COUNSELLING IS A DIAGNOSIS FREE ZONE

water colour by Simone Bell

N A V I G A T I N G T H E M A Z E

December 21, 2025

Exploring the theory and practice of therapy through a dialogue with the book The Gift of Therapy by Dr. Irvin Yalom:

CHAPTER TWO: AVOID DIAGNOSIS

The title is clear. It's a very short chapter in The Gift of Therapy, with a nod to the managed care climate in the US when Yalom writes in the chapter's subtitle: except for insurance companies. Yalom is referring to the fact that mental health coverage in the US is provided by private insurance companies that requires that "... therapists arrive quickly at a precise diagnosis and then proceed on a course of brief, focused therapy that matches that particular diagnosis."

Yalom does concede that in some cases the medical model is appropriate for mental health care, but in the majority of cases he insists it is not. He wisely explains that making a quick diagnosis and proceeding with treatment precisely and briefly has little to do with reality. "It represents instead the illusory attempt to legislate scientific precision into being when it is neither possible nor desirable. ... A diagnosis limits vision, it diminishes ability to relate to the other as a person. Once we have made a diagnosis, we tend to selectively inattend to aspects of the patient that do not fit into that particular diagnosis, and correspondingly overattend to subtle features that appear to confirm an initial diagnosis."

I have no trouble accepting what he writes, but since I live and work in Canada and for the most part I'm writing for Canadians, I completely understand if you find yourself asking, wtf's all that got to do with me? Fair enough, so let's take a minute to circle back to the issue of mental health diagnosis in the context of the Canadian health care system.

In spite of all the challenges it faces we have our universal health care system, but for the most part it doesn't cover the professional services of a clinical counsellor. Many people have recourse to Family and Employee Assistance Plans (EFAPs) or benefit insurance plans, both provided by employers and most do cover counselling services.

Psychiatrists are obvious among medical doctors trained and authorized to diagnose mental health conditions, but they are not the only physicians who can.

The list includes, family physicians, paediatricians, emergency medicine specialists and neurologists. All of these MDs can prescribe medications. 

Two professions that are not medical doctors  are trained and authorized to diagnose mental health conditions. (1) clinical psychologists, and (2) nurse practitioners. Nurse practitioners can prescribe medications, but clinical psychologists cannot. 

On top of all that, I discovered something in my fact-checking that, as a clinical counsellor, I find interesting:

In Canada, family doctors make the most mental health diagnoses and counselling is the most common form of mental health care. Registered clinical counsellors like me are not trained or licensed to diagnose mental health disorders. And that is fine with me. As I stated above, most people seek out a counsellor for reasons that do not, and should not, require a diagnosis.

I know it gets complicated, but let me put it this way: while I am intensely grateful there are physicians well-trained to diagnose physical issues using objective methods of symptom evaluation, using those same methods are inadequate to grasp and appreciate the mystery of what it means to be human. (And the mystery extends beyond our thinking, rational mind, but that's a topic for another column.)

Here I call on Dr. Yalom to back me up: "In the therapeutic enterprise we must tread a fine line between some, but not too much objectivity ... (because too much) ... may threaten the human, the spontaneous, the creative and uncertain nature of the therapeutic venture."

I may be overly dramatic when I call on the words of a poet to offer a perspective here, but it's important to remember that the counsellor is trained above all to encourage a relationship of safety and vulnerability in the therapy sessions.

And for the client, being vulnerable may be a dangerous place to find themselves. So above all, the counsellor's interventions must be undertaken with care. The Irish poet W.B.Yeats puts the delicate dance of human relationships this way:

But I, being poor, have only my dreams;

I have spread my dreams under your feet;

Tread softly because you tread on my dreams.

I know it's a love poem, but as I've been working my way through this piece the words and images of the poem have been gently nudging at my mind. Initially, a person may enter a counsellor's office in problem-solving mode, seeking answers to fix their relationships, anxiety, depression, problem-drinking or a myriad of other challenges. Sometimes a good solution-focused counsellor can help with that, but perhaps more often a deeper examination of one's life and relationships is required. That's when things get complicated and diagnoses aren't much help.

Of course all this doesn't mean to say that a person shouldn't seek out a counsellor to help dealing with a diagnosis they may have received from one of the professions I mentioned above.

And I hope I've made it clear that sometimes a clinical, objective approach to the therapeutic relationship is appropriate. But more often than not counsellors need to be convinced that the people who have put their trust in them are more complicated and mysterious than any diagnosis.