Counselors’ Perceptions of Ethical Considerations for Integrating Neuroscience With Counseling

Chad Luke, Eric T. Beeson, Raissa Miller, Thomas A. Field, Laura K. Jones

As with many advancements in science and technology, ethical standards regarding practice often follow innovation. The integration of neuroscience with counseling is no exception, as scholars are just beginning to identify important ethical concerns related to this shift in the profession. Results of an inductive thematic analysis exploring the perspectives of 312 participants regarding the ethics of integrating neuroscience with counseling are presented. This study is the first of its kind to explore mental health counselors’, counselors-in-training’s, and counselor educators’ perceptions of neuroscience integration. The researchers identified a continuum of concern ranging from no concerns to grave concerns. In addition, they identified four specific ethical quandaries: a) neuroscience does not align with our counselor identity, b) neuroscience is outside the scope of counseling practice, c) challenges with neuroscience and the nature of neuroscience research, and d) potential for harm to clients. Implications include four key considerations for counselors prior to proceeding with integrating neuroscience into practice.

Keywords: neuroscience, integration, counselor identity, ethics, counseling practice


The integration of neuroscience with the mental health professions continues, and with this expansion comes the risks associated with any nascent area of innovation (Luke et al., 2019). Neuroscience integration, as used herein, is understood using Beeson and Field’s (2017) definition of neurocounseling, a synonym for the integration of neuroscience with counseling:

A specialty within the counseling field, defined as the art and science of integrating neuroscience principles related to the nervous system and physiological processes underlying all human functioning into the practice of counseling for the purpose of enhancing clinical effectiveness in the screening and diagnosis of physiological functioning and mental disorders, treatment planning and delivery, evaluation of outcomes, and wellness promotion. (p. 74)

Counselors and the counseling profession, under code C.2.b of the American Counseling Association’s ACA Code of Ethics (2014), are charged with scrutinizing innovations and specialty areas prior to and throughout their use in clinical practice; this is a safeguard to protect clients from risky or poorly evidenced theory or practices. For example, some of these risks, as they pertain to neuroscience (i.e., the study of the brain and central nervous system) and neurobiology (i.e., literally, the biology of the neurons and the nervous system), include accuracy, embellishment, misapplication, and hype (Beeson & Field, 2017; Kim & Zalaquett, 2019; Luke, 2016).

The first and perhaps most salient ethical concern in terms of counseling values is that neuroscience integration is not a unilaterally benevolent addition to counseling (Luke, 2019). Although limited research has focused specifically on mental health counselors, several authors have closely examined the effects of using neurobiological language and frameworks to explain and understand mental health disorders in other mental health fields (Fernandez-Duque et al., 2015; Haslam & Kvaale, 2015; Lebowitz et al., 2015; Luke et al., 2019; Nowack & Radecki, 2018). Haslam and Kvaale (2015) summarized the literature on the effects of brain-based explanations of mental health conditions, such as schizophrenia and depression. Their findings challenge long-held notions that biogenic and neurobiological explanations for mental health and psychopathology are singularly positive. The larger assumption in the profession has been that biomedical explanations can reduce self-blame and public shaming of individuals with substance use and other mental health disorders (Badenoch, 2008; Lebowitz & Appelbaum, 2017). Unfortunately, these biological explanations can at times carry unintended consequences that operate against this positive outcome. Clients may be less likely to invest in psychosocial treatments, believing that while on the one hand their biogenic (i.e., brain-based) condition (e.g., depression) is not their fault, it is also therefore out of their control (Lebowitz & Appelbaum, 2017). In other words, one risk of these biological explanations is that they may reduce outcome expectancy with counseling, while increasing the belief that only biological-based treatments (e.g., psychotropic medication) will work for them.

Mental health providers also seem to be similarly affected by these biased perceptions, at times experiencing less empathy for clients in cases framed as neurobiologically based (Lebowitz & Ahn, 2014). Lebowitz et al. (2015) demonstrated that these negative effects could be mitigated somewhat through training. However, Haslam and Kvaale (2015) asserted that it is imprudent to believe that training is sufficient, because “it is unlikely that all of the ill effects of biogenetic explanation can be reversed simply by educating laypeople about bioscience, or that the fundamental problem is their ignorance of neuroplasticity and epigenesis” (p. 402). It is notable that the research above did not include mental health counselors, so the extension of these concerns to counselors remains uncertain. Nevertheless, the concerns seem warranted regarding the allure of neuroscience conceptualizations (Beeson & Miller, 2019; Field et al., 2019; Luke, 2020). Fernandez-Duque et al. (2015) demonstrated how easily humans can be deceived based on the use of the “prestige of science” hypothesis (p. 926). In a series of experiments, the authors used superfluous neuroscientific jargon and images to fool participants into viewing the content as more veracious. Additionally, concerns about the encroachment of science-based reductionism on the humanistic ethos of counseling has begun to resound through the counseling literature (Beeson, Field, et al., 2019; Beeson & Miller, 2019; Field, 2019; Luke, 2019; Luke et al., 2018). Wilkinson (2018) offered a review of the threats of neuroscience to counseling by highlighting the perceived superiority of objective brain-based methods over the humanistic principles of the counseling profession.

Nowak and Radecki (2018) introduced a special issue in the Consulting Psychology Journal: Practice and Research focused on “neuro-mythconceptions.” The authors explored the many ways that neurobiology might be exploited by professionals to justify their current practices. Their concern centered on how plausible neuroscience-based claims can sound. Such plausibility results in professionals passing along dubious information to clients in the name of cutting-edge advances in optimizing human performance. The risk of neuromyths also have been cited in the professions of counseling (Beeson, Kim, et al., 2019; Kim & Zalaquett, 2019) and education (Dekker et al., 2012; Deligiannidi & Howard-Jones, 2015; Gleichgerrcht et al., 2015; Karakus et al., 2015; Macdonald et al., 2017; Papadatou-Pastou et al., 2017; Simmonds, 2014).

Purpose of the Present Study

The potential concerns identified above highlight the need to consider potential ethical implications of counselors integrating neuroscience within their practice. Although ethical concerns regarding the implementation of neuroscience have been referenced anecdotally in conceptual reviews (e.g., Beeson & Miller, 2019; Field, 2019; Luke, 2019; Wilkinson, 2018), no studies were found that explored concerns of the counseling community regarding the broader ethical assumptions about the integration of neuroscience with practice. Therefore, this research is the first to empirically address this critical gap by eliciting the counseling community’s perceptions of ethical concerns related to the integration of neuroscience and counseling. The research question guiding this study explored if counselors perceive ethical concerns pertaining to integrating neuroscience with their counseling practice, and if so, the nature of these concerns.


This study utilized a survey-based qualitative methodology to explore counselors’ perceived ethical concerns regarding the integration of neuroscience with their counseling practice (Merriam & Tisdell, 2016). A single open-ended survey question was selected for qualitative data analysis in this study. This question was part of a larger survey examining counselor perceptions of neuroscience and neuroscience integration with counseling. Given the exploratory nature of the study and the current status of neuroscience literature in the counseling profession, a thematic analysis of a single item from a larger survey was chosen. This methodology was best suited to obtain a general, broad understanding of the concerns within the profession. Use of thematic analysis is consistent with other research in which a standardized measure of the construct (i.e., ethical integration of neuroscience with counseling) does not exist (Bengtsson et al., 2007; Donath et al., 2011). A total of 458 participants completed the larger survey, with 312 participants (67.9%) responding to the question, “What ethical concerns do you have regarding the integration of neuroscience into clinical practice (if any)?”


Integration of neuroscience with counseling practice affects multiple professional roles within the counseling profession. As such, the survey was developed for counselors, counselor educators, and counselors-in-training. We sought to gain responses from counseling practitioners, counselor educators and supervisors, and current master’s- and doctoral-level counseling students. Inclusion criteria for the study consisted of at least one of the following: (a) being licensed as a counselor, (b) belonging to a professional counseling organization, (c) being a current student in a counseling program, or (d) being a current faculty member in a counseling program. Participants who did not meet one of these four criteria were excluded from the study.

Participants varied in their educational attainment, with the highest percentage of participants having graduated with their master’s degree and not pursued doctoral study (35.3%, n = 110). This group was followed by master’s-level students (27.2%, n = 85), doctoral-level graduates (22.1%, n = 69), and doctoral-level students (15.4%, n = 48). Most of the sample (81.4%, n = 254) had attended programs accredited by the Council for the Accreditation of Counseling and Related Educational Programs (CACREP). Many participants (60.9%, n = 190) reported they were exposed to neuroscience in their graduate programs.

The majority of doctoral-level graduates (85.5%, n = 59) were full-time faculty members in counselor education programs. The other 10 doctoral-level graduates were either administrators of clinics, working in private practice, or retired. Of those 59 faculty members, 62.7% (n = 37) provided direct counseling services within the past year. In comparison, 81.0% (n = 205) of the non-faculty participants provided direct counseling services in the past year. When combined, the majority of the sample (77.9%, n = 243) provided direct counseling services within the past year.

The mean number of years of counseling experience was 10.13 years, with a large amount of variance (SD = 10.87). The range for years of experience was 0 to 40 years. Doctoral graduates had the most years of experience on average (M = 19.91, SD = 11.04). They were followed by master’s graduates who were not pursuing doctoral study (M = 11.70, SD = 10.42), doctoral students (M = 7.29, SD = 5.21), and current master’s students (M = 1.74, SD = 4.98). A subset of the sample comprised full-time counselor educator faculty (18.9%, n = 59). Faculty members in the study had more counseling experience (M = 17.83 years, SD = 11.00) than non-faculty participants (M = 8.33, SD = 10.04). No age differences existed by education level. The mean age for the sample was 42.55 years (SD = 13.66) with a range from 21 to 82 years.

Approximately half (54.5%, n = 170) of participants were currently licensed as counselors or psychologists. In addition, 31.1% (n = 97) held the National Certified Counselor (NCC) certification. The majority of the sample (87.5%, n = 273) were members of counseling associations. Participants self-reported their gender identity, racial/ethnic identity, age, and number of years of counseling experience. The sample consisted of 73.3% (n = 229) females, 25.0% (n = 78) males, 1.0% (n = 3) non-binary, and 0.6% (n = 2) transgender. One person did not report gender identity. The survey gave participants the option to report multiple racial/ethnic identities. Fifteen percent of participants (n = 48) identified as multiracial, whereas 84.6% identified as Caucasian/White (n = 264, of which 45 were multiracial). Of the remaining participants, 8.0% identified as Asian or Asian American (n = 25, of which 19 were multiracial), 5.4% as African American/Black (n = 17, of which 13 were multiracial), 3.8% as Hispanic or Latinx (n = 12, of which 10 were multiracial), 1.0% as American Indian or Alaskan Native (n = 3, of which three were multiracial), and 0.3% as Arab/Arab American (n = 1, of which zero were multiracial). No participants identified as Pacific Islanders.


The question addressed in this article was drawn from questions used in a larger study that explored training and attitudes related to neuroscience and counseling. The question used in this study was included intentionally as a means to gain a better understanding of perceptions of the ethics of neuroscience integration, recognizing it as a stand-alone construct for the purposes of analysis. The full survey was constructed by the authors, following a thorough review of the literature around the integration of neuroscience in counseling. All survey questions were constructed to conform to Patton’s (2015) conventions and recommendations for qualitative questions, such as using open-ended and neutral questions, asking one question at a time, and avoiding “why” questions. The specific question analyzed and presented in this report was “What ethical concerns do you have regarding the integration of neuroscience into clinical practice (if any)?”

We utilized convenience and snowball sampling to recruit participants, which makes calculating response rate difficult. However, as the purpose of the project was exploratory and the method qualitative, the participants were not intended to be fully representative. The potential response bias inherent to this study could mean that participants were aware to some degree of the status of the profession with regard to integrating neuroscience into clinical practice, both positively and negatively. Following IRB approval, the authors electronically distributed the Survey Monkey–created online survey to the following: neuroscience interest networks in counseling, the counselor education listserv, CESNET-L, and direct emails to colleagues for distribution. A link to the informed consent and full questionnaire was included in the email. Interested participants clicked on the link and were asked to give their consent in order to continue to the survey. Three separate requests for participants were disseminated, with each request coming 2 weeks apart. Participants who completed the survey in full had the option of submitting their email in a separate survey to be included in a drawing for two signed copies of neuroscience in counseling texts.

Role of the Researchers

To limit unconscious bias in the research process, we engaged in discussions throughout survey development, data collection, and data analysis. Such conversations detailed our respective passions, assumptions, histories, and visions of the profession. Several prior assumptions emerged in this recursive process. These ethical concerns largely mirrored the issues raised in existing literature and described in the introduction section of this article. The primary assumption included the belief that incorporating neuroscience into counseling is a largely positive endeavor but that counselors should follow ethical guidelines outlined by professional counseling organizations to avoid ethical concerns related to integration. One author explicitly assumed that participants would generally default to the ACA Code of Ethics in their response, such that responses might begin with, “According to the ACA Code of Ethics regarding new specialty areas of practice. . . .” One author assumed that most participants would preface their response with “It depends on what you mean by ‘integration’” because integration was intentionally undefined in the survey. We continually challenged and actively reflected on these assumptions in order to understand the impact on the authors’ relationship with the data and subsequent themes (Hays et al., 2016; Hunt, 2011). We also engaged in reflective writing, particularly through writing memos (Hunt, 2011), in order to maintain awareness of worldviews and potential for bias in coding. Commonly referred to as reflexivity, this process aided in being transparent about assumptions rather than trying to behave as if any researcher would be able to be free from biases in approaching a set of data (Hays et al., 2016). Additionally, we established an electronic audit trail that enabled returning to the data, tracking the process, and checking that the coding remained close to the words of the participants. Lastly, two of the authors served as auditors for the results, having familiarized themselves with the data, but refraining from engagement in analysis and theme development.

Data Analysis

We selected thematic analysis, grounded in a pragmatist framework (Duffy & Chenail, 2008), to guide the inquiry into perceptions regarding the ethics of integrating neuroscience and counseling. Clarke and Braun (2017) defined thematic analysis as “a method for identifying, analyzing, and interpreting patterns of meaning (‘themes’) within qualitative data” (p. 297). We reviewed literature related to content analysis and thematic analysis and found that there was significant overlap (and sometimes merging) of the two approaches in published literature. Our best understanding of the two related approaches is that they exist on a continuum, with content analysis stopping at the manifest level of analysis and thematic analysis continuing to identify broader meanings. Although we stayed very close to the participants’ responses in coding, we did move beyond content analysis “categories” to extract some inductive-level themes across cases.

We followed Braun and Clarke’s (2006) six-phase framework, utilizing an inductive and semantic approach to thematic analysis. Braun and Clarke described these connected approaches to analysis as “a process of coding the data without trying to fit it into a preexisting coding frame, or the researcher’s analytic preconceptions . . . themes are identified within the explicit or surface meanings of the data” (pp. 83–84). Given that the data were obtained through an open-ended survey question versus an in-depth interview protocol that could capture greater context and meaning, we aimed to stay close to participants’ exact words. In this way we resisted the urge to include guesses at participants’ motivations or assumptions as part of themes. The emergent codes and themes reflect an inductive, descriptive account of participants’ perceptions. We followed the subsequent steps in analyzing the data.

The first three authors served as members of the coding team for data analysis. We first familiarized ourselves with the data by reading all responses through several times and taking notes on general observations and personal reactions to the data (Braun & Clarke, 2006). Afterward, we met via videoconferencing and looked at all the responses together, line by line, to begin identifying initial codes. The average length of responses was one to two sentences; the range of responses was from one word to over 200 words (a paragraph).

We then searched for patterns in the data, noting frequently used words and phrases and commonly expressed ideas. Fourth, we identified connections and grouped codes into preliminary themes. In doing so, we further expanded the overarching themes into subthemes, capturing some of the nuance represented in participants’ responses. We discussed and resolved differences in coding data via consensus.

Fifth, we reviewed the preliminary themes in light of the raw data and the research question, paying particular attention to our own perspectives and values. The third author re-read each participant response and matched each response to one of the theme groups. Parts of responses at times fell into different theme groups. For example, one participant wrote, “Ethical concerns would be keeping into consideration what the clinician’s scope of practice is, the potential for any side effects or results of rapid growth and brain training, and what insurance companies will cover.” The first part was coded in theme 2 (scope of practice) and the second part was coded in theme 4 (potential harm).

The first and second authors worked with the codes and themes in a more abstract and creative manner, developing thematic maps and conceptual continua that reflected relationships between and among participant responses. This process led to combining some themes and changing the title of other themes to better reflect the descriptive accounts of participants. Lastly, in refining the theme list, we discussed theme definitions and final theme names, attempting to capture the nature and essence of each thematic group (Braun & Clarke, 2006; Clarke & Braun, 2017). Clarke and Braun (2017) noted that “each theme has an ‘essence’ or core concept that underpins and unites the observations, much like characters have their own psychological makeup and motivations” (p. 108). In examining these underlying core concepts in our data, we identified questions that seemed to be illuminated through participants’ expressed concerns. As an additional step, we calculated frequency counts to convey the saturation of each theme within the data. Because the purpose of tallying frequencies was to report the strength of qualitative findings rather than to specifically quantify the results, greater weight was given to qualitative data than quantitative frequencies.


In reviewing the conceptual maps of participant responses, it appeared that participants varied in their degree of ethical concerns. To make meaning of this variation, the authors placed responses on a continuum from “none” to “yes.” These items were coded based upon whether an ethical concern was reported and under what conditions the ethical concerns existed. Some participants (4.2%, n = 13) entered “n/a,” but it could not be determined if these responses indicated whether they had any ethical concerns.

Continuum of Ethical Concerns

During the initial review of the data, the authors observed a response range that led to a further analysis of the continuum of responses. Most participants (78.2%, n = 244) indicated some level of ethical concern regarding the integration of neuroscience in counseling. These responses had various degrees of certainty and conditions. Most responses (65.1%, n = 203) fell into the yes, with no conditions grouping. Example responses included: “Deeply concerned” and “There’s a lot of misinformation out there! It’s a complex subject and I have seen varying degrees of ability to explain things easily and correctly. Also I think sometimes people want it to provide answers that it can’t or read more into the research than is truly there.”

The second category identified was yes, if/only (3.5%, n = 11). One example response included in this subtheme was: “I would only be concerned if counselors use their knowledge of the brain to profess some magical or intellectual superiority in controlling a client.” The third category was none, but (3.2%, n = 10). For example, responses included in this subtheme were: “none—except more research is needed,” and “none other than the importance of competence.”

The fourth category we identified was just like any other (3.2 %, n = 10). Some participants indicated that they had ethical concerns that were no different than for other methods of counseling. For example, one participant stated they felt “the same as with any other evidence-based practice: counselors need quality training and an understanding of what it means to be ‘competent.’” A fifth category was unethical not to integrate (3.2%, n = 10). An example response included in this subtheme was: “At this point, it would be unethical NOT to formally integrate these studies” (emphasis in original). Nearly 20% of participants (19.9%, n = 62) believed there were no ethical concerns regarding the integration of neuroscience in counseling. Given the methods of the study, the “n/a” responses were kept separate from the no ethical concerns group, as the analysis aimed to stick close to the participants’ actual words rather than infer their intention. Therefore, “n/a” could have been listed for any number of possible reasons that could not be determined in the current study. These responses were further divided into the following groups: (a) participants who believed there were explicitly no ethical concerns (13.8%, n = 43), (b) participants who believed there were no ethical concerns at the current moment (3.8%, n = 12), and (c) participants who believed there were no ethical concerns as long as certain conditions were met (2.2%, n = 7). This continuum provided a richer understanding of the emergent themes, as discussed below.

Themes of Participant Concerns

     Most participants (78.2%, n = 244) identified ethical concerns. From the continuum above, these are the responses from the following groups: unethical not to integrate; no ethical concerns but; ethical concerns if/only; ethical concerns with no conditions; and ethical concerns just like any other. The analysis of these responses produced a total of four themes and ten subthemes and are summarized in Table 1. The four major themes were: neuroscience does not align with our counselor identity, neuroscience is outside the scope of counseling practice, challenges with neuroscience and the nature of neuroscience research, and potential harm to clients. For each subtheme, response frequencies are reported to provide a contextual understanding of how commonly the theme occurred. Subthemes all were deemed equally meaningful, regardless of the response frequency.

Theme 1: Neuroscience Does Not Align With Our Counselor Identity

     The first theme was reflective of participants’ concerns that integrating neuroscience into counseling might be inherently inconsistent with or even violate counselors’ identity. Specifically, participants emphasized the loss of humanistic principles by either directly using the word “humanistic” or using terms consistent with humanistic principles (e.g., holism, human-first, subjective data, process, compassion, relationship, and wellness). Two subthemes related to the overarching theme were as follows: Subtheme 1.1) overemphasis and/or overreliance (n = 27), and Subtheme 1.2) reductionism and/or determinism (n = 25). These connected, yet discrete, subthemes reflected participants’ particular areas of apprehension. These areas of concern centered on either giving too much weight to biological, brain-based conceptualizations at the cost of clients’ subjective worlds (e.g., “undervalue subjective experience”) or reducing human experience in a way that neglected human agency (e.g., “reducing human experience to just science”).

Theme 2: Neuroscience Is Outside the Scope of Counseling Practice

The second theme was reflective of participants’ reservations that neuroscience was within counselors’ scope of practice based on educational backgrounds, training, knowledge, and/or skills. Three subthemes were identified as follows: Subtheme 2.1) training and education (n = 59), Subtheme 2.2) lack of standards for training and practice (n = 21), and Subtheme 2.3) competence (n = 69). Sample responses from this theme included feeling “woefully untrained.”  Some participants focused more on academic background and elements of training (e.g., continuing education, supervision) as indicative of scope, whereas other participants highlighted counselors’ understanding of neuroscience concepts, focusing more on knowledge and application skills. A smaller group of responses emphasized the absence of current training and/or practice standards (e.g., “inadequate training standards”). This line of responses included concerns around an absence of qualified trainers, certification opportunities, and/or general laws and regulations.

Theme 3: Challenges With Neuroscience and the Nature of Neuroscience Research

The third theme captured participants’ varied reservations about the general field of neuroscience and the accurate translation of neuroscience research into clinical work. Participants expressing concerns in this area seemed to be asking, “How can we be sure this is done right or well?”  Subtheme 3.1, ever-changing and evolving (n = 14), included responses related to challenges counselors might face in staying current with neuroscience findings. These concerns were centered around the vastness of the field and the fast pace at which research is emerging. Subtheme 3.2, quality of research (n = 23), included more critical commentary on the type of research being conducted in the neuroscience field (e.g., relevance of lab-based research to clinical practice, insufficient applied research). Subtheme 3.3, interpreting and applying research (n = 52), emphasized concerns with counselors overstating, speculating, misrepresenting, and misinforming clients of neuroscience research and concepts. Participants voiced concerns with “overhyping findings,” “unknown practical use,” and the “ever-changing and not fully understood” research base.

Theme 4: Potential for Harm to Clients

The fourth theme reflected participants’ concerns that integrating neuroscience into counseling could put clients, and potentially counselors, at risk. A total of 18 participants used the exact phrase “potential harm” or the related idea of informed consent. Fourteen participants referred to concerns with potential harm, and four people noted concerns with informed consent. In Subtheme 4.1, neuroscience information may be intentionally misused in a way that harms clients (n = 21), participants feared counselors deliberately using “embellishment” and “manipulation.” Subtheme 4.2, unintended potential negative side effects (n = 18), reflected ways that integration could inadvertently harm clients or harm counselors These concerns included giving false hope and creating problems with insurance claims to issues with liability and malpractice.


Table 1

Summary and Frequencies of Themes and Subthemes

Theme Subtheme Description Frequency Sample Statements
Theme One: Neuroscience does not align with our counselor identity Sub 1.1 Overemphasis and/or overreliance The integration of neuroscience in counseling may lead to counselors giving preference to non-humanistic aspects of the client and/or the treatment process (e.g., psychopharmacology, science, the brain). n = 27


• Too reliant on brain
• Science over compassion
• Defaulting to neuro
• Brain obsession
• Undervalue subjective
Sub 1.2 Reductionism and/or determinism The integration of neuroscience in counseling may lead to counselors moving away from holistic conceptualizations and limiting human agency.  


n = 25



• Oversimplification
• Takes away focus on
• Reducing human experience
to just science
• Cultural bias
Theme Two: Neuroscience is outside the scope of counseling practice Sub 2.1 Training and education Counselors do not have sufficient training and/or educational backgrounds to ethically integrate neuroscience into counseling practice.  

n = 59


• Insufficient training
• Woefully undertrained
• Not having qualifications
• Scope of training
• No formal supervision
Sub 2.2

Lack of standards for training and practice

There are insufficient standards for guiding the training and practice of neuroscience integration. n = 21 • Lack of laws, regulations, and
• Standards for qualifications
• Qualifications of trainers
Sub 2.3 Competence Counselors are integrating neuroscience into counseling practice without sufficient knowledge and/or skills. n = 69


• Lack of knowledge
• Scope of competence
• Not being informed
• Skill level of clinician
Theme Three: Challenges with neuroscience and the nature of neuroscience research Sub 3.1
Ever-changing and evolving
The field of neuroscience is continuously evolving, serving as a barrier to counselors staying sufficiently up to date to ethically integrate principles into counseling practice. n = 14


• Ever-changing and not totally
• Staying current
• Constantly evolving
• Keeping up to date
• Vastness of the field
Sub 3.2 Quality of research Neuroscience research is often too complex, poorly conducted, and/or insufficient for counselors to apply to their work. n = 23


• More research needed
• Poor research
• Generalizability of research
• Lack of scientific foundation
of knowledge
• Unknown practical use
Sub 3.3 Interpreting and applying research Neuroscience research is being misunderstood, misinterpreted, and/or inaccurately applied to clinical practice. n = 52


• Accurately interpreting and
• Overstatement
• Misrepresenting science
• Giving incorrect information
Theme Subtheme Description Frequency Sample Statements
Theme Four: Potential for harm to clients Sub 4.1 Manipulation Neuroscience information may be intentionally misused in a way that harms clients.  

n = 21


• Manipulation leading to
• Misuse of knowledge
• Controlling the client
Sub 4.2 Unintended potential negative side effects The integration of neuroscience into counseling may have unintended negative consequences on clients and/or counselors. n = 18


• Jargon alienates – feeling
• Clients misperceiving
counselor identity/role and
not attending other

Note. N = 312



Counselors, counselor educators, and counselors-in-training reported a wide range of ethical concerns regarding the integration of neuroscience with clinical practice. These concerns largely reflected existing ethical guidelines (ACA, 2014) and existing literature related to neuroscience and counseling (e.g., Beeson & Miller, 2019; Field, 2019; Luke, 2019; Wilkinson, 2018). We developed four primary themes through the data analysis process. In reviewing these themes, we identified questions that participants seem to be asking through their expressed concerns. Each of the themes shared a meaningful connection, through implication and association, with major sections of the ACA Code of Ethics (ACA, 2014). These connections are discussed below.

Theme 1: Neuroscience Does Not Align With Our Counselor Identity

Humanistic concerns in this theme reflect counselor concerns that the integration of neuroscience may shift the profession away from wellness and focus on pathology. As already noted, other scholars have shared this concern (Wilkinson, 2018). However, other authors have alluded to the possibility for neuroscience to expand rather than reduce the client experiences and actually enhance counselor identity (Beeson, Field, et al., 2019; Beeson & Miller, 2019; Field et al., 2019; Ivey & Daniels, 2016).

Humanistic concerns are consistent with criticisms in the literature regarding essentialism (Schultz, 2018). Essentialism, in particular Schultz’s neuroessentialism, is the process of reducing individuals down to mere brain function. This position reflects the positivist, materialist approach to science in general and neuroscience in particular. All human experience is based in neurobiological process (Kalat, 2019), which can feel deterministic and therefore diminish the hope that counselors are called to instill (Schwartz et al., 2016). This theme aligns with several ACA ethical codes, including counselor professional identity and values (Beeson & Miller, 2019). However, influential scholars in the counseling profession have elevated how neuroscience is an extension of the wellness perspective, akin to the professional identity of the counseling profession (Cashwell & Sweeney, 2016; Ivey et al., 2017; Russell-Chapin, 2016). Whereas this theme indicates that some counselors believe neuroscience poses ethical risks to professional identity, the reality remains unclear.

Theme Two: Neuroscience Is Outside the Scope of Counseling Practice

Concerns regarding the requisite knowledge or expertise of counselors aligns well with two specific ACA ethical code standards in this regard: C.2.a. Boundaries of Competence and C.2.b. New Specialty Areas of Practice. This theme assumes that there is a standard of competence that exists. In order for a counselor to be competent, there must be a standard to which they are compared. However, what qualifies a counselor to be competent integrating neuroscience is unclear. There are a few neuroscience-related standards outlined in the American Mental Health Counseling Association (AMHCA) Standards for the Practice of Clinical Mental Health Counseling (2020) pertinent to biological bases of behavior and CACREP practice standards (2015) pertinent to neurobiology. However, these standards are not widely known among counselors and lack recommendations for implementation (Beeson, Field, et al., 2019). This lack of explicit direction is similar to concerns regarding the implementation of other counseling standards, such as the Multicultural and Social Justice Counseling Competencies (Ratts et al., 2016).

Theme Three: Challenges With Neuroscience and the Nature of Neuroscience Research

The third theme highlighted the concern that understanding and applying the body of literature that undergirds integration are essential (Field et al., 2019; Luke, 2019). Neuroscience literature is ever-changing, ever-evolving. This rapid pace of change creates two challenges for counselors. First, counselors could have difficulty staying abreast of the state of the art of integration, leading to the potential for using outdated information in practice. Second, counselors might integrate early findings too quickly before there is enough evidence to support their integration. The quality of neuroscience-related research also appears to be a barrier to integration in that counselors may struggle to discern high-quality research from low-quality research (Gruber, 2017; Kim & Zalaquett, 2019). Related to this, counselors face the challenge of accurately interpreting and applying relevant research for practice. Results indicate a primary concern related to issues of accuracy, leading to misapplication, overstating implications, and misinforming clients. This concern is elevated by other research warning against presumed superiority in neuroscience research, given the potential for neuroscience to seduce, allure, and enchant consumers of literature (Coutinho et al., 2017; Lilienfeld, 2014; Weisberg et al., 2008). Concerns regarding the accuracy of neuroscience knowledge among counselors also have been cited (Kim & Zalaquett, 2019). However, counselors in at least one study indicated more accurate neuroscience knowledge and average endorsement of neuromyths when compared to educators, undergraduate students, and coaches (Beeson, Kim, et al., 2019).

These concerns align with several ACA ethical codes, including Section C: Professional Responsibility (2014). When counselors practice based on emergent literature with which they are only superficially familiar, they risk miscommunication with clients and damaging the veracity and integrity of the profession as it relates to client care. This finding is consistent with previous research (Bott et al., 2016; Luke, 2016) that highlights the risk of using information without great care.

Theme Four: Potential for Harm to Clients

The fourth theme has the highest salience for the profession, as safeguarding client safety and welfare are paramount (Kaplan et al., 2017). Results indicated that manipulation is a real concern among participants. Manipulation can occur through misuse, misrepresentation, embellishment, and controlling of clients through invoking neuroscience (Bott et al., 2016). Respondents reported that the actions leading to client harm may be overt. For example, in a desperate attempt to instill hope in a client, a counselor might overstate the concept of neuroplasticity. Similarly, in an effort to present as more competent than perhaps they feel, a counselor might use neuroscience-laden language with clients, resulting in alienation (Lebowitz et al., 2015). Harm may also occur through unintended consequences of integration. Clients may experience negative side effects such as false hope, deflected responsibility, and forgoing medical consultation. Similar concerns have been found in recent literature (Haslam & Kvaale, 2015; Lebowitz & Applebaum, 2017). These authors note that although on the surface integration seems positive, harm is possible. This underscores the purpose and importance of the ACA Code of Ethics regarding new specialty areas: “Counselors practice in specialty areas new to them only after appropriate education, training, and supervised experience. While developing skills in new specialty areas, counselors take steps to ensure the competence of their work and protect others from possible harm” (ACA, 2014, C.2.b).


As with any qualitative data analysis, transferability is limited. The authors obtained the data from an online survey, using a convenience and snowball sampling method. Therefore, respondents may have had strong opinions regarding neuroscience and not necessarily be representative of the profession. Another limitation was the use of a single, open-ended question that did not allow for an in-depth follow-up. We made conservative inferences regarding the meaning and intent of the data in the discussion. However, interviews would have allowed for more context into participants’ answers. This has long been viewed as a threat to trustworthiness and transferability (Creswell & Plano-Clark, 2018). The structure of the survey in general and the question also could have influenced this result. For example, there was insufficient information available from the responses to know respondent motivation for “n/a” or “none” responses. Although it is likely that respondents did not feel they had enough information to identify ethical concerns, other reasons for such a response are also possible. White females also were overrepresented in the survey sample. This representation is consistent with surveys of CACREP-accredited graduate programs, in which White females are also overrepresented in student and faculty composition (CACREP, 2017). The findings from this study may have been different had the sample been more diverse. The voice of counselors-in-training may be overrepresented in the data. This may also reflect the increasing interest in new counselors-in-training and counselor educators–in–training of neuroscience-informed counseling (Beeson, Field, et al., 2019; Kim & Zalaquett, 2019).

Implications for Practice and Research

This research highlights the need for continued debate and evolution of who we are as counselors and what role neuroscience integration plays in our professional identity, training, and practice. Remaining silent runs the risk of counselors indiscriminately, and perhaps unethically, integrating neuroscience without adequate consideration to counselor professional identity (Luke, 2020). Forgoing these discussions also introduces the risk that counselors may not ensure that such integration enhances rather than detracts from our professional identity. Failing to do so would further support concerns described in 20/20: A Vision for the Future of Counseling (Kaplan & Gladding, 2011). The concerns highlight the consistent trend that best practices tend to be “dictated to counselors by other mental health professions” (p. 371).

A second implication is the need to clarify counselors’ scope of practice with regard to neuroscience. Only one comprehensive set of standards related to neuroscience currently exists (AMHCA, 2020). Yet even with these standards there is little awareness or training around application. Understanding scope will support preventing client harm by ensuring the previous themes are addressed. In this way, counselors will better understand the strengths and limitations of integrating neuroscience information with practice. Further, counselors should continue to practice humility regarding neuroscience evidence. In doing so, they will ensure that they also will be maintaining values (e.g., humanistic orientation) that are hallmarks of the counseling profession.

The results of this study highlight the need for more training in accessing, interpreting, and being current in neuroscience research. This focus includes the need to increase resources to support high-quality neuroscience-based studies in counseling. As scholars have asserted (e.g., Myers & Young, 2012), neuroscience provides a unique strategy to evaluate the outcomes of counseling services. The challenge, as we demonstrate in this article, is how the profession moves forward in view of these ethical standards. It is one thing to assert that counselors operate only within their scope of competence. It is another thing to articulate and circumscribe the limits of competence in an emergent area like neuroscience.

Determining ethical concerns regarding the integration of neuroscience in counseling requires several professional milestones to be met. This could begin with consensus building in the profession regarding neuroscience and counselor scope of practice. To accomplish this step, counselors need to define what it means to integrate neuroscience with practice. As noted in the current study, participants relied on their own operationalization of the integration of neuroscience. The resulting data seemed to indicate that most viewed this integration as neuroeducation (Miller, 2016) or technical applications (e.g., neurofeedback). Many have expressed more broad integration of neuroscience (e.g., Field et al., 2019) as a means to conceptualize client experiences and guide the selection and timing of various techniques.

Next, once integration is defined, there needs to be a clear standard for the training and practice of all master’s-level students (e.g., how much neuroscience does a master’s-level counselor need to know?). In addition, standards for advanced practice postgraduation also require consideration. It is unrealistic to think that master’s-level programs can prepare counselors to be experts in any area of practice, including neuroscience. As such, the profession also needs to define how much training is enough to ethically practice technology-based (e.g., neurofeedback) and non–technology-based (e.g., using to guide case conceptualization and treatment planning) integration. In doing so, counseling will create the scope of practice that can be used as a gauge of competence and limit risks to practicing outside of one’s scope.

Lastly, the counseling profession needs to develop an intentional research effort to validate training standards and therapeutic outcomes related to integration. Additional research is needed before we can appropriately discern future directions of integration. The current paucity of neuroscience literature in the counseling profession is concerning. Of particular concern is the lack of empirical and outcomes-based articles. The lack of training in how to design and evaluate research using emerging paradigms, such as the National Institutes of Health’s Research Domain Criteria, further isolates counselors from participating in national discourse regarding the future classification of mental functioning and mental health diagnoses. As the profession accomplishes these tasks, we will promote ethical care, limit the potential for harm, and ultimately advance the profession as a whole.


Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.



American Counseling Association. (2014). ACA code of ethics.

American Mental Health Counselors Association. (2020). AMHCA standards for the practice of clinical mental health counseling.

Badenoch, B. (2008). Being a brain-wise therapist: A practical guide to interpersonal neurobiology. W. W. Norton.

Beeson, E. T., & Field, T. A. (2017). Neurocounseling: A new section of the Journal of Mental Health Counseling. Journal of Mental Health Counseling, 39(1), 71–83.

Beeson, E. T., Field, T. A., Reckner, J. L., Luke, C., & Jones, L. K. (2019). Neuroscience research, training, and practice: Adding to or subtracting from counselor identity? Journal of Counselor Leadership and Advocacy, 6(2), 97–113.

Beeson, E. T., Kim, S. R., Zalaquett, C. P., & Fonseca, F. D. (2019). Neuroscience attitudes, exposure, and knowledge among counselors. Teaching and Supervision in Counseling, 1(2), 1–19.

Beeson, E. T., & Miller, R. M. (2019). Grounding neuro-informed practice in a humanistic framework: A response to Wilkinson. The Journal of Humanistic Counseling, 58(2), 95–107.

Bengtsson, M., Ohlsson, B., & Ulander, K. (2007). Women with irritable bowel syndrome and their perception of a good quality of life. Gastroenterology Nursing, 30(2), 74–82.

Bott, N. T., Radke, A. E., & Kiely, T. (2016). Ethical issues surrounding psychologists’ use of neuroscience in the promotion and practice of psychotherapy. Professional Psychology: Research and Practice, 47(5), 321–329.

Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2), 77–101.

Cashwell, C. S., & Sweeney, T. J. (2016). Jane E. Myers: Legacy of a life well lived. Journal of Counselor Leadership and Advocacy, 3(1), 4–11.

Clarke, V., & Braun, V. (2017). Thematic analysis. The Journal of Positive Psychology, 12, 297–298.

Council for the Accreditation of Counseling and Related Educational Programs. (2015). 2016 CACREP standards.

Council for the Accreditation of Counseling and Related Educational Programs. (2017). Annual report 2016.

Coutinho, J. F. P., Perrone-McGovern, K. M., & Gonçalves, Ó. F. (2017). The use of neuroimaging methodology in counselling psychology research: Promises, pitfalls, and recommendations. Canadian Journal of Counselling, 51(4), 327–348.

Creswell, J. W., & Clark, V. L. P. (2018). Designing and conducting mixed methods research (3rd ed.). SAGE.

Dekker, S., Lee, N. C., Howard-Jones, P., & Jolles, J. (2012). Neuromyths in education: Prevalence and predictors of misconceptions among teachers. Frontiers in Psychology, 3, 1–8.

Deligiannidi, K., & Howard-Jones, P. A. (2015). The neuroscience literacy of teachers in Greece. Procedia:  Social and Behavioral Sciences, 174, 3909–3915.

Donath, C., Winkler, A., Graessel, E., & Luttenberger, K. (2011). Day care for dementia patients from a family caregiver’s point of view: A questionnaire study on expected quality and predictors of utilization – Part II. BMC Health Services Research, 11(76), 1–7.

Duffy, M., & Chenail, R. J. (2008). Values in qualitative and quantitative research. Counseling and Values, 53, 22–38.

Fernandez-Duque, D., Evans, J., Christian, C., & Hodges, S. D. (2015). Superfluous neuroscience information makes explanations of psychological phenomena more appealing. Journal of Cognitive Neuroscience, 27(5), 926–944.

Field, T. A. (2019). Bridging the brain-body divide: A commentary and response to Wilkinson. The Journal of Humanistic Counseling, 58(2), 108–118.

Field, T. A., Beeson, E. T., Luke, C., Ghoston, M., & Golubovic, N. (2019). Counselors’ neuroscience conceptualizations of depression. Journal of Mental Health Counseling, 41(3), 260–279.

Gleichgerrcht, E., Luttges, B. L., Salvarezza, F., & Campos, A. L. (2015). Educational neuromyths among teachers in Latin America. Mind, Brain, and Education, 9, 170–178.

Gruber, D. R. (2017). Three forms of neurorealism: Explaining the persistence of the “uncritically real” in popular neuroscience news. Written Communication, 34(2), 189–223.

Haslam, N., & Kvaale, E. P. (2015). Biogenetic explanations of mental disorder: The mixed-blessings model. Current Directions in Psychological Science, 24(5), 399–404.

Hays, D. G., Wood, C., Dahl, H., & Kirk-Jenkins, A. (2016). Methodological rigor in Journal of Counseling & Development qualitative research articles: A 15-year review. Journal of Counseling & Development, 94(2), 172–183.

Hunt, B. (2011). Publishing qualitative research in counseling journals. Journal of Counseling & Development, 89(3), 296–300.

Ivey, A. E., & Daniels, T. (2016). Systematic interviewing microskills and neuroscience: Developing bridges between the fields of communication and counseling psychology. International Journal of Listening, 30(3), 99–119.

Ivey, A. E., Daniels, T., Zalaquett, C. P., & Ivey, M. B. (2017). Neuroscience of attention: Empathy and counseling skills. In T. A. Field, L. K. Jones, & L. A. Russell-Chapin (Eds.), Neurocounseling: Brain-based clinical approaches (pp. 81–100).

Kalat, J. W. (2019). Biological psychology (13th ed.). Cengage.

Kaplan, D. M., Francis, P. C., Hermann, M. A., Baca, J. V., Goodnough, G. E., Hodges, S., Spurgeon, S. L., & Wade, M. E. (2017). New concepts in the 2014 ACA Code of Ethics. Journal of Counseling & Development, 95(1), 110–120.

Kaplan, D. M., & Gladding, S. T. (2011). A vision for the future of counseling: The 20/20 Principles for Unifying and Strengthening the Profession. Journal of Counseling & Development, 89(3), 367–372.

Karakus, O., Howard-Jones, P. A., & Jay, T. (2015). Primary and secondary school teachers’ knowledge and misconceptions about the brain in Turkey. Procedia: Social and Behavioral Sciences, 174, 1933–1940.

Kim, S. R., & Zalaquett, C. (2019). An exploratory study of prevalence and predictors of neuromyths among potential mental health counselors. Journal of Mental Health Counseling, 41(2), 173–187.

Lebowitz, M. S., & Ahn, W.-K. (2014). Effects of biological explanations for mental disorders on clinicians’ empathy. Proceedings of the National Academy of Sciences, 111(50), 17786–17790.

Lebowitz, M. S., Ahn, W.-K., & Oltman, K. (2015). Sometimes more competent, but always less warm: Perceptions of biologically oriented mental-health clinicians. International Journal of Social Psychiatry, 61(7), 668–676.

Lebowitz, M. S., & Appelbaum, P. S. (2017). Beneficial and detrimental effects of genetic explanations for addiction. International Journal of Social Psychiatry, 63(8), 717–723.

Lilienfeld, S. O. (2014). The Research Domain Criteria (RDoC): An analysis of methodological and conceptual challenges. Behaviour Research and Therapy, 62, 129–139.

Luke, C. (2016). Neuroscience for counselors and therapists: Integrating the sciences of mind and brain (1st ed.). SAGE.

Luke, C. (2019). Response to Wilkinson: A neuro-informed humanistic perspective. The Journal of Humanistic Counseling, 58(2), 86–94.

Luke, C. (2020). Neuroscience for counselors and therapists: Integrating the sciences of mind and brain (2nd ed.). Cognella Academic Press.

Luke, C., Miller, R., & McAuliffe, G. (2019). Neuro-informed mental health counseling: A person-first perspective. Journal of Mental Health Counseling, 41(1), 65–79.

Luke, C., Redekop, F., & Jones, L. K. (2018). Addiction, stress, and relational disorder: A neuro-informed approach to intervention. Journal of Mental Health Counseling, 40(2), 172–186.

Macdonald, K., Germine, L., Anderson, A., Christodoulou, J., & McGrath, L. M. (2017). Dispelling the myth: Training in education or neuroscience decreases but does not eliminate beliefs in neuromyths. Frontiers in Psychology, 8, 1314.

Merriam, S. B., & Tisdell, E. J. (2016). Qualitative research: A guide to design and implementation (4th ed.). Jossey-Bass.

Miller, R. M. (2016). Neuroeducation: Integrating brain-based psychoeducation into clinical practice. Journal of Mental Health Counseling, 38(2), 103–115.

Myers, J. E., & Young, J. S. (2012). Brain wave biofeedback: Benefits of integrating neurofeedback in counseling. Journal of Counseling & Development90(1), 20–28.

National Institutes of Health. (2014, September). NIH awards initial $46 million for BRAIN Initiative research.

Nowack, K., & Radecki, D. (2018). Introduction to the special issue: Neuro-mythconceptions in consulting psychology—Between a rock and a hard place. Consulting Psychology Journal: Practice and Research, 70(1), 1–10.

Papadatou-Pastou, M., Haliou, E., & Vlachos, F. (2017). Brain knowledge and the prevalence of neuromyths among prospective teachers in Greece. Frontiers in Psychology, 8(804), 1–13.

Patton, M. Q. (2015). Qualitative research and evaluation methods (4th ed.). SAGE.

Ratts, M. J., Singh, A. A., Nassar-McMillan, S., Butler, S. K., & McCullough, J. R. (2016). Multicultural and Social Justice Counseling Competencies: Guidelines for the counseling profession. Journal of Multicultural Counseling and Development, 44(1), 28–48.

Russell-Chapin, L. A. (2016). Integrating neurocounseling into the counseling profession: An introduction. Journal of Mental Health Counseling, 38(2), 93–102.

Schultz, W. (2018). Neuroessentialism: Theoretical and clinical considerations. Journal of Humanistic Psychology, 58(6), 607–639.

Schwartz, S. J., Lilienfeld, S. O., Meca, A., & Sauvigné, K. C. (2016). The role of neuroscience within psychology: A call for inclusiveness over exclusiveness. American Psychologist, 71(1), 52–70.

Simmonds, A. (2014). How neuroscience is affecting education: Report of teacher and parent surveys. Wellcome Trust.

Weisberg, D. S., Keil, F. C., Goodstein, J., Rawson, E., & Gray, J. R. (2008). The seductive allure of neuroscience explanations. Journal of Cognitive Neuroscience, 20, 470–477.

Wilkinson, B. D. (2018). The limits of neuroscience in counseling: A humanistic perspective and proposed model. The Journal of Humanistic Counseling, 57(1), 70–78.


Chad Luke, PhD, NCC, MAC, ACS, LPC/MHSP, is an associate professor at Tennessee Tech University. Eric T. Beeson, PhD, NCC, ACS, LPC, CRC, is a core faculty member at The Family Institute at Northwestern University. Raissa Miller, PhD, LPC, is an assistant professor at Boise State University. Thomas A. Field, PhD, NCC, CCMHC, ACS, LPC, LMHC, is an assistant professor at the Boston University School of Medicine. Laura K. Jones, PhD, MS, is an assistant professor at the University of North Carolina at Asheville. Correspondence may be addressed to Chad Luke, Clinical Mental Health Counseling, Tennessee Tech University, P.O. Box 5031, Cookeville, TN 38505,

Counselors and the Military: When Protocol and Ethics Conflict

Elizabeth A. Prosek, Jessica M. Holm

The U.S. Department of Veterans Affairs (VA) and TRICARE have approved professional counselors to work within the military system. Counselors need to be aware of potential ethical conflicts between counselor ethical guidelines and military protocol. This article examines confidentiality, multiple relationships and cultural competency, as well as ethical models to navigate potential dilemmas with veterans. The first model describes three approaches for navigating the ethical quandaries: military manual approach, stealth approach, and best interest approach. The second model describes 10-stages to follow when navigating ethical dilemmas. A case study is used for analysis. 

Keywords: military, ethics, veterans, counselors, competency, confidentiality

The American Community Survey (ACS; U.S. Census Bureau, 2011) estimated that 21.5 million veterans live in the United States. A reported 1.6 million veterans served in the Gulf War operations that began post-9/11 in 2001 (U.S. Census Bureau, 2011). Gulf War post-9/11 veterans served mainly in Iraq and Afghanistan, in operations including but not limited to Operations Enduring Freedom (OEF), Iraqi Freedom (OIF), and New Dawn (OND) (M. E. Otey, personal communication, October 23, 2012). Holder (2007) estimated that veterans represent 10% of the total U.S. population ages 17 years and older. Pre-9/11 data suggested that 11% of military service members utilized mental health services in the year 2000 (Garvey Wilson, Messer, & Hoge, 2009). In 2003, post-9/11 comparative data reported that 19% of veterans deployed to Iraq accessed mental health services within one year of return (Hoge, Auchterlonie, & Milliken, 2006). Recognizing the increased need for mental health assessment, the U.S. Department of Defense (DOD) mandated the Post-Deployment Health Assessment (PDHA) for all returning service members (Hoge et al., 2006). The PDHA is a brief three-page self-report screening of symptoms to include post-traumatic stress, depression, suicidal ideation and aggression (U.S. DOD, n.d.). The assessment also indicates service member self-report interest in accessing mental health services.

Military service members access mental health services for a variety of reasons. In a qualitative study of veterans who accessed services at a Veterans Affairs (VA) mental health clinic, 48% of participants reported seeking treatment because of relational problems, and 44% sought treatment because of anger and/or irritable mood (Snell & Tusaie, 2008). Veterans may also present with mental health symptoms related to post-traumatic stress disorder (PTSD), depression, and suicidal ideation (Hoge et al., 2006). Depression is considered a common risk factor of suicide among the general population, and veterans are additionally at risk due to combat exposure (Martin, Ghahramanlou-Holloway, Lou, & Tucciarone, 2009). The DOD (2012) confirmed that 165 active-duty Army service members committed suicide in 2011. Furthermore, researchers asserted that suicide caused service member deaths more often than combat (O’Gorman, 2012). Hoge et al. (2004) reported that veterans were most likely to access mental health services 34 months post-deployment. Unfortunately, researchers suggested that service members were hesitant to access mental health treatment, citing the stigma of labels (Kim, Britt, Klocko, Riviere, & Adler, 2011). Studies indicated that mental health service needs are underestimated among the military population and are therefore a potential burden to an understaffed helping profession (Garvey Wilson et al., 2009; Hoge et al., 2006). In May of 2013, the DOD and VA created 1,400 new positions for mental health providers to serve military personnel (DOD, 2013). Moreover, as of March 2013, the DOD-sponsored veterans crisis line reported more than 800,000 calls (DOD, 2013). It is evident that the veteran population remains at risk for problems related to optimal mental health functioning and therefore requires assistance from trained helping professionals.

Historically, the DOD employed social workers and psychologists almost exclusively to provide mental health services in the military setting. Recently, the DOD and VA expanded services and created more positions for mental health clinicians (U.S. VA, 2012). Because licensed professional counselors (LPCs) are now employable by VA service providers (e.g., VA hospitals) and approved TRICARE providers (Barstow & Terrazas, 2012), it is imperative to develop an understanding of the military system, especially of the potential conflict that may exist between military protocol and counselor ethical guidelines. The military health system requires mental health professionals to be appropriately credentialed (e.g., licensed), and credentialing results in the mandatory adherence to a set of professional ethical standards (Johnson, Grasso, & Maslowski, 2010). However, there may be times when professional ethical standards do not align with military regulations. Thus, an analysis of the counselor ethical codes relevant to the military population is presented. At times, discrepancies between military protocol and counselor ethical codes may emerge; therefore, recommendations for navigating such ethical dilemmas are provided. A case study and analysis from the perspective of two ethical decision-making models are presented.


Ethical Considerations for Counselors


The mission of the American Counseling Association (ACA) Code of Ethics (2005) is to establish a set of standards for professional counselors, which ensure that the counseling profession continues to enhance the profession and quality of care with regard to diversity. As professional counselors become employed by various VA mental health agencies or apply for TRICARE provider status, it is important to identify specific ethical codes relevant to the military population. Therefore, three categories of ethical considerations pertinent to working with military service members are presented: confidentiality, multiple relationships, and cultural competence.



The ACA Code of Ethics (2005) suggests that informed consent (A.2.a., p. 4) be a written and verbal discussion of rights and responsibilities in the counseling relationship. This document includes the client right for confidentiality (B.1.c., p. 7) with explanation of limitations (B.1.d., p. 7). The limitations, or exceptions, to confidentiality include harm to self, harm to others and illegal substance use. In the military setting, counselors may need to consider other exceptions to confidentiality including domestic violence (Reger, Etherage, Reger, & Gahm, 2008), harassment, criminal activity and areas associated with fitness for duty (Kennedy & Johnson, 2009). Also, military administrators may require mandated reporting when service members are referred for substance abuse treatment (Reger et al., 2008). When these conditions arise in counseling, the military may require reporting beyond the standard ethical protocol to which counselors are accustomed.

Counselors working in the VA mental health system or within TRICARE may need to be flexible with informed consent documents, depending on the purpose of services sought. Historically, veterans represented those who returned from deployment and stayed home. Currently, military members may serve multiple tours of combat duty; therefore, the definition of veterans now includes active-duty personnel. This modern definition of veteran speaks to issues of fitness for duty, where the goal is to return service members ready for combat. Informed consent documents may need to outline disclosures to commanding officers. For example, if a service member is in need of a Command-Directed Evaluation (CDE), then the commander is authorized to see the results of the assessment (Reger et al., 2008). Fitness for duty is also relevant when service members are mandated to the Soldier Readiness Program (SRP) to determine their readiness for deployment. In these situations, counselors need to clearly explain the exception to confidentiality before conducting the assessment. Depending on the type of agency and its connection to the DOD, active-duty veterans’ health records may be considered government property, not the property of the service provider (McCauley, Hacker Hughes, & Liebling-Kalifani, 2008). It is imperative that counselors are educated on the protocols of the setting or assessments, because “providing feedback to a commander in the wrong situation can be an ethical violation that is reviewable by a state licensing authority” (Reger et al., 2008, p. 30). Thus, in order to protect the client and the counselor, limitations to confidentiality within the military setting must be accurately observed at all times. Knowledge of appropriate communication between the counselor and military system also speaks to the issue of multiple relationships.


Multiple Relationships

Kennedy and Johnson (2009) suggested creating collaborative relationships with interdisciplinary teams in a military setting in order to create a network of consultants (e.g., lawyers, psychologists, psychiatrists), which is consistent with ACA ethical code D.1.b to develop interdisciplinary relationships (2005, p. 11). However, when interdisciplinary teams are formed, there are ACA (2005) ethical guidelines that must be considered. These guidelines state that interdisciplinary teams must focus on collaboratively helping the client by utilizing the knowledge of each professional on the team (D.1.c., p. 11). Counselors also must make the other members of the team aware of the constraints of confidentiality that may arise (D.1.d., p. 11). In addition, counselors should adhere to employer policies (D.1.g., p. 11), openly communicating with VA superiors to navigate potential discrepancies between employers’ expectations and counselors’ roles in best helping the client.

In the military environment, case transfers are common because of  the high incidence of client relocation, which increases the need for the interdisciplinary teams to develop time-sensitive treatment plans (Reger et al., 2008). Therefore, treatment plans not only need to follow the guidelines of A.1.c., in which counseling plans “offer reasonable promise of success and are consistent with abilities and circumstances of clients” (ACA, 2005, p. 4), but they also need to reflect brief interventions or treatment modalities that can be easily transferred to a new professional. Mental health professionals may work together to best utilize their specialized services in order to meet the needs of military service members in a minimal time allowance.

For those working with military service members, consideration of multiple relationships in terms of client caseload also is important. Service members who work together within the same unit may seek mental health services at the same agency. Members of a military unit may be considered a support network which, according to ethical code A.1.d., may be used as a resource for the client and/or counselor (ACA, 2005, p. 4). However, learning about a military unit as a network from multiple member perspectives may also create a dilemma. Service members within a unit may be tempted to probe the counselor for information about other service members, or tempt the counselor to become involved in the unit dynamic. McCauley et al. (2008) recommended that mental health professionals avoid mediating conflicts between service members in order to remain neutral in the agency setting.

However, there are times when the unit cohesion may be used to support the therapeutic relationship. Basic military training for service members emphasizes the value of teamwork and the collective mind as essential to success (Strom et al., 2012). It is important for counselors to approach military service member clients from this perspective, not from a traditional Western individualistic lens. Mental health professionals also are warned not to be discouraged if rapport is more challenging to build than expected. Hall (2011) suggested that the importance of secrecy in the military setting might make it more difficult for service members to readily share in the therapeutic relationship. Researchers noted that military service members easily built rapport with each other in a group therapy session, often leaving out the civilian group leader (Strom et al., 2012). It might behoove counselors to build upon the framework of collectivism in order to earn the trust of members of the military population. Navigating the dynamic of a unit or the population of service members accessing care at the agency may be a challenge; however, counselors are able to alleviate this challenge with increased knowledge of the military culture in general.


Cultural Competence

The military population represents a group of people with a unique “language, a code of manners, norms of behavior, belief systems, dress, and rituals” and therefore can be considered a cultural group (Reger et al., 2008, p. 22). Reger et al. (2008) suggested that many clinical psychologists learned about military culture as active service members themselves. While there may be many veterans currently working as professional counselors, civilian counselors also serve the mental health needs of the military population; and as civilians, they require further training. The ACA Code of Ethics (2005) suggests that counselors communicate with their clients in ways that are culturally appropriate to ensure understanding (A.2.c., p. 4). This can be achieved by prolonged exposure to military culture or by seeking supervision from a professional involved with the military mental health system (Reger et al., 2008). Strom et al. (2012) outlined examples of military-specific cultural components for professionals to learn: importance of rank, unique terminology and value of teamwork. It behooves counselors intending to work with the military population to learn terminology in order to understand service members. For example, R&R refers to vacation leave and MOS or rate refers to a job category (Strom et al., 2012).

Personal values may cause dilemmas for a mental health professional working within the VA system. This can be especially true during times of war. Stone (2008) suggested that treating veterans of past wars may be easier than working with military service members during current combat because politics may be intensified. A counselor who does not support the current wartime mission may be conflicted when clients are mandated to return to active-duty assignments (Stone, 2008). The ACA Code of Ethics (2005) addresses the impact of counselors’ personal values (A.4.b., pp. 45) on the therapeutic relationship. It is recommended that counselors be aware of their own values and beliefs and respect the diversity of their clients. Counselors need to find a way to value the contributions of their client when personal or political opinion conflicts with the DOD’s plans or efforts overseas. If one wants to be successful with this population, Johnson (2008) suggested the foundational importance of accepting the military mission. If this is in direct conflict with the counselor’s values, it may be recommended for the counselor to consider the client’s value of the mission.

The ACA ethical code stresses the importance of mental health professionals practicing within the boundaries of their competence and continuing to broaden their knowledge to work with diverse clients (ACA, 2005, C.2.a., p. 9). Counselors should only develop new specialty areas after appropriate training and supervised experience (ACA, 2005, C.2.b., p. 9). Working within the VA mental health system, mental health professionals may be asked to provide a service in which they are not competent (Kennedy & Johnson, 2009). Such a request may occur more frequently here than in other settings, due to the high demand of mental health services and low availability of trained professionals (Garvey Wilson et al., 2009; Hoge et al., 2006). Counselors must determine if their experience and training can be generalized to working with military service members (Kennedy & Johnson, 2009), and may be their own best advocate for receiving appropriate training.

Awareness of when and how military service members access mental health services also might be important to consider. Reger et al. (2008) reported that military personnel were more likely to access services before and after a deployment. Researchers specified a higher prevalence rate of access 34 months after a deployment (Hoge et al., 2004). The relationship of time between deployment and help-seeking behaviors suggests that counselors should be prepared for issues related to trauma. For women, combat-related trauma is compounded with increased rates of reported military sexual trauma (Kelly et al., 2008). Counselors would benefit from additional trainings in trauma intervention strategies. The VA and related military organizations offer many resources online to educate professionals working with military members with identified trauma symptoms (U.S. VA., n.d.).

Advocating for appropriate training in areas of incompetence is the responsibility of the professional, who should pursue such training in order to best meet the needs of the military population. It is best practice for mental health professionals to be engaged in ongoing trainings to ensure utilization of the latest protocols and treatment modalities (McCauley et al., 2008). Trainings may need to extend beyond general military culture, because each branch of service (e.g., Army, Marines, Navy) could be considered a cultural subgroup with unique language and standards. For example, service members in the Army are soldiers, whereas members of the Navy are sailors (Strom et al., 2012).

This article has outlined many ACA (2005) ethical guidelines pertinent to working with the military population. However, as presented, there are times when counselor ethical codes conflict with military regulations. Counselors interested in working in the military setting or with military personnel may consider decision-making models to address ethical dilemmas.


Recommendations for Counselors


The military mental health system has almost exclusively employed psychologists and social workers. Counselors interested in employment within VA agencies or as TRICARE providers may utilize the resources created by these practitioners to better serve the military population. Two ethical decision-making models are presented, and a case study is provided to demonstrate how to implement the models.


Ethical Models

The ACA Code of Ethics (2005) advises counselors to adhere to the code of ethics whenever possible, working towards a resolution of the conflict (H.1.b., p. 19). If a favorable resolution cannot be formed, counselors have the choice to act in accordance with the law or regulation. Psychology researchers have suggested ethical models for professionals to use during times of dilemma within the military setting. The first model presented considers three overarching approaches to address ethical dilemmas; and the second model presented is a more specific stage model with which to approach dilemmas. These models may serve to assist counselors as the counseling profession gains more experience in the VA system and eventually develops counselor-specific decision-making models.

Approach model. Johnson and Wilson (1993) identified three approaches for psychologists to consider when navigating the ethical quandaries of the military mental health system. The first, the military manual approach, occurs when professionals adhere strictly to military regulations without consideration for the specific client’s needs. The second, the stealth approach, occurs when there is strict adherence to the mental health professionals’ code of ethics, regardless of the legalities surrounding the circumstances. While the client’s best interests may be at the forefront in this approach, the counselor must also take into account the possibility of being the subject of legal action for not adhering to the standards set by the military. For example, the counselor may use ambiguous wording within the client file or leave some information out altogether, so that if the files were requested, the client’s information would be protected (Johnson & Wilson, 1993). The third, the best interest approach, occurs when the counselor maintains focus on the client’s best interest while also adhering to the standards of the military. This may require professionals to adhere to the minimum professional standards in order to accommodate the client’s best interest. Although most professionals have deemed this approach the best option, it also leads to the most ambiguity. Under certain circumstances, the counselor also must take into account what is in the best interest for society as a whole, while also navigating a responsibility to the client and the military mental health system. Researchers in psychology responded to the ambiguity of this model by developing a more specific stage model to assist professionals with ethical dilemmas.

Stage model. Barnett and Johnson (2008) proposed a 10-stage model to follow when navigating an ethical dilemma. They advise that professionals must do the following:

1.   Clearly define the situation.

2.   Determine what parties could be affected.

3.   Reference the pertinent ethical codes.

4.   Reference the pertinent laws and regulations.

5.   Reflect on personal thoughts and competencies on the issue.

6.   Select knowledgeable colleagues with whom to consult.

7.   Develop alternate courses of action.

8.   Evaluate the impact on all parties involved.

9.   Consult with professional organizations, ethics committees and colleagues.

10. Decide on a course of action.

Barnett and Johnson (2008) also noted that once a decision is made, the process does not end. It is best practice to monitor the implications and, if necessary, modify the plan. Documentation throughout this entire process is necessary for the protection of the counselor, the client and other involved stakeholders. Counselors working in the military mental health system may find this 10-stage model helpful when navigating ethical dilemmas.

To better understand the implementation of the two presented ethical decision-making models, a case study was developed. The case is then conceptualized from both the approach model and stage model, and the ethical dilemmas associated with the case are discussed.


Case Study

Megan is a licensed professional counselor employed at a clinic that serves military service members. She provides individual outpatient counseling to veterans and family members, as well as facilitates veteran support groups. Megan’s client, Robert, is a Petty Officer First Class in the Navy. Robert is married with two children. In recent sessions, Megan became concerned with Robert’s increased alcohol use. Recently, Robert described a weekend of heavy drinking at the local bar. Although Robert drove after leaving the bar both nights, Megan suspected that he was not sober enough to drive. In a follow-up session, Robert reported that his binge-drinking weekend caused friction at home with his wife, and that he missed his children’s soccer games. During his most recent session, Robert was visibly distressed as he disclosed to Megan that he received orders for a deployment in 3 months. Robert is anxious about informing his wife and children of the pending 6-month deployment, as he knows it will only increase conflict at home. Robert reported that his family could use the increase in pay associated with family separation and tax-free wages during deployment. However, he also knows that deployments cause tension with his wife, which has already increased due to Robert’s recent drinking binges. While leaving the session, he mentioned with a laugh that he would rather go to the bar than go home.


Analysis from approach model. Megan may consider using Johnson and Wilson’s (1993) ethical approach model as she conceptualizes the potential ethical dilemma presented in Robert’s case. From a military manual approach, Megan may need to report Robert’s recent alcohol abuse behavior to his superior, as it may impact his fitness for duty on his next deployment. And although Robert has not been caught drinking and driving or charged with a crime, his behavior also puts him at risk of military conduct violations. However, when Robert originally came to the clinic, he did so of his own accord, not under orders, which could mean that notifying a commanding officer is an ethical violation. In consideration of the stealth approach, Megan may review the ACA (2005) ethical guidelines and conclude that there are no violations at risk if she chooses not to report Robert’s drinking habits. However, Megan contemplates whether addressing Robert’s drinking binges is in his best interest overall. She understands that the money associated with deployment is important to Robert’s family at this time; however, his drinking may put him at increased risk during deployment. Finally, Megan applies the best-interest approach to Robert’s situation. Megan may refer Robert to the center’s substance use support group. This referral will be reflected in Robert’s records, but if he begins receiving treatment for his alcohol abuse now (3 months before deployment), there may be time for Robert to demonstrate significant progress before his fitness for duty assessment.


Analysis from stage model. Megan may consider her ethical dilemma from Barnett and Johnson’s (2008) 10-stage model. In stage 1, she clearly defines the situation as Robert’s alcohol abuse and pending deployment. In stage 2, Megan considers who may be affected in this situation. She understands that Robert’s family would benefit from the extra money associated with the deployment, and therefore the family may be impacted if Robert is not deployed. Megan also notes that the family is already negatively impacted by his recent drinking binge (e.g., conflict with his wife, missed soccer games). If Robert’s problematic drinking continues, he is at risk for evaluation and promotion issues. In stage 3, Megan reflects upon the ACA (2005) ethical codes in order to better understand her dilemma from a counselor’s view. Robert has a right to confidentiality (B.1.c., p. 7) with limitations including illegal substance use (B.1.d., p. 7). However, Robert’s current substance is alcohol, which is a legal substance. Megan considers the importance of his support network (A.1.d., p. 4) including his family and unit, but she does not have the ethical right to disclose her concerns about his substance abuse. In stage 4, Megan considers the pertinent laws and regulations of the dilemma. As per the clinic regulations, she is aware that if she makes a substance use program referral, it will be reflected in Robert’s record, which is the property of the military. Megan also is aware that Robert has not committed a documented crime of driving under the influence.

In stage 5 of the 10-stage ethical decision-making model, Megan must reflect on her personal thoughts and competencies. She is very concerned about Robert’s increased use of alcohol and is worried for his safety if deployed. Megan feels less confident in her ability to accurately assess for substance use problems. She facilitates the PTSD support group for the clinic, which is her specialty area. Megan recognizes that she is fond of Robert as a client and is disappointed that he could be jeopardizing his family and career with his alcohol abuse. She considers whether she is overreacting to his binge-drinking incident because of her higher expectations of him. In stage 6, Megan consults with her colleague who leads the substance use support groups at the clinic. She describes Robert’s recent abuse of alcohol and inquires as to whether he is a good candidate for the substance use group, needs more intense treatment, or needs no treatment at all. The colleague suggests that the group would be a very appropriate fit for someone with Robert’s symptoms.

In stage 7, Megan develops her course of action to refer Robert to the substance use group. Then, in stage 8, she evaluates the plan for potential impact on parties involved. Megan conceptualizes that Robert may be at risk for losing his deployment orders if he is accessing substance use treatment. Megan believes she has reduced this potential impact by referring to the substance support group, rather than an inpatient treatment facility, which may be more appropriate for a dependence issue. Megan recognizes that attending a 90-minute group each week will take Robert away from his family, but she also realizes that the 90-minute commitment is less than his current time spent away from the family when binge drinking. Megan reflects upon how her therapeutic relationship with Robert may be strained at the time of referral, and is prepared for a potential negative response from her client. She trusts in their therapeutic relationship and moves forward. In stage 9, Megan presents her planned course of action to her supervisor at the clinic. The supervisor approves the referral for the support group, but also suggests that Megan consider a referral to couples counseling for Robert and his wife, which may assist with resolving conflicts before the deployment.

In the final stage, Megan proposes the treatment plan of action to Robert in their next session. Megan explains that she feels ethically obligated to refer Robert to the substance use support group, and that as of now, Robert may make this choice for himself. Megan and Robert discuss the potential that substance use treatment may no longer be a choice in the future if his current drinking behavior continues. There is more discussion of fitness for duty and how participation in the support group will positively reflect upon the assessment in the future. Megan also presents Robert with the recommendation of couples counseling to help mediate relationship conflicts before deployment. She reports that if Robert and his wife decide to receive couples counseling, she can provide a referral for them at that time.

With the ethical decision-making models presented, the counselor is able to successfully navigate the military mental health system, while still maintaining the professional standards of the counseling profession. In each model, the situation is resolved with considerable attention to the client’s best interest, while maintaining the expectations of the military clinic. Psychologists developed the two ethical models presented, and counselors may choose to utilize these approaches until more counselor-specific ethical processes are created. As counselors become more permanent fixtures in the VA mental health system and as TRICARE providers, opportunities to develop an ethical decision-making model will likely arise.




The recent inclusion of counselors as mental health professionals within the VA system and as TRICARE providers allows for new employment opportunities with the military population. However, these new opportunities are not without potential dilemmas. Counselors interested in working with service members need to be educated on the potential conflict between counselor professional ethical guidelines and military protocols. Future research in the counseling field may develop a counselor-specific ethical decision-making model. In the meantime, counselors may utilize or adapt the ethical decision-making models created by other mental health professionals, who have a longer history working with the military population.



American Counseling Association. (2005). ACA code of ethics. Retrieved from

Barnett, J. E., & Johnson, W. B. (2008). The ethics desk reference for psychologists. Washington DC: American Psychological Association.

Barstow, S., & Terrazas, A. (2012, February). DoD releases TRICARE rule on independent practice for counselors. Counseling Today, 54(8), 10. Retrieved from

Garvey Wilson, A. L., Messer, S. C., & Hoge, C. W. (2009). U.S. military mental health care utilization and attrition prior to the wars in Iraq and Afghanistan. Social Psychiatry and Psychiatric Epidemiology, 44, 473481. doi:10.1007/s00127-008-0461-7

Hall, L. (2011). The importance of understanding military culture. Social Work in Health Care, 50, 418. doi:10.1080/00981389.2010.513914

Hoge, C. W., Auchterlonie, J. L., & Milliken, C. S. (2006). Mental health problems, use of mental health services, and attrition from military service after returning from deployment to Iraq or Afghanistan. The Journal of the American Medical Association, 295(9), 10231032. doi:10.1001/jama.295.9.1023

Hoge, C. W., Castro, C. A., Messer, S. C., McGurk, D., Cotting, D. I., & Koffman, R. L. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. The New England Journal of Medicine, 351(1), 1322. doi:10.1056/NEJMoa040603

Holder, K. A. (2007). Comparison of ACS and ASEC data on veteran status and period of military service: 2007. U.S. Census Bureau: Housing and Household Economics Statistics Division. Retrieved from

Johnson, W. B. (2008). Top ethical challenges for military clinical psychologists. Military Psychology, 20, 4962. doi:10.1080/08995600701753185

Johnson, W. B., Grasso, I., & Maslowski, K. (2010). Conflicts between ethics and law for military mental health providers. Military Medicine, 175, 548553.

Johnson, W., & Wilson, K. (1993). The military internship: A retrospective analysis. Professional Psychology: Research and Practice, 24(3), 312318. doi:10.1037/0735-7028.24.3.312

Kelly, M. M., Vogt, D. S., Scheiderer, E. M., Ouimette, P., Daley, J., & Wolfe, J. (2008). Effects of military trauma exposure on women veterans’ use and perceptions of Veterans Health Administration care. Journal of General Internal Medicine, 23, 741747. doi:10.1007/s11606-008-0589-x

Kennedy, C. H., & Johnson, W. B. (2009). Mixed agency in military psychology: Applying the American Psychological Association ethics code. Psychological Services, 6(1), 2231. doi:10.1037/a0014602

Kim, P. Y., Britt, T. W., Klocko, R. P., Riviere, L. A., & Adler, A. B. (2011). Stigma, negative attitudes about treatment, and utilization of mental health care among soldiers. Military Psychology, 23, 6581. doi:10.1080/08995605.2011.534415

Martin, J., Ghahramanlou-Holloway, M., Lou, K., & Tucciarone, P. (2009). A comparative review of U.S. military and civilian suicide behavior: Implications for OEF/OIF suicide prevention efforts. Journal of Mental Health Counseling, 31(2), 101118.

McCauley, M., Hacker Hughes, J., & Liebling-Kalifani, H. (2008). Ethical considerations for military clinical psychologists: A review of selected literature. Military Psychology, 20, 720. doi:10.1080/08995600701753128

O’Gorman, K. (2012, August 16). Army reports record suicides in July [Blog post]. Retrieved from

Reger, M. A., Etherage, J. R., Reger, G. M., & Gahm, G. A. (2008). Civilian psychologists in an army culture: The ethical challenge of cultural competence. Military Psychology, 20, 2135. doi:10.1080/08995600701753144

Snell, F., & Tusaie, K. R. (2008). Veterans reported reasons for seeking mental health treatment. Archives of Psychiatric Nursing, 22(5), 313314. doi:10.1016/j.apnu.2008.06.003

Stone, A. M. (2008). Dual agency for VA clinicians: Defining an evolving ethical question. Military Psychology, 20, 3748. doi:10.1080/08995600701753177

Strom, T. Q., Gavian, M. E., Possis, E., Loughlin, J., Bui, T., Linardatos, E.,…Siegel, W. (2012). Cultural and ethical considerations when working with military personnel and veterans: A primer for VA training programs. Training and Education in Professional Psychology, 6(2), 6775. doi:10.1037/a0028275

U.S. Census Bureau, American Community Survey. (2011). B21002: Period of military service for civilian veterans 18 years and over (2011 American Community Survey 1-year estimates). Retrieved from

U.S. Department of Defense. (n.d.). Enhanced post-deployment health assessment (PDHA) process (DD Form 2796). Retrieved from

U.S. Department of Defense. (2012). Army releases July suicide data, No. 683-12. Retrieved from

U.S. Department of Defense. (2013). DOD, VA and HHS partner to expand access to mental health services for veterans, service members, and families, No. 353-13. Retrieved from

U.S. Department of Veterans Affairs. (n.d.). PTSD: National center for PTSD. Retrieved from

U.S. Department of Veterans Affairs (2012, April). VA adding family therapists and mental health counselors to workforce. Retrieved from

Elizabeth A. Prosek, NCC, is an Assistant Professor at the University of North Texas. Jessica M. Holm is a doctoral student at the University of North Texas. Correspondence can be addressed to Elizabeth A. Prosek, University of North Texas, 1155 Union Circle #310829, Denton, TX 76203-5017,