Monthly Archives: February 2016

A counselor’s view of advanced breast cancer

By Cheryl Fisher February 29, 2016

Breast cancer touches all of our lives, and I am no exception. In February 1996, I went for my first mammogram. I was only 33 at the time, but I had read about the importance of having a baseline mammogram for early detection of breast cancer. Early detection meant cure, right? As a single mother of two young daughters, I was all about early detection and cures.

So, I went for a mammogram, astonished at how my 34B’s were able to squish like a schnitzel on the chilled mammography plate. The technician greeted me with a smile and warm hands, and for both I was grateful. The procedure, while uncomfortable, was not unbearable. I mean, I had given birth to Branding-Images_Canceran 8-pound baby without so much as an episiotomy. This was a simple walk in the park. The technician informed me that no news was good news, and I left feeling initiated (once again) into the sisterhood of womankind.

You can imagine my shock when I received a call mid-March that something unusual had been detected in my mammogram and that I needed to return for an amplification. The previously chipper technician met me with a solemn face and greeted me in almost a whisper. She did not make eye contact. The amplification was done in silence. Again I was told that I would be contacted if something was detected.

A week later, I was scheduled for a needle biopsy. As I lay facedown, my left breast dangling through the hole in the hospital table, thoughts raced through my head: “What if it is cancer? I can’t stop working. How will I take care of the girls?”

“No,” I told myself. “This is not cancer. I’m only 33 after all, and who gets cancer this young? I am a vegetarian. I am an aerobics instructor, for heaven’s sake! I don’t feel sick!”

I was provided with a bag of ice to place over the area of my breast that had been biopsied. They had found three suspicious areas and removed them, leaving a marker just in case … In case of what? I wondered. I left with my bag of ice and a fearful heart.

I started noticing articles in newspapers and magazines about young women with breast cancer. Had these always been there? Was I just now seeing them? I went home, hugged my daughters and cried. I cried the entire weekend as I waited for Monday’s pathology report.

I went alone to the hospital. I didn’t want to feel like I had to take care of another human being if my news was grim. I wasn’t sure I could take care of myself, let alone another person.

I went to the desk and announced my arrival. Again, the quiet whispered reception. I was immediately whisked away to a back office. Alone. Alone with a running video titled Living With Breast Cancer. Oh, my God! It’s true! I must have breast cancer. They’re preparing me by showing this video.

I began rehearsing how I would tell my family … my parents … my brothers … my daughters. The pathologist arrived and sat in a chair across from me. I took a deep breath. I don’t think I exhaled until I had been home for several days.

The pathologist began. “Well, we found three suspicious nodules and we removed them.” OK, buddy, so what are they?

“I’m curious,” he continued. “Have you ever experienced a trauma to the left breast?”

A trauma? You mean other than the needle biopsy that occurred the previous week? “No,” I replied in a small voice while still holding my breath. “Not that I am aware of. Why?”

“These are calcifications that appear to be from a traumatic blow to the breast,” he answered.

Let me get this right. I have been poked, prodded and petrified because of benign calcifications that possibly occurred during a Thanksgiving round of family football?

“So, I do not have cancer?” I whispered.

He shook his head and finally made eye contact. I was flooded with relief. I would live. I would raise my daughters. I would endure their teenage antics, their graduations, their weddings perhaps. I might even experience grandchildren!

What I wasn’t prepared for was the second wave of emotion that I experienced — anger. Anger at the time wasted, waiting and worrying for four excruciating days before I had to return to the hospital, find parking and sit in a room for 20 minutes watching a video about breast cancer. Anger at waiting for a doctor to hand over my fate. To me, this seemed so insensitive and cruel. What is wrong with health care that we treat the disease without treating the person?

However, I was 33 years old, a single mother, and I had just been told that I did not have cancer. I left that hospital, lived my young life and put breast cancer aside — until recently.

The call

I am a licensed clinical professional counselor. I had been in private practice for a few years when I received an email from METAvivor (, a local nonprofit group whose mission includes providing emotional support to individuals living with stage 4 metastatic breast cancer and promoting funding for research projects. The organization was looking for a therapist to facilitate a support group focused on meaning construction and stage 4 metastatic breast cancer.

Author and psychiatrist Viktor Frankl provided us with a foundational understanding of the importance of meaning construction in his classic book Man’s Search for Meaning. He proposed that the search for meaning was universal to the human experience and that it was a prerequisite for mental and physical well-being. Furthermore, an inability to make sense of our situation has been found to be associated with poor health. Therefore, a cancer support group that promoted meaning-making could provide patients with the necessary tools to experience a sense of well-being, even in light of their diagnoses.

My clinical practice had included counseling for bereavement and hospice care, but I had been spending more time working with survivors of trauma and had focused my advanced training in the area of trauma and spirituality. So, I wasn’t certain that I was going to be the best person to facilitate a support group for stage 4 metastatic breast cancer. Regardless, I agreed to co-facilitate the pilot group with a colleague from a local hospice.

The pilot group lasted eight weeks. During that time, I became acutely aware that the youngest member of the group was experiencing her diagnosis in a much different way than her older counterparts were. She was a 30-year-old married woman who had been diagnosed with stage 4 metastatic breast cancer eight months prior to the launch of the group. She had a beautiful 6-month-old baby boy who provided all of us such joy when he visited our group. Her disease appeared to be relentless, however, resulting in a complete bilateral mastectomy and oophorectomy and causing her days of nausea and fatigue. She would come to group pale and weak, convinced that the last round of treatment had to be curative because of its great potency. She died two months after our group ended.

According to the Metastatic Breast Cancer Network, approximately 162,000 women in the United States are living with stage 4 metastatic breast cancer, and only 27 percent will survive as long as five years. This translates to one death from metastatic breast cancer every 14 minutes. Of this population, 5 percent are women younger than 45. Metastatic breast cancer is more aggressive the younger the person is at onset; only 2 percent of premenopausal women with metastatic breast cancer survive longer than five years following their diagnosis of advanced cancer. Most women living with breast cancer may share similar experiences regarding self-image, relationships and support issues, but unique needs appear to exist among young women living with advanced breast cancer.

As a result of meeting the young woman in our pilot support group, I conducted my dissertation research on spirituality and meaning-making in premenopausal women diagnosed with stage 4 metastatic breast cancer. I dedicated my dissertation to her and to all of the young women living with advanced breast cancer, and I committed my work to serve as the voice of those who can no longer speak. What follows is some of the wisdom provided to me by the women in my pilot group and research study.

I am woman?

The treatment for advanced breast cancer involves invasive surgeries that remove not only what many women described as their femininity (breast tissue and nipples) but also their fertility (ovaries and uterus). As a result of treatment, women were catapulted into early menopause and became subject to the physical and psychological manifestations of estrogen depletion.  These manifestations included weight gain related to decreased metabolism, hot sweats, dry skin, decrease in vaginal lubrication and decline in libido.

According to the women in my study, the experience of metastatic breast cancer had stripped them of their bodies, their fertility, their youth and their sexuality. Extensive research demonstrates that physical alterations of the body related to the treatment of breast cancer may have negative effects on identity, confidence, mood, esteem, sexuality, self-satisfaction and quality of life. Treatment may involve not only the removal of breast tissue and nipples, surrounding lymph nodes and ovaries, but also the insertion of an external port to receive chemotherapy. This may be followed by radiation therapy. The body is left scarred and burned with an existing portal that emerges from the upper trunk.

Many of the women in my study described feeling like a “freak,” a “mess” or a “patchwork quilt.” All of the women described feeling detached from their bodies following their treatments. The body that remained was described as lifeless and clinical, almost corpselike.

BFFs and other strangers

The struggle to cultivate authentic relationships was a common theme in this study. The women spoke of their desire to be able to discuss the genuinely harsh reality of their diagnoses with family members and friends. However, the women felt that a substantial portion of their circles of support were unable (or unwilling) to assimilate adequately and comprehend the grave world of living with advanced cancer. The women were asked (directly and indirectly) by family and friends to compartmentalize their experience with cancer and to act as if they were not ill. Such requests led at times to feelings of anger, resentment and, eventually, rejection and isolation.


In addition, there appears to be an absence of sensuality as it relates to the body that remains. This, combined with decreased libido, proved to be a common issue for all the participants in my study. The women expressed a desire to resume an active, healthy sex life with their partners, but they struggled with experiencing a lack of sex drive and feeling unattractive.

Research indicates that women younger than 45 who are diagnosed with breast cancer have more difficulty adjusting than do older women. These younger women have lowered overall quality-of-life ratings linked to concerns about body image, partner relationships and sexual functioning, and they also exhibit less adaptive coping styles.

It also appears that having casual sexual encounters becomes less attractive when living with advanced cancer. One of the women described the need to feel emotionally safe before allowing a stranger into the scarred world of breast cancer. She noted, “I will need to trust the person to tell my whole story.”

Legendary living

Engaging in honest dialogue regarding the fears experienced by a person living with a life-threatening illness seems to provide some degree of anxiety relief for the person. This appears to be the result of directly identifying and addressing that which concerns the individual.

For example, many of the women in this study spoke of their fear of being forgotten and not having a part in the rearing of their children. This discussion provided opportunities to identify ways that might allow their values and beliefs to continue to exist even after their lives ceased. Among the ways these women attempted to provide continuity of their presence in the lives of their families was through writing letters, keeping journals and signing cards for future events.

In addition to memory-making projects, all of the women in the study were involved in using their stories to promote education and awareness of the specific needs of young women living with stage 4 metastatic breast cancer.

Pink isn’t my color

In addition to feeling isolated from family and friends, these young women living with advanced breast cancer described feeling alienated from the breast cancer community as a whole. The “pink” model of breast cancer awareness strives to inspire hope of survival and a cure. However, these women live with a diagnosis that mandates that they are not in remission and that the cancer has spread to other organs. For them, there is no cure at this time. One woman in the study described the pink ribbon as “a noose that is killing me.”

Faith and peace

Psychiatrist and author Irvin Yalom proposed, “If we must die, if we constitute our own world, if each is ultimately alone in an indifferent universe, then what meaning does life have?”

As one of the study participants said, life-threatening illness can “suck the meaning out of life, making the person feel already lifeless.” In facing death, we are faced with making sense of life, and it would appear that we make choices about how to live our lives until death. Therefore, anything that affirms life force, meaning and importance to others can counter the sense that death has made its claim.

Frankl reminds us that we have the ability to choose how we respond regardless of our circumstance. This can be empowering even when facing death. The women in my study discussed the role of choice. One woman described using humor to help her cope with the chemotherapy. Another described an attitude of gratitude: “I show gratitude more often. … It is liberating to know I can choose happiness.”

The women spoke of feeling a sense of being part of a bigger, universal plan. In particular, they described feeling that a divine presence was actively participating in their illness. Some women in the study felt that their diagnosis was a wake-up call to be more present in their lives and to be closer to the transcendent. Each described a restoration process of reclaiming and redefining her life.

Other women in the study believed that their spiritual faith gave them the strength to endure the changes brought about by their illness and its subsequent treatment. Interestingly, all of the women described experiencing a richer, more authentic life that a “loving presence” had transformed from the ashes of advanced cancer.


As counselors, we have an incredible opportunity to help support young women living with advanced breast cancer in the following ways.

Body talk: We can help these women (and their partners) reconnect with their bodies in a healthy and empowering manner. We can talk about sexuality and recognize the role that it plays in our emotional, spiritual and physical well-being. To support premenopausal women who are living with advanced breast cancer, we need a greater understanding of their fears around rejection and increased recognition of the role that sexual intimacy plays in their lives. This is a focus of my current research.

Bittersweet friendships: We can validate the changes that occur in these women’s friendships and offer grief work around these losses. We can help clients establish healthy boundaries in relationships that feel authentic and protective. In addition, we can promote the strengthening of those relationships that are nurturing and empowering.

Legacy work: We can help clients cultivate strategies for legacy. Lillie Shockney, administrative director of the Johns Hopkins Breast Center, has written an exceptional book titled 100 Questions & Answers About Advanced and Metastatic Breast Cancer that helps clients and families navigate the challenges of advanced breast cancer. It also provides excellent ideas for being present and remembered beyond the cancer. In addition to her book, Shockney hosts exceptional retreats for families living with advanced breast cancer and provides a forum for discussion, connection and community to these patients and families.

Beyond the pink ribbon: We can connect young women who have advanced breast cancer to communities that are validating and supportive. Wonderful online communities include Young Survivors Coalition ( and the Pink Daisy Project (

Faith and justice: Facing death directly can be strangely comforting and empowering. However, counselors may be uncomfortable facilitating a candid dialogue that might be painful for their clients. Furthermore, counselors need to be open to their own discomfort in discussing death and dying. Counselors are encouraged to work from a conviction that they are helping rather than hurting clients by asking them to lean into the discomfort that comes from confronting one’s death. These clients are faced with family members and friends who are reluctant or unable to join them on this journey of facing death. Counselors have the opportunity to embody the existential experience and join the client on this difficult journey. The essence of relational, embodied theology is not captured simply by the empathic presence of the counselor, nor the rites and rituals that inspire spiritual and psychological nourishment. The essence of embodying suffering is to give voice to marginalized persons and to tell their stories. Better still, counselors can be instrumental in nurturing the intrinsic divine wisdom that is present in all of us and empowering clients to tell their own stories.




Cheryl Fisher is a licensed clinical professional counselor in private practice in Annapolis, Maryland. Additionally, she is a visiting full-time faculty member in the pastoral counseling program at Loyola University Maryland. Her current research is titled “Sex, spirituality and stage 3 breast cancer.” Contact her at

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Music: A powerful ally in your counseling sessions

By Courtney Armstrong

How much would you pay for a piece of equipment that had the ability to modify a person’s mood within minutes, reduce anxiety, heal grief and bring couples closer together? Fortunately, you already have access to this powerful therapy tool, and it costs you little to nothing. Its name is music.

I inadvertently discovered the persuasive power of music when I was an undergraduate working at a shoe store in Atlanta. When we played upbeat music such as soca (a fast-tempo style of calypso) in the store, customers danced in the aisles, and we merrily sold shoes all day long. But after a while, the staff grew tired of listening to steel drums, so we decided to play blues music. Even though customers also swayed to these soulful rhythms, they seemed less pumped up about buying pumps. Sales plummeted.

Ironically, we heard that business increased at a nearby bar. We joked that after a few minutes of listening to the wails of Walter “Wolfman” Washington in the shoe store, patrons started to think, “Ah, Branding-Images_Musichell. Nobody loves me, and I don’t have any money.” So they would saunter off to the bar down the street instead.

Most of us know intuitively the impact that music can have on our emotions, and neuroscience research is now validating the therapeutic properties of music. Yet many counselors aren’t taking advantage of this mellifluous instrument and using it in their sessions. I was thrilled when I read how American Counseling Association President Thelma Duffey uses music with her clients to help them craft their “musical chronology and emerging life story” (see “Counseling and leading with creative spirit,” July 2015). Prompting clients to create music playlists has also been tremendously helpful for my clients, especially those who are healing from grief and trauma. In this article, I’ll share examples of how you can use music in your sessions, even if you don’t think you’re that creative.

Using music playlists to heal grief

The pain of grief comes from feeling isolated, cut off and separated from someone or something we loved. Composing a playlist of songs that reflects the grieving person’s relationship with a lost loved one can dissolve that sense of isolation and help the client feel an ongoing connection to what he or she has lost.

For example, creating a music playlist sparked a huge breakthrough for my client “Tony,” whose son “Andy” had died of a heroin overdose. Prior to using music in our sessions, Tony had attempted to avoid his emotions by intellectualizing his feelings or abruptly changing the subject whenever a pang of grief surfaced in our sessions.

One day Tony mentioned that the song “I Dreamed a Dream” from the musical Les Misérables perfectly reflected the dejection he felt. When I offered to play this song in our session, he protested, “No! Don’t play it. That song completely levels me. If I hear it, I’ll be a wreck for the rest of the day.” 

This led to a discussion about how music can convey the complexity of our feelings better than words can. Rather than focus only on songs that reflected Tony’s grief, however, I suggested that he consider making a playlist of songs that captured the essence of his relationship with his son. Tony liked this idea and began by pulling a few songs from Andy’s favorite artists. Then he added his own preferred music. What follows are several of the songs that Tony selected and his reasons for choosing them.

1) “Father and Son” by Cat Stevens. This song reminded Tony of happy times when he and Andy would camp together and have heart-to-heart talks while they hiked and fished.

2) “My Boy” by Phillip Phillips. This song reflected recent years when Andy was struggling with insecurities and Tony had attempted to reassure him and encourage him to believe in himself.

3) “My Immortal” by Evanescence. Tony wept as we played this pretty song that contains lyrics such as “these wounds won’t seem to heal,” while the song’s words “you still have all of me” affirmed Tony’s continuing bond with Andy.

4) “Stay Gold” by Stevie Wonder. Tony’s affect brightened when he played this tune, stating that it gave him the determination to go on with life in the face of his pain. The lyrics suggest that despite all the suffering, life is but “a twinkling of an eye,” and that love and compassion make life worthwhile in the end.

5) “Sleep” by Eric Whitacre. This song comforted Tony, making him feel OK about taking the time he needed to rest and heal. The song also helped him imagine Andy sleeping peacefully and no longer suffering.

After we listened to the songs together, Tony commented, “Before I did this, all these songs and feelings were rolling around in my head, disjointed and unorganized. This gave me a way to face my fears and bring some order and coherence to my feelings. Even though many of the songs are sad, they give me hope and the will to move forward.”

Creating a playlist that is therapeutic

Even though research suggests that listening to a sad song can offer consolation, you don’t want your clients to make playlists composed solely of songs that will amplify their pain. As Tony commented, the song “I Dreamed a Dream” would have made him “a wreck for the rest of the day” if he had listened to it in isolation.

The secret to making a playlist healing instead of heartbreaking is to start with one or two songs that reflect the client’s current emotional state, then add three or four songs that gradually move the client toward his or her desired emotional state.

This suggestion is based on the concept of entrainment. Entrainment occurs when the rhythm of one object’s movement synchronizes with the rhythm of another. Christiaan Huygens, the Dutch scientist who invented the pendulum clock, documented this phenomenon around 1665 when he observed that two pendulum clocks sitting side by side would fall into a synchronous rhythm with each other. Similarly, our brain waves, heartbeat and motor areas are inclined to align with a song’s rhythm, which helps us to process our emotions and move forward.

Reprocessing trauma with empowering playlists

Entrainment playlists can also be a very effective way to empower trauma survivors and banish their feelings of helplessness. For instance, in my book The Therapeutic “Aha!”: 10 Strategies for Getting Your Clients Unstuck, I share how music helped my client Maddie, who had been the victim of a gang rape at a friend’s party when she was a teenager.

Maddie came to me for therapy when she was well into her 30s, frustrated that she was still carrying a great deal of rage, shame and guilt related to this incident. A former dancer, Maddie liked the idea of using music to process her traumatic experience. In addition, she discovered that dancing to the music helped her work through emotional material that she had not been able to access previously.

Maddie’s playlist began with the show tune “Everything’s Coming Up Roses,” depicting the naive innocence, excitement and optimism of a child. Then the scene transitioned to Billy Idol’s “Rebel Yell,” reflecting the lightness, fun and excitement of being a cheerleader in high school. Maddie explained that this song also symbolized the way that she and her friends were discovering how to use their sexual power, by flirting and dancing a little sexier as they cheered. She clarified: “I never wanted to use that power other than to find somebody to love me. But women learn to play the game and use this power to get what they think they want.”

The music and dance scene then spiraled downward into the horrific gang rape she had experienced. She chose the song “Fat Bottomed Girls” by Queen for this scene to reflect the randy, entitled attitude the boys used to justify their sexual aggressiveness toward her. Next, the dance meandered through the tormented journey she wandered for years after the incident, vacillating between rage and shame as she continued to look to others for love, approval and acceptance.

photo-1445743432342-eac500ce72b7Maddie ended her playlist with an instrumental song titled “Redemption” and the song “Unwell” by Matchbox 20. Puzzled by these two choices, I said, “I’m curious about these last songs. In my mind, you didn’t do anything wrong. What do you think you need to be redeemed from?”

Maddie widened her eyes and dropped her jaw as she exclaimed, “Wow, you’re right. I’m still carrying guilt as if dancing like a cheerleader caused this incident. I’m going to revise this.”

When Maddie returned to our next session, she said, “Most of the songs in the original dance piece don’t resonate strongly for me anymore. They are like pieces of a puzzle that I have already worked. They still fit in the big picture, but I am done with them.”

She concluded that “Black River” by the Lizzy Ross Band now summed up the way she felt about the event because the song was about a woman who had reclaimed her power. Although Maddie had been to many therapists over the years, after just two sessions of processing her traumatic experience through music and dance, she felt like she had finally found the resolution she’d been seeking. Her mood was positive. After a few more sessions, she felt ready to terminate therapy and begin dancing again.

Neuroscience support

Over the past decade, neuroimaging studies have demonstrated that music influences brain structures involved in emotion and associative learning. Additionally, research has demonstrated that listening to music with slow, “relaxing” tempos or upbeat, “joyful” tempos decreases the release of stress hormones such as cortisol.

Music has also been shown to mitigate pain and release endogenous opioids in the brain. Interestingly, researchers have found that even sad music stimulates activity in the reward and pleasure centers of the brain.

In his book This Is Your Brain on Music, neuroscientist and music researcher Daniel Levitin reported that when humans sing together, our brains release oxytocin, a powerful hormone that promotes emotional bonding. Music making and related activities such as drumming, singing, chanting and dancing have traditionally been pastimes that societies engaged in together to strengthen bonds, connect spiritually and foster group cohesion. Likewise, we can use music in the consulting room to strengthen the therapeutic alliance, help depressed clients feel less isolated and even bring couples closer together.

Closing thoughts

Incorporating music into your counseling sessions is an enjoyable intervention that can help clients resolve painful feelings more quickly and completely than when using traditional talk therapy alone. I’ve often witnessed dramatic changes when using music in my therapy sessions. Perhaps it is because music helps clients navigate feelings that defy words and integrate those feelings into a more coherent narrative.

Even when music evokes painful emotions, most people find it consoling, and counselors can assist clients in identifying songs that transition them toward more equable emotional states. When used in these intentional ways, music is virtually free of side effects — excepting the occasional flashes of spontaneous smiles, impromptu foot tapping and unsolicited body swaying.




Courtney Armstrong is a licensed professional counselor in private practice who specializes in grief and trauma recovery. She is the author of Transforming Traumatic Grief (2011) and her latest book, The Therapeutic “Aha!”: 10 Strategies for Getting Your Clients Unstuck (2015). Contact her at

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Controversies in the evolving diagnosis of PTSD

By Lennis G. Echterling, Thomas A. Field and Anne L. Stewart

PTSD headshotsTrauma is as old as humanity itself. In fact, for nearly 3,000 years, such epic poems as The Odyssey and The Iliad have given eloquent voice to the psychic scars of war. These “hidden wounds” of combat included overwhelming feelings of anxiety, horrific nightmares, heightened startle reactions, flashbacks of battle scenes and a profound sense of alienation years after the conflicts had ceased. Despite powerful accounts over the millennia of the psychic impact of trauma, it was only 35 years ago that the Diagnostic and Statistical Manual of Mental Disorders (DSM) introduced the condition known as posttraumatic stress disorder (PTSD). Since then, the evolving diagnosis of PTSD has generated numerous and intense controversies. Only dissociative identity disorder has stirred up more debates among researchers and practitioners.

Now that counselors are playing an increasingly important role as service providers for both military and civilian survivors of trauma, it is vital that we become familiar with the historical context and current issues regarding PTSD.

Conceptualizations of trauma

The origins of the PTSD diagnosis stem from two dramatically different conceptualizations of its cause and symptoms. The psychological movement began in the 1790s and considered the syndrome to be primarily a mental one involving altered consciousness and amnesia, which later became known as dissociation.

The somatic movement, which conceptualized a physiological basis for the syndrome, began in England during the 1860s, when researchers described “railway spine” as a consequence of the physical traumas of railroad accidents. During the past 150 years, wars have spurred health care providers to consider, to varying degrees, these contrasting perspectives in hopes of better understanding and treating the psychiatric casualties of combat.

Trauma and wars

From the U.S. Civil War to the recent conflicts in Iraq and Afghanistan, researchers and practitioners have returned again and again to the impact of war-related violence on the psyches of military troops. In the past, however, the prior lessons learned were largely abandoned and ignored in the decades of peacetime that followed wars.

For example, many physicians who were followers of the somatic movement proposed that traumatized Civil War combat veterans were suffering from a cardiac injury, which they labeled “soldier’s heart.” At the same time, other health care providers relied on a psychological conceptualization of the condition, which they referred to as “nostalgia.”

In World War I, psychiatrists originated the term “shell shock” because they considered the symptoms to be physiological reactions to the intense shock waves that emanated from artillery explosions. Other mental health practitioners, influenced by Sigmund Freud’s theories, diagnosed the condition as “war neurosis.”

With the beginning of World War II, many service members once again experienced the horrors of combat. Initially, those who developed posttraumatic reactions were discharged. However, when psychiatrists found that the degree of relatedness in the military unit was a protective factor, they developed treatment strategies for what they termed “combat fatigue.” These treatment strategies emphasized emotional support and rapid return to active duty.

Again, interest in trauma faded once World War II came to an end. Nevertheless, we should note that the first use of the term “posttraumatic” occurred in a follow-up study on veterans who had been diagnosed with combat fatigue. In the heat of battle in the Korean War, the American Psychiatric Association published the first edition of the DSM. The new manual briefly acknowledged that combatants experienced short-lived psychological reactions to war but did not label the syndrome a psychiatric disorder.

Not until the Vietnam War did the demand for a combat-related trauma diagnosis reach a tipping point. In the early 1970s, many returning U.S. veterans exhibited problematic and life-threatening behaviors. At first these behaviors were attributed to noncombat-related neurosis or psychosis. However, with public war protests growing, veterans began advocating for a new disorder called “post-Vietnam syndrome.” Mental health professionals began holding “rap groups” with Vietnam veterans about their experiences and led panel discussions at professional conferences. These efforts led to the American Psychiatric Association’s decision in 1980 to formally accept PTSD as a legitimate diagnostic category in the DSM-III. 

The long-term conflicts in both Iraq and Afghanistan once again have focused attention on the traumas that combatants endure and the pervasive impact of PTSD on the lives of returning veterans. The Rand Corp. estimated the prevalence of PTSD in Iraq and Afghanistan war veterans to be 14 percent, which is twice the estimated lifetime prevalence rate for civilians. With multiple and longer deployments, the risk of military combatants developing PTSD is even greater.

Trauma and the DSM 

In 1951, the DSM-I, which was a slim volume of 130 pages, introduced the syndrome “gross stress reaction.” Although not a disorder, the inclusion of this reaction proved to be both significant and influential for two reasons. First, it acknowledged that the syndrome was a risk not only for veterans of war but also for civilian survivors of catastrophic events. Second, it asserted that this syndrome applied to “normal” persons who experienced intolerable stress, thus disagreeing with the then-dominant psychodynamic assumption that these psychiatric casualties were vulnerable individuals who possessed predisposing neurotic conditions.

In the second edition of the DSM, published in 1968, the American Psychiatric Association revised the title of the syndrome to “transient situation disturbances,” a label with a more clearly negative term. Still, it was not considered a disorder.

Finally, in 1980, PTSD was included as a mental disorder in the DSM-III. It also became the first disorder to include a diagnostic criterion — a traumatic event — that was entirely external to the individual and outside the range of usual human experience. Examples of traumatic events included rape, combat, accidents and disasters. If the event was a “normal” one, such as the loss of a job or divorce, the person’s reaction was diagnosed as an adjustment disorder. Other criteria for PTSD included re-experiencing symptoms, engaging in avoidance and having arousal symptoms.

The addition of PTSD to the DSM-III was not without controversy. Given the disorder’s emphasis on combat-related trauma, there was concern the Vietnam War had politicized the decision with its emphasis on the hidden wounds of combat veterans. Because their dysfunction now was directly tied to military service and not to personality flaws, the Veterans Administration (now the Department of Veterans Affairs) was required to offer services to affected soldiers. In addition, PTSD was recognized as a disorder that merited disability status. Consequently, the Veterans Administration requested more government funding to meet the increased need for psychological services.

Seven years later, the DSM-III-R (revision) appeared with several minor refinements to the diagnosis of PTSD, including operationalizing the symptom clusters. A major contribution of this edition was to identify, for the first time, age-specific features that children and adolescents exhibit in response to trauma.

In 1994, the DSM-IV eliminated the requirement for the precipitating stressor for PTSD to be outside the range of normal human experience. It also expanded the definition of traumatic events to include the indirect experiences of observers and the loved ones of the victims. As a consequence of adding vicarious traumas, the number of qualifying events for PTSD increased by 59 percent. No other diagnosis in the history of the DSM had undergone such a drastic expansion (known as “conceptual bracket creep”) from one volume to another. The DSM-IV-TR (text revision) was introduced six years later and tightened the definition of a traumatic event to something that is “extreme” and “life threatening.” It also added several diagnostic specifiers, such as “acute,” “chronic” and “delayed onset.”

After many postponements, the DSM-5 was finally released in 2013 in a massive volume of 947 pages. The most obvious change in this current edition is that PTSD is no longer classified as an anxiety disorder. Instead, it is included in a new chapter titled “Trauma- and Stressor-Related Disorders.” Another significant change is that the DSM-5 now places restrictions on the operational definition of a traumatic stressor. For example, witnessing an event no longer qualifies as a traumatic stressor unless the person is physically present. In most cases, observing an event through the media is excluded. The DSM-5 also no longer requires an intense emotional reaction to the event because this lacked predictive utility. A new specifier now includes dissociative symptoms such as depersonalization and derealization.

Swinging pendulum

Like a pendulum, the conceptualization of PTSD has swung back and forth over the past century. In the time of Freud, its cause was attributed largely to the individual’s character deficits. During World War II, it was understood to be a normal reaction to persistent combat exposure. Thus, the pendulum moved toward identifying the traumatic event itself as the chief culprit of dysfunction. Following the war, most mental health practitioners gave greater weight to the extreme stressor as the primary cause. This view was reflected in the first edition of the DSM, when it was posited that any “normal” individual would develop symptoms after exposure.

As traumatized veterans returned from the Vietnam War, special interest groups began advocating for the addition of PTSD to the DSM-III to publicly acknowledge the hidden wounds of war. Perhaps most important, by requiring that the stressor had to be outside of normal human experience and so severe that any normal person could be affected, the DSM-III definition of PTSD reflected theBranding-Images_PTSD farthest swing of the pendulum toward placing onus for dysfunction on the traumatic event.

On the basis of new evidence that the majority of survivors did not develop PTSD after exposure to traumatic events, the DSM-IV represented the pendulum’s move back toward the interaction between internal and external causation, judging the individual’s emotional reaction to be just as crucial in the development of psychopathology. In other words, the event itself was no longer considered the sole cause of PTSD. Instead, traumatization was defined both as exposure to an event and an individual’s subsequent response of intense fear, helplessness or horror.

During development of the DSM-5, some scholars suggested that the event should be removed entirely as a diagnostic criterion for PTSD, resembling a return to Freud’s conception of dysfunction being attributed solely to the individual.

A developmental perspective

One serious limitation of the first three editions of the DSM was the lack of consideration of any potential developmental differences in reactions to extreme stress. Therefore, a major contribution of the DSM-III-R was to identify age-specific features that children and adolescents exhibit. For example, the DSM-III-R noted that young children were more likely to relive the trauma in repetitive play.

Still, researchers and clinicians working with children noted that the PTSD criteria in the DSM were not developmentally sensitive and did not capture clinically relevant symptoms for children living in chronically unsafe conditions. A proposal to include a new diagnosis, developmental trauma disorder (DTD), was considered for inclusion in the DSM-5. This diagnosis was proposed on the basis of findings from developmental psychopathology, clinical presentations of children exposed to chronic interpersonal violence and emerging evidence from the field of neurobiology regarding the impact of trauma on brain development. Ultimately, the proposal for DTD was not accepted for inclusion in the DSM-5. The discussion of the merits of an alternative classification system for children experiencing complex trauma is continuing.

Current issues

In addition to the controversies regarding the definition and criteria of PTSD, criticisms have continued to emerge regarding the transparency, representation and integrity of the DSM revision process. Critics have cited the secrecy of the DSM-5 development process and the apparent lingering presence of pharmaceutical company influence on DSM task force members as factors affecting the process.

Many advocates are worried that PTSD is underdiagnosed and undertreated among veterans of both current and past conflicts. For example, an estimated 271,000 Vietnam veterans continue to suffer from PTSD, according to a recent study by Charles Marmar published in JAMA Psychiatry. The New York Times reported that the incidence of PTSD among current military personnel more than doubled between 2005 and 2010, resulting in an overburdened Veterans Affairs (VA) health system. In 2011, the 9th U.S. Circuit Court of Appeals demanded that the VA overhaul its mental health services because delayed and inadequate services were being provided to returning U.S. veterans with PTSD. Harkening back to the conceptualization of “shell shock” in World War I, there now is growing recognition that primary blast waves have caused serious and permanent traumatic brain injuries among veterans of the Iraq and Afghanistan wars.

The prevalence of PTSD among civilians is also a serious problem. The National Sexual Violence Resource Center reported that half of the survivors of sexual assault are estimated to meet diagnostic criteria for PTSD. The high incidence of wide-ranging traumatic events among both children and adults has led many to recommend the use of trauma-informed care involving collaborative, supportive and skill-based interventions that address the pervasive impact of trauma. Recent research also has underscored the need to refine our conceptualization of PTSD by recognizing the crucial role that shame can play in its dynamics. Anxiety regarding external dangers has long been considered the primary emotion of PTSD, but the perceived internal threat of exposing one’s shame often predominates for many survivors, especially among those who have experienced interpersonal violence.

In marked contrast to the issue of underdiagnosis of PTSD, many professionals who intervene after disasters typically provide public education that normalizes reactions to catastrophes. Their criticism of the DSM is that broadening PTSD diagnostic criteria may have the unintended consequence of pathologizing natural human reactions to highly disturbing incidents. A related current issue is that many researchers and practitioners are calling for greater awareness of the phenomenon of posttraumatic growth, suggesting that the majority of trauma survivors eventually achieve higher levels of personal maturity, wisdom and well-being.

In our current environment, PTSD remains a diagnosis that involves controversies. As promoters of human growth and development, counselors are in a unique position to be active participants in this conversation. We can engage most effectively by contributing to refinements in conceptualization, discoveries through research, innovations in practice and empowerment through advocacy efforts that promote the resilience of trauma survivors. Given the prevalence of PTSD and the severity of its impact on individuals, families, relationships and communities, it is our duty as counselors to play a crucial role in alleviating the anguish and pain of those who suffer the consequences of this disorder.

Yes, trauma is as old as humanity. But as our theory, research and practices continue to evolve in the midst of PTSD controversies, we can envision a more humane future in which the diagnosis and treatment of trauma survivors offers healing and hope.




Knowledge Share articles are developed from sessions presented at American Counseling Association conferences

Lennis G. Echterling is a professor of counselor education and director of the Ph.D. in counseling and supervision program at James Madison University in Harrisonburg, Virginia. His most recent book is Thriving! A Manual for Students in the Helping Professions. Contact him at

Thomas A. Field is an associate professor and associate program director in the master’s counseling program at City University of Seattle. He also works as an independent contractor at a private practice in the Seattle area. Contact him at

Anne L. Stewart is a professor in the Department of Graduate Psychology at James Madison University. She is the president of the Virginia Play Therapy Association, and her most recent book is Play Therapy: A Comprehensive Guide to Theory and Practice. Contact her at


Letters to the editor:



Help for those who hoard

By Laurie Meyers

TV shows such as Hoarding: Buried Alive and Hoarders have brought hoarding disorder (HD) to a new level of public consciousness. The shows provide portraits of people who hoard, typically at a moment of crisis when they are on the brink of being evicted or having their houses condemned. Years of collecting “stuff” — much of which often has no monetary value — has narrowed their living space to a single room, part of a room or even just a place to sit.

Often, the living conditions are almost unimaginable. In many instances, kitchens have become unusable and utilities, including running water, have been cut off. Food has been left to rot, garbage Branding-Images_Hoarderis everywhere, and in the case of those who hoard animals, the resident lives among animal feces and even dead and dying animals.

Because these shows typically provide only a snapshot of the more sensational aspects of the lives of those who hoard, however, viewers rarely receive insights into the mental health disorder behind the chaos. Viewers are also unlikely to understand that the dramatic assisted cleanups that conclude the shows are not truly the end of the story; unless the person’s behavior is treated, all the “tidying up” will be for naught, because the same problematic actions and habits will reemerge. In fact, say counselors who work with those who hoard, treating the hoarding behavior is a difficult and often yearslong process.

Hoarding as a distinct disorder

In the past, hoarding was classified as a symptom of obsessive-compulsive disorder (OCD) or obsessive-compulsive personality disorder. However, the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders classified hoarding as a distinct disorder related to OCD. This is because OCD and HD may share certain characteristics, but they also feature significant differences, says Victoria Kress, an American Counseling Association member and past president of the Ohio Counseling Association who studies hoarding.

“Individuals with OCD and HD both have obsessive thoughts, rational or irrational, that affect their daily lives. These obsessions link certain behaviors with grave and undesirable consequences,” she explains. “For example, those with OCD might obsessively believe that they will get into an automobile accident if they do not lock their front door three times before leaving the house. On the other hand, those with HD might believe that they will suffer great sadness and loss if they discard an item of sentimental value. A fear of discarding items is one of the most notable features of HD, and those with this disorder often fear that they will accidentally discard an item that is valuable or will become valuable.”

Experts estimate that approximately 2 to 6 percent of the U.S. population has HD. Although often associated with those older than 50 — the average age at which those with HD seek help — in most cases the behavior begins during adolescence or young adulthood.

As a person with HD gets older, symptoms increase. Hoarding behavior may become more pronounced by a person’s mid-30s but often does not become truly debilitating until one’s 50s, Kress says. “This is due to a number of reasons,” she explains. “Primarily, individuals with this disorder do not experience debilitating consequences as the result of hoarding until the behaviors have increased and material items have collected over time.”

In addition, those who are younger often live with others — parents, roommates, partners or spouses — which can help keep the behavior in check, notes Nicole Stargell, an ACA member who also studies HD and has co-authored several studies with Kress. In fact, in some cases, the death of a spouse or partner contributes to the disorder spiraling out of control, she says.

Even when individuals with HD are not keeping the behavior in check, they can often hide it from friends and family simply by never letting anyone else enter their homes, says Kress, a national certified counselor who has experience working with this client population. However, as hoarding symptoms become more severe over time, the behavior begins to create significant social isolation, financial difficulty and hazardous living conditions, she says.

Hoarding behavior

As is the case with many other mental health disorders, researchers have not been able to pinpoint what causes HD. According to Kress, HD is characterized by a client’s desire to obtain and accumulate possessions but does not seem to be associated with poverty-related factors such as lack of food, shelter, clothing or money. She adds that the disorder can be exacerbated by — but is not caused by — trauma.

Hoarding is also not the same as, or even a natural progression of, allowing clutter to accumulate, experts say. Although the behaviors may share a superficial resemblance, they are quite different, says Mark Chidley, a licensed mental health counselor in Fort Myers, Florida, who works with clients struggling with HD. “The difference lies in the compulsive nature of acquiring [objects and possessions inherent with HD] and the distress when faced with discarding [them],” he explains.

Those with HD also don’t seem to recognize that being unable to use a room for its intended purpose — for instance, using a bathroom instead as a storage locker — is indicative of a significant problem, continues Chidley, who is also the author of Helping Hoarders: A Guide for Families, Counselors and First Responders.

“Lots of folks get a bit messy for a time, but [they] will act to clean up before they lose use of a space and do not show … compulsivity and distress when they go to clean up,” he says. “Cleaning up a cluttered space remains just a pain in the derriere for most of us, not something to be avoided at all costs.”

People who hoard find it nearly impossible to discard items because they attach significant emotional value to those objects, say Stargell and Kress. Although the objects sometimes have monetary value, they are just as likely to be items that are normally discarded as trash, such as napkins, cups or straws, says Stargell, an assistant professor of counseling and the field placement and testing coordinator at the University of North Carolina at Pembroke. Regardless, clients who hoard will consider the items to be tremendously valuable.

“The value that individuals with HD place on hoarded objects is often not monetary. They are valuable due to their usefulness or sentimental qualities,” says Kress, who is the community counseling clinic director, clinical mental health counseling program coordinator and addiction counseling program coordinator at Youngstown State University in Ohio. “Individuals with HD place unjustified value on objects and fear harmful, often unrealistic consequences if they are discarded.”

For example, someone who collects napkins might cite a particular napkin as having value because it was used at an anniversary dinner with a spouse, Stargell says. “However, it’s not just that napkin — it’s every napkin from every dinner ever,” she stresses. Another example of misplaced value would be someone who collects cups from a fast-food restaurant because the cups may be “useful” someday. In the process, however, the person gathers and keeps hundreds of cups, Stargell says.

But for those with HD, it’s never just one item, and it’s never enough, experts say.

Health risks

As hoarding behavior progresses, it can pose significant risks to both physical and mental health. “The functional impairment associated with HD is often compared to [that of] schizophrenia and bipolar disorders,” Kress points out.

The conditions under which people who hoard live are frequently unsafe and unsanitary, compromising their well-being. “Medically, this can run the full gamut of conditions that are created or pre-existing conditions that are worsened by being in close proximity to decaying materials, coupled with an increasingly sedentary lifestyle,” Chidley explains. Decaying matter and the potential for accompanying pest infestations can exacerbate these individuals’ respiratory conditions, increase their likelihood of contracting an infectious disease or even expose them to toxic materials, he says. The flammable detritus around them can pose a fire hazard, while the lack of clear walking space increases the risk of injuries from tripping and falling, he adds.

“If a hoarder has a chronic condition such as diabetes, self-care is usually limited or nonexistent, and the disease trajectory is accelerated,” Chidley concludes.

Hoarding can be life-threatening not just because of the attendant health risks, but also due to the person’s reluctance to let outsiders in. “[One client] fell and injured herself in her home and, after making it to her bed, she lay in her own feces without food or water for four days before realizing she was going to die if she didn’t call for help,” says Polly Kahl, a licensed professional counselor in West Lawn, Pennsylvania, who specializes in treating clients with HD.

“Shaming reactions from those around them make hoarders less likely to call for help,” Kahl explains. “[They sometimes choose] unsanitary and unsafe living conditions without plumbing or electricity rather than risk being embarrassed and shamed.”

Some of the most horrific living conditions involve those who hoard animals. Although these individuals believe they are saving the animals, the truth is that they are not able to care for them properly. Those who hoard animals often have an almost unimaginable number of animals living in the home with them. Stargell knows of one case in which the person had collected 200 dogs. Because those who hoard take on so many animals, they are often surrounded by feces and the bodies of the animals that have died due to neglect. Those who hoard animals also have a tendency to bring in sick animals, thus introducing extra health risks to themselves and the animals they already have, Stargell says.

Kress and Stargell say animal hoarding is characterized not just by the denial or lack of insight that accompanies object hoarding, but also by delusional thinking. “They are convinced that they are helping the animals, that they are loving them,” Stargell says. These individuals may even believe that this is their calling in life — to help animals that would not have a good life without them (or so they think), she adds.

Hoarding affects not only the individual with the problematic behavior but also his or her loved ones and the community, Kress says. “The unsanitary condition of their homes presents a hazard to surrounding homes in the form of increased rodent populations, bug infestations and fire hazards,” she explains. “Cluttered living spaces present significant challenges to medical first responders in reacting to emergency situations, which may be more likely to occur due to the fire hazards and chronic health conditions that are associated with HD.”

Treatment challenges

Because HD is more treatment resistant than many other mental health disorders, treatment is slow, sometimes taking as long as three to five years, Stargell says. Part of the problem is that those who hoard are rarely motivated to change.

“Hoarders are traditionally in … denial about their own conditions and, when confronted, usually become very defensive, even verbally attacking, toward those who want to help them,” Kahl says. “The longer the condition has gone on, the more in denial and defensive the hoarder will be.”

Kahl likens hoarding to addiction in that both involve denial and a strong sense of shame. Another similarity is that, as with addiction, those living with the person who hoards may reinforce the hoarding behaviors and their attendant emotional distress, she says.

“There is a synergy between hoarders and those who live with them which can go a couple of different ways,” Kahl explains. “Many roomies [or family members] respond by trying to intentionally shame or embarrass the hoarder into cleaning up their act. This further solidifies the hoarding behavior by intensifying the hoarder’s defensiveness. The other common response to the hoarder is to avoid confronting them because of their [negative] behavior when confronted. As with addictions, this serves to enable further hoarding.”

“Occasionally, partners or housemates of hoarders gradually acclimate to their hoarded surroundings, developing their own ‘clutter blindness,’ and they become hoarders as well,” she adds.

Although those close to someone who hoards may enable or exacerbate the condition (even if unintentionally), they are also often the key to the person finally getting help. In another similarity to addiction cases, those who hoard often refuse to seek treatment until family members or other loved ones force the issue, say the counselors interviewed for this article.

Treatment suggestions

Even so, clients with HD may initially present in a counselor’s office with other issues such as depression or attention-deficit/hyperactive disorder, both of which are frequently comorbid with HD, say Kress and Stargell.

Stargell says clues to the underlying HD often turn up in clients’ descriptions of their families, social relationships and daily lives. For instance, clients might mention not socializing much because of their reluctance to let friends into their house or discuss family members refusing to visit because of the condition of their home. If clients bring up losing a job or being “forced” into therapy by family, counselors should be sure to explore all of the underlying factors because problems related to hoarding may be involved, Stargell says.

“Oftentimes, people with hoarding disorder have poor overall physical health,” says Stargell, citing another red flag for which counselors should be on the lookout. Indicators of hoarding might be hidden in the underlying causes of the client’s bad health, such as not going to the doctor because the person is avoiding the world or being unable to eat properly because the kitchen or eating areas are inaccessible, she explains.

Clients who hoard may also incur frequent injuries because they regularly trip and fall over accumulated clutter, Chidley says, or they may have respiratory problems caused by exposure to mold or toxic substances in their homes.

For treatment to be successful, clients with HD will eventually need in-home support, if not with a counselor, then with case managers or others trained in working with those who hoard, Kress says. However, it is possible to begin treatment in the counseling office. Kress and Stargell say that cognitive behavior therapy techniques such as thought stopping and cognitive restructuring have been shown to be effective when treating HD.

Counselors also need to help these clients understand the thinking that forms the foundations of their behavior. This might involve asking them to maintain a “thought journal” that tracks what they collect and why, Stargell suggests. For instance, clients might note that yesterday they went to a fast-food restaurant, purchased a drink and saved the cup and straw for future use. Counselors then encourage clients to consider the reasons why they might not need to save the cup and straw, such as “I already have 700 cups and straws,” or “I will only ever use five cups and straws,” Stargell explains.

Even speaking hypothetically about disposing of items can be extremely stressful for these clients, Kress points out. For that reason, it can be helpful for counselors to introduce emotional regulation and distress tolerance skills.

“Clients with hoarding disorder often have difficulties generalizing skills learned in sessions to real-life situations,” Kress says. “Practicing coping skills during hypothetical discussions may reinforce learning and the appropriate application of skills.”

Once clients start to understand the thoughts and feelings that underlie their hoarding behavior, counselors can then work on helping them restructure irrational thoughts into more logical and factual beliefs, Kress says. “For example, a client may work to replace the thought ‘If I throw away this newspaper, I may find out that it is of value and lose out on a fortune’ with ‘It is unlikely that if I throw away this newspaper, I will lose out on a fortune,’” she explains.

Counselors should move slowly with those who hoard in order to gain their trust. Because people with hoarding disorder are often experiencing shame and embarrassment and are typically sensitive to what they may perceive as rejection or judgment, they need to feel a strong sense of acceptance from the counselor, Kress says.

People who hoard typically lack self-awareness and insight. They are unable to accurately see and assess the destructive effect that hoarding has on their lives, Kahl says. For this reason, counselors must help these clients make the connection between their hoarding and its myriad unhealthy consequences.

“As with addiction, the best way to achieve this is by helping them see the consequences of their hoarding,” Kahl says. “In one case, a hoarder was … desiring [of] help because she realized her adult children had refused to enter her home for years. Now that she had grandchildren, she needed to clean out her home if she ever hoped to have them over to visit or come for family events like Thanksgiving dinners.”

Adds Kress, “Threats of eviction, loss of independent living, legal action and social isolation are some of the consequences that these clients face as a result of their behaviors. Because impaired insight is a facet of this disorder, interventions that focus specifically upon enhancing motivations, such as motivational interviewing, may be a helpful adjunct to other treatment approaches for this disorder.”

Once clients feel comfortable and open to change, it is important to incorporate family and other loved ones into treatment — with the client’s permission — so that they can help provide support and encouragement, Kress says.

Kress also suggests using exposure therapy to help clients. This process involves “practicing” disposing of items by discussing it hypothetically, either in the counseling office or in the client’s home. Once clients are ready to let go and discard, counselors can enlist the help of professional organizers or cleanup crews to remove discarded items, she says. But in some circumstances — such as impending eviction — counselors will not have enough time to slowly integrate exposure therapy.

“In this case, counselors should do their best to support the client and process mass cleanup events as a traumatic experience before working toward continued insight,” Kress says. “In situations that require immediate action, counselors should be prepared for the client to experience extreme emotional distress and may wish to include assessment for suicidal ideation.”

Because HD affects all aspects of these clients’ lives, practitioners should be prepared to provide referrals to other professionals such as physicians as well as to community resources such as vocational services, Kress notes. Although counseling those with HD does not require special training, Kress suggests that practitioners educate themselves by staying up to date on the literature and, if possible, attending training sessions.

Kress reiterates the challenges of working with clients who have HD. “They are deeply entrenched in their ideas and the importance of holding on to their items,” she says. “Also, they often don’t want to change. It is almost always someone else who is pushing them to make changes. Their ambivalence to change can be a real treatment barrier, so I like to focus on enhancing their motivation to want to change, because without that, you have nothing to work with.”




If you’d like to learn more, ACA offers a Practice Brief on hoarding disorder, written by Nicole A. Adamson, Chelsey A. Zoldan and Victoria E. Kress, at

In addition, Kress, Nicole Stargell, Zoldan and Matthew J. Paylo wrote an article titled “Hoarding Disorder: Diagnosis, Assessment and Treatment” for the January 2016 Journal of Counseling & Development.

Stargell and Kress will be presenting an Education Session on hoarding disorder on April 1 at the ACA Conference & Expo in Montréal.




Contact the following counselors interviewed for this article:




Laurie Meyers is the senior writer for Counseling Today. Contact her at

Letters to the editor:

Influential thinkers

By Bethany Bray

Who are the major influences on today’s counseling professionals? What voices, both within and outside of the profession, are counselors listening to and intently following?

Recently, Counseling Today posed these questions to a random assortment of American Counseling Branding-Images_InfluenceAssociation members and a few select counseling leaders. The responses were as diverse as the association’s membership. From personal mentors and supervisors to eminent thinkers and authors, from human rights champions to neuroscientists and others on the cutting edge of research, today’s counselors are influenced by a wide variety of voices.

We invite you, in turn, to consider who influences your work as a counselor. The exercise may spur some self-reflection on what methods and philosophies you place value on and how you have learned and evolved over the course of your career. We encourage you to share your responses in the comments section for this article.




I am greatly influenced by Thelma Daley, a phenomenal leader within and outside of the profession. She exudes knowledge, vision, compassion, diligence and grace. Anyone who has ever worked with her has benefited from her ability to lead without imposition and her humility without passivity. I am fortunate to have been mentored by her before, during and after my presidency.

As ACA’s first African American president in 1975-1976, Thelma Daley is truly a living legend in our profession who has greatly influenced a community of thinkers. If being a trailblazer weren’t amazing enough, she is also an influential thinker and past president of Delta Sigma Theta, the largest African American sorority in the world. I continue to learn from Thelma and hope to pay it forward by modeling her ideals of stewardship to emerging leaders in counseling. — Cirecie West-Olatunji, associate professor in the counseling program and director of the XULA Center for Traumatic Stress Research at Xavier University of Louisiana in New Orleans and past president (2013-2014) of ACA




I’ve been most influenced by Michael White, a narrative family therapist from Australia. White suggests we are most successful when we attend to the unique stories clients share and strive to use these stories to help clients shape a more positive, solution-focused narrative. This new narrative is broader in perspective and helps normalize negative experiences. Our stories connect us, prevent us from being alone and are key to understanding our uniqueness. Attending closely to clients’ stories allows us to use those stories to communicate, bridge gaps and increase the trust with our clients.

I also lean toward story and narrative as I consider this question. Antoine de Saint-Exupéry’s The Little Prince offers me solace and guidance when helping others. The author uses the allegory of the little prince to teach the importance of mindfulness. He warns against pursuing power for power’s sake, the folly of conceit, the foolishness of becoming lost in drunkenness, the risks of pursuing success and achievement, the sadness of the unreflective life and the peril of scholarship in lieu of living.

Like the story’s fox or rose, individuals become unique and special when observers take time to care for them and tend to their needs. While the science of counseling is essential, nothing is more important than appreciating the distinctive humanity of those in our care.

“Goodbye,” said the fox. “And now here is my secret, a very simple secret: It is only with the heart that one can see rightly; what is essential is invisible to the eye.” — Brian Van Brunt, author and counselor educator who lives in Manchester, New Hampshire, and serves as executive director of the National Behavioral Intervention Team Association




My parents, who were unaccompanied minor refugees, have endlessly helped others throughout their lives and instilled social justice values in me at a young age. With this mindset, I gravitated toward human rights/social justice leaders such as Steve Biko, Aung San Suu Kyi, Gandhi, Harriet Tubman and Martin Luther King Jr., who inspired and profoundly influenced my counseling work. I am motivated and encouraged by their fearless courage, tireless energy, robust strength and resiliency, limitlessly placing others before self and utilizing infinite creativity [while] striving for social change toward equity and equality for all. 

They remind me that giving up is not an option and barriers should be viewed as tenacious opportunities to empower others through positivity, patience, hope and humor. I am honored and humbled to stand on the shoulders of the social justice/human rights giants who have sacrificed and paved the way for counselors to continue their social justice legacy. — Rita Chi-Ying Chung, professor in the counseling and development program at George Mason University in Fairfax, Virginia, president of Counselors for Social Justice and ACA fellow




I don’t really see [influence] as any single voice that counselors are listening to right now. What is exciting to me in the counseling field is the collective voices of therapists coming together and helping each other to go into private practice, negotiate rates and even some talk of forming unions so we have more negotiating power with the insurance companies and our employers. Throughout much of the history of the counseling profession, we counselors have been isolated and on our own. Now so many therapists are starting blogs and online forums and coming together. I really think that because of this, we’re on the cusp of some good things coming into our profession. Counselors want change, and 2016 could be the year it happens. — Marina Williams, licensed mental health counselor (LMHC) working in private practice in Boston




There has been no greater influence on my counseling career than Stephen Southern (professor and chair of psychology and counseling at Mississippi College). His approach to counseling using his keen wit, questioning of common norms and progressive thinking makes me acutely cognizant of how counseling is a lifelong learning profession. His passions for social justice, advocacy and empathy challenge me to consistently question and evaluate my own judgments and perceptions. Southern has influenced my work by helping me broaden my awareness and deepen my insight to better serve my clients and students. — Jessica Cole, licensed professional counselor supervisor (LPC-S), clinical professor at Mississippi College and psychological health coordinator with the Mississippi National Guard




I owe a debt of gratitude to the following health care pioneers: Alia Crum for demonstrating how our thoughts affect us on a physiological level and Jon Kabat-Zinn for showing us how mindfulness practice can produce cognitive, behavioral and even chromosomal change. Nicholas Cummings and Nadine Burke Harris for integrating health care, which is creating a more person-centered and effective health care system. Daniel Amen, who empowers clients and advances our profession by using brain-scan technology to demonstrate the positive effects of counseling, nutrition, social engagement and medicine. The feminist therapists and the recovery movement, [which] prove that personal transformation takes place when we join together to create societal change. Carl Rogers, Irvin Yalom and Scott Miller, who demonstrated that no matter how skilled we become with cognitive behavior therapy, motivational interviewing and trauma-informed therapy — which are all important — nurturing the counselor-client relationship is the quintessential evidence-based practice. Finally, Gerald Juhnke for teaching me through example how to see the person instead of the problem and for recognizing the need beneath the behavior. — Russ Curtis, licensed professional counselor (LPC) and associate professor at Western Carolina University




Courtland Lee (ACA president, 1997-1998) is most influential to me as a counselor and counselor educator. I first read his work during my master’s program. I was encouraged by how he centered multiculturalism and social justice in his writing. His writing introduced me to the concept of cultural identity development. This helped me make sense of my own identity development as a person of color and later inspired me to study the ethnic identity development of Chicanxs. Through him, I was introduced to the concepts of cultural validation and cultural encapsulation — notions that have helped in my work with students of color in higher education and in designing educational experiences for white counseling students. Finally, he is a tremendous role model of how to carry oneself as a man of color in a predominantly white profession. He is confident, proud and charismatic. I model my professional presentation after him. — Carlos P. Hipolito-Delgado, associate professor and program leader in the counseling program at the University of Colorado Denver and chair of the ACA Foundation




Most recently my work has been influenced by Jeremy Safran and Christopher Muran’s approach as outlined in their book, Negotiating the Therapeutic Alliance: A Relational Treatment Guide. This approach resonates with me because it includes elements from experiential, dialectic, Gestalt and humanistic approaches. It is born from the highly researched and validated notion that the therapeutic alliance is the most significant predictor of treatment outcomes.

The approach is also highly applicable in therapy, no matter your theoretical orientation. It speaks in terms of metacommunication in the here and now, which they refer to as “mindfulness in action.” The book offers several detailed examples of “ruptures” in the relationship that occur during sessions and how to repair the ruptures in the moment, basically allowing room for the therapist’s humanness to be a part of the didactic. The importance of attending to what is happening in the room between therapist and client is used as a tool to help illuminate relational patterns.

This dance of noticing ruptures, attending to them and ultimately repairing them fosters an even stronger bond, which as research has shown, leads to better client outcomes. — Sabrina Marie Hadeed, LPC, assistant clinical director and wilderness therapist at Evoke Therapy Programs in Bend, Oregon, and doctoral candidate at Oregon State University




Samuel Gladding’s focus on creativity has been tremendously influential in my work as a counselor. Early on and through the years, Sam’s works reinforced my belief that when talk is not enough, we owe it to our clients to find innovative ways of working with them. This belief motivated me to embark on a trajectory that has been nothing short of incredible. I value the creative spirit — the creative force — and believe that when counselors and clients connect to these and to each other, wonderful things are possible.

The works of Judy Jordan, Jean Baker Miller, Irene Stiver and Jan Surrey profoundly influence my work as a counselor through their writings on relational-cultural theory. Years ago, they introduced the notion that people grow through connection, not separation, and deepened my understanding of authenticity, mutuality and resilience.

Linda Hartling and Evelin Lindner’s human dignity and humiliation studies also significantly influence my counseling. They are critical thinkers whose work provides a lens from which I can conceptualize client cases and deepen my understanding of people and life.

Finally, David Daniels, Helen Palmer, Russ Hudson, Richard Riso, David Fauvre and other leaders in enneagram personality studies have provided a life-changing influence. Through their work with the enneagram, they helped me pragmatically consider the many worldviews with which clients come to counseling and provided a structure by which I could better understand my own.

My operational framework for counseling is integrative and includes important aspects of each of these influences. Shane Haberstroh and I are developing a model we named Developmental Relational Counseling, which speaks to the role of awareness, connection, compassion, power and feedback in the counseling process. I am grateful to these influential thinkers and to the many others who continue to bring me energy and inspire my work. — Thelma Duffey, ACA president (2015-2016) and professor and chair of the Department of Counseling at the University of Texas at San Antonio




As I have grown as a counselor over the years, there is not one idea or approach I can think of that influences me the most. I do know my five years of working in mental health rehabilitation impacted me the most, however, and shaped me as a counselor. It was my “feet on the ground” training. It taught me how to think on my feet and how to cope with individuals in crisis.

I worked in mental health rehabilitation from my bachelor’s level all the way to my LPC, so it has a huge impact on the way I approach my clients now in private practice. I learned to empathize and to develop healthy boundaries during my time in mental health rehabilitation. I also had the opportunity to work with a great range of individuals one does not always see in private practice. — Christina S. Mehal, LPC-S in private practice in Jennings, Louisiana




The individuals who are having the greatest influence on my counseling practice are those in the fields of neuroscience, mindfulness and trauma. I have been guided by the work of Daniel Siegel, Bessel van der Kolk, Norman Doidge, Kelly McGonigal, Rick Hanson, Pat Ogden, Stephen Porges, Bonnie Badenoch, Christopher Germer, Elisha Goldstein, Bill O’Hanlon, Robert Scaer, Ron Siegel and Jon Kabat-Zinn. For my clients, the concept of neuroplasticity holds a promise of hope for lasting change. At the same time, the explanation of the hard-wired neural firing patterns allows clients to release their feelings of personal insecurity, guilt, shame and blame placing.

I believe that as research continues to explore the mind-body connection, we will find out that each of us has more control over our physical and mental health than we realize. Mindfulness techniques will become part of the gold standard for any counseling practice. — Jerry D. Ryan, LPC and certified rehabilitation counselor in Oregon City, Oregon




There have been many influential thinkers and writers within our profession, and I will highlight just one. Irvin Yalom’s broad array of writing has impacted me throughout my career, most especially through one initial concept that runs throughout his writing: the installation of hope.

Hope for me is the bright light, the avenue on which we travel to go forward. Yalom named this within the therapeutic frame of reference for me. Hope can be an elusive feeling for those experiencing loss or fear in any form, trauma from various sources or personal identity struggles. Developmental transitions can leave us feeling uncomfortable in our personhood and often lead to feelings of hopelessness. The absence of hope while experiencing serious mental health concerns can be dangerous, and as a counselor, I have utilized many strategies to assist clients in recapturing that hope, that bright light.

With a seemingly simple concept as the necessity of hope, Yalom effectively implored us as counselors to instill that concept in our clients. Knowing hope is vital is a small part of the task of instilling it within a client’s world. That is our work, and the concept has propelled me in all my clinical work, as well as teaching and leadership throughout my career. There is something engaging about a positive, encouraging and hopeful person, and if that describes a counselor, that combination can be magical within the counseling process. — Catherine B. Roland, LPC, chair of the Ph.D. counselor education and M.A. clinical mental health counseling programs at the Chicago School of Professional Psychology, Washington, D.C., campus, and ACA president-elect




From Barry Duncan, whom I encountered as a first-year graduate student, I learned about approaching therapy from a strength-based perspective, and this has been my guiding principle in the work I have done over the last decade.

From Irvin Yalom I learned that death anxiety is an enormous influence on our day-to-day decisions. Staring at the Sun was a transformative book, and I’ve used its principles countless times in helping clients to obtain deeper insight about concepts such as “wasted time,” a drive to be true to oneself and the difficulty of living in the moment.

From Brené Brown I learned — and am learning, every single day — about how vulnerability counteracts shame so that we can all live more authentic lives. I learned to support clients through the discomfort of being in the muck of uncertainty and how to live more wholeheartedly. — Jennie Steinberg, licensed marriage and family therapist and licensed professional clinical counselor in private practice in Los Angeles




Steven Hayes’ work with acceptance and commitment therapy and Carl Rogers’ emphasis on empathic presence in the counseling relationship have a great deal of influence in my therapeutic approach. I find that present-moment awareness (mindfulness) offers the most effective avenue for change, both in the counseling session and in a client’s daily life. With a positive therapeutic relationship underlined by empathic presence, the opportunity for impact is greater.

Also, philosopher Ken Wilber and Buddhist monk Thich Nhat Hanh have a great deal of influence on my therapeutic approach. Wilber’s integral psychology contributes ideas and establishes new paradigms that offer attention to mind-brain integration — an effective tool as more science is inserted into ancient wisdom surrounding the mind. On the other hand, the simplicity of Hanh’s mindfulness teachings create tools to help clients focus on the effects of their clinging to the past or longing for the future while missing the miracle of the present moment. — Linda Good, LPC and mental health service provider in Johnson City, Tennessee




C. Gilbert Wrenn and Carl Rogers were certainly my first serious reads as a professional, and I keep coming back to their writings on a regular basis. They humanized counseling and also the process of writing. I also like reading Jeffrey Kottler. He has excellent insights into human nature and who we are as counselors. Irvin Yalom’s novels are fantastic reads too, and

he provides stories that are sensitive and touch the fabric of what it is like to be human. Mark E. Young is one of my favorite authors (and people) too. His book on helping skills, Learning the Art of Helping: Building Blocks and Techniques, is rich in metaphors and excellent examples.

Mihaly Csikszentmihalyi, the author of Creativity and Flow, is the professional outside of counseling who has influenced my work most. Csikszentmihalyi is an excellent researcher, clear writer, deep thinker and insightful contributor to the process of creativity, purposefulness and meaningfulness. I also continue to read H. Richard Niebuhr and Reinhold Niebuhr for their emphasis on ethics, moral responsibility and social justice. Finally, I love reading Ronald A. Berk’s wonderful and funny book on teaching, Professors Are From Mars, Students Are From Snickers. It is about injecting appropriate humor into the classroom as a way of teaching. — Samuel Gladding, professor of counseling at Wake Forest University in Winston-Salem, North Carolina, and past president (2004-2005) of ACA




The composer Igor Stravinsky has influenced my work as a counselor — in particular, his only full opera, The Rake’s Progress (1951). Using a very literate libretto by Chester Kallman and W.H. Auden, this Faust story has all the ingredients true to life: finding meaning and purpose in life through activity that covers thinking, loving and doing.

The hero, Tom Rakewell, succumbs to the distorted belief that fate alone determines his outcome and that “good works are of no avail, for heaven predestines all.” It also features a transgender-like character, Baba the Turk, a bearded lady who falls in love with Tom but is jilted. The opera’s epilogue is a timeless multicultural and transcendent appeal to banish idle hearts, hands and minds so as to promote the overall good in individuals and in the world at large. — Peter A. Manzi, a national certified career counselor and master career counselor who lives in Rochester, New York, and is contributing faculty in the School of Counseling, College of Social and Behavioral Sciences, Walden University




Individuals who don’t work in the counseling field and who most heavily influence my approach as a counselor are my clients. It is truly remarkable to observe both how fragile and resilient human beings can be. It is also inspiring to hear how honest people can be when they are in an emotionally safe environment. By extending an invitation to treat the therapy office as a laboratory where we can dissect anything we’d like to, I have been fortunate enough to examine the fascinating mind, in awe of its beauty and complexity. Some of

my most pivotal growing experiences have taken place as the result of these humbling moments in session when I’m learning from the true experts. — Alyson Carr, LMHC, qualified supervisor and doctoral candidate at the University of South Florida in Tampa




Jane Myers (ACA president, 1990-1991) was first of all an advocate for anyone marginalized by those with power and sway over others. I was already aware of social injustices, but she helped me to find ways to act upon my convictions. As rehabilitation counselor educators, for example, we sought to infuse into the education of all counseling students their responsibilities as advocates for persons with disabilities.

Jane spearheaded the development of a curriculum and competencies for gerontological counseling, adopted by both the Council for Accreditation of Counseling and Related Educational Programs and the National Board for Certified Counselors, respectively. These accomplishments, and the establishment of the Association for Adult Development and Aging as an ACA division, were overshadowed only by her career-long advocacy and research on wellness counseling, both in this country and abroad. A colleague described her as a brilliant mentor, prolific scholar, counselor and counselor educator. She was indeed that and more. — Thomas Sweeney, professor emeritus of counselor education at Ohio University, executive director emeritus of Chi Sigma Iota International and past president (1980-1981) of ACA




Within the counseling profession, my framework is shaped by Carl Rogers. His concepts align with my approach to elementary school counseling, and I use his theories every day. In my practice as an elementary school counselor, I tap into a Rogerian school of thought where I apply principles to students’ social and emotional development through the lens of a person-centered approach. It is so important to meet [children] where they are developmentally and empower them to apply tools to continue to grow in a healthy manner.

Carl Rogers advocates for what I consider the crux of my counseling practice: the notion of unconditional positive regard. Feeling worthy at school empowers children to take chances and know they are supported. Shaping young minds is a daunting task, but to me, the Rogerian approach is the best way to reach children and teach them they are valued and worthy of unconditional love.

Outside the realm of counseling, another Mr. Rogers is the inspiration for my daily practice: Fred Rogers. His approach to children and life in general is so inspiring, and I use it in my daily practice with elementary school children. His gentle nature and direct way of speaking to children like they are worthy beings is so important. His iconic television show (Mister Rogers’ Neighborhood) was such a staple for children and truly showed what it meant to be loved and treasured as a human being. I try to impart that same notion in my practice every day, where my office is safe space for children.

In a school environment, we are given the responsibility of spending five days a week shaping children into productive members of society. My role as an elementary school counselor is one that Mr. Fred Rogers filled every day, making sure that kids felt heard, understood and loved. — Rebecca M. Cordisco, an elementary school counselor in Hillsborough, New Jersey




I have been inspired by many people outside of the counseling profession, but one woman stands out: Helen Taussig. She was a famous pediatrician, surgeon, cardiologist and professor at Johns Hopkins University School of Medicine. I was doing a part-time counseling internship in the hospital. By chance I was chosen to have dinner at her home and, after dinner, we toured her greenhouse. She treated every growing plant differently. This one a little water. That one some plant food. Very deliberately she moved about, preening this one, pruning that. Then she turned and said, “People are like plants. … Give to each according to need,” and she humbly walked on. — Lee Richmond, professor of education at Loyola University in Baltimore and past president (1992-1993) of ACA




Abraham Maslow’s hierarchy of needs comes to mind for the value the pyramid lends psychotherapists as a tool to better understand the etiology of their clients’ circumstances. The pyramid and its concepts can be an effective mechanism to help clients see the importance of procuring and maintaining love and belonging, as well as conceptualizing the

benefits that can be gained while working toward self-actualization.

Maslow’s work underscores the importance of individuals awakening to the value of identifying peak experiences in their daily lives and encourages the pursuit of transcendence. How these two crucial elements unfurl assists the individual to experience a more authentic and meaningful life. Life is perceived through the meaning we apply to our experiences, which, therefore, assists in illuminating the true meaning of life. Life is in the details. — Vanessa L. Dahn, LPC, adjunct professor of sociology and psychology at Colorado State University-Pueblo, Pikes Peak Community College and Southern New Hampshire University, and executive director of Safe Landing Group Center, a facility for at-risk youth in Calhan, Colorado



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Nearly 40 counselors provided input for this article. Read more responses from practitioners on who and what influences their work at our online exclusive here. Then add your voice to the conversation by telling us about your major influences in the comments section at the end of the article.




Bethany Bray is a staff writer and social media coordinator for Counseling Today. Contact her

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