Boundaries, Scope, Diagnosis & Diagnosis Dilution

“No doctor should assume responsibility for the health of one he loves or one he hates” – Dr. Michaels, And Be a Villain, A Nero Wolfe Mystery by Rex Stout

These words were written by one of my favorite authors in 1974, as Dr. Michaels was being interviewed by Nero Wolfe and his sidekick, Archie Goodwin, as they worked to take down the nefarious Arnold Zek.

Boundaries
Boundaries are not only important, they are critical. They not only protect our clients, but they also protect us as workers. Dr. Michaels, in the Nero Wolfe Mystery And Be a Villain by Rex Stout makes an incredibly important point: boundaries are not just about the use of self in our individual practices, they’re also about whom we accept to take on as clients, and whom we recuse ourselves from working with.

While I have found that certain positions such as Community Health Workers (CHWs) and Patient Health Navigators (PHNs) can have a little leeway, since these positions are non-therapeutic in nature, and are about connecting clients to resources and brokering information between providers, I still think the best practice is that they don’t work with those with whom they have a personal relationship.

Some in the CHW community disagree, given their role as communal workers. I think this is also fair, and I again point to the work that they’re doing as non-therapeutic in nature, and therefore subject to some amount of leeway: they’re working as brokers and educators within their own communities. They know their communities (and themselves) best. So far it seems to be working quite well, in many different communities, around the world.

Then there are those positions such as Social Workers, Psychologists, Life Coaches, Psychiatrists, and all the branches of Medicine where there really is no leeway: we don’t take on family, friends, loved ones, or enemies as clients. Period.

We also don’t take on those cases where we’ve heard too much. For instance, if a case has been brought up over and over and over and over again in case conference, it’s better to refer the case to a clinician outside of the organization or agency: no matter how well trained the clinicians at an agency are, no matter how trained they are to be impartial, the client – ethically – deserves a real fresh start when they’re being transferred because the clinician and client have agreed that it isn’t working out. It is unfair to provide the client with a “fresh start” while the person that they’re having their “fresh start” with has heard a large portion of the background story, and the problems that the worker and client were having together.

Boundaries also mean staying within our professional scope and training.

Scope
Scope of practice is important, ethically and legally.

Few pediatricians are trained to accurately diagnose Fetal Alcohol Syndrome (a specialist must be called). Clinical Social Workers do not all work with the same populations (some specialize in grief and loss, some are generalists, others specialize in childhood and adolescent issues, others in addictions, etc.). Life Coaches may have some knowledge of psychology, yet it is against the law (and also ethically improper) for them to provide psychotherapy, counseling, or interventions in any way that are clinical in nature. Psychologists do not have the same psychopharmacological training as Psychiatrists do, etc. Each and every one of us have a defined scope of practice that we must work within.

When we respect our own educational boundaries, when we recognize and proudly proclaim that in certain situations “I don’t know” it frees us to work within the scope of our own knowledge (and removes from us the pressure of being an all known expert). It allows us to safely make referrals to colleagues (of which there is the side benefit of building our professional network). It protects the best interests and safety of our clients, and it protects ourselves.

It is impossible to know everything, and there is a great deal of danger in assuming because one has a little bit of knowledge in many subjects, that one is professionally able to work in all of them.

Unfortunately, not everyone stays within their scope of practice (and this is a serious problem). Also problematic is when those who do not stay within their scope of practice and training attempt to diagnose, or provide off the cuff diagnosis.

Diagnosis & Diagnosis Dilution

Unless someone is fully qualified, they should not attempt to assign diagnoses and labels to others, and never to themselves (there are a plethora of reasons why it is improper to self-diagnose).

No matter how much one thinks they’ve read, one is neither qualified nor ready until they’ve taken the very heavily supervised coursework and completed a heavily supervised process.

Just so one can understand what it takes for a Social Worker to eventually be clinically qualified: we must take Graduate level Psychopathology, have two field placements over two years with 1:1 supervision for one hour, once a week (minimum), and 9 other graduate credits in evidence based clinical course work. Then there’s the initial licensing exam (which *still* doesn’t make one qualified).

After initial licensure you get hired and work under another clinician’s license. At this point, after all this coursework and a masters, the only expectation your supervisor generally has of you when you start is that you have a basic understanding of differential diagnosis. Then, with regular supervision, and after 3,000 hours of paid clinical work (where you hone your differential diagnosis and counseling skills daily, M-F, 9-5) you can sit for the clinical licensing part of the exam.

Assuming you pass, you then earn your clinical designation. But guess what? New York State views that as a learner’s permit because it will still be about another three years (with weekly supervision sessions) before you get your R privilege that lets you have a home practice/open up your own private office (that means they want to make sure you’re still working, supervised, under someone).

Differential diagnosis of mental health disorders is not easy. It is a time consuming, slow, laborious skill to learn because it’s more than the DSM: it is quite literally thousands of hours of working with clients attempting to draw out from them the necessary and nuanced information to make an accurate clinical diagnosis of which the DSM plays but one small roll.

If one wants the capability to diagnose and to be taken seriously, they need to do the time and coursework necessary to get it. This of course saying nothing of the inaccuracy of psychiatric diagnosis in general and its questionable use in therapy. That’s another (post-modern, sociological view of disability) discussion for later (hopefully sometime this month).

Related and also problematic is the situation of Diagnosis Dilution (usually occurring when individuals self-diagnose themselves): there are clinical standards to determine if one has depression, bi-polar, anxiety disorders, etc. By self-diagnosing oneself, and providing improper diagnosis to others, the general public begins to view these diagnosis in a casual manner, with less and less understanding that they’re very real mental health conditions, that can have a real and pervasive impact on someone’s life.

Build your boundaries (learn from mistakes), know your scope, and don’t diagnose unless you’re trained and licensed to do so.

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