A vulnerable population is defined as a group that is more at risk of physical, psychologic, and social harm or lacks the means to protect themselves [1]. A group's lack of protection may be due to past or existing marginalization or lack of access to services due to social, economic, and/or political circumstances [70]. Consequently, women as a group can be classified as a vulnerable population [1]. For example, women are twice as likely to be diagnosed with depression, and studies show that gender differences in presentation of depressive symptoms may start as early as adolescence [81]. They are also 1.5 to 2 times more likely than men to be diagnosed with an anxiety disorder [141]. Women are at a higher risk of violence by their intimate partners, and in some countries, they are at higher risk for human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS). Their gender and the differential access to resources and privileges impacts their protective capacities. A woman may be afraid to ask her spouse/partner to wear a condom because to do so could be perceived as accusing him of adultery and could result in negative repercussions, such as domestic violence [1]. Women who perceive and experience sex discrimination (conceptualized as a social stressor) are more likely to have poor health or a diagnosis of clinical depression [142].

The feminist movement can be classified in three different waves. The first wave spanned the 19th century to the early 20th century. Middle-class women in the 1830s formed charitable and benevolent societies to help sex workers and the destitute. They later embraced the cause of slavery and put voice to the abolitionist movement [24]. Feminists during this time also advocated for the importance of bringing women's influence into men's spheres, such as for women's right to vote [112]. The Seneca Falls Declaration of 1848 rejected the prevailing doctrine of women's innate inferiority. After the Civil War, these first-wave feminists took up the temperance movement, which continued into the early part of the 20th century. During this time, they also focused on social welfare and labor reform, advocating for reform of working conditions in factories and for women and child laborers, specifically limiting women's working hours, developing minimum wage, and banning child labor [24]. Women's enfranchisement was also another key issue during this wave [90]. After women won the right to vote in 1920, this first wave of feminism waned and lost momentum [16]. In this first wave, issues of class and race can affect women's lives were largely ignored, as the recognized movement was largely co-opted by upper-class White women [90,112].

The second wave of feminism in the United States began in the 1960s and continued until the 1990s. The 1960s were a time of civil, social, and political discontent. The youth of this generation questioned the existing authority and government structures, the Vietnam War, and the marginalization and oppression of various minority groups (e.g., racial/ethnic minority groups, women, and gays and lesbians). In Betty Friedan's book The Feminine Mystique, she analyzed the time period after World War II and the social, cultural, and political forces that reinforced notions of women's bodies, domesticity, and femininity and how they impeded women's freedoms [144]. She later co-founded the National Organization for Women (NOW) [19].

The third wave of feminism started in 1990 and continued to around 2013 [112]. With roots in black feminist work, this wave is considered diverse, with no one philosophical stance; however, the third wave was viewed as a new feminist discourse for understanding gender relations that takes into account the inadequacies of the previous waves [48,82]. Third-wave feminists saw themselves as, "making right some of the second wave's wrongs. In many cases, feminists of the third wave perceived themselves as rebelling against their second-wave predecessors [88]. They posit many of their arguments in response to or in reaction to second-wave positions on sexuality, power, and culture" [57]. Third-wave feminists gave women the latitude to define feminism for themselves, and they strove to make the movement more inclusive and diverse [48]. This third wave has underpinnings in postmodernism, contending for individual choice and individualized feminism [112]. These feminists targeted young women who may believe in feminism but are concerned with the negative connotations [4]. Feminists of this period emphasized individual empowerment; however, critics assert that they did not adequately focus on collective activism to challenge systemic injustices and inequities perpetuated by structural forces [146]. While Ms. was the platform for many feminists in the second wave, the third wave took on utilizing homemade pamphlets (zines) and the Internet to disseminate their views using blogs, art, and music [88].

Third-wave feminists argued for intersectionality. The first and second waves of feminism downplayed the role of ethnicity and race and instead emphasized the unity of all women—the sisterhood of women and issues pertinent to all women [48]. Third-wave feminism argues that multiple, simultaneous oppressions exist, including oppression stemming from gender and race/ethnicity, and they are inseparable and intertwined [48]. In other words, women inhabit simultaneous conditions of marginality based on race, class, sexual orientation, age, and many more factors [82,144]. As a result, the third wave of feminism advocated for a more inclusive approach, embracing other social groups (e.g., racial/ethnic minority women, gay women, etc.) [4]. Queer theory, for example, emerged during this period [144]. There are three core tenets of intersectionality [84]:

Liberal feminists argue that the differences between men and women are due to sex role socialization and patriarchal ideologies embedded in social institutions [52]. The fight for gender equality is at the heart of liberal feminists' work, with a goal to pave equal opportunities and access for men and women [175]. One of the solutions to remedy gender inequality proposed by liberal feminists is the implementation of laws to provide equal access [49; 175].

Radical feminists link women's oppression to the sexism that permeates every dimension of day-to-day lives [49; 175]. They argue that gender differences are rooted in the notion of essentialism [52,148]. Essentialism propounds that women's identity is linked to a single trait, specifically that women are more caring and nurturing and less aggressive than men. Neither essential gender role is superior, but the existing social order is predominantly patriarchal and reinforces male attributes [52,148]. Sexism is so deeply ingrained that some radical feminists have argued for separatism, advocating for an exclusive "womanculture"—a female science, female religion, female arts, rejection of the nuclear family, etc. [17,115]. In other words, existing institutional structures should be recreated to be more woman-oriented [176]. These political tenets had underpinnings of destruction, and Valerie Solanas's SCUM Manifesto became the prominent symbol for radical feminists [115]. One of the major criticisms of radical feminism lies in their assertion for essentialism, focusing on the objectification of a woman's body and a reductionistic explanation linking women's roles to biology [148].

Marxist feminism is viewed as revolutionary. Although these feminists argue for structural change, they focus on class structure, as they believe women's oppression is rooted in capitalism [17; 149; 175]. Women's socioeconomic positions and classism are at the heart of this type of feminism. Marxist feminists trace patriarchy and women's oppression to women's roles being historically limited, meaning that patriarchy can only be eradicated if the separation of public and private work (i.e., housework) disappears [175]. Therefore, women are doubly oppressed as a result of their sex and class [149]. To Marxist feminists, domestic work is considered productive work, because although this work is "invisible," it is still important [116]. Therefore, Marxist feminists target women's work (both paid and unpaid) and focus on raising revolutionary consciousness of working women to instigate change [17]. They also posit that classism results in disparities in access to resources, manifested as, for example, healthcare disparities. However, beyond this, Zrenchik and McDowell assert that classism also results in the unequal distribution of respect and admiration [91]. Segments of the poor in society are therefore often labeled as "immoral," "criminal," or "dirty" [91]. Marxism feminism has resurfaced in recent years as globalization has increased poverty, migration, and violence around the world [150]. Marxist feminists attempt to understand these trends as the struggle within class, race, and gender.

Global feminists emphasize the issues of oppression, marginalization, and discrimination among all women globally. They maintain that other non-dominant and non-Western perspectives should be taken into account, focusing on oppression as it relates to neocolonialism (economic structures created by former colonial powers to maintain colonies' dependencies) and global capitalism [16,118]. Issues such as education, sex work, and access to health care are important topics for global feminists [16].

The focus of postcolonial feminism is on women in developing countries. Postcolonial feminists argue that Western and androcentric models of feminism are not appropriate for women born and living in developing countries, particularly those that experienced white/Western imperialism [149]. Their struggles and subjective experiences are uniquely different from white women in Western industrial countries [149].

The notion of abnormality is heavily influenced by social and cultural norms. Early philosophers have depicted women as irrational beings [16]. Harris and Lighter assert that, historically, when women were the focus of attention in the mental health fields, they were "in the role of patient or repository of psychopathology, not as exemplar of healthy personality development" [36]. In the 1700s and 1800s, women's mental illness was linked to sin and vice [152]. Later, women's mental illness was tied to the "weaker" female constitution due to menstruation, pregnancy, and menopause [71,152]. Some even argued that a woman's womb moved aimlessly throughout the body, causing insanity and draining life energy [71]. Hysteria, a disorder that involved the nervous system, was commonly diagnosed among women in the 18th and early 19th centuries, and many physicians believed this was a natural state for women (e.g., excitability, difficulty, egocentrism), but a "morbid state" for men [120].

Some have argued that the negative construction of women's bodies and behaviors essentially functioned as social control. Women's roles were maintained and perpetuated by labeling socially unacceptable behaviors as "hysterical," "insane," or "neurotic" [71]. Overall, a feminist approach to science minimizes a "masculine" approach to ensure it is not the predominant perspective [153]. Existing traditional personality theories are based on traditionally male values and benchmarks of normality; a feminist approach advocates for a shift to honoring women's values and experiences [177].

Some experts have argued that the DSM is androcentric and that the diagnostic labels are gender biased and judgmental of women, arising from the psychopathologization of women and their roles [121,177]. In 1968, the DSM-II portrayed hysterical personality disorder as an extreme parody of femininity [120]. Personality disorders like dependent personality disorder, borderline personality disorder, and histrionic personality disorder reinforce notions about the pathology of dependency and emotionality, attributes generally ascribed to women [154]. Interestingly, dependent personality disorder is not associated with men, despite the fact that, historically, men were often reliant on women to care for the home and to provide caregiving [27,72]. Borderline personality disorder is also diagnosed more often in women than men and is characterized by impulsivity, instability in relationships, and intense fear of abandonment, which consequently leads to behaviors to avoid abandonment [95]. Women who express volatility and anger are more likely to be categorized as having borderline personality disorder and prescribed medication [178]. Overdiagnoses of certain psychiatric conditions are a reflection of how social institutions respond to women who deviate from socially accepted norms of femininity [178,179].

Although there are several types of feminism, a few principles or overarching themes are common among them and in feminist therapy. It is important to remember that feminist therapy is not meant to exclude men or to isolate women from men. The goal of feminist therapy is to assist every individual to break out of stereotypical expectations regarding gender norms and behaviors that ultimately lead to dysfunction [4]. Feminist therapists believe that gender, power, and culture are important contextual factors influencing clients' personal experiences and views [181].

Another important aspect of feminist counseling is de-emphasizing hierarchal relationships. Patriarchal ideologies and power imbalances permeate society. As such, many relationships that women experience may be hierarchal and oppressive. In feminist counseling, the therapeutic relationship should minimize hierarchal relationships and reflect a more collaborate and egalitarian partnership between the client and the clinician [15,158]. One way to promote egalitarian relationships in the clinical process is for the practitioner to be transparent with the objectives of the therapy and to avoid the use of clinical and professional jargon that the client cannot understand [20,181]. Many women may have felt disempowered by the medical community [181]. Facilitating mutual goal-setting and providing information about therapy are also recommended [158].

Feminist practitioners advocate for social change in order to eradicate injustices and oppression. On the other hand, a nonsexist clinician focuses on assisting women to minimize the distress they experience due to traditional gender role socializations and to adjust to discrimination and gender role inequalities. Feminist counseling/therapy emphasizes change at the macro level, to cultural, social, and political forces, that will help to eliminate women's problems and result in social justice. Nonsexist counseling/therapy focuses more on a client's intrapsychic state rather than the environment in which the client exists [20].

The goal of gender role analysis is to assist clients to identify the specific gender role expectations and messages that influence their behaviors as well as behaviors that they engage that might reflect specific gender role expectations that ultimately impede them from achieving their goals [124,177]. Five steps are necessary in true gender role analysis. First, the clinician helps the client to identify various gender role beliefs and expectations experienced from early childhood [60]. Second, the clinician and the client discuss how these expectations have affected the client's life negatively and positively. Third, the client works to identify internalized beliefs based on these gender role expectations. Fourth, with the help of the clinician, the client will decide which of the internalized beliefs he/she would like to address. Finally, a specific plan is developed to implement and monitor changes [60]. It is important for clients to understand the sources of gender role messages and to identify what reinforcers and punishments exist for adhering to these messages [159]. Clients should be encouraged to evaluate the costs and benefits if they were to eliminate certain messages.

Again, feminist therapy is not limited to women. For example, men who are diagnosed with body image dissatisfaction can use bibliotherapy within a feminist framework to educate themselves on healthy body image, nutrition, and self-esteem [97]. Any intervention aiming to ultimately empower clients to move out of socially learned scripts may be feminist.

Assertiveness has been defined as behaviors that involve standing up for one's rights without violating the rights of others [60,161]. Assertive skills training frequently involves cognitive-behavioral strategies to assist clients in verbalizing their needs/desires, developing social skills, and reducing anxiety that arises when executing assertive behaviors [161]. Many feminist practitioners argue that women may need to be taught assertiveness skills due to the fact that assertiveness is not usually considered a desirable female attribute. The underlying assumption of assertiveness training is that after women are educated about their personal rights and taught skills to overcome perceived barriers, other positive outcomes (e.g., enhanced self-esteem) will follow [25].

Feminist practitioners work with clients to promote awareness of the differences in power relations between men and women in society (also known as power analysis) [60,124]. The first step is to explore definitions of power with the client and to assist clients to identify which definition of power best fits within the client's value orientation. Subsequent steps involve helping the client to recognize internalized messages about power and to alter them [15]. In order to model egalitarian relationships, the therapeutic environment becomes crucial. As discussed, in feminist counseling and therapy the clinician/client relationship is collaborative. Instead of the clinician simply diagnosing the client's distress, the therapist and client dialogue and work collaboratively to discuss potential reasons and meanings of the symptoms [29]. Clients are given the position of the expert and control what occurs in therapy. They also have the freedom to voice disagreements with the practitioner [18].

As discussed, many feminists have criticized Freudian concepts such as penis envy, the Electra complex, and mothers as roots of psychologic disorders. One of the predominant themes in feminist psychoanalysis is that because of experiences during infancy, women tend to have a deeper emotional connection with others [12]. In feminist psychoanalysis, the client is encouraged to explore how Oedipal issues reinforce existing gender identities and male domination [60]. The role of the clinician is to simultaneously serve as the mother and therapist to facilitate the client's work in balancing the tasks of individuating and emotionally connecting with others [12].

This type of therapy focuses on the family system, a group of individuals characterized by marked transactional patterns and dynamics of interpersonal relationships [66]. These patterns are the focal points, as they influence how members act and react [66,185]. Six elements have been identified as the heart of feminist family therapy [68,128]:

Kohlberg's theory of moral development has been criticized for being androcentric, meaning the dilemmas capture male moral development and do not apply to women. Furthermore, some experts argue that Western conceptualizations of ethics are based on the premise that there are a set of universal, rational, neutral, objective, and impartial rules that are applied to everyone [53]. For example, the concept of justice is based on the assumption that the individual is autonomous and independent, with a rational ability to exercise control [46]. Carol Gilligan, a leading critic of Kohlberg's work, asserted that men and women have different ways of conceptualizing morality, and therefore, the decisions made will be different [35]. In her study, for example, girls did not want to make a moral decision without considering the social context; they wanted to avoid conflict, and their thinking reflected a need to take into account interpersonal relationships using principles of care (e.g., empathy, awareness of others and their feelings) [186]. In a cross-cultural study in Turkey, women managers scored higher on reproductive moral imagination (i.e., taking on the perspectives of another individual) than men [101]. The authors argued that women tend to take interpersonal relationships into account in their moral decision making.

The Feminist Therapy Institute developed a Feminist Therapy Code of Ethics, which offers a set of guidelines to supplement rather than replace the code of ethics of the field in which a practitioner practices (Table 1). The Feminist Code of Ethics covers five areas that direct practice, training, and research [30]:

Cultural diversity and oppressions

Power differentials

Overlapping relationships

Therapist accountability

Social change

The feminist ethical decision-making model involves seven steps. Although it is presented in a linear manner, the practitioner frequently moves back and forth through the steps [37].

Step 1 involves recognizing the problem. The recognition of the problem is influenced by a range of factors, including the practitioner's level of experience and his/her values system. Often, a feeling of discomfort might arise for the practitioner, and it will be crucial to identify feelings and reactions that might influence understanding of the problem.

Defining the problem is step 2. This consists of identifying the nature of the conflict and whether it stems from potential discrepancies between the code of ethics, laws, clinical issues, and agency guidelines. To the extent possible, the client should assist in defining the nature of the problem. Defining the problem also involves evaluating how the practitioner's and client's contextual factors (e.g., gender, race/ethnicity, age, and other social variables) affect the situation. On the emotional-intuitive side, the practitioner should begin to examine his/her feelings of potential discomfort.

Step 3 of the feminist ethical decision-making model is generating solutions. As various potential solutions are brainstormed, a cost-benefit analysis should also be conducted for each option. The risks and benefits should also be considered. The client should be involved to the fullest extent possible in the brainstorming and cost-benefit analysis. The emotional-intuitive component continues in this step, as the practitioner should reflect on initial reactions that arise with each option.

The next step is selecting a solution. Practitioners should determine the solution that is the best fit both emotionally and rationally for both the client and him or herself. It should be a solution that meets everyone's needs, can be implemented, and is acceptable to both parties [37,165].

Reviewing the process is step 5. In the review process, the practitioner should carefully consider how a solution was reached. Questions that may be helpful to this process include:

Implementing and evaluating the solution should be undertaken next. The plan will be implemented, and the consequences can be observed and noted. In some cases, new information comes to light and the problem will be redefined.

The final step in the process is continuing reflection. The lessons learned from the experience should be reflected upon in order to be applied to future situations. Practitioners should determine what they would do differently, what they have learned, and how they have changed as a result of the decision [165].

Feminism and multiculturalism share many commonalities and roots. Both concepts grew out of social movements in the 1960s that challenged the established norms. Both recognize the marginalization and discrimination experienced by women and racial/ethnic minority groups and how this is reinforced and perpetuated by societal infrastructures, and both emphasize strength, human growth, and potential instead of pathology [55]. The client, rather than the clinician, is considered the expert in telling his/her story [103]. Because of their concerns with oppression and marginalization, counselors from both perspectives are entrenched in social advocacy work, fighting for justice and equality, and reducing disparities [103]. Despite sharing similar values and coming out of a shared history, these two philosophies have remained in their distinct spheres [55].