Crossing the invisible line: Overcoming resistance to psychiatric care referral

Key Points

Editor's Note: This paper refers almost solely to "psychiatric referral," since the term "psychiatry" seems to be the most rife with negative connotation (in terms of societal stigma).

When a pediatrician decides it is time to refer a child or adolescent to a mental health clinician, an invisible line has been crossed. The child officially needs "mental health care." This is a psychologically difficult realization for many parents and children. As such, helping a family cross "the invisible line" and accept a mental health care referral is often more problematic than encountered for other subspecialty referrals.

Further complicating the referral process are the many logistical obstacles involved in referring a child or teenager to mental health services, especially a child and adolescent psychiatrist. Consider a study conducted in 2002 of 206 primary care offices. It found that though 650 of 4,012 patients ages 4 to 15 years old were referred for mental health treatment, only 61% of the referred families actually saw a mental health provider in the six-month period following the initial primary care referral.¹

Addressing the logistics

There are many logistical concerns when making a mental health referral. First, few child psychiatrists are available, particularly in rural communities.² As a result of this shortage, long waiting lists exist, such that any momentum built up towards completing a referral is lost.³

In addition, many child psychiatrists now only attend to diagnostic concerns and medication management, while psychotherapy, school consultation, and other services are provided by additional clinicians. Thus referring a child for mental health treatment often means opening the door to a whole mental health team. Unfortunately, the members of these teams can often work without collaboration.

Therefore, when referring to a psychiatrist or mental health consultant it is important to talk to that provider after his or her initial assessment, to discover if additional treaters will become involved and to designate who will be the "team leader" in coordinating the various aspects of the child's mental health care.

There is a lot of confusion about who does what in mental health treatment. This leads many families to ask: "now, who are you sending me to? What kind of treatment is this going to be?" It is thus noteworthy to mention that, whereas only psychiatrists and, in some states, nurse practitioners can provide psychiatric medication management, multiple types of mental health care providers offer psychotherapeutic treatment. In order of highest educational background, the following clinicians provide therapy: psychiatrists (MD), psychologists (PhD or PsyD), social workers (MSW), and mental health clinicians or counselors (often trained at the bachelor's degree level).

Often a person's title does not accurately convey his or her expertise. For example, some psychiatrists are not generalists (meaning they provide both psychopharmacologic and psychotherapeutic treatment) and will focus their practice solely on forensic consultation or other specialties. Some psychologists, on the other hand, will only offer neuropsychological diagnostic evaluations. Social workers may only provide case management without a psychotherapeutic component. Learning about the individuals in one's area of practice, and taking the time to learn which mental health clinicians have expertise, interest, and the temperament to work well with one's pediatric population, can make a huge impact on whether referrals "stick."

An additional technical problem in referring a child for psychiatric treatment is that of insurance coverage. Analogous to a builder who subcontracts plumbing or electrical work to another individual, large insurance companies often "carve out" mental health care services to smaller, "mental health care only" companies. These mental health care insurers have separate eligibility rules and reimbursement rates from the company with whom they contract. Frustrated with the low reimbursements and heavy paperwork involved in working with some of these "carve-out" companies, many child and adolescent psychiatrists and psychologists have refused to join many or any insurance panels.