"CE Corner" is a continuing education article offered by the APA Office of CE in Psychology.
Any comments contained in the article represent the experts’ analysis as individuals, are not made in any official capacity as members of an APA committee, and are not intended to reflect the view of the Ethics Office or Committee.
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CE credits: 1
Learning objectives: After reading this article, CE candidates will be able to assess:
- Whether to take on or continue working with a patient.
- What action to take if you suspect you lack the right tools to treat a patient.
- How best to transition a patient to another’s care and find ongoing training and consultation for yourself.
In her early years as a clinician, Christine A. Courtois, PhD, learned that a patient was cutting herself—a condition Courtois had never treated before. "I basically froze and became numb," recalls Courtois, a trauma expert and mental health consultant in the Washington, D.C., area. "It freaked me out, and I didn’t know I was freaked out."
Fortunately, Courtois knew she should consult with colleagues. One immediately told her what she needed to do: hospitalize the patient. Courtois talked with the patient about this option, and the patient agreed it made sense. Courtois was also on staff at a hospital, so she was able to treat the patient at an inpatient unit there and receive consultation on the case.
Courtois’s experience is far from rare: Clients often presents clinicians with challenges that are outside their range of experience, skill, knowledge or expertise. While this is understandably a more common phenomenon for early career psychologists who are still gaining clinical experience, more seasoned therapists aren’t immune. That may be because they haven’t had training in the area in question or have not kept current with the latest research, for example.
How do you determine if you’re in over your head with a client, and if you find this to be the case, what should you do about it? Clinical experts share their advice.
Making the right call
In assessing whether to take on or continue working with a patient, consider objective criteria, such as whether the client’s issues are technically within your scope of competence, as well as more subjective criteria, such as a client’s behavior and your reactions to it.
Guidance for determining your competence is in Section 2 of APA’s Ethics Code. It calls for clinicians to have sufficient "education, training, supervised experience, consultation, study, or professional experience" in a given domain to practice in it competently.
In some cases, it’s clear whether you have those ingredients: If you know you’re well trained in general clinical and counseling skills with adults but less so in such areas as head injury, schizophrenia or eating disorders, recognize and acknowledge that, says Jeffrey N. Younggren, PhD, a clinical professor at the University of Missouri in Columbia. Tell the patient that others have more expertise in these areas and refer him or her accordingly, he advises.
"You can’t suddenly say, I’m a neuropsychologist, a health psychologist, a developmental psychologist or a forensic psychologist," he says. "These and a number of other areas require specialty training." (For that matter, the Ethics Code requires that you maintain competence in your practice area, for example, through continuing education, training, supervision and mentorship.)
Less clear are cases that border on your areas of expertise but aren’t completely within them, says Giorgio Tasca, PhD, an associate professor of psychology at the University of Ottawa who specializes in treating adults with eating disorders. In such instances, assess whether the patient’s issues are largely within your domain of expertise and whether you could easily learn the necessary skills to treat those that are not.
For example, perhaps you are trained in treating generalized anxiety disorder and you are asked to treat a client with social phobia. Getting properly trained in evidence-based treatments for social phobia would be relatively easy since the condition is in the anxiety-disorders family. But if a client has early psychosis and you have no training in treating psychotic disorders, it’s best to refer, Tasca says.
Also look for more personal signs that you may be operating outside of your expertise, recommends Jeff Zimmerman, PhD, an independent practitioner in Manhattan and Katonah, New York, and Waterbury, Connecticut. These include client complaints that they don’t feel like they are improving or that they think they’re getting worse.
Your own internal reactions are also important clues. If you feel bored, impatient, overwhelmed, numb or hyperanxious about the client’s well-being, consider those reactions as signals that the therapy is off course and determine why. For help assessing yourself, see an article in Practice Innovations (Vol. 2, No. 4, 2017) by Samuel Knapp, EdD, Michael C. Gottlieb, PhD, and Mitchell L. Handelsman, PhD.
It’s also important to know that clients with certain symptoms, behaviors and diagnoses are more likely to be outside a typical practitioner’s scope of practice than others. Examples include people with suicidal tendencies, borderline personality disorder or traits, psychotic or dissociative disorders, or histories of trauma or child abuse. Families in severe conflict can also be difficult to work with and require specific competencies, Zimmerman says.
For many clinicians—perhaps especially those who have been in practice for decades—treating clients of different cultures and ethnicities can also be challenging without adequate training, says Sherry Benton, PhD, professor emeritus at the University of Florida in Gainesville and founder of the company TAO (Therapy Assistance Online), which provides online tools for therapy clients.
"Not considering the cultural context can get you into trouble," she says. "You may think you know what you’re doing more than you really do."
Deciding that a client might not be the right fit can happen at various points in treatment, Zimmerman says. The first is when you get a referral. Zimmerman, for example, received a call from a physician to take on a patient with an active cocaine addiction. Knowing that he lacked expertise in the area, Zimmerman immediately provided the physician with names of three local treatment facilities. "That was an easy one because I could hear on the phone that it wasn’t appropriate for me."
The next opportunity to determine whether a patient is a good fit for a psychologist’s skills is during the diagnostic interview, which can occur over one or more sessions. These sessions require the psychologist to assess the client’s main issues and to establish treatment goals. Framing the case in these ways should help you determine whether you’re competent to treat the person, Zimmerman says. This is also a time to test out personal compatibility and whether it’s possible to develop a good working alliance.
Practitioners may also deem they are no longer competent to treat certain patients when new issues or diagnoses become evident well into treatment. A client in couples counseling, for example, may disclose that he was abused as a child. A woman with depression may reveal she has an eating disorder. Or a client you’ve been treating for anxiety may develop severe headaches that she had not reported before.
The course of action
If you suspect you lack the right tools to treat a patient, contact a trusted supervisor or consultant, says Courtois. Don’t feel embarrassed to ask for help. "All psychologists need to have the humility and understanding that not everybody can treat every case," she says.
Asking for help doesn’t mean the therapy is doomed, either: It may actually help you get the therapy back on track by providing insight into a therapeutic impasse and helping to redirect treatment. And if the consultation reveals that you are not competent to treat the patient, the consultant can guide you to end therapy and make appropriate referrals in a therapeutic manner.
A note of caution: Don’t seek consultation on listservs, Zimmerman warns, as you may inadvertently breach patient confidentiality. Besides, you don’t know who you’re communicating with and vice versa, and there is only so much information a psychologist can share online—so there’s no way you can properly present all the nuances of a case.
If you think a case is beyond your scope of practice, consider taking these additional steps:
Talk to your client. Sharing your concerns with your client is the respectful, ethical and clinically appropriate thing to do, Zimmerman says. Have a frank discussion with the client indicating that you don’t have the skills to treat some or all of the issues he or she is presenting.
Refer out all or some of the care. Depending on the situation, it may be time to refer your client to another therapist. This can be for the entire treatment, or just for aspects you’re not trained in. For example, let’s say your expertise is cognitive-behavioral therapy and your client initially entered therapy to become more assertive with her boss. But part way into treatment, you learn she was abused as a child. Knowing that you are not trained in child-trauma treatment but that this issue could impact how the client interacts with her boss, you could state that you will continue to use cognitive-behavioral methods to help her stand up to her boss, but you will refer her to a colleague to help her work on the early trauma.
If you do refer out, place competence and reputation above theoretical orientation, advises clinical psychologist Steven Hollon, PhD, a professor of psychology at Vanderbilt University in Nashville.
"I can think of people with different backgrounds from mine who I’d refer people to without hesitation, and people with the same background who I wouldn’t necessarily suggest as referrals," he says.
In keeping with generally accepted practice, Courtois also recommends providing at least three names of potential referrals, with information about their backgrounds and expertise.
When you refer out for part of treatment, get a release from the patient so you can communicate with the other provider about the patient’s progress and how your joint work may facilitate his or her therapy, Zimmerman adds. As with the client who’s working on becoming more assertive with her boss, clarify the parameters and goals of treatment so the client understands the scope of the work each clinician will be providing, he recommends.
Don’t abandon the client. If you end up deciding you’re not competent to treat a client, be sure to arrange for him or her to transition to appropriate care, says Courtois. For starters, explain why you are ending therapy in a clear, supportive and specific manner. Write down what you want to say ahead of time and share the wording with a colleague to make sure your tone is neutral and supportive, she suggests.
Even—or perhaps especially—if a patient poses a danger to himself or herself and you do not feel sufficiently equipped to provide treatment, you are ethically obligated to find appropriate care that will protect the patient, Courtois adds. Failing to provide a safety net could lead to the patient’s physical harm and is likely to exacerbate the very issues that he or she entered therapy for.
In some cases, you might need to take further steps to ease the patient’s transition into another practitioner’s care, notes David Shapiro, PhD, a clinical and forensic psychologist in Fort Lauderdale, Florida. Two years into treatment with a patient, he discovered she had dissociative identity disorder. He lacked expertise in treating the condition and didn’t want to practice outside the bounds of his competence, but at the same time he had developed a strong therapeutic relationship with her and didn’t want to abandon her. His solution? He found an appropriate expert to treat her, and he joined them in an initial session. As the client began to work with the second therapist, Shapiro continued to see her in individual therapy, gradually reducing the number of visits as the new therapist took over.
Adapt to special circumstances. Working in rural or other under-resourced areas brings extra challenges in determining and referring patients whose conditions may not be treatable with your skill set. You may be the only mental health provider in a large radius, so there may not be good local referral options and you may need to look for outside experts. (APA’s Ethics Code acknowledges the reality of a lack of appropriate services, but it says that providers with closely related training or experience can provide emergency treatment until they find appropriate care.)
What’s more, gaining more knowledge in a particular area can be taxing financially because you’re assuming extra time and work that is not easily reimbursed.
Fortunately, opportunities to gain appropriate knowledge expediently are growing in quantity and quality, says Benton, who worked in rural Kansas before moving to Miami.
"You can do whole in-depth courses and webinars online and consult with others in ways you couldn’t even a few years ago," she says. Additionally, telemedicine is providing a lifeline for patients who didn’t have one before. To find such opportunities, explore APA’s website for webinars and continuing education, tap your state association and reach out to relevant APA divisions. (For a full list, go to www.apa.org/about/division.)
Get in-person support. Another great option is hiring a mentor, says Zimmerman. This person’s job is to help you build your skill set in your new area of interest, so it’s a formal relationship, not a casual one. Paying the mentor helps to ensure that he or she allocates the necessary time to this endeavor. To find a mentor, seek an expert in the area you want to learn more about—someone who teaches, writes and does this specialty work on a routine basis. Also choose a mentor based on good personal fit—someone you connect with and trust. Consider hiring the person for the long haul so you can hash out issues and consult about clinical challenges on an ongoing basis.
A related option: join a regular support and development group with fellow therapists. There, look for colleagues with whom you can develop a long-term, trusting relationship and talk openly about cases and how to build your skill set, Zimmerman says.
Indeed, operating within the bounds of your competence should be an ongoing practice and at its best, an ever-expanding one, Younggren says.
"You always need to be putting yourself in a position of consulting, reading and asking yourself whether you know anything about this," he says. "And if you don’t, you can learn—but you need to get the education, training and experience to do that."
Deliberate Practice for Psychotherapists: A Guide to Improving
Rousmaniere, T. Routledge, 2016
Self-Awareness Questions for Effective Psychotherapists: Helping Good Psychotherapists Become Even Better
Knapp, S., et al. Practice Innovations, 2017
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