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Wise Counsel Interview Transcript: An Interview with Richard Shulman, Ph.D. on Volunteers in Psychotherapy

David Van Nuys, Ph.D.

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Dr. David Van Nuys: Welcome to "Wise Counsel" a podcast interview series sponsored by www.mentalhelp.net, covering topics in mental health, wellness, and psychotherapy. My name is Dr. David Van Nuys. I am a clinical psychologist and your host.

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On today's show, we will be talking about the Volunteers in Psychotherapy program with Dr. Richard Shulman. Richard Shulman PhD. completed his doctoral degree in clinical psychology at the University of Toledo, after having graduated Phi Beta Kappa from Wesleyan University and then attended the University of Michigan. He is currently the director of the non-profit organization Volunteers in Psychotherapy, or VIP. As a licensed clinical psychologist, he founded VIP together with three other psychologists and two non-profit specialists.

Volunteers in Psychotherapy Incorporated 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 non-profit alternative to the loss of client privacy and control experienced under managed care.

Now, here's the interview:

Dr. David: Dr. Richard Shulman, welcome to "Wise Counsel".

Dr. Richard Shulman: Sure. Thanks for having me on the show.

Dr. David: Well for the past 10 years or so, you've been running an award winning, community based non-profit organization called VIP, which stands for Volunteers in Psychotherapy. Tell us about your organization and how it works.

Dr. Richard: It's sort of a response to some of the problems that have come up in both public clinics and managed care insurance. We set up VIP as a way that anybody could earn strictly private psychotherapy. We function in the greater Hartford area. The way that our clients earn therapy with us is that they volunteer privately and independently at a non-profit, charitable, or government agency of their choice. In other words, a person can call us saying they would like private psychotherapy and we tell them if they are willing to volunteer at a soup kitchen, a hospital, a nursing home, an agency that helps the blind, an environmental organization, the volunteer ambulance or fire corp., an extremely wide range of non-profits, charities, and government agencies.

They do that privately. The agency where they volunteer doesn't know that they are connected with us, for their privacy. The way we set it up is for every four hours of volunteer work that they donate to whatever number of charities that earns them a therapy session through our network of licensed psychotherapists. Everyone contributes to the common good. Our clients are doing significant amounts of volunteer work elsewhere. The therapists that work with us receive a relatively low fee through funds we've developed.

Private donors give to us because we are a charity registered with the IRS. We apply for grants mostly locally and regionally to support what we are doing.

We donate all administrative work in order to get this off the ground so to speak. We donate local phone and office space. As I say, everyone contributes to the common good. Ultimately, what results is that anyone whether they can afford or not, whether they have insurance or not, can earn psychotherapy that is strictly private. That's the only service that we provide. We don't do evaluations. We sign agreements with our clients that we won't be speaking about them to anyone else, nor will we be filling out any forms about them. It's strictly an old-fashioned framework for people to explore difficulties in their personal lives and in their families.

Dr. David: That's fascinating. It seems particularly timely now. I know you have been doing it for 10 years. But, during this time of cutbacks in social services, it seems like it is such a win-win. It's a win for the people who can't afford to get psychotherapy otherwise. It's a win for all of those organizations that are benefiting from their volunteer time.

Dr. Richard: As well as the benefits that the clients get for doing the volunteer work themselves.

Dr. David: I think that's a very interesting point too. I know that you are one of the founders of this. What first gave you the idea?

Dr. Richard: I'd worked in several different public clinics. There were a number of things. One of them is it's pretty well known these days that if a psychotherapist contracts with an insurance company--a managed care company-- to provide therapy through their auspices, they are often required to send whatever documentation that the insurance company who is paying for it requires. What that means, in a sense, is that the therapy is in private and it is really not under the control of the client.

That's one of the major things. We really wanted to provide psychotherapy what we thought were optimal conditions. It would be strictly private, also under the control of the client and with the client essentially earning it themselves doing something that makes it an exchange. If they can't afford to pay for it out of their own pocket, they are using whatever resources, energy, and initiative they have to do something good, which helps out in the community.

The other major thing is I worked at a poor person's clinic for many years in downtown Hartford. There, I saw many people who wanted psychotherapy and, increasingly, they were blocked from access to it. Instead, the clinic became a place that focused on medication and implied to people really what they had was some unspecified brain disease. Many of these people were folks that had been in and out of state hospitals, or in and out of emergency rooms. If they trusted you and got to know you over time, they often told you about some pretty horrific secret life circumstances.

Many of the women had been sexually abused or raped at some point. Some of the men had also been sexually seduced or had been in some type of personal difficulty that was very upsetting to them. People that grew up in homes that were very violent or where alcohol and drugs were used, these were folks that had no resources. But they, like anybody else, had human troubles. For good reason, didn't wear their heart on their sleeve, so to speak, to mix a metaphor. They had secret troubles that would benefit them if they had a chance to talk about. All of those influences went into myself and a group of other psychologists, feeling that we could probably set up a much better system for provision of psychotherapy than what was going on in either through managed care, or at many public clinics.

Dr. David: You mentioned medication at one point. I am wondering, how do you deal with that in your program?

Dr. Richard: The way that we deal it with it is we strictly delimit what we do. We make a point of saying to people that we are only a psychotherapy organization. We are happy for them to do whatever they want to do about arranging medication. That is, whether they want to try and arrange it or whether they don't want to try arranging getting medication. That would be something that they do independently elsewhere.

There are many public clinics in the Hartford area that focus on the provision of medication. But, there's limited access to therapy. We wanted to be a place that strictly was talking to people under what we thought were optimal conditions for therapy. We feel it's their purview to decide whether they want to receive medication or not. I should point out, that in some ways, this is a reaction to some of the subtle ways that some of us that set up VIP.

We saw how many clients would be coerced or nudged, in different clinics where we had worked, towards taking medication whether they wanted it or not. Their therapist at the clinic was sometimes coerced to secretly provide information about their psychotherapy client to the person who provided medication in the clinic. That is, if it was a an M.D. or typically an M.D. though it might have been an advance practice registered nurse who only saw a client very briefly once every couple of months to provide medication, they might feel uncomfortable about decisions they have to make about medications.

And they might insist on knowing what was going on in someone's therapy and what was the opinion of the therapist about medication decisions. So, we did not want to re-create that type of system. We wanted to set up a system where we would talk as openly as clients wanted to about their personal difficulties or decisions. But ultimately, they will just decide about their medication decisions, since it is their body, and their decisions to be made.

Dr. David: I am really struck by your respect for the client's privacy and the degree to which you've kind of bit over backwards to ensure that their privacy is observed. Which is all the more remarkable in our current time in which so much information is available through the Internet and people are ask to sign a waive and give permission to have their information sent all over the place.

Dr. Richard: That is right. Many times people come in for what they think is going to be the most private encounter that they will have, talking about their personal lives to some type of a licensed psychotherapist. Either in public clinics or through managed care, or wherever they go. They are often immediately, as you point out, you have also to release to sign asking that the therapist be allowed to divulge information and speak to all sorts of other people who might need information about them.

We absolutely wanted to avoid that. What we sign with our clients is you might describe it as a 'reverse release of information.' We sign an agreement saying that through VIP, we are only willing to see them as long as it is agreed between therapist and client that we won't be speaking to anyone about them. But of course, they have a right to speak to anyone about their therapy and to explain out another option that people can always deceive them in what we call 'family therapy.' That if there are important other people to the client, whether they are related by blood or marriage or if they are just someone who is important to them in their life.

They could always choose to have some type of a conjoint session with the psychotherapist if they thought it would be productive and constructive in terms of telling difficult matters in their life. And if I can add one little thing, one thing that we emphasized is that many times the moist poignant things that got said in therapy, the things communicated that get to the heart of some difficult or complex personal matter are often expressed somewhat indirectly or poetically, or phlegmatically.

And if you listen to people in that way, if you listen to random stories that they seem to tell you, psychotherapy clients often let you know indirectly that they know the nature of the framework in which you see them. That is, clients are people who will often hint that they know if it's not a private conversation. For example, whenever I am being taped like in situation like this, I never forget about the fact that I am being taped at the time. And similarly, I think of a person comes in for psychotherapy, but knows that you are going to be speaking to their ex-spouse or that you are going to be speaking to a probation officer, or you're going to be speaking to a lawyer about them.

Believe me, they never lose track of that and in some subtle ways though they will hint that they know that is the nature of the conversation. And in contrast, if it's a strictly private conversation that is just about as honest exploration as can go on about their personal life or their family life, they know when that is the case also.

Dr. David: That is a good point. I've got some questions about the therapist. Do you screen the therapist? Do they share a common orientation? Or is there a variety of theoretical perspectives that they represent?

Dr. Richard: Sure, yeah, there is no monolithic, theoretical orientation of the therapist who participates. We do screen them. In fact, not only do we get copies of their resume, information about their licensure, etc. but the main thing we do is we sit down with them at some point before they work with us. And we ask them to anonymously present a therapy session. That is to talk about without using any names or any identifying information. A therapy session that they have done recently in great detail.

So, we get a sense of really how they think about what is being communicated by the client to them. And pay attention to framework issues about privacy and payment and other subtle things that are often neglected. But the main thing that we are looking for is to see whether the therapist had been trained to be good listeners. For example, we will hear out what the client is saying even if something rude manners they have before they think that they know something meaningful about someone's life.

And also to get to that sort of description of listening for phlegmatic or poetic ways in which people will express themselves. We are looking to see whether they have had training in listening to the pattern in which a person may express themselves that is more than what they are just saying directly.

And that is why I'm alluding to things like random stories that a person may happen to off the tip of their tongue tell you that it may have something to do with how they are feeling and especially may in some way reflect on the therapist's relationship with the client that sometimes is expressed indirectly. Psychoanalyst like Harold Shurls or Robert Lang had written about this at great length about listening to what stories that a person tells you that are not just what they say to you directly.

Dr. David: Sure, and I'm really on that same page. But it sounds like quite what you are describing would be very congruent for people who have been through some kind of dynamically oriented psychotherapy training. What about somebody who is coming out of say cognitive behavioral therapy background? Do you think they would qualify as well or not?

Dr. Richard: Well, I would not make an issue just by the seeming nature of the program that they come out because many people coming out of a graduate program have been exposed to various models of listening. That is why I say that when we screen people, it's really like a two-hour session where we sit down with them and go through a session that they have done. And with a fine-tooth comb, just to get a sense of whether they really are listening to all the subtle ways which our clients communicate. How they feel about themselves or what options seem reasonable for them in terms of managing the difficulties they have. It really comes down to whether people pay attention to what the client is saying and listen to them rather than some being some type of an orthodox-adherent to a theory going into the therapy session.

Dr. David: OK, so I am getting the impression that this is not an opportunity then for interns, for example who are looking to get hours towards a degree or towards licensure.

Dr. Richard: That's just been a technical matter; our board of directors have always felt that since we are offering therapy in a relatively new model, most people expect that they will either pay for their therapy or get it through their insurance. And since we are holding out a different model, I am saying that we think there are benefits to this. That one thing we did not want people to have questions about, was the credentials of their therapist through VIP.

So our board for years now is held to a policy that we would only work with licensed psychotherapist, although, we acknowledge that really we would love to have greater influence on students or advance students. As you point out people on internships or in a placement who are looking for training experiences. We would love to do that but we get a bit worried about at this time about the public having any doubts about the people who are providing therapy to us.

One of the ways we compromise on that is we give free public talks all the time to local graduate programs. Both describing VIP, and not only describing volunteers and psychotherapy in detail but the centerpiece of the talk is a case example that really exemplifies that poetic or phlegmatic listening that I was talking about. And in fact, it was a case that had to do with someone who is offering their private therapy to be discussed in a grand round setting that would reveal them publicly to people. This would take their previously private therapy and allow for them to be known and their personal issues to be discussed in front of about 80 people at a hospital.

The person went on talking, at length, at first saying that they'd love to participate in the grand rounds and have their personal case be discussed by all these unknown therapists. But then they started to talk about all the people who gossip behind their backs and they had doctors who don't just talk to their patients but instead gossip around and talk about them.

So derivatively you might say or in that poetic story in "I Hope I'm Being Clear", this client, even though they said they'd love to take their previously private therapy and have it be discussed in a public forum, indirectly they were talking about all the ways in which people feel bad if they hear people gossiping about them, talking behind their back or they talked about, as they said, physicians who could potentially lose the allegiance and the trust of their patient if they were to divulge personal information more broadly.

Dr. David: Sure. I definitely do follow you and I'm sure our listeners do, too, that our clients will frequently communicate at different levels or communicate metaphorically or send them a mixed message of some sort.

Dr. Richard: Right. So this is something that we'd many times spoken to local graduate programs about it to make sure that students are exposed to that. But currently, we're not in a position to have student therapist provide therapy through VIP.

Dr. David: OK. Do you have any way of verifying that the clients that you see in fact are putting in their volunteer hours?

Dr. Richard: Sure. Absolutely. In fact, it's built in to our system that our clients get documentation from their volunteer agency of the hours they put in and then they forward it to us. So in other words, a person gets a copy of a computerized printout at the hospital where they volunteered that shows how many hours they've volunteered. They get a thank-you letter from a soup kitchen that's preprinted in the personal manages their volunteer work was just the right time. "Thanks very much, Jane Doe, you came in here last Saturday and donated eight hours."

They get us a copy of their schedule, their time run but the main point being that the documentation is given to them not to us. The client doesn't have to divulge in any way that they're in therapy through us but it's an earn-as-you-go system. That's the currency, so to speak, is some form of documentation that clearly comes from the agency to them stating how many hours they volunteered. To give another example, we even give extra credit where if a person donates blood to the Red Cross, all they need to do is get some of the forms that the Red Cross gives them that say things like "Drink a lot of fluid. Don't workout too much for 48 hours." We give them a 4-hour credit for donating blood and they can simply just get that documents from the Red Cross and then give it to us.

Dr. David: That's terrific! I love the fact that you require volunteer service of the clients and, in fact, you suggest that the process of doing volunteer work may aid in their recovery. Do you have any evidence that, in fact, this does happen?

Dr. Richard: Certainly, I can point to some type of a study that does that but there was a doctoral study that was performed a couple of years ago, a dissertation study about VIP. They interviewed a whole bunch of our clients privately asking them about this sort of a nexus that they were in, that they were both in therapy and helping out other people in the community. I think, there was certainly the evidence of the people who participated from VIP, that is the VIP client, saying pretty specifically that they enjoyed doing both. I could tell you that we certainly hear from our clients, I think, indirectly that they're pleased that they're not getting handout. They feel like that there's a fair exchange going on here where they're earning their therapy instead of just getting a handout or getting charity from someone else.

Also, we've been surprised to find out that a bunch of our clients have enquired to make sure that their therapist was being paid so that they didn't feel--first of all, they felt good about the fact that they were helping out in the community in some way that was meaningful to them in order to earn this therapy. Plus, they were glad to find out that the therapist wasn't just doing this in some way that was personally, in my thing, ministering to them or donating to them but that there was some remuneration also that was going to the therapist.

You could also point out to whatever intrinsic value the volunteer work had to the client. Sometimes, our clients will mention to us the specific meaning to them of why they choose to volunteer at the Children's Hospital or the hospice. It had to do with something to do in their own personal life that in some way they felt good for giving back in that particular way.

Dr. David: Yes. I can't sight any studies off the top of my head either but I have been doing reading in the emerging field of Positive Psychology. It seems to me that I have read studies that indicate that giving is a component in happiness--giving and gratitude and forgiveness and things like that. So I could see where the volunteer work could be supported theoretically from that point of view. Now I know in many ways, this service is a response to managed care and you've spoken to this some already. But I want to give you a chance to spell it out more if you care to in terms of what you see as the limitations of the managed care system for mental health services.

Dr. Richard: Sure. Well, there are bunch but I hope I'll hit on a bunch of them. First, many managed care companies--and mental health agencies in general--imply to people that they have some type of a quasi-disease entity going on within them. That is, the first thing that happens is they're given some type of a diagnostic label. It's implied to them that they have a clinical depression as opposed to saying to someone "You seemed demoralized. You seemed sad. You seemed as if your prospect for happiness--you're not optimistic at all that you could ever return to being happy."

So one element that had to do with people, with being implied to them and written up in a way their mental health encounter as if what's going if they have a quasi-medical disorder. Beyond that is I knew it too early that it's just the issue of the lack of privacy. Sometimes clients know this, sometimes they find out in their early encounters with the therapist. But it isn't going to be a private discussion that in the fine print of the documentation between them, the insurance company and the therapist that it's been agreed to that the therapist can send to us whatever reports are required by the insurance company, the managed care company. It means then their client, anytime they're talking, is sitting there thinking, "This isn't just staying in the room."

If there's any really powerful revelation that they want to make about their life or traumas that they've gone through or difficulties that they want to speak about, things that they wouldn't so easily speak about elsewhere, that they never know if their therapist might be recording that sending them out in some way that it becomes part of their permanent medical or insurance record. That's a really major element. Beyond that, there's just the issue that the managed care company is making decisions about their life. You do get situations in which people are told, "Look, if you don't take medication, you can't continue to be seen in therapy." The insurance company may have decided that they think there's a greater possibility that someone will do better if they're on medication. This is separate, independent from the issue of whether the client wants this or not.

Dr. David: Yes. Similarly, the insurance companies often will reimburse a therapist for treating certain conditions but not for others. So sometimes therapists feel like they have to manufacture a diagnosis that will be acceptable and don't they also sometimes make the client complicit and, essentially, having to fabricate something.

Dr. Richard: Sure. I belong to several online list served of psychologists and other psychotherapists and I hear people talk about this type of thing all the time. I like the way you put it that there's sort of a collusion or some complicity between the therapist and client that they both know they're not being fully honest in order to gain the insurance payments. Then, what type of an honest relationship or discussion can you have if a major part of it--the funding part of it--is somehow tied to a dishonest collusion and a, generally, dishonest system.

Dr. David: Yes. Now, are there certain kinds of cases that your group won't take?

Dr. Richard: Not necessarily. I mean, for children or adolescents, we won't see them individually, that's an example. We wouldn't see a 14-year-old because, ultimately, they're not an autonomous and responsible member of society who can decide to come in to see us on their own. We can't guarantee that we wouldn't have to divulge information, say, to their parents. So we're happy to see kids within family therapy sessions so that everybody is speaking in front of one another. Also, just because almost for practical reasons, many times you can get to the heart of the matter if you meet as a family and hear everybody's perspective and see what's going on amongst them.

But outside of that, I can't think of things that we would not do except for the issue that we tell people that we'll only see them under private circumstances. So for example, if somebody comes in and they say, "Oh, that sounds great" and then somewhere along the line say, "Well, really, I've got some custody battle going on. I have fight with the Department of Children and Family is going on." You have to sign a letter or you have to be in touch with them even as simply as to collaborate that I keep coming in. We wouldn't do that.

We want the client to deal with their own responsibilities or their own legal situations in their life and we're happy to have private and, hopefully, honest discussions with them about these things. But we're not agreeing to get coerced, to be pulled into other types of systems that we think would sort of dilute the private conversation, that is, what we have to offer with people.

Dr. David: OK. Back on the managed care issue, one of the other limitations is that they often specify that the therapist can only see the client for a certain number of times like five or six times. I gather you don't place that sort of restriction.

Dr. Richard: Sure. That reminds me one of the things I should have said earlier when you asked about problems that we perceived with managed care. We're just that type of thing that type of decision is taken out of the client's hands and we try and set the VIP up as sort of a consumer situation more. We think that it's more honest to say that "Look, these are elective decisions" whether someone is seeing in psychotherapy and how long and how much it's worth to them.

We specifically set up a relatively high work requirement--that four hours of volunteer work that we require VIP clients to do--so that the client was making their own consumer decisions about the worth of therapy to them. We essentially say to our clients, "As long as you're willing to do four hours of volunteer work to earn every therapy session, then you can decide how long you're seeing in therapy. Even whether you're seen once a week or even twice a week, if someone is going through a difficult time, the client is in the driver's seat making those decisions.

Dr. David: Yes, this seems like such a wonderful and sensible approach. Are there any other such Centers elsewhere in the country?

Dr. Richard: We've consulted a few times with different organizations to encourage them to borrow from this model. Sometimes going and meeting with people in a particular community or giving a presentation about this either to people in the community who are just interested in mental health issues or to psychotherapists who are thinking of developing some type of a charitable organization like this. We, actually--since we've developed some publicity about what we're doing--a little bit over the last few years, we'd had it roughly 72 or 75 different therapists who've contacted us from different communities with an eye towards developing something like VIP.

It is a secondary interest of ours right now. We are pursuing grant funding where we might be able to inexpensively put more substantially consult with these community groups and help them borrow from our idea or modify it in some way that suits them and develop their own organization in their own community. We've maintained a little [indecipherable] for this purpose and we tell therapists that we're willing to talk to them for up to an hour on the phone to brainstorm with them about how they might get going in something like this. As we're saying a minute ago, if we develop just some relatively modest funding, we would be able to do more ongoing consultation that really culminated in a group developing their own 501(c)3 charitable agency.

Dr. David: I think that's a wonderful vision for the future and I hope that it comes to past. I know that I will be sharing some information about your program with a local community mental health center group that might be interested in adopting this model. So as we wind down here, I wonder if there's anything I've missed in our conversation that maybe you didn't have a chance to say.

Dr. Richard: One technical thing, I wouldn't mind giving out our website and phone number just so people could either read more about us or contact us if they did have an interest in pursuing any of the things that we discussed today, would that be OK?

Dr. David: Sure, please do.

Dr. Richard: Sure. Our phone number here is--again, the name of the organization is Volunteers in Psychotherapy and our website is www.CTVIP.org, our phone number 860-233-5115.

Dr. David: Dr. Richard Shulman, thanks so much for being my guest today on "Wise Counsel".

Dr. Richard: Hey, thanks very much for offering this opportunity to explain what we do and, hopefully, make contacts with other people who are interested in it.

Dr. David: I hope you enjoyed this interview with Dr. Richard Shulman and I hope you are as impressed by his work as I am. As you heard being mentioned, one of the potential outcomes of the program that I'm impressed by is that the clients may, in fact, improve partly as a result of donating their time to help others. You heard me suggest that I thought that the Positive Psychology Movement might have produced research that would support this notion.

In fact, on my bookshelf, is a book titled "Why Good Things Happen to Good People?" and the subtitle of that book is "The exciting new research that proves the link between doing good and living a longer, healthier, happier life." This is a recent book by Stephen Post, PhD and Jill Neimark and I highly recommend it. It does, in fact, provide ample evidence that would support the idea that volunteer service would be part of the client healing process.

You've been listening to "Wise Counsel", a podcast interview series sponsored by MentalHelp.net. If you found today's show interesting, we encourage you to visit MentalHelp.net where you can add a comment or question to this show's web page, view other shows in this series, or simply page through the site which is full interesting mental health and wellness content.

Access this show's page in Show Archive information; be at the podcast box on the MentalHelp.net home page. If you like "Wise Counsel", you might also like "Shrink Rap Radio", my other interview podcast series which is available online at www.ShrinkRapRadio.com. Until next time, this is Dr. David Van Nuys and you've been listening to "Wise Counsel".