17. Diagnosis Debacle
Season 1, Episode 17
Hannah shares how an aggressive conflict over a diagnosis with a parent led to the discharge of her client who wanted to work with her. She discusses how she handled the aggression and how she would handle diagnoses differently in the future.
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Episode Transcript - Diagnosis Debacle
Allie Joy 00:08
So, Kathryn, with the work that we do, we have to talk about diagnosing a lot, right, but it can be very challenging at times. Would you agree?
Kathryn Esquer 02:11
Oh, absolutely. And diagnoses are absolutely not everything in the therapy room. But a lot of times we have to work with them for insurance purposes, for research purposes, for treatment planning, like diagnoses are part of what we do. And sometimes, you know, we have clients who don't agree with what we come up with as a diagnosis.
Allie Joy 02:36
Mm hmm. Yes, we're going to hear from Hannah, who is going to share her story about how she was trying to work with a client but their parent did not agree with her diagnosis. It led to some verbal things being said to her, and ultimately we'll find out what happened but it did not end well.
Kathryn Esquer 02:56
Not at all. So just a friendly reminder that this episode is for entertainment purposes. It's not a substitution for clinical consultation, ethical guidance or therapy itself.
Allie Joy 03:08
All right, well, this is episode number 17 of Am I a bad therapist? Let's get into it.
Kathryn Esquer 03:18
Well, Hannah, welcome to Am I a bad therapist? Can you tell us a little bit about yourself where you're at in your career, how you got there.
Hannah Delano 03:29
Thanks for having me. My name is Hannah Delano. I'm a licensed professional counselor in Northern Virginia, actually just finished my license in May or had it issued. So I finished grad school in 2017. So it's kind of a long journey. We're a military family. So that just makes everything a little harder. But I've worked in pretty much most settings I could think of I've worked at a college counseling center, a psychiatric hospital, private practice in home work had a school so and now I'm just doing outpatient therapy, and my practice, I've kind of been all over them.
Kathryn Esquer 04:11
You've had quite the diverse experience. And before I get into your story, I need to know like, did you have a favorite setting like you chose outpatient now? Was that a choice by necessity? Or is this what you've been hoping for? Did you have a favorite before that?
Hannah Delano 04:28
Well I loved working at the hospital. It was just really fast paced, and it was I would do the intake assessments I'd get time with clients or patients but also we would coordinate with emergency rooms to find beds for patients and we had like office so you we were working with a bunch of people together. So it was a little more social than just regular private practice, which can be a little lonely sometimes.
Allie Joy 04:57
It really be lonely sometimes. Oh my gosh, I feel that a lot.
Kathryn Esquer 05:03
So Hannah, you're gonna share a story with us that happened while you were at, at your setting at a school environment. So tell us about why you're a bad therapist.
Hannah Delano 05:14
I think about that every day. But um, so I was working at a high school, and my company was contracted. And so the school had, like, almost 2000 students, and they had four school counselors and one social worker, so they were just kind of stretched thin. So I would come in, and I would work with just five or six students that needed the most support to try and keep them in school, instead of having to go to alternative school or be suspended, expelled. So the kids from behavioral issues to more emotional like suicidal issues. And I have just started working with a student, and we do an assessment process to get it approved and started. And that usually takes two or three hours to do. So we meet with the student and the parent and do a lot of paperwork, get a full history get releases for anyone they worked with before. And because it's an insurance funded program, we have to provide a diagnosis at the end. And so we do the assessment, then later, I do the diagnosis and write everything up. So there's time between the assessment and meeting with the parent to go over the initial treatment plan. So I have met with the parent. And I have kind of had, this was a tough parent, like I was, I was kind of told before that they can be a little tough. And the assessment process, they had a lot of questions very thorough, they seemed a little unsure about everything. So when I met with them to go over the treatment plan, they actually had someone that they know really well at the school come into the meeting to which I was fine with. And as soon as we started the meeting, and I, you know, gave her a copy of the treatment plan. She saw the diagnosis, and she just got very upset with me about what it was. So this was actually something that had been chosen by the director of the program, like in coordination with me, but she had the final say of what it was. Yeah, so let me let me get this straight. So you had just started working with this patient? You sounds like you have a really thorough intake process, which actually sounds quite luxurious. Sometimes. It takes a lot of paperwork, okay. It's not that luxurious. And you consulted with the director, forgive me if I'm using the wrong title, but the center director and came up with a appropriate diagnosis. You share this with the patient, the patient's mother, and the another school person who was there. And the mother is upset about the diagnosis. Yes, she was very upset she she started like raising her voice saying that I was unprofessional that why is this diagnosis on paper before it had been gone over with her. And I tried to explain that this was the initial treatment plan and the purpose of the meeting was to go over it to have her sign it so nothing was like approved by her yet. But she just kind of escalated and, and I'm a people pleaser. I don't like conflict. So I was like, behind my desk wanting to cry. She called me unprofessional, said that therapist can't diagnose. So just a lot of things. And I was kind of, I've never had an experience with the client or a parent. Like that. So it just threw me off a lot. And I'm glad someone else was in there with me.
Allie Joy 09:21
So you had said you had heard this, that they might be a little bit difficult. Did they have a history with the school of maybe of like saying things or how did you get that warning? If you can speak to that at all about the parent.
Hannah Delano 09:33
I think they had several kids at the school and I just knew from administration and other school staff. Like the fair amount of history of coming up there often getting, being unhappy with things often she was just very unsure of the whole program from the beginning. So I had heard of other interactions like that, so I knew it wasn't just me. But I definitely wasn't expecting that level.
Allie Joy 10:03
Right? Yeah, even with the warning, I'm sure your brain didn't think, you know, it didn't create that scenario in your head per se. So what was running through your mind, I noticed that you kind of felt like you wanted to cry, what else was going through your head at that moment when she was questioning not only the diagnosis, but your clinical capabilities? What were you thinking?
Hannah Delano 10:22
Yeah. Well, I was fairly new to working at the school. So I was worried, you know, if the parent had more relationship with school staff, you know, what they would think of me? Was, was this the right diagnosis was the right call, how will this impact the student, because the student wasn't in the meeting at that time. So I didn't know what to do. So I was just kind of sitting there shell shocked.
Kathryn Esquer 10:51
I can absolutely relate to this. I was once in once an intern. Like I'm always still interning in life. I was an intern, and I was doing an organizational consultation, like a weekend consultation with a pretty large, high powered group. And I was helping my supervisor implement just an intervention or intervention. And I assume the this board of directors, all older men, I'm like, still in graduate school in my early 20s, young female, and they waited till my supervisor who was about their age left, and they just ripped me like ripped me apart. They like went after like the the efficacy, the strategy, everything. And I just remember, when you're telling a story, I have not thought about that moment, and so long, and when you're telling me like sitting behind your desk, wanting to cry, while they tear you apart, like that feeling of just inadequacy and like, but I'm the one supposed to be elite steering the ship here is is absolutely so intimidating and unsettling. And so I think I can relate to what you went through, maybe not exactly,
Allie Joy 13:27
So Hannah, your story has resonated so much with me because I have shared before on the podcast, I worked in a school based health center in schools, and I loved it. But it was challenging to be like in a mental health world, while also functioning in the educational world. So I'm curious, do you think that this parent had some concern about the diagnosis somehow being on the educational record? Like do you think that played a piece into what was going on? Like thinking that it wasn't separate or things like that?
Hannah Delano 13:56
That was a big part of it because the student had an IEP. So I don't think the parent fully understood that our program was fully separate from the school because it was a an insurance funded program. It had nothing to do with the school. So all the confidentiality required applied there. Some records were shared with the social worker, but I think there was some concern there about maybe the school finding out and I know the student had had a full psych eval done before, but the parent wouldn't share it with us. So that was kind of because if the client has a previous diagnosis, we'll just use that instead of coming up with our own. So that was one of the problems too. Yeah.
Allie Joy 14:47
Did they say like, do you I mean, it sounds like they didn't share much, but it didn't seem like they didn't agree with that diagnosis as well or did you get any more information around why they wouldn't share?
Hannah Delano 14:58
They do I didn't talk to the parent about that a lot I that was through that the school worker that was close with the parent, they wouldn't even share it with them really. So maybe they just didn't agree. I don't know the parents full views on mental health. So I think they just maybe didn't fully understand what their child was going through.
Kathryn Esquer 15:23
So all of this, all of this conflict came up just solely around the student's diagnosis. And you don't just share what the diagnosis was or how you came to it. But you know, were you confident that that diagnosis was accurate? Or was there wiggle room that maybe this parent was coming from a place of, of accuracy?
Hannah Delano 15:45
That was one of the things was, what can we check? If we could change it? What would we change it to? And the director said, we're not going to change the integrity of the diagnosis just because the parent doesn't like it? So I mean, I, I know it's hard from A to our assessment to come up with a fully accurate diagnosis. So then, I'm always kind of hesitant to do a more severe diagnosis, I guess he would say, but there was some, some concern about some psychotic features. So I think that's what the parents had the most problem with.
Allie Joy 16:25
I can, yeah, I was gonna say, I can see that too. It just sounds like, I wish and I'm sure you did, too, like that it was just handled differently of like, you know, it's totally acceptable for clients to ask us questions around diagnosing and especially if it is, you know, maybe something they consider more intense. But I'm confident that you would have been willing to have that discussion. So it's interesting their response to you.
Hannah Delano 16:53
Yeah, I don't think they wanted to, to hear like I went through the checklist of how the diagnosis was decided upon the process of happen, how we recommend a full evaluation be done, then it was just a provisional diagnosis. They just weren't happy.
Kathryn Esquer 17:14
So how did this meeting this was you another school employee and the parent? How did this end? And what did you do next, as you're sitting there trying not to cry?
Hannah Delano 17:26
I tried to I just because I was still a resident at the time. So I wasn't fully licensed. So I, I kind of could fall back on saying that I would have to go to my supervisor about it and see what can be done. So the meeting kind of ended there with me explaining that I would have to talk to them if we could change the diagnosis to something that they would be more agreeable with. Because at that point, they weren't going to sign the treatment plan. And without that, we could continue the service. So that was kind of the end of the meeting there.
Allie Joy 18:02
Who was the other? I was curious. Who was the school person you said that was with you? What was their role?
Hannah Delano 18:09
They were they were one of the special education staff so that they supported the client in the classroom. Okay. Relation to their IEP.
Allie Joy 18:23
Gotcha. Okay. I was just curious about that piece, too.
Kathryn Esquer 18:28
And so this meeting kind of ended with the termination of services, hmm.
Hannah Delano 18:35
I called my supervisor after and they consulted with the director and everything. And the director basically said that we weren't going to change the diagnosis. So they offered a couple of options, like writing on the treatment plan that the parent didn't consent that they consented with the goals with the parent wasn't willing to sign anything with the diagnosis on it. So we had to terminate services. And that was still with two or three months of school left.
Kathryn Esquer 19:06
Wow. And did you ever get to debrief with the child with the student with the patient?
Hannah Delano 19:15
Yeah, that was, that was probably the hardest part for me is I thought, a really strong rapport with the client. And they weren't very trusting of a lot of people like they would just come to my office a lot wanting to talk things through. I had to de escalate them from getting in a fight a couple times. So they actually after the meeting with the parent, they walked in my office later. That's kind of how to say, hey, we have to talk and had to tell them that we I wouldn't be able to work with him anymore. So that was really hard for me because I knew they kind of rely on my support.
Kathryn Esquer 19:54
Wow, that must have been so hard.
Hannah Delano 19:56
I had to frame it in a way that wasn't blaming the parent, you know, I had to explain that that's their parent, that's their right. They know the child the best. So the client had a lot of conflict with the parent. So that didn't really help. It's just a sad situation overall, because they, they really needed the help, and they couldn't get ahead.
Kathryn Esquer 20:23
Yeah. And there's so much talk in our field about the utility, or the efficacy or just just why we continue to use diagnoses. And you know, we could spend, we can have a whole podcast discussing the both sides of that. So, you know, without getting into that, like it just that one hinging point, this is just a critical example of how important diagnoses are in today's treatment world, right? So important that you cannot continue services without them in some in some environments, and also so impactful that people will terminate services because of the diagnosis. And I think this is a clear example of, of the dichotomy of diagnoses.
Allie Joy 21:12
Yeah, and then it's so hard to when the client, you know, the student wanted the treatment. And that's like, in Connecticut, we do have this provision, where like, I think it's over 16, a child, you know, the student, like a client can consent, and they can get access to six services, like sessions without parental consent, and then it can be renewed and refreshed. But it feels really yucky to me, like, it's very difficult to go down that route or like to think about it. Because, again, we always want parental consent, of course, but we also want to treat, you know, the client who needs it. So even here in my State of Connecticut, it gets really tricky of like, if a parent doesn't agree, you know, again, we have some wiggle room legally, but it doesn't feel great clinically, or as a person. So it's just really hard to see that when we have someone who wants services that we can't, we can't give them.
Hannah Delano 22:04
A lot of clinicians I work with won't even work with minors because they don't want to, to deal with the parent, child dynamic and confidentiality and everything.
Kathryn Esquer 22:15
Yeah, and that's so that's so sad. I see the point, I see the need to protect your own energy as a clinician, but, you know, in my area, there's such a shortage of clinicians that work with children, adolescents, it's such in dire need. And, you know, a lot of that is coming from this, the ambiguity and the messiness and the murkiness, which is what we deal with on a daily basis, which is what this we talk about every every episode, but particularly with with child patients, where the parent is a major factor in their treatment.
Allie Joy 22:52
Yeah, it's similar here to in Connecticut, where most providers, like when you're looking for a provider to work with children, most people have to go through agencies because a lot of private practice Owners Group Practice clinicians are fairly similar, where they don't work with kids. And again, if it's not your thing, it's not your thing. But it's very challenging when you're trying to connect people with services. And it can be so complicated of like, you know, that piece of it. So I see both sides, but it doesn't make it easy either way.
Kathryn Esquer 23:19
Oh, talking about all the goods, the bads and in betweens, right.
Allie Joy 23:24
Okay, so, Hannah. Well, I'm sure we were about to ask the same question. Hannah, what would you say to another clinician, who was going through something like this? What advice would you give? Like, what did you kind of see, in hindsight, what would you say?
Hannah Delano 23:41
I would say, to definitely consult with your supervisor and kind of process you know, knowing that you have the clinical skills, and you have the training, even if a parent is questioning it, that you're the professional in the situation. I kind of had to take some time after that to kind of like I cried in the car on the way home, but I called a couple people and I felt better after that. And just, I knew the parent was coming from the place of love for their child and concern for their child. So I try not to take it personally from the parent.
Kathryn Esquer 24:23
That's a beautiful statement. Try not to it's so hard not to. It's almost impossible not to but Absolutely. It was different perspectives. And both of you were concerned and wanted to help help the client. beautifully put. And have you encountered any situations like this since then, where a patient or patient's guardian has really conflicted with you?
Hannah Delano 24:49
I was trying to just think of that minute ago. I haven't had a situation that severe where I was kind of it was almost too aggressive in a way that I was concerned. You know, working in the hospital, we would have patients come in involuntary. So if they were an adult family members would be trying to call them to see if they were there. And we couldn't tell them or parents would be very unhappy that the child was committed. And we didn't have any say in that process, you know, that was through the court. So I've definitely dealt with people being unhealthy. But never to to that degree.
Kathryn Esquer 25:36
Do you think you'd do anything differently next time? Because there will be a next time.
Hannah Delano 25:45
So good question. I think I would try to hold my ground and try and be more confident. I was still a resident at that time. So you know, imposter syndrome is real. And even with my license, I still still feel it. Trying to stick to your clinical guns, I guess I would say, just try and be I tried to be as calm as I could. I'm pretty pretty calm personality. So I didn't react to the parent.
Kathryn Esquer 26:20
That's the part I have the most trouble I want my, I'm a very reactive person. So I can I can relate to that. My struggle is to stay calm, I can stick to my guns, but stay calm. It seems like you're the vice versa.
Hannah Delano 26:35
I think it's important to pay attention to the other end of the spectrum where like, I like to avoid conflict. So just kind of keeping in mind, am I making this choice? Because I don't want conflict or is this the the best choice to make?
Allie Joy 26:48
Oh, that's a really good point. I like that. That's a good like self awareness there to make sure it's not our stuff coming into the room. Awesome. Well, Hannah, if anyone does want to connect with you, outside of the podcast, how can they find you?
Hannah Delano 27:04
Um, I have a Psychology Today page and I'm a member of the teletherapist network. I haven't dove into the world of professional social media yet, so I don't have an Instagram or anything like that. But they can also ask me for my email too.
Allie Joy 27:21
Perfect. Well, thank you so much for sharing your story today. It was so great to hear again, your like just self awareness how you handled this, and a story I'm sure many of our listeners can relate to.
Hannah Delano 27:33
Yeah, thanks for having me.