Therapeutic Fit; When should we refer out?

In graduate school I remember being asked if it was a requirement to be in therapy, to understand the therapeutic process. I was surprised and yet intrigued by this question. No, my program did not make that a requirement. Generally this question came from counseling students from other universities, at my internships. The other students were working on a Master in Counseling (LPC, when fully licensed) and I was working on my Master in Social Work (LCSW when fully licensed). Apparently some university programs make weekly therapy a requirement. Most Social Work programs focus on a generalist approach, which covers many other areas, including mental health. It’s such an interesting concept. Because if you are going to be a therapist, I believe that you should understand what therapy entails. And that includes sitting on the other side of that office… as the client. I have an appreciation of this. Especially when I am asked, have you been to a therapist before? It’s a legitimate question that I feel clients have the right to ask. It normalizes the therapeutic process. It makes them feel that they are not alone in the need to seek out help. Thus I will tell you a secret. Yes, I have been through therapy before. I have had positive and negative experiences with therapy and therapists. But, I continued to seek therapy because I believe in it. It’s really that simple. I know very personally what it is like to be on that sofa. I know all of the emotions that go along with it, including fear and vulnerability. I also know that having been on the sofa, it also helps me to be a better therapist. In my humble opinion, life and experience are our best educators.

On the other hand, I also know what it is like to feel that my therapist was not a good fit. Or that they were not qualified or experienced in the area that I needed. Poor therapy experiences can make clients terminate early and be less likely to seek out assistance . It also may have an impact on the client’s feelings towards therapy in general. Primum non nocere which means in Latin, “First, do no harm.” We should all strive to “not do harm, “particularly as a helping profession. And there are many ways that therapists can harm clients. But I am writing about the harm of when we do not refer a client out. It is something that is definitely discussed in MSW graduate school and in the National Association of Social Workers ethics. NASW writes this process in the NASW Standards for Clinical Social Work Practice, 2005, Chapter 12, page 15, “When additional knowledge and skills are required to address clients’ needs, the clinical social worker shall seek appropriate training, supervision, or consultation, or refer the client to a professional with the appropriate expertise.”

It’s hard to admit that we are not the best person to help someone. In fact, it takes a great deal of strength to be able to say, “I am sorry. I am not qualified to help you in this area, but I know someone who does. Let me give you their information.” As a professional, we all have areas of strengths and weaknesses. We need to be very self-aware of what is and isn’t appropriate treatment for clients. We also have to take care of ourselves. The significance of burn out and compassion fatigue rates are significant. But isn’t that a part of the therapeutic process? Making sure that the therapeutic relationship or “fit” is a good one? Clients need to feel that they can trust you. Clients should feel comfortable to come into your office, and tell you how they are really feeling. That amount of trust is sacred. And since it is a relationship, a therapeutic one, we should also be able to openly communicate with the client. Therapists have rights just as clients do. One of those rights is to feel safe.

So what are some things that we can do, to prevent harm? Be able to recognize when we are not the right therapist for the client. The therapeutic relationship is extremely important, and we need to focus on the fit. A referral should be made if the therapist does not have expertise in the client’s areas of need. During the initial session the therapist should explain the importance of therapeutic rapport. Have open communication with the client about if they feel comfortable talking to you. Let the client know it’s a safe space and that the client can tell you if they are not comfortable. Open communication about the therapeutic relationship should continue until termination, whether one session or twenty. How do I know if I should refer my client to another therapist? If we listen to our clients and our professional instincts, we will know the answer.

Angie Simonton, LCSW-BACS

Follow me at angiesimontonlcsw.org, Twittter@RamblingsofaMSW, Instagram @ramblingsofamsw, email: angiesimontonlcswbacs@gmail.com

Disclaimer: I am a Mandatory Reporter at all times. I am not a medical physician and can not give out medical advice. If you are in a crisis please call 911 or go to your nearest emergency room.