Monthly Archives: May 2023

Voice of Experience: Swords and shields

By Gregory K. Moffatt May 30, 2023

Man shouting with abusive words at another man who has one finger on his lips asking for silence


The lady who sat across from me was livid. Her fiery red hair was accentuated by her clenched jaw and loud tone. She was furious about a decision I’d made that she perceived had affected her son negatively. My decision had been the right one, but she wasn’t in a place where she could view things objectively. That was totally understandable.

Earlier, after a terse phone call with me, she had demanded an in-person meeting with my boss and me. During her 20-minute tirade in front of my boss, she stared through me as she assaulted my professionalism, my ethics and my competence. After she finished, she crossed her arms, sat back in her chair and muttered, “Hmmmph!” as if to say, “So what do you say to that, mister?”

I took a breath and quietly replied, “Ma’am, you are not my enemy.”

Almost anything I said could have launched us into a battle for which she was well prepared. I suspect she had run various scenarios through her head in anticipation. But she didn’t know what to do with someone who wouldn’t push back. I completely disarmed her.

“We both want your son to succeed.” I left it at that.

Her face fell and her mood changed almost as if a switch had been thrown. Within minutes, she was talking about solutions, and we actually made progress. When she left that day, she gave me a genuinely warm handshake.

In this verbal battle, she had led with her sword. Recognizing how people fight (use their swords) and defend (protect with their shields) with words and behaviors can be a powerful way to move past counterproductive actions.

People use their swords when they feel attacked, threatened or cornered and they believe that the best defense is a good offense. John Gottman’s Four Horsemen of the Apocalypse (contempt, stonewalling, criticism, and defensiveness) are examples of swords.

People use their shields when they feel attacked, threatened or cornered and they don’t believe they have the skills to fight back successfully. Substance misuse and withdrawal are shields.

Albert Ellis once said that a therapist should never be offended by what someone says. That is hard to do when we feel attacked or threatened by our clients, but the point Ellis was trying to make is that it isn’t about us. To paraphrase Ellis, when our clients are using their swords against us, it should tell us something about them, our relationship or the topic we are addressing. It isn’t about us.

Many years ago, one of my clients with borderline personality disorder (BPD) challenged me every time we had an appointment. “I was reading a book by so-and-so. … Have you read him?”

“No. Never heard of him.”

The client would react to my comment with eye rolling, disbelief and, often, sarcastic responses such as, “I thought you were a professional.”

As is often true with BPD, she wasn’t trying to insult me exactly. She was trying to prove to herself that we were equals. The sword she used was intended to cause me to question my professionalism. If I had tried to use a sword myself or defend with a shield, the battle would have either escalated or at the very least ended in a stalemate.

By refusing to use my sword, while also refusing to cower with a shield, I disarmed her.

Ironically, passive aggression is actually a sword disguised as a shield. Its purpose is to cause hurt in the one being ignored, not to protect oneself from an attack.

Self-righteousness is another example of using defense as a weapon. Making the statement “I would never have an affair like you did” is intended to hurt another.

Therapists use swords sometimes. Confrontation is an aggressive technique — more of an epee than a sword. We don’t intend to hurt, however. We are forcing our clients to think rather than to raise their own sword or shield.

Recognizing who is using a sword and who is using a shield can help couples argue more productively (and, hopefully, less) in marriage and family therapy. It can also help therapists work with resistance and anger in teens and mandated clients.

Borrowing from Freud’s concept of defense mechanisms, I formulated the following statement that has helped me many times over the years. I believe that all behaviors that are dysfunctional, that are not physiological, are defensive. If I can figure out what people are afraid of, I can tell you why they are doing what they are doing.

In a way, if I can tell what they are afraid of, I can see clearly how they are using their swords or shields. In so doing, I know what to address in therapy and, equally important, how to address it.


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

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.

The mental toll of adult bullying

By Lisa R. Rhodes May 25, 2023

A woman being bullied at work. Two coworkers are pointing and laughing at her. She has her hands on her hand, looking down, appears stressed.

Antonio Guillem/

Adult bullying is a social and mental health issue. Regardless of the reasons why a person is targeted by a bully, research shows that its impact can be disastrous to a person’s health and well-being.

According to a survey of 2,000 U.S. adults conducted by the Harris Poll on behalf of the American Osteopathic Association in 2017, 31% of Americans have been bullied as an adult. Of those adults who are targets of bullying, 71% report that they suffer from stress, 70% struggle with anxiety and depression, 39% experience loss of sleep, 26% experience headaches and 55% deal with a loss of confidence.

Characteristics of bullying behavior

Sometimes the more exemplary a person’s character, the more likely they are to be bullied at home or in the workplace. Melissa Spino, a licensed professional counselor (LPC) in Michigan, says although anyone can be demeaned by a bully, a person who is highly skilled in the workplace or socially authentic and admired by others can often (unknowingly) arouse feelings of inadequacy and jealousy in a bully that can fuel their harmful behavior.

“Someone that is respected and popular often infuriates a bully into action because it brings to the forefront that the adult bully is lacking in these areas and it’s a hit to their self-worth,” says Spino, who has counseled people who bully or those affected by bullying for more than a decade. “To feel better about themselves, the adult bully may target the person, [which results in] a short-term ego boost, helping them feel superior. It’s a short-term fix that has to be repeated often and becomes a vicious pattern.”

Jessi Eden Brown, a licensed mental health counselor with a private practice in Lake Forest Park, Washington, says having a positive personality, a strong ethical code and a committed work ethic can often make “good employees” susceptible to bullying by their supervisor or manager, who may view their noteworthy character as a vulnerability or weakness.

If an employee is “nice and goes along with the rules,” then the bully may view them as “someone they can mess with,” Brown notes. In addition, people who are more susceptible to bullying behavior tend to be nonconfrontational and value professionalism and diligence over office politics and “game playing,” she adds.

“Aggressors detect these traits and seize the opportunity to break the target’s spirit, knowing the target will take the criticism to heart and will be unlikely to confront the bully’s behavior, especially when the bully outranks them,” Brown explains.

In addition, someone who is engaging in bullying behavior in the workplace may attempt to belittle or put down a subordinate or co-worker to make themselves look better to the company’s leadership or their other colleagues, says Brown, who is also an LPC in Colorado. These bullies “need to be the most respected, honored person in the room,” she notes. “They tend to be driven by status, opportunity and power; in myopic pursuit of these goals, bullies consistently rank their needs and desires above others’ merit and rights.”

Brown says with an identity so tied to self-importance, “many workplace bullies feel injured by criticism or defeat, which gives rise to the defiance, anger and sabotage we see them unleash onto their targets.”

Tony Grace, an LPC with a private practice in Portland, Oregon, says a person’s vulnerabilities can also attract the ire of a bully. Bullies often look for people who “tend not to fight back, exercise their ability to say no and are under-resourced in some way,” Grace says. For example, people who don’t have many social connections, have trouble setting personal boundaries or recognizing personal boundary violations, have low self-esteem or self-worth, are too trusting or are emotionally wounded may be more susceptible to being the target of bullying behavior, he notes.

“Bullies are looking to take the least amount of risk for the maximum amount of benefit. The benefit, of course, is a sense of power and control,” Grace notes.

Natalia Tague, a licensed professional counselor and director of clinical operations at the Western Tidewater Community Services in Suffolk, Virginia, stresses that while it is important for counselors to keep in mind that bullies are hurt people who have not learned healthy ways to handle their pain, a bully’s behavior is their sole responsibility — and never the responsibility of the person they are targeting.

The personal strain of workplace bullying

In addition to the health impacts of bullying, an adult may also experience struggles in their personal life as a result of the harmful behavior of bullying in the workplace. Brown, who works as the professional coach for the Workplace Bullying Institute, says some of her clients report that being bullied at work added significant strain to their lives.

“Coping with bullying at work consumes valuable resources in terms of energy, compassion, motivation and time. Many targets invest additional time and effort into their work, with the hope that an improvement in performance or output will solve the problem” Brown explains. “This approach rarely works — remember bullies target high performers — and it saps reserves the target would normally have allocated to other life pursuits.”

As a result, a target’s family, friends and community ties may also experience strain and stress that originates from the workplace bully’s conduct, Brown adds. “Numerous clients have reported the ripple effects of being targeted by a workplace bully eventually damaged their personal relationships to the point of divorce, dissolved friendship and other painful estrangements,” she notes.

Workplace bullying can also affect a person’s finances and career. The person being bullied may be forced to quit their job as a result of a bully’s actions, or they may choose to leave a harmful work environment that is affecting their mental health and well-being.

Grace and Brown both say they decided to become entrepreneurs after being bullied in the workplace.

“I took a job that I thought was my dream job [eight years ago] and it quickly became a living nightmare because I was being bullied by a colleague and eventually by my boss,” Grace recalls. “I had to repeatedly set boundaries with both staff members, but eventually I left the job and went into private practice. It was one of the best decisions I have made as it provided me a sense of professional freedom I had not experienced before.”

Brown says she was bullied out of two jobs over the course of her career and went into private practice in 2009. “Like most targets, I was a dedicated, skilled, high-performing employee. I poured my heart into these jobs,” she notes. However, Brown says she was “driven out” for “adhering to strong ethical principles and pushback on business practices that consistently placed profit over the well-being of clients.”

Helping clients recover from bullying

The counselors interviewed for this article recommend a variety of therapeutic approaches to help clients who have been bullied heal, including person-centered and trauma-informed therapy, cognitive behavior therapy (CBT), dialectic behavioral therapy, acceptance and commitment therapy, and eye movement desensitization and reprocessing.

It can take a while for people who have been bullied to build rapport and trust, especially those who have been bullied for a long time, Grace says. “Building trust will require the counselor to not only be patient but also transparent,” he explains. “Creating a secure attachment may require the counselor to model vulnerability and self-disclose their own humanity.”

For example, Grace says a counselor could disclose their own experiences with bullying, how they learned to set boundaries, how they became their own advocate or how they now give themselves permission to have their own wants or needs.

Many of Brown’s clients report having been bullied throughout their lives — at school, at home and within their larger community. People who have been continuously bullied often present with complex trauma, which is compounded if they also experience workplace bullying as an adult, she says.

Brown uses psychoeducation to help clients who have been bullied realize they are not to blame for the bully’s maltreatment. She also uses CBT techniques to help clients set goals for their recovery, which can include journaling to explore ideas for bolstering self-care, reframing their thoughts to find a sense of optimism in their lives and forming a robust support network.

“I teach targets how to compartmentalize their stress so that their time away from work can be less affected by the bullying and more intentionally directed toward self-care, spending quality time with family and friends, and engaging in other meaningful, restorative activities,” Brown says.

She also helps clients identify successful coping strategies that have worked in the past, acquire new coping tools and establish self-care routines. This process, Brown says, often leads to her helping clients develop an exit strategy, which includes exploring their interests, professional strengths and accomplishments, so they will be prepared to leave their job if necessary.

“Not only does this help to rebuild eroded self-confidence, but it also frames the client’s next steps, which could involve job seeking, obtaining specialized training, retirement planning, relocating, etc.,” Brown says. “Every exit plan is tailored to the client’s unique situation. The plan is intended to remind the client that they have choices and to weave the beginnings of a safety net so exercising that choice becomes less daunting.”

Brown also advises employees of workplace bullying to document the harmful behavior in case they decide to approach higher management or human resources to file a complaint or pursue alternative avenues for redress (e.g., involve a union representative, hire an attorney, negotiate a severance package).

Moving forward

Although every person’s experience is unique, it is possible for clients who have been bullied to learn to heal through counseling. Tague advises clients who have been bullied to remind themselves that “bullying is about the bully” and not about them.

“Bullies bully [others] to relive their own inner turmoil, not because the target of the bullying has done something to invite or deserve the behavior,” she explains. It can be helpful to reframe bullying behavior in this way, Tague says, because externalizing it allows the target to place the blame where it belongs — with the bully.

“Externalizing also allows the target to view the bullying behavior as separate from themselves, allowing them to feel compassion for the bully and reduce the power the bully wields over them,” she adds.

It’s normal to experience aftereffects from harmful bullying behavior, Tague notes. But sometimes people who have been bullied have a hard time moving past the hurt, and this, she stresses, is when they definitely need to seek help through counseling.

“Significant events such as bullying can change an individual. They will never be the same person they were before,” Spino says. But she adds that she’s seen that clients’ wounds can heal with time and work.

Just working through the negative effects of bullying can be “an indicator of their inner strength and resilience, which is something we focus on in therapy and it’s also a positive reminder of who they are at their core,” Spino says. “They need this reassurance that the person bullying them didn’t win and that they are not permanently damaged.”

Brown also recommends that people who have been bullied channel any unresolved feelings into becoming an advocate for others who have been abused or who cannot speak for themselves. For example, clients could volunteer on behalf of the survivors of domestic violence or another meaningful cause where they can help others. And over time, she says people who are targets of bullying can learn to “take back” some of what was taken from them.


 Read more about working with adults with bullying behaviors in Counseling Today’s May cover story. 


Lisa R. Rhodes is a senior writer for Counseling Today. Contact her at

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.

Kimberly Frazier: Presidential year in review

Counseling Today May 23, 2023

Headshot of Kimberly Frazier

ACA President Kimberly Frazier, 2022-2023 (Photo courtesy of Kimberly Frazier)

June marks the end of Kimberly Frazier’s term as the 71st president of the American Counseling Association. Frazier has accomplished much over these past 12 months. Surrounded by supportive colleagues, she has worked hard to move the counseling profession and ACA forward with her three spotlight initiatives: justice, equity, diversity and inclusion (JEDI); wellness and self-care; and mentoring.

Making diversity and inclusion a priority

Kimberly Frazier presenting at the ACA Conference & Expo

Kimberly Frazier presents the welcome address to the Korean Counseling Association during the ACA Conference & Expo. (Photo courtesy of Alex Webster/Pinpoint National Photography)

One of Frazier’s passions — both professionally and personally — is creating resources and advocating for marginalized people, so it’s not surprising that she put the JEDI initiative front and center during her ACA presidency.

In February, Frazier, along with Rheeda Walker, discussed Black mental health and wellness on a special episode of ACA’s podcast, The Voice of Counseling. And at the 2023 ACA Conference & Expo, Frazier announced that she had created a new award honoring Thelma Daley, who was the first Black woman to serve as ACA president (1975-1976).

“Dr. Daley has not only inspired me, but she helped pave the way to leadership for so many others,” Frazier says. “The Dr. Thelma T. Daley Advocacy and Equity Award will recognize our member advocates who have made a real difference by advocating on behalf of Black and Brown communities.”

Advocating for counselor wellness

Frazier acknowledges that counselors cannot be leaders, advocates, clinicians and mentors without first learning to take care of themselves. The first step, she says, is often being aware of one’s own personal wellness and self-care needs.

“We cannot pour from an empty cup as counselors,” Frazier reminds her colleagues.

Frazier worked closely with ACA to select a Counseling Awareness Month theme that focused on wellness and self-care. This year’s theme, “Get Fit for Your Future,” reminded counselors to prioritize keeping their physical, emotional, social, spiritual and mental health “in shape.” ACA kicked off Counseling Awareness Month with a workout video designed for counselors on April 1 and a Peloton ride with Frazier and ACA CEO Shawn Boynes on April 8. And all month long, counselors took advantage of curated resources on the ACA website that aimed to help them “get fit” for their future.

Focusing on mentoring

Throughout her presidency, Frazier has emphasized that mentoring is key to developing a confident and skilled group of future advocates and leaders.

On June  21, she will lead a virtual mentoring summit, which features a keynote address and two speaker sessions on successful mentoring, how to select a mentor and the benefits of mentoring. This event will help program leaders and mentors discover new ways to execute their mentoring efforts, and it will help new professionals and students learn best practices in finding a mentor and fostering a healthy mentoring relationship.

ACA President Kimberly Frazier and students from HBCU Cares at the 2023 ACA conference

Kimberly Frazier with the HBCU Cares students at the ACA Conference & Expo: Denzell Brown, Brittany Hinkle and Serena Bradshaw from Howard University; Brittney Watson Greene from North Carolina Central University; Tyreeka Williams, Kacie Rebe Dentleegrand and Allyson Graham from North Carolina A&T State University. (Photo courtesy of Alex Webster/Pinpoint National Photography)

Frazier was also able to bring together two of her initiatives — JEDI and mentoring — by helping ACA form a partnership with HBCU Cares, an organization that aims to raise awareness of and access to mental health for diverse students at historically Black colleges and universities (HBCUs). Through a partnership between ACA, HBCU Cares and the Substance Abuse and Mental Health Services Administration, a group of HBCU Cares students was able to attend the ACA conference for the first time.

“Partnerships such as this will help raise ACA’s visibility outside of the counseling realm and connect us with entities that lacked awareness about the importance of counseling and the counseling profession,” Frazier says.

Inspiring others

Through her presidential spotlights, speaking engagements and monthly Counseling Today columns, Frazier has motivated, inspired and challenged her colleagues to push themselves to be better counselors, advocates and leaders for the profession and the communities they serve. In her Counseling Today columns, Frazier went beyond simply telling readers what JEDI, wellness and mentoring should look like; she also encouraged her colleagues to put her advice into action by ending each column with a challenge related to one of her presidential initiatives.

ACA President Kimberly Frazier and CEO Shawn Boynes on stage at the 2023 ACA Conference

Kimberly Frazier and Shawn Boynes deliver opening remarks at the ACA Conference & Expo. (Photo courtesy of Alex Webster/Pinpoint National Photography)

Frazier continues to challenge and inspire those in the profession and organization. She fondly recalls watching Beverly O’Bryant speak during the opening session of the 2002 ACA conference. Seeing O’Bryant on stage in that leadership role illustrated to Frazier what could be achieved through hard work and stellar mentorship.

“Seeing her made me feel seen,” Frazier recalls. “I hope that I can inspire another counselor to see themselves inside of ACA working as a leader and an advocate, just as I was inspired when I watched Dr. Beverly O’Bryant speak during the opening session of the ACA conference many years ago.”

Throughout her presidency, Frazier has also reminded her colleagues, “The advocacy continues.” That message will serve as a guiding light for ACA and the counseling profession even after Frazier’s presidency comes to an end this June.

Conceptualizing diagnosis through a social justice lens

By Christine Banks-VanAllen May 18, 2023

Black woman in a yellow shirt staring off to the side.


Arianna and her grandmother sit on opposite sides of the cramped counseling office with their arms crossed, looking away from each other. The tension in the room is palpable. You offer Arianna a glass of water, and after introducing yourself, you invite her to share what brought her into your office today. Her grandmother glances up at you, while Arianna continues to gaze downward, methodically twirling her scuffed phone in her hands.

In this first session, you learn that Arianna, who is a 16-year-old African American adolescent, has recently been suspended from school following her third fight this school year. As a child, Arianna had adverse experiences, including physical neglect, parental separation and parental addiction, and she was placed in the custody of her grandmother at age 6. She exhibits anger and aggression toward her younger siblings and is failing several classes in school because she doesn’t turn in her work. Arianna tells you she has been diagnosed with a range of mental health disorders, including attention-deficit/hyperactivity disorder (ADHD), oppositional defiant disorder (ODD) and major depressive disorder (MDD).

Her grandmother turns to you and says in an exasperated tone, “Her medication just isn’t working anymore. Please talk some sense into her.”

As Arianna’s new counselor, what are your initial diagnostic impressions? What cultural considerations strike you as the most relevant in her case? How might her experiences of early adversity shape her symptoms today, and what might these different diagnostic labels mean to her? How might your diagnostic impressions change if Arianna was of a different age, race, class or gender?

In most practice settings, counselors use diagnosis in assessment, case conceptualization, treatment planning and managed care reimbursement. Unfortunately, the use of diagnosis across mental health professions has a complicated history with respect to multiculturalism and social justice. Diagnostic classification has been used as a tool of oppression throughout history by defining societal conceptions of “normal” and “abnormal” and pathologizing “otherness” under the guise of medical and scientific objectivity. Diagnosis tends to place the onus of psychological dysfunction on individuals, with historically limited regard for the cultural, systemic and ecological factors shaping individuals’ experiences. Counselors confront important philosophical and ethical questions regarding multiculturalism and social justice as we conceptualize our relationship with diagnosis. This article examines the historical legacy of diagnosis and offers considerations for infusing social justice into counselors’ diagnostic practices.

Historical prejudice in diagnostic classification

Behaviors defined as mental illness have historically been those that violate societal expectations of appropriate behavior within a given context. Definitions of “normal” and “abnormal” are rooted in socially dominant conceptions of what acceptable behavior should be in sociocultural context. Deviance from socially constructed definitions of “normal” has historically led to pathologization of those not conforming to social expectations, while simultaneously placing the blame of pathology within the individual. For example, early attempts at classifying mental disorders included pseudoscience theories such as phrenology (the debunked “study” of skull shape and size used to classify people’s intelligence, personality and abilities that led to “scientific” rankings of race and gender) and drapetomania (a term coined by Samuel A. Cartwright in 1851 to describe a “mental illness” that caused enslaved people to want to escape from captivity). These two theories are clear examples of scientific racism that advanced the use of medical classification to pathologize both otherness and individuals’ adaptive responses to coping with trauma.

Although mental health diagnoses have progressed and moved away from these diagnostic ghosts of our past, they continue to focus on symptoms of psychological distress occurring within the individual, rather than within the broad culture, community and society in which the individual exists. It doesn’t matter if it is society’s prejudices and oppressions that traumatize its members; individuals carry the “disorder” of living with adversity.

Autism spectrum disorder, for example, has experienced a shift in diagnostic framing over time. In the first edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), what we now consider autism spectrum disorder was labeled as “childhood schizophrenia” and was used to justify the widespread institutionalization of people with autism. Over time, the conceptualization of autism has shifted into that of a neurodevelopmental disorder, assimilating previous diagnoses of pervasive developmental disorder not otherwise specified, childhood disintegrative disorder and Asperger’s disorder along the way. This assimilation of related diagnoses marks one reason why the prevalence of autism has risen so drastically over the past several decades.

Another important reason for this rise includes better diagnostic awareness that autism can be found in individuals who are not young, white or male. The revised fifth edition of the DSM states that boys are four times more likely to be diagnosed with autism than girls, and that most girls are “missed” unless their autistic symptoms are accompanied by significant cognitive impairments. Autism also continues to be underdiagnosed in young people of color and, if diagnosed, tends to be diagnosed later than in white youth.

Furthermore, the neurodivergence movement views neurodevelopmental disorders such as autism and ADHD as a form of identity rather than a disorder or a disability, and the impact of difference only becomes problematic within the context of a nonsupportive environment. At the same time, diagnosis continues to enable individuals with autism access to much-needed care and support, which places these individuals in a precarious balance between labels of disability and neurodivergence. Is autism a mental disorder, a form of disability or a type of neurodiversity? Perhaps in another 50 years, we’ll know.

Complicating matters further is the medicalization of diagnosis used today in accessing reimbursement. The first editions of the DSM espoused a markedly psychoanalytic bent, where disorders represented reactions of the personality. The medical model, introduced in the third edition of the DSM, launched the DSM’s gradual descent into the medicalization of diagnosis and the use of diagnosis to justify treatment. The perceived objectivity we see in diagnosis today — ticking off symptom boxes and diagnosing based on clusters of symptoms — often misses the underlying causes of distress, the sources of our clients’ psychaches.

The parable of the blind men and an elephant illustrates the problem with diagnosing in isolation. A group of blind men each describe what they believe an elephant must be based on touching individual parts of the elephant. One man, feeling the elephant’s trunk, believes it is a snake. Another, feeling the elephant’s leg, believes it is a tree trunk. A third, feeling the elephant’s tail, believes it is a rope. When we diagnose disparate symptoms as disparate diagnoses, we tend to treat individual symptoms in isolation from one another and fail to see the whole elephant.

Do Arianna’s three diagnoses of ADHD, ODD and MDD help us to see her psychache more clearly or have we missed the elephant? How do we as counselors conceptualize mental health issues that are difficult to treat such as trauma or the oppressions of an unjust society? How do we balance the historical legacy of using diagnostic classification to pathologize otherness with the present-day reality that those same diagnoses are now used to secure rights and access to care for previously marginalized individuals? The same diagnoses that complicate Arianna’s care also afford her the ability to sit in your office seeking mental health care. To put it simply, it’s complicated.

Conceptualizing diagnosis

In many cases, diagnosis benefits clients. Having a name for their symptoms can be tremendously validating for many clients. It allows them to understand their experiences and recognize that they are not alone in their distress. Diagnosis also allows clients access to needed services, such as school-based supports for youth with neurodevelopmental disabilities or gender-affirming care for transgender individuals. And nearly ubiquitously in the world of managed care, diagnosis is used to justify reimbursement and payment for counseling services, enabling individuals to afford mental health care.

My relationship with diagnosis became personal when my son was diagnosed with autism spectrum disorder in 2021. At the time, his diagnosis came as a surprise to me. I was sure that his language delays were related to him being isolated from his peers during the COVID-19 pandemic and that his rigidities stemmed from the anxiety he had unfortunately inherited from me. In the nearly 18 months since receiving his diagnosis, I have come to recognize many benefits of mental health diagnosis. I no longer describe his pattern of pacing around the perimeter of rooms as “orbiting.” I now see it as a form of visual stimming, a self-soothing repetitive behavior he uses to self-regulate when he is either over- or understimulated. Naming precedes understanding; learning to name his symptoms and his condition has allowed me to better understand and accommodate his needs. Additionally, his diagnosis has enabled our family to access vital community supports — including special education services and support from our county board of developmental disabilities — and financial reimbursements through our family’s private health insurance.

However, as in the case of Arianna, mental health diagnosis can pose problems. Many counselors experience a philosophical divide between the counseling profession’s strength-based orientation and the medical-model orientation used in the DSM. Although the DSM describes itself as a value-free, scientific manual of mental illness, dominant cultural values remain entrenched in the structure and content of the DSM, reflecting historical and societal trends regarding definitions of normal and abnormal behaviors.

Diagnosis has the greatest potential to harm individuals from nondominant cultural groups, for whom over-, under- and misdiagnosis may add additional stigmatization onto existing layers of oppression. Consider the following:

  • Among African Americans, paranoia may be a healthy and adaptive coping strategy against societal violence and oppression.
  • African Americans often face a minimization of symptoms due to a false perception that they feel less pain than other racial groups. Conversely, African Americans are overrepresented in inpatient and psychiatric emergency room settings and are more likely to receive severe or persistent diagnoses (such as schizophrenia) over other affective disorders.
  • Women are more likely to receive a mental health diagnosis than men. Women’s reported pain symptoms have historically been minimized as hysterical or hypochondriacal.
  • Men are less routinely screened for eating disorders and sexual abuse.
  • Diagnosis rates are higher among lower socioeconomic groups. Rates of coerced treatment increase with rates of economic decline.
  • An increasing number of children receive diagnoses that are perceived to be severe and lifelong.
  • Long-term effects of antipsychotic medication use in children are unknown but may include obesity, diabetes, cardiovascular issues and possible reduced life expectancy.
  • ADHD rates are growing across the United States, with some of the highest rates observed among children in low-income communities and in children identifying as multiracial.

In comparing my son’s diagnostic experiences with Arianna’s, the differences appear striking. While my son’s diagnosis provides an explanation of his symptoms, a name that neatly packages the etiology of the disorder with his present-day symptoms, Arianna’s does not. As a trauma-focused counselor, I wonder whether Arianna’s present-day symptoms spanning elements of inattention, mood dysregulation, impulsivity and behavioral outbursts represent not three distinct disorders but diverse manifestations of how she has learned to cope with early adversity in her life. And what might these three distinct diagnoses — possibly being interpreted by Arianna as three different things wrong with her — mean to her?

Having the privilege to name someone else’s experience for them through the giving of a diagnosis is a power I hope we as counselors never take for granted. My son’s diagnosis provided feelings of empowerment, understanding and access, but Arianna’s diagnoses, on the other hand, seem to have fostered feelings of frustration, shame and helplessness. I also can’t help but wonder how Arianna’s positionality as a young African American woman might have shaped her diagnostic experiences differently than my experiences seeking care for my young white son.

Integrating social justice into diagnosis

The ethics of mental health diagnosis extend past the bounds of the counseling profession: Recall that the DSM is published by the American Psychiatric Association and that counselors have never been included alongside psychiatrists in revising the manual we are tasked to use. So counselors must remain mindful that by engaging in diagnosis, we are responsible for approaching diagnosis from the social justice lens of our own professional philosophy.

Fortunately, counselors have several tools at our disposal to approach diagnosis from a philosophy of social justice. Our first tool is the 2014 ACA Code of Ethics, which includes the following standards that inform counselors’ ethical decision-making process around diagnosis.

  • Proper Diagnosis (Standard E.5.a.): Counselors must carefully select and appropriately use assessment techniques “to provide proper diagnosis of mental disorders.” This means that counselors must make accurate diagnoses based on clients’ presenting symptoms and life experiences. Diagnoses should not inflate symptoms to appease reimbursement entities, nor should diagnoses downplay symptoms to avoid potentially stigmatizing diagnoses.
  • Cultural Sensitivity (Standard E.5.b.): Counselors must consider clients’ cultural factors when conceptualizing diagnosis. We must remain mindful of how culture shapes both our clients’ and our own understandings of distress and how oppressive cultural factors may shape development of mental distress in the first place.
  • Historical and Social Prejudices in the Diagnosis of Pathology (Standard E.5.c.): Counselors must recognize patterns of historical misdiagnosis and pathologization among oppressed groups. This means that we must understand how diagnosis has been used historically to pathologize otherness and make present-day diagnoses that support equity and justice for all clients.
  • Refraining From Diagnosis (Standard E.5.d.): Counselors must consider the positive and negative implications of diagnosis and refrain from making diagnoses that may harm clients.

Taken together, these standards in our ACA Code of Ethics highlight the importance of diagnosing intentionally and with an awareness of how diagnosis may be used to help or harm.

The Multicultural and Social Justice Counseling Competencies provide us with another tool. As a socioecological model, these competencies recognize that multicultural and social justice work does not operate only in the domain of the intrapersonal but also within linked systems of oppression that must be addressed if we are to do good with our individual clients. The following paragraphs offer recommendations for conceptualizing diagnosis through the lens of social justice, as organized around the attitudes and beliefs, knowledge, skills, and action-based competencies listed in the Multicultural and Social Justice Counseling Competencies. These recommendations are not exhaustive and are intended to offer introductory tools for beginning to approach diagnosis from a lens of social justice.

The first set of recommendations relates to counselors’ attitudes and beliefs about diagnosis and social justice. Before counselors can advance justice work for others, they must develop an awareness of how their own social identities, assumptions, beliefs and biases intersect with the social identities of clients and the counseling relationship.

  • Contextualize diagnosis: Remember that diagnosis exists in a sociocultural, linguistic, political, economic and time-oriented context. Diagnostic classification systems and criteria are generally biased toward Western, Eurocentric/white, male, middle-class values and life experiences. When considering a diagnosis, ask yourself the following questions: Would you come to the same diagnostic conclusions in a different context or with a client of a different age, race, class or gender? Would you conceptualize their distress differently if you were of a different age, race, class or gender?
  • Assess implicit biases: Consider taking the free Implicit Association Test (developed by Harvard University) to gauge areas of implicit bias that you may carry. Although we as counselors have the power to choose if or how we act on our biases, understanding our own hidden biases can build awareness of subtle racial, class-based or gendered perceptions that may shape our initial diagnostic impressions.
  • Reflect on strengths: Although diagnostic criteria read like a list of problems or deficits, learn to conceptualize symptoms through the counseling profession’s strength-based lens. Reflect on clients’ strengths in coping with the distress of their symptoms, and the distress of society’s response to their symptoms. Help clients identify present-day “symptoms” that reflect past adaptive coping strategies.

The second set of recommendations relates to counselors’ knowledge about diagnosis and social justice. Counselors must understand how privilege and marginalization have been enacted within mental health diagnosis and develop knowledge around conceptualizing diagnosis from a philosophy of equity and justice for all clients.

  • Know your population: Learn about the culture of clients you are likely to see in your practice. Diagnostic bias is more likely to occur when counselors do not fully understand the community or culture of the clients they serve. Seek professional development, consultation, supervision, readings or other forms of immersion to increase your cultural knowledge. Remember that it is not the client’s responsibility to teach you about their culture during the diagnostic assessment.
  • Educate clients about their diagnosis: You may be surprised that many clients don’t even know that they have a diagnosis. When you make a diagnosis, take time to educate your clients about their diagnosis and explore what their diagnosis means to them. Provide diagnostic education in the context of your work together, rather than leaving clients to educate themselves on “therapy TikTok.”
  • Educate other professionals: Although many allied professionals — including case managers, teachers, children’s service professionals, legal advocates and reimbursement entities — use diagnosis in their work, most have no formal training in diagnosis and may carry misperceptions about what diagnoses mean. Offer trainings to allied professionals to support informed, collaborative care in the community.
  • Be mindful of trauma: Experiences of trauma are much more common and diverse than the DSM’s criteria for posttraumatic stress disorder suggest. Trauma symptoms resulting from adverse childhood experiences — such as abuse, neglect and household dysfunction — and other forms of developmental trauma may result in affective, somatic, attentional, behavioral or relational symptoms that, if missed, may erroneously point toward mood, anxiety or disruptive disorders. Receiving disparate, symptom-based diagnoses to account for developmental trauma reactions risks inaccurate diagnosis, polydiagnosis, pathologization of psychologically adaptive trauma responses, and fragmented, ineffective care. Ask questions about the client’s life circumstances at the time in which the client’s symptoms initially occurred. Reframe diagnostic thinking from “What’s wrong with you?” to “What happened to you?”
  • Know the implications: Diagnoses carry real-world implications for clients far beyond the counseling relationship. In my own practice, I have seen diagnoses allow young people to access the supports they need, opening the door to gender-affirming care or special education services. I have also seen diagnoses create barriers for young people, including the denial of military service based solely on a diagnosis received during adolescence. Examine how a particular diagnosis might affect a client’s future goals. If there is the potential that a diagnosis may help or hinder your client in the future, have conversations about the potential implications of that diagnosis with your client early and often. Approach diagnosis with care, especially with children or adolescents, or with clients from cultural backgrounds you are less familiar with.

The third set of recommendations relates to counselors’ skills in practicing diagnosis within a framework of social justice. These recommendations describe specific culturally responsive communication, evaluation and relational skills to improve conceptualization of diagnosis, particularly with marginalized clients.

  • Utilize the Cultural Formulation Interview: The Cultural Formulation Interview, included in the fifth edition of the DSM, is a 16-item assessment measure that examines the impact of culture on a client’s presenting symptoms. Incorporate this tool into your standard diagnostic assessment practice.
  • Utilize narrative approaches: Narrative therapy’s emphasis on externalizing, deconstructing and restorying narratives can identify the external basis of many clients’ presenting concerns, including forms of trauma and sociopolitical oppression. Think about decoloniality in your conceptualization of clients’ distress.
  • Honor cultural norms and preferred modes of counseling: Accommodate cultural preferences regarding eye contact, personal space, rate of speech and inclusion of personal supports during the diagnostic process. Standard forms of “talk therapy” tend to be biased in favor of white, middle-class values. Inquire about clients’ preferences for other forms of support and treatment, including music, art, spirituality or group work.

The fourth set of recommendations relates to counselors’ actions in practicing diagnosis within a framework of social justice. These recommendations center on specific actions counselors may initiate to enact more just and equitable diagnostic practice with clients and within their communities.

  • Diagnose collaboratively: Counselors are less likely to over-, under- or misdiagnose when diagnosis is discussed and assessed collaboratively with clients. Support clients’ own understanding and conceptualizations of the problems they face. Recognize that our external assessment of clients’ emotions, behaviors and presenting symptoms is incomplete without understanding the client’s own internal cognitive and sociocultural schemas. Again, think in terms of decoloniality.
  • Utilize parsimony: According to the American Psychological Association, the law of parsimony states that the simplest explanation of an event or observation is often the preferred explanation. Choose the fewest distinct diagnoses that best account for the client’s presenting symptoms. For example, if a client who was previously diagnosed with posttraumatic stress disorder presents with new symptoms of anxiety or hypervigilance, consider those symptoms within the context of their existing diagnosis before adding additional diagnoses.
  • Take time to conceptualize the whole person: Take time to formulate a full case conceptualization of your client, with your diagnostic impressions serving as just one source of information. Do not define a client by their diagnosis alone or refer to a client by their diagnosis. Take time to understand who your client is as a whole person before formulating a diagnosis. The developmental counseling and therapy theory advanced by Allen Ivey is invaluable for conceptualizing clients’ experiences in this way.
  • Reassess previous diagnoses: Just because a client has a previous diagnosis listed in their medical record doesn’t mean it is accurate, current or beneficial. As a counselor, it is your ethical responsibility to conduct an accurate assessment with the client, using a framework of multiculturalism and social justice to inform your own diagnostic determinations. Consider whether clients’ previous diagnoses are culturally relevant, appropriate and necessary. Consult and gain collateral information from colleagues and treatment teams to inform collaborative diagnosis.

As counselors, the ability to diagnosis is a privilege we must not take lightly. The power of naming diagnoses can help or harm clients; it can allow them access to care or just as easily provide a justification for the denial of services and support. When done well, diagnosis offers clients a name to represent the psychaches they feel, a name which helps clients understand and address the problems they face. But when done poorly, diagnosis may pathologize clients’ normative attempts at coping with adversity or inappropriately blame individuals for the struggles of living in an oppressive and unjust society. We owe our clients the privilege of a just conceptualization — one that takes into account clients’ unique strengths, histories and circumstances without defaulting to the unexamined diagnoses of the DSM. Arianna and so many others deserve that from us.


headshot of Christine Banks-VanAllen

Christine Banks-VanAllen is an adjunct instructor and doctoral student in counselor education and supervision at Kent State University. She is a licensed professional clinical counselor supervisor in Ohio and is certified in eye movement desensitization and reprocessing. She has worked in a community mental health setting for the past six years and specializes in trauma treatment with adolescent girls. Her scholarly interests center on the intersections between trauma, diagnosis, adolescence and social justice. Contact her at

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

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.

ACA hosts webinar on navigating Medicare reimbursement

By Lisa R. Rhodes   May 16, 2023

Colorful bubbles shaped paper with the a megaphone icon and the word "Medicare"


On April 19, the American Counseling Association hosted a webinar discussing the Mental Health Access Improvement Act. This law, which was passed by Congress in December 2022 and goes into effect in January 1, 2024, allows licensed professional counselors (LPCs) and licensed marriage and family therapists (LMFTs) to be reimbursed by Medicare for providing mental health treatment and services to adults age 65 and older as well as some people under the age of 65 who are disabled or have permanent kidney failure.  

Matthew Fullen, an associate professor of counselor education at Virginia Tech whose research focuses on the mental health of older adults, began the discussion by recalling the decadelong effort to pass the law. He noted the partnership between the ACA, the Medicare Mental Health Workforce Coalition, Arnold & Porter, and other professional and grassroots organizations in lobbying Congress to update Medicare’s mental health provider regulations and close the gap in federal law that historically excluded LPCs and LMFTs. The last time Medicare’s mental health provider regulations were updated was 1989.   

The new law enables LPCs and LMFTs to expand their reach to new clients and in new health care settings, such as federally qualified health centers, rural health clinics, Medicare hospice interdisciplinary teams and Medicare integrated behavioral health and primary care programs.  

“Counselors are now officially at the table in how Medicare thinks about mental health care,” said Fullen, past co-chair of the ACA Public Policy and Legislation Committee.  

Under the new law, LPCs and LMFTs will be known as “non-physician practitioners,” which refers to any Medicare provider other than a physician (e.g., social worker, psychiatric nurse). To enroll in Medicare as a mental health care provider, counselors must have earned a master’s or doctorate degree that qualifies them to work as a licensed mental health counselor, professional counselor or clinical professional counselor in their state. They must have also completed two years of postgraduate supervised clinical experience in mental health counseling and have licensure in the state where they intend to provide services.   

Monique Nolan, an attorney at Arnold & Porter with 20 years of health regulatory experience, told the audience that early this summer, the Centers for Medicare and Medicaid Services (CMS) will issue a proposed rule to address how the agency plans to enroll LPCs and LMFTs into the Medicare program, and how payment rates, which are adjusted every year, will be established. ACA will provide written public comments after the proposed rule is released.  

“We expect that the agency will, as the months go on, begin to provide more information around implementation and the steps that you will need to go through to join the [Medicare] program as well as to generally orient you to Medicare,” Nolan added.  

Kristine Blackwood, who serves as counsel at Arnold & Porter’s legislative and public policy practice, provided the audience with an overview of the Medicare program, which was signed into law in 1965. The program provides federal health care insurance for people aged 65 and older, eligible younger people with disabilities and individuals with end-stage renal disease.  

“Traditional” Medicare is a fee-for-service health insurance program offered through the federal government. Traditional Medicare is divided into two parts: Part A provides hospital coverage and includes inpatient care in hospitals, skilled nursing facilities, hospice care and some home health care. Part B provides medical coverage and includes certain physician services, outpatient care, durable medical equipment and preventive services. Blackwood said LPCs and LMFTs will provide mental health treatment and services as nonphysician practitioners under the provisions for Part B.  

Medicare Advantage, also known as Part C, allows people to get Medicare coverage from a private health plan that contracts with the federal government. This plan covers all the same services under Part A and Part B and provides care through physicians who are in-network, Blackwood said. Unlike the fee-for-service program, Part C may also provide coverage for vision, hearing and dental services. After the new law goes into effect on Jan. 1, 2024, LPCs and LMFTs can also be reimbursed for mental health treatment and services provided through Medicare Advantage, Blackwood noted.  

“This is going to be a whole new market [to] access new clients,” she said.  The new law will “open up a lot of opportunities for LPCs.”  

LPCs may also benefit from the provisions in the Counseling Compact, which allow for reciprocal licensure in states that are a part of the compact, Blackwood said. ACA is keeping a close eye on the proposed rule to ensure that the CMS understands and will work to accommodate the compact.  

We will not know what is in the proposed rule until it is released, but Nolan said that questions regarding diagnostic (psychological) testing, telehealth services and the use of current procedural technology codes may also be addressed.  

Fullen acknowledged that the passage of this law was thanks to the persistence of ACA’s alliance with other professional partners and the advocacy of counseling professionals who sent emails, wrote letters and attended meetings with lawmakers to let their voice be heard.  

“We see through this legislative victory [a] real contribution to equity and social justice in a way that provides more access to care for people who really need it,” Fullen said.  


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Lisa R. Rhodes is a senior writer for Counseling Today. Contact her at

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.