Tag Archives: Voice of Experience

Voice of Experience: Billing guilt

By Gregory K. Moffatt February 18, 2020

I am a very poor bookkeeper. I will admit that up front. I am capable, but I just don’t enjoy managing the finances of my clinical setting. Perhaps more importantly, for many years I felt guilty about charging my private practice clients.

Therefore, I was hesitant to mention overdue balances or to expect payment from my clients at the time of service. It just felt awkward. If clients didn’t pay their bills, I often would let their accounts slide into history and eventually ended up closing their files with an amount due in the ledger.

Then one day, many years into my practice, I got some new accounting software and decided to clean up my old books. For no reason other than curiosity, I went back through all my overdue accounts and was stunned. The total owed by overdue clients was in the thousands of dollars.

Granted, this was over a long period of time — more than 10 years — but those individual accounts that I let slide had added up. I could have bought a new car with that money. Fortunately, my private practice was not my primary source of income. Otherwise, I very likely would have been operating in the red.

It is uncomfortable asking for payment, but this seems to be true only for counselors. Can you think of any other service in which the vendor is hesitant about asking for payment? I can’t. Whether they are plumbers, mechanics, dentists, morticians or babysitters, people get paid for providing a service.

Nearly all of my new counselors, interns and supervisees express some hesitation about charging clients. One experienced counselor, in fact, asked me to look over her revamped informed consent. Her fees were clearly listed.

“You aren’t charging enough,” I told her.

“Really?” she said sheepishly. “I don’t want to be greedy.”

I asked her what her time, education and experience were worth. She had two degrees, was fully licensed both as a professional counselor and as a marriage and family therapist, and had several years of practice under her belt. Yet her fees were the same as when she was still in supervision.

I asked, “Are you providing a service that has value to your clients?” Of course, she said yes.

“Then there is nothing wrong with being paid what you are worth, at least within the market standards.”

She decided to raise her rate — and she deserved the higher fees. She also saw no change in her client base. In other words, none of her clients questioned paying a rate consistent with the standard in the field. As it should be.

One of my colleagues who has run a successful private practice for many years taught me something on this topic. She had a basket in her waiting area with a sign: “Check goes in the basket before you come back” (to the therapy room).

These days, her sign probably says something like, “Payment on my cash app must come through before therapy starts.” I don’t know. But the point is that she set an expectation for payment that was reasonable and clear, and people lived up to her expectations.

Even though my informed consent said payment was due at the time of service, I wasn’t clear about what my expectations for my clients were. My practice demonstrated vague expectations, so my clients back then lived down to them.

I completely understand why we feel guilty about charging as professional counselors. After all, we are helpers, not mercenaries. But few things in life are free.

If a client balks at my fee, I’m happy to provide referrals. I’m also very generous with pro bono hours — as are most therapists. But I no longer feel any guilt about charging my clients or my supervisees. I’ve invested in my career, it costs me money to run my practice, and I’m good at what I do.

“How much is your marriage worth to you?” I asked one potential client who hesitated at starting marriage counseling. (Sometimes I asked, “How much does a divorce cost?” That usually put things in perspective.)

“I guess it is worth $150 an hour,” he said, referring to the fee his therapist was charging. And it was worth it for the therapist too. She used her expertise to help heal a damaged relationship just as a physician might use medication or surgery to help the body heal.

Regardless of whether you have a sliding scale or a fixed rate, accept third-party payments or are cash only, you are providing a service. You spent time, money and energy developing and maintaining your expertise. You deserve to be compensated.

 

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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.

 

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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.

Voice of Experience: The boring (and risky) part of the job

By Gregory K. Moffatt December 23, 2019

I spent almost 10 years as a lecturer at the FBI National Academy in Quantico, Virginia. The very best of the best from every possible area of forensic science were clustered together in the behavioral science unit deep underground on sublevel two.

I learned a lot from my colleagues in those years, but the most memorable thing I heard while I was there was this: “Agents will get themselves in far more trouble with their pens than they will with their guns.”

Written documentation lasts forever, and poorly written documentation can cost you your job. Most agents never have to take their guns out of their holsters through most of their careers, but every one of them will write hundreds of pages of reports over the course of 25 or 30 years. That is a very long paper trail, and it provides plenty of opportunities to do it wrong.

The counseling profession is much the same. I like to believe that most of us will never get in trouble for egregious ethical violations — the equivalent of an unauthorized shooting in law enforcement. But all of us will, like my FBI friends, write hundreds of pages of reports over the course of our careers.

We will file insurance documentation, create case notes, develop treatment plans, and perhaps write excuse notes to employers, teachers, colleges and other important people in the lives of our clients. Some of us will provide written statements to the court, child protective services, and other government agencies.

Most of our documents will never be seen by anyone other than us, our staffs, and perhaps insurance company employees. But sometimes, others will see our written work.

Once when I was consulting with a business, the company employee assistance program representative had required an employee to seek a mental health evaluation to ensure the employee was not a risk to self or others at the worksite. The written report from the psychologist was more than two pages long and full of opinion and subjective commentary about the client. But the worst part was the first sentence: “I declare that the employee is sane.”

Sanity is a legal term, not a mental health term. If the case involving this employee had gone to court and the psychologist had been questioned on the stand, the first thing a lawyer would have done would be to drop the Diagnostic and Statistical Manual of Mental Disorders on the bench and ask the psychologist to flip to the page where “sane” shows up. It isn’t there. The psychologist would have, at the very least, looked incompetent.

Likewise, to declare someone “sane,” ethically one must have training and expertise in competency evaluations. Because this psychologist apparently didn’t know the meaning of the word, I suspect she did not possess the requisite training. A single word on a more than two-page letter could have created major troubles for this psychologist with the ethics committee of her licensing board.

It’s likely this psychologist had never written such a letter before and didn’t think to run it by a colleague before sending it. That was risky. An otherwise (what I can assume to be) stellar career could have been derailed by the pen.

With this in mind, I propose five simple rules for counseling professionals:

Rule 1: If you don’t have to write it down, don’t. The letter from the psychologist could easily have been limited to one sentence: “I do not find this client to be a risk to self or others.” That was the mandate and all that the company wanted to know.

Rule 2: Be objective. What do you see or hear that is clear, pertinent to the case, and that another therapist sitting in the room would also see? Avoid adjectives and modifiers. The psychologist wanted to help her client, but her personal feelings about the client were irrelevant in that situation. Another therapist in the room might have had different feelings.

Rule 3: Use professional and clinical language carefully. “Sane”?  Really? If you haven’t diagnosed depression, for example, don’t say that a client is “depressed.”

Rule 4: Assume someone else — a judge, a jury, a licensure board member, an attorney — might someday see what you have written. Don’t write anything that you would be ashamed or embarrassed for someone else to see.

Rule 5: If you don’t have one already, find a mentor who can help you polish the writing part of your career.

I was trained as a person-centered counselor and, consequently, kept very few case notes. Looking back, I’m embarrassed at what I produced in those days when I was beginning to learn the art of writings things like progress notes. Today things are much different, and I’m hopeful this word of caution will help you get there quicker than I did.

 

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Voice of Experience: Diagnosing and its future impact

By Gregory K. Moffatt November 21, 2019

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.

Image via Flickr http://bit.ly/2lfWuka

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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.

 

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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.

Voice of Experience: Looking for honesty in the supervisory relationship

By Gregory K. Moffatt October 24, 2019

Sitting in a workshop for supervisors at the American Counseling Association’s annual conference in 2018, I listened to the presenter discuss cases of ethical violations by licensed counselors around the country. All of us in the room were stunned at some of the flagrant violations that had occurred. Among the examples presented were counselors sleeping with their clients, marrying past clients, and seeing clients regularly in social settings. Some of these counselors were disciplined by their state licensing boards, while others voluntarily surrendered their licenses and left the profession.

It’s a good thing that none of them lived in Georgia, the state where I practice, or they could have gone to jail. In Georgia, it is a felony to sleep with your client or to terminate with a client for the explicit purpose of engaging in a sexual relationship.

The 25 or so supervisors in the room were surprised at the risks these counselors had taken. The obvious question was: “How did it get that far?” We were stunned that any professional would throw all of their education and training away so casually, not to mention the damage they might have done to their clients.

Around the same time, I was managing a situation in which one of my supervisees had committed an unintentional ethical violation right before being fully licensed. This counselor, whom I’ll call Pat, had made a mistake and realized the error within a few days. Without hesitating, Pat called me to ask how to correct it.

We worked through the scenario and came up with a plan. Then came the question I had anticipated from Pat: “What does this mean in regard to you signing my paperwork next month for licensing?”

The harsh answer was that I would not be able to sign off on the paperwork at the time. This particular ethical violation served as clear evidence that Pat wasn’t ready yet for a license, or else the lapse wouldn’t have occurred. Such a scenario is exactly why we undergo supervision as counselors. Supervision isn’t a formality.

My decision wasn’t the end of the line for Pat though. Pat accepted the consequences of the breach and the remediation that I required. As a result, just a few months later, I was happy to sign off. Pat is now fully licensed and in a successful private practice, and I haven’t an iota of concern that Pat will make such a blunder again.

Sitting in that ACA workshop, I realized how fortunate I was that Pat had trusted me enough to risk a delayed license by telling me what had happened. I realized that I must have done something right as a supervisor, although it wasn’t deliberate in regard to Pat’s particular issue.

After that incident, I started speaking more overtly with all of my interns and supervisees about what they would do should they commit an ethical violation that might delay them getting their license. I told them I was wondering whether I had created an appropriate environment (as I must have done with Pat) so that they would be willing to tell me about any violations. This opened up a discussion that continued for several weeks.

My story here isn’t meant only for supervisors. If you are currently a graduate student or counselor in supervision, I hope that you have a trusting relationship with your supervisor. If you don’t — if you couldn’t go to her or him and say, “I messed up,” even when knowing that your licensing process may slow down — you need to either adjust that relationship or find another supervisor.

If you are a supervisor, you must make this an overt part of your discussions with supervisees. Since that 2018 ACA Conference, I have had conversations about this issue on a regular basis with all of my new supervisees and interns, and I believe it has strengthened their trust in me. My situation with Pat was one of only a very few serious ethical issues I have had to manage as a supervisor. Even so, we must be prepared for them, and we must prepare our future counselors for them.

Perhaps most importantly, if you are licensed, you must have a confidant or mentor in the field whom you trust enough to confide in when you make mistakes. This person can guide you through sticky ethical situations and must also be willing to tell you when you have messed up. This brings the risk of being reported to a licensing board, but taking that risk is crucial to our professionalism as counselors. The greater risk in an ethical breach is to the client. What it costs us is secondary.

 

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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.

 

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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.

Voice of Experience: Confidentiality – The core of ethics

By Gregory K. Moffatt September 17, 2019

As my colleague and I chatted casually in the copy room about life’s odds and ends, she mentioned a client I had referred to her some months earlier.

“Thomas [not the client’s real name] is doing so well,” she commented absentmindedly. “Thank you for the referral.”

Nobody was around to hear us, but I couldn’t believe my ears. My colleague had just used a client’s name. Even though I had referred the client to her and I knew she was seeing him, I was shocked she had identified him so casually.

When we study counseling ethics, we often use phrases such as “do no harm” or “what is in the best interest of the client” as general landmarks for ethical dilemmas. In the 2014 ACA Code of Ethics, nearly all of the ethical standards, from Section A through Section I, in some way or another relate back to protecting the client from harm.

Although I use these benchmarks myself and often mention them to my supervisees and interns, I would suggest that confidentiality comes in at a close second place for the core of our ethical conduct.

Our informed consent, release of information documents, and testimony in court are all centered around the importance of maintaining the confidentiality of our clients. We don’t leave client files lying about on our desks or open on our computer screens.

Current common practice in office construction is to have windows in all office doors. The attorney for the university where I teach loves this practice. But this approach creates an ethical problem for us as counselors. We cannot maintain the confidentiality of our clients’ identities if passersby can easily glance in the window and see them.

When the Health Insurance Portability and Accountability Act (HIPAA) was first introduced to us, I resented it as another governmental intrusion into my work, but I came to realize its power to protect the confidential information of our clients — the very thing I am advocating here. While I don’t necessarily “love” HIPAA, I value it highly and comply with all of its requirements. I pay heed to HIPAA not simply to keep from getting into trouble, but rather to protect my clients.

The very words in this article model my respect for client confidentiality. I have changed the name of the client and a few of the specifics regarding the interaction between my colleague and me. If either of them happened across this article, there is little chance that they would recognize themselves. The gist of the story is true, but some details were changed to protect both the client and my colleague.

I drill a high regard for confidentiality into the minds of my clinicians. I want to ensure that they are so sensitized to this part of our ethics that even the smallest breach will scream at them.

While I certainly appreciate a word of thanks from a colleague if I refer a client, I don’t want to hear, “Thanks for referring Thomas to me …” Even the simple use of a client’s first name in a private conversation between colleagues is a big deal. If we allow that, what other slips will we allow?

I couldn’t let the situation pass. According to Standard D.1.d. of the 2014 ACA Code of Ethics, it is my duty to address ethical lapses within the field. This provision says that if we perceive an ethical violation, we should first approach colleagues directly to resolve it.

As awkward as it was, I gently told my friend it made me uncomfortable that she had used the client’s name. I had scarcely finished the sentence before her mouth dropped open and she quickly covered it with her hand upon the realization of what she had done. She apologized and said she knew better. Somewhat to my surprise, she also thanked me for modeling ethical conduct and for respectfully calling this out to her. She won’t make that mistake again, and I’m glad I did the right thing.

Thomas will never know what happened. But this isn’t just about Thomas. It is about a way of behaving that protects all of our clients, regardless of whether they will ever find out.

Basketball legend John Wooden has been credited with saying, “Character is how you behave when no one is watching.” Ethical behavior, including confidentiality, is perhaps most clearly reflected when no one is watching.

 

 

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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.

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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.