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 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 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 knowing 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 in New York State: 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 master’s, 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.


I believe that one of the mistakes that those in the various and affiliated helping professions can find themselves making is falling into is the trap of giving advice (speaking of, this post isn’t advice to anyone: it’s just my beliefs. Take it, leave it, modify it…the choice is entirely yours).

I am of the very strong belief that the only ones who should ever be giving out advice professionally are consultants which is a very different role (and one I’ve often held as a business consultant) than the roles held in the helping professions.

Consulting is a very different practice than working in the helping professions. In consulting I am being paid to provide professional advice based upon very specialized knowledge I have, within the scope of my education, training, and experience. In the helping professions, we are paid to help our clients elicit the answers that exist within themselves, and to be a guiding light, and a reflection board for them, so that they can make their own decisions.

The Problems With Giving Advice

There are two main problems I see with giving advice (and you can read this in a plethora of text books, conference proceedings, and on more blogs than this one. This idea is not unique and it’s certainly not originally mine):

  1. The worker becomes responsible for the advice.
    This means that if the advice fails the client, the worker is responsible. This also means that If the advice helps the client, the client doesn’t get to claim victory over their work.
  2. The advice is coming from the helper and the helper’s perspective.
    We are not experts on our clients or our client’s lives. The client is the expert on themselves, not us. This means that we, as the helper, are saying what we think is best for the client, rather than listening to the client and helping them verbalize what they think is best for themselves.

Advice giving isn’t the only, or main problem though.

I have worked with a number of various helping professionals who will agree with what I wrote above in its entirety…and yet, when it comes time to write a client’s goals and service plan, will then let their pen fly across the paper: using their words, their thoughts, their beliefs of what their client’s goals are, instead of the client’s words, the client’s thoughts, the client’s beliefs, the client’s goals.

The exact same problems exist here/with this as they do in the section above.

When I studied Motivational Interviewing is when I learned what – for me – is the ideal in goal setting, and it looks a little like this: Instead of making goal suggestions, or asking a client “what are your goals?” I ask a client a scaling question:

“On a scale from 1-10, with 1 being the farthest away from being where you want to be, and 10 being you’re exactly where you want to be, and everything in life is near perfect, and unicorns are dancing around you as we speak, where are you right now?”

Then the client will respond, and say they say something like:

“Well, right now I’m at a 4.5”

And then I might say:

“Wow, a 4.5! Okay, how do you know you’re at a 4.5, and not a 4?”

And I will then, in the words of one of my many incredible teachers and mentors, Mr. Sobota: “shut up and stare at them.” while I reflectively listen.

When the client is done, I will generally use an affirmation, or a reflective statement based on what they said. And then I’ll say:

“So, on that same scale, if you were to take the leap from 4.5 to 5, what would be different? What would being at a 5 look like?”

I then shut up and stare at them again. When they’re finished, I then go:

“So what would you need to do, to get from a 4.5 to a 5?”

And here’s where it gets totally critical: you shut up and stare at them again. As soon as they start telling you what it will take for them to get from a 4.5 to a 5 you start writing as fast as you can, because what they’re telling you is their entire goal list and service plan…literally, they’re telling you everything they need to do to get to the next step closer to where they want to be, so take good and detailed notes. 

After this, at least for this session, it’s generally smooth sailing: you should have a lot of:

“So what I hear you saying is…[read back what you wrote down as reflective statements/affirmations]…so if I understood you correctly, you would like to work on [goal] and you believe that you can accomplish this goal by [action]…”

You can then take all of those (now confirmed/adjusted and then re-confirmed) notes, and transpose them to whatever agency goal/service plan forms you’re forced to work with.

Guess what’s missing from here? Any of my interests, any of my biases…any of me determining what I think my client wants…and since it all came from my client they are the one who bears responsibility if their plan doesn’t work (and then you can help the tweak their plan, if that’s the case, or work through roadblocks int he exact same way)…but they client is also the one who gets to claim victory when their plan DOES work! THEY did it! CHEERLEAD THE HECK OUT OF THEM!

What if my client is making the wrong choices? Selecting the wrong goals? What if what they’re choosing will get them sent back to jail or won’t help them reach recovery?

Generally speaking, it doesn’t matter a lick if you agree with your client’s goals or not. There are, of course, exceptions: if those goals are robbing a bank, or injuring themselves or someone else, or anything similar to any of these situations…then what you think becomes very important and safety is paramount (codes of ethics, and laws almost everywhere support this).

That said, even in a drug treatment program the client may not have a goal of entering into recovery…and that’s okay: the consequences are theirs, not yours. A client who may need to see a job coach as part of their probation may not want to engage in services. That’s okay too: you’re not the parole officer. You’re merely presenting the client with an opportunity to engage in work or not and informing them of what the consequences might be if they engage, or if they choose not to engage. What they choose to do with that opportunity (and the consequences: positive, negative, or neutral) are their’s to bear alone.

What our job is, as workers, as helpers, is to help our clients enumerate what their goals are, to help them elicit from within themselves the way in which they  believe they will best be able to reach those goals, and if the client’s goals aren’t safe, or may have devastating consequences it is our job to help them understand what those potential consequences might be, to work with them to ensure that they (and others are safe), and to help them see alternatives.

However, at the end of the day, our clients must be the ones to develop their goals, to develop their own service and care plans, and to make their own choices. Sometimes those choices are incredible and beautiful to behold. Sometimes those choices will land them back in jail, which can be terribly painful to watch…but that’s okay too: they have every right to make that choice, especially if they’ve worked with you to examine all of their potential options, and all of the potential consequences that can be foreseen, based upon their goals and interests.