Ohio Counseling Association

Volume 40, Issue 2
Summer 2014


Page 2

Guidelines—Summer 2014

Call for Submissions
Attention professionals, students
and counselor educators! Please
consider submitting your papers,
ideas or proposals to Guidelines.
Each issue strives to provide information on legal/ethical issues,
advocacy, current trends, student
perspectives, and articles from
professionals in the field. All
submissions are given consideration. Submissions can be directed
to the editor, Jared Rose, at


Victoria E. Kress, PhD, LPCC-S, NCC


Contact Information


Statehouse News
Carolyn Towner & Amanda Sines


Crisis Interventions for Child Survivors of
Natural Disasters
Katherine Hutson, CT


Adolescent Suicide Postvention and
Prevention Planning
Valerie M. Capucini, CT


Grief Support Session for Children
Lori A. Hunt, MAC, PSC


Ohio Counseling Association
8312 Willowbridge Place
Canal Winchester, OH 43110

Executive Director’s Greetings
Rachel M. O’Neil, PhD, LPCC-S

Guidelines is published by the
Ohio Counseling Association,
a branch of the American Counseling Association. The opinions
expressed in the articles and
advertisements within this newsletter are those of the authors and
not the association. Direct questions, suggestions, and comments
to the editor, Jared Rose, at

President’s Message

Counseling Those with Hoarding Disorder:
Basic Considerations for Practice
Chelsey A. Zoldan, Nicole A. Adamson, &
Victoria E. Kress, PhD, LPCC-S, NCC


Advocating for Mental Health Treatment
in Corrections
Latoya Caver-Jackson



Moral Injury: An Emerging Issue
Scott Campbell, CT, Keith Clark, CT, &
Scott Hall, PhD, LPCC-S

Vol. 40, Issue 2

Page 3

FEATURES (cont.)

Six Key Questions to Ask Yourself When
Deciding Whether or Not to Pursue a
Doctorate in Counseling
Brent G. Richardson, PhD, LPCC-S


Applying Theory to Practice:
Constructing Dignity with Our Words
Michael J. Leskosky


Promoting Clinical Competencies and Advocacy:
Reflections from a Workshop Addressing Current
Issues and Tips for Working with Sexual Minorities
The 2013-2014 ALGBTICO Board of Directors


Victoria Kress
Kara Kaelber
Meghan Fortner
Connie Patterson
Chelsey Zoldan
Tom Davis
Executive Director
Rachel O’Neil
Shaun Renato

Journal of Counselor Practice

Save the Date - November 5-7,2014
Registration Coming Soon!

Varunee Faii Sangganjanavanich
Guidelines Newsletter
Jared Rose
Cassandra Pusteri
Bylaws & Political Action
Carrie VanMeter
Ethics & Professional Identity
Kelly Kozlowski,
Stephanie McGuire-Wise
Jim Hyland
Government Relations
Brandy Kelly Gilea
Media & Public Relations
Phil Isco
Mia Hall,
Stephanie Fellenger
Professional Development
Michael Lewis
Towner Policy Group
OCSWMFT Board Liaison
Matthew Paylo

Guidelines—Summer 2014

Page 4

Dear Members of OCA,
It is hard to believe, but I first became involved with OCA 20 years ago. At that time I could not
have imagined I would be honored with the privilege of serving as your president. What is especially
thrilling is that I have the opportunity to serve during such a vibrant time in our organization’s
As we transition executive councils, I would like to take a moment to thank Meghan Fortner, our
past-president, and Tim Luckhaupt, our past-executive director for their leadership and support over the
past year. They have laid a solid foundation that our organization can use to support OCA as we move
Moving forward, Dr. Rachel O’Neil, OCA’s new executive director, is bringing a wealth of
experience and many innovative ideas to OCA. We also recently hired a
new conference planner who will help us make this year’s All Ohio
Counselors Conference a success.
Over the next year, one of my initiatives will be to identify and
grow more leaders within our organization. To thrive as an organization,
we need our members to be involved in supporting OCA. Many of you
have resources that have yet to be tapped, and talents and experiences
that can strengthen our organization. To fully realize the unique
strengths of all OCA members, I am actively recruiting and engaging
new volunteers. If you are interested in serving on a taskforce or committee, please email me and let me know of your interest. We can work
together to find a place in OCA that is a good fit for you.
I mentioned these are exciting times to be involved in OCA. The
passage of House Bill 232 marks a historic change that highlights
Ohio’s commitment to standards; standards which help to facilitate our professional credibility. HB 232 requires that (starting in
2018 and for those graduating after 2018) those who graduate from an
Ohio counseling program will need to be graduates of a clinical mental
health program, clinical rehabilitation program, or addiction counseling
program accredited by the Council for Accreditation of Counseling and
Related Educational Programs (CACREP) to be considered for licensure
in Ohio. This change makes Ohio the first state to require a CACREP
degree for licensure (for those graduating from an Ohio program).
Thanks to those who have worked hard to facilitate the passage
of this bill. Counselors in Ohio have always been leaders in our profession and the passage of this bill is one more indicator of our firm counselor identity and value of standards. Other states will soon follow our
lead, and we should be proud to call ourselves “Ohio counselors”!
As always, please let me know if you have suggestions or ideas
on how we can better serve you and our membership. I am excited
about OCA’s future and it is a privilege to serve as your President!
Victoria E. Kress, PhD, LPCC-S, NCC

Vol. 40, Issue 2

Page 5

Crisis Interventions for Child Survivors of Natural Disasters
Katherine Hutson, CT
On the afternoon of May 20, 2013 an EF5 tornado hit the town of Moore, Oklahoma leveling houses
and businesses, and seriously damaging two elementary schools. Media coverage portrayed stories of children
crouched in the hallways and teachers leading the students in prayer as the storm wreaked havoc on the town
and schools. The loss of life and property caused by the tornado was extensive, and every child at the two
elementary schools was impacted by the disaster in some way. In the wake of this incident, crisis counseling
was among the many services offered to survivors. Undoubtedly, many adults in the community required
counseling to come to terms with what had happened, but what about the children? What are normative
reactions for child survivors of natural disasters? And what are the best practices as far as intervention
and counseling is concerned?
Reactions to a natural disaster among children can vary even more widely than the reactions of adults.
Additionally, a child’s reaction to a crisis event is largely
determined by developmental age, past experiences, and
mental health standing prior to the crisis event (Baggerly
& Exum, 2008). Children experiencing a natural disaster
can exhibit symptoms including fear, depression, guilt,
loss of interest, sleep disturbance and night terrors,
appetite disturbance, aggressiveness, flashbacks, nightmares, substance abuse, poor concentration, and separation anxiety with the degree of symptom severity varying
by the child’s developmental age (Baggerly & Exum,
2008). Psychosomatic symptoms such as headaches and
stomachaches may also be present and, as with adults, these symptoms may result in a diagnosis of several
disorders including stress, anxiety, and depression disorders (Baggerly & Exum, 2008).
As unique as each child’s reaction is to a natural disaster, so too should be the intervention
or combination of interventions used to help the child. A wide array of techniques and resources are
available to assist crisis counselors in working with child survivors of natural disasters. Parents play a vital
role in the way their child responds to a disaster because children look to cues from their parents on how to
react (Baggerly & Exum, 2008). If a child sees his or her parents interacting coolly with others about the
event, they may be more likely to be calm and accept and cooperate with helpers. At the time of a natural
disaster it is helpful for parents to maximize their child’s positive trait of good communication skills by talking
to their child(ren) about their emotions and concerns (Baggerly & Exum, 2008). Parents and counselors may
need to utilize more creative communicative modes such as drawing or playing for younger children (Baggerly
& Exum, 2008). Psychoeducation for parents, teachers, and children to give information about the normative
scope of natural disaster reactions may be reassuring to the child (Baggerly & Exum, 2008). According to
Baggerly & Exum (2008), “Providing a handout of typical children’s cognitive, emotional, physiological,
behavioral, and spiritual symptoms will help parents and teachers focus on the normalcy of children’s responses, rather than seeing them as pathological” (p. 83). Normalizing a child’s reaction can boost their selfefficacy (Baggerly & Exum, 2008). Parents and teachers should also instill a structured routine that is stable
and manageable, preferably reestablishing as much of the normal routine from prior to the disaster event as
possible (Baggerly & Exum, 2008).

Guidelines—Summer 2014

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Using cognitive behavioral therapy (CBT) procedures in a child-friendly playful atmosphere, a counselor can assist a child to “(a) play a game of identifying indicators that they are safe at the present time, (b) draw
a picture of a safe place, and (c) develop a safety plan for future disasters” (Baggerly & Exum, 2008, p.86). To
assist with anxiety, counselors can teach relaxation techniques to children such has blowing bubbles or a
pinwheel, muscle group relaxation, and focusing on happy times by drawing pictures of happy places and
memories (Baggerly & Exum, 2008). For more intensive cases, counselors can use CBT to help a child
client manage intrusive thoughts pertaining to disasters and manage avoidance behaviors by
systematic desensitization (Baggerly & Exum, 2008).
Counselors trained in play therapy use a variety of creative toys such as
paper, crayons, markers, dolls, zoo animals, blocks, puppets, rescue vehicles, toy
medical kits, etc., to engage a child in communicative play. Children use play to
express their trauma narrative which assists the child to resolve symptoms, build
resiliency, and resume normal development (Baggerly & Exum, 2008). While some
play therapists are directive and others are nondirective, the general understanding
among play therapists is that children will use play materials to act out anxieties and
fears (Webb, 2011). As children play, counselors must give therapeutic responses of
content and feeling, enlarge the meaning, and facilitate accurate understanding of
the event (Baggerly & Exum, 2008).
A few limitations are present when using play therapy in the immediate
response of a natural disaster. Initially, depending upon the type of disaster and extent of destruction, it may be difficult for a counselor to find or create a contained
space in which to meet child clients (Webb, 2011). Blankets or waterproof coverings
for the ground may help create a space to conduct sessions (Webb, 2011). To be able to conduct sessions
with minimal play materials Webb (2011) suggests counselors pack “easily transported colored and plain paper and markers… they may also bring a bag of small toys including small dolls, rescue vehicles, boats, a toy
medical kit, and toy musical instruments” (p. 136). With adequate planning and preparation these obstacles can
be overcome and play therapy can be used in the field or in the office for intervention following a natural
Another means of communication for children lies in the creative arts. Expressive or creative arts can
take a variety of forms from drawing or painting, to music and dancing. Using music to process feelings
during grief work with children and adolescents has been shown to decrease depressive symptoms
(Davis, 2010). The creative use of music in crisis counseling intervention “supports a humanistic approach of
valuing one’s creative power as a crucial force in change and healing” (Davis, 2010, p. 131). An especially
useful aspect of creative arts counseling is that it can easily be used with children who are not able to verbally
express complex feelings, whether because they lack the vocabulary or because they have communication
challenges in general. A small limitation of this technique may be that school or counseling practice budgets
may not allow for the purchase of musical instruments. An quick and easy remedy to this limitation is to use a
variety of ordinary objects to make sounds such as pencils, pots and pans, cans, clapping hands, etc. (Davis,
Reactions to natural disasters and the symptoms of those reactions may manifest differently in children
based on their developmental age and individual circumstances. A variety of techniques to working with
children can minimize long term effects of natural disasters. No matter which technique chosen, whether it be
CBT, Play Therapy, or Creative Arts Therapy, counselors should make sure that an intervention fits the
child’s developmental age, personality, and counseling needs. If these criteria are met, a crisis intervention counselor can make a world of difference for children experiencing natural disasters.

For more information, or to request references, contact the author at

Vol. 40, Issue 2

Page 7

Adolescent Suicide Postvention and Prevention Planning
Valerie M. Capucini, CT
According to the Centers for Disease Control and Prevention (CDC; 2012), suicide is the third leading
cause of death for individuals between the ages of 10 and 24. Due to the pervasive nature of adolescent suicide, it is necessary to explore this crisis in order to develop appropriate prevention and postvention methods.
Prevention is a vital tool for ensuring the safety of an individual as well as the safety of a school or
group of adolescents. According to Stanard (2000), due to the connection between depression and suicidal risk,
it is necessary to ensure adolescents are properly screened for mental illness. As part of prevention, individuals
working with adolescents should be made aware of troubling behaviors and mental health symptoms. They
should also work toward ensuring these adolescents are receiving proper care. One preventive measure that is
used is “gatekeeping” in which teachers, coaches, counselors, friends, neighbors, and family members are all
trained to recognize warning signs of suicide and offer assistance (Jackson-Cherry & Erford, 2014). Recognizing warning signs is a key piece of prevention.
According to the Substance Abuse & Mental Health Services Administration (SAMHSA), mental
health can affect students’ ability to perform academically. Additionally, following a suicide of someone they
know, adolescent’s normal coping mechanisms break down and become disorganized which can
impact their ability to perform in school (Thompson, 1995). The impact of a student suicide can be
extremely detrimental not only to other students, but also the school community as a whole (SAMHSA, 2012).
The impact of a student suicide can cause a significant amount of emotional response, therefore it is imperative
to prepare for this type of crisis in order to provide proper interventions. Additionally, adolescent survivors of
suicide are at a greater risk for suicide than their peers (Valente, Saunders, & Street, 1988).
After understanding the need for a prevention plan, it is necessary to look at the key components of
such a plan. According to SAMHSA (2012), the main components of suicide prevention include training,
education, and screening. Part of the training necessary includes helping teachers and other school staff to
recognize certain risk factors and behaviors. Risk factors and behaviors can include the presence of mental
disorders, violence, other recent suicides within society or the school, and behavioral changes (Stanard, 2000).
Additional risk factors can include previous suicide attempts, being currently involved in treatment, and a
family history of mental health problems (Kerr, 2009). It is also necessary to create relationships with
local providers and work towards getting at-risk students referred to counselors (SAMHSA, 2012).
By ensuring at-risk students are being seen, it is
possible to foster a safer and more effective learning
Beyond a prevention program, it is also
necessary to develop a postvention plan for use in the
event an adolescent completes suicide. The first piece
of a postvention plan is a team, sometimes known as a
crisis response team. Some individuals that may be
beneficial in a postvention plan team include individuals from the school counselors, mental health agencies,
hospitals, funeral homes, police departments, social
service agencies, the media, and representatives from
various culture groups (Celotta, 1995).

Guidelines—Summer 2014

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Once a proper postvention team is assembled, it is necessary to determine the purpose
of postvention.
The purpose of postvention following adolescent suicide is to help individuals cope with the death
and to also prevent any other tragedies that may occur as a result (SAMHSA, 2012). Further tragedies and
complications can come as a reaction to the suicide and need to be understood in order to prevent them. Adolescents can romanticize death and view suicide as a means of escape which can put others in danger of becoming suicidal (Valente et al., 1988). The phenomena of individuals being triggered by another’s suicide is
known as contagion (Kerr, 2009). Additionally, individuals who have survived a loved one’s suicide often
have complex reactions that typically include feelings of denial, shame, anger, blaming, fear, guilt, or
hostility (Thompson, 1995). Due to the strong and negative nature of these feelings, it is important to have an
effective postvention plan to help survivors in the aftermath of suicide.
As a clinical or school counselor, preparing a postvention plan is a necessary task that may be
intimidating. One plan that addresses the aftermath of suicide is the Counselors, Administrators, Parents, and
Teachers (or CAPT Team) approach suggested by Maples et al. (2005). This approach is based on understanding four key stages and how to react to each. The first stage is shock and disorganization.
During this stage, members may use medical and behavioral strategies to combat fears, anxiety, numbness,
and denial (Maples et al., 2005). The second stage is expressions of anguish and remorse which may include
feelings of guilt or regret. At this stage it is recommended for team members to focus on teaching cognitive
behavioral strategies to students caught in a negative feedback loop of regrets or guilt (Maples et al., 2005).
According to Valente et al. (1988), survivors frequently look for any way they could have triggered or prevented suicide. The third stage is exploring the meaning of the loss which may include counseling as an intervention, either personal or group based (Maples et al., 2005). At this point it is important to have previously
established community contacts so that students can be referred for counseling appropriately and in a timely
manner. Also, educational and student initiated support groups can be developed within the school as a way
to help students express feelings and reactions to their classmate’s death (Kerr, 2009). The fourth and final
stage is emergence toward new goals which is possible after resolution of the existential search (Maples et
al., 2005). Setting sights on new goals shows progress for the individual and aids in the healing process.
Quinnett (2009) identifies three main groups to focus on after a suicide which are family,
clients close to the deceased, and staff. Steps that are recommended to take with family include calling to
offer condolences, offer referrals to grief support, and ask family members how they are coping. Counselors
working with the family should ensure they have a good understanding of grief counseling techniques,
complicated bereavement and mourning, and feelings related to grief so that they are prepared to work with
these individuals (Jackson-Cherry & Erford, 2014). Main steps to take while interacting with clients who
knew the deceased include providing information, crisis work, investigating risk in others, and returning to
routine as soon as possible (Quinnett, 2009). It is necessary to control rumors and carefully observe clients’
behavior in order to prevent several suicides in reaction to the first through contagion effect (Kerr, 2009).
Some ways to work with staff include opening a discussion, referring individuals out for counseling,
personally spending time with other staff to show care and compassion, and knowing when to seek outside
consultation (Quinnett, 2009). By ensuring the safety and health of staff, it is possible to continue helping
those in need. Additionally, Kerr (2009) recommends that all postvention team members have access to
food and water and that they split up duties to ensure they are not being over worked psychologically or physically.
For more information, or to request references,
contact the author at VCapucin@Heidelberg.edu.
For resources, suicide prevention coalitions in your
area, and more, visit OhioSPF.org.

Vol. 40, Issue 2

Page 9

Grief Support Sessions for Children
Lori A. Hunt, MAC, PSC
As a society we struggle with death and dying issues especially when
children are involved. Experiencing a loss of a parent, grandparent, close family member, friend or even a loved pet can be one of the most traumatic times a
child can face in childhood. People often leave children out of conversations
about the dying and death process in order to shield them from this difficult but
real part of life. By having a safe place for children to come and talk about
what they are feeling, ask blunt questions, and explore this life experience for
themselves benefits the grieving process. Providing activities which help them
explore what they are feeling and thinking helps the child realize that their
thoughts and feelings are like most people who have experienced a loss. Using
creative expressions helps the child to hold on to memories of their loved one
and gives them a way to express what they are feeling inside. Memories helps
one to go through the grieving process. A grieving session can aid them in
realizing they will have some sad days and better days.

The purpose within this grieving session is for making meaningful memory possession. Meaningmaking projects help to facilitate healthy adaptation to loss within a grief support group. It is geared towards
elementary/middle school.

The rationale for creating a meaningful memory possession is because a struggle with meaninglessness
is a cardinal marker of debilitating bereavement reactions across many populations (Neimeyer et al., 2011).
The meaning-making contributes to adaptive outcomes (Neimeyer et al., 2011). It helps the child to construct a
special item which has a distinct meaning to them. The effort of finding meaning can play a constructive role
in the grieving process (Neimeyer et al., 2011) as well as the role of meaning-making has emerged as a key
treatment in complicated grief (Hobb et al., 2010.)

One of the goals of this activity is to create a way for a child to remember their loved one in order to
continue the memories of the deceased. According to Byock (1997), hospice often helps clients complete what
they term “the five things of relationship completion - saying ‘I forgive
you,’ ‘Forgive me,’ ‘Thank you,’ ‘I love you,’ and ‘Goodbye’ ” (p. 140).
Just as it helps the dying person to complete these five tasks, it helps the
loved ones left behind to say through the creative expression I love you
and goodbye, but I will always remember you. By creating a memorial it
will help them remember the memories of their loved one.


Page 10

Guidelines—Summer 2014

The person will choose a variety of words and/or phrases that describe the loved one that they want to
remember. They will create a product (aka Acoustic Poem) that embodies their memory of their loved one.

You will need to supply the following materials:
 Construction paper, and any art supplies such as markers, paints, colored pencils,
laminator, etc.,
 a small basket of sweet candy and sour candy, and
 the book Sweet, Sweet Memory (Woodson, 2000).

To begin the activities, bring out a basket of candy. Point out to the children which ones are sour and
which candies are sweet. Allow each child time to choose a candy, open and consume it. In order to begin a
conversation with the children ask them the following questions:
 If you ate a sour piece of candy followed by a sweet piece, what taste would be in your mouth?
 Would it be totally sweet?
 How many pieces of candy would you have to eat to get a sweet flavor in
your mouth?
Then explain to the participants that this is the way memories of our loved
ones are. Right now, at times we may feel sad and down when we think of different
things. There may be a sour taste in our mouths, but if we think of the happy and fun
memories that sour tastes starts to become sweet.
Next, read aloud the book Sweet, Sweet Memory (Woodson, 2000). Discuss
what memory Jacqueline was holding on to about her grandpa and how did this help
her? As participants what is one thing they want to remember about their loved one
and what could they create that would illustrated this memory. After the discussion
introduce the Acoustic Poem activity.

Acoustic Poem
Explain to participants that they are going to receive a sheet of construction paper that they will write
the name of their loved one vertically on the paper (leaving space in between each letter). Next to each letter
they are going to write a word or phrase that describes the loved one and then decorate the border of the poem.
Share with them the following example:

Really fun
I liked him a lot
Could read me stories
Kept me laughing
Once participants are done with this activity, volunteers can share with the group.

Vol. 40, Issue 2

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Discuss how the participants felt while doing this activity. Some questions to ask them would be: What
was the most challenging? Most memorable moment? Funniest? Scariest? After the discussion, laminate the
poems and give to children.

By participating in the activities a grieving person can be aided by creating a memory product. The
memory product can help them hold onto memories about their loved one. Everly (2009) suggests that grieving
people should be helped to realize that memories of positives things will never go away and will always
remain. Memories can comfort a grieving person. By creating the memory object it begins the reconciliation
which describes the process of adjusting to the loss and accepting the reality of life without the loved one
(Henderson & Thompson, 2011). Cohen and Mannario (2004) explain in order to accomplish reconciliation,
children must accept the loss, experience the pain of the death, adjust to the world and their self-identity
without the deceased, convert the relationship to one of the memory, find meaning in the loss, and enjoy the
comfort of other people in their lives (Henderson & Thompson, 2011). Shapiro et al. (2006) point out that
memory is a central issue in bereavement.

For more information, or to request references, contact the
author at LHunt@FindlayCitySchools.org.

Guidelines—Summer 2014

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Greetings from the OCA Executive Director!
Rachel O’Neil, PhD, LPCC-S
It is with great enthusiasm that I write my first column as Executive Director for the Ohio
Counseling Association (OCA). My term officially began on July 1; however, I’ve spent the
past few weeks working with Tim Luckhaupt, former OCA Executive Director, to help negotiate a seamless transition process. Although Tim has left me very big shoes to fill, I am
excited to collaborate with OCA President, Dr. Victoria Kress, and the rest of the 2014-2015
OCA Executive Council in a continued effort to advance the mission of OCA.
My time in OCA first began in 2002. As a first semester Masters’ student, I was eager
to learn as much as I could about the counseling profession. I attended the All Ohio Counselors’
Conference (AOCC) for the first time in 2003. What an incredible experience it was to network
with counseling professionals from across the state! It was at AOCC in 2004 that I had the
privilege to co-present my very first professional conference session, with my faculty mentor
(and current OCA President), Dr. Victoria Kress. My involvement with OCA continued as I
moved into the role of President of the Eastern Ohio Counseling Association (a chapter of
OCA). In the past 12 years, I’ve held numerous positions within OCA, including chair of the
bylaws and policies committee, and a member of the ethics, awards, and journal taskforce committees. Most recently, I served as the Editor for the Journal of Counselor Practice.
I mention all of the above not in an effort to showcase my vita; but rather, to highlight my
service and dedication the OCA. This is a professional organization for which I am personally
invested, and my new role as executive director is more than simply a job. We are at an important time in the profession, and it is the responsibility of organizations like OCA to advocate
for counselors and the counseling profession. I feel incredibly lucky to be in a position of
working towards continuing the advancement of the counseling profession.
When I applied for the OCA ED position, I
spoke of my desire to take the organization the next
level. It is my hope that we will continue to grow
both membership and retention of members
within the organization. I am humbled by the
opportunity to serve Ohio counselors and it is a privilege to work with OCA President, Dr. Victoria Kress,
OCA Past-President, Meghan Fortner, and OCA
President- Elect, Dr. Kara Kaelber, as well as with the
other members of the Executive Council.
In closing, I want to thank you all for your
continued support the Ohio Counseling Association! Please feel free to contact me at
OCAExDir@Outlook.com or (330) 259-7330.

Vol. 40, Issue 2

Page 13

Counseling Those with Hoarding Disorder: Basic Considerations for Practice
Chelsey A. Zoldan, Nicole A. Adamson, & Victoria E. Kress, PhD, LPCC-S, NCC
Over the past several years, hoarding behaviors (i.e., retaining mass amounts of items for sentimental
or material purposes) have been documented in popular television shows and captured the attention of the
general. Once considered to be a subtype of Obsessive-Compulsive Disorder (OCD), researchers have
recently identified Hoarding Disorder (HD) as a distinct disorder that has much less in common with
OCD than previously believed. The American Psychiatric Association’s (2013) fifth edition of the Diagnostic
and Statistical Manual of Mental and Emotional Disorders (DSM-5) includes Hoarding Disorder (HD) as a
new, unique mental health diagnosis.

The APA (2013) estimated that 2-6% of the population meet HD criteria. The disorder is characterized by a desire to obtain and accumulate both animate and inanimate objects, an inability to discard items
that have no apparent use or value, and an impaired ability to complete activities of daily living due to
cluttered living spaces (Frost & Hartl, 1996). The literature has reported that those with HD experience
impairment greater than those with depressive and substance-use disorders, and comparable to schizophrenia
and bipolar disorders (Tolin, Frost, Steketee, Gray, & Fitch, 2008).
While HD is reported more frequently in older adult populations (i.e. 55-94; APA, 2013), the initial
onset is believed to occur during childhood and adolescence, usually before an individual reaches
age 20 (Ayers, Iqbal, & Strickland, 2014). Hoarding Disorder symptoms often reach clinical significance by
the mid-30s (APA, 2013), although average treatment-seeking age is 50 (Samuels et al., 2008). Symptoms
appear to worsen the longer they remain untreated, and early intervention leads to a more positive prognosis.

Counselor Considerations
Those with HD are unlikely to enter treatment on their own volition. As mentioned above, there is a
significant disparity between the average age at which symptoms reach clinical significance and the average
age of those who seek treatment. Often times, these clients present at the request of loved ones, due to court
orders and threats of eviction, or for the treatment of a comorbid disorder.

Guidelines—Summer 2014

Page 14

Depressive Disorders and attention-deficit/hyperactivity disorder (ADHD) are frequently found concurrently
with this disorder, and traumatic life events are often linked with the onset of hoarding symptoms. Attending to
comorbid issues can make treatment planning considerably more complex, but is imperative for successful
It is helpful to include loved ones in treatment because social relationships and family functioning
can be severely impaired by hoarding behaviors. Additionally, clients with HD have difficulties generalizing
skills learned in therapy to outside situations, and it is recommended that counselors visit clients’ homes to practice skills
in the home environment. However, individuals with HD are
likely to experience much shame and embarrassment about the
state of their homes, and they may demonstrate a great deal of
resistance allowing anyone into their homes. As such, it is
important that counselors build a strong therapeutic relationship with the client early in treatment.
The formation of a strong therapeutic alliance is
critical to producing favorable treatment outcomes when
working with those with HD. It is very important for counselors to be mindful of their attitudes and nonverbal
communication during these visits, so as not to appear
judgmental. It is important to remember that those with HD genuinely experience high levels of
distress at the thought of discarding items. Validation and expressed understanding of the reality of these
feelings can be helpful in building trust. Self-reflection, supervision, peer consultation can help counselors
monitor personal reactions.
Working with those who have HD takes patience and skill. Often times, those with HD demonstrate
low levels of insight into their symptom severity and its impact upon others. Insight may become so impaired
that delusions are present. For example, those who hoard animals sometimes have delusions that they are
protecting and caring for the animals, when in fact, the animals are visibly ill or have died. Counselors
should work to develop a holistic treatment plan that addresses personal and social implications of
HD. Hoarding Disorder presents many unique challenges to not only those who suffer from the disorder, but
to the larger community. Cluttered environments often become home to a variety of pests, including rodents
and cockroaches. These environments are also associated with toxic odors, food contamination, mold growth,
and overall unsanitary living conditions (Bratiotis, 2013; Frost, 2010). Increased bacteria growth in homes and
apartments can easily spread to the surrounding environment. In addition to sanitary concerns, cluttered living
spaces present fire hazards and make it difficult for medical or first responders to take action in emergency
situations. Danger to others is magnified when those who have HD live in apartment complexes, duplexes, and
condominiums due to close proximity to others’ living spaces.

A Community Problem
Hoarding Disorder also affects the larger community due to the need for public assistance.
The association between work-impairment and job loss with HD often leads to a need for public financial assistance and disability benefits. Those with HD often have comorbid mental health and chronic medical conditions. Often times, counselors may need to encourage clients to seek services for these untreated conditions,
and assist them in obtaining medical coverage. Medication misplacement also may become a hindrance to
wellness, as cluttered environments are conducive to this.

Vol. 40, Issue 2

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Hoarding Disorder truly is a community problem that requires collaboration with multiple resources in
the community. Counselors can expect to work with fire departments, disposal and organization services,
sanitation departments, health departments, child and animal welfare services, departments of aging, housing
departments, and medical care providers. Some cities have formed hoarding task forces that unite community
resources and various professional and nonprofessional personnel to address HD cases within their

Assessment and Treatment
Because HD was formerly conceptualized as a subtype of OCD, formal assessments for OCD were
typically used to assess for HD symptoms. Assessment measures created specifically for DSM-5 criteria for
HD are now available. As mentioned before, HD is associated with considerable impairment in insight, and
this must be considered when utilizing self-report assessment methods. Counselors should combine information from self-report measures, behavioral-tasks, reports from loved ones and other health professionals,
and home vistis/photographs to provide a comprehensive and more accurate assessment of an individual’s
symptoms. Instruments such as the Savings Inventory Revised (SI-R; Frost, Steketee, & Grisham, 2004) and
the Hoarding Rating Scale-Interview (HRS-I; Tolin, Frost, & Steketee, 2010) are available for free download
Cognitive-Behavioral Therapy (CBT) protocols for HD have been developed (Steketee & Frost, 2007;
Tolin, Frost, & Steketee, 2007), and are currently considered to be the strongest treatment approach for the
disorder. Effective treatment can be delivered individually or in group settings, and peer-facilitated support
groups may also be a helpful adjunct to treatment (Frost, Ruby, & Shuer, 2012; Muroff, Bratiotis, & Steketee,
2011). It is strongly recommended that treatment takes place in the office and in the client’s home.
Home visits can be difficult due to client resistance or counselor restrictions. Case managers and nonprofessional personnel who are trained in assisting those with HD may be more viable alternatives to counselor
home-visits. It has been found that home visits by non-professionals can enhance treatment outcomes nearly as
significantly as counselor visits (Muroff, Steketee, Bratiotis, & Ross, 2012).
When working with cases of HD, counselors should be prepared to make referrals to the a variety of
resources. Due to high rates of work-impairment and job loss, it may be helpful to refer clients to vocational
services to assist in improving work performance and job placement. Employment can help individuals to
become financially independent, leading to discontinuity of public financial assistance and reducing financial
burdens potentially placed upon loved ones. Referrals to psychiatric services for medication to treat cooccurring mental health disorders may be necessary. Additional services, such as those that provide organization and trash removal, will likely be needed.
Comprehensive approaches to addressing HD can alleviate negative effects of the disorder upon
clients, their loved ones, and the greater community. This disorder requires a counselor who is patient, nonjudgmental, and willing to assist in coordination of adjunct services. While prognosis varies dependent upon
several factors, counselors can help individuals with this disorder experience significant improvement in
quality of life and overall functioning.

For more information, or to request references, contact the lead author at

Guidelines—Summer 2014

Page 16

Advocating for Mental Health Treatment in Corrections
Latoya Carver-Jackson
In 1963, President John F. Kennedy signed a law called the Community Mental Health Centers
Construction Act that was developed to promote deinstitutionalization of the mentally ill. This policy was based on the expectation that community mental health centers would be able to maintain mental health
for those released into the community. Ultimately, the strain on community mental health services due to such
deinstitutionalization lead to other issues, like homelessness for those suffering from mental illness, as well as
to systems, such as the prison system becoming de facto mental health communities (Rosenberg & Rosenberg,
There is a growing need to reevaluate the way that mentally ill persons are sentenced, as well as how
they are treated once inside the prison system. It would be prudent for the correctional system to not
just house inmates, but actually rehabilitate and treat the mentally ill so that they will be better able
to function once they are released back into society (Weaver, 2007). Some counselors are familiar with
how the corrections system looks like today; there has
been a shift of large numbers of mentally ill people into
the jails and prisons that has often been referred to as
the criminalization of the mentally ill. The lack of quality treatment in the community, coupled with the current
trend of using the criminal justice system to deal with
mental illness, has given way to a crisis situation and
the need for some type of reform (Knoll, 2006). After
reading about the correlation between mental health and
the prison system and watching various videos about
the topic, I am inspired as a graduate counseling student
to engage in the role of an advocate to work towards systems change by advocating for improvements to our correctional system (Granello &
Young, 2012).
One of the relatively recent mechanisms that have been designed to address the issue of criminalization
of the mentally ill is the establishment of mental health courts. These grant funded courts are specialized to
deal with mentally ill persons that have been charged with a crime. These courts are a collaboration between
legal and mental health professionals with the goal of developing a comprehensive treatment plan to address
the individuals’ mental illness in an effort to reduce recidivism. The results for this type of court so far have
been promising, but future success is predicated on being able to find the financial resources to
continue these types of courts in the community (Knoll, 2006).
The long-term effects of deinstitutionalization have blended the mental health system with the correctional system, such that it is ill-equipped to deal with mental illness effectively. This places mentally ill people
that are caught up in criminalization in a dire situation. Obviously unable to receive adequate treatment in the
community, they are then subject to a correctional system that is structured to punish and not treat. The
challenge going forward is for advocacy efforts by counselors to provide quality treatment in an
appropriate setting, and in essence work to reverse the trend of using the prison system as a default to provide structured care for the mentally ill (Knoll, 2006).

For more information, or to request references, contact the author at

Vol. 40, Issue 2

Page 17

Government Affairs Report: Ohio Counseling Association, Sumemr 2014
Carolyn Towner, & Amanda Sines, OCA Lobbyists

Governor Signs House Bill 232
House Bill 232, sponsored by State Representatives Barbara Sears (R – Maumee) and Zach Milkovich
(D – Akron), makes several changes and updates to the laws governing the Counselor, Social Worker and Marriage and Family Therapist Board and its licensees. The Governor signed the Act on April 10, 2014 and the
Act will be effective on July 10, 2014.
The legislation passed the Ohio House of Representatives on November 6, 2013 by a vote of 74-23.
The legislation was then considered in the Senate Medicaid, Health and Human Services Committee. The bill
was amended and reported out on April 2, 2014 and passed the Ohio Senate floor the same day by a vote of 31
– 0. Also on April 2, 2014, the Ohio House of Representatives concurred with the changes to the bill made in
the Ohio Senate.
When the bill was before the House Health Committee, Victoria Kress testified in support of the legislation on behalf of the Ohio Counseling Association. In her testimony, Victoria said: “OCA supports the
provision that will require counseling programs in Ohio to have accreditation by the Council for
Accreditation of Counseling and Related Educational Programs (CACREP) by January, 2018.
Ohio is a state that has a long history of having high standards related to counseling licensure laws.
These laws serve to ensure consumers of counseling services are provided with services rendered by
well-qualified counselors. This change to the statute will continue this tradition.” Testimony was
submitted on behalf of Victoria in the Ohio Senate.
A copy of the final bill and analysis is available at www.legislature.state.oh.us and then enter House Bill

Jim Rough to Retire from Licensure Board
Jim Rough, Executive Director of the Counselor, Social Worker and Marriage & Family Therapist
Board, will be retiring at the end of the Summer. Jim has served as the Executive Director since March, 2005.
Within a short time of becoming the Executive Director, Jim implemented the eLicense system for online
Jim focused on many customer focused initiatives and developed an excellent working relationship with OCA’s Board. Jim was vital to the implementation of the Listserv in 2012, which widened
the Board’s ability to communicate with all licensees. Jim was also instrumental in the drafting, discussions

Legislature Wraps Up Business Before Breaking for Summer Recess
and passage of House Bill 232. Jim was the recipient of OCA’s Public Policy & Legislation Award in 2010.
Prior to leaving for the Summer, the Ohio General Assembly passed a number of Mid-Year Budget
Review bills for the Governor. At this time it is not known if any committees will be meeting in July or August. The legislators are scheduled for a possible session the weeks of September 16, September 23,
and September 30.

Guidelines—Summer 2014

Page 18

The general election is November 4 and then the legislators are expected to return the weeks of November 12,
November 18, November 25, December 2, December 9, and possibly December 16, 2014.

Governor's Mid-Year Budget Review
The Governor’s Mid-Year Budget Review (MBR) legislation, House Bill 472, was introduced earlier
this year and contained increases in severance taxes, cigarette taxes, and the CAT tax to fund decreases in the
state income tax. House Bill 472 was a large and comprehensive proposal, so the House split the bill into 13
separate proposals: House Bill 483 – 493, House Bill 369 and House Bill 375. House Bill 472, remains in the
House Ways and Means Committee and has received little attention since it’s introduction.
In two of the proposals, House Bill 483 and House Bill 369, changes were proposed to the Chemical
Dependency Professional licensure sections. The language in both bills created an endorsement for treating
"pathological and problem gambling" and defined it to mean a persistent and recurring maladaptive gambling
behavior that is classified in accepted nosologies, including the diagnostic and statistical manual of mental
disorders and the international classification of diseases, and in editions of those nosologies published after the
effective date of this section.
The endorsement was to be issued through the Chemical Dependency Professional licensure board.
However, the way the proposed language was written it was not clear that licensed counselors would not be
required to get a separate endorsement from the Chemical Dependency
Professional Board to treat problem gambling. Currently under section
4758.03, counselors licensed under 4757 qualify for an exemption to the
requirements of the Chemical Dependency Professional Board.
The Ohio Department of Mental Health and Addiction
Services had agreed to submit an amendment to make clear that
other licensees were not subject to the endorsement requirements
added to section 4758 of the law. The Ohio Counseling Association
and the CSWMFT Board supported the amendment. However, the House
Finance Committee did not make the requested changes to House Bill 483
and in fact, added the language to a second MBR proposal, House Bill
369. Both HB 483 and HB 369 then passed the House of Representative
and were sent to the Ohio Senate for consideration.
In the Ohio Senate, OCA sought an amendment to clarify the
licensed counselors are not required to seek a separate endorsement to
treat problem gambling. This clarification was adopted by the Ohio
Senate in House Bill 483 and later the Conference Committee agreed to
the amendment which removed the provisions of the bill that could have subjected licensed counselors to getting an endorsement through the Chemical Dependency Professionals Board to treat gambling disorders.
The conference committee on House Bill 483 also made several changes to mental health and
addiction funding. This has been a controversial topic of debate during the MBR process. A compromise
was reached as follows for a total of $52.5 million:
 $6.5 million for prevention services
 $7.5 million for RSS services
 $5 million for recovery housing
 $4.4 million for grants to counties for drug courts
 $24.1 million for additional mental health and addiction services including recovery supports with
an emphasis on housing and filling gaps in care
 $5 million for community programs

Vol. 40, Issue 2

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Among the items in the House Bill 483 conference report is the acceleration of the income tax reductions adopted as part of the budget process last year. The small business income tax credit was increased from
50% to 75 %, however, this applies only to tax year 2014 and was made conditional, based on the state's
ending fund balance after the following steps are taken: transfer up to $300 million to the Medicaid Reserve
Fund and accelerate the personal income tax reduction from 8.5 percent to 10 percent for tax year 2014. Both
the full House and Senate accepted the conference report on June 4, 2014 and the legislation has been signed
by the Governor.
Many of the provisions of House Bill 369 (Sprague), which concerned mental health and drug addiction, were included in House Bill 483.

Opiate Addiction and Abuse
The Governor and the Ohio House of Representatives has made the issue of opiate addiction a central issue over the last couple of years. Last summer a group of legislators traveled the state
hearing testimony regarding the opiate abuse epidemic. As a result of those hearings, the House Health and
Aging Committee formed a subcommittee to consider legislation introduced regarding opiate addiction.
Several of the bill introduced as a result of the traveling committee
have already been signed into law. The House is expected to convene a traveling committee again this summer. The focus of those
forum will be the opiate crisis as it relates to the courts and
the justice system. Here is status updates on the legislative action
on the bill addressing drug addiction:

House Bill 170 (Johnson and Stinziano), which allows
licensed health professionals to prescribe, administer,
dispense, or furnish naloxone to a person who is, or a
person who is in a position to assist a person who is, apparently experiencing or who is likely to
experience an opioid-related overdose without being subject to administrative action or criminal
prosecution. Naloxone is a drug the counters the effects of opiates. It can be administered nasally.
Status – Signed by the Governor and effective March 11, 2014.

House Bill 314 (Baker and Kunze), which requires a prescriber to obtain written informed consent
from a minor's parent, guardian, or other person responsible for the minor before issuing a controlled substance prescription to the minor. The bill specifies that the informed consent requirement
has three components: assessing the minor's mental health and substance abuse history, discussing
with the minor and the minor's parent, guardian, or another authorized adult certain risks and
dangers associated with taking controlled substances containing opioids, and obtaining the signature of the parent, guardian, or authorized adult on a consent form. The bill includes an exemption
for medical emergencies. Status – Signed by the Governor on June 16, 2014.

House Bill 332 (Wachtmann and Antonio), which establishes standards and procedures for opioid
treatment of chronic, intractable pain resulting from noncancer conditions. Status – Being considered by the House Health and Aging Opiate Addiction Treatment and Reform Subcommittee.


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Guidelines—Summer 2014

House Bill 341 (Smith), which require prescriber to review
patient information in the State Board of Pharmacy's Ohio
Automated Rx Reporting System (OARRS) before prescribing
an opioid analgesic or a benzodiazepine. The bill does allow
for exemption to this mandate. The bill also requires
prescribers to register with OARRS. Status – Signed by the
Governor on June 16, 2014.

House Bill 359 (Sprague), which requires disclosure of the
addictive nature of certain prescription drugs. Status - Being considered by the House Health and
Aging Opiate Addiction Treatment and Reform Subcommittee.

House Bill 366 (Sprague), which requires hospice care programs to establish procedures to prevent diversion of controlled substances that contain opioids. Status – Signed by the Governor on
June 17, 2014.

House Bill 367 (Driehaus and Sprague), which requires the health curriculum of each school
district to include instruction in prescription opioid abuse prevention. Status – Passed the House
of Representatives on March 12, 2014 by a vote of 93-1. Referred to the Senate Education

House Bill 369 (Sprague), which requires the Medicaid program and health insurers to cover
certain services for recipients with opioid addictions, establishes requirements for boards of alcohol, drug addiction, and mental health services regarding treatment services for opioid addiction to
help defray payroll costs associated with a court's employment of drug court case manager,
provides a state share of the capital costs of recovery housing projects and makes appropriations.
Status – Many of the provisions of HB 369 were ultimately included in House Bill 483, a part of
the Governor’s Mid-Biennial Review package.
House Bill 378 (Smith and Sprague), which prohibits a
physician from prescribing or personally furnishing certain drugs
to treat opioid dependence or addiction unless the patient is
receiving appropriate behavioral counseling or treatment. Status Being considered by the House Health and Aging Opiate Addiction Treatment and Reform Subcommittee.

On January 24, 2014, OCA submitted comments regarding House Bill 378. During testimony on the legislation a witness suggested an amendment that would
define "appropriate" behavioral treatment as treatment by a provider certified by the Ohio Department
of Mental Health and Addiction Services. OCA is concerned that such a requirement could limit access
to behavioral health services because in most cases, it is a facility that is certified through the Ohio
Department of Mental Health and Addiction Services, not the individual provider. If such a requirement were put in place, licensed counselors and other providers practicing in private practice or other
settings would be excluded from offering these services to patients also receiving medicated assistance


Vol. 40, Issue 2

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House Bill 501 (Smith and Sprague), which adds the drug Zohydro to the list of Schedule I
controlled substances. Status – Being considered by the House Health and Aging Opiate Addiction
Treatment and Reform Subcommittee.

Senate Bill 313 (Kearney), which provides an immunity from arrest, prosecution, conviction, or
supervised release sanctioning for a minor drug possession offense for a person who seeks or
obtains medical assistance for self or another person who is experiencing a medical emergency as a
result of ingesting drugs or alcohol. Status – Being considered by the Senate Criminal Justice

House Bill 546—Music Therapy Bill Introduced
House Bill 546, sponsored by State Representative Mike Dovilla ( R – Berea), would require licensure of persons providing music therapy services and would license such persons as music therapists. The bill
creates a music therapy advisory committee consisting of five persons familiar with the practice of music
therapy. Three of the persons would be licensed musical therapists, one member a licensed health care professional who is not a licensee, and one member who is a consumer.
In order to be licensed as a musical therapist, an individual would be required to submit an
application; be at least18 years of age or older; submit proof of having successfully completed an academic
program with a bachelor’s degree or higher degree in music therapy approved by the American Music Therapy
Association or its successor organization; pay a fee of $150; submit proof of passing the examination for board
certification by the Certification Board for Music Therapists; and submit proof of successful completion of a
minimum of 1,200 hours of clinical training, with at least 180 hours in pre-internship experience and at least
900 hours in internship experience (internship must be approved by an academic institution, the American
Music Therapy Association or any successor organization or both).
From the bill it appears the licensees will be placed under a different board, but blank spaces
are in the bill instead of the name of where this new licensure group will be placed. The bill was introduced in
May and has not had any hearings in the House Health and Aging Committee, to which it was referred.

House Bill 265—Accessible Parking Spaces or Disability Parking Spaces
House Bill 265, sponsored by State Representatives Stinziano and Grossman, would alter the designation of special parking spaces for persons with disabilities that limit or impair the ability to walk by designating such spaces as "accessible
parking spaces" or "disability parking spaces" (rather than "handicapped parking
spaces" or "disability parking spaces"). The bill also provides that a new or replacement sign designating a special parking location that is posted on or after the bill's
effective date must bear the word "accessible" and cannot bear any form of the word
"handicap," except that a sign bearing the word "handicap" may remain posted after
the bill's effective date until it is replaced. The bill eliminates obsolete references to
parking cards.
On April 9, 2014, the bill was reported out of the House Health and Aging
Committee and is awaiting a floor vote in the Ohio House. The bill is supported by


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Guidelines—Summer 2014

Senate Bill on Civil Commitments Signed by Governor
Senators David Burke (R –Marysville) and Charleta Tavares (D – Columbus) introduced Senate Bill
43 and Representatives Margaret Ruhl (R – Mt. Vernon) and Peter Stautberg (R – Cincinnati) introduced
House Bill 104, which would make changes to court ordered treatment of those with mental illness. The
intent of the legislation is to provide clarity to the probate courts that they have within their purview to order
out-patient treatment, not just court ordered hospitalization. The bill removes references to “hospitalization”
when discussing treatment, so the courts could order any treatment. The bill also places the affidavit to initiate
court ordered treatment into the law. The bills modify the term “treatment plan” and specifically states that a
treatment plan may include the following services:
 Community psychiatric supportive treatment;
 Assertive community treatment;
 Medications;
 Individual or group therapy;
 Peer support services;
 Financial services;
 Housing or supervised living services;
 Alcohol or substance abuse treatment;
 Any other services prescribed to treat the patient's mental illness and to either assist the patient in
living and functioning in the community or to help prevent a relapse or a deterioration of the
patient's current condition.
Senate Bill 43 provides that certain specified persons who act in good faith and who procedurally or
physically assist in the court-ordered treatment of a person do not come within any criminal provisions and are
free from liability to the person receiving court-ordered treatment. The bill allows for the payment of attorney's fees for an attorney appointed by the probate division for an indigent who allegedly is a person suffering
from alcohol and other drug abuse and who may be ordered to undergo treatment for alcohol and other drug
abuse. The bill establishes a fee of $25 for the filing of an affidavit and proceedings for a mentally ill person
subject to court order.
Each bill received several hearing in their respect committees. And the issue saw mental health advocates with opposing positions on the proposal. NAMI Ohio was supportive of the bill, while other
groups such as Ohio Association of County Behavioral Health Authorities objected because many
parts of the state lacked the capacity and resources to implement the legislation. Many other groups
and legislators echoed the need for additional funding to adequately address the problems within the system.
House Bill 104 was amended on June 19, 2013 to clarify the bill is not a mandate to commit patients to
outpatient care, but it is available to the courts. It was reported out of committee on November 20, 2013 and
passed by the full House of Representatives on December 11, 2013 by a vote of 87-6. The bill was referred to
the Senate Civil Justice Committee.
Senate Bill 43 was considered by Senate Civil Justice Committee and was reported out of the
Committee on February 19, 2013 and was passed by the full Senate by a vote of 32-0 on the same day. The
bill was then referred to the House Judiciary and was amended and reported out of the Committee on May 21,
2014 and passed the Ohio House 89 – 0 on June 3, 2014. The bill was signed by the Governor on June 17,
Copies of legislation are available at:

Contact Your Lobbyists

Carolyn Towner and Amanda Sines
Towner Policy Group, LLC.
33 North Third Street, Suite 320
Columbus, Ohio 43215
614-221-7157 (telephone)

Vol. 40, Issue 2

Page 23

Moral Injury: An Emerging Issue
Scott Campbell, CT, Keith Clark, CT, & Scott Hall, PhD, LPCC-S
Keith and I (Scott C.) are veterans of the United States Coast Guard (USCG) and current Counselor
Trainees from the University of Dayton. Scott H. is one of our professors and a veteran of the Unites States
Army having served in psychological operations and Special Forces. We all joined the military and were
each inspired by the nature of our respective missions which was (and is) to primarily help those
who are in distress—a similar role to a Professional Counselor. As Veterans, we feel a kinship with the
Men and Women who serve in uniform and wish to improve the efficacy of mental health services available to
them. We have witnessed the ongoing struggle for Professional Counselors to gain parity with other health
care providers who treat our veterans. This battle has slowly shifted in ways that recognize the tremendous
need for the mental health care of our veterans and the willingness for Professional Counselors to be included
in the system as qualified and accessible providers. Implementation of a great idea, however, takes
much longer than anticipated and there remains many challenges still ahead.
Service members returning from a war zone are confronted with a myriad of issues including the
transition back in to the family, community, and civilian careers (if in reserve military). This is not an easy
effort especially if Post-Traumatic Stress Disorder (PTSD) is involved; an increasingly common injury to
returning service members. So, how can student clinicians gain a better understanding of the nuances and best
practices of working with veterans who have PTSD?
The key, in part, is by understanding the culture of the service member along with how PTSD in the
veteran context is developed. PTSD is now a well-known and unfortunate consequence of trauma. Soldiers
exposed to combat are at an increased risk of developing the symptoms of PTSD, and those who have killed in
combat, handled human remains, or have been exposed to combat repeatedly are at greatest risk. For some
soldiers, the symptoms will abate with time. Other soldiers are able to overcome their disorder through one of
the many developed treatments for PTSD. However, standard PTSD treatments do not work for all PTSD
veterans, and it may be due to a fundamental difference in the cause of their trauma.
Litz, et.al. (2009) speculated that for these treatment resistant soldiers, their PTSD was rooted
in shame and guilt—a moral injury. This idea resonated with all three of us. The notion of guilt (about
what someone has done) and shame (about who
someone is) strikes at the core of one's identity. This
core holds our morality or said another way, our code of
conduct, honor, and camaraderie. We believe that all
persons have this, yet with veterans there is an implicit
and explicit code that follows them throughout life. It is
part of their identity. My code (Scott H.) was “de
oppresso liber” (liberate the oppressed). When I became
a paratrooper it was All the Way! For Keith and Scott C.
the motto was Semper Paruatus (Always Ready). As in,
we are always ready for the call to rescue. As veterans,
we each have followed our respective codes in ways that
constantly remind us of who we are and how we are
living. Sometimes this awareness can be troubling if it
seems that we aren't measuring up.

Guidelines—Summer 2014

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Soldiers encounter a variety of situations in which a clear answer is not available, and they must make
a split second decision. Their quick thinking may protect them in that moment, but they will have to
live with their decision for the rest of their lives. Therein lies the traumatic experience from a moral
angle. We have found through clinical experience, conversations, and therapeutic comparisons, that shame
and guilt based PTSD can in fact be viewed as a Moral Injury with an approach to treatment through Adaptive
Moral Injury, however, must be dealt with differently than the typical fear-based PTSD
symptoms, yet there are few options available. Eye Movement Desensitization Reprocessing (EMDR),
Prolonged Exposure (PE), Cognitive Processing Theory (CPT), cognitive therapies, relaxation training,
psychodrama, and adventure based therapies have been used to treat Moral Injury with vague and often
uncertain outcomes.
Many scholars and clinicians are beginning to understand that the contextualizing of PE and other
traditional PTSD strategies may not help individuals who have done horrific things, or who at the very least
think they have done horrific things. Gray et al. (2012) illustrate this point:
In the case of morally injurious combat and operational experiences, there are instances
where judgments and beliefs about the transgressions may be quite appropriate and accurate
and yet excruciating. Furthermore, attempts to attribute these actions to the “context of
war,” even when appropriate, may ring hollow and/or undermine a therapist's credibility to
a service member steeped in a culture of personal responsibility. Thus, different techniques
must be used to address morally injurious military events (p.471).
Adaptive Disclosure is an emerging treatment of moral injury with PTSD and as a treatment seeks to
embrace the culture of personal responsibility in the military by owning up to one’s actions in the form of
emotive confession. Adaptive Disclosure also seeks to target maladaptive beliefs by using empty-chair
exercises to promote exposure to corrective experiences. In this empty chair
technique, the client is asked to have an imaginary conversation with a
compassionate, generous, supportive, and forgiving moral authority figure. The
hope and goal of this exercise is to get each and every soldier to be kind and
empathic to themselves and understand that these events do not have to define
them as people. Community work and giving back are also integral ideals of
Adaptive Exposure and the healing process.
War related trauma is a smoldering powder keg for our returning
veterans and the match was lit several years ago. Soldiers may be exposed to
many traumatic experiences in war, and in some they may have acted outside of
their own moral values. When Soldiers are ready to unpack their experiences,
we must be ready to meet them with the best practices. Adaptive Disclosure is
one technique that appears to hold great promise in treating veterans who have
suffered a moral injury and for us, along with other veterans, a step toward
helping returning to one's best self. An excellent resource to compliment the
moral struggle of veterans is Edward Tick's (2005) book War and the Soul:
Healing our Nation's Veterans from Post Traumatic Stress Disorder.

For more information, or to request references, contact the lead author at
HerrCampbell@SBCGlobal.net .

Guidelines—Summer 2014

Page 25

Six Key Questions to Ask Yourself When Deciding Whether or Not to Pursue a
Doctorate in Counseling
Brent G. Richardson, PhD, LPCC-S
Although we do not offer a Ph.D. or Ed.D. in Counseling at Xavier University, our masters students regularly seek faculty advice on whether or not to pursue a doctorate. The following six questions have helped
students be deliberate, reflective, and proactive in making this very important decision.

1. Do I fully understand what is involved in the process?
Students are encouraged to “pick the brains” of those who have gone down that path (even if they did
not finish). Without a doubt, the biggest challenge for most is the dissertation. The coursework should not be
that much more challenging than your masters program. You might also have to prepare for other new
experiences such as taking oral and written comprehensive exams and completing portfolios. It is important
that students do sufficient research to enable them to have a clear understanding of responsibilities and
expectations of various programs.


Vol. 40, Issue 2

Page 26

2. Do I have sufficient experience in the field?
In practitioner-oriented fields such as counseling, many professors feel it is important that individuals
obtain a minimum of two years of relevant experience before pursuing a doctorate. This might be less important in fields such as history or philosophy. Universities and agencies are less likely to hire counselor
educators whose professional experiences are limited or less relevant. Also, this professional experience will
enable you to participate more fully in classroom discussions. If you decide to go directly from a masters
program to a doctoral program, you may want to consider programs which allow and encourage you to work as
a counselor during your program. This is particularly important for students pursuing a doctorate in community counseling or clinical mental health counseling who need a minimum of two years of supervised, postmasters clinical experience before they can become independently licensed. It is recommended that you obtain
your independent license before you complete your doctorate.

3. What is motivating me; why do I want to get a
For most people, there is more than one motivator (e.g., prestige, a
desire to teach, increase in career options, increase in pay, parental or family
pressure or encouragement, research interests). There seems to be a correlation between motivating factors and completion rates. For example, there
were eight doctoral students in my study group at The College of William
and Mary. Each of us completed the course work and passed the comprehensive exams. However, only four earned their doctorates. The others will
likely remain ABD (All But Dissertation). One common denominator for
those who finished was a desire to teach. We knew we would be unable to
secure a full time teaching position without our doctorates. The primary
motivators for those who did not finish seemed to be prestige and/or increased job flexibility/options. Other faculty members have shared similar
experiences regarding motivating factors and completion rates.

4. On a scale of 1 to 10, how motivated am I to obtain the degree?
This is a very important question and it demands an honest assessment. You do not want to invest the
effort and money unless you are confident that you will have the time, dedication, resources, energy, and
support to see it through. As the cliché goes, perspiration is more important than inspiration. How willing and
able are you at this time in your life to finish a program?

5. How supportive is my support system; do I have the necessary resources?
Those who do not finish often complain about feeling “burned out” and/or unsupported as they are
starting to conceptualize and write their dissertation. Many (by necessity or choice) find themselves working
fifty hours a week as well as juggling numerous personal and professional responsibilities. Balance is the key.
The program has to be a high priority – for you and your significant others. Students who feel supported are
more likely to find the time and energy to complete the process.


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6. Am I willing to spend 10 to 20 hours a week, for 18 to 24 month, researching
and writing about one topic?
The thought of writing a dissertation can be very overwhelming and intimidating.
One of the most challenging aspects is selecting a topic and developing a viable research
question. Students who are able to choose a research question that piques their interest (as
well as the interest of others) are going to be more likely to find the necessary endurance
to finish the marathon. Many students have found the book Dissertations and Theses from
Start to Finish (Cone & Foster, 2006) to be an invaluable guide for making the process
more understandable and manageable. It is important to remember that no one writes a
dissertation. They write the first page, then the second page, then the third page…. Eventually, they have a dissertation. Embrace the process. Enjoy the journey.

Concluding Remarks
These questions were designed to help students begin to determine whether or not they are ready to
pursue a doctorate in counseling at this stage of their lives. Students who can answer affirmatively to most or
all of these questions will need to ask themselves and others additional questions to determine which schools
best meet their needs, interests, and situation. Fortunately, there are a number of excellent doctoral programs
in counseling in Ohio and other states.

For more information, or to request references, contact the author at

Applying Theory to Practice: Constructing Dignity with Our Words
Michael J. Leskosky
Although counseling students are presented with a comprehensive variation of educational material surrounding numerous
theoretical orientations and therapeutic modalities throughout their
academic learning experiences, some often find it challenging to
identify which ideological paradigm will best suit their own personal counseling style, or which intervention techniques will prove
most advantageous for effective practice. The process of establishing one’s own counseling approach is not simple procedure of
selection and implementation, but rather a continuous accumulation
of personal insight, knowledge, skills, and professional growth
(Remley & Herlihy, 2014). Students, regardless of their theoretical
preferences, can begin to cultivate their counseling approach by designating the origin of their development in
the fundamental principles and ethical values that guide our profession. That is, the wellness model, along with
core themes of advocacy, empowerment, and respect for human dignity, can serve as a foundation for students
as they begin to build a professional identity (American Counseling Association [ACA], 2014; Remley &
Herlihy, 2014). Such philosophical ideals can be readily demonstrated through the careful monitoring of the
meaning our words convey and utilization of person-first language.

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Putting Language into Perspective
Adopting a postmodern lens, our perceptions of reality, knowledge, and the ways in which we understand the world are believed to be socially constructed, or the products of social processes (Corey, 2013). More
precisely, as we communicate in our daily interactions, the language and specific words we use all create
meaning and contribute to our understanding of a given concept (Corey, 2013). Thus, the manner in which we
interact with our clients, and with each other, is of great significance due to the potential effects our words may
engender. Even the slightest alteration in one’s language may be the difference between expressing empathy
and compassion to a client, or pity and sorrow.

The Wellness Model
The American Psychiatric Association (APA) asserts
that the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5; APA, 2013) is not intended to
label individuals with mental illnesses, but rather function as a
classification system that includes a delineation of symptoms
associated with a particular disorder. Despite this clarification,
mental health diagnoses are nonetheless perceived as undesirable labels in our society and, as a result, clients frequently
experience feelings of shame or status loss (Russell &
Norwich, 2012). Perhaps this stigmatizing phenomenon is the
result of the DSM-5’s medically based orientation and
accompanying nomenclature that is used to characterize
mental health concerns such as illness, disorder, psychopathology, disturbance, dysfunction, and impairment (APA, 2013). Who could imagine that these words would yield
unfavorable and condescending associations?
Contrary to the medical model, counseling philosophy supports the application of the wellness
model in which the aim of therapeutic practice is not to cure an illness, but to assist clients with achieving an
optimal degree of daily functioning and quality of life (Remley & Herlihy, 2014). Complementing this nonpathologizing framework, the ACA Code of Ethics (2014) espouses, “using the profession and practice of
counseling to promote respect for human dignity and diversity” (p. 2). Embracing the antecedent notions, and
also in agreement with feminist perspectives, I would advocate for the utilization of the term distress in an
effort to foster the avoidance of stigmatizing individuals with a label of disordered (Corey, 2013). Although
this replacement of words may appear very simplistic, the
meaning of distress is vastly different from that of disorder. With this implementation, we can begin to deconstruct
the stereotypes, biases, stigma, and barriers that depreciating
language may reinforce and begin to create a new interpretation of distress among the general public, one of understanding that is driven by education and regards distress as a developmental occurrence in which individuals experience natural
and normal responses to the many challenges one may encounter throughout the lifespan (ACA, 2013; Corey, 2013).


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Person-First Language
Similar to the aforementioned nuances of language, the organization of our words may likewise
markedly affect the messages we are communicating (Jensen et al., 2013). Throughout my own graduate level
counseling experience, I have occasionally gasped upon hearing rare statements from my peers such as,
“autistic clients,” and “depressed people.” These comments reveal how effortlessly novice counseling
students, myself included, may unintentionally impose a label of meaning on another individual. When
diagnoses are used as an adjective (e.g. “autistic clients”), identity is implied (Jensen et al., 2013). Hence, a
person’s identity becomes defined by the diagnosis, as opposed to any of the other boundless qualities that
encompass an individual’s identity and more authentically reflect one’s existence as a human being (Jensen et
al., 2013). The use of person-first language (i.e. individuals with autism) not only displays recognition for the
dignity and uniqueness of individuals experiencing mental health distresses, but also empowers those individuals to construct, characterize, or identify with their subjective occurrence of distress however they deem
meaningful and appropriate.

Concluding Remarks
Although the present article does not offer readers with an innovative or revolutionary doctrine of
novel thought, I do hope that my remarks will motivate some to consider the meaning their words are conveying and result in the greater use of nonpathologizing and person-first language, especially among developing
students seeking a career path of advocacy and social justice such as myself. We advance the counseling
profession, reinforce our underlying ethical and philosophical values, and model for others each time we
actively choose to utilize language that affirms the worth of individuals experiencing distress. Moreover, we
can advocate for social justice by breaking down marginalizing biases and promote the freedom for personal
growth without stigmatizing labels through constructing new meanings of distress in our daily interactions. Be
an agent of social change and use your words to give a voice where it is needed today.

For more information, or to request references, contact the author at

Vol. 40, Issue 2

Page 30

Promoting Clinical Competencies and Advocacy:
Reflections from a Workshop Addressing Current Issues and Tips for
Working with Sexual Minorities
Shawn Burton, MSEd, LPC-CR, Jessica A. Headley, MA, LPC-CR,
Phil Hughes, MA, LPC- CR, Amy Moore, MAEd, LSW, LPC-CR,
J. Alex Reed, MEd, LPC-CR, NCC, & Jared S. Rose, MA, LPC-CR, NCC
(The 2013-2014 ALGBTICO Board of Directors)
This past April, the Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling of
Ohio (ALGBTICO) and the The University of Akron’s Alpha Upsilon Chapter of Chi Sigma Iota (CSI) joined
forces to offer a workshop entitled, Becoming an Agent of Change: Current Issues and Practical Tips for
Mental Health Practitioners Working with Sexual Minorities. The workshop provided attendees with information to increase their knowledge, skills, and awareness surrounding topics such as queer theory, LGBT
affirmative therapy, gender dysphoria, and gender transition. This article, highlighting the major themes of the
workshop, will address ways in which counselors working with LGBT clients can embrace an affirmative
approach, participate in continued learning opportunities, foster connections, and engage in advocacy.

Embrace an Affirmative Approach
An affirmative approach to working with LGBT clients is vital during every step of the counseling process to include, but not limited to: scheduling an appointment, environment, the initial greeting, the counseling
setting, case conceptualization, diagnosis, and treatment. To guide these practices for the LGBT populations,
LGBT affirmative therapy was introduced to create an atmosphere that is
marked by openness, support, and non-judgment. Affirmative therapy is
generally understood as a lens through which counselors examine heterosexist beliefs and behaviors through ongoing self-reflection. Further, it
entails challenging oppressive practices that occur within the counseling
relationship, the community, and the broader culture. To learn more about
LGBT affirmative therapy, please visit: http://aamftca.org/aamft-cacertification-programs-lgbt/.
Another way to embrace an affirmative approach is to review and incorporate current professional
competencies and standards into clinical practice to include

Competencies for Counseling with Lesbian, Gay, Bisexual, Queer, Questioning, Intersex and Ally
Individuals (Association for Lesbian, Gay, Bisexual, & Transgender Issues in Counseling
[ALGBTIC], 2012): http://www.algbtic.org/resources/competencies;

Competencies for Counseling with Transgender Clients (ALGBTIC, 2009): http://
www.algbtic.org/resources/competencies; and

Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People
(World Professional Association for Transgender Health, 2012): www.wpath.org.


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As you review these competencies and standards, we encourage you to identify topics that you would
like to learn more about and seek out opportunities to do so!

Participate in Continued Learning Opportunities
A professional counselor’s role as a continued learner is not only influenced by her/his desire to learn
more about topics of interest; it is also a professional responsibility. Have you read current LGBT literature?
Are you knowledgeable about current trends? In order to be an effective service provider and advocate for
LGBT clients it is essential to know what is going on and what is being done with this population. Reading
journal articles (from counseling journals such as the Journal of LGBT Issues in Counseling) and relevant
books by leaders in the field are two ways to continue to learn about the LGBT population. Also, our website,
ALGBTICO.com, has articles and references for anyone who is in need of some information and/or links to
online resources. A couple other invaluable opportunities that can be beneficial to counselors are area workshops (most offer CEU’s) and Safe Zone trainings. Safe Zone trainings are most often half-day sessions
facilitated by trained individuals who provide up-to-date happenings within the LGBT communities and
opportunities for advanced learning. With a deeper understanding of issues facing the LGBT populations,
professional counselors will be able to foster connections to create change on the individual, community, and
national level.

Foster Connections
There are many avenues that you can take to foster
connections with LGBT communities and allies. Are you
aware of your local LGBT organizations? If not, we encourage you to locate them and create a resource list for your
clients. We also encourage you to reach out to these organizations and get involved! Through these connections, you will
grow both personally and professionally. And, you can create
more connections! For example, consider inviting your local
LGBT center come to your employment and provide a staff
Another way to foster connections is to identify allies
who can help you further develop your clinical competencies
and advocacy skills. These individuals may be a professor who taught one of your courses, another professional in the field, a scholar who writes about LGBT issues, or a member of the LGBT community. While there is
no guarantee that these individuals will be able to work with you, they may be able to connect you with someone who can.

Engage in Advocacy
Advocacy takes many forms, from seemingly “simple” gestures (e.g. using affirmative language) to
large-scale acts (e.g. creating affirmative laws), all of which make a positive, impactful difference. In order to
effectively advocate for LGBT individuals it is important that you educate yourself, ask questions, and support
the LGBT individuals in your own life. We encourage you to “walk the walk” by joining organizations such as
Parents, Friends, & Family of Lesbians & Gays (PFLAG.org), The Gay, Lesbian, & Straight Education Network (GLSEN.org), and The Gay & Lesbian Alliance Again Defamation (GLADD.org).

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There are any number of ways you can engage in advocacy for this population. Start by learning to use
the words gay, lesbian, bisexual, transsexual, transgender, and ally comfortably and correctly. Further, let
LGBT individuals know you care by volunteering with organizations that support the LGBT community. You
could even write a newsletter or journal article to promote affirmative practice or advocacy efforts.

As part of your affirmative and advocacy efforts, please consider
actively joining ALGBTICO, your state counseling organization in need of
more hearts, voices, and helping hands to make a difference! The mission of
ALGBTICO is to promote greater awareness and understanding of LGBT issues
among members of the counseling profession, students and related helping
occupations. ALGBTICO also promotes greater awareness and understanding of
persons of various sexual and/or affectional identities not represented within the
identities presumed by “LGBT” such as queer, intersex, and ally. ALGBTICO is
a state branch of the national ALGBTIC (a division of the American Counseling
Association), and a division of the Ohio Counseling Association. As part of our
ongoing focus to better help professional counselors working with LGBT
clients, we have begun construction of regional resources guides to aide you and
your clients in finding affirmative services in your area. If you would like to be
include in the guide for your area, please contact us so we can include you. Further, we have also already
begun planning for our spring 2015 workshop. If you have LGBT topics you wish to learn more about, or
know a presenter from which our participants would benefit, please feel free to share that information with us
as well.