Monthly Archives: May 2013

ALGBTIC reacts to Jason Collins’ coming out

Heather Rudow May 3, 2013

With the headline “Why NBA center Jason Collins is coming out now,” 12-season NBA veteran Collins Jason_Collins_2012_3wrote himself into the history books. Collins, who played this past season for the Washington Wizards and is now a free agent, penned an article for Sports Illustrated and, with it, became the first active male professional athlete in a major American team sport to publicly come out as gay.

In the piece, which debuted online last Monday and will run in this coming Monday’s issue of the magazine, Collins writes:

I’m a 34-year-old NBA center. I’m black. And I’m gay.

I didn’t set out to be the first openly gay athlete playing in a major American team sport. But since I am, I’m happy to start the conversation. I wish I wasn’t the kid in the classroom raising his hand and saying, “I’m different.” If I had my way, someone else would have already done this. Nobody has, which is why I’m raising my hand.

Collins’ announcement has been lauded as a victory for the gay community and, in the few days since it was first posted online, has received a wide range of public support. Leaders of the Association for Lesbian, Gay, Bisexual and Transgender Issues in Counseling (ALGBTIC), a division of the American Counseling Association, are also voicing their support, adding that Collins’ story may serve as a helpful tool for counselors to use with clients who may be dealing with similar experiences.

“Jason Collins’ recent announcement that he is gay highlights not only his personal convictions but also the great progress that our society has made towards acceptance of LGB individuals,” says ALGBTIC board member Samuel Sanabria. “The reception that he received as the first male athlete to come out while playing a major U.S. professional team sport, especially from fellow athletes and people involved in professional sports in this country, is very encouraging. Jason Collins serves as a role model for young LGB individuals and can be an inspiration for those young people — young athletes in particular — who are struggling with their own sexual identity or who are contemplating coming out.”

Like Sanabria, ALGBTIC President Pete Finnerty thinks Collins’ bold step will be helpful to many youths struggling with their sexuality, especially young men. However, Finnerty says he finds both positives and negatives in the media attention surrounding Collins’ coming out.

“His mostly welcomed coming out notes how times [are changing], as he is the first active male player in a major U.S. sport to come out while still playing,” Finnerty says. “This is groundbreaking for the testosterone-pumped and often homophobic atmosphere of men’s team sports. It also breaks [down] ignorant stereotypes about gay men. Collins is a tough basketball player who fouls and scrambles for loose balls. Collins defeats the notion gay men are prissy, ‘girly’ men who ‘might get hurt in a tough sport,’ as an unnamed athlete once told me.”

But on the flip side, Finnerty continues, “it also shows how sexism, genderism and heterosexism continue to not only retain prevalence but also power in the minds of Americans. Think not? Tell me why Americans do not make a big deal about [athletes] such as Brittany Griner, the first pick in this year’s WNBA draft, who came out about a month ago. Perhaps because she was often thought to be [like] a man because of her physical stature and to even progressively minded persons [it] ‘looked like she could be gay.’ This shows the continuation of the American struggle to overcome gender and orientation stereotypes.”

Richmond Wynn, multicultural consultant for ALGBTIC, is appreciative of the support Collins is receiving from prominent figures such as President Obama.

“This is huge for all of us — athletes, gay people, especially gay men of color, and our allies,” Wynn says. “Jason joins others who have decided to live openly as gay despite the backlash. I admire his courage, and I hope that his story is inspiring to athletes as well as those from other walks of life who may be struggling with how to make peace with themselves.”

Wynn suggests counselors could use Collins’ story as a way to help clients who are dealing with sexual orientation issues talk about the process of coming out and discuss the risks and benefits of living openly as gay.

“It is important for counselors to understand their clients’ difficulties within the context of their lives,” Wynn says. “While Jason is a role model for many, the challenges of living authentically as a member of a marginalized group still exist.”

Counselors might also consider discussing Collins’ story with clients, colleagues, friends and family, Wynn suggests, as a way of exploring what it means to be an ally to the gay community.

Finnerty thinks Collins’ story would be especially useful for counselors working with young, male clients.

“This man defies stereotypes and shows [that] being LGBTQQIA doesn’t mean you have to fit into what somebody else’s box is,” Finnerty says. “We can be who we are, which may be an African American, educated, physical basketball player who happens to be gay. This allows us to have a deeper conversation with those persons who often say, ‘There’s nobody out there like me to look up to.’”

 Heather Rudow is a staff writer for Counseling Today. Contact her at



One counselor’s mission to expand mental health access in Haiti

Heather Rudow May 2, 2013

OLYMPUS DIGITAL CAMERAAmerican Counseling Association member and first-generation Haitian-American Florence Saint-Jean is striving to bring better mental health care access and awareness to the people of Haiti. In particular, Saint-Jean is working to create a trauma intervention curriculum to be used by professionals within Haiti.

Saint-Jean, a counselor and Ph.D. student at Duquesne University’s Executive Counselor Education Program, collaborated with mental health associations in the United States and Haiti to create a curriculum that will be taught to doctors, nurses, teachers and religious leaders.

A member of ACA’s International Counseling Interest Network and Trauma Interest Network, Saint-Jean also volunteers with the Haitian American Caucus (HAC) and oversees HAC-U.S. program operations. Saint-Jean says that volunteering, along with the January 2010 earthquake that devastated the country, helped spur the idea for the curriculum. With an epicenter 16 miles west of the capital of Port-au-Prince, the earthquake measured a 7.0 magnitude, had 52 aftershocks and resulted in more than 230,000 deaths. Three million other Haitians were impacted in various ways, including their mental health.

Though Saint-Jean was born in the U.S., her parents were born in Haiti and she has always felt a strong tie to the country. Its culture deeply influenced her upbringing, and she still has a lot of family living there, including four nephews and several aunts, uncles and cousins.

“Many of my nephews and cousins who went to school in Port-au-Prince were affected by the earthquake because they had to return to the countryside where the education system is limited for teens and adults,” Saint-Jean says. “Therefore, many of them still aren’t attending school. “

A few of Saint-Jean’s family members who were present during the earthquake are still so traumatized by the event that they refuse to return to the city.

“One of my aunts only goes to the city when she has to go to the airport,” Saint-Jean continues. “In addition, my other aunt, who is a pastor’s wife, has been sleeping in the church building since the earthquake. Her home, the church and a school are all in the same yard. My aunt is so scared of being crushed in her home that she sleeps in the church.”

Some of Saint-Jean’s relatives also died in the earthquake.

The trauma her own family members endured, coupled with the fact that many of her counseling clients in the U.S. are Haitian immigrants, made the news of the earthquake hit close to home.

Saint-Jean became increasingly interested in the mental health efforts after the earthquake in particular, “especially after hearing testimonials, reading the literature and realizing how limited mental health [care] is in Haiti,” she says. “I then began collaborating with the director of our HAC-Haiti compound [about how I could help].”

Several months after the earthquake, Saint-Jean traveled to Haiti and found it “crushing to see the collapsed buildings and despair. Port-au-Prince, a city that was once filled with rich landscapes, was covered in debris.”

Saint-Jean says she also found a troubling lack of mental health services and literature available.

Saint-Jean points to a 2012 issue of the Journal of Black Psychology that cites Haiti as having the lowest number of mental health workers of all Caribbean countries and among the lowest in the world. Haiti has between 20 and 23 psychiatrists, between nine and 30 psychiatric nurses and no professional counselors available in the entire country, according to that issue of the journal. A 2003 Pan American Health Organization report counted two psychiatric hospitals in the public sector as being responsible for serving more than 10 million Haitians.

“After the 2010 earthquake, the world realized how vulnerable and unprepared Haiti was to responding to natural disasters and the mental health issues that would surface,” Saint-Jean says. “Since the earthquake, there is still unresolved trauma.”

Nonetheless, she says, Haiti is taking “baby steps” toward providing mental health services, and the U.S. is helping out.

“Since the earthquake, mental health professionals in Haiti and the U.S. have established a psychological association called L’Association Haitienne de Psychologie, and [they] had their first conference in 2010,” Saint-Jean continues. “In addition, many nonprofits in the U.S. have been implementing mental health training to professionals. Popular [non-governmental organizations] are also providing mental health support. However, their time is temporary and their multicultural training is limited.”

Saint-Jean believes the best strategy is to train professionals who are native Haitians. “Though we are trying,” Saint-Jean says, “there is still so much to be done.”

After examining the history, education and religious views of Haitians, Saint-Jean found a stigma against mental illness within the country.

“Many natives are not likely to seek help from a mental health professional, and there is a recognized high prevalence of psychological trauma and adverse consequences of trauma,” she says. “Therefore, I suggested introducing a culturally competent trauma intervention curriculum consisting of basic techniques that can be implemented by professionals such as teachers, doctors, nurses and religious leaders who are readily accessible by Haitian natives.”

The curriculum, currently in a pilot stage, will be implemented at the HAC-Haiti compound in Croix-des-Bouquet in December.

The curriculum will use basic learning methods to achieve the following objectives:

  • Develop a foundation for psychoeducation and challenge stigmatized mental health ideologies
  • Teach professionals basic trauma assessment and intervention skills

 “I want counselors to be aware of the state of counseling around the world,” Saint-Jean says. “I know that we are very interested in global counseling these days, however many of us in the profession do not realize the extent to which we need counseling around the world.”

She believes the idea of developing multicultural competence has become increasingly popular over the years, and the need for it is great.

“The counseling profession is aiming to be an inclusive and diverse practice,” Saint-Jean says. “However, how do we do that when we are not aware of what is happening with counseling around the world? If a physician heard that there was a cure for HIV/AIDS in Asia, would he or she not want to know about it? Or if an engineer heard that buildings were collapsing in Africa with some of the same materials that are being used in the U.S., would he or she want to investigate this? The same applies for counselors. If we are a caring and helping profession, then that can’t be limited to the four walls of our office.”

Heather Rudow is a staff writer for Counseling Today. Contact her at

The dawn of a new DSM

Compiled by Jonathan Rollins May 1, 2013


The whispers, controversy and speculation surrounding the possible contents of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) seemingly began as soon as professionals opened the cover to the DSM-IV text revision back in 2000. Later this month, that speculation will finally end as the American Psychiatric Association unveils the final version of the DSM-5.

Although the American Psychiatric Association recently released the manual’s table of contents online, it has otherwise kept a tight lid on the final product, leading to a large dose of guesswork concerning how changes to the DSM might affect the way that mental health professionals practice and pursue insurance reimbursement.

Counseling Today asked several American Counseling Association members who have been carefully following the development of the DSM-5 to offer their insights regarding what changes to expect and the implications these changes could have for counselors and the clients they serve.

Look who’s talking

  • Brande Flamez is a core faculty member in the Counselor Education and Supervision Department at Walden University and supervises the LEAD program at the Garcia Center for at-risk youth in Corpus Christi, Texas. She serves on the American Counseling Association Governing Council, was recently elected president-elect of the Association for Humanistic Counseling and is the incoming chair of the ACA Publications Committee.
  • Carman S. Gill is president-elect of the Association for Spiritual, Ethical and Religious Values in Counseling and a member of ACA’s DSM-5 Proposed Revision Task Force. She also serves as chair of counseling programs at Argosy University, Washington, D.C.
  • K. Dayle Jones is associate professor and coordinator of the mental health counseling program at the University of Central Florida, where she teaches courses on assessment and diagnosis of mental disorders. She is a member of the World Health Organization’s International Advisory Group for the revision of the International Classification of Diseases (ICD-11) section on mental and behavioral disorders. A past chair of ACA’s DSM-5 Proposed Revision Task Force, she also wrote Counseling Today’s “Inside the DSM-5” column.
  • Monica Kintigh is a licensed professional counselor, consultant and trainer in private practice who serves on ACA’s DSM-5 Proposed Revision Task Force. She is a past member-at-large for the American College Counseling Association and formerly worked at the Texas Christian University Counseling Center.
  • Casey A. Barrio Minton is associate professor and counseling program coordinator at the University of North Texas and president-elect of the Association for Assessment and Research in Counseling. Her focus is clinical mental health counseling, and she is particularly interested in how the DSM affects the ways that counselors render services. She regularly teaches graduate-level courses in diagnosis and treatment planning.
  • Paul R. Peluso chairs the ACA DSM-5 Proposed Revision Task Force. He is an associate professor in the Florida Atlantic University Department of Counselor Education and editor-in-chief of Measurement and Evaluation in Counseling and Development.
  • Joshua Watson is an associate professor in the counselor education program at Mississippi State University-Meridian, where he regularly teaches courses in diagnosis and assessment in the clinical mental health specialization. He has more than 13 years of clinical experience in a number of mental health settings and is a past president of the Association for Assessment and Research in Counseling.

The DSM-5 won’t be available for purchase until later in May. What do we know about its contents with a fairly high degree of certainty?

Paul R. Peluso: One of the things that we do know for certain is that the multiaxial diagnostic system that has been in place since DSM III in 1980 is being done away with. I think this might be one of the more disorienting elements of DSM-5 for practitioners as they try to conceptualize disorders on just one axis. There has not been a lot of “official” discussion about what this will look like or how this will work, so I would bet that this could be very disconcerting initially. We will see how long it takes to get over this disorientation.

Another thing we know for certain is what the titles of diagnoses will be, and as a result, what has been included or excluded. This is because the American Psychiatric Association has released the table of contents for the DSM-5 (available at Some of the things the table of contents revealed were that diagnoses that were rumored to be eliminated were not — for example, some personality disorders — and that other disorders were incorporated into new categories — for example, Asperger’s disorder. However, what we do not know is what the final diagnostic criteria will be.

Carman S. Gill: We know there are philosophical and structural changes to the manual, as well as changes to key diagnoses. For example, the bereavement clause has been removed from major depressive disorder, and Asperger’s is no longer a stand-alone diagnosis but part of autism spectrum disorder.

Joshua Watson: The overall layout of the DSM will be changing. Chapters will be reordered to align with the World Health Organization’s ICD-11 (International Classification of Diseases, 11th edition). Additionally, this reordering was done to position chapters based on their relatedness to one another in terms of symptoms, characteristics and diagnostic criteria. This should help those counselors who are attempting to make a differential diagnosis with their clients.

Despite much opposition, the creation of the proposed autism spectrum disorder will be appearing in the DSM-5. This new disorder collapses the previous DSM-IV diagnoses of autistic disorder, Asperger’s disorder, childhood disintegrative disorder and pervasive developmental disorder into a single diagnosis.

There had been discussion of consolidating the personality disorders into a single personality spectrum disorder, but the decision was made to hold off on that change. Although the 10 categorical personality disorders listed in DSM-IV remain, Section 3 of the new DSM encourages clinicians to further research how these disorders could better be represented and treated on a continuous spectrum.

K. Dayle Jones: The multiaxial system has been eliminated. There will be no separation of disorders that are currently identified in the DSM-IV as Axis I Clinical Disorders, Axis II Personality Disorders and Mental Retardation and Axis III General Medical Conditions. Furthermore, Axis IV Psychosocial and Environmental Problems and Axis V Global Assessment of Functioning have been removed.

Monica Kintigh: There has been more feedback solicited from professionals outside of psychiatry this time than in past revisions. There has also been an attempt to make the DSM-5 more closely linked with ICD codes.

Many of the thresholds for diagnosis have been lowered, and some diagnoses have been added that might appear to identify a wide margin of the population. There has been more of an attempt for clinicians to use assessments for diagnosis and ongoing treatment rather than categorical checklists.

Brandé Flamez: Four principles guided the revision of the DSM:
1) clinical utility, 2) research evidence, 3) continuity with previous editions and 4) no prior restraints placed on the level of change permitted between the DSM-IV and DSM-5. Keeping these four principles in mind, work groups assessed what elements do not meet the needs of clinicians. They worked on improving diagnostic criteria that are not precise, reducing “not otherwise specified” disorders, how better to assess the severity of symptoms, how to treat disorders that often occur together, such as depression and anxiety, and how to include assessment of symptoms that may not be included in the criteria.
The use of dimensional assessment will also be included. Current Axis I-III will be collapsed, and we will no longer use the Global Assessment of Functioning (GAF) scale.

Casey A. Barrio Minton: It is fair to say that the DSM-5 will include a major reorganization to align with the American Psychiatric Association’s beliefs regarding the origins and development of various mental disorders. Although specific revisions have not yet been revealed, I expect we will see a general loosening of diagnostic thresholds so that more people will meet criteria for mental disorders via DSM-5 as compared with via DSM-IV.

Many potential changes within the DSM-5 have been discussed online, in print and in the media. What potential change has grabbed your attention? Which potential changes are most likely to grab the attention of practicing counselors?

Brandé Flamez: A dimensional assessment has been included to improve the sensitivity and specificity of the criteria. It appears that these changes will help counselors recognize differences from person to person and more accurately diagnose people and lead to a more focused treatment. Currently, the DSM-IV disorders are arranged by categories that include a specific list of symptoms for each mental illness. In this system, a person either has a symptom or not, and to receive a certain diagnosis, a person would be required to have a certain number of symptoms to receive a diagnosis. If this number is not met, the disorder cannot be diagnosed. With the new dimensional approach, clinicians would rate the presence and severity of the symptoms — very severe, severe, moderate and mild — the frequency and duration. The rating system can help track our clients’ progress and document all symptoms, not just the symptoms related to the diagnosis.

In terms of diagnoses, the proposed autism spectrum disorder and posttraumatic stress disorder (PTSD) grabbed my attention. The Neurodevelopmental Disorders Work Group’s recommendation of the autism spectrum disorder has received a lot of attention in the media and literature. Current disorders such as autistic disorder, Asperger’s disorder, childhood disintegrative disorder and pervasive developmental disorder not otherwise specified will be a new category called autism spectrum disorder. The symptoms of these four disorders will represent a continuum from mild to severe instead of a simple yes-or-no diagnosis to the specific disorder.

PTSD will be included in a new chapter on trauma- and stressor-related disorders. The proposed changes include adding “directly” in Criterion A1 and that PTSD in preschool children is a subtype of PTSD instead of a separate diagnosis. Dissociative symptoms subtype has also been proposed. More attention is given to symptoms, and there will be four distinct diagnostic clusters rather than three.

Also, hoarding disorder is being added to the DSM-5.

Casey A. Barrio Minton: There has been much discussion regarding the American Psychiatric Association’s movement to dimensional assessments in addition to the more traditional categorical assessments. In particular, a number of professionals voiced concern regarding validity and reliability of new dimensional assessments which would, in essence, dictate how clinicians go about diagnosing disorders versus what symptoms they see that lead to a diagnosis.

I doubt we will see inclusion of the dimensional assessments in the DSM-5 to the degree feared by many. However, I believe it is critical that we attend to this shift in philosophy. In particular, professional counselors will benefit from understanding how to take a holistic approach to assessment, and they must be able to evaluate clinical implications of utilizing assessment measures with unknown validity.

I believe professional counselors will be anxious to see the degree to which criteria have changed for disorders most frequently diagnosed in practice: substance use disorders (and the proposed collapsing of substance abuse and dependence), mood disorders (and the proposed removal of rule-outs related to bereavement) and anxiety disorders (and the general loosening of some criteria).

Monica Kintigh: Diagnosis of any substance use disorder will no longer be divided between use and dependence. The threshold is much lower for diagnosis with alcohol use disorder, for example, which may impact college counselors.

Diagnosis of autism spectrum disorder has been broadened with discrete categories that will include what might have been diagnosed as Asperger’s in the past. Some children formerly diagnosed with Asperger’s may find a diagnosis in the communication disorders and/or under autism spectrum disorder.

Disruptive mood dysregulation disorder falls under depressive disorders. This is a childhood disorder that can be diagnosed for severe recurrent temper outbursts to common stressors.

Carman S. Gill: One major change that grabbed my attention was the price tag! The DSM-5 starts at $199 per copy. That’s a big increase and a lot for counselors to pay.

In terms of diagnoses, I wonder about the changes to substance abuse and dependence. Substance use disorders, including alcohol use disorder, are no longer characterized as abuse and dependence, but seen on a continuum of symptoms from mild to severe. This is consistent with the paradigm shift to a dimensional way of conceptualizing the DSM.

Also of note is disruptive mood dysregulation disorder. This disorder is grouped with depressive disorders and is intended for individuals ages 6-18. It is seemingly in response to repeated diagnosis of bipolar disorder in those under 18 and follows a bipolar path.

Joshua Watson: Perhaps the biggest change will be the shift to dimensional assessment of client presenting problems. Although this change has the potential to strengthen the services counselors can offer to their clients, it will represent a fundamental change from current practice and take some getting used to for counselors.

K. Dayle Jones: Many changes in the DSM-5 revised disorders involved reducing symptom requirements needed for diagnosis. Counselors may find these changes blur the boundary between normality and pathology.

Paul R. Peluso: I think one of the longer-term changes that will grab counselors’ attention is the change in the diagnosis of personality disorders. According to the last proposed revision, personality disorders were going to be assessed on five categories of functionality. Narrative prototypes that focus on the client’s experience of the particular personality issue replace the symptom-focused diagnostic criteria that we are used to. Many practitioners familiar with this believe that this might be better in the long run for clients to understand their particular personality disorder and even accept it, which is often a precursor to change.

I think another area that will catch clinicians’ attention immediately is the reported reduced thresholds for many disorders. For example, in substance use disorder and alcohol use disorder the thresholds for receiving a diagnosis were, at last report, lowered, which allows for more individuals to be identified as having a disorder. The same is reported to be true with attention-deficit/hyperactivity disorder (ADHD). In addition, with ADHD, attention-deficit disorder is no longer a separate diagnosis. To what degree this is beneficial or harmful to clients remains to be seen. Counselors will need to pay attention to this.

What specific ways might changes in the DSM-5 affect counselors?

Casey A. Barrio Minton: We are still uncertain regarding specific effects on professional counseling practice, and effects are likely to vary depending on specific work settings. For example, counselors who work with individuals previously diagnosed with autism spectrum disorders may find that their clients need to undergo new assessments to determine whether they still meet diagnostic criteria and, if so, still qualify for educational and supportive services. Counselors who work in systems that require a diagnosis of substance dependence to qualify for services might find themselves needing to find new ways to classify impairment under the new, more general, substance use disorder.

I’ve heard some counselors speculate that the anticipated loosening of diagnostic thresholds will mean that more clients are able to access services through public mental health and private insurance. But managed mental health care systems can only handle so much. If, indeed, the DSM-5 leads to “rising” rates of mental illness and, in turn, rising rates of help seeking, I suspect professional counselors will find themselves in the midst of systematic changes regarding who qualifies for what services under what circumstances.

Joshua Watson: These changes will have a significant impact on the practice of counselors. For one, this move to a dimensional-based assessment model will mean that the multiaxial diagnostic system we have used for the past 33 years will no longer be used. Under the old model, Axis I was reserved for major mental disorders, Axis II for personality disorders and mental retardation, and Axis III for medical illnesses. In the new model, these three axes are collapsed into one single axis that would include all psychiatric and medical illnesses. Additionally, the GAF score rating system commonly included on Axis V will no longer be used. This foundational change will affect the way counselors diagnose their clients, structure treatment plans and interact with managed care and other third-party reimbursement sources.

Carman S. Gill: The underlying paradigm shift will be difficult to transition to. In terms of the diagnoses I commented on earlier, I believe the transition from abuse and dependence to one continuum will result in difficulty in conceptualization and communication of diagnosis until the integration is complete, which could take years. Also, most studies on this continuum and its cutoff score indicate high rates of diagnosis of substance abuse.

Disruptive mood dysregulation disorder may be helpful for counselors struggling to conceptualize the symptoms exhibited by some younger clients. The fear, however, is that once the diagnosis is made, the likelihood of medicating the client — as opposed to trying to help the client develop coping skills and wellness behaviors — increases dramatically.

Paul R. Peluso: I think that with the DSM-5, as with a lot of medicine today, consumers are becoming advocates for themselves. They are becoming savvy about their own health care, and this will include their mental health care. As a result, if DSM-5 is not a quality product, I think we are going to see clients use the power of the Internet and social media to voice their concerns. They will become advocates for change.

Counselors will need to likewise become savvy. Whereas before, when DSM-IV or even DSM-IV-TR came out, many licensed counselors could not diagnose, today, diagnosis is within their scope of practice legally. In the past, I think counselors played a more passive role because they did not have as much of a direct role in diagnosis. Almost 20 years after DSM-IV and 13 years after DSM-IV-TR, this has changed radically. Counselors en masse are much more sophisticated in their knowledge base and training, and they have a much more active role to play in understanding the power to diagnose — and the impact of this on clients. As a result, I think you are going to see many counselors embracing their ethical obligations under the core ethical principle of justice to advocate for their clients’ needs as diagnostic criteria change.

Monica Kintigh: Counselors will need to be more aware of assessment criteria and need to learn the scaling criteria for each diagnosis, which was different for each diagnosis during the field trials. Additionally, the new DSM-5 may completely reorganize diagnosis and assessment of personality disorders.

What else do counselors really need to know about the impending release of the DSM-5? Why should they be paying attention?

K. Dayle Jones: There is confusion among all mental health professionals about when to start using the DSM-5. There is no mandated date as of yet that a counselor must begin using the DSM-5.

Monica Kintigh: At this point, we don’t really know what changes were made after the last opportunity for feedback, which was in June 2012. However, we can expect that the DSM-5 will be different enough that we will want to be attending workshops and working in consultation with others as we begin to use this tool to help us understand our clients. School counselors, who typically do not use the DSM as a diagnostic tool, will also want to be familiar with the changes to better serve the students on their campuses.

Paul R. Peluso: Counselors should pay attention for two reasons. First, I think there will be a number of changes to the reimbursement schedules from insurance companies. Now that counselors are participating in insurance reimbursement more than ever, this will be very important. Again, no one knows yet how insurance companies will react to DSM-5, nor do we know how they will react to the presumed regular updates.

On a bigger scale, counselors will need to decide whether the DSM is still a worthwhile diagnostic system or if they should migrate to another one. For example, the ICD, currently in its 10th edition, is a diagnostic system developed by the World Health Organization and used internationally. Many counselors may be unaware that the ICD is also the source for the numeric codes that are currently associated with the DSM-IV-TR diagnoses. The DSM-5 will reportedly have both the ICD-9 and ICD-10 codes associated with them. This is because not all physicians use ICD-10. However, the ICD-11 is currently under development and is scheduled to be released in 2015. The bottom line is that counselors who are concerned about DSM-5 should begin to inform themselves and look beyond the traditional diagnostic system.

Brandé Flamez: As previously mentioned, the DSM-5 will include new disorders — for example, hoarding disorder — while other disorders will be collapsed, some disorders will be removed and others will undergo a name change. It is important to understand that the only disorders that have been finalized were released in a report on Dec. 1, 2012. All other disorders are still subject to revisions until the DSM-5 comes out.

Counselors should be aware that the manual is used for assessing and diagnosing disorders; it will not include treatment for any disorder. Because most managed care companies require a DSM diagnosis to bill for services, I think counselors can benefit from starting to familiarize themselves
with the foundational changes and how these changes might affect any of their current clients.

Carman S. Gill: Like it or not, billing drives a lot of what we do in terms of diagnosis. There is not much turnaround time to become familiar with the changes. Starting now, or as soon as possible, is imperative, which is why I personally appreciate the American Counseling Association’s advocacy and information on this topic.

Joshua Watson: While many counselors may choose to use the DSM as more of a guide in their work with clients, it remains important to be current on all the new changes because most managed care companies require a DSM diagnosis to bill for services delivered. Understanding the changes and how clients should now be diagnosed using the dimensional-based approach will facilitate the counseling process for all parties involved.

Casey A. Barrio Minton: It is critical that professional counselors understand ways in which new DSM-5 criteria may influence clients’ access to services, help-seeking behaviors and mental health stigma. Some individuals may be motivated to seek services after learning that what they are experiencing is not “normal” or “healthy.” Others may be discouraged or stigmatized regarding a label indicating that they are mentally ill, even if such a label would not have been applied the day before the DSM-5 was released.

As counselors, we also need to consider emerging neurobiological evidence regarding distress, while not losing track of the holistic, strength-based and developmental foundations that make our profession unique. My favorite DSM quote comes from Amundson, and I think it is critical that we remember it now: At the end of the day, the DSM is simply a “collection of tales of suffering and complaint.” As professionals, it’s up to us to decide what we do with that suffering and complaint.

Any additional thoughts that you’d like to share?

Brandé Flamez: The release of the final version of the DSM-5 will take place May 18-22 at the American Psychiatric Association’s 2013 Annual Meeting in San Francisco. In the meantime, counselors, counselor educators and students can begin to familiarize themselves with the upcoming changes. There have been several inaccurate media reports speculating on new diagnoses that might appear, leading to confusion about the DSM-5. The DSM-5 website has a great deal of information concerning the future manual. However, one should note that the information on the website is not final, and counselors will want to familiarize themselves with the final changes in May.

Carman S. Gill: I think it is imperative that counselors have multiple learning opportunities as soon as possible to master this material. This edition of the DSM may not be what we were looking or hoping for, but it will happen. I’d rather we as a profession be ahead of the curve and be able to conceptualize — even reframe — from a counseling standpoint for the benefit of our clients.

Paul R. Peluso: As we move forward into the next few years, I believe there will be an emergence of “counselor science” — a science based on universal human questions, but from a unique counseling perspective rather than a psychological, educational or sociological one. I think it is a shame that counselors were shut out of the DSM-5 process, with limited exception in the field trials. We have the opportunity to assert our legitimacy, rather than wait for it to come from others, as we evaluate the benefits of DSM-5 from a counseling perspective.

In addition to being helpers, healers and advocates, we are also scientists. Over the last 15 or more years, our discipline has taken great strides to apply scientific rigor to evidence-based practices, outcome-informed learning and peer-reviewed empirical articles. Today, we can claim to be full-fledged scientists of counseling regardless of whether a counselor enjoys the nuances of statistical procedures or if a counselor never intends to publish a single article. As such, we have the right — and the obligation — to call into question any process or procedure, as well as its output, that does not submit to the fundamental rigors of scientific research. In the end, I believe that through this period of time, counselors may see themselves asserting their legitimacy as scientists and leading the call for change in the field.

Jonathan Rollins is the editor-in-chief of Counseling Today. Contact him at

When religion and sexual orientation collide

By Michelle R. Cox

Rainbowcross_landingImagine a world filled with counselors who all shared the same beliefs, values and attitudes. For those counselors to effectively serve their clients, the clients should also share the same beliefs, values and attitudes as the counselors, right?

Thank God I don’t live in that world. Counselors are as diverse as the clients they serve, meaning the values of the counselor may not always align with the values of the client. Some may think that Christian counselors with conservative beliefs against same-sex orientation should not provide counseling to that population. Others may think that those same counselors should be obligated to affirm same-sex orientation. Then there are some Christian counselors who, because they can’t affirm same-sex orientation, feel they should not provide counseling services to sexual minorities.

Controversy within the profession

There has been controversy within the counseling profession about whether students in counseling-related programs should be able to refer lesbian, gay, bisexual and transgender (LGBT) clients to more competent counselors if a conflict exists with those counseling students’ religious beliefs. Jennifer Keeton, a former graduate counseling education student at Augusta State University, claimed she was ordered to undergo remediation and alter her central religious beliefs after she revealed her religious convictions about gender identity. Keeton filed a lawsuit against the university, which was later dismissed.

More recently, the Michigan House of Representatives passed House Bill 5040, or the Julea Ward Freedom of Conscience Act, that protects the right of students to object to providing certain counseling services if they conflict with the students’ religious beliefs or moral convictions. This bill applies to public or private degree or certificate granting colleges, universities, junior colleges and community colleges in the state of Michigan and restricts those institutions from disciplining or discriminating against students with religious and professional conflict. Additionally, an Arizona bill was signed that protects the religious expression of students. It includes a statement that colleges of that state will not discriminate against students in counseling, social work or psychology programs because the students refuse to counsel clients about goals that conflict with the students’ religious beliefs, as long as the students consult with their supervising instructors to avoid harming the clients.

Diversity among counselors

There are differences among counselor educators based on gender, ethnicity, sexual orientation and religion. Christian counselors are also diverse in their religious affiliations, which include Roman Catholic, Episcopal, Presbyterian, Methodist, Baptist and scores of others denominations.

According to an article written in the Seminary Ridge Review by Gilson Waldkoenig in 2002, denominations are “compromises between churchly and sectarian forms.”

Denominations develop based on how people interpret biblical teachings to support modern-day issues. Denominations differ in how they view same-sex orientation. Members of conservative denominations tend to interpret the Bible in a strict, nonflexible manner and believe homosexuality is sinful. They believe the Bible word for word, while members of liberal denominations believe the Bible must be applied to modern times. Conservative Christians may not affirm same-sex orientation and may be opposed to same-sex marriage, while more liberal Christians may be more accepting of same-sex orientation.

As students enroll in counseling-related programs, they bring with them their own personal values, beliefs and attitudes. Clients also enter the counseling relationship with their own personal values, beliefs and attitudes. Although a counselor may not agree with a client’s lifestyle, sexual orientation or beliefs, the counselor still has an ethical responsibility to separate those feelings from her or his role as a counselor.

In some cases, however, I believe that it may be more effective if the counselor and client share similar values and beliefs. On many occasions, I have met with clients who unwaveringly lived according to their faith traditions and desired to speak with someone who understood the power of that faith. I comfortably and gladly accepted the opportunities to listen to my clients discuss their dependence on and trust in God and how it was the center of their lives. I was able to relate to those clients because we shared a common value. I wonder how effective an atheist counselor would have been for these clients and whether that counselor would have considered referring those clients to a Christian counselor.

Because there are diverse populations seeking counseling, I believe there should also be diverse populations of counselors available to meet those clients’ needs. Although we have an ethical responsibility to avoid imposing our values on our clients, we also must work within our boundaries of competency to avoid harming our clients.

Counseling implications

No one would expect a counselor who is an atheist to accept the values of a Christian client; therefore, no one should expect a conservative Christian counselor to accept the values of a gay or lesbian client. However, according to the ACA Code of Ethics, all counselors should be aware of their own personal values and be careful not to impose those values on their clients. Although I don’t believe that counselors should be required to compromise their religious beliefs, they should be prepared to work with diverse populations and should seek professional development if they do not feel competent to work with them.

Derald Wing Sue and David Sue provide suggestions for working with sexual minorities in the sixth edition of their book Counseling the Culturally Diverse: Theory and Practice. I think many of their suggestions may be very helpful for counselors who have conservative Christian values opposing same-sex orientation. I have added some of my own thoughts after each suggestion that may help counselors avoid compromising their faith when working with sexual minorities.

  • Examine your own views about heterosexuality (and homosexuality) and assume that you may have family, friends or co-workers who are sexual minorities. Clients should be treated with respect and genuine concern regardless of sexual orientation. Treat clients the way you would want another counselor to treat your own loved ones.
  • Understand that the client’s problem can be a result of discrimination or society’s view of homosexuality. You should examine your feelings regarding social justice toward all people and how you would advocate for individuals in other situations.
  • Recognize that some problems may be completely unrelated to sexual orientation. Before assuming an inability to assist LGBT clients, first determine the problem. You may find that you are more than capable of providing effective counseling services to your LGBT client.
  • Do not attempt to have clients renounce or change their sexual orientation. Your role as a counselor is not to change the orientation of the client but rather to provide strategies for treatment that are appropriate for meeting the client’s goals. Although you may not accept the sexual orientation of the client, you can accept the gay or lesbian client as a human being who deserves your professionalism.
  • Realize that LGBT clients may themselves have strong religious faith but encounter exclusion. You may find comfort in knowing that your LGBT client possesses a strong faith in God. Although you may not interpret the Bible in the same way, you can both rest in the idea that God is in control of the client’s problems.

Counseling clients who are diverse and different from us requires patience, understanding and a genuine concern for the well-being of all people. It is likely that we will encounter a counseling situation in which we work with someone of a different race, ethnicity or sexual orientation. However, if we are to be effective in our practices, we must make an attempt to assist all clients in resolving issues — in spite of our differences and without compromising our faith.



Michelle R. Cox is an associate professor in the school counseling and school psychology programs at Azusa Pacific University, as well as an associate counselor at Victor Valley College. Contact her at or

Letters to the editor:


20/20 can’t reach consensus on education requirements for license portability

Jonathan Rollins

T2020_landingrying to bring closure to a process that began seven years ago in Montreal, the delegates to the 20/20: A Vision for the Future of Counseling initiative met for the final time at the ACA Conference & Expo in Cincinnati to discuss the two remaining “building blocks to counselor license portability.” The group reached consensus at the 2012 conference in San Francisco on the other building block, choosing “Licensed Professional Counselor” as the common licensure title for counselors.

Tasked in Cincinnati with reaching consensus on both a counselor scope of practice proposal and recommendations for common educational requirements for licensure, the delegates went 1-for-2. After roughly 90 minutes of discussion, the delegates voted 28-1 to accept a common scope of practice for counselors. The delegates could not, however, reach agreement on education requirements.

The major reason it is so difficult for counselors to move their licenses from one state to another is because there is little consistency from state to state regarding counselor licensure titles, counselor scope of practice and education requirements to become a counselor. The goal of the 20/20 Building Blocks to Portability Project was for the 31 participating organizations to reach consensus in those three areas so that a common licensure title, counselor scope of practice and counselor education requirements could be recommended to all 50 state licensing boards.

Everyone gathered at the 20/20 meeting in Cincinnati, which was open to the public, seemed to grasp the magnitude and difficulty of the assignment to reach consensus. In opening the session, ACA President Bradley T. Erford addressed the 20/20 delegates, saying, “Over this seven-year journey … we have all compromised. We have all given a little so the counseling profession can gain a lot. Let’s keep our minds and hearts open today.”

William Green, the president of the American Association of State Counseling Boards (AASCB), which co-sponsored the 20/20 initiative with ACA, also urged the delegates to focus on the endgame. “If we wish to address license portability, we need to reach consensus on these two issues [scope of practice and education requirements],” he said. “You are indeed the builders of the future of the counseling profession.”

At last year’s conference in San Francisco, the 20/20 delegates endorsed the concept that having a single accrediting body for educational requirements would be a clear benefit to the counseling profession. Two accrediting bodies participated in the 20/20 process — the Council for Accreditation of Counseling and Related Educational Programs (CACREP) and the Council on Rehabilitation Education (CORE).

The proposal on the table in Cincinnati recommended inclusion of graduation from a CACREP-accredited mental health counseling or clinical mental health counseling program in model licensure language. It also recommended development of grandparenting language to be applied to graduates of CORE-accredited programs and graduates from other CACREP program areas for a time-limited period.

Although many of the 20/20 delegates expressed strong support for the proposal, other delegates voiced concern that endorsing the proposal would leave CORE and rehabilitation counselors “disenfranchised.”

Many of the delegates voiced their belief that the true solution to the problem is to have CACREP and CORE pursue a merger and urged those representing the two accrediting organizations to “come together.” The organizations did discuss a merger in 2007 but ultimately couldn’t reach an agreement.

Whether the two entities have a desire to revisit those talks remains to be seen. “We are in a very different place today than we were in 2007,” said CACREP President and CEO Carol Bobby, who also served as CACREP’s delegate to 20/20. Bobby told the 20/20 delegates that CACREP has had at least preliminary discussions concerning the possibility of exploring development of its own standards for accrediting rehabilitation counseling programs.

“We are a long way away from this third building block to license portability [common education requirements], which is a shame,” said facilitator Kurt Kraus as time ran out on the 20/20 discussions.

“We’ve gotten further than any other group has with this topic,” said Barry Mascari, AASCB’s representative to 20/20. “I’m a little disappointed we ended up with the ball on the 1-yard line.”

“I have come to realize the last yard belongs to CORE and CACREP,” added Burt Bertram, the 20/20 delegate representing the Association for Specialists in Group Work.

Carrie Wilde, who served as the delegate for the American Rehabilitation Counseling Association throughout the life of the 20/20 initiative, voiced her disappointment that the initiative was ending without its ultimate goal having been met. However, in an education session updating attendees on the 20/20 initiative the next day, she tried to strike a note of hope and optimism. “While the formal process is done,” she said, “I believe the conversation will continue.”

Although the 20/20 delegates could not reach consensus on all three building blocks to licensure portability, ACA Chief Professional Officer David Kaplan said the plan is to present the common licensure title and scope of practice to all of the organizations that participated in 20/20 to ask for their endorsement. If a consensus endorsement is achieved, AASCB and ACA will then request that state licensing boards adopt the common licensure title and counselor scope of practice as well.

Jonathan Rollins is the editor-in-chief of Counseling Today. Contact him at