Clinical Impact Statement: This manuscript provides essential information to mental health clinicians in private practice to help them better meet needs for interpersonal support. The article highlights considerations and suggestions about how to intentionally access interpersonal support and develop a consultation or peer group as part of a self-care plan.
Recently we have heard a lot about the importance of therapist self-care. Jeffrey Barnett (2014) made a strong case that self-care is an ethical imperative based on the APA Ethics Code principles of beneficence and maleficence, as well as the guidelines related to competence, managing personal problems and conflicts, and avoiding harm. Self-care has both emotional and physical health implications, and since we are the primary instrument used to help clients, we need to be as fit as we can be. Often, due to the nature of the work, therapists spend hours a day in the presence of suffering and pain. This can adversely impact therapist well-being. As Rick Hanson (2013) suggests, we are what we pay attention to: “What you pay attention to—what you rest your mind on—is the primary shaper of your brain.” This applies to our clients but also to ourselves. Self-care becomes a way for therapists to counteract the detrimental health effects that may be implicit in providing therapy. One important avenue for self-care is making sure we have emotional support around the work.
In a recent qualitative study (Vivino et al., 2019), we found that almost all therapists interviewed said that they needed and valued having colleagues with whom to talk about cases, explore ethical concerns, share information about business practices and struggles, and promote personal and professional growth. While many of the therapists in our study found ways to meet this need, a surprising number were unsure or found it difficult to find avenues to meet this need consistently.
In addition, our study revealed that many of our participants also felt isolated in private practice. Providing therapy is a wonderful way to connect with clients’ potential and to experience compassion for another person, but it can also mean connecting with another person’s pain and distress. Even the most resilient among therapists can benefit from support. Whether you are starting out as a therapist, have been at it for a while, or are even winding down your practice, it is useful to consider your needs for peer support and how you might consistently meet this need. Although there are many ways that therapists can engage in self-care activities, creating regular opportunities to connect with supportive colleagues is an important component of self-care. We offer the following considerations based on our personal experience and discussions with many therapists in private practice.
Suggestions for Private Practitioners
Intentionally connect with an interactive community. A good starting place for meeting the need for connection might be as informal as sharing a building or space with other therapists in private practice or joining a topic-specific community that provides ample opportunities for interactions through meetings, listservs, etc. The important adjective here, though, is “interactive.” Both formal and informal communities will vary in this dimension, and you’re likely to benefit most from those that directly promote interactions and connections (as opposed to more passive interactions such as saying hello to a fellow suite mate or sitting in a continuing education class. More active interactions promote more interpersonal learning and, we believe, more emotional benefit). There is evidence that satisfying relationships are associated with better health, greater happiness, and even a longer life (Lieberman, 2013). This is most likely true for therapists in private practice as well.
For example, I (BT) shared building space in two separate locations. In the first, I rarely saw another therapist. The other six or so clinicians using the offices were generally not there when I was and there was no common area or any effort to facilitate interactions among us. In contrast, in the other set of suites I shared, some effort was made to encourage interactions. There was a common kitchen area where a snack table invited us to pause a bit and the ‘landlord’ (also a psychologist) gathered interested folks together twice a year for a ‘networking’ party. Others we know who share office space plan monthly lunches or other forms of social get togethers.
Other types of professional communities can also serve as your interactive community although many vary a great deal in how much they promote interactions between members (e.g., communities of therapists providing a particular approach such as systems work or those working with problem-based issues like trauma clients). The ones that we heard about that seemed most effective in meeting therapists’ need for connection were those that had regular meetings either in person or through conference calls and intentionally focused on building a sense of belonging and comraderie.
Form a peer consultation or support group. Many of the therapists we have talked to stressed how valuable it is to be part of a peer consultation group (sometimes called peer supervision although technically, unless unlicensed, it is “consultation”). We define this as a structured, formal group that meets regularly and has a fixed membership. It is important to know that these groups can have various structures. Below are some variations to consider:
- Frequency: Meetings can be weekly, biweekly, or monthly depending on the needs and desires of the group members and can last an hour to several hours. It’s important to be flexible in this area because it just might not be reasonable to meet weekly for some individuals, while once a month might be more doable.
- Membership: This may vary from colleagues and friends you know already to acquaintances or even other clinicians who don’t know one another well who meet through some common connection such as all working in a similar space or through a larger organization (e.g., state association, professional group), or even word of mouth. We’ll talk more about this when we discuss challenges, below.
- Structure: Peer consultation or support groups can also vary quite a bit based on the structure of the group. We recommend not leaving this to chance but rather purposefully identifying what structure will work best for your group. This doesn’t have to be a rigid structure and members should be open to changing it if it isn’t meeting everyone’s needs. Without some agreed upon structure, you run the risk of people feeling their needs are not getting met and the peer group having a lack of focus. Like any group, these types of groups run the risk of having a monopolizer among them or just individuals with different needs clashing over what is talked about. The structure could be that all members get a set amount of time at every meeting, in which case one group member should be appointed as time keeper. Alternatively, fewer members might discuss cases at each meeting but have more time, and then other members will have time in the next meeting.
Some questions a beginning group might ask themselves are: What is our focus in terms of areas of discussion? Do we want to explore difficult or challenging cases, discuss business related issues, focus on theoretical conceptualizations or intervention, explore the person of the therapist and countertransference issues? A peer consultation group is not a substitute for your own therapy, nor a substitute for professional consultation either clinically (e.g., working with a specialist around borderline personality disordered clients) or ethically (e.g., contacting your malpractice carrier).
Some of what you can hope to achieve in a peer consultation group includes: creating interpersonal connection, having a place to discuss challenging cases to gain new insights and receive support, sharing ideas about building and maintaining a practice, exploring countertransference issues, sharing helpful interventions and resources, gaining new perspectives on the work and how we do it, exploring ethical or diversity issues, as well as helping to get unstuck, combat a sense of isolation, or be more accountable around what we do behind closed doors.
While finding connections to fellow therapists might seem an obvious solution to the problem of isolation for those of us in private practice, there can be challenges to getting this need for connection and professional support met. Below we list a few possible challenges that may be encountered.
Not knowing what you don’t know. When I (BT) transitioned from a full-time institutional job, where I had “team meetings” built into my daily schedule, into a solo private practice, I didn’t consider this need. In building my practice I was focused more on getting clients in, adjusting to being in charge of my own schedule, and other practicalities of billing, note taking, etc. I knew I liked the idea of being in a group of suites where there were other therapists, but if I were to do it again, I would intentionally consider creating time and space in my schedule for peer connections. Therapists are often not aware of what they need or are going to need, particularly interpersonal needs, until there is some evidence that their needs are not being met. Unfortunately, this can lead to therapists being ineffective or making poor decisions. Therapeutic relationships might suffer—or even worse, therapists could make poor decisions that place their clients or themselves at risk.
Competing priorities. For therapists in private practice, time is money. We don’t get paid for involving ourselves in professional activities outside of client time. Devoting time to connecting with other professionals and colleagues means choosing not making money and also not attending to the other parts of our lives outside of our profession (e.g., relationships, family, relaxation, exercise). One way that made this easier for me (BT) was to form a group with colleagues I knew and liked a great deal. Although we are pretty good about staying focused on our professional struggles, we also really enjoy each other’s company, so getting together has a social feel to it and meets personal as well as professional needs.
Finding the “right” people. One complaint raised about consultation groups is that it’s difficult finding people where there is a good connection or who are willing to expand their group to include new members. Although we are asked to do so repeatedly during graduate training, as we went from supervisor to supervisor and peer group to peer group, it isn’t easy to feel trust for and open up with just anyone in our later professional lives. And if you have found such a group, you may feel protective and hesitant to add new, more unknown members. It is often difficult for therapists to be vulnerable with one another. There can be a tendency for therapists to want to appear professional and competent. Revealing insecurities or concerns about clinical decisions or personal anxieties can seem risky professionally, yet this is how a peer consultation group can be most helpful. Sometimes the line between professional persona and acknowledging needs can be confusing. Therapists don’t want to risk hurting their professional reputations by revealing inadequacies.
Taking the Initiative
We believe it is not a question of whether we as therapists need support but more what is the best way to get those support needs met? If you recognize the need but are struggling to find a way to get your needs met, don’t give up. Keep trying. In today’s world, we don’t all have to be in the same place to be available to one another for support; for example, secure video conferencing is easily available and viable option for many people in terms of scheduling and travel. If you don’t know people with whom to create a group, think about starting a group yourself by reaching out through listservs or other professional associations or reaching out to others who share your building or office space. Even meeting with one other person regularly can create that meaningful connection. Yes, everyone is busy—but that doesn’t mean one can’t find two hours a month to get support. It may be one of your most important forms of self-care.
Steps to starting a peer consultation group:
- Choose to make a supportive community part of your professional life and as part of your individual “self-care plan.”
- Reflect on what type of group might work best for you at your career development stage and dependent on what you feel you can reasonably commit to. Some examples might include a support group of others who are early career therapists or just starting a private practice; a group of therapists concerned about issues of social justice; other therapists interested in exploring countertransference; basic case consultation; or individuals who have similar philosophical or theoretical backgrounds.
- Identify others through listservs, professional friends and colleagues, former graduate school peers or alumni.
- Once a group of at least two members has been identified, meet to get to know one another or reconnect and explore issues of structure, frequency, membership, format, or ground rules.
- Periodically assess how the process is working and adjust as needed.
Cite This Article
Thompson, B., & Vivino, B. (2019). An independent practice does not need to be an isolated practice: Increasing connection as a method of self-care in private practice. Psychotherapy Bulletin, 54(4), 5-9.
Barnett, J. E., & Corcoran, K. (2018). Competence, ethical practice, and going it alone. Psychotherapy Bulletin, 53(4), 6-23.
Barnett, J. (2014, December). Distress, burnout, self-care, and the promotion of wellness for psychotherapists and trainees: Issues, implications, and recommendations. [Web article]. Retrieved from: http://www.societyforpsychotherapy.org/distress-therapist-burnout-self-care-promotion-wellness-psychotherapists-trainees-issues-implications-recommendations
Hanson, R. (2013, September 24). How to grow the good in your brain. Greater Good Magazine. Retrieved from https://greatergood.berkeley.edu/article/item/how_to_grow_the_good_in_your_brain
Lieberman, M. (2013). Social: Why our brains are wired to connect. New York, NY: Crown Publishers.
Vivino, B. L., Thompson, B. J., Spangler, P. T., Wolf, J., Hill, C. E., Hillman, J., & Youn, S. J. (2019). What do therapists need: A qualitative analysis of the needs of psychotherapists in private practice. Manuscript in preparation.