referring a client for intensive treatment

Thanks kindly for considering me as a resource to aid your client’s continued healing. If you would like to make a referral for intensive work, please consider–and be prepared to discuss with me–the following points first:

1. Highly dissociative clients are not suitable for a multi-hour intensive format in an outpatient setting unless they are much further along in their work. I respectfully ask that you adequately evaluate your client for any factors that presently contra-indicate deeper work taking place in an intensive treatment format in a private therapy office setting. Some contra-indications include:

• Inadequate diagnostic evaluation of the client to determine the presence of unrecognized (or covert) dissociative features, paired with any history of the client having unremitting or frequently intrusive/jarring internal experiences that defy conventional explanation;
• Current or recent suicidal thoughts or impulses that have translated into suicide attempts–including preparation to attempt;
• Current or recent non-suicidal, self-harming thoughts or impulses that have translated into actual self-harming behavior–including preparation to self-harm;
• Any concerns, based on past experience, that higher levels of emotional intensity could lead the client to rely on alcohol or other mind-altering (or overdose-risk) substances to numb the pain;
• A persistent or recurring push from the client for immediate relief of whatever pain they are experiencing;
• Indications from the client that they believe that intensive work would be a good alternative to engaging in ongoing therapy — just so they can ‘get it done’, ‘get through it’, or avoid unpleasant realities — rather than seeing intensive work as an enhancement to the ongoing work they’re already doing; and,
• Profound attachment injury that surfaces repeatedly in the normal course of conducting week-to-week therapy with your client, resulting in an intractably fraught interpersonal dynamic.

If there is any question on the above points, it is preferable for you to contact me first and then refer your client to speak with me only once we agree that it is appropriate to do so. This can mitigate the potential negative impact of your client feeling rejected if it becomes clear that intensive work would be more appropriate at some point in the future.

​2. How have you assessed this client for the variety of manifestations of dissociation? Have you used a formal assessment instrument, or are you ‘eyeballing’ the client’s symptoms and assuming ‘what you see is what you get’ and that they don’t ‘dissociate’? If you have not assessed deeply and thoroughly, I highly recommend that you administer Paul Dell’s Multidimensional Inventory of Dissociation (MID). The MID, MID Analysis, and its interpretive manual are available free of charge at www.MID-assessment.com. 

Once you have conducted the initial evaluation and the follow-up clinical interview to qualify your client’s self-report, please forward the spreadsheet to me stripped of identifying information (aside from initials or a Client ID) if you still think the referral is appropriate. Please be aware that the DES-II is a screening device only, that it frequently offers up ‘false negatives’, and that is not at all adequate, in isolation, for evaluating the full range of dissociative phenomena. The SCID-D is also helpful, but it costs a significant amount of money to purchase if you do not currently use/own it, and it requires more training to administer and interpret. Additionally, it is less specific in delineating symptoms that may prohibit effective reprocessing using EMDR therapy.

3. How do you plan to support the client both BEFORE and AFTER the intensive work? Please ask the client to sign a mutual HIPAA consent (a blank copy of which you can obtain by clicking here). Pre- and post-intensive support is all the more important if the work will involve addressing attachment/abandonment/betrayal, owing to the need to avoid leading the client to feel abandoned when they leave the intensive if their work is incomplete. Most feel considerable relief and transformation, but some are incomplete in their work when we run out of time.​

4. It is very important that both you and your client review the FAQ section of this website to ensure that basic questions are addressed and clarified upfront.

Thank you again for considering referring your client to me. I very much appreciate the opportunity to support their continued move toward health.

Please click/press here to contact me to facilitate a referral.