Episode 101

I remember hearing the advice “refer out” in my early career. It was usually around substance use or personality disorders. I remember feeling like there must be a piece I was missing. Why were these seasoned therapists saying to refer out? If they don’t feel they have the competency to do so, then I certainly wouldn’t be able to either! 

What I found out over time is that it wasn’t really about the severity of the issues the client was having. The reason they were referring is because they didn’t feel they had the experience to work with the person. That started me thinking two things 1. What kind of  training did they need? 2. What if they had the knowledge but didn’t feel confident in it? 

I truly believe that the most important piece of the work we do is not about information, its about relationships.  The rest is something we can learn. I believe that you have the skills that you need to do substance use work. I believe that you do not need to refer out and that the majority of folks who come in with substance use are using at a level that is appropriate for most therapists to work with.


You’re listening to the All Things Substance podcast, the place for therapists to hear about substance use from a mental health perspective.  I’m your host, Betsy Byler and I’m a licensed therapist, clinical supervisor, and a substance abuse counselor.  It is my mission to help my fellow therapists gain the skills and competence needed to add substance use to their scope of practice.   So join me each week as we talk about All Things Substance.

Welcome back to the All Things Substance podcast. This is episode 101. It’s officially the start of fall. And you’ll hear a little bit of a cold setting in, but it’s nothing that’s gonna be a big deal and I still wanted to make sure the podcast gets out to you.

Last week, we covered a myth. The myth says that you need another certification or another license in order to do substance use work. We broke that down to find out why that’s not true. And I wanna clarify, I’m specifically speaking about the work that people do in the United States. You have to pay attention to wherever you live and their regulations. 

I got an email from a listener in Bermuda, and they told me that in Bermuda, they have a very specific license and that substance use work requires a master’s. I’m guessing that their statutes look a little different from those in the United States. 

I do my best to make sure that my podcasts are applicable to people all over the world as I know that there are listeners all over the world. When it comes to licensing, though, that is something that you’re gonna have to know the laws for your own country or territory to make sure that you are practicing within those guidelines.

This week, we’re gonna be talking about a mistake that I see therapists making. It might be a controversial mistake, but I encourage you to stay with me so that I can explain the whole thing. The mistake I see is therapists referring out when there’s substance use popping up. My encouragement is going to stop referring out.

I believe that in the majority of cases in outpatient mental health, where substance use is a problem that it’s going to be at a level that you probably can do on your own. This is not to say that outside support isn’t necessary or isn’t a great idea. But I have seen lots of places where the instant knee-jerk reaction is to refer out. So before I get into the why,  let’s talk about this a little further.

The idea of referring out, simply refers to sending a client to another therapist if we don’t have the competency to work with them. In and of itself, I think that is an excellent standard. We need to know our limits. We need to know when something isn’t in our wheelhouse. We also need to know if there’s someone that we can’t work with.

Every one of us has certain sensitivities to issues and people. We have to be really aware of our own issues and our own biases to make sure that the client is getting the care they need. So let’s talk about the reasons that you would refer out. First let’s talk about the person. 

I don’t know if therapists often talk about as directly as we do about referring because of scope of practice. But I think it’s equally important. The few times that I have referred out in my career, it has been because of the person, not because of the subject matter. There are many times when I was asked to take something on and I did not have the expertise. But being as though I’ve worked in rural areas, there wasn’t a lot of choice. 

I specifically recall when I moved to the area where I am now, I was asked about working with an adolescent on the autism spectrum.  I had done some work with kids who had some developmental disabilities in the past, but by no means had I had specific training or was I gifted in that area at all. The person who was asking me was frustrated because they had already asked the other therapists in our small agency. And they had said, Nope, not in my scope of practice. 

She wanted this person to have services and I do work with adolescents. And so I said, I don’t have training for that, but I will try, I’ll do my best. I’ll do some reading.  And she said “sold, they’re yours.”  I met with them and their parents.  The parent was well aware that there’s not a lot of therapists in the area that take their specific insurance and they knew that I wasn’t specializing in this area either. 

I talked with them about my background, about how I work with clients and as long as she is aware that this is not my specialty. I am more than happy to work with their child and seek resources and supervision where I need to. I ended up working with that particular client for about five years. It went well. There were things I would Google and behavior modification techniques I talked with the parents about, but mostly it was about working with them on the things that they brought up. Hearing them, validating them, building a relationship. In some ways, it was just like any other therapy client. 

Now, there are people who specialize in working with folks on the spectrum. I have had the pleasure  of having two experts in our area work on my team in the past and it was amazing. They had such great interventions. However, when I had the chance to work with the client I had, would it be better for me to be upfront about not having that in my training and work with the client or for the client to have no services at all.

 I have seen the idea of referring out used in a way to say I don’t like these people and I don’t wanna work with them. It’s been troubling to me when I’ve seen it, but it’s also hard to call someone on. I mostly see it around things like substance use and personality disorders. People who have personality disorders are historically difficult to manage in therapy.

There are a lot of issues that pop up that make that relationship really difficult. I am going to assume that most people aren’t using the refer out in a negative way. That they truly believe that they are not equipped to work with this client. What I’m wondering is are people having a really strict and somewhat rigid view of what’s in their scope and not?

When I say refer out, I mean specifically to look at a person’s presenting problems and decide that you do not have the expertise to do treatment with this person and finding an appropriate referral source for someone who does specialize in that treatment. According to our ethics, our responsibility is to make sure that the person gets to the next provider.

We are to make sure they have referral sources and we are supposed to make sure that they make the connection so that clients are not being abandoned. It is difficult for clients to move from one therapist to another. I think most of us can understand that. 

I remember a time in my life using my EAP benefits and the agency that we went through you could do your EAP with one person, but if you wanted to continue therapy, once your three or six visits were done, you had to switch therapists. As a therapist myself, I was really surprised by that. I didn’t want to switch therapists.  I had just spent a few sessions with this particular person, liked them and wanted to continue, but it was the policy of the agency that that couldn’t happen. I even went to the supervisor to say what and was told that that’s their policy. 

We like to know who we’re going to see. We like to build a relationship and we like to have a common history. Having to start over once you’ve already made the step of coming into therapy is hard. The longer you’ve been in therapy with someone, and then you have to refer out, the harder it will be and the less likely they will be to follow through. 

I know that there are points that people feel overwhelmed in the substance use realm, and they don’t know what to do next. What I am here to say is you can find out and it’s not as difficult or different as you think. The skills you already have will suffice. You just have to know how to translate them from mental health to substance use. 

I can tell you that over the years, I’ve only referred out a small handful of people. And generally it wasn’t because of the issues they brought to me, it was because of the person. I can get along with pretty much anyone. But in these cases, I couldn’t. One case in particular was a man who had significant violence against women. I was not concerned for my safety at that point, but this person was there as a court mandated client. So they didn’t want to be there and part of that had been around substance use and violence against women.

As I spoke with this person, I did not get the sense that this was going to work. This person had some beliefs that I think might have had some psychosis to them about women and the way they feel about him and had some very strong paranoia. Paranoia is not easy to reason with.  and it could have been very easy for this person to decide that I was somehow on the opposite side and was out to get him. That would have destroyed any kind of relationship that he and I would have, and it would’ve made it so we couldn’t work together.

I thought about it, talked about it in supervision with my supervisor and made the decision that a male therapist would be best. This would eliminate the fact that this person found women to be wholly untrustworthy. I am not judging him for his belief. There were a lot of complicated factors and reasons why this man felt the way he did, but I couldn’t in good conscience treat.  

Another time I had to refer out was because I knew the partner of the person in my office. I happened to be the on-call person that day in the office, which means if somebody called in a crisis, or if somebody stopped in and needed a crisis appointment, I was the person that was going to see them.

So I get a call from the front desk, there’s a community member here and they say that they’re having a crisis. Okay. I get up. I go out, I bring them in. I get their name. As I’m sitting there listening to the beginning of their story, I’m running this name through my head and I’m like, this sounds really familiar and I’m just repeating it over and over in my head.

How do I know this name? How do I know this name? And then the person mentions their partner’s name. Bam. I know who this is. We’re on a committee together. We work together very closely on a specific project. And so this person is telling me their story and I’m tuned in talking about options and things that they could do to get this crisis handled and talking about ongoing care.

When the session was done, I talked to them about follow up and suggested that I transfer them to another therapist in the agency. They did not want that to happen. They were upset and felt that they had made a connection with me and did not want to transfer. And I had to explain that I had a conflict of interest that I worked very closely with the person that I believe is their partner and that it is not ethical for me to see them. 

I live in a really rural area. And there are times that dual relationships happen and there really isn’t a way around it. For instance, I had a number of staff people who, being in recovery, attended recovery meetings in the area. There were clients of ours who also attended those recovery meetings. 

Sometimes we can’t have as much separation as we want in these instances though it was available and I felt compelled ethically to put these two people with other therapists. I had only met each of them once. I tried to stay connected to make sure that they got to the person that I referred them to, but I believe both of them dropped off. It was super hard for them to do it. 

When we go in to meet a new provider of our own, whether it’s a doctor, therapist, dentist, whoever, and we meet them for the first time we are testing out a relationship with them. We’re seeing how it feels. Do I like them? What do I think about what they say? How do I feel about that? By the end we’ll know, kind of how we feel to have to start over again is disheartening. 

There are some agencies that have it, that newer clinicians are doing a ton of assessments and then referring clients on. My guess is that in the beginning, they let the person know you will not be seeing me because having that conversation just 50 minutes later is a real down point for the client. 

We do have an ethical responsibility to refer out when something is out of our scope. Sometimes the imposter syndrome issue can pop up and we feel like, well, there’s a lot of people out there who are better at this or that than me.

We’re talking about needing to refer out when something is truly beyond you. You can learn how to do things. We can learn what we need to know. We have to decide what is in the best interest of the client and take into account all of the factors that are happening at that moment. Sometimes there are other reasons to refer. 

I’m thinking of two specific examples.  One is an issue of countertransference. We know that transference is a thing. Clients replay their relational issues with us.  Some of the things that get into our relationship with our clients are exactly what happens to our clients in their own relationships. We just replay what we know. So we see that happen and that’s really normal. The counter transference is also normal.

It’s just something that we don’t really talk about very much. We’ve talked about it in school. At least a lot of us did that we’re supposed to be aware of, but I think therapists feel like we’re supposed to be above that. Like once you’ve been in the field a while you can manage all countertransference. And the truth is, is that we can’t, there will be somebody in your career that you are having a hard time separating from a person that you know. 

It could be a client who reminds you of a parent of a sibling of a child. And try as you might, you are responding to them in a way that is not truly about what the client is saying but instead is about your own experience with the person they remind you of. I have talked about that in supervision with staff all the time over the years. Who does that remind you of is a question I would often ask. 

Typically the person that I’m talking to the supervisee was able to figure out, oh, they remind me of this person who I really don’t like very much. And they’re able to separate it. There are some instances though, where the resemblance, the issues they’re just far too similar and the person is just not able to make the separation. 

It could be that it’s not the person, but the thing they’re bringing in.  If a client lost a family member to suicide and the therapist did as well. Depending on where they are in their grief journey. The therapist might not be able to make that separation. That’s another reason we would refer out. 

Lastly, we might refer out if the person isn’t making progress. This is a little rarer. I do hear people talk about it, but I don’t know that we end up doing it. It’s more a sign of frustration because all the things we’ve tried have not made any dent in maladaptive patterns of coping or ways that the client responds. A lot of times it really requires a conversation with the client about that very thing. How do they feel about the progress they’ve made? What do they view as the things that they want? 

There may be an occasion to refer out if somebody isn’t making progress. I don’t know that that’s super common, but I am guessing that there are legit ways and times when that is appropriate.

For me, the problem with referring out as a piece of advice is that it’s cutting off what the client was there to do. I wanna be sure that if we are referring out that it is because it is the only option and the best option. The number of people who will actually reengage with a new therapist is small in my opinion. 

Over the years that I ran the agency, we had referral coordinators who would try to help make sure that people didn’t get lost. The majority of people who got referrals to go to a different agency did not follow through in a six month period. They may have later, but I didn’t have access to that information.

It is difficult for people to make the very first call to come in for therapy. It is difficult for them on the day of the appointment to come. It is difficult for them when they sit down the very first time with you. Having to do that all over again with a new person that is challenging. If we don’t have to, I don’t think we should.

The thing that clients hear is not the thing that we say. We might tell them all of the good clinical reasons why we’re referring them. What they hear is I’m too fucked up for you. You can’t help me because I am a disaster. Most of the time, they don’t hear that you can’t help them because you don’t have the training. They really truly believe that they are the problem. 

For a lot of folks, this adds to the already long list of reasons why they don’t believe they can get better. I think it is at times dangerous to be referring out and I believe it should be done with the utmost care. A lot of the articles that I read as I was thinking about this talk about referring out some of the care rather than all of the care. 

I think that sometimes it feels messy to work with another therapist, but the reason that people say that is the same reason I’m talking about is that we don’t wanna lose the client in the meantime. 

The reason that clients get better is important here. I’m not sure how many of you have read the research that’s come out over the last, I don’t know, 20 or so years about how people get better. There’s research that’s come out of all sorts of places in the United States and elsewhere about what factors cause people to get better.

If we’re looking at a pie chart and we’re looking at why clients get better, much of how that happens has to do with them, nothing to do with us. It’s external factors. It’s ego strength, genetics, lifestyle, social support, and so on. When it comes to the therapist things, our modalities, our theoretical orientation, our techniques matter very little. They barely rank in terms of what’s important. 

The single most important factor is the relationship with a helping professional. Specifically the quality of that relationship. So I want you to think about that. We go to school and we spend a hundred grand to become therapists, to learn modalities, to learn theoretical framework, techniques, all of it. And yet the thing that makes clients better, that we have control over is something you either have, or you don’t. You either can build solid relationships with people or you can’t.

I think we can learn how to do it better. But if you don’t have the ability to connect with people, I don’t know that that can be taught. Certainly therapists of all different kinds, build good relationships. It doesn’t have to be only the extroverts or only the introverts or only this kind of person or that kind of person. The quality of that relationship though, is the biggest predictor of success in therapy. Our training is secondary at best. 

We have the opportunity to sit with a person and bear witness to their life. And there is something about that interaction that is healing in and of itself. Why it works I don’t totally know. I know though that if it didn’t, I wouldn’t have a job and neither would you. It is healing to be heard. It is healing to be validated. It is healing being in the presence of another human who cares for you. 

When you look at the work that you do every day with your people, the most important thing isn’t the techniques you bring them. It’s the relationship. When I ask people about therapy experiences and if it was helpful or not, they always tell me about the relationship. If they say it was helpful, I’ll ask them what was helpful. And it’s because they felt heard and listened to, and they felt that the therapist cared about them. At times they will mention the therapist had great ideas and good skills to teach them. But that is secondary. Always. 

If they didn’t like the therapy experience, it’s typically because they didn’t feel a connection with the therapist. They felt like the therapist was distant or just phoning it in somehow. So the reason I harp on this, because I sort of harp on it, is because in the realm of what we are talking about substance use, what you know about substance use is not nearly as important as who you are. 

Who you are, is going to make the biggest impact. You can learn the rest. You have therapy skills, you have techniques, you have ideas on behavior change. You just need to know how to translate them to substance use. They will work. Cuz I can tell you now there is not a single modality for substance use. There is no DBT of substance use or EMDR of substance use. Substance use gets treated like everything else in a mishmash of things. It’s extremely case dependent. Each person is gonna be really different. So what they need is really different.

So when I say stop referring out, what I mean is that the majority of the people that come into an outpatient mental health program likely do not need intensive treatment. Here’s why. In a substance use treatment program. The majority of people there are there because the court is making them, I used to run data every year about referral sources for my program.

So for 14 years I had data about where the clients came from. 92 to 96%, depending on the. We’re there because the court made them. Child protection, probation, parole, DWIs DA’s office, you name it. But they were there because they were mandated to be there. In mental health, that is a very small number. Most folks are not being forced into therapy. So the people who are showing up in therapy are typically voluntary. 

The reason people need substance use treatment is because their substance use is now at a level that’s getting them into legal trouble. The conclusion here is that people who are in outpatient mental health have not gotten in significant trouble with their substance use yet. And therefore don’t need that level of treatment. I have found that to be true. 

There certainly are people who fall through the cracks. Absolutely. There are people who show up in outpatient mental health and are hiding their use significantly. They’re still going to work, carrying on relationships, look functional, and yet they’re using to a significant degree. Those people might need adjacent substance use treatment. They still need you though. 

I would bet that if we look at all of the people using substances at any given time, the majority of them will not be using them problematically. This is everyone who smokes or drinks or uses in any way. The majority of them are not going to be in a severe range. The most severe are gonna be out at the edges. So if we make a typical bell curve, right?

So go back to your statistics class, 68% of people in a given category are gonna fall in plus one minus one standard deviation from the mean, and what that means is that if we look at substance use 68% of the people who are drinking alcohol, smoking weed, or any other drugs Fall in that middle category, which is pretty standard to normal, heading out to maybe a little more moderate, use. 

The next category out plus two standard deviations from the mean that encompasses 95% of the people. The people on the outskirts, the people who from 95 to a hundred or 99.7%. That’s gonna be your severe range. That’s gonna be the they’re at risk of dying you probably need a specialist range. 

The majority of people are going to be in those other categories. That is in your wheelhouse. If someone has more severe use, you can absolutely refer to a specialist. I would challenge you though that you can be their primary therapist and get them substance use treatment on the side. And you can work closely with them. That is not a conflict. That is extra support. Substance use treatment often has groups a couple times a week. That’s excellent for people. We only get people one hour a week. If that..

It would be great for them to have some more professional services other days of the week. It will increase their chances of getting sober if that’s the goal. Referring out is our responsibility. If we truly do not have the skills that we need. My challenge is that I think you have the skills. You may not have all the information you need, but you certainly have the skills.

I would encourage you to test it out. Start asking about substance use in a more direct way. If you’re not sure how to start I invite you to a webinar that I am hosting for free on October 18th at 8:00 PM eastern 5:00 PM pacific. I am hosting the free webinar, to help you stop avoiding the substance use talk: the five steps to confidently ask about your client’s use of drugs or alcohol. 

In this webinar, I will teach you the five steps that I use to start the conversation and do it in a way that is going to feel good to you both. It will not alienate your client. Our clients want to tell us the truth. They’re scared to, because they’re scared of judgment and they’re scared of having to stop. And they’re scared of what it’s gonna mean, but they want to be known. As humans the desire I believe of our heart is to be truly known. They get to practice that with us. 

Substance use is a part of that and I truly believe in all of my being that you have what it takes to do this. I would love to see you there on October 18th at this webinar. It’s live and so if you’re able to attend live, I would love to be able to interact with you. The steps are easy and something that you’re gonna be able to use the very next day. You can register for this event at betsybyler.com/steps. That’s S T E P S. I really hope that you are able to attend. I would love to see you there. Sign up for the free webinar at betsybyler.com/steps.

Next week, we’re gonna be talking about a mindset shift. Sometimes the way we think about something needs to shift a little bit in order for us to see things in a new light. I hope you’ll join me for that podcast. And until then have a great week. 

This podcast is designed to provide accurate and authoritative information in regards to the subject matter covered. It is given with the understanding that neither the host, the publisher or the guests are rendering legal, clinical or any other professional information.

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