by Lisa Ferentz, LCSW-C, DAPA

To Refer Out or Not to Refer OutAs 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.

Read more on Practice Issues here.

7 thoughts on "To Refer Out or Not to Refer Out, That is the Question!"

  1. Ray Weinstein says:

    My therapist recently moved his office to an office in his home. He has home security cameras by his outside door. When his wife or kids are home they could potentially see clients on the screen. He also has a soundless motion activated camera in his therapy room. He says he has it for his personal safety and no one But him can ever see that one. But it makes me wonder if my confidentiality is compromised. I’ve been working with him for many years. He’s really helped me tremendously. I trust him and slime to him about the cameras. He allows me to move my seat and sit below the camera so only the top of my head shows. Do I stay or leave?

    1. lisaferentz says:

      I think you are bringing up a very legitimate concern. Therapy is most beneficial when you feel truly safe and trust that everything about the process, and your identity, remains confidential. I would continue to broach this issue with your therapist as it seems that having a camera inside the therapy room might compromise your sense of anonymity, privacy, and confidentiality.

  2. sarah sebikari says:

    Hi can an LCSW refer a patient to another specialist eg nutritionist, MD of different specialty such as internist?

    1. Lisa Ferentz says:

      Hi Sarah, It’s fine for a social worker to make recommendations regarding other resources for clients, and it’s up to the client whether they want to follow through and use that recommendation or not. – Lisa

  3. MT says:

    I’m a counseling student working in a nonprofit contracted with the state, so we are all called counselors without having that actual distinction. I am working with a family that consistently triggers me and makes me upset and angry, and I am sure I’m not being helpful. I’ve requested they be transferred to another counselor and my superiors said no, because no one else will travel that far that direction (it’s an hour south from our office) due to having many families an hour north. I’m not trained in working with parents who physically abuse their children, are about two steps behind pre-contemplation, and intend to continue doing it, and the DHS Child Welfare caseworker and supervisor have confirmed no intentions of intervening at this point. I feel its unethical for me to continue working with them, but cannot find the right words to explain this to my superiors in a way that will illustrate the ethical issue. Any suggestions?

    1. Gerri Baum says:

      My apologies for overlooking your comment and question. Though a bit of time has passed since you posted, and I’m hoping this is no longer an issue for you, I wanted to still give you feedback in the event you are faced with the same or similar problem in the future. The best ethical argument is that you don’t feel qualified to help them. In our professional code of ethics it clearly states that we should not be providing services to clients when we are not qualified to do so. To continue to be forced to work with them is a deviation in the standard of care and sets your agency up for liability issues. Rather than saying you don’t like the parents or feel anger towards them, focus on the fact that you don’t feel clinically qualified to provide good service.

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