Stop Doing What Worked Ten Years Ago with Dr. Elizabeth Carr

welcome to Mental Health Evolution, a podcast about what's changing in mental health and why it matters. I'm your host, Rachel Harrison, inviting you into honest conversations with people from all perspectives in the field. Clinicians, tech founders, investors, insurance companies, and all the folks in between. Let's explore what's working, what's not, and what's next. Welcome back to the Mental Health Evolution Podcast where we talk about how mental health care is changing and where it's headed. Today we are joined by Dr. Elizabeth Carr, a clinical psychologist and the founder and CEO of Kindland's Psychotherapy in Gaithersburg, Maryland. Elizabeth leads a team of 20 doctoral and master's level clinicians and has navigated multiple industry disruptions from COVID to the telehealth boom to corporate consolidation, while keeping her practice community focused and financially sustainable. A former Navy psychologist and sought after speaker on practice management, she recently published a piece that I think is going to resonate deeply with the practice owners and clinicians in our audience and it is the centerpiece of our conversation today. Elizabeth, welcome.

Hi Rachel, thanks for having me.

Of course. It's great to have you here. And as always, before we dig into the conversation with our guests, we're going to highlight a few articles that are relevant to today's conversation and these will be in the show notes for you to check out if you want to dig in a little further. The first one is an article titled A Workforce under Pressure Preparing the Behavioral Health Workforce for Today and Tomorrow. And this is from the National Council for Mental well Being. And this is from 2025 and it lays out the scale of behavioral health workforce shortage with projections showing tens of thousands of of unfilled positions in the years ahead. It points to things like burnout, limited training pathways and licensure barriers as key drivers and makes the case that closing the gap will require strong leadership at the practice level. Next is an article titled telehealth and Hybrid Practice are Here to Stay from the APA Monitor on psychology from 2024 and this monitor looks at how telehealth has shifted from a pandemic workaround to a permanent part of how care is delivered, with the share of psychologists offering teletherapy jumping from 20% before COVID to 67% today. It raises important questions about how to structure services and staffing in a hybrid landscape. And lastly, I want to highlight the article that Dr. Carr wrote called Strategic Positioning during Industry Upheaval. This is from January 2026 and Elizabeth's article takes a clear eyed look at the forces reshaping the mental health practice landscape from consolidation to the telehealth aftermath, and offers practical guidance for practice owners at every level on how to think strategically rather than reactively. It's a great piece and we are so excited to have Dr. Carr here to talk us through this. So let's go ahead and dig into our conversation. All right. Your article opens with some observations about what's happening now in our field. You talk about a well established practice closing, unexpectedly experienced clinicians who are quietly looking for new positions, referral volume shifting for practice owners who may be feeling some of this but not understanding why. Can you kind of set the stage stage for us about what you're seeing and your perspective of the landscape right now?

Absolutely. You know, one of the things that you referenced in the first article was this shift towards telemedicine and in particular one of the things that I've noticed recently that heard an accounting firm for mental health professionals just published a report that showed that the majority of appointments happening with those solo practitioners are virtual appointments. And even when they have a brick and mortar space, still the majority of their appointments are virtual appointments. And I suspect, I think a big part of what happened was during COVID a lot of people saw a big uptick in demand for outpatient services and people that were unhappy in agency work thought this was their opportunity to kind of put out their own shingle and the barrier to entry was dramatically dropped because they didn't have to get a space. And so I think that that really met the moment. What I suspect is happening now is that VC and private equity firms also saw the demand, also realized that virtual was an easy entry point and have built platforms that are leaving these solo practitioners really scrambling to compete for eyes and to have people just know who they are. I think that the psychology today seems to be flooded now with people who are on these platforms and people are saying who have been using it for years, that they're just not getting the referrals that they used to get from it.

Yeah, I mean that brings up a very interesting point because I hear that from colleagues all over that referrals have declined. And yet at the same time I hear in the media Sometimes from bigger companies. I think some of the bigger companies even kind of market this way and say, hey, it's impossible to get in anywhere we can get you in quickly kind of thing. Right. And it's interesting because I think it misses some of what is happening on the ground. There's like a disconnect there.

Yeah. And I think a big part of that is the gap between the need and affordability. Because if you think about when Covid was happening, people were miserable, but they also, they weren't going to restaurants, they weren't traveling, they weren't going to movies, and they had a lot of disposable income or, or discretionary income that they could invest in their mental health. I think the difference is now people are also really stressed, but they also don't feel like they have the income to invest in their own healthcare. And so I think that's a huge shift from even just a few years ago.

Yeah. So what are you seeing about the economic factors that are influencing practices right now?

Yeah, so I think part of it is that there is high demand, but many people really need to use their insurance. And so if you're not an insurance based practice, I think that that market is tight. I think that's part of it. And cost is significant. And so if you have the phone ringing off the hook, then you need the manpower to answer those calls in terms of administrative support. And so I think all of that is part of the challenge for a practice owner to figure out how to navigate.

You mentioned in your article sort of this barbell pattern where both the smallest practices and some of the largest practices are facing a lot of pressure, while certain mid sized practices are sort of in a stronger position. Can you talk about, how would you define first of all, small, medium, large practices, some of the variability here?

Yeah, I think like I was saying before, I think for the people who are very new to private practice and don't have five or 10 or 15 years of marketing behind them, it's hard for them to get a voice in the marketplace to be known and to be heard. And just relying on a platform like Psychology Today just isn't cutting it for a lot of people now. So I think that's where the squeeze is happening, especially for the solo practitioners, particularly the solo practitioners that are entirely virtual because then they're competing with these VC platforms. Also. I think the thing that I've also seen, especially with some of the larger platforms, is when there was so much demand, a lot of practices exponentially grew, took on a lot of Overhead space, physical space for long term rental contracts. And as the market is constricting now, there are practices that just have a lot of empty space that are a drain financially.

Yeah, that makes sense. So the larger practices maybe then having more of that overhead that they can't sustain the solo or smaller just not being able to get into that marketplace in the same way.

And I think the smaller ones in particular that are virtual competing with these platforms, whereas the bigger ones, it feels more like kind of a too big to fail kind of situation.

Yeah. What about this competition? I want to talk more about that. What do you see as the struggle there? What do some of these VC companies and tech companies have that a solo practitioner does not? What makes it sort of an uneven playing field?

Sure. Well, you know, if you think about one of those things is that when you talk about SEO, my website has been around for over 20 years and I've been adding blogs to it for over 20 years. So there's just a lot of keyword strength to that.

Yeah.

So we're ranking really well. But if I had just started my practice a couple of years ago and I'm by myself and I may or may not have been adding blogs and it's just very hard to get on, you know what we used to call like page one. Now there's the forever scroll. But still you could go down 20, 30 entries before you even start seeing a typical solo practitioner's website. Because it's mostly Psychology Today, Zoc Doc and those kinds of websites, they're behemoth. So whenever I get above one of those, I feel like I'm really cooking, you know?

You are. That's impressive.

Yeah. And the newer companies, you know, like BetterHelp, they just have oodles of dollars to spend on marketing and whole departments to think about SEO where the little guys, we just don't have that.

No, no. Yeah. There's time, there's overhead, there's all of those things. So not being backed by a venture capitalist certainly limits what we, what we can do. And I think marketing in general. Right. Not just even SEO, but I hear on podcasts advertised, I see it everywhere. I was riding in a taxi in New York City and there were mental health companies advertising there. Right. So it's like all over. Whereas a solo practitioner is never going to be all over in what they can reach for. Visibility in marketing.

Yeah. And it's almost sort of like it's a different service when you are offering an in office, in person experience. And so I think when people are Looking for virtual therapist versus looking for brick and mortar place where they can see a therapist. Those are two, oftentimes two different shoppers. And it does, I think give some practices a distinct advantage if their marketing is hyperlocal and their connections and their referral base is hyperlocal and there's an actual location that people are coming to.

Well, and that's interesting. I, I hear that data about what you said at the beginning about the herd accounting data for our practice in particular. Most people are looking for in person that might be that local piece that you're talking about. They may do hybrid or switch to telehealth at some point. But the initial call, they really want to come and sit down.

Yes. And we might be getting self selection bias. Right. Because they're calling us because that's what they want.

True.

Certainly true. But I also think that particularly in the wake of COVID people have a lot of virtual fatigue and don't necessarily want something as intimate as therapy to be one more screen activity for them.

Right.

I think that is a part of it.

Well. And I know a lot of therapists who feel similarly. Right. Like they miss that, like in person, sitting in a room together interaction particularly.

I found, you know, even when Covid was still going on, but at least we had vaccinations, my child therapists were like, I will suit up and hazmat outfit. I am coming back to the office because I cannot do one more play therapy on the screen with the child. Yeah. And then after that it was a couple's therapists. You may want to be able to lean over and put the hand on somebody's knee that's getting escalated and you can't do that through the screen in the same way. Yeah.

And I think about in, you know, child therapy, like you're, you're moving around the room, there's so much changing constantly. And when you're attached to a screen, so much harder to do that.

Yeah. One of our therapists made a humorous kind of like TikTok video about that replicating it as the child. And it was really funny. The whole thing about like meet my dog and it just is very scattered and yeah, it's. They, they were very excited to come back to the office right away. They were the first ones to come back to the office.

Definitely. I saw a similar pattern there. Yeah. So it is interesting. I want to ask you also about AI, but first I want to talk about these large practices. You mentioned that inability maybe to be as agile. What else do you see as a Disadvantage. And you said like buying space and then not having enough room to fill it anymore. Are there any other factors there for large practices?

Well, I think, you know, when you have large practice, you need more systems. Even for our size, we need more systems because everything starts to break at a certain point. I was talking with someone the other day about how it's pretty predictable that when you're a solo practitioner you track your incoming calls on a piece of paper or a spiral bound notebook. Right. And then eventually you're like, this isn't going to work and you have to go to Excel for a spreadsheet. And then at some point, maybe when you have 712 therapists, you're like, this spreadsheet's not going to cut it. And then you start researching CRMs.

Right.

But those are kind of predictable benchmarks where at a certain size the system you have won't work anymore and you have to upgrade to the next one. But all of these systems cost money. Oh yes, right. 20 years ago I had paper files. Now I have a DAC that's almost $2,000 a month and I'm doing a CRM and, and I have an admin team and all of that. And the more you grow, the more systems that you need, the more you grow, you realize, oh, I probably need to have legitimate W2 employees and I can't nervous about having 1099s.

And that's more costly for sure.

And more costly too. And as you grow, sometimes I, I know for myself, as I've grown, I want to do more for my clinicians. So you start layering on things like other benefits and things like that. Well, that's great. But then if those are expected and then the economy contracts, then you're more vulnerable because you have these financial obligations that you've made to people.

Right, right. That makes perfect sense. And yeah, I think about all the systems and all the costs of the systems. One of the things I've seen in the last couple of years is that those systems that are necessary to run the business have really raised their prices consistently.

Yeah.

And yet for an insurance based practice, there's no way to raise the rate even for self pay. It's what the market will bear. Right, right. So there's the limit in what other people can raise their prices and they've had to because of the economy. Totally understand it. And yet we're in a position where we can't.

Right.

So it just crunches everything that much more.

Everything. And we offer health insurance and holy moly. You know, I think it's like 24% up. It's about to go.

Yes, yes. It's outrageous.

Yeah.

Yeah. So going back even to how, you know, small as in solo makes sense. How would you define a medium versus a large practice? I'm curious about that. If our listeners are thinking, what category do I fall in here?

Yeah. So to me, I think if you have multiple sites, in my mind, I think of that as a larger practice.

Okay.

The other thing I find is that large if you take insurance is very different than large if you are fee for service. When I tell people that we're approximately 20 clinician fee for service practice people are like, wow, that's really big. Right. Because will the market bear 20 fee for service people all collected in one location? Whereas I talk to people who have grown insurance based practices in five years and they have 65 clinicians. Well, that seems to me to be nearly impossible at a fee for service level. So I do think that large is a little bit dependent on where is your location and what is your business model and are you specializing in something or not? I met a woman at a conference recently who specializes in PCIT in Texas. Oh, yeah. And I think she could probably go nationwide as kind of like a chain for that. She's very smart about marketing and it's a niche market that could be marketed, I think at a national level.

Yeah, that's an interesting thought. And so what are you seeing that mid size practices? We haven't really talked about that one. What's the advantage there?

Yeah, I think that you are still small enough to be nimble and pivot if you need to. And I think being able to pivot if you need to is really essential and not to have every single system deeply entrenched and unchangeable.

Yeah. And the more people you have, the more difficult that is to be nimble.

And I think sometimes it's hard for us particularly because I think most of us are not particularly business people to get our minds around the numbers and what's going on. And when something is shifting in a very large organization, I think financially things can go south really quickly. Whereas I think if you're a little bit more midsize and a little bit more nimble, you understand the numbers maybe perhaps a little bit better and you have more ability to respond quickly to something that's going on.

Yeah. Any other advantages that you see for mid sized practices?

Um, well, one thing I know for myself is that I don't need a lot of middle management.

Mm.

I Am the phone, a friend. When somebody has an ethical problem or a customer service concern, the clinicians, they're calling me. And Frank, frankly I love that part of the job. But I noticed that a lot of mid sized practices and larger practices have people in those positions that are clinic managers, service line managers, things like that, that are clinicians and that's an extra expense as well. This is part about being larger and taking on more and more kind of creeping expenses.

Yeah, definitely. I kind of stuck AI in there. And that isn't really something that was in your article, but because it's so prevalent in coming into our field, both with AI chatbots sort of acting as emotional supports in some way as well as note takers and all of that. I'm curious to get your take on all of that.

You know, one of the things that I really enjoy is looking at the industry and saying where is it going and what's happening? And I think that the more manualized kinds of interventions are probably going to be the most vulnerable to AI. And so if I were doing something perhaps like CBT I or exposure response prevention, I think I'd be most nervous about AI because I think people will quickly think that they can write bots that can do a lot of those more manualized interventions. If you are relational in your therapeutic approach and really leaning on that human interaction particularly I think in person human interaction, then it's much, much harder for AI to replace that. So I think one thing if you're nervous about AI is to, to do some self reflection about what am I offering that AI can't replace and lean into that. Yeah, that's what I've done. In terms of what are we offering that venture capitalists can't easily replace? And like a high quality place where every single clinician is an expert in what they do in person, that's just not something that's scalable particularly.

Yeah. So that kind of seats your place at the table locally as a service provider that feels like it's not vulnerable to consolidation.

Well, if you think about sort of like the fancy restaurants in dc, there's a few of them, there's not a million of them.

That's true.

Where if you are something like Chipotle or Cava, you can scale and you can go national and they're both are legitimate businesses, but they're different businesses and they have different constraints and they have different populations that they're serving. And I feel like that metaphor is really helpful to me when I think about the different kinds of practices that are around.

I like that. And that is the consolidation idea is we have a recipe that works and we're going to just make it so that every place can reproduce that recipe over and over and over again. Yeah, yeah. Versus we're going to make something new and unique and come in and experience that and it will be different every. Every day. If you're in the restaurant metaphor. Yeah, I like that. It's a really good metaphor, actually. It makes me think about a lot of different practices. One of the things I've thought of too in this is generalist versus specialist.

Oh, yeah. That's interesting one too.

Right. Because I do think if we're just offering reflective listening or workbook sheets or recommending stuff to read or some psychoeducation, I mean, that's all important for sure. But I also think that can be more easily replicated.

Right, right. And you know, the thing that I think AI has not figured out yet is that even if you are more purely Rogerian, you don't endorse and support everything somebody says they're going to do. Right. And I. This is a huge blind spot for these and a danger, frankly, and a vulnerability in terms of being sued. Because you see it already in stories where someone, an adolescent says, do you think this noose will hold my body weight? And it looks at it and says, yeah, I think it's going to work. That's not what we do.

No.

Right. And I think that that's the part that maybe the programmers will figure out how to get it to cut it out, but they don't seem to be close to it yet.

Yeah. And that. That is certainly a whole rabbit hole. But I want to ask you another question. You've written about what you call paper tigers, which are threats that get a lot of airtime but might be overstated relative to the real strategic challenges practice owners are facing. Or what do you see in all of these pieces or in pieces we haven't even talked about yet as the real strategic challenges versus the noise.

I think some of the real strategic challenges are market disruption and being able to look at the market and understand what's happening in the industry and then reflect on how is that shift consistent with what you are doing in your practice and then being open to pivot as needed right now. For example, we were talking before we started about how the demand for child and adolescent services has really skyrocketed in the last 10 years. And when I started private practice, I only saw adults. I used to say, I only see people 35 and above. So like really adults. And if our practice were today only seeing adults, we would be a very different practice. But when I was growing, we would get phone calls or people that wanted adolescents and we didn't see adolescents. And so I found someone really good that saw adolescents. And then we got calls for children and I didn't see children and she didn't see children. So then we recruited someone really good for children. But that's really responding to what's the demand in the industry? What are people looking for? And that's like right now we get a lot of calls for emdr and we don't have someone that's doing emdr. We're looking somebody wants to do a part time EMDR job, we're open to it. But that's where, you know, knowing what the demand is, maybe even looking at your Google Analytics to say what are people searching under when they get your site? Because it's really interesting to say, oh, look at that. Everybody wants couples therapy, but we don't offer couples therapy or everybody wants emdr and we're not doing that. I think just watching the market so you can respond to the market is really important.

Yeah, yeah, I love that. Well, given the fact that we are about out of time, what is one thing that you would sort of like to leave our listeners with? Whether it's a client, whether it's a clinician, whether it's a large business owner in this field, what do you think is an important thing, thing to take away from this conversation?

I think it's to think broadly about what you're doing. You know, people always say it all the time that particularly if you're a business owner, that you have to have some quiet days where you stop and get out of the grind and think like you're 5,000ft above looking down at it, get some distance and reflect on what you're doing and what's changing. Because we can't just keep doing the same thing we did five, 10, 20 years ago and think it's gonna work today because things are changing. I remember when I started private practice, people talking about whether or not they would accept credit cards. And I can't imagine now, right. Not accepting credit cards. I know it'd be impossible. Right. But that's the change and being open to the change.

Right. The change is changing. So what are we gonna do? I Love that. Well, Dr. Carr, thank you so much for being here and for being part of this conversation and to our listeners. Thank you for tuning in all of the articles and ways to connect with Elizabeth and her article will be in the Show Notes and we will be back next week with more conversations about how mental health care is evolving. Thanks for listening and bye for now.