptoms (obsessions and compulsions), its range of subtypes, and how it differs from related and superficially similar conditions. Participants have also been introduced to the fundamental stages of ERP, the mechanics of fear learning and safety learning, and the assessment tools used to characterize and track symptom severity. With this foundation, practitioners are better positioned to recognize OCD in their caseloads, to refer appropriately to specialists, and to begin building the specialized clinical skills that effective OCD treatment requires.
For additional resources, the International OCD Foundation (IOCDF) provides extensive educational material, clinician referral directories, and current research summaries at iocdf.org.

References
American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787
Brierley, M. E. E., Thompson, E. M., Albertella, L., & Fontenelle, L. F. (2021). Lifestyle interventions in the treatment of obsessive-compulsive and related disorders: A systematic review. Psychosomatic Medicine, 83(8), 817-833. https://doi.org/10.1097/PSY.0000000000000984
Jalal, B., Chamberlain, S. R., & Sahakian, B. J. (2023). Obsessive-compulsive disorder: Etiology, neuropathology, and cognitive dysfunction. Brain and Behavior, 13(6), e3000. https://doi.org/10.1002/brb3.3000
Lebowitz, E. R., Marin, C., Martino, A., Shimshoni, Y., & Silverman, W. K. (2020). Parent-based treatment as efficacious as cognitive behavioral therapy for childhood anxiety: A randomized noninferiority study of supportive parenting for anxious childhood emotions. Journal of the American Academy of Child & Adolescent Psychiatry, 59(3), 362-372. https://doi.org/10.1016/j.jaac.2019.02.014
Scahill, L., Riddle, M. A., McSwiggin-Hardin, M., Ort, S. I., King, R. A., Goodman, W. K., & Leckman, J. F. (1997). Children's Yale-Brown Obsessive Compulsive Scale: Reliability and validity. Journal of the American Academy of Child & Adolescent Psychiatry, 36(6), 844-852. https://doi.org/10.1097/00004583-199706000-00023
Stein, D. J., Ruscio, A. M., Altwaijri, Y., Chiu, W. T., Sampson, N. A., Aguilar-Gaxiola, S., ... Kessler, R. C. (2025). Obsessive-compulsive disorder in the World Mental Health surveys. BMC Medicine, 23(1), 416.
Steinberg, J. S., Morris, S. H., & Jaffee, S. R. (2025). 'Excessive and unreasonable': The relation between clinical insight and clinical correlates and treatment outcomes in obsessive-compulsive disorder across the life course. Child Psychiatry & Human Development, 56(1), 192-200.
Ziegler, S., Bednasch, K., Baldofski, S., & Rummel-Kluge, C. (2021). Long durations from symptom onset to diagnosis and from diagnosis to treatment in obsessive-compulsive disorder: A retrospective self-report study. PLOS ONE, 16(12), e0261169. https://doi.org/10.1371/journal.pone.0261169

D'Souza, J. (2026). A Comprehensive Introduction to the Diagnosis and Treatment of Obsessive-Compulsive Disorder. Continued Counseling, Article 131. Available at www.continued.com/counseling.
Feb 4, 2026
1 CE Credit
Supporting Queer and Trans Clients in the Current Political Climate: Ethical Dilemmas and Interventions in Trying Times
Giselle Levin, PsyD
This text-based course is an edited transcript of the webinar, Supporting Queer and Trans Clients in the Current Political Climate: Ethical Dilemmas and Interventions in Trying Times, presented by Giselle Levin, PsyD on October 6, 2025.
Course Overview
This course provides a comprehensive examination of the current sociopolitical landscape affecting queer and transgender clients in the United States. It explores the profound impact of anti-transgender legislation, media rhetoric, and healthcare bans on the mental health and psychosocial functioning of gender-diverse individuals. Through the lens of minority stress theory and clinical case studies, the course outlines specific ethical dilemmas mental health providers face, including issues related to detransition, "Do-It-Yourself" (DIY) hormone therapy, and documentation safety. Ultimately, it provides clinicians with actionable interventions and advocacy strategies to support client resilience and navigate these complex challenges.
Course Information
Giselle Levin, PsyD (they/she/he), is a licensed psychologist in the state of California specializing in transgender healthcare and sex therapy. Giselle completed their doctorate at Pace University in New York, NY, and trained as a postdoctoral resident in LGBT mental health at the San Francisco VA Medical Center. They currently work as a gender specialist at the University of California San Francisco - Child and Adolescent Gender Center. Giselle is a member of UCSF’s Mind the Gap consortium of gender-affirming providers for youth and is in the process of completing their AASECT sex therapy and WPATH transgender healthcare certifications.
Disclosures
- Presenter Disclosure:
  - Financial: Dr. Giselle Levin, PsyD received an honorarium for presenting this course. Giselle Levin has published articles on transgender healthcare, sex therapy, multiple minority stress, and adapting evidence-based interventions for marginalized populations.
  - Non-financial: Giselle Levin has no relevant non-financial relationships to disclose.
- Content Disclosure: This learning event does not focus exclusively on any specific product or service.
- Sponsor Disclosure: There is no external sponsor for this course.
Limitations/Risks
- Practitioners should cultivate cultural humility and cultural competence while committing to respect the diverse ethical and legal obligations associated with different regions and cultures.
- This course is geared toward mental health professionals who already possess fundamental knowledge and skills necessary to work with LGBT individuals.
- Ensure that you have adequate training prior to working with the above populations; consult or refer out as necessary.
- You are ethically required to refer out if you hold significant negative bias toward LGBT individuals.
- Reparative/conversion therapy is unethical and harmful.
Ethics Codes
Below are links to Ethics Codes for some of the major behavioral health professions. Please ensure you always refer to your own ethical code.
- AAMFT: https://www.aamft.org/Legal_Ethics/Code_of_Ethics.aspx
- ACA: https://www.counseling.org/resources/aca-code-of-ethics.pdf
- APA: https://www.apa.org/ethics/code
- NBCC: https://nbcc.org/assets/ethics/nbcccodeofethics.pdf
- NAADAC: https://www.naadac.org/code-of-ethics
- NASW: https://www.socialworkers.org/About/Ethics/Code-of-Ethics/Code-of-Ethics-English
Learning Outcomes
After this course, participants will be able to:
- Explain at least three reasons for increased mental health concerns in queer and trans clients, including substance use, depression, suicidality, anxiety, self-harm, and disordered eating.
- Analyze ethical conflicts and considerations when working with queer and trans clients, including youth and their families.
- Identify two interventions that can be used with queer and trans clients to mitigate the impact of minority stress on mental health.
Current Climate
It's Going Down in History...
The current sociopolitical environment in the United States and globally is characterized by a significant intensification of rhetoric and policy directed against transgender and gender-diverse individuals. Providers and clients alike are navigating a period that some historical records may eventually classify as a time of persecution. For example, Wikipedia currently hosts an article titled "Persecution of transgender people under the second Trump administration," highlighting the severity with which these legislative and social shifts are being documented and perceived.
The rhetoric has shifted dangerously from pathologizing transgender individuals as "mentally ill" to framing them as "actively malicious" or as "terrorists." This progression—from stigmatization to dehumanization—is a known trajectory in the persecution of marginalized groups. This dehumanization manifests in several specific ways:
- Removal of Legal Rights: There are active efforts to strip transgender individuals of legal protections and recognition.
- Purge of Trans Government Employees: Reports indicate threats to the careers of transgender individuals working within the federal government and military sectors.
- Restriction on Passports and International Travel: New policies and proposals threaten the ability of transgender people to travel freely and safely.
- Promotion of Trans Healthcare Misinformation: Major news outlets, including those traditionally viewed as progressive, have published articles that question the validity and safety of gender-affirming care, causing confusion even among supportive allies.
- Attempts to Shut Down and Intimidate Providers: Clinics providing gender-affirming care (GAC) face threats to funding and legal intimidation, leading some to close or cease services.
- Portrayal of Trans People as Social Threats: The framing of transgender individuals, particularly trans women, as threats to women and children contributes to a hostile social environment.
Passport Updates
The ability to obtain accurate identification documents is a critical component of safety and social functioning for transgender individuals. Recent executive orders and legal challenges have centered on the inclusion of "biological sex" on passports, threatening to reverse progress made in allowing gender markers that align with an individual's identity (such as "X" markers or allowing self-selection of "M" or "F").
While lower courts have blocked some discriminatory policies, allowing some individuals to successfully update their documents, the threat of reversal remains. For example, a transgender man who passes as cisgender male may have a driver's license with an "M" marker. If his passport were forced to revert to an "F" marker based on birth assignment, international travel would become dangerous. Presenting a passport with a female marker while appearing phenotypically male in countries with strict gender laws or hostile climates could lead to harassment, detainment, or violence.
Furthermore, these restrictions impact families. Parents of transgender children express profound fear regarding travel. A parent of a six-year-old transgender girl, who has socially transitioned and lived as a girl for years, may fear that traveling internationally could result in accusations of child abuse or the removal of the child from their custody if documents do not align with the child's presentation. These fears effectively trap families within the country, limiting their freedom of movement.
State-by-State Map for GAC Youth Bans
The legal landscape regarding gender-affirming care for youth is a patchwork of bans, restrictions, and protections that varies significantly by state. It is crucial for providers to understand that the bans targeting gender-affirming care often prohibit treatments that are deemed medically necessary by every major medical association in the country.
A critical ethical and legal distinction exists regarding these bans: the medications being banned for gender-affirming care are often legal and routinely prescribed for other conditions. For instance, puberty blockers (GnRH analogues) are the standard treatment for precocious puberty (puberty occurring too early). A child with precocious puberty can access these medications with standard parental consent. However, in states with bans, a transgender child seeking the exact same medication to pause puberty for gender-affirming purposes—a fully reversible intervention—is denied access. This highlights the discriminatory nature of the legislation, which targets the identity of the patient rather than the safety of the medication.

Image Caption: As of 2025, over 25 states have enacted bans on best practice medical care for transgender youth, with some states making it a felony crime to provide such care (Movement Advancement Project, 2025).

As illustrated in the map above, the legal status of care is volatile:
- Felony Crime to Provide Care: Enacted in states such as North Dakota, Oklahoma, Idaho, Alabama, South Carolina, and Florida.
- Bans to Provide Care: Enacted in over 20 states including Texas, Utah, Georgia, and North Carolina.
- Protections: States like California, New York, and Minnesota have enacted "shield laws" or remain states where care is legal.
However, legality does not guarantee access. Even in "green" states, clinics may face immense pressure to stop providing care due to funding threats or harassment.

Other GAC Updates
Beyond state laws, other systemic threats are eroding access to care:
- Surgical Centers: Many surgical centers have voluntarily stopped providing care to youth under 19, even in states where it remains legal for those under 18 with parental consent. This age limit is often a reaction to executive orders or fear of litigation rather than clinical guidelines.
- Clinic Closures: Some major medical centers have shut down their gender health programs entirely due to political pressure, effectively abandoning patients who rely on them for hormone management and mental health support.
- Funding Threats: There are ongoing threats that the Centers for Medicare & Medicaid Services (CMS) could withdraw federal funding from hospitals that provide gender-affirming care. Because most major hospitals rely on CMS funding for their general operations, this threat endangers the financial viability of entire medical institutions, forcing them to choose between financial survival and providing specialized care.
Tracking Anti-Trans Legislation
Given the rapid changes in legislation, mental health providers must stay informed about the laws in their specific jurisdiction. Reliable resources for tracking this information include:
- Erin in the Morning: An independent journalist providing an "Anti-Trans Legislative Risk Assessment Map" and frequent updates.
- ACLU: Tracks anti-LGBT bills moving through state legislatures.
- Trans Legislation Tracker: A comprehensive database of bills impacting transgender rights.
Impact on Patients
Increase in DSM-5 Symptoms & Decrease in Psychosocial Functioning
The hostile political climate has a direct and measurable impact on the mental health of queer and transgender clients. Clinicians are observing a rise in clinical symptoms and a decline in psychosocial functioning across the lifespan, from young children to older adults.
Commonly observed symptoms include:
- Depression and Anxiety: Exacerbated by chronic uncertainty and fear.
- Suicidality and Self-Harm: Rates are rising as hope for a safe future diminishes.
- Disordered Eating: Often linked to attempts to control body shape or suppress secondary sex characteristics.
- Somatic Complaints: Many children present with gastrointestinal (GI) issues, often linked to anxiety or avoiding school bathrooms due to safety concerns.
- School Refusal: Children are increasingly refusing to attend school due to bullying and lack of safe facilities.
- Social and Family Conflict: The political climate has polarized families, leading to rejection or conflict where there may previously have been tolerance.
- Decreased Job Performance: The stress of potential job loss (e.g., for military or government employees) impacts professional functioning.
Research supports these clinical observations. A study by Lee et al. (2024) found statistically significant increases in suicide attempts among transgender youth aged 13-17 in the first year after state-level anti-transgender laws were enacted. Furthermore, exposure to news about anti-transgender legislation is associated with higher levels of depression, anxiety, and physiological stress responses (Dhanani & Totton, 2023). Restar et al. (2024) also found that transgender adults living in states with hostile policy environments reported significantly higher symptoms of depression and anxiety compared to those in more protective states.
Understanding Increase in Symptoms
The correlation between the political landscape and mental health symptoms is driven by several factors:
- Reduced Access to Care: Patients fear losing access to hormones or puberty blockers. For a young person who has socially transitioned, the prospect of undergoing an endogenous puberty that contradicts their gender identity is terrifying.
- Bullying and Harassment: School environments have become increasingly hostile, with reports of physical assaults and death threats against queer students becoming more common.
- Job Instability: Transgender individuals in the military or federal sectors face the potential erasure of their careers.
- Media Exposure: Constant exposure to dehumanizing media rhetoric acts as a chronic stressor. While some clients may try to disconnect, many feel a need to monitor the news to assess threats to their safety ("knowing the hunter is out there").
- Fears of Future Discrimination: Anxiety is often future-oriented, focused on the potential for forced detransition, family separation, or the need to flee the country.
Minority Stress Theory
Minority Stress Theory provides a framework for understanding how societal stigma translates into individual mental health outcomes. It posits that marginalized groups face chronic stress distinct from the general population.

Image Caption: The relationship between external stressors and internal psychological processes leading to adverse health outcomes (Testa et al., 2015).

As defined by Testa et al. (2015), the theory divides stressors into:
- Distal Stress Factors (External): These are objective events such as discrimination, rejection, victimization, and non-affirmation of identity.
- Proximal Stress Factors (Internal): These are the internal psychological processes resulting from the distal stressors, including internalized transphobia, expectations of rejection, and concealment of identity.
These factors combine to degrade mental and physical health, leading to higher rates of suicide and chronic illness.

Multiple Minority Stress
Clients often hold multiple marginalized identities, leading to compounded stress (intersectionality). Clinicians must consider the unique experiences of:
- BIPOC Communities: particularly Black, Indigenous, and Latinx transgender individuals who face racism alongside transphobia.
- Immigrant Communities: Undocumented families may fear that seeking gender-affirming care will draw attention to their immigration status.
- Religious Minorities: Jewish and Muslim transgender individuals may face rising antisemitism or Islamophobia in addition to transphobia.
- People with Disabilities: There is a high overlap between neurodivergence (specifically autism) and gender diversity. Attacks on disability rights and healthcare access further marginalize this population.
- Veterans: Those relying on the VA for care face specific anxieties regarding federal policy changes.
Increase in Disordered Eating
Disordered eating in the transgender population is often functionally different from that in cisgender populations. It can be a mechanism to manage gender dysphoria by altering the body. For example, starvation may be used to stop menstruation or reduce breast tissue development, while other behaviors might be used to reduce muscle mass or curves.
Research indicates that gender-affirming hormone therapy (GAHT) is protective against disordered eating. When individuals can access hormones that align their physical body with their gender identity, the need to use maladaptive eating behaviors to control their body often decreases. Conversely, losing access to GAHT may precipitate a relapse into disordered eating. Additionally, logistical barriers, such as the lack of safe bathrooms, can lead to restrictive behaviors (avoiding food and water) to prevent the need to use the restroom during the school or work day.

The Dangers of Conversion Therapy
With the restriction of affirmative care, some political factions promote "conversion" or "reparative" therapy as an alternative. This practice attempts to change a person’s sexual orientation or gender identity.
Data from the 2015 U.S. Transgender Survey highlights the extreme danger of this approach. Youth exposed to conversion therapy had a 55% increase in the risk of attempting suicide compared to those who were not. The risk of running away from home also doubled. These risks were highest for those exposed to the practice at a young age (between 11 and 14) (Campbell & van der Meulen Rodgers, 2023).
Mental health professionals have an ethical mandate to "Do No Harm." Engaging in or referring clients to conversion therapy violates this fundamental ethical principle.
Ethical Dilemmas

The current political climate creates complex ethical dilemmas where legal mandates, client safety, and clinical best practices may conflict.

Can You Support Detransition?
Case Study: Jay Jay is an 80-year-old transfeminine nonbinary veteran who, after a lifetime of suppressing their identity, began estrogen therapy. They experienced great joy in developing a feminine body. However, due to economic factors, Jay lost their housing in San Francisco and had to move to a rural area in Oregon to afford a home. In this new environment, Jay perceived a high threat of transphobia and physical violence. Consequently, Jay decided to stop taking hormones and "detransition" to ensure their physical safety.
Ethical Consideration: Clinicians may struggle with supporting a client in stopping a treatment that clearly benefits their mental health. However, in this case, the detransition is driven by external safety concerns rather than an internal shift in identity. Research indicates that over 82% of individuals who detransition do so because of external factors like family rejection or societal stigma, rather than a realization that they are not transgender.
In this scenario, the clinician’s role is to respect the client's self-determination and safety needs. Supporting Jay involves validating the unfairness of the situation, helping them grieve the loss of their authentic expression, and prioritizing their physical safety and housing stability.

When Clients Choose to Go DIY
Case Study: Jasper Jasper is a 23-year-old trans man who wishes to take testosterone. However, he distrusts the medical establishment, fearing that a formal prescription could be tracked or cut off by future legislation. Instead, he obtains testosterone from an unregulated source ("DIY"). He wants to continue therapy to process the changes but refuses to see a medical provider for the hormones.
Ethical Consideration: This presents a dilemma regarding scope of competence and safety. A therapist cannot prescribe or manage medication. However, refusing to treat Jasper could alienate him from his only source of mental health support.
The recommended approach is harm reduction. Similar to working with a client who uses substances or engages in self-harm, the clinician does not condone the risky behavior but works to minimize danger. This involves:
- Acknowledging the client's valid fears of the medical system.
- Educating the client on the risks of unmonitored hormone use (e.g., polycythemia, liver strain).
- Encouraging any possible safety steps (e.g., "If you won't see a doctor for a prescription, would you consider getting blood work done at a private lab to check your levels?").
- Discussing safe injection practices.
Documentation & Ethics
With the Department of Justice and other entities issuing subpoenas for medical records of transgender patients, documentation has become a safety issue.
Key Questions for Clinicians:
- Diagnosis: Do you include a diagnosis of Gender Dysphoria (F64.0)? While necessary for insurance coverage, it can also serve as a flag in medical records. If a client is paying out of pocket or seeking therapy for unrelated issues (e.g., anxiety), is the diagnosis necessary?
- Names and Pronouns: Do you document the client's chosen name and pronouns in the official chart, or keep them in a separate "shadow" file? Documenting them validates the client but could expose them if records are seized.
- Relationship Status: How are same-sex partners documented?
Intervention: Adopt a consent-forward approach. Have transparent conversations with clients about documentation. Ask: "I want to respect your identity, but I also want to protect your privacy. Here are the risks and benefits of documenting your chosen name in the official record. What do you prefer?"

Should We Delay GAC?
Case Study: Molly Molly is a 16-year-old trans girl who has socially transitioned and is desperate to start estrogen. Her therapist and doctors agree it is medically appropriate. However, her parents, while affirming of her identity, are terrified of the political climate. They want her to wait until she is 18 or until the political situation stabilizes to ensure her safety.
Ethical Consideration: This is a conflict of values: Safety vs. Authenticity. The parents prioritize physical safety; Molly prioritizes the quality of her life and her authentic development.
Intervention: The clinician's role is to facilitate a values-based conversation. For Molly, living as a boy might feel like a fate worse than the risk of discrimination. The therapist can help the family navigate this by validating the parents' fear while highlighting that denying care also carries severe risks (e.g., suicidality, worsening dysphoria). The goal is to help the family find a consensus that respects the adolescent's developing autonomy and the reality of their dysphoria.

Can Therapists Be Political?
Historically, mental health professions encouraged neutrality. However, the current context challenges this stance.
- The Personal is Political: The DSM-5 itself is a sociopolitical document, not just a scientific one. The laws governing practice are political. Conceptions of mental health are shaped by societal values.
- Ethical Obligation: Hope and Puckett (2024) argue that mental health providers are ethically required to engage in advocacy. Silence in the face of legislation that harms clients can be complicit.
- Scope of Advocacy: Advocacy can take many forms, from voting and calling legislators to attending protests or simply creating a safe, affirming space in the therapy room.
Image Caption: Engaging in public advocacy is one form of ethical action for mental health providers (Image: G. Levin).
Recommendations

General Recommendations for Providers
1. Consultation: Do not make decisions in isolation. Consult with legal experts regarding state laws and with colleagues regarding ethical gray areas.
2. Avoid Rash Decisions: Do not preemptively strip all charts of pronouns or cease care based on rumors. Base actions on verified legal and clinical information.
3. Communication: Clearly communicate your stance on privacy and advocacy to your clients. Knowing their therapist is "on their team" is a vital intervention in itself.
4. Advocacy: Engage in advocacy appropriate to your capacity. "Be loud" where you can.
5. Self-Care: Vicarious trauma is real. Find your own sources of resilience and joy.
Building Rapport
- Explicit Allyship: Do not assume clients know you are safe. State clearly that you are committed to LGBT rights.
- Proactive Inquiry: Do not wait for the client to bring up the news. Ask: "I know there has been a lot of heavy news regarding trans rights lately. How is that impacting you?"
- Knowledge: Do not place the burden of education on the client. Stay informed about major legislative updates so the client does not have to explain basic news events to you.
Recommendations for Patients: The Crash Pad
Clinicians can use the metaphor of a "Crash Pad" with clients. If the client feels they are climbing a dangerous cliff (navigating society), they cannot control whether they fall (legislation/discrimination), but they can build a crash pad to catch them.
Components of a Crash Pad:
- Community: Connection with other trans people.
- Supportive Individuals: A trusted cousin, friend, or therapist.
- Affirming Environments: A workplace or hobby group where they are respected.
- Practices: Meditation, exercise, or art that grounds them.
- T4T Relationships: "Trans for Trans" relationships, where partners share a mutual understanding of the gendered experience, can be a profound source of safety and intimacy.
Image Caption: The "Crash Pad" intervention helps clients visualize and strengthen their support network.

Queer/Trans Joy as Resistance
While it is necessary to discuss trauma and safety, it is equally important to center Queer and Trans Joy. Encouraging clients to access joy—through community events, pride celebrations, or personal expression—is a form of resistance against a system that seeks their misery
Recommendations for Parents
Parents often ask how much they should share with their children about the political climate.
- Assess Capacity: Consider the child's age and emotional maturity.
- Assume Knowledge: Children often know more than parents realize through social media and peers.
- The "Need to Know" Approach: A parent can ask, "Do you want to know what is going on in the news, or do you want me to handle it?"
  - Example: A father asked his 12-year-old daughter this question. She replied that she just wanted to be a kid. The father agreed to carry the burden of political awareness and advocacy so she could focus on her childhood. This is a model of protective parenting.
Using a Values-Based Approach
When clients or families feel stuck, a values clarification exercise can be powerful.

Image Caption: Mapping conflicting values helps clients understand their decision-making process in complex situations.
Clinicians can help clients identify their core values (e.g., Authenticity, Safety, Family Harmony) and acknowledge that these values may currently be in conflict. There is no single "right" answer; different clients will prioritize different values (like Jay choosing safety vs. Molly choosing authenticity).

Resources
Providing clients with concrete resources is an essential intervention.
- Relocation and Logistics:
  - Keshet Move to Thrive: Offers interest-free loans for relocation.
  - Project Open Arms: Resettlement project for trans families.
  - Elevated Access: Volunteer pilots providing free transportation to states with legal healthcare access.
- Legal and Support:
  - Trans Family SOS: Guiding families through legal and medical navigation.
  - Trevor Space: Online community for LGBTQ youth.
  - Human Rights Campaign: Emergency funds and resources.
References
American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). American Psychiatric Association. https://doi.org/10.1176/appi.books.9780890425787
Campbell, T., & van der Meulen Rodgers, Y. (2023). Conversion therapy, suicidality, and running away: An analysis of transgender youth in the US. Journal of Health Economics, 89, 102750. https://doi.org/10.1016/j.jhealeco.2023.102750
Dhanani, L. Y., & Totton, R. R. (2023). Have you heard the news? The effects of exposure to news about recent transgender legislation on transgender youth and young adults. Sexuality Research and Social Policy, 20(4), 1345-1359. https://doi.org/10.1007/s13178-023-00869-7
Hope, D. A., & Puckett, J. A. (2024). Bans on evidence-based care for transgender and gender diverse people present risks for clients and dilemmas for mental health providers. Cognitive and Behavioral Practice, 31(1), 15-19. https://doi.org/10.1016/j.cbpra.2023.08.001
Lee, W. Y., Hobbs, J. N., Hobaica, S., DeChants, J. P., Price, M. N., & Nath, R. (2024). State-level anti-transgender laws increase past-year suicide attempts among transgender and non-binary young people in the USA. Nature Human Behaviour, 8(11), 2096-2106. https://doi.org/10.1038/s41562-024-01928-0
Movement Advancement Project. (2025). Healthcare laws and policies: Bans on best practice medical care for transgender youth [PDF]. Movement Advancement Project. https://www.lgbtmap.org/img/maps/citations-youth-medical-care-bans.pdf
Restar, A., Layland, E. K., Hughes, L., Dusic, E., Lucas, R., Bambilla, A. J., & Kershaw, T. (2024). Antitrans policy environment and depression and anxiety symptoms in transgender and nonbinary adults. JAMA Network Open, 7(8), e2431306. https://doi.org/10.1001/jamanetworkopen.2024.31306
Testa, R. J., Habarth, J., Peta, J., Balsam, K., & Bockting, W. (2015). Development of the Gender Minority Stress and Resilience Measure. Psychology of Sexual Orientation and Gender Diversity, 2(1), 65-77. https://doi.org/10.1037/sgd0000081

Citation
Levin, G. (2025). Supporting Queer and Trans Clients in the Current Political Climate: Ethical Dilemmas and Interventions in Trying Times. Continued - Counseling, Article 118. Available at www.continued.com/counseling
Oct 6, 2025
1 CE Credit
ADHD and Women: Ethical and Practice Implications for Clinical Providers
Christina Marsack-Topolewski, LMSW, PhD, MSW
This text-based course is an edited transcript from a live webinar presented by Christina Marsack-Topolewski, PhD, MSW, LMSW.
Introduction
It is a pleasure to present this comprehensive overview of ADHD and its ethical and practical implications for clinical providers working with women. The number of women diagnosed with Attention-Deficit/Hyperactivity Disorder continues to increase, bringing to light a unique set of challenges and considerations. Women frequently manage a multitude of life responsibilities and demands, which can present significant daily hurdles when coupled with ADHD. Living with ADHD can affect nearly every aspect of life, including one's professional life, financial stability, educational pursuits, the experience of motherhood, and other interpersonal relationships.
Furthermore, for women navigating life with ADHD, these challenges can be compounded by the presence of co-occurring conditions. This article will provide a framework for understanding the distinct complexities and journeys that women with ADHD often encounter. It will also discuss various interventions, strategies, and resources designed to support women with ADHD and their loved ones, acknowledging that the impact of ADHD extends beyond the individual to their entire relational network.
Learning Outcomes
After engaging with this material, participants will be able to:
- Identify the characteristics, signs, and symptoms of ADHD in adulthood that are unique to women.
- Describe co-occurring conditions commonly experienced by women with ADHD.
- Explain practical and evidence-based strategies to support women with ADHD and their loved ones.
Limitations and Risks
Supporting women with ADHD can be complex, and their coinciding needs can be wide-ranging. This discussion will not cover every aspect of these topics. Therefore, continued and additional training and education on this topic are recommended. Treatment and approaches to support individuals with ADHD and other comorbid challenges do not coincide with a one-size-fits-all approach. Practitioners should engage in cultural humility at all times and acknowledge cultural variations in mental health and treatment. Adequate support often requires the use of a multi-disciplinary team to ensure comprehensive treatment.
What is ADHD?
According to the guidelines from the American Psychiatric Association’s Diagnostic and Statistical Manual, Fifth Edition (DSM-5), the criteria for individuals ages 17 and older include:
“Frequent inattention, seen through at least five of the following, for at least six months, in a way that is inappropriate developmentally”:
- Careless mistakes and lack of close attention to detail
- Difficulty paying attention on tasks
- Does not listen when addressed
- Gets too side-tracked to finish chores or workplace duties
- Loses materials or equipment necessary for tasks
- Forgetfulness in daily living
- Difficulty in organizing tasks
- Easily distracted; daydreaming
- Difficulty or dislike of work that requires sustained mental effort
- Procrastination
(American Psychiatric Association, 2022)
Continued - What is ADHD?
Per the guidelines from the American Psychiatric Association’s Diagnostic and Statistical Manual, Fifth Edition (DSM-5), the criteria for individuals ages 17 and older also include:
“Frequent hyperactivity and impulsivity, seen through at least five of the following, for at least six months, in a way that is inappropriate developmentally”:
- Fidgeting, squirming, tapping
- Leaves seat when expected to sit
- Running or climbing at inappropriate times, feelings of restlessness
- Inability to play quietly
- Is often “on the go” and/or “driven by a motor”
- Talks excessively
- Blurting out responses
- Trouble waiting for turn
- Interrupting, intruding in conversations
Note: Six or more symptoms of inattention and/or hyperactivity-impulsivity are required for children up to age 16.
(American Psychiatric Association, 2022)
These diagnostic criteria provide a foundational understanding of ADHD. However, it is crucial to recognize that the manifestation of these symptoms can differ significantly between genders, particularly in adulthood. For individuals over the age of 17, the presence of at least five symptoms in either the inattention or hyperactivity-impulsivity domain, persisting for at least six months in a developmentally inappropriate manner, is indicative of ADHD. The impact of these symptoms on daily functioning across multiple settings is also a key diagnostic consideration.
ADHD Symptoms
Other symptoms commonly observed include:
- Poor time management (e.g., trouble multitasking)
- Emotional dysregulation (e.g., frequent/chronic stress, constant state of worry)
- Low frustration tolerance
- Mood swings
- Challenges focusing on a task
- Difficulties coping with stress
- Temper
(Mayo Foundation for Medical Education and Research, 2024)
When considering ADHD symptoms in adulthood, particularly for women, the challenges often extend beyond the core diagnostic criteria. Poor time management, including difficulties with multitasking, can profoundly impact adult life, where demands are often high and varied. Emotional dysregulation, manifesting as frequent stress, constant worry, or mood swings, can significantly affect an individual’s well-being and relationships. A low frustration tolerance can lead to interpersonal difficulties, especially in demanding roles such as parenting. Many women with ADHD report feeling overwhelmed by the daily tasks required to manage a household and career, often leading to internal frustration and self-criticism. The inability to focus on tasks and difficulties in coping with stress further exacerbate these challenges, contributing to a sense of being perpetually behind or unable to meet expectations.
ADHD in Adults
These conditions are required, too:
- Before age 12, must experience several inattentive or hyperactive-impulsive symptoms
- The symptoms must impact the person in at least two settings
- Clear evidence that the symptoms “interfere with or reduce the quality of” the person’s social, school and work activities
- Another mental disorder doesn’t better account for the symptoms
(American Psychiatric Association, 2013)
For an adult diagnosis of ADHD, it is essential to establish a developmental history of symptoms appearing before age 12. This underscores the understanding of ADHD as a neurodevelopmental disorder. Furthermore, the symptoms must be pervasive, affecting the individual in at least two significant settings, such as home, school, work, or social environments. This criterion highlights the functional impairment caused by ADHD, distinguishing it from transient difficulties. The impact must be clearly evident in a reduction of quality in social, academic, or occupational functioning. Finally, it is crucial to rule out other mental disorders that might better explain the symptoms, although co-occurring conditions are common and will be discussed further.
Symptoms may be common in women
- Racing thoughts
- Talking excessively
- Difficulty maintaining relationships
- “A scarred and wounded self-esteem”
- Stigma associated with their condition
(Holthe & Langvik, 2017)
Research indicates that certain ADHD symptoms are more commonly observed in women. These include racing thoughts, which can contribute to anxiety and overwhelm, and talking excessively, which may be a manifestation of internal hyperactivity. Difficulty maintaining relationships is a significant concern, often stemming from challenges with consistency, emotional regulation, or perceived social missteps. Many women with ADHD report a "scarred and wounded self-esteem," resulting from years of struggling with undiagnosed or misunderstood symptoms, leading to feelings of inadequacy or failure. The stigma associated with their condition further compounds these emotional burdens, often leading to shame and a reluctance to seek help or disclose their diagnosis. These gender-specific manifestations are crucial for clinicians to recognize for accurate diagnosis and tailored intervention.
Struggles Associated with Dysexecutive Functioning & ADHD
Visible:
- Running late, not making deadlines
- Presenting as “scattered”
- Outward aggression, frustration
Invisible:
- Self-esteem and self-efficacy implications
- Loneliness and isolation
- Internal frustration
- Anxiety
- Depression
The challenges associated with dysexecutive functioning in ADHD can be categorized into visible and invisible struggles. Visible struggles are those observable by others, such as consistently running late, failing to meet deadlines, appearing disorganized or "scattered," and exhibiting outward aggression or frustration. These external manifestations often lead to negative feedback from colleagues, family members, and friends, reinforcing feelings of inadequacy.
Invisible struggles, though less apparent to others, are deeply impactful. These include significant implications for self-esteem and self-efficacy, as women with ADHD may internalize their difficulties as personal failings rather than symptoms of a neurological condition. This can lead to profound feelings of loneliness and isolation, as the effort to maintain relationships becomes overwhelming or as perceived failures lead to withdrawal. Internal frustration is a constant companion, a silent battle against one's own cognitive processes. Furthermore, anxiety and depression are frequently co-occurring invisible struggles, often stemming from the chronic stress of managing ADHD symptoms and the emotional toll of perceived failures and social misunderstandings. Recognizing both visible and invisible struggles is essential for a holistic understanding of the impact of ADHD on women.
Masking of Symptoms
May mask in the following ways:
- Avoid interrupting others (by being quiet)
- Compensatory strategies to support routines and organization
- Exhibit perfectionistic tendencies
- Mirror what others do (e.g., this is common to other conditions and masking)
- Try very hard to focus and be overly conscientious
- Engage in substance misuse (e.g., this may hide/manage their symptoms in social environments)
- Engage in socially appropriate sports and physical activities – which may also mask symptoms
Masking can diminish the adverse effects of ADHD. Masking can be exhausting.
Masking is a common coping mechanism for women with ADHD, where they consciously or unconsciously hide their symptoms to conform to social expectations or avoid negative judgment. This can manifest in various ways, such as deliberately avoiding interrupting others by remaining quiet, even when they have something to contribute. Many develop elaborate compensatory strategies to maintain routines and organization, which, while effective in presenting a semblance of order, can be incredibly draining. Exhibiting perfectionistic tendencies is another form of masking, as an intense focus on flawless execution can be an attempt to overcompensate for perceived deficits in attention or organization. Mirroring the behaviors of others in social situations is also common, allowing them to blend in and avoid drawing attention to their struggles.
The effort to try very hard to focus and be overly conscientious is a constant internal battle, leading to significant mental fatigue. In some cases, individuals may engage in substance misuse as a maladaptive coping mechanism to hide or manage their symptoms in social environments, seeking to calm racing thoughts or reduce anxiety. Furthermore, engaging in socially appropriate sports and physical activities can also serve as a form of masking, as these activities may provide an outlet for hyperactivity or a structured environment that temporarily alleviates symptoms. While masking can temporarily diminish the adverse effects of ADHD in social or professional settings, it is an incredibly exhausting process that can lead to burnout, increased anxiety, and a profound sense of inauthenticity.
Executive Functioning
Executive functioning refers to a set of cognitive processes that are crucial for controlling behavior and operating effectively in daily life. These functions act as the "orchestra conductor" of the mind, enabling individuals to plan, organize, reason, and problem-solve. For individuals with ADHD, particularly women, challenges in executive functioning can profoundly impact various aspects of their lives.
Consider the intricate process of planning a trip: it involves booking flights, coordinating layovers, checking luggage, navigating security, and arranging accommodation and transportation. For a woman with ADHD, these seemingly straightforward tasks can become overwhelming due to difficulties with planning, sequential thinking, and managing multiple steps. If children are involved, the complexity escalates further, requiring meticulous organization of their belongings, car seats, and schedules. The ability to foresee potential issues, prioritize tasks, and maintain focus throughout such a multi-step process relies heavily on intact executive functions.
When executive functions are impaired, even routine daily activities can become monumental challenges. This can lead to visible struggles, such as missed deadlines and disorganization, and invisible struggles, including low self-esteem, internal frustration, and social isolation. Understanding the specific executive functioning deficits a woman with ADHD experiences is paramount for tailoring effective interventions. The goal is to develop strategies and coping mechanisms that support these cognitive processes, enabling her to navigate daily demands more effectively and enhance her overall quality of life. This includes recognizing and capitalizing on her strengths, as many individuals with ADHD possess remarkable creativity, quick thinking, and the ability to generate novel ideas, which can be leveraged in various settings, particularly in the workplace.
Diagnosis
Women in adulthood are equally likely to be diagnosed with ADHD as men.
- Misdiagnosis
- Underdiagnosis
- Overdiagnosis
- Late-diagnosis (Long & Coats, 2022)
The diagnostic landscape for ADHD presents unique considerations for women. While childhood diagnoses show a significant male-to-female ratio (approximately 3:1, with 75% boys compared to 25% girls), this ratio tends to equalize in adulthood. This suggests a notable pattern of underdiagnosis in girls during childhood, potentially due to masking behaviors, differing symptom presentations, or societal expectations that often lead to girls’ symptoms being overlooked or misattributed. Consequently, many women receive a late diagnosis in adulthood, often after years of struggling with unexplained difficulties and accumulating negative self-perceptions.
The phenomenon of misdiagnosis is also prevalent, as ADHD symptoms in women can overlap with or be mistaken for other conditions like anxiety, depression, or bipolar disorder. Conversely, there is also a concern for overdiagnosis in some contexts. The implications of late diagnosis are significant; women may miss out on early interventions and the development of effective coping strategies, leading to a cumulative impact on their self-esteem, relationships, and professional lives. The elevated demands of adulthood, such as managing careers, households, and families, can make undiagnosed or unmanaged ADHD particularly challenging, with potentially severe consequences like job loss or financial instability. Therefore, increased awareness among clinicians about the unique presentation of ADHD in women is crucial for timely and accurate diagnosis.
Prevalence of ADHD
- Childhood prevalence: 7.8 to 9.5% of children in the United States (Polancyznk et al., 2014)
- Adulthood prevalence: 4.4% of adults in the United States (Kessler et al., 2006)
- Global estimates:
- Persistent adult ADHD (with a childhood onset) = 2.58% or 139.84M in 2020
- Symptomatic adult ADHD (regardless of childhood onset) = 6.76% or 366.33M in 2020 (Song et al., 2021)
The prevalence of ADHD varies across different age groups and global regions. In the United States, childhood prevalence ranges from 7.8% to 9.5%, encompassing both boys and girls. For adults in the United States, the prevalence is estimated at 4.4%. Global estimates provide a broader perspective: persistent adult ADHD, defined as having a childhood onset, was estimated at 2.58% or approximately 139.84 million individuals in 2020. Symptomatic adult ADHD, which includes individuals regardless of childhood onset, showed a higher global prevalence of 6.76%, affecting around 366.33 million people in 2020. These figures underscore the widespread nature of ADHD across the lifespan and globally, emphasizing the importance of understanding its impact on diverse populations, including women. The disparity between childhood and adult prevalence, particularly the equalization of gender ratios in adulthood, highlights the need for continued research and clinical attention to how ADHD manifests and is diagnosed in women.
Propensity of ADHD
- About 2.5% of adults have ADHD (Simon et al., 2009); keep in mind other estimates indicate adults with ADHD comprise 2-4% of the population.
- Men’s and women’s rates of ADHD
- Men’s and women’s rates of risky/impulsive behaviors are similar.
- Women with persistent ADHD tended to be less likely to have hyperactive symptoms and to drive recklessly, but women had more anxiety (Cortese et al., 2016).
While general estimates suggest that about 2.5% to 4% of adults have ADHD, the gender-specific nuances are particularly insightful. As previously noted, the rates of ADHD diagnoses tend to equalize between men and women in adulthood, a significant shift from the childhood prevalence. Interestingly, research indicates that men and women with ADHD exhibit similar rates of risky or impulsive behaviors. However, a study by Cortese and colleagues (2016) found that women with persistent ADHD were less likely to present with overt hyperactive symptoms and were less prone to reckless driving compared to their male counterparts. This subtle difference in symptom presentation further contributes to the underdiagnosis of ADHD in women, as their hyperactivity may manifest more internally as racing thoughts or excessive talking rather than overt physical restlessness. A notable finding from this research is that women with ADHD often experience higher levels of anxiety, which aligns with broader population trends where women are more frequently diagnosed with anxiety disorders. This increased anxiety can complicate the clinical picture, sometimes leading to ADHD symptoms being overshadowed or misattributed to anxiety alone. Understanding these gender-specific propensities is vital for accurate assessment and tailored therapeutic approaches.
Co-Occurring Conditions in Women with ADHD
Co-occurring conditions
Adults with ADHD have a greater likelihood to experience other co-occurring conditions.
- Anxiety
- Autism spectrum disorder
- Depression
- Bipolar disorder
- Substance use disorder
(Micai et al., 2023; Pehlivanidis et al., 2020)
The presence of co-occurring conditions is a significant aspect of ADHD in adulthood, particularly for women. Research consistently demonstrates that adults with ADHD have a substantially higher likelihood of experiencing other mental health conditions. Common co-occurring conditions include anxiety disorders, which often manifest as chronic worry, panic attacks, or generalized anxiety. Autism spectrum disorder (ASD) can also co-occur with ADHD, presenting a complex diagnostic picture where symptoms of both conditions may overlap or exacerbate each other. Depression, including major depressive disorder, is frequently observed, often stemming from the chronic stress, emotional dysregulation, and interpersonal difficulties associated with unmanaged ADHD. Bipolar disorder is another condition that can co-occur, making differential diagnosis and treatment planning particularly challenging due to the fluctuating mood states. Finally, substance use disorders are also more prevalent among adults with ADHD, sometimes used as a maladaptive coping mechanism to self-medicate or manage overwhelming symptoms. Clinicians must be vigilant in screening for these co-occurring conditions to provide comprehensive and integrated care. A recent meta-analysis by Micai et al. (2023) highlighted the elevated risks, noting that adults with ADHD face five times the risk of comorbid anxiety, 4.5 times the risk of major depression, 8.75 times the risk of bipolar disorder, and 4.6 times the risk of substance use disorder compared to individuals without ADHD. This underscores the critical need for a thorough assessment that considers the full spectrum of potential co-occurring challenges.
Many domains of life impacted
ADHD in women can profoundly impact numerous domains of life, often due to the elevated social, employment, financial, relational, and functional demands placed on adults. The expectation to juggle multiple roles and responsibilities can become immensely overwhelming when compounded by ADHD symptoms.
- School and Work Life: Challenges in academic and professional settings are common. This can include difficulties with organization, time management, focus, and meeting deadlines, leading to underperformance, job changes, or unemployment. A study by Biederman et al. (2021) found that adults with ADHD were less likely to be currently employed (52% vs. 72% of peers without ADHD) and experienced more job changes over a decade (5.4 vs. 3.4). They also reported less satisfaction with family, social, and professional lives.
- Social Challenges: Intimate relationships, friendships, and peer interactions can be strained. Difficulties with listening, impulsivity in conversation, or inconsistency in plans can lead to misunderstandings and relationship breakdowns. Morley and Tyrrell (2023) found that female university students diagnosed with ADHD in adulthood reported significant social, academic, and psychological difficulties, including stigmatization and social discrimination.
- Family and Parenting: For women who are mothers, the demands of parenting can be particularly challenging. Managing household tasks, children's schedules, and personal needs while contending with ADHD symptoms can lead to immense frustration and feelings of inadequacy. The constant juggle often results in a feeling of being "at the bare bones" in terms of daily functioning, as one client described it, struggling to keep even basic necessities like milk in the fridge.
- Sleep Quality: Poor sleep hygiene is frequently reported, which further exacerbates ADHD symptoms and negatively impacts overall functioning and well-being.
The cumulative effect of these impacts can significantly diminish a woman's quality of life, highlighting the urgent need for tailored support that addresses the multifaceted nature of ADHD in adult women.
Case Example #1
Married mother of 4 struggles with ADHD (diagnosed in childhood), OCD, and anxiety. Spouse does not “believe in” mental health conditions. A lot of shame surrounding challenges. Mother has developed many coping strategies – still difficult. Balancing work, house obligations, and child rearing is immensely overwhelming.
This case illustrates the profound complexities faced by women with ADHD, particularly when compounded by co-occurring conditions and unsupportive family dynamics. The client, a married mother of four, grapples with a childhood diagnosis of ADHD, alongside obsessive-compulsive disorder (OCD) and profound anxiety. A significant barrier to her well-being is her spouse's disbelief in mental health conditions, which creates an environment of shame and discourages her from seeking or utilizing necessary support, including medication or therapy. Despite having developed numerous coping strategies since her early diagnosis and achieving professional success, the immense demands of balancing work, household obligations, and child-rearing have become overwhelmingly challenging. The added pressures of children's illnesses, childcare issues, or school breaks further intensify her struggles, especially within a traditional household where domestic responsibilities are primarily hers. This scenario highlights the critical need for interventions that not only address the client's symptoms but also navigate complex family systems and societal expectations.
Case Example #2
Female in early 40s, twice exceptional. Has childhood diagnosis of ADHD, anxiety. History of an eating disorder. Recent divorce – now back to the workforce. Recently single (now single mother of 3 children). New work position acquired around the time of her divorce. Struggling with meeting and juggling the multi-faceted needs of work, motherhood, home life, food in fridge. FMLA.
This case exemplifies the compounding stressors that can overwhelm a woman with ADHD, particularly during significant life transitions. The client, a female in her early 40s, is "twice exceptional," indicating both giftedness and a neurodevelopmental diagnosis. She has a childhood diagnosis of ADHD and anxiety, coupled with a history of an eating disorder. Her recent divorce has thrust her back into the full-time workforce after a significant hiatus, adding immense financial and logistical pressure. Now a single mother of three children, she finds herself struggling to meet the multifaceted demands of her new work position, motherhood, and maintaining a functional home life, to the extent that even basic tasks like keeping food in the refrigerator become a struggle. Her anxiety is heightened, and she experiences daydreaming at work, impacting her ability to meet professional demands. The severity of her challenges has led her to explore options like the Family and Medical Leave Act (FMLA) to gain a temporary reprieve and re-stabilize. This case underscores the need for comprehensive, tailored support that considers the interplay of ADHD with past traumas, co-occurring conditions, and current life circumstances, emphasizing the importance of practical strategies and external supports to manage overwhelming daily responsibilities.
Shared Terminology
- Autonomy: Making informed, independent decisions. Having control over own actions, choices, and life.
- Self-determination: The ability to determine what is best for yourself without force or coercion.
In the context of ethical practice, understanding autonomy and self-determination is paramount when working with women with ADHD. Autonomy refers to an individual's capacity to make informed, independent decisions and to have control over their own actions, choices, and life. For women with ADHD, this can be particularly challenging due to the internal and external pressures they face, including societal expectations and the impact of their symptoms on decision-making processes. Clinical providers must work to nurture and foster a therapeutic relationship predicated on respect and empowerment, helping clients to understand their diagnosis and its implications within their multifaceted lives.
Self-determination is closely related, emphasizing an individual's ability to determine what is best for themselves without external force or coercion. In cases where a client's environment, such as a spouse who dismisses mental health conditions, undermines their ability to make choices about their care, clinicians must support the client in finding ways to exercise their self-determination, even if it means adopting more private or "close to the vest" coping strategies. The ethical imperative is to help clients recognize and build upon their strengths, providing hope and a framework that extends beyond the challenges of ADHD, while also acknowledging the gender-specific pressures that women with ADHD often navigate. This involves a delicate balance of validating their experiences, offering practical support, and advocating for their right to make choices that enhance their well-being.
Ethical Considerations & Complexities in Supporting Women with ADHD and their Families
- Balancing viewpoints and perspectives
- Self-determination and autonomy should be at the forefront of all conversations
- Strength-based approach
- Using the client at the forefront of planning and treatment
- Safety is key
- Dreams for now and the future
- What’s realistic and doable?
- Capitalizing on supports
- Using relevant formal supports
- Importance of support from informal support networks
- Robust social networks
- Community (reduction of social isolation and loneliness)
- Changing and evolving needs
- Women with ADHD
- Other supports and their capacity
Supporting women with ADHD and their families involves navigating a complex ethical landscape that requires careful consideration of multiple factors. A primary ethical consideration is the need to balance various viewpoints and perspectives, particularly when family members hold differing beliefs about mental health. The principles of self-determination and autonomy must remain at the forefront of all clinical conversations, ensuring that the woman's right to make informed decisions about her care is respected, even if those decisions diverge from external recommendations.
A strengths-based approach is crucial, focusing on identifying and leveraging the client's inherent abilities and resources. This involves placing the client at the forefront of planning and treatment, ensuring that interventions are tailored to her unique needs and aspirations. Safety is always a key consideration, especially when symptoms or co-occurring conditions might pose risks to the individual or others. Clinicians should also explore the client's dreams for both the present and the future, helping to establish goals that are realistic and doable within her current context.
Capitalizing on both formal and informal supports is vital. Formal supports include professional services, while informal support networks, such as friends, family, and community groups, play a critical role in reducing social isolation and loneliness. It is important to foster robust social networks, recognizing that the give-and-take dynamic of relationships is essential for long-term sustainability. The needs of women with ADHD and their support systems are constantly changing and evolving, requiring clinicians to remain flexible and adaptive in their approach. This includes assessing the capacity of other supports within the family unit to ensure that the burden of care is not unduly placed on any one individual.
Ethics & ADHD in Women
Code of Ethics – Ethical Principles
- Service
- Dignity and Worth of the Person
- Who decides?
- Right to decline treatment and other recommendations
- Importance of Human Relationships
(National Association of Social Workers, 2023)
The ethical principles guiding practice with women with ADHD are deeply rooted in core professional codes of ethics. The principle of Service emphasizes the clinician's commitment to helping people in need and addressing social problems. For women with ADHD, this means providing comprehensive support that extends beyond symptom management to address the broader impacts on their lives, including employment, relationships, and overall well-being.
The principle of Dignity and Worth of the Person is paramount. This involves recognizing and respecting the inherent value of each individual, regardless of their diagnosis. A critical aspect of this principle is acknowledging the client's autonomy and their right to self-determination. This raises questions such as "Who decides?" when it comes to treatment plans and life choices. It firmly establishes the client's right to decline treatment and other recommendations, even if the clinician believes they would be beneficial. This requires a delicate balance of providing informed guidance while respecting personal agency.
Finally, the Importance of Human Relationships underscores the significance of building strong, collaborative relationships with clients and their support networks. This principle recognizes that individuals are interconnected and that interventions are most effective when they consider the broader family and community context. For women with ADHD, fostering robust social networks and ensuring instrumental engagement with others can significantly enhance their quality of life and well-being. This also extends to the clinician-client relationship, which should be built on trust, empathy, and mutual respect.
Ethical Responsibilities to Clients
Social workers respect and promote clients' right to self-determination and assist clients in their efforts to identify and clarify their goals. Social workers may limit clients’ right to self-determination when, in the social workers’ professional judgment, clients’ actions or potential actions pose a serious, foreseeable, and imminent risk to themselves or others.
(NASW Code of Ethics, 2023)
(Principle E): Respect for People's Rights and Dignity: Psychologists respect the dignity and worth of all people, and the rights of individuals to privacy, confidentiality, and self-determination. Psychologists are aware that special safeguards may be necessary to protect the rights and welfare of persons or communities whose vulnerabilities impair autonomous decision making.
The ethical responsibility to clients, particularly those with ADHD, centers on upholding their right to self-determination. As outlined in the National Association of Social Workers (NASW) Code of Ethics, social workers are mandated to respect and promote clients' autonomy, actively assisting them in identifying and clarifying their personal goals. This means empowering women with ADHD to make choices about their lives and treatment, even when those choices may differ from professional recommendations. However, this right is not absolute; clinicians may ethically limit self-determination when a client's actions or potential actions pose a serious, foreseeable, and imminent risk to themselves or others. This requires careful professional judgment and a clear understanding of the boundaries of intervention.
Similarly, the American Psychological Association (APA) Code of Conduct, under Principle E, emphasizes "Respect for People's Rights and Dignity." Psychologists are expected to respect the inherent dignity and worth of all individuals, along with their rights to privacy, confidentiality, and self-determination. The APA code also acknowledges that special safeguards may be necessary to protect the rights and welfare of vulnerable individuals or communities whose vulnerabilities might impair their autonomous decision-making capacity. This is particularly relevant for women with ADHD, who may experience cognitive or emotional challenges that impact their ability to make fully autonomous decisions at all times. Therefore, clinicians must balance the promotion of self-determination with the responsibility to protect clients from harm, always striving to empower them while ensuring their safety and well-being.
Ethics & ADHD in Women
Code of Ethics – Ethical Responsibilities to Clients
1.02 Self-Determination
The principle of self-determination, as articulated in ethical codes such as the NASW Code of Ethics (Section 1.02), is a cornerstone of responsible clinical practice with women with ADHD. This principle mandates that clinicians respect and actively promote their clients' right to make their own choices and decisions. For women navigating life with ADHD, this means empowering them to identify their own goals and clarify what they want for their lives, rather than imposing external expectations or solutions.
In practice, this translates to collaborative treatment planning where the woman with ADHD is an active participant in setting her therapeutic objectives. It involves providing her with comprehensive information about her diagnosis, potential interventions, and available resources, allowing her to make informed choices. This also means respecting her right to decline certain treatments or recommendations, even if they are medically or clinically advised, provided her decision does not pose a serious, foreseeable, and imminent risk to herself or others. The clinician's role is to support her in exploring the implications of her choices, fostering her capacity for independent decision-making, and building her confidence in managing her condition. This ethical stance ensures that interventions are client-centered and uphold the dignity and autonomy of the individual.
Practical and Evidence-Based Strategies
Treatment Goals
- Ensure the recognition of strengths and use a strengths-based approach
- Start with the basics
- Develop effective strategies and coping mechanisms
- Support facets of life that are impacted
- Help clients move toward better physical and psychological functioning
- Provide support to address multi-faceted impacts of ADHD and other co-occurring conditions
- Seek pathways to elevate strengths and build self-esteem
- Enable clients to live full, meaningful, and rewarding lives
Effective treatment for women with ADHD is guided by several key goals, all centered on empowering the individual and enhancing her overall quality of life. A foundational goal is to ensure the recognition of strengths and consistently employ a strengths-based approach. This involves identifying and building upon the woman's unique talents, resilience, and positive attributes, fostering a sense of self-efficacy and hope.
Another crucial goal is to "start with the basics." This means addressing fundamental areas of functioning that may be impacted by ADHD, such as sleep hygiene, nutrition, and foundational organizational skills. By establishing a solid foundation, clients can build confidence and gradually integrate more complex strategies. The development of effective strategies and coping mechanisms is paramount, equipping women with practical tools to manage their symptoms and navigate daily challenges.
Treatment should also aim to support all facets of life that are impacted by ADHD, including employment, relationships, finances, and parenting. This holistic approach ensures that interventions are comprehensive and address the real-world difficulties clients face. A core objective is to help clients move toward better physical and psychological functioning, promoting overall health and well-being.
Furthermore, it is essential to provide support to address the multifaceted impacts of ADHD and any co-occurring conditions. This often requires an integrated approach that considers the interplay between various diagnoses. Ultimately, treatment goals should seek pathways to elevate strengths and build self-esteem, counteracting the years of negative self-perception that many women with ADHD experience. The overarching aim is to enable clients to live full, meaningful, and rewarding lives, recognizing their inherent worth and potential beyond their diagnosis.
Practical Solutions
- Understand unique needs, realities, and experiences of women and pair supports accordingly
- Help loved ones understand what ADHD is like and daily implications
- Focus on solving problems, being proactive
- Take breaks
- Exercise and physical activity
- Focus on strengths
- Family meetings – to help with communication and routines
- Establish and utilize routines
- Visual and auditory supports
- Maintain a healthy lifestyle
- Financial organization and money management
- Symptom management skills
- Prioritize sleep, self care, and well being
- Consider (when applicable) employment supports
Implementing practical solutions for women with ADHD requires a tailored approach that acknowledges their unique needs and experiences. Firstly, it is crucial to understand the specific realities and challenges women face and to pair supports accordingly. This might involve addressing the societal pressures of juggling multiple roles, such as career, motherhood, and household management.
Educating loved ones about what ADHD is like and its daily implications is vital. This can foster empathy and understanding, reducing blame and promoting a more supportive environment. Encouraging a focus on problem-solving and proactive strategies helps clients move beyond reactive responses to challenges. Incorporating regular breaks, exercise, and physical activity can significantly improve attention, mood, and overall well-being.
A consistent emphasis on strengths is essential, helping women with ADHD recognize and leverage their unique abilities, such as creativity, quick thinking, or hyperfocus in areas of interest. Implementing family meetings can improve communication and establish clear routines, which are highly beneficial for managing ADHD symptoms. Establishing and consistently utilizing routines, supported by visual and auditory aids, can provide much-needed structure and predictability.
Maintaining a healthy lifestyle, including prioritizing sleep, self-care, and overall well-being, is foundational for symptom management. Developing financial organization and money management skills is also critical, as ADHD can often impact financial stability. Specific symptom management skills, tailored to individual needs, should be taught and practiced. Finally, when applicable, exploring and implementing employment supports can help women with ADHD thrive in their professional lives, ensuring reasonable accommodations and strategies for workplace success. These practical solutions, when consistently applied, can significantly enhance a woman's ability to manage ADHD and improve her quality of life.
Consider Dynamics in Couples
NON-ADHD PARTNER:
- Feelings
- Behaviors
- Internal narrative
ADHD PARTNER:
- Feelings
- Behaviors
- Internal narrative
When ADHD is present in one partner, the dynamics within a couple can become particularly complex, impacting both the individual with ADHD and their non-ADHD partner. Understanding the distinct feelings, behaviors, and internal narratives of each partner is crucial for effective intervention.
For the non-ADHD partner, common feelings include anger, frustration, sadness, and disappointment. They may feel overwhelmed by the perceived disorganization, forgetfulness, or impulsivity of their ADHD partner, leading to resentment and a sense of carrying an unequal burden. Their behaviors might include nagging, micromanaging, or withdrawing emotionally. The internal narrative of the non-ADHD partner often revolves around themes of "I have to do everything," "I'm not being heard," or "Why can't they just try harder?" They may struggle to differentiate between intentional neglect and ADHD symptoms, leading to personalizing their partner's challenges.
For the ADHD partner, feelings often include shame, guilt, inadequacy, and frustration. They may feel misunderstood, criticized, or constantly "beaten down" by their partner's reactions. Their behaviors might include procrastination, avoidance, or defensiveness when confronted about symptoms. The internal narrative of the ADHD partner often involves self-criticism, such as "I'm not good enough," "I'm always letting people down," or "I'm trying my hardest, but it's never enough." They may struggle with emotional dysregulation, leading to mood swings or outbursts, which further strain the relationship.
Effective couples therapy for ADHD involves helping both partners understand ADHD as a neurological condition, not a character flaw. It focuses on developing communication strategies, establishing clear expectations, and implementing practical solutions for managing symptoms. The goal is to foster empathy, reduce blame, and create a supportive environment where both partners feel understood and valued, moving towards a more balanced and harmonious relationship dynamic.
Parenting with ADHD
Medications may not last long enough through the day so that moms can both work effectively at the office and do caregiving duties when they get home (Seay, 2022).
In the article, Terry Matlen, an ADHD consultant, recommended moms:
- Help their families understand what ADHD is like
- Focus on solving problems, not blaming
- Take breaks to cool down or re-energize
- Have family meetings and learn how to communicate
- Create routines
Parenting with ADHD presents a unique set of challenges for mothers, often exacerbated by the demanding nature of modern life. One significant issue is the duration of ADHD medication efficacy; many mothers find that their medication wears off before they finish their workday, leaving them unmedicated for the demanding caregiving duties upon returning home (Seay, 2022). This can lead to increased struggles with organization, patience, and executive functioning during critical evening hours.
Terry Matlen, a renowned ADHD consultant, offers valuable recommendations for mothers navigating these complexities. She emphasizes the importance of helping family members, including children and partners, understand what ADHD is like. This fosters empathy and reduces misunderstandings, shifting the focus from blame to collaborative problem-solving. Matlen also advises mothers to prioritize self-care by taking breaks to cool down or re-energize, acknowledging the immense mental and emotional toll of managing ADHD while parenting. Implementing family meetings can be instrumental in improving communication and establishing clear routines, which are vital for creating a predictable and supportive home environment. Routines provide structure that can significantly alleviate the organizational challenges inherent in ADHD, benefiting both the mother and her children. By adopting these strategies, mothers with ADHD can enhance their parenting effectiveness and improve overall family dynamics.
Potential Concerns for Women and their Families
- Shortage of medications and generic medication
- Are ADHD medications harmful? Role of medication
- Organizational challenges
- Listening skills
- Whether medication should be stopped during pregnancy
Several potential concerns can impact women with ADHD and their families, requiring careful consideration and clinical guidance. A significant issue that has emerged is the shortage of ADHD medications, particularly generic versions. This can lead to disruptions in treatment, increased stress, and difficulties in maintaining symptom control, profoundly affecting daily functioning and quality of life.
Another common concern revolves around the safety and role of ADHD medications, especially during sensitive periods like pregnancy. Women often grapple with questions such as "Are ADHD medications harmful?" and "Whether medication should be stopped during pregnancy." These are complex decisions that require thorough discussion with medical professionals, weighing the risks and benefits for both the mother and the developing fetus.
Beyond medication, organizational challenges are a pervasive concern. These can manifest in various aspects of home life, work, and personal management, leading to chronic stress, missed appointments, and a sense of being perpetually overwhelmed. Difficulties with listening skills, a common ADHD symptom, can impact communication within relationships, leading to misunderstandings and frustration for both the woman with ADHD and her family members. Addressing these concerns requires a multi-faceted approach that combines medication management (when appropriate), behavioral strategies, organizational tools, and open communication within the family unit.
Special Considerations for Motherhood while Navigating Life with ADHD
Motherhood, while profoundly rewarding, can be exceptionally challenging for women navigating life with ADHD. The inherent demands of raising children—from managing schedules and household tasks to providing consistent emotional support—can exacerbate ADHD symptoms and create significant stress.
- Organizational Structures, Routines: The need for robust organizational structures and consistent routines becomes paramount. ADHD can make it difficult to establish and maintain these, leading to chaos and overwhelm. Clinicians can help mothers develop practical systems for managing household chores, meal planning, and children's activities, often utilizing visual aids and reminders.
- Visual Supports: Visual supports, such as chore charts, visual schedules, and color-coded organizational systems, can be invaluable tools for both the mother and her children. These external aids reduce the reliance on working memory and executive functions, making daily tasks more manageable.
- Outside Supports: Leveraging outside supports is crucial. This can include formal supports like professional organizers, ADHD coaches, or childcare assistance, as well as informal supports from family, friends, or community groups. Delegating tasks and accepting help can significantly alleviate the burden.
- Divisions of Duties in the Household: Equitable divisions of duties within the household are essential, especially if a partner is present. Open communication about responsibilities, acknowledging the impact of ADHD on certain tasks, can prevent resentment and foster a more collaborative environment. For single mothers with ADHD, this might involve creative solutions for outsourcing tasks or building a strong support network.
Ultimately, supporting mothers with ADHD involves a holistic approach that acknowledges the unique interplay between ADHD symptoms and the demands of parenting, providing tailored strategies to promote both the mother's well-being and a stable, nurturing environment for her children.
Tips for Clinicians Supporting Moms with ADHD
- Support use of routines
- Make problem solving a focus
- Help client avoid blame
- Support efforts to accept the reality of living with ADHD
- Support home structure to benefit all family members, including children
(Agnew-Blais et al., 2022)
Clinicians supporting mothers with ADHD can employ several effective strategies to enhance their clients' well-being and family functioning. Firstly, consistently supporting the use of routines is paramount. Routines provide predictability and structure, which are incredibly beneficial for individuals with ADHD in managing their daily lives and reducing cognitive load. Helping mothers establish and adhere to consistent schedules for themselves and their children can significantly alleviate stress and disorganization.
Secondly, making problem-solving a central focus of therapy is crucial. Instead of dwelling on past mistakes or perceived failures, guide clients to identify specific challenges and collaboratively develop practical, actionable solutions. This empowers mothers to feel more in control and capable of navigating difficulties.
Thirdly, it is vital to help clients avoid blame, both self-blame and external blame. Many mothers with ADHD internalize their struggles as personal failings, leading to shame and guilt. Clinicians can reframe these challenges as symptoms of a neurodevelopmental condition, fostering self-compassion and reducing the emotional burden. Similarly, addressing any blame from family members and facilitating understanding can create a more supportive home environment.
Fourth, supporting efforts to accept the reality of living with ADHD is a significant therapeutic step. Acceptance does not mean resignation but rather a realistic understanding of the condition's impact and a commitment to developing effective coping mechanisms. This can lead to greater self-awareness and a more adaptive approach to daily life.
Finally, clinicians should actively support the development of a home structure that benefits all family members, including children. This might involve strategies for decluttering, creating designated spaces for belongings, and implementing consistent household rules. By creating an organized and predictable home environment, clinicians can help reduce chaos, improve family dynamics, and enhance the overall quality of life for everyone involved. Resources from organizations like CHADD on coaching, organization, time management, and Cognitive Behavioral Therapy (CBT) can be invaluable tools for both clinicians and clients.
Care Techniques
- Awareness
- Medication (stimulants, nonstimulants, off-label use of anti-depressants)
- Cognitive-behavioral therapy, relaxation training, stress management, couples or family therapy
- Job mentoring, job/behavioral coaching in executive functioning skills
- Sleep hygiene
- Focus on strengths
- Digital detox and limits
- Exercise
- The power of…
- Laughter
- Knowledge
- Influence over ADHD
A comprehensive approach to caring for women with ADHD involves a combination of techniques tailored to individual needs. Awareness is the foundational step; understanding ADHD as a neurodevelopmental condition, rather than a character flaw, is crucial for both the individual and their support system.
Medication often plays a significant role in managing ADHD symptoms. This includes stimulants, nonstimulants, and sometimes off-label use of antidepressants, all of which should be carefully considered and managed by a medical professional.
Therapeutic interventions are equally important. Cognitive-behavioral therapy (CBT) helps individuals identify and change negative thought patterns and behaviors associated with ADHD. Relaxation training and stress management techniques equip clients with tools to cope with the chronic stress and emotional dysregulation that often accompany ADHD. Couples or family therapy can address relational dynamics strained by ADHD, fostering better communication and understanding.
For professional life, job mentoring and job/behavioral coaching in executive functioning skills can provide targeted support for workplace challenges, such as time management, organization, and task completion.
Prioritizing sleep hygiene is essential, as poor sleep can exacerbate ADHD symptoms. Strategies to improve sleep quality, such as consistent sleep schedules and a conducive sleep environment, are vital.
A consistent focus on strengths helps to build self-esteem and confidence, allowing women with ADHD to leverage their unique talents and abilities. Implementing digital detox and limits can reduce distractions and improve focus in an increasingly connected world. Regular exercise is a powerful tool for managing symptoms, improving mood, and reducing anxiety.
Finally, recognizing the power of laughter, knowledge, and influence over ADHD can be transformative. Laughter provides emotional release and perspective. Knowledge empowers individuals to understand their condition and advocate for their needs. And fostering a sense of influence over ADHD, rather than being controlled by it, cultivates agency and resilience. These care techniques, when integrated thoughtfully, can significantly improve the quality of life for women with ADHD.
Strategies and Supports
- Balancing expectations, roles, and responsibilities
- Pomodoro technique
- Task decomposition/breaking down of tasks
- Reminders
- Section 504 - Access, Reasonable accommodations
Effective strategies and supports are essential for women with ADHD to navigate their daily lives successfully. A key area of focus is balancing expectations, roles, and responsibilities. Women often face immense pressure to excel in multiple domains, and ADHD can make this balance particularly challenging. Clinicians can help clients identify realistic expectations, prioritize tasks, and delegate responsibilities where possible, fostering a more sustainable lifestyle.
Practical techniques can significantly aid in managing attention and productivity. The Pomodoro Technique, for instance, involves working in focused intervals (e.g., 25 minutes) followed by short breaks, which can help maintain concentration and prevent burnout. Task decomposition, or breaking down large tasks into smaller, more manageable steps, reduces overwhelm and makes daunting projects feel more achievable. Utilizing various reminders, such as digital alarms, sticky notes, or visual cues, can compensate for forgetfulness and aid in task initiation and completion.
In educational and employment settings, understanding and advocating for Section 504 access and reasonable accommodations is crucial. Section 504 of the Rehabilitation Act of 1973 prohibits discrimination based on disability and ensures that individuals with disabilities have equal access to programs and activities. For women with ADHD, this might translate to accommodations such as extended time on assignments, a quiet workspace, flexible scheduling, or access to assistive technology. By implementing these strategies and leveraging available supports, women with ADHD can enhance their executive functioning, improve productivity, and experience greater success and well-being in all aspects of their lives.
Practical Tips for Women with ADHD
- Practice wellness
- Stay active and connected with others
- Connect with others and find community
- Develop a support system
- Check out community resources and events
- Consider being a part of a faith-based community
- Recognize internal signs and symptoms that may co-occur/be associated with ADHD
- Support co-occurring conditions
For women living with ADHD, integrating practical tips into daily life can significantly enhance well-being and symptom management. A fundamental tip is to practice wellness holistically, encompassing physical, mental, and emotional health. This includes prioritizing adequate sleep, nutritious eating, and stress-reduction techniques.
It is crucial to stay active and connected with others. Regular physical activity can help manage hyperactivity and improve focus, while social engagement combats feelings of isolation. Actively seeking to connect with others and find community is vital. This might involve joining support groups, clubs, or shared interest groups where individuals can relate to similar experiences, fostering a sense of belonging and reducing loneliness.
Developing a robust support system—including friends, family, and professionals—provides a safety net and a source of encouragement. Additionally, exploring community resources and events can open doors to new opportunities for learning, social interaction, and practical assistance. For some, considering involvement in a faith-based community can offer spiritual support, a sense of purpose, and a structured social environment.
Finally, it is important to recognize internal signs and symptoms that may co-occur or be associated with ADHD, such as anxiety, depression, or emotional dysregulation. Being attuned to these internal cues allows for proactive management and seeking appropriate support for co-occurring conditions. By integrating these practical tips, women with ADHD can build resilience, enhance their coping skills, and cultivate a more fulfilling and balanced life.
Keep in mind…
Supports can be put in place to manage and alleviate the symptoms of ADHD. In the family and other contexts, striving for interdependence is key. Use the strengths to balance the needs of the total unit.
It is crucial to remember that while ADHD presents significant challenges, effective supports can be implemented to manage and alleviate its symptoms. The goal is not to eliminate ADHD, but to empower individuals to thrive despite its presence. In family and other relational contexts, striving for interdependence is key. This means fostering an environment where individuals can rely on each other's strengths and support each other in areas of weakness, rather than expecting complete self-sufficiency from every member. By recognizing and utilizing the unique strengths of each individual, the needs of the entire unit can be balanced, leading to greater harmony and collective well-being. This collaborative approach ensures that the burden of ADHD is shared, and that everyone contributes to creating a supportive and functional environment.
Remember
There is always something that can be done to help women living with ADHD improve their quality of life (which also helps the overall family quality of life). Consider helping individuals develop routines, strategies, coping mechanisms, and opportunities to build on strengths, augment social supports, and build self-esteem.
It is a fundamental truth that interventions and support can always be provided to help women living with ADHD enhance their quality of life. This improvement extends beyond the individual, positively impacting the overall family quality of life. Clinical providers should focus on empowering these women by assisting them in developing practical routines, effective strategies, and adaptive coping mechanisms. Creating opportunities to build on their inherent strengths is paramount, fostering a sense of self-efficacy and competence. Furthermore, actively working to augment their social supports—both formal and informal—can combat isolation and provide a vital network of assistance and understanding. Ultimately, the consistent effort to build self-esteem is crucial, helping women with ADHD to recognize their inherent worth and capabilities, leading to a more fulfilling and meaningful life.
Additional Information & Resources
DSM-5 Diagnostic Criteria in ADHD
See link for DSM-5-TR diagnostic criteria (pages 2-7): https://www.pbm.va.gov/PBM/AcademicDetailingService/Documents/508/10-1659_ADHD_QRG_P97097.pdf
https://www.aafp.org/dam/AAFP/documents/patient_care/adhd_toolkit/adhd19-assessment-table1.pdf?ref=clarityxdna.com
Resources
Resources for Adults with ADHD (copy and paste links into a new browser window):
- ADHD Fact Sheets (Note: there is a whole section of resources for adults with ADHD and parents)
- https://chadd.org/understanding-adhd/adhd-fact-sheets/
- Attention Deficit Disorder Association (ADDA)
- https://add.org/resources/
- CHADD
- https://chadd.org/for-adults/overview/
- National Institute of Mental Health
- https://www.nimh.nih.gov/health/publications/adhd-listing
Resources - Books
- ADHD & Marriage, where “The ADHD Effect on Marriage” author Melissa Orlov and psychiatrist and author Dr. Ned Hallowell blog about marriages when at least one spouse has ADHD. Hallowell, his wife (Sue Hallowell), and Orlov wrote “Married to Distraction.”
- “Executive Functioning Skills for Adult ADHD: Proven Techniques and Exercises to Learn Time Management, Increase Focus, and Stop Procrastinating,” by Catherina Kaylie
- “FAST MINDS: How to Thrive If You Have ADHD (Or Think You Might),” by Craig Surman, Karen Weintraub, and Tim Bilkey
- “Faster Than Normal: Turbocharge Your Focus, Productivity, and Success with the Secrets of the ADHD Brain” by Peter Shankman, who was diagnosed with ADHD in his 30s
- “Smart But Stuck: Emotions in Teens and Adults with ADHD,” by Thomas E. Brown, PhD
- “Taking Charge of Adult ADHD,” by Russell A. Barkley, PhD
- The New York Times 6 Books for adults living with ADHD (March 24, 2024): https://www.nytimes.com/2024/03/25/well/mind/adult-adhd-books.html
How to Engage in Consistency in Parenting as a Parent with ADHD
Resource: https://www.youtube.com/watch?v=1XvM9WSHgZI
Workplace Accommodations
Video: https://www.youtube.com/watch?v=-Cfatp1gy-8
Employees in the Workplace
Video: https://www.youtube.com/watch?v=_HXV2doQVlM
Supports and Resources - Websites for women with ADHD:
Website: https://www.qbtech.com/blog/top-6-must-visit-websites-for-women-with-adhd/
Books for Women with ADHD:
Website: https://www.additudemag.com/slideshows/adhd-books-for-women/#:~:text="The Queen of Distraction"&text=Written by a psychologist, this,and respected psychologist Sari Solden.
Information regarding Women and ADHD
Website: https://www.understood.org/en/topics/adhd-women
Kaleidoscope Society
Website: https://www.kaleidoscopesociety.com/
Duke Center for Girls & Women with ADHD
Website: https://adhdgirlsandwomen.org/
Verywell Mind
Website: https://www.verywellmind.com/add-symptoms-in-women-20394
ADDitude
Website: https://www.additudemag.com/category/adhd-add/adhd-in-adults/add-women/?srsltid=AfmBOorsazRsrqhshU8sI3xhryVJpBhtfxgnZY18IGNpQ0-g_t58f0yT
ADDA – Attention Deficit Disorder Association
Website: https://add.org/women-with-adhd/
References
Agnew‐Blais, J. C., Wertz, J., Arseneault, L., Belsky, D. W., Danese, A., Pingault, J. B., ... & Moffitt, T. E. (2022). Mother's and children's ADHD genetic risk, household chaos and children's ADHD symptoms: A gene–environment correlation study. Journal of Child Psychology and Psychiatry, 63(10), 1153–1163.
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Additional Current References
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Citation
Marsack-Topolewski, C. (2025). ADHD and Women: Ethical and Practice Implications for Clinical Providers. Continued Counseling - Article 110. www.continued.com/counseling
Sep 24, 2025
1 CE Credit