Interview with Richard Shulman, Ph.D.
Cynthia Levin, Psy.D.
Published on Mentalhealth.net on Jul 1st 2000
Richard Shulman, Ph.D. completed his doctoral degree in Clinical Psychology at the University of Toledo after having graduated Phi Beta Kappa from Wesleyan University and then attending the University of Michigan. He is currently the Director of the nonprofit organization, Volunteers in Psychotherapy (VIP). As a Licensed Clinical Psychologist, he founded VIP together with three other psychologists and two nonprofit specialists. Volunteers in Psychotherapy, Inc. provides psychotherapy that is truly private, in exchange for volunteer work that clients donate elsewhere to the community charity of their choice. VIP is a nonprofit alternative to the loss of client privacy and control experienced under managed care.
Dr. Shulman helped to create VIP after roughly a decade’s work at Hartford Hospital – Institute of Living, where he had provided psychotherapy to Hartford’s poor or uninsured population and had supervised and trained therapists at the outpatient clinic. He continues to serve, now as a volunteer, on the Institutional Review Board of Hartford Hospital – Institute of Living, which oversees ethical and informed consent issues in psychiatric and medical research. He had completed the Greater Hartford Clinical Psychology Internship Consortium, including Hartford Hospital, University of Connecticut Health Center, Newington Veteran’s Administration Hospital and Capitol Region Mental Health Center.
He previously worked at the Children’s Outpatient program of Wheeler Clinic, and served as Psychological Consultant to Nutmeg Big Brothers – Big Sisters. He had delayed graduate school for one year to serve as a Community Service Volunteer, working with troubled boys in a Dr. Barnardo’s school south of London.
Essays by Dr. Shulman and news articles describing Volunteers in Psychotherapy, its functioning and rationale, are available on the VIP website: www.CTVIP.org. Dr. Shulman will participate in a symposium about Volunteers in Psychotherapy at this summer’s annual American Psychological Association convention.
Dr. Shulman can be reached at:
Volunteers in Psychotherapy, Inc.
7 South Main Street
West Hartford, CT 06107
Dr. Cindy Levin (CL): Over the past 2-3 years, Rich, you’ve been working hard at developing an organization called Volunteers in Psychotherapy (VIP). Can you please explain to our viewers what Volunteers in Psychotherapy is all about?
Dr. Rich Shulman (RS): SureWe’re a small and relatively new non-profit organization that was founded by four psychologists and two non-profit specialists. Volunteers in Psychotherapy makes psychotherapy available to anyone – and at no cost – in exchange for them doing volunteer work elsewhere, for the community charity of their choice.
In a sense, our clients “pay” for their therapy through VIP by independently picking a charitable organization in the community where they want to donate volunteer time. They pick their volunteer organization independently of us and without that agency knowing of their connection with VIP. The clients go and do volunteer work at that organization and in exchange we see them in therapy.
We wanted to set up a method of offering psychotherapy that was distinct from what have become standard practices, in private practices and especially in public clinics and hospitals. Several other psychologists and myself had worked in settings where we felt that there were a lot of problematic standard practices that would be best avoided if we could set up this independent structure.
Another significant focus of VIP was to be able to provide psychotherapy independently of the influence of insurance and managed care. We particularly wanted to make therapy available to people who either couldn’t afford to pay for truly private psychotherapy of reasonable length, or to people who felt that managed care damaged and encroached upon useful private psychotherapy for themselves.
CL: Can you please explain to our viewers in more detail about how managed care affects the delivery of psychotherapy services and what some of those problems are that managed care creates for therapy clients?
RS: First, when a person seeks out psychotherapy through managed care it’s the insurance company that’s making decisions about their therapy. The insurer decides whether the patient gets referred for therapy at all, as well as determining the length of time that they are referred for psychotherapy.
When I worked at a poor person’s clinic several years ago, I had two separate instances in which young adult women came in for therapy stating that they finally wanted to talk about being sexually abused when they were children. In both cases, their “third party payer” insisted that they would not pay for such “unfocused” or “exploratory” therapy discussions. The payer wanted to decide what would be discussed. Managed care has been criticized for dictating the nature or focus of therapy.
The flip-side of this is that the insurance company, the third-party payer, can financially benefit by limiting access to psychotherapy or by rationing access to the length of someone’s therapy. Considering that private psychotherapy often costs in the realm of $100 or more per hour, although it can be less, it’s greatly to the third-party payer’s financial advantage if they don’t pay those types of fees. Insurers simply limit access to psychotherapy or encourage people to take medication. This is one of the ways that the third-party payer really intrudes very much into psychotherapy.
Another big problem with managed care is the lack of privacy. Most managed care organizations require therapists who work with them to send them detailed reports about the psychotherapy and private life of the client. This is often part of the managed care contract the therapist signs. A consumer who isn’t savvy about how managed care works might assume that when they see a therapist using their insurance they are having a strictly private discussion with their psychotherapist. In actuality, though, the psychotherapy client probably has signed away the right to their privacy because the contracting therapist is typically required to send off reports about these private discussions to the insurer at some set interval, say every three sessions or every six sessions. The managed care company may say that they require these reports in order to decide whether they will continue to fund the psychotherapy.
CL: How is the client affected by this requirement of the insurance company to obtain private information about the client’s therapy?
RS: Clients are greatly affected. People just don’t speak as openly when they know that their privacy is not absolute. For example, you made a point of giving me informed consent that this conversation is being taped. Whenever I have gone on TV or on radio or had taped interviews like this, I point out to whoever is interviewing me, that both of us are very conscious that there’s a tape recorder going right now – it obviously influences how frankly and spontaneously you talk about things.
People are always conscious of the context in which they’re speaking, and therapy is no different. People tend to censor themselves and to be much more circumspect about revealing details of what’s going on in their lives, or in revealing aspects of themselves that they’re ashamed of or that they find a bit problematic, when they know that there is the possibility that someone else will hear what they have said.
Now this is part-and-parcel of psychotherapy in general. If one person is talking to another and giving them great detail about the ins and outs of what their life is really like, how they think, and how they see things, people can be anxious enough in psychotherapy about revealing these things to a therapist. People only develop trust in their therapist gradually, over time (and rightfully so). Now, how much more inhibited are they going to be if they know that this is not strictly a private conversation, but that it is being reported to a third party?
In an article that I wrote called “Lost Confidence and Confidentiality in Psychotherapy,” which is posted on our website at http://www.CTVIP.org, I provide an example of how people may hint that they know when therapy is not private. People will give clues that they know they’re going to censor themselves and hold back what they talk about if they are aware that there is some risk of the therapy not being totally confidential. The example I give in the article demonstrates all the subtle, somewhat camouflaged ways in which a person may allude to the fact that their therapy is not totally private, and how that impinges on the types of private and frank conversations that they can have with their therapist.
If you’re working with somebody in psychotherapy, if you’re really trying to understand another human being and what makes them tick, and if you’re paying attention to all the subtleties of how they talk to you about their life, a well-trained therapist should be able to hear all the indirect hints by which that person talks about how they’re experiencing talking to you in psychotherapy. People will intimate to you that they can’t speak openly if reports about their private lives are being sent out to an insurance company.
Managed care has just decimated privacy because of the financial power that they have since they are the ones paying for therapy. Their power is quite widespread considering that 80-85% of people who are insured have some type of managed benefits in their mental health care insurance plan.
However, even the Supreme Court has emphasized the crucial feature of privacy in psychotherapy. A person must be certain that what they talk about in therapy remains their private business.
All of these reasons made us feel that it would be crucial to set up an old fashioned sort of framework for doing psychotherapy where there was no third-party payer making decisions about people’s therapy; where there was no third-party payer demanding to have information about somebody’s private psychotherapy discussions. That’s why we constructed Volunteers in Psychotherapy.
VIP permits people to be completely in control of their therapy. VIP returns the client to their position as the consumer who is, in a sense, paying for their therapy. Accordingly, no one else has a right to know about their private discussions concerning their personal life.
CL: Now that you’ve clearly delineated the problems with managed care, can you give an example of what some of those problematic standard practices are that you had experienced in other mental health settings, which you had alluded to earlier?
RS: When I was working in the outpatient clinic at Hartford Hospital, a downtown, urban hospital that merged with the Institute Of Living, it was obvious that much less psychotherapy was being offered to patients. The clinic mostly treated people who were on state and federal support. It was financially beneficial even for the government as a third-party payer (and for the hospital) to limit people’s access to psychotherapy. In that clinic, people were increasingly cut off from individual therapy and put into short-term therapy groups and medication groups; there was much more emphasis on medication and much less on psychotherapy over the years I worked there.
Having worked for years in Connecticut in local clinics and hospitals, I can tell you that there are severe compromises that people have to make if they go to public institutions for psychotherapy. They’re not in control of their own therapy. They don’t have privacy. Decisions such as the type of treatment they will receive and how long their therapy might continue, whether they end up in a group or a short-term group, or get nudged towards medication, are substantially in the hands of the insurance company and of the institution that they go to.
CL: Rich, thank you for spelling out many of the problems of managed care and some of the problematic standard practices that have developed in different mental health settings. This is all so important for clients and the general public to be aware of so that they know what they’re getting into when they decide to enter psychotherapy through a managed care company and/or how managed care can affect the delivery of psychotherapy services in general.
CL: Clearly, though, a significant benefit of Volunteers in Psychotherapy is that it affords the patient the opportunity to speak openly and frankly without having to worry about a third-party person or lack of confidentiality.
Another significant benefit it would seem that is built into the organizational model of VIP is the act of volunteerism. Considering that there’s a large literature about the benefits people receive when they go and give help to others, how have you seen the act of volunteering impacting your clients in therapy?
RS: The requirement of having clients volunteer their time to a charitable cause they believe in provides another crucial constructive element of VIP. It requires people, first of all, to not just be recipients. It sets up VIP as being an exchange between equals; it is egalitarian in a sense because we’re giving somebody the opportunity to buy our services if they want them. The way they do that is by picking a charitable cause that they think is important and going and putting their efforts into it.
Also, the act of volunteering puts the person in the position of being the helper to other people. They are not simply recipients of help. Volunteering and helping others reverses that image of themselves, which can be quite therapeutic. By putting in a substantial amount of time where they are the person helping out other people, it also typically puts them in the position of being appreciated and valued by the organization where they donate their time.
Volunteering also provides people with the subtle symbolic message of “Hey, you have something to offer to the community.” We built this element into the program because we’re implying to people that they have something valuable to offer. Ultimately, it means that people go out and they rub elbows with other people in the community. It all constructively builds confidence, appreciation, and self-appreciation on the part of the volunteers.
CL: Volunteering sounds very effective as a conjoint therapeutic intervention.
RS: Yes it is.
CL: Rich, does the client get to choose on their own the organization they want to volunteer their time at in exchange for psychotherapy?
RS: Pretty much. We have people check with us because we want to make sure their volunteer agency fits within our guidelines, which is that it has to be a 501(c)3; the legal designation the IRS gives when they approve a charitable organization that aims to serve the community. But, we do give credit to people for working at just about any non-profit organization of their choice. There is a little leeway to this where we will give credit, say if someone works at a state hospital that isn’t technically a non-profit, but it’s certainly still in the same spirit of serving the community.
CL: So, when a patient comes to you for therapy services, what is the range of services that you provide at Volunteers in Psychotherapy?
RS: Well, we think part of the strength of what we offer is that we only provide psychotherapy. We make clear to people that our organization is only an avenue towards them getting private discussions about their lives. It’s varied enough that it could be individual therapy for an adult, it could be couples therapy, or it could be family therapy that may involve children.
We make it clear to people that we won’t do evaluations for any third-party, that we won’t be giving out any reports to any third-party, that we won’t get involved in custody battles or legal issues with them. This practice is meant to obviate or make impossible that VIP be used for any, what you might call, secondary gain. For instance, that a person might be coming in because they really just want to satisfy their probation officer.
Sometimes people come to therapists with all sorts of other hidden agendas. One of the ways that we’re very efficient is that we say to people “That’s not a service that we offer; it’s strictly psychotherapy and strictly private.” This helps to really focus people on what it is that we have to offer and make sure that none of these resources are wasted.
RS: Another way that we enforce the notion of taking responsibility for their psychotherapy is that we require people to be responsible for the sessions. We have a no-show or a cancellation fee that they would have to pay if they were irresponsible about appointments with us; and again, it’s meant to be egalitarian. It respects the client and the therapist in their work together.
CL: An arrangement that probably over the long term leads to a greater sense of empowerment for themselves.
RS: Right, exactly.
CL: How do people find out about Volunteers in Psychotherapy? Where do most of your referrals come from?
RS: Most are self-referred, and in fact, we think that’s ideal. Ultimately, I think psychotherapy is self-examination and it’s often an attempt to look honestly at things that we all tend to kid ourselves about, or blind ourselves to, especially our difficulties in life or our personal and inter-personal difficulties. Our clients are mostly people who are self-referred and have an interest in pursuing therapy and this kind of self-exploration.
Most of the people who come to us have heard about our organization in the media, in some form. They pursue contacting us on their own, getting more information about us, and calling our phone number where we have an outgoing information tape that describes the program. We have brochures that we put out at all sorts of libraries and social service institutions, YMCA’s, and volunteer centers. People may hear about us through Infoline (a statewide information and referral service). Or people will privately learn about us through our website at http://www.CTVIP.org.
One significant subgroup that has an interest in us are people who have already had a bad experience with their own insurance or who have gone through the experience of trying to get psychotherapy say through an EAP (Employee Assistance Program) where they work. They may be concerned about the potential lack of privacy, or the possibilities that an employer who is self-insured may permit the personnel department or other people to have information about whether they seek psychotherapy for themselves or their family.
We also get people who have tried using their managed care benefits and are very unhappy when they realize that they are limited in their access to therapists — or they realize the lack of privacy involved when reports are sent to their insurer. Some people have resented their insurer pressuring them to take medications; or finding out that their insurer pressured their therapist to get them on medication.
So, we get people who are delighted to find out that there is an option to get therapy in the community that does not involve the lack of privacy and the lack of control that comes from insurance. Some people are thrilled that they can do volunteer work to pay for their therapy. They like the fact that VIP is not a “hand out.”
CL: I’m sure the benefits that VIP provides are a big relief for many people seeking out therapy services, and are clearly some of the reasons that your organization stands out.
I can’t help wondering, though, how you’ve been able to make VIP happen in a time when, unfortunately, so many aspects of our society, including healthcare, have turned very much towards the financial bottom line and away from such pure altruism?
RS: Well, although it’s true that money is a part of life, people also realize that important personal matters are what make people tick;that there is a need for most human beings to have some comfort about how they feel about themselves and how they go through living their lives. And sometimes people need to have privacy in order to honestly explore what is going on in their lives when there are difficult personal matters to discuss.
One of the reasons that VIP has financial support to do this work is because we make the case to individual donors that there is a glaring gap and a pressing need in the community for there to be some resource like us. Managed care benefits for psychotherapy have been drastically cut back in recent years -much more so than even medical services have been cut. We need to preserve a private place where people can talk about their lives. People have responded and have financially supported us so that we can do this work.
Now, in part, they partner up with us and choose to donate to us because they recognize that we are making a financial sacrifice in order to make this service available. For example, our Board of Directors is made up of all volunteers, and all of the administrative work we do to set up this service is unrecompensed — unsalaried. Also, I provide the office and the telephone for VIP, which limits overhead.
We applied to the IRS who conferred on VIP our status as an independent, charitable, tax-exempt organization. Our mission is not in lining our own pockets, but rather our mission is in serving the community. I think donors recognize that there is benefit in having this type of safety valve in the community and we make this same case when we apply to local philanthropic or charitable foundations. Over the course of our first year in applying for grants, we’ve been awarded seven grants, six of them from Connecticut Philanthropic Foundations and one from an international charity. They have all given us small to moderate amounts of seed money to get VIP up and running. Obviously this is seed money, and we are still looking for more financial support.
I should also point out that the therapists who provide therapy through VIP are reimbursed; we do get some reimbursement for providing therapy services. However, in order to establish the amount of reimbursement, we had an independent committee of our board do a survey of what were the average fees locally for therapists. We cut that fee in half and then lowered it even more – so we’re paid less than half the average local private practice fee.
This reduced amount of reimbursement that VIP therapists get signals to people who might support us financially that, again, we’re not lining our own pockets. We’re doing this because therapy is an important service to make available and it currently isn’t available to the public without clients making serious compromises in their therapy. Also, the fact that clients are willing to provide volunteer services in exchange for psychotherapy is evidence that people value therapy and they are willing to work for our services. Therefore, this is not a charitable “hand out.” Everyone involved in VIP contributes to the common good.
CL: Can you describe in more detail about what your professional background has been, since it sounds like some of the work experiences you had in the past helped to push you towards the development of Volunteers in Psychotherapy?
RS: Sure, I had worked at a Connecticut outpatient clinic where I’d worked more with children and families. Then I worked for years with adults and families at a downtown, urban hospital, Hartford Hospital, which merged with the Institute of Living. We provided sort of a “poor persons” clinic.
Especially in that clinic, I felt that the clients were cut out of the loop; that they were not the ones seen as the consumers. There was a third-party payer involved, and so it wasn’t that the clients themselves were absolutely deciding that they wanted psychotherapy. There was no symbolic sense that they were willing to pay for it by giving something towards their own therapy.
I thought that putting the client back into the position of being the consumer would ultimately serve the psychotherapy much better. We needed a way to put the client back in control – to have them “pay for” their therapy, and decide if it was worth continuing to work to pay for. And of course, clients then get to preserve their privacy. People who come to public clinics don’t tend to feel that they are the consumers who are purchasing the services they want – much of what they get is dictated to them. I’d been discussing some of these problems for years with the psychologists who are on our board (Drs. Mark Burrell, Karen D’Avanzo and Rachel Sampson), and we’d been brainstorming about ways to make such improvements. Volunteers in Psychotherapy was meant to reverse these problems.
When I left the Hartford Hospital – IOL clinic to set up a private practice, I specifically publicized the fact that I would not work with any insurers. Instead, I set a low fee in my private practice and saw people for that fee. I publicized the compromises that managed care demanded. I also started a pilot program, offering short-term no-fee therapy sessions in exchange for VIP-style volunteer work.
CL: So, since Volunteers in Psychotherapy focuses purely on psychotherapy without the bothers of insurance companies, do you think you will eventually offer training opportunities for psychology graduate students who want real in-depth training in psychotherapy?
RS: Well, I think that you are touching on something where there’s a real need. Through VIP, I give a lot of talks in college and graduate school psychology classes. I think that students are in a real bind right now, especially for people who are in training, because of managed care taking over the economic landscape.
Students who are bright, sensitive, and attuned to what it is to be a human being and the problems that people can face in their lives, have an opportunity to learn all sorts of subtleties and complexities about doing human service work. However, they often come to realize that psychotherapy is being undermined by the current predominant economic system (managed care). I think that many social work students and psychology students, marriage and family therapy students, all sorts of people who are training to be therapists in one form or another are confronted with the fact that there are going to be economic realities that may severely undermine and distort the type of therapy that they’ll be able to provide.
One of the reasons we give public talks is to say to people “Look, we don’t think you have to compromise your standards. We don’t think you have to compromise the types of best practices that should exist in psychotherapy, either as therapists or as clients who are trying to make sense of their lives and improve them.” We make the argument that it’s possible to set up these independent non-profit organizations that would allow you to work in the way that you think would be most valuable and helpful to people. As therapists, you don’t have to compromise your principles within managed care or existing institutions. You don’t have to resign yourself to work your entire career doing things that you don’t believe in and that you think are ultimately harmful or not as helpful as they should be for the people that you work with. You can work with people in the same way that you would want for yourself or others you’re close to.
Many established therapists recognize all the compromises that go on in managed care and they chafe at them tremendously. Many therapists struggle with the fact that managed care pays them to work in a way that they bridle at; that they think is ultimately highly compromised. In a sense, we say to them and we say to students “Yes, we think you can set up independent nonprofit approaches like VIP. Or a modified version of VIP.” We encourage people to do that.
We would love to do training here at some point, although it’s just the realities of logistics right now that we are not yet doing that. We need to focus on establishing VIP in its service to the community, we need to make VIP more visible to the public, and we need to establish funds to continue. But ultimately, yes, we’d love to work with students. In fact, we’ve had a fair amount of contact from local students who are pressed to find a Practicum site that they find is meaningful. They want to have the experience of learning about in-depth therapy; what it means to sit with another human being and help them make sense out of the complexities and the problems in their lives. We hope that somewhere in a few years we will be providing that kind of training opportunity, which also helps to preserve meaningful psychotherapy in the community.
CL: That sounds great. There must be so many students right now in graduate schools that would chomp-at-the-bit to get an opportunity to be able to see what kinds of alternatives are out there, to see that they don’t have to deal with managed care, and to truly get that in-depth training in psychotherapy.
CL: What are some recommendations that you would offer to other clinicians who may be interested in starting an organization similar to Volunteers in Psychotherapy?
RS: Well, I guess just encouragement that it’s possible to do. We’re happy to consult with people about how to get started and we’ve already started to brainstorm with people about how they might set up programs similar to VIP in their own communities; or perhaps modified based on their own particular interests and local needs. Hopefully we can help people just as we have been helped — so they don’t “re-invent the wheel” — or help them avoid mistakes that we made in setting this up.
CL: And where do you see the future of Volunteers in Psychotherapy going? Where would you like to be say 5 years from now?
RS: I suppose as you mentioned in that earlier question, we’d love to be a place where students could get a taste of what it’s like to do therapy unimpeded by some of the problematic constraints of managed care. To help students develop respect for the complexities of doing psychotherapy and understanding another person in depth. Beyond that, we’re not sure. I think we want to be able to offer these types of services in the community and we’d like to have perhaps a range of therapists who we could offer to potential clients.
But outside of that, setting up a non-profit like this has been a bit of an adventure and probably we can’t really foresee bends in the road in terms of what things will be like in 5 years. But, I think those of us who set this up and have spent some years doing it, we certainly want to be around to help offer this to others. We want to be a reminder to a lot of people in the community that therapy is not just any type of talk, that you need to have certain ground rules laid out in order to be effective in helping people with their lives. That privacy and client control is crucial, before you even begin listening to people and trying to understand their lives.
We hope that VIP will be an example that says it is still possible to do something like this.
CL: Well, it certainly sounds like Volunteers in Psychotherapy has set a wonderful example for many people who would like to start a similar organization. I really want to thank you, Rich, for sharing all of the positive ways that Volunteers in Psychotherapy benefits people’s lives.