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.

Why Therapist Directories Are A Waste Of Time

This post is for all of you who have been considering or actively using listings in therapist directories.  I frequently get asked from consultees which directories they should list in.  I also frequently see colleagues debating on bulletin boards and listservs the merits and demerits of individual directories.  So I figure it’s time to offer you my perspective.  Please bear in mind that I am sharing my experience and opinions here, and if you’ve had a different one, hopefully you’ll mention it on the comments.  If you own a directory service, I hope you’ll disclose that as well.

When I started building my practice, I had a lot of time to spend filling out various online directories.  I literally spent hours filling out profiles that promised to make me visible to potential patients.  To be fair it gave me the opportunity to hone my bio and elevator speech, but other than that I now think that I was wasting my time.  But let’s talk a little about why directories may be a waste of your time, because I think it points to a larger misconception about marketing your practice online.

Billboard in a bottle.

Many therapists still approach the internet as if it was a giant Yellow Pages.  We often create static content, the equivalent of a business card, cover letter and resume, and then slap it up on a website, or a directory.  Then we sit back and wait for the phone to ring.  It’s like we imagine that we created a giant billboard and threw it into the world wide web.  But in reality, it’s more like a message in a bottle, thrown in a vast ocean.  We imagine that that will get us recognized.  It usually doesn’t, and here’s why.

If you google “find a therapist” you will literally find dozens of website directories guaranteed to help patients find the right provider.  If you’re ambitious you could spend hours and days finding all of them and entering your information.  Many of them are free, some charge money, and a few don’t let you know whether they will charge or not until you’ve entered all of your information.  One of the main problems with directories is exactly that there are so many of them.

One thing I’ve learned from starting up social networks for other companies is that you always need a critical mass of members as quickly as possible.  If you launch a site you have a few days to a week to achieve this in most cases.  Otherwise potential members will log in to your site, look around and see little activity, and leave.  So low enrollment of providers in a directory will drive little traffic to it.

On the other hand, if you take a directory like Psychology Today’s you will see that they did achieve a critical mass, and have more traffic.  But the problem here is that this is because every therapist and her maiden aunt is now listed there.  So the problem becomes how to set yourself apart from the rest.  If you are determined to spend time on listing yourself in a directory, I’d suggest that you pay for the PT one and try to distinguish yourself as best you can.  In fact, the Psychology Today site is the only directory I even try to keep current and pay for anymore.

Speaking of keeping current, here’s the other potential pitfall of directories:  The more you participate in, the more you’ll need to update your content, remember more passwords, and check back in.  Some directories require you to log in any time you get a message from a potential client (or spam) in an effort to drive up their traffic.  It’s a lot of hassle for little ROI.

If you are determined to list yourself in directories, please consider the following:

  • If you are planning on practicing online, does the directory have global traffic?
  • If you are planning on practicing in a certain geographic location, does the directory get traffic from your part of the world?
One way to research this a little is to run the site’s address on Alexa, which will often tell you some information about traffic or rankings by country.
But while we’re talking about Alexa, let’s talk about how those numbers can be misleading.  Alexa allows you to download the Alexa toolbar, which allows you to check a site’s alexa traffic rank, but it also allows Alexa to tabulate traffic to any site your browser visits, which is part of how they get those numbers.  So it is very easy to drive traffic numbers up artificially.  How?  Easy, set your homepage to your website, and every time you open up your browser, it opens to your site, and adds to your number of visits.  Not enough?  No problem, have all of your family members do the same on their computers.  Within days, your ranking will rise dramatically, without any real rise in potential referral visits. So keep that slight-of-hand in mind when you look at a therapist directory’s traffic. Maybe they do have 100s of visits a day, or maybe they have 10 people who have that site as their home page to drive up traffic.
So Now You Know.

When I review my practice referrals, I received probably %10 of them from a directory, usually Psychology Today.  The majority of my referrals came from word of mouth, insurance company lists, and increasingly my blog and articles.  By now, many of you will know where I am going with this:  It is content and interaction that convert visits to your website into referrals.  There is not a similar conversion rate from visits to your directory profile and calls to you, or even visits to your website.

Some may disagree with me, but my take on directories is that they are a waste of time, and that they capitalize on therapists’ reluctance to generate interactive and dynamic content.  Put simply, people want to hang up their cybershingle and then go back to passively waiting for the phone to ring.

To spend a lot of time finding and listing yourself in a therapist directory is to confuse worry with effort.  What you should be doing (Oh Nos! A therapist used the word “should” 😉 ) is generating content and creating opportunities for interaction with colleagues and potential patients.  Examples of generating content include:

  • writing brief informative blog posts
  • tweeting links to articles that you find interesting to establish your “brand”
  • offering a free hangout on Google+ on your niche topic
  • creating a meditation podcast that people can download from your site
  • networking in Second Life or attending the Online Therapy Institute’s open office hours
  • doing a five-minute vblog on a CBT technique

I’ve done many of the above, and this blog post is another example.  I guarantee you that this post will generate a new referral for me at some point soon, much sooner than my Psychology Today profile will.

So please take the time you could be playing it safe cutting and pasting your info into yet another directory, and instead take some risks, create some new content, or join in a conversation online.  Web 2.0 is not about being a digital classified ad. Use your time marketing to do what therapists do best: Relate.

Integrity Is Your Brand.

Recently I had two experiences which took me a bit by surprise. The first was when a representative from an online gambling site contacted me and asked me to consider affiliating with their website.  Apparently they had read several of my blogs and found my site and the posts to be in their words “respectable” and “well written.” They wondered how much I’d charge for them to be able to include a link to their site in my next blog.

As many of you can guess, I derive no direct monetary income from this blog.  The revenue I do get comes in requests for consultation, workshops and speaking engagements from people find me through this site, and summer is slower in those areas.  Needless to say the idea of making some money from the blog is always tempting.  And I have nothing against online gambling per se.  But I declined, and at this point I can’t imagine accepting advertising or affiliating.  It might be more tempting if Blizzard or Nintendo were to call, but even then I would have to decline.  Not because I think affiliate marketing is inherently wrong, but because in this case something more valuable is at stake.

The second experience didn’t involve money, but it was actually an even harder decision.  Not long ago I had the privilege of being elected to the board of a professional organization.  I’ve been on several boards, so I was expecting to commit a lot of time and work to this one.  What I wasn’t expecting was to get a call from the chair about my blog.  Seems that someone had forwarded a post where I criticized several organizations for their stance on technology, including this one.  I was told that I’d have to retract the post, and refrain from making any future critical posts about the group.

This is an organization I think highly of, and I can tell that the members of this group are not just in it for the title.  I’m sure I could have done a lot of good serving on it.

But again, I had to decline.

Neither money nor a titular position is more important than my integrity.  In fact, I’d go so far as to say to you that integrity is your brand.

It’s important not to make the mistake of demonizing either of the two parties in the examples.  There is nothing inherently wrong with marketing or in my opinion online gambling.  But I have not built my reputation on being an expert on gambling, and I’m not one.  So even though the website might derive benefit from having a respectable blog link to them, I wouldn’t.  Sure money is great, but as I said, something more valuable, my integrity, might be lost.  I have worked too hard and too long to risk losing that.

I can also understand the board’s point of view: As an ambassador of the organization, whatever I say about it, critical or otherwise could be problematic for them.  I don’t agree with them entirely, but when I understood what was expected my choice was clear.  This blog isn’t Mashable, but many of you have been reading it for as long as it has been up.  And people expect me to tell it like it is, whether it be about technology, gamer-affirmative therapy, or growing your private practice.  If you’ve read the comments you know that everyone doesn’t always agree with my point of view.  But many people have come to find the blog, and me, consistent and honest.  There are other people who can do board work, but without my integrity there is no blog.

At the risk of sounding self-righteous, I know that writing this has made a difference in the lives of therapists and the patients they treat.  It has allowed me to gain access to publications and groups to spread the word that technology is not incompatible with therapy, and that gamers need therapists who are culturally competent in gaming rather than contemptuous prior to investigation.  Seasoned clinicians have told me that they have begun to rethink some of the cherished ideas our field holds about addiction, and fledgling therapists have sought me out for supervision on how to grow and market a profitable and socially just practice.  And of course writing for all of you has helped me feel “powered-up” to continue to do the work even when there’s pushback from colleagues and our field.

I’m not telling you this just for catharsis.  And I don’t have that “Blog With Integrity” badge on the blog just for show.  Here’s what I want to make sure you know:

One day, maybe very soon if it hasn’t already happened, you’re going to realize you’re a success.  You’ll realize that you haven’t been worrying about your practice as much, or that your caseload is full, or that you’re being asked to teach on your expertise.  One day, you’re going to be a success.  And when that happens, you’re going to have opportunities that require you to make tough choices.  Because people will notice you’ve become successful. Whether it be those word of mouth referrals or podcast interviews, you’re going to have become more influential.  Some people will want to harness your influence to help them, others will want to harness it to control it.  And the only person who can decide what choice to make is you.

If you don’t feel comfortable seeing yourself as successful or influential, that’s your problem.  Ignorance is always a vulnerability.  You matter.  The work you do matters.  Your thoughts and opinions matter.  Its when we don’t think we have an impact that we hurt our patients, our families, our business, in fact our world.

Immanuel Kant once said, “Act only according to that maxim whereby you can at the same time will that it should become a universal law.”  I take this to mean act as if anything you were about to do in your life would become a universal law for how to do it.  That’s heavy stuff.  It’s not easy to decide how to act in a way that you’d be willing to have be the way to act for the rest of your life. In this case, blog with integrity.

Integrity is your brand.  Are you willing to do what keeps you whole and constant in your therapy, business and life?  Do you stand up for the things you believe in even when they cost you money, comfort or being liked? And perhaps most difficult, are you willing to notice your success, admit that you matter, and live with the knowledge that you have an impact on the world?

What Google+ Could Mean For Therapy

Every technology reveals the hand that shaped it.  The technology of the 21st Century is no exception:  Social Media has proliferated because human beings are inherently social creatures, even when that sociability takes on different forms.  And the explosion of access to information was detonated by our own curiosity.

For better or for worse (usually worse) our ability to engineer and zeal to use technology usually outstrips our ability to behave well with it, and in a large part I believe that this is what spurs on our refinement of it.  Listservs are a great example:  They allowed amazing access to online community through emails and postings, and they elevated the concept of “flame war” in comments to a new level.  Eventually, email and bulletin boards were insufficient to allow us to be sociable, and Web 2.0, with its emphasis on interactivity and real-time community was born.

And then Facebook, MySpace, Friendster and other social network platforms quickly outstripped the listserv and bulletin board.  The emphasis became on finding and connecting with old friends, acquiring new ones, and maintaining a steady if sometimes awkward flow of real-time announcements, status updates and feedback to them.  The online world expanded exponentially, and in fact that interactivity and information became overwhleming.

Which brings us to Google+.

For those of you who have not had the pleasure, Google+ is a new social networking platform (and in many ways much more than that) which has brought a new level of functionality to online social media.  Although it is still in beta, the number of people participating in the largest usability test in the history of the world is growing by leaps and bounds.  If your patients have not mentioned it, it is only a matter of time before they do, and that alone should be a good reason to learn to use it.  But in fact, Google+ has already begun to show me how valuable it may be in actual treatment.

So today I want to introduce you to two of the core concepts of Google+, Streams and Circles, and show you how each of these may present you and your patients with an arena to talk about psychological concerns and skills in therapy.


The Google+ system of circles is as powerful as it is flexible.  Whereas on Facebook you really had only one big group of people called your Friends, Google allows you to create and label various circles, such as “Friends,” “Colleagues,” and “Family.”



The interface let’s you drag the name and image of different people located on the top to one or more of the circles below.  When you mouse over the circle it expands to give you an idea of who you have put in it.  And if you drag a person to the grey and white circle on the far left, you can create a new circle, one which you label yourself.  For example, I have a circle for “Minions.”  I’ve always wanted minions.

This graphic representation of the way we can and often do categorize people in our life may allow our patients to visualize the decisions and boundaries they struggle with in real life.  This can be especially useful with patients on the autistic spectrum.  We can begin by empathizing with them when we upload our 1000 email contacts, and discover that we now have an overwhelming 1,000 individuals to make sense of.  Who goes where?  Is everyone a friend?  Can we put people in more than one circle?  Decide to take them out of one and into another, like say out of “acquaintance” and into “friend”?  What sort of circles might we want to create that Google+ didn’t give us?

People with Aspergers often have exceptional spatial reasoning, and can find mapping out relationships very helpful.  Now they have a dynamic way to do this, and a visual representation of how unruly and confusing social relationships can be.  Even though we can use this only as a powerful metaphor and coneptual tool, we could go even further.  Inviting a patient to bring in their laptop and taking a look at Google+ could be a helpful intervention.  We could help them explore and decide how to set up their own personal boundaries and affectional investment.

Or imagine for a second you are working on emotional regulation issues with a patient.  You can encourage them to create circles like “love them,” “Push my buttons,” “scary,” “feel sad,” and help them take a snapshot of their life at any given time to see who they want to put in each circle.  Do some people go in more than one circle of affect?  Do they notice that they are taking people in and out of circles frequently, or never?

Or imagine working with social phobia, and trying to help the patient brainstorm what activities they might want to try to invite someone to.  They can create circles like “Go to movies,” “Have dinner,” “Learn more about them,” and other options for various levels and types of engagement, and then they can sort people into those.  And all of a sudden they also have a visual list of who they can call when they are trying to socialize.

Last example, working with trauma and/or substance abuse.  Circles can be created for “Triggers me,” “Can call when I want a drink,” “My supports,” “self-care partners,” etc.  Then populate each with the people in their life, so they have a ready-made resource for when they are in crisis.  It also can be very illuminating to share and explore this in therapy, allowing you to make comments like, “what do you make of the fact that most of the people in your family circle are also in your triggers one, but not in the support one?  What do you think you could do about that?”

So these are just a few quick examples of how you can use the Circle concept of Google+ to understand your patients better, help them understand themselves better, and use social media to intervene in a variety of situations.


In Google+ circles go hand in hand with your Stream or Streams.  A stream is a stream of comments, updates, links to information, invitations, photos, video and other media, posted by people in your circles.  It is probably important to note here that similar to Twitter, you can invite people into your circle without their permission, but that doesn’t mean they will invite you back.  And you can set each circle to have different levels of access to your posts.  In other words, circles and streams together allow you to learn and set boundaries.  Here’s what a Stream can look like:

This is only the fraction of the incoming Stream, which gives you a sense of how multimedia, interactive, and possibly uninteresting some of it could be sometimes.  Much like Twitter, or like life.  If we had to pay attention to everyone all the time in the same way, we would become very fatigued.  Like our patients with ADHD, we would be overwhelmed despite our best attempts to understand at times.  Again, we can use this technology that our patients may be familiar with to begin to deepen our empathic attunement with them.  But it gets even more interesting.

If you look at the upper left-hand corner under Stream, you will see a list of your circles, in this case family, friends, acquaintances, etc.  Now if you click on any of those circles, the Stream changes.  Specifically, it changes to list only the posts from the people in any given circle clicked.  This synergy between circles and streams highlights not only the importance of privacy, but that focussing our attention is inherently a social as well as cognitive function.

Imagine working with an adolescent and reviewing their streams together.  What sorts of media, comments, and concerns are streaming through their lives at any given moment?  And what is the consequence of having 500 “friends” in their friend circle?  Do they feel intimate or able to attend to all of these friends?  Or are there some times that they may be more interested in attending to some friends than others?  If so, why?  Might it be time to start to rethink what it means to be a friend?  Is it ok to select who they attend to at certain times?  Do they really find the content they get from A interesting?  And if it is consistently uninteresting, does that say anything about their relationship?  Sorting through Streams to make sense of their world quickly becomes a talk about sorting through their values and their relationships.

For a second example, let’s return to the patient with ADHD.  Perhaps they could create circles for “School,” “Fun,” “Work,” “Family,” and sort people that way.  That way when they are doing work for school they can focus only on the Stream for the School Circle, which may contain links to papers, classmate comments, or lecture recordings from their professor.  If that stream starts to have too many other types of posts, maybe that is an indicator that someone is in the wrong circle, or that they need to only be in the “Fun” one until that paper is done.  Remember the circles are easily adjusted back and forth, so this is neither difficult or permanent to do.  But these types of decisions and focussing techniques may be crucial to staying on task.  (For those of you who might be ready to suggest that they not need to follow any Streams when they are studying, I encourage you to take a look with them at how much academic content and collaborative learning is done online before you rush to judgment.  It’s not always just “playing on the computer” now.)

Other ways that you can use Streams to help your patients therapeutically may come to mind if you reflect on the names of their circles.  Do they really want to follow the Stream of posts from their “Pushes My Buttons Circle?”  Maybe they’d rather tune into a steady Stream from their “Supports” circle instead?  And what might happen if they created a circle for “Intimates” that only contained people that touched them in deeply meaningful ways?  Could they still enjoy their “Friends” Stream, but switch to a “Skeleton Crew” one when they are needing to simplify their social life?

We make these decisions all the time, we just aren’t always conscious or overt about it.  And if we don’t make those decisions, we often suffer for it by overextending or stressing ourselves.  We need to have boundaries and filters.  We need to be able to focus and set limits and values.  These needs have begun to be more clearly revealed by the technology of Google+.  Knowing about that technology may improve our ability to treat our patients.

Five Tips For Your Practice This Summer