The Future of Psychotherapy

Michael Fitzgerald

There is no doubt that in the last decade of the century, the public imagination has 
been captured by molecular genetics as it applies to the brain as well as
 neurochemistry. Indeed there have been significant advances in our understanding 
of the brain. This has put psychotherapy under more pressure as it is more difficult 
to come up with exciting new discoveries in psychotherapy that will capture the 
imagination of the public like molecular genetics. It is likely that the brain
 will remain, for the next 50 years at least, very much to the forefront of the public and 
the journalistic concerns. All this will only underpin even more the philosophy of 
the logical positivists, which values empirical propositions based on actual 
observations and which will continue to have a huge influence on Irish psychiatry 
in the 21st century. This positivistic psychiatry, with its uncritical acceptance
 of Popperian empirical realism, has defined acceptable knowledge in a very narrow reductionistic way. The dominant view will continue to be that all that can
 be known about psychological problems is commensurate with what can be measured.

The Challenge for Psychotherapists

It is going to be even more difficult in the future for psychotherapists to find space for the theory of psychoanalysis and derived psychotherapeutic and counselling techniques or for interpretations given to patients which resonate with the dialectic of experience and have the ‘ring of truth’. The great challenge for psychotherapists 
and counsellors will be to find the space in the dialogue. It is going to be an 
enormous uphill battle for psychotherapists and counsellors to counter this 
positivist psychiatry, which has focused on biology and the “‘mind machine’ 
Biological psychiatrists and biological psychologists will continue to be more
 comfortable with so-called objective, “macho” knowledge which Karl Popper 
calls “it is known”, but have difficulty with subjective knowledge, which Karl
 Popper calls “I know”.


Nevertheless the 21st century is going to provide a challenge to both those who 
focus on a biological view and those who focus on a psychological view. They will 
need to dialogue with each other and combine the rational and romantic views of 
the human being. This integration and respect for the other point of view is going 
to be a major challenge in the 21st century.

Widening Schism

Human beings will only benefit where both points of view are applied as 
appropriate. Unfortunately at present the schism between those who practise the biological approaches and those who practise the psychological approaches is 
growing ever wider. Indeed the concern expressed by Sir Denis Hill many years
 ago (1954) when he was Professor of Psychiatry at the Institute of Psychiatry in London, is even more true now than it was then. He stated that “there is a risk that 
a psychiatry dominated by physical methods of treatment, and promoting little but
 physiological research related to them, will regress to unpsychological attitudes to
 mental disorder such as existed at the beginning of the 20th century.”

New Forms of Psychotherapy

Chris Dare (1996) points out that new forms of psychotherapy will be invented and
 that some of these will have a long term effect on the development of 
psychotherapy as a subject. He sees mergers of some schools of psychotherapy and
 splits in others. He believes that the evolution of psychotherapy will be modified 
by the necessity of providing evidence for the effectiveness of the psychotherapies. 
On the positive side he points out that the search for meaning in psychotherapy will
 continue. It is interesting that he believes that psychodynamic psychotherapy will
 become increasingly similar to cognitive behaviour therapy. I believe that he is 
correct in pointing out that consumer pressure will have a considerable effect in the
 provision of psychotherapies for human problems. Indeed there will be
 development in the 21st century of consumer groups’ demand in the provision of
 psychotherapy from governments. At present we have consumer groups for almost 
every possible condition but none as far as I am aware pressing for the increase in 
psychotherapy as its main aim.

Increasing Need

The need for psychological interventions at any one time is enormous and
 estimated to be 15 to 20% of the population, and since the 2nd World War this 
figure is probably increasing. There is definite increase in suicidal behaviour,
 depression and psychosocial problems in children. Clearly this increase cannot be 
explained on the basis of genetic data or of simple biological factors. We have to
 look to the psychosocial domain to explain this increase in rates of psychological
 problems. We have not explained satisfactorily why the rates of psychological
 problems are increasing particularly in a time of increasing affluence. It is
 surprising that with an increase in affluence there is a parallel increase in alienation 
and depression, and inevitably, psychotherapists and counsellors will have an 
increased role in dealing with these problems. There certainly is enough work for 

Hard Data Required

It is critical that in the 21st century the gap between psychotherapy researchers and
 clinicians reduces. At present unfortunately the two groups of workers tend to work 
independently and are not much influenced by each other. This is a very serious 
matter because hard data of a quantifiable nature is going to be necessary if
 governments are to be persuaded to increase the budgetary commitment to 
psychotherapy. It is particularly unfortunate that there is such a gap between
 clinicians and researchers when there is such strong evidence in favour of
 psychotherapy and indeed psychotherapy could be argued for purely on economic 
grounds. It is going to be critical that psychotherapists and counsellors take on the challenge of hard data and not turn away from it or dismiss it. It is highly likely in the 21st Century that governments and Health Boards who purchase psychotherapy
 services for various populations will only do so on the basis of strong scientific
 evidence of a quantifiable nature. Simple assertions of the value of psychotherapy 
and counselling will no longer carry any weight. The relationships then will be
 simple economic ones between purchasers and providers of services, and it will be
 necessary for psychotherapists to speak the appropriate language of this 

Research Models

Since the need for health and psychological services is limitless so far as we can
 determine, and the resources of any government are finite, decisions will always
 have to be made on which treatments to support. These will increasingly be made
 on the basis of empirical evidence and not on what some famous professional 
might state was the case in the past. The psychoanalytic psychotherapies could be
 at risk unless much greater emphasis is placed on empirical evidence.
 Unfortunately psychoanalytic psychotherapy and counselling is not well suited to 
the randomised-controlled trial, which is the gold standard for treatment efficacy.
 In this research model, persons with psychological problems are randomly 
allocated to psychoanalytic psychotherapy and to an alternative intervention, for
 example, placebo therapy or behaviour therapy. It is important then that the 
patients who are in receipt of these treatments are as homogeneous as possible.
 This is the model used in drug trials.

Chiesa and Fonagy (1999) discuss alternative models of investigation. They are 
interested in effectiveness as it is shown in the real world of psychotherapy and 
counselling practice.

Seligman (1995) points out that many efficacy studies “omit too many crucial
 elements of what is done in the field.” The Association for Psychoanalytic 
Psychotherapy in the U.K. has proposed a multi-centre study which they expect 
will have “the additional advantage of being able to offer expectable success rates
 and of making a major contribution to bench marking, which is one of the 
recommendations of the Strategic Review” of psychotherapy services in the U.K.
 (Chiesa and Fonagy, 1999; Department of Health, 1997a; 1997b; 1998) This study 
will examine the effectiveness of psychotherapy in “real life”, that is routine 
clinical practice in the Health Service. Nevertheless reviews of the effectiveness of
 psychoanalytic treatments have shown them to be valuable (IPA, 1999).

Fonagy and Target (1996), in a landmark study of child psychoanalysis of 763
 patients, showed that “child psychoanalysis to be particularly effectively for
 seriously disturbed children under 12 years suffering from a variety of psychiatric disorders, particularly those which involve anxiety.”

In terms of child psychotherapy most studies show an overall improvement rate of
 between 67% and 78%. The spontaneous improvement rate (that is improvement
 without treatment) has been put at about 25% (Kolvin et al., 1981).

Howard (1986) has shown that there is a positive relationship between the amount 
of psychotherapy and the amount of patient benefit i.e. by 8 sessions approximately
 50% of (2,400) patients had improved, and by 26 sessions 75% had improved.

Economic Arguments

The benefit of a psychotherapeutic approach to relieving human misery is strong. 
It is possible to argue for psychotherapy purely on economic grounds, i.e. that it
 reduces general medical service demands by 20% and reduces inpatient hospital
 stays (Talley, et al., 1994; Anchor, 1989). The research is also very clear that it is 
more effective than placebo and more effective than no treatment (Fitzgerald,
 1987; Mallan, 1973). In addition it speeds up the rate of recovery of patients with
 many psychological problems. There is also evidence that some patients with 
serious psychological problems gain a benefit which is additive from a
 combination of pharmacological and psychotherapeutic interventions. The additive
 effect is due to differential effects of the two treatments. In addition there is 
growing interest in psychotherapy integration and this will happen much more in
 the future (Stricken and Gould, 1993; Karasu, 1982). There is also evidence that
 group and individual therapy work in different ways (Sheehan and Fitzgerald, 1994). The differential effects of different forms of psychodynamic approaches are
 clearly a focus for further research.

Theory of Mind

There is no doubt that the theory of psychoanalysis will evolve in the future in 
unexpected ways as it has in the past. We have moved from an instinctual theory 
propounded by Sigmund Freud to an object relations theory and now to 
appropriating elements from cognitive psychology for example ‘theory of mind’ 
concepts which are enriching psychoanalysis.

Theory of mind approaches are useful in patients with Asperger’s syndrome, where
 there are meta-representational deficits. A theory of mind deficit means that one
 person is unable to perceive and comprehend the thoughts and feelings of others, 
i.e. that other people have minds.

We are now much more sensitive to meta-representational deficits that patients 
have i.e. the ability to think about thoughts which include one’s own as well as
other people’s. We are trying to help people with severe problems to “read minds”,
 a capacity which is necessary to explain and predict the behaviours of other people 
in a social world. It is this meta-representational deficit that makes life confusing 
and frightening and leads many people to withdrawal and avoidance (Leslie, 1987).
 It people with these deficits are given interpretations based on an energy discharge
 model of psychoanalysis these interpretations will not make any sense to them.

These patients’ deficits are in the object relations area but the new type 0f 
interpretation and effort to help them is quite far from the object relations model of 
psychoanalysis as originally delineated. There is little doubt that, in the 21st 
century, psychoanalysis will see further theoretical developments along the lines
 described here.

It is very likely that in the 21st century conferences will take place where
 psychotherapists and counsellors will be in discussion with biochemists and brain 
neuroimagers about the effects of psychotherapy on various biological and 
neuroimaging parameters.

[Michael Fitzgerald is Henry Marsh Professor of Child & Adolescent Psychiatry


(1) Anchor K. (1989). The Handbook of Medical Psychotherapy: ‘Cost-
effectiveness strategies in Mental Health.’ Hogrese and Humber.

(2) Chiesa M., Fonagy P. (1999). Psychoanalytic Psychotherapy, 3, 3, 259 – 272.

(3) Dare C. (1996). ‘The Future Directions of Psychotherapy in the NHS.”
Psychoanalytic Psychotherapy, Volume 10, Page 32-45.

(4) Department of Health (1997a). A First Class Service: Quality in the NHS.
 London: HMSO.

(5) Department of Health (1997b). The New NHS – Modern, Dependable.
 London HMSO.

(6) Department of Health (1998). Modernising Mental Health Services: Safe,
 Sound and Supportive. London: HMSO.

(7) Fitzgerald M. (1987). ‘The Effectiveness of Psychotherapy.’ The Journal
 of the Irish Forum for Psychoanalytic Psychotherapy, 1.1, 29-35.

(8) Fitzgerald M. (1998). ‘Child psychoanalytic psychotherapy.’ Advances in
Psychiatric Treatment, 4, 18 -24.

(9) Fonagy P., Target M. (1996). ‘Predictors of outcome in child 
psychoanalysis: A retrospective of 763 cases at the Anna Freud Centre.’ Journal of
 the American Psychoanalytic Association, 44, 27 – 78.

(10) Hill D. (1954). ‘Psychotherapy and Physical Methods of Treatment in
 Psychiatry.’ Journal of Mental Science, 100, 360 – 374.

(11) Howard K. I. (1986). ‘The Dose-Effect Relationship in Psychotherapy.’
 American Psychologist, 41,159-164.

(12) International Psychoanalytic Association (1999). An open door review of
 outcome studies in psychoanalysis. London: University College London.

(13) Kolvin I., Garside R., Nichol A. (1981). Help Starts Here. London

(14) Leslie A. M. (1987). ‘Pretence and representation: The origins of Theory
 of Mind.’ Psychological Review, 94, 412-426.

(15) Mallan D. H. (1973). ‘The Outcome Problem in Psychotherapy Research.’
 Archives of General Psychiatry, 29, 719 – 729.

(16) Nathan P., Gorman J. (1998). A Guide to Treatments That Work. New York:
 Oxford University Press.

(17) Parry G., Richardson A. (1996). NHS Psychotherapy Services in England:
 Review of Strategies Policy. London: Department of Health.

(18) Roth A., Fonagy P. (1996). What Works for Whom: Limitations and
 Implications of the Research Literature. New York: Guildford Press.

(19) Seligman M. E. P. (1995). ‘The effectiveness of psychotherapy: The 
consumer report study.’ American Psychologist 50, 965-974.

(20) Sheehan J., Fitzgerald M. (1994). ‘Measuring Progress in Psychoanalytic
 Psychotherapy.’ Group Analysis, 27, 2, 211 -220.

(21) Stricken G., Gould J. (1993). (Eds). Comprehensive Handbook of
 Psychotherapy Integration. London: Plenum.

(22) Talley P. F, Strupp H. H., Butler S. (1994). Psychotherapy Research and
 Practice. Harper Collins: London.