Opinion: Private Practice: Students and New Graduates (Part Two)

By Malinda Dobyne, LMSW, ACSW, QCSW

Welcome back to part two of Private Practice: Students and New Graduates. If you missed part one, click here to read the previous article. I concluded that article with our integrity and competency being a “ART” form that develops over time. This article will explore the influence of these characteristics in the context of social workers’ ethical responsibilities to their clients, colleagues, and the practice setting.

Integrity, competence, respect, education, training, supervision, and consultation are interwoven throughout our ethical responsibilities. I view integrity as the foundation and competence as the brick and mortar for the work we do as social workers. The Oxford Learner’s Dictionaries defines integrity as “the quality of being honest and having strong and moral principles” (Oxford University Press, n.d.). It further defines competence as “ the ability to do something well” (Oxford University Press, n.d.). These definitions align with the NASW Code of Ethics. Our professional integrity and competence development start with academic coursework and continues through internships or field placements. Internships are opportunities to apply academic knowledge in real time under the guidance of an experienced supervisor or field instructor. Professional growth continues through consultation, gainful employment, volunteering, training, and continuing education.

Supervision and consultation are instrumental in strengthening and maintaining our social work ethical responsibilities. According to the NASW Code of Ethics, supervision is “the relationship between supervisor and supervisee in which the responsibility and accountability for the development of competence, demeanor, and ethical practice take place” (2024). In this article, I define consultation as a collaborative interaction between colleagues. Consultation is used for discussing difficult cases, diagnostic clarity, and treatment strategies amongst other topics. At the core of successful supervision and consultation is self-reflection. Self-awareness is the result of self-reflection and cultivates integrity and competence.

My position is that private practice should not be an option as a field placement or employment for a new graduate. Through consultation with other field instructors and supervisors, there is a current trend that supervisees are more focused on fulfilling academic or licensure requirements rather than learning and applying knowledge in real-time. It’s difficult to imagine this mindset in the least structured of available placements. The inherent challenges of this setting are supervisors being less accessible for immediate guidance, less opportunity to learn and practice, and high appointment no-show or cancellation rates.

In review of the literature, the no show or cancellation rate at best is 10-20% with 50% being typical. These statistics include both in-person and telehealth. A supervisee is missing valuable hands-on experience with these rates. I find these rates to be significant and warrant further discussions on filling this gap with other experiential options. Lastly, the other observation with supervisees is the lack of respect for supervisors’ time and guidance. Supervision is an added responsibility for most and without additional compensation. Supervisees should be mindful that they are learning and practicing under supervisors’ license. And it’s important to use supervision for its intended purpose.

The no-show rate coupled with the lack of commitment to supervision may explain my growing observation of inadequate client care by limited licensed mental health professionals as a whole. Specifically for social workers, it’s incongruent with our ethical responsibilities. During my work as an emergency room social worker, there were countless times outpatient therapists would send their client for a safety assessment. My colleagues and I noticed clients were sent prior to completing the initial intake. The intake was stopped at the point clients were providing current and/or past suicidal thoughts, suicide attempts, and self-harming behaviors information. Many times, our assessment identified low or no evidence of risk.

My experiences and consultations with colleagues, the patient would’ve been spared a five-hour emergency room visit had the intake been completed. Although we appreciated and understood therapists’ caution, there are other implications this scenario raises. Therapists’ competence to assess risk. The likelihood of therapists caring for clients with no too mild risk levels is a thing of the past. Other implications include impeding therapeutic rapport, clients’ fear of disclosing future safety concerns, belief they’re too bad to be helped, and reluctance to engage in mental health treatment. Therapists’ comfort in assessing risk can mitigate these implications.

Additionally, inadequate assessment skills contribute to the undertreatment of clients. Unfortunately, I’m witnessing this more and more in my current position. Clients are being referred to the partial hospitalization program for concerns of worsening psychiatric symptoms. Skill development/refresher, diagnostic clarification, medication recommendations/management, structure, and case management assistance are the outcomes therapists are seeking. Cognitive Behavioral Therapy and Dialectal Behavioral Therapy skills are taught in the program which many therapists acknowledge limited proficiency in one or both. Few engage in care coordination with their clients’ other providers, re-evaluate interventions in the absence of improvement, or refer out when needed. This information is confirmed by clients and apparent during program treatment. This is disheartening and leaves the following questions; 1) how many clients are undertreated? 2) why aren’t basic skills being taught in therapy? and 3) how will therapists foster ongoing skill development with their limitations?

In conclusion, the world of private practice can be a very lonely whether you are practicing solo or within a group. The lack of inherent support makes it important that therapists have the required knowledge, skills, and competence. Students and new social workers should have more time developing these required attributes before engaging in private practice. If private practice remains a viable employment option, consultation should be required for a specified time for new fully licensed social workers. Supervision and consultation with trained and competent social workers are avenues for development and support. Without utilizing these supports, upholding our commitment to promote clients’ wellbeing is futile. More importantly, we aren’t adhering to our ethical responsibilities as social workers. In the words of Warren Buffett, “risk comes from not knowing what you're doing” BrainyQuote.com, n.d.). Development is an ongoing process. We all need support regardless of competence, experience, and expertise.

Malinda Dobyne, LMSW, ACSW, QCSW, has provided mental health care for over 30 years in home and hospital settings, as well as 20+ years in the private practice setting. Currently, she is employed full-time as a Clinical Director and Social Work Supervisor for a partial hospitalization program in Michigan. Additionally, Malinda is the founder and owner of Inner Guidance Therapy and Consultation Services, PLLC and provides psychotherapy, clinical supervision, peer consultation, and mental health awareness workshops. She can be contacted at (734) 740-3371. 

References

National Association of Social Workers (2024, August 3). Code of Ethics. https://www.socialworkers.org/About/Ethics/Code-of-Ethics/Code-of-Ethics-English

Oxford University Press. (n.d.). Integrity. Oxford Learner’s Dictionaries. Retrieved August 28, 2024, from https://www.oxfordlearnersdictionaries.com/us/definition/english/competence?q=competence

Oxford University Press. (n.d.). Competence. Oxford Learner’s Dictionaries. Retrieved August 28, 2024, from https://www.oxfordlearnersdictionaries.com/us/definition/english/competence?q=competence