Suddenly, sometime in the mid-1980s, as the managed care revolution raged around them, therapists emerged as if from a dream to find that terms like "heath care delivery systems," "covered lives" and "capitated health plans" had gone from being mind-numbing policyspeak to urgent pocketbook issues. As an entire profession nervously scanned the horizon, anyone at a national conference who had something vaguely credible to say about whether the Golden Age of Private Practice was truly coming to an end was able to attract a capacity crowd. Since that time, as the sense of imminent crisis has gradually subsided, most therapists have grown much less interested in such crystal-ball gazing. Many appear to have accepted the fact that they no longer live such sheltered lives and have adapted to the economic realities of the mental health field today. In fact, lots of clinicians talk confidently about having weathered the storm, freeing themselves from managed care and, in some cases, recasting their services as coaching or consulting so as to emancipate themselves entirely from the world of corporatized mental health care.
But is this just another example of therapists' notorious head-in-the-sand attitude toward the business of therapy? What does lie ahead for the more than half-million psychiatrists, psychologists, social workers, mental health counselors, marriage and family therapists and other professionals who continue to call what they offer the public "psychotherapy"?
Lacking the sense of urgency that accompanied the dawn of managed care, therapists today seem to have little interest in the cautious generalizations and policy jargon of health care industry analysts, while few of their clinical colleagues have emerged as leaders with a compelling grasp of the Big Picture of therapy practice in the 21st century. So when one hears a quote like "health care delivery in 20 years will bear as little resemblance to the managed care organizations of today as Henry Ford's Model T had to space technology," most informed observers can quickly identify the source--Nicholas Cummings, psychotherapy's most quotable soothsayer and, arguably, one of the prime architects of modern mental health practice.
For the last 40 years, Cummings has cast himself as both a friend to the ordinary practitioner and a visionary capable of seeing just around the curve to the next stage in the evolution of the health care marketplace. His contributions to the field are almost indistinguishable from the signal turning points in the delivery of therapy services over that period. The story of his career reveals much about the changing economics of mental health and the emergence of much of what we now take for granted about how therapy is practiced and the personal career options available to today's practitioners.
The Birth of Coverage for Psychotherapy
When Cummings started out as a young psychologist in the late 1950s, not a single health plan included psychotherapy. For the actuaries of the health insurance world, psychotherapy was simply too vague and ethereal to be taken seriously. But Sidney Garfield, cofounder of Kaiser Permanente, the nation's first HMO, had become increasingly aware of complaints from overworked physicians within the Kaiser system about the time spent dealing with "hypochondriacs"--patients who required attention for problems that had little to do with physical disease. Believing that psychotherapy might be the key to reducing the workloads of his physicians and realizing enormous cost savings, Garfield hired Cummings, who had recently resigned from the graduate faculty at Cornell University after only three weeks, unable to tolerate the bureaucratic snail's pace of academic life. Cummings's assignment was to investigate the impact of including psychotherapy as a benefit in the Kaiser plan. …