Question: How can I determine when I should refer a client to another professional if I feel unable to help them due to my limitations versus when I feel uncertain or lacking in confidence about my abilities to connect with the client?
I want to ensure that I’m providing helpful therapy to my clients and not causing any harm by continuing to work with a client when it’s not in their best interest. However, I also want to avoid referring clients because of my insecurities.
What signs should I look for that indicate that I’m unable to provide the support the client needs? How can I differentiate between genuine limitations and feelings of lacking confidence?
Also, what are some effective strategies for referring clients to other professionals, and how can I do so in a way that is sensitive to their needs and ensures a smooth transition?
Response from Dr. Chua: The best time for a referral is after an assessment. The assessment should give you enough information to understand your client’s history, current struggles, therapy goals, and treatment needed. If you are not trained to provide the treatment that fits your client, you can refer to someone who is or find a supervisor who will supervise your work (provided you have at least some didactic learning on the treatment and the problem).
Be honest with yourself and your clients. Don’t pass yourself off as an expert if you are still learning. For instance, I’m not an expert in treating patients with ADHD, and if the client is looking for an expert rather than someone who is learning, I will refer to someone more experienced. If you’re not confident, I recommend practising under supervision until your confidence increases. The lack of confidence will likely impact your treatment decisions and the therapeutic alliance. Your supervisor can also give you a more objective perspective on your abilities.
You can also use treatment outcome measures to ensure your client progresses and improves. My clients complete the OQ-45 TA (a progress outcome measure) at the start of every session, and we will discuss progress at least at the 6th session (assuming a 12-session structure) or more frequently if warranted. If your client is not improving and the alliance is not strong, it is unlikely that things are going the right way. You will need to reassess what you are doing – it might be the therapist-client fit, the treatment-client fit, or other issues hindering your client’s progress.
Discuss it with your client and collaboratively decide whether it’s best to refer. Explain why you think it would be better for your client to work with someone else (often, it’s about expertise). Ask your client for feedback on how the treatment is going. Clients are often protecting our feelings by telling us everything is going well. The objective measures will facilitate an honest discussion if it’s the case your client isn’t improving.
Even though you’re not rejecting your client, your client might feel like it’s a rejection. You want your client to have the best transfer experience possible. You can give a couple of options and continue discussing with your client about the timeframe. Some clients are ready to leave, but some are not. So there may be a short overlap between you and the new therapist. Ask permission to share information with the new therapist to smooth the transfer.
If your client wants to stay, discuss alternate strategies. For example, try a new treatment or medication, and get more supervision for yourself. Collaboratively choose a new plan with your client and agree to reassess in a couple of sessions to check if the new direction is working.
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