A Critical Examination of Diagnostic Privilege and Systemic Pathology in Healthcare

Introduction:

The Unseen Truth of Diagnostic Privilege

The landscape of mental healthcare currently faces a profound challenge, exemplified by the ongoing dispute surrounding diagnostic privilege for Licensed Mental Health Counselors (LMHCs) in New York State. This specific issue, while seemingly confined to professional licensure, serves as a critical microcosm of deeper systemic pathologies embedded within the broader domains of mental healthcare, law, and governance. The concerns among LMHCs are escalating due to the New York State Department of Education (DOE) imposing new diagnostic educational criteria, despite the profession’s long-standing qualifications and established practice of diagnosing as a formal part of their education and state approved credentialing. This imposition is not merely an administrative adjustment; it represents an unnecessary burden on an already proficient and board approved and State recognized profession.  

At its core, this situation reveals a complex power and control dynamic that permeates the relationships between various psychological professions, the prevailing medical model, insurance entities, and legal authorities. This intricate web of influence creates a significant barrier to LMHCs’ ability to perform their diagnostic work, which is an essential clinical service for the public. The decision by NYS and the DOE to add diagnostic “privileges” to an established profession can be seen as a form of institutional gaslighting, casting considerable doubt on the system’s capacity to manage, let alone resolve, the profound moral and ethical debate it has inadvertently ignited. Furthermore, these new requirements threaten LMHCs’ income potential, restrict job access, and jeopardize their future viability as a profession, underscoring the severe practical consequences of these systemic maneuvers.  

The Wounded Healers Institute (WHI) offers a unique and critical perspective on these systemic issues, advocating for a transformative approach rooted in Moral-Ethics. Founded by Adam O’Brien, PhD, LMHC, CASAC, the WHI’s stance emerges from extensive lived experience with dissociative phenomena, active addiction, and trauma survivorship. This background informs their advocacy for trauma-informed, dissociation-informed, and addiction-informed care, which collectively form the foundation for recovery-informed and healing-informed care. This comprehensive approach inherently challenges the prevailing medical diagnostic standards and significantly questions the established scope of practice within psychology, medicine, and law. The central argument advanced by the WHI is that professional checks-and-balances have been created separate but not equal and co-opted by other professions greed, leading to the emergence of addictive and dissociative pathology within the professions themselves. The proposed solution, Moral-Ethics, directly addresses these unacknowledged and undiagnosed addictions and dissociations, seeking to restore balance and integrity to the healing professions.

This report aims to deconstruct the intricate intersections of law, ethics, and morality within professional practice. It will delve into the historical context that shaped current professional boundaries, expose the manifestations of systemic addictions, and meticulously examine 99 specific moral-ethical observations. The ultimate goal is to illuminate a path forward, emphasizing the critical distinction between education and training, ethics and morals, and the conscious and unconscious dimensions of the human mind. This differentiation is crucial for discerning who truly comprehends the complexities of healing and systemic well-being, and who remains bound by outdated or self-serving paradigms. The analysis presented here provides a robust framework, grounded in solid reasoning and relatable rationale, for challenging the field of psychology’s diagnostic privilege and the underlying moral assumptions it legally imposes on licensed professionals. The pervasive belief that those in authority will fiercely defend their power and control is not unfounded; historical patterns reveal that governmental, psychological, and medical models have previously misled the public, prioritizing corporate influence, professional lobbying, and governmental overreach above the citizenry’s protection. This historical pattern underscores the necessity of a critical examination of current practices.  

The Foundations of Disparity: Historical Context and Professional Gatekeeping

The current state of diagnostic privilege and professional contention within mental healthcare is deeply rooted in the historical evolution of its various disciplines. Understanding this trajectory, from early community support to the modern diagnostic imperatives, is crucial for comprehending the present “us versus them” dynamic. This historical analysis reveals how initial compromises and the self-serving interests of established professions inadvertently cultivated a system prone to gatekeeping and, paradoxically, to its own forms of systemic addiction.

The Evolution of Mental Health Professions: From Community Support to Diagnostic Imperatives

The counseling profession, particularly what evolved into Licensed Mental Health Counseling (LMHC), emerged in the early 1900s, coinciding with the Industrial Revolution. As people migrated to cities seeking work, a void in traditional rural community support became apparent. Counseling initially filled this need, providing career support and connections to essential services, primarily assisting individuals through difficult life transitions in metropolitan environments. This early form of counseling often addressed what are now diagnostically equivalent to V-Codes in the American Psychiatric Association’s (APA) Diagnostic Statistical Manual (DSM)—issues related to “stage of life” or specific normative experiences that were not directly diagnosable or billable. The absence of a direct billing mechanism for these crucial, yet non-pathological (V-codes), services presented a significant challenge for the nascent profession.  

In contrast, Social Work, an already established profession, traced its origins to the charity or philanthropic and Christian model during the Reconstruction Era, spanning from 1880 to 1915. This historical precedence meant that when LMHCs sought to codify as a distinct profession decades later, they faced the formidable challenge of justifying their existence alongside similar, entrenched disciplines like Social Work and Psychology. To secure its place and gain professional “clout,” LMHCs found it necessary to align with the prevailing system’s demands. This alignment led to the assumption of diagnostic ability, a seemingly reasonable expectation given the master’s level education required for LMHCs. However, this strategic compromise, driven by the need for professional recognition and financial viability, fundamentally altered the profession’s trajectory.  

A pivotal force in this transformation was the insurance industry. Insurance companies would not reimburse for services without a formal diagnosis, effectively compelling LMHCs to adopt diagnostic practices to survive as a profession. This external pressure underscores how the law, the medical model, and the existing psychological structure, including malpractice and health insurances, imposed a necessity on LMHCs and, by extension, on every other psychological and medical profession. The historical trajectory reveals that mental health support, initially a common-sense community service, became professionalized and subsequently commodified. The requirement for LMHCs to “placate to the systems needs instead of the clients and our own” by adopting diagnostics for billing purposes illustrates how financial incentives and bureaucratic structures distorted the original purpose of helping. This suggests that the “system”—comprising legal frameworks, the medical model, and insurance policies—prioritizes economic viability and control over the actual needs of the public, leading to a state where what was once considered “Abnormal Psychology has now become the norm”.  

The Paradox of “Privilege”: How Professional Boundaries Create Systemic Harm

The establishment of distinct professional boundaries, often through legislative means, has inadvertently created a paradox of privilege that contributes to systemic harm. Policymakers, in their attempt to differentiate professions and ensure distinct scopes of practice, deliberately avoided including the word “diagnosing” in the original LMHC charter. This legal choice point was ostensibly about making “practical sense” of what this new profession was doing differently from existing ones. However, this omission, whether intentional or not, laid the groundwork for future disputes and power imbalances.  

The inherent risk factor for therapists, who directly engage with the complexities of human suffering, is considerably higher than for “auxiliary professions” such as insurance companies or legal entities. These auxiliary professions often observe from a detached “watchtower,” dictating what they perceive as real, true, ethical, and moral, yet they are not the ones whose direct actions have lives on the line. This disconnect highlights a fundamental inequity: if one profession is held to a stringent moral standard, then, logically, all professions, especially those influencing public well-being, should be held to the same standards and be held accountable for their adherence.  

The deliberate omission of “diagnosing” in the LMHC charter was not a simple historical oversight but a strategic act of privilege from policymakers and legal minds. This act, driven by a need to differentiate professions for “practical sense” and billing, inadvertently created a system where accountability is unevenly distributed. Those “watching from their watchtower”—the auxiliary professions—dictate terms without bearing direct clinical risk, effectively using diagnostic privilege as a shield against their own moral and ethical responsibilities. This perpetuates a system where “very little moral justice comes out of the ethical legal processes, other than their job security,” thereby reinforcing a cycle of unaccountability. This dynamic underscores how the pursuit of professional differentiation, when untethered from a broader moral framework, can lead to significant societal detriment.  

The “Us vs. Them” Dynamic: LMHCs as a Case Study in Sibling Rivalry

The current contestation of LMHCs’ diagnostic ability by other psychological professions has resulted in new credentialing and licensing requirements for existing LMHCs, despite their long-standing practice of diagnosing. Is one profession psychology learning a different State approved curriculum in psychology? This situation has fostered a pronounced “us versus them” dynamic within the field, reflecting a deeper professional moral and ethical dilemma. This trend is characterized as “professional gatekeeping” and a manifestation of “cancel culture” within Western society. It stems from the privilege of those who, in their self-interest, appear to have forgotten the foundational principles of service and respect for those they are meant to serve.  

This “canceling” mentality, where established professions like Social Workers—who preceded LMHCs—seek to limit the diagnostic “privilege” of newer professions, casts doubt on the system’s capacity to manage ethical debates. While self-interested voting is a typical human behavior, it stands to reason that higher moral principles should guide such decisions. However, the evidence suggests otherwise, pointing to underlying professional “addiction and dissociative” tendencies as the reasons these principles are often ignored.  

The “us vs. them” dynamic is not merely a competitive struggle but a manifestation of a systemic “addiction or dependence issue that is unrecognized in the literature”. The “gatekeeping” by established professions like Social Workers points to a deep-seated need to maintain power and control, even at the expense of public service. This “addiction to power” prevents genuine collaboration and ethical behavior, as evidenced by the “double standards for those who tout morals as if they were the ethics and the law, but they do not follow them”. This dynamic actively prevents “real changes from happening in society”. It is a reflection of a system that, in its pursuit of self-preservation, perpetuates a cycle of professional rivalry that ultimately harms the very public it claims to protect.  

Table 1: Comparison of Minimum Clinical and Licensure Requirements in New York State

MINIMUM REQUIREMENTS	MENTAL HEALTH COUNSELOR WITH LIMITED PERMIT	LICENSED MASTER SOCIAL WORKER	LICENSED MENTAL HEALTH COUNSELOR	LICENSED CLINICAL SOCIAL WORKER
EDUCATION (completed)	Masters degree in Mental Health Counseling-60 credit hours in SED-approved program or equivalent	Masters degree in Social Work-60 credit hours in SED-approved program or equivalent	Masters degree in Mental Health Counseling-60 credit hours in SED-approved program or equivalent	Masters degree in Social Work-60 credit hours in SED-approved program or equiva
INTERNSHIP (completed)	Specific content areas must include assessment, psychopathology, group dynamics, counseling theory and skill practice, career development. 600 clock hours of supervised internship and clinical instruction -with mental health counseling as required focus.	No required clinical education or clinical skill practice. 900 clock hours of supervised internship in social work practice – clinical mental health focus is NOT required.	Majority of 60 credit hour program is required to be focused on clinical education and preparation. No additional clinical internship required beyond original Master’s degree.	Minimum of 12 hours of clinical coursework including assessment and diagnosis, social work treatment and practice. No additional clinical internship required beyond original masters degree.
LIMITED PERMIT EXPERIENCE (completed)	Required-work site must be approved by SED/OP prior to counting hours toward licensure. Permit granted only to persons who meet all but additional experience beyond masters degree and LMHC exam. Minimum of 600 clock hours during internship must have had mental health counseling as focus.	N/A	No longer needed permit is replaced by license after experience and exam. requirements are met. 3,000 clock hours (not including internship hours) over 2 years of supervised experience in a SED-approved setting. Supervision by LMHC, LCSW, licensed psychologist. psychiatrist, psychiatric nurse or physician’s assistant.	Not required. 2,000 client contact hours over 3-6 years of supervised. experience in SED-approved setting. Supervision by LCSW, licensed psychologist or psychiatrist.
EXAMINATION	Must pass comprehensive exam within masters degree program	Must pass LMSW exam – Assn. of Social Work Boards (ASWB)	Must pass LMHC exam-National Clinical Mental Health Counselor. Exam (NCMHCE)	Must pass LCSW exam Assn. of Social Work Boards (ASWB)
ADDITIONAL REQUIREMENT	Child Abuse Reporting Training	Child Abuse Reporting Training	Child Abuse Reporting Training	Child Abuse Reporting Training

Source: New York Mental Health Counselors Association (NYMHCA.ORG)

This table vividly illustrates the minimal differences in credentialing, licensing, training, and education requirements between LMHCs and Social Workers. The visual comparison of educational and experiential requirements immediately highlights the striking similarities, underscoring the argument that LMHCs already possess the necessary qualifications for diagnosis. This direct evidence supports the claim that the new requirements are arbitrary, serving primarily as a mechanism for gatekeeping rather than genuine professional development or public protection. The table further reveals the incongruence within the system, demonstrating how professions with highly similar training pathways can face disparate recognition and authority. This disparity reinforces the assertion that the system is not functioning optimally and is driven by factors beyond mere competence, perpetuating a “paradox of ‘Separate but Equal’ Professions”, particularly from a Department of Education.  

Unveiling Systemic Addictions and Dissociations: A Moral-Ethical Lens

The Wounded Healers Institute’s core theoretical framework posits that the pervasive systemic issues within mental health are not merely administrative oversights or professional rivalries but rather symptoms of undiagnosed collective pathologies. These pathologies, rooted in a flawed understanding of morality and ethics, are perpetuated by unrecognized addictions and dissociative tendencies at the systemic level.

Addiction as Trauma-Related Dissociation: Re-defining Pathology

A cornerstone of the Wounded Healers Institute’s framework is the assertion that addiction is inherently transdiagnostic and that the field of psychology has largely overlooked its profound connection to dissociative processes. Dr. O’Brien’s doctoral research fundamentally redefines addiction, presenting it not as a moral failing or a singular disease, but as a form of “dissociation, which is predicated on trauma and stress responses that are normal responses to all-too-common events”. This re-conceptualization shifts the understanding of addiction from an individual pathology to a natural, albeit often maladaptive, human response to overwhelming and underwhelming experiences.  The mainstay of the presentation is that of addiction memory and how PTSD, which is really dissociation, is what people are “addicted to”, and also dependent on or trauma bonded to.

This perspective critically challenges the widely held “chemical imbalance idea” as the primary cause of mental health conditions. Instead, it posits that psychiatric medications themselves can induce “traumatic, somatic, and addiction memory disturbances,” further complicating the picture of mental well-being. A crucial conceptual leap in this framework is the hypothesis that the “physical body as the psychological unconscious”. This proposition aims to level the playing field between the traditionally disparate fields of psychology and medicine, suggesting a unified understanding of human experience where physical symptoms are seen as manifestations of unresolved psychological material.  

If addiction is understood as dissociation stemming from unresolved trauma, and the system itself exhibits “addictive and dissociative pathology,” then the system is, in essence, diagnosing itself through its actions. The resistance to change, the pervasive denial, the tactical ignorance, the abusive maneuvers, and the gaslighting observed within professional and governmental bodies are not simply flaws; they are the very symptoms of the system’s own “unacknowledged and undiagnosed addictions and dissociation”. This implies that the system’s inability or unwillingness to produce a clear operational definition of addiction, despite its prevalence, is a form of self-preservation of its own pathology. By avoiding this fundamental truth, the system inadvertently prevents genuine healing and perpetuates the very conditions it purports to address, demonstrating a profound systemic self-deception.  

The System’s Blind Spots: Perfectionism, Altruism, and Ambition as Undiagnosed Addictions

The Wounded Healers Institute extends its critique by identifying certain socially lauded traits—perfectionism, altruism, and ambition—as undiagnosed addictions. These characteristics, often viewed as virtues, can become pathological when they serve to perpetuate harmful systemic dynamics. The observation is that these “positive addiction pathology” frequently manifest in bureaucratic environments, where leaders may prioritize their titles and positions over the genuine needs of those they serve. This pursuit of “more”—more diagnoses, more regulation, more security, more power, more documentation, and more data—is seen as the “primary disease of human beings,” equating to an insatiable drive for increased control.  

The identification of perfectionism, altruism, and ambition as undiagnosed addictions reveals a critical blind spot within the very professions that claim to heal. These traits, while often lauded in professional contexts, become pathological when they serve to perpetuate a system that thrives “off of someone else’s surviving or slave labor” and maintains the status quo. This suggests that the pursuit of “good”—such as helping others or maintaining order—can become an addictive process that blinds professionals and systems to their own moral failings. Ultimately, this leads to more harm than good by actively resisting necessary change and perpetuating the very problems they are meant to solve. The system’s inability to recognize these internal pathologies prevents it from evolving towards more effective and morally aligned practices.  

The “Moral Character Clause”: A Legal Tool for Ethical Control, Not Moral Integrity

A significant point of contention in the current professional landscape is the “Moral Character Clause” mandated by the NYS Office of Professions for licensure renewal. This clause, as presented in the official documentation, explicitly “equates ethics with morality and the law”. This conflation is deeply problematic from a philosophical and practical standpoint. The argument is made that true moral integrity, if genuinely present, would render extensive laws and ethical codes less necessary; conversely, the reliance on such detailed ethical frameworks suggests a fundamental absence of inherent morality within the system. The demand is clear: if morality is a prerequisite for licensed professionals, then the same standard must be reciprocally applied to the governmental and auxiliary systems that impose these requirements.

The historical context provides a stark warning: actions that were once “completely legal to do what the German did in concentration camps” underscore the inherent danger of blindly adhering to laws without a guiding moral compass. This historical precedent highlights that legality does not automatically equate to morality. The “Moral Character Clause” is not a genuine measure of moral integrity but a strategic legal instrument used by those in power to exert control and enforce obedience. By equating ethics with law and morality, the system attempts to subsume individual moral conscience under bureaucratic authority, effectively weaponizing morality to maintain its “status quo” and suppress dissent. This practice, reminiscent of historical abuses where legality superseded morality, reveals a deep-seated fear of true moral accountability and a preference for controlled, rather than genuine, ethical behavior. It also implies that the system is “addicted and dependent on the system” and therefore cannot see its own moral deficiencies.  

Table 2: Analysis of the NYS Office of Professions Moral Character Clause

Question Number	Inquiry	Analysis of Legal vs. Moral Focus
1	Since your last registration application, have you been found guilty after trial, or pleaded guilty, no contest, or nolo contendere to a crime (felony or misdemeanor) in any court?	Legal Focus: Directly pertains to criminal convictions, which are matters of law, not necessarily morality. A legal finding of guilt does not inherently define moral character.
2	Since your last registration application, has any licensing or disciplinary authority revoked, annulled, cancelled, accepted surrender of, suspended, placed on probation, or refused to issue or renew a professional license or certificate held by you now or previously, or fined, censured, reprimanded or otherwise disciplined you?	Legal/Ethical Focus: Pertains to disciplinary actions by professional bodies, which are based on ethical codes and legal regulations, not explicitly on a defined moral framework.
3	Since your last registration application, are criminal charges pending against you in any court?	Legal Focus: Concerns ongoing legal processes, not a determination of moral character. An accusation is not a moral failing.
4	Since your last registration application, are charges pending against you in any jurisdiction for any sort of professional misconduct?	Legal/Ethical Focus: Relates to pending professional misconduct charges, which, like disciplinary actions, are rooted in ethical codes and legal frameworks.
5	Since your last registration application, has any hospital or licensed facility restricted or terminated your professional training, employment, or privileges, or have you voluntarily or involuntarily resigned or withdrawn from such association to avoid the imposition of such action due to professional misconduct, unprofessional conduct, incompetency, or negligence?	Legal/Ethical Focus: Addresses professional restrictions or terminations, which are typically based on violations of established ethical guidelines or legal standards of practice.

Source: NYS Education Department, Office of the Professions

Upon review of this table, it becomes evident that the majority of the inquiries within the “Moral Character Clause” are fundamentally legal in nature. This observation underscores the argument that the state’s definition of “moral character” is predominantly framed through a legalistic lens, rather than a nuanced understanding of ethical principles or genuine moral integrity. By focusing on criminal convictions, disciplinary actions, and pending charges, the clause conflates adherence to law with moral uprightness. This approach suggests that the system, rather than fostering a truly moral professional, aims to ensure legal compliance and control. This serves as the concrete basis for the subsequent 99 moral-ethical observations, each implicitly or explicitly challenging the system’s narrow definition and application of “moral character” and highlighting the “double standards” and the system’s “addiction to their own privilege”.  

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References

O’Brien, A. (2023a). Addiction as Trauma-Related Dissociation: A Phenomenological Investigation of the Addictive State. International University of Graduate Studies. (Dissertation). Retrieved at woundedhealersinstitute.org/courses/addiction-as-dissociation-model-course/

O’Brien, A. (2023b). Memory Reconsolidation in Psychedelics Therapy. In Path of the Wounded Healer: A Dissociative-Focused Phase Model for Normative and Pathological States of Consciousness: Training Manual and Guide. Albany, NY: Wounded Healers Institute. Retrieved at woundedhealersinstitute.org/courses/addiction-as-dissociation-model-course/

O’Brien, A. (2023c). Path of the Wounded Healer: A Dissociative-Focused Phase Model for Normative and Pathological States of Consciousness: Training Manual and Guide. Albany, NY: Wounded Healers Institute. Retrieved at woundedhealersinstitute.org/

O’Brien, A. (2024a). Healer and Healing: The re-education of the healer and healing professions as an advocation. Re-educational and Training Manual and Guide. Albany, NY: Wounded Healers Institute. Retrieved at woundedhealersinstitute.org/

O’Brien, A. (2024e). Path of the Wounded Healers for Thrivers: Perfectionism, Altruism, and Ambition Addictions; Re-education and training manual for Abusers, Activists, Batterers, Bullies, Enablers, Killers, Narcissists, Offenders, Parents, Perpetrators, and Warriors. Re-Education and Training Manual and Guide. Albany, NY: Wounded Healers Institute. Retrieved at woundedhealersinstitute.org/

O’Brien, A. (2025). American Made Addiction Recovery: a healer’s journey through professional recovery. Albany, NY: Wounded Healers Institute. Retrieved at woundedhealersinstitute.org/

*This is for informational and educational purposes only. For medical advice or diagnosis, consult a professional.