by Lisa Ferentz, LCSW-C, DAPA
As a consultant to many beginning and seasoned mental health professionals, I am amazed by how often ethical concerns find their way into the clinical conversation. One of the more common dilemmas is whether or not to continue treating a long-standing client when a new issue emerges in therapy and the therapist feels ill equipped to address it. This might be because the subject matter is personally triggering for the therapist, or they feel overwhelmed because, by their own admission, they are lacking in that area of expertise. Ambivalence regarding “what to do next” can play out for clinicians in several different ways. Some are eager to get my permission to refer that client out, feeling relieved by the prospect of not having to be in over their heads. In these cases, they may be underestimating their own abilities to be helpful. Others feel strongly about the need to keep that client “because we have a long-standing therapeutic relationship” and it “wouldn’t be right to suggest terminating and transferring to someone else.” This mindset can be further complicated when the client has abandonment issues or trust issues. These clients typically reject the notion of being referred out, claiming that “it took so long to trust one therapist, I can’t start over again with another one.” For the therapist with his or her own abandonment issues, the notion of “letting a client go” can seem untenable as well.
There can’t be a “cookie cutter’ approach to this issue. There are definitely times when referring out makes the most sense. Clients are entitled to get the best possible care. Working with someone who has an expertise in addressing their presenting problems and symptoms is one way to increase the likelihood that they will receive that high level of quality care. Many clients stay with their therapists for years beyond when they are actually getting help, or growing and changing in tangible ways. They stay because they are loyal to the relationship, because they don’t want to hurt the therapist’s feelings, or because it’s way to coast and not really move forward in dealing with painful or difficult material. Conversely, there is incredible healing power in a trusting, well established, and effective therapeutic alliance. Just because the therapist is confronted with an issue that is less familiar to them doesn’t mean they have to automatically refer out.
What’s most important, and ethical, is a willingness on the part of the therapist to be totally honest with their client about their level of expertise. If the client still insists that they don’t want to transfer out, then the therapist should commit to getting additional education and support so their efficacy can be enhanced. This can take the form of consultation with an expert, peer supervision, attending trainings related to the subject matter, and doing additional reading on the topic. When I provide consultation in these cases, I can see the therapist’s growth and believe they are continuing to be effective in their work. There should still be an ongoing assessment of the extent to which the therapist is genuinely being helpful. An important caveat to staying with the client relates to the therapist’s counter-transference. If the clinician feels constantly triggered, it means he or she is in limbic system, not pre-frontal cortex. And that means they lose the ability to reason, analyze, consider cause and effect, and access insights. All of which are key ingredients in being an effective clinician! Triggering can be the result of hearing material that “hits too close to home,” or hearing material that is completely out of their realm of expertise. Some clinicians get triggered when they feel either emotionally or physically unsafe in the client’s presence. In any case, the clinician becomes overwhelmed and the client doesn’t get the support and guidance they deserve. And as an aside, clinicians also have the right to feel emotionally and physically safe in their work!
Bottom line, this issue needs to be transparent and openly processed with the client. Using the trust and concern that already exists in therapeutic relationship can help with the outcome, regardless of whether the client remains in treatment or is referred out. Please share any experience you have had with the issue of whether or not to transfer a client.
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