The ethics of choosing your clients

[Pragma]

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I am not an extensive practitioner, but I have found a discussion in another thread interesting.

To what extent is it our right as providers to try to choose what types of clients we see? Is specializing in a particular type of disorder, or saying that I provide services only for men or women, etc. appropriate from an ethical standpoint?

In my experience, psychologists do this type of stuff all of the time. That's how they build the practices that they want (especially if their services are in demand and they aren't hurting for referrals). But some folks seem to have the sentiment that we can't turn people away (refer out) and need to be prepared to treat just about anyone, even if we don't want to (for a variety of possible reasons - lack of training in an area, personal bias against a subgroup, etc).

I am very interested in opinions/thoughts about this. I also am interested in justification for choosing to take or not take certain types of payment, etc.

 

[Pragma]

What if you are competent, but prefer not to see certain types of cases. For example, what if I really did not like seeing Axis II clients or clients with substance abuse problems (that is actually not true for me, but for the sake of providing an example). Could I have a practice where I refer those types of cases out based solely on personal preference? Would that be ethical, or am I obligated to treat these cases?

This is a different question than referring due to personal biases, which is being discussed in another thread.

 

[MBellows]

I don't see a problem with being a specialist and turning away cases. I think the primary argument for this approach is having a good awareness of your competence. I always cringe when I see practitioners who advertise that they treat any disorder under the sun for any age of client. It's very difficult to have depth of expertise in so many areas. While I'm not a practitioner primarily, I feel like I can do more for clients by becoming an advanced expert in a few areas as opposed to becoming a master of nothing and knowing a little about a lot.

Generally, specialization is seen as good and acting outside of your specialization is bad. That's where capitalism and ethics align perfectly. In fact, operating outside of an area that you have competency in (and the ACA, APA, and I think the NASW all have clearly defined criterion for competency in select areas, including working with LGBTQ, geriatric, etc.) is seen as unethical.

Where this becomes problematic however, is in smaller areas (I'm in a major city, so it's easier to refer out to another provider whom I know will provide competent care). If you're one of few providers in an area, or perhaps you're one of the only providers who offers evidence-based treatments in your area, it becomes more difficult to justify referring out when you know that you may actually be the most competent person to see a particular patient (even when there might be limits to your competence compared to someone elsewhere who may specialize in the area in question).

I generally agree here, I still haven't decided whether I want to work primarily in rural, middle, or metro areas, and this is one of my major concerns. I'm dedicated to EBP more than most people who I've met in my program, or in the area that I'm in generally, and I would feel really uneasy referring a client that wasn't in my specialty out when I can find almost everyone who I would refer out to on PsychToday listing over 9000 practice areas (usually including EMDR, Tic-Tac-Toe therapy, and Christian Counseling).

 

[MBellows]

What if you are competent, but prefer not to see certain types of cases. For example, what if I really did not like seeing Axis II clients or clients with substance abuse problems (that is actually not true for me, but for the sake of providing an example). Could I have a practice where I refer those types of cases out based solely on personal preference? Would that be ethical, or am I obligated to treat these cases?

This is a different question than referring due to personal biases, which is being discussed in another thread.

I have a hard time imagining anyone competent in substance abuse service provision that doesn't like to work in that area. It would take some major tenacity to work 2000+ hours in SA without enjoying it.

Give it 2 months and not liking Axis II won't be a thing anymore. =P

 

[Pragma]

I have a hard time imagining anyone competent in substance abuse service provision that doesn't like to work in that area. It would take some major tenacity to work 2000+ hours in SA without enjoying it.

Give it 2 months and not liking Axis II won't be a thing anymore. =P

Well I suppose it depends if you consider specialization = competence. In the other thread, some folks were arguing that working with LGBTQ populations, for example, shouldn't require specialization. I tend to think that substance abuse shouldn't either, although I think training programs generally do a poor job addressing the issue.

So assuming you are a generalist, is just saying you are not a specialist in that area sufficient to refer ethically? Because I am not certain that "lack of specialization" = incompetence for a lot of very common issues.

 

[bcliff]

Well I suppose it depends if you consider specialization = competence. In the other thread, some folks were arguing that working with LGBTQ populations, for example, shouldn't require specialization. I tend to think that substance abuse shouldn't either, although I think training programs generally do a poor job addressing the issue.

So assuming you are a generalist, is just saying you are not a specialist in that area sufficient to refer ethically? Because I am not certain that "lack of specialization" = incompetence for a lot of very common issues.

Working with LGBT populations should require no more specialization than working with any racial minority population, and using the justification that LGBT folk are more likely to come in for issues pertaining to their minority status than someone who is a person of color, therefore clinicians should be able to deny them services due to lack of 'specialization' (although the pathology may be something as general as depression, GAD, etc.) is perpetuating the stigma associated with being LGBT therefore increasing the likelihood that these people will have mental health issues relating to their sexuality.

While having a doc not want to see you for being gay isn't the worst thing in the world, it's not the right direction a progressive field like psychology should be heading.

Substance abuse is the result of behaviors that an individual has chosen to make and is a DSM disorder, while being gay is something inherent (whether it's socialized or biological is irrelevant) and is not in the DSM. I understand that certain clinicians might specialize in certain minority groups, but I don't think it's fair for a clinician to deny services to a minority because they aren't a specialized in treating 'their kind of people' especially for issues that are not related to their sexuality.

 

[Pragma]

Substance abuse is the result of behaviors that an individual has chosen to make and is a DSM disorder, while being gay is something inherent (whether it's socialized or biological is irrelevant) and is not in the DSM. I understand that certain clinicians might specialize in certain minority groups, but I don't think it's fair for a clinician to deny services to a minority because they aren't a specialized in treating 'their kind of people' especially for issues that are not related to their sexuality.

Your statements here reflect some of the common stigmas out there when it comes to the debate about the disease model for addictions. It certainly is a debate, but your statement suggests that you have made up your mind despite much evidence to the contrary.

Obviously a tangent...

 

[MBellows]

Well I suppose it depends if you consider specialization = competence. In the other thread, some folks were arguing that working with LGBTQ populations, for example, shouldn't require specialization. I tend to think that substance abuse shouldn't either, although I think training programs generally do a poor job addressing the issue.

So assuming you are a generalist, is just saying you are not a specialist in that area sufficient to refer ethically? Because I am not certain that "lack of specialization" = incompetence for a lot of very common issues.

Please don't get me wrong. I think that you can work with people with those problems without having a specialization. Take substance abuse for instance, there are minimum criterion dealing with what qualifies an individual to be specialized in it. While you can work with people without having met those criterion, I think that you would be on shaky ethical ground if you don't get some regular supervision or consultation with a specialist, if even informally.

 

[Pragma]

Please don't get me wrong. I think that you can work with people with those problems without having a specialization. Take substance abuse for instance, there are minimum criterion dealing with what qualifies an individual to be specialized in it. While you can work with people without having met those criterion, I think that you would be on shaky ethical ground if you don't get some regular supervision or consultation with a specialist, if even informally.

That brings up an interesting question for me. Considering that there are things we'd probably typically consider kosher to be seen by a "generalist" - say depression, anxiety (and I would argue substance abuse too since it is also very common), to what extent is everything specialized now? Because I don't think everything needs to be specialized.

Of course, the above comment from another poster just reinforces my frustration about substance abuse specifically though, as I have met many practitioners in the field that clearly view substance users as morally defective and a product of choice despite strong evidence to suggest that those choices are made with drastically different levels of salience due to neurochemical processes and genetic factors. Undergraduates in some of my classes seem to have a better grasp that than some psychologists I have met - which is sad considering how common substance abuse occurs and interacts with mental heatlh symptoms in our clinical populations. It reflects poor training, stigma, and a lack of understanding of a very important subculture, IMO.

 

[deleted176373]

What if you are competent, but prefer not to see certain types of cases. For example, what if I really did not like seeing Axis II clients or clients with substance abuse problems (that is actually not true for me, but for the sake of providing an example). Could I have a practice where I refer those types of cases out based solely on personal preference? Would that be ethical, or am I obligated to treat these cases?

This is a different question than referring due to personal biases, which is being discussed in another thread.

I think the obligation is to identify suitable resources for the client you do not wish to see. You absolutely have the right not to treat clients that you are qualified to treat, but I think that in emergent cases you do have an ethical obligation to provide emergent services until more appropriate services can be identified (think natural disaster or actively suicidal patients). This does not mean that you own them at that point.

M

 

[MBellows]

That brings up an interesting question for me. Considering that there are things we'd probably typically consider kosher to be seen by a "generalist" - say depression, anxiety (and I would argue substance abuse too since it is also very common), to what extent is everything specialized now? Because I don't think everything needs to be specialized.

You know, I wouldn't really judge what should be seen as "ok" to be seen by a generalist for as based on its commonality. I'm not sure how I would go about it, but commonality has nothing to do with the skills needed to have good outcomes.

The second question that it brings up for me is, "should anyone ever stop having supervision?" I think the answer to that question is a decided "Hell no." That doesn't mean that everyone needs formal supervision, but at least have some form of collaboration so that you don't bring your own biases in or be blinded by your own ineptitude.

 

[futureapppsy2]

Working with LGBT populations should require no more specialization than working with any racial minority population, and using the justification that LGBT folk are more likely to come in for issues pertaining to their minority status than someone who is a person of color, therefore clinicians should be able to deny them services due to lack of 'specialization' (although the pathology may be something as general as depression, GAD, etc.) is perpetuating the stigma associated with being LGBT therefore increasing the likelihood that these people will have mental health issues relating to their sexuality.

Isn't the idea behind multicultural competence that we do need to pay attention to issues of race, ethnicity, cultural, sexuality, gender, etc., even when they are not the presenting concern and that clinicians should be trained with regards to how those can affect clients' presentation, response to treatment, etc., etc? Some psychologists argue that therapists should be matched to clients based on those characteristics whenever possible because of they would arguably have a better understanding of what the client's experience as a member of a given (often minority or disenfranchised) group or groups are like (which can be a dangerous assumption for both the client and and the therapist if managed poorly but beneficial in other situations).

The second question that it brings up for me is, "should anyone ever stop having supervision?" I think the answer to that question is a decided "Hell no." That doesn't mean that everyone needs formal supervision, but at least have some form of collaboration so that you don't bring your own biases in or be blinded by your own ineptitude.

+1

 

[Pragma]

You absolutely have the right not to treat clients that you are qualified to treat, but I think that in emergent cases you do have an ethical obligation to provide emergent services until more appropriate services can be identified (think natural disaster or actively suicidal patients). This does not mean that you own them at that point.

Very interesting perspective and definitely in line with what I have heard in the "real world" - do you think there are limits on how you decide who not to treat (assuming the cases are not emergent)?

 

[Pragma]

You know, I wouldn't really judge what should be seen as "ok" to be seen by a generalist for as based on its commonality. I'm not sure how I would go about it, but commonality has nothing to do with the skills needed to have good outcomes.

Also an interesting notion. I guess I always figured that there were some "bread and butter" diagnoses like depression, anxiety disorders, and substance dependence.

One could specialize in any area, but how do you decide if specialized training is required? I am speaking from a clinical population standpoint - not from a technical skill standpoint (e.g., neuropsychology).

 

[MBellows]

One could specialize in any area, but how do you decide if specialized training is required? I am speaking from a clinical population standpoint - not from a technical skill standpoint (e.g., neuropsychology).

That's a good question, I'd be interested to see any research on outcomes and different levels of continuing education or specific coursework held by the therapist.

 

[Pragma]

While having a doc not want to see you for being gay isn't the worst thing in the world, it's not the right direction a progressive field like psychology should be heading.

This isn't really what the thread is about, but okay.

Working with LGBT populations should require no more specialization than working with any racial minority population, and using the justification that LGBT folk are more likely to come in for issues pertaining to their minority status than someone who is a person of color, therefore clinicians should be able to deny them services due to lack of 'specialization' (although the pathology may be something as general as depression, GAD, etc.) is perpetuating the stigma associated with being LGBT therefore increasing the likelihood that these people will have mental health issues relating to their sexuality.

Isn't the idea behind multicultural competence that we do need to pay attention to issues of race, ethnicity, cultural, sexuality, gender, etc., even when they are not the presenting concern and that clinicians should be trained with regards to how those can affect clients' presentation, response to treatment, etc., etc? Some psychologists argue that therapists should be matched to clients based on those characteristics whenever possible because of they would arguably have a better understanding of what the client's experience as a member of a given (often minority or disenfranchised) group or groups are like (which can be a dangerous assumption for both the client and and the therapist if managed poorly but beneficial in other situations).

To also quote what T4C said in another thread:

Oy vey. There are reams of literature that would disagree with you. For instance, a gay man losing his gay male partner of 20 years would have FAR different issues with depression and grieving than a heterosexual male losing his heterosexual female wife of 20 years. This isn't my area of work, nor is therapy something I do much of anymore, but I'm sure others can cite some good articles.

I wonder if someone who does not want to work with the queer population, for whatever reason, might just be able to say "Mental health issues as experienced by LGBTQ individuals are unique due to a number of factors. As such, I recommend that you see a provider who has expertise working with this population."

It is just a question. I personally have worked with numerous LGBTQ individuals in the past, but I wonder if this is the type of thing someone might say if they did not want to work with this population. Is that ethical? Can we use a lack of specialization as a way to not see clients we don't want to work with? Is that a sneaky way out of doing something or a genuinely good referral?

 

[Doctor Eliza]

Well I suppose it depends if you consider specialization = competence. In the other thread, some folks were arguing that working with LGBTQ populations, for example, shouldn't require specialization. I tend to think that substance abuse shouldn't either, although I think training programs generally do a poor job addressing the issue.

So assuming you are a generalist, is just saying you are not a specialist in that area sufficient to refer ethically? Because I am not certain that "lack of specialization" = incompetence for a lot of very common issues.

I think you might be in the minority arguing that substance abuse should not require specialization. There are whole training programs and licensure for licensed chemical dependency counselors. Such licensure does not exist for diagnoses like depression and anxiety. I absolutely agree that doctoral programs neglect training in substance abuse. In my scientist-practitioner program, we literally had one lecture on substance abuse tx in our CBT class and that was the entirety of our training on that topic.

Dr. E

 

[Pragma]

I think you might be in the minority arguing that substance abuse should not require specialization. There are whole training programs and licensure for licensed chemical dependency counselors. Such licensure does not exist for diagnoses like depression and anxiety. I absolutely agree that doctoral programs neglect training in substance abuse. In my scientist-practitioner program, we literally had one lecture on substance abuse tx in our CBT class and that was the entirety of our training on that topic.

Dr. E

Well historically there has definitely been division between MH and SU treatment, although I believe doctoral psychologists are considered competent to treat under their licenses in most (all?) states. Perhaps it is a pipe dream of mine, but considering how common it is in our own clinical populations, one might consider it a basic to know about models of addiction, treatment options, and client-intervention matching characteristics that are important if you want to be a decent psychologist.

The fact that there are other practitioners out there to treat the illness is in no way different (in my mind) than the fact that we have MA level providers treating the same stuff we treat as psychologists anyways. Someone with their chemical dependency certification may not even hold a bachelor's degree in some states, let alone have expertise in assessing for factors that are known to be important for integrated treatment of dual disorders (which constitute 50-75% of people presenting at substance abuse treatment facilities).

 

[Doctor Eliza]

I think there is a balancing act. If everyone decides that they only want the easy patients, there are so many people who won't get served. This has become an issue with the child psychiatrists in my town. Of the PP child psychiatrists, I'd say 90% do not accept insurance. If you must use your insurance, you will need to go to the local children's hospital. The wait time at the hospital is typically 6 months or greater. This has created a situation where only the financially comfortable have reasonable access to care. On top of that, the PP folks turn away clients that might be slightly complicated. I had one client who was so desperate that his financially strapped mom borrowed the $550 needed for the psychiatric intake from friends and relatives. After having the intake, the MD said that yes, your kid is bipolar but I won't treat him. The justification was that his non-custodial father (who rarely saw him) did not approve of psychiatric tx. Mom was solely responsible for the child's medical care and the psychiatrist had not even spoken to dad. He just didn't want any possible trouble in the future. I have also had clients discharged from tx with their psychiatrists due to one hospitalization.

In my opinion the child psychiatrists in my town have gone too far. Yes, easy patients are nice and no one can compel anyone to see anyone. But at a certain point, if you just want a cushy job, you need a different profession.

Best,
Dr. E

 

[Doctor Eliza]

Well historically there has definitely been division between MH and SU treatment, although I believe doctoral psychologists are considered competent to treat under their licenses in most (all?) states. Perhaps it is a pipe dream of mine, but considering how common it is in our own clinical populations, one might consider it a basic to know about models of addiction, treatment options, and client-intervention matching characteristics that are important if you want to be a decent psychologist.

The fact that there are other practitioners out there to treat the illness is in no way different (in my mind) than the fact that we have MA level providers treating the same stuff we treat as psychologists anyways. Someone with their chemical dependency certification may not even hold a bachelor's degree in some states, let alone have expertise in assessing for factors that are known to be important for integrated treatment of dual disorders (which constitute 50-75% of people presenting at substance abuse treatment facilities).

I do think we need better training on this topic in grad school. Absolutely. But I wonder if the population you work with has skewed your sense of how common this issue is in typical outpatient settings? As you can imagine, based on my limited training in substance, I do not see clients who come in with substance issues as their presenting problem. So if they say that's why they are coming in, I am not given them as patients. In my almost 4 yrs in PP, I have only had to refer out about one person per year after an intake where I discovered that substances were a major concern. Actually, none of our 25ish psychologists see substance. Our PP does have 3 LISW LCDC's who see substance patients. I have no problem sending people to them, because I know they are way more qualified. I have never felt that the inability to treat this topic has held me back.

Dr. E

 

[Doctor Eliza]

To clarify, I think we all do need to know the models of addiction and what is out there in terms of tx. I don't think we all need to know the ins and outs of that tx or be able to provide it ourselves.

 

[Pragma]

I do think we need better training on this topic in grad school. Absolutely. But I wonder if the population you work with has skewed your sense of how common this issue is in typical outpatient settings? As you can imagine, based on my limited training in substance, I do not see clients who come in with substance issues as their presenting problem. So if they say that's why they are coming in, I am not given them as patients. In my almost 4 yrs in PP, I have only had to refer out about one person per year after an intake where I discovered that substances were a major concern. Actually, none of our 25ish psychologists see substance. Our PP does have 3 LISW LCDC's who see substance patients. I have no problem sending people to them, because I know they are way more qualified. I have never felt that the inability to treat this topic has held me back.

Dr. E

The base rates (depending on which epidemiological surveys you look at) for substance abuse in the general population are quite high - in fact, comparable to base rates for the more common mental illnesses (e.g., anxiety, depression). We are talking maybe 10% of the population here (you are more likely to find substance use issues than ADHD in an adult), with much higher rates among those with mental illnesses. I am not sure where you practice, but one of the things I am concerned about is the lack of appropriate assessment for substance related issues. Many clients are also not honest about it during screenings because of the stigma, or view it as an issue secondary to their mental illness (even though perhaps both are primary).

 

[Doctor Eliza]

The base rates (depending on which epidemiological surveys you look at) for substance abuse in the general population are quite high - in fact, comparable to base rates for the more common mental illnesses (e.g., anxiety, depression). We are talking maybe 10% of the population here (you are more likely to find substance use issues than ADHD in an adult), with much higher rates among those with mental illnesses. I am not sure where you practice, but one of the things I am concerned about is the lack of appropriate assessment for substance related issues. Many clients are also not honest about it during screenings because of the stigma, or view it as an issue secondary to their mental illness (even though perhaps both are primary).

Yeah, I knew you were going to jump all over that. I don't doubt that it is out there and a lot of it, but perhaps these folks are being seen in other tx settings (e.g., there is a major center devoted to substance tx nearby)? I don't know where they are going, I just know I have been able to manage not to see them and they have been able to get services. And I agree assessment is absolutely important. I ask every patient about substance use on intake and probe from there. Of course some are likely lying, but then again patients lie to you about a lot of things.

Since you feel versed in substance tx, wouldn't you say that someone who qualifies for a substance dx needs a very different type of intervention than someone who is "just" depressed? There are ways in which they are medically at risk and likely to do things that put themselves in harm's way. It seems to me much more akin to an eating disorder dx than a depression/anxiety one. It really feels like a specialty more than something a generalist can handle.

Dr. E

 

[LivingOffLoans]

My own stance on the issue is mixed. I don't believe it's ethical to turn anyone away from treatment. At the same time, I feel it is unethical to work a case that you know with certainty is beyond your scope of practice and is of an urgent nature that requires immediate attention, and would cause harm to the patient if you did not refer them. To me, that is different than simply saying "I don't work with borderlines, substance abusers, eating disorders, etc..." Every case is different, so it is really hard to make a black and white decision on anything. But I would never flat out abandon a patient; I would at the very least work with them to secure someone they were comfortable with. Plus, I think ongoing supervision, continuing education, peer consultation, and consuming literature regularly are all great tools in working with new issues. When we all start our training, it's all new to us, so at what point do we become so entitled that we start becoming selective about who we will and will not see, even if we know we could treat those we turn away? I guess it's contextual, but in my experience I tend to hear reasons that sound like greed or ignorance.

 

[Pragma]

Since you feel versed in substance tx, wouldn't you say that someone who qualifies for a substance dx needs a very different type of intervention than someone who is "just" depressed? There are ways in which they are medically at risk and likely to do things that put themselves in harm's way. It seems to me much more akin to an eating disorder dx than a depression/anxiety one. It really feels like a specialty more than something a generalist can handle.

Dr. E

Not really. In fact, I think a big part of the problem is in the attitudes of the treatment providers (not you necessarily, but in general). It isn't just having competency in motivational interviewing techniques that is important - but the degree of empathy a therapist can actually have for their client.

Brief interventions can be quite effective for people with addiction issues. But the factors associated with success are more often therapist-related (i.e., degree of empathy/management of stigma) than one might imagine. And even in the cases where they are not effective, a fair amount of subcultural knowledge can help a therapist quite a bit to empathize with these clients and help them to engage in services when they might not under other circumstances.

 

[MBellows]

Not really. In fact, I think a big part of the problem is in the attitudes of the treatment providers (not you necessarily, but in general). It isn't just having competency in motivational interviewing techniques that is important - but the degree of empathy a therapist can actually have for their client.

I'm mixed with this. I think it's unfair to say that someone one genetic predisposition reacts to an abnormal life event in such away that causes a self-reinforcing loop (say depression for instance) is any different than another (substance abuse). The only difference I see is that some of the abused chemicals make it harder to stop either through more intense limbic reinforcement or through other physiological issues (tissue dependence). The problem that I have, and this is probably just a gut reaction that I need to work on, is when I see parents who do drugs (usually meth or crack) and have their kids test positive for it. I generally don't see it as any different than causing traumatic physical abuse (often co-occurring anyway) and have to restrain myself from potentially damaging comments or actions.

 

[Pragma]

I'm mixed with this. I think it's unfair to say that someone one genetic predisposition reacts to an abnormal life event in such away that causes a self-reinforcing loop (say depression for instance) is any different than another (substance abuse). The only difference I see is that some of the abused chemicals make it harder to stop either through more intense limbic reinforcement or through other physiological issues (tissue dependence). The problem that I have, and this is probably just a gut reaction that I need to work on, is when I see parents who do drugs (usually meth or crack) and have their kids test positive for it. I generally don't see it as any different than causing traumatic physical abuse (often co-occurring anyway) and have to restrain myself from potentially damaging comments or actions.

So would you choose not to see child abusers because of that gut reaction? Just curious. We probably aren't the best person for a case if we are restraining ourselves.

 

[Pragma]

My own stance on the issue is mixed. I don't believe it's ethical to turn anyone away from treatment. At the same time, I feel it is unethical to work a case that you know with certainty is beyond your scope of practice and is of an urgent nature that requires immediate attention, and would cause harm to the patient if you did not refer them. To me, that is different than simply saying "I don't work with borderlines, substance abusers, eating disorders, etc..." Every case is different, so it is really hard to make a black and white decision on anything. But I would never flat out abandon a patient; I would at the very least work with them to secure someone they were comfortable with. Plus, I think ongoing supervision, continuing education, peer consultation, and consuming literature regularly are all great tools in working with new issues. When we all start our training, it's all new to us, so at what point do we become so entitled that we start becoming selective about who we will and will not see, even if we know we could treat those we turn away? I guess it's contextual, but in my experience I tend to hear reasons that sound like greed or ignorance.

Is it entitled to have preferences and act on them? Just curious where all of this obligation comes from if someone is setting up their own practice. I also wonder how much new training or continuing education I need to get in every possible area if my potential clients are going to determine my scope of practice.

 

[MBellows]

So would you choose not to see child abusers because of that gut reaction? Just curious. We probably aren't the best person for a case if we are restraining ourselves.

Honestly, it depends on what the client wanted to be seen for. Long term substance abuse treatment or other issue that like that, I would probably make my feelings about what they have clear, after assessing any risk for it continuing to occur (an ethical responsibility) and explain that I may not be the best choice in therapist because of those feelings and direct them to someone that I know could treat them better. If it were for crisis management, I would just have to deal with it long enough to stabilize and refer out.


On a completely separate note, and I'll probably delete this after my first cup of coffee, has anyone ever been reminded of yearly physicals by the juxtaposition of these two smilies?


👍

 

[Pragma]

Honestly, it depends on what the client wanted to be seen for. Long term substance abuse treatment or other issue that like that, I would probably make my feelings about what they have clear, after assessing any risk for it continuing to occur (an ethical responsibility) and explain that I may not be the best choice in therapist because of those feelings and direct them to someone that I know could treat them better. If it were for crisis management, I would just have to deal with it long enough to stabilize and refer out.


On a completely separate note, and I'll probably delete this after my first cup of coffee, has anyone ever been reminded of yearly physicals by the juxtaposition of these two smilies?


👍

I am quoting this so that you can't delete it...because that is funny!

What do you mean by "make my feelings about what they have clear"? What if your feelings are judgmental or harmful? What if you are biased against them? Is making your feelings known better than referring out, even if you cause harm by the former?

 

[MBellows]

I am quoting this so that you can't delete it...because that is funny!

What do you mean by "make my feelings about what they have clear"? What if your feelings are judgmental or harmful? What if you are biased against them? Is making your feelings known better than referring out, even if you cause harm by the former?

Wow. I'm still pre-coffee so this may contain a similar error. That should have read, "make my feelings clear about what they have done." Not in an "I can't treat you because I find you/what you do disgusting," but perhaps a "I may not be the best person to treat you because I don't understand xxx and I don't think that me spending the energy to cover up those feelings or struggle to understand would be ethical to you as a client, as you would be paying me to pay attention to you and help you with your problems, not my own."

 

[Pragma]

Wow. I'm still pre-coffee so this may contain a similar error. That should have read, "make my feelings clear about what they have done." Not in an "I can't treat you because I find you/what you do disgusting," but perhaps a "I may not be the best person to treat you because I don't understand xxx and I don't think that me spending the energy to cover up those feelings or struggle to understand would be ethical to you as a client, as you would be paying me to pay attention to you and help you with your problems, not my own."

I guess you just haven't defined what the feelings are. If they are important enough to share with the client, I would assume they are somewhat significant, and any form of self disclosure ought to take into consideration potential harm.

 

[Psychadelic2012]

Since you feel versed in substance tx, wouldn't you say that someone who qualifies for a substance dx needs a very different type of intervention than someone who is "just" depressed? There are ways in which they are medically at risk and likely to do things that put themselves in harm's way. It seems to me much more akin to an eating disorder dx than a depression/anxiety one. It really feels like a specialty more than something a generalist can handle.

Dr. E

I'm really glad you said this. PP therapy for someone knee-deep in substance abuse just won't cut it. In such a case, the PP therapist should always work as an adjunct provider, perhaps with the intention of providing continuity of care. Once (or even twice) per week 1-hour sessions won't do enough to promote change, even if that therapist has experience. Most likely, their experience came from an environment that was much more intensive anyway (i.e., inpatient, reisdential, halfway treatment, etc.).

 

[Pragma]

I'm really glad you said this. PP therapy for someone knee-deep in substance abuse just won't cut it. In such a case, the PP therapist should always work as an adjunct provider, perhaps with the intention of providing continuity of care. Once (or even twice) per week 1-hour sessions won't do enough to promote change, even if that therapist has experience. Most likely, their experience came from an environment that was much more intensive anyway (i.e., inpatient, reisdential, halfway treatment, etc.).

But more intensive treatment or more treatment does not necessairly mean better outcomes, and there is data suggesting that brief interventions can be quite effective. Not sure why a PP psychologist would refer out aside from not wanting to see the client or the need for immediate medical intervention.

 

[MBellows]

I guess you just haven't defined what the feelings are. If they are important enough to share with the client, I would assume they are somewhat significant, and any form of self disclosure ought to take into consideration potential harm.

As I said, a general poor choice of words this morning. Take my latter example as being what I would most likely say to a client. More stressing a lack of understanding and competence to work in that area than anything. Though socio-behaviorally one could also view that sort of self-disclosure as a mild attempt at behavioral modification, but I won't get into that argument as I haven't been fully versed on behavioral interventions (that'll be a 10k investment in my not-so-distant future).

 

[AcronymAllergy]

My personal opinion is to err on the side of "personal liberty" for the practitioner, and to allow them to essentially see (or not see) whatever types of clients they so choose.

On the assessment side of things, an example of something marginally similar could be practitioner who chooses not to conduct psychoeducational evals, or evals for individuals referred from social security for disability determination.

 

[Pragma]

The problem that I have, and this is probably just a gut reaction that I need to work on, is when I see parents who do drugs (usually meth or crack) and have their kids test positive for it. I generally don't see it as any different than causing traumatic physical abuse (often co-occurring anyway) and have to restrain myself from potentially damaging comments or actions.

I would probably make my feelings about what they have clear, after assessing any risk for it continuing to occur (an ethical responsibility) and explain that I may not be the best choice in therapist because of those feelings and direct them to someone that I know could treat them better.

As I said, a general poor choice of words this morning. Take my latter example as being what I would most likely say to a client. More stressing a lack of understanding and competence to work in that area than anything. Though socio-behaviorally one could also view that sort of self-disclosure as a mild attempt at behavioral modification, but I won't get into that argument as I haven't been fully versed on behavioral interventions (that'll be a 10k investment in my not-so-distant future).

I guess I am maybe thick-headed, but isn't your first statement above somewhat suggestive that you harbor negative feelings towards this subpopulation?

If so, I doubt you are alone and I don't think it is unreasonable to refer. But in the other thread, I would imagine someone would tell you this is your problem and that if you cannot address this bias and learn to work with these folks, then you probably aren't cut out to be a psychologist. I mean, child abusers have a high likelihood of having been victimized themselves as a child, for example...

But I am with what AA said above. If you don't want to see child abusers in your practice, I think it is your right not to so long as you can provide an appropriate referral.

 

[MBellows]

I guess I am maybe thick-headed, but isn't your first statement above somewhat suggestive that you harbor negative feelings towards this subpopulation?

Absolutely I do.

If so, I doubt you are alone and I don't think it is unreasonable to refer. But in the other thread, I would imagine someone would tell you this is your problem and that if you cannot address this bias and learn to work with these folks, then you probably aren't cut out to be a psychologist.

It may be my problem, and it may be something that I end up addressing in self-care later, but there are large swaths of the population that I can still work with.

I mean, child abusers have a high likelihood of having been victimized themselves as a child, for example...

While my philosophical beliefs urge me to be compassionate my personal experience tells me that if someone does something to hurt you, it's a learning experience that you shouldn't do it to others because hurting people is bad.

 

[Pragma]

While my philosophical beliefs urge me to be compassionate my personal experience tells me that if someone does something to hurt you, it's a learning experience that you shouldn't do it to others because hurting people is bad.

If it were that simple, then I doubt that it would be such a common issue.

I just want to clarify to people that I think referring out is fine and that unless you are the only provider in an area, choosing your patients to some extent is also fine. I don't really understand the notion that we need to be all things to all clients. If we don't want to see a client (for whatever reason), we probably shouldn't see them. I am using substance abuse as an example of a reason that I commonly see clinicians refer out, which I think has more to do with stigma in many cases, although I consider it to be something very basic that psychologists ought to know about. It sucks that so many training programs do a poor job of addressing it.

 

[MBellows]

If it were that simple, then I doubt that it would be such a common issue.

Of course I know that, but at this stage in my life I generally don't plan on looking for areas where I would consider becoming an abuser any more a normal reaction to anything than I would a perpetrator of genocide.

As for the rest of your comment, I don't think you'll get much more than a confirmation of your own beliefs from me.

 

[Pragma]

As for the rest of your comment, I don't think you'll get much more than a confirmation of your own beliefs from me.

Darn it. I wanted to get more confirmation of my beliefs before the afternoon 🙂

 

[snater]

But I am with what AA said above. If you don't want to see child abusers in your practice, I think it is your right not to so long as you can provide an appropriate referral.

And perhaps more importantly, in terms of client care, does any client not deserve to have a therapist who isn't uncomfortable working with their population? All therapists are human and imperfect. To expect any given therapist to be completely devoid of bias is unreasonable. What is reasonable is for a person to acknowledge where they have bias or discomfort around a topic and refer out, rather than provide therapy due to some pressure to appear unbiased and in the end, compromise the quality of care the client could be receiving.

 

[Psychadelic2012]

But more intensive treatment or more treatment does not necessairly mean better outcomes, and there is data suggesting that brief interventions can be quite effective. Not sure why a PP psychologist would refer out aside from not wanting to see the client or the need for immediate medical intervention.

I don't doubt this to be true for someone with a mild interference. But how can this possibly be true for someone with true substance dependence, for example? Someone using 10 bags of heroin a day? Drinking so much they have DTs? Surrounded by friends and family who use? How can 1-2 hours a week possible crack that (no pun intended)?

 

[futureapppsy2]

And perhaps more importantly, in terms of client care, does any client not deserve to have a therapist who isn't uncomfortable working with their population? All therapists are human and imperfect. To expect any given therapist to be completely devoid of bias is unreasonable. What is reasonable is for a person to acknowledge where they have bias or discomfort around a topic and refer out, rather than provide therapy due to some pressure to appear unbiased and in the end, compromise the quality of care the client could be receiving.

This is pretty much my POV on this issue. Also, I think if we expect therapists not to have biases and assume that biases make someone a de facto bad therapist. that will just make people less willing to address those biases through supervision, professional development, and referring out and thus make it more likely that biases negatively impact clients.

 

[Ollie123]

I'm somewhere in the middle on the addiction substance use issue (and that is my primary area).

On the one hand, I think its foolish how much it gets ignored. I do genuinely believe everyone should have some level of comfort with it. However, it is VERY important to define what we mean by treating substance use. Some withdrawal syndromes (alcohol, benzos) can be deadly. Even if not formal detox, these programs really do require medical management.

On the other hand, I had a supervisor who (while as a whole was actually one of the best clinicians I've worked with) was uncomfortable working with even extremely low levels of substance use. College kid who smokes a small amount of pot once a month? Quit or we won't do therapy anymore.

Like anything we deal with, substance use exists on a continuum. The average solo practitioner is probably not equipped to deal with someone whose depression is so severe they make a genuine suicide attempt in the waiting room. That doesn't mean we refer out anyone who says they get sad sometimes. So to with SUDs. Its pretty unusual for a substance users "bottoming out" to be their first contact with the healthcare system, and often not the mental healthcare system. When substance use isn't addressed, these are lost opportunities for intervention. Sometimes its because the practitioner takes an "I don't want to know about it" stance or just assumes its not there unless the client brings it up (which I consider bad practice to the point of being unethical). Other times its because they are uncomfortable discussing the topic. Which I can understand, but just because it can be "tough" to ask a client about their suicidal thoughts doesn't mean its okay to ignore it if you have suspicions.

Anyways, I could go on for awhile but I'll leave it at that. Certainly not everyone needs to be ready to see clients whose addiction might kill them at any moment. I do think everyone should be comfortable assessing for it, aware of how it may impact treatment of comorbid diagnoses, and feel reasonably comfortable at least providing a motivational intervention for someone with low-level abuse.

 

[Pragma]

I don't doubt this to be true for someone with a mild interference. But how can this possibly be true for someone with true substance dependence, for example? Someone using 10 bags of heroin a day? Drinking so much they have DTs? Surrounded by friends and family who use? How can 1-2 hours a week possible crack that (no pun intended)?

I think it is pretty obvious that a great deal of people will need acute intervention (e.g., detox) in order to make initial steps. Also, I do believe that our general trend towards reducing length-of-stay for people is not ideal. But let's talk about post detox. Why not an outpatient PP psychologist? If outpatient therapy is a reasonable part of their treatment plan, why not?

I think it is important to remember that a lot of people get better just on their own or just via outpatient 12-step intervention.

There actually is kind of a fun article about this topic by Bill Miller - I'll post a link. http://www.ncbi.nlm.nih.gov/pubmed/10822741

 

[Pragma]

Like anything we deal with, substance use exists on a continuum. The average solo practitioner is probably not equipped to deal with someone whose depression is so severe they make a genuine suicide attempt in the waiting room. That doesn't mean we refer out anyone who says they get sad sometimes. So to with SUDs. Its pretty unusual for a substance users "bottoming out" to be their first contact with the healthcare system, and often not the mental healthcare system. When substance use isn't addressed, these are lost opportunities for intervention. Sometimes its because the practitioner takes an "I don't want to know about it" stance or just assumes its not there unless the client brings it up (which I consider bad practice to the point of being unethical). Other times its because they are uncomfortable discussing the topic. Which I can understand, but just because it can be "tough" to ask a client about their suicidal thoughts doesn't mean its okay to ignore it if you have suspicions.

Very much agree with you here. I believe it is under assessed and underappreciated in the presence of other mental health conditions. That's obviously a big part of the push for more integrated treatment, which doesn't necessarily have to mean an addictions specialist + a mental health specialist.

There is definitely a need for specialists out there. I just think that a psychologist ought to be able to adequately assess and refer, at a minimum. If outpatient therapy was a reasonable part of that person's treatment plan, why couldn't a psychologist provide that? It isn't rocket science - and as I mentioned before, the specialists in some states only have an associate's degree. I think a big part of the problem there is the within-field stigma and attitudes towards clients that use substances. But I get that some people just aren't very knowledgeable about the subpopulation, but I find just find that depressing.

ETA: Beyond me saying that I don't like how we don't address it much in training, I also want to mention that I believe the addictions field could really benefit from more involvement from psychologists. There are a lot of really interesting interactions with the whole "integrated care" concept based on differing treatment philosophies, and a lot of places where chiming in would be great.

For example, I'd imagine a psychologist could provide some pretty good advice to someone dually-diagnosed who is being told by their AA sponsor that "medication = crutch" - and I could also see that psychologist providing some insight to the patient about how AA as an organization has actually published literature about how it can be dangerous NOT to take medication and that some sponsor's personal opinion does not reflect that of the organization. Then they could also talk about how much the research supports the use of AA, but help that dually-diagnosed client to keep it in perspective. Just one thought about a practical way that an outpatient psychologist could intervene.

 

[Pragma]

This is pretty much my POV on this issue. Also, I think if we expect therapists not to have biases and assume that biases make someone a de facto bad therapist. that will just make people less willing to address those biases through supervision, professional development, and referring out and thus make it more likely that biases negatively impact clients.

Which brings me back to my main question...because we can't guarantee that all therapists are going to go out there and work on all of their biases.

Can someone build a practice just seeing the types of clients that they want to see (and therby exclude others based on their preferences - regardless of whether it is a simple preference or a preference due to personal bias)?

I am basically saying that a) people already do this and b) it is probably fine so long as you are not the sole provider around. Philosophically, I just wonder how this jives with our views of discrimination and bias. Because we discriminate all of the time based on things like payment, referrals coming from people we like vs. random referrals, etc.

 

[Ollie123]

As for the broader question at hand, I'm not sure there is a definitive answer - for me it all depends on context. Do I have a problem with the director of a top-notch academic clinic picking and choosing the most interesting cases while letting the underlings see the more run-of-the-mill ones? Obviously even there some will depend on context, but in general I think most would view that as fine. If an intake reveals someone is actively suicidal, can we just say "Sorry, I only see people for weight management" and show them the door, with no further obligation? Obviously that would be a big problem.

So to me, this is going to depend entirely on context. I firmly believe in professional autonomy - psychologists should have a right to decide how they want to practice and be able to exert some control to make that happen. Removing that right invites scope-of-practice issues since it places more pressure to see everyone regardless of competence. I'm not a big fan of slippery-slope arguments, but I also worry it opens the door for telling people when they need to practice. If a clinical researcher has an active lab and someone wants therapy with them because they heard they are an expert, are they obligated to serve as that person's therapist? Certainly not, but I think it opens the door for that.

For me, the line is largely drawn at the entrance to the room. Once we've passed the provisional intake phase and are in the therapy phase, they are my patient. Once that therapeutic relationship has started to form, I would need to have a very good reason for referring out. I think most commonly that would be an issue of competence, inability to have a productive therapeutic relationship (not all clients/therapists will work well together), etc. Some logistical issues are obvious exceptions (e.g. client or therapist moving away).

I'd think all of the above would be obvious - the tough part is the middle. Is a therapist who sets up shop in the ritzy part of town "choosing" high SES clients? If a poor, minority, working class family scrapes together the money and makes travel arrangements for that person to see their daughter and they turn them away when they arrive at the door... personally, I'd be absolutely comfortable saying the therapist is an abhorrent, disgusting individual, but I'm also not sure its something the profession/legal system could or should realistically monitor.

What I don't like about the medical system as a whole and what I think all too often isn't considered is the "investment" people make in therapy. Here, I'm not just talking about personal but financial. I suppose its a somewhat crass way of looking at things, but given the financial state of most of the folks I see I think its an important consideration. I don't know that I've ever had a client whose progress in therapy was linear. Typically, its flat for awhile....then a bump up, then back down, then bump up even higher, etc. and only near the end is progress typically steady. I view those early sessions as an investment. Some of it is in skills, but some of it is in therapeutic relationship and other factors. Sure,we're charging per the hour, but I view those early sessions as an "investment". If I terminate, they may or may not (and I err on the side of "not") be able to pick up where they left off. Do they then deserve a partial or full refund off the early sessions? Legally no, but if I were in that situation I'd almost certainly feel like I'd cheated the person out of money.

Anyways, I'm rambling at this point so I'll just leave it with this. Not an easy yes/no answer. Context is important. Any "choosing" that happens should definitely happen on the front end if at all possible. I think it has to be taken case-by-case.

 

[Pragma]

What I don't like about the medical system as a whole and what I think all too often isn't considered is the "investment" people make in therapy. Here, I'm not just talking about personal but financial. I suppose its a somewhat crass way of looking at things, but given the financial state of most of the folks I see I think its an important consideration. I don't know that I've ever had a client whose progress in therapy was linear. Typically, its flat for awhile....then a bump up, then back down, then bump up even higher, etc. and only near the end is progress typically steady. I view those early sessions as an investment. Some of it is in skills, but some of it is in therapeutic relationship and other factors. Sure,we're charging per the hour, but I view those early sessions as an "investment". If I terminate, they may or may not (and I err on the side of "not") be able to pick up where they left off. Do they then deserve a partial or full refund off the early sessions? Legally no, but if I were in that situation I'd almost certainly feel like I'd cheated the person out of money.

It is a very interesting thought. I definitely think there is a difference between referring out on the front end and referring out once you are engaged in treatment.

To add to your thought, how about we refund clients who don't get better while we are at it? When I was on postdoc, clients complained about their previous therapists quite a bit whenever I discussed therapy as a recommendation following their assessment. Some felt it was pointless, had no direction, therapist just chatted with them without really giving them much to try, etc. Perhaps we ought to refund those folks?

I think there are definitely great times to refer out - one being when it does not seem that the intervention is working or the therapeutic alliance is strong enough. Then perhaps sending them to someone else would help to avoid wasting time and money?