Why I Say No To Referrals

The other day I tried to refer someone to my colleague Susan Giurleo and she said no.  In the process I got to learn more about what she focuses on, and I was reminded that I never wrote this post.  So here goes..

I say no to a lot of referrals.  It’s easier to do that with a full practice, but I used to do this even when I was starting out.  Here’s why:

1. In life and work I try to face my fear. 

Like most people, I have had adversity in my life, and one thing I have learned is that I am my best self when I am not thinking or acting out of fear.  When I first started my practice I just wanted referrals.  Heck, I just wanted the phone to ring.  And I noticed that.  I realized that I was about to recreate a fear-based work environment similar to one I’d just left.  And hadn’t I turned down some interviews and a job offer because I wanted to go into business?  I needed to calm down and not get desperate.  Nobody wants a desperate therapist.

I also knew that if I became focused solely on filling up my office hours I’d have a harder time setting limits on what I did in therapy.  In fact that would in my opinion contaminate the treatment relationship, because I’d be worrying that patients would leave rather than paying attention to them, and avoiding difficult conversations because I didn’t want to “lose them” and lose money.  If I wasn’t able to contain or face my anxiety, how could I help anyone else contain or face theirs?

2. I’m a good enough therapist to not try to be good enough for everyone.

When I was in grad school, it was the perfect storm.  As students, we social workers had it drilled into our heads that we had to help everyone.  This was a natural fit with my yearning to help everyone that I came into contact with, in order to prove I was good at what I did.  Remember the phrase “a Jack of all trades is a master of none?”  That’s where I’d be if I kept on the road if my ego and my grad school had held sway.

But after a short amount of time I realized that there was plenty of work to go around, AND that different people enjoyed working with different types of patients.  So now I am confident enough to know that I can do the work and enjoy it.

3. I’m an excellent therapist with some patients.

After a few years, I had done enough good work, and enough medicore work, to begin to notice when I was doing excellent work.  I do good enough work with couples, depression and anxiety.  I do mediocre work with eating disorders drug addiction and alcoholism.  Where I am an Epic Therapist is with gamers, geeks, LGBT individuals, adolescents and trauma.

By saying this I am not diminishing any of the issues or groups I am less than Epic with.  Nor am I trying to say I am the best therapist in the world, there are lots of people who do just as good or better treatment than I do.  What I am saying is that I am a specialist and a thought leader in very specific niche, that’s what makes me Epic.  Think of what that work is for you, and that will be what makes you Epic.

Since I do the traditional 45-50 min psychotherapy hour, and since I need to sleep sometimes, I can only see a finite number of patients in a week.  Saying no to referrals allows me to continue providing therapy at the most optimal level, and I can honestly say that my work is often enjoyable and always gratifying and meaningful.

4.  Saying no to referrals allows me to have a socially just practice.  Let’s talk money for a minute.  After all, that’s one of if not the main reason one wants a full practice, to make money.  I need to make a certain amount of it to support my family and contribute to our household.  But I have always been clear that I want a diverse practice, and that includes working with low-income patients.  So I always have a certain number of hours that I offer PB+5 or 10 appointments.  In order to provide those I need to be thoughtful about the patients I begin working with for reasons financial as well as clinical.  This means being thoughtful about referrals for reasons financial as well as clinical, and that means saying no to referrals.

5. Saying no can be a networking opportunity.

When I don’t take a referral, I usually try to make a referral for the caller.  Just because I say no to a referral doesn’t mean I can’t be useful in recommending someone else.  This keeps me engaged with my colleagues and understanding who might be a good referral for any given person.  I can be more informative than a list from an HMO, and hopefully it gives a more educated referral for the person.

This is also good business, because it helps me continue to talk with my peers about who they enjoy working with, and what their expertise is.  It also has generated more informed referrals for me, both for patients and supervisees.

So these are some of the reasons I often say no to new referrals:  To say no to fear, to stay clear with myself about my strengths and weaknesses, to do the best clinical work, make enough money to do pro bono work, and to be a part of a professional network.  It’s OK to say no to referrals, even when you’re starting out.  Especially when you’re starting out.

Comments

  1. Well put, Mike! I have come to the same conclusions in running my private practice. I am excellent doing some types of work, mostly assessment, and excellent with certain types of clients. I would rather refer a client to someone who will provide excellent service to them, as I think that is the ethical thing to do. Fortunately I have built up enough of a niche so that I am able to avoid the desperation you speak of, in thinking I have to fill every slot. I believe the right people will find their way to me, because I am the right person for them. I appreciate your putting this succinctly.

    • Mike Langlois, LICSW says:

      Hi Kim, sounds like you’ve had enough experience to have faith in this. A lot of times my new consultees are fresh to private practice and have not experienced the cycles we see. That makes them all the braver in my eyes when they pass up a not so great referral.

  2. Hey Mike – Really good thoughts in this!
    thanks for the food for thought!
    take care, Kathy

  3. Mike, I love how you wrote that. I couldn’t agree more. I know that there are certain types of clients that I don’t do good work and I love to refer them to others who do. It feels good to be that honest with the client and myself. It is also good modeling for the client. I know that I do not work well with children. It isn’t my thing so I have a nice list of child therapists that I refer to.

    I attempt to run my practice out of love and not fear. So when things are quiet I take that as the universe telling me that I need to rest. I work to enjoy the break because I know that things will once again get busy.

    Thanks for sharing and reminding me! Renee

    • Mike Langlois, LICSW says:

      Hi Renee, that’s a great reframe about the universe telling you that you need to rest. I think that we often encourage our patients to “sit with not-knowing,” and sometimes we need to walk the walk ourselves. Come again soon.

  4. I say no, too. If I sense on the phone that a potential client and I are not a good fit, I just let the person go by giving them a referral to someone else. He or she might be perfect for another type of therapist. Sometimes this gets tricky, because there aren’t that many women who do what I do in my part of SoCal and I have high credibility, so people try to push their way in. A fine line we walk between making sure we take care of ourselves as well as taking care of the people that find us.

    • Mike Langlois, LICSW says:

      Hi Stephanie, if I was doing business consulting for you I’d say that what makes it tricky is exactly why you may want to be writing an eBook, or giving a training certification program on it! Hope you’re doing that stuff. Thanks for your comment!

  5. Excellent post Mike,
    Recognizing that we can’t do everything is an important element of understanding that working with people that you do your best work with is energizing and not depleting.

    I’m sure many therapists when they start out, will take any referral,to build their practice …its a learning process- we all have bills to pay and it takes a brave soul to turn work down when “we have to keep the wolf from the door” 😉

    With experience and confidence though we find out our niche and strengths… and if we are wise, we build a practice on them.

    I manage and own a thriving and busy practice, I have always been leary of therapists who claim they can “do it all”.

    I recently discovered your blog Mike… great content, keep up the good work.

  6. Mike,
    I don’t think I understand what you mean by this post. How is saying No to someone who has been referred by a colleague any different than a potential client who finds you in some other way?

    I’m in private practice. Every phone call I get is coming from some kind of search or referral. Every call I get I screen for appropriateness of my work.

    What does a referral mean to you? does it mean that the other therapist automatically must take that person? that’s not what it means to me. I think of it as sharing the names of qualified people who Might take them on.

    Help me out = what am I missing in your post?

    • As with Lynne, I also wonder if I’m missing something here.

      I will happily take referrals unless I have good reason to believe it’s inappropriate for me to work with a client. I do offer the first session at half price and make it clear that this is to allow myself and the client to decide whether or not to work together. That said, I have limited faith in assessments: my experience is that the ‘real’ issues are often not apparent until later on.

      I think referrals are in some ways the life blood that flows through therapist networking. I will refer clients to other therapists but will be discerning to ensure as good a match as I can identify, given what I know at the time.

      • Mike Langlois, LICSW says:

        Hi Patrick, I don’t see it exactly that way. I’m not half-working on the intake, so I won’t asked to get paid half. And I think we’re allowed to decide whether to work with the patient and vice verse, so no need for half-fees because of that. I think my point is that it is ok to say no to referrals for a variety of reasons including fiscal ones.

  7. Thanks for the mention, Mike.
    Yep, I said ‘no’ to that referral, but I thought awhile about taking it.
    I wanted to help you out and who you were referring, but when I thought about what they needed and my expertise, it just didn’t fit.

    Honestly, I could take on a few more clients right now, but I’ve learned that waiting for the ‘right fit’ clients pays off in the long run, both financially and in my personal mental health.

    (But really appreciate you thinking of me for the referral) : ).

  8. Ann Flosdorf-Mitchell, LCSW-R, ACSW says:

    What a great article. Thanks, Mike! I am looking to move my career more in the direction of full-time private practice and consulting work, in other words, doing what I love and what I am good at. None of us are great at everything, and there is room for us to be “epic” where we are. I also appreciate your PB+5 formula. I like the concept and believe we can all afford to do some of this work. I like the way you put it together.

  9. I absolutely agree with all that you’ve said Mike. I, too, try as best I can to run a socially aware practice which often means that I am helping more clients for free than I am charging!!

    Thank you for reminding me that, although it is important to be able to earn a living from what I have chosen to do, there is a more important ethical dimension that must also be considered..

  10. I agree with this but only as it applies to situations when it’s very clear from the start I wouldn’t be a good fit. For instance, I don’t see kids, sometimes parents find me (not sure how) and I have to refer them out…other than that my information is very clear about who and what I treat, it leaves little room for interpretation. So I don’t say no a lot and it’s worked out fine. Also the initial problem is almost never the actual problem. For instance, I had a client who found me because he needed help with gaming too much. Turns out he had more of an identity and social anxiety problem. We ended up working very little on the actual gaming.
    Having a niche is imperative but there is always room for expansion with training and an open mind. I am excellent with couples but I would have never known that if I had never stated seeing couples (which was out of necessity at the time)
    I also think we have to be careful not to turn people away because of other reasons that may have nothing to do with their presentation but more to do with things like insurance or their ability to pay our fees.

    • Mike Langlois, LICSW says:

      Hi Elvita, I think it is ok to refer to somebody else if they can’t afford my fee. I have a set number of PB+5 and 10 appointments, but the rest of the time I need to have people who can pay me for my work. Thanks for the comment!

  11. One of the biggest reasons I may move into private practice eventually is precisely this reason – I know I’m great with some clients, and less good with others, but working in a community mental health clinic, I don’t get to “opt out” of working with anyone I’m assigned…and neither do the clients. The result is that I have a few clients who do not want to work with me, and whose issues are not my strong suite either. I wrote a bit about it on my blog http://practicewisdom.blogspot.com/2011/08/to-what-extent-do-you-specialize.html

    • Mike Langlois, LICSW says:

      Thanks Natalie, I hope folks will take a look at your blog. I think that agencies might be surprised if they let people pick and choose a bit, many of us like working with patients that others would consider difficult.

  12. Penny L. Longoria says:

    Mike- I enjoyed this post. As a new MSW student I am looking for guidance. I am in the field now as a therapeutic case manager. Unfortunately, we get “assigned” clients and families; therfore, there is no luxury of choice. We only have a few therapists on staff. I find it restrciting and unhelpful if we do not have a therapist which makes a good fit for the client. As well as therapists choosing which clients they want to take on, I encourage clients to shop around for a good fit. Thanks for your break down on this issue. -Penny L. Longoria

    • Mike Langlois, LICSW says:

      Penny, your welcome. I think it is great that you are encouraging patients to shop around, there should be more of that!

  13. An excellent post I look forward to reading more. I look forward to reading more. It is easy to get swept up in all the aspects of a practice that one health gets sacreficed

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