Recognizing needs beyond the program

Criterion 42 begins the referral function by identifying needs that exceed the facilitator's or program's capacity. The need may concern health, safety, housing, legal advice, or support the client cannot obtain within the service. Some limitations can be addressed by a qualified colleague; others require care elsewhere or a pause in participation. The facilitator needs an accurate view of the team's competence, staffing, equipment, and authorization. This assessment continues after intake because circumstances and disclosures can change. Criteria 43 through 46 develop the explanation, selection of resources, confidentiality, and assistance that follow.

Learning Objectives

By the end of this module, the trainee will be able to:

• Identify an unmet need and connect the finding with the referral tasks in Criteria 43 through 46.
• Define scope of practice as trained, licensed, and demonstrably competent, and locate their own boundaries within it.
• Ground the duty to work within one's competence in the professional standards that govern it.
• Recognize the categories of client need that commonly exceed facilitator or program capacity.
• Identify medical care requirements the program cannot provide and refer questions of clinical suitability and legal authorization to the appropriate professionals.
• Distinguish a facilitator level limitation from a program level limitation, and route each accordingly.
• Identify unmet needs at screening and, equally, as they emerge midstream during preparation, ceremony, or integration.
• Recognize overidentification with the helper role and the specific ways it corrupts accurate identification.
• Treat identification as an ethical act that protects the client, the facilitator, and the field.
• Track screening and assessment from receipt through review and a documented decision.
• Verify that conditions and accommodations can be met before the affected service.

Key Terms

Identification. The accurate recognition that a client presents a need or challenge which this facilitator or this program cannot meet. It is the first step of the referral function and the precondition of every step that follows.

Scope of practice. The activities a practitioner is permitted and qualified to perform under the applicable law, professional rules, and program role. Demonstrated competence remains necessary within those permissions.

Boundaries of competence. The professional ethics principle that a practitioner provides services only within the boundaries of their competence, based on education, training, supervised experience, consultation, study, or professional experience (American Psychological Association, 2017, Standard 2.01).

Facilitator level limitation. A need that exceeds this particular facilitator's competence while remaining within the program's overall capacity, which can often be met by an internal referral to a colleague with the relevant training.

Program level limitation. A need that exceeds the capacity of the program as a whole, such as an absent medical capability or a care requirement no member of the team is qualified or permitted to provide, which requires an external referral.

Emergent need. A need that appears after screening, during preparation, ceremony, or integration, which requires the facilitator to reassess capacity midstream rather than treating the intake decision as final.

Overidentification with helping. A tendency to take on responsibilities beyond one's role or to overlook a limitation because stepping back feels personally difficult. Supervision can help identify how this affects decisions.

Unmet medical requirement. A need for assessment, monitoring, treatment, or emergency capability that the proposed service cannot safely and lawfully provide. It requires a change in the plan and appropriate clinical or legal consultation.

Core Teaching

Recognizing an unmet need

Ask what the person needs and whether the service can provide it at the time it is needed. Acute psychiatric symptoms, complex medical concerns, withdrawal, unsafe housing, and legal questions can exceed a program's capacity in different ways. Record the specific finding and its implications for the current plan. Avoid reducing the person to a diagnosis or treating the referral as evidence that they are unsuitable for support altogether. Recognition should lead directly to a plan for the next step, with urgency determined by the person's condition. The later referral criteria provide the detail for carrying that plan through.

Professional scope and demonstrated competence

The APA ethics code describes boundaries of competence in relation to education, training, supervised experience, consultation, study, and professional experience. Its direct professional obligations apply to the psychologists it governs; other practitioners need to establish the standards and laws governing their own roles. The principle remains useful when evaluating a facilitation service: list the activities each person is qualified and authorized to perform, and the support they need to perform them competently. Field specific practice guidance from APPA and BrainFutures also addresses practitioner preparation and care. A training certificate, confidence, or personal experience with a substance should not be treated as interchangeable with a professional license or competence in a particular clinical task (American Psychological Association, 2017; American Psychedelic Practitioners Association & BrainFutures, 2023).

Needs that may require another service

Review medical, psychiatric, social, legal, and cultural needs. New psychotic symptoms, marked mood changes, suicidal thoughts, uncontrolled physical symptoms, or complicated substance withdrawal can require clinical assessment. Housing insecurity, food insecurity, unsafe relationships, and lack of transport may require practical services as well as emotional support. A client may also need a practitioner with relevant cultural knowledge or a form of therapy that the team does not provide. The presence of a condition is a reason to assess its current implications, rather than a basis for assuming every person with that diagnosis requires the same response. Urgent danger follows the procedures in Criteria 36 and 37.

Medical requirements the program cannot meet

Specify the care required and identify who is responsible for evaluating it. For example, a client may need cardiac assessment, medication management, or monitoring that the current program cannot provide. Consult the appropriate clinician and verify the proposed service's authorization with counsel where necessary. The program should not proceed on the assumption that a reassuring letter removes the need for ongoing safeguards. Equally, a limitation at this site does not establish that the person has no lawful treatment options. Consider appropriate conventional care, an authorized research pathway when relevant, or another adequately equipped service without promising access or suitability.

Assessment before participation

Use screening to identify relevant health history, medication and supplement use, prior adverse experiences, current symptoms, and practical conditions after departure. Give the client a way to discuss sensitive information privately and explain why each question is being asked. Consider recent suicide attempts, mania or psychosis, cardiac and seizure history, withdrawal risk, and the complexity of medication use through the appropriate clinical process. Screening can identify concerns before a session, but it cannot guarantee that every relevant need will be disclosed or detected. A delay may carry financial, emotional, and practical costs for the client; explain the decision and help address those costs without letting them determine safety.

Reassessment when circumstances change

Ask about changes at each relevant stage. New medication, a recent injury, worsening sleep, a frightening interaction at home, or a late disclosure may alter the plan. Avoid assuming that delayed disclosure was intentional concealment; a person may not have understood the question, felt safe enough to answer, or recognized its relevance. Document what is now known and obtain the necessary review. Staff need authority to pause a service even when the client has traveled, paid, or joined a waiting group. The immediate response depends on whether the person has already received a substance and what can be done safely from that point.

Personal and organizational pressures

Notice when loyalty to the program, fear of disappointing the client, or concern about revenue begins to influence the assessment. A practitioner may minimize a limitation because they want to remain useful, and a manager may encourage proceeding because cancellation is costly. Use consultation, written criteria, and a clear escalation route to make these pressures discussable. Record the clinical or practical reason for the decision and identify who reviewed it. The client should receive an accurate explanation of the need and the program's limits, together with help finding the next appropriate step. Staff should be able to raise a concern without retaliation.

Assessing what the setting can actually provide

Review the person's needs against the staff and resources available on the day. A clinician listed as an adviser may not be present, available by telephone, or responsible for treatment. Confirm who has accepted each responsibility, what response time is realistic, and what happens if that person is unavailable. Record an unmet requirement before the session begins. A name on a staffing chart does not supply a service.

Assess practical access as part of this review. Ask about mobility, toileting, communication, hearing, vision, sensory sensitivities, and assistance with ordinary activities. Discuss accommodations with the client. A person who needs a quiet space should know whether one exists and how it can be used safely. A person who relies on an interpreter should know whether that interpreter will be available throughout the relevant encounters. Avoid excluding someone based on an assumption that has not been discussed or assessed.

Staff capacity also changes. Illness, fatigue, competing emergencies, or an unexpected absence may make a previously adequate plan insufficient. The program needs a clear way to postpone or stop work when staffing cannot meet the agreed requirements. Identify who can make that decision and how other participants will be supported. Scheduling pressure does not resolve an absent clinical capability.

New information after screening

Ask about changes in medications, health, sleep, substance use, living circumstances, and the client's wish to participate. Use a neutral opening: “Has anything changed since we last spoke that could affect today?” People disclose late for many reasons, including misunderstanding a question, embarrassment, a new diagnosis, or uncertainty about whether a detail is relevant. Establish the facts before assigning a motive.

New symptoms may require urgent assessment. A person reporting chest discomfort needs questions about the current situation and prompt medical help when an emergency is suspected. A detailed referral explanation can follow once immediate safety is addressed. An old clearance does not automatically answer a new concern, and a signed waiver does not supply the care the program lacks.

A psychiatric history requires appropriately qualified assessment in the context of the proposed intervention. Morton and colleagues (2023) reported adverse experiences, including increased manic symptoms, in a survey of people with bipolar disorder who had used psilocybin. The survey cannot establish an individual's risk or replace clinical assessment. It does support asking carefully about sleep, mood elevation, and the need for clinical input instead of assuming that enthusiasm for participation means readiness.

Recognizing pressure and an unsafe destination

Speak privately with the client when a partner, employer, family member, or group may be influencing participation. Ask whether they want to proceed and whether declining would create a problem at home. A relative who paid for the program does not acquire authority to make the client's decisions. If the person describes violence or coercion, ask what contact is safe and connect them with appropriate support. Do not confront a suspected abuser or send a revealing message without considering the client's safety and applicable duties.

The place a person returns to can affect what support is feasible. Ask about sleeping arrangements, food, caregiving, transportation, and who can be contacted. A client without stable housing may need practical assistance alongside any mental health care. A program that cannot provide overnight support needs to acknowledge that limit before recommending a plan that depends on it.

Documenting a limit without turning it into an identity

Describe the requirement and the current gap. For example: “The client reports a recent change in medication. The required clinical review has not been completed, so today's session is postponed.” This explains a decision without describing the person as unsuitable in every setting or permanently unable to participate. State whether further assessment could change the decision, while avoiding promises about a future outcome.

Seek consultation when the boundary is uncertain. Provide enough relevant information for a useful opinion through an authorized process. Record who was consulted, what advice was given, and what decision followed. If the need remains unmet, explain the next step and arrange referral assistance. Consultation is valuable only when the resulting decision is carried into practice.

Making an accommodation concrete

Ask the client to describe what works for them in comparable settings. “A quiet room” may mean no conversation, a lower speaker volume, a door that remains open, or a place where they can see staff without being watched by the group. “Help with mobility” may concern stairs, the height of a chair, or a toilet transfer. Clarify the task before deciding whether it can be provided.

Agree on who will assist and how the client will request it. Test the arrangement before the altered state begins. The person should know where the space is, how to reach it, and what support will remain available there. Record the practical agreement in language the team can use. This gives the client a chance to identify a problem while it is still easy to correct.

Turning screening information into a decision

Build the screening process around the decisions the program must make. Administrative staff can collect forms and identify missing fields. Qualified practitioners review findings within their competence, decide whether additional information is needed, and record the outcome. A completed questionnaire should show who reviewed it and when. Keep the original answers available so a later reader can understand the decision and any change in it.

Use distinct statuses for incomplete information, review pending, requirements met, participation deferred, and a need the program cannot meet. Write the reason beside the status. A blank medication field may mean none, forgotten, declined, or not yet asked. Clarify it directly. When a required record is missing, identify who will obtain it and whether the proposed service must wait. Leave the uncertainty visible until it is resolved.

A clinical review that answers a defined question

Give the reviewing clinician an accurate description of the proposed intervention, relevant staffing and monitoring, and the specific concern. Request an assessment within that clinician's role. Depending on the intervention and history, that may involve medical records, examination, medication review, or testing determined by the clinician. The workbook should not impose a single test panel on every client or imply that a screening score can establish medical suitability.

Read the response for conditions and limitations. A clinician may recommend follow up, further testing, a change in setting, or monitoring that the program cannot provide. Record each requirement and who verifies it. If the opinion concerns a different substance or an earlier health status, obtain clarification. The staff member scheduling the session needs an accurate service status without being asked to interpret clinical findings independently.

Reviewing the whole person at intake

Include the reason for seeking support, current treatment, health and substance history relevant to the intervention, past adverse experiences, current symptoms, and ordinary functioning. Ask about the person's strengths, preferred supports, communication needs, and responsibilities after departure. Offer private discussion of sensitive questions and explain their relevance. Collect enough detail to make a sound decision while avoiding an unnecessary demand for a full trauma narrative.

Review pregnancy or breastfeeding where relevant to the proposed intervention, as well as allergies, cardiac and seizure history, psychiatric symptoms, current substance use, and withdrawal concerns through the appropriate clinical process. Ask about recent changes, including medication used only occasionally. A person may regard a supplement, sleep aid, or nonprescription product as unrelated to a medication question. Give examples that help them answer accurately and send consequential questions to the clinician.

Defining responsibility for a temporary arrangement

When a colleague can meet an identified need, confirm the arrangement in practical terms. Record the task accepted, availability, location, response method, and what happens during absence. If the plan depends on monitoring, equipment, interpretation, mobility assistance, or overnight support, verify that those resources are present. A temporary arrangement should have an end point and a review if the client's condition changes.

Review the plan again before the affected service. A staffing change can invalidate an earlier capacity decision even when the client's health is unchanged. Give staff authority to raise the concern and name the person who decides whether to proceed. Record the decision and the explanation given to the client. Financial staff should receive the information needed to address practical consequences without receiving unrelated clinical detail.

Reviewing exclusions and access problems

Examine deferrals and exclusions periodically for patterns. Are clients repeatedly arriving before a necessary assessment is reviewed? Are people with the same communication need being declined because an accommodation has never been arranged? Are cost and geography preventing access to the required referral? Review the actual cases and distinguish a justified service limit from a process the organization can improve.

Keep a route for reconsideration when the facts or available resources change. State what information could alter the decision and who reviews it. If the program cannot provide the service, explain that limit accurately and continue the referral work appropriate to the person's needs. The record should preserve the decision at each point without turning a temporary limit into a permanent description of the client.

Clinical and Decision Tools

Tool 1 The referral sequence

Use identification, explanation, resource selection, privacy review, and follow through as connected tasks.

Tool 2 Categories of need that exceed capacity

Identify the specific need and the urgency of obtaining help.

Tool 3 Reviewing an unmet medical requirement

Document the required care, current capacity, and questions for the responsible clinician or legal adviser.

Tool 4 Two levels of limitation

Ask in order: is this beyond me? If so, is it also beyond us? The answer determines internal versus external referral.

Tool 5 Pressures that can affect the decision

Review personal, financial, staffing, and organizational factors that could lead someone to overlook a limitation.

Tool 6 Identification checklist

Confirm the need was seen accurately, at the right level, in time.

Screening review and service decision

Worked Example Seeing the Limit Under Pressure

This fictional example applies the practices discussed in this module.

Context: On the morning of a ceremony, a client who cleared screening mentions offhand that he has been getting chest tightness on his morning walks and never mentioned it because he assumed it was nothing. He has flown in, paid, and the group is assembled.

New information: The facilitator records the reported exertional chest tightness and promptly seeks appropriate medical assessment. Current or recurrent chest symptoms or other emergency signs require urgent help. The earlier screening decision is reviewed before any session can proceed.

Identifying the concern: Exertional chest tightness needs medical assessment. The facilitator checks whether symptoms are present now and activates urgent help when indicated. They do not diagnose the cause.

Program capacity: The facilitator and program cannot provide the required cardiac assessment. An external medical referral is needed.

Arranging assessment: The program cannot provide the required medical evaluation. The session is postponed while appropriate care is arranged. Emergency care is obtained promptly if the current symptoms warrant it.

Addressing practical consequences: The facilitator acknowledges the travel, payment, and disappointment and refers financial questions to the responsible staff member. These concerns are addressed alongside the care plan without treating them as evidence that participation is safe.

Checking the urge to assume excessive responsibility: The facilitator asks himself the honest question: would I see this limit as clearly if seeing it were free? The answer clarifies the decision.

Handing off: The need is identified and documented. How it is explained to the client, what resource it is matched to, how his privacy is protected, and how he is helped to actually get the evaluation are the work of Criteria 43 through 46.

Case Vignettes

For each vignette, identify the concern, describe the response, and explain your reasoning. Record your responses on a separate page.

Vignette A

A client discloses during preparation that she is living with a partner who has become violent toward her. The facilitator, focused on the upcoming ceremony and confident in the healing power of the work, treats this as material to be processed in session rather than as a need requiring outside help.

Guided questions: What category of need is this, and who meets it? Why is treating it as ceremony material a failure of identification? What did the facilitator's confidence in the work cost this client?

Vignette B

A facilitator with no somatic training encounters a client whose material is surfacing almost entirely through the body. A colleague on the team is trained in exactly this. The facilitator, unwilling to appear less capable in front of the client, presses on alone.

Guided questions: What level of limitation is this, and what was the correct route? What did the facilitator prioritize over the client? Why does knowing your colleagues' competencies matter to this criterion?

Vignette C

A client seeking ibogaine for opioid dependence has a cardiac history. The facilitator, determined to help, spends two weeks trying to find a physician willing to provide monitoring during a domestic session, treating the requirement as a logistical obstacle to be solved.

Guided questions: What clinical requirements need assessment? What authority and capabilities must the proposed setting have? What appropriate care for opioid dependence should be discussed while these questions remain unresolved?

Vignette D

On the morning of a session, a client reports a manic episode two years earlier that was not recorded at intake. The facilitator proceeds without clinical review because screening was previously marked complete.

Guided questions: Why is identification a live task rather than a completed intake decision? What role did sunk cost play? What should have happened when the disclosure was made?

Vignette E

A facilitator prides herself on being able to hold anything a client brings, and has never made an external referral in three years of practice. She experiences the suggestion that she refer a client as an implication that she is not good enough.

Guided questions: What should the facilitator review about their caseload, competence, and consultation? What information would help determine whether appropriate referrals were missed? Why is referral frequency alone insufficient to judge the quality of practice?

Role Play and Practice Scripts

Practice with a partner or team, then exchange roles. Use fictional details and discuss the choices made in each response.

Testing a limit with a colleague

Practice presenting a specific uncertainty to a supervisor: “This client needs support with X. My relevant training is Y. I am unsure whether the proposed work is within my role. What further assessment or referral is needed?”

Reviewing individual and program capacity

In a team discussion, identify the required service, who is qualified and authorized to provide it, and whether that person is available. Decide whether an internal handoff can meet the need or an external referral is required.

Naming an unmeetable requirement plainly

Practice: “The care you need during the proposed session is beyond what our program can provide. We cannot proceed under the current arrangements. We will discuss an appropriate assessment and the available alternatives.”

Consulting about professional limits

Practice naming a pressure that could affect your judgment, such as payment, reputation, or wanting to help a particular person. Ask a supervisor to review the actual requirements and your proposed decision.

Additional Practice

An accommodation that is not available

A client disclosed a need for an interpreter and a quieter room. At arrival the interpreter is absent and the quiet room is being used for storage. The client has traveled with a partner who insists the session proceed.

Practice questions: Describe the private conversation, the review of actual capacity, and the decision process. What can be resolved today, what requires postponement, and how will practical consequences be addressed?

Applied Record Exercise

An uploaded assessment with an unmet condition

The intake system marks a client ready because an assessment is uploaded. The assessment requests a medication review and additional monitoring, neither of which is arranged. A deposit has been paid.

Task: Read the file status, identify the conditions, assign the qualified review, and write the service decision and client explanation.

Review: The trainee separates receipt from review, verifies actual capacity, and records the decision without allowing scheduling or payment to substitute for an assessment.

Self Assessment and Reflection

Knowledge check

Describe identification of an unmet need and its relationship to explanation, matching, confidentiality, and referral assistance.

Define scope of practice, and state the professional standard that governs boundaries of competence.

Name the categories of client need that commonly exceed facilitator or program capacity.

Describe how to decide whether required care can be provided within the program or requires another setting.

Distinguish a facilitator level from a program level limitation, and state the route each takes.

Explain why identification must remain live midstream and not close at intake.

Explain how personal investment in helping a client can interfere with recognizing a limit, and describe a useful consultation.

Reflection

Write your actual scope: what are you trained to do, licensed to do, and demonstrably competent in? Where does each list end?

Review a recent case that raised a question about referral. What supported the decision, and what information was missing?

Where does the pull to be the one who helps operate most strongly in you? What would it cost a client if you did not notice it?

Observed Practice Assessment

Use the uploaded assessment exercise and add pressure to proceed because the client has already paid and traveled.

The trainee locates the unfulfilled condition, identifies the qualified reviewer, assesses the site's actual capacity, and records an accurate service status. They explain the concern and next step to the client, address practical consequences, and preserve the assessment and decision history. A proposed accommodation is checked in practice.

Treating an unread assessment as approval, resolving a clinical question outside competence, or allowing revenue to override an unmet care requirement requires another supervised attempt.

The assessor records the scenario, date, work reviewed, observed performance, feedback, and any required practice. Use the ratings demonstrated, needs further practice, or not observed for each task. A verbal answer alone cannot establish performance on a task requiring demonstration. Confirm readiness only for the work assessed and within the trainee’s authorized role.

Summary

Identify needs that exceed the facilitator’s role or the program’s capacity at intake and as circumstances change. Compare the required care with actual qualifications, authority, staffing, equipment, access, and follow up. Ask about new symptoms, medications, communication needs, coercion, and the destination after the session. Obtain consultation when the requirement or boundary is uncertain. A qualified, available colleague may meet an internal need; a program limitation requires another route. Explain a pause or referral in terms of the specific requirement and current gap, and document who will arrange the next step.

References

American Psychedelic Practitioners Association, & BrainFutures. (2023). Professional practice guidelines for psychedelic-assisted therapy (1st ed.). https://www.brainfutures.org/mental-health-treatment/professional-practice-guidelines/

American Psychological Association. (2017). Ethical principles of psychologists and code of conduct (2002, amended effective June 1, 2010, and January 1, 2017). https://www.apa.org/ethics/code

Morton, E., Sakai, K., Ashtari, A., Pleet, M., Michalak, E. E., & Woolley, J. (2023). Risks and benefits of psilocybin use in people with bipolar disorder: An international web-based survey on experiences of ‘magic mushroom’ consumption. Journal of Psychopharmacology, 37(1), 49-60. https://doi.org/10.1177/02698811221131997