When a Therapist Feels Uncomfortable: Deciding Whether to Continue or Refer
Scope of practice, competence and the role of supervision
Have you ever had a client stay in your mind long after the session has ended? This might happen because you are concerned about the client or perhaps you may feel uncertain, ineffective, irritated, frightened, repelled or simply out of your depth ... Maybe the prospect of referring the client feels like a relief.
Referral may be clinically necessary. The relief attached to the idea may also indicate that we need to examine what's happening in the therapist further. A sound decision considers what the client requires, what the therapist can competently provide, the risks involved, the therapist’s current capacity and what is happening within the therapeutic relationship.
Discomfort alone cannot answer the referral question but it can tell us where to begin looking.
What is therapeutic discomfort?
Therapeutic discomfort can include anxiety about making a mistake, dread before a session, frustration about limited progress, helplessness in the face of suffering, fear of a client’s anger or conflict between the client’s behaviour and the therapist’s values. It may appear as an urge to reassure, rescue, confront, withdraw or end therapy.
Therapists have nervous systems, histories, values and sore points. Pretending otherwise mostly makes their reactions harder to see. The clinically useful question is not simply, “How do I feel about this client?” It is, “What does this feeling lead me to do?”
A therapist who feels helpless may become overly directive. One who fears a client’s anger may avoid necessary questions. A therapist who feels responsible for keeping the client stable may extend sessions, soften boundaries or postpone a difficult conversation. Another may become unusually detached or cold and begin to describe a referral as an objective clinical necessity.
Some clinicians understand these reactions as countertransference. The term is useful, although the underlying process belongs to every therapeutic approach. All therapists need to recognise how their internal responses affect attunement, judgement and behaviour.
Scope of practice, competence and fitness to practise
The phrase “outside my scope” is often used to describe several different problems. It may refer to the recognised work of the counselling profession, the therapist’s individual competence, the limits of an employment role or service, or the therapist’s present fitness to practise. These require separate consideration.
The Australian Counselling Association (ACA) and the Psychotherapy and Counselling Federation of Australia (PACFA) concur that scope of practice is a defined professional requirement grounded in a counsellor’s knowledge, skills, experience and competence. Both organisations require practitioners to establish and maintain competence through professional development and supervision, monitor the limits of their practice and recognise that registration does not qualify them to work with every client, intervention or level of complexity (ACA, 2021, 2022; PACFA, 2017, 2018). They also agree that when a counsellor cannot safely and competently meet a client’s needs, the practitioner must consider appropriate referral, provide information about suitable services and ensure that decisions are guided by the client’s best interests and informed consent.
These requirements call for case-specific judgement. “Trauma”, for example, may refer to a client who needs attuned, well-paced counselling while processing a painful experience. It may also involve severe dissociation, current violence, substance dependence, medical instability or a level of risk requiring specialist and multidisciplinary care. The relevant question is about what this client needs from this therapist in this context.
Fitness to practise is also distinct from competence. A therapist may have the necessary training and experience while temporarily lacking the emotional, cognitive or physical capacity to work effectively. Illness, acute personal distress, exhaustion and cumulative exposure to trauma can impair practice. Both ACA and PACFA require practitioners to monitor these factors and take action when their capacity is affected (ACA, 2022; PACFA, 2017).
What is the discomfort telling you?
Therapist discomfort may arise from several sources at once:
The therapist’s history, values, assumptions or current circumstances.
The client’s behaviour or interpersonal patterns.
Something developing between this particular client and therapist.
A genuine gap in knowledge, skill or experience.
Risk, intimidation, boundary violations or unsafe working conditions.
The emotional impact of witnessing suffering
A meta-analysis found that countertransference reactions were modestly associated with poorer psychotherapy outcomes, while successful management of countertransference was associated with better outcomes. The studies were heterogeneous, so the findings do not mean that feeling uncomfortable automatically harms therapy or requires referral. They suggest that therapists should notice these reactions early, discuss them in supervision and make deliberate adjustments to their practice (Hayes et al., 2018).
Therapists’ ability to respond constructively to challenging interpersonal encounters also appears relevant. Anderson et al. (2009) assessed therapists’ responses to difficult simulated interactions and found that these interpersonal skills predicted differences in outcomes across 1,141 clients. Research on alliance ruptures similarly suggests that successful rupture resolution is associated with better outcomes (Eubanks et al., 2018)
Discomfort becomes clinically useful when the therapist can notice it, think about it and assess its effect on the work. Enduring discomfort while continuing the same unhelpful behaviour offers little benefit to the client.
A practical process for deciding whether to continue or refer
1. Begin with what the client requires
Start by identifying the therapeutic task as precisely as possible. What are the client’s goals? What assessment, knowledge and interventions are required? What risks need to be monitored? Does the client need additional or specialist support from another professional or service? How urgently is that input needed?
This prevents a whole person from being labelled “too complex” when one component of their care requires additional expertise. Referral of one aspect of treatment does not always require ending an established therapeutic relationship.
2. Specify the competence question
“I am not competent” is too broad to guide a decision. A more useful assessment asks:
What would competent work with this client require?
Which relevant knowledge and skills do I already have?
What is missing?
Can that gap be addressed promptly through supervision, consultation or focused professional development?
Can I develop the required competence without asking the client to carry avoidable risk while I learn?
Do I have enough support to recognise deterioration or respond to increased risk?
Confidence is a bad substitute for this assessment. A therapist can feel anxious and work competently and they can also feel calm while practising beyond their competence.
3. What happens to the therapy when you feel uncomfortable?
The therapist can then look for observable effects:
What do I begin doing more or less of with this client?
Am I becoming rescuing, avoidant, passive or overly controlling?
Which topics do I move away from?
Am I maintaining ordinary boundaries and clinical standards?
Has my formulation narrowed because of my reaction?
Would I make the same referral decision if this client had a different identity or background?
If my discomfort reduced tomorrow, would I still believe referral was clinically indicated?
And the answer to that final question does not decide the case however it can expose how much the wish for relief is influencing the therapist’s judgement.
4. Take the raw, unpolished version to supervision
A useful supervision conversation may begin with a direct statement:
“I want to refer this client, and I need help working out whether the reason is competence, risk, my current capacity or my response to them.”
The supervisor can then examine the client’s needs and progress, the therapist’s formulation and interventions, what is occurring in the therapeutic relationship, the therapist’s internal response and the wider professional and organisational context. The supervisor should also consider whether they have sufficient expertise to guide the work. Specialist consultation may be needed when the presenting issue sits outside the supervisor’s own competence.
PACFA includes courage among the personal attributes relevant to ethical practice, defining it as making decisions and interventions in clients’ best interests “despite personal discomfort” (PACFA, 2017, p. 5). Courage here involves honest examination of the decision. It may support a difficult referral, a necessary conversation with the client or continued work with stronger supervision and safeguards.
The developing evidence for supervision is promising, although it remains less definitive than the profession sometimes suggests. A recent systematic review and meta-analysis found that supervision was generally associated with beneficial effects on therapist competence, therapeutic alliance and client symptoms. Several pooled effects were non-significant, and outcomes varied according to the comparison condition and study design (Schreyer et al., 2025). Useful supervision engages directly with competence, risk, client progress, relational process and therapist behaviour.
5. Consider the full range of options
The decision extends beyond continuing unchanged or ending immediately. Options include:
Continue with purposeful supervision. This may be appropriate when the work is within the therapist’s competence, risk is manageable, the client is benefiting and the therapist can reflect on their discomfort without it continuing to impair care.
Continue with additional safeguards. More frequent supervision, specialist consultation, focused training, outcome monitoring or a clearer risk plan may address a defined and manageable gap.
Use shared or multidisciplinary care. A GP, psychiatrist, dietitian, alcohol and other drug service, specialist trauma clinician or another professional may provide a component of care while counselling continues.
Refer or transfer the work. This may be indicated when core competence is absent, the gap cannot be addressed within a safe timeframe, risk exceeds the therapist’s capacity or available support, fitness to practise is impaired, or the therapist’s response continues to compromise care despite supervision.
The likely consequences of each option also matter. Referral may involve cost, waiting lists, repeated retelling, loss of an established therapeutic relationship or another experience of perceived rejection. These consequences do not require a therapist to continue unsafe or ineffective work but they do belong in the ethical assessment.
When referral is the appropriate decision
A referral should be discussed respectfully and, where possible, planned collaboratively. Telling someone that they are “too complex” can feel shaming and gives them little useful information. A clearer explanation might be:
“Your needs now include specialised support with X. I think you would benefit from a practitioner or service with specific experience in Y. I would like us to talk through the options and how we can manage the transition.”
Good referral practice includes checking whether the proposed service is suitable, discussing availability and cost, obtaining consent before sharing information and considering what support the client needs during the transition. When an immediate transfer is unnecessary, the therapist may be able to provide a bridge while the client establishes care elsewhere.
The therapist should document the clinically relevant decision-making: the client’s needs and risks, consultation or supervision obtained, options considered, the client’s preferences, the reason for the decision and the agreed plan. A client record needs the clinical rationale, rather than a full transcript of the therapist’s internal experience.
Discomfort deserves examination
Therapeutic work asks practitioners to remain present with uncertainty, strong emotion, conflict and suffering. Some discomfort accompanies deeper and more honest work. Other discomfort points towards a limit that needs to be respected.
The decision to continue or refer becomes more reliable when it is based on the client’s needs, the therapist’s demonstrated competence, current fitness, available support and an honest account of what the discomfort is doing within the therapy. Supervision provides a place to make that assessment before relief, fear or professional pride makes the decision on the therapist’s behalf.
If you are trying to decide whether a client requires referral, clinical supervision can help you examine the competence, relational, ethical and systemic parts of the decision and develop a clear plan for what happens next.
Looking for individual supervision? Explore our supervision options here.
References
Anderson, T., Ogles, B. M., Patterson, C. L., Lambert, M. J., & Vermeersch, D. A. (2009). Therapist effects: Facilitative interpersonal skills as a predictor of therapist success. Journal of Clinical Psychology, 65(7), 755–768. https://doi.org/10.1002/jclp.20583
Australian Counselling Association. (2021). Scope of practice for registered counsellors (2nd ed.). https://theaca.net.au/viewdocument/pending-ai-aca-scope-of-practice
Australian Counselling Association. (2022). Code of ethics and practice (Version 16). https://theaca.net.au/viewdocument/pending-ai-aca-scope-of-practice
Eubanks, C. F., Muran, J. C., & Safran, J. D. (2018). Alliance rupture repair: A meta-analysis. Psychotherapy, 55(4), 508–519. https://doi.org/10.1037/pst0000185
Hayes, J. A., Gelso, C. J., Goldberg, S., & Kivlighan, D. M. (2018). Countertransference management and effective psychotherapy: Meta-analytic findings. Psychotherapy, 55(4), 496–507. https://doi.org/10.1037/pst0000189
Psychotherapy and Counselling Federation of Australia (2017). Code of ethics. https://pacfa.org.au/common/Uploaded%20files/PCFA/Documents/Documents%20and%20Forms/PACFA-Code-of-Ethics-2017.pdf
Psychotherapy and Counselling Federation of Australia. (2018). Scope of practice for registered counsellors. https://www.pacfa.org.au/common/Uploaded%20files/PCFA/Documents/Documents%20and%20Forms/Scope-of-Practice-for-Registered-Counsellors-2018.pdf
Schreyer, B., Leithner, C., Eilers, R., Gossmann, K., & Rosner, R. (2025). The effects of clinical supervision on supervisees and patient outcomes in psychotherapy: A systematic review and meta-analysis. Frontiers in Psychiatry, 16, Article 1705578. https://doi.org/10.3389/fpsyt.2025.1705578