Tip # 98 Making Referrals

We all need at times to refer a client to a colleague or to an additional health professional. You may pride yourself on being a generalist, trained and experienced to work with a wide range of clients. There are always a few clients who will be best served by someone else.

I not only use all the brains I have,
but all I can borrow.

Woodrow Wilson

I think knowing what you cannot do
is more important than knowing what you can.

Lucille Ball 

Cues to refer:

  • A client calls for an appointment to your private practice and gives a complicated story about puzzling gastrointestinal symptoms. Your experience with GI conditions is limited and you have a colleague nearby who works in a medical practice and sees many such cases.
  • You know enough to advise a client undergoing chemotherapy for cancer. However, your mother has just been diagnosed with breast cancer. You are not sure if you can keep from crying or mentioning your mother when working with the client. (See Tip #16, Handling Your Own Feeling, (available in the Practice Workbook, Vol 1.)
  • A client comes to you for diet guidance for diabetes. You find out that his physician closed her practice a few months ago and the client has not begun with a new one.
  • A family brings their teen to you and it is obvious that she has the beginning of an eating disorder. They know a therapist whom they used to see for their son, but would rather just have their daughter meet with you. She is very interested in nutrition and has lots of questions.
  • You have decided to limit your practice to diabetes and weight management. A client calls for a consult on food allergies.
  • A weight management client is not making any changes and you suspect depression and/or anxiety. (See Tip #41, When Your Client Is Depressed, in Practice Workbook, Vol. 2).
  • You have experience working with families and teens to develop healthy eating habits. You also work with clients with eating disorders, including young teens and their families. You realize that you have recently been losing patience with the teens. After discussion with a supervisor, you see that this is because your own teenager is acting rebellious and you can’t help but transfer some reactions. For your own sake as well as your clients’, you choose to define your practice as not including young teens until you get beyond that stage in your family’s life.
  • An ongoing client seems to get off track from healthy behaviors when anxiety or emotions pop up. You know of a local stress management class or other resource that you believe would support your work with this person.
  • You work in a wellness or weight management setting and a client comes in with a BMI of 19 who wants to lose “ten more pounds.”  It looks as if the client has an eating disorder, but it is tempting to try working with the client for a while.

A format for referring: This is just one possible format. It can be useful to have a format to rely on when you are unsure how to proceed.

  • Reflect what you hear from the patient’s perspective. “You have a lot of questions and worries about the best way to eat when doing the chemo.” “Your focus on food and weight is taking up a lot of your life and it bothers you that you haven’t had a period in three months. I hear that you are scared to eat more.” “You clearly care a lot about your health. You called me and want help to eat well for your diabetes.”
  • State a truth or two. “My expertise is not in the area of oncology. I have a colleague who has helped a lot of people in your situation.” “Your lack of periods is most likely due to inadequate nutrition. I have found that in this situation it works well to meet with a dietitian who specializes in eating disorders.”  “Several of our patients with that same concern have found it helpful to meet with a counselor.” “Research has shown that working with a therapist on anxiety management makes it easier to reach weight management goals.”
  • Ask permission to provide a referral or resources. “Would you like me to give you her name and number?” “I have names of several therapists who help people let go of obsessive food and weight thoughts. Would you like their contact information?”
  • Wait for a response before giving the referral.

When the referral is for your own reasons, keep what you share to a minimum and word it from the client’s perspective. If you are tempted to share your personal reasons for making the referral, review Tip #1, Self-Disclosure (in the Practice Workbook, Vol 1).

  • “That is a practice specialty that I don’t work with. I want you to have the very best dietitian.”
  • “At this time I am not taking clients in your daughter’s age group.”
  • “I will be taking some time off from my practice in the next few months and I want you to have someone you will be able to see weekly.”

Additional notes about eating disorders for those who do not treat them:

When you have determined that a client has an eating disorder and will be best treated by an experienced team, hold back your nutrition expertise. The sooner you make a referral to an eating-disorder professional, the better. You pride yourself on your knowledge and so it may be quite difficult to refuse to answer detailed nutrition questions.  This is one time to fake ignorance to get the client to see an eating-disorder professional. If the client is not in treatment yet (and is in denial), trying to treat him in your setting or even answering simple questions is doing the client a disservice.

A team approach is the standard of care. The team will include a psychotherapist, dietitian and primary care provider (ideally with eating-disorder experience). A psychiatrist and family therapist may also be needed. It is not unusual for the client to be willing to see only one at first. For example, she may want to see an RD because she has lots of food questions, or a psychiatrist or therapist if she is depressed.  It will then be up to the eating-disorder professionals to assemble a team. Develop relationships with eating-disorder professionals nearby to refer to.

Making referrals is a tricky part of your job. Ask for help and practice, practice, practice.

  • When you suspect that it would be best to refer a client to someone else but you feel unsure or confused, consult with a supervisor, colleague or the professional you may refer to.
  • When you are fortunate enough to know that you will be seeing a client who needs a referral, review this Tip and go over your wording with a colleague. Consider bringing notes to the session.
  • When a referral doesn’t go very well, go back and play with an approach and wording that may have worked better. Practice it in your head or with a colleague.
  • If you feel guilty about sending a client away, remind yourself thatprofessionals find the very best care for their patients.
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