The DBH Professional Network
The DBH Professional Network
One of the most challenging tasks as a therapist or treatment specialist is recognizing when your client is declining in treatment. It often takes many different treatment approaches and medications before a client feels like their signs and symptoms are improving and sometimes, a client needs a higher level of care, regardless of the treatment approaches you have prescribed. Maybe you have been treating your client for years and a level of trust has been built but you feel that you hit a plateau in therapy? Or maybe a new issue has come up in therapy that may be triggering for you? Or maybe your client relapsed?
Whether your client has been diagnosed with an eating disorder, a substance abuse disorder, a mental health disorder or a behavioral disorder; relapses often happen and it is important for a therapist to recognize when their client needs to go into a higher level of care such as a partial hospitalization program or a residential treatment program. Recommending that your client needs to seek a higher level of care is not a failure on your part, as a therapist, but rather it is a sign that you are a great therapist and you want what is best for your client.
When should you refer your client to a higher level of care?
- If you feel ill-equipped to address a new issue that comes up in therapy: Recognizing your weaknesses and referring your client to a treatment program that specializes in a treatment that you do not practice or are not certified to practice makes you a better therapist and is ethically the best decision for the client.
- If your client is suicidal or homicidal: By law, you must activate a 5150 and make sure your client receives immediate care at the nearest medical facility.
- If your client is actively engaging in self-harm: Any type of self-harm behavior such as cutting, hair pulling, or purging should be warning signs that your client needs a higher level of care.
- If your client has reached a plateau in therapy: Your client will often devote a large amount of energy to convince you that he or she is doing well and progressing however their signs, symptoms and family members state otherwise. Maybe your client is not relapsing but if your client is not steadily improving, they may need a higher level of care.
- If your client pulls back at the mention of a treatment center or program: When you start to mention to your client that he or she may benefit from a higher level of care and he/she becomes defensive or agitated, this is a warning sign. Therapists often become entangled in countertransference. When we hear things like, “He/she trusts me a lot and trust would be broken if I referred to a treatment center” then we know the client is crafting a case to avoid the treatment setting. Removing obstacles to treatment is an important part of the therapist-client relationship.
- If your eating disorder client is terrified to integrate a registered dietitian into treatment: Avoidance of talking about the food component is avoidance of what is needed to fully recover.
- If you do not have current pounds or a weight on your eating disorder client: One of the benefits of working with a multidisciplinary team is the ability to collaborate weekly and receive updates on the client’s weight and labs. Even the most adept clinician cannot tell visually if a client is doing damage to their body with purging, bingeing, or restricting behaviors. Potassium and other electrolyte imbalances are one of the most dangerous health consequences of an eating disorder, which are not visible upon physical assessment. Weekly, biweekly, or monthly “blind” weights are a good way to monitor behavioral trends that may be reflected in weight trends.
- If your client relapses: Any sign of relapse indicates that the current therapy is not working and therefore your client needs to be transitioned to a higher level of care.
- If your client expresses issues that are triggering for you: As a therapist we need to protect our own emotional and mental health and sometimes transference and countertransference can impair our judgment. Clients may bring up difficult issues that may be too triggering for us to handle and it is important to recognize when your emotional or mental health, as a therapist, is in jeopardy or is comprised. This may not call for a higher level of care per say but rather this may be a reason to transfer your client to another outpatient therapist.
Why should you refer your client to a higher level of care?
It is important to recognize why we came into our careers in the first place, to improve the lives of people and be an advocate for mental health. When your client is showing warning signs that their current treatment plan/therapy is not enough, it is important to remember to keep your client’s best interest in mind. Referring your client does not mean you failed as a therapist and you should not take it personally. It is important to communicate to your client why you believe they should be transferred to a higher level of care and that it is not your personal decision but rather your professional decision. Explain to your client that by not transferring into a higher level of care, their condition can worsen and they have the potential to cause harm to themselves, to their loved ones and to others around them. It is also important to educate your client on the different levels of care and what to expect from each level of care. You can always give them the option of treating them again as their therapist once they successfully complete their treatment program. Remember that we must keep our client’s mental, physical and emotional health our first priority.