Consult, Get Educated, Get Supervised, And, Get Therapy – Referrals Are Based On Your Competence

It has happened again. I have a supervisee struggling with a desire to refer her client out because of a conflict in values.  It’s a common occurrence for mental health professionals, those in training, as well as those providing the training to find their personal values to be in conflict with those of our clients / students / supervisees.  (Some would say that this is an issue of countertransference.)

Last year about this time, there was a rich discussion taking place on one of my favorite online discussion lists (CESNET-L) referencing the Ward v. Wilbanks litigation in Michigan.  In the midst of that discussion was the thoughtful voice of Perry C. Francis, Ed.D., LPC, NCC, ACS. Perry is a professor and also the Coordinator of the counseling clinic at Eastern Michigan University – the university that was at the center of this debate.  I had asked for his permission and he graciously agreed to allow me to share his thoughts on this subject with you.

Colleagues:

Let me begin with full disclosure.  I am a member of the faculty at EMU where the Ward v. Wilbanks case originated and am one of the litigants in the case.  The Ward v Wilbanks case is motivation for the legislation in Michigan.  This same legislation has already passed in Arizona.  It has been proposed in several states and is being fought against by the American Counseling Association, American Psychological Association, National Association of Social Workers, and several civil rights groups across the nation.

Secondly, I remind you that truth is usually the first casualty of a lawsuit (or any other “war”) so anything you read in the popular press generally does not capture the entire scope of the issues, especially one as value and issue laden as Ward v. Wilbanks.  Everything I have read about the case has never capture all that needs to be known in order to make an informed decision.  Rather it has been slanted to fit the political agenda of the writer or omits facts to fit the space provided for the telling of the story.

To the larger issue being discussed (values based referrals), I point you to an excellent article written by Shiles (2009) which outlines the issues and proposes what I think is an excellent course of action in cases of values based conflicts.  In short, there is a process one must go through prior to making any referral that begins with consultation with a colleague about the issue, obtaining critical education and supervision, and, if needed, one’s own therapy to deal with whatever those issues are that may be triggered in the clinician.  There may be other intervening steps, but this outlines the basics.  Then the referral is based upon the issues of competence to provide services, not issues of values.

As many clinicians know, clients may bring up issues to discuss that are very sensitive to the client well after the initial sessions have taken place.  The client determines the counselor is someone in whom trust can be given and only then gives up the real issues for consideration.  To make a referral because the client’s issues are somehow conflictual with the counselor’s values makes the sessions about the counselor and not the client.  It is also a hidden form of discrimination and a micro aggression that continues to deny appropriate services to those in need.

As for the issue of making referrals because of an inability to help clients (ACA Code of Ethics A.11.b.), this has to do with competence.  A conflict of values is not about competence.  We are expected to be competent in dealing with a diverse population.  Competence is also not an either/or issue but something that we are always developing.  Thus, when a client brings up an issue that has more to do with things that make me uncomfortable (i.e., values conflict), I am to do  something about me (consult, obtain education or supervision, get therapy), not refer the client.

Finally (although there is so much more that can be said), many counselors (school counselors, counselors in rural areas, etc.) may not have the luxury of large referral network or any referral network.  They may be assigned a client base (e.g., school counselors) or the only counselor in the school or agency.  What am I to do when the client (student) presents with issues that conflict with my values?  I am to be a compassionate and caring professional and provide the best and most clinically appropriate services I can within the limitations of the agency I work and my abilities as a professional counselor.  That is the ethical and professional thing to do.

As a profession, we need to struggle with this issue, balancing the needs & rights of the client to receive competent professional services while helping new and experienced clinician increase their ability to provide services to a diverse population.

Respectfully,

Perry C Francis”

And, later that same day as part of the ongoing discussion, Perry added the following . . . .

This is a very powerful, rich, and wide ranging discussion.  As one person already pointed out, the tone, depth, and emotion in the posts reflect a lot about us as professionals who are struggling with our own issues in this area as well as trying to define it for the students that many of us work with.

Let me point out a few ideas:

1)      This issue is not about religion.  Religion is only the vehicle for the current discussion and issue.  This is about values, both professional and personal.  It is about how self-aware we are of those personal and professional values and how we manage them while in a therapeutic relationship with another human being.  As many experienced therapists will tell you, you already have worked with someone whose values differ from yours, it just never came up in the session.  When it does, it is generally too late to refer without doing some sort of damage.  Managing your values helps to make it about the client and not just about you.

2)      Counseling was once thought to be a values free endeavor. But we soon discovered that values impact the counseling process.  Just read the literature and you will see how values and the management of values play an important role in counseling.

3)      A person can hold deeply held values and not ascribe to or believe in any particular religion.  As a practicing Christian and former ordained minister (Lutheran), I realize that Christianity is a broad religion that encompasses many strands, just as does Islam, Buddhism, etc.  To paint all people of any religion with the same brush is to miss the many colors within the group.  There are generally more in-group differences than between-group differences.

4)      There will always be anecdotal examples that are the exception to the rule.  Precisely because they are anecdotal, they cannot become the rule.  The anecdotal case pushes us to develop and refine ethical decision making and our own ability to think critically.

5)      Ethics are generally written in an aspirational mode realizing that they are what we aspire to but sometimes miss due to the frailty of the human condition.  The ACA Code of Ethics is a mixture of both aspirational and mandatory ethics.  Yet the focus is always on how we can best serve the client.  That is one place where the debate resides. How we can best serve our client, by referring if there is an irreconcilable values conflict so no harm comes, or working on managing that conflict in such a way so the client is not harmed.  In either case, we will be less effective than if the values between the client and the counselor were completely congruent. Alas, that does not always happen.

6)      So what do we do?  We debate, we develop as persons and professionals, and we seek what is in the best interest of our individual clients by aspiring to be the best we can be.  That requires continual vigilance and management of our personal and professional values and how they impact the counseling relationship.

Finally, if you have read this far, let me point you towards the British Counseling Association Code of Ethics.  It has, what I think is a great preamble that outlines the professional values of counseling and the personal moral qualities of a professional counselor.  It is worth a look.

Respectfully

Perry C. Francis, Ed.D., LPC, NCC, ACS
Professor & Counseling Clinic Coordinator

Eastern Michigan University”

In the midst of building or expanding your private practice, this is a heartfelt and gentle reminder to consider the intersection of your personal values and your clinical practice. 

Your choices related to this intersection are a direct reflection of your professional competence – as a clinician, as a clinical supervisor, as an educator, and as a business person. 

Ethical referrals are based on your clinical and business competence. 

When you find yourself stuck or in an uncomfortable or perplexing situation . . . . Consult.  Get educated.  Get supervised.  Or, get therapy.  

Let me know if I can help.