Victor Yalom: Well, Nick, good to have you here at the Brief Therapy Conference in San Diego, 2008. I believe you’ve long been a proponent of brief therapy and intermittent therapy throughout the lifespan.
Nick Cummings: Correct. In fact, I started that in the 1950's.
VY: Really? Tell me about that.
NC: I was trained as a psychoanalyst and went into a psychoanalytic practice in San Francisco. I did this for a number of years and decided that if I were lucky—I had an epiphany one night—that by seeing patients four times a week for seven years, in my entire lifetime, if I live long enough, I might touch 70 lives. And it occurred to me that that's not why I became a psychologist.
VY: Now, for some people, touching 70 lives deeply would seem like a good thing.
NC: Well, in those days there was no prepayment, so it was essentially treating the diseases of the rich–people who could pay. And to pay for four sessions a week, you had to have some money. It occurred to me that there was a great need out there among working people that didn't have these services available. If they had mental health issues—in those days all you had was psychoanalysis—they didn't go into it. Minority groups—for example, African-Americans—turned to religion when they had distress, because psychotherapy wasn't available to them. We were the first program to make it available to them for free. And the idea that African-Americans didn't go into psychotherapy turned out to be a myth, because when we provided it, we had many African-Americans in the late 1950's in our program in San Francisco. So after practicing psychoanalysis for a while, and butting up against the psychoreligion of the San Francisco Psychoanalytic Institute, which was absolutely rigid in those days, I decided this was not what I wanted to do, and I was wondering what I was going to do.
My wife said to me one day, "Kaiser Permanente is looking for a chief psychologist." So I applied, found out there were some 56, 58 people that applied, and I made the final cut of half a dozen finalists. In my interview with the founders of Kaiser Permanente, which was very young in those days—Kaiser Permanente was formed post-World War II—they said to me, "If you take this job, you've got to agree that for the first six months we can fire you with no questions asked." I found out later I got the job because the other five finalists said, "No way," and they withdrew. To me, that was like waving a red flag in front of a bull.
My wife said to me one day, "Kaiser Permanente is looking for a chief psychologist." So I applied, found out there were some 56, 58 people that applied, and I made the final cut of half a dozen finalists. In my interview with the founders of Kaiser Permanente, which was very young in those days—Kaiser Permanente was formed post-World War II—they said to me, "If you take this job, you've got to agree that for the first six months we can fire you with no questions asked." I found out later I got the job because the other five finalists said, "No way," and they withdrew. To me, that was like waving a red flag in front of a bull.
VY: You liked the challenge.
NC: I loved the challenge. "I'm going to take this job and I'm going to show you that I can succeed." After I started, I found out why they had made this challenge: my predecessor had been Timothy Leary. Do you remember Timothy Leary, the High Priest of LSD? He was the chief psychologist of Kaiser Permanente before me.
VY: Wow, who would’ve thought that?
NC: This was before he went to Harvard and got into LSD and so forth. But he was so interested in doing research that they couldn't get him to send one of his people over to the hospital to do a bedside consult. So one day, Sidney Garfield told me—Dr. Garfield was the founder of Kaiser Permanente—he came to work and the second thing he did was hang up his coat. The first thing he did was pick up the phone and fire Tim Leary. And then he decided that he didn't want anything more to do with psychologists. They went for a couple of years without them, but then decided they couldn't get along without them. And Dr. Garfield, interestingly, although he was a physician, didn't want the department vested in psychiatry. He wanted psychologists doing the work, because Kaiser Permanente was beginning to realize that a lot of the so-called medical conditions were really emotional problems translated into physical symptoms. And they said, “A psychiatrist is ultimately a physician”–wearing white coats in those days—“and it's just going to ingrain in the patient that this is a physical issue.” So he wanted it done by psychologists. Two years later he decided he was going to try again; I was interviewed, and I stepped into that post.
VY: You’ve had obviously a long, illustrious, and sometimes controversial career; we could spend hours going through all of it. So to be brief, what were a few of the things you did at Kaiser that you thought were instrumental?
NC: The first thing: in those days, you never started therapy until you did a social worker intake. Then, after the social worker intake, you did a battery of tests. Those were absolutely mandatory before therapy could start.
VY: Was this just at Kaiser?
NC: No, this was the United States! And the battery of tests were the ubiquitous Wechlser Intelligence Scale, Rorschach, Thematic Apperception Test, the Bender Gestalt, and the Machover Draw-A-Person. You had to do those five tests—it was written in the bible of psychotherapy in those days.
VY: Wow. I had no idea.
NC: Before you did the battery of tests, you had a social worker do an intake interview. By the time the therapist saw the patient, the patient had told his or her story two other times. Now this was the third time. We eliminated the first two. Everybody said, "They're going to be sued up the kazoo. This will not work." We never got sued. The first person to see the patient was the therapist.
VY: Makes sense.
NC: Which is what we do now! That was radical in 1957. It worked. So that's one of the things we did.
I had the power to hire eleven psychologists, twelve of us in all. And I had my own psychoanalytic couch, being trained as a psychoanalyst, so I ordered eleven more psychoanalytic couches, all with nice tufted black leather, just like Freud's. We started seeing plumbers, carpenters, bus drivers, restaurant servers…
I had the power to hire eleven psychologists, twelve of us in all. And I had my own psychoanalytic couch, being trained as a psychoanalyst, so I ordered eleven more psychoanalytic couches, all with nice tufted black leather, just like Freud's. We started seeing plumbers, carpenters, bus drivers, restaurant servers…
VY: How many times a week? Would you see them more than once a week?
NC: We insisted in the beginning we had to see them twice a week at least. And we'd ask them to lie on the couch, but they were uncomfortable. They'd want to get up off the couch. So I had another epiphany.
I saw a working class man that had back trouble. He’d exhausted all 33 orthopedic surgeons at San Francisco Kaiser, and they all decided, "This is all in your head; go see the shrink." I asked him to lie on the couch. He said, "Sure, Doc," and he lay on the couch face down. I said, "No, no, you don't understand. I want you to lie on your back." He turned over and said, "Sure, Doc, but how are you going to examine my back if I'm lying on it?" I said, "No, no, no, I'm not going to examine your back." He said, "What are you going to do, Doc?" I said, "We're going to talk." "Oh!" He jumped up off the couch, grabbed a chair, put it opposite me, sat down, and said, "OK, Doc, what do you want to talk about?"
So we decided to get rid of the couches. We called up Goodwill and when they came out to pick them up they looked at them and said, "What are these? Nobody can sleep on them: they slope. You can't sit on them because they don't have a back. We don't want them." They refused 12 couches! So I called up the Salvation Army. They came out and they said the same thing: "These are ridiculous, what are we going to do with these?" So I called up St. Vincent de Paul. And I told them we had 12 nice black leather tufted couches that we wanted to give away. I got my staff—we were on the third floor—and I said, "We're going to take these couches and we're going to carry them in the elevator and stack them up on the street on the corner. And I'm going to stand out there." When the truck pulled up at the appointed time, they said, "We don't want these." I said, "They're yours. I'm going to walk away, and if I have to call the police that you're littering the sidewalk… Because they're yours, you agreed to take them." That's how we got rid of the couches! So we started seeing patients face-to-face. I was immediately declared a traitor from psychoanalysis.
I saw a working class man that had back trouble. He’d exhausted all 33 orthopedic surgeons at San Francisco Kaiser, and they all decided, "This is all in your head; go see the shrink." I asked him to lie on the couch. He said, "Sure, Doc," and he lay on the couch face down. I said, "No, no, you don't understand. I want you to lie on your back." He turned over and said, "Sure, Doc, but how are you going to examine my back if I'm lying on it?" I said, "No, no, no, I'm not going to examine your back." He said, "What are you going to do, Doc?" I said, "We're going to talk." "Oh!" He jumped up off the couch, grabbed a chair, put it opposite me, sat down, and said, "OK, Doc, what do you want to talk about?"
It suddenly hit me that everybody in the world knows that when you talk to people, you talk face-to-face–except psychoanalysts.
It suddenly hit me that everybody in the world knows that when you talk to people, you talk face-to-face–except psychoanalysts. You have to sit behind the couch so the patient can't see you.So we decided to get rid of the couches. We called up Goodwill and when they came out to pick them up they looked at them and said, "What are these? Nobody can sleep on them: they slope. You can't sit on them because they don't have a back. We don't want them." They refused 12 couches! So I called up the Salvation Army. They came out and they said the same thing: "These are ridiculous, what are we going to do with these?" So I called up St. Vincent de Paul. And I told them we had 12 nice black leather tufted couches that we wanted to give away. I got my staff—we were on the third floor—and I said, "We're going to take these couches and we're going to carry them in the elevator and stack them up on the street on the corner. And I'm going to stand out there." When the truck pulled up at the appointed time, they said, "We don't want these." I said, "They're yours. I'm going to walk away, and if I have to call the police that you're littering the sidewalk… Because they're yours, you agreed to take them." That's how we got rid of the couches! So we started seeing patients face-to-face. I was immediately declared a traitor from psychoanalysis.
VY: So your traitor status started early in your career.
NC: Very early in my career–actually much earlier, before I became a psychologist, but anyway, that's another story.
Your Therapist for Life
So we started seeing patients face-to-face, and instead of asking them to free-associate, which working people didn't know how to do… See, up until that time, the only people we treated were the educated class who had read about psychoanalysis and were eager to try it. So when you'd say, "Free-associate," they would do it. These people didn't know how to free-associate. They knew how to talk. We started listening to them and began to develop focused, targeted therapy addressing the problem. Do you remember a man named Michael Balint?VY: Heard the name.
NC: Michael Balint helped found mental health in the British universal health system after World War II. In his 1950 book, The Doctor, the Patient, and the Illness, he said that physicians have to become more like psychologists, and psychologists have to become more like physicians. He said that the idea that a psychologist is going to treat a patient so that for the rest of his life he will never have another neurotic symptom is insane. It's crazy. Physicians don't practice that way. You come in, you have the flu, you're treated for the flu. After the flu is cured, you're dismissed. But two or three years later, you may come in with a leg injury, with a fall, with whatever. And you're treated for that. Psychologists should treat people for the condition that brings them in.
VY: There’s no magical, comprehensive cure.
NC: That's right. So we started doing that, and the hostility was enormous. We never terminated a patient. When we got to the place where the patient said, "Gee, Doc, I'm feeling great, do I have to come in?" I'd say, "No, we're going to interrupt our treatment. Just like you go to your doctor for your physical problems, you come here if you ever have another problem that you can't solve yourself."
VY: People don’t have the idea if the doctor cures an illness or a virus, that that’s the end of their relationship with the doctor.
NC: Exactly. We extrapolated that into psychotherapy. This was absolutely heresy in those days. I was attacked, not just by psychoanalysts, but by colleagues. And it worked because the patient could come in for life. We began calling itbrief intermittent psychotherapy throughout the life cycle. "I am your doctor for the rest of your life." And the interesting thing was we found out it was transferable—that patients who might not have come in for four years would start talking as if they'd been in last week.
VY: Kind of like old friends: if you don’t see a friend for a long time, you pick up where you left off.
NC: Exactly. I might not remember the last conversation that well, but they did. And it worked. Now, they didn't know that there were other forms of treatment, but for what we were doing, it worked. And Kaiser said, "How do we know that these people are doing well?"–because calling them up and asking them "How are you feeling?" is unreliable.
Kaiser got interested in psychotherapy because they found out that 60 to 70 percent of their physician visits in primary care had psychological, not medical, conditions. So we decided to follow these people the year after they'd been in, the second year after, the third year, and see what their overutilization of health care was, because they would be running to the doctor when they actually had psychological problems. We found that we were reducing medical overutilization by 65 percent within five years after the initial contact, with no further therapy. And that's how the medical cost offset attracted the National Institute of Mental Health, the Veterans Administration, and so forth. We started a series of research.
The acceptance in medicine was terrific. The acceptance from government in Washington was terrific.
He convinced us that we were going in the right direction. A lot of my staff was beginning to chafe under the attacks, but all of this bolstered our resolve and we kept going, and we'd write about it and we'd publish. All of us became consultants in Washington, D.C. over this. For example, I became a consultant to Ted Kennedy when he was head of the Senate subcommittee on healthcare. At the same time, I was in private practice.
So this is how we developed the model of brief intermittent psychotherapy throughout the life cycle. Later we changed it to focused intermittent psychotherapy because our adversaries had made such a dirty word out of "brief." We decided to call it "focused" or "solution-based" or whatever.
Kaiser got interested in psychotherapy because they found out that 60 to 70 percent of their physician visits in primary care had psychological, not medical, conditions. So we decided to follow these people the year after they'd been in, the second year after, the third year, and see what their overutilization of health care was, because they would be running to the doctor when they actually had psychological problems. We found that we were reducing medical overutilization by 65 percent within five years after the initial contact, with no further therapy. And that's how the medical cost offset attracted the National Institute of Mental Health, the Veterans Administration, and so forth. We started a series of research.
The acceptance in medicine was terrific. The acceptance from government in Washington was terrific.
The rejection from my colleagues was intense. I was accused of destroying psychotherapy singlehandedly.
The rejection from my colleagues was intense. I was accused of destroying psychotherapy singlehandedly. And I said, "Well, it's just a pleasure to learn I'm that powerful." But nonetheless, this is what I had to put up with. I contacted Michael Balint and asked if he could come to San Francisco and spend a week with us. And I wanted him to meet with our psychologists and physicians. He asked, "Can I bring Alice?"—his wife. Victor, we got both of them for one week and we would go from morning, have dinner, and go into the evening. We got him and Alice for one week, not counting airfare and hotel, for $1000. Both of them, in the late 1950's.He convinced us that we were going in the right direction. A lot of my staff was beginning to chafe under the attacks, but all of this bolstered our resolve and we kept going, and we'd write about it and we'd publish. All of us became consultants in Washington, D.C. over this. For example, I became a consultant to Ted Kennedy when he was head of the Senate subcommittee on healthcare. At the same time, I was in private practice.
So this is how we developed the model of brief intermittent psychotherapy throughout the life cycle. Later we changed it to focused intermittent psychotherapy because our adversaries had made such a dirty word out of "brief." We decided to call it "focused" or "solution-based" or whatever.
VY: Now, how did you get from there to starting the California School of Professional Psychology, the first independent professional school?
NC: I found out, in talking to students in the late 1960's, that the same conditions were extant with them that were there when I went through a doctoral program. Clinicians were not allowed to join the faculty. They had to have lots of publications, etc. etc.—all things clinicians don't do, because clinicians are busy seeing patients. So I started working with the education and training board of the APA to try to change the rules of APA accreditation to allow clinical faculty to be brought on board with the same status as nonclinical faculty. I utterly failed. Finally, one night in the middle of the night, I couldn't sleep and I had another epiphany. I said, "I have to start our own school." I was president of the California Psychological Association at the time; Don Schultz was our executive officer. The next morning I could hardly wait to tell Don my idea. And Don started saying, "You know, Nick, you're working a little bit too hard. I think you should maybe take a rest." I suddenly realized Don was treating me like I was having a psychotic episode or something with my idea.
VY: It seems work is what drives you and keeps you alive.
NC: It's invigorating. Especially if it's innovative.
I have to change careers every seven years because once I succeed at something, administration bores the dickens out of me.
I have to change careers every seven years because once I succeed at something, administration bores the dickens out of me. I have to go out and create again. This is why we're forming this new program.VY: We’ll get to that in a second.
NC: So anyway, Don says, "How are you going to pull this off?" Ronald Reagan was governor of California in those days. No friend of psychology. But Reagan was having a fight with the University of California on the Board of Regents. And I knew that he might listen to this idea, not because he liked psychology, but because he wanted to do something to the Board of Regents.
VY: They say politics makes strange bedfellows.
NC: Absolutely. He had an administrative assistant named Dr. Alex Shariffs who had been Dean of Students at Berkeley, and I knew Alex. So I called Alex up and said, "Can you give me an appointment with the governor?" "Oh, what's this about?" When I told him, he said, "Hey, that sounds like a great idea!" So he arranged it. When we walked in, the governor said, "Dr. Cummings, today is very busy." They were having the eruption on the San Francisco State College campus.
VY: Yeah, late 60’s.
NC: Yeah. "You've got 20 minutes." We were there for almost two hours. Once he heard it, he kept asking questions. Finally he said, "Dr. Cummings, I'll make a promise to you. You get a first-class faculty, a first-class library, you get an endowment and a curriculum that makes sense, and I will order the head of the department of education in the state of California to accredit you."
VY: That’s a dramatic story.
NC: I thought, "How do I get a first-class library? This takes millions of dollars." I discovered in my research that any Ph.D. in the state of California had complimentary access to the Berkeley and UCLA libraries. So I got a card and all of my students got duplicates. And they all used the University of California libraries, using my card.
VY: So they were all using Nick Cummings’s card!
NC: We got it later amended that any doctoral student could use the state facilities. When we got it changed, they had their own cards as bona fide doctoral students. So we solved the library problem. We got a first-class faculty because I got 200 psychologists to volunteer to teach for free for 18 months—they would all teach one course. And they loved it. And this was sort of like our endowment. Teaching free for 18 months launched us, because we didn't have the money up front.
VY: That’s a lot of free labor.
NC: A lot of free labor, but it was very productive free labor. They loved it, and they loved interacting with our students. And we had a very innovative program.
Originally we started with the San Francisco and Los Angeles campuses. The San Francisco campus was above a machine shop.
Originally we started with the San Francisco and Los Angeles campuses. The San Francisco campus was above a machine shop.
VY: I heard about that. I heard there were pillows on the floor and all the students had to be in group therapy.
NC: Yep, absolutely. But when the big machines were running on the first floor, the whole second floor would shake and vibrate. The Los Angeles campus was in a condemned Elks Lodge, and the building was right on MacArthur Park and was due to be torn down. We got it for nothing. But the problem was, right in the middle of class there could be plaster falling off the walls. But within a year we got enough money, got our own facilities, and moved out of these. And then we founded the San Diego and finally the Fresno campuses. And this launched the professional school movement in the United States. So today, even though the APA has accredited doctoral programs, there are clinician faculty members in universities.
VY: Before we get to the new program you’re launching, what are your thoughts on the status of professional school education now?
NC: It has failed.
VY: How so?
NC: I formed the National Council of Schools of Professional Psychology—NCSPP. And I had set it up with Washington, the department of education, that it would be the accrediting body for the professional schools. Remember that our first classes at CSPP were in the 1970's; I founded it in the '69-'70 school year. We held our first meeting, and I said, "I'm doing the last thing for the professional school movement." We had to ratify the articles of incorporation, etc., etc., and elect a president. They elected Gordon Derner, who was my mentor at Adelphi. Gordon had run three times for APA president and lost, and he wanted APA respectability. He talked the group into going for APA accreditation, which was the biggest mistake–they signed their death knell at that point because the APA made them hire full-time faculty. Now, I could get ten to 12 part-time faculty to teach 12 courses for the same cost of hiring one faculty member who taught two courses. So we had created the business basis for the professional schools to succeed even though they were tuition-dependent. But once they had to get full-time faculty, they couldn't make ends meet. What they're doing now, unfortunately, is turning out hoards of master's-level practitioners and PhDs. They're accepting 900 GRE scores—it used to be if you weren't 1600, you couldn't get in. And they're flooding the market because they need the tuition. In that sense, they've failed.
VY: You’re known for making strong statements, and to say “failed” seems… There are certainly lots of good programs, and lots of good psychologists coming from these programs.
NC: And there are lots of very poor psychologists coming from these programs. I say about them that some of the best psychologists I've ever worked with came from the professional schools, and some of the worst have come from these same professional schools. The range of ability is incredibly large. The old saying that you can't make a silk purse out of a sow's ear also applies that you can't make a sow's ear out of a silk purse. The bright students do well, and they flourish in the professional schools. And then there are students that limp through.
VY: Jumping ahead, you’re starting a new program this coming fall: the Nicholas Cummings Doctorate in Behavioral Health. What’s the idea behind this?
NC: The idea behind this is we have launched a plethora of professions out there. We not only have psychologists; we have social workers, we have MFTs, and we have MA-level counselors. All of these organizations fight each other. And when the newer organizations are looking for licensure, the older organizations fight them, just like psychiatry tried to prevent psychology from getting licensure. We tried to prevent social work from getting licensure. We now try to prevent MFTs from getting licensure, master's-level counselors from getting licensure. So we have created a very antagonistic atmosphere with a profession called psychotherapy that is fractionated into organizations that are fighting each other.
Also, we have drifted so far away from health care that we have created two silos. We have a huge silo called health care, and it gets a trillion dollars a year. And over here we have a tiny silo called mental health that gets the crumbs. In the last ten years, where we've passed parity in 44 states, the portion of the budget that goes to mental health has dropped from 8 percent to 4.5 percent—almost half.
Also, we have drifted so far away from health care that we have created two silos. We have a huge silo called health care, and it gets a trillion dollars a year. And over here we have a tiny silo called mental health that gets the crumbs. In the last ten years, where we've passed parity in 44 states, the portion of the budget that goes to mental health has dropped from 8 percent to 4.5 percent—almost half.
VY: Parity hasn’t helped.
NC: Parity has done nothing, because when you pass parity, the managed care companies either create more herculean hurdles for mental health and for physical health, or they drop mental health altogether from their package. So we have declined by almost 50 percent in funding; the mental health silo's getting smaller and smaller. The American people pay for health care. They do not pay for mental health care on federal funding. That is an afterthought; it's the crumbs.
Until we become an integral part of health care, we will always, always get the crumbs.
Until we become an integral part of health care, we will always, always get the crumbs.VY: So how are we going to do that, and how is your program going to help with that?
NC: Our program trains master's-level psychotherapists who've been in the field for several years and are savvy. They've been up against the world of hard knocks; they know what it's like out there. They know that psychotherapy has declined by 40 percent in the last decade. They are ready to upgrade and learn a new profession called behavioral health provider, to work in medical settings side by side with primary care providers, with equal status. You can't work in a medical setting unless you're called "doctor"—there is that chauvinism.
VY: So how are they going to get equal status? Even psychologists don’t get equal status.
NC: Psychologists go into medical settings and they make fools of themselves. They don't know a type-II diabetic from a type I-diabetic. They make so many errors, they don't know what medical protocol is, and they don't know how the health system works–they've been isolated in this other silo. So they're not accepted. Then they become defensive. They see that medicine is relegating us to a lower status. When we integrate behavioral care providers into primary care settings on a ratio of one BCP to six PCPs—BCP being behavioral care provider, PCP being primary care physician…
VY: One behavioral care provider to six physicians?
NC: In some systems they've loved it so much they've upped it to three—twice as many as our original model.
You always have to have at least two BCPs in every medical setting, because one is doing the treatment while the other is doing what we call the “hallway handoff.” When a physician is seeing one of the 60 to 70 percent of her or his patients that have severe psychological issues, instead of writing out a prescription and getting the heck out of the office—because they've learned that if this patient opens up and collapses and cries, they're stuck there for the next hour, and they have a waiting room full of patients—they can say, "You know, Mr. Smith, Dr. Jones, my colleague down the hall, I think can help us with your case." And the physician walks Mr. Smith only a few steps down the hall to Dr. Jones's office. And Dr. Jones is a behavioral care provider. The physician introduces the patient to Dr. Jones, and they sit down–the primary care physician doesn't dump the patient–they sit down, but only for a couple of minutes. And then he excuses himself, goes back to his office. The BCP takes over and does a 15- to 20-minute interview. They have been trained to engage the patient in treatment.
Now, Victor, the amazing thing is, we've done this with the U.S. Air Force, we've done this with several VA centers, we've done it in TRICARE [U.S. Military Health Plan], with returning veterans, and in community health centers. I named it the hallway handoff and the term has stuck. Eighty-five to 90 percent of patients who experience the hallway handoff will follow up and get into treatment, whereas when the physicians makes a referral to an outside therapist…
You always have to have at least two BCPs in every medical setting, because one is doing the treatment while the other is doing what we call the “hallway handoff.” When a physician is seeing one of the 60 to 70 percent of her or his patients that have severe psychological issues, instead of writing out a prescription and getting the heck out of the office—because they've learned that if this patient opens up and collapses and cries, they're stuck there for the next hour, and they have a waiting room full of patients—they can say, "You know, Mr. Smith, Dr. Jones, my colleague down the hall, I think can help us with your case." And the physician walks Mr. Smith only a few steps down the hall to Dr. Jones's office. And Dr. Jones is a behavioral care provider. The physician introduces the patient to Dr. Jones, and they sit down–the primary care physician doesn't dump the patient–they sit down, but only for a couple of minutes. And then he excuses himself, goes back to his office. The BCP takes over and does a 15- to 20-minute interview. They have been trained to engage the patient in treatment.
Now, Victor, the amazing thing is, we've done this with the U.S. Air Force, we've done this with several VA centers, we've done it in TRICARE [U.S. Military Health Plan], with returning veterans, and in community health centers. I named it the hallway handoff and the term has stuck. Eighty-five to 90 percent of patients who experience the hallway handoff will follow up and get into treatment, whereas when the physicians makes a referral to an outside therapist…
VY: They’ve got to first have the courage to call the person, set up an appointment, go across town.
NC: Only 10 percent get there.
VY: Wow.
NC: Literally only 10 percent. So this increases our patient flow by 900 percent! It's amazing. And it's consistent. Cherokee Health System in Tennessee has adopted this model. It's going great guns. Native Americans are really getting engaged in treatment because there's no stigma. This is a seamless part of the health system. You're not being abandoned by your physician and thrown into a mental health system where, "Oh gosh, my doctor thinks there's something wrong with my head." Even if they know this is a behavioral care provider, they see it as part of the health system, and the stigma is gone. It solves access, for crying out loud. You know, I have decided that we perpetuate stigma and access in our current practice, inadvertently.
VY: How so?
NC: Patients have a hard time getting to us. They have to call, make an appointment, go across town, leave the health system, go into a mental health system. The stigma becomes an issue, so they deny their own access because they don't want the stigma. We make it harder for the patient to get to us because psychologists do not congregate in health centers. If you look, physicians are herd animals. Every community has a medical plaza.
VY: They have a hospital and a medical office building next to it, or in the hospital.
NC: That's where podiatrists practice; that's where optometrists practice. Psychologists are across town in a solo office.
VY: Well, a lot of psychologists don’t think that they’re medical providers. We’re having conversations, as you said, with people about life—about their relationships, about their family, about their work.
NC: That's why we get the crumbs: because the American financial system pays for health care; it doesn't pay for psychosocial care.
VY: You said earlier that when professional schools joined with APA, I forgot your wording, but it was something like they made a pact with the devil. Don’t you think that, by identifying ourselves as medical providers when we’re really not, in some sense we’re making a pact with the devil, despite the financial gains of it?
NC: You just mentioned the fallacy. You said, "Wouldn't we identify ourselves with medical care?" There's no such thing now. When you talk to a nurse, they're not in medical care. They're in health care. When you talk to a podiatrist, they're not in medical care. They're in health care. Every health care profession recognizes that: "Oh, no, we're apart. We're not going to be medical care." Psychology has not caught up to the fact that, in 1985, the Supreme Court ruled that health care was subject to the same anti-trust laws as every business, and medicine lost their stranglehold on health care. You have these independent professions. And you know who figured this out first?
VY: Who?
NC: Nurses. Nurses used to be the lapdog of physicians. They'd do all the scutwork. Nursing now has established nurse practitioners. Only two percent of physicians go into primary care because that's not where the money is. The money is in specialties. Within 10 to 15 years, the primary care physicians in the United States are going to be nurse practitioners. Nurses know this. So the 26 nurse practitioner programs and nursing schools in the country this fall, 2008, upgraded their nurse practitioner program from an MA to a doctorate, because they're getting ready to be the primary care physicians. They've already done that. They own emergent care. You go to a doc in a box, it's going to be a nurse. The nurses are going full-blast, because they say, "It's not the medical system anymore! It's the health care system, and we're going to lead the way in health care."
VY: Let’s get back to your program in behavioral health. What are people going to learn in this program, and how are you going to teach it?
NC: They're going to take survey courses in the basic sciences. They're going to learn chemistry, they're going to learn physics, they're going to learn biochemistry, they're going to learn organic chemistry—not to the extent that they’re proficient in these, but they have a working acquaintance.
VY: In a year and a half they’re going to learn chemistry, physics?
NC: The mission of this program is to train skilled practitioners who are intelligent consumers of science—the opposite of what the APA does.
The APA trains scientist-professionals. So while they're trying to do both, they end up with second-rate scientists and piss-poor professionals.
The APA trains scientist-professionals. So while they're trying to do both, they end up with second-rate scientists and piss-poor professionals.VY: Don’t mince your words, here.
NC: I'm not! I'm not. You know that.
VY: Tell me how you really feel!
NC: So for once, we say, "Let's do what all the health care professions do." We train skilled professionals that are intelligent consumers of science. That's what medicine does, that's what nursing does, that's what podiatry does, that's what optometry does, that's what dentistry does. Psychology hasn't figured this out yet.
VY: OK. So they’re going to get some survey, some general understanding, and what else? What are they going to do with this?
NC: During those 18 months, you spend two days a week in a medical setting and you rotate from outpatient to hospitals to cancer clinics, on and on. You learn the lingo of health care. Psychologists do not know the lingo of health care, and this is why they're fish out of water when they try to work in medical settings. They're going to become proficient in working like physicians work, but on the psychological side.
VY: So you’re assuming that these people–they’re master’s-level therapists, they’ve had quite a bit of experience–they have good therapy skills already.
NC: Yes.
VY: So you’re not there to teach them more therapy skills.
NC: No, we are not.
VY: So they know something about science; they learn about the medical system.
NC: Yeah.
VY: What do they need to know that they don’t know already? In other words, how do you take your existing clinical skills and modify them so that they work? Because I assume they already know a lot.
NC: They don't know how to do the hallway handoff.
VY: So what are three keys to doing the hallway handoff?
NC: They're chained to the 50-minute hour. The managed care companies always pay us on what we do in a 50-minute hour. And the more they squeeze the fee on that 50-minute hour, the more they squeeze us. So number one: abandon the 50-minute hour. It is archaic. As I say in the foreword to my latest book, the 50-minute hour is outdated in our nanosecond generation.
VY: Well, I’d say in that kind of setting I can see the disadvantage. But for ongoing depth, life-changing therapy, it works pretty well. And a lot of people do still want that.
NC: Then we're going to do what David Barlow recommends: that we should have a health care when we're part of health care. And that's called behavioral care. Then we have something called psychotherapy that continues to do what it's doing. But it's going to have to figure out how it gets paid, because under health reform, medical necessity is going to prevail, not life change. Americans are not going to pay taxes to fund a life-change system.
VY: Makes sense to me. So back to the hallway handoff: break the 50-minute hour. What else? What are the other skills?
NC: Role modeling. When you start, you sit in and watch an experienced person do the hallway handoff.
VY: Right. So what does the experienced person do, what do they know, that therapists need to learn?
NC: It's a skill that's hard to describe in words.
VY: I’ve never seen you at a loss for words, so do your best.
NC: There's no word for it; you are actually role modeling. And by role modeling, you learn to zero in very rapidly on the patient's presenting problem, which is something physicians do routinely because they have seven minutes with a patient. The average PCP visit in America is seven minutes. And in that, they've got to make a diagnosis and a treatment plan and so forth. We're not asking students to do it in seven minutes. We're giving them 15 to 20. But they learn to do it. And third, you learn what physicians need to do their job. And that's when they become so dependent on us that we achieve equal status.
VY: Well, this sounds good. It sounds like there’s a need for that.
NC: We're trying to respond proactively to where we see health reform going.
VY: You’ve been a visionary in our field, an innovator, so let’s get you on record here. Where do you see health reform going?
NC: I see that
psychotherapy's either going to have to become part of the health system or lose out entirely.
psychotherapy's either going to have to become part of the health system or lose out entirely. Medical necessity will prevail. Marriage and family therapy, marriage counseling, occupational counseling is out. Look at the federal parity law that was passed last month.VY: What you’re saying is it’s out of being paid for by tax dollars.
NC: Yes. MFTs are out. As David Barlow has seen, he said there are going to be these two systems: the traditional system, which we'll call psychotherapy…
VY: So that’s going to continue.
NC: That's going to continue, but they're going to have to figure out how to fund it. And it'll have to be funded out of pocket because it's not going to be part of health care. So if you want a life change, pay for it. Now, if the American people want it badly enough, they'll pay for it out of pocket, just like they do for alternative medicine.
VY: And there will still be some form of community medicine and various nonprofit counseling centers.
NC: Absolutely. But it will not be the golden age of psychotherapy that we've had in the past.
VY: When was the golden age?
NC: I'd say the 1950's.
VY: Private insurance was paying for it then?
NC: No. Private insurance came later.
VY: So we’ll be going back to the golden age, then.
NC: In the golden age of psychotherapy, there was a tremendous shortage of psychotherapists. People would wait sometimes for weeks and months for an interview.
VY: A golden age for therapists! Not for the public.
NC: Not for the public, absolutely not. I'm thinking you're asking me, "What's the fate of psychotherapists in the future?" And I'm talking about how the golden age is over. The competition is fierce. We now have 700,000 licensed psychotherapists in the United States. We only have 750,000 physicians! So we have almost as many psychotherapists as we have physicians, and they're all competing for a declining number of patients.
VY: So, in economic terms, you think we have an oversupply?
NC: Terribly. I call it a glut. A glut is more than an oversupply. I talk to students nowadays; they graduate and they can't pay their student loans.
VY: Yeah, it’s tough. But you’ve made some dire predictions before. When I started graduate school, I heard you speak, and you said something to the effect of, “Private practice is dying.” And it doesn’t seem to be, although the economics is not as attractive as it used to be.
NC: Now what year would that have been, Victor?
VY: That was about 1984.
NC: Because the book I published–I'm trying to remember the name of it–but at any rate, it predicted the decline of solo practice and why we had to succeed in doing group practices, which we didn't succeed in. Consequently, we're working at the same fee scale that we had in 1980, 1990.
VY: Exactly. So in real dollars, fees are half what they used to be.
NC: So my prediction—OK, it didn't die, but it sure is limping. It's the walking wounded.
VY: Right. Now, as I said, you’ve been a visionary and you’ve started a lot of new things, but let me be devil’s advocate for a minute.
NC: Oh, you can't do that, Victor.
VY: Sounds like you made some great changes at Kaiser, but if you look at where Kaiser’s at now, they provide very limited mental health services.
NC: Absolutely.
VY: If people are suicidal, they can get in. If not, it will take a few weeks, and they may not get back in for a month. And they’ll get a few sessions in most places.
NC: Correct.
VY: I imagine that must be somewhat disappointing for you.
NC: Terribly. But we're now in the third generation from the founders of Kaiser, and each succeeding generation becomes less like the Kaiser Permanente vision and more like the managed care routine.
VY: All right. You started the professional schools and you’ve said they’re a failure.
NC: Yes.
VY: You started American Biodyne, which was an innovative managed care organization.
NC: It was the only managed care organization where it was completely run by psychologists.
VY: Right. And that was bought out by Magellan. And what’s the status of it now?
NC: It's the pits!
VY: It’s the pits. So, you started three great things with great promise, and they’re all the pits. What makes you keep going and trying something new?
NC: I'm very proud of the fact that clinicians can be on faculties in psychology. I'm very proud of that. Maybe the professional school movement went astray, but there were some gains there. Kaiser Permanente is in its third generation; it doesn't have the vigor and vitality of the founders. I mean, Sid Garfield and Morris Collen, those people were fantastic physicians who saw that psychology was more important than psychiatry, and so forth. Naming a psychologist chief of mental health for all of Northern California was unthinkable.
VY: Thanks for balancing out your record. You’ve had some lasting successes as well.
NC: Yeah. So at any rate, there have been great disappointments because people tend to—what should I say—return to the mean.
VY: So you told me at the beginning that you’re 85 years old.
NC: Yes.
VY: You look fantastic.
NC: Well, thank you.
VY: You still have a great deal of energy.
NC: Thank you.
VY: What keeps you going?
NC: Productive work. I love it.
I hate golf, and when you hate golf, you're not allowed to retire, because all retirees have to move to Florida and play golf.
I hate golf, and when you hate golf, you're not allowed to retire, because all retirees have to move to Florida and play golf. I hate golf so I can't retire. But I joke about that. I really, really enjoy productive work. This month, my 47th book is coming out.VY: Wow.
NC: All my books do well. Eleven Blunders That Cripple Psychotherapy in America: A Remedial Unblundering is shaking up the APA. People are reading it. I get invited all over to talk at meetings and state conventions and so forth on the subject. So maybe I was put on this earth to be an agent provocateur. I don't know. But nonetheless, I am proud of my profession. I love this profession. I have never left it. I want it to succeed. It dismays me that we've created a profession that is full of economic illiterates. They don't think that private practice is a business, yet they have a product called psychotherapy. They have a place of business called their office.
VY: A unique skill set.
NC: A unique skill set. They collect a fee. They pay taxes on that fee. It has all the attributes of a business but they say, "No, no, I'm not in business."
VY: I heard recently that a lot of psychotherapists are reluctant to accept credit cards because they feel they’re enabling their clients to get into debt, rather than use the preferred method of payment in this country.
NC: Hippocrates said it is the obligation of the physician to do no harm, and he lists a number of things that the physician has to do. Then he talked about the obligations of the patient, and the first one was to pay the fee. Now, that was Hippocrates in 300 B.C.! And psychologists haven't learned that. You go to a physician's office, and when you check out, you pay the fee. At many physicians’ offices now, you pay the fee when you check in. Psychologists haven't learned that, and they say, "I didn't become a therapist to make money."
When I ask them, "Did you become a therapist to lose money?" they don't know what to say.
When I ask them, "Did you become a therapist to lose money?" they don't know what to say.VY: So what parting words of advice would you have for young psychologists, students wanting to get into the field, people in mid-career to ensure their continued success?
NC: Pick your graduate school carefully.
VY: OK. If you’re going to graduate school, pick it carefully
NC: Make sure that they are teaching business courses, teaching you where the profession is going and how you have to evolve to keep up—all the things that most ivy-covered professors have no idea about. And drop your anti-business bias. Drop your guru worship. We're at a conference right now that is founded on guru worship. There was a time when we worshiped our leaders because we had no evidence-based therapy. If you wanted to prove something, you'd say, "Well, Sigmund Freud said…" or "Anna Freud said…" or "Carl Jung said…" Now, under health reform, if you don't do evidence-based therapy, you won't get reimbursed. So pick your graduate program carefully. I would say most of them are worthless. Again, I'm mincing my words, I know.
VY: You mentioned evidence-based treatment. What’s your general thought about that, and manualized treatment as well?
NC: The problem with evidence-based treatment as it's going now—it's very recent—I refer to the three E's of psychotherapy. We need to do what the IOM has told medicine it has to do–we have to catch up to that.
VY: What’s IOM?
NC: The Institute of Medicine. Their "Closing the Quality Chasm," one of the greatest reports ever written about health care, alludes to this: that there's too much non-effective treatment going on out there. But at any rate, Chambliss has called our attention to the need for evidence-based, the first E. Barlow has come along and he said, "Now wait a minute, what often works in the laboratory doesn't work in the treatment room. So we also have to look ateffectiveness. Does the evidence-based that worked in the laboratory work now in real life?" That's the second E. And the third E was developed by some guy named Nick Cummings, and it stands for efficiency: that we not only need evidence and effectiveness, but we also need efficiency.
Let's take an example in medicine. There was a time when everybody got a coronary bypass: expensive, intrusive. It took months to recover. Now we find out that a lot of the people can be treated with a stent instead of a coronary bypass. That's efficiency. The coronary bypass was effective, but it wasn't efficient. Psychotherapy does not look to develop efficiency. And this is one of the things we're doing in this program: we're creating the kind of efficiency that goes from getting 10 percent of the patients referred to 90 percent. Those are the three E's that I use. Stopping at evidence-based would be a mistake. It has to be proven in the field.
Let's take an example in medicine. There was a time when everybody got a coronary bypass: expensive, intrusive. It took months to recover. Now we find out that a lot of the people can be treated with a stent instead of a coronary bypass. That's efficiency. The coronary bypass was effective, but it wasn't efficient. Psychotherapy does not look to develop efficiency. And this is one of the things we're doing in this program: we're creating the kind of efficiency that goes from getting 10 percent of the patients referred to 90 percent. Those are the three E's that I use. Stopping at evidence-based would be a mistake. It has to be proven in the field.
VY: And what about manualized therapies that are being taught? How do you manualize a human relationship, especially given that everyone is different?
NC: At American Biodyne, we had 68 proven group interventions or therapies–all time-limited, manualized psychotherapy. And they were guidelines; they were not cookbooks.
Ultimately, therapist ingenuity, insight and decision trump the manual.
Ultimately, therapist ingenuity, insight and decision trump the manual.VY: I’m glad to hear you say that.
NC: Too many manuals are considered sacrosanct. That's a mistake. The word "manualized" to me is a dirty word because it denotes, "Here's the bible that you can't deviate from." I don't believe in that. The guidelines we had for our programs were based on our research. For example, if I can give you one innovation that was just absolutely fantastic…
VY: Sure, why not?
NC: Borderline personality disorder—the scourge of all therapists. If you see borderlines, get ready—someday you're going to be sued, as Bryant Welch, who defends psychologists all over the country, said. We developed a program for treating borderlines. We created an esprit de corps where the borderlines would police each other, which a therapist can't do. And we created an atmosphere where, "If I can't do this, I'm not going to let you get away with it."
VY: These are in groups.
NC: These are in groups. And our research showed how effective this was.
VY: Was the group identified as being for borderlines?
NC: Yeah.
VY: So they accepted their diagnosis?
NC: "You're a borderline." The first such group we did we called the "last-chance group." We had a group of borderlines that, for one of the Blue Cross plans, were so egregious that Blue Cross was considering dropping their health insurance. And I said, "Give me one more chance." They were all borderline women. See, male borderlines are scarce in psychotherapy because they go into the criminal justice system. They do things that get themselves in jail. Female borderlines disrupt the mental health system, not the criminal system. So most of our borderlines were women. And we called this the "Losers Group." "If you flunk this therapy, you're out of the health plan. I have prevailed upon the heads of Blue Cross Blue Shield to give you one last chance. I want to let you know that I have a side bet that you're all going to flunk. It's a sizable bet and I don't think I'm going to lose, because I don't throw my money away." So they're motivated: "I'll show this SOB." But then you create an atmosphere where they police each other. And then from there—and we would only have 20 group sessions, two hours each—they start to be able to form boundaries for themselves for the first time. And then we allow them brief intermittent psychotherapy throughout the life cycle. "Whenever you can, come back." It works. My therapist said, "I'm terrified when I have one borderline in my office. You want me to have eight??"
VY: Well, that could get into a whole other discussion about why there’s so little group therapy going on when it’s such an effective mode of treatment. But before we wrap up, getting back to words of wisdom, one was for therapists to pick their grad schools carefully if they’re going; the second was, if they’re practicing, to think of themselves as businesspeople. Any more words of advice?
NC: Be flexible and innovative. Unfortunately, too much of psychotherapy has been carved in stone. It is turning itself into obsolescence. Patients are ultimately our customers. The main characteristic of a customer is if they don't like your product, they don't buy it. And that's what we are now. Patients have been misled into now saying psychotherapy takes too long. They accept medication.
VY: I don’t know that they’re not buying it. I think the demand is still there and probably stronger than ever. I think its more an oversupply, as you said.
NC: That's one. But the actual number of referrals for psychotherapy have declined by 40 percent. Let me give you a very concrete figure. In 1995, 92 percent of all patients discharged from a psychiatric hospital were referred for outpatient psychotherapy. In 2005, it dropped to 10 percent. Ten percent!
VY: They’re not being referred–not that they’re not wanting it.
NC: They're put on a medication regimen. They're not being referred, but… If a customer wants the iPod, they're going to get it. If they really wanted psychotherapy, they'd get it. They say they're satisfied with the medication. Psychotherapy is not in its golden era; we would see articles in 1950 that psychology was going to solve the world's ills.
VY: And in the 60’s, drugs were, and in the 70’s, encounter groups were; and then it was the decade of the brain. Hope springs eternal.
NC: Yeah. But if a product keeps up… Nobody is going to buy a 1980's Apple computer.
If Apple hadn't kept up, if they hadn’t made the iPod, etc., they would have gone out of business. We also have to innovate.
If Apple hadn't kept up, if they hadn’t made the iPod, etc., they would have gone out of business. We also have to innovate.VY: You’ve certainly walked the walk in your life. It’s been a pleasure to review your lifetime of innovations, creativity and contributions, even if they occasionally disrupt things and annoy people. It’s been a great pleasure talking with you, so thank you very much.
NC: Thank you very much, Victor.
