PN: And with psychological problems, do you also believe that group interventions are more effective?
Cummings: That's what the research seems to be telling us. The differential between a group program for substance abuse and individual psychotherapy is so astronomical that nobody even argues about it anymore. But we are beginning to see the same thing with problems like depression, agoraphobia, panic and anxiety disorders.
PN: Many therapists believe that protocol-based treatment leaves out the most important elements that make therapy work. What do you see as the essence of an effective protocol?
Cummings: That it's research based. You construct a protocol and keep trying out and measuring your results. There is no such thing as a finished protocol--you're always reevaluating it and trying it out. But I think there are a few elements that we know are necessary ingredients, whether the protocol addresses a medical or a psychological condition. All protocols have an educational component. Patients learn very frankly, with no punches being pulled, what diabetes is or what borderline personality is or what Bipolar Disorder is. Every protocol teaches patients how to monitor and evaluate their own condition--diabetics learn to monitor their blood sugar, people with Borderline Personality Disorder learn how to monitor their mood and their sense of being blown like a leaf in the wind. Every protocol has a buddy system and a peer culture that the therapist can utilize. I cannot think of any psychological protocol in which exercise would not be an important component.
PN : With all of your confidence in protocol-based approaches, you've also written that two-thirds of the people within any of these population-based, group approaches are going to need individual attention at some point. Could you explain that?
Cummings: People are very diverse, even if they share a common condition. When someone hits a snag in a program, there should always be the option of seeing him or her individually as needed. But I believe that only 25 percent of the therapy of the future will be individual. Actually, that's 25 percent of the time allotted, and much less than 25 percent of the people being treated. Because if you have a practitioner who spends 25 percent of her time in individual therapy and 75 percent in time-limited group psychotherapy and psychoeducational disease and population-based models, 75 percent of the practitioner's time will yield more like 90 percent of the patients. But clearly practitioners of the future will have to learn how to do group psychotherapy in time-limited modules. They'll have to learn how to do individual therapy that's focused and targeted, not open ended. And therapists of the future will have to take business courses in graduate school, just as physicians are starting to do in medical school.