Clinical Impact Statement: This article is part of the 2018 special focus Turning Point: A time when things changed in psychotherapy practice, research, or training. This article shares understanding on the function of community health centers and describes a clinician’s personal experiences with working in such a setting including benefits and difficulties. Recommendations for how one may enrich their career while working for a community health center is provided.
Like everyone else I worked hard to get to where I am today, so why decline an offer from a prestigious hospital with an academic appointment to work at a community health center? There are a number of reasons why someone may want to work for a community health center including interest in working with serious or chronic mental health needs, interest in working with people experiencing poverty and racial and ethnic minority groups, interest in working for a small non-profit organization, and the ability to use state and federal loan repayment programs, among others.
Why a CHC?
Community health centers (CHCs) and community mental health centers were developed in the late 1960s and 1970s through a federal initiative. CHCs are designed to cater to the community in which they are located. Furthermore, they provide care to underinsured and uninsured persons, provide care to communities with a shortage of health care options and act as a health care safety net, and have a governing board where a majority of members are clients of the CHC (Taylor, 2004).
The majority of clients who seek health care from community health centers are uninsured and fall within lower socioeconomic status brackets. CHCs serve underserved populations and are located in federally designated medically underserved areas or serve a federally designated medically underserved population. As such, CHCs make up part of the United State’s health care safety net. For many CHCs, Medicaid is the most often used insurance payer and persons are seen regardless of ability to pay (Taylor, 2004). For psychologists interested in providing care to persons with lower access to care and/or to persons with low-income or who are economically marginalized, CHCs offer a means to work with these populations. Before working at a CHC, I was mostly interested in serious mental illness and psychosis. Meanwhile, through this work, I began to come across more instances of my clients’ struggling with poverty. This germinated my interest in economically marginalized populations. In addition, CHCs provide services for a racially, ethnically, and linguistically diverse client population. More than half of CHC clients are persons of color and a third are provided services in languages other than English (Taylor, 2004). Aside from my interest in serious mental illness, I’ve also always had interest in diversity and racial and/or ethnic discrimination. Given that many persons of color also experience economic marginalization, this was another way that I naturally developed interests in the mental health sequelae of living in poverty.
Often, persons experiencing poverty withstand multiple life stressors and adversities and have a high prevalence of mental health disorders (American Psychological Association, 2017). Sometimes, as is often the case with serious mental illness, one’s symptoms can lead to economic hardship and therefore low-socioeconomic status (Stansfeld, Clark, Rodgers, Caldwell, & Power, 2011). Other times, the stressors of poverty correlate to the development of mental health symptoms later in life (Javanbakt et al., 2015). Given this, community health centers are a great way to work with persons with serious mental illness and/or chronic mental health needs, a number of whom would go unserved in other settings. While working at a CHC I have been able to witness firsthand how societal inequities influence people’s physical and mental health. Many of my clients are painfully aware of these inequities, often voicing their frustration with how the lack of financial security or stable housing worsens their mental health status.
Benefits and Challenges of Working for a CHC
CHCs may be relatively small in scale in comparison to other health care organizations such as hospitals, with the benefits that working for a smaller organization can offer, such as a close-knit community, the ability to easily communicate and collaborate with others, and the ability for psychologists to integrate their training and liaison with other disciplines. As CHCs are required to have comprehensive primary care, this is an opportunity for psychologists to work closely with those providers and establish high quality integration between behavioral health and primary care. While working at a CHC I have had the ability to learn much about primary care and even communicate with my primary care colleagues more regularly than with my mental health colleagues.
Many community health centers, if not most, qualify for National Health Service Corps (NHSC) loan repayment programs. The NHSC offers non-taxed loan repayment to psychologists and other mental health professionals who work in federally qualified health professional shortage areas. These health professional shortage areas are defined by the U.S. Health Resources and Services Administration and are often CHCs. NHSC provides up to $50,000 dollars in loan repayment funding for two-year contracts which can be renewed afterward on a yearly basis. For early career psychologists and other health care professionals, this is a great way to manage the costs of education. I am extremely grateful that this program exists; visit https://nhsc.hrsa.gov/ for the most up-to-date information on the NHSC.
While being drawn to community health centers due to my interests in serious mental illness, economically marginalized populations, racial and ethnic diversity, and for the loan repayment opportunities, I have struggled with the lack of an academic focus at CHCs, and have noticed myself missing the rich educational opportunities and experiences that could help expand my career if I worked for an academic institution. However, this is not the case for all community health centers. Some community health centers have a partnership with local hospitals and academic institutions. It does not hurt to try to forge partnerships like this in order to get the best of both worlds. I am fortunate that my current organization is partnered with a large hospital where I have a clinical appointment and can therefore use resources like their medical library and grand rounds for continuing education. Moreover, I get to participate in enriching activities like membership in various committees and networking opportunities with others with similar interests. Psychologists and mental health professionals can additionally partner with local colleges and universities to obtain academic appointments and work on research and teaching activities. Likewise, psychotherapists working at CHCs can partner with nearby doctoral and masters level psychology, social work, and mental health counseling graduate programs to foster supervision experiences and provide practicum and internship training to future generations of psychotherapists.
Psychotherapists at CHCs can contribute their unique clinical experiences to initiatives focused on research and/or policy. Community health centers also benefit from having psychologists as part of their multidisciplinary team. Psychologists’ training offers a skill set that benefits the clientele of community health centers. Psychologists are trained not only in evidence based interventions and psychological testing but also likely have training and/or experience in leadership roles (Carr & Miller, 2017).
My Decision to Stay
Despite all of the rewards of working in community health centers, I began to struggle with inadequate salary and feeling like my CHC did not fully understand or value my skill set as a psychologist. So, even though I loved the population, I took time to interview elsewhere to keep my options open. Meanwhile, using my leadership and communication skills, I worked to inform my CHC of both my career needs and how being able to get these needs met would benefit the organization. Though I was blessed to be given offers at nearby well-known organizations with academic affiliations and related benefits, I ultimately chose to remain at my CHC for two main reasons. First, NHSC loan repayment is a compelling factor. Second, my CHC and I were able to work together to address the aspects of my experience that I felt were lacking.
This was a difficult decision. Some of my colleagues to this day do not understand why I chose to remain with the CHC, and others reading this may feel the same. This highlighted another issue I have experienced when sharing with others that I work at a CHC. I have felt a negative bias directed towards myself and other psychologists and psychotherapists who work at CHCs. I feel at times that others judge my training, my knowledge, and my capabilities as a psychologist based on the fact that I work at a CHC. It feels as if others assume that I may be poorly trained or unable to make the cut to work at a more prestigious organization. But why should I let unfounded assumptions from others deter my career choices and divert me from my interests? This was my turning point. When examining my needs and wants, I decided that, as long as I am able to follow my passion in terms of my clinical and research interests, obtain adequate career development opportunities, and get my loans paid off, then I am fine. In the end, many of these items would have been met in my current position or in a new setting; however, NHSC loan repayment tipped the balance. It has truly been a lifesaver for me as I entered graduate school during the height of the recent economic recession. When I obtained student loans during this time, interest rates skyrocketed to all-time highs. However, in the past three years I was able to wipe out half of my loans! To me, that is definitely worth dealing with the occasional negative judgment from peers who have biases about CHCs. Now, I plan to retire the rest of my loans while working with a highly underserved population with mental health needs that fascinate me, all the while working for a cause that I find highly rewarding.
Cite This Article
Greig, A. (2018). Choosing to work for a community health center: A career turning point. Psychotherapy Bulletin, 53(2), 28-32.
American Psychological Association. (2017). Stress and health disparities: Contexts, mechanisms, and interventions among racial/ethnic minority and low-socioeconomic status populations. Retrieved from http://www.apa.org/pi/health-disparities/resources/stress-report.aspx
Carr, E, R., & Miller, R. (2017). Expanding our reach: Increasing the role of psychologists in public and community mental health, Psychological Services, 14(3), 352-360. doi: 10.1037/ser0000094
Javanbakht, A., King, A. P., Evans, G. W., Swain, J. E., Angstadt, M., Phan, K. L., & Liberzon, I. (2015). Childhood poverty predicts adult amygdala and frontal activity and connectivity in response to emotional faces. Frontiers in Behavioral Neuroscience, 9, 1-8. doi: 10.3389/fnbeh.2015.00154
National Health Service Corps. (n.d.). https://nhsc.hrsa.gov/
Stansfeld, S, A., Clark, C., Rodgers, B., Caldwell, T., Power, C. (2011). Repeated exposure to socioeconomic disadvantage and health selection as life course pathways to mid-life depressive and anxiety disorders. Social Psychiatry and Psychiatric Epidemiology, 46(7), 549-558. doi: 10.1007/s00127-010-0221-3
Taylor, J. (2004, August 31). The fundamentals of community health centers. Retrieved from https://www.nhpf.org/library/details.cfm/2461