A portion of this article is featured in the spring issue of BCACC’s Insights magazine. You’ll find more information about Insights magazine, including full issues you can read online, as well as guidelines for contributors, here.
Social media and Google have dramatically changed the way people get information about mental health. Terms like depression, anxiety, bipolar, narcissism, and ADHD are used freely by people in all kinds of circumstances about themselves and others. Countless people who are formally diagnosed or self-diagnosed can be found on social media discussing experiences, challenges, and coping methods.
On the plus side, mental health stigma has changed and more open conversations are happening. But what about people who Google symptoms, assign themselves a label, and sometimes their own treatment plan? Or those who come to sessions and mistrust professional support because it doesn’t match what they saw on TikTok?
We talked to six RCCs with different areas of specialty to get their perspectives and tips on how they approach therapy with so-called “expert clients.”
Colleen Vantol, RCC-ACS
Colleen Vantol, RCC-ACS, has been in the counselling profession since 2005 and says the number of expert clients has grown exponentially.
“Gone are the days of milling in the library or book store in the self-help section,” she says. “Today, we can use the internet for access to YouTube segments, Ted Talks, podcasts, audiobooks, documentaries, self-assessments, to name a few, and all at the touch of a finger. What once was restricted to location and opportunity is now continuously available in the palm of our hand.”
Hence, the birth of the expert client. Of course, as Vantol points out, Google is a tool proven to be a rich source of both information and misinformation, leaving the user to decide validity. Googling symptoms can turn underlying anxiety into “medical student syndrome” — when we are influenced by the information to the extent that we believe we exhibit the symptoms.
Confirmation bias is Vantol’s biggest concern with expert clients.
“Most people have a sense of what’s going on for them, and at times, clients will self-diagnose, and at other times, they will diagnose those around them,” she says. “Confirmation bias allows us to gravitate to the information available to us that is congruent with our underlying hypothesis, beliefs, and values.”
The most common self-diagnosis Vantol sees lately is narcissist personality disorder (NPD) — as much as 20 per cent of her caseload. But here’s the twist: only one client was worried they were a narcissist, a concern prompted by their 12-year-old child. All the rest felt their partner, parent, or child was manifesting narcissistic attributes.
When any client comes in with a congruence between diagnostic attributes and self-assessment, Vantol starts by asking the client what their understanding is of their self-assessment and to give examples of behaviours they believe are consistent with that understanding.
“Often, the client has limited or inaccurate knowledge,” she says. “At times, the ‘example’ is not reflective of a diagnosis but rather reflects conflict styles or communication patterns or is supplied from a limited world view.”
Noting that it is beyond a counsellor’s scope to make diagnostic inferences, after some dialogue about how they experience their self-assessment, she invites the client to connect with professionals who are qualified to diagnose and she reiterates her role as treating symptoms.
“From here, we head back into presenting symptoms, which I am qualified to treat,” says Vantol.
By focusing effectively on symptomology, the client transitions from self-diagnosis towards identifying needs, concerns, and therapeutic goals. Vantol typically starts with narrative therapy to move through preconceived notions and provide deeper context for their inferences and lived experiences.
“The goal is always to support personal revelation, deepen the connection to self, and support positive outcomes by way of supplying therapeutic tools,” she says, noting that challenging a client’s belief requires a level of established respect and rapport, otherwise there is risk of therapeutic rupture. “Although many roads lead to Rome, each person’s path may be different, and it’s up to the therapist to supply the guidance.”
Vantol acknowledges that some RCCs may find expert clients challenging. She encourages her supervisees to reflect on areas where they lack confidence in their clinical skills. Because knowledge is the basis for expert clients, a counsellor must feel competent and confident in identifying incongruencies between understanding and experience.
“Having this awareness negates unnecessary stress or tension within the counselling sessions as clients will provide an enriching opportunity for skill development and identifying areas of clinical weakness,” says Vantol. “Being openminded and adaptive and continuously seeking sound knowledge to support clients is a necessary faction of having strong clinical skills, but it is not sufficient without insight into how to navigate misinformation in a supportive and non-judgmental way.”
David Denis, RCC
David Denis, RCC, has been in clinical practice in B.C. since 2009 and is also a member of the College of Registered Psychotherapists of Ontario. Previously, he practiced as a licensed Naturopathic Doctor (ND) in Ontario with a focus on mental health. In both his practice as a counsellor, which focuses on mood and anxiety disorders, functional disorders, performance psychology, and general stress, as well as in his practice as an ND, he often has clients who self-diagnose.
“Working as an ND, I would often see clients who had mental health problems that were presenting somatically in part and clients who had gone through the traditional medical system receiving no answers or, even worse, being told it was ‘all in their head,’” says Denis, listing fibromyalgia, irritable bowel syndrome, chronic fatigue, and Lyme disease as examples. “Sometimes, people wouldn’t have a diagnosis in mind, but they knew something was wrong and no one could tell them what it was.”
That early experience helped Denis hone an approach that both validated client experience but also helped them understand their experience more holistically and accurately. Now, as a counsellor, he sees similar dynamics at play. Many of his clients have post-concussion symptoms and functional disorders, diagnoses that come from the neurologists he works with. But not all clients have their conditions validated in the medical system.
“We help people to understand that what they’re dealing with is real, but that there’s probably an emotional component to it as well,” he says.
He starts by understanding the client’s experience as best as he can, an essential and standard skill for any counsellor.
“Because of my training as an ND, I get really focused on the full holistic experience,” he says.
If it is a headache, for example, Denis wants all the details of exactly how the headache feels, how it starts, and all the factors that go into it, as if the headache were being treated.
“I find it’s important for me to understand what they’re experiencing in order to be able to help them,” he says.
Doing this also helps the clients, who want to be understood.
“If I’m going to talk to them about the role stress plays, they need to feel like I actually understand their experience to be able to stay open to a new way of thinking about what’s happening to them,” says Denis.
Denis adds that every mental health diagnosis has a physical aspect.
“Anxiety is incredibly physical. Most people feel butterflies in their stomach or a lot of pressure and tension in their chest, changes in their heart rate, body temperature,” says Denis. “Depression and mood problems, similarly, are very physical, and it can feel very hard to even move at times if it’s severe.”
But while society is generally very accepting of the physical symptoms of depression and anxiety, there’s often a mind-body divide with symptoms like headaches or chronic pain and people are less likely to consider an emotional component. Stress, trauma, and repressed anger may all result in physical symptoms but people can be afraid to look at these emotions.
“They may have learned from past experience that it’s not okay to be angry, that it’s not okay to have certain emotions,” says Denis. “Those emotions can become dangerous and cause major problems. Then they become really shut down and repressed, and that’s often what I feel is happening with clients who present predominantly with physical complaints and are hesitant or maybe defensive.”
When the client feels fully understood, trust and rapport are established, and the client is more open to other ways to think about their experience, including what Denis considers psychoeducation. He often speaks to clients directly about a diagnosis and its potential validity — even reading to them from the DSM — about the emotional factors that might be at play. For example, with something like chronic pain.
“People might tiptoe around [chronic pain] and not want to be challenging, afraid of invalidating the client’s experience or having the client feel like they’re being told it’s all in their head,” says Denis. “But ultimately, if there is something happening that’s emotional and that’s driving the loop causing this pain, then it’s important to actually talk about it as such,” he says. “In fact, it’s a hopeful message because there’s a lot we can do to help manage emotions differently and more directly, and if that improves the headaches, then fantastic. This gives us a pathway and a way of working that maybe they’ve never tried before.”
If there is a rigid attachment to a diagnosis, Denis says it is really important to reflect on what that diagnosis does for them and why they are attached to it: “It’s happening for a reason and it’s really important to understand that.”
Oralie Loong, RCC
In a recent blog post, Oralie Loong, an RCC who specializes in Autism and AuDHD, wrote: “Autism is not considered an illness or a problem, and as such, it does not need to be ‘diagnosed.’ Instead, the process of figuring out if a person is Autistic is really a process of identification.”1
In her interview for this article, Loong further explains that when we consider Autism and other types of neurodivergence from the lens of the social disability model, they are not “disorders” because it is not the neurodivergence itself that necessarily causes disability, but rather society that causes disability.
“What this means is that most of the distress that comes from being Autistic can be prevented when societal barriers are removed through accommodations and supports,” she says.
Another important distinction from typically diagnosed conditions: “With Autism, we focus not on changing Autistic ways of being, but rather on making it more possible for an Autistic person to be Autistic.”
However, someone might wonder if they are neurodivergent in some way and come to therapy with questions.
“I think of this category of people as neuro-questioning,” says Loong. “They are at the beginning of their journey to figure themselves out, and in the end, they may or may not determine that they are Autistic.”
Loong would meet this with curiosity and start exploring which Autistic traits they feel most fit their experiences.
“If they have support needs, I encourage them to start addressing those needs with or without an explanation as to why those needs exist,” she says. “I would suggest they take several online Autism screening questionnaires and read Unmasking Autism by Dr. Devon Price. My Adult Autism Screening is also a great option for neuro-questioning adults, as it walks them through whether they may meet the diagnostic criteria for Autism.”
If other RCCs have clients self-diagnosing as Autistic or are wondering if they have traits, she recommends they also respond with curiosity rather than judgment.
“Most people have a lot of incorrect ideas about what Autism is, given that depictions in the media are so limited in their version of Autism represented,” says Loong. “Unless the RCC has additional training in the vast ways that Autism can present, there should be no judgment towards a self-diagnosed client. If you can’t provide that to a client, please refer them to a counsellor who can, or seek consultation so that you can provide an affirming approach to their self-diagnosis.”
Loong says that if a parent or caregiver brings this up in therapy about a child, she suggests they get onto assessment waitlists, which can be very long.
“British Columbia is unique in Canada in that every Autistic child up to age 19 gets access to government funding for service providers, including RCCs, and equipment,” she says. “While formal diagnosis isn’t always necessary for adults, for kids and teens, it is important so they can access funding and supports.”
Loong says it’s important to consider the end goal when looking at which approach to take with different neurodivergent identities.
“The end goal typically is to figure out and access the supports and accommodations that will allow the neurodivergent person to live a fulfilling and meaningful life, which of course looks different for every person,” she says. “This goal sometimes is reachable without formal diagnosis, but sometimes a formal diagnosis is required.”
For example, with ADHD, a formal diagnosis may be important if the individual wants to try ADHD medication or for kids and teens to access school-based supports.
“Under the Neurodiversity Paradigm, we consider all types of neurodivergence to be valid and have worth, but sometimes the society we live in dictates that a formal diagnosis is necessary,” says Loong.
1 Loong, Oralie (Jan 4, 2024). Empowering self-diagnosed Autistics to be the architects of their own identities. https://neurodivergentcounselling.ca/empowering-self-diagnosed-autistics-to-be-the-architects-of-their-own-identities/
Jack Cehak
Jack Cehak, RCC, has been in practice since 1978 and has witnessed many changes to the profession over the years, including an increase in self-diagnosis and psychiatry in general. To illustrate, he compares the DSM-2, which came out in 1968 with 185 diagnoses in 32 pages, with the DSM-5-TR, which was published in 2022.
“The DSM-5-TR has 947 diagnoses and 1,120 pages,” he says. “The psychiatric nomenclature has introduced itself into normal English along the way, and since social media, that’s just exacerbated.”
When a client comes in with what they believe is a diagnosis, Cehak uses the narrative therapy approach developed by Michael White, David Epstein, and Stephen Madigan, his preferred therapy since 1996.
“I think of any diagnosis as a closed suitcase,” he says. “Basically, you don’t know anything about this person other than he comes in with a label. The label has no meaning until you open it up and see what’s inside.”
The most common self-diagnoses Cehak sees in his office are depression and anxiety, and that’s where he starts: “Tell me about depression / anxiety: when does it come into your life?” He explains that asking this relational question begins to recontextualize the diagnosis.
“Rather than it being something that’s inside the person — by definition a diagnosis is something inside a person — I am now recontextualizing it into the person’s life, and in the process of doing that, the person and I get to understand how he becomes vulnerable to depression,” says Cehak.
Though simplified for the purposes of the article, the discussion with the client then focuses on the situations or circumstances that led to that vulnerability and the client’s degree of participation in that process and how they have managed in the past.
“Working in that deconstructive process, depression becomes less of an issue of discussion and more on the sideline, and now we are solving the problem that led to the depression,” he says. “Depression here is a symptom rather than the problem.”
From there, they can carry on to examining other items in the “suitcase,” progressing step by step through circumstances that do or don’t cause the client to feel vulnerable to the feelings they have led them to label themselves as having anxiety or depression. The important part is that the client sees that they have handled certain circumstances in the past and that their problems are solvable.
“The thing around anxiety and depression is that people have been so educated into the idea that this is something in themselves — that this is an imbalance in the brain,” says Cehak.
Cehak distinguishes the questions he asks using narrative therapy from the medical model.
“In the medical model, asking such questions is for the purpose of gathering information to establish a foundation for a diagnosis, the development of the diagnosis, family history of a diagnosis etc.,” says Cehak. “In narrative therapy, [the questions] have the purpose of recontextualizing a decontextualized situation, in this case, something called a depression — the suitcase — therefore, finding the problem or problems that created the symptom called a depression or not finding such problems and concluding this is an endogenous depression or both.”
Alexandria Butterfield
Alexandria Butterfield, RCC, works primarily with eating disorders, now in private practice but previously with public health. While she notes that this may not be true across the board, in her practice, the majority of eating disorder cases she sees are self-diagnosed, largely thanks to social media bringing awareness and validation to disordered eating.
“When people come in with a self-diagnosis of an eating disorder, oftentimes from information online, it may be the first time they’ve been able to put language towards it,” she says, adding that clients may have a lot of shame around it, and coming to therapy may be the first time they’re seeking treatment as a way to change that.
The only times Butterfield goes against a diagnosis is if there has been a misdiagnosis by a doctor, which can happen if the client hasn’t reported all their symptoms or if there is less education around eating disorders in general.
“Perhaps they’re not saying that they’re purging or they may not be falling into a low-weight criteria that’s typical of anorexia, but if you look at their blood work, if you look at their eating behaviours and how much it consumes their thoughts, rigidity, perfectionism, it really does more likely fall into an anorexia diagnosis.”
And this is also where social media has been beneficial because it has revealed eating disorder populations that don’t meet stereotypes. For example, “avoidant food intake restrictive disorder” or AFIRD is an eating disorder Butterfield works with.
“AFIRD is very common with individuals with Autism, but not always, and it has nothing to do with body image and everything to do with sensitivity, spices, crunch-like texture,” she says.
People with AFRID often think of themselves and get called “picky eaters” and have horrific experiences in treatment and socially. With AFRID, the focus is more about operating in a world that can be very triggering in contrast to eating disorders where there is a focus on body image and emotions.
“If you look at the recent research and advocacy work in eating disorders, it is a lot more focused on believing people’s personal experiences and less focused on the diagnosis,” says Butterfield. “Usually people have self-identified it, and usually people have hit their own personal rock bottom before they go to counselling about it.”
In many cases, the presentation is that people feel that can keep it together in public at work, school, and with friends and family. The struggle happens behind the scenes, often for a very long time before help is sought. Whether counsellors should refer a self-diagnosed clients depends on whether the client is ready to work on their disordered eating — and also what else is going on.
“If you think they’ve there’s trauma or other things in their life, it may be helpful to go through that first before getting into disordered eating work, if you have a good relationship,” she says.
However, she does encourage counsellors towards more psychoeducation, especially around harm-reduction — encouraging clients to speak to their doctor or go to a walk-in clinic, monitoring blood work, monitoring suicidality, and more — because eating disorders can have permanent health consequences, including death.
“In terms of diving into the nitty gritty, because it is so sensitive, I would love if everyone was able to look towards me or others who specialize, but people have to be ready to make changes,” she says.
Caroline Wright, RCC
For many years, Caroline Wright, RCC, Wright worked in Alberta schools providing psychological assessments and therapy. She also worked in residential treatment centres for youth and their families. Now, her practice in B.C. is therapy only, specializing in anxiety and trauma.
When clients come in with a self-diagnosis, her approach is the same as it would be if they had a formal diagnosis from a qualified professional.
“Perhaps I’m stating the obvious, but I have found that clients who come to therapy with a formal diagnosis can also present as wary and distrustful,” says Wright. “My approach to this would be to avoid debating the validity of the diagnosis. The individual gets to have their opinion. Instead, I would first assert that I am not in a position to diagnose, but I am very interested in finding out how this diagnosis they have embraced helps or hinders them.”
For example, a client with a (self)diagnosis of depression may come in with the hope that therapy will help them be happier. Wright would use narrative therapy to externalize the problem, discover the nature of it, and get a rich description of it.
“Then I would map the effects that depression has had on their life, move onto discovering ways the individual has stood up to these effects and then explore possibilities for doing so in the future,” she says.
Questions she might ask: How has depression impacted your moods and your emotional well-being? How has depression influenced your important relationships? How does depression show up in your body? How has depression affected what you do in your day-to-day life?
While Wright would generally not get into a discussion about the validity of the diagnosis, if the diagnosis is important to the client, Wright would tie it into what the client wants in therapy.
Questions she might ask: What is it about the diagnosis of depression that makes sense to you? How is the diagnosis helpful to you for understanding what you want to change or work on? Does the diagnosis offer any possible directions for therapy or change to you? Do you have any worries or concerns about this diagnosis? If so, are you interested in addressing these first?
In the appendix of her book Scaffolding to the Heart: Safety-Enhancing Ideas for Narrative Trauma Work (Caroline Wright, 2023), Wright has collected a list of general worries that individuals have brought to therapy, as well as their counter statements, to address nervousness and anxiety about therapy. Examples include a tremendous sense of immediacy (“I have to fix everything right away today or soon after today.”) and fear of failure and setbacks, to name just two.
“For those clients who are experiencing worry or wariness about the therapy process, sharing this list and asking if any of the worries are relevant to them, and then discussing the pertinent ones, can help build trust and comfort.”
