Tag Archives: Voice of Experience

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.

Voice of Experience: Giving away power

By Gregory K. Moffatt July 11, 2019

“Are you Dr. Moffatt?” a soft voice said as Antoine (not his real name) stepped into my office.

I nodded. He was a 20-something African American male. He explained that he had been arrested for assault. His court requirements included completing 12 counseling sessions for anger management. I quickly perused the copy of the court mandate Antoine had brought with him as he stood by respectfully.

“So, let me get the picture,” I said. “You got in a fight. A white guy arrested you. A white guy represented you in court, and a white guy sentenced you and sent you to see a white guy for 12 weeks. Is that about right?”

Antoine tried to stifle a smile but failed. “Yeah, that’s pretty much it,” he acknowledged.

“Well,” I said, “according to this court document, the only mandate is that we have to meet for 12 weeks. We can do whatever you want. We can talk about life, sports, or stare at the wall. Whatever you like. At the end of 12 weeks, assuming you show up, I’ll sign off. Or, if you like, we can work on what might have led to your arrest. If we do, then maybe I can learn something about you, and you can learn something about yourself and hopefully never see a jail cell again.”

When I tell that story to new clinicians, they argue that it would have been unethical to see Antoine for 12 weeks but not do therapy. We would have done therapy, but that isn’t the issue. The mandate didn’t require that I show progress or that the client cooperate. The document only required him to attend.

I’m not playing word games. Alcoholics Anonymous has done this since its inception. Individuals can attend, not say a word, be resistant, and they can show little or no progress or even relapse. Showing up is a giant step on the long road to recovery.

Predictably, mandated clients bring resistance with them. We have no power to force any of our clients to change. The wording of the court mandate allowed me to give away power from the get-go by stating the obvious: I couldn’t force Antoine to change or engage in therapy. (Be aware that some court mandates do require growth.)

I also gave Antoine power by stating something else that was obvious. He was nonwhite, and I was just another white man in a system in which he had no power. I gave him permission (power) not to trust me, and in so doing, ironically, I began to earn his trust.

Mandated counseling makes giving power to our clients especially challenging, and resistance is predictable. Because I’m white, I was pretty sure Antoine assumed that I wouldn’t understand him or his culture. He had no reason to trust me. If I had been in his shoes, I wouldn’t have trusted me either.

Giving away power is one of the things in our therapeutic tool boxes that can help us earn trust very quickly. My technique worked. Within minutes, Antoine was at least willing to give me a chance.

I do something similar with child clients because children are also mandated in a way. Guardians bring them to me — a stranger — often without even asking these children their thoughts about it.

But like Antoine, young children learn to trust me almost as soon as they cross my office threshold. I meet them at the door, welcome them in and say, “You can do about anything you want in here. If there is something you can’t do, I’ll tell you.”

Some children test me with a question such as, “Can I break something?”

“If you feel like you need to,” I reply.

I often watch them as they roam around my playroom, shooting occasional glances at me, seemingly waiting for me tell to them what they can’t do. Saying “no” is rarely necessary.

Antoine turned out to be one of my favorite adult clients. If I hadn’t given him power from the start, he probably still would have shown up and been respectful and cooperative. But growth may not have happened.

Instead, over our 12 weeks, he was fully engaged — starting with our very first session — and he grew tremendously. Several times I saw his eyes light up as he had epiphanies about his decision-making processes. He gained insight into his behavior and developed numerous coping and problem-solving strategies that make it unlikely he will ever see the inside of a courtroom again, at least as a defendant.

I still think about Antoine and his sly smile during our first meeting. Witnessing his growth was satisfying, and that is why I became a counselor in the first place. I doubt I would have ever earned his trust without giving him power from the beginning.

 

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Gregory K. Moffatt is a veteran counselor of more than 30 years. 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: Invisible people, Part 3: The homeless

By Gregory K. Moffatt June 3, 2019

He was the only student in my class who didn’t turn his papers in on time. He was constantly late and regularly fell asleep in class. I felt insulted by his seeming lack of respect for my classroom, for me and for our discipline. If I could have dropped him from the class, I would have. I almost resented the days he showed up.

But he wasn’t truly lazy, and he wasn’t intentionally disrespectful. Instead, he was a struggling member of the third group of invisible people I am highlighting in this series. It had never occurred to me that this student might be homeless, but a conversation with one of my colleagues opened my eyes to his situation. What I learned totally changed the way I saw him. I had been so blind.

The student was the eldest of three siblings who had been living with their mother in a homeless shelter. Mom had married young and had no job skills. When her husband left her, she had no money to pay the rent for their meager apartment. After months of eviction notices, the movers came in and swept everything in the apartment to the curb in less than an hour.

His mother spent the rest of that morning trying to find a place for them to stay. In the meantime, thieves helped themselves to their unsecured possessions on the curb. An afternoon rain had soaked their clothes, bedding and personal belongings. Much of what they owned was ruined. When my student and his siblings came home from school, they found their mother sitting on a broken dresser — dropped by a member of the eviction team — guarding what possessions they had left.

My student slept on a cot in a large room with several other families in the shelter. There was no place to store things other than under their cots, and things put there were often pilfered by other residents. Even an old pair of shoes might be better than those someone was already wearing.

Common bathrooms meant lines, especially in the mornings as my student tried to ready himself, wearing one set of clothes one day and his second set the next. Like others in the shelter, he washed out what he could in the sink, hoping the clothes would dry on the end of his cot by the next day.

This family was homeless because of divorce and a thoughtless ex-husband. Divorce happens to almost half of the U.S. population, so there was nothing unusual in that circumstance alone. My attitude toward my student made it clear I hadn’t even considered that there might be much more to his story.

Many of the people who are homeless in our nation struggle with addiction. Others are seriously mentally ill. To save money many years ago, my home state decided to get out of the mental health business. Mental health patients who were deemed not to be a risk to self or others were sent home or let out on the street, and the facilities closed. Some families couldn’t care for their family members who were mentally ill, and these individuals became nomads.

But there are also many people who are homeless who have merely fallen on hard times. Some men and women travel from one state to the next in search of job opportunities that might enable them to settle down with their families. They spend their nights in shelters, doorways, alleys or their cars.

Those who want to pull themselves out of the abyss of homelessness are met with barriers at every turn. Businesses don’t want them warming themselves in their shops. Cynical pedestrians cross the street to avoid saying, “I don’t have any money for you.” Esteem is further eroded by words such as, “You’ll just spend it on drugs.”

Services for those who are homeless are often inaccessible. For example, in Atlanta, the labor pool (where men and women go to find work) was many blocks away from where most shelters were located. It was smarter to sleep under a nearby bridge, thus possibly being first in line the next morning. Better that than to sleep in a shelter and not being allowed to leave until 7 a.m., thus risking being at the end of long lines and having less chance of securing a job for the day.

People who are homeless can also be stalled by people like me — a college professor and professional counselor who should have known better. My student had no place to study at the shelter, no place to keep his homework, and no money to buy his books. With limited transportation options, he was perpetually tardy. And he was exhausted all of the time from caring for his family, working when and where he could, and getting insufficient sleep in the crowded shelter.

Our clients who are homeless need transportation, food, clothing and jobs. I know that we aren’t social workers, but those who work with the homeless have to think pragmatically.

I’m glad that I learned about this student’s story — which has a happy ending. He and his family got back on their feet, he graduated from college, and life is better. It frightens me to think how many other people I might not have seen clearly, however, because of my cultural blindness.

 

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Dear readers: I would value hearing from you if you found this series on cultural awareness (invisible people) helpful. My primary writing goal is always to help us do our jobs better. You help me do that with your comments, questions and ideas.

Previous articles in this series:

Voice of Experience: Invisible people, Part 1: Native Americans

Voice of Experience: Invisible people, Part 2: The incarcerated

 

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Gregory K. Moffatt is a veteran counselor of more than 30 years. 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.