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(p. 565) The Private Practitioner and Family Issues 

(p. 565) The Private Practitioner and Family Issues
Chapter:
(p. 565) The Private Practitioner and Family Issues
Author(s):

Lauren Behrman

DOI:
10.1093/med:psych/9780190272166.003.0043
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Subscriber: null; date: 20 September 2017

This chapter is born through my own life experience of blending private practice and motherhood over three decades, in addition to listening to the voices of women practitioners all over the country who have shared their concerns and questions with me on a “Moms in Practice” virtual support group for the past four years. The group addresses issues arising from all aspects of the intersection of practice and motherhood from contemplating practice, motherhood, pregnancy, practice with babies, up through all of the stages of childhood development. Women practitioners have brought questions and concerns about all aspects of the worlds of practice and parenthood and related unique topics, including special needs children, adopting babies and older children, acquiring children in new relationships, their children’s illnesses, emergencies and sick days, their miscarriages, divorces, and college searches as these intertwine with and impact their practice. This chapter explores the reciprocal impacts of practice on parenthood and parenthood on practice. To gain a perspective of the experiences of fathers in private practice, I interviewed a small sample of “Dads in Practice,” both married dads and divorced dads with shared parenting time.1

One Mom’s Story

It was 1999 and I was sitting on the floor in my home office working with Sandy, a feisty four-year-old girl with gleaming deep brown eyes. We were “playing” with my dollhouse, and she was weaving an intricate family drama with my Playmobil dolls, playing out her struggles and worries in her story. On the other side of the double doors, my three children, aged two, four, and six were home from school, and even though they knew to be quiet when mommy was working, I could imagine the sound of their voices. They were playing and doing homework with their nanny, and I began to (p. 566) question myself: “Here I am, sitting on the floor and giving my undivided attention to other people’s children, while my own children are with a nanny inches from where I sit. What is wrong with this picture?” It was at that moment that I realized that the practice model that had worked for me for the past 14 years was no longer viable, and I needed to shift my practice paradigm.

I had been in practice for close to nine years prior to becoming a mother and had a well-established referral base in two different locations. At the time I became a mother, over 80% of my practice time was being spent conducting psychological evaluations and psychotherapy of preschool and school-aged children, as well as parent guidance sessions for their parents. Much of my work took place from 3 p.m. to 8 or 9 p.m. That model worked for the years before my three children were born, as well as during the time they were infants and preschoolers. By closing my two outside office locations and working solely out of a home office, I was able to tailor my hours to be most available to my children before they entered elementary school. I was home with my children much of the day to take them to Mommy and Me, Gymboree, Musical Munchkins, the playground, play dates, and their doctor’s appointments, and was then able to work in the afternoons while my children napped and after they went to bed. With some childcare in the late afternoons, I could take time off for dinner and then see a few clients after the children were asleep. However, once they entered elementary school, the landscape completely changed.

When my oldest son went to elementary school and was out of the home from 8 a.m. to 4 p.m., I was seeing the bulk of my clients during afternoons and evenings and often missed my children’s bedtime routine and did not see my children until the next morning. On days when I had early morning patients after working late the prior evening, I might not see my children for close to 48 hours; it felt as if I had been in another city, even though my office was in my home. I realized that if I didn’t change things quickly, I was about to miss a great deal of my children’s childhood.

My Solution

The writing was on the wall; the hours I had carved out for my practice were no longer feasible with school-aged children. The practice population I had focused on was primarily available during the hours I needed to be available for my children, and I quickly needed to find clients who could be seen primarily during daytime hours. With that intention, I went to an annual convention of the American Psychological Association, “shopping” for ideas for a practice niche that would interest me, would match my skillset, and would primarily be limited to the hours that my children were in school. I attended seminars on anger management groups for children, couple therapy, psychotherapy with women undergoing infertility treatment, and co-parent counseling for divorced parents, to name a few. By the end of the convention, I came away with many ideas for shifting my practice focus and population so that the majority of my work could be carried out during daytime hours.

After much thought, I decided that the co-parent counseling niche would best meet my skillset, areas of interest, and hours that I wanted to devote to practice. Co-parent counseling was more of a time-limited intervention, meetings could be scheduled less frequently than psychotherapy, and it was often court-ordered, which compelled clients to engage in the intervention. As a result, (p. 567) my clients were more willing to come in to see me during the daytime. Over time, what began as a niche practice in co-parent counseling blossomed into a full-spectrum divorce-services niche that included mediation, parent coordination, and collaborative divorce roles as a child specialist and neutral process facilitator. This supplemented my psychotherapy practice and expanded my network of referral partners.

Not only had I shifted my practice into a specialty niche that was free of insurance and managed care, I had also found an area of practice that was protective of children and families, which meshed with my core values. Additionally, when I had a predominately child psychotherapy practice, I was isolated in my home office seeing clients much of the workday. In my new practice niche, I began to work in conjunction with attorneys, judges, financial professionals, and other mental health professionals and found myself in a stimulating and supportive professional community. Some of the collegiality I had always treasured during training, or when working on a team in a professional setting, was now part of my everyday work experience. Becoming part of multiple interdisciplinary organizations focusing on this area of practice, I found myself in leadership roles, founding local chapters of national organizations, writing, speaking, teaching, and participating in a supportive peer supervision group, rich in resources for parenting coordinators that has been going strong for over 10 years. All of these additional professional activities were growth-producing and enlivening for me.

Lessons Learned in the Trenches

Looking back at my own professional journey, I wish I had recognized that I was a small business owner early on in my career and that I had focused on mastering the business skills that I needed to make that part of the practice more efficient and less stressful. Somehow, flying by the seat of my pants, I always figured out how to make it work.

As a mom and independent practitioner, it’s important to recognize that as your children grow and develop, their needs change as well, and your way of working in private practice needs to change too. For example, infants and preschool children have more fluid schedules, and parents have more choice about when to enroll them in structured programs and what kinds of schedules to set up (e.g., three-day preschool, half or full days, mornings or afternoons, no preschool, full daycare). Once children enter elementary school, their schedule becomes more fixed and determined by their school districts and governmental requirements. Children also begin to engage in more afterschool activities, sports teams, and so forth. The needs of elementary school children are different than those of children in middle school, high school, and college. A proactive approach is needed that considers how the needs of your developing/growing family will impact your private practice and how you schedule clients, the types of work you accept, and the possible need to do different kinds of work or see different types of clients at different phases of your family’s life cycle. While I was able to shift my work as my family evolved and grew, I did not approach it with the consciousness that would have allowed me to strategize, anticipate, and plan for the shifts that my practice would require as my children grew. I have recognized this only in retrospective.

(p. 568) An Opportunity to Pay It Forward

One of my greatest professional pleasures is “paying it forward,” sharing experiences, resources, frustrations, and satisfactions with moms in practice from around the country once a month in an open conference call I facilitate through The Practice Institute (TPI). Women who are considering becoming parents and those who are at all stages of parenthood and practice have joined together and brought their questions and concerns to our conference call. Pregnant first-time mothers-to-be, mothers of teens, adoptive moms, stepmoms, gay moms, moms of special needs children, and moms of college-age and adult children all have been represented on our calls. The calls are a mixture of practice consultation and support and are open to TPI members as well as the general public.

These calls are announced in weekly email announcements by TPI, and any practitioners can add themselves to the distribution list. You can also check TPI’s website (thepracticeinstitute.com) for upcoming events and sign up for the event right on the website. On any given call, there may be anywhere from one to 15 participants, and each call addresses different topics based on the needs of the women who are attending.

Finding Balance: A Universal Concern

The most common concern among these mothers in independent practice has to do with finding balance; that is, being able to juggle the demands of motherhood with being a clinician and small business owner. These concerns are also common to single fathers in practice and dads shouldering equal parenting responsibilities with their partners. Research has found levels of professional autonomy and flexibility of hours to be the highest-rated satisfaction variables with this choice of a career path (Walfish & O’Donnell, 2008). Independent practice lends itself perfectly to blending with parenthood at all stages of life. The flip side is that there is a huge occupational hazard—the risk of burning yourself out by taking care of dependent children and needy clients while not taking adequate care of yourself. Additionally, at some stages of our lives, we may also be taking care of members of our extended families as well. It is critical to attend to self-care and to consciously and intentionally set up your practice so that there is a balance between practice and your own life. The flexibility and autonomy of independent practice allow you to choose one or more niche populations that will be available when you want to work and during the times that work best for the needs of your family. It is the intentionality and planning that are so important. Rather than letting the practice take over your life and seep into all available moments, planning the hours you want to work, and then matching your interests and skills with a population available during those times, will allow you to work smarter and not shortchange either your family or your practice.

You can approach your practice with either a model of scarcity or one of abundance. The scarcity model calls for you to work every possible moment and take every client who calls because (p. 569) you are fearful that the well will dry out and if you don’t take this new client there will never be another one. The model of abundance calls for intentional planning of what is optimal and feasible for you. Intentionally focus on what hours you want to fill, and then work to fill those times while maintaining the balance and boundaries that are necessary so that your practice and personal life can coexist. There is an additional benefit of creating strong referral partnerships by referring clients to colleagues who are available during the hours you have chosen not to work. These cross-referrals breed goodwill and build your referral network, offering the opportunity to “cross-refer” and keep you on the “top of mind” in your referral partners’ stable of resources. There are so many different options available for niche practices that can suit a practitioner’s availability and interests; it is important to find the one or two that work well for you.

As the owner of your independent practice, it is also possible to shift and change as your family’s needs evolve through the developmental stages. Anticipating those transitions and actively researching your options in advance can help create a smooth flow, integrating the needs of yourself and your family with a manageable practice that allows you to find that optimal work/life balance and avoid burnout.

Can Women Have It All?

In an article in Atlantic Monthly, Anne-Marie Slaughter (2012) writes about her experience combining work in a high-profile government position as the former State Department Undersecretary while at the same time parenting young children. “Can women have it all?” she asks. In this article she explores the problems and challenges faced by professional women and posits that women “tell themselves stories and lies” about their ability to “have it all”—healthy marriages, exciting careers, and thriving children. She states:

Here I step on to treacherous ground mined with stereotypes. From years of conversations and observations, however, I’ve come to believe that men and women respond quite differently when problems at home force them to recognize that their absence is hurting a child, or at least that their presence would likely help. I do not believe fathers love their children any less than mothers do, but men do seem more likely to choose their job at a cost to their family, while women seem more likely to choose their family at a cost to their job. (p. 92)

She goes on to say:

Many factors determine this choice, of course. Men are still socialized to believe that their primary family obligation is to be the breadwinner; women, to believe that their primary family obligation is to be the caregiver. But it may be more than that. When I described the choice between my children and my job to Senator Jeanne Shaheen, she said exactly what I felt: “There’s really no choice.” She wasn’t referring to social expectations, but to a maternal imperative felt so deeply that the “choice” is reflexive. (p. 92)

(p. 570) I believe these concepts extend to the experience of fathers in practice, and that the stereotypes she alludes to in her article are applicable to my male colleagues, modified by cultural, sociological, and generational factors.

Experiences of Fathers in Practice

My conversations with Dads in Practice confirmed my hypothesis that the experiences of fathers in practice depend highly on the degree to which these fathers envisioned themselves as primary caregivers, and the ways in which they had set up childrearing responsibilities with their partners. For many dads, being in practice was comparable to any other full-time career, perhaps with the added benefit of greater flexibility in scheduling to allow for attending children’s school events and activities.

In my dialogs with male colleagues who are fathers in practice, many of the themes were consistent with the ideas Slaughter posited. One independent practitioner father stated: “Men’s lives don’t change so much when children are born; women’s lives do … caring for children falls more on women’s shoulders … in dual-income families, mothers still do more childcare and housework” (S. Demby, personal communication, April 22, 2016). This practitioner and father imagines that there is some gender difference, saying “as a group, mothers tend to feel more preoccupied about the time work takes them away from their children than fathers.” Dr. Demby went on to state that there is a cultural shift under way in certain segments of the population in which “Gender roles and norms are becoming more fluid and changing … some subgroup of parents where fathers are as involved in child care as mothers. I see fathers walking around my neighborhood with baby carriers on their chests—it’s a different generation” (S. Demby, personal communication, April 22, 2016).

In speaking with male colleagues, I did have a dialog with two fathers who have taken more of a shared caretaking role in their children’s lives and have found that they were able to have the flexibility to do this as a result of being in independent practice. One of the major concerns for independent practitioner fathers was the stability and predictability of their income. While women practitioners have certainly expressed concerns about the predictability of their income in practice, the emphasis is not the same as the men’s in families where women are contributing a second income.

One model discussed consisted of maintaining a full- or part-time institutional position for a steady paycheck and benefits while gradually building up a private practice. For this father, it was only after his children went to college that he embarked on a full-time independent practice. He now finds himself working longer hours in his practice, including evenings and weekends, and believes he would not have had as much quality time with his children had he been in independent practice during their younger years. In their family, his wife was working part time and was more available to the children (S. Demby, personal communication, April 22, 2016).

Concerns about income stability for practitioners solely in private practice were echoed by a father of young children currently in full-time private practice. This man and his wife chose to partner equally in the care of their children, each taking shifts of childrearing time and working (p. 571) time. This father feels he is one of the few practitioner fathers he knows who is solely in private practice, with most preferring to have some stable source of income: “Most take on gainful employment and their private practice is moonlighting on the side” (D. Sonotore, personal communication, February 15, 2016). He believes that most practitioners who embark on independent practice are often not the main breadwinners in the family and have a partner who is working full time or has some other source of income and can operate at a loss for a few years until the practice gets off the ground. For him, the stress of income instability is palpable on a daily basis, and he wishes that he had become more established in his practice before he became a father (D. Sonotore, personal communication, February 15, 2016).

Another dad in full-time private practice, who is divorced with residential parenting time with his son 50% of the time, remarked that he had to design his life around parenting his son. He saw his practice as what made it possible to be present for his son after school on days when his son was with him, and he never scheduled work on those days. Like myself, he too found a practice niche that allowed him to manage his hours to allow for optimal time parenting his son. He realized that he often needed to sacrifice his work for the needs of his son, such as by cancelling his clients on days that his son was ill and could not go to school. He found that the flexibility offered by being in practice made it possible to experience parenting in the full way that he wished.

Looking back, this practitioner saw that he succumbed to stress and anxiety at times as the demands of being a parent, attending to his practice, and producing income as a single father were intense. He did not prioritize self-care and found himself not as relaxed and accepting in his parenting as he would have wished to be. He reflects on his experience as a father and private practitioner, stating, “Private practice offers autonomy, and along with that comes some financial unpredictability. One needs to be one’s own boss when asking for so much time off—you’re the only one that would give it to yourself” (D. Sonotore, personal communication, February 15, 2016).

Opportunities Versus Challenges for Parents

Practitioners with family obligations must weigh their options prior to embarking on a private practice. It is always prudent to look at the cost/benefit analysis to determine whether the benefits of making this choice outweigh the potential costs or risks. This is an important decision that needs to be carefully thought out.

Benefits

When I look back upon my 31 years of practice, I have no regrets about my career choice. Having been in practice while raising a family has afforded me a significant degree of independence and empowerment in being able to develop new interests and opportunities, pursue a variety of other professional activities, sustain a healthy work environment, and earn a good income. One of the great benefits has been the freedom from worry about “job security.” Throughout these years (p. 572) of practice in the busy times and the quiet times, I have always known that my “job” is secure. Whenever there was a downturn in referrals and the practice was quieter than I would have liked, I always knew that I could develop other practice areas and populations, invest time in developing professional relationships, learn new skills, and pursue other professional activities such as writing, leadership, speaking presentations, committee work, and networking, for example.

I began to welcome the periods of relative quiet and felt secure in knowing that the work was cyclical and that the practice would rebuild. At one time, when the practice was in a longer-than-typical lull, I reinvigorated it by “borrowing” a colleague’s office in a new location and using this opportunity to reconnect with all my old colleagues, mentors, and peers. Within a few months, the referrals began to flow into both locations and the practice had rebooted. When I became a mother, I was heartened by the flexibility of scheduling and the ability to adjust my schedule (sometimes at the last minute) when necessary. With a full-time at-home office, I was able to fit in rescheduled clients very early in the morning or late at night, or even on a weekend if necessary, with little disruption to my family.

Throughout the course of my career, my private practice took many different forms and was able to shift and change to sync up with the changing needs of my growing family. I was able to target a population that was available during the hours that worked best for my family and to build a practice that allowed me to work when my children were in school and spend quality time with my children when they were home. In addition, I was able to work around their class trips, special events, recitals, and parents’ meetings by being able to anticipate these events and adjust my schedule accordingly. By having the freedom to try new ways of working, including carving out the time for continuing education training and mentoring, the practice remained fresh, stimulating, and suited to my professional needs, the needs of my family, and the needs of my clients.

Challenges

Some of the greatest advantages of being in private practice for working moms and dads with shared parenting responsibilities are also some of its greatest challenges. Independent practitioners must keep the referral pipeline strong and open. That might translate into carving out time to focus on networking and other marketing activities. Maintaining strong personal and professional relationships is particularly important for sustaining a strong network of referral partners. It is wise to make the time to follow up with referral partners and to demonstrate excellent customer service, both to clients and professional colleagues who refer. For parents in practice, this additional time invested in practice building and maintenance activities takes away from time spent with children and family.

Anxiety over Financial Uncertainty

This is a particular challenge for solo independent practitioners, especially single moms and dads and those parents who are sole or primary providers in their families. In speaking to both moms and dads in practice, the uncertainty of income was a primary concern. Many men I have spoken (p. 573) with chose not to be in full-time independent practice when their children were young and sometimes held a part- or full-time job in an institution in addition to a small private practice “on the side” so they could maintain a consistent and predictable income. In these cases, these men saw themselves as primary providers, and their wives were either stay-at-home moms or worked more of a part-time schedule and took on more responsibility for childrearing.

Caregiver Burnout

Being in independent practice can be emotionally challenging when you are dealing with a heavy caseload of clients in crisis, clients with traumatic histories, and those in high conflict. You are a caregiver at home as well as at work. You also are exposed to the second-degree stress that arises from recurrent exposure to clients’ trauma; this can activate your “fight, flight, or freeze response” while you must remain in an empathic stance (Izzo & Karpel-Miller, 2010).

Impact of Being Parents on our Work with Parents

I began working with children and families early in my practice, long before becoming a mother myself. For years, my education in child development and the psychotherapeutic and assessment techniques I applied to working with that population were sufficient to work effectively with children and their parents. However, once I became a parent and experienced the intensity of emotions, the exhaustion, the devotion, and the ways my own vulnerabilities were tapped, and my resilience and strengths were tested in relationships with children at all developmental stages, I recognized the element that had been missing in my earlier understanding of what it means to be a parent. I joked that I wanted to write apology letters to all the parents I had ever worked with before I became a mother. As one colleague states:

When our clients talk to us about their parenting experience, our experience with our children informs our work. We have deeper understanding of what it means to have children. The tension and the gifts … we know firsthand what it means to have all kinds of stressors in your life … loving your kids and having to balance all kinds of things. (J. Steiger, personal communication, March 12, 2016)

Since we are psychotherapists, have studied child development, and see every day the importance of good parenting and the impact of bad parenting, there is an additional layer of challenge for parents who are also practicing in the mental health field. We are painfully aware of child development and the impact of stressors on our children. We are also more aware of the complexity involved in raising children. Our own experiences of being parents help us to be much more realistic about the challenges of parenting, and as a result we can be much more empathic to what our clients are experiencing with their children.

(p. 574) In our offices, we often hear husbands who make the statement:

“I’m the one with all the pressure; you’re home all day, how hard can it be?” Do these fathers understand the emotional agility required when raising children, how one has to expand their capacity? There are no conquests in childrearing and the work and responsibility increase exponentially with more than one child. (J. Steiger, personal communication, March 12, 2016)

As parents in independent practice, we “develop an empathy for the experience of parenthood, and approach parents who have made many errors with a lot of good intentions with the empathy necessary to break the pattern, break the cycle” (J. Steiger, personal communication, March 12, 2016).

Concluding Thoughts

Mary Matalin, who spent two years as an assistant to President George Bush and the counselor to Vice President Dick Cheney before stepping down to spend more time with her daughters, wrote: “Having control over your schedule is the only way that women who want to have a career and a family can make it work” (as cited in Slaughter, 2012, p. 87). This is what we can access as a parent in practice: If we intentionally and purposefully build it, we can have a great deal of control over our schedule, and in this way, we can make having a meaningful career and a family work without shortchanging either our children or our practices.

By choosing independent practice and setting up our work with intention, we not only have the best opportunity to participate both in family and professional life, but we also have control over our work hours, the type of work we do, the amount of work, and the culture of our work environments. We also have control over our choices of when and how to diversify and reinvigorate our practices, and what kind of outside professional communities and activities we wish to engage in. As primary caretakers of young children, we are able to shift our work hours and foci as our children grow and their developmental needs change. To me, independent practice has been the key to being present for my children through all their stages of development, while simultaneously experiencing a rewarding professional life.

References

Izzo, E., & Karpel-Miller, V. C. (2010). Second-hand shock: Surviving & overcoming vicarious trauma. Scottsdale, AZ: High Conflict Institute Press.Find this resource:

    Slaughter, A-M. (July/August, 2012). Why women still can’t have it all. Atlantic Monthly, 85–101.Find this resource:

      Walfish, S., & O’Donnell, P. (2008). Satisfaction and stresses in private practice. Independent Practitioner, 28, 135–138.Find this resource:

        Notes:

        1. With gratitude to my colleagues Steven Demby, PhD, David Sonotore, CSW, and Jeffrey Steiger, CSW.