Identifying a need, creating unique practices

Psychologists develop successful niche practices to provide the services that their communities seek.

By Rebecca A. Clay

"Niche." According to Webster's, the word means both "a recess in a wall" and "a situation or activity specially suited to one's character or abilities." Both definitions ring true for practicing psychologists.

Faced with an unyielding wall of market forces that have made it increasingly difficult to maintain traditional psychotherapy-only practices, practitioners are carving out small openings big enough to fit new careers.

One psychologist discovered he was good at mediating between divorcing spouses and has made that the centerpiece of his practice.

Another specializes in helping clients overcome temporary disabilities.

Still another has built a practice out of half a dozen different niches ranging from psychological evaluations to correctional psychology.

For those who find that traditional practices on their own can no longer sustain them, the stories of these and other successful niche psychologists offer hope and practical strategies.

Take Michael J. Bjornson, PhD, for example. As director of the behavioral medicine program at Intermountain Hematology/Oncology Associates, Bjornson works alongside physicians and nurses to treat cancer patients at several hospitals in Salt Lake City. With a roster of services that includes psychotherapy, biofeedback, hypnosis, meditation, imagery and deep relaxation techniques, he helps patients handle depression, stress and chronic pain and tackles issues such as smoking, weight loss and gain, body image, sexual functioning and genetic-testing decisions.

Perhaps most importantly, Bjornson helps patients adhere to what are often difficult treatment regimens. One patient, for example, got nauseated and sick even just thinking about the chemotherapy medication she had to swallow once a week. Bjornson used biofeedback and systematic desensitization to help her learn cognitive and relaxation skills. Moving from simply looking at the pill bottle to holding the medication in her hands, the patient practiced bringing elevated anxiety levels down. By the end of the fourth session, her anxiety was gone and she was able to take her chemotherapy, thus leading to a better medical outcome.

"There are some exciting data that suggest these services not only improve patients' quality of life but may also lengthen survival time," says Bjornson, adding that he hopes to collect data confirming both his and the oncologists' beliefs that many patients he sees use medical services less frequently and more appropriately. "There's a huge need for these services."

Overcoming disabilities

Helping people overcome temporary disabilities is another growth area for niche psychologists. Al S. Fedoravicius, PhD, who recently retired as psychology service chief of the behavioral medicine program at the Albuquerque Veterans Affairs Hospital, now helps restore functioning to patients who are "excessively" disabled by illness or physical trauma.

Working with Behavioral Therapy Associates in Albuquerque, Fedoravicius starts by consulting with the physician to find out why he or she believes the client's disability is disproportionate to his or her medical problems. If he agrees with the diagnosis, the next step is to probe for factors that are keeping the client entrenched in what Fedoravicius calls "chronic illness behavior."

One clue may lie in family relationships. Clients may use their symptoms as a way of attracting relatives' attention, says Fedoravicius. Their social skills represent another fruitful area for exploration. "It's easier," he says "to say, 'I'm sick' than to say, 'I'm anxious when I have to interact with people.'" Once he's identified the problem, Fedoravicius uses relaxation training and cognitive restructuring. These techniques can be especially helpful for clients with asthma and other breathing problems--a group Fedoravicius believes is especially prone to panic disorders. Panic accounts for about 90 percent of off-hour emergency-room visits among clients with chronic obstructive pulmonary disease, underscoring the need for psychologists and physicians to collaborate.

"Psychologists used to believe that there were medical problems and psychological problems," he says. "But the fact of the matter is that dualism does not exist."

Mediating in divorce

Michael A. Willett, PhD, of Birmingham, Mich., also has a niche not all psychologists would enjoy: divorce mediation.

Willett had a general practice when a high-profile case changed his life. A local court had spent years trying in vain to come up with a custody arrangement a divorcing couple would accept. In desperation, the judge finally turned the case over to Willett. Bringing the couple together in his office, he quickly brokered an agreement.

"Attorneys' training is adversarial," explains Willett, who attributes his success with the case to keeping the couple's lawyers out of the room. "My training focuses on resolving issues. I don't have an allegiance to any specific orientation."

Local courts now refer thorny cases to Willett. So do other therapists frightened off by the high-conflict intensity. As a result, the task of helping couples decide their children's fate in divorce has become an ever-increasing part of his practice.

Over the three years he's been engaged in this work, Willett has developed a standard procedure for helping parents in the throes of divorce. The first step is to see the parents in a joint session, followed by one or two individual sessions. Each parent then completes a document Willett calls a "parent-time agreement," which outlines parents' ideal solutions for such problems as their children's post-divorce residence. After both parents submit their proposals, Willett reconciles the two versions and brings the couple back to his office to "tweak the document" into final form. Once they sign the agreement, Willett forwards it to the attorneys for incorporation into the divorce decree.

Willett suspects this still rare niche will become more common once courts realize that psychologists can save them time, energy and money. But this work isn't for everyone, he admits. You have to be a lot more directive than psychologists are trained to be. And you have to be incredibly patient.

"You're entering the lion's den," says Willett, who thrives on the challenge such cases represent. "You have to be careful to avoid being devoured."

Coaching executives

The niche Connie Bradley Mann, PhD, has filled couldn't contrast more with Willett's. For one thing, she works in an office on the grounds of the five-star Greenbrier resort in White Sulphur Springs, W.Va. For another, she works with clients who really want to see her.

Mann and the physicians at the Greenbrier Clinic offer diagnostic and preventive health services to executives and other upscale guests attracted by the hotel's world-class golf courses, spa treatments and mountain scenery. Guests who decide to add a thorough health checkup to their stay at the resort can ask to see Mann while they're undergoing the two-day evaluation process. Although Mann obviously can't provide full-fledged psychotherapy during the consultations, she can help clients identify issues and suggest ways of tackling them.

"I've been fascinated to discover what it's possible to accomplish with open, motivated clients in one hour," says Mann, who's been at the clinic for a decade.

She cites one client as an example. A high-profile executive feeling overwhelmed by responsibilities, he was reluctant to seek psychological help in his own community. At their initial session three years ago, Mann helped the client devise a stress-fighting plan. At a recent follow-up, they explored reasons for his excessive drinking and discussed possible substitutes for the pleasure alcohol brought him. The client will check in again during a business meeting at the resort this summer.

To expand her reach, Mann has also started offering executive coaching over the phone. This service targets clients who have established a relationship with her during a resort stay and want to keep talking. To avoid problems related to practicing across state lines, Mann limits the service to coaching rather than psychotherapy.

The fact that the hotel hosts dozens of conventions and business meetings a year has encouraged Mann to branch into a new sideline: She has developed several programs she presents to executives or their spouses. One program focuses on healing through laughter; another explores ways of coping creatively in times of rapid change.

Surviving in rural areas

In Wyoming, where antelope outnumber people, the population isn't big enough to support a psychologist specializing in a single niche. Stephen J. Goldman, PhD, hasn't let that stop him. In fact, he has become a master at identifying needs and filling them in a state where psychologists are few and far between.

"You have to develop a lot of niches to compete in this market," he says. "You have to develop ancillary areas to fill out your practice."

When Goldman launched his private practice 15 years ago, he specialized in performing psychological evaluations for Social Security, sheltered workshops, vocational rehabilitation organizations and other agencies that needed screening of current or prospective clients.

As more psychologists started to offer similar services, Goldman sought a new specialty. His role as volunteer clinical director of Wyoming Associated State Incident Stress Team put him in contact with law-enforcement personnel and a new niche: pre-employment assessments for the local sheriff's office, police department and university security office. The only problem? The agencies hire only a dozen or so employees a year.

Eager to expand his skills and his practice, Goldman has now segued into a role as director of mental health services and psychology at the Wyoming State Penitentiary. That doesn't mean he has dropped his other niches.

"I don't sit at home waiting for the phone to ring," says Goldman, who also offers individual psychotherapy, industrial consulting and employee assistance program services on weekends. "I look at the needs of the marketplace and fill them. There isn't a day planner big enough to accommodate all my roles."Y

Rebecca A. Clay is a writer in Washington, D.C.



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