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Setting Clear and Ethical Boundaries with Clients

Section 20
Referrals

Question 20 | Test | Table of Contents

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Let's look at boundaries as they relate to the referral process. Just as you cannot be all things to all people, so there is no one social institution that will serve all the needs of a complex individual in a complex society. Failure to refer can have tragic consequences in cases when the physical health of the client is in question or when physical factors may play a potential role in the client's quality of life.

For example, the possible physical complication of a client with anorexia nervosa requires the monitoring of physiological consequences by a physician. This example of the boundary of referral to a physician in the case of anorexia nervosa is pretty clear cut.

♦ 4 Questions to Explore Referrals
But let's look at a more complicated example. What if you have been seeing a client for several years and you feel a colleague who specialized in, for example, Gastault training would be of benefit to your client? As you know being referred usually carries with it elements of rejection, anger, hope, and expectation.
-- 1. How do you introduce the idea of a referral to alleviate your client's feeling of being rejected?
-- 2. How do you handle possible anger from the client regarding your suggestion concerning a referral?
-- 3. How do you introduce the idea of a referral to another therapist, while not raising false hope in the client?
-- 4. How do you bring your client's expectation level regarding the new therapist into line with reality…so he or she does not view the new therapist as a cure-all for their problems?

Think over your current or past clients whom you felt may have needed a referral. Think of a client you referred to another agency or professional. Now think of a client you did not refer to another agency or professional that possibly could have benefited from the treatment or services of another. Where and how did you draw this boundary in your mind? Was a referral not made as a measure to avoid dealing with you client's possible feelings of rejection, anger, hope, and expectation?

♦ 3 Key Test Questions Regarding Ethical Referrals
Thus, three boundary questions are proposed here.
The first question is, when to refer and when not to refer?
The second question is, when does referring or not referring serve to meet my own needs and not the needs of my client?
To find an answer to these two boundaries ask yourself the following three questions:
1. What is the context of the situation for considering a referral?
2. Would my client's goals be better served by a referral?
3. What is the potential harm resulting from referring or not referring to another?

- Abramson, M. (1996a). Reflections on knowing oneself ethically: Toward a working framework for social work practice. Families in Society, 77(4), 195-202.
Reviewed 2023

Peer-Reviewed Journal Article References:
Hiefner, A. R., & Woods, S. B. (2019). Implementing integrated behavioral health: Testing associations between shared clinical time and space and provider referrals. Families, Systems, & Health, 37(3), 206–211. 

Muran, J. C., & Eubanks, C. F. (2020). Introduction: Pressure in the therapeutic relationship. In J. C. Muran & C. F. Eubanks, Therapist performance under pressure: Negotiating emotion, difference, and rupture (pp. 3–12). American Psychological Association.

Pinner, D. H., & Kivlighan, D. M. III. (2018). The ethical implications and utility of routine outcome monitoring in determining boundaries of competence in practice. Professional Psychology: Research and Practice, 49(4), 247–254.

Shapiro, E. L., & Ginzberg, R. (2003). To accept or not to accept: Referrals and the maintenance of boundaries. Professional Psychology: Research and Practice, 34(3), 258–263.

QUESTION 20
What are four possible reactions your client may have when a referral to another professional or agency is suggested? To select and enter your answer go to Test.

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