Human Beings Don’t Come in Specialties

I have become uneasy with a culture in our field where competency can become so hyper-compartmentalized that every time a new layer of a client’s life enters the room, the reflex is to send them somewhere else. A person begins therapy for trauma, and then sex becomes part of the conversation, so perhaps they need a sex therapist. Their relationship begins struggling, so perhaps now they need a couples therapist. They realize they may be autistic, and suddenly they need somebody who specializes in neurodivergence. They begin talking about obsessive rumination or chronic illness or kink or dissociation or a relationship structure that does not fit neatly inside a conventional framework, and again the answer becomes: you need somebody else for that.

I want to be careful here because I am not arguing that therapists should be able to do everything. They absolutely should not. There are treatments I am not trained to provide, populations I do not specialize in, and circumstances where referral is not only appropriate but necessary. If somebody comes to me specifically looking for Exposure and Response Prevention for OCD, I am not an ERP therapist. I have not completed the training necessary to claim expertise in ERP, and I would want that person to work with somebody who has. Curiosity is not competence. Reading a book is not training. Consultation does not magically transform a therapist into a specialist, and ethical humility around our limitations matters enormously.

But I also think there is a meaningful difference between saying, you need a treatment I am not trained to provide, and saying, a part of your human experience has emerged that I do not understand very well yet. Those are not always the same thing, and I worry that sometimes, as a profession, we have started treating them as though they are.

I cannot tell you the number of clients who have come to me after working with generalists who did not have enough depth in particular areas, or with clinicians whose specialization was so narrow that other important parts of the client’s experience were consistently missed. I have worked with people who saw sex therapists who could talk comfortably about sexuality but did not necessarily understand systems, dissociation, or complex trauma—and therefore struggled to understand how those things were shaping a person’s erotic life. I have worked with couples who previously saw therapists who understood relationship dynamics but did not understand queer partnerships particularly well. I have worked with people whose therapists became surprisingly uncomfortable when sex entered the room, especially when the conversation involved kink, nonmonogamy, expansive relationships, or forms of intimacy that did not resemble the therapist’s own assumptions about what a healthy relationship should look like.

And I have seen the reverse. A clinician may understand trauma beautifully but have very little understanding of neurodivergence. A couples therapist may interpret shutdown as emotional avoidance when what they are actually witnessing is nervous system overwhelm. A therapist may interpret a client’s difficulty identifying their emotions as resistance rather than alexithymia. The problem is not that every clinician has gaps. Of course we do. The problem, to me, is what we do when those gaps become visible.

For me, one of the most important commitments I make to new clients is that if something emerges during our work that I do not feel adequately competent in, I will tell them, and then I will go learn. I will seek consultation. I will read. I will find training. I will look for people who understand the topic more deeply than I do. I will listen to lived experience. I will examine whether I am missing something culturally, developmentally, systemically, medically, or clinically. I will do everything within reason to address my own lapse in understanding quickly enough that it can become integrated into the treatment we are already doing, because I do not want my clients to feel like every time we encounter something complicated, their care is suddenly going to become disruptive.

If somebody has been doing meaningful trauma work with me for a year and somewhere in that work we discover that they experience obsessive rumination, chronic illness, sexual difficulties, questions around neurodivergence, or some other area that I do not know enough about yet, my first question is not automatically, who else should I send you to? My questions are usually more like: what is happening here? How does this fit into everything we already understand about you? What do I need to know more about? Can this be ethically and competently integrated into the work we are already doing? And if it cannot, what kind of additional support would genuinely serve you? Sometimes the answer is referral. Sometimes the answer is adjunctive care. Sometimes the answer is simply that I need to expand my own understanding.

I think that distinction matters because therapy is not only a collection of interventions. Therapy is also a relationship, and good therapy rests, in large part, on the therapeutic alliance. For many clients, that alliance is not incidental to the work. Particularly for people with developmental trauma, attachment trauma, histories of chronic misattunement, or relational experiences where vulnerability was not met well, the relationship with the therapist can become deeply meaningful. It can take months, and sometimes years, for someone to bring certain parts of themselves into the room. They finally tell their therapist that they think they are queer. They finally disclose that they dissociate during sex. They finally talk about a sexual fantasy they have carried tremendous shame around. They finally reveal something about a kink or erotic interest that they have never said out loud before. They finally begin wondering whether they are autistic.

And then, at precisely the moment when some incredibly vulnerable piece of the self enters the therapeutic relationship, they hear—however kindly—that is not really my specialty. Let me give you some referrals. Sometimes that is exactly the right thing to say. But sometimes I wonder whether we think enough about the relational cost of saying it. Because what the clinician means may be, I want you to receive competent care. What the client experiences may be something else entirely.

What the clinician means may be, I want you to receive competent care. What the client experiences may be, this part of me cannot come with you.

If somebody has already spent much of their life feeling like they are too much, too complicated, too difficult, too strange, too emotional, too sexual, too traumatized, too neurodivergent, or simply requiring more than other people were willing to give, I think we have to take seriously the possibility that repeatedly fragmenting their care can reproduce something familiar. I am not suggesting that referral itself is traumatizing. But relationships matter. Continuity matters. Attachment matters. Having to start over matters. Having to retell your story matters. Learning a new nervous system matters. For clients with complex trauma especially, the repeated severing of meaningful therapeutic relationships may not be clinically neutral.

Some of the clients I feel the most for are the ones who tell me they saw six therapists before they came to me, or eight, or more. Sometimes each therapist helped with something. But often what I hear is a story of repeated partial understanding. This clinician understood their trauma but not their sexuality. Another understood their sexuality but not their dissociation. Someone understood their relationship but not their neurodivergence. Someone else knew a great deal about anxiety but had almost no framework for attachment. Every room held one piece of them, and very few rooms seemed able to tolerate the whole thing at once. Eventually, some clients start to conclude that the problem is them. They begin to believe that they are simply too complicated for therapy.

That is the part that breaks my heart a little, because people are complicated. Of course they are. That is not a pathology. It is the condition of being a person.

And I think there is something deeply healing about being in relationship with somebody who responds to that complexity not with retreat, but with curiosity. Showing curiosity about another person’s experience is meaningful on an attachment level. A caregiver does not have to already understand every interest, fear, identity, relationship, or problem their child will ever encounter. They do not have to be an expert in everything. But we hope they are willing to turn toward the child and say, tell me about that. Help me understand. What is this like for you? I do not know much about this, but I want to. There is something profoundly powerful about another human being communicating, through their attention and effort, that you matter enough for them to become interested in your world.

I think therapy can contain something similar. This is almost the same reason why, very non-clinically, I keep a growing list of books, movies, restaurants, shows, music, hobbies, and other things that clients mention in sessions. It is not because I am trying to turn therapy into friendship. I am not. It is because attention is relational. If somebody tells me about the book that changed their life, I am curious. If they talk about something that brings them to life, I notice. And if they bring something painful into the room that I do not fully understand yet, I want my first response to be curiosity instead of recoil.

Not because curiosity alone is clinically sufficient. It is not. But because curiosity says something. It says: I care about you. I see you. You are not too complex. You deserve my energy. I am willing to keep trying to understand you.

I also want to be careful not to turn this into a moral standard for how every therapist should practice. I know that part of my own devotion to continued learning is probably related to my neurodivergence. Psychology and psychotherapy are genuinely fascinating to me. I can go extremely deep into a clinical topic because it scratches some very specific part of my ADHD brain, and learning about a new modality, a new population, a new theory, or some obscure corner of human relational experience is something I actually enjoy. Not every therapist wants to spend their free time reading about dissociation, sex therapy, attachment neuroscience, neurodivergence, consensual nonmonogamy, or whatever clinical rabbit hole has captured my attention that month, and I do not judge people for that.

But I do think our broader culture of hyper-compartmentalized competency deserves examination, because sometimes we have become so afraid of working outside a narrow niche that we forget that competent practice can also involve expanding competence. Humility should not only mean, I do not know this, therefore I cannot touch it. Sometimes humility looks like, I do not know enough yet, and I need to learn.

The longer I do this work, the more convinced I become that depth and breadth are not enemies. Trauma affects sexuality. Sexuality affects relationships. Relationships activate attachment. Neurodivergence shapes communication, embodiment, sensory experience, and emotional processing. Culture shapes all of it. Gender shapes it. Chronic illness can alter a person’s identity, eroticism, nervous system, partnership, grief, and sense of self. People are systems, and if we are going to work deeply with people, our clinical thinking probably needs to be systemic too.

I have become known in my own community as a therapist who does not flinch very easily at complexity, and I take a lot of pride in that. Not because I think I know everything. I absolutely do not. But I am willing to remain curious. I am willing to consult. I am willing to train. I am willing to say, I do not know enough about this yet, and then do something about that.

I am not going to disappear because you became more complicated.

Again, sometimes I will need to bring another professional into the work. Sometimes I will recommend a different kind of treatment. Sometimes the ethical thing will absolutely be to refer. But I do not want referral to become an automatic answer to human complexity, and I do not think clients should have to become less complex in order for me to remain their therapist.

At some point, specialization can become fragmentation. I think our field should be willing to ask where that line is, and whether we have sometimes protected our categories of expertise more carefully than we have protected continuity, curiosity, and the whole person sitting in front of us.