网爆门

Earlier this year Stephen Kinnock, speaking at a conference for GPs, suggested that there was an 鈥榰nregulated private sector鈥� of therapists who were contributing to an 鈥榦verdiagnosis鈥� of mental health conditions.¹ He was also concerned about the ease of anyone setting themselves up as a therapist. This latter point remains a truth in the UK where the profession is unregulated 鈥� but that鈥檚 for another day.

I felt some real irritation on hearing Kinnock鈥檚 comments, agreeing with 网爆门鈥檚 response that described them as 鈥榰nfounded and harmful鈥�. It felt unfair that an MP with status and access to a nationwide platform could be shown to be so publicly ill-informed. I indulged in some unfair generalisations and stereotyping of politicians in the immediate aftermath, before I checked in with myself and reined them in.聽

But then I followed my initial reaction with some reflection and wondered whether there was a greater confusion all round. Maybe our clients are confused 鈥� do they think we can diagnose them? Do any of us, as counsellors, think we can? Do we ever fall into the trap of confusing our regular exposure to therapy situations with clinical expertise and authority to diagnose? Perhaps in our heads it sounds something like: 鈥業鈥檝e seen this presentation so many times before, and I鈥檓 sure I know what it is.鈥� If so, in our heads is where it should stay.聽

Who can diagnose?聽

Typically those who can formally diagnose have a medical background and specific training. GPs are able to make determinations on common mental health conditions, such as depression and anxiety, and psychiatrists, who are doctors with specialist training, are most likely to diagnose less common or more complex presentations. Clinical psychologists, counselling psychologists and some members of community mental health teams can also make diagnoses, sometimes under the guidance of a psychiatrist. 聽

Counsellors and therapists should only diagnose if they have the specific experience, training and qualification to do so. This is made very clear to those on professional training courses. I teach on an integrative counselling diploma course, and my training curriculum includes time developing an understanding of the Diagnostic and Statistical Manual of Mental Disorders, now in its fifth revised edition (DSM-5-TR). The focus of this learning is on developing a sense of history and context to diagnosis. In particular, the understanding of how diagnostic labels change over time, as well as how they impact various groups in society, can assist students in a deeper understanding of prejudice, discrimination and social control. For example, the changing nature of diagnoses that impact women, from hysteria and frigidity in the 19th century to vaginismus and borderline personality disorder in the 21st,² or the overrepresentation of black people with schizophrenia and psychosis diagnoses.^3听

Counsellors and therapists are taught to understand the manual鈥檚 place within the broad mental health sector, enquire about any diagnosis when meeting clients, and to be interested in how the client experiences their diagnosis. In other words, to stay client-focused, open and curious.聽

But in practice counsellors meet a lot of people. We get to know clients with certain diagnoses and have regular exposure to them: we therefore pick up cues and information and learn 鈥榦n the job鈥�. Even when we are clear about our role, including where it starts and ends, we still need to exercise caution lest we allow 鈥榗asual diagnosis鈥� to seep in and pervade our work.聽

Social media

The internet has provided the opportunity for increased access to information of all kinds, including detailed articles about mental health. Anyone can find the symptoms of narcissistic personality disorder, complex PTSD, unstable personality disorder, bipolar disorder etc. In addition, the less technical language of TikTok, X, Instagram and Facebook makes mental health conditions accessible to a vast audience, along with definitions, prognosis and 鈥榯reatment鈥� options. The world of diagnosis is everywhere 鈥� no longer the preserve of psychiatrists 鈥� the lexicon has changed, and everyone is seemingly an authority or has a view. Tests and assessments abound; selfdiagnosis is a thing.^4听

Mental health labels are more widely used, and there is far less stigma around using them. Certainly, those in positions of power, such as celebrities, influencers and members of the royal family, freely speak out now about mental health and their lived experiences of it. We read their posts about their depression and books on their anxiety, and see their TV documentaries about bipolar disorder. Our own clients are seeing all of this, and so are we as therapists.聽

搁颈蝉办蝉听

When clients come to us they can present with direct questions about their mental health conditions, primed by social media, with the expectation that we ought to know about and are authorised to comment on them. We might be tempted to, but the Ethical Framework is clear about the need to 鈥榳ork within our competence鈥�.^5听

Despite this we need to be careful about our language. We might not be immune to the risk of getting pulled into using the widespread language of social media with our clients that is misleading, misperceived or clumsy, such as casual terminology and ill-thought-out phrases. We need to avoid any communications that inadvertently stray into diagnostic territory.聽

I have seen examples of both deliberate and inadvertent diagnosis emerge as themes in complaints people make to 网爆门 about their counsellor or therapist. And I have heard or read how these can negatively聽impact clients in the short and long term, such as the casually expressed words from a counsellor that come scarily alive for clients at 3am: 鈥楬ave I got a personality disorder, just like my dad?鈥�, 鈥楧oes having bipolar mean I鈥檓 going to die early?鈥�, 鈥業f I have complex PTSD, will I ever be OK again?鈥�

Some of our clients are highly vulnerable, looking to us for answers and, at times, for safe things to hang on to. Words help them make sense of themselves and their lives. Sometimes a confirmation from us can provide something solid to attach to 鈥� a diagnosis is real and tangible, a 鈥榯hing鈥� that can feel safer to clients in the short term. But as we know, their sense of self doesn鈥檛 come from a couple of words from us said in haste but from the multilayered, nuanced, complex meaning they make of themselves, sorting through their experiences and what other people have said of them to reach a new and unique meaning of self. That is our business.聽

Keeping safe聽

First, it is important that we maintain a knowledge of diagnoses and take proactive steps to keep up to date with changes in definitions, symptoms and treatments. It is relevant, for example, that we know borderline personality disorder is now also known as 鈥榚motionally unstable personality disorder鈥� and that the idea of there being no effective treatment for personality disorder is outdated. This knowledge of contemporary mental health is important so we have a context for when clients tell us they have a particular diagnosis. We need to know what a diagnosis covers and some of the controversies with certain terms, but essentially our focus is on how it impacts the client. Is a particular label helpful, or does it feel limiting, damaging or constricting? Do they embrace or reject this?聽

We may suggest to a client that if they are worried or interested they might actively seek a diagnosis, starting with a conversation with their GP. We might explore with them how it would feel if they received a diagnosis or if they didn鈥檛 鈥� and this exploration, this open curiosity, of course, is at the heart of counselling. We may even need to take safeguarding action if the mental health of a client concerns us.聽

But we do need to be thoughtful and careful with our language, clear and specific, removing any shorthand or clumsy expressions so that we don鈥檛 inadvertently mislead or confuse clients. 聽

It is also worth us taking some time to acknowledge and reflect on alternative perspectives to medical diagnosis. There are challenges to the whole 鈥榖elief system鈥� of mental health diagnosis and the system of psychiatry 鈥� for example, the 鈥楧rop the Disorder鈥� movement.⁶ This may throw up further the issue of what we as counsellors are making a choice to believe in, promote and reinforce in our work. It鈥檚 important that we are explicit with clients about our beliefs if they are salient to the therapeutic contract.聽

It starts, as good practice often does, with contracting. Through my practice, teaching and involvement in 网爆门 competence frameworks, I have learned that clear and specific contracting is the bedrock of our work. Fundamentally, contracting frames the work with 鈥楬ere is what is possible, here is what I can offer, and here are some things that are not part of my role鈥�. Getting this part right in a meaningful and dynamic way protects both client and counsellor from shock or confusion further down the line.聽