Psychotherapy Status Report: Past Achievements/Current Failures/Future Disruptions

• A Very Brief History of Psychotherapy
• Five Major Achievements in Psychotherapy
• Five Major Failures
• Five Future Trends
• Conclusion

A Very Brief History of Psychotherapy

Depending upon how you look at it, psychotherapy is among the oldest of professions — or one of the newest. Lacking effective active treatments, doctors always got by with some combination of supportive psychotherapy, magic, and placebo effect.

The Shaman in prehistoric times was the first psychotherapist — diagnosing and treating the mental and physical ills of tribal members by negotiating with the spirits on their behalf. In settled agricultural societies, priests assumed the same role, though the negotiation was with gods, not spirits. Then came the philosophers.

All the basic principles of CBT were laid out by the Epicurean and Stoic philosophers in ancient Greece and Rome. The Arab world, one thousand years ago, was the first to have a separate profession of psychiatry, whose practitioners developed techniques of psychotherapy quite similar to how we practice today. And Pinel substituted psychotherapy for chains in caring for the mentally ill in Paris 225 years ago.

Modern psychotherapy began with the few practitioners of psychoanalysis in Vienna 140 years ago — but psychotherapy quickly became a growth industry, both in the number of practitioners and in the wide variety of techniques they used in their practice.

One hundred years ago, there were very few people who would label themselves psychotherapists; now there are almost 200,000 in the US. About 60% hold a master’s degree, 40% are PhD’s; 70% are female; and average age is 45. Seventy percent of therapists provide mostly individual therapy; 30% also work with couples and/or families. Therapists in private practice usually see 20-25 patients a week; charge anywhere between $75-$200 for sessions that last 50 minutes; and on average, see patients for anywhere between1 and 12 sessions. The average wait time for a first appointment is several weeks.   

CBT is the most popular form of treatment followed by psychodynamic approaches. Two thirds of therapists feel deep satisfaction in their work, but half report having felt burned out at times during their careers. The US Bureau of Labor Statistics estimates that the number of therapists will increase by about 20% by 2030. You can find many more interesting statistics characterizing therapists and therapies here: 

My purpose in writing this piece is to provide my personal, and admittedly biased, view of the major achievements and major failures of our psychotherapy enterprise — and to provide some guesses of what likely future directions will be.

Five Major Achievements in Psychotherapy

The Therapeutic Relationship

The greatest paper in the history of psychotherapy was among the first — Saul Rosenzweig’s 1936 “Some Implicit Common Factors in Diverse Methods of Psychotherapy.” Rosenzweig correctly predicted that the most robust finding in all the later extensive psychotherapy research would be that “everybody has won, and all must have prizes.” His “Dodo Bird verdict” (borrowed from Carroll’s “Alice in Wonderland”) asserted that most comparisons of the efficacy of various forms of psychotherapy result in tie scores. Although therapies may differ greatly in theory and technique, the greatest contributors to good outcomes are the factors all have in common; the therapeutic relationship, patient and therapist positive expectations, healing rituals, catharsis, and regression to the mean with the passage of time. The success of any given form of therapy is not proof of its specific theories or practice, because so much of the variance comes from what is shared across therapies, not what is particular to each. This is not to deny that specific techniques have specific value for specific indications, but it does focus therapist attention on getting right the more general factors that cut across therapies. Rosenzweig guessed the Dodo Verdict without the benefit of any controlled studies, but many thousands of subsequent well-controlled, randomized comparison studies have proven him remarkably prescient.

Documenting The Efficacy of Psychotherapy

The most important thing I’ve ever done in my career was serving on the NIMH committee that funded the early studies of CBT and DBT during the 1980s. These were the early days in systematic psychotherapy research applying the model of clinical trials — the controlled, randomized comparison method that had already revolutionized medical research and efficacy studies of psychiatric medications. 

The few million dollars that supported research documenting the efficacy of CBT and DBT have since benefited millions of patients worldwide. In contrast, NIMH has since spent many tens of billions of dollars on brain and gene research that has provided little to no benefit to patients. The research success of CBT and DBT legitimized psychotherapy and led to their widespread acceptance as reimbursable treatments worldwide. Tens of thousands of therapists have subsequently received systematic training in CBT and DBT — and both have generated extensive professional literatures and also books aimed at patient education and self-help materials, virtual and written. Psychotherapy would not be nearly so widely accepted today if it lacked this demonstration of efficacy.

Expanding The Scope of Psychotherapy and Its Specificity

Modern psychotherapy began with Freudian psychoanalysis, usually conducted several times a week, with the patient lying on a couch and free associating. Within decades, innovative pioneers developed less regressive short and long-term psychodynamically-based therapies that eventually largely replaced the original model. Almost simultaneously, behavior therapy had its origin in Pavlov’s dog conditioning experiments and was brought into clinical practice through innovations introduced by John Watson, B. F. Skinner, and Joseph Wolpe.

Cognitive therapies developed independently by Albert Ellis and Aaron Beck became popular in the 1970s and dialectical behavior therapy was developed at about the same time. In subsequent decades, at least 50 different psychotherapies have been named and defined. This profusion of different therapies is not an unmixed blessing (as we shall soon see), but it has vastly augmented the toolkit of modern therapists and increased the specificity of psychotherapy techniques for depression, panic attacks, generalized anxiety, phobias, anorexia, bulimia, addictions, sexual, and many other disorders. 

Research Comparing Psychotherapy with Psychiatric Medications

The ultimate test of psychotherapies is not how they do against one another (because such comparisons routinely result in tie scores (actually, CBT is usually found to be more effective than others), but rather how they do against medications (when either might be indicated) and how they do against no specific treatment (when meds are not indicated). The evidence of hundreds of studies across different therapies, different medications, and different disorders is that psychotherapy and meds are about equally effective when both might be indicated and that the combination of both may be more effective than either alone. Meds work quicker (not entirely true); psychotherapy has more enduring effects. 
A useful rule of thumb is that psychotherapy alone may be indicated for most milder psychiatric problems; psychotherapy or meds, alone or in combination for moderately severe symptoms, and meds plus supportive therapy for more severe and enduring symptoms. Very mild and transient symptoms do well with watchful waiting (or, as prescribed in the UK, self-help materials or self-help groups).

Reducing Stigma

Mental illness had been more easily accepted before the urbanization that followed the industrial revolution. And in some cultures, the mentally ill had even been revered as a source of spiritual power and insight. But stigma increased dramatically when individuals with mental illness became inconvenient denizens of crowded cities. The typical expectation was that the mentally ill were all badly out of touch with reality; useless; in the way; untreatable; likely to deteriorate and become dangerous; and worthy only of warehousing in badly overcrowded, dingy, smelly, neglectful inpatient snake pits. This stigmatization of mental illness has been much dissipated with the expansion of disorder definitions according to the DSM; the inclusion in the DSM of much less severely impaired individuals; and the widespread experience of psychotherapy in the general population. Many people, especially in cities, have been in therapy or know someone who has.   

Five Major Failures

Lack Of Access

In the US, most people needing psychotherapy can’t get it or wait months on waiting lists. Some of this is due to a shortage of trained therapists. Some is due to lack of parity in insurance coverage and tricky ways insurance companies have of avoiding responsibility for reimbursement. Some is due to geographical distribution of therapists — people with psychiatric symptoms live everywhere, but almost all psychotherapists live in cities.

But economic inequality is by far the greatest culprit in depriving needed psychotherapy for the very people who are experiencing the greatest psychosocial stresses. Add to this that most therapists are white, come from middle class backgrounds, and have little experience with or empathy for (or deep understanding of) people of color, with diverse cultural experiences and values, and with the economically disadvantaged. It is a great failure of public funding in rich nations that the needs of the vulnerable, most in need, are so often neglected. 

Lack of access is exacerbated by the fact that most psychotherapists focus on doing the most possible for each individual patient, rather than having the public health ethos of striving to do the greatest good for the greatest number. Many psychotherapists exclusively conduct long term therapies with very ambitious goals, resulting in long waiting lists or no treatment at all for those frozen out of the system. Most patients want and need only brief treatments aimed at symptom relief. Long term therapy is valuable, but it should be the exception, not the usual first reflex.

Community mental health centers, often vastly understaffed and with therapists with less training, are expected to treat a crushing number of patients per week. And then there has been the emptying of psychiatric hospitals without needed therapeutic services, housing, and vocational support

Lack of Integration

There has been a tension during the past 50 years between the psychotherapy splitters (those who create an ever-expanding list of new psychotherapies) and the psychotherapy lumpers (those seeking to integrate psychotherapy into one coherent whole). Despite the best efforts of the lumpers (count me in here), the splitters are winning out. At last count, there are more than 50 named psychotherapies — a veritable alphabet soup. Most therapists are narrowly trained in one type of therapy and remain tribally loyal to it — applying the same techniques to all their patients rather than developing sound conceptualizations and treatment plans for each individual, integrating and flexibly applying the specific techniques most appropriate for that individual.

Most training programs are narrow in focus — locked into the techniques developed and taught by their founders, rather than teaching a wide array of the best techniques from across all models. Cognitive therapies are now by far the most prominent in the world because they have been by far the most flexible — over the past 40 years incorporating behavioral, psychodynamic, experiential, and recovery techniques and applying them flexibly to a widening range of symptoms within their theoretical framework

Losing The Battle with Drug Companies

Psych meds are essential for those with severe psych symptoms, and often necessary for those with moderate symptoms. Even though most people with milder symptoms would do better with psychotherapy or watchful waiting, a startling 20% of the general population are instead regularly taking a very often unnecessary psych medication.  

There are three causes of this overuse of psych meds and accompanying/underuse of psychotherapy; 1) drug companies spent billions of dollars promoting meds; virtually nothing has been spent promoting psychotherapy; 2) 80% of psych meds are prescribed by primary care doctors with little training and great eagerness to get a satisfied patient quickly out of the office; and 3) psychotherapists are so hard to access in most communities. This overuse of meds and underuse of therapy is bad for patients, bad for therapists, bad for society — it is good only for drug companies.

Underemphasizing Supportive Therapy

The flourishing of specific techniques of therapy has obscured the fact that supportive psychotherapy is valuable and should be part of every patient encounter, whether in a medical or a psych setting. With the exception of some psychiatric residency programs, there are few training programs teaching how to do supportive therapy, and few books and papers describing it. This, despite the facts that supportive therapy is the only helpful tool most doctors have had during most of the history of medicine, that psychotherapeutic support creates hope, reverses demoralization, and counters isolation, and that supportive psychotherapy requires more skill and empathy than the use of specific techniques.  

Failing To Include Evolutionary Perspectives

Darwin was the greatest psychologist who ever lived. He had three seminal insights that should vitally inform modern psychotherapy: 1) we have inherited many of our emotions and behaviors from our animal ancestors in the same way we inherited our bodily morphology; 2) we are unaware of the underlying motivations of our behaviors; and 3) many of our now maladaptive behaviors are relics of a time when they were much more adaptive.

An evolutionary perspective helps patients normalize their symptoms by better understanding where they come from and why they have them. It is normal to grieve as the price of love. It is normal to feel sad when we fail as a motivator to do better in the future. It is normal to have anxiety and phobias in response to dangers, to feel paranoid when confronted by potential enemies, to be dependent when in need of help, to overeat when delicious food is available, and so on.

Normal feelings and behaviors become problematic symptoms only when they are severe, prolonged, stereotyped, and not adapted to the current environmental contingencies. Understanding the normal roots of symptoms reduces the patient’s feeling of being uniquely damned and points the way to more adaptive responses. The valuable application of an evolutionary perspective toward psych symptoms has been described for 30 years — but most psychotherapists are woefully ignorant about it. Notably, one of Aaron Beck’s last papers did include an evolutionary perspective on depression. 

Five Future Trends

Teletherapy

Telemedicine has been around for 60 years, particularly for providing services in rural areas and particularly in psychiatry. But all this was on a small scale until Covid isolation protocols temporarily made telethetherapy the predominant way for psychotherapists and patients to communicate and for young psychotherapists to be trained. States temporarily relaxed licensing restrictions that had prevented therapists from extending their reach across state jurisdictions. The results were remarkable — many therapists (and patients) preferred zoom to in-person sessions because they afforded greater scheduling convenience, eliminated travel, allowed access to a greater range of therapists, reduced waiting time for first sessions, reduced therapist overhead, and achieved surprisingly high rates of patient and therapist satisfaction.

The lifting of Covid restrictions has made teletherapy something of a geographical jumble. Different states now have very different licensing requirements, some welcoming teletherapists from other states, some tightly restricting, and many in between. But the trend is clear — more and more, psychotherapy (like so many other aspects of life) will be done remotely via screens, rather than in person.

Text Therapy

Covid isolation also resulted in the explosive growth, increasing acceptance, and commercialization of text-based therapy. The convenience and advantages of easy and expanded access, flexible scheduling, efficiency, and low cost are clear. But texting as a psychotherapy modality also has some real advantages over in-person meetings. Patients are often more open in texts than face to face, and less likely to ignore or reject therapist’s comments. Writing gives them the opportunity to think through their problems, and texts can be read and reread and considered in a way not possible with fleeting verbal communication. One exception may be CBT, where clients are encouraged to take good notes of the most important points of the session.

The disadvantages of texting are also obvious — the lack of visual appraisal and non-verbal cues can lead to incomplete evaluations and miscommunication. We can’t really trust the few generally positive studies on texting as they may be biased, but my guess is that it will play an increasing role with the advent of a new generation of patients and therapists, who have grown up using texting as one of their major forms of relatedness.

Competition From Coaching

Life coaching is a fast-growing profession with over 70,000 coaches practicing worldwide. Theoretically, coaching and psychotherapy have different goals, practitioners, and consumers. Therapists receive more extensive training, require more formal licensure, and treat psychological symptoms that are diagnosed, coded, and compensated as “mental illness.” Coaches receive much less training, have much looser licensure requirements, and provide wellness training to improve business, interpersonal, organizational, or sports performance and to enhance life satisfaction. People with more severe problems need psychotherapists; those who are generally doing well but want to do better may seek coaching. Coaching has the advantage of less stigma (no DSM disorder required); but the disadvantage of not being reimbursed by medical insurance. As coaching becomes more available and well known, it will doubtless draw many people who would otherwise have seen therapists.

Corporatization

Psychotherapy began as mostly an individual endeavor — one practitioner contracting with one patient who paid out of pocket. Soon however, and particularly after World War II, psychotherapists increasingly began working in institutional settings — hospitals, outpatient departments, community mental health clinics, the military, and VA facilities. Especially beginning with managed care in the 1990s, psychotherapists have increasingly worked as employees of increasingly larger and larger private, for-profit groups.

Teletherapy has recently exponentially speeded up the concentration of psychotherapist — one company has accumulated a network including tens of thousands. This has the possible advantages of improving patient access and quality control but drains money from the system and risks creating inappropriate uniformity and decreased quality.  

Artificial Intelligence

I have previously written on the very real risk that computers will replace psychotherapists.  

Conclusion

It is the best of times and the worst of times for psychotherapy. Best because we have so many therapists and effective therapies. We can help most patients more than medication can and no profession is more interesting or fulfilling. I am a much better person than I otherwise would have been because my patients taught me so much. Worst because the field is so unnecessarily fragmented, so poorly compensated, and so at risk of being controlled by corporate interests and/or reduced by coaching or replaced by artificial intelligence.  

The best hope for the future, both for patients and practitioners, is to do our job well. We must integrate the hodgepodge alphabet soup of existing therapies by combining what works best from each within the context of a sound conceptualization. Therapists should no longer be trained in, and express fealty to, just one school of therapy. We should discuss, but rather feel comfortable applying techniques across all relevant schools, flexibly meeting the specific needs of each patient.

Psychotherapists have, since the dawn of time, provided comfort and solace to mankind. Labels change — shaman, priest, minister, doctor, psychiatrist, psychologist, social worker, counselor, nurse, occupational therapist, coach, and many more. But the essential function of explaining and healing human suffering has always, and likely always will be part of the human condition.  

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