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The Future of Psychotherapy: Questions asked

Werner Kierski the editor-in-chief of Contemporary Psychotherapy. He is a psychotherapist, lecturer and tutor.

Important changes taking place in the UK world of psychotherapy raise the question: what might the future look like? Although, as with any future, the future of psychotherapy in the UK, cannot be known, these very changes can give us an idea of the direction in which we are headed.

We are referring to the forthcoming government regulation of the profession and the funding of a massive CBT programme throughout the country. In addition, both for students and qualified therapists, the requirement for academic rigour in psychotherapy training and research, will become ever more important.

With these thoughts in mind Contemporary Psychotherapy asked a number of key psychotherapists – Professor Emmy van Deurzen, head of the New School of Psychotherapy and Counselling and former head of the UKCP; Holly Connolly, Subject Leader for Humanistic Counselling, University of Chichester; Alan Frankland, former course leader for the Counselling and Psychotherapy programme at Nottingham Trent University and external examiner for a number of training programmes; Dr Elizabeth Campbell, president of the British Psychological Society – for their predictions. All agreed that the forthcoming regulation is potentially positive, and should lead to clearer structures and high professional standards. However concerns were also raised, one of which was that attempts would be made to squeeze all therapies under one umbrella. The government may also be seduced, it was feared, into focusing only on so-called “evidence-based” modalities at the expense of those for which the “evidence” has yet to be formalised. As Professor Mick Cooper recently pointed out, it is the relationship that is the crucial element of effective psychotherapy but relationship-based modalities are not currently perceived to be “evidence-based.”

All those interviewed recognised CBT as a valuable therapeutic tool, but warned that it is over-rated and tends to be used as a ‘one size fits all’ tool. There were also concerns that the NHS, trying to deliver CBT cheaply, will fail to treat mental health problems appropriately and effectively; some therefore considered that the private sector may become an important influence in maintaining a necessary therapeutic diversity.

It was not totally clear to the interviewees how the many modalities will be affected by the changes, but therapists and trainers have been asked to communicate with each other across modalities to agree the best training and supervision in order to meet the challenges.

But let the experts speak for themselves:-

Question: At the moment some strong influences may alter the field of psychotherapy and counselling in the UK. The influences are: The government initiative to regulate the profession, the growing influence of CBT and the increased access to therapy funding. Taking everything into account what do you personally think will influence the field?

Elizabeth Campbell: The government in future may not recognise some theoretical models and regulation will ask for evidence-based models. The government did not follow suggestions to have different regulatory bodies for different types of psychologies or psychotherapies; it will all be under one roof. There will also be, in future, European regulation of psychotherapy. The European Association for Psychotherapy is lobbying for this. At the moment the UK is behind everyone in Europe in the field of regulation.

Alan Frankland: I think it is very hard to say, and I do not have the confidence in making predictions that I had a few years back when I wrote a chapter on the future for Counselling Psychology (in Handbook of Counselling Psychology, Woolfe, Dryden and Strawbridge, 2003).  There is a clear intention by the government to provide some kind of psychological therapy for more people, but I do not think that this will be delivered by people who we would currently regard as psychotherapeutically competent; the ‘low intensity therapies’ will, I think, be delivered by minimally trained (or retrained) operatives and by machines and even the higher intensity stuff will, I think, often be delivered on the cheap. This is because there will not be enough money allocated to fund the thing properly, but NHS leaders will still be keen to ‘show’ that they are meeting targets for delivering services. Outside the NHS, however, I think we shall continue to develop and that well trained therapists and counsellors (with high level trainings to Masters and Doctoral levels) will refine ways of helping and delivering services which can be shown to be effective when properly delivered over a reasonable (but not necessarily very long) period of time. My guess is that we shall see more practitioners integrating insights from what we would currently see as Clinical Neuropsychology, Cognitive and CBT approaches and (just as strongly represented) phenomenological and relational approaches. I think the style of working will be relational in tone, because complex work cannot be over schematised into simple procedural paradigms, but I have no doubt that the content of the encounters will include cognitive strategies and ways of working related to the relatively new findings about infant (and later) changes in brain activities associated with relational and other experience that is currently coming to the fore.

Emmy van Deurzen: In the UK, registration with the HPC will definitely happen.  This will create a clearer structure for the different sectors of the profession and will also have advantages in terms of professionalism: no VAT to pay, government recognition, etc.  Though people are afraid of this now, it will actually be an advantage in many ways.  The government investment in short-term therapy (IAPT) is also a good thing.  Having more short-term interventions available will make more people aware of the need for longer-term work as well.

Question: What are the main factors, in your estimation, that influence the possible changes you just described?

Alan Frankland: I think the thrust of developments in the NHS will (often) be related to the bottom line, i.e. financial considerations – trying to appear to be providing a widely available and classy service on the cheap. I fear that Counselling Psychologists and some Psychotherapists in NHS employment will be dragged along the same route towards becoming distant service co-ordinators and supervisors for under-trained operatives whose intentions will be good, but whose skills (and hence satisfactions) will often be low. I think that practice in relation to people with mental health issues is slipping away from either psychotherapeutic or medical models of treatment/therapy and back to a risk-aversive warehousing model, dominated by ideas of containment.

Emmy van Deurzen: Collaboration of psychotherapists, psychologists, counsellors and psychiatrists would be an important factor in this.  We also need a longer period of time to bed down these changes and make them work for the profession.
Question: If you are thinking of several factors that influence the future of psychotherapy, which one of these do you feel is the most important? And why?

Emmy van Deurzen: Integration of different methods is a very important new development, which will increase over the years to come.  There is a convergence of different methods and absorption of rival approaches by each method.  This will lead to interesting new ways of working.

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Holly Connolly: In 5 to 10 years time it looks likely that there will be more public confidence in counselling owing to its increased availability and forthcoming regulation introducing strict standards of practice.  Lord Layard’s report does seem to endorse the value of mental health, which looks likely to boost public belief in counselling.
Although many therapists may currently feel obliged to learn about CBT methods, I wonder whether learning to use CBT will loosen some practitioner’s theoretical models – both enhancing their own practice and enabling them to contribute creative possibilities to CBT. In the future more commitment to meet the more rigorous standards will be needed from trainees; some students may fall by the way side.

We will probably continue to have alternative minded rebels who find ways to practice their own thing, possibly changing the name of what they do.

Question: How do you think the diverse landscape of the many theoretical modalities might be affected? Will there be an increase, decrease or no change in the number of modalities?

Elizabeth Campbell: What is slightly alarming is the stronghold of CBT and how this affects funds for training. We thrive on diversity not just one approach. Therefore, a lot of psychological therapy courses teach at least 2 models, such as systemic, psychodynamic or interpersonal psychotherapy (IPT)

Holly Connolly: Some styles of practice may not be recognised owing to the promotion of CBT. Whilst CBT has a proven track record, it also has significant limitations and is not a cure for all. The values framework within which therapists operate is as important as the therapeutic process itself.  It seems the government could be promoting a mechanistic approach to psychotherapy, neglecting to recognise the significance of the framework.  That’s why at the University of Chichester we are incorporating in our training familiarity with CBT methods within a Humanistic framework, which we believe is of great benefit to clients.

Alan Frankland: I think we are already seeing the effects of the government fantasy that CBT is a cheap cure-all, but they are not as negative as some would have feared. The therapeutic community (counsellors, psychotherapists, counselling and psychotherapeutic psychologists and some psychiatrists) has already seen through the rhetoric, but people know which side their bread is buttered. Thus we are seeing courses springing up offering a CBT model for Person-Centred therapists etc. This is paralleled by a conceptual move from within CBT as well. As more practitioners realise there is greater subtlety in the human condition and human troubles, so they are evolving the model. I meet more therapists, for example, who call themselves cognitive rather than CBT, who are moving to a schema focus, who are integrating mindfulness, although that is also being degraded, not to say bastardised in many cases to a mechanistic procedure taught to, almost done to, others rather than practised with them. The situation is complex and I do not think it’s all bad by any means, but we do have to remain vigilant about quality. Too much that is labelled as CBT in NHS settings is simple psycho-education and sometimes not much more than psychologised bossiness! We have to try to ensure that the whole thing is not dumbed-down and that humane and relational values are at the heart of policies aimed to help troubled people, otherwise real opportunities will be lost and huge amounts of money wasted.

Emmy van Deurzen: Initially a decrease, certainly within the public sector, but ultimately an increase as the basic approaches reimbursed by the NHS will leave a lot to be desired and people will create new ones in the margins. Existential therapy has a future as an antidote to CBT, especially because of its capacity for integration of different methods within a philosophically clear and meaningful framework and because it addresses people’s true concerns.  It is also more open to cross-cultural issues than most other therapies.  This will become an increasingly important issue.
Question: What advice do you give psychotherapists and counsellors in preparation for the next years 5 to 10 years and beyond?

Holly Connolly: I think we all need to find ways to adapt to the forthcoming changes, be resilient, and to keep believing in our own worth as counsellors as well as our capabilities to meet any new requirements.  Also, to walk the talk and keep communicating with each other.  We also need to be politically aware and spot and use opportunities to influence the growth of the profession positively in the next few years.

Alan Frankland: More specifically for the next five to ten years I think people entering this work will have to take their intellectual abilities and academic training seriously. I am not sure it ever was enough to be a good and warm person with a panoply of skills to be a good therapist. I am more and more sure that it won’t be in the future. Although there are some undoubted drawbacks to professionalisation and academic qualifications and it’s entirely clear that cognitive capacities, however excellent, are not enough in themselves to make a passable therapist, I think our clients deserve and the world (employers and clients) will demand that not only can we do the job in the consulting room, but that we can understand and express why we do what we do and enter into dialogue with other professionals who may not share our conceptual and value frames; and I think that we should demand of ourselves a real engagement with new knowledge, with research and audit, as well as maintaining professional organisations that help us to do our jobs whilst also offering protection to the public who use our services.

Emmy van Deurzen: Get as much training [as possible] in a wide variety of approaches and then get a clear philosophical framework for thinking for oneself and enabling clients to do the same.  Don’t panic; trust in the future of the profession which will become increasingly important as society evolves and leaves people less connected and less clear in terms of their purpose and meaning.