The Joys and Challenges of Clinical Social Work in Private Practice
Lynne Spevack, LCSW; Chairperson, NASW-NYC Private Practitioners Group; Psychotherapist; Practice Building Consultant
Editor’s Note: A previous version of this article appeared in Working in Social Work: The Real World Guild to Practice Settings by Jessica Rosenberg, PhD, LCSW, and is presented with permission from Routledge.
When I first ventured into private practice, I imagined that I was leaving behind the humdrum responsibilities of agency work. I soon found that I was mistaken. I came to learn that, in fact, being in private practice is in some ways like creating your own agency— one in which you are responsible for everything the agency had taken care of behind the scenes: marketing, billing, bookkeeping, determining policies and procedures, janitorial and clerical duties, among other things. Like many of my colleagues in agency practice, I bemoaned and resented the documentation requirements which I felt stole precious time from working with my clients. As a private practitioner, I’ve come to understand that while I have the authority to decide how to document my work, I also have the responsibility to ensure that I’m fulfilling my legal, ethical and professional obligations to maintain complete and accurate case records.
There are many other double-edged aspects to the autonomy of private practice work. One of the gravest responsibilities is that of caring for clients in crisis. I dare say that every private practice clinician encounters critical circumstances which necessitate decisive action, often at a moment’s notice. Should a suicidal client be hospitalized, or treated from home? Should parents be informed of a child’s drug use, or will that jeopardize the therapeutic alliance? Is a parent’s slap child abuse or corporal punishment, and should it be reported? There are many gray areas and many judgment calls, often followed by agonizing days or weeks before the situation is resolved. Although clinicians in various settings encounter such situations, agency-based social workers have the comfort of knowing that they are a part of a team of clinicians working together to make such staggering, life-altering decisions. Although private practitioners do consult with supervisors and peers when critical situations arise, ultimately the responsibility is ours alone. Clinicians practicing privately must have sufficient clinical training, experience, and skill to handle unexpected critical situations at the moment they arise, sometimes without any opportunity to consult with supervisors or colleagues.
A related issue is that of arranging for emergency coverage for clients. It’s my policy to encourage my clients to contact me any time of the day or night if the need arises (for example, if they are having thoughts of suicide). In such situations, I may have a distressed client call me on a daily basis until the crisis has subsided. But when the topic of emergency coverage arose in a professional meeting, one colleague was appalled at the idea of being “on call” every day and night for the rest of her career; her policy is to instruct such clients to contact a suicide hotline or hospital emergency room. With this, as with many of the decisions one makes in private practice, there is no standard policy or procedure to follow; the private practitioner has the freedom, and the responsibility, to decide for herself.
Many of my private practice colleagues complain of feeling isolated from their peers. Collegial contact is a windfall of agency work that we often take for granted. It takes some thought and effort for a private practitioner to carve out time from a busy schedule to take care of one’s own needs. Some private practitioners round out their workdays by teaching, supervising, or consulting. Similarly, full-time private practitioners must set aside time and money for supervision, continuing education, vacation and sick days. When one is not salaried, it’s tempting to scrimp on self-care and to devote every hour to income producing activities—although this would be a serious mistake.
Some social workers contemplating private practice mistakenly believe that their practice will have to be restricted to working with privileged white, wealthy and well-educated clients, often referred to as “the worried well.” I’ve found that my offices in Brooklyn and Manhattan draw clients of various races, religions, ethnicities and socio-economic status, as well as émigrés from other countries. Having a diverse caseload carries with it the responsibility to strive to be culturally sensitive and as knowledgeable as possible—a challenge in a city where 170 different languages are spoken by people who have come from all over the world.
Many social workers in private practice are interested in earning a good income and also committed to working with poor and working class clients. Many of us offer a sliding fee scale or reserve a portion of our caseload for low fee or pro bono cases. It’s my experience that one can maintain a viable and profitable private practice if this is done judiciously.
One of the greatest satisfactions of private practice is the ability to be available to my clients over the course of many years. Many of my clients begin therapy doing one piece of work and later return for help in tackling a new challenge. At termination, I encourage my clients to stay in touch, which many of them do. It’s satisfying for me and, I believe, a better arrangement for them.