January 29, 2012

Public versus Private

Last September, I started a clinical internship at a chronic pain centre in one of Montreal's hospitals. A few weeks ago, I started a concurrent training program at a private psychology clinic. The differences between these two experiences are striking:

Physical environment and space. The pain centre is housed in a small wing of a large hospital, and there is a distinct lack of space. The clinic director and associate directors have their own offices, but the part-time doctors, visiting fellows, residents, and psychology interns shift around as needed, sharing offices and computers. The rooms in which we see patients are relatively barren, with fluorescent lighting and hospital beds; on busy days when no rooms are free, psychology staff have been known to see patients in the conference room and the kitchen.

In contrast, the office at the private clinic is lovely--exposed brick, plants, and tasteful, comfortable furniture. The handful of therapists all take turns using the office, but when I book it, it's mine and there's no risk of having to conduct psychotherapy in the kitchen.

Multidisciplinary collaboration. At the pain centre, we have biweekly meetings to discuss patients as a team; rheumatologists solicit advice from anesthesiologists, internists seek advice from psychologists, and I learn a lot. If during a session with me, a patient has a question about medication or another component of his medical treatment, I can usually snag a doctor in the hall and get him or her to join us for a few minutes. Sometimes pain centre doctors come into the psych office to see if one of the psychologists or interns is free to sit in on an appointment with a patient and provide an on-the-spot psych evaluation.

Private practice is much less multidisciplinary. At the private clinic, I'm by myself or with my supervisor, who is a psychologist. If I need to, I can (with the client's consent) contact his or her GP or psychiatrist, but it's not usually necessary.

Social support and interaction. At the pain centre, after my patient leaves, I usually go across the hall to discuss the session with my supervisor. I might get stopped on the way by the patient's doctor, wanting to know the result of my psych evaluation; by a anesthesiology resident who wants to know more about CBT; or by a fellow psych intern who wants me to read over a report she's written.

At the private clinic, when the client leaves, I'm by myself. I can call my supervisor at any time, but I'm physically alone and it's easy to see why some therapists find private practice lonely.

Patients versus clients. At the pain centre, we use the term patient rather than client. To me, this term fits because the pain centre is part of the public healthcare system (i.e., it's not for profit, services are free, and everyone has access) and because it's primarily a medical clinic. The advantage: many patients have been waiting months for an appointment and are therefore grateful to be seen and unfazed by an extra hour in the waiting room or by psychotherapy in the kitchen. The disadvantage: some patients aren't keen on seeing a psychologist, agreed to it only because their pain centre doctor insisted, and have no qualms about missing appointments without calling.

In private practice, I see clients--people who have researched and chosen the clinic where I work from among many options, and who are paying to see me. This creates a different dynamic, wherein the client is more of a consumer. A therapy hour is always fifty minutes, both client and therapist are expected to be on time, and clients are unlikely to miss sessions without calling. Unlike in the public system, all of my clients are people with the time, money, and motivation to seek psychotherapy.

Although I'm new to both positions, I suspect that the differences I've observed reflect global differences between working in a hospital or other public clinic and working in private practice. There are clear advantages and disadvantages to both milieux, and it's not hard to see why nearly every psychologist I know works in both.


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