Sitting in my office, I carefully filled out the insurance form in front of me. My client had requested third-party billing, and I was just learning to navigate the insurance system. In the space dedicated to the DSM-III-R diagnosis (yes, this was a long time ago), I carefully read and reread the criteria to be certain I had correctly diagnosed my client.
In graduate school, I had been drilled on the risks of labeling, so I made sure I was careful not only about the diagnosis but also about how the diagnosis might affect my client. Labels, as we all learn, have built-in hazards.
I am certain, even all these years later, that my diagnosis was correct and that I covered the issue effectively with my client. What I didn’t think about in those days, however, was how the diagnosis might affect my client 10, 20 or even 30 years in the future. This oversight makes me shudder. This is something I was NOT taught in graduate school or residency.
Regardless of the diagnosis, once we have written a number from the ICD-10 or DSM-5 on a piece of paper, that label will follow the client forever. Teachers, psychologists, licensing agencies and employers may end up viewing the person through the lens of those diagnoses well into the future, even when those diagnoses may no longer apply. Just as distressing, the client may view himself or herself through that lens too — in many cases, long after the diagnosis is no longer pertinent.
One of my clients was struggling through a serious family crisis. She was on the verge of suicide and was prescribed an antidepressant by her physician. After a brief hospital stay, she began to improve. In assisting her through that crisis, I was relieved not to have to add to her financial struggles. I filed with insurance, which paid for all of her session costs.
Little did I know how much this action would complicate her future. Fifteen years later, my former client, long since healed and healthy, completed school as a nurse practitioner. But when she submitted her paperwork for her medical license, she was denied because of her “suicidal” history. Unable to get even an entry-level position in the field, she decided to take a part-time job as a school bus driver. But, again, because of her mental health history, she was denied a commercial driver’s license.
My diagnosis and her hospitalization followed her almost two decades into the future and seriously interrupted her life, haunting her with memories of a very troubled time.
For this reason, I’ve talked more people out of hospitalization than into it. I now am aware of the potential long-term effects of hospitalization — something most of my clients have no way of knowing. I also stopped taking insurance payments years ago, in part for this same reason.
I’m not suggesting that we refrain from using diagnostic codes or that we don’t hospitalize. Sometimes we must. Likewise, I’m not suggesting that professional counselors stop taking insurance payments. I have had that luxury, but many clinicians do not. What I am suggesting is that, at a minimum, we take the time to think about the potential ramifications of these diagnoses 10 or 20 years into the future. We can’t know every possible outcome, of course, but some things are predictable.
When clients ask if I take insurance, my answer is always no. I explain that even though it may cost them more out of pocket at the moment, the upside is that there will be no permanent record of their visit other than what is confidentially maintained in my office. It is rare that any future organization could have access to their information. Exceptions would be related to a subpoena or a security clearance for government jobs, but in three decades of practice, that has happened to me only a few times (other than in cases that were highly likely to go to court from the beginning of the therapeutic relationship).
So, when considering whether to diagnose a child with attention-deficit/hyperactivity disorder or a learning disability, keep in mind that the diagnosis could have dramatic effects for that individual in college or even in future jobs. Likewise, diagnosing a client with a personality disorder is, by definition, stating that the person has an “enduring condition.” This might have detrimental effects when the client applies for a job in law enforcement, when working with children, or when pursuing a career in other potentially sensitive fields. Although a diagnosis may sometimes be necessary, we owe our clients our best look into the future before making a final determination.
Gregory K. Moffatt is a veteran counselor of more than 30 years and the dean of the College of Social and Behavioral Sciences at Point University. His monthly Voice of Experience column for CT Online seeks to share theory, ethics and practice lessons learned from his diverse career, as well as inspiration for today’s counseling professionals, whether they are just starting out or have been practicing for many years. His experience includes three decades of work with children, trauma and abuse, as well as a variety of other experiences, including work with schools, businesses and law enforcement. Contact him at Greg.Moffatt@point.edu.
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.