At some point in your career, you may begin working with a client who challenges your ability to provide compassionate counseling. In some cases, it may be possible for you and the client to work together and overcome this difficulty. In other cases, providing a referral to another mental health professional may best serve both you and the person you’re working with.
You may find the decision to terminate therapy, even by providing a referral to another counselor, a difficult one. You might be unsure when it’s ideal to continue trying to work with your client and when referral may be a better decision.
Here, we’ll go over a few situations when you may want to consider referring a client to another professional. We’ll also offer tips for taking care of yourself at those times when providing therapy seems more difficult.
If They Would Be Better Served by a Specialist
Some people seek therapy with a general idea of the issues they’re experiencing, such as depression, anxiety, or grief. Others may seek help for a variety of symptoms they don’t understand. Some individuals discover, as they begin the therapy process, that deeper issues underlie the symptoms they originally wanted help with.
You may discover in the early stages of therapy that an individual has mental health challenges you don’t have the training to address. These may include symptoms of personality disorders, dissociative disorders, or psychosis. These conditions may require specialized treatment.
For example, if you’ve only trained in cognitive behavioral therapy, you may not be the most helpful professional for a person living with borderline personality disorder (BPD). You may wish to refer the individual to a counselor who practices dialectical behavioral therapy, which is often a more effective treatment for BPD.
It’s also important to note any physical symptoms your client experiences. Mental health conditions can involve somatic symptoms, but the opposite can also hold true. A client may have symptoms of depression, anxiety, or stress due to physical health issues. Getting medical treatment could help resolve the emotional symptoms.
Culturally competent counseling is not considered specialized treatment. It’s possible to provide quality care to a marginalized person even when you don’t share their background. Generally, it is inappropriate to refer someone simply because you’re unfamiliar with their culture, ethnic background, or sexual orientation.
Instead, you can use what’s known as broaching to bring up the topic. Broaching means taking initiative to bring up challenging topics such as racism and misgendering. By acknowledging areas of potential emotional pain, you can show your willingness to approach the subject with empathy, even if you’ve never experienced it personally. Then you might choose to read up on these subjects yourself, pursue continuing education on the issue, or talk to a more experienced colleague.
If Continuing Therapy Poses an Ethical Risk
There may come a time in therapy when you realize someone you’re working with has vastly different beliefs and values than you do. For example, someone may mention they support a different political party or have religious beliefs that clash with your own. These views may seem to challenge your ability to provide compassionate care.
But according to the American Counseling Association’s code of ethics, therapists should be able to bracket their personal beliefs and convictions, setting them aside while providing counseling services. The needs of the client come first in therapy. Letting your discomfort color the therapeutic relationship can affect its success. If you use value judgments as a reason to refer someone to another professional, the individual may feel abandoned. This perceived abandonment could prevent them from continuing in therapy with another counselor.
Instead of ending therapy, reach out to your supervisor, or talk to your own therapist about your difficulties. Working to address your discomfort can help you reach a place where you’re still able to provide ethical counseling, regardless of how you feel personally. That being said, it’s possible you may simply be unable to work with some clients. In these cases, referral may be in both of your best interests.
It is appropriate to refer someone to another professional if something within the counseling relationship affects your ability to provide therapy. Some people, for instance, may flirt casually with their therapists. The flirting could create an opportunity to discuss transference and provide room for exploration. But when a client persists in flirting or making romantic gestures, continuing therapy may not be in their best interest. It’s still a good idea to consult with your supervisor before providing a referral though.
Another challenging situation is when a client presents with issues similar to those you’re currently experiencing. It may help to consider whether your situation could provide insight and have a positive impact on therapy. But some experiences may bring up painful memories that get in the way of treatment. Working with your own therapist or talking to your supervisor about the situation can help you determine the best way to proceed.
Terminating therapy may also be wise when a client has threatened you with physical violence. It’s important to put your client’s needs first in most cases, but not at the expense of your own safety. You do not have to continue working with someone when doing so puts yourself at risk.
If the Client Is Not Benefiting from Therapy
Therapy isn’t always easy for the therapist or for the person seeking help. There may be sessions where progress seems to stall or your client reports a setback. If this continues to happen, you may wonder whether therapy is serving your client. The therapeutic relationship is a relationship, so it requires participation from both sides. You can offer very little when a client doesn’t actively participate in therapy.
Having a conversation about this in session could shed some light on the situation. Consider asking the individual where they see therapy going or if they’re having trouble with some part of the process. You may want to talk to your supervisor about next steps if the person you’re working with:
- Seems unwilling to discuss the situation.
- Shows little interest in putting work into therapy.
- Is consistently late or doesn’t show up for therapy.
Some clients may no longer seem to benefit from therapy if they’ve already made significant progress. Someone who has addressed the issues they sought therapy for, made positive changes, and developed coping strategies may have gained the tools they need to maintain their present state of wellness. Having a conversation in session could help the person determine if they’ve gotten what they need from therapy. Someone who feels ready to end therapy may not know how to bring up the issue themselves.
Alternatives to Referrals
Experts in counseling ethics advise waiting to refer a client until you’ve tried all other options.
When you do make the decision to refer a client, it’s important to consider your reasons for making a referral. Ask yourself if you can address your lack of knowledge yourself. Therapists are generally expected to continue their education and develop their counseling abilities throughout their careers. This may include training in less common mental health concerns or cultural competence.
Seeking support from colleagues or your supervisor can help you gain insight. They could also give you a second opinion on a difficult situation. Sometimes it helps to have the perspective of someone who has similar training but no direct involvement.
It’s also important to practice self-care when working with people you dislike or feel overly challenged by. Mindfulness exercises and relaxation techniques can often help. However, it is also important to take time for yourself outside of work. Maintaining a good work-life balance can keep occupational challenges from overwhelming you.
Therapists can benefit from therapy too. If you’re struggling to deal with your emotions surrounding a difficult encounter in therapy, consider working with a counselor trained in providing therapy to other mental health professionals.
- Baker, B. (2009). How to deal with clients you don’t like. Monitor on Psychology, 40(2). Retrieved from https://www.apa.org/monitor/2009/02/clients
- Clay, R. A. (2017). Coping with challenging clients. Monitor on Psychology, 48(7). Retrieved from https://www.apa.org/monitor/2017/07-08/challenging-clients
- Martz, E., & Kaplan, D. (2014). New responsibilities when making referrals. Counseling Today. Retrieved from https://www.counseling.org/docs/default-source/ethics/ethics_ocober-2014.pdf?sfvrsn=2
- Natwick, J. (2017). On the ethics of ending: Terminations and referrals. Counseling Today. Retrieved from https://www.counseling.org/docs/default-source/ethics/ethics-columns/ethics_may_2017_terminations-and-referrals.pdf?sfvrsn=ea25522c_6