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Saturday, January 1

Private Practice: A View from the Trenches

Tom Kenemore, PhD, LCSW

Two stereotypes about private practice in Social Work emerge repeatedly. One is that private practitioners are able to compete in the mental health marketplace and that they are the largest group of providers of mental health service in the nation. They deserve legitimate recognition for their mental health expertise and their unique psycho-social perspective. The rationale for their legitimacy includes an argument that they provide access to clinical services to a vast number of working class and middle class individuals who would otherwise not utilize services. Mary Richmond, discussing the potential for private practice in 1922, remarked that “. . . the skill here described can be utilized quite as well in the homes of the rich as in those of the poor, that in the one as in the other, personality can be thwarted and retarded, developed and enriched.” (1) Their historically recent successful struggles for parity in the mental health service field indicate their legitimacy and justify their recognition. Achievement of third-party-payment legislation and licensure, nation-wide, is largely attributed to this group’s efforts. The American Board of Examiners in Clinical Social Work, the Clinical Social Work Federation and NASW (though representing a much broader constituency) convey this message.

 The second stereotype characterizes social work practitioners as leading social workers’ abandonment of their traditional mission: “. . . to help poor people, to improve community life, and to solve difficult social problems.” (2) In a scathing criticism of the directions Social Work has taken, Harry Specht and Mark Courtney have suggested that “... the growing influence of private practitioners within the profession has contributed to the tendency of the profession ... to use more of its political clout to push for licensure and vendorship privileges for clinicians than for services to the needy or for better working conditions for public agency social workers.” (3) The message here is that private practitioners are abandoning their legitimate clients, abandoning their social work professional identities, and diverting essential resources away from public service initiatives.

Who are private practice social workers? What are they doing? What are their experiences? How do they view the future? While stereotypes tend to contain a grain of truth, they ordinarily, and often purposively, do not accurately reflect the phenomena being described. It occurred to me that going to the trenches to get some impressions from social workers who are engaged in a significant way in developing and maintaining a private practice might provide an “insider’s” perspective on their day-to-day experiences. The impressions that follow admittedly reflect my own biases as an educator and practitioner and are in no way presented as representing private practitioners overall nor do they result from systematic data collection and analysis. I selected a few practitioners who clearly do not fit either stereotype well and who are passionate and articulate about their private practices. I hope that my informal conversations with the following area social workers shed some light on the questions asked above.

Giesela Grumbach, LCSW and her colleague Yolanda Jordan, LCSW have developed a private practice which provides social services to the African American community on the south side of Chicago. Clearly identifying themselves as social workers, they have developed contracts with social service agencies and work to help families broken by involvement in the social welfare system re-unify. They are committed to “hanging in there” with parents who have had their children taken away until they can get their kids back. Their services provide a continuity that is often unavailable with the often disjointed service delivery in child welfare. Their practice focus ensures that the interests of the families are attended to. They do get some private pay clients who hear about their specialization by word of mouth. They necessarily use a sliding-fee scale to accommodate their clients’ ability to pay.

Giesela currently spends less of her time with the practice due to other professional commitments. She serves as an Interim Unit Leader for the University of Illinois Extension Program. She notes that the demands of private practice include dealing with insurance companies which can be a “big headache.” Also, negotiating with the foster care system which is a big part of the practice can be quite challenging. Needing to deal with social service agencies and needing to educate workers about the perspective of the parents she works with can be daunting. Often agency workers are not involved in the change process and only become invested in a particular client before a court date. Providing in-home therapy to clients is often necessary and can be challenging. Giesela enjoys working with client systems and being involved in the change process. She views furnishing a “holding relationship” with her clients, who often don’t see hope, as an essential component of her approach. She describes herself as a\ generalist practitioner incorporating therapy, negotiation with systems, advocacy and supervision. There is a constant need to improve and update a mastery of practice skills. Continuing education is a must. Giesela sees private practice as constantly expanding with new arenas opening up to the profession. In particular, she sees a growing acceptance of therapy in the African American community.

Yolanda’s part in the practice is close to full-time. Early in her career she made a decision to pursue private practice because she knew she wanted to “be on my own without an agency governing over me.” She recognized that organizations have policies and methods that may not fit the clients she wanted to work with. “With African American clients, you have to think outside the box and be creative regarding ethnicity and values.” She emphasizes her post-graduate training at the Family Institute in Chicago as influencing her practice approach. She utilizes systems theory to understand families and works in a variety of ways with clients who are primarily working class African Americans. She engages in developmental work with young adult and middle-aged women and often finds herself helping clients with significant relationship issues resulting from early trauma. Work with families in the child welfare system includes both work with parents toward re-unification and work with children. She has incorporated Christian counseling with some of the couples she works with recognizing the importance of spiritual beliefs and church participation in the lives of many of her clients. She has worked with Muslim, Catholic, and Baptist affiliated clients. This specialization has enabled her to receive referrals from payors who list her as providing spiritual counseling. She also incorporates EAP work in her practice and has contracts with some private firms. Yolanda enjoys working with people and knowing she can help improve their lives. She is especially happy when clients have a “light bulb” experience, and are then able to move forward with significant changes. She is pleased when she gets referrals from former clients as it confirms that her work is valued. She enjoys working with the Department of Children and Family Services (DCFS) providing knowledge and resources both to her clients and to the public agency. Yolanda notes that the negatives of private practice include “overwork” involving availability most evenings for DCFS clients and the persistence of a waiting list. She also frequently struggles with countertransference issues because many of her clients are in their 30s and have a great deal in common with her. Other challenges include difficulties helping mentally ill clients comply with medication protocols and the experience of sometimes having clients abruptly stop treatment. Yolanda believes the future of private practice looks hopeful though social workers need better reimbursement and many clients lack health insurance or otherwise can’t afford service. She is working on developing a program for adolescent girls involving mentorship and “Rites of Passage” groups.

Nathan Dougal, LCSW has recently initiated a private practice. After graduating, he worked at a social service agency serving primarily Latino and African American youth that maintained contractual arrangements with a community mental health agency and a therapeutic school while establishing his practice. His specialty is psychoanalytically informed practice with adults. He has completed an adult psychotherapy training program at the Institute for Psychoanalysis. Nathan also does ongoing work with ex-offenders struggling with reentry after long term incarceration, poor Latino kids in Cicero, teens at an alternative high school and kids from multi-problem families. Nathan, who is involved in a great deal of networking, believes it is important for a private practitioner to develop a niche and that one’s niche should be based on a strong interest as well as expertise. He sees practice as integrating and balancing ethical and business principles. The pleasures Nathan identifies include the opportunity to be involved in people’s fascinating stories and have the freedom to make responsible choices about how to practice and with whom. He believes a good therapist will recognize that therapists and clients have much in common and that therapy is about “being the author of one’s own life.” He believes there is a self-selection process in private practice based on the long term commitment required which weeds out people who can’t make a serious investment in seeing the therapy process through. He thinks the experience of being a client helps the therapist recognize and sustain the necessary commitment and interest. Like Yolanda, he thinks private practice provides a venue for creative development of one’s professional career compared with work in an organization. His leadership of a mentor group for the Illinois Society for Clinical Social Work exposes him to social workers who are contemplating development of a private practice. His contact suggests that the first three-to-five years after graduation are about “paying dues,” getting training, and gaining the confidence to initiate a practice. A big challenge of private practice is the recognition that “I’m in charge of making it happen.” It requires constant awareness and energy and a business perspective. He particularly enjoys helping individuals and families create more meaningful lives.

Virginia McDonough, LCSW is an established private practitioner in Naperville. She has been in practice fifteen years. In her view, people today expect to have coverage for mental health services. She believes the message out in the community is that people can get help and are responsible to get help when they need it. What she loves most about private practice is the freedom it= provides. Besides providing therapy services, she also works as a mediator. She describes a positive tension between consumers of services (who are expecting increasing expertise) and private practitioners (who must stay abreast of techniques and approaches that are most effective) which in her experience makes private practitioners who stay in business quite effective. Her practice is client-centered. She has experienced her own growth through gaining knowledge, skills, and incorporating spirituality work— and is drawn to share her knowledge with others. Her own growth is a primary reference for believing she can help others grow. Virginia works with people across the income spectrum and utilizes a sliding fee scale in her practice. She believes social workers are particularly well oriented for private practice because they incorporate a holistic perspective. She, like Mary Richmond, believes that social work skills, expertise and perspective are needed “across the spectrum of income and social class.”

 It appears that social work private practice is alive and well. The American Board of Examiners in

Clinical Social Work (a national organization offering an advanced credential in clinical social work practice) indicates that 75% of its credentialed holders report that they are engaged in private practice (part-time or full-time). The NASW Illinois Chapter reports that 52% of its members are in private practice (part-time or full-time). Sharon Williams, President of the Illinois Society for Clinical Social Work, sees private practice as a growth area for social workers and indicates that private practitioners are faced with very challenging issues related to managed care. She also believes that continuing education is a necessity for effective practice.

The examples presented here are selected to illustrate the notion that social workers in private practice are more complex and diverse than either stereotype suggests. They have not necessarily abandoned the poor and underserved. They also do not necessarily fit neatly into the category of “psychotherapist treating mental illness.” These representative practitioners appear to be quite diversified in their interests, approaches, and beliefs. What they seem to have in common is an intense involvement in their work, a desire and ability to operate independently, a realistic recognition of the challenges of operating a small business and a need to be creative. Discovering more about private practitioners, how they perceive and experience practice and what they actually do, might help us overcome the limiting stereotypes that have come to dominate our discussions. It might also provide an opportunity for the private practitioners to contribute their knowledge, experience and expertise to the profession.

Thomas K. Kenemore, Ph.D., L.C.S.W. is on the faculty of Chicago State University. He is currently engaged in a qualitative study of the experiences of ex-offenders. He is editor of the Child & Adolescent Social Work Journal, an internationally subscribed, practice-oriented professional journal, emphasizing research, cultural diversity, diversification of practice approaches, and their application with children, adolescents, and their families. He maintains a private practice, and provides clinical and organizational consultation to service agencies.

He is President Emeritus of the Institute for Clinical Social Work in Chicago, and his background also includes work at higher education institutions (Loyola University of Chicago/School of Social Work, Chicago School for Professional Psychology) and social service organizations (Children’s Home & Aid Society of Illinois, Jewish Family and Community Service).

He also currently serves as a Vice President on the American Board of Examiners in Clinical Social Work, an advanced credentialing organization; and is the Board Representative for the Northeastern District of the Illinois Chapter of the National Association of Social Workers.

Posted on 01/01/05 at 02:32 PM

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