Private practitioner can work profitably with marginalized populations

By Fran Shahar, Ph.D.
July 1, 2008



What is public interest psychology?
Any time we help heal people who feel damaged or impaired in their ability to enjoy life and participate, we are engaging in the public interest. It is important not to trivialize anyone’s pain or quest to feel whole.

Beyond the individual we serve, each person is part of larger and larger systems that have ripple effects: that person within the family, his or her neighborhood, job and the world. In that sense, any good therapy we do is part of the larger good in that it contributes to repairing the world.

Primary, tertiary and secondary prevention are crucial to the public interest, be they through advocacy, education, treatment or public policy. An ounce of prevention is better than a pound of cure. The best treatment is not having to do any treatment at all. If we can work with people before they damage the next generation or before they inflict violence on someone else or themselves, that’s much better than trying to pick up the pieces afterward and all of that is part of engaging in the public interest. On one level then, any good psychotherapy is psychotherapy in the public interest.

Working with marginalized populations
There is another level of public interest psychology that includes working with marginalized populations. The public mental health system is in a state of crisis. Mental health centers keep closing. In Georgia, case managers are forced to have caseloads of 200 or more clients. No one can give or receive quality care under those circumstances, especially to clients who generally have the fewest resources, psychologically and economically.

Through Medicaid and Medicare reimbursement, it is possible to see people who formerly would have been treated at a mental health center without having to give your time away. Medicaid and Medicare both pay as much or more than managed care companies and help make mental health care accessible to the poor and disabled. (In the case of Medicare, the client is responsible for $50 and the government pays $50.) Using a billing company is not very expensive and takes the pain out of filing and tracking claims. In addition to public funding, most psychologists have some kind of sliding scale and are required by our Ethics Code to give back to the community through pro bono work.

There is a Jewish saying from the ethics of our ancestors: It is not incumbent on us to complete the task, but neither are we free to refrain from doing anything. One of the great rewards of working with marginalized populations is that of tertiary and secondary prevention and the ability to effect social change, one by one. The more we as a profession encourage each other to do this, the more we can help improve the common good.

Specializing in the treatment of one or more marginalized population is also good business sense. For example, there is a tremendous need for people who are able and willing to work with people with severe and persistent mental illnesses (or the families thereof), refugees, severe trauma survivors, diversion courts, kids in the foster care and/or juvenile justice systems and people in nursing homes.

You don’t have to create an agency or non-profit to work with marginalized populations. You need to have the desire to make yourself available to people who would otherwise most likely not get served. As with any area of practice, you have to develop competency in that area through supervision, reading, workshops etc. Good intentions are not enough. You also have to realize that no population is homogeneous and that all groups have racial, cultural, gender, class and sexual orientation differences.

You need to familiarize yourself with the special needs of the population of interest and make the necessary connections within the community to help facilitate meeting those needs. For example, I work with many clients with Bipolar Disorder and have a couple of psychiatrists I can call on their cell phones and coordinate immediate crisis management, often while the client is sitting in my office.

Risks and benefits of working with marginalized populations
Marginalized populations are marginalized because they lack access to resources. Many are poor, socially isolated and in need of multiple services. At times the multitude of problems may feel overwhelming to the therapist. The therapist may be called upon to assume tasks usually associated with intensive case management. This requires more knowledge and collaboration with community resources and can be frustrating and time consuming.

In addition, the course of therapy is likely to be different from talk therapy with a YAVIS (young, attractive, verbal, intelligent and successful) client and may include more coaching and psychoeducation. Some marginalized clients may be at greater risk of harm to self or others, for which the therapist needs to be vigilant. It is important for the therapist to maintain balance by not having too many high-risk clients and by making sure that he or she has the necessary resources to replenish himself or herself.

A person may have a severe and persistent mental illness, for example, but it need not be the sum total of that person’s identity. Even the most difficult and disabled clients can have fuller lives. The therapist needs to remind himself or herself that small increments of change can make enormous differences in the quality of someone’s life. This is an important factor to prevent burn-out in the therapist.

We are all imprisoned by the boundaries of our own limitations. The goal of good therapy is to help the person find greater and greater spheres in which to function and enjoy life by extending those boundaries. Freud referred to this as our ability to love, work and play. To know that one has been a part of helping someone move from a position of disempowerment and disengagement to more empowerment and more engagement is not only a public service, it is a tremendous gift to the therapist.

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Fran Shahar, Ph.D., is a licensed psychologist in private practice in Decatur, Ga. She can be reached at (404) 235-1171 or at fshahar@mac.com.

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