What To Do About Declining Referrals in a Rapidly Changing Landscape

• Demand for mental health care is clearly high. People are seeking help, referrals are being requested, and general public acceptance of mental health treatment continues to improve. This is clear by the number of requests for clinicians on BBMHG and the UWSPA. Yet, as many of you have likely noticed, the majority of these requests are for in-network clinicians (INN), and many out-of-network (OON) clinicians are experiencing slower referrals and more difficulty maintaining full caseloads.

• INN clinicians are generally seeing steadier referral streams and expressed less day-to-day anxiety in your email responses to me about maintaining a full case load. Still, many of you feel ambivalent about staying on insurance panels, questioning long-term sustainability with the rising costs of living and practicing in NYC and issues around payment. Some of you also question the ethics of the insurance industry itself, but are hesitant to leave the financial stability that seeing patients through insurance provides you. For others, staying INN is also value-driven decision for you: quality care within the system feels deeply important to you. Many of you mentioned your training in social work school and have concerns about accessibility. You understand that the system is far from perfect, but want to work in the current framework in order to provide care that feels affordable and that you yourself would want to have access to. INN clinicians do mention experiencing more competition because of large-scale, INN online practices making it more difficult to keep a full case load. But not nearly as much as OON clinicians describe.

• OON clinicians are navigating more instability and uncertainty in their practices. Nearly all of you described a noticeable decline in referrals over the last few years. But many of you expressed determination to not return to an INN model. You described a real commitment to stay OON and reported feeling very good about this decision. You love the independence and not needing to wait to be paid by an insurance company. Like your INN colleagues, for many of you, your decision is also value-driven. You do not want to participate in a for-profit insurance system that you feel does not fully value your work or compensate at a level that feels workable for living in NYC. But nearly all of the OON clinicians that replied to me responded that they had more open slots, many new clients requesting in-network care, and slower conversion from inquiry to intake, as patients have multiple options to choose from. There’s also your universal hesitation to raise fees—even after years without giving yourself a raise. Most of you are very reluctant to raise fees because of the rising cost of living and inflation in the United States. You expressed concern about losing clients if you raise your fees and do not want to add financial stress to their lives.

• Universally, there is a feeling that private practice therapy feels professionally crowded and that there is a lot of competition in the referral space. Many of you attributed this to the number of new graduates moving directly into private practice and the rapid rise of telehealth platforms. You also expressed awareness that more and more ways clients are searching for therapists in different ways including spaces like ChatGPT and other AI platforms. You also voiced frustration about the futility you felt with certain practice building efforts you have made whether that is a Google Ad campaign, SEO optimization, or using social media.

In sum, across the board, people feel that referrals are less frequent, whether INN or ONN, but clearly ONN clinicians seem to be feeling this more. I want to be very clear and state the obvious: this is not about clinicians doing something wrong or that our work as OON clinicians is somehow less valuable these days. If anything, people are working harder than ever. But the way prospective clients engage with mental health care is rapidly changing. 

Clients are more cost-conscious. Inflation is real, and therapy is a financial decision. Many now start in-network unless there’s a strong personal recommendation. And that is a very, very important thing to note. Please realize that a strong personal recommendation will often outweigh the convenience of online care or picking someone at random from a list.  But at the same time, if there is no strong personal recommendation, large insurance-driven telehealth platforms have made access to care faster and easier—often becoming the first stop. From a systems perspective, this makes sense. But it also means many clinicians are never part of the initial search. How to be a part of that initial search is likely key to remaining relevant and being able to offer the great care that so many of you provide.

So the demand is there—including people seeking great OON care, but access to it feels challenging.

So what’s working?

Clinicians are turning back toward each other. You all responded with colleagues and former clients being a primary way for which you are generating referrals. You told me that genuine relationships seem to be working the best. Good old fashioned “word of mouth”.

Referrals grounded in real relationships, where there is genuine familiarity and trust, are becoming what people are relying in practice as much as they are the listservs and directories, if not much more.

If this is not a big part of your practice yet, here are key actionable steps that you can take to build your practice using a relational approach.

• Let people know when you have openings.
  Don’t assume colleagues will think of you automatically. A simple, occasional message—specific about who you’re looking to see—goes a long way. Try to stay “top of mind” in the clinicians who have historically referred to you. For example, I can think of a few therapists I consistently refer to just because I know their great work AND they remind me when they have openings. They always reach out when they have openings so that I know to refer to them.

• Be clear about your niche if you have one.

  Be explicit about your niche in your messaging and on your website, and when you network with colleagues. Instead of “I see adults,” try: “I’m especially looking for high-functioning professionals with anxiety and burnout.” Make it easy for someone to send a patient to you because they remember that you have this area of interest.

• Follow up after you refer someone to a colleague or vice versa

  A quick check-in (“how did that referral work out?” or “thank you so much for that amazing referral”) keeps your professional connections strong. Make yourself available to the clinicians. Offer your cell phone and make it easy to be in touch with you. My personal recommendations for reading up on skills for this are the books Superconnectors and Never Lead Alone. These best-sellers are must-read books for people in business for themselves.

• Build a small, reliable referral circle.
  Identify 10 clinicians you genuinely trust across specialties and really focus on those relationships. These are the people you will refer to and who will refer back to you. Host a gathering for those clinicians. Regularly check in with them. Host meet-ups for each other. Diversify the group by skills and client niches to make cross-referrals easier. The most successful clinicians in private practice have done and maintained this type of relationship building for the years.

• Respond quickly to inquiries.

  Even a warm, timely “I’ll get back to you shortly and thank you so much for considering treatment with me” improves the likelihood that a potential referral will stay engaged. Do not let a text go “on read” for days from a colleague, or ignore an email that could lead to a potential referral. Getting back to people immediately goes a long way. 

• Use Listerservs well 

  If you are on listservs, consider receiving each email as it comes in real time and not the digest. By the time the digest has come out, the request has likely been answered. Be clear about why you would help a particular client when answering a referral and make it very easy for the client or therapist to reach out to you.

• Make it easy to say yes to treatment with you.

  Clear communication about fees, availability, and next steps reduces drop-off during that first contact. I am a strong proponent of listing fees on the website and explaining how OON care works. Make it easy to meet and start treatment.

• Adjust thoughtfully—not reactively.
  If things feel slower, pause and assess. Small, deliberate shifts are more effective than big, fear-based changes. Build networking into your work week (I personally love the book, Book Yourself Solid). Aim for 1-3 meetings with colleagues per week. All possible through intentional networking through groups or listservs.

• Stay visible in real ways.
  Not just through profiles or listings, but through actual participation—groups, online conversations, and shared professional spaces. Be helpful to your colleagues, but always be mindful of avoiding the overpromotional “reply to all” on a listserv. Respond individually to people and start to make real connections.

This is not about doing more. But it is about being more intentional about professional relationships.

Community is no longer just a supplement to referral streams such as Psychology Today. For many clinicians, relationships are becoming the primary infrastructure in which people maintain their practices. People will continue to refer people that they know, like, and trust whether INN or OON.

Groups like BBMHG and the UWSPA exist for this reason. Not just to exchange information, but to build real professional relationships—ones that sustain both our practices and ourselves and in turn will help many, many people.

Because while systems shift, trusted connections remain the most reliable path forward.

So host a gathering or organize a group. Reach out to our big community and let’s make many new connections that will sustain each other.

Kari Groff MD

Founder, BBMHG