When to Refer Clients, and How to Do It Without Causing Harm
with Dr. Lisa Marie Bobby and Dr. Brianna Ector, PsyD, Serenity and Wellness Pathways
The Tuesday Session That Changes the Shape of the Room
Referring is not a confession that you failed. It is a clinical maneuver with a sequence, and you can be good or bad at it.
You have been seeing this client for eight months. Depression, some anxiety, a job they are ambivalent about. Ordinary, good work, the kind you are genuinely competent at. And then partway through a Tuesday session they say something you were never trained to hold, and you sit in a very particular pause, wondering whether referring at all means you have failed the person in front of you. Nobody taught us this part. Graduate school handed us the ethics code language about boundaries of competence and then handed us a caseload.
My guest is Dr. Brianna Ector, PsyD, a licensed clinical psychologist and the owner of Serenity and Wellness Pathways, a fully virtual private practice. She is a PSYPACT member, which is how she reaches a population that is geographically scattered and badly underserved. Her clients are largely trauma-exposed queer people of color, and she does most of her relationship and couples work inside the polyamorous community. She chose this specialty in graduate school and steered her coursework, her electives and her trainings toward it before she ever graduated. She has no book, no course, and a small solo practice, which is precisely why this conversation is as candid as it is.
We recorded it in a hallway at the APA 2026 convention. I had asked her what she wished other therapists understood about her work, she started to answer, and about two sentences in I stopped her, because she was saying something our profession does not say out loud. So we sat down on the conference floor and recorded it right there, ambient noise and all.
We got into why competence is cheaper than avoidance, the four-move sequence for referring someone out without making them feel like a problem you could not handle, the dual role that is widely practiced and rarely named as a violation in print, why calling it couples therapy stigmatizes a client before the first session begins, the intake-form audit that costs nothing and takes an afternoon, and where to get accredited continuing education that state licensing boards actually accept, including one detail about APA division trainings that surprised me and I have been doing this a long time.
Hold onto one word while you listen: well-meaning. Strip it out and this becomes an accusation, which is neither accurate nor what she said.
"Just because I'm a part of the community doesn't mean I know everything." — Dr. Brianna Ector, PsyD
Moments from this episode
Episode transcript
Dr. Brianna: It is so important for us as professionals to get competent in more than one population, more than just the one that matches us. But especially for those of us who do match within the community, which I myself do, to make sure that we are doing the work, that we are helping to educate other people so that they can engage in our communities without causing harm.
Dr. Lisa: I am sitting down with Dr. Brianna Ector, who is going to tell us a little bit about a really interesting specialty that she has that is so important. And as you guys know, one of the things I love to do on this podcast is just illuminate interesting people doing interesting things, and Dr. Ector, you are one of them. So why don't you tell us a little bit more about your work?
Dr. Brianna: Thank you. So I have a small private practice. It is by the name of Serenity and Wellness Pathways. I primarily work with queer folks of color who have been trauma exposed. It is fully virtual, and I am also a member of PSYPACT, so I work in several different states as well, so that I am able to meet my population where they are at, because a lot of them are pretty spread out. And unfortunately there aren't a ton of therapists who specialize in that area or feel really comfortable working with the community, especially with the unique challenges that get added when we layer trauma on top of race and ethnicity, on top of queerness, and all those layers.
Dr. Brianna: And then I also work with couples and relationships, and so I tend to do a lot of my work within the polyamorous community, just simply because, again, there is that lack of resources in that area. And I also have that interest in that community, and love the research, and love to spend time with the community.
Dr. Brianna: And I have noticed, as I have done the work and as I was doing my training, a lot of it is just getting to be comfortable and competent in the area and with the community. Understanding the language, understanding the community, understanding how things function, and then shifting the very things that we are trained on in school to adapt in the way that they are supposed to be adapted for that specific community.
Dr. Lisa: Well, you know what, one of the things. So we were just chatting here at APA 2026, and I asked you, what do you think is so important for other therapists to know about working with this population? And you started to share your perspective, and I was like, wait, stop. We need to record this.
Dr. Lisa: It was so powerful. And so would you mind sharing with our friends what it is about this work that most other clinicians don't fully get, from your perspective?
Dr. Brianna: It is both not as difficult as we would like to think it is, and also still requires our skill and our training and us to do well and become competent in the area.
Dr. Brianna: A lot of the basics for what we do when we are working with different populations, different communities, the basics of the skills is the same. The psychoeducation is the same. How we implement is what is a little different, and how different communities will react to different modalities and what works best just needs to be adjusted.
Dr. Brianna: And it is pretty easy to actually learn those competencies if you take the time to do so. And the community is fantastic to work with.
Dr. Brianna: It is just when we don't take the time to get competent, when we don't take the time to learn the extra pieces, we both, one, leave communities without any care at all and unable to find therapists who are competent, and then we also find that we cause harm.
Dr. Brianna: And the most well-meaning therapists cause harm, because they are just not competent in the ways that they should be. They are stepping on things in ways that they shouldn't. And there is training. The education does exist. And so taking the time to do that is so important. So many of my clients come to me being harmed from very well-meaning therapists.
Dr. Brianna: And that work is very difficult to work with because, you know, you have to help them understand what happened to them, grieve those pieces, and then also provide a corrective experience through your experience as well. And so it is so important for us as professionals to get competent in more than one population, more than just the one that matches us. But especially for those of us who do match within the community, which I myself do, to make sure that we are doing the work, that we are helping to educate other people so that they can engage in our communities without causing harm.
Dr. Lisa: I am so glad you are saying all this out loud, Dr. Brianna, because I feel like this is something we don't talk about enough in our profession, around scope, but specifically self-awareness around scope.
Dr. Lisa: And this comes up for me in my practice with my colleague Jesse Stanley, who is standing right over here. But, you know, I am dually licensed. I am a psychologist, and I am also a marriage and family therapist. And what I see so frequently is that clinicians, oftentimes in private practice, they will say yes to a lot of things.
Dr. Lisa: We see all the time people who are really just trained in clinical mental health taking on couples and families, where systems. I mean, marriage and family therapists have a whole different type of training and educational and developmental experience. And what I feel like you are saying is sort of the same thing, and broadly applicable. There are important things to know and competencies to have, and to be able to have self-awareness around, like where we need to call in reinforcement, where we need to make a referral. So that is one of my takeaways from this so far.
Dr. Brianna: Humility is so important. Understanding that, oh, I am out of my depth. And if I want to work with this particular community, that is fine. Go get the education that you need. There is continuing education that is very much available to us, and it isn't hard to gain these competencies. But making sure that we know, hey, I have stepped out of my scope, and I would really love to help you. Okay, go learn. Go learn so you can.
Dr. Lisa: And before this conversation is over, I am definitely going to get your recommendations around where you would go, a trustworthy place to get that training, if somebody wanted to pursue it. But first, how would you describe what those special competencies really are, or what you know that makes you effective at this work? I mean, lived experience, but beyond that, that a therapist would want to learn more about.
Dr. Brianna: The biggest piece I would say is trauma-informed care. Ensuring that when you are working in these communities, because especially when it comes to queer communities of color in particular, it is very rare that you are going to have a client come through your door who has not experienced some kind of trauma.
Dr. Brianna: And the importance of making sure their autonomy is actually focused and front and center, and that you are not another person who is coming in and taking that from them in your attempts to help, is so important, as they are going through their identity, going through what is going on for them.
Dr. Brianna: Helping them put in context the historical things going on around them, so that they understand that things are not just happening because you are you. It is happening because of all of these things around you and all of these other pieces. And that is something that I know a lot of my clients have found very healing, understanding that there are structural pieces to the oppression they have experienced, structural pieces to what has gone on for them.
Dr. Brianna: Even when it comes to mistreatment they have had in medical fields, discussing the structural pieces that underpin that, even when they do put my career in a bad light in certain ways. But there are things that the psychological community has done that is awful to communities of color, to a lot of different communities, where we would be here all day on that soapbox.
Dr. Brianna: But being able to acknowledge those pieces of history with your client, and then put them in the context for them, and then help them move through that and make meaning, is such an important piece of it. And we have to know that knowledge ourselves, of our field, in order to be able to help our clients through that. It also helps them to trust us when we can be honest, because they know some of these things have happened, and they will sometimes wait and see if we will bring it up.
Dr. Lisa: So what are you thinking of right now? We are brave on this show. We go dark. What are the things that you are thinking of, when it comes to, I mean, there are bigger world systemic harms for sure, but things that people have experienced in this profession that maybe therapists need to have visibility around and acknowledge in order to create that trust and safety?
Dr. Brianna: Yes. Where I think of in particular is harms that can come from when a therapist decides to be both a couples counselor and an individual therapist for a person.
Dr. Lisa: Don't get me started.
Dr. Brianna: The amount of clients I have experienced who have had harm from that happening, from that boundary violation. When we have heard many of their experiences, oftentimes the therapist was very well-meaning. Very well-meaning, but not trained. Not at all trained in that area, not competent in that area, and should not have been doing that.
Dr. Brianna: And so then it becomes a discussion of, you know, this person never should have been both therapists for you. That was an ethical violation that occurred for you. And processing through that with them, that yes, this experience was awful for you, but it wasn't just awful because of what was going on in your relationship and how you communicated in that space.
Dr. Brianna: It was awful because the person who was trying to help you was not helping you in a way that was helpful. It doesn't mean they were trying to be hurtful, which they are not, oftentimes. But we do cause harm. Well-meaning people can cause harm, and we have to acknowledge that and have that humility again of, I am out of my scope. I have never done this before. At least ask.
Dr. Lisa: So, just so every therapist within the sound of our voice knows, an actual couples and family therapist or relational expert would never do that. And if you are a civilian stumbling on this interview, know that one of the red flags of a therapist is that they would do that. It is a dual relationship. And I think it is important to say this out loud, and we might be upsetting some people right now, but it is also widely done by clinicians who, again to your point, are well-meaning. They don't know better, and it does cause harm. So thank you for saying that out loud.
Dr. Brianna: Yeah, it causes immense harm, and I just feel like we don't talk about that enough, how much harm we cause, and then the public just isn't aware. They trust us. And that trust is misplaced when we are not keeping to where our competencies are, when we are not being humble and having the humility to know where our end of scope is. And that is for any healthcare professional, not just psychologists. We all need to know where our scope ends so that we don't cause harm.
Dr. Lisa: Absolutely. Okay, so then, part of your work too, you mentioned people in polyamorous relationships. I would love to hear your perspective about this, because I feel like that is another thing that we are. I mean, even as a marriage and family therapist, and granted, I went to school a while ago, there is maybe three sentences in my sex therapy class. But it was in a sex therapy class. It actually wasn't in a relationship systems class. So I would love to hear your thoughts on what a therapist would need to know or understand about people in these relationships that they might not know if they haven't had that lived experience or any professional training, which is frequently the case.
Dr. Brianna: Yeah. I think something that is important to notice is the amount of stigma they have had before they have even come into your room.
Dr. Brianna: Even in the way that we talk about work with relationships, calling it couples therapy is stigmatizing for folks in a polyamorous relationship, because it is that assumption that there is only two.
Dr. Brianna: And so even in the language that we use, we are stigmatizing the community. So being very aware of that as you are coming into working in this community. What is the language that is very much heteronormative and very much monogamy first that I am already using, that needs to be shifted? Because those are small ways in which we cause harm before we have even started the therapy session.
Dr. Lisa: I would probably do that without even thinking about it. I would say, oh, working on your relationship, but I would call it couples. But you are absolutely right. It is not, and that in itself is prioritizing one type of relationship structure over others.
Dr. Brianna: Yeah. We are already communicating with our language that two is what is normal. And that can be a barrier when we already start like that, so that is something really important for us to understand.
Dr. Brianna: There is another piece, which is checking your own bias about what you personally feel about relationships before coming into this space, because that does very much aim sometimes how we ask questions, or looking through even our intake to see where that language needs to be adjusted to be more open, to be more questioning and curious and not as guided to how it is supposed to be.
Dr. Brianna: And so there are things in our intakes that need to be adjusted. I know when I first started working with polyamorous relationships, that was one of the first things I did, was going through my intake. Where, what is my intake that I learned in grad school, that I got this template? What fits, what doesn't? What needs to be adjusted so that I am more open, because I am working with more than just monogamous relationships?
Dr. Brianna: And so it is being very intentional about coming into the community, being very intentional about learning the language, understanding things like compersion and other pieces of how we understand how these relationships function, and how they function in healthy ways. But a lot of the work is the same as we do in monogamous relationships. It is communication.
Dr. Lisa: So somebody who is maybe in a relationship that they are wanting to open up, or actively practicing polyamory, what are some of the things that they are trying to navigate that a therapist would need to be prepared for, that is going to be different? That is not communication skills training, as is so often the case.
Dr. Brianna: A lot of it, the biggest piece, is the layeredness of the boundaries. We are supposed to often recommend that people are in their own individual care while they are in couples work, so that they are actually doing the work outside of session too, to make sure that they are developing the skills they need to develop.
Dr. Brianna: But there is also that piece of understanding that the layeredness of that boundary navigation is completely different in polyamorous dynamics. Because we have to go through the pieces of that, where each piece is coming from, how we are each understanding things, and finding that space where it works best for everyone.
Dr. Brianna: And so ensuring that you are keeping that place of free will, of we are trying to get you to live the most authentic version of your lives that works for you all, in the way that fits what y'all need.
Dr. Brianna: And so making sure we are keeping that openness is really important, because there isn't going to be a singular answer or a common answer. Oftentimes when we are figuring out how the dynamic should function, each one is unique. Each person's needs in it are unique.
Dr. Brianna: And whether or not kink is coming into the picture also adds extra layers of what these boundary negotiations look like, and how we find space and time for this. Because when we add more adults to a situation, we add more people with jobs, more people with very busy schedules, and more people with lots of responsibilities. And so figuring out how we are negotiating all those pieces together in ways that is effective communication, and how we are adjusting for each other, is so important.
Dr. Lisa: Well, and also coming to a, because it is one thing for a person to get clear about what they feel okay with. But then to get into alignment and agreement with one partner is challenging. And then multiple partners, that is really four-dimensional relational work right there. So that is super cool.
Dr. Lisa: Okay, so then one last question on this subject. There is one thing, like if somebody really wanted to amplify their specialization in working with polyamorous relationships, or queer identifying people of color, you are going into that with an intention, and there are opportunities to do continuing education, which I am going to ask you about.
Dr. Lisa: But I think that the sleeper for a lot of therapists in private practice is they are just kind of, you know, like, I just work with adults. Eighteen to dead, whatever it is, and that is about as much as they differentiate. And then what will happen is that an individual client maybe came in for depression or anxiety, or the garden variety stuff, especially over the course of a longer term relationship, might start saying, I think I want to open up my relationship, but I don't know how to talk to my partner about that, for example.
Dr. Lisa: Any just basic things, advice that you would have for a therapist who might not have seen that coming, on how to. And again, this is beyond the scope of a podcast to give somebody everything that they need, but just basic recommendations for
Dr. Lisa: facilitating that moment. But then, like, when do you refer? Because the other part is that this is an established relationship. There is trust. And I have also talked to people where they have been in a therapeutic relationship, and they said somewhere along the lines, I think I might be questioning my gender identity. I wonder sometimes if I might be trans.
Dr. Lisa: And a therapist freaks out and says, I can't see you anymore, gives them a referral, and never talks to them again. I have literally heard that story, so I feel like there needs to be that middle path. Does that make sense?
Dr. Brianna: It does, because that is incredibly harmful for folks when that happens. When they finally feel comfortable with their therapist enough to share this piece of themselves, and then it is almost rejected. And again, that piece of, you are coming from not trying to cause harm, but you did. That is harmful.
Dr. Brianna: And so it is so important to, one, yes, when we have an established client and we realize they are out of scope, yes, we do need to refer out, but there is a gentle way to do that.
Dr. Brianna: And there is a way that talks to them about it and doesn't make them feel as if they are a problem that you can't handle. Being very, again, that piece of humility, of explaining, this is my competence, this is my scope. What you are looking for and the journey that you are about to go on is so important, and so important for you, and I want you to do that with someone who can fully help you engage in that in ways that I am simply not trained to do.
Dr. Brianna: And there is a way to do that gently and hand them off to the next person gently, that doesn't require just, oh my God, you have done something I can't deal with, I am dropping you, here is on to the next person, here is a referral. Please don't do that to folks. It is so, so harmful, and it does happen so often.
Dr. Brianna: When we hit the point of, okay, you are beyond my scope. And I have had that happen as well with a client, where it wasn't in terms of gender or a trauma piece, but there was something that I was just fully untrained for. Fully untrained for. I could recognize it, I could diagnose it, and so we had to have a session where we discussed that. This is what is going on for you, this is the type of treatment you need, and unfortunately I can't provide that here in this space for you. I am going to help you find someone else who can. I am going to keep working with you until you can. And I gently handed them off.
Dr. Brianna: But we have to be able to say, I can't do this. I would love to help you. I have very much enjoyed working with you, but I can't do this, and I want you to receive the help that you need, versus me giving you pieces of what I can give you and you not actually being able to get what you need.
Dr. Lisa: Thank you so much for this good advice. I really appreciate that. Okay, so before I let you go, you mentioned several times over this conversation just the importance of continuing education. So if you were somebody listening to this and wanted to go to a trusted source, from your perspective, where would you send them? Is there an organization, or even something within APA that people might not know about?
Dr. Brianna: So a lot of the trainings I do are through APA, because it is easy enough. They have the nice little list for us, and I know that they are credentialed and it is all set. Other places that are really good: Society for Clinical Hypnosis.
Dr. Lisa: Oh, wait. They are fantastic. I did not see that one coming. The Society for Clinical Hypnosis.
Dr. Brianna: Yes. It might be experimental, but I am pretty sure it is clinical hypnosis. Really good training, especially if you are working in trauma with that kind of population, and for folks with anxiety. I have done trainings with them and they have been absolutely fantastic. I have also done some trainings in emotion-focused couples counseling that have been absolutely fantastic. I am blanking on the name of the society for that, but I am pretty sure it is literally emotion-focused therapy.
Dr. Brianna: But going through the different divisions that we have here in APA, a lot of them do have trainings, and they are almost always fantastic. And so I highly recommend those.
Dr. Lisa: So one question. You and I are both psychologists, but we have a lot of friends who listen to this podcast. They might be master's level clinicians, LCSWs. Can any mental health professional come to an APA accredited training, through a division?
Dr. Brianna: Yes. Anyone can. You just have to pay for them. And for folks with different degrees, oftentimes they have the different kinds of CEs for the different degrees. And there is also, if you have a local state, I know there is the Virginia Association of Clinical Psychologists, they do trainings as well. Every state has their local association, so looking through those trusted spaces where we know things are accredited, those are the best places to get your extra trainings.
Dr. Lisa: Such good advice. And so, for those of you not very familiar with the APA, there are, what, 52 different divisions, I think. So much interesting stuff.
Dr. Brianna: Fifty-six at least.
Dr. Lisa: They have trauma. So trauma. I do some stuff with Division 13 of the APA, Society for Consulting Psychology, so there is so much good stuff. And so for anybody listening, I would recommend just go to APA at apa.org. And you will see a list of divisions, and they have psychoanalytic, they have marriage and family therapy, they have trauma therapy, and then you can click through to the division webpage.
Dr. Lisa: And I think all the divisions maintain an education committee where they have different trainings. And from my experience they are very high quality and also frequently very low cost compared to a lot of other things you can find. And typically, at least in my experience, many state licensing boards, like if you are an LCSW or something, if you go to an APA accredited continuing education event, they usually take those hours, because the APA has a really good reputation.
Dr. Lisa: So I really appreciate you just helping people know where to go. I think that is important.
Dr. Brianna: Definitely. And for students, they are always discounted usually. And so that is the thing too. I knew where I wanted to specialize when I was in school. And yes, part of it comes from my own identities and my own participation in these communities, but also, just because I am a part of the community doesn't mean I know everything.
Dr. Brianna: And so as a student, I made sure to guide my classes, my extras, the trainings I did as well, into that area. And so it is never too early to start learning about the population you are interested in. I highly recommend students doing it. It helps so much when you get out to already have an idea of where you want to start.
Dr. Lisa: And so then very lastly, for any of our friends listening to this, this has been such an illuminating conversation, first of all, but I think one of the big takeaways is, where are your boundaries, when to refer, what is in your scope, what is not? If somebody wanted to refer a client to you, tell us more about your practice and how somebody might get in touch with you, or even just reach out and say hi and start to establish that relationship with you.
Dr. Brianna: Yes. So my practice, the quickest way to learn about it is my website. You can also reach me through my contact page if you ever want to get in touch with me or have questions.
Dr. Brianna: Typically, like I said, I work a lot with queer folks of color who have been trauma exposed, and then folks in polyamorous relationships, and folks trying to navigate those spaces and figuring out how to make the relationships function in the way that best works for them. It is fully virtual. I am a member of PSYPACT, so I can work in several different states. I love my work. I love my little practice. It is great.
Dr. Lisa: I think I love you. It has been such a great conversation, and you are such a joy and just a treasure. Your generosity with your knowledge and your experience, and it feels like you also have a heart for teaching. And you wear stars on your face. You had me at hello.
Dr. Lisa: And we will link to that obviously in the show notes, and we will put Dr. Ector's contact information. And what a phenomenal referral partner.
Dr. Brianna: Thank you so much.
Dr. Lisa: Thanks for listening to Love, Happiness, and Success for Therapists. If you found today's episode helpful, please share it with a friend or colleague. And if you would like more support on your journey, whether that is growing your skills, evolving your practice, becoming certified as a coach, or just feeling more inspired in your work, come visit me at growingself.com. Click on the For Therapists section and sign up for my newsletter so we can keep in touch, and let us also connect on LinkedIn. I am at Dr. Lisa Marie Bobby. Take care, and I will talk to you next time.
What to take with you
Competence is cheaper than avoidance.
The dominant frame in this category is risk and liability, which makes clinicians avoid whole categories of client. The fundamentals transfer, the adjustments are learnable, the trainings are open to master's-level clinicians, and the actual risk sits in not bothering.
Well-meaning is the point, not the excuse.
The clinicians causing this harm are not malicious and they are not rare. They are trained, licensed, caring people working slightly past what their education actually covered. Holding both of those facts at once is what makes this conversation possible to have.
Referring is a skill, not a confession.
Every competing article treats the referral as a decision point. It is a clinical maneuver with a sequence, and you can be good or bad at it. The version where you keep working with the client until the handoff is complete is the version almost nobody teaches.
The most common harm is a dual role hiding in plain sight.
One clinician serving as both individual and couples therapist for the same person is widely practiced, rarely named as a violation in print, and something Dr. Ector sees the fallout from regularly.
Stigma arrives before the client does.
The default vocabulary of the profession assumes two people in a relationship and one shape for a family. Auditing your own questions and your intake paperwork costs nothing and takes an afternoon, which makes it the highest-return item in the entire episode.
Start before you need to.
She chose her specialty in graduate school and steered her coursework, electives and trainings toward it before she ever graduated. For students and early-career clinicians that is the single most actionable thing here, and student rates on accredited trainings are usually discounted.
What we cover, in order
- When should a therapist refer a client to someone else?
- How do you refer a client without making them feel rejected?
- What does scope of practice actually mean in private practice?
- How do therapists become competent with a population they were not trained for?
- Where can therapists get accredited continuing education that state boards accept?
- Why knowing when to refer isn't the same as doing it well
What's in this article
No. And if that is the worry that brought you here, I want to put it down before we start. The clinicians we are talking about in this episode are careful, licensed, well-meaning people who were working slightly past what their training actually covered, usually without knowing it. Dr. Ector is one of the most generous people I have ever recorded with on this subject, and her whole argument is that the fix is easier than we fear.
That is exactly who this is for. The therapist who says "I just work with adults" is the person most likely to hit this, because a client you have seen for eight months can disclose something on a Tuesday that was never in your training. You do not need a specialty. You need a plan for that Tuesday.
Three things. A four-move sequence for referring a client out without making them feel like a problem you could not handle. A specific instruction to go read your own intake paperwork with fresh eyes. And the names of where to get accredited continuing education, including one detail about APA division trainings that surprised me and I have been doing this a long time.
You do not, and this is the part of the conversation I am most glad we recorded. I asked her directly whether a master's-level clinician, an LCSW for instance, can attend an APA division training. The answer is yes. CEs are issued by degree type, and state licensing boards generally accept APA-accredited hours.
When to Refer Clients, and How to Do It Without Causing Harm
You have been seeing this client for eight months. Depression, some anxiety, a job they are ambivalent about. Ordinary, good work, the kind you are genuinely competent at. And then partway through a Tuesday session they say something that changes the shape of the room, and you realize you are holding something you were never trained to hold. If you have ever sat in that particular pause, wondering when to refer clients and whether referring at all means you have failed the person in front of you, here is the short answer. You refer when the work has moved outside what your training actually prepared you for, and referring well is a clinical skill you can get good at rather than a confession you have to make.
Nobody taught us this part. Graduate school handed us the ethics code language about boundaries of competence and then handed us a caseload. What it did not hand us was a script for the conversation where you tell someone you have built real trust with that you are not the right clinician for the thing they just risked telling you. That gap comes up constantly among the therapists in the Therapist Growth Collective, far more often than anyone admits out loud at a conference.
Which is roughly where this episode came from. I was standing in a hallway at the APA 2026 convention and I asked Dr. Brianna Ector what she wished other therapists understood about her work. She started to answer, and about two sentences in I stopped her, because she was saying something our profession does not say out loud and I wanted you to hear it in her words rather than mine. So we sat down on the conference floor and recorded it right there, ambient noise and all.
Before we get into what she said, I want to be straight with you about what an article can and cannot do. What follows is real and useful and I want you to take it into your Monday. But reading about how to refer someone gently does not build the reflex, and reading about competence does not give you a person to call at four in the afternoon when you are ninety minutes from a session and genuinely unsure whether to keep going. That part happens in relationship with other clinicians who are working on the same thing. It is the entire reason I built the Therapist Growth Collective and why the professional development work we do at Growing Self exists at all. Our people are working therapists who got tired of figuring this out alone in a home office. So take what is here, and know that the place it turns into practice is with colleagues.
When should a therapist refer a client to someone else?
You refer when the client's needs fall outside the competence you could actually document, meaning your education, your training, your supervised experience, your consultation, and your study. Not outside your comfort. Outside your competence. Those are different things and the difference is the whole ballgame, because comfort grows just from exposure while competence only grows from training.
Dr. Ector's answer to what most clinicians miss about this is two things held together, and she says it three separate times across the episode. It is both easier than we would like to think, and it still requires real skill. The basics of what we do carry across populations. The psychoeducation is largely the same. What changes is implementation, and how a specific community responds to a given modality, and that part has to be adjusted deliberately rather than assumed.
Then she says the thing that made me stop. The most well-meaning therapists cause harm, because they are simply not competent in the ways they should be, and they step on things they should not be stepping on. Her clients arrive at her practice already harmed by clinicians who wanted to help them. That work is hard, she says, because you have to help someone understand what happened to them, grieve it, and then also give them a corrective experience. Hold onto the phrase well-meaning there. Strip it out and this becomes an accusation, which is both inaccurate and not what she said. These are careful people working slightly past their training, which is a completely different problem from malpractice and it has a completely different fix. If you want the harder-edged version of the boundary between the two, we have a whole piece on how to avoid ethical violations in therapy practice.
So the trigger for a referral is not a feeling of discomfort and it is not the arrival of an unfamiliar identity or relationship structure in your office. It is the honest answer to a narrower question: do I have training for what this person actually needs next, and if not, can I get it in time to be useful to them. Sometimes the answer is that you can, and you go get it. Sometimes it is that you cannot, and the kind thing is to say so.
If you are reading this and doing the arithmetic on a specific person, that arithmetic is very hard to do from inside your own caseload. It is the most common thing our therapists bring to consultation, and not because they are unsure of the ethics. They are unsure whether this particular client, with this particular history, is one they can serve well. That is the conversation, and it goes better out loud with someone who is not you.
How do you refer a client without making them feel rejected?
You name it as your scope rather than their problem, you tell them the thing they need is worth having, you help find the next clinician instead of handing them a list, and you keep working with them until the handoff is actually complete. That last piece is the one nobody teaches and it is the one that decides whether the referral heals or wounds.
I brought her a story I had heard more than once. A client in an established therapy relationship, real trust built over months, who finally says something like: I think I might be questioning my gender identity. And the therapist panics, says they cannot see them anymore, hands over a referral, and never speaks to them again. Dr. Ector did not hesitate. That is incredibly harmful, she said, because the client finally felt safe enough to share a piece of themselves and the response landed as rejection. And again: the therapist was not trying to cause harm. They did anyway.
Her alternative is not complicated, which is exactly why its absence from the literature is strange. You explain your competence and your scope. You tell them that what they are moving toward matters and that you want them to have it from someone trained to help them engage with it. You stay warm. You do the looking. And, in her words, you keep working with them until they can transition. She describes doing precisely this with a client whose presenting issue turned out to be something she could recognize and diagnose but was fully untrained to treat. She named it, told them what kind of treatment they needed, said she could not provide it in that room, and then helped them find someone and kept seeing them in the meantime. There is a version of this that is really about your own limits rather than theirs, and if that is live for you, our piece on when to let therapy clients go covers the harder judgment calls.
The sequence is four moves, and what makes it work is not the words. It is that the client can tell you are still on their side while you are doing it.
- Name your scope, not their problem. This is my competence, not your failure.
- Affirm what they actually need. The work ahead of you matters, and it is worth having.
- Help find the next clinician. You do the looking, not them.
- Keep working until the handoff lands. Do not stop before they are seen.
The harmful version is the same story with the last two moves removed: trust offered, then a referral and silence. That is the whole difference, and it is worth knowing that the difference is entirely in your hands.
Worth saying plainly: this is boundary work, and it is the generous kind rather than the defensive kind. If your instinct is that holding a boundary and staying warm are in tension, that is worth examining, and setting boundaries as a therapist is a good place to start.
Most of the therapists I work with can describe the gentle referral perfectly in the abstract and then freeze in the actual session, because the actual session has a real person's face in it. That is not a knowledge gap. It is a rehearsal gap, and it is one of the specific things we practice with each other in the Collective, out loud, before it counts.
What does scope of practice actually mean in private practice?
In practice it means a clinical skill rather than a licensure category, which is the opposite of how the internet defines it. The APA Ethical Principles of Psychologists and Code of Conduct is clear enough at Standard 2.01: psychologists provide services with populations and in areas only within the boundaries of their competence, based on education, training, supervised experience, consultation, study, or professional experience. Notice that none of those six words is "license." Standard 2.03 then adds the obligation to maintain competence over time, which is the part that turns this from a static box into an ongoing practice. If you want the foundational read this episode builds on, it is our piece on therapist scope of competence.
What I said to her on the recording is that we do not talk about this enough in our profession, and specifically we do not talk about self-awareness around scope. I am dually licensed, as a psychologist and as a marriage and family therapist, so I have watched this from both sides for a long time. What I see constantly is clinicians in private practice saying yes to a lot of things. People trained in clinical mental health taking on couples and families, when systems work is a genuinely different training, a different education, and a different developmental experience. I am not describing bad people. I am describing a structure that makes it very easy to drift.
Then she named the specific case, and it is the sharpest thing on the recording. The harm she sees most often comes from one therapist deciding to be both the couples counselor and the individual therapist for the same person. The volume of clients she has seen come through that is significant. Often the therapist was very well-meaning, she said, and not trained at all in that area, and should not have been doing it. So it becomes a conversation with the client about how this person never should have been both of your therapists, and what happened to you was an ethical violation, and the reason that experience was awful was not only what was happening in your relationship. It is a dual relationship. It is also, as I said on air knowing we might upset some people, widely done. Our article on dual relationships when therapy clients refer their friends works through the adjacent version of the same trap.
She takes it wider than psychology at the end of that passage, and she is right to. Every healthcare professional needs to know where their scope ends so they do not cause harm. The public trusts us, and that trust is misplaced when we are not honest with ourselves about where our competence stops.
How do therapists become competent with a population they were not trained for?
You learn the specific community rather than a general theory of difference. The fundamentals you already have transfer. What you add is the language, the way the community actually functions, an audit of your own assumptions and paperwork, and accredited training in the two or three competencies that carry the most weight. She names those competencies directly, and the first one will not surprise you while the second and third might.
Trauma-informed care is the biggest piece, she says. With queer clients of color in particular it is rare to have a client come through who has not experienced some kind of trauma. Which also means the clinician's own exposure is part of the picture, and doing this work well over years requires you to take your own accumulated exposure as seriously as you take the clinical skill.
Second is client autonomy, and she frames it as a warning rather than a value statement. Make sure you are not another person coming in and taking their autonomy away in your attempts to help, while they are working through their identity and whatever else is going on for them. Sit with the shape of that sentence for a second. She is describing help as a thing that can be done to someone. It is the same tension underneath whether therapists should give advice, and it is a harder question than it looks.
Third is historical and structural context, treated as an active intervention rather than background reading. Helping a client understand that what is happening to them is not happening because of who they are, but because of a set of structures around them, is something she says her clients have found genuinely healing. That includes mistreatment in medical settings, and it includes our own field. There are things the psychological community has done to communities of color that are awful, she said, even when saying so puts her own profession in a bad light. Being honest about it is also what earns trust, because clients often already know the history and are quietly waiting to see whether you will bring it up.
This is where the research is unusually direct, and it is worth knowing about even if you never see a client in the populations she serves. Owen and colleagues found that when clients perceived their therapist as missing opportunities to engage with cultural identity, outcomes were worse, and that perceived therapist cultural humility buffered that effect. Cultural humility, in other words, is not a disposition. It is a measurable clinical variable that shows up in outcome data.
Then we got to the part I have not stopped thinking about. She works largely with clients in polyamorous relationships, and I asked what a therapist would need to understand that they would not know without lived experience or training. Her answer started with stigma, and specifically with stigma that arrives before the client does. Calling it couples therapy, she said, is stigmatizing for someone in a polyamorous relationship, because it assumes there are only two. I admitted on the spot that I would have said it without thinking, and I have been a marriage and family therapist for a long time. She is describing our default vocabulary as heteronormative and monogamy-first, and pointing out that these are small ways we cause harm before the session has even started. Her practical instruction is to check your own bias about relationships before you walk into the room, because it shapes how you ask questions, and then to go read your own intake form and find where the language needs to open up. That is genuinely free and it takes an afternoon. If you want the broader frame for this, staying non-judgmental in the face of values conflicts gets at the same muscle.
And the research backs the paperwork point harder than most clinicians realize. Schechinger, Sakaluk, and Moors surveyed 249 consensually non-monogamous therapy clients and found that roughly one in five reported their therapist lacked basic knowledge about consensual non-monogamy, and nearly one in ten reported their therapist pushed them to end the relationship. Both were linked to clients leaving therapy early. That is not a preference finding. That is a dropout finding, which means the harm is measurable in the one outcome we all claim to care about.
The rest of what she describes is more clinical than political. Boundary navigation is structurally different when there are more than two people, because each person's needs are distinct and there is no single or common answer to how a dynamic should function. More adults means more jobs, more schedules, and more logistics to negotiate. Kink adds layers. And then, she says, a lot of the work is the same as it is with monogamous couples, and it is communication. The companion read here is cultural competence in therapy and the blind spots we do not see, which covers the general version of this specific lesson.
Here is the honest thing about auditing your intake form. It takes an afternoon and almost nobody does it, because it is the kind of task with no deadline attached. The therapists who actually finish it tend to be the ones who told a colleague they were going to. That is most of what our community does, and it is less glamorous and more useful than it sounds.
Where can therapists get accredited continuing education that state boards accept?
Start with the APA divisions. There are more than 50 of them, nearly all maintain an education committee, and the trainings are frequently high quality and low cost compared to most of what you will find. Your state association is the second place to look, and every state has one. Both are what she calls trusted spaces where you already know the accreditation is real.
Then comes the detail I did not expect, and it is the most useful thing in the episode for a lot of you. I asked her directly whether a master's-level clinician, an LCSW for instance, can attend an APA-accredited training through a division. Yes, she said. Anyone can. You pay for it, and for different degrees they often run different CEs matched to the degree type. In my experience state licensing boards generally accept APA-accredited hours, because the APA's reputation carries. And students are usually discounted.
One more thing from her, aimed at students and early-career clinicians but useful at any stage. She knew where she wanted to specialize while she was still in school, and she deliberately steered her classes, her electives, and her trainings toward it before she graduated. Her line is that it is never too early to start learning about a population you are interested in. If you are earlier in this than she was, finding your niche as a therapist is the practical version of that advice.
She also named the Society for Clinical Hypnosis as excellent training, especially for trauma and anxiety work, which I did not see coming. And she has done emotion-focused couples work training that she rated highly. Both are listed in the resources section at the foot of this article. The point stands regardless: the trainings exist, they are accessible, and the barrier is almost never money.
That is the honest state most people are in by this point in the article. The Therapist Growth Collective is not a course. It is the group of working clinicians where the conversation about which training is worth your Saturday actually happens, from people who took it last month.
Come See What It Is LikeThe clinicians who follow through on continuing education are almost never the ones with the most free time. They are the ones with a standing reason to show up somewhere and say what they are working on. That is the mechanism, and it is the mechanism we built the Collective around.
Why knowing when to refer isn't the same as doing it well
I want to be honest with you about something before you close this tab. Everything above is real. The four moves work. Dr. Ector uses them, I use them, and clients on the other side of them can tell the difference. But I would be doing you a disservice if I let you finish this article thinking that reading it was the work.
Here is what usually happens instead. You read something like this. Something clicks, and you feel a little more solid than you did an hour ago. You make a mental note to handle it differently the next time a client says the unexpected thing. And then a client says the unexpected thing, at 4:15 on a Thursday, in a session where you are already tired, and what comes out of your mouth is whatever your nervous system has been doing for the last decade. Then you drive home turning it over.
That is not a discipline problem and it is not a competence problem. You are trying to run new behavior in the exact moment the old pattern is most active, alone, with a real person watching your face. It is the hardest possible conditions, and most of us are doing it without anyone to debrief with afterward. Which is worth naming as a structural feature of how we work rather than a personal failing. We spend our days holding space for other people and then close the office door with nobody holding any for us, which is also how vicarious trauma accumulates without anyone noticing.
You also do not have to have fumbled one of these to be interested in doing it better. That is worth saying directly, because the helper identity makes it strangely hard to hear. Going and getting trained in something you are not yet good at is not an admission that you are behind. It is the most sophisticated professional move available to you, and it is what the best clinicians I know have always done. Dr. Ector is a member of the community she serves and she still says out loud that being part of it does not mean she knows everything. If that is her standard, none of us needs a better excuse.
What actually changes the outcome is having colleagues who know your specific caseload, who you can message after a session that went sideways, and who will tell you the truth about whether the referral you are contemplating is a scope call or an avoidance call. That is what the Collective is. Not lectures. A standing group of working therapists paying attention to each other's practices. If something in this article landed on a specific person you are seeing right now, that is the signal to say it out loud to someone. Come see what it is like, and if you want to talk it through with us first, we will give you a real answer rather than a sales pitch. And if the thing you are actually circling is the line between therapy and coaching, that has its own set of traps, which we cover in coaching ethics for therapists.
One last thing, and then I will let you go. Referring someone well is not the moment your work with them ends. It is the last piece of care you give them, and it is one of the few pieces they will remember precisely. Getting it right is worth practicing before it counts, and practicing it with other clinicians is what we are here for.
xo,
Dr. Lisa Marie Bobby
P.S. If you have a colleague who is currently seeing one person for individual therapy and also seeing that person with their partner, send them this. That is who it is for.
About this episode's experts
Dr. Brianna Ector, PsyD
Dr. Brianna Ector is a licensed clinical psychologist and the owner of Serenity and Wellness Pathways, a fully virtual private practice. She is a PSYPACT member, which is not a detail to skip past: it is how she reaches a population that is geographically scattered and badly underserved. Her clients are largely trauma-exposed queer people of color, and she also does most of her relationship and couples work inside the polyamorous community. She chose this specialty in graduate school and built toward it deliberately, steering her coursework, her electives, and her trainings toward it before she ever graduated. She trains through APA divisions and she is unusually careful about the difference between belonging to a community and being competent to treat it.
What makes her worth listening to is not a platform. She has no book to promote, no course, and a small solo practice, which is precisely why the conversation is as candid as it is. She is willing to describe her own field's history of harm toward communities of color even when doing so puts her profession in a bad light, and she is willing to name the specific thing well-meaning colleagues do that lands her their former clients. She does both without a trace of contempt for the people she is describing, which is the reason it lands instead of putting anyone on the defensive.
I also want to say what I said to her at the end of the recording. She is a genuine referral partner for us, not a courtesy mention. She serves a population Growing Self gets asked about and cannot always serve well, and if you have a client who needs what she does, she is where I would send them. You can reach her through her contact page.
Dr. Lisa Marie Bobby
Licensed psychologist, licensed marriage and family therapist, board-certified coach, and clinical supervisor. Founder of Growing Self Counseling and Coaching. Author of Exaholics: Breaking Your Addiction to an Ex Love. Host of the Love, Happiness & Success podcast and Love, Happiness & Success for Therapists. She has been supporting the growth of therapists and clinicians for over twenty years, with a focus on the professional development, ethics, and sustainability of working clinicians and the practices they build.
Questions therapists ask about scope, competence and referrals
When the client's needs fall outside the competence you could actually document through education, training, supervised experience, consultation, or study. The test is competence, not comfort. Discomfort with an unfamiliar identity or relationship structure is a signal to get trained, not automatically a signal to refer. The referral is indicated when you cannot acquire the competence in time to be useful to this particular person.
It can be. APA Standard 2.01 limits practice to the boundaries of your competence, and Standard 2.03 obligates you to maintain competence over time. The more common real-world situation is not a clean violation but a drift, where an established client's needs evolve past what you trained for. That is why the honest self-assessment matters more than the rulebook here.
Four moves. Frame it as your scope rather than their problem. Tell them the thing they need is important and worth having. Help find the next clinician rather than handing them a list. Keep working with them until the handoff is actually complete. The last one is the move most therapists skip and the one that determines whether the referral heals or wounds.
Dr. Ector names one clinician serving as both the individual therapist and the couples therapist for the same person. It is a dual relationship, it is widely practiced, it is rarely called an ethical violation in print, and she regularly sees clients who were harmed by it. The therapists doing it are usually well-meaning and untrained for the systems work rather than careless.
It is a clinical skill, not a licensure category. Your license tells you what you may legally do. Your competence tells you what you can actually do well, and it comes from education, training, supervised experience, consultation, and study. Those two boundaries are not the same, and the gap between them is where most of this harm happens.
The fundamentals transfer and the implementation adapts. What you add is the community's language, an understanding of how the community actually functions, an audit of your own bias and your intake paperwork, and accredited training in the competencies that carry the most weight. For trauma-exposed queer clients of color, Dr. Ector names trauma-informed care, protecting client autonomy, and treating structural and historical context as an active intervention.
Because it assumes there are only two people, which stigmatizes clients in polyamorous relationships before the first session begins. The default vocabulary of the profession is heteronormative and monogamy-first. The fix is free: audit the language in your questions and in your intake form so it is open and curious rather than pointed at one assumed answer.
Anywhere the form assumes one relationship structure, two partners, or one family shape. Dr. Ector describes going through her grad-school intake template question by question when she began working with polyamorous clients, asking what fits and what does not. It costs nothing, it takes an afternoon, and it is the single highest-return item in this episode.
APA divisions are the primary recommendation. There are more than 50, nearly all maintain an education committee, and the trainings are frequently high quality and low cost. State associations are the second source and every state has one. The Society for Clinical Hypnosis is named specifically as strong training for trauma and anxiety work.
Yes. Any mental health professional can attend an APA division training, including LCSWs and other master's-level clinicians. CEs are frequently issued in versions matched to the degree type, state licensing boards generally accept APA-accredited hours, and students are usually offered discounted rates.
Sources cited in this episode
- American Psychological Association. (2017). Ethical principles of psychologists and code of conduct (2002, amended effective June 1, 2010, and January 1, 2017). See Standard 2.01, Boundaries of Competence, Standard 2.03, Maintaining Competence, and Standard 3.05, Multiple Relationships. https://www.apa.org/ethics/code
- Schechinger, H. A., Sakaluk, J. K., & Moors, A. C. (2018). Harmful and helpful therapy practices with consensually non-monogamous clients: Toward an inclusive framework. Journal of Consulting and Clinical Psychology, 86(11), 879-891. https://doi.org/10.1037/ccp0000349
- Owen, J., Tao, K. W., Drinane, J. M., Hook, J., Davis, D. E., & Foo Kune, N. F. (2016). Client perceptions of therapists' multicultural orientation: Cultural (missed) opportunities and cultural humility. Professional Psychology: Research and Practice, 47(1), 30-37. https://doi.org/10.1037/pro0000046
- American Psychological Association, Division 44. Consensual non-monogamy fact sheet. A practical clinician-facing companion to the Schechinger et al. findings, and the most directly usable resource on this list for a therapist who wants to start today. https://www.apadivisions.org/division-44/resources/consensual-non-monogamy.pdf
Organizations and resources mentioned in the recording: the APA divisions (apa.org/about/division), more than 50 of them, nearly all with an education committee running accredited trainings, and the primary continuing education recommendation in Chapter 10; Division 13, the Society for Consulting Psychology, named by Dr. Lisa as one she works with; the Society for Clinical Hypnosis, named by Dr. Ector in Chapter 10 as excellent training for trauma and anxiety work; an emotion-focused couples therapy training organization she has trained with and rates highly; state psychological and counseling associations, of which the Virginia Association of Clinical Psychologists is named as an example of the type and every state has an equivalent; PSYPACT, the interstate compact that lets Dr. Ector practice across multiple states and reach a geographically scattered population; and Serenity and Wellness Pathways PLLC, her fully virtual private practice.
