Resistance to Private Practice
by Deborah Davies
Over the last couple of years I have become aware of how unprepared many newly-trained therapists feel when they embark on establishing their own practice. When I was asked by several newly-qualified therapists to pass on advice as to how they might build a successful private practice, I was happy to offer a few tips – not anything earth-shattering but nuts and bolts suggestions along the lines of perhaps considering creating a website and where they might find inexpensive business cards which they could take to conferences and the like. Later, when I would see these colleagues, I would ask how their work was going. I found that for some of them the advice had proven helpful and for others not at all. Given that my suggestions remained standard I found myself wondering what was going on. The therapists I was talking to were, as far as I knew, equally competent and their practices were in the same geographic area of London. So why were some able to create a growing practice and others struggling to keep a constant base of two or three clients?
As I considered these questions I found myself remembering my time as a trainee working at a placement at a leading London hospital. It was a dynamic learning environment and, with the exception of the three paid staff, the rest of the team – six to ten therapists (this number has grown since I left) – were unpaid and expected to commit to a full day once-a-week and an additional half day every three months for a group meeting. If you come from a financially secure environment this loss of potential earning is not necessarily a problem, but during my time at the hospital I witnessed the distress of those who carried the desire to devote themselves to others coming up against the real constraints of paying a mortgage and earning a living. In one particular case I saw a good therapist being asked to compromise on her bread-and-butter job to such a degree that she had to make a choice either to support herself financially or leave the placement. There was, surprisingly, no flexibility as far as the leader of the team was concerned. This promising therapist, whose working-class background meant she had no cushion in her bank account, was unable to finish and qualify. Already I was getting an impression of how our dedication to our work can be challenged by the necessity to look after our own needs. Were the therapists who were forced by circumstances to put their financial needs first being selected-out in a Darwinian survival-of-the-fittest set-up created by the expectations of a largely middle-class and idealistic psychotherapy community?
From the outset, trainee therapists working towards accreditation are called upon to relegate their financial considerations to a low position on their hierarchy of needs. Much of the NHS, whether it be a large hospital or a GP practice, is supplementing its shrinking resources by having trainee psychotherapists work/volunteer for them. This is mostly a good trade-off as I feel the only way to become a truly competent therapist is to see as many and as varied a population of clients as possible before qualifying. But I remember being left with the feeling that the compassion and empathy that we are encouraged to feel towards our clients is sometimes not extended to ourselves. Are we being trained to over-ride our own needs? What expectations might the psychotherapy community be re-enacting for the training therapist? Is the compensated Oral personality and grandiose nature of the therapist being encouraged? The generally accepted assumption is that, unlike many other professions, being a therapist is a vocation. This is especially true within the humanistic model; intuitively we feel positive regard and acceptance should be given without condition (ie without charging). As a result there is a not-so-unconscious discomfort when we hand over an invoice at the end of the month; it doesn’t feel right to charge for something that rises spontaneously from us. I can remember occasions when I have felt like a prostitute selling her time. Perhaps, in defence of such an analogy, we try to imitate the opposite, committing ourselves if not to a vow of poverty as our brothers in religious orders might do but to something that is not so different in the moral expectation.
Another environmental attitude, “ …our deep concern that private practice should be necessary at all.” has been articulated by Michael Jacobs and Moira Walker (cited in Syme, 1994:5). They expressed a belief that counselling should only rightfully be practiced through the NHS or charities and put forward their argument as follows: because people who seek therapy are desperate through no fault of their own, help should be provided free of cost. I find this point of view interesting but also potentially problematic since it treats the client as a passive recipient, even a victim. I imagine that Jacobs and Walker would agree that if the only therapy provided were through the NHS or charities, there would be a need to ensure that it was provided on an open-ended basis and not limited to the short term (6/12, maybe 21 sessions) currently on offer. This of course would incur vast costs and would virtually eliminate private practice that, after all, arose out of a need that was not being met within the system.
Quiet moral expectation informs us all; I wonder however whether some therapists are perhaps immobilized by the belief that to set up a private practice is to pursue self-interest and personal gain. Could part of the problem for some newly-trained therapists be that the therapeutic community trains (and perhaps even selects) us to set aside our needs to such an extent that we feel it is wrong to promote our practices? I think I can safely say that those of us who have chosen to become therapists, are already inclined to take care of others; while I believe that such care is indeed part of our work, the concern I am expressing here is about how we support the therapist who wants to form a private practice. Have we created a class system which only allows a privileged group of people, who are not overly concerned by the costs of therapy, unpaid work and necessary training, to become therapists?
If a therapist believes she can forego her own needs, what sort of expectation does she set up in the client? When our clients leave the therapy session what sort of intimate relationship will they be able to build if they have sat with a therapist who has not brought him or her self into the session? One particularly powerful moment I experienced with a narcissistic client of mine arose from her casual approach to whether or not she paid me that week; my careful explanation that I had needs which were not necessarily the same as hers, presented her with a difficult but important consideration, that of separateness and difference. She recoiled in pain as she slowly recognized that in this area she was still, child-like, expecting my needs to be the same as hers. Had I not stayed with the knowledge that on a fundamental level my needs also deserved consideration, then I would have allowed my client to remain in an infantile place with regard to differentiation.
The counselling profession mushroomed in the seventies and eighties, its incubator pastoral and charitable organizations that offered marriage guidance and the like. Therapists weren’t necessarily expected to make a living from this work. Charity offers kindness and real help to the downtrodden but like everything it has its shadow, and for me the shadow emerges from a 19th Century belief that the worthy should take care of the less fortunate. The client comes to therapy at the benevolence of the therapist; there is a one-step-up and one-step-down relationship and, at an unconscious level, the client may believe that he must be rescued. However, while compassion is an essential part of providing a therapeutic environment, the belief that we must perform charity creates an imbalance in the relationship which may keep the client narcissistically fixated and impede genuine contact.
I believe that to be truly therapeutic we must be present for our clients (Hycner, 1991) but I would add that for us to be present for our clients we must also be there for ourselves. The therapist setting out to create a “private practice” so that he might help others goes up against a profession fixated on mother-complex stuff. Separation and individuation are regarded as suspect and perceived as selfish and not really congruent with a caring profession. A therapist who had difficulty separating from his own mother (or mother substitute) might, I suggest, be susceptible to the message that one must not earn legitimately for oneself.
When we separate, go it alone, whether it be from our mother or from our training institute, we are defining ourselves. I believe this requires that we do something we ask of our clients, that is, work with the ability to stay “not knowing“ – one of the hardest challenges for clients in therapy. Not-knowing is also a major challenge for the therapist as he waits for clients to come through the door; the difference is that, as therapists, we are aware that in the not-knowing something can happen and be created. The transformation from trainee to fully-qualified therapist is a process informed by our environment, our sense of Self and our expectations about what we are able to accomplish.
Deborah Davies is an integrative psychotherapist in private practice in London. She is interested in working with the creative process and helping clients work through creative block.
Image: Chat du 8ème by [phil h]
Syme, Gabrielle (1994) Counselling in Independent Practice Counselling in Context series. Editors: Walker M. and Jacobs M. Buckingham, UK: Open University Press.
Hycner, Richard (1991) Between Person and Person, Highland, NY: The Gestalt Development.