Contemporary issues in private practice: spotlight on the self-employed mental health counselor.
Welcome to this special edition of the Journal of Mental Health Counseling (JMHC), Contemporary Issues in Private Practice. As a long-term mental health counselor (MHC) in private practice, I have taken great pleasure in collaborating with the JMHC and its editor, Quinn Pearson. Pearson conceived and promoted the idea for this special issue not only as a contribution to the literature but also as a service to the nearly 7,000 members of the American Mental Health Counselors Association (AMHCA), the majority of whom identify as private practitioners (W. M. Hamilton, personal communication, February 20, 2013).
The selection of private practice as a journal focus seems to be unique. A review of the last 10 years of journals of other associations, including the bundle of American Psychological Association (APA) journals, Social Work from the National Association of Social Workers (NASW), and The Journal of Marital & Family Therapy from the American Association of Marriage and Family Therapy (AAMFT) revealed that none had devoted an entire issue to the topic of private practice, and very few single articles were about private practice. Only a single article among all the APA journals was devoted to private practice, though there were many special issues on other topics; though there were articles devoted to executive coaching, consultation, and psychotherapy, they did not specify a private practice setting (APA, 2013b). In a review of the past 10 years of Social Work tables of contents, only one article was devoted exclusively to the issues of private practice social workers (i.e., Green, Baskind, Mustian, Reed, & Taylor, 2007). While AAMFT's Journal of Marital & Family Therapy published many articles for and about "therapists," presumably applying to couples and family therapists in a variety of settings (treatment centers, hospitals, faith-based organizations, military settings, and private practice, yet not exclusively for private practitioners) only one article (i.e., Crane & Payne, 2009) could be found directly related to private practice, in this case managed care utilization. It is possible that a more comprehensive study that encompassed a variety of other journals would only reinforce the assertion that there have been very few studies related to private counseling practice.
CRITICAL THINKERS AND CLINICAL THINKERS
In conversations with Pearson, the editor acknowledged the dichotomy between the context of researchers, academicians, and educators and that of clinicians and practitioners. Historically, researchers and clinicians have struggled to work collaboratively, to merge the best of their resources. The resources of researchers include labs, personnel, incentives, revenue streams, and expertise in advanced research design. The resources of clinicians include abundant access to study participants and field-trial data and ample clinical expertise. Clinician resources, however, do not synchronize with researcher assets in that productivity in clinical settings is incentivized by hourly units of services provided, behavioral improvements in caseload, symptom reduction, revenue earned per session, capitated services (incentives for less lengthy treatment), and client satisfaction. Work conditions related to privacy, confidentiality, and human participant issues create barriers to research in the clinical setting, and MHCs receive little or no employment-specific credit for academic publications. Funding scarcity and potential disruption to essential delivery of services can be costly impediments to site-based research. There seem to be more scholarly articles published about the need to merge the scholarly research with applied settings than there are on private practice (Abdul-adil et al., 2010; Brannan, 2003; Curtis, Lenze, Hawley, & Osborne, 2009; Hohmann & Shear, 2002; Jensen & Foster, 2010; Joyce, Wolfaardt, Sribney, & Aylwin, 2006; March et al., 2005; Miller et al., 2010; Oka & Whiting, 2012; Santos, Henggeler, Burns, Arana, & Meeisler, 1995; Wells, 1999; Zarin, Pincus, West, & McIntyre, 1997).
This research versus "real world" dichotomy could also be thought of as the "critical thinker versus clinical thinker" condition. While both communities use critical and clinical thinking skills, academia lends itself more to knowledge-enhancing critical thinking while the real world of abundant anecdotal data deepens the clinical thinking skills of MHCs on a daily, even hourly, basis. Perhaps this special issue can function as a symbol of alliance between the two groups. As a clinician, my appreciation goes to Pearson for extending the JMHC's scholarly focus to private practitioners.
WHO ARE PRIVATE PRACTITIONERS?
Some readers may be seasoned full-time psychotherapists for whom private practice is their exclusive source of livelihood. Others may be new practitioners just setting up offices or considering doing so. Some may be solo practitioners and others in large group practices. Some may be multiple-function MHCs with part-time private practices along with other employment or more secure income sources. Some private practices function within other infrastructures, as with a practice affiliated with a physician's office or within a faith-based organization. Some clinicians may identify as providers of counseling exclusively, and others may diversify their direct service with consulting, executive coaching, and other services considered adjuvant to the classic provision of psychotherapy. Sole proprietorships, limited liability corporations, professional corporations, partner/associates groups, and independent practice associations are others of the many ways MHCs may design their practices. Because there are so many possible private practice arrangements, it is difficult to ascertain how many private practices or practitioners there are in the United States.
While AMHCA membership is primarily comprised of private practitioners (Executive Director W. M. Hamilton, personal communication, February 20, 2013), it is difficult to ascertain the true scope of private practice as an employment sector or its economic impact. Private practitioners may identify as such across many disciplines, including mental health counseling, psychology, social work, couples and family therapy, psychiatric nursing, psychiatry, and allied specialties such as art and music therapy. Many sources reference the numbers of licensed mental health professionals, but although all private practitioners are licensed, not all those licensed work in private practice. Estimates of the numbers of total mental health professionals are as follows: licensed professional counselors, 120,000 (American Counseling Association [ACA], 2011); licensed clinical psychologists, from 93,000 (APA Center for Workforce Studies, 2013a) and 174,000 (U.S. Department of Labor, 2012); licensed clinical social workers, from 101,995 (NASW, 2011) and 202,924 (ACA, 2011) up to 310,000 (NASW, 2006); licensed couples and family therapists, from 50,000 (AAMFT, 2013) to 54,785 (ACA, 2011); and psychiatric/mental health nurse practitioners 22,471 (U.S. Department of Health and Human Services Health Resources and Services Administration, 2010). Except for NASW (2011), these sources do not clarify how many licensees identify as private practitioners. It has been suggested that 30% to 60% of NASW members or licensees identify as private practitioners, but that is speculation (Psychology Career Center, 2013).
Organizations such as the National Board for Certified Counselors and Affiliates, Inc. (P. Leary, personal communication, March 23, 2013) and the American Association of State Counseling Boards do not maintain easily accessible data about how many certified counselors or licensees work in private practice (P. Hard, personal communication, March 23, 2012). Though the Occupational Outlook Handbook (U.S. Department of Labor, 2012) indicates that the mental health field is expected to grow, it says nothing about private practice employment. Better sources, though limited, might be private insurance companies that maintain panels of approved providers, but that would reflect only practitioners who agree to participate or are approved to be on panels, excluding those who remain client-fee-for-service only or who serve on some but not all panels. Other sources that may reflect the breadth of private practice employment are online Therapist Locator services offered by professional associations, such as AMHCA and AAMFT, and online fee-for-listing promoters, such as Psychology Today, yet these may not cover well-established clinicians who do not need this type of marketing because of full caseloads or person-to-person referrals. Identifying and isolating comprehensive and accurate data about the impact of private practice in terms of sheer numbers and economics would be a good research question, though beyond the scope of this article. The NASW (2006) website has an impressive section about social worker employment through its Center for Workforce Studies. Perhaps the counseling field will one day replicate this model or collaborate with its sister disciplines or the Department of Labor to make private practice data more complete.
REFLECTIONS ON THE RECENT PAST AND THE FUTURE OF PRIVATE PRACTICE
Considering the substantial advantages and disadvantages, moving into private practice should be carefully analyzed. The advantages are clear: freedom to be the primary decision-maker; choice in work location/hours/ fees/projects; ability to work from a preferred theoretical approach; and an elective decision by both client and clinician to work together. These need to be weighed against the disadvantages: complete responsibility for all financial matters (overhead, insurance policies, furnishings, equipment, continuing education, fees for extra services such as billing, accounting, administrative work, etc.); inconsistent revenue streams; and financial barriers for uninsured or under-resourced clients to access service. However, there is no need to despair. There are plentiful resources for MHCs wishing to begin or build up their private practices (e.g., Barry, 2005; Davis, 1996; Grand, 2004; Grodzki, 2003, 2000; Hunt, 2005; Kolt, 1999; Lawless, 1997; Pipal, 1997; Steele, 2003; Stout & Grand, 2006).
I remember the advent of managed care, and the compelling fears it brought that counselor livelihoods would be consigned to administrative assistants at the other end of the phone making decisions about clinical care and thus diminishing, wholesale, the need for and the locus of control for mental health counseling. At that time, AMHCA was squarely confronting the systemic change to the new paradigm; it provided access to healthcare experts like Jeri Davis (1996), who empowered MHCs to claim their rightful place in the landscape of managed care systems and mental health service delivery. From another perspective, Janet Pipal (1997; and as cited in Weiss, 2004, and Ackley, 1995) challenged MHC participation in managed care or at best elucidated the choice of whether to be involved with managed care with decrees about protecting practitioners' sanity and the merits of determining one's own clinical authority.
Now, as then, the numerous mental health disciplines continue to sort through questions about whether "to be or not to be a managed care provider" while also finding ways to qualify or compete with the professional merits of other disciplines. What I have found instructive in the last 20-plus years has been the realization that where there are humans, there will be problems. While infrastructures designed to respond to mental health needs may change with the seasons, there seems to be no end to the problems of members of society. Sadly, there always will be far too many young children who grow up to be adult children of (fill in the addiction), or survivors of domestic violence or other abuses; there will always he natural disasters that bring loss and trauma; there will always be accidents, illness, death, tragedies, and grief; some relationships will invariably encounter conflicts or betrayals, and families will experience vulnerabilily; there are likely to always be symptoms to manage, addictions from which to recover; there will always be conflict and, dare it be said, even wars. Mental health professionals will always be in demand.
What may change is how the mental health field organizes and delivers care. The changes are likely to be ever-evolving, multi-factorial, and progressive. Private practices will not be the only venue, nor will schools, jails, or community centers be the only dispensaries of mental health services. The profession will grapple with economic, political, geopolitical, social justice-related, and technology-related dimensions of how best to get care to persons in need while also protecting their livelihoods. Private practitioners and community mental health personnel may find themselves in a position to innovate partnerships that bridge gaps between the haves and the have-nots. For example, in my own community, both a large private practice and a large nonprofit mental health agency have adopted the progressive strategy of "purchasing" several "beds" in a local hospital psychiatric unit to ensure access to inpatient care for their own patients. Private practitioners may contract to give specialized clinical care to schools, for example, by taking counseling oi1 the road to sites where youth need therapy. MHCs might partner in providing more varied and accessible group counseling options more affordably.
The changing climate of healthcare and reform will likely impact service delivery. Technology gives promise of more options for connecting with underserved communities in remote areas and facilitating the care of persons with differing abilities or with limited provisions so that they can "attend therapy" electronically. Such developments make a very strong case for close collaboration between critical thinkers and clinical thinkers that will find its way into the professional literature.
WELCOME TO THE SPECIAL ISSUE: CONTEMPORARY ISSUES IN PRIVATE PRACTICE
My message of seeking new possibilities is consistent with the selection of articles from the many proposals welcomed for this special issue. We might adapt to changing economic or market conditions by diversifying our practices with multiple revenue streams based on our life circumstances, skills sets, and interest areas (Nener Colburn, 2013). Whether or not the field of mental health is ready for technology, our consumers increasingly are native speakers of the language, and we are becoming bilingual with respect to how, if, when, and why practitioners must adapt to digital and alternative electronic means of communication (Sude, 2013). With the numbers of persons in rural settings considered to be underserved by mental health services, or even metaphorically as we increasingly live in a world without walls (or county lines), the observations of Cohn and Hasting (2013) on rural practice are relevant, particularly their insight into the mental health needs of rural populations. And the phrase old skin, new wine comes to mind when reflecting on classic and enduring ethical practices as they apply to both conventional and changing private practice settings (Brennan, 2013).
This introductory article would not be complete without a heart-felt thank you to the issue's contributors, and also to the many who submitted proposals for consideration. The special edition was announced in the summer of 2012, and Quinn Pearson and I received over 20 proposals for consideration. Of those, six were accepted, and four emerged as publication-ready in time for the special edition. Thanks also to the subject matter experts who agreed to review manuscripts. And thank you, readers, for inviting some of these thoughts into your awareness, as you continue, wind down, or begin your private practice adventure.
A FINAL NOTE
To every JMHC reader who identifies as a private practitioner, long-term or new, I wish you well. In spite of the challenges that private practice presents, the opportunities it offers for a deeply meaningful and gratifying professional life can eclipse them. While the expenses may be high and the earning potential unpredictable, there are many unquantifiable benefits associated with the identity of private practitioner. These dividends may be intangible, or indescribable, but many colleagues consider them to be bonuses to conventional remuneration and fringe benefits.
What are some of the qualitative rewards? It is a privilege to walk with persons in their suffering, to sit for hours at a time with the magic and the mystery of the human condition, to be continually intellectually stimulated and emotionally stirred, to be energized when clients make strides or experience victories over their circumstances, and to regularly find joy in one's work. May everyone have such an impressive benefits package in their life's work.
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Ackley, D. C. (1999). Breaking free of managed care a step-by-step guide to regaining control of your practice. New York, NY: The Guilford Press.
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Brannan, A. M. (2003). Ensuring effective mental health treatment in real-world settings and the critical role of families. Journal of Child and Family Studies, 12, 1-10.
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Grodzki, L. (2003). Twelve months to your ideal private practice: A workbook. New York, NY: W. W. Norton.
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Lawless, L. L. (1997). How to build and market your mental health practice. New York, NY: John Wiley & Sons.
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Neuer Colburn, A. A. (2013). Endless possibilities: Diversifying service options in private practice. Journal of Mental Health Counseling, 35, 198-210.
Oka, M., & Whiting, J. (2013). Bridging the clinician/researcher gap with systemic research: The case for process research, dyadic, and sequential analysis. Journal of Marital & Family Therapy, 39, 17-27.
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Stout, C. E., & Grand, L. C. (2006). Getting started in private practice: The complete guide to building your mental health private practice. Hoboken, NJ: John Wiley & Sons.
Sude, M. E. (2013). Text messaging and private practice: Ethical challenges and guidelines for developing personal best practices. Journal of Mental Health Counseling, 35, 211-227.
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Judith A. Harrington is in fulltime private practice in Birmingham, Alabama. Correspondence about this article should be sent to Dr. Judith A. Harrington, 2330 Highland Avenue South, Birmingham, AL, 35205. Email: firstname.lastname@example.org.
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|Author:||Harrington, Judith A.|
|Publication:||Journal of Mental Health Counseling|
|Date:||Jul 1, 2013|
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