I recently had a light-bulb-moment and realized I was being too rigid with my policy against communicating about shared clients between Individual Therapists (ITs) and Family Therapists (FTs). I analyzed the rationale behind my communication ban. Even though the ban was an overreaction, it was a reaction to something worth exploring. Therapists are heavily trained and supervised to be careful in how we speak to our clients, however, we are often not as mindful when communicating with each other about our clients. Obtaining a signed Consent to Exchange should not be our only ethical consideration when we decide to consult with each other about shared clients. I would like to “start the conversation” (get it?) exploring best practices for communication between ITs and FTs.
Please note; I am specifically addressing communication between ITs and FTs. Though some of the ideas can be extended when considering communication IT to IT, or consulting with a psychiatrist, teacher, or community worker, I have not fully considered nor addressed those contexts in writing this blog.
I believe I have become a little skittish about communication between ITs and FTs due to past conversations with therapists about our mutual clients that were unhelpful, and sometimes even detrimental to our work. Even though we all had the best intentions when consulting, experiences of feeling gossipy, scolded, bossed, jumping to conclusions, and getting sucked into the system of dysfunction come to mind when I think of conferencing between ITs and FTs about mutual clients.
I believe that there are two main reasons communication between ITs and FTs is so precarious. One reason is that Individual Therapy and Family Therapy can often have conflicting agendas, especially in the beginning of therapy. ITs are advocating for the esteem and agency of the individual and Family Therapists are advocating for the family system, which may require individual sacrifice. If we are not careful to maintain our differentiation, we become vulnerable to getting pitted against one another. The other reason we need to be careful when consulting is a bit the opposite: that therapists can get along too well. Who better to talk to about a challenging case than another kind and empathetic therapist? This comfort-level becomes problematic when issues that should be brought to supervision get brought to the collaborating therapist. We would not process supervision issues with our clients, and we should not be doing so with their other therapists either.
Although there are risks to case consultations between ITs and FTs, there can also be significant benefits. It is truly case-by-case. I would like to create more permeable boundaries between myself, as the FT, and my clients’ ITs. Moving forward, I propose guidelines, dos-and-don’ts, and sample list of questions to guide case consultations between ITs and FTs.
Suggested Guidelines for Communication with Between ITs and FTs about Shared Clients
Note: Safety trumps all. If safety issues emerge, all therapists involved need to be aware.
- Both IT and FT will thoroughly explore the pros and cons of communication between therapists before consulting. Not all clients who are in both FT and IT want, need, or should have their therapists communicate.
- Both IT and FT will clearly outline what will be discussed between therapists. Therapists will clarify whether or not there is anything they would like to be kept from the other therapist.
- If ITs and FTs participate in group supervision together, ITs or FTs will not be present during each others’ supervision about that case.
- ITs and FTs will give impressions only and not direct quotes.
- ITs and FTs will take time to develop an independent relationship first before exchanging information, about 2-4 sessions, so that everyone can form their own impressions.
- ITs and FTs will not discuss the case unplanned and unbeknownst to the clients.
- ITs and FTs will support each other’s work and stay united to the best of their ability.
- This models a supportive and collaborative system.
- Everything shared with IT and FT will be something that either has already been shared with clients, or will be shared with clients soon.
Times When it May be Appropriate for ITs and FTs to Conference:
- Safety. Always.
- When the IT needs more information to inform diagnosis
- When IT or FT is working to engage or keep clients engaged.
- When work in IT is largely related to goals in FT, ex. anger reduction, assertiveness
When Not to Conference:
- When your objective is to advocate for your client’s side.
- When you are doing the work of your clients. For example, sharing things they are shy to
- share, coordinating logistics they could coordinate themselves.
- When you are still emotionally processing a session.
- When the client insists, along the lines of trying to send a message to the other therapist.
- When what you are looking for is really supervision.
- Casually, around the office or socially.
Sample Structure for Consultation:
- How did you determine this dx?
- What are the treatment goals?
- What is the treatment modality?
- What are the strengths you see this client can lend to individual/couple work?
- What are the vulnerabilities and areas for growth you see could hinder this work?
- How are you addressing safety?
- What are your expectations of how IT or FT will support your work?
- Are there any conflicting agendas? Can those be negotiated?
Elaborating the reasons for these proposals may be a longer conversation that I am happy to have, and for which we do not need a Consent to Exchange! I cringed as I wrote some of these down, as I have been in violation of many of my very own new ethical guidelines. I believe this exploration has already increased my awareness of how I conceptualize and consult about cases, which I hope will be an increased benefit to my clients. I hope it has been helpful for those reading this as well.
S. Spencer Northey, LCMFT
Licensed Clinical Marriage and Family Therapist