Latest / The Mental Health Evolution / Ep 45: Stop Doing What Worked Ten Years Ago with Dr. Elizabeth Carr

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Ep 45: Stop Doing What Worked Ten Years Ago with Dr. Elizabeth Carr · The Mental Health Evolution

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(Transcribed by TurboScribe. Go Unlimited to remove this message.) This podcast is part of the Frederick podcast
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network.
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Learn more at listenfrederick.com.
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Welcome to Mental Health Evolution, a podcast about
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what's changing in mental health and why it
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matters.
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I'm your host, Rachel Harrison, inviting you into
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honest conversations with people from all perspectives in
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the field, clinicians, tech founders, investors, insurance companies,
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and all the folks in between.
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Let's explore what's working, what's not, and what's
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next.
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Welcome back to the Mental Health Evolution podcast,
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where we talk about how mental health care
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is changing and where it's headed.
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Today, we are joined by Dr. Elizabeth Carr,
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a clinical psychologist and the founder and CEO
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of Kentland's Psychotherapy in Gaithersburg, Maryland.
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Elizabeth leads a team of 20 doctoral and
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master's level clinicians and has navigated multiple industry
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disruptions, from COVID to the telehealth boom to
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corporate consolidation, while keeping her practice community focused
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and financially sustainable.
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A former Navy psychologist and sought-after speaker
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on practice management, she recently published a piece
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that I think is going to resonate deeply
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with the practice owners and clinicians in our
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audience, and it is the centerpiece of our
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conversation today.
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Elizabeth, welcome.
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Hi, Rachel.
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Thanks for having me.
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Of course, it's great to have you here.
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And as always, before we dig into the
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conversation with our guests, we're going to highlight
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a few articles that are relevant to today's
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conversation, and these will be in the show
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notes for you to check out if you
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want to dig in a little further.
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The first one is an article titled, A
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Workforce Under Pressure, Preparing the Behavioral Health Workforce
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for Today and Tomorrow, and this is from
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the National Council for Mental Wellbeing, and this
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is from 2025.
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And it lays out the scale of behavioral
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health workforce shortage, with projections showing tens of
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thousands of unfilled positions in the years ahead.
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It points to things like burnout, limited training
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pathways, and licensure barriers as key drivers, and
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makes the case that closing the gap will
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require strong leadership at the practice level.
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Next is an article titled, Telehealth and Hybrid
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Practice Are Here to Stay, from the APA
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Monitor on Psychology from 2024, and this monitor
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looks at how telehealth has shifted from a
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pandemic workaround to a permanent part of how
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care is delivered, with the share of psychologists
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offering teletherapy jumping from 20% before COVID
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to 67% today.
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It raises important questions about how to structure
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services and staffing in a hybrid landscape.
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And lastly, I want to highlight the article
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that Dr. Carr wrote called Strategic Positioning During
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Industry Upheaval.
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This is from January 2026, and Elizabeth's article
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takes a clear-eyed look at the forces
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reshaping the mental health practice landscape, from consolidation
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to the telehealth aftermath, and offers practical guidance
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for practice owners at every level on how
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to think strategically rather than reactively.
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It's a great piece, and we are so
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excited to have Dr. Carr here to talk
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us through this.
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So, let's go ahead and dig into our
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conversation.
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All right.
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Your article opens with some observations about what's
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happening now in our field.
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You talk about a well-established practice closing
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unexpectedly, experienced clinicians who are quietly looking for
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new positions, referral volume shifting.
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For practice owners who may be feeling some
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of this but not understanding why, can you
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kind of set the stage for us about
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what you're seeing and your perspective of the
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landscape right now?
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Absolutely.
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You know, one of the things that you
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referenced in the first article was this shift
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towards telemedicine.
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And, in particular, one of the things that
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I've noticed recently that heard an accounting firm
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for mental health professionals just published a report
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that showed that the majority of appointments happening
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with those solo practitioners are virtual appointments.
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And even when they have a brick-and
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-mortar space, still the majority of their appointments
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are virtual appointments.
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And I suspect, I think a big part
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of what happened was during COVID, a lot
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of people saw a big uptick in demand
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for outpatient services.
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And people that were unhappy in agency work
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thought this was their opportunity to kind of
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put out their own shingle.
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And the barrier to entry was dramatically dropped
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because they didn't have to get a space.
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And so, I think that that really met
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the moment.
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What I suspect is happening now is that
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VC and private equity firms also saw the
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demand, also realized that virtual was an easy
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entry point, and have built platforms that are
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leaving these solo practitioners really scrambling to compete
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for eyes and to have people just know
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who they are.
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I think that the psychology today seems to
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be flooded now with people who are on
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these platforms.
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And people are saying who have been using
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it for years that they're just not getting
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the referrals that they used to get or
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meant.
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Yeah.
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I mean, that brings up a very interesting
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point because I hear that from colleagues all
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over that referrals have declined.
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And yet, at the same time, I hear
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in the media, sometimes from bigger companies, I
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think some of the bigger companies even kind
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of market this way and say, hey, it's
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impossible to get in anywhere.
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We can get you in quickly, kind of
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thing, right?
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And it's interesting because I think it misses
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some of what is happening on the ground.
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There's a disconnect there.
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Yeah.
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And I think a big part of that
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is the gap between the need and affordability.
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Because if you think about when COVID was
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happening, people were miserable, but they also, they
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weren't going to restaurants, they weren't traveling, they
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weren't going to movies, and they had a
6:08
lot of disposable income or discretionary income that
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they could invest in their mental health.
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I think the difference is now people are
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also really stressed, but they also don't feel
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like they have the income to invest in
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their own health care.
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And so I think that's a huge shift
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from even just a few years ago.
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Yeah.
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So what are you seeing about the economic
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factors that are influencing practices right now?
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Yeah.
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So I think part of it is that
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there is high demand, but many people really
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need to use their insurance.
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And so if you're not an insurance-based
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practice, I think that that market is tight.
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I think that's a part of it.
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And cost is significant.
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And so if you have the phone ringing
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off the hook, then you need the manpower
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to answer those calls.
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In terms of administrative support.
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Yeah.
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So I think all of that is part
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of the challenge for a practice owner to
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figure out how to navigate.
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You mentioned in your article sort of this
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barbell pattern where both the smallest practices and
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some of the largest practices are facing a
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lot of pressure, while certain midsize practices are
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sort of in a stronger position.
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Can you talk about how would you define,
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first of all, small, medium, large practices, some
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of the variability here?
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Yeah.
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I think, like I was saying before, I
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think for the people who are very new
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to private practice and don't have five or
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10, 15 years of marketing behind them, it's
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hard for them to get a voice in
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the marketplace, to be known and to be
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heard.
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And just relying on a platform like Psychology
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Today just isn't cutting it for a lot
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of people now.
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So I think that's where the squeeze is
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happening, especially for the solo practitioners, particularly the
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solo practitioners that are entirely virtual, because then
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they're competing with these VC platforms also.
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I think the thing that I've also seen,
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especially with some of the larger platforms, is
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when there was so much demand, a lot
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of practices exponentially grew, took on a lot
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of overhead space, physical space, for long-term
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rental contracts.
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And as the market is constricting now, there
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are practices that just have a lot of
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empty space that are the drain financially.
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Yeah, that makes sense.
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So the larger practices maybe then having more
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of that overhead that they can't sustain, the
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solo or smaller just not being able to
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get into that marketplace in the same way.
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And I think the smaller ones in particular
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that are virtual competing with these platforms, whereas
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the bigger ones, it feels more like kind
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of a too-big-to-fail kind of
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situation.
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Yeah.
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What about this competition?
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I want to talk more about that.
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What do you see as the struggle there?
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What do some of these VC companies and
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tech companies have that a solo practitioner does
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not?
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What makes it sort of an uneven playing
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field?
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Sure.
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Well, you know, think about one of those
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things is that when you talk about SEO,
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my website has been around for over 20
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years, and I've been adding blogs to it
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for over 20 years.
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So there's just a lot of keyword strength
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to that.
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Yeah.
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So we're ranking really well, but if I
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had just started my practice a couple of
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years ago, and I'm by myself, and I
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may or may not have been adding blogs,
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it's just very hard to get on, you
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know, what we used to call like page
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one.
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Now there's the forever scroll, but still you
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could go down 20, 30 entries before you
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even start seeing a typical solo practitioner's website,
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because it's mostly psychology today, ZocDoc, and those
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kinds of websites, right?
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And they're behemoths.
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So whenever I get above one of those,
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I feel like I'm really cooking.
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You are.
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That's impressive.
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And the newer companies, you know, like BetterHelp,
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they just have oodles of dollars to spend
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on marketing and whole departments to think about
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SEO.
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We're the little guys, we just don't have
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that.
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No, no.
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Yeah, there's time, there's overhead, there's all of
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those things.
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So not being backed by a venture capitalist
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certainly limits what we can do.
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And I think marketing in general, right, not
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just even SEO, but I hear on podcasts
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advertised, I see it everywhere.
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I was riding in a taxi in New
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York City and there were mental health companies
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advertising there, right?
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So it's like all over, whereas a solo
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practitioner is never going to be all over
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in what they can reach for visibility in
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marketing.
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Yeah.
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And it's almost sort of like it's a
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different service when you are offering an in
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-office, in-person experience.
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And so I think when people are looking
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for a virtual therapist versus looking for a
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brick and mortar place where they can see
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a therapist, those are two, oftentimes two different
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shoppers.
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And it does, I think, give some practices
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a distinct advantage if their marketing is hyper
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-local and their connections and their referral base
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is hyper-local and there's an actual location
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that people are coming to.
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Well, and that's interesting.
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I hear that data about what you said
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at the beginning about the herd accounting data.
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For our practice in particular, most people are
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looking for in-person.
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That might be that local piece that you're
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talking about.
11:18
They may do hybrid or switch to telehealth
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at some point, but the initial call, they
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really want to come and sit down.
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Yes.
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And we might be getting self-selection bias
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because they're calling us because that's what they
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want.
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It's certainly true.
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But I also think that particularly in the
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wake of COVID, people have a lot of
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virtual fatigue and don't necessarily want something as
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intimate as therapy to be one more screen
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activity for them.
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I think that is a part of it.
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Well, and I know a lot of therapists
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who feel similarly, right?
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They miss that in-person, sitting in a
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room together interaction.
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Particularly, I found even when COVID was still
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going on, but at least we had vaccinations,
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my child therapists were like, I will suit
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up and hazmat outfit, but I'm coming back
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to the office because I cannot do one
12:07
more plate therapy on the screen with the
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child.
12:10
And then after that, it was a couple
12:11
of therapists, they might be able to lean
12:13
over and put the hand on somebody's knee
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that's getting escalated and you can't do that
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through the screen in the same way.
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Yeah.
12:20
And I think about in child therapy, like
12:23
you're moving around the room, there's so much
12:26
changing constantly.
12:27
And when you're attached to a screen, that's
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so much harder to do that.
12:31
Yeah.
12:31
One of our therapists made a humorous kind
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of like TikTok video about that, replicating it
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as the child.
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And it was really funny.
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The whole thing about like, meet my dog
12:40
and it just is very scattered.
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And yeah, they were very excited to come
12:46
back to the office right away.
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They were the first ones to come back
12:49
to the office.
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Definitely.
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I saw a similar pattern there.
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Yeah.
12:54
So it is interesting.
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I want to ask you also about AI,
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but first I want to talk about these
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large practices.
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You mentioned that inability maybe to be as
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agile.
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What else do you see as a disadvantage?
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And you said like buying space and then
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not having enough room to fill it anymore.
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Are there any other factors there for large
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practices?
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Well, I think, you know, when you have
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a large practice, you need more systems, even
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for our size.
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We need more systems because everything starts to
13:25
break at a certain point.
13:26
I was talking with someone the other day
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about how it's pretty predictable that when you're
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a solo practitioner, you track your incoming calls
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on a piece of paper or a spiral
13:35
bound notebook.
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And then eventually you're like, this isn't going
13:38
to work.
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And you have to go to Excel for
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a spreadsheet.
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And then at some point, maybe when you
13:42
have seven, 12 therapists, you're like, this spreadsheet's
13:46
not going to cut it.
13:46
And then you start researching CRMs. But those
13:49
are kind of predictable benchmarks where at a
13:52
certain size, the system you have won't work
13:54
anymore.
13:54
And you have to upgrade to the next
13:55
one.
13:56
But all of these systems cost money.
13:58
Oh, yes.
13:59
Right.
13:59
20 years ago, I had paper files.
14:01
Now I have a EHR that's almost $2
14:03
,000 a month.
14:05
And I'm doing a CRM.
14:06
And I have an admin team and all
14:09
of that.
14:09
And the more you grow, the more systems
14:10
that you need.
14:11
The more you grow, you realize, oh, I
14:12
probably need to have legitimate W-2 employees.
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And I'm nervous about having 1099s.
14:18
And that is more costly.
14:20
For sure.
14:20
More costly too.
14:22
And as you grow, sometimes I know for
14:24
myself, as I've grown, I want to do
14:26
more for my clinicians.
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So you start layering on things like other
14:30
benefits and things like that.
14:31
Well, that's great.
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But then if those are expected, and then
14:36
the economy contracts, then you're more vulnerable because
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you have these financial obligations that you've made.
14:43
Right.
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Right.
14:44
That makes perfect sense.
14:46
And yeah, I think about all the systems
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and all the costs of the systems.
14:50
One of the things I've seen in the
14:51
last couple of years is that those systems
14:54
that are necessary to run the business have
14:56
really raised their prices consistently.
15:00
Yeah.
15:00
And yet for an insurance-based practice, there's
15:03
no way to raise the rate.
15:04
Even for self-pay, it's what the market
15:07
will bear.
15:08
Right.
15:08
Right.
15:08
So there's the limit in what other people
15:11
can raise their prices and they've had to
15:13
because of the economy.
15:15
Totally understand it.
15:17
And yet we're in a position where we
15:19
can't.
15:20
Right.
15:20
So it just crunches everything that much more.
15:23
Everything.
15:24
And we offer health insurance and holy moly,
15:26
you know, I think it's like 24 percent
15:27
up.
15:28
It's about to go.
15:28
Yes.
15:29
Yes.
15:29
It's outrageous.
15:31
Yeah.
15:32
Yeah.
15:32
So going back even to how, you know,
15:35
small as in solo makes sense, how would
15:39
you define a medium versus a large practice?
15:42
I'm curious about that if our listeners were
15:44
thinking, what category do I fall in here?
15:46
Yeah.
15:47
So to me, I think if you have
15:48
multiple sites in my mind, I think of
15:50
that as a larger practice.
15:51
Okay.
15:53
The other thing I find is that large,
15:56
if you take insurance, is very different than
15:58
large of you are fee for service.
16:00
When I tell people that we're approximately 20
16:03
clinician fee for service practice, people are like,
16:05
wow, that's really big.
16:07
Right.
16:07
Because will the market bear 20 fee for
16:10
service people all collected in one location?
16:12
Whereas I talk to people who have grown
16:14
insurance based practices in five years and they
16:16
have 65 clinicians.
16:17
Well, that seems to me to be nearly
16:18
impossible at a fee for service level.
16:20
So I do think that large is a
16:23
little bit dependent on where is your location
16:25
and what is your business model and are
16:28
you specializing in something or not?
16:30
I met a woman at a conference recently
16:32
who specializes in PCIT in Texas and I
16:36
think she could probably go nationwide as kind
16:38
of like a chain for that.
16:40
She's very smart about marketing and it's a
16:43
niche market that could be marketed, I think,
16:45
at a national level.
16:46
Yeah.
16:47
That's an interesting thought.
16:49
And so what are you seeing that midsize
16:52
practices?
16:53
We haven't really talked about that one.
16:54
What's the advantage there?
16:56
Yeah, I think that you are still small
16:59
enough to be nimble and pivot if you
17:01
need to.
17:01
And I think being able to pivot if
17:03
you need to is really essential and not
17:06
to have every single system deeply entrenched in
17:09
and unchangeable.
17:11
Yeah.
17:11
And the more people you have, the more
17:14
difficult that is to be nimble.
17:17
And I think sometimes it's hard for us,
17:19
particularly because I think most of us are
17:20
not particularly business people, to get our minds
17:22
around the numbers and what's going on.
17:25
And when something is shifting in a very
17:28
large organization, I think financially things can go
17:32
south really quickly.
17:33
Whereas I think if you're a little bit
17:34
more midsize and a little bit more nimble,
17:37
you understand the numbers maybe perhaps a little
17:40
bit better and you have more ability to
17:41
respond quickly to something that's going on.
17:44
Yeah.
17:45
Any other advantages that you see for midsize
17:48
practices?
17:49
Well, one thing I know for myself is
17:52
that I don't need a lot of middle
17:54
management.
17:56
I am the phone a friend when somebody
17:58
has an ethical problem or a customer service
18:00
concern with clinicians, they're calling me.
18:03
And frankly, I love that part of the
18:04
job.
18:05
But I noticed that a lot of midsize
18:06
practices and larger practices have people in those
18:10
positions that are clinic managers, service line managers,
18:14
things like that, that are clinicians.
18:16
And that's an extra expense as well.
18:18
This is part about being larger and taking
18:20
on more and more kind of creeping expenses.
18:23
Yeah, definitely.
18:25
I kind of stuck AI in there and
18:28
that isn't really something that was in your
18:29
article.
18:30
But because it's so prevalent in coming into
18:34
our field, both with AI chatbots sort of
18:37
acting as emotional supports in some way, as
18:41
well as note takers and all of that.
18:43
I'm curious to get your take on all
18:46
of that.
18:47
You know, one of the things that I
18:48
really enjoy is looking at the industry and
18:49
saying, where is it going and what's happening?
18:51
And I think that the more manualized kinds
18:55
of interventions are probably going to be the
18:58
most vulnerable to AI.
18:59
And so if I were doing something perhaps
19:04
like CBTI or exposure response prevention, I think
19:08
I'd be most nervous about AI because I
19:12
think people will quickly think that they can
19:14
write bots that can do a lot of
19:16
those more manualized interventions.
19:17
If you are relational in your therapeutic approach
19:21
and really leaning on that human interaction, particularly
19:24
I think that in-person human interaction, then
19:28
it's much, much harder for AI to replace
19:30
that.
19:31
So I think one thing if you're nervous
19:32
about AI is to do some self-reflection
19:35
about what am I offering that AI can't
19:37
replace and lean into that.
19:40
Yeah.
19:41
That's what I've done in terms of what
19:42
are we offering that venture capitalists can't easily
19:45
replace.
19:46
And like a high quality place where every
19:48
single clinician is an expert in what they
19:50
do in person, that's just not something that's
19:53
scalable, particularly.
19:55
Yeah.
19:56
So that kind of seats your place at
19:59
the table locally as a service provider that
20:02
feels like it's not vulnerable to consolidation.
20:06
Well, if you think about sort of like
20:07
the fancy restaurants in DC, there's a few
20:10
of them.
20:10
There's about a million of them.
20:11
That's true.
20:12
Where if you are something like Chipotle or
20:14
Cava, you can scale and you can go
20:16
national and they're both are legitimate businesses, but
20:19
they're different businesses and different constraints and they
20:22
have different populations that they're serving.
20:23
And I feel like that metaphor is really
20:25
helpful to me when I think about the
20:27
different kinds of practices that are around.
20:29
I like that.
20:30
And that is the consolidation idea is we
20:34
have a recipe that works and we're going
20:38
to just make it so that every place
20:41
can reproduce that recipe over and over and
20:44
over again.
20:44
Yeah.
20:46
Yeah.
20:46
Versus we're going to make something new and
20:49
unique and come in and experience that and
20:52
it will be different every day if you're
20:55
in the restaurant metaphor.
20:57
Yeah.
20:57
I like that.
20:58
It's a really good metaphor, actually.
21:00
It makes me think about a lot of
21:03
different practices.
21:04
One of the things I've thought of too
21:05
in this is generalist versus specialist.
21:09
Oh, yeah.
21:09
That's one too, right?
21:11
Because I do think if we're just offering
21:15
reflective listening or workbook sheets or recommending stuff
21:21
to read or some psychoeducation, I mean, that's
21:25
all important for sure.
21:26
But I also think that can be more
21:28
easily replicated.
21:30
Right.
21:31
Right.
21:31
And, you know, the thing that I think
21:33
AI has not figured out yet is that
21:35
even if you are more purely Rogerian, you
21:38
don't endorse and support everything somebody says they're
21:41
going to do.
21:43
Right.
21:44
And I think this is a huge blind
21:46
spot for these and a danger, frankly, and
21:49
a vulnerability in terms of being sued, because
21:52
you see it already in stories where someone,
21:55
an adolescent says, do you think this noose
21:57
will hold my body weight?
21:59
And it looks at it and says, yeah,
22:00
I think it's going to work.
22:01
That's not what we do now.
22:03
Right.
22:04
And I think that that's the part that
22:06
maybe the programmers will figure out how to
22:08
get it to cut it out, but they
22:10
don't seem to be close to it yet.
22:13
Yeah.
22:13
And that is certainly a whole rabbit hole.
22:17
But I want to ask you another question.
22:19
You've written about what you call paper tigers,
22:22
which are threats that get a lot of
22:23
airtime, but might be overstated relative to the
22:27
real strategic challenges practice owners are facing.
22:30
What do you see in all of these
22:32
pieces or in pieces we haven't even talked
22:35
about yet as the real strategic challenges versus
22:39
the noise?
22:40
I think some of the real strategic challenges
22:43
are market disruption and being able to look
22:46
at the market and understand what's happening in
22:48
the industry and then reflect on how is
22:51
that shift consistent with what you are doing
22:53
in your practice and then being open to
22:56
pivot as needed.
22:57
Right now, for example, we were talking before
22:59
we started about how the demand for child
23:01
and services has really skyrocketed in the last
23:04
10 years.
23:05
And when I started private practice, I only
23:07
saw adults.
23:08
I used to say, I only see people
23:09
35 and above.
23:11
So I'm like really adult.
23:13
And if our practice were today only seeing
23:16
adults, we would be a very different practice.
23:19
But when I was growing, we would get
23:22
phone calls for people that wanted to have
23:23
lessons and we didn't see adolescents.
23:25
And so I found someone really good that's
23:27
adolescents.
23:27
And then we got calls for children and
23:29
I didn't see children and she didn't see
23:30
children.
23:31
So then we recruited someone really good for
23:32
children.
23:33
But that's really responding to what's the demand
23:35
in the industry.
23:36
What are people looking for?
23:38
And that's like right now, we get a
23:39
lot of calls for EMDR. We don't have
23:41
someone that's doing EMDR. We're looking.
23:43
Somebody wants to do a part-time EMDR
23:45
job.
23:45
We're open to it.
23:46
But that's where, you know, knowing what the
23:49
demand is, maybe even looking at your Google
23:50
Analytics to say, what are people searching under
23:53
when they get your site?
23:54
Because it's really interesting to say, oh, look
23:56
at that.
23:57
Everybody wants couples therapy, but we don't offer
23:59
couples therapy or everybody wants EMDR and we're
24:01
not doing that.
24:02
I think just watching the market so you
24:04
can respond to the market is really important.
24:06
Yeah.
24:07
Yeah.
24:07
I love that.
24:08
Well, given the fact that we are about
24:10
out of time, what is one thing that
24:13
you would sort of like to leave our
24:15
listeners with, whether it's a client, whether it's
24:18
a clinician, whether it's a large business owner
24:21
in this field, what do you think is
24:23
an important thing to take away from this
24:25
conversation?
24:26
I think it's to think broadly about what
24:29
you're doing.
24:30
You know, people always say it all the
24:31
time that, particularly if you're a business owner,
24:34
that you have to have some quiet days
24:36
where you stop and get out of the
24:37
grind and think like you're 5,000 feet
24:40
above, looking down at it, get some distance
24:43
and reflect on what you're doing and what's
24:46
changing.
24:47
Because we can't just keep doing the same
24:48
thing we did 5, 10, 20 years ago
24:50
and think it's going to work today because
24:52
things are changing.
24:53
I remember when I started private practice, people
24:55
talking about whether or not they would accept
24:57
credit cards and I can't imagine now not
25:00
accepting credit cards.
25:02
It'd be impossible, right?
25:03
But that's the change and being open to
25:06
the change.
25:07
Right.
25:08
The change is changing.
25:09
So what are we going to do?
25:11
I love that.
25:13
Well, Dr. Carr, thank you so much for
25:15
being here and for being part of this
25:17
conversation.
25:18
And to our listeners, thank you for tuning
25:21
in.
25:21
All of the articles and ways to connect
25:24
with Elizabeth and her article will be in
25:26
the show notes.
25:27
And we will be back next week with
25:30
more conversations about how mental health care is
25:32
evolving.
25:33
Thanks for listening.
25:35
And bye for now.
25:36
Thanks for listening to the Mental Health Evolution
25:40
podcast.
25:41
Join the conversation, find us on socials, send
25:44
us your thoughts and tell us what you're
25:45
seeing in your corner of the mental health
25:47
world.
25:48
Until next time, stay curious and keep evolving.