Client referrals

Odysseus

I have had issues with this topic since I started in this profession, but I'm just wondering what other people think. As some will know a lot of my clinical work is done for the HSE Addiction Services; what I like about it is I just don't deal with addiction, in order for me to see a patient they must have a history of addiction or be currently affected by another’s addiction. However, I believe I can't treat a person's addiction in isolation; so I deal with what ever other issues are there, e.g. comorbid disorders, history of abuse, criminality; basically whatever is there and can be treated by a psychotherapist. I was delighted when we dropped the word addiction from the title counsellor a number of years ago as it does not reflect the work I do.

I regularly get referrals from other therapists/psychologists from other services saying that whilst working with a client they uncovered addiction issues and either would I take over the therapy or even worse see the client for the addiction issues and the other therapist would continue with the therapy they where already engaged in.

I will always agree to do the former, but the latter is just unethical from my viewpoint. Two therapists working with one client at the same time is just a professional ticking time bomb as far as I'm concerned.

Anyway to give a recent example I received a call from a therapist in one of our major sexual violence services during the week, they had identified addiction issues with a client at the assessment stage [thank god at least the person had not started therapy before they where pushed on this time] and would I agree to see the client and refer them back when the addiction issues where dealt with so that they could then start to address the sexual violence aspect of their life.

I generally look for reasons to take a person on, rather than not take them on so I agreed to see the person. However, there are some so called "experts" in the treatment of addiction that hold the view that when treating addiction the addiction is primary and should be treated first. Only when the client has remained drug free for say approx two years can we then deal with the more difficult issues such as sexual violence. The referring therapist was clearly under the opinion the above opinion.

Now as a psychoanalyst that theory doesn't hold much water with me, but you don't have to be a psychoanalyst to disagree with it. All I ask of my clients is to attend and speak; I explain how free association works at the initial consultation, so we only go where the client associations bring us. The rational behind the "expert" opinion is that traumatic issues are too difficult to deal with in early recovery, leading the client to relapse back into active drug use

I work my way as we are not dealing with "repressed" experiences that the client is unaware of, generally a significant amount of people who experience abuse additionally experience some form of intrusive thoughts about the abuse, so it's not like I'm going in with a JCB digging up material, though it is often still traumatic to put words on the experience. This basically means that with the recent referral once I have assessed the client and formed the opinion we can work together, I will be dealing with their addiction, sexual violence issues and whatever else comes into play.

Now I'm very open about what way people work, once I'm not being asked to work that way. Whilst training as a psychoanalyst I started working in a rehab centre which was very Minnesota in its outlook, which for those would don't know a lot about addiction treatment is the outlook from which a lot of the so called experts hold. So whilst I may not agree with a particular way of working I try to understand it and respect it, for example the Minnesota Model does help some people overcome their addiction, I would not try to deny it.

Now in one way I acknowledge that I was very lucky to have the very broad training that I had, however, these phone calls/referrals always leave a bad taste in my mouth. This finally gets us to my questions:

1. As a therapist/psychologist do you agree with these so called specialisations, i.e. training as a bereavement counsellor, addiction counsellor, sexual violence etc? This is different to working in a service that supplies a service to such issues, or gaining clinical experience in such an area to broaden your skill base.

2. Do you think it is ethical to start treatment with someone and then just refer them on because another issue comes into play during treatment? Even if you do not have much experience in an area, should your clinical training, experience and the use of your clinical supervision not facilitate you in working with the client?

3. Whilst the range of psychological issues that a client can present with is vast; as a psychotherapist/psychologist do you think that you should be able to treat most of the issues that a person may present with. I acknowledge that we cannot be experts [and I really hate that word] in all areas of psychological care. However, within our own area should we not be able to treat the majority of issues that fall within our remit?

4. As I noted I get a lot of referrals from other therapists, once an addiction issue is uncovered. Is this because people feel that a specialised treatment is required by a specialised service? Or is their a prejudice against treating addicts? I have experienced both but I'm interested in what you guys think.

Apologies for the long post, but it was need in order to provide a background to the above questions.