The role of psychological counseling for patients with mental disorders is to identify and refer

First, clarify the core conclusion: For ordinary psychological counselors who do not have the right to prescribe psychiatric services, identification and referral are indeed the most core and bottom-line role when facing patients with mental disorders.

I just received my first consultation from a sophomore student last week. The parent came to me and said that the child had recently had a conflict with his roommate, refused to go to class, and had been lying at home for almost half a month. He wanted me to help with his interpersonal relationships. As soon as I entered the consultation room, I felt something was wrong. The child sat with his eyes fixed, and he took a long time to respond to anything I asked him. He said that he always heard his roommates scolding him downstairs, and that his cell phone was being monitored. When I asked about family history, his grandmother had a history of medical treatment for "mental disorders" when she was young. I didn't say much at the time. I sat with him for a while and handed him a cup of hot drink. Then I turned around and told his parents that in this case, he had to go to the city Jingwei Center to see a doctor immediately without delay. Later, he was diagnosed with early stage schizophrenia. Because of early intervention, he is now well controlled with medication. Last week, his mother sent a message saying that the child has returned to school.

To be honest, when I first entered the industry, I also felt that after learning so many counseling techniques, how could I extrapolate it as soon as I encountered someone who was suspected of having a mental disorder? Doesn’t that make me look useless? Until I heard a true story from a senior in the industry: a novice counselor received a case of bipolar disorder. At that time, the counselor was in the early stages of a manic episode. He talked a lot, was energetic, and always felt that he could make a lot of money. The counselor did not recognize it, and followed other people's ideas to do "intrinsic motivation mining". After three visits, he smashed things at home, injured his parents with a knife, and the family members came to visit him. Not only did the counselor lose money, but his professional qualification was also revoked. Oh, by the way, I went to a psychiatrist before my visit. The doctor asked me to take medicine, but the consultant told me, "It's the medicine that's 30% toxic. Your inner energy has been suppressed, so you don't need to take medicine." It's really scary to think about it now.

There are indeed different voices in the industry on this matter. Not everyone thinks that psychological counselors can only make identification and referrals. For example, many CBT (cognitive behavioral therapy) counselors have experience working with psychiatrists. For example, patients with obsessive-compulsive disorder and post-traumatic stress disorder can use specialized clinical techniques to intervene after their symptoms stabilize, which can actually have a very good effect on the recovery of social functions. ； There are also family therapy counselors who, when encountering children with mood disorders, can help the entire family adjust their interaction patterns on the premise that the children follow the doctor's instructions and take medication, which can also greatly reduce the probability of recurrence. But no matter which school of counselor you are, as long as you follow the rules, you will not skip the step of "identification" - you can't even figure out whether the person you are visiting is in the attack phase or the stable phase, whether you have taken medication as prescribed by the doctor, or whether there are undiscovered symptoms of hallucinations and delusions. No matter how good your skills are, they are in vain and may even be counterproductive.

To use an inappropriate analogy, a psychological counselor is like a general clinic in the community. You can treat people with colds, fevers, headaches, and brain fever, and can also provide rehabilitation guidance for patients with chronic diseases. But if someone comes to check that the temperature is 40 degrees, and they are coughing up blood and having difficulty breathing, you can't force them to prescribe cold medicine, right? Only by quickly transferring to a higher-level hospital for examination and CT scan can you really be responsible for the patient. This is the principle of identification and referral. It’s not that we don’t want to help, but that we know the boundaries of our abilities and that the treatment of mental disorders is first and foremost a medical matter. Getting patients to the corresponding department as early as possible is more important than anything else.

I have been doing counseling myself for eight years. Now, in the first 15 minutes of the first interview, I will always ask the risk screening questions: How was your sleep and diet in the past week? Have you ever had a voice that others couldn’t hear, or a strange idea that others didn’t believe? Have you ever had thoughts of harming yourself or others? Have you ever been to a psychiatric clinic before? Are you taking any medication? By asking these questions, you can basically screen out 80% of the cases that need to be referred first. When I encounter someone who is suspicious, I will not hide it, but directly tell the visitor: "I feel that part of your state may need to be evaluated by a psychiatrist first to rule out pathological problems. This does not mean that you are 'seriously ill'. Let's clarify the most basic issues first, and then if we need psychological counseling assistance, we can continue the conversation, which will be more efficient." ”So far, no visitor has ever been offended because of my referral. Everyone can actually feel that you are really thinking about him.

Oh, by the way, I also want to clarify a misunderstanding: many people think that "identification and referral" means just pushing people away, but that's not the case at all. You have to tell the visitor where to find a regular psychiatric hospital and how to describe his symptoms to the doctor. If the visitor feels ashamed and is unwilling to go, you have to do some psychological construction. Even if the visitor is in a critical condition, you have to accompany the visitor to contact his family and the hospital to ensure that he can really get treatment. This is a complete identification and referral process. It is not just about saying "You go see a doctor."

After all, when we are in this business, our original intention is to help people, but the prerequisite for helping people is always not to cause trouble. Identifying referrals may sound trivial, but it is the first lesson for every psychological counselor when they enter the profession, and it is also the bottom line that we must adhere to throughout our lives. Sometimes "pushing someone out" is the most useful help you can give them.