The Mental Health Referral

An MTís Obligation to the Client

By Jeremy Smith

Making a mental health referral can be a difficult decision for any massage therapist. Am I certain this client needs mental health services? Will he be offended if I suggest he sees a counselor? Will he return after such a referral? These are a few of the questions massage therapists face as they consider referring clients for psychological services. Although trusting your instinct is a good rule to follow in these situations, here are some general guidelines for when to make mental health referrals and how to approach the delicate subject with your clients. Remember, it’s imperative that massage therapists not attempt to counsel clients themselves without appropriate training. Mental health counseling is clearly outside the scope of practice of massage therapy.

Following my graduation from massage school, I worked in a chiropractic clinic for about a year. In that time, I saw a number of clients who presented with both significant physical and psychological issues. As students, we were instructed on the necessity of referral resources, including physicians, chiropractors, and mental health professionals. However, the conditions under which a client might be referred to a mental health professional were less clear. Now, after completing a mental health counseling master’s program, I reflect on those early clients and their psychological issues.

Who Needs a Referral?

David first appeared at the chiropractic clinic with extreme back pain from a fall that had exacerbated a pre-existing back injury. David carried a cane, as well as an extensive medical history. He was on a number of powerful painkillers and was seeing a handful of medical professionals on a weekly basis.

After working with David for several weeks, it became clear to me that he had both legitimate physical symptoms, as well as an unhealthy fixation with his injury. He talked at length about the type and quantity of painkillers he was taking, and several times arrived barely able to speak due to the effects of the drugs he was taking. Clearly, David’s identity had become strongly associated with his illness. Divorced and unable to drive or work because of his back issues, David’s life had become completely intertwined with his medical appointments and the attention he received as a result of his injury. Even the layperson could see that David was sick and in need of services beyond what the medical community could offer. Luckily, in the course of his many treatments, David was referred to a psychiatrist.

David’s case is an extreme example. His reliance on prescription painkillers presented a high possibility for substance abuse. Depression among people with serious physical illness is common. Even before my training as a mental health professional, intuition told me that David’s fixation with illness and disease were obsessive and unproductive in returning him to an acceptable state of well-being.

A second example comes from my time in private practice. Kim was in her mid-30s and in the process of trying to get pregnant. She and her husband had been trying for more than a year with no success and no medical explanation as to why the process was proving so difficult. I saw Kim once a month over the course of several months and with each visit she seemed to grow increasingly distraught. She talked openly about her struggles and I had no problem approaching the mental health referral subject following an appointment wherein Kim had cried, or more accurately sobbed, while on the table.

“Kim, I can tell you’re really upset,” I said to her as calmly and compassionately as possible. “How would you feel about talking to somebody?” Fortunately for Kim, her mother happened to be a psychologist and was able to plug her into a network of mental health professionals. In this instance, Kim’s stress was apparent and superficial. Of course, tears are clear-cut signs of distress. However, not every client will present with such obvious cues.

Pay Attention to Client Cues

Several cues may present in the course of a session, or across several sessions, that lead the massage therapist to believe a mental health referral is appropriate. These may come in the form of subtle cues regarding a client’s mood. For instance, the normally boisterous client who appears somber over several months following the death of her mother would certainly warrant a mental health referral. Drastic shifts in mood or behavior are well-documented indicators of mental distress. Note such shifts in the client’s record and be attentive to these issues, especially for clients you know well.

Other cues may appear in conversation and may refer to a client’s difficulty in coping with a specific event. Listen for these kinds of comments: “I just don’t know how I’m going to get through this,” or “I thought I’d be over this by now.” These phrases clearly signify a client’s difficulty in coping. Other statements from the client may be less obvious. Feel free to ask gentle, carefully worded questions in order to get the information you need to decide on a referral. But keep in mind, you only need enough information to determine if a referral is necessary; issues regarding scope of practice may arise if you delve too deeply. Also, questions beginning with “what” and “how” generally produce more information than those that can be answered with a simple yes or no. Questions beginning with “why,” on the other hand, imply blame and may make a client defensive. For this reason, mental health professionals rarely, if ever, use “why” to begin a question.

In the first client example, David provided a number of red flags that strongly suggested a mental health referral was in order. His confusion and slurred speech, as well as statements like, “They’re giving me the strongest stuff they can,” indicated a growing physical and psychological dependence on the medications he was taking. His demeanor and resignation to a lifetime of pain and discomfort demonstrated either a profound lack of hope or further evidence of drug-seeking behavior.   

Making the Referral

One of the biggest challenges in making a mental health referral can be the delivery. How do I tell a client that I’m worried about them, or that I think they need to see a professional? Remember, a referral is simply a suggestion. Just as clients can accept or ignore your advice regarding stretching and water intake, they are also free to accept or ignore your advice regarding a mental health appointment. If the referral is delivered with a tone of compassion and sincere interest in the client’s well-being, then only the most fragile of egos will be offended by such a referral. Here are a few steps to help you through the process:

Wait for the appropriate moment. If the client has shown an unusual level of irritability over the past six weeks, or if a client says something midway through a session that you believe warrants a mental health referral, do not interrupt the session for the purpose of a referral. Remember Kim? Despite her breaking down early in the session, I avoided an immediate urge to get help. Of course, I asked if she was OK and if she wanted to continue, but a referral of any type is best discussed at the end of a session.

Approach the referral as you would any other. In other words, voice your concern for the client, but remain professional. Don’t go overboard in your own emotional reaction. A good referral might begin like this: “It sounds like these issues with your wife are taking a toll on you. I’m concerned about you. How would you feel about talking with someone about these issues?” Be prepared to make the referral. Have business cards for the mental health professional you intend to refer clients to, or at least a name and phone number.

This may be uncomfortable. If the thought of making a mental health referral produces a high level of anxiety in you, practice it with a friend or in front of a mirror. Referrals are an obligation of every health-care professional and must be made where appropriate, both for the welfare of clients and to maintain your professionalism as a massage therapist. Put on your professional cap, your scrubs, a lab coat, or whatever it takes to give you the strength to do what is naturally an uncomfortable task. As health-care professionals, none of us wants to see our clients in a kind of pain that we are not qualified to treat. Referring your clients on to other health professionals, however, is one ethical way you can help.

Final Thoughts

Mental health referrals will likely not occur during your first session with a client. Unless a client makes direct threats of suicide or harm to others, your ongoing relationship with a client over time will likely be what allows you to perceive changes in mood or behavior. Comments made over weeks or months may also accumulate to a point that warrants referral.

There will come a time when you will need to refer clients, so make connections with a mental health professional today. Just as with massage therapists, there is great diversity among mental health professionals. If you can find a counselor, psychologist, etc., you trust, chances are your clients will agree. Asking professionals about their personal philosophy toward treatment and about their professional orientation is completely acceptable and may help you in directing a client to the right mental health specialist.

Finally, use your own discretion. Obviously, every situation you may encounter in the course of your career cannot be covered in one broad stroke. Many of the issues clients present with in the massage therapy setting are vague and mysterious. Mental health issues share that quality. Not every client you see will require a mental health referral, but if you practice long enough, you’re sure to see someone who will. Being prepared and confident in your assessment will go a long way in easing the burden of a mental health referral. And remember, issues of the mind and body are not so far removed from one another. To assist a client physically, a referral for some psychological treatment may prove absolutely essential.


Jeremy Smith is a part-time massage practitioner in Berea, Kentucky. He holds a master’s degree in mental health counseling from Eastern Kentucky University and now investigates issues of mind-body connectedness. Contact him at