How should a therapist go about refusing to treat a patient?

November 27, 2006 9:26 PM

A friend of mine underwent counseling at a trauma center. After the first several sessions, today his therapist had a supervisor come in, sat him down, and after 45 minutes of excruciating back and forth, essentially told him that because of what he did for a living, he could no longer attend therapy there.

At all. As in no other therapist at the center could see him and there was no one they could refer him to. As I said in my question, it took them 45 minutes to reach this point. Before getting there, they made him feel, "small, dirty, and absolutely unwanted." This seems absolutely insane to me. They work at a trauma center! Can a therapist (at a TRAUMA center!) essentially say, "you're too messed up, I can't treat you, go away?" What are his rights?

If it matters, my friend runs an adult website. Nothing extreme, just straight naked girls.

posted by chichimimizu to health & fitness (30 comments total)

I'm not sure at all, but it is quite likely these people are just jerks (well, a much stronger word than jerk). Have him find another therapist, there are lots of them out there, most of whom are decent people.
posted by cschneid at 9:38 PM on November 27, 2006

I'm not a lawyer nor anyone with applicable expertise, but offhand, I'd say they're within their rights to refuse to treat anybody. That doesn't mean I agree with or endorse their reason, however, though it does indicate that maybe your friend is well rid of them. How helpful could they possibly be if they'll turn down trade being judgmental?

How hard would it be for him to find another therapist? Is he way out in a rural area someplace?
posted by davy at 9:41 PM on November 27, 2006

How should a therapist go about refusing to treat a patient?

Carefully so as not to cause further problems.

Meanwhile: trauma for what (if relevant) and does the therapy involve any sorta group discussion or interaction with other patients especially of the female gender?
posted by scheptech at 9:45 PM on November 27, 2006

So sorry for your friend. Talk about kicking someone when they're down.

FWIW, I've found some therapists and therapy centers to be incredibly judgmental about anything they perceive as reeking of "alternative lifestyle." I usually don't mention any of the things that would place me squarely in this category until I've asked them quite a lot about their views and approaches to such matters. For future reference, I think your friend should lie about what he does for a living (if he has to reveal that -- and, for that matter why on earth would he?) until he has a better sense of how they're going to react.
posted by treepour at 9:47 PM on November 27, 2006

He was actually referred to the center by another therapist because of extensive trauma in his past. He waited six weeks to get an appointment.

Although it wouldn't be hard for him to get another therapist, it just doesn't feel right for him to let it go. The way in which they told him they couldn't see him and the reason they did it is unbelievable.

I keep saying it, but honestly, this is a (state-funded) TRAUMA center. They treat people who've had intensely unpleasant lives; who are, to put it bluntly, fucked up. Who are quite literally "on the brink." Had they done this to him a week ago, the blow would have been devastating. They didn't even refer him to another therapist and after he left, there was neither a call nor an e-mail. Nothing.
posted by chichimimizu at 9:48 PM on November 27, 2006

Meanwhile: trauma for what (if relevant) and does the therapy involve any sorta group discussion or interaction with other patients especially of the female gender?

The center is state-funded, and only takes individuals with MassHealth (we're in Boston). These are typically low-income people. People who've had hard lives, much like my friend.

It was strictly one-on-one. The therapist he was seeing was a young, attractive woman, so yeah, their reservations were somewhat understandable. However, the center had two other male therapists. They wouldn't even provide their names.
posted by chichimimizu at 9:51 PM on November 27, 2006

Massachusetts? The state with more lawyers per capita than any other?

Are you thinking what I'm thinking, Pinky?
posted by rokusan at 9:55 PM on November 27, 2006

Health care practitioners are permitted to refuse to care for any person for any reason. There are only a few narrowly-defined exceptions for practitioners who are specifically hired to be present in a place to treat emergencies, when refusal to treat would pose an immediate threat to life or limb.

An example of someone who wouldn't be permitted to refuse would be, say, the only E/R physician on duty in a remote hospital. If a patient came in, say from a car accident, and was unstable, the E/R physician would be expected to care for the patient to the extent of stabilizing the patient. Refusal to do so would be a violation of commonly accepted standards of care. Sending suicidal or homicidal patients back out on the street would be another example of such a violation.

Barring that kind of violation, there's no situation I can envision where a therapist or a center couldn't refuse care to a person on an outpatient basis. Of course, there are many ways to communicate this, and it sounds like your friend came away unhappy.

However, the facts of the situation you describe sound bizarre, and I think there must either be a miscommunication somewhere along the line, or some information that we're not aware of. No competent therapist would belittle a patient.

I also find it hard to believe that an entire center would refuse to treat a patient simply because he runs an adult website. Even though permissible, that's just sort of bizarre. There are nuances; the center's funding may be contingent on religious or other guidelines, or some kind of morals clause. Or it may not be practicing according to standard guidelines; there are plenty of self-help centers out there that endorse bizarre belief systems and offer highly questionable "therapy." But there may be other reasons that weren't communicated to you, or that your friend didn't understand.

When you say "trauma center," do you mean the commonly accepted definition of a public hospital that accepts Federal funds to treat people who suffer severe accidental or intentional physical injury? Or is this some kind of psychologic trauma center?
posted by ikkyu2 at 9:55 PM on November 27, 2006 [1 favorite has favorites]

I also find it hard to believe that an entire center would refuse to treat a patient simply because he runs an adult website. Even though permissible, that's just sort of bizarre.

The entire center didn't refuse. This is the story as my friend told it to me: The supervisor who was present during the meeting suggested that a female therapist wouldn't be best for him, because of what he did for work. My friend said, "there must be some female therapists here who may disagree with what I do but would be able to put it aside and treat me." To which the supervisor replied "yea, maybe." My friend then agreed and asked if he could see a male therapist at the center. The supervisor said that they, in fact, had two male therapists who were both completely booked.

This is the trauma center in question:
posted by chichimimizu at 10:01 PM on November 27, 2006

Well that didn't work at all: www.traumacenter.org
posted by chichimimizu at 10:02 PM on November 27, 2006

I'm a little surprised that no one has made a Grosse Point Blank reference yet.

Is it a religiously affiliated center? If so, it may be in their policies to deny treatment due to what may be perceived as contrary to their beliefs. If so, that's actually within their rights - but only if it's privately funded. Since that's clearly not the case, I can't think of a good reason they would deny him treatment.
posted by honeydew at 10:03 PM on November 27, 2006

Sending suicidal or homicidal patients back out on the street would be another example of such a violation.

And this is kind of my point. My friend very well could have been suicidal. Again, trauma center. Had they done this last week or a month ago when he was really in pain, it would have ended him.
posted by chichimimizu at 10:04 PM on November 27, 2006

chichimimizu: The story starts to make more sense. In my understanding, the average low-income, publically funded mental health provider here in the USA has probably 100 patients waiting for every patient undergoing treatment. There is a drastic, terrible shortage of public mental health care. Most patients who ned it can't get it, period.

For whatever reason, your friend's practitioner wasn't comfortable in the therapeutic relationship. That's her right and privilege as a practitioner, and it is important for her to be aware when her own issues prevent her from giving top quality care.

The rest was probably just scheduling/availability issues. The idea that a public mental health center's practitioners were fully booked and even overbooked is the opposite of surprising; it is the rule across the nation.
posted by ikkyu2 at 10:08 PM on November 27, 2006 [1 favorite has favorites]

The rest was probably just scheduling/availability issues. The idea that a public mental health center's practitioners were fully booked and even overbooked is the opposite of surprising; it is the rule across the nation.

But the supervisor didn't say that all the other therapists were completely booked, only the two male therapists that she was ostenibly willing to let him see. She essentially said that every other female therapist at the center, booked through or not, would be uncomfortable with what he did with a living. What are the odds? She didn't even give him the option of seeing someone else.

Totally not what I wanted to hear, ikkyu2. But yes, your answers sound rational and you are most likely right. At the moment I'm just spitting-ass mad and it just doesn't seem fair or just or moral or humane. This will most likely end with a whole mess of angry letters and my friend finding a better, profoundly more professional therapist.
posted by chichimimizu at 10:16 PM on November 27, 2006

I think they could have fit him in if they wanted to. Maybe the first therapist didn't feel comfortable, whatever. Maybe for a "good" reason, maybe for narrow-minded throwback notions of The Adult Industry. Maybe there was something weird in the interactions between your friend and the first therapist that we don't know about. Barring something extreme (e.g. disruptive, threatening, etc.), the supervisor should have referred him to a different therapist at the center, and should certainly not have endorsed any kind of this-guy-is-too-weird-or-creepy-to-help view. I would be head-popping-off-my-neck mad if I were in your shoes.

Their website presents the organization as happening, connected, active, community players. You might try to figure out if you or someone you know knows anyone on the board or on the staff, and then approach that person with your concerns. If you can't find a person with whom you have a connection, I would go to the director or the highest person that you can reach.

I would stress how the treatment of your friend conflicts with the basics set forth by the Center's mission statement, stated values, blah blah blah, as well as basic professional procedures. E.g. "All clients of the Trauma Center receive a careful initial assessment ..." etc.

Also, FWIW, from the website there seems to be a slight waft of personality cult as to the "Medical Director and Founder" of the center.
posted by ClaudiaCenter at 10:56 PM on November 27, 2006

After all the excitement about pharmacists who refused to give the pill because it objected with their religion, I think you have an interesting news story with this. If it is indeed the case that a medical practitioner can refuse treatment for spiritual reasons, I am sure there are a lot of readers out there who wants to know about it. And they might get similarly angry about this as they got angry about the pill. Start contacting newspapers.
posted by gmarceau at 11:22 PM on November 27, 2006

If I were in the therapist's position, the issues would probably revolve around whether the problem your friend came in to talk about related to his work, and how he talked about that work.

Your question makes it sound like his problem had nothing to do with his work? Is that right? If so, I can see why you and he are mad.

If not, or if his work is something he talked about a great deal, and if those comments are dismissive of or offensive to women, then if I were his counselor, I might have enough problems with him to feel that I could not, in good conscience, help him. Deciding not to treat him in those circumstances is actually a good outcome -- you do not want your therapist so pissed off at you that she can't objectively treat you. In this way, being a therapist is different from being a pharmacist or doctor -- the client's rapport with the therapist is the fundamental basis for successful treatment, and without that rapport, very little work can actually be accomplished.

I have a professor who is known for her multicultural awareness and therapy experience, and her ability to set aside her own prejudices/biases/internalized shit to work with a diverse group of clients. She still refuses to work with sex offenders, because they push too many of her buttons. She knows that she can't provide them with any help due to her own limitations, and so she's decided the most mature, responsible thing to do is not to try. I don't think that drawing these lines is particularly unusual, and in the end, I think a therapist who knows her own limitations is a better therapist than one who tries to treat everyone.

And I agree with ikkyu2 that the further refusals sound like "underfunded overburdened clinic" rather than moral condemnation. The first therapist may also have spoken about your friend to the other therapists in the center, compromising his care if he were to see one of them now.

Obviously, if the supervisor was an asshole, I can see why your friend would be upset, but it seems like there are a lot of valid reasons why he may have been turned away.
posted by occhiblu at 11:45 PM on November 27, 2006

Are you thinking what I'm thinking, Pinky?

Uh... yeah, Brain, but where are we going to find rubber pants our size?

Don't waste any more time thinking about it, just get another recommendation, or find another therapist. If you're seeing a therapist, the last thing you need is more baggage.
posted by krisjohn at 11:52 PM on November 27, 2006

I am Brain. And what's more so is the state ethics board.
posted by ewkpates at 3:41 AM on November 28, 2006

I think if I were in your friend's position, I would ask the Trauma Center for a copy of his records there along with a letter explaining why they are unable or unwilling to treat him. Get it all in writing. Doesn't he have a right to this information?

Having this might clarify the actual reasons for the denial of service and help in the decision of what to do next.
posted by Robert Angelo at 6:17 AM on November 28, 2006

MA may be the state with the most lawyers per capita, but I'd bet it's also the state with the most therapists. Especially in Greater Boston. Many of them are bad. Find another one. (I am not saying most of the therapists in the area are bad, or that any specific percentage of them are, but lots of them should have taken up some other trade.)

From the center's website:The Trauma Center has become a division of Justice Resource Institute (JRI), a large nonprofit
organization dedicated to social justice . . .That sounds like maybe they think his vocation was inconsistent with 'social justice.'
posted by Kirth Gerson at 7:10 AM on November 28, 2006

It sure sounds as if they handled this badly, but I'd caution that your friend's story, as genuinely hard as it is for him, may not be the whole story. There may well have been reasons beyond his vocation that his therapist felt uncomfortable, reasons that he's either unwilling to talk about, or resolutely doesn't understand. 45 minutes is a long time to take to tell someone that their job precludes their getting treatment at the agency.

None of which is to suggest that your friend is a bad person, or lying, or anything like that. I'd just point out that by your own admission the issues your friend is dealing with are quite complex, and all you're hearing is his side of the story as to why they decided to stop treatment. There are, usually, however, probationary procedures for providing treatment when uncomfortable situations arise.
posted by OmieWise at 7:38 AM on November 28, 2006 [1 favorite has favorites]

Aside:

Health care practitioners are permitted to refuse to care for any person for any reason.

Seriously? Physicians can refuse to serve people on the basis of their race or religion and not get sued to oblivion with the cheerful help of the DoJ?
posted by ROU_Xenophobe at 7:52 AM on November 28, 2006

The entire center didn't refuse. This is the story as my friend told it to me: The supervisor who was present during the meeting suggested that a female therapist wouldn't be best for him, because of what he did for work. My friend said, "there must be some female therapists here who may disagree with what I do but would be able to put it aside and treat me." To which the supervisor replied "yea, maybe." My friend then agreed and asked if he could see a male therapist at the center. The supervisor said that they, in fact, had two male therapists who were both completely booked.

Why did your friend still want to see a female therapist? And how did his line of work come up? Did they ask him what kind of website he had after he told them that he ran a web site? I'm guessing that they got a bad vibe from him and just exercised their rights (generally) to provide services to those for whom they choose to do so.
posted by jcwagner at 8:27 AM on November 28, 2006

And how did his line of work come up? Did they ask him what kind of website he had after he told them that he ran a web site?
I would be amazed if a therapist did not ask what a client did for a living.

I'm guessing that they got a bad vibe from him and just exercised their rights (generally) to provide services to those for whom they choose to do so.
I'm guessing that this is idle speculation that's based on nothing contained in this thread.
posted by Kirth Gerson at 10:19 AM on November 28, 2006

Seriously? Physicians can refuse to serve people on the basis of their race or religion and not get sued to oblivion with the cheerful help of the DoJ?

Certainly. Catholic OB/Gyns don't have to perform abortions, for instance. The principle extends all the way down to any doc, any patient, any treatment, with the exceptions I outlined above.

As it happens, most docs don't take advantage of this privilege - I don't think I ever have - although I've known a few surgeons who wouldn't operate on people with AIDS.
posted by ikkyu2 at 10:32 AM on November 28, 2006

Defensive much, Kirth?

I would be amazed if a therapist did not ask what a client did for a living.

Well, it's one thing to say "I work with computers" or "I run a website" but volunteering the information that one runs an adult website might be a bit much. It's like asking "are you sexually active?" and having the patient respond with a detailed description of recent sexual encounters. That kind of behavior might make the therapists uncomfortable. I know a lot of people who do social work, counseling and related work, and they are constantly evaluating their clients with respect to safety and security issues. Often, just the fact that a client or potential client makes his therapists uncomfortable would be enough for them to discontinue working with a person.

For these people, uncomfortable doesn't mean homeless or destitute or addicted, it means they feel that the person is likely to or just may engage in violent or predatory behavior. Depending on the situation, they will usually refer the potential client to a different program, but they may not if they don't feel that the person is willing to be helped by talk therapy. Also, the fact that someone has financial means (as it sounds like the person in question does) will often mean that they receive lower priority for scarce resources than the destitute.

I'm guessing that this is idle speculation that's based on nothing contained in this thread.

Isn't that what the green is for? I must have missed the part where you told us all the right answer. The OP said that it might be related to the web site. Absent official policy not to treat pornographers, what other way than personal decision would they choose not to treat the person based on his profession? Are you imagining a grand anti-porn conspiracy designed to deny certain health-related services to pornographers?
posted by jcwagner at 2:24 PM on November 28, 2006

Finally (sorry for the consecutive posts), it's not at all surprising to me that they might be concerned about having someone they might view as a predator (i.e. trying to get impressionable, down on their luck young women to pose for nude pictures, etc.) around the vulnerable people who are likely to be in group therapy or just passing through the center at the same time.
posted by jcwagner at 2:28 PM on November 28, 2006 [1 favorite has favorites]

[a few comments removed, please keep it on topic or take it to metatalk or email, thanks]
posted by jessamyn at 6:49 PM on November 28, 2006

It sounds to me like a gross violation of ethics. Also, being a trauma center that sees presumably suicidal or otherwise severely messed up people, that sending him away did place him at risk of hurting himself because of their failure to treat. Of course, if he's not that bad off, it would be a better idea to just see someone else and maybe file a complaint with the board of ethics.
posted by Mr. Gunn at 9:13 PM on November 29, 2006