Step 11. Referring to Another Service

When a client’s preferences prove inconsistent with the active listener’s competencies, then referral becomes a strong possibility. That ordinarily means recommending another therapist or treatment. The critical difference between offering an alternative and proposing another is that the former is performed by the same clinician, whereas the latter is conducted by a different person or service.

In his first contact, Joe described an extensive history of domestic violence (see video). His husband, recently deceased, had screamed at him, bullied him, and watched his every move in the house. He frequently slapped him as well.

What did Joe want from therapy? Joe replied that he wanted to stop feeling so edgy all the time, feeling the constant sense of threat. He wanted to stop waking in the night, feeling terrified in his bones without knowing why. “I feel him everywhere,” he said, “in the walls, watching, waiting.”

In terms of a particular kind of treatment, Joe said that he had had counseling before when his mother died, and while he found it beneficial to talk and thought the counselor was “a lovely person,” it was not what he wanted now. His doctor had recommended CBT or perhaps “E R something [EMDR, eye-movement and desensitization and reprocessing],” and after hearing more about them, he liked how they sounded. Joe explained that he wanted something focused, to the point, and direct. “I don’t want to talk about my life anymore,” he said, “I want to dig my hands into the wall and pull that f****er out.”

At this point, the clinician recognized that what Joe sought in both treatment methods and therapy goals differed from what he could comfortably and competently provide. And his preferences were well supported by the research evidence. The therapist, Alex, said:

Alex: I appreciate you saying about what you’re looking for in therapy, and it’s probably different from how I tend to work. But it’s great you are able to say about what you want. What I can offer is closer to the kind of counseling you had before.

Joe: Oh, OK.

Alex: My work is mainly about listening and helping clients talk about whatever they want to talk about. It’s open and supportive and encouraging, but I can hear you asking for focus and structure, and it’s less of that. It doesn’t, for instance, have the techniques that you might have in CBT or EMDR.

Joe: Oh, right. That does sound good. But, yes, I had it before, and it was really good, but, yes, this time, I do think I probably want something more focused.

Alex: That’s fine. Different people want different things, and there’s no pressure here to work with me. I’ve got some colleagues I can put you in touch with who offer what you are looking for.

Joe: So, is that more of a focused approach?

Alex: Yes. I’ve got colleagues who do both CBT and EMDR. They are both well-evidenced for the problems you want to address. Shall I tell you a bit about each of them, and we can see which one might sound preferable to you?

Joe: Thanks. I do appreciate that.

As in the case of Joe, before making the referral, inquire into the reasons behind the client’s preferences and educate the client, if necessary, on alternative effective interventions. In other words, do not rush to referral: Explore preferences and possibilities, and only when there is a clear mismatch between what the client wants and what the clinician can offer (within the bounds of best evidence) should a referral be made.

There is surprisingly little in the psychotherapy research on how to successfully refer a client on to another practitioner. The following are principles of referral consistent with personalizing care:

• Identify what you can and cannot offer clients (your scope of practice) so that you have a clearer and earlier sense of when referral may be indicated.
• Accept your limitations as a clinician to avoid experiencing referral as a sign of personal failure but as your commitment to optimizing care for your clients.
• Refer onwards in a collaborative way with the client so that it is experienced as a shared decision, rather than an imposition.
• Beware that some clients experience referral as a sign of rejection, so emphasize that it is due to your limitations as a therapist, rather than their failure as a client.
• Have concrete suggestions and specific sources in mind, as opposed to vague referrals to other services.  

Watch the following video:

Consider the following chat scenarios: 1) Your client (user) is struggling with an eating disorder but you have not completed the listener training guide and do not feel competent/confident about supporting them. How will you refer them to another listener? Share your way of offering another listener in the box below while focusing on the messages you would send and not the LSR protocol (using the Listener Support Room to refer the chat). 2) Another user has passive thoughts of suicide. Keeping in mind of the referral tips outlined in this step, share how you would refer them to another service.