(Psycho)social networking
Private practice counselors need to give careful consideration to providing appropriate referrals, not just taking them
By Stacy Notaras Murphy
How long does it take for you to return a phone call?
Do you have a waiting list?
Would you ever slide your fee?
Do you keep up with clinical literature?
Do you have leather furniture in your office?
These are just a few questions that, when answered honestly, could provide insight into a person's psychotherapy practice. It might sound personal, perhaps even argumentative, but knowing details of the way others run their practice is vital to providing appropriate referrals to your clients.
Many counselors in private practice focus on their own answers to such questions, particularly when cultivating a network of contacts to boost a caseload. But the flipside of this knowledge is just as important. If you have a strictly vegan client who is uncomfortable touching leather, it might be useful to know the decorating choices of the psychiatrist or acupuncturist whose skills complement your counseling work with that person. Likewise, it might help to know how much time those referrals can offer and for what fee so you can assure your client that you have made a careful, well-researched suggestion. Best practices dictate that counselors offer multiple names when asked for a referral, and this requires some advance footwork.
"Do your homework. It is well worth the time invested to survey a few of your colleagues or other health-related professionals regarding referrals for at least the most common issues," says Deborah Legge, an American Counseling Association member in private practice in Buffalo, N.Y., who also works as a private practice mentor. Specifically, she advises that counselors build relationships with attorneys, primary care physicians, neurologists, nutritionists, massage therapists, support and therapy groups, inpatient facilities and other specialists, such as those for eating disorders, addictions, family therapy and couples work.
"Remember that you are your client's advocate," Legge says. "There may be times when you and your client recognize the need for a second opinion or an additional care provider. Your client may be intimidated or afraid to speak up, but you can't be. It is up to you to help your clients find a voice and get their needs met."
Scouting for names
"It really comes down to whether I've had some experience with the person," says Ruby Blow, an ACA member who owns Development Counts in Atlanta. "For example, when I'm referring to another counselor – I'm seeing a couple and want to refer one person out for individual work – I would refer them to a therapist whom I've either worked with in a setting before and had consultation with, or someone I've supervised or taught, or someone whom I know of their clinical skills set, character and ethics."
Blow recently sought out and invited to lunch a psychiatrist whose location is close to her practice. She explains that she doesn't believe simple proximity is a sound enough reason to make a referral. Before deciding she would be comfortable referring her clients to him, Blow also wanted to learn about his clinical philosophy. "I don't presume that because someone has the right letters behind their name, it means they're practicing competently and ethically," Blow says.
"I believe it's hard to refer to somebody for therapy if you've never met them or worked with anyone who has worked with them," explains Lynn Grodzki, a psychotherapist and business coach for therapists based in Silver Spring, Md. "In the mental health profession, we're often only really comfortable giving a referral to someone we know personally or whose work we know well. Often that means one or two degrees of separation at the most."
Grodzki, whose latest book is Crisis-Proof Your Practice: How to Survive and Thrive in an Uncertain Economy, describes this work as building your own Rolodex. "You can start to identify who is the best at whatever skill. Who do you hear is at the top of their game? Psychiatrist, massage therapist, couples therapist – set a time to meet up. The nice part about that is that you do get to meet this person, and it can be the start of a mutual relationship."
Grodzki recommends that counselors ask members of their supervision groups for their preferred providers, listen to their clients' suggestions and join related professional organizations. "I know therapists who do a lot of couples work and divorce work and have joined professional mediation organizations for just that purpose," she explains. "All of this is to say that I think we need to be connected. We need these networks to be able to serve our clients well and also to feel like we're in community with others."
What to say
When asking other practitioners about their practice, Grodzki recommends explaining your intent right up front and using a slightly modified version of the so-called "elevator speech."
Grodzki suggests saying, "I'm a therapist, and I've heard your name several times before. I need a psychiatrist to refer to, and I would like to talk with you briefly to make sure that I understand how you work." Relevant questions might touch on the psychiatrist's approach to medication and whether he or she is willing to work with a client's current counselor on a treatment plan. It's also helpful to learn how the practitioner prefers to be contacted and what the expected lag time is before a reply is made, she says.
Grodzki adds that a personal relationship with the referral source can help down the road, perhaps during coordinated treatment. "I've made referrals that don't work out well at all. I had one where I became alarmed at the amount of medication being prescribed, and I urged the client to get a second opinion," she recalls. "Working at cross purposes is not uncommon." With client-approved communication between the counselor and other practitioners, a more comprehensive treatment plan may become a reality.
Licensed professional counselor David Zachau and his wife Diana Santantonio, a psychologist, run a psychotherapy practice in Elyria, Ohio. Zachau, a member of ACA, encourages counselors not to be shy when asking for details about how another clinician runs a practice. "Most of the psychiatrists in our area will have one or two counselors or social workers already in house. New counselors should be aware of the risks of sending a client for medication and then losing the client due to that circumstance," he says, noting that new counselors may be less comfortable inquiring about this practice.
Santantonio agrees: "You want to refer to a psychiatrist who doesn't steal patients. You have to be aware that that occurs and follow up. If you do refer a client to a psychiatrist and they end up not coming back to you, touch base and find out what happened."
Networking goes both ways
"A person who is seeking out a professional network has to have a sense of what they, themselves, are bringing to the table," Blow says. "In my experience, when I have a person who is newer to the profession contacting me in an attempt to network, that person is often seeking something but seldom offering something. The best thing they can do is develop a sense of what they have to offer.
"When I contacted the psychiatrist, I explained that I have clients who occasionally need med management, [so] I'm offering him something. Certainly there became some reciprocity. The best thing you can do to gain entry into the professional community is to bring something to the table, a willingness to give something of yourself."
Blow stresses the need for counselors to be both clear and specific about what they have to offer when approaching complementary professionals. "Counselors across the board struggle with identity questions," she says. "We weren't intended to be social workers or junior psychologists; we were trained to be more accessible to the community. We can show the benefits we bring to the 'wounded well,' enhancing relationships, enhancing careers, helping others find more fulfillment. Counselors need to develop a confidence about what it is we have to offer so we have a sense of who we are."
Blow presents a "Career Awakening" workshop intended both for new professionals and those at the midpoint of a helping career. "I think the main takeaway [from the workshop] is that people need to think about what they're offering, not about what they want to get," she says. "If you are offering information or resources, you have a better chance of forming a professional network."
Santantonio says new counselors who call her seeking work or supervision can distinguish themselves from other mental health practitioners by emphasizing the differential diagnosis experience they receive in counseling degree programs. "Counselors have very sophisticated diagnostic training and should recognize that as an asset," she advises.
Continuous networking
Counselors can stay plugged into the local provider landscape by skimming neighborhood blogs to see who is being recommended, checking in with local clergy to find out whom they refer to or even asking their personal doctors for ideas.
As part of the intake request, Zachau and Santantonio recommend that counselors request the names of the other practitioners new clients are seeing. Counselors can then use the client's own experience as a guide for gauging the quality level of other providers.
"You can contact the primary care physician just when you're starting out with a client," Zachau says. "Secure the client's permission first, and then send [the physician] a letter saying you're seeing the patient for anxiety, or whatever, and that you just wanted to let them know. You can learn a lot about the physician's practice from interactions with it and from your client's opinion of it. That kind of sharing of clinical information has the other advantage of increasing the likelihood that the physician will refer back to you."
Putting yourself in position to observe the clinician's skills firsthand is another way to learn more about a potential referral source. "Sometimes I do just literally ask about their theoretical orientation," Blow says. "You'd be surprised that people who work for years say they don't think much about their theoretical orientations. But mostly what I do is observe. Who is asking intelligent questions at a workshop [or] giving case examples? If I like how the person is describing the work, I ask for their information."
Joan Phillips, an LPC in Norman, Okla., advises counselors to constantly be thinking about building their networks and looking for clues to the quality of potential referrals. When trying to get a sense of another clinician's practice style, Phillips says, "I listen to how they present case info if they are at a CEU (continuing education unit) event or training and maybe talk to them during a break about particular cases or ideas. I also ask any counselors I know whom they refer to and why and listen for repeated names or cautions."
Phillips, a member of ACA, notes that CEU events provide excellent opportunities to see and hear providers in their element and to gain an understanding of how they really work. She makes a practice of inviting professionals from complementary disciplines to speak at her office and then offers CEUs to colleagues to come and join the conversation. (When Phillips sees that a potential presenter's credentials and content meet Oklahoma's CEU standards, she contacts the state licensure office with the appropriate information and receives CEU approval documents to distribute to attendees.)
"The guest gets good PR and a chance to share their knowledge. Attendees get a low-cost, quality CEU and access to pick the brain of the speaker. I get the same plus some income, and everyone sees my office and location. We all enjoy the camaraderie and networking, so it's worked well for me," she says.
Grodzki adds that the process of building a referral list is never finished. "I see this as an ongoing, lifelong process of building our Rolodexes," she says. "I've been practicing for over 25 years, and I even get stuck – maybe the person I always referred to has retired or isn't working – so I still have to talk to others." u
Stacy Notaras Murphy is a licensed professional counselor practicing in Washington, D.C.
Letters to the editor: ct@counseling.org