Shirah Vollmer MD

The Musings of Dr. Vollmer

The Referral

Posted by Dr. Vollmer on July 7, 2010

James, a psychotherapist, is seeing Gary, a twenty-four year old patient since he was sixteen. Over the years, he heard about Gary’s significant other, Dan. Gary and Dan had an on-again off-again relationship. Many times, Dan would go with Gary to his appointments, waiting patiently in the waiting room. James heard about Dan from Gary’s point of view, but James never had a conversation with him. Dan calls James and matter-of-factly asks for a referral. “Do you want a man or a woman?” James asks. “A woman,” Dan replies. James is not sure whether to probe further, so he decides not to. He is also not sure whether he should bring up this conversation with Gary. Again, he decides not to. James gives Dan three names; all respected colleagues.

Nine months later, one of the respected colleagues, Nadine, calls James to say “thank you”. James is happy that Dan made the connection; not surprised that it took a long time. Maybe Dan called the other two people and they did not work; maybe Dan took nine months to make the phone call. Nadine suddenly seems to be more friendly with James. James is uncomfortable, not with Nadine’s friendliness, but with the possibility that Nadine is being particularly nice in the hope of getting more referrals from James. James tells himself that he is being cynical. James and Nadine have been colleagues for over ten years. James trusts Nadine; hence the referral. Still, James has a nagging feeling. James also knows that he has no right to know what happens between Dan and Nadine, as this is a private relationship. Nadine knows that too.

Making a referral to a colleague is a layered experience. James’ first concern is to protect his patient Gary. Dan’s phone call does not seem to disrupt that relationship. James’ second concern is to help Dan. James does not know Dan well, but he knows the therapists, and he trusts that his referrals can deal with a variety of issues which might arise in the treatment. James’ third concern is to help out his colleagues. A referral supports a practice; it also reinforces the bond between therapists. On the other hand, if the referral results in disappointment, by the therapist ,the patient, or both, then James is going to get the heat.

Giving and receiving referrals is the backbone of psychotherapy, yet James wonders if there is a framework to think about this process. “Is every interaction with a colleague a show-off event to continue to stay in practice?” James wonders. Perhaps being humble, is actually a mock humility to prove to one’s colleagues that one is able to look at himself; as if to show-off even further. The thought process behind a referral seems to be secretive; a secret even from the person making the referral. Maybe there is a secret, or not so secret wish for reciprocation. Maybe there is a secret, or not so secret wish, for attention from the colleague. James’ nagging feeling continues. He needs to seek consultation; he needs a referral. The irony is not lost on him.

6 Responses to “The Referral”

  1. Suzi said

    I don’t know about this stuff. The only thing I understand about referals is that if a counsellor/therapist (me… if that ever happens) begins working with a client who’s needs exceed the counsellor’s abilities or clashes with tricky stuff that the counsellor/therapist’s personal life, then it is best practice to refer them to someone who is more able to help.

    I am kind of glad that James didn’t take Dan on as a client but I don’t really know why.

    Also… don’t understand all the other stuff that is naging at James about his collegue and stuff like that. Or… I can’t know why James is being weirded out about this stuff.

    And… doesn’t James have supervision? Ohh – it gets tricky if the collegue he’s getting weird vibs from is his supervisor – ohh… hence the referal? Is that what it’s about?

    But that’s not been said in the information so… I can’t really know.

    Gosh – interesting story… it makes one want to fill in the blanks… such a dangerous thing to do within a theraputic relationship though… isn’t it?

    • Shirah Vollmer said

      Referrals are tricky. Dan did not want to see James. He just wanted a referral. However, it would have been unethical to accept Dan as a patient given James’ relationship with Gary. Gary needs to be able to talk openly about Dan and if he knew that Dan was a patient, this could create a dilemma. Having said that, most situations are not that clear cut. James is feeling uncomfortable because he is not sure that Nadine likes him as a person and she is looking to expand her friendship network, or, more likely, Nadine is hoping for more referrals so consciously or unconsciously she has become ingratiating towards James. Yes, for James to go to supervision, he most likely has to look for a recommendation, and hence the process starts all over again.

  2. Suzi said

    Actually Shirah,

    If James has been practising for a while, perhaps it would be best for him to take note of his nagging intuition. If he’s going for a referal and Nadine is his current supervision (is she called a supervisor?), then… isn’t that a tad awkward? I guess they’re professional therapists… surely they can talk about it.

    “A referral supports a practice; it also reinforces the bond between therapists. On the other hand, if the referral results in disappointment, by the therapist ,the patient, or both, then James is going to get the heat.”

    Politics is everywhere it seems. It makes everything so much more difficult.

    • Yes, the nagging feeling is important for James to pay attention to. However, it is hard to decipher. He needs supervision to help him with that. James referred Dan to Nadine. Nadine is a colleague. Yes, politics is everywhere, but we can still try to understand the pushes and pulls to our behavior.

  3. Shelly said

    I’m not sure that professionals (other than you) put a great deal of thought into whom to refer to whom. I am certain that you would try to find the best fit between client and therapist, but for some reason, I think it’s more of “You scratch my back, I’ll scratch yours.” Psychiatry works like politics, doesn’t it?

    • Yes and no. There is a certain amount of reciprocity, but there is also a lot of thought about who should be at the other end of that reciprocity. Politics are everywhere, but most folks want the best for their patients. The problem, like most things, is that there is a conscious and unconscious part to the referral, so it is sometimes hard to get a handle on the process.

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