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When a Client Needs More Support: Referral Guidelines

For members who need possible psychological guidance, certain professional tactics should be followed.

"She keeps calling herself fat, but she's really just pregnant. She is seven months along, and continues to restrict her calories and exercise a lot. We've had several discussions, but she does not appear to be following my advice. I am worried about the baby's health, not to mention hers. How can I get through to her? Maybe I should refer her back to her doctor. Or, maybe she has body image problems and needs a therapist. What do you think I should do?"

Fitness professionals refer clients to other professionals for many reasons: to follow up on symptoms of illness or injury, to send clients to nutrition professionals, or to encourage clients to get professional help for psychological concerns such as substance abuse, depression or eating disorders. We refer clients to other professionals when an issue exceeds our scope of practice. We also refer when we feel our clients need to confront a serious issue they may be denying.

Most fitness professionals are comfortable recommending that clients seek medical help for illness or injury, but are less confident in their ability to confront a client about a possible psychological concern. Every client is different, so every referral situation is different. The following are some general suggestions on referring a client for professional help.

Check in with your team

Discuss your concerns about a client with your supervisor and work team. Your colleagues can help you decide whether you are justified in your response, or overreacting. They may have faced similar situations themselves and have good suggestions.

Your employer may already have policies and guidelines in place for making referrals, including for psychological concerns. You may be asked to document your referral conversations, and follow up in some way. If you are uncomfortable confronting your client about the issue, perhaps someone with more experience can do this instead.

Prepare to refer

Be ready with a specific referral recommendation. You may wish to refer clients back to their healthcare providers, or you may recommend another type of professional. Be prepared to give clients specific contact information for the dietician, physical therapist, etc., you plan to recommend. If they need to complete a new medical clearance form, have that ready as well.

Make a decision about the bottom line: What will you ask them to do, and how will you follow up? Will you continue to work with them? Will you require new medical clearance or contact with their provider? Will you need to stop working with them because the situation exceeds your scope of practice?

Gather your evidence. Before you speak with clients, make a list of specific, observed behaviors and statements. Clients find it more difficult to dismiss your point of view if you have solid evidence. Rather than saying, "You seem too concerned about your body image," you will want to say, "Every time we meet, you make many derogatory comments about being fat." Or, "I have recommended that you reduce your exercise intensity, but your exercise log shows that you are exercising longer and harder than you were last month."

Meet with your client

Schedule a time to speak with your client in private about your concerns. If no private place is available, find a spot out of earshot. If your client is a minor, you should also speak to the parents, as well, on a separate occasion.

Open the conversation by expressing your concern. "I am worried about you because ... ." For the opening example, you might say something like, "Here are the nutrient requirements for pregnant women. I am concerned that you are far short of these. I am worried about your health and your baby's development." Then cite the evidence you have gathered.

Once you have voiced your concerns and evidence, give clients time to respond. Don't interrupt them as they are speaking, and listen with an open mind to their point of view. You may wish to modify your recommendations, or to tell clients you need some time to formulate your response. Express confidence in their ability to cope with the situation, and to achieve a positive outcome.

References
Bartlett, S., R. Anderson and R.T. Cotton. Chapter 11: Referral. ACE Lifestyle & Weight Management Consultant Manual (C.X. Bryant and D.J. Green, Eds.) American Council on Exercise: San Diego, Calif., 2008.
Johnson, J.H., E.M. Haskvitz and B.A. Brehm. Applied Sports Medicine for Coaches. Lippincott, Williams & Wilkins: Baltimore, Md., in press.
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