Are You Guilty of Abandonment?
David Kaplan
One of my pet peeves about professional counselors is that we seem to be willing to refer clients at the drop of a hat. This seems to begin in graduate school where so many counseling students are given the message: If you are uncomfortable with a client for any reason, all you need to do is refer them to another counselor. If you are not comfortable with their presenting problem, culture, sexual orientation, attitude, or approach to life, no problem – send them to someone else.
I can’t tell you how many times I have heard counselors make such statements as, “I don’t work with anyone addicted to drugs” or “If a GLBT client came to my office and wanted to talk about their same sex relationship I would refer them out” or “If a pregnant girl or woman came in my office and wanted to talk about the option of an abortion, I would send them to another counselor” or “I have never worked with that particular presenting problem so I gave them the phone number of a counselor who had more experience”.
The willingness to refer clients who don’t meet your comfort level ignores the underlying problem with this approach – clients can (and do) perceive this as abandonment. And my definition of client begins from the very moment a person contacts you about their initial appointment and hasn’t even seen you once. Why? Because if you give someone who has inquired about your services – or that you have only seen briefly – the message that you won’t provide counseling because of their particular problem or characteristic, there is a reasonable chance that they will not be willing to face rejection twice by contacting a second professional counselor. And in my book, that constitutes abandonment.
But doesn’t the ACA Code of Ethics (available at www.counseling.org/ethics) say that we should refer clients we can’t help? Sure. But the focus is clearly on the needs of the client, not the counselor. The termination and referral section of the code (section A11) states that you should refer if the client is not likely to benefit from your services. It does not say that you can refer if you do have the necessary skills or resources to provide the counseling but are merely uncomfortable. The code also does not say that you need to refer every client who has a presenting problem that you have never previously worked with. If that was a mandate, how in the world would we grow and learn new skills and areas of expertise? Instead of abandoning a new client with a unique issue or diagnosis, find as much information as you can and get appropriate supervision to provide quality services to that client.
Has referral caused you to be guilty of abandonment?
David Kaplan is a Past-President of the American Counseling Association and it’s current Chief Professional Officer.
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Perhaps many, if not most counselors, have been guilty at some time of referring a client due to personal discomfort rather than lack of expertise. This does not make it right. But this is a part of the personal growth of the counselor. The American Counseling Association’s Code of Ethics states that “Counselors gain knowledge, personal awareness, sensitivity, and skills pertinent to working with a diverse client population.” Further, the Mission of the ACA as set forth in the Code of Ethics is: “The mission of the American Counseling Association is: “to enhance the quality of life in society by promoting the development of professional counselors, advancing the counseling profession, and using the profession and practice of counseling to promote respect for human dignity
and diversity.”
Before referring a client, members of the ACA should examine their own values to determine if they are adhering to the above ethical imperatives. Supervision can often help with the process. Only if and when counselors are honest with themselves can bias we uncovered and dealt with. There is a lot unsaid on this and there are many articles and books already covering the topic. These are just some of my preliminary thoughts.
David,
To answer you question, I have not been guilty of abandonment. I have not worked in outpatient settings clinically. I have only worked in residential, foster care, and home-based services. In these cases, I have closed out the client cases or they have been removed from the program. Sometimes this removal is from the court or other referring agency and sometimes it is our agency requesting the referral. In this sense, our program and me have given up on clients saying that our program was not working and that another is needed. Some I am sure felt abandoned. When I transition clients back to the community, I work hard to make that transition as easy as possible to their new therapist. When I moved to Michigan and took my current job, I transitioned out of another residential program. I planned with staff, administration, and my clients for this transition. Some felt abandoned but many welcomed the ability to talk about the natural life loss and how to deal with it.
However, there is a larger issue present in your question. It is the one of competence. ACA Code of Ethics Section C.2.a speaks to this issue. I cannot ethically practice in an area without the proper training. The issues of addiction, sexual identity, abortion are taught in graduate counseling programs. How to help the client deal with those issues is part of helping the client. While I have my own issues and values which are made clear at the start of counseling, they are not focused upon clients but they are neither hidden. If a client would come to me with serious addiction issues, I would consult with clinicians within my agency and those professional relationships outside. I would refer back to my books on the issue and I would review current research on the issue. But I have had some level of training and experience in this area.
This solution may not work in all areas. For example, I currently work in the field of juveniles who have sexually offended. It is highly specialized. I started with no experience but I was supported and trained by a great clinical supervisor and other clinicians within the residential program. Over time (several years), I learned how to do provide care to this population. I would be concerned for those attempting to do so without training. It is much more difficult than picking up a book and doing it. In this case the counselor would be practicing outside the bounds of competence and thus being unethical.
I’ll close stating that the ACA Code of Ethics (and really all ethical codes) are designed to be guidelines and to help clinicians Think and Be ethical. It is a character change.
Bryan Funk
A reminder to ACA members (and, sorry this is for ACA members only) you may call 1-800-347-6647 x314 for an Ethics Consult. Paul Fornell, Director, Ethics and Professional Standards is available to discuss your ethical questions and dilemmas. So, pick up your phone and call. You may also send him (that’s me) an email at ethics@counseling.org
I’m so glad to see you write about this David. I’ve received so many emails and posts from folks who have been abandoned by their therapists.
And when it comes to transference issues, the “competence” card is really a cop out as far as I’m concerned. Isn’t it actually about the therapist’s own reluctance to dealing with their own stuff?
We can’t say to clients we’re therapists…but only if it doesn’t get messy!
Interesting, I`ll quote it on my site later.
Thank you
It is very interesting that you appear to be concentrating on how helpful it is for the counselor to stretch their wings. How about the client? If the client is drunk and sick with a co-occurring diagnosis, guess what? They don’t need to see you Mr. Generalist, they need to see the guy down the block who specializes in Alcohol and Drug work. It is in the client’s best interest to be referred out instead of being some sort of lesson in addictions for this generalist. The Crew are all counselors with Masters and licenses who work hard all day putting people back together. We are sick and tired of the ACA and their concentration on “doctoral-level educators”. This was obviously written by one of them. Have you noticed we are leaving the ACA?
I think I will try to recommend this post to my friends and family, cuz it’s really helpful.
David writes “The willingness to refer clients who don’t meet your comfort level ignores the underlying problem with this approach – clients can (and do) perceive this as abandonment. And my definition of client begins from the very moment a person contacts you about their initial appointment and hasn’t even seen you once. ”
Boy this topic has certainly generated a lot of opinions! (grin) I must say that I agree with “The Crew” however, in that a clinician should be aware of their competency and comfort level in deciding whether he/she is the best practitioner for a client presenting with specific issues. I agree, David, that our first contact with a client is important in making that determination, but my experience has been that clients are receptive once I explain to them why Clinician X might be better able to assist them with the growth they change they are expecting with treatment. I actually think its unethical to practice as a generalist, and it gets under my skin when I network with colleagues and ask “what clients should I refer to you” and their answer is “oh, I see anybody.”
We all have our areas of clinical expertise and I think we do consumers a disservice when we attempt to treat conditions for which we either have no training or are unable to develop rapport due to our own moral/value system. Every clinician is not for everyone…and I think that a client can feel just as abandoned sitting across from a therapist who is judgmental or insecure about their treatment.
Just my .02!
Shawn