ICF Referring a Client to Therapy PDF

Referring a Client to Therapy A SET OF GUIDELINES © International Coaching Federation This guide is a resource for coaches to understand when and how to refer a client to a mental health or other helping professional when the client’s needs are outside a coach’s competencies. The goal is to help...

Referring a Client to Therapy A SET OF GUIDELINES © International Coaching Federation This guide is a resource for coaches to understand when and how to refer a client to a mental health or other helping professional when the client’s needs are outside a coach’s competencies. The goal is to help coaches recognize and know how to manage a client who has a mental health issue that goes outside the scope of coaching. The role of the coach is to co-create with the client opportunities for seeking professional help when appropriate. The following guidelines are based on the expert opinions of mental health professionals and coaches from Australia, Canada, South Africa, the Netherlands, and the United States about how to know when someone may be developing a serious mental health issue and how to refer the person to a mental health professional. These guidelines are a general set of recommendations about how you can help someone who may be experiencing a mental health issue. Each individual is unique and it is important to tailor your support to that person’s needs. These recommendations will not be appropriate for every person. The guidelines are designed for providing assistance in developed English-speaking countries and may not be suitable for other cultural groups or those in countries with different health systems. We are launching this first version set of guidelines as a pilot, and your feedback is important. As a way to engage the global community and to improve the guide for coaches, we invite feedback from users. You can submit feedback online at Refer to Therapy Guide Feedback. To access the form, enter the code: Guide_Feedback The copyright for these guidelines is owned by the International Coaching Federation (ICF), however, they may be reproduced for noncommercial purposes along with an acknowledgement to ICF. Alicia M. Hullinger [email protected] Joel A. DiGirolamo [email protected] Cite as: Hullinger, A. M. and DiGirolamo, J. A. (2018). Referring a client to therapy: A set of guidelines. Retrieved from International Coaching Federation website: http://www.coachingfederation.org/client-referral-whitepaper. REFERRING A CLIENT TO THERAPY: A SET OF GUIDELINES | 2 CONTENTS 4 Introduction 5 Coaching versus Psychotherapy 7 Why refer 9 When to refer 11 Signs for referral 17 How to refer 18 After the referral 19 Emergency situations 20 Confidentiality Guidelines 20 General resources 22 Endnotes REFERRING A CLIENT TO THERAPY: A SET OF GUIDELINES | 3 INTRODUCTION According to the World Health Organization (WHO), depression and anxiety disorders, including stress-related psychiatric conditions, will be the major health disorders globally by 2020, rivaling cardiovascular diseases. This means that you will be increasingly likely to encounter a client with a mental health issue. This guide is a resource for coaches to understand when and how to refer a client to a mental health professional. The goal is to help coaches recognize and know how to manage a client who shows up with a mental health issue that goes outside the scope of coaching. Making a referral means inviting a client to discuss referral, cocreating options, and empowering the client to take action by identifying resources or making an appointment. A referral to another helping professional is warranted when a client delves into an issue that goes beyond a coach’s competency level. Having a list of helping professionals on file as a reference offers a useful resource for you and your client. In the process of coaching, a client may bring up an issue related to mental health. Weighing the options, a coach can postpone, continue, or terminate coaching. Some clients who seek coaching may exhibit severe mental health problems that need to be addressed in therapy, sometimes referred to as counseling. Coaches need to be aware of their limits and recognize when a client needs more than what coaching can provide. The coaching agreement serves as a tool for both you and your client to set the parameters of what is and what is not addressed in coaching. The field of psychology frequently refers to working with the whole person; that is, interacting with the many components that make up an individual (the psychological, biological, emotional, social, and cultural). In this sense, a coach may encounter client issues that are outside of their expertise and scope—which is to be expected. Referring a client to therapy or another resource is part of the coaching process. Other resources include a support group, a mentor, a specialist coach, or a spiritual representative. Having a list of helping professionals on file as a reference offers a useful resource for you and your client. The most important indicator to keep in mind when deciding whether or not to refer a client to a therapist is level of daily functioning. Ask yourself, “Is the client’s issue interfering with their daily functioning?” Daily functioning refers to a wide range of activities for personal self-care, such as feeding, grooming, work, homemaking, and leisure. If a client does not have the capacity (internal and external resources) to function in daily activities (professionally or personally), then it is likely time to make a referral. A mental health professional is equipped to diagnose and help the individual develop coping skills to manage deep emotions related to difficult situations. REFERRING A CLIENT TO THERAPY: A SET OF GUIDELINES | 4 A client may display issues that create barriers for moving forward. The client may benefit f rom working with a mental health professional if the client raises issues that relate to a history of unresolved emotional issues preventing the client f rom moving forward or if current life circumstances are creating barriers for making progress in the coaching process for growth. COACHING VERSUS PSYCHOTHERAPY When a client is experiencing mental health issues ... we shoudl refer them to the appropriate professional for diagnosis and treatment. Coaching is one of many helping professions. Other modalities of support include mentoring, consulting and psychotherapy. Understanding the difference between coaching and psychotherapy, also referred to as therapy or counseling, is important to best serve the needs of the client. We can think of mental health like physical health: When a person has physical symptoms, such as a sore throat or persistent cough, that interfere with daily life, they should see a physician to diagnose and treat the problem. Similarly, when a client is experiencing mental health issues (i.e. a condition that prevents an individual’s mind from working normally), we should refer them to the appropriate professional for diagnosis and treatment. The material in this guide is a synthesis of information, drawing from both the medical model approach and the dimensional approach to understanding abnormal mental health states1. Other approaches to mental health have been emerging. The guide applies where mental health is viewed through the medical model perspective on a spectrum. The medical model for mental health has been the dominant approach in the field of psychotherapy2. The medical model emphasizes diagnosis and pathology. This means that the approach tends to take a pathological perspective in which behavior is regarded as psychologically “abnormal” or “unhealthy.” A client’s problem is viewed as a “disorder” within the medical model framework. From this perspective, the client tends to be viewed as fundamentally flawed. Some have been critical of the medical model, suggesting that labeling could provoke shame and inadequacy, causing the person to feel worse. Labeling a person as “abnormal” or with a “disorder” also contributes to the stigmatization that goes along with therapy. The medical approach classifies disorders based on specific symptoms and diagnoses treatment based on a classification system. Psychopathology is viewed as absent or present within this categorical approach to mental health. Gaining more interest and support from professionals in the field, the dimensional or psychosocial approach views mental health on a spectrum. This approach classifies mental health by quantifying a person’s symptoms, rather than saying it simply is or is not present. The process of quantification looks at how much, or the degree to which a particular characteristic REFERRING A CLIENT TO THERAPY: A SET OF GUIDELINES | 5 is present. This approach creates a profile of characteristics instead of assigning a label. Psychopathology is viewed dimensionally via measures, such as frequency and severity. From a dimensional perspective of mental health, function can be seen on a spectrum as opposed to a binary category (function or dysfunction). An individual may be functioning well in one area of life and not functioning well in another area—this may be when both coaching and counseling could work together. We can start identifying differences between coaching and psychotherapy by looking at definitions set forth by major associations for the professions. Keep in mind, these terms have a range of definitions and they can mean different things in different cultures. The International Coaching Federation (ICF) defines coaching as “partnering with clients in a thought-provoking and creative process that inspires them to maximize their personal and professional potential3.” The main distinctions between coaching and psychotherapy are based on focus, purpose and population. The American Psychological Association (APA) defines psychotherapy as “the informed and intentional application of clinical methods and interpersonal stances derived from established psychological principles for the purpose of assisting people to modify their behaviors, cognitions, emotions, and/or other personal characteristics in directions that the participants deem desirable4.” The main distinctions between coaching and psychotherapy are based on focus, purpose, and population5. Coaching focuses on visioning, success, the present, and moving into the future6. Therapy emphasizes psychopathology, emotions, and the past in order to understand the present. The purpose of coaching is frequently about performance improvement, learning, or development in some area of life while therapy often dives into deep-seated emotional issues to work on personal healing or trauma recovery. Coaching tends to work with well-functioning individuals whereas therapy work tends to be for individuals with some level of dysfunction or disorder. Therapy works more with developing skills for managing emotions or past issues than coaching. As an analogy, a coach is like an athletic trainer while a therapist is like a medical doctor specializing in sports medicine. Both draw from a shared body of knowledge that includes anatomy, kinesiology, nutrition, and the like. The trainer works from the assumption that the athlete is essentially sound in body and is focused on improving fitness and performance. The trainer will refer the athlete to the team doctor if there is reason to believe he or she has an injury. Similarly, coaches and therapists work with the same material but with different skill sets and to different ends. A coach may explore the past, family life, or emotions of their client in the service of understanding the client’s origin stories being told about the present and future. REFERRING A CLIENT TO THERAPY: A SET OF GUIDELINES | 6 What is important is that a coach does not diagnose nor does a coach offer treatment. Through observations, a coach can make a formulation on what the client needs. Draw the line if a client needs help that goes outside your qualifications, experience, or contract with the client. A coach can and should make a referral when necessary. The remainder of this guide outlines why, when, and how to refer a client to a mental health professional. WHY REFER The ICF Core Competencies and Code of Ethics both include imperatives for referring clients to other support professionals as needed. Additionally, research shows that early intervention through referral can positively impact clients’ mental health outcomes. What is important is that a coach does not diagnose nore does a coach offer treatment. Upholding the Coach’s Ethical Responsibility When issues are raised by a client that are outside a coach’s level of expertise or scope of services it falls under a coach’s ethical responsibility to help the client identify and access other resources. As a benchmark, ICF has outlined this responsibility in its Core Competencies and Code of Ethics. The first ICF Core Competency, Meeting Ethical Guidelines and Professional Standards, asks the coach to demonstrate “understanding of coaching ethics and standards and ability to apply them appropriately in all coaching situations.” This includes clearly communicating the distinctions between coaching and other support professions and referring the client to another support professional as needed, knowing when a referral is needed, and being familiar with the available resources. ICF’s Code of Ethics includes the following obligations for coaches: Section 3.18: Carefully explain and strive to ensure that, prior to or at the initial meeting, my coaching client and sponsor(s) understand the nature of coaching, the nature and limits of confidentiality, financial arrangements, and any other terms of the coaching agreement. Section 3.23: Encourage the client or sponsor to make a change if I believe the client or sponsor would be better served by another coach or by another resource and suggest my client seek the services of other professionals when deemed necessary or appropriate. Staying within Coaching Scope of Work The coaching agreement is an important resource for both the coach and client. The agreement should explicitly state the scope of coaching. The services you offer to your client should be clearly outlined in the coaching agreement. This is addressed by the second ICF Core Competency, REFERRING A CLIENT TO THERAPY: A SET OF GUIDELINES | 7 Establishing the Coaching Agreement; i.e., understanding what is required in the specific coaching interaction and coming to agreement with the client about the coaching process and relationship. The following is an example of a clear statement of the scope of coaching: Coaching is not therapy. I do not work on “issues” or dig into the past. I leave that work up to you. I assume my clients are whole and completely functional. We will look at where you are today and I will help you remove the obstacles, move forward, set personal and professional goals and take action to create the life you desire. If for any reason I feel other therapeutic professional services are required, I will request you get the help you need.7 Helping by Referring Can Make a Difference The most important thing to remember is that early intervention for a mental health issue increases the chances of them getting better and sooner. Intervention means taking action when a client displays signs of loss in their mental health. It entails knowing when and how to act and what resources to call upon. The most important thing to remember is that early intervention for a mental health issue increases the chances of them getting better and sooner. Research shows: • The problem, most likely, will not go away unless there is intervention by taking action • Help received in time equals a high rate of recovery • Taking action (intervention) improves an individual’s quality of life and may save a life • Late intervention equals overall interruption in an individual’s performance Your role as a coach—as an outside observer—plays an important role in getting help for an individual: • Expression of interest plus support can be a critical factor in helping a struggling individual • Some individuals are not willing to reach out for help The Mental Health First Aid training developed by Mental Health First Aid Australia is available to the public worldwide and provides a useful fivestep action plan8: • Approach, assess, and assist with any crisis • Listen and communicate nonjudgmentally • Give support and information • Encourage appropriate professional help • Encourage other supports REFERRING A CLIENT TO THERAPY: A SET OF GUIDELINES | 8 WHEN TO REFER So, how do you know when to refer a client to therapy or other resource? The following sections provide guidelines on indicators to monitor and assess the need to make a referral. Coaching at Competency Level Providing optimal services to a client means coaching within the scope of your coaching agreement, expertise, and competency level. If a client is facing a challenge that goes beyond your experience and expertise as a coach, or if you feel uncomfortable working with a client on a particular issue, you should consider other resources for them. Let the client know that you feel the issue is outside your area of expertise. Empower your client by co-creating options and identifying other resources to address the issue, including therapy if appropriate. Self-reflection and self-awareness are important in recognizing when an issue is beyond your scope and competency as a coach. Self-reflection and self-awareness are important in recognizing when an issue is beyond your scope and competency as a coach. Be sure to monitor your own reactions and feelings. Also, identify your own assumptions and biases of mental health issues. In many cultures, issues of mental health are viewed very negatively (as a stigma), so as a coach, you can help overcome this stigma in how you approach the issue. If interactions with your client prompt concern or discomfort, or they interfere with your work, then your services might not be the best fit for the client. Consider consulting your coaching mentor or supervisor or trained mental health professional to help determine if a referral is appropriate if you feel any of the following: • Responsible for your client • Pressure to solve your client’s problems • Stressed out by your client’s issues • Like the problem is more than you can handle • Anxious when your client approaches you • Your client is too dependent or reliant on you • Like you have failed your client Interfering with Daily Functioning Observe the level of your client’s impairment. Impairment refers to an alteration in an individual’s health status so as to interfere with activities of daily living, such as self-care. When the problem gets in the way of everyday functioning (professionally, personally, or socially), you should make a referral to a mental health professional. Daily functioning refers to a wide range of activities for personal self-care, such as feeding, grooming, work, homemaking, and leisure. Mental health is on a spectrum, so REFERRING A CLIENT TO THERAPY: A SET OF GUIDELINES | 9 consider duration, frequency, and intensity of impairment. Help from a mental health professional is warranted when the issue lasts for weeks and affects functioning in daily life. Not Making Progress If the problem is interfering with the client’s effective coaching progress and is not moving forward after a reasonable amount of time, then the client might have an underlying issue that could be worked out in therapy. Mental health is on a spectrum, so consider duration, frequency and intesity of impairment. A client may be functioning in everyday activities, but they may not be making any progress with coaching because psychological issues are a barrier. Perhaps a past issue that still needs healing continually arises in sessions, getting in the way of progress. Or, a client may want to continuously process feelings in sessions. Self-defeating behavior may also get in the way of attempts to change. In these situations, the client may benefit from a mental health professional who can work with the client on past or deep-seated emotional issues. If the feelings are getting in the way of the client being able to process them and they are blocked from gaining insight and taking action towards growth, a referral should be made. If the client moves into being stuck about a past incident and cannot seem to get past it, then therapy is likely required. Being stuck means that the client brings up recurring issues, continually refers to being a victim, or continues to suffer ill effects from trauma. As a coach, you can ask your client where something came from, but you do not linger on it. The reason to inquire is to unlock what is keeping the client stuck. If acknowledging the past is enough for the client to move forward, then you can continue coaching. If the issue needs to be processed more deeply, then you should make a referral. A client who is functioning in daily activities but is not making progress in coaching may benefit from coaching and counseling simultaneously— the coach continues to work with the client on what was agreed upon in the contract while the client goes to a counselor to work on psychological issues. What is important is to ensure that the client is making progress in coaching. A coach may be able to work with a client while the client is going to counseling or the client may need to work out the psychological issues first, and then return to coaching. Consulting When Uncertain If you have questions or are unclear on what needs to happen, you can consult with your coaching mentor or supervisor to determine whether or not to refer your client to therapy. Seek consultation with someone who has an in-depth understanding in this area. You can also contact a mental health professional to discuss a situation as many therapists offer REFERRING A CLIENT TO THERAPY: A SET OF GUIDELINES | 10 brief consultation services for free. You should have a list of other helping professionals on file for your reference and as a resource for your clients. Indicators of Distress or an Emergency Immediate danger to the client or someone else requires direct intervention (see “Emergency Situations,” on page 18). Common issues that warrant a referral to therapy include anxiety, depression, eating disorders, post-traumatic stress (PTSD), substance abuse, suicidal ideation, and thought disorders. The next section describes signs of distress associated with these issues. Use your professional experience, judgment, and instincts. Do not ignore any signs of concern in your client’s behavior. A client who is functioning in daily activities but is not making progress in coaching my benefit from coaching and counseling simultaneously. SIGNS FOR REFERRAL9 The descriptions of the mental health categories in this guide are not meant to help diagnose clients but to help coaches better understand and recognize problems that warrant referring a client to therapy. The mental health issues described are the most common problems that a coach is likely to encounter. For more information on other mental health issues (“categories”) see the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Common mental health issues include: • Anxiety • Depression • Eating disorders • Post-traumatic stress disorder (PTSD) • Substance abuse or addiction • Suicidal ideation • Thought disorders Signs of Psychological Distress10 • Marked changes in mood such as irritability, anger, anxiety, or sadness. • Decline in performance at work or school • Withdrawal from social relationships and activities • Changes in weight and appearance, including negligence of personal hygiene • Disturbances in sleep, either oversleeping or difficulty falling or staying asleep REFERRING A CLIENT TO THERAPY: A SET OF GUIDELINES | 11 Watching for a Cluster of Signs As you work with your client, look for a cluster of signs or chronic symptoms. A cluster of signs can indicate the level of distress. If the client is experiencing strong, persistent negative emotion, then a mental health professional is trained to help in this problem area. When watching for a cluster of signs, notice the duration, frequency, and intensity of the symptoms. If the client is having ongoing distress, persisting symptoms, and repeating negative patterns, then you should make a referral to a mental health professional. Many clients experience one or more of the signs and symptoms, for example, but at a level where they can be appropriately addressed in coaching. Draw the line for referral based on your qualifications, experience, and contract with the client. A cluster of signs can be grouped into personal life, professional life, behavioral plus emotional, physical, and safety risk indicators for distress. The presence of one of the signs alone does not necessarily mean that the client is experiencing mental health issues. However, the more indicators you notice, the more likely your client needs help from a mental health professional. A cluster of signs can be grouped into personal life, professional life, behavioral plus emotional, physical, and safety risk indicators for distress. A cluster of small signs (e.g., emotional outbursts, repeated excuses for not doing the homework, and pattern of fatigue) indicates a need to take action on behalf of your client. Anxiety Excessive feeling of worry, nervousness, or apprehension about reallife events; recurring intrusive thoughts or concerns Duration Occurring more days than not for at least six months Symptoms • Restlessness, feeling keyed up or on edge • Being easily fatigued • Difficulty concentrating or mind going blank • Irritability • Muscle tension, sweating, trembling, dizziness, or rapid heartbeat • Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep) REFERRING A CLIENT TO THERAPY: A SET OF GUIDELINES | 12 Depression Feelings of severe sadness, emptiness, and hopelessness or loss of interest or pleasure in daily activities Duration When feelings of sadness disrupt daily life and persist for more than 2 weeks Symptoms • Loss of interest and pleasure in daily activities • Significant weight loss or gain • Insomnia or excessive sleeping • Restlessness, irritability • Lack of energy • Difficulty concentrating • Feelings of worthlessness, helplessness, or excessive guilt • Recurrent thoughts of death or suicide Note: Grief is a normal process of reacting to loss. If grief becomes overwhelming or a person is not able to think of the present or future, this this may indicate depression. Eating Disorders When eating and feeding behavior, such as overeating or undereating, demonstrates psychological distress and impairment; extreme emotions, attitudes, and behaviors surrounding weight and food issues Duration Recurrent episodes or persistent behaviors Symptoms • Constant or obsessive thoughts about food • Elimination of entire food groups, in the absence of medical reasons • Planning or changing their life around diet or food, in the absence of medical reasons • Decreased energy level • Difficulty sleeping • Mood swings anxiety, depression, and irritability REFERRING A CLIENT TO THERAPY: A SET OF GUIDELINES | 13 Post-traumatic Stress Disorder (PTSD) or Trauma Feelings of trauma or stress in people who have experienced a terrifying event, such as warfare, a natural disaster, a car accident, or sexual assault Duration Have lasted at least one month Symptoms • Re-experiencing symptoms: • Intrusive thoughts, nightmares, or flashbacks • Avoidance symptoms: • Avoiding specific thoughts or feelings, people, or situations that ` serve as reminders of the event • Negative mood and cognition symptoms: • Negative thoughts or beliefs about one’s self or the world • Feeling detached, isolated, or disconnected from other people • Being stuck in severe emotions related to the event • Memory problems that are exclusive to the event • Hyperarousal symptoms: • Difficulty concentrating • Irritability, anger, temper • Hypervigilance • Sleep disturbances Substance Abuse or Addiction Addiction, or dependence on a particular substance or activity Duration Displaying a couple or all of the symptoms within 12 months Symptoms • Increasing tolerance to the substance (alcohol or drug) • Requiring the substance throughout the day • Avoiding other activities and failing to meet obligations, such as at home, work or school • Dismissing or resenting expressions of concern from loved ones • Hiding use from family and friends • Seeking the company of other users and cutting off social ties with non-users REFERRING A CLIENT TO THERAPY: A SET OF GUIDELINES | 14 • Experiencing withdrawal symptoms in the absence of the substance • Using heavily (binging) for many hours or several days • Feeling unable to quit Suicidal Ideation Thoughts or acts of self-harm or killing oneself intentionally; has a suicide plan Duration Recurrent thoughts of death, suicidal ideation, or suicidal plans; any past suicidal attempts within 24 months Symptoms • Talking about feeling hopeless • Talking about having no reason to go on living • Making a will or giving away personal possessions • Searching for a means of doing personal harm, such as buying a gun • Sleeping too much or too little • Eating too little or eating too much, resulting in significant weight loss or weight gain • Engaging in reckless behaviors, including excessive alcohol or drug consumption • Avoiding social interactions with others • Expressing rage or intentions to seek revenge • Showing signs of anxiousness or agitation If you believe that someone may be at risk of self-harm or hurting another person, refer to “Emergency Situations” on page 18. Thought Disorders Behavior or speaking that indicates problematic, illogical, or incoherent patterns of thinking Duration Displaying a couple of symptoms for a significant portion of the time for at least one month Symptoms • Paranoia, delusions, hallucinations, or false beliefs • Rapid, illogical, or incoherent speech • Rapidly discusses several unrelated topics REFERRING A CLIENT TO THERAPY: A SET OF GUIDELINES | 15 • Frequent interruptions in train of thought • Inability to follow a logical train of thought • Belief that a person or entity has removed the person’s thoughts Once you have determined that your client might benefit from seeing a mental health professional, then you should bring up the subject in a supportive way. Your role is to provide support, offer options, and identify resources. When making a referral, have a list of current and reliable therapists with contact information and the services they offer on hand. Consider having a few therapists with different specialties on the list. Other resources include talking to a trusted friend, colleague, clergy person, community member, going to a support group, or seeing a therapist for the issue. HOW TO REFER Meet privately with your client. Choose a time and place where you will not be interrupted. Bring up the topic when you both have time, do not feel rushed, and are not preoccupied. Set a positive tone. A good way to start the conversation is by expressing your concern and care for your client’s well-being. Set a positive, calm tone. Be hopeful, gentle, patient, supportive, direct, honest, and nonjudgmental. Stay focused and be specific. Point out specific signs, behaviors, or changes that you have observed. Ask and listen. Ask open-ended questions that deal directly with the issue to help create awareness for the client. Actively listen to the client by recognizing, acknowledging, and validating what you heard. Allow for silence. Allow your client time to tell the story. Ask the client how they feel about your suggestion to go to therapy. Encourage the client to share their response to what you have said. Restate your concern and care for the client. Identify resources and referrals. Share information you have about the referral you are suggesting and the potential benefit to the client. Keep the lines of communication open. End the conversation in a way that allows you or the client to revisit the subject another time if they wish. You can offer to assist the client in making the appointment by allowing the client to call and schedule an appointment while they are in your office if you are meeting in-person. REFERRING A CLIENT TO THERAPY: A SET OF GUIDELINES | 16 Your client may not be receptive to seeing a therapist the first time you make the suggestion. You may need to suggest therapy more than once if the mental health issue continues to come up in coaching sessions after the initial referral. A client may refuse or feel reluctant to go to therapy for many reasons. Some may not be aware of the problem. Some people may avoid therapy for fear of being considered “weak” or “crazy.” Others may not have access to quality mental health care. Or perhaps the person has had a negative experience with therapy in the past. A person may have religious or cultural beliefs that keep them from seeking professional assistance. In some cultures therapy has a stigma. You may need to suggest therapy more than once if the mental health issue continues to come up in coaching sessions after the initial referral. It is important to normalize mental health issues and treatment. As a coach, you can address your client’s fear or reluctance to go to therapy by explaining the benefits of going to a mental health professional. Millions of people around the world seek help for mental health issues in order to improve their well-being. You can explain that many people who go to therapy are normal, mentally healthy individuals who want to learn better coping skills for everyday issues. Reassure your client that asking for help is a sign of strength and not weakness. Acknowledging the client’s courage and their value for selfcare demonstrates your support for them. An analogy might be a useful way to explain the benefits of therapy. For example a person who is having heart palpitations would not benefit from seeing a dermatologist—they would need to see a cardiologist to address issues related to the heart and a dermatologist for issues related to the skin. Ultimately, the decision to go to counseling is up to the client. They may not want to seek professional help, which is acceptable. If the person does not want help from a mental health professional, let them know that if they change their mind in the future about seeking help they can contact you. Respect your client’s right to not seeking help unless you believe that they are at risk of harming themselves or others. If you suspect a client to be suicidal, you should contact the support services in their local area to manage the situation. You can follow up with the client as part of your coaching process. Because of confidentiality guidelines in the mental health field, it is up to the client as to whether or not they share this information with you. Accept that they may not want to share this information with you. By following up, however, you are expressing concern and care. Use your best judgment. If you think that your client cannot fully benefit from coaching until they address the issue, then be direct with your client by suggesting that you put coaching on hold until they are ready to engage in therapy. Remember—you are not a therapist. REFERRING A CLIENT TO THERAPY: A SET OF GUIDELINES | 17 AFTER THE REFERRAL You have referred your client to other resources that might serve them better. Now what? You and your client may work together to identify whether or not to continue coaching. It is acceptable to follow up with the client to see how the therapy is going. Following up and checking in on the client’s decision is also part of the referral process, showing support and managing accountability. If the client is not open to the suggestion, remember that it is their decision whether or not to go. If the client raises the same issue blocking progress in the future, circle back to the original suggestion one more time. At that point you may need to decide whether or not you want to continue coaching. Refer back to your coaching agreement with the client to go over what is and what is not covered in coaching. Following up and checking in on the client’s decision is also part of the referral process. If your client decides not to go to therapy, remember that it is their choice. Accept their decision. Make it clear to your client that you are willing to revisit the subject, whenever they wish. If eventually you decide that they cannot be coached effectively until they address the issue, then let your client know and suggest that you postpone coaching until they can take full benefit from it. EMERGENCY SITUATIONS Emergency situations are rare but do occur, so having a plan for handling them is helpful. If you believe your client is in imminent danger of killing or injuring themselves or another person, phone the local police or emergency services immediately. Your local police are well trained to handle all types of emergencies, including psychological ones. If they determine that a mental health professional is needed, they will contact the appropriate services. If you are concerned about a client but do not believe the danger is immediate or if you are unsure, you can contact one of the therapists in your list of contacts and ask for a consultation on the client’s behavior. Many therapists offer brief consultation services for free. If you believe that someone may be at risk of self-harm or hurting another person: • Call your local emergency number • Stay with the person until help arrives • Ask what means they have that may cause harm (e.g. guns, knives, medications, or other things that may cause harm). If they have a means to cause harm: REFERRING A CLIENT TO THERAPY: A SET OF GUIDELINES | 18 • Instruct the client to give the object to someone for safekeeping • Discuss who can be notified of the risk and weapon and follow up • Notify the police or emergency responder and ask to do a “wellness check” • Listen, but do not judge, argue, threaten, or yell If you think someone is considering suicide, get help from a crisis or suicide prevention hotline. For contact information for crisis centers, go to the websites for Befrienders Worldwide or the International Association for Suicide Prevention, or visit the International Suicide Prevention Wiki. CONFIDENTIALITY GUIDELINES Emergency situations are rare, but do occur, so having a plan for handling them is helpful. The legal aspects of confidentiality of a client’s files will vary around the world. Be sure to familiarize yourself with your local jurisdiction’s laws on confidentiality. Use this information to assure your client of the rules that a mental health professional must follow. Keep in mind that clients have the right to privacy regarding their mental health and treatment. The client may or may not want to share this information with you. Respect the client’s privacy and ensure all instances in which you would breach confidentially are clearly outlined in the coaching contract. Confidentiality is important for trust, but client safety is paramount, so be clear that this dynamic holds the most weight in your relationship. You typically should never share with others what the client has shared with you unless the situation involves a serious risk of harm to the person or someone else. The potential risks of not sharing the information must be your first concern. A therapist can answer your questions about making referrals. They can also provide other referral ideas. They can consult with you regarding specific behaviors of a client. Remember, due to local legislation, therapists may have rules of confidentiality to abide by. This means they may not be able to talk with you about a person you have referred without a signed release. For example, without a written consent from the client, a therapist may not even be able to acknowledge any contact with the client. REFERRING A CLIENT TO THERAPY: A SET OF GUIDELINES | 19 GENERAL RESOURCES Befrienders http://www.befrienders.org/ An independent charity and global network of centers that provides emotional support to prevent suicide worldwide. GoodTherapy.org https://www.goodtherapy.org/about-us.html An association of mental health professionals from around the world who are dedicated to reducing stigma and harm in therapy. Through its continuing education and content efforts, GoodTherapy.org advocates for healthy, collaborative, and non-pathologizing therapy. International Association for Suicide Prevention https://www.iasp.info/ A nongovernmental organization concerned with suicide prevention. Keep in mind that clients have the right to privacy regarding their mental health and treatment. Mental Health First Aid Australia https://mhfa.com.au/ National nonprofit organization that develops, evaluates, and provides a variety of mental health training programs and courses. The program has been adapted for use in a number of countries (See: Global Directory of Licensed Mental Health First Aid Programs at http://www.mhfainternational.org/international-mhfa-programs.html.) PsychCentral.com https://psychcentral.com/ Mental health social network that provides a directory of mental health resources and lists of symptoms for mental health disorders.11 World Health Organization http://www.who.int/topics/global_burden_of_disease/en/ Specialized agency of the United Nations concerned with international public health and provides information on global burden of disease, including mental health disorders, in various parts of the world. REFERRING A CLIENT TO THERAPY: A SET OF GUIDELINES | 20 ENDNOTES 1 Cavanagh, M., & Buckley, A. (2014). Coaching and mental health. In E. Cox, T. Bachkirova, & D. Clutterbuck (Eds.), The complete handbook of coaching (pp. 405-417). Los Angeles, CA: Sage. 2 The authoritative guides representing the medical model are the DSM-5 and the ICD-10. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) is the American Psychiatric Association’s guide for diagnosing mental disorders and is used by health care professionals in the United States and much of the world. The International Classification of Diseases, Tenth Edition (ICD-10) is also a widely used medical classification system by the World Health Organization. 3 International Coach Federation. (2017). What is professional coaching? Retrieved from https://coachingfederation.org/faqs 4 American Psychological Association. (2017). Recognition of psychotherapy effectiveness. http://www.apa.org/about/policy/resolution-psychotherapy.aspx. 5 Maxwell, A. (2009). How do business coaches experience the boundary between coaching and therapy/counselling? Coaching: An International Journal of Theory, Research and Practice, 2(2), 149-162. 6 Auerbach, J. E. (2001). Personal and executive coaching: The complete guide for mental health professionals. Pismo Beach, CA: Executive College Press. 7 Elliot, Tina. (2017). Frequently asked questions about personal coaching. Retrieved from http://www.synergycoaching.org/general-faq.htm#q3). 8 Mental Health First Aid Australia. (2017). Retrieved from https://mhfa.com.au/ about/our-activities/what-we-do-mental-health-first-aid. 9 Information in this section comes from the following sources: American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5) (5th ed.). Arlington, VA: American Psychiatric Association. American Psychological Association. (2017). Retrieved from www.apa.org. GoodTherapy.org. (2017). Retrieved from www.goodtherapy.org. PsychCentral. (2017). Retrieved from www.psychcentral.com. 10 As outlined by the American Psychological Association. 11 Copyright 2017 PsychCentral.com. All rights reserved. Reprinted here with permission. REFERRING A CLIENT TO THERAPY: A SET OF GUIDELINES | 21 © International Coaching Federation REFERRING A CLIENT TO THERAPY: A SET OF GUIDELINES | 22