Value Conflicts in Therapy: Refer Out or Not?

Camille McDaniel (00:28)
Before we jump into today’s episode, I want to share something with you. I’m super excited. Do not skip over this ad. I’m really glad to bring you this new information. But first, let me reach out to those of you who have been in sessions and something didn’t fully add up. Like the symptoms were there, but you’re thinking, is this really just mental health or could something else be going on? And that moment matters more than sometimes we realize.

because if we miss what’s happening on the physical side, we can end up treating something psychologically that actually needs a different kind of attention. And that’s where my book, Medical Mimics, comes in. It’s gonna help you stay aware of when the biological side of your client may be showing up even beyond, way after the initial assessment has taken place. So you can then ask better questions, think more clearly, and respond more confidently.

in session. And I also, this is what I’m excited about, have an announcement. My newest book, The Counselor’s Career Roadmap, is now also available on Amazon. This one is especially for those of you who are in graduate school or you are early career counselors and you’re realizing there’s a gap between what I learned in grad school and what I’m expected to do now post-grad.

It helps you to navigate that transition so that you’re not left trying to piece everything together on your own. You can actually learn more about each book on my website, camillemcdaniel.com. And again, both books are ready for purchase on Amazon. You can also actually get a sneak peek and look at the table of contents.

even get an excerpt that you can read. I am super excited about this and looking forward to how it’s going to help so many mental health professionals in the field. All right, now on to today’s episode.

Camille McDaniel (02:33)
Welcome back to Christ in Private Practice. It’s so great to have you here for another episode. So there’s a question that continues to surface across the mental health field. I’ve seen it over the years. Like every now and again, I’ll see it. A couple years might pass by or a year passed by, I see it again. And the question is, can I refer a client out because of a value conflict?

And it’s a value, really and truly, it’s a value conflict where there’s something that the client has said or somewhere where the client works or something that the client believes or that just doesn’t sit with the therapist. They just don’t have the same view. So it’s not revolving around safety or it’s not revolving around lack of training from the therapist.

But ⁓ because something about what the client’s beliefs or worldview or choices don’t sit well with them, they have wondered, you know, is it okay for me to just refer out? I know that that has also popped up, especially given the current climate of the world today. There are just a lot of different issues and challenges that are going on in the world. And people are feeling strongly, very, very strong about their view, depending on what topic you might happen to bring up.

I know that some have even suggested that if the therapist isn’t aligned with what the client is doing or saying or where they work or whatever, the relationship is just not going to work. But today I want to take a look at this through maybe a little bit of a different lens because if we’re not careful, we can begin to confuse discomfort with lack of capacity to do our job.

properly and those are not the same. So just because we’re not comfortable or something is different, you know, that doesn’t necessarily mean that we have lost capacity to provide care for this individual or proper informed consent so that this individual will know what kind of care they are receiving from us. So first let’s just take it to our ethical codes.

⁓ because I think that that’s a really important place to start so that we don’t really get into a lot of opinions and just kind of going back and forth with each other. Our ethical codes

say that therapists should not practice outside of their scope, should not impose any of their views on someone else. We know about that. We talk about that often. That therapists should be competent.

in the area that they are providing care, right? And that’s with a lot of the different organizations, American Counseling Association, the APA or American Psychological Association, we have the NASW, we have AAMFT. So we have actually a lot of organizations that will kind of point out that there are certain reasons why maybe you might provide a referral, but then,

It doesn’t include though just not feeling comfortable. You know that that is not something but it’s more so that the code of ethics point to competence. So are you not competent to do your job really? know discomfort

is not an impairment. So we want to be really clear you know here that

feeling challenged ⁓ or frustrated, or internally conflicted and angry, it doesn’t mean that you are impaired in such a way that you are not able to provide the proper counseling care. Impairment, like when we’re talking about.

ethics, know, so ethically speaking, and impairment refers to something that is much more significant where, you know, you have compromised functioning in one area or more that makes you that that makes it so that you are unfit to clearly think and provide the treatment modalities that would be necessary or that you have a serious deficit.

or challenge in some emotional or psychological area or physical area. So it’s going to prevent you in one way or another. So that’s what we were talking about when we say impairment. You have to be really aware of that because you want to be able to know why you are seeking a referral and can it be justified?

if it was called into question with your board of ethics.

So when a therapist may say that I feel triggered, so I can’t work with this client, we do need to pause and we want to just ask ourselves, is this true impairment? Now, sometimes it might be, I have seen it. I’ve literally been in a

kind of a situation, a session situation where there was more than one therapist involved and I have seen real triggers pop up that caused real impairment to then be displayed. So yeah, sometimes we might need to assess, hey, is a real impairment showing up or is this discomfort that just requires support, supervision, consultation

this type of impairment possibly even requires for you to step away from the profession and go seek your own counsel and treatment, you know, take a little time off, get some counseling, get some treatment and then assess whether or not it is going to even be good for your overall health and wellness to come back and provide counseling when certain things could pop up in in any type of of counseling session.

So you know these are it’s not interchangeable, impairment and discomfort are really not the same things and we want to sit with that and really evaluate that. And then we want to take a look at you know when the words I just can’t you know become a little too easy to say because there’s a there’s a subtle shift

that starts happening in some spaces where when we disagree, it all of a sudden becomes harmful. But you know, it’s not just that we can sit with the fact that we do not see something the same way, but instead the fact that there is a disagreement on this particular topic means that you yourself are being harmed by not agreeing.

⁓ discomfort all of a sudden then kind of becomes something that we just we can’t hold space for at all. We have to get rid of it. We cannot tolerate it and we cannot work with it. And avoidance then becomes the solution but it’s then framed as ethical care. But ethically we’re actually not called to only work with

what feels easy or what feels aligned, what feels comfortable. If that were the standard then I mean goodness we would really not have nearly as many people to serve truthfully because

how often are you going to be able to sit with people who think like you, talk like you, look like you, views like you, every everything

everything the same as you, there’s no conflict anywhere. I mean, the number of times that that’s going to pop up in your lifetime is going to be very slim, if at all. So we have to really evaluate this because if we don’t, like I said, it could really impact the number of people that we would end up serving if that was the case.

and the perspectives that we would decide to sit in front of and how effective we would be as clinicians. And then over time, that’s not gonna really strengthen our profession overall. I think that that would greatly weaken our profession if we could only sit with people that made us comfortable. And so,

because referring out is a real thing, you know, when should we then refer out? I mean, it’s like, when is it, when is it really appropriate? And again, our codes of ethics do align and instruct on when it might be appropriate to refer out and

not that there’s step by step, you know, instructions for referring out, but it does talk to

what would constitute an inability to service a client who comes your way and kind of mentioned a little bit of that, but you know, it’s gotta be grounded in clinical reality, not just a preference. It has to be something again, if someone challenged you on that decision and your licensing board got involved.

you would have to be able to firmly explain clinically why this was in the best interest of the client. So then

the question becomes is this about the client’s care or is this about my internal reactions to something that was said and I just don’t feel I can deal with any more internal reactions.

I mean a referral might be appropriate, not even might, a referral would probably be appropriate when you really and truly can not maintain objectivity. If you are being honest with yourself, you know you cannot be objective. Okay, that would be a good reason to refer. Or if your like clinical work is being compromised, if a therapeutic relationship has broken down beyond repair.

But let me just say this though, let me kind of like add this one piece to it because when I was thinking about this, there’s something still hanging there with me that doesn’t feel totally comfortable because it shouldn’t be that we can just be like, well, you know what? This would actually harm the client if I were to see them because I don’t agree with their political view or I don’t agree with where they work or I don’t know, that’s not where it should end.

I think there needs to be again more. And we would have to take a look at the difficulty. What kind of difficulty are we dealing with here? Because just being difficult for you is not really enough. And just because there’s disagreement on views, that’s again not enough to not be able to provide care.

because we do have professional responsibility. And part of being a clinician is developing the capacity to actually sit with difference. I mean, we literally are not only sitting with it, we are helping our clients in certain cases to sit with differences that show up in their own lives. And we have to regulate our internal reactions. And we help others.

to regulate their reactions and we have to find ways to remain grounded even when we disagree and when it feels really hard because you know the next step cannot always be an immediate referral. The next step is possibly consultation, possibly clinical supervision. It might be just sitting with yourself in personal reflection.

because our ethical codes across mental health disciplines really do emphasize ongoing self-awareness and professional growth as part of being a competent mental health professional.

So it’s something to really sit with, know, and think about. And for those of us who are also integrating faith ethically and professionally, this…

This adds just like another layer. And it is that we need to be clear that we’re not required to co-sign on everything that our clients come in with, our clients’ views, our clients’ beliefs. We’re not required to co-sign on that or agree with every single thing in order to provide ethical care. sometimes it’s going to look like

holding our convictions and our convictions are not their convictions.

Sometimes it’s maintaining our clinical professionalism and being clinically responsible externally even when we may not agree internally.

That’s not compromise. That’s actually having discipline.

that’s having professionalism, that’s being ethical. And one of the things that helps that, which I have mentioned time and time and time again in our time together in some of these podcasts episodes is that, especially when we’re talking about faith integration and ethical faith integration, which is what Christ in private practice is basically about largely, we talk about making sure that we are clear

on how we are to serve, how we are going to integrate our worldview, which involves our faith, and how we are going to provide informed consent. So when you are operating off of informed consent, then the client knows what they are coming to you for. They understand how you operate. They understand what treatment they might be receiving from you. And that doesn’t stop them from having different views.

What it does is helps them to just understand the framework that you’re going to provide for them when it comes to the treatment and what influences that framework. We still may find that we’re sitting with clients who have very strong views, opinions, and other things going on that do not align with what our thoughts are, what our views are, what our opinions are. So instead of us

kind of asking, do I feel aligned? Do I feel like I agree enough to continue working with this client? Probably I would say something that’s a lot more clinically sound is to say, am I still capable of providing competent and ethical care? And if the answer is yes, then the presence of discomfort may actually be just part of your work.

Not a reason to actually refer out and to, you know, stop working with a client. So, can you refer out based on value conflicts? Not simply because you disagree or because you’re uncomfortable, not because it challenges you, but seriously, referrals must be based on some clinical impact.

or even some safety concern, right? We talked about safety is a real thing that we need to take into account. We have seen things go on in the news. We know it happens. So safety concerns are real and those can be reasons why you may need to refer somebody out. But we also wanna base it on clinical impact, not just personal preference. if you cannot,

explain it to your licensing board, you need to take a step back and assess. Get clinical supervision if that’s applicable or get consultation or just sit in taking some time to really reflect on how you are, how you’re doing things. So not every difficult season or session is a signal to step away but sometimes it is a signal that we have an opportunity to grow.

in our skills, in our steadiness, and in our professional responsibility. So if this episode resonated with you or it’s something that you know has challenged somebody that you are working with or is a colleague to you, share this. It’s good for discussion. There are some points given.

in this episode that I think we could really sit with and ask ourselves, you know, what would the licensing board say about this? What would my code of ethics organization say about this? So yes, share it please and ⁓ and comment and like and if you happen to be, ⁓ you know, watching this on YouTube, go ahead and click the follow so that way you actually will get notified though when I when I upload these.

although many of you stop by and ⁓ watch it regularly anyway and many more of you are listening to it from Apple Podcasts and Spotify and so if you happen to be over there, go ahead and subscribe. Thank you for the comments. Somebody I think just not too long ago gave a referral.

on I think it was Apple, Apple podcast. Thank you. I didn’t even know people were voting on the um or not voting, I shouldn’t say voting, there’s no like voting going on but um people were rating, rating the podcast and I appreciate that. Thank you. You don’t have to do that so um much appreciated and until we meet again for another episode as always, God bless you.