Referring to psychologists: why “fit” matters

A psychologist colleague recently described a session with a new patient. When she asked why the person had been referred to her, the patient replied: “My GP said you were such a lovely person.” I’m sure she is. But it raises a clinical question: is “lovely” really a sufficient basis for referral, given the range and complexity of presentations seen in general practice?

In Australian primary care, referrals to psychologists and clinical psychologists are often made on practical grounds — who has an appointment available, who is nearby, or who is someone the GP happens to know. Yet referrals have critical implications for outcomes.

The Australian Government’s Better Access evaluation found that over 12 months, 47% of users who accessed mental health care showed clinically significant improvement on a measure of depressive symptoms (PHQ-9), 26% showed no clinically significant change, and 27% showed clinically significant deterioration. This does not mean that therapy caused deterioration. However, it is a sobering reminder that “someone available” is not necessarily “someone suitable”.

As with referrals to medical specialists, referrals to psychologists are best made intentionally, guided by the patient’s needs and some knowledge of the clinician, their capacity to form a good alliance with the patient, and their specific areas of expertise. Referral decisions are more likely to improve outcomes when they reflect a genuine consideration of the “fit” between the needs of the patient and the psychologist. Considerations may include matching therapy to the patient’s psychological organisation, motivation and aims rather than convenience. That said, this level of choice isn’t always available. In rural and remote areas, where options are limited, the focus may shift from finding an ideal match to making the best use of available resources and greater collaboration with the psychologist.

Choosing the right therapeutic frame

General practice consultations are necessarily brief, but a few moments of genuine listening can still reveal a great deal about how a person relates, tolerates emotion and reflects on experience. The way a patient tells their story can be as important in guiding the referral as the diagnostic label we record.

A patient who presents a highly structured, “medicalised” narrative and asks directly for tools or strategies may be signalling a preference for practical, skills-based treatment. Someone who keeps circling back to the same disappointments or conflicts in relationships may be inviting work that helps them understand recurring relational themes. Noticing how a patient manages affect and dependency in the room gives a better sense of referral fit than a checklist of symptoms.

Different therapies are designed to promote different outcomes. For busy referrers, this can be distilled into a few practical decision points.

Structured therapy

Referral to a practitioner providing structured therapies (such as cognitive behavioural therapy) are often a good fit when:

• Symptoms are clearly defined and circumscribed (for example, panic, phobias, insomnia, obsessive–compulsive symptoms);
• The patient prefers direction, structure and practical strategies; and
• The immediate goal is symptom reduction and behaviour change rather than exploration of developmental origins.

These approaches may also be useful when affect regulation is poor, or the person is in acute crisis, offering containment before any deeper work is attempted.

Short-term psychodynamic therapy

A referral to a practitioner providing brief psychodynamic (time‑limited) work tends to fit when:

• Distress centres on a clear interpersonal or relational focal conflict;
• The patient is generally well‑functioning, with enough ego strength to tolerate some emotional discomfort, and
• The patient evidences psychological mindedness and curiosity about links between past and present.

Within a Mental Health Treatment Plan (MHTP) context, the psychologist’s work stays focused and bounded: one clearly defined issue is worked with intensively over a limited number of sessions.

Longer term therapy

Referral to a practitioner providing longer‑term supportive or exploratory psychotherapy is most indicated when:

• Problems are chronic, characterological or embedded in long‑standing relational patterns;
• There is a history of complex or developmental trauma;
• Previous brief or structured interventions have provided only partial or short-lived benefit; and
• The patient is seeking enduring personality change and a deeper sense of self‑understanding.

As an example, in psychodynamic psychotherapy, the central task often involves strengthening the patient’s capacity to understand internal experience (mentalisation), emotional tolerance and the capacity to relate without collapse or rigid defences.

Under Better Access, most patients are eligible for up to 10 subsidised psychology sessions per calendar year (with specific exceptions, including eating disorder treatment plans). Ten sessions may be sufficient for circumscribed problems, but is often insufficient for complex trauma or long-standing relational patterns. When longer-term therapy is indicated, it is helpful to say this early: Medicare may support the beginning of treatment, but not the full course, and some out of pocket cost may apply.

Toward more intentional referrals

None of this is a critique of GPs working under pressure. Rather, it is an invitation for the GP to make the referral a little more focused on the patient’s needs and the subtler competencies of the psychologist. Many clinicians develop specialised skills — for example, in eating disorders, psychosis, neurodiversity or complex trauma — that are not interchangeable across presentations.

In practice, a few small shifts in how GPs refer can be effective in enhancing optimum outcomes:

• Clarify the primary presentation (and any additional layers). Depression combined with trauma, substance misuse, chronic pain, neurodiversity or high interpersonal risk represents a different clinical task from depression alone and should influence referral choice.
• Ask about fit, not just availability. A brief question to the psychologist can be helpful: “What presentations do you most often work with, and what do you tend to refer on? Does your clinic triage referrals?” Caution is warranted with clinicians who report seeing “everyone” and never referring on.
• Include a brief formulation. Two or three lines describing what the person struggles to hold in mind, and what tends to happen in relationships, can support a better match and a faster start.
• Attend to culture, language and context. For patients from migrant and CALD backgrounds, it is important to consider experience in providing culturally responsive care.
• Agree upfront how progress will be reviewed. Feedback that includes both symptom change and broader markers such as agency, coherence and meaning‑making can support timely course correction.
• Review early and act if there is drift. A brief check‑in after a few sessions (“more stuck, the same, or a little better/finding it useful?”) can prompt earlier adjustment if the match is not working.

Referrals matter because they shape the therapeutic relationship that and the patient’s expectations of therapy. A small shift from convenience-based referral toward fit-oriented referral — and a shared plan to review progress — can improve outcomes and reduce the risk of avoidable deterioration.

Adjunct Professor Robert Schweitzer (QUT) is a clinical and counselling psychologist. Previous appointments include Course Convenor of the postgraduate program in clinical psychology at QUT and Chair of the Queensland Board of the Psychology Board of Australia (PBA). He is currently in private practice and Course Convenor of the INSIGHT Psychodynamic Psychotherapy Registrar Program.

The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated. 

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