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?”
“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