Referral and Transference

What is a Referral?

The act of officially sending someone to a person or an authority that is qualified to deal with them is called as reference. For example, Legal aid or any kind of professional help, can often provide referral to other type of agencies. In counselling, a referral should be considered when you believe that your client’s problems go beyond your own experience or expertise.

It can also so be done when you feel uncomfortable helping your client with some issues. The act of directing a patient to a therapist, physician, institution, etc for revaluation, consultation or treatment is called as referral. Making a referral at the appropriate time is part of the professional conduct for counsellors in practice.

Clients coming from all walks of life can present with many difficulties. Each client is unique. One of the counsellors’ ethical obligations is to work within the competencies and the job description. Sometimes, it so happens, that the client needs help with other issues such as medical help, debt, or legal difficulties. This is where the referral is useful. The client should never feel that help is not available to them.

So if the client asks for help in any legal matter, then a referral is made to the appropriate legal professional who can be of the help to him. Sometimes when the client needs medical intervention then he is referred to the appropriate medical doctor, if patient has severe mental health issues, a trained medical doctor is the one to help him.

If the client is under the influence of any substance like alcohol or drugs, he should be referred to an expert in this area.The procedure should be a smooth journey from one professional helper to another so that all the aspects of the client’s problems or difficulties can be dealt with.

So a referral can be defined as a practice of helping the client to find expert assistance that he needs and which the Counselor or the therapist cannot provide to him. Directing the client to another counselor or therapist who has higher level of training or some special expertise related to the clients need is involved in this process.

Referral is when the Counselor makes recommendations as to where else the client might seek treatment for him. It is important to note that being referred to; may lead to the client experiencing some difficult emotions. Hence, before the referral, it is extremely important to explain the decisions and the reasons clearly and calmly to the client. What the client might gain from the referral must be made clear. The Counselor may also help the client to work through their reaction regarding the referral.

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Purpose of Referral

At some point, the client may challenge your ability to provide counselling. At some point you will begin to work with the client who challenges your ability to provide compassionate counseling. it may be possible for you and the client to work together to overcome this difficulty, or providing a reference to another counselor or therapist, may be best for both you and the person you are working with. Ending the therapy maybe a difficult decision to make for both the therapist and the client.

Situations in which you want to consider it necessary to refer the client to another professional are:

If the client will be better served by another Specialist

They would be better served by a specialist when individuals come to therapy for issues they are experiencing such as depression and anxiety or grief. Individuals may seek help from the therapist for things they do not understand.

As the therapy progresses, deeper issues that underlies symptoms can we see may have mental health challenges that you have no training to address. For example, personality disorder, psychosis etc are the conditions which require specialised treatment. The client may need medical treatment to resolve some of their issues.

If continuing therapy poses an ethical risk

The therapist may realise that the individual that he is working with has different beliefs and values then himself. For example, they have different religious beliefs, sexual orientation, belong to a different political party, etc. It may happen that these differences may challenge the therapists ability to provide compassionate care.

According to the code of ethics, the therapist should be able to separate the personal the life and convictions, setting them aside while counselling. The needs of the client are of utmost importance. Letting your discomfort or your differences affect the therapeutic relationship and eventually its success. If you use these values as the reason to refer the client to another professional, he may feel rejected or abandoned.

This perceived rejection may cause problems while continuing the therapy with another counselor. Instead of ending the therapy, the Counselor may try to talk to his own therapist about the difficulties if he is unable to work with his clients. Even then if he is unable to work with the client then reference may be in the best interest of both the therapist and client.

If the client is not benefitting from therapy

The therapeutic process is not always easy for the therapist or for the individual seeking help. There may be sessions where the progress seems to stop or the client may report some sort of setback. If this continues, then the therapist has to think whether therapy is serving the client or not. In the therapeutic process and the relationship it is required that there is participation from both sides.

The therapist can offer very little when the client doesn’t actively participate in the therapy. Having an open conversation about the sessions may reveal things regarding this situation. The therapist may ask questions to check where therapy is going or whether the client is having trouble with some part of the process.

The therapist may have to think about this if the person that he is working with.

• seems unwilling to discuss certain aspects of the situation.
• shows little or no interest in taking efforts and putting in work into therapy.
• is consistently late or doesn’t show up for therapy.

Some clients may no longer benefit from therapy. This happens when a significant progress has been made in the therapeutic process. Some of the issues that the client wanted to resolve have been addressed and the client has made positive changes and also developed coping strategies that they may need to maintain the present state of well-being.

Having a conversation regarding these could help the therapist determine if the client has got what he needed from therapy. Some clients you may feel ready to end therapy but may not know how to bring up the issue themselves.

Alternatives to Referrals

Many experts in the area of counselling ethics advice waiting to refer a client until the therapist has tried all other options. When the therapist makes the decision to refer a client, it is important to consider his reasons for making the referral. The therapist has to ask himself whether it is because of the lack of knowledge. Therapists are generally expected to update their knowledge, continue their education and develop the counselling abilities throughout their career. They must undergo training regarding various mental health concerns or cultural competencies.

Seeking the support of colleagues and supervisors or seniors may help the therapist to gain this insight regarding the reason for referral. They could also help the therapist by giving a second opinion on a difficult situation of the client. Sometimes it is helpful to have the point of view or perspective of someone who has a similar kind of training but with no direct involvement in the therapeutic process.

It is also very important to practice self care when working with people whom you are not comfortable with or if you feel overly challenged by them. Relaxation techniques and mindfulness exercises can help you regarding this. It is also important to take time for yourself outside of work.

Maintaining a good work life balance can help you deal with these occupational challenges that overwhelm you. Therapists may also benefit from therapy. A co-counselor can help you regarding this. If the therapist is struggling to deal with his emotions when helping the client in a difficult situation this is very helpful.

Type of Therapy offered

When the type of therapy that the counselor offers is not suitable for the client and if the counselor or therapist believes that a different approach would be more beneficial for the client then a referral can be considered.

Concerns of Safety

When the counselor is working on his own and if the client is very aggressive or threatening, then the counselor may refer the client to an agency or institute where the therapist may have better safety arrangements.

Unable to work with the client because of personal issues

Sometimes the counselor/therapist is going through some problems in his own personal life. He may work well with the number of clients with many difficulties but with the clients who have problems that are close to the counselors own difficulties, then the counselor may find it difficult to work with the client. In such cases, the counsellor may make the decision to refer the client to another counselor to deal with the problems they are facing.

When should an individual be referred to a mental health professional or counselor? If the individual shows any of the following kind of behavior

• Threats of harm to either self or others.
• if the individual shows an inability to follow through on responsibilities.
• if the individual is unable to cope and repeatedly seeks help from others.
• if the person feels burdened or overwhelmed by his problems
• if symptoms of depression, insomnia, feelings of guilt, inability to concentrate, etc are seen.
• significant loss or trauma
• disordered thoughts or speech
• substance abuse
• emotional distress

It is very important that the clients are not taken by surprise about the referral. It could feel like rejection and also lead them to believe that their problems are very complex and are also therefore difficult to solve. So preparation for the reference should be done and must be discussed with the client. It must be conveyed to the client right from the start when it is being considered.

The client must be informed regarding the strengths and the different areas that the other professional is trained in and how it will help the client. The client has to me made aware from the beginning that referral is not threatening but that it is a genuinely helpful action that will support them in getting the right kind of help at the right time.

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What is Transference?

Transference is nothing but redirection of feelings about a specific person on to someone else. It refers to the client’s projection of the feelings about to someone else on to their therapist. For example, a patient who has a lost a parent as a child may look to the therapist for unconditional love and acceptance.

While the therapist may genuinely care for the patient, it may not feel like enough. The therapist will fall short of what his or her patient believes he/she needs. The patient may then feel hurt and perhaps angry and deeply disappointed.

What is Counter Transference?

Counter-transference is a redirection of the therapists’ feelings towards the client. From the above example, the therapist whose patient looks to the therapist as a parental substitute, feels disappointed, may make the therapist feel misunderstood and perhaps coerced by the patient.

Transference and counter-transference both, can take many different forms. They can be difficult to perceive and individuals therapists have different approaches to address these issues. Transference and counter-transference both are fundamental aspects of every therapeutic relationship and the awareness of them by both the therapist and the client are crucial for successful work.

Transference and counter-transference offer the opportunity to talk with the client about the patterns of interpretation and relationships with other meaningful people in their life. Articulation of a patients’ patterns of interacting needs to be observed and understood. Because these patterns are connected with familial relationships, the therapists’ ability to recognise and understand them is important.

The old and often rigid patterns of interaction need to be understood and recognized. They must be discussed in the therapy sessions. The process of of analysing and talking about his old patterns can help the patient gradually see how he or she participates in other meaningful relationships. Also the therapists’ own self awareness and observation, willingness to talk about what is going on between them are important in the ongoing therapeutic process.

Recognizing transference and counter-transference gets easier and better with time and experience. The longer we work with an individual, the more we are able to see the patterns of emotions and the interpersonal dynamics within the therapeutic relationship. As transference often come from development experiences including trauma, it is important to be gentle, caring, non judgemental. The pace of rapport development, strengthening the connection with the client, will allow the therapist to explore transference sensitively and in a way that promotes healing.

Transference can be very difficult to recognize because it is dependent on the ability of the therapist to see whether the clients’ response is in the present moment or whether it is being influenced by some internal beliefs and blueprint about the relationship.

Communicating about transference to the client can be tricky. Every therapist has his own way of doing it. Often it is helpful to give psycho- education about what transference is and ask about the therapeutic relationship. The therapist can also ask about what else they are experiencing, or when else they have experienced a particularly strong emotion, or whether they have noticed a dynamic in the therapeutic relationship.

Encouraging feedback and asking about the experience regarding the relationship and establishing a mutual understanding with them also helps. It may not be always easy for the client to share about their feelings about the therapist. Many at times, the client himself may not be aware about his feelings or beliefs. By facilitating a dialogue, the therapist can help his client to recognise how they are relating to the therapeutic relationship.

One of the biggest anxieties of the therapists is about dealing with counter- transference. Dealing with counter-transference starts with becoming aware of it. Being aware of your own state of mind can help the therapist differentiate and recognise the impact that the client may be having on him. It is important to identify your interpersonal tendencies in order to be mindful of how they might impact the therapeutic relationship.

Mindfulness helps the therapist to be more attuned when counter- transference is occurring. Practicing being in the present can help the therapist to notice when his emotions or bodily experiences shift or become intense. For example, if the therapist is holding his breath, it means that he has shifted his feelings from the present to being anxious, annoyed, etc.

Self-soothing and self-regulation are important. Use sensory integration and breath work to self regulate. It is important that the therapist remembers that he doesn’t have to share his own story at the moment. But, he can show the client a depth of empathy that someone else not going through the same experience might miss.

Experiencing counter-transference is normal. The client that the therapist encounters will remind him of the others that he has met in his life. Acknowledging this fact will help the therapist to keep his perspective. Actively participating in the therapeutic relationship means that the therapist will hold many ideas at once and also create space for the clients experiences also. The client may trigger emotions or memories during the session.

Taking deep breaths or pausing before responding to ensure that the response is appropriate will help. If the response is the reaction to the therapists’ own feelings then it may damage the relationship. Slowing down and being conscious of the thoughts and emotions is helpful. Also, once the session is over, the therapist should bring to notice and talk about this to his superiors/seniors or colleagues for feedback and processing.

Many therapist share what they are experiencing with the client. They may share their observations in a way that facilitates exploration and collaboration with the client by doing this in a non judgemental manner. It is very important that the therapist understands that it is not mandatory for him to do anything about counter-transference.

It is simply about being aware of your own feelings and not be ruled by them. When you are comfortable with your own feelings, you are free to allow other thoughts and emotions to come. The less resistant we are about our own feelings the more capable we become to accept those of others.

A therapist can gain insight into a client’s thought patterns and behavior through transference if they can identify when it is happening and understand where it is coming from. Transference usually happens because of behavioral patterns created within a childhood relationship.

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Categories of Transference

There are different categories of transference:

Positive transference

Enjoyable and happy aspects of past relationships are projected onto the therapist. This can allow the client to see the therapist as caring, wise, and empathetic, etc. This is beneficial for the therapeutic process.

Negative transference

Anger, hate or hostile feelings are projected onto the therapist. While it sounds detrimental or damaging for the therapeutic process, if the therapist recognizes and acknowledges this, it can become an important topic of discussion and allow the client to examine emotional responses.

Sexualized transference

When a client feels attracted to their therapist. This can include feelings of intimacy, sexual attraction, reverence, romantic or sensual emotions.

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Types of Transference

Maternal transference

Associating the therapist with a mother figure who is seen as loving, influential, nurturing, or comforting. This type of transference can generate trust or negative feelings, depending on the relationship the client had with their mother.

Paternal transference

Seeing the therapist as a father figure who is powerful, wise, authoritative, and protecting. This may evoke feelings of admiration or agitation, depending on the relationship the client had with their father.

Sibling transference

Can reflect dynamics of a sibling relationship and often occurs when a parental relationship is lacking.

Non-familial transference

Happens when clients idealize the therapist and reflect stereotypes that are influencing the client. For example, a priest is seen as holy, and a doctor is expected to cure and heal ailments.

Sexualized transference

Occurs when a person in therapy has a sexual attraction to their therapist. This is an all-consuming attraction toward the therapist and can be detrimental to the therapeutic alliance and client’s progress.

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Examples of Referral and Transference

Examples of referrals

• When the clients needs legal aid
  
  
• The client is facing financial problems and needs help and guidance for that.
  
  
• The client may have issues with substance/internet addiction and other problems which needs help from experts in that field.
  
  
• The counselor is unable to deal with the clients issues because of either lack of knowledge or his own issues.
  
  
• The kind of therapy he offers is not suited for the client’s personality or his problems.

Examples of transference

• You may meet a new person and immediately see a physical resemblance to your ex-spouse. You then attribute mannerisms of your ex to this new person.
  
  
• You observe characteristics of your father in a new boss. You attribute fatherly feelings to this new boss. They can be good or bad feelings.
  
  
• Transference in therapy happens when a patient attaches anger, hostility, love, adoration, or a other possible feelings onto their therapist or doctor.
  
  
• Opponent — If the client is transferring feelings associated with an adversarial relationship, such as a troubled relationship with a parent or sibling, the client will argue, become defensive, and may oppose recommendations the therapist makes.
  
  
• Guru — The client may view the therapist as an all-wise figure on a higher spiritual plane. In this case, the therapist can do no wrong in the client’s eyes.
  
  
• Ideal lover — If the client has experienced difficult romantic relationships or if they’ve failed to establish romantic relationships, the client may be prone to developing a romantic or erotic association with the therapist.
  
  
• The client admires therapist and tells him that he reminds him of his best friend/parent/teacher.
  
  
• The client displaces anger on the therapist while talking about an abusive parent and making generalised statements like all men are like that.
  
  
• The clients places unrealistic demands on the therapist.
  
  
• A client may become furious with the therapist when he tries to discuss homework assignment. She fells that she is a grown up and should not be given homework.