Responsibilty to refer up?

I have been thinking about this in regard to a post on another part of the forum.

Do you think at a certain point a therapist has an ethical obligation to reccommend a higher level of care if you need one and he/she is not helping you, or you are getting worse? I don't mean abandoning you but reccommending outpatient treatment, PHP, groups, inpatient, or even referring you on?

I find it a bit strange looking back that my therapist never addressed my very low functioning. In the fall she made a comment about how I only seem to get worse, and eventually during our painful rupture in Feb made a comment about how I am "too sick" for her to know how to help me alone. But she never referred me anywhere or talked to me about how badly I was doing except these times. It was my pdoc who told me I needed more specific help, outpatient at the hospital, because my functioning was so bad. I have done way better since I have been there, but it makes me wonder why she never encouraged/referred or even suggested I needed more help than she was able to provide, until the end.

Now that I'm doing therapy at the hospital now where they are more used to people with more serious mental illnesses it makes me wonder why Ex-T saw me for over 5 yrs without reccommending I get additional help. I honestly think I was too sick for her, maybe that's part of what happened (although that still doesn't make sense because she still wanted to see me). My pdoc made a comment about how I shouldn't be frustrated because it takes a long time to work your way up from "a mental ilness as severe and low functioning as yours has been for a long time." The psychologist also made a comment about how she wished they had sent me to the hospital for treatment earlier before things had gotten so out of control. I have been working again since Feb but things like agoraphobia and horrible self-care and the picking/self-harm get so much worse when they aren't treated. I don't get how my ex-T just told me it was up to me to decide I wanted to do something about them, and I spent all that time with my ex-T trying to snap out of it while things snowballed. Even at the hospital I keep saying it's my fault that things got so bad and I couldn't fix them, and they keep trying to tell me that mental illness is real and it's not my fault because it's hard to get over these things on your own, especially if you never learned how to care for yourself.

It just makes me wonder why we never talked about/worked on this stuff. Why we never addressed my horrible self-esteem and self-hatred issues, my urges to hurt myself, and my low level of functioning in general. It was more like every time I quit a job or got a medical withdrawal for school she'd be mad at me. Same for the self-harm. I went through 15 jobs in our last year of therapy, got evicted from 3 places for bad cleanliness issues, made myself physically ill from my eating habits, dropped every term of school, and started self-harming to the point of needing stitches again. I just wonder why she was never concerned and never considered maybe I COULDN'T just snap out of it.

I'm finally getting better very, very slowly. But things had gotten SO SO bad and low functioning.

Yes, in my basic counseling course, my counseling lecturer has always stressed need to refer up to higher levels of care if one doesn't think one can provide competent level of care, especially if patient is getting worse.

If she wasn't helping (as in your functioning, self esteeem etc wasn't improving in general), she also should have referred you, in my view.

Ethics for psychologists are generally stricter than those for counsellors too.

She should have sought supervision and/or peer consultation!
I'm sorry, I think your ex T really should have referred you up way way way earlier than 5 years.

Treating beyond scope of therapist competency is unethical. Slightly out of competency be might be ok, but definitely not when patient deteriorates significantly in functioning.

My first T was a primary care counselor who referred me out to hospital outpatient clinical psychology when I took a dip in functioning though I remained pretty dang high functioning.

"Do no harm!"

I'm quite shocked at your ex T! What you describe, that increase in symptoms over a year(!!)...I'm really shocked she didn't suggest more intensive care.

He definitely should have at least offered to refer you.

Both my T and my Pdoc have done so in the past. With my therapist, I wasn't at all interested in changing therapist. My difficulties weren't really related to him or any failure on his part; rather, my difficulties at that time were entirely related to my bipolar disorder being completely out of whack, which was really more of a medical issue. Thus, I did take my pdoc's advice and had some testing done to verify diagnosis and saw another pdoc for a second opinion (which confirmed my pdoc was on the right track). Eventually, I did start making progress, but I respected both my T and pdoc for being so open to input from other practitioners. In my case, my lack of progress was simply due to being in a very unstable place, and in time things started moving again.

Yes, in my training experience that is the rule of thumb. They may not make recommendations based on functioning so much as risk - either you're in danger of hurting yourself (or others) or are medically compromised in some way, say by an eating disorder or addiction. Clearly you were had more than one serious risk factor so I'm pretty shocked she didn't refer you.

Thank you, it seems strange to me in retrospect. I was fairly bad, struggling and low functioning all of the time I saw her (5.5 yes) but it got worse and worse. I just find it odd she kept basically telling me to snap out of it. I'm doing hospital outpatient clinical psych and seeing a pdoc there too and I feel like I'm actually getting better. I probably would have needed some convincing to do this a few years ago because I was so attached to her, but I wish I had gotten this help sooner. They care about my safety and health --my anemia is finally gone and it's good to have people who take my safety fears and self-harm seriously, encourage me to go for stitches and liver test following OD and such. Working slowly on stuff like eating and cleaning, and I need to do it... It's hard to do stuff like work and school when you aren't coping with life.

All I did with ex-T was talk about my fear of abandonment, which was my choice to talk abt because I'm obsessive but i feel like it would have been good if she'd told me I needed more help a long time ago. I would have done anything she asked.

I honestly think she was uncomfortable with my suicidal urges. She kept telling me I wouldn't do it. She was also uncomfortable with my self-harm. But badly enough to frequently need stitches seems worth talking about in therapy and maybe a sign you need help?

I had a therapist passive-aggressively blame me for not getting better, even though I had brought up my concerns with the therapy style numerous times, and she ignored or dismissed my concerns every single time.

Thanks. Things kind of came to a bad place and she just abandoned me for 5 weeks (to "encourage" me to commit to the hospital outpatient even though I was still on the waiting list). At this point things were soooo bad though that this was the last straw and I just couldn't take it. It seemed like a sign I was worthless, being left alone like that.

You were brave to do that. I adored mine and never would have complained or asked for anything, but I just wonder why she didn't refer me. I obviously needed more help.

I hate the blame thing... Doesn't do anything positive.

Honestly, what you need sounds more on the more serious end of outpatient clinical psych too (suicide attempt, stitches, physical ailments, deep depression affecting basic functioning, chronic job loss) - serious/complex in the sense of it's really unlikely it's going to be "12 cbt sessions and wham! You're fine!"

I'm not a trained professional though, and just basing my view on what your pdoc said and what some people I know who've had chronic difficulty holding on to jobs due to their illness severity.

I do want to encourage you (should you feel discouraged) that recovering to a high level of functioning is possible, because I've heard several such stories from peers in my mental illness support group.

I've actually gotten quite a bit better now that I have new meds. I'm obsessing about 50% of what I was and the suicidal thoughts have gone way down. My outpatient hospital pdoc is brilliant.

I've been seeing the hospital psych for 5 months and it's taken us this long to get there. Basically I am on an eating plan, taking vitamins (anemia gone), self-harm is way less, sleeping more regularly, and I'm starting to do cleaning stuff each week. There's a long way to go though, thankfully not limited to 12 sessions! It's taken so long just to get here. She's trying to get me to let people in to help me clean but it's too shameful right now. I haven't slept in my bed in months because my bedroom is too disgusting. Lately I have been sleeping in a reclining chair because the dog keePs peeing on the couch. I'm still struggling, but it has gotten better. I'm also very isolated although I'm working now. I feel so pathetic to be like this at 32.

She keeps saying we need to work on safety/health stuff first, which seems right. I like being able to check off the lists every week too for eating/cleaning... It's sad, but I kind of need it. I like her too, she's very patient about all the stupid stuff I do and doesn't get mad if I slip. Plus I feel so much relief to have someone else care about these basic things and encourage me, and it doesn't feel like a horrible scary secret how badly I take care of myself anymore. It's scary to be doing that badly and just be told over and over to snap out if it. I feel a lot safer now that I have someone actually helping me look after myself.

It makes me realize how badly I needed this and for how long I needed this. This is the first time I haven't felt as scared, and like I'll be taken seriously and don't have to try to dig myself out by myself (and I can't).

This whole situation is still so painful. It's hard not to find some way to blame myself for how our relationship ended, and it makes everything so much worse. I'm so hurt and not sure how much is my fault. My brain feels like a sad pretzel.

PinkFlamingo,

I know I'm just typing words and your feelings of self-blame are naturally strong - but none of it is your fault.

I understand that you probably are attached to her (5 years, after all!) but none of this is your fault.

At the risk of criticizing your ex T whom you're attached to, I think this is her failure to provide you / connect you to the higher level of care you need.

She made you feel you had to "snap out of it" and you felt blamed and also experienced functioning deterioration...all this points that she didn't have the competency to treat you but yet she didn't refer you up or even suggest more supports (I dunno, like intensive outpatient programs?) in addition to seeing her.

She let you down.

It hurts to lose the relationship with her though she failed you, I understand.

I'm glad that you're improving under the care of your hospital psychologist. You deserved this level of care that you're now experiencing a long time ago, before you suffered such a decline in functioning.

Your ex T really failed you.

Thanks for your feedback!! It's hard to not blame myself for stuff.

She hurt me a lot... Not just because of this but it's hard to process what happened.

*offers a hug* Intellectually you may know it isn't your fault, but emotionally, it's really understandable why...especially when you kept getting the message to "snap out of it". From a therapist, a mental health clinician, no less!

People think recovering from mental disorders just requires willpower.

If that was the case, there wouldn't be a need for therapists and psychiatrists.

She should have had your well being in mind (perhaps she does/did, but she still didn't see she was in well over her head), you trusted her to know how to treat you.

You put your trust in her knowing what she was doing, and so felt like you failed because you wasn't getting better, and it must be so hurtful that someone you trusted so much to know what they were doing ended up harming you.

It's not your fault you needed a higher level of care. It is really on her that she witnessed your struggles and did not strongly suggest higher levels of care, and even blamed you.

I hope you can process this therapeutic relationship with your current hospital psychologist. I'm sure she'll understand that you're hurting and grieving.

*hugs*

I think some T's just aren't very competent. It's hard to accept that we may have seen a not very competent T. I think that probably there is a percentage of Ts who are just not good at their job. No idea what that percentage is. Could be 20%, 50% or higher. Some people just don't have what it takes and probably don't know this. Perhaps the Ts also don't always have very good supervision, or also don't take the right stuff to supervision.