Taking the Plunge

My close colleagues, my professional age-mates and I have been practicing long enough now – that many of us have had the pleasure of watching clients shift their labors from the couch to the therapist’s chair. When a client embraces the process as a profession, or a young supervisee launches a practice – there are new worlds of relatedness, identification, over-identification, projections, memories, and mirroring that open wide in the consultation room.

Many young therapists find themselves in a group, hospital or agency practice that fits their deepest need for collaboration, advancement, group work, institutional support and collective mission. Other clinicians, usually the more introverted, sometimes the more idealistic, find it extremely difficult to split their loyalties between the client and the institution.

I was one of the latter. I felt profoundly compromised by the necessary realities of agency practice and funding. The relationships I most treasured were with the people I was treating. Everything else – in-service trainings, never ending team-meetings, administratively focused supervision, new titles, hours spent strategizing about program development and implementation, bureaucratic gate-keeping, paperwork, and regulations – turned instantly to sand in my mouth, something to swallow down or spit out, on my way back to vital hours of client contact.

If what I loved was direct service with clients, my agency life-span was going to be short lived. Institutional advancement meant moving further and further away from client contact, taking on more administrative, programmatic, and teaching/supervisory duties. I didn’t want less client contact – I wanted more. This need, above all, drove me out into the world of full-time individual, autonomous practice.

But not without facing down giant waves of internal and external resistance: What made me think that I could start my own business? How audacious of me to presume that I had something to offer that would be worth anything in comparison to the resources of a large mental health agency? The biggest blocks in my path were unwittingly constructed by my colleagues who were happy in institutional practice:

“How will you ever pay for your own insurance?”
(I do)

“You won’t have any paid vacation or sick days! You’ll be on call 24 hours a day!”
(No one has ever contacted me after ten o’clock at night – even when I’ve offered)

“You’ll have to get on a managed care panel, and they pay so little, it won’t be worth it!”
(I’ve never accepted insurance)

Yet, those very same colleagues enthusiastically gave out my cards to their extended family, and friends of friends, and helped me build the practice they were certain was dangerous, foolish, and impossible for me to launch. It seemed, from their perspective that I was choosing to leap off of a crowded life-raft into a vast sea. Yet, once I dove in, they all wanted to see me safely reach the unseen shore.

I fretted for sometime that I would be abandoning the mission of social work: I would have to see only the “worried well” in a private practice, and be unable to help those with “real problems.” For myself, I have found ample opportunity to support people in poverty, fight for social justice, advocate for systemic change- from my own office. I set my own fees, see the insured, the uninsured, and those that choose not to use their insurance – maintaining a caseload balanced along the socio-economic continuum. I call out systemic biases when I see my clients perpetuating them or succumbing to them. I no longer have to collaborate with institutions that inadvertently harm or pathologize the very people they attempt to serve. I have a better chance of facing down and taking responsibility for my own shadow – than becoming complicit in hiding from the long dark shadows cast by many of our societal institutions.

Its true that there are cases that I cannot take on alone: that require a coordinated team, a containing space, a collective, universalizing, group experience or simply different level of service that I can provide. But I can refer those cases well and with integrity. I can take some case-managerial responsibility for everyone who contacts me, whether I can treat them or not, to make sure that I can directly connect them, or at least bring them several steps closer to the services that they do need.

I recognize the mark on the clinicians I’ve mentored who will eventually jump into the deep themselves:

A clear confident relationship to their own intuition.

A belief in the generativity of their own personal psychotherapy and a warm mutually admiring relationship with their own private therapist.

The ability to self-structure.

A hunger for individual, personal growth over approval or admiration.

A general skepticism with regard authority.

A willingness to confront systems and individuals with information they might not want to hear.

Some unique personal history, trauma, or narrative burden that places them outside of the mainstream, coupled with a drive to make that personal burden into a tool in their own lives and the lives of others.

And a highly developed capacity to be alone.

Some fear the “isolation” of autonomous practice – I suspect that those truly called to the work rarely feel alone at all – but instead find creative synergy and deep working partnerships with each client that crosses their office threshold. I work on high-stakes projects with twenty to thirty amazing collaborators, who, for the most part, I feel deeply partnered by, who teach me and inspire me, challenge me and confront me and drive my growth every week. When, exactly am I isolated?

True, sometimes a therapeutic partnership struggles to get off the ground, deteriorates, seems to fail to accomplish what it set out to do, or troublesome flaws in the contract are uncovered – and then it is absolutely necessary to have access to professional advisors, supervisors, mentors, peers and teachers to help you get back on track.

I encourage all therapists who are thinking of transitioning to private practice to seek out a private supervisor, a peer-supervision group, and/or a reading group so that there are established supervisory relationships already in place- well before the first client calls. It helps to set your intention, have a sense of preparedness, and chart your course through the open seas.

And it will give you something to do while you are waiting for the phone to ring.

It may take some exploration before you find a good fit – you want to find someone who has similar clinical values to your own, yet, may still use an approach quite different from your own (or your therapist’s).

Ideally it will be someone you feel safe with. A mentor that understands that the boundary between supervision and therapy is simultaneously distinct and porous, as our own wounds, hopes and fears will be activated by the work. Part of the function of supervisory support is to help us discern how our old injuries, private pain and blind spots are being activated in the room. A good private supervisor will not merely watch over your cases for quality assurance and monitor your work – but they will take on the job of nurturing your professional identity as it grows steadily out of your own heart.

There will be times in the work, especially early on, when you and a client will be innocently, intuitively wandering down some new path of inquiry together – and suddenly you will trip over a bleeding wound or fall into a grief hole of your own that you never even knew was there. Shit gets stirred up, as they say.

After sessions like those, sitting in supervision, trying to sort my own pain from my client’s my supervisor would say: “Perhaps you are your most important patient for the moment?” She wouldn’t open things further – knowing that I had my own therapy for that – but she wouldn’t step back either – helping me to hold and acknowledge the feeling as it emerged. Then, as it was integrated and digested, we would find a way together to make it of use in the very therapy that had activated it.

The logistics of getting started often seem daunting – but usually just take some research and leg work. Licensure criteria need to be met, malpractice insurance purchased, business cards printed. Finding a space for a few hours a week to begin with, establishing some on-line presence through a web site and therapy referral directories are necessary tasks, as well as spreading the word among your colleagues, friends, family, doctors, service providers.

How you are going to introduce yourself the world, what you are going to say that you do is a separate process. There are many many people on line and in the therapeutic community that can assist you in marketing your practice. Often the advice is to define your niche, your area of specialization, and I know that works well and is a valuable necessity for many practitioners.

As a generalist, who deeply enjoys having a diverse practice – I will throw a small but respectful wrench into that construct:

It is important to know your strengths and your professional parameters – but I have seen many people turn their specialization into a limitation. Practice preferences held too too tightly end up excluding cases you won’t see rather than drawing in the ones you will. Don’t underestimate the satisfactions of forging a connection to someone outside of your known tribe. Skills built over time in one area can be enormously powerful in another.

Save enough space to surprise yourself. Leave some room in your definition of your work so that your practice can make your life larger, and the current can carry you to lands you would never see otherwise.

copyright © 2012
All rights reserved Martha Crawford

20 responses

  1. Pingback: An adoptee operated mental health practice/clinic/facility in Minnesota..? | Land of Gazillion Adoptees

  2. Oh, thanks for replying so quickly. I just wanted to say I really enjoy reading you blog (especially as I currently find myself torn in different directions regarding my next career move and your blog’s full of really useful ideas!).

  3. Thank you for this. As with all of your posts, I find this very thoughtful and to the point. I particularly felt that your ‘criteria’ for taking the plunge is right on the money. It also applies to the qualities that make for good therapy, and are seldom articulated so clearly and simply.

  4. Thanks very much.

    Strangely – I had several clinical social workers and psychologists among my first private clients. I realized in writing this that I have watched over – either as supervisees or as patients – almost 20 clinicians as they started their practices.
    It’s been illuminating, through identifying with their process, to revisit and recommit to my own choices, and notice a few things that we all have in common.

    Thanks for your kind comment

    M.

  5. Hi Martha– I had forgotten what it was like to start my practice; you remind me of some of the important ways we have to support ourselves– being connected to others, either by way of seeking out mentors, and by being connected to peers. So valuable–
    thanks–
    Robin

  6. Wow, I really enjoyed this. I have not even decided on my grad school yet but much of this still really resonated with me. I do feel that a private practice is my calling and I loved your list of “recognizable marks” that you see on clinicians who you know will take the plunge. This piece reassured me that I’m on the right path (well, the only path, truthfully) for me.

  7. I’m glad that you found it helpful and that it speaks to your aspirations.

    I spent abut 3 &1/2 years in agency practice, and it was in many ways the most intense part of my training – I would never wish it away, it changed me in ways I am forever grateful for, and it was an amazing apprenticeship.

    I recommend that, when its feasible, people start in public service and open their eyes to experiences that they might not have otherwise.

    Good luck with prepping for grad school!
    M.

  8. I am definitely looking forward to whatever I end up doing before I am able to start my own practice for exactly the reasons you wrote. I feel it will be a necessary experience and will also get me (way) out of my comfort zone!

  9. Thanks, Martha, for another great post and for advocating a stint in public service. I so agree! My years in non-profit agencies and institutions were like another stint in grad school! The lessons learned there were eye opening on so many levels and continue to inform my work today.

    While reading your words, I realized that I, too, prefer my supervisees to have experienced life from the margins and to have embraced some of the challenges and recognized some of the advantages that come from those edges. Now that you’ve floated that up into my awareness and I’ve named it, I’ll be claiming that for sure.

    And, as for your reference to nicheing a practice . . . the use of nicheing, in my opinion, is a great way to focus your resources i.e. time and money when marketing a practice. However, it doesn’t need to restrict who therapist sees or what s/he offers in practice. It just gives potential referral sources a way to remember and talk about you. (Half my practice is traditional clinical work; the other half is coaching / consulting with therapists to help them build strong private practices.)

    Thanks, again, for sharing so openly. Hope you’re planning on turning this blog into a book. If so . . . I’m buying!

  10. Thank you Tamara for your kind and thoughtful comments

    Nicheing is a great tool when held lightly – and it is part of the process of consilidating a professional identity, defining who you are, and what you do in the world.

    I’d love to figure out how to translate all this into a book at some point – but the amount of research into that process, and my limited technical skills means I have to find the time and space to take that on! Thanks for the encouragement!

    best,

    Martha

  11. Martha, I’ve just stumbled across your marvellous blog. I’m a voluntary therapist, building client hours whilst I study towards accreditation. Your frustration at the bureaucracy within agencies (not to mention uncertainty about funding) resonated with me – and I’m a newbie! I have a fantasy about working in private practice some years down the road, but at this stage of my training, your ‘criteria’ reflect my areas for growth. I wonder where I’ll be after 12 years of experience…? 🙂

  12. I’m so glad you have found it helpful – as I write, I often imagine I am writing for those who are studying this process, for students, for supervisees, for my younger professional self – I’m very glad that it is reaching folks entering this amazing field.

    Thanks for your kind comments and for reading.

    Martha

  13. This was timely for me to read as a client. My former therapist was wonderful but our time was ended because of her agency’s policies. I realize there are many reasons why things happen the way they do but reading this has clarified a number of things I’ve been thinking concerning what has happened.

  14. It’s true there are many policies and procedures that are generated by state, federal, medical associations and insurance regulations, as well as by the agencies themselves that can create treatment barriers for clients and for therapists

    I’m glad this was helpful for you.

    M.

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