Provisional psychologist, and confused about where to work after graduating? Read this.

6 May

I often have provisional psychologists ask me about career pathways. Where to work, public health vs private practice, solo vs group, not-for-profits — there are all kinds of conundrums which arise.

I’ve worked across most of these settings (with the exception of a private hospital setting), though I caveat that all of my public experience has been in the forensic field, which may be quite different to clinical public mental health work.

Deciding on a clinical work setting (research/academia are other pathways to consider) is a difficult question, and one which will require you to sift through your values, lifestyle needs, interests; and manage your FOMO. I promise you won’t pigeonhole yourself — and there will always be lots of opportunity to move.

Here are some of my thoughts on each of the work settings, and the pros and cons of each. I’ve tried to be unbiased here — I have no skin in the game and am not hiring for a private practice or involved in recruiting for public mental health — but of course inevitably bring biases based on my own experiences.

Public mental health

This may involve work in inpatient or outpatient settings, in hospitals, prisons or community based settings. Essentially, you’ll be employed by the state, or by an organisation largely funded by the state (some are set up as not-for-profits, but receive state funding).

There are large benefits to working in public health — though I notice an increasing shift away from it amongst new graduates. I’ve worked in public health since I graduated and will continue to do so, for values-based reasons (i.e., working with people with complex needs who can’t afford private care) and other lifestyle reasons.

Public health usually involves working within a team, which is best practice clinically when starting out, and allows you to learn from other people in a supported manner. Clients can often bring more complex presentations, which allows you to build strong formulation skills, and you won’t have to worry about things like caps on Medicare session funding. You’ll learn a lot about service delivery and health policy, which are really important aspects of healthcare. There’s often support for professional development and in-house training, legal teams to address thorny questions about subpoenas and risk, and managerial support for risk (and other) issues. You’ll (hopefully!) learn a lot about being a good psychologist.

You’ll need more time to read, train and learn as a beginning psychologist, and public roles often have this built in (e.g., through registrar supervision pathways).

The cons?

Some public health organisations are in a real culture crisis at present, with high rates of bullying, harassment, and occupational violence, and expectations of overtime. The best way to work this out is by asking people who work there about the culture (and remembering that you aren’t stuck if you end up in one of these roles), and asking some specific questions during interviews (e.g., what is the attrition rate? When and why did the last incumbent leave? How long has this role been vacant?). The culture will often differ within organisations, from team-to-team.
Lower remuneration than private practice, with very slowly shifting annual progression. At some stage it’s likely you’ll feel like you’ve topped out from a career progression pathway, unless you want to be a manager. This shouldn’t be a concern for the first 8-10 years though.
Some clinical stagnation, if you work in a specific field and only see the same presentation with no diversity, especially in an acute setting (where there is often more limited therapeutic scope).

Private practice

This type of work involves working in a for-profit model. This could either be in a hospital-based setting, prisons, community agencies, or an outpatient group private practice. I haven’t worked in a private hospital setting — but have heard that the pros and cons can be similar to public mental health, with an added con of pressure to see as many patients as possible, less supervision, and less clinically rigorous practice.
As always, not every organisation — so do your homework.

Employment in a group private practice (again, haven’t done this, but have worked as a sub-contractor in a group practice for almost three years) is a nice way of bridging into private practice in a very supported manner, with supervision, clinical leadership, and team work.

Private practice offers a great diversity of clinical work, and you can specialise as much or as little as you want. Your clients will most often actually want to be there, it can be easier to achieve positive outcomes thereby increasing satisfaction, and you can hone your clinical skills and learn new ones. There are private practices offering all kinds of work at present, including assessment, report-writing, and group work.

Practices can be of varying quality, and the main things I would look for are things like fairness of pay, whether pay and leave structures at least match the public system (and ideally surpass), no requirements of weekend/after-hours work unless you consent and are offered penalty rates, reasonable expectations of client load (e.g., any practice mandating you see 6-7 clients per day as a beginning psychologist is going to burn you out very quickly), and professional development opportunities.

Sub-contracting in a group practice is another way, and allows you the support of directors who know what they are doing, administrative support, rooms, referral and marketing support, and a team to work with. This is usually a fee split model, with a 50/50 split more common if you are just starting out, often moving into a 60/40 split. 70/30 tends to be offered more rarely, and most often from bulk-billing practices only (which come with their own set of challenges). I’m deliberately sharing these specific figures because there is so much reticence around discussing money, and such secrecy, which inhibits people from making informed choices.

If you sub-contract, ensure that you are actually afforded the advantages of sub-contracting, i.e., control over your diary, days and hours of work, choice of leave dates (e.g., you shouldn't be mandated to work over certain periods), an appropriate minimum billing expectation (5 clients/day* is usually what is needed to make things sustainable from the practice end), choice of client presentations, and ability to set your own fee. You don’t want to be a sub-contractor with the expectations of an employee, but none of the perks (leave, superannuation).

I very strongly support people commencing their private practice careers in a group practice. There’s so much to learn, and so many policies to be aware of — going solo straight after finishing your degree likely means you probably won’t be equipped with the clinical or procedural knowledge you need, and your clients will thus likely not have optimal outcomes.

Cons?

It can be difficult to know which practice will be a good fit for you, with appropriate governance and clinician care. There are so many group practices, with differing standards of quality. Some practices may have less-than-ideal ethical stances in relation to client or clinician care, with a focus on profits > people.
Financially, working in an employment model might start to rankle over time, and subcontracting work might seem more appealing.
The hours and pay of contracting may seem appealing, but remember that you will likely be doing some work on your own time (e.g., writing letters, treatment planning). In public work, this is all absorbed into your day. I usually estimate 1-1.5 hours of extra work for a full client day.
From a workload perspective, private practice usually entails seeing clients for a bulk of the day, and it can be difficult to sustain this, without the buffers of meetings etc which usually come with public work. Of course, this will depend on your temperament, capacities, and needs.
Private practice work can often be restricted to client-facing work, which makes it difficult to develop competencies in other areas such as health policy or service development.

Going Solo

The big one.

This is what I thought I’d be doing when I imagined being a psychologist, and I’ve only just launched into this on a part-time basis, with the full understanding that I may well choose to go back to a contractual role (or some other sort of work) if the demands of running a business prove too onerous.

I have seen an increasing trend of newly qualified people moving straight into solo work. I very strongly recommend that people who are newly qualified seek a more supported work environment initially.

Working solo requires a reasonable level of clinical competence, awareness of legislative requirements and best practice - all of this takes time to build. Going solo means you are entirely responsible for the business — the marketing, referrals, structure, policies, clinical practice, finding supervision etc. It’s wonderful, but a big task — and perhaps one to launch into only once you have the clinical and procedural basics down.

Other settings

Other settings might involve schools, not-for-profits, privately funded organisations, and the corporate sector. Stepping outside primary healthcare settings will usually mean that you will need to know the psychology code of ethics very well, and be prepared to advocate for yourself and the specific needs of a psychologist (e.g., privacy around case notes, access to supervision by a psychologist).

These roles can be very interesting, but I’d recommend that you ensure that you have adequate supervision so you can build your skills in competent and ethical psychological practice.

General guidelines?

Think carefully about your values and lifestyle needs, and what sort of work that might be aligned with. Are you are a stage in life where you need more flexibility? Are you saving for a house deposit? Are you burnt out and want a slower pace? Do you need part-time work? Do you need hybrid work? Would you prefer to work closer to home? There are many things to weight up, and these are all valid questions.

It's probably not your dream job if it's a 1.5 hour train ride away. It’s definitely not your dream job if it requires that you sacrifice your health and well-being.
Consider a blend. Working part-time in two roles (I’ve found that three roles reliably burns me out) might be a good mix, and will bring clinical diversity.
What are your core learning needs? Which role will best meet those? Where will you have the best supervision?
How will you be treated? Putting everything aside, being a psychologist is hard work, and working within a team where you feel comfortable, safe and valued is essential.

*I still think this is likely too high for many early career/beginning psychologists.

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Disclaimers:

Views my own only.
This is general commentary, not specific career advice.

Ahona Guha