Watching Lindsay Clancy’s prescribers, I’m struck by a few things. I’m not here to weigh in on their individual practices, but to speak to the ways that the system as a whole does not prepare clinicians to practice independently. Therapists are under-prepared to practice independently.
Working in non-profits for 11 years, I saw clinicians move into private practice as a way to beat their burnout. Unfortunately, our systems of care are so broken that sometimes private practice seems like the only way to be paid adequately for your expertise and to have the work-life balance non-profit agencies love to say they value. This is such a shame, because we need more experienced people to stay in non-profit work (and I say this as someone who also recently made the decision to move into full-time private practice to be able to spend more time with my kids).
The prescribers’ testimony in the Lindsay Clancy case highlighted 5 things that happen when people move into private practice without having the strong foundational knowledge that comes from working within a larger system of care. You can’t learn all of this in graduate school – the way we prepare clinicians is truly through on-the-ground experience.
5 Key Ways Clinicians Are Under-Prepared for Private Practice
One: Insufficient foundational knowledge in documentation
Many therapists struggle with documentation. Documentation guidelines are inconsistent across the field due to different agencies preferring different types of notes (Do you DAP? Do you SOAP? Do you BIRP?).
One thing that providers should learn, particularly if they have ever billed insurance, is that there needs to be a golden thread linking an initial intake to a diagnosis. This connects to a treatment plan that lays out how your planned intervention will treat the condition and lead to the client’s intended outcomes and goals. Each subsequent session has to connect the client’s presentation to that diagnosis and treatment plan (medical necessity) and lay out how you used your intervention in that session.
Two: Insufficient assessment of intrusive thoughts and psychotic symptoms
What are intrusive thoughts?
In postpartum anxiety and OCD, intrusive thoughts are often thoughts or images of harming your infant. These thoughts cause distress to the person experiencing them. In the case of postpartum OCD, intrusive thoughts may become obsessive and lead to compulsions (repetitive behavior) to manage the thoughts and prevent the unwanted outcome. With anxiety, someone may begin to avoid certain caretaking activities because of the persistent worry that they may cause harm.
What is psychosis?
Psychosis involves symptoms like hearing voices, seeing things that others cannot see, or having delusional thoughts/beliefs about yourself and/or others. For example, Ayana Lage’s book Missing Me describes her experiences hearing the voice of god (auditory hallucinations), believing her child was the second coming (delusional belief of grandeur), and that the doctors in the hospital were demons trying to kill her (delusional paranoid belief).
Simple questions to assess intrusive thoughts vs psychotic symptoms
A couple of simple questions to ask include:
- Are these thoughts distressing to you? Asking this helps determine whether the thought is an ego dystonic (disturbing, unaligned thought), which makes it more likely to be a symptom of anxiety or OCD
- Do you think you are likely to act on this thought OR do you plan to act on these thoughts? People may still act on thoughts that don’t align with their values or that are disturbing to them. Someone with anxiety or OCD is less likely to do so. The theory here is that the intrusive thoughts actually lead to an over-protective instinct. However, with psychotic symptoms, someone may still act on an ego dystonic thought. For example, Ayana Lage says that if the voice of god told her to send her child to heaven, she would have been likely to follow through with that.
Three: Insufficient awareness of resources available for the perinatal period
As much as we have made strides in recognizing maternal mental health, it is clear that we have a long way to go when a provider treating a postpartum woman misses using common, standard assessments for postpartum depression.
We can’t all be experts at everything. My next section will focus on that. The important thing is to recognize when something is beyond your scope. Here are two resources to know for the perinatal mental health treatment:
- Postpartum Support International offers 24/7 support lines staffed by perinatal mental health practitioners, connection to local resources specifically for the perinatal period (practitioners who have taken advanced training and certification courses to effectively treat perinatal mental health)
- Charlie Health offers virtual IOP for perinatal maternal health in some states. They work with most insurance companies and Medicaid (but do not accept Medicare primary). This is a newer option and may not have been available to Lindsay Clancy.
Four: Insufficient awareness and transparency of scope of practice
Mental health providers need to be transparent about their credentials. If you do not have additional training in a certain field of mental health, you are not an “expert” and I’d be wary of calling yourself an “advanced practitioner” in that discipline, too. We also need to continue to seek consultation when we are working with complex cases that test us, even after becoming independent practitioners.
I have blogged before about the importance of knowing your scope of practice when it comes to treating trauma. This is true no matter your focus or population/s of interest. If you do not have advanced training in an area of interest, either seek that training or know providers in your area who do. Seek consultation and supervision as you expand your practice into new fields. Do not overstate your credentials.
Five: The system is failing when multiple providers can prescribe psychotropic medications without care coordination
There is a mental health system failure when multiple prescribers can treat the same patient for the same condition/s without any awareness.
Insurance companies sometimes catch that there is duplication of services (which often comes with a clawback for services rendered), but this can take months or longer. If someone is paying out of network (privately paying for services), this may not get caught at all. Controlled medications, like stimulants and benzodiazepines, are recorded in a centralized system to prevent misuse. Most medications, including antidepressants and antipsychotic medications, are not centralized in this way.
This contributes to medication misuse, toxicity, and ultimately to questions about who is responsible for a patient’s care and treatment outcomes.
If you’re a client, how should you find a qualified private practice therapist?
- ALWAYS ask about your therapist’s advanced training in the issue you’re presenting with. What training have they completed and do they participate in ongoing training?
- Check their credentials: Are they licensed to practice in your state? You can check licensing boards to make sure they remain in good standing. You can also check business records to make sure their business is in good standing.
If you’re a therapist, how can you prepare to move into private practice or update your practice?
- Consult with a professional consultant or with a colleague. If you don’t have a colleague who is more experienced than you in documentation or crisis calls, contact me at at the button below. I’m experienced in clinical decision making during crises in Colorado and New York. I also spent 11 years in non-profits supporting new clinical supervisors, managers, and reviewing intake assessments, treatment plans, and progress summaries for Medicaid compliance.