Tag Archives: Voice of Experience

Voice of Experience: Losing Summer

By Gregory K. Moffatt January 30, 2023

Blur photo of emotions moment of girl with flowers waiting for first summer.

Sorn340 Studio Images/Shutterstock.com

My client, a 22-year-old woman named Summer, sat across from me with a blank stare. (The client’s name and some details have been altered to protect the client’s confidentiality.) We had worked together for several months as she battled addictions, relational issues, childhood trauma and a host of other rapids she had to navigate during her relatively short life.

She described what she could remember of her most recent binge. It was a night of excessive drinking with three men she met at a club that led to a rape she couldn’t remember because of a blackout. She awoke to a gray morning lying in a parking lot. In pain, missing clothing and realizing what had happened, she blamed herself. No thoughts of calling the police or going to the hospital. She didn’t even know the first names of any of the three men.

This wasn’t the first time either. Some days, I felt that she was trying to impress me with her exceedingly risky behaviors, and other times, I felt angry — countertransference because I seemed to care more about her safety and her future than she did.

As one would imagine with any client struggling with this level of alcoholism, her life was in turmoil. She didn’t have a single stable relationship other than with me. She had lost several different jobs and been evicted from apartments twice during our time together. And on this day, in addition to the events a few nights before, she informed me her boss was considering terminating her from her current position because she repeatedly failed to show up for work.

She asked me if I would write a letter to him confirming that she was in therapy and working on her issues. It is one of the very few times I agreed to this request. With a release of information in hand, I wrote a short letter, confirming that she had been in therapy and that we were working on the underlying issues that led to her troubles at work.

In addition, I added a line I had never before written and have never written since: “If at all possible, I am hopeful that she can keep this job. It is the one stable and healthy thing in her life.”

Gratefully, the boss agreed to allow her to stay on a probationary status. She had four weeks to follow through on the conditions of her probation. I was hopeful.

Then, just one week later, Summer showed up for what ended up being our last appointment. She had failed to live up to her conditions for even a week, and she was terminated. With tears in the corners of her eyes and a shamed expression on her face, she informed me she was moving to Texas where she had a cousin who was going to allow her to stay with her until she could get back on her feet.

She left that day, and I never saw her again. I lost Summer. Given her trajectory, I wasn’t confident she would live to see her 25th birthday. It was one of the hardest terminations I’ve ever had to manage.

But, thankfully, that isn’t the end of Summer’s story. I thought of her many times over the years and wondered how I could have better helped her. Then one day, maybe 20 years later, a handwritten letter arrived in my mailbox. I recognized her name on the return address immediately.

close up of man holding envelope with a letter inside

fizkes/Shutterstock.com

It was a long letter, nearly three pages, and much of it detailed her life after leaving Atlanta. In short, she stopped drinking, went back to college, married, became a nurse and had three children. Even as I tell you this story, I still feel relief that she survived and learned to thrive.

But the most meaningful part of her letter was the opening two sentences: “Hi, Dr. Moffatt. I don’t know if you remember me, but [short summary of our work together] and I’ve never forgotten what you did for me.”

I know that many of my clients have deeply appreciated the work that I did with them, and sometimes they tell me to my face. Many of the children I’ve seen over the years have become thriving adults, and I’ve crossed paths with them here or there. It’s always satisfying to see their lives moving on.

But I’ve never been so sure I lost someone as I was with Summer. That letter, the last contact we ever had, reminds me that we never know how we are affecting our clients in a positive way, even if those effects come about somewhere further down the road.

 


Gregory K. Moffatt is a veteran counselor of more than 30 years and the dean of the College of Social and Behavioral Sciences at Point University. His monthly Voice of Experience column for CT Online seeks to share theory, ethics and practice lessons learned from his diverse career, as well as inspiration for today’s counseling professionals, whether they are just starting out or have been practicing for many years. His experience includes three decades of work with children, trauma and abuse, as well as a variety of other experiences, including work with schools, businesses and law enforcement. Contact him at Greg.Moffatt@point.edu. 


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

Voice of Experience: Home visits

By Gregory K. Moffatt December 19, 2022

It was early in the 1990s. I had been in practice maybe six or seven years. I’d paid my dues in general practice, hoping one day to focus exclusively on family and children. At that time, nearly all my clients were children or families with children.  

Most of my clients were either single-parent families, divorced and blended families, or families in the middle of divorce. It was heartbreaking for me to observe the pains of broken families — lost dreams, heartache, the unknown, financial devastation, and the many other factors that can make divorce so painful. These are things we have all seen many times even for those just starting out in the profession. 

One family was limping along trying to salvage their 10-year marriage. I’d seen them and their three children several times in my Atlanta office, but most of my clinical work focused on the marriage.  

The couple faced many challenges in finding times to meet with me. They both worked full time; he was a postal worker and she was a nurse. Their home was 35 miles from my office through heavy Atlanta traffic. For each appointment, they had to pick up children at daycare, scurry home as quickly as possible, change clothes, meet the babysitter and head north to my office to make our 6 p.m. appointment.  

To arrive on time, everything had to go as planned — no car troubles, no late days at work, no late or no-show babysitters. The stress of a long day at work, coupled with the rush to get out the door on time, often led to arguments in their 45-minute drive to my office. If this happened, they were so harried when they arrived that it took several minutes for them to recenter before we could get down to business in our session. 

Despite all of that, we were making progress until one day I got a call just 30 minutes before they were supposed to arrive. Everything had gone wrong that day, and they were not only canceling the appointment but also withdrawing from therapy. 

That is when I had an idea. I suggested we have a final session the following week, and I would help them find a referral. But this time, I offered to meet them in their home. They heartily agreed. 

Their dimly lit living room was full of commotion: Pets were running around, and I could hear young children in a nearby bedroom. But I realized the only one who was uncomfortable was me. They were more relaxed than I’d ever seen them. Although it was a less-than-ideal environment for therapy, they were comfortable in their own space. I saw them in a way I’d never seen them before. 

It was then that I realized that I was unintentionally adding to their marital challenges by the very nature of my practice. They had to spend extra money on babysitters — money they didn’t have. And before each appointment, they spent the entire day dreading the potential problems they might encounter trying to make it to my office by 6 p.m. — my latest appointment option. 

After this realization, I offered to meet with them twice a month in their home and they agreed. Six months later when we terminated, their marriage was much healthier. Just a year or so ago, I received an email from the wife. They are still married, their children are grown, and life has settled. 

Home visits create numerous challenges for us as counselors. Most obviously, boundary crossing is an issue, but in the home visits I’ve done, I’ve never had any problems arise from these boundary crossings. Until about 50 years ago, half of all physicians made house calls without any issue. And some still do! 

Safety, of course, is a concern, but social workers have made home visits for decades demonstrating that safety issues can be managed.  

Instead of making a home visit, I could have offered a later appointment time or one on the weekend, but that would have compromised my own family life boundaries. Finding a closer referral could have worked, but that would have required them to start over.  

While I admit these challenges, among others, need to be considered, if we really want to pursue diversity and consider cultural issues, shouldn’t that include the challenges I faced with this family? I am confident that I opened my mind to alternative methods of delivering clinical services in an ethical and responsible way.  

Just like telehealth, there is no one-size-fits-all approach. For example, I couldn’t meet alone with an individual client at their home. Although there are many limits to offering in-home services, I’ve never regretted making that decision. 

 


Gregory K. Moffatt is a veteran counselor of more than 30 years and the dean of the College of Social and Behavioral Sciences at Point University. His monthly Voice of Experience column for CT Online seeks to share theory, ethics and practice lessons learned from his diverse career, as well as inspiration for today’s counseling professionals, whether they are just starting out or have been practicing for many years. His experience includes three decades of work with children, trauma and abuse, as well as a variety of other experiences, including work with schools, businesses and law enforcement. Contact him at Greg.Moffatt@point.edu. 


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

Voice of Experience: Self-assessment and professional growth

By Gregory K. Moffatt November 17, 2022

A soon-to-be fully licensed clinician sat across from me for one of our last supervision sessions. I told him the same thing I say to everyone when they get to this point. After today, you will have your license in your hand, and depending on the nature of your practice, you never have to talk to another mental health professional again for the rest of your career.

Although it is improbable that any clinician will literally never speak to another person in the field, it is not at all improbable that they may not have any “supervision” for the rest of their career. That should make us all shudder. I regularly present trainings — often on supervision, ethics or both — at conferences. I can tell who is there to learn and who is there just to get a piece of paper that says they sat in a room for five hours. I wouldn’t want my counselor to be in the latter group.

I want the newly trained clinicians I supervise to see the ethical responsibility they have for their own self- assessment, competence and professional growth. Those who isolate themselves in their own practices and see clients day in and day out, are at risk of being the same counselor a year from now that they are today. They won’t have someone sitting across from them each month asking them “What are your strengths and what are your weaknesses?” like I do with my supervisees.

Using a 10-point scale, I evaluate my supervisees using nine areas of competence: ethics, theory, diagnostics, case presentation, clinical skills, documentation, diversity, self-care and remediation. I ask my supervisees to rank where they are in these nine areas during the final weeks of supervision, and they almost always rate themselves higher that I rate them.

I know why. They are very good at the things they know and the issues they face regularly. But what they lack sometimes is a recognition of what they don’t know — questions they don’t even stop to ask.

For example, when I asked one clinician, “On a scale of one to ten, where are you in your understanding of the Diagnostic and Statistical Manual of Mental Disorders (DSM)?” she gave herself a nine. But when I probed a bit, she admitted she hadn’t even looked at the latest edition, DSM-5-TR, and didn’t know what changes had been made. She is a competent clinician who knows what she needs to know with the clients she sees every day. But she didn’t know what she didn’t know. That is why supervision, consultation and training are critical.

Some clinicians are just lazy and unethical. They won’t grow because they don’t want to. I can’t do much about them.

But others fail to pursue professional growth because they don’t know any better. Evidence of weak professional growth might look like the following: You see your continuing education requirements as “hours you have to get” as opposed to opportunities for growth. If this is the case, I have concerns about your professionalism.

Some clinicians wait until the month their license renewal is due and then scramble to get any continuing education credits that meet their state requirements. Hmmm, that doesn’t scream “professional” to me.

If a counselor doesn’t see the need to regularly meet with other professionals in the field, discuss cases or ask for someone to look over and evaluate their work, then it sounds like someone who thinks they have “arrived” and have nothing else to learn.

When it comes professional growth, I practice what I preach. A few years ago, a married couple came to me in an attempt to repair their seriously broken relationship. It was an incredibly complex and challenging case for me. Even though I’ve been in practice for decades and started my general practice in the 80s as a family therapist, I’m not a licensed marriage and family therapist (LMFT), so I wasn’t fully confident I was seeing everything I needed to see with this couple.

I sought supervision from a LMFT I trusted. He was humbled at my request because he was my former student and former supervisee. But he had far more experience in the marriage and family arena than I did. I consulted with him for months about this case, and happily the marriage survived.

In addition to seeking supervision when needed, I also evaluate myself using the nine areas of competence that I use to evaluate my supervisees (i.e., ethics, theory, diagnostics, case presentation, clinical skills, documentation, diversity, self-care and remediation).

My challenge to you is to rate yourself on these nine areas and, even more important, have a colleague rate you as well. If you don’t have a colleague who knows you well enough to evaluate you, then that tells you that you have some work to do.

Colored Lights/Shutterstock.com

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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 future of mental health

By Gregory K. Moffatt October 19, 2022

I love trying to forecast how the counseling profession will be different 10 years, 20 years or 50 years in the future. I sometimes wonder if any of the fathers of psychology ever did that. After all, the field has come a long way in the past 100 or so years. Here are a few of the major developments:

  • In 1900, psychology moved away from psychoanalytic thinking and toward behaviorism, which dominated the field for 50 years.
  • In the first part of the 20th century, mental health measurements and testing as we know it today didn’t really exist. The idea began with psychologist Alfred Binet’s development of the IQ test at the turn off the 20th century, but measurements weren’t even in our jargon until the 1950s or so.
  • Cognitive psychology began to gain steam in the 1950s but was eventually overtaken by existential and humanistic theories in the 1970s.
  • Cognitive behavior therapy (CBT) predominated in the 1990s, and in 2022, dialectical behavior therapy and intensive family therapy are trends.
  • Until managed care became commonplace in the late 1980s, there was no such thing as solution-focused brief therapy and almost nobody (except for CBT folks) used the language “evidence based.”
  • The Health Insurance Portability and Accountability Act didn’t exist until 1996.
  • In 2013, the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) was the first revision of the DSM to accept input from clinicians in its construction as opposed to revisions being done exclusively by a committee.
  • And only a few years ago, we began talking about “telemental health.” Even though I didn’t have any intentions of doing telehealth counseling, I still pursued telehealth training around 2017 to ensure I was covered if I had to talk to clients on the phone. At the time, Zoom and other digital platforms were either nonexistent or brand new.

So where is the profession headed in the next 30 years? Here are my top three predictions:

1) Telehealth will expand. Prior to the pandemic, most clinicians saw clients face to face. Today, not only are more clinicians foregoing expensive offices and associated costs to work on digital platforms, but clients are expecting this option as well.

While telehealth has limitations, it can provide services for people who could otherwise not afford it. It also allows people to access mental health services in remote areas. My personal counselor’s office is over an hour from where I live. If I were to see him in person, it would require half a day. An hour up, an hour back and an hour in session — and that doesn’t consider the traffic issues that are common in Atlanta.

That means I would not be seeing clients and I would be spending money and time instead. But with telehealth, appointments with my counselor take exactly one hour and I’m done — no travel, no expense, no traffic and minimal intrusion into my own client load. This has made therapy more affordable as well as more accessible.

2) Hourly pay will decrease. Because of telehealth, the average hourly rate for the profession is going to plummet. Unless a clinician is a specialist in an area that is hard to find, what used to be an average of $150 an hour will probably sink below $50 an hour.

There are many telehealth agencies that are already paying just $30 or so an hour to licensed clinicians. I don’t think the profession will allow that to continue, but the days of $150 an hour or more are fading.

3) The focus of graduate programs will change. All CACREP programs address 10 content areas. One of them is diversity. When I was in graduate school in 1985, there were no courses on diversity, and it wasn’t required to get a license (when licensing came about in the late 1980s). Today taking a course on diversity is not only required but also assumed to be an ethical obligation.

I suspect that as telehealth continues to evolve, CACREP and graduate programs will include telehealth and related issues as part of the required training for new counselors. Before the pandemic just two years ago, my counseling interns had not received telehealth training, and no graduate programs that I know of required it or even offered it for students.

But as the pandemic greeted us in 2020, I needed my interns to have telehealth training, so I required it. Consequently, many graduate programs now required it as well because it helps students get internship placements. I predict that soon telehealth will be a requirement for graduate counseling program curriculum and for licensure.

 

In a previous column from two years ago, I wrote about how shifts in health care change how we do business. Even since then, times have changed, and we keep evolving. I’m interested in what you think will change with the mental health profession. Please contact me and let me know your thoughts.

alphaspirit.it/Shutterstock.com

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Related reading: See Counseling Today‘s January 2021 cover story, “The forces that could shape counseling’s future

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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: Diversity and third-culture kids

By Gregory K. Moffatt September 21, 2022

Pita Design/Shutterstock.com

My client was a 19-year-old female presenting with anxiety. She had just started college, and her anxieties had led to trouble concentrating and making friends, and they sometimes kept her awake at night. She was also troubled by the fact that until recently, she had been easygoing and didn’t get ruffled quickly.

The client was a child of a missionary family, and for over a decade, she had lived in South America. But she was born in the United States and had spent nearly all her grade school years in a rural community on the east coast where she now attended college. She and her family also made regular visits back to the United States during those ten years when she was living abroad.

One would have thought that returning to the United States for college after spending the last 10 years in South America would have been an easy transition for her. After all, she was already an easygoing individual, she functioned well in her adoptive culture, and she never had any issues on her sabbaticals home to the United States. But it wasn’t easy, and she couldn’t understand why.

But I had an idea.

When she left the United States, she was only nine years old. The world she knew was long gone because of the passage of time and her own development from child to adult. On top of that, in her visits back to the United States, she spent most of her time looking up old friends or enjoying the company of relatives until her trip was up and she had to go “home” in South America.

As a white girl with blond hair, she was an anomaly in Ecuador. She lived in a community where English wasn’t spoken. Although she spoke Spanish without much of an accent, it was still not her first language. She was not a true Ecuadorian.

But when she returned to the United States, she also discovered that she was not a true American either. Being gone most of her adolescence, she had missed 10 years of acculturation. TV shows, movies, music and cultural events were just some of the things she couldn’t relate to. It was like she walked into a very long movie just at the end; she didn’t know what was going on around her.

My client was what is referred to as a third-culture kid — people whose identity is influenced by their parents’ culture and the culture(s) in which they are raised. Third-culture kids are often the children of missionaries, nongovernmental organization workers or military families. My client obviously didn’t totally belong to the guest culture (Ecuador), but she didn’t belong to her home culture anymore either. Not every third-culture kid’s experience, of course, is as stressful as my client’s. Most of her stress stemmed from the fact that she was not prepared for feeling like an outsider in her home culture.

Transitions from one culture to the next are easiest when the cultures are similar, when the visit is short, and — as is often true for Americans — when they take U.S. culture with them. When I hear about someone from the United States traveling abroad and I learn that they stayed in American hotels, ate American food and spoke nothing but English, then I know they took America with them.

But for missionaries and NGO families, living on the economy almost necessitates diversity of culture, longer stays, and an inability or lack of desire to take America with them. The “American” stands out and may take years to be thought of as an insider.

At the same time, attempting to gain acceptance in the chosen culture by default also means leaving one’s home culture behind. Third-culture individuals are like ships without a flag.

In our never-ending attempts to improve our understanding of diversity, it would be easy to overlook third-culture kids. Based simply on appearance, people may not realize someone is a third-culture kid. I could have easily missed the significance of my client’s third-culture status and focused only on her anxiety. That would have, at best, slowed down her healing.

Recognizing that she was really neither American nor Ecuadorian helped her understand why she didn’t seem to fit in a culture where she looked like everyone else. This realization was the beginning of her developing coping strategies that worked quickly and helped her symptoms of anxiety abate.

Large international agencies often employ mental health workers to assist their personnel when they transition to a new culture as well as when they are ready to transition back to the United States. But smaller agencies such as the one my client was associated with may leave navigating this transition up to the individual, which is what happened to my client.

When I was a graduate student in the 1980s, “diversity” generally focused on issues of race. Fortunately, our thoughts on diversity have evolved since the 1980s, but we still have a long way to go. And we can start by recognizing overlooked areas of diversity, such as third-culture kids, and developing strategies to help them.

 

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Read more on the nuances of counseling third-culture kids in a recent article from Counseling Today: “Growing up between cultures

 

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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.