Clinical Impact Statement: This manuscript uses a fictional character from 2068 to explore themes and approaches to psychotherapy. Operating on the principle that past behavior is the best predictor of future behavior, robust and recursive elements of existential, feminist, Adlerian, Gestalt, cognitive- behavioral, and neuropsychological perspectives are highlighted as likely contributors to the future of psychotherapy.
Simeon woke from the nightmare, sweaty and frightened. He groped for his Calm Now (CN) program, plugging it into his ear-port. He didn’t just hear soothing music, he felt it; his breathing slowed, his forehead relaxed. The gentle instructions, in the voice he’d chosen, brought calmness and tranquility. Thanks to an activated parasympathetic nervous system, within minutes, he was emotionally regulated.
Simeon faced a choice. He could continue with his usual daily social, vocational, and recreational routines, or he could take time for personal exploration. This was the fourth morning in the past two weeks that he’d awakened from a similar nightmare. Maybe the CN program wasn’t enough. Thanks to his grandmother’s influence, for nearly all of his 25 years, Simeon had been interested in understanding life at a deeper level. He made remote contact (RM) with his grandmother, conferred a bit, and decided to invest time in symptom relief and growth-producing insight. He logged into his Living Calendar (LC), reset his November 15, 2068, work schedule, and moved his evening date an hour later. He punched in codes that his company’s employee support program provided and input his symptoms and goals. Instantly, the company sent Simeon a virtual therapist, a hologram named Indigo.
For the next hour, Simeon interacted with Indigo. He shared his dream, engaged in guided emotional processing, and began recognizing how his dream was related to a near-death experience he had during an air quality emergency that happened six months ago in his dome complex. “Duh,” he thought to himself. “I should have put that together.” He contemplated connections between his trauma, his daily distress, and his disconnected interpersonal relationships. Exhilarated, Simeon requested three more sessions that week. By Friday, Simeon’s Spoken Daily Log (SDL) read, “Monday was a turning point. Even though I was nearly asphyxiated 6 months ago, I’m letting go of the pain, integrating the experience into my life, and functioning from a place of authentic self again. The week was packed with meaning. I’m communicating more effectively and choosing interpersonal connections rather than my usual distancing. My grandmother always talked about the thrill of being a psychotherapist; now I understand why. I’m so glad she nudged me to get the help I needed. Thanks grandma! Thanks Indigo!”
Although he always thought of her as his quirky Grandma Nola, Simeon’s grandmother was a real (non-virtual) 75-year-old retired psychotherapist. Grandma Nola had provided in-person counseling and psychotherapy, and had contributed to the ongoing process of updating the data bases used around the globe for virtual psychotherapy.
Having been preoccupied with his own life and issues, Simeon didn’t know much about Grandma Nola’s past. He didn’t realize that, 50 years ago, as a graduate student in clinical psychology (2017-2021), she had been studying and writing about the existential, cognitive, behavioral, psychodynamic, and feminist-multicultural themes she would use in her work as a psychotherapist and researcher. Much later, when he enrolled in a History of Psychotherapy course, he would recognize his grandmother’s influence on how Indigo had worked with him.
Past as Prologue
Simeon’s nightmare was linked to a 2068 global air quality crisis that had severely damaged systems across the globe, resulting in thousands of fatalities. But Simeon’s traumatic experience could have occurred any time in human history. His distress could have been due to an automobile crash, intergenerational trauma, cultural oppression, a mudslide or tsunami, child sexual abuse, or emotional neglect. Humans have been, are, and will be physically, psychologically, and emotionally vulnerable.
In 2018, Grandma Nola was in the University of Montana library. She had a class assignment to go back 50 years and identify recurring themes in the development and application of psychotherapy. As a 25-year-old graduate student, Nola had an immense drive to learn everything she could about psychology and psychotherapy.
Social Context, Gender, and Relational Solutions
Nola used a popular counseling and psychotherapy theories textbook to begin exploring themes and issues in the history of psychotherapy (Sommers-Flanagan & Sommers-Flanagan, 2018). She was captivated by a short summary of Naomi Weisstein’s (1968) critique of psychology’s and psychiatry’s constructions of gender. Nola searched and found an original Weisstein article online and the words resonated with her experience. Immediately, she found herself in a timeless space of learning and discovery. From Weisstein, she leapt back to Alfred Adler’s (1931) ideas on feminism and social interest (aka: Gemeinschaftsgefühl). Then, she circled forward to Bowlby’s (1969) and Ainsworth’s (1969) work on attachment. She took the pulse of psychoanalysis, finding that it wasn’t dead, but transformed. She loved the quotation, “Libido is object-seeking, not pleasure-seeking” (Fairbairn, 1952, p. 82). Looking at the past aided Nola in her understanding of contemporary feminist theory and therapy. The underlying principles of relational cultural therapy (Jordan, 2010) became clear. She recognized that social context and relational connection, long downplayed in psychology, was a theme that connected the past, present, and future of psychotherapy.
Recursive Themes: Bringing There and Then to Here and Now
Nola’s assignment took her to the late 1960s. Once there, she discovered books and articles written by Jean Baker Miller, Albert Bandura, Aaron Beck, Albert Ellis, Rollo May, Donald Meichenbaum, Fritz and Lore Perls, Carl Rogers, and B. F. Skinner. But her focus didn’t hold. She flitted back and forth in time, reading the Rogers-Skinner debates, finding a copy of Mary Cover Jones’s (1924a, 1924b) articles on deconditioning, then taking a side-track to C. G. Jung (1953), and returning, as her professor insisted, to neuroscience, psychotherapy outcome research, and interactive roles of biology, environment, culture, and volition in psychopathology, recovery, and wellbeing. In addition to social context, gender, and relational insights, she found additional themes and principles.
Exposure and Counterconditioning
From Jungian theory to existentialism to behavior therapy to acceptance and commitment therapy and eye-movement desensitization, Nola discovered the core principle: Thou shalt avoid avoidance. Nearly every perspective, for distinct and indistinct theoretical reasons, advocated approaching and embracing anxiety and feared stimuli. As she connected this idea with contemporary movements toward psychology’s interest in obtaining prescription privileges, she became increasingly skeptical of quick fixes that might dull emotional and cognitive awareness.
In her future work, she questioned the overuse of primitive psychotropic drugs for mood control and testified before the United Nations to help establish global credentials for virtual and human psychotherapists. Grandma Nola was instrumental in insisting that virtual psychotherapists, like Indigo, integrate behavioral classical conditioning and existential embracing of emotion and interpersonal connection into their programming.
Therapeutic Relationships: Real and Virtual
As Nola continued reading for her project, she focused in on what Wampold and Imel (2015) called the great psychotherapy debate. Intrigued, she quickly concluded that both common factors and technical procedures were critical to efficacious psychotherapy. In particular, she became interested in relationally-based common factors (Norcross & Lambert, 2018; Sommers-Flanagan, 2015). Even more specifically, she began exploring in-vivo and virtual therapeutic relationships.
In 1969, Carl Rogers was applying client-centered therapy principles to the field of education. Rogers’s core conditions for psychotherapy were deeply meaningful to Nola. Although she imagined Rogers as averse to a future where his core conditions were implemented virtually, she started viewing congruence, unconditional positive regard, and empathic understanding as transferrable to virtual counseling and psychotherapy.
Nola thought that perhaps Jerome Frank could have helped Carl Rogers make the leap from real to virtual. In 1961, Frank had written about common healing factors that transcended culture and specific method. Frank posited that specific healing myths, rituals, and settings could be (and would be) vastly different, depending on social context. Although Frank didn’t write about virtual psychotherapists, his vision opened up the possibility, “My position is not that technique is irrelevant to outcome. Rather, I maintain that . . . the success of all techniques depends on the patient’s sense of alliance with an actual or symbolic healer” (1961, p. xv).
As it turned out, given the right social and cultural context, Indigo could become Frank’s symbolic healer. Nola discovered, in 2018, that clients who choose online or virtual counseling reported having a positive therapeutic alliance—even if the alliance was with a non-living entity (Sommers-Flanagan & Sommers-Flanagan, 2017).
Humans easily anthropomorphize devices. Simeon quickly felt a sense of alliance and attachment to Indigo. Whether we explain it through attachment theory or classical conditioning, alliance and attachment are natural byproducts of repeated positive interactions. In 2068, relational components of psychotherapy will remain central, but these “relationships” are likely to include many variations: virtual encounters with other humans; relational interactions between humans in distress and artificial intelligences functioning as helping entities (such as Indigo); anonymous, internet-based group work; and amalgamations of all of the above.
The Brain, the Body, and Behavior
Advances in neuroscience are exciting, palpable, and no doubt will influence psychotherapy’s future. However, as Nola discovered in 2018, it can be difficult to distinguish between research-based implications for psychotherapy and popular hype of the so-called “new brain science” (Satel & Lilienfeld, 2013). The challenge for Nola and other psychotherapy researchers in the future is to separate the neuroscience wheat from the neuroscience shaft.
Mind-body dualism is a consistent theme in psychology and medicine. Over time, Grandma Nola’s position held brain and body as one. Distinct from, but similar to, van der Kolk’s (2014) emphasis on the body, Nola fought to integrate brain and body into a fully functioning partnership. But like Rogers’s battle with psychiatry in the 1960s, this was not an easy fight (see Sommers-Flanagan & Sommers-Flanagan, 2018). The biomedical push for biogenetic and pharmacological interventions, including psychosurgery, was a continual force with which Nola contended. She held that developing emotional awareness, encouraging interpersonal connection, and empowering human choice was preferred over biomedical interventions. But sometimes her grip on that position was threatened.
Combining themes from the past and looking to the future brings up unlikely partnerships. Theoretical propositions from attachment, feminist, Adlerian, person-centered, and existential perspectives heavily favor the therapeutic relationship as foundational for change. In contrast, the learning theories that are foundational to cognitive-behavioral therapy—the most empirically supported treatment of our generation, circa 2018—are far more technical and procedural, often bracketing or downplaying the transformative role of therapeutic relationships.
Most likely, therapists who believe in the centrality of the therapeutic relationship for healing and change wouldn’t easily endorse the partnership of relationship with technology. However, Simeon’s Indigo program wove relationship and technology together in ways that could and did create meaning, new learning, and insight for Simeon. We are reasonably certain that by 2068 there will be sophisticated devices able to offer comfort, promote insight, and capitalize on teachable moments in the lives of a broad swath of a technologically savvy generation.
Hopefully, though, the goal(s) of psychotherapy will be both basically unchanged and appropriately articulated for the times. Regardless of how technical Simeon’s intervention might be, we believe the 2068 Simeon will long for healthy relationships, intimate connections with real people, meaningful work, and a sense of fulfillment. Indigo will weave this understanding into its treatment of Simeon, and likely Simeon will benefit. But we also predict that many humans will not accept a virtual therapist, and will prefer a human psychotherapist. And, as Grandma Nola would attest, Indigo will not program itself. Human therapists, thinkers, and scientists will continue to explore how to best help others heal, grow, learn, and develop.
The morning after the nightmare, when Simeon plugged his chosen program into his ear-port, he immediately benefited from counter-conditioning. Simeon didn’t know the research-based origins of counter-conditioning or the subsequent neuroscientific support of exposure therapies. All he did was take time to face his psychological issues, reporting his reactions into his SDL; these reactions were automatically uploaded into his Psychological Needs Profile (PNP). In turn, Simeon was given assignments designed to increase his self-efficacy (Bandura, 1977), expose him to his anxieties (Jones, 1924a), and offer him opportunities for deepening interpersonal connections (Jordan, 2010; Yalom, 1980). The feedback and feedforward processes integrated into his PNP helped Indigo support Simeon as he engaged in daily decision-making that moved him toward psychological health.
Given Simeon’s positive response to psychotherapy with Indigo, it might feel easy to conclude that the future of psychotherapy is rosy. However, psychotherapy research and practice has always been fraught with conflict; there’s no reason to expect smooth sailing ahead.
Science and Art
Divisions between the science of psychotherapy research and the art of clinical practice persist. This will not change. Fifty years from now, humans may have an even wider range of choices available to them when it comes to pursuing relief from distress or pursuing psychological growth. Some researchers and practitioners will insist that psychotherapy be an interpersonal experience; others will fight to integrate empirically-based principles into virtual scenarios; still others will hold a stronger allegiance to profit than science or principle. Consequently, the future will be shaped, in part, from battles for principles and funding. As different groups influence state, national, and global policies and beliefs, distribution of funds will undoubtedly shape the future of psychotherapy.
As access to medical and psychological assistance becomes increasingly virtual, traditional boundaries such as state and national credentials will give way to international credentialing. “Mid-level” providers will play a significant role, as will virtual providers such as Indigo. Corporations and other communal entities such as governments and insurance companies will invest in the layered provision of physical and mental health care.
Fifty years from now, assuming we’ve solved our urgent political and climate challenges, humans will continue to seek meaningful work, fulfilling relationships, and recreational opportunities. Humans will still experience trauma, pursue intellectual stimulation, and long for connection and meaning. There will be human-caused and natural disasters. Psychotherapists, both living and virtual, will offer integrated interventions, tailored closely to the person, place, needs, and resources. Greater awareness of the role of cultures, genders, and other intersecting identities, along with environments and biological factors, will inform these interventions and relationships. Surgical or medical interventions, although available, will not address longings for insight and self-improvement. These interventions will not answer the existential questions we associate with being fully human. These tasks, we hope, will continue to be in the domain of human psychotherapists at the helm of a vast array of virtual assistants.
One such psychotherapist will likely be Simeon, who after his work with Indigo, asked Grandma Nola for a referral for a human psychotherapist. He then followed in her footsteps, eventually being accepted into a prestigious graduate program in the field we currently refer to as Clinical Psychology. Then, at some point in the future, we suspect he will publish an article in Psychotherapy Bulletin.
Cite This Article
John Sommers-Flanagan, J. & Sommers-Flanagan, R. (2018). Recursive and emerging themes in psychotherapy: Past, present, and future. Psychotherapy Bulletin, 53(4), 7-12.
Adler, A. (1931). What life should mean to you. Oxford, England: Little, Brown.
Ainsworth, M. D. (1969). Object relations, dependency, and attachment: A theoretical review of the infant-mother relationship. Child Development, 40(4), 969-1025. http://dx.doi.org/
Bandura, A. (1977). Self-efficacy: Toward a unifying theory of behavioral change. Psychological Review, 84(2), 191-215. http://dx.doi.org/10.1037/0033-295X.84.2.191
Bowlby, J. (1969). Attachment. New York, NY: Basic Books.
Fairbairn, W. R. (1952). Psychoanalytic studies of the personality. Oxford, England: Routledge & Kegan Paul.
Frank, J. D. (1961). Persuasion and healing: A comparative study of psychotherapy. Oxford, England: Johns Hopkins University Press.
Jones, M. C. (1924a). The elimination of children’s fear. Journal of Experimental Psychology, 7(5), 382-390. http://dx.doi.org/10.1037/h0072283
Jones, M. C. (1924b). A laboratory study of fear: The case of Peter. Pedagogical Seminary, 31, 308-315. https://doi.org/10.1080/08856559.1924.9944851
Jordan, J. V. (2010). Relational-cultural therapy. Washington, DC: American Psychological Association.
Jung, C. G. (1953). Two essays on analytical psychology (R. F. C. Hull, Trans.). New York, NY: Pantheon Books.
Norcross, J. C., & Lambert, M. J. (2018). Psychotherapy relationships that work III. Psychotherapy, 55(4), 303-315. doi: 10.1037/pst0000193
Rogers, C. R. (1969). Freedom to learn: A view of what education might become. Columbus, OH: Charles E. Merrill Publishing.
Satel, S., & Lilienfeld, S. O. (2013). Brainwashed: The seductive appeal of mindless neuroscience. New York, NY: Basic Books.
Sommers-Flanagan, J. (2015). Evidence-based relationship practice: Enhancing counselor competence. Journal of Mental Health Counseling, 37(2), 95-108. https://doi.org/
Sommers-Flanagan, J., & Sommers-Flanagan, R. (2017). Clinical interviewing (6th ed.). Hoboken, NJ: Wiley.
Sommers-Flanagan, J., & Sommers-Flanagan, R. (2018). Counseling and psychotherapy theories in context and practice: Skills, strategies, and techniques (3rd ed.). Hoboken, NJ: Wiley.
van der Kolk, B. (2014). The body keeps the score: Brain, mind, and body in the healing of trauma. New York, NY: Viking Books.
Wampold, B. E., & Imel, Z. E. (2015). The great psychotherapy debate: The evidence for what makes psychotherapy work (2nd ed.). New York, NY: Routledge/Taylor & Francis Group.
Weisstein, N. (1968). Kinder, kuche, kirche as scientific law: Psychology constructs the female. Boston, MA: New England Free Press.
Yalom, I. D. (1980). Existential psychotherapy. New York, NY: Basic Books.