Remember 2012? A lot of water has passed under the bridge since then, but who would have predicted some of the events that have taken place in the intervening years?
Who would have predicted the 2012 Olympic Games would have been a stunning success that brought people in the UK, albeit briefly, closer together? Who would have predicted that we’d now have left the European Union? And who would have predicted that Vladimir Putin would have invaded Ukraine? Some things are easier to predict than others. What about the future of therapy?
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The future of psychotherapy, past and present
I hadn’t realised this till recently, but every decade for the past four decades or so, psychotherapy’s own Mystic Meg, Professor John Norcross, together with other colleagues, has been predicting the future of psychotherapy for the coming decade. The subject of their focus has been psychotherapy in the United States, but, as with many things, what starts in the US often spreads beyond its borders.
In previous iterations, Norcross and colleagues accurately predicted a shift in theoretical orientation from psychoanalytic to cognitive–behavioral therapy (1980’s); a reduction in the proportion of psychiatrists conducting psychotherapy (1990’s); the expansion of practice guidelines, behavioral medicine, and pharmacotherapy (2000’s).
For the last decade, they predicted that mindfulness therapies and psychotherapy conducted via the internet would flourish. By and large, then, their predictions have proved to be accurate.
Delphi methodology – the modern-day crystal ball
In coming up with their published predictions for the 2020’s, John Norcross and colleagues have used Delphi survey methodology, of which I’m a big fan. The primary goal of the Delphi process is to develop consensus among an expert panel on complex questions. In this case the process (conducted by e-poll) was to develop expert consensus on psychotherapy in the US during the next decade.
In Delphi methodology, a panel of experts respond to the same questionnaire over at least two rounds. In the first they answer the questionnaire anonymously and without access to peers’ responses. In subsequent rounds, they see peers’ responses and can revise their predictions accordingly.
The latest questionnaire contained six sections on:
- Theoretical orientations (36 items)
- Therapeutic methods/interventions (47 items)
- Psychotherapists (12 items)
- Psychotherapy platforms (6 items)
- Psychotherapy formats (10 items)
- Forecast scenarios (30 items, see below for examples)
For the first five sections, respondents were asked to predict whether each psychotherapy practice would increase or decrease over the next 10 years, using a 7-point Likert scale ranging from 1 = great decrease to 7 = great increase. For the sixth section, respondents were asked to place the predicted scenarios in rank order of likelihood.
Examples of predicted scenarios * Psychotherapists devote a greater percentage of sessions to cultivating strengths as opposed to treating psychopathology * The overall effectiveness of psychotherapy improves appreciably * Psychotherapists increasingly personalize therapy to patient’s biomedical or genetic markers * Revolutionary new techniques of psychotherapy are discovered and replace traditional treatments * What is the likelihood that a group of expert psychotherapists can accurately predict the future of psychotherapy?
So, what does the future hold?
“People in this country have had enough of experts,” declared Michael Gove (then Lord Chancellor) in the runup to the UK’s Brexit referendum. Sadly for Gove, polling showed the public to have rather more trust in ‘experts’ than politicians. The experts referred to then were academics, but who were the experts in the Delphi poll?
“People in this country have had enough of experts”Michael Gove, then Lord Chancellor in 2016
The expert population in question were drawn from 67 living contributors to the second edition of the History of Psychotherapy and 40 editors of mental health journals routinely publishing articles on psychotherapy. In all 56 of them participated in two rounds of predictions and achieved consensus on most items. There’s not room to profile them in full, but here’s a flavour of what they predicted:
Of the 36 orientations on offer, nine are expected to increase, 15 are expected to stay about the same, and 12 are expected to decrease over the next decade. The five expected to increase most are multicultural, mindfulness, cognitive-behavioural, motivational interviewing and acceptance and commitment therapies.
Expected to decrease most are classical psychoanalysis, transactional analysis, reality, gestalt and existential therapies. Also expected to decrease (though not to the same degree) are person centred, psychodynamic, humanistic and solution-focused therapies.
Eighteen therapeutic methods/interventions are predicted to increase, 18 to stay about the same, and 11 to decrease. In, come online self-help, virtual reality and social networking, as well as routine outcome monitoring and fostering the therapeutic alliance. According to the experts we’ll also be using strengths-oriented methods such as positive psychology, teaching emotional regulation and relapse prevention. We’ll also be giving clients more homework.
Out, will go free association, aversive conditioning, encounter exercises and (sadly) dream work. Sad also to see the predicted decrease in the use of paradoxical interventions. I always think there’s nothing quite like a well targeted paradoxical intervention. The use of psychedelic drugs as an intervention will apparently stay more or less the same, but it’s not clear in what context or by whom.
Who will we be, in this bright future? Experts predicted that six professional groups of psychotherapists of would expand, five would stay about the same, and one would diminish over the next decade (bear in mind these are predictions of US trends). Master-level counsellors and clinical social workers are predicted to increase the most in the next 10 years. Psychiatric nurses, personal coaches, masters-level family therapists, and self-help groups are also expected to increase.
Numbers of psychologists, peer counsellors, and paraprofessionals are expected to remain about the same. The proportion of psychiatrists providing psychotherapy is expected to further decline.
The pandemic drove most of us that continued to practise either online (willingly or not) or outside. But what of the future – will we simply go back to face to face when we feel it’s safe to do so?
Our experts predicted the growth of e-therapy in the coming decade, with videoconferencing and multiple or flexible platforms most likely to increase. Therapy via smartphone apps, telephone and texting are also predicted to grow, whereas the frequency of in-person, face-to-face sessions is expected to remain about the same.
What of the formats in which therapy will be delivered, for example short versus long term? What of psychoeducational groups in which we’ve seen considerable growth recently, partly though not exclusively in IAPT settings?
The experts predict growth in short-term therapy (5 – 12 sessions), psychoeducational groups for specific disorders, population-level interventions (no, I’m not sure either), crisis intervention and very short-term therapy (1- 3) sessions.
Predicted to stay the same are individual therapy, couple/marital therapy, group therapy and conjoint family therapy. The sole format predicted to decrease further is long term therapy.
What are we going to be doing more and less of?
First, the two scenarios that are not going to happen. To begin, our experts were sceptical about the discovery of revolutionary new techniques of psychotherapy that will replace traditional treatments. Second, presumably tongue in cheek, they also predicted a lesser likelihood that experts will accurately predict the future of therapy.
What are we going to be doing more of? According to the experts we’ll increasingly personalise therapy to clients’ cultural identity, transdiagnostic characteristics (e.g., preferences, stage of change), and primary disorder/condition. Therapy will become more integrated into primary care. We’ll be spending more time cultivating strengths as opposed to treating psychopathology, and overall length of therapy (in sessions) will decrease.
Predicted to stay more or less as they are: the influence of artificial intelligence and machine learning on treatment matching and the effectiveness of psychotherapy; the number of full-time positions keeping pace with the number of new psychotherapists entering the field, and the overall effectiveness of psychotherapy.
That’s the US, but what about the UK?
Those are the predictions of our experts for the US for the coming decade. Therapy in the UK, however, sits within a very different landscape, so how many of those predictions may also apply to the UK? We think many will, but rather than addressing each of the six sections covered by our experts, we’re going skip straight to our own predicted scenarios.
In terms of the overall therapy landscape we predict:
1. Funding for mental health will not achieve parity with physical health. Even pre-pandemic, it was little more than a faint hope. Now, there’s not even a prayer. Sadly, there are signs it’s going to get quite a bit worse.
2. We’ll see an expansion of therapist numbers, both in IAPT and elsewhere. Within IAPT, there will be a broad relationship between those training places and job roles. For those funding their own training in counselling and psychotherapy, not so much.
3. There will be no Next Big Thing. There may be a smattering of new approaches. They will be evolutionary rather than revolutionary. None will make a jot of difference to the overall effectiveness of therapy. Some, however, may prove very lucrative for their developers.
If that’s enough doom and gloom for you, then fear not, because we predict there are going to be some bright spots on the horizon. This is where we’ll see therapy outcomes improve.
The really exciting stuff is going to be at the intersections of therapy personalisation, therapist responsiveness, use of routine outcome monitoring and feedback, and a range of activities that fit under the broad description of deliberate practice. But what will that look like?
This won’t be universal, but we’re going to be personalising therapy to the client a lot more. With exceptions, we’ve been expecting the client to fit around the therapy rather than the other way around. If you doubt this, ask yourself for whose benefit the 50 minute hour exists.
We’re going to be more responsive. To the specifics of clients’ cultural backgrounds, but also to their particular therapy needs, preferences and other characteristics. There’s already plenty of evidence of the difference this makes. Perhaps the trend towards greater therapy integration is one indication of this?
We’ll be attending more carefully to the working alliance, as predicted by our experts. Not just the relationship or bond element, but also the goal and task elements. We’ll be taking every opportunity to make sure the client is getting what they have come for, at the start and as therapy unfolds.
Increasingly, we’ll become more thoughtful about how we measure progress towards the client’s goals. This will involve a more personalised and flexible use of outcome, alliance and goal based measures.
Finally, and this is a fervent hope as well as a prediction, therapy consumers will be much more informed. We know by now many of the factors that predict successful outcomes. As practitioners, and more generally as a profession, we need to be sharing this knowledge so that prospective clients are able to make informed choices when they seek out therapy.
That’s it! Let us know what you think of the predictions above, and share your own below.
Just like you we thrive on feedback.
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