Should I accept this referral?

By Ellen Anderson, Ph.D
November 10th, 2023
psychologist referral

Not long ago, I received a call from a woman requesting an intake appointment. I don’t use a scheduler and prefer to pre-screen clients myself. She was unclear about her referral source. Something seemed vaguely familiar and following a gut feeling, I pressed her for more information. It became apparent that she was the mother of an adult client whom I was currently treating. Moreover, the toxicity of the parent-child relationship had been the focus of many sessions. Yikes! I barely dodged this bullet and was more than a bit irritated. This was yet more proof that there is no such thing as a good surprise!

While the above example is at the extreme end, outside of the context of family therapy, accepting referrals from existing clients can be fraught. Psychologists often receive referrals from patients who presumably have been satisfied with their treatment.

Past and current clients may give your name to their friends, siblings, children, extended family, co-workers or even their boss. Despite the best intentions, it can be difficult to avoid treating two people who have their own relationship outside of therapy.

The American Psychological Association’s ethics rule 3.05 on Multiple Relationships includes the following:

“A multiple relationship occurs when a psychologist is in a professional role with a person and (1) at the same time is in another role with the same person, (2) at the same time is in a relationship with a person closely associated with or related to the person with whom the psychologist has the professional relationship, or (3) promises to enter into another relationship in the future with the person or a person closely associated with or related to the person.”

The ethics code goes on to say, “A psychologist refrains from entering a multiple relationship if the multiple relationship could reasonably be expected to impair the psychologist’s objectivity, competence, or effectiveness in performing his or her functions as a psychologist, or otherwise risks exploitation or harm to the person with whom the professional relationship exists. Multiple relationships that would not reasonably be expected to cause impairment or risk exploitation or harm are not unethical.”

Given that word of mouth is a frequent source of referral, how does a psychologist go about determining whether treating two people, known to each other outside of therapy, will pose harm?

Some things to consider:

It does not matter whether the original client (let’s call her Patient 1) is currently in treatment or not. Patient 1 may want to return to treatment in the future. I can think of multiple instances where I have treated Patient 1 and accepted a family member, long after Patient 1’s treatment ended. Patient 2’s ongoing treatment may impact on whether Patient 1 feels comfortable in returning for treatment.

It is meaningful that Patient 1 has made this referral, but it may be difficult to ferret out the nature of the meaning! Is the referral as it seems at face value or a “gift” for the therapist? Is Patient 2 aware of the pre-existing relationship between the therapist and the referrer? If the nature of the pre-existing relationship is not transparent, it is more difficult for the therapist to avoid inadvertently “leaking” information and maintain strict boundaries.

It is impossible to be certain at the outset that both parties will have no difficulty in “sharing” a psychologist. While Patient 1 may present a straightforward and uncomplicated situation, Patient 2 is unknown, and the situation should be considered risky. It is an ego boost to imagine that there is no other qualified professional who might handle the second patient’s treatment but often, other appropriate professionals can be identified.

Expectation gaps are inevitable. Both the treating professional and the new client will have expectations based on their relationship with the original patient. Case in point: A year after terminating treatment with a mid-career professional, I received a phone call from her sister, whom she had referred to me. It seemed low risk and I accepted the referral.

After a few sessions, it became clear that Patient 2 had highly unrealistic expectations. Though my prior treatment of her sister was uncomplicated and not focused on family of origin dynamics, the same was not true for her sister. She terminated treatment soon after.

Much as no two siblings ever share the same parents, each patient-client relationship is influenced by a multitude of factors. Eliminating the “prior relationship” factor makes therapy a great deal less complicated.

Sometimes the inter-relationship between the two patients is not evident to anyone until both people are already established in treatment. This presents a dilemma for the therapist.

Psychologists who treat people in areas where there is limited access to mental health professionals, for example those in rural areas or college counseling settings, often encounter client overlap.

The therapist who inadvertently discovers that they are treating the roommate, friend, or even boyfriend/girlfriend of an existing client is in a tough situation. It is often not an option to simply terminate one of the clients. Seeking out consultation from a trusted colleague or ethics professional is advisable in such cases.

Despite all these factors, there are instances where it is possible to ethically treat two clients who are friends or family members. In such instances, the relationships between all three parties are transparent. The relationship between both clients is positive, not conflicted and not the focus of therapy. The therapist has little difficulty in seeing both patient’s problems as distinct and non-overlapping. Confidentiality and neutrality can be easily maintained.

Other than family therapy, treating two people who are known to each other simply makes therapy more complicated than it needs to be. If in doubt, try to find another referral for the client.

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