Cummings: First, don't get sucked in by the bubble that we're seeing now because some private practitioners seem to be doing so well. Second, realize that psychotherapy is finally going to go where it should have gone from the very start--to be an integral part of general health care. So the most important thing you can do to prepare for the health care system of the future is to become proficient in health psychology--the application of behavioral and psychological techniques to medical conditions. There is no such thing as a physical illness without its behavioral dimension. For example, depression is an accompaniment of almost every chronic condition, and non-compliance with medical regimens is one of the costliest issues within our current health care system. Some conditions are especially notorious for non-compliance. The worst is hypertension, probably because with hypertension, patients often don't feel any serious discomfort. They just suddenly have a heart attack; there's no incentive to change their lifestyle. Hypertension, diabetes and asthma account for almost 30 percent of all the medical expenditures in the 25 to 55 age group, and it's mostly because of non-compliance and problems in handling stress. But to tease out the psychological component of patients' problems, therapists will need to know much more about the whole range of physical diseases.
PN: On a concrete level, how will therapists actually spend their time in the kind of health care system you envision?
Cummings: Most of their time will be spent leading time-limited, protocol-based, psychoeducational groups that have been shown to reduce medical costs and improve patients' functioning more than traditional medical treatment. One type of group might be called "disease management" groups--these are designed for people with the same medical condition: rheumatoid arthritis, asthma, diabetes--all of which are chronic, have no biomedical "cure" and are extremely frustrating conditions for traditionally trained primary care physicians, who don't really know what to do with these kind of patients once the diagnosis is made. And then there are "population-based" groups that address conditions that are not primarily medical--like Borderline Personality Disorder, depression, substance abuse, Panic Disorder--but which impinge drastically on the medical system.
PN: Is it groups like that you have in mind when you say at least 50 percent of the mental health services of the future will be psychoeducational?
Cummings: Correct. The future of health care will be based on increasing the self-efficacy of people in dealing with all the chronic conditions that modern medicine can arrest but not cure and providing psychological services in a much more effective and efficient way. With many medical problems, therapists in the future will be involved with helping people learn the specific things they can do to influence the state of their health, for example, monitoring their own blood sugar, their own exercise, their own stress level and so forth, getting them out of what Martin Seligman calls "learned helplessness." A major role for therapists in the future will be getting people out of taking the position of "I'm helpless. I may as well adjust to my illness."