The Art of the Counselling Referral

By Tim Clark

Massage Therapists often pick up on unspoken signs that a client might benefit from counselling but how do we know the right time to suggest counselling* to our clients? And what’s the best way to approach what can be a delicate topic?

Watch out for the signs

Recognising that someone might benefit from counselling is not always as easy as it is with, say, the client who starts crying when they’re on the table. Some of the subtler telltale signs I’ve encountered include:

• Strong startle responses to firm pressure – This can suggest that a client is stuck in sympathetic ‘fight-or-flight’ mode or hypervigilance, unconsciously defending against an unseen threat, perhaps a remnant of unresolved trauma.
• Clients who constantly apologise, and seem desperate to be the ‘perfect client’ or always put the therapist’s needs before their own – This can be a sign of excessively high standards which often go hand-in-hand with stress and anxiety. That most destructive and hard-to-shake of feelings – shame – might also be involved.
• Clients who request ‘punishment’ (i.e. extremely firm pressure) by the massage therapist – This might suggest a belief that they deserve to be punished. Again, shame might be involved.
• Clients who cannot tolerate even mild pressure, who may believe that any degree of discomfort is too overwhelming to bear – This client may hold beliefs about their own inadequacy, weakness or defectiveness.

These signs alone are not reason enough to suggest to a client that they seek counselling, but they might be a starting point for a discussion about the client’s experience.

Check your observations with the client

We might see generalised muscle tension and assume the client is an anxious person but we may simply be seeing them on a particularly stressful day or after a tough gym session. They might be tearful and we assume they are depressed but maybe their dog recently died.

Start by reflecting back your observation, checking its accuracy and eliciting some ideas about the client’s experience. For example: “I notice it seems important to you to make sure I’m taken care of. Does that ring true for you? Is that something you often do with people? Do you have an idea of what that might be about?”

It may not be necessary to go any further, but you’re at least letting the client know that it is safe to talk about their mental health.

Notice that these questions are closed ‘yes or no’ questions? We’re not looking to explore or resolve the client’s distress but to get an indication of their willingness to talk about things, to build trust and to ensure that our understanding of their experience is accurate.

Warm up to the idea of getting help

How direct you are with a client about the need to see a counsellor will depend largely on what your relationship is like and how much information they have volunteered. They might be very comfortable telling you they’ve been depressed or anxious and may already be seeing a counsellor.
If it seems like counselling is a new or unwelcome concept for the client, broaching the topic can require a delicate touch. Keep it gentle. Warm up to it. ‘Going in for the kill’ risks alienating your client, especially if the relationship is not yet well-developed. While some clients will be receptive to the suggestion, others will have preconceptions about counselling and might take it as a sign that you think they aren’t coping or that you think there is something wrong with them.

Should a client seem unwilling to acknowledge a mental health problem that you have good reason to think exists, tread very lightly. Denial is a powerful protective mechanism that can become very helpful to people.

It is not our job to tear down our clients’ protective factors.

Where the client is able to acknowledge they have a problem, a useful question can be, “Do you have someone you can talk to about that?”

If the client says they usually talk to their partner, family members or work colleagues, you might ask, “Does it feel like that is helping?”

If the answer is yes, it may be best to leave it there. If the answer is no, it may feel appropriate to suggest other avenues of support. You might introduce the idea of counselling with a question such as, “Have you ever seen a counsellor before?” or “Do you think some counselling might help?”

‘Counselling’ can be a less threatening word than ‘psychotherapy’ or ‘psychology’ but adequately describes what happens in all three.

Help the client make the decision

Clients may want to look for a counsellor independently, or they may prefer your guidance. There are numerous ways you and your clients can look for good local practitioners. The following have online listings of registered counsellors:

• Psychotherapy and Counselling Federation of Australia (PACFA)
• Australian Counselling Association (ACA)
• Australian Psychological Society (APS)

Other helpful sources include:

• Australian Government’s Health Direct website
• Good Therapy Australia

It’s wise to keep on file the details of a number of mental health practitioners in your area, so that you can ‘warm-link’ your clients to someone you think might be well-suited. If you feel that this is outside your comfort zone, the best port-of-call for clients is their GP, who can diagnose a mental health problem and refer appropriately.

Counselling outcomes can be better if the client has an expectation that the counsellor is well-regarded, competent and a good match. This is important because the therapeutic relationship in counselling is the keystone of change, not the counsellor’s level of training, job title or the modalities they use. What matters most is that there is a strong bond between client and therapist. Clients may need encouragement to ‘shop around’ until they find someone who is a good fit.

Counsellor, Psychotherapist, Psychologist or Psychiatrist … what’s the difference?

Counsellors and psychotherapists are trained largely in the communication and relationship aspects of counselling and do not provide diagnoses or prescribe medication. Currently, they are not able to offer services covered by Medicare or private health insurance rebates.

Psychologists may diagnose and are more likely to be engaged in clinical research. They are generally able to offer services covered by Medicare rebates but do not prescribe medication. There are many different types of psychologists according to specialisation (e.g. forensic, developmental, exercise) or the extent of focus on counselling (clinical psychologist versus counselling psychologist).

Psychiatrists are trained medical doctors who offer clinical treatment to people whose mental health problems require medication and close monitoring. Massage therapists do not refer clients to psychiatrists.

Before settling on a therapist, it is worth finding out individual practitioners’ rates. These rates can vary greatly and in some cases will be negotiable. Medicare rebates do not necessarily make it cheaper to see a psychologist, especially if treatment lasts more than ten sessions.

Make the referral

It may be adequate to simply give the client the counsellor’s details and allow them to make contact, or you may wish to make a formal referral with the client’s informed consent. If so, keep it brief. It is enough to say that the client reports feeling depressed, for example, or would like some help dealing with stress. Giving your assessment of the client’s mental health or life situation (e.g. “I think the client may be suffering PTSD”) may prejudice the counsellor’s view of the client, which can have an undesirable influence on the psychotherapeutic relationship. Regardless, the counsellor will perform a thorough intake assessment with the client.

Not all clients

I don’t write any of this under the assumption that all clients need to see a counsellor or that it is our job to ensure that our clients with mental health problems get to counselling.

It is our job to help and care for our clients, and we do that within our scope of practice in whatever way we think is most clinically reasonable.

Even if we can plant the seed of an idea in a client’s mind that they don’t have to hold on to pain or that they could talk to someone about a problem they’re having, we’re doing just that.

*In this article, I’ve use the general term ‘counselling’ to refer to services provided by qualified and registered counsellors, psychotherapists and psychologists.

About the Author

Tim Clark is a massage therapist and psychotherapist in Melbourne, with a particular interest in how the two interrelate. Watch his presentation on the Pleasure-Purpose Principle at AMT’s 2018 national conference.